Albayan University/ College of Pharmacy

Pharmacology & Toxicology Dept. 2019-2020

4th Stage Clinical Pharmacy Lecture { 1 } presented by
Dr. Atheer S. Alsabah

COMMON COLD

Common cold: is a self-limiting viral infection of the upper respiratory tract.

Different types of viruses can produce symptom of the common cold including:
rhinoviruses (half of the cases), adenoviruses & influenza virus.
The probable routes of transmission are:
1- Manual transmission (e.g. hand- to-hand contact).
2- Inhalation of droplets spread by sneezing and coughing.

Virus invades nasal & bronchial epithelia, attaching to specific receptors lead to
damage the ciliated cell resulted with release of inflammatory mediators and then
inflammation of the tissues lining the nose (increase permeability of capillary cell
walls, oedema, nasal congestion, sneezing, then fluid might drip down and back to the
throat and spreading the virus to the throat and upper chest causing cough & sore
throat.

Patient assessment with common cold:

A-Age:
Very young patients and very old patients required referral. Also the age affect
the choice of treatment.
Pre-school children are more common to suffer from common cold.

B-Duration:
Abrupt onset of symptoms------- may indicate flu.
Gradual onset of symptoms------- may indicate common cold.

C-Symptoms:
Symptoms typically are worst on day 2 or 3 of illness and last about 1 week (but
in about 1/4 of patients it may last for about 2 weeks or longer).

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Symptoms of common cold are:

1-Sore throat:
The throat is often feels dry and sore during a colds and it is usually the 1 st sign
of common cold.
2-Runny / congested (or blocked) nose:
(Initially clear watery fluid-------after 1-2 days become thicker mucus).
3-Sneezing/ coughing
4-Aches and pains:
Headache may occur, but a persistent or worsening frontal headache (pain
above or below the eyes) may be due to sinusitis -----referral for further
investigations.
(Note: headache of sinusitis increase by lying down or bending forwards).
5-Low grade fever (feeling hot but in general a high temperature (>37.5) is rare in
common cold (<1% of patients)).
The presence of fever may indicate FLU rather than common cold.
6-Earache: A blocked uncomfortable ear is often present and does not need referral if
it does not persist. A very painful ear needs referral.

D- Previous history:
Patient with a history of asthma or lung disease (e.g. chronic bronchitis)
------required referral for further investigations.
E- Patient with delirium and patient with pleuretic chest pain -------required referral
for further investigations.

F- Differential diagnosis:
The pharmacist must try to differentiate between viral infection and conditions
that present with similar symptoms (e.g.; flu, sinusitis, allergic & chronic rhinitis), as
well as the complications associated with the common cold.

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 Differentiating between colds and flu (which required referral for further
investigations) is needed. Patients often use the word “flu” when describing a
common cold. Flu is generally considered to be likely if:
1- Temp. is 38c or higher (37.5 in elderly).
2- At least one of the respiratory symptoms (cough, sore throat, nasal
congestion, or rhinorrhoea) is present.
3-At least one of constitutional symptoms (headache, malaise, myalgia, sweat,
chills, and prostration) is present.
4-Flu occurs more often in winter seasons, cold attack any time of year.

NOTE: In common cold the upper respiratory symptoms are the most prominent
while in flu the constitutional symptoms are predominant and fever is present in more
than 95% of patient.
Flu often starts abruptly with sweat and chills, muscular aches and pain in the
limbs, a dry sore throat, cough and high temperature. Someone with flu may be bed
bound and unable to go to their usual activities. There is often a period of generalized
weakness and malaise following the onset of symptoms. A dry cough may persist for
some time.

Sinusitis is a complication that can arise from the common cold. Following the
cold, sinus air spaces can become filled with nasal secretions, which stagnate because
of a reduction in ciliary function of the cell lining the sinuses. Symptom starts with
localized pain that become more sever when the condition persist, bending down,
moving the eye from side to side, coughing or sneezing often exacerbate the pain.

G- Present medication:
If one or more appropriate remedies have been tried without success (failed
medication) ------------- referral for further investigations.

