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The Dose Transcript for October 26, 2023

Host: Brian Goldman

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BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. We're getting into flu season. Step into a pharmacy and you see right away that cold and cough remedies are big business. Many of them contain phenylephrine, a decongestant. Recently, a panel of experts in the U.S. said that the popular decongestant is ineffective in helping with a stuffy nose. And this week, one of the largest pharmacy chains in the U.S. announced they're pulling some cough and cold medications with phenylephrine from their shelves. While that hasn't happened in Canada yet, this week, we're wondering when it comes to treating a cold, what does and does not work. Hi, Dr. Peter Lin.

PETER LIN: Hey, Brian.

BRIAN GOLDMAN: Do any of your patients actually ask you for advice on how to treat a cold?

PETER LIN: Never. They just wander around and they buy whatever the boxes say, you know? And the boxes usually promise you the wonderful things. I'm going to cure everything, the complete cure. And so therefore, a lot of people are just buying it and trying different things on their own. Very little advice from us. And I think most patients are doing that around the country.

BRIAN GOLDMAN: But they ask for antibiotics, don't they?

PETER LIN: Yes. So they will come in and ask for antibiotics. But I notice that because of all this antibiotic stewardship and you've heard about don't overuse antibiotics, I think people have been getting the message. We certainly still have patients that want antibiotics.

BRIAN GOLDMAN: So they shouldn't be asking for antibiotics for a virus, but they should be asking for your advice because we know that you are a fund of knowledge on this topic. But before we begin, can you give us a Hi, my name is? Tell us what you do and where you do it.

PETER LIN: Yeah. Hi, I'm Peter Lin. I'm a family doctor in Toronto and I'm also a medical director at the Canadian Heart Research Centre. And also, I work with you on CBC.

BRIAN GOLDMAN: And I'm glad about that. Let's begin our conversation. Why did the Food and Drug Administration advisory panel call phenylephrine Ineffective?

PETER LIN: Yeah. So basically, in the past, we've always had it added into the mix. And so basically, phenylephrine for those that don't know what these fancy chemical names are, it's basically a vessel constrictor. So it takes your arteries and it constricts them down. And by doing that, if your nose is all congested, all the vessels are opened. So therefore, if we constrict it down, we can take away some of that congestion. And so that's why it was called a decongestant. But unfortunately, it didn't work very well. So it came into light when we used to have pseudoephedrine. So pseudoephedrine is the same idea. It constricts your blood vessels and it worked very well. Unfortunately, that particular molecule can be easily made into methamphetamine. So methamphetamine is not good. That's a street drug. And so therefore, they said, let's get rid of all of these over-the-counter packages that people can buy and convert them into a street drug. And so that's why you have to ask the pharmacist for these things in behind the counter. So because of that, then phenylephrine became the popular one that we can stick in, except it just doesn't work very well. A lot of the medication, when you take it by mouth, orally, goes through your intestine, and it actually gets broken down by your intestines. So very little medication actually goes into your bloodstream. And then whatever ends up going in there might squeeze your arteries elsewhere and raise your blood pressure, but very little of it actually gets to your nose area. And so when they did proper studies, and when we mean proper studies, you have to have a placebo controlled side. So in other words, they're getting a dummy thing, and then we compare whether there is any benefit. And when they did those types of studies, they noticed that there was no benefit of this phenylephrine. And so these studies have been around for quite a while, but the whole board unanimously said this is an additive in there that's not working. And so their recommendation to the FDA is let's remove things. So if it's not working, why should we have it in there? And if there is a chance of raising people's blood pressure because it's squeezing arteries elsewhere, so now there's a potential for harm and there is no benefit. And so that's why their recommendation is to take it out.

BRIAN GOLDMAN: And to be clear on something, the advisory panel was referring to phenylephrine in pill form, not the nasal spray for the reason you just said. If you just direct it to the nose, if you just put it in your nose through an over-the-counter nasal spray, then it might actually have some decongestant action.

PETER LIN: Right, because the intestine is not there to break things down. So therefore, you would have some activity. So that's why they said the spray is okay. And even though we say that the spray is okay, there's limitations on how many days you should be using it. Because if you keep squirting this stuff up there, basically, your nose gets used to it. So therefore, unless that chemical is there, then basically, you are not going to have any relief. You'll keep getting congested.

