codo q final manual 1

8/6/2019 Codo Q Final Manual 1

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Codo-QMEDICAL MANUAL

COUGH



Index

• Cough: Basics

• Clinical conditions of cough

• Symptomatic management of cough

• Codo-Q – The product

• Codo-Q – Indications, Dosage and Tolerability

• Highlights of Codo-Q

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Cough: basicsWhat is cough?

A sudden, noisy expulsion of air from the lung is called cough.

A cough is a sudden and often repetitively occurring defense reflex which helps to clear thelarge breathing passages from excess mucus secretions, irritants, foreign particlesand Microbes.

Coughing can happen voluntarily as well as involuntarily, though for the most part,involuntarily coughing is an action the body takes to get rid of substances that are irritatingthe breathing passages. Physiologically cough is a protective, primitive reflex in healthyindividuals.

Cough is an important reserve mechanism especially in a patient with lung disease. In manylung diseases, mucociliary clearance is impaired (reduced) and therefore cough isnecessary to remove the increased amount of secretions of waste materials.

Cough may be associated with sore throat, hoarseness, nose block, breathlessness,heartburn or chest pain, dizziness, disturbance in sleep, distress on exercise or running,restlessness, general body aches, urinary incontinence, lack of concentration, stomachache,nausea, vomiting and swollen glands.

Cough can be an important factor in the spread of infection.

Cough is common

Cough is common and at times distressing, may be temporary or permanent symptom.

About 20% of the children suffer from cough and nearly 5% of childhood visits to physicianare related to cough. In India, because of industrialization the prevalence of cough isincreasing day by day.

Also the people who smoke have the 7.6% prevalence of nocturnal and 8% of morningscough. Also the people who never smoke have the 2.4% prevalence of nocturnal and 2.3%of mornings cough.

The persons who exposed to soil, fuel combustion has the 2.5% prevalence of nocturnaland 2.7% of mornings cough.

Cough as a symptoms and is the second most common reason for seeking medical advice(National Lung Health Education Program).

Types of cough (Based upon duration)

A. Acute cough:

An acute cough is that which is lasting less than 3 weeks and is usually associated with virallaryngo-tracheo-bronchitis but may signify other bronchopulmonary infections.

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http://en.wikipedia.org/wiki/Reflex

http://en.wikipedia.org/wiki/Reflex



Acute cough can be temporary and of minor consequence; it can be potentially lifethreatening in pneumonia, CHF and pulmonary embolism.

B. Chronic cough:

Chronic cough is that which is lasting for weeks or more.

A specific diagnosis of the cause of chronic intractable (uncontrollable) cough can be madeby history alone in the majority (80%) of patients.

When all studies on adults are analyzed the most common cause is post nasal drip (PND),mucus dripping from the nose and/or sinuses into the back of the throat, and then down intothe larynx, trachea and lungs. PND from rhinitis &/or sinusitis is the most common cause of chronic cough in adults.

Various studies show that, from 38% to 87% of cases of chronic cough are from PND.

(Irwin et. al. Chest 1998; 114:133S-181S)

According to Irwin et al, the most common cause of chronic cough in children is asthma,followed by PND and then gastro esophageal Reflux disease (GERD).

Also GERD is the known cause of irritating cough due to reflux of acidic contents into thepharynx.

Indeed, chronic nonproductive cough, especially at night, may be the sole presentingcomplaint of patients who subsequently prove to have bronchial asthma.

A chronic cough is the diagnostic identification of chronic bronchitis but also occurs inasthma, tuberculosis, bronchiectasis, and bronchogenic carcinoma.

Cough reflex

Coughing may be produced voluntarily, but more often it results from reflex stimulation of the cough center.

The cough center which controls coughing, located in the medulla oblangata of the brain.Antitussives and other cough medicines focus their action on the cough center.

The Cough receptors are the free nerve endings located near the surface of the upper andlower airways. Various agents, including noxious gases and fumes, foreign bodies, virusesand bacteria, acid, and other irritants, stimulate cough receptors to send signals to the

cough center in brain. The brain then sends signals back to the lungs and respiratorymuscles. In response, there is first a deep inhalation and then a forced exhalation.

