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may 2015Professional develoPment and Practice suPPort for the self care Program

Vol.16 number 4

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Treating coughs and colds

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Refresher Training(Counter Connection)

2 inPHARMation May 2015 I © Pharmaceutical Society of Australia Ltd.

John bell says

Vol.16 number 4

may 2015

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Contents

PharmaCisT CPD 4 facts behind the fact card: Treating coughs and colds

PharmaCy assisTanT’s EDuCaTion14 counter connection: Treating coughs and colds

rEguLars03 health column

19 noticeboard

Each year, adults can develop between two and four colds and children between five and ten.

See page 4, Facts Behind the Fact Card: Treating coughs and colds

3inPHARMation May 2015 I © Pharmaceutical Society of Australia Ltd.

treating coughs and coldsby Jill malek

health column

coughs and colds are common. it is estimated that each year an adult will contract between two and four colds. children are more susceptible to viral infections due to their underdeveloped immune systems, and may contract between five and ten colds annually. Providing advice and offering appropriate treatment to manage the symptoms of coughs and colds is an important role for pharmacists and pharmacy assistants.

cough is the most common symptom that doctors and pharmacists are presented with by patients in australia. consumers may present with a range of symptoms, from a cough that has just started to one that has been irritating them for many weeks. the most common cause of cough is an upper respiratory tract infection (urti) such as the common cold. however, the presence of a cough may indicate an underlying condition that needs to be identified and treated before cough symptoms are addressed.

asking symptom-based questions about the cough helps determine the likely cause, the most appropriate treatment and if referral is needed. Questions about the

characteristics of the cough, the colour and nature of the sputum, when it started, how long and how often it has been occurring, as well as patient characteristics are necessary in providing the most appropriate consumer-tailored treatment.

Pharmacists and pharmacy assistants are skilled at recognising the signs and symptoms of cough and cold symptoms. treating coughs and colds involves gathering patient information, assessing the needs of the consumer, recommending suitable treatment and providing counselling. With the tga recommendations for cough and cold preparations for children, pharmacists and pharmacy assistants need to be aware of the current evidence-based treatment options when providing symptomatic relief to children with coughs and colds.

treatment options for coughs and cold symptoms are vast and varied. the principles of evidence-based medicine and the potential for adverse effects should always be considered before recommending any over-the-counter (otc) cough preparations. many cold preparations are a combination of

ingredients including decongestants, antihistamines, and analgesics, as well as cough suppressants and expectorants.

combination cold treatments should only be recommended if multiple cold symptoms such as muscle aches, nasal congestion and cough symptoms are present. however, in many cases symptomatic relief can be achieved with monotherapy or a product with two active ingredients. multi-ingredient preparations have a limited role in the management of cold symptoms.

consumers often need information and reassurance about the self-limiting nature of colds and the unnecessary use of antibiotics in the treatment of urtis.

this issue of inPharmation magazine identifies the treatment options available for treating the symptoms of coughs and colds both in adults and children less than six years. it also discusses how to differentiate between chesty and dry coughs, as well as colds and flu. efficacy of current cough and cold treatments is also reviewed, and red flags requiring medical referral are highlighted.

dear Pharmacy,

With the peak of the cold & flu season around the corner, an opportunity presents to provide outstanding care, service and trusted solutions for your customers.

Pharmacy continues to be the channel of choice for australian shoppers seeking otc preparations for cough, cold & flu. With the ever-changing dynamics of new product offerings, the regulatory landscape and consumer trends, it is critical to refresh your knowledge across this category frequently and we are proud to partner with the Psa for this cough & cold edition.

as the market leaders in the cough and throat categories* with the duro-tuss®, riKodeine® and difflam® brands, the team at inova are committed to a strong and enduring partnership with the pharmacy channel and will continue to work with your pharmacy to ensure mutual growth and success this coming Winter and into the future.

We thank you for the on-going support and commitment to our brands and for your contribution to our success.

inova Pharmaceuticals (A Valeant Company)

* Aztec Pharmacy Scan Sales (Value). MAT to 22/02/2015

This issue of inPHARMATION is supported by an unrestricted educational grant from iNova Pharmaceuticals.


John bell says

Treating coughs and coldsby Jill malek

learning objectivesafter reading this article, pharmacists should be able to:

• recognise the signs and symptoms of cough and colds

• differentiate between chesty and dry coughs, and recommend appropriate treatment options

• differentiate between common cold and flu, and recommend appropriate treatment options

• identify treatment options for coughs and colds for children <6 years of age

• discuss the efficacy of treatments for coughs and colds.

Competencies addressed: 1.3, 6.1, 6.2, 7.1, 7.3.

This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.

Each year, adults can develop between two and four colds and children between five and ten.1 People commonly seek advice from pharmacists about symptoms associated with coughs and colds. Treatment is based on identifying and treating any underlying condition before providing symptomatic relief.2

Facts Behind the Fact Card treating coughs and colds Pharmacist cPd module number 259

Sarah, 32 years old, comes to the pharmacy asking for a cough mixture to relieve her persistent, productive cough. She has had a head cold for about three days and now she has a cough. The cough has been around for about two days and it’s keeping her awake at night. She is not pregnant or breastfeeding and is taking no medicine.

treating coughscough is the most common symptom that doctors and pharmacists are presented with by patients in australia.3 the presence of a cough may indicate an underlying condition that needs to be identified and treated before cough symptoms are addressed (see Practice point 1).2

to determine if, when and how best to treat a cough4:

• gather patient information including when the cough symptoms started, patient characteristics and medical and lifestyle history (e.g. age, pregnancy, breastfeeding and immune status, history of hypersensitivity or adverse reactions to medicines)

• assess the needs of the patient and if necessary, refer for further assessment

• recommend treatment after considering the aim of the treatment and the various treatment options available

• provide counselling that is supported by written information (e.g. how to use the medicine, any adverse effects, non-pharmacological management and follow-up).

Symptomscoughs are generally classified based on the duration of symptoms and may be acute (generally lasting <2 weeks), sub-acute (lasting about 3–8 weeks) and chronic coughs, which persist for longer than 8 weeks.4,5 See Practice point 2.

a cough can also be distinguished by its symptoms. a productive (wet or ‘chesty’) cough produces sputum and expels secretions from the lower respiratory tract.4 clear or white sputum is considered normal whereas thick yellow, green or brown sputum may be due to a lower respiratory tract infection such as bronchitis (although this is not considered a reliable diagnostic indicator).4,6


Practice point 1

Causes of cough

in adults

acute cough (<2 weeks): upper and lower respiratory tract infections, environmental or occupational exposure to irritants, exacerbation of a pre-existing condition (e.g. chronic obstructive pulmonary disease or asthma, acute pulmonary embolism, foreign body aspiration).4,5

subacute (3–8 weeks): Post-infection (due to airway inflammation, disruption of epithelial integrity, mucus hypersecretion, transient airway responsiveness), upper airway cough syndrome, whooping cough, gastro-intestinal reflux disorder.4,5

Chronic (>8 weeks): allergic rhinitis, asthma, bronchiectasis, chronic bronchitis, chronic rhinosinusitis, environmental exposure (e.g. tobacco smoke, dust, asbestos, pollutants, allergens, chemicals), gastro-oesophageal reflux disease (gord), heart failure, medicines (e.g. ace inhibitors, beta-blockers, nsaids), obstructive sleep apnoea, protracted bacterial bronchitis, psychogenic cough, tuberculosis.4,5

in children

acute viral respiratory infection, cough in the absence of other symptoms (i.e. rhinorrhoea, fever, and malaise) may be related to pneumonia or bronchiolitis, asthma (predominant nocturnal cough), pertussis (paroxysms of coughing), gastro-oesophageal reflex disease (gord) (more prevalent with feeding and usually accompanied by reflux), suppurative lung disease (cough more prevalent in the morning), or foreign bodies (usually associated with choking).25

Facts Behind the Fact Cardtreating coughs and colds Pharmacist cPd module number 259

an acute non-productive (dry) cough is dry, tight, tickly and irritating.7 it may be due to a recent cold or influenza (post-viral cough) or caused by dry atmosphere, air pollution or a change in temperature.6 this type of cough has no obvious physiological purpose and produces no sputum.4,7 a patient presenting with a chronic non-productive cough should be referred for further examination as it may be due to an underlying condition.4 however, chronic coughs caused by upper airways cough syndrome (uacs) (previously known as post-nasal drip) can be managed by a pharmacist.6 See Practice point 3.

asking symptom-based questions about the cough helps to determine the cause, the most appropriate treatment and if referral is needed. See Table 1.

