OTC Cough and Cold

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Cough and Cold treatments really don't have a ton of medications, and this will episode will help you remember them.

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Welcome to the Memorizing Pharmacology podcast. I'm Tony Guerra, pharmacist and author of the Memorizing Pharmacology book series, bringing you mnemonics, cases, and advice for succeeding in Pharmacology. Sign up for the email list at memorizingfarm.com to get your free suffixes cheat sheet or find our mobile-friendly self-paced online pharmacology review course at residency.teachable.com forward slash P forward slash metal games. Let's get started with the show.

Alright, welcome to OTC allergy cough and cold. We'll go over antihistamines, decongestants, nasal inhalers, expectorants, cough suppressants, and analgesics but it's an amazingly small number of medications with all of these different lists. So let's start with antihistamines and we need to talk about the antihistamine snowman first to make sure we know what antihistamine we're talking about.

So we're talking about H1 antihistamines versus H2 antihistamines. So an H1 antihistamine and this snowman has one nose our allergy antihistamine it's like diphenhydramine which is Benadryl or Loratadine which is Claritin. So when we say antihistamine we're thinking H1 but technically an H2 antihistamine and that's why we have two buttons at the stomach our H2 blockers so they're also antihistamines but we don't call them that.

And so famotidine which is Pepcid and now zantac's brand name has taken famotidine which has always been Pepcid cymetidine and Tagamet nicetidine and acid for acid reduction. So just to be clear the antihistamines we're talking about are the ones in the nose in this particular video.

So let's talk about the first versus second generation. The first generation is diphenhydramine or Benadryl and if you've ever gotten Tylenol PM that's the PM part of it so Tylenol PM is actually two different drugs chlorpheniramine or Chlor trimeton is one that we don't use a ton anymore uh it only lasted about four hours but it used to be in packages when you had some kind of really bad allergic issue they make you super sleepy so really not a good thing especially if you've got someone driving or somebody does driving for a living.

So the second generation came along and what you'll notice is that each one of these has a pair so the second generation non-drowsy antihistamines were loratadine and then when that went off patent all of a sudden destler adidine showed up which is Clarinex so Claritin declaren X when cetirizine's packet patent went away levocetirizine comes along which is xyzel the owl if you've seen the commercials and then terphenidine was removed from the market because of cardiac issues but Fexofenadine which is the safe metabolite is Allegra.

So those are our five second generation antihistamines that we use. So let's take a look at Benadryl or diphenhydramine and it's again we're going to use the eye match mnemonic so indication mechanism adverse contraindications and what a healthcare professional should do to make it so that's easier to take.

So allergy and insomnia that's the indication. The mechanism well it's an H1 antihistamine so it's first generation though so it's also going to have anticholinergic effects that's going to be important for adverse effects. So as we've kind of gone into really a lot of depth anticholinergic was our Bud cat so the drowsiness dry mouth confusion and there's a paradoxical effect where in young children a lot of times it'll actually make them hyper instead of tired so confusion is a little bit of an addition to the mnemonic I've used before.

So uh angle closure glaucoma that's one of the contraindications and then on the beers list so we want to avoid it in the elderly because of that drowsiness and confusion and we don't want to have Falls and things like that. So A couple mnemonics some people call it better drill because you're so tired and then no dryfin hydramine so no driving hydramine reminds you not to drive on this one.

Claritin and alivert levocetirizine which is xyzel Fexofenadine which is Allegra these tend to be the popular ones now. The ones that have kind of Taken hold. So in terms of indication it's all the same thing it's all an allergy they're all H1 blockers they're all second generation not sedating and they really in terms of adverse effects and contraindications we really don't have a ton there but you really do want to tell them to prophylax before allergy season not wait until allergy season and say okay we'll take your antihistamines if you know allergy.

Season is coming, go ahead and get on that regimen right away. So Loratadine has the adidine ending, be careful that's a little bit close to t-i-d-i-n-e which is the H2 blocker so it's famotidine and so forth. Uh levocetirizine or even cetirizine if you take that TIR make it a tear to remind you that it's allergy eyes, it's the saddest owl I could ever find. And then Allegra if you put the r here it makes a-l-l-e-r-g change the a to a y and you have allergy. So I got paid a million dollars to figure that out, I want to be that guy.

