Pharmaceutical care when dispensing OTC drugs for symptomatic treatment and prevention of colds

A fever is any body temperature elevation over 100°F (37.8°C). A healthy person’s body temperature fluctuates between 97°F (36.1°C) and 100°F (37.8°C), with the average being 98.6°F (37°C). The body maintains stability within this range by balancing the heat produced by the metabolism with the heat lost to the environment. The “thermostat” that controls this process is located in the hypothalamus, a small structure located deep within the brain. The nervous system constantly relays information about the body’s temperature to the thermostat, which in turn activates different physical responses designed to cool or warm the body, depending on the circumstances.

A dramatic rise in body temperature often includes the following symptoms: A. Loss of fluid results in dehydration. B.The hypothalamic set-point is increased, raising metabolism. C. Blood vessels in skin dilate. D. Sweat glands produce excess perspiration. E. Increased pulse rate. F. Increased hypothalmic set-point may introduce chills and shivering to promote heat production from muscles. G. Skin becomes more heat-sensitive

Causes and symptoms Fevers are primarily caused by viral or bacterial infections, such as pneumonia or influenza. Conditions that can induce a fever: Allergic reactions; autoimmune diseases; trauma, such as breaking a bone; cancer; excessive exposure to the sun; Intense exercise; hormonal imbalances; certain drugs; damage to the hypothalamus.

Causes and symptoms (cont’d) Malignant hyperthermia is a rare, inherited condition in which a person develops a very high fever when given certain anesthetics or muscle relaxants in preparation for surgery.

Causes and symptoms (cont’d) Most fevers caused by infections are acute, appearing suddenly and then dissipating as the immune system defeats the infectiousagent. An infectious fever may also rise and fall throughout the day, reaching its peek in the late afternoon or early evening. A low-grade fever that lasts for several weeks is associated with autoimmune diseases such as lupus or with some cancers, particularly leukemia and lymphoma.

Fever. Causes in kids Infections (bacterial, viral, fungal) Overheating Stress Toothing Allergic reactions Water-electrolite dysbalance Vaccinations

"Threatenings" symptoms A fever requires emergency treatment under the following circumstances: • newborn (three months or younger) with a fever over 100.5°F (38°C) • infant or child with a fever over 103°F (39.4°C) • fever accompanied by severe headache, neck stiffness, mental confusion, convulsions, or severe swelling of the throat

Threatening symptoms (cont’d) A very high fever in a small child can trigger seizures (febrile seizures) and therefore should be treated immediately. A fever accompanied by the above symptoms can indicate the presence of a serious infection, such as meningitis, and should be brought to the immediate attention of a physician. A fever over 100.5°F (38°C) 3 days and longer A fever over 37,5°C 2 weeks and longer

Fever of unknown origin (FUO) When temperature elevation occurs for an extended period of time and no cause is found, the term FUO is then used. The far majority of these patients are eventually found to have one of several diseases: Tuberculosis remains an important cause, especially when it occurs outside the lungs. Allergies to medications can also cause prolonged fever (sometimes patients will have other symptoms suggesting an allergic reaction, such as a rash). HIV is a potential cause of fever. (Patients with HIV are an especially difficult problem, as they often suffer from many unusual infections).

Treatment Drugs to lower fever (antipyretics) can be given if a patient (particularly a child) is uncomfortable. These include aspirin, acetaminophen (Tylenol), and ibuprofen (Advil). Aspirin should not be given to a child or adolescent with a fever since this drug has been linked to an increased risk of Reye’s syndrome (A disorder principally affecting the liver and brain, marked by the rapid development of life-threatening neurological symptoms) Bathing a patient in cool water can also help alleviate a high fever.

Treatment (cont’d) Antipyretic Aspirin is the prototype of the analgesic–antipyretic–anti-inflammatory drugs and the most commonly used salicylate. It is effective in pain of low to moderate intensity, involving the skin, muscles, joints, and other connective tissue. It is useful in inflammatory disorders, such as arthritis, but many people prefer drugs that cause less gastric irritation.

Treatment (cont’d) Propionic acid derivatives ibuprofen (Motrin, Advil), ketoprofen (Orudis), naproxen (Naprosyn) are available OTC these drugs are usually better tolerated than aspirin, they are much more expensive and may cause all the adverse effects associated with aspirin and other prostaglandin inhibitors

Acetaminophen Acetaminophen is available in tablet, liquid, and rectal suppository forms and is in numerous combination products marketed as analgesics and cold remedies. It is often prescribed with codeine, hydrocodone, or oxycodone for added analgesic effects.

Treatment (cont’d) Acetaminophen can cause liver damage; ibuprofen is a relative of aspirin that can cause gastrointestinal upset and bleeding. Total daily dosage should not be excessive (with Tylenol, above four doses of 1000 mg each; with ibuprofen, above 2400 mg).

The following guidelines are provided to help consumers make more informed choices when selecting OTC products: Always read the labels and know the ingredients in the products. Never take more than the recommended dose. Do not use aspirin-containing medicines for children and teenagers with influenza, chickenpox or other viral illnesses. Rare cases of Reye syndrome have been associated with the use of aspirin in this population. Reye syndrome is a serious illness characterized by liver damage, vomiting, and sometimes coma. It has a 50% mortality rate, and those who survive can be left with permanent brain damage. Therefore, acetaminophen-containing products are recommended for children with fever. NSAIDs may be used in children over six months of age.

