Cough, Cold, & Flu Part I
What is Buckley's cough syrup and why does it taste so bad?
"It tastes awful and it works." Some have guifenesin, diphenhydramine, or APAP. All have menthol and pine needle oil, which taste bad. They are alcohol and sugar free.
How old does a patient have to be to purchase dextromethorphan in Indiana?
18 years old.
What is the maximum about of sudafed that should be taken in 24 hours?
240mg.
How long can rhinoviruses survive outside of the body?
3-4 hours.
When should a patient notify their healthcare provider if their symptom worsen or do not improve while using an oral decongestant?
7 days.
What is a subacute cough?
A cough that lasts 3-8 weeks.
What is an acute cough?
A cough that lasts less than 3 weeks.
What is a chronic cough?
A cough that lasts longer than 8 weeks.
What is a nonproductive cough?
A dry, hacking cough caused by viral respiratory tract infections, atypical bacterial pathogens, GERD, and drug-induced.
What drugs can induce a cough?
ACE-inhibitors can cause cough in 20% of patients. Beta-blockers can also cause cough in patients with obstructive airway diseases.
What are the active ingredients and brand names of pain relievers/fever reducers?
Acetaminophen (Tylenol), ibuprofen (Motrin), and naproxen (Aleve).
What is the mechanism of action of pseudoephedrine?
Acts directly on both alpha and beta adrenergic receptors producing vasoconstriction of respiratory mucosa, relaxation of the bronchioles, and increased heart rate and contractility.
What are non-pharmacologic treatments for cold, flu, and cough?
Adequate fluid intake (2L/day), adequate rest (7-9 hours), increased humidification, and nasal irrigation.
How should Chloraseptic spray be used?
Adult- spray 5 times every 2 hours. Allow to stay for 15 seconds, then spit. Children- same as above, only use 3 sprays.
What are nasal decongestants used for?
Alpha adrenergic agonists that cause constriction of dilated arterioles, which decreases edema, increases nasal ventilation and drainage, relieves headache caused by congested sinuses, and decreases irritation of the nostrils and mucous membranes caused by excessive nose blowing.
What are the side effects of first generation antihistamines?
Anticholinergic side effects, such as dry mouth, blurred vision, difficulty in urination, constipation, irritability, and dizziness.
If a combo product says "allergy," what ingredients are likely in the product?
Antihistamine.
If a combo product says "cold" or "flu," what ingredients are likely in the product?
Any combination of decongestants, antihistamines, cough suppressants, and/or antipyretics.
What are the directions for use of a nasal spray (atomizer)?
Blow nose, do not shake bottle, administer one spray with head in upright position, sniff deeply while squeezing bottle.
What are the active ingredients and brand names of antihistamines?
Brompheniramine (Dimetapp), chlorpheniramine (Chlor-Trimeton), clemastine (Tavist), diphenhydramine (Benadryl), doxylamine (NyQuil), phenindamine (Nolahist), and dexbrompheniramine (Drixoral).
What are the alkylamine antihistamines that are available OTC?
Brompheniramine (Dimetapp), dexbrompheniramine (Drixoral), chlorpheniramine (Chlor-Trimeton), and triprolidine (Actifed).
What are the risks of using dextromethorphan in high doses?
Can lead to CNS effects similar to other abused substances.
What are the adverse effects of oral decongestants?
Cardiovascular stimulation (elevated BP, tachycardia, palpitations, arrhythmias) and CNS stimulation (restlessness, insomnia, anxiety, tremors, fear, hallucinations).
What are the directions for use of levmetamfetamine (Vick's Vapor inhaler)?
Children <2: Do not use. Children 2-6: Ask doctor. Children 6-12: 1 inhalation in each nostril. 12-adult: 2 inhalations in each nostril.
What are exclusions for treatment of cough?
Children <4 years, cough >7 days, adults with fever >103 F, children with fever >102 F, cough accompanied with shortness of breath, chest pain, hemoptysis, chills, night sweats, tight-feeling throat, swollen legs/ankles, cyanosis, unintentional weight loss, rash, and persistent headache, cough with thick yellow, tan, or green mucus, cough worsens as cold/flu resolves, suspected drug-induced cough, asthma, COPD, chronic bronchitis, and CHF.
