What Cold Medications Are Safe For My Heart?

It’s the cold and flu season here in St. Louis. That means the beds in my hospital are filling up with people who have upper respiratory infections of one kind or another and have developed complications. Not uncommonly,  the skeptical cardiologist is asked to consult on one of his  heart patients who has developed worsening heart failure or atrial fibrillation as a consequence of the pulmonary issues.

In the office it seems like every other patient has recently had a flu-like illness and is still dealing with lingering symptoms, most commonly a persistent cough.

At this time of year I get a lot of questions  from patients which come down to  “What over the counter medication can I take for my cold/flu/cough symptoms that is safe for my heart?”

My answer prior to writing this post  has always been  “Take anything that does not contain pseudoephedrine.”

Pseudoephedrine  (brand name Sudafed)is a decongestant, so often OTC cold meds that contain it will add a D to the title.

It is a sympathomimetic drug meaning that it stimulates the part of the autonomic nervous system that is responsible for “flight and fight” activation. This system kicks in the heart rate goes up, the blood pressure goes up and the heart beats stronger. Blood vessels constrict to nasal passages, thereby reducing fluid build up and resulting in the decongestant properties of the drug.

You won’t find it on the shelves in your local pharmacy because methamphetamine can be produced from it. Laws vary from state to state but at a minimum you will  have to present your driver’s license and you will be allowed to purchase a limited amount from the pharmacist.

A related drug, phenylpropanolamine,(which was used in OTC cold remedies and for weight loss)  was removed from the market in 2000 after the FDA warned of an increased risk of hemorrhagic stroke in young women

I use the little red 30 mg Sudafed pills when my nose is really running badly (think 30 tissue/ hour) and I’m sneezing frequently and it dries me up pretty effectively.  After I take it I feel like I’ve consumed a really highly caffeinated (think Starbucks) cup of coffee for about 4 hours. For this reason, I don’t take it within 6 hours of going to bed.

Sudafed is often combined with other cold , sinus and flu OTC remedies with names like:

Allegra-D, Alka-Seltzer Plus Cold Medicine Liqui-Gels, Aleve Cold and Sinus Caplets, Benadryl Allergy and Sinus Tablets, Claritin-D Non-Drowsy 24 Hour Tablets, Contac Non-Drowsy 12 Hour Cold Caplets, Robitussin Cold Severe Congestion Capsules, Sudafed  24 Hour Tablets, Triaminic Cold and Cough Liquid, Thera-Flu Cold and Cough Hot Liquid, Tylenol Sinus Severe Congestion Caplets, and Vicks 44M Cough, Cold and Flu Relief.

Adverse Effects of Pseudoephedrine: Stroke, Blood Pressure, Heart Rate

A 2003 paper from Mexico identified 22 cases of stroke (out of 2500 stroke cases at their center) that were associated with taking agents like pseudoephedrine within 24 hours. The majority were with phenylpropanolamine but there were 4 cases associated with pseudoephedrine. Given how often pseudoephedrine is taken and how few strokes were reported, it is difficult  to draw any conclusions that  pseudoephedrine causes stroke

In 2005, a review of all studies looking at oral pseudoephedrine concluded

This analysis demonstrates that pseudoephedrine causes a small but significant mean (1–mm Hg) increase in SBP, with no significant effect on DBP and a slight increase in HR (3 beats/min)

On average, these are very minor changes in blood pressure and heart rate and would be unlikely to cause any problems in the vast majority of patients with significant heart disease or hypertension.

The study found NO increased rate of adverse effects (such as heart attacks or strokes) in the patients taking pseudoephedrine.

Coridicin Hbp, A Typical Mixture Of OTC Ingredients

One of my patients pulled from her purse an OTC cold remedy that appeared to have the American Heart Association seal of approval.

IMG_3315

The HBP refers to high blood pressure and the blurb on the front claims this is cold relief for people with High Blood Pressure.

This is really just marketing hype to get patients to buy a more expensive combination of otherwise cheap ingredients.

Let us look closely at the benefits and side effects of this typical and common OTC cold/sinus/flu remedy

Typical “Multi-symptom” OTC Cold/Flu/Sinus/Cough Ingredients

-Acetaminophen (tylenol)- helps with aches, pain, headache and fever.

-Dextromethorphan (look for DXM or DM) is commonly found  in these kinds of multi-ingredient brand name products and is promoted as reducing cough (as an antitussive). However, there is very little evidence to support its efficacy.  This study found 30 mg dextromethorphan no better than placebo at reducing cough. The Cochran Database  Review in 2012 concluded :

There is no good evidence for or against the effectiveness of OTC medicines in acute cough.

