1. Respiratory disorder 1-Cold and flu. 2-Cough. 3-Sore throat..4-Allergic rhinitis

2. Cold and flu Common cold comprise a mixture of viral infection Self limiting. Many people choose to treated symptom by the OTC drug. OTC drug may interact with prescribed drug occasionally with serous consequences.

3. Significance of question and answers.

4. Age Establishing who the patient is child or adult. Children are most susceptible to URTI than adults.

5. Duration Rapid onset----------true of flu Gradual onset ----------- common cold The symptoms of the common cold may last for 7-14 days. Cough may persist after the worst of the cold is over.

6. Symptoms 1-Runny\blocked nose: Rhinorrhoea is initially clear watery fluid which is then followed by a thicker and more tenacious mucus(may be purulent). Nasal congestion occur because of dilatation of blood vessels leading to swelling of the lining surfaces of the nose.

7. Symptoms 2- Summer colds : Nasal congestion Sneezing. Irritant water eye. Similar to that accrue in the allergic rhinitis.

8. Symptoms 3-sneezing / cough Sneezing occur due to nasal passages irritation A cough may be present due to irritation of pharynx (produced a dry tickly cough) or bronchus (caused be post nasal drip).

9. Symptoms 4-Headache Occur due to inflammation and congestion The headache may be due to sinusitis (frontal headache) Patient with flu are most likely to experience muscle and joint pain than in common cold

10. Symptoms 5. High Temperature The presence of fever may be an indication that the patient has a flu rather than a cold.

11. Symptoms 6. Sore throat Throat feel dry and sore during cold. Sore throat may be the first sign that a cold is imminent.

12. Symptoms 7.Earache Earache is a common complication of cold especially in children. When nasal catarrh( الزكام (is present,the ear can feel blocked(due to the block of Eustachian tube). This situation is often resolved by inhalation and decongestant. When the middle ear filled with the fluid and become a site for secondary infection(acute otitis media), the ear become a cute painful and require antibiotic for treatment. the pain can managed by paracetol and ibuprofen

13. Symptoms 8.Facial pain\frontal headache May signify sinusitis Sinuses are air containing spaces in the bony structures adjacent to the nose (maxillary sinuses) and above the eyes (frontal sinuses). In case of cold the lining surfaces become inflamed and swollen, producing catarrh. The secretions drain into the nasal cavity if the drain blocked,the fluid build up in the sinus and become susceptible to secondary bacterial infection producing persistent pain in sinus area

14. Symptoms 9.flu Differentiation between cold and flu may be needed to make decision whether referral is needed Patient in(at risk ) group might be considered for antiviral treatment. Flu is generally considered to be likely if : Temperature is 38 c or higher (37.5c in the elderly). A minimum of one respiratory symptom (cough, sore throat, nasal congestion or rhinorrhoea) is present. A minimum of one constitutional symptom (headache,malaise,myalgia,sweats\chills, prostration) is present.

15. Symptoms Flu often starts abruptly with sweats and chills muscular aches and pain in the limbs,a dry sore throat, temperture, generalized weakness,malaise and a persistent dry cough True influenza is relatively uncommon compared to the large number of flu like infections that occur. Influenza is generally more unpleasant,although both usually settle with no need for referral. Flu can be complicated by secondary lung infection (pneumonia) especially very young,very old patients and have pre existing heart or lung disease.

16. Symptoms 10. Asthma Asthmatic attack can be triggered by respiratory viral infection (indicated referral).

17. Previous history. 1- chronic bronchitis. flu often cause exacerbation of their bronchitis. In this saturation the doctor is likely to increase the dose of inhaled anticholinergic and B 2 agonist and prescribed antibiotics.

18. Present medication. OTC drug –drug interaction. If medication has already been tried for relief of cold symptoms with no improvement and if the remedies tried were appropriate and used for a sufficient amount of time, referral to the doctor might occasionally be needed. In most cases of colds and flu, however, OTC treatment will be appropriate.

19. When to refer. Eaeache not setting with analgesic Facial pain /frontal headache In the very young In the very old Heart and lung disease Persistent fever and productive cough With delirium With pleuritic chest pain Asthma

20. Treatment time scale. 10-14 days then gone to advised there doctor if not improved.

21. Management. OTC for symptomatic treatment. Placebo play a role in the management. Poly pharmacy should avoided. In autumn 2007, the US Food and Drugs Administration (FDA) voted that further research on effectiveness in children was needed for decongestants, antihistamines, expectorants and cough suppressants. A ban was recommended on cough and cold products containing these ingredients for children under 6 years. The UK subsequently reviewed evidence of safety and as a result some constituents can no longer be used in children under 2 years.

