Download MtM essentials for cold, flu, and sinusitis management

CREDIT:
2.0
Continuing Education
EARN CE CREDIT FOR THIS ACTIVITY AT WWW.DRUGTOPICS.COM
AN ONGOING CE PROGRAM OF THE UNIVERSITY OF CONNECTICUT
SCHOOL OF PHARMACY AND DRUG TOPICS
educationaL oBJectiVeS
Goal: The goal of this activity is to compare
and contrast the common cold, influenza, and
sinusitis and discuss the role of the pharmacist
as the medication expert for various treatment
options and as a source to triage patients
when needed.
After participating in this activity,
pharmacists will be able to:
●
●
●
●
●
Compare the clinical presentations of the
common cold, flu, and sinusitis
Describe nonpharmacologic and
pharmacologic therapy for the common cold,
flu, and sinusitis
Summarize the efficacy and safety of
popular herbal products for the common
cold, flu, and sinusitis
Discuss essentials of pharmacist triage
for the patient with cold, flu, and sinusitis
symptoms
Compare differences between adult and
pediatric populations as they relate to the
common cold, flu, and sinusitis
The University of Connecticut School of
Pharmacy is accredited by the Accreditation
Council for Pharmacy Education as a provider
of continuing pharmacy education.
Pharmacists are eligible to participate in the
knowledge-based activity, and will receive up to 0.2
CEUs (2 contact hours) for completing the activity,
passing the quiz with a grade of 70% or better, and
completing an online evaluation. Statements of credit
are available via the CPE Monitor online system and
your participation will be recorded with CPE Monitor
within 72 hours of submission.
ACPE# 0009-9999-15-035-H01-P
Grant Funding: This activity is supported by an independent educational grant from Boehringer Ingelheim
Pharmaceuticals, Inc.
Supported by an educational grant from Genentech
Novartis Pharmaceuticals Corporation
Activity Fee: There is no fee for this activity.
MtM essentials for
cold, flu, and sinusitis
management
Danielle M. Miller, PharmD
ASSISTANT CLINICAL PROFESSOR, NORTHEASTERN UNIVERSITY SCHOOL OF PHARMACY, BOSTON, MASS.,
AND AMBULATORY CARE CLINICAL PHARMACY SPECIALIST, BOSTON MEDICAL CENTER, BOSTON, MASS.
Tayla N. Rose, PharmD
ASSISTANT CLINICAL PROFESSOR, NORTHEASTERN UNIVERSITY SCHOOL OF PHARMACY, BOSTON, MASS.,
AND AMBULATORY CARE CLINICAL PHARMACY SPECIALIST, LYNN COMMUNITY HEALTH CENTER, LYNN, MASS.
Abstract
The common cold, influenza (flu), and sinusitis are common upper respiratory
tract infections (URIs) that frequently result in unnecessary primary care office
visits, missed school days among children, and missed work days among adults.
Because of their viral etiology (except in less common cases of bacterial sinusitis),
these illnesses are considered to be self-limiting. Treatment recommendations are
focused on symptom management, including pharmacologic, nonpharmacologic,
and/or complementary alternative medicine options. Community pharmacists are
uniquely positioned healthcare providers adequately trained to assess patients’
symptoms and triage care. Serving as the initial healthcare provider, pharmacists
are able to identify whether patients are eligible for self-care or whether they
require a referral to a primacy care provider. In the setting of self-care, pharmacists
serve as medication experts to recommend over-the-counter (OTC) pharmacologic
options and/or nonpharmacologic options for symptom management.
Expiration date: October 10, 2018
To obtain CPE credit, visit www.drugtopics.com/cpe
and click on the “Take a Quiz” link. This will direct
you to the UConn/Drug Topics website, where you will
click on the Online CE Center. Use your NABP E-Profile
ID and the session code: 15DT35-PTK48 to access
the online quiz and evaluation. First-time users must
pre-register in the Online CE Center. Test results will
be displayed immediately and your participation will
be recorded with CPE Monitor within 72 hours of completing the requirements.
For questions concerning the online CPE
activities, e-mail: [email protected].
Faculty: danielle M. Miller, Pharmd, and tayla n. Rose, Pharmd
Dr. Miller is an assistant clinical professor at Northeastern University School of Pharmacy, Boston, Mass.,
and an ambulatory care clinical pharmacy specialist at Boston Medical Center, Boston, Mass. Dr. Rose
is an assistant clinical professor at Northeastern University School of Pharmacy, Boston, Mass., and an
ambulatory care clinical pharmacy specialist at Lynn Community Health Center, Lynn, Mass.
Faculty Disclosure: Dr. Miller and Dr. Rose have no actual or potential conflict of interest associated with
this article.
Disclosure of Discussions of Off-Label and Investigational Uses of Drugs: This activity may contain discussion
of unlabeled/unapproved use of drugs in the United States and will be noted if it occurs. The content
and views presented in this educational program are those of the faculty and do not necessarily represent those of Drug Topics or University of Connecticut School of Pharmacy. Please refer to the official
information for each product for discussion of approved indications, contraindications, and warnings.
36
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O ctob er 2015
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IMAGE: GETTY IMAGES/CANDYBOXIMAGES
Initial release date: October 10, 2015
continuing education
cpE sEriEs: MtM For tHE pAtiENt WitH rEspirAtorY
DisEAsE
Welcome to the CPE series, Medication
Therapy Management for the Patient
with Respiratory Disease, which was
designed for pharmacists who take care
of patients with respiratory disease.
Beginning in April 2015 and continuing
through December 2015, pharmacists
can earn up to 18 hours of CPE credit
with 9 monthly knowledge-based activities from the University of Connecticut
School of Pharmacy and Drug Topics.
introduction
The common cold, influenza (flu), and sinusitis are commonly encountered upper respiratory tract infections (URIs) that comprise
a majority of visits to primary care offices
and are often inappropriately treated with
a prescription antibiotic.1,2 In addition to
prescription drug use, there are an abundance of nonprescription products, including herbal and complementary alternative
medicine (CAM) products, available to treat
symptoms related to the common cold, flu,
and sinusitis.3 Community pharmacists are
aptly placed as first-line healthcare providers able to assess patients’ symptoms,
determine self-care eligibility, and make
nonpharmacologic and/or pharmacologic
recommendations as appropriate.
symptoms associated
with the common cold,
flu, and sinusitis
The common cold, often simply referred
to as a cold, is a viral infection of the upper respiratory tract. While there are numerous viruses that may cause a cold,
rhinovirus is the most common. Although
relatively benign in nature, colds are the
primary reason for missed school and
workdays for children and adults, respectively.4 Colds often develop slowly, with a
one- to three-day incubation period after
viral exposure, and begin with a sore or
“scratchy” throat and rhinorrhea, followed
by sneezing and cough. Other symptoms
commonly associated with a cold include
itchy or watery eyes (Table 1).5-7 Systemic
symptoms such as headache, fever, myDrugTopics .c om
This series kicked off in April and May
with MTM essentials for asthma management—Part 1 and Part 2. In June and
July, the focus shifts to MTM essentials
for chronic obstructive pulmonary disease (COPD) management. The August
CE activity is a primer on inhalers and
nebulizers. In September, pharmacists
have the opportunity to learn about allergic rhinitis management. In October,
the CE activity covers MTM essentials
for cold, flu, and sinusitis management.