BRIAN GOLDMAN: We're talking about oral phenylephrine or products, over-the-counter cough and cold remedies that contain oral phenylephrine because they are incredibly common among the most common ingredients found in over-the-counter cough and cold remedies. Health Canada says they're reviewing the U.S. Panel's decision. How likely is it that they will pull or recommend that over-the-counter cold and cough remedies with phenylephrine be pulled from the shelves?

PETER LIN: Yeah, I think it'll be fairly straightforward because once the companies are told by the FDA, for example, that you have to get rid of this stuff within your product, then they have to reformulate everything. So all the products have to be reformulated, all the boxes have to change, all the labelling has to change. And I think if they're doing that for the United States, it's unlikely that they're not going to do that for Canada because it'll just be the same products that they send us over here, with just different packaging with French and so on and so forth on there, but then the product will be the same. So my guess is that if the U.S. sort of pulls it, even if Canada says nothing, the products will start disappearing with the phenylephrine because they're not going to make a separate version for us and a separate version for the United States, which is sort of the biggest market. So I think we're going to see this one disappear. And just for people to know, don't worry about it, because it wasn't doing much at all. So in the past, right, we were adding all sorts of things. There was antihistamines put into these things, and so people were drowsy and all sorts of stuff. So at that time, we sort of said more the better. But I think now we're starting to say, let's make sure that what we're giving people is not making things worse. So we don't want people dopey. And so therefore, a lot of them have taken out the antihistamines, the old ones that make you sleepy. And so by removing these things, we're just trying to get what we need as opposed to the extra stuff that's always been there. And I think that's what you're seeing now is the removal of things that have always been there and only giving you the things that are actually working.

BRIAN GOLDMAN: Let's pull back a little bit. How much do over-the-counter cold medicines actually help with the symptoms of a cold?

PETER LIN: Well, right now, I think the acetaminophen and perhaps ibuprofen, those are the ones that take away fever. They're the ones that take away pain. Those may be helpful. And I think if you see little Johnny kind of lying there and then you give them these things, they sort of perk up. And even as adults, I think we perk up. Some of the cough suppressants may be helpful if you have that dry hacking cough. I think that those ones are a bit useful there as well to try and suppress that cough. But all of the other stuff, for example, the antihistamines and all these other things in the phenylephrine, basically, those ones are not helpful, and that's why they're no longer part of the program or package.

BRIAN GOLDMAN: The phenylephrine ingredient which we've been talking about is primarily in daytime over-the-counter cough and cold remedies and sinus remedies for that matter as well. Then there's... Let's flip over to the night side when, you know, certainly, phenylephrine was, you know, made you more likely to be wired awake, you know, wide awake. But let's go the opposite way. Now you're trying to sleep and you've got a stuffy nose. What about the over-the-counter remedies for nighttime use?

PETER LIN: Yeah. So now all of a sudden, you have a daytime one and a nighttime one that tries to put you to sleep. So this is where you'll end up having some of those drowsy antihistamines and those kinds of things. And so the question is would you have done just as well? So in other words, if you just curled up, went to sleep, would it be just as well? I think the coughing is the one that is a bit of a problem. So if we could increase hydration. So in other words, humidifiers, those kinds of things in around you, we can actually decrease that drying out effect. There's also one other phenomenon, which is as you lie down, if you think about your windpipe as being swollen, so as you lie down, that swollen area starts to dangle. And as it dangles, it pulls on those linings. And those linings have nerve endings in them, and that triggers that funny cough that you get as you're trying to lie down. So in that particular situation, we tell people you might have to sit kind of half propped up, in which case, you might not get that lying down, or lie down very gently so that dangling thing is not happening and triggering all those nerve endings to happen. So we can do a lot of interesting things to help you sleep, and medicating you heavily may not be the, you know, the top choice, although a lot of people seem to like that. From my patient's point of view, right, take two spoons of this stuff and it'll make you go away.

BRIAN GOLDMAN: What about, you know, the, you know, one of the major ingredients of cough suppressants, over-the-counter cough suppressant is dextromethorphan. What do we know about that?

