Arzneimittelforschung 2008; 58(11): 557-568
DOI: 10.1055/s-0031-1296557
Local Anaesthetics
Editio Cantor Verlag Aulendorf (Germany)

Efficacy and Safety of Ambroxol Lozenges in the Treatment of Acute Uncomplicated Sore Throat

EBM-based clinical documentation
Christian de Mey
1   ACPS – Applied Clinical Pharmacology Services, Mainz-Kastel, Germany
,
Hubertus Peil
3   Boehringer Ingelheim Pharma GmbH & Co. KG, Medical Services Department, Ingelheim am Rhein, Germany
,
Stephan Kölsch
2   Boehringer Ingelheim GmbH, Corporate Division Medicine, Group Consumer Health Care, Ingelheim am Rhein, Germany
,
Jürgen Bubeck
2   Boehringer Ingelheim GmbH, Corporate Division Medicine, Group Consumer Health Care, Ingelheim am Rhein, Germany
,
Jean-Michel Vix
2   Boehringer Ingelheim GmbH, Corporate Division Medicine, Group Consumer Health Care, Ingelheim am Rhein, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
19 December 2011 (online)

Abstract

Sore throat is the hallmark of acute pharyngitis. Although usually caused by viral infections, it is frequently treated with antibiotics. Such inappropriate use of antibiotics might best be challenged by offering efficacious and safe symptomatic pain relief instead. However, there is need for robust evidence to support such alternatives.

Presently, the evidence from randomised, placebo-controlled, double-blind clinical trials (RCT) with the local anaesthetic ambroxol (CAS 23828-92-4) in the treatment of sore throat is being reviewed. This relates to five RCT in 1,772 patients; 1,713 were evaluable with regard to efficacy. Treatment with ambroxol lozenges was statistically significantly superior to placebo in reducing sore throat pain intensity with a high level of consistency of the estimated effect across the different studies. The effect had an early onset and lasted up to at least 3 h after a single first lozenge. The pain relief was associated with a statistically superior regression of pharyngeal redness and inflammation; with ambroxol, the overall efficacy was more frequently rated as at least “good”.

Treatment with the ambroxol lozenges was well tolerated. There was heterogeneity in reporting adverse events: in one later study with less severe baseline pain intensity there was more frequent reporting of hypoaesthesia of the oral cavity and tongue as an untoward phenomenon. In patients with more severe baseline pain this reflection of the medication’s pharmacological action was only rarely reported as untoward.

It is concluded that lozenges containing 20 mg ambroxol are a safe and efficacious treatment for acute uncomplicated sore throat of recent onset in adult patients.