The November CE activity includes druginduced pulmonary disease recognition
and management and idiopathic pulmonary fibrosis. The series concludes in December with a focus on MTM essentials
for cough management.
The series also offers applicationbased and practice-based activities in
2016.
algia, and general malaise are less common with a cold and more indicative of the
flu.8 The average duration of a cold varies
from seven to 10 days, with the exception
of the cough, which can last up to three
weeks and is often considered the most
bothersome symptom for patients.4,8 Colds
are generally considered to be self-limiting;
however, because they are often a reason
for children and adults staying home from
school or work, afflicted individuals may
find themselves turning to various overthe-counter (OTC) products to help alleviate
their symptoms. Some patients may visit
the doctor’s office in search of an antibiotic despite the viral nature of the infection.8
Regardless of the treatment that patients
seek, it is important to keep in mind that
symptom management is the preferable
treatment for colds, as there is no cure
for the causative virus. The common cold
is a contagious virus spread primarily via
self-inoculation through the nasal mucosa
or conjunctival membranes. Spread of the
infection can be prevented by proper hand
washing, disinfecting frequently touched
objects such as toys or door handles, and
avoiding close contact with others.4
The flu is a highly contagious respiratory infection caused by the influenza virus. Two types of influenza virus, Type A
and Type B, cause disease in humans. Type
A is further divided into various subtypes
based on the genetic makeup of the viral
surface proteins.9,10 Influenza Type A is considered more pathogenic than Type B and
is responsible for most outbreaks.5 The
strains vary yearly and are often unpredict-
The best way to
prevent the flu is
to receive the flu
vaccine each year,
ideally before
flu season, as
antibodies against
the virus develop
approximately
two weeks after
vaccination.
able. Yearly vaccination is prudent because
of the constant variability in virus strains
caused by “antigenic shift” and “antigenic
drift.”11 Although some symptoms of the flu
are similar to those of a cold, flu symptoms
are more abrupt in onset and more severe
in nature. Symptoms typically include a
high fever (≥100-102°F), chills, myalgia,
fatigue, sore throat, stuffy or runny nose,
and headache (Table 1).5-7 Most individuals who are otherwise healthy will recover
from the flu in a few days. However, the
World Health Organization (WHO) estimates
that 250,000 to 500,000 deaths are related to the flu each year. The incubation
period of the virus is 18 to 72 hours, but
viral shedding begins 24 hours before the
onset of symptoms and may last for five to
O ctob er 2015
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37
Continuing Education
TABLE 1
MtM eSSentiaLS FoR coLd, FLu, and SinuSitiS ManageMent
symptomatic treatment
for the common cold
CLiniCAL PResentAtion oF
CoMMon ResPiRAtoRY inFeCtions
Common cold
Influenza
Sinusitis
Common symptoms:
Sore/scratchy throat, cough,
nasal congestion, rhinorrhea,
itchy/watery eyes, sneezing
Common symptoms:
Fever, myalgia, headache,
rhinitis, sore throat, cough,
general body aches/fatigue
Common symptoms:
Nasal congestion and/or
discharge, facial pain, cough,
fever
Possible symptoms:
Low-grade fever, chills,
headache, myalgia, general
malaise
Possible symptoms:
Nausea, vomiting, diarrhea
Possible symptoms:
Sore throat, cough, laryngitis,
headache, loss of smell, tooth
pain
Onset of symptoms:
Slowly over the course of 1-3
days
Onset of symptoms:
Sudden
Onset of symptoms:
Evolves over days
Source: Ref 5-7
10 days. The virus is easily spread among
individuals, entering the respiratory tract of
the host where it begins to proliferate.5 The
best way to prevent the flu is to receive the
flu vaccine each year, ideally before flu season, as antibodies against the virus develop
approximately two weeks after vaccination.
Flu season may begin as early as October,
may peak in January and February, and may
continue to persist until May. The Centers
for Disease Control and Prevention (CDC)
therefore recommends that all individuals
over the age of six months be vaccinated
as early as possible. However, it is appropriate to receive the vaccination at any point
during flu season.12
Acute rhinosinusitis, or sinusitis for
short, is defined as an inflammation of the
mucosal lining of the nasal passage and
paranasal sinuses and is usually considered to be mild to moderate in nature.2
Most acute sinusitis cases are viral (90%98%), with the rhinovirus and coronavirus
as causative agents. However, bacterial etiology does occur less commonly (2%-10%
of cases).13 URIs, although mostly viral in
nature, often precede the development
of acute bacterial rhinosinusitis (ABRS).
TABLE 2
Organisms commonly responsible for ABRS
include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.14 Clinical presentation will therefore vary
depending on the etiology of the infection.
Symptoms commonly associated with sinusitis include nasal discharge beginning as
clear and watery and becoming more thick
and discolored by day four or five, congestion, cough, and sore or “scratchy” throat
(Table 1).5-7 Fever and/or myalgias are possible in the first 24 to 48 hours. Bacterial
sinusitis is usually distinguished from viral
sinusitis based on the duration of symptoms, severity of symptoms, or worsening
of symptoms (Table 2).6 According to the Infectious Diseases Society of America (IDSA)
Clinical Practice Guidelines for Acute Bacterial Rhinosinusitis in Children and Adults, a
patient presenting with any one of the three
criteria in Table 2 is clinically considered
to have ABRS.6 Duration of sinusitis also
varies based on etiology. Viral sinusitis is
shorter in duration, lasting approximately
five to 10 days with a peak in symptoms
around days three to six, whereas bacterial sinusitis usually persists for more than
seven to 10 days.6
ACute BACteRiAL RHinosinusitis
CLiniCAL PResentAtion
Patient must meet any one of the following criteria:
• Symptoms of acute sinusitis persisting ≥10 days without signs of improvement
• Severe signs/symptoms characterized by high fever ≥102°F and purulent nasal discharge or
facial pain lasting ≥3 to 4 consecutive days beginning at symptom onset
• Worsening symptoms, such as new-onset fever, headache, or increase in nasal discharge after
initial improvement (“double sickening”)
Source: Ref 6
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The widespread prevalence of the common cold results in many consumers purchasing OTC products for self-treatment.
