Two pharmacists figured out that oral phenylephrine doesn't work

I feel like I'm living under a rock, how is everyone in these comments so intimately familiar with this subject? I've never heard the word "phenylephrine" in my life.

You may not know the word "phenylephrine", but you almost certainly know Sudafed (and perhaps its generic name, pseudoephedrine).

If you live in the US or several other places, you probably know that the "good" Sudafed is kept behind the counter, and you have to sign for it. You may have also noticed that there is another version, called "Sudafed PE", that you can just pick up off the shelf.

A lot of people have done that and concluded for themselves that the PE version didn't work. That's why there are so many people commenting that they already knew the thing the article is about.

So... a lot of people were familiar with "PE", and apparently a lot of them knew that it stood for "phenylephrine". And it all touches on a bunch of existing controversy about why the effective medication is locked up.

It wasn't always. People knew that Sudafed was an pretty effective drug. (It was even used, under a different brand, on Apollo missions -- there was a TV ad with an astronaut endorsing it.) A lot of people are grumpy that a well-known effective medicine was made hard to get, and something else sneakily substituted.

The point being, it's not entirely a surprise that people are aware of the phenylephrine -- especially if they're older than, say, 40, and live in the United States. They remember, sniffily, when cold medicine started to suck.

you probably know that the "good" Sudafed is kept behind the counter, and you have to sign for it.

In my state, that's not how it works. You have to have a doctor's prescription to get it, which means you have to have a doctor -- and getting a doctor is incredibly difficult.

Ugh, that's even worse. (Looks like that's Oregon and Mississippi, for anyone else curious.)

There's really no reason this shouldn't be OTC.

What's even worse than that is that the only allergy medicine that was really effective for me is no longer manufactured at all, because one of the ingredients was pseudoephedrine. Once these stupid regulations came into effect, sales of it plummeted to the point where it was no longer worth making it.

For years, I had friends in other countries buy it and mail it to me, but that's no longer an option at all.

What are the other ingredients? I suspect one is Benadryl (diphenhydramine) and that's still OTC in the US.

As a connoisseur of alergy meds, I'm also stumped. I know many allergy meds were sold as 'D' formulations that included pseudoephedrine, but I wasn't aware of any sold exclusively that way.

Benedryl is what I switched to. It took a long time to get acclimatized to it enough that I wasn't perpetually on the edge of going to sleep!

It was Drixoral, which is a combination of pseudoephedrine and dexbrompheniramine. You can get dexbrompheniramine OTC and combine it with pseudoephedrine and it's OK -- but not quite the same because Drixoral was a time release thing.

I wonder if your doctor could get a compounding pharmacy to make it for you? That is an option sometimes.

Probably, but that would require a prescription and I've not yet been able to find a primary care doctor (there is an acute shortage of them around here).

This is a fantastic write up and as for anecdotal confirmation, an award winning career journalist cited his “on deadline” setup was a box of Sudafed and a pot of Coffee, then a bottle of Jack Daniels once it was all in. Very effective compound and I also didn’t know the PE longhand…only went to the counter…

I can’t even imagine this combo; I can barely tolerate Sudafed alone.

It’s like drinking 15 cups of espresso all at once for me. Jittery; quick tempered; but a clear head and nose. Good with the bad when you’re ill but holy fuck would it be brutal without the head cold + alcohol + caffeine.

My wife and I find that taking a whole 120mg (12 hour) pill makes us too jittery, but they're easily broken in half, and half a pill gives acceptable decongestant effects while making the side effects a bit better.

A little red sudafed and a caffeine pill was my normal cram session. I thought it was the stimulant effect for years until I was diagnosed with adhd and my doc said what I was doing is called the sudafed test. If it helps you focus, you have adhd. I was self medicating without realizing it. It wasn't a great idea, it has more side effects than the main stimulant adhd drugs.

In early 2000s, I switched to using codeine for cough after seeing commentary that is the best treatment for cough/lungs without any bad side effects. That person, a physician noted that all others will have some effect.

I usually pick these cough syrups with codeine when traveling overseas, and has worked extraordinary well, including for my then young children. They are recovering by the 2nd or 3rd day after sleeping though the night without coughing. Obviously children dosage. I think sleep was the medicine.

Codeine is indeed the right stuff for a cough. Unfortunately it was made a controlled Rx-only drug in the US in the 1960s because it could be abused. Now US OTC cough medicine sucks.

Thanks this is helpful, I'm aware of the Sudafed/meth issue but I didn't realize the alternatives were all clearly labeled PE. That explains why it's so obvious to a lot of people.

It isn't labeled as such in the UK. Both the "full fat" version and the placebo worthless one are just called Sudafed - but the proper one is kept behind counter and you have to ask for it.

Well for me I remember the big news about gangs buying up cold tablets for the pseudoephedrine that they had in them to make meth, so the pharmacies making it harder to buy them. Then the new ones on the shelves (which are marketed as ‘PE’ here) just plain don’t work at all, unlike the real ones (which you can still get but you have to ask the pharmacist for). So I read the ingredient list and googled it, and was annoyed to find my experience confirmed and that they’d replaced a really useful medication with one that basically everyone reported didn’t work.

Well for me I remember the big news about gangs buying up cold tablets for the pseudoephedrine that they had in them to make meth, so the pharmacies making it harder to buy them.

You missed the step where cartel super-producers (that didn’t depend on small qtys of feedstock from pharmacies) just started producing 5% more to make up for it.

The organized producers appreciated the government shutting down their nibbling competitors.

Sucks for the public though, paying the price for an ineffective measure.

It's not that simple. Industrial-scale meth production (obviously) doesn't use Sudafed; amateur small-scale production does. But small-scale meth production has its own distinct externalities: it sites "meth labs" in residential areas, which catch fire, create hazardous waste problems (some of which require specialist cleaning crews), and attract additional crime.

The policy doesn't have to cut off the meth supply to be successful on its own terms.

This just isn't a factor anymore, Big Meth produces a product so cheap that it would be ridiculous to try to produce it at a small scale.

Moreover we already have the most draconian and well funded drug agency of any OECD democracy, surely they could cope with some trailer park meth labs without having to hassle everyone with allergies or a cold.

You're still looking at this as a drug restriction problem --- we all agree, that's hopeless --- and not as a neighborhood safety problem.

I just don’t see how selling snake oil made my neighborhood safer. Like I don’t see how those two things are connected at all other than through motivated reasoning. Not to mention anybody can still walk into my local Walgreens at 4 A.M. with a mask and a tire iron and take as much Sudafed as they’d like.

Selling snake-oil didn't. Sudafed PE shouldn't have been sold.

A nation wide blanket restriction is a dumb way to go about any attempt at neighborhood safety. It is a best indirect. But again, making meth in a home lab hasn't been economically viable for the better part of 10 years now, so why is the restriction still in place?

And for that matter, small-scale meth enthusiasts, wisely or not, were in fact robbing stores for it at the time. Meth access aside, there’s probably some social benefit to tamping down on robberies in these places where sick and vulnerable people need to go for their meds.

The policy doesn't have to cut off the meth supply to be successful on its own terms.

Here in Australia we had project STOP in Queensland which started about 20 years ago, and there's an analysis of the outcomes here - https://www.aic.gov.au/publications/tandi/tandi509

tl;dr it did stop pseudoephedrine going to meth labs BUT it has had no long term impact on the number of labs being detected nor seemingly on the availability of crystal meth.

To me that's an abject failure of a policy, but some people look at it like "we restricted a precursor successfully!" and count it as a win.

And that meth was actually cleaner and more pure than the current cartel stuff.

Hard-won experience? I vaguely remember when Sudafed got put behind counters because it was used to make meth. I don't frequently get sick. Often, the last medication I bought is expired by the time I need it again. One year, I found something that worked for me. Another year, I thought I bought the same thing, but it just didn't work. The one I had originally bought (same brand) had a behind-the-counter version that worked. It's annoying to catch the pharmacy when it's open, but now I just ask the pharmacist for generic Sudafed with the smallest-lasting dose (so I can decide if I want to take more).

I've found with most medications looking for an active ingredient and an amount is helpful. You can search for effectiveness or side-effects. The brand I got last time isn't always available and they'll have 3-hour or 12-hour versions with warnings about exceeding recommended dosages (or mixing medications). Or company annoyingly package similarly-branded things that just aren't the same.

I've found with most medications looking for an active ingredient and an amount is helpful. You can search for effectiveness or side-effects.

Is this not common practice? I would be uncomfortable taking an ambiguously labeled “cold medicine” pill, personally. I know which medicines are effective for me and which are a waste of time and money.

The vast majority of the population has zero interest in looking at what is in medicine, and even less interest in researching those long complicated names.

They buy a brand that promises to fix what they don’t like, and if it works, they buy more next time.

This is something quite striking in US where there is a full aisle of "cold medicines", "headache pills", "back pain reliefs", "muscle ache aides" etc, and they are all the same stuff (ibuprofen/"Advil" or paracetamol/acetaminophen/"Tylenol") in different packages. In Finnish pharmacies it's mostly just three or so "generic" paracetamols or ibuprofens in different brands.

This is something quite striking in US where there is a full aisle of "cold medicines", "headache pills", "back pain reliefs", "muscle ache aides" etc, and they are all the same stuff (ibuprofen/"Advil" or paracetamol/acetaminophen/"Tylenol") in different packages

Some years back, Reckitt (British-Dutch multinational) got in trouble with the ACCC (Australia's competition and consumer protection regulator) for doing this. Selling "Headache Pain", "Back Pain", "Period Pain", etc all next to each other, despite all having identical active ingredients. The ACCC took them to court for misleading consumers, and won.

https://www.accc.gov.au/media-release/full-federal-court-ord...

Yeah that was their Nurofen brand.

"We can charge twice as much if we put it in a pink packet and say it's for period pain".

Very deceptive.

You get that in the US, too. The funny thing is that in many cases, the generic compound is sold in a box that is similar to the box that the "brand-name" version is sold in; they'll sell the same thing in different colored boxes.

https://www.cvs.com/search?searchTerm=acetomeniphen https://www.cvs.com/search?searchTerm=ibuprofin

I think this only supports their point. If you follow the acetomeniphen link and filter only for CVS brand items, there's still 51 different ones. Sure some are sensible divisions, like low dose for children, liquid versions, nighttime versions with something to make you drowsy.

But there's also one bottle of pills labeled as Arthritis Pain Relief. And one labeled as Muscle Pain relief. Which both have exactly the same medicine and the same time release capsules.

