Introduction ⬇
ATC Class:RO5DA09
VA Class:RE302
AHFS Class:
Generic Name(s):
- Dextromethorphan Hydrobromide
Dextromethorphan, a derivative of levorphanol, is an antitussive agent.
Uses ⬆ ⬇
Dextromethorphan is used for the temporary relief of coughs caused by minor throat and bronchial irritation such as may occur with common colds or with inhaled irritants. Dextromethorphan is most effective in the treatment of chronic, nonproductive cough. The drug is a common ingredient in commercial cough mixtures available without prescription.
Although cough and cold preparations that contain cough suppressants (including dextromethorphan), nasal decongestants, antihistamines, and/or expectorants commonly are used in pediatric patients younger than 2 years of age, systematic reviews of controlled trials have concluded that nonprescription (over-the-counter, OTC) cough and cold preparations are not more effective than placebo in reducing acute cough and other symptoms of upper respiratory tract infection in these patients.116 Furthermore, adverse events, including deaths, have been (and continue to be) reported in pediatric patients younger than 2 years of age receiving these preparations.116 (See Cautions: Pediatric Precautions and see Acute Toxicity: Manifestations.)
For information on abuse of dextromethorphan, see Cautions.
For use of dextromethorphan hydrobromide in fixed combination with quinidine sulfate in the treatment of pseudobulbar affect (PBA), see Dextromethorphan Hydrobromide and Quinidine Sulfate 28:92.
Dosage and Administration ⬆ ⬇
Administration 
Dextromethorphan preparations are administered orally. Lozenges containing dextromethorphan hydrobromide should not be used in children younger than 6 years of age and liquid-filled capsules containing the drug should not be used in children younger than 12 years of age, unless otherwise directed by a clinician.110
Dosage
Dosages of dextromethorphan hydrobromide and dextromethorphan polistirex are expressed in terms of dextromethorphan hydrobromide.105
The usual dosage of dextromethorphan hydrobromide for adults and children 12 years of age or older is 10-20 mg every 4 hours or 30 mg every 6-8 hours, not to exceed 120 mg daily, or as directed by a clinician.105,106,110 The usual dosage for children 6 to younger than 12 years of age is 5-10 mg every 4 hours or 15 mg every 6-8 hours, not to exceed 60 mg daily, or as directed by a clinician.105,106 Children 2 to younger than 6 years of age may receive 2.5-5 mg every 4 hours or 7.5 mg every 6-8 hours, not to exceed 30 mg daily, or as directed by a clinician.105,106 Dosage in children younger than 2 years of age must be individualized. Suggested dosages for children younger than 2 years of age† for some cough and cold preparations have been published in various references for prescribing and parenting.116 Using recommended dosages for adults and older children, some clinicians have extrapolated dosages for these preparations based on the weight or age of children younger than 2 years of age.116 However, these extrapolations were based on assumptions that pathology of the disease and pharmacology of the drugs are similar in adults and pediatric patients.116 There currently are no specific dosage recommendations (i.e., approved by the US Food and Drug Administration [FDA]) for cough and cold preparations for this patient population.116 (See Cautions: Pediatric Precautions.)
The usual dosage of dextromethorphan hydrobromide as the extended-release oral suspension containing the polistirex for adults and children 12 years of age or older is 60 mg twice daily. The usual dosage as the extended-release oral suspension for children 6 to younger than 12 years of age is 30 mg twice daily; children 2 to younger than 6 years of age may receive 15 mg twice daily.
Cautions ⬆ ⬇
Adverse effects with dextromethorphan are rare, but nausea and/or other GI disturbances, slight drowsiness, and dizziness sometimes occur. The drug produces no analgesia or addiction and little or no CNS depression.
