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Fourth year / Clinical Pharmacy
COMMON COLD
Common cold: is a self-limiting viral infection of the upper respiratory
tract.
Different types of viruses can produce symptom of the common cold
including: rhinoviruses (half of the cases), adenoviruses & influenza
virus.
The probable routes of transmission are:
1- Manual transmission (e.g. hand- to-hand contact).
2- Inhalation of droplets spread by sneezing and coughing.
Virus invades nasal & bronchial epithelia, attaching to specific
receptors lead to damage the ciliated cell resulted with release of
inflammatory mediators and then inflammation of the tissues lining the
nose (increase permeability of capillary cell walls, oedema, nasal
congestion, sneezing, then fluid might drip down and back to the throat
and spreading the virus to the throat and upper chest causing cough &
sore throat.
Patient assessment with common cold:
A-Age:
Very young patients and very old patients required referral. Also the
age affect the choice of treatment.
Pre-school children are more common to suffer from common cold.
B-Duration:
Generally (see flu later):
Abrupt onset of symptoms------- may indicate flu.
Gradual onset of symptoms------- may indicate common cold.
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C-Symptoms:
Symptoms typically are worst on day 2 or 3 of illness and last about
1 week (but in about 1/4 of patients it may last for about 2 weeks or
longer).
Symptoms of common cold are:
1-Sore throat:
The throat is often feels dry and sore during a colds and it is usually
st
the 1 sign of common cold.
2-Runny / congested (or blocked) nose:
(Initially clear watery fluid-------after 1-2 days become thicker
mucus).
3-Sneezing/ coughing
4-Aches and pains:
Headache may occur, but a persistent or worsening frontal
headache (pain above or below the eyes) may be due to sinusitis ----referral for further investigations.
(Note: headache of sinusitis increase by lying down or bending forwards).
5-Low grade fever (feeling hot but in general a high temperature (>37.5)
is rare in common cold (<1% of patients)).
The presence of fever may indicate FLU rather than common cold.
6-Earache: A blocked uncomfortable ear is often present and does not
need referral if it does not persist. A very painful ear needs referral.
D- Previous history:
Patient with a history of asthma or lung disease (e.g. chronic
bronchitis) ------required referral for further investigations.
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E- Patient with delirium and patient with pleuretic chest pain ------required referral for further investigations.
F- Differential diagnosis:
The pharmacist must try to differentiate between viral infection and
conditions that present with similar symptoms (e.g.; flu, sinusitis, allergic
& chronic rhinitis), as well as the complications associated with the
common cold.
Differentiating between colds and flu (which required referral for further
investigations) is needed. Patients often use the word “flu” when
describing a common cold. Flu is generally considered to be likely if:
1- Temp. is 38c or higher (37.5 in elderly).
2- At least one of the respiratory symptoms (cough, sore throat, nasal
congestion, or rhinorrhoea) is present.
3-At least one of constitutional symptoms (headache, malaise,
myalgia, sweat, chills, and prostration) is present.
4-Flu occurs more often in winter seasons, cold attack any time of
year.
NOTE: In common cold the upper respiratory symptoms are the most
prominent while in flu the constitutional symptoms are predominant and
fever is present in more than 95% of patient.
Flu often starts abruptly with sweat and chills, muscular aches and
pain in the limbs, a dry sore throat, cough and high temperature. Someone
with flu may be bed bound and unable to go to their usual activities.
There is often a period of generalized weakness and malaise following
the onset of symptoms. A dry cough may persist for some time.
Sinusitis is a complication that can arise from the common cold.
Following the cold, sinus air spaces can become filled with nasal
secretions, which stagnate because of a reduction in ciliary function of the
cell lining the sinuses. Symptom starts with localized pain that become
more sever when the condition persist, bending down, moving the eye
from side to side, coughing or sneezing often exacerbate the pain.
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G- Present medication:
If one or more appropriate remedies have been tried without success
(failed medication) ------------- referral for further investigations.
