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Inhibition of Cough-Reflex Sensitivity by Benzonatate and Guaifenesin In Respiratory Medicine (2009) 103, 902e906 available at www.sciencedirect.com journal homepage: www.elsevier.com/locate/rmed Inhibition of cough-reflex sensitivity by benzonatate and guaifenesin in acute viral cough Peter V. Dicpinigaitis a,*, Yvonne E. Gayle a, Gail Solomon b, Richard D. Gilbert c a Albert Einstein College of Medicine and Montefiore Medical Center, 1825 Eastchester Road, Bronx, NY, 10461, USA b Reckitt Benckiser, Inc., 399 Interpace Parkway, Parsippany, NJ, 07054, USA c TKL Research, Inc., 365 West Passaic Street, Rochelle Park, NJ, 07662, USA Received 8 September 2008; accepted 9 December 2008 Available online 1 January 2009 KEYWORDS Summary Cough; Acute cough due to viral upper respiratory tract infection (URI) is the most common form of Antitussive; cough and accounts for tremendous expenditure on prescription and non-prescription cough Guaifenesin; products worldwide. However, few agents have been shown in properly conducted clinical Benzonatate; trials to be effective for cough due to URI. The present study evaluated the effect of benzo- Capsaicin; natate 200 mg (B), guaifenesin 600 mg (G), their combination (B þ G), and placebo (P) on Common cold capsaicin-induced cough in 30 adult nonsmokers with acute URI. On 3 separate days within a 7-day period, 1 h after ingesting randomly assigned study drug in a double-blind fashion, subjects underwent capsaicin cough challenge testing, which involved inhalation of incre- mental doubling concentrations of capsaicin until the concentration of capsaicin inducing 5 or more coughs (C5) was attained. Each subject received 3 of 4 possible study drugs. G (p Z 0.01) but not B (p Z NS) inhibited cough-reflex sensitivity (log C5)relativetoP.The combination of B þ G suppressed capsaicin-induced cough to a greater degree than B alone (p < 0.001) or G alone (p Z 0.008). The mechanism by which the combination of B þ G causes a potentiation of antitussive effect remains to be elucidated. Our results suggest that B þ G may be an effective therapy for acute cough due to the common cold (URI). ª 2008 Elsevier Ltd. All rights reserved. Introduction Cough is the most common complaint for which patients in 1 * Correspondence to: Peter V. Dicpinigaitis, Einstein Division/ the United States seek medical attention. Acute cough Montefiore Medical Center, 1825 Eastchester Road, Bronx, NY due to viral upper respiratory tract infection (URI) is the 10461, USA. Tel.: þ1 718 904 2676; fax: þ1 718 904 2880. most common form of cough and results in tremendous E-mail address: [email protected] (P.V. Dicpinigaitis). financial expenditure on prescription and non-prescription 0954-6111/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2008.12.008 Inhibition of cough-reflex sensitivity by benzonatate and guaifenesin in acute viral cough 903 (over-the-counter) cough and cold products worldwide. Suggestive symptoms included acute onset of cough, fever, However, few of the currently available antitussive agents myalgias, rhinitis, nasal congestion, and sneezing. Symp- have been shown, in properly conducted clinical trials, to toms suggestive of a possible bacterial infection, such as be effective in suppressing cough due to URI.2,3 The sinus pain and purulent nasal discharge, excluded a subject narcotic opioids, such as codeine, have been demonstrated from enrollment. Other exclusion criteria included: history to be ineffective for acute cough associated with URI.4,5 If of asthma or other pulmonary disease; use of medications achieved, the antitussive effect of opioids often occurs at potentially affecting cough-reflex sensitivity (i.e., opiates the expense of troubling or intolerable side effects, such as and angiotensin converting-enzyme (ACE) inhibitors); and sedation or gastrointestinal disturbance.6 ingestion of the following types of medications within the Guaifenesin, the glyceryl ether of guaiacol (a constit- following time periods prior to study entry: short-acting uent of guaiac resin from the wood of Guajacum officinale antihistamines (48 h); short-acting pseudoephedrine (12 h); Linne´), is a component of numerous cough and cold prod- long-acting pseudoephedrine (24 h); non-steroid nasal ucts available worldwide. Guaifenesin is termed an sprays (12 h); cough suppressants and expectorants (24 h). expectorant since it is believed to alleviate cough discom- Female subjects were required to be using adequate fort by increasing sputum volume and decreasing its contraception. viscosity (hydration hypothesis), thereby promoting effec- 7 tive cough. Guaifenesin remains the only expectorant Study design approved by the United States Food and Drug Administra- tion (FDA).8 Despite its availability and common usage for This was a randomized, double-blind, placebo-controlled decades, few studies have evaluated the antitussive effect study of crossover design whose aim was to evaluate the of guaifenesin. A recently published trial demonstrated the effect of a combination of benzonatate and guaifenesin, ability of guaifenesin to inhibit cough-reflex sensitivity in relative to