Usage
- This combination medication is prescribed for the relief of productive cough associated with bronchospasm in conditions like acute and chronic bronchitis, bronchial asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis, emphysema, and other bronchopulmonary disorders with co-existing bronchospasm, mucus plugging, and difficulty expectorating.
- Pharmacological Classifications:
- Ammonium Chloride: Expectorant
- Bromhexine: Mucolytic
- Terbutaline: Beta2-adrenergic agonist, bronchodilator
- Mechanism of Action: This combination works through a three-pronged approach: Ammonium chloride acts as an expectorant, increasing respiratory fluid production and thinning mucus. Bromhexine, a mucolytic, breaks down the mucus, making it less viscous and easier to expel. Terbutaline, a bronchodilator, relaxes the bronchial smooth muscle, widening the airways and facilitating easier breathing.
Alternate Names
- While “Ammonium Chloride + Bromhexine + Terbutaline” is the generic name, specific brand names vary regionally.
- Some possible brand names may include formulations containing menthol.
How It Works
- Pharmacodynamics: Bromhexine reduces mucus viscosity by disrupting disulfide bonds in mucoproteins. Terbutaline relaxes bronchial smooth muscle by stimulating beta2-adrenergic receptors, leading to bronchodilation. Ammonium chloride increases respiratory secretions, thinning the mucus.
- Pharmacokinetics:
- Absorption: All three components are absorbed orally.
- Metabolism: Terbutaline is metabolized in the liver. Bromhexine is partially metabolized in the liver. Ammonium Chloride is not significantly metabolized, it gets converted to urea and hydrochloric acid.
- Elimination: Terbutaline and its metabolites are primarily excreted in the urine. Bromhexine and its metabolites are excreted in the urine. Ammonium Chloride is cleared via the kidneys.
- Mode of Action: Bromhexine acts on mucus-secreting cells and increases lysosomal activity to break down thick mucus. Terbutaline stimulates beta2-adrenergic receptors in the bronchi, leading to smooth muscle relaxation and bronchodilation. Ammonium chloride acts as an irritant, increasing mucus secretion.
Dosage
Standard Dosage
Adults:
- Syrup: 5-10 ml three times a day (depending on the formulation).
- Tablet: One tablet three times a day (depending on the specific formulation)
- Maximum daily dose: Should not exceed the equivalent of 15mg of Terbutaline and 24mg of Bromhexine.
Children:
- Children (6-12 years): 2.5-5 ml of syrup three times daily.
- Children under 6 years: Not generally recommended unless deemed absolutely necessary by a physician. Dosage needs to be carefully determined by a physician.
Special Cases:
- Elderly Patients: Start with the lowest dose and titrate upwards based on patient response and tolerance. Monitor cardiovascular side effects.
- Patients with Renal Impairment: Caution is advised, dosage adjustment may be required.
- Patients with Hepatic Dysfunction: Caution is advised, dosage adjustment may be required.
- Patients with Comorbid Conditions: Use with caution in patients with diabetes mellitus, cardiovascular diseases, hypertension, hyperthyroidism, and gastric ulcers. Close monitoring is required.
Clinical Use Cases
Dosage in clinical settings like intubation, surgery, mechanical ventilation, ICU, and emergencies needs individualized treatment strategies based on patient needs and condition. Specific guidelines for these cases with this particular combination are not established.
Dosage Adjustments
Adjustments based on organ dysfunction, metabolic disorders, or genetic polymorphisms are essential.
Side Effects
Common Side Effects
- Nausea, vomiting, diarrhea, indigestion, stomach upset, dizziness, headache, tremors, increased heart rate, skin rash, and sweating.
Rare but Serious Side Effects
- Allergic reactions (rash, itching, swelling, difficulty breathing)
- Severe QTc prolongation or arrhythmias (with Terbutaline)
- Paradoxical bronchospasm
- Seizures (especially in patients with epilepsy)
- Hypokalemia
Long-Term Effects
- Chronic complications from prolonged Terbutaline use may include cardiovascular issues.
Adverse Drug Reactions (ADR)
- Significant ADRs needing urgent intervention: Severe allergic reactions, cardiac arrhythmias, worsening of respiratory symptoms.
