Usage
This combination medication is prescribed for the relief of cough and congestion associated with various respiratory tract infections and conditions, such as bronchitis, bronchial asthma, emphysema, and other bronchopulmonary disorders where bronchospasm, mucus plugging, and difficulty in expectoration coexist. It combines drugs from different pharmacological classifications:
- Ammonium Chloride: Expectorant
- Bromhexine: Mucolytic
- Menthol: Cough suppressant, local anesthetic/counterirritant
- Terbutaline: Bronchodilator (Beta2-adrenergic agonist)
The medication works by thinning and loosening mucus (Bromhexine), making it easier to cough up (Ammonium Chloride), opening up the airways (Terbutaline), and soothing throat irritation (Menthol).
Alternate Names
There are no officially recognized alternate names for this specific combination. However, it’s crucial to recognize that it’s a combination of four distinct drugs, each with their own alternate names: Ammonium Chloride, Bromhexine Hydrochloride, Levomenthol, and Terbutaline Sulfate. This combination is marketed under various brand names, which vary depending on the manufacturer and region. Some examples include Tuspel Plus, Rhinil, Medler AF, Abokof BR, Broncorex, and Medkuff-BR.
How It Works
Pharmacodynamics:
- Ammonium Chloride: Increases respiratory tract fluid, reducing mucus viscosity.
- Bromhexine: Breaks down mucopolysaccharides, reducing mucus viscosity and promoting mucociliary clearance.
- Menthol: Activates cold receptors, causing a cooling sensation and relieving throat irritation.
- Terbutaline: Relaxes bronchial smooth muscle by stimulating beta-2 adrenergic receptors, leading to bronchodilation.
Pharmacokinetics:
- Absorption: All components are absorbed orally.
- Metabolism: Bromhexine is metabolized in the liver. Terbutaline is primarily metabolized by conjugation. Information on the metabolism of ammonium chloride and menthol in this context is limited in the provided sources.
- Elimination: All components are primarily eliminated renally, either unchanged or as metabolites.
Dosage
Standard Dosage
Adults:
The standard adult dosage is 5-10 ml three to four times a day, with a maximum daily dose of 40 ml.
Children:
This combination is generally not recommended for children under 6 years of age or those weighing less than 25 kg. For children over 6 years, the dosage should be determined by a physician based on weight and age.
Special Cases:
- Elderly Patients: Dosage adjustments may be necessary due to age-related decline in kidney and liver function. Start with a lower dose and monitor carefully.
- Patients with Renal Impairment: Dose reduction is typically required, based on the degree of impairment.
- Patients with Hepatic Dysfunction: Use with caution as dosage adjustments might be necessary.
- Patients with Comorbid Conditions: Caution should be exercised in patients with heart disease, high blood pressure, diabetes, hyperthyroidism, glaucoma, seizures, an adrenal gland tumor, or a history of peptic ulcers.
Clinical Use Cases
Dosage for specific clinical use cases like intubation, surgical procedures, mechanical ventilation, ICU use, and emergency situations is not explicitly defined for this combination and should be determined on a case-by-case basis by the treating physician, considering the patient’s specific condition and needs.
Dosage Adjustments
Dosage modifications should be considered for renal/hepatic dysfunction, metabolic disorders, or genetic polymorphisms affecting drug metabolism. Consult with a physician for appropriate adjustments.
Side Effects
Common Side Effects:
Nausea, vomiting, diarrhea, indigestion, bloating, stomach upset, headache, dizziness, sweating, skin rash, tremors, and increased heart rate.
Rare but Serious Side Effects:
Allergic reactions, irregular heartbeats, hypokalemia, muscle cramps, difficulty breathing, and worsening of asthma symptoms.
Long-Term Effects:
Information regarding specific long-term effects of this particular drug combination is not available in the provided sources. However, prolonged use of terbutaline can potentially lead to tolerance and decreased effectiveness.
Adverse Drug Reactions (ADR):
Severe allergic reactions, significant changes in heart rate or rhythm, and severe hypokalemia.
