Module 5: Coughs and Colds Module 4: Pain and Analgesiafile/MCA-Module-05.pdf · Buttercups Training Medicine Counter Assistant Module 4: Pain and Analgesia Introduction to Coughs

Buttercups Training Medicine Counter Assistant

Module 4: Pain and Analgesia

Introduction to Coughs and Colds .......................................................................... 2 Colds ............................................................................................................. 5 Coughs .......................................................................................................... 11 Sinusitis ........................................................................................................ 15 Sore Throats ................................................................................................... 16 Chronic Sore Throat .......................................................................................... 18 Laryngitis....................................................................................................... 19 1. Prodigy guidance: www.cks.library.nhs.uk 2. C&D Guide to OTC 34th Edition April 2009 3. BNF 59 March 2010: www.bnf.org/bnf 4. Medicines, Ethics and Practice No33 July 2009 5. Community Pharmacy: Symptoms, Diagnosis and Treatment: 2nd Edition, Paul Rutter 6. Electronic Medicines Compendium (eMC): www.medicines.org.uk/emc 7. Medicines and Healthcare products Regulatory Agency: www.mhra.gov.uk 8. Echinacea: Linde K, Barrett B, Bauer R, Melchart D, Woelkart K. Echinacea for preventing

and treating the common cold. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD000530. DOI:10.1002/14651858.CD000530.pub2: www2.cochrane.org/reviews/en/ab000530.html

9. Vitamin C: Hemilä H, Chalker E, Douglas B. Vitamin C for preventing and treating the common cold. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD000980. DOI: 10.1002/14651858.CD000980.pub3: www2.cochrane.org/reviews/en/ab000980.html

10. Herbal Medicines. London: Pharmaceutical Press: www.medicinescomplete.com/mc/herbals

11. Dietary Supplements. London: Pharmaceutical Press: www.medicinescomplete.com/mc/diet

Module 5: C

oughs and Colds

Contents

References and Further Reading

Module 5: Coughs and Colds


Module 5 Version 1: October 2010 Page 2 Copyright Buttercups Training Ltd


At this point in the course it will be useful to take a brief look at the underlying causes of a diverse range of conditions we call “infections”. All infections are caused by one or other type of micro-organism. Let’s look at what we mean by the terms ‘micro-organism’ or ‘microbe’, of which there are four main classes; bacteria, fungi, protozoa and viruses. Although you will no doubt have learnt something about these organisms previously, it will do no harm to refresh our memories. DDeessppiittee tthhiiss,, wwee aarree pprroobbaabbllyy mmoosstt aawwaarree ooff mmiiccrroo--oorrggaanniissmmss wwhheenn tthheeyy ccaauussee uuss pprroobblleemmss,, lliikkee ccaauussiinngg ffoooodd ttoo ggoo ooffff oorr wwhheenn aa wwoouunndd bbeeccoommeess iinnffeecctteedd.. LLeett’’ss llooookk aatt tthhee ffoouurr mmaaiinn ccllaasssseess::

Introduction to Coughs and Colds

Microbiology Microbiology is the study of extremely small living organisms – called micro-organisms - so small that they cannot be seen without a microscope. Even though we cannot see them, micro-organisms are all around us; they have been found in every possible environment from the frozen arctic to hot springs at the bottom of the ocean and everywhere in between. We have even found a meteorite that was once part of Mars which is claimed to contain fossilised microbes, although this is, of course, still controversial. There are an estimated one billion E.coli bacteria living inside our intestines and every external part of our bodies is teeming with a huge range of different microbes. Most micro-organisms are either harmless to us or are even beneficial; the E.coli in our intestines help us to digest food; bacteria are now used to produce human insulin and other hormones; both bread and beer are made using yeast – perhaps making it a micro-organism we couldn’t live without?

Objectives On completion of this section you will be able to: • Identify the three main classes of micro-organism and suggest an infection that each

type can cause




Bacteria are very simple, single-celled organisms which consist of a strong cell wall surrounding the cytoplasm (cell fluid) in which floats a ring of DNA. Although they can be a variety of shapes and sizes, they all have the same basic features (shown left). The most common shapes are spheres and cylinders (rod shaped), but some have more exotic twists and spirals. Visit the website http://microscopy.fsu.edu and explore some of the beautiful images of bacteria (and viruses).

