Guaifenesin Treatment
by R. Paul St. Amand, M.D.Over the past 37 years, I have successfully treated 3,500 fibromyalgia patients with several uricosuric (gout) drugs including, most recently, the simple medication, guaifenesin. Many of my patients have also had vulvodynia, which I consider part of the disease.
Symptoms of Fibromyalgia
Among the many symptoms of fibromyalgia, the most prominent are pain and stiffness in the muscles, tendons, and ligaments. Other common symptoms include fatigue, irritability, depression, poor memory, and lack of concentration. Fibromyalgics typically also suffer with irritable bowel syndrome, urethral syndrome, painful intercourse, headaches (often one-sided), burning hands and feet, and more. In short, people with fibromyalgia have a lot of complaints.Fibromyalgia appears to be an inherited biochemical abnormality that primarily affects women. Symptoms can develop at any age, including childhood, and progress in cycles. At first, they may be mild, with long gaps or remissions between attacks. Eventually, however, the symptoms worsen, with no more good days in between the bad days.
After patients begin taking guaifenesin, the symptoms reverse as they developed, in cycles, but several times faster — like rewinding a videotape of one's illness. Unfortunately, they often are worse than before, since the reversal involves many areas simultaneously. Gradually and progressively, however, more good days appear, cluster together, and the patient is finally restored to normal. My experience is that about two months at the proper dosage reverses at least one year of accumulated disease.
Treatment and Theory
Guaifenesin, a drug used to liquefy mucus, is mildly uricosuric. Uricosuric drugs are used to treat gout by causing urinary excretion of uric acid. Many years ago, quite by accident, I discovered that uricosuric drugs also work for fibromyalgia. (I must stress, however, that fibromyalgia and gout have no connection.) Unlike the potent uricosuric drugs used in the past, guaifenesin has few, if any, side effects.Having stumbled onto an effective treatment, it seemed appropriate to formulate a theory based on the results. Upon analyzing twenty-four hour urine collections in a few patients, before and after treatment, I found a significant increase in the excretion of phosphate and a moderate increase of oxalate and calcium after guaifenesin was started. I suspected that the body cells of fibromyalgics retain abnormal amounts of substances that should have been excreted by the kidneys. This abnormality, which may be due to an inherited enzymatic deficiency, leads to symptoms fibromyalgics experience in so many tissues and systems of the body.
My hypothesis, which is subject to further research, is that an excess of intracellular phosphate, and possibly oxalate, builds up in cells and depresses formation of energy (ATP) in the cells' "power stations," the mitochondria. Other researchers have discovered multiple biochemical abnormalities in connection with fibromyalgia.
Management Facts
The required dosage of guaifenesin is determined by patient response. It varies from 300 mg. twice a day to as high as 3,600 mg per day. Guaifenesin has been used for over twenty years; has no significant, listed side effects; and is safe for children.Treatment progress is measured both by symptom improvement and by filling in body maps showing the location and size of tender points, spasms, or hard patches felt in the muscles and ligaments. As guaifenesin "clears" fibromyalgia out of the body, these patches decrease in size and eventually disappear.
Aspirin & Aloe: A key aspect of treatment is that salicylates, contained in aspirin and other compounds, completely block the effects of all uricosuric drugs, including guaifenesin. Moreover, skin readily absorbs salicylates into the body. Salicylates are manufactured by all plants, the choicest parts of which are concentrated to make herbal medications, many cosmetics, and deodorants.
Thus, patients being treated with guaifenesin cannot take aspirin or herbal medications, or use any skin creams or topical products which contain herbs, including aloe. Castor oil, Listerine, Ben Gay, and razors with aloe strips are among the many culprits that block the action of guaifenesin. When blocking occurs, patients have no adverse effects; they simply obtain no benefit for fibromyalgia.
Hypoglycemia: Another complicating factor in guaifenesin treatment is hypoglycemia, or "low blood sugar," better defined as carbohydrate intolerance. Some of the many symptoms of hypoglycemia are tiredness, panic, palpitations, and lightheadedness after eating sugar or starch. Hypoglycemia can be controlled by a strict diet that eliminates sugar, most carbohydrates, and caffeine.
As an endocrinologist, I see many hypoglycemics and have found that around 40% of my fibromyalgia patients are hypoglycemic. It is mandatory that the two syndromes be treated concurrently, or the patient will not feel better. The added energy drain of hypoglycemia, untreated, can also make guaifenesin treatment intolerable.
Maintenance Dosage: Since inherited abnormalities like fibromyalgia cannot be cured, only controlled, patients must take guaifenesin for the rest of their lives, or the symptoms will return. Therefore, a maintenance dosage is necessary, usually the same amount it took to clear them. Some of my earliest patients have been taking uricosuric drugs for over 30 years, and maintain a high quality of life.
*DISCLAIMER: "The materials and information on this web site are intended to provide general information for you. Please consult your physician on specific medical questions. Do not use the information given on these pages as a substitute for a physician consultation. All information on this server is provided without warranty of any kind. Further, we do not warrant, guarantee, or make any representations regarding the use, or the results in terms of correctness, accuracy, reliability, currentness, or otherwise."
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Guaifenesin - Fibromyalgia / Myofascial Pain Syndrome Medications
This is EXPERIMENTAL THERAPY.
Dr. Devin Starlanyl, MD© Devin Starlanyl, 1995-1998.
Guaifenesin (pronounced like "Gwhy-fen-es-in"), is a medication often used to loosen phlegm and mucus in lungs. It has been in use for over 20 years. R. Paul St. Amand M.D., an Internal Specialist, Endocrinologist and professor at UCLA, a has discovered that it may reverse the process of fibromyalgia. He suspects that one inherited problem in FMS is a tendency toward a defect in phosphate excretion, which ultimately causes an accumulation of phosphates within the mitochondria (our cellular "chemical factories"). We're not sure of the exact mechanism.Guaifenesin is the active ingredient in many cough medication expectorants. If possible, use the pure guaifenesin (now only available in the USA in prescription form), because the over-the-counter varieties have sugar and alcohol. Store guaifenesin between 59 and 86 degrees F -- not in the refrigerator or very warm room. You may become thirsty at first, and want to carry some pure water around. Drink a lot of water. Guaifenesin will thin your thick secretions, and help your body get rid of some wastes.
The average starting dose is 300 mg twice a day, although some people who are sensitive to medications may have to start at 300 mg a day. (If you have reactive hypoglycemia as a perpetuating factor, you MUST be on a balanced "Zone" diet for the reversal to take place. (See "Mastering the Zone" by Barry Sears PhD for recipes and information.) Dr. St. Amand has found less patients needing the diet than I have, but his patients appear to be more sensitive to "blocking" factors. Remember, we are trail-blazing here.) There will probably be a period of flu-like fatigue as stored toxins and excess phosphates start releasing. You should have a noticeable reaction in 3 to 10 days. If you get no reaction, something is blocking the guaifenesin, you have reactive hypoglycemia, or you need to raise the dosage to 600 mg twice a day if tolerated. Your body is working hard during this time to process wastes so that they can be excreted. After this, if needed, guaifenesin dosage is generally raised 300 mgs a day at a time, after 10 days, until the reversal begins. Map your pain patterns before starting this therapy, and mark each area from 1 to 10 in pain intensity to help you monitor therapy progression.
AVOID SALICYLATE USE DURING GUAIFENESIN TREATMENT. SALICYLATES, FOUND IN MEDICATIONS LIKE ASPIRIN, MANY HERBS AND TRILISATE WILL BLOCK THE BODY'S EFFORTS TO EXCRETE EXCESS PHOSPHATES. If you use salicylate, the wastes are liberated, but will circulate in the blood without being excreted. Large quantities of herbs and herbal teas should be avoided -- many are rich in salicylate. Small amounts of herbs for seasoning are acceptable. Even aloe has salicylate. Every person has a different degree of sensitivity to salicylate on guai. Some people are able to tolerate more than others without guai being blocked. Many topical creams, such as some topical rubs, sunscreens and cosmetics are salicylate-containing. Check with your pharmacist. Many common medications such as Alka-Seltzer, Listerine and Pepto-Bismol have salicylate.
Dr. St. Amand has found three subsets in his practice. One group goes through FMS reversal relatively quickly at 300 mg twice a day. They often feel bad solidly until their symptoms clear suddenly. The largest subset reverses at 600 mg twice a day. Another subset needs 1800 mg a day or more, and just goes along slowly through the reversal process. Soon you will get periods of time where symptoms ease. Often the reversal is cyclical, with symptom-free periods interspersed with "cycling". At least 40% of the people need more than 1600 mg a day. The calcium excreted is limited to inappropriate calcium surplus. None of Dr. St. Amand's patients have developed osteoporosis. Dr. St. Amand warns people that guaifenesin therapy is "not for the faint of heart". During the cycling you can have odd skin rashes, hair loss, burnt taste in your mouth, pimples, gunky eyes, and an acidy smelling perspiration unique to guaifenesin reversal (fortunately), and very strong-smelling, acid urine. The urine gets very dark -- deep yellow, or even brown. Vaginal secretions turn acidy, and can irritate. During guaifenesin therapy, avoid adding a lot of phosphoric acid to your body. Colas are loaded with it. It makes no sense to add a lot of phosphoric acid to when your body is already working hard to get rid of its excess.
Reversal signs and symptoms are NOT side-effects of guaifenesin. They are from toxins and waste being released by the guai, and are a good sign, though it won't feel like it. At least you'll understand why you often felt "toxic". You were.
