For medical professionals only
Specifications for the use of common medicines
On May 7, 2024, the State Food and Drug Administration issued an announcement on adjusting the list of psychotropic drugs, including dextromethorphan (click to view the detailed instructions) in the list of Class II psychotropic drugs, which will come into force on July 1, 2024.
Source: Screenshot of the Food and Drug Administration
I believe everyone is a little confused about this, Jiexiaoyao has summarized the 4 most asked questions by doctors, come and find out!
Q1: Dextromethorphan is a commonly used antitussive drug, why does it need to be included in the management of Class II psychotropic drugs?
Dextromethorphan is the dextrot isomer of levomorphine, which is a central antitussive drug, which can inhibit the brain cough center and produce antitussive effect. Its antitussive effect is equal to or slightly stronger than that of codeine. It can be used to temporarily relieve cough caused by throat and bronchial irritation caused by colds or inhalation of irritating substances, and can also be used to solve the problem of inability to sleep due to acute cough [1-2].
Dextromethorphan does not exhibit clear central pharmacological effects (eg, analgesia, respiratory depression, addiction, etc.) at therapeutic doses (60 to 120 mg daily, divided doses), but can exhibit dissociation at high doses (5 to 10 times the labeled dose), similar to other N-methyl-D-aspartate receptor inhibitors (eg, ketamine, phencyclidine)[3].
Cough suppressants that seem to have nothing to do with addiction or dependence can lead to serious adverse consequences due to abuse.
In the past 20 years, there have been more and more reports of dextromethorphan abuse in adolescents, mostly in the age group of 15 to 16 years, and there have been many cases of adolescents dying from overdose of dextromethorphan capsules or high-dose injection of dextromethorphan poisoning [4].
Q2: What is the relationship between the dosage and effect of dextromethorphan abuse?
Symptoms of a single overdose of dextromethorphan vary with dose. When taking a dose of 100-200 mg, restlessness and euphoria appear; At a dose of 200-500 mg, exaggerated auditory and visual sensations, hallucinations, imbalances appear; Dose 500-1000 mg, audiovisual disturbances, altered consciousness, unresponsiveness, mania, panic, partial dissociation; The dose > 1000 mg, hallucinations, delusions, dyskinesia, complete dissociation[5].
Long-term users (months to years) develop drug dependence and withdrawal symptoms due to persistent abuse, including severe fatigue, depression, stomach upset, tremors, and delayed dystonia [6].
In an analysis of serious adverse events such as dextromethorphan-induced addiction and psychiatric abnormalities, it was found that the average single dose of 44 patients was 555.34 mg, including 450.00 mg for minors, 609.83 mg for adults, and (10.42±4.82) mg·kg-1 for emergency patients with overdose poisoning.
According to the Martindale Drug Codex and related literature, more than 20 times the recommended dose of dextromethorphan used in a single use may cause drug overdose, poisoning, or mental status changes. For example, cognitive and emotional changes are manifested as inattention, a sense of brain hollowness, slurred speech, followed by tracheal spasm, respiratory depression, etc.
Q3: Dextromethorphan should be used in strict accordance with the instructions, how to control the dose?
Take oral tablets, for example.
- adults: 15-30 mg 3-4 times daily;
- Children: 7.5 mg once for children 2 to 6 years of age, 15 mg once for children 7 to 12 years of age, 30 mg once for children over 12 years of age, three times daily. No more than 4 times in 24 hours.
Q4: What other issues should I pay attention to when using dextromethorphan?
- For patients with a lot of sputum, dextromethorphan may cause airway obstruction, so it is generally not recommended for patients with respiratory failure or asthma conditions.
- Special attention should be paid to patients who are taking drugs such as monoamine oxidase inhibitors, serotonin reuptake inhibitors (such as fluoxetine, paroxetine), bupropion, linezolid and other drugs, or have been taking these drugs for less than two weeks, so as not to enhance the excitatory effect of the nerve center.
- During the period of taking the drug, it is forbidden to drive a machine, a car, a boat, engage in high-altitude work, mechanical work and operate precision instruments.
A doctor asked: dextromethorphan is a powerful antitussive drug, not suitable for patients with a lot of phlegm, so is there a problem with expectorant or mucolytic agent?
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| Deacetyl piloside | Flunarizine | Domperidone | Levofloxacin |
| Cefoperazone sodium, sulbactam sodium | Calcium gluconate | atorvastatin calcium | Pregabalin |
| Levothyroxine sodium | Lactulose | Isosorbide mononitrate | Febuxostat |
| dopamine | Promethazine | Benbromarone | Phloroglucinol |
| Oseltamivir phosphate | Metronidazole | Acyclovir | Montmorillonite powder |
| Ketotifen fumarate | Betahistine | Metoclopramide | Montelukast sodium |
| Piperacillin sodium, tazobactam sodium | Methylprednisolone | Ceftazidime | Bisoprolol fumarate |
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参考文献：[1]OTCProductInformation:DELSYM(DEXTROMETHORPHAN)-dextromethorphansuspension,extendedrelease,RBHealth(US)LLC,UpdatedOctober9,2019
[2] OTCProductInformation:DEXTROMETHORPHANHBR15MG-dextromethorphanhbrcapsule,liquidfilled,HumanwellPuraCapPharmaceutical(Wuhan),Ltd.,UpdatedNovember7,2019
[3] Zou Yuzhen, Han Fei, Mei Dan. Chinese Journal of Hospital Pharmacy, 2019(3):5.DOI:10.13286/j.cnki.chinhosppharmacyj.2019.03.21.
[4] Zhang X . Addiction risk and prevention strategies of dextromethorphan abuse[J]. Chinese Journal of Drug Abuse Prevention and Control, 2020, 26( 5): 283-285.
[5] Antoniou T，Juurlink DN. Dextromethorphan abuse[J]. CMAJ，2014，186（16）：631-632．
[6] Rong Youming, Wu Shifu, Tian Yuejie, et al. Chinese Journal of Drug Dependence, 2020, 29(3):6.