A Magical Pharmacy Tour: Demystifying the OTC Medications—Side B

posted in Allergies, Medication News

Spring 2019 (March through May) in the Chicago area will not be fondly remembered for its weather.  I certainly never remember snow being on the ground on my late April birthday until this year. The cooler temperatures and the record rainfall in Chicago for the month of May (over 8 inches) have helped some with allergy symptoms from tree pollen and have helped some who get allergy symptoms from mold spores.  However, to reference the 1980s, we can’t be like Mr. T and remove all of the trees (besides, we’d rather be like Mike anyway).  Spring still affected many who react to low-moderate levels of tree pollen or to the low levels of grass pollen this month.  And, the first impulse is still to go to the ‘Allergy’ shelf at the local pharmacy to find something without having to deal with insurance coverage of medication.

Last month’s tour of the ‘Allergy’ shelves at the pharmacy focused mainly on those medications that were once only available by prescription and are considered to be the ones more likely to work for symptoms of itchy nose, sneezing, nasal congestion and itchy/red/watery eyes.  There are some other groups of medications that are thought to be effective. These other groups deserve some mention about their effectiveness and safety.

  1. The ‘Mucinex line.’   The active ingredient of Mucinex is called guaifenesin, which is supposed to make the mucus less thick and easier to blow out of the nose or to cough up from the chest.  It is in a lot of over-the-counter medications manufactured by different companies.  Even the company that makes the brand Mucinex makes different versions of it.  ‘Mucinex-D’ means that Mucinex is combined with a decongestant (phenylephrine).  ‘Mucinex-DM’ means that Mucinex is combined with a cough suppressant (dextromethorphan).  ‘Mucinex Fast Max’ means that there is a capsule for the daytime that has guaifenesin, acetaminophen (i.e. Tylenol), phenylephrine and dextromethorphan and a capsule for the nighttime that includes an antihistamine. Guaifenesin is considered by medical professionals to be a relatively weak compound.  A 2014 analysis of publications (called a meta-analysis) about guaifenesin showed mixed results about its effectiveness.  Guaifenesin should not be relied upon to be the main product to use for nasal/sinus symptoms.
  1. The ‘Robitussin family’ of cough suppressants. When I was a child—more than a couple of decades ago-my mother and father always gave me Robitussin for any cough I had.  It helped that it came in a cherry flavor to “make the medicine go down” (a reference from a 1960s film that was remade last year).  Robitussin contains dextromethorphan.  So do these: Theraflu, Coricidin; Delsyn—among others. As with Mucinex, the manufacturers of Robitussin and the other cough suppressants create various forms by adding combinations of a decongestant or guaifenesin or an antihistamine.   Despite over a half century of use, the medical literature does not indicate that dextromethorphan is likely to be very potent.  And, there are reports of psychotic symptoms developing with high doses of dextromethorphan.
  1. Dayquil and Nyquil. These two medications are mentioned occasionally mentioned by patients when they have to come to the office after many days of symptoms. Both have Tylenol and dextromethorphan; Dayquil also has phenylephrine for decongestion. Nyquil doesn’t have phenylephrine because it can cause insomnia.  But, Nyquil has an antihistamine called doxylamine that can be helpful for achieving some dryness and causing drowsiness.

As you can see from these groups, there is a theme behind many over-the-counter medications that are manufactured by various companies.  They have some combination of dextromethorphan (cough suppressant), Tylenol or ibuprofen (for pain relief and fever), guaifenesin, phenylephrine (decongestant) and a sedating antihistamine.  And, the potency of these is low to moderate at best.

A few comments about some other items on the shelves

  1. Herbal Medications: I saw the product names ‘Histaminia,’ ‘Sabadil,’ ‘Alkalol’ and ‘Oilogic Sinus/Allergy.  Zicam is a recognizable name of an herbal medication containing Galphimia that is considered to be homeopathic (i.e. initial extremely low amounts of a substance that can be increased in the dose).  Although many of the modern drugs are derived from plants, the issues with these OTC medications are ‘Safety First’ since they can interact with other medications and ‘Effectiveness Second’ since they are often not well-studied in carefully designed experiments.
  2. Saline Nasal Sprays. Brand name examples include ‘NeilMed’ and ‘Simply Saline.’  They remove an inhaled allergen or pollutant that deposits on the inside of the nasal cavity and they can reduce the amount of mucus that is in the nasal cavity.
  3. Sinus Plumber.’ This product contains the active ingredient capsaicin that is derived from chili peppers.  It might be able to block nerve fibers in the lining of the nasal cavity that lead to nasal congestion through a type of desensitization with repeated use.
  4. Nasalcrom.  This was a very commonly prescribed medication before the mid-1990s because its mechanism was to prevent harmful granules being released from a major immune cell involved in causing allergy symptoms.  It is considered to be a very safe medication.  But, studies in the 1990s showed it was less effective than steroid nasal sprays and this medication is thought of today by allergists primarily as the basis for a board certification exam question about immune cell function.

The bottom line about all of these OTC medications:  If they work, make sure there are no side effects; be encouraged to find out why you need them if you use them for more than several days.  If they don’t work in the first couple of days, get advice from a health care professional.

Dr. Klein