Headaches are very common. Don't try to rush detox. It took a long time for your body to get this sick. You can't clean it up overnight.
Sometimes guai works on feeder deposits. These are large deposits which release vast quantities of debris as these huge myofascial lumps dissolve. Your body can only handle so much at one time. Excess debris forms temporary deposits -- even on the teeth sometimes, until the body catches up processing the wastes. Expect plateaus in the reversal process. Don't get discouraged. We are all different. Allow your body to find the best pace. It will eliminate the waste material as efficiently as it can. Meanwhile, do whatever you can to help it. Drink lots of water, get as much rest as you can, and avoid stress.
Knowing that guai thins secretions and works at a cellular level, I think it may partially work mechanically, cleaning off gummy cellular membranes. Thinner secretions also allow more efficient breathing. I feel that our reversal depends on the nature of our deposits: how many, how dense they are, how much and what kind of tissue is displaced and how good your body is at detoxifying. Also important is our electrolytic balance -- we need balance for body maintenance, and to handle the disruption caused by extra calcium phosphate (and who knows what else) release. A good mineral supplement will help. This reversal process is not easy, but neither is FMS/MPS. There's no way out but through.
Controlled studies measure group response, not individual response, each of us is unique. The only double-blinded study on FMS guaifenesin therapy was done by Robert Bennett M.D. at Oregon Health Sciences University. This study of 20 women showed guaifenesin equal to placebo. This response is not uncommon when attempting to design experiments for old medications with new usages. The study is flawed by no fault of Dr. Bennett, who has done great things for "fibromites", nor of Dr. St. Amand, who served as advisor to the study. We are only now discovering some of the variables and fine-tuning treatment. This is experimental.
Point 1: The study was started before we knew the reversal does not take place if reactive hypoglycemia is present. I have found that a little over 85% of the people I have seen with FMS have reactive hypoglycemia as a perpetuating factor. We are talking of about 1000 patients. Some of these with mild FMS "reversed" with the Zone diet alone. Of those who tried guaifenesin (over 500), we are getting about 75 to 80 % drastic improvement. The others didn't stay with the therapy due to the toxic-release effects or inability to follow the diet, except for a less than 5% who did not get better. Some needed to delete colas from their diet, since they took in as much phosphoric acid as was coming out otherwise. Much of this therapy may depend on the acid/base balance of the body. Nancy Medeiros (see the end of the chapter) is keeping a running tally of Internet fibromites on guaifenesin therapy.
Point 2: All the patients in the study were given 600 mgs of guaifenesin twice a day. Dr. St. Amand, an internist/endocrinologist and professor of medicine at UCLA, has now found that only about 50% of patients respond at this dosage, even these won't respond if they have reactive hypoglycemia. FMS is not a condition that responds to "cookbook" medicine.
Point 3: Dr. St. Amand did not know about the blockage of guaifenesin by some salicylate-containing herbs until September 1995. The study ended in June 1995. Each of us has a varying tolerance of salicylate. Now that I am "clearer" of whatever acids and materials come out on "guai" therapy, I can tolerate cola now and then. I still can't use stevia as a sugar substitute. Taking even a little of this herb brings on the FMS achies.
Point 4: The response to guai is not a placebo response. Placebos do not result in dark, smelly urine that cleans iron stains off the toilet bowl. Toilet bowls do not respond to placebo effect. I have heard stories from fibromites who years ago had been placed on guaifenesin therapy for asthma or upper respiratory problems. They had to discontinue guai due to a "worsening" of FMS symptoms, darkened urine etc. years before they heard of FMS guai therapy. Patients who have been seen by Traditional Chinese Healers, Naturopaths and other alternative specialists have reported that they had been very toxic and acidic, but that they became "balanced" on guaifenesin therapy.
Perhaps the phosphoric and oxalic acids coming out in the urine (and dark "toxic sweat") carry with them quinolinic acid. I. Jon Russell has found that we create this toxin instead of serotonin in an alternate tryptophan (kynurenine) metabolic pathway. We just don't know. Yet. Guai is not a cure. But I have tried many remedies. Some have helped. Most have not. I have seen many people given a new lease on life with guai, and have experienced it myself, as has Dr. St. Amand. Others have enjoyed periods of symptom remission.
With most people, guaifenesin therapy seems to result in remission of symptoms. This is not a cure. The symptoms will reappear if you overdo. We have found that at least 50% of people with FMS have reactive hypoglycemia, and need this. Otherwise you can be "reversed -- have all the tender spots go away -- and you will still feel bad until you deal with the hypoglycemia. You may never become symptom-free, because many symptoms may be due to other processes, but you will be a lot more comfortable until a cure can be found.
*DISCLAIMER: "The materials and information on this web site are intended to provide general information for you. Please consult your physician on specific medical questions. Do not use the information given on these pages as a substitute for a physician consultation. All information on this server is provided without warranty of any kind. Further, we do not warrant, guarantee, or make any representations regarding the use, or the results in terms of correctness, accuracy, reliability, currentness, or otherwise."
Guaifenesin General Information
What is Guaifenesin?
Guaifenesin is an expectorant, that is, a medication that promotes elimination of mucus from the lungs. The expectorant effects of guaifenesin promote elimination of mucous by thinning the mucous and lubricating the irritated respiratory tract. Guaifenesin is an ingredient in many over-the-counter cough and cold products. It is a safe medication that may even be used by children. Derived from a tree bark extract called guaiacum, it was first used to treat rheumatism during the 16th century. Guaifenesin was first approved by the FDA in 1952. Twenty years ago, the extract was synthesized, pressed into tablets and named guaifenesin. Today, there are many formulations of guaifenesin available. Guaifenesin is an expectorant with weakly uricosuric effects that has been shown to effectively release phosphate and oxalate compounds from the body through the urine. According to a survey of Dr. R. Paul St. Amand’s patients, the administration of guaifenesin caused a 60 percent increase in the excretion of phosphate, as well as a rise in both calcium and oxalate excretion of up to 30 percent when taking guaifenesin.How Does Guaifenesin Work?
Dr. R. Paul St. Amand, M.D., Assistant Clinical Professor of Endocrinology at Harbor-UCLA believes guaifenesin therapy can significantly promote good health. Dr. St. Amand’s theory of the medicinal effects of guaifenesin is based on the premise that excess calcium and inorganic phosphate compounds accumulate within cells to produce a state of hyperpermeability. This condition allows excess fluids, ions and other unwanted substances to flow into cell mitochondria, disrupting normal cell function, including production of ATP, the body’s energy source. Dr. St. Amand believes these factors cause the body to experience an energy deprived state, in which widespread bodily functions are disrupted. Dr. St. Amand also feels a possible genetic defect in some patients may be responsible for the abnormality in natural phosphate excretion, thus resulting in the buildup of these chemicals and subsequent symptoms.A Note About Fibromyalgia
Fibromyalgia (FM) is a chronic disorder characterized by widespread musculoskeletal pain, tender points, and fatigue, and according to the American College of Rheumatology, fibromyalgia affects 3 to 6 million Americans. It primarily occurs in women of childbearing age, but children, the elderly, and men can also be affected. People with this syndrome also experience sleep disturbances, morning stiffness, irritable bowel, anxiety, depression and other symptoms.Treatment of fibromyalgia requires a comprehensive approach. The physician, physical therapist, and patient may all play an active role in the management of fibromyalgia. There are many theories and treatments being discussed and applied by different researchers and practitioners, but according to one leading physician, guaifenesin is the most effective treatment to date for reversing the effects of this debilitating disease.
Guaifenesin (oral)
(gwye FEN e sin)
Anti-Tuss, Bidex, Breonesin, Duratuss G, Fenesin, Ganidin NR, GG 200 NR, Guaifenesin LA, Guaifenex G, Guaifenex LA, Humibid L.A., Humibid Pediatric, Liquibid, Muco-Fen 1200, Muco-Fen 800, Muco-Fen LA, Naldecon-EX Senior, Organidin NR, Pneumomist, Q-Bid LA, Robitussin, Scot-Tussin, Touro EX
What is the most important information I should know about guaifenesin?• Drink plenty of extra fluids while you are taking this medication. Extra fluids may help to relieve chest congestion.
• Do not crush or chew the tablets. Swallow them whole or break them in half where they are scored to make them easier to swallow.How is guaifenesin commonly used and known?
• Guaifenesin is an expectorant. Guaifenesin loosens phlegm and increases the lubrication of your lungs allowing for a productive cough and decreased chest congestion.
• Guaifenesin is used to reduce chest congestion caused by the common cold, infections, or allergies.
• Guaifenesin may also be used for purposes other than those listed in this medication guide.What should I discuss with my healthcare provider before taking guaifenesin?
• Talk to your doctor before taking guaifenesin if you have other medical conditions or if you take other medicines.
• Guaifenesin is in the FDA pregnancy category C. This means that it is not known whether guaifenesin will harm an unborn baby. Do not take this medication without first talking to your doctor if you are pregnant.
• It is also not known whether guaifenesin passes into breast milk. Do not take this medication without first talking to your doctor if you are breast-feeding a baby.
• Guaifenesin has not been approved by the FDA for use by children younger than 2 years of age.Pregnancy
• Although one analysis found a correlation between guaifenesin use in the first trimester and an increased risk of hernia in the fetus, others found no increased risk of fetal malformations. Thus, guaifenesin should be used in pregnancy only if the physician feels that the potential benefits outweigh the potential and unknown risks.
