Cold and Flu

Cold and Flu

1. Respiratory Problems ( Cold and Flu ) Dr. Omer Q. B. Al- lela PhD in clinical pharmacy ISPOR, ISOP member, ICIT 2021-2022

2. Introduction 2 Cold and Flu A mixture of viral upper respiratory tract infections (URTIs). More than 200 different virus types can produce symptoms of the common cold, including rhinoviruses (accounting for 30-50% of all cases), coronaviruses, parainfluenza virus, … Self-limiting but over-the-counter (OTC) medicines used for symptomatic relief. Cold remedies may interact with prescribed therapy

3. Cold and Flu 3 Flu is generally considered to be likely if: Temperature is 38◦C or higher (37.5◦C in the elderly); A minimum of one respiratory symptom – cough, sore throat, nasal congestion or rhinorrhoea – is present; or A minimum of one constitutional symptom – Headache, malady, muscle pain, sweating/chills, prostration – is present. Flu often starts with sweats and chills, muscular aches and pains in the limbs, a dry sore throat, cough and high temperature. There is often a period of generalized weakness and malaise following the worst of the symptoms.

4. Cold and Flu 4 True influenza is relatively uncommon compared to the large number of flu-like infections that occur. Flu can be complicated by secondary lung infection ( pneumonia ). Complications are much more likely to occur in the very young, the very old and those who have pre-existing heart disease, respiratory disease (asthma or chronic obstructive pulmonary disease (COPD), kidney disease, a weak immune system or diabetes.

5. Cold and Flu 5 Transmission by coughing and sneezing infected mucus particles does occur, although it is a secondary mechanism . This is why good hygiene (washing hands frequently and using dispos­able tissues) remains the cornerstone of reducing the spread of a cold. Children contract colds more frequently than adults with on average 5-6 colds per year compared to 2-4 colds in adults

6. What Pharmacist need to know 6 Age (Child, adult) Duration of symptoms Runny/blocked nose Summer cold Sneezing/coughing Generalised aches/ headache High temperature Sore throat Earache Facial pain/frontal headache Asthma Previous history Allergic rhinitis Heart disease Present medication

7. Significance of questions 7 Age Duration : True Flu usually comes with rapid onset The symptoms of the common cold usually last for 7–14 days . Cough , may persist longer Runny / blocked nose Rhinorrhoea occurs in most patients Initially a clear watery fluid, may followed by thicker . Nasal congestion occurs because of dilatation of blood vessels that narrows the nasal passages, which are further blocked by increased mucus production.

8. Significance of questions Summer colds Nasal congestion , sneezing and irritant watery eyes. Sneezing / coughing Sneezing occurs because the nasal passages are irritated. A cough may be present either because the pharynx is irritated or as a result of irritation of the bronchus caused by postnasal drip. Aches and pains / headache Due to inflammation and congestion of the nasal passages and sinuses . If persistent or worsened (sinusitis). People with flu often report muscular and joint aches . 8

9. Significance of questions 9 Facial pain / frontal headache Sinuses are air containing spaces in the bony structures adjacent to the nose (maxillary sinuses) and above the eyes (frontal sinuses). In a cold their lining surfaces become inflamed and swollen . The secretions drain into the nasal cavity. If the drainage passage becomes blocked , fluid builds up in the sinus and can become secondarily ( bacterially ) infected.

10. Significance of questions High temperature Those suffering from a cold often complain of feeling hot, but in general a high temperature will not be present. The presence of fever may be an indication that the patient has flu rather than a cold Sore throat The throat often feels dry and sore during a cold and may sometimes be the first sign. 10

11. Significance of questions Earache Earache is a common complication of colds, especially in children. When nasal catarrh is present , the ear can feel blocked. This is due to blockage of the Eustachian tube Middle ear is an air-containing compartment. This is an ideal site for a secondary infection to settle. When this does occur, the ear becomes acutely painful and is called acute otitis media ( AOM ). 11

12. Significance of questions Previous history People with a history of COPD may be advised to see their doctor if they have a bad cold or flulike infection Present medication The pharmacist must check any medicines being taken by the patient. It is important to remember that interactions might occur with some of the OTC medicines. If medication has already been tried for relief of cold symptoms with no improvement and if the remedies tried were appropriate and used for a sufficient amount of time, referral to the doctor might occasionally be needed. 12

13. When to refer Earache not settling with analgesic In the very young, In the very old Heart or lung disease, e.g. COPD, kidney disease, diabetes, Asthma Compromised immune system (immunosuppressive agent) With persisting fever and productive cough With delirium With pleuritic-type chest pain Treatment timescale Once the pharmacist has recommended treatment, patients should be advised to see their doctor in 10–14 days if the cold has not improved. 13

14. Management The pharmacist’s role is to select appropriate treatment based on the patient’s symptoms and available evidence, and taking into account the patient’s preferences. Antibacterials are not effective or appropriate as both infections are viral . The same non-prescription medicines are used to treat the symptoms of both the common cold and influenza. To reduce the likelihood of catching or passing on infection (5) : If possible, stay away from people with colds or influenza. Avoid crowded places where the risk of infection is greater. Do not touch nose or eyes after being in physical contact with somebody who has a cold or influenza. Wash hands thoroughly , especially after blowing the nose. Throw away paper tissues and Keep rooms well aired . 14

15. Management 15 A-Non pharmacological measures: Non -drug therapy include: 1-Saline solution can soothe the irritated tissue and moisturized nasal mucosa (4). And it can be given to all age group and pregnancy (1) . There are already formulated saline drops or spray products in the market: Dose : use as often as needed (5) . 2-Regarding influenza (1, 5) : - Rest , preferably by staying in bed. -Try to get plenty of sleep . - Drink as much as possible, as large amounts of fluid are lost during a fever. -Adequate nutrition .

