Is it safe to give Macbery syrup (containing Chlorpheniramine Maleate and dextromethorphan Hydrobromide) to a 75-year-old female patient with bronchial asthma and a current cold and cough, who is already taking Foracort (formoterol and budesonide)?

No, Macbery syrup should NOT be given to this patient

Dextromethorphan and chlorpheniramine are contraindicated or highly problematic in elderly asthmatics, particularly during an acute respiratory illness that may trigger bronchospasm.

Critical Safety Concerns

Dextromethorphan in Asthma

• Dextromethorphan has limited to no efficacy for cough due to upper respiratory infections (URIs) and is not recommended for this indication 1
• While dextromethorphan may provide short-term symptomatic relief in chronic bronchitis, there is no evidence supporting its use in asthma-related cough 1
• The ACCP guidelines explicitly state that in patients with acute cough due to URI, central cough suppressants like dextromethorphan have limited efficacy and are not recommended (Grade D recommendation) 1

Chlorpheniramine (First-Generation Antihistamine) Risks

• First-generation antihistamines can cause significant anticholinergic effects including bronchial secretion thickening, which is particularly dangerous in asthmatics 1
• These agents can impair mucociliary clearance and potentially worsen airway obstruction in patients with reactive airway disease
• In elderly patients (75 years old), anticholinergic side effects are amplified, including confusion, urinary retention, and increased fall risk

Age-Specific Concerns

• Beta-agonist response declines with advancing age, making elderly asthmatics more vulnerable to respiratory complications 1
• The British Thoracic Society specifically warns that elderly patients require careful consideration when prescribing respiratory medications 1

Recommended Alternative Approach

Immediate Management

• Continue and optimize her current Foracort (budesonide/formoterol) regimen - this combination is evidence-based for asthma control 2, 3, 4
• Consider using budesonide/formoterol as both maintenance and reliever therapy if cough worsens, as this strategy reduces exacerbations by 54% compared to inhaled corticosteroid alone 3

If Cough Suppression is Absolutely Necessary

• Only after ruling out asthma exacerbation as the cause of increased coughing, codeine (not dextromethorphan) may be considered for very short-term use (a few days maximum) in chronic bronchitis-type cough [1, @19@]
• However, this should be a last resort and only if the cough is severely impacting quality of life and not responding to optimized asthma therapy

Proper Evaluation Required

• Assess whether this represents an asthma exacerbation requiring increased inhaled corticosteroid dosing or short course of oral corticosteroids 1
• Rule out post-nasal drip/upper airway cough syndrome (UACS) as the cause, which would require different treatment 1
• Evaluate for gastroesophageal reflux disease (GERD) if cough persists despite asthma optimization 1

Key Clinical Pitfall to Avoid

The most dangerous error here is treating what appears to be a simple "cold and cough" with over-the-counter combination medications in an elderly asthmatic. The ACCP guidelines explicitly state that over-the-counter combination cold medications (with exception of older antihistamine-decongestant combinations) are not recommended until proven effective in randomized trials (Grade D recommendation) 1. This patient's increased coughing may represent:

• An asthma exacerbation triggered by viral URI
• Inadequate asthma control
• A complication requiring medical reassessment

The doctor should reassess this patient's asthma control and optimize her existing inhaled corticosteroid/long-acting beta-agonist therapy rather than adding a potentially harmful cough suppressant combination 1, 5.