Self-Care for Colds, Coughs, and Viral Ailments

CASE 1: NATURAL MEDICINES FOR COLD RELIEF

A mother approaches the pharmacy counter with her 3-year-old daughter and a question for the pharmacist. Her daughter did not sleep the previous night due to the onset of cold symptoms—a runny, stuffy nose and a bothersome cough. Mom is hesitant to give the child an antihistamine or decongestant because she remembered some concerns from several years ago about using these medications in children. She would rather use something natural to relieve her daughter’s symptoms anyway. The 3-year-old has no known allergies to medications or foods and only takes a children’s multivitamin once daily. What information should the pharmacist provide regarding the use of a natural remedy for cold symptom relief in this child?

ANSWER

Because no known cure for the common cold exists, the goals of treatment include symptom relief and prevention of transmission to others. Mom is correct in that the FDA had issued warnings and, in some instances, product labeling changes due to risks of adverse effects regarding the use of cold medications in children younger than 2 years. Emphasis on OTC medications is recommended; if pharmacotherapy is deemed necessary, all product labeling should be followed to reduce risk of harm from these agents.¹ Regarding nonprescription interventions for alleviating cold symptoms in children, it is prudent to underscore the importance of adequate rest, increased fluid intake (particularly if the child is febrile), proper diet, and humidification. Use of a product containing camphor, menthol, or eucalyptus, such as Vicks VapoRub, may help to alleviate congestion at bedtime.1 Counsel mom on the importance of hand hygiene and frequent hand washing or the use of hand sanitizer to eradicate the cold virus and reduce its spread to others.

CASE 2: MANAGING NASAL CONGESTION IN PREGNANCY

A 28-year-old pregnant woman approaches the pharmacist seeking a recommendation. She is suffering from a head cold and her associated symptoms include headache, nasal congestion, and clear nasal drainage. For treatment of cold symptoms prior to becoming pregnant, she would normally reach for a cocktail of a systemic antihistamine, nasal decongestant, and guaifenesin; however, now that she is pregnant, she is not sure which treatment option is best. She has no known allergies and takes a prenatal vitamin once daily. What recommendations should the pharmacist provide?

ANSWER

Myriad nonprescription cough and cold remedies are available, and patients frequently consult their pharmacist to identify the optimal therapy for their symptoms. Pregnant women are no exception; they may desire to avoid traditional pharmacologic interventions due to concerns of how these medications may affect their fetus. Pharmacists must be aware of the risks associated with the use of OTC medications in pregnancy. In this case, because cold symptoms are not life-threatening, many health care providers would recommend nonpharmacologic treatment options for symptom relief, including the use of a humidifier and elevation of the head while sleeping. In addition, saline nasal spray can be used to alleviate nasal congestion. If these interventions fail or medication is deemed necessary, pregnant patients have several options for relieving their symptoms. First-generation antihistamines diphenhydramine and chlorpheniramine have consistently been shown to be safe during pregnancy.^2-4 Systemic decongestants, however, including pseudoephedrine, have demonstrated an increased risk of fetal malformations and should be avoided during pregnancy.⁵ For headache relief, acetaminophen is generally considered safe for use. In this case, educate the patient on implementing nonpharmacologic interventions for symptom relief. If pharmacologic treatment is desired or her symptoms are deemed severe, recommend the use of a firstgeneration antihistamine for the shortest term at the lowest effective dose and that she discuss this with her obstetrician.

CASE 3: NASAL SALINE FOR CONGESTION RELIEF

A 38-year-old man comes to the pharmacy looking for a recommendation on whether to purchase a Neti pot. He suffers from bothersome year-round allergies for which he has been taking a combination of an inhaled corticosteroid and inhaled antihistamine for several years. After seeing a segment on indoor allergies on the evening news, he wondered if he might be eligible to use a Neti pot to reduce his medication use and improve his symptoms. He would like the pharmacist’s opinion on the use of an OTC nasal teapot for alleviating his symptoms and whether it would be safe to use in combination with nasal medications. What advice would be reasonable to share with him at this time?

