Professional Documents
Culture Documents
Monograph 5
A continuing
pharmacy
education activity
for pharmacists
Supported by an
independent educational
grant from
Activity Preview
Fever, cough, cold, and allergy are among the most frequently
occurring ailments affecting Americans, as well as the most
commonly self-treated conditions. Pharmacists are the logical
health care professionals to assist patients with self-care decisions
related to these conditions, because pharmacists are available at
the point of purchase and are the only health care professionals
who receive in-depth formal education and skill development in
nonprescription pharmacotherapy.
This monograph addresses self-care for fever, cough, the
common cold, and allergic rhinitis. Each condition is defined
and its pathophysiology is reviewed. Exclusions for self-treatment
are presented and explained. Self-care optionsnonprescription
medications and nonpharmacologic interventionsare discussed
in the context of a self-treatment algorithm. Each section of
the monograph concludes with a list of Points to Remember
that provides a quick summary of the major concepts and
recommendations.
Accreditation Information
The American Pharmacists Association is
accredited by the Accreditation Council for
Pharmacy Education as a provider of continuing
pharmacy education (CPE). The ACPE Universal
Activity Number assigned to this activity by
the accredited provider is 202-000-10-126-H01-P. To obtain
2.5 hours of CPE credit (0.25 CEUs) for this activity, complete
the CPE exam and submit it online at www.pharmacist.com/
education. A Statement of Credit will be awarded for a passing
grade of 70% or better. You have two opportunities to successfully
complete the CPE exam. Pharmacists who successfully complete
this activity before May 1, 2013, can receive credit.
Learning Objectives
At the completion of this activity, the pharmacist will be able to:
1. Discuss the etiology, pathophysiology, and detection of
fever.
2. Describe the different types of cough and explain how the
treatment approach differs for each.
3. Compare and contrast the pathophysiology and symptoms
of the common cold with those of allergic rhinitis.
4. Differentiate between patients with the common cold,
allergic rhinitis, cough, or fever who are candidates for selftreatment and patients whose care should be managed by
a primary care provider.
5. Describe nonpharmacologic interventions for the common
cold, allergic rhinitis, cough, and fever.
6. Discuss the nonprescription medications used to manage the
common cold, allergic rhinitis, cough, and fever, including
product selection considerations, correct dosing and
administration, contraindications, and adverse effects.
Advisory Board
Kelly Scolaro, PharmD
Clinical Assistant Professor
Director of Pharmaceutical Care Labs
Eshelman School of Pharmacy
University of North Carolina
Chapel Hill, North Carolina
Karen Tietze, PharmD
Professor of Clinical Pharmacy
Philadelphia College of Pharmacy
University of the Sciences in Philadelphia
Philadelphia, Pennsylvania
Support
This activity is supported by an independent educational grant
from Procter & Gamble.
Disclosures
Kelly Scolaro, PharmD, has served as a reviewer for Elsevier.
Karen Tietze, PharmD, declares no conflicts of interest or
financial interests in any product or service mentioned in this
activity, including grants, employment, gifts, stock holdings, and
honoraria.
APhAs editorial staff declares no conflicts of interest or financial
interests in any product or service mentioned in this activity,
including grants, employment, gifts, stock holdings, and
honoraria.
This publication was prepared by Cynthia Knapp Dlugosz,
BPharm, of CKD Associates, LLC, on behalf of the American
Pharmacists Association.
Introduction
Fever
An idiosyncratic reaction.
Examples of medications that can
induce hyperthermia are listed in
Table 1.
Hypersensitivity is the most common mechanism of drug-induced
hyperthermia. An elevated body temperature usually develops after 7 to
10 days of treatment, although fever
and other signs and symptoms (e.g.,
rash, urticaria, eosinophilia) may begin sooner if the patient was exposed
to the causative agent previously.
Hyperthermia induced by vaccines
usually occurs within 48 hours of
vaccination.
