it's Thyme to Bronchostop this nonsense

I’m sorry, I just could not resist that headline.

Whilst working a locum shift the other week, I noticed a couple of new products had leapt their way to the pharmacy shelves. “Bronchostop”. Sounds interesting, I thought, until I moved a bit closer and noticed that they are, in actual fact, a herbal cough remedy, and my vague excitement was replaced with a bit of my soul dying. Then I saw the price tag, and the anger kicked in.

Brought to us by our old friends at Omega Pharma, Bronchostop syrup contains thyme extract and marshmallow root, whilst the lozenges just contain thyme extract. Omega claim that it “relieves any type of cough”, and that it “takes the hassle out of choosing a solution”. Well, I must say, I’m pleased to hear that, because I find one of the main stressors in my life is choosing which cough remedy to use. I mean, it’s just so complicated to decide if you have a dry or a chesty cough, then realise that it makes no difference anyway as most cough medicines don't work, so you then just by a cheapo honey and lemon thing to make yourself feel placebo-ey better. 

So, given that the great all-consuming cough medicine dilemma of my life has now been sorted out by Omega, I can spend some quality time looking up the evidence to see if it works.

It turns out that there are some preliminary trials which suggest thyme might improve cough symptoms. However, these all use specific cough syrups with different combinations of ingredients compared to Bronchostop, so they’re not very helpful. Because the product is being sold as a traditional herbal remedy, the manufacturers don’t need to bother collecting any evidence that it works before it goes on sale- their claims are based entirely on “traditional use”, which means nothing at all scientifically.

One attempt at a clinical trial compared thyme syrup with a “real” expectorant, bromhexine, and found no difference over a five day period. There are a number of problems with this though- firstly, bromhexine isn’t commonly used in cough medicines. Secondly, there’s little to no good evidence that expectorants work anyway, so we’re comparing something that may or may not work with something that doesn’t.

Worryingly, the websitewww.bronchostop.co.uk contains absolutely no safety information whatsoever. It doesn’t tell you who can’t use it, who needs to be careful using it, or what any of the side effects might be.

What side effects could it possibly have, you’re wondering. After all, its just a herb. We eat it, so it can’t be that bad, right? Well, sort of. The amounts used in food tend to be a lot lower than when it is used as a herbal medicine.

On the whole, thyme is well tolerated, but occasional gastrointestinal effects can occur. Uncommonly, and more seriously, people can have allergic reactions to it. It can interact with drugs, including those that thin the blood, those used in Parkinson’s disease, those with anticholinergic or cholinergic effects, oestrogens (research suggests it may decrease the effects of HRT, but theoretically also the contraceptive pill), and non-steroidal anti-inflammatory drugs. It may cause problems in people with bleeding disorders, who are undergoing surgery, or who have hormone sensitive cancers. We have no idea of the effects that medicinal amounts of thyme can have in pregnant or lactating women.

It seems to me, however, that its main adverse effect will be on your bank balance. This stuff is £8.99 for a 200ml bottle or £4.99 for 20 pastilles- that’s a whole lot more than simple linctus, which is about £1.50 and which will probably do just as good a job.

Hxxx

Coldzyme: a result of real science being left out in the cold

There’s no getting away from it, folks. Its sniffle season. For the next 6 months or so, the sounds of sneezes, coughs, and millions of noses being blown will echo throughout the nation.

We all know by now that the common cold is a virus. We all know that there is no cure. We also all know that, although you feel like crawling into a small dark warm cave and dying at the time, its usually much better after a few days, and it goes away of its own accord. Cold and flu remedies do nothing to actually get rid of your cold- they are there to make you feel better during it, although many of them are actually irrational combinations of products in shiny boxes with a redonkulously high price.