Treatment options

the initial treatment of cough is to specifically manage the cause of the cough. once this has been addressed, cough treatment involves managing cough symptoms by8:

• avoiding exposure to environmental factors that can cause coughing

• practising vocal hygiene measures (e.g. adequate hydration, avoiding vocal strain, smoking cessation, reducing alcohol, reducing caffeine intake)9 and using methods such as steam or honey

• using medicines such as sedating antihistamines, high-dose proton pump inhibitors, short-term cough suppressants, low-dose inhaled corticosteroids, or a trial of nebulised lignocaine in severe cases.

an acute non-productive or productive cough is often self-limiting. over-the-counter (otc) medicines are

Table 1. symptom-based questions6 ask questions about… explanation/rationale

Characteristics of the cough • Wet, chesty – produces sputum; may be a post-viral cough, if >2 weeks consider chronic bronchitis, bronchiectasis or cystic fibrosis

• Dry cough – no sputum; may be a post-viral cough or due to an allergic reaction

• A whooping cough – possibly pertussis. Ask about immunisation history

• Chronic – adults: may suggest asthma, rhinitis, gastro-oesophageal reflux disease (GORD) or adverse reaction to medicine; child: may suggest asthma, bacterial bronchitis, physiological abnormalities; refer to doctor

• Wheeze and difficulty breathing may be associated with asthma; refer to doctor

• Barking ‘brassy’ cough, hoarse voice, stridor – associated with croup in children

Sputum colour • Clear and white – no infection

• Yellow, green or brown – usually indicative of infection

• Rust-coloured – may indicate pneumonia

• Pink-tinged – left ventricular failure

• Dark red – carcinoma

Nature of sputum • Thin and frothy – left ventricular failure

• Thick, yellow – possibly asthma

• Strong, foul-smelling – bronchiectasis or abscess

Time of onset Morning – may be UACS, bronchiectasis, chronic bronchitis

Duration Acute <2 weeks, sub-acute 3–8 weeks, chronic >4 weeks; may indicate cause

How often Adult: recurrent may suggest chronic bronchitis (especially if smoker)

Child: if a family history of allergy, asthma or hay fever may suggest asthma; referral is required

Age Adult: with increasing age, may suggest carcinoma, bronchitis, or pneumonia

Child: suggestive of URTI but consider asthma if cough is at night and non-productive

Smoking history Chronic and recurrent cough common in people who smoke that can develop into chronic bronchitis and emphysema

Cough in a child May be associated with an inhaled foreign body


John bell says

Practice point 2

symptoms of cough

acute cough is a common symptom often associated with a viral upper respiratory tract infection (urti) but may also be a sign of an underlying condition. this type of cough can appear suddenly and occur with fever, rhinorrhoea and/or sore throat. an acute cough associated with a viral urti is self-limiting, is often non-productive, may get worse in the evening and will cease within 1–2 weeks of the infection clearing.3,4,11

infants and young children may develop an acute cough caused by croup. it may be harsh and sounds like a bark, and is often associated with difficulty breathing and an inspiratory stridor (noisy breathing). referral for further medical review is required if a patient presents with these symptoms.4,29

subacute cough may occur after an infectious cough. a subacute cough tends to present as a persistent non-productive cough that can last up to eight weeks. it usually resolves without treatment. however, if the cough persists and is affecting the patient’s sleeping and lifestyle, refer the patient for further medical review as an inhaled corticosteroid therapy may be required. antibiotic therapy has no role in treatment of this type of cough.4

Chronic cough can be associated with certain medical conditions and some medicines (see Practice point 1). it is often associated with the chronic inhalation of cigarette smoke either actively or passively.2 Patients experiencing this type of cough should be encouraged to cease smoking.11 this type of cough requires regular monitoring and review.4

Facts Behind the Fact Card

frequently recommended however, there is little evidence for or against their efficacy in either adults or children.10,11 the principles of evidence-based medicine and the potential for adverse effects should be considered before recommending otc cough preparations.4 if a cough lasts longer than two weeks, refer the patient for further examination.4 See Practice point 2.

Non-productive cough

many otc cough preparations for non-productive cough contain demulcents, suppressants and sedating anti-histamines. See Table 2.

demulcents may suppress coughing by forming a protective layer over the pharynx and relieve the irritation that triggers a dry cough especially at night.12 they can be given safely to children.11 these preparations include cough syrups that contain sugar, glycerol or honey.12 honey is considered to have bactericidal properties and it is thought to be effective in relieving the symptoms of urti, including cough. in some studies, honey has been given as a single dose before bedtime or diluted in a drink. however, a cochrane review of honey for acute cough has concluded that there is no strong evidence for or against the use of honey in acute cough in children.13 honey should not be given to children under 12 months of age due to the risk of botulism.12,14

cough suppressants/antitussives act to depress the cough reflex to reduce the frequency and intensity of coughing. they provide symptomatic relief of a non-productive cough.11 the use of medicine to suppress this type of cough should be based on either the underlying disease or the symptoms the patient is experiencing.3,4

sedating (first generation) antihistamines have been used for non-productive coughs associated with allergic rhinitis.4 their action relates to drying mucous membranes.6 if the cough is productive, avoid sedating anti-histamines due to the risk of mucus plugs forming.11 non-sedating antihistamines are not effective in reducing cough in patients with the common cold.15

Productive cough

most otc cough preparations for productive coughs contain expectorants and mucolytics.

expectorants may increase bronchial mucus production making secretions easier to remove by coughing or ciliary transport.10 guaifenesin, a commonly used expectorant, is believed to increase sputum volume and decrease its viscosity, allowing effective cough in patients with urti.15 however, guaifenesin may also exert some antitussive effect by inhibiting cough reflex sensitivity explaining its use for symptomatic relief of dry, non-productive cough.15,16

treating coughs and colds Pharmacist cPd module number 259

Table 2. Drug choice in treating cough2,4,11 type of cough agent example dose formulation

Dry Demulcent Sucrose, glycerol, honey

Honey – Child: >12 months: 1–2 teaspoons 30 mins before bedtime

Oral liquid

Lozenge

Opioid cough suppressant/ antitussive

Codeine Adult: 15–30 mg 3–4 times daily Oral liquid

Tablet

Pholcodine Adult: 10–15 mg 3–4 times daily

Child: 6–12 years, 2.5–5 mg 3–4 times daily

Oral liquid

Lozenge

Dihydrocodeine Adult: 5–10 mL every 4–6 hours Oral liquid

Dextromethorphan Adult: 10–20 mg every 4 hours OR every 6–8 hours (max 120 mg daily)

Oral liquid

Lozenge

Chesty Expectorant Guaifenesin 200 mg every 4 hours Oral liquid

Senega and ammonia

10–20 mL up to 4 times daily Oral liquid

Mucolytic Bromhexine Adult: 8–16 mg 3 times daily

Child: >6 years, 8 mg 3 times daily

Oral liquid (multi-use bottles and single-use sachets)

Tablet (solid and dissolvable)