These OTC medications are viable options
for the treatment of cold symptoms such
as cough, nasal congestion, runny nose,
watery eyes, myalgia, and general malaise.
As there are more than 200 available OTC
cough/cold products, many formulated as
combination products, it is imperative for
patients to choose the most appropriate
product based on their symptoms.8 Pharmacists are able to quickly and accurately
assess a patient’s symptoms with respect
to characteristics, history, onset, and any
aggravating/remitting factors and establish whether patients are eligible to selftreat. This approach is better known as
QuEST SCHOLAR (Figure 1).15
Essential pharmacologic treatment options for cough/cold symptoms include
analgesic/anti-inflammatory agents, antihistamines, decongestants, expectorants,
and antitussive products. Analgesics such
as aspirin, acetaminophen, ibuprofen, and
naproxen are commonly employed for both
their analgesic and anti-inflammatory properties, with acetaminophen most commonly
found in OTC cold products.8 It is thought
that respiratory symptoms arise secondary
to an inflammatory process caused by the
virus, most notably via the prostaglandin E2
mediator, supporting the use of nonsteroidal
anti-inflammatory drugs (NSAIDs).16-19
Runny nose, itchy/watery eyes, and
sneezing respond well to the use of antihistamines, as these symptoms are thought
to result from histamine release caused by
an inflammatory response to the causative
virus.20 First-generation antihistamines such
as chlorpheniramine and doxylamine are
efficacious in reducing nasal symptoms as
monotherapy but are considered to be more
efficacious in treating cold symptoms when
combined with other agents.21 Drowsiness
is a well-known side effect of first-generation antihistamines because of their ability
to cross the blood-brain barrier. Due to this
troublesome side effect, first-generation
antihistamines should be used with caution
in certain patient populations, such as the
elderly and those who require mental alertness. Nonsedating second-generation antihistamines such as loratadine, fexofenadine,
DrugTopics .c om
continuing education
and cetirizine lack this side effect but unfortunately have not been shown to effectively
treat histamine-mediated cold symptoms.22
Nasal congestion is caused by swelling
in the nasal mucosa tissue and obstruction of the airways due to vasodilation and
increased vascular permeability as a result
of the inflammatory processes associated
with the common cold.23,24 Phenylephrine
(PE) and pseudoephedrine (PDE) are FDAapproved oral decongestants that constrict
dilated blood vessels in the nasal mucosa,
thereby relieving nasal congestion. Although
still available without a prescription, PDE has
been moved to behind pharmacy counters
to regulate sales because of its role in the
illegal production of methamphetamine.25
This barrier in accessibility led to the reformulation, or brand-name extension, of many
products to replace PDE with PE, therefore
keeping decongestants readily available
in the aisles. The addition of “PE” to commonly known brands was used to distinguish the replacement of PDE with PE.26
Unfortunately, the recommended PE single
dose of 10 mg is considered less effective
than PDE single dose of 60 mg because PE
undergoes extensive systemic metabolism,
leading to low bioavailability.27,28 In addition
to the low bioavailability, the two agents also
differ in duration of action. Because of a
shorter half-life (2–3 hours), PE is dosed every four hours compared to PDE, which has
a longer half-life and can be dosed every four
to six hours.29,30 Following product reformulation, concern grew for the low bioavailability of
PE (38%), compared to PDE (90%), resulting
in the Citizen’s Petition of February 1, 2007,
which was filed with the FDA to increase the
maximum allowable PE dose from 10 mg to
25 mg.31 However, following the meeting of
the Nonprescription Drug Advisory Committee
in December 2007, it was concluded that 10
mg of oral PE is safe and effective as an OTC
nasal decongestant in adults and that insufficient evidence exists to increase the dose to
25 mg.32 While there is a plethora of literature
to support the efficacy of a single 60-mg oral
PDE dose for nasal congestion, there is a
FIGURE 1
QuEST SCHOLAR Mnemonic for assessing self-care among patients
QuEST
• Quickly and accurately assess the patient.
• Establish that the patient is an appropriate
self-care candidate.
• Suggest appropriate self-care strategies.
• Talk with the patient.
• Symptoms: What are the main and associated/related symptoms?
• Characteristics: What are the symptoms like?
• History: What has been done so far? Has this ever happened
and was prior treatment successful?
SCHOLAR
• Onset: When did this particular problem start?
• Location: Where is the problem?
• Aggravating factors: What makes it worse?
• Remitting factors: What makes it better?
Source: Ref 15 (Used with permission of the American Pharmacists Association)
lack of literature available to support the use
of PE at a higher dose. Even more conflicting,
one study concluded that 10 mg of oral PE
was no more effective than placebo in the
treatment of nasal symptoms.27,33 Patients
should therefore be educated accordingly as
brand-name products they had previously
used may now contain a different chemical
ingredient, increasing concern for potential
drug-drug or drug-disease interactions, and
differences in efficacy.
Cough is often the most irritating and
longest lasting symptom associated with the
common cold, lingering for up to three weeks.
Airway inflammation, excess mucus production, and postnasal drip are mechanisms responsible for cough.34,35 Treatment of cough
depends on whether the cough is productive
or nonproductive. Productive coughs may
warrant the use of an expectorant such as
guaifenesin, whereas nonproductive coughs
may warrant the use of an antitussive such
as dextromethorphan. However, combining
the two ingredients can be useful in certain
situations to alleviate not only cough frequency but also the physical symptoms of chest
discomfort associated with excess mucus.
Although many studies have demonstrated
efficacy with dextromethorphan alone for non-
pause&ponder
Which herbal supplements have you recently seen
in the media claiming to prevent and/or treat upper
respiratory tract infections?
