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Maximizing Patient Interaction at the Pharmacy Counter: OTC Medications for Allergic Rhinitis and the Common Cold

INTRODUCTION—INTERACTION WITH PATIENTS AT THE PHARMACY COUNTER

Pharmacy technicians have always been a critical part of the health care team. The technician's role is becoming even more important as pharmacists focus their efforts on direct patient care. Because of this shift in responsibilities, pharmacists may have less time to spend in the front end of the pharmacy to discuss self-care issues with patients. Since allergic rhinitis (AR) and the common cold are two of the most common reasons for patients to seek self-care counseling, it is vital for the technician to develop the ability to gather relevant information.1 Importantly, this information is not to be used by the technician to make a direct recommendation to the patient. Rather, the information the technician gathers should be communicated to the pharmacist to allow him or her to make a rapid and accurate triage decision and to decide when a nonprescription product or device might be helpful.1,2,3 During the discussion with the patient, there are several useful pieces of information to be ascertained. A useful tool that can aid the technician in conducting an efficient patient interview is a memory aid the author calls “CADCOM.” Each letter stands for a component of the patient interview process. “C” stands for the condition which prompted the patient to enter the pharmacy. In this lesson, the conditions under discussion are allergic rhinitis and the common cold. Much of the lesson will allow the technician to help the pharmacist determine which patients can safely use nonprescription products and which should be referred to a prescriber. “A” reminds the technician to ask about the age of the patient. “D” is a reminder to ask about the duration of the symptoms. The second “C” represents the interview step of asking the patient about contraindications and other medical conditions. The final two letters, “OM,” complete the structured interview by asking the patient about other medications they are taking, as well as nicotine and alcohol use. Each of these patient variables is discussed in more detail below.

Patient age

While speaking to the patient, the technician should inquire about the patient's age. It is tempting to assume that the potential purchaser is the patient, but he or she may be a mother or father who wishes to give the product to an infant. Age is critical because most nonprescription product labels have an age below which they cannot be used safely without a physician recommendation.1 These requirements exist because some medications can be unsafe in certain age groups or because there are no studies showing the active ingredients to be effective in certain groups. The pharmacist must know the age of the patient before making a decision.1

Duration of the condition

Another critical piece of information is how long the condition has been present.1 Some symptoms, such as cough, can be caused by the common cold or an allergy but also by other more serious conditions.1 If the cough lasts too long, it can point to the presence of a more serious underlying condition which must be evaluated by a physician, such as cystic fibrosis or emphysema.1 This information must be communicated to the pharmacist.

Contraindications; Other medical situations

Products that are used for the treatment of AR and the common cold also carry numerous precautions or contraindications against their use if the patient has additional medical issues (eg, pregnancy, breastfeeding) or symptoms (eg, fever, rash, productive cough).1 Thus, the technician can ask potential purchasers a general question such as: Do you (or your child) have any other medical conditions or symptoms that I should tell the pharmacist about?

Use of other medications, alcohol, or nicotine

Many nonprescription products carry warnings against their use if the patient is taking certain prescription medications or if he or she drinks alcoholic beverages. Some should not be used if the problem is due to smoking (e.g., chronic cough). To gather the necessary information for the pharmacist, the technician may consider asking questions such as: Are you taking any other medications at this time? Do you drink alcohol or smoke? However, it is important to remember that personal conversations with patients should be addressed in an area of the pharmacy where others cannot overhear the discussion.1

Presenting information to the pharmacist

Once the information is gathered, a patient summary can be presented to the pharmacist. For example, there is an older gentleman asking for a cough product. He has had a nagging cough for 3 or 4 weeks, and he is a lifelong smoker. He takes a medication for high blood pressure, but he cannot remember the name. This brief synopsis of the patient interview provides vital information to the pharmacist. As a result, the pharmacist can approach the patient and inquire more deeply into his medical issues, including the specific medication that he uses for his blood pressure and the symptoms that accompany his cough.

