Controlling Flu-Like Symptoms

“I don’t feel well.” These 4 little words are dreaded by parents, spouses, teachers, and employers alike. Although health care professionals will spend the next few months actively encouraging their patients to receive annual flu shots, we know that many patients will not heed those warnings and will succumb to the flu and other winter colds. In the absence of universal flu shots, germ prevention becomes key. In addition to encouraging flu shots, health care professionals can encourage patients to cover their mouths when they cough or sneeze and to thoroughly wash their hands throughout the day.

Pharmacists are on the frontline of cold and flu prevention. The community pharmacist has the opportunity to help identify and counsel patients with flulike symptoms. While patients frequently visit multiple physician specialists for various conditions, pharmacists are the cornerstone health care provider and a reliable health care resource. Knowing your patients and their ailments is essential when recommending an OTC cough and cold reliever for short-term use.

The Case

AD is an 18-year-old woman who has been visiting your pharmacy in the past year to have her prescriptions filled. You know from past counseling sessions that she is a freshman at the local university. AD is browsing the cough and cold aisle, picking up box after box to view labels and ingredients. She seems to be wiping her nose frequently and is periodically coughing without covering her mouth.

When AD comes to the counter to collect the monthly prescription she refilled, she hands you a basket filled with various OTC medications. You ask her how she is feeling and what you can do to help. AD explains that her nose feels “pretty stuffed up,” and that she just “can’t stop coughing up stuff.” She mentions how one of her teachers dismissed her from class and insisted she go home and rest. She is a bit anxious because she fears getting behind on schoolwork and also has a demanding part-time job as a waitress in the evening. AD also recently visited the dentist and was told her wisdom teeth need to be extracted.

You ask AD if she would be interested in participating in a brown bag session. You explain what happens during a brown bag consult and tell AD you are interested in reviewing and re-educating her on her medications. It might even result in cost savings and less anxiety. AD says she wants to start feeling better as soon as possible and appreciates your time, advice, and feedback about her health.

Upon reviewing AD’s current medication profile and OTC products, you find the following:

• Ortho Tri-Cyclen Lo daily
• Ibuprofen 600 mg every 6 hours as needed (usually filled 3 or 4 days early)
• Hydrocodone/acetaminophen 5/500 every 4 to 6 hours daily as needed for dental pain
• Fluoxetine 10 mg daily
• OTC Mucinex Fast-Max Cold & Sinus
• OTC acetaminophen 500 mg every 4 to 6 hours as needed

You have some questions and suggestions about AD’s medications and health. During your discussion, AD admits that she recently started smoking and has not received this year’s recommended flu shot. She knows and understands the consequences of smoking, but explains that it helps her relax, reduces her stress, and eases periodic depression. You ask AD about her anxiety, and she attributes it to her workload, demands at school, lack of exercise, and the fact that she has not been eating or sleeping much lately. You explain how stress and depression can lead to illness and insist she learn to manage her anxiety without the crutch (and long-term effects) of smoking. AD agrees to explore healthy stress management options and to talk with her primary care physician about the dosing of her fluoxetine, which has never been titrated.

You ask AD about her recent dental visits and encourage her to follow up. Dental pain can contribute to a variety of short- and long-term issues. AD understands that it is best to be proactive and that her wisdom teeth may be contributing to her symptoms.

You review AD’s OTC medications and pull out duplicate products. You explain to her that she does not need anything with additional acetaminophen because of the potential for drug toxicity. You also explain that the hydrocodone in the acetaminophen combination product should help to reduce pain and suppress her cough. AD tells you she has been taking her prescription ibuprofen and hydrocodone/acetaminophen on a regular basis because of frequent headaches and mouth pain. Despite this increase in usage, the hydrocodone has not reduced her coughing episodes.

AD admits to being nonadherent to her medications and appreciates your suggestions of using timers and phone apps to increase adherence. You tell AD that, because she is taking an antidepressant, you would not recommend any OTC product with dextromethorphan without her provider’s permission. You also make some temporary nonpharmacologic suggestions to AD: throat lozenges, a topical throat and chest aromatic, a compact humidifier, and plenty of daily water intake.

Dr. Drury works as a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin. She earned her doctor of pharmacy degree from Midwestern University College of Pharmacy. Her blog, Compounding in the Kitchen, an innovative amalgam of pharmacy and cooking, appears on www.PharmacyTimes.com/blogs/compounding- in-the-kitchen. Read, and enjoy!