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JUNE 2013
Colds and flu
V ol .14
Number 5
Print Post approved
PP255003/05274
QCPP
Approved
Refresher Training
(Counter Connection)
John Bell says Contents
JUNE 2013
V ol .14
Number 5
Managing editor Andrew Daniels
Production coordinator Kylie Davis
Contributor Jan Castrisos
Peer Review Marnie Firipis
Layout Caroline Mackay
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The information contained in this material is
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Influenza (flu) and the common cold are both viral infections
involving the upper respiratory tract.
See page 04, Facts Behind the Fact Card: Colds and flu
Pharmacist CPD
04
Facts Behind the Fact Card: Colds and flu
Pharmacy assistants’ education
12
Counter Connection: Colds and flu
Regulars
03
16
John Bell says
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inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
John Bell says
Coping with common colds
By John Bell, Self Care Principal Adviser
We’re frequently asked
to provide products
for, and advice about,
colds and flu. So much
so that products in the
cough/cold category
are the most commonly
requested in the non‑prescription
department in pharmacy.
However, it’s the category in which there
seems to be the least satisfaction amongst
customers. There are probably a number
of reasons for this. Firstly, despite our
customers’ expectations, there is no miracle
cure for a cold or the flu; the best we can
provide is good symptomatic treatment.
Secondly, and quite significantly, some of
the products which can be self selected
don’t always measure up to the claims that
are made for efficacy (it’s worth taking the
time to recommend the more effective
S3 products).
Also, it’s important that we (and our
customers) are able to distinguish between
a cold and the flu. By far most customers
who stagger into our pharmacies sniffling,
sneezing and coughing will have a cold –
not the flu. If they really had the flu with
its more sudden onset of symptoms –
headache, general aches and pains,
exhaustion and fatigue – they’d have
trouble leaving the house and getting to
the pharmacy.
Of course, some hardy customers do ‘soldier
on’ into the pharmacy, regardless of the
severity of their symptoms; so the table on
page 13 of Counter Connection will help
you differentiate between these conditions.
The What Stop Go protocol (see page 14)
will also assist in choosing the right product
to recommend.
As we know, these infections are caused
by viruses, so antibiotics are not effective
(the presence of yellow/green mucus is
not necessarily an indication of a bacterial
infection, it’s simply an indication that
our immune system is doing its job).
And this is a message we need to reinforce
to our customers. Taking antibiotics
inappropriately only serves to increase
antibiotic resistance both in the community
and in the individual.
There are antiviral prescription-only
medications for the flu (Tamiflu and
Relenza), however their beneficial effect
is limited and they need to be used at
the first onset of symptoms. Page 9 gives
more details.
We have a role to play in promoting
prevention of these (mostly) wintery
infections; by way of advocacy of general
hygiene measures and flu vaccination for
those at risk. There are many myths and
misconceptions about flu vaccination
and these are raised in Practice Point 4 on
page 8.
The safety and efficacy of cough/
cold products for children is another
important issue which is addressed in
this inPHARMation.
Ear, Nose & Throat 1117
2011
Coughs
Ear, Nose and Throat 0086
2011
The common cold, allergy and cigarette smoke are common causes of
coughing, but a cough can also be a symptom of a serious illness or a side
effect of a medicine. Treatment for a cough depends on its cause.
Cold and Flu
Coughingisanormalreflextoprotect
and clean our airways (respiratory tract).
Coughingclearsirritatingmaterial(e.g.,
smokeordust)andexcesssecretions
(mucus,sputum,phlegm)fromour
throat,airpassagesandlungs.The
sound and pattern of a cough depends
on its cause.
Causes of coughing
Cough is a symptom of a range of
medical conditions and sometimes a
person may have more than one reason
for coughing.
Causes of coughing include:
•Postnasaldrip(catarrh)–excessnasal
secretions which run down into the
backofthethroat.Oftencaused
byallergy,commoncoldsorsinus
infection
Common colds and the ‘flu’ (influenza) are viral infections affecting the
nose, sinuses, throat and airways. Antibiotics do not work against these viral
infections, but colds and the flu usually get better on their own.
Medicines may relieve some of the uncomfortable symptoms of colds and flu.
•Asthma
When someone has a cold or flu,
•Respiratorytractinfections(e.g.,colds,
the fluid from their nose, mouth
bronchitis,croup,whoopingcough,
and airways contains the infecting
pneumonia)
virus. Colds and flu spread when this
•Inhaledirritants(e.g.,cigarettesmoke,
infected fluid passes to someone-else
dust,fumes,aforeignbody)
(e.g., by touch, coughing, sneezing).
•Lungdisease(e.g.,cysticfibrosis,
Colds spread easily, especially between
COPD,cancer)
children who spend a lot of time
•Gastroesophagealreflux(heartburn)
together (e.g., at childcare or school).
–Astomach
acidinfectious
rises up into
thefirst one
cold is most
in the
oesophagus
coughing
or two days and
aftertriggers
symptoms
develop.
Signs and symptoms
Self Care is a program of the Pharmaceutical Society of Australia.
symptoms
include:
Self Care is committed to providing currentCold
and reliable
health
information.
•Runnynose
•Blockednose(congestion)
•Sorethroat
•Red,wateryeyes
•Sneezing
•Coughing
•Mildfever
•Headache
•Tiredness.
Flu (influenza) symptoms are similar to
cold symptoms, but are usually more
severe and may also include:
•Highfevers,sweatingandshivering
•Achingmusclesandjoints
•Weaknessandlethargy
•Lossofappetite,nauseaandvomiting.
Cold and flu symptoms usually go within
10 days, although a cough may last
longer.
Protection against influenza
A‘fluinjection’willgiveprotection
againstthe‘flu’.Vaccination,before
the‘flu’seasonstartseachyear,is
Self Care is a program of the Pharmaceutical Society of Australia.
Self Care is committed to providing current and reliable health information.
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inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
3
John Facts
Bell says
Behind the Fact Card
Colds and flu
Pharmacist CPD
Module number 238
By Jan Castrisos
up to
Colds and flu
2
CPD Credits
GROUP 2
This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.
Influenza (flu) and the common
cold are both viral infections
involving the upper respiratory
tract. Because they share
many symptoms, people often
use the terms cold and flu
interchangeably.
More than 200 different viruses can cause the common cold including rhinoviruses and adenoviruses.
Learning objectives
After reading this article, the
pharmacist should be able to:
• Compare and contrast the
pathophysiology and symptoms
of the common cold with those of
influenza.
• Differentiate between patients
with the common cold and
influenza.
• Understand the Therapeutic
Goods Administration changes
to the guidelines for managing
cough and colds in children.
• Describe treatment regimens
and provide advice for the
management of the common cold
and influenza.
Competencies addressed (2010):
1.1, 1.2, 1.3, 2.2, 2.3, 6.1, 6.1, 6.2, 6.3,
4
Colds and influenza
Risk
It is important to know the difference
between a cold and the flu to effectively
advise customers. Colds are very common
– adults can get two to four colds per year
while children can get as many as three
to 12.1
Everyone is at risk of getting a cold or flu;
however, because there are a variety of
situations and circumstances, some people
are at increased risk. Those at increased
risk include:3,4
Respiratory tract infections (RTIs) are the
most common acute problem dealt with
in primary care. Hence it is essential that
pharmacists have a thorough knowledge
of the symptoms to ensure any differential
diagnosis is not missed.2,3
The widespread prevalence of the common
cold and the multitude of symptoms
affecting the individual, coupled with
the ever-increasing array of single-agent
and combination products available for
treating them, can lead to a great deal of
patient confusion and inappropriate or even
dangerous self-medication.