DrugTopics .c om
productive, dry cough, others have found no
difference between dextromethorphan and
placebo.36-38 The American College of Chest
Physicians recommends the combination of
brompheniramine, a first-generation antihistamine, and PDE for acute cough.39
As most people do not typically suffer
from just one symptom, cold relief products
generally contain a combination of multiple
medications targeted at alleviating an array of
cold symptoms. This strategy can be beneficial for patients, as evidenced by a placebocontrolled trial that found that acetaminophen
and PDE used in combination provided better
relief of URI-associated pain and congestion
than either agent used as monotherapy.40
However, the use of combination products
can also be harmful for patients by exposing
them to unnecessary medications and their
associated adverse effects. Pharmacists
can help patients choose the right product
by educating them to properly read OTC product packaging and to select certain agents
based on individualized symptoms. Not only
is it imperative for patients to understand the
symptoms that they are treating, but they
must also understand the directions for use,
including maximum daily intake of individual
medications. OTC products are considered
safe when used in recommended amounts;
nevertheless, these agents are associated
with adverse events that can worsen when
dose limitations are exceeded.8
Because of the similarity between cold
and flu symptoms (Table 1), patients should
be counseled to seek medical attention if
O ctob er 2015
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Continuing Education
MtM eSSentiaLS FoR coLd, FLu, and SinuSitiS ManageMent
FIGURE 2
Indications for antiviral agents for the treatment and prophylaxis
of the influenza virus
• Hospitalized patients with severe, complicated
Indications to
prescribe
antiviral
treatment
influenza-like illness or laboratory-confirmed influenza
• Patients with influenza-like illness or laboratory-confirmed
influenza who are at risk of complications in the outpatient setting
• Patients with severe, complicated influenza-like illness or
laboratory-confirmed influenza in the outpatient setting
Indications
to consider
antiviral prophylaxis
if close contact*
has occurred with
an infected person
during the
infectious period§
• Healthcare workers
• Persons at risk of influenza-related complications
• Pregnant women
*Close contact: Self-inoculation of mucosal surfaces after droplet exposure to respiratory secretions (coughing or sneezing) from an infectious person.
§
Infectious period: One day before fever until 24 hours after resolution.
Source: Ref 5 (Adapted with permission)
symptoms do not resolve within seven to 10
days. Pharmacists can also educate patients
about nonpharmacologic treatment recommendations such as saline nasal irrigation,
gargling with warm salt water, increased
fluid intake (such as hot tea with lemon and
honey and chicken noodle soup), adequate
rest, and increased humidification with mist
vaporizers or hot showers.7
treatment
recommendations for
influenza
According to the CDC, WHO, and IDSA,
patients presenting with flu-like symptoms
should be diagnosed clinically. There are,
however, rapid influenza diagnostic tests
available. Unfortunately, while the specificity of these tests is high (>95%), rapid
flu tests have variable sensitivity, ranging
from 10% to 70%, and negative results
cannot rule out the flu. Real-time reverse
transcriptase polymerase chain reaction
tests and viral cultures are available, but
these techniques take more than 24 hours
pause&ponder
How can you
more effectively
counsel patients
on the selection
of appropriate
combination cough
and cold products?
40
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O ctob er 2015
to produce results.5 Because of the generally self-limiting course of the flu virus,
antiviral treatment is recommended only
for certain patient populations. Prophylactic treatment is also available and recommended for individuals who may have
been in close contact with someone with
the flu (Figure 2).5
There are two antiviral drug classes indicated for the treatment and prevention of
influenza: neuraminidase (NA) inhibitors and
adamantanes. Only two antiviral drugs, both
belonging to the NA inhibitor medication
class, are FDA approved for the prevention
and treatment of the flu in the outpatient
setting: oseltamivir (Tamiflu) and zanamivir
(Relenza) (Table 3).41,42 NA inhibitors prevent
the release of virions from an infected host
by inhibiting the enzyme neuraminidase,
thereby reducing viral spread. NA inhibitors
work on both influenza subtypes.43 Initiation
of NA inhibitors within 36 to 48 hours of
symptom onset has been associated with
a statistically significant reduction in the
time to symptom resolution. Initiating these
agents in a timely manner is important because they have not shown effectiveness in
patients who have been experiencing symptoms for longer than 48 hours. According to
a systematic review and meta-analysis of
the two NA inhibitors, use of these agents
within two days of symptom onset in children resulted in symptom resolution 0.5 to
1.5 days sooner than in those not receiving
a NA inhibitor.44,45 In contrast, the adamantanes, rimantadine and amantadine are not
routinely recommended in clinical practice.
Drug resistance, side effects, and lack of
efficacy against influenza Type B virus limit
their use.46 Young, healthy individuals are
excluded from antiviral therapy and instead
should be educated about nonpharmacologic treatment options such as rest and
adequate hydration. Specific symptoms
may be treated with OTC antipyretic and/or
anti-inflammatory agents. The use of aspirin or aspirin-containing products should be
avoided in children and teenagers because
of the risk of Reye’s syndrome.47
treatment
recommendations for
sinusitis
Pharmacologic recommendations for the
treatment of sinusitis vary depending on
the cause: bacterial or viral. In general, antibiotics should not be routinely prescribed
for acute mild to moderate sinusitis as it
is often viral in nature. Pharmacists may
help to reassure patients during this watchful waiting period and counsel patients to
contact their primary care provider if symptoms last for more than seven days, if
symptoms worsen after initial improvement,
or if symptoms are accompanied by a high
fever (≥102°F), excruciating facial/dental
pain, or pain/tenderness over the sinuses.2
Overall, acute sinusitis is a self-limiting viral
infection that often co-occurs with a URI or
the common cold. Nonpharmacologic treatment recommendations include applying a
warm compress over the face or breathing
in steam from a hot shower to help alleviate sinus pain and facilitate mucus drainage. Nasal irrigation can also help to clean
out the nasal passages. Patients should
maintain adequate hydration to dilute mucus buildup and promote drainage. Patients
should also elevate the head of the bed
when sleeping to prevent congestion and
should obtain plenty of sleep to help fight
off the infection.
