Self-Care for Cough, Cold, and Flu

Case 1: Pneumococcal Immunization Education

Q: A 68-year-old woman approaches the pharmacist seeking some information about her vaccine needs. She wants to get her influenza vaccination, like she does every year, while she waits for a refill of her prescription antihypertensive medication. She also wants to know if she is eligible to get a pneumococcal vaccination and, if so, which one. At her last follow-up appointment with her physician, she was instructed to get the vaccination, but she cannot remember which type was suggested. She has never had a pneumococcal vaccination. She has a history of hypertension and hyperlipidemia, for which she takes lisinopril 10 mg once daily and atorvastatin 10 mg once daily, respectively. What information should the pharmacist provide regarding a pneumococcal vaccination for this woman?

A: Secondary bacterial pneumonias caused by Streptococcus pneumoniae are a common cause of hospitalizations during the winter and influenza season. Immunizing this woman with both inactive vaccines on the same visit is an excellent strategy to ensure she is protected against both infectious diseases. According to the Advisory Committee on Immunization Practices, all adults 65 years and older should routinely receive the series of the pneumococcal conjugate vaccine (PCV13) and the pneumococcal polysaccharide vaccine (PPSV23).^1,2 Importantly, both of the pneumococcal vaccine types should not be given during the same visit; administration of the pneumococcal and influenza vaccines simultaneously poses no issue.³ Because this patient is pneumococcal vaccine—naïve, she should receive the PCV13 vaccine first, followed by the PPSV23 vaccine 1 year later. The sequencing of these types of vaccinations is designed to optimize the antibody response and the protection conferred from vaccine administration in older adults.^1,2

Case 2: Persistent Cough

Q: A 71-year-old man comes to the pharmacy looking for a recommendation for a cough medicine. He describes a dry cough and occasional episodes of shortness of breath, which he first noticed approximately 6 months prior to this encounter and have been occurring intermittently since. He reports a significant medical history, including hypertension, hyperlipidemia, atrial fibrillation, and peptic ulcer disease, for which he takes amlodipine 10 mg daily, metoprolol succinate 50 mg daily, amiodarone 400 mg twice daily, warfarin 5 mg daily, atorvastatin 40 mg daily, and famotidine 40 mg every morning. Upon questioning, he denies ever smoking cigarettes or other forms of tobacco and reports having tried a cough syrup containing dextromethorphan, which provided no relief. What recommendations should the pharmacist provide?

A: Chronic cough persisting longer than 7 days and accompanied by episodes of shortness of breath, as in this patient’s case, warrants referral for medical evaluation. This patient should not be given a recommendation to try another antitussive or expectorant medication, given his description of symptoms and persistence of cough despite dextromethorphan use.⁴ Considering his medical history and long-term medication use, a cough secondary to the use of amiodarone cannot be ruled out at this time. Signs and symptoms of drug-induced interstitial lung disease or pulmonary fibrosis may include exertional dyspnea, which may develop gradually with progressive worsening, accompanied by a nonproductive cough that does not respond to traditional antitussive medications.⁵ The duration of drug exposure prior to the appearance of pulmonary symptoms varies greatly; in most cases, patients may experience pulmonary symptoms for 6 months or longer before seeking medical advice.⁵ It is estimated that 1% to 15% of individuals using amiodarone long term experience this type of toxicosis. Therefore, it is important that pharmacists remain vigilant in identifying this cause of drug-related cough.⁵

Case 3: Nonpharmacologic Interventions for Alleviating Congestion

Q: A 64-year-old woman comes to the pharmacy looking for a recommendation to alleviate her cold symptoms. She is suffering from a head cold and has been unable to sleep comfortably for the past several nights due to nasal congestion. She has a medical history of anxiety, dyslipidemia, and hypertension. She reports taking an antidepressant for the anxiety and a statin for her cholesterol level. She has been told that her blood pressure is difficult to control despite numerous medications, the names of which she cannot recall. Because of her blood pressure, she has been told to avoid certain OTC medications. She would prefer to avoid all drugs, if possible, and use something natural or drug-free to alleviate her congestion and sleep better. What advice would be reasonable to share with her?

