Dr. Branham is a clinical instructor at the University of North Carolina Eshelman School of Pharmacy in Chapel Hill, North Carolina. Dr. Stefanie Ferreri is the director of the Community Pharmacy Residency Program at the University of North Carolina, Chapel Hill.
Mary, a 70-year-old woman, presents to the pharmacy counter complaining of a sore throat, cough, and runny nose. She asks the pharmacist, “What product would be best for me? There are so many choices.”
Although the common cold is often a self-limiting condition, patients frequently rely on OTC medications to lessen bothersome symptoms. The common cold is considered one of the top 5 diagnosed illnesses in the United States, with nearly 1 billion reported cases per year.1,2 Specifically, adults <60 years of age often experience approximately 2 to 4 colds annually, whereas adults >60 years of age typically have 1 cold per year.1
Given the widespread prevalence of common cold symptoms, coupled with the increasing number of available OTC cough and cold products, questions such as the one Mary asked may be commonly encountered in the pharmacy setting. In fact, without a pharmacist consultation, patients may select a selfcare product that is inappropriate or even potentially dangerous.
Common Cold Treatment Approach
Patients may present with symptoms of the common cold at any time throughout the year, although the “cold season” is considered to run from late August through early April.1 Because no cure currently exists, treatment goals should include reducing symptoms, improving daily functioning, and preventing the spread of disease to others.3
Back to the patient case: it is possible that Mary may have a contraindication to many of the products available in the OTC aisle. A pharmacist may not always recognize these contraindications by quickly selecting a product based on symptoms alone. Therefore, it is imperative for pharmacists to accurately assess the patient by asking about the chief complaint and gather other essential background information, such as medications and medical conditions the patient may have. If the patient is deemed a self-care candidate, then the pharmacist can formulate an individualized treatment plan.
Gathering Essential Background
Not every MTM session should result in a lengthy complex medication review. In fact, in many cases like the common cold, appropriate background data may simply be gathered in the aisle or a consultation room. Regardless of the time that pharmacists can allot to the MTM session, they should investigate some minimal patient background parameters.3 First, patients should be asked for a description of the symptoms. This may include questions that reveal the onset of the disease, as well as its severity and associated symptoms. Second, the pharmacist should be familiar with relevant patient history. Focused questions should reveal patient age, weight, height, and occupation in some cases. Also, it is essential to determine a patient’s medication allergies, history of adverse reactions to medications, current medical conditions, as well as current medications, both prescription and nonprescription.2
Assessment of the Patient
Cold symptoms, including cough, malaise, chills, sore throat, low-grade fever, and nasal congestion, may be confused with other respiratory disorders. Failure to recognize an underlying condition may delay treatment. When assessing the severity of a patient’s condition, it is important to differentiate the patient’s symptoms and identify primary complaints. Not all patients are self-care candidates and in some cases should be referred to their primary care provider. Patients who are not appropriate candidates for self-treatment of the common cold include patients with: (1) underlying chronic cardiopulmonary disease (asthma, chronic obstructive pulmonary disease [COPD], congestive heart failure); (2) AIDS or chronic immunosuppressant therapy; (3) chest pain; (4) fever of >101.5°F; (5) hypersensitivity to OTC medications; or (6) frailty and advanced age.2
Formulating a Plan and Educating the Patient
An MTM session involves selecting the most appropriate therapy while considering patient preferences. In formulating the plan, it is critical to explain to the patient why you recommend a particular therapeutic approach. When choosing to recommend a pharmacologic agent, the patient must be educated on how to properly take the medication. This may include providing the patient with the appropriate dose, frequency of administration, administration instructions, and maximum days that therapy should be used. Explain to patients the most common side effects they are likely to encounter, as well as storage instructions. Patients should also leave the consultation with a demonstrated understanding of general care measures and a course of action to take if symptoms of the cold do not improve or worsen.2
Nonpharmacologic Therapy for Colds
A variety of nonpharmacologic measures are options that pharmacists may suggest to a patient during an MTM session, including adequate rest, increased fluid intake, and nutritious meal or snack selections. Inexpensive foods such as tea with lemon and honey, chicken soup, and broths may be good recommendations to increase fluid intake.
Limited evidence is available to suggest that chicken soup may have a mild anti-inflammatory effect. In a trial published in 2000 by Rennard et al, chicken soup was evaluated for its ability to inhibit neutrophil migration.4 The authors concluded that chicken soup did significantly inhibit neutrophil migration. Moreover, the authors further suggested that neutrophil mitigation may be related to the anti-inflammatory effect of chicken soup.
Some patients may also experience symptom improvement when utilizing humidifiers or vaporizers. Humidifiers produce a cool mist, whereas vaporizers heat water to produce steam. For the temporary relief of nasal congestion, pharmacists may recommend Breathe Right nasal strips. These strips consist of a flexible “spring-like” band that reduces snoring and relieves nasal congestion by gently opening the nasal passages.5 For sore or scratchy throats, the pharmacist may suggest that the patient gargle with warm salt water. Additionally, saline nasal sprays may be used to relieve nasal congestion and dryness.