There's a Migraine variant label, a Tension Headache variant label. Just "Headache" relief. There's Back and Body pain relief (though that one is Apsirin, it's just showing up in the acetomeniphen search).

Most of them (especially the cold medicines) are not just ibuprofen/acetaminophen but are a "cocktail" that will also include dextromethorphan, guaifenesin, phenylephrine, diphenhydramine, etc in different combinations/amounts depending what they are intended for. I don't personally use them but I could see how it could be useful rather than buying a bunch of individual medications.

Sounds like an untapped market just waiting for more market differentiation to ‘help’ the consumer!

You must not have allergies. Congratulations. Joking aside, I wouldn't know a single thing about these drugs if I didn't have crushing seasonal allergies.

My reply is a bit off-topic, but: I'm beginning to personally notice a correlation with sugar intake and degree of my allergy symptoms. I can't say if I was just oblivious before, or the personally correlation is recent. I started noticing it when I began avoiding foods containing sugars or breads. My allergies aren't completely gone, but they very much spike up when I relapse on my voluntary diet restriction.

While I can't say I have definitive proof, my allergies decreased significantly after I was diagnosed with an autoimmune disease, and as a result started consuming less sugar (among other things like dairy). I still get allergies, but much less severe than then first 3 decades of my life.

Allergies are worsened by dehydration. To rehydrate, drink one cup of water every 45 min and after you finish one put a speck of salt at the back of your tongue. Don't go over 8 max 10 cups in a day. Unless you're under extreme conditions you don't really need more than 5 cups per day once you're properly hydrated. The Eight Cups was developed for military basic training, not every day life. The other thing that can help allergies is washing your nose out with Ocean Nasal Spray (actual product name). The key is to pull it through your nose and caught it into your mouth and spit it out a couple of times in a row w fresh sprays. That clears mold and breaks that immune resistant slime, whatever it's called.

I have seasonal allergies and I found an effective method for myself: When I realize the allergies are kicking in (usually after 6 hours of watery eyes and sneezing) I take a claritin and a zyrtec together, as well as spraying my nose with Flonase. Usually this knocks it off and I will keep taking one of the once-a-day meds for a bit to prevent reoccurrence.

Zyrtec and Flonase together is probably the best normal combo and is generally accepted to be ok.

Disclaimers: I'm not a doctor. Combining a nose spray and a pill is generally accepted practice and studied in several peer review studies I've seen. Stacking claritin and zyrtec pills together is not generally accepted practice, so don't do it.

Yes, cetirizine and fluticasone are a good long-term treatment for allergies.

Direct decongestants like pseudoephedrine are of limited use because you quickly develop a tolerance and they become ineffective. With corticosteroid nasal sprays, they work best after consistent use over several days and keep working more or less forever.

Neither Claritin nor Zyrtec are options for me. They both make me very ill.

I have a permanent non-allergic rhinitis, but even for allergic rhinitis you would be prescribed local steroids (momethasone mostly), or systemic antihistamines (desloratadine etc), or both, is this not common in the US?

Yes. The third ingredient -- a decongestant like real sudafed -- is common too. Some people only need one or two of these drugs; others need all three at the same time.

It's the internet. I have a feeling a lot of people are not. One tab for HN, another tab for wikipedia.

It’s pretty handy to know the names of all these drugs because frequently there is a nineteen dollar package of Advil and a nine dollar package of Walgreens Ibuprofen. It’s pretty easy to figure out all the names of these drugs because all the generics say things like “compare with Claratin.” And it’s smart to use the generic because the active ingredients are molecule for molecule the same.

I guess the generics could be using cheap corn starch…

Some medications, the adjuvants/buffering compounds help a lot to alleviate issues or maximize the effectiveness of the drug. Things like PH buffers to do less damage to stomach linings, etc.

Same with pesticides - the brand name products often include things like better surfactants that make them much more effective. At least based on the papers I’ve read.

Not always of course.

I strongly agree that non-experts in HN comments write as if they are experts. Without some sort of upvote counter, it becomes hard to distinguish confident bullshit from expertise.

Certain individuals are prolific bullshitters too. I’d read a questionable comment and notice it’s the same person.

(My observation is general, not specific to this topic)

As someone who also browses Reddit, I assure you that an upvote counter does little to prevent confident bullshit.

That might define you, but not the rest of us. Think about it, most people likely to reply on this subject probably know something about it.

If you take any kind of OTC medicine, it’s assumed that you’ll read the directions (which includes the list of ingredients). Clearly most people don’t, and they just rely on the marketing material printed on the box/bottle to understand what the medicine does.

If they did read the ingredient list, people would realize that all those products in the pharmacy are mostly remixes of the same handful of chemicals sold at different prices.

Just because two medications contain the same active ingredient doesn't mean they'll have the same results. A lot of work gets put into speed and location of of release.

Sure, but one hopes that a national brand takes care to avoid any type of contamination that might cause a scare on the level of the Tylenol scandal in the 80s. A generic making 20-some store brands might be more lax.

I do know to always buy the generic version of a medicine when it's available, but I also generally rely on the FDA to not let companies lie about what a drug does. Apparently that has failed in this case.

I guess I only buy decongestants like once a year at most though, I would probably pay more attention if I needed them more often.

If they did read the ingredient list, people would realize that all those products in the pharmacy are mostly remixes of the same handful of chemicals sold at different prices.

This is one of the major problems with putting pseudoephedrine behind the counter. It had been an ingredient in many of these combination products -- after all, if you have a cold, you have the combination of symptoms that come with a cold and want to take the corresponding combination of drugs.

But the combination products are convenience products. You could just as well buy the ingredients individually and take them together. People buy the combination product to be saved the trouble, which isn't compatible with the trouble of getting something from behind the counter.

So there generally isn't a combination product available with the decongestant that actually works in them. And phenylephrine, in addition to not working, has more dangerous side effects (e.g. larger increase in blood pressure) than pseudoephedrine. But now it's the thing in the bottle grandma gets when she has a cold.

I think a lot of people watched this Vox video about sudafed 2 months ago and became armchair experts tbh: https://youtu.be/ZlFF7A8nk0w

Some of us have first hand knowledge and found alternatives too

When I'm sick I "do my own research". If you are similar you are familiar with over the counter remedies and their purported effects. Not that many 'effective' medicines are available over the counter in the US and this was a very popular one.

Please make room for me under there. Same feeling. :(

It's the "active" ingredient in most cold medicine. There's real Sudafed behind the counter, and everything else is just varying amounts of phenylephrine, acetaminophen, guaifenesin, and dextromethorphan. If you read labels for otc medication, you see these same names over and over again.

Lol… I am more familiar with it via watching Breaking Bad than anything else.

But in general for any HN topic the people who have something to say get attracted to the article.

I think it'll depend on who you are. If you have allergies or often suffer from nasal congestion, you'll likely know it. If you're someone whose nose just kinda works, there's no reason you'd be aware of it.

Many of us have severe allergies.

I came to the conclusion about these drugs on my own years ago.

I have bad allergies and have at times relied on Sudafed so that I could breath through my nose. It was apparent to me the very first time I tried a product where phenylephrine had replaced Sudafed that phenylephrine does not work at all. I never purchased another product with phenylephrine.

I've found that conservative and non-continuous use of Afrin is a better option for me.

https://xkcd.com/2501/

I'm extremely familiar because I suffer from severe hayfever. When they made pseudoephedrine unavailable, it was immediately obvious that the replacement, phenylephrine, didn't work at all.

So I have a sore spot about this whole issue. I get made to suffer in order for lawmakers to have an empty gesture toward addressing the meth problem.

The US is so weird. Elsewhere, like Canada, pseudoephedrine is readily available without needing to present any ID. I always bring some with me when I travel just in case.

Everyone knows phenylephrine is useless.

In case you're not aware, it's because pseudoephedrine is used to make meth. As for why it's restricted in the US and not Canada, the DOJ believes that meth production in Canada is relatively low compared to the US [1].

[1] https://www.justice.gov/archive/ndic/pubs13/13853/product.ht...

As a pedantic correction was used to make meth. Once the supply ran out it became just one more step to make whatever it needed other ways.

Practically speaking, lots of things are used to make meth. I had to give ID last time I bought acetone. Which is crazy for all sorts of big brother reasons.

I’m not a chemist, but as I understand it, meth isn’t too often made with PE anymore, yet, it sits behind the counter forever now.

I’m not a chemist, but as I understand it, meth isn’t too often made with PE anymore, yet, it sits behind the counter forever now.

Sadly, far too many laws, once on the books, are never considered for removal, even when the original reason for their enactment no longer applies.

Unless enough of us voters badger our congress critters to repeal the "hide the PE" law, it will continue to sit behind the counter.

Sigh. If they put it back out where smurfs could gather it they would start using it again.

Its interesting how Americans are so trained to interpret everything as a failure of government we will find a way to think that the law that prevents meth makers from using sudafed is outdated because meth makers are prevented from using sudafed.

They've already come up with better, cheaper, more efficient methods. They don't need Sudafed anymore, so removing the stupid restriction won't affect meth production at all.

Do you actually believe this? It seems completely ignorant of human behavior to me.

You see, it's not about dealing with large-scale operations. It's about keeping that one neighbor you have who always makes poor choices from grabbing 1000 boxes of Sudafed and blowing up their house. They don't care what the industrial process is, they care what they can get away with in their living room.

Throttle access to pseudoephedrine sufficiently and they will look elsewhere. Make it easy to get and they'll DIY. You know, I even admire the DIY spirit involved. I just don't admire the externalities.

The subtext of your argument is that you think you can legislate away human behavior.

There is a cheap process to make meth, and there’s another process that involves Sudafed. Banning Sudafed does not stop meth production. But here you are still supporting a ban on Sudafed - because of what some theoretical person might do with it ignoring that they’re doing it now without it.

I don’t believe this is a logical failure, I believe whatever culture you grew up in imparted this way of thinking.

The culture I grew up in is one where this happened about once a month. Well, before Sudafed became hard to get. Then the rate of it occuring dropped precipitously.

It's almost like people in fact do base their choices on what's easily available.

Nobody should care whether meth makers are prevented from using sudafed; we should (maybe) care if they're prevented from making meth.

They switched methods, and the new method seems to be more cost-effective so it's unlikely they'd switch back even without the restrictions.

https://dynomight.net/p2p-meth/

Obviously this isn't reflective of any actual history, but in the first season of Breaking Bad, one of the early innovations that the main characters made to how they produced meth was coming up with a method that avoided needing PE. If I remember correctly, they instead used methylamine, which is an amusingly smart choice by the writers because it literally starts with the word "meth" but has absolutely no utility when making meth, so they didn't have to worry about people getting any ideas from the show.