Cough occurs due to stimulation of cough receptors in

• Nose

• Lower part of oropharynx

• Larynx

• Trachea

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• Lower respiratory tract (Bronchi)

• Ear

The nerves in the upper airways predominantly initiate cough because the greatestprotection against the entry of foreign material in to the LRT is required at this level.

The larynx, being the guard of the lung, possesses abundant sensory innervation, which a

mere biscuit crumb can activate to produce violent coughing.

The bronchi and the trachea are so sensitive to light touch that excessive amount of anyforeign matter or any other cause of irritation initiate the cough reflex.

The terminal bronchioles and even the alveoli are very sensitive to the corrosive chemicalstimuli sulfur dioxide gas and chlorine.

Depending on which cough receptors are stimulated, afferent impulses pass mainly throughthe Vagus nerve or its braches to the cough center located near respiratory center in themedulla oblongata.

The motor output are sent from the cough center to the respiratory muscles, larynx andbronchiole tree.

Phases of cough

The cough reflex consists of three phases:

i) Inhalation

ii) A forced exhalation against a closed glottis, and

iii) A violent release of air from the lungs following opening of the glottis, usuallyaccompanied by a distinctive sound.

Diaphragm (innervated by phrenic nerve) and external intercostal muscles (innervated bysegmental intercostal nerves) contract, increasing the volume of the lungs and making thepressure of air within the lungs lower than atmospheric pressure.

Air rushes into the lungs in order to equalize the pressure.

1. About 2.5 litres of air is inspired

2. The glottis closes (muscles innervated by recurrent laryngeal nerve) and vocal cordshut tightly to entrap the air within the lungs. This reduces the volume of the lungs,therefore increasing pressure.

3. The abdominal muscle contract forcefully pushing against the diaphragm while other respiratory muscles, such as internal internal intercostal muscles, also contract

forcefully. Consequently, the pressure in the lungs raises to as high as 100 mm Hgor more. The pressure of air within the lungs is now greater than atmosphericpressure and so air is trying to escape.

4. The vocal cord and the epiglottis suddenly open widely so that air under pressure inthe lungs explodes outward. Indeed, this air is sometimes expelled at velocities ashigh as 75 to 100 miles an hour.

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Cough reflex (Flow chart)

Irritation of larynx, trachea, and bronchi

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Impulse

Cough centre in brain

Deep inspiration

Closer of glottis

Contraction of abdominal and

respiratory muscles

Sudden release of air under pressure

Expulsion of mucus & or foreign material

Cough receptors

Stimulation



Clinical conditions of cough

Nonproductive cough (Dry cough)

Also called as cough without expectoration or cough without sputum.

A dry cough may develop toward the end of a cold or after exposure to an irritant, such asdust or smoke.

This type of cough is an irritative phenomenon which encountered frequently.

The irritative stimulus may be

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Cough

Non-Productive or Dry cough

(Without sputum)

Common causes:

• Smoking

• Allergic

• Post-operative

• Common cold conditions like

sinusitis (due to post nasal drip)

• Psychogenic

• Hacking

• Others

Productive or wet cough

(With sputum)

Common causes:

• URTIs: pharyngitis, laryngitis

and tonsillitis

• LRTIs: Pneumonia,

Bronchitis

• Tuberculosis

• Other lung infections



• Mechanical

• Chemical

• Thermal

• Inflammatory, including reactions from infection

Smoker’s cough

Smoking or use of other forms of tobacco can lead to irritation of the throat, larynx, lower respiratory tract or even esophagus.

Smoker's cough develops as a consequence of phlegm (sticky fluid secreted by the mucusmembrane) buildup in the trachea.

Cigarette smoke destroys or paralyzes the cilia, so the only way that phlegm can beremoved is via coughing.

Smokers may present with dry cough or sometimes productive cough.