Practice point 3

upper airway cough syndrome

upper airway cough syndrome (uacs), previously known as post-nasal drip is often caused by allergy or secondary to a variety of rhinosinus conditions including allergic or vasomotor rhinitis, rhinitis medicamentosa or pregnancy-associated rhinitis.4,6,30,31 it is the most common cause of chronic cough and is associated with sinus discharge running down the back of the throat causing frequent coughing (or throat clearing) and may worsen when lying down.6,30

if a patient presents with an acute cough, check if they are clearing their throat more frequently and swallowing mucus. ask if the patient is also experiencing symptoms associated with allergies such as sneezing, nasal discharge, conjunctivitis and itching of the oral cavity, as uacs is often associated with allergies.6 check when the patient is experiencing the cough, such as during times of the year known for increased airborne allergens.

if the cause of uacs can be identified, treat the cause first. this may involve avoiding allergens and irritants or reducing and ultimately ceasing use of nasal decongestants for rhinitis medicamentosa. if the cause is unknown, a sedating antihistamine may be helpful.11,30

related fact cards Colds and flu

Coughs

Sinus problems

Pain relievers

Cold sores

mucolytics such as bromhexine are included in cough preparations for productive cough to decrease bronchial mucus viscosity making it easier to clear mucus by coughing.10 there is limited evidence for efficacy and should not be used for patients with chronic bronchitis or coPd.11

bromhexine and guaifenesin are combined in cough preparations to offer symptomatic relief from productive coughs especially if there is excess mucus present.17 however, some combination products have doubtful therapeutic value.16 the combination of an expectorant and a suppressant should be avoided even though the drug doses may be suboptimal.11

it is preferable to recommend a single ingredient cough preparation consisting of either a demulcent, opioid cough suppressant, expectorant or mucolytic rather than a combination cough product.11 See Table 2.

When to refer

Patients with a cough associated with certain symptoms, should be referred for further medical examination. these symptoms include4,6:

• a cough lasting longer than 2 weeks

• chest pain

• persistent fever

• stridor or other respiratory noises

• cough that recurs on a regular basis including nocturnal cough especially in children

• cough associated with flu-like symptoms

• haemoptysis

• pain on inspiration

• discoloured or purulent sputum

• suspected adverse reaction

• wheeze and/or shortness of breath.

treating coldscolds are generally caused by a viral infection of the upper respiratory tract (urt) that is usually acute, mild and self-limiting.7 typically cold symptoms include a sore throat, occasionally a fever (a temperature of 38.5 °c or higher), sneezing, nasal discharge, nasal congestion and a cough.18 hoarseness, loss of taste and smell, mild burning of the eyes, and a feeling of pressure in the ears or sinuses, due to obstruction and/or mucosal swelling, may also occur. thirty percent of colds also feature a cough that starts after nasal symptoms lessen. a mild increase in body temperature may occur and infants and young children are more likely to develop higher temperatures. infants may be irritable, have a blocked nose which may cause difficulty feeding, and develop diarrhoea.19

Table 3. Differentiating between common cold and flu7,8,16

common cold influenza

cause Viral infection Viruses Influenza A and B

Speed of onset Develops over 7 days Appears suddenly

Spread Spread through droplets and contact with fomites (virus-contaminated objects), so infection control precautions (e.g. hand hygiene, patient isolation, use of personal protective equipment) are essential

Symptoms Rhinorrhoea, nasal congestion, sneezing, coughing, headache, sore throat, tiredness, earache, facial pain, red and watery eyes

More severe than cold symptoms

Sore throat, fever, headache, muscle aches and soreness, congestion, and cough

Swine flu is also associated with vomiting and diarrhoea, high fever, sweating, aching muscles and joints, weakness, fatigue, loss of appetite

diagnosis Symptomatic Nucleic acid amplification tests (NAATs)

duration Generally self-limiting and lasts for 7–10 days

Can last up to several weeks

treatment Symptomatic treatment, e.g. rest, increased fluids, pain relief

In an otherwise healthy individual, symptomatic treatment, e.g. rest, increased fluids, pain relief

Those at high risk of complications, consider antiviral therapy:

Oseltamivir 75 mg (child: 1 year or older and <15 kg: 30 mg; 15-23 kg: 45 mg; 23–40 kg: 60 mg; >40 kg: 75 mg) orally, 12-hourly for 5 days

Zanamivir (adult and child 5 years or older) 10 mg by inhalation using the device provided, 12-hourly for 5 days



John bell says

Table 4. Common cold symptoms and treatment options7,11,22

Symptom treatment option comments example

Sore throat Soothing agents, e.g. honey, sucrose

Act to sooth throat and reduce coughing

Contained in lozenges

Difflam Honey and lemon lozenges

Analgaesics, e.g. paracetamol, NSAIDs

Act to relieve pain associated with sore, irritated throat

Dimetapp capsules, Lemsip capsules and powder, Panadol products

Anti-inflammatories, e.g. NSAIDs – benzydamine, flurbiprofen

Reduce throat inflammation and associated pain

Available in lozenges, throat gargles, throat sprays

Difflam lozenges and Anti-inflammatory Throat Spray, Nurofen Cold and Flu tablets, Strepfen Intensive lozenges

Antiseptics, e.g. povidone-iodine, amylmetacresol, cetylpyridinium, dichlorobenzyl alcohol

Help to kill micro-organisms

Available in lozenges, throat gargles and spray

Difflam Sore Throat Gargle with Iodine

Local anaesthetics, e.g. lignocaine, benzocaine

Numbs throat to provide pain relief

Available as lozenges and gargles

Difflam Anaesthetic lozenges

Nasal congestion

Decongestants, e.g. oxymetazoline, phenylephrine, pseudoephedrine, xylometazoline

Provide short-term relief of congestive symptoms

Can cause rebound congestion when used continuously for more than 5 days

May cause agitation, insomnia, anxiety and increase blood pressure

Available as single or combination preparations in tablets, liquid and nasal spray

Duro-Tuss liquid, lozenges and tablets, Sudafed Sinus Day and Night Relief tablets, Robitussin liquid and tablets

Saline Sooth inflamed nasal passages

Loosens and softens mucus

Available as a spray

Fess, Narium, Otrivin Saline Plus

Sneezing and nasal discharge

Sedating antihistamines, e.g. chlorpheniramine, diphenhydramine, promethazine

Dry up mucus in nose and airways

Less-sedating antihistamines have not been shown to be of benefit in treating cold symptoms

Available single or in combination

Benadryl for the Family syrup, Demazin syrup and tablets

Ipratropium Rapid onset of action

Can cause nasal dryness, irritation and headache

Atrovent Nasal Spray

Raised temperature

Paracetamol First choice of treatment for raised temperature

Available as single or combination

Codral, Demazin,

Dimetapp, Lemsip, Panadol, Robitussin Cold and Flu tablets

Aches and pains

Paracetamol

NSAIDs

Used to treat pain associated with sore throat, headache, muscle aches and sinus pain

Available as single or in combination preparations

Nurofen Cold and Flu, Nurofen Sinus Pain, Panadol Sinus Pain and Congestion

Cough Demulcents

Expectorants

Mucolytics

Suppressants

Sedating antihistamines

See Table 2

Available as single or in combination preparations

Duro-Tuss liquids, lozenges and tablets, Bisolvon liquid, pastilles and tablets, Dimetapp capsules and liquid, Rikodeine Vicks Cough Syrup for Chesty Coughs

Practice point 4

oTC cough and cold medicines for children

tga recommendations for the sale of otc cough and cold medicines for children include the following23:

• children under 6 years should not be given medicines to treat cough and cold symptoms.

• children aged 6–11 years should only be given medicines to treat cough and cold symptoms on the advice of a doctor, pharmacist or nurse practitioner.

• if a cough and cold medicine is indicated for children aged between 6–11 years, the correct dosage should be included on the label to avoid guesswork.

• cough and cold medicines should be in child-resistant packaging.

• Particular efforts should be made to inform consumers and health professionals that children under 6 years should not be given cough and cold medicines.

• there is no need to change the scheduling of these medicines or their availability through pharmacies or other retail stores.




treating children 6 years and under otc cough and cold medicines are not recommended for children under 6 years of age. there is a lack of evidence for either efficacy or safety to support the use of these medicines in this age group. although there are no immediate safety risks, the potential risks outweigh the limited benefits of using otc cough and cold preparations.23,24 See Practice point 4.

