Seasonal Flu: Prescription (Rx) vs. Over-The-Counter (OTC) Medications Healthy Transitions Seasonal Flu: Prescription (Rx) vs. Over-The-Counter (OTC) Medications Farah Barada, PharmD Katelyn Vautrin, PharmD Zachary Pentoney, PharmD

Table of Contents What is influenza? Transmission and Prevention Background and flu statistics Signs and symptoms Transmission and Prevention Proper hygiene Vaccinations Over-The-Counter (OTC) Therapy Available medications Drug-Disease Interactions Prescription Therapy When is it appropriate to see your doctor

What is Influenza? Also known as: “the flu” Viral infection that attacks your respiratory system, including your nose, throat and lungs 3 types: Influenza A, B, and C Populations most at risk: Young children Adults >65 years old Pregnant women People with weakened immune systems People who have multiple chronic illnesses Important to note that this is a viral infection, so ABX will not work!! Type A & B: can cause seasonal epidemics of disease; Type C: usually more mild, non-epidemic producing http://www.biospectrumasia.com/biospectrum/news/122252/who-dont-antibiotics-unless-prescribed

Flu Statistics: 2013-2014 53,470 confirmed cases of influenza in the United States 46,727 (87.4%) cases were Influenza A virus 6,743 (12.6%) cases were Influenza B virus 9,635 reported hospitalizations due to influenza Peak mortality rate of 8.7% for “Pneumonia and Influenza (P&I)” mortality Most hospitalizations attributed to Influenza A CDC, Morbidity and Mortality Weekly Report

Flu Severity Severity can depend on a number of things: Which strains of the flu are causing the epidemic The availability and quantity of flu vaccine When the vaccine becomes available How many people choose to get vaccinated How well the flu vaccine is matched to the flu viruses that are circulating

Signs and Symptoms Fever (or feeling feverish/chills) Cough Sore Throat Runny or stuffy nose Muscle or body aches Headaches Fatigue Potentially vomiting and diarrhea *Not everyone with the flu will have a fever **Vomitting and diarrhea more common with children than adults ***Symptoms usually last for a few days to less than 2 weeks http://oldhookmedical.com/send-your-cold-packing/

Complications from the Flu Possibility of developing complications Can range from mild to life-threatening complications or even death Examples include pneumonia, bronchitis or sinus and ear infections Can also trigger other chronic conditions you may have, such as asthma or congestive heart failure *Can trigger asthma attacks, decompensated heart failure

Transmission Virus spreads mainly through droplets in the air Occurs when someone who has the flu coughs, sneezes or spits Can also be transmitted from contact with infected surfaces Touching surfaces that contain flu virus and then either touching your eyes, nose or mouth

Transmission **Important to note: you may pass on the flu to someone else before you even know you’re sick Most healthy adults are able to infect another person 1 day before symptoms develop and up to 5-7 days after symptoms develop Large window where you have the ability to infect someone else! *Children or people w/ weakened immune systems may be able to infect people for a longer period of time because they can’t get rid of the virus fast enough

Prevention Wash your hands!! Make sure healthcare providers also wash their hands and wear gloves Cover your mouth and nose when sneezing or coughing Germs can travel 3 feet or more! Avoid sick contacts If you are sick, avoid close contact with others *Cough into your elbow, not your palm!

Audience Question: What is the recommended length of time to wash your hands per the CDC? A: 15 seconds B: 20 seconds C: 30 seconds D: 1 minute Proper hand hygiene: -Use soap and warm water, rubbing hands together for at least 20 seconds. Make sure to get your palms, fingernails, in between your fingers and backs of your hands -If your hands are not visibly dirty, may use an alcohol based hand sanitizer

Hand Washing Tips Reiterate points just mentioned http://www.ttsh.com.sg/csi/

Prevention The most important way to prevent yourself from getting the flu is to get vaccinated!!! http://www.differencebetween.info/difference-between-vaccination-and-immunization

