Usage
- This combination is prescribed for the symptomatic relief of productive cough associated with respiratory conditions like bronchitis, bronchial asthma, emphysema, and other bronchopulmonary disorders where bronchospasm, mucus plugging, and difficulty in expectoration coexist. It is also used to treat cough with mucus and chronic obstructive pulmonary diseases (COPD).
- Pharmacological Classification: This is a combination drug containing a mucolytic (Ambroxol), an expectorant (Guaifenesin), and a bronchodilator (Terbutaline).
- Mechanism of Action: Ambroxol works by breaking down the structure of mucus, making it less viscous and easier to expel. Guaifenesin increases the volume of fluids in the airways, further thinning the mucus and aiding its removal. Terbutaline, a beta-2 adrenergic agonist, relaxes the smooth muscles in the airways, widening them and easing breathing.
Alternate Names
- No internationally recognized non-proprietary name exists for this combination.
- Brand Names: Brand names vary regionally; some examples include Ascoril-D, TusQ, Trump-A, and Kofarest PD.
How It Works
- Pharmacodynamics: Ambroxol reduces mucus viscosity and promotes mucociliary clearance. Guaifenesin increases respiratory fluid volume and reduces mucus adhesiveness. Terbutaline relaxes bronchial smooth muscles, causing bronchodilation.
- Pharmacokinetics:
- Ambroxol: Well-absorbed orally. Metabolized primarily in the liver and excreted renally.
- Guaifenesin: Readily absorbed from the GI tract. Metabolized in the liver and excreted in the urine.
- Terbutaline: Administered orally or subcutaneously. Metabolized in the liver and excreted renally.
- Mode of Action: Ambroxol breaks down mucopolysaccharides in mucus. Guaifenesin is thought to stimulate receptors in the gastric mucosa, triggering a reflex increase in respiratory tract secretions. Terbutaline binds to beta-2 adrenergic receptors on bronchial smooth muscle cells, activating adenylate cyclase and increasing intracellular cAMP, leading to muscle relaxation.
- Elimination Pathways: Primarily renal excretion for all three components after hepatic metabolism.
Dosage
Standard Dosage
Adults:
- Syrup: 5-10ml three times a day (depending on the specific product’s concentration). Maximum dose should not exceed 20ml three times per day. Consult the specific product’s information for dosage.
- Tablets: Dosages vary depending on the product; consult product’s information for dosage.
Children:
- Dosages vary with age and formulations (drops or syrup). Consult a pediatrician for appropriate dosing. Pediatric doses are generally lower and based on weight or age.
- Drops: Children (6 months - 2 years): 0.5-1 ml twice or three times daily.
- Syrup: Children (2 - 5 years): 2.5 ml three times daily. Children (above 5 years): 5 ml 2 - 3 times daily.
Special Cases:
- Elderly Patients: Initiate with lower doses and monitor closely for adverse effects. Dosage adjustments may be necessary depending on renal or hepatic function.
- Patients with Renal Impairment: Reduce dose or extend dosing interval in severe renal impairment.
- Patients with Hepatic Dysfunction: Use with caution. Dosage adjustments may be necessary.
- Patients with Comorbid Conditions: Use with caution in patients with diabetes, hypertension, hyperthyroidism, cardiovascular disease, or gastric ulceration. Close monitoring is recommended.
Clinical Use Cases
- Intubation, Surgical Procedures, Mechanical Ventilation, ICU Use, Emergency Situations: The combination is typically not used in these settings. Terbutaline alone may be used in some cases for bronchospasm.
Dosage Adjustments
- Dosage adjustments are necessary based on patient-specific factors such as renal function, hepatic function, age, and comorbid conditions.
Side Effects
Common Side Effects
- Nausea, vomiting, dizziness, headache, tremor, nervousness, skin rash, stomach upset, palpitations, increased heart rate, dry mouth, diarrhea, shivering, itching, sweating.
Rare but Serious Side Effects
- Allergic reactions (e.g., skin rash, itching, hives, swelling of the face, lips, tongue, or throat, difficulty breathing), severe dizziness, fainting, irregular heartbeat, worsening of asthma symptoms.
Long-Term Effects
- Not well-established for this combination.
