Risk of major birth defects after first-trimester exposure to carbocisteine and ambroxol: A multicenter prospective cohort study using counseling data for drug safety during pregnancy

To assess the risk of major birth defects after first-trimester exposure to carbocisteine and ambroxol during pregnancy, we conducted a prospective cohort study using counseling data for drug use during pregnancy provided by the Japan Drug Information Institute in Pregnancy and Toranomon Hospital. Counseling information, including drug usage and participants' demographic information, was collected between April 1988 and December 2017. Pregnancy outcome data, including major birth defects, were obtained using a questionnaire administered 1 month after delivery. The risks of major birth defects after first-trimester exposure to carbocisteine (n = 588) and ambroxol (n = 341) were compared with those of nonteratogenic drug use during the first trimester (n = 1525). The adjusted odds ratio (aORs) for major birth defects was calculated using a multiple logistic regression analysis adjusted for confounders. The incidence of major birth defects was 1.2% (7/588) and 2.1% (7/341) in the carbocisteine and ambroxol groups, respectively, which was comparable to the control group (26/1525, 1.7%). Results of multiple logistic regression demonstrated similar nonsignificant risks for both carbocisteine (aOR: 0.66, 95% confidence interval [CI]: 0.40-1.1, p = 0.11) and ambroxol (aOR: 1.1, 95% CI: 0.18-7.2, p = 0.88). No specific major birth defects were reported in the carbocisteine or ambroxol groups. This study demonstrated that carbocisteine and ambroxol exposure during the first trimester was not associated with an increased risk of major birth defects. These results could help in counseling for the use of these drugs during pregnancy and further alleviate anxiety in patients.

Avoiding the prenatal programming effects of glucocorticoids: are there alternative treatments for the induction of antenatal lung maturation?

BACKGROUND

The long-term outcomes of antenatal glucocorticoids (GCs) vary between reports, and have generated controversy in terms of repeated and single-course events, causing irreversible effects on endocrine set points.

AIM

This study aimed to assess the effects of alternative therapeutic agents other than synthetic glucocorticoid GC administration for fetal lung maturation.

METHODS

A review of literature from PubMed, EMBASE, Cochrane Library, and Google Scholar was conducted to assess the use of alternative therapies to synthetic GCs using recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). End points included the rates of respiratory distress syndrome (RDS), mRNA expression for pneumocyte type II, concentration of surfactant proteins in alveolar lavage, morphological differences, histological proof of lung maturation, and angiogenesis or quantification of the surfactant pool.

RESULTS

In all 41 studies examined, we found that ambroxol showed positive effects on lung maturation, but it has yet to be analyzed with sufficient significance in humans. Interleukins and TNF-alpha produce accelerated lung maturation, but have only been evaluated in basic research/experimental studies. Growth factors promote structural and functional growth in all phases of lung maturation, but little is known about their reciprocal effects and exact mechanisms as therapeutics. Thyroid releasing hormone or vitamin A cause detrimental side effects or were less effective for lung maturation.

CONCLUSIONS

The efficacy and safety of these alternative agents are differentiated and none up to now can be recommended as an alternative to GCs.

Ambroxol as a pharmacological chaperone for mutant glucocerebrosidase

Gaucher disease (GD) is characterized by accumulation of glucosylceramide in lysosomes due to mutations in the GBA1 gene encoding the lysosomal hydrolase β-glucocerebrosidase (GCase). The disease has a broad spectrum of phenotypes, which were divided into three different Types; Type 1 GD is not associated with primary neurological disease while Types 2 and 3 are associated with central nervous system disease. GCase molecules are synthesized on endoplasmic reticulum (ER)-bound polyribosomes, translocated into the ER and following modifications and correct folding, shuttle to the lysosomes. Mutant GCase molecules, which fail to fold correctly, undergo ER associated degradation (ERAD) in the proteasomes, the degree of which is one of the factors that determine GD severity.