What are the directions for use of propylhexedrine (Benzedrex)?
Children <6: Ask doctor. 6-adult: 2 inhalations in each nostril not more than every 2 hours for a max of 3 days.
For what patients are topical saline nasal products recommended for?
Children less than 4 years old and pregnant/breastfeeding women.
Who should not take codeine?
Children under 6- vulnerable to serious adverse effects from just low doses.
What is the standard antitussive against which others are measured?
Codeine. Technically OTC in some cough syrups, but most states restrict this to prescription only.
How does humidity affect cold viruses?
Cold viruses survive better in low humidity and cold weather.
What is the mechanism of action of antihistamines?
Common cold is an infection caused by a virus that releases kinins, which cause inflammation in the lining of the nose.
How is rebound congestion treated?
Completely withdrawal topical vasoconstrictor, initially d/c medication in only one nostril, discontinue topical decongestant and give oral decongestant, and administer nasal saline drops or spray (ocean, ayr, nasal).
Who should avoid oral decongestants?
Contraindicated in patients taking MAO-Is, and should be avoided in heart disease, HTN, diabetes, thyroid disorders, BPH, and narrow angle glaucoma.
What products are available for patients with HTN?
Coricidin HBP. The syrup is not sodium or sugar free.
What are the active ingredients and brand names of cough suppressants (antitussives)?
Dextromethorphan (Delsym), codeine, diphenhydramine (Benadryl), and camphor & menthol (VICK'S Vaporub).
What ingredients are usually in DayQuil?
Dextromethorphan and APAP.
What ingredients are usually in NyQuil?
Dextromethorphan, doxylamine, and APAP.
What ingredients are generally found in Alka-Seltzer products?
Dextromethorphan, phenylephrine, chlorpheniramine, and ASA.
What ingredients are usually found in Delysm?
Dextromethorphan, sometimes with guaifenesin or phenylephrine.
If a combo product says "cough," what ingredients are likely in the product?
Dextromethorphan.
What products with antitussives are available for patients with diabetes or HTN?
Diabetic Tussin and Scot-Tussin. These are sugar, alcohol, and sodium free.
What are the ethanolamine antihistamines that are available OTC?
Diphenhydramine (Benadryl), doxylamine, and clemastine (Tavist).
If a combo product says "night time" or "PM," what ingredients are likely in the product?
Diphenhydramine or doxylamine.
What is the mechanism of action of phenylephrine?
Direct acting sympathomimetic that has strong alpha and weak beta action, which allows for minimized cardiovascular side effects. Can also be used for hemorrhoids and ophthalmic preparations.
What are the main routes of transmission for the common cold?
Direct contact or aerosol transmission.
How often should levmetamfetamine be used?
Do not use more often than every 2 hours or for more 7 days.
What are the adverse effects of dextromethorphan?
Drowsiness, GI upset, nausea, and dizziness.
What are the adverse effects of codeine?
Drowsiness, lightheadedness, loss of appetite, N/V, and constipation.
What are common short-acting (2-4 hrs) intranasal decongestants?
Ephedrine, levmetamfetamine, naphazoline, phenylephrine, and phropylhexadrine.
What are the complications of cough?
Exhaustion, insomnia, musculoskeletal pain, hoarseness, urinary incontinence, syncope, and rib fractures.
What age of children can oral decongestants be used in?
FDA advised not to be used in children under 2, but many manufacturers have voluntarily opted to state do not use in children under 4.
What are camphor and menthol used for?
FDA approved for the alleviation of cough by producing a sensation of coolness and local anesthetic effect on the respiratory tract. Available in ointments and steam inhalants.
What are expectorants used for?
Facilitate the removal of mucus and other irritants from the respiratory tract and decrease the viscosity of thickened secretions.
What are the federal and state limits on pseudoephedrine?
Federal limits: 3.6g per day, 9g per month. State limits: 7.2g per month.
