Common Cold and Flu

Lecture 3

Dr Wejdan Shroukh
Slides prepared by MSc. Rasha Maraqa
 Cold and Flu

Flu and the common cold are both respiratory

illnesses but they are caused by different viruses.

Because these two types of illnesses have similar

symptoms, it can be difficult to tell the difference
between them based on symptoms alone.
 Flu
Flu is generally considered to be likely if:

- Temperature is 38 ◦C or higher (37.5 ◦C in the elderly).

- A minimum of one respiratory symptom – cough, sore

throat, nasal congestion or rhinorrhea.

- A minimum of one constitutional symptom – headache,

malaise, myalgia, sweats/chills is present.

There is often a period of generalized weakness and

malaise following the worst of the symptoms, and this
may last a week or more.

A dry cough may also persist for some time.

 Flu

Someone with flu may be bedbound and

unable to go about usual activities, and this
differentiates it from viruses causing cold
 Coronaviruses (COVID-19)
People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to
severe illness. Symptoms may appear 2-14 days after exposure to the virus.
Anyone can have mild to severe symptoms. People with these symptoms may have COVID-19:

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
When to Seek Emergency Medical Attention

Trouble breathing
Persistent pain or pressure in the chest
New confusion
Inability to wake or stay awake
Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone
 Cold and Flu
In general, flu is worse than the common cold, and symptoms are more intense.
People with colds are more likely to have a runny or stuffy nose. Colds generally do not result in serious
health problems, such as pneumonia, bacterial infections, or hospitalizations.
Sign and Symptoms Cold Flu
Symptoms Onset Gradual Abrupt
Fever Rare Usual
Aches Slight Usual
Chills Uncommon Fairly Common
Fatigue, weakness Sometimes Usual
Sneezing Common Sometimes
Stuffy Nose Common Sometimes
Sore throat Common Sometimes
Chest discomfort, Mild to moderate Common
cough
Headache Rare Common
 Coronavirus vs. Flu
• Flu: Typically, a person develops symptoms anywhere from 1 to 4 days after infection.

• COVID-19: Typically, a person develops symptoms 5 days after being infected, but symptoms can
appear as early as 2 days after infection or as late as 14 days after infection, and the time range
can vary.

• Flu: Most people with flu are contagious for about 1 day before they show symptoms. adults with
flu appear to be most contagious during the initial 3-4 days of their illness but many remain
contagious for about 7 days.

• COVID-19: How long someone can spread the virus that causes COVID-19 is still under investigation.
It’s possible for people to spread the virus for about 2 days before experiencing signs or
symptoms and remain contagious for at least 10 days after signs or symptoms first appeared.
 Coronavirus and Flu
flu can be complicated by secondary lung infection
(pneumonia).

Such complications are much more likely to occur in:

- The very young, who have not yet developed

resistance.

- The very old and frail, who may have impaired

immunological responses.

- And those who have pre-existing heart disease or

respiratory disease (asthma or COPD), where further
damage is more critical.

- Diabetic patients.
 Common Cold
The common cold is a conventional term for a mild upper
respiratory illness.

The hallmark symptoms of which are nasal stuffiness and

discharge, sneezing, sore throat and cough.

Common cold is one of the MOST common categories of

self-medication that requires pharmacist advice and
patient counseling.
 Cold and Flu
What you need to know/ 1. Age
Establishing who the patient is – child or adult – will influence the pharmacist’s decision about the
necessity of referral to the doctor and choice of treatment.

Children are more susceptible to URTI than are adults and may get complications.

Very young children and babies are also at increased risk of bronchiolitis, pneumonia and croup, and
these conditions need to be considered.

Older people, particularly if they are frail and have co-

morbidities (e.g. diabetes), may be at risk of complications
such as pneumonia.
 Cold and Flu
What you need to know/ 2. Duration
Patients may describe a rapid onset of symptoms over hours (Flu), or a gradual onset over a day or
two (Cold).
The symptoms of the common cold usually last for 7–14 days. Some symptoms, such as a cough,
may persist after the worst of the cold is over and coughing for 3 weeks is not unusual.

