Cough medication

Have you ever entered into a pharmacy hoping to get your cough treated without seeing a doctor? The pharmacist dispenses you a cough medication but after that only you realise that the ingredients from the cough medication are different from the cough medication you got last time. Why is that so? Basically, there are 2 major types of cough medications which are available over the counter – expectorants and suppressants.

    1. How do I know which cough medications to take?

Expectorants are used to treat productive cough by loosening and liquefying the phlegm to make it easier for the phlegm to be cough out. The active ingredients in expectorants include guaifenesin, ammonium chloride and sodium citrate. Mucolytics, such as bromhexine, carbocystein and acetylcysteine, which can be found in some cough syrups like Unizet®, Duro-Tuss Expectorant®, Mucoprom® and Rhinathiol® works by breaking down the excessive thick and viscous phlegm. The syrups mentioned above may be available in any Malaysia retail pharmacy. How about tablets? Is there any expectorant that is available in tablet form? Fortunately, there are, for example Mucinex®, bromhexine and Parbon-Cough® expectorant. However, they can only be taken in children age 12 years and above, except bromhexine.

On the other hand, cough suppressants, also known as antitussives, work by blocking the body’s cough reflex or desire to cough. Cough suppressants are used to treat dry cough only and should not be used to treat productive cough because it will promote mucus accumulation, creating a favorable environment for bacteria to grow in the airways which will worsen the cough and increase the risk of pneumonia (lung infection). Medicines that act as cough suppressants are normally containing pholcodine and dextromethorphan. Patients can also opt to take a cough suppressant in tablet form. Copastin®, which contains cloperastine hydrochloride, is used to treat unproductive cough in people who prefers tablet more than syrup.

It is a no-no to use a cough suppressant and an expectorant at the same time because both of the medications work oppositely from each other. However, it may be useful to take an expectorant during the day and an antitussive at night to aid in sleeping.

The illustration showed some cough syrups to help with productive cough (with phlegm).

Mucinex® which is available as tablet dosage form for chesty cough.

The illustration showed some medications to help with dry cough.

   2.     Does any of the cough medication containing antihistamines for treating runny nose and blocked nose or known as ‘common cold’?

   

              Cough medications, such as Bena®, Uphadyl forte® (diphenhydramine), Cough-en®, Actifed® Expectorant (tripolidine hydrochloride) and Sedilix-DM® (promethazine hydrochloride), contain antihistamine which can benefit a patient who has cough and runny nose at the same time. However, these antihistamines can make cause drowsiness. Therefore, it may impair the person’s ability to drive or operate machinery. More details on antihistamine can be viewed in our “Keep those sneezing and wheezing away!!!” article.

The illustration showed some cough syrups containing flu medication (antihistamine) and nasal decongestant (eg: pseudoephedrine) to help with flu and runny nose.

    3.     Some cough medications should be used with care in patients with severe hypertension, heart diseases and diabetes.

Most of the cough syrups contain sugar which is not suitable for diabetic patient. There are many cases of diabetic patients admitted to the hospital with high blood sugar level because of self-administering sugary cough syrup. Mucoprom® syrup is sugar-free which is particularly useful for diabetic patients with productive cough. Diabetic patients with dry cough can go for Tussidex® Forte which is non-sedating, sugar-free syrup or Copastin® which is in tablet form.

Cough medications which contain nasal decongestant such as pseudoephedrine or phenylephrine should always be used with care in patients with severe hypertension and heart diseases as these active ingredients can increase the heart rate and blood pressure of a person. Moreover, the oral nasal decongestant can temporarily increase blood glucose level of a diabetic patient. Therefore, you should always consult your physician or pharmacist before taking any medications. Further elaborations can be viewed in our “Keep those sneezing and wheezing away!!!” article.

