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# Tuso (Tussin / Dextromethorphan)
## Overview
Dextromethorphan is a synthetic analog of codeine. It acts as an NMDA receptor antagonist and a sigma-1 receptor agonist, elevating the cough threshold in the cough center of the medulla oblongata. It lacks analgesic and addictive properties at therapeutic doses.
## Primary Indications
Symptomatic relief of non-productive cough associated with common cold, bronchitis, or inhaled irritants.
## Adult Dosing
* **Immediate-Release:** 10–20 mg every 4 hours or 30 mg every 6–8 hours.
* **Extended-Release:** 60 mg every 12 hours.
* **Maximum Dose:** 120 mg per 24 hours.
## Pediatric Dosing
* **Children 6–12 years:** 5–10 mg every 4 hours or 15 mg every 6–8 hours. Maximum 60 mg/24 hours.
* **Children 4–6 years:** 2.5–5 mg every 4 hours or 7.5 mg every 6–8 hours. Maximum 30 mg/24 hours.
* **Children <4 years:** Generally not recommended unless directed by a pediatrician. Risk of toxicity outweighs benefits in this population.
## Dose Adjustments
* **Renal/Hepatic Impairment:** No specific criteria established; use with caution in severe hepatic impairment due to first-pass metabolism. Generally not indicated if underlying pathology requires strict safety monitoring.
## Contraindications
* Hypersensitivity to dextromethorphan.
* Concurrent use (or use within 14 days) of Monoamine Oxidase Inhibitors (MAOIs).
## Adverse Effects
* **Common:** Dizziness, lightheadedness, drowsiness, nausea, stomach pain.
* **Serious:** Serotonin syndrome (when combined with serotonergic agents), confusion, visual hallucinations, and respiratory depression (in overdose).
## Key Drug Interactions
* **MAOIs:** Fatal hyperpyrexia, coma, and death may occur.
* **SSRI/SNRI/Tricyclics:** Increases risk of serotonin syndrome.
* **CNS Depressants (Alcohol, Benzodiazepines):** May enhance sedative effects.
* **CYP2D6 Inhibitors (e.g., Fluoxetine, Quinidine):** May significantly increase plasma concentrations of dextromethorphan.
## Monitoring
* Monitor for symptom relief and duration of cough.
* If cough persists >7 days or is accompanied by fever, rash, or persistent headache, reassess diagnosis to rule out serious underlying infection or pathology.
## Clinical Pearls
* **"De-glu" caution:** Do not crush or chew extended-release formulations.
* **Overdose:** Abuse (Robo-tripping) of dextromethorphan is increasing due to dissociative effects at supratherapeutic doses. Screen for misuse in pediatric/adolescent patients.
* **Efficacy:** Evidence for cough suppression in acute upper respiratory infections is variable and often inconsistent; ensure the cough is truly non-productive before advising suppression.
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*Disclaimer: This information is for educational purposes and does not replace professional clinical judgment. Always verify current prescribing information, dose-specific contraindications, and institutional protocols via official drug references (e.g., Lexicomp, Micromedex, or the FDA prescribing label) before clinical use.*
