Patients require pharmacists' expert help to get symptomatic relief.
Yvette C. Terrie, BSPharm, RPh
For any individual suffering from a cold or the flu, getting symptomatic relief is a top priority. Fortunately, there are a plethora of OTC products available for alleviating the discomfort often associated with cold and flu symptoms, such as coughing, fever, chills, sore throat, nasal and chest congestion, sneezing, extreme fatigue, and aches. Pharmacists are in a pivotal position to assist patients in the proper selection and use of OTC cough, cold, and flu medications.
Cold vs Flu
Although colds may occur at any time, cold season in the United States lasts from late August through early April and is often considered to be one of the leading causes of absence from work and school.1,2 In general, the symptoms associated with the common cold appear within 1 to 3 days after incubation. Typically, patients may experience a sore throat initially, followed by sneezing, rhinorrhea, nasal congestion, headache, coughing, and malaise.1,2 Patients may also experience a low-grade fever; however, colds are rarely associated with a fever above 100ºF.1,2 The symptoms associated with colds typically last for 7 to 14 days. Patients should be advised to seek medical care if their symptoms persist or worsen or if they exhibit any signs of infection, such as a high fever, or nasal or respiratory secretions that are not clear.1
In the United States, the flu season generally occurs between October and May, with the peak of the season falling between late December and March.3 Flu symptoms usually come on quickly (within 3-6 hours) and consist of a fever, body aches, dry cough, and extreme tiredness.4 Table 1 provides an overview of the differences between cold and flu symptoms.
OTC Cough, Cold, and Flu Products
Nonprescription products currently available for the management of cough, cold, and flu symptoms include decongestants, antihistamines, expectorants, cough suppressants, and antipyretics/analgesics. OTC cough, cold, and flu products are available as single-entity products as well as combination products for multisymptom relief. When possible, the use of multiple ingredient products should be avoided to eliminate the unnecessary use of medications or therapeutic duplications. Some products are formulated for daytime and nighttime use as well.
In addition, there are various local anesthetic and antiseptic products for treating sore throats. A host of homeopathic/ alternative medications, such as echinacea and high-dose vitamin C and zinc, are commonly used by many individuals for the treatment of the common cold. There are also products formulated free of sugar, alcohol, dextrose, sucrose, sorbitol, sodium, fructose, glycerin, and dyes for the diabetic patient population, and products for those with hypertension that are decongestant-free.
Although traditional dosage forms, such as liquids, tablets, caplets, and capsules, are still widely used, product manufacturers have also developed unique product formulations, such as orally disintegrating tablets and strips, soft chew tablets, nasal swabs, nasal strips, and topical vapor patches. These formulations are designed to meet the needs of many patients by providing convenient administration, accurate dosing, and easy-to-use drug delivery systems to accommodate patients with dysphagia or those who prefer the convenience these formulations offer.
Local anesthetics such as benzocaine or dyclonine hydrochloride are often used for the temporary relief of pain associated with sore throat. OTC anesthetic products are formulated as lozenges, throat sprays, and medicated orally disintegrating strips, which may be used every 2 to 4 hours as needed. Some products also contain local antiseptics such as cetylpyridinium chloride or hexylresorcinol and/or camphor or menthol.1
Decongestants are indicated for the temporary relief of nasal and eustachian tube congestion and cough associated with postnasal drip.1 Available systemic OTC decongestants include pseudoephedrine and phenylephrine. Common adverse effects associated with the use of oral decongestants include insomnia, nervousness, and tachycardia. Patients with certain medical conditions who are sensitive to adrenergic stimulation (ie, hypertension, diabetes, coronary artery disease, prostatic hypertrophy, and elevated intraocular pressure)1 should avoid the use of decongestants.
While many medications are available as single-entity products, some contain a combination of an antihistamine and a decongestant for multisymptom therapy. Because antihistamines and decongestants interact with several medications and are contraindicated in various patient populations, such as those taking monoamine oxidase inhibitors,1 pharmacists should screen for possible drug interactions or contraindications prior to recommending these products.