Post operative cough

Postoperative respiratory complications have become increasingly numerous and it is foundthat the problem is not a simple one.

Scott and Cutler' were the first to postulate the theory that cough is initiated by a reflexbronchospasm after the operation.

After an anesthesia and an operation there is a risk of developing chest infection.

Anaesthesia and surgery interfere with the normal ways in which the lungs keep themselvesclear of secretions and infection (Chest infection; section 6, royal college of anaesthetics, 2006 ).

Following thoracic surgery, patients often suffer from persistent coughing (Sawabata et al.,

2005 ).

Persistent dry cough post-operatively can lead to patient discomfort, abdominal strain or disturbed sleep.

Psychogenic cough

It is self-conscious activity of the patient to draw attention.

Patients with a chronic dry cough (longer than 4 months) that seems to defy all explanationand resist all the usual standard treatment. This is known as psychogenic cough.

It is also called as “tic disorder,” “vocal tic,” or “honking cough.”

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Hacking cough

A short, weak repeating coughs; often caused by irritation of the larynx by a postnasal drip.

It can be result from side effects of angiotensin-converting enzyme inhibitor therapy andsmoking.

Habit cough

A habit cough is a cough that occasionally develops in children after a cold or other airwayirritant.

Habit cough is characterized by a small, harsh tinny type sound, and becomes persistent for weeks to months. The cough's hallmarks are severe frequency, often a cough every 2–3seconds, and the lack of other symptoms such as fever. The diagnosis is made when thechild falls asleep and the cough stops completely. Any other pathologic cough will not totally

stop at night. The child can have trouble falling asleep but once asleep will not cough.

Allergic rhinitis

Allergic rhinitis is an allergic reaction that occurs when your immune system overreacts tosubstances that you have inhaled (often pollen).

The two types of allergic rhinitis are

• Seasonal allergic rhinitis (hay fever) which occurs year-round. Hay fever is causedby outdoor allergens, and

• Perennial allergic rhinitis by indoor allergens (such as dust mites, pet dander, mold).

Symptoms of allergic rhinitis resemble a cold, but they are not caused by a virus. Symptomscan be mild or severe. Many people who have allergic rhinitis also have asthma.

Signs and Symptoms:

Allergic rhinitis can cause many symptoms, including the following:

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Causes:

Seasonal allergic rhinitis is caused by an allergic reaction to pollens and spores (dependingon the season and area) as they are carried on the wind. Sources include:

• Grass pollen (late spring and summer)

• Tree pollen (spring)

• Fungus (mold growing on dead leaves, common in summer)

Year-round allergic rhinitis is caused by an allergic reaction to airborne particles from thefollowing:

• Pet dander

• Dust and household mites

• Cockroaches

• Molds growing on wall paper, house plants, carpeting, and upholstery

Risk Factors:

• Family history of allergies

• Having other allergies, such as food allergies or eczema

• Exposure to cigarette smoke

Asthma

Asthma is also caused by allergens like dust, pollen grains etc.

A chronic dry cough may be a sign of mild asthma. Other symptoms may include wheezing,

shortness of breath, or a feeling of tightness in the chest.

Common cold conditions

Acute viral rhinopharyngitis is commonly called the cold. It is contagious, viral infectiousdisease of the upper respiratory system, primarily caused by rhinoviruses (picornaviruses) or coronaviruses. It is the most common infectious disease in humans; there is no known cure,but it is rarely fatal.

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Stuffy, runny nose

Sneezing

Post-nasal drip

Red, itchy, and watery eyes

Swollen eyelids

Itchy mouth, throat, ears, and face

Sore throat

Dry cough

Headaches, facial pain or pressure

Partial loss of hearing, smell, and taste

Fatigue



Common colds are seasonal, with more occurring during winter.

Symptoms

Common symptoms are-

Symptoms may be more severe in infants and young children.

The symptoms of a cold usually resolve after one week, but can last up to three weeks.

Complications

The common cold can lead to opportunistic infections or superinfections such as acutebronchitis,

• Bronchiolitis, croup,

• Pneumonia,

• Sinusitis, otitis media,

• Strep throat.