22. Drug treatment. 1-Decongestants  Sympathomimetics (e.g. pseudoephedrine) can be effective in reducing nasal congestion. Nasal decongestants work by constricting the dilated blood vessels in the nasal mucosa. The nasal membranes are effectively shrunk, so drainage of mucus and circulation of air are improved and the feeling of nasal stuffiness is relieved. These medicines can be given orally or applied topically. Tablets and syrups are available, as are nasal sprays and drops. If nasal sprays/drops are to be recommended, the pharmacist should advise the patient not to use the product for longer than 7 days. Rebound congestion (rhinitis medicamentosa) can occur with topically applied but not oral sympathomimetics. The decongestant effects of topical products containing oxymetazoline orxylometazoline are longer lasting (up to 6 h) than those of some other preparations such as ephedrine. The pharmacist can give useful advice about the correct way to administer nasal drops and sprays.

23. Cautions Diabetes. Heart disease. Hypertension. Hyperthyroidism.

24. Interactions MAOIs (e.g. phenelzine). Reversible inhibitors of monoamine oxidase A (e.g. moclobemide). Beta-blockers Tricyclic antidepressants (e.g. amitriptyline) – a theoretical interaction-that appears not to be a problem in practice.

25. Drug treatment.  Antihistamines. Antihistamines could theoretically reduce some of the symptoms of a cold: runny nose (rhinorrhoea) and sneezing. These effects are due to the anticholinergic action of antihistamines. The older drugs (e.g. chlorphenamine, promethazine) have more pronounced anticholinergic actions than do the non-sedating antihistamines (e.g. loratadine, cetirizine, acrivastine). Antihistamines are not so effective at reducing nasal congestion. Some (e.g. diphenhydramine) may also be included in cold remedies for their supposed antitussive action or to help the patient to sleep (included in combination products intended to be taken at night). Evidence indicates that antihistamines alone are not of benefit in the common cold but that they may offer limited benefit for adults and children in combination with decongestants, analgesics and cough suppressants.

26. Interactions The problem of using antihistamines, particularly the older types (e.g. chlorphenamine), is that they can cause drowsiness. Alcohol will increase this effect, as will drugs such as benzodiazepines, phenothiazines or barbiturates that have the ability to cause drowsiness or CNS depression. Antihistamines with known sedative effects should never be recommended for anyone who is driving, or in whom an impaired level of consciousness may be dangerous (e.g. operators of machinery at work). Because of their anticholinergic activity, the older antihistamines may produce the same adverse effects as anticholinergic drugs (i.e. dry mouth, blurred vision, constipation and urinary retention). These effects are more likely if antihistamines are given concurrently with anticholinergics such as hyoscine or with drugs that have anticholinergic actions such as tricyclic antidepressants.

27. Interactions Antihistamines should be avoided in patients with prostatic hypertrophy and closed-angle glaucoma because of possible anticholinergic side-effects. In patients with closed-angle glaucoma, they may cause increased intraocular pressure. Anticholinergic drugs can occasionally precipitate acute urinary retention in predisposed patients, e.g. men with prostatic hypertrophy. While the probability of such serious adverse effects is low, the pharmacist should be aware of the origin of possible adverse effects from OTC medicines.

28. Interactions At high doses, antihistamines can produce stimulation rather than depression of the CNS. There have been occasional reports of fits being induced at very high doses of antihistamines and it is for this reason that it has been argued that they should be avoided in epileptic patients. However, this appears to be a theoretical rather than a practical problem. Antihistamines can theoretically antagonise the effects of betahistine.

