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College of pharmacy/University of Baghdad .Clinical pharmacy Dept Fourth year. Community Pharmacy workshop.



.(Common cold: is a self-limiting viral infection of the upper respiratory tract (1 :(The probable routes of transmission are (2 .(Manual transmission (e.g. hand- to-hand contact-1 .Inhalation of droplets spread by sneezing and coughing-2 Note: contrary to common belief, cold environment or sudden chilling do not increase .(susceptibility to viral upper respiratory infection (1

(Patient assessment with common cold (questions and answers :A-Age

Very young patients and very old patients required referral. Also the age affect the choice of treatment .((3 :(B-Duration(3): Generally (see flu later .Abrupt onset of symptoms-------------------May indicates flu .Gradual onset of symptoms-----------------May indicates common cold

Symptoms typically are worst on day 2 or 3 of illness and last about 1 week( but in about 1/4 of patients :it may lasts for about 2 weeks or longer) (2). Symptoms of common cold are

:Sore throat-1 The throat is often feels dry and sore during a colds and it is usually 1st sign of .(common cold (3 :Runny / congested (or blocked) nose-2
.((Initially clear watery fluid-------after 1-2 days (2) become thicker mucus (3)

Sneezing/ coughing (3-3

:Aches and pains-4

Headache may occurs but a persistent or worsening frontal headache (pain above or .(bellow the eyes) may be due to sinusitis ------------referral for further investigations(3 .(Note: headache of sinusitis increase by lying down or bending forwards) (3) 1

Low grade fever (feeling hot but in general a high temperature (>37.5) is rare


.(((in common cold (3) (<1% of patients (2 .(The presence of fever may indicate FLU rather than common cold (see flu later Earache: A blocked uncomfortable ear is often present and does not need referral if it does -6 .(not persist. A very painful ear needs referral (3

:D-Previous history
Patient with a history of asthma (asthmatic attack can be triggered by respiratory viral infection) or lung disease e.g. chronic bronchitis (which can be complicated by secondary chest infection) .(-----------required referral for further investigations(3

:Differentiating between colds and flu is needed. Flu is generally considered to be likely if .(Temp. Is 38c or higher (37.5 in elderly-1 At least one of the respiratory symptoms (cough, sore throat, nasal congestion, or rhinorrhoea) is -2 .present At least one of constitutional symptoms (headache, malaise, myalgia, sweat, chills, and -3 .prostration) is present

In common cold the upper respiratory symptoms are the most prominent while in flu the .(constitutional symptoms are predominant and fever is present in more than 95% of patient(2 Flu often starts abruptly with sweat and chills, muscular aches and pain in the limbs, a dry sore throat, cough and high temperature. Someone with flu may be bedbound and unable to go to their usual activities. There is often a period of generalized weakness and malaise following the onset of .symptoms. A dry cough may persist for some time Flu generally settle with no need for referral, however , flu can be complicated by secondary lung infection (pneumonia)---------------therefore any patient with Flu and warning sign and symptoms of complication (severe or productive cough, persisting high fever, delirium ,pleuretic chest .(pain) -------required referral for further investigations (3

(However reference 3 recommends referring any patient with symptoms indicative of Flu) :(G-Present medication(3
If one or more appropriate remedies have been tried without success (failed medication) ------------.(referral for further investigations (3 Also patients taking chronic immunosuppressive drug therapy (e.g. corticosteroid or ciclosporin) .(--------------referral (1

:Treatment timescale
Once the pharmacist has recommended treatment, patient should be advised to see the Dr. in 10-14 .(days if cold has not improved(3

:Management :(A- To reduce the likelihood of catching or passing on infection (8

.If possible, stay away from people with colds or influenza .Avoid crowded places where the risk of infection is greater .Do not touch nose or eyes after being in physical contact with somebody who has a cold or influenza .Wash hands thoroughly, especially after blowing the nose .Throw away paper tissues after use to prevent the spread of infection .Keep rooms well aired