PETER LIN: So dextromethorphan is a fairly weak version of things. So that's what is going to be DM. So therefore, if you see the letters dM, that's going to be your cough syrup. It's not the strongest one in the world. However, it doesn't seem to have a whole lot of drowsiness, so it doesn't hit the drowsy centres. The DM one does work. I find that sometimes, people find that just hot steam may be helpful. So if you just take some hot water in a cup and then you blow on it and you breathe the steam, that may actually coat the lining. You know how when you take a shower and all your windows are steamed up, what we want to do is create that layer of steam in your tubes, so in through your nose and into the back of your throat and down into the top part of your windpipe, we would like to have that layer of steam there. And so therefore, when you breathe across, you're breathing across that layer of steam as opposed to breathing across sort of some denuded area. So when you hack a lot, the lining gets torn up kind of like tiles off your roof, you know, with a big storm going through. And if those tiles are torn up, now you're exposing those little nerve endings and now you get the tickle and then the hack. And then the more you hack, the more of those tiles that you'll flick off. So therefore, I find that steam seems to coat those areas. So now, basically, as you're breathing or talking, the air is not directly going over a raw spot.

BRIAN GOLDMAN: One of the reasons why I mentioned dextromethorphan really leads me into something else that I want to make sure that we cover, and that is the use of over-the-counter cough and cold remedies in young kids. What do we know about that?

PETER LIN: Yes. So the Paediatric Society was pretty clear that we should be avoiding these things. So they showed, you know, way back that it wasn't really working. And so therefore, we have to be careful. And we certainly don't want things that make them drowsy, right? Because in kids, the worry that we have is that their tubing is much smaller. So therefore, the chance of them plugging up with mucus and things like that and blocking one of those tubings is much higher. So that's why we need to keep an eye on these kids. So we don't like to heavily medicate our children, and that's why we like steam and humidifiers and all these other simple things. And I know this sounds terrible, but we had those little suction things that we can suction, you know, the mucus out of the nose and those kinds of things. So we go back to some mechanical things to keep the airways clear.

BRIAN GOLDMAN: And under the age of six, do not use over-the-counter cough and cold remedies with kids.

PETER LIN: Correct.

BRIAN GOLDMAN: That's the thing. You know, you understand the pathophysiology really well, but I want to make sure that everybody understands that. That's a very clear and crisp recommendation.

PETER LIN: And this is coming from the Paediatric society. So it's not coming from you or I. It's coming from a society that has looked at this and they said there is no benefit and there may be potential harm. And that's the problem. It's because there may be potential harm.

BRIAN GOLDMAN: I want to now switch to another medication. It's an antihistamine that also has now picked up a well-earned reputation for potentially causing more harm than good. And that is an old style antihistamine, diphenhydramine, also known as Benadryl. We're still administering it for people who have anaphylactic reactions and allergic reactions in the emergency department. And that's despite some serious questions about its efficacy and safety. So what does the research say about how it works for relieving allergy and cold systems? It's the oldie, maybe not necessarily goodie.

PETER LIN: Well, the oldie is the one that we turn to, right? Because at that time, the other ones were even worse. So Chlor-Tripolon and all these other ones were even more drowsy and things like that, so Benadryl was our go to. And because we've always gone to it and it always worked and it was quite powerful as an antihistamine for allergic reactions, that's why we went to it. However, it had all these brain side effects. It made you drowsy and so on and so forth. And so therefore, we don't want somebody that's having difficulty breathing or coughing to be drowsy. So if you want to think of it that way, we don't want to introduce another layer of potential complication. So let's say I'm drowsy, I can't cough up the mucus, now the mucus is collecting and now I'm kind of choking on the mucus. So you can understand why we would like to avoid that. And that's why they've been removing all these sort of the older antihistamines that made people very drowsy because of the potential harm. Having said that, way back, we didn't have a lot of choices, right? So it's kind of like I still remember my old cell. You remember the cell phone, the flip phone. You thought you were so cool because you had a flip phone, right? Like if I handed you a flip phone right now, you would say, what is this, right? So basically, things have moved forward. And I think that's how I think we should be looking at this. You know, the fact that they're removing phenolphthalein, it's because science has moved forward. In other words, we've proved that it's not helpful. So let's move on so we don't have to use this old technology. And so therefore, for people that have remembered all these old things that we used to use, let's move forward. So let's get the good things out of our medications, but let's leave those bad side effects behind.

BRIAN GOLDMAN: We do now have a whole host of Non-drowsy antihistamines which work just as well and don't cause drowsiness.

PETER LIN: Correct. And so therefore, we can move to those options. And do we need an antihistamine? You know, so in the past, we said, okay, you're congested, so let's give you antihistamine, decongestant, let's just give everything. But do you need all of those things to be on board? And the answer's maybe no. So let's start off with just some hot water and breathe the steam.

BRIAN GOLDMAN: I don't know about you, but I remember a few years ago, that COLD-fX was heavily advertised for colds and flus. You just sighed, so I'm sure your... that's one thing your patients probably ask you about that. What do we know about... Today about its effectiveness?

