Community Pharmacy - E-Book
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Community Pharmacy - E-Book


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273 pages

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Now in a new edition – the leading Australian community pharmacy guide, covering common conditions seen by community pharmacists throughout Australia and New Zealand.

Fully revised and now in its second edition, Community Pharmacy: Symptoms, Diagnosis and Treatment 2e is an essential pharmacy resource.

Ideal for both pharmacy students and practicing pharmacists, Community Pharmacy provides a guide to differential diagnosis of symptoms commonly seen by community pharmacists throughout Australia and New Zealand.

Organised by body system, Community Pharmacy provides symptom-specific pharmaceutical questions and algorithms for the purposes of differential diagnosis.

More than 12 new treatment medicines have been added to this new edition, along with eight new case studies.

All conditions, products and recommendations have been revised to reflect current local drug scheduling and clinical practice, and the book’s evidence base has been updated in line with sources including the National Prescribing Service, Australian Prescriber, Australian Medicines Handbook, the Therapeutic Guidelines and Pharmaceutical Society of Australia guidelines.

Community Pharmacy: Symptoms, Diagnosis and Treatment 2nd edition incorporates evidence-based practice into every chapter, and addresses current issues like alternative treatments and complementary therapies, weight loss products and pre-quit nicotine use.

This full-colour pharmacy text also offers students and instructors additional web-based resources through Elsevier’s Evolve online platform including additional images for dermatology and ophthalmology, additional case studies and an additional chapter on Evidence-Based Practice.

This new edition also has the added benefit of providing online activities for practicing pharmacists undertaking essential Continuing Professional Development. These activities have been accredited for 10 hours of Group 2 CPD (or 20 CPD credits) suitable for inclusion in an individual pharmacist’s CPD plan and have been accredited by the Australian Pharmacy Council.

• covers the most common conditions seen in community pharmacies • evidence base for over-the-counter (OTC) recommendations for each condition • provides symptom-specific questions and algorithms for the purposes of differential diagnosis • discusses prevalence and epidemiology of each condition • practical prescribing summary tables • Hints and tips boxes covering product use advice • self-assessment – multiple choice questions, review questions and case studies • full-colour throughout, with colour photographs of important conditions • Helpful abbreviations • Glossary of terms • Useful websites • Online Evolve resources for students and instructors • Online activities for Continuing Professional Development (CPD)


Self care
Research design
Atopic dermatitis
Family medicine
Otitis externa
Allergic conjunctivitis
Differential diagnosis
Oral candidiasis
Women's health
Angiotensin-converting enzyme
Random sample
Abdominal pain
Primary care
Allergic rhinitis
Tension headache
Cluster headache
Chronic bronchitis
Smoking cessation
Health care
Clinical trial
Otitis media
Irritable bowel syndrome
Internal medicine
General practitioner
Back pain
Common cold
Respiratory system
Peptic ulcer
Hearing impairment
Diabetes mellitus
Chronic obstructive pulmonary disease
Myocardial infarction
Health care provider
Department of Health Services
Perforated eardrum
New Zealand
Urinary tract infection
United Kingdom
Pelvic inflammatory disease
Non-steroidal anti-inflammatory drug
Evidence-based medicine
Major depressive disorder
Body mass index
ACE inhibitor
National Institutes of Health


Publié par
Date de parution 20 octobre 2011
Nombre de lectures 2
EAN13 9780729580793
Langue English

Informations légales : prix de location à la page 0,0381€. Cette information est donnée uniquement à titre indicatif conformément à la législation en vigueur.


Table of Contents

Cover Image
Front Matter
Preface to the UK edition
How to use this book
UK acknowledgements
Useful websites
Chapter 1. Respiratory system
Chapter 2. Ophthalmology
Chapter 3. Otic conditions
Chapter 4. Central nervous system
Chapter 5. Women's health
Chapter 6. Gastroenterology
Chapter 7. Dermatology
Chapter 8. Musculoskeletal conditions
Chapter 9. Paediatrics
Chapter 10. Specific product requests
Evidence Based Pharmacy Practice
Answers to case study questions
Glossary of terms

Front Matter

Community Pharmacy
Australian and New Zealand edition
Paul Rutter BPharm, MRPharmS, PhD
Principal Lecturer, School of Pharmacy,
University of Wolverhampton, UK
David Newby BPharm, PhD
Associate Professor, Faculty of Health,
University of Newcastle, Australia
Original UK edition by Paul Rutter

Sydney Edinburgh London New York Philadelphia St Louis Toronto


Churchill Livingstone
is an imprint of Elsevier
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
This edition © 2012 Elsevier Australia
First edition published by Elsevier Australia in 2008
This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher.
Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation.
This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication.
National Library of Australia Cataloguing-in-Publication Data
Rutter, Paul.
Community pharmacy: symptoms, diagnosis and treatment /
Paul Rutter, David Newby.
2nd ed.
ISBN 978 0 7295 4079 7 (pbk.)
Newby, David.
Publisher: Melinda McEvoy
Developmental Editor: Rebecca Cornell
Publishing Services Manager: Helena Klijn
Project Coordinators: Karthikeyan Murthy & Lisa Shillan
Edited by Shaukia Mir
Proofread by Annette Musker
Technical edit by Jerry Perkins & Lynne MacKinnon
Cover design by Georgette Hall
Internal design by George Ajayi
Index by Robert Swanson
Typeset by Toppan Best-set Premedia Limited
Printed by China Translation & Printing Services Ltd