Alright let's go to the next one Alpha One Agonist and vasoconstriction like what's going on? I thought we were just doing OTC stuff. Well an alpha one Agonist you'll probably know pseudoephedrine which is Sudafed, oxymetazolin or oxymetazoline sometimes I hear is Afrin and then phenylephrine which is neo-sinephrine. The big difference is pseudoephedrine is something you take every day or you can take daily, it's a tablet whereas oxymetazolin and phenylephrine are both inhaled or nasal inhalers and that's going to make a really big difference when it comes to some side effects in terms of those.

And I always use the pop mnemonic so just like your ears pop on the plane nasal congestion just think of a big pop once that nasal congestion goes away. So pseudoephedrine starts with a P, oxymetazoline with an O, phenylephrine with a p going on the pseudoephedrine um.

So let's start with what it's for sinus congestion and it can be used as an adjunct in allergic rhinitis. It does have that alpha-1 vasoconstriction but the problem is it's systemic versus that nasal which is a little bit more local so we're going to get that anxiety and insomnia just kind of a restlessness that comes along with it.

So the contraindications and I've got this little hand holding a heart so it's angina coronary artery disease closed angle glaucoma hypertension all these things are really things you don't want to have if you're going to be taking pseudoephedrine. And the way that I think about all the adverse effects I just think of energy drinks if you have one too many energy drinks anxiety insomnia restlessness that's pseudoephedrine.

And then the next ones we'll see in a second so watch out for any other stimulants that might interact with Sudafed. Okay oops next one here is oxymetazoline which is Afrin and phenylephrine neosinephrine we're going to see it's the exact same thing as sudafed or Pseudoephedrine with the i the M the a except we have something called rebound congestion.

So around three to five days you might get rhinitis medicamentosa rhinitis medicamentosa is where and I've got this picture here of somebody who has congestion, the word breathe because now they can breathe they've taken their medication the phenylephrine and oxymetazolin and now they've got it again. So the rebound congestion that's something that is really inherent to these and nasal inhalers contrasting the Sudafed or the pseudoephedrine tablets.

Fluticasone mometasone we see that sewn ending so common with many of the steroids these are nasal versions of it so with those oral versions we're always washing our mouth out to make sure that we don't get candidiasis we don't get dysphonia which is that hoarseness or difficulty speaking.

So looking at the names, the brand names kind of give it away Flonase and Nasonex but they're both for allergic rhinitis they're both anti-inflammatory steroids. The adverse effect tends to be a dry nose and nosebleeds infections like TB and varicella are something that we really want to avoid reducing the immune response.

And then you really want to use this daily as soon as that allergy season starts so it takes about three to four days to see that optimal effect and we do want to watch growth rate because it is a steroid after all. So they've got a guy here looking at his clock like I don't understand when I took the oxymetazolin, the Afrin my nose was cleared in a couple minutes well it's going to take a couple days with these guys.

Alright dextromethorphan so this is the D and M so the dextro makes the D, the methorphan makes the m in Robitussin DM or Mucinex DM, they both have the same ingredients, the dextromethorphan part. Okay, we'll get to the guaifenesin in a minute, that's the cough suppressant for a non-productive cough. Okay, it works in the medullary cough Center and it can get that CNS toxicity, dizziness or something called robocopping that if you use it illicitly. Hepatitis is a contraindication and really what you want to try to do is stop that cough from happening in the first place, a cool humidifier can sometimes do that. You might call it instead of dextromethorphan, you might call it dry cough methorphan because that's really what you want is if that's a dry cough it's not really producing anything uh dextromethorphan is your man.