Drug-induced hyperthermia can
be differentiated from other causes
by (1) establishing a temporal relationship between the fever and the
administration of a drug, (2) observ
ing a temperature elevation despite
improvement of the underlying disorder, and (3) identifying possible
allergic symptoms. Management
involves discontinuing the suspected
drug whenever possible; if feasible,
Aminoglycosides
Amphotericin B
Cephalosporins
Chloramphenicol
Clindamycin
Imipenem
Isoniazid
Macrolides
Mebendazole
Nitrofurantoin
Para-aminosalicylic acid
Penicillins
Rifampin
Streptomycin
Sulfonamides
Tetracyclines
Vancomycin
Antineoplastics
l-Asparaginase
Bleomycin
Chlorambucil
Cytarabine
Daunorubicin
Hydroxyurea
6-Mercaptopurine
Procarbazine
Streptozocin
Cardiovascular
agents
Epinephrine
Hydralazine
Methyldopa
Nifedipine
Procainamide
Quinidine
Streptokinase
Central nervous
system agents
Amphetamines
Barbiturates
Benztropine
Carbamazepine
Haloperidol
Lithium
Monoamine oxidase
inhibitors
Nomifensine
Phenothiazines
Phenytoin
Selective serotonin
reuptake inhibitors
Thioridazine
Tricyclic antidepressants
Trifluoperazine
Other agents
Allopurinol
Atropine
Azathioprine
Cimetidine
Corticosteroids
Folate
Infliximab
Inhaled anesthetics
Interferon
Iodides
Metoclopramide
Propylthiouracil
Prostaglandin E2
Salicylates
Tolmetin
Vaccines
Normal
Fever
Oral
95.9F99.9F
(35.5C37.7C)
100.0F (37.8C)
Rectal
97.9F100.4F
(36.6C38.0C )
100.5F (38.1C)
Tympanic
96.3F99.9F
(35.7C37.7C )
100.0F (37.8C)
Case 1. Fever
The mother of JPa 4-year-old girlis called to pick up her child from preschool
because JP has developed a fever. JP had seemed tired and irritable that morning,
and refused to eat breakfast; however, when the mother checked JPs temperature that
morning as a precaution, it was in the normal range (98.4F using an electronic oral
thermometer). JPs temperature at 1:30 pm, as measured by the preschool teacher using
an infrared tympanic thermometer, is 101.2F. According to the mother, JP has no history
of high fevers or seizures.
What is the best course of action in this case?
a.
b.
c.
d.
The mother should sponge JP with tepid water to help bring down the fever.
The mother should administer a nonprescription antipyretic medication to JP as
soon as possible, because JPs temperature is dangerously high.
JP should be seen by a primary care provider as soon as possible.
The mother should dress JP in light clothing, encourage her to drink fluids, and
monitor her temperature periodically using the same thermometer and site each
time. Antipyretic medication could be administered if JP seems very uncomfortable.
No
No
Yes
Yes
Yes
Yes
Medical management
Medical management
Yes
No
Oral temperature >101F (38.3C)
or equivalent?
Exclusions
for Self-Treatment
Patients
>6 months
of age with rectal
Patients
>6 months
of(40C)
age with
temperature
104F
or rectal
temperature
equivalent 104F (40C) or
equivalent
Children <6 months of age with rectal
Children
<6 months
of(38.3C)
age with rectal
temperature
101F
temperature
101F
(38.3C) that are
Severe symptoms
of infection
Severe
symptoms of infection that are
not self-limiting
not
Riskself-limiting
for hyperthermia
Risk
for hyperthermia
Impaired
oxygen utilization
Impaired
oxygen
utilization
(e.g.,
severe
(e.g., severe
COPD,
respiratory
distress,
COPD,
respiratory distress, heart failure)
heart failure)
Impaired immune function (e.g., cancer, HIV)
CNS damage (e.g., head trauma, stroke)
Children with history of febrile seizures
or other seizures
Fevers
Fevers that
that persist
persist >3
>3 days
days with
with
or
or without
without treatment
treatment
Children
Children who
who develop
develop spots
spots or
or rash
rash
Children
Children who
who refuse
refuse to
to drink
drink any
any fluids
fluids
Children
Children who
who are
are very
very sleepy,
sleepy, irritable,
irritable,
or
or difficult
difficult to
to awaken
awaken
Children
Children who
who are
are vomiting
vomiting and
and
cannot
cannot keep
keep down
down fluids
fluids
.