Bacterial cells reproduce in the same way as our own cells do, by copying their DNA and then splitting the cell in two, with each half getting its own copy of the DNA. Sometimes the copy isn’t a perfect one and potentially a new, possibly improved type of bacterium is ‘born’. This fact has led to strains of bacteria which are capable of fighting back against the antibiotics we use to kill them, a sobering thought considering the mortality rate prior to the discovery of penicillin. One of these ‘strains’ that you will no doubt have heard of is called MRSA, Methicillin Resistant Staphylococcus aureus. This bacterium has become resistant to a wide range of antibiotics allowing it to cause serious and life-threatening infections – an elegant example of evolution in action.

AAlltthhoouugghh oofftteenn hhaarrmmlleessss,, iiff ccoonnddiittiioonnss aarree rriigghhtt,, bbaacctteerriiaa ccaann mmuullttiippllyy vveerryy rraappiiddllyy rreeaacchhiinngg mmaassssiivvee nnuummbbeerrss iinn jjuusstt aa ffeeww bbaacctteerriiaall ggeenneerraattiioonnss.. IIff tthheeyy aarree aalllloowweedd ttoo mmuullttiippllyy uunnooppppoosseedd bbyy tthhee iimmmmuunnee ssyysstteemm,, tthheeyy ccaann ggiivvee rriissee ttoo aa wwiiddee rraannggee ooff iinnffeeccttiioonnss,, ffrroomm sseeppttiiccaaeemmiiaa aanndd mmeenniinnggiittiiss ttoo lleepprroossyy aanndd ttuubbeerrccuulloossiiss..

Fungi are a very varied group of organisms, not all of them are microscopic; they include simple, single-celled organisms like yeasts as well as multi-cellular (many cells) organisms like moulds and mushrooms. Yeasts are essentially similar in structure to bacteria, with the addition of a separate nucleus surrounded by a nuclear membrane (their DNA is not free-floating but is protected by a membrane). Most fungi have a more complex structure than bacteria and yeasts. They grow as long threads called hyphae (shown right) and are made up of many cells in an organised pattern. FFuunnggii tteenndd ttoo ccoolloonniissee ((ggrrooww oonn)) tthhee sskkiinn,, hhaaiirr aanndd nnaaiillss aanndd tthheeyy aarree rreessppoonnssiibbllee ffoorr mmaannyy ooff tthhee ccoommmmoonn,, mmiinnoorr sskkiinn iinnffeeccttiioonnss ssuucchh aass aatthhlleettee’’ss ffoooott oorr rriinnggwwoorrmm..

Fungi

Bacteria Simple Bacterial Cell Structure

Cell Membrane

Cell Wall

Nuclear Material

Cytoplasm

Hyphae




Protozoa are also single-celled organisms. They live in a water environment such as in ponds, ditches, soil and sea. Like fungal cells they also have a nuclear membrane surrounding their genetic material. They include some of the largest single-celled organisms known to science, with some very large protozoa achieving 2mm in length. MMoosstt pprroottoozzooaa aarree hhaarrmmlleessss ttoo mmaann,, bbuutt aa ffeeww ddoo ccaauussee ddiisseeaassee.. MMaallaarriiaa ((sseeee MMoodduullee 77)) iiss ccaauusseedd bbyy aa pprroottoozzooaann,, ssoo iiss aammooeebbiicc ddyysseenntteerryy,, aa ddiiaarrrrhhooeeaall ddiisseeaassee tthhaatt kkiillllss ppeeooppllee bbyy tthhee tthhoouussaannddss iinn ddeevveellooppiinngg ccoouunnttrriieess.. Visit the following website to see some videos of protozoa: http://microscopy.fsu.edu/moviegallery/pondscum/protozoa/amoeba/index.html

Viruses are the smallest of the true micro-organisms, so small that even bacteria can be infected by them. They can only be seen using an electron microscope which magnifies in excess of 25,000 times. Viruses are made up of a core of genetic material (DNA or RNA) inside a coat of protein. The protein coat protects the genetic material from the outside world. Viruses are very different from the other types of micro-organisms because they are entirely parasitic; they can only reproduce when inside other living cells (a host cell). They cannot grow in any sort of nutrient medium. To grow and reproduce they must take over the energy and protein producing systems of the host cell; in effect they hijack the cell for their own use. The appearance and shape of viruses is very variable, some are shown below.