Community pharmacy has evolved significantly over the last few decades. Although the role of pharmacists in delivering primary healthcare has been longstanding, the demand for self-care in the community has increased dramatically. In Australia it is estimated that over $4 billion is spent annually on self-care items, most of which are medicines. This contrasts with just over $8 billion spent annually on medicines subsidised on prescription by the government through the Pharmaceutical Benefits Scheme.
A number of factors have influenced the trend towards greater self-care, including increased patient autonomy, better access to information about treatments and the availability of more effective non-prescription medicines. The latter has come about partly through the rescheduling of prescription medicines to non-prescription. Pharmacists in Australia and New Zealand are in a unique position in that the scheduling of medicines in these countries includes a special classification, Pharmacist Only (or Restricted in NZ), which falls between the Prescription Only and Pharmacy Only schedules, and requires involvement of the pharmacist in their sales. This contrasts with the UK, which only has Prescription Only and Pharmacy classifications, and the USA, where medicines are either Prescription Only or they can be sold in a range of retail outlets. Drugs that fall into the Pharmacist Only category are those that, it has been decided, would benefit from the input of the pharmacist. This should be seen as a privilege, and not be taken for granted. It is important that pharmacists use this opportunity to demonstrate that the public gains by these additional restrictions.
Some may argue that community pharmacy has clear conflicts of interest. On the one hand, as a healthcare professional, the health and safety of the patient are paramount. However, as a retailer, profitability and making sales are important. Community pharmacists make a significant amount of their income by selling things, in contrast to other healthcare professionals who are largely remunerated for their cognitive services. Therefore, it is important that, when assisting the public in making choices about purchasing medicines, pharmacists ensure their advice and guidance is based on the best available evidence to maximise the outcomes for the patient. It is hoped that this book will help pharmacists, both practising and in training, to diagnose and differentiate problems that are amenable to self-care, and then make choices of appropriate management that have evidence to support their efficacy.
David Newby

Preface to the UK edition
Demand on healthcare professionals to deliver high quality patient care has never been greater. A multitude of factors impinge on healthcare delivery today, including an ageing population, more sophisticated medicines, high patient expectation, health service infrastructure as well as adequate and appropriate staffing levels. In primary care the medical practitioner role is pivotal in providing this care and they remain the central member of the healthcare team, but demands on their time mean other models of service delivery are being adopted in the UK and in other developed countries that utilise other healthcare professionals.
This is leading to the traditional boundaries of care between doctors, nurses, and pharmacists being broken down. In particular, certain medical practitioner responsibilities, which were once seen as their sole domain, are now being performed by nurses and pharmacists, for example it is now common practice in many doctors’ surgeries to have practice nurses who run specialist clinics, for example asthma and diabetes clinics, and more recently nurse and pharmacist prescribing.
Probably of greatest impact to community pharmacy practice in the UK and elsewhere is the continued de-regulation of medicines. This has included products from new therapeutic classes (e.g. antiemetics and H2 antagonists), allowing community pharmacists scope to manage more conditions without the need to refer patients to a medical practitioner. The global market for over-the-counter medicines is considerable, and rising. In 1991 US customers spent $10.2 billion on OTC medicines, which had risen to $19.1 billion by 2000. Similar trends have been seen in UK and European markets and this upward trend looks set to continue.
A combination of factors has fuelled this worldwide increase in OTC sales: including government health-care policies that have encouraged self-care and self-medication; a greater emphasis on cost containment by healthcare organisations; an unprecedented rise in the number of medicines deregulated from prescription-only control to OTC status, aided by streamlined and less bureaucratic administration; and the profit interests of pharmaceutical companies, especially when ethical patents expire.
Pharmacists will have to demonstrate that they are competent practitioners to be trusted with this additional responsibility. Therefore pharmacists will require greater levels of knowledge and understanding about commonly occurring medical conditions. They will need to be able to recognise their signs and symptoms, and use an evidence-based approach to treatment.
This is the catalyst for this book. Although other books targeted for pharmacists on diagnosis are published, this book aims to give a more in-depth view of minor conditions and how to differentiate them from more sinister pathology that may present in a similar way. The book is intended for all pharmacists, from undergraduate students to experienced practitioners.
It is hoped that the information contained within the book is both informative and useful.
Paul Rutter


Community pharmacists are the most accessible healthcare professionals. No appointment is needed to consult a pharmacist and patients can receive free, unbiased advice almost anywhere. On a typical day a pharmacist practising in an ‘average’ community pharmacy can realistically expect to help between 5 and 15 patients who present with various symptoms for which they are seeking advice, reassurance, treatment or a combination of all three. Unlike most other healthcare professionals, community pharmacists do not normally have access to the patient's medical record and thus have no idea about what the person's problem is until a conversation is initiated. This presents the community pharmacist with a great challenge to correctly differentially diagnose the patient.

Communication skills
For the most part pharmacists will be totally dependent on their ability to question patients in order to arrive at a differential diagnosis. This is in stark contrast to the GP and, to a lesser extent, the nurse, who can draw on physical examination and diagnostic tests to help them arrive at a diagnosis. Opportunities for pharmacists to perform a physical examination are limited by the lack of privacy within a pharmacy and also a lack of training in correct examination technique; diagnostic testing is never employed because of the costs (which would have to be passed on to the patient) and the invasive nature of most tests (e.g. blood taking for analysis).
Having said this, a number of studies have shown that, in more than three-quarters of all cases, taking a patient history alone will result in the correct diagnosis. This figure rises slightly if a history is supplemented with a physical examination and yet further if laboratory investigations are also conducted.
It is vital, therefore, that pharmacists possess excellent communication skills to ensure the correct information is obtained from the patient. This will be drawn from a combination of good questioning technique, listening actively to the patient and picking up on non-verbal cues.
In addition to having skills in listening, the pharmacist must also be able to communicate information to the patient. While this is often done verbally, it is important that, where appropriate, written information is provided to back up any verbal instructions. Many of the websites provided at the end of each disease state and in the ‘Useful websites’ section of this book provide links to additional information to supplement counselling. Also, all Pharmacist Only medicines in Australia are required to have a Consumer Medicines Information leaflet, as do some Pharmacy Only medicines. If appropriate, these should also be considered. Another good source of written materials is the Pharmacy Self Care fact sheets, available through the Pharmaceutical Societies in Australia and New Zealand (see and ).

