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?”
Decongestants
My answer prior to writing this post has always been “Take anything that does not contain pseudoephedrine.” After reviewing the scientific literature I have changed that recommendation.
Pseudoephedrine (brand name Sudafed) is a decongestant. Over-the-counter cold (OTC) medications that contain it will typically add a D to the title (Nyquil-D for example).
It 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.
You won’t find pseudoephedrine in an isolated form 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.
Sympathomimetic Medications
Pseudoephedrine and methamphetamine are sympathomimetic drugs. Such drugs mimic natural hormones that are part of the autonomic nervous system that is responsible for “flight and fight” activation. When this system is activated the heart rate goes up, the blood pressure goes up and the heart beats stronger.
Other sympathomimetic drugs which have been utilized in OTC cold preparations include
- Ephedrine.
- Phenylephrine.
(Phenylephrine was just (Sept/2023) declared by the FDA as ineffective and will be removed from such products from now on.)
Sympathomimetic drugs like pseudoephedrine have systemic effects on the cardiovascular system. Blood vessels constrict to the nose and sinuses, thereby reducing fluid buildup and resulting in the “decongestant” properties of the drug. Blood vessle constriction occurs throughout the body, however, which has raised concerns that this may result significant worsening of hypertension or increase stroke risks.
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.
Most of this stroke risk was in women taking appeetite suppressants and no effect was seen in men taking OTC cold medications (see here.)
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 from this study.
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.
Therefore, I have stopped restricting my patients from taking pseudoephedrine. Personally, I find pseudoephedrine to be quite effective.
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.
Coricidin 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.
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. If you are having difficulty sleeping, it is possible a sedating antihistamine will help but it does nothing for the cold symptoms.
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 I now feel it is 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.
Coricidin Coolness
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