Although colds are generally not serious;
babies, the elderly and anyone whose
immune system is compromised can
be at risk of developing more serious
complications.
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
• newborns
• young children, especially those in
day‑care or preschool
• people with underlying chronic diseases
such as asthma and cardiac disease
• immunocompromised individuals
(e.g. chemotherapy patients)
• people living in shared accommodation
such as boarding schools and
nursing homes
• elderly people >65 years of age
• Aboriginal and Torres Strait Islander
people aged 15 years and over.5
Epidemiology
The common cold is an acute, self-limiting
viral infection involving mucous membranes
of the upper respiratory tract. More than
200 different viruses can cause the
common cold including rhinoviruses and
adenoviruses. About 30% to 50% of all colds
Colds and flu
are caused by one of the many rhinoviruses:
they occur all year round.3,4
Flu is an acute infectious RTI caused by
influenza viruses A, B and C of the family
Orthomyxoviridae. The Type A viruses
are the most virulent human pathogens
amongst the three influenza types and
cause the most severe infections. Influenza
A also has a high propensity for antigenic
change, allowing it to escape recognition by
the body’s immune system. This antigenic
change uses an avian intermediate host
(IH) causing epidemics and pandemics. In
particular, Type A viruses have a remarkable
ability to undergo periodic changes in the
antigenic characteristics of their envelope
glycoproteins, the haemagglutinin and the
neuraminidase.
Among the influenza Type A viruses that
infect humans, three major subtypes of
haemagglutinins (H1, H2, and H3) and
two subtypes of neuraminidases (N1 and
N2) have been described. Influenza Type
B viruses have a lesser propensity for
antigenic change, and only antigenic drifts
in the haemagglutinin have been described.
Most cases of flu occur within a 6–8
week period around winter and spring.
Type B causes a similar, though possibly
milder infection than Type A. It can cause
epidemics but has no intermediate host.
Influenza Type C does not cause epidemics
and causes only mild infections. Influenza
epidemics occur, on average, every three
years. Influenza pandemics have occurred
four times in the past 100 years and can
cause many deaths.3,4,6,7
Virus strains are eventually named
according to influenza virus type, the town
where the virus was first isolated, number
of isolates, year of isolation and major type
of important proteins e.g. Influenza B/Hong
Kong/330/2001.
Pharmacist CPD
Module number 238
the influenza virus, the rhinovirus can
also be transmitted using this route.
The importance of large particle droplets
caused by sneezing or coughing is less
well documented.
• Direct contact with infectious secretions.
Some viruses may be spread by hand
contact (e.g. shaking hands, telephone
handles) then autoinoculation through
contact with the nose or eyes.
• The main reservoir of viruses is in young
children. They are more susceptible
because of the lack of antibodies as
well as having a larger concentration of
the virus in secretions. Most commonly,
transmission occurs in the home,
in schools, and in day-care centres where
very young children are in close regular
contact with each other and their carers.
The incubation period varies depending
on the causative virus. It is usually 1–2 days
for the rhinoviruses and three days for
the coronaviruses, but people can remain
infectious for several weeks.4,6,8
Facts Behind the Fact Card
Practice point 1
Medications that may cause a
chronic cough
• Ace inhibitors – dry persistent cough
develops in the first month of therapy
in a minority of people as a side effect.
Some examples are:
-- enalapril
-- ramipril
-- perindopril
-- captopril.
• Beta-blockers – dry persistent cough
develops in the first month of therapy
in a minority of people as a side effect.
Some examples are:
-- propranolol
-- atenolol
-- carvedilol
-- oxprenolol.
Transmission of the influenza virus
• Transmission of the influenza virus occurs
by smaller particle droplet inhalation
and usually affects the upper respiratory
tract. The virus reproduces within the
epithelium and destroys the cilia.
The incubation period of the influenza virus
is 1–3 days after the onset of symptoms.6
Symptoms and diagnosis
Common cold
Many people will come into the pharmacy
for advice regarding the common cold.
Transmission
Transmission of the common cold
Transmission of the common cold varies
depending on the type of virus implicated.
The following three transmission routes are
recognised:
• Inhalation of airborne respiratory droplets
from people infected with the virus. Small
particle droplets linger in the air and are
highly contagious. Although this is the
more common route of transmission of
Related Fact Cards
Colds and flu
Coughs
Ear problems
Sinus problems
Pain relievers
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
5
John Facts
Bell says
Behind the Fact Card
Practice point 2
Antibiotic use for cold and flu15
Overuse and misuse of antibiotics
is making it harder to treat bacterial
infections and antibiotics are losing their
power against illness causing bacteria.
The World Health Organization has
recently declared antibiotic resistance
‘one of the greatest threats to human
health today’.
Pharmacists have an important role
in helping to address this problem
by counselling customers about the
ineffectiveness of antibiotics for the
treatment of viral infections. Direct
customers to the NPS Medicinewise
website for information regarding
the irrelevant use of antibiotics for a
viral infection.
Points to make are:
• Antibiotics are only effective against
bacteria and not viruses – colds, flu
and most coughs are caused by viruses
and will get better on their own.
• Cold and flu symptoms should be
treated and the immune system can
fight the virus – antibiotics will not
help you get better quickly, and may
give you side effects such as diarrhoea
and thrush. Antibiotics won’t stop your
virus spreading to other people.
• Don’t take someone else’s antibiotics.
• Take antibiotics only as directed,
if prescribed.
• Practise good hygiene to help stop the
spread of germs.
Pharmacists should refer a customer to
the doctor if they suspect that he or she
has a secondary bacterial infection or
if the person is a high risk category for
complications. (See complications page 8)
6
Colds and flu
Pharmacist CPD
Module number 238
A predictable sequence of symptoms is
as follows:
• A ‘scratchy’ or sore throat appears first and
usually resolves quickly.
• Nasal obstruction (i.e. congestion) and
rhinorrhoea predominate by day two or
day three.
• Nasal secretions are initially clear, thin
and watery.
• Cough appears by day four or five
although it develops in fewer than 20%
of people.
Temperature is usually normal, particularly
when the pathogen is a rhinovirus or
coronavirus. However cold symptoms in a
baby or child may include increased body
temperature.
Most symptoms due to uncomplicated colds
resolve within seven to 10 days but some
symptoms may occasionally last 2–3 weeks.
Diagnosis is based on clinical signs and
symptoms and exclusion of more serious
illnesses. Viral cultures or specific diagnostic
testing are unnecessary as the common
cold is self-limiting.
People with asthma are not at greater
risk of rhinovirus infection compared to
healthy individuals, but they do suffer
from more frequent lower respiratory tract
(LRT) infections and have more severe and
longer‑lasting LRT symptoms. The presence
of LRT symptoms such as wheezing can
effectively exclude the common cold.
Complications of the common cold can
include sinusitis, bronchitis, and bacterial
pneumonia, exacerbation of asthma or
Chronic obstructive pulmonary disease
(COPD) and middle ear infections.
Most people do not develop complications
from colds. When complications do develop
they may be severe but rarely life threatening.
The elderly are at risk of more serious
life threatening complications if infected
by the influenza virus and this disease
must be distinguished from the common
cold. Table 1 indicates the general
differences between the common cold and
influenza.6,10,12
Influenza
Infection with influenza is characterised by a
sudden onset of:
•
•
•
•
•
•
•
•
fever
chills
severe malaise
myalgia (especially in the back and legs)
dry cough
nasal obstruction
dry sore throat
headache (often with photophobia).
Respiratory symptoms may be mild at first
but as the infection progresses, LRT illness
becomes more dominant, with a persistent
raspy, productive cough. Fewer virus particles
are required to infect the LRT compared to
the upper respiratory tract (URT).