Etiologies of allergic rhinitis and the common cold

The etiologies of AR and the common cold differ greatly.1 AR occurs when patients breathes in substances to which they have become sensitized.4 The offending allergen can be pollen from weeds or trees, cockroach or dust mite feces, cat dander, horse hair, cosmetics, window cleaners, or mold.5,6 When the patient inhales these allergens, they cause damage to cells, resulting in the release of chemicals that are responsible for AR symptoms, including histamine.1

The cause of the common cold is a viral pathogen that penetrates the body's defense system.1 While many viruses cause cold-like symptoms, the top offender is a group known as rhinoviruses.1 When patients are infected by a rhinovirus, they transfer infective particles onto surfaces. Virus transfer can occur from viral particles being coughed out into the environment. Infected patients may have the virus on their hands from coughing into them or touching their noses. The virus can then be transferred to anything they touch. For instance, when an uninfected person shakes the hand of someone with a cold or touches an infected surface, the virus can be transferred through hand-to-hand or hand-to surface-contact. The final step is touching the nose or mouth with contaminated hands. This allows the virus to enter the patient’s body. Consequently, rhinoviruses are highly successful at reaching large groups of the population.1,4

MANIFESTATIONS OF ALLERGIC RHINITIS AND THE COMMON COLD

The list of complaints related to AR and the common cold is long, but with careful investigation, the technician can help the pharmacist determine which condition the patient most likely has.

Manifestations of allergic rhinitis

When a patient inhales an allergen, the immune system reacts to produce a predictable set of symptoms.1,4 One is a runny nose, which is also referred to as rhinorrhea. This nasal discharge is clear and copious, requiring the patient to continually wipe the nose.1 The second problem is nasal congestion. The nostrils can become so plugged that the patient cannot breathe. This requires the patient to blow the nose and to breathe through the mouth. Nasal congestion and rhinorrhea associated with AR often shift from nostril to nostril in an unpredictable manner, so the patient complains of both symptoms.1 Another nasal symptom that is bothersome is nasal itching.1,4 The itching is inside the nose, and patients resort to such measures as pushing the nose upward with the heel of the hand to relieve the itch.1 AR also causes the patient to sneeze.1,4 These sneezes are usually quiet and shallow in nature and they occur in groups known as paroxysms—one right after the other. Further, AR affects the eyes of many patients. The eyes itch and produce appreciable tearing. The eyes also become red and some patients notice a blue discoloration under the eyes, known as the allergic shiner.4

Manifestations of the common cold

The common cold is caused by numerous viruses, and the symptoms they produce differ from each other to some degree; however, generalized symptoms are usually present.1 The first cold symptom is often a sore throat,7-9 and sore throat pain can range from mild scratching to severe pain.7 Shortly after the onset of sore throat, nasal symptoms develop.8 They begin as rhinorrhea, but with the common cold the nasal secretions turn thick and discolored, leading to severe nasal congestion. Eventually, the patient develops a cough. Early in the infection, the cough is loose or productive because it helps the patient expel infected mucus in the lungs. Thus, this early productive cough is helpful and should be allowed to continue. For some patients, though, the cough can persist long after the excess mucus in the lungs is no longer a problem. This persistent cough (known as nonproductive cough) is not helpful, and it can be stopped without harming the patient.1

Other recognition clues

There is one major similarity between symptoms of AR and the common cold: troubling nasal blockage. However, there are many differences between AR and the common cold.1 They include the following1:

  • Nasal discharge (rhinorrhea) remains clear with AR, but discharge becomes thick and purulent with the common cold.
  • Sneezing with the common cold is occasional, unlike the paroxysms that occur with AR; nasal itch and eye symptoms are uncommon with the common cold, but are a prominent feature of AR.
  • Sore throat is not a hallmark feature of AR, but sore throat is a manifestation of the common cold.
  • AR symptoms often arise suddenly; common cold symptoms develop gradually and in a certain sequence (eg, sore throat > nasal problems > cough).
  • Common cold symptoms usually last no more than a week or so; AR symptoms can last indefinitely.
  • Most people only get 1 to 2 common colds a year; AR may occur year-round or whenever the allergen is present.
  • Other family members are often affected with identical symptoms when the common cold is the culprit; with AR, the patient may be the only one in the family affected.1