Contraindications
- Hypersensitivity to any component of the medication.
- Acute asthma attacks.
- Hypertrophic obstructive cardiomyopathy.
- Tachyarrhythmia.
- Severe underlying cardiovascular conditions.
Drug Interactions
- Beta-blockers (e.g., propranolol)
- Antidepressants (e.g., amitriptyline, amoxapine)
- Diuretics (e.g., furosemide)
- Methylxanthines (e.g., theophylline)
- Corticosteroids (e.g., prednisone)
- Antibiotics (e.g., neomycin)
- MAO inhibitors
- Alcohol
Pregnancy and Breastfeeding
- Pregnancy: Limited data available. Consult a doctor, as the drug might be unsafe during pregnancy due to potential harm to the developing fetus.
- Breastfeeding: It’s unknown whether the drug passes into breast milk. Exercise caution and consult a physician before use.
Drug Profile Summary
- Mechanism of Action: Bromhexine reduces mucus viscosity, Terbutaline is a bronchodilator, and Ammonium chloride is an expectorant.
- Side Effects: Nausea, vomiting, dizziness, headache, tremors, increased heart rate, skin rash. Serious side effects include allergic reactions, arrhythmias, seizures, hypokalemia.
- Contraindications: Hypersensitivity, acute asthma attacks, hypertrophic obstructive cardiomyopathy, tachyarrhythmia.
- Drug Interactions: Beta-blockers, antidepressants, diuretics, methylxanthines, corticosteroids, MAO inhibitors, alcohol.
- Pregnancy & Breastfeeding: Caution advised. Consult a physician.
- Dosage: Varies depending on age, condition, and formulation. See detailed dosage section.
- Monitoring Parameters: Respiratory rate, heart rate, blood pressure, potassium levels, and pulmonary function tests.
Popular Combinations
While this combination itself is used, other expectorants or bronchodilators might be added depending on the patient’s condition. The specific combination needs to be determined based on the clinical scenario.
Precautions
- General Precautions: Pre-existing heart, liver, kidney, or lung diseases; epilepsy, diabetes, hyperthyroidism.
- Pregnant Women: May cause adverse effects on the fetus.
- Breastfeeding Mothers: Potential risk to newborns.
- Children & Elderly: Age-specific dosage.
- Lifestyle Considerations: Avoid alcohol; driving caution advised due to potential dizziness.
FAQs (Frequently Asked Questions)
Q1: What is the recommended dosage for Ammonium Chloride + Bromhexine + Terbutaline?
A: Adults: 5-10ml of syrup or one tablet three times daily (depending on the formulation), not to exceed 15mg Terbutaline and 24mg Bromhexine/day. Children (6-12 years): 2.5-5ml of syrup three times daily. Adjust for renal/hepatic impairment and comorbid conditions. Consult a physician for pediatric doses under 6.
Q2: What are the common side effects?
A: Nausea, vomiting, diarrhea, dizziness, headache, tremors, increased heart rate, skin rash.
Q3: Can pregnant or breastfeeding women take this medication?
A: Caution advised. It’s crucial to consult a doctor before using this medicine during pregnancy or while breastfeeding.
Q4: How does this medication work?
A: Ammonium Chloride thins the mucus, Bromhexine breaks it down, and Terbutaline opens the airways.
Q5: What are the serious side effects to watch out for?
A: Allergic reactions, severe QTc prolongation, paradoxical bronchospasm, seizures, and hypokalemia.
Q6: What drugs should be avoided while taking this combination?
A: Beta-blockers, antidepressants, diuretics, methylxanthines, corticosteroids, MAO inhibitors, alcohol.
Q7: What conditions make this combination contraindicated?
A: Hypersensitivity to the ingredients, acute asthma attacks, hypertrophic obstructive cardiomyopathy, and tachyarrhythmia.
Q8: Are there any specific monitoring parameters?
A: Respiratory rate, heart rate, blood pressure, potassium levels, lung function tests.
Q9: What should patients with diabetes do while taking this medication?
A: Monitor blood sugar levels regularly, as this combination can affect glucose metabolism.
Q10: Can I drive after taking this medicine?
A: Use caution while driving or operating machinery, as dizziness may occur.