It's used in the P2P method and is a DEA List 1 chemical. It's definitely real chemistry, not fake chemistry. Much of the chemistry on the show was close enough while being vague enough not to actually help anyone who couldn't read the voluminous research papers on the matter.

Interesting! I must have misunderstand whatever explanation I heard about this back when watching it (which isn't super surprising in retrospect, given that my chemistry knowledge is limited to having taking AP chem in high school, which I'm now realizing was over a decade ago...)

They did throw in some red herrings, deliberately, I think, but the vibe overall was real enough. But honestly the show in general is pretty lackluster from a chemistry nerd standpoint (as is the synthesis of illicit substances in general, real snoozefest of gross white powders turning into gross illegal white powders), there are a bunch of youtube channels doing chemistry that is both more interesting AND won't cause visits from the nice people at the three letter agencies.

Phenylacetone, acetic acid, and methylamine are the ingredients in the Breaking Bad process. There are some fictional aspects, such as the blue color, but the process is real and has become the dominant method of producing meth. It's more cost-effective as I understand it, so removing restrictions on pseudoephedrine probably wouldn't have any effect on the meth supply today.

https://dynomight.net/p2p-meth/

Yup. A while back, I was stopped at the register buying less than a liter of acetone and denatured alcohol (for cleaning molds and bonding surfaces for advanced composites) at the same time — forbidden. So I checked out one and paid, then checked out & paid for the other in two immediately sequential transactions. The check-out woman and I shared a small chuckle at how (in-)effective those measures were...

It's not so much "used to make meth" as that it is some very simple chemistry away from being meth, and that chemistry, when employed by the amateurs who use Sudafed to make meth, is particularly rough on the neighbors.

Pseudoephedrine was a massive source of meth a decade or two ago.

https://www.nbcnews.com/id/wbna28802912

"Mexican authorities said they have seized nearly 3 tons of pseudoephedrine from a ship that arrived from South Korea."

Paraphrasing, it's not a big deal that it's used to make meth - it's a big deal that it's used to make exploding meth labs.

Yes. Pseudoephedrine itself is a mild stimulant. Tweaking the molecule (npi) turns it into a powerful stimulant.

I think the implication is that the rest of the world isn’t overrun by tweakers?

Who needs meth when you have poutine and maple syrup to get you through Christmas?

Everyone knows phenylephrine is useless.

Easy to say now once it’s proved.

It's been pretty common knowledge for years that it doesn't work. That doesn't mean that common knowledge was right, but it certainly isn't a case of everybody only now claiming they knew it.

Nope, I remember the first time I tried to use a phenylephrine based cold tablet it after the big uproar about putting pseudoephedrine behind the counter - this is more than a decade ago. I’ve always had relief from pseudoephedrine but I felt absolutely no effect from the phenylephrine tablets (apart from the paracetamol they also contain, but zero decongestant effect). I looked it up and other people were reporting the same, I was so annoyed I never bought it again and from then always ask for the real thing.

Weird thing was the pharmacists always want to know why you’re asking (even beyond doing the drivers license check) and I had to say every time that the off the shelf tablets do literally do nothing for me.

It never worked for me, but I thought that was a "because me" thing.

It makes me both exhausted and unable to sleep, and although I'm not very good at very many things, I'm generally an exceptional sleeper so this was something I wasn't willing to experiment on dosage experiments to make it work.

We've known for ages - https://www.forbes.com/sites/daviddisalvo/2015/10/26/the-pop...

Ha. I think everyone who tried it said this. I think every conversation I've had with a sick person has included the phrase "this over the counter stuff doesn't do anything". The most cursory search of the internet finds an article from 2006 with the literal phrase "There's just one problem. Phenylephrine doesn't work, and most in the pharmaceutical industry know it."

https://reason.com/2006/12/21/step-away-from-the-cold-medici...

And 2005 is the year Phenylephrine replaced Pseudoephedrine, so it's not like it took anyone any time at all to figure this out.

Except anyone could have known it did nothing for them. My sister and I confirmed this many years ago.

Actually, it's funny. My parents aren't Libertarian, but they kinda lean that way in terms of not trusting the government - etc. When they restricted pseudoephedrine, they immediately were suspicious about phenylephrine and eventually came to the conclusion that it doesn't do anything. They'd demand pseudoephedrine and claim that phenylephrine was just a way to restrict pseudoephedrine while allowing pharma to rip us off, yada yada. That's where my strong disdain for phenylephrine came from. Once I was in college buying my own medicine, I came to the same conclusion that one worked and one didn't. Pseudoephedrine was just a miracle drug to me, I remember stopping taking it too early and feeling blegh within hours.

Everyone who is easily congested already knew it.

I recall it being the year it came out when I heard it was useless.

If it took that long for regulators and the drug industry to figure out that phenylephrine is worthless, I certainly don't hold out much hope for more advanced cures.

The same is true if corruption rather than incompetence is the explanation.

But not in (at least much of) the UK apparently. I was on vacation in England and Scotland a year ago and many in our group came down with an annoying cold.

Every chemist had piles of phenylephrine tablets but no pseudoephedrine (or even phenylephrine nasal spray, which works quite well). I did not have a fun time explaining to my sniffly girlfriend why these were all trash and there was no point in buying them - she just wanted some relief and couldn't understand how I would somehow know better than all the different drugs on the shelves. It made me feel like some nutty conspiracy theorist, insisting that the medicine was all phony.

Thankfully it didn't derail the trip, and in the end I found some other nasal spray that sort-of worked.

I've found plain 'ol saline nasal spray works well enough... and, a hot toddy helps clear the sinuses.

Regular use of a neti pot has changed the life of my nasal passages. It's a great device.

Mint tea too! Or some Fisherman's Friends

I’ve bought pseudoephedrine tablets at Boots on a trip but I think I did have to ask at the counter.

The UK's pharmaceutical culture is poor. If "NICE" doesn't think something is the right way to treat a condition, forget it. Even people with diagnosed conditions can struggle to acquire medication. Also, beware of daring to mention the name of a medication, because that's a sign of "drug seeking"! (Luckily I've not been on the receiving end of this, but know folks who have.)

Pharmacies in the UK absolutely do stock pseudoephedrine. It's usually behind the counter and you have to ask for it.

"Sinutab, or own brand, without pain relief" is what you're looking for, for anyone reading.

It is generally available behind the counter in chemists all over the UK. One simply has to ask, and there are no ID requirements.

There is a limit to how many they will supply, but I'm not sure what it is. Generally available now in two forms, with and without paracetamol.

It used to be available off the shelf, but that changed about 15-20 years ago, for the same illicit drug production issues.

Please keep nationalistic flamebait out of your comments here. It leads to nationalistic flamewar (in the general case—not in this thread, but that was by luck).

https://news.ycombinator.com/newsguidelines.html

I'm puzzled by this comment.

The first thing that sprung to mind when reading the article was how terrible it was to be treated like a drug abusing criminal whenever we tried to purchase anything containing pseudoephedrine in the United States.

Pharmacist can't figure out how to scan an out of country license, makes you get your passport. Can't figure out how to scan your passport, makes you get additional ID. Can't figure out what to do with additional ID, shrugs and says sorry you can't have this medicine. I'm sorry, what??? Is this a joke? I was turned away at the pharmacy buying cold medication?

Don't even get me started about prescriptions that family members literally depend on for their livelihoods and the continuous monthly battle to keep those prescriptions filled. And I'm not just referring to stimulants.

Insofar as I can tell the prevalence of phenylephrine is due solely to this dumb policy under the umbrella of The dumb War on Drugs.

If this is somehow nationalistic flamebait, or somehow leads to nationalist flamewar, I fail to see how that is my fault. I pay plenty of US taxes, I buy my medicines elsewhere.

It's not puzzling if you look at it just from the most superficial level, which is how internet dynamics work. Any comment of the form "$country is so $bad. Elsewhere, like $other-country, $good" is going to evoke angry replies in the general case.

Edit: while I have you, can you please review https://news.ycombinator.com/newsguidelines.html and adhere to the guidelines more closely? You broke them in other places recently as well (e.g. https://news.ycombinator.com/item?id=38696491)

On the plus side, https://news.ycombinator.com/item?id=38664857 was great and I am going to send you a repost invite for it!

Everyone knows phenylephrine is useless.

It’s pretty easy to find phenylephrine on the shelves in Canada (I’d say about half the drugs use it vs pseudoephrine) so obviously somebody is buying it. Anecdotally, I always tell people to read the labels and only buy pseudoephrine based medication, and it’s consistently a surprise to people - I don’t think the difference was anywhere near universally known.

People buy homeopathic remedies by the truckload too. They are even less effective than phenylephrine.

The average person has no clue how to evaluate medicines. Stupid laws should not impede those of us who do have said clue.

That's strange and I was surprised reading in the article that phenylephrine is ineffective. Basically this is the only combo that works for me all the time: https://www.drugs.com/mtm/pheniramine-and-phenylephrine.html

It's available as Neo Citran in the EU. Tried a couple of other meds, neither worked, nor the parts of the combo separately (combined with other stuff). Only side effect is that it knocks me out a bit, making me feel tired. At least falling asleep is easier. It's the side effect of pheniramine.

I feel like anyone who has tried a PE drug knew they didn’t work. I’ve wondered for a solid decade why they existed. I’ll happily wait in the tweaker line for my pseudo.

It's long past time to remove that regulatory friction. Instead, it's spread to other drugs. My wife got a cold last week and sent me off to get some other non-pseudo drug. Despite being on the shelf, unlocked, it triggered a driver's license scan at checkout. Very dystopian.

It doesn't seem dystopian to me at all. I get carded when I buy alcohol; in fact, I got declined recently buying alcohol, because my license had expired, but would not have been for Sudafed, where the ID is just there to rate limit purchases.

This is a very old, recurrent HN debate.

I got declined recently buying alcohol, because my license had expired

Were they under the impression you might get younger when you renew your license or was this some kind of automated machine that auto-denies without any recourse?

The reason they don't allow expired licenses for alcohol purchases is because an older, similar-looking person (sibling, etc.) could just give their expired license to someone who's underage.

And the reason they insist on checking the ID of a 40 year old man with gray in his beard and photoaged skin is because... 1) A teenager might be a special effects makeup artist.. or 2) because the law compels them to be bureaucratic twats who follow the rules even when the rules make no sense.