Treatment timescale:
Once the pharmacist has recommended treatment, patient should be
advised to see the Dr. in 10-14 days if cold has not improved.
Management:
Non-pharmacological measures:
Non -drug therapy include:
1- Increased fluid intake which may loosen the mucus and promote
drainage.
2- Adequate rest may help to recover quickly.
3- Adequate nutrition
4- Saline solution; can soothe the irritated nasal tissue and
moisturized nasal mucosa, and it can be given to all age groups
and during pregnancy.
Pharmacological therapy:
Decongestants (sympathomimetics):
A-Systemic (oral) decongestants: like pseudoephedrine and phenylphrine.
They reduce nasal congestion by constricting dilated blood vessels in the
nasal mucosa.
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C/I: Systemic (oral) decongestants cause stimulation of the heart, increase
the BP and may cause hyperglycemia. Therefore they should avoid in
(D.M, Ischemic heart disease (angina, M.I), hypertension, and
hyperthyroidism).
D/I: Avoid concomitant use with MAOI because of risk of hypertensive
crisis, avoid in patients taking beta blockers & TCAs, avoid in first
trimester of pregnancy.
B-Topical(drop/spray) Nasal Decongestants( sympathomimetics):
1-Classification and Doses:
type
Short acting (4-6 hours).
Example(s)
Dose
phenylphrine,
naphazoline, 2 drops/sprays q 4-6 hours
tetrahydrozoline
p.r.n
(but naphazoline
q 6
hours)
Intermediate acting (8-10 Xylometazoline (Otrivine®):
2 drops/sprays q 8-10
hours).
0.1%: >12 years
hours p.r.n
0.05%: 2-12 years
Long acting (12 hours).
Oxymetazoline (Nazordine®):
0.05%: >12 years
0.025%: 2-12 years
2 drops/sprays q 12 hours
p.r.n
2-Nasal Spray or Drop:
- Nasal sprays are preferable for adults and children aged over 6 years
because spray has a faster onset of action and cover a large surface area.
- Nasal drops are preferable for children aged below 6 years because their
nostrils are not sufficiently wide to allow effective use of sprays.
(The drops cover a limited surface area and easily swallowed which
increase the possibility of systemic effects).
3-Topical Nasal decongestants (sympathomimetics) can be recommended
for those patients in whom Systemic (oral) decongestants are to be
avoided.
(i.e. D.M, Ischemic heart disease (angina, M.I), hypertension, and
hyperthyroidism).
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4-Duration of Topical Nasal Decongestants (sympathomimetics) use:
If topical (drops or sprays) decongestants are to be recommend, the
pharmacist should advice the patients not to use the product for longer
than 7 days (3-5 days in some references) because:
Rebound congestion (Rhinitis medicamentosa) can occur with topically
applied (especially short acting) but not with oral sympathomimetics.
5-Topical nasal decongestants: can be given to pregnant women after the
1st trimester of pregnancy.
*Not OTC for children < 2 years.
*Not recommended for children <6 months (or 3 months in BNF)
because they are obligate nose breathers and rebound congestion can
cause obstructive apnea. Saline nose drop can be used from birth to help
with congestion. This would be more suitable and safer alternative than
topical sympathomimetics.
Note: regarding saline solution:
- There are already formulated saline drops or spray products in the
market, or it may be prepared in the pharmacy.
- Saline solution can be prepared by the patient using one teaspoonful of
table salt in seven ounces of warm water and administered with a bulb
syringe (dose 2-6 drops in each nostril four times daily or as needed) &
discard any unused portion.
Antihistamines:
Antihistamine can reduce some of symptoms of a cold: runny nose
(rhinorrhoea) and sneezing but are not so effective in reducing nasal
congestion.
Antihistamine can be classified into:
A- Sedating Antihistamine:
Examples of OTC sedating antihistamine are:
Chlorpheniramine (Histadin® tablet and syrup), Dexchlorpheniramine
(polaramine® tablet), and Diphenhydramine (Allermine® tablet and
syrup), and Triprolidine (Actified® tablet and syrup).