Abuse
Abuse and recreational use of dextromethorphan have been reported with nonprescription (over-the-counter [OTC]) dextromethorphan-containing preparations and with dextromethorphan powder sold illicitly.111,112,113,114,115 Dextromethorphan is a safe and effective cough suppressant with minimal adverse effects when used at recommended dosages; however, the drug can have euphoric, stimulant, and dissociative effects at higher dosages.111,112,113,114,115 Abuse of the drug for its euphoric and dissociative effects occurs mainly in adolescents.112,113,114,115
While dextromethorphan abuse is not a new phenomenon, a more recent trend involving illicit sale of pure dextromethorphan powder that has been encapsulated and sold as a street drug has caused concern.111 There also has been an increasing trend in abuse of dextromethorphan-containing OTC preparations.115 One study that analyzed the trend in dextromethorphan abuse in California identified Coricidin® HBP® Cough and Cold tablets as the most commonly abused OTC product.115 Abuse of dextromethorphan can result in serious adverse events, including death.111,112,113,114 (See Acute Toxicity.) Fatalities have been reported in adolescents that were possibly associated with consumption of powdered dextromethorphan sold illicitly in capsules.111
Precautions and Contraindications
Administration of dextromethorphan may be associated with histamine release, and the drug should be used with caution in atopic children. Dextromethorphan also should be used with caution in sedated or debilitated patients and in patients confined to the supine position. Dextromethorphan should not be taken for persistent or chronic cough (e.g., with smoking, emphysema, asthma) or when coughing is accompanied by excessive secretions, unless directed by a clinician. If cough persists for longer than 1 week, tends to recur, or is accompanied by high fever, rash, or persistent headache, a clinician should be consulted.
Individuals with phenylketonuria (i.e., homozygous deficiency of phenylalanine hydroxylase) and other individuals who must restrict their intake of phenylalanine should be warned that some commercially available preparations of dextromethorphan contain aspartame (NutraSweet®), which is metabolized in the GI tract to phenylalanine following oral administration.
Because cases of apparent serotonin syndrome, including 2 fatalities, have been reported in patients receiving dextromethorphan and monoamine oxidase (MAO) inhibitors concomitantly, dextromethorphan preparations should not be used in patients receiving these drugs or for 2 weeks after discontinuing them.109,110 For detailed information on serotonin syndrome, including its management, see Drug Interactions: Drugs Associated with Serotonin Syndrome, in the Monoamine Oxidase Inhibitors General Statement 28:16.04.12.
Pediatric Precautions
Despite the lack of efficacy in children younger than 2 years of age, dextromethorphan use in such children has continued, in some cases with other prescription and/or nonprescription (over-the-counter, OTC) cough and cold preparations containing other agents (e.g., antihistamines, expectorants, nasal decongestants).116 In a report published by the US Centers for Disease Control and Prevention (CDC), cough and cold preparations containing dextromethorphan, acetaminophen, carbinoxamine, doxylamine, and/or pseudoephedrine were determined by medical examiners or coroners to be the underlying cause of death in 3 infants 6 months of age or younger during 2005.116,117 The actual cause of death might have been overdosage of one drug, interaction of different drugs, an underlying medical condition, or a combination of drugs and underlying medical conditions.116 In addition, an estimated 1519 children younger than 2 years of age were treated in emergency departments in the US during 2004-2005 for adverse events, including overdoses, associated with cold and cough preparations.116 (See Acute Toxicity: Manifestations; also see Cautions: Pediatric Precautions in Pseudoephedrine Hydrochloride 12:12.12.)
The dosages at which cough and cold preparations can cause illness or death in pediatric patients younger than 2 years of age are not known, and there are no specific dosage recommendations (i.e., approved by the US Food and Drug Administration [FDA]) for patients in this age group.116 (See Dosage and Administration: Dosage.) Because of the absence of dosage recommendations, limited published evidence of effectiveness, and risks for toxicity (including fatal overdosage), FDA stated that nonprescription cough and cold preparations should not be used in children younger than 2 years of a the agency continues to assess safety and efficacy of these preparations in older children. Meanwhile, because children 2-3 years of age also are at increased risk of overdosage and toxicity, some manufacturers of oral nonprescription cough and cold preparations agreed to voluntarily revise the product labeling to state that such preparations should not be used in children younger than 4 years of age. FDA recommends that parents and caregivers adhere to the dosage instructions and warnings on the product labeling that accompanies the preparation if administering to children and consult with their clinician about any concerns. Clinicians should ask caregivers about use of nonprescription cough and cold preparations to avoid overdosage.
