College of pharmacy/University of Baghdad .Clinical pharmacy Dept Fourth year. Community Pharmacy workshop.

2009-2010

COUGH

Cough: Cough is one of the more common conditions for which patients request pharmacist
assistance .Cough is a protective reflex action caused by when the airway is being irritated or obstructed. Its purpose is to clear the airway (1). Coughing is a non-specific symptom that can be .( ) linked to over 100 conditions, ranging from minor and self-limiting to life-threatening The majority of coughs presenting in the pharmacy will be caused by an upper respiratory tract viral infection and they often associated with other symptoms of cold (1). However, the patient with cough may also present with other symptoms that required referral to the physician for .further investigations

Types of cough
Productive (wet, chesty) cough: which expels secretions from the lower respiratory tract -1
that if retained could impair the ventilation and increases the possibility of respiratory tract ( (infections (2).(note: colored sputum may indicate infections(1 Nonproductive (dry) cough: in which no sputum is produced (1) and has no physiologic -2 .(purpose (2). These cough are usually caused by viral infections and are usually self-limiting (1

:Chesty-Nonproductive-3
Some patients say that they are not producing sputum and they say that they can "feel it on their chest ",(3) where there is congestion on the chest but no mucus is produced, and this should .( be treated as a productive rather than non-productive cough ( 2, 4

(Patient Assessment of cough (questions and answers

Duration-1
.Most coughs are self-limiting and will be better within a few days with or without treatment In general cough of longer than 2 weeks duration should be referred to the Dr. for further .(investigations (1

Nature of cough-2
:Whether the cough is A-Dry or B-Wet (i.e. there is sputum): and if it is wet Then we ask about the color of the :sputum .(Non-colored (clear or whitish) no infection and we can recommend an OTC products (1 Colored sputum (green, yellow, or rusty) and sometimes contain blood (haemoptysis) .(All these may indicate chest infections and require referral (1

:Associated Symptoms -3 A-Fever, night sweats, weight loss, and haemoptysis: may indicate TB (tuberculosis)
.(referral for further investigations (1 1

B-A recurrent night-time cough especially in children with or without wheezing may indicates
.(Asthma referral for further investigations (1 .((Especially if there is a family history of eczema, asthma, hay fever (1) : Night cough in children: fairly common in association with a cold but in the absence of cold symptoms could indicate asthma (8). (Symptom of cold include: sore throat, Runny / congested (or blocked) nose). C-Cough with frothy sputum, breathlessness (especially in bed during the night) may indicate .(heart failure referral for further investigations (1 .((Note: other symptom of heart failure may be swollen ankles (1) (history of C.V. disease ) ( if there is a history of heart disease especially with a persisting cough, then referral is advisable (1) :D-Postnasal Drip It is a common cause of coughing and may be due to sinusitis referral for further (1) investigations .(Postnasal Drip is characterized by a nasal discharge that flows behind the nose and into the throat . Patient present with swallowing mucus or frequent clearing of the throat .((more than usual (4

E-Chest pain, shortness of breath (SOB), wheezing, Whooping

.(investigations (1

referral for further

:F-Croup Croup usually occurs in infants, the cough is harsh, barking (1), and paroxysmal (occurring in bouts) (4), and the child often has difficulties in breathing and stridor (noisy inspiration) (4) .referral for further investigations (Note: Croup usually develops a day or so after the onset of cold-like symptoms ) G-Coughing during the recumbent (supine, lying down), with heartburn may indicate Gastro esophageal reflux disease(GERD) which may be improved by antacid or histamine-2 receptor .(antagonists(H2RA) (3).( we will study it later

H-Smoking: if cough is related to smoking, refer the patient to primary care provider; such cough
.(should not be self-treated with cough suppressant and/or expectorant (3 Patient who smokes is more prone to chronic recurrent cough. Over time this might be develops ) .(into chronic bronchitis or emphysema) (4 : A change in the nature of a smoker's cough (e.g. more productive or frequent, or a different sound) may suggest malignancy So, a smoker's cough that has changed in nature referral (2).