It is often said that if someone did come up with a cure for the common cold, they would be millionaires. I was, therefore, surprised to read this week in Chemist + Druggist magazine that indeed, the first ever product to not only treat the symptoms but to act on the virus itself was winging its way to pharmacy shelves as we speak. Really? Because blimey charlie, if that's the case, then this product should be Big News. 

Image source: http://www.sourcewire.com/news/84612/by-cod-now-your-plate-of-fish-chips-could-stop

The product is ColdZyme, a mouth spray that costs £8.99 for 20mLs. Seems a pretty fair price to pay for a product which claims to cure the most prominent infectious disease in the western hemisphere. It seems odd, though, that instead of this marvellous scientific breakthrough being plastered all over the media and medical literature, the article announcing it is tucked away quietly in a barely read corner of a trade journal.

What is this breakthrough, miracle product that will powerfully break down viruses? Well, an enzyme called trypsin. An enzyme that already merrily and plentifully kicks about in your digestive system, breaking down proteins. An enzyme which, for the purposes of this product, is inexplicable being derived from cod (which has meant that I have had to resist the urge to refer to it as somewhat fishy.) An enzyme which should be stored at temperatures of between -20 and -80 degrees Celsius, to prevent autolysis. Now, I've seen some fancy medicine packaging in my time, but never a simple mouth spray bottle that can manage such cold chain storage feats. So, if trypsin really is present in this product, then it seems fairly likely that its going to be inactive, unless the manufacturers have found a way of warping room temperature. Or you happen to be in Winnipeg in the middle of winter.

Medicine vs. Medical Device

The manufacturers make some really very extraordinary claims on their website, including one textbook example of special pleading. Their product, they state, isn’t a medicine. It’s a medical device, because it has no systemic effect. They then of course go on to helpfully tell us about the systemic effect it has:

“The medicines currently on the market only treat the various symptoms of a cold. ColdZyme treats the cause of the symptoms – the virus itself – and thus works both preventively against the common cold and shortens the duration of illness if you have already been infected.”

Right. So in the same breath, they are claiming that the product only forms a barrier, no more. But then they are also claiming that this barrier affects the ability of the virus to produce illness if you are already infected- viruses which are already through that barrier and inside your body. Come on, Enzymatica, you can’t have it both ways.

The Evidence

All these claims are backed up by evidence, right? Well, there is a tiny trial performed on only 46 people, which isn’t published anywhere. I can’t say whether or not it is a well designed trial, because I can’t see it in full, so to be honest, we pretty much have to just discount it. What we can do, however, if have a look to see if there is any other decent published information looking at the effect of trypsin on the cold virus. So I turned to the medical databases Medline and Embase, to trawl through the published medical literature. 

I did find one experiment which looked at the trypsin sensitivity of several human rhinovirus serotypes(1). And this appears to have found that viruses are only really susceptible to trypsin when there have been exposed to low pH, followed by neutralization- something which wont have happened to your common or garden cold viruses. I couldn’t find much else suggestive of a clinically significant antivirus action of trypsin.

The practicalities

This isn’t a simple, one-off- couple of sprays and away flies your cold sort of product. You have to use it every two hours, as well as after you brush your teeth and before you go to bed, and you have to continue this “until your symptoms are relieved”. That’s one hell of a regime. I have difficulty remembering to use medicines twice daily, never mind every two hours. I’ve never used this product, but I’d imagine that if it really does leave a “barrier” coating in your mouth, its a pretty unpleasant sensation. I can’t imagine many people sticking closely to these dosage instructions, and if the mechanism of action is as the manufacturer’s claim, skipping doses would cause the product to fail (if, indeed, it works in the first place)

We are also directed to “Start using ColdZyme^® as soon as possible when you detect symptoms of a cold.”. Now, those of use who suffer with cold sores who have ever used aciclovir cream will know that this is often easier said than done- you probably haven’t got the stuff in the house, or at work, and by the time you’ve managed to get your hands on some, its already too late- your cold sore is out loud and proud, and using the drug will be pointless. Its likely that the very same thing will apply here. And remember that the incubation period for a cold is about 2 days- so the virus will already be cosily settled into your body before you even know about it. Its therefore completely ludicrous that this product claims to be able to reduce the length of a cold simply by forming a barrier.  

