Allergic rhinitis

Seasonal allergic rhinitis (hay fever) affects 10–15% of people in the
UK and millions of patients rely on OTC medicines for treatment.
The symptoms of allergic rhinitis occur after an inflammatory
response involving the release of histamine which is initiated by allergens
being deposited on the nasal mucosa. Allergens responsible for
seasonal allergic rhinitis include grass pollens, tree pollens and fungal
mould spores. Perennial allergic rhinitis occurs when symptoms are
present all year round and is commonly caused by the house dust mite,
animal dander and feathers. Some patients may suffer from perennial
rhinitis which becomes worse in the summer months.
What you need to know
Age (approximate)
Baby, child, adult
Duration
Symptoms
Rhinorrhoea (runny nose)
Nasal congestion
Nasal itching
Watery eyes
Irritant eyes
Discharge from the eyes
Sneezing
Previous history
Associated conditions
Eczema
Asthma
Medication
Significance of questions and answers
Age
Symptoms of allergic rhinitis may start at any age, although its onset is
more common in children and young adults (the condition is most
common in those in their twenties and thirties). There is frequently
ALLERGIC RHINITIS 49
a family history of atopy in allergic rhinitis sufferers. Thus children of
allergic rhinitis sufferers are more likely to have the condition. The
condition often improves or resolves as the child gets older. The age of
the patient must be taken into account if any medication is to be
recommended. Young adults who may be taking examinations should
be borne in mind, because treatment that may cause drowsiness is best
avoided in these patients.
Duration
Sufferers will often present with seasonal rhinitis as soon as the pollen
count becomes high. Symptoms may start in April when tree
pollens appear and the hay fever season may start 1 month earlier in
the south than in the north of England. Hay fever peaks between the
months of May and July, when grass pollen levels are highest and
spells of good weather commonly cause patients to seek the pharmacist’s
advice. Anyone presenting with a summer cold, perhaps of
several weeks’ duration, may be suffering from hay fever. Fungal
spores are also a cause and are present slightly later, often until
September.
People can suffer from what they think are mild cold symptoms for
a long period, without knowing they have perennial rhinitis.
The PRODIGY classification of allergic rhinitis:
Intermittent. Occurs less than 4 days per week or for less than 4
weeks
Persistent. Occurs more than 4 days per week and for more than
4 weeks
Mild. All of the following – normal sleep; normal daily activities,
sport, leisure; normal work and school; symptoms not troublesome
Moderate. One or more of the following – abnormal sleep; impairment
of daily activities, sport, leisure; problems caused at work or
school; troublesome symptoms
(Source: www.prodigy.nhs.uk)
Symptoms
Rhinorrhoea
A runny nose is a commonly experienced symptom of allergic rhinitis.
The discharge is often thin, clear and watery, but can change to a
thicker, coloured, purulent one. This suggests a secondary infection,
although the treatment for allergic rhinitis is not altered. There is no
need for antibiotic treatment.
50 RESPIRATORY PROBLEMS
Nasal congestion
The inflammatory response caused by the allergen produces vasodilatation
of the nasal blood vessels and so results in nasal congestion. Severe
congestion may result in headache and occasionally earache. Secondary
infection such as otitis media and sinusitis can occur (see p. 19).
Nasal itching
Nasal itching commonly occurs. Irritation is sometimes experienced
on the roof of the mouth.
Eye symptoms
The eyes may be itchy and also watery; it is thought these symptoms
are a result of tear duct congestion and also a direct effect of pollen
grains being caught in the eye, setting off a local inflammatory
response. Irritation of the nose by pollen probably contributes to eye
symptoms too. People who suffer severe symptoms of allergic rhinitis
may be hypersensitive to bright light (photophobic) and find that
wearing dark glasses is helpful.
Sneezing
In hay fever the allergic response usually starts with symptoms of
sneezing, then rhinorrhoea, progressing to nasal congestion. Classically,
symptoms of hay fever are more severe in the morning and in the
evening. This is because pollen rises during the day after being released
in the morning and then settles at night. Patients may also describe a
worsening of the condition on windy days as pollen is scattered, and a
reduction in symptoms when it rains, or after rain, as the pollen clears.
Conversely, in those allergic to fungal mould spores the symptoms
worsen in damp weather.
Previous history
There is commonly a history of hay fever going back over several
years. However, it can occur at any age, so the absence of any previous
history does not necessarily indicate that allergic rhinitis is not the
problem. The incidence of hay fever has risen during the last decade.
Pollution, particularly in urban areas, is thought to be at least partly
responsible for the trend.
Perennial rhinitis can usually be distinguished from seasonal rhinitis
by questioning about the timing and the occurrence of symptoms.
People who have had hay fever before will often consult the pharmacist
when symptoms are exacerbated in the summer months.
ALLERGIC RHINITIS 51
Danger symptoms/associated conditions
When associated symptoms such as tightness of the chest, wheezing,
shortness of breath or coughing are present, immediate referral is
advised. These symptoms may herald the onset of an asthmatic attack.
Wheezing
Difficulty with breathing, possibly with a cough, suggests an asthmatic
attack. Some sufferers only experience asthma attacks during
the hay fever season (seasonal asthma). These episodes can be quite
severe and require referral. Seasonal asthmatics often do not have
appropriate medication at hand as their attacks occur so infrequently,
which puts them at greater risk.
Earache and facial pain
As with colds and flu (see p. 19), allergic rhinitis can be complicated
by secondary bacterial infection in the middle ear (otitis media) or the
sinuses (sinusitis). Both these conditions cause persisting severe pain.
Purulent conjunctivitis
Irritated watery eyes are a common accompaniment to allergic rhinitis.
Occasionally this allergic conjunctivitis is complicated by a secondary
infection. When this occurs, the eyes become more painful
(gritty sensation) and redder, and the discharge changes from being
clear and watery to coloured and sticky (purulent). Referral is needed.
Medication
The pharmacist must establish whether any prescription or OTC
medicines are being taken by the patient. Potential interactions between
prescribed medication and antihistamines can therefore be
identified.
It would be useful to know if any medicines have been tried already
to treat the symptoms, especially where there is a previous history of
allergic rhinitis. In particular, the pharmacist should be aware of the
potentiation of drowsiness by some antihistamines combined with
other medicines. This can lead to increased danger in certain occupations
and driving.
Failed medication
If symptoms are not adequately controlled with OTC preparations, an
appointment with the doctor may be worthwhile. Such an appointment
is useful to explore the patient’s beliefs and preconceptions about
hay fever and its management. It is also an opportunity to suggest
ideas for the next season.
52 RESPIRATORY PROBLEMS
When to refer
Wheezing and shortness of breath
Tightness of chest
Painful ear
Painful sinuses
Purulent conjunctivitis
Failed medication
Treatment timescale
Improvement in symptoms should occur within a few days. If no
improvement is noted after 5 days, the patient might be referred to
the doctor for other therapy.
Management
Management is based on whether symptoms are intermittent or persistent
and mild or moderate. Options include antihistamines, nasal
steroids and sodium cromoglicate (sodium cromoglycate) in formulations
for the nose and eyes. OTC antihistamines and steroid nasal
sprays are effective in the treatment of allergic rhinitis. The choice of
treatment should be rational and based on the patient’s symptoms and
previous history where relevant.
Many cases of hay fever can be managed with OTC treatment and it
is reasonable for the pharmacist to recommend treatment. Patients
with symptoms that do not respond to OTC products can be referred
to the doctor at a later stage. Pharmacists also have an important role
in ensuring that patients know how to use any prescribed medicines
correctly (e.g. steroid nasal sprays, which must be used continuously
for the patient to benefit).
Antihistamines
Many pharmacists would consider these drugs to be the first-line
treatment for mild to moderate and intermittent symptoms of allergic
rhinitis. They are effective in reducing sneezing and rhinorrhoea,
less so in reducing nasal congestion. Non-sedating antihistamines
available OTC include acrivastine, cetirizine and loratadine. All are
effective in reducing the troublesome symptoms of hay fever and have
the advantage of causing less sedation than some of the older
antihistamines.
Cetirizine and loratadine are taken once daily while acrivastine is
taken three times daily. Recommended doses should not be exceeded.
ALLERGIC RHINITIS 53
For sale OTC, acrivastine, cetirizine and loratadine can be recommended
for children over 12 years.
While drowsiness is an extremely unlikely side-effect of any of the
three drugs, patients might be well advised to try the treatment for a
day before driving or operating machinery. Recent evidence suggests
that loratidine is less likely to have any sedative effect than the other
two, but the incidence of drowsiness is extremely small.
Acrivastine, cetirizine and loratadine may be used for other allergic
skin disorders such as perennial rhinitis and urticaria.
Older antihistamines, such as promethazine and diphenhydramine,
have a greater tendency to produce sedative effects. Indeed, both drugs
are available in the UK in OTC products promoted for the management
of temporary sleep disorders (see p. 311). The shorter half-life of
diphenhydramine (5–8 h compared with 8–12 h of promethazine)
should mean less likelihood of a morning hangover/drowsiness effect.