No
Nondrug measures antipyretic
agent if patient has discomfort or
patient/caregiver requests agent
No
MedicalMedical
management
management
Yes
D/C therapy
CNS = central nervous system; COPD = chronic obstructive pulmonary disease; D/C = discontinue; HIV = human immunodeficiency virus.
Source: Feret B. Fever. In: Berardi RR, Ferreri SP, Hume AL, et al., eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th ed. Washington, DC: American Pharmacists Association;
2009:89
Acetaminophen
Aspirin
Ibuprofen
Naproxen sodium
Weight (lb)
Acetaminophen
611
1217
1823
2435
3647
4859
6071
7295
96
40b
80b
120b
160
240
320
400
480
650
Ibuprofenc
611
1217
1823
2435
3647
4859
6071
7295
96
Not recommended
50
75
100
150
200
250
300
200400 (maximum 1,200
mg/day)
a
Dosing information based on a usual pediatric acetaminophen dosage of 1015 mg/kg. Single doses may be
repeated every 46 hours as needed, not to exceed five doses in 24 hours.
b
This dose is not included in the approved nonprescription labeling; it is provided to assist pharmacists in
determining appropriate doses.
c
Dosing information based on a usual pediatric ibuprofen dosage of 7.5 mg/kg. Single doses may be repeated
every 68 hours as needed, not to exceed four doses in 24 hours.
On April 28, 2009, the FDA issued a final rule requiring manufacturers of nonprescription
antipyretic/analgesic products to revise their labeling to include new safety information.
Of note, the word acetaminophen or NSAID (for products containing salicylates,
ibuprofen, or naproxen sodium) must appear highlighted or in bold type in a prominent
font size on both the product container and outer carton. This change applies to
single-ingredient products as well as products that contain acetaminophen or NSAIDs
in combination with other active ingredients. In addition, the product container and
outer carton must include a warning about the risk of severe liver damage when using
acetaminophen or the risk of severe stomach bleeding when using NSAIDs. Manufacturers
are required to implement all of the changes listed in the final rule by April 28, 2010.
On June 29 and 30, 2009, three FDA advisory committees considered a series of options
for further reducing the incidence of liver injury associated with acetaminophen use that
exceeds the maximum recommended daily dose (4 g per day). Their recommendations
included:
Limiting the amount of acetaminophen in nonprescription products to 325 mg per tablet
(650 mg recommended dose).
Lowering the maximum recommended daily dose of acetaminophen.
Standardizing the concentration of liquid acetaminophen products for pediatric use.
The FDA had not taken any action on these recommendations at the time this monograph
was finalized.
The FDA has encouraged health care providers to help prevent the morbidity and mortality
of acetaminophen-induced hepatotoxicity and NSAID-related GI and renal effects by
educating their patients about the following:
Appropriate safety precautions for the use and storage of nonprescription antipyretics/
analgesics as drug products.
The wide variety of strengths, formulations, and combinations of acetaminophen- and
NSAID-containing products available with and without a prescription.
Correct dosing frequency for each of the acetaminophen or the NSAID formulations.
Correct weight-based dose for each child.
Use of the correct measuring device for the liquid formulations.
Risks of taking nonprescription antipyretics/analgesics with prescription or other
nonprescription medications.
Signs and symptoms of self-recognizable adverse effects.
Potential problems associated with simultaneous use of more than one antipyretic/
analgesic product.
Cough
Points to Remember
Fever is a controlled elevation in body temperature above the normal core temperature
range. The febrile response is a normal physiologic reaction to disease, not a disease
itself.
Most fevers are self-limiting and rarely pose severe consequences unless the oral
temperature exceeds 106F (41.1C). The main reason for treating fever with antipyretic
agents is to alleviate patient discomfort.
Rectal temperature measurement is the most accurate method; however, oral, tympanic,
and temporal measurements also are accurate if taken appropriately.
Sponge baths using topical isopropyl or ethyl alcohol to reduce fever should be
discouraged.
Patients should be evaluated by a primary care provider if a 3-day course of
self-treatment is not successful.