29. Interactions Alcohol Hypnotics Sedatives Betahistine Anticholinergics, e.g. trihexyphenidyl (benzhexol), tricyclics

30. Side effects Drowsiness (driving, occupational hazard) Constipation Blurred vision.

31. Cautions closed-angle glaucoma. prostatic obstruction. Epilepsy. liver disease.

32.  Zinc Two systematic reviews have found limited evidence that zinc gluconate or acetate lozenges may reduce continuing symptoms at 7 days compared with placebo.  Echinacea A systematic review of trials indicated that some echinacea preparations may be better than placebo or no treatment for the prevention and treatment of colds. However, due to variations in preparations containing echinacea, there is insufficient evidence to recommend a specific product. Echinacea has been reported to cause allergic reactions and rash.  Vitamin C A systematic review found that high-dose vitamin C (over 1 g/day) taken prophylactically reduced the duration of colds by about 8%. Cough remedi

33. Prevention of flu Pharmacists should encourage those in at-risk groups to have an annual flu vaccination. In the UK, the health service now provides vaccinations to all patients over 65 years and those below that age who have chronic respiratory disease (including asthma),chronic heart disease, chronic renal failure, diabetes mellitus or immunosuppression due to disease or treatment. Community pharmacists are in a good position to use their PMRs (patient medication records) to target patients each autumn and remind them to have their vaccination. A nasal spray containing a viscous gel is marketed with claims that it prevents progression of the first signs of a cold into a full-blown infection. It is used four times a day from the time symptoms are experienced. The theoretical basis for its action is that the gel is slightly acidic (whereas viruses are said to prefer an alkaline environment) and that its viscous nature traps the viruses. There are no published trials of effectiveness.

34. Antivirals The effectiveness of antivirals during a pandemic cannot be known until used in such a situation and can only be guessed at based on experience in seasonal influenza and in those infected with avian flu. It is believed that they are likely to reduce the chance of developing complications, reduce the chance of dying and shorten the time taken to recover from an infection. It is possible that using antivirals for the non-infected members of a household when another member has the infection could reduce the spread of the pandemic. There is uncertainty as to how much resistance to antivirals could be present in a pandemic virus. Three antiviral products are licensed for use: oseltamivir, zanamivir and amantadine. Only the oseltamivir and zanamivir neuraminidase inhibitors are recommended by the Department of Health and WHO for use in a pandemic. National Institute for Health and Clinical Excellence does not have recommendations for a pandemic but supports the use of neuraminidase inhibitors for those who are in at-risk groups in seasonal flu outbreaks. Amantadine is generally not recommended because of its lower efficacy, side-effects, and because rapid resistance can develop to its use.

35. Antibiotics A serious complication of flu is the development of pneumonia and this In the case of a viral pneumonia, antibiotics are of no value although clinically it is difficult to tell the difference and antibiotics are usually given especially in a hospital setting with a severe illness. The current avian flu outbreak has been mainly complicated by viral pneumonia. Most uncomplicated infections in the community do not require antibiotics. They are now recommended for those at risk, such as people who have pre-existing Chronic Obstructive Pulmonary Disease (COPD), compromised immunity, diabetes, heart or lung disease. In these situations if there is no improvement within 48 h of starting antibiotics, can be either directly due to the flu virus or due to a secondary bacterial infection. Then the person should be seen by the GP.

36. Cough

37. Coughing is a protective reflex action caused when the airway is being irritated or obstructed. Its purpose is to clear the airway so that breathing can continue normally. The majority of coughs presenting in the pharmacy will be caused by a viral URTI. They will often be associated with other symptoms of a cold. The evidence to support the use of cough uppressants and expectorants is not strong but some patients report finding them helpful.

38. What you need to know Age (approximate) Baby, child, adult Duration Nature Dry or productive Associated symptoms Cold, sore throat, fever Sputum production Chest pain Shortness of breath Wheeze Previous history COPD (chronic bronchitis, emphysema, chronic obstructive airways disease) Asthma Diabetes Heart disease Gastro-oesophageal reflux Smoking habit Present medication

39. Significance of questions and answers

40. Age Establishing who the patient is – child or adult – will influence the choice of treatment and whether referral is necessary.

41. Duration Most coughs are self-limiting and will be better within a few days with or without treatment. In general, a cough of longer than 2 weeks’ duration that is not improving should be referred to the doctor for further investigation. Patients are often concerned when a cough has lasted for, what seems to them to be, a long time. They may be worried that because the cough has not resolved, it may have a serious cause

42. Nature of cough Unproductive (dry, tickly or tight) In an unproductive cough, no sputum is produced. These coughs are usually caused by viral infection and are self-limiting.

