Pharmacological Therapy

1. Symptomatic Therapy
Choice of therapy depends on which symptoms are most bothersome to the patient
1.1. Analgesics (Non-Opioid) & Antipyretics
  • Eg Paracetamol, Ibuprofen
  • Beneficial when influenza symptoms eg malaise & fever are prominent
  • Avoid salicylates in children ≤18 yr of age because of the risk of Reye Syndrome
1.2. Bronchodilators: Beta2-Agonists
  • May be used to reduce the duration & severity of cough in some patients, but routine use for cough palliation is not recommended
  • Use should be individualized to those who are most likely to benefit
    • Eg use is justified in patients w/ clinical evidence of airflow obstruction or bronchial hyperresponsiveness eg wheezing or bothersome cough
  • Effects: Studies have shown that more patients report decrease in cough after 7 days of inhaled bronchodilator as compared to placebo or antibiotic
1.3. Cough & Cold Preparations
  • Codeine or Dextromethorphan
    • May be justified for a nonproductive irritating cough, given short term for cough relief
    • Patients w/ cough lasting >2-3 wk are the most likely to benefit
    • Suppress the cough reflex by a direct action on the cough center in the medulla of the brain
    • Modest effect on severity & duration of cough
    • Typically not very effective in patients w/ acute or early cough due to colds or other viral URTI
  • Mucolytic agents are not advised
  • Adverse Reactions:
    • GI disturbances, N/V; hypersensitivity reactions (bronchospasm, rashes); Other effect (hypotension)
  • Special Instruction:
    • Use w/ caution in patients w/ gastric or duodenal ulcer
  • Dosage Guidelines
    a. Acetylcysteine (N-acetylcysteine)
    • 200 mg PO 8 hrly
    b. Ambroxol
    • 60-120 mg PO divided 8-12 hrly
    • Extended-release: 75 mg PO 24 hrly
    c. Bromhexine
    • 8-16 mg PO 6-8 hrly
    d. Carbocisteine (Carbocysteine)
    • Initial dose: 750 mg PO 6-8 hrly, then 1.5 g/day PO in divided doses
  • Adverse Reactions:
    • GI effect (stomach pain); hypersensitivity reaction (rashes)
  • Special Instruction:
    • Use w/ caution in patients w/ renal failure
  • Dosage Guidelines
    a. Cyclidrol (Sobrerol)
    • 200 mg PO 12 hrly or up to 800 mg daily in divided doses
  • Adverse Reactions:
    • GI disturbances (GI discomfort, rarely taste alterations); Other effects (rarely, headache, dyspnea, urticaria, erythema, dermatitis)
  • Special Instruction:
    • Contraindicated in patients w/ hepatic cirrhosis, hepatic impairment, cystathionine-synthetase enzyme deficiency & severe renal failure
  • Dosage Guidelines
    a. Erdosteine
    • 300 mg PO 8-12 hrly
  • Adverse Reactions:
    • GI disturbances (GI discomfort, N/V)
  • Special Instruction:
    • Use w/ caution in patients w/ persistent or chronic cough, asthma, chronic bronchitis or emphysema
    • Discontinue use if cough persists for >7 days w/ fever, rash or persistent headache
  • Dosage Guidelines
    a. Guaifenesin
    • 600 mg PO 12 hrly or 200 mg 4 hrly
    • Max dose: 1200 mg in 24 hr
  • Adverse Reactions:
    • CNS effect (somnolence, faintness, clouding of consciousness, dizziness, headache); Other effects (palpitation, GI disturbance)
  • Special Instructions:
    • Use w/ caution in patients w/ excessive mucus discharge, limited mucociliary function, hepatic dysfunction, renal insufficiency, & diabetes
  • Dosage Guidelines
    a. Levodropropizine
    • 60 mg PO 8 hrly
2. Antibiotics for Pertussis
  • Use is supported only for confirmed or suspected B pertussis cases when there is a high probability of exposure or during an outbreak
  • Erythromycin is the drug of choice for treatment & prophylaxis of pertussis in people of all ages
  • Two small comparative studies suggest that Clarithromycin & Azithromycin are at least as effective as Erythromycin for pertussis treatment
  • Co-trimoxazole may be used as an alternative when macrolides cannot be given
  • Antibiotics are primarily used to decrease shedding of the pathogen & therefore decrease the spread of the disease
    • Patient isolation for 5 days from the start of treatment is a necessary precaution
    • Antibiotic therapy does not appear to resolve symptoms if it is initiated 7-10 days after the onset of illness but does prevent spread to others
2.1. Antibacterial combination
  • Adverse Reactions:
    • GI effects (N/V, anorexia, diarrhea, rarely antibiotic-associated diarrhea/colitis, glossitis); Dermatologic effects (rash, pruritus, photosensitivity); Hypersensitivity reactions can range from mild (eg rash) to severe/life-threatening (eg Stevens-Johnson syndrome); Urogenital (crystallization in the urine)
    • Rarely hematologic effects which may be more common if given for long periods or w/ high doses; rarely hepatic effects, renal effects; aseptic meningitis has occurred
  • Special Instructions:
    • Maintain adequate fluid intake
    • Contraindicated in patients allergic to sulfonamides
    • Use w/ extreme caution or not at all in patients w/ hematological disorders esp megaloblastic anemia due to folic acid deficiency
    • Use w/ caution in patients w/ renal impairment or severe hepatic dysfunction & w/ caution in patients w/ folate deficiency (may consider administration of Folinic acid)
  • Dosage Guidelines
    a. Co-trimoxazole [Sulfamethoxazole (SMZ) & Trimethoprim (TM)]
    • SMZ 800 mg & TM 160 mg PO 12 hrly x 14 days
2.2. Macrolides
  • Adverse Reactions:
    • GI effects (N/V, abdominal discomfort, diarrhea & other GI disturbances, antibiotic-associated diarrhea/colitis); Other (candidal infections)
    • Hypersensitivity reactions are uncommon (urticaria, pruritus, rash, rarely anaphylaxis); rarely cardiotoxicity, hepatotoxicity; dose-related tinnitus/hearing loss have occurred w/ some macrolides
    • Azithromycin & Clarithromycin tend to cause less GI disturbances than Erythromycin
  • Special Instructions:
    • May take w/ food to decrease gastric distress
    • Use w/ caution in patients w/ hepatic dysfunction
  • Dosage Guidelines
    a. Erythromycin
    • Childn: 40-50 mg/kg/day PO divided 6-12 hrly x 14 days
    • Adults: 500 mg PO 6 hrly x 14 days
  • b. Roxithromycin
    • Childn >40 kg: 5-8 mg/kg/day PO divided 12 hrly x 7-10 days
    • Adults: 150 mg PO 12 hrly x 7-10 days or 300 mg PO 24 hrly x 7-10 days
  • Advanced Macrolides
    a. Azithromycin
    • Childn: 10 mg/kg PO 24 hrly x 5-7 days
    • Adults: 500 mg PO 24 hrly x 3 days or 500 mg PO 24 hrly x 1 day followed by 250 mg PO 24 hrly x 4 days
  • b. Clarithromycin
    • Childn: 7.5 mg/kg PO 12 hrly x 5-10 days
    • Adults: 500 mg PO 12 hrly x 7-14 days
    • Extended-release: 1000 mg PO 12 hrly x 7-14 days

All dosage recommendations are for non-pregnant & non-breastfeeding women, non-elderly adults w/ normal renal & hepatic function unless otherwise stated.

Not all products are available or approved for above use in all countries. 

Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.

Click the link below for specific prescribing information of products available in respective countries.

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