Approaches to differential diagnosis

Try to avoid using acronyms
Traditionally, the use of acronyms has been advocated to help pharmacists remember what questions to ask a patient. However, it is important that pharmacists do not rely solely on acronyms in trying to differentially diagnose a person's presenting complaint; acronyms are rigid, inflexible and often inappropriate. Every patient is different and therefore it is unlikely that an acronym can be fully applied and, more importantly, using acronyms can mean that you miss vital information that could shape your course of action. Some of the more commonly used acronyms are discussed briefly below.

This is the simplest acronym to remember but it is also the worst one to use. It gives the pharmacist very limited information from which to work and it is unlikely that a correct differential diagnosis will be made. If used at all, it should be with caution and it is probably only useful for counter assistants to use when a patient first presents, so that a general picture of the person's presenting complaint can be established.
Meaning of the letter Attributes of the acronym W Who is the patient? Positive points W What are the symptoms? Establishes presenting H How long have the complaint symptoms been present? A Action taken? Negative points M Medication being taken? Fails to consider general appearance of patient. No social/lifestyle factors taken into account; no family history sought; not specific or in-depth enough; no history of previous symptoms
Other acronyms that have been suggested as being helpful for pharmacists in differential diagnosis are ENCORE, ASMETHOD and SIT DOWN SIR. Although these three acronyms are more comprehensive than WWHAM, they are still limited. No one acronym takes into consideration all of the factors that might impinge on the differential diagnosis. All fail to establish a full history from the patient in respect to lifestyle and social factors or the relevance of a family history. They are very much designed to establish the nature and severity of the presenting complaint. This, in many instances, will be adequate but for intermittent conditions (e.g. irritable bowel syndrome, asthma, hayfever) they might well miss important information. Likewise, positive family history with certain conditions (e.g. psoriasis, eczema) provides useful clues in establishing a diagnosis. Meaning of the letter Attributes of the acronym E Explore Positive points N No medication ‘Observe’ section suggests taking into account the appearance of the patient – does he or she look very unwell? C Care O Observe R Refer E Explain Negative points Sections on ‘No medication’ and ‘Refer’ add little to the differential diagnosis process. No social/lifestyle factors taken into account; no family history sought Meaning of the letter Attributes of the acronym A Age/appearance? Positive points S Self or someone else? Establishes the nature of the problem and if the patient has suffered from previous similar episodes M Medication? E Extra medicines? T Time persisting? H History? O Other symptoms? Negative points D Danger symptoms? Exact symptoms and severity not fully established. No social/lifestyle factors taken into account; no family history sought Meaning of the letter Attributes of the acronym S Site or location? Positive points I Intensity or severity? Establishes the severity and nature of problem and if the patient has suffered from previous similar episodes T Type or nature? D Duration? O Onset? W With (other symptoms)? N Annoyed or aggravated? Negative points S Spread or radiation? Fails to consider general appearance of patient. No social/lifestyle factors taken into account; no family history sought I Incidence or frequency pattern? R Relieved by?
The Pharmaceutical Society of Australia has developed a protocol for non-pharmacist staff for both symptom-based requests and product-specific requests. The protocol is based around the words WHAT, STOP and GO:

WHAT – what is the problem

STOP – assess the situation

GO – proceed if appropriate
The acronyms WHAT and STOP stand for: Meaning of the letter W Who is the patient? H How long have they had the symptoms? A Actual symptoms – what are they? T Treatment for this or any other conditions? S Symptoms that should be referred T Totally sure? O Overuse or abuse? P Pharmacist only or pharmacist preferred * * Where the patient expresses a desire to speak to the pharmacist
If non-pharmacist staff encounter any of the STOP conditions they should refer to the pharmacist. This protocol is aimed at screening patients, and pharmacists are encouraged to use the guide to develop protocols in specific areas of the pharmacy.

Clinical decision making
Whether we are conscious of it or not, most people will – at some level – use clinical decision making to arrive at a differential diagnosis. Diagnostic reasoning is a component of clinical decision making and involves recognition of cues and analysis of data. Very early in a clinical encounter, and based on limited information, a pharmacist will arrive at a small number of hypotheses. The pharmacist then sets about testing these hypotheses by asking the patient a series of questions. The answer to each question allows the pharmacist to narrow down the number of possible diagnoses either by eliminating particular conditions or confirming his or her suspicions of a particular condition. Once the questioning is over, the pharmacist should be in a position to differentially diagnose the patient's condition.

Key steps in the process

1. Formulating a diagnosis based on the patient and the initial presenting complaint
Before any questions are asked of the patient you should think about the line of questioning you are going to take:

• What is the general appearance of the patient? Does the person look well or unwell? Is the person you are about to talk to the patient or someone acting on the patient's behalf? This will shape your thinking as to the severity of the problem.

• How old is the patient? This is very useful information. Epidemiological studies for a wide range of conditions and disease states have shown that certain age groups will suffer from certain problems. For example, it is very unlikely that a child who presents with cough will have chronic bronchitis but the probability of an elderly person having chronic bronchitis is much higher.

