Tusnel Pediatric Drops

For adults and adolescents 12 years of age and older, the standard dosing for guaifenesin depends on the formulation used.

• Immediate-Release (IR): The typical dose is 200 mg to 400 mg taken orally every 4 hours as needed. It is critical not to exceed a total of 2,400 mg (2.4 grams) in any 24-hour period.
• Extended-Release (ER): The typical dose is 600 mg to 1,200 mg taken orally every 12 hours. These tablets are designed to release the medication slowly over time. The maximum dose for ER formulations is also 2,400 mg per 24 hours (e.g., two 1,200 mg tablets).

Pediatric dosing must be calculated carefully based on the child's age. The FDA and manufacturers generally provide the following guidelines:

• Children 6 to under 12 years: 100 mg to 200 mg every 4 hours (IR). Do not exceed 1,200 mg in 24 hours.
• Children 4 to under 6 years: 50 mg to 100 mg every 4 hours (IR). Do not exceed 600 mg in 24 hours.
• Children under 4 years: Use is generally not recommended unless specifically directed by a pediatrician. There is a high risk of accidental overdose and lack of proven efficacy in this age group.

For extended-release products, use is typically restricted to children 12 years and older unless a specific pediatric ER product is available and labeled for younger ages.

Renal Impairment

Guaifenesin is primarily excreted by the kidneys. While specific dosage adjustments are not typically required for mild renal impairment, patients with moderate to severe kidney disease should use guaifenesin with caution. There is a theoretical risk of metabolite accumulation, and in rare cases of extremely high doses, a risk of kidney stones (nephrolithiasis).

Hepatic Impairment

Because guaifenesin is metabolized in the liver, patients with severe hepatic impairment should consult their doctor before use. However, for standard short-term use, no specific dose adjustments are currently mandated in the clinical literature.

Elderly Patients

Elderly patients may be more sensitive to the side effects of medications. While no specific dose reduction is required for guaifenesin based on age alone, healthcare providers often recommend starting at the lower end of the dosing range, especially if the patient has age-related declines in renal function or is taking multiple other medications.

To achieve the best results and minimize side effects, follow these instructions:

• Hydration: Drink a full glass of water with each dose. Increased fluid intake is vital as it works synergistically with guaifenesin to help thin and loosen mucus.
• Food: Guaifenesin can be taken with or without food. If you experience stomach upset, taking it with a small meal or snack may help.
• ER Tablets: Extended-release tablets (like Mucinex) must be swallowed whole. Do not crush, chew, or break the tablet, as this will destroy the time-release mechanism and cause the entire dose to be released at once, increasing the risk of side effects.
• Liquid Formulations: Always use the provided measuring cup or syringe. Household spoons are not accurate for measuring medication.
• Storage: Store at room temperature (68°F to 77°F or 20°C to 25°C) in a dry place away from direct sunlight.

If you are taking guaifenesin on a regular schedule and miss a dose, take it as soon as you remember. However, if it is almost time for your next scheduled dose, skip the missed dose and resume your regular timing. Never take two doses at once to make up for a missed one.

An acute overdose of guaifenesin is rarely life-threatening but can cause significant discomfort.

• Signs of Overdose: Severe nausea, persistent vomiting, extreme dizziness, and in some cases, the formation of kidney stones if very high doses are taken chronically.
• Emergency Measures: If an overdose is suspected, contact your local poison control center or seek emergency medical attention immediately. Treatment is generally supportive, focusing on hydration and managing gastrointestinal symptoms.

> Important: Follow your healthcare provider's dosing instructions. Do not adjust your dose or the frequency of use without medical guidance. If your cough lasts more than 7 days, returns, or is accompanied by fever, rash, or persistent headache, consult a doctor.

Guaifenesin is generally well-tolerated when used at recommended dosages. However, some patients may experience mild adverse effects. The most common side effects involve the gastrointestinal system and the central nervous system:

• Nausea and Vomiting: This is the most frequently reported side effect. It often feels like a mild 'queasiness' shortly after taking the dose. It is usually transient and can be mitigated by taking the medication with food.
• Dizziness: Some users report a lightheaded sensation. This is typically mild and does not interfere with daily activities, but patients should be aware of how the drug affects them before driving.
• Headache: A dull, aching sensation in the head may occur. This usually resolves as the medication is cleared from the system.
• Stomach Pain: Mild abdominal discomfort or cramping may occur, particularly with higher doses.