PREVENTION AND TREATMENT OF ALLERGIC RHINITIS

Preventing AR is a far more effective strategy than trying to alleviate symptoms that have already occurred.4 Technicians can advise patients that the most effective preventative measures for AR are avoidance and environmental control.1,5 If the allergen is known, the patient should take every possible measure to avoid it. This may include: avoiding dogs or cats, disposing of houseplants, and staying inside (or wearing a face mask) during heavy pollen seasons. Environmental control may necessitate drastic measures such as removing all carpeting in the house or installing high efficiency air filters over the home's air vents.1,6 Several nonprescription drugs have also shown to be effective in patients who have symptoms of AR.

Cromolyn sodium nasal solution (Nasalcrom)

Cromolyn sodium nasal solutionis the only nonprescription medication that helps prevent some AR symptoms when used as directed.1 As mentioned above, cellular damage due to inhaled allergens is the cause of AR symptoms, and cromolyn nasal solution stabilizes the cells so they are not damaged.1 Cromolyn nasal solution should not be used in those who are under the age of 2 years. Patients aged 2 years and older should spray the drug into the nostrils once and repeat administration every 4 to 6 hours, but not more than 6 times daily. Patients should use cromolyn nasal solution for a full week before contact with the allergen, considering it reaches its maximal effect after 1 to 2 weeks of daily use.1 Cromolyn helps control rhinorrhea, nasal itching, allergic stuffy nose, and sneezing that occur with AR.1 If there is no improvement within 2 weeks, the patient should stop using cromolyn nasal solution and see a physician to determine the cause of the symptoms. Technicians should inquire whether the patient has any of the following symptoms for which cromolyn nasal solution is not recommended for use without first consulting a physician: fever, discolored nasal discharge, sinus pain, or wheezing. Cromolyn nasal solution is not indicated for asthma, sinus infections, or common cold symptoms.1 Patients who are pregnant or breastfeeding should not use cromolyn nasal solution without speaking to their physician first. Finally, patients should be instructed not to share bottles with anyone else.1

First-generation antihistamines

Antihistamines block the effects of the histamine released when cells are damaged though exposure to allergens.4 They relieve rhinorrhea, nasal pruritus, and sneezing. Examples of first-generation antihistamines include diphenhydramine (eg, Benadryl), chlorpheniramine (eg, Chlor-Trimeton Allergy), and doxylamine (commonly used for sleep, but also available in cough/cold combinations such as some Nyquil products).1 The technician should ask whether the patient has contraindications for these products, including any breathing problems (eg, emphysema, chronic bronchitis), difficulty urinating from an enlarged prostate, or angle-closure glaucoma. Patients must be warned that these products will make them drowsy and that they should exercise caution when driving or operating machinery; diphenhydramine causes greater sedation than the others.1 Also, alcohol and sedatives can increase the drowsy effects of this drug class. First-generation antihistamines are not recommended for use in children under the age of 6 years as they can cause an unpleasant stimulating effect that inhibits sleep in this age group.1 It should be noted that the age restrictions for some combination products containing antihistamines may be above the age of 6 years. If so, the higher age cut-off on product labeling should be followed. Patients who are pregnant or breastfeeding should speak to their physician before using first-generation antihistamines.1

