Re: E-DRUG: E-DRUG Demazin Syrup Response from MaLAM

["Peter Mansfield" <Peter.Mansfield@flinders.edu.au>]

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E-DRUG Demazin Syrup Response from MaLAM

Mark Dunn requested a response from MaLAM.

We have written about misleading promotion of "cough mixtures" many times. 
Our most recent report was written by Agnes Vitry and published in the
January / February MaLAM Australia News.  She wrote:

Follow-up:  Whitehall's promotion of Robitussin (dextromethorphan and/or
guaiphenesin and/or pseudoephedrine)
Our September 1995 Australian MaLAM News featured the promotion of
Robitussin.  The Robitussin range of products are all combinations,
including at least one of the following ingredients: guaiphenesin,
pseudoephedrine, dextromethorphan.  We questioned the company about the
efficacy of guaiphenesin, the risk to benefit ratio of pseudoephedrine in
the common cold and the rationale supporting the combination of a cough
suppressant (dextromethorphan) with an expectorant in the same preparation
(see below).

No response from Wyeth-Ayerst
Our letter was sent to Whitehall, the Australian distributor.  In October
1995, we received a letter from M. Alex Michaels, Vice President Medical
Affairs, Wyeth-Ayerst in USA, stating that "we will be corresponding with
you again in the near future.  We are interested in providing professionals
and consumers with accurate product information for all of our products
including Robitussin brand products and appreciate your similar efforts in
this regard".  We have not received any further correspondence.

Cough treatment
Cough is an important protective physiological mechanism.  It may also be
the symptom of an underlying disorder which is important to identify and to
treat specifically.  In some cases, a symptomatic treatment may be
warranted.  Cough suppressants are used for non-productive coughs.  They
should not be used in productive coughs because they may cause sputum
retention.  Expectorants are claimed to promote expulsion of bronchial
secretions but clinical evidence for their efficacy is lacking.  
In this context, the advertisement for Robitussin range of products was
rather provocative.  It claimed "Doctors differentiate between coughs. So
does Robitussin" despite the fact that Robitussin DM contained an illogical
combination of a cough suppressant with an expectorant.  Unfortunately,
Robitussin DM is not the only one.  At least two other preparations,
Dimetapp Cold Cough Flu Liquid Caps marketed by the same company and Sigma
Relief Syrup marketed by Sigma also contain both guaiphenesin and
dextromethorphan.  
Dozens of cough and cold preparations contain pseudoephedrine, a drug with
a poor risk to benefit ratio. (see below).  By contrast, there is no single
ingredient preparation containing dextromethorphan, which may be useful for
cumbersome non-productive coughs.  
Drug companies like Whitehall, Wyeth-Ayerst and Sigma would be well advised
to replace their current range of products with useful single ingredient
preparations.

Pharmacists: beware of inappropriate promotion!
"Big business from the winter bugs", "How to turn an unhealthy consumer
into a healthy profit": Pharmacists should be aware that just as in
previous years, drug promotion for cough and cold products will soon
flourish in professional journals.  They should be prepared to have a
critical look at the products which are promoted so that they can give
useful and trustworthy advice to patients.

Some ingredients included in Robitussin cough preparations
Guaiphenesin is claimed to be an expectorant.  Our review of the published
literature as well as authoritative drug textbooks concluded that clinical
evidence of efficacy for guaiphenesin was lacking. 
Pseudoephedrine is a sympathomimetic drug claimed to be a nasal
decongestant.  While its clinical usefulness is doubtful, serious
cardiovascular adverse effects have been reported.
Dextromethorphan is an opioid cough suppressant.  It is often recommended
as a drug of choice when a cough suppressant is needed because the
incidence of central nervous system adverse effects and risk of dependence
is less than with other opioid  derivatives.

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To put the above into perspective Wyeth-Ayerst are the only company to fail
to provide any answer to questions from MaLAM  in the past 5 years.  

In response to Mark's personal experience, we don't give our 3 children
such drugs and they recover quickly also.  One of them likes to take
paracetamol sometimes but the others always decline the offer. 

In practice as a GP I see many people who complain about having waisted
money on mixtures which did not work.  However if they thought it worked
(eg because of spontaneous recovery, placebo effect or "real efficacy")
then they would not feel the need to come to see me!

"Peter Mansfield" 
<Peter.Mansfield@flinders.edu.au>



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