Colds may cause acute exacerbations of asthma, emphysema or chronic bronchitis.

Cause and susceptibility

The common cold is most often caused by infection with one of the 99 known serotypes of rhinovirus, a type of picornavirus. Around 30-50% of colds are caused by rhinoviruses.Other viruses causing colds are coronavirus (causing 10-15%), human parainfluenzaviruses, human respiratory syncytial virus, adenoviruses, enteroviruses, or metapneumovirus. 5-15% is caused by influenza viruses. In total over 200 serologicallydifferent viral types cause colds.

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• Cough

• Sore throat

•

Runny nose

• Blocked nose

• Sneezing

• Pink eyes

• Muscle weakness

•

Uncontrollable shivering

• Fatigue

• Loss of appetite



Sinusitis

Inflammation of the sinuses (air cavities in the head).Acute: last for < 3 weeks Chronic: last for >=3 weeks

Virtually every adult gets 1-3 "colds" a year (children get more).

Chronic sinusitis affects an estimated 37 million people a year, and is the most commonchronic condition for which people seek medical attention.

People suffering from sinusitis miss on average 4 days of work per year due to their condition.

Approximately 0.5 to 2% of colds and influenza-like illnesses are complicated by acutebacterial sinusitis in adults

(Berg O, Carenfelt C, Rystedt G, et. al.)

Asymptomatic sinusitis is occurs in common cold and other acute ENT infections. (Rhinology 1986;24: 223-225.)

Symptoms

Same as rhinitis, plus: facial pain, fever, more severe or intractable cough. Most patientswith sinusitis will have nasal inflammation as well (i.e., rhinosinusitis). Note: the only symptom of many patients with chronic sinusitis may be chronic cough.

Causes

Viral infection, bacterial infection, fungal infection, allergy, blockage by polyps. Sinusitisbecomes 'chronic' when there is inadequate treatment and/or inadequate drainage of sinuses.

Risk factors

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Air pollution and smoke

Allergies

Asthma

Dental work

Deviated nasal septum, nasal bone spur

Foreign body in nose

Frequent swimming or divingGastroesophageal reflux disease (

GERD)

Overuse of nasal decongestants

Pregnancy

http://www.umm.edu/ency/article/000265.htm

http://www.umm.edu/ency/article/000265.htm



Symptoms of tonsillitis include a severe sore throat (which may be experienced as referredpain to the ears), painful/difficult swallowing, coughing, headache, myalgia (muscle aches),fever and chills.

Chronic lung disease

A productive cough could be a sign that a disease such as chronic obstructive pulmonarydisease (COPD) is getting worse.

Nasal discharge draining down the back of the throat (postnasal dripsyndrome)

This can cause a productive cough or the feeling of need to clear the throat.

Whooping cough

Whooping cough is also known as Pertussis. It is a highly contagious disease caused by the

bacterium Bordetella pertussis.

It derived its name from the "whoop" sound made from the inspiration of air after a cough.Although many medical sources describe the whoop as "high-pitched", this is generally thecase with infected babies and children only, not adults.

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Symptomatic management of cough

Evaluation of patient with cough

The essential first step in evaluating a patient complaining of cough is to obtain a thoroughhistory with particular attention to the following aspects:

• Acute and chronic

• Productive or non productive

• Character

• Time relationship

• Type and quality of sputum

• Associated features

Investigations

If the cough persists for more than a week

• X-ray of chest - to rule out pneumonia or tuberculosis or pleurisy

• Microscopic examination of sputum - can reveal bacteria and white blood cells.

• Endoscopy - to rule out oesophageal reflux, hiatus hernia, abdomen disorders, etc.

Prevention of cough

Avoid

• Smoking & dust exposure

• Working in areas of noxious fumes or polluted air

• Cold food items

• Contact with infected persons or wear a protective mask

• Continuous usage of nasal decongestant sprays and cough syrups

Take

• Rest in room with good ventilation

• Plenty of fluids - water, juices to dilute mucous for easy expulsion

• Frequent light and small meal to reduce vomiting in oesophageal reflux

• Steam inhalation to loosen the phlegm

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• Vitamin C and zinc to shorten the duration of cold or disease

Why suppression of cough is required?