Other Information ⬆ ⬇
Acute Toxicity
Pathogenesis
Dextromethorphan has a low order of toxicity, with the potential for toxic effects following acute overdosage being low.100,101,102,103,104 Although a few cases of toxicity and death have been reported,100,101,102,103,104,111,112 doses in excess of 100 times the usual adult dose have not been fatal.100
Manifestations
Manifestations following acute overdosage of dextromethorphan have included nausea, vomiting, drowsiness, dizziness, blurred vision, nystagmus, ataxia, shallow respiration, urinary retention, stupor, toxic psychosis, seizures, and coma.100,101,102,103,111,112 However, the presentation of dextromethorphan intoxication depends on the ingested dose.112 Manifestations of minimal intoxication include tachycardia, hypertension, vomiting, mydriasis, diaphoresis, nystagmus, euphoria, loss of motor coordination, and giggling/laughing.112 Manifestations of moderate intoxication include those associated with minimal intoxication, hallucinations, and a plodding ataxic gait (“zombie-like” walking).112 Severely intoxicated individuals may be agitated or somnolent.112
From 1969-1981, the US Food and Drug Administration received 15 case reports of adverse reactions to dextromethorphan in children 1-10 years of a these reactions included hallucinations, urticaria, nausea, insomnia, and hysteria, but no fatalities.100 Deaths that were possibly associated with consumption of powdered dextromethorphan (sold illicitly in capsules) have been reported in adolescents.111 Ataxia, facial edema, and urticaria occurred following acute ingestion of 225 mg of dextromethorphan in a 2-year-old child,100 and lateral nystagmus, ataxia, unstable gait, and excitability occurred in a 22-month-old child who ingested 360 mg of the drug.102 Lethargy, somnolence, ataxia, and nystagmus occurred in a 3-year-old who ingested 270 mg of the drug.101
Treatment
Treatment of dextromethorphan overdosage includes symptomatic and supportive measures.102,103,112,113,114 In one child, ataxia resolved rapidly following IV naloxone, and other neurologic manifestations resolved within 8 hours.102 In another child, manifestations of toxicity resolved following IV naloxone and oral administration of activated charcoal.101
Pharmacology
Dextromethorphan retains only the antitussive activity of other morphinan derivatives. The drug is about equal to codeine in depressing the cough reflex and has no expectorant action. In therapeutic dosages, dextromethorphan does not inhibit ciliary activity.
Pharmacokinetics
Dextromethorphan is rapidly absorbed from the GI tract and exerts its antitussive effect in 15-30 minutes after oral administration. The duration of action is approximately 3-6 hours with conventional dosage forms.
Chemistry and Stability
Chemistry
Dextromethorphan is an antitussive agent. Dextromethorphan is the methyl ether of the dextrorotatory form of levorphanol, an opiate analgesic. Dextromethorphan hydrobromide occurs as practically white crystals or crystalline powder and is sparingly soluble in water and freely soluble in alcohol.
Stability
Dextromethorphan preparations should be stored in tight containers, and solutions and liquid-filled capsules containing dextromethorphan should be stored in tight, light-resistant containers.
Dextromethorphan is incompatible with penicillins, tetracyclines, salicylates, phenobarbital sodium, hydriodic acid, and high concentrations of sodium or potassium iodide.
