Usage
- This combination medication is prescribed for productive cough (cough with mucus) associated with bronchospasm (tightening of airways) in conditions like bronchitis, bronchial asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis, and emphysema.
- Pharmacological Classification: This is a combination drug containing a mucolytic (Bromhexine), expectorant (Guaifenesin), bronchodilator (Terbutaline), and a topical anesthetic/cooling agent (Menthol).
- Mechanism of Action: Bromhexine breaks down mucus, Guaifenesin thins and loosens mucus, Terbutaline relaxes and widens airways, and Menthol provides a cooling and soothing effect on irritated airways.
Alternate Names
- While the generic name is Bromhexine + Guaifenesin + Menthol + Terbutaline, several brand names exist internationally and regionally.
- Brand Names: Broncorex® is a well-known example. Several other brand names are available depending upon the region and country.
How It Works
- Pharmacodynamics: Bromhexine increases the production of serous mucus in the respiratory tract, reducing the viscosity of sputum. Guaifenesin increases fluid volume in the airways, lubricating the irritated respiratory tract and promoting efficient coughing. Terbutaline stimulates beta-2 receptors in the lungs, causing bronchodilation. Menthol stimulates cold receptors, producing a cooling sensation and relieving minor throat irritation.
- Pharmacokinetics: All components are absorbed orally. Terbutaline is metabolized in the liver, while Bromhexine is partially metabolized. Elimination is primarily renal. Guaifenesin is excreted unchanged.
- Mode of Action: Bromhexine acts by depolarizing the cell membranes of serous cells which leads to an increase in mucus secretions. Guaifenesin increases the output of respiratory tract fluid by irritating the gastric mucosa and stimulating vagal afferent pathways. Terbutaline relaxes bronchial smooth muscle by acting as a selective beta2 adrenergic agonist. Menthol activates TRPM8 ion channels which results in a cooling sensation.
- Receptor Binding, Enzyme Inhibition or Neurotransmitter Modulation: Terbutaline is a beta-2 adrenergic agonist. Other components are not known to specifically bind to receptors or directly influence enzyme activity or neurotransmitters.
- Elimination Pathways: Bromhexine and its metabolites are primarily excreted in the urine. Guaifenesin is also eliminated in urine mostly unchanged. Terbutaline and menthol are metabolized in the liver, with subsequent elimination through the kidneys.
Dosage
Standard Dosage
Adults:
- The usual dose is 10ml (2 teaspoons) three times a day.
Children:
- 6-12 years: 5ml (1 teaspoon) three times a day.
- 2-6 years: 2.5 ml three times a day.
- Below 2 years: Not recommended.
Special Cases:
- Elderly Patients: Dose adjustments may be needed based on individual patient health and organ function.
- Patients with Renal Impairment: Dose adjustment is required in patients with severe renal impairment.
- Patients with Hepatic Dysfunction: Dose adjustments are necessary in patients with severe hepatic impairment.
- Patients with Comorbid Conditions: Caution should be exercised in patients with hypertension, diabetes mellitus, hyperthyroidism, cardiovascular diseases, and peptic ulcers.
Clinical Use Cases
The combination medication is not specifically indicated for intubation, surgical procedures, mechanical ventilation, ICU use, or emergency situations. It is primarily used for symptomatic relief of cough associated with bronchospasm in certain respiratory conditions.
Dosage Adjustments
- Dosage adjustments should be considered for patients with renal or hepatic impairment.
Side Effects
Common Side Effects
- Nausea, vomiting, diarrhea, drowsiness, headache, dizziness, skin rash, tremor, stomach upset, fast heartbeats, dry mouth.
Rare but Serious Side Effects
- Allergic reactions (difficulty breathing, swelling of face, lips, tongue, or throat), severe skin rash, paradoxical bronchospasm (worsening of breathing), irregular heartbeats, chest pain.
Long-Term Effects
- There’s limited data available on long-term side effects.
Adverse Drug Reactions (ADR)
- Severe allergic reactions, paradoxical bronchospasm, cardiac arrhythmias.
Contraindications
- Hypersensitivity to any components of the formulation.
