Science Friday - A Common Cold Medicine Ingredient Doesn’t Work. What Now?

Episode Date: October 31, 2023

Twenty years ago, scientists found that phenylephrine, listed as a decongestant in many cold medicines, didn’t work. What can you use instead? In September, an advisory committee for the Food and Drug Administration unanimously confirmed that phenylephrine—a common ingredient in cold medicines, including some types of Mucinex and Robitussin—doesn’t work.For many physicians, pharmacists, and cold-sufferers, this came as no surprise. Phenylephrine’s ineffectiveness had been an open secret in the healthcare community for decades.In 2005, Dr. Randy Hatton, clinical professor at the Pharmaceutical Outcomes and Policy Department at the University of Florida, managed the University of Florida Drug Information and Pharmacy Resource Center hotline. He often received calls from pharmacists reporting that phenylephrine-based drugs had no effect on improving colds.He came across research from Dr. Leslie Hendeles, professor emeritus of the College of Pharmacy, also at the University of Florida, from a decade prior. Dr. Hendeles had also found that the substance was ineffective. They partnered up and petitioned the FDA to publicly confirm their finding. Their collaboration was the first step toward the FDA’s recent announcement.But despite the announcement, the removal of these drugs from shelves is not guaranteed. Pharmaceutical companies are appealing the FDA’s decision, and are trying to stall an official declaration that prohibits their sale.Guest host Flora Lichtman talks with Dr. Hatton and Dr. Hendeles about the long road to the FDA’s announcement.They discuss how their research proved phenylephrine’s ineffectiveness, and which drugs people can turn to instead as cold season approaches.To stay updated on all things science, sign up for Science Friday's newsletters. Transcripts for each segment will be available the week after the show airs on sciencefriday.com. Subscribe to this podcast. Plus, to stay updated on all things science, sign up for Science Friday's newsletters.

Doctors have been trying to spread the word about an ineffective cold medicine ingredient for decades. The compelling thing is to do the right thing. The evidence showed that oral phenylifer was ineffective. So why should it be on the market? It's Tuesday, October 31st, 2023. But what's that behind you? Boo! It's Science Friday.

I'm Cyfry producer D. Petersmith. A couple months ago, the FDA confirmed that oral phenyephyran, an ingredient used in popular cold medicines like pseudafed, doesn't work. This came after decades of research backing this up. So why did it take so long for an official government acknowledgement? Guest host Floralictin talks to two pharmacists about their years-long effort to bring their case to the FDA, how drugstores are responding, and what cold medicine alternatives we should turn to instead. Dr. Randy Hatton is a clinical professor at the University of Florida, and Dr. Leslie Henliss is a professor emeritus at the College of Pharmacy, also at the University of Florida.

Welcome to Science Friday. Thank you. Thank you. Okay. Tell me about this debunked ingredient, phenolephrine. When did it first appear in cold medicines, Randy? Well, it's actually been first in cold medicines quite a very long time ago, all the way back in the 1930s. So it has been around a very long time.

However, when it was first marketed, it was marketed as a nasal spray. Not orally taken. No, it was about a decade later that it was marketed as an oral form. So it's been around for a long time, but am I right that this was an open secret that it didn't work? Yes. That is the feedback we've gotten from many pharmacists and from some patients that they know that it doesn't work. Leslie, is this the kind of thing that you all discuss at pharmacist holiday parties? No. It's been a conversation that's occurred like at continuing education meetings and from pharmacists just asking questions, why did it get switched? And by the way, it's not just

cold products. It's a huge number of allergy products as well. Stuffy nose can be caused by the common cold or it can be caused by a seasonal allergy like ragweed during the August, September season. And nasal stuffiness can be a problem continuously, and it most often causes people to have difficulty sleeping. Yeah, so people rely on these medicines that ultimately are doing nothing. Correct. But sometimes they might be taking a product. For example, in the case of allergies, they may be taking an antihistamine decongestine combination, and the antihistamine components still provides benefit for the runny nose, the red watery, itchy eyes, but not the nasal stuffiness. That's why the decongestants combined in it. In those cases, the patient may get

some symptom relief, but not for the nasal stuffiness. Randy, how did Operation Debunk phenolephrine begin? Well, it began by getting calls to our statewide drug information center at the University of Florida. After pseudoephedrine was moved behind the counter and manufacturers reformulated their products to substitute phenylphrine for pseudophedrine in their oral decongestive products, pharmacists started calling the Drug Information Center asking the question, does oral phenolifer work? Or what is the correct dose of oral phenylphrine? Now, the Drug Information Center is a teaching laboratory for doctor of pharmacy students at the time, and they would receive questions, formulate the

question, research them, and then provide an answer back. As part of that search, we quickly came across Dr. Hendeliz's article from 1993, where he had reviewed oral decongestants and found that oral phenolephrine was ineffective. Since we knew each other, and our offices were quite close together. We got together, started talking about this and set out our quest to try to determine at first whether the evidence supported oral phenyliferate or not, and then follow on to try to take action once we determined that we felt that the evidence was clear that it was in effect. Leslie, I want to come back to your scientific work in a minute, but just, Randy, why did pharmacists suspect it didn't work? Like, why were they calling in the first place?

the customers, the patients that they had were complaining. They were used to taking products that had pseudoephed, which is quite effective when taken poorly. And now all of a sudden they were getting products that were ineffective. They were complaining it didn't work like their old pseudoephedrine products. Now this is confusing because, for example, a common brand name of pseudoephedrine that used to be in front of the counter was pseudafed. This was rebranded as pseudafed PE, and most people aren't really careful about what they grab off the counter. And so when they took that home, it didn't work like the product that they had previously used. Leslie, let's talk about the evidence.

