Dextromethorphan and chlorpheniramine: Drug information

(For additional information see "Dextromethorphan and chlorpheniramine: Patient drug information" and see "Dextromethorphan and chlorpheniramine: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)

Brand Names: US

Coricidin HBP Cough/Cold [OTC];
Cough & Cold [OTC];
Dimetapp Long Act Cough/Cold [OTC] [DSC];
Robitussin Child Cough/Cold LA [OTC];
Robitussin Nighttime Cough [OTC];
Triaminic Cough/Runny Nose [OTC];
Vicks NyQuil Childrens Cld/Cgh [OTC]

Pharmacologic Category

Alkylamine Derivative;
Antitussive;
Histamine H₁ Antagonist;
Histamine H₁ Antagonist, First Generation

Dosing: Adult

General dosing guidelines; consult specific product labeling.

Cough, cold symptoms

Cough, cold symptoms: Oral:

Tablet:

Dextromethorphan 30 mg/chlorpheniramine 4 mg: One tablet every 6 hours as needed (maximum: dextromethorphan 120 mg/chlorpheniramine 16 mg every 24 hours).

Liquid:

Dextromethorphan 15 mg/chlorpheniramine 2 mg per 5 mL: 10 mL every 6 hours (maximum: dextromethorphan 120 mg/chlorpheniramine 16 mg every 24 hours).

Dextromethorphan 15 mg/chlorpheniramine 2 mg per 10 mL: 20 mL every 6 hours (maximum: dextromethorphan 120 mg/chlorpheniramine 16 mg every 24 hours).

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Older Adult

Avoid use (Ref).

Dosing: Pediatric

(For additional information see "Dextromethorphan and chlorpheniramine: Pediatric drug information")

Cough, cold symptoms

Cough, cold symptoms:

Note: Multiple concentrations of oral liquid formulations exist; close attention must be paid to the concentration when ordering or administering. Safety and efficacy for the use of cough and cold products in infants and young children are limited; the AAP warns against the use of these products for respiratory illnesses in infants and young children (Ref).

Liquid:

Dextromethorphan 5 mg/chlorpheniramine 0.67 mg per 5 mL (eg, Vicks Children's NyQuil Cold and Cough Multi Symptom Relief):

Children 6 to <12 years: Oral: 15 mL every 6 hours as needed. Maximum daily dose: 60 mL per 24 hours (dextromethorphan 60 mg/chlorpheniramine 8 mg per 24 hours).

Children ≥12 years and Adolescents: Oral: 30 mL every 6 hours as needed. Maximum daily dose: 120 mL per 24 hours (dextromethorphan 120 mg/chlorpheniramine 16 mg per 24 hours).

Dextromethorphan 7.5 mg/chlorpheniramine 1 mg per 5 mL (eg, Robitussin Children's Cough-Cold Long Acting):

Children 6 to <12 years: Oral: 10 mL every 6 hours as needed. Maximum daily dose: 40 mL per 24 hours (dextromethorphan 60 mg/chlorpheniramine 8 mg per 24 hours).

Children ≥12 years and Adolescents: Oral: 20 mL every 6 hours as needed. Maximum daily dose: 80 mL per 24 hours (dextromethorphan 120 mg/chlorpheniramine 16 mg per 24 hours).

Dextromethorphan 15 mg/chlorpheniramine 2 mg per 5 mL (eg, Scot-Tussin):

Children ≥12 years and Adolescents: Oral: 10 mL every 6 hours as needed. Maximum daily dose: 40 mL per 24 hours (dextromethorphan 120 mg/chlorpheniramine 16 mg per 24 hours).

Dextromethorphan 18 mg/chlorpheniramine 4 mg per 5 mL (eg, Maxi-Tuss DM):

Children 6 to <12 years: Oral: 2.5 mL every 4 hours as needed. Maximum daily dose: 15 mL per 24 hours (dextromethorphan 54 mg/chlorpheniramine 12 mg per 24 hours).

Children ≥12 years and Adolescents: Oral: 5 mL every 4 hours as needed. Maximum daily dose: 30 mL per 24 hours (dextromethorphan 108 mg/chlorpheniramine 24 mg per 24 hours).