Preparations ⬆ ⬇
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
Dextromethorphan Hydrobromide
Routes | Dosage Forms | Strengths | Brand Names | Manufacturer |
|---|
Oral | Capsules, liquid-filled | 15 mg | Robitussin® Long-Acting CoughGels® | Pfizer |
| Lozenges | 5 mg | Hold® DM | Ascher |
| | 10 mg | Sucrets® DM Cough Formula | Insight |
| Solution | 7.5 mg/5 mL* | Dextromethorphan Hydrobromide Solution | |
| | 10 mg/5 mL* | Dextromethorphan Hydrobromide Solution | |
| | | Vicks® 44 Custom Care Dry Cough | Procter & Gamble |
| | 15 mg/5 mL* | Dextromethorphan Hydrobromide Solution | |
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
Dextromethorphan Hydrobromide Combinations
Routes | Dosage Forms | Strengths | Brand Names | Manufacturer |
|---|
Oral | Capsules, liquid-filled | 10 mg with Acetaminophen 325 mg, Chlorpheniramine Maleate 2 mg, and Phenylephrine Hydrochloride 5 mg | Alka-Seltzer Plus® Cold & Cough Formula Liquid Gels® | Bayer |
| | | Tylenol® Cold Multi-Symptom Nighttime Rapid Release Gels® | McNeil |
| | 10 mg with Acetaminophen 325 mg, Doxylamine Succinate 6.25 mg, and Phenylephrine Hydrochloride 5 mg | Alka-Seltzer Plus® Night Cold Formula Liquid Gels® | Bayer |
| | 10 mg with Acetaminophen 325 mg and Phenylephrine Hydrochloride 5 mg | Alka-Seltzer® Plus Day Cold Formula Liquid Gels® | Bayer |
| | | Vicks® DayQuil® Cold & Flu Relief LiquiCaps® | Procter & Gamble |
| | 15 mg with Acetaminophen 325 mg and Doxylamine Succinate 6.25 mg | Vicks® NyQuil® Cold & Flu Relief LiquiCaps® | Procter & Gamble |
| For solution | 30 mg with Acetaminophen 1 g, Guaifenesin 400 mg, and Pseudoephedrine Hydrochloride 60 mg per packet | Theraflu® Max-D Severe Cold & Flu | Novartis |
| Kit | 12 Tablets, film-coated, Acetaminophen 325 mg with Dextromethorphan Hydrobromide 10 mg and Phenylephrine Hydrochloride 5 mg (Comtrex® Daytime Caplets®) 12 Tablets, film-coated, Acetaminophen 325 mg with Chlorpheniramine Maleate 2 mg, Dextromethorphan Hydrobromide 10 mg, and Phenylephrine Hydrochloride 5 mg (Comtrex® Nighttime Caplets®) | Comtrex® Cold & Cough Day-Night Maximum Strength Caplets® | Novartis |
| Solution | 3.3 mg/5 mL with Acetaminophen 108.3 mg/5 mL, Doxylamine Succinate 1.25 mg/5 mL, and Phenylephrine Hydrochloride 1.6 mg/5 mL | Tylenol® Cold Multi-Symptom Nighttime | McNeil |
| | 3.3 mg/5 mL with Acetaminophen 108.3 mg/5 mL, Guaifenesin 66.6 mg/5 mL, and Phenylephrine Hydrochloride 1.6 mg/5 mL | Tylenol® Cold Multi-Symptom Severe | McNeil |
| | | Tylenol® Cold & Flu Severe | McNeil |
| | 3.3 mg/5 mL with Acetaminophen 108.3 mg/5 mL and Phenylephrine Hydrochloride 1.6 mg/5 mL | Tylenol® Cold Multi-Symptom Daytime | McNeil |
| | | Vicks® DayQuil® Cold & Flu Relief | Procter & Gamble |
| | 5 mg/5 mL with Acetaminophen 108.3 mg/5 mL and Doxylamine Succinate 2.08 mg/5 mL | Vicks® NyQuil® Cold & Flu Relief | Procter & Gamble |
| | 5 mg/5 mL with Acetaminophen 160 mg/5 mL | Children's Tylenol® Plus Cough & Sore Throat | Prestige Brands |