How should I take guaifenesin?
• Take guaifenesin exactly as directed by your doctor. If you do not understand these directions, ask your pharmacist, nurse, or doctor to explain them to you.
• Take each dose with a full glass of water. Drink plenty of extra fluids while you are taking this medication. Extra fluids may help to relieve chest congestion.
• Take guaifenesin with food if it upsets your stomach.
• Do not crush or chew the tablets. Swallow them whole or break them in half where they are scored to make them easier to swallow.
• The capsules may be swallowed whole, or they may be opened and the contents sprinkled on soft food such as pudding or applesauce then swallowed whole without crushing or chewing.
• To ensure that you get a correct dose, measure the liquid form of guaifenesin with a special dose-measuring spoon or cup, not with a regular table spoon. If you do not have a dose-measuring device, ask your pharmacist where you can get one.
• Store guaifenesin at room temperature away from moisture, heat, and direct sunlight.What happens if I miss a dose?
• Take the missed dose as soon as you remember. However, if it is almost time for your next dose, skip the missed dose and take only your next regularly scheduled dose. Do not take a double dose of this medication.
What happens if I overdose?
• An overdose of guaifenesin is unlikely to occur. If you do suspect an overdose, call an emergency room or poison control center near you.
What should I avoid while taking guaifenesin?
• Use caution when driving, operating machinery, or performing other hazardous activities. Guaifenesin may cause dizziness. If you experience dizziness, avoid these activities.
What are the possible side effects of guaifenesin?
• No serious side effects are expected from guaifenesin therapy. Stop taking guaifenesin and seek emergency medical attention if you experience an allergic reaction (difficulty breathing; closing of your throat; swelling of your lips, tongue, or face; or hives).
• Other, less serious side effects may be more likely to occur. Continue to take guaifenesin and talk to your doctor if you experience
· dizziness or headache,
· a rash, or
· nausea, vomiting, stomach upset, diarrhea, abdominal pain, or drowsiness may occur.
• Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.What other drugs will affect guaifenesin ?
• There are no known interactions between guaifenesin and other medicines, although the possibility exists. Talk to your doctor and pharmacist before taking any prescription or over-the-counter medicines.
Dosing—
• The dose of guaifenesin will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of guaifenesin. If your dose is different, do not change it unless your doctor tells you to do so.
For regular (short-acting) oral dosage forms (capsules, oral solution, syrup, or tablets):
For cough:
Adults—200 to 400 milligrams (mg) every four hours.Children younger than 2 years of age—Use and dose must be determined by your doctor.
Children 2 to 6 years of age—50 to 100 mg every four hours.
Children 6 to 12 years of age—100 to 200 mg every four hours.
For long-acting oral dosage forms (extended-release capsules or tablets):
For cough:
Adults—600 to 1200 mg every twelve hours.
Children younger than 2 years of age—Use is not recommended.
Children 2 to 6 years of age—300 mg every twelve hours.
Children 6 to 12 years of age—600 mg every twelve hours.Where can I get more information?
• Your pharmacist has additional information about guaifenesin written for health professionals that you may read.
Improvement of Cervical Factor with Guaifenesin
by Jerome H. Check,M.D., H.G Adleson, B.S.,
Chung-Hsis Wu, M.D.Guaifenesin is an expectorant capable of increasing respiratory tract fluid. It is a common ingredient of many antitussive preparations. A study was designed to see whether this agent could also improve cervical mucus, as manifested by improved sperm survival and fertility.
Materials and Methods
Forty couples with a minumum of 10 months of infertility were selected where there was no sperm motility on postcoital testing. Hostile cervical mucus rather than defective spermatogenesis was assumed on the basis of accepting in the study only those couples where the baseline spermogram after 48 hours abstinence had at least a count of 25 x 10 6/cc, a 2-cc volume, 70% motility, grade 3 of 4 quality, and less than 20% abnormal forms.The postcoital test was performed on the 2nd day before the temperature rise. Two baseline postcoital tests with no sperm motility 2 hours after intercourse were required before the couple was entered in the study. After wiping off the cervix with cotton, the mucus was aspirated with a tuberculin syringe. If the mucus quality (spinn-barkeit, ferning, lack of cellularity) was good but with no sperm motility, the couple was not included in the study. Similarly, if cervical mucus was absent, the couple was not accepted for the study.
Ovulation was established on the basis of a serum progesterone level x2 over 10/ng/ml taken 1 week before menses and a biphasic basal body temperature chart with a minimum of a 13-day luteal phase. If drug therapy was required to establish ovulation, the couple could be selected as long as the drug required was not clomiphene citrate and/or human menopausal gonadotropins.
Each woman was treated with 200mg guaifenesin orally three times daily from day 5 to her temperature rise in either the commonly available antitussive elixir form or in capsule form.
Response to guaifenesin as reflected by postcoital evaluation was scored as "no improvement" (no motile sperm), "marked improvement" (at least 3 to 5 sperm per high-powered field with good linear progressive motion), or "slight improvement" (some motile sperm but a number or quality of motility inferior to standards set for the "marked improvement" category). Mucus quality was judged before and after guaifenesin as to spinnbarkeit and cellularity. If the patient showed some improvement in the postcoital test, then the therapy was continued for a minumum of 6 months unless conception occured first. If there still was no sperm survival after two treatment cycles, the therapy was considered a faliure and was stopped. Though the patient would then be treated with other methods, as far as this study was concerned she would only be listed in the "no improvement" category. No patient in the study was allowed to have treatment with any other therapy that could positively or negatively influence the cervical mucus.
The tubal factor was investigated by either hysterosalpingogram or laparoscopy. Seventy percent of the patients had a laparoscopy.
Total
Marked Improvement
Slight Improvement
No Improvement
Number of patients in Subgroup 40
23 (57.5%)
7 (17.5%)
10 (25%)
I
10
8
1
1
II
30
15
6
9
Number pregnant I
8
7
1
0
II
8
8
0
0
% pregnant I
80
87.5
100
0
II
26.6
53
0
0
Total 40
65.2
14.3
0
Results
The response to guaifenesin is seen in Table 1. Twenty-three of 40 patients showed marked improvement in postcoital following treatment, while 7 showed slight improvement was associated with improvement in the mucus quality (improved spinnbarkeit and decreased cellularity).
Fifteen pregnancies in 23 couples (65.2%) occurred in the group showing marked improvement in the postcoital tests after guaifenesin therapy. One patient with only a mild improvement in sperm survival achieved a pregnancy. In ten patients with hostile mucus as the only detectable cause of the infertility, eight became pregnant in an average 2.4 months. In the remaining eight patients achieving pregnancies, where other fertility problems coexisted, there was an average of 5.6 months of treatments with guaifenesin. One patient, despite a marked improvement in sperm survival and no other apparent cause for infertility, did not achieve a pregnancy after 6 months of guaifenesin therapy. Only one of seven patients showing a slight improvement in sperm survival achieved pregnancy. The failure of eight patients to achieve pregnancices despite marked improvement in sperm survival can be accounted for by other associated fertility problems.
Discussion
The results indicate that guaifenesin may improve cervical mucus and improve fertility. A double-blind study was not deemed necessary, since it was easy to follow the objective parameter of sperm survival and correlate this with subsequent fertility. There is no evidence that psychological factors can adversely affect cervical mucus in the presence of ovulation. The exact mechanism of action of guaifenesin is not known, though it would seem to be reasonably similar to its mechanism of improving respiratory tract secretions. Other methods of treating the cervical factor have been reviewed by Blasco. An additional technique employing high-dose estrogen in combination with human menopausal gonadotropins has been described more recently. The quoted pregnancy statistic following conventional therapy of the cervical factor has been under 30%. With guaifenesin therapy 40% of the entire cervical factor group conceived. In the subgroup of patients whose fertility problem seemed likely to be related to the cervical factor only, 80% conceived. These statistics will probably improve when guaifenesin therapy is combined with other treatment modalities for the cervical factor.
Fertility and Sterility
May 1982*DISCLAIMER: "The materials and information on this web site are intended to provide general information for you. Please consult your physician on specific medical questions. Do not use the information given on these pages as a substitute for a physician consultation. All information on this server is provided without warranty of any kind. Further, we do not warrant, guarantee, or make any representations regarding the use, or the results in terms of correctness, accuracy, reliability, currentness, or otherwise."
Prevention of recurrent HIV-associated Sinusitis
Name Of Substance Guaifenesin [USPD 1998; p. 348]
Accessed May 15, 2000.Standard Chemical Name 1,2-Propanediol, 3-(2-methoxyphenoxy).
