Tag Archives: OTC cold medications

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

 

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