Pox Virus

Mumps Virus

Protozoa

Viruses

Herpes Simplex

Staphylococcal Phage (infects bacteria)

Tobacco Mosaic Virus




Viruses cause many diseases such as measles, mumps, polio, colds and influenza ('flu'). Human viruses are often specific to a particular type of human cell. The influenza virus only reproduces in the cells of the respiratory tract. Many viral infections in man are mild and may not produce any symptoms. A few, like rabies are extremely serious. Some human viruses can cause disease in other animals. Likewise, we can catch some viruses from animals. TThhrroouugghhoouutt tthhee rreemmaaiinnddeerr ooff tthhiiss ccoouurrssee wwee wwiillll eennccoouunntteerr aa vvaarriieettyy ooff iinnffeeccttiioonnss ccaauusseedd bbyy aa wwiiddee rraannggee ooff mmiiccrroo--oorrggaanniissmmss.. YYoouu mmaayy ffiinndd iitt uusseeffuull ttoo rreeffeerr bbaacckk ttoo tthhiiss sseeccttiioonn wwhheenn lleeaarrnniinngg aabboouutt aa ppaarrttiiccuullaarr iinnffeeccttiioonn aanndd iittss ccaauusseess.. The common cold is an infection caused by a virus; there are over 200 different viruses which can cause the symptoms of a cold. The cold virus can survive on door handles, telephones, keyboards and other objects. If an infected object is touched and then you touch your eyes or nose, the virus can find its way into the body where it can multiply and cause infection. We touch our eyes or nose at least every 2-3 hours, so there is ample chance for the virus to enter our body.

SSiinnccee yyoouu ccaann aallssoo ccaattcchh aa ccoolldd bbyy iinnhhaalliinngg ddrroopplleettss ooff mmuuccuuss iinnffeecctteedd wwiitthh aa ccoolldd vviirruuss,, iitt iiss aallssoo vveerryy iimmppoorrttaanntt ttoo ccoovveerr tthhee mmoouutthh aanndd nnoossee wwhheenn ssnneeeezziinngg aanndd ccoouugghhiinngg..

Colds

The lining of the nasal passages (and other bodily orifices) consists of a layer of mucus producing cells supplied by blood vessels (a mucous membrane). Mucus is a thick, sticky substance produced by the cells of the mucous membrane and functions as a cleaner or lubricator. In this case mucus has two functions: 1. It keeps the inside of the nose moist and supple 2. It traps dust, dirt and harmful particles, as well as micro-organisms, preventing them from

being inhaled into your lungs It is an unpleasant fact that in a 24 hour period we produce around 1 litre of mucus; this passes down the back of the throat, into the stomach, hopefully destroying any microbes it may contain. During a cold this volume of mucus can increase dramatically in an attempt to cleanse the airways.

Objectives On completion of this section you will be able to: • Understand the cause of the common cold and identify its symptoms • Know when to refer cold symptoms to the pharmacist • List the side effects and restrictions on the use of decongestant medicines • Provide appropriate advice and medicinal treatment for colds




When the cold virus enters the body and attacks the cells of the mucous membrane, they swell and produce even more mucus; the blood capillaries also swell. This leads to fluid accumulation and encourages even more mucus to be produced. The enlarged blood vessels reduce airflow through the nose making it difficult to breathe. So the nose runs with mucus and, combined with the swollen blood vessels, this creates a blocked, or congested, sensation. If the extra mucus is allowed to remain for too long then bacteria may colonise (grow) in it, leading to a further infection.

TThheessee ssyymmppttoommss ccaann llaasstt ffrroomm 22--1144 ddaayyss,, bbuutt mmoosstt ppeeooppllee rreeccoovveerr aafftteerr aa wweeeekk..

Symptoms begin 2-3 days after infection with the cold virus and will include: • Runny nose • Sore throat • Sneezing • Cough • Fever (high temperature) • Blocked nose (congestion) • Watery eyes • Headache • Tiredness/muscular aches and pains

Referral Criteria In general, anyone suffering from a cold and showing one or more of the following symptoms or complications should be referred to your pharmacist: • Wheezing • Sore throat which doesn’t improve after 3 days • Pain on breathing or coughing • Earache • Blood stained or coloured mucus • Shortness of breath • A cough that is dry at night and productive in the morning • If the symptoms have lasted longer than 14 days • A cough that is worsened by exercise • If there is a rash • If neck stiffness is present (risk of meningitis) • Headaches in children (risk of meningitis)

The standard referral criteria apply as always.




The principle aim of treatment for a cold is to relieve the symptoms so as to make the patient comfortable whilst the body’s immune system deals with the infection. There have been some attempts to shorten the duration of a cold by the use of medicine, with little supporting evidence, however as yet, there is no cure. Due to the huge range of viruses that can be responsible, a vaccine is unlikely to be developed; although anyone who does discover a cure or prophylactic medicine (preventer) for the cold is likely to become very rich!