Treatment timescale:
Once the pharmacist has recommended treatment, patient should be advised to see the
Dr. in 10-14 days if cold has not improved.

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 Management:

Non-pharmacological measures:
Non -drug therapy include:
1- Increased fluid intake which may loosen the mucus and promote drainage.
2- Adequate rest may help to recover quickly.
3- Adequate nutrition
4- Saline solution; can soothe the irritated nasal tissue and moisturized nasal
mucosa, and it can be given to all age groups and during pregnancy.

Pharmacological therapy:
1-Decongestants (sympathomimetics):
A-Systemic (oral) decongestants: like pseudoephedrine and phenylphrine. They
reduce nasal congestion by constricting dilated blood vessels in the nasal mucosa.
C/I: Systemic (oral) decongestants cause stimulation of the heart, increase the BP and
may cause hyperglycemia. Therefore they should avoid in (D.M, Ischemic heart
disease (angina, M.I), hypertension, and hyperthyroidism).
D/I: Avoid concomitant use with MAOI because of risk of hypertensive crisis, avoid
in patients taking beta blockers & TCAs, avoid in first trimester of pregnancy.

B-Topical(drop/spray) Nasal Decongestants( sympathomimetics):

 Classification and Doses:

type Example(s) Dose

Short acting (4-6 hours).
Intermediate acting (8-10
hours).
phenylphrine, naphazoline, 2 drops/sprays q 4-6 hours
tetrahydrozoline p.r.n
(but naphazoline q 6
hours)
Xylometazoline (Otrivine®): 2 drops/sprays q 8-10
0.1%: >12 years hours p.r.n
0.05%: 2-12 years

Long acting (12 hours). Oxymetazoline (Nazordine®): 2 drops/sprays q 12 hours

0.05%: >12 years p.r.n
0.025%: 2-12 years

 Nasal Spray or Drop:

- Nasal sprays are preferable for adults and children aged over 6 years because spray
has a faster onset of action and cover a large surface area.
- Nasal drops are preferable for children aged below 6 years because their nostrils are
not sufficiently wide to allow effective use of sprays.
(The drops cover a limited surface area and easily swallowed which increase the
possibility of systemic effects).

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  Topical Nasal decongestants (sympathomimetics) can be recommended for
those patients in whom Systemic (oral) decongestants are to be avoided.
(i.e. D.M, Ischemic heart disease (angina, M.I), hypertension, and hyperthyroidis m)

 Duration of the use of Topical Nasal Decongestants (sympathomimetics):

If topical (drops or sprays) decongestants are to be recommend, the pharmacist should
advice the patients not to use the product for longer than 7 days (3-5 days in some
references) because:
Rebound congestion (Rhinitis medicamentosa) can occur with topically applied
(especially short acting) but not with oral sympathomimetics.

 Topical nasal decongestants: can be given to pregnant women after the 1st
trimester of pregnancy.

*Not OTC for children < 2 years.

*Not recommended for children <6 months (or 3 months in BNF) because they are
obligate nose breathers and rebound congestion can cause obstructive apnea. Saline
nose drop can be used from birth to help with congestion. This would be more
suitable and safer alternative than topical sympathomimetics.

Note: regarding saline solution:

- There are already formulated saline drops or spray products in the market, or it may
be prepared in the pharmacy.
- Saline solution can be prepared by the patient using one teaspoonful of table salt in
seven ounces of warm water and administered with a bulb syringe (dose 2-6 drops in
each nostril four times daily or as needed) & discard any unused portion.

2-Antihistamines:
Antihistamine can reduce some of symptoms of a cold: runny nose (rhinorrhoea)
and sneezing but are not so effective in reducing nasal congestion.
Antihistamine can be classified into:

A- Sedating Antihistamine:
Examples of OTC sedating antihistamine are:
Chlorpheniramine (Histadin® tablet and syrup), Dexchlorpheniramine (polaramine®
tablet), and Diphenhydramine (Allermine® tablet and syrup), and Triprolidine
(Actified® tablet and syrup).

