Tusnel Diabetic Liquid
It is used to thin mucus so it can be taken from the body by coughing.It is used to relieve coughing.
Drug Class
Expectorant, Antitussive
Pharmacologic Class
Expectorant (Guaifenesin); NMDA receptor antagonist, Sigma-1 receptor agonist (Dextromethorphan)
Pregnancy Category
Category C
FDA Approved
Jan 1970
DEA Schedule
Not Controlled
Overview
What is this medicine?
This medication is used to help relieve cough and chest congestion. Guaifenesin helps to thin and loosen mucus in your lungs, making it easier to cough up. Dextromethorphan helps to reduce the urge to cough.
How to Use This Medicine
Taking Your Medication Correctly
To get the most benefit from your medication, follow your doctor's instructions carefully. Read all the information provided with your prescription and follow the instructions closely. You can take this medication with or without food, but if it causes stomach upset, take it with food to help minimize discomfort.
It's essential to drink plenty of non-caffeinated liquids, unless your doctor advises you to limit your fluid intake. When taking the liquid form of this medication, measure your dose accurately using the measuring device provided with the medication. If no device is included, ask your pharmacist for a suitable measuring tool.
Storing and Disposing of Your Medication
Store your medication at room temperature in a dry place, avoiding the bathroom. Keep all medications in a safe location, out of the reach of children and pets. Dispose of unused or expired medications properly. Do not flush them down the toilet or pour them down the drain unless instructed to do so by your doctor or pharmacist. If you're unsure about the best way to dispose of your medication, consult with your pharmacist, who may be aware of drug take-back programs in your area.
What to Do If You Miss a Dose
If you take this medication on a regular schedule, take the missed dose as soon as you remember. However, if it's close to the time for your next dose, skip the missed dose and resume your regular dosing schedule. Do not take two doses at the same time or take extra doses. If you take this medication as needed, do not take it more frequently than directed by your doctor.
To get the most benefit from your medication, follow your doctor's instructions carefully. Read all the information provided with your prescription and follow the instructions closely. You can take this medication with or without food, but if it causes stomach upset, take it with food to help minimize discomfort.
It's essential to drink plenty of non-caffeinated liquids, unless your doctor advises you to limit your fluid intake. When taking the liquid form of this medication, measure your dose accurately using the measuring device provided with the medication. If no device is included, ask your pharmacist for a suitable measuring tool.
Storing and Disposing of Your Medication
Store your medication at room temperature in a dry place, avoiding the bathroom. Keep all medications in a safe location, out of the reach of children and pets. Dispose of unused or expired medications properly. Do not flush them down the toilet or pour them down the drain unless instructed to do so by your doctor or pharmacist. If you're unsure about the best way to dispose of your medication, consult with your pharmacist, who may be aware of drug take-back programs in your area.
What to Do If You Miss a Dose
If you take this medication on a regular schedule, take the missed dose as soon as you remember. However, if it's close to the time for your next dose, skip the missed dose and resume your regular dosing schedule. Do not take two doses at the same time or take extra doses. If you take this medication as needed, do not take it more frequently than directed by your doctor.
Lifestyle & Tips
- Drink plenty of fluids (water, juice) to help loosen mucus.
- Avoid irritants like smoke, dust, and pollutants.
- Use a humidifier to moisten the air.
- Do not exceed the recommended dose.
- This product is sugar-free, making it suitable for individuals with diabetes.
Available Forms & Alternatives
Dosing & Administration
Adult Dosing
Standard Dose:
10-20 mL (containing 200-400 mg Guaifenesin and 20-40 mg Dextromethorphan) orally every 4 hours as needed
Dose Range:
10 - 20 mg
Condition-Specific Dosing:
maxDailyDose:
Not to exceed 120 mL (2400 mg Guaifenesin, 240 mg Dextromethorphan) in 24 hours
Pediatric Dosing
Neonatal:
Not established
Infant:
Not established
Child:
Children 6 to under 12 years: 5-10 mL orally every 4 hours as needed (max 60 mL/24 hours). Children 4 to under 6 years: 2.5-5 mL orally every 4 hours as needed (max 30 mL/24 hours). Not recommended for children under 4 years of age.
Adolescent:
Children 12 years and older: Same as adult dosing.
Dose Adjustments
Renal Impairment:
Mild:
No specific adjustment recommended, use with caution.
Moderate:
No specific adjustment recommended, use with caution.
Severe:
Use with caution; consider extended dosing intervals due to potential accumulation of metabolites, especially for Dextromethorphan.
Dialysis:
Not well studied; use with caution. Dextromethorphan and its metabolites are renally excreted.
Hepatic Impairment:
Mild:
No specific adjustment recommended, use with caution.
Moderate:
Use with caution; consider reduced dose or extended dosing intervals due to impaired metabolism of Dextromethorphan.