Antipyretic Agent
Drug
Potential Interaction
Acetaminophen
Alcohol
Acetaminophen
Warfarin
Aspirin
NSAIDs, including
COX-2 inhibitors
Aspirin
Valproic acid
Ibuprofen
Aspirin
Ibuprofen
Phenytoin
NSAIDs (several)
Bisphosphonates
NSAIDs (several)
Digoxin
Alcohol
Anticoagulants
Antihypertensive
agents, -blockers,
ACE inhibitors,
vasodilators,
diuretics
Methotrexate
ACE = angiotensin-converting enzyme; COX = cyclooxygenase; GI = gastrointestinal; INR = international normalized ratio; NSAID = nonsteroidal anti-inflammatory drug.
vide symptomatic relief of nocturnal cough associated with childhood upper respiratory infection.
Humidification, which increases
the amount of moisture in inspired
air and may soothe irritated airways.
Adequate hydration, which may
promote the formation of secretions that are less viscous and
thus easier to expel.
Neither lozenges nor honey should
be used to relieve cough in children
younger than 1 year of age. Lozenges
represent a potential choking hazard;
honey may cause infant botulism.
Humidifiers (ultrasonic, impeller,
or evaporative types) and vaporizers
(humidifiers with a medication well
or cup for volatile inhalants) are used
to increase the amount of moisture
in inspired air. It is important to note
that high humidity may increase the
amount of mold and dust mites in the
home, thereby worsening allergies.
Humidifiers and vaporizers also disperse minerals and microorganisms
into the air. Cool-mist humidifiers and
vaporizers are preferred to warm-mist
humidifiers and vaporizers because
fewer bacteria grow at the cooler
temperatures and there is less risk
of scalding if the unit is tipped over.
Humidifiers and vaporizers must be
cleaned daily and disinfected weekly.
To maintain adequate hydration,
most people should consume approximately eight 8-oz glasses of water
daily. The clinical benefits of increasing
hydration beyond this level in patients
with acute upper respiratory tract
infections are debatable. Excessive
fluid intake may cause fluid overload
Asthma
Productive cough most days of the month at least 3 months of the year for at least
2 consecutive years
10
Coughwith
withthick
thickyellow
yellowsputum
sputumoror
Cough
greenphlegm
phlegm
green
Fever>101.5F
>101.5F(38.6C)
(38.6C)
Fever
Unintendedweight
weightloss
loss
Unintended
Drenchingnighttime
nighttimesweats
sweats
Drenching
Hemoptysis
Hemoptysis
Historyororsymptoms
symptomsofofchronic
chronic
History
underlyingdisease
diseaseassociated
associatedwith
with
underlying
cough(e.g.,
(e.g.,asthma,
asthma,COPD,
COPD,chronic
chronic
cough
bronchitis,CHF)
CHF)
bronchitis,
Foreignobject
objectaspiration
aspiration
Foreign
Suspecteddrug-associated
drug-associatedcough
cough
Suspected
Coughfor
for>7
>7days
days
Cough
Coughthat
thatworsens
worsensduring
duringselfselfCough
treatment
treatment
Developmentofofnew
newsymptoms
symptoms
Development
duringself-treatment
self-treatment
during
Yes
Yes
Medical management
Medical management
Yes
Yes
No
No
Dry (nonproductive) cough?
Dry (nonproductive) cough?
No
No
Nondrug measures (vaporizers,
Expectorant + Nondrug measures
hydration). Antitussive if cough
(vaporizers, hydration).
affects sleep or work.
Antitussive if cough affects sleep
Reevaluate in 7 days
or work. Reevaluate in 7 days
Symptoms improved?
Symptoms improved?
No
No
Medical management
Medical management
Yes
Yes
Continue treatment until cough
Continue treatment until cough
is gone. Reevaluate as needed
is gone. Reevaluate as needed
CAM = complementary and alternative medicine; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease.
Source: Tietze KJ. Cough. In: Berardi RR, Ferreri SP, Hume AL, et al., eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th ed. Washington, DC: American Pharmacists
Association; 2009:204.
of nonprescription antitussives or
expectorants in the treatment of
acute cough in adults or children. In
particular, there is little evidence that
antitussives are effective for coughs
associated with the common cold or
other upper respiratory tract infections. The reason may be that cough
associated with upper respiratory
tract infections usually is a voluntary
cough controlled in the cerebral cortex, while nonprescription antitussives
act on the cough control center in
the medulla oblongata. Pharmacists
should be aware that patients are
likely to continue using nonprescription antitussives and expectorants
whether or not evidence of efficacy
exists; these medications generally
are well tolerated and usually pose
few safety risks if administered in accordance with labeled instructions.