Decongestants belong to a class of drugs called sympathomimetics which stimulate a certain part of the nervous system. One effect of this stimulation is to narrow the blood vessels; this reduces the inflammation in the nasal membrane and hence reduces the nasal congestion. If applied topically directly to the nasal lining by nasal drops or sprays, they can work within minutes. If taken by mouth these drugs take longer to work but will also last for longer.

Treatment Options

There is a huge range of cold remedies designed to relieve the various symptoms and you should try and familiarise yourself with these products. Explore the products on your shelves and look for the symptoms they treat and the medicines they contain. Remember, though, that the more medicines a product contains, the greater the risk of suffering from side effects or even overdose. It is often better to recommend multiple products each containing only one drug to try and minimise the risks. There is also the possibility that ingredients included in a combination product can have opposing effects which may cancel each other out.

Decongestants

Pseudoephedrine and phenylephrine are taken orally as tablets, capsules or liquids to reduce congestion. Because of their general action on the nervous system, they can have undesirable side effects including increased blood sugar levels, increased heart rate, and muscle tremor. Due to these side effects, oral decongestants must be avoided by people with: • Heart problems • High blood pressure • Overactive thyroid gland • Diabetes • Other medication, as there are many drug interactions




The following phrase may help you remember the groups of people who must not take decongestants:

In addition to the problems of side effects and rebound congestion, there are a number of other issues concerning the use of decongestants. Decongestants have a stimulant effect on the body, increasing the rate of the heart and the activity of the nervous system (think of how you feel when you are scared or excited and adrenaline is coursing through your body, the effect is the same). At the very least, this can cause some people to have difficulty getting to sleep and so decongestants shouldn’t be taken in the evening or at night. Because of this stimulant effect however, decongestants show a serious potential for abuse. Some people have used decongestants alone, or mixed with illegal drugs to get a “buzz”. But more worryingly, they can be used as an ingredient to actually make illegal drugs.

MMonkeys

DDon’t

TTruly

BBeHHave

PProperly

MMedicines – many interactions

DDiabetes

TThyroid problems

BBlood pressure: HHeart disease

PPregnant

Oxymetazoline and xylometazoline are applied topically via drops and sprays. If used in excess, or for too long, topical decongestants, can cause what is known as ‘rebound congestion’. This means that the congestion improves whilst using the product but then appears to get worse and the medicine no longer works to relieve it. You don’t need to understand why this happens but it does mean that... PPrroodduuccttss ccoonnttaaiinniinngg tthheessee mmeeddiicciinneess mmuusstt nnoott bbee uusseedd ffoorr lloonnggeerr tthhaann sseevveenn ddaayyss ccoonnttiinnuuoouussllyy..




Antihistamines are used to treat a variety of conditions; they are covered in detail in Module 7 (Summer and Travel Medicine). In this particular case, they are used to dry up nasal secretions and reduce sneezing, although they will not have much of an effect on congestion. Some antihistamines commonly encountered in cold remedies include diphenhydramine, chlorphenamine, promethazine and triprolidine. These are known as the ‘traditional’ or ‘older’ antihistamines and they will cause drowsiness. They are often included in night-time cold remedies for that very reason, allowing the patient to sleep despite their cold symptoms.

Operators of machinery and drivers should be warned of this effect. In day-time cold remedies, antihistamines are often used in combination with decongestants; this should counteract their drowsy effect so that there is no overall change in the patient’s state of alertness.

Legal Matters In 2007 the sale and supply of pseudoephedrine hit the headlines due to its potential for illicit conversion to methylamphetamine, commonly known as crystal meth, an addictive class A drug. The Medicines Health Regulatory Authority (MHRA) proposed restrictions on the amount that could be sold OTC, and that the transaction must be carried out by a pharmacist. The Royal Pharmaceutical Society of Great Britain (RPSGB) issued its own guidance as follows: • Pharmacy staff should continue to be alert for frequent requests, or

requests for large amounts • Pack sizes are restricted to 720mg (12 tablets) of pseudoephedrine or

180mg of ephedrine, with sales limited to one pack per customer and to be carried out by a pharmacist.

Pharmacy as a profession responded well to enforcing these stricter controls and as a result made a big impact on reducing the misuse and abuse of pseudoephedrine and, consequently, on crystal meth. It was hailed as a success for pharmacy and highlighted its ability to manage drug misuse. Of course, the controls are still in place and we must all remain vigilant.