:B-Non pharmacological measures: Non -drug therapy include .(increased fluid intake which may loosen the mucus and promote drainage (1-1 .(getting adequate rest may help to recover quickly (1-2 ( adequate nutrition (1-3 saline solution (discussed later) can soothe the irritated nasal tissue and moisturized nasal mucosa -4 .((2). And it can be given to all age group and during pregnancy (1 : There are already formulated saline drops or spray products in the market ( Dose : use as often as needed (8

:C- Pharmacological therapy

:(Decongestants (sympathomimetics-1
A-Systemic (oral) decongestants: like Pseudoephedrine and phenylphrine. They reduce nasal
.(congestion by constricting dilated blood vessels in the nasal mucosa (3 C/I: Systemic (oral) decongestants cause stimulation of the heart, increase the BP and may cause : (hyperglycemia. Therefore they should avoid in (3 .(D.M, Ischemic heart disease (angina, M.I), hypertension, and hyperthyroidism ) : )( : (Cough or common cold) preparation for compound :(B-Topical(drop/spray) Nasal Decongestants( sympathomimetics :(Classification and Doses (1-1

.(Short acting (4-6 hours Intermediate acting (8-10 .(hours .(Long acting ( 12 hours

phenylphrine, Naphazoline, tetrahydrozoline :(Xylometazoline(Otrivine years 12< :0.1% years 2-12 :0.05%

drops/sprays q 4-6 2 hours p.r.n
(but Naphazoline q 6 hours)

drops/sprays q 8-10 2 hours p.r.n

:(Oxymetazoline(Nazordine drops/sprays q 12hours 2 years 12< :0.05% p.r.n years 2-12 :0.025%

??? (Nasal Spray or Drop (1,3-2 Nasal sprays are preferable for adults and children aged over 6 years because spray has a .faster onset of action and cover a large surface area

Nasal drops are preferable for children aged below 6 years because their nostrils are not .sufficiently wide to allow effective use of sprays
.(But the drops cover a limited surface area and easily swallowed which increase the possibility of systemic effects )

Topical Nasal decongestants (sympathomimetics) can be recommended for those patients in whom -3 .(Systemic (oral) decongestants are to be avoided (3
.(i.e. D.M, Ischemic heart disease (angina, M.I), hypertension, and hyperthyroidism)

:(Duration of treatment with Topical Nasal Decongestants (sympathomimetics-4 If topical; (drops or sprays) decongestants are to be recommend, the pharmacist should advice the patients not to use the product for longer than 7 days (3) (3-5 days in some references (1)) because: Rebound congestion (Rhinitis medicamentosa) (with congestion returning often worse than before)(4) can occur with topically applied (3) (especially short acting (1)) but not with oral .(sympathomimetics (3 3

:Topical nasal decongestants-5 .(can be given to pregnant women after the 1st trimester (i.e. the 1st three months) of pregnancy (5*
.(Not OTC for children < 2 years (1* Not recommended for children <6 months (or 3 months in BNF) because they are obligate nose * breathers and rebound congestion can cause obstructive apnea (6). Saline nose drop can be used from birth to help with congestion. This would be more suitable and safer alternative than topical .(sympathomimetics (5

:Administration of nasal spray and nasal drop-6 ()

Antihistamine can reduce some of symptoms of a cold: runny nose (rhinorrhoea) and sneezing but are not so effective in reducing nasal congestion (3). There is no evidence that any antihistamine is preferable .(to another in the treatment of rhinorrhea (4 :Antihistamine can be classified into

:A- Sedating Antihistamine

:Examples of OTC sedating antihistamine are Chlorpheniramine (Histadin tablet and syrup), Dexchlorpheniramine (polaramine tablet), and (Diphenhydramine (Allermine tablet and syrup

