Asthmalytic and Antihistamine Compounds

Transcription

1 Asthmalytic and Antihistamine HYSICIANS SPECIALIZING IN DISEASES P of the chest often find it necessary to prescribe bronchodilating compounds and antihistamines. Concurrently, pharmaceutical manufacturers are attempting to meet this increased demand by introducing new and altered formulas. This has resulted in some confusion regarding evaluation of the efficiency of those available, many of which are simiiar in composition. The purpose of this communication is to tabulate the content and trade name of those which are commonly prescribed. all have a sedative, usually barbiturate in doses ranging from 8 to 30 mg. (Y8 to Y2 gr.); one has a "tranquilizer" in place of the barbiturate. Practically all contain a theophylline salt with an average dose of 100 to 200 mg. (1 Y2 to 3 gr.). In addition to this triad of sympathomimetic, xanthine, and sedative there may be other ingredi REPORT OF THE COMMITIEE ON ALLERGY AMERICAN COLLEGE OF CHEST PHYSICIANS ents; some contain expectorants, usually potassium iodide or glyceryl guaiacolate, some have an antihistamine, and one contains aspirin and Vitamin C. There is no question of the effectiveness of these compounds since they all contain ephedrine, which is a potent anti-asthmatic drug; however the inadequate amount of theophylline salt in the mixture is of questionable value. These compounds are available in liquid form, and as immediate-action tablets and capsules, delayed-action tablets, and prolonged-action tablets. Some are compounded without the theophylline salt for patients who cannot tolerate it, and in general there is a compound available to fit the requirements of practically any specialized need. All are valuable, as a comparison of Table 1 will indicate. This table is by no means complete, nor does it include all the various forms in which one compound may be marketed. Many are packaged in liquid form, as a pediatric tablet or capsule, as a delayedaction compound, and as a delayed-action mixture. For example, there is Tedral plain, Tedral delayed-action tablets, Tedral pedi 106 atric s u s p e ~ Tedral s i o n, sustained-action tablets, and even Tedral suppositories. It is virtually impossible to outline a complete pharmacologic list of ast h m ai ytic compounds and the table is intended merely ASTHMALYTIC COMPOUNDS Most of the asthmaiytic compounds contain ephedrine in 25 mg. (% gr.) d o s e s minor ~ differences. The individual adult to indicate the similarities, as well as the several contain an isomer and others a dose is listed for the most part. For prolonged or sustained-action, the dose is usual compound of ephedrine. To counteract the pressor e f f eof c the t ~ sympathomimetic, they ly doubled, for the pediatric dose it is usuall\' halved. In c o n ttor these a ~ tcompounds, it ~ u be s tpointed out that ephedrine capsules are available alone in 25 mg. (% gr.) and 50 n1g. (% gr.) size, while phenobarbital in 15 or 30 mg. (Yt or Y2 gr.) dose are equally available. Both are very inexpensive. The official syrup of ephedrine contains 16 mg-. (Yl gr.) per teaspoonful (4.0 ml.), and elixir phenobarbital also contains 16 mg. ( ~gr.) of the active ingredient to the teaspoonful. 4 ~mixture of both in the proper predetermined relationship makes an excellent compound for children. Other ingredients may be added at will. l\s can be seen, all the compounds listed in the table are very effective for the average case of asthma. a ~ t h m a l y t i c Preference for one or a n o t as h ehas r ~ been indicated.. may be individual or based on information subject to variable interpretations or previous experience. 4.\NTIHISTAMINE COMPOUNDS 4 ~ l t hantihistamines o u g h are not a ~effective in relieving bronchospasm ab they