However, if a clinical diagnosis of ABRS
is made, empiric antibiotic treatment should
be initiated immediately. Amoxicillin-clavulanic acid is considered a first-line option
for ABRS in both children and adults. In
adults with a penicillin allergy, alternative
first-line options include doxycycline or a
respiratory fluoroquinolone (levofloxacin
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continuing education
TABLE 3
neuRAMiniDAse inHiBitoRs FoR tHe tReAtMent AnD
PReVention oF inFLuenZA
Antiviral agent
FDA-approved indications
Oseltamivir
• Prophylaxis in patients aged ≥1 year
• Treatment of acute, uncomplicated flu
in patients aged ≥1 year who have not
been symptomatic for >48 hours
Zanamivir
• Prophylaxis in patients aged ≥5 years
• Treatment of acute, uncomplicated flu
in patients aged ≥7 years who have not
been symptomatic for >48 hours
Treatment (by mouth twice daily for 5 days)
Prevention (by mouth once daily for 10 days)*
Children aged 1-12 years:
• ≤15 kg: 30 mg
• >15-23 kg: 45 mg
• >23-40 kg: 60 mg
• >40 kg: use adult dosage
Children aged 1-12 years:
• ≤15 kg: 30 mg
• >15-23 kg: 45 mg
• >23-40 kg: 60 mg
• >40 kg: use adult dosage
Children aged ≥13 years and adults:
• 75 mg
• CrCl <30 mL/min: 75 mg once daily
for 5 days
Children aged ≥13 years and adults:
• 75 mg
• CrCl <30 mL/min: 75 mg every other
day for ≥10 days
Children aged ≥7 years and adults:
• 2 inhalations (10 mg) via the Diskhaler
Children aged ≥5 years and adults:
• 2 inhalations (10 mg) via the Diskhaler
Abbreviations: CrCl, creatinine clearance.
*Oseltamivir may be used prophylactically for up to 6 weeks and zanamivir for up to 4 weeks during community influenza outbreaks.
or moxifloxacin). Because of increased
resistance against S. pneumoniae and S.
pneumoniae plus H. influenzae, macrolides
and trimethoprim-sulfamethoxazole, respectively, are no longer recommended for initial
treatment. In uncomplicated ABRS, the duration of therapy is five to seven days in
adults and 10 to 14 days in children. An adjuvant intranasal corticosteroid can be used
with antibiotics, particularly in patients with
a history of allergic rhinitis. However, the
use of topical or systemic decongestants
and antihistamines should not be recommended as adjuvant therapy. These agents
may dry out the nasal mucosa and prevent
normal clearance of secretions.6
Herbal products: Do they
work and are they safe?
Various vitamins, supplements, and herbal
remedies are promoted as “natural” options
for the prevention and treatment of URIs.
Because of the plethora of these products
available on pharmacy shelves, pharmacists
will often be asked to provide a recommendation. As such, pharmacists must be well
informed regarding the safety and efficacy of
these products. Several commonly encountered products are reviewed below.
pause&ponder
How often do you
use the QueSt
ScHoLaR method
when triaging
patient symptoms?
DrugTopics .c om
Source: Ref 41,42
can flowering plants in the Asteraceae family.
Echinacea species are promoted as immune
system stimulants and protectors against
the common cold. Three species of Echinacea (purpurea, angustifolia, and pallida) are
used in herbal products.51 These products
may include the aerial (above-ground) and/
or root portions of the plant in varying proportions. Additionally, these products come in
various formulations, including oral tablets
and capsules, liquid extracts, juices, and
teas. These differences in composition and
formulation lead to a high degree of variability among products. It is important to consider these inconsistencies and how they
might affect the safety and efficacy of the
various products.
A systematic review conducted in 2013
evaluated a variety of Echinacea products
versus placebo for the prevention and treatment of the common cold.52 Investigators
concluded that Echinacea is not effective
for the treatment of colds. Prophylactic
Echinacea did not significantly reduce the
incidence of cold; however, a nonsignificant
trend toward prevention was observed.
Other studies have found that Echinacea
purpurea may decrease the duration and
severity of cold symptoms when initiated
shortly after symptom onset; however, Echinacea angustifolia is not beneficial.1
Echinacea may cause nausea and headache and is known to have a poor taste.51
It has also been associated with rashes,
particularly in children.52 Echinacea may
Echinacea
inhibit cytochrome P450 1A2 and induce
Echinacea refers to a genus of North Ameri- cytochrome P450 3A4, leading to potenAndrographis paniculata
Andrographis paniculata (andrographis) is an
herb with a long history of use in traditional
Indian, Chinese, and Thai medicine.48 In addition to its use in many other ailments, it is believed to prevent and treat the common cold.
A Swedish formulation of andrographis, Kan
Jang, when used prophylactically at a dose of
100 mg twice daily five days per week for a
minimum of two months, may reduce the risk
of the common cold by twofold.49 In terms of
common cold treatment, one particular andrographis product, KalmCold, demonstrated
a statistically significant reduction in symptoms versus placebo at a dose of 100 mg
twice daily for five days.50 Patients had been
symptomatic for fewer than three days upon
taking the first dose.
Andrographis is generally well tolerated
but may cause diarrhea, vomiting, nosebleed,
and itchy rash.48,50 Caution should be used
in patients taking immunosuppressive, antihypertensive, or anticoagulant medications
as andrographis may stimulate the immune
system, and increase the risk of bleeding and
hypotension.48
Take away: Andrographis, in the form
of Kan Jang and KalmCold, may be effective in the prevention and treatment of the
common cold, respectively. Results are not
generalizable to all andrographis products.
If this agent is used for treatment, patients
should start taking the medication within 72
hours of symptom onset.
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tial drug-drug interactions.51 The clinical
impact of these interactions is unclear.
Additionally, it may stimulate the immune
system and should be avoided in patients
who are immunosuppressed, including
those taking immunosuppressive medications. Patients should be counseled on the
possibility of an allergic reaction, especially
those with a history of atopy.
Take away: Echinacea products should
not be recommended for the prevention or
treatment of the common cold because of
the lack of consistency among products
and the lack of compelling evidence. If patients do elect to use an Echinacea product, Echinacea purpurea may have greater
benefit than other species.
Elderberry
Elderberry (Sambucus nigra) is marketed
for the treatment of influenza. Elderberry is
thought to stimulate the immune system by
significantly increasing the production of cytokines.53 One study showed that patients
with the flu who used elderberry extract four
times daily experienced pronounced symptom improvement after 3.1 days versus 7.1
days in patients taking placebo.54 Patients
included in this study had been symptomatic for less than 48 hours. It is important to
note that this study was conducted using a
specific product (Sambucol, Nature’s Way);
results should not be extrapolated to all
elderberry products. Another study found
that elderberry lozenges taken four times
daily for two days significantly improved influenza symptoms within 48 hours when
patients took the first dose within 24 hours
of symptom onset.55 Both of these studies
were small, with each including approximately 60 patients; therefore, results may
not be generalizable to the entire population.
Elderberry is well tolerated in supplemental form. Patients should be warned
that eating raw elderberries may cause
nausea, vomiting, and diarrhea. Cooking the elderberries eliminates this risk.56
Elderberry may stimulate the immune system and should be avoided in patients with
autoimmune disease and those taking immunosuppressants.