Cough, weakness, sweating and fatigue
may persist for several days or occasionally
for weeks. Children may have higher
temperatures, as well as nausea, vomiting
or abdominal pain, and infants may present
with a sepsis-like syndrome (e.g. diminished
spontaneous activity, less vigorous sucking,
apnoea and temperature instability).6,11
Treatment
Common cold
There is no magic cure for the common cold.
Treatment aims to ease symptoms, improve
daily functioning and prevent the spread of
disease to others whilst the immune system
clears the virus.
Table 1. Influenza or the common cold?9,10,11
Symptom
Common cold
Influenza
Spectrum of illness
Local – nose and throat
Systemic
Speed of onset
Gradual
Sudden
Fever
None to mild
Usually high – lasts 3– 4 days
General aches
None to slight
Usual – often severe
Fatigue and weakness
Mild
Usual – may last 2–3 weeks
Headache
None to mild
Prominent
Exhaustion
Rare
Early and prominent
Stuffy nose
Common
Sometimes
Sore throat
Sometimes
Common
Sneezing
Usual
Sometimes
Cough, chest discomfort
Mild
Common, can become severe
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
Colds and flu
Children
The Australian Therapeutics Goods
Administration (TGA) has for some years
been carrying out a comprehensive review
of the safety and efficacy of over-the-counter
(OTC) cough and cold preparations for the
treatment of cough and cold symptoms in
children less than 12 years of age.
The TGA has concluded that there is
currently a lack of evidence of efficacy for
OTC cough and cold medicines in children
aged less than 12 years of age and the
historical profile of adverse reactions
indicates that there are potential risks
involved in using these medicines in
children. The risks are greater in children
aged less than six years compared to those
aged between six and 11 years. Therefore,
the TGA has said that these medicines
should not be used for treating children
under six years of age, and that they
should only be administered to children
aged 6–11 years on the advice of a doctor,
pharmacist or nurse practitioner.13
The first indication of a common cold in
a baby or toddler is often a congested or
runny nose. Nasal discharge may be clear at
first, but then usually becomes thicker and
turns shades of yellow or green. A baby’s
immune system needs time to conquer
the cold. If the baby has a cold with no
complications, it should resolve within
a week.14
Babies younger than 2–3 months of age
should be referred to the doctor early in the
illness. In newborns, the common cold can
quickly develop into croup, pneumonia or
another serious illness. Even without such
complications, a stuffy nose can make it
difficult for babies to breast feed or drink
from a bottle. This can lead to dehydration.
The TGA review found that while there
are no immediate safety risks with these
products, there is evidence that they may
cause harm to children and the benefits
of using them in children have not
been proven.
On 1 September 2012 the following changes
were made to the recommendation for the
sale of cough and cold medicines in children.
• Cough and cold medicines should not be
given to children under six years of age
• Cough and cold medicines should only be
given to children aged 6–11 years of age
on the advice of a doctor, pharmacist or
nurse practitioner
Pharmacist CPD
Module number 238
Cough and cold medicines used for
treating children that contain at least
one of the below active ingredients are
affected by the changes.
Type of medicine
Active ingredients
antihistamines
brompheniramine
chlorpheniramine
dexchlorpheniramine
diphenhydramine
doxylamine
pheniramine
promethazine
triprolidine
antitussives
codeine
dextromethorphan
dihydrocodeine
pentoxyverine
pholcodine
mucolytics/
expectorants
bromhexine
guaifenesin
ipecacuanha
senega and ammonia
decongestants
Facts Behind the Fact Card
Practice point 3
PDL advice on TGA
recommendations
A media poll in Pharmacy News
12 March 2013 suggested around
40% of pharmacists would probably
supply cough and cold medicines to
children less than six years old believing
that there are no safety risks with
these products.
As reported in Pharmacy News 12 March
2013 Albert Regoli (director of PDL)
issued the following warning on the
topic of OTC cough and cold changes for
children under six:
phenylephrine
pseudoephedrine
oxymetazoline
xylometazoline
These medications may still be
recommended for any other approved
indication. According to the Approved
Product Information (eMIMS), other
approved indications for promethazine
(Phenergan) for example, are allergies,
nausea and vomiting, sedation and
‘other’ (e.g. symptomatic management
of chickenpox). Phenergan does currently
have a dose recommendation for 2–5 year
olds for allergy, sedation, travel sickness,
nausea and vomiting.
Always check the literature before
recommending any of these medications
for children for indications other than for
cough and cold treatment.
Most useful advice
The most useful advice especially for
children up to the age of 11 years is:
• The child should stay home and rest.
• The use of paracetamol or ibuprofen for
fever, sore throats, aches and pains.
• A fever can lead to mild dehydration
due to sweating, causing tiredness and
headache. Advice is to drink plenty of
fluids such as water, fruit juices and
clear soups.
• Steam inhalations (e.g. humidifiers)
help clear mucous and clear a blocked
nose. It is a temporary effect, but may
be useful before bedtime (especially for
children) to help them get off to sleep.
‘Pharmacists owe a duty of care to take
reasonable steps to avoid foreseeable
risks of injury to others, so in the case of
supplying cough mixtures, that duty of
care extends to children, and particularly
young children become even more of a
risk,’ he said.
‘If a pharmacist knowingly supplies
a cough mixture to a child under the
recommended age and the child
does suffer some damages as a result,
there is going to be a possible case for
negligence.’
However, Mr Regoli said the mere supply
of medicine did not necessarily mean a
pharmacist had breached their duty of
care as other factors came into it.
These factors may include:
(but not limited to)
• whether a doctor was involved in the
recommendation
• whether the pharmacist knew or should
have known that a child would consume
the medicine
• the quality of the warnings that the
pharmacist disseminated at the time of
the medicine supply
• the unique characteristics of the child.
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
7
John Facts
Bell says
Behind the Fact Card
Practice point 4
Immunisation
Immunisations should be current.
There is no vaccine against the cold,
but encourage those at risk to ask their
doctor about the flu vaccine, pneumonia
vaccine as well as tetanus, diphtheria
and whopping cough booster. (See The
Australian Immunisation Handbook 10th
edition 2013 for an update).
Myths about the flu shot
1.The flu shot causes the flu.
The truth is that a flu shot takes up to
two weeks to become effective; so if a
person gets infected before the vaccine
has had enough time to work, they will
fall sick.
2.It’s too late to get vaccinated if you
have already had the flu this year.
The flu vaccine is designed to protect
against multiple strains of the influenza
virus. It is possible to get the flu more
than once, each time caused by a
different strain. Even if you have had
the flu, a vaccine can still protect
against other strains of the virus.
3.Flu shots are 100% effective.
The truth is you can still fall sick with
the flu even after being vaccinated.
However, it has been found that
vaccinated people are 62% less likely
to get the flu and are at far lower risk
of requiring medical care if they do
get sick.
4.People who are allergic to eggs can’t
get a flu shot.
Flu shots are risky only if you have
severe egg allergies. Most people
who have egg allergies are not at risk
of any complications with a flu shot.
Side effects are mild, such as hives or
itchy skin.
Colds and flu
Pharmacist CPD
Module number 238
• Saline nasal sprays or drops (e.g. Fess,
Narium) may help thin nasal secretions
while avoiding the risk of rebound
congestion due to decongestant nasal
sprays. They are a good alternative for
young children and babies especially just
before feeding.
What about cold remedies for
children over six years and adults?
There are many cold remedies in the
pharmacy that can relieve symptoms.
