What Cold Medications Are Safe For My Heart: 2020 Update

Little has changed in the 8 billion dollar world of useless and confusing over the counter (OTC)  cold, flu, and sinus medications since I wrote: “What Cold Medications Are Safe For My Heart” in 2015.

I still advise avoiding combination OTC cold meds and utilizing specific medications for specific symptoms.

The original post covers most of the usual suspects in this mostly useless arena. I updated it in 2016 with comments on a few additional OTC components: Alka-Seltzer, phenylephrine, and doxylamine which I have included below.

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  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.

Therefore, 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 that 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 doxylamine 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.


My advice for 2020 is unchanged from 2015. 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

N.B. Consumer Reports seems to agree with me in a 2017 post on this topic (which doesn’t credit me.)

N.B/ 2 My original post includes a Duane Allman reference.

N.B. 3 Alka-Seltzer Plops Into The OTC Cold Market is one of my favorite sub-headings.

10 thoughts on “What Cold Medications Are Safe For My Heart: 2020 Update”

  1. I found your 2015 post the day after my recent cold medication saga began.

    Sadly I caught a cold the very day I was discharged following a 3 day TIkosyn hospitalization and catheter ablation (2nd ablation in 10 months). The nurse advised NO sudafed or decongestants and YES to guafenesin if needed for cough. I developed headcold stuffiness and difficulty breathing through my nose. No cough.

    The next day (NYE) I went to my pharmacy and saw Corecidin HBP Cough & Cold on the shelf (two ingredients, no acetaminophen); asked the pharmacist to check for interactions with my meds – Tikosyn, Eliquis, Lisinopril: none.

    Took one pill at 10 pm. My RHR was around 55bpm before bed.
    Woke up NYD and my HR had ranged from 90-110bpm all night (per Apple 4 watch). It stayed in that range all day. I did some research on the cold med and found on the manufacturer’s website that there were risks for patients with CARDIOVASCULAR DISEASE: tachycardia, arrythmia for starters. This info is not on the box anywhere and it is “marketed” for patients with High Blood Pressure.

    Called cardiologist office on Jan 2. Metopropolol prescribed to keep HR below 100 until my follow up in 4 days.

    Follow up confirmed atrial flutter had returned. ARNP advised that she would have prescribed Flonase for the stuffiness; she was not the RN in the hospital on discharge day. Cardioversion scheduled for Jan 16 (3rd in 13 months).

    Lessons learned: 1) I should have called cardiologist office sooner, even if it was New Year’s Day. 2) given my heart’s arrythmia tendencies, don’t take anything. ever.

    Question I’ll never get a straight answer to: did the single dose of Coricidin cause the arrythmia to return?

  2. Thank you for the timely update as I chased my runny nose through the weekend and opted for your previous advice. Your insight into this practical issue is much appreciated. Now excuse me while I find another tissue…

    1. I was prompted to reissue this advice as my former eternal fiancee’ and now wife (along with many of my patients)has had a prolonged bout of what we are terming “a cold”.
      and one of my patients was prescribed Tessalon recently for her cough. She stopped taking it because it made her feel “loopy”
      I’m not sure if I covered it in my first post butThe medical letter wrote this in 2011 about benzonatate/Tessalon
      The FDA recently warned that accidental ingestion of the antitussive benzonatate (Tessalon Perles, and others) by children less than 10 years old can be fatal.1 This widely prescribed oral agent, which has been available in the US since 1958, can also cause severe morbidity and death in older children and adults, and not only in overdosage.

      Benzonatate is a polyglycol derivative structurally related to procaine and tetracaine. It acts peripherally on stretch receptors in the lower respiratory tract to suppress the cough reflex. If the patient chews or sucks the liquid-filled capsules or “softgels”, the drug can cause laryngospasm, bronchospasm and circulatory collapse. Adverse effects that can occur after swallowing an intact capsule include a feeling of numbness in the chest, mental confusion, a sensation of burning in the eyes, and visual hallucinations.

      Taken in overdose, benzonatate can rapidly cause seizures, cardiac arrhythmias and death. Serious adverse outcomes reported to the National Poison Center between 2000 and 2006 occurred in 116 patients (41 in children <6 years old), with 4 deaths.2 The 5 children known to the FDA who died from benzonatate ingestion were ≤2 years old and some apparently took only one or two capsules. In one well-documented case report, a 17-year-old girl who intentionally took 10 or more 200-mg capsules developed seizures, cardiac arrest from which she was resuscitated, and then blindness, which persisted.3 When a cough suppressant is truly necessary, dextromethorphan or even codeine might be a safer choice.