Take away: Elderberry may be beneficial, in addition to other supportive care,
in patients with the flu. However, patients
at high risk of complications should be
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Pharmacists should use the QuEST
SCHOLAR technique for all patients
presenting with symptoms of URIs to
elicit pertinent information, formulate an
assessment, determine eligibility for selfcare, and create a treatment or referral
plan as appropriate.
referred to their primary care provider for
evaluation and potential treatment with
antiviral agents.
Garlic
Garlic is believed to have antibacterial and
antiviral properties and therefore is often
used for prevention and treatment of the
common cold. One small study evaluated
the effect of garlic on the occurrence of
the common cold when taken once daily
for 12 weeks during cold season.57 Results indicated that garlic taken prophylactically may decrease the incidence of
cold compared to placebo. However, in patients who did develop cold, there was no
difference in the duration of symptoms.
Patients may be hesitant to use garlic
on a long-term basis because of the side
effects of bad breath, body odor, and rash.57
Garlic may decrease plasma concentrations
of isoniazid and saquinavir and should not
be used concomitantly with these medications. Garlic may have antiplatelet and anticoagulant activity and should be used with
caution in patients taking warfarin.58
Take away: Prophylactic use of garlic
may reduce the incidence of colds, however, side effects may be intolerable.
Ginseng
Both American ginseng and Panax ginseng have been studied for use in URIs.
Patients may not be aware of the distinction between these two products. This is
an important starting point for discussion,
as their use differs significantly.
One specific extract of American ginseng, CVT-E002, has shown possible
efficacy in three randomized controlled
trials.59-61 Combined results suggest
that American ginseng taken daily for
three to four months during flu season
may decrease the risk of contracting the
common cold and flu in adults and may
decrease the severity of symptoms in
those patients who do develop URI. Furthermore, the use of this product appears
to decrease the likelihood of contracting
more than one cold in a given season.60
American ginseng is well tolerated, with
headache being the most commonly reported adverse effect.62
Panax ginseng may also be referred to
as Asian ginseng. One small study evaluated the effect of Panax ginseng taken
daily for 12 weeks on immune response
to influenza vaccination.63 Patients received the influenza vaccine during the
fourth week of the study. Results showed
a significant increase in antibody titers
and a decrease in the occurrence of flu.
The most common adverse effect associated with Panax ginseng is insomnia.64
Both types of ginseng appear to decrease the efficacy of warfarin and should
not be used concomitantly.62,64 Women
with estrogen-sensitive cancers and conditions should avoid ginseng due to its potential estrogenic activity. Additionally, ginseng may increase risk of hypoglycemia in
patients taking antidiabetic medications.
Take away: Prophylactic American
ginseng used during flu season may decrease the incidence and severity of URIs.
Panax ginseng may improve response to
influenza vaccination.
Pelargonium sidoides
Pelargonium sidoides, also known as
Umckaloabo, is a species of a South African flowering plant related to the geranium.65 The active ingredient used in herbal
supplements is derived from the root of
the plant. It has been evaluated for use
in the common cold and sinusitis. A ranDrugTopics .c om
continuing education
domized controlled trial evaluated the effect of 1.5 mL of liquid P. sidoides extract
taken three times daily for 10 days versus placebo for treating symptoms of the
common cold.66 Patients in the treatment
group experienced less severe symptoms
and fewer days until clinical cure versus
those patients taking placebo. A small,
unpublished study suggested that patients who take 60 drops of Umckaloabo
extract three times daily for 21 days may
experience decreased duration of sinusitis
symptoms.67
Umckaloabo is well tolerated, but potential adverse effects include itchy rash,
gastrointestinal upset, and conjunctivitis.65 It is believed to have stimulatory effects on the immune system and should
be avoided in patients taking immunosuppressant medications and those with autoimmune diseases.
Take away: P. sidoides may be effective for the treatment of the common cold.
Further study is needed to determine the
effectiveness of Umckaloabo for treating
the symptoms of sinusitis.
Vitamin C
Vitamin C supplementation is often perceived by patients to boost the immune
system and to prevent the common cold.
Unfortunately, evidence indicates that
daily vitamin C supplementation does not
in fact decrease the risk of cold. However,
in patients who do contract the common
cold, a Cochrane review showed that
those who regularly use vitamin C as a
daily supplement experience a decreased
duration of cold: 8% shorter in adults and
14% shorter in children.68 The value of this
marginally shortened duration should be
weighed against the associated cost and
pill burden. Patients may also believe that
large doses (1-3 g) of vitamin C are beneficial in treating the symptoms of the common cold. There is no evidence to support
the use of high-dose therapeutic vitamin
C once a cold has started.68
Although vitamin C is generally well tolerated at doses used for daily supplementation, at high doses, it may cause gastrointestinal symptoms (such as nausea,
vomiting, and diarrhea) and urinary tract
stones.69 Patients should be encouraged to
avoid using more than the recommended
upper intake level of 2000 mg per day.
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Take away: Daily vitamin C supplementation may help to decrease the duration
of colds in adults and children; however,
high-dose vitamin C should not be recommended for treatment of the common cold.
Zinc
Zinc has been shown to inhibit rhinoviral
replication in in-vitro studies and therefore is often marketed to the public as an
effective agent for prevention and treatment of the common cold. Overall, data
do not strongly support the prophylactic
use of zinc.70 If zinc is taken prophylactically for at least five months, children may
experience a decreased incidence of the
common cold and associated absences
from school.71 In terms of treatment, two
systematic reviews have demonstrated
that zinc lozenges at doses greater than
75 mg/day reduce the duration of symptoms (nasal discharge, congestion, sneezing, sore throat, hoarseness, cough, and
muscle ache) by approximately one day
when treatment is initiated within 24
hours of symptom onset.70,71 It is important to counsel patients that to achieve
the efficacious dose, one lozenge must be
used every two to three hours, depending
on the product. This frequency of administration may be burdensome for patients.
Oral zinc is normally well tolerated;
however, patients may complain of bad
taste and nausea.72 Agents used to improve the flavor of zinc-containing products, including citric acid and sugar alcohols (sorbitol, mannitol) may chelate zinc,
and therefore decrease efficacy. Zinc
interacts with quinolone and tetracycline
antibiotics, resulting in reduced absorption of both agents. Patients should be
counseled to take antibiotics two hours
before or four hours after zinc.
Intranasal zinc has been associated
with permanent loss of smell, and as
such, popular formulations were discontinued in 2009.73 However, these products
may still be available online, so patients
should be strongly advised to avoid the
use of intranasal zinc.