Tablet:

Dextromethorphan 30 mg/chlorpheniramine 4 mg:

Children ≥12 years and Adolescents: Oral: One tablet every 6 hours as needed. Maximum daily dose: 4 tablets per 24 hours (dextromethorphan 120 mg/chlorpheniramine 16 mg per 24 hours).

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling; however, chlorpheniramine is metabolized via the liver; therefore, a dosage adjustment may be necessary.

Adverse Reactions

See individual agents.

Contraindications

Use with or within 14 days of discontinuing MAO inhibitor; do not use to sedate a child

Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Warnings/Precautions

Concerns related to adverse effects:

• CNS depression: May cause CNS depression, which may impair physical or mental abilities; patients must be cautioned about performing tasks which require mental alertness (eg, operating machinery or driving).

Concurrent drug therapy issues:

• Sedatives: Effects may be potentiated when used with other sedative drugs or ethanol.

Special populations:

• CYP2D6 poor metabolizers: Dextromethorphan is metabolized by hepatic CYP2D6. Poor metabolizers of CYP2D6 may have exaggerated or prolonged effects of dextromethorphan. Increased risk may be seen with concomitant use of potent CYP2D6 inhibitors; use with caution (Abduljalil 2010; Jurica 2012; Sager 2014; Zhou 2009).

• Pediatric: Antihistamines may cause excitation in young children. Do not exceed pediatric dosing recommendations. Not for OTC use in children <6 years of age.

Dosage form specific issues:

• Phenylalanine: Some products may contain phenylalanine.

Other warnings/precautions:

• Self-medication (OTC use): Patients with glaucoma or prostatic hyperplasia should consult healthcare provider prior to use. Patients with chronic cough (associated with COPD or smoking) and/or productive cough (eg, copious amounts of phlegm) should be evaluated by a healthcare provider prior to use. Ask healthcare provider prior to using with sedatives. If cough does not improve, is accompanied by rash, fever, or headache, or persists >7 days during use, discontinue use and consult a physician. Do not exceed recommended dose.

Warnings: Additional Pediatric Considerations

Safety and efficacy for the use of cough and cold products in pediatric patients <4 years of age are limited; the AAP warns against the use of these products for respiratory illnesses in young children. Serious adverse effects including death have been reported (in some cases, high blood concentrations of pseudoephedrine were found). Many of these products contain multiple active ingredients, increasing the risk of accidental overdose when used with other products. The FDA does not recommend OTC uses for these products in pediatric patients <2 years of age and recommends using with caution in pediatric patients ≥2 years of age. Health care providers are reminded to ask caregivers about the use of OTC cough and cold products in order to avoid exposure to multiple medications containing the same ingredient (AAP 2018; CDC 2007; FDA 2017; FDA 2018). Antihistamines should not be used to make an infant or child sleepy. Multiple concentrations of oral liquid formulations exist; close attention must be paid to the concentration when ordering or administering.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Liquid, Oral:

Robitussin Child Cough/Cold LA: Dextromethorphan hydrobromide 7.5 mg and chlorpheniramine maleate 1 mg per 5 mL (118 mL) [contains fd&c red #40 (allura red ac dye), propylene glycol, sodium benzoate]

Robitussin Nighttime Cough: Dextromethorphan hydrobromide 7.5 mg and chlorpheniramine maleate 1 mg per 5 mL (118 mL) [alcohol free; contains fd&c red #40 (allura red ac dye), propylene glycol, sodium benzoate; fruit punch flavor]

Vicks NyQuil Childrens Cld/Cgh: Dextromethorphan hydrobromide 15 mg and chlorpheniramine maleate 2 mg per 15 mL (236 mL) [acetaminophen free, alcohol free, aspirin free; contains fd&c red #40 (allura red ac dye), propylene glycol; cherry flavor]

Syrup, Oral:

Dimetapp Long Act Cough/Cold: Dextromethorphan hydrobromide 7.5 mg and chlorpheniramine maleate 1mg per 5 mL (118 mL [DSC]) [alcohol free; contains fd&c blue #1 (brilliant blue), fd&c red #40 (allura red ac dye), propylene glycol, sodium benzoate]