In addition to lacking evidence for efficacy, dextromethorphan is used as a recreational drug due to its side effect as a  dissociative hallucinogen in very high doses. Per Wikipedia:

It may produce distortions of the visual field – feelings of dissociation, distorted bodily perception, and excitement, as well as a loss of sense of time. Some users report stimulant-like euphoria, particularly in response to music

-Chlorpheniramine is an antihistamine. It’s one of the oldest antihistamines and as such is “sedating”. This means it almost certainly is going to make you drowsy. I remember trying to function on medical wards 30 years ago when it was the only antihistamine available and it turned me into a zombie for 24 hours.

. Since newer non-sedating antihistamines (like loratadine which is available OTC and generic) have become available I cannot fathom how something like Coricidin has survived.

What is the antihistamine in this hodgepodge of drugs doing for your cold symptoms? Nothing, other than making you drowsy. Antihistamines are useful for allergically related runny nose or sneezing.

What Are the Downsides of Multiple Medication Cold Remedies

I think you are much better off avoiding these brand name mixtures of different active ingredients.

Instead, you should take what you need for a specific symptom in the appropriate dosage and time interval.

Thus, if you have pain, take  the minimal dose of tylenol that relieves it and repeat when it comes back.

If you have a cough, recognize that the OTC ingredients are no better than placebo and are being abused as recreational drugs. Most coughs go away shortly but if one is particularly troublesome and persistent get a cough suppressing drug from your physician.

If you have a really runny nose with a lot of sneezing it is probably OK to take pseudoephedrine even if you are a heart patient or have high blood pressure. Take it as I described above. Start with 30 mg of the little red Sudafed pills , wait an hour to see how you feel. Take a second if it has not been effective.  Repeat at 4-6 hour intervals as needed. Take your blood pressure at least once after starting it.

Don’t buy the multi-symptom multiple ingredient combinations which are simply a marketing tool to get you to spend more money on something from which you won’t benefit.

The second and third items are Coricidin bottles which had been used as slides
Various guitar slides. Includes two original Coricidin bottles from the 1970s–the favorite of many slide guitar players, including Duane Allman.. from king nate/Flickr user”johnny from space 1

I see no reason to ever take coricidin. In the late 1960s, however, legend has it that Duane Allman  had a cold on his birthday.  His brother Greg gave him two gifts: a glass bottle of coricidin pills and Taj Mahl’s debut album. From this he learned how to play slide guitar by listening to Statesboro Blues.

And the rest is history.

I “Ain’t Wastin’ Time no More” on OTC Cold Meds…. Super Bowl is approaching.

ACP

 

 

17 thoughts on “What Cold Medications Are Safe For My Heart?”

  1. Oscar William Wing has been taking Robitussin Cough & Cold DM since January 23, 2015, proving your statement in this blog that OTC cough medicines are ineffective. His cough is persistent. A prescription for the medication you eluded to in this post would be appreciated.

  2. Dr. P., What about phenylephrine? Is it effective as a decongestant with less effect on blood pressure? That is the claim.

    1. Sorry about the delay on this response. I had spent some time looking at phenylephrine and thought about writing a separate post on it but …. time flies.
      Anyway, what I found was
      1. Phenylephrine (oral) is not better than placebo in reducing congestion.
      2. Phenylephrine (oral) appears safe with little to suggest it raises blood pressure or heart rate significantly .
      Thus, phenylephrine seems to function as placebo in the various cold and flu concoctions.
      The nasal spray form of it is effective but there are concerns that patients may not be able to stop using it.

  3. Doctor, in your years of practicing, have you found a common link between Coricidin Cough & Cold (not flu, given the large quantities of acetaminophen) and death from recreational users?

    I ask because I’m aware some people use this particular brand in high doses to achieve a dissociative high. Yet when I search for Coricidin Cough & Cold related deaths, my search yields no results.

    Coricidin has been linked to deaths, but reports never disclose whether or not the deceased was using Cough & Cold formula vs Flu formula.

    Any thoughts or facts would be greatly appreciated.

    -Mark

    1. I haven’t researched this particular topic extensively but I think this article (https://www.goodrx.com/blog/six-ways-to-get-rid-of-cough-from-post-nasal-drip/) is a reasonable summary of treatment options. I wasn’t aware that fluticasone is now available over the counter until reading this. Of the treatment options mentioned the only ones that I would be careful with are ones that incorporate the decongestant pseudo-ephedrine. I would not advise pseudo-ephedrine for anything but short term use.

    1. Thanks Loretta! Sad to see Greg Allman just died. Maybe I’ll pull out my Coricidin bottle and play a few slide licks along with my Hammond B3 emulation and put Brothers and Sisters on the turntable.

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