2024 Allergic Rhinitis and Cold Notes (PDF)

Allergic Rhinitis & The Common Cold RHCHP School of Pharmacy Self-Care Fall Facilitators Readings & References Leticia Shea, PharmD, BCACP...

Allergic Rhinitis & The Common Cold RHCHP School of Pharmacy Self-Care Fall Facilitators Readings & References Leticia Shea, PharmD, BCACP Required [email protected] This packet 303-964-6182 Key Points PowerPoint Learning Objectives After studying the required readings, the student will be able to: 1. Describe common upper respiratory tract conditions in adolescents and adults. 2. Differentiate between common upper respiratory tract conditions and corresponding symptoms, 3. Discuss potential management strategies for common upper respiratory tract conditions, 4. Recommend appropriate therapy for common upper respiratory tract conditions. 5. Explain the goals of treating allergic rhinitis 6. Identify the 4 main classes recommended for the treatment of allergic rhinitis. 7. List the OTC intranasal corticosteroids by brand and active ingredient name. 8. Explain the mechanism in which intranasal corticosteroids provide benefit in the setting of allergic rhinitis and post-viral ARS. 9. Differentiate the OTC intranasal corticosteroids by first generation and second generation INCS. 10. Explain the difference between 1st generation and second generation INCS. 11. Provide the INCS that is preferred for use in pregnancy. 12. Explain the side effects associated with intranasal corticosteroids 13. List the intranasal antihistamine available OTC. 14. Explain the mechanisms (of action) provided by the intranasal antihistamine and why it is superior to oral antihistamines in the management of allergic rhinitis. 15. Explain the side effects that an individual may experience when using the OTC intranasal antihistamine. 16. Differentiate between 1st generation and 2nd generation antihistamines. 17. Identify the 1st generation antihistamines that exhibit the highest amount of sedatative properties. 18. Identify the oral 2nd generation antihistamines by their brand and active ingredient names. 19. Explain why the antihistamine/mast cell stabilizer eye drops are superior to antihistamine/vasoconstrictor eye drops for the treatment of allergic conjunctivitis. 20. List the brand name and active ingredients of the 2 antihistamine/mast cell stabilizer eye drops now available OTC. 21. Review the timeline associated with the common cold (ARS). 22. Explain when post-viral ARS may be expected. 23. Identify symptoms that are consistent with bacterial ARS instead of viral ARS. 24. Explain the medications that may be used to treat rhinorrhea for the common cold. 25. List the medications that may treat congestion for allergic rhinitis. 26. List the medications that may treat congestion for the common cold. 27. Explain rhinitis medicamentosa, and which medications are associated with this condition. 28. Provide counseling points so that a patient can avoid experiencing rhinitis medicamentosa. 29. List the type of side effects a patient may experience if they are taking a 1st generation antihistamine. The management of respiratory illnesses including allergic rhinitis, acute rhinosinusitis, influenza, and pharyngitis involves a combination of pharmacological interventions and nonpharmacological measures. The “common cold” can present in numerous ways and may manifest as viral pharyngitis or viral sinusitis. For allergic rhinitis, antihistamines, intranasal corticosteroids, and intranasal decongestants offer symptom relief. Acute rhinosinusitis may require antibiotics, (if bacterial), nasal decongestants, and saline nasal irrigation. Influenza can be managed with antiviral medications if initiated early, but often simply requires symptom management (& lots of rest). Pharyngitis treatment includes pain relievers, throat lozenges, and antibiotics (for bacterial infections). Nonpharmacological recommendations such as adequate rest, hydration, and supportive care are essential for all these conditions. Individualized treatment plans should consider the severity, underlying causes, and patient preferences to optimize outcomes and improve the overall well-being of patients. INTRODUCTION Most people will experience will experience an upper respiratory tract (URT) condition. Moreover, according to the Centers for Disease Control and Prevention (CDC), adults in the United States experience an average of two to three upper respiratory tract infection (URTI)s per year. URT conditions are most common during the fall and winter months, but can occur at any time of the year. Most of these infections are caused by viruses with the most common ones being rhinovirus, coronavirus, and influenza, and do not necessitate antibiotics. However, research reveals that up to 10 million antibiotic prescriptions are prescribed inappropriately for respiratory tract infections each year. A cohort study consisting of approximately 