    4.     Which medication can cause dry cough?

The most common medication which can cause dry cough in approximately 20% of the population taking it is angiotensin converting enzyme (ACE) inhibitors which is one of the classes of high blood pressure medications. Medications under this class include Enalapril, Lisinopril, Ramipril and Perindopril. The dry cough is usually self-resolving. If the cough persists for more than 2 weeks and is bothersome, please seek help from your physician and do not stop taking it without talking to pharmacist or physicians. Usually, switching to another medication class can reduce the cough.  

The illustration showed a class of high blood pressure medications known as ACE inhibitors (ended with –pril) which will cause dry cough.

    5.     What are common side effects of cough medicine?

Generally, adults do not experience serious adverse effects from cough medicine if take it at recommended dose that advised by healthcare professionals or instructed on the label of the product. However, cough medicines can cause some mild side effects such as drowsiness, rashes, stomach upset, nausea, vomiting, nervousness, blurred vision, restlessness and irregular heartbeat. Due to the drowsiness of the medicine, the people should not drive or operate machinery after taking it. Alcohol should be avoided when you are taking the medicine.The side effects of the medicines varied from people to people. To know more detailed on side effect of the cough medicine you are taking, you may read the information on the leaflet that provided with the medicine.

The illustration showed certain cough syrups may cause one of the common side effect, which is drowsiness. Please talk to your pharmacist if you need a non-drowsy medication for cough.

  

    6.     Do cough medicines lead to addiction?

Cough syrup that contains dextromethorphan, codeine or pseudoephedrine will cause addiction if taken in large dose. Addiction to drug will eventually cause the individual to abuse it and experience overdose. However, if the medicine is taken at recommended dose at a short time, it will only provide therapeutic effect and does not pose any health risk.

When people take the cough syrup that is mentioned above at large doses, the medicine will produce a feeling or state of intense excitement and happiness. At 25 to 50 fold of the recommended dose, the medicine may cause individual to have hallucinations, out-of-body experiences, changes in visual perception, loss of control with their own body and irregular heartbeat.

                If the cough syrups are taken in large quantities for long term, it will lead to organ damage especially brain, heart and lung and then death.

                 Since cough syrup is the preparation that combine cough suppressant with other ingredients, the people will also have drug abuse from other ingredients. For example, the people abusing cough syrup that contain codeine and paracetamol, the individual will have paracetamol overdose besides codeine overdose and lead to liver damage.

    7.     Which cough medication(s) is/are safe children?

Cough-en®, Sedilix-DM®, Sedilix-Rx® and Tussidex® Forte can be given for children who are more than 2 years old having dry cough. There are other brands which are safe for children more than 2 years old having cough with phlegm as well, such as Actifed® Expectorant and Parbon-Cough® expectorant. Parents should give the cough syrup by following the dosing instruction on the product label carefully or advice of healthcare professionals. And, parents should use the dosing cup that provided to make sure that the amount of medicine that give to children is exactly the same as the dose labelled.

For children under age 2, cough medicine should not be given. The reason is these medicines were mostly not studied in children. The medicines are always studied in adult population. Therefore, the benefit of cough medicine for children is not clear and the potential risk for them may be greater. 

Instead of cough medicine, parents can give one to two teaspoon(s) of honey for coughs and sore throat of kids before their bedtime and give them plenty of liquids daily to increase hydration and thin mucus. For kids that younger than age 1, honey is not recommended. However,  Prospan® syrup can be given 2.5mL three times daily for 1 week.  If your child’s nose is blocked, saline nasal drops can be used with two to three times per day to ease the removal of mucus from nose.

General tips for the public, for children with age less than 2 years old having common cold symptoms or cough symptoms, please seek help from paediatrician (child-specializing physicians).

Important tips:

1.     If you experience shortness of breath, wheezing, or cough up blood when you cough, please consult your doctor instead of self-medicating by buying over-the-counter cough medicine.

2.     Most people only need to take cough medicine for a few days to ease their cough. Please do not use it for long time.If your cough lasts more than two weeks after taking cough medicine, talk to your doctor.