2 Volume 48, No.1 July ~ ASTHMALYTIC AND ANTIHISTAMINE COMPOUNDS 1 7 TABLE I-COMPOSITION OF FREQUENTLY PRESCRIBED ASTHMALYTIC COMPOUNDS* Manufacturer Ephedrine*Barbiturate* Theophylline*Other Ingredients Aladrine Table Rock or 8 seco 8 X Merit Amesec Lilly 25 amo Amodrine Searle race 25 pheno Arlcaps U. S. Vitamin 25 pheno 25 X Aspirin & Vitamin C Asminyl Cole 30 pheno Brondilate Walker 15 buta 20 X Isoproterenol Bronkotab Breon 25 pheno Thenyldiamine + Glyceryl guaiacolate Dainite Irwin Neisler 15 pheno With or without K 1 Deltasmyl Roussel 15 pheno Prednisone Ephedrine with Amytal Lilly 25 amo 50 X Ephedrine with Abbott 25 penta 25 X Nembutal or 50 Ephedrine \\'ith Seconal Lilly 25 seco 50 X Ephoxamine Spencer race 30 X X Phenyltoloxamine Franol Winthrop benzyl 30 pheno Glynaphyllin First Texas 25 pheno Hyadrine Searle race 25 X 150 Diphenhydramine Isufranol Winthrop benzyl 32 pheno Isoproterenol in outer layer and lemon flavor in middle layer of coating. Luasmin Brewer 30 pheno Marax Roerig 25 X 130 Hydroxyzine (Atarax) Mudrane Poythress 16 pheno K 1 or glyceryl guaiacolate Nephenalin Leeming 25 pheno Isoproterenol in coating Numa (prolonged Wynn 50 buta action) Phyllophed Rexall 30 pheno Quadrinal Knoll 25 pheno Kl Synate-M Central race 25 seco K 1 + Niacinamide Tedral Warner 25 pheno 8 or 125 With or without Thephesin Wilcox 25 buta 25 chlorpheniramine pheno Chlorpheniramine + glyceryl guaiacolate Vert"quad Knoll 25 pheno Glyceryl guaiacolate *in milligrams *Adapted from Harris, M. C. and Shure, N., Sensitivity Chest Diseases F. A. Davis Company, Philadelphia, are in relieving the symptoms of allergic rhinitis and sometimes eczema, since these two conditions frequently co-exist with bronchial asthma, they are often prescribed by the chest physician. When antihistamines were first introduced, it was thought by some that they would be the ultimate treatment for allergy and that, in effect, they might prove to be specific for the condition. This was based on the assumption that histamine liberated by the interaction of antigen and antibody caused all the symptomatology. Originally the antihistamines were presumed to exert their activity through an intermediary, histamine or cholinesterase. Later, however, it w a thought ~ that the antihistamines acted through hyaluronidase, the depolarization ferment by hyaluronic acid. This theory was based on the concept that hyaluronidase favored diffusion of histamine, increasing the area of its action. It was felt that this activity on the part of hyaluronidase was impeded by antihistamines. Both of these theories were discarded long ago, along with the suggestion that antihistamines upset an interactivity between histamine and adrenaline, which, according to the proponents of this theory, liberated histamine. All of these theories are

