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## Dextromethorphan
### Overview
Dextromethorphan is an antitussive agent that acts centrally on the cough center in the medulla. It is available in various formulations, including immediate-release and extended-release, and often combined with other ingredients in multi-symptom cold and cough products.
### Primary Indications
* Symptomatic relief of cough.
### Adult Dosing
* **Immediate-release:** 10-20 mg every 4 hours as needed, or 30 mg every 6-8 hours as needed.
* **Extended-release:** 60 mg every 12 hours.
* Maximum daily dose: Typically 120 mg for immediate-release formulations. Specific maximums may vary by product.
### Pediatric Dosing
* **Age 6-11 years:** 5-10 mg every 4 hours as needed, or 15 mg every 6-8 hours as needed. Maximum daily dose: 60 mg.
* **Age 2-5 years:** 2.5-5 mg every 4 hours as needed, or 7.5 mg every 6-8 hours as needed. Maximum daily dose: 30 mg.
* **Under 2 years:** Use is generally not recommended due to increased risk of serious adverse effects. Consult with a pediatrician.
### Dose Adjustments
No dose adjustment is typically required for hepatic or renal impairment, but caution and lower doses may be considered in severe impairment.
### Contraindications
* Hypersensitivity to dextromethorphan.
* Use within 14 days of MAOI therapy (risk of serotonin syndrome).
* Asthma, emphysema, or chronic bronchitis where mucus expectoration is important (may suppress cough reflex excessively).
### Adverse Effects
* Drowsiness, dizziness, nausea, vomiting, constipation.
* Potential for abuse and misuse, leading to euphoria, hallucinations, and CNS depression at supratherapeutic doses.
### Key Drug Interactions
* **MAOIs, SSRIs, SNRIs, triptans, other serotonergic agents:** Increased risk of serotonin syndrome.
* **CYP2D6 inhibitors (e.g., fluoxetine, paroxetine, quinidine):** May increase dextromethorphan plasma concentrations, potentially increasing toxicity.
* **Alcohol and CNS depressants:** Additive sedative effects.
### Monitoring
* Monitor for effectiveness of cough suppression.
* Assess for adverse effects, particularly CNS effects and signs of serotonin syndrome if co-administered with serotonergic agents.
* Monitor for signs of abuse or misuse.
### Clinical Pearls
* Dextromethorphan is found in many over-the-counter combination products; review all ingredients to avoid duplication or unintended drug interactions.
* Effectiveness for chronic cough is less established than for acute cough.
* Educate patients about the potential for abuse and the risks associated with exceeding recommended doses.
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*Disclaimer: This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and guidelines for definitive recommendations.*
