Pseudoephedrine
Pseudoephedrine, sold under the brand name Sudafed among others, is a sympathomimetic medication which is used as a decongestant to treat nasal congestion. It has also been used off-label for certain other indications, like treatment of low blood pressure. At higher doses, it may produce various additional effects including stimulant, appetite suppressant, and performance-enhancing effects. In relation to this, non-medical use of pseudoephedrine has been encountered. The medication is taken by mouth.
Side effects of pseudoephedrine include insomnia, elevated heart rate, increased blood pressure, restlessness, dizziness, anxiety, and dry mouth, among others. Rarely, pseudoephedrine has been associated with serious cardiovascular complications like heart attack and hemorrhagic stroke. Some people may be more sensitive to its cardiovascular effects. Pseudoephedrine acts as a norepinephrine releasing agent, thereby indirectly activating adrenergic receptors. As such, it is an indirectly acting sympathomimetic. Pseudoephedrine significantly crosses into the brain, but has some peripheral selectivity due to its hydrophilicity. Chemically, pseudoephedrine is a substituted amphetamine and is closely related to ephedrine, phenylpropanolamine, and amphetamine. It is the -enantiomer of β-hydroxy-N-methylamphetamine.
Along with ephedrine, pseudoephedrine occurs naturally in ephedra, which has been used for thousands of years in traditional Chinese medicine. It was first isolated from ephedra in 1889. Subsequent to its synthesis in the 1920s, pseudoephedrine was introduced for medical use as a decongestant. Pseudoephedrine is widely available over-the-counter in both single-drug and combination preparations. Availability of pseudoephedrine has been restricted starting in 2005 as it can be used to synthesize methamphetamine. Phenylephrine has replaced pseudoephedrine in many over-the-counter oral decongestant products. However, oral phenylephrine appears to be ineffective as a decongestant. In 2023, pseudoephedrine was the 292nd most commonly prescribed medication in the United States, with more than 400,000 prescriptions. In 2023, the combination with brompheniramine and dextromethorphan was the 281st most commonly prescribed medication in the United States, with more than 700,000 prescriptions. In 2023, the combination with loratadine was the 300th most commonly prescribed medication in the United States, with more than 400,000 prescriptions.
Medical uses
Nasal congestion
Pseudoephedrine is a sympathomimetic and is well-known for shrinking swollen nasal mucous membranes, so it is often used as a decongestant. It reduces tissue hyperemia, edema, and nasal congestion commonly associated with colds or allergies. Other beneficial effects may include increasing the drainage of sinus secretions, and opening of obstructed Eustachian tubes. The same vasoconstriction action can also result in hypertension, which is a noted side effect of pseudoephedrine.Pseudoephedrine can be used either as oral or as topical decongestant. Due to its stimulating qualities, however, the oral preparation is more likely to cause adverse effects, including urinary retention. According to one study, pseudoephedrine may show effectiveness as an antitussive drug.
Pseudoephedrine is indicated for the treatment of nasal congestion, sinus congestion, and Eustachian tube congestion. Pseudoephedrine is also indicated for vasomotor rhinitis and as an adjunct to other agents in the optimum treatment of allergic rhinitis, croup, sinusitis, otitis media, and tracheobronchitis.
Other uses
s and other catecholaminergic agents are known to have wakefulness-promoting effects and are used in the treatment of hypersomnia and narcolepsy. Pseudoephedrine at therapeutic doses does not appear to improve or worsen daytime sleepiness, daytime fatigue, or sleep quality in people with allergic rhinitis. Likewise, somnolence was not lower in children with the common cold treated with pseudoephedrine for nasal congestion. In any case, insomnia is a known side effect of pseudoephedrine, although the incidence is low. In addition, doses of pseudoephedrine above the normal therapeutic range have been reported to produce stimulant effects including insomnia and fatigue resistance.There has been interest in pseudoephedrine as an appetite suppressant for the treatment of obesity. However, due to lack of clinical data and potential cardiovascular side effects, this use is not recommended. Only a single placebo-controlled study of pseudoephedrine for weight loss exists and found no significant difference in weight lost compared to placebo. This was in contrast to phenylpropanolamine, which has been found to be more effective at promoting weight loss compared to placebo and has been more widely studied and used in the treatment of obesity.
Pseudoephedrine has been used limitedly in the treatment of orthostatic intolerance including orthostatic hypotension and postural orthostatic tachycardia syndrome. However, its effectiveness in the treatment of POTS is controversial. Pseudoephedrine has also been used limitedly in the treatment of refractory hypotension in intensive care units. However, data on this use are limited to case reports and case series.
