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# Dextromethorphan
## Overview
Dextromethorphan is an antitussive (cough suppressant) that acts on the cough center in the medulla oblongata. It is available in various formulations, often combined with other ingredients in over-the-counter cold and cough products.
## Primary Indications
Symptomatic relief of cough.
## Adult Dosing
* **Immediate-release oral:** 10-20 mg every 4 hours, or 30 mg every 6-8 hours.
* **Extended-release oral:** 60 mg every 12 hours.
* **Maximum:** Generally no more than 120 mg in 24 hours for immediate-release formulations. Extended-release maximum is also typically 120 mg in 24 hours, depending on the specific product. Specific maximums can vary by product and formulation.
## Pediatric Dosing
* **Children 6 to <12 years:**
* Immediate-release oral: 5-10 mg every 4 hours, or 15 mg every 6-8 hours.
* Maximum: 60 mg in 24 hours.
* **Children <6 years:** Dextromethorphan is **not recommended** for use in children younger than 6 years due to increased risk of serious adverse events, including central nervous system depression, respiratory depression, and death.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Dose reduction may be considered, although specific guidelines are limited. Dextromethorphan is metabolized by CYP2D6 and CYP3A4, which can be affected by liver function.
## Contraindications
* Hypersensitivity to dextromethorphan.
* Use within 14 days of MAO inhibitor therapy (risk of serotonin syndrome).
* Use in children <6 years of age.
## Adverse Effects
Common: Dizziness, drowsiness, nausea, vomiting, stomach upset.
Serious: Confusion, hallucinations, respiratory depression, serotonin syndrome (especially when combined with other serotonergic agents), abuse potential.
## Key Drug Interactions
* **MAO Inhibitors (including MAOIs, furazolidone, procarbazine, linezolid):** Increased risk of serotonin syndrome.
* **SSRIs, SNRIs, tricyclic antidepressants, other serotonergic drugs:** Increased risk of serotonin syndrome.
* **CYP2D6 Inhibitors (e.g., fluoxetine, paroxetine, quinidine, bupropion):** May increase dextromethorphan plasma concentrations, increasing the risk of adverse effects.
* **CYP3A4 Inhibitors (e.g., ketoconazole, itraconazole, macrolide antibiotics):** May increase dextromethorphan plasma concentrations.
* **Alcohol:** Increased risk of CNS depression.
## Monitoring
* Monitor for effectiveness in suppressing cough.
* Monitor for adverse effects, particularly CNS effects and signs of serotonin syndrome.
* Assess for potential abuse.
## Clinical Pearls
* Dextromethorphan is often found in combination products. Always review all active ingredients to avoid duplication and potential harm.
* The risk of serotonin syndrome is significant when dextromethorphan is taken with MAO inhibitors or other serotonergic agents.
* Due to potential for abuse and serious adverse effects, use with caution and at the lowest effective dose, especially in adolescents and young adults.
* Avoid use in children under 6 years old.
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**Disclaimer:** This information is intended for healthcare professionals and is not a substitute for clinical judgment. Always consult the most current prescribing information, drug databases, or product labeling for complete and up-to-date information before making any treatment decisions.