Take away: Patients interested in using
zinc should be counseled that it does not
prevent the common cold. Although zinc
may decrease symptoms in patients with
the common cold, this benefit is achieved
only if treatment is started almost immedi-
ately and the lozenges are taken every two
to three hours.
Other products
Patients may inquire about the use of apple
cider vinegar as a holistic treatment for a
multitude of health concerns, including sinusitis.74 It is believed to have antibacterial
properties. At this time, however, there is
no clinical evidence to support its use in
sinusitis. Bromelain is a digestive enzyme
found in pineapple.75 When taken orally, this
agent is believed to decrease swelling in
the sinus cavity, however, there is no reliable evidence to support its use in sinusitis. The aforementioned products should
not be recommended for the prevention or
treatment of URIs.
Herbal supplements should be avoided
in children and women who are pregnant
or breastfeeding. Pharmacists should consult the Natural Medicines database for
information regarding the safety, efficacy,
and drug-drug interactions associated with
herbal products and other CAMs.
Pharmacist’s referral: Is
self-care appropriate?
As the most accessible healthcare professionals, pharmacists are in a strong
position to decrease the unnecessary use
of urgent care services by accurately triaging patients’ symptoms. If a pharmacist
can recognize the pattern of a viral illness
and recommend appropriate symptomatic
self-care treatment, he or she may prevent a costly trip to the doctor’s office
and a potentially inappropriate antibiotic
prescription. However, it is equally important that a pharmacist be able to identify
patients who need further medical evaluation. Therefore, pharmacists should use
the QuEST SCHOLAR technique for all patients presenting with symptoms of URIs
to elicit pertinent information, formulate
an assessment, determine eligibility for
self-care, and create a treatment or referral plan as appropriate.
Cold
Patients presenting with symptoms of
the common cold should first be evaluated for appropriateness of self-care.
The following patients should be referred
to their primary care provider for further
evaluation: those presenting with chest
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MtM eSSentiaLS FoR coLd, FLu, and SinuSitiS ManageMent
pain, shortness of breath, or a temperature above 101.5°F; patients with chronic
diseases that involve the respiratory and
immune systems (eg, asthma, chronic obstructive pulmonary disease, congestive
heart failure, AIDS); frail elderly patients;
children aged less than nine months;
and patients with worsening symptoms
despite appropriate self-treatment.15 If
self-care is deemed appropriate, patients
should be educated on the nature of viral
illness, mainly that curative therapies are
not available and that treatment should
focus on individual symptoms that are
bothersome. Pharmacists should offer to
assist the patient in selecting an appropriate product and counsel the patient on
the appropriate use of the product. Finally,
patients should be educated on strategies
to prevent the spread of the virus to others, such as appropriate hand hygiene. All
patients should be encouraged to seek
medical evaluation if symptoms have not
resolved within seven to 14 days.15
Flu
Pharmacists should interview patients
with suspected influenza to identify those
at high risk for developing complications.
High-risk patients include pregnant women, Alaskan natives and American Indians,
individuals aged younger than five or older
than 65 years, patients aged younger than
19 years who are receiving aspirin therapy, residents of long-term care facilities,
immunocompromised patients, morbidly
obese patients, and those with chronic
disease.76 Patients meeting the aforementioned criteria should be referred to
their primary care provider for evaluation
and possible treatment with a NA inhibitor.
For patients not at high risk for complications, pharmacists should recommend
appropriate supportive care and discuss
strategies to prevent spread of the infection to others, such as using appropriate
hand hygiene, staying home from school/
work until 24 hours after temperature returns to normal, and wearing a facemask
if patients must go out.77 Adult patients
should be encouraged to seek medical
care if they experience chest pain or trouble breathing, confusion or dizziness, or
persistent vomiting. Children should see
a doctor if they experience increased irritability, unusual fatigue, abnormal breath-
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ing, fever with rash, or dehydration. All
patients should seek care if symptoms
initially improve before worsening.
Sinusitis
Patients presenting with symptoms of sinusitis should be evaluated for the presence
of symptoms indicative of bacterial illness
(Table 2).6 Patients meeting these criteria
should be referred to their primary care provider for evaluation and antibiotic therapy.
In patients who present with symptoms indicative of viral illness, pharmacists should
explain the likelihood of viral infection and
recommend watchful waiting and symptomatic treatment (nasal irrigation and intranasal
corticosteroids). Patients should be encouraged to avoid antihistamines and decongestants and to seek medical care if improvement is not seen in seven to 10 days or if
they experience “double sickening”.6
the common cold, flu,
and sinusitis in pediatric
populations: Are they the
same?
As with all medications, it is important to
remember that pediatric patients often
require different doses of medication.
In 2007, manufacturers voluntarily withdrew infant preparations of cough and cold
medications, and in 2008, the FDA recommended that OTC cough and cold products should no longer be used in children
aged younger than two years.78,79 These
changes came as a result of reports of
serious adverse effects, such as seizures,
tachycardia, loss of consciousness, and
in some cases, death. Additionally, these
agents had not demonstrated efficacy
in patients aged younger than six years.
Later in 2008, manufacturers voluntarily
further restricted the use of OTC cough
and cold products, with labels changed to
state that these products should not be
used in children aged younger than four
years.80 Additionally, improved packaging
and measuring devices were developed to
prevent accidental overdose. After these
changes, emergency department visits for
adverse events related to these medications decreased significantly.79 It is crucial
that pharmacists counsel patients that
OTC cough and cold medications are not
appropriate for children aged younger than
four years. It is also important to educate
parents regarding age- or weight-based
dosing of specific products, as parents
may plan to use the same agent for multiple children. Parents should be taught
to read ingredient labels on combination
products to ensure that maximum doses
are not exceeded and that aspirin is not
inadvertently administered to children.
There are many other important considerations that pharmacists must take into
account when triaging pediatric patients
with URIs. Disease presentation may be
different from that in adults, as well as potential complications. For example, children
with the flu are more likely to present with
vomiting and diarrhea compared to adults,
and subsequently they are at increased risk
of hospitalization.9, 76 Herbal supplements
do not have sufficient data to support their
use in the pediatric population and therefore should not be recommended for use in
children. Additionally, OTC and prescription
medications may need dose adjustments
based on the age or weight of the patient.
conclusion
The high prevalence and viral etiology of
the common cold, flu, and sinusitis among
both pediatric and adult populations afford
community pharmacists the opportunity to
assess for self-care eligibility. As highly accessible, uniquely positioned healthcare
providers, community pharmacists play a
key role in decreasing primary care visits,
patient costs, and inappropriate antibiotic
use. As medication experts, pharmacists
are adequately trained to provide OTC pharmacologic treatment recommendations,
as well as nonpharmacologic options for
symptom management when appropriate. Pharmacists play a role not only in
determining self-care eligibility, but also in
identifying patients ineligible for self-care,
warranting a referral.