Immunizations What is a vaccine? How do vaccines work? Medication that helps our immune system fight certain bacteria and viruses that may invade our body and cause disease Goal of vaccinating is to prevent or control infection How do vaccines work? Antibodies are produced because the vaccines are made of weakened or inactive forms of bacteria or viruses Antibodies made by the body’s immune system in response to the presence of a foreign substance such as a bacteria or virus Antibodies target and destroy the bacteria or virus within the vaccine Our immune system then records the process by which it was able to fight off the disease If re-exposed the body remembers how it fought the virus or bacteria and it protects itself

SEASONAL INFLUENZA (Flu) VACCINE Who should receive the vaccine? EVERYONE over the age of 6 months High risk for complications 6 months of age or younger and those 65 years of age or older chronic medical conditions, including heart disease, lung disease (for example, asthma), diabetes, kidney disease, liver disease, and blood disorders Residents of nursing homes and other long-term care facilities Women who will be pregnant during the flu season Health care workers and caregivers of those at highest risk

SEASONAL INFLUENZA (Flu) VACCINE  When should you get the seasonal flu vaccine?  Best to get in September or as soon as the vaccine is available Can still get vaccinated in March or April Best to receive the flu vaccine each year because disease protection is short-lived Why do I need to get vaccinated against the seasonal flu every year? Seasonal flu viruses change from year to year and your immunity can decline over time Not protected from a new strain that is circulating in the present year

Types of Flu Vaccines Traditional flu shot High dose flu shot Injection, Intramuscularly High dose flu shot Ages 65 and older triggers the body to produce more antibodies against the virus Intranasal (FluMist®) Ages 2-49 years, healthy people Live vaccine Not for People with compromised immune systems Have a severe egg allergy Pregnant

Myths vs Fact of the Flu Vaccine You can get the flu from the flu vaccine The flu is just a bad cold The flu shot is covered under Medicare part B Young/healthy people don’t need to get the vaccine The risk of a true allergic reaction from the flu vaccine is very rare Getting a shot is the only way to vaccinate against the flu More than 9,000 people are hospitalized each year for flu-related complications Getting a vaccine last year means I don’t have to get one this year MYTH MYTH FACT MYTH FACT MYTH FACT MYTH

PNEUMOCOCCAL (Pneumonia) VACCINE What is pneumococcal disease? Bacteria Streptococcus pneumonia Affects the lungs (pneumonia), blood (bacteremia) and brain (meningitis). Spread Coughing, sneezing, or contact with respiratory secretions Who should receive the pneumococcal vaccine? All people 65 years of age or older Residents of nursing homes or long-term care facilities People from 19 to 64 years old who smoke or have asthma People 2 to 64 years old who have chronic health conditions or a disease that weakens the immune system

Quick Reminder! ZOSTER (Shingles) VACCINE Tdap Shingles is a viral disease caused by the varicella zoster virus same virus as the chickenpox It is a painful skin rash with blisters that is usually localized to one side of the body and may last 2 to 4 weeks 60 years of age or older / ONE time dose Tdap provides protection against tetanus, diphtheria, and pertussis (whooping cough) Adults age ≥ 65 who have close contact with an infant

Immunizations Recap Important to keep up-to-date with you immunizations Where can you go to get vaccinated? Local pharmacies Doctor’s offices

Managing the Flu at Home “OTC” Approaches Symptoms Directed

Symptom-Targeted Therapies

Flu Symptoms Recap Headaches  pain medications Body aches  pain medications/anti-inflammatory agents Fever  antipyretics Cough  antitussives Fatigue/weakness  fluids* and rest Sore throat  local “anesthetics” Congestion  decongestants *Caution on fluids if fluid restrictions

Managing Headache/Body Aches Medication Options General Facts Acetaminophen (Tylenol) 325-500 mg every 4-6 hours as needed Ibuprofen (Motrin) 200-400 mg every 4-6 hours as needed Aleve (Naproxen) 220 mg every 12 hours as needed Take ibuprofen or naproxen with food Medication limits Tylenol: 4,000 mg per 24 hours Ibuprofen: 1,200 mg per 24 hours Naproxen: 660 mg per 24 hours