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S/Es: include sedation and drowsiness (patients should be informed) and
anticholinergic S/Es (i.e. dry mouth, urinary retention, constipation, …..)
and the elderly patients are more susceptible to these.
Accordingly they are not recommended (or used with caution) for
patients with: Glaucoma, or prostate hypertrophy and in elderly patients.
D/I: the sedative effects of antidepressants, anxiolytics, and hypnotics are
likely to be enhanced by sedating antihistamine.
B- Non-Sedating Antihistamine:
Examples of OTC non-sedating antihistamine are: Loratadine
(clarityn® tablet and syrup), and cetirizine (Zirtek® tablet and syrup).
They are generally preferable over the older antihistamines because of
much lower incidence of S/Es.
Adult dose of loratadine: 10 mg once daily.
Note: although the drowsiness is rare, but the warning that these drugs
may affect driving and skilled tasks is still present.
Combination products: sympathomimetics
Antihistamine (for rhinorrhoea and sneezing):
(for
congestion)
+
Example of OTC products is:
Actifid® tablet and syrup: which composed of Triprolidine (sedating
antihistamine), and pseudoephedrine (sympathomimetics).
Analgesics, antipyretics, and cough preparations:
Systemic analgesics and antipyretics (e.g. paracetamol, Ibuprufen) are
effective for aches or fever & sore throat which may be associated with
common cold.
In addition, cough, when present, may be treated by suitable cough
products (see cough).
5-Vitamin C in common cold:
A review of trial data concluded that Vitamin C:
*Does not prevent colds.
*Appears to reduce the duration of symptoms when ingested in large
dose (up to 1g daily) although the response is variable.
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6-Zinc lozenges: can decrease the duration & severity of common cold,
but evidences is currently insufficient to recommended zinc to treat
common cold.
7-Vapour inhalation: with menthol crystals as a steam.
8-Vaccination: Annual “flu” vaccination for at-risk group (those have
chronic respiratory diseases “asthma”, chronic heart diseases, chronic
renal failure, D.M. &………..etc
Allergic Rhinitis
Rhinitis is simply inflammation of the nasal lining, characterized by
rhinorrhoea, nasal congestion, sneezing, and itching.
Allergic rhinitis may be regarded as seasonal allergic rhinitis (SAR),
commonly known as hay fever. Or perennial allergic rhinitis (PAR)
(increasingly called intermittent & persistent allergic rhinitis).
Seasonal allergic rhinitis occurs in response to specific allergens
usually present at predictable times of the year, during the plant's
blooming seasons. Perennial allergic rhinitis is a year-round disease
caused by non-seasonal allergens such as house dust mites, animal
dander, molds,….etc.
Many patients have a combination of both (year-round symptoms and
seasonal exacerbation).
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Patient assessment with allergic rhinitis:
1-Symptoms:
The patient usually have all four classical symptoms of nasal itch,
sneeze, rhinorrhoea, and nasal congestion, however, the patient might
also suffer from ocular irritation, giving rise to allergic conjunctivitis.
The nasal discharge is often thin, watery, and clear, but it may be
change to colored and purulent one, which may indicate secondary
infection. However the treatment is not altered and Antibiotic are usually
not needed.
Symptoms of allergic rhinitis may be confused with that of common
cold; the two conditions may be distinguished by the following points:
Allergic rhinitis
Common cold
1-nasal discharge usually remain clear
and if it became thickened , it takes much
longer to do so
2-sneezing is frequent
1-the initially clear nasal discharge
usually thickened and become purulent
within few days
2-sneezing is normally less frequent and
paroxysmal
3-nasal itching is present
3-nasal itching doesn’t normally occur
4-ocular symptoms present
4- usually no ocular symptoms
5-symptoms usually begin quite suddenly 5-onset of symptoms is more gradual
6-symptoms continue for as long as the 6-symptoms last for about four to several
patient is exposed to the allergens , often days
for several weeks
7-symptoms occur at the same time each 7-can occur at any time of the year but
year, in spring or summer when the more usually in the winter months
pollen that cause allergy is being
produced (symptoms of perennial allergic
rhinitis occur whenever the patient is in
contact with allergens)
8-only affect isolated individuals.