Antihistamines




Pain-killers, such as paracetamol, ibuprofen and aspirin, are often used in cold remedies in combination with other ingredients to relieve muscular aches and pains and headache. They also have the advantage of being antipyretic (they reduce fever). As discussed above, it is better to recommend products containing individual drugs rather than a combination product to give the customer more flexibility in dosing, and to reduce the possibility of overdosing (particularly on paracetamol). However, if you do sell combination remedies make sure that you alert the customer to the inclusion of an analgesic within the medicine. Ibuprofen suspension and paracetamol suspension are available for children, and you should ensure that the customer reads the directions for dosage.

Analgesics

Aspirin and ibuprofen belong to a class of drugs called NSAIDs (Non Steroidal Anti Inflammatory Drugs). They were discussed in detail in Module 4 and you should be able to remember the following facts: • Aspirin and ibuprofen may not be given to someone with a history of asthma unless the

customer knows that they are not sensitive to them • Customers with stomach problems such as ulcers should not take ibuprofen or aspirin • Ibuprofen suspension can be given to children over 3 months (check product licence) • Aspirin cannot be given to children under 16 years of age • Aspirin should not be used in pregnancy

Aromatic Inhalations Aromatic inhalations containing volatile substances such as eucalyptus oil or menthol may be useful to soothe coughs (see below) and improve nasal congestion. Applying it as a chest rub or to pillows can be of benefit but is not recommended for infants under 3 months old and asthmatic patients may find volatile oils too irritant. Be aware that inhalants may be liable to abuse as they can be used to enhance the effects of other drugs which are said to create a “buzz.”

Other treatments




Very often a cough goes hand-in-hand with a cold. Coughing is a natural part of the body’s defence system and serves an important purpose. A cough can be an indicator of infection, inflammation or irritation of the body’s airways. We all cough once or twice every hour to clear the airways of any mucus or debris. The coughing will become more frequent and more intense when there is an infection present There are two types of cough your customers may present you with: • Dry (non-productive) • Chesty (productive)

Echinacea Echinacea is a herbal remedy that increases the number of white blood cells (needed for the immune system to work) and is claimed to have anti-viral properties. It is not suitable for use in pregnancy, breast feeding women, people with HIV, asthma, multiple sclerosis or diabetes. There is little sound evidence for its effectiveness as a preventer of colds but there are some studies that show that extracts of the plant can reduce the duration of and lessen the symptoms of a cold.8,10

Vitamin C Vitamin C is often included in cough and cold remedies for its beneficial effects on the immune system. When a person has an infection their vitamin C levels are rapidly depleted so it is a natural assumption that replacing it will help recovery. Again, there is some evidence to show that vitamin C can reduce and shorten the symptoms of a cold. It may ‘strengthen’ an individual’s immune system making them slightly less likely to contract a cold, although the evidence is not conclusive.9,11

Coughs

Objectives On completion of this section you will be able to: • Identify the causes and types of cough and know when to refer a cough to the pharmacist • Provide appropriate advice and medicinal treatment for a cough • Understand the legal restrictions on the sale of cough and cold remedies in children




The lungs are like sponges – they are made up of millions of tiny air sacs. Around each sac is a network of blood vessels that take oxygen from the air inside the sac. If those little sacs get full of mucus then it is more difficult to get the oxygen across the membrane and into the blood. The lungs send messages to the brain to say “expel the mucus” and the brain initiates what is known as the cough reflex. It is very important that we do not interfere with this natural process. What do you think might happen if you stop the cough reflex from occurring? The mucus and debris cannot be removed from the lungs and so there is more chance of causing a chest infection. The two different types of cough therefore require different treatment. SSoo hhooww ccaann yyoouu bbee ssuurree wwhhiicchh ttyyppee ooff ccoouugghh aa ccuussttoommeerr hhaass?? AAsskkiinngg tthhee ccuussttoommeerr wwhheetthheerr tthheeyy hhaavvee aa cchheessttyy oorr ddrryy ccoouugghh iiss rraarreellyy ssuucccceessssffuull;; hhooww ddoo tthheeyy kknnooww?? AAsskk tthheemm hhooww tthheeyy ffeeeell,, hhooww tthheeiirr cchheesstt ffeeeellss aanndd wwhheetthheerr tthheeyy aarree ccoouugghhiinngg aannyytthhiinngg uupp..