3.     If you are taking other medicines, you should check with your doctor or pharmacist before buying any cough medicine.

4.     Check the ingredients in cough medicine before buying. Some cough mixtures contain other active ingredients such as paracetamol. If you are already taking paracetamol, you should consult your pharmacist and buy the preparations that do not have the medicines you are taking. This is because take too much single ingredients (overdose) will cause serious effects. For instance, paracetamol overdose can damage your liver. This is particularly important when you are helping your child to look for a cough medicine.

Authors:

1. Jamie Lim Jo Shin

          BPharm (Hons) (IMU)

2. Lau Hie Hie

    BPharm (Hons) (IMU)

Editors:

1.  Lok Ker Yee

    BPharm (Hons) (IMU)

2. Loh Pui Yee

    BPharm (Hons) (IMU)

3. Jordy Wong Der Yuan

    BPharm (Hons) (IMU)

Oral Contraceptive Pills - Part 1

How much do you know about the "Morning after Pill"?

Contraception refers to the methods that are used to prevent pregnancy. Some methods of contraception, such as using condoms, can also be used to prevent some sexually transmitted diseases (STDs). Besides using physical barrier (eg. using condom), using oral contraceptive pill (OCP) is definitely another effective way to achieve successful contraception but OCPs are definitely useless in preventing STDs.

In simple words, oral contraceptive pills are classified into emergency contraceptive pills and also daily contraceptive pills.

Emergency contraceptive pills, also known as "morning after pill", is an oral medication that is taken after sexual activity to prevent pregnancy. To make it easy, the "morning after pill" works by preventing the sperm from meeting the eggs (ova). Hence, ''morning after pill'' is not an abortion pill and it will not end an existing pregnancy.

You can go for emergency contraceptive pills in the following situations, for example:

(a) Had unprotected sex

(b) Missed dose(s) for daily routine contraceptive pills or patches

(c) Condom broke or slipped off after ejaculation

(d) Rape cases

There are basically two different types of emergency contraceptive pills, namely levonorgestrel and ulipristal acetate.

1. Levonorgestrel

Levonorgestrel, which is an example of a progesterone (female hormone), is often used together with oestrogen (another female hormone) as oral contraceptive pills. When levonorgestrel is used alone as "morning after pills'', its concentration used will be higher than the daily oral contraceptives because high concentration of levonorgestrel is needed to prevent fertilization by inhibiting ovulation and thickening the cervical mucus to trap the sperms.

Levonorgestrel-containing products should be taken as soon as possible (preferably within THREE days after unprotected sex) in order to have better effects in preventing pregnancy. The chance of preventing pregnancy ranges from 75% to 85%, depending on how soon the person takes the levonorgestrel-containing products after the unprotected sex. The levonorgestrel-containing "morning after pills" do not require prescription in Malaysia.

Postinor2® contains two immediate-release 0.75mg levonorgestrel tablets. After the first pill is taken, the second tablet should be taken 12 hours later. Surprisingly, some researches actually showed that there is no difference in the effects if two pills are taken together, take two pills 12 hours apart as recommended or wait, as long as, 24 hours to take the second dose. However, in Malaysia setting, one pill followed 12 hours later by another pill is still highly recommended. 

Escapelle® contains one sustained-release 1.5mg levonorgestrel tablet. It does not require a second dose and hence it is more preferred than Postinor2® but its cost will be higher than Postinor2®. In terms of preventing pregnancy after unprotected sex, there is no significant difference between Escapelle® and Postinor2®.

Bear in mind that, 2 courses of Postinor2® or Escapelle® should not be exceeded in a month. Exceeding 2 courses in a month might lead to irregular menstruation (including delayed or early) or spotting issue.

2. Ulipristal acetate

Ulipristal acetate prevents fertilization by inhibiting ovulation (release of egg from ovaries) and changing the womb conditions to affect the implantation of fertilized egg.