Remember, cold remedies often contain
several ingredients. Some cause drowsiness,
which may be welcome at bedtime when
the customer indicates difficulty sleeping
as a symptom. As some products contain
paracetamol, be careful not to recommend
more than the maximum safe dose of
paracetamol if the customer is taking
paracetamol tablets.
It is possible that a customer may have a
contraindication to many of the products
available in the OTC cough and cold
area of the pharmacy. It is imperative
for pharmacists to accurately assess
the customer by asking about the most
distressing symptom and gather other
essential background information, such
as other conditions and medications.
If the patient is deemed clear of any
contraindications then the pharmacist can
formulate an individualised treatment plan.
Gathering information
Pharmacy staff should gather appropriate
information background as follows:
1.Description of the symptoms including
when they started and the severity.
2.Familiarisation with relevant patient
history such as age, weight and height
(often obvious) and occupation to help
with recommendations.
3.Medication allergies or adverse reactions
to medications.
4.Current medical conditions as well as
current medications both prescription
and OTC.
Complications
An awareness of alternative or underlying
diagnoses should be considered if:
• A sore throat is the main symptom
(streptococcal tonsillitis should be
considered, especially if the patient is
younger than 15 years of age).
• Rhinitis has been present for more than
14 days (e.g. allergic rhinitis).
8
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
• The illness started suddenly with
fever, chills, and severe muscle aches
(e.g. influenza or pneumonia).
• The patient has pleuritic pain, large
amounts of sputum or blood in the
sputum (e.g. pleurisy or pneumonia).
• There is an earache (e.g. otitis media) or
there is facial pain (e.g. sinusitis).
• Features of meningism are present (such
as altered consciousness, photophobia,
hypotonia, neck stiffness, seizures, and
tachycardia).
• Asthma, COPD, congestive heart failure,
type 1 or type 2 diabetes, heart disease
or other long-term (chronic) medical
conditions exist.
• The customer is frail and of advanced age.
• The customer has a fever (a temperature
of 38.5°C or higher) and is feeling unwell
(e.g. a painful headache or stomach pain)
and has not responded to paracetamol
or ibuprofen.
• There is worsening of symptoms during
self-treatment.
• The customer is on immunosuppressant
therapy.
• Rash exists with a fever (e.g. measles or
chicken pox).
• The customer complains of shortness of
breath, tiredness and lack of energy.
OTC cough and cold medicines
As already stated there is no cure for
the common cold and treatment is
recommended to relieve symptoms.
Analgesics
Simple analgesics such as paracetamol,
ibuprofen or aspirin may relieve fever,
headache, sore throat and sinus discomfort.
• Paracetamol is the analgesic of choice, as
it has fewer adverse effects.
• Ibuprofen should not be used in babies
under 6 months of age.
• Aspirin should not be given to children
under 16 years old due to the risk of
Reye’s syndrome.
• Aspirin should be avoided during
breastfeeding due to the theoretical risk
of Reye’s syndrome in the infant.
• Asthmatics should avoid aspirin and
ibuprofen as they may precipitate
bronchospasm in some asthmatics.
• People with heart disease and peptic
ulcer or a history of gastric bleeding
should avoid aspirin or ibuprofen.
Colds and flu
Pharmacist CPD
Module number 238
Influenza
Decongestants
Cough medicines
Decongestants are the medicines of choice
for a blocked or stuffy nose. They can be
taken orally or in the form of nasal sprays
or drops.
Cough medicines are either mucolytics,
expectorants or suppressants. They have
questionable efficacy, particularly in acute
cough associated with upper respiratory
tract infections (URTIs).
Oral decongestants (e.g. pseudoephedrine,
phenylephrine) and nasal sprays or drops
(e.g. oxymetazoline, phenylephrine, and
xylometazoline) may be taken on an
“as needed” basis for short term relief of
rhinorrhoea and nasal congestion.
• Evidence of benefit in children under
12 years is unclear.
• Use of these preparations in children
under 6 years is contraindicated.
• Topical nasal decongestants are more
effective than oral decongestants,
but their use for more than 3 to 5 days
may result in rebound congestion.
• Oral decongestants should be used
with caution in patients with diabetes,
heart disease, hypertension, prostatic
hypertrophy and hyperthyroidism.16
Antihistamines
Antihistamines are classed as sedating and
less-sedating.
• Sedating antihistamines also
known as first generation
antihistamines (e.g. chlorpheniramine,
dexchlorpheniramine, diphenhydramine,
promethazine) may help to relieve a
runny nose but can cause sedation and
drowsiness. The use of antihistamines is
controversial. Histamine does not play a
role in the pathogenesis of the common
cold. First generation antihistamines
possess anticholinergic action that may
reduce nasal secretions. These products
are S3 and must be recommended by
the pharmacist.
They should be avoided in the elderly and
people with benign prostatic hypertrophy
or glaucoma.
• Less-sedating antihistamines
(e.g. loratadine, cetirizine, desloratadine)
are indicated for allergic rhinitis and are
not effective for treating the symptoms
of a cold.
Other drugs for rhinitis
The intranasal anticholinergic ipratropium
bromide may improve rhinorrhoea but
should also be avoided in the elderly and
people with benign prostatic hyperplasia
or glaucoma.
Facts Behind the Fact Card
Mucolytics (e.g. bromhexine) reduce
mucous viscosity and aid its expectoration.
Although they are marketed for this
purpose the evidence of efficacy for cough
with URTIs is limited.
Suppressants (e.g. codeine,
dextromethorphan, dihydrocodeine,
pholcodine) are meant to decrease
coughing. Because coughing is a natural
response to substances in the lungs they
should be avoided in people suffering
from certain airways diseases especially
in children.
Prevention
Influenza is an important vaccinepreventable disease that causes illness
in people of all ages. Annual influenza
vaccination is important to help maintain
immunity to influenza.
The National Centre for Immunisation
Research and Surveillance for Vaccine
Preventable Diseases at the Children’s
Hospital Westmead found hospital
admissions of children with the flu were
highest in children aged less than five years
of age.
The Australian Immunisation Handbook
10th edition 2013 has updated its
recommendation as follows:
Contraindicated in people with respiratory
failure, asthma or COPD.17
Expectorants (e.g. guaifenesin) are used
with the aim of promoting expectoration of
bronchial secretions in productive cough.
It remains unclear whether cough products
offer any benefit in relieving coughs
associated with a cold. Combination
products containing expectorants and
suppressants should be avoided. In many
instances the cough should be evaluated
separately from the common cold to
determine if an underlying condition may
be present.17
Lozenges
Anti-inflammatory, antibacterial or
anaesthetic lozenges or gargles may help to
relieve a sore throat, although they have no
effect on the viral infection.
Vitamin C18,19,20
High doses of vitamin C have not been
shown to prevent colds but may reduce the
duration and severity of symptoms. Doses of
2000 mg per day can cause stomach
cramps, kidney stones and diarrhoea.
Echinacea17,20
It is not known whether echinacea really can
prevent or treat colds or flu. This is because
most echinacea preparations have not been
tested in reliable clinical trials. Therefore,
there is no reliable information on how
much echinacea a customer would need to
take, or how long it should be taken for.
“Annual influenza vaccination is strongly
recommended for any adult or child (over six
months of age) who wishes (or whose parents
wish them) to be protected against influenza.”
The use of Agrippal, Fluarix, Influvac or
Vaxigrip in children aged five years to less
than 10 years is strongly preferred; however,
Fluvax may be used when no timely
alternative vaccine is available and parents
are informed of the potential increased risk
of fever.
Annual immunisation is strongly
recommended for older people, pregnant
women, those at risk and those who work
or live with these vulnerable groups.