What are exclusions for treatment of common cold/flu?
Fever >101.5 F, chest pain, shortness of breath, worsening of symptoms/development of additional symptoms, asthma, COPD, CHF, AIDS, chronic immunosuppressant therapy, frail elderly patients, infants <9 months, and hypersensitivity to recommended OTC medication.
What symptoms are typical of the flu?
Fever, headache, muscle/joint aches, fatigue, chest congestion, and severe cough.
What does the American College of Chest Physicians (ACCP) recommend for the treatment of cough due to the common cold?
First generation antihistamine/decongestant combo.
What does the American College of Chest Physicians (ACCP) recommend for the treatment of cough due to upper airway cough syndrome (productive cough)?
First generation antihistamine/decongestant combo.
How effective is dextromethorphan?
For cough suppression, as effective as codeine on a mg-to-mg basis.
What is the only expectorant that is available on the market?
Guaifenesin (Mucinex).
What are the active ingredients and brand names of expectorants?
Guaifenesin, which is found in Mucinex and Robitussin.
What does the ACCP say about guifenesin, antitussives, second generation antihistamines, and zinc?
Guifenesin is not recommended based on inconsistent benefit, antitussives show mixed results, 2nd gen antihistamines are ineffective, and zinc is NOT effective for cough.
What ingredients are in plain robitussin?
Guifenesin.
What is the place in therapy of second generation antihistamines in cold and cough?
Have not demonstrated efficacy in the common cold, attributed to the lack of anticholinergic activity. Do serve a role in allergic rhinitis.
What are the benefits and risks with TheraFlu products?
Ideal for body aches, fever, and sore throat. Have a high APAP content, which could be dangerous.
What are the advantages of nasal decongestants?
Induce prompt and profound vasoconstriction with relief of congestion, not as systemically absorbed, and short acting can be used in a patient with HTN.
What are the side effects of levmetamfetamine?
Lack vasopressor effects and does NOT carry the warning for patients with cardiac conditions, HTN, hyperthyroidism, diabetes, or difficulty urinating.
What is the peak incidence of cold season?
Late August to early April.
What symptoms are caused by a rhinovirus infection?
Leads to the release of inflammatory mediators, causing nasal congestion, runny nose, and sore throat.
In what patients might dextromethorphan be indicated?
May be indicated in patients for whom adverse effects of codeine are particularly bothersome.
What is the mechanism of action of diphenhydramine as an antitussive?
May be mediated through anticholinergic activity. Great nighttime agent to induce sleep in the patient with a nonproductive cough.
What symptoms are typical of a common cold?
Nasal congestion, sneezing, sore throat, chest congestion, and mild, dry, hacking cough.
What is the goal of therapy for common cold?
No cure- reduce bothersome and limiting symptoms and prevent transmission of cold virus.
Does getting chilled or wet cause a cold?
No- there is some correlation, but it does not cause it.
What patients should not take first generation antihistamines?
Not FDA approved for use in children under 5 years old, not recommended for patients with glaucoma or BPH, and caution in patients with asthma.
What are the adverse effects of guaifenesin?
Occasionally causes gastric disturbance, nausea, and vomiting.
What place in therapy do antitussives have?
Patients with dry, nonproductive coughs are candidates for cough suppression with antitussives.
What piperidine antihistamines are available OTC?
Phenindamine (Nolahist).
What ingredients are found in common OTC demulcents?
Phenol, benzocaine, and menthol.
What factors affect the susceptibility and transmission of viruses?
Poor nutritional status, smoking (weakens immune system), increased population, sedentary lifestyle, fatigue, and emotional stress.
What are the disadvantages of nasal decongestants?
Potential to develop rhinitis medicamentosa, rebound congestion may be expected when topical decongestants are used longer than 3 days, effect is more common with short-acting agents.
What age ranges generally have the most colds per year?
Preschool children will have 6-10 colds per year, adults will have 2-4 colds per year, and adults over 65 will have 1 cold per year.
What are demulcents used for?