Antitussive Agents. Codeine.
Approved antitussive dosages of codeine are shown in Table 7. Codeine-
11
12
Common Cold
Children Age 45 ya
Codeine
1020 mg every 46 h
(120 mg)
510 mg every 46 h
(60 mg)
Dextromethorphan
hydrobromide
1020 mg every 4 h or
30 mg every 68 h (120 mg)
510 mg every 4 h or 15 mg
every 68 h (60 mg)
Diphenhydramine citrate
Diphenhydramine HCl
Guaifenesin
200400 mg every 4 h
(2.4 g)
100200 mg every 4 h
(1.2 g)
Drug
Current product labeling states do not use in children younger than 4 years of age, based on a voluntary action by manufacturers.
Not recommended for use in children younger than 6 years of age except under the advice of a primary care provider.
a
b
13
14
in Table 8.
Patients who are not good candidates for self-treatment of the common cold include:
Patients with concurrent underlying chronic cardiopulmonary
diseases (asthma, COPD, congestive heart failure).
Patients with acquired immunodeficiency syndrome.
Frail patients of advanced age.
Other exclusions for self-treatment
are listed in Figure 3.
Treatment and Prevention of
the Common Cold
There is no known cure for the
common cold. Thus, the goal of selftreatment is to reduce bothersome
symptoms. Self-treatment strategies
for the common cold are outlined in
Figure 3.
Preventing transmission of common cold viruses is an important
goal. The U.S. Centers for Disease
Control and Prevention encourage
people with a coldas well as anyone who comes into direct contact
with those peopleto wash their
hands frequently with soap and warm
water for 15 to 20 seconds. As a point
of reference, this is approximately the
amount of time it takes to sing the
Happy Birthday song twice.
Individuals who do not have ready
access to soap and water may use
soap substitutes (e.g., hand sanitizers). Products containing ethyl alcohol
(62% to 95% concentration), benzalkonium chloride, salicylic acid, pyroglutamic acid, or triclosan have been
proven effective. Individuals who use
gel sanitizers should rub their hands
together until the gel is dry.
Whenever possible, patients with
the common cold should cough or
sneeze into a tissue, dispose of the
tissue, then wash their hands. If a tissue is not available, patients should
cough or sneeze into the crook of the
arm rather than using their hand to
cover their nose or mouth.
Rhinoviruses can survive up to
3 hours on skin and objects such as
telephones and stair railings. Studies
conducted during the 1980s found
that use of antiviral disinfectants
(e.g., Lysol) and antiviral tissues (e.g.,
Kleenex Anti-Viral) may help to prevent
transmission of the common cold.
The cold and flu product is an ideal choice for GPs symptoms.
The cold and flu product is a good choice but should be used for 1 or 2 days
only.
GP should not purchase this product. She would be better served by a different
product.
GP should not purchase this product. She should check with her primary care
provider before attempting self-treatment.
Allergic rhinitis
Watery eyes; itchy nose, eyes, or throat; repetitive sneezing; nasal congestion; watery
rhinorrhea; red, irritated eyes with conjunctival injection (i.e., prominent conjunctival blood
vessels)
Asthma
Sore throat (moderate to severe pain), fever, exudate, tender anterior cervical adenopathy
Common cold
Sore throat (mild to moderate pain), nasal congestion, rhinorrhea, and sneezing common;
low-grade fever, chills, headache, malaise, myalgia, and cough possible
Croup
Fever, rhinitis, and pharyngitis initially, progressing to cough (may be barking cough), stridor,
and dyspnea
Influenza
Myalgia, arthralgia, fever 100F to 102F (37.8C to 38.9C), sore throat, nonproductive
cough, moderate to severe fatigue
Otitis media
Pneumonia or bronchitis
Chest tightness, wheezing, dyspnea, productive cough, changes in sputum color, persistent fever
Sinusitis
Tenderness over the sinuses, facial pain aggravated by Valsalvas maneuver or postural
changes, fever >101.5F (>38.6C), tooth pain, halitosis, upper respiratory tract symptoms for
>7 days with poor response to decongestants
Fever, headache, fatigue, rash, swollen lymph glands, and eye pain initially, possibly
progressing to gastrointestinal distress, central nervous system changes, seizures, or paralysis
Whooping cough
Initial catarrhal phase (rhinorrhea, sneezing, mild cough, sneezing) of 1 to 2 weeks, followed
by 1 to 6 weeks of paroxysmal coughing
15
Exclusions
forfor
Self-Treatment
Exclusions
for
Self-Treatment
Exclusions
Self-Treatment
Exclusions
for
Self-Treatment
Yes
Yes
management
Medical Medical
management
Yes
Yes
See FIGURE 2
See Figure 2
Yes
Yes
See FIGURE 4
See Figures 4 & 5
No
No
Recommend nondrug
nondrugmeasures
measures
Recommend
such as
as adequate
adequatehydration
hydrationand
and
such
rest. Identify
Identify most
mostproblematic
problematic
rest.