Other older antihistamines are relatively less sedative, such as
chlorphenamine (chlorpheniramine) and clemastine. Patients may
develop tolerance to their sedation effects. Anticholinergic activity is
very much lower among the newer drugs compared to the older drugs.
Interactions. The potential sedative effects of older antihistamines are
increased by alcohol, hypnotics, sedatives and anxiolytics. The alcohol
content of some OTC medicines should be remembered.
The plasma concentration of non-sedating antihistamines may be
increased by ritonavir; plasma concentration of loratadine may
be increased by amprenavir and cimetidine. There is a theoretical
possibility that antihistamines can antagonise the effects of betahistine.
Side-effects. The major side-effect of the older antihistamines is their
potential to cause drowsiness. Their anticholinergic activity may result
in a dry mouth, blurred vision, constipation and urinary retention.
These effects will be increased if the patient is already taking another
drug with anticholinergic effects (e.g. tricyclic antidepressants, neuroleptics).
At very high doses, antihistamines have CNS excitatory rather than
depressive effects. Such effects seem to be more likely to occur in
children. At toxic levels, there have been reports of fits being induced.
As a result, it has been suggested that antihistamines should be used
with care in epileptic patients. However, this appears to be a largely
theoretical risk.
Antihistamines are best avoided by patients with narrow- (closed-)
angle glaucoma, since the anticholinergic effects produced can cause
an increase in intraocular pressure. They should be used with caution
in patients with liver disease or prostatic hypertrophy.
54 RESPIRATORY PROBLEMS
Decongestants
Oral or topical decongestants may be used to reduce nasal congestion
alone or in combination with an antihistamine. They can be useful in
patients starting to use a preventer such as a nasal corticosteroid (e.g.
beclometasone) or sodium cromoglicate where congestion can prevent
the drug from reaching the nasal mucosa. Topical decongestants can
cause rebound congestion, especially with prolonged use. They should
not be used for more than 1 week. Oral decongestants are occasionally
included such as pseudoephedrine. Their use, interactions and adverse
effects are considered in the section on ‘Colds and flu’ (see pp. 21–2).
Eye drops containing an antihistamine and sympathomimetic
combination are available and may be of value in troublesome eye
symptoms, particularly when symptoms are intermittent. The sympathomimetic
acts as a vasoconstrictor, reducing irritation and
redness. Some patients find that the vasoconstrictor causes painful
stinging when first applied. Eye drops that contain a vasoconstrictor
should not be used in patients who have glaucoma or who wear soft
contact lenses.
Steroid nasal sprays
Beclometasone nasal spray (aqueous pump rather than aerosol
version), fluticasone metered nasal spray and triamcinolone aqueous
nasal spray can be used for the treatment of seasonal allergic rhinitis.
A steroid nasal spray is the treatment of choice for moderate to
severe nasal symptoms that are continuous. The steroid acts to reduce
inflammation that has occurred as a result of the allergen’s action.
Regular use is essential for full benefit to be obtained and treatment
should be continued throughout the hay fever season. If symptoms of
hay fever are already present, the patient needs to know that it is likely
to take several days before the full treatment effect is reached.
Dryness and irritation of the nose and throat, and nosebleeds have
occasionally been reported; otherwise side-effects are rare. Beclometasone,
fluticasone and triamcinolone nasal sprays can be used in
patients over 18 years of age for up to 3 months. They should not be
recommended for pregnant women or for anyone with glaucoma.
Patients are sometimes alarmed by the term ‘steroid’, associating it
with potent oral steroids and possible side-effects. Therefore the
pharmacist needs to take account of these concerns in explanations
about the drug and how it works.
Sodium cromoglicate
Sodium cromoglicate is availableOTCas nasal drops or spray and as eye
drops. An OTC nasal spray product containing sodium cromoglicate
ALLERGIC RHINITIS 55
with a small amount of decongestant is available. The amount of
decongestant is said to be too small to produce rebound congestion.
Cromoglicate can be effective as a prophylactic if used correctly. It
should be started at least 1 week before the hay fever season is likely to
begin and then used continuously. There seem to be no significant
side-effects, although nasal irritation may occasionally occur.
Cromoglicate eye drops are effective for the treatment of eye symptoms
that are not controlled by antihistamines. Cromoglicate should
be used continuously to obtain full benefit. The eye drops should be
used four times a day. The eye drops contain the preservative benzalkonium
chloride and should not be used by wearers of soft contact
lenses.
Topical antihistamines
Nasal treatments
Azelastine and levocabastine are used in allergic rhinitis. The BNF
suggests that treatment should begin 2–3 weeks before the start of
the hay fever season. Azelastine and levocabastine are available as
aqueous nasal sprays. Their place in treatment is likely to be for mild
and intermittent symptoms. Azelastine can be used in adults and
children over 5 years of age; levocabastine can be used in adults
and children over 12 years of age. Advise the patient to keep the
head upright during use to prevent the liquid trickling into the throat
and causing an unpleasant taste.
Eye treatments
Levocabastine eye drops can be used in children over 12 years of age
and adults for the treatment of seasonal allergic conjunctivitis.
Further advice
1 Car windows and air vents should be kept closed while driving.
Otherwise a high pollen concentration inside the car can result.
2 Where house dust mite is identified as a problem, regular cleaning
of the house to maintain dust levels at a minimum can help. Special
vacuum cleaners are now on sale that are claimed to be particularly
effective.
Hay fever in practice
Case 1
A young man presents in late May. He asks what you can recommend
for hay fever. On questioning, he tells you that he has not had hay
fever before, but some of his friends get it and he thinks he has the
56 RESPIRATORY PROBLEMS
same thing. His eyes have been itching a little and are slightly watery,
and he has been sneezing for a few days. His nose has been runny and
now feels quite blocked. He will not be driving, but is a student at the
local sixth-form college and has exams coming up next week. He is
not taking any medicines.
The pharmacist’s view
This young man is experiencing the classic symptoms of hay fever for
the first time. The nasal symptoms are causing the most discomfort; he
has had rhinorrhoea and now has congestion so it would be reasonable
to recommend a corticosteroid nasal spray providing he is aged
18 or over. If he is under 18, an oral or topical antihistamine could be
recommended, bearing in mind that he is sitting for exams soon and so
any preparation that might cause drowsiness is best avoided. His eyes
are slightly irritated, but the symptoms are not very troublesome.
You know that he is not taking any other medicines, so you could
recommend acrivastine, loratadine or cetirizine. If the symptoms are
not better in a few days, he should see the doctor.
The doctor’s view
A corticosteroid nasal spray is likely to be more effective. If he cannot
use the OTC product because he is under 18, acrivastine, loratadine or
cetirizine would be worth a try. Even though they are generally nonsedating
they can cause drowsiness in some patients. The student
should be advised not to take his first dose just before the exam! If
his symptoms do not settle, then referral is appropriate. He may
benefit from sodium cromoglicate eye drops if his eye symptoms are
not fully controlled by the antihistamine. It is often worthwhile trying
an older antihistamine as an alternative because some people are
unaffected by the sedative properties, or an alternative non-sedating
one such as fexofenadine.
Case 2
Awoman in her early thirties wants some advice. She tells you that she
has hay fever and a blocked nose and is finding it difficult to breathe.
You find out that she has had the symptoms for a few days; they have
gradually got worse. She gets hay fever every summer and it is usually
controlled by chlorphenamine tablets, which she buys every year and
which she is taking at the moment. As a child, she suffered quite badly
from eczema and is still troubled by it occasionally. She tells you that
she has been a little wheezy for the past day or so, but she does not
have a cough, and has not coughed up any sputum. She is not taking
any other medicines.
ALLERGIC RHINITIS 57
The pharmacist’s view
This woman has a previous history of hay fever, which has, until now,
been dealt adequately with chlorphenamine tablets. Her symptoms
have worsened over a period of a few days and she is now wheezing. It
seems unlikely that she has a chest infection, which could have been a
possible cause of the symptoms. She should be referred to the doctor at
once since her symptoms suggest more serious implications such as
asthma.
The doctor’s view
This woman should be referred to her doctor directly. She almost
certainly has seasonal asthma. In addition to the hay fever treatment
recommended by her pharmacist, it is likely that she would also
benefit from a steroid inhaler such as beclometasone. Depending on
the severity of her symptoms, she would probably be prescribed a
beta-agonist, such as a salbutamol inhaler, as well. This consultation is
a complex one for a doctor to manage in the usual 10 min available in
view of the time required for: information-giving, explanation about
the nature of the problem, the rationale for the treatments and the
technique of using inhalers.
58 RESPIRATORY PRO

Sore throat

Most people with a sore throat do not consult the doctor – only about
5% do so and many will consult their pharmacist. Most sore throats
that present in the pharmacy will be caused by viral infection (90%),
with only one in ten being due to bacterial infection, so that treatment
with antibiotics is unnecessary in most cases. Clinically it is almost
impossible to differentiate between the two. The majority of infections
are self-limiting. Sore throats are often associated with other symptoms
of a cold.
Once the pharmacist has excluded more serious conditions, an
appropriate OTC medicine can be recommended.