Synonyms
Glycerol guaiacolate
Glyceryl guaiacyl ether
Guaiacol glyceryl ether
Guaiphenesin
Methoxypropanediol
Glyceryl guaiacolate
Guaiacyl glyceryl ether
Protocol ID Numbers Terminated NIAID ACTG 186
Pharmacological Action
MODE OF ACTION: Increases sputum and bronchial secretions by reducing adhesiveness and surface tension. By reducing the viscosity of secretions, guaifenesin increases the efficiency of the cough reflex and ciliary action in removing accumulated secretions from the trachea and bronchi. The drug is readily absorbed from the gastrointestinal tract and readily metabolized and excreted in the urine. It has a plasma half-life of 1 hour. The major urinary metabolite is beta-(2-methoxyphenoxy) lactic acid. In study that assessed changes in nasal symptoms among 23 HIV-infected patients receiving either 3 weeks of guaifenesin (2400 mg daily) or placebo, the guaifenesin group reported less nasal congestion and thinner postnasal drainage. Guaifenesin appears to be effective in managing HIV-infected patients with symptomatic rhinosinusitis. [PDR 1997; p 1605]
Diseases Studied/treated Prevention of recurrent HIV-associated sinusitis. [Protocol ID: ACTG 186 ] Classification Code Expectorant [USP DI 2000; p. 1659]
Other Major Uses
Used as expectorant in pharyngitis, bronchitis, and asthma. [PDR 1997; p 1605]
Substance Interactions
May interfere with laboratory test for diagnosis of carcinoid syndrome may falsely elevate the VMA test for catechols. [PDR; 1997; p 1605]
Adverse Effects
No serious adverse effects have been reported with the use of guaifenesin. Doses of guaifenesin larger than those required for expectorant action may produce emesis, but GI upset at ordinary dosage levels is rare. [PDR 1995; p 461]
Contraindications Contraindicated in patients with hypersensitivity to guaifenesin. [PDR 1997; p 1605]
Chemical/physical Data
MOLECULAR FORMULA: C10-H14-O4
MOLECULAR WEIGHT: 198.22 [USPD 1998; p. 348]
MELTING POINT: 78.5-79 C [Merck Index 1996; p. 777]
ELEMENTAL COMP: C60.59%, H7.12%, O32.29% [Merck Index 1996; p. 777]
SOLUBILITY: Soluble in water, ethanol, chloroform, glycerol, propylene glycol, DMF moderately soluble in benzene; practically insoluble in petroleum ether. [Merck Index; 1996; p 777]
METHOD OF DELIVERY: Oral. [AHFS Drug Information 1997; p 2092]
STORAGE INSTRUCTIONS: Store at temperatures no greater than 30 C (86 F). Protect from freezing. [Protocol ID: ACTG 186 ]
Management of sinusitis in adult cystic fibrosis. Am J Rhinol. 1997 Jan-Feb;11(1):11-4. MED/95140436. Friedman WH, Katsantonis GP, Bumpous JM.
Staging of chronic hyperplastic rhinosinusitis: treatment strategies. Otolaryngol Head Neck Surg. 1995 Feb;112(2):210-4. MED/95180023. Sisson JH, Yonkers AJ, Waldman RH.
Effects of guaifenesin on nasal mucociliary clearance and ciliary beat frequency in healthy volunteers. Chest 1995 Mar;107(3):747-51. IPA/95. /1081197. Wagner DL, Patel VS.
Steady-state human pharmacokinetics and bioavailability of guaifenesin and pseudoephedrine in a sustained-release tablet relative to immediate-release liquids. Int J Pharm; VOL 114 ISS Feb 14 1995, P171-176, (REF 6). MED/95023331. Brock MH, Dansereau RJ, Patel VS.
Use of in vitro and in vivo data in the design, development, and quality control of sustained-release decongestant dosage forms. Pharmacotherapy 1994 Jul-Aug;14(4):430-7. MED/93198678. Croughan-Minihane MS, Petitti DB, Rodnick JE, Eliaser G.
Clinical trial examining effectiveness of three cough syrups [see comments]. J Am Board Fam Pract 1993 Mar-Apr;6(2):109-15. MED/93023477. Wawrose SF, Tami TA, Amoils CP.
The role of guaifenesin in the treatment of sinonasal disease in patients infected with the human immunodeficiency virus (HIV). Laryngoscope. 1992 Nov;102(11):1225-8. Entry Month 199212 Last Revision Date 20001107 Guaifenesin [USPD 1998; p. 348] - Guaifenesin [USPD 1998; p. 348]
---------------------------- Always watch for outdated information. ----------------------------
This material is designed to support, not replace, the relationship that exists between you and your doctor. This information is designed to support, not replace, the relationship that exists between you and your doctor.
*DISCLAIMER: "The materials and information on this web site are intended to provide general information for you. Please consult your physician on specific medical questions. Do not use the information given on these pages as a substitute for a physician consultation. All information on this server is provided without warranty of any kind. Further, we do not warrant, guarantee, or make any representations regarding the use, or the results in terms of correctness, accuracy, reliability, currentness, or otherwise."
Interference With Lab Tests
Guaifenesin can falsely elevate the results of laboratory tests for vanillylmandelic acid (VMA), which is the main urinary metabolite of catecholamines (adrenaline and noradrenaline). In addition, it is well known that guaifenesin can cause false positive results in tests for the serotonin metabolite, 5-hydroxyindoleacetic acid . You should stop taking guaifenesin 48 hours before giving urine for either of these tests.By the way, aspirin also interferes with VMA and 5-HIAA tests. Ephedrine and caffeine cause increased values in 5-HIAA tests. Foods that are high in serotonin (avocados, bananas, eggplant, pineapples, plums, and tomatoes) can also cause false positives in 5-HIAA tests. An awful lot of foods and even artifical coloring and flavoring can cause false positives on a VMA test.
*DISCLAIMER: "The materials and information on this web site are intended to provide general information for you. Please consult your physician on specific medical questions. Do not use the information given on these pages as a substitute for a physician consultation. All information on this server is provided without warranty of any kind. Further, we do not warrant, guarantee, or make any representations regarding the use, or the results in terms of correctness, accuracy, reliability, currentness, or otherwise."
Salycilate Sensitivity
Salicylate sensitivity is the body's inability to handle more than a certain amount of salicylates at any one time. A salicylate sensitive person may have difficulty tolerating certain fruits, vegetables, or any products which contain aspirin.
What Are Salicylates?
Salicylates are chemicals that occur naturally in many plants. They act as preservatives to delay rotting and as protectants against harmful bacteria and fungi. They are stored in the bark, leaves, roots, and seeds of plants. Salicylates can be found naturally in some foods and its compounds are used in various products.
Symptoms of Intolerance
Salicylates sensitivity can manifest itself in many ways:Anaphylaxis (rare)
Asthma
Breathing difficulties
Changes in skin color
Congestion
Fatigue
Headaches
Hyperactivity
Itchy skin, rash, or hives
Itchy, watery, or swollen eyes
Lack of concentration or memory
Mouth ulcers or raw hot red rash around mouth
Nasal polyps
Persistent cough
Sinusitis
Some cognitive and perceptual disorders
Stomach aches or upsets
Swelling of eyelids, face, and lips
Swelling of hands and feet
Urgency to pass water or bedwetting
WheezingSources of Salicylates
Here is a list of products that may contain aspirin or salicylate compounds:Acne products
Breath savers
Bubble baths
Cosmetics
Fragrances and perfumes
Gums - mint flavored
Hair shampoos, conditioners, or sprays
Herbal remedies
Lipsticks
Lotions
Lozenges
Medications
Mouth washes
Muscle pain creams
Pain medications
Razors with aloe strips adjacent to the cutting edge
Shaving creams
Skin cleansers or exfoliants
Sun screens or tanning lotions
Supplements derived from rose hips or bioflavonoids
Topical creams
Toothpastes
Wart or callus removersWatch Out for These Terms
When reading labels be sure to also watch out for these terms:Aspirin
Acetylsalicylic acid
Artificial food colorings
Artificial flavorings
Azo dyes
Benzoates (preservatives)
Benzyl salicylate
Beta-hydroxy acid
Choline salicylate
Disalcid
Ethyl salicylate
Isoamyl salicylate
Magnesium salicylate
Menthol
Methyl salicylate
Mint
Octylsalicylate
Peppermint
Phenylethyl salicylate
Salicylate
Salicylic acid
Salicylaldehyde
Salicylamide
Salsalate
Sodium salicylate
SpearmintSalicylates in Foods
Raw foods, dried foods, and juices contain higher levels of salicylates than cooked food. The salicylate content in foods is highest in unripened fruit and decreases as the fruit ripens. All fruit and vegetables should be ripe and thickly peeled before eating. Salicylates are often concentrated just under the skin of fruit and vegetables, and in the outer leaves of vegetables.The Feingold Program
For those people who want to avoid salicylates and feel overwelmed with the challenge, should take a few minutes to visit the Feingold Association Web site. Shula Edelkind of the Feingold Association (feingold.org) reports they do ongoing product information research. She states, "All people have to do is use our Foodlist & Shopping Guide. We have done the hard work for them. People can avoid the colorings, flavorings and salicylates, and still have a 'normal' American diet complete with fast food and junk food."*DISCLAIMER: "The materials and information on this web site are intended to provide general information for you. Please consult your physician on specific medical questions. Do not use the information given on these pages as a substitute for a physician consultation. All information on this server is provided without warranty of any kind. Further, we do not warrant, guarantee, or make any representations regarding the use, or the results in terms of correctness, accuracy, reliability, currentness, or otherwise."
Guaifenesin in the News
FDA orders most long-acting guaifenesin products off marketOnly Adams' Mucinex product currently approved; other manufacturers have until end of November to distribute 'illegal' products.
Last October, FDA issued warning letters stating that single-ingredient extended-release guaifenesin products are new drugs and require an approved new drug application for legal marketing under the Federal Food, Drug, and Cosmetic Act. The only approval, issued in July 2002, is for guaifenesin 600 mg extended-release tablets from Adams Laboratories.
In the warning letters, sent to 66 manufacturers, FDA stated that its actions "reflect the Agency's effort to maintain the necessary incentives for companies to develop and submit to FDA scientific evidence to prove the safety and effectiveness of marketed drug products."