3 108 COMMITTEE ON ALLERGY Diseases of the Chest TABLE 2-ANTIHISTAMINES COMMONLY PRESCRIBED GROUP 1. ETHANOLINES: This group is composed of highly efficient antihistamines. All possess atropinelike activity. Unfortunately, drowsiness is marked in this group. The amount of drowsiness varies slightly from one anti-histamine to another, and from one patient to another. Gastrointestinal side effects are minimal. Generic Narne 1. Diphenhydramine 2. Doxylamine 3. Bromodiphenhydramine 4. Carbinoxamine 5. Dexcarbinoxamine 6: Phenyltoloxamine Benadryl (Parke-Davis) Decapryn (Merrell) Ambodryl (Parke-Davis) Clistin (McNeil ) Twiston (McNeil) Bristamine (Bristol) 25 to 50 gm. q. 4 or 6 h mg. q. 4 h. 25 mg. q. 4 h. 4 mg. q. 4 or 6 h. Ambenyl (Parke-Davis) Benadryl with ephedrine ( Parke-Davis) Benylin (Parke-Davis) H ydryllin (Searle) Ambenyl (Parke-Davis) Algie (Spencer) Anfac (Pharmafac) Contramal CP (Phys. Prod.) Ephoxamine (Spencer) Naldecon (Bristol) Sinutab (Warner-Chilcott) Toldex (Pitman-Moore) Tristacomp (Phys. Prod.) GROUP 2. ETHYLENEDIAMINES: These are mildly sedative. They are local anesthetics and all are liable to cause mild gastrointestinal side effects in some patients. Generic N arne 1. Tripelennamine 2. Clemizole 3. Thenylpyramine 4. Pyrilamine Pyribenzamine (Ciba) Alecur (Roerig) Histadyl (Lilly) Thenylene (Abbott) Neo-Antergan (Merke Sharp & Dohme) 50 mg. q. 4 h mg. q. 4 h mg. q. 4 h. 25 mg. q. 4 h mg. q. 4 h. (Continued on following page) Dibistine (Ciba) M ultihist (Dorsey) Plimasin (Ciba) Pyribenzamine with ephedrine (Ciba) Corenil (MeNeil) Co-Pyronil (Lilly) Histaclopane (Lilly) Histadyl and ASA Compo (Lilly) Histadyl with ephedrine (Lilly) Hista-Vadrine (First Texas) Isoclor (Arnar-Stone) Neo-Rhiban (Kendall) Pentryl (Chilcott) Semikon (Messengill) Thenylene APC (Abbott) Citra (Boyle) Contramal CP (Phys. Prod.) Duadacine (Lloyd Bros.) Multihist (Dorsey) Nalertan (Neisler) Napril (Marion) Neocafotan (Premo) P.P.A. (Dorsey) Restamine (Strasenburgh) Rynalert (Neisler) Rynatan (Neisler) Super Rhi-Lief (Walker, Corp. & Co.) Triaminic (Dorsey) Tristacomp (Phys. Prod.) V.R.I. (Sig: Inc.) V rsinus (Dorsey)

4 Volume 48, No.1 July 1965 ASTHMALYTIC AND ANTIHISTAMINE COMPOUNDS 10g TABLE 2 (Continued) 5. Thenyldiamine 6. Antazoline 7. Thonzylamine Thenfadil (Winthrop) Antistine (Ciba) Neohetramine (Wamer mg. q. 4 h. Chilcott) Neo-Synephrine Compo (Withrop) Dibistine (Ciba) GROUP 3. ALKYLAMINES: Drowsiness is less marked in this group. They are known to cause cerebral nervous stimulation. Generic Name I. Pheniramine 2. Chlorpheniramine Trimeton (Schering) Chlor-Trimeton (Schering) Histadur (Wynn) Teldrin (Smith Kline & French) 4 mg. q. 4 or 5 h. 8-12mg.q.8-12h mg. q h. Triaminic (Dorsey) Algic (Spencer) Aristomin (Lederle) Contramal (Phys. Prod.) Coridicin (Schering) Coridicin-D (Schering) Cortiforte (Schering) Coryban-D (Roerig) Covanamine (Van Pelt & Brown) Demazine (Schering) Duadacin (Lloyd Bros.) Histadur (Wynn) Hista-Vadrin (First Texas) Metreton (Schering) Naldecon (Bristol) Nalertan (Neisler) Napril (Marion) Nolamine (Camrick) Novahistine (Pitman-Moore) Omade (Smith Kline & French) Phenate (Mallard) Prednaman (Dome) Pyrroxate (Upjohn) Rynalert (Neisler) Rynatan (Neisler) Super Rhi-Lief (Walker, Corp. & Co.) Tirstacomp (Phys. Prod.) 3. Dexchlorpheniramine 4. Tripolidine 5. Pyrrobutamine 6. Brompheniramine 7. Dexbrompheniramine Polaramine (Schering) Actidil (Burroughs Pyronil (Lilly) Dimetane (Robins) Disomer (White) 2.5 mg. q. 6 h. 15mg.q.80rI2h. 4-8 mg. q. 4 or 6 h. Guaiamine (Sutliff & Co.) Actifed (Burroughs Wellcome & Co. ) Co-Pyronil (Lilly) Dimetapp (Robins) Disophrol (White) GROUP 4. PHENOTHIAZINES: In addition to their antihistaminic activity these possess marked sedative action and therefore are utilized as such. Agranulocytosis and liver toxicity have been reported. Generic Name 1. Promethazine Phenergan (Wyeth) mg. q. 12 h. 2. Isothipendyl Theruhistin (Ayerst) 4 mg. q. 4h. Keyl (Ayerst) 3. Methdilazine Tacaryl (Mead Johnson) 8 mg. q. 4 h. (Continued on following page)