What you need to know
Age (approximate)
Baby, child, adult
Duration
Severity
Associated symptoms
Cold, congested nose, cough
Difficulty in swallowing
Hoarseness
Fever
Previous history
Smoking habit
Present medication
Significance of questions and answers
Age
Establishing who the patient is will influence the choice of treatment
and whether referral is necessary. Streptococcal (bacterial) throat
infections are more likely in children of school age.
Duration
Most sore throats are self-limiting and will be better within 7–10 days.
If it has been present for longer, then the patient should be referred to
the doctor for further advice.
SORE THROAT 41
Severity
If the sore throat is described as being extremely painful, especially in
the absence of cold, cough and catarrhal symptoms, then referral
should be recommended when there is no improvement within
24–48 h.
Associated symptoms
Cold, catarrh and cough may be associated with a sore throat. There
may also be a fever and general aches and pains. These are in keeping
with a minor self-limiting viral infection.
Hoarseness of longer than 3 weeks’ duration and difficulty in
swallowing (dysphagia) are both indications for referral.
Previous history
Recurrent bouts of infection (tonsillitis) would mean that referral is
best.
Smoking habit (see also ‘Smoking cessation’)
Smoking will exacerbate a sore throat and if the patient smokes it can
be a good time to offer advice and information about quitting. Surveys
indicate that two-thirds of people who smoke want to stop.
Present medication
The pharmacist should establish whether any medication has been
tried already to treat the symptoms. If one or more medicines have
been tried without improvement, then referral to the doctor should
be considered.
Current prescriptions are important and the pharmacist should
question the patient carefully about them. Steroid inhalers (e.g. beclometasone
(beclomethasone) or budesonide) can cause hoarseness and
candidal infections of the throat and mouth. Generally they tend to do
this at high doses. Such infections can be prevented by rinsing the
mouth with water after using the inhaler. It is also worthwhile
checking the patient’s inhaler technique. Poor technique with
metered-dose inhalers can lead to large amounts of the inhaled drug
being deposited at the back of the throat. If you suspect this is the
problem, discuss with the doctor whether a device that will help
coordination or perhaps a different inhaler might be needed.
Any patient taking carbimazole and presenting with a sore throat
should be referred immediately. A rare side-effect of carbimazole is
agranulocytosis (suppression of white cell production in the bone
marrow). The same principle applies to any drug that can cause
42 RESPIRATORY PROBLEMS
agranulocytosis. A sore throat in such patients can be the first sign of a
life-threatening infection.
Symptoms for direct referral
Hoarseness
Hoarseness is caused when there is inflammation of the vocal cords in
the larynx (laryngitis). Laryngitis is typically caused by a self-limiting
viral infection. It is usually associated with a sore throat and a hoarse,
diminished voice. Antibiotics are of no value and symptomatic advice
(see ‘Management’ below), which includes resting the voice, should be
given. The infection usually settles within a few days and referral is
not necessary.
When this infection occurs in babies, infants or small children, it
can cause croup (acute laryngotracheitis) and present difficulty in
breathing and stridor (see p. 31). In this situation referral is essential.
When hoarseness persists for more than 3 weeks, especially when
it is not associated with an acute infection, referral is necessary. There
are many causes of persistent hoarseness, some of which are serious.
For example, laryngeal cancer can present in this way and hoarseness
may be the only early symptom. A doctor will normally refer
the patient to a ear, nose and throat (ENT) specialist for accurate
diagnosis.
Dysphagia
Difficulty in swallowing can occur in severe throat infection. It can
happen when an abscess develops in the region of the tonsils (quinsy)
as a complication of tonsillitis. This will usually result in a hospital
admission where an operation to drain the abscess may be necessary
and high-dose parenteral antibiotics may be given.
Glandular fever (infectious mononucleosis) is one viral cause of sore
throat that often produces marked discomfort and may cause dysphagia.
If this is suspected, referral is necessary for an accurate diagnosis.
Most bad sore throats will cause discomfort on swallowing but not
true difficulty and do not necessarily need referral unless there are
other reasons for concern. Dysphagia, when not associated with a sore
throat, always needs referral (see p. 73).
Appearance of throat
It is commonly thought that the presence of white spots, exudates
or pus on the tonsils is an indication for referral or a means of
differentiating between viral and bacterial infection, but this is not
always so. Unfortunately the appearance can be the same in both types
SORE THROAT 43
of infection and sometimes the throat can appear almost normal
without exudates in a streptococcal (bacterial) infection.
Thrush
An exception not to be forgotten is candidal (thrush) infection that
produces white plaques. However, these are rarely confined to the
throat alone and are most commonly seen in babies or the very elderly.
It is an unusual infection in young adults and may be associated with
more serious disorders that interfere with the body’s immune system,
e.g. leukaemia, HIV and acquired immune deficiency syndrome
(AIDS), or with immunosuppressive therapy (e.g. steroids). The
plaques may be seen in the throat and on the gums and tongue.
When they are scraped off, the surface is raw and inflamed. Referral
is advised if thrush is suspected and the throat is sore and painful. See
p. 304 for more information about oral thrush.
Glandular fever
Glandular fever is a viral throat infection caused by the Epstein–Barr
virus (EBV). It is well known because of its tendency to leave its victims
debilitated for some months afterwards and its association with the
controversial condition myalgic encephalomyelitis (ME). The infection
typically occurs in teenagers and young adults, with peak incidence
between the ages of 14 and 21. It is known as the ‘kissing disease’!
A severe sore throat may follow 1 or 2 weeks of general malaise. The
throat may become very inflamed with creamy exudates present. There
may be difficulty in swallowing because of the painful throat. Glands
(lymph nodes) in the neck and axillae (armpits) may be enlarged and
tender. The diagnosis can be confirmed with a blood test, although this
may not become positive until 1 week after the onset of the illness.
Antibiotics are of no value; in fact if ampicillin is given during the
infection, a measles-type rash is likely to develop in 80% of those with
glandular fever. Treatment is aimed at symptomatic relief.
When to refer
Sore throat lasting 1 week or more
Recurrent bouts of infection
Hoarseness of more than 3 weeks’ duration
Difficulty in swallowing (dysphagia)
Failed medication
44 RESPIRATORY PROBLEMS
Treatment timescale
Patients should see their doctor in 1 week if the sore throat has not
improved.
Management
Most sore throats are caused by viral infections and are self-limiting
in nature with 90% of patients becoming well within 1 week of the
onset of symptoms. The pharmacist can offer a selection of treatments
aimed at providing some relief from discomfort and pain until
the infection subsides. Oral analgesics are first-line. A systematic
review found that simple analgesics (paracetamol, aspirin and
ibuprofen) are very effective at reducing the pain from sore
throat. Lozenges and pastilles have a soothing effect. There is some
evidence that benzydamine spray is effective in relieving sore throat
pain.
Oral analgesics
Paracetamol, aspirin and ibuprofen have been shown in clinical trials
to provide rapid and effective relief of pain in sore throat. A systematic
review showed no benefit of adding other analgesic constituents. The
patient can be advised to take the analgesic regularly to sustain pain
relief. (For a discussion of doses, side-effects, cautions and contraindications
for simple analgesics, see p. 201.) Flurbiprofen lozenges were
reclassified from POM to P for sore throat for adults and children
aged 12 and over. They contain 8.75 mg of flurbiprofen and one
lozenge is sucked or dissolved in the mouth every 3–6 h as required,
to a maximum of five lozenges. Flurbiprofen lozenges can be used for
up to 3 days at a time.
Mouthwashes and sprays
Anti-inflammatory (e.g. benzydamine)
Benzydamine is an anti-inflammatory agent that is absorbed through
the skin and mucosa and has been shown to be effective in reducing
pain and inflammation in conditions of the mouth and throat. Sideeffects
have occasionally been reported and include numbness and
stinging of the mouth and throat. Benzydamine spray can be used in
children of 6 years and over, whereas the mouthwash may only be
recommended for children over 12.
SORE THROAT 45
Local anaesthetic (e.g. benzocaine)
Benzocaine and lidocaine are available in throat sprays.
Lozenges and pastilles
Lozenges and pastilles can be divided into three categories:
antiseptic (e.g. cetylpyridinium)
antifungal (e.g. dequalinium)
local anaesthetic (e.g. benzocaine).
Lozenges and pastilles are commonly used OTC treatments for sore
throats and, where viral infection is the cause, the main use of antibacterial
and antifungal preparations is to soothe and moisten the
throat. Lozenges containing cetylpyridinium chloride have been
shown to have antibacterial action.
Local anaesthetic lozenges will numb the tongue and throat and can
help to ease soreness and pain. Benzocaine can cause sensitisation and
such reactions have sometimes been reported.
Caution. Iodised throat lozenges should be avoided in pregnancy
because they have the potential to affect the thyroid gland of the fetus.
Practical points
Diabetes
Mouthwashes and gargles are suitable and can be recommended.
Sugar-free pastilles are available but the sugar content of such products
is not considered important in short-term use.
