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Acute psychosis with Coricidin cold medicine

PGY-IV Creighton—Nebraska Psychiatry Residency Program 985578 Nebraska Medical Center Omaha, Nebrraska 68198-5578 fax 402/354-6301 doctorsharma{at}hotmail.com

Vijay Dewan, MD

Assistant Professor of Psychiatry University of Nebraska Medical Center Staff Psychiatrist Department of Mental Health and Behavioral Sciences Omaha Veterans Affairs Medical Center

Frederick Petty, PhD MD

Professor and Vice Chair for Research Department of Psychiatry School of Medicine Creighton University Associate Chief Department of Mental Health and Behavioral Science Omaha Veterans Affairs Medical Center

Published Online, August 2, 2005. www.theannals.com, DOI 10.1345/aph.1G193

Case Report. A 54-year-old white man was admitted to an inpatient psychiatric facility for management of acute psychotic symptoms. He presented to the emergency department (ED) with paranoid thoughts, auditory hallucinations, and preoccupation with religion. While in the ED, he stated that the care providers were "dogs with the power of darkness." He also described being possessed by demons and used as a messenger by them. He said that these symptoms started 3 days earlier, soon after using Coricidin HBP Cough and Cold tablets to relieve cold symptoms; he had taken up to 8 capsules in 24 hours, although the recommended dose on the packaging is 4 doses in 24 hours. The next day he experienced severe auditory hallucinations, paranoia, and hyper-religiosity.

A thorough medical evaluation in the ED was negative. He had no previous history of drug allergy, psychiatric problems, or substance abuse; however, his medical history was significant for myocardial infarction and lymphoma. There was no family history of psychosis. Medications on admission were aspirin 375 mg/day, lisinopril 20 mg/day, clopidogrel 75 mg/day, and simvastatin 40 mg/day. He had received aspirin, lisinopril, and simvastatin for a few years. Clopidogrel was started a few months before presentation. Although the possibility of this reaction occurring from his current drugs is very low, their contribution could not be ruled out. The patient received intramuscular haloperidol 5 mg, and Coricidin HBP was discontinued. A computed tomography scan revealed a low attenuation lesion in the left cerebellar hemisphere consistent with an old infarct. He was admitted to an inpatient psychiatric facility. The symptoms resolved over 2 days with no additional psychotropic medication, and he was discharged.

Discussion. Coricidin HBP Cough and Cold Medicine is an OTC product containing dextromethorphan 30 mg and chlorpheniramine 4 mg per tablet. Dextromethorphan, an antitussive agent with affinity for the sigma opiate receptor, may cause psychosis by its metabolite dextrophan, which is a noncompetitive antagonist of the NMDA receptor.² Individuals who have rapid metabolizer phenotype CYP2D6 may be more susceptible to the psychotogenic effects.³ Chlorpheniramine is an antihistamine that antagonizes histamine H₁ receptors.

At the time of writing, only one interaction involving the drugs our patient received has been reported. Clopidogrel potentiates the effects of aspirin on collagen-induced platelet aggregation, but coadministration in our patient did not significantly alter the bleeding time.⁴

At high doses, Coricidin HBP can lead to agitation, hallucinations, tachycardia, and confusion.⁵ Clinical manifestations of dextromethorphan and chlorpheniramine overdose are similar to some extent. However, a possibility of an unexplained mechanism involving the causation of these symptoms with the use of Coricidin could not be ruled out. According to the Naranjo probability scale, the relationship of the adverse reaction to Coricidin HBP is possible.⁶

Patients and healthcare providers should be reminded of the adverse effects described here from fairly safe OTC drugs when used in doses exceeding those recommended.

References

1. Roberge RJ, Hirani KH, Rowland PL 3rd, Berkeley R, Krenzelok EP. Dextromethorphan- and pseudoephedrine-induced agitated psychoses and ataxia: case report. J Emerg Med 1999;17:285-8.[Medline]
2. Schadel M, Sellers EM. Psychoses with Vicks Formula 44-D abuse.CMAJ 1992;147:843-4.
3. Schadel M, Wu D, Otton SV, Kalow W, Sellers EM. Pharmacokinetics of dextromethorphan and metabolites in humans: influence of the CYP2D6 phenotype and quinidine inhibition. J Clin Psychopharmacol 1995;15:263-9.[CrossRef][Medline]
4. Physicians desk reference. www.pdr.net/pdrnet/librarian (accessed 2005 Jul 25).
5. Abuse of Coricidin HBP cough & cold tablets: episodes recorded by a poison center. Am J Health Syst Pharm 2001;58:1811-4.[Abstract/Free Full Text]
6. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions.Clin Pharmacol Ther 1981;30:239-45.[Medline]

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