Tablet, Oral:

Coricidin HBP Cough/Cold: Dextromethorphan hydrobromide 30 mg and chlorpheniramine maleate 4 mg [DSC] [contains fd&c yellow #6(sunset yellow)alumin lake]

Coricidin HBP Cough/Cold: Dextromethorphan hydrobromide 30 mg and chlorpheniramine maleate 4 mg [contains fd&c yellow #6(sunset yellow)alumin lake, sodium benzoate]

Cough & Cold: Dextromethorphan hydrobromide 30 mg and chlorpheniramine maleate 4 mg [decongestant free; contains fd&c yellow #6(sunset yellow)alumin lake]

Tablet Chewable, Oral:

Triaminic Cough/Runny Nose: Dextromethorphan hydrobromide 5 mg and chlorpheniramine maleate 1 mg [scored; contains aspartame, fd&c blue #2 (indigo carm) aluminum lake; cherry flavor]

Generic Equivalent Available: US

May be product dependent

Pricing: US

Chewable (Triaminic Cough/Runny Nose Oral)

1-5 mg (per each): $0.27

Liquid (Robitussin Child Cough/Cold LA Oral)

1-7.5 mg/5 mL (per mL): $0.05

Liquid (Robitussin Nighttime Cough Oral)

1-7.5 mg/5 mL (per mL): $0.05

Tablets (Coricidin HBP Cough/Cold Oral)

4-30 mg (per each): $0.37

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Administration: Pediatric

Oral: Administer oral liquids with an accurate measuring device; do not use a household teaspoon (overdosage may occur).

Use: Labeled Indications

Cough, cold symptoms: Symptomatic relief of runny nose, sneezing, itchy/watery eyes, or itchy nose/throat due to common cold, hay fever, or other upper respiratory allergies; symptomatic relief of cough due to minor throat and bronchial irritation associated with a cold

Medication Safety Issues

Older Adult: High-Risk Medication:

Beers Criteria: Chlorpheniramine, a first-generation antihistamine, is identified in the Beers Criteria as a potentially inappropriate medication to be avoided in patients 65 years and older (independent of diagnosis or condition) due to its potent anticholinergic properties resulting in increased risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity; use should also be avoided due to reduced clearance with advanced age and tolerance associated with use as a hypnotic. Exposure to concurrent anticholinergic drugs also increases risk of falls, delirium, and dementia; consider total anticholinergic burden when conducting medication reviews (Beers Criteria [AGS 2023]).

Metabolism/Transport Effects

Refer to individual components.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Acetylcholinesterase Inhibitors: May diminish the therapeutic effect of Anticholinergic Agents. Anticholinergic Agents may diminish the therapeutic effect of Acetylcholinesterase Inhibitors. Risk C: Monitor therapy

Aclidinium: May enhance the anticholinergic effect of Anticholinergic Agents. Risk X: Avoid combination

Ajmaline: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Alcohol (Ethyl): CNS Depressants may enhance the CNS depressant effect of Alcohol (Ethyl). Risk C: Monitor therapy

Alizapride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Amantadine: May enhance the anticholinergic effect of Anticholinergic Agents. Risk C: Monitor therapy

Amezinium: Antihistamines may enhance the stimulatory effect of Amezinium. Risk C: Monitor therapy

Anticholinergic Agents: May enhance the adverse/toxic effect of other Anticholinergic Agents. Risk C: Monitor therapy

Artemether and Lumefantrine: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Azelastine (Nasal): May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Benzylpenicilloyl Polylysine: Antihistamines may diminish the diagnostic effect of Benzylpenicilloyl Polylysine. Management: Suspend systemic H1 antagonists for benzylpenicilloyl-polylysine skin testing and delay testing until systemic antihistaminic effects have dissipated. A histamine skin test may be used to assess persistent antihistaminic effects. Risk D: Consider therapy modification