Several pharmacological chaperones have already been shown to assist correct folding of mutant GCase molecules in the ER, thus facilitating their trafficking to the lysosomes. Ambroxol, a known expectorant, is one such chaperone. Here we show that ambroxol increases both the lysosomal fraction and the enzymatic activity of several mutant GCase variants in skin fibroblasts derived from Type 1 and Type 2 GD patients.

Ambroxol lozenges: new drug. Sore throat: better to just suck on hard candy

No more relief than from sucking on hard candy for what is a minor, short-lived condition, but lozenges can provoke some adverse effects.

Uric acid plasma level and urine pH in rats treated with ambroxol

It was a chance discovery that ambroxol parenteral administration led to urinary bladder stone formation in rats. This study was undertaken to examine the serum uric acid levels and urine pH in rats after ambroxol parenteral treatment. Ambroxol influence on the uric acid level was measured in 5 rats (Rattus sp.) treated with 60 mg/kg (dissolved in injection water, sc, daily) during 2 weeks. Ambroxol influence on urine pH was examined on 45 rats divided into 3 groups. Rats from the 1st and 2nd group received 30 and 60 mg/kg/24h ambroxol, respectively. Urine was collected once daily and measured with strip kit. All values were presented as the means with standard deviations. The Student t test was used to compare the means, p < 0.05 was considered as significant. Dynamics of pH changes was measured in 4 rats treated with 60 mg/kg/24h of ambroxol. Controls received 1 mL of injection water sc. Serum uric acid level increased up to 8.7 +/- 1.0 mg/dL vs. 5.7 +/- 1.0 mg/dL in control (p < 0.002). In the 1st and 2nd group urine pH increased up to 7.5 +/- 0.5 and 7.6 +/- 0.5 vs. 6.7 +/- 0.4 (p < 0.05). Ambroxol withdrawal resulted in sequential urine pH decrease. 11 days after interruption of ambroxol therapy pH reached the starting value. Urine pH changes and possible disturbances in uric acid metabolic pathway may influence on the stone formation in rats after ambroxol parenteral treatment. The influence of ambroxol on urinary tract GAG layer and the balance between xanthine and CaOx in the urine should be checked.

Parenteral ambroxol treatment causes xanthine and calcium oxalate stones in rats

INTRODUCTION

Ambroxol (ABX) is known to promote bronchial secretion and is used as an expectorant. This study was undertaken to document the connection between ambroxol parenteral treatment and bladder stones in rats.

MATERIAL AND METHODS

Forty-five wild rats (Rattus sp.) were divided into three equal groups. Rats from the first and second groups received ABX s.c. during 2 weeks in total doses of 30 mg/kg per 24 h and 60 mg/kg per 24 h, respectively. Rats from the control group received 1 mL of injection solution s.c. One month after the treatment termination, animals were sacrificed and urinary tracts without urethra were dissected. Stones found in the bladders were measured, weighed and chemically analysed. Voiding cystography was performed to exclude pathology of the lower urinary tract. Photo documentation was produced.

RESULTS

From the first and second groups, 33% and 47% of rats, respectively, had solitary stones in the bladder. In one case from the second group, there was a huge stone in the bladder and urethra. There were no stones in rats from the control group. The mean length of stones was 1.38 +/- 0.23 mm and 1.41 +/- 0.60 mm in the first and second groups, respectively. Mean stone weight was 1.2 +/- 0.2 x 10(-3) g and 1.44 +/- 0.54 x 10(-3) g. Stones were composed of 67% of xanthine and 33% of calcium oxalate.

CONCLUSIONS

Ambroxol parenteral treatment caused xanthine and oxalate stone formation. Attention should be paid to the possibility of urinary stone formation after long-term ABX treatment.

Safety and usage pattern of an over-the-counter ambroxol cough syrup: a community pharmacy-based cohort study

INTRODUCTION

Mucoactive substances such as ambroxol, available in several countries as over-the-counter (OTC) medicines, are used for the treatment of acute and chronic bronchitis.

