1 Cold x Flu x Infections Respiratory diseases PharmDr. Alena Petříková What will you learn today?  Patient counselling in self-medication  Treatment of symptoms of flu or „flulike syndrom“:  Rhinitis  Sore throat  Cough  Fever  Children; pregnancy What is the difference?  Common cold  Flu  Bacterial infections  What are the symptoms? Upper respiratory tract infection what all does this include?  Rhinitis  Rhinopharyngitis  Tonsilopharyngitis  Laryngitis acuta  Epiglottitis acuta  Difteria (black cough) etc. Upper respiratory tract Etiology Viral  rhinitis ac., rhinopharyngitis ac., tonsilopharyngitis ac., sinusitis ac., otitis media ac., laryngitis subglottica Bacterial  tonsilopharyngitis ac., sinusitis ac., otitis media ac., epiglotitis ac. The division of symptoms and findings of streptococcal and viral tonsillitis 9 Flu  Patient, 35 yrs, is coming to your pharmacy complaining about having a flu.  What will you ask him? How will you help him? 10 Flu  Myxovirus influenzae type A, B, C  Large pandemia caused by type A only Symptoms?  Incubation of 18 -24 hours  Fever of 38 to 40 C,  chills, arthralgia, myalgia, generalized fatigue and exhaustion,  a dry cough 1-2 days  Patient can hardly wake up from his bed! Flu – duration  Duration 4 to 7 days  Complications of pneumonia, karditidis, otitis  Caution – children and elderly (cardio and pneumo illnesses!) Therapy?  Bed rest  Hydration  Antipyretics  NSAIDs  Antitussives  Neuraminidase inhibitors - zanamivir, oseltamivir Flu - treatment Oseltamivir (Tamiflu tablets., Inj.) Indication Treatment of influenza in patients (older 1 year) who present with symptoms typical of influenza at the time of its occurrence in the population. Efficacy has been demonstrated when treatment is initiated within 2 days after onset of symptoms. Treatment 75 mg (1 capsule) 2 times daily for 5 days Flu - treatment Zanamivir (Relenza inh. Plv.) indication Treatment and prophylaxis of influenza type A and B in adults, adolescents and children aged 12 years. treatment 2 inhalations (10 mg) 2 times daily for 5 days. The maximum effect is achieved by treatment with the administration of the first signs of influenza illness, preferably within the first 2 days. Flu - vaccines Method of administration: The vaccine is administered intramuscularly, usually into the deltoid region. As with all products of biological nature can not be ruled manifestation of hypersensitivity to any component of the vaccine and therefore when vaccinating a dilution of 1:1.000 epinephrine or corticosteroids should be available to reduce the symptoms of these reactions arising immediately after vaccination. For this reason, should be vaccinated person under the supervision of a physician 30 minutes after administration of the vaccine. Flu - vaccines Influenza vaccines usually have shelf life 12 months when stored in the refrigerator in an intact container at a temperature from +2 ° C to +8 ° C. The vaccine should be protected from light. The vaccine should be shaken thoroughly before use and visually inspected for any foreign particles. The vaccine should be consumed within 8 hours after unpacking the container. Vaccines‘ Reimbursement from health insurance - a partial reimbursement -individuals over 65 years -Severe chronic respiratory and cardio-vascular disease -With diabetes mellitus and other metabolic diseases -With cystic fibrosis, chronic renal insufficiency, chronic anemia - Congenital or acquired disorders of immune diseases (eg HIV infection, treatment with immunosuppressants, cytotoxic agents or high doses of corticosteroids, radiotherapy, etc.) Flu – vaccines Contraindication • Persons with acute febrile illness should not be vaccinated until at least 2 weeks after full cure. • Known severe allergic reaction (eg egg protein) at least one component of the vaccine is a contraindication for vaccination against influenza. • If after immunization of complications occur, then the next dose immunization of the same vaccine is contraindicated in the meantime until they are clarified causes of this complication. • First trimester (or first half) pregnancy is a contraindication for vaccination against influenza; in the 2nd and 3 trimester is possible that vaccination, especially if it is assumed that a pregnant woman is exposed to potential risk of infection during an influenza epidemic. 