 
  • References

  • 1 Haverkorn M, Goslings WRJ, Valkenburg HA. Streptococcal pharyngitis in the general population. A controlled study of streptococcal pharyngitis and its complications in the Netherlands. J Infect Dis. 1971; 124: 339-47
  • 2 Bridges-Webb C, Britt H, Miles DA, Neary S, Charles J, Traynor V. Morbidity and treatment in general practice in Australia. Aust Fam Physician. 1993; Mar 22: 336-9 342–6
  • 3 Valkenburg HA, Haverkorn MI, Goslings WRO, Lorrier JC, de Moor CE, Maxted WR. Streptococcal pharyngitis in the general population: 2. The attack rate of rheumatic fever and acute glomerulonephritis in patients not treated with penicillin. J Infect Dis. 1971; 124: 348-58
  • 4 Evans CE, McFarlane AH, Norman GR, Neale KA, Streiner DL. Sore throats in adults: Who sees a doctor?. Can Fam Physician. 1982; 28: 453-8
  • 5 Mclsaac WJ, Levine N, Goel V. Visits by adults to general practitioners for the common cold. J Fam Pract. 1998; 47: 366-9
  • 6 Vingilis E, Brown U, Hennen B. Common colds. Reported patterns of selfcare and health care use. Can Fam Physician. 1999; 45: 2644-52
  • 7 SORE THROAT (Differential Diagnosis in Primary Care). Lippincott Williams & Wilkins; 2007 http://wwww.rongdiagnosis.com/symptoms/throat_white_patches/book-causes-4a.htm
  • 8 Ellen R. Wald ER. Antibiotic Treatment of Pharyngitis. Pediatr Rev. 2001; 22: 255-6
  • 9 De Meyere M, Matthys J. Guideline acute sore throat [Dutch]. Huisarts Nu. 1999; 28: 193-201
  • 10 Dagnelie CF, Zwart S, Balder FA, Romeijnders ACM, Geijer RMM. NHG-standaard Acute Keelpijn (eerste herziening). Huisarts Wet. 1999; 42: 271-8 (Guideline on acute tonsillitis of the Dutch College of General Practitioners, first revision.)
  • 11 Agence Francaise de Securite Sanitaire des Produits de Sante Systemic antibiotic treatment in upper and lower respiratory tract infections: official French guidelines. Clin Microbiol Infect. 2003; 9: 1162-78
  • 12 Finnish Medical Society Duodecim. Sore throat and tonsillitis. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience John Wiley & Sons; 2005. Dec 28
  • 13 National Health Service. CKS-Library. Acute sore throat. Version 1.1 updated October 2008 http://wwwcks.library.nhs.uk/sore_throat_acute/view_whole_guidance
  • 14 Management of Sore Throat and Indications for Tonsillectomy. SIGN Publication No. 34 1999, ISBN 1899893 66 0, 1999
  • 15 British Columbia Health Services. Diagnosis and management of sore throat. 2003 iskra.bfm.hr/Sore_Throat/sore-throat-british-colombia.pdf
  • 16 Institute for Clinical Systems Improvement (ICSI). Acute pharyngitis. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2005 May.
  • 17 University of Michigan Health System. Pharyngitis. Ann Arbor (MI): University of Michigan Health System; 2006 Oct.
  • 18 Bisno AL, Gerber MA, Gwaltney Jr JM, Kaplan EL, Schwartz RH. for the Infectious Disease Society of America. Diagnosis and management of group A streptococcal pharyngitis: a practice guideline. Clin Infect. 1997; 25: 574-83
  • 19 Bisno AL, Gerber MA, Gwaltney Jr JM, Kaplan EL, Schwartz RH. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis. 2002; 35 (2) 113-25
  • 20 Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR. American Academy of Family Physicians; American College of Physicians-American Society of Internal Medicine; Centers for Disease Control. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med. 2001; 134: 506-8
  • 21 Cooper RJ, Hoffman JR, Bartlett JG, Besser RE, Gonzales R, Hickner JM, Sande MA. Centers for Disease Control and Prevention. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med. 2001; 134: 509-17
  • 22 Center RM, Witherspoon JM, Dalton HP, Brody CE, Link K. De diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981; 1: 239-46
  • 23 Mathhys I, De Meyere M, van Driel ML, De Sutter A. Differences Among International Pharyngitis Guidelines: Not Just Academic. Ann Fam Med. 2007; 5: 436-43
  • 24 Mclsaac WJ, Goel V. Sore throat management practices of Canadian family physicians. Fam Pract. 1997; 14: 34-9
  • 25 Holmberg SD, Faich GA. Streptococcal pharyngitis and acute rheumatic fever in Rhode Island. JAMA. 1983; 250: 2307-12
