Responding to Cough & Cold Symptoms - PDF

RESPONDING TO SYMPTOMS: COUGH & COLD NURUL AIN MOHD TAHIR, PHD, RPH FACULTY OF PHARMACY UNIVERSITI KEBANGSAAN MALAYSIA LEARNING OBJECTIVES Identify causes & symptoms of cough and common cold Explain when referral is required Recommend the appropriate treatment for common cold...

RESPONDING TO SYMPTOMS: COUGH & COLD NURUL AIN MOHD TAHIR, PHD, RPH FACULTY OF PHARMACY UNIVERSITI KEBANGSAAN MALAYSIA LEARNING OBJECTIVES Identify causes & symptoms of cough and common cold Explain when referral is required Recommend the appropriate treatment for common cold & different types of cough Cough and Cold 2  INTRODUCTION Cough and cold are mild respiratory tract problems that often coexist Cough is a protective mechanism to clear the airways from contaminants/reaction to infection Common cold is usually caused by viral infection & normally present as a complex of symptoms Cough and Cold 3 COUGH  COUGH Cough is a natural defense mechanism of the body to help clear foreign items from the airways Two main types of cough: A productive cough (chesty cough with sputum) or A non-productive cough (dry, tight, tickly) Coughs are either classified as acute or chronic in nature acute cough lasts < 3 weeks chronic cough lasts > 8 weeks Cough and Cold 5  COUGH Most coughs are self-limiting but cough > 3 weeks & not improving requires referral for further investigation Most common cause of acute cough is viral URTI Viral coughs typically present with sudden onset & associated fever Associated cold symptoms are often present Cough and Cold 6  COUGH: Differential diagnosis Serious causes of cough that require medical referral if suspected:  Asthma  Croup  Chronic bronchitis  Adverse drug reactions  Heart failure  Tuberculosis  Gastro-oesophageal reflux disease (GORD)  Carcinoma of the lung Cough and Cold 7 COUGH: Specific Questions Age of the patient Children will most likely be suffering from a URTI but asthma & croup should be considered With increasing age, conditions such as bronchitis, pneumonia & carcinoma become > prevalent 8 Cough and Cold COUGH: Specific Questions Nature/colour of sputum Dry/productive Mucoid (clear & white) sputum suggests that no infection is present Yellow, green or brown sputum normally indicates infection Frothy, pink-tinged sputum may suggest heart failure 9 Cough and Cold COUGH: Specific Questions Duration of cough About 3 days may suggest URTI At 3 weeks duration may indicate acute or chronic bronchitis Longer duration > 3 months may suggest chronic bronchitis, tuberculosis or carcinoma 10 Cough and Cold COUGH: Specific Questions Periodicity Adult patients with recurrent cough might have chronic bronchitis, especially if they smoke Care should be emphasized in children who present with recurrent cough & have a family history of eczema & hay fever --- might suggest asthma 11 Cough and Cold COUGH: Specific Questions Smoking History Patients who smoke are more prone to chronic & recurrent cough Over time this might developed into chronic bronchitis & COPD 12 Cough and Cold  COUGH: Referral  Persistent nocturnal cough in children  Cough persisting for > 3 weeks and not improving  Coloured sputum (yellow/green/brown)  Blood-stained sputum  Chest pain  Wheeze/SOB  Severe pain on inspiration  Suspected ADR  Cough associated with weight loss and/or fatigue Cough and Cold 13  Cough Preparations Cough suppressants (antitussives) Dry, irritating coughs Expectorants & mucolytics Chesty, productive coughs Decongestants Wheezy coughs Demulcents Soothe any kind of cough Cough and Cold 14 Cough suppressants (antitussives) OPIODS ANTIHISTAMINES Cough and Cold 15 Opioids The compounds available are: codeine, pholcodine and dextromethorphan Act on the cough centre in the brain to depress the cough reflex Dextromethorphan is the most widely used opioid constituent of OTC cough preparations Codeine & pholcodine are rated as > potent than dextromethorphan, but have a greater side-effect profile Codeine may cause sedation, constipation & addiction Cough and Cold 16 Antihistamines  The compounds available are: chlorpheniramine, diphenhydramine, promethazine, triprolidine  Exert a central & peripheral inhibitory action on neuronal pathways involved in the cough reflex  Also exert anticholinergic side-effects including drying up bronchial & nasal secretions  May also cause sedation with may aid cough sufferers to sleep at bedtime  NOT recommended for patients with glaucoma or prostate problems Cough and Cold 17  Cough Preparations Cough suppressants (antitussives) Dry, irritating coughs Expectorants & mucolytics Chesty, productive coughs Decongestants Wheezy coughs Demulcents Soothe any kind of cough Cough and Cold 18  Mucolytics Mucolytics are useful to loosen thick mucosal secretions & to help expel the excess phlegm Examples include acetylcysteine, carbocisteine, ambroxol & bromhexine Cough and Cold 19  Expectorants Expectorants are used to assist mucus removal Compounds available are: guaifenesin, ammonium chloride, ipecacuanha & squill Guaifenesin is the only active ingredient that has any evidence of effectiveness There is little risk of adverse effects from expectorants & they do not interact with other drugs Cough and Cold 20  Decongestants The sympathomimetics ephedrine & pseudoephedrine are used as decongestants in cough remedies Useful in coughs where tissues of the upper respiratory tract are congested, as they shrink swollen mucosa & open up the airways Should be avoided in patients with cardiovascular condition, diabetes or thyroid problems Must be avoided by patients taking MAOIs or beta-blockers Cough and Cold 21  Demulcents Coat the mucosa of pharynx & provide short-term relief of the irritation that provokes reflex coughing Compounds