The correct answer is number 2, and that's the real reason they won't accept expired IDs either.

Incidentally, the TSA does accept expired IDs. I flew with one and TSA didn't say anything to me; they scanned it into their computer then waved me through like normal. Then the bartender at the airport pointed it out and refused to serve me.

YMMV, re: TSA. My wife's license was due to expire a week after flying, and they gave her a bunch of shit about how lucky she was that she wasn't trying to leave the following week.

Probably more because they wanted to give her shit (notably pretty, or notably mean to them?) than anything else.

Personally, when in a stirring shit mood, it can be fun to ask them what section of the law/code they think says that. I don’t think I’ve ever gotten a straight answer from TSA, and very rarely a straight answer from a police officer.

  When I’ve been travelling with things that have specific actual laws that apply to them, I’ve taken to printing out the actual applicable laws (and their policies). It’s rare they actually follow them at first (and multiple times I’ve had them instruct me to do something that would violate them, or had they themselves violate them), but showing them politely usually helps.

I even had TSA once (many years ago), bring me my checked luggage with a gun in it (legally) to the gate in the terminal, and ask me to unlock it right there and demonstrate it was unloaded. A case with ammunition in it too (also legally). To do that demonstration, I’d have to pick it up and manipulate it.

I politely declined, not wanting to get shot or arrested, and showed them their policy instead which is that needed to be done before security, outside of the ‘sterile area’ - and I in fact had done so. They insisted a couple more times, I insisted I wasn’t going to violate the law or their policies, they got a supervisor which got angry at them, and they eventually left. And it was transported to my destination, unmolested, as was I.

Still a hassle, and quite concerning - they either legitimately thought it might be loaded and transported it anyway, or were so confused they did that song and dance for awhile until they could figure it out - and thought the answer was to have the passenger handle a potentially loaded gun in the secure area of the airport to demonstrate everything was actually fine? Or wanted to jam me up by creating an actual crime in progress?

No actual feel good answers to be found there, unfortunately.

Personally, when in a stirring shit mood, it can be fun to ask them what section of the law/code they think says that. I don’t think I’ve ever gotten a straight answer from TSA, and very rarely a straight answer from a police officer.

In the US, the reality we live in is that knowledge of the law is explicitly not a requirement for these jobs. A police officer is not required to know what law you are breaking, and can legally arrest you if they genuinely believe you are breaking a law they only imagine exists.

Whether this ought be the case is a separate discussion. But this is the landscape in which a series of court decisions have left us.

Yup, which is why when in a shit stirring mood, you’d better be prepared to get some on you.

The TSA's official policy is to accept IDs within a year of expiration: https://www.tsa.gov/travel/security-screening/identification

TIL, thanks! :)

They could do the same with current licenses, either temporarily or permanently. When I was in my 20's I had a stack of old but unexpired drivers licenses because having your current address on your license makes makes some things easier.

That’s why a lot of places now scan the ID. Presumably the vast majority of times whoever lost/gave up/sold the ID got a new one from the local BMV and the old one will be flagged.

I don't think (really, "I hope") that these scans aren't hitting the government database, allowing the government to easily build a dataset of every time you buy alcohol/tobacco/pornography/whatever -- that is uncomfortable even to me and I'm not really a libertarian.

The 2d barcodes and magstripes on these cards do have all the info that's printed, though, so I would bet that a "gifted" ID that hasn't expired but which you've replaced or claimed as lost would still work at a retailer who scans IDs.

Yeah, the scanners they use for age restriction are just standalone devices that show the age without the user having to figure it out themself.

They scan an unsigned, unencrypted PDF417 barcode with AAMVA encoding with no attestation or online verification features.

Ha, thats funny.

some kind of automated machine that auto-denies without any recourse?

This describes a lot of bureaucratically-minded humans, fwiw.

But you don't have your identity logged with the government when you buy alcohol. They just verify the age and forget all the information on your ID immediately.

They're not rate-limiting my purchases of alcohol; they are rate-limiting my purchases of Sudafed. That's the only reason they need my ID for it. Meanwhile, the data they're theoretically collecting is useless. Everybody gets colds.

I’ll happily wait in the tweaker line for my pseudo.

HA! Indeed! I got a three pack from Costco. Should last a while.

How much paperwork and what forms of ID were required to buy that much at one time? It sounds like a sarcastic question, but it is a serious one. The last time I was prescribed a codeine based cough syrup, my signature was required enough times to make me compare to financing a car/house.

It's the same process for any amount up to the limit.

and that process is????

In Washington state at least I just have to let them scan my drivers license.

It depends where you live, but usually ID check + signature

I don't think that's allowed where I live. But hey. We have gun shows every other month and a strangely coincidental amount of gun deaths. But at least I'm protected from dealing with colds.

Just had to show my driver's license. And I didn't want to buy that much, that's just how they sell it at my Costco. Bundled in three's.

It literally did nothing at all.

Before I started using Flonase for my congestion, real Sudafed was the only thing that would work when I had to fly. If I forgot, take off and landing would be miserable because my ears wouldn’t pop.

You probably know given your username, but Sudafed is also great for diving to avoid barotrauma (MEBT). Just need to ensure it's not less than the 12 hour formulation, lest it wear off at depth.

A year ago I had an eardrum suddenly and randomly rupture (probably due to an infection I never felt before it happened) and after it healed a bit, my ENT told me that I should take it before a flight just to be sure to open the eustachian tubes.

Oddly a few days later I overheard pilots in the airport lounge talking about times their eardrum ruptured due to a cold or something. It’s an injury that’s not uncommon for them.

Now I pop one before a fight every time just to be safe. If you’ve never had an eardrum rupture let’s just say it isn’t fun.

My eardrum rupture was amazing. Would recommend :)

Not so much “fun” as “blessed relief”. I picked up some sort of nasty flu in Mexico in about 2005, and my eustachian tubes got blocked for a few weeks, resulting in an ear infection with pressure building up behind the eardrum in one of my ears.

When that drum finally burst I felt so much better. It was a sharp pain, and it was a bit gross, but so much better…

Pseudoephedrine did nothing for me (it usually works great) and it took a a course of co-amoxiclav to finally clear up the infection.

Ah, my pressure buildup happened in a few hours and it did suck. The rupture was more scary (literally hearing my ear explode) than painful, but the process after was really awful. I could barely stand at one point and even a year later I have bad tinnitus and some (thankfully minor) hearing loss.

I seem to recall reading something that said there is an effective does of phenylephrine, if you take it by itself, 2x the dose works, but if you take it with other meds, it might be ok by itself. Something about the stomach acid neutralizing it. Might help to take it with food too.

What you’re probably thinking of is topical (is that the right word here?) phenylephrine. If you snort it, like as a nasal spray, and it soaks directly into the inflamed nasal tissue, then it has an effect. Swallowing it does not.

Analogy: you wouldn’t eat hemorrhoid cream.

Well there's this report [1] from 2007 that suggests a 25 mg dose works significantly better than the 10mg dose generally available. I'm pretty sure that's not the report I'm recollecting, but it was easy to find.

Possibly a digested version of this report from 2015 [2] which found The relative bioavailability of phenylephrine 10 mg was doubled (Fbio 2.11, 95%CI 1.89, 2.31) when combined with acetaminophen 1000 mg, while the absorption half-time was reduced by 50 %. When combined with 500 mg of acetaminophen, bioavailability increased by 64 % (Fbio 1.64). Phenylephrine 5 mg in combination with acetaminophen 1000 mg produced a phenylephrine plasma time-concentration profile similar to that seen with phenylephrine 10 mg administered alone.

Combining information from the first and second reports, the generally available 10 mg dose isn't very effective, but increasing to 25 mg is much more effective --- and you can double the absorption of 10 mg phenylephrine by also taking 1000 mg of acetaminophen the recommended adult dose of 'extra strength' Tylenol in the US). So take double the dose or with something else (tested specifically with acetaminophen, but anecdotally, seems to also work with ibuprofen), and it may work much better than alone. Given that it's been much easier to obtain phenylephrine than more effective decongestants, it's useful to know what you can try to make it work, if that's all you have.

[1] https://pubmed.ncbi.nlm.nih.gov/17264159/

[2] https://pubmed.ncbi.nlm.nih.gov/25475358/

They hitched a profitable ride on the placebo effect bandwagon

I think we need like three or four different certifications escalating in terms of difficulty to get:

0) generally recognized as safe and free of containments - it won't kill you and you get what is on the label. This should be applied and enforced through some kind of mandatory batch testing. Supplements desperately need this because you really have no idea about what you're getting.

1) Plausible Efficacy - this is 0 plus a plausible efficacy for the marketing claim. I.e there is some mechanism of action or reasonable amount of evidence this could work. Marketing would have to make this clear. Most OTC medications should be under this standard.

2) FDA proven efficacy - this is the highest standard of proof, basically the current standard. Prescription medications should be held to this standard.

maybe 3) YOLO/Emergency/Terminal illness authorization - can't be marketed, only listed in a government index and you need a DR co-sign and acknowledge that it may kill you, is unproven and the outcome is recorded for the purposes of later study.

Or we could just dissolve it and go back to being responsible for our own outcomes.

How can an individual without a laboratory be responsible for the contents of a pill they purchased?

Read a detailed review from a well-regarded neutral party with a laboratory.

Ah yes, because those are always easy to come by.

Question: how do you know that this third party is both well-regarded and neutral?

Answer: Read a detailed review from a well-regarded neutral party that conducts laboratory reviews.

Just a small example of why the entire mentality behind "being responsible for our own outcomes" is utter bullshit. You want to be responsible for all your own outcomes, go live on an island by yourself. The rest of us live in a complex society where everyone is interdependent, and where strong governance over the things we depend on for survival is extremely important.

Self-responsiblity being "bullshit" is the most childish sentiment I've heard all year.

Each of us are responsible for holding others accountable too, as we all currently do with other products.

Someone's pill makes someone grow a third arm, they'll be on John Oliver in no time. And without being able to hide behind "FDA said it's OK" (a la opioid epidemic) they'll feel the full brunt of the consequences.

Soviet-style dumping the power and responsiblity on government bureaus is lazy & stupid vice masquerading as virtue.

Rather than an agency that is accountable to publicly elected officials, in your mind profit driven entertainment businesses would perform this role more reliably?

Self-responsibility is just a phrase. When elaborated into the idea you have suggested it crumbles. By the time the market corrects industrial causes of human suffering, far too much preventable suffering will have occurred.