  • 26 Poses RM, Cebul RD, Wigton RS. You can lead a horse to water — improving physicians’ knowledge of probabilities may not affect their decisions. Med Decis Making. 1995; 15: 65-76
  • 27 Infectious Diseases and Immunization Committee, Canadian Paediatric Society. Group A Streptococcus: a re-emergent pathogen. Can Med Assoc J. 1993; 148: 1909-11
  • 28 Dajani A, Taubert K, Ferrieri P, Peter G, Shulman S. Treatment of acute streptococcal pharyngitis and prevention of rheumatic fever: a statement for health professionals. Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, the American Heart Association. Pediatrics. 1995; 96: 758-64
  • 29 Hart WJ. Streptococcal pharyngitis. A demonstration of the inaccuracy of clinical diagnosis without culture. Can Fam Physician. 1976; 22: 34-9
  • 30 Shank JC, Powell TA. A five-year experience with throat cultures. J Fam Pract. 1984; 18: 857-63
  • 31 Mainous III AG, Hueston WJ, Clark JR. Antibiotics and upper respiratory tract infection. Do some folks think there is a cure for the common cold?. J Fam Pract. 1996; 42: 357-61
  • 32 McGregor A, Dovey S, Tilyard M. Antibiotic use in upper respiratory tract infections in New Zealand. Fam Pract. 1995; 12: 166-70
  • 33 Touw-Otten FWM, Staehr Johansen K. Diagnosis, antibiotic treatment and outcome of acute tonsillitis: report of a WHO regional office for Europe study in 17 European countries. Fam Pract. 1992; 9: 255-67
  • 34 Klajokvic M. Sore throat presentation and management in general practice. N Z Med J. 1993; 106: 381-3
  • 35 Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians. A national survey 1989–1999. JAMA. 2001; 286: 1181-6
  • 36 Del Mar C. Managing sore throat: a literature review. II. Do antibiotics confer benefit?. Med J Aust. 1992; 156: 644-9
  • 37 Del Mar CB, Glasziou PR. Do antibiotics shorten the illness of sore throat? The Cochrane Library. In: Douglas R, Berman S, Black RE, et al (eds). Acute Respiratory Infections Module of The Cochrane Database of Systematic Reviews. 1996
  • 38 Mclsaac WJ, David White D, Tannenbaum D, Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. Can Med Assoc J. 1998; 158: 75-83
  • 39 Pichichero ME, Disney FA, Talpey WB, Green JL, Francis AB, Roghmann KJ et al. Adverse and beneficial effects of immediate treatment of Group A beta-hemolytic streptococcal pharyngitis with penicillin. Pediatr Infect Dis J. 1987; 6: 635-43
  • 40 Middleton DB, D’Amico F, Merenstein JH. Standardized symptomatic treatment versus penicillin as initial therapy for streptococcal pharyngitis. J Pediatr. 1985; 106: 870-4
  • 41 Del Mar CB, Glasziou PR, Spinks AB Antibiotics for sore throat. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD000023.
  • 42 Petersen I, Johnson AM, Islam A, Duckworth G, Livermore DM, Hayward AC. Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007; 335: 982-4
  • 43 Ohlsson A, Clark K. Antibiotics for sore throat to prevent rheumatic fever: Yes or No? How the Cochrane Library can help. CMAJ 28. 2004; 171 (7) 721-5
  • 44 Taylor JL, Howie JG. Antibiotics, sore throats and acute nephritis. J R Coll Gen. Pract. 1983; 33: 783-6
  • 45 Mclsaac WJ, Goel V. Sore throat practices of Canadian family physicians. Fam Pract. 1997; 14: 34-9
  • 46 Arthur JD, Bass JW, York WB. How is suspected streptococcal pharyngitis managed? A study of what physicians actually think and do. Postgrad Med J. 1984; 75: 241-8
  • 47 Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ. 1997; 315: 1211-4
  • 48 Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N. Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. BMJ. 1998; 317: 637-42
  • 49 Dosh SA, Hickner JM, Mainous 3rd AG, Ebell MH. Predictors of antibiotic prescribing for nonspecifi c upper respiratory infections, acute bronchitis, and acute sinusitis. An UPRNet study. Upper Peninsula Research Network. J Fam Pract. 2000; 49: 407-14
  • 50 Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study. BMJ. 2004; 328: 444-7