• Drowsiness: While guaifenesin is not a sedative, some individuals may feel slightly tired or lethargic.
• Diarrhea: Loose stools may occur as a result of gastrointestinal irritation.
• Skin Rash: A mild, itchy rash (urticaria) may develop in sensitive individuals. This is often a sign of a mild allergic reaction and should be monitored closely.

• Nephrolithiasis (Kidney Stones): There have been rare reports of kidney stones composed of guaifenesin metabolites in individuals who consume excessively large quantities of the drug over long periods. This is not a risk for standard, short-term use for a cold.
• Severe Dizziness: In rare cases, the lightheadedness may be severe enough to cause imbalance.
• Confusion: Very rare reports of mild mental clouding have been noted, particularly in elderly patients or those taking high doses.

While extremely rare, some side effects require immediate medical intervention.

> Warning: Stop taking Guaifenesin and call your doctor immediately if you experience any of the following:

• Anaphylaxis (Severe Allergic Reaction): Symptoms include swelling of the face, lips, tongue, or throat; difficulty breathing or swallowing; severe wheezing; and a rapid heart rate. This is a medical emergency.
• Severe Skin Reactions: The development of blisters, peeling skin, or a widespread red rash should be reported immediately.
• Severe Persistent Vomiting: If you cannot keep fluids down, you may be at risk for dehydration.
• Hematuria (Blood in Urine): While not directly linked to standard use, any changes in urination or blood in the urine while taking guaifenesin should be evaluated to rule out kidney stones or other renal issues.

Guaifenesin is intended for short-term use (usually no more than 7 days). Long-term use is not recommended unless under the direct supervision of a physician. Potential risks of prolonged use include:

• Masking Underlying Conditions: Chronic use may hide the symptoms of a more serious condition, such as chronic obstructive pulmonary disease (COPD), asthma, or lung cancer.
• Kidney Stone Formation: As mentioned, chronic over-consumption is linked to the development of guaifenesin-based renal calculi.
• Tolerance: While physical dependence does not occur, the effectiveness of the drug for a chronic cough may diminish over time as the underlying pathology remains unaddressed.

No FDA black box warnings for Guaifenesin.

Guaifenesin is considered one of the safest OTC medications when used according to the label instructions. It does not have the high abuse potential or severe toxicity profile associated with many other respiratory medications. However, its safety is predicated on using it for the correct type of cough (productive) and for the appropriate duration.

Report any unusual symptoms to your healthcare provider. If you notice any side effects not listed here, contact your doctor or pharmacist for further guidance. You may also report side effects to the FDA at 1-800-FDA-1088.

Guaifenesin is a safe and effective expectorant for most people, but certain precautions must be observed to ensure its proper use. The most critical safety point is that guaifenesin is intended for the relief of a productive cough (a cough that produces mucus). It is not effective for a dry, hacking cough caused by smoking, asthma, or emphysema. Using guaifenesin for these conditions without medical advice can delay the diagnosis of a serious respiratory issue.

There are currently no FDA black box warnings for Guaifenesin. It has a long history of safe use in both adult and pediatric populations when administered at recommended dosages.

• Allergic Reactions / Anaphylaxis Risk: Individuals with a known hypersensitivity to guaifenesin or any of the inactive ingredients in the specific formulation (such as dyes or preservatives) should avoid this medication. Signs of a reaction include hives, swelling, and respiratory distress.
• Chronic Cough: If you have a cough that has lasted for more than 7 days, or if your cough is a chronic condition like those seen in smokers or people with asthma, do not use guaifenesin without consulting a healthcare provider. A persistent cough may be a sign of a condition that requires different medical treatment.
• Fever and Other Symptoms: If your cough is accompanied by a high fever, persistent headache, or a skin rash, these may be signs of a bacterial infection or other serious illness. Guaifenesin will not treat an infection; you may need antibiotics or other prescription medications.
• Nephrolithiasis Risk: Patients with a history of kidney stones should use guaifenesin with caution. While the risk is low at standard doses, the metabolites of guaifenesin can contribute to stone formation in predisposed individuals or at very high doses.

