Learning Objectives. Introduction. Disclosures. Cough. Types of Cough 10/24/2017. October 26, 2017

Transcription

1 Learning Objectives October 26, 2017 Natasha Colvin, PharmD Assistant Professor Department of Pharmacy Practice South University School of Pharmacy - Columbia Describe the types of cough and the treatment approach for each. Discuss the etiology and pathophysiology of the common cold and influenza. Identify patients with cough, the common cold and influenza who are candidates for self-treatment. Discuss over-the-counter medications used to manage cough, the common cold and influenza, including clinical pearls for each. Disclosures The speaker of this presentation has nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation. Introduction Cough, cold, and flu are ailments that affect Americans each year Cough is the most common symptom for which patients seek care The common cold is one of the top 5 illnesses diagnosed in the US Influenza is a highly contagious viral infection Cough, cold, and flu are among the most common conditions that patients routinely self-treat given their widespread prevalence However, the abundance of over-the-counter products available can lead to patient confusion and inappropriate or even dangerous selftreatment Cough A vagally mediated, defensive respiratory reflex Produced when sensory receptors throughout the larynx are activated by mechanical or chemical stimuli Involuntary cough is controlled by the cough control center in the medulla oblongata Voluntary cough is controlled in the cerebral cortex Types of Cough Cough Duration Cause(s) acute < 3 weeks - viral upper respiratory tract infection (ie common cold) subacute 3 8 weeks - infection - bacterial sinusitis - asthma chronic > 8 weeks - upper airway cough syndrome (postnasal drip) - asthma - gastroesophageal reflux disease (GERD) 1

2 Types of Cough Cough Purpose Characteristics productive helps expel - effective lower respiratory - ineffective wet or chesty tract secretions - clear (bronchitis) - purulent (bacterial) - discolored (inflammatory disorders) - malodorous (anaerobic bacterial) nonproductive dry or hacking none associated with: - viral respiratory tract infections - atypical bacterial infections - GERD - cardiac disease - ACE inhibitors & β-blockers Exclusions for Self- Cough with thick yellow sputum or green phlegm Fever > F (38.6 C) Unintended weight loss Drenching nighttime sweats Coughing up blood or blood-stained mucus History of chronic underlying disease associated with cough (e.g., asthma, chronic obstructive pulmonary disease (COPD), chronic bronchitis, congestive heart failure (CHF), GERD) Foreign object aspiration Suspected drug-associated cough Cough > 7 days Cough that worsens or develop new symptoms during self-treatment General Nonpharmacologic therapy Nonmedicated lozenges or hard candies Honey Cool-mist humidification Adequate hydration with ~8oz of water/day Pharmacologic therapy Antitussives ( cough suppressant ) Protussives ( expectorant ) Antitussives GOAL: To increase the cough threshold Drugs of choice for nonproductive coughs Codeine (with noncodeine active ingredients) Schedule V (must not contain > 200 mg/100 ml) Can cause nausea, vomiting, sedation, dizziness and constipation Caution with elderly, pregnancy, CNS depressants and respiratory issues Antitussives GOAL: To increase the cough threshold Dextromethorphan Equipotent to codeine Can cause drowsiness, nausea, vomiting, stomach discomfort and constipation Caution with elderly, pregnancy, CNS depressants, serotonergic agents NOT to be administered for at least 14 days after discontinuation of monoamine oxidase (MAO) inhibitor Antitussives GOAL: To control or eliminate cough by increasing the cough threshold Diphenhydramine Not considered a first-line choice Can cause sedation, dizziness, dry mouth, blurred vision and constipation Caution with elderly and CNS depressants Safe in pregnancy Camphor & Menthol Topical formulations that can be toxic/lethal if small are amounts ingested 2

3 Protussives GOAL: To loosen/thin secretions, making coughs more productive Drug of choice for ineffective productive coughs Guaifenesin Only FDA-approved expectorant Can cause nausea, vomiting, dizziness, headache, rash, diarrhea, drowsiness, stomach pain and mild increase of uric acid excretion Caution with previous kidney stones NOT to be used to treat effective productive coughs NOT to be used for chronic coughs associated with asthma, COPD, emphysema, or smoker s cough Common Cold A self-limited viral infection of the upper respiratory tract Most commonly caused by rhinoviruses Peaks in the early fall and late spring Children average 6-10 colds per year Adolescents and adults average 2-4 colds per year Modes of transmission: touch a contaminated surface then deposit the virus into nose or eye contact with aerosols produced by coughing, sneezing, or talking Risk factors include: smoking, allergic disorders affecting the nose or pharynx, increased population density, a sedentary lifestyle, and psychologic stress Course of the Common Cold Onset symptoms begin 1-3 days after infection Day 1 sore or scratchy throat appears first fever Day 2 or 3 nasal obstruction/congestion (clear/thin yellow or green/thick) runny nose Day 4: or 5 nonproductive cough Duration symptoms typically last 7-10 days nasal secretions return clear/thin Influenza A contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs Best prevented by getting a flu vaccine each year Common signs/symptoms include: fever, cough, sore throat, runny/stuffy nose, muscle/body aches, headaches, fatigue, vomiting and diarrhea Onset is about 1 to 4 days after exposure, bout lasts 1-2 weeks Modes of transmission: Droplets made when people with flu cough, sneeze or talk Touching a surface/object that has flu virus on it, then touching mouth, eyes or nose Complications include: bacterial pneumonia, ear infections, sinus infections, dehydration, worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes and even death Exclusions for Self-Treatment of Common Cold / Influenza Fever > F (38.6 C) Chest pain Shortness of breath Worsening of symptoms or development of additional symptoms during self-treatment Concurrent underlying chronic cardiopulmonary diseases (asthma, COPD, CHF) Acquired immunodeficiency syndrome (AIDS) Frail patients of advanced age Infants < 9 months of age Hypersensitivity to recommended OTC medications General Treatment of Common Cold / Influenza Nonpharmacologic therapy Pharmacologic therapy Adequate fluid intake and rest Decongestants Nutritious diet Antihistamines Humidification Local anesthetics Hand sanitization Systemic Cough/sneeze into tissue or antipyretics/analgesics crook of the arm Antitussives Disinfectants Protussives Nasal strips Aromatic products Upright position 3