Intranasal decongestants on the market include ephedrine, epinephrine, levmetamfetamine, naphazoline, tetrahydrozoline, and oxymetazoline. Patients should be reminded that the overuse of topical decongestants is associated with rhinitis medicamentosa (rebound congestion) and use should be limited to 3 to 5 days to avoid this condition.1
OTC Cough Products
Products available for treating cough include oral antitussives, expectorants, and topical antitussives. Several cough products, such as topical creams, ointments, lozenges, vapor inhalants, and patches, contain the antitussive ingredients camphor and menthol.7
Guaifenesin is the only FDA-approved expectorant, and is indicated for the symptomatic relief of acute ineffective productive cough.7 Although guaifenesin is not associated with any drug–drug interactions and is generally well tolerated, patients may report adverse effects such as nausea, vomiting, and gastrointestinal (GI) upset.7 Expectorants are available in various dosage forms, including liquids, syrups, granules, tablets, and liquid-filled capsules.
Codeine, dextromethorphan, and diphehydramine are the available FDAapproved OTC oral antitussives.7 At antitussive dosages, codeine is classified as a Schedule V narcotic and is available without a prescription in 30 states.7 Codeine is considered to be the “gold standard” antitussive and is indicated for the suppression of nonproductive cough.7 Codeine acts centrally on the medulla to increase the cough threshold. When used at antitussive doses, codeine has low toxicity and carries little risk of addiction.7
The majority of OTC cough suppressants contain dextromethorphan, which is indicated for the suppression of nonproductive cough caused by chemical or mechanical respiratory tract irritation.7 Examples of available dosage forms for dextromethorphan include syrups, liquids, suspensions, orally disintegrating medicated strips, liquid-filled gelcaps, granules, and lozenges. Nausea, vomiting, GI discomfort, dizziness, and constipation are the most common adverse effects associated with the use of dextromethorphan.7
Diphenhydramine is classified as a nonselective first-generation antihistamine. Although this agent is approved by the FDA as an antitussive, it is not considered a first-line antitussive. It acts centrally in the medulla to increase the cough threshold. 7 Diphenhydramine is also indicated for the suppression of nonproductive cough caused by chemical or mechanical respiratory tract irritation.
For pain relief, headache, and fever associated with the common cold and the flu, systemic analgesics are commonly used. Caution should be used in those patients with a history of GI upset or renal or hepatic impairment and those on pharmacologic agents that interact with OTC analgesics.1 Because many combination cough, cold, and flu products contain analgesics, such as aspirin, acetaminophen, ibuprofen, or naproxen, patients should be advised to always check the ingredients of cold medications to avoid therapeutic duplications, unnecessary drug use, possible drug–drug interactions, and contraindications.
Prior to recommending any cough, cold, or flu medications, pharmacists should always screen for potential allergy sensitivities, drug–drug interactions, and possible contraindications. Factors that may be considered when selecting products include the patient’s symptoms, concomitant medical conditions, allergy history, and current drug regimen, as well as lifestyle and personal preferences. It is important to ensure that patients are thoroughly counseled on the proper use of these products. To ensure accuracy, patients should be reminded to always utilize calibrated measuring devices when administering liquids and to read all labels prior to administration to ensure proper dosage. To prevent serious medication errors, patients should always be reminded to read labels carefully, adhere to package dosing and administration information, and check the expiration dates of products.
Parents/caregivers should only give children those products manufactured specifically for the pediatric population and should always consult their pediatrician or pharmacist when in doubt regarding the appropriateness or dose of the medication. In addition to assisting patients in the proper selection of cough, cold, and flu products, pharmacists can reinforce the importance of utilizing nonpharmacologic measures that may aid in the relief of cold and flu symptoms. These include the use of vaporizers or humidifiers, saline nasal sprays, or nonmedicated strips to relieve nasal congestion, as well as adequate hydration and rest.
Patients should also be encouraged to seek medical attention from their primary health care provider when warranted, especially if symptoms appear to worsen or linger or if patients experience high fever or show signs of infection.
When possible, patients should be reminded to get their annual flu vaccine, especially those patients on the Centers for Disease Control and Prevention recommendation list for the flu vaccine. Patients should also be reminded of preventative measures for potentially reducing or preventing the transmission of colds and flu, such as routine handwashing, use of hand sanitizers when soap and water are not available, avoiding direct contact with an individual with a cold, and always sneezing or coughing into a tissue and not into the hand.
Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.