Unless you are philosophically indifferent to human suffering your ideas about self-responsibility are empty nonsense. You have no grounds to criticize others for childish sentiments.

But this is starting from a conclusion that government bureaus are more effective at alleviating human suffering than market competition. That they're faster, and more effective, and so on.

That's simply not true, and we have the entire experience of the eastern bloc that's conclusively proven it's not true.

You're simply pretending organisations like the FDA are something they're not, and that they're nothing but good, and all ills must be blamed on private actors. That's picking your conclusion first based on an emotional need to have a warm cozy paternalistic fantasy of a protector government.

Whereas in reality it's the opposite. The rapid innovation of the private sector, driven by consumers who want their suffering alleviated in the fastest and most effective way, is the suffering alleviator. And the slow, obstructive, and competition-free corrupted public sector, the FDA, is the one causing drug innovation costs to be sky high, thereby causing excess deaths and suffering that the private sector would otherwise have been preventing.

You're siding with the baddy and blaming the goodies for his wrongdoing.

No, I'm not pretending that the FDA is nothing but good, that is a straw man. What I said was correct as I said it, you didn't need to invent a point that I did not make.

Your arguments come from a hypercapitalist fantasy that systemically fails to protect vulnerable populations. Letting market forces satisfy the need of alleviating human suffering is terribly naive nonsense. When the corporations get around to policing themselves, if they do at all, the human toll will be far greater than if we as a society continue to vote for representatives who will reign them in.

You see and comprehend flaws in the current system, but you for some reason cannot see or comprehend that the dumb things you are writing here are much worse.

Bringing up paternalism in this conversation is especially puerile nonsense.

I laughed quite hard about the "vote for people to reign them in". Guess what: they don't care about you at all. They don't even know you. They know the big drug companies quite well though... You might say they even get along well.

A vote is simply an abdication of responsiblity to people far away, who you don't even know, who don't even have liability if they fail to do as they promised.

I guess you're quite young. You'll learn how the world is eventually. You think you're fighting your own little independent fight, but you're actually just an ant serving a nest you've never seen.

If there were any market incentive whatsoever for that, it would already exist. The FDA does not have magical anticompetitive powers that make people care less. We have private and public postal services and railroads operating alongside each other.

The best case scenario is that there is enough market will to allow a lab to monopolize the market, leaving you with the same problems as today but with even less standing in the way of fraud, like companies just paying for good reviews. The realistic case is that no such testing would happen, just like it was before the FDA.

If there were any market incentive whatsoever for that, it would already exist.

Consumer Reports already exists. https://www.consumerlab.com/ exists.

And the FDA is part of why there is no market for it. Note, for instance, tat the above-mentioned site reviews supplements, which don't have as many restrictions (and which do very much need these kinds of reviews).

like companies just paying for good reviews

That would conflict with "respected review company", and leave an opportunity for a company that doesn't accept any kind of payment.

What kind of precedent is there for this pattern working successfully, long term, in any industry? 'Review companies' get sabotaged all the time if they were ever reliable at all. I sure wouldn't want to rely on one for medicine I give to my family if it was anything like relying on Yelp for a decent restaurant. I'm not at all convinced that the open market is a valid locale for these incentives - it seems to come with inherent conflict of interest.

Maybe it's reasonable for us to agree that some kinds of oversight are worth funding as a society without waiting for incentives to sprout up out of the ground.

To be explicitly clear, I also think it might be a good idea to have a government-funded review laboratory in this context. (I don't automatically think it would thereby be uncorruptible, or even harder to corrupt, but guaranteeing its existence seems important.) But there's a huge difference between "review" and "prohibit".

In the internet age they have 100x more information available to them than during the snake oil age the FDA was formed during. There was no Googling "percocet reviews" back then.

Additionally, we're now under a caveat venditor regime regarding product liability, whereas back then it was caveat emptor. Them being able to say "FDA approved it" lets them dump responsibility too (see opioid epidemic).

Dumping the responsibility on a government bureau, while knowing full well those are on the opposite ends of the spectrums of reliability and innovation versus startups, is completely adsurd.

It's strange that this got such downvoting in such a tech savvy community. You'd think they'd know better.

You can’t “look up” the business practices of a business that doesn’t let anyone in to take a look unless forced to.

If a drug company on the other side of the planet is adulterating the drugs in a way that makes people sick 20 years from now, your bad reviews will show up 20 years too late.

If fly-by-night retailers on Amazon can game the reviews for USB flash drives, you sure as bet that an unregulated pharmaceutical company could.

You choose your own risks.

If you buy from the internet from a fly-by-night based in India because someone on an internet forum said it was good, you can.

If instead you only take what your doctor provides, and pick a doctor who checks independent tests of drugs before prescribing them, you can.

There's a lot of people who take drugs who don't have the capacity or capability to evaluate risk before they consume them. And doctors prescribe a drug, not a manufacturing facility. They don't have any clue who will manufacture it, or where.

How do you propose that someone who purchases an ibuprofen at a convenience store verify that it is safe, if independent audits are no longer legally required? Where would someone find independent test results? How would they know where it was made?

I can't even begin to imagine how horrific the world would become if our way of determining whether all drugs were safe was reduced to just Googling for reviews about them.

In what world does Googling for reviews result in accurate, unbiased, independent product information? Can I have some of what you're smoking? (I'll be sure to Google it first.)

The idea is getting a negative response because this is a tech savvy community, everyone here is well aware that Google is an abusive monopoly that's far more concerned with leveraging its market power to line its pockets than it is with delivering accurate information.

I can maybe buy that a free market solution could work for this, but citing Google as an example of a free market... nah, actually, I can't buy it at all. Are we really floating the idea that we don't need an FDA because Consumer Reports could do all the research we need to determine whether drugs are safe after they hit the market?

Perhaps you could keep the FDA, as a purely advisory institution.

FDA approves you? Your product gets an FDA sticker. Otherwise, you sell it without one.

Then people could choose how much they care what the FDA thinks. After all, the FDA rubber stamped the opioids. Your friendly local heroin dealer can gives you the same stamp of approval for his poppy based products.

Also prevents the FDA actively killing people by raising the barriers to getting new drugs to them in time. Win win for all (except the FDA I suppose).

they'd know better

Yes, how much of an hassle it is to wade through 90% of crap and fake reviews when shopping for an insignificant mechanical widget or software app in some unfamiliar topic.

Do not want.

Guess what: you've always got the option of asking your doctor about it. If anyone would know, and have access to the best data, it'd be them.

Immunity from liability makes for a powerful incentive to get FDA approval.

Underwriters Laboratory and Consumer Reports are two free market answers.

Yeah but consumer reports is telling you whether your clothes will get clean in the washer, not whether you’ll die. Pretty much anything they test is regulated by safety by someone else.

UL is a better example but it is defacto required by the US legal environment for any serious retailer. And UL/ETL stamps are notoriously faked on imported items. If that was the standard my drugs were made to, I’d avoid imports altogether, and trust only drugs made by a company that can be sued in my local court jurisdiction.

The government has a proper role in preventing harm.

#3 exists - drug trials occur in hospitals (research hospitals?). My only knowledge is late stage cancer where death is all but a certainty, so they can test new cancer drugs with doctor/patient/etc/drug company consent and oversight. Your ability to enter a trial is largely out of your hands though - if your case fits the conditions for a test you can ask around or your doctor may offer, but plenty of factors can rule you out.

Taking "no hope" patients into a clinical trial is something of a bad-science dillema.

On one hand you have patients either a certain death diagnosis. They'll take anything, they have nothing to lose.

From the drug trial point of view its more complex. Your death and side-effects are recorded. It's not great if half the people in a study die. What if 90% die? Adding lots of one type of patient yo one side of a study, without adding similar to the control group, invalidates the whole study.

And people who are already "hopeless" may end up masking the good outcomes for people earlier in treatment.

Currently there's no mechanism for random unproven drugs to be disseminated outside of a study, but equally its a rare study that wants to add "certain death" candidates to the roster.

If we want "hail mary" options in drug administration then we need that to exist outside of nedical studies. And formalising this would be difficult because one senses that moves in this direction would open the door to massive exploitation and profiteering by both snake-oil salesmen and big pharma.

The FDA doesn’t prove anything. They evaluate claims.

I'd take "FDA proven" to be shorthand for "proven to FDA's satisfaction".

I was surprised when I heard they are taking phenylephrine off the market.

In my anecdotal experience, it was extremely effective at drying out my sinuses, which did reduce congestion. So I asked some family and friends and their responses were mixed. Some said it did nothing and others swore it was effective.

I'm not claiming that phenylephrine is in fact generally effective, just wondering out loud if there could be more to the story. I.e., it works for some people and not others.

Anecdotes are not science. But if enough people share an experience, sometimes there is more to the story.

Read that again in context to the two people who found the science of why it does not work..

You are defeating your argument...

What’s a case study but a fancy anecdote? It’s not very sciencey to form an opinion after a study and shut down conflicting evidence.

I don't think you've made the point you intended to.

There is a problem with the studies these pharmacists are referencing. They are measuring nasal resistance, however, the measurement is not sufficient to capture the combination of things that make up nasal resistance. It's a combination of how much mucus is being secreted vs the degree of sinus inflammation.

New theory: Allergy sufferers are likely primarily experiencing sinus inflammation. Pseudoephedrine is the better solution for that. For those of us who are dealing with secretion - phenylephrine is effective.

https://www.jacionline.org/article/S0091-6749(06)00633-6/ful...

Anecdotes are not science. But if enough people share an experience, sometimes there is more to the story.

Solely relying on anecdotes as evidence is not science, but they’re absolutely a critical part of it!

Science is expensive and moves slow. Sometimes anecdotes are all you have.

Just because the science doesn't exist doesn't mean anecdotes are completely invalid.

That's what I was trying to say. Anecdotes are the seeds of hypotheses, and enough anecdotes with well-understood conditions make a study population.

Science is expensive and moves slow.

I don't know if I agree that science is slow. Certainly scientific consensus is slow though. The churn of ideas at the forefronts of fields is rapid. In my field (machine learning/statistics) I'd say too rapid/short term incentive focused.

I really take umbrage at the idea that science is some purely objective, ideal process. It's messy, and scientists are opinionated and stubborn. Some of the most obstinate people I've met are tenured professors... They kind of have to be. It takes time for good ideas to weather the initial criticisms, persist through replication and testing, and to take hold.

Science is slow for sure. You need to gather samples and run tests. Often testing for causality is impossible, because you literally need to "cause" the issue in your sample group and that raises ethical issues if the thing you're "causing" is harmful.