Mouthwashes and gargles
Patients should be reminded that mouthwashes and gargles should not
be swallowed. The potential toxicity of OTC products of this type is
low and it is unlikely that problems would result from swallowing
small amounts. However, there is a small risk of systemic toxicity from
swallowing products containing iodine. Manufacturers’ recommendations
about whether to use the mouthwash diluted or undiluted should
be checked and appropriate advice given to the patient.
Sore throats in practice
Case 1
A woman asks your advice about her son’s very sore throat. He is 15
years old and is at home in bed. She says he has a temperature and that
she can see creamy white matter at the back of his throat. He seems
lethargic and hasn’t been eating very well because his throat has been
so painful. The sore throat started about 5 days ago and he has been in
bed since yesterday. The glands on his neck are swollen.
46 RESPIRATORY PROBLEMS
The pharmacist’s view
It would be best for this woman’s son to be seen by the doctor. The
symptoms appear to be severe and he is ill enough to be in bed.
Glandular fever is common in this age group and is a possibility. In
the meantime you might consider recommending some paracetamol in
soluble or syrup form to make it easier to swallow. The analgesic and
antipyretic effects would both be useful in this case.
The doctor’s view
The pharmacist is sensible in recommending referral. The description
suggests a severe tonsillitis, which will be caused by either a bacterial or
viral infection. If it turns out to be viral, then glandular fever is a strong
possibility. The doctor should check out the ideas, concerns and expectations
of the mother and son and then explain the likely causes and
treatment. Often it is not possible to rule out a bacterial (streptococcal)
infection at this stage and it is safest to prescribe oral penicillin, or
erythromycin if the patient is allergic to penicillin. Depending on the
availability of laboratory services, the doctor may take a throat swab,
which would identify a bacterial infection. If the infection has gone on
for nearly 1 week, then a blood test can identify infectious mononucleosis
(glandular fever). Although there is no specific treatment for
glandular fever, it is helpful for the patient to know what is going on
and when to expect full recovery.
Case 2
A teenage girl comes into your shop with her mother. The girl has a
sore throat which started yesterday. There is slight reddening of the
throat. Her mother tells you she had a slight temperature during the
night. She also has a blocked nose and has been feeling general aching.
She has no difficulty in swallowing and is not taking any medicines,
either prescribed or OTC.
The pharmacist’s view
It sounds as though this girl has a minor URTI. The symptoms
described should remit within a few days. In the meantime, it would
be reasonable to recommend a systemic analgesic, perhaps in combination
with a decongestant.
The doctor’s view
The pharmacist’s assessment sounds correct. Because she has a
blocked nose, a viral infection is most likely. Many patients attend
their doctor with similar symptoms understandably hoping for a quick
cure with antibiotics, which have no place in such infections.
SORE THROAT 47
Case 3
A middle-aged woman comes to ask your advice about her husband’s
bad throat. He has had a hoarse gruff voice for about 1 month and has
tried various lozenges and pastilles without success. He has been a
heavy smoker (at least a pack a day) for over 20 years and works as
a bus driver.
The pharmacist’s view
This woman should be advised that her husband should see his doctor.
The symptoms that have been described are not those of a minor
throat infection. On the basis of the long duration of the problem
and of the unsuccessful use of several OTC treatments, it would be
best for this man to see his doctor for further investigation.
The doctor’s view
A persistent alteration in voice, with hoarseness, is an indication for
referral to an ENT specialist. This man should have his vocal cords
examined, which requires skill and special equipment that most family
doctors do not have. It is possible he may have a canceron his vocal
cords (larynx), especially as he is a smoker.

Cough

Coughing is a protective reflex action caused when the airway is being
irritated or obstructed. Its purpose is to clear the airway so that
breathing can continue normally. The majority of coughs presenting
in the pharmacy will be caused by a viral URTI. They will often
be associated with other symptoms of a cold. The evidence to support
the use of cough suppressants and expectorants is not strong but some
patients report finding them helpful.
What you need to know
Age (approximate)
Baby, child, adult
Duration
Nature
Dry or productive
Associated symptoms
Cold, sore throat, fever
Sputum production
Chest pain
Shortness of breath
Wheeze
Previous history
Chronic bronchitis
Asthma
Diabetes
Heart disease
Gastro-oesophageal reflux
Smoking habit
Present medication
Significance of questions and answers
Age
Establishing who the patient is – child or adult – will influence the
choice of treatment and whether referral is necessary.
COUGH 29
Duration
Most coughs are self-limiting and will be better within a few days with
or without treatment. In general, a cough of longer than 2 weeks’
duration that is not improving should be referred to the doctor for
further investigation.
Patients are often concerned when a cough has lasted for, what
seems to them to be, a long time. They may be worried that because
the cough has not resolved, it may have a serious cause.
Nature of cough
Unproductive (dry, tickly or tight)
In an unproductive cough no sputum is produced. These coughs are
usually caused by viral infection and are self-limiting.
Productive (chesty or loose)
Sputum is normally produced. It is an oversecretion of sputum that
leads to coughing. Oversecretion may be caused by irritation of the
airways due to infection, allergy, etc. or when the cilia are not working
properly (e.g. in smokers). Non-coloured (clear or whitish) sputum is
uninfected and known as mucoid.
Coloured sputum may sometimes indicate a bacterial chest infection
such as bronchitis or pneumonia and require referral. In these
situations the sputum is described as green, yellow or rust-coloured
thick mucus and the patient is more unwell usually with a raised
temperature, shivers and sweats. Sometimes blood may be present in
the sputum (haemoptysis), with a colour ranging from pink to deep
red. Blood may be an indication of a relatively minor problem such as
a burst capillary following a bout of violent coughing during an acute
infection, but may be a warning of more serious problems. Haemoptysis
is an indication for referral.
Antibacterials/antibiotics are not usually indicated for previously
healthy people with acute bronchitis. Most cases of acute bronchitis
are caused by viral infections, so antibacterials will not help. Two
systematic reviews of antibacterials for acute bronchitis found only
slight benefit, possibly reducing the duration of illness by about half a
day. Some people who have a tendency towards asthma develop a
wheezy bronchitis with a respiratory viral infection. They may benefit
from inhalation treatment used in asthma.
If a person has had repeated episodes of bronchitis over the years
they might have chronic bronchitis (defined as a chronic cough and/or
mucus production for at least 3 months in at least 2 consecutive years
when other causes of chronic cough have been excluded). So careful
questioning is important to determine this.
30 RESPIRATORY PROBLEMS
There is general consensus that antibacterials should be considered
if the person is elderly, has reduced resistance to infection, has
co-morbidity (such as diabetes or heart failure) or is deteriorating
clinically.
In heart failure and mitral stenosis the sputum is sometimes described
as pink and frothy or can be bright red. Confirming symptoms would
be breathlessness (especially in bed during the night) and swollen
ankles.
Tuberculosis (TB)
Until recently thought of as a disease of the past, the number of TB
cases has been rising in the UK and there is increasing concern about
resistant strains. Chronic cough with haemoptysis associated with
chronic fever and night sweats are classical symptoms. TB is largely
a disease of poverty and more likely to present in disadvantaged
communities. In the UK most cases of respiratory TB are seen in ethnic
minority groups, especially Indian and Africans. Human immunodeficiency
virus (HIV) infection is a significant risk factor for the development
of respiratory TB.
Croup (acute laryngotracheitis)
Croup usually occurs in infants. The cough has a harsh barking
quality. It develops 1 day or so after the onset of coldlike symptoms.
It is often associated with difficulty in breathing and an inspiratory
stridor (noise in throat on breathing in). Referral is necessary.
Whooping cough (pertussis)
Whooping cough starts with catarrhal symptoms. The characteristic
whoop is not present in the early stages of infection. The whoop is the
sound produced when breathing in after a paroxysm of coughing.
The bouts of coughing prevent normal breathing and the whoop
represents the desperate attempt to get a breath. Referral is necessary.
Associated symptoms
Cold, sore throat and catarrh may be associated with a cough. Often
there may be a temperature and generalised muscular aches present.
This would be in keeping with a viral infection and be self-limiting.
Chest pain, shortness of breath or wheezing are all indications for
referral (see p. 59).
Postnasal drip
Postnasal drip is a common cause of coughing and may be due to
sinusitis (see p. 199).
COUGH 31
Previous history
Certain cough remedies are best avoided in diabetics and anyone with
heart disease or hypertension (see pp. 36–7).
Chronic bronchitis
Questioning may reveal a history of chronic bronchitis, which is being
treated by the doctor with antibiotics. In this situation further treatment
may be possible with an appropriate cough medicine.
Asthma
A recurrent night-time cough can indicate asthma, especially in
children, and should be referred. Asthma may sometimes present as
a chronic cough without wheezing. A family history of eczema, hay
fever and asthma is worth asking about. Patients with such a family
history appear to be more prone to extended episodes of coughing
following a simple URTI.
Cardiovascular
Coughing can be a symptom of heart failure (see p. 60). If there is
a history of heart disease, especially with a persisting cough, then
referral is advisable.
