Clinical

The C-V of Winter Ailments

With the winter season just around the corner, now is the time for community pharmacists and their teams, to be promoting the message that consumers should visit them first, for advice and treatment of common winter ailments.

Research shows that 18% of GP appointments are for minor ailments. Community pharmacists are in fact, best placed to offer advice on these conditions and over-the-counter available and appropriate medications.

Furthermore, the winter months provide the perfect opportunity for pharmacy to drive home the self-care message and ease the pressure on GP surgeries and A&E departments.

Pharmacists should be continuing to remind consumers not to take antibiotics for colds and flu, sore throat, coughs, vomiting and diarrhoea.

Overuse of antibiotics in Ireland, and around the world, represents one of the most significant threats to long term public health. According to the IPU, health services are experiencing an increase in the levels of antibiotic resistant infections, and this is largely being attributed to the overuse and misuse of antibiotics.

The self-care agenda has been driven hard this year with the arrival of Covid-19, as more consumers take charge of their health and in booting their immune systems. However, self-medication may not be appropriate for every patient in view of pre-existing medical conditions or because of interactions with other prescription and non-prescription medications. This reinforces the importance of pharmacists, who have been trained to ask the
right questions so they can give appropriate advice.

It has been previously revealed that treatment results for common ailments such as coughs and sore throats were equally good regardless of whether patients were treated at a pharmacy, A&E or GP practice, highlighting community pharmacy as a solution to the increasing burden on a stretched health service.

Community pharmacy can have an extremely positive impact on the health of the communities it serves due to the engagement pharmacy teams have with their patients every day. Pharmacists will offer advice on conditions and medications, and if appropriate, they will refer a patient to their GP if they feel it necessary.

In this article, we take a look at the Top 10 conditions and issues which will present to pharmacy.

1. Common Cold
The common cold is a condition that is prevalent in the community and is associated with a variety of symptoms. Typically, it is an acute, self-limiting viral infection of the upper respiratory tract that is most frequently caused by rhinoviruses.

Symptoms commonly associated with the common cold include coughing, nasal congestion, low-grade fever, and fatigue, usually presenting 1 to 2 days after exposure. Generally, most symptoms subside within 7 to 10 days, although some symptoms can persist for up to 3 weeks.

2. Flu
The common cold is often mistaken for the flu. The flu is caused by the influenza virus, classified as type A, B, or C.
Types A and B affect humans, with type A generating more severe symptoms. The influenza virus can be dangerous in older people and in those patients who are immunocompromised.

Nevertheless, people with influenza are sicker than those experiencing common cold symptoms and commonly manifest such signs and symptoms as temperatures greater than 102°F, chills, headaches, myalgia, and malaise. There are a number of simple health habits that can assist in preventing the spread of infectious pathogens like the influenza virus. This includes things such as avoiding close contact, staying home when you are sick, covering your mouth and nose when sneezing, cleaning your hands, and avoiding contact with your nose, eyes, or mouth.

Advising patients on good health habits and providing handouts is a simple way pharmacists can provide sound advice that is easy to follow.

Former Minister for Health, Simon Harris TD, recently announced the government is to make the flu vaccine available to all children aged 2-12 and all at risk groups. The news follows a recommendation by the Irish Pharmacy Union for the flu vaccine to be made freely available to everyone who wants it during the coming flu season.

Commenting on the announcement IPU Secretary General Darragh O’Loughlin said, “While we would have liked to see the scheme extended further, making the flu vaccination available to children aged 2-12 and to all at risk groups without charge is definitely a step in the right direction. It will help increase our capacity to combat seasonal flu and prevent it from overwhelming the health system during the winter.”

Last year, over 1.1 million flu vaccines were delivered in Ireland, an increase of over 60% since pharmacies were first permitted to administer the vaccine a decade ago. Given that the convenience and availability of the vaccine has led to greater uptake, the IPU believes that pharmacists should be allowed to administer the vaccine to people in nursing homes and workplaces.

3. Cough
Cold and flu season is the time of the year when pharmacists are more likely to see patients scanning the pharmacy shelves in search of the perfect remedy to manage a cough. Patients may be overwhelmed by the numerous OTC cough products, but pharmacists are in an ideal position to evaluate and aid patients in selecting a cough product for self-treatment, as well as to encourage patients to seek further medical care when warranted.

During winter, most coughs are caused by viruses such as colds and flu and can be safely managed at home using OTC remedies. Coughs are classified as “acute” or “chronic”. An acute cough is most common and lasts up to three weeks. It’s usually caused by a cold or flu virus and most improve after one to two weeks.

