Cough medicine: advice and a rant.

This is a response to la_directora, who got given codeine for a cough even though she told her doc it made her sick in the past.  I started to reply to her, realized it was way too long for a reply, and am posting here instead.  The post will be divided into two parts – first, advice on alternatives to codeine for cough, and second, a rant or two.

First, practical pharma advice:

1.  For non-narcotic cough relief: benzonatate (brand name Tessalon) works great, is most definitely still on the market, is stronger than codeine for cough suppression, last longer than codeine (who wants to take a med every 4 hours when you could do it every 8 hours instead?), and has a lower rate of adverse effects than codeine. Both in the literature and in my experience, it’s superior to codeine in every way. Downsides of Tessalon – it makes many people sleepy and a few people get really goofy on it.  So not a good drug to take at work. It’s a great bedtime drug. Tessalon will also cause numbness or even paralysis of the mouth and throat if you’re stupid enough to chew it or suck it until it dissolves.  But it is a tiny little slippery gel capsule so why would you do that?

2.  For non-narcotic cough relief that won’t mess with your head, inhaled asthma medicines rock.  Atrovent HFA, an inhaled medication, directly suppresses cough (it’s an anticholinergic, and coughing is a cholinergic reflex – memorize this phrase and repeat to your doctor if you want to convince an ignorant doc to prescribe this).  In my experience, it helps more people than codeine or tessalon, and it doesn’t make you sleepy.  It’s my first choice for daytime cough relief.  Inhaled albuterol can also give relief, but has no direct impact on the cough reflex – it just helps you clear the irritation faster and reduces swelling.  But, albuterol can make your heart race and it wears off quickly.  Serevent is an extended release medication in the same family as albuterol which is less likely to cause rapid heartbeat. Advair mixes serevent and a bit of steroid, and is pretty effective for post-bronchitis cough (which can linger for up to a month).

OK, now for the rants:

First, codeine for cough.  Don’t get me wrong, codeine’s a really useful medicine for severe pain, I prescribe it regularly for that.  But, in head-to-head blinded comparison to dextromethorphan (the cough suppressant in nyquil or robitussen DM), codeine’s weaker than DM!  And they have similar mechanisms of action, so if one didn’t work the other is unlikely to help.  And codeine (and, actually DM) has addiction potential, which isn’t an attractive feature.  About the only thing codeine has going for it is that it’s a little safer for a fetus, so I suppose I might give it to a pregnant women (but would prefer to use one of the inhaled meds above, and just avoid treating the fetus at all).

So why do so many doctors prescribe codeine for cough?  I’ve yet to see a reason.  Patients mostly like it for the “feel no pain” aspect of it, which is nice but gets back to that addiction issue….  So rant number one is about how if my fellow doctors would actually look at the research, we’d see a lot less codeine being prescribed for cough!

Second – it’s a recurring story:  the patient says “doctor, I’m allergic to codeine, it makes me vomit”.  Then the doc looks down his long, snobby nose at the patient and says “that’s not an allergy, it’s a side effect” and then prescribes the med.  Um… it’s true the patient was not using the precisely correct terminology, but she’s still got a perfectly valid reason to avoid the drug!  Perhaps if she’s tried EVERYTHING else (including vicodin) and nothing worked, then it might be worth trying codeine.  But with so many other good options on the market, why on earth would you give the patient a drug that’s known to make her sick? 

OK, I’ll stop ranting now!

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