I know it can be used as a cold preventative, but how many people who feel completely fine are going to remember to use the product every two hours, every day, for the entirely of the cold season?

To Summarise

So, do I think there is scientific evidence to back up the extraordinary claims being made by ColdZyme? I might do when hell freezes over. Or at least when some decent trials are published, which might take just as long.  Do I think that this product should be sold through pharmacies? Absolutely not- this isn’t, if you ask me, real medicine. This is pure pseudoscience, trying its best to fool you into buying real medicine. Do I think lots of people will buy this, use it once or twice, then leave it to languish in their bathroom cabinet? Absolutely.

Here’s the problem though: this stuff will appear on the shelves of pharmacies all over. The pharmacists wont have a clue what this stuff is, and because they are really busy and probably quite tired at the end of each day, they wont be able to do the sort of evidence review I have managed to squeeze into a quiet moment. So they’ll get asked about it, and they’ll sell it. Some people will buy it and will feel better after a few days, and will think that the spray has made them better, forgetting that colds are self-limiting anyway. A customer might come back in the pharmacy one day, and say something like “hey, that new-fangled spray got rid of my cold!”, and the pharmacy staff will end up making recommendations on the basis of customer feedback and anecdotes, rather than on the basis of rational, scientific evidence. In my eyes, this really is a shame, and by selling this sort of nonsense, we really are cheapening our profession, and we're causing our customers to waste their money. 

If patients ask me about it, when I’m working behind the counter, I’ll tell them something along the lines of: “there’s no evidence or logical way that it works. It seems to be a bit of an expensive gimmick, with no decent basis to it. You’ll feel horrible with your cold, but it will start to go away of its own accord, I promise. In the meantime, you’d be much better off looking after yourself, having plenty of fluids and rest, and taking paracetamol according to the packet.”

Hxxx

Common Community Pharmacy Annoyances

It's funny how variable working in a community pharmacy can be. Nowadays, I locum here and there, and I tend to really enjoy it. I usually do evening shifts, so you have an hour or two of bedlam, followed by several hours of blissful calm and quiet, where you get to sort out all the outstanding things, do lots of other bits and pieces like checking owings, controlled drug stock levels, and cleaning. I usually also end up having bizarrely deep and meaningful conversations about life, love and philosophy with whoever I am working with. Usually when I leave a pharmacy it is as clean and tidy as possible, I've sorted out what I can, and have left notes for anything that I haven't been able to deal with fully.

I say all this because I lately did one of *those* locum shifts. The ones where it is constantly busy, no prescription is straightforward, the fax machine isn't working, and you seem to have to deal with every problem under the sun. On this particular locum shift, I think my colleagues and I encountered every single type of category of impolite customer possible in a 4 hour shift.

So, because the only way that we can cope with such things is to laugh about them, and because I fancy a self-indulgent rant, here is my compilation of the things in pharmacy that annoy me and that happened in that locum shift.

The Mythical Taxi
Some people do get a taxi to their local supermarket. I have done it myself. But it would appear that taxi companies must have an amazingly lucrative trade in ferrying people to and from pharmacies if the frequency of use of the phrase "Can you do it quickly please, I've got a taxi waiting" is anything to go by. These are not, as far as I am aware, magic words that will somehow warp the time-space continuum so that I am able to dispense and check a twenty item prescription in a mere matter of seconds. Whether or not you actually have a taxi waiting will simply mean that your prescription gets put in the queue in the same place it would have done anyway, and you will wait the same amount of time as you would have done anyway. Needless to say, I suspect that many of these taxis don't actually exist, but merely a tactic used by some people to attempt to "hurry their prescriptions along".