Which option is best for you (aches)? Medical Condition Interactions Heart disease Use Tylenol High blood pressure Heart failure Medical Condition Interactions Kidney disease Use Tylenol Diabetes Glaucoma Marplan (isocarboxazid), Nardil (phenelzine), Parnate (tranylcypromine), Azilect (rasagiline), Emsam (selegiline)

Which option is best for you (aches)? Medication Interactions Coumadin or other “blood thinners” Use Tylenol, but still need to be monitor closely MAO-Is (e.g., Nardil, Parnate, Emsam, Azilect) No preference Medication Interactions Anti-depressants (e.g., Lexapro, Zoloft, Celexa) Use Tylenol Blood pressure medications or “water pills” Marplan (isocarboxazid), Nardil (phenelzine), Parnate (tranylcypromine), Azilect (rasagiline), Emsam (selegiline)

Managing Fever Medication Options General Facts Acetaminophen (Tylenol) 325-500 mg every 4-6 hours as needed Ibuprofen (Motrin) 200-400 mg every 4-6 hours as needed Aleve (Naproxen) 220 mg every 12 hours as needed Take ibuprofen or naproxen with food Medication limits Tylenol: 4,000 mg per 24 hours Ibuprofen: 1,200 mg per 24 hours Naproxen: 660 mg per 24 hours

Which option is best for you (fever)? Medical Condition Interactions Heart disease Use Tylenol High blood pressure Heart failure Medical Condition Interactions Kidney disease Use Tylenol Diabetes Glaucoma Marplan (isocarboxazid), Nardil (phenelzine), Parnate (tranylcypromine), Azilect (rasagiline), Emsam (selegiline)

Which option is best for you (fever)? Medication Interactions Coumadin or other “blood thinners” Use Tylenol, but still need to be monitor closely MAO-Is (e.g., Nardil, Parnate, Emsam, Azilect) No preference Medication Interactions Anti-depressants (e.g., Lexapro, Zoloft, Celexa) Use Tylenol Blood pressure medications or “water pills” Marplan (isocarboxazid), Nardil (phenelzine), Parnate (tranylcypromine), Azilect (rasagiline), Emsam (selegiline)

Managing Cough Medication Options General Facts Determine type of cough Dry cough Delsym (dextromethorphan) two teaspoonfuls (10 mL) every 12 hours as needed Wet cough Mucinex (guaifenesin) 600-1200 mg tablets every 12 hours Take Mucinex with a full glass of water (unless you have fluid restrictions). Medication limits Delsym: 4 teaspoonfuls (20 mL) per 24 hours Mucinex: 2400 mg per 24 hours

Which option is best for you (cough)? Medical Condition Interactions Heart disease Use either based on type of cough High blood pressure Heart failure Medical Condition Interactions Kidney disease Use either based on type of cough Diabetes Look for sugar-free formulations Glaucoma Marplan (isocarboxazid), Nardil (phenelzine), Parnate (tranylcypromine), Azilect (rasagiline), Emsam (selegiline)

Which option is best for you (cough)? Medication Interactions MAO-Is (e.g., Nardil, Parnate, Emsam, Azilect) ABSOLUTELY CANNOT use Delsym or cough suppressants containing dextromethorphan Use Mucinex for wet cough Anti-depressants and related agents (e.g., Lexapro, Zoloft, Celexa, Reglan, Abilify) Avoid Delsym and similar cough suppressants Marplan (isocarboxazid), Nardil (phenelzine), Parnate (tranylcypromine), Azilect (rasagiline), Emsam (selegiline)

Managing Fatigue/Weakness Therapeutic Options Avoid caffeine and other stimulants Drink plenty of fluids unless you have fluid restrictions Rest/sleep is key!