This is often poorly recognized, so expectations of recovery may be unrealistic, and it is worth
advising patients that this may happen.
 Cold and Flu
What you need to know/ 3. Symptoms

a. Runny/blocked nose

Most patients will experience a runny nose (rhinorrhoea). This is initially a

clear watery fluid, which is then followed by the production of thicker
and often colored mucus.

Nasal congestion occurs because of dilatation of blood vessels, leading to

swelling of the lining surfaces of the nose and can cause discomfort. This
swelling narrows the nasal passages that are further blocked by
increased mucus production.
 Cold and Flu
What you need to know/ 3. Symptoms

c. Sneezing / coughing

Sneezing occurs because the nasal passages are irritated and congested.

A cough may be present either because the pharynx is irritated

(producing a dry, tickly cough) or as a result of irritation of the bronchus
caused by postnasal drip.
 Cold and Flu
What you need to know/ 3. Symptoms
d. Aches and pains/headache

Headaches may be experienced because:

1- inflammation and congestion of the nasal passages and sinuses.

2- A fever may also cause headache.

A persistent or worsening frontal headache (pain above or below the

eyes) may be due to sinusitis.

Drinking adequate fluids and rest will generally help.

People often report muscular and joint aches and this is more likely to
occur with flu than with the common cold.
 Cold and Flu
What you need to know/ 3. Symptoms

g. Facial pain/frontal headache

If this happens, more persistent pain arises in the sinus

areas. The maxillary sinuses are most commonly
involved.

It can become secondarily (bacterially) infected but this

is rare.
 Cold and Flu
What you need to know/ 3. Symptoms
g. Facial pain/frontal headache

Antibiotics however may be recommended if the symptoms of sinusitis (These may be reasons to direct patients
for further assessment):

- Persist for more than 10 days

- Or are severe with fever (>38◦C)
- Severe local pain, discolored nasal discharge

When these features are not present, treatment should be aimed at symptom relief.

Options include paracetamol or ibuprofen to reduce pain; an intranasal decongestant (for a maximum of 1 week,
in adults only) may help if nasal congestion is problematic.
 Cold and Flu
What you need to know/ 3. Symptoms

e. High temperature

Those suffering from a cold often complain of feeling hot, but

in general a high temperature (e.g. exceeding 38◦C) will not be
present.

The presence of fever may be an indication that the patient

has flu rather than a cold.
 Cold and Flu
What you need to know/ 3. Symptoms

f. Sore throat

The throat often feels dry and sore during a cold and may
sometimes be the first sign that a cold is imminent (about to
happen).

A sore throat can be a prominent (well-known) feature in colds

and flu, and it is often treated erroneously (incorrectly) as a
throat infection.
 Cold and Flu
What you need to know/ 3. Symptoms
Under normal circumstances, the middle
ear is an air containing compartment.
f. Earache However, if the Eustachian tube is blocked,
is a common complication of colds, especially in children. the ear can no longer be cleared or air
pressure equilibrated by swallowing and
may feel uncomfortable and deaf.

often resolves
spontaneously, but
decongestants and
inhalations can be helpful
 Cold and Flu
What you need to know/ 3. Symptoms
Sometimes the situation worsens when the
middle ear fills up with fluid and is under
f. Earache pressure. When this does occur, the ear
is a common complication of colds, especially in children. becomes acutely painful and this is called
acute otitis media (AOM)
 Cold and Flu
What you need to know/ 3. Symptoms

f. Earache
A secondary infection may follow, but even in the context of infection,
the evidence for antibiotic use is conflicting with some trials showing
benefit and others showing no benefit from taking antibiotics.

Antibiotics have also been shown to increase the risk of vomiting, diarrhea and rash, and these risks can
be greater than the potential for benefit.

Antibiotics are most useful in children under 2 years of age with pain in both ears OR with a painful ear
with discharge from that ear (otorrhoea), so in these circumstances suggesting getting a fairly rapid
doctor or nurse assessment is appropriate.