The Dry Chesty Cough
"What sort of a cough is it?" "Well, its a dry, chesty cough."
No, no it isn't. It's either dry or its chesty, its not both. And either way, there is little point buying anything for it given that there is no evidence that any cough medicines work.

The Evil Eyes
Glaring at me continuously for the entire time that I am dispensing your prescription will not in any way speed up my work, and in fact may have the opposite effect as I am more likely to lumber around in a sloth-like manner just to annoy.

"I Need To Be Somewhere"
At 6:05pm, a woman handed in her prescription of 4 items. At 6:07pm, having spent all of two minutes repeatedly sighing and tapping her feet, she asked to speak to the pharmacist. Off I went, leaving a prescription half-dispensed. She demanded to know how long her prescription was going to be (the one I left to go and speak to her), because she needed to be somewhere. I gave her an estimation, told her I was doing it now, then went off to complete it. She then asked to speak to me a further three times to find out how long it was going to be, each time meaning it would take a little longer. "But I need to be somewhere at 6:15!!" she told me each time. I handed her the prescription at 6:12pm, thanking her for her patience. She then proceeded to rant for several minutes about how long the prescription had taken and how it meant she was going to be late and she had to be somewhere at 6:15. She eventually stopped complaining at exactly 6.15, and I returned to the dispensary, whereupon I noticed out of the corner of my eye that she had taken the time to hang around to complain about how long it had taken her to get her prescription to some of her friends who she just happened to bump into in the shop. Goodness only knows what time she actually left.

Invading Privacy
If you have ever picked up a prescription from a pharmacy, you will have probably been asked to confirm your address. This is so that we can make sure that you actually get the correct prescription. This is not because we are evil assassins or because we want to sit in a bush outside your house and spy on you- we really don't- and you're address is written on the prescription so if we wanted to we could anyway. On this locum shift, however, we were accused of invading someone's privacy for asking for this information. "I don't need to give you that information!" he declared. The counter assistant advised him that this is a routine question to ensure that we give out the correct prescription. But this wasn't good enough, and he wanted to speak to someone in charge. Off I went into the breach. I told him that he could come into the consultation room to give us his address so no one could overhear, but this was "an inconvenience", apparently.

By this time, he was shouting and other people in the queue were staring at him.

Again, I advised that we routinely confirm the address to ensure that the correct prescription is given out.

He decided to prove that the prescription was his instead by giving out his name, date of birth, and by telling me every item that was on the script. Loudly. One of which was sildenafil (Viagra).

Magicking Up Medicine
Me: "I'm sorry, we don't have that item in stock. There is a manufacturing problem on it, so we can't get it from our suppliers"
Patient: "But I need it"
Me (in head): "Oh I see. Well if you can hold on a few minutes, I'll just nip round the back into our large pharmaceutical manufacturing factory, dig out the raw materials, and whip you up a batch right now then"
Me (in real-life): "I understand, but I'm really sorry, we can't get any in at the moment."
Patient: "But I need it."
Me: "Where is the nearest wall please, so that I can bash my head against it repeatedly?"

The Expert Customer
I'm advising a patient about how to manage their child's teething problems. Another customer waiting in the queue decides to chip in with "Those Nelsons Teetha sachets are really good." (Nelsons Teetha sachets are homeopathic, therefore contain nothing of use and have no pharmacological effect). From then on, I (and my many years of training and experience) might as well not exist, as nothing I say can steer the patient away from believing that Nelsons Teetha are simply THE best thing since sliced bread, and in her eyes I'm obviously a terrible pharmacist for not recommending them immediately.

Impatient Patient Questioning
You ask the patient all the usual questions. They're all answered with a loud sigh, vacant eyes, and a disinterested "yes" or "no" at all the bits that they think are right. I could be asking anything, and I'd get the same response. So sometimes, I like to mix it up a bit and throw in a question they're not expecting. If its something like Nytol or a codeine containing medicine, I'll ask "Do you take it regularly?" to which the response is usually a bored yes. In which case, I advise them that I can't sell them any, then swiftly duck for cover when they inevitably throw things at me.