20 Rhinitis, sinusitis Rhinitis Young woman is coming to your pharmacy asking for something effective for runny nose. What questions will you ask her? Rhinitis Rhinitis symptoms - inflammation of the nasal cavity. - Itchy nose and sneezing - Swollen nasal mucosa - Runny nose Categories: - allergic (perennial, seasonal) - Infectious (bacterial virus x) - Other (eg, iatrogenic, geriatric, idiopathic - heat\cold) 23 Rhinitis  98% of viral origin!!!  What does it mean???  Chronic and recurrent, often allergic  Only 0.5-2% bacterial complication  How does it look?  Geriatric rhinitis 24 Alergic Rhinitis  Cause: herbs, dust, animals, ….  Distinguish between viral and allergic rhinitis – different treatment!  Treat the one you are able to treat in the pharmacy- OTC! Sedative antihistamines  bisulepin Dithiaden  dimetinden Fenistil  azelastin Allergodil  promethazin Prothazin Non-sedative antihistamines  cetirizin Zyrtec, Zodac…  loratadin Claritin, Flonidan…  levocetirizin Xyzal  desloratadin Aerius 27 Geriatric rhinitis  Narrowing of the airways  Loss of mucosal glands  Changes in the microcirculation - drying  It is accompanied by gastroesophageal reflux  Diuretics, antihypertensives, β-blockers, anxiolytics, antivertiginosa Therapy of geriatric rhinitis  Humidification of air in the nose  Mucolytics  Antihistamines -2nd generation  Decongestants contraindicated, especially sprays!  Sleeping with the head supported  Do not eat, drink before bedtime Rhinitis - general recommendations • Nasal decongestants- possibe to use oxymetazolin (Nasivin, Oxamet), xylometazolin (Olynth, Otrivin), nafazolin (Sanorin) • Local treatment (nose drops, spray) prefered to systematic treatment (tablets) • Nose sprays are generally considered to be more suitable and gentle then nosal drops • Usage: no longer then 1 week • Pregnant woman with pregnancy hypertention should avoid these remedies! • Every remedy dries the mucosal although advertisement says the opposite! Drug formulations Formulations:  Drops  Sprays  What are the benefits for the patient?  What are the obstacles in using certain formulation? 31 Decongestants How do they work??  Sympathomimetics  Osmotically active Decongestants - sympatomimetics  xylomethazolin (OLYNTH, OTRIVIN)  oxymethazolin (Nasivin) - for babies 0-1 years - For children 1-7 years - For adults  Naphazoline (Sanorin)  dimetinden + phenylephrine (Vibrocil)  carbethopendecinium bromide (Mukoseptonex) - only disinfection effect  carbethopendecinium bromide + Ephedrine (E Mukoseptonex - only Rp.)  Pseudoephedrine (Modafen), phenylephrine(Coldrex, Paralen Plus) Sympathomimetics  The possibility of addiction - take 4 -7 days only!!  Drying of mucous membranes  ↑ blood pressure, tachycardia, mydriasis  Addictive – REBOUND PHENOMENA!!  How to loose the addiction?  How to restore normal function of nasal mucoses?  How lond does it take? Sympathomimetics Contraindications!  CI of spray in children under 2 years, cardiovascular diseases, glaucoma, thyreosis, iMAO (antidepressants)  CI pseudoephedrine: diabetes, pregnancy, up to 12 years Osmotically active = Hypertonic saline solutions  ↓ congestion of nasal mucosa (decongestation)   mucin secretion => restoration of the natural protection of the mucosal  improved motility of cilia synchronization and frequency Examples Rhinitis in pregnant women YES Sprays with sea water (e.g. Sterimar), Vincentka spray or Pinosol nose drops and nose unguentum containing etheric oils. NO There are also drugs available in tablet form. Examples are products Modafen, Nurofen stopgrip, aspirin plus Coldrex etc. These contain a combination of several active compunds depressing cold, cough and high temperature. Using a combination of several substances in pregnancy is not considered ideal, and generally are not recommended. Questions to be asked o How long do you have the runny nose? o What and for how long have you already used? o Are you allergic to anything? (Alergic rh.) o Which other symptoms do you have? o Think about contraindications! (HT, DM, glaucoma, pregnancy…) o How old is the patient? (children, elderly) 41 Sore throat 42 Sore throat Where is it localised? Diagnostics - the nature of pain + its duration - The circumstances of its formation and degradation - Accompanying symptomatology - shortness of breath - temperature - Swollen tonsils 43 Sore throat What do we ask? o What is the nature of pain? o How long does the pain last? o The circumstances of emergence of pain in the neck. o Getting worse? o What are the accompanying symptoms? o Hyperthermia is present? o It is visible swelling in the neck? o What were the attempts at self-medication? Sore throat When to be sent to a doctor: 1. The patient cannot eat and have problems with fluid intake. 