Do not advise that antibiotics may be needed as this raises expectations that may not be met; it is better
to say that examination is required.
 Cold and Flu
What you need to know/ 3. Symptoms

f. Earache

In summary, a painful ear can initially be managed

by the pharmacist. There is evidence that
paracetamol and ibuprofen are effective treatments
for AOM.

However, if pain were to persist or be associated

with an unwell child (e.g. high fever, very restless
or listless, vomiting), then referral to the GP would
be advisable.
 Cold and Flu
Present medication

The pharmacist must ascertain if any medicines are being taken by

the patient.

It is important to remember that interactions might occur with some

of the constituents of commonly used OTC medicines.

If medication has already been tried for relief of cold symptoms with
no improvement, and if the remedies tried were appropriate and
used for a sufficient amount of time, referral for primary care
assessment might occasionally be needed.

In most cases of colds and flu, however, OTC treatment will be

appropriate.
 Cold and Flu
When to refer
- If medication has already been tried for relief of cold symptoms with no improvement, and if
the remedies tried were appropriate and used for a sufficient amount of time.

- Earache not settling with analgesic - In the very young

- In the frail and old - Asthma

- With pleuritic-type chest pain

sudden and intense sharp, stabbing, or
burning pain in the chest when inhaling
and exhaling.

- In those with heart or lung disease, for example, COPD, kidney disease, diabetes,
compromised immune system

- With persisting fever and productive cough

 Coronaviruses (COVID-19)
• The rationale is that the virus in droplets can survive for 24–48 h on hard, non-porous surfaces;
for 8–12 h on cloth, paper and tissue; and for 5 min on hands.

• Wash your hands often with soap and water for at least 20 seconds, especially after blowing your
nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food.

• Avoid touching your eyes, nose, and mouth with unwashed hands.

• Stay home when you are sick.

• Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
 Cold and Flu
Prevention of Colds and flu: Hygiene advice

Basic good hygiene measures may help to prevent spread.

People should use tissues to cover their mouth and nose when coughing or sneezing and should put
used tissues in a bin as soon as possible.

Ethanol (60–95%)-based hand sanitizers are widely used in healthcare settings and can contribute to
reducing transmission of colds and flu.

Touching contaminated hands, surfaces and objects can therefore transfer the virus.
 Cold and Flu
Prevention of Colds and flu: Hygiene advice

Pharmacists should encourage those in at-risk groups to have an annual flu vaccination.

Who should take flu vaccination?

All patients over 65 years
Those below that age who have chronic respiratory disease (including asthma)
Chronic heart disease
Chronic renal failure
Chronic neurological disease
Diabetes mellitus
Immunosuppression due to disease or treatment
Pregnant women
People living in long-stay residential care
 Cold and Flu
Management

The pharmacist’s role is to select appropriate treatment based on:

1- The patient’s symptoms

2- Available evidence

3- The patient’s preferences.

 Cold and Flu
Management

The UK Medicines and Healthcare products and Regulatory Agency (MHRA) advised that
the following OTC cough and cold remedies should no longer be sold for children under 6
years:

 Antitussives: Dextromethorphan and pholcodine

 Expectorants: Guaifenesin
 Nasal decongestants: Ephedrine, oxymetazoline, phenylephrine, pseudoephedrine and
xylometazoline
 Antihistamines: Brompheniramine, chlorphenamine, diphenhydramine, doxylamine,
promethazine and triprolidine

Remember that all aspirin-containing products are contraindicated in all children under
the age of 16. This includes oral salicylate gels.
 Cold and Flu
Management/ 1. Decongestants
Sympathomimetics

Sympathomimetics can be effective in reducing the symptoms of nasal congestion.

 
These medicines can be given orally or applied topically. Tablets and syrups are available, as are nasal sprays
and drops.
 
If nasal sprays/drops are to be recommended, the pharmacist should advise the patient not to use the
product for longer than 7 days.
 
Rebound congestion can occur with topically applied, but not oral sympathomimetics.
  
 
The MHRA (the Medicine and Healthcare Products Regulatory Agency) advises that these decongestants can
be used in children between the ages of 6 and 12 years, but should not be used in children under the age
of 6.