:Medication-4 A-If one or more appropriate remedies have been tried without success (failed medication)
.(referral for further investigations (1 B-Effective product for similar previous cough: the pharmacist should consider patient's .(satisfaction or dissatisfaction with specific products i.e. patient's preferability (3 :.C-Drug-induced cough: e.g Angiotensin-converting enzyme (ACE) inhibitors (e.g. captopril, Lisinopril, -1 Enalapril ) can induce cough in about 10% of patients (especially women), the cough is usually nonproductive, occurs within the first few months of therapy refer and suggest the ( . alternative: Angiotensin II receptor antagonists (valsartan, losartan, .)(1 .The antiarrythmic agent amiodarone-2

\
2

Treatment timescale
The patient should seek medical attention if the cough does not improve in 7-10 days. Or if the .(cough persists longer than 3 weeks even if it has respond to OTC drugs (3

Management
:Non-drug measures Demulcents : slowly dissolving hard candies or other lozenges in the mouth (1) which may*
contain ingredients such as honey and lemon, or glycerol. They are thought to coat the pharyngeal mucosa, soothing inflammation and reducing irritation, and can be used to treat both productive . (and non-productive coughs(2 They are usually harmless and cheap and have a useful placebo effect. They can be used for any type of cough(5). (They considered to be safe in children and pregnant women) (1) but should not be given to children under three years of age because of the risk of choking (2 ). If recommended they .(should be given 3-4 times daily (4 General advice to patient with cough and cold is to increase fluid intake to about 2 Litters / day * .((1). (About 8 to 10 glasses daily

:Non-prescription medications
(( and dextromethorphan are used for dry cough. Although all three may be effective, dextromethorphan and Pholcodeine have a lower risk of constipation and dependence developing. In addition, both Pholcodeine and codeine can cause drowsiness whereas dextromethorphan is non-sedating in most people ( 2 ). .(At antitussive doses , opioids have no significant drug interactions with other drugs( 5

A-Antitussive (cough suppressants): Codeine, Pholcodeine

:Codiene-1
cough mixtures : : e.g. of codeine containing cough mixtures available in Iraq are: Tussiram syrup, Pulmocodin syrup S/Es: even at OTC doses codeine can cause constipation and at high doses, respiratory depression .((1), therefore it is best avoided in patients with impaired respiratory function e.g. Asthma (3 : 4 ( However, in practice this is very rarely observed and does not preclude the use of cough (suppressant in asthmatic patients

Note: Codeine is well known as a drug of abuse and sales must be refused because ) .(of knowledge or likelihood of abuse) (1
(,Dextromethorphan (Sedilar tablet, drop-2 .(Generally it is considered non-sedating and has fewer side effects (1 :(Dose (4 Adults years 12- 5 years 1-5 15 mg four times daily mg four times daily 7.5 mg four times daily 2.5
4 dextromethorphan 3 : ........

.Diphenhydramine (Allermine): Which is one of the sedating antihistamines-3 :(The antitussive doses are (3

Adult
mg every 4hours 25 (max. 150mg/day)

years 12- 6
mg every 4hours 12.5 (max. 75mg/day)

years 2-6
mg every 4hours 6.5 (max. 37.5mg/day)

.S/Es and precautions: see later

B-Expectorants and Mucolytics: which are used for wet cough.( But see the placebo effects
.(of cough preparations later

Glyceryl guaiacolate (also called Guaifenesin): Which is the only FDA approved OTC -1
.(expectorant (3 :(Doses (4

Adults
200 mg four times daily

years 12- 6
mg four times daily 100

years 1-6
mg four times daily 50

........ 4 Guaifenesin 3 :

Bromohexine (Solvodin syrup, and tablet): which is one of the Mucolytics drugs, used for -2
.wet cough . Adult dose : one tablet or one Tablespoonful 3-4 times daily

