L2 OTC_Cold & flu_1445_stv.pdf

Cold & Flu : Managing symptoms and supporting self-care Common cold Common cold It is a mild viral infection affecting the nose, throat, sinuses and upper airways. • Its peak incidence is during autumn and winter, but it can occur at any time of year. • A self-limiting ( approximately two out o...

Cold & Flu : Managing symptoms and supporting self-care Common cold Common cold It is a mild viral infection affecting the nose, throat, sinuses and upper airways. • Its peak incidence is during autumn and winter, but it can occur at any time of year. • A self-limiting ( approximately two out of three patients recovering over time without consulting a medical practitioner). Common cold • It is predominantly transmitted via direct contact. • It also may exacerbate respiratory diseases, such as asthma and chronic bronchitis Common cold Risk factors • Infants & children • Individuals with weakened immune systems or chronic medical conditions • Staying indoors and in close contact with infected individuals • Low humidity • Inadequate or poor-quality of sleep • Psychological stress • Smoking Common cold Signs and symptoms of the common cold include: • Sore throat • Runny nose • Coughing • Sneezing • Stuffy nose • Post-nasal drip • Mild headaches and body aches • Mild to moderate fever (<39°C, <102ºF), more common in children but rare in adults • Watery eyes • General malaise Common cold The incubation period for the common cold is 24 to 72 hours, although it can be as short as 10 to 12 hours. A scratchy or sore throat and sneezing are usually the first signs of the common cold, followed by profuse nasal discharge, congestion and cough Common cold Red-flag symptoms: . Fever ≥39°C (102ºF) or chills in adults • Fever for 5 days or more, or fever returning after a feverfree period in adults • Fever ≥38°C (100ºF) in infants • Rising fever or fever lasting more than 2 days in children of any age • Symptoms that do not improve or that worsen in children • Excessive irritability in children Common cold Red-flag symptoms: • Lack of appetite or poor feeding in children • Bulging in the soft spot of the skull in children (bulging fontanelle) • Symptoms of meningitis (severe headache, high fever, neck pain or stiffness, photophobia) • Confusion • Vomiting • Severe diarrhoea • Severe dehydration Influenza (flu) Influenza (Flu) • It is an acute respiratory infection caused by influenza viruses that affect the upper respiratory tract. • It is contagious and affects all parts of the world, representing a year-round disease burden. • It can cause mild to severe symptoms and, at times, can lead to hospitalization and death, particularly among vulnerable groups, such as children, the elderly, pregnant women and individuals with chronic medical conditions. • Influenza viruses are classified into four types: A, B, C and D • The A(H1N1) and A(H3N2) are viruses that routinely circulate among individuals Influenza (Flu) • Similarly to the common cold, influenza is spread via direct contact, indirect contact and airborne transmission • Most people recuperate from influenza in less than two weeks, but some individuals may develop complications. • Influenza may potentially exacerbate chronic cardiovascular conditions and respiratory disease, like asthma Influenza (Flu) Risk factors • Children under five years old • Elderly • Pregnant women • Individuals with chronic medical conditions (such as cardiovascular, haematological, pulmonary, renal, metabolic, hepatic or neurodevelopmental diseases) • Individuals with immunosuppressive conditions (such as malignant diseases or HIV/AIDS) or individuals receiving steroids or chemotherapy • Healthcare workers Influenza (Flu) Signs and symptoms of the common cold include: • Fever • Chills • Marked muscle or body aches; • Runny nose • Stuffy nose • Coughing (usually dry cough) • Sore throat • Fatigue • Headache • Severe malaise • Vomiting and diarrhea (more common in children, rare in adults). Influenza (Flu) As compared with the common cold, the onset of influenza symptoms is more sudden. Cough can be severe and last for two or more weeks The incubation period is about 2 days, but ranges from 1-4 days. Comparison of signs and symptoms of the common cold & influenza Treatment Treatment of Common Cold The goal of therapy is: •Prevent transmission of cold virus. •Reduce bothersome symptoms. Centre for Disease Control and Prevention (CDC), United States encourages frequent hand cleansing with soap to reduce transmission of cold viruses. Pharmacological treatment • The common cold is usually self-limiting • The aims of using non-prescription drugs is to relieve symptoms and improve quality of life while the infection runs its course and resolves over time. • The use of medicines not only aids in restoring normal nasal function but may also help prevent secondary complications. Pharmacological treatment Selecting the most optimal treatment products can be overwhelming for some patients …. Why?? • Due to the plethora of available medicines, brands and formulations available. • Single-ingredient products are still preferred due to greater dosing flexibility as well as reduced risk of confusion, inadvertent overdose, or inadvertent underdose. • Some patients may prefer combination products, and pharmacists should use their professional judgement to counsel patients on the most appropriate product. Antibiotics are ineffective against viral infection Pharmacological treatment 1. Decongestants (topical or systematic). 2. Antihistamines. 3. Antitussives and expectorants. 4. Systemic analgesics. 5. Local anaesthesia: (benzocaine, dyclonine). 