Undiagnose, Unprescribe, Unharm… part II

This rant is inspired by something I witnessed yesterday when I went into my local pharmacy to pick up my mother-in-law’s meds.  I rarely ener a commercial pharmacy, so this was a novel experience for me.  Anyway, it is flu-season here in Oz, so I was in a line of coughing, sneezing, nose-wiping folks who were all queuing for some over-the-counter remedies.   As I waited, I watched in disbelief as each ‘patient’ was asked the same questions by a range of pharmacy assistants:

  • Is your cough a dry, moist or a chesty cough?   (Chesty cough? Did I miss something in Med School, are they not all ‘chesty’?)
  • What colour is your snot?
  • Are you allergic to anything?

Based on the answers to these questions, the PA then produced a tailored remedy for each annoying cough.  Apparently there is a different linctus for green snot with a moist cough  vs.  a dry cough with haemoptysis!  It took a great deal of self-restraint, to stop myself from either jumping the counter and demanding evidence for this practice,  OR  claiming that I had a bad, whoop-like cough with purple snot and screwing the whole system….

Being the mild-mannered guy I am, I decided to internalise my anger and post a blog on the use of cough mixtures.  There are a lot of these on the market with a lot of ingredients: mucolytics, anti-tussives, alcohol, codeine, antihistamines, anticholinergics… the list goes on.

So do they work?  Well… NO.  The folks at the Cochrane review have done a look into the studies in 2008 and shown no good evidence that they effect one’s cough any better than placebo.  To my mind, this makes sense – I give people Propofol and they cough – why would a mild analgesic do any better?

Is here a down side?  Well they cost money and the Cochrane review found some had ill-effects.  In 2008 the FDA in the U.S. issued a black-box label for these medicines for children under 2 years:  “Besides fatalities, adverse effects reported include convulsions, rapid heart rates, and reduced levels of consciousness.”

So in my mind they are not any good, and possibly harmful – so don’t use them, don’t advise your patients to use them and if you are like me “unprescribe” them.  I have been doing this for years now and find parents are often surprised when you explain the evidence to them – these medicines are an entrenched meme in Western society.

You might need to do an “anti-snake oil sales” pitch with a few tricks to convince them.  I like to describe a cough as a reflex, them pull out the tendon hammer and tap the parents knee – ask them: ” do you think this medicine would stop your leg from jumping?”

If that doesn’t work I go for scare tactics eg. “There is a reason your child is coughing – to clear inflammed mucous, bacteria and debris from their lungs – if they don’t cough what will happen?”

Comments?  I would love to hear from any pharmacists out there – do they really teach his stuff in pharmacy school?  Or is it just a good money spinner each winter?


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