For standard, short-term use of guaifenesin, routine laboratory monitoring (such as blood counts or liver function tests) is not required. However, if a patient is using guaifenesin off-label for chronic conditions, or if they have pre-existing renal impairment, a healthcare provider may occasionally monitor:

• Renal Function: To ensure the kidneys are effectively clearing the drug's metabolites.
• Urinalysis: To check for signs of crystalluria (crystals in the urine) which could lead to stone formation.

Guaifenesin generally does not cause significant impairment. However, because dizziness and mild drowsiness are possible side effects, you should observe how the medication affects you before driving a car or operating heavy machinery. If you feel lightheaded, avoid these activities until the sensation passes.

There is no known direct chemical interaction between guaifenesin and alcohol. However, many liquid 'cough and cold' products contain both guaifenesin and alcohol (as a solvent). Furthermore, alcohol can dehydrate the body, which counteracts the goal of guaifenesin (which is to hydrate mucus). It is generally recommended to limit alcohol intake while recovering from a respiratory infection to support the immune system and maintain hydration.

Guaifenesin does not require a tapering period. You can stop taking it as soon as your symptoms resolve. There is no risk of a withdrawal syndrome. If your symptoms do not improve after 7 days of use, you should discontinue the drug and see a doctor, as the medication is clearly not addressing the underlying cause of your cough.

> Important: Discuss all your medical conditions with your healthcare provider before starting Guaifenesin, especially if you have a persistent cough or kidney problems.

Guaifenesin itself does not have any absolute contraindications with other drugs that result in life-threatening interactions. However, the primary concern lies in combination products. Many OTC medications contain guaifenesin along with other active ingredients like dextromethorphan (an antitussive) or pseudoephedrine (a decongestant).

• MAO Inhibitors (MAOIs): While guaifenesin does not interact with MAOIs, if it is taken in a combination product containing dextromethorphan or pseudoephedrine, it must NOT be used within 14 days of taking an MAOI (e.g., phenelzine, selegiline). This combination can lead to a hypertensive crisis or serotonin syndrome.

• Anticoagulants (e.g., Warfarin): There are very rare reports that high doses of guaifenesin might slightly alter platelet aggregation, potentially increasing the effects of blood thinners. While not a major concern for most, patients on anticoagulants should monitor for unusual bruising or bleeding.
• Lithium: Some expectorants can affect how the kidneys process lithium, potentially leading to increased lithium levels. Monitoring by a healthcare provider is advised if these are used together.

• Other Cough and Cold Medications: The most significant 'interaction' is the risk of accidental overdose. Many products contain guaifenesin under different brand names. Taking multiple products can lead to a total dose exceeding the 2,400 mg daily limit, increasing the risk of nausea and kidney stones.
• Muscle Relaxants: Since guaifenesin has a mild NMDA-antagonist effect, it may theoretically enhance the sedative effects of other muscle relaxants (like cyclobenzaprine), though this is rarely clinically significant at standard doses.

• Hydration Status: While not a drug-food interaction in the traditional sense, the efficacy of guaifenesin is heavily dependent on hydration. Consuming large amounts of caffeine (a diuretic) may counteract the drug's ability to hydrate bronchial secretions.
• Grapefruit Juice: Unlike many other drugs, guaifenesin metabolism does not involve the CYP3A4 enzyme, so grapefruit juice does not significantly affect its levels.

• Diuretic Herbs (e.g., Dandelion, Juniper): These may increase the risk of dehydration, potentially making guaifenesin less effective at thinning mucus.
• St. John's Wort: No significant interaction has been documented, as guaifenesin is not a major CYP450 substrate.