Severe:
Use with caution; consider reduced dose or extended dosing intervals due to impaired metabolism of Dextromethorphan.
Confidence:
Medium
Pharmacology
Mechanism of Action
Guaifenesin acts as an expectorant by increasing the volume and decreasing the viscosity of respiratory tract secretions, making coughs more productive. Dextromethorphan acts centrally on the cough center in the medulla oblongata, elevating the cough threshold. It is an NMDA receptor antagonist and a sigma-1 receptor agonist.
Pharmacokinetics
Absorption:
Bioavailability:
Guaifenesin: Well absorbed; Dextromethorphan: Well absorbed, undergoes extensive first-pass metabolism.
Tmax:
Guaifenesin: ~1 hour; Dextromethorphan: ~2-2.5 hours.
FoodEffect:
Not significantly affected by food.
Distribution:
Vd:
Guaifenesin: Not extensively studied; Dextromethorphan: Widely distributed.
ProteinBinding:
Guaifenesin: Not extensively protein bound; Dextromethorphan: Not extensively protein bound.
CnssPenetration:
Guaifenesin: Limited; Dextromethorphan: Yes (acts centrally).
Elimination:
HalfLife:
Guaifenesin: ~1 hour; Dextromethorphan: ~1.4-3.9 hours (parent), Dextrorphan: ~11-13 hours.
Clearance:
Guaifenesin: Rapid; Dextromethorphan: Varies based on CYP2D6 phenotype.
ExcretionRoute:
Renal (primarily metabolites).
Unchanged:
Guaifenesin: Very little; Dextromethorphan: Small amount.
Pharmacodynamics
OnsetOfAction:
Guaifenesin: Within 30 minutes; Dextromethorphan: 15-30 minutes.
PeakEffect:
Guaifenesin: ~1 hour; Dextromethorphan: ~2.5 hours.
DurationOfAction:
Guaifenesin: ~4-6 hours; Dextromethorphan: ~5-6 hours.
Safety & Warnings
Side Effects
Serious Side Effects: Seek Medical Attention Immediately
Although rare, this medication can cause severe and potentially life-threatening side effects. If you experience any of the following symptoms, contact your doctor or seek medical help right away:
- Signs of an allergic reaction, such as rash, hives, itching, red, swollen, blistered, or peeling skin (with or without fever), wheezing, tightness in the chest or throat, trouble breathing, swallowing, or talking, unusual hoarseness, or swelling of the mouth, face, lips, tongue, or throat.
Other Possible Side Effects
Like all medications, this drug can cause side effects. However, many people do not experience any side effects or only have mild ones. If you have side effects that bother you or do not go away, contact your doctor for advice.
Reporting Side Effects
This list does not include all possible side effects. If you have questions or concerns about side effects, discuss them with your doctor. You can also report side effects to the FDA at 1-800-332-1088 or online at https://www.fda.gov/medwatch. Your doctor is available to provide medical advice about side effects.
Although rare, this medication can cause severe and potentially life-threatening side effects. If you experience any of the following symptoms, contact your doctor or seek medical help right away:
- Signs of an allergic reaction, such as rash, hives, itching, red, swollen, blistered, or peeling skin (with or without fever), wheezing, tightness in the chest or throat, trouble breathing, swallowing, or talking, unusual hoarseness, or swelling of the mouth, face, lips, tongue, or throat.
Other Possible Side Effects
Like all medications, this drug can cause side effects. However, many people do not experience any side effects or only have mild ones. If you have side effects that bother you or do not go away, contact your doctor for advice.
Reporting Side Effects
This list does not include all possible side effects. If you have questions or concerns about side effects, discuss them with your doctor. You can also report side effects to the FDA at 1-800-332-1088 or online at https://www.fda.gov/medwatch. Your doctor is available to provide medical advice about side effects.
Seek Immediate Medical Attention If You Experience:
- Cough that lasts more than 7 days, comes back, or occurs with fever, rash, or persistent headache (could be signs of a serious condition).
- Nervousness, dizziness, or sleeplessness.
- Severe nausea, vomiting, or stomach pain.
- Signs of an allergic reaction (e.g., rash, itching, swelling, severe dizziness, trouble breathing).
- Signs of serotonin syndrome (e.g., agitation, confusion, rapid heart rate, muscle stiffness, sweating, shivering).
Before Using This Medicine
Before Taking This Medication: Important Information to Share with Your Doctor
It is essential to inform your doctor about the following:
Any allergies you have, including allergies to this medication, its components, or other substances, such as foods or drugs. Be sure to describe the allergic reaction you experienced, including any symptoms that occurred.
If you have a cough that produces a significant amount of mucus, a chronic cough caused by smoking or exposure to smoke, or lung conditions like asthma or emphysema.