15,000 outpatients with acute URTIs discovered that 41% of patients prescribed antibiotics did not require them. The unwarranted use of antibiotics can lead to negative outcomes, including antibiotic resistance, adverse events, and added expenses. Adverse events caused by antibiotics are generally mild, such as diarrhea or rash, but can be severe, including Stevens-Johnson syndrome, Clostridioides difficile colitis, anaphylaxis, and even sudden cardiac death. It is crucial to differentiate between conditions that do not require antibiotics and those that almost always require them. Healthcare professionals should adopt an evidence-based method for antibiotic use for URTIs to achieve antibiotic stewardship goals of enhancing patient outcomes, minimizing unintended consequences, and preventing unnecessary healthcare expenditures. Allergic Rhinitis Allergic rhinitis (AR) is an atopic immunoglobulin E (IgE) mediated [type 1 hypersensitivity] disorder characterized by nasal congestion, clear rhinorrhea, sneezing, postnasal drip, and nasal pruritis. Patients may also present with itchy eyes, sore throat, and ear fullness. The frequency of symptoms determines classification. Intermittent AR occurs less than 4 days/week or for less than 4 weeks/year. Persistent AR occurs for at least 4 days/week and for at least 4 weeks/year. Symptoms may be classified as mild, [do not interfere with quality of life (QOL)], or moderate- to-severe, (interfere with QOL, which includes sleep disturbance, impairment of work or school, and/or impairment of daily activities such as leisure activities or sports). Symptom presentation varies with sore throat more likely with persistent AR.[5,6] An outlier that helps to delineate AR from the common cold is pruritis, which occurs more often with AR and includes nasal, pharyngeal, and/or bilateral ocular pruritis. Table 1 provides common signs and symptoms for URI conditions. AR is an immune response to an antigen (pollen, ragweed, dander, etc)- that when an individual is allergic to said antigen, it then becomes an allergen. Allergens binds to IgE on mast cells which leads to the release of several proinflammatory mediators, leading to congestion, sinus pressure, and so on.. Comorbidities often seen with AR include asthma and atopic dermatitis. Both of these conditions are also IgE mediated, so it makes sense that in an individual that has already presented with this type of hypersensitivity in the bronchi and/or the dermis, they are primed for also exhibiting such a sensitivity in their nose (and eyes). Conjunctivitis The presentation of allergies in the eye, termed allergic conjunctivitis, impacts QOL significantly, and recognizing appropriate management strategies is important to mitigate worsening symptoms. Nonpharmacologic recommendations are fundamental. The American Academy of Ophthalmology recommend the combined dual action antihistamine/mast cell stabilizers as first-line options for the management of allergic conjunctivitis, including for chronic use. (Table ?). Single ingredient agents are only available via prescription and may not provide as fast of an improvement as seen with the dual action agents.19 Caution patients about combination ocular antihistamine/vasoconstrictors due to risk of rebound and diminished efficacy. Caution should also be taken with the use of oral antihistamines (including second generation) in patients that suffer from allergic conjunctivitis. Oral antihistamines may worsen dry eye syndrome and impair the tears film protective barrier, in turn worsening the conjunctivitis. If oral antihistamines are continued, artificial tears may help alleviate tear deficiency and diminish the allergens (inflammation) on the ocular surface. Goals of treatment It is paramount to control one’s AR to prevent further worsening. The continual recruitment and stimulation of cytokines will only lead to a worsening condition that will be more difficult to control. ӽ Control symptoms ӽ Minimize inflammation ӽ Reduce fatigue during the day and improve sleep at night ӽ Prevent worsening of asthma and/or atopic dermatitis (if present)  Table 1. Allergic Rhinitis Medications Intranasal Corticosteroids (INCS) Intranasal antihistamine (INAH) Oral Antihistamines Decongestant (2nd gen only) Rhinocort (budesonide) 1st gen Astepro (azelastine) Allegra (fexofenadine) Pseudoephedrine (po) Nasacort (triamcinolone) 1st gen Claritin (loratidine) Phenylephrine (po) (IN) Flonase (fluticasone) 2nd gen Xyzal (levocetirizine) Levmetamfetamine (IN) Nasonex (mometasone) 2nd gen Zyrtec (cetirizine) Naphazoline (IN) Oxymetazoline (IN Propylhexedrine (IN) Xylometazoline (IN) IN, intranasal; INAH, intranasal antihistamine; INCS, intranasal corticosteroid; po, by mouth AR Treatment The American Academy of Allergy, Asthma, and Immunology (AAAAI) and the American College of Allergy, Asthma, and Immunology (ACAAI) have joined to provide guidance on seasonal AR and created a 2017 guideline, with updated guidance consensus-based-statements for rhinitis in 2020 (Figure 1).