The common cold is self-limiting and symptoms typically resolve within 7 to 10 days. Patients who do not experience symptom improvement after this time period, or who experience worsening symptoms, should be seen by a primary care provider.
Pharmacologic Therapy for Colds
With so many OTC products to choose from, it is easy to understand why a patient can be overwhelmed when selecting an appropriate cold medication. If a patient’s chief complaint is nasal congestion, then a systemic or topical decongestant may be appropriate. Decongestants are classified as adrenergic agonists that stimulate alpha-adrenergic receptors to constrict blood vessels. This consequently results in decreased mucosal edema. Pseudoephedrine (Sudafed) and phenylephrine (Sudafed PE) are common in systemic decongestants found in OTC preparations. Topical decongestants such as naphazoline, oxymetazoline, phenylephrine, and xylometazoline are also available.
Common adverse effects associated with decongestants include cardiovascular stimulation (elevated blood pressure, tachycardia, palpitation, or arrhythmias) and central nervous system stimulation (restlessness, insomnia, anxiety, tremors, fears, or hallucinations).2 Though these adverse effects are more common in systemic decongestants, the use of decongestant products may exacerbate disease states sensitive to adrenergic stimulation.2,6,7
Patients with hypertension, cardiovascular disease, hyperthyroidism, depression or other psychiatric conditions should be cautioned before using decongestant products. If recommending a topical decongestant, it is important to advise the patient to limit the use of the product to 3 to 5 days due to concern for rhinitis medicamentosa (rebound congestion). It is important to also note that the use of topical decongestants may be impractical in elderly patients who may lack the dexterity to self-administer the agent properly.
Decongestants may interact with many medications. Patients using a monoamine oxidase inhibitor should avoid decongestant use due to the potential for increased blood pressure.8 Likewise, patients using tricyclic antidepressants, such as amitriptyline, nortriptyline, or imipramine, should consider an alternative cold treatment.
Oral decongestants are often found in combination products along with first-generation antihistamines. Antihistamines, when used alone, are not an effective treatment for cold symptoms. Some evidence, however, suggests that when antihistamines are used in combination with decongestants, patients may experience mild improvement and relief from rhinitis.9 Despite limited evidence suggesting nasal symptom improvement, first-generation antihistamines should be recommended with caution, particularly in the elderly.
The use of first-generation antihistamines is associated with many anticholinergic side effects—most notably, sedation. The decrease in rhinorrhea observed with antihistamine use is likely due to the inhibition of cholinergic stimulation.9 This effect is present only in first-generation antihistamines and is not seen in more selective nonsedating antihistamines.
Local OTC anesthetic products are available to provide temporary relief of sore throat. These products contain active ingredients such as benzocaine, pectin, and dyclonine and may be used every 2 to 4 hours. Patients with a history of allergic reaction to anesthetics should avoid products with benzocaine.
Systemic analgesics (eg, aspirin, acetaminophen, ibuprofen, or naproxen) may be effective treatments for general aches or headaches that sometimes present with the common cold. These products often are marketed as combination products with decongestants, expectorants, or antitussives. Though combination products may be convenient, avoid recommending such products if other active ingredients are unnecessary for the patient.
Nonprescription medications are commonly used to treat cough associated with the common cold. Unfortunately, many OTC products such as codeine or dextromethorphan have been shown to be ineffective in reducing cough associated with cold.10 Cough is a common symptom that presents in many patients with underlying disorders such as gastroesophageal reflux disease, respiratory tract infections, congestive heart failure, asthma, or COPD. Therefore, the pharmacist should exercise caution when recommending a nonprescription product to a patient with an unknown etiology of cough.
In many instances, cough should be evaluated separately from the common cold to determine if an underlying condition may be present. It is important to note that the use of a nonprescription product for self-care of cough should not exceed 7 days.11 Until randomized controlled trials demonstrate that cold medications are effective cough suppressants, their use is not indicated in patients for this purpose at this time.
Common cold symptoms, although self-limiting, can impact a patient’s quality of life, and therefore, patients may approach pharmacists with questions regarding options for treatment. Nonpharmacologic treatment measures may be recommended in all patients encountered during an MTM session, regardless of age. When nondrug measures fail to relieve symptoms and pharmacologic treatment is desired, the pharmacist should consider essential background information and medication preference before recommending a product.
When selecting an OTC medication, it is important to alert patients to read the label closely to identify the ingredient(s) and review the dosing instructions, potential side effects, and warnings associated with the medication. Patients should always be advised to seek additional care from their primary care provider if cold symptoms worsen or do not improve within 10 to 14 days.