16. Management 16 A- P harmacological treatment 1- Decongestants (sympathomimetics): Decongestants constrict the dilated blood vessels of the nose (5) .   a- Systemic (oral) decongestants : like Pseudoephedrine, phenylphrine and ephedrine (3, 5) . C/I: Systemic (oral) decongestants cause stimulation of the heart, increase the BP and may cause hyperglycemia . Therefore they should avoid in (3) : ( D.M, Ischemic heart disease (angina, M.I), hypertension, and hyperthyroidism ).   b- Topical (drop/spray) Nasal Decongestants ( sympathomimetics): recommended for those patients in whom Systemic (oral) decongestants are to be avoided Dose Example(s) Type 2 drops/sprays q 6 hours p.r.n Phenylphrine , Naphazoline, tetrahydrozoline Short acting (4-6 hours). 2 drops/sprays q 8 hours p.r.n   Xylometazoline ( Otrivine ®): 0.1%: > 12 years 0.05%: <12 years Intermediate acting (8-10 hours). 2 drops/sprays q 12hours p.r.n   Oxymetazoline( Nazordine ®): 0.05%: > 12 years 0.025%: < 12 years Long acting (12 hours).

17. Management 17 Nasal Spray or Drop (1, 3) : - Nasal sprays are preferable for adults and children aged over 6 years because spray has a faster onset of action and cover a large surface area. - Nasal drops are preferable for children aged below 6 years because their nostrils are not sufficiently wide to allow effective use of sprays. (But the drops cover a limited surface area and easily swallowed which increase the possibility of systemic effects). -Duration of treatment with Topical Nasal Decongestants (sympathomimetics) : (drops or sprays) decongestants are to be recommend, the pharmacist should advice the patients not to use the product for longer than 7 days (3) (3-5 days in some references (1) ) because: Rebound congestion (Rhinitis medicamentosa).

18. Management 18 2-Antihistamines:   Antihistamine can reduce some of symptoms of a cold: runny nose ( rhinorrhoea ) and sneezing but are not so effective in reducing nasal congestion (3) .   Antihistamine can be classified into: A-Sedating Antihistamine : Examples of OTC sedating antihistamine are: chlorphenamine (chlorpheniramine), dexchlorpheniramine , clemastine , triprolidine and diphenhydramine. S/E s : include sedation and drowsiness ( patients should be informed ) and anticholinergic S/Es (i.e. dry mouth, urinary retention, constipation…) and the elderly patients are more susceptible to these (8) . Accordingly they are not recommended (3) (or used with caution (7) ) for patients with: Glaucoma, or prostate hypertrophy and in elderly patients . Drug Interactions : the sedative effects of antidepressants, anxiolytics, and hypnotics are likely to be enhanced by sedating antihistamine (7) .

19. Management 19 B-Non-Sedating Antihistamine: Examples of OTC non-sedating antihistamine are: Loratadine and cetirizine. They are generally preferable over the older antihistamines because of much lower incidence of S/Es (8) . Adult dose of Loratadine: 10 mg once daily. Note : although the drowsiness is rare , but the warning that these drugs may affect driving and skilled tasks is still present (7, 8). Important : Because of their antimuscarinic actions the sedating antihistamines should be used with care in conditions such as angle-closure glaucoma , and prostatic hyperplasia; antimuscarinic adverse effects are not a significant problem with the non-sedating antihistamines (9) .

20. Management 20 3-Combination products : sympathomimetics (for congestion ) + Antihistamine (for rhinorrhoea and sneezing): The antihistamine is usually combined with Sympathomimetics because : A- The suppression of rhinorrhea can provokes congestion so the sympathomimetics will offset this effect. B -Sympathomimetics may also help to counteract sedation caused by the antihistamines (because the Sympathomimetics cause CNS stimulation) (6) . 4-Analgesics, antipyretics: - Paracetamol, aspirin and ibuprofen can be used to reduce fever, if present, and ease headache and muscle pains in influenza and general discomfort with colds. - Aspirin is restricted in its use by its pronounced side-effect profile, and may not be given to children under 16 years because of its association with Reye’s syndrome , a rare but occasionally fatal encephalopathy in children (5) .

21. Management 21 5-Inhalants: Preparations containing volatile substances for inhalation , either directly or via steam , produce a sensation of clearing the nasal passages and are used for the relief of cold symptoms. They have few, if any, contraindications (5) .   6-Vitamin C in common cold: Vitamin C does not prevent colds and even high-dose vitamin C (over 1 g/day) produce minimum benefits (2, 3, 6) . In case of vitamin C effervescent tablets , large quantities of sodium bicarbonate are required in this formulation, which could disturb the electrolyte balance of patients with cardiovascular diseases , especially those whose sodium intake is restricted (6) .

22. References   1- Handbook of Non-prescription drugs.2010 2- Community Pharmacy. Symptoms, Diagnosis and Treatment. By Paul Rutter.2011 3- Symptoms in the pharmacy. A guide to the managements of common illness. 6th edition By Alison Blenkinsopp and Paul Paxton .2009 4-Applied therapeutics :the clinical use of drugs.2004 5- Nathan A. fasttrack . Managing Symptoms in the Pharmacy. Pharmaceutical Press; 2008. 6-Nathan A. Non-prescription medicines. 4th edition. London: Pharmaceutical Press; 2010. 7-BNF. 68 8- A. Nathan .How to treat hay fever and associated allergic conditions in the pharmacy . the pharmaceutical journal (vol 268). 27 April 2002 pages 575-578. 9-Martindale. 36.

23. TQ