A variant You ask the patient if they are taking any other medications, to which they sigh and say "no". It's only when they're about to hand over their money that they a) ask what would happen if they were taking medicines, then confess, or b) whip out an inhaler and proceed to take a couple of puffs right in front of you after they have just told you that they don't have asthma or COPD.

Specifics
The patient can inexplicably only take one or two brands of generics for a product. You are, of course, expected to telepathically know this and dispense the right one, and woe betide anyone who doesn't. Now, I am entirely understanding of cases where a patient has specific requirements for one type of product- maybe an allergy to an excipient, say. But when there is not reason for it, and the patient is shouting at you for not giving them "the right medicine" despite them at no point telling you what "the right" one is, then I tend to feel a bit put out.

Mobile Misery
Now I am known for being attached to my mobile phone. However, one of the most annoying things when working in retail is having to deal with customers who refuse to hang up theirs whilst you are trying to have a conversation with them. Over a pharmacy counter, we often need to give detailed counselling, and of course we need to ask a lot of questions. I can't really do that if you are also listening to so-and-so discussing who was drunkest down the pub the other night. At this particular locum shift, I had to attempt to explain that there was an item owing on a prescription to a chap who was having just such a conversation. The icing on the cake was when he said to his phone-based friend "Hang on, I can't hear you, this stupid woman keeps talking about something and wont give me my prescription". Needless to say, despite me explaining the owing and handing him an owing slip, he returned a few minutes later demanding to know where the missing item was. This "stupid woman" then had to patiently and politely re-explain everything I had already told him.

How do I deal with situations like this? Politely, professionally, and with a smile on my face. I might have a bit of a rant and a laugh about it later in the back of the pharmacy, but outwardly in these situations I remain as calm as possible and attempt to be as helpful as I can. I've had many years of practice. The worst thing about this shift was that I was working with a new counter assistant and a newly qualified pharmacist, and I could see their morale slipping minute by minute. Their shoulders slumped, their smiles became more forced, and I found myself desperately trying to reassure them that this is just how some days go. Of course, we pharmacy types do make mistakes on occasion, and inconveniences do happen. I can understand that, when it comes to health, people can be scared and anxious, and that can come across as aggression. It is my firm belief, however, that a little bit of kindness and manners get you everywhere, and I am always much more likely to respond positively to calm and polite customers than those who default to outright rudeness, although I will do what I can to ensure that I help them all.

Hxxx

Vicks, feet, and a whole load of nonsense.

And so it was that I ventured onto Facebook last night, for the first time in a while. And what I discovered there was an intriguing post about putting Vicks Vaporub on your feet to cure a cough.

A very quick google search suggests this is a long-standing bit of nonsense that's been doing the rounds with pretty much exactly the same wording for years. I thought it might be worth revisiting. so, here it is in its entirety, with my skeptical, critical thinking thoughts inserted in blue. I guess its a bit of an example about how to think about claims that appear at first glance to be too good to be true:

"Some of us have used Vicks Vaporub for years for everything from chapped lips to sore toes and many body parts in between. <Wait, What? Who uses Vicks Vaporub for chapped lips? I've never heard of anyone do this, ever. Firstly, it would sting lots, and secondly it could potentially be highly toxic, given its essential oil content, and aspiration risk when swallowed due to petroleum. I wouldn't put the stuff anywhere near my mouth.> But I’ve never heard of this. And don’t laugh, it works 100% of the time <100% of the time? Nothing in medicine works 100% of the time, so alarm bells are ringing loudly, unless this is the single most important medical discovery that's ever happenee, ever.>, although the scientists who discovered it aren’t sure why. <what scientists?>