If you have taken certain medications for depression or Parkinson's disease within the last 14 days, including isocarboxazid, phenelzine, tranylcypromine, selegiline, or rasagiline, as this may increase the risk of severely high blood pressure.
If you are currently taking linezolid or methylene blue, as these medications can interact with this drug.
To ensure your safety, it is crucial to provide your doctor and pharmacist with a comprehensive list of all your medications, including:
Prescription and over-the-counter (OTC) drugs
Natural products
* Vitamins
Additionally, inform them about any existing health problems. This information will help your doctor determine whether it is safe for you to take this medication with your other drugs and health conditions. Never start, stop, or change the dosage of any medication without first consulting your doctor.
It is essential to inform your doctor about the following:
Any allergies you have, including allergies to this medication, its components, or other substances, such as foods or drugs. Be sure to describe the allergic reaction you experienced, including any symptoms that occurred.
If you have a cough that produces a significant amount of mucus, a chronic cough caused by smoking or exposure to smoke, or lung conditions like asthma or emphysema.
If you have taken certain medications for depression or Parkinson's disease within the last 14 days, including isocarboxazid, phenelzine, tranylcypromine, selegiline, or rasagiline, as this may increase the risk of severely high blood pressure.
If you are currently taking linezolid or methylene blue, as these medications can interact with this drug.
To ensure your safety, it is crucial to provide your doctor and pharmacist with a comprehensive list of all your medications, including:
Prescription and over-the-counter (OTC) drugs
Natural products
* Vitamins
Additionally, inform them about any existing health problems. This information will help your doctor determine whether it is safe for you to take this medication with your other drugs and health conditions. Never start, stop, or change the dosage of any medication without first consulting your doctor.
Precautions & Cautions
It is essential to inform all your healthcare providers, including doctors, nurses, pharmacists, and dentists, that you are taking this medication.
To minimize the risk of severe side effects, do not exceed the dosage prescribed by your doctor. Taking more than the recommended amount can increase your chances of experiencing serious adverse effects. Additionally, do not take this medication for a longer period than specified by your doctor.
If you are following a low-sodium or sodium-free diet, consult with your doctor before taking this medication, as some products may contain sodium. Similarly, if you have phenylketonuria (PKU), discuss this with your doctor, as certain products may contain phenylalanine.
Please note that some formulations of this medication may not be suitable for children of all ages. If you have any questions or concerns, consult with your doctor.
If you are pregnant, planning to become pregnant, or are breastfeeding, inform your doctor. It is crucial to discuss the potential benefits and risks of this medication to both you and your baby to make an informed decision.
To minimize the risk of severe side effects, do not exceed the dosage prescribed by your doctor. Taking more than the recommended amount can increase your chances of experiencing serious adverse effects. Additionally, do not take this medication for a longer period than specified by your doctor.
If you are following a low-sodium or sodium-free diet, consult with your doctor before taking this medication, as some products may contain sodium. Similarly, if you have phenylketonuria (PKU), discuss this with your doctor, as certain products may contain phenylalanine.
Please note that some formulations of this medication may not be suitable for children of all ages. If you have any questions or concerns, consult with your doctor.
If you are pregnant, planning to become pregnant, or are breastfeeding, inform your doctor. It is crucial to discuss the potential benefits and risks of this medication to both you and your baby to make an informed decision.
Overdose Information
Overdose Symptoms:
- Nausea, vomiting, stomach upset
- Dizziness, drowsiness, confusion
- Nervousness, irritability, restlessness
- Blurred vision
- Rapid heart rate
- Hallucinations
- Ataxia (loss of coordination)
- Respiratory depression (slow, shallow breathing)
- Seizures
- Coma
What to Do:
Seek immediate medical attention or call a Poison Control Center (1-800-222-1222). Bring the product packaging with you. Treatment is supportive and symptomatic.
Drug Interactions
Contraindicated Interactions
- Monoamine Oxidase Inhibitors (MAOIs) (concurrent use or within 14 days of stopping MAOIs due to risk of serotonin syndrome with Dextromethorphan)
Major Interactions
- Serotonergic drugs (e.g., SSRIs, SNRIs, TCAs, triptans, mirtazapine, bupropion, linezolid, tramadol, St. John's Wort) - increased risk of serotonin syndrome with Dextromethorphan.
- CYP2D6 inhibitors (e.g., quinidine, fluoxetine, paroxetine, amiodarone, celecoxib) - can increase Dextromethorphan levels and adverse effects.
Moderate Interactions
- Alcohol and other CNS depressants (increased sedation and CNS depression)
- Other cough/cold preparations (risk of additive effects or overdose if containing similar ingredients)
Minor Interactions
- None commonly cited for Guaifenesin or Dextromethorphan at typical OTC doses.