[5,14] Medications used in the management of AR include antihistamines (oral and nasal), decongestants (oral and nasal), intranasal corticosteroids (INCS), and intranasal ipratropium (Rx only).[5,14] This unit we will only be discussing to OTC products, which fortunately include all first line recommendations. Evidence-based guidance is organized based on the type and severity of AR, with intermittent AR having different guidance than that of persistent AR. For intermittent AR, first-line recommendations include oral antihistamines (second generation) or intranasal antihistamines (INAH). When symptoms are reported as moderate/severe, first-line recommendations include INAH or oral second-generation antihistamines; first generation oral antihistamines are not recommended. This differs with persistent AR in which first-line recommendations are intranasal corticosteroids (INCS) monotherapy for mild symptom management and INCS and INAH dual therapy for moderate/severe symptoms. First-line management of seasonal AR includes INCS and INAH therapy. INCS provide symptom relief for all symptoms associated with AR including congestion, rhinorrhea and pruritis. If sufficient symptom control is not attained with INCS monotherapy, the AAAAI/ACAAI guidelines recommend adding an INAH, which include azelastine (available OTC) and olopatadine (intranasal olopatadine not yet OTC)..[5,14] Although extremely popular and widely available, second-generation oral antihistamines have fallen out of favor for the management of persistent symptoms. Second generation antihistamines provide minimal if any additional clinical benefit when added to an INCS.[5,14] When INCS monotherapy is insufficient, addition of an INAH is recommended. While some studies may show some symptom relief when adding an oral second-generation antihistamine to INCS, the evidence as a whole does not support a significant clinical benefit. Importantly, INCS and INAH alleviate congestion, whereas oral antihistamines do not. Oral second-generation antihistamines may provide benefit for targeted symptom management of pruritis and rhinorrhea, and are recommended as a first-line option for intermittent AR.[5,14] See Figure 1 for a depiction of the medications recommended for allergic rhinitis. Oral second-generation antihistamines are best reserved for acute therapy when exposure to allergen will be short-term (e.g., an individual with cat allergy having dinner at a home with a cat).[5,14] Cromolyn sodium is another option that is helpful for acute short-term allergen exposure. Nasal saline irrigation for treatment of AR has shown benefit in AR symptom resolution. If patients wish to try saline nasal irrigation, sterile water should be used as tap water may contain the amoeba, Naegleria fowleri. If tap water is used, it should be boiled for 1-5 minutes and cooled. Figure 1. Evidence-Based Recommendations for the Management of Allergic Rhinitis Intranasal Corticosteroids (INCS) Moderate/Severe Symptoms Moderate/Severe Symptoms If looking for If looking for rapid relief or rapid relief or 1: Oral antihistamine mucosal edema 1: INCS + INAH mucosal INCS downregulate inflammatory or INAH prevents edema responses by targeting inflammatory delivery of prevents cells directly. They also activate agents, an 2: INCS delivery of PAR IAR 2: INCS intranasal or monotherapy agents, an glucocorticoid receptors which oral intranasal or decongestant oral suppress cytokines that promote recommended 3: INAH decongestant inflammation. INCS treat all 3: INCS + INAH for < 5 days monotherapy recommended symptoms associated with AR: for < 5 days rhinorrhea, congestion, swelling, pruritis, you name it. All INCS agents exhibit equal If looking for rapid relief or If looking for efficacy, although the total rapid relief or Mild Symptoms PAR 1: Oral antihistamine mucosal edema First line: INCS bioavailability of second-generation Mild Symptoms IAR mucosal edema prevents or INAH delivery of prevents intranasal steroids are significantly delivery of agents, an 2nd line: Oral agents, an lower than that of first-generation 2: Oral antihistamine intranasal or antihistamine or INAH intranasal or agents. This is beneficial in that + pseudoephedrine oral oral decongestant decongestant less systemic exposure results in 3rd line: Oral recommended antihistamine + recommended less risk for systemic effects, so 3: INCS for < 5 days pseudoephedrine for < 5 days IAR, intermittent allergic rhinitis; INAH, intranasal antihistamine; INCS, intranasal corticosteroid; PAR, persistent allergic rhinitis 2nd generation INCS may be preferable in younger patient populations or those that wish to minimize systemic exposure. INCS are superior to oral antihistamines and equal in efficacy to INAH. Maximal effect may take days or even weeks in patients with