6. Combination products. Pharmacological treatment 1. Decongestants (topical or systematic) • They are adrenergic agonists( sympathomimetics) , causing vasoconstriction and decreasing sinusoid vessel engorgement and mucosal edema. • They are indicated, for temporary relief of nasal and eustachian tube congestion and for cough associated with post-nasal drip. Summary comparison between topical and oral nasal decongestants How to Treat Rhinitis Medicamentosa ? •Slowly withdrawing of topical decongestant •Replace topical decongestants with topical normal saline •Using topical corticosteroid. ➢ Topical steroids have been proven useful during this transition period, as well as oral steroids for severe cases. ➢ An effective adjunct to this therapy is buffered saline solution in the form of nasal irrigation, which not only moisturizes the nasal mucosa, but provides medication-free, non-addicting decongestant relief. ➢ Patients can be kept on nasal saline irrigation for long-term periods without any concerns for side effects, and this has proven to be useful when it comes to preventing relapse (repeat use of topical decongestants). Decongestants Drug Interactions Pharmacological treatment 2. Antihistamines • They are anticholinergic can be used for treatment of rhinorrhoea and sneezing • First-generation antihistamines such as brompheniramine, chlorphenamine, diphenhydramine, doxylamine and promethazine, can be used to dry respiratory secretions. • However, they are less effective in relief of nasal congestion. • Second- and third-generation antihistamines like cetirizine, fexofenadine and loratadine have not been demonstrated to be effective against common cold symptoms, which are independent of histamine activity involvement. So these drugs should be avoided in the management of such symptoms ( True or Fals ) ?? 3. Antitussives & Expectorants Cough with cold is unproductive cough → for that it is ineffective and not recommended to use antitussive and expectorant. 4. Systemic Analgesics • Aspirin , acetaminophen , ibuprofen, naproxen are effective for aches and fever. • Aspirin and aspirin-containing medication are avoided in children why ? Reyes syndrome • Paracetamol is usually recommended first-line for patients with multimorbidity or polypharmacy issues due to its more favorable safety profile. 5-Local Anesthetic •Local anesthetic as benzocaine , dychlonine hydrochloride are used for temporary relief of soar throats. •It could be used every 2-4 hours. 6.Combination Products • Decongestants and antihistamines are marketed in many combinations including decongestant/antihistamine combinations. • Various combinations with analgesics, expectorants, and antitussives. • Products may be marketed for night-time (containing sedative antihistamines) or for daytime (containing no sedative antihistamines). • Phenylpropanolamine containing products have been discontinued (risk of hemorrhagic stroke). Think of examples of combination drugs marketed in the KSA?? Treatment of influenza • Treatment of influenza is primarily symptomatic for individuals with uncomplicated seasonal influenza. • Patients who are at high risk of developing severe or progressive complications from influenza may benefit from the use of antiviral agents • Early treatment may reduce the duration of the flu as well as complication risks. • Flu vaccination • Receiving an annual flu vaccination is the most effective method of preventing influenza infection. • Vaccination has been associated with reduction of risk of flu infection and transmission, hospitalization, and risk of flurelated death in at-risk individuals Non-pharmacological treatment for both Cold & Flu Non-pharmacological treatment • Drinking plenty of fluids (warm drinks may soothe a sore throat and loosen congestion); • Avoiding drinks that can cause dehydration (e.g., caffeine ); • Using vaporisers to warm and moisten the air; • Inhaling steam during a hot shower to relieve a blocked or runny nose • Applying ointments to soothe dry, cracked skin around the nose; • Sucking a lozenge and drinking honey and lemon to relieve sore throat and cough; • Eating regular, healthy meals, and limiting sugar, salt, and fat intake; • Taking plenty of sleep and rest; • Avoiding respiratory irritants, such as smoke, air pollutants and dust; and • Using isotonic or hypertonic saline solutions to rinse the nasal cavities Patient history-taking process Questions & answers Invite questions from the audience. Identifying referral conditions Red-flag signs and symptoms accompanying cough include • Cough that lasts for more than three weeks; • Unexplained cough that recurs on a regular basis; • Discolored or purulent sputum present with cough; • Coughing blood (haemoptysis) or blood present in sputum; • Chest pain (may be suggestive of a cardiovascular cause); • Shortness of breath (dyspnea), breathlessness, wheezing (may be suggestive of other conditions, such as asthma, pulmonary embolism, pleural effusion); • Persistent nocturnal cough in children (may be suggestive of asthma); Red-flag signs and symptoms accompanying cough • Worsening of shortness of breath from chronic conditions (may be suggestive of an asthma or chronic obstructive pulmonary disease exacerbation); • Pain on inspiration; • Stridor (high-pitched noise) or other respiratory noises; • Debilitating symptoms in elderly; • New or altered cough in a smoker aged 45 years and above; • New or altered cough in an immunocompromised individual • New or altered cough in an individual who has visited a COVID-19 exposure site or a country where tuberculosis is endemic. Red-flag signs and symptoms accompanying sore throat • Sore throat that lasts for more two weeks; • Marked tonsillar exudate accompanied with fever and swollen glands (may be suggestive of glandular fever or bacterial