• What sex is the patient? As with age, sex can dramatically alter the chances of suffering from certain conditions. Migraines are five times more common in women than men, yet cluster headache is nine times more common in men than women.

• What is the presenting complaint? Some conditions are much more common than others. Therefore you could form an idea of what condition the patient is likely to be suffering from based on the laws of probability. For example, if a person presents with a headache then you should already know that the most common cause of headache is tension headache, followed by migraine and then cluster headache. Other causes of headache are rare but obviously need to be eliminated. Your line of questioning should try to confirm or refute the most likely causes of headache.

2. Asking questions
The questions you ask the patient will be specific to that patient. After establishing who the person is, how sick he or she is and what the presenting complaint is, a number of targeted questions specific to that patient should be asked. The following scenario will illustrate this point:
A 31-year-old female asks for advice about a headache she has.
What are your initial thoughts? ( 1. Formulating a diagnosis based on the patient and the initial presenting complaint ):

• the patient is present

• the patient is female and in her early thirties

• the patient looks and sounds OK

• epidemiology states that tension headache is most likely but females are more prone to migraine than males.
What line of questioning do you take? ( 2. Asking questions. ) Your main aim is to differentiate between tension and migraine headache:

Nature of the pain
Tension headache usually produces a dull ache, as opposed to the throbbing nature of migraine pain:

• patient's response: dull ache

• pharmacist's thoughts: suggestive of tension headache.

Location of the pain
Tension headache is generally bilateral; migraine is often unilateral:

• patient's response: all over

• pharmacist's thoughts: suggestive of tension headache.

Severity of pain
Tension headache is not usually severe and disabling; migraine can be disabling:

• patient's response: bothersome more than stopping her doing things

• pharmacist's thoughts: suggestive of tension headache.
The answers so far are indicative of tension headache. However, further specific questions relating to lifestyle and previous and family history should be asked. It would be expected that there was no family history of migraine and there is probably some trigger factor causing the headache, for example increased stress due to work or personal pressures. The patient might therefore have had similar headaches in the past.
Finally, even though at this stage you are confident of your differential diagnosis you should still ask a couple of questions to rule out any sinister pathology. Obviously you are expecting the answers from these questions to be negative to support your differential diagnosis. Any questions that invoke the opposite response to that expected will require further investigation.

3. Confirming facts
Before making a recommendation to the patient it is always helpful to try and recap the information elicited. This is especially important when you have had to ask a lot of questions. It is well known that short-term working memory is relatively small and that remembering all the pertinent facts is difficult. Summarising the information at this stage will not only help you formulate your final diagnosis but will also allow the patient to add further information or to correct you on facts that you have failed to remember correctly.
The way in which one goes about establishing what is wrong with the patient will vary from practitioner to practitioner. However, it is important that whatever method is adopted it must be sufficiently robust to be of benefit to the patient. Using a clinical decision-making approach to differential diagnosis allows you to build a fuller picture of the patient's presenting complaint. It is both flexible and specific to each individual, unlike acronyms.

Product-based requests
Many people will come into a pharmacy to purchase a specific product. Pharmacists should never assume that just because the patient has heard of, or used, the product before that they are adequately informed about the medicine. It is important that product-specific requests are treated with the same rigour as symptom-based requests. Pharmacists should establish whether use of the product is appropriate. Inappropriate use in this context is not related only to overuse or abuse, but also includes using the wrong product for the symptoms, or not using the product in the optimal way (e.g. using analgesics intermittently when regular use for short periods of time is more appropriate to break the pain cycle). After establishing who the medicine is for, and whether they have used it before, it is important that questions about the complaint being treated are asked including the severity and duration, anything they have tried so far, and what other medical conditions and medicines they may take. Only after establishing that use is appropriate should the sale proceed.

It is important that pharmacists document their activities. Apart from the legal requirements for documentation, such as the recording of the sales of certain Pharmacist Only medicines, professional standards and the Competency Standards for Pharmacists all state the need to maintain adequate records. This includes documenting overuse or inappropriate use of medicines, treatment plans, required follow-up of patients and referrals or discussions with healthcare professionals. This may be done electronically using the patient records of the dispensing computing system or in paper form, such as pre-printed referral forms. The latter are available from some of the suppliers of pharmacy stationery.

How to use this book
This book is divided into ten chapters. The first nine are systems based and structured in the format shown in Figure 1 . The final chapter is product based and has a slightly different format. A list of abbreviations and a glossary are included at the end of the book.

Fig. 1
Structure of this book.

Key features of each chapter
At the beginning of each chapter a short section addressing basic anatomy and history taking specific to that body system is presented. A basic understanding of the anatomical location of major structures is useful when attempting to diagnose/exclude conditions from a patient's presenting complaint. It would be almost impossible to know whether to treat or refer a patient who presented with symptoms suggestive of renal colic if one doesn't know where the kidneys are. However, this book is not intended to replace an anatomy text and the reader is referred to the list of further reading for anatomy texts.

Self-assessment questions
Twenty multiple choice and at least two case study questions are presented at the end of each chapter. These are designed to test factual recall and applied knowledge. They start with simple traditional multiple choice questions in which the right answer has to be picked from a series of five possible answers, and work up to more complex, interrelated questions.
The case studies challenge you with ‘real-life’ situations. All are drawn from practice and have been encountered by practising pharmacists, but have been modified for inclusion in the book. For all questions, a set of answers is provided at the end of the book to allow self-reflection.

Elements included under each condition
The same structure has been adopted for every condition. This is intended to help the reader approach differential diagnosis from the position of clinical decision-making. To help summarise the information, tables and algorithms are included for many of the conditions.