43. Productive (chesty or loose) Sputum is normally produced. It is an oversecretion of sputum that leads to coughing. Over secretion may be caused by irritation of the airways due to infection, allergy, etc., or when the cilia are not working properly (e.g. in smokers). Non-coloured (clear or whitish) sputum is uninfected and known as mucoid. Colored sputum may sometimes indicate a bacterial chest infection such as bronchitis or pneumonia and require referral. In these situations the sputum is described as green, yellow or rust-coloured thick mucus and the patient is more unwell usually with a raised temperature, shivers and sweats. Sometimes blood may be present in the sputum (haemoptysis), with a color ranging from pink to deep red. Blood may be an indication of a relatively minor problem such as a burst capillary following a bout of violent coughing during an acute infection, but may be a warning of more serious problems. Haemoptysis is an indication for referral.

44. Productive (chesty or loose) Antibacterial s/antibiotics are not usually indicated for previously healthy people with acute bronchitis. Most cases of acute bronchitis are caused by viral infections, so antibacterial will not help. Two systematic reviews of antibacterials for acute bronchitis found only slight benefit, possibly reducing the duration of illness by about half a day. Some people who have a tendency towards asthma develop a wheezy bronchitis with a respiratory viral infection. They may benefit from inhalation treatment used in asthma. If a person has had repeated episodes of bronchitis over the years, they might have chronic bronchitis (defined as a chronic cough and/or mucus production for at least 3 months in at least two consecutive years when other causes of chronic cough have been excluded). So careful questioning is important to determine this.

45. Tuberculosis (TB) Until recently thought of as a disease of the past, the number of TB cases has been rising in the UK and there is increasing concern about resistant Strains. Chronic cough with haemoptysis associated with chronic fever and night sweats are classical symptoms. TB is largely a disease of poverty and more likely to present in disadvantaged communities. In the UK, most cases of respiratory TB are seen in ethnic minority groups, especially Indians and Africans. Human immunodeficiency virus (HIV) infection is a significant risk factor for the development of respiratory TB.

46. Croup (acute laryngotracheitis) Croup usually occurs in infants. The cough has a harsh barking quality. It develops 1 day or so after the onset of cold- like symptoms. It is often associated with difficulty in breathing and an inspiratory stridor (noise in throat on breathing in). Referral is necessary.

47. Whooping cough (pertussis) Whooping cough starts with catarrhal symptoms. The characteristic whoop is not present in the early stages of infection. The whoop is the sound produced when breathing in after a paroxysm of coughing. The bouts of coughing prevent normal breathing and the whoop represents the desperate attempt to get a breath. Referral is necessary

48. Associated symptoms Cold, sore throat and catarrh may be associated with a cough. Often there may be a temperature and generalized muscular aches present. This would be in keeping with a viral infection and be self-limiting. Chest pain, shortness of breath or wheezing are all indications for referral.

49. Postnasal drip Postnasal drip is a common cause of coughing and may be due to sinusitis.

50. Previous history Certain cough remedies are best avoided in diabetics and anyone with heart disease or hypertension.

51. Chronic bronchitis Questioning may reveal a history of chronic bronchitis, which is being treated by the doctor with antibiotics. In this situation, further treatment may be possible with an appropriate cough medicine.

52. Asthma A recurrent night-time cough can indicate asthma, especially in children, and should be referred. Asthma may sometimes present as a chronic cough without wheezing. A family history of eczema, hay fever and asthma is worth asking about. Patients with such a family history appear to be more prone to extended episodes of coughing following a simple URTI.

53. Cardiovascular Coughing can be a symptom of heart failure.If there is a history of heart disease, especially with a persisting cough, then referral is advisable.

54. Gastro-oesophagea l Gastro - oesophageal reflux can cause coughing. Sometimes such reflux is asymptomatic apart from coughing. Some patients are aware of acid coming up into their throat at night when they are in bed.

55. Smoking habit Smoking will exacerbate a cough and can cause coughing since it is irritating to the lungs. One in three long-term smokers develop a chronic Cough If coughing is recurrent and persistent, the pharmacist is in a good position to offer health education advice about the benefits of stopping smoking, suggesting nicotine replacement therapy where appropriate. However, on stopping, the cough may initially become worse as the cleaning action of the cilia is re-established during the first few days and it is worth mentioning this. Smokers may assume their cough is harmless, and it is always important to ask about any change in the nature of the cough that might suggest a serious cause.