Betahistine: Antihistamines may diminish the therapeutic effect of Betahistine. Betahistine may diminish the therapeutic effect of Antihistamines. Risk C: Monitor therapy

Blonanserin: CNS Depressants may enhance the CNS depressant effect of Blonanserin. Management: Use caution if coadministering blonanserin and CNS depressants; dose reduction of the other CNS depressant may be required. Strong CNS depressants should not be coadministered with blonanserin. Risk D: Consider therapy modification

Botulinum Toxin-Containing Products: May enhance the anticholinergic effect of Anticholinergic Agents. Risk C: Monitor therapy

Brexanolone: CNS Depressants may enhance the CNS depressant effect of Brexanolone. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Bromopride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Bromperidol: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Buprenorphine: CNS Depressants may enhance the CNS depressant effect of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine at lower doses in patients already receiving CNS depressants. Risk D: Consider therapy modification

Cannabinoid-Containing Products: Anticholinergic Agents may enhance the tachycardic effect of Cannabinoid-Containing Products. Risk C: Monitor therapy

Cannabinoid-Containing Products: CNS Depressants may enhance the CNS depressant effect of Cannabinoid-Containing Products. Risk C: Monitor therapy

Chloral Betaine: May enhance the adverse/toxic effect of Anticholinergic Agents. Risk C: Monitor therapy

Chlormethiazole: May enhance the CNS depressant effect of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used. Risk D: Consider therapy modification

Chlorphenesin Carbamate: May enhance the adverse/toxic effect of CNS Depressants. Risk C: Monitor therapy

Chlorprothixene: Anticholinergic Agents may enhance the anticholinergic effect of Chlorprothixene. Risk C: Monitor therapy

Cimetropium: Anticholinergic Agents may enhance the anticholinergic effect of Cimetropium. Risk X: Avoid combination

CloZAPine: Anticholinergic Agents may enhance the constipating effect of CloZAPine. Management: Consider alternatives to this combination whenever possible. If combined, monitor closely for signs and symptoms of gastrointestinal hypomotility and consider prophylactic laxative treatment. Risk D: Consider therapy modification

CNS Depressants: May enhance the adverse/toxic effect of other CNS Depressants. Risk C: Monitor therapy

CYP2D6 Inhibitors (Moderate): May increase the serum concentration of Dextromethorphan. Risk C: Monitor therapy

CYP2D6 Inhibitors (Strong): May increase the serum concentration of Chlorpheniramine. Risk C: Monitor therapy

CYP2D6 Inhibitors (Strong): May increase the serum concentration of Dextromethorphan. Risk C: Monitor therapy

Daridorexant: May enhance the CNS depressant effect of CNS Depressants. Management: Dose reduction of daridorexant and/or any other CNS depressant may be necessary. Use of daridorexant with alcohol is not recommended, and the use of daridorexant with any other drug to treat insomnia is not recommended. Risk D: Consider therapy modification

DexmedeTOMIDine: CNS Depressants may enhance the CNS depressant effect of DexmedeTOMIDine. Management: Monitor for increased CNS depression during coadministration of dexmedetomidine and CNS depressants, and consider dose reductions of either agent to avoid excessive CNS depression. Risk D: Consider therapy modification

Difelikefalin: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Dimethindene (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Disulfiram: May enhance the adverse/toxic effect of Products Containing Ethanol. Management: Do not use disulfiram with dosage forms that contain ethanol. Risk X: Avoid combination

Doxylamine: CNS Depressants may enhance the CNS depressant effect of Doxylamine. Risk C: Monitor therapy

DroPERidol: May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (eg, opioids, barbiturates) with concomitant use. Risk D: Consider therapy modification

Eluxadoline: Anticholinergic Agents may enhance the constipating effect of Eluxadoline. Risk X: Avoid combination

Esketamine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Flunarizine: CNS Depressants may enhance the CNS depressant effect of Flunarizine. Risk X: Avoid combination

Flunitrazepam: CNS Depressants may enhance the CNS depressant effect of Flunitrazepam. Management: Reduce the dose of CNS depressants when combined with flunitrazepam and monitor patients for evidence of CNS depression (eg, sedation, respiratory depression). Use non-CNS depressant alternatives when available. Risk D: Consider therapy modification