It's not even the human parts that are flawed with science either.

Science is fundamentally flawed by nature because in science and therefore reality as you know it you cannot prove anything to be true. You can only falsify things in science. Proof is the domain of mathematics.

Anecdotes are the material for new hypotheses, so they are very much part of the scientific process.

This reminds me of the debate around monosodium glutamate (MSG) causing headaches. There were early scientific reports which found no real link and that it was probably psychosomatic nonsense. However more recent studies found that some people have a heightened sensitivity to glutamate, and since it is a literal neurotransmitter there is a promising pathway for the mechanism of action.

Biology is stupendously complex, it's difficult to make hard and fast rules about something being categorically effective or ineffective.

Thanks for this comment. I maintain the unpopular position that both 1) phenylephrine is mildly effective for drying out my sinuses, and 2) MSG definitely gives me headaches, unlike salt, so most likely glutamate is the culprit.

Silly fun fact, the chemical code for MSG (e621) just happens to also be the name of the largest furry "booru" site on the internet. I have no idea why this is.

I think the fact that different drugs work differently on different people is criminally underrated.

What form are you talking about? The nasal spray isn’t being removed because it is effective. It’s the oral version that isn’t effective.

Also the placebo effect is real. So even if the boxes had always been packed with sugar pills, you would expect some people to report that it was effective for them.

Additionally, even if it did have some mild effect, oral pseudoephedrine is better in nearly every way.

I've been looking for this comment in all these stories regarding the ineffectiveness of phenylephrine!

I have a similar story. Congestion is not a symptom I typically get. Covid, however, decided to shake things up and introduce me to a new set of symptoms... One of those was congestion such that my head felt like a balloon. Without experience treating this symptom, I went out and ended up with Sudafed PE, oral phenylephrine. It worked _immediately_, it was like a balloon deflating. It worked so well that these headlines regarding phenylephrine's ineffectiveness still cause bemusement...

anddd that's my story.

I had the same experience with phenylephrine. It dried out my sinuses, which helped me slightly with decongestion but moreso with post-nasal drip.

The effect was not dramatic, and as I understand it, people with allergies need that dramatic effect to be able to breath well.

It seems to me phenylephrine was effective for something different than what the FDA had in mind, but due to their folly, now both phenylephrine and pseudoephedrine are unavailable to the average person.

Are you referring to tablets or nasal spray?

My anecdote is that for me I've known phenylephrine worthless for decades and seek out pseudoephedrine when I need actual relief. Now we have two data points.

The oral absorption of phenylephrine is erratic. Perhaps that is why it was not used as an oral decongestant until it was the only choice. It had long been known that enzymes in the gut lining metabolized oral phenylephrine to inactive metabolites, reducing the amount of the active compound that could enter the bloodstream. The most cited study found that an oral dose of phenylephrine had an absorption rate of 38 percent of an oral dose of phenylephrine, but this study measured more than just the compound's active form. Later studies with more sensitive tests found that less than 1 percent of oral phenylephrine enters the bloodstream in an active form.

Perhaps you have a less active form of the enzyme that degrades it.

As someone who has worked in healthcare for 20+ years now, at least in those circles it was widely known that phenylephrine was a placebo at best, when it was mandated as the on the shelf replacement for psuedoephedrine (Sudafed) nasal decongestant. Again in healthcare circles there was a clear understanding of this being a DEA driven policy to replace an effective medicine that could be abused to create methamphetamine with a different medicine that was ineffective but could not be turned into street drugs. As best as I can tell the policy resulted in harm to millions of people while not reducing the spread and availability of methamphetime one bit and ancillary costs to the healthcare system in the billions of dollars.

Off the top of my head, https://pubmed.ncbi.nlm.nih.gov/19230461 from 2009 but there are many earlier studies as I recall.

From what I've read there are basically no effective treatments for coughing. Dextromethorphan and guafenesin are equally useless. Or at least no better than staying hydrated.

Dextromethorphan has some effect at least. Not sure that it helps much with coughing, but it does something. I've heard codine can help with coughing although again the primary effect seems to be sedation.

IME, guafenesin can be helpful for making coughs more productive, hydration helps with that too, and again IME, so do spicy foods. Mixing cough suppresants and expectorants together makes no sense, but is common --- if I'm trying to clear the junk in my lungs with an expectorant, why am I supressing the coughs that are needed?

I'm trying to clear the junk in my lungs with an expectorant, why am I supressing the coughs that are needed?

Because you need sleep too. And if a cough isn’t productive, having more of them doesn’t help, it only hurts.

The ideal case is to have a minimal number of coughs that are productive.

Well, expectorant in the morning, and suppressant before bed?

Point is, suppressants don't suppress. They don't do anything. Expectorants seem to do something but don't actually make coughs more productive.

I usually just take a cough suppressant anytime it feels like I am coughing unnecessarily, and take an expectorant if I feel like I have phlegm stuck in me. No matter the time of day.

Guafensin is the only one I've been recommended to use by a doctor but that was a few years ago. I think it hasn't stood up to scrutiny based on what I've read more recently.

I wouldn't call either useless, but which to use depends on the exact scenario. There's basically three options for coughs with support behind them, the problem is most professionals neglect distinguishing when to use which and just prescribe willy-nilly:

For suppression of 'ticklish' coughing (i.e. where any form of very minor irritant in the air will set off a coughing fit): Dextromethorphan, which is an antitussive (and which is psychoactive and depending on genetics WILL make you trip even at therapeutic non-abuse doses)

For 'sticky' coughs where the mucus refuses to depart: Ambroxol, which functions as a Mucolytic, i.e. it makes the mucus/phlegm thinner by causing partial breakdown of them, i.e. it fucks with phlegm composition which in turn fucks with the phlegm's rheological parameters

For 'dry' coughs, where there isn't enough mucus: Guaifenesin, which functions as an expectorant (albeit as explained below, "Secretolytic" seems like the better term by far), ramping up mucus production/bronchial secretions/hydration. (avoid confabulating with Guanfacine.)

And then of course for ticklish coughs/antitussive action, there's two other, much better solutions, but ones with it's own issues: Codeine & Dihydrocodeine. Works wonders — as long as your CYP2D6 doesn't function in an atypical manner, in which case it'll either not work at all or get you way too high.

Part of the problem is that a lot of the literature uses the word "expectorant" in the same way I used it above, but really, the more appropriate word to describe guaifenesin is "Secretolytic".

Obligatory disclaimer:

this comment isn't medical advice, I'm neither a medical professional nor a medical paraprofessional, in case of concerns, contact/consult an appropriate medical professional and/or appropriate medical paraprofessional.

I wish I knew why no combination of Guaifenesin & Ambroxol seems to exist on the market, but there probably exists SOME reason.

To any professionals reading this:

Sorry for the low quality content, I know it's very flawed

I often wondered why German pharmacies continue to stock homeopathic remedies. Maybe phenylephrine was our equivalent?

As someone who suffered chronic congestion, and had experienced the effectiveness of pseudoephederine, it was immediately obvious that phenylephrine did nothing. It's just surprising that this "open secret" has taken 20+ years to be publicly confronted.

Zinc gluconate is often promoted as "homeopathic", but the formulations sold e.g. as Zicam do contain the active ingredient in significant amounts and, apparently, are effective at shortening or mitigating colds if taken early enough.

Zinc is literally the only pharmaceutical intervention that has been shown to possibly have efficacy in reducing the length of the common cold.

But it's not homeopathic -- the defining property of "homeopathic" remedies is that they have been progressively diluted until they consist of only pure water.

fellow german and medical student here. the reason is twofold. The first part is pretty obvious, it’s a great way to make money for pharmacists and physicians, it’s pretty much unregulated, has huge margins and is often paid by the patient instead of the gesetzliche Krankenkassen.

The second part, why they are getting away with it, is that naturalistic and pseudoscientific healing BS has a long, long history in Germany. Schulmedizin, at least somewhat, had the image of being perverted by Jewish influences. "Völkische Medizin" the OG Heilpraktiker in some sense, started most of the Quack stuff you see today. The same circles are also still infested with nationalist and anti-jewish sentiments á la "the globalists" to this very day. It’s a crazy, crazy world if you take a closer look.

Yikes! I did not know this.

For the last 20+ years, I've lived in states where you had to show ID at the pharmacy counter to get your hands on the real thing. So I made it my (probably annoying) mission to ask every pharmacist if phenylephrine was effective for anyone. I don't recall a single time I got a "yes".

It shows you something about the priorities of the system that the company got a similarly-named substitute to sell (that's what they need out of medicine), but we didn't get a substitute for what we needed out of the medicine.

Even outside of healthcare circles, most folks I know were aware from anecdotal experience that the OTC phenylephrine was practically useless, and that the psuedoephedrine behind the counter was the way to go if you had a cold. Night and day difference between the two.

The only problem is that the pharmacy always seems to be closed when you need it.

Incredible — DEA couldn’t harm enough people directly with their budget so they laundered the task out to CVS and Johnson & Johnson!

Welcome to the war on drugs - Ruining lives and wasting huge amounts of money for absolutely zero benefit since forever.

I briefly worked as a retail pharmacy technician 12 years ago. There were a few pharmacists that I worked with during this time and all of them were aware that phenylephrine essentially did nothing.

I hadn't really thought about it until now, but these pharmacists did not directly work with each other, so it must have been obvious that phenylephrine was ineffective.

All professionals knew it did nothing. But the problem is by law FDA only needs to certify that OTC medications are safe not that they are effective. So drug companies go to town making billions off those old safe but useless medications

The real change is to add the mandate of efficacy to FDA for OTC medications.

Indeed. My Walgreens has a whole section of clearly and not-clearly labeled homeopathics for these symptoms.

People want to buy them and they won’t get hurt, let em, I guess.

People want to buy them and they won’t get hurt, let em, I guess.

I would qualify that as, if people know what they're buying and want to buy them.

And if they know what homeopathy is, they wouldn’t be buying it.

Oh man, good luck with that one. I’ve never had someone super into horoscopes that would stop being super into them, no matter how much you proved they were bullshit.

They will try to shiv you though if you keep trying.

I've found the best approach is showing a genuine humility and interest in the "lore" and "vibe" of it, the sort of witchy mystical aesthetic while keeping a firm understanding that you're clear it has no predictive power. People don't usually initially get into these for it's effectiveness but for other reasons

I’m guessing you have fewer angry ex wives than I do, hah.