56. Present medication Angiotensin-converting enzyme (ACE) inhibitors

57. When to refer Cough lasting 2 weeks or more and not improving Sputum (yellow, green, rusty or blood-stained) Chest pain Shortness of breath Wheezing Whooping cough or croup Recurrent nocturnal cough Suspected adverse drug reaction Failed medication

58. Treatment cough suppressants. not be confirmed to have any significant effect (placebo ). 1.Codein / pholcodine.  pholcodine produce fewer side effect (constipation, respiratory depression,less liable for abuse).  codeine should be avoided in the treatment of children's and never be used for child under 1 year old.  both can induce drowsiness. 2.Dextrometharphan.  Less potent,has few side effects,not cause drowsiness.  Can be given for children over 2 years old.  Low potential for abuse. 3-demulcent.(glycerin,lemon and honey or simple linctus ).  They have soothing effect but not have active ingredient.  They are safe for children and pregnant women.

59. Treatment Expectorants. (guafenesin) Theoretically act by 2 mechanisms 1- act directly by stimulating bronchial mucus secretion, leading to increased liquefying of seputum,making easy to cough out. 2-act indirectly by irritation of GIT,which has sub sequent action on respiratory system resulting in increase mucus secretion. guafenesin should be given in high dose to produce therapeutic efficacy.

60. Cough remedies :other constituent Antihistamine. ( diphenhydramine,and promethazine ). Combination of it with cough suppressant is useful that antihistamine can help to dry up secretion,and help to sleep (night dose ). Cause drowsiness. D-D interaction with phenothiazines and TCA. (have additive anticholinergic and sedative effects.

61. Cough remedies :other constituent Sympathomimetics or decongestant (Psedoephedrine). They have bronchodilator and decongestant action. It has stimulant action (insomnia ). Should be used with caution in 1.DM. 2.Coronary heat disease (angina ). 3.Hypertension. 4. hyperthyriodism.

62. Cough remedies :other constituent Theophylline. Has bronchodilator action. Has a lot of side effect(nausea,GI irritation, palpitation,insomnia and headache). D-D interactions (cimetidine and erythromycin potentiat the action of theophylline while the levels of theophylline are reduced by smoking and drugs like carbamazepine phenytion and rifampicin )

63. Practical point. Diabetes.(syrup,,, infection). Steam inhalation.(productive cough ). Fluid intake. (lung hydration ).

64. Sore throat.

65. Viral infection(90%). Associated with other symptoms of common cold.

66. Significance of question and answer.

67. age Establishing who the patient is will influence the choice of treatment and whether referral is necessary. Streptococcal (bacterial) throat infections are more likely in children of school age.

68. Duration Most sore throats are self-limiting and will be better within 7–10 days. If it has been present for longer, then the patient should be referred to the doctor for further advice. Most sore throats are self-limiting and will be better within 7–10 days. If it has been present for longer, then the patient should be referred to the doctor for further advice.

69. Severity If the sore throat is described as being extremely painful, especially in the absence of cold, cough and catarrhal symptoms, then referral should be recommended when there is no improvement within 24–48 h.

70. Associated symptoms Cold, catarrh and cough may be associated with a sore throat. There may also be a fever and general aches and pains. These are in keeping with a minor self- limiting viral infection. Hoarseness of longer than 3 weeks’ duration and difficulty in swallowing (dysphagia) are both indications for referral.

71. Previous history Recurrent bouts of infection (tonsillitis) would mean that referral is best.

72. Smoking habit Smoking will exacerbate a sore throat, and if the patient smokes then it can be a good time to offer advice and information about quitting. Surveys indicate that two-thirds of people who smoke want to stop (see also ‘Smoking cessation’ in the chapter on ‘Prevention of Heart Disease’).

73. Present medication 1)The pharmacist should establish whether any medication has been tried already to treat the symptoms, If one or more medicines have been tried without improvement, then referral to the doctor should be considered. 2)Current prescriptions are important and the pharmacist should question the patient carefully about them. a. Steroid inhalers (e.g. beclometasone or budesonide) can cause hoarseness and candidal infections of the throat and mouth. Generally, they tend to do this at high doses. b.Such infections can be prevented by rinsing the mouth with water after using the inhaler. It is also worthwhile checking the patient’s inhaler technique. c. Poor technique with metered-dose inhalers can lead to large amounts of the inhaled drug being deposited at the back of the throat.