ANSWER

Saline nasal irrigation can bring relief to those who suffer from chronic nasal allergy symptoms. Data appear to demonstrate a benefit when it is used as adjunctive therapy for the treatment of nasal symptoms, including congestion and rhinorrhea; however, individuals who use daily saline nasal irrigation may experience worsening sinusitis symptoms upon discontiuation.⁶ Minor adverse effects are common and include nasal dryness, fullness in the ears, and, rarely, epistaxis; the beneficial effects appears to outweigh these effects.⁷

Recently, the FDA warned of possible infectious risks associated with nasal saline irrigations. To reduce the risk of infection, individuals using these devices should use distilled or sterile water, boiled and cooled tap water, or water passed through a filter with an absolute pore size of 1 micron or smaller. Counsel this patient on device care, including washing the device with distilled, sterile, or boiled and cooled tap water, and drying the inside with a paper towel or allowing it to air dry between uses.⁸ Use of the nasal teapot prior to use of nasal medications may help to remove congestion and improve contact of nasal sprays with the nasal mucosa, possibly improving the benefit from these agents.

CASE 4: FALLACIES ABOUT FLU

A 68-year-old woman wants to speak to the pharmacist about whether to receive the influenza vaccine this year. Last winter, she received her influenza vaccine at the local senior center’s annual clinic, but she contracted the flu anyway and was sick with body aches and a fever for a week. A friend told her that because she had the flu and the vaccine from the past season, her body has enough protection against the flu—even without a vaccination—for this flu season. She is allergic to penicillin and takes multiple medications for blood pressure, cholesterol, and thyroid function, and she does not want to receive the vaccine if it is unnecessary. What recommendations or education on the influenza vaccine should the pharmacist offer?

ANSWER

For the 2014-2015 influenza season, more than 17,000 hospitalizations were attributed to laboratoryconfirmed influenza, with a particularly high rate of hospitalization in individuals 65 years or older.⁹ Staggering statistics on the morbidity and mortality associated with this viral respiratory illness and associated complications are presented each year; despite this, numerous misperceptions and misinformation on the efficacy and safety of the influenza vaccination persist. For this patient, remind her that, given her age, she is in a particularly high-risk group for hospitalization if she were to contract this illness. The explanation for her illness last season may be multifaceted: she may have contracted a respiratory viral illness that mimics influenza, she may have contracted a strain of influenza not covered by the season’s formulation, she may have been exposed to influenza before the vaccine was fully effective, or her immune system may not have created enough antibodies to establish adequate immunity.¹⁰ Encourage her to become immunized as soon as possible, as it can take up to 2 weeks for adequate immune response and antibody surveillance to be established following immunization. For the 2015-2016 influenza season, numerous vaccine products are available. The Advisory Committee on Immunization Practices does not have a preference for which vaccine should be administered to a particular patient or group, although manufacturer labeling may vary. If the patient is interested and if the product is available, a high-dose formulation may be used. Since immune protection wanes and vaccine formulations change annually, vaccination is indicated.¹⁰

Got an interesting question regarding OTC medications? Contact the authors at otccasestudies@pharmacy.rutgers.edu and share the details. Your case could be featured in an upcoming column!

Dr. Bridgeman is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. Dr. Mansukhani is a clinical assistant professor at the Ernest Mario School of Pharmacy, Rutgers University, and a transitions-of-care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey.

References

• Scolaro KL. Colds and allergy. In: Krinsky DL, ed. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 18th ed. Washington, DC: American Pharmacists Association; 2015.
• Gilbert C, Mazzotta P, Loebstein R, Koren G. Fetal safety of drugs used in the treatment of allergic rhinitis: a critical review. Drug Safety. 2005;28:707-719.
• Schatz M, Zeiger RS, Harden K, Hoffman CC, Chilingar L, Petitti D. The safety of asthma and allergy medications during pregnancy. J Allergy Clin Immunol. 1997;100:301-306.
• Seto A, Einarson T, Koren G. Pregnancy outcome following first trimester exposure to antihistamines: meta-analysis. Am J Perinatol. 1997;14:119-124.
• Werler MM. Teratogen update: pseudoephedrine. Birth Defects Res A Clin Mol Teratol. 2006;76:445-452.
• Nsouli TM, et al. Long-term use of nasal saline irrigation: harmful or helpful? ACAAI 2009; Abstract O32.
• Harvey R, Hannan SA, Badia L, Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database of Systematic Reviews. 2007;3(CD006394). doi: 10.1002/14651858.CD006394.pub2.
• Is rinsing your sinuses safe? FDA website. www.fda.gov/ForConsumers/ConsumerUpdates/ucm316375.htm. Accessed September 28, 2015.
• Situation report: summary of weekly FluView. CDC website. www.cdc.gov/flu/weekly/summary.htm. Accessed September 30, 2015.
• Misconceptions about seasonal flu and flu vaccines, questions and answers. CDC website. www.cdc.gov/flu/about/qa/misconceptions.htm. Accessed September 30, 2015.