symptoms
symptoms
Cough
primary
complaint?
Cough
primary
complaint?
No
No
Symptoms related
relatedto
toallergy
allergy
Symptoms
alone?
alone?
No
No
Gopage
to next page
Go to next
16
Additional
Additional
complaint of
complaint of
sleeplessness?
sleeplessness?
Yes
Yes
Fever most
Fever most
problematic
problematic
Pharyngitis most
Pharyngitis most
problematic
problematic
Systemic analgesics
Systemic analgesics
Systemic
Systemic
antipyretics
antipyretics
Saline gargles or
Saline gargles or
local anesthetic
local anesthetic
sprays or lozenges
sprays or lozenges
No
No
Symptoms resolved
Symptoms resolved
after 7-14 days of
after 7-14 days of
therapy?
therapy?
No
No
Yes
Yes
Assess patient as
Assess patient as
needed
needed
AH = antihistamine; AIDS = acquired immunodeficiency syndrome; CAM = complementary and alternative medicine; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease;
OTC = over-the-counter.
Source: Scolaro KL. Disorders related to colds and allergy. In: Berardi RR, Ferreri SP, Hume AL, et al., eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th ed. Washington,
DC: American Pharmacists Association; 2009:180.
Points to Remember
17
Children Age 46 ya
Phenylephrine bitartrateb
Phenylephrine HCl
Pseudoephedrine
Current product labeling states do not use in children younger than 4 years of age, based on a voluntary action by manufacturers.
Used in effervescent dosage forms.
c
Not recommended for use in children younger than 6 years of age except under the direction of a primary care provider.
a
b
Effect
Methyldopa
18
Brompheniramine maleate
Chlorcyclizine HCl
Chlorpheniramine maleate
Clemastine fumarate
Dexbrompheniramine maleate
1 mg every 46 h (6 mg)
Dexchlorpheniramine maleate
1 mg every 46 h (6 mg)
Diphenhydramine citrate
Diphenhydramine HCl
Doxylamine succinate
Phenindamine tartrate
Pheniramine
Pyrilamine maleate
Thonzylamine HCl
Triprolidine HCl
These medications are not recommended for use in children younger than 6 years of age except under the advice of a primary care provider.
These medications are not recommended for use in children younger than 12 years of age except under the advice of a primary care provider.
19
Points to Remember
The common cold is a self-limited viral infection of the upper respiratory tract. Symptoms
typically disappear gradually after 7 to 10 days but may persist for 14 days or longer.
The common cold usually begins with a sore throat, followed rapidly by rhinorrhea,
nasal obstruction, and sneezing. Cough, when present, usually is nonproductive. In
contrast to influenza, systemic symptoms (e.g., fever, myalgias) usually are absent or
mild.
Because of unresolved concerns about the risks associated with the use of
nonprescription cough and cold medications in children, parents and other caregivers
should be encouraged to rely primarily on nonpharmacologic measures for children
younger than 6 years of age, particularly those younger than 4 years of age.
The recommended approach to the use of nonprescription medications in older children
and adults is symptom-specific therapy with single-entity products. Products that combine
two or more active ingredients targeting multiple symptoms are convenient, but the
convenience must be weighed against the risks from taking unnecessary agents.
