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?


  1. You are so very correct. We are also aware of the evidence & we do urge patients not to use these medications.However, there are strong pressures from different sources to push their use. The worst is the patient! Most every FP/IM will tell you patients want something-anything.So, when our advice to increase intake of water doesn’t work, the next toxic thing is guaifenesen.I never recommend anything else. These drugs are expensive & can have consequences with maintenance medication or toxic effects from using too much acetaminophen.

    Sadly, the other pressure is from our employers.We are in direct opposition to what their goal is, which is to sell as much as possible.They do that by attractively advertising these drugs & the locations where they’re kept.

    Our goal is to give the patient the most education possible & have them use the least amount of medication possible.Thats why few of us will recommend a combination product.

    There is no advertisement for water, which is the best expectorant available. Sadly, we can only educate so far & when our day gets busy & its apparent the pt wants to BUY something, a simple bottle of guaifenesin will do the trick.

    Thats my opinion as a pharmacist.

    • Casey Parker says

      Thanks Linda, a refreshing look into the process by which patients acquire these meds. Your position as both employee and “patient advocate” is a tricky one.

      There are many Docs and nurses who recommend these meds without much evidence – my feeling is that we as a profession are people who “like to help” and “be liked” – we therefore are very bad at doing nothing in the face of a distressed patient.

      I hate too much government regulation – but maybe this is the only way you can remove these from harm’s way – at least it would make it easier on you guys if a prescription were required.

  2. I always recommend against guaifenesin, as it’s no more effective than water and tends to be expensive even as such an old drug. Most dry coughs I addressed with dextromethorphan, though with stern warnings to stick to the dosing on the box and not if they were taking SSRIs (though the clinical significance of serotonin syndrome with that combination is usually way overblown) or had opioid allergy. Folks with wet coughs were told not to treat the cough itself, and to drink plenty of fluids. In pharmacy school, we were taught codeine is the gold standard when it comes to antitussives, but most pharmacies and pharmacists won’t sell it OTC anymore.

  3. I think you must have been at the Pharmacy the day the cruise ship full of flu / cold ridden occupants disgorged it’s contents!
    I think Linda and Adam more or less nailed it from an employee community pharmacists perspective.
    I don’t know that it’s so different to hospital docs prescribing senegar and ammonia or pholcodiene syrup to meet patients expectations that somebody do something for their cough! explanations take time and not all patients are readily swayed by logic, evidence etc so at times it’s easier to aquiesce to their demands.
    Is is so different from your post on giving ventolin when the evidence is that it does nothing for acute hyperventilation – the placebo paradox?
    *declaration* I have, on very rare occasions and in desperation, given my kids a dose of pholcodine in the wee small hours of the night – usually after a puff of salbutamol hasn’t sufficed for their post viral ‘asthmatic’ cough!

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