S/Es: include sedation and drowsiness (patients should be informed) and

anticholinergic S/Es (i.e. dry mouth, urinary retention, constipation, …..) and the
elderly patients are more susceptible to these.

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Accordingly they are not recommended (or used with caution) for patients with:
Glaucoma, or prostate hypertrophy and in elderly patients.

D/I: the sedative effects of antidepressants, anxiolytics, and hypnotics are likely to be
enhanced by sedating antihistamine.

B- Non-Sedating Antihistamine:
Examples of OTC non-sedating antihistamine are: Loratadine (clarityn® tablet
and syrup), and cetirizine (Zirtek® tablet and syrup).
They are generally preferable over the older antihistamines because of much
lower incidence of S/Es.
Adult dose of loratadine: 10 mg once daily.

Note: although the drowsiness is rare, but the warning that these drugs may affect
driving and skilled tasks is still present.

3-Combination products: sympathomimetics (for congestion) + Antihistamine (for

rhinorrhoea and sneezing):

Example of OTC products is:

Actifid® tablet and syrup: which composed of Triprolidine (sedating
antihistamine), and pseudoephedrine (sympathomimetics).

4-Analgesics, antipyretics, and cough preparations:

Systemic analgesics and antipyretics (e.g. paracetamol, Ibuprufen) are effective
for aches or fever & sore throat which may be associated with common cold.
In addition, cough, when present, may be treated by suitable cough products (see
cough).

5-Vitamin C :
A review of trial data concluded that Vitamin C:
*Does not prevent colds.
*Appears to reduce the duration of symptoms when ingested in large dose (up to
1g daily) although the response is variable.

6-Zinc lozenges: can decrease the duration & severity of common cold, but evidences
is currently insufficient to recommended zinc to treat common cold.

7-Vapour inhalation: with menthol crystals as a steam.

8-Vaccination: Annual “flu” vaccination for at-risk group (those have chronic
respiratory diseases “asthma”, chronic heart diseases, chronic renal failure, D.M.
&..etc

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 Allergic Rhinitis

Rhinitis is simply inflammation of the nasal lining, characterized by rhinorrhoea,

nasal congestion, sneezing, and itching.

Allergic rhinitis may be regarded as seasonal allergic rhinitis (SAR), commonly

known as hay fever. Or perennial allergic rhinitis (PAR) (increasingly called
intermittent & persistent allergic rhinitis).

Seasonal allergic rhinitis occurs in response to specific allergens usually present at

predictable times of the year, during the plant's blooming seasons. Perennial allergic
rhinitis is a year-round disease caused by non-seasonal allergens such as house dust
mites, animal dander, molds,….etc.

Many patients have a combination of both (year-round symptoms and seasonal

exacerbation).

:Patient assessment with allergic rhinitis

1-Symptoms:
The patient usually have all four classical symptoms of nasal itch, sneeze,
rhinorrhoea, and nasal congestion, however, the patient might also suffer from ocular
irritation, giving rise to allergic conjunctivitis.
The nasal discharge is often thin, watery, and clear, but it may be change to
colored and purulent one, which may indicate secondary infection. However the
treatment is not altered and Antibiotic are usually not needed.
Symptoms of allergic rhinitis may be confused with that of common cold; the
two conditions may be distinguished by the following points:

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 Allergic rhinitis Common cold
1-nasal discharge usually remain clear 1-the initially clear nasal discharge
and if it became thickened , it takes much usually thickened and become purulent
longer to do so within few days
2-sneezing is frequent 2-sneezing is normally less frequent and
paroxysmal
3-nasal itching is present 3-nasal itching doesn’t normally occur
4-ocular symptoms present 4- usually no ocular symptoms
5-symptoms usually begin quite suddenly 5-onset of symptoms is more gradual
6-symptoms continue for as long as the 6-symptoms last for about four to several
patient is exposed to the allergens , often days
for several weeks
7-symptoms occur at the same time each 7-can occur at any time of the year but
year, in spring or summer when the more usually in the winter months
pollen that cause allergy is being
produced (symptoms of perennial allergic
rhinitis occur whenever the patient is in
contact with allergens)
8-only affect isolated individuals. 8-highly contagious, therefore other
family members or friends may well be
suffering at the same time and the
infection will be quite common within the
community.