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test questions
1. Which of the following correctly pairs the
upper respiratory infection with its most
common causative agent?
a. Influenza: influenza B
b. Bacterial sinusitis: M. catarrhalis
c. Common cold: rhinovirus
d. Viral sinusitis: S. pneumoniae
2. Which of the following pairs best matches
the upper respiratory infection with its
typical clinical course?
a. Influenza: sore throat followed by
rhinorrhea and cough lasting 10 to 14 days
b. Bacterial sinusitis: fever, body aches, and
fatigue lasting up to 14 days
c. Common cold: headache, facial pain, and
fever lasting less than 10 days
d. Viral sinusitis: nasal congestion, scratchy
throat, and cough lasting five to 10 days
3. Which of the following clinical presentations
suggests a patient is likely to have bacterial,
rather than viral, sinusitis?
a. Symptoms lasting more than 10 days
b. Cough
c. Fever lasting less than 48 hours
d. Nasal discharge
4. Which of the following patient-reported
symptoms suggests the presence of influenza
versus the common cold?
a. Body aches
b. Runny nose
c. Productive cough
d. Stuffy nose
5. JG is a 42-year-old woman diagnosed
with acute bacterial rhinosinusitis. She
has no history of recent hospitalization,
immunodeficiency, or penicillin allergy and has
not used antibiotics in the past month. Which
of the following treatment options is the most
appropriate recommendation for JG?
a. Azithromycin 500 mg on day one, then
250 mg daily on days two to five
b. Sulfamethoxazole-trimethoprim
800 mg/160 mg twice daily for 10 days
c. Amoxicillin-clavulanate 875 mg/125 mg
twice daily for five days
d. Levofloxacin 750 mg daily for 10 days
6. Which of the following statements regarding
influenza antiviral medications is true?
a. Influenza antiviral medications are usually
prescribed for 14 days.
b. Antiviral medications should be
recommended for all patients with influenza.
c. Oseltamivir should not be recommended
in patients with asthma and COPD.
d. Influenza antiviral medications are
most effective if started within 48 hours of
symptom onset.
7. Which of the following nonpharmacologic
recommendations would be most appropriate
to help alleviate sinus pain in a patient with
sinusitis?
a. Nasal irrigation
b. Warm facial compress
DrugTopics .c om
c. Gargling with warm salt water
d. Increased hydration
8. All of the following antihistamines have
been shown to be effective for treating cold
symptoms as monotherapy or in combination
with other agents except for:
a. Doxylamine
b. Loratadine
c. Chlorpheniramine
d. Brompheniramine
9. Andrographis products may decrease
symptoms of the common cold if initiated
within __ hours of symptom onset:
a. 24
b. 36
c. 48
d. 72
10. Which of the following is true regarding daily
supplemental use of vitamin C?
a. Vitamin C may prevent the common cold,
but it has no effect on symptom duration in
patients with the common cold.
b. Vitamin C may decrease symptom
duration in patients with the common cold,
but it does not prevent the common cold.
c. Vitamin C may be effective in both
preventing the common cold and decreasing
symptom duration in patients with the
common cold.
d. Vitamin C is not effective in either preventing
the common cold or decreasing symptom
duration in patients with the common cold.
11. Which of the following is the most important
counseling point regarding the use of zinc?
a. Intranasal zinc may result in permanent
loss of smell.
b. Zinc lozenges are effective when taken
two to three times daily.
c. Zinc has no effect on the duration of the
common cold.
d. Prophylactic use of zinc sulfate may
reduce the risk of the common cold if taken
daily for at least five weeks before exposure.
12. Which herbal product may be effective
in decreasing the duration of influenza
symptoms?
a. Elderberry b. Garlic
c. P. sidoides d. Ginseng
c. They are unable to provide
recommendations regarding herbal
supplements.
d. They are uniquely positioned healthcare
providers equipped to accurately triage
patients’ symptoms.
15. The role of pharmacist triage for patients
presenting with symptoms of acute sinusitis
may include all of the following except:
a. Preventing an unnecessary primary care
physician visit
b. Filling an antibiotic prescription in less
than 15 minutes
c. Counseling the patient regarding watchful
waiting
d. Decreasing patient cost (eg, copays)
16. NC is a 27-year-old woman who is 35 weeks
pregnant with her first child and presents to
the pharmacy counter while you are on duty.
She reports that her husband was diagnosed
with the flu yesterday and has been running
a fever all day today. She wants to know
what she can do to remain healthy. Which
of the following is the most appropriate
recommendation for NC at this time?
a. Refer her to her primary care physician, as
she may be eligible for prophylactic treatment.
b. Wish her luck, as she is most likely going
to catch the flu.
c. Counsel her to avoid further contact with
her husband until symptoms resolve.
d. Reassure her she is in the clear, as he is
not contagious after 24 hours.
17. Current product labeling states that OTC
cough and cold medications should not be
used in patients aged younger than:
a. One year
b. Two years
c. Three years
d. Four years
18. Which of the following is the best agent to
recommend for a three-year-old patient with
past medical history of asthma diagnosed
with influenza?
a. Oseltamivir b. Amantadine
c. Zanamivir d. Rimantadine
13. Community pharmacists may employ the
QuEST SCHOLAR method to gather patient
information in order to:
a. Diagnose the patient’s complaint
b. Recommend an OTC product
c. Determine self-care eligibility
d. Accurately fill the prescription
19. Aspirin and aspirin-containing products
should be avoided in children and teenagers
with flu-like symptoms because of the
concern for:
a. Raynaud disease
b. Rhinoviral replication
c. Reye’s syndrome
d. Respiratory depression
14. Which of the following statements regarding
community pharmacists is true?
a. They are unable to provide OTC
recommendations without a physiciandiagnosed problem.
b. Their job consists solely of pouring pills
from big bottles into smaller bottles.
20. Which of the following most appropriately
represents the correct duration of antibiotic
therapy for ABRS in pediatric patients?
a. Five to seven days
b. Five to 10 days
c. 10 to 14 days
d. 14 to 21 days
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18. Maher SA, Dubuis ED, Belvisi MG. G-protein coupled
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2. Smith SR, Montgomery LG, Williams JW Jr. Treatment
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