Pharmacists should keep parents and caregivers informed of the most current evidence-based information about the treatment of coughs and colds in children including3,24,25:

• most coughs and colds don’t require treatment and will not respond to antibiotics

• cough and cold medicines are of no proven benefit and may be harmful to children under the age of six years

• most viral respiratory infections are self-limiting and that cough and cold products will not change the duration of their child’s illness

• expected time course of symptoms for coughs and colds is usually 5–7 days but can be up to 3 weeks

• encourage the parent to see a pharmacist, doctor or nurse practitioner if their child’s symptoms do not improve, or worsens (e.g. if a suspected foreign body, tachypnoea, dyspnoea, vomiting, inability to feed, persistent fever, lethargy)

• provide consistent information about the use of cough and cold medicines in children which is in line with tga advice.

Patient information:

• nPs medicineWise cough and cold brochure www.nps.org.au/__data/assets/pdf_file/0004/211567/nPs-Cold-and-Flu-Brochure-may-2014.pdf

Pharmacist information:

• Psa factsheet: changes to cough and cold medicines for children. at: www.psa.org.au/supporting-practice/tga-advice/tga-advice-cough-and-cold-medicines-for-children

• nPs medicineWise factsheet: over-the-counter cough and cold remedies – not for young children. at: www.nps.org.au/publications/health-professional/health-news-evidence/2012/over-the-counter-cough-and-cold-remedies-not-for-young-children

Cold and flu – differential diagnosis

differentiating between a ‘cold’ and ‘the flu’ can be difficult. initially, influenza presents with systemic symptoms including fever, rigors, headaches, myalgia, malaise, and anorexia.19 both are due to viral infections, however influenza presents with more severe symptoms that appear rapidly. See Table 3.

Treatment options

all cold treatments are designed to provide symptomatic relief.19 there are many cold preparations available and most are a combination of ingredients including decongestants, antihistamines, and analgesics, as well as cough suppressants and expectorants.20 only recommend combination cold treatments if the patient has multiple cold symptoms such as muscle aches, nasal congestion and cough symptoms.20 however, in many cases symptomatic relief can be achieved with monotherapy or a product with two active ingredients. multi-ingredient preparations have a limited role in the management of cold symptoms.6

When treating cold symptoms, initially address any underlying causes. recommend adequate fluid intake. Provide the patient with information about the self-limiting nature of colds and that their symptoms will usually be resolved in 7–10 days. also inform the patient that antibiotic treatment of urti does not alter the clinical outcome of the illness or prevent further complications. give the patient written information about coughs, colds and flu.4,19,21

see table 4 for symptomatic treatment options of the common cold. the patient’s symptoms and medication history need to be identified, then the most appropriate single or combination treatment recommended.6,20

When to refer

if a patient is experiencing the following symptoms, they should be referred for further review. these symptoms include7:

• fever

• discoloured sputum

• shortness of breath and/or wheezing

• chest pain.

• therapeutic goods administration factsheet: otc cough and cold medicines for children – final outcomes of tga review. at: www.tga.gov.au/otc-cough-and-cold-medicines-children-final-outcomes-tga-review

Treatment options

supportive therapies are the main treatment options for children under 6 years with a cough or cold due to an urti.3

these therapies include3,19,25:

• simple non-pharmacological cough mixtures (e.g. paediatric simple linctus or those containing glycerol or honey and lemon) may be helpful to provide symptomatic relief

• one-to-two teaspoons of honey taken 30 minutes prior to bedtime may be helpful for children over 12 months of age

• steam and vapour in a closed room or shower, may be effective in the relief of nasal congestion, but care must be taken to avoid burns

• menthol-based rubs placed on the child’s clothing may ease nocturnal cough

• maintain hydration as a fever can lead to mild dehydration due to sweating, causing tiredness and headache

• saline nasal sprays or drops (e.g. Fess, Narium) to help thin nasal secretions, which may be helpful for young children and babies especially just before feeding

• rest and stay home from childcare or school and avoid exposure to cigarette smoke

• paracetamol or ibuprofen for pain relief in children caused by sore throat, muscle pain or high fever (a temperature higher than 38.5 °c).

Complementary therapies

some cough and cold preparations recommended for children contain complementary therapies. common agents include echinacea, vitamin c and zinc. there is little evidence of any therapeutic benefit from these agents.24

ivy leaf extract (hedera helix) is used to treat conditions including chronic bronchitis in children and coughs and is thought to exert an expectorant and antispasmodic action on the respiratory tract.26 although there has been some research into its effectiveness and safety in children under the age of 18 years, further research is needed.26 ivy leaf extract


John bell says

preparations have been shown to be safe when taken at recommended doses and are well tolerated.27 ivy leaf extract is contained in duro-tuss children’s cough liquid, blackmores cough combat ivy leaf extract, Prospan chesty cough relief and lozenges.

lactoferrin, a glycoprotein, is found in many biological fluids such as tears, saliva, nasal and bronchial secretions, gastrointestinal fluids, colostrum and particularly breast milk. there is some evidence for its use as a cold preventative and in reducing the symptoms of cold.28

lactoferrin is contained in faulding immune biotic and duro-tuss cough liquid 6 months+.

references1. NPS MedicineWise. Common cold. 2014. At: www.nps.org.au/

conditions/respiratory-problems/respiratory-tract-infections/for-individuals/conditions/common-cold

2. De Blasio F, Virchow JC, Polverino M, et al. Cough management: a practical approach. Cough 2011;7(7). At: www.coughjournal.com/content/7/1/7

3. Wurzel DF, Marchant JM, Chang AB. Drug treatments of childhood coughs. Aust Prescr 2014;37:115–9. At: www.australianprescriber.com/magazine/37/4/115/9

4. Sansom LN, ed. Australian pharmaceutical formulary and handbook. 23rd edn. Canberra: Pharmaceutical Society of Australia; 2015. p. 524–7.

5. Gibson PG, Chang AB, Glasgow NJ, et al. CICADA: cough in children and adults: diagnosis and assessment. Australian cough guidelines summary statement. Med J Aust 2010;192(5):265–71. At: www.mja.com.au/journal/2010/192/5/cicada-cough-children-and-adults-diagnosis-and-assessment-australian-cough

6. Rutter P, Newby D. Community pharmacy: symptoms, diagnosis and treatment. Australia and New Zealand edition. 2nd edn. Sydney: Churchill Livingstone Australia; 2011.

7. Pharmaceutical Society of Australia. Non-prescription medicines in the pharmacy: a guide to advice and treatment. Canberra: PSA; 2012.

8. Respiratory tract infections: Cough. In: eTG complete. Melbourne: Therapeutic Guidelines; 2014. At: http://online.tg.org.au/complete/

9. Patient.co.uk. Hoarseness. 2014. At: www.patient.co.uk/doctor/hoarseness-pro

10. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub5.

11. Rossi S, ed. Australian medicines handbook. Adelaide: Australian Medicines Handbook; 2015. At: www.amh.net.au/online/view.php?page=index.php

12. MyDr. Cough: dry cough treatments. 2014. At: www.mydr.com.au/respiratory-health/cough-dry-cough-treatments

13. Oduwole O, Meremikwu MM, Oyo-Ita A, Udoh EE. Honey for acute cough in children. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD007094. DOI: 10.1002/14651858.CD007094.pub4.