Second-generation antihistamines

The second-generation antihistamines are often referred to as nonsedating antihistamines because they are less likely to cause drowsiness compared with first-generation products. They include loratadine (eg, Claritin Non-Drowsy), cetirizine (eg, Zyrtec Allergy), fexofenadine (eg, Allegra Allergy), and levocetirizine (eg, Xyzal).1 Patients with kidney disease or who are pregnant or breastfeeding should not use nonsedating antihistamines without physician supervision. Loratadine and cetirizine should not be used if the patient has liver disease unless a physician is supervising their care.1 The technician should ask the patient if he or she has a known allergy to a prescription medication known as hydroxyzine, in which case the pharmacist should not recommend cetirizine1; the chemical structures are so similar that they may also have an allergy to cetirizine. Labels of levocetirizine products caution against use if the patient is allergic to cetirizine (eg, Zyrtec), but they do not carry a warning against use if the patient is allergic to hydroxyzine. None of the nonsedating antihistamines can be used for unsupervised self-care in patients under the age of 2 years; levocetirizine should not be used under the age of 6 years. Fexofenadine should not be recommended in those over the age of 65 years.1 Cetirizine and levocetirizine labels carry the following precautions: the product may cause drowsiness, the patient should avoid alcoholic drinks, and caution must be exercised when driving or operating heavy machinery. Levocetirizine labels caution patients to speak to a physician before use if they have ever had trouble urinating or emptying the bladder. Finally, patients who purchase fexofenadine should be instructed to avoid fruit juices due to a drug interaction that would reduce the amount of fexofenadine absorbed by the body. .10

Decongestants

Patients with AR who use cromolyn or antihistamines may find their nasal congestion is not fully relieved.6 In these cases, decongestants may be of use, and for this reason, they are combined with antihistamines (eg, Claritin-D, Zyrtec-D, Allegra-D).1 These medications will be discussed in more detail with the presentation of treatments for the common cold.

Intranasal corticosteroids

Intranasal corticosteroids sprays are another treatment option for allergic rhinitis. Several are available at this time: Nasacort Allergy 24HR and Children’s Nasacort (both with triamcinolone acetonide); Flonase Allergy Relief, Children’s Flonase and ClariSpray (all containing fluticasone propionate); Rhinocort Allergy Spray and Children’s Rhinocort (both with budesonide); and Flonase Sensimist and Children’s Flonase Sensimist (both with fluticasone furoate).11-14 These products have a distinct advantage when compared to older AR therapies. They relieve the four major AR symptoms: nasal congestion, nasal pruritus, rhinorrhea, and sneezing.4,11 Flonase and Flonase Sensimist also relieve itching watery eyes.

The technician should ask the age of the patient and report it to the pharmacist so the pharmacist can make an informed therapeutic choice. Rhinocort should not be used without a prescriber's recommendation in patients under the age of 6 years, but Flonase can be recommended for children 4 years and older and Nasacort and Flonase Sensimist in those aged 2 years and above. Patients should be asked whether they are pregnant or breast-feeding because they should not use them without speaking to a physician first. The technician should ask whether the patient has ever had an allergic reaction to the active ingredient (eg, sudden swelling of the face or tongue, rash, wheezing or feeling faint), so the pharmacist can advise him/her not to use it. The labels of Flonase and ClariSpray advise patients not to use them to treat asthma, but technicians should ask patients contemplating purchase of any of these products about using it for asthma, since none are useful for asthma. Similarly, the labels of Rhinocort caution patients not to use it for the common cold, but none of these products are useful for this condition.

The technician should urge prospective purchasers to speak to a physician before use if there is a recent nose ulcer or surgery, or if the patient has suffered a nose injury that has not healed. Labels also advise against unsupervised use if the patient has or has a history of glaucoma or cataracts. Labels of Rhinocort and Nasacort also advise patients not to use them if they have an eye infection. The technician should ask the patient about other medications being used, and must inform the pharmacist if the patient is taking/using: (1) a steroid for allergies, asthma or skin rash, (2) ketoconazole for a fungal infection (Flonase products and ClariSpray only), or (3) a medication for HIV infection, such as ritonavir (Flonase products and ClariSpray only). 

