Best Practices for OTC Cold Medication Recommendations

The common cold is frequently attributed to the rhinovirus, but more than 200 viruses can cause the common cold, according to the American Lung Association.¹ Despite the large number of viruses that cause cold symptoms, the common cold usually resolves on its own, giving patients the option to self-medicate with OTC medications to ease their symptoms.

Solid Recommendations Require Detective Work

When making recommendations, pharmacists often have an arsenal of “go-to” drugs they recommend. However, a prudent clinician never proceeds without first collecting information about the patient’s history of present illness.

“Since the common cold has such non-specific symptoms, pharmacists should ask patients about their symptoms,” said Donald Backus, PharmD, a pharmacist at Oregon Health and Science University in Portland. “We should keep track of what they’re presenting with symptom-wise and make sure it’s not something more serious.”

Non-specific symptoms such as headache, fever, and congestion associated with the common cold can often be managed with OTC medications. However, eye exudate and coughing up green phlegm, or seemingly mild symptoms that have persisted for more than a week without improvement, are signs of a more severe illness. Such presentation warrants an immediate referral to the clinic.

If the pharmacist determines that the patient’s symptoms can be self-managed, the next step is to gather information about pre-existing medical conditions as well as prescription and OTC medications and supplements the patient is taking.

Jason Varin, PharmD, director of alumni relations at the University of Minnesota College of Pharmacy in Minneapolis encourages clinicians to find out which medications the patient has tried and whether those medications have worked for them in the past. Of equal importance is to identify the patient’s desires before recommending any OTC drugs.

“If patients have symptoms consistent with a cold, what are they looking for in the way of relief?” he said. “Perhaps a runny nose is not an issue, but they have a cough and want to sleep.” Other patients may seek relief from minor aches and a sore throat.

Gathering background information helps the pharmacist make a well-informed recommendation. Refining the recommendation may involve helping the patient read ingredient labels to identify ingredients that may aggravate pre-existing conditions-such as certain antihistamines that can induce drowsiness, making it dangerous to drive and operate heavy machinery.

For Betty Louton, PharmD, a population health clinical pharmacist at Banner Health in Phoenix, Arizona, simplifying the medication administration regimen helps improve patient reception and adherence.

She said that she finds her patients also enjoy the convenience of 12-hour dosing when many cough and cold medications are dosed twice or more a day with the Alka Seltzer Cold and Flu product line extension. They also reported the reconstituted powder soothed their scratchy throats.

“By default, I look for medications that only have to be taken once a day as opposed to twice daily, or every 4-6 hours, it’s easier-especially for patients who are already taking so many other medications,” Louton said.

For cold-like symptoms that can be managed with OTC medications, pharmacists distinguish their recommendations by the category.

DECONGESTANTS:

Pharmacists have different preferences when it comes to decongestants. Varin chooses pseudoephedrine as his go-to drug because of its potent vasoconstrictive properties. However, side effects such as increased heart rate and insomnia make it unsuitable for patients who have uncontrolled hypertension or heart conditions.

For these and other patients, alternatives include oral phenylephrine and nasal sprays such as oxymetazoline and phenylephrine. Varin pointed out that phenylephrine is less effective than pseudoephedrine but carries a lower risk of affecting blood pressure, the heart, or disrupting sleep. He saves nasal sprays as a last resort-an option he personally reserves when flying with a head cold.

“The eustachian tubes that help the inner ear adjust to changing air pressure become congested, and the inability of the inner ear to depressurize can be extremely painful,” Varin said. “Nasal spray decongestants can be beneficial in this situation.”

However, he advised against using nasal spray decongestants for more than a few doses to avoid rebound congestion and sinus irritation.

ANTIHISTAMINES:

Antihistamines help dry up excess mucus. While diphenhydramine (Benadryl) is highly effective, it comes with some precautions. The drug can cause severe drowsiness, paradoxical stimulation in children, increased fall risk in elderly patients, and may worsen urinary disorders such as benign prostatic hypertrophy and urinary retention.