Ulipristal acetate-containing products can be taken within FIVE days after unprotected sex. Interestingly, it works in the fifth day just as good as the first day after unprotected sex. It works differently compared to levonorgestrel-containing 'morning after pill' and is shown to be more effective than levonorgestrel-containing products. However, it is recommended not to have more than 1 course of ulipristal acetate-containing product in a month.  Exceeding 1 course in a month might lead to irregular menstruation (including delayed or early) or spotting issue.

The ulipristal acetate-containing "morning after pill" also does not require prescription in Malaysia but it might require prescriptions from the physicians in other countries, such as New Zealand and Australia. However, it is more costly compared to levonorgestrel-containing product.

Frequently asked questions about "Morning after Pills"

1. Is emergency contraception right for me?

2. Can I use both levonorgestrel-containing product and ulipristal acetate-containing product together for better pregnancy prevention?

It is recommended  not to use two different kinds of morning-after pills (like Postinor2 and ella) at the same time, because they may counteract each other and not work at all. And do not take more than one dose of either type of morning-after pill at the same time because it will not give you extra protection from pregnancy, but it can make you feel sick.

3. Is the Morning-After Pill Safe?

Emergency contraception is safe - millions of people have used different kinds of emergency contraception for more than 30 years. So far no serious complications had been reported. 

Taking the morning-after pill more than once won't hurt you. But it is definitely not a good idea to use the morning-after pill as your regular, go-to method of birth control. That's because:

• The morning-after pill doesn't prevent pregnancy as well as other forms of birth control like the IUD, patch, ring and daily contraceptive pills.
• Taking the morning-after pill over and over again is more expensive than being on a regular method of birth control.
• The morning-after pill can cause temporary side effects that are harmless but annoying (like bleeding between periods or nausea).

Although it is totally safe to take the morning-after pill as recommended -- it is just not the best way to prevent unintended pregnancies in long-term.

4. How effective are those "morning after pills"? 

Levonogestrel pills, including the brands Postinor2 and Escapelle, are up to 89% effective when taken within the first 24 hours after unprotected sex. However, they are less effective as time passes, for example, it will only be 75% effective when it is taken on the third day after unprotected sex.

ella is 85% effective if taken within 120 hours (five days) after unprotected sex. It stays just as effective as time passes after sex.

The morning-after pill will not prevent pregnant for any unprotected sex you may have after taking the pills.

5. Does My Weight Affect Which Kind of Emergency Contraception I Can Use?

Yes, it does.

If you'd rather take a pill, ella is the brand of emergency contraceptive that works best -- no matter what you weight. But If you have a body mass index (BMI) that's higher than 35, it will be less effective.

If the IUD or ella are not the options for you, it is perfectly safe to take Postinor2 or Escapelle . But if you have a body mass index (BMI) that is higher than 25, it is less effective. If you have a body mass index (BMI) that is higher than 30, it may not work at all.

6. Am I still at risk of pregnancy if I have sex after taking emergency contraceptive pills?

Yes. Emergency contraceptive pills only protect against pregnancy when you take them after sexual activity. That means you can still get pregnant if you take emergency contraception and then have sex again without using another kind of contraception or your birth control fails. If you still don't want to get pregnant, you will need to take emergency contraceptive pills again.

Although emergency contraceptive pills would probably still protect you if you had sex immediately after taking them, there is no research to show how long they would work.




Thank you so much for reading and I will be continuing the oral contraceptive pills (OCP) with part 2 focusing on daily contraceptive pills!

Are you excited for the next post? It will be related to cough medications! Do you know that one of blood pressure medications is able to induce dry cough? If you would like to know more about it, then just stay tune for next Sunday! :)

Have a pleasant day!

Author:

Jordy Wong Der Yuan

BPharm (Hons) (IMU)

Editors:

Chang Jen Nee

BPharm (Hons) (IMU)

Lok Ker Yee

BPharm (Hons) (IMU)

Dengue fever

How well do you know about dengue fever?