  • 51 van Driel ML, De Sutter A, Deveugele M, Peersman W, Butler CC, De Meyere M, De Maeseneer J, Christiaens T. Are Sore Throat Patients Who Hope for Antibiotics Actually Asking for Pain Relief?. Ann Fam Med. 2007; 4: 494-9
  • 52 Bertin L, Pons G, d’Athis P, Lasfargues G, Maudelonde C, Duhamel JF et al. Randomized, double-blind, multicenter, controlled trial of ibuprofen versus acetaminophen (paracetamol) and placebo for treatment of symptoms of tonsillitis and pharyngitis in children. J Pediatr. 1991; 119: 811-4
  • 53 Schachtel BP, Fillingim JM, Lane AC, Thoden WR, Baybutt RI. Caffeine as an analgesic adjuvant. A double-blind study comparing aspirin with caffeine to aspirin and placebo in patients with sore throat. Arch Intern Med. 1991; 151: 733-7
  • 54 Schachtel BP, Fillingim JM, Thoden WR, Lane AC, Baybutt RI. Sore throat pain in the evaluation of mild analgesics. Clin Pharmacol Ther. 1988; 44: 704-11
  • 55 Schachtel BP, Thoden WR. A placebo-controlled model for assaying systemic analgesics in children. Clin Pharmacol Ther. 1993; 53: 593-601
  • 56 Schachtel BP, Cleves GS, Konerman JP, Brown AT, Markham AO. A placebo-controlled model to assay the onset of action of nonprescription-strength analgesic drugs. Clin Pharmacol Ther. 1994; 55: 464-70
  • 57 Sauvage JP, Ditisheim A, Bessede JP, David N. Double-blind, placebo-controlled, multi-centre trial of the efficacy and tolerance of niflumic acid (Nifluril) capsules in the treatment of tonsillitis in adults. Curr Med Res Opin. 1990; 11: 631-7
  • 58 Benarrosh C. Multicenter double blind study of tiaprofenic acid versus placebo in tonsillitis and pharyngitis in children. Arch Pediatr. 1989; 46: 541-6
  • 59 Manach Y, Ditisheim A. Double-blind, placebo-controlled multicentre trial of the efficacy and tolerance of morniflu-mate suppositories in the treatment of tonsillitis in children. J Int Med Res. 1990; 18: 30-6
  • 60 O’Brien JF, Meade JL, Falk JL. Dexamethasone as adjuvant therapy for severe acute pharyngitis. Ann Emerg Med. 1993; 22: 212-5
  • 61 Wunderer H. Mund- und Rachentherapeutika. Dtsch Apoth Ztg. 1986; 26: 2281-92
  • 62 Fastnacht S. Mund- und Rachentherapeutika. PTA Apoth. 1993; 22 (12)
  • 63 Bernstein J, Nelson F. A double-blind evaluation of an aspirin containing gum tablet for relief of the pain of common sore throat. J Int Med Res. 1974; 2: 76-80
  • 64 Blagden M, Christian J, Miller K, Charlesworth A. Multidose flurbiprofen 8.75 mg lozenges in the treatment of sore throat: a randomised, double-blind, placebo-controlled study in UK general practice centres. Int J Clin Pract. 2002; Mar 56 (2) 95-100
  • 65 Watson N, Nimmo WS, Christian J, Charlesworth A, Speight J, Miller K. Relief of sore throat with the anti-inflammatory throat lozenge flurbiprofen 8.75 mg: a randomised, double-blind, placebo-controlled study of efficacy and safety. Int J Clin Pract. 2000; Oct 54 (8) 490-6 Erratum in: Int J Clin Pract. 2000;54(10):686
  • 66 Schachtel BP, Homan HD, Gibb IA, Christian J. Demonstration of dose response of flurbiprofen lozenges with the sore throatpain model. Clin Pharmacol Ther. 2002; May 71 (5) 375-80
  • 67 Flurbiprofen: new indication Lozenges: NSAIDs are not to be taken like sweets!. Prescrire Int. 2007; Feb 16 (87) 13-
  • 68 Becker DE, Reed KL. Essentials of local anesthetic pharmacology. Anesth Prog. 2006; 53: 98-109
  • 69 Butterworth IV JF. Clinical aspects of local anesthesia. In: Bailin MT. ed. HEAL: Harvard Electronic Anesthesia Library. Philadelphia: Lippincott Williams &Wilkins; 2001
  • 70 Wonnemann M, Helm I, Stauss-Grabo M, Röttger-Luer P, Tran CT, Canenbley R et al. Lidocaine 8 mg sore throat lozenges in the treatment of acute pharyngitis. A new therapeutic option investigated in comparison to placebo treatment. Arzneimittelforschung. 2007; 57 (11) 689-97
  • 71 Kagan G, Huddlestone L, Wolstencroft P. Two lozenges containing benzocaine assessed in the relief of sore throat. J Int Med Res. 1982; 10: 443-6
  • 72 Dempster JH. Post-tonsillectomy analgesia: the use of benzocaine lozenges. J Laryngol Otol. 1988; Sep 102 (9) 813-4
  • 73 Fuller PB. The relationship between preintubation lidocaine and postanesthesia sore throat. AANA J. 1992; 60: 374-8