Chronic cough lasts for eight or more weeks. The most common causes include acid reflux, asthma, TB, COPD, bronchitis and smoker’s cough. Red-flag signs include:
• Coughing up blood
• Unexplained weight loss
• Night sweats
• Cough worsening after three weeks
• Shortness of breath
• Voice changes
• Lumps/swellings in neck
• Chest pain

Dry or chesty cough?
A dry cough is caused by inflamed airways due to a viral infection such as a cold or flu. A chesty cough produces phlegm. This is caused by the lungs producing extra fluid due to an infection. It is important to get a detailed overview of the patient’s symptoms. Is their cough productive? How long have they had the cough and what action has been taken? Pharmacists should ask if a patient has any medical conditions that may affect any treatment or product you recommend.

The role of cough medicine is to ease symptoms while the body heals. There are many brands of OTC cough medicines. However, there are only three basic types: Expectorants help thin mucus, making it easier to cough up. The ingredient is guaifenesin.

Suppressants help cut the number of times someone coughs. The active ingredient listed is usually dextromethorphan (DM). Other cough suppressants include camphor, eucalyptus oil, and menthol.

Combination cough products have more than one active ingredient. They have both guaifenesin and dextromethorphan. Cough medicines may also contain ingredients to help coat and soothe the throat.

Combination products may have medicines to ease other symptoms, that may include decongestants for stuffy nose, antihistamines for allergies or a runny nose, or painkillers.

Cough drops can also help relieve a cough and may ease a sore throat (see below).

4. Sore Throat
Sore throat is a hallmark symptom of both viral and bacterial infections of the upper respiratory tract. Sore throat is a self-limiting complaint, resolving within three days in 40% of sufferers and within one week in 85% of people – even in those cases with a bacterial aetiology. The key symptom of sore throat is pain at the back of the mouth, which can vary from localised mild discomfort to intense pain on swallowing.

Sore throat can also be caused by irritants such as air that is low in humidity, smoking, air pollution, excessive yelling, postnasal drip caused by allergies, and breathing through the mouth. Injury to the back of the throat and
stomach acid backing up into the throat and mouth are other causes of sore throat.

Sore throat symptoms are easily recognised. The throat hurts and is irritated, swollen, or scratchy. Pain increases when swallowing. Some sufferers may also have tenderness in the neck.

Sore throat that is due to a virus should go away within 7 to 10 days. When a person has strep throat, however, throat pain starts out gradually and quickly becomes severe and constant.

Patients should be referred to their GP if they have a persistent fever of 38oC plus which doesn’t improve with analgesics, they have any difficulty swallowing or breathing or they are in severe pain.

For sore throat sufferers presenting in pharmacy, regular use of paracetamol or ibuprofen-based products can be recommended to relieve pain (soluble analgesics can be gargled to provide targeted pain relief). Customers can also be advised to use simple mouthwashes at frequent intervals (e.g. warm, salty water) until the discomfort and swelling subsides. Sucking pastilles or lozenges stimulates saliva secretion, which lubricates the throat, and many throat sweets also contain soothing ingredients, such as glycerine and honey, to help relieve irritation.

5. Nasal Congestion
Nasal congestion is a blocked, stuffy or bunged-up feeling in the nose. Depending on the cause, it can last a short while (a few days) or can be persistent. In adults and children it is usually an annoying symptom rather than a serious one. In babies, however, a blocked-up nose may make it difficult to breathe or feed. Some of the causes of nasal congestion include:
• Infections: the common cold and other respiratory tract infections, including influenza (flu) and sinusitis
• Allergies, including hay fever
• Persistent rhinitis

6. Sinusitis
The sinuses are small, air-filled spaces inside the cheekbones and forehead which drain into the nose. Sinusitis means inflammation of a sinus. Most bouts of sinusitis are caused by an infection. Most cases of sinusitis are acute (lasting 1-4 weeks) but some may go on to a more persistent (chronic) sinusitis.

Pain and pressure in the face and head, as well as a stuffy or runny nose, are the chief complaints among those experiencing sinusitis. The location of this pain or pressure usually depends on which sinuses are affected, and
head movement or leaning forward typically increases both the pain and pressure.

Other symptoms may include postnasal drip, cough, sore throat, fever, fatigue, tooth pain, bad breath, and reduced sense of taste or smell. A yellow or green discharge from the nose or throat is also common. If an infection lasts more than 10 days without evidence of improvement, is accompanied by a fever with severe symptoms, or exhibits “doublesickening” (improves, then worsens), it is most likely bacterial and will require antibiotics.

Sinusitis is usually treated with painkillers and decongestants.

7. Cold Sores
Cold sores are small blisters that develop on the lips or around the mouth. They are caused by the herpes simplex virus and usually clear up without treatment within seven to 10 days.

Sufferers may not have any symptoms when they first become infected with the herpes simplex virus. An outbreak of cold sores may happen some time later.

Cold sores often start with a tingling, itching or burning sensation around the mouth. Small fluid-filled sores then
appear, usually on the edges of your lower lip. Those affected can seek a number of treatments from pharmacists that reduce the duration of cold sores when used at first sign of a break out.

Symptoms of cold sores usually occur after something has triggered the virus, like a rundown immune system or cold, dry weather leading to dry, chapped lips.

Prior to a breakout, there are certain sign to look out for such as:
• Tingling lips
• Sore mouth that makes eating, and drinking uncomfortable
• Fever
• Sore throat
• Swollen lymph nodes in the neck

Nothing can prevent an outbreak, however there are a number of treatments that work to reduce the duration of cold sore symptoms such as:
• OTC antiviral creams can speed up the healing process
• Cold sore patches containing hydrocolloid gel that ordinarily treats skin wounds. The patch is placed over the cold sore while it heals
• In severe cases, the patient should be referred to their GP so that antiviral tablets may be prescribed.

8. Ear Infections
Ottis Media is an inflammation of the middle ear and is often associated with sore throats, colds or other respiratory issues where the infection spreads to the middle ear. It is very common in children.

The patient can suffer from temporary hearing loss and pain or discomfort in their ear. Patients can avoid ottis media by getting their annual flu vaccination. Ottis Media usually happens very quickly for a short duration. If the patient has had the symptoms for a few weeks or month it may be an acute ear infection and should visit their doctor. Antibiotics are usually prescribed as treatment. The pharmacy can offer pain relief with ear drops or antihistamines if the inflammation is causing discomfort.

If customers are prescribed ear drops or use OTC products, it is important they are shown how to use them properly and reminded that ear drops should be discarded 28 days after opening.

9. Vitamins & Supplements
In the darker months, Vitamin D is one of the most important potential deficiencies to avoid. Vitamin D has several important functions within the body, including regulating the amount of calcium and phosphate needed to keep bones and teeth healthy.

Deficiency carries with it a whole host of health problems including rickets in children, and osteomalacia, the adult equivalent, which causes bone pain and tenderness.

Humans obtain vitamin D mainly from the action of sunlight on the skin, but in Ireland the sun is only strong enough for vitamin D production in the summer months. So, although a small surplus is built up over the summer, most people are probably vitamin D deficient in the winter. Add to that the fact that vitamin D is only found in small amounts in food – such as eggs, oily fish and fortified foods such as breakfast cereals – and it becomes clear why taking a supplement is recommended for ‘at risk’ groups.

It is recommended that everyone takes a 10mcg vitamin D supplement daily, particularly in autumn and winter. All babies and young children aged six months to five years should be given a daily supplement containing vitamin D in the form of drops to help them meet the requirement for this age group of 7-8.5mcg of vitamin D a day.

Breastfed infants may need drops containing vitamin D from one month of age if the mother has not taken vitamin D supplements throughout pregnancy. However, babies fed infant formula will not need vitamin D drops until they are receiving less than 500ml a day, as these products are often fortified with vitamin D.

Echinacea is probably the most common herbal supplement associated with the prevention and treatment of colds. This plant is promoted as an immunesystem stimulant.

Elderberry, or Sambucus nigra, is commonly used for treating symptoms related to the flu. It is thought to have antioxidant and immune-modulating properties. There is evidence to suggest that elderberry does reduce symptoms of the flu.

Elderberry is well tolerated and there are very few reports of adverse effects with usage. Those taking it should be warned not to eat raw or insufficiently cooked elderberries; cyanogenic glycosides are metabolized to cyanide in the GI tract, causing nausea, vomiting, dizziness and weakness.

Vitamin C is a water-soluble vitamin that has an important role in various physiological processes. There have been a significant number of clinical studies completed to determine the efficacy of vitamin C treatment in the common cold. At doses used for daily supplementation, vitamin C is generally well tolerated.

Zinc is a mineral that is considered an essential nutrient. Studies have shown that a mild zinc deficiency can elicit changes in the patient’s immune status, increasing their risk for infection.

Vitamin E is most commonly known as a fat-soluble antioxidant. It is often put in oils to extend the shelf life of the product and prevent the oil from becoming rancid.