longstanding untreated symptoms. Special populations ӽ Budesonide (Rhinocort) – preferred in pregnancy Adverse effects: Local irritation of the nasal mucosa, including drying and burning, and discomfort from the run-off into the throat of the liquid medication is reported by 2 to 10 percent of patients using sprays. Formulations containing alcohol or propylene glycol are more irritating than aqueous preparations (check Flonase preparations for alcohol) Intranasal Antihistamine(INAH) Azelastine (Astepro) is the first and only OTC INAH. It is highly effective in managing AR symptoms, including congestion, rhinorrhea, pruritis, you name it. Like INCS, INAH is really effective at mitigating multiple components in ithe IgE mediated pathways. Importantly, azelastine is more than a H1 histamine receptor antagonist. It is also a “mast cell stabilizer”. Azelastine and its metabolite, desmethylazelastine, are H1-receptor antagonists, while azelastine also inhibits histamine release from mast cells. Azelastine and desmethylazelastine compete with free histamine for binding at H1-receptor sites, thereby inhibiting the physiologic effects of histamine. Studies indicate that azelastine inhibits other mediators of allergic reactions (e.g., leukotrienes and PAF). Decreased chemotaxis and activation of eosinophils have also been demonstrated with azelastine. Azelastine may also interfere with histamine- and leukotriene-induced bronchospasm. All in all, azelastine is a really excellent agent for treating AR, without the systemic (anticholinergic) effects of oral 1st generation antihistamines, while being much more efficaceous than the oral second generation antihistamines. Oral Second Generation Antihistamines Second generation antihistamines (aka H1-antagonists) are highly selective for histamine H1-receptors. They do not inhibit histamine production, they inhibit histamine from binding to the H1 receptors. H1-antagonists compete with free histamine for binding at H1- OTC Antihistamines receptor sites. This competitive Second generation First generation (Sedating) antagonism blocks the effects of fexofenadine (60–120 mg) (Allegra®) Diphenhydramine histamine on H1-receptors in levocetirizine (5 mg) (Xyzal®) Doxylamine the GI tract, uterus, large blood loratadine (10 mg) (Claritin®) Pyrilamine Figure 2. ASTEPRO (azelastine OTC product) cetirizine (10 mg) (Zyrtec) Brompheniramine vessels, and bronchial muscle. They mostly do not readily cross the blood-brain Sedation Comparison KEY Dexbrompheniramine barrier (BBB), although some may may have the affinity to do so at lower levels Highly sedating Pheniramine than that exhibited with first generation antihistamines. (See figure for sedative Moderately sedating Chlorpheniramine properties of OTC antihistamine which corresponds with their ability to cross Mildly sedating Meclizine Sedation possible the BBB) Second generation antihistamine preferentially bind at H1-receptors Sedation unlikely in the periphery rather than within the brain, which accounts for some of its No sedation nonsedating character. H1-blockers are similar in structure to anticholinergics, local anesthetics, antispasmodics, and ganglionic- and adrenergic-blocking agents, sharing some of their properties. H1-blockers possess anticholinergic Figure 3. OTC Antihistamines Sedation Comparison properties in varying degrees (mostly evidenced with 1st generation antihistamines, not 2nd); Most second generation antihistamines do not exert significant anticholinergic effects at therapeutic concentrations. Oral antihistamines can treat most allergic symptoms, but are NOT effective in treating nasal congestion. No matter your pharmacologic choice for treating AR, don’t forget about the importance of non-pharmacologic actions. Non pharmacologic recommendations for allergic rhinitis AND allergic conjunctivitis include: Avoid allergen Avoid eye rubbing Apply cold compresses over the eyes Bathing/showering before bedtime Eyelid cleansers to remove allergen Frequent clothes washing Hypoallergenic bedding Refrigerated artificial tears Sunglasses as barrier to airborne allergens Conjunctivitis The presentation of allergies in the eye, termed allergic conjunctivitis, impacts QOL significantly, and recognizing appropriate management strategies is important to mitigate worsening symptoms. Nonpharmacologic recommendations are fundamental (See box above). The American Academy of Ophthalmology recommend the combined dual action antihistamine/mast cell stabilizers as first-line options for the management of allergic conjunctivitis, including for chronic use. (Table 2). Previously only prescription only, there are now 2 options available OTC for first line therapies: ketotifen 0.25% and olopatadine 0.1%, 0.2%, 0.7%. Caution patients about combination ocular antihistamine/vasoconstrictors (pheniramine/naphazoline) which are also sold OTC for allergic conjunctivitis, however due the