Arriving at a differential diagnosis
A table summarising the key questions that should be asked for each condition is included. The relevance (i.e. the rationale for asking the question) is given for each question. This will allow pharmacists to determine what questions to ask of every patient to enable a differential diagnosis.
For some conditions, such as those that affect the eye and some skin conditions, it will be possible for the pharmacist to have a look at the affected area. We would encourage pharmacists to examine these conditions if possible—to assist in this, photographs demonstrating standard presentations of these complaints have been included in those chapters relating to these types of conditions. However, it is important to note that patients may not present with ‘classical’ signs, and careful questioning is usually required to help reach a differential diagnosis.

Primer for differential diagnosis
A ‘primer for differential diagnosis’ is available for a number of the conditions covered. This algorithmic approach to differential diagnosis is geared towards nearly or recently qualified pharmacists. This feature is not intended to be solely relied upon in making a differential diagnosis but to act as an aide memoire. It is anticipated that the primers will be used in conjunction with the text, thus allowing a broader understanding of the differential diagnosis of the condition being considered.

Trigger points indicative of referral
A summary box of trigger factors when it would be prudent to refer the patient to a medical practitioner is presented for each condition.

Evidence-based non-prescription medicines and practical prescribing and product selection
These two sections present the reader, first, with an evaluation of the current literature on whether a non-prescription medicine works and, second, with a quick reference to the dose of the medicine and when it cannot be prescribed. This does not replace textbooks such as Stockley's drug interactions or Briggs’ Drugs in pregnancy and lactation, but it does allow the user to find basic data in one text without having to reach for three or four other texts to answer simple questions.
The pregnancy recommendations in this book are based largely on those of the Australian Drug Evaluation Committee's (ADEC) Pregnancy Categories ( Table 1 ). In some instances respected evidence-based texts, such as the Australian Medicines Handbook , have taken a more pragmatic approach and have suggested limited use in pregnancy may be appropriate despite not having an ADEC category of A. In these instances this is noted in the summary tables. However, given that pharmacists should only be managing minor, self-limiting conditions, it is prudent that no medicines are recommended in the first trimester, unless they carry an ADEC category of A.
Table 1 ADEC pregnancy categories ADEC category Definition A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed B1 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage B2 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals are inadequate or may be lacking, but available data show no evidence of an increased occurrence of fetal damage B3 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have shown evidence of an increased occurrence of fetal damage, the significance of which is considered uncertain in humans C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible D Drugs that have caused, are suspected to have caused or may be expected to cause an increased incidence of human fetal malformations or irreversible damage. These drugs may also have adverse pharmacological effects X Drugs that have such a high risk of causing permanent damage to the fetus that they should not be used in pregnancy or when there is a possibility of pregnancy

Hints and tips boxes
A summary box of useful information is provided near the end of each condition. This contains information that does not fall readily into any of the other sections but is none the less useful. For example, some of the hints and tips boxes give advice on how to administer eye drops, suppositories and other forms of medicines that are not taken via the oral route.

References, further reading and web sites
To supplement the text, at the end of each condition a list of selected references and reading is provided for those who wish to seek further information on the subject. Web sites are also provided, as many people now have internet access. All the sites have been checked and were active and relevant at the time of writing (January 2011).
Finally, all information presented in the book is accurate and factual as far as the authors are aware. It is acknowledged that guidelines change, products become discontinued and new information becomes available over the lifetime of a book. Therefore, if any information in the book is not current or valid, the authors would be grateful of any feedback, positive or negative, to ensure that the next edition is as up-to-date as possible.

Reviewers of Australian edition
Dr Rhiannon Braund
PhD, BPharm, BSc (Bioc), MPS, FNZCP, RegPharmNZ
School of Pharmacy, University of Otago, New Zealand
Mark Naunton
BPharm (Hons), PhD, AACPA
Discipline of Pharmacy, University of Canberra
Nerida Firth
BPharm (Honours First Class)
School of Pharmacy & Molecular Sciences, James Cook University
Ben Gilbert
B App Sci Env Des, B Pharm, GradDip Tox, MPS
Faculty of Health, University of Canberra
Erica Sainsbury
BPharm (Hons), MSc, GradDipEdStudies (Higher Ed), PhD, MPS, MACE, FHERDSA
Faculty of Pharmacy, The University of Sydney
Peter Guthrie
B Pharm MPS
The Pharmacy Guild of Australia

UK acknowledgements
Every chapter has been reviewed by a GP with a particular speciality in that area, or by another expert in that field.
Chapter 1 (Respiratory system) and Chapter 4 (The central nervous system)
Dr Nick Dunn MB DM MRCGP MSc
Senior Lecturer in Primary Medical Care, Southampton
Dr Dunn teaches at Southampton University medical school and works in general practice part time.
Chapter 2 (Ophthalmology) and Chapter 3 (Otic conditions)
General Practitioner, Sunnyside Surgery, Portsmouth
Dr Raw specialises in education for primary healthcare professionals from GP registrars to clerical staff.
Chapter 5 (Women's health)
Dr Charlotte Day MBBS BSc (Hons) MRCGP MFFP DRCOG
Principal General Practitioner, Baffin's Road Surgery, Portsmouth
Dr Day specialises in contraceptive and sexual health services.
Chapter 6 (Gastroenterology)
Dr Patrick Craig-McFeely MA MBBS MRCGP DCH DRCOG Dip Ther
General Practitioner, The Surgery, High Street, Hindon, Wiltshire
Dr Craig-McFeely specialises in therapeutics and medical education and has an interest in rheumatology.
Chapter 7 (Dermatology)
General Practitioner, Sunnyside Surgery, Portsmouth
Dr Tollast lectures in primary care dermatology and is a clinical assistant at the Portsmouth Skin Centre.
Chapter 8 (Musculoskeletal conditions)
Mr Keith Waldon
Vice-chair of the Society of Sports Therapists
Chapter 9 (Paediatrics)
Mrs Amanda Bevan MRPharmS
Southampton General Hospital, Directorate Pharmacist specialising in Paediatrics
Chapter 10 (Specific product requests)
Dr John Purvis MRPharmS PhD CertVetPharm ILT
Associate Dean for teaching and learning and Senior Lecturer in clinical pharmacy, University of Bradford
Dr Purvis specialises in pathophysiology and differential diagnosis.