Managing Sore Throat Medication Options General Facts Cepacol Lozenges Two lozenges (one after the other) every 4 hours as needed Cough Drops One drop every 2 hours as needed Cepacol lozenges/cough drops Allow to dissolve slowly in mouth Do not chew Medication Limits Cepacol lozenges: 12 lozenges per 24 hours Cough drops: 12 cough drops per 24 hours Cepacol contains dextromethorphan and benzocaine

Which option is best for you (sore throat)? Medical Condition Interactions Heart disease Use either High blood pressure Heart failure Medical Condition Interactions Kidney disease Use either Diabetes Look for sugar-free formulations Glaucoma Marplan (isocarboxazid), Nardil (phenelzine), Parnate (tranylcypromine), Azilect (rasagiline), Emsam (selegiline)

Which option is best for you (sore throat)? Medication Interactions MAO-Is (e.g., Nardil, Parnate, Emsam, Azilect) CANNOT use Cepacol lozenges Use cough drops that contain benzocaine or menthol Anti-depressants and related agents (e.g., Lexapro, Zoloft, Celexa, Reglan, Abilify) Avoid Cepacol lozenges Marplan (isocarboxazid), Nardil (phenelzine), Parnate (tranylcypromine), Azilect (rasagiline), Emsam (selegiline)

Managing Congestion Therapeutic Options General Facts Sudafed (sinuses) 60 mg every 4-6 hours as needed 120 mg every 12 hours as needed 240 mg every 24 hours as needed Sudafed PE (sinuses) 10 mg every 4 hours as needed Coricidin HBP Max Strength Flu Two tablets every 6 hours as needed Afrin (nasal) 2-3 sprays in each nostril two times per day Other options Humidified air Saline rinses Sudafed can be taken with or without food but faster onset on empty stomach (~30 min). Medication limits Sudafed: 240 mg per 24 hours Sudafed PE: 60 mg per 24 hours Afrin: 3 days Coricidin: 8 tablets per 24 hours Saline rinses must be with CLEAN water Try the immediate release formulations first before the extended release ones

Which option is best for you (congestion)? Medical Condition Interactions Heart disease Use saline rinse, humidified air or Afrin High blood pressure Heart failure Use saline rinse, humidified air Kidney disease Diabetes Use saline rinse, humidified air, or Afrin* Medical Condition Interactions (cont’d) Glaucoma Use saline rinse, humidified air or Afrin Prostatic hyperplasia/urinary obstruction Use Use saline rinse, humidified air or Afrin* Seizures Thyroid disorders Use saline rinse, humidified air or Afrin* Marplan (isocarboxazid), Nardil (phenelzine), Parnate (tranylcypromine), Azilect (rasagiline), Emsam (selegiline) *indicate caution still for Afrin but benefits seem to outweigh risks

Which option is best for you (congestion)? Medication Interactions MAO-Is (e.g., Nardil, Parnate, Emsam, Azilect) CANNOT use Sudafed, Sudafed PE, or Afrin Use saline rinse, or humidified air Migraine medications (e.g., DHE 45, Migranal) Use saline rinse or humidified air Anti-depressants and related agents (e.g., Lexapro, Zoloft, Celexa, Effexor, Cymbalta) Avoid Sudafed and Sudafed PE Use Afrin, saline rinse, or humidified air Marplan (isocarboxazid), Nardil (phenelzine), Parnate (tranylcypromine), Azilect (rasagiline), Emsam (selegiline) *indicate caution still for Afrin but benefits seem to outweigh risks

Directed Therapy Anti-viral medications

Directed Therapy: Seeing the Doctor Tamiflu® (oseltamivir phosphate) ONLY effective if started within 48 hours of onset of symptoms 5 days of therapy Twice a day May need it if no flu shot and exposed to someone with the flu (post-exposure prophylaxis) Side effects Common: nausea, vomiting Rare: skin reactions, changes in behavior

When to the call or see the doctor? No improvement/worsening in symptoms after a few days (especially if 7 days with OTCs and no improvement) Difficulty breathing Uncontrollable vomiting, dehydration Stiff neck, severe headache Good idea to let the doctor know if you have flu symptoms and you also have: Diabetes COPD Asthma Heart disease

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Seasonal Flu: Prescription (Rx) vs. Over-The-Counter (OTC) Medications Healthy Transitions Seasonal Flu: Prescription (Rx) vs. Over-The-Counter (OTC) Medications Farah Barada, PharmD Katelyn Vautrin, PharmD Zachary Pentoney, PharmD