OBJECTIVE

This study was designed to evaluate the "real life" behavior of consumers with non-prescription access to an ambroxol cough syrup with special focus on tolerability and the pattern of product usage.

METHODS

Customers who bought the ambroxol syrup were recruited in 300 community pharmacies in Germany. Baseline data were collected from the participants in the pharmacy. Completing a self-administered questionnaire, participants provided information on tolerability, self-perceived effectiveness and usage pattern.

RESULTS

2,707 participants were recruited in 266 pharmacies. 2,664 questionnaires were evaluable. At baseline, the respondents reported a complex pattern of symptoms. Productive cough, congested airways, dry cough, cough irritation in the throat and soreness in the throat were the most common ones. 67 patients (2.5%) reported a total of 81 adverse events (AE) which were usually mild in nature and mostly affecting the gastrointestinal tract (n = 53) followed by skin and subcutaneous tissue disorders (n = 9). No serious or unknown AE were reported. In general, 97% of the participants assessed the safety as "very good" (51%) or "good" (46%). Overall, the respondents complied with the indications for use and the recommended dosages, with only 0.7% of the participants using the maximum daily dose. 92% of the patients assessed the self-perceived effectiveness as "very good" (29%) or "good" (63%) and 89% were willing to purchase this ambroxol cough syrup again.

CONCLUSIONS

This study confirms that ambroxol is used according to the advice given in the patients' leaflet and supports the already established safety and efficacy of this product in acute bronchitis. It also demonstrates that the use of an OTC cough medication can be successfully monitored in a pharmacy-based cohort study.

Anémie hémolytique immunoallergique due à l'ambroxol

INTRODUCTION

Drug-induced immune hemolytic anemia is a rare cause of hemolytic anemia.

CASE RECORD

A 68-year-old male patient developed an acute intravascular hemolysis with acute renal failure. Common causes of hemolysis were ruled out and the patient rapidly improved. An immune mechanism was confirmed by the positivity of the direct antiglobulin test with anti-IgA in the presence of ambroxol only, one of the drug the patient had received during 6 days before hospitalization.

DISCUSSION

To our knowledge, this is the first report of ambroxol-induced immune hemolytic anemia. This case also underlined that the direct antiglobulin test should also be performed with anti-IgA to rule out any false negative.

[Efficacy of intravenous or atomizing ambroxol for prevention of respiratory distress syndrome in preterm infants]

OBJECTIVE

Ambroxol induces the synthesis of surfactant in lung alveolar type II cells. Some studies have shown its effectiveness for the prevention of respiratory distress syndrome (RDS) in preterm infants. This study aimed to compare the efficacy of two different ways of ambroxol administration, ie, intravenous injection and atomizing inhalation, for the prevention of RDS in preterm infants.

METHODS

A total of 125 preterm infants born between 28-37 weeks of gestation were randomly assigned into three groups: Intravenous and Atomizing ambroxol treatment groups (n=40 each) or Control group (n=45). The Intravenous group was injected with 15 mg/kg of ambroxol through the umbilical vein immediately after birth and then received 30 mg/kg of ambroxol daily for 2 days by intravenous drip. The Atomizing group was administered with 30 mg/kg of ambroxol daily for 2 days by atomizing inhalation immediately after birth. The Control group received no ambroxol treatment. The incidences of RDS and complications as well as the blood gas results 6 hrs after birth were compared among the three groups.

RESULTS

The incidence of RDS was 7.5%, 5.0% and 24.4% in the Intravenous, Atomizing and Control groups respectively. There were no significant differences in the incidence of RDS between the two ambroxol treatment groups. However, the incidence of RDS in the two treatment groups were noticeably lower than in the Control group (P < 0.05). The blood gas results did not show significant differences between the two ambroxol treatment groups but both groups demonstrated improved blood gas results compared with the Control group at 6 hrs after birth (P < 0.05). The incidence of complications, such as pulmonary hemorrhage, respiratory failure, intraranial hemorrhage, in the two ambroxol treatment groups was reduced compared with the Control group (P < 0.05), but there were no differences between the two ambroxol groups.