74. Symptoms for direct referral

76. Hoarseness Hoarseness is caused when there is inflammation of the vocal cords in the larynx (laryngitis). Laryngitis is typically caused by a self-limiting viral infection. It is usually associated with a sore throat and a hoarse, diminished voice. Antibiotics are of no value, and symptomatic advice (see ‘Management’ below), which includes resting the voice, should be given. The infection usually settles within a few days and referral is not necessary.

77. Hoarseness When this infection occurs in babies, infants or small children, it can cause croup (acute laryngotracheitis) and present difficulty in breathing and stridor. In this situation, referral is essential. When hoarseness persists for more than 3 weeks, especially when it is not associated with an acute infection, referral is necessary. There are many causes of persistent hoarseness, some of which are serious, For example, laryngeal cancer can present in this way and hoarseness may be the only early symptom. A doctor will normally refer the patient to a ear, nose and throat (ENT) specialist for accurate diagnosis.

78. Dysphagia Difficulty in swallowing can occur in severe throat infection. It can happen when an abscess develops in the region of the tonsils (quinsy) as a complication of tonsillitis. This will usually result in a hospital admission where an operation to drain the abscess may be necessary and high-dose parenteral antibiotics may be given. Glandular fever (infectious mononucleosis) is one viral cause of sore throat that often produces marked discomfort and may cause dysphagia,If this is suspected, referral is necessary for an accurate diagnosis. Most bad sore throats will cause discomfort on swallowing, but not true difficulty and do not necessarily need referral unless there are other reasons for concern. Dysphagia, when not associated with a sore throat, always needs referral.

79. Appearance of throat It is commonly thought that the presence of white spots, exudates or pus on the tonsils is an indication for referral or a means of differentiating between viral and bacterial infection, but this is not always so. Unfortunately, the appearance can be the same in both types of infection and sometimes the throat can appear almost normal without exudates in a streptococcal (bacterial) infection.

80. Thrush An exception not to be forgotten is candidal (thrush) infection that produces white plaques. However, these are rarely confined to the throat alone and are most commonly seen in babies or the very elderly. It is an unusual infection in young adults and may be associated with more serious disorders that interfere with the body’s immune system, e.g. leukaemia, HIV and acquired immune deficiency syndrome (AIDS), or with immunosuppressive therapy (e.g. steroids). The plaques may be seen in the throat and on the gums and tongue. When they are scraped off, the surface is raw and inflamed. Referral is advised if thrush is suspected and the throat is sore and painful.

82. Glandular fever Glandular fever is a viral throat infection caused by the Epstein–Barr virus. It is well known because of its tendency to leave its victims debilitated for some months afterwards and its association with the controversial condition myalgic encephalomyelitis. The infection typically occurs in teenagers and young adults, with peak incidence between the ages of 14 and 21 years. It is known as the ‘kissing disease’,A severe sore throat may follow 1 or 2 weeks of general malaise, The throat may become very inflamed with creamy exudates present, There may be difficulty in swallowing because of the painful throat. Glands (lymph nodes) in the neck and axillae (armpits) may be enlarged and tender. The diagnosis can be confirmed with a blood test, although this may not become positive until 1 week after the onset of the illness. Antibiotics are of no value; in fact if ampicillin is given during the infection, a measles- type rash is likely to develop in 80% of those with glandular fever. Treatment is aimed at symptomatic relief.

83. When to refer 1)Sore throat lasting 1 week or more 2) Recurrent bouts of infection 3) Hoarseness of more than 3 weeks’ duration 4) Difficulty in swallowing (dysphagia) 5) Failed medication

84. Treatment timescale Patients should see their doctor after 1 week if the sore throat has not improved.

85. Management Most sore throats are caused by viral infections and are self- limiting in nature, with 90% of patients becoming well within 1 week of the onset of symptoms. The pharmacist can offer a selection of treatments aimed at providing some relief from discomfort and pain until the infection subsides. Oral analgesics are first-line treatment. A systematic review found that simple analgesics (paracetamol, aspirin and ibuprofen) are very effective at reducing the pain from sore throat. Lozenges and pastilles have a soothing effect. There is some evidence that benzydamine spray is effective in relieving sore throat pain.