Pseudoephedrine is also used as a first-line prophylactic for recurrent priapism. Erection is largely a parasympathetic response, so the sympathetic action of pseudoephedrine may serve to relieve this condition. Data for this use are however anecdotal and effectiveness has been described as variable.
Treatment of urinary incontinence is an off-label use for pseudoephedrine and related medications.
Available forms
Pseudoephedrine is available by itself over-the-counter in the form of 30 and 60mg immediate-release and 120 and 240mg extended-release oral tablets in the United States.Pseudoephedrine is also available over-the-counter and prescription-only in combination with numerous other drugs, including antihistamines, analgesics, cough suppressants, and expectorants.
Pseudoephedrine has been used in the form of the hydrochloride and sulfate salts and in a polistirex form. The drug has been used in more than 135 over-the-counter and prescription formulations. Many prescription formulations containing pseudoephedrine have been discontinued over time.
Contraindications
Pseudoephedrine is contraindicated in patients with diabetes mellitus, cardiovascular disease, severe or uncontrolled hypertension, severe coronary artery disease, prostatic hypertrophy, hyperthyroidism, closed-angle glaucoma, or by pregnant women. The safety and effectiveness of nasal decongestant use in children is unclear.Side effects
Common side effects with pseudoephedrine therapy may include central nervous system stimulation, insomnia, restlessness, excitability, dizziness, and anxiety. Infrequent side effects include tachycardia or palpitations. Rarely, pseudoephedrine therapy may be associated with mydriasis, hallucinations, arrhythmias, hypertension, seizures, and ischemic colitis; as well as severe skin reactions known as recurrent pseudo-scarlatina, systemic contact dermatitis, and non-pigmenting fixed drug eruption. Pseudoephedrine, particularly when combined with other drugs including narcotics, may also play a role in the precipitation of episodes of psychosis. It has also been reported that pseudoephedrine, among other sympathomimetic agents, may be associated with the occurrence of hemorrhagic stroke and other cardiovascular complications.Due to its sympathomimetic effects, pseudoephedrine is a vasoconstrictor and pressor agent, a positive chronotrope, and a positive inotrope. The influence of pseudoephedrine on blood pressure at clinical doses is controversial. A closely related sympathomimetic and decongestant, phenylpropanolamine, was withdrawn due to associations with markedly increased blood pressure and incidence of hemorrhagic stroke. There has been concern that pseudoephedrine may likewise dangerously increase blood pressure and thereby increase the risk of stroke, whereas others have contended that the risks are exaggerated. Besides hemorrhagic stroke, myocardial infarction, coronary vasospasm, and sudden death have also rarely been reported with sympathomimetic ephedra compounds like pseudoephedrine and ephedrine.
A 2005 meta-analysis found that pseudoephedrine at recommended doses had no meaningful effect on systolic or diastolic blood pressure in healthy individuals or people with controlled hypertension. Systolic blood pressure was found to slightly increase by 0.99mmHg on average and heart rate was found to slightly increase by 2.83bpm on average. Conversely, there was no significant influence on diastolic blood pressure, which increased by 0.63mgHg. In people with controlled hypertension, systolic hypertension increased by a similar degree of 1.20mmHg. Immediate-release preparations, higher doses, being male, and shorter duration of use were all associated with greater cardiovascular effects. A small subset of individuals with autonomic instability, perhaps in turn resulting in greater adrenergic receptor sensitivity, may be substantially more sensitive to the cardiovascular effects of sympathomimetics. Subsequent to the 2005 meta-analysis, a 2015 systematic review and a 2018 meta-analysis found that pseudoephedrine at high doses could increase heart rate and physical performance with larger effect sizes than lower doses.
A 2007 Cochrane review assessed the side effects of short-term use of pseudoephedrine at recommended doses as a nasal decongestant. It found that pseudoephedrine had a small risk of insomnia and this was the only side effect that occurred at rates significantly different from placebo. Insomnia occurred at a rate of 5% and had an odds ratio of 6.18. Other side effects, including headache and hypertension, occurred at rates of less than 4% and were not different from placebo.
Tachyphylaxis is known to develop with prolonged use of pseudoephedrine, especially when it is re-administered at short intervals.
There is a case report of temporary depressive symptoms upon discontinuation and withdrawal from pseudoephedrine. The withdrawal symptoms included worsened mood and sadness, profoundly decreased energy, a worsened view of oneself, decreased concentration, psychomotor retardation, increased appetite, and increased need for sleep.
Pseudoephedrine has psychostimulant effects at high doses and is a positive reinforcer with amphetamine-like effects in animals including rats and monkeys. However, it is substantially less potent than methamphetamine or cocaine.