Advise Patients on Cold, Cough, Flu Medications and When to Seek Medical Care

During cold and influenza season, individuals infected with these viruses may experience a variety of symptoms, including body and muscle aches, coughing, fever, a general feeling of malaise, headaches, nasal congestion, sneezing, and sore throat. Moreover, individuals with COVID-19 may experience 1 or more of these symptoms in varying degrees.

Many individuals will elect to initially self-treat mild to moderate symptoms associated with these viruses using the multitude of non-prescription medications on the market, such as analgesics/antipyretics, anesthetic and antiseptic products for sore throat, antihistamines, cough expectorants and suppressants, and decongestants. These medications are available as multi-ingredient or single-entity products.

As accessible health care providers, pharmacists can assist patients in the proper selection and use of these products; assess whether self-treatment is appropriate, especially in individuals with preexisting medical conditions and/or those taking prescription medications; and encourage them to seek further medical care when warranted for severe symptoms. Pharmacists can also encourage patients who are exhibiting signs of COVID-19 and influenza to get tested so therapy with recommended prescription antivirals can be initiated as soon as possible when appropriate to improve clinical outcomes.

Clinical Studies

Investigators of a study, whose findings were published in Academic Pediatrics,sought to characterize pediatric medication error adverse events (AEs) involving OTC cold and cough medications to identify preventable factors.¹ They found that between 2009 and 2016, a total of 4756 cases were shown to have a significant AE related to an OTC cold and cough drug ingredient, and 513 (10.8%) cases were due to a medication error. Approximately 50% of medication errors involved children 2 to 6 years old (n = 235; 45.8%) and many involved medications administered by a parent (n = 231; 45.0%) or alternative care-giver (n = 148; 28.8%).¹ Moreover, in virtually all cases (93.2%), the medication error involved the wrong dose of the medication, and a health care facility evaluation was needed in 381 (74.3%) cases. The most common medication errors resulting from use of cold and cough medications were related to dextromethorphan and diphenhydramine dosing. Investigators concluded that continued standardization of measuring devices, concentrations, and units of measure, along with patient education, are necessary to further decrease medication errors from cold and cough medications.¹

Another study sought to investigate the published clinical data on OTC misuse, focusing on antihistamines, codeine- and dextromethorphan-based cough medicines, and the nasal decongestant pseudoephedrine. The authors concluded that their findings from this systematic review showed that OTC misuse issues are extensive worldwide, with the most vulnerable patient populations including adolescents and young adults. They also noted that because of a lack of proper monitoring systems, the real incidence is unknown and health care professionals should be vigilant, using ad hoc preventive actions because of the potential for grave AEs associated with OTC misuse issues.²

Before making any recommendations, pharmacists should always evaluate a patient’s allergy and medical history and medication profile to screen for contraindications or interactions and tailor recommendations accordingly. During counseling, pharmacists should also inform patients that they should always read labels prior to administration to ensure accurate dosing and to understand the frequency of administration and recommended duration of use, particularly if they are using multiple products, to avoid excessive dosing, therapeutic duplications, and unnecessary drug use.

During counseling, pharmacists should also inform patients that in 2008, the FDA recommended that children younger than 2 years not use OTC cold and cough medications because of concerns about efficacy and safety, and soon after, manufacturers voluntarily relabeled these medications for children 4 years and older.^3,4 Moreover, the American Academy of Pediatrics recommends avoiding cold and cough medications in children younger than 6 years.³ Remind parents and caregivers to use only those OTC products manufactured specifically for children and when in doubt, regarding the appropriateness or dose of the medication, consult a pediatrician or pharmacist. Moreover, remind parents and caregivers to always use calibrated drug measuring devices provided with the selected OTC products when administering liquid medications and to read all labels prior to administering medications to children to ensure proper accuracy and dosage.

Always encourage patients with other comorbidities and/or who are taking other medications to discuss the use of OTC cold, cough, and influenza medications with their primary health care providers to ascertain appropriateness of use. When possible, pharmacists should emphasize the importance of adherence to CDC recommendations regarding COVID-19 booster vaccines and obtaining annual influenza vaccinations, and offer available vaccines to patients if feasible. Pharmacists can also suggest various nonpharmacologic measures that help provide relief of mild cold, COVID-19, and influenza symptoms, such as maintaining adequate hydration and rest and using humidifiers, nonmedicated nasal strips, saline nasal sprays, and vaporizers to relieve nasal congestion.

Also encourage patients to seek medical attention from their primary health care providers if they experience a cough that lasts more than 14 days or that lingers or worsens; a headache; a high or persistent fever of 101.5° F (38.6° C, oral) or higher; nausea; a sore throat that persists for several days; or signs of bacterial infection, such as severe chest congestion, shortness of breath, significant ear pain, or thick nasal or respiratory secretions that are not clear.

Study results have shown that the implementation of various preventive measures, such as avoiding individuals who have a cold, COVID-19, or influenza; handwashing; and using hand sanitizers with at least 60% alcohol when soap and water are not available, decrease or prevent the transmission of these viruses.⁵

Pharmacists can also direct patients to valuable patient education resources that provide information to differentiate between the viruses, such as the following:

• Cold versus flu https://www.cdc.gov/flu/symp-toms/coldflu.htm#:~:text=The%20symptoms%20of%20flu%20can,a%20runny%20or%20stuffy%20nose.

• Similarities and differences between flu and COVID-19 https://www.cdc.gov/flu/symptoms/flu-vs-covid19.htm

References

1. Wang GS, Reynolds KM, Banner W, et al. Medication errors from over-the-counter cough and cold medications in children. Acad Pediatr. 2020;20(3):327-332. doi:10.1016/j.acap.2019.09.006

2. Schifano F, Chiappini S, Miuli A, et al. Focus on over-the-counter drugs’ misuse: a systematic review on antihistamines, cough medicines, and decongestants. Front Psychiatry. 2021;12:657397. doi:10.3389/fpsyt.2021.657397

3. Use caution when giving cough and cold products to kids. FDA. February 8, 2018. Accessed October 10, 2022. https://www.fda.gov/Drugs/ResourcesForYou/SpecialFeatures/ucm263948.htm

4. Horton DB, Gerhard T, Strom BL. Trends in cough and cold medicine recommendations for children in the United States, 2002-2015. JAMA Pediatr. 2019;173(9):885-887. doi:10.1001/jamape-diatrics.2019.2252

5. Keeping hands clean. CDC. Updated June 15, 2022. Accessed October 10, 2022. https://www.cdc.gov/hygiene/personal-hygiene/hands.html

About the Author

Yvette, C. Terrie, BSpharm, RPH, is a consulting pharmacist and medical writer in Haymarket, Virginia.