Immunisation helps to protect against
serious complications (such as pneumonia)
that may arise as a result of contracting the
virus. Immunisation should ideally occur
between March and May, before the onset
of the flu season. Protection develops about
two weeks after the injection and lasts for
up to one year.
Antivirals
Antiviral medicines may also be used
to shorten the duration of symptoms
and reduce the risk of complications.
The antivirals currently available in Australia
are the neuraminidase inhibitors:
Oseltamivir (Tamiflu) – capsule or powder
for oral solution.
Zanamivir (Relenza) – inhaled via a diskhaler
• They are S4 and only available on a
doctor’s prescription.
• Treatment must commence within
48 hours of the onset of symptoms.
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
9
John Facts
Bell says
Behind the Fact Card
Colds and flu
Pharmacist CPD
Module number 238
References
• They shorten symptom duration by one
day and reduce the time to return to work
by half a day.6
• They reduce the incidence of
complications.
• Common side effects are nausea and
vomiting. It is therefore recommended
that they are taken with food.
Neuraminidase inhibitors are not
recommended unless influenza is
circulating in the community, when they
may be considered only for people at risk
of complications. They may be used in
institutional prophylaxis and pandemics.
They are not recommended for routine
prophylaxis against influenza; annual
influenza immunisation is recommended to
prevent infection.
In a small study in immunocompromised
people there was no significant difference in
the incidence of influenza between people
who took a course of oseltamivir compared
to those who took placebo.
They may be used to prevent influenza
in poorly vaccinated communities at
risk e.g. when institutional outbreak
control is necessary, or at the direction of
10
public health authorities as an adjunct to
other measures.6
Symptoms of the flu may be treated as for
the common cold.
In a small proportion of cases, influenza can
lead to:
• Secondary bacterial pneumonia –
occurs when bacteria invade the lungs.
Symptoms include shortness of breath,
green or yellow phlegm (mucous), chest
pains and a temperature. Death rates
are high, but it is less lethal than primary
influenza pneumonia.
• Primary influenza pneumonia –
symptoms include difficulty with
breathing and blue discoloration of the
skin (cyanosis).
• Inflammation of the brain or heart –
can occur during recovery from the flu.
• Reye’s syndrome – this leads to brain
inflammation and liver degeneration
and is fatal in between 10 and 40 per
cent of cases. Children under 16 years
should not be given any medication
containing aspirin as it increases the risk
of Reye’s syndrome.17
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
1. Patient.co.uk accessed at: www.patient.co.uk/doctor/upperrespiratory-infections-coryza
2. Cardiff University accessed at: www.cardiff.ac.uk/biosi/
subsites/cold/commoncold.html
3. Merck Manual for Health Care Professionals. Respiratory virus.
At: www.merckmanuals.com
4. Therapeutic Guidelines Limited. eTG complete [CD-ROM].
North Melbourne.
5. Better Health Channel Victoria accessed at: www.
betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/
flu_influenza?open
6. Gould L. Cold and Flu. InPHARMation. 2007;8(2):6–10.
7. Australian Health Management Plan for Pandemic Influenza
Canberra accessed at: www.flupandemic.gov.au/internet/
panflu/publishing.nsf/Content/whatis-1
8. Clinical Knowledge Summaries UK accessed at www.cks.
nhs.uk/common_cold/background_information/definition/
transmission
9. WebMD accessed at: www.webmd.com/cold-and-flu/coldguide/colds-risk
10.Helms RA, Quan DJ, Herfindal ET, Gourley DR, et al. Textbook
of Therapeutics Drug and Disease Management. 8th ed.
Pennsylvania USA Lippincott, Williams & Wilkins.
11.Blenkinsopp A, Paxton P, Blenkinsopp J. Symptoms in the
Pharmacy A guide to the Management of Common Illness.
5th ed. Blackwell Publishing Oxford UK. Pages 17–20.
12.Rutter P, Newby D. Community Pharmacy Symptoms,
Diagnosis and Treatment. Australian and New Zealand 2nd
edn. Sydney: Elsevier; 2012.
13.Therapeutic Goods Administration accessed at: www.tga.
gov.au/newsroom/btn-cough-cold-medicines-121126.
htm#hprofessionals
14.Mayo Clinic Rochester accessed 18 March 2013 at: www.
mayoclinic.com/health/common-cold-in-babies/DS01106/
DSECTION=symptoms
15.Immunisation Handbook 10th edition 2013.
16.Rossi S, ed. Australian medicines handbook. Adelaide:
Australian Medicines Handbook; 2012. (Accessed 20/2/2013)
At: www.amh.net.au/online/view.php?page=index.html
17.Pharmaceutical Society of Australia. Australian
pharmaceutical formulary and handbook. 22nd edn.
Canberra: The Pharmaceutical Society of Australia; 2012.
18.Flu smart accessed (3/3/2013) at: http://flusmart.org.au/
about-the-flu/
19.Douglas RM, Hemila H, Chalker E, et al. Vitamin C for
preventing and treating the common cold. Cochrane
Database Syst Rev. 2007; 3:CD000980.
20.National Centre for Immunisation Research and Surveillance
(NCIRS). Accessed at: http://ncirs.edu.au/news/2009/
paediatric-influenza-WA-2nd-indigenous-workshop.pdf
Colds and flu
Pharmacist CPD
Module number 238
Facts Behind the Fact Card
Assessment questions for the pharmacist
Colds and flu
Personal ID number:
— — — — — —
Full name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pharmacy:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Suburb:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Assessment due 31 July 2013
Before undertaking this assessment, you need to
have read the Facts Behind the Fact Card article
and the associated Fact Cards. This activity has
been accredited by PSA as a Group 2 activity.
Two CPD credits (Group 2) will be awarded to
pharmacists with four out of five questions correct.
PSA is authorised by the Australian Pharmacy
Council to accredit providers of CPD activities
for pharmacists that may be used as supporting
evidence of continuing competence.
Submit online at www.psa.org.au/selfcare
1.The order in which common cold
symptoms appear is:
3.The following responses relate to the
use of cough and cold preparations in
children aged 2–6 years of age. Which
ONE response is INCORRECT?
a. Cough first; fever second; nasal
symptoms last.
b. Fever first; sore throat second;
nasal symptoms last.
c. Nasal symptoms first; sore throat
second; cough last.
d. Sore throat first; nasal symptoms
second; cough last.
2. Which ONE of the following
statements best describes the
concomitant use of guaifenesin and
dextromethorphan?
a. This combination is first-line
therapy for cough associated with
the common cold.
b. This combination is not as
effective as concomitant use of
guaifenesin and codeine.
c. This combination generally is
considered to be irrational.
d. None of the above.
up to
Circle one correct answer from each
of the following questions.
Submit answers
Fax:
2
CPD Credits
GROUP 2
Accreditation number: CS130005
(02) 6285 2869
This activity has been accredited for Group 2 CPD
(or 2 CPD credits) suitable for inclusion in an individual
pharmacist’s CPD plan.
Mail: Self Care Answers
Pharmaceutical Society of Australia
PO Box 42
DEAKIN WEST ACT 2600
Please retain a copy for your own purposes.
Photocopy if you require extra copies.
a. Using cough and cold
medications in small children
can delay medical advice being
sought for more serious illnesses
such as asthma, influenza,
pneumonia, bronchitis or middle
ear infection.
b. Possible side effects of cough
and cold medications are
allergic reactions; increased or
uneven heart rate; slow and
shallow breathing; drowsiness
or sleeplessness; confusion or
hallucinations; convulsions;
nausea; constipation.
c. Overuse of these products or
overdose can lead to serious
harm.
d. There are no issues with their use
as children are small adults.