Okay guaifenesin so this is Robitussin or Mucinex with or without the DM so without the DM it is just guaifenesin with the DM it's guaifenescent and dextromethorphan. So I want to make clear this is an expectorant we'll talk about a mucolytic in a minute so this is an expectorant for mucose secretion that loosens and thins the phlegm makes it easier to expectorate. Adverse effects are just less common same with contraindications and really it's just if you have that cough for a week maybe you should see a physician or a provider and I've just got a picture of kind of some slime here and exit for expectorant uh and I've heard it sometimes called Green flemisin instead of guaifenesin just kind of an easier way to remember what this thing does.

Okay acetylcysteine now this is a mucolytic now this is not over the counter but what I wanted to do was contrast it because sometimes you'll see that they say guaifenesin is a mucolytic, it's an expectorant. So acetylcysteine though the actual utility in cystic fibrosis is somewhat unclear cystic fibrosis acetaminophen overdose those are two uses we would have for acetylcysteine or muco Mist. It is mucolytic and it loosens those bronchial secretions if you inhale it and then it replenishes the glutathione in the liver from the acetaminophen metabolites so if you're doing those kinds of chemistry in your particular pharmacology class that's really how it protects it against an acetaminophen overdose.

Nausea and vomiting are adverse effect as well as you know you just want to be careful with asthma maybe a GI bleed or something like that and then there's a poor taste when it's inhaled. So the way to remember acetylcysteine is for Cystic Fibrosis is we have this cyst in cystic fibrosis and then when you look at acetyl you take the acetyl group and you think about n acetyl paraaminophenol what is an acetyl peraminophenol well that is acet amino fin okay so that's the whole chemical name or APAP if you've had it abbreviated before okay uh so this is just a bigger picture of it if you want to see kind of how the cystic fibrosis compares to a healthy lung.

Alright ibuprofen so Advil and Motrin and then the naproxen is the Aleve pain fever and inflammation this is important because we're going to contrast it with acetaminophen in a minute mechanism. It's a non-steroidal anti-inflammatory drug and NSAID so non-steroidal is just a way of saying it's not prednisone but it's an anti-inflammatory, it's cycloxygenase inhibitor and we're not going to get into the weeds with that right now. If you want to talk about Celebrex and celecoxib, you can kind of get into the weeds when you start putting in prescription drugs but GI distress, ulceration certainly adverse effects especially if you used a long term. If you have any kind of an allergy to aspirin or stomach ulcer, heart failure, liver disease this really tends to hold on to fluid and those are conditions where you really don't want to hold on to fluid.

And then always mentioning take it with food, it does tend to upset the stomach. So one contrast is well when do I take Ibuprofen when do I take them peroxin well ibuprofen you have to generally take like four times a day where an approxen maybe two times a day or three times a day so that tends to be it. And then I had a pretty decent graphic about peptic ulcers and then here is a larger version if you wanted to look at that uh just kind of explaining what's going on we didn't talk about helicobacter pylori which is really the causative factor in many ulcers but that's getting into prescriptions and triple and quad therapy which we will not.

Alright last one here is going to be acetaminophen or Tylenol. You'll notice that in the indications it has pain and fever just like ibuprofen but the inflammation is missing so that's the one question you get over and over again. It's a non-narcotic analgesic and it's just really liver damage, liver conditions that's really one place we really want to be careful.

And then watch for overdose with RX meds and what I mean by that is maybe somebody's on something called Vicodin and there is acetaminophen in it and then they're taking Tylenol over the counter or they're maybe taking some combination cold product that has acetaminophen in it. Really you don't want to go over 3 000 milligrams in a day, you know the upper end is 4 000 but you really want to be careful there.

So n acetyl peroaminophenol that's how we made acetaminophen or APAP and then here are the stages of liver damage and I just wanted to have it up here so that if that's something you wanted to kind of go through you could. And then a larger version of the same graphic okay all right again this is for informational purposes only it is not medical advice if you have a medical condition consult a medical professional.

Thanks for listening to the memorizing pharmacology podcast. You can find episodes cheat sheets and more at memorizingfarm.com. Again, you can sign up for the email list at memorizingfarm.com to get your free suffixes cheat sheet or find our mobile-friendly self-paced online pharmacology review course at residency.teachable.com forward slash P forward slash mobile. And thanks again for listening.

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Find my book here: https://geni.us/iA22iZ

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