Monitoring
Baseline Monitoring
Patient medical history (especially diabetes, liver/kidney disease, psychiatric conditions, current medications)
Rationale: To identify contraindications, potential drug interactions, and risk factors for adverse effects.
Timing: Prior to initiation of therapy.
Routine Monitoring
Symptom improvement (cough frequency/severity, mucus production)
Frequency: Daily, during treatment period.
Target: Reduction in cough, easier expectoration.
Action Threshold: Lack of improvement after 7 days, worsening symptoms, or development of new symptoms (e.g., fever, rash) warrants medical evaluation.
Adverse effects (e.g., nausea, dizziness, drowsiness, rash)
Frequency: Daily, during treatment period.
Target: Absence of significant adverse effects.
Action Threshold: Presence of severe or persistent adverse effects, or signs of serotonin syndrome (agitation, confusion, rapid heart rate, muscle rigidity).
Symptom Monitoring
- Cough frequency and intensity
- Sputum production and consistency
- Nausea/vomiting
- Dizziness/lightheadedness
- Drowsiness
- Headache
- Rash or allergic reactions
- Signs of serotonin syndrome (agitation, hallucinations, rapid heart rate, fever, sweating, shivering, muscle stiffness/twitching, loss of coordination, nausea, vomiting, diarrhea)
Special Patient Groups
Pregnancy
Category C. Use only if the potential benefit justifies the potential risk to the fetus. Consult a healthcare professional before use.
Trimester-Specific Risks:
First Trimester:
Limited data, but generally considered low risk for Guaifenesin and Dextromethorphan. Avoid if possible, especially in the first trimester, unless clearly needed.
Second Trimester:
Generally considered safer than first trimester, but still use with caution and only if clearly indicated.
Third Trimester:
Generally considered safer than first trimester, but still use with caution and only if clearly indicated. Dextromethorphan has been used in late pregnancy without clear evidence of harm, but caution is advised.
Lactation
L3 (Moderate risk). Both Guaifenesin and Dextromethorphan are excreted into breast milk in small amounts. Use with caution. Monitor infant for drowsiness or irritability. Consult a healthcare professional.
Infant Risk:
Low to moderate risk. Potential for drowsiness or irritability in the infant, especially with higher doses or prolonged use of Dextromethorphan. Guaifenesin is generally considered compatible with breastfeeding with caution.
Pediatric Use
Not recommended for children under 4 years of age due to potential for serious adverse effects and lack of proven efficacy. For children 4-11 years, use pediatric-specific formulations and follow age-appropriate dosing strictly. Always use a measuring device.
Geriatric Use
Use with caution in elderly patients, as they may be more susceptible to the sedative and anticholinergic effects of Dextromethorphan. Start with the lower end of the adult dosing range and monitor for adverse effects. Consider co-morbidities and polypharmacy.
Clinical Information
Clinical Pearls
- Tusnel Diabetic Liquid is sugar-free, making it a suitable option for patients with diabetes or those avoiding sugar.
- Advise patients to stay well-hydrated to maximize the expectorant effect of guaifenesin.
- Counsel patients on the risk of serotonin syndrome, especially if they are taking other serotonergic medications or MAOIs. Emphasize the 14-day washout period for MAOIs.
- Warn patients about potential drowsiness and dizziness, and advise caution when driving or operating machinery.
- Over-the-counter cough and cold products should not be used in children under 4 years of age.
- Patients should seek medical attention if cough persists for more than 7 days, recurs, or is accompanied by fever, rash, or persistent headache.
Alternative Therapies
- Single-ingredient Guaifenesin (for chest congestion only)
- Single-ingredient Dextromethorphan (for cough suppression only)
- Non-pharmacological measures (e.g., humidifiers, saline nasal sprays, honey for cough)
- Other antitussives (e.g., benzonatate, codeine/hydrocodone - prescription only)
- Other expectorants (e.g., N-acetylcysteine - prescription/specific indications)
Cost & Coverage
Average Cost:
Typically $5-$15 per 4 fl oz (118 mL) bottle
Generic Available:
Yes
Insurance Coverage:
Over-the-counter (OTC) products are generally not covered by prescription insurance plans, but may be eligible for FSA/HSA reimbursement.
General Drug Facts
If your symptoms or health issues persist or worsen, it's essential to contact your doctor for further guidance. To ensure your safety, never share your medication with others or take someone else's medication. Some medications may come with an additional patient information leaflet, so be sure to check with your pharmacist for more information. If you have any questions or concerns about your medication, don't hesitate to reach out to your doctor, nurse, pharmacist, or other healthcare provider. In the event of a suspected overdose, immediately call your local poison control center or seek medical attention. When seeking help, be prepared to provide details about the medication, including the amount taken and the time it happened, to ensure you receive the best possible care.