Consequences of cough may be multifold as shown in the table.

System Impact of cough

Constitutional symptoms Excessive sweating, anorexia, exhaustion.

GIGastroesophageal reflux events, aggravatepiles or fissure in the anus.

Increased intra- abdominalpressure

Hernia may occur in diaphragm or the muscleof the abdomen (umbilical hernia, incisionhernia, etc.)

Genitourinary Urinary incontinence

Musculoskeletal Diaphragmatic rupture, ribs fracture

Neurological Dizziness, bursting headache

Psychosocial Fear of serious disease, Self-consciousness

Respiratory Exacerbation of asthma

Constitutional symptoms Excessive sweating, anorexia, exhaustion.

Quality of life Decreased

Management of cough

A. Cough suppressants

Antitussives depress the medullary cough center ( dextromethorphan, and codeine) or anesthetize stretch receptors of vagal afferent fibers in bronchi and alveoli (benzonatate)

Dextromethorphan, a congener of the narcotic levorphanol is effective as a tablet or syrup ata dose of 15 to 30 mg 1 to 4 times/day for adults or 0.25 mg/kg qid for children.

Codeine, has antitussive, analgesic, and sedative effects, and nausea, vomiting,constipation, and tolerance are common adverse effects.

Other opioids (eg, hydrocodone, hydromorphone, methadone, morphine) have antitussiveproperties but are avoided because of high potential for dependence and abuse.

Benzonatate, in liquid-filled capsules, is effective at a dose of 100 to 200 mg po tid.

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B. Expectorants

Expectorants are thought to decrease viscosity and facilitate expectoration, or coughing up,of secretions, but are of limited benefit.

Guaifenesin (200 to 400 mg po q 4 h in syrup or tablet form) is most commonly usedbecause it has no serious adverse effects.

C. Mucolytic/mucokinetics

The drugs like bromhexine, ambroxol are considered to be having mucolytic (lysis of mucus)and mucokinetic (facilitation of mucus transport) properties.

D.Topical treatments

Topical treatments, such as acacia, licorice, glycerin, honey, and wild cherry cough drops or syrups (demulcents), are locally and perhaps emotionally soothing but are not supported byscientific evidence.

E. Bronchodilators

Bronchodilators, such as salbutamol, terbutalin and ipratropium , or inhaled corticosteroids,can be effective for cough after URI and in cough-variant asthma.

http://www.merck.com/mmpe/sec05/ch045/ch045c.html

Other categories of drugs used in combination

Category Drugs

Decongestants Pseudoephedrine, Phenylephrine,Phenylpropanololamine

Antihistamines Chlorpheniramine, Cetirizine, Fexofenadine,Levocetirizine

NSAIDs & others Paracetamol, Ibuprofen, Nimesulide, Diclofenac,Aceclofenac

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Codo-Q – The product

Codo-Q: Composition

Each 5 ml of syrup contains:

Codeine phosphate 10 mg

Chlorpheniramine maleate IP 4 mg

Mentholated syrup qs

Pharmacokinetics of Codo-Q

Codeinephosphate

CPM

Absorption Rapid Rapid

Protein binding 7-25 % 72%

Metabolism Liver

rapid

Liver, lungs andkidney

Excretion Via urine within 24hrs

Via urine within 24hrs

Half-life 2-4 hrs 15-20 hrs

Pharmacodynamics of Codo-Q

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Cough suppressant: codeine phosphate

Anti-histamine: CPM



Codeine phosphate

Codeine commonly marketed as its salt codeine phosphate, an opioid used in theprevention of cough, diarrhea, mild to sever pain, irritable bowel syndrome.

Mechanism of action

It acts as a cough suppressant by depressing the central pathways of the cough reflex in thebrain.