naphazoline (vasoconstructor-aka decongestant for the eye) there is risk of rebound and these agents do not provide the level of efficacy seen with the antihistamine/mast cell products. Caution should also be taken with the use of oral antihistamines (including second generation) in patients that suffer from allergic conjunctivitis. Oral antihistamines may worsen dry eye syndrome and impair the tears film protective barrier, in turn worsening the conjunctivitis. If oral antihistamines are continued, artificial tears may help alleviate tear deficiency and diminish the allergens (inflammation) on the ocular surface. Table 2. OTC medications for allergic conjunctivitis Brand Names Active ingredients Medication Class Zaditor Ketotifen 0.25% Antihistamine/Mast cell stabilizer Pataday Olopatadine 0.1%, Olopatadine 0.2%, 0.7% Antihistamine/Mast cell stabilizer Opcon-A Pheniramine 0.315%/Naphazoline 0.0268% Antihistamine/vascoconstrictor Upper Respirator Tract Infections (URTI) The diagnosis of URTI is typically made clinically based on symptoms such as nasal congestion, rhinorrhea, cough, or sore throat lasting 7-14 days. URTI is a diagnosis of exclusion in patients with high-risk comorbidities such as immunodeficiencies or chronic disease. The differential diagnosis for URTI includes more serious illnesses such as pneumonia, epiglottitis, pertussis, meningitis, bacterial rhinosinusitis, noninfectious rhinitis, AR, and vasomotor rhinitis. Testing is usually not needed for diagnosis, but tests to consider include rapid antigen detection testing or throat culture for streptococcus, rapid antigen testing for influenza, pulse oximetry to assess for hypoxia and lower respiratory tract infection, and chest x-ray for pneumonia. Chest X-rays should be reserved for patients with clinical suspicion of pneumonia, acute upper airway infection with comorbid conditions, and patients with If symptoms not resolving, may have symptoms persisting > 3 weeks. Sore Throat: Topical throat products and/or analgesics post viral ARS and INCS may be Malaise: analgesics helpful Rhinosinusitis, a term used to describe inflammation of the nose and paranasal sinuses, often presents with nasal congestion, Overall nasal discharge (anterior and/ resolution of or posterior nasal drip), and Days 1-3 Sore throat, malaise Days 4-7 Nasal symptoms worsen, thicker excretions symptoms facial pressure or pain.[6,9] Allergic rhinitis is different from rhinosinusitis, although symptom overlap exists, such as rhinorrhea and nasal congestion. The cold Day 0 Day 14 is a form of rhinosinusitis, acute Nasal symptoms, rhinorrhea, congestion, possible cough from Days 2-10 rhinosinusitis (ARS), and may postnasal drip be described as viral, post-viral, or bacterial. Viral ARS is defined when symptoms last up to 10 days. Rhinorrhea: 1st generation antihistamines Post-viral ARS is defined by Congestion: Oral or intranasal decongestant episodes that last longer than 10 days, but < 12 weeks. INCS, intranasal corticosteroid Figure 4. ARS Symptom Time Table Bacterial ARS (often referred to as bacterial sinusitis) is determined by symptoms that worsen after 5-7 days, or last longer than 10 days with exacerbating symptoms. It is important to differentiate between post viral ARS and bacterial ARS. Evidence supports resolutions of symptoms utilizing INCS in place of antibiotics specific to the setting of post viral ARS. For example, intranasal mometasone 200mg twice daily produced significant symptom improvements in comparison to amoxicillin and placebo. [Fokkens, 2020; Meltzer 2005] Thus, simply because the cold remains beyond 10 days, does not immediately indicate the need for antibiotics! Bacterial ARS symptoms include three of the following: fever >102.2°F (39°C), discolored mucus, double-sickening (recovery from initial illness then worsening), elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ERP), local severe pain (often unilateral in presentation).[4,9,10] A depiction of the common cold timeline, including the point in which post-viral ARS may be expected, with corresponding medications for symptom management is provided (Figure 4) Bacterial sinusitis, as stated above, presents with more severe symptoms: Congestion, cough, post-nasal drip for more than 10 days, facial pain (often described as maxillary tooth pain), fever > 102 F, and symptoms worsening after initial improvement (this is the definition of “double sickening”). In the case of bacterial ARS antibiotics may be indicated. However, current guidelines stress that antibiotics are not always necessary. The following depiction provides the recommended treatment pathways that may be considered for the management of bacterial sinusitis: Analgesic Watchful waiting: if s/sx do not improve Antipyretic in 7 days, antibiotics warranted. Congestion, cough, INCS Intranasal saline post-nasal drip > 10 days without symptom resolution Option 1 Facial pain Maxillary