8-highly contagious, therefore other
family members or friends may well be
suffering at the same time and the
infection will be quite common within the
community.
2-Associated symptoms:
A- Earache and facial pain:
As with cold and flu, allergic rhinitis can be complicated by secondary
bacterial infections in middle ear (otitis media) or the sinuses (sinusitis),
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therefore patients with painful ear or painful sinuses -------------required
referral.
B-When associated symptoms such as wheezing, tightness of the
chest, shortness of breath are present -------------referral.
(These symptoms may represent the onset of an asthmatic attack).
C- Eye symptoms:
The eyes may be itchy and also watery (allergic conjunctivitis),
occasionally, this may be complicated by a secondary bacterial infection
in which the eye become redder with gritty sensation, and the discharge
change from clear watery to colored and sticky (purulent).
3-Seasonal variation:
Repetitive and predictable seasonal symptoms characterize SAR,
whereas symptoms that occur throughout the year without any oblivious
seasonal pattern characterize PAR.
4-Triggers:
Classically symptoms of hay fever are more severe in the morning
and evening this is because pollen rises during the day after being
released in the morning and then settled at night.
Hay fever symptoms worsen also on windy days, while symptoms
may be reduced after rain and when the patients stay indoors.
Symptoms of PAR are worsening on damp weather and persist when
indoors.
5-Family history:
If a first degree relative suffers from atopy then hay fever is the most
likely cause of rhinitis.
6- Medication:
a. If one or more appropriate remedies have been tried without
success (failed medication) ------------- referral.
A. Medications of other conditions to avoid D-D interactions between
the recommended OTC and these drugs (e.g. D-D interaction
between the prescribed drugs and antihistamines).
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Treatment timescale:
If no improvement is noted after 5 days of therapy ------the patient should
be referred.
Management:
Non-pharmacological advices:
SAR
PAR
1-stay indoors as possible (particularly in 1-Regular cleaning of the house (and
the morning and early evening) and keep all bedding at hot water) to maintain dust
windows closed.
level at a minimum.
2-In the car, keep windows closed.
2-Lower household humidity, remove
houseplants, maintain good ventilation.
3-Wear closed-fitting sunglass when going
out and a mask if symptoms are really
severe.
Pharmacological therapy:
- Pharmacists now possess a wide range of options to treat SAR and PAR.
- Medications used can be divided into two categories:
Topical: corticosteroids, antihistamines, mast cell stabilizers,
and decongestants.
Systemic: Antihistamine and decongestants.
1-Topical therapy:
A-Steroid nasal sprays: Beclometasone, and fluticasone, triamcinolone:
- Steroid nasal spray is the treatment of choice for moderate to severe
nasal symptoms, and superior to oral antihistamine.
- They can be used in patients aged over 18 years for up to 3 months.
- Ideally treatment should be start at least 2 weeks before symptoms are
expected.
- Regular use is essential for full benefit and it should be continued
throughout the hay fever season (this is should be explain carefully to the
patient to ensure compliance) and repeated each year.
- If symptoms are allergy present, the patient needs to know that it take
several days before full effect is reached.
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Doses:
Beclometasone spray (50 mcg/ one spray): 2 sprays into each nostril b.i.d
------once the symptoms have improved-----it may be possible to decrease
the dose to one spray b.i.d.
Triamcinolone spray (55 mcg/ one spray): 2 sprays into each nostril once
daily ------once the symptoms have improved-----it may be possible to
decrease the dose to one spray once daily.
Fluticasone spray (50 mcg/ one spray): 2 sprays into each nostril once
daily, preferably in the morning (if the symptoms are not improved, it
may be possible to increase the dose to 2 sprays b.i.d) ------once the
symptoms have improved-----it may be possible to decrease the dose to
one spray once daily.
- They should not be recommended for pregnant or lactating mother, or
anyone with glaucoma.