So how do you prove scientifically that this is ineffective? Well, there's two parts to that. First is conduct studies. You select patients with either stuff, from a cold or stuffiness from allergies, and in a double-blind manner, meaning that neither the patient nor the investigator knows which compound they're getting, you give them the medication or a placebo and measure their nasal stuffiness on a scoring system. Or what was done early on in this process was to measure nasal airway resistance. If you're feeling a stuffy

nose, air is not moving through your nose, and if you open it up, air begins to move, and you can measure the flow of air indirectly by a decrease in airway resistance. One piece of this that will interest your audience from a scientific standpoint is the answer as to why does fetalephyr not work when you swallow it, but it does work very well when you spray it into the nose. The answer to the question is that there is enzymes in the gut and in the liver that inactivate the compound before it gets into the bloodstream, so it can't get to the nose. So you found scientifically that it wasn't working well or it wasn't working at all?

Well, in the more modern studies that have used good technique and good statistical analysis, it didn't work differently from a placebo, in other words, a sugar pill. Okay, so it was a decades-long saga to get the FDA onboard. So let me just see if I can summarize. You have this data suggesting phenolephrine is not effective. And eventually the FDA agrees to take a look. But after reviewing, the answer comes back, no, there's not enough data to say one way or another. So then more modern studies happen.

You do a FOIA request for unpublished studies. The drug company, Sharon Plough, runs a study where they gave oral doses of four times the usual dose found in medicine, and they find no effect. then there's another FDA advisory committee meeting, and finally they agree, this ingredient doesn't do anything. And then just last week, CVS says it's polling these drugs, which seems like a big deal. But is the FDA going to say, drug makers, you can't use this anymore? Well, they haven't reached a decision yet, but I can't see how they can say anything different when their own advisory committee voted 16 to 0 that it doesn't have any. efficacy different from a placebo. I think there's been a lot of pressure on the agency from the

consumer health care product association. And I think there's some political issues there, but I think ultimately they will probably take some action and I think that the oral form of phenolephrine will be removed. There are other medications over the counter currently that are very effective. And so if it's removed, it's not going to deprive a patient of having a treatment. What should I be taking? Well, it depends on whether you have a cold or whether you have an allergy. If you have an allergy, there is a topical nasal steroid like flonase or nasicort. That's extremely effective. And it's taken during the entire season that you have symptoms. And it is like a silver bullet. If you have a cold, you can spray fentanyl efferves.

into your nose or one of the longer acting forms like aphrine. Works exactly the same as phenolephrine in the nose, but it has a longer duration of action. Randy, it seems like this process has taken a long time. Is that frustrating? Yeah, you can't help but be frustrated, but it was a long process. Even now that there's been this advisory committee meeting where they voted unanimous leave that it was ineffective, it'll still be drawn out. You know, the FDA has a period of time where they can make a tentative final decision. There is no guidelines for how long that could be.

That could be quite a long period of time. Then they open it up for public comment. That is usually around three months, but it can be extended if they think this is such an important issue that requires more. Then they have a period of time of usually around six months where they will respond to those comments. And even at that point, should they decide that to make the final determination that oral fendil effort is ineffective, they would give manufacturers some period of time to reformulate their products. And that could be quite a period of time. There won't be any recall because there is no safety issue because, as Leslie mentioned, it's not absorbed enough to be affected. It's also not absorbed enough to be toxic. You know, I wanted to know why you two

made this your hill. Like, this is a lot of work over many, many years. What compelled you both to do this? The compelling thing is to do the right thing. We felt the evidence was pretty clear that oral fennel effluent was ineffective. Yet it's on the market. Patients are spending their harder money on these products, and we take a very evidence-based approach to the way we recommend drug therapies to patients. So the evidence showed it didn't work. So why should it be on the market? And further, a drug, whether it's over-the-counter or it's a prescription drug, not only has to be safe, it has to be effective. And oral phenyliferate is not effective. So I've been teaching pharmacists and physicians how to optimally use these medications for asthma and allergies for almost 50 years.

It's been my job to be on top of what's effective and what's not and to teach that information. So that's been my motivation. Well, I want to thank you both for doing this work. As a consumer and a frequent cold sufferer, I have two little kids. I am very grateful to you. Our pleasure. Thank you for your attention to this important issue. As Leslie said, giving the message out is part in teaching people's is very important to us.

That was Dr. Randy Hatton, clinical professor at the University of Florida, and Dr. Leslie Hendlis, Professor Emeritus, also at the University of Florida. And that's it for today. Lots of folks help put the show together, including Sandy Roberts. George Harper. Annie Nero. Jason. Rosenberg. Next time, we'll explore One Doctor's efforts to provide answers that are often lacking

after a miscarriage by studying placentas from lost pregnancies. Thanks for listening. I'm Deep Peter Schmidt. We'll see you soon on Science Friday.