Fighting the Flu: Your Best Defenses

Pharmacists can be a fundamental educational resource for patients by providing information regarding the transmission and prevention of the influenza virus, recommending and administering the annual influenza vaccination, and counseling on the various nonprescription products on the market for managing the most common symptoms associated with the virus.

In the United States, although annual epidemics of influenza usually occur during the fall or winter, the peak can occur as late as April or May.¹ Moreover, according to statistics from the Centers for Disease Control and Prevention (CDC), an estimated 5% to 20% of the US population gets influenza, more than 200,000 individuals are hospitalized each year due to flu-related complications,1-3 and an average of more than 20,000 children younger than 5 years are hospitalized due to influenza and its complications.^1-3 Furthermore, 3000 to 49,000 individuals die of influenza complications and approximately 90% of those deaths affect individuals 65 years and older.⁴

Certain patient populations, such as the elderly, pediatric patients, pregnant women, and individuals with certain medical conditions (ie, asthma, diabetes, or cardiovascular disease) are more susceptible to developing complications from the influenza virus.^5,6 Examples of flu-related complications include bacterial infections such as pneumonia, otitis media, sinus infections, and dehydration.^5,6 The influenza virus can even exacerbate certain medical conditions (ie, congestive heart failure, asthma, or diabetes).^5,6

Signs, Symptoms, Transmission

The incubation period of the flu can range from 1 to 4 days, with an average of 48 hours. The onset of flu symptoms can be mild or severe. Hallmark symptoms in adults include abrupt onset of chills, headache, high fever, fatigue, dry cough, sore throat, rhinorrhea, and generalized aches and pains, especially in the back and legs.^7-9 Gastrointestinal symptoms, such as nausea, vomiting, and diarrhea, may also occur, but are more prevalent in the pediatric patient population than in adults.^7-9 Virus transmission can be airborne via respiratory droplets, direct contact with an infected person, or through contact with contaminated objects.^7-9 Many healthy individuals can transmit the flu to other individuals beginning on the first day prior to the development of symptoms and up to 5 days after becoming sick.^7-9

Prevention

Many health experts agree that prevention is the most effective strategy to manage exposure to the flu. To prevent the seasonal flu, the Advisory Committee on Immunization Practices of the CDC recommends an annual vaccination for all persons 6 months or older, preferably before the onset of influenza activity in the community.^9-11

Whereas many experts agree that receiving the annual vaccination is the best defense in preventing or lessening the severity of the flu, many individuals do not get the recommended vaccination due to misconceptions. The CDC states that although the flu vaccine is not perfect, overall evidence supports the public health benefit of obtaining a yearly flu vaccination.¹⁰ Moreover, the annual vaccination is vital for individuals 65 years and older who are especially vulnerable to serious illness, complications, and death.¹⁰ More in-depth information regarding the influenza vaccination can be found on the CDC website at www.cdc.gov/flu/ protect/keyfacts.htm (Table 1).

Nonprescription Products for Managing Influenza Symptoms

Every year, many individuals elect to use available nonprescription medications to treat and manage symptoms generally associated with the influenza virus. Pharmacists can be an essential source of information when it comes to aiding patients in the selection and proper use of these nonprescription products (Online Table 2). For the management of common symptoms associated with the influenza virus, nonprescription products include decongestants, antihistamines, expectorants, cough suppressants, antipyretics/ analgesics, and anesthetic and antiseptic products. These products are available in a variety of dosage forms to meet the needs of various patient populations. There are also homeopathic or alternative medicine remedies marketed for the prevention of the influenza virus.

Table 2: Examples of Nonprescription Products for Managing Symptoms Commonly Associated with the Influenza Virus

Homeopathic/Alternative Medicine Flu Remedies

• Boiron Oscillococcinum Quick Dissolving Pellets
• Hyland’s DEFEND Severe Cold and Flu
• NatraBio Children's Cold and Flu Relief
• FluNada Cold & Flu Relief
• Sambucus FluCare

Lozenges/Sprays/Liquids for Sore Throat

• Cepastat lozenges
• Cepacol lozenges
• Cepacol Sensations Cooling
• Chloroseptic lozenges, sprays, and medicated strips
• Hall’s sore throat lozenges
• Sucrets sore throat lozenges
• Tylenol Cold Sore Throat Liquid
• Ricola herb sore throat lozenges

Decongestants

• Systemic Decongestants Sudafed Children's Sudafed PE
• Intranasal Decongestants Afrin Nasal Spray Mucinex Nasal Spray Neo-Synephrine Little Noses Decongestant Nose Drops Vicks Sinex
• Nasal Decongestant Inhalers Vicks Vapor Inhaler Benzedrex Inhaler