14. Centers for disease control and prevention. Botulism. 2014. At: www.cdc.gov/nczved/divisions/dfbmd/diseases/botulism/

15. Dicpinigaitis PV, Colice GL, Goolsby MJ, et al. Acute cough: a diagnostic and therapeutic challenge. Cough 2009;5(11). At: www.coughjournal.com/content/5/1/11

16. Cough and cold preparations. In: eTG complete. Melbourne: Therapeutic Guidelines; 2014. At: http://online.tg.org.au/complete/

17. MDbriefcase. Managing cough as a symptom in general practice. 2014. At:

18. NPS MedicineWise: What are the symptoms of a cold? 2014. At: www.nps.org.au/conditions/respiratory-problems/respiratory-tract-infections/for-individuals/conditions/common-cold/for-individuals/symptoms

19. Patient.co.uk. Upper respiratory infections – coryza. 2014. At: www.patient.co.uk/doctor/upper-respiratory-infections-coryza

20. WedMD. Cold, flu, and cough health center: cough medicine and cough syrups. 2012. At: www.webmd.com/cold-and-flu/cold-guide/cough-syrup-cough-medicine?page=2

21. NPS MedicineWise: Colds, coughs and flu: what you can do patient brochure. 2014. At: www.nps.org.au/__data/assets/pdf_file/0004/211567/NPS-Cold-and-Flu-Brochure-May-2014.pdf

22. eMIMS cloud. Sydney: MIMS Australia Pty Ltd; 2015.

23. Therapeutics Goods Administration. OTC cough and cold medicines for children – Final outcomes of TGA review. 2012. At: www.tga.gov.au/otc-cough-and-cold-medicines-children-final-outcomes-tga-review

24. Sung V, Cranswick N. Cough and cold remedies for children. Aust Prescr 2009;32:122–4. At: www.australianprescriber.com/magazine/32/5/122/4

25. The Royal Children’s Hospital Melbourne. Cough. 2012. At: www.rch.org.au/kidsinfo/fact_sheets/Cough/

26. NPS MedicineWise. Ivy leaf extract for children’s coughs. 2014. At: www.nps.org.au/topics/how-to-be-medicinewise/Medicinewise-questions/medicinewise-questions/ivy-leaf-extract-for-childrens-coughs

27. Grabo-Strauss M, Atiye S, Warnke A, et al. Observational study on the tolerability and safety of film-coated tablets containing ivy extract (Prospan Cough Tablets) in the treatment of colds accompanied by coughing. Phytomedicine 2011;18(6):433–436.

28. Vitetta L, Coulson S, Beck SL, et al. The clinical efficacy of a bovine lactoferrin/whey protein Ig-rich fraction (Lf/IgF) for the common cold: a double blind randomized study. Complement Ther Med 2013;21(3):164–71.

29. The Royal Children’s Hospital Melbourne. Croup (laryngotracheobronchitis). 2011. At: www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/

30. Pratter MR. Chronic Upper Airway Cough Syndrome Secondary to Rhinosinus Diseases (Previously Referred to as Postnasal Drip Syndrome): ACCP Evidence-Based Clinical Practice Guidelines. Chest 2006;129(1_suppl):63S-71S

31. Medscape. Chronic cough. 2014. At: http://emedicine.medscape.com/article/1048560-overview

Sarah’s cough appears to be a symptom of a mild, acute URTI. You explain to Sarah that her infection is self-limiting, and symptoms usually resolve within 7–10 days.

After questioning, Sarah tells you that her cough is chesty and is worse at night. You suggest the use of a combined mucolytic/expectorant cough liquid as it may provide symptomatic relief of the cough caused by a build-up of excess mucus.

You also offer Sarah some saline nasal drops to clear and thin nasal secretions, some paracetamol for any associated pain or fever, and advise her to drink more fluids to remain well hydrated. You encourage her to return to the pharmacy if she does not feel better in 1–2 weeks.

You provide her with Colds and flu and Coughs PSA Self Care Fact Cards.




Circle one correct answer from each of the following questions.

before undertaking this assessment, you need to have read the facts behind the fact card article and the associated fact cards. this activity has been accredited by Psa as a group 2 activity. two cPd credits (group 2) will be awarded to pharmacists with four out of five questions correct. Psa is accredited by the australian Pharmacy council to accredit providers of cPd activities for pharmacists that may be used as supporting evidence of continuing competence.

Please submit your assessment by 30 June 2015

submit answers

submit online at www.psa.org.au/selfcare

fax: 02 6285 2869

mail: self care answers Pharmaceutical society of australia Po box 42 deaKin West act 2600

accreditation number: cs150005

this activity has been accredited for 2 group 2 cPd credits suitable for inclusion in an individual pharmacist’s cPd plan.

— — — — — —Personal id number:

full name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

suburb: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . state: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Treating coughs and coldsassessment questions for the pharmacist

Please retain a copy for your own purposes. Photocopy if you require extra copies.

1. Which onE of the following regarding acute cough is CorrECT? acute cough is defined as a cough:

a) lasting up to 2 weeks.

b) associated with a condition recognised to cause cough.

c) Persisting after therapy.

d) lasting more than 8 weeks.

2. Which onE of the following BEsT describes the combined use of guaifenesin and dextromethorphan? This combination is:

a) first-line therapy for cough associated with the common cold.

b) not as effective as concomitant use of guaifenesin and codeine.

c) generally considered to be irrational.

d) appropriate for treatment of a productive cough.

3. Which of the following antitussives is recommended for use in children aged 2–6 years?

a) codeine.

b) dextromethorphan.

c) Pholcodine.

d) none of the above.

4. regarding treatment for cold symptoms, which onE of the following statement is CorrECT?

a) echinacea is effective in reducing symptom duration and severity in children.

b) it is preferable to recommend a single ingredient cough and cold preparation rather than a combination product.

c) although cold preparations are not recommended for children under 6 years, there is conclusive evidence supporting the efficacy of these preparations in adults.

d) antibiotic treatment of urti is effective in preventing further complications from the condition.

5. a patient presents with an acute, non-productive cough. The first treatment option that is mosT likely to be offered is:

a) attempt to identify any underlying cause of the cough and treat or refer patient if necessary.

b) reassure the patient and suggest supportive treatments such as rest, hydration and pain relief as appropriate.

c) refer the patient to a doctor for further medical review.

d) recommend the patient an opioid cough suppressant preparation.


73141RikodeineDstrs 2015-04-21T15:03:27+10:00

requests for cough and cold treatments are very common in the pharmacy especially as the cooler weather arrives. it is important that you know what questions to ask, when it is appropriate to recommend a product and when to refer the customer to the pharmacist.

Treating coughs and coldsby Jill malek This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.

Maria has two children, Peter aged 4 years and Michael aged 12 years. Both have blocked noses and a cough and she would like a cough syrup to help treat their symptoms. She has used Duro-Tuss Dry Cough Liquid plus Nasal Decongestant for her children previously for a cold but thinks the children may have the flu.

coughcoughing helps to clear the airways. coughing is caused by an irritation of the lining of the throat and lungs. this irritation may be due to an infection such as a common cold or influenza (flu), an allergy, changes in temperature, something in the throat, an irritant (e.g. cigarette smoke) or inflammation (swelling). coughing may also be a symptom of a serious illness or a side effect of a medicine.

treatment for a cough depends on what is causing the cough and the type of cough.

Types of cough

coughs are usually classed as either dry (non-productive) or chesty (productive).

• a dry cough is described as dry, tight, tickly and irritating. this type of cough produces no sputum or phlegm (thick mucus). it can be worse at nights when lying down and cause disrupted sleep. for example, upper airways cough syndrome (previously known as post-nasal drip) is associated with a non-productive cough and a constant clearing of the throat.

• a chesty cough produces phlegm. it is often described as ‘wet’. the phlegm is usually clear or white. if the phlegm is yellow, green or brown, if may be a sign that there is an infection such as bronchitis. a chesty cough may also be a sign of asthma, heart failure or chronic bronchitis.

some coughs have a distinctive sound. croup is an infection of the throat and is associated with a harsh, barking cough. it is often worse at night when the air is cooler. croup is usually seen in children under 5 years old but sometimes it may occur in older children (aged between 3–8 years).

Common colds and the ‘flu’ (influenza) are viral infections affecting the nose, sinuses, throat and airways. Antibiotics do not work against viral infections. Colds and the flu usually get better on their own. Medicines may relieve some of the symptoms of colds and flu.