Topical and systemic decongestants are the mainstays of symptomatic treatment for the
common cold. They should be used with caution in patients with hypertension, diabetes,
and other chronic diseases. Topical agents should not be used for more than 3 to 5
days to avoid rhinitis medicamentosa (rebound congestion).
Evidence does not support the use of antihistamine monotherapy, antitussives, or
expectorants for treatment of symptoms related to colds.
Local anesthetics and systemic analgesics have good evidence for the treatment of pain
due to sore throat or fever related to colds.
20
Allergic Rhinitis
Mild Intermittent
Mild Persistent
Moderate/Severe
Intermittent
Moderate/Severe
Persistent
Facial features
Systemic symptoms
Cognitive impairment
Fatigue
Irritability
Malaise
21
Yes
Yes
No
No
Yes
Yes
Mild IAR
Mild IAR
Moderate/severe PAR?
Moderate/severe PAR?
No
No
Moderate/
Moderate/
severe
IAR
severe IAR
Mild PAR
Mild PAR
Sneezing,
Sneezing,
rhinorrhea,
rhinorrhea,
or itching
or itching
Conjunctivitis
Conjunctivitis
Congestion
Congestion
Sneezing,
Sneezing,
rhinorrhea,
rhinorrhea,
or itching
or itching
Oral AH
Oral AH
Intraocular AH
Intraocular AH
or saline
or saline
Oral or topical
Oral or topical
decongestant
decongestant
Oral AH and/or
Oral AH and/or
intranasal
intranasal
cromolyn
cromolyn
Assess in
Assess in
3-4 days
3-4 days
Side effects or
Side effects or
ADRs?
ADRs?
Yes
Yes
Symptom
Symptom
controlled?
controlled?
Continue
Continue
therapy unless
therapy unless
symptoms
symptoms
worsen or
worsen or
ADRs occur
ADRs occur
Yes
Yes
Yes
Yes
If PAR, recheck
If PAR, recheck
in 2-4 weeks
in 2-4 weeks
Symptoms
Symptoms
controlled?
controlled?
No
No
No
No
Switch to
Switch to
alternative
alternative
drug
drug
No
No
If IAR, continue
If IAR, continue
therapy as
therapy as
needed unless
needed unless
symptoms
symptoms
worsen or
worsen or
ADRs occur
ADRs occur
Excluded from self-treatment unless already diagnosed with allergic rhinitis and nonprescription therapy approved by a PCP.
ADR = adverse drug reaction; AH = antihistamine; IAR = intermittent allergic rhinitis; PCP = primary care provider; PAR = persistent allergic rhinitis; Rx = prescription.
Source: Scolaro KL. Disorders related to colds and allergy. In: Berardi RR, Ferreri SP, Hume AL, et al., eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care.
16th ed. Washington, DC: American Pharmacists Association; 2009:193.
22
symptoms.
Allergen Avoidance and
Nonpharmacologic Therapy
Examples of recommended allergen avoidance measures are listed
in Table 14. Pharmacists should edu-
Pollens
Molds
Cockroaches
Pollutants
23
Effect
Phenytoin
Drug
Children Age 25 y
Cetirizine HCl
10 mg every 24 h
Loratadine
10 mg every 24 h
10 mg every 24 h
5 mg every 24 h
The 10-mg dose should be used by adults older than 65 years of age only with the advice and supervision of a primary care provider.
24
Points to Remember
25
26
References
Hersh EV, Moore PA, Ross GI. Over-thecounter analgesics and antipyretics: a critical
assessment. Clin Ther. 2000;22:50048.
27
Appendix A. Guidelines
for Oral Temperature
Measurements
Using Electronic
Thermometers
Appendix B. Guidelines
for Rectal Temperature
Measurements
Using Electronic
Thermometers
1.
2.
3.
4.
Digital Probe
1.
2.
3.
4.
5.
6.
7.
6.
7.
28
5.
6.
7.
8.
Appendix C. Guidelines
for Tympanic
Temperature
Measurements
1.
2.
3.
4.
5.
6.
Appendix D. Guidelines
for Temporal
Temperature
Measurements
1.
2.
3.
4.
5.
6.
CPE Exam
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answer to each question.
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30
CPE Instructions
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1.
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3.
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