Have you ever experienced it before?

Well, dengue fever is an infection transmitted by female Aedes mosquitoes (you can see the mosquitoes have black and white striped legs!!!) Dengue fever is an endemic in tropical and subtropical areas of the world (for instance Asian and Latin American).

This infection is caused by a single positive-stranded RNA virus of the Flaviviridae family, which consists of four distinct, closely related serotypes (DEN-1, DEN-2, DEN-3, and DEN-4). After being bitten by the infected mosquito, the virus will replicate in the lymph nodes and spread to the blood and other tissues through the lymphatic system, causing inflammatory responses and internal bleeding.

The symptoms of dengue fever usually only appear after exposure for about 4-7 days (average incubation period is 3-14 days). Hence, dengue fever can be asymptomatic in the beginning of the infection. It can only be diagnosed few days after the infection of the virus. The condition can become mild or serious depending on how quickly the infected person get treatment.

How will you identify if you are having dengue?

What should you do?

There are some symptoms which can help you to identify dengue. Let me share with you my personal experience of dengue fever to help you understand more about it. Just about a month ago, I had an unforgettable experience with the dengue fever. Dengue fever can be detected easily because you can identify the symptoms as soon as possible if you know them well. 

Day 1

The first symptom appeared was severe headache that I have never experienced before. Besides that, I can feel muscle and joint pain that radiated to my limbs, which were the upper arms and legs. However, I just assure myself that everything is alright and I tried to rest and massage my head and limbs before sleeping. 

Day 2

Unfortunately the second day, the pain did not improve. Additionally, I was having fever so I took Panadol (paracetamol) so that I could sleep soundly that night.

Day 3

The symptoms were not improving at all instead, it was accompanied with additional symptoms, which were coughing, poor appetite and fatigue. I lay on my bed for almost 12 hours. I recalled not even being able to hold and wash a plate after having lunch. I felt worried as I jogged at a park near my house few days ago and it may be an exposure to the mosquitoes.

At night, my daddy brought me to a clinic. Doctor prescribed a sedative cough syrup and two painkillers (paracetamol and mefenamic acid) for high fever of 39.5^OC and muscle pain. However, it was a nightmare since then. On that night, I could not sleep as I had diarrhoea twice in the middle of night, accompanied with nausea.

Day 4

Early the next morning, I vomited after having my nutritious drink that I used to drink every morning. I tried to rest in bed meanwhile I was compliance to take the medication. I could eat some food despite feeling nausea. It was alright during the day, however I experienced 5 times diarrhoea and I vomited green substance during midnight.

Day 5

I went back to the clinic again the next morning and I found out that I still have a fever of 38.4^OC. My blood was drawn and sent to the laboratory for test immediately. A rapid 20 minutes test kit for dengue was conducted but the result shown was negative. Doctor asked me to go back home to wait for the laboratory result. Meanwhile, additional medication of antibiotic (amoxicillin) and antiemetic (metoclopramide) were prescribed for me. After 2 hours, I was called and informed that the laboratory result was out and my platelet was 82 x 10⁹/L, which was lower than the normal lower limit of 150 x 10⁹/L. The doctor referred me to the hospital because I was suspected to have dengue fever due to PERSISTENT high fever and low platelet count.

I was admitted to the hospital in the evening. A full history of my symptoms were collected and I was given normal saline drip. Doctors came and asked me about my current conditions thrice a day so that warning signs of dengue fever can be monitored closely. My blood was taken four times daily for monitoring purpose. I was having period, hence sign of bleeding was monitored very closely by the doctors.

Day 6

Generally still weak. During the evening, they stopped my normal saline drip when my haematocrit level returned back to the normal range.  My platelet count increased gradually. However, I still have on-off fever and diarrhoea, so paracetamol (Panadol) and oral rehydration salt were given to me. However, my fever was still persistent. Thrombophlebitis was observed on my hand for drip and when the drip was taken off, my fever subsided.