5 11 () COMMITTEE ON ALLERGY Diseases of the Chest TABLE 2 (Continued) FIGURE 5. A HETEROGENOUS GROUP: cyproheptadine, meclizine and hydroxyzine could have been included here, but have been omitted purposely because they are not primarily indicated in allergy. Members of this group are claimed to have few, if any, side effects. Generic Name 1. Chlorcyclizine Di-Paraline (Abbott) 50 mg. q. 12 h. Emprazil (Burroughs Perazil (Burroughs 50 mg. q. 12 h. Fedrazil (Burroughs Wellcome & Co. ) 2. Phenindamine Thephorin (Roche) mg. q h. Nolamine (Carnrick) 3. Buclizine 4. Dyphenylpyraline 5. Dimethindene Softran (Stuart) Diafen (Riker) End Allergy (Amfre Grant) Hispril (Smith Kline & French) Forhistal (Ciba) 50 mg. t.i.d. 2 mg. 3 or 4 h. 5 mg. q. 12 h. 1 mg. q. 4 h. Thephorin-AC (Roche) (Adapted from Harris, M. C. and Shure N., Sensitivity Chest Diseases, F. A. Davis Company, Philadelphia, 1964). based on the conviction that histamine is the sole chemical mediator of allergy. In a limited sense, this belief is justified for most symptoms are connected with some liberation of histamine. Studying the differences in the formulas and side effects of the antihistamines listed in Table 2 may be of help to the physician in prescribing them. For night time, for example, one may prefer to prescribe an antihistamine which produces drowsiness, to assure the patient a good night's rest; during the daytime such an antihistamine might well be avoided. If a particular antihistamine is ineffective and a change is desired, one may substitute an antihistamine from a different group rather than from the group originally prescribed. Occasionally, it may be worthwhile to combine two or three antihistamines with different formulas for their synergistic effect. Several pharmaceutical firms have done this. There are many more and undoubtedly much more recent antihistamines than those mentioned in Table 2; also there are many multiple combinations made up in capsule, tablet, and liquid form. However, it is best to avoid using such combinations of drugs, if possible, and prescribe only the individual drugs that are warranted and indicated. For that reason, combinations of antihistamines have been listed but not stressed. M. COLEMAN HARRIS, M.D., F.C.C.P. San Francisco, California NORMAN SHURE, M.D. Los Angeles, California LEON UNGER, M.D., F.C.C.P.,. Chicago, Illinois, Chairman, Committee on Allergy COLLEGE FELLOWSHIP PROGRAM The American College of Chest Physicians is offering three fellowships, as indicated below: 1. Eudowood Fellowship for Tuberculosis with a grant of $2, per year for postgraduate training in the United States in tuberculosis. Candidates must hold the ECFMG certificate. 2. Li Shu-Fan Fellou1ship for Postgraduate Study in Chest Disease appropriates $1, annually for a t\\'elve month period of training in any country. If the postgraduate training is taken in the United States, the ECFMG certificate would be required. 3. Alfred A. Richman Fellowship for Chest Disease offers $ a month for a period of one year's postgraduate study in any country. Candidates must hold the ECFMG certificate if training in the United States. Physicians interested in these fellowships should contact Dr. Andrew L. Banyai, Chairman of the Council on International Affairs, at the Executive Offices of the College.