86. Oral analgesics Paracetamol, aspirin and ibuprofen have been shown in clinical trials to provide rapid and effective relief of pain in sore throat. A systematic review showed no benefit of adding other analgesic constituents. The patient can be advised to take the analgesic regularly to sustain pain relief and the NHS Clinical Knowledge Service advises: ‘A regular full dose is better than “now and then” to ease pain until symptoms go’. (For a discussion of doses, side-effects, cautions and contraindications for simple analgesics, see p. 197.) Flurbiprofen lozenges are used for sore throat for adults and children aged 12 years and over. They contain 8.75 mg of flurbiprofen, and one lozenge is sucked or dissolved in the mouth every 3–6 h as required, to a maximum of five lozenges. Flurbiprofen lozenges can be used for up to 3 days at a time.

87. Mouthwashes and sprays Anti-inflammatory (e.g. benzydamine) Benzydamine is an anti-inflammatory agent that is absorbed through the skin and mucosa and has been shown to be effective in reducing pain and inflammation in conditions of the mouth and throat. Side-effects have occasionally been reported and include numbness and stinging of the mouth and throat. Benzydamine spray can be used in children of 6 years and over, whereas the mouthwash may only be recommended for children over 12 years.

88. Local anaesthetic (e.g. benzocaine) Benzocaine and lidocaine are available in throat sprays.

89. Lozenges and pastilles Lozenges and pastilles can be divided into three categories: 1)antiseptic (e.g. cetylpyridinium) 2)antifungal (e.g. dequalinium) 3)local anaesthetic (e.g. benzocaine). Lozenges and pastilles are commonly used OTC treatments for sore throats, and where viral infection is the cause, the main use of antibacterial and antifungal preparations is to soothe and moisten the throat. Lozenges containing cetylpyridinium chloride have been shown to have antibacterial action. Local anaesthetic lozenges will numb the tongue and throat and can help to ease soreness and pain. Benzocaine can cause sensitisation and such reactions have sometimes been reported. Caution: Iodised throat lozenges should be avoided in pregnancy because they have the potential to affect the thyroid gland of the fetus.

90. Allergic rhinitis

91. Seasonal allergic rhinitis (hay fever) affects 10–15% of people in the UK, and millions of patients rely on OTC medicines for treatment. The symptoms of allergic rhinitis occur after an inflammatory response involving the release of histamine, which is initiated by allergens being deposited on the nasal mucosa. Allergens responsible for seasonal allergic rhinitis include grass pollens, tree pollens and fungal mould spores. Perennial allergic rhinitis occurs when symptoms are present all year round and is commonly caused by the house dust mite, animal dander and feathers. Some patients may suffer from perennial rhinitis, which becomes worse in the summer months.

92. What you need to know Age (approximate) Baby, child, adult Duration Symptoms Rhinorrhoea (runny nose) Nasal congestion Nasal itching Watery eyes Irritant eyes Discharge from the eyes Sneezing Previous history Associated conditions Eczema Asthma Medication

93. Significance of questions and answers

94. Age Symptoms of allergic rhinitis may start at any age, although its onset is more common in children and young adults (the condition is mostcommon in those in their twenties and thirties). There is frequently a family history of atopy in allergic rhinitis sufferers. Thus, children of allergic rhinitis sufferers are more likely to have the condition. The condition often improves or resolves as the child gets older. The age of the patient must be taken into account if any medication is to be recommended. Young adults who may be taking examinations should be borne in mind, because treatment that may cause drowsiness is best avoided in these patients.

95. Duration Sufferers will often present with seasonal rhinitis as soon as the pollen count becomes high. Symptoms may start in April when tree pollens appear and the hay fever season may start 1 month earlier in the south than in the north of England. Hay fever peaks between the months of May and July, when grass pollen levels are highest and spells of good weather commonly cause patients to seek the pharmacist’s advice. Anyone presenting with a summer cold, perhaps of several weeks’ duration, may be suffering from hay fever. Fungal spores are also a cause and are present slightly later, often until September.

96. Symptoms

97. Rhinorrhoea A runny nose is a commonly experienced symptom of allergic rhinitis. The discharge is often thin, clear and watery, but can change to a thicker, coloured, purulent one. This suggests a secondary infection, although the treatment for allergic rhinitis is not altered. There is no need for antibiotic treatment.