A dry (non productive) cough This is where the cells of the mucous membrane have become swollen and are raw, sore and inflamed. It is often felt as a tickle in the back of the throat which triggers the coughing and there is little mucus production. In this case, coughing is harmful because it removes the protective, soothing mucus that is present. This makes the cells even more uncomfortable, leading to more coughing in a vicious cycle that needs to be stopped.

A chesty (productive) cough This is where the person feels that they are coughing something up – referred to as mucus, phlegm or sputum. This is usually clear or pale green, however if it is yellow, brown or dark green it could indicate a bacterial infection and the patient should be referred.

Referral Criteria A note on chronic (long-lasting) coughs: There are many reasons why a cough may persist for weeks or even months; the majority of which can be serious conditions and so a chronic cough must be referred to your pharmacist. Causes of chronic cough include: asthma, pneumonia, bronchitis, COPD (a lung disease associated with smoking), tuberculosis and lung cancer. In addition, a certain class of blood pressure medicines can cause a chronic dry cough which stops soon after the drug is stopped. This is one of the reasons why patients on other medication must always be referred. The following symptoms must be referred to your pharmacist: • A cough lasting longer than two weeks • A regularly recurring cough • Shortness of breath/wheezing • Chest pain or pain when breathing • Coloured sputum (especially yellow or brown) • Blood in the sputum




AA ccoouugghh ssuupppprreessssaanntt mmuusstt nneevveerr bbee uusseedd ffoorr aa cchheessttyy,, pprroodduuccttiivvee ccoouugghh aass iitt wwiillll ssttoopp tthhee ccoouugghh rreefflleexx aanndd pprreevveenntt eexxcceessss mmuuccuuss bbeeiinngg eexxppeelllleedd..

Treatment of a Cough

Expectorants Expectorants are commonly recommended for (chesty) productive coughs. An expectorant causes cells to produce thinner mucus so that it is easier to clear by coughing. It is important to tell your customers that they will still cough after having an expectorant – expectorants do not stop the cough, they make it easier to remove the mucus making the cough less painful and reducing its duration. Guaifenesin is the most commonly used expectorant and is found in a variety of products. It is not known to interact with any other drugs so, if used alone, can be a safe option for those on other medication (although you should still refer to the pharmacist). It can cause side effects of nausea, diarrhoea and headache although these occur rarely unless the stated dose is exceeded. Ipecacuanha and ammonium chloride are often found in older, traditional remedies but there is little conclusive evidence of their effectiveness. Productive coughs are helped by an adequate intake of fluid and anything soothing, such as a syrup, which makes the cough less uncomfortable without suppressing it.

Suppressants Suppressants (antitussives) are recommended for (dry) non-productive coughs. Suppressants are actually opioid drugs related to morphine, with one of their side effects being to suppress the cough reflex in the brain. Methadone is a powerful opioid used mainly as a heroin substitute, but it is also prescribed by doctors to treat a dry cough in terminally ill patients. Of course, we can’t recommend methadone to our customers but the theory is the same and other, much weaker, opioids can be used. Codeine is a powerful suppressant but will also cause drowsiness and constipation. Its use is now limited because of its addictive nature and it should not be recommended to patients (see Module 4 for a discussion of the opioids and their potential for abuse). In any case, the CHM has advised that liquid codeine-containing products for coughs must not be sold for use in children under 18 years old or breast-feeding mothers.7 Pholcodine and dextromethorphan are weak opioids recommended for troublesome dry coughs. Although these two medicines can theoretically cause drowsiness and constipation, it rarely occurs at the dosages given in OTC cough medicines.




Often cough syrups act merely as soothers to try and comfort the sufferer and soothe any soreness whilst the lungs get on with the business of clearing the trouble. They may also be used when the cough is just a tickle as a result of a virus or too dry an atmosphere. Soothers and demulcents like glycerin, honey, treacle and simple linctus which are soft, gentle and sticky can be used in this way (but are not good for your teeth, unless sugar-free!).

Diphenhydramine Diphenhydramine is an antihistamine which can reduce a cough in two ways. It causes drowsiness and the sedative effect may help to suppress a cough; this is often used in night-time cough remedies but may cause problems during the day. The second way it can help is when nasal secretions drip down the back of the throat causing an irritating cough (known as post-nasal drip); an antihistamine can dry up these secretions and thus improve the cough.

Antihistamines should not be used in patients with prostate or thyroid problems, glaucoma, or certain gastrointestinal and heart problems.