Fosphenytoin-Phenytoin: Chlorpheniramine may increase the serum concentration of Fosphenytoin-Phenytoin. Risk C: Monitor therapy

Gastrointestinal Agents (Prokinetic): Anticholinergic Agents may diminish the therapeutic effect of Gastrointestinal Agents (Prokinetic). Risk C: Monitor therapy

Glucagon: Anticholinergic Agents may enhance the adverse/toxic effect of Glucagon. Specifically, the risk of gastrointestinal adverse effects may be increased. Risk C: Monitor therapy

Glycopyrrolate (Oral Inhalation): Anticholinergic Agents may enhance the anticholinergic effect of Glycopyrrolate (Oral Inhalation). Risk X: Avoid combination

Glycopyrronium (Topical): May enhance the anticholinergic effect of Anticholinergic Agents. Risk X: Avoid combination

Hyaluronidase: Antihistamines may diminish the therapeutic effect of Hyaluronidase. Risk C: Monitor therapy

HydrOXYzine: May enhance the CNS depressant effect of CNS Depressants. Management: Consider a decrease in the CNS depressant dose, as appropriate, when used together with hydroxyzine. Increase monitoring of signs/symptoms of CNS depression in any patient receiving hydroxyzine together with another CNS depressant. Risk D: Consider therapy modification

Ipratropium (Oral Inhalation): May enhance the anticholinergic effect of Anticholinergic Agents. Risk X: Avoid combination

Isoproterenol: Chlorpheniramine may enhance the therapeutic effect of Isoproterenol. Risk C: Monitor therapy

Itopride: Anticholinergic Agents may diminish the therapeutic effect of Itopride. Risk C: Monitor therapy

Ixabepilone: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Kava Kava: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Kratom: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Lemborexant: May enhance the CNS depressant effect of CNS Depressants. Management: Dosage adjustments of lemborexant and of concomitant CNS depressants may be necessary when administered together because of potentially additive CNS depressant effects. Close monitoring for CNS depressant effects is necessary. Risk D: Consider therapy modification

Levosulpiride: Anticholinergic Agents may diminish the therapeutic effect of Levosulpiride. Risk X: Avoid combination

Lisuride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Lofexidine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Magnesium Sulfate: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Memantine: NMDA Receptor Antagonists may enhance the adverse/toxic effect of Memantine. Risk C: Monitor therapy

Methotrimeprazine: Products Containing Ethanol may enhance the adverse/toxic effect of Methotrimeprazine. Specifically, a disulfiram-like reaction may occur and CNS depressant effects may be increased. Management: Avoid products containing alcohol in patients treated with methotrimeprazine. Risk X: Avoid combination

Metoclopramide: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

MetyroSINE: CNS Depressants may enhance the sedative effect of MetyroSINE. Risk C: Monitor therapy

Mianserin: May enhance the anticholinergic effect of Anticholinergic Agents. Risk C: Monitor therapy

Minocycline (Systemic): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Mirabegron: Anticholinergic Agents may enhance the adverse/toxic effect of Mirabegron. Risk C: Monitor therapy

Monoamine Oxidase Inhibitors: Dextromethorphan may enhance the serotonergic effect of Monoamine Oxidase Inhibitors. This may cause serotonin syndrome. Risk X: Avoid combination

Nabilone: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Nitroglycerin: Anticholinergic Agents may decrease the absorption of Nitroglycerin. Specifically, anticholinergic agents may decrease the dissolution of sublingual nitroglycerin tablets, possibly impairing or slowing nitroglycerin absorption. Risk C: Monitor therapy

Olopatadine (Nasal): May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Opioid Agonists: CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification

Ornidazole: May enhance the adverse/toxic effect of Products Containing Ethanol. Specifically, a disulfiram-like reaction may occur. Risk X: Avoid combination

Orphenadrine: CNS Depressants may enhance the CNS depressant effect of Orphenadrine. Risk X: Avoid combination

Oxatomide: May enhance the anticholinergic effect of Anticholinergic Agents. Risk X: Avoid combination