each individual drug and placebo, on cough- subjects with acute URI, thus suggesting an antitussive as reflex sensitivity to inhaled capsaicin in 30 otherwise well as expectorant action for the drug.9 healthy volunteers with acute viral URI. Upon enrollment, Benzonatate, a long chain polyglycol derivative chemi- subjects were randomized to receive 3 of 4 possible study cally related to procaine, is a peripherally-acting, oral drug combinations, one on each of 3 successive visits anesthetic agent whose mechanism of cough suppression is occurring on 3 separate days within a 7-day period. The 4 believed to involve inhibition of pulmonary stretch recep- possible study drug combinations included: benzonatate tors.10 Studies performed soon after its approval in the 200 mg (Inwood Laboratories, Commack, NY); guaifenesin United States a half century ago showed benzonatate able 600 mg (BI Chemicals, Petersburg, VA); benzonatate to inhibit experimentally-induced cough as well as to 200 mg þ guaifenesin 600 mg; and placebo, all prepared as suppress subjectively-measured pathological cough.11 No identically-appearing capsules. Subjects underwent capsa- further clinical trials of benzonatate have been published in icin cough challenge testing, to measure cough-reflex decades. sensitivity, 1 h after ingestion of study drug, administered Given the urgent need for better cough suppressant in a double-blind manner, on each of the 3 visits. The 1-h therapy, the goal of the present study was to evaluate, in pre-test interval was chosen to coincide with high plasma a prospective, randomized, double-blind, placebo- levels of each study drug. The dosages of study drugs were controlled manner, the antitussive effect of the combina- chosen to concur with current FDA-approved standards. tion of benzonatate and guaifenesin in subjects with acute The FDA regulates the use of capsaicin in clinical trials and URI. Cough-reflex sensitivity was measured by capsaicin required that no more than 3 successive doses (challenges) inhalation cough challenge. Capsaicin, the pungent extract be administered to a single subject in this study. Therefore, of red peppers, has been demonstrated in over two decades the 4 study treatments were investigated with a (4,3,N ) of clinical experience to induce cough in a safe, dose- balanced incomplete block design, in which each subject dependent and reproducible manner,12,13 and therefore has received 3 of the 4 treatments according to a pre- become an important tool for the assessment of the effect determined randomization scheme, over the course of 3 of a pharmacological intervention on cough-reflex sensi- study visits. This study was approved by the Institutional tivity.14 The most commonly used endpoints of capsaicin Review Board of Montefiore Medical Center, Bronx, New cough challenge are C and C , the concentrations of 2 5 York. All subjects provided written, informed consent. capsaicin inducing 2 or more, and 5 or more coughs, respectively. The C5 has been shown to be the most reproducible parameter in capsaicin cough-reflex sensi- Capsaicin cough challenge testing tivity measurement.12 Capsaicin was prepared and administered as previously described.12 Briefly, a stock solution (0.01 M) of capsaicin Methods (Formosa Laboratories, Taiwan, ROC) was prepared and subsequently diluted with physiological saline to yield serial Subjects doubling concentrations ranging from 0.49 mM to 1000 mM. Fresh dilutions were prepared on each day of testing. Subjects were otherwise healthy adult nonsmokers (life- Subjects inhaled single, vital-capacity breaths of time nonsmokers or ex-smokers having abstained from capsaicin aerosol administered via nebulizer (model 646; smoking >5 years) who developed symptoms consistent DeVilbiss Health Care Inc., Somerset, PA) controlled by with acute viral URI within 72 h of study enrollment. a dosimeter (KoKo DigiDoser; nSpire Health Inc., Louisville, 904 P.V. Dicpinigaitis et al. CO). The nebulizer used in this study was modified in two with fixed terms for sequence, subject within sequence, ways. First, an inspiratory flow regulator valve (RIFR; nSpire period, and treatment. Treatments were compared pair- Health Inc.) was added, which limited inspiratory flow to wise using Fisher’s Least Significant differences. 0.5 L/s regardless of excessive inspiratory force, thereby guaranteeing a constant and reproducible inspiratory effort with each breath. Second, the straw and baffle assembly of Results the nebulizer was welded in place, thereby eliminating the variations in nebulizer output that occur when these Thirty subjects (19 female, 11 male; mean age 42.2 Æ 14.0 components are detached for washing and then reattached, [SD]) were enrolled and completed all 3 required study with resulting variable distances between the jet orifice visits. No significant adverse events were reported. Twenty- and straw. Given the nebulizer output of 1.007 mL/min, three subjects (77%) were lifetime nonsmokers; 7 subjects duration of aerosol delivery was programmed at 1.2 s to (23%) were distant ex-smokers (>5 years). The number of provide 0.02 mL aerosol per inhalation.
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