PETER LIN: Yeah, so now it's not so effective. So I think back then, they were trying to do studies to prove that this was working or not working. But nowadays, we pretty much know that it doesn't work, so therefore, let's avoid those ones. Now, during that time, people did use it. And did they get better because they got better naturally, or was it the COLD-fX that was doing it? I don't know. So I think nowadays, the movement now is away from COLD-fX again, just like we're moving against all these decongestants going up into your nose orally like taking pill version.

BRIAN GOLDMAN: You reminded me of something, Peter, you know, on what you just said, that if patients... If I was pretty sure they had a cold and they clamoured for an antibiotic, sometimes, I would answer them that if I give you an antibiotic, you'll get better in seven days. And if I don't give you an antibiotic, you'll get better in a week. You knew I'd have something to say, didn't you?

PETER LIN: Yes, yes. And you're absolutely right. Like you're absolutely right. And so that's the thing, is that how do I know that it was actually improving or not improving, that kind of thing. And the problem is as a person, I feel terrible, so I will take whatever I can get my hands on to feel better, especially if it's promising me that it's going to completely cure you or fix the whole complete cold or whatever. And so therefore, I'm of course going to grab on anything. And the fact that I got better, then I'm going to assume that that thing helped me get better because I don't know what it would have been like without taking it. And that's the problem. And that's why they have to do these trials to sort of show is there benefit or no benefit. I mean, in the rest of medicine, we have to do that, right? So if you have a new drug for whatever disease, you have to compare it to nothing, placebo, and then you have to show that it's of benefit. So that's why we want to make sure that these studies are done. And in those days, we didn't do a whole lot of them. We just sort of said we think it helped people, and then that's when people started using it on their own.

BRIAN GOLDMAN: Well, we've done a bit of a number on a lot of the oral over-the-counter cough and cold remedies. So let's turn to an ointment. What about Vicks VapoRub and things like that?

PETER LIN: I still remember that, you know, on your chest, and there was something magical about this thing going on there. I think if you read the data, the Vicks VapoRub, it's the menthol. And there is some study that says the menthol may affect viruses, for example. So it's like a chemical way of disrupting the virus. So just like we use alcohol, you know, to kill off viruses, it can disrupt the virus. So there is some fact to the fact that the menthol may be doing something.

BRIAN GOLDMAN: Okay, let's turn to some other remedies that are non-prescription but are certainly recommended by some. What about, say, vitamin C or zinc?

PETER LIN: Yeah, vitamin C, I mean, the good news about that, if you took more vitamin C, your body could use the vitamin C, we're all a little bit low. And number two is that even if you took too much, you'll just end up, you know, sending it out into the bathroom and into the pee, right? So therefore, there's no issue with it. You're not going to get toxic. Some people believe in zinc. So we're typically low in zinc. So therefore, zinc lozenges and zinc pills, people have used that as well. But many of these things for sure do not have fantastic studies that says people that took this much vitamin C did better than people that did not take this much vitamin C. Similarly, I always tell people, you know, chicken soup, you always hear about chicken soup. And I don't have a study that says, although there were some studies that they tried to do with chicken soup as well to show benefit. And I think the benefit of let's say something like chicken soup is to rehydrate you. So give you lots of fluids. And the second thing is that the oil on that broth coats the back of your throat. So by coating the back of your throat, that would be helpful in terms of giving you that layer of protection on that sort of raw part of your throat. And of course, gargling with salt water was something that, you know, we always recommended. And the salt water did two things. One is if there were bacteria, let's say you had strep throat or something like that, the salt water would leach out the water from the bacteria. So therefore, there was some sort of insult to the bacteria. But more importantly, it was taking swelling away from the back of your throat. So it was trying to extract the water that had built up because of the swelling from the infection, and that gave you some relief. The only thing, if you're going to do the saltwater gargle, it's one glass of warm water with, you know, one or two teaspoons of salt in it. If you're going to do that, then make sure you gargle and wash off the salt afterwards because you don't want to leave salt on the back of your throat because that will end up drying it out too much. So these simple things may actually work. And I look at it this way, Brian, you know, gargling with salt water, I can't do a whole lot of harm, right? I'm not asking you to take some weird pill or things like that. And so therefore, if there's not a whole lot of harm and maybe it might take down some swelling and maybe it might get rid of some bacteria, I don't mind doing that, and I don't need a huge study to show me that that's useful. So if there isn't a lot of harm and it's easy to do, why not? So for example, honey and lemon, you know, that's okay, right, because the harm side is not that much. If you have diabetes, your sugar might go up a little bit. But other than that, you know, hot water, honey, lemon, I tell my patients, that's fine. If you want to try that, that's always good.