Flu (influenza) symptoms are like cold symptoms, but are usually more severe and may also include:

• fever and chills (sweating and shivering)

• aching muscles and joints• feeling weak • loss of appetite, nausea and vomiting• diarrhoea.

Most cold and flu symptoms usually last less than 10 days. A cough may last longer.

Protection against influenzaA ‘flu injection’ will give protection against the flu. It is best to have the flu vaccine in autumn each year, as influenza is most common from late autumn to early spring. The flu vaccine is especially recommended for people over 65 years and their carers, adults with certain medical conditions, pregnant women, Aboriginal and Torres Strait Islander people aged

Colds and flu

EAR, NOSE & THROAT

When someone has a cold or the flu, the fluid from their nose, mouth and airways contains the infecting virus. Colds and flu spread when this infected fluid passes to someone-else (e.g. by touch, coughing, sneezing). Colds spread easily, especially between children who spend a lot of time together (e.g. at childcare or school). A cold is most easily spread (infectious) in the first one or two days after symptoms develop.

Signs and symptomsCold symptoms include:

• runny nose• blocked nose (congestion)• sore throat• red, watery eyes• sneezing• cough• fever• headache • feeling tired.

The common cold, allergy and cigarette smoke are common causes of coughing, but a cough can also be a symptom of a serious illness or a side effect of a medicine. Treatment for a cough depends on its cause.

• lungdisease(e.g.cysticfibrosis,chronicbronchitis,cancer)

• gastro-esophagealreflux(heartburn)–stomachacidrisesupintotheoesophagusandcausescoughing

• heartfailure• anxietyandhabit• somemedicines(e.g.anti-inflammatorypainrelieversandsomebloodpressuremedicines).

Coughs

EAR,NOSE&THROAT

Coughingisanormalreflextoprotectandcleanourairways(respiratorytract).Coughingclearsirritatingmaterial(e.g.smokeordust)andexcesssecretions(mucus,sputum,phlegm)fromourthroat,airpassagesandlungs.Thesoundandpatternofacoughdependsonitscause.

Causes of coughingCoughisasymptomofanumberofmedicalconditions.Sometimesapersonmayhavemorethanonereasonforcoughing.

Causesofcoughinginclude:

• post-nasaldrip–mucusfromthenoseandsinusesrunsdownthebackofthethroat.Oftencausedbyallergy,commoncoldsorsinusinfection

• asthma• respiratorytractinfections(e.g.colds,bronchitis,croup,whoopingcough,pneumonia)

• inhaledirritants(e.g.cigarettesmoke,dust,fumes,aforeignobject)

Counter Connectiontreating coughs and colds Pharmacy assistant’s education module 259


John bell says

Treatment

cough treatments will not cure a cough; they may help relieve the symptoms of cough. treating a cough depends on the symptoms and the type of cough. if a customer has a dry, non-productive cough, recommend a treatment that soothes the throat and/or suppresses (stops) the cough. if the cough is chesty and productive, recommend a cough treatment that contains an expectorant and/or mucolytic agent that may help break up the mucus making it easier to cough up. a cough medicine that suppresses a cough is not suitable for a chesty cough. See Table 1.

cough medicines may contain multiple ingredients to treat a range of symptoms. some cough medicines contain antihistamines to dry up a runny nose. others contain paracetamol or ibuprofen to relieve pain and fever. ensure the customer has the symptoms to be treated with these ingredients. if not, recommend a cough treatment containing a single ingredient to treat a single symptom.

always ask the customer if they are taking other medicines. some medicines may interact with ingredients in cough medicines. combination products can contain ingredients not suitable to be taken during pregnancy. guaiphenesin and bromhexine are safe in pregnancy. table 1 lists examples of different treatment options for dry and chesty coughs.

coldscolds are caused by viruses. there are no medicines that can cure a cold. some medicines such as cough suppressants, expectorants and mucolytics, antihistamines, pain relievers and decongestants may ease the symptoms of colds and flu. antibiotics do not work against viral infections and are not useful for treating colds.

Table 1. Treatment options for dry and chesty coughs

type of cough

treatment option comments

Dry suppressant

Pharmacy medicines (Schedule 2)

• Pholcodine (e.g. Duro-Tuss Dry Cough Liquid and Lozenges, Difflam Anti-inflammatory Lozenges with Cough Suppressant)

• Dextromethorphan (e.g. Bisolvon Dry Liquid and Pastilles, Benadryl for the Family Dry Forte, Robitussin Dry Cough Forte)

Pharmacist Only medicines (Schedule 3)

• Dihydrocodeine (e.g. Rikodeine)

• May give relief of dry (non-productive) cough

• Suppresses the urge to cough

• Should not be given for a chesty cough

• Avoid in airway diseases, e.g. asthma

• Available as cough syrup and lozenges

Chesty Expectorant

Pharmacy medicines (Schedule 2)

• Guaiphenesin and bromhexine (e.g. Duro-Tuss Chesty Forte Cough Liquid and Tablets, Benadryl Chesty Forte, Dimetapp Chesty Cough Elixir, Robitussin Chesty Cough Forte)


• Guaiphenesin and pseudoephedrine (Robitussin Chesty Cough & Nasal Congestion PS Oral Liquid)

• Help to cough up phlegm, and include guaiphenesin and ammonium chloride

• Available as capsules or cough syrups; some are sugar-free

• Pseudoephedrine is a nasal decongestant that unblocks the nose; may cause rapid heartbeat, anxiety, restlessness, trouble sleeping and a dry mouth

• Ask about any medical conditions, e.g. high blood pressure

• If recommending a combined product, ask if the customer is using any other product, e.g. paracetamol

mucolytic

Pharmacy medicine (Schedule 2)

• Bromhexine (Bisolvon Chesty Forte, Bisolvon Chesty Kids, Duro-Tuss Chesty Cough Liquid Bromhexine)


• Bromhexine and pseudoephedrine (Bisolvon Chesty Cough Liquid plus Nasal Decongestant)

• Helps break down thick, sticky mucus in the chest, making it easier to cough up

• Bromhexine can occasionally cause stomach upsets

• Pseudoephedrine is a nasal decongestant that unblocks the nose; it may cause a rapid heartbeat, anxiety, restlessness, trouble sleeping and a dry mouth

• Ask if using products with similar ingredients, e.g. pseudoephedrine

Difference between common cold and flu

often it may be difficult to tell the difference between the common cold and influenza (the flu). customers may tell you they have the flu when they have a cold. although viruses cause both conditions, the symptoms of the flu are usually more severe and often appear suddenly. it is important to recognise the difference between the common cold and the flu so you provide the most appropriate information and know when to refer to the pharmacist. See Table 2.

if you think the customer is showing signs and symptoms of the flu, refer them to the pharmacist.

Treatment

to relieve the symptoms of a cold, advise customers to:

• rest

• drink plenty of water and non-alcoholic fluids

• avoid exposure to cigarette smoke

• inhale steam to help relieve a blocked nose (check with a doctor or pharmacist before using in children).

to soothe a sore throat and coughing, advise customers to:

• gargle with warm salty water, anti-inflammatory, anaesthetic or antiseptic gargles (avoid in young children)

• suck on an ice cube or a throat lozenge (avoid in young children)

• drink hot water with honey and lemon.

medicines used to ease cold symptoms include:

Decongestants used to treat a blocked or runny nose. they are available as tablets, nasal sprays and drops and should be taken for short-term relief. these agents should be avoided in customers with high blood pressure (e.g. contained in sudafed sinus day and night relief tablets, robitussin liquid and tablets).

sedating antihistamines help to relieve a runny nose but can cause drowsiness. these products are Pharmacist Only medicines and referral to the pharmacist is required (e.g. contained in benadryl syrups). less-sedating antihistamines are indicated for allergic rhinitis and not effective for treating a cold.