Guaifenesin can interfere with certain laboratory diagnostic tests:

• Vanillylmandelic Acid (VMA) Test: Guaifenesin or its metabolites may cause a false-positive increase in urinary VMA levels. This test is often used to screen for adrenal gland tumors (pheochromocytoma). You should stop taking guaifenesin at least 48 hours before a VMA urine collection.
• 5-Hydroxyindoleacetic Acid (5-HIAA) Test: Guaifenesin may also interfere with the colorimetric determination of 5-HIAA, a test used to diagnose carcinoid syndrome.

For each major interaction, the mechanism usually involves either additive pharmacodynamic effects (in combination products) or interference with chemical assays in lab tests. The management strategy is typically to avoid combination products that contain redundant ingredients and to inform laboratory personnel of guaifenesin use before diagnostic testing.

> Important: Tell your doctor about ALL medications, supplements, and herbal products you are taking, including those for cough and cold symptoms.

There are very few absolute contraindications for guaifenesin, which contributes to its status as a widely available over-the-counter medication. However, it must NEVER be used in the following circumstances:

1. 1Hypersensitivity to Guaifenesin: If a patient has had a documented allergic reaction to guaifenesin in the past, including anaphylaxis, angioedema (swelling under the skin), or severe urticaria (hives), the drug is strictly contraindicated. Re-exposure can lead to increasingly severe and potentially fatal allergic responses.
2. 2Inability to Swallow (for ER forms): Extended-release tablets are contraindicated in patients who cannot swallow the tablet whole (e.g., those with severe dysphagia or those requiring a feeding tube). Crushing the tablet to facilitate administration leads to 'dose dumping,' where the 12-hour dose is absorbed instantly, potentially causing toxicity.
3. 3Children Under Age 4: Most regulatory bodies and manufacturers now contraindicate the use of cough and cold medicines, including guaifenesin, in children under 4 years of age due to the lack of proven efficacy and the high risk of serious adverse events, including respiratory depression and accidental overdose.

These are conditions where the use of guaifenesin requires a careful risk-benefit analysis by a healthcare professional:

• History of Nephrolithiasis (Kidney Stones): Because guaifenesin metabolites can form stones, individuals with a history of uric acid or calcium oxalate stones should use the drug with caution and ensure they remain exceptionally well-hydrated.
• Chronic Bronchitis or Emphysema: In these conditions, the cough is a necessary mechanism to keep the airways open. While guaifenesin can thin the mucus, it should only be used if the healthcare provider determines that increasing the volume of secretions will not overwhelm the patient's ability to clear them.
• Phenylketonuria (PKU): Some chewable or liquid formulations of guaifenesin are sweetened with aspartame, which contains phenylalanine. Patients with PKU must check the inactive ingredients list carefully.

There is no significant evidence of cross-sensitivity between guaifenesin and other classes of expectorants or respiratory medications. However, patients who are sensitive to guaiac-based products or certain wood resins should be monitored closely during their first few doses.

> Important: Your healthcare provider will evaluate your complete medical history, including any history of allergies or kidney issues, before prescribing or recommending Guaifenesin.

Guaifenesin is categorized by the FDA under the old Pregnancy Category C. This means that animal reproduction studies have not been conducted, and there are no adequate and well-controlled studies in humans.

• First Trimester: Some epidemiological studies have suggested a possible link between guaifenesin exposure in the first trimester and certain minor birth defects (like inguinal hernias), though the evidence is not conclusive. Most doctors recommend avoiding guaifenesin during the first 13 weeks of pregnancy unless absolutely necessary.
• Second and Third Trimesters: It is generally considered safer in later pregnancy, but it should still only be used if the potential benefit justifies the potential risk to the fetus. Always consult an obstetrician before use.

It is not known whether guaifenesin is excreted in human milk. Because the drug has a very short half-life (1 hour) and low protein binding, the amount a nursing infant would be exposed to is likely very low. However, because there is a lack of definitive data, breastfeeding mothers should consult their healthcare provider. The primary concern is often not the guaifenesin itself, but other ingredients (like alcohol or decongestants) found in combination cough syrups.

