cough medicines

Last edited 03/2023 and last reviewed 05/2023

• all cough medicines (cough linctuses) are available over the counter, except for controlled drugs
• there are two types of over the counter (OTC) cough medicine:
  • cough expectorant
  • cough suppressant - decrease cough reflex to normal levels, most common OTC suppressant is dextromethorphan
  • although there is little evidence that either is effective (1).

• the logic behind use is that:
• a 'dry cough' with little phlegm requires a cough suppressant e.g. codeine and pholcodeine linctus.
• a 'productive cough' requires a cough expectorant to help bring up phlegm e.g. 'ammonia and ipecacuanha mixture BPC' - expectorants are designed to force the cough reflex to propel the phlegm out of the bronchi - there is no evidence that they have any effect.

Note:

• opiate antitussives (codeine or pholcodine) are not recommended since it has no greater efficacy than dextromethorphan and the side effects are much greater
• pholcodine is an antitussive, given to treat dry or painful cough
  • pholcodine is an opioid medicine approved in adults and children older than 6 years of age to treat non-productive (dry) cough and, in combination with other active substances, for the treatment of symptoms of cold and influenza:
    • reviews have examined the link between prior use of pholcodine and an increased risk of anaphylaxis during general anaesthesia involving neuromuscular blocking agents (NMBAs)
    • has been a decision for the withdrawal of pholcodine from UK market as a precautionary measure (1)

      Advice for healthcare professionals (1):

      • pholcodine-containing cough and cold medicines are being withdrawn from the UK market as a precaution following a review which found that their benefits do not outweigh the increased risk of the very rare event of anaphylaxis to neuromuscular blocking agents (NMBAs) used in general anaesthesia
      • ask patients scheduled to undergo general anaesthesia involving NMBAs whether they have used pholcodine-containing medicines, particularly in the past 12 months, and maintain awareness about the potential for perianaesthetic anaphylaxis related to NMBAs
      • do not dispense or sell pholcodine-containing medicines
        • consider recommending appropriate treatment alternatives for patients who present with a new dry cough or who are currently taking pholcodine
      • pharmacies should follow the MHRA Class 2 Medicines Recall Notice to quarantine stock of pholcodine-containing medicines and return it to the manufacturer
      • report suspected adverse drug reactions to the Yellow Card scheme

Reference:

• (1) Dicpinigaitis PV et al. Acute cough: a diagnostic and therapeutic challenge. Cough. 2009;5:11
• (2) Drug Safety Update volume 16, issue 8: March 2023: 1