FDA also intends to publish a notice in the Federal Register about its policy on unapproved drugs. In a talk paper posted to the FDA Web site, the agency explained that it reviewed products in this category after approving the Adams' product last July, and it concluded that products with unproven safety and effectiveness should not remain on the market when an approved product had become available. This preserves the incentives for companies to develop and submit new drug applications, as required by law, FDA added.
Guaifenesin's main use is for productive coughs. It is the only FDA-approved nonprescription expectorant. As a pre-1962 product, its effectiveness has never been well established, but it causes few adverse effects and is commonly included in many cough-and-cold products. As part of FDA's review of OTC products, immediate-release guaifenesin was previously ruled to be safe and effective.
NOTE: Now in 2004 Guaifenesin in dosages of 600mg and below are ONLY available Over The Counter (OTC)!
*DISCLAIMER: "The materials and information on this web site are intended to provide general information for you. Please consult your physician on specific medical questions. Do not use the information given on these pages as a substitute for a physician consultation. All information on this server is provided without warranty of any kind. Further, we do not warrant, guarantee, or make any representations regarding the use, or the results in terms of correctness, accuracy, reliability, currentness, or otherwise."
Treatment of Fibromyalgia in Detail
Robert Bennett MD, FRCP
If you are reading this you probably have a common syndrome of chronic musculoskeletal pain called fibromyalgia. This chronic pain state is now appreciated to be caused by abnormalities of sensory processing within the spinal cord and brain. As such you will usually experience a bewildering (both to you and your doctor) array of bodily and psychological problems that can seldom be “cured”. However, armed with both patience and knowledge, many fibromyalgia patients can be helped to live with less pain and be more productive. In my own evolving experience of dealing with this problem I can identify 7 aspects of management that are of importance for your doctor to successful manage your fibromyalgia.My Advice to Doctors who care for Fibromyalgia Patients
1. Realize that FM patients are going to be a chronic challenge.
2. Be non-judgmental and prepared to be an advocate.
3. Understand the pathophysiological basis for symptoms.
4. Analyze and treat pain complaints in a systemic approach.
5. Recognize and treat psychological problems at an early stage.
6. Recognize associated syndromes of disordered sensory processing.
7. Involve all FM patients in a program of stretching and gentle aerobic exercise.
Treatment of pain in fibromyalgia
Pain is the primary over-riding problem for most of you. Many of the problems you experience are largely a secondary consequence of having chronic pain. When pain is even partly relieved, fibromyalgia patients experience a significant improvement in psychological distress, cognitive abilities, sleep and functional capacity. A total elimination of pain is currently not possible in the majority of fibromyalgia patients. However worthwhile improvements can nearly always be achieved by a careful systematic analysis of the pain complaints. As a generalization fibromyalgia related pain can be divided into general pain (i.e. the chronic background pain experience and focal pain (i.e. the intensification of pain in a specific region – usually aggravated by movement). The latter is probably a potent driving force in the generation of central sensitization. Attempts to break the pain cycle, to enable patients to be more functional are especially important. In general, most FM patients do not derive a great deal of benefit from NSAID preparations or acetoaminophen, although NSAIDs are very useful in the treatment of associated joint pain problems such as osteoarthritis. Prednisone and other steroids have been shown to be ineffective in the long term treatment of fibromyalgia.
General Pain. The use of NSAIDs (e.g. ibuprofen, aspirin etc.) is usually disappointing; it is unusual for FM patients to experience more than a 20% relief of their pain, but many consider this to be worthwhile. Narcotics (propoxyphene, codeine, and oxycodone) often provide a worthwhile relief of pain. In most patients, concerns about addiction, dependency and tolerance are ill founded. Ultram (Tramadol) and Ultracet (tramadol + Tylenol), are the most useful pain medications in many patients. They both have the advantages of having a low abuse potential and is not a prostaglandin inhibitor; tramadol reduces the epileptogenic threshold and it should not be used in patients with seizure disorders.
Currently opiates are the most effective medications for managing most chronic pain states (Friedman OP 1990, Portenoy 1996) . Their use is often condemned out of ignorance regarding their propensity to cause addiction, physical dependence and tolerance (Melzack 1990, Portenoy et al 1997, Wall 1997) . While physical dependence (defined as a withdrawal syndrome on abrupt discontinuation is inevitable) is inevitable, this should not be equated with addiction (Portenoy 1996). Addiction is a dysfunctional state occurring as a result of the unrestrained use of a drug for its mind-altering properties; manipulation of the medical system and the acquisition of narcotics from non-medical sources are common accompaniments. Addiction should not be confused with "pseudo-addiction". This is a drug-seeking behavior generated by attempts to obtain appropriate pain relief in the face of under-treatment of pain. Opiates should never be the first choice for pain relief in fibromyalgia, but they should not be withheld if less powerful analgesics have failed. In my experience many fibromyalgia patients want to try opioid medications, but then give up on them due to unacceptable side effects, such as mental fog, increased tiredness, dizziness, constipation and itching.
Local Pain. Although you are experiencing widespread body pain -- a manifestation of central sensitization -- you will also have multiple areas of tenderness in muscles - so called "myofascial trigger points". The severity of pain and the location of these "hot spots" typically varies from month to month, and the judicious use of myofascial trigger point injections and spray and stretch (see section on focal pain) is worthwhile in selected patients. It is often worthwhile for your physician to identify the most symptomatic points for myofascial therapy.
The steps involved in the injection of trigger points are:
1. Accurate identification of the trigger point.
2. Identification and elimination of aggravating factors.
3. The precise injection of the myofascial trigger points with 1% procaine (a local anesthetic).
4. Passive stretching of the involved muscle after the local anesthetic has taken effect; this is
often aided by spraying the overlying skin with an ethyl chloride spray.In most FM patients, this myofascial therapy needs to be repeated over a period of several weeks and occasionally over several months. Unresponsiveness is usually due to failure to eliminate an aggravating factor, imprecise injection of the trigger point, or failure to inject satellite trigger points. Trigger points are usually injected with 3 to 5 ml of 1-% procaine. Please note that these are not “steroid shots”.
Performing “myofascial spray and stretch” often enhances the efficacy of trigger point injections immediately after the injections. Spray and stretch consists of an application of a vapocoolant spray, such as ethyl chloride over the muscle with simultaneous passive stretching. A fine stream of the spray is aimed toward the skin directly overlying the muscle with the active trigger point. A few sweeps of the spray are passed over the trigger point and the zone of reference. This is followed by a progressively increasing passive stretch of the muscle.
Evaluation by an occupational and physical therapist often provides worthwhile advice on improved ergonomics, biomechanical imbalance and the formulation of a regular stretching program. Hands-on physical therapy treatment with heat modalities is reserved for major flares of pain, as there is no evidence that long-term therapy alters the course of the disorder. The same comments can be made for acupuncture, TENS units and various massage techniques.
Treatment of Sleep Disorders.
Non-restorative sleep is a problem for most of you and contributes to your feelings of fatigue and seems to intensify their experience of pain. Effective management involves (1) ensuring an adherence to the basic rules of sleep hygiene, (2) regular low grade exercise, (3) adequate treatment of associated psychological problems (depression, anxiety etc.) and (4) the prescription of low dose tricyclic antidepressants (amitryptiline, trazadone, doxepin, imipramine etc. Some fibromyalgia patients cannot tolerate TCAs due to unacceptable levels of daytime drowsiness or weight gain. In these patients benzodiazopine-like medications such as Ambiem (zolpidem) are usually very useful. Some fibromyalgia patients suffer from a primary sleep disorder, which requires specialized management. About 25% of male and 15% of female fibromyalgia patients have sleep apnea. Unless specific questions about this possibility are asked sleep apnea will often be missed. Patients with sleep apnea usually require treatment with positive airway pressure (CPAP) or surgery. By far the commonest sleep disorder in fibromyalgia patients is restless leg syndrome. This can be effectively treated with L-Dopa/carbidopa (Sinemet 10/100 mg at suppertime) or clonazepam (Klonipin 0.5 or 1.0 mg at bedtime).Exercise for Fibromyalgia Patients
Fibromyalgia patients cannot afford not to exercise as deconditioned muscles are more prone to microtrauma and inactivity begets dysfunctional behavioral problems . However, musculoskeletal pain and severe fatigue are powerful conditioners for inactivity. All fibromyalgia patients need to have a home program with muscle stretching and gentle strengthening, and aerobic conditioning. There are several points that need to be stressed about exercise in FM patients: (i) Exercise is health training, not sport’s training. (ii) Exercise should be non-impact loading. (iii) Aerobic exercise should be done for 30 minutes each day. This may be broken down into three 10 minute periods or other combinations, such as two 15 minute periods, to give a cumulative total of 30 minutes. This should be the aim -- it may take 6-12 months to achieve this level. (vi) Strength training should emphasize on concentric work and avoid eccentric muscle contractions. (vii) Regular exercise needs to become part of the usual lifestyle; it is not merely a 3-6 month program to restore them to health. Suitable aerobic exercise includes: regular walking, the use of a stationery exercycle or Nordic track (initially not using the arm component). Patients who are very deconditioned or incapacitated should be started with water therapy using a buoyancy belt (Aqua-jogger).