Useful websites
Directory of Open Access Journals
Bandolier (evidence-based journal)
British Medical Journal
Health Services Research Journal
Pharmaceutical Journal (UK)
The Lancet
The Medical Journal of Australia
The Medical Journal of New Zealand
Australian Prescriber
Government sites
Australian Department of Health
New Zealand Ministry of Health
Therapeutic Goods Administration
New Zealand Medicines and Medical Devices Safety Authority (Medsafe)
The Australasian Cochrane Centre
National Institute for Health and Clinical Excellence (UK)
Pharmacy Guild of Australia
Pharmacy Guild of New Zealand
World Health Organisation
Pharmaceutical Society of Australia
The Pharmaceutical Society of New Zealand
The Society of Hospital Pharmacists of Australia
New Zealand Hospital Pharmacists’ Association
Royal Pharmaceutical Society of Great Britain
Centre for Clinical Effectiveness
Turning Research into Practice (TRIP)
Australian Clinical Trials Registry (includes NZ trials)
Dermnet (Dermatology resources)
General health sites for patients

Chapter 1. Respiratory system

In this chapter

Background 1

General overview of the anatomy of the respiratory tract 1

History taking and physical exam 2

Cough 2

The common cold 11

Sore throat 18

Rhinitis 24

Self-assessment 35


Diseases of the respiratory tract are the most common reasons for consulting a GP and represent over 13% of the problems managed by GPs in Australia ( Britt et al 2009 ). Although respiratory disease can cause significant morbidity and mortality, the vast majority of conditions are minor and self-limiting.
Community pharmacists are often the first health professional the patient seeks advice from and, as such, provide a filtering mechanism whereby minor self-limiting conditions can be treated appropriately with the correct medicine and patients with more sinister pathology referred on to the GP for further investigation.

General overview of the anatomy of the respiratory tract
The basic requirement for all living cells to function and survive is a continuous supply of oxygen. However, a by-product of cell activity is carbon dioxide, which, if it is not removed, poisons and kills the cells of the body. The principal function of the respiratory system is therefore the exchange of carbon dioxide and oxygen between the blood and atmospheric air. This exchange takes place in the lungs, where pulmonary capillaries are in intimate contact with the linings of the air spaces in the lung: the alveoli. All other structures associated with the respiratory tract serve to facilitate this gaseous exchange.
The respiratory tract is divided arbitrarily into the upper and lower respiratory tracts. In addition to these structures, the respiratory system also includes the oral cavity, rib cage and diaphragm.

Upper respiratory tract
The upper respiratory tract comprises those structures located outside the thorax: the nasal cavity, the pharynx and the larynx.

Nasal cavity
The internal portion of the nose is known as the nasal cavity. The nasal cavity is connected to the pharynx through two openings called the internal nares. Besides receiving olfactory stimuli (smell), the nasal cavity plays an important part in respiration because it filters out large dust particles and warms and moistens incoming air.

The pharynx is divided into three sections:

• >nasopharynx, which exchanges air with the nasal cavity and moves particulate matter towards the mouth

• >oropharynx and laryngopharynx, which serve as a common passageway for air and food

• >laryngopharynx, which connects with the oesophagus and the larynx and, like the oropharynx, serves as a common pathway for the respiratory and digestive systems

Larynx (voice box)
The larynx is a short passageway that connects the pharynx with the trachea. The glottis and epiglottis are located here and act like ‘trap doors’ to ensure that liquids and food are routed into the oesophagus and not the trachea.

Lower respiratory tract
The lower respiratory tract is located almost entirely within the thorax and comprises the trachea, bronchial tree and lungs.

Trachea and bronchi
The trachea connects the larynx with the bronchi. The bronchi divide and subdivide into bronchioles and these in turn divide to form terminal bronchioles, which give rise to the alveoli where gaseous exchange takes place. The epithelial lining of the bronchial tree acts as a defence mechanism and is known as the mucociliary escalator. Cilia on the surface of the cells beat upwards in organised waves of contraction, thus expelling foreign bodies.

The lungs are cone shaped and lie in the thoracic cavity. Enclosing and protecting the lungs are the pleural membranes; the inner membrane covers the lungs and the outer membrane is attached to the thoracic cavity. Between the membranes is the pleural cavity, which contains fluid and prevents friction between the membranes during breathing.

History taking and physical exam
Cough, cold, sore throat and rhinitis often coexist and an accurate history is therefore essential to differentially diagnose a patient who presents with symptoms of respiratory disease. A number of similar questions must be asked for each symptom, although symptom specific questions are also needed (these are discussed under each heading, below). Currently, examination of the respiratory tract is outside the scope of practice of the community pharmacist.