CONCLUSIONS

Early administration of either intravenous or atomizing ambroxol can produce a positive efficacy for the prevention of RDS in preterm infants. The two different ways of administration seem to result in a similar efficacy in the prevention of RDS.

Efficacy and tolerability of ambroxol hydrochloride lozenges in sore throat. Randomised, double-blind, placebo-controlled trials regarding the local anaesthetic properties

Two confirmatory clinical trials were performed to investigate the efficacy and tolerability of ambroxol lozenges at doses of 20 mg and 30 mg relative to placebo in relieving the symptoms of sore throat of at least moderately severe intensity in patients suffering from oro-pharyngeal catarrh accompanied by pain on swallowing, feeling of scratchiness, burning and urge to cough.

OBJECTIVE

Description and comparison of the efficacy and tolerability of lozenges containing 20 mg or 30 mg ambroxol hydrochloride (trans-4-[(2-amino-3,5-dibrom-benzyl)amino]cyclohexano hydrochloride, CAS 18683-91-5) in relieving acute sore throat, in comparison to placebo.

DESIGN

Two similar, multi-centre, prospective, placebo-controlled, randomised, double-blind trials involving three days of treatment with up to 6 lozenges containing 20 or 30 mg ambroxol hydrochloride per day.

SUBJECTS

There were enrolled three-hundred-thirty-one (331, study I) and three-hundred-eighty-three (383, study II) outpatients with acute uncomplicated sore throat of at least moderately severe intensity which is not suspected to be due to bacterial pharyngitis.

TREATMENTS

Double-blind treatment with up to six lozenges per day containing either 20 mg or 30 mg ambroxol hydrochloride or placebo (a lozenge with a distinct minty flavour).

MAIN OUTCOME MEASURES

The time-weighted average pain relief over the first 3 h after the first lozenge as a ratio of the baseline pain intensity of sore throat (SPIDnorm) and the patients' evaluation of efficacy and tolerability at the end of each day of the three days treatment.

RESULTS

All treatments led to a reduction of pain intensity; the means (+/- SD) SPIDnorm after the 1st lozenge were 0.53 +/- 0.28 or 0.50 +/- 0.30 or 0.38 +/- 0.28 with 20 mg or 30 mg ambroxol hydrochloride or placebo respectively in study I, and 0.53 +/- 0.30 or 0.60 +/- 0.28 or 0.39 +/- 0.31 in study II; the effect of treatment was statistically significant (p: 0.0002 or p: 0.0033 in study I and p: 0.0005 or p: 0.0001 in study II, respectively, for the comparison of 20 mg or 30 mg ambroxol hydrochloride vs. placebo). The improvement with the active treatments was greater than with placebo (95% confidence interval (CI) estimates of the mean treatment differences vs. placebo were 0.08 to 0.23 or 0.05 to 0.20 for lozenges with 20 mg or 30 mg ambroxol hydrochloride, respectively, in study I, and 0.06 to 0.21 or 0.13 to 0.28 in study II). At the end of each subsequent ambulatory treatment day with up to six lozenges per day, a statistically significantly higher proportion of patients scored a higher level of efficacy for the active treatments with ambroxol hydrochloride compared to placebo. The treatments investigated were equally well tolerated.

CONCLUSIONS

Sucking lozenges containing 20 mg or 30 mg ambroxol hydrochloride has a beneficial pain-relieving effect in patients with acute sore throat, superior to that achieved by sucking a placebo lozenge. While both strengths were equally well tolerated, the higher strength of 30 mg ambroxol hydrochloride did not prove more effective. The findings confirm that the previously discovered local anaesthetic properties of ambroxol hydrochloride do have beneficial clinical implications.