Oxomemazine: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Oxybate Salt Products: CNS Depressants may enhance the CNS depressant effect of Oxybate Salt Products. Management: Consider alternatives to this combination when possible. If combined, dose reduction or discontinuation of one or more CNS depressants (including the oxybate salt product) should be considered. Interrupt oxybate salt treatment during short-term opioid use Risk D: Consider therapy modification

OxyCODONE: CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification

Paraldehyde: CNS Depressants may enhance the CNS depressant effect of Paraldehyde. Risk X: Avoid combination

Parecoxib: May increase the serum concentration of Dextromethorphan. Risk C: Monitor therapy

Peginterferon Alfa-2b: May decrease the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Peginterferon Alfa-2b may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Perampanel: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Piribedil: CNS Depressants may enhance the CNS depressant effect of Piribedil. Risk C: Monitor therapy

Pitolisant: Antihistamines may diminish the therapeutic effect of Pitolisant. Risk X: Avoid combination

Potassium Chloride: Anticholinergic Agents may enhance the ulcerogenic effect of Potassium Chloride. Management: Patients on drugs with substantial anticholinergic effects should avoid using any solid oral dosage form of potassium chloride. Risk X: Avoid combination

Potassium Citrate: Anticholinergic Agents may enhance the ulcerogenic effect of Potassium Citrate. Management: Patients on drugs with substantial anticholinergic effects should avoid using any solid oral dosage form of potassium citrate. Risk X: Avoid combination

Pramipexole: CNS Depressants may enhance the sedative effect of Pramipexole. Risk C: Monitor therapy

Pramlintide: May enhance the anticholinergic effect of Anticholinergic Agents. These effects are specific to the GI tract. Risk X: Avoid combination

Procarbazine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Ramosetron: Anticholinergic Agents may enhance the constipating effect of Ramosetron. Risk C: Monitor therapy

Revefenacin: Anticholinergic Agents may enhance the anticholinergic effect of Revefenacin. Risk X: Avoid combination

Rivastigmine: Anticholinergic Agents may diminish the therapeutic effect of Rivastigmine. Rivastigmine may diminish the therapeutic effect of Anticholinergic Agents. Management: Use of rivastigmine with an anticholinergic agent is not recommended unless clinically necessary. If the combination is necessary, monitor for reduced anticholinergic effects. Risk D: Consider therapy modification

Ropeginterferon Alfa-2b: CNS Depressants may enhance the adverse/toxic effect of Ropeginterferon Alfa-2b. Specifically, the risk of neuropsychiatric adverse effects may be increased. Management: Avoid coadministration of ropeginterferon alfa-2b and other CNS depressants. If this combination cannot be avoided, monitor patients for neuropsychiatric adverse effects (eg, depression, suicidal ideation, aggression, mania). Risk D: Consider therapy modification

ROPINIRole: CNS Depressants may enhance the sedative effect of ROPINIRole. Risk C: Monitor therapy

Rotigotine: CNS Depressants may enhance the sedative effect of Rotigotine. Risk C: Monitor therapy

Rufinamide: May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced. Risk C: Monitor therapy

Secnidazole: Products Containing Ethanol may enhance the adverse/toxic effect of Secnidazole. Risk X: Avoid combination

Secretin: Anticholinergic Agents may diminish the therapeutic effect of Secretin. Management: Avoid concomitant use of anticholinergic agents and secretin. Discontinue anticholinergic agents at least 5 half-lives prior to administration of secretin. Risk D: Consider therapy modification

Selective Serotonin Reuptake Inhibitors (Strong CYP2D6 Inhibitors): Dextromethorphan may enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors (Strong CYP2D6 Inhibitors). This could result in serotonin syndrome. Selective Serotonin Reuptake Inhibitors (Strong CYP2D6 Inhibitors) may increase the serum concentration of Dextromethorphan. Management: Consider alternatives to this drug combination. The dose of dextromethorphan/bupropion product should not exceed 1 tablet once daily. Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity. Risk D: Consider therapy modification