A: Although there is no OTC remedy to cure the common cold, a plethora of pharmacologic and nonpharmacologic treatment options exist to provide supportive care and mitigate symptoms. A myriad of nonpharmacologic interventions for alleviating nasal congestion are available and can be used in lieu of traditional pharmacologic treatments, or in tandem with them, to alleviate bothersome nasal congestion. In this patient’s case, given her desire to avoid drug therapies and restore sleep, she should be told to maintain adequate hydration, particularly with warm liquids, and nutrition; elevate the head of her bed or use pillows to promote nasal drainage while she lies supine; consider using a humidifier or vaporizer or inhaling steam while in the shower; and consider using intranasal saline via a spray or a nasal teapot.⁶ Additionally, the patient should consider using nasal strips, applied to clean dry skin of the bridge of the nose, as another nondrug option for relieving nighttime congestion.⁷ Application of topical products containing aromatic oils, such as menthol, camphor, or eucalyptus, may also help relieve her symptoms.⁶ In addition, it is a good idea to underscore the importance of good hand hygiene to reduce the spread of cold viruses to others.

Case 4: Herbal Remedies for Preventing Influenza

Q: A 47-year-old woman would like a recommendation for a good vitamin supplement to prevent colds, coughs, and the flu. Her friend told her that supplementation with vitamin C with rosehips helped her stay well last winter; therefore, this patient is interested in purchasing a similar product to stay healthy. As an elementary school teacher who is frequently exposed to sick children, she desires to stay well and avoid losing time from work. She has a medical history of hypothyroidism, for which she takes levothyroxine 75 mcg daily. What should the pharmacist recommend regarding the use of an herbal supplement with vitamin C for preventing colds and influenza?

A: Influenza, a viral respiratory illness, is far more debilitating than the common cold. Flu symptoms may include myalgia, fatigue, high fever, and dehydration. The CDC recommends a 3-fold approach to preventing and managing influenza, including annual influenza vaccination; preventive measures, such as proper hand hygiene, limited contact with individuals who are sick, avoidance of others while sick, and disinfection of surfaces; and the use of antiviral medications, if indicated and prescribed.⁸ Regarding this patient’s question, although her friend believes that supplementation with vitamin C with rosehips contributed to her wellness during the past flu season and vitamin C is likely safe at doses below 2000 mg per day, its efficacy at preventing the common cold or influenza is largely unsubstantiated.⁹

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

• CDC. Recommended adult immunization schedule—United States—2016. CDC website. cdc.gov/vaccines/schedules/downloads/adult/adult-schedule.pdf. Accessed October 5, 2016.
• Immunization Action Coalition. Ask the experts: diseases & vaccines. Pneumococcal vaccines (PCV13 and PPSV23). IAC website. immunize.org/askexperts/experts_pneumococcal_vaccines.asp. Updated July 22, 2016. Accessed October 5, 2016.
• Immunization Action Coalition. Ask the experts: topics. IAC website. immunize.org/askexperts/administering-vaccines.asp. Accessed October 7, 2016.
• Tietze KJ. Cough. In: Krinsky DL, ed. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 18th ed. Washington, DC: American Pharmacists Association; 2015.
• Trewet CB. Interstitial lung disease/pulmonary fibrosis. In: Tisdale JE, Miller DA, eds. Drug-Induced Diseases: Prevention, Detection, and Management. 2nd ed. Bethesda, MD: American Society of Health-Systems Pharmacists; 2010:359-371.
• 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.
• How do Breathe Right Nasal Strips work? Breathe Right website.breatheright.com/how-breathe-right-strips-work.html. Accessed October 5, 2016.
• CDC says “take 3” actions to fight the flu. CDC website. cdc.gov/flu/protect/preventing.htm. Updated August 1, 2016. Accessed October 5, 2016.
• The Medication Learning Company (MLC). Vitamin C (ascorbic acid) monograph. Natural Medicines Comprehensive Database. MLC website. https://naturalmedicines-therapeuticresearch-com.proxy.libraries.rutgers.edu/databases/food,-herbs-supplements/professional.aspx?productid=1001. Accessed October 5, 2016.