To stop night time coughing in a child (or adult as we found out personally), put Vicks Vaporub generously on the bottom of the feet at bedtime, then cover with socks. <Feet seem to be a favourite of the quackery world, what with detox patches, reflexology and all that sort of thing. Alarm bells are a lot louder already. Why would Vicks be particularly effective on your feet? Is this as compared to any other parts of your body, or compared to nothing at all? Wouldn't it sting, and could it have potential to cause sensitisation in the area? Where is the prior plausibility here?>  Even persistent, heavy, deep coughing will stop in about 5 minutes and stay stopped for many, many hours of relief. <A coughing fit usually does stop after a few minutes of its own accord regardless of treatment. If it doesn't, and you're coughing constantly for more than 5 minutes, you probably need to be checked out by a doctor.> Works 100% of the time and is more effective in children than even very strong prescription cough medicines. <There are very few prescription cough medicines, on account of the fact that most preparations for cough don't really work anyway.Again, this 100% of the time claim is quite extraordinary and would require major clinical evidence to back it up.> In addition it is extremely soothing and comforting and they will sleep soundly. <Is the stinging, cold sensation you get with menthol really soothing?>

Just happened to tune in A.M. Radio and picked up this guy talking about why cough medicines in kids often do more harm than good, due to the chemical makeup of these strong drugs so, I listened. <What guy? What radio station? What are you on about? The only medicines now available for coughs in children OTC in the UK are glycerol and simple linctus paed- basically, sugary water. No "strong drugs here".> It was a surprise finding and found to be more effective than prescribed medicines for children at bedtime, in addition to have a soothing and calming effect on sick children who then went on to sleep soundly. <Where is this finding published? What sort of a study was it and how was it designed? How many participants were there? Was there a control group, or a comparator group and if so, what was the comparator? As it happens, none of these questions really matter given the studies themselves don't actually exist>

My wife tried it on herself when she had a very deep constant and persistent cough a few weeks ago and it worked 100%! <anecdote. It worked 100%, but in one person? This doesn't even make sense.> She said that it felt like a warm blanket had enveloped her, coughing stopped in a few minutes and believe me, this was a deep, (incredibly annoying!) every few seconds uncontrollable cough, and she slept cough-free for hours every night that she used it. <I'd imagine it would actually just feel like you had some oily gunk on your feet that would sting a little bit and feel cold. Who is this wife, and why should we believe this anecdote from an anonymous person? There's no way to remove regression to the mean as an explanation to this, but by now I'm suspecting this wife with a cough is mainly mythical>

If you have grandchildren, pass this on. <so presumably you don't need to bother if you're simply a parent, only if you're a grandparent?> If you end up sick, try it yourself and you will be absolutely amazed at how it works! <Actually, I suspect I'll just feel a bit silly. And will have minty-smelling feet>"


So of course I have done a search for the evidence and claims included in the post and have found a grand total of Nothing At All. I will say this though: If I was the manufacturer of Vicks, and someone had done some studies which found my product to be 100% effective, I would sing it loudly from every rooftop I could find. I would be the manufacturer of The Number One Most Effective Medical Product In The World Ever, and I would make sure that I made my millions on the back of that fact, as well as collecting my Nobel prize for Medicine and probably world peace as well. What I probably wouldn't do is ignore the claims, and continue on selling my product and advising that its used in a way which has a less than 100% chance of it working.

Direct harms from following this advice could include dermatitis and skin reactions. Indirect harms? Well, you've slathered some slippery, oily unguent onto the bottom of your feet. When you take your socks off, you may be slip-sliding all over the place.

The moral of the story is:Very rarely should you believe anything posted on Facebook. Unless its me, posting a link to my blog, of course.

Hxxx

UPDATE: I get a LOT of hits on this blog because of this post. If you've stumbled across it, i would love to know whether it has had any impact on what you thought about whether putting Vicks on your Feet would work, so please do leave a comment or drop me an e-mail.