Combination Products

• Advil Cold & Sinus
• Advil Congestion Relief
• Alka-Seltzer Plus Severe Cold & Flu
• Aleve D Sinus & Cold
• Coricidin HBP Maximun Strength Flu
• Coricidin HBP Cold & Flu
• Dimetapp Nighttime Cold & Congestion
• Mucinex Fast-Max Cold, Flu & Sore Throat
• Mucinex Night Time Cold & Flu
• Nyquil Cold & Flu Relief
• Vicks Dayquil Cold & Flu Liquicaps
• Vick’s Nature Fusion Cold & Flu Relief
• Pediacare Children’s Flu Plus Acetaminophen
• Theraflu Cold & Flu products

When recommending any of these products, pharmacists should evaluate a patient’s symptoms, medical conditions, allergy history, and current drug regimen, as well as lifestyle and personal prefer ences. Patients with severe symptoms and/or very young children should always be referred to their primary health care provider when warranted.

In addition to OTC preparations formulated for the pediatric patient population, there are also products formulated specifically for patients with diabetes that are free of sugar, alcohol, dextrose, sucrose, sorbitol, sodium, fructose, glycerin, and dyes, as well as products for those with hypertension (eg, Coricidin HP Flu products [Bayer]) that are also decongestant-free. To avoid the unnecessary use of medications or therapeutic duplications, patients should be cautious when using multiingredient products.

Conclusion

During counseling, pharmacists should seize the opportunity to stress the importance of obtaining a yearly flu vaccination, as well as suggest various nonpharmacologic measures that may aid in relieving flu symptoms, such as the use of vaporizers or humidifiers, saline nasal sprays (eg, Little Noses Saline Mist for children or Ocean Nasal Spray), or nonmedicated breathing strips (eg, Breathe Right) to relieve nasal congestion.

During illness, patients should also maintain adequate hydration and get plenty of rest. Pharmacists can remind patients that clinical studies have shown that the implementation of various preventive measures—such as routine handwashing, using hand sanitizers when soap and water are not available, avoiding direct contact with an individual with the flu, and always sneezing or coughing into a tissue and not into the hand—have been effective for potentially decreasing or preventing transmission of the influenza virus. Patients should also be encouraged to seek medical attention from their primary health care provider if symptoms worsen or linger, if they experience high fever, or if they exhibit signs of infection.

Prior to recommending any products for managing the flu, pharmacists should also search for possible interactions or contraindications. Pregnant and lactating females and those with chronic medical conditions should always consult with their primary health care provider before using any nonprescription medication. In addition, during counseling, remind patients to always read labels prior to administration and to check ingredients, especially if using multiple products, to avoid therapeutic duplications or excessive dosing.

It is also important for patients to adhere to the recommended dosages, administration guidelines, and duration of use. To ensure proper dosage and accuracy, it is vital to recommend that parents and caregivers always use calibrated measuring devices when administering liquids and to read all labels prior to administering medications to children. Parents and caregivers should only give children nonprescription products manufactured specifically for the pediatric population and consult their pediatrician or pharmacist when in doubt regarding the appropriateness or dose of the medication.

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

• Clinical signs and symptoms of influenza. Centers for Disease Control and Prevention website. www.cdc.gov/flu/professionals/acip/clinical.htm. Updated January 26, 2015. Accessed September 1, 2015.
• Seasonal influenza q&a. Centers for Disease Control and Prevention website. www.cdc.gov/flu/about/qa/disease.htm. Updated August 17, 2015. Accessed September 1, 2015.
• Information for schools. Centers for Disease Control and Prevention website. www.cdc.gov/flu/school/qa.htm. Updated August 7, 2015. Accessed September 1, 2015.
• Influenza: epidemiology and prevention of vaccine-preventable diseases. Centers for Disease Control and Prevention website. www.cdc.gov/vaccines/pubs/pinkbook/flu.html. Accessed September 1, 2015.
• Impact of the Flu. FLUFACTS.com website. www.flufacts.com/know/impact.jsp. September 17, 2015
• People at high risk of developing flu-related complications. Centers for Disease Control and Prevention website. www.cdc.gov/flu/about/disease/high_risk.htm. Updated January 8, 2015. Accessed September 1, 2015.
• Scolaro K. Disorders related to colds and allergy. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 18th ed. Washington, DC: American Pharmacists Association; 2015.
• Symptoms. Flu.gov website. www.flu.gov/symptoms-treatment/symptoms/. Accessed September 1, 2015.
• Derlet R. Influenza clinical presentation. Medscape website. http://emedicine.medscape.com/article/219557-clinical. Updated January 5, 2015. Accessed September 1, 2015.
• Vaccine effectiveness - how well does the flu vaccine work? Centers for Disease Control and Prevention website. www.cdc.gov/flu/about/qa/vaccineeffect.htm. Accessed September 1, 2015.
• The flu vaccine. FLUFACTS.com website. www.flufacts.com/prevent/vaccine.jsp. Accessed September 1, 2015.