Recognition and treatment of psychological distress
As you suffer from chronic pain there is a distinct possibility that you may develop secondary psychological disturbances, such as depression, anger, fear, withdrawal and anxiety. When “an event” is associated with the onset of the fibromyalgia you may adopt the role of a "victim". Sometimes these secondary reactions become the "major problem" for some patients. The prompt diagnosis and treatment of these secondary features is essential to effective overall management of fibromyalgia patients. Some fibromyalgia patients develop a reduced functional ability and have difficulty being competitively employed. In such cases your doctor will hopefully act as an advocate in sanctioning a reduced or modified load at work and at home. Unless you have a severe psychiatric illness (e,g, major depressive illness or a psychosis), referral to psychiatrists is usually non-productive. Psychological counseling, particularly the use of techniques such as cognitive restructuring and biofeedback, may benefit some patients who are having difficulties coping with the realities of living with their pain and associated problems.
Fibromyalgia associated syndromes
It is not unusual for fibromyalgia patients to have an array of bodily complaints other than musculoskeletal pain. It is now thought that these symptoms are a result of the abnormal sensory processing – as described in the previous section. Recognition and treatment of these associated problems are important in the overall management of your fibromyalgia.
Non-restorative sleep
Cognitive dysfunction
Chronic fatigue
Cold intolerance
Restless leg syndrome
Multiple sensitivities
Irritable bowel syndrome
Dizziness
Irritable bladder syndrome
Neurally mediated hypotension1. Chronic fatigue: The common treatable cause of chronic fatigue in fibromyalgia patients are: (1) inappropriate dosing of medications (TCAs, drugs with antihistamine actions, benzodiazapines etc.), (2) depression, (3) aerobic deconditioning, (3) a primary sleep disorder (e.g. sleep apnea), (4) non-restorative sleep (see above) and (5) neurally mediated hypotension (see below). A new drug called Provigil is of some help when used intermittently for management of fatigue.
2. Restless leg syndrome: This strictly refers to daytime (usually maximal in the evening) symptoms of (1) unusual sensations in the lower limbs (but can occur in arms or even scalp) that are often described as paresthesia (numbness, tingling, itching, muscle crawling) and (2) a restlessness, in that stretching or walking eases the sensory symptoms. This daytime symptomatology is nearly always accompanied by a sleep disorder - now referred to as periodic limb movement disorder (formerly nocturnal myoclonus). Treatment is simple and very effective – DOPA / Levodopa (Sinemet) in an early evening dose of 10/100 (a minority require a higher dose or use of the long acting preparations).
3. Irritable bowel syndrome: This common syndrome of GI distress that occurs in about 20% of the general population is found in about 60% of fibromyalgia patients. The symptoms are those of abdominal pain, distension with an altered bowel habit (constipation, diarrhea or an alternating disturbance). Typically the abdominal discomfort is improved by bowel evacuation. Due to abnormal sensory processing these symptoms may be quite distressing to fibromyalgia patients. Treatment involves (1) elimination of foods that aggravate symptoms, (2) minimizing psychological distress, (3) adhering to basic rules for maintaining a regular bowel habit, (4) prescribing medications for specific symptoms; constipation (stool softener, fiber supplementation and gentle laxatives such as bisacodyl), diarrhea (loperamide or diphenoxylate) and antispasmodics (dicyclomine or anticholinergic / sedative preparations such as Donnatal).
4. Irritable bladder syndrome: This is found in 40-60% of fibromyalgia patients. The initial incorrect diagnoses are usually recurrent urinary tract infections, interstitial cystitis or a gynecological condition. Once these possibilities have been ruled out a diagnosis of irritable bladder syndrome (also called female urethal syndrome) should be considered. The typical symptoms are those of suprapubic discomfort with an urgency to void, often accompanied by frequency and dysuria. In a sub-population of fibromyalgia patients this is related to a myofascial trigger point in the pubic insertion of the rectus abdominus muscles – and may be helped by a procaine myofascial trigger point injection). Treatment: involves (1) increasing intake of water, (2) avoiding bladder irritants such as fruit juices (especially cranberry), (3) pelvic floor exercises (e.g. Kagel exercises) and the prescription of antispasmodic medications (e.g. oxybutinin, flavoxate, hyoscamine).
5. Cognitive dysfunction: This is a common problem for many fibromyalgia patients. It adversely affects the ability to be competitively employed and may cause concern as to an early dementing type of neurodegenerative disease. In practice the latter concern has never been a problem and patients can be reassured. The cause of poor memory and problems with concentration is, in most patients, related to the distracting effects of chronic pain and mental fatigue. Thus the effective treatment of cognitive dysfunction in fibromyalgia is dependent on the successful management of the other symptoms.
6. Cold intolerance: About 30% of fibromyalgia patients complain of cold intolerance. In most cases this amounts to needing warmer clothing or turning up the heat in their homes. Some patients develop a true primary Raynaud’s phenomenon (which may mislead an unknowing physician to consider diagnoses such as SLE or scleroderma. Many fibromyalgia patients have cold hands and feet, and some have cutis marmorata (a lace like pattern of violaceous discoloration of their extremities on cold exposure). Treatment involves: (1) keeping warm, (2) low-grade aerobic exercise (which improves peripheral circulation), (3) treatment of neurally mediated hypotension (see below), and (4) the prescription of vasodilators such as the calcium channel blockers (but these may aggravate the problem in-patients with hypotension).
7. Multiple sensitivities: One result of disordered sensory processing is that many sensations are amplified in fibromyalgia patients. In general fibromyalgia patients are less tolerant of adverse weather, loud noises, bright lights and other sensory overloads. Treatment involves being aware that this is a fibromyalgia-related problem and employing avoidance tactics.
8. Dizziness: Is a common complaint of fibromyalgia patients. Before this symptom is attributable to fibromyalgia a thorough for other causes should be pursued (e.g. postural vertigo, vestibular disorders, 8th nerve tumors, demyelinating disorders, brain stem ischemia and cervical myelopathy). In many cases no obvious cause is found, despite sophisticated testing. Treatable causes related to fibromyalgia include: (1) proprioceptive dysfunction secondary to muscle deconditioning, (2) proprioceptive dysfunction secondary to myofascial trigger points in the sterno-cleido-mastoids and other neck muscles, (3) Neurally mediated hypotension (see below) and (4) medication side effects. Treatment is dependent on making an accurate diagnosis. In patients in whom no obvious cause is found a trial of physical therapy, concentrating on proprioceptive awareness may prove worthwhile.
9. Neurally mediated hypotension: Patients with this problem usually have a low blood pressure that does not go up normally on standing or on exercise. Although such patients often have a low ambient BP with postural changes, these findings are not a prerequisite for diagnosis. A tilt table test with the infusion of isproterenol is the most reliable way to confirm this diagnosis. Treatment involves: (1) education as to the triggering factors and their avoidance, (2) increasing plasma volume (increased salt intake, prescription of florinef), (3) avoidance of drugs that aggravate hypotension (e.g. TCA’s, anti-hypertensives), (4) prevent reflex (prescribe ß-adrenergic antagonists or disopyramide) and (5) minimize the efferent limb of the reflex (prescribe a2-adrenergic agonists or anti-cholinergic agents).
Cognitive Therapy - What is it and how does it help?
by Carol Burckhardt Ph.D
All comprehensive fibromyalgia (FM) treatment programs include non-drug components such as cognitive-behavioral treatment. This broad treatment area emphasizes the relationship between thoughts, beliefs, emotions and behavior. In fact, it assumes that thoughts are powerful determiners of how we feel and behave and that altering maladaptive thought patterns will result in desirable behavior changes. Cognitive strategies include education in recognizing thought patterns that are maladaptive along with learning and practice of specific techniques for decreasing distress, pain, fatigue, and anxiety. Cognitive therapy contains 4 components: (1) coping skills training, (2) self-control training, (3) problem-solving skills training, and (4) cognitive restructuring methods. Although I have found that most people with FM already engage in a number of positive coping strategies, are ready to learn relaxation strategies and able to develop better ways to solve problems, when approaching the area of cognitive restructuring some people respond skeptically.“Oh, here we go again! Just thinking positively doesn’t take my symptoms away.”
“If I change the way I think about my pain and my pain decreases, people (my
family, my work colleagues, my doctor) are going to believe that fibromyalgia is ‘all
in my head.’”“What am I supposed to do, try to fool myself into believing that things are different?”
Let’s explore cognitive restructuring with the goal of understanding better what it is and what it isn’t and what its potential is for helping people with FM manage their symptoms better.
Have you ever worried about anything? Have you ever felt your body relax when someone said a kind word to you? If so, you have experienced the intimate connection between thoughts and feelings. Think about it, when you worry your body responds with sensations of anxiety (knots in your stomach, increased heart rate, sweaty palms, insomnia). Yet, the negative things you are worrying about aren’t actually happening at the time that you are worrying. They are happening only in your thoughts. On the positive side, if someone says, “I’m really sorry that you are in so much pain,” or, “I want to help in any way I can,” you may feel your muscles relax, your stomach stop churning, and your breathing become less shallow. Again, these body reactions happen even though the helper only said something to you. She didn’t massage your muscles, give you a Zantac or even tell you to breathe deeply. If you want to try out this connection in a simple way, think about eating a lemon or savoring a piece of Godiva chocolate and see what happens. Bet you start to salivate. What I’m trying to convince you of is that a very powerful connection exists between how you think, how you perceive messages from yourself and others, and how you feel both emotionally and physically.