Legal Matters

Treatment of Coughs and Colds in Children Under 12 Years of Age7 Following a review of children’s cough and cold preparations by the Commission on Human Medicines (CHM), new guidance was issued in March 2008 on treating children with coughs and colds. Due to a lack of evidence regarding their effectiveness coupled with concerns over the dangers of overdose, a range of measures were introduced to ensure the safe use of these products in children under 12 years of age. The main changes are: • Cough and cold remedies containing certain ingredients* must no longer

be used in children under 6 years of age

• Products for children from 6-12 years old will continue to be available in pharmacies where advice can be given, although some combinations which are illogical (such as cough suppressants and expectorants) are being phased out

• All liquid products will be in a child resistant container (CRC) * Products affected: See next section




Sinusitis is a condition that often accompanies a cold and, as it is a cause of pain, is also discussed in Module 4. The pain, which is felt under the eyes and in the head, particularly when bending down, is associated with congestion and catarrh. Symptoms of sinusitis include: • Pain behind the eyes • Sore eyes and tenderness • Nasal congestion

All OTC cough and cold medicines containing the following active ingredients are affected by the previous CHM Guidance: • Antitussives (suppressants) : dextromethorphan and pholcodine • Expectorants: guaifenesin and ipecacuanha • Nasal decongestants: ephedrine, oxymetazoline, phenylephrine, pseudoephedrine and

xylometazoline • Antihistamines: brompheniramine, chlorphenamine, diphenhydramine, doxylamine,

promethazine and triprolidine Instead of selling these treatments, simple advice should now be given to parents of young children with coughs and colds: • Coughs and colds are self limiting conditions and will usually get better by themselves in 5-7

days • Trying simple measures such as ensuring your child has plenty to drink and gets enough rest

will help • Paracetamol or ibuprofen can be used to reduce your child’s temperature and any aches and

pains • For young babies particularly those who are having difficulty feeding, normal saline drops are

available to help thin and clear nasal secretions • If your child is over the age of 1, a warm drink of lemon and honey may help to ease a cough

(babies under 1 year should not be given honey due to a risk of a bacterial infection) • Encourage all the family to wash their hands to prevent the spread of colds from infected

secretions • Tissues should be used to catch cough or sneeze droplets and then disposed of in a bin

Sinusitis

Symptoms




Treatment consists of a suitable analgesic and a decongestant. Infection often causes inflammation in the respiratory tract and when it affects the throat (pharynx), this is known as pharyngitis. If the inflammation affects the tonsils it is known as tonsillitis. In either case, we know it as a sore throat. The cause of the infection may either be viral, bacterial or fungal. 60-90% of all throat infections are caused by a virus5 and therefore will not respond to antibiotics such as penicillin. These cases can therefore be safely treated in the pharmacy by giving appropriate advice and medicines to relieve the symptoms.

Referral Criteria Refer to the pharmacist if the pain is severe, prolonged or the customer is unwell.

Treatment Options

Sore Throats

Background

Throat Infections

Bacterial infections will normally require treatment from the doctor so you should refer all suspected cases to your pharmacist. They can be distinguished from viral infections by the following signs and symptoms: • Sudden onset of discomfort • Worsens over a few days • Lymphoid tissue (glands in the neck) often swells • Sufferer feels generally unwell • Pustules may be present on the tonsils

Rarely, fungal infections can also occur, particularly in asthmatic patients who use corticosteroid inhalers and fail to rinse their mouth out after use.

Objectives On completion of this section you will be able to: • Identify the causes of a sore throat and know when to refer to the pharmacist • Use extended questioning techniques to obtain a fuller picture of a customer’s condition • Provide appropriate advice and medicinal treatment for a sore throat




There are a wide variety of products available to relieve sore throats, most commonly in the form of lozenges or sprays. A lozenge is a bit like a hard, boiled sweet except that it also contains a medicine. Pastilles are also available which are like lozenges but soft and chewy. There are many different active ingredients found in these products, most of which are either antiseptic, anaesthetic or both. You should familiarise yourself with the various products and ensure you are aware of their instructions for use. Much of the benefit of using a lozenge comes from stimulating the salivary glands to lubricate the throat. The sucking action increases the production of saliva and lozenges often have fruity flavours which also stimulates saliva. Drugs can then be added to the lozenge in order to increase their effectiveness. Throat sprays and mouthwashes/gargles have the advantage that they can be targeted directly at the affected area for immediate relief of pain.