Gastro-oesophageal
Gastro-oesophageal reflux can cause coughing. Sometimes such reflux
is asymptomatic apart from coughing. Some patients are aware of acid
coming up into their throat at night when they are in bed.
Smoking habit (see also ‘Smoking cessation’)
Smoking will exacerbate a cough and can cause coughing since it is
irritating to the lungs. One in three long-term smokers develop a
chronic cough. If coughing is recurrent and persistent, the pharmacist
is in a good position to offer health education advice about the
benefits of stopping smoking, suggesting NRT where appropriate.
However, on stopping, the cough may initially become worse as the
cleaning action of the cilia is re-established during the first few days
and it is worth mentioning this. Smokers may assume their cough is
harmless, and it is always important to ask about any change in the
nature of the cough that might suggest a serious cause.
Present medication
It is always essential to establish which medicines are currently being
taken. This includes those prescribed by a doctor and any bought
OTC, borrowed from a friend or neighbour or rediscovered in the
32 RESPIRATORY PROBLEMS
family medicine chest. It is important to remember the possibility of
interactions with cough medicine.
It is also useful to know which cough medicines have been
tried already. The pharmacist may decide that an inappropriate
preparation has been taken, e.g. a cough suppressant for a productive
cough. If one or more appropriate remedies have been tried
for an appropriate length of time without success, then referral is
advisable.
Angiotensin-converting enzyme (ACE) inhibitors
Chronic coughing may occur in patients, particularly women,
taking ACE inhibitors such as enalapril, captopril, lisinopril and
ramipril. Patients may develop the cough within days of starting
treatment or after a period of a few weeks or even months. The
exact incidence of the reaction is not known and estimates vary
from 2% to 10% of patients taking ACE inhibitors. ACE inhibitors
control the breakdown of bradykinin and other kinins in the
lungs, which can trigger a cough. Typically the cough is irritating,
non-productive and persistent. Any ACE inhibitor may induce
coughing and there seems to be little advantage to be gained
in changing from one to another. The cough may resolve or may
persist; in some patients the cough is so troublesome and distressing
that ACE inhibitor therapy may have to be discontinued. Any patients
in whom medication is suspected as the cause of a cough should be
referred to their doctor. Angiotensin 2 receptor antagonists, which
have similar properties to ACE inhibitors and which do not affect
bradykinin, can be used as an alternative preparation if cough is
a problem.
When to refer
Cough lasting 2 weeks or more and not improving
Sputum (yellow, green, rusty or blood-stained) (for further details, see p. 61)
Chest pain
Shortness of breath
Wheezing
Whooping cough or croup
Recurrent nocturnal cough
Suspected adverse drug reaction
Failed medication
After a series of questions the pharmacist should be in a position to
decide whether treatment or referral is the best option.
COUGH 33
Treatment timescale
Depending on the length of time the patient has had the cough and
once the pharmacist has recommended an appropriate treatment,
patients should see their doctor 2 weeks after the cough started if it
has not improved.
Management
Pharmacists are well aware of the debate about the clinical efficacy of
the cough remedies available OTC. In particular, the lack of scientific
evidence that expectorants have any effect and the use of combinations
with apparently contradictory ingredients have been cited.
However, many people who visit the pharmacy for advice do so
because they want some relief from their symptoms and, while the
effectiveness of cough remedies remains unproven, they can have a
useful placebo effect.
The choice of treatment depends on the type of cough. Suppressants
(e.g. pholcodine) are used to treat unproductive coughs, while expectorants
such as guaifenesin (guaiphenesin) are used in the treatment of
productive coughs. The pharmacist should check that the preparation
contains an appropriate dose, since some products contain subtherapeutic
amounts. Demulcents like Simple Linctus that soothe the throat
are particularly useful in children and pregnant women as they contain
no active ingredients.
The BNF gives the following guidance.
Expectorants: A simple expectorant mixture may serve a useful
placebo function and is inexpensive.
Suppressants: Where there is no identifiable cause (underlying disorder),
cough suppressants may be useful; e.g. if sleep is disturbed.
Demulcents: Preparations such as simple linctus have the advantage
of being harmless and inexpensive. Paediatric simple linctus is particularly
useful in children, and sugar-free versions are available.
Productive coughs should not be treated with cough suppressants
because the result is pooling and retention of mucus in the lungs and a
higher chance of infection, especially in chronic bronchitis.
There is no logic in using expectorants (which promote coughing)
and suppressants (which reduce coughing) together as they have opposing
effects. Therefore, products that contain both are not therapeutically
sound.
Cough suppressants
Controlled trials have not confirmed any significant effect of cough
suppressants over placebo in symptom reduction.
34 RESPIRATORY PROBLEMS
Codeine/pholcodine
Pholcodine has several advantages over codeine in that it produces
fewer side-effects (even at OTC doses codeine can cause constipation
and, at high doses, respiratory depression) and pholcodine is less liable
to be abused. For these reasons, codeine is best avoided in the treatment
of children’s coughs and should never be used in children under
1 year. Both pholcodine and codeine can induce drowsiness, although
in practice this does not appear to be a problem. Nevertheless, it is
sensible to give an appropriate warning. Codeine is well known as a
drug of abuse and many pharmacists choose not to recommend it.
Sales often have to be refused because of knowledge or likelihood of
abuse. Pholcodine can be given at a dose of 5 mg to children over
2 years of age (5 mg of pholcodine is contained in 5 ml of pholcodine
linctus BP). Adults may take doses of up to 15 mg three or four times
daily. The drug has a long half-life and may be more appropriately
given as a twice-daily dose.
Dextromethorphan
Dextromethorphan is less potent than pholcodine and codeine. It is
generally non-sedating and has few side-effects. Occasionally, drowsiness
had been reported but, as for pholcodine, this does not seem to be
a problem in practice. Dextromethorphan can be given to children
of 2 years and over. Dextromethorphan was generally thought to have
a low potential for abuse. However, there have been rare reports of
mania following abuse and consumption of very large quantities,
and pharmacists should be aware of this possibility if regular purchases
are made.
Demulcents
Preparations such as glycerin, lemon and honey or Simple Linctus are
popular remedies and are useful for their soothing effect. They do not
contain any active ingredient and are considered to be safe in children
and pregnant women. Their pleasant taste makes them particularly
suitable for children but their high syrup content should be noted.
Expectorants
Two mechanisms have been proposed for expectorants. They may act
directly by stimulating bronchial mucus secretion, leading to increased
liquefying of sputum, making it easier to cough up. Alternatively, they
may act indirectly via irritation of the gastrointestinal (GI) tract,
which has a subsequent action on the respiratory system resulting
in increased mucus secretion. This latter theory has less convincing
evidence than the former to support it.
COUGH 35
Guaifenesin (guaiphenesin)
Guaifenesin is commonly found in cough remedies. In adults, the dose
required to produce expectoration is 100–200 mg, so in order to have
a theoretical chance of effectiveness, any product recommended
should contain a sufficiently high dose. Some OTC preparations contain
subtherapeutic doses. In the USA, the Food and Drugs Administration
(FDA, the licensing body) reviewed OTC medicines, and
evidence from studies supporting guaifenesin was sufficiently strong
for the FDA to be convinced of its efficacy.
Cough remedies: other constituents
Antihistamines
Examples used in OTC products include diphenhydramine and
promethazine. Theoretically these reduce the frequency of coughing
and have a drying effect on secretions, but in practice they also induce
drowsiness. Combinations of antihistamines with expectorants are
illogical and best avoided. A combination of an antihistamine and a
cough suppressant may be useful in that antihistamines can help to dry
up secretions and, when the combination is given as a night-time dose
if the cough is disturbing sleep, a good night’s sleep will invariably
follow. This is one of the rare occasions when a side-effect proves
useful. The non-sedating antihistamines are less effective in symptomatic
treatment of coughs and colds because of their less pronounced
anticholinergic actions.
Interactions. Traditional antihistamines should not be used by patients
who are taking phenothiazines and tricyclic antidepressants because
of additive anticholinergic and sedative effects. Increased sedation will
also occur with any drug that has a CNS depressant effect. Alcohol
should be avoided because this will also lead to increased drowsiness.
See p. 23–4 for more details of interactions, side-effects and contraindications
of antihistamines.
Sympathomimetics
Pseudoephedrine is the most commonly used oral decongestant included
in cough and cold remedies (see also p. 21) for its bronchodilatory
and decongestant actions. It has a stimulant effect that may lead
to a sleepless night if taken close to bedtime. It may be useful if the
patient has a blocked nose as well as a cough and an expectorant/
decongestant combination can be useful in productive coughs. Sympathomimetics
can cause raised blood pressure, stimulation of the
heart and alterations in diabetic control. Oral sympathomimetics
should be used with caution in patients with
36 RESPIRATORY PROBLEMS
diabetes
coronary heart disease (e.g. angina)
hypertension
hyperthyroidism
Interactions. Sympathomimetics should be avoided by patients taking
monoamine oxidase inhibitors (e.g. phenelzine)
reversible inhibitors of monoamine oxidase A (e.g. moclobemide)
beta-blockers
tricylic antidepressants (e.g. amitriptyline); a theoretical interaction
which does not seem to cause problems in practice.
