Cough syrups are slowly making their way from their hallowed presence in the medicine cabinet to just another means of intoxication (Rupa Gulab’s chick-lit Girl Alone pitched the cough syrup bottle as the protagonist’s constant companion through health and sickness.) Doctors around the world are shying away from prescribing the once-revolutionary drug as innumerable studies have been unable to prove their efficacy, with many even likening their effect to placebos. Of course, in India, they remain the general practitioner’s favourite and can even be bought over the counter without a prescription.
Do cough syrups work? Most linctuses contain active ingredients in combinations — antihistamines, decongestants, expectorants, suppressants and antipyretics — that are prescribed for different kinds of cough. Swaraj Mishra, ENT consultant at Moolchand Medcity in New Delhi, explains, “The type of cough syrup advised differs from patient to patient. For instance, both Benadryl and Corex, the most popular brands available in the market, work on completely different principles and have different functions; one is an expectorant while the other is a suppressant, but people assume them to be the same and buy them anyway.”
The ingredients of the syrups too are a matter of concern. “Sedation is a serious side effect of certain medications because there is no standardisation of cough syrup contents in the market,” says Anil Sachdeva, director of pediatric emergency, critical care and pulmonology at Ganga Ram Hospital. ‘Cough syrup’ is a blanket term for different kinds of formulations for different kinds of symptoms. “This is why it is essential that a doctor be consulted before using any of the readily available products,” says Sachdeva.
In 2008, the US Food and Drug Administration (FDA) issued a public health advisory warning parents against giving cold and cough medicines to children under two years. Drug makers responded by voluntarily changing the labelling of their products to recommend them for children older than four. The warning came close on the heels of a Cochrane report. The independent non-profit partner of the World Health Organisation, which conducts systematic reviews of trials, concluded that “there is no good evidence for or against the effectiveness of over-the-counter (OTC) medicines in acute cough”. Even within the UK, the latest guidelines advise parents and caregivers to cease using OTC cough and cold medicines for children under six, where side effects such as allergic reactions, effects on sleep or hallucinations are a genuine cause for concern. Professionals in the medical industry state that this warning should be taken seriously in India as well and urge extreme caution while administering doses to children. A GlaxoSmithKline spokesperson states that “recommended doses for various age groups are mentioned in the product prescribing information and these need to be adhered to. In general, cough preparations are not recommended in children less than two years of age.”
Amit Sen Gupta, joint convener of the Jan Swasthya Abhiyan, talks about the role of aggressive and unethical marketing in the pharmaceutical industry. “Cough syrups have disappeared from standard textbooks of medicine and pharmaceutical literature for decades now. But in India you do not have a system of continuously monitoring medicines that are available in the market, irrespective of their scientific validity,” he says. He also says there is no medical logic in suppressing cough — it is the body’s beneficial response to an allergic reaction or an infection, which is trying to expel something it doesn’t want, in this case phlegm. Gupta suggest instead the use of simple remedies of traditional Indian medicine, such as honey and clove and steam inhalation for the expulsion of phlegm.
However, many Indian doctors stress on the importance of proper consultation and prescription. Sachdeva prefers treating the cause of a cough rather than the cough itself, which can range from a seasonal allergy, mild infection and asthma to a pneumonia and bronchitis. “If the patient has dry cough, then an antiallergic syrup with single medication is preferable, or maybe a suppressant if the cough is severe,” he says. The consensus among doctors is that if a cough persists for more than three days, seeing a doctor is the prudent step. That plus carefully monitoring the dosage is the best way forward.