Throat Infections Continued Remember you learnt about the 2WHAM questions earlier in the course? Sometimes these do not obtain enough information from the customer to be able to decide on the cause of their condition. Here are three more questions that can also help to gather information:

• Progress – is it getting better, worse or spreading? • History – have you suffered with it before? • Illness – are there any other symptoms – do you feel well otherwise? We refer to these questions as 2WHAMPHI. Finding out whether the sore throat is worsening, whether there has been a history of sore throat or tonsillitis, and particularly whether or not the customer feels ill are all very important questions.

Treatment Options

Antiseptics Tyrothricin is an antibiotic that is useful for reducing the severity and duration of a throat infection. If used early enough it can prevent the infection from progressing and it can be used in children as young as three. Many preparations contain antifungal or antiseptic ingredients such as benzalkonium chloride, dequalinium chloride, cetylpyridinium chloride and hexylresorcinol. Evidence for their effectiveness is not conclusive but their inclusion in sore throat remedies is logical.

A customer suffering from tonsillitis will almost certainly recognise the symptoms and will be able to recite a long history of throat problems. These customers should be referred to the pharmacist as should anyone whose sore throat has not improved after three days or is unresponsive to treatment.




The word ’chronic’ indicates a habitual or continual condition, not necessarily a severe or dreadful one. In this case it is caused by continuing irritation.

Anaesthetics Anaesthetic agents such as benzocaine and lidocaine will numb the throat, thereby relieving pain. They do sometimes cause sensitisation (an allergy develops) so their use should be limited to a maximum of 5 days. The loss of sensation caused by an anaesthetic can make swallowing difficult in children and the elderly. Care should also be taken when consuming hot food and drinks so as not to burn the anaesthetized mouth.

Flurbiprofen Flurbiprofen is an NSAID targeted specifically at treating sore throats. It is found OTC only in lozenge form and will reduce the inflammation and pain of a sore throat. The usual restrictions to the sale of NSAIDs apply (see Module 4), it is not suitable for children under 12 and must not be used for longer than three days.

Benzydamine Benzydamine is another NSAID found in some sprays and a mouthwash which can be used as a gargle to relieve pain and inflammation.

Hexetidine Hexetidine is also found in some mouthwashes and has both anaesthetic and antiseptic activity.

Chronic Sore Throat

Certain activities might cause a chronic sore throat: • Chronic sinus infection • Chronic mouth breathing • Singing • Speaking or shouting • Alcohol abuse • Coughing and vomiting • Smoking

A Word of Warning! Pus can accumulate between the tonsil and its bed although only the affected tonsil is visible. This is called “quinsy” and it starts off as tonsillitis. Swallowing will become increasingly difficult and is a potentially serious situation as choking can occur if both tonsils swell. You should always refer difficulty in swallowing, which can also be associated with glandular fever, oesophagitis and other serious conditions.




AAllwwaayyss rreeffeerr aa cchhrroonniicc ssoorree tthhrrooaatt ttoo yyoouurr pphhaarrmmaacciisstt..

Laryngitis is the term given to inflammation of the larynx, or voice box, it is sometimes called ‘hoarseness’. Inflammation of the vocal cords in the larynx causes a gruff, husky voice or even complete (temporary) loss of voice. This is usually caused by a virus which will get better of its own accord. Resting the voice for a couple of days should improve the problem. In young children laryngitis can cause “croup” which produces tightening of the airways and difficulty in breathing. AAss yyoouu ccaann sseeee,, cchhrroonniicc llaarryynnggiittiiss mmaayy bbee aa ssiiggnn ooff ssoommeetthhiinngg vveerryy sseerriioouuss ssoo yyoouu sshhoouulldd rreeffeerr hhooaarrsseenneessss ttoo tthhee pphhaarrmmaacciisstt aafftteerr 33 ddaayyss.. Treatment includes drinking plenty of fluids to lubricate the throat, with the use of lozenges to stimulate saliva and aid lubrication. Analgesics can be used if there is any pain, however the best treatment is just to ‘rest’ the voice, i.e. try to talk as little as possible and certainly no raising of the voice or singing!

Laryngitis

Background

There are also some other causes of hoarseness: • Arthritis • Cancer • Vocal cord abuse (shouting?) • Psychological issues • Thyroid problems • Solvent abuse • Inhalation of smoke

Treatment Options

Objectives On completion of this section you will be able to: • Identify the symptoms of laryngitis and know when to refer to the pharmacist

Documents

Module 5: Coughs and Colds Module 4: Pain and Analgesiafile/MCA-Module-05.pdf · Buttercups Training Medicine Counter Assistant Module 4: Pain and Analgesia Introduction to Coughs