Theophylline
Theophylline is sometimes included in cough remedies for its bronchodilator
effect. OTC medicines containing theophylline should
not be taken at the same time as prescribed theophylline since
toxic blood levels and side-effects may occur. The action of theophylline
can be potentiated by some drugs, e.g. cimetidine and
erythromycin.
Levels of theophylline in the blood are reduced by smoking and
drugs such as carbamazepine, phenytoin and rifampicin that induce
liver enzymes, so that the metabolism of theophylline is increased and
lower serum levels result.
Side-effects include GI irritation, nausea, palpitations, insomnia and
headaches. The adult dose is typically 120 mg three or four times daily.
It is not recommended in children. Before selling any OTC product
containing theophylline, check that the patient is not already taking
the drug on prescription.
Practical points
Diabeties
In short-term acute conditions the amount of sugar in cough medicines
is relatively unimportant. Diabetic control is often upset during infections
and the additional sugar is not now considered to be a major
problem. Nevertheless, many diabetic patients may prefer a sugar-free
product, as will many other customers who wish to reduce sugar
intake for themselves and their children, and many such products
are now available. As part of their contribution to improving dental
health, pharmacists can ensure that they stock and display a range of
sugar-free medicines.
Steam inhalations
These can be useful, particularly in productive coughs. Some clinical
trials indicate benefit and none have found any harm. The steam helps
COUGH 37
to liquefy lung secretions and patients find the warm moist air comforting.
While there is no evidence that the addition of medications to
the water produces a better clinical effect than steam alone, some may
prefer to add a preparation such as menthol and eucalyptus or a
proprietary inhalant. One teaspoonful of inhalant should be added
to a pint of hot (not boiling) water and the steam inhaled. Apart from
the risk of scalding, boiling water volatilises the constituents too
quickly. A cloth or towel can be put over the head to trap the steam.
Fluid intake
Maintaining a high fluid intake helps to hydrate the lungs and
hot drinks can have a soothing effect. General advice to patients
with coughs and colds should be to increase fluid intake by around
2 L a day.
Coughs in practice
Case 1
Mrs Patel, a woman in her early twenties, asks what you can recommend
for her son’s cough. On questioning you find out that her
son, Dillip, aged 4, has had a cough on and off for a few weeks. He
gets it at night and it is disturbing his sleep although he doesn’t seem
to be troubled during the day. She took Dillip to the doctor about
3 weeks ago, and the doctor explained that antibiotics were not
needed and that the cough would get better by itself. The cough is
not productive and she has given Dillip some Tixylix before he goes
to bed but the cough is no better. Dillip is not taking any other
medicines. He has no pain on breathing or shortness of breath. He
has had a cold recently.
The pharmacist’s view
This is a 4-year-old child who has a night-time cough of several weeks’
duration. The doctor’s advice was appropriate at the time Dillip saw
him. However, referral to the doctor would be advisable because the
cough is only present during the night. A recurrent cough in a child
at night can be a symptom of asthma, even if wheezing is not present.
It is possible that the cough is occurring as a result of bronchial
irritation following his recent viral URTI. Such a cough can last for
up to 6 weeks and is more likely to occur in those who have asthma or
a family history of atopy (a predisposition to sensitivity to certain
common allergens such as house dust mite, animal dander and pollen).
Nevertheless, the cough has been present for several weeks without
improvement and medical advice is needed.
38 RESPIRATORY PROBLEMS
The doctor’s view
Asthma is an obvious possibility. It would be interesting to know if
anyone else in the family suffers from asthma, hay fever or eczema and
whether Dillip has ever had hay fever or eczema. Any of these features
would make the diagnosis more likely. Mild asthma may present in
this way without the usual symptoms of shortness of breath and
wheezing.
An alternative diagnosis could still include a viral URTI. Most
coughs are more troublesome and certainly more obvious during the
night. This can falsely give the impression that the cough is only
nocturnal. It should also be remembered that both diagnoses could
be correct, as a viral infection often initiates an asthmatic reaction.
Because the diagnosis is uncertain and inhaled oral steroids may be
appropriate, referral to the doctor is advisable.
If, after further history-taking and examination, the doctor feels
that asthma is a possibility, then treatment would be based on the
British Thoracic Society guidelines, which are summarised in the BNF.
Naturally this would only be carried out after full discussion and
agreement with the parents. Many parents are loath to have their
child labelled as an asthma sufferer. The next problem is to prescribe
a suitable inhalation device for a 4-year-old child. This may be an
inhaler with a spacer device or a breath-actuated inhaler or a drypowder
inhaler. It would be usual to try a twice-daily dosage for 2–3
weeks and then review for future management.
The parent’s view
‘I was hoping the pharmacist could recommend something but she
seemed to think Dillip should see the doctor. She didn’t really explain
why though.’
Case 2
A man aged about 25 asks if you can recommend something for his
cough. He sounds as if he has a bad cold and looks a bit pale. You find
out that he has had the cough for a few days, with a blocked nose and
a sore throat. He has no pain on breathing or shortness of breath. The
cough was chesty to begin with but he tells you it is now tickly and
irritating. He has not tried any medicines and is not taking any
medicines from the doctor.
The pharmacist’s view
This patient has the symptoms of the common cold and none of
the danger signs associated with a cough that would make referral
necessary. He is not taking any medicines, so the choice of possible
COUGH 39
treatments is wide. You could recommend something to treat his
congested nose as well as his cough, e.g. a cough suppressant and a
sympathomimetic. Simple Linctus and a systemic or topical decongestant
would also be a possible option. If a topical decongestant were
to be recommended, he should be warned to use it for no longer than
1 week to avoid the possibility of rebound congestion.
The doctor’s view
The action suggested by the pharmacist is very reasonable. It may be
worthwhile explaining that he is suffering from a viral infection that is
self-limiting and should be better within a few days. If he is a smoker it
would be an ideal time to encourage him to stop.

Colds and flu

The common cold comprises a mixture of viral upper respiratory tract
infections (URTIs). Although colds are self-limiting, many people
choose to buy OTC medicines for symptomatic relief. Some of the
ingredients of OTC cold remedies may interact with prescribed therapy,
occasionally with serious consequences. Therefore, careful attention
needs to be given to taking a medication history and selecting an
appropriate product.
What you need to know
Age (approximate)
Child, adult
Duration of symptoms
Runny/blocked nose
Summer cold
Sneezing/coughing
Generalised aches/headache
High temperature
Sore throat
Earache
Facial pain/frontal headache
Flu
Asthma
Previous history
Allergic rhinitis
Bronchitis
Heart disease
Present medication
Significance of questions and answers
Age
Establishing who the patient is – child or adult – will influence the
pharmacist’s decision about the necessity of referral to the doctor and
choice of treatment. Children are more susceptible to URTI than
adults.
COLDS AND FLU 17
Duration
Patients may describe a rapid onset of symptoms or a gradual onset
over several hours; the former is said to be more commonly true of flu,
the latter of the common cold. Such guidelines are general rather than
definitive. The symptoms of the common cold usually last for 7–14
days. Some symptoms, such as a cough, may persist after the worst of
the cold is over.
Symptoms
Runny/blocked nose
Most patients will experience a runny nose (rhinorrhoea). This is
initially a clear watery fluid, which is then followed by the production
of thicker and more tenacious mucus (this may be purulent). Nasal
congestion occurs because of dilatation of blood vessels, leading to
swelling of the lining surfaces of the nose. This narrows the nasal
passages, which are further blocked by increased mucus production.
Summer colds
In summer colds the main symptoms are nasal congestion, sneezing
and irritant watery eyes; these are more likely to be due to allergic
rhinitis (see p. 49).
Sneezing/coughing
Sneezing occurs because the nasal passages are irritated and congested.
A cough may be present (see p. 29) either because the pharynx
is irritated (producing a dry, tickly cough) or as a result of irritation of
the bronchus caused by postnasal drip.
Aches and pains/headache
Headaches may be experienced because of inflammation and congestion
of the nasal passages and sinuses. A persistent or worsening
frontal headache (pain above or below the eyes) may be due to
sinusitis (see below and p. 199). People with flu often report muscular
and joint aches and this is more likely to occur with flu than with the
common cold (see below).
High temperature
Those suffering from a cold often complain of feeling hot, but in general
a high temperature will not be present. The presence of fever may be
an indication that the patient has flu rather than a cold (see below).
Sore throat
The throat often feels dry and sore during a cold and may sometimes
be the first sign that a cold is imminent (see p. 41).
18 RESPIRATORY PROBLEMS
Earache
Earache is a common complication of colds, especially in children.