Local anaesthetic properties of ambroxol hydrochloride lozenges in view of sore throat. Clinical proof of concept

Acute oro-pharyngeal catarrh is characterised by mild to severe sore throat, such as pain on swallowing, feeling of scratchiness, burning and urge to cough. The present study was conducted to explore whether the test compound is going to show clinical relevance and is a suitable medication for the relief of these symptoms.

OBJECTIVE

Description and comparison of the efficacy and tolerability of lozenges containing 20 mg ambroxol hydrochloride (trans-4-[(2-amino-3,5-dibrombenzyl)amino]cyclohexano hydrochloride, CAS 18683-91-5) in relieving acute sore throat, in comparison to placebo.

DESIGN

Multi-centre, prospective, placebo-controlled, randomised, double-blind trial involving two days of treatment with up to 6 lozenges containing 20 mg ambroxol hydrochloride per day.

SUBJECTS

Two-hundred-eighteen (218) patients were enrolled (97 males, 121 females, average age: 39.4 +/- 15 years, range: 17-81 years); 215 were treated: 107 with 20 mg ambroxol and 108 with placebo; 26 discontinued prematurely (13 in each treatment group). 208 patients constituted the intent-to-treat (ITT) dataset (105 and 103 for treatment with ambroxol and placebo, respectively); 196 patients constituted the perprotocol (PP) dataset (97 and 99, respectively); all treated patients were part of the dataset for safety analysis.

TREATMENTS

Double-blind treatment with up to 6 lozenges per day containing 20 mg ambroxol hydrochloride or placebo (a lozenge with a distinct minty flavour).

MAIN OUTCOME MEASURES

The time-weighted average pain relief over the first 3 h after the first lozenge as a ratio of the baseline pain intensity of sore throat (SPIDnorm) and the patients' evaluation of efficacy and tolerability at the end of each day of treatment.

RESULTS

Both treatments led to a reduction of pain intensity; the mean (+/- SD) SPIDnorm after the 1st lozenge were 0.39 +/- 0.27 and 0.28 +/- 0.25 for 20 mg ambroxol hydrochloride and placebo, respectively; the treatment effect of ambroxol was statistically significantly superior compared to placebo (p: 0.0029; 95% confidence interval estimate of the mean treatment difference for ambroxol minus placebo: 0.04 to 0.18). At the end of each subsequent ambulatory treatment day with up to 6 lozenges per day, a statistically significantly higher proportion of patients scored a higher level of efficacy for the active treatments with ambroxol hydrochloride compared to placebo. The investigational treatments were equally well tolerated.

CONCLUSIONS

Sucking lozenges containing 20 mg ambroxol hydrochloride has a beneficial pain relieving effect in patients with acute sore throat, superior to that which otherwise can be achieved by sucking a placebo lozenge. This finding confirms that the preclinical local anaesthetic properties of ambroxol hydrochloride may have beneficial clinical implications.

Effects of a short course of treatment with acebrophylline on the mucus rheological characteristics and respiratory function parameters in patients suffering from chronic obstructive pulmonary disease

A total of 30 patients (27 males and 3 females) with a mean age of 62.6 +/- 3.9 years, suffering from chronic obstructive pulmonary disease were recruited into this open study to evaluate the clinical efficacy and the safety of a short course of treatment with 100 mg acebrophylline, twice daily for 14 days. To assess the effectiveness of the drug, symptoms and signs, such as cough intensity and frequency, auscultatory pattern, dyspnoea, cyanosis, difficulty of expectoration, sputum quantity, appearance and density, were evaluated at baseline and after 1, 3, 5, 7, 10 and 14 days of therapy. In addition the rheological properties of the bronchial mucus (viscosity and spinnability) were measured and respiratory function tests were performed before and after treatment. There was a progressive improvement of all evaluated symptoms and signs, resulting in improvement of the auscultatory pattern, as well as dyspnoea. This was accompanied by improvement or normalization of the respiratory function indices, which showed statistically significant differences (P < 0.01) between the baseline and the endpoint values, apart from total lung capacity. Blood-gas analysis demonstrated a significant increase of PaO2 and a significant decrease of PaCO2 values at the end of the treatment period (both P < 0.01). In general, acebrophylline was well tolerated. No clinically relevant or significant changes in any of the routine laboratory parameters were found on comparing the values obtained before and after treatment. Only three patients complained of epigastric pain, but this was not so severe or long-lasting as to require the discontinuation of the treatment.