2. The pain lasts longer than three days and is accompanied by high fevers. 3. Pain in children is accompanied by fever and lasts longer than two days. 4. Redness of the neck is visibly red or white plaque is visible, or are "swollen" tonsilles. 5. For small children is very dangerous epiglotitis! Sore throat - therapy Tonsilitis Acute bacterial inflammatory disease are indicated to treat with antibiotics according to causal sensitivity. The empirical antibiotic treatment of angina is still the drug of first choice recommended by the V-Penicillin Macrolide antibiotics are indicated only when a contraindication beta-lactam antibiotic therapy (allergy), as is currently observed higher resistance of pathogens causing angina to macrolide antibiotics. Sore throat - therapy GARGLES - KLOKTADLO - salinic - Vincentka (min. water spray, lozenges) - "Powder" (magistral preparation) - Containing iodine - Sol. jodi glycerolica - Iodopovidonum - Jox sol. - Must know how to use (diluted in a ratio of 1:20 or 1:40 potable water, ie, 2.5-5 ml according to the enclosed measuring cup or 1/2-1 teaspoon to 100 ml of water). - Betadine sol. - Uses a 10% concentration Sore throat - therapy GARGLES - Hexetidin (Stopangin sol.) - Used undiluted - "Kutvirtovo kloktadlo" - magistraliter preparation, contains formaldehyde, dilution - 20 drops in glasses of water - 3% solution of hydrogen peroxide - Benzydamini hydrochloride. (Tantum verde sol.) used undiluted Sore throat - therapy Sprays - hexetidin (Stopangin spray) - benzydamini hydrochl. 0,15% (Tantum verde spray) - benzydamini hydrochl. 0,3% (Tantum verde forte spray) - iodpovidonum (Jox spray) Sore throat - therapy sprays - Fusafungin (Bioparox spray) - Local antibiotic therapy - Suitable for stronger pain (caused by bacterial infection) - Administered four times daily in the oral cavity Sore throat – therapy LOZENGES -Containing substances with a disinfectant effect  chlorhexidinum (Septofort)  aminotridecain adipate (Septisan)  dichlorbenzenmethanolum + amylmetacresolum (Strepsils)  benzydamine hydrochl. (Tantum verde P)  dichlorbenzenmethanolum + amylmetacresolum + menthol (Neo Angin)  hexylresorcinolum + benzalkonii chloridi (Coldrex proti bolesti v krku) Sore throat – therapy LOZENGES -disinfectant + a local anesthetic effect  chlorhexidin + tetracain (Drill)  dichlorbenzenmethanolum + amylmetacresolum + lidocain (Strepsils plus)  benzoxonium chlorid + lidocain (Orofar)  Chlorhexidin + benzokain (Hexoraletten)  KI? (cardio, thyreosis, allergy, DM)  Patient counselling?? Sore throat – LOZENGES Herbal lozenges  Honey  Salvia  Thyme  Lichen islandicus Sore throat - pregnancy YES - Can be recommended tridekanamin adipate (Septisan lozenges), chlorhexidine (Septofort lozenges) - Suitable and stronger pain is often used fusafungin (Bioparox spray) - Salinic gargle (Vincentka, powder gargle) NO - Avoid products containing local anesthetic (Drill lozenges, Strepsils Plus lozenges, pastilles Orofar, Septolete) - Do not use products with iodic povidone (Jox, jodglycerin) - Preparations containing sage (Salvium officinalis) Tea mixtures  Tilia cordata  Sambucus niger  Plantago  Thymus serpillum  Thyme off.  Verbascum off. Hydratation  Tussilago  Anise  Fennel  Licorice  Marjoram  Meadowsweet 61 Cough 62 Types of cough?? Productive x Dry How do they sound? Names of medicines? Expectorancia x Antitussics 63 Cough: patient counselling What are the necessary questions to be asked? Is it for you? How does the cough sound? (wet x dry) How long does it take? When is it? What are the other symptoms? What have you already taken? 64 Expectorantia  Mucolytics  Secretolytics  Secretomotorics Mucolytics Bromhexinum, ambroxolum  ↑ secretion of surfactant  thinning secretions  activation of the ciliary epithelium Patient counselling! ADRs GIT, possibility of allergies, Usage after eating, importance of hydration Secretolytics N-acetylcystein, carbocystein  cleaves the disulfide bonds of mucus glycoproteins  antioxidant effect Patient counselling!  