2-Associated symptoms:
A- Earache and facial pain:
As with cold and flu, allergic rhinitis can be complicated by secondary bacterial
infections in middle ear (otitis media) or the sinuses (sinusitis), therefore patients with
painful ear or painful sinuses -------------required referral.
B-When associated symptoms such as wheezing, tightness of the chest, shortness
of breath are present -------------referral.
(These symptoms may represent the onset of an asthmatic attack).
C- Eye symptoms:
The eyes may be itchy and also watery (allergic conjunctivitis), occasionally, this may
be complicated by a secondary bacterial infection in which the eye become redder
with gritty sensation, and the discharge change from clear watery to colored and
sticky (purulent).

3-Seasonal variation:
Repetitive and predictable seasonal symptoms characterize SAR, whereas
symptoms that occur throughout the year without any oblivious seasonal pattern
characterize PAR.

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 4-Triggers:
Classically symptoms of hay fever are more severe in the morning and evening
this is because pollen rises during the day after being released in the morning and then
settled at night.
Hay fever symptoms worsen also on windy days, while symptoms may be reduced
after rain and when the patients stay indoors.
Symptoms of PAR are worsening on damp weather and persist when indoors.

5-Family history:
If a first degree relative suffers from atopy then hay fever is the most likely cause
of rhinitis.

6- Medication:
a. If one or more appropriate remedies have been tried without success (failed
medication) ------------- referral.
A. Medications of other conditions to avoid D-D interactions between the
recommended OTC and these drugs (e.g. D-D interaction between the
prescribed drugs and antihistamines).

Treatment timescale:
If no improvement is noted after 5 days of therapy ------the patient should be referred.

:Management

Non-pharmacological advices:
SAR PAR
1-stay indoors as possible (particularly in 1-Regular cleaning of the house (and
the morning and early evening) and keep all bedding at hot water) to maintain dust
windows closed. level at a minimum.

2-In the car, keep windows closed. 2-Lower household humidity, remove
houseplants, maintain good ventilation.
3-Wear closed-fitting sunglass when going
out and a mask if symptoms are really
severe.

Pharmacological therapy:
- Pharmacists now possess a wide range of options to treat SAR and PAR.
- Medications used can be divided into two categories:
Topical: corticosteroids, antihistamines, mast cell stabilizers, and
decongestants.
Systemic: Antihistamine and decongestants.

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1-Topical therapy:
A-Steroid nasal sprays: Beclometasone, and fluticasone, triamcinolone:
- Steroid nasal spray is the treatment of choice for moderate to severe nasal
symptoms, and superior to oral antihistamine.
- They can be used in patients aged over 18 years for up to 3 months.
- Ideally treatment should be start at least 2 weeks before symptoms are expected.
- Regular use is essential for full benefit and it should be continued throughout the
hay fever season (this is should be explain carefully to the patient to ensure
compliance) and repeated each year.
- If symptoms are allergy present, the patient needs to know that it take several days
before full effect is reached.

Doses:
Beclometasone spray (50 mcg/ one spray): 2 sprays into each nostril b.i.d ------once
the symptoms have improved-----it may be possible to decrease the dose to one spray
b.i.d.

Triamcinolone spray (55 mcg/ one spray): 2 sprays into each nostril once daily
------once the symptoms have improved-----it may be possible to decrease the dose to
one spray once daily.
Fluticasone spray (50 mcg/ one spray): 2 sprays into each nostril once daily,
preferably in the morning (if the symptoms are not improved, it may be possible to
increase the dose to 2 sprays b.i.d) ------once the symptoms have improved-----it may
be possible to decrease the dose to one spray once daily.