BRIAN GOLDMAN: You mentioned humidified air or using vaporizers. What are your thoughts on warm humidified air versus cold?

PETER LIN: Yeah, so it just depends on what you're going to put in the water. So if you put in purified water or distilled water, you can do the cold one. So the cold one just basically shakes the molecules and sends it into the air, whereas the warm one is actually kind of boiling it. So only water vapour gets into the air. So any minerals and stuff like that stay within the unit itself. And that's why you get scales and stuff like that on those hot humidifiers. On the ones where they just use the ultrasonic way of shaking the water and putting into the air, you may shake some of those minerals and they'll come out. And that's why when people were using that, they said there's this sort of fine white powder that comes all over my furniture. Now, that's a problem, because if you breathe in that fine white powder as well with the humidified air, that becomes a problem. So if you're going to use those ultrasonic ones, then you'd use distilled water or filtered water in there so that you don't have a lot of those particles coming out.

BRIAN GOLDMAN: Last question I want to ask you, Peter. You know, some of us would actually like to prevent getting colds in the first place. So what do you recommend for people to stay healthy during this cold season?

PETER LIN: Yeah, and we're going to have. So right now, it's sort of the simple colds, right? Enterovirus, Rhinoviruses, those are the ones that are moving around. COVID, of course, is in the background there floating around. Our positivity rate is around 20%. And then RSV is going to come join the party and flu is going to join the party soon as well. So we're going to have a lot of viruses out there. And remember, all of them need you to suck it into your body. They cannot enter your body unless you breathe it in. So that's why the masking around people might be useful. I know that nobody likes mask, but just around crowded places and stuff like that. And remember, if you are sick, please don't go to somebody else because the virus is depending on you to reach the next person and breathe on them and let them suck it in. And perhaps, you know, for the older folks, if you're going to get a little hug from little Johnny, just hold your breath when little Johnny is coming in. So if you're not sucking in, you're not going to pick up the virus. Because I've heard a lot of old people going, but I miss my hugs, you know, from my grandkids. I go, go hug them. Just don't breathe while you're hugging them. And that way, you won't suck in their virus.

BRIAN GOLDMAN: Dr. Peter Lin, thank you so much for getting us up to speed on what works and what doesn't work as we enter this cold and flu season.

PETER LIN: Thank you, Brian, and thanks for all the good work that you're doing.

BRIAN GOLDMAN: Right back at you. That's Dr. Peter Lin, a family doctor in Toronto and CBC's house doctor. Here's your dose of smart advice. Last month, an advisory committee told the U.S. Food and Drug Administration that the popular decongestant, phenylephrine, is no better than a placebo. That's based on recent well-conducted studies. Phenylephrine is the leading decongestant found in popular cold and sinus remedies like Sudafed and DayQuil, and is used by millions of people. The decision concerns phenylephrine in pill form only. It doesn't apply to nasal sprays, which are still thought to be somewhat effective. Oral products containing the decongestant are still available in Canada. In general, over-the-counter cold and cough remedies should not be given to children less than six years of age, as they may cause serious and even life threatening side effects. The antihistamine, diphenhydramine or Benadryl, found in some cold remedies has been around for decades. The growing number of doctors and the Canadian Society of Allergy and Clinical Immunology say the antihistamine is less effective and less safe than newer alternatives. There's conflicting evidence for a variety of common cold remedies. Vitamin C won't help prevent colds in most people, but may shorten the duration of symptoms. Studies are mixed on the effectiveness of echinacea. Studies on zinc have also had mixed results. Zinc has potentially harmful side effects like throat and stomach irritation and temporary loss of smell. Acetaminophen and ibuprofen can relieve headaches and muscle aches associated with colds, but these should be used sparingly. Fluids, especially warm liquids and honey can help provide comfort. Both vaporizers and humidifiers may help ease throat irritation and congestion. The best ways to prevent colds and flus are the same ones recommended to reduce the risk of getting COVID: vaccines that prevent flu, COVID and RSV, wearing an N95 or KN95 mask and wider use of air filtration systems that filter out virus particles. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you like this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Stephanie Dubois. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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What are the best ways to treat a cold? - Transcript

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