Counter Connection treating coughs and colds Pharmacy assistant’s education module 259



simple pain relievers, such as paracetamol and non-steroidal anti-inflammatory medicines (nsaids), are used to ease the pain of a headache, sinus pain, sore throat, aches, fever and shivering (e.g. advil, Panadol, nurofen).

Local anaesthetics are used to ease the pain of sore throats. they are available as lozenges and oral spray and numb the throat (and mouth). When taking these products, care should be taken not to eat or drink hot food because this may result in a burnt mouth and throat (e.g. difflam anaesthetic throat lozenges, cepacaine solution).

anti-inflammatories are used to treat a sore throat. they are available as lozenges, oral rinses and sprays. they have been shown to reduce pain, and inflammation in the mouth and throat (e.g. difflam anti-inflammatory throat lozenges, strepfen intensive throat lozenges).

Combination products

many cold treatments are a combination of medicines. these combination cold treatments should only be taken if the customer has many cold symptoms such as body aches, cough, and nasal and chest congestion. if not, combination treatments may result in a patient taking unneeded medicines or accidently taking excess medicine (e.g. paracetamol).

treatment options for children 6 years and under cough and cold medicines should not be given to children younger than 6 years. refer any child aged 11 years and less to the pharmacist. there are some treatment options that you can recommend for children:

• nasal saline drops (e.g. fess little noses, narium baby) – loosens mucus to relieve blocked noses and clear phlegm. these products are often packaged with a bulb syringe, which can be used to suck the mucus out of the nose (ask the pharmacist for more information).

• soothing syrups (e.g. simple linctus) – forms a protective coating over the throat which may soothe a sore throat and ease a cough.

• Pain relief (e.g. Panadol or nurofen) – relieves pain and fever.

Complementary therapies

some cough and cold preparations recommended for children contain complementary therapies such as echinacea, vitamin c and zinc. more recently other complementary therapies have been included in cough and cold preparations for children including:

• ivy leaf extract (hedera helix) is used to treat conditions including chronic bronchitis in children and coughs. ivy leaf extract preparations have been shown to be safe when taken at recommended doses and are well

tolerated. although there has been some research into its effectiveness and safety in children under the age of 18 years, further research is needed. ivy leaf extract is contained in Prospan cough liquid, duro-tuss children’s cough liquid, little coughs and blackmores cough combat

• Lactoferrin is found in tears, saliva, nasal and bronchial secretions, gastrointestinal fluids, colostrum and particularly breast milk. there is some evidence to suggest it has an anti-viral and immune boosting effect however, more research is needed. lactoferrin is contained in duro-tuss children’s cough liquid.

many parents and caregivers are attracted to complementary therapies as they are seen as natural medicines. however, there is not enough scientific evidence to show that natural medicines are effective in the prevention and treatment of a cold in children. if they have any further questions, refer them to the pharmacist.

Parents and caregivers can be given self-care options for caring for children with colds including:

• steam and vapour to soothe the inside of the nose and thin any mucus but care must be taken to avoid burns

• oral hydration fluids to thin mucus, and also avoids the risk of dehydration

• rest • avoiding cigarette smoke.

When to refer to pharmacistbefore recommending a cough and cold treatment, ask the customer to describe their symptoms (e.g. dry or chesty cough) and how long they have had them. ask them their age and what medicines they are taking. also enquire if their immunisation is up-to-date and if they smoke.

use the What-stop-go protocol to determine when to refer to the pharmacist.

relevant Self care fact cardsbelow is a list of Psa self care fact cards relevant to this month’s topic, treating coughs and colds. become familiar with these cards and use them when counselling and advising customers.

• colds and flu• coughs

Table 2. Difference between a common cold and the flu

common cold influenza (flu)

cause Viral infection Viruses Influenza A and B

Speed of onset Develops over 7 days Appears very suddenly

time when it occurs

Any time during the year; very common Usually seasonal during the winter months

Spread Very contagious; spread through droplets and contact with people who have the virus

Very contagious; spread through droplets and contact with people who have the virus

Symptoms Runny nose, nasal congestion (blocked nose), sneezing, coughing, headache, and sore throat, tiredness, earache, facial pain, red and watery eyes

More severe than cold symptoms including sore throat, fever, headache, muscle aches and soreness, congestion, and cough.

duration of illness Self-limiting; lasts about 7–10 days Up to several weeks

treatment Rest, increased fluids, pain relief, decongestants, antihistamines, cough medicines, lozenges, vitamin C, echinacea

Symptoms of the flu may be treated as for the common cold

Antiviral medicines may also be used to shorten the duration of symptoms and reduce the risk of complications, e.g. oseltamivir (Tamiflu) and zanamivir (Relenza).

Prescription-only (S4)


John bell says

What-Stop-Go When to refer to the pharmacist if the customer has a cough or cold

Who is the patient? • Children <12 years

• Elderly – conditions such as bronchitis and pneumonia may co-exist

• Pregnant or breastfeeding

How long have the symptoms been present? Cough lasting longer than 2–3 weeks

actual symptoms – what are they? • Wheezing or a harsh barking cough such as croup

• Cough which is worse in the morning, at night or after exercise

• Severe cough followed by a whoop

• Mucus is blood-stained or has a bad odour

Treatment for this or any other condition?

(e.g. other medicines and conditions)

• Existing medicines may cause cold or flu like symptoms (e.g. cough)

• There are some important interactions between some medicines and some conditions and cough and cold preparations

symptoms or side effects caused by other conditions and/or medicines?

• Symptoms or side effects caused by other medicines

• Existing medical conditions

• Existing allergies

Totally sure? If you are unsure, refer to the pharmacist

Requested product is not appropriate or you are unsure

overuse – how often has the customer been taking the medicine or self-treating the condition?

Suspect misuse or abuse

Pharmacist preferred? • Customer requests to speak to the pharmacist

• Requested product is a Pharmacist Only medicine or you believe a Pharmacist Only medicine is appropriate for the customer

go ahead Treat only if any of the above conditions are not an issue otherwise refer to the pharmacist

After using the What-Stop-Go protocol, you determine that Maria’s children are showing symptoms of a common cold. Although viruses cause both colds and flu, the children’s symptoms have taken about 3–4 days to develop. They started with sore, dry throats and now have congested chests and runny noses. You tell Maria you don’t think her children have the flu and that most colds usually clear in about 7–10 days.

You tell Maria that cough and cold medicines should not be given to children under the age of 6 years as it has been shown that these medicines are not effective and may cause serious side effects. Although only one of Maria’s children is under 6 years of age, you refer both the children to the pharmacist.

While waiting to talk to the pharmacist, you give Maria the Colds and flu Self Care Fact Card.

Counter Connection treating coughs and colds Pharmacy assistant’s education module 259



— — — — — —Personal id number:

full name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pharmacy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

suburb: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . state: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Circle one correct answer from each of the following questions.

before undertaking this assessment, you need to have read the counter connection article and the associated fact cards.

the pass mark for each module is five correct answers. Participants receive one credit for each successfully completed module. on completion of 10 correct modules participants receive an achievement certificate.

Please submit your assessment by 30 June 2015

Please retain a copy for your own purposes. Photocopy if you require extra copies.

Treating coughs and coldsassessment questions for the pharmacy assistant

submit answers

submit online at www.psa.org.au/selfcare

fax: 02 6285 2869

mail: self care answers Pharmaceutical society of australia Po box 42 deaKin West act 2600

1. Which onE of the following statements is CorrECT?

a) difflam Plus anti-inflammatory throat lozenges contain a local anesthetic to soothe a sore throat.

b) all cough suppressant agents are available in Pharmacy medicines.

c) an example of a mucolytic agent, used to treat a chesty cough, is guaiphenesin.

d) none of the above.

2. Which of the following statements is CorrECT?

a) antibiotics are needed to treat and cure a cough.

b) a chesty cough can be described as dry and hacking.

c) dry coughs produce a lot of phlegm or sputum.

d) medicines may ease cough symptoms, not provide a cure.