include: glycerin, liquid glucose, syrup, honey Pastilles (e.g. glycerin, lemon & honey) provide a more prolonged soothing effect than liquids Pharmacologically inert & safe for everyone However, some preparations contain Cough and Cold high sugar content 22  Combination products Many of the OTC cough preparations are combinations of agents. Some products contain pharmacologically rational combinations (e.g. antitussive with decongestant, or expectorant with decongestant) A few combination products contain sub-therapeutic doses of active ingredients, or illogical combinations (e.g. cough suppressant with expectorant). Cough and Cold 23 THE COMMON COLD THE COMMON COLD The common cold is extremely prevalent, with children contracting colds > frequently than adults Caused by viral URTI including rhinoviruses (30-50% of all cases) & coronaviruses (10% of infections) Transmission is via nasopharyngeal droplets, released by sneezing & coughing, inhaled directly or passed on to fingers via surfaces where droplets land Cough and Cold 25 THE COMMON COLD-Symptoms Onset is gradual, with initial discomfort in the eyes, nose & throat Symptoms are mild to moderate There is sneezing & nasal discharge (rhinorrhoea), usually followed by congestion May be sore throat & cough due to irritation of pharynx & postnasal drip In addition, headache, mild- moderate fever & general malaise may be present Most colds resolve in 1 week, although complications may follow with secondary bacterial infections Cough and Cold 26  THE COMMON COLD-Questions Onset of symptoms Nature of symptoms Aggravating factors Flu (Influenza) Marked myalgia, chills & Headache/pain that is symptoms tend to malaise, loss of appetite worsened by have a more abrupt are > prominent in flu sneezing, coughing & onset than the than the common cold bending over suggests common cold sinus complications Common cold occurs Presence of ear pain any time throughout may indicate middle the year compared to ear involvement (otitis flu which is seasonal media) Cough and Cold 27 THE COMMON COLD-Referral Acute sinusitis not responding to Opportunity to build decongestant therapy Patients with certain medical conditions (e.g. heart/lung disease, Opportunity diabetes, to build immunocompromised patients) Earache Freedom not responsive to analgesic to invent Vulnerable patient groups, such as Opportunity to build children < 2 years old & the elderly Patients with Fewsymptoms indicative of flu competitors Cough and Cold 28  THE COMMON COLD-Treatment SYMPTOM TREATMENT The goal of the treatment is to Cough Antitussives or expectorants provide symptomatic relief Nasal congestion Oral/topical decongestants Most drug Rhinorrhoea Antihistamines preparations often contain a combination Sore throat Local anesthetics or systemic analgesics of ingredients intended to treat 2 or Fever & headache Systemic analgesics/ antipyretics > symptoms Cough and Cold 29 Antihistamines Sedating antihistamines are used to treat rhinorrhea Usually co-formulated with sympathomimetics to counteract the congestion & sedation that they tend to cause Sedating antihistamines should be used with caution because they can decrease mental awareness & impair performance Cough and Cold 30  Systemic decongestants Constrict dilated blood vessels & swollen nasal mucosa, easing congestion & helping breathing Compounds used are sympathomimetic amines: pseudoephedrine, phenylephrine & oxymetazoline Patients should be advised not to take a dose just before bedtime because their mild stimulant action can disturb sleep Should be avoided by patients with high blood pressure, heart disease, hyperthyroidism or diabetes Must be avoided by patients taking MAOIs or beta-blockers Cough and Cold 31  Topical/nasal decongestants Vasoconstricting effect is localized to area of application Provide fast relief with minimal absorption Compounds used are oxymetazoline, xylometazoline, ephedrine & phenylephrine Should not be used for > 7 days otherwise rhinitis medicamentosa (rebound congestion) can occur Cough and Cold 32  SPECIAL POPULATIONS SPECIAL POPULATIONS Elderly and Certain Children Pregnant Women Medical Conditions Cough and Cold 34  CHILDREN OTC cough and cold products should not be used in children under 2 years of age The Ministry of Health issues a notice in 2009 restricting the use of cough & cold preparations containing antitussives, antihistamines & decongestants in children up to 6 years of age; & ordered a manufacturing company to include a warning in the product label which states: “Not to be used in children less than two years of age” & “To be used with caution on doctor or pharmacist’s advice in children 2-6 years of age” 35 Cough and Cold SPECIAL POPULATIONS Elderly and Certain Children Pregnant Women Medical Conditions Cough and Cold 36 PREGNANT WOMEN Always weigh the benefits versus the risks when recommending OTC cough and cold preparations Consider non-pharmacological therapy such as rest & fluids Recommend the smallest effective dose whenever possible. Pregnancy category for common active ingredients:  Category B – Chlorpheniramine, diphenhydramine  Category C – Pseudophedrine, phenylephrine, oxymetazoline, xylometazoline, dextromethorphan 37 Cough and Cold SPECIAL POPULATIONS Elderly and Certain Children Pregnant Women Medical Conditions Cough and Cold 38 Elderly and Certain Medical Conditions Elderly Products containing antihistamines should be used with caution Patients with hypertension, DM, and thyroid disease Products containing decongestants should be avoided due to its vasoconstriction & sympathomimetic properties Patients with glaucoma & benign prostate hypertrophy (BPH) Products containing antihistamines should be avoided Cough and Cold 39 Thank you Cough and Cold 40