The pharmacist can give useful advice about the correct way to administer nasal drops and sprays.
 Cold and Flu
Management/ 1. Decongestants- Sympathomimetics

Nasal Drops Administration Nasal Spray Administration

 Cold and Flu
Management/ 1. Decongestants- Sympathomimetics
 Cold and Flu
Management/ 1. Decongestants
Sympathomimetics
  
 
 Cold and Flu
Management/ 1. Decongestants
Sympathomimetics
  
 
4. Decongestants/Sympathomimetics
 Cold and Flu
Management/ 1. Decongestants- Sympathomimetics

Cautions
- Diabetes; can increase blood glucose levels.

- Heart disease; cause stimulation of the heart

- Hypertension; increase blood pressure

- Hyperthyroidism; The hearts of hyperthyroid patients are more vulnerable to irregularity, so stimulation of
the heart is particularly undesirable.

- They have stimulating effects on the central nervous system (CNS)

Unwanted effects when taken by mouth and are unlikely to do

so when used topically.
 Cold and Flu
Management/ 1. Decongestants- Sympathomimetics

Interactions: Avoid in those taking

MAOIs (e.g. phenelzine); a hypertensive crisis can be induced.. This interaction can occur up to 2 weeks after a
patient has stopped taking the MAOI, so the pharmacist must establish any recently discontinued medication.

Beta-blockers
 Cold and Flu
Management/ 1. Decongestants- Sympathomimetics

Restrictions on sales of pseudoephedrine and ephedrine

In response to concerns about the possible extraction of pseudoephedrine and ephedrine from OTC products
for use in the manufacture of methylamphetamine (crystal meth), restrictions were introduced in 2007.

The medicines are available only in small pack sizes, with a limit of one pack per customer, and their sale has to
be made by a pharmacist or by suitably trained pharmacy staff under the supervision of a pharmacist.
 Cold and Flu
Management/ 2. Antihistamines
 Cold and Flu
Management/ 2. Antihistamines

Histamine is a chemical messenger mostly generated in mast cells.

Histamine, via multiple receptor systems, mediates a wide range of cellular responses, including:

- Allergic and inflammatory reactions.

- Gastric acid secretion.
- Neurotransmission in parts of the brain.

Histamine is present in practically all tissues, with significant amounts in the lungs, skin, blood vessels, and GI
tract.

It is found at high concentration in mast cells and basophils.

Histamine functions as a neurotransmitter in the brain. It also occurs as a component of venoms and in
secretions from insect stings.
 Cold and Flu
Management/ 2. Antihistamines
 Cold and Flu
Management/ 2. Antihistamines
 Cold and Flu
Management/ 2. Antihistamines
Could theoretically reduce some of the symptoms of a cold: runny nose (rhinorrhoea) and sneezing.

First-generation antihistamines reduce rhinorrhea by 25-35%.

These effects are due to the anticholinergic action of antihistamines.

The older drugs (e.g. chlorpheniramine, promethazine) have more pronounced anticholinergic actions than the
non-sedating antihistamines (e.g. loratadine, cetirizine, acrivastine).

Therefore the non-sedating antihistamines are less effective in reducing symptoms of a cold.

Antihistamines are not so effective at reducing nasal congestion.

 
Some (e.g. diphenhydramine) may also be included in cold remedies for their supposed antitussive action or to
help the patient to sleep (included in combination products intended to be taken at night).
 
Evidence indicates that antihistamines alone are not of benefit in the common cold but that they may offer
limited benefit for adults in combination with decongestants, analgesics and cough suppressants.
 Cold and Flu
Management/ 2. Antihistamines
 Cold and Flu
Management/ 2. Antihistamines

Side Effects:
The problem of using antihistamines, particularly the
older types (e.g. chlorphenamine), is that they can
cause Drowsiness.

