Over‐the‐counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults

Christina C Chang; Allen C Cheng; Anne B Chang

doi:10.1002/14651858.CD006088.pub4

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Figure 1

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Children ‐ global assessment, Outcome 1 Not cured or not improved.

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Analysis 1.2

Comparison 1 Children ‐ global assessment, Outcome 2 Not improved.

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Analysis 1.3

Comparison 1 Children ‐ global assessment, Outcome 3 Not cured.

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Analysis 2.1

Comparison 2 Children ‐ secondary outcomes, Outcome 1 Mean cough score at day 3.

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Analysis 2.2

Comparison 2 Children ‐ secondary outcomes, Outcome 2 Mean score at day 10.

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Analysis 2.3

Comparison 2 Children ‐ secondary outcomes, Outcome 3 Adverse events (no. of people).

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Analysis 3.1

Comparison 3 Adults ‐ global assessment, Outcome 1 Not cured or not improved.

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Analysis 3.2

Comparison 3 Adults ‐ global assessment, Outcome 2 Not improved.

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Analysis 3.3

Comparison 3 Adults ‐ global assessment, Outcome 3 Not cured.

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Analysis 4.1

Comparison 4 Combined children and adults, Outcome 1 Not cured or not improved.

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Analysis 4.2

Comparison 4 Combined children and adults, Outcome 2 Not improved.

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Analysis 4.3

Comparison 4 Combined children and adults, Outcome 3 Not cured.

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Analysis 4.4

Comparison 4 Combined children and adults, Outcome 4 Adverse events (no. of people).

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Mucolytics as an adjunct to antibiotics to reduce cough in acute pneumonia in children and adults
Patient or population: children and adults with acute pneumonia Settings: any Intervention: mucolytics (and antibiotics)¹ Comparison: antibiotics
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Assumed risk	Corresponding risk	Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Placebo	Mucolytics
Number of people who had not improved or had not been cured (follow‐up: 7 to 10 days)	16 per 100	14 per 100 (7 to 26)	OR 0.85 (0.4 to 1.8)	221 (2)	⊕⊕⊝⊝ low^2,5	Fewer people represents a benefit
Cough score Scale from: 0 (absent) to 3 (very severe) (follow‐up: 3 days)	The mean cough score in the control groups was 1.45	The mean cough score in the intervention groups was 0.25 lower (0.33 to 0.17 lower)		120 (1)	⊕⊕⊝⊝ low^2,3,4	Data for children only
Adverse events (follow‐up: 10 days)	See comment	See comment	Not estimable	120 (1)	See comment	1 study in children provided data specific to participants with pneumonia ‐ there were no adverse events
Complications (e.g. medication change)	See comment	See comment	Not estimable	0 (0)	See comment	Complications were not measured in the trials
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; OR: odds ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹In addition to antibiotics, people with pneumonia often use over‐the‐counter (OTC) cough medications when at home or request OTC cough medications when in hospital to suppress an annoying cough. There is a question as to whether suppressing cough may prolong pneumonia. Over‐the‐counter cough medications can include antitussives, expectorants, antihistamine‐decongestants, antihistamines and mucolytics (such as bromhexine, ambroxol and neltenexine). ²Allocation concealment unclear. ³Scale not validated. ⁴Sparse data. ⁵Sparse data; confidence interval does not rule out the potential for 'more people' not improved or cured with mucolytics.

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Comparison 1. Children ‐ global assessment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not cured or not improved Show forest plot	1	120	Odds Ratio (M‐H, Fixed, 95% CI)	0.40 [0.10, 1.62]

2 Not improved Show forest plot	1	120	Odds Ratio (M‐H, Fixed, 95% CI)	0.40 [0.10, 1.62]

3 Not cured Show forest plot	1	120	Odds Ratio (M‐H, Fixed, 95% CI)	0.36 [0.16, 0.77]

Comparison 1. Children ‐ global assessment

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Comparison 2. Children ‐ secondary outcomes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mean cough score at day 3 Show forest plot	1	120	Mean Difference (IV, Fixed, 95% CI)	‐0.25 [‐0.33, ‐0.17]

2 Mean score at day 10 Show forest plot	1	120	Mean Difference (IV, Fixed, 95% CI)	‐0.15 [‐0.17, ‐0.13]

3 Adverse events (no. of people) Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

Comparison 2. Children ‐ secondary outcomes

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Comparison 3. Adults ‐ global assessment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not cured or not improved Show forest plot	1	101	Odds Ratio (M‐H, Fixed, 95% CI)	1.21 [0.48, 3.04]

2 Not improved Show forest plot	1	101	Odds Ratio (M‐H, Fixed, 95% CI)	1.21 [0.48, 3.04]

3 Not cured Show forest plot	1	101	Odds Ratio (M‐H, Fixed, 95% CI)	0.32 [0.13, 0.75]

Comparison 3. Adults ‐ global assessment

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Comparison 4. Combined children and adults

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not cured or not improved Show forest plot	2	221	Odds Ratio (M‐H, Fixed, 95% CI)	0.85 [0.40, 1.80]

2 Not improved Show forest plot	2	221	Odds Ratio (M‐H, Fixed, 95% CI)	0.80 [0.38, 1.67]

3 Not cured Show forest plot	2	221	Odds Ratio (M‐H, Fixed, 95% CI)	0.34 [0.19, 0.60]

4 Adverse events (no. of people) Show forest plot	2	221	Odds Ratio (M‐H, Fixed, 95% CI)	1.2 [0.34, 4.22]

Comparison 4. Combined children and adults

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