Adverse Drug Reactions (ADR)
- Angioedema, Stevens-Johnson Syndrome (rare).
Contraindications
- Hypersensitivity to any components of the formulation.
- Pre-existing ischemic heart disease or significant risk factors for it.
- Thyrotoxicosis.
- Gastric ulceration.
- Hypertrophic cardiomyopathy.
Drug Interactions
- Beta-blockers (e.g., propranolol) may reduce the effectiveness of terbutaline.
- Other sympathomimetic drugs may increase the risk of cardiovascular side effects.
- Antidepressants (e.g., MAO inhibitors, tricyclic antidepressants) may potentiate the effects of terbutaline.
- Diuretics and corticosteroids may enhance hypokalemia caused by terbutaline.
- Xanthine derivatives may potentiate hypokalemia.
- Certain antibiotics (e.g., erythromycin) may interact with terbutaline.
- Caffeine may increase the risk of side effects.
Pregnancy and Breastfeeding
- Pregnancy Safety Category: Safety in pregnancy has not been established. Use with caution and only if potential benefits outweigh the risks.
- Breastfeeding: It is unknown if components are excreted in breast milk. Use with caution.
Drug Profile Summary
- Mechanism of Action: Mucolytic, expectorant, and bronchodilator actions combine to ease cough and improve airway clearance.
- Side Effects: Nausea, vomiting, dizziness, headache, tremor, nervousness, rash, stomach upset, palpitations, increased heart rate.
- Contraindications: Hypersensitivity, ischemic heart disease, thyrotoxicosis, gastric ulcer.
- Drug Interactions: Beta-blockers, sympathomimetics, antidepressants, diuretics, corticosteroids, xanthines, certain antibiotics, caffeine.
- Pregnancy & Breastfeeding: Use with caution. Safety not established.
- Dosage: Consult product information for specifics. Adjust according to age, condition, and renal/hepatic function.
- Monitoring Parameters: Respiratory rate, heart rate, blood pressure, potassium levels, lung function tests.
Popular Combinations
- This is already a combination product.
Precautions
- General Precautions: Assess for allergies, cardiac disease, renal/hepatic impairment, diabetes, hyperthyroidism before starting treatment.
- Specific Populations: Use cautiously in pregnancy/breastfeeding. Consult a pediatrician for pediatric dosing. Start with lower doses in the elderly.
- Lifestyle Considerations: Patients should avoid alcohol, as interactions are unknown. Caution patients about potential dizziness and drowsiness affecting driving or operating machinery.
FAQs (Frequently Asked Questions)
Q1: What is the recommended dosage for Ambroxol + Guaifenesin + Terbutaline?
A: The dosage varies with the specific product and patient factors. Refer to the product information and adjust for age, renal/hepatic function, and concomitant medications. Adult doses usually range from 5-10 ml of syrup three times a day. Pediatric dosages are lower and must be determined by a pediatrician.
Q2: Can this combination be used in patients with asthma?
A: It can be used in patients with asthma to relieve cough and bronchospasm. However, caution should be exercised, and close monitoring is recommended.
Q3: What are the common side effects?
A: Nausea, vomiting, dizziness, headache, tremor, nervousness, skin rash, and gastrointestinal upset are common.
Q4: Is it safe to use during pregnancy?
A: Safety in pregnancy has not been established. Use with caution and only if the potential benefits outweigh the risks.
Q5: Are there any drug interactions I should be aware of?
A: Yes, several drug interactions are possible, including those with beta-blockers, antidepressants, and certain antibiotics. Consult the Drug Interactions section for more details.
Q6: Can I use it with other cough and cold medications?
A: It is generally not recommended to use this combination with other cough and cold medications, especially those containing sympathomimetics or antihistamines, without consulting a doctor, as it may increase the risk of side effects.
Q7: What should I do if I experience side effects?
A: If you experience side effects, contact your doctor. They may recommend adjusting the dose or discontinuing the medication.
Q8: How should this medication be stored?
A: Store in a cool and dry place, away from direct sunlight and out of the reach of children. Refer to specific product instructions for temperature ranges.
Q9: Can this combination be used long-term?
A: Long-term use should be under the guidance of a physician. The risks and benefits should be carefully evaluated.