| | | Triaminic® Cough and Sore Throat | Novartis |
| | 5 mg/5 mL with Acetaminophen 160 mg/5 mL and Chlorpheniramine Maleate 1 mg/5 mL | Children's Tylenol® Plus Cough & Runny Nose | McNeil |
| | 5 mg/5 mL with Acetaminophen 160 mg/5 mL, Chlorpheniramine Maleate 1 mg/5 mL, and Phenylephrine Hydrochloride 2.5 mg/5 mL | Children's Dimetapp® Multi-Symptom Cold & Flu | Pfizer |
| | | Children's Tylenol® Plus Flu | McNeil |
| | 5 mg/5 mL with Acetaminophen 166.6 mg/5 mL | Tylenol® Cold & Cough Daytime | McNeil |
| | 5 mg/5 mL with Acetaminophen 166.6 mg/5 mL and Doxylamine Succinate 2.08 mg/5 mL | Tylenol® Cold & Cough Nighttime | McNeil |
| | 5 mg/5 mL with Brompheniramine Maleate 1 mg/5 mL and Phenylephrine Hydrochloride 2.5 mg/5 mL | Children's Dimetapp® Cold & Cough | Pfizer |
| | 5 mg/5 mL with Chlorpheniramine Maleate 0.67 mg/5 mL | Children's Vicks® NyQuil® Cold/Cough | Procter & Gamble |
| | 5 mg/5 mL with Chlorpheniramine Maleate 1 mg/5 mL and Pseudoephedrine Hydrochloride 15 mg/5 mL | Kidkare® Cough & Cold Liquid | Watson |
| | 5 mg/5 mL with Doxylamine Succinate 2.08 mg/5 mL | Vicks® NyQuil® Cough | Procter & Gamble |
| | 5 mg/5 mL with Guaifenesin 50 mg/5 mL and Phenylephrine Hydrochloride 2.5 mg/5 mL | Robitussin® Children's Cough & Cold CF | Pfizer |
| | 5 mg/5 mL with Guaifenesin 100 mg/5 mL | Pediacare® Cough & Congestion | Prestige Brands |
| | 5 mg/5 mL with Phenylephrine Hydrochloride 2.5 mg/5 mL | Children's Sudafed PE® Cold & Cough | McNeil |
| | | Pediacare® Multi-Symptom Cold | Prestige Brands |
| | | Triaminic® Daytime Cold & Cough | Novartis |
| | 6.7 mg/5 mL with Guaifenesin 66.7 mg/5 mL | Vicks® Formula 44® Custom Care Chesty Cough | Procter & Gamble |
| | 7.5 mg/5 mL with Acetaminophen 160 mg/5 mL and Chlorpheniramine Maleate 1 mg/5 mL | Triaminic® Multi-Symptom Fever | Novartis |
| | 10 mg/5 mL with Acetaminophen 216.7 mg/5 mL and Chlorpheniramine Maleate 1.3 mg/5 mL | Vicks® Formula 44® Custom Care Cough & Cold PM | Procter & Gamble |
| | 10 mg/5 mL with Guaifenesin 100 mg/5 mL* | Cheracol D® Cough Formula | Lee |
| | | Dextromethorphan Hydrobromide with Guaifenesin Syrup | |
| | | Diabetic Tussin® DM | Health Care Products |
| | | Guiatuss DM® | Goldline |
| | | Robitussin® Peak Cold Cough + Chest Congestion DM | Pfizer |
| | | Robitussin® Sugar-Free Cough + Chest Congestion DM | Pfizer |
| | 10 mg/5 mL with Guaifenesin 100 mg/5 mL and Phenylephrine Hydrochloride 5 mg/5 mL* | Robitussin® Peak Cold Multi-Symptom Cold® | Pfizer |
| | 10 mg/5 mL with Guaifenesin 200 mg/5 mL | Diabetic Tussin® DM Maximum Strength | Health Care Products |
| | | Robitussin® Maximum Strength Cough + Chest Congestion | Pfizer |
| | | Robitussin® Peak Cold Maximum Strength Cough + Chest Congestion | Pfizer |
| | 15 mg/5 mL with Guaifenesin 100 mg/5 mL* | Safe Tussin® | Kramer |
| | 15 mg/5 mL with Promethazine Hydrochloride 6.25 mg/5 mL* | Promethazine Hydrochloride with Dextromethorphan Hydrobromide Cough Syrup | |