Contraindications
Hypersensitivity to any of the components, pre-existing ischemic heart disease or significant risk factors for it, active peptic ulcer disease, pheochromocytoma, and epilepsy.
Drug Interactions
Beta-blockers (e.g., propranolol), MAO inhibitors, tricyclic antidepressants (e.g., amitriptyline), diuretics (e.g., furosemide), methylxanthines (e.g., theophylline), corticosteroids, some antibiotics (e.g., neomycin), and alcohol. The provided sources do not list detailed CYP450 interactions.
Pregnancy and Breastfeeding
Use with caution during pregnancy and breastfeeding only if the potential benefits outweigh the potential risks. The safety of this combination during pregnancy has not been definitively established. Consult a physician for further evaluation.
Drug Profile Summary
- Mechanism of Action: Mucolytic, bronchodilator, expectorant, cough suppressant.
- Side Effects: Nausea, vomiting, diarrhea, dizziness, headache, increased heart rate, tremors, skin rash. Rarely: allergic reactions, irregular heartbeats.
- Contraindications: Hypersensitivity, ischemic heart disease, peptic ulcer, pheochromocytoma, epilepsy.
- Drug Interactions: Beta-blockers, MAO inhibitors, tricyclic antidepressants, diuretics, methylxanthines, corticosteroids, some antibiotics, alcohol.
- Pregnancy & Breastfeeding: Use with caution if benefits outweigh risks. Consult a physician.
- Dosage: Adults: 5-10 ml TID-QID (max 40ml/day). Pediatric: Consult a physician.
- Monitoring Parameters: Respiratory rate, heart rate, blood pressure, potassium levels, and lung function.
Popular Combinations
Specific information on commonly used drug combinations is not available in the given sources. However, these medications are often combined with other drugs depending on the underlying condition being treated.
Precautions
- General Precautions: Screen for allergies, metabolic disorders, and organ dysfunction.
- Pregnant Women: Assess risks and benefits carefully.
- Breastfeeding Mothers: Potential risk of neonatal exposure.
- Children & Elderly: Age-specific dosing and monitoring.
- Lifestyle Considerations: Avoid alcohol, as it may worsen side effects. Driving may be impaired due to potential dizziness and drowsiness.
FAQs (Frequently Asked Questions)
Q1: What is the recommended dosage for Ammonium Chloride + Bromhexine + Menthol + Terbutaline?
A: Adults: 5-10 ml three to four times a day (maximum 40 ml/day). Pediatric: Consult a physician for weight/age-based dosing.
Q2: Can this combination be used in asthmatic patients?
A: Yes, terbutaline is a bronchodilator that can help asthmatic patients. However, use cautiously and under a physician’s supervision.
Q3: What are the common side effects?
A: Nausea, vomiting, diarrhea, headache, dizziness, and skin rash are common side effects.
Q4: Are there any serious side effects?
A: Yes, though rare, serious side effects can include allergic reactions, irregular heartbeats, and hypokalemia. Seek immediate medical attention if these occur.
Q5: Can I drive while taking this medication?
A: This medication may cause dizziness and drowsiness. It’s advisable to avoid driving or operating machinery until you know how it affects you.
Q6: What should I do if I miss a dose?
A: Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and return to your regular schedule. Do not double the dose.
Q7: Can I take this medication while pregnant or breastfeeding?
A: Consult your doctor before taking this medicine if you are pregnant, planning a pregnancy, or breastfeeding. The potential benefits should outweigh the potential risks to the fetus or infant.
Q8: How should I store this medication?
A: Store in a cool, dry place away from sunlight.
Q9: What are the contraindications for this medicine?
A: This combination is contraindicated in individuals with hypersensitivity to any of its components, ischemic heart disease, active peptic ulcer, pheochromocytoma, and epilepsy.
Q10: How does this combination relieve cough and congestion?
A: It thins and loosens the mucus, making it easier to cough up, relaxes and opens airways, and provides a soothing effect on the throat.