3. how long does a cold usually last? Which is the mosT appropriate answer?

a) 1–2 days.b) 7–10 days.c) 2 weeks.d) 2 months.

4. Colds and flu are caused by:

a) a fungal infection.b) a bacterial infection.c) a viral infection.d) none of the above.

5. Peter, 28 years old, comes to the pharmacy requesting rikodeine for a dry cough. Which of the following statements regarding appropriate supply is mosT correct

a) rikodeine is not appropriate as it is indicated for a chesty cough.

b) as the pharmacy assistant you must consult the pharmacist as rikodeine is a Pharmacist only medicine (s3).

c) rikodeine is contains dextromethorphan, which is a cough suppressant.

d) b) and c).

6. margaret approaches you in the pharmacy, and says she thinks she has the flu. she asks you if she should see a doctor to get some antibiotics. Based on the information from the Colds and flu self Care Fact Card, which of the following statements is TruE?

a) You can be vaccinated against both colds and influenza.

b) flu symptoms are similar to cold symptoms but may also include high fevers, sweating and shivering.

c) antibiotics are used to treat colds and flu.

d) all of the above.


What’s coming up in inPHARMation?next month’s inPHARMation will focus on eczema and xeroderma.

eczema is a general term for any type of dermatitis or itchy rash. it affects about 1-in-5 people over the course of their lives. inflammation and pruritus are common symptoms of all types of eczema. Xeroderma (dry skin) is a known trigger for eczema especially if it is left untreated.

Pharmacists and pharmacy assistants can assist customers to prevent dry skin and provide appropriate advice on how to treat eczema flares. the June issue of inPHARMation outlines the causes and triggers of eczema (including dry skin) and discusses the treatment of eczema flares, as well as self care for the prevention and maintenance of healthy skin.

self care achievers Self Care presents certificates to staff who successfully complete a year of Counter Connection modules. We would like to congratulate the following people:

conferences

year 14Nicole O’Hanlon

year 12Elizabeth Thurrowgood

Jillian Fuller

Lisa McKenzie

year 11Davina Collins

Debra Hansen

Heddy Joseph

Jennifer Burston

Kerri Newman

Rachel Wood

Susan Singor

Wendy Moss

year 10Angela Harrigan

Kaye Neilson

Rickki Bracken

year 9Jenny Barrow

Julie Davis

Maria Ravalico

Michelle Bulk

Rebecca-Jo Costello

Sharon King

year 8Chris Ball

Elizabeth Lewis

Hellen Smythe

Jan Cronin

Jennifer Inglis

Jenny Adcock

Karee Parnell

Megan Gill

year 7Chris Tencate

Diane Jeeves

Jenny Kearney

Joy Croft

Kym Simmons

Laura Tickle

Lee Murray

Michelle Heemskerk

Tracey Johnston

year 6Carol Hawley

Dawn Cross

Fiona Martin

Jenny McCarthy

Kim Wynan

Kylie Curry

Kylie McCulloch

Natasha Payne

Rebecca Marsh

Stephanie O’Brien

year 5Annie Drummond-Henman

Jade Ollington

Jayde Ballis

Lana Tamindzic

Madi Bennett

Natalie Hunt

Natalie Kittel

Sarah Critchley

Kelly Mitchell

year 4Jessica Jones

Kelly Matthews

Kerrie Leonard

Kirsty Wright

Kylie Keoh

Lyn Halliday

Michelle Craig

Rebecca Anderson

year 3Amy Andrews

Asha Das

Caroline Ayton

Colleen McLean

Dearne O’Sullivan

Edwina Beresford

Freda Elias

Hathaichanok Overton

Jessica Jones

Jessica Nelson

Kaitlan Bright

Kate Toms

Liljana Smilevska

Linda McKeddie

Melanie Glen

Melissa Nicholson

Melissa Warner

Michelle Reynolds

Narelle Boxhall

Patricia Crawford

Rochelle Fields

Shannon Eggleston

Stacey Bray

year 2Amanda Lee

Angela Malone

Carley White

Carmel Trevorrow

Carole Garra

Catherine Moore

Chanel Clancey

Dearne O’Sullivan

Debbie De Bono

Deborah Yeadon

Dianna Lee

Donna Potter

Elizabeth Everett

Elizabeth McStravick

Emily Dunsmore

Grace Rainey

Hayley Goddard

Heather Lamers

Hilda Ringk

Jackie Birdling

Jennifer Fry

Jessica Morgan-Thomas

Joanna Ibrahim

Kate Moore

Kathryn McKenzie

Kim Meier

Lisa McDonald

Lyndsay Tom

Mandy Miller

Margaret Appino

Marion Attenborough

Michelle Hinchcliffe

Michelle Reynolds

Nadine Beeby

Nicola Shephard

Nicole Gray

Prue Marinelli Marinelli

Sabina Dedic

Sonia Weir

Sophia Wynne

Stephanie Charge

Sue Brown

Talia Dean

Wendy Hodge

Yvonne Coutis

Zephia Austin

year 1Afifa Saleh Zada

Alison Herden

Alison Rowe

Amelia Krause

Andrea Kendall

Andrew Roberts

Anita Ziba

Anne Drenth

Belinda Scott

Bianca Henderson

Briana Peterson

Bryan Hann

Caitlyn Roberts

Catie Thompson

Cheryl Hill

Christine Kairouh

Christine Slaney

Daisy Green

Dakota Barker

Darijo Cakarun

Debbie Ormiston

Denise Clothier

Denise Wells

Elizabeth Hooper

Emily LaRoche

Evelyn Kok

Fiona Stewart

Gabrielle Davies

Gayle Tatana

Gracie Rogan

Hannah Burchell

Hayley Swadling

Helen Doak

Helen Doutty

Janne Raimondo

Jeanette Maher

Jessica Hess

Jessica McIver

Joehanna Angeles

Jolyon Smith

Kate Simpson

Katerina Varnavas

Kristy Cummins

Kristy Mahony

Laura Giles

Lauren Cox

Leanne Campbell

Leanne Russell

Leeanne Heslop

Leona Zhang

Lisa McKenzie

Margaret Nixon

Mary Stacey

Marzena Gniot

Maureen Harris

Mikayla Watson

Milorad Vujacic

Morgan Peart

Narelle Kensit

Narelle Lockwood

Olga Missaghian

Olivia Bennett

Pam Brown

Paula Clark

Rachel Sheridan

Rebecca Rankin

Rickki Bracken

Robyn Foster

Sally Marks

Sally Romeyn

Samantha Allen

Sandra Kolanek

Sarah Reay

Sarah Welch

Stacey Coles

Susie Moretta

Theresa Schulz

noticeboard

Conferencesmedicines in the bush symposium24 MayDarwin Convention Centrewww.psa.org.au/event/medicines-in-the-bush-symposium

13th national rural health Conference24–27 MayDarwin Convention Centre, NTwww.ruralhealth.org.au/conference

ConPharm 201511th Annual Consultant Clinical Pharmacy Seminar29–31 MayPark Hyatt Melbournewww.aacp.com.au/about/conpharm

Psa1531 July–2 AugustSofitel Wentworth, Sydneywww.psa.org.au/psa15

national health calendar datesmay

24–30 national Palliative Care Weekwww.palliativecare.org.au

25–31 Kidney health Weekwww.kidney.org.au

31 World no Tobacco Daywww.who.int/tobacco/wntd

June

1–30 Bowel Cancer awareness monthwww.bowelcanceraustralia.org/awareness

22–28 World Continence Weekwww.who.int/campaigns

26 red nose Daywww.rednoseday.com.au

July

6–12 sleep awareness Weekwww.sleephealthfoundation.org.au

12–18 Diabetes awareness Weekwww.diabetesaustralia.com.au

73153_DL_Tonsilitis 2015-04-21T15:10:52+10:00

http://www.ruralhealth.org.au/conference

http://www.who.int/campaigns/world-health-day/2015/event/en/

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