| | 5 mg/mL with Guaifenesin 50 mg/mL and Phenylephrine Hydrochloride 2.5 mg/mL | Suppress® DX Pediatric Drops | Kramer Novis |
| Suspension | 5 mg/5 mL with Acetaminophen 160 mg/5 mL | Pediacare® Fever Reducer Plus Cough & Sore Throat | Prestige Brands |
| | 5 mg/5 mL with Acetaminophen 160 mg/5 mL and Chlorpheniramine Maleate 1 mg/5 mL | Pediacare® Fever Reducer Plus Cough & Runny Nose | Prestige Brands |
| | 5 mg/5 mL with Acetaminophen 160 mg/5 mL, Chlorpheniramine Maleate 1 mg/5 mL, and Phenylephrine Hydrochloride 2.5 mg/5 mL | Children's Tylenol® Plus Multi-Symptom Cold | McNeil |
| | | Pediacare® Fever Reducer Plus Multi-Symptom Cold | Prestige Brands |
| | | Pediacare® Fever Reducer Plus Flu | Prestige Brands |
| | 5 mg/5 mL with Acetaminophen 160 mg/5 mL and Phenylephrine Hydrochloride 2.5 mg/5 mL | Pediacare® Fever Reducer Plus Cold & Cough | Prestige Brands |
| Tablets | 10 mg with Acetaminophen 325 mg, Guaifenesin 200 mg, and Phenylephrine Hydrochloride 5 mg | Tylenol® Cold & Flu Severe | McNeil |
| | | Tylenol® Cold Head Congestion Severe | McNeil |
| | 10 mg with Acetaminophen 325 mg and Phenylephrine Hydrochloride 5 mg | Tylenol® Cold Multi-Symptom Daytime | McNeil |
| | 10 mg with Acetaminophen 325 mg and Phenylephrine Hydrochloride 15 mg | Comtrex® Cold & Cough Multi-Symptom Relief Maximum Strength Tablets | Novartis |
| | 30 mg with Chlorpheniramine Maleate 4 mg | Coricidin® HBP® Cough & Cold | Schering-Plough |
| Tablets, chewable | 10 mg with Chlorpheniramine Maleate 2 mg and Pseudoephedrine Hydrochloride 30 mg | Dicel® DM | Centrix |
| Tablets, extended-release | 15 mg with Acetaminophen 500 mg and Chlorpheniramine Maleate 2 mg | Coricidin® HBP® Flu Maximum Strength | Schering-Plough |
| | 30 mg with Guaifenesin 600 mg | Mucinex® DM | Reckitt Benckiser |
| | 60 mg with Guaifenesin 1200 mg | Maximum Strength Mucinex® DM | Reckitt Benckiser |
| Tablets, film-coated | 10 mg with Acetaminophen 325 mg, Chlorpheniramine Maleate 2 mg, and Phenylephrine Hydrochloride 5 mg | Theraflu® Warming Relief Nighttime Multi-Symptom Cold | Novartis |
| | 10 mg with Acetaminophen 325 mg and Phenylephrine Hydrochloride 5 mg | Comtrex® Non-Drowsy Maximum Strength Caplets® | Novartis |
| | | Theraflu® Warming Relief Daytime Multi-Symptom Cold | Novartis |
| | | Tylenol® Cold Multi-Symptom Daytime | McNeil |
| | 15 mg with Acetaminophen 325 mg, Guaifenesin 200 mg, and Phenylephrine Hydrochloride 5 mg | Tylenol® Cold Head Congestion Severe | McNeil |
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
Dextromethorphan Polistirex
Routes | Dosage Forms | Strengths | Brand Names | Manufacturer |
|---|
Oral | Suspension, extended-release | equivalent to Dextromethorphan Hydrobromide 30 mg/5 mL | Delsym® | Reckitt Benckiser |
Copyright ⬆ ⬇
AHFS® Drug Information. © Copyright, 1959-2024, Selected Revisions February 1, 2016. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, MD 20814.
† Use is not currently included in the labeling approved by the US Food and Drug Administration.