infections); • Odynophagia (pain with swallowing) or true difficulty in swallowing (may be suggestive of mechanical blockage or bacterial infections); • Sore throat with mouth ulceration, blistering, small haemorrhages under the skin or skin rashes (may be suggestive of agranulocytosis); and • Suspected adverse drug reaction or medicine-induced agranulocytosis (examples of medicines known to contribute to agranulocytosis include captopril, carbimazole, cytotoxic medicines, clozapine, sulfasalazine and sulphurcontaining antibiotics). Cases Common Cold & Children LS calls the pharmacy with questions regarding the rhinovirus, or the common cold, which her 2 boys contracted at school. Her children are aged 5 and 7 years and have had low-grade fevers, malaise, and nasal congestion for the past few days. What should the pharmacist recommend? Common Cold & Children In children, the common cold is a mild viral illness, usually precipitated by rhinoviruses. • Because the common cold is self-limiting and the data with OTC antihistamine, antitussives, and decongestants are lacking for children, the risks of starting OTC medications for children with rhinovirus outweigh the benefits. • Nonpharmacologic treatment, including nasal saline irrigation, has been shown to relieve upper respiratory–tract infection symptoms and decrease school absence. • Choosing pharmacologic treatment for colds in children, data are limited to analgesics or antipyretics. If the symptoms of fever are bothersome, LS can give her children antipyretics acetaminophen or ibuprofen. • Advise her to avoid combination products for the common cold in children. Common Cold During Pregnancy VK is a 29-year-old pregnant woman who asks about selfcare for her cold symptoms, which started with a sore throat and then a runny nose. Her husband had the same symptoms a few days earlier, and Alka Seltzer Plus PowerMax helped him. VK had a low-grade fever earlier in the day and the previous night. She asks if she can use the same medication as her husband. What advice should the pharmacist give VK about Alka Seltzer Plus PowerMax? Common Cold During Pregnancy • Overall recommendations for pregnant patients are to target specific symptoms using nonpharmacologic and/or single-ingredient pharmacologic treatment. • Advise to avoid combination, extra-strength, and long-acting OTC products. • Alka Seltzer Plus PowerMax is a combination of dextromethorphan and phenylephrine for day and dextromethorphan, doxylamine, and phenylephrine for night. Given that VK has not reported a cough, she should avoid the cough suppressant dextromethorphan. • VK should also avoid systemic decongestants, such as phenylephrine and pseudoephedrine, as they have been linked with malformations, such as abdominal wall defects, hip dislocation, and inguinal hernia. ➢ ➢ ➢ ➢ Advise her to use acetaminophen to address the fever. Intranasal cromolyn is considered a first-line treatment for a runny nose during pregnancy. Cromolyn is a mast cell stabilizer that treats rhinitis. Antihistamines chlorpheniramine and diphenhydramine are also considered compatible with pregnancy. • In addition to pharmacologic recommendations, VK should increase fluid intake and strive for adequate rest and a nutritious diet. Also advise her to increase humidity via humidifiers, steamy showers, or vaporizers. Hot tea with honey and lemon and saltwater gargles may help ease her sore throat. Cold or Cough With Diabetes LH is a 54-year-old man who has a dry cough and nasal congestion. He has felt sick for the past few days, so he went to see his health care provider. LH’s COVID-19 and flu tests came back negative. His physician recommended he buy an OTC medication to treat his cold and cough. LH would like a sugar-free medication, as he recently received a diagnosis of diabetes. He does not take any medications. What should the pharmacist recommend to LH? Cold or Cough With Diabetes LH is complaining of 2 symptoms: dry cough and nasal congestion. • Most dry coughs are caused by postnasal drip; therefore, he can take a first-generation antihistamine, such as diphenhydramine. • For the nasal congestion, LH may benefit from the antihistamine but can also use nasal decongestants, such as pseudoephedrine. If he chooses to use a nasal decongestant, he should monitor his blood glucose closely, as it may raise his blood sugar level. • There are specific OTC formulations with less sugar, such as Diabetic Tussin syrup or Robitussin sugar free. However, these products would not be appropriate for LH because he does not need an expectorant at this time. • If he needs cough drops or lozenges for the sore throat, he could consider sugar-free lozenges, such as those from Cepacol, Cold-Eeze, or Ricola. Cold or Cough With Diabetes Fever and Nasal Congestion TY is a 38-year-old man who has had a fever and nasal congestion for the past 3 days. He also complains of occasional shortness of breath. TY went to a local pharmacy to get tested for COVID-19, but his results were negative. He still feels sick and wants recommendations on how to treat the fever and nasal congestion. What recommendations should the pharmacist provide? Fever and Nasal Congestion ➢ Because TY is complaining of fever and shortness of breath, he should be referred to his primary care provider to be evaluated. ➢ Although he tested negative for COVID-19, he should also get tested for influenza and other viruses that may be circulating. Patients who have a fever lasting more than 3 days should be referred to a physician. ▪ Other patients who should be referred include those who complain of a cough that gets worse or lasts more than 7 days, dizziness, nasal congestion, new onset of symptoms, pain, redness, or sleeplessness. Thank you