• Approved Age Ranges: Guaifenesin is generally approved for children 4 years and older.
• Dosing: Dosing must be strictly age-appropriate. Over-the-counter cough and cold medicines have been associated with serious side effects in young children, including seizures and rapid heart rate, usually due to accidental overdose.
• Growth Effects: There are no known effects of short-term guaifenesin use on pediatric growth or development.
• Conditions NOT Approved: Guaifenesin is not approved for treating chronic coughs in children, such as those associated with asthma or cystic fibrosis, without specialist supervision.

Elderly patients (65 and older) may be at an increased risk for certain side effects:

• Dehydration: Seniors often have a decreased thirst reflex. Since guaifenesin requires hydration to work, elderly patients must be prompted to drink enough water.
• Renal Clearance: Age-related decline in kidney function may slow the elimination of guaifenesin metabolites. While this rarely requires a dose change, it may increase the risk of nausea or dizziness.
• Polypharmacy: Seniors are more likely to be taking multiple medications. It is crucial to check that guaifenesin does not interact with their existing regimen or that they are not taking multiple products containing the same ingredient.

In patients with significant renal impairment (GFR < 30 mL/min), the excretion of the inactive metabolite beta-(2-methoxyphenoxy)-lactic acid is delayed. While the metabolite is inactive, its accumulation has been theoretically linked to the rare formation of kidney stones. Patients with end-stage renal disease or those on dialysis should use guaifenesin only under close medical supervision.

Specific studies in patients with hepatic impairment are limited. However, since the liver is the primary site of metabolism, those with severe cirrhosis (Child-Pugh Class C) should be monitored for increased side effects like nausea and dizziness, which may indicate higher-than-normal plasma levels of the parent drug.

> Important: Special populations require individualized medical assessment to ensure that the benefits of guaifenesin use outweigh any potential risks.

Guaifenesin exerts its primary therapeutic effect as a secretolytic expectorant. It increases the volume and water content of the airway surface liquid (ASL). It is thought to act by irritating the gastric mucosa, which then triggers a vagal reflex (the gastropulmonary reflex) that stimulates efferent parasympathetic pathways to the bronchial glands. This results in an increase in the secretion of low-viscosity fluids from the serous glands in the lining of the respiratory tract.

Additionally, guaifenesin acts as an uncompetitive antagonist at N-methyl-D-aspartate (NMDA) receptors. By binding to these receptors, it may modulate excitatory neurotransmission. It also acts as an agonist at Sigma-1 receptors, which are involved in protein folding and calcium signaling in the endoplasmic reticulum. These neuropharmacological actions may contribute to its mild analgesic and muscle-relaxant properties, which are distinct from its respiratory effects.

The onset of action for immediate-release guaifenesin is rapid, with patients often noticing a change in cough productivity within 30 minutes. The duration of effect for IR formulations is approximately 4 to 6 hours, while extended-release formulations provide a sustained effect for 12 hours. Guaifenesin does not appear to suppress the cough reflex itself (unlike dextromethorphan); instead, it changes the nature of the cough to make it more effective at clearing the airways. There is no evidence of tolerance development with short-term use.

| Parameter | Value |

|---|---|

| Bioavailability | High (Rapidly absorbed) |

| Protein Binding | Low (Not significantly bound) |

| Half-life | ~1 hour |

| Tmax | 15–30 minutes (IR); 1–2 hours (ER) |

| Metabolism | Hepatic (Oxidation/Hydroxylation) |

| Excretion | Renal (~90% as metabolites) |

• Molecular Formula: C10H14O4
• Molecular Weight: 198.22 g/mol
• Solubility: Sparingly soluble in water; soluble in alcohol and chloroform.
• Structure: Guaifenesin is a propanediol derivative, specifically 3-(2-methoxyphenoxy)-1,2-propanediol. It consists of a guaiacol ether linked to a glycerol moiety.

Guaifenesin is the primary representative of the Expectorant class. While other agents like bromhexine or ambroxol are used in other countries, guaifenesin remains the only FDA-approved expectorant in the United States. It is often grouped with 'Mucolytics' (like acetylcysteine), but its mechanism is distinct; mucolytics chemically break down mucus bonds, while expectorants like guaifenesin increase the fluid volume to thin the mucus naturally.