Alright, you got me there.

you don't want to go down the road of the "FDA mandating efficacy". However, requiring "truth in medicating" i.e. demonstrable efficacy rates would be nice.

you don't want to go down the road of the "FDA mandating efficacy".

This has long been a thing already.

https://www.fda.gov/drugs/drug-safety-and-availability/fda-c...

Many OTC medicines, including phenylephrine, are sold because they have an ingredient that FDA generally recognizes as safe and effective (GRASE) when used as recommended on the product labeling, which is documented in an “OTC monograph.” If FDA determined that oral phenylephrine is not effective, the agency would first issue a proposed order removing phenylephrine from this monograph.

https://en.wikipedia.org/wiki/Generally_recognized_as_safe_a...

The funny thing is phenyl ephedrine is actually very effective - when given IV, or directly applied to mucus membranes. Which this OTC drugs will never be used for.

So it is an effective drug, overall. Just not when used this way.

So good luck nailing whichever bureaucrat approved this.

Every human with a nose knew it didn’t work, because when you took it, it didn’t work. The fact it was marketed was purely a regulatory exploit by pharmaceutical companies. The truth is, they could have continued to let pseudoephedrine be behind the counter and it would have been fine. But someone realized phenylephrine was approved OTC and sounded sort of like pseudoephedrine, so they could claim the shelf space and edge pseudoephedrine products.

Their defense to the FDA in being allowed to continue to market despite being proven even before they began their cynical ploy was consumers want convenience, which sadly is clearly true, that despite knowing if you walked five feet further and got the pseudoephedrine they would get relief they grabbed the drug conveniently placed. Fortunately lobbying money only went so far this time.

This is sadly so true for many many categories of consumer products; by the time sufficiently enough people discover the product is bullshit to turn general public opinion the original sales already made the "innovator" enough money to make the whole endeavor worthwhile.

Someone make an app where you scan the barcode and it gives you the scoop (Is it BS/dangerous etc).

A lot of pharmacies have limited hours and long lines for people to say "give me the thing" compared to just grabbing it off the shelf at any time of day with no line.

Some people I know are essentially nocturnal, and have to significantly disrupt their lives whenever they have to do an irregular medication pickup rather than having it shipped ahead of time.

So it can be beyond just "slightly more work" for many people to get it.

Personally, I try to remember to get some whenever I refill meds at the pharmacy, not because I go through it that often, but because if I'm feeling poorly enough that I'm taking it, I probably am not in a state where I want to wait an hour in line just to ask for it.

My dad is a physician and as far back as I can remember, he said it was worthless.

Misleading title (par for the course for what Scientific American has become).

Decongestants work.

Oral phenylephrine does not.

Pseudoephedrine works just fine but it was moved behind the counter long ago and now you have to ask the pharmacist for it, because besides the fact that it's a great decongestant it can also be used for making meth. TIWWCHNT (this is why we cannot have nice things).

The over-the-counter replacement for pseudoephedrine is phenylephrine and it's basically a placebo when ingested orally. (It works well in nose drops and nasal spray.)

TIWWCHNT

Because of asshole governments that wage beyond-insane wars on drugs?

There's much insanity and cruelty that's done in the name of fighting drug use.

I don't think restricting sale of medicine that is often used to make methamphetamine is one of them. Back when it was over the counter, how much of the profit from selling pseudoephedrine decongestants was really profit from selling a meth precursor?

Private profits from legal meth seems like a problem any society has to deal with.

Lol they did not buy the precursor, they stole it.

Had this same conversation with someone missing a number of teeth, they reported that chicken feed contains pseudoephedrine and is able to be collected by using a piece of wood as a capillary sieve.

I had a conversation in around 1992 with someone missing a number of teeth who claimed that AIDS probably came from mutated molecules of latex rubber in "those damned condoms".

https://erowid.org/archive/rhodium/chemistry/chickenfeed.htm...

Or because of asshole manufacturers of illegal and dangerous drugs?

Porque no los dos?

Did it prevent meth usage? Meth production just moved to Mexico and became more potent as the production was industrialized. Overdoses increased, addiction rates increased.

Poor law with no thought process behind it. I think there is still push to make prescription only as well.

I have a friend in law enforcement, and he claims that their crackdown on meth labs where he worked (Indiana), even before the Sudafed restrictions, was not to reduce supply. Even in Indiana in the early aughts, most of the street drugs came from Mexico. Rather it was due to the hazard that the meth labs caused to the surrounding area (not to mention financial issues with remediating property that had been so used).

Yes

"A Simple and Convenient Synthesis of Pseudoephedrine From N-Methylamphetamine" https://improbable.com/airchives/paperair/volume19/v19i3/Pse...

"Pseudoephedrine works just fine but it was moved behind the counter long ago and now you have to ask the pharmacist for it... ..The over-the-counter replacement for pseudoephedrine is phenylephrine and it's basically a placebo"

But this is the entire issue, they knew this from the get-go and made billions based on fraud.

How many Nyquil/Dayquil and other decongestant commercials have you seen in your life time... Ive seen thousands. to the point their jingle and tagline are still easy to recall.

The issue here is fraud, most of the marketed products were oral.

So, here is a conspiracy: If they knew that it was useless, but sounded good on the label - then maybe they could get away with putting even less of the substance, if any, in the products to save costs?

I would assume the FDA would require batch testing at some interval?

You can see the FDA tests here:

https://www.fda.gov/drugs/science-and-research-drugs/drug-qu...

It's not something they do for very many drugs or very often.

I always buy as much Pseudoephedrine as I can since I get regular head colds. It's always funny to ask for "as much as I can get".

Same. Any time I visit a pharmacy counter for any reason, I add "and the largest box of sudafed you can legally sell me", to make sure I always have a stockpile on hand.

Ok, we've put that in the title above. Thanks!

Not technically a decongestant, but I swear by Ectoine nasal spray, personally. As far as I understand, Ectoine is extracted from bacteria that live in harsh conditions like in the extremely salty dead sea. It does so by building a water barrier around itself, or something like that.

It's sold as an anti allergic nasal spray (it definitely helps with my light dust allergy at night) but it also works very well when suffering from Rhinitis.

Also doesn't build dependence, which is a big plus.

Ha! As far as I'm aware, every drug promoted as "doesn't build dependence" turns out to build dependence. Even cocaine and diazepam used to be pitched as not dependence-forming.

True, though at least I can say from myself that after prolonged use not using it for a few weeks has no adverse effects (unlike classical decongestant sprays).

Something to keep in mind is that how fast dependence builds can vary very largely between people.

I have a few times taken opioids for weeks on end because I had very invasive surgery with quite extraordinary amounts of pain during recovery, and have never felt the desire to take more after the pain stopped being above a very high threshold.

I've known others who have taken opioids for a couple days for something that healed much more rapidly, being very afraid to take them, and had to be sure they disposed of any left because they definitely felt the urge to take more beyond relieving immediate pain.

I suspect it also varies between drugs in the same person. I've been using temazepam (as prescribed) for years, and if I don't take it for a while, it's not a huge issue - I don't crave it, and I don't have any withdrawal symptoms. Similarly with opioids - I was using them for months due to chronic pain (codeine or tramadol, again as prescribed), and when I was advised to try stopping them in case they were contributing to some other symptoms, I just stopped that day without any issue (even though the consultant said it might be "worse than quitting heroin").

On the other hand, I tried _one_ cigarette at university, and spend the next day or so with a near constant thought in the back of my head - "I should get some more cigarettes".

I'm pretty sure that's not chemical dependence. The "one shot and you're a junkie" myth is a myth. I think it takes a bit of determination to get addicted to nicotine.

Ok, but this is not an opioid, and it has no known rebound effect. The compound had been on the market and in use in consumer products for more than 20 years.

it has no known rebound effect

That sounds like "famous last words". The fact that they don't know of the effects is probably because they carefully avoided looking for them.

I've tried cocaine; didn't like it. I use OTC codeine/paracetamol for pain; I don't need the paracetamol, but you can't buy straight codeine OTC in the UK, so I'm forced to buy a proprietary compound. I'm never tempted to take it if I don't need it.

So it probably sounds as if I'm the type who doesn't fall to addictions; but in fact I've been addicted to alcohol and nicotine for 40 years. I've tried repeatedly to quit both, and failed.

There's just one psychoactive drug I've used that is definitely not addictive: LSD. If you can bear to continue tripping for more than about 3 days, it stops working, no matter how high the dose, and you won't get re-sensitized until several weeks of abstinence.

I've bad hay fever, for which an allergist prescribed corticosteroid nasal spray. When I told him I didn't want to take it until allergy season because of dependence, he told me that's not a problem and the drug will work better if I take it ALL the time. He is the medical professional I guess but I still couldn't bring myself to take that advice.

People build weird behavioral dependencies around nasal sprays in rare circumstances, but its not a real risk. If you take enough corticosteroids long enough you can have mild withdrawals after stopping but again its not really a thing to worry about.

Your doctor is right, corticosteroid nasal sprays need to be taken before the onset of symptoms to be most effective. They basally dampen the allergic response and if you already have a bunch of immune signaling molecules bouncing around its too late.

And heroin. And Percocet. And OxyContin.

So how does it actually work? Sounds like a gimmick to me. Bacteria produced anti-allergy nasal spray?

https://en.m.wikipedia.org/wiki/Ectoine

Not medical advice, but you'd probably get a similar response just by using regular ol' saline nasal spray for those lighter allergy or dust symptoms.

I've tried, but regular water sprays don't last as long, somehow.

What's the consensus on eucalyptus oil sucking pills? Seems to work for me.

I remember using Vicks® VapoRub as a kid for congestion and it seemed to work.

Lucky. It was boiled onions for me.

An Atlantic article recently suggested that this is due to the feeling of coolness on the throat and not actually the opening of nasal passages. https://www.theatlantic.com/health/archive/2023/10/humans-ha...

That's the strangest name for "cough drop" I've ever heard.

Eucalyptus oil is an effective decongestant. You can put it in an oil burner or a humidifier as well.

So many folks saying "phenylephrine is useless". The oral formulation, yes, precisely because not enough of the drug actually makes it to your nasal passages.

So just take a nasal spray. I get it, all the pills that include it should have it removed, but I don't understand why people just wouldn't use the nasal spray. Personally I don't like decongestant drugs at all because I always feel like I get a stronger "rebound", and a netty pot makes me feel considerably better in any case.

The effect from the nasal spray is fast and quite strong. Sometimes it even hurts, but there are days when having a very dry nose is the better option.

Because if you're using a spray then you may as well use Xylometazoline.

but I don't understand why people just wouldn't use the nasal spray.