  • 74 Klemola UM, Sarrnivaara L, Yrjola H. Post-operative sore throat: effect of lignocaine jelly and spray with endotracheal intubation. Eur J Anaesthesiol. 1988; 5: 391-9
  • 75 Nathan A. Colds and sore throats. Pharm J. 1996; 256: 24-7
  • 76 Bircher AJ, Messmer SL, Surber C, Rufli T. Delayed-type hypersensitivity to subcutaneous lidocaine with tolerance to articaine: confirmation by in vivo and in vitro tests. Contact Dermatitis. 1996; 34: 387-9
  • 77 Guerriero SE. Methemoglobinemia caused by topical benzocaine. Pharmacotherapy. 1997; 17: 1038-40
  • 78 Tush GM, Kuhn R J. Methemoglobinemia induced by an over-the-counter medication. Ann Pharmacother. 1996; 30: 1251-4
  • 79 Coleman MD, Coleman NA. Drug induced methaemoglo-binemia. Treatment issues. Drug Saf. 1996; 14: 394-405
  • 80 Edwards C, Stillmann P. Sore throats and colds. Pharm J. 1993; 250: 731-4
  • 81 Kramer A, Hoeppe H, Krull B, Pitten FA, Rosenau S. Antiseptic efficacy and acceptance of Octenisept computed with common antiseptic mouthwashes. Zentralbl Hyg Um-weltmed. 1997; Jan 200: 443-56
  • 82 Giuliana G, Pizzo G, Milici ME, Musotto GC, Giangreco R. In vitro antifungal properties of mouthrinses containing antimicrobial agents. J Periodontal. 1997; 68: 729-33
  • 83 Chadwick B, Addy M, Walker DM. Hexetidine mouthrinse in the management of minor aphthous ulceration and as adjunct to oral hygiene. Br Dent J. 1991; 171: 83-7
  • 84 Petersen JK. Complications in patients on therapeutic drugs. Int Dent J. 1986; 36: 83-6
  • 85 Weisdorf DJ, Bostrom B, Raether D, Mattingly M, Walker P Pihlstrom B et al. Oropharyngeal mucositis complicating bone marrow transplantation: prognostic factors and the effect of Chlorhexidine mouth rinse. Bone Marrow Transplant. 1989; 4 (l) 89-95
  • 86 Tyrakowski T, Greczko I, Sedlaczek A, Banach B, Bartlomwicz M, Wojciechowska M et al. Electrophysiological investigation of the effects of Ambroxol on the transepithelial Na+ ion transport pathway in airways. Pol J Pharmacol. 1998; Jan-Feb 50 (1) 31-8
  • 87 Weiser T, Wilson N. Inhibition of tetrodotoxin (TTX)-resistant and TTX-sensitive neuronal Na(+) channels by the se-cretolytic ambroxol. Mol Pharmacol. 2002; Sep 62 (3) 433-8
  • 88 Schutz A, Grund HJ, Pschorn U, Aicher B, Peil H, Müller A et al. Gillissen A. Local anaesthetic properties of ambroxol hydrochloride lozenges in view of sore throat: Clinical proof of concept. Arzneimittelforschung. 2002; 52: 194-9
  • 89 Fischer I, Pschorn U, Vix JM, Peil H, Aicher B, Müller A et al. Efficacy and tolerability of ambroxol hydrohloride lozenges in sore throat: Randomised, double-blind, placebo-controlled trials regarding the local anaesthetic properties. Arzneimittelforschung. 2002; 52: 256-63
  • 90 Thomas M, Del Mar C, Glasziou P. How effective are treatments other than antibiotics for acute sore throat?. Br J GenPract. 2000; 50: 817-20
  • 91 Flurbiprofen: new indication Lozenges: NSAIDs are not to be taken like sweets!. Prescrire Int. 2007; Feb 16 (87) 13-
  • 92 Disse BG. The pharmacology of Ambroxol – review and new results. Eur J Respir Dis. 1987; 153 (Suppl) 255-62
  • 93 Disse BG, Ziegler HW. Pharmacodynamic mechanism and therapeutic activity of Ambroxol in animal experiments. Respiration. 1987; 51 Suppl (1) 15-22
  • 94 Pfeifer S, Zissel G, Kienast K, Müller-Quernheim J. Reduction of cytokine release of blood and broncheoalveolar mononuclear cells by Ambroxol. Eur J Med Res. 1997; 2 (3) 129-132
  • 95 Gillissen A, Bartling A, Schoen S, Schultze-Werninghaus G. Antioxidant function of Ambroxol in mononuclear and polymorphnuclear cells in vitro. Lung. 1997; 175: 235-42
  • 96 Felix K, Pairet M, Zimmermann R. The antioxidative activity of the mucoregulatory agents: Ambroxol, bromhexine and N-acetyl-L-cysteine. A pulse radiolysis study. Life Sci. 1996; 59: 1141-7
  • 97 Lapenna D, de Gioia S, Ciofani G, Cucurullo F. Ambroxol is a scavenger of hypochlorous acid and monochloramine. Pharmacology. 1994; 49: 132-5
  • 98 Gillissen A, Hinkel U. Treatment of sore throat with ambroxol lozenges. Results of a community-based observational study (PHOBS). MMP. 2005; 28: 399-402