These ongoing thoughts are the little voice in your head that babbles to you all the time. Sometimes people I see in counseling aren’t aware that they are constantly engaged in a running automatic dialog. If that seems to be the case, I ask them to spend the next week listening to themselves. Invariably, they come back with all sorts of tales that their conscious mind has been telling them. This cognitive part is always actively evaluating, rationalizing, scheming, analyzing and distorting reality at times. Have you ever said something and then wondered, “Why did I say that?” followed by, “That was a dumb thing to say.” Or maybe your neighbor brought over a plate of freshly baked cookies. You smiled, thanked her and felt both a little happy and a little sad. Then you realized that your thoughts were centering around, “She probably thinks I can’t cook. I look like such a mess and my house is a disaster. I’m just inadequate.”
All people engage in cognitive distortions from time to time. Some very common negative thoughts that people with FM have include:
“Why me?” Life isn’t fair.”
“My pain will never get better.”
“I shouldn’t ask for help.”
“No one understands me.”
What cognitive restructuring focuses on is helping you to identify the long-standing patterns of automatic thinking associated with unhappiness, anxiety, depression, and physical symptoms. Once these patterns are identified, you can decide if you wish to change them. In other words, cognitive restructuring is an active, individual process that you control. A good therapist serves as a guide to the process, often asking questions such as,
“Can you think of an alternative way to view this situation?”
“Is believing that you are worthless helpful to you?”
“Is your pain always this bad?”
“Who told you that you should ______?”
Sometimes she/he might suggest a different label like,
“Instead of seeing yourself as a martyr, maybe you could think of yourself as a
nurturer.”“Maybe instead of telling yourself that you should do something, you could ask
yourself if you want to do it.”These questions and suggestions are meant to help you reframe or restructure your thoughts into more realistic and helpful thoughts. As these new thoughts and belief become more a part of you, they won’t feel foreign or feigned. For example, reframing the belief that life isn’t fair into, “perhaps that is true, but believing and telling myself that doesn’t help me feel any better; instead I will tell myself that living my life to the fullest is more important than being frustrated about whether it is fair,” is likely to change your emotional state from one of depression and anger to one of peace and joy. As the ancient writer of Proverbs said, “ A depressed spirit saps one’s strength but a happy mind is good medicine.(17:22) ”
First published in The Fibromyalgia Times, 3(3), 14-15, 1998
Fibromyalgia in Frida Kahlo's life and art
The great Mexican painter Frida Kahlo (1907-1954) is without doubt one of the most intense and emotive artists of the twentieth century. Frida's life changed dramatically at the age of 18, when she was involved in a terrible accident. A streetcar violently impacted the bus in which she was riding. She suffered multiple bone fractures, including the third and fourth lumbar vertebrae, and had a deep abdominal wound inflicted by a metal rod. She was confined for several months in a plaster corset. From that time on, Frida suffered severe, widespread pain and profound fatigue. Generalized pain and exhaustion lingered with her for the remainder of her life.
Through the years, a variety of diagnoses were offered to explain her chronic illness, such as tuberculosis and syphilis, that were later ruled out. She received diverse types of treatments, including medications and long periods of confinement in a metal or plaster corset. In efforts to relieve her pain, she underwent several orthopedic operations on her spine, both in Mexico and in the United States, without improvement in her symptoms.
Despite her debilitating illness, Frida was engaged in an active social life. She had a tempestuous marriage to the famous Mexican muralist Diego Rivera. She traveled extensively and had relationships with the world leaders and artistic personalities of her time. Frida began painting after her accident. During periods of immobilization in a plaster corset, she used a special easel, and a mirror was attached to the canopy of her bed so that she could focus on herself. Although her painting skills were largely self-taught, she was also acquainted with the traditional schools of painting. Both in her oeuvre and in her customs, she looked back with devotion to her Mexican roots. The Surrealists claimed her as one of their own. The stillness of her self-portraits reflects the influence of her father, who was a photographer.
Frida used to describe her own paintings as "the most frank expression of myself". Her self-portraits are impassioned. Anguish and pain are the common themes of her work. These emotions are dramatically expressed in her oil painting, "The Broken Column (see picture on left). As Hayden Herrera observed, Frida's determined impassivity creates an almost unbearable tension. Pain is made vivid by nails driven into her naked body. A gap resembling an earthquake fissure splits her torso. The opened body suggests surgery. Inside her torso, we see a cracked ionic column. The corset's white straps accentuate her beautiful body. Her hips are wrapped in a cloth suggestive of Christian martyrdom. She stares straight ahead with dignity. Tears dot her cheeks, but her features refuse to cry. An immense and barren plain in the background conveys physical and emotional suffering.
To explain Frida's chronic illness, we offer an alternative diagnosis. Our opinion is that she suffered posttraumatic fibromyalgia. This prevalent syndrome is characterized by persistent widespread pain, chronic fatigue, sleep disorders, and vegetative symptoms, and by the presence of tender points in well-defined anatomic areas. The concept of fibromyalgia as a clinical entity as we know it today was probably unknown to most physicians of the early twentieth century. Our diagnosis explains her chronic, severe, widespread pain accompanied by profound fatigue. It also explains the lack of response to diverse forms of treatment. The onset of fibromyalgia after physical trauma is well-recognized.
A drawing in Frida's diary reinforces our diagnostic impression. She depicts herself in pain, and 11 arrows point to anatomic sites that are near the conventional fibromyalgia tender points. Of course, because fibromyalgia is an illness without anatomic sequelae, our contention cannot be proven or disproven. What appears certain is that Frida's self-portraits convey widespread pain and anguish with the emotional overtones that fibromyalgia patients frequently use to describe their illness.
We are indebted to Dr. Leonardo Zamudio, who allowed us to have access to Frida Kahlo's medical records, to Ms Dolores Olmedo, who gave permission to reproduce "The Broken Column," and to Dr. Robert Kalish, who kindly reviewed the manuscript.
Manuel Martinez-Lavin, MD, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
Mary-Carmen Amigo, MD, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
Javier Coindreau, MD, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
Juan Canoso, MD, American British Cowdray Hospital, Mexico City, Mexico
REFERENCES
1. Herrera H. Frida: a biography of Frida Kahlo. New York: Harper Row; 1983.2. Tibol R. Frida Kahlo: una vida abierta. Mexico City: Universidad Nacional Autonoma de Mexico; 1998.
3. Zamora M. Frida Kahlo: the brush of anguish. San Francisco: Chronicle Books; 1990.
4. Monsivais C. Vazquez-Bayod R. Frida Kahlo: una vida, una obra. Mexico City: Conaculta; 1992.
5. Del Conde T. Frida Kahlo: la pintora y el mito. Mexico City: Universidad Nacional Autonoma de Mexico; 1992.
6. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990; 33:160-72.
7. Martinez-Lavin M, Hermosillo AG, Rosas M, Soto M-E. Circadian studies of autonomic nervous balance in patients with fibromyalgia: a heart rate variability analysis. Arthritis Rheum 1998; 41:1966-71.
8. Buskila D, Neumann L, Vaisberg G, Alkalay D, Wolfe F. Increased rate of fibromyalgia following cervical spine injury: a controlled study of 161 cases of traumatic injury. Arthritis Rheum 1997; 40:446-52.
9. Freeman P. Frida Kahlo: Diario: autorretrato intimo. Mexico City: La Vaca Independiente; 1995.
MORE GUAIFENESIN MEDICAL INFORMATION
WHY IS THIS MEDICATION ORDINARILY PRESCRIBED?
Guaifenesin is used to relieve chest congestion . Guaifenesin may help control symptoms but does not treat the cause of symptoms or speed recovery. Guaifenesin is in a class of medications called expectorants. It works by thinning the mucus in the air passages to make it easier to cough up the mucus and clear the airways.
How should this medicine be used?
Guaifenesin comes as a tablet, a capsule, an extended-release (long-acting) tablet, dissolving granules, and a syrup (liquid) to take by mouth. The tablets, capsules, dissolving granules, and syrup are usually taken with or without food every 4 hours as needed. The extended-release tablet is usually taken with or without food every 12 hours. Follow the directions on the package or on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take guaifenesin exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.
Guaifenesin comes alone and in combination with antihistamines, cough suppressants, and decongestants. Ask your doctor or pharmacist for advice on which product is best for your symptoms. Check nonprescription cough and cold product labels carefully before using two or more products at the same time. These products may contain the same active ingredient(s) and taking them together could cause you to receive an overdose. This is especially important if you will be giving cough and cold medications to a child.
Nonprescription cough and cold combination products, including products that contain guaifenesin, can cause serious side effects or death in young children. Do not give these products to children younger than 4 years of age. If you give these products to children 4 to 11 years of age, use caution and follow the package directions carefully.
If you are giving guaifenesin or a combination product that contains guaifenesin to a child, read the package label carefully to be sure that it is the right product for a child of that age. Do not give guaifenesin products that are made for adults to children.
Before you give a guaifenesin product to a child, check the package label to find out how much medication the child should receive. Give the dose that matches the child's age on the chart. Ask the child's doctor if you don't know how much medication to give the child.
If you are taking the liquid, do not use a household spoon to measure your dose. Use the measuring spoon or cup that came with the medication or use a spoon made especially for measuring medication.
Swallow the extended-release tablets whole with a full glass of water. Do not break, crush, or chew them.
If you are taking the dissolving granules, empty the entire contents of the packet onto your tongue and swallow.