tooth pain Acute bacterial Fever > 102 degrees F sinusitis Symptoms worsening Option 2 after initial improvement (“double- sickening”) Analgesic Antipyretic Intranasal saline Amoxicillin or Amoxicillin/clavulanate +/- INCS Items in gray are FYI only Beta lactam allergy → doxycycline, levofloxacin or moxifloxacin INCS, intranasal corticosteroids; s/sx, signs/symptoms Figure 5. Bacterial ARS Treatment Algorithms Pharyngitis Pharyngitis is inflammation of the pharynx or a sore throat. It may be infectious or non-infectious and corresponding symptoms are important to determine appropriate care. Pharyngitis is most often viral in origin. Of note, co-occurrences of SARS-CoV-2 and bacterial streptococcal pharyngitis are possible, so monitoring and testing, as indicated, is imperative. If symptoms are persistent beyond 10 days Pharyngitis or worsen after 7 days, bacterial etiology is Congestion (Sore Throat) possible. Bacterial pharyngitis is most Pseudoephedrine (po) often caused by group A Streptococcus Benzocaine (T) Phenol (T) (GAS) infection, and commonly referred Menthol (T) to as strep throat. If symptoms are Acetyl Salicylic Acid (T) persistent beyond 10 days or worsen after 7 days, bacterial etiology is possible. Budesonide (IN) Acetaminophen (po) Bacterial pharyngitis is most often caused Mometasone (IN) by group A Streptococcus (GAS) infection, Ibuprofen (po) Fluticasone (IN) and commonly referred to as strep throat. Triamcinolone acetonide (IN) naproxen (po) If bacterial pharyngitis is suspected, Cromolyn sodium* (IN) aspirin (po) GAS testing should be performed prior to prescribing antibiotics. This is another diphenhydramine (po) service in which community pharmacists Fexofenadine* (po) Fever are beginning to provide, testing for Strep Pyrilamine(po) A, and prescribing antibiotics if individuals brompheniramine (po) test positive for group A Streptococcus. Pain Chlorpheniramine(po) management is an important component in Dexbrompheniramine (po) the care of pharyngitis. Systemic analgesics Rhinorrhea provide the best level of pain management IN, intranasal; po, by mouth; T, topical but may not be appropriate for patients with * Provides relief of this symptom ONLY in the setting of allergic rhinitis comorbidities or receiving medications Figure 6. Medications and symptoms targeted for those comorbidities that may further interact (e.g., NSAIDs and congestive heart failure, NSAIDs with medications for the management of heart failure or blood pressure lowering medications). Pain management may include oral analgesics and/or topical analgesics. There are several over-the- counter sprays and lozenges that enable almost immediate, albeit short-term, relief for sore throat (Table 6). Figure 6 provides medications according to symptoms they target. Keep in mind that the second generation anthistamines will only be effective at treating rhinorrhea if it is caused due to allergic rhinitis. They will not improve rhinorrhea if it is as a result of a viral infection (or bacterial). Influenza Influenza, caused by a single-stranded, segmented, negative-sense, RNA virus of the Orthomyxoviridae family, is a major cause of mortality and morbidity worldwide. Seasonal epidemics in adults and children are associated with an estimated 3-5 million cases of severe illness and about 290,000- 650,000 deaths annually. Transmission occurs via respiratory droplets and fomites, with an incubation period of 1-4 days. Complicated or severe disease is more likely in persons with chronic medical conditions or immunosuppression, pregnant women, residents of nursing homes or long-term- care facilities, American Indians/Alaska Natives, and persons with morbid obesity. Major complications include primary influenza pneumonia, secondary bacterial pneumonia, and exacerbation of underlying chronic medical conditions. Diagnosis of influenza is crucial as antivirals are most effective when given early in the course of the disease. Clinical diagnosis based on symptoms alone can be made when influenza prevalence is high, with a 75% accuracy rate in adults during influenza season. Nasopharyngeal swabs are preferred for influenza testing due to their high sensitivity and specificity. Symptoms include an abrupt onset of fever, headache, myalgia, and malaise.