Day 7

I was discharged when the vital signs and laboratory result were improving after monitoring for the first golden 48 hours. Patients are not allowed to discharge if there is any WARNING SIGNS of dengue fever such as severe abdominal pain, persistent vomiting, fluid accumulation in the body, respiratory distress, decrease in platelet count, increase in haematocrit level, and nose or gum bleeding, as well as severe damages of organs (liver, central nervous system, heart, kidneys and others). These severe condition is known as dengue shock syndrome (DSS).

Since I was improving, doctors told me to rest at home and I was told to follow up at clinic after a week. After discharge, I still felt tired so I just sleep long hours and rest well at home. My tiredness slowly improved but my weight shockingly decreased by about 2kgs to less than 40kg that I have never seen for years. However, I was blessed that I have fast recovery when my appetite started to improve with my mummy’s great care and home-cooked food. Our mothers are the great people in the world. So do appreciate and Happy Mother’s Day to all readers!!! J

So, after reading my story, do you have some rough idea about the symptoms, diagnosis and treatment of dengue fever? Take note of the informations being highlighted in red, purple and green respectively.

Other information that you should know:

There are many over-the-counter products which are available in the pharmacy for dengue fever to speed up the healing. An example of the products is the papaya leaf extract, which can help to increase white cell and platelets, as well as normalises the clotting profile of dengue patients. There are different dosage forms of the products, for examples capsules and liquid extracts. You can buy it in the pharmacy store. Make sure to consult the pharmacist to get a safe, trustable and approved brands of products.

Besides that, if you are infected with different serotypes of dengue virus (either “Asian” genotypes DEN-2 and DEN-3) again, you will suffer more compared to the first exposures to the infected mosquitoes as higher viral burdens and stronger inflammatory effect will be produced which can lead to higher tendency to bleed!!!

Since the recurrent infection will be more severe, isn’t there is any prevention of dengue fever, for instance vaccine?

At the moment, there is no vaccine available. There is currently a dengue vaccine (CYD-TDV) under phase 3 efficacy trials which hopefully done in July 2016. The vaccine consists of a recombinant live, attenuated, tetravalent dengue vaccine that was efficacious against virologically confirmed dengue (VCD) and severe VCD which potentially lower the hospitalisation of the patients in endemic area of dengue infection.

While waiting for the approval of the dengue vaccine, you can always buy a mosquito repellent available in pharmacy store if you are going for jogging or jungle trekking at places prone to have Aedes mosquito. You can also wear long sleeves and pants to prevent mosquito bites during the day and evening. Always keep your home area clean and avoid stagnant water in the flower pots to avoid breeding places for the mosquito.

As a summary, 

The most prominent symptoms of dengue fever are sudden onset of high fever for about 5-7 days, severe headache, and vomiting. Other symptoms that are not mentioned are: rashes and retro-orbital pain (pain around the sockets of the eyes). Please seek for medical advice from doctor if you experience the similar condition I had experienced.

Doctors will evaluate these symptoms and if you are being suspected for dengue fever, the doctors will take your blood immediately to confirm dengue fever. 

If your platelet is lower than the normal lower limit reading of 150 x 10⁹/L, you will be suspected to have dengue fever. You will be referred to the hospital to get treatment immediately which includes normal saline and symptomatic treatment (for instance fever, vomiting, and others) if you still experience any of them during hospital stay.

You will be discharged when the platelet count are increasing in trend and there is no warning signs of dengue fever being detected. You can always prevent mosquito bites by using mosquito repellent and protective clothing.

Still having doubt about dengue fever? Kindly comment here to let us know about it.

Author:

Lok Ker Yee

B Pharm (Hons) (IMU)

Editors:

Chang Jen Nee

B Pharm (Hons) (IMU)

Tan Sue Fern

B Pharm (Hons) (IMU)