- They should not be recommended for pregnant or lactating mother, or anyone with
glaucoma.
Side effects: are (nosebleed, dryness and irritation of nose and throat).

Note: Patient sometimes alarmed by the term (steroid) therefore the pharmacist needs
to take account of these concerns.

B- Mast cell stabilizers Sodium cromoglicate:

- Available OTC as nasal drop or spray (4%) and as eye drop.
- Like CS, Sodium cromoglicate is a prophylactic agent, but their place in nasal
symptoms of allergic rhinitis is limited because it is less effective than CS and it
needs more frequent administration (4-6 times a day).
- It is preferably started 1 week before the hay fever season is likely to begin and then
used continuously whilst exposed to allergens.
- There are no significant side effects although nasal irritation may occur.
- It is not known to be teratogenic (OK in pregnancy) or to have any drug interactions
and can be given to all patients groups.

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Note: An OTC spray containing Sodium cromoglicate (2%) with a small amount of
decongestant (xylometazoline 0.025%) is also available, and the amount of
decongestant is said to be too small to produce rebound congestion.

C-Topical Decongestants: discussed in common cold

D-Topical antihistamine:

- It include: Azelastine and levocabastine nasal sprays are used in mild and
intermittent symptoms.

- The treatment preferably starts 2-3 weeks before the start of hay fever season.

Note: advise the patient to keep the head upright during use to prevent the liquid
trickling into the throat and causing an unpleasant taste.

- Azelastine nasal spray: can be given to adults and children over 5 years of age. The
dose is one application in each nostril twice daily. It should not be recommended for
elderly patient. It appears to have no drug interactions and it can be safely given
during pregnancy.

- Levocabastine nasal spray: can be given to adults and children over 12 years of age.
The dose is two applications in each nostril twice daily (which may be increased if
necessary to 3 or 4 times daily). It is not recommended during pregnancy (but some
references said: can be safely given).

2-Systemic (oral) therapy:

A-Decongestants: discussed in common cold

B-Antihistamines:
Antihistamine can reduce some of symptoms of allergic rhinitis: runny nose
(rhinorrhoea) and sneezing, and itching. They are also effective, but to a lesser extent,
against allergic conjunctivitis. While less effective in reducing nasal congestion.

Note: for maximum effectiveness, antihistamine should be taken when symptoms

expected (i.e. before) rather than after they have started.

Antihistamine can be classified into:

1- Sedating Antihistamine:
Examples of OTC sedating antihistamine are:
Chlorpheniramine (Histadin® tablet and syrup), Dexchlorpheniramine (polaramine®
tablet), and Diphenhydramine (Allermine® tablet and syrup)

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S/Es: include sedation and drowsiness (patients should be informed) and
anticholinergic S/Es( i.e. dry mouth, urinary retention, constipation , …..) and the
elderly patients are more susceptible to these.
Accordingly they are not recommended (or used with caution) for patients with:
Glaucoma, or prostate hypertrophy and in elderly patients.

D/I: the sedative effects of antidepressants, anxiolytics, and hypnotics are likely to be
enhanced by sedating antihistamine.

2- Non-Sedating Antihistamine:
Examples of OTC non-sedating antihistamine are:
Loratadine (clarityn® tablet & syrup), acrivastine and cetirizine (Zirtek® tablet &
syrup).
They are generally preferable over the older antihistamines because of much lower
incidence of S/Es.
Note: although the drowsiness is rare, but the warning that these drugs may affect
driving and skilled tasks is still present.

Non-sedating OTC age Dose

antihistamine
Loratadine Over 2 years Over 6 years: 10 mg once
daily
years: 5 mg once daily 2-5

Cetirizine Over 6 Over 6 years: 10 mg once

years daily

Acrivastine Over 12 Over 12 years: 8 mg as

years necessary up to 3 times daily

C- Combination products:
Sympathomimetic (for congestion) + Antihistamine (for rhinorrhoea and sneezing):
Example of OTC products is:
Actifed® tablet and syrup: which composed of Triprolidine (sedating antihistamine)
and Pseudoephedrine (sympathomimetic).

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