4. Regarding treatment of symptoms
of colds and flu which ONE of the
following is most correct?
a. Oral decongestants are more
effective than topical nasal
decongestants.
b. Oral and nasal decongestants,
sedating antihistamines and
intranasal anticholinergics may all
provide relief from rhinorrhoea.
c. Echinacea is effective in reducing
symptom duration and severity in
children.
d. Less-sedating antihistamines
are the medicines of choice
for rhinorrhoea caused by the
common cold.
5. Which ONE of the following
antitussives has been approved
for use as a cough suppressant for
children aged 2–6 years?
a. Codeine.
b. Dextromethorphan.
c. Pholcodine.
d. None of the above.
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
11
John BellCounter
says Connection
Colds and flu
Pharmacy assistant’s education
Module 238
Colds and flu
By Jan Castrisos
This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.
The common cold and influenza
(flu) are both viral infections.
They share many symptoms, and
people often use the terms cold
and flu as if they were one and the
same infection.
It is important to know the
difference between a cold and
the flu to effectively advise
customers. Colds are very
common – adults can get 2–4
colds per year while children can
get as many as 3–12.
The common cold and influenza are contagious and are most commonly spread by respiratory droplets from
sneezing or coughing.
Ear, Nose & Throat 1117
2011
Coughs
The common cold, allergy and cigarette smoke are common causes of
coughing, but a cough can also be a symptom of a serious illness or a side
effect of a medicine. Treatment for a cough depends on its cause.
Coughingisanormalreflextoprotect
and clean our airways (respiratory tract).
Coughingclearsirritatingmaterial(e.g.,
smokeordust)andexcesssecretions
(mucus,sputum,phlegm)fromour
throat,airpassagesandlungs.The
sound and pattern of a cough depends
on its cause.
Causes of coughing
Cough is a symptom of a range of
medical conditions and sometimes a
person may have more than one reason
for coughing.
Ear, Nose and Throat 0086
Cold and Flu
Common colds and the ‘flu’ (influenza) are viral infections affecting the
nose,
sinuses, throat and airways. Antibiotics do not work against these viral
•Asthma
infections, but colds and the flu usually get better on their own.
•Respiratorytractinfections(e.g.,colds,
Medicines
may relieve some of the uncomfortable symptoms of colds and flu.
bronchitis,croup,whoopingcough,
pneumonia)
•Inhaledirritants(e.g.,cigarettesmoke,
Causes of coughing include:
dust,fumes,aforeignbody)
When
someone has a cold or flu,
•Postnasaldrip(catarrh)–excessnasal the•Lungdisease(e.g.,cysticfibrosis,
fluid from their nose, mouth
secretions which run down into the
and COPD,cancer)
airways contains the infecting
backofthethroat.Oftencaused
•Gastroesophagealreflux(heartburn)
virus.
Colds and flu spread when this
byallergy,commoncoldsorsinus
– stomach
acid rises
up into the
infected
fluid passes
to someone-else
infection
and triggers
coughing
(e.g.,oesophagus
by touch, coughing,
sneezing).
Colds spread easily, especially between
children who spend a lot of time
Self Care is a program of the Pharmaceutical Society of Australia.
together (e.g., at childcare or school).
Self Care is committed to providing current and reliable health information.
A cold is most infectious in the first one
or two days after symptoms develop.
•Coughing
•Mildfever
•Headache
•Tiredness.
Flu (influenza) symptoms are similar to
cold symptoms, but are usually more
severe and may also include:
•Highfevers,sweatingandshivering
•Achingmusclesandjoints
•Weaknessandlethargy
Signs and symptoms
•Lossofappetite,nauseaandvomiting.
Cold symptoms include:
Cold and flu symptoms usually go within
10 days, although a cough may last
longer.
•Runnynose
•Blockednose(congestion)
•Sorethroat
•Red,wateryeyes
•Sneezing
Protection against influenza
A‘fluinjection’willgiveprotection
againstthe‘flu’.Vaccination,before
the‘flu’seasonstartseachyear,is
Self Care is a program of the Pharmaceutical Society of Australia.
Self Care is committed to providing current and reliable health information.
Related Fact Cards
Colds and flu
Coughs
Ear problems
Sinus problems
Pain relievers
12
2011
Customers will frequently come into the
pharmacy asking for cold and flu medicine.
Pharmacy assistants should be aware of
what questions to ask, when it is appropriate
to recommend a product and when they
should refer a customer to the pharmacist.
What is the difference
between the common cold
and the flu?
Unlike the common cold, the onset of
symptoms for flu is very sudden and fast. While
a cold and the flu are both infectious viral
illnesses, cold symptoms are usually mostly
around the nose and head. The flu is much
more severe, with symptoms such as fever,
chills and body aches. A person suffering from
the common cold can generally walk about
and work but a flu patient usually does not feel
like getting out of bed.
How is the cold and flu
spread?
The common cold and flu are contagious and
are most commonly spread by respiratory
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
droplets from sneezing or coughing. They can
also be spread by shaking hands with an infected
person with poor handwashing techniques (small
children), then touching the eyes, nose or mouth
after coming in contact with the virus. Some viruses
live on surfaces such as door handles and table
surfaces for up to two hours.
What are the symptoms of a
cold?
The common symptoms of a cold are:
•
•
•
•
•
•
blocked nose (congestion)
runny nose
sneezing
tired and generally feeling unwell
mild temperature (occasionally)
mild sore throat, hoarseness and cough.
Symptoms generally peak after 2–3 days, and
then gradually clear. However, the cough may
persist for up to four weeks after the infection has
gone due to inflammation in the airways that can
take a while to clear.
Flu symptoms are more severe. These include
fever, chills, muscle aches and pains and
headaches.
Colds and flu
Pharmacy assistant’s education
Module 238
Influenza or the common cold?
Symptom
Common cold
Influenza
Severity
Usually not severe
Serious problems can occur such as pneumonia
Speed of onset
Gradual
Sudden
Fever
None to mild
Usually high – lasts 3– 4 days
General aches
None to slight
Usual – often severe
Tiredness and weakness
Mild
Usual – may last 2–3 weeks
Headache
None to mild
Yes
Exhaustion
Rare
Yes and starts early
Stuffy nose
Common
Sometimes
Sore throat
Sometimes
Common
Sneezing
Usual
Sometimes
Cough, chest discomfort
Mild
Common, can become severe
What is the role of the
pharmacy assistant?
You need to understand the legal and
professional requirements for supplying
a Pharmacy medicine (S2) and Pharmacist
Only medicine (S3) to ensure the safe and
appropriate supply of non-prescription cold
and flu medicines.
It is important to gather as much
information as possible. A good approach is
to have a conversation with the person and
show them that you really do care about
helping them manage their symptoms.
Often they will tell you the information you
need if you ask a few open questions and
listen carefully to the answers. If you are
uncertain or something doesn’t make sense,
always refer to the pharmacist.
Use the WHAT STOP GO protocol on
page 14 to help decide how best to help
customers and who should be referred to
the pharmacist. If your customer directly
requests a particular product it is wise to
firstly ask if this product has worked for
them before with an open ended question.
For example ‘You’ve had this product before,
how did it go for you?’ This allows you to
establish why the customer is requesting a
particular product.
Cold and flu treatments
There is no magic cure for the common cold.
There is no treatment that will shorten the
length of the infection. Treatment aims to
ease symptoms whilst the immune system
clears the virus.
On 1 September 2012 the following changes
were made to the recommendations for the
Counter Connection
provide reassurance that cold symptoms,
while annoying and at times uncomfortable,
are not dangerous and will go away in time.
