What Cold Medications Are Safe For My Heart: 2016 Update

The most popular  skeptical cardiologist post is one written a year ago concerning over-the-counter (OTC)  cold medications.
Little has changed in the 8 billion dollar world of useless and confusing OTC  cold, flu, and sinus medications since then.
I still advise avoiding them and utilizing specific medications for specific symptoms.
I’m updating the article with additional comments on two frequently encountered drugs that I did not cover originally.

Alka-Seltzer Plops Into The OTC Cold Market 

I had always viewed Alka-Seltzer as an effervescent tablet which was a treatment for acid reflux, a.k.a. upset stomach, but the brand (now owned by Bayer) has moved aggressively into the bewildering morass of over the counter OTC cold meds. Indeed, when Alka-Seltzer began in 1931 it was a combination of aspirin and sodium bicarbonate (baking soda) marketed for upset stomachs. Popular commercials from the 1960s featured the catchy jingle (still stuck in my head) “Plop, Plop, Fizz, Fizz. Oh What a Relief It Is” often sung by Speedy, an odd anthropomorphic creature with an Alka-Seltzer thorax and cap.

(The jingle was written by Tom Dawes of The Cyrcle (Red Rubber Ball) and not by the father of Juliana Margulies)
Recently, I  received a request from an out-of-town guest who was suffering from a cough and upper respiratory infection (URI) to purchase Alka-Seltzer plus in the form of a tablet that dissolves in hot water .
At his request, Alka-Seltzer Plus Day Multi-Symptom Cold and Flu was purchased at the local Walgreen’s.
The ingredients are typical for many of  the Alka-Seltzer products:
-dextromethorphan (promoted for cough but ineffective with considerable side effects, see my initial post)
-acetaminophen (Tylenol, for pain and fever)
-phenylephrine (decongestant )

Phenylephrine: Ineffective Substitute for Pseudoephedrine

I didn’t cover phenylephrine in my previous post. It has taken the place of pseudoephedrine in  on the shelf over the counter URI (OTSOTCURI) medications.
Like pseudoephedrine, phenylephrine is a sympathomimetic drug, meaning it stimulates receptors of the sympathetic nervous system. Unlike pseudoephedrine, phenylephrine is useless as a decongestant when taken in the dosages available over the counter.
A study published in february, 2015 confirmed what previous studies had suggested: phenylephrine in dosages of 10 to 40 mg daily was no more effective than placebo in reducing symptoms of nasal congestion.
An accompanying editorial called on OTSOTCURI manufactures to remove this useless drug from their products.
Alas,  all of the Alka-Seltzer preparations that claim to treat congestion utilize phenylephrine as the decongestant.
The transition to useless phenylephrine took place when pseudoephedrine was taken off the shelves and put behind the counter to reduce its usage in making methamphetamine.
Therefor, Alka-Seltzer plus multi-symptom cold and flu contains two useless ingredients plus acetaminophen (Tylenol).
You can buy a large bottle of cheap generic acetaminophen and take exactly the right dose you need for relieving fever or body aches without paying for two useless accompanying drugs which have the potential for giving you unwanted side effects.

Nighttime Sleep Aids In OTC Cold Meds

I covered the most common drug found in OTC cold meds that are promoted for nighttime use, diphenhydramine/benadryl, in my previous post.
Nighttime Alka-Seltzer products contain a similar sedating antihistamine called doxylamine succinate. For example , Alka-Seltzer Severe Cold and Cough Liquid Night (ASCCLN) contains:
-Acetaminophen 650 mg
-Dextromethorphan hydrobromide 30 mg
-Doxylamine succinate 12.5 mg
Doxylamine is the active ingredient in the brand name sleep aid Unisom and the “ZZquil” products from the Nyquil brand that are promoted for inducing sleep. It is available in cheap, generic form at a cost of 7.90$ for 96 25 mg tablets.  According to drugbank.ca:

“It is also the most powerful over-the-counter sedative available in the United States, and more sedating than many prescription hypnotics. In a study, it was found to be superior to even the barbiturate, phenobarbital for use as a sedative.”

Note that the effective dosage recommended in separate sleep aids is 25 mg not the 12.5 mg found in Alka-Seltzer OTC cold meds, Thus, if you want an effective dosage of doxyylamine to help you sleep, you must double the recommended dosage of Alka-seltzer  SCCLN  which gives you too much acetaminophen and dextromethorphan.
Doubling these drugs raises the potential for side effects. Common dextromethorphan side effects include nausea/vomiting, dizziness, diarrhea, nervousness. Too much acetaminophen can damage the liver.
In addition, both dextromethorphan and acetaminophen interact with multiple other medications. Dextromethorphan is known to interact with 76 medications.
Acetaminophen can increase the INR (measure of blood thinning) in patients taking warfarin and increase the risk of dangerous bleeding.
As I summarized previously:

“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 pseudoephedrine 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.”

Hypnotically Yours,
-ACP