The technician or pharmacist can warn patients that, while using these medications, the growth rate of some children might be slowed. Patients should not share the bottle to prevent transmission of infectious agents. Further, when using Nasacort and Rhinocort, some symptoms may improve on the first day of treatment, but it may take up to a week of daily use to feel the maximal symptom relief. Patients should also be instructed to always tell their physician that they are using these products.

The technician or pharmacist should warn patients that they must stop using these nasal sprays and speak to a physician if:

  • They have, or come into contact with, someone who has chickenpox, measles or tuberculosis
  • They do not improve within seven days of starting therapy, or if they develop new symptoms such as severe facial pain or thick nasal discharge, as these problems may indicate an infection (Flonase products and ClariSpray only)
  • They have or develop symptoms of an infection such as a persistent fever (Rhinocort and Nasacort only)
  • They notice a constant whistling sound coming from the nose, as this may indicate damage inside the nose (Flonase/ClariSpray only)
  • They develop new changes to vision that begin after starting use of the product.
  • They have severe or frequent nosebleeds.

As is the case with all nonprescription products, it is vital for the technician to caution the patient to read and follow all label directions.

PREVENTION AND TREATMENT OF THE COMMON COLD

The common cold can be prevented with several useful tips that technicians can offer to patients.1 First, patients should cough or sneeze into the crook of the elbow, rather than the hands. This prevents particles from getting onto the patient's hands and being transferred to others. Each patient should be taught to wash the hands frequently with antibacterial soap or alcohol gels, especially during common cold seasons.1 Finally, patients should be taught to keep their fingers away from their eyes, nose, and mouth to prevent self-inoculation.1 While treatments for the common cold address the specific symptoms, they do not cure the viral infection. There are several OTC treatments that are available for nasal congestion, runny nose, sneezing, sore throat, and cough.

Treating nasal congestion

Nasal congestion is one of the most bothersome common cold symptoms.1 When experiencing nasal congestion, the patient usually cannot breathe normally, so he or she has to breathe through the mouth, which dries the mouth and makes sleeping and eating more difficult.1,7 Further, the patient may feel the need to blow the nose, which can force infected fluids into the sinus cavities. Nasal congestion of the common cold can be treated with topical nasal decongestants, oral nasal decongestants, nasal dilators, or nasal aspirators.1

Nasal decongestants

The most common nonprescription intervention for nasal congestion is the use of nasal decongestants.1 These products shrink swollen nasal blood vessels, opening the nostrils so the patient can breathe. They can be purchased as topical products (eg, sprays, drops, inhalers) or oral products (eg, tablets, capsules, oral liquids). There are several differences between topical and oral products, but they share a common set of contraindications. The technician should ask whether the patient has any of the following before approaching the pharmacist: (1) heart disease or hypertension, (2) diabetes mellitus, (3) thyroid disease, (4) trouble urinating due to an enlarged prostate, or (5) if the patient is pregnant or breastfeeding. No decongestant is safe for self-use in these patients unless they speak to their physicians, and it is critical to inform the pharmacist if a contraindication is present.1

Topical nasal decongestants may be purchased as oxymetazoline (eg, Afrin), propylhexedrine (eg, Benzedrex), or phenylephrine (eg, Neo-Syneprine).1 Each has an age restriction below which they must not be used. The minimum ages are 12 years (phenylephrine) or 6 years (propylhexedrine, oxymetazoline). Patients must be reminded to read the dosing directions carefully to prevent adverse effects.1 In addition, technicians should warn patients that topical nasal decongestants can cause temporary burning, stinging, sneezing, or increased nasal discharge following use. Further, only one person should use the product to prevent spread of infection.1