If your symptoms do not improve within 7 days or if you also have a high fever, a rash, or a headache that does not go away, call your doctor.
Other uses for this medicine
This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information.
What special precautions should I follow?
Before taking guaifenesin,* tell your doctor and pharmacist if you are allergic to guaifenesin, any other medications, or any of the ingredients in the guaifenesin product you plan to take. Check the package label for a list of the ingredients.
* tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take.
* tell your doctor if you smoke and if you have or have ever had a cough that occurs with a large amount of phlegm (mucus) or if you have or have ever had a breathing problem such as asthma, emphysema, or chronic bronchitis. If you will be taking the dissolving granules, tell your doctor if you are on a low magnesium diet or if you have kidney disease.
* tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking guaifenesin, call your doctor.
* if you have phenylketonuria (PKU, a inherited condition in which a special diet must be followed to prevent mental retardation), you should know that the dissolving granules may be sweetened with aspartame, a source of phenylalanine.What special dietary instructions should I follow?
Return to topDrink plenty of fluids while you are taking this medication.
Unless your doctor tells you otherwise, continue your normal diet.
In case of overdose, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 911.
What other information should I know?
Ask your pharmacist any questions you have about guaifenesin.
It is important for you to keep a written list of all of the prescription and nonprescription (over-the-counter) medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.
* Albatussi®n EX
* Bidex®
* Buckley's® Chest Congestion
* Diabetic Tussin® EX
* Fenesin® IR
* Ganidin® NR
* Genatuss®
* Glytuss®* Guai-Aid®
* Guaiatussin®
* Guaifen® NR
* Guiacough®
* Guiatuss®
* Halotussin®* Humibid® E
* Hytuss®
* Liquibid®
* Lotussin®
* Mallotuss®
* Mastussin®
* Miltuss® EX
* Mucinex®
* Mytussin®
* Naldecon-EX®
* Orgadin®
* Organidin® NR
* Phanasin®* Q-Tussin®
* Ri-Tussin®
* Robafen®
* Robichem®
* Robitussin®
* Scot-Tussin®
* Siltuss® DAS
* Siltussin®
* SoloGuai®
* Sorbutuss®
* T-Tussin®
* Tusscidin®
* Tussin®
Brand names of combination products:
* AccuHist® PDX (containing Brompheniramine, Dextromethorphan, Guaifenesin, Phenylephrine)
* Albatussin® PE (containing Guaifenesin, Phenylephrine)
* Benylin® Expectorant (containing Dextromethorphan, Guaifenesin)
* Betavent® (containing Carbetapentane, Guaifenesin)
* Bitex® (containing Codeine, Guaifenesin)
* Bromhist® PDX (containing Brompheniramine, Dextromethorphan, Guaifenesin, Phenylephrine)
* Broncholate® (containing Ephedrine, Guaifenesin)
* Brondil® (containing Dyphylline, Guaifenesin)
* Bronkaid® (containing Ephedrine, Guaifenesin)
* Bronkotuss® (containing Chlorpheniramine, Ephedrine, Guaifenesin)
* Brontex® (containing Codeine, Guaifenesin)
* Carbatuss® (containing Carbetapentane, Guaifenesin, Phenylephrine)
* Carbetaplex® (containing Carbetapentane, Guaifenesin, Phenylephrine)
* Cheracol® D (containing Dextromethorphan, Guaifenesin)
* Cheracol® with Codeine (containing Codeine, Guaifenesin)
* Cheratussin® (containing Codeine, Guaifenesin)
* Codafen® (containing Codeine, Guaifenesin)
* Codiclear® DH (containing Guaifenesin, Hydrocodone)
* Comtrex® Deep Chest Cold Non Drowsy (containing Acetaminophen, Guaifenesin)
* Coricidin® HBP Chest Congestion (containing Dextromethorphan, Guaifenesin)
* Deconex® (containing Guaifenesin, Phenylephrine)
* Difil® G (containing Dyphylline, Guaifenesin)
* Dilaudid® Cough (containing Guaifenesin, Hydromorphone)
* Dilex-G® (containing Dyphylline, Guaifenesin)
* Dilor-G® (containing Dyphylline, Guaifenesin)
* Donatuss DC® (containing Dihydrocodeine, Guaifenesin, Phenylephrine)
* Donatussin® (containing Chlorpheniramine, Dextromethorphan, Guaifenesin, Phenylephrine)
* Drituss® DM (containing Dextromethorphan, Guaifenesin)
* Duratuss® DM (containing Dextromethorphan, Guaifenesin)
* Dyfilin® GG (containing Dyphylline, Guaifenesin)
* Dyflex-G® (containing Dyphylline, Guaifenesin)
* Dyphysin® (containing Dyphylline, Guaifenesin)
* Endacof® XP (containing Guaifenesin, Hydrocodone)
* Entuss® (containing Guaifenesin, Hydrocodone)
* Gentex® HC (containing Guaifenesin, Hydrocodone, Phenylephrine)
* Gentex® LQ (containing Carbetapentane, Guaifenesin, Phenylephrine)
* Glycotuss-DM® (containing Dextromethorphan, Guaifenesin)
* Guaifen® DM (containing Dextromethorphan, Guaifenesin)
* Guiatussin® DM (containing Dextromethorphan, Guaifenesin)
* Halotussin® DM (containing Dextromethorphan, Guaifenesin)
* Humibid® CS (containing Dextromethorphan, Guaifenesin)
* Hycotuss® (containing Guaifenesin, Hydrocodone)
* Kwelcof® (containing Guaifenesin, Hydrocodone)
* Levall® (containing Carbetapentane, Guaifenesin, Phenylephrine)
* Lotussin® DM (containing Dextromethorphan, Guaifenesin)
* Lufyllin-GG® (containing Dyphylline, Guaifenesin)
* Mintuss® G (containing Guaifenesin, Hydrocodone, Phenylephrine)* Mucinex® Cold (containing Guaifenesin, Phenylephrine)
* Mucinex® Cough (containing Dextromethorphan, Guaifenesin)
* Mudrane® GG (containing Aminophylline, Ephedrine, Guaifenesin, Phenobarbital)
* Mytussin® AC (containing Codeine, Guaifenesin)
* Mytussin® DM (containing Dextromethorphan, Guaifenesin)
* Naldecon® DX (containing Dextromethorphan, Guaifenesin)
* Narcof® (containing Guaifenesin, Hydrocodone)
* Nariz® (containing Guaifenesin, Phenylephrine)
* Nazarin® (containing Guaifenesin, Phenylephrine)
* Nortuss® EX (containing Dextromethorphan, Guaifenesin)
* Numonyl® DX (containing Dextromethorphan, Guaifenesin, Phenylephrine)
* Oratuss® (containing Carbetapentane, Guaifenesin)
* Panfil® (containing Dyphylline, Guaifenesin)
* Primatene® (containing Ephedrine, Guaifenesin)
* Prometh with Codeine (containing Codeine, Guaifenesin, Promethazine)
* Q-Tussin® DM (containing Dextromethorphan, Guaifenesin)
* Qual-Tussin® DC (containing Guaifenesin, Hydrocodone, Phenylephrine)
* Quibron® (containing Guaifenesin, Theophylline)
* Robafen® DM (containing Dextromethorphan, Guaifenesin)
* Robitussin® DM (containing Dextromethorphan, Guaifenesin)
* Scot-Tussin® (containing Dextromethorphan, Guaifenesin)
* Siltussin-DM® (containing Dextromethorphan, Guaifenesin)
* Simuc-DM® (containing Dextromethorphan, Guaifenesin)
* Simuc-HD® (containing Guaifenesin, Hydrocodone, Phenylephrine)
* Sine-Off® Cold and Cough (containing Acetaminophen, Dextromethorphan, Guaifenesin)
* Sitrex® (containing Guaifenesin, Phenylephrine)
* Slo-Phyllin® GG (containing Guaifenesin, Theophylline)
* Sudafed® PE Cold & Cough (containing Acetaminophen, Dextromethorphan, Guaifenesin, Phenylephrine)
* Theocon® (containing Guaifenesin, Theophylline)
* Theolate® (containing Guaifenesin, Theophylline)
* Theomar G.G.® (containing Guaifenesin, Theophylline)
* Theophyll-GG® (containing Guaifenesin, Theophylline)
* Theospect® (containing Dyphylline, Guaifenesin)
* Theraflu® Flu & Chest Congestion (containing Acetaminophen, Guaifenesin)
* Triaminic® Chest & Nasal Congestion (containing Guaifenesin, Phenylephrine)
* Trispec® DMX (containing Dextromethorphan, Guaifenesin)
* Trituss® (containing Dextromethorphan, Guaifenesin, Phenylephrine)
* Tusnel® (containing Brompheniramine, Dextromethorphan, Guaifenesin)
* Tussi Organidin® (containing Codeine, Guaifenesin)
* Tussidin® DM (containing Dextromethorphan, Guaifenesin)
* Tylenol® Chest Congestion (containing Acetaminophen, Guaifenesin)
* Tylenol® Sinus Congestion and Pain Severe (containing Acetaminophen, Guaifenesin, Phenylephrine)
* Vicks® 44E (containing Dextromethorphan, Guaifenesin)
* Vicotuss® (containing Guaifenesin, Hydrocodone)
* Zotex® (containing Dextromethorphan, Guaifenesin, Phenylephrine)
* Zyrphen® (containing Guaifenesin, Phenylephrine)GuaifenesinTreatment.com - all rights reserved