Serotonergic Agents (High Risk): Dextromethorphan may enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Suvorexant: CNS Depressants may enhance the CNS depressant effect of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended. Risk D: Consider therapy modification

Thalidomide: CNS Depressants may enhance the CNS depressant effect of Thalidomide. Risk X: Avoid combination

Thiazide and Thiazide-Like Diuretics: Anticholinergic Agents may increase the serum concentration of Thiazide and Thiazide-Like Diuretics. Risk C: Monitor therapy

Thioridazine: Chlorpheniramine may enhance the arrhythmogenic effect of Thioridazine. Thioridazine may increase the serum concentration of Chlorpheniramine. Management: Avoid this combination when possible. If used, monitor closely for arrhythmia as well as general toxicity of chlorpheniramine. Risk D: Consider therapy modification

Tiotropium: Anticholinergic Agents may enhance the anticholinergic effect of Tiotropium. Risk X: Avoid combination

Topiramate: Anticholinergic Agents may enhance the adverse/toxic effect of Topiramate. Risk C: Monitor therapy

Trimeprazine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Umeclidinium: May enhance the anticholinergic effect of Anticholinergic Agents. Risk X: Avoid combination

Valerian: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Zolpidem: CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. Risk D: Consider therapy modification

Zuranolone: May enhance the CNS depressant effect of CNS Depressants. Management: Consider alternatives to the use of zuranolone with other CNS depressants or alcohol. If combined, consider a zuranolone dose reduction and monitor patients closely for increased CNS depressant effects. Risk D: Consider therapy modification

Pregnancy Considerations

Refer to individual monographs.

Breastfeeding Considerations

Refer to individual monographs.

Dietary Considerations

Some products may contain phenylalanine and/or sodium.

Mechanism of Action

Chlorpheniramine maleate: Antihistamine with H₁-receptor activity

Dextromethorphan: A nonopioid antitussive, increases cough threshold by its activity on the medulla oblongata

Pharmacokinetics (Adult Data Unless Noted)

See individual agents.

Brand Names: International

International Brand Names by Country

For country code abbreviations (show table)

(CO) Colombia: Docefal | Docefal tosus | Tusbron;
(DO) Dominican Republic: Chemitusin Antitusivo;
(EC) Ecuador: Acrotussin;
(EG) Egypt: Codaphen d | Codaphen n | Neo pulmolar | Pulmolar;
(GB) United Kingdom: Venos night time;
(HK) Hong Kong: Dextromine;
(ID) Indonesia: Bronkaf | Novadryl;
(IN) India: Adzutus d | Aerodil dx | Agikuff d | Alkof dx | Ambrodil d | Atminic dca | Bricarex dx | Brutus dx | Chericof 12 | Cheston cs | Cheston d | Codistar DX | Codzi d | Cofdex plus | Cofstop cdx | Conaril dx | Corex-dx | Corico DX | Coriminic dm | Cozin dx | Cufease | Dilo dx | Emcoril dx | Ephrilime plus | Exiplon-dm | Franklor cs | Grilinctus dx | Histolin-dx | Kofgard d | Lastuss D | Magnatuss dx | New tixylix | Norvent d | Noxcold dx | Ocimel d | Panthor nf | Phensedyl dmr | Phensedyl dx | Phensedyl-dm | Piril-dx | Piriton cs | Protussa | Pulmorest d | Rexcof dx | Rinza | Rizet dx | Salmodil dx | Sedorex dx | Siricodin-dm | Supko d | Tekof | Tixylix dx | Topex dx | Toxolite DX | Toxolite-PD | Tricof | Viscodyne D | Xitol D | Zedex sf | Zerotuss d;
(IQ) Iraq: Antusin | Sedafen d | Tussidad;
(JO) Jordan: Sanafen forte | Sanafen plus;
(KE) Kenya: Coscof dx linctus | Respira-d;
(PK) Pakistan: Babynol;
(PR) Puerto Rico: Coricidin hbp cough & cold | Maxichlor DM | Triaminic Cough & Runny Nose;
(TH) Thailand: Cofta cough linctus | Decol | Dephandon | Dextromine | Dextrophen | Farotus | Ida | Itane | Mezophan | Pastina | Tussicon;
(UG) Uganda: Cosyp d;
(VE) Venezuela, Bolivarian Republic of: Yonalat;
(VN) Viet Nam: Vacoridex;
(ZM) Zambia: Respira-d