Because of their anticholinergic activity, the older

antihistamines may produce the same adverse effects
as anticholinergic drugs (i.e. dry mouth, blurred vision,
constipation and urinary retention).
 Cold and Flu
Management/ 2. Antihistamines

Interactions (increase side effects)

Alcohol
Hypnotics
Sedatives
Betahistine
Anticholinergics (such as hyoscine), ipratropium or tiotropium

Cautions
Closed-angle glaucoma
LUTS in men
Liver disease
 5. Antihistamine

(First Generation)
5. Antihistamine
5. Antihistamine
 Cold and Flu
Management/ 3. Zinc

Two systematic reviews have found limited evidence that zinc gluconate or acetate lozenges may
reduce continuing symptoms at 7 days compared with placebo.

The use of zinc has been shown to inhibit viral growth, and a randomized controlled trial (RCT)
suggested that zinc could reduce the duration of cold symptoms. However, this has not been
substantiated in subsequent RCTs.

Specifically, four of eight subsequent trials showed no benefit, and the other four may have been
biased by the patients’ ability to recognize the adverse effects of zinc.

Because of these inconsistent study results, zinc cannot be recommended for adults.

It is therefore generally not recommended that people take zinc supplements for colds.
 Cold and Flu
Management/ 4. Echinacea ‫القُنفُذيَّة اُألرجُوا ِنيَّة‬

A systematic review of trials indicated that some echinacea

preparations may be better than placebo or no treatment for the
prevention and treatment of colds.

However, due to variations in preparations containing echinacea,

there is insufficient evidence to recommend a specific product.

Echinacea has been reported to cause allergic reactions and

rash.
 Cold and Flu
Management/ 5. Vitamin C

A systematic review found that high-dose vitamin C (over 1 g/day) taken prophylactically could
reduce the duration of colds by a slight amount (about 8%).

Although it is relatively cheap and safe, general advice is that there is not much to be gained from
taking extra vitamin C for colds.
 Cold and Flu
Management/ 6. Inhalations

Breathing in warm moist air generated by steam (with or without the addition of aromatic oils) has traditionally
been used to reduce nasal congestion and soothe the air passages.

These usually contain aromatic ingredients such as eucalyptus or menthol. There has been a move away from
recommending steam inhalations for children because of the risk of scalding, and aromatic inhalants should not
be used in those 3 months or younger.
 Cold and Flu
Management/ 7. Nasal sprays or drops?

Nasal sprays are preferable for adults and children over 6 years old because the small droplets in the spray
mist reach a large surface area.

For children under 6 years old, drops are preferred because in young children the nostrils are not sufficiently
wide to allow the effective use of sprays.

Pediatric versions of nasal drops should be used where appropriate. Nasal saline drops or sprays may help to
reduce nasal congestion in babies and young children.
 Case Study 1
Mrs Allen, a regular customer in her late 60s, 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 atorvastatin 20 mg daily.

Mrs. Allen asks you if it is worth her husband taking extra vitamin C as she has heard this is
good for colds. She wondered if this might be better than taking yet more medicines.
 Case Study 1/ answer
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 (paracetamol) for his
sore throat and headache and a topical decongestant or an inhalation to clear his
blocked nose.
 Case Study 1/ answer
The pharmacist’s view
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 may slightly reduce the length and severity of colds,
although this is not a large effect, but that it won’t do much harm.

You show her some vitamin C products and tell her their cost. You also ask if Mr Allen has had
a flu shot as he is in an ‘at-risk’ group.

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.
 Case Study 2
A man comes into the pharmacy just after Christmas 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 (terrible) 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 has not 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 glucose readings,
which have all been between 8 and 11 mmol/l – 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.
 Case Study 2/ answer
The pharmacist’s view
The history indicates flu.

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 a higher risk of complications from flu.

It would be best for this woman to be seen by a GP.

In this situation, a doctor or nurse would want to check her chest for signs of a
secondary infection.

The pharmacist’s support is often helpful.

 Case Study 2/ answer
The pharmacist’s view

Most cases of flu usually resolve within 7 days.

The complications can include AOM, bacterial sinusitis, bacterial pneumonia and, less
commonly, viral pneumonia and respiratory failure.

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; however, the husband would almost
certainly have caught the infection by now, if susceptible.