[2,12] Many pharmacists in the community are now able to provide this testing and corresponding antiviral prescriptions when the test is positive. For individuals otherwise healthy, influenza requires rest and symptom management which includes the requirement for a lot of rest, and possibly analgesics for high fevers (that last for several days) and the aches and pains associated with misery that is the flu. The BEST treatment is prevention. (aka obtaining the annual flu shot). Symptom management Symptom management should be targeted to the symptoms an individual is experiencing. Often times combination “cough and cold products” contain active medications that are not needed. Additionally combination products may include subtherapeutic dosing of certain products that may minimize their efficacy in treating the symptom for which it is indicated. Combination products often include acetaminophen, which should be noted as it is important to counsel patients to take precaution in not taking acetaminophen in other formulations. Symptoms change as the condition progresses, so selecting medication that targets only the symptoms currently being experienced is best. (See Figure 6 for symptoms and corresponding medications) “Treating” the common cold The common cold can be difficult to provide evidenced-based recommendations due numerous variabilities of the common cold. Such variabilities include the causative viruses, differing presentation in the young and old, expansive options for treatment, and co-morbidities that may impact treatment and presentation.[8,9] Figure 4 provides a depiction of the timeline associated with acute viral rhinosinusitis and medication management options in alignment with corresponding symptoms. Oral first-generation antihistamines may provide benefit for days 1 and 2 following symptom onset. Unlike allergic rhinitis, histamine levels are not elevated in nasal secretions with the common cold.] First-generation, (not second- generation antihistamines) exhibit competitive antagonism of acetylcholine at neuronal and neuromuscular muscarinic receptors, which explains benefit in reducing cold symptoms. In a study evaluating persons with colds, no differences were observed between loratadine (a second generation antihistamine) and placebo regarding viral shedding rates, viral titers, overall infection rates, illness rates, or symptom scores. Therefore, second generation antihistamines do not provide any benefit for the common cold. Short term use of oral and nasal decongestants provides beneficial effect for congestion symptoms.[5,9] Intranasal decongestants are recommended for short term use (< 5 days) to avoid rebound congestion (rhinitis medicamentosa) from alpha-receptor tachyphylaxis. Intranasal decongestants provide rapid relief of congestion by decreasing nasal mucosal edema. Rhinitis medicamentosa: Rhinitis medicamentosa, also known as ‘rebound congestion’ is inflammation of the nasal mucosa caused by the overuse of topical nasal decongestants. It is classified as a subset of rhinitis: drug-induced rhinitis. A common clinical history is a patient with nasal congestion from a cold or rhinitis who uses an over-the-counter intranasal decongestant for relief, and then continues to use the decongestant for weeks, months, or years. Cessation of the intranasal decongestant is followed by rebound congestion that is quite profound, leading to more use of the decongestant.’’ Treatment of rebound includes discontinuation of the intranasal decongestant and utilization of intranasal corticosteroids. The first week is often the most difficult for weaning or withdrawal. Several studies confirm efficacy of nasal corticosteroids in the treatment and prevention of rhinitis medicamentosa. Although not always necessary, short-course oral corticosteroids are the most effective way to break the cyclic use of topical vasoconstrictors. The oral corticosteroids are often used for 5-10 days, with nasal corticosteroids started at the same time and continued until the process is corrected. Saline nasal irrigation with saline solutions may also be helpful. Table 3. Differentiating Upper Respiratory Tract Conditions Condition Causative agents (etiology) Key diagnostic findings Viral ARS (the common cold) Adenovirus, enterovirus, coronavirus, respiratory Nasal congestion, nasal discharge/postnasal drip, reduction/loss of smell, syncytial virus sore throat, cough, malaise Post viral ARS Adenovirus, enterovirus, coronavirus, respiratory Nasal congestion, nasal discharge/postnasal drip, reduction/loss of smell, syncytial virus sore throat, cough lasting beyond 10 days but less than 12 weeks. Bacterial ARS H. influenzae, S. pneumoniae, and Moraxella Discolored mucus, severe local pain, fever >102.2°F (39°C), elevated CRP/ catarrhalis ERP, double sickening, reduction/loss of smell, maxillary tooth/facial pain/ tenderness, facial congestion Influenza Influenza Abrupt onset of fever, headache, myalgia, malaise Pharyngitis Viral or bacterial, group A Streptococcus Bacterial: Sore throat, fever, absence of cough Viral: Sore throat in addition to any of the symptoms present with ARS Allergic rhinitis Allergens Airway inflammation, mucous hypersecretion, pruritis ARS, acute rhinosinusitis; CRP, C-reactive protein; ERP, erythrocyte sedimentation rate Table 4. Medications for Allergic Rhinitis & ARS OTC Product Active Ingredient Adult Dosing Intranasal corticosteroids (INCS) May cause burning sensation of the nose, stinging of the nose, epistaxis, dizziness, headache First generation INCS Nasacort Triamcinolone