The main function of coughing is airway clearance. Particles are cleared from the lungs by a combination of coughing and the mucociliary escalator (the upward beating of the finger-like cilia in the bronchi that moves particles trapped in mucus up to the pharynx to be swallowed). Cough is the most common respiratory symptom and one of the few ways by which abnormalities of the respiratory tract manifest themselves.
Coughs can be described as either productive (chesty, wet, phlegmy) or non-productive (dry, tight, tickly). However, many patients will say that they are not producing sputum, although they go on to say that they ‘can feel it on their chest’. In these cases the cough is probably productive in nature and should be treated as such.
Coughs can be either acute or chronic. Australian guidelines define coughs as follows ( Gibson et al 2010 ):

• >Acute cough: cough duration of <2 weeks

• >Protracted acute cough (children): cough duration between 2 and 4 weeks

• >Chronic cough (children): cough duration of >4 weeks and

• >Chronic persistent cough (adults): cough duration of >8 weeks
Although these times are only considered indicative, patients who present with coughs, other than acute coughs (without alarm symptoms), are usually best referred to a medical practitioner.

Prevalence and epidemiology
Conditions that present with cough are among the most common reasons why patients seek care. Australian data indicates that cough is the most common reason for visiting a doctor after check-ups, prescriptions, and test results, and results in over 75,000 presentations to GPs annually ( Britt et al 2009 ). Acute coughs are most often associated with viral infection, for example the common cold, and are one of the most common presentations in pharmacies.

A five-part cough reflex is responsible for cough production. Receptors located mainly in the pharynx, larynx, trachea and bifurcations of the large bronchi are stimulated via mechanical, irritant or thermal mechanisms. Neural impulses are then carried along afferent pathways of the vagal and superior laryngeal nerves, which terminate at the cough centre in the medulla. Efferent fibres of the vagus and spinal nerves carry neural activity to the muscles of the diaphragm, chest wall and abdomen, which contract, followed by the sudden opening of the glottis that creates the cough.

Arriving at a differential diagnosis
Common causes of an acute cough include infection, allergies and upper airways cough syndrome (previously called post-nasal drip). Viral URTIs are the most common cause of an acute cough at all ages. Recurrent viral bronchitis is most prevalent in preschool and young school-aged children and is the most common cause of persistent cough in children of all ages. It is the pharmacist's responsibility to differentiate other causes of cough from viral causes and also to refer those cases of cough that might have more serious pathology. Asking symptom-specific questions will help the pharmacist to determine if referral is needed ( Table 1.1 ).
Table 1.1   Specific questions to ask the patient: Cough Question Relevance Sputum colour

• >Mucoid (clear and white) is normally of little consequence and suggests that no infection is present

• >Yellow, green or brown sputum normally indicates infection. However, mucopurulent sputum is probably caused by a viral infection and does not require automatic referral

• >Haemoptysis can be rust coloured (pneumonia), pink tinged (left ventricular failure) or dark red (carcinoma) Nature of sputum

• >Thin and frothy suggests left ventricular failure

• >Thick, mucoid to yellow can suggest asthma

• >Offensive, foul-smelling sputum suggests either bronchiectasis or lung abscess Onset of cough •   A cough that is worse in the morning suggests upper airways cough syndrome, bronchiectasis or chronic bronchitis Duration of cough

• >URTI cough can last for more than three weeks and is called a ‘post-viral cough’. However, coughs lasting longer than 2 weeks should be viewed with caution because they might indicate a more sinister pathology

• >The longer the cough is present, the more likely serious underlying pathology is responsible. For example:

• >3 days duration: most likely an URTI

• >3 weeks duration: more likely acute or chronic bronchitis

• >3 months duration: chronic bronchitis, tuberculosis and carcinoma become more likely Periodicity

• >Adult patients with recurrent cough might have chronic bronchitis, especially if they smoke

• >Care should be exercised in children who present with recurrent cough and have a family history of eczema, asthma or hayfever. This might suggest asthma and referral would be required for further investigation and pulmonary function tests Age

• >Children will most likely be suffering from an URTI but asthma and croup should be considered

• >With increasing age conditions such as bronchitis, pneumonia and carcinoma become more prevalent Smoking history •   Patients who smoke are more prone to chronic and recurrent cough. Over time this might develop into chronic bronchitis and emphysema

Clinical features of acute viral cough
Viral coughs typically present with sudden onset and associated fever. Sputum production is minimal and symptoms are often worse in the evening. Associated cold symptoms are also often present; these usually last between 7 and 10 days. Duration of longer than 14 days might indicate a ‘post-viral cough’ or a bacterial secondary infection but this is clinically difficult to establish without analysing sputum samples.

Conditions to eliminate

Acute cough

Laryngotracheobronchitis (croup)
One of the less common causes of acute cough in children is croup. This is most commonly caused by parainfluenza and respiratory syncytial viruses and it typically affects infants aged between 6 and 36 months old, with the peak incidence at 12–24 months. It occurs in approximately 2% of pre-school infants, and is more common in boys (ratio 3   :   2). The cough is described as having a barking (seal-like) quality and the child usually has a preceding history of an upper respiratory tract infection. Attacks typically occur at night and subside within a few hours, although they can recur. Steam inhalation has been recommended since the 1800s, however evidence for its efficacy is lacking. Australian guidelines recommend the use of short courses of corticosteroids in even mild cases of croup as these have been shown to reduce hospital admission rates and prevent re-presentation. Therefore, referral to a physician should be considered.