Prevention of chronic bronchitis exacerbations with ambroxol (mucosolvan retard). An open, long-term, multicenter study in 5,635 patients

Different therapies can be applied for the prevention of chronic bronchitis exacerbations: vaccinations, antibiotics, immunomodulating and mucoregulating drugs. Among the latter, ambroxol was tested in a multicenter open study in 5,635 outpatients during a 6-month winter period. The results achieved in a large and heterogeneous number of patients confirm the positive trend already observed in a multicenter double-blind study versus placebo in 214 patients. Particularly significant is the decrease in the number of exacerbations with time, above all in patients with more than 2-3 episodes. In parallel, the improvement in the clinical pattern, observed through the contemporaneous assessment of respiratory signs and symptoms and of the length of antibiotic therapy, confirms the soundness of the results achieved.

Ambroxol for the prevention of chronic bronchitis exacerbations: long-term multicenter trial. Protective effect of ambroxol against winter semester exacerbations: a double-blind study versus placebo

In a 6-month, double-blind multicenter trial conducted over the winter, the effects of daily administration of ambroxol retard (75 mg) were compared with those of placebo in preventing exacerbations and improving symptoms and clinical signs in chronic bronchitis patients. The trial was completed by 110 patients in the ambroxol group and by 104 in the placebo group. Initially, there were no significant differences between the groups. By the end of the 2nd month of treatment, 67.2% of the ambroxol group had had no exacerbations compared to 50.4% in the placebo group. At the end of the 6-month trial, 45.5% of the treatment group had had no exacerbations, compared to only 14.4% of the control group. These differences were statistically significant. Patients in the treatment group lost significantly fewer days through illness (442) and had fewer days when they needed antibiotic therapy (371) compared to the placebo group patients (837 and 781). Ambroxol also produced statistically significant symptomatic improvement, measured as difficulty in expectoration, coughing, presence of dyspnea and the auscultatory signs as compared to controls. Since ambroxol was well tolerated and compliance was good, it appears like a drug of choice for pharmacological prophylaxis of chronic bronchitis.

Lack of effect of ambroxol, a bronchial secretolytic agent, on gastric mucus in man

The effect of ambroxol, a bronchial mucolytic agent, on gastric mucus was investigated in man. Ten patients with bronchial hypersecretion were treated with ambroxol 30 mg t.i.d. by the oral route for 10 days. Before and after treatment the amount of total mucoproteins in the gastric juice was measured and a 'mucoprotective index' was calculated. Neither quantitative nor qualitative changes in gastric mucus were observed after ambroxol treatment. Our results show that the drug does not exert lytic effects on the gastric mucus layer and hence is devoid of damaging activity on the gastric mucosa.

[Hemostatic disorders with secretolytics? A contribution to drug safety]

Based on literature and on the results of this open clinical trial we conclude, that there is no connection between application of the above named group of drugs and the change in parameters of haemostasis function, which might lead to a manifest haemorrhagic diathesis. Within the period surveyed of 14 days no case of induced coagulopathy and particularly no thrombocytopenia was seen. The substances under consideration themselves did not exert any anticoagulatory effect nor did they potentiate or inhibit the effect of a concurrently given cumarin derivative.