      1. FDA. FDA Drug Safety Communication: Death resulting from overdose after accidental ingestion of Tessalon (benzonatate) by children under 10 years of age. Available at http://www.fda.gov/Drugs/DrugSafety/ucm236651.htm. Accessed January 27, 2011.

      2. ML Winter et al. Benzonatate ingestion reported to the National Poison Center Database System (NPDS). J Med Toxicol 2010; 6:398.

      3. V Cohen et al. Cardiac arrest with residual blindness after overdose of Tessalon (benzonatate) Perles. J Emerg Med 2009 Nov 4 (epub).

      1. When a cough suppressant is truly necessary, dextromethorphan …wait didn’t you just say above that this is ineffective? I wouldn’t want to pay for a substitute that was worthless just because it was worthless and safe.

  3. I find that the Irish remedy of a good hot toddy is as effective as anything. alcohol is a good cough suppressant and the added benefit of a good night sleep aids in allowing the immune system to recover. Not for everyone, I understand.

    1. Joe, you are, indeed, the hot toddy man!
      But I firmly believe that any alcohol consumption (on the basis of absolutely zero scientific information) suppresses the immune system, potentially fostering longer and more severe viral infections.
      On the other hand,your theory that the improved sleep quality afforded by the intoxicating liquor overcomes this might be relevant.
      you and I should run a randomized, controlled trial (if not randomized, then perhaps exuberant, if not controlled, perhaps chaotic) with half of cold sufferers consuming two hot toddies per night, the others remaining abstemious.

  4. I discovered that when I have severe upper respiratory congestion sitting in a recliner and not moving at all relieves the congestion. As soon as I move my head the congestion returns. This works for me without any meds. I do drink a lot of liquids when I have a cold. This is, of course, rather inconvenient but, if I’m sufficiently miserable, I can’t do much of anything anyway, so sitting perfectly still for an hour or two at a time is a realistic option.

  5. I haven’t had a cold in years and never get a flu shot. At 74 years of age, I think not getting a yearly flu shot is rather stupid to say the least. As for alcohol, this poison doesn’t work for me. I find any form of alcohol to be the most nauseous substance one can ingest. As for pain medications, they cure nothing and can potentially make ailments and pain much worse in the long run. As example, doing a long run results in dehydration and even if you hydrate on the run you are still dehydrated. This can make all pain medications dangerous especially the ones which damage the liver or kidneys. In conclusion, my recommendation is stay away from cold medications and alcohol. Go with healthy foods such as fresh blueberries, blackberries, raspberries, almonds just to mention a few.

    The sum up the doctor’s advice: Don’t just pop the pills thinking they will do anything good for you.

  6. Dear TSC,

    Thank you for broaching this important topic. I often wonder, as I make my recommendations to my emergency patients, about the problems Sudafed presents to those of us with high blood pressure and/or irregular heartbeats. Having said that, I would like to share with your audience my “kitchen sink” approach to colds (URI = bronchitis = flu after 48 hours = common cold) I see in the emergency department. I tell the patients to combine any or all of the following unless previously prohibited:

    1. No antibiotics-they can hurt you more in this setting than they help.
    2. More water than I usually drink,
    3. Do everything you can to get more sleep.
    4. Breathe Rite nasal strips, or cheaper generics.
    5. Nasal rinse in the hot shower 2 times a day with saline solution and a neti pot.
    6. Behind the counter Sudafed 60 mg 4 times per day as tolerated.
    7. Dark chocolate greater than 60% cocoa as tolerated.
    8. OTC fluticasone nasal steroid
    9. Robitussin-DM (not withstanding the previous warning by the TSC)
    10. Aleve/Naprosyn 220 mg each 4-6 hours as needed for aches pains and cough
    11. A narcotic, if you can get it, at night only to suppress coughing and get sleep. There are positives and negatives associated with this practice.

    The cough can last up to 6 WEEKS! New fever, increasing shortness of breath, worsening chest pain are all signs that you should be evaluated or reevaluated. Please do not tell your emergency doctor that “I know my body and that it is only after I get antibiotics that I will get better” or similar.

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