acetonide 2 sprays (55mcg/spray) per nostril once daily Rhinocort Budesonide 2 sprays (32mcg/spray) per nostril once daily; once clinical response obtained, decrease to 1 spray per nostril daily Second generation INCS Flonase Fluticasone 2 sprays (27.5mcg/spray) per nostril once daily for 1 week; after first week, 1-2 sprays per nostril may be used Nasonex Mometasone 2 sprays (50mcg/spray) per nostril once daily Intranasal antihistamine (INAH) May cause bitter taste, headache, dysesthesia, drowsiness Astepro Azelastine (0.15% spray) 1-2 sprays (205.5mcg/spray) per nostril once to twice daily Intranasal Cromolyn May cause burning sensation/stinging of the nose NasalCrom Cromolyn sodium 1 spray per nostril every 4 hours at least use 3-4 times daily Oral First Generation Antihistamines May cause anticholinergic adverse events (dry mouth, dry eyes, constipation) Benadryl Diphenhydramine ARS: 25-50 mg every 4-6 hours, max 300 mg daily Cough: 25mg every 4-6 hours, max 150mg daily Chlor-Trimeton Chlorpheniramine 4 mg every 4-6 hours, max 24 mg daily Less Drowsy Dramamine Meclizine Not indicated for cough or cold (indicated for vertigo and N/V associated with motion sickness) Dramamine Dimenhydrinate Not indicated for cough or cold (indicated for vertigo, N/V motion sickness) Unisom Doxylamine 10 mg every 4 to 6 hours as needed. Max: Do not exceed 6 doses (60 mg) per 24 hours. (Only available OTC as 25mg!) Hah. Mostly used as a sleep aid, not for cough/cold. Combination products Brompheniramine These are found in cough/cold/flu combination products. Dexbrompheniramine Menstruation products Pyrilamine Found in a combination menstruation pain product (with acetaminophen & caffeine or acetaminophen and pambrom) Oral Second Generation Antihistamines May cause headache, diarrhea Allegra Fexofenadine 120 mg once daily or 60 mg twice daily Claritin Loratidine 10 mg once daily or 5 mg twice daily Xyzal Levocetirizine 5 mg once daily Zyrtec Cetirizine 10 mg once daily Intranasal decongestants May cause epistaxis, burning/stinging of nasal passages; Caution for rebound congestion, don’t use for more than 5 consecutive days Levmetam-fetamine Levmetam-fetamine 2 inhalations in each nostril not more than every 2 hours and not more than 7 days (Vapor Inhaler) Naphazoline (Privine) Naphazoline 1-2 sprays each nostril every 6 hours for a maximum of 3 days Afrin, Vick’s Sinex Severe, Oxymetazoline 2-3 sprays each nostril every 12 hours for a maximum of 3 days; do not exceed 2 doses in 24 hours Mucinex Sinus-MAX Neo-Synephrine Phenylephrine 2-3 sprays each nostril every 4 hours for a maximum of 3 days Benzedrex Propylhexedrine 2 inhalations in each nostril (while blocking the other nostril) not more than every 2 hours for a maximum of 3 days Sinosil Xylometazoline 2-3 sprays each nostril every 8-10 hours for a maximum of 3 days Oral decongestants Caution in patients with a history of angina, arrhythmias, cerebrovascular disease, uncontrolled HTN, bladder outlet obstruction, glaucoma, hyperthyroidism, or Tourette syndrome; risk vs benefit should be considered in older adults. SudafedPE Phenylephrine 60 mg orally every 24 hours Sudafed Pseudoephedrine 60 mg orally every 4 to 6 hours or SR tablets, 120 mg orally every 12 or 24-hours, 240 mg orally every 24 hours; max, 240 mg per day Topical Throat Pain Relief Products Cepacol Maximum Benzocaine 15mg Dissolve 1 lozenge slowly in the mouth; may use once every 2 hoursc Strength Throat Drop Lozengers Chloraseptic Sore Throat Phenol 1.4% Spray once to the area of discomfort; allow to stay in place for 15 seconds and then spit out; may Spray be used every 2 hours Biovanta Dual Action Sore Acetyl Salicylic Acid 6mg Apply one spray of each to affected area no more than once every 30 minutes Throat Spray Mucinex InstaSoothe Sore Benzocaine 7% Spray onto area of discomfort and allow to stay in place for 1 minute, then spit out; may be used 4 Throat + Pain Relief Menthol 1% times daily Vicks VapoCool Sore Benzocaine 5% Spray onto area of discomfort and allow to stay in place for 1 minute, then spit out; may be used 4 Throat Spray Menthol 1% times daily Vicks VapoCool Sore Benzocaine 15mg Dissolve 1 lozenge slowly in the mouth; may use once every 2 hours Throat Lozenges Menthol 20mg Vicks VapoCool Severe Menthol 20mg Dissolve 1 drop slowly in the mouth; may use once every 2 hours Sore Throat Drops Eye Drops for the Management Allergic Conjunctivitis Zaditor Ketotifen 0.025% Instill 1 drop into the affected eye(s) twice daily every 8 to 12 hours, maximum: do not exceed 2 applications/day Pataday Olopatadine 0.1%: Instill 1 drop into each affected eye twice daily (allow 6-8 hrs between doses) 0.1%, 0.2%, 0.7% 0.2%, 0.7%: Instill 1 drop into each affected eye once daily Opcon-A Pheniramine 0.315%, Instill 1 to 2 drops into the affected eye(s) up to 4 times daily Naphazoline 0.02675% References 1. 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