For patients on the go, Louton recommended a non-sedating antihistamine such as fexofenadine (Allegra) or loratadine (Claritin) in the morning, while reserving diphenhydramine’s sedative effects to help induce sleep and itching at night.

COUGH:

To date, guaifenesin remains the only OTC medication on the market for cough. Louton reserves this drug for deeper chest cough. Although there are a variety of guaifenesin-containing products on the market, Louton recommended Mucinex® for patients.

“Most of guaifenesin-containing products are 50-100 mg, but that’s not a high enough dose for an adult to thin out thick mucus,” Louton explained. She recommended cough suppressant-containing Mucinex DM for patients with frequent, deep chest cough; but she encourages pharmacists to warn patients of the risks of taking the liquid as opposed to the tablets or capsules.

“People take the liquid more often than they should, and this is especially problematic with the elderly and kids because overusing it causes hallucinations.”

ANTIPYRETICS:

Acetaminophen appears to be a top choice antipyretic among the pharmacists interviewed. Varin recommends acetaminophen for mild-to-moderate fever but reserves ibuprofen for patients who experience moderate fever in addition to pain.

Louton said that acetaminophen has several features that make it her first-line antipyretic recommendation. Among these are its faster onset compared with ibuprofen and longer-duration compared with other commonly used non-steroidal anti-inflammatory drugs (NSAIDs). Additionally, unlike NSAIDs such as ibuprofen, aspirin, and naproxen, acetaminophen does not cause gastrointestinal upset or exhibit blood-thinning effects. However, as with any drug, it has a few drawbacks, perhaps the most important of these being the risk for hepatoxicity associated with exceeding the recommended maximum daily dose.

Backus and Louton agree that NSAIDs make suitable second-line choices. Backus considers adding an NSAID when staggering antipyretic therapy.

Louton avoids recommending aspirin for several reasons. “Many people take blood-thinning medications, and you certainly don’t know what they’re on if you’re talking to them at the drugstore.”

She also steers clear of recommending the drug for children. Children less than 18 years of age who take aspirin during the course of a prodromal viral illness run the risk of developing Reye syndrome-an aspirin-induced form of hepatotoxicity.²

Clinical manifestations include lactic acidosis, microvesicular fat, and hepatic dysfunction accompanied by coma and encephalopathy. Signs of hepatic trauma or failure include elevated serum aminotransferase levels, hyperammonemia, and encephalopathy. Serum bilirubin levels, however, tend to show only moderate elevation in the condition. Nowadays, the condition has become rare-thanks to patient education and prudent avoidance.

Dietary supplements

Seventy-seven percent of Americans reported using dietary supplements in 2018, according to the Council for Responsible Nutrition-an all-time high. Given this trend, pharmacists will play an increasingly critical role in educating patients and helping to separate the facts from the hype. However, clinicians agree that many supplements have limited evidence supporting their benefit in mitigating cold symptoms.

Some data suggest that vitamin C, zinc, echinacea, and garlic offer some benefit in reducing both the severity and duration of cold symptoms, but Varin cautioned that evidence is conflicting. Moreover, as with any product ingested, dietary supplements also carry some risks.

For example, garlic can interfere with blood thinners. Although zinc is an essential element and has been shown to help ameliorate some symptoms associated with the common cold, intranasal zinc has been linked to anosmia, or loss of smell-which may be permanent.³

References:

• American Lung Association. Fact About the Common Cold. American Lung Association’s website. https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/influenza/facts-about-the-common-cold.html.

• National Institute of Diabetes and Digestive and Kidney Diseases. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Last updated July 27, 2017. https://www.ncbi.nlm.nih.gov/books/NBK548900/

• Hsieh H, Vignesh KS, Deepe GS Jr. et al. Mechanistic studies of the toxicity of zinc gluconate in the olfactory neuronal cell line Odora. Toxicology in Vitro. September 2016. https://doi.org/10.1016/j.tiv.2016.05.003