:C-Additional Constituents Theophylline: which is one of the bronchodilators, and it is available in some OTC products but-1
it is best avoided because patients requiring medication to help with shortness of breath (SOB) or wheeze are best referred (4). And because of the problems associated with theophylline, and the .( availability of wide range of safer alternative treatment (5

Sympathomimetics (e.g. Pseudoephedrine and Phenylphrine): these are commonly included -2

.(in cough and cold remedies for their bronchodilator and decongestant actions (1 They may be useful if the patient has blocked nose as well as cough, but they can increase the BP ,stimulate the heart, and alter the diabetic control therefore they are not recommended for : patients with Coronary artery diseases (Angina, MI, .), Hypertension, Diabetes mellitus, and .(Hyperthyroidism (1

Sedating Antihistamine: like Diphenhydramine, and chlorpheniramine,., which may be -3

added to antitussives ( combination with expectorant is illogical) and they are effective especially if .(the dry cough is disturbing sleep(1 S/Es: include sedation and drowsiness and anticholinergic S/Es (i.e. dry mouth, urinary retention, .(constipation, ..)(4 :They are not recommended (1) (or used with caution (6)) for patients with .(Glaucoma or prostate hypertrophy (4 .( Note: Non-sedating antihistamines are less effective for cough (2

:
( ) -1 -2 ) ( -3 -4 -5 , , , : )-6 (................ , ) ( -7 ) ( ) ( -8

Further reading
(

Placebo effects of cough preparations (4-1

Antitussive probably have a limited role in the treatment of acute non-productive cough .patients should be encouraged to increase fluid intake and told that their symptoms will resolve in time on their own. If medication is required then any active ingredient could be recommended and the side effect profile and abuse tendency rather than clinical efficacy will drive choice. On this :basis .Dextromethorphan: will be 1st line therapy* .(Codiene: will be 2nd line therapy (because of side effect profile and abuse tendency * Antihistamine: should not be used routinely, unless night-time sedation is perceived additional * .benefit to the patient sleep In addition, most products to treat productive cough are probably no more effective than placebos, however, if the patient has confidence in a product's efficacy then their use should not be .discourage

:Diabetic patient and the sugar contents of cough medicines-2

Current thinking is that in short term acute conditions the amount of sugar in cough .(medicines is relatively unimportant (1 However sugar-free products are available and may be used for diabetic patients and by patients ) .(who wish to reduce sugar intake for themselves and their children as part of dental health) (1 After therapy is stopped, an ACE inhibitor-induced cough typically takes up to four weeks to -3 .( resolve but can linger for up to three months( 2

:(Pediatric Dextromethorphan doses(7-4 (( Sedilar : 5

Age months 1-3 months 3-6 7months-1 year Dose mg t.i.d 0.5-1 mg t.i.d 1-2 mg t.i.d 2-4 Equivalent no. of drops of ((sedilardrop:15mg/ml About 1drop t.i.d About 2drop t.i.d About 3drop t.i.d

: References Alison Blenkinsopp and Paul Paxton .Symptoms in the pharmacy . A guide to the managements -1 .of common illness. 4th edition .2002 Sarah Marshall . Over-the-counter advice for coughs. The Pharmaceutical Journal (Vol 278) 20 -2 .January 2007 . page:85-88 Handbook of Non-prescription drugs.-2002 3 Community Pharmacy. Symptoms, Diagnosis and Treatment. 2004-4 .Nathan A. Non-prescription medicines. 3rd edition. London: Pharmaceutical Press; 2006 -5 BNF-6 Pediatric dosage handbook. 8th edition 2001-2002 . by Carol K. takem-7 .Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press; 2008 -8

:Homework: complete the following table

Trade names Tussiram syrup

Compositions

Adult dose Iraq drug) ( guide Two teaspoonful times 3-4 daily ml qid 5-10

Caution or contraindications

Samilin

Tussilet

Pulmocodin

one teaspoonful Tid