References ⬆
Only references cited for selected revisions after 1984 are available electronically.
100. Food and Drug Administration. Cold, cough, allergy, bronchodilator, and antiasthmatic drug products for over-the-counter human use; tentative final monograph for OTC antitussive drug products. [21 CFR Part 341] Fed Regist . 1983; 43:48576-95.
101. Katona B, Wason S. Dextromethorphan danger. N Engl J Med . 1986; 314:993. [PubMed 3960067]
102. Shaul WL, Wandell M, Robertson WO. Dextromethorphan toxicity: reversal by naloxone. Pediatrics . 1977; 59:117-9. [PubMed 840529]
103. Dodds A, Revai E. Toxic psychosis due to dextromethorphan. Med J Aust . 1967; 2:231.
104. Weir JH. Dextromethorphan danger. N Engl J Med . 1986; 314:993.
105. Food and Drug Administration. Cold, cough, allergy, bronchodilator, and antiasthmatic drug products for over-the-counter human use; final monograph for OTC antitussive drug products. [21 CFR Parts 310, 341, and 369] Fed Regist . 1987; 52:30042-57.
106. Food and Drug Administration. Over-the-counter drug products; final monographs for antiemetic, antitussive, bronchodilator, and anthelmintic drug products; updating and technical changes. [21 CFR Parts 336, 341, and 357] Fed Regist . 1988; 53:35808-10.
107. Sovner R, Wolfe J. Interaction between dextromethorphan and monoamine oxidase inhibitor therapy with isocarboxazid. N Engl J Med . 1988; 319:1671. [PubMed 3200285]
108. Rivers N, Horner B. Possible lethal reaction between Nardil and dextromethorphan. Can Med Assoc J . 1970; 103:85. [PubMedCentral][PubMed 20311659]
109. Sporer KA. The serotonin syndrome. Implicated drugs, pathophysiology and management. Drug Saf . 1995; 13:94-104. [PubMed 7576268]
110. Wyeth Consumer Healthcare. Robitussin® (dextromethorphan hydrobromide) CoughGels® liquid-filled capsules patient information. Radnor, PA. 2003.
111. Anon. FDA warns against abuse of dextromethorphan (DXM). FDA Talk Paper. 2005 May 20.
112. Boyer EW. Dextromethorphan abuse. Pediatr Emerg Care . 2004; 20:858-63. [PubMed 15572980]
113. Schwartz RH. Adolescent abuse of dextromethorphan. Clin Pediatr (Phila) . 2005; 44:565-8. [PubMed 16151560]
114. Banerji S, Anderson IB. Abuse of Coricidin HBP cough & cold tablets: episodes recorded by a poison center. Am J Health-Syst Pharm . 2001; 58:1811-4. [PubMed 11596695]
115. Bryner JK, Wang UK, Hui JW et al. Dextromethorphan abuse in adolescence: an increasing trend: 1999-2004. Arch Pediatr Adolesc Med . 2006; 160:1217-22. [PubMedCentral][PubMed 17146018]
116. Srinivasan A, Budnitz D, Shehab N et al. Infant deaths associated with cough and cold medications—two states, 2005. MMWR Morb Mortal Wkly Rep . 2007; 56:1-4. [PubMed 17218934]
117. Food and Drug Administration. Cough and cold medications in children less than two years of age. Rockville, MD; 2007 Jan 12. From FDA website. [Web]
118. Harris G. Makers pull infant cold medicines. New York Times, 2007 Oct 11. From NYTimes.com website. [Web]
119. FDA public health advisory: nonprescription cough and cold medicine use in children. Rockville, MD; 2007 August 15. From FDA web site. [Web]
120. Richwine L. U.S. panel against cold drugs for kids under 6. Reuters, 2007 Oct 19. From Reuters website. [Web]
500. Food and Drug Administration. Drugs for human use; unapproved and misbranded oral drugs labeled for prescription use and offered for relief of symptoms of cold, cough, or allergy, enforcement action dates. Notice. [Docket No. FDA-2011-N-0100] Fed Regist. 2011; 76:11794-8.