4 Decongestants GOAL: To decrease sinus vessel engorgement and mucosal swelling Pseudoephedrine (PSE) Stored behind the pharmacy counter; limit 3.6 g/day or 9 g/month Phenylephrine (PE) Has replaced PSE in new products; effectiveness is controversial Both Side effects include: restlessness, insomnia, anxiety, tremors, fear, hallucinations, elevated blood pressure, tachycardia DO NOT use in pregnancy; PSE compatible with breastfeeding Adequate medical supervision required in patients with hypertension, diabetes, hyperthyroidism, glaucoma, heart disease, MAO inhibitor therapy or prostate issues Decongestants GOAL: To decrease sinus vessel engorgement and mucosal swelling Oxymetazoline Topical decongestant formulated as a nasal spray Preferred topical decongestant during pregnancy Not to be used > 3-5 days at a time due to rebound congestion Side effects include: burning, stinging, sneezing, local dryness or trauma from tip 1 st -Generation Antihistamines GOAL: To reduce runny nose and sneezing when given in combination with decongestants Brompheniramine Chlorpheniramine Diphenhydramine NOT to be used in children < 6 yo unless a primary care provider has recommended use Side effects include: sedation, impaired performance, anxiety, hallucinations, and appetite stimulation High doses cause insomnia, blurred vision, dry eyes, dry mouth, constipation and urinary retention Local Anesthetics GOAL: To provide temporary relief of sore throat Benzocaine Dyclonine Available as lozenges, throat sprays, and oral disintegrating strips Generally used every 2-4 hours Should be avoided in patients with history of allergic reactions to anesthetics Systemic Antipyretics/Analgesics GOAL: To reduce fever and aches Acetaminophen (APAP) Should be avoided in patients with liver issues Caution as APAP is found in other products; limit 3,000 mg/day Drug of choice in pregnancy NSAIDS (aspirin / ibuprofen / naproxen) Should be avoided in pregnancy, heart disease, stroke, use of blood thinners, or peptic ulcers Aspirin should be avoided in children < 16 y.o. due to risk of Reye s syndrome Cough Case AG, a 71-year-old man, approaches the pharmacist 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. His past medical history consists of hypertension, hyperlipidemia, atrial fibrillation, and peptic ulcer disease. His current medications are: Amlodipine 10 mg 1 PO QD Metoprolol succinate 50 mg 1 PO QD Amiodarone 400 mg 2 PO QD Warfarin 5 mg 1 PO QD Atorvastatin 40 mg 1 PO QD Famotidine 40 mg 1 PO QAM 4

5 Cough Case AG denies smoking and use of other forms of tobacco. He has tried a dextromethorphan cough syrup which provided no relief. What should the pharmacist recommend to AG? a. AG should continue dextromethorphan. b. AG should try codeine. c. AG should try guaifenesin. d. AG should be referred for medical evaluation. Common Cold Case GP, a 57-year-old woman, approaches the pharmacist with a combination product intended for the relief of common cold and flu symptoms. Each caplet contains acetaminophen 325 mg, dextromethorphan 10 mg, and phenylephrine 5 mg; the dosage is two caplets every 4 hours. GP describes symptoms suggestive of the common cold, with nasal stuffiness, runny nose, sneezing, and a scratchy throat the past two or three mornings. GP identifies congestion and rhinorrhea as the most troublesome symptoms. Her current medications are: Aspirin 81 mg - 1 PO QD Hydrocodone 7.5 mg/apap 325 mg - 1 tab PO QID PRN pain Common Cold Case What should the pharmacist tell GP about the product she has selected? a. The cold and flu product is an ideal choice for GP s symptoms. b. The cold and flu product is a good choice but should be used for 1 or 2 days only. c. GP should not purchase this product. She would be better served by a different product. d. GP should not purchase this product. She should check with her primary care provider before attempting self-treatment. Influenza Case RD, a 58-year-old female, comes to the pharmacy to refill her prescriptions for metformin and saxagliptin. She says her diabetes mellitus is controlled well with medication and lifestyle modifications. She states that because it is October, she is concerned about getting the flu. She had it last year and could not get out of bed for a week. Her friend recommended that she get some special vitamins that prevent the flu. She has never had the flu shot and is not against it. She has no allergies to foods or medications. Influenza Case What should the pharmacist recommend to RD as the most effective way to prevent influenza? a. Get the influenza vaccination each year. b. Take Vitamin C 200 mg/day. c. Have frequent contact with sick individuals to strengthen her immune system. d. Take a cough/cold/flu combination product daily. References Tietze KJ. Cough. In: Berardi RR, Ferreri SP, Hume AL, et al., eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th ed. Washington, DC: American Pharmacists Association; 2009: Scolaro KL. Disorders related to colds and allergy. In: Berardi RR, Ferreri SP, Hume AL, et al., eds. Handbook of Nonprescription Drugs: An Interactive Approach to SelfCare. 16th ed. Washington, DC: American Pharmacists Association; 2009: Cdc.gov. (2017). Key Facts About Influenza (Flu) Seasonal Influenza (Flu) CDC. [online] Available at: [Accessed 18 Sep. 2017]. 5

6 Natasha Colvin, PharmD Assistant Professor of Pharmacy Practice South University School of Pharmacy Columbia (803)