When nasal catarrh is present, the ear can feel blocked. This is due to
blockage of the Eustachian tube, which is the tube connecting the
middle ear to the back of the nasal cavity. Under normal circumstances
the middle ear is an air-containing compartment. However, if the
Eustachian tube is blocked, the ear can no longer be cleared by
swallowing and may feel uncomfortable and deaf. This situation
often resolves spontaneously, but decongestants and inhalations can
be helpful (see ‘Management’ below). Sometimes the situation
worsens when the middle ear fills up with fluid. This is an ideal site
for a secondary infection to settle. When this does occur, the ear
becomes acutely painful and can require antibiotics. The infection is
called acute otitis media (AOM). AOM is a common infection in
young children. In the UK about 30% of children visit their GP with
AOM each year and 97% receive antibiotics. The evidence for antibiotic
use is conflicting with some trials showing benefit and others no
benefit for taking antibiotics. Antibiotics have also been shown to
increase the risk of vomiting, diarrhoea and rash, and it is known
that in about 80% of children AOM will resolve spontaneously in
about 3 days without antibiotics.
In summary, a painful ear can initially be managed by the pharmacist.
There is evidence that both paracetamol and ibuprofen are effective
treatments for AOM. However, if pain were to persist or be
associated with an unwell child (e.g. high fever, very restless or listless,
vomiting), then referral to the GP would be advisable.
Facial pain/frontal headache
Facial pain or frontal headache may signify sinusitis. Sinuses are
air-containing spaces in the bony structures adjacent to the nose
(maxillary sinuses) and above the eyes (frontal sinuses). In a cold
their lining surfaces become inflamed and swollen, producing catarrh.
The secretions drain into the nasal cavity. If the drainage passage
becomes blocked, fluid builds up in the sinus and can become secondarily
(bacterially) infected. If this happens, persistent pain arises in the
sinus areas. The maxillary sinuses are most commonly involved. When
the frontal sinuses are infected, the sufferer may complain of a frontal
(forehead) headache. The headache is typically worsened by lying
down or bending forwards.
Flu
Differentiating between colds and flu may be needed to make a decision
about whether referral is needed. Patients in ‘at-risk’ groups
COLDS AND FLU 19
might be considered for antiviral treatment. Flu is generally considered
to be likely if
. temperature is 388C or higher (37.58C in the elderly).
. a minimum of one respiratory symptom (cough, sore throat, nasal
congestion or rhinorrhoea) is present.
. a minimum of one constitutional symptom (headache, malaise, myalgia,
sweats/chills, prostration) is present.
Flu often starts abruptly with sweats and chills, muscular aches and
pains in the limbs, a dry sore throat, cough and high temperature.
Someone with flu may be bedbound and unable to go about usual
activities. There is often a period of generalised weakness and malaise
following the worst of the symptoms. A dry cough may persist for
some time.
True influenza is relatively uncommon compared to the large
number of flu-like infections that occur. Influenza is generally more
unpleasant, although both usually settle with no need for referral.
Flu can be complicated by secondary lung infection (pneumonia).
Complications are much more likely to occur in the very young, the
very old and those who have pre-existing heart or lung disease
(chronic bronchitis). Warning that complications are developing
may be given by a severe or productive cough, persisting high fever,
pleuritic-type chest pain (see p. 59) or delirium.
Asthma
Asthmatic attacks can be triggered by respiratory viral infections.
Most asthma sufferers learn to start or increase their usual medication
to prevent such an occurrence. However, if these measures fail, referral
is recommended.
Previous history
People with a history of chronic bronchitis (defined as a chronic cough
and or mucus production for at least 3 months in at least 2 consecutive
years when other causes of chronic cough have been excluded) may be
advised to see their doctor if they have a badcold or flu-like infection as it
often causes an exacerbation of their bronchitis. In this situation the
doctor is likely to increase the dose of inhaled anticholinergicsandbeta-2
agonists and prescribe a course of antibiotics. Certain medications are
best avoided in those with heart disease, hypertension and diabetes.
Present medication
The pharmacist must ascertain any medicines being taken by the
patient. It is important to remember that interactions might occur
with some of the constituents of commonly used OTC medicines.
20 RESPIRATORY PROBLEMS
If medication has already been tried for relief of cold symptoms
with no improvement and if the remedies tried were appropriate and
used for a sufficient amount of time, referral to the doctor might
occasionally be needed. In most cases of colds and flu, however,
OTC treatment will be appropriate.
When to refer
Earache not settling with analgesic (see above)
Facial pain/frontal headache
In the very young
In the very old
In those with heart or lung disease, e.g. chronic bronchitis
With persisting fever and productive cough
With delirium
With pleuritic chest pain (for further discussion see p. 59)
Asthma
Treatment timescale
Once the pharmacist has recommended treatment, patients should be
advised to see their doctor in 10–14 days if the cold has not improved.
Management
The use of OTC medicines in the treatment of colds and flu is widespread
and such products are heavily advertised to the public. There is
little doubt that appropriate symptomatic treatment can make the
patient feel better; the placebo effect also plays an important part
here. For some medicines used in the treatment of colds, particularly
older medicines, there is little evidence available from which to judge
effectiveness. The pharmacist’s role is to select appropriate treatment
based on the patient’s symptoms and available evidence, and taking
into account the patient’s preferences. Polypharmacy abounds in
the area of cold treatments and patients should not be overtreated.
The discussion of medicines that follows is based on individual
constituents; the pharmacist can decide whether a combination of
two or more drugs is needed.
Decongestants
Sympathomimetics
Sympathomimetics (e.g. pseudoephedrine) can be effective in reducing
nasal congestion. Nasal decongestants work by constricting the
COLDS AND FLU 21
dilated blood vessels in the nasal mucosa. The nasal membranes are
effectively shrunk, so that drainage of mucus and circulation of air
are improved and the feeling of nasal stuffiness is relieved. These
medicines can be given orally or applied topically. Tablets and syrups
are available, as are nasal sprays and drops. If nasal sprays/drops are
to be recommended, the pharmacist should advise the patient not to
use the product for longer than 7 days. Rebound congestion (rhinitis
medicamentosa) can occur with topically applied but not oral sympathomimetics.
The decongestant effects of topical products containing
oxymetazoline or xylometazoline are longer lasting (up to 6 h)
than those of some other preparations such as ephedrine. The pharmacist
can give useful advice about the correct way to administer nasal
drops and sprays.
Problems
The pharmacist should be aware that some of these drugs
(e.g. ephedrine, pseudoephedrine), when taken orally, have the potential
to keep patients awake because of their stimulating effects on the
central nervous system (CNS). In general, ephedrine is more likely to
produce this effect than the other sympathomimetics. It is reasonable
to suggest that the patient avoids taking a dose of the medicine near
bedtime.
Sympathomimetics can cause stimulation of the heart, an increase
in blood pressure, and may affect diabetic control because they
can increase blood glucose levels. They should be used with caution
(current BNF warnings) in people with diabetes, those with
heart disease or hypertension, and those with hyperthyroidism. Hyperthyroid
patients’ hearts are more vulnerable to irregularity, so
that stimulation of the heart is particularly undesirable for such
patients.
Sympathomimetics are most likely to cause these unwanted effects
when taken by mouth and are unlikely to do so when used topically.
Nasal drops and sprays containing sympathomimetics can therefore
be recommended for those patients in whom the oral drugs are less
suitable. Saline nasal drops or the use of inhalations would be other
possible choices for patients in this group.
The interaction between sympathomimetics and monoamine
oxidase inhibitors (MAOIs) is potentially extremely serious; a hypertensive
crisis can be induced and several deaths have occurred in such
cases. This interaction can occur up to 2 weeks after a patient has
stopped taking the MAOI, so the pharmacist must establish any
recently discontinued medication. There is a possibility that topically
applied sympathomimetics could induce such a reaction in a patient
22 RESPIRATORY PROBLEMS
taking an MAOI. It is therefore advisable to avoid both oral and
topical sympathomimetics in patients taking MAOIs. Cautions:
diabetes
heart disease
hypertension
hyperthyroidism
Interactions. Avoid in those taking
MAOIs (e.g. phenelzine)
reversible inhibitors of monoamine oxidase A (RIMAs) (e.g.
moclobemide)
beta-blockers
tricyclic antidepressants (e.g. amitriptyline) – a theoretical interaction
that appears not to be a problem in practice.
Phenylpropanolamine and stroke
A study conducted in the USA showed an association between the
use of phenylpropanolamine (PPA) and haemorrhagic stroke. The
most significant increased risk in the US study was among women
who took PPA in appetite-suppressant products, which are not available
in the UK. It is important to note that there are differences
between the USA and the UK in the way PPA is used as a
non-prescription medicine. The maximum daily dose is 100 mg in
the UK compared with 150 mg in the USA. A review conducted by
the UK Committee on Safety of Medicines in 2000 concluded that
any risk associated with PPA use in preparations and doses used in the
UK appears to be very small. Nevertheless, most UK products
containing an oral decongestant have since been reformulated to
exclude PPA.
Antihistamines (see also p. 53)
Antihistamines can reduce some of the symptoms of a cold: runny nose
(rhinorrhoea) and sneezing. These effects are due to the anticholinergic
action of antihistamines. The older drugs (e.g. chlorphenamine
(chlorpheniramine), promethazine) have more pronounced anticholinergic
actions than do the non-sedating antihistamines (e.g. loratadine,
cetirizine, acrivastine). Antihistamines are not so effective
at reducing nasal congestion. Some (e.g. diphenhydramine) may also
be included in cold remedies for their supposed antitussive action
(see p. 36) or to help the patient to sleep (included in combination
products intended to be taken at night).