Topical nasal decongestants can cause a condition known as rhinitis medicamentosa or rebound congestion, especially if a product is used too often, for too long a period of time, or if the patient applies too much medication (i.e., too many sprays).1 Misuse of oxymetazoline is an example. Its label directs users to apply oxymetazoline no more often than every 10 to 12 hours. However, when it wears off, some patients notice that their nasal congestion is worse than it was before they used the product. This may be a result of the body compensating by rushing blood into the formerly constricted nasal blood vessels. The increased stuffiness and blockage prompt some patients to increase the number of sprays or to use the product too often (eg, every 4 to 6 hours).1 As the days pass, the nasal blockage becomes more severe until it reaches the point that the patient may be using the drug every 2 to 3 hours in an attempt to breathe through the nose. The nasal decongestant is now actually the cause of a continued congestion and the patient is trapped in a cycle of accelerated and increased product use.1 For this reason, product labeling cautions patients to stop using topical nasal decongestants after 3 days and to consult a physician if symptoms persist. Technicians can be alert for abuse of these products. Repeated sales to the same individual are a clue, and patients should be urged to speak to the pharmacist for assistance in these cases.1

Technicians can also help pharmacists prevent abuse of these products by those who wish to obtain a high. Recent concerns about misuse and abuse of propylhexedrine have emerged in the medical literature.15 When patients request a product with this ingredient, it is prudent to ask some questions that target the duration of congestion symptoms and contraindications for use. If the patient appears nervous, has contraindications for use, or is a frequent purchaser, the pharmacist should be notified immediately.

Oral decongestants that are commonly used to treat nasal congestion include pseudoephedrine (eg, Sudafed) and phenylephrine (eg, Sudafed PE).1 In addition to the contraindications listed above, the technician should also ask patients if they have fever and, if so, communicate this contraindication to the pharmacist. The minimum age for both products is 4 years. The technician should ask the patient who is contemplating a purchase of an oral nasal decongestant whether he or she is taking a monoamine oxidase inhibitor (MAOIs).1 These medications are occasionally prescribed for depression, psychiatric conditions, or Parkinson's disease. They include such drugs as phenylzine, tranylcypromine, isocarboxazid, and selegiline. If the patient is taking an MAOI, this information must be communicated to the pharmacist because oral nasal decongestants should not be used at the same time as MAOIs or for at least 2 weeks after the MAOI has been discontinued.1 Patients should be instructed to take oral decongestants exactly as recommended and to discontinue the medication if dizziness, nervousness, or sleeplessness occur. Further, if the symptoms do not improve in 7 days, the patient should stop using the product and seek physician care.1 Notably, pseudoephedrine-containing products are required to be kept behind the counter to prevent abuse by those persons who operate methamphetamine (meth) labs. Two recently introduced pseudoephedrine products, Nexafed and Zephrex-D, are more difficult to convert into meth and may be preferable to help stem the tide of meth abuse.16,17

External nasal dilators

External nasal dilators, such as Breathe Right Nasal Strips, are an alternative method to relieve nasal congestion for patients who do not wish to use an oral or topical nasal decongestant or who have contraindications to their use.1 These small plastic strips are adhesive-backed. Patients remove the paper covering over the adhesive and place the strip laterally over the nose, between the bridge and tip. When the strip is released, the plastic attempts to return to its original flattened shape; and by so doing, the strip pulls the nostrils slightly open to facilitate breathing. These nasal strips are safe in women who are pregnant and breastfeeding, and they do not have any medical or drug contraindications.1

Treating rhinorrhea and sneezing

As discussed above, histamine is not the cause of the most prevalent common cold symptoms. Nevertheless, chlorpheniramine and doxylamine are effective at relieving rhinorrhea and sneezing associated with the common cold.1

Treating sore throat

Sore throat can be caused by several medical conditions. Most are trivial but some are serious (eg, aplastic anemia).1 For this reason, the technician should first ask the patient who is complaining of sore throat whether he or she has other common cold symptoms. If the patient does not have rhinorrhea, nasal congestion, or cough, a referral to a physician is the safest course of action.1 Sore throat associated with the common cold can be a mild scratching discomfort, but it can be overtly painful for some people.1 Technicians should ask about the following situations, which require pharmacist intervention and referral to a medical provider: (1) severe sore throat; (2) a sore throat that has lasted for more than 2 days; (3) sore throat that is accompanied or followed by difficulty in breathing, fever, headache, rash, swelling, nausea, or vomiting; or (4) a patient who is under the age of 2 years.1 Therapeutic choices for sore throat include oral analgesics and topical lozenges or sprays. Oral analgesics such as acetaminophen, ibuprofen, and naproxen sodium are safe and effective for sore throat if all of the directions on product labeling are followed.1