Some explanations for the changes to the
recommendations are:
Over-the-counter (OTC) cough and cold
medicines do not work for children younger
than six years and in some cases may
pose a health risk especially as serious
complications may be missed.
sale of cough and cold medicines in children.
• Cough and cold medicines should not be
given to children under six years of age.
• Cough and cold medicines should only
be given to children aged 6–11 on the
advice of a doctor, pharmacist or nurse
practitioner.
Most useful advice
The most useful advice for adults and
especially for children up to the age of
11 years is:
• Stay home and rest.
• Use paracetamol or ibuprofen for fever,
sore throats, aches and pains.
• A fever can lead to mild dehydration due to
sweating, causing tiredness and headache.
Advice is to drink plenty of fluids such as
water, fruit juices and clear soups.
• Steam inhalations (e.g. humidifiers) help
clear mucus and clear a blocked nose.
It is a temporary effect, but may be useful
before bedtime (especially for children)
to help them get off to sleep. Although
there is no scientific evidence that
addition of substances such as menthol
or eucalyptus oil to inhaled steam provide
any additional benefit, they may provide
a placebo effect. They should be used
at a dilution of five mL to approximately
500 mL of hot water.
• Saline nasal sprays or drops (e.g. Little
Noses, Fess, Narium) may help thin nasal
secretions while avoiding the risk of
rebound congestion that decongestant
nasal sprays can cause. Saline nasal drops
are a good alternative for young children
and babies.
When responding to concerned parents
about treating their child, it is important to
The efficacy and risk of such medications
needs to be studied in children. The doses
are determined by assuming that children
are ‘little adults’. If a medicine is to be used
in children, it should be studied in children.
Cough and cold medications should not be
exceptions to this rule.
OTC cough and cold medicines
Decongestants
Decongestants are the medicines of choice
for a blocked or runny nose. They can be
taken orally or administered in the form of
nasal sprays or drops.
Oral decongestants (e.g. pseudoephedrine,
phenylephrine) and nasal sprays or drops
(e.g. oxymetazoline, xylometazoline) may
be taken for short term relief of a runny or
blocked nose.
Antihistamines
Antihistamines are classed as sedating and
less-sedating.
Sedating antihistamines (e.g.
chlorpheniramine, dexchlorpheniramine,
diphenhydramine, promethazine) may help
relieve a runny nose but can cause sedation
and drowsiness.
These products are S3 and referral to the
pharmacist is required for supply.
Less-sedating antihistamines
(e.g. loratadine, cetirizine, desloratadine)
are indicated for allergic rhinitis and not
effective for treating a cold.
Cough medicines
Cough medicines are either expectorants or
suppressants.
Expectorants (e.g. bromhexine,
guaiphenesin) help bring up mucous from
the airways. They help make coughing
easier as they thin the mucous making the
cough more productive.
Suppressants (e.g. codeine,
dextromethorphan, dihydrocodeine,
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
13
John BellCounter
says Connection
How to correctly give
medication to children
• Give a dosage according to the
child’s weight, not age. Have the
pharmacist check it is correct.
• Always measure the medicine with
a dropper, dosage cup or other
accurate measuring device. Kitchen
teaspoons used for cooking are not
accurate. One metric teaspoon =
five mL.
• Paracetamol or ibuprofen may
be given with other medicines,
such as antibiotics or OTC cold
medicines. Make sure the OTC
cold medicine does not already
contain paracetamol or ibuprofen;
otherwise the child may be given a
double dose. Do not give OTC cold
medicines to children younger than
12 years of age unless instructed to
do so by the pharmacist.
• Liquid medicines may be mixed
in with soft foods or liquids.
Chewables may be crushed and
added to food, such as yoghurt,
applesauce and peanut butter. Mix
the medicines with a small amount
of food or drink, so you can be sure
the child takes it all.
Why no antibiotic?
An antibiotic is not needed if a virus is
causing an infection like the common
cold and flu. This is because:
• Antibiotics do not kill viruses.
Antibiotics only kill bacteria.
• Antibiotics may cause side-effects
such as diarrhoea, rashes, thrush,
feeling sick.
• Overuse of antibiotics when they
have not been necessary has led to
some bacteria becoming resistant
to them. This means that some
antibiotics might not be as effective
when they are really needed.
Colds and flu
Pharmacy assistant’s education
Use the What Stop Go protocol to decide when to refer
What Stop Go
Refer to the pharmacist.
Who is the patient?
Children less than 12 years (new recommendations)
Elderly- conditions such as bronchitis and pneumonia
may co-exist
Pregnant or breastfeeding
How long have the symptoms been present?
Recurring persistent or deteriorating symptoms such as
cough lasting longer than 2 or 3 weeks
Actual Symptoms – what are they?
Wheezing or a harsh barking cough
Cough which is worse morning, night or after exercise
Severe cough followed by a whoop
Mucus is blood stained or has a bad odour
Fever or fever with a rash
Treatment for this or any other condition?
(e.g. other medicines and conditions)
Existing medicines may cause cold or flu like symptoms
(e.g. cough)
There are some important interactions between some
medicines and some conditions and cough and cold
preparations
Symptoms or side effects caused by other conditions
and/or medicines?
Symptoms or side effects caused by other medicines
Existing medical conditions
Existing allergies
Totally sure? If you are unsure, refer to the pharmacist
Requested product is not appropriate or you are unsure
Overuse – how often has the patient been taking the
medicine or self-treating the condition?
Suspect misuse or abuse
Pharmacist preferred?
Customer requests to speak to the pharmacist
Requested product is a Pharmacist Only medicine or you
believe a Pharmacist Only medicine is appropriate for the
customer
GO – refer to the pharmacist
Go ahead and treat if any of the above conditions are not
an issue otherwise refer to the pharmacist.
pholcodine) are meant to decrease
coughing. Because coughing is a natural
response to substances in the lungs they
should be avoided in people suffering from
certain airways diseases especially in children
and should be referred to the pharmacist.
Echinacea
Cough products are generally not effective in
relieving coughs caused by a cold. Combination
products containing both expectorants and
suppressants should be avoided.
Flu treatments
Lozenges
Anti-inflammatory, antibacterial or
anaesthetic lozenges or gargles may help to
relieve a sore throat, or a cough, although
they have no effect on the viral infection.
For a child aged four years and older, cough
drops or lozenges may help soothe the
throat. Remember not to give cough drops or
lozenges to a child younger than four years
because of the risk of choking. Dose on the
package should be strictly adhered to.
Vitamin C
High doses of vitamin C may reduce the
duration and severity of symptoms, but
doses of 2000 mg or more per day can cause
stomach cramps and diarrhoea.
14
Module 238
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
It is not known whether echinacea really can
prevent or treat colds or flu. This is because
most echinacea preparations have not been
tested in reliable clinical trials.
Symptoms of the flu may be treated as
for the common cold. Antiviral medicines
may also be used to shorten the duration
of symptoms and reduce the risk of
complications. The antivirals currently
available in Australia are oseltamivir (Tamiflu)
and zanamivir (Relenza). They are Prescription
only (S4) and require a doctor’s prescription.
Prevention of cold and flu
Another difference between the common
cold and the flu is that the flu may be
preventable. Every year, only a handful of
strains of the influenza virus cause most of
the flu across the world. Annual influenza
vaccines are available. While the vaccine
is fairly effective, unanticipated flu strains
can evolve against which the vaccine will
not work.
Colds and flu
Pharmacy assistant’s education
Module 238
Counter Connection
Assessment questions for the pharmacy assistant
Colds and flu
Personal ID number:
— — — — — —
Full name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pharmacy:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Suburb:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Circle one correct answer from each
of the following questions.