Upper airways cough syndrome
Upper airways cough syndrome (UACS), previously referred to as post-nasal drip, is characterised by a sinus or nasal discharge that flows behind the nose and in to the throat. Patients should be asked if they are swallowing mucus or notice that they are clearing their throat more than usual, as these features are commonly seen in patients with UACS. Allergies are one cause of UACS. Coughs caused by allergies are often non-productive and worse at night. However, there are usually other associated symptoms, such as sneezing, nasal discharge/blockage, conjunctivitis and itching oral cavity. Cough of allergic origin might show seasonal variation, for example allergic rhinitis. Other causes include vasomotor rhinitis (caused by odours and changes in temperature/humidity) and post-infectious UACS after an URTI.
If UACS is present, it is better to direct treatment at the cause of UACS (e.g. antihistamines or decongestants) rather than just treat the cough.

Chronic cough

Chronic obstructive pulmonary disease (COPD)
Chronic obstructive pulmonary disease is a serious chronic lung condition involving destruction of the lung tissue (emphysema) and chronic bronchitis (CB). The exact prevalence of COPD in Australia is uncertain. However, it is estimated that just over 2 million people in Australia have some type of COPD, nearly half of which have a mild form that is often ignored ( Australian Lung Foundation 2010 ). Early intervention (e.g. stopping smoking) in these milder forms could prevent serious deterioration in the lung function. Therefore, pharmacists can play an important role in identifying and counselling patients with early signs of COPD. This has led appropriately trained pharmacists to use spirometers to screen patients.
CB is the most common cause of chronic cough in adults. Patients often present with a longstanding history of recurrent acute bronchitis in which episodes become increasingly severe and persist for increasingly longer periods until the cough becomes continual. The definition of CB is coughing up sputum on most days for three or more consecutive months over the previous 2 years. In non-smokers the likely cause of CB is UACS, asthma or gastro-oesophageal reflux .
CB starts with a non-productive cough that later becomes productive. The patient should be questioned regarding smoking habit. If the patient is a smoker the cough will usually be worse on waking. Secondary infections contribute to acute exacerbations seen in CB. It typically occurs in patients over the age of 40 and is more common in men. Pharmacists have an important role to play in identifying smokers with CB as this provides an excellent opportunity for health promotion advice and assessing the patient's willingness to quit smoking.

Asthma affects 10–12% of children and approximately 10% of adults in Australia ( Australian Centre for Asthma Monitoring 2008 ), and in New Zealand it is reported to affect 15% of adults and 20% of children ( Anonymous 2002 ). This is considerably higher than in many other countries. Asthma is a chronic inflammatory condition of the airways characterised by coughing, wheeze, chest tightness and shortness of breath. However, asthma can present solely as a non-productive cough. This is especially true in young children, in whom the cough is often worst at night. Over time, other symptoms such as wheeze, dyspnoea and a productive cough can develop. Asthma can be associated with a personal or family history of atopy, and made worse by medicines such as non-steroidal antiinflammatory agents and beta-blockers. Diagnosis should be made by a combination of a medical history, symptoms and lung function tests.

Medicine-induced cough or wheeze
A number of medicines can cause bronchoconstriction, which presents as cough or wheeze. Angiotensin-converting enzyme (ACE) inhibitors are most commonly associated with cough and can affect up to one in five patients. The cough is not dose-related and time to onset is variable, ranging from a few hours to more than 1 year after the start of treatment. Cough invariably ceases after withdrawal of the ACE inhibitor but takes 3 to 4 weeks to resolve. Other medicines associated with cough or wheeze are non-steroidal antiinflammatories (NSAIDs), methotrexate, amiodarone and beta-blockers. If an adverse drug reaction (ADR) is suspected then the pharmacist should discuss alternative medicine with the prescriber, for example, almost all patients with ACE inhibitor cough can tolerate angiotensin II receptor blockers.

Rare causes of cough
Cough can be a symptom of many other conditions, although the majority will be rarely encountered in community pharmacy. However, it is important to be aware of these rare causes of cough to ensure that appropriate referrals are made.

Productive coughs

Heart failure
Heart failure is a condition diagnosed most commonly in the elderly. Based on self-reports, approximately 1.4% of the Australian population have heart failure or oedema ( AIHW 2010 ). The prevalence rises with increasing age – 2.6% of people aged 55–64 are affected and this increases to over 8% of patients aged 75 and over ( AIHW 2010 ). Heart failure is characterised by insidious progression and diagnosing early mild heart failure is extremely difficult because the symptoms are not pronounced. Often, the first symptoms patients experience are shortness of breath and dyspnoea at night. As the condition progresses from mild/moderate to severe heart failure patients might complain of a productive, frothy cough, which may have pink-tinged sputum.

Bronchiectasis is caused by irreversible dilation of the bronchi. Characteristically, the patient has a chronic cough of very long duration, which produces copious amounts of mucopurulent sputum (green–yellow in colour) that is usually foul smelling. The cough tends to be worse in the morning and evening. In longstanding cases the sputum is said to display characteristic layering, with the top being frothy, the middle clear and the bottom dense with purulent particles.

Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis and is transmitted primarily by inhalation. After many decades of decline, the number of new TB cases occurring in some industrialised countries is now starting to increase. In Australia the incidence has been relatively constant at 5–6 cases per 100,000 population ( Barry & Konstantinos 2009 ), with similar rates in New Zealand ( World Health Organization 2009 ). However, the incidence is significantly higher in the indigenous population, and in people who were born in countries where TB is common. TB is characterised by its slow onset and initial mild symptoms. The cough is chronic in nature and sputum production can vary from mild to severe with associated haemoptysis. Other symptoms of the condition are malaise, fever, night sweats and weight loss. However, not all patients will experience all symptoms. A patient with a productive cough for more than two weeks who exhibits one or more of the associated symptoms should be referred for further investigation, especially if they fall into one of the groups listed above. Chest X-rays and sputum smear tests can be performed to confirm the diagnosis.

Bacterial infection is usually responsible for pneