Symptoms in the Pharmacy :Respiratory Problems (3)
Practical points
Diabetics
The National Pharmaceutical Association and Diabetes UK jointly
publish a useful list of OTC products and their sugar and sweetener
content. In short-term use for acute conditions, the sugar content of
OTC medicines is less important.
These may be useful in reducing nasal congestion and soothing the air
passages, particularly if a productive cough is present. A systematic
review found there was insufficient evidence to judge whether there
might be a benefit from this treatment. For further discussion of
their use. Inhalants that can be used on handkerchiefs,
bedclothes and pillowcases are available. These usually contain
aromatic ingredients such as eucalyptus. Such products can be useful
in providing some relief but are not as effective as steam-based inhalations
in moistening the airways.
Nasal spray or drops
Nasal sprays are preferable for adults and children over 6 years of age
because the small droplets in the spray mist reach a large surface area.
Drops are more easily swallowed, which increases the possibility of
systemic effects.
For children under 6 years of age drops are preferred because in
young children the nostrils are not sufficiently wide to allow
the effective use of sprays. Paediatric versions of nasal drops should
be used where appropriate. Manufacturers of paediatric drops advise
consultation with the doctor for children under 2.
Prevention of flu
Pharmacists should encourage those in at-risk groups to have an
annual flu vaccination. In the UK the health service now provides
vaccinations to all patients over 65 and those below that age who
have chronic respiratory disease (including asthma), chronic heart
disease, chronic renal failure, diabetes mellitus or immunosuppression
due to disease or treatment. Community pharmacists are in a good
position to use their PMRs to target patients each autumn and remind
them to have their vaccination.
Colds and flu in practice
Case 1
Mrs Allen, a regular customer in her late sixties, asks what you can
recommend for her husband. He has a very bad cold; the worst
symptoms are his blocked nose and sore throat. Although his throat
feels sore, she tells you there is only a slight reddening (she looked this
morning). He has had the symptoms since last night and is not feverish.
He does not have earache but has complained of a headache.
When you ask her if he is taking any medicines, she says yes, quite a
few for his heart. She cannot remember what they are called. You
check the PMR and find that he is taking aspirin 75 mg daily, ramipril
5 mg daily, bisoprolol 10 mg daily and simvastatin 40 mg daily.
Mrs Allen asks you if it’s worth her husband taking extra vitamin C
as she’s heard this is good for colds. She wondered if this might be
better than taking yet more medicines.
The pharmacist’s view
The patient’s symptoms indicate a cold rather than flu. He is
concerned most with his congested nose and sore throat. He is taking
a number of medications, which indicate that oral sympathomimetics
would be best avoided. You could recommend that he take regular
simple painkillers or suck a soothing lozenge or pastille for his sore
throat and that he try a topical decongestant or an inhalation to clear
his blocked nose. The symptoms may take about 1 week before they
start to clear. You offer these alternatives to Mrs Allen to see what she
thinks her husband might prefer. You explain that taking vitamin C
might reduce the time taken for the cold to get better by about half a
day. You show her some vitamin C products and tell her their cost.
You also ask if Mr Allen has had a flu jab as he is in an ‘at-risk’ group.
The doctor’s view
The advice given by the pharmacist is sensible. A simple analgesic such
as paracetamol could help both the headache and sore throat. The
development of sinusitis at such an early stage in an infection would
be unlikely but it would be wise to enquire whether his colds are
usually uncomplicated and to ascertain the site of his headache.
The patient’s view
‘I came to the pharmacist because we didn’t want to bother the doctor.
The pharmacist asked me about which symptoms were causing Pete
(my husband) the biggest problem and he gave me a choice of what to
use. I wanted to know what he thought about vitamin C and he told
me about how it might make the cold shorter. In the end though I
decided not to bother with it because it would have been quite expensive
with the other medicines as well, especially as it was unlikely to
make that much difference. I thought I would give him some fresh
orange juice instead.’
Case 2
A man comes into the pharmacy just after Xmas asking for some
cough medicine for his wife. He says that the medicine needs to be
sugar-free as his wife has diabetes. On listening to him further, he says
she has had a dreadful cough that keeps her awake at night. Her
problem came on 5 days ago when she woke in the morning, complaining
of being very achy all over and then became shivery, and
developed a high temperature and cough by the evening. Since then
her temperature has gone up and down and she hasn’t been well
enough to get out of bed for very long. She takes glipizide and
metformin for her diabetes and he has been checking her glucometer
readings, which have all been between 8 and 11 – a little higher than
usual. The only other treatment she is taking is atorvastatin; she is not
on any antihypertensives. He tells you that she will be 70 next year.
The pharmacist’s view
The history indicates flu. It would be best for this woman to be seen by
her GP. She has been ill for 5 days and has been mostly bedbound
during this time. There are several features that suggest she might be at
higher risk from flu. I would suggest that her husband call the doctor
out to see her, as she does not sound well enough to go to the surgery.
Sometimes people are reluctant to call the doctor as they feel they
might be ‘bothering’ the doctor unnecessarily. The pharmacist’s
support is often helpful.
The doctor’s view
The infection is likely to be flu. She is in the higher-risk group for
developing complications (age and diabetes), so it would be reasonable
to advise referral. Most cases of flu usually resolve within 7 days.
The complications can include acute otitis media, bacterial sinusitis,
bacterial pneumonia and less commonly, viral pneumonia and respiratory
failure. In the USA there are 110 000 admissions per year for
influenza with about 20 000 influenza-related deaths. Over 90% of
these deaths have been in those over 65.
In this situation the doctor would want to check her chest for signs
of a secondary infection. A persisting or worsening fever would point
to a complication developing. There would be little point in prescribing
an antiviral, e.g. zanamivir, as it is only effective if started within
2 days of symptom onset. One review has found it to be effective in
reducing the duration of flu symptoms by about 1 day if started soon
enough. It would also be advisable to check whether or not her
husband had had the flu vaccine. The incubation time for flu is 1–4
days and adults are contagious from the day before symptoms start
until 5 days after the onset of symptoms.
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