98. Nasal congestion The inflammatory response caused by the allergen produces vasodilatation of the nasal blood vessels and so results in nasal congestion. Severe congestion may result in headache and occasionally earache. Secondary infection such as otitis media and sinusitis can occur

99. Nasal itching Nasal itching commonly occurs. Irritation is sometimes experienced on the roof of the mouth.

100. Eye symptoms The eyes may be itchy and also watery; it is thought these symptoms are a result of tear duct congestion and also a direct effect of pollen grains being caught in the eye, setting off a local inflammatory response. Irritation of the nose by pollen probably contributes to eye symptoms too. People who suffer severe symptoms of allergic rhinitis may be hypersensitive to bright light (photophobic) and find that wearing dark glasses is helpful.

101. Sneezing In hay fever the allergic response usually starts with symptoms of sneezing, then rhinorrhoea, progressing to nasal congestion. Classically, symptoms of hay fever are more severe in the morning and in the evening. This is because pollen rises during the day after being released in the morning and then settles at night. Patients may also describe a worsening of the condition on windy days as pollen is scattered, and a reduction in symptoms when it rains, or after rain, as the pollen clears. Conversely, in those allergic to fungal mould spores the symptoms worsen in damp weather.

102. Previous history There is commonly a history of hay fever going back over several years. However, it can occur at any age, so the absence of any previous history does not necessarily indicate that allergic rhinitis is not the problem. The incidence of hay fever has risen during the last decade. Pollution, particularly in urban areas, is thought to be at least partly responsible for the trend. Perennial rhinitis can usually be distinguished from seasonal rhinitis by questioning about the timing and the occurrence of symptoms. People who have had hay fever before will often consult the pharmacist when symptoms are exacerbated in the summer months.

103. Danger symptoms/associated conditions When associated symptoms such as tightness of the chest, wheezing, shortness of breath or coughing are present, immediate referral is advised. These symptoms may herald the onset of an asthmatic attack.

104. Wheezing Difficulty with breathing, possibly with a cough, suggests an asthmatic attack. Some sufferers experience asthma attacks only during the hay fever season (seasonal asthma). These episodes can be quite severe and require referral. Seasonal asthmatics often do not have appropriate medication at hand as their attacks occur so infrequently, which puts them at greater risk.

105. Earache and facial pain As with colds and flu (see p. 21), allergic rhinitis can be complicated by secondary bacterial infection in the middle ear (otitis media) or the sinuses (sinusitis). Both these conditions cause persisting severe pain.

106. Purulent conjunctivitis Irritated watery eyes are a common accompaniment to allergic rhinitis. Occasionally, this allergic conjunctivitis is complicated by a secondary infection. When this occurs, the eyes become more painful (gritty sensation) and redder, and the discharge changes from being clear and watery to coloured and sticky (purulent). Referral is needed.

107. Medication The pharmacist must establish whether any prescription or OTC medicines are being taken by the patient. Potential interactions between prescribed medication and antihistamines can therefore be identified. It would be useful to know if any medicines have been tried already to treat the symptoms, especially where there is a previous history of allergic rhinitis. In particular, the pharmacist should be aware of the potentiation of drowsiness by some antihistamines combined with other medicines. This can lead to increased danger in certain occupations and driving.

108. Failed medication If symptoms are not adequately controlled with OTC preparations, an appointment with the doctor may be worthwhile. Such an appointment is useful to explore the patient’s beliefs and preconceptions about hay fever and its management. It is also an opportunity to suggest ideas for the next season.

109. When to refer Wheezing and shortness of breath Tightness of chest Painful ear Painful sinuses Purulent conjunctivitis Failed medication

110. Treatment timescael Improvement in symptoms should occur within a few days. If no improvement is noted after 5 days, the patient might be referred to the doctor for other therapy

111. Management Management is based on whether symptoms are intermittent or persistent and mild or moderate. Options include antihistamines, nasal steroids and sodium cromoglicate (sodium cromoglycate) in formulations for the nose and eyes. OTC antihistamines and steroid nasal sprays are effective in the treatment of allergic rhinitis. The choice of treatment should be rational and based on the patient’s symptoms and previous history where relevant. Many cases of hay fever can be managed with OTC treatment and it is reasonable for the pharmacist to recommend treatment. Patients with symptoms that do not respond to OTC products can be referred to the doctor at a later stage. Pharmacists also have an important role in ensuring that patients know how to use any prescribed medicines correctly (e.g. steroid nasal sprays, which must be used continuously for the patient to benefit).