Primarily used to relieve sore throat. Often found as lozenges, gargles, and sprays.
What are the directions for use of metered-dose pump spray?
Prime pump before first use, insert pump gently into nose with head tilted forward, sniff deeply while depressing the pump.
What are the active ingredients and brand names of decongestants?
Pseudoephedrine (Sudafed) and phenylephrine (Sudafed PE).
What are the goals of treatment for cough?
Reduce the number and severity of cough episodes and prevent complications.
What symptoms can a pharmacist recommend treatment for?
Rhinorrhea, congestion, cough, headache, and sore throat.
Describe the symptom onset of a common cold.
Scratchy throat may be noticed within 1-2 days after contact, followed by a thin, watery nasal discharge and sneezing. Within 1-2 days, this discharge may become more thick and purulent. Most annoying/troublesome symptoms last 4-5 days and usually disappear after 7-14 days.
What do demulcents provide temporary relief from?
Sore throat, mouth pain, minor irritation of mouth and gums, pain due to minor dental procedures, and pain associated with canker sores.
What are the directions for use of nasal drops?
Squeeze bulb to withdraw medication, lie on bed with head tilted back, place recommended number of drops into one nostril, gently tilt head side to side, lie on bed for a couple of minutes.
What is the mechanism of action of dextromethorphan?
Synthetic, nonnarcotic agent that has no analgesic, sedative, respiratory depressant, or addictive properties at usual doses.
If a patient becomes sick quickly, has joint pains, body aches, and high fever, what do they likely have?
The flu.
How many viral strains can cause the common cold, and what are the most common viruses responsible?
There are about 200 total strains that can cause the common cold, most commonly *rhinovirus*, coronavirus, influenza viruses, parainfluenza viruses, adenoviruses, echoviruses, and respiratory syncytial virus.
Why does the common cold cost so much money?
There is no other category of self-medication that requires more of the pharmacist in terms of time, advice, and patient counseling. It has also been described as the most expensive illness in the US due to lost days at work and school.
What patients might be good candidates for nasal strips?
Useful in patients who need to avoid sympathomimetic agents, pregnancy, children, and elderly who take numerous medications.
What is the benefit of oral decongestants?
Useful in reaching deep into the nasopharyngeal and sinus passages where topical solutions may not be accessible, and induces less intense vasoconstriction locally, therefore has NOT been associated with rebound congestion.
If a combo product says "non-drowsy," "day time," or "AM," what ingredients are likely in the product?
Usually indicates that it contains a decongestant (pseudoephedrine) and does NOT have an antihistamine.
If a combo product says "sinus," what ingredients are likely in the product?
Usually signifies a decongestant (pseudoephedrine or phenylephrine) and/or an analgesic (APAP).
How do rhinoviruses produce an infection?
Virus must penetrate the protective mucous that covers the nasal epithelium.
What are the directions for use of nasal inhalers?
Warm the inhaler in hand before use, gently insert the inhaler tip into one nostril, sniff deeply while inhaling, wipe inhaler tip after each use.
What is a productive cough?
Wet cough that expels secretions from the lower respiratory tract. Secretions can be clear, purulent, or discolored. Can be associated with bacterial infection.
What questions should be asked during patient assessment and counseling?
What are your symptoms? Is your nasal discharge thick or discolored? What medications have you used to treat your symptoms? What medications are you currently taking? Are you allergic to any medication? Have you ever experienced an adverse reaction to any medication? Do you have HTN or other CV diseases? Glaucoma? Diabetes? BPH? Seizure disorder? Are you pregnant or breast-feeding? If the medication is for a child, how old is the child?
What are first generation antihistamines generally used for?
Widely used in cough and cold preparations for relief from rhinorrhea and sneezing, but have no effect on nasal congestion.
What are common long-acting (8-12 hrs) intranasal decongestants?
Xylometazoline and oxymetazoline.
Are colds are more common in the winter?
Yes- people are indoors more in close quarters with low humidity.
What products are on the market to prevent methamphetamine abuse?
Zephrex-D and Nexafed are meth-deterring products.