OTC: Cough and Cold

Common Cold Etiology

Common “Virus”

→ Rhinovirus common agent

Common Cold Transmission

• Self-inoculation with viral-laden secretions

• aerosol transmission

increased risk of transmission if:

• smoking

• high pop density

• sedentary lifestyle

• chronic stress

Common Cold Progression

• 1-3 days

  • sore throat, sneezing

  • low-grade fever (100ºF) ((may be viral))

• 2-3 days → most infectious

  • rhinorrhea

  • peak symptoms

  • peak viral concentration (most infectious)

• 4-5 days

  • residual cough late-stage

Symptoms last about: 7-14 days

Differentiating Factors…

1. Common Cold: slow onset

2. Allergic Rhinitis: bilateral, watery/itchy eyes

3. Asthma: wheezing

4. Bacterial Throat Infection: exudate

5. Influenza: sudden onset, fatigue

6. Sinusitis: fever over 101.5ºF indicative of bacterial infection

7. COVID-19: fever, fatigue, loss of taste/smell

Nonpharm Approaches to Cold

1. limit transmission

2. wash hands

3. hand sanitizers

4. increased fluid intake

5. rest

6. chicken noodle soup

7. increased humidification

Cold: Exclusions to Self-Treatment

• Fever >100.4ºF (may be bacterial)

• chest pain

• shortness of breath

• COPD, asthma, coronary heart failure

• immunocompromised

• frail

• infants < 3 months of age

• symptoms no improve 7-14 days

Single vs Combo Products

Single entity products → preferred

• treats appropriate symptoms only

• better dosing accuracy

Combo products → ease of use (cheaper)

• unnecessary products for no symptoms

Decongestants

Indication: sinus and nasal congestion

Sympathomimetics: alpha-AR agonists

• vasoconstriction, adrenaline effects

• clears sinuses

ADR: cardiovascular + CNS stimulation

hypertension, tachycardia, anxiety, tremors, insomnia

Decongestant Pre-cautions

• Do NOT use with MAOI’s

• Do NOT use if patient has uncontrolled:

  • hypertension

  • hyperthyroidism

  • diabetes

  • coronary heart disease

• Do NOT use with Tricyclic Antidepressants

  • increased cardiovascular toxicity

Pseudoephedrine

decongestant of choice

• q4-6 hours in 24 hours

2 - 6 years → 15 mg

6 - 12 years → 30 mg

>12 years → 60 mg

CMEA 2005

Combat Methamphetamine Epidemic Act

• logs patient name, address, point of sale

SALE LIMITS:

no more than 3.6 g per day (3600 mg/day)

no more than 9 g per 30 days (9000 mg/30day)

no more than 7.5 g per mail order

#30 count bottle x sudafed mg = how much in 30 days

9000 - x = mg left can buy/other sudafed mg strength

Topical Decongestants (nasal)

Oxymetazoline (Afrin)

• > 6 years old

• 2-3 sprays q10-12 hours

Phenylephrine 0.5% - 1%

• >12 years

• 2-3 sprays q4 hours

Phenylephrine 0.125%

• 2 - 6 years old

• 2-3 sprays q4h

chronic use = rebound contestant

do not use more than 3-5 days

can be used for both cold and allergies*

Antihistamines for Cold

→ First generation only effective in cold

• anticholinergic effects relieves inflammatory responses

• sedation for sleeping while sick

• antitussive effects

• beneficial for patients with heart problems who cannot take psuedofed

chlorophenamine, diphenhydramine

→ Second generation not for cold use

Local Anesthetics (Analgesia)

Demulcents and Anesthetics Local Action

• Demulcents; cover mucus throat membrane

  • cough drops

• Anesthetics; inhibit pain proprioception

  • Benzocaine

  • Menthol

  • Phenol Spray (good for children)

Systemic Analgesics

ASA, APAP, and NSAIDs

• treat swelling of sinus cavity, headache, aches, fevers, throat pain

Cough Classifications

1. Acute < 3 weeks

   1. treatable with OTC

   2. viral agent causation

2. Subacute 3 - 8 weeks

3. Chronic > 8 weeks

Wet Cough vs Dry Cough

Wet Cough: productive cough

• expels secretions and mucus from lower respiratory tract

• bacterial infections, bronchitis

Dry Cough: nonproductive cough

• hacking, no physiological purpose

• viral infections, GERD, meds

Exlcusions to Cough Self-Care

• Children < 4 years of age

• Thick yellow sputum/green phlegm

  • may be bacterial causative agent

• Productive cough (?)

• Fever

• Shortness of breath

• unintended weight loss

• night time sweats

• chest pain

• persistent headache

• swelling in legs/ankles

• underlying conditions: asthma, COPD, chronic bronchitis, coronary heart failure

• drug induced cough

• lasting > 7 days

Differentiation Factors: Cough

1. Asthma: wheezing, cough at night

2. CHF: Edema

3. COPD: productive cough

4. GERD: heartburn, worse when laying down

5. Lower Resp. Infection: fever, discolored phlegm

6. Allergies: runny nose

7. Viral URTI: sneezing, runny nose

Honey Therapy for Cough

5-10 mL PO before bedtime

→ DO NOT use honey if < 1 year old

• risk of botulism

2-5 years: ½ teaspoon

6-11: 1 teaspoon

12-18: 2 teaspoons

Antitussives

MOA: increases cough threshold

• Codeine

• Dextromethorphan

• Diphenhydramine

• Chlophedianol

• Topical for throat (menthol, camphor)

Codeine

First Line Antitussive for Cough

weak opiate agonist for 18 years and older

→ converted to morphine by CYP2D6

increases cough threshold

dries out resp. mucosa

dosing: max 200 mg/100 mL

60 mg/dose, 360 mg/day

SE opiate associated: constipation, dependence, respi. depression, hypotension

Codeine Drug Interactions

• CNS depressants

• 2D6 inducers/inhibiitors

  • antiarrhythmics, SSRIs, H2RA

Dextromethorphan

Second Line Antitussive for Cough

Robitussin

→ increases cough threshold (non-opiate) via antagonism of NMDA receptors

• abuse potential

• limited efficacy

10-20 mg q4 hours, max 120 mg/day

DIs: MAOIs, antidepressants, antipsychotics, 2D6/3A4 substrates

Diphenhydramine

First Generation Sedating Antihistamine

→ may be used as antitussive

least effective, but may dry out post-nasal drip

Guaifenesin

Protussive/Expectorant

Mucinex

MOA: increases hydration of resp. tract and reduces mucus viscosity

→ indicated for acute productive coughs with thick secretions

• 200-400 mg q4 hours

may be used in the elderly as a substitution for inadequate water drinking/hydration

bottom line advice for cough

cough caused by post-nasal drip

• 1st generation antihistamine + decongestant

cough interfering with sleep/work

• codeine or dextromethaphan