Side effects: are (nosebleed, dryness and irritation of nose and throat).
Note: Patient sometimes alarmed by the term (steroid) therefore the
pharmacist needs to take account of these concerns.
B- Mast cell stabilizers Sodium cromoglicate:
- Available OTC as nasal drop or spray (4%) and as eye drop.
- Like CS, Sodium cromoglicate is a prophylactic agent, but their place in
nasal symptoms of allergic rhinitis is limited because it is less effective
than CS and it needs more frequent administration (4-6 times a day).
- It is preferably started 1 week before the hay fever season is likely to
begin and then used continuously whilst exposed to allergens.
- There are no significant side effects although nasal irritation may occur.
- It is not known to be teratogenic (OK in pregnancy) or to have any drug
interactions and can be given to all patients groups.
Note: An OTC spray containing Sodium cromoglicate (2%) with a small
amount of decongestant (xylometazoline 0.025%) is also available, and
the amount of decongestant is said to be too small to produce rebound
congestion.
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C-Topical Decongestants: discussed in common cold
D-Topical antihistamine:
- It include: Azelastine and levocabastine nasal sprays are used in mild
and intermittent symptoms.
- The treatment preferably starts 2-3 weeks before the start of hay fever
season.
Note: advise the patient to keep the head upright during use to prevent the
liquid trickling into the throat and causing an unpleasant taste.
- Azelastine nasal spray: can be given to adults and children over 5 years
of age. The dose is one application in each nostril twice daily. It should
not be recommended for elderly patient. It appears to have no drug
interactions and it can be safely given during pregnancy.
- Levocabastine nasal spray: can be given to adults and children over 12
years of age. The dose is two applications in each nostril twice daily
(which may be increased if necessary to 3 or 4 times daily). It is not
recommended during pregnancy (but some references said: can be safely
given).
2-Systemic (oral) therapy:
A-Decongestants: discussed in common cold
B-Antihistamines:
Antihistamine can reduce some of symptoms of allergic rhinitis: runny
nose (rhinorrhoea) and sneezing, and itching. They are also effective, but
to a lesser extent, against allergic conjunctivitis. While less effective in
reducing nasal congestion.
Note: for maximum effectiveness, antihistamine should be taken when
symptoms expected (i.e. before) rather than after they have started.
Antihistamine can be classified into:
1- Sedating Antihistamine:
Examples of OTC sedating antihistamine are:
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Chlorpheniramine (Histadin® tablet and syrup), Dexchlorpheniramine
(polaramine® tablet), and Diphenhydramine (Allermine® tablet and
syrup)
S/Es: include sedation and drowsiness (patients should be informed) and
anticholinergic S/Es( i.e. dry mouth, urinary retention, constipation , …..)
and the elderly patients are more susceptible to these.
Accordingly they are not recommended (or used with caution) for
patients with: Glaucoma, or prostate hypertrophy and in elderly patients.
D/I: the sedative effects of antidepressants, anxiolytics, and hypnotics are
likely to be enhanced by sedating antihistamine.
2- Non-Sedating Antihistamine:
Examples of OTC non-sedating antihistamine are:
Loratadine (clarityn® tablet & syrup), acrivastine and cetirizine (Zirtek®
tablet & syrup).
They are generally preferable over the older antihistamines because of
much lower incidence of S/Es.
Note: although the drowsiness is rare, but the warning that these drugs
may affect driving and skilled tasks is still present.
Non-sedating
antihistamine
OTC age
Dose
Loratadine
Over 2 years
Over 6 years: 10 mg once daily
2-5 years: 5 mg once daily
Cetirizine
Over 6 years
Over 6 years: 10 mg once daily
Acrivastine
Over 12 years
Over 12 years: 8 mg as necessary up
to 3 times daily
3-Combination products:
Sympathomimetic (for congestion) + Antihistamine (for rhinorrhoea and
sneezing):
Example of OTC products is:
Actifed® tablet and syrup: which composed of Triprolidine (sedating
antihistamine) and Pseudoephedrine (sympathomimetic).
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