2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs [PubMed 37139824]
Abduljalil K, Frank D, Gaedigk A, et al. Assessment of activity levels for CYP2D6*1, CYP2D6*2, and CYP2D6*41 genes by population pharmacokinetics of dextromethorphan. Clin Pharmacol Ther. 2010;88(5):643-651. doi: 10.1038/clpt.2010.137. [PubMed 20881950]
American Academy of Pediatrics (AAP). Cough and cold medicines should not be prescribed, recommended or used for respiratory illnesses in young children. Updated June 12, 2018. Available at http://www.choosingwisely.org/clinician-lists/american-academy-pediatrics-cough-and-cold-medicines-for-children-under-four/
Centers for Disease Control and Prevention (CDC). Infant deaths associated with cough and cold medications--two states, 2005. MMWR Morb Mortal Wkly Rep. 2007;56(1):1-4. [PubMed 17218934]
Childrens Dimetapp Long-Acting Cough Plus Cold (chlorpheniramine maleate/dextromethorphan hydrobromide liquid) [prescribing information]. Madison, NJ: Pfizer; received November 2020.
Childrens Robitussin Cough and Cold Long-Acting (chlorpheniramine maleate/dextromethorphan hydrobromide liquid) [prescribing information]. Madison, NJ: Pfizer; received November 2020.
Coricidin HBP Cough & Cold Cough (chlorpheniramine maleate/dextromethorphan hydrobromide) [prescribing information]. Whippany, NJ: Bayer Healthcare, LLC; no date.
Coricidin HMP Cough and Cold Cough Suppressant (chlorpheniramine maleate/dextromethorphan hydrobromide tablet, film-coated) [prescribing information]. Whippany, NJ: Bayer Healthcare, LLC; May 2017.
Food and Drug Administration (FDA). Most young children with a cough or cold don't need medicines. July 18, 2017. Available at https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm422465.htm. Last accessed November 2, 2018.
Food and Drug Administration (FDA). Use caution when giving cough and cold products to kids. Updated February 8, 2018. Available at https://www.fda.gov/drugs/resourcesforyou/specialfeatures/ucm263948.htm. Last accessed November 2, 2018.
Jurica J, Bartecek R, Zourkova A, et al. Serum dextromethorphan/dextrorphan metabolic ratio for CYP2D6 phenotyping in clinical practice. J Clin Pharm Ther. 2012;37(4):486-490. doi: 10.1111/j.1365-2710.2012.01333.x. [PubMed 22548589]
Maxi-Tuss DM (chlorpheniramine maleate/dextromethorphan hydrobromide) [prescribing information]. Brooksville, FL: MCR American Pharmaceuticals; January 2018.
Sager JE, Lutz JD, Foti RS, et al. Fluoxetine- and norfluoxetine-mediated complex drug-drug interactions: in vitro to in vivo correlation of effects on CYP2D6, CYP2C19, and CYP3A4. Clin Pharmacol Ther. 2014;95(6):653-662. doi: 10.1038/clpt.2014.50. [PubMed 24569517]
Scot-Tussin DM SF Maximum Strength Cough Cold (chlorpheniramine maleate/dextromethorphan hydrobromide liquid) [prescribing information]. San Diego, CA: IriSys, LLC; received November 2020.
Vicks Children's NyQuil Cold and Cough Multi-Symptom Relief (chlorpheniramine maleate/dextromethorphan hydrobromide) [prescribing information]. Cincinnati, OH: Procter & Gamble; August 2019.
Zhou SF. Polymorphism of human cytochrome P450 2D6 and its clinical significance: part II. Clin Pharmacokinet. 2009;48(12):761-804. doi: 10.2165/11318070-000000000-00000. [PubMed 19902987]

Topic 9013 Version 270.0

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Dextromethorphan and chlorpheniramine: Drug information