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# Dextromethorphan
## Overview
Dextromethorphan is a cough suppressant (antitussive) that acts on the cough center in the medulla oblongata. It is available in various formulations, including immediate-release and extended-release oral products, and in combination with other agents.
## Primary Indications
Symptomatic relief of cough due to minor throat and bronchial irritation.
## Adult Dosing
* **Immediate-release oral:** 10-20 mg every 4 hours as needed, OR 30 mg every 6-8 hours as needed. Maximum dose: 120 mg per 24 hours.
* **Extended-release oral:** 60 mg every 12 hours.
Dosing for combination products will vary based on the specific ingredients and their individual dosing recommendations.
## Pediatric Dosing
* **Age 6 to under 12 years:** 5-10 mg every 4 hours as needed, OR 15 mg every 6-8 hours as needed. Maximum dose: 60 mg per 24 hours.
* **Age 12 years and older:** Same as adult immediate-release dosing.
**Note:** Dextromethorphan is not recommended for cough in children under 6 years of age unless specifically directed by a healthcare provider.
## Dose Adjustments
No specific dose adjustments are typically required for renal or hepatic impairment, but caution is advised, especially in severe impairment.
## Contraindications
* Hypersensitivity to dextromethorphan.
* Use within 14 days of MAOI therapy (risk of hypertensive crisis).
* Coadministration with strong CYP2D6 inhibitors.
* Use in patients with certain respiratory conditions (e.g., asthma, emphysema) where the suppression of cough may be detrimental.
## Adverse Effects
Common: Drowsiness, dizziness, nausea, vomiting, constipation.
Serious: Serotonin syndrome (especially with coadministration of serotonergic agents), respiratory depression (rare at therapeutic doses), abuse and dependence (recreational misuse).
## Key Drug Interactions
* **MAOIs:** Hypertensive crisis.
* **Serotonergic agents (SSRIs, SNRIs, TCAs, triptans, etc.):** Increased risk of serotonin syndrome.
* **CYP2D6 inhibitors (e.g., quinidine, fluoxetine, paroxetine):** May increase dextromethorphan plasma concentrations, increasing risk of toxicity.
* **Alcohol:** Additive CNS depressant effects.
## Monitoring
Monitor for efficacy (cough suppression) and adverse effects, particularly CNS effects and signs of serotonin syndrome. Assess for potential misuse.
## Clinical Pearls
* Dextromethorphan is often found in combination cold and cough products; be aware of all active ingredients to avoid polypharmacy and overlapping toxicities.
* The abuse potential of high-dose dextromethorphan is significant; counsel patients on appropriate use.
* Extended-release formulations should not be crushed or chewed.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and guidelines for definitive patient management decisions.*