Guidelines Aspirin and NSAIDs can cause ulcers and increase the risk of bleeding, and should be avoided by people with known ulcer disease or certain blood diseases. People who are scheduled for elective surgeries should inform their doctors that they are taking aspirin or NSAIDs. A true aspirin allergy is rare. Aspirin allergy consists of hives, occasionally difficulty breathing, and rarely shock, within three hours of taking aspirin. Aspirin can precipitate bronchoconstriction (“aspirin asthma,” pseudoallergy) due to inhibition of PGE2 synthesis and overproduction of leukotrienes. Aspirin allergy is most common among individuals who have asthma, urticaria, and nasal polyps. Individuals with aspirin allergy should also avoid NSAIDs because they are chemically similar to aspirin. Aspirin can cause complications during pregnancy and should be avoided during pregnancy. Aspirin can increase the effectiveness of blood thinning by Coumadin and may increase the risk of bleeding.

Breathing Swallowing Separating (channelization) Speech (articulation)

INFLAMMATORY DISORDERS OF THE PHARYNX Inflammatory disorders of the pharynx most commonly present as throat or neck pain. Disphagia, odynophagia, and airway obstruction are other frequent complaints. The pharynx is a dynamic conduit for inspired air and ingested matter, responsible for diverting each into the trachea or esophagus, respectively. This process may be impaired by anything which obstructs or restricts the mobility of the pharynx.

EVALUATION Key historical considerations Age of patient Onset and duration History of recent trauma (including possible foreign body) Inflammatory symptoms - fever, pain, malaise, malodorous breath Status of nasal airway: congestion, obstruction, rhinorrhea, purulent discharge, allergic history, snoring Reflux symptoms such as heartburn or water brash Associated ear pain Disphagia or odynophagia Dyspnea or stridor Other associated symptoms Recent exposure to infectious discharge Cancer risk factors: smoking history

Strep throat Strep often produces white patches in the throat and on the tonsils, as well as red, swollen tonsils. Pus may be seen in the back of the throat.

Strep throat may cause the lymph nodes in the neck to become swollen and tender.

Pharyngitis. Symptoms sore throat additional symptoms are dependent on the underlying microorganisms step throat may be accompanied by fever, headache, swollen lymph nodes in the neck viral pharyngitis may be associated with runny nose (rhinorrhea) and postnasal discharge severe cases of pharyngitis may be accompanied by difficulty swallowing and rarely difficulty breathing Signs and tests.    A physical exam with attention to the pharynx to assess whether drainage/coating (exudates) are present, as well as skin, eyes, neck lymph nodes is frequently done.

Oropharyngoscopy Swollen, erythematous mucosa of the oropharynx and hypopharynx, often with edema of the uvula and soft palate. Swollen cyanotic lymphatic follicles on the posterior wall Mucous or purulent discharges on the posterior wall

Complications complications of strep throat: rheumatic fever, glomerulonephritis (kidney inflammation), chorea, bacteremia (bloodstream infection) and rarely streptococcal shock syndrome in some severe forms of pharyngitis (e.g., severe mononucleosis-pharyngitis) airway obstruction may occur peritonsillar abscess, retropharyngeal abscess

A sore throat caused by a cold virus usually resolves in one to two weeks without treatment. On the other hand, a sore throat caused by the streptococcus bacterium (strep throat) should be treated with antibiotics to prevent damage to the heart valves (phenoxymethylpenicillin 500 mg four times a day or cefaclor 250 mg three times daily). Generally, streptococcus bacteria cause a more severe sore throat and a higher fever than viral sore throats. In some cases, strep may cause nausea, a lack of appetite, or pain in the head and abdomen.

A less common sign of strep infection is a rash that appears on the neck and chest, eventually spreading to the rest of the body. When this rough, sandpaper-like rash develops, the infection is known as scarlet fever. Although the full body rash may be alarming, it will start to fade after a few days

Sneezing, runny nose, and cough more frequently accompany sore throats due to a cold virus, rather than streptococcus infections. Sometimes, a throat culture is necessary to establish the cause of the sore throat. Antibiotic treatment may lessen symptoms and duration of illness and decrease the chance for complications

Acute Tonsillitis The most common organism is beta hemolytic streptococcus, but viral organisms can also cause exudative tonsillitis. Other causative organisms include staphylococcus aureus, streptococcus viridans, and various hemophilus species.

Catharal and Follicular Tonsilitis The tonsils are red, enlarged and painfulness with an exudate or studded with white follicles. Tender, firm cervical adenopathy is often present

Tonsillar hypertrophy

Treatment Taking antibiotics unnecessarily can contribute to the growing problem of microbial resistance. When bacteria are frequently exposed to antibiotics, they may become "superbugs" that can't be treated with standard medications.

Treatment Since fever and painful swallowing can lead to dehydration, it's important to increase intake of fluids to combat it. Water and ginger ale are good choices. A patient should avoid citrus drinks which can irritate an inflamed throat.

Treatment Medications that are available OTC for the temporary relief of sore throat due to the common cold usually contain anesthetics such as benzocaine and dyclonine or menthol and come in the form of lozenges, gargles, sprays.

Treatment Pain Relievers Over-the-counter pain relievers, like acetaminophen, ibuprofen, or naproxen, can temporarily dull the pain of a sore throat. (Do not give aspirin to children and teenagers because of the risk of the rare but potentially fatal Reye's syndrome.)