Effective symptoms control

Codeine is generally accepted as a standard or reference antitussive against which newantitussive medications can be compared.

A voluntary pathway associated with cough related to URTI is not affected by codeine, and areflex pathway associated with induced and chronic cough is inhibited by codeine.

Eccles R, 1996 Oct-Dec;9(5-6):293-7

The opioid codeine has been a mainstay in the treatment of cough for decades and it iswidely regarded as the 'gold standard' cough suppressant.

Bolser DC, Davenport PW . 2007 Feb;7(1):32-6

Codeine, dextromethorphan, and guaifenesin are equally effective in relieving coughsymptoms.

Croughan-Minihane MS, Petitti DB, Rodnick JE, Eliaser G. 1993 Jul-Aug;6(4):429.

Codeine can be use safely in the recovering alcoholic or addict.

Stock CJ. DICP. 1991 Jan;25(1):49-53

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http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bolser%20DC%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Davenport%20PW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bolser%20DC%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Davenport%20PW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract



Chlorpheniramine maleate

Chlorpheniramine commonly marketed as its salt Chlorphenamine maleate (CPM) is a first-generation alkylamine antihistamine used in the prevention of the symptoms of allergicconditions such as rhinitis and urticaria.

Mechanism of action

Chlorpheniramine is a first generation H1-receptor antagonist which competetively blocksH1-receptor sites on tissues for duration of 4-6 hrs.

Its sedative effects are relatively weak compared to other first-generation antihistamines.

Effective symptom control

Chlorpheniramine effectively relieves the symptoms

• Sneezing

• Cough, cold and allergy

• Sinusitis

• Congestion

• Runny nose or Nasal discharge

• Nasal itching

Key properties

Most commonly used H1- antihistaminic agent in the management of cough and commoncold.

H1-receptor antagonists are usually first-line treatment given for seasonal allergic rhinitis.

Kaiser HB. 1990 Dec;86(6 Pt 2):1000-3.

Effective medications that have been used for decades in the management of allergicrhinitis.

Kaiser HB. 1990 Dec;86(6 Pt 2):1000-3

The differences with regard to safety among the second-generation antihistamines aresmaller than are the differences between the first generation

Casale et al., 2003 May;111(5):S835-42

More effective than cetrizine in the short term management of seasonal allergic rhinitis(SAR), perennial allergic rhinitis (PAR). Cetrizine is effective in long term management of thesame.

Curran MP , Scott LJ , Perry CM. 2004;64(5):523-61.

H1 antihistaminics are useful as antiallergic anti-inflammatory agents

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http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Curran%20MP%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Scott%20LJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Perry%20CM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Curran%20MP%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Scott%20LJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Perry%20CM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract



Assanasen P, Naclerio RM . 2002;17:101-39.

Chlorpheniramine dose not have any significant CNS related side effects.

Shanon et al., 1993;20(3-4):239-46.

Mentholated syrup

Menthol is an organic compound naturally occurring in mint plants. It was first isolatedfrom peppermint oil in 1771 in the West, but it may have been in use in Japan for muchlonger.

Menthol is widely used in a number of products to increase the therapeutic quality.

Menthol, in lozenges, nasal sprays, vapo-rubs, inhalers, and cough syrups, is widely usedas a treatment for rhinitis that is associated with acute upper respiratory tract infection andallergy. Menthol as a plant extract has been used in traditional medicine in Asia for thetreatment of respiratory diseases for hundreds of years.

Most of menthol's uses are related to its stimulation of the skin's cold receptors. Thisproperty makes menthol produce a cooling effect when administered or inhaled or applied tothe skin.

Because of its cooling effect, menthol is used in products meant to relieve

• Cold

• Nasal skin irritation

• Sore throat

• Nasal congestion.

• Headache

In traditional Asian medicine, menthol may be prescribed for nausea, headache, cold, or sore throat. When used as a supplement for health reasons, menthol is usually taken in theform of peppermint oil.

Key properties

Menthol stimulates the menthol receptor (cold receptors) on the sensory nerves thatmodulate the cool sensation. It has been graduated from the realms of herbal medicine intothe field of molecular pharmacology. The physiologic and pharmacologic mechanisms thatunderlie the widespread use of menthol as a treatment for the relief of nasal congestionassociated with rhinitis and its effects on the drive to breathe and symptomatic relief of

dyspnea.(Eccles R, 2003 May;3(3):210-4)

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http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Assanasen%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Naclerio%20RM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.wisegeek.com/what-is-peppermint.htm

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Assanasen%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Naclerio%20RM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.wisegeek.com/what-is-peppermint.htm



Codo-Q – Indications, Dosage and Tolerability

Codo-Q – Indications

• Smokers cough

• Allergic cough

• Post-operative cough

• Cough secondary common cold conditions like sinusitis (due to post nasal drip)

• Psychogenic cough

• Hacking cough

• Cough with infections like pharyngitis, tonsillitis, sinusitis

Codo-Q – Dosage

Component Normal dose Maximumadult dose

Children’s dose

Codeine 10mg every 4 to 6

hrs

20mg/day Less than 2 yrs not recommended

Children 2-6 years: 2.5-5mg every 4 to6 hrs

Children 6-12 years: 5-10mg every 4 to6 hrs

Chlorpheniramine 4mg every 4 to 6hrs

24mg/day

Less than 6 yrs not recommended

6 – 11yrs 2mg oral every 4 to 6 hrs

(Maximum 12mg/day)

Adults

Children

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Codo-Q – Tolerability

Adverse effect of Codo-Q

• Codeine phosphate related: Constipation, Drowsiness, dizziness, nausea & vomiting.

• Cholrpheniramine related: Drowsiness, dry mouth/nose and throat, nausea &vomiting, loss of appetite, constipation. Photosensitivity, rash, urticaria, angioedema,urine retention

Contraindications of Codo-Q

Codeine is contraindicated in patients with:

Known hypersentivity or idiosyncratic reaction to codeine, Acute respiratory depression,Chronic constipation, During labour when delivery of a premature infant is anticipatedas it may produce codeine withdrawal symptoms in the neonate, Active alcoholism,Diarrhoea caused by pseudomembranous colitis or poisoning

Contraindications of Chlorpheniramine

Allergy to any antihistamines, Narrow angle glaucoma, Bladder neck obstruction,Symptomatic prostatic hypertrophy, Asthmatic attack, Stenosing peptic ulcer,Pyloroduodenal obstruction, Not to be used in neonates

Use in pregnancy & lactation

Not recommended for breastfeeding mothers, unless the potential benefits to the patient areweighed against the possible risk to the infant.

Not recommended in children below 2 years.

Drug- drug Interactions

Watchful with

• CNS depressants

• Anticholinergics

• Antihypertensives

• Opioid analgesics

• Tranquillisers, sedatives and hypnotics

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• Ethanol

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Highlights of Codo-Q

The combination of time tested molecules

Provides safe drive to longer breath

Improves the quality of life

Codeine: Benefits

• “Mainstay & Gold standard” in the management of cough

• Inhibits reflex pathway associated with acute and chronic cough

• Rapid and effective cough control

• Time tested action in productive or non productive cough

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Complete therapy: Patient & physician compliant

Chlorpheniramine: Benefits

• Most commonly prescribed H1 antihistaminic agent

• Effective control of cough where there is allergy or common cold

• Good responsiveness in cigarette smoke induced COPD & common cold

• Provides symptomatic relief in URTI & LRTI

• Faster & surer action in nasal allergic inflammation

• Better patient compliance in seasonal and allergic rhinitis

• More effective than cetrizine in the short term management of allergic rhinitis& sinusitis

• Co-prescription with antibiotics

• Less CNS related side effects

Menthol: Benefits

• Stimulates the cold receptors and provide the cooling sensation

• Provides symptomatic relief in nasal congestion, cold and headache

• Better patient compliance in cough associated with RTI

• Provide safe drive to longer breath

codo q final manual 1

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