Many patients prefer medicated lozenges for sore throat. These are hard candy-like dosage forms that are dissolved in the mouth no more often than every 2 hours.1 Companies also market liquids that can be swished around the mouth or gargled for 15 to 60 seconds (as recommended on the label) and expectorated, up to 4 times daily, or sprayed into the mouth as directed on the label.1 Safe and effective ingredients for minor sore throat in lozenge form include menthol (eg, N’Ice, Halls); benzocaine; benzocaine combined with menthol (eg, Chloraseptic Max, Cepacol Extra Strength); dyclonine (eg, Sucrets); and dyclonine combined with menthol (eg, Sucrets Sore Throat & Cough). Liquid sore throat products include those containing phenol (eg, Chloraseptic).1

Treating cough

As described above, cough associated with the common cold can be productive and helps clear the lungs of irritating and/or infective materials.1 However, if the lungs are clear but the patient is still coughing, the cough is known as a nonproductive or nuisance cough.1

When a patient presents with cough, the technician should determine the age of the patient, considering the lower age restriction for cough products varies greatly.1 Further, any cough that lasts for 1 week or more or recurs should be referred to a physician. Thus, if the patient informs the technician that the onset of cough was 9 to 10 days before the present day, the time for safe self-treatment of cough has already passed and the patient should see a physician.1 Technicians should also ask whether the patient has fever, rash, or persistent headache because the pharmacist will need to refer these patients to a physician.1 Patients must be cautioned not to use cough products for persistent or chronic cough, such as that occurring with smoking, asthma, or emphysema. Also, patients should not use anti-cough products if the cough is accompanied by excessive sputum (phlegm).1 If the patient does not have any of the above-mentioned issues, self-treatment may be appropriate. If the cough is productive, the only nonprescription ingredient proven effective at thinning mucus and aiding cough is guaifenesin (eg, Mucinex).1 The pharmacologic action of guaifenesin can be helped by drinking plenty of fluids, which also helps thin the mucus.1

If the cough is nonproductive, the pharmacist has several choices for cough suppressant therapy.1 The most common is dextromethorphan (eg, Delsym). This ingredient is sometimes abused by teens, so repeated sales to the same individual should be avoided. Dextromethorphan products also carry an MAOI warning, which is identical to package labeling for oral nasal decongestants. Dextromethorphan products are not recommended for use in children under the age of 4 years.1

Diphenhydramine is an antihistamine with cough-suppressing action found in such products as Theraflu Nighttime Multi-Symptom Severe Cold Hot Liquid Powder.1 These combination products should not be recommended for those under the age of 12 years.1 As an antihistamine, it carries all of the contraindications listed for diphenhydramine in the above section detailing treatment of allergic rhinitis.1

Camphor/menthol ointments such as Mentholatum and Vicks VapoRub are safe and effective for nonproductive cough in those aged 2 years and above.1 The patient should rub them on the throat and chest in a thick layer up to 3 times daily and may cover them with a warm, dry cloth if desired.1 Patients must be cautioned not to place them in the mouth or nostrils and to avoid heating them in any manner, such as in a microwave. Doing so can cause the product to splatter on the patient, resulting in burns of third-degree severity.1

Menthol in lozenge form is also effective for a nonproductive cough, and these products are the same as those covered above for sore throat. They are safe and effective in patients aged 2 years and older. If a specific product carries a higher age restriction, however, the higher age cut-off applies.