Vitamin E is also similar to vitamin C in that it also plays a role in keeping the immune system healthy. Researchers are working hard to understand this role, but it appears that there are several mechanisms involved:

1. Reduction of PGE2 production by the inhibition of COX-2 activity mediated through decreasing NO production

2. Improvement of effective immune synapse formation in naive T cells and the initiation of T cell activation signals

3. Modulation of Th1/Th2 balance. Higher natural killer cell activity and changes in dendritic function, such as lower IL-12 production and migration, were observed

During the cold and flu season good nutrition and proper sleep is essential. Foods high in vitamin E are vegetable oils (especially wheat germ oil), nuts, kiwi, mango, spinach, broccoli, tomatoes, eggs, fish, and avocados.

10.The Paediatric Patient
When temperatures start turning colder and kids are inside and interacting with each other in greater numbers, cold and flu season inevitably follows.

Children under the age of 6, and particularly under age 2, are at an especially high risk during cold and flu season. Whilst it is known that antibiotics won’t help when it comes to clearing up an infection, there are steps pharmacists can advise parents to take to help their child feel better while their immune system battles the virus.

Advise on keeping the child hydrated to help reduce cold and flu symptoms and make them feel better. Fevers can result in dehydration. Children suffering with the cold or flu may not feel as thirsty as they normally would, and they may be uncomfortable when drinking, so it’s important to encourage them to drink plenty of fluids.

Medicated nasal sprays aren’t recommended for young children. Fortunately, there are several easy ways to clear up a stuffy nose without medication.

Use a cool-mist humidifier in the child’s room. This will help break up mucus. Another option is using a saline nasal spray or drops, which makes thin mucus easier to blow out or remove with a bulb syringe. This is especially helpful before feeding and bedtime.

Medication Summary:
Decongestants – These help to reduce nasal congestion by constricting the dilated blood vessels in the nasal mucosa. This reduces swelling and oedema of the nasal mucosa, making it easier to breathe. Decongestants are not suitable for pregnant and breast-feeding women and patients with hypertension. Nasal sprays and oral tablets should not be used concurrently.

Oral analgesics – Analgesics and antipyretics help to reduce pain and fever associated with sore throats and colds. Ibuprofen also reduces inflammation, which can help if sinuses are inflamed. Paracetamol and ibuprofen can be used in conjunction with one another but should be taken two to three hours apart for maximum benefit.

Combination products – Can contain ingredients such as a decongestant, analgesic, cough suppressant, antihistamine or an expectorant. These can be used up to their maximum dose for up to seven days unless they contain sedating antihistamines, when they should only be used for up to three days. Antihistamines work by drying up nasal secretions and should be used with a decongestant as they are relatively ineffective on their own. They can also cause drowsiness, so are often found in combination products to aid insomnia associated with having a cold.

Inhalants, vapour rubs and saline products – Inhalants work by helping to clear the nasal passages, while steam inhalation will help ease nasal congestion by loosening mucus. Saline preparations relieve congestion by helping to liquefy mucous secretions. Inhalants, rubs and saline products can be used daily until symptoms are cleared. They can be used as an alternative by patients who cannot tolerate decongestants.

Sore throat treatments – Most sore throats are caused by a viral rather than a bacterial infection, so don’t need antibiotics. Medicated lozenges or anaesthetic sprays can help relieve the symptoms of sore throat. Gargling regularly with an antibacterial mouthwash or warm, salty water can reduce any swelling and inflammation, while sucking pastilles or lozenges will stimulate saliva secretion to lubricate the throat and help relieve irritation.

Cold sore treatments – Cold sores usually clear up without treatment within seven to 10 days but antiviral creams, such as aciclovir or penciclovir, can be used to ease symptoms and speed up the healing time. Antiviral tablets are generally more effective than creams at treating severe cold sores, but are usually only prescribed in more intractable cases. Patches that contain a hydrocolloid gel can be placed over the cold sore to hide the affected area while it heals.

Efficient Merchandising
The cough and cold season could also provide the perfect opportunity to reorganise fixtures in your pharmacy with a clear merchandising plan featuring beacon brands in both the P and GSL sections.

You really need to think about the winter season and make a proper planogram, that provides a merchandising tool on a tablet, so that any member of staff can scan the fixture and see what it should look like. Make sure that you feature the national bestsellers, as these beacon brands act as visual clues for customers and direct them to the products they are looking for.

There needs to be some offers that make the pharmacy look competitive and it is crucial that staff are trained to provide advice on seasonal ailments and OTC products.

Staff should also deliver public health messages by reminding customers to have a flu jab and, for example, when selling cough medicine finding out if the customer is a smoker and whether they would like help to quit. They won’t necessarily think the water tablets they are taking for their blood pressure are important but they could react with the decongestant in a cold remedy and cause problems. This could be a cue for the pharmacist to check through their medication records to ensure they are getting appropriate advice.

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