I heard it didn't work! But I haven't exactly gone looking for studies.

Also I know I'm doing it wrong. I read instructions somewhere that say if you spray it in your nose and it dribbles back out again, you didn't get it into your sinuses, where it needs to be. Every. Damn. Time.

No article touching on pseudoephedrine is complete without a link to A Simple and Convenient Syntheses of Pseudoephedrine From N-Methylamphetamine[1]

1: https://improbable.com/airchives/paperair/volume19/v19i3/Pse...

I'm dead! "While N-methylamphetamine itself is a powerful decongestant, it is less desirable in a medical setting because of its severe side effects and addictive properties. Such side effects may include insomnia, agitation, irritability, dry mouth, sweating, and heart palpitations. Other side effects may include violent urges or, similarly, the urge to be successful in business or finance."

I will agree they're undesirable side effects, but I bet they'll get some takers.

the urge to be successful in business or finance.

That does appear to be frowned on today.

The thing no one will investigate is the obvious test data the pharma companies produced to show that phenylephrine supposedly worked. Any data that showed it worked was obviously fraud and yet companies made billions over 20 years from it. This is the real crime and I doubt this fraud started and ended with phenylephrine. How many other drugs are useless sold to us because no one bothered to doublecheck the data?

There was no trial to prove phenylephrine was effective, thus there was no fraud.

Phenylephrine has been available for over a century. It was an unapproved drug. The FDA grandfathered it in (as it did many drugs) by just making sure it wasn't harmful.

Most serious nasal congestion sufferers would have been wary of phenylephrine for some years.

I feel uncomfortable asking for pseudoephedrine by name, but I do so anyway, because my doctor told me that phenylephrine was hopeless 15 years ago.

So, we took the political route, contacting then-congressman Henry Waxman, whose committee at the time had FDA oversight. Waxman’s office wrote four letters imploring the agency to reconsider oral phenylephrine’s effectiveness.

For all the hate that politicians get on public forums like hn, this is one of the few cases where they actually made a difference.

The only thing that can stop a bad guy with a politician is a good guy with a politician.

Phenylephrine gives me food poisoning like symptoms, so I have to avoid it. Apparently common cold stuff used something different than Phenylephrine when I was a kid, because they did used to work before they started making me ill. Thank goodness for Dextromethorphan!

The article suggests that dextromethorphan (which is a cough suppressant, not a decongestant) might be ineffective as well.

Can’t speak to the effectiveness of OTC decongestants but an ENT once gave me topical cocaine inside of my nostrils. That really opened me up and I could breathe for what seemed like the first time in a long time. The permanent solution is septioplasty with turbinate reduction in my case.

Sounds like we have similar issues (ENT also recommended septioplasty & turbinate reduction for me). Benadryl and Flonase work very well for me. Guessing you've tried those, but just in case you haven't...

I remember DayQuil being a lifesaver when I was in college in the early 00's and I needed to power through a day of classes with a bad cold. Then I remember at some point in the later 00's it just didn't work anymore (turns out they switched normal decongestant meds to phenylephrine in 2006). Once I found that out I started buying the behind-the-counter stuff with pseudoephedrine and it suddenly worked again. Not sure you need to be a pharmacist to figure this stuff out.

Something with Dayquil - it has other medicines that do work for pain and cough suppression. Depending on your symptoms, those two can work and make you feel better even though you're not getting any real decongestion benefits. That makes it harder to detect that the decongestion part isn't working. That is, of course, until you're introduced to the stuff that really does work and then wonder how you went so long without it.

How dare they do their own research.

Sadly "do your own research" usually means saving a few Facebook political memes and panning through Infowars headlines.

Yeah no shit!

EDIT: in Australia you can still buy pseudo you just have to show ID. Everyone knows PE doesn’t work.

Yeah, it's pretty weird here. Pharmacies stock both: the placebo on the shelves, and the real one behind the counter, usually called "such-and-such ORIGINAL" or something.

So if you don't want a placebo, you have to know that the real one exists, ask for it, and then present ID so they can track how much you're buying.

I've only bought the real one a couple of times. One was to help with a long-lasting post-viral cough in advance of an important meeting. I can't for the life of me recall how I already knew about the distinction.

The trade-off was worth it, though, since there's no longer a meth problem.

We just need someone to figure out how to make fentanyl out of phenylephrine

I need more caffeine. My brain read,

"Two Hot Pharmacists Figured Out That Decongestants Don't Work"

Maybe you’ve been browsing too many alternative websites.

I actually have HN to thank for knowing this. About a year ago someone pointed out how useless the non-pseudo alternatives are. Colds are nowhere near as bad anymore.

same here, I remember reading a random reply on here about it and then getting Claritin-D or whatever at a CVS near me when I had a cold and then covid. Both times I experienced huge relief.

This has been apparent to anyone who has taken both. Phenylephrine is garbage. I haven't taken a decongestant since pseudoephedrine went behind the counter.

BTW, Diego Armando Maradona [1] was suspended for doping in the 1994 FIFA World Cup because of phenylephrine which is now not considered doping.

[1] https://youtu.be/Da_CDPRG2j0

Snorting salt water works for me though it's very unpleasant. Very spicy food/capsaicin as well.

https://archive.is/wLY8e

Am I the only person who never takes oral decongestants anyways? Afrin or other nasal sprays work much better for me and have no side effects if used for just a couple days.

I mean, anyone with sinus allergies who has tried all the medications knows that phenylephrine doesn't work. While it's been nice to have "official" confirmation, it was incredibly obvious to those of us who really benefited from the old pseudoephedrine version of Sudafed.

Rather than put my name on a state government watchlist that tracked whether or not I bought "too much" Sudafed, I figured out that Zyrtec (cetirizine) worked well enough for me, and could be had cheaply at discount warehouse stores.

pseudopseudoephedrine?

Wait wait hold up:

Other nonprescription drugs like guaifenesin (sold in Mucinex and Robitussin), dextromethorphan (sold in Robitussin DM), and antihistamines for a cold like chlorpheniramine likely don't help with coughs and colds.

I knew about phenylephrine, but is there specifically evidence against these other drugs?

You really can't fault stores for selling a placebo if people keep buying it. The real question is why do people keep buying it?

This is a problem of knowledge, and a problem of trust. People have been generally ignorant about the ineffectiveness of phenylephrine, because most people have enough trust in their pharmacy that they would not expect the entire "decongestants" section at the store to be 100% snake oil. But our pharmacies sold us snake oil, did it for decades, and FDA backed them up on it. And we ate it up like innocent puppies.

I don't think this means capitalism is broken, and I don't think it means people are so stupid that we're doomed, and I don't think it means we need government intervention at every step.

But we shouldn't let this one slide by. We shouldn't let the pharmacies the ignorance card: they knew they were selling us a placebo. How many other products fall into this pattern? We should all think about taking a take a step back and performing a trust audit on our pharmacies.

Personally, I suspect we won't always have to keep facing this problem of never knowing which suppliers are trustworthy. I suspect there's something missing. I don't know what it is: an app, like a peer review app? A website? A law? A non-profit research group? A revolution? A man can have hope.

American pharmacies aren't just pharmacies, they're hypermarts. Combined with lax FDA regulations on supplements, beauty, and wellness products, totally useless crap like "wrinkle vanishing" creams, copper bands, Kino tapes, and CBD "pain relief" creams are heavily marketed to customers. Following that, it should come as no surprise that herbal remedies and marginally-useless OTC medications, tantamount to vitamin B12 shots, sell an apparent power to defy science and the appearance of agency in instances where only palliative care is possible. Emptor nimium pecuniam habet.

Takeaway: when faking data, make sure your numbers are randomly distributed. ;)

Seriously, this was fascinating and disturbing that it took so long.

I’ve known this for a long time. Put me on a watchlist and give me my meth, my sinuses are clogged.

I figured it out myself

Seems like the entire food regulatory body the USDA and the FDA are just in the pocket of the industry. Lack of funding is the least of it. Paid off and corrupt is likely the better characterisation.

Seems like Literally nothing you eat is regulated at all.

Unless it kills you. Then if it kills people the FDA acts only after they see a good amount of people dying.

Almost all of this is universal knowledge now. I wonder why there's no outrage or pressure to change.

I hope a lawyer jumps on this and sues on behalf of the American public.

Refund all instances of the sold chemical, put the company out of business. Is it possible?

If it can't be refunded funnel the money into actually creating an effective regulatory body. One can dream.

I've only ever had Xylometazoline spray for the nose and pseudoephedrine tablets work and both can only be really taken for a short period of time. Overuse of Xylometazoline will have the opposite effect.

Anyone who took it instead of pseudoephedrine knew this. If not for the crystal meth panic it would never have seen the market.

Nice to be vindicated. To this day people look at me like some kinda maniac when I talk about the difference in effect before and after they took pseudo out.

The only reason I know is because someone's mother hoarded pseudo tablets and had probably 30 years supply.

One year as a teenager I got such bad hayfever that my nose was literally just running constantly and I was losing 2 litres of water an hour in just watery eyes, I could barely see, my skin was inflamed, and I was having trouble breathing.

All the hayfever medicine I took was totally ineffective.

She gave me a single pill, and the effect was actually incredible. I've never seen such an enourmous effect in such a short time from any medicine except maybe morphine. In the space of 15 minutes I was almost completely back to normal. My nose not only stopped running, but became completely unclogged. My eyes stopped watering and subsequently completely lost any irritation, my skin cleared up and my breathing was completely normal.

Not only that, but after suffering like that for days, I was completely normal for the rest of the season. The drug just completely broke some kind of inflammation cycle and the hayfever never returned.

I really think that the gaslighting around this was a kind of crime perpetrated on people. Rarely has there ever been a drug that can improve quality of life so effectively. Hayfever for those who suffer it significantly is truly hell. It's not a scratchy throat or itchy eyes, it's a full body experience. Imagine having a bad flu,but it can last months, and nobody has any sympathy for you whatsoever. And then society takes away a completely effective treatment, substitutes with one that has essentially zero impact, and gaslights you incessantly that you're wrong and it works at least almost as well.

End rant I guess.

>The most cited study found that an oral dose of phenylephrine had an absorption rate of 38 percent of an oral dose of phenylephrine, ...

That's not very much.

Another thing -- if you are ever need Sudafed (the real stuff) and they are out ask for one of the allergy medicines, the -d version. Claritin-D, Zertec-D all have the primary active ingredient as Sudafed bundled with the Allergy medicine.