Coming into cold and influenza season, the withdrawal of such a well-used cough suppressant may feel like a step backwards. But, on the contrary, it is a step forward for safety.

Anaesthetists have been calling for pholcodine to be removed from over-the-counter medications since it has been linked to six deaths over the past three years in Australia. In addition, long-term observations found a link between pholcodine use and anaphylactic (severe allergic) reactions when a person is given a neuromuscular blocking agent. Anaesthetists administer neuromuscular blocking agents during surgeries and procedures. Withdrawal of pholcodine overseas has proven to stop this risk.

Pholcodine may stimulate or sensitise the immune system the same way a bacteria or virus does. Our immune systems remember the foreign substance and become hyper alert and ready to fight the foreign substance rapidly upon subsequent exposure. Anaphylaxis happens when there is an overreaction. For example, anaphylaxis happens with antibiotics in some people. The person may not have a noticeable reaction with the first course; however, when introduced the second time, the immune system overreacts with an allergic reaction that, with further exposure, may become anaphylaxis.

Not everyone will develop anaphylaxis with antibiotics; nor will everyone develop anaphylaxis with pholcodine and neuromuscular blocking agents. However, medication use is balanced on the risks involved in taking the medication against the benefits gained. Because less risky alternatives are available, the Therapeutic Goods Administration decided to withdraw pholcodine from sale.

Tips for managing a persistent cough

Pholcodine is used for dry, persistent coughs. I suggest always looking at the cause of the cough first before suppressing it. Such as:

• If you have a runny nose and are coughing, primarily as you lie down, try a nasal decongestant and an extra pillow under your head.
• If you have a chest infection, suppressing the action which assists you in ridding yourself of phlegm is not helpful. Instead, use an expectorant that loosens the congestion in your chest.
• If you live with asthma, a dry cough is often a sign of a worsening condition and an imminent acute attack. Therefore, a dry cough in a person living with asthma requires immediate attention.
• Hayfever may cause a drip down the back of your throat. Post-nasal drip irritates your throat, causing a cough. Antihistamines and hayfever nasal sprays are better options for hayfever.
• Have you started a new medication? Some common blood pressure medications are associated with dry cough.
• A psychogenic cough happens when a dry cough becomes a habit. It can result from a traumatic experience or ongoing stress, which would benefit from a discussion with a health professional.
• Children are most susceptible to the adverse effects of cough and cold preparations. Please seek advice before using any preparation with a child. Keeping fluids up and promoting rest is the best and safest action.

The list of products being recalled is as follows (all strengths):

1. AMCAL DRY COUGH FORTE pholcodine, oral liquid bottle
2. APOHEALTH DRY TICKLY COUGH RELIEF pholcodine 1mg/mL oral liquid bottle
3. APOHEALTH DRY COUGH RELIEF PE & NASAL DECONGESTANT oral liquid bottle
4. BENADRYL DRY, TICKLY COUGH FORTE pholcodine 4mg/mL oral liquid bottle
5. BLOOMS THE CHEMIST DRY COUGH RELIEF & NASAL DECONGESTANT PE oral liquid bottle
6. CHEMISTS’ OWN DRY TICKLY COUGH FORTE pholcodine 4 mg/mL oral liquid bottle
7. CHEMISTS’ OWN KIDDICOL FOR CHILDREN COUGH & COLD oral liquid bottle
8. CHEMISTS’ OWN DRY COUGH PLUS NASAL DECONGESTANT PE oral liquid bottle
9. CHEMISTS OWN KIDDICOL CHILDREN’S COUGH MIXTURE oral liquid bottle
10. CODRAL DRY COUGH FORTE STRENGTH pholcodine 4mg/mL oral liquid bottle
11. DURO-TUSS DRY COUGH LIQUID and dry cough lozenges
12. DIFFLAM PLUS DRY COUGH + ANTIBACTERIAL + ANTI-INFLAMMATORY lozenges
13. DURO-TUSS DRY COUGH LIQUID PLUS NASAL DECONGESTANT oral liquid bottle
14. DURO-TUSS DRY COUGH LOZENGES orange flavour blister pack
15. DURO-TUSS COUGH LIQUID EXPECTORANT oral liquid bottle
16. DURO-TUSS PE DRY COUGH LIQUID + NASAL DECONGESTANT oral liquid bottle
17. LOGICIN DRY COUGH Pholcodine 1mg/mL oral liquid bottle
18. NOUMED DRY COUGH LIQUID FORTE pholcodine oral liquid bottle
19. PHARMACY HEALTH DRY COUGH RELIEF pholcodine  oral liquid bottle
20. PHARMACY CHOICE DRY COUGH RELIEF FORTE pholcodine liquid bottle
21. PHARMACY CHOICE PHOLCODINE DRY FORTE oral liquid bottle
22. PRICELINE PHARMACY DRY TICKLY COUGH MIXTURE pholcodine bottle
23. SOUL PATTINSON DRY TICKLY COUGH MEDICINE pholcodine oral liquid bottle
24. TERRY WHITE CHEMMART DRY COUGH RELIEF pholcodine oral liquid bottle

If you have one of these products at home, please return it to your local pharmacy for destruction. Flushing medications into sewerage or grey waste pollutes the environment.

Final note

If you have recently used these products, the effects of this reaction tend to wear off after three years. If you have taken these products within three years, please ensure that this is noted if you are having a surgical procedure. 

Always ask your pharmacist if an over-the-counter medication is suitable for you.

By Donna Itzstein, Pharmacist and Credentialled Diabetes Educator