Interactions. The problem of using antihistamines, particularly
the older types (e.g. chlorphenamine), is that they can cause
COLDS AND FLU 23
drowsiness. Alcohol will increase this effect, as will drugs such as
benzodiazepines, phenothiazines or barbiturates that have the ability
to cause drowsiness or CNS depression. Antihistamines with known
sedative effects should never be recommended for anyone who
is driving, or in whom an impaired level of consciousness may be
dangerous (e.g. operators of machinery at work).
Because of their anticholinergic activity, the older antihistamines
may produce the same adverse effects as anticholinergic drugs (i.e. dry
mouth, blurred vision, constipation and urinary retention). These
effects are more likely if antihistamines are given concurrently
with anticholinergics such as hyoscine, or with drugs that have
anticholinergic actions such as tricyclic antidepressants.
Antihistamines should be avoided in patients with prostatic hypertrophy
and closed-angle glaucoma because of possible anticholinergic
side-effects. In patients with closed-angle glaucoma they may cause
increased intraocular pressure. Anticholinergic drugs can occasionally
precipitate acute urinary retention in predisposed patients, e.g. men
with prostatic hypertrophy.
While the probability of such serious adverse effects is low, the
pharmacist should be aware of the origin of possible adverse effects
from OTC medicines.
At high doses, antihistamines can produce stimulation rather than
depression of the CNS. There have been occasional reports of fits
being induced at very high doses of antihistamines and it is for this
reason that it has been argued that they should be avoided in epileptic
patients. However, this appears to be a theoretical rather than a
practical problem. Antihistamines can theoretically antagonise the
effects of betahistine.
Interactions:
alcohol
hypnotics
sedatives
betahistine
anticholinergics, e.g. trihexyphenidyl (benzhexol), tricyclics
Side-effects:
drowsiness (driving, occupational hazard)
constipation
blurred vision
Cautions:
closed-angle glaucoma
prostatic obstruction
24 RESPIRATORY PROBLEMS
epilepsy
liver disease
Zinc
Two systematic reviews have found limited evidence that zinc gluconate
or acetate lozenges may reduce continuing symptoms at 7 days
compared with placebo. Thus there is indication of some benefit.
Echinacea
A systematic review of trials indicated that some echinacea preparations
may be better than placebo or no treatment for the prevention
and treatment of colds. However, due to variations in preparations
containing echinacea, there is insufficient evidence to recommend
a specific product.
Vitamin C
A systematic review found that high-dose vitamin C (over 1 g per day)
reduced the duration of colds by about half a day (a reduction of
approximately 15% in duration).
Cough remedies
For discussion of products for the treatment of cough, see p. 34.
Analgesics
For details of analgesics, their uses and side-effects, see p. 201.
Products for sore throats
For discussion of products for the treatment of sore throat, see p. 45.
Practical points
Diabetics
The National Pharmaceutical Association and Diabetes UK jointly
publish a useful list of OTC products and their sugar and sweetener
content. In short-term use for acute conditions, the sugar content of
OTC medicines is less important.
Steam inhalations
These may be useful in reducing nasal congestion and soothing the air
passages, particularly if a productive cough is present. A systematic
review found there was insufficient evidence to judge whether there
might be a benefit from this treatment. For further discussion of
their use, see p. 37. Inhalants that can be used on handkerchiefs,
bedclothes and pillowcases are available. These usually contain
COLDS AND FLU 25
aromatic ingredients such as eucalyptus. Such products can be useful
in providing some relief but are not as effective as steam-based inhalations
in moistening the airways.
Nasal spray or drops?
Nasal sprays are preferable for adults and children over 6 years of age
because the small droplets in the spray mist reach a large surface area.
Drops are more easily swallowed, which increases the possibility of
systemic effects.
For children under 6 years of age drops are preferred because in
young children the nostrils are not sufficiently wide to allow
the effective use of sprays. Paediatric versions of nasal drops should
be used where appropriate. Manufacturers of paediatric drops advise
consultation with the doctor for children under 2.
Prevention of flu
Pharmacists should encourage those in at-risk groups to have an
annual flu vaccination. In the UK the health service now provides
vaccinations to all patients over 65 and those below that age who
have chronic respiratory disease (including asthma), chronic heart
disease, chronic renal failure, diabetes mellitus or immunosuppression
due to disease or treatment. Community pharmacists are in a good
position to use their PMRs to target patients each autumn and remind
them to have their vaccination.
Colds and flu in practice
Case 1
Mrs Allen, a regular customer in her late sixties, asks what you can
recommend for her husband. He has a very bad cold; the worst
symptoms are his blocked nose and sore throat. Although his throat
feels sore, she tells you there is only a slight reddening (she looked this
morning). He has had the symptoms since last night and is not feverish.
He does not have earache but has complained of a headache.
When you ask her if he is taking any medicines, she says yes, quite a
few for his heart. She cannot remember what they are called. You
check the PMR and find that he is taking aspirin 75 mg daily, ramipril
5 mg daily, bisoprolol 10 mg daily and simvastatin 40 mg daily.
Mrs Allen asks you if it’s worth her husband taking extra vitamin C
as she’s heard this is good for colds. She wondered if this might be
better than taking yet more medicines.
26 RESPIRATORY PROBLEMS
The pharmacist’s view
The patient’s symptoms indicate a cold rather than flu. He is
concerned most with his congested nose and sore throat. He is taking
a number of medications, which indicate that oral sympathomimetics
would be best avoided. You could recommend that he take regular
simple painkillers or suck a soothing lozenge or pastille for his sore
throat and that he try a topical decongestant or an inhalation to clear
his blocked nose. The symptoms may take about 1 week before they
start to clear. You offer these alternatives to Mrs Allen to see what she
thinks her husband might prefer. You explain that taking vitamin C
might reduce the time taken for the cold to get better by about half a
day. You show her some vitamin C products and tell her their cost.
You also ask if Mr Allen has had a flu jab as he is in an ‘at-risk’ group.
The doctor’s view
The advice given by the pharmacist is sensible. A simple analgesic such
as paracetamol could help both the headache and sore throat. The
development of sinusitis at such an early stage in an infection would
be unlikely but it would be wise to enquire whether his colds are
usually uncomplicated and to ascertain the site of his headache.
The patient’s view
‘I came to the pharmacist because we didn’t want to bother the doctor.
The pharmacist asked me about which symptoms were causing Pete
(my husband) the biggest problem and he gave me a choice of what to
use. I wanted to know what he thought about vitamin C and he told
me about how it might make the cold shorter. In the end though I
decided not to bother with it because it would have been quite expensive
with the other medicines as well, especially as it was unlikely to
make that much difference. I thought I would give him some fresh
orange juice instead.’
Case 2
A man comes into the pharmacy just after Xmas asking for some
cough medicine for his wife. He says that the medicine needs to be
sugar-free as his wife has diabetes. On listening to him further, he says
she has had a dreadful cough that keeps her awake at night. Her
problem came on 5 days ago when she woke in the morning, complaining
of being very achy all over and then became shivery, and
developed a high temperature and cough by the evening. Since then
her temperature has gone up and down and she hasn’t been well
enough to get out of bed for very long. She takes glipizide and
COLDS AND FLU 27
metformin for her diabetes and he has been checking her glucometer
readings, which have all been between 8 and 11 – a little higher than
usual. The only other treatment she is taking is atorvastatin; she is not
on any antihypertensives. He tells you that she will be 70 next year.
The pharmacist’s view
The history indicates flu. It would be best for this woman to be seen by
her GP. She has been ill for 5 days and has been mostly bedbound
during this time. There are several features that suggest she might be at
higher risk from flu. I would suggest that her husband call the doctor
out to see her, as she does not sound well enough to go to the surgery.
Sometimes people are reluctant to call the doctor as they feel they
might be ‘bothering’ the doctor unnecessarily. The pharmacist’s
support is often helpful.
The doctor’s view
The infection is likely to be flu. She is in the higher-risk group for
developing complications (age and diabetes), so it would be reasonable
to advise referral. Most cases of flu usually resolve within 7 days.
The complications can include acute otitis media, bacterial sinusitis,
bacterial pneumonia and less commonly, viral pneumonia and respiratory
failure. In the USA there are 110 000 admissions per year for
influenza with about 20 000 influenza-related deaths. Over 90% of
these deaths have been in those over 65.
In this situation the doctor would want to check her chest for signs
of a secondary infection. A persisting or worsening fever would point
to a complication developing. There would be little point in prescribing
an antiviral, e.g. zanamivir, as it is only effective if started within
2 days of symptom onset. One review has found it to be effective in
reducing the duration of flu symptoms by about 1 day if started soon
enough. It would also be advisable to check whether or not her
husband had had the flu vaccine. The incubation time for flu is 1–4
days and adults are contagious from the day before symptoms start
until 5 days after the onset of symptoms.