Before undertaking this assessment, you
need to have read the Counter Connection
article and the associated Fact Cards.
The pass mark for each module is five
correct answers. Participants receive one
credit for each successfully completed
module. On completion of 10 correct
modules participants receive an
Achievement Certificate.
1. Cold symptoms:
a. Usually start suddenly.
b. Commonly include a high fever.
c. Usually start with discomfort in
the nose or throat.
d. Usually last for two weeks.
2. Which ONE of the following
statements relating to the sale of
cough and cold medicines in children
is correct?
a. Cough and cold medicines
should only be given to children
aged 6–11 years on the advice
of a doctor, pharmacist or nurse
practitioner.
b. Cough and cold medicines should
not be given to children aged
6–11 years.
c. Cough and cold medicines
should only be given to children
aged 2–6 years on the advice of
a doctor, pharmacist or nurse
practitioner.
d. There are no changes to the
recommendations for children
aged between 6–11 years.
3.The mother of a two-year-old has
requested some advice for her child
Assessment due 31 July 2013
who is sneezing a lot with benign
prostatic hyperplasia.
d. An adult customer with a raspy dry
throat and blocked nose and who is
not taking any other medications.
Submit answers
Submit online at www.psa.org.au
Fax:
(02) 6285 2869
Mail: Self Care Answers
Pharmaceutical Society of Australia
PO Box 42
DEAKIN WEST ACT 2600
5. When discussing the dose of
paracetamol which ONE of the
following statements is correct?
Please retain a copy for your own purposes.
Photocopy if you require extra copies.
who is unwell. You ask her a number of
questions and find that her child has
the symptoms of the common cold.
Which ONE of the following statements
contains the most appropriate advice to
give this mother?
a. Paracetamol can be given for the
fever, saline nose drops for the
blocked nose and pholcodine for
the cough.
b. Paracetamol can be given for the
fever, saline nose drops for the
blocked nose and lozenges for the
cough.
c. The child should be kept at home and
rest. Saline nose drops can be used for
a blocked nose and paracetamol can
be given for a fever.
d. Ibuprofen can be given for the
fever, dexchlorpheniramine
(Polaramine) for the runny nose
and pholcodine for the cough.
4. Which one of the following customers
does NOT require referral to the
pharmacist?
a. A child aged 7–12 years of age.
b. A customer with a slight fever
and blocked nose taking blood
pressure medication.
c. A customer with a mild headache
a. Five mL of liquid can be measured
using a regular teaspoon.
b. The dose should be calculated
using the child’s weight and
checked by the pharmacist.
c. Liquid ibuprofen must not be
mixed in yoghurt.
d. Children’s paracetamol tablets
cannot be crushed.
6.The mother of a three-year-old child
has requested a bottle of phenergan
(promethazine). The family is leaving
on an overseas flight the next day and
she wants it to help the child sleep.
She gave it to the child on her last
flight six months ago but discarded
the remainder as she thought she no
longer needed it.
Which ONE of the following is the
correct response?
a. The customer cannot have the
medication as the child is less than
6 years of age.
b. The customer can have the
medication as it is not being
used for a cold so you supply the
medication with counseling on the
appropriate dose.
c. The customer can have the medication
as it is not being used for a cold so you
refer the customer to the pharmacist
as it is an S3.
d. There is no problem with supplying
this medication as it is an S2.
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
15
Members notice board
John Bell says
& Self Care achievers
Self Care achievers
Self Care presents certificates to staff who
successfully complete a year of Counter
Connection modules.
Year 5
Jacki Perrett
Judy Hastings
Sunayna Odhavji
Nola Woodward
Nadine Kearney
Kelly Mudford
Faye Thompson
We would like to congratulate the following
people who have received the following:
Jeremy Huggins
Sarah Reay
Elizabeth Graovac
Katrina Leader
Carla Rauchle
Alex Clarke
Karen Morris
Linda McKeddie
Kristina Smith
Julie Henley
Tara Black
Erin Taylor
Year 4
Year 2
Nathalie Van Der
Houwen
Kate Lieschke
Year 12
Olga Missaghian
Shilaja Thekkute
Year 7
Maree Rudder
Dolores Cardona
Year 11
Glenda Gaskell
Kerrie Lowry
Carlita McConnell
Heather O’Sullivan
Julie Davis
Dianne Kuhnemann
Kelly Matthews
Year 9
Sandra Baird
Raelene Rivett
Stacy Sapienza
Louise Runnalls
Selina O’Halloran
Olga Katsoulis
Annie Hubbard
Tanya Lehane
Helen Campbell
Kerry-Anne Purvis
Tom Adamson
Tanya Curtis
Sheila Thorsen
Cheryl Kimmince
Kelly Holdsworth
Jessica Presland
Deborah Heinrich
Sue Brown
Tammy McLaren
Stacey Folau
Lucy Cowie
Susie Moretta
Fran Begley
Jane Rutherford
Year 6
Julie Killen
Huriye Irfanli
Tracy Bacon
Cathy Butta
Esther Kok
Dylan Hunt
Rachel Webb
Sandy Ballenhagen
Lauren Mather
Candace Clement
Daniela Egloff
Cath Semmler
Jemma Newtown
Rosemary Brenton
Year 8
Deborah Lang
Year 3
Ilinka Perntoska
Jan Cronin
Antonietta Barracu
Virginia Woodbridge
Assia Baban
Debra Russell
Ashley Way
Year 1
Sue Loip
Lynelle Miller
Theresa Grimsey
Helen Nakos
Bev Holliday
Faye Soya
Conferences and calendar dates
Conferences
Conferences
WineHealth 2013
Pharmacy Australia Congress 2013
18 – 21 July
Sydney Convention and Exhibition Centre
Sydney, NSW
www.winehealth.com.au
10 – 13 October
Brisbane Exhibition Centre, Qld
www.psa.org.au/pac
Enhancing optimal pharmaceutical care
through technology
12th Commonwealth Pharmacists Association
and the 33rd Caribbean Association of Pharmacy
Conference
11–18 August
The Atlantis Hotel, Nassau Bahamas
www.pharmacybahamas.com
4th Global Drug Safety Conference &
Exposition
14 – 16 October
Brisbane Exhibition Centre, Qld
www.psa.org.au/gds13
AMSI Conference 2013
14 November
Details to be announced
PSA Victorian Clinical Weekend
24 – 25 August
Wyndham Resort, Torquay, Victoria
International Pharmaceutical Federation
(FIP) World Congress 2013
31 August – 5 September
Dublin, Ireland
www.fip.org/dublin2013
National health calendar dates
June 2013
10 – 16 Mens Health Week
www.menshealthweek.org.au
July 2013
JulEYE Eye Health Awareness
Pharmacy 2013
4 – 7 September
Sheraton Mirage Port Douglas, Qld
www.pharmacyconference.com.au
www.eyefoundation.org.au
14 – 20 National Diabetes Week
www.diabetesaustralia.com.au
22 – 28 National Pain Week
www.chronicpainaustralia.org
16
inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd.
Christina Cortese
What’s coming up
in inPHARMation
Next month’s inPHARMation will
cover the topic of wound care in the
pharmacy.
Pharmacists are frequently asked
for advice on how to treat various
wounds, ranging from cuts and
grazes, to burns and blisters, to
post-surgical wounds and more.
Pharmacists are well placed to
appropriately treat many wound
presentations and thereby help
to reduce some of the pressure on
hospital emergency departments.
The article will explain wound
healing, the management of a
variety of wounds, including
dressing selection and the triggers
for referral. Together with some
treatment tips, the article looks
at some common medicines that
affect wound healing.