- Pre-existing ischemic heart disease.
- Gastric ulcer.
- Hypertrophic cardiomyopathy
- Pheochromocytoma.
Drug Interactions
- Beta-blockers (e.g., propranolol) may reduce the effectiveness of Terbutaline.
- MAO inhibitors may potentiate the effects of Terbutaline.
- Diuretics may cause hypokalemia, which can interact with Terbutaline.
- Concomitant use with other sympathomimetics should be done with caution.
- Bromhexine may increase the concentration of antibiotics in bronchial secretions.
- Alcohol interaction is unknown and should be avoided.
Pregnancy and Breastfeeding
- Pregnancy: Terbutaline and Guaifenesin are Pregnancy Category C. Bromhexine is Pregnancy Category B. It should be avoided, especially in the first trimester.
- Breastfeeding: Terbutaline is excreted in breast milk. The safety profile is not fully established for other components. It is generally not recommended during breastfeeding.
Drug Profile Summary
- Mechanism of Action: Mucolytic, expectorant, and bronchodilator combination.
- Side Effects: Nausea, vomiting, headache, dizziness, tremor, etc. (refer to Side Effects section for details).
- Contraindications: Hypersensitivity, ischemic heart disease, gastric ulcer.
- Drug Interactions: Beta-blockers, MAO inhibitors, diuretics.
- Pregnancy & Breastfeeding: Not recommended, especially in the first trimester and during breastfeeding.
- Dosage: Adults: 10ml TDS; Children (6-12 yrs): 5ml TDS (refer to dosage section for specific cases).
- Monitoring Parameters: Respiratory rate, heart rate, blood pressure, blood glucose levels (especially in diabetic patients), potassium levels, thyroid function tests (in hyperthyroid patients).
Popular Combinations
While this combination itself is quite popular, sometimes other medications may be added based on individual patient conditions, like antibiotics for infections, or inhaled corticosteroids for asthma control.
Precautions
- General Precautions: Assess for allergies, metabolic disorders, organ dysfunction, and co-existing medical conditions before initiating therapy.
- Pregnant Women: Avoid, particularly in the first trimester.
- Breastfeeding Mothers: Not recommended.
- Children & Elderly: Use with caution. Dosage adjustments are often required.
- Lifestyle Considerations: Avoid alcohol. Smoking cessation is advised.
FAQs (Frequently Asked Questions)
Q1: What is the recommended dosage for Bromhexine + Guaifenesin + Menthol + Terbutaline?
A: Adults: 10ml TDS, Children (6-12 years): 5ml TDS (see dosage section for other age groups and special cases).
Q2: What are the common side effects?
A: Common side effects include nausea, vomiting, diarrhea, headache, dizziness, tremor, and skin rash.
Q3: Can this combination be used in asthmatics?
A: Yes, it is indicated for cough associated with bronchospasm, including in asthmatics. However, it should be used cautiously and as a part of a comprehensive asthma management plan.
Q4: Is it safe during pregnancy?
A: It is not recommended during pregnancy, particularly in the first trimester, due to limited safety data and the potential for adverse effects.
Q5: What are the contraindications to this combination?
A: Contraindications include hypersensitivity, ischemic heart disease, gastric ulcer, hypertrophic cardiomyopathy.
Q6: Are there any drug interactions I should be aware of?
A: Yes, it can interact with beta-blockers, MAO inhibitors, diuretics and other sympathomimetics.
Q7: Can it be used in patients with diabetes?
A: It should be used with caution in diabetics, with careful monitoring of blood glucose levels, as Terbutaline might increase blood sugar levels.
Q8: What should I do if a patient experiences side effects?
A: Mild side effects often resolve spontaneously. If side effects are persistent or severe, discontinue the medication and consult a physician.
Q9: Can this medication be used in children under 2 years of age?
A: No, it is not recommended for children under 2 years of age.
Q10: What is the mechanism of action of each ingredient in this combination?
A: Bromhexine breaks down mucus, Guaifenesin makes it less sticky, Terbutaline expands airways, and Menthol provides a soothing effect.