S/Es: include sedation and drowsiness (patients should be informed) and anticholinergic S/Es (i.e. dry
.(mouth, urinary retention, constipation) and the elderly patients are more susceptible to these (7 Accordingly they are not recommended (3) (or used with caution (6)) for patients with: Glaucoma, or .prostate hypertrophy and in elderly patients Drug Interactions: the sedative effects of antidepressants, anxiolytics, and hypnotics are likely to be .(enhanced by sedating antihistamine (7

:B- Non-Sedating Antihistamine

:Examples of OTC non-sedating antihistamine are .(Loratadine (clarityn tablet and syrup), and cetirizine (Zirtek tablet and syrup .(They are generally preferable over the older antihistamines because of much lower incidence of S/Es (7 .Adult dose of Loratadine: 10 mg once daily
Note: although the drowsiness is rare, but the warning that these drugs may affect driving and skilled tasks is still present
.(7 (6,

Combination products: sympathomimetics (for congestion) + Antihistamine (for rhinorrhoea and -3


: The antihistamine is usually combined with Sympathomimetics because A-The suppression of rhinorrhea can provokes congestion so the Sympathomimetics will offset this .effect B- Sympathomimetics may also help to counteract sedation caused by the antihistamines (because the Sympathomimetics cause CNS stimulation), but not counteract other side effects such as dry mouth , .(urinary retention,.(4 : Example of OTC products is Actifed tablet and syrup: which composed of Triprolidine (sedating antihistamine) and Pseudoephedrine

:(Analgesics, antipyretics, and cough preparations (2-4

Systemic analgesics and antipyretics (e.g. Paracetamol, Ibuprofen) are effective for aches or fever .which may be associated with common cold .(In addition, cough, when present, may be treated by suitable cough products (see cough

:Vitamin C in common cold-5

:A review of trial data conducted in 2000 concluded that Vitamin C .Does not prevent colds* 4

Appears to reduce the duration of symptoms when ingested in large dose (up to 1gm daily) * .(although the response is variable(5 .(Reduce the duration by less than 1 day and severity by about 22%) (1) Taking mega doses of vitamin C can have an adverse consequences particularly for group of :patients who are already at risk .Vitamin C is a reducing agent and may interfere with diabetic urine glucose tests -1 .It has also been reported to counteract the action of anticoagulants -2 . It may increase the production of urinary oxalate , leading to renal stone-3 In case of vitamin C effervescent tablets, large quantities of sodium bicarbonate are required in this -4 formulation, which could disturb the electrolyte balance of patients with cardiovascular diseases , .(especially those whose sodium intake is restricted (4 : 1 : .

:(Treatment influenza(8
.Rest, preferably by staying in bed.Try to get plenty of sleepDrink as much as possible, as large amounts of fluid are lost during a fever .Avoid smoking.Treat with over-the counter antipyretics and other medications as symptoms require .Consult a doctor if the symptoms have not gone after a week, or sooner if symptoms worsen ) ( - 2 .

Common Cold Common Cold ( ) - 1 -2 ) (-3 -4 - 5 -6 - 7 --8 References

Handbook of Non-prescription drugs. 2002-1 Applied therapeutics :the clinical use of drugs.2004-2 .Symptoms in the pharmacy . A guide to the managements of common illness -3 .4th edition By Alison Blenkinsopp and Paul Paxton .2002 Nathan A. Non-prescription medicines. 3rd edition. London: Pharmaceutical Press; 2006.4 .Community Pharmacy. Symptoms, Diagnosis and Treatment -5 .By Paul Rutter.2004 BNF. 52-6 5

A. Nathan .How to treat hay fever and associated allergic conditions in the pharmacy . the -7 .pharmaceutical journal (vol 268). 27 April 2002 pages 575-578 .Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press; 2008 -8

:Homework: complete the following table Trade name

Coldin tablet


Caution or contraindications

Coldin syrup

Actifedtab and syrup

Flu out tablet