Codeine is available in some states as a Schedule 5 OTC cough suppressant (Cheratussin AC).1 However, pharmacists must monitor sales of these products to prevent abuse. Codeine can aggravate constipation and should not be recommended for patients with chronic pulmonary diseases or shortness of breath without physician supervision. Further, these products are not recommended for children under 6 years of age without physician supervision.1 

To further differentiate between AR and the common cold, the following pharmacy practice case is presented:

Pharmacy practice

On a warm June day, a man appearing to be in his late 20s asks the pharmacy technician for assistance. He says, "I think I have a cold or something. I have been sneezing over and over and my nose has been running for 3 or 4 weeks now. I just cannot stop this runny nose. My eyes itch all of the time, too. I think it is a really bad virus to have lasted this long." With some questioning, the technician discovers that the patient has no sore throat or cough, but he does have nasal blockage at times. His wife had a cold a couple of months ago.

Questions to Consider:

  1. Do the patient's problems appear to be related to AR or the common cold?
  2. What therapeutic choices does the pharmacist have?
  3. What questions should the technician ask the patient to assist the pharmacist?

Solving the case

This patient believes he has a common cold, but several clues point to AR. First, he does not have the common symptoms of a rhinovirus infection, such as sore throat or cough. Second, the rhinorrhea of a common cold turns purulent and thick within a few days. Thirdly, common cold viruses do not usually produce repeated sneezing, nor do they cause ophthalmic involvement, such as tearing and itching. Further, a common cold should not have lasted for 3 or 4 weeks. Finally, the fact that his wife had a common cold a couple of months ago is too long a period for him to now be experiencing the same rhinovirus. There is sufficient evidence that his problem is, in fact, due to AR. The pharmacist can advise the patient of the need to identify the offending allergen(s) and to control his environment to prevent further exposure. If needed, the patient may wish to premedicate with cromolyn nasal solution to prevent his symptoms. He can treat some of his active symptoms with first- or second-generation antihistamines, and he may also opt to try intranasal corticosteroids. This patient is clearly an adult, so questions about his age are not overly important. The duration of the condition is already known. However, the patient should be questioned regarding his current medical conditions and other symptoms (eg, fever) as well as the medications he is already taking. By communicating this information to the pharmacist, the technician can allow him or her to effectively and efficiently choose an appropriate therapeutic option for this patient's AR.

What to Do About Unknown Products. Manufacturers have marketed thousands of products that claim to prevent, cure, or treat these conditions but which lack any proof that they are safe or effective.1 Some are herbal such as echinacea or garlic. Others are mixtures of unproven ingredients, such as Airborne. Zinc is promoted with conflicting evidence in such products as Cold-Eeze and Zicam, and intranasal zinc should be avoided since it has been associated with anosmia (loss of smell).18 There are also cold remedies that are homeopathic. Homeopathic products contain ingredients that are so highly diluted that the final product only contains water or inert chemical powders such as lactose. No homeopathic product has ever been proven safe or effective for any condition. When patients ask about these products, the technician should refer them to the pharmacist so he/she can explain these issues and recommend a product that is safe and effective.

CONCLUSION

Allergic rhinitis and the common cold cause a great deal of confusion for patients, but with judicious questioning, the technician can help the patient determine which condition is present. Each condition presents challenges regarding the most appropriate therapeutic choice, and each therapeutic choice requires careful questioning to ensure it is safe and effective for that particular patient. With knowledge of such variables as patient age and contraindications, the technician can aid the pharmacist in making the best decision for each patient's unique case.

REFERENCES

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  14. Flonase Sensimist. GSKwebsite. https://www.flonase.com/products/sensimist/. Accessed January 4, 2020.
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  16. Acura Pharmaceuticals, Inc. website. http://www.nexafed.com/consumer/?gclid=Cj0KEQiA7NyiBRCOhpuCm9Dq6b4BEiQA9D6qhXwnO2KFarwJWVtnTTGMkMLhav21WIZECX8Zm3LpdZ0aAjeY8P8HAQ. Accessed January 4, 2020.
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