ADRs headache, allergies  KI asthmatics  Detoxification of paracetamolum poisoning Secretolytics Erdosteinum  cleaves the disulfide bonds  antioxidant effect  progrug »↓ GI irritation  anti-inflammatory effect  ↑ efficacy of antibiotics Secretomotorics  Menthae piperitae etheroleum  Anisi etheroleum  Pini pumilionis etheroleum  Eucalypti etheroleum Other expectorancia:  Emetin  Kalii iodidum  Bromoform  Amonii chloridum  Guaifenesin 72 Expectorantia in Pregnancy YES In more serious manifestations of cough and phlegm is relatively safe alternative therapy administered acetylcysteine ​​(ACC Long, ACC 200, NAC AL 600) Ambroxol is used to treat disorders of surfactant in the fetus and is considered a relatively safe alternative. On physician's recommendation for a limited time you can also use products containing bromhexine NO Conversely guajfenesin (eg broncho Codrex syrup Guajacuran tbl.) Should not be used in the first trimester and is not recommended even in other periods of pregnancy 74 Antitussics  Codeine-type  Non-codeine type 75 Antitussics Formulations:  Tablets  Sirupus  Solution  What is the most suitable for children? 76  It acts in the brain stem  Codeine, ethylmorfin, dextromethorphan  Interaction:  SSRIs (fluoxetine, paroxetine),  MAOIs (moclobemide, selegiline, St. John's worth)  AB Codeine type antitussics 77 Patient counselling  Ussual use to reduce night cough  Addictive!  Use only for necessary time!  Contraindicated in wet cough!  Concentration decrease! Codeine type antitussics 79 Non-codeine type antitussics  Local anesthetic  Butamirate, dropropizin  Contraindication pregnancy (1st trimester)  ADRs in GIT 81 Non-codeine type antitussics Pregnancy - You can use dextromethorphan (contained in the product Humex syrup, Robitussin syrup antitusikum) - Codeine is considered in this indication as well as safe drug - Preparations containing butamirate (Tussin, SINECOD) can be used with the exception of a short first trimester, when it was their administration is contraindicated - at other drugs does not exist enough experience and manufacturers do not recommended them for pregnant women Herbal remedies in pregnancy It should be noted that the views that all vegetable and natural is safe for pregnant women, have long been overcome! The sore throat is often recommended sage (Salvia off.) during pregnancy should not be used! Sage was found to be harmful to the fetus and may have a teratogenic effect! The pregnant patient should consult a pharmacist in the selection of tea mixture (or bronchial cough). Safe as the use of lime tea (Tilia), melissa, plantain. Echinacea can be used short term, but some of the alcohol extracts contain relatively high alcohol content. 83 Fever 84 Fever When the body temperature higher than 39 °C should be promptly initiated therapy! Higher temperature – hyperthermia – till 38 °C Hyperpyrexia – above 38 °C To treat or not to treat?? Pregnancy: Shown that there is a much greater risk when untreated high temperature than with antipyretics! 85 Fever – possibility of treatmeant Most frequent medicines: paracetamolum ibuprofenum acetylsalicylic acid naproxenum diclofenacum paracetamolum (Paralen, Panadol, Medipyrin) •paracetamol crosses the placenta •After his administration - an increased risk of malformations or adverse effects was not observed during the first trimester. •The recommended safe dose of 3 x 500 mg daily •It is advisable tablets and suppositories •Risk only when the mother's overdose, because there is a failure of fetal liver •CI – I. Trimester, alćohol, liver problems Acetylsalicylic Acid (Acylpyrin, Anopyrin, Superpyrin, Aspirin) • Evidence of a teratogenic effect of aspirin administered in high doses in the medium during the second. and III. trimester (500- 1300 mg / day) was not confirmed • Adverse effects of aspirin result from inhibition of cyclooxygenase and the subsequent decreased production of prostaglandins • When taken during the third trimester, the fetus may cause premature closure of the ductus arteriosus to prolong pregnancy and increased risk of bleeding during childbirth for both mother and neonate •CI – children till yrs, gastric ulcer, bleeding, alcohol, AB, CHOPN, III. trimester 88 ibuprofenum (Ibalgin, Nurofen, Brufen) • In the short-term use of ibuprofen in the first and second trimester, the incidence of adverse effects and the possibility of developmental defects very small • Increased incidence of persistent pulmonary hypertension of the newborn and a higher probability of abortion only during the regular and prolonged use • In the third trimester should be more careful, especially during the anticipated delivery • If you must be administered during pregnancy drug from the group of NSAIDs with strong antipyretic effect as ibuprofen drug of first choice •(recommended to prefer him before acetylsalicylic acid) • Can be used with hyperthermia unresponsive to paracetamol naproxenum (Nalgesin) •Although it is primarily used to treat inflammatory diseases, may in some cases be used as an antipyretic. • Naproxen passes through the placenta • For naproxen, as the sole representative of a group of NSAIDs have been shown when used by women during pregnancy increased the incidence of cleft palate in newborns • Contraindications throughout pregnancy!!! diclofenacum •diclofenac easily passes the placental barrier and the highest penetration was recorded during the first trimester of pregnancy. •at high doses can lead to accumulation of diclofenac in tissues of the fetus and the teratogenic risk is significantly increased. In this period, therefore the potential risk of teratogenic effects on the fetus and the highest diclofenac should not be administered during embryogenesis. •occasional low doses has not been any studies confirmed teratogenic effect of diclofenac and legitimate indications it can be used during the second and the first half of the third trimester. •at the end of the third trimester of pregnancy are generally of the side effects described in the risk of premature closure of ductus ateriosus fetus, delayed delivery, increased bleeding during and persistent pulmonary hypertension. Summary Name 1. trimester 2. Trimester 3. trimester Before birth labor Acetylsalicylic Acid NO NO CI CI Diclofenacum KI NO NO CI Ibuprofenum NO YES YES CI Naproxenum CI CI CI CI Paracetamolum YES YES YES YES Flu and cold Risk factor in pregnancy are: 1. hyperthermia 2. long and irritating cough is an exhaustive factor for the whole organism mothers 3. fever may be complicated as sinusitis Does not represent for a woman or a child for an extremely high risk, but just the fact that women treat themselves may pose a hazard. Vitamine supplements - Daily dose of vitamin C during pregnancy should not exceed 500 mg - Recommended the soluble (effervescentní tablets), because they can cause stomach irritation - Should be used only the multivitamin preparations, which are primarily intended for use in pregnancy 94 Other treatment options 95 Other treatment options - Echinacea - Vitamine C - Zinc, selenium - Propolis 96 Conclusions  80% of disease of viral origin  Rational therapy - not antibiotics  Symptomatic treatment  Regime measures, hydration, stop smoking 97 Patient counselling examples 98 Example 1  Young man is coming to pharmacy and asking a strong effective medicine for flu. He doesnt have time to stay in bed, he must go to work tomorrow.  What questions do you ask?  What are his symptoms?  Which medicine would you recommend?  What are the treament measures? 99 Example 2  Middle age woman is coming to pharmacy and is complaining about never-ending rhinitis. She wants something very effective in order to finally get off the runny nose.  What questions do you ask?  How long does the rhinitis take?  Which medicines is she using?  What should she do to fight the rebound phenomena? 100 Example 3  A young father was sent to pharmacy to pick up a anti—cough sirupus for his 4 year daughter.  What questions do you ask?  What kind of cough is it?  How long does it take?  Are there any other symptoms?  Did they use anything else before?  What are the treatment measures? 101 Example 4  A pregnant women would like to have something for flu. She is very worried about the health of the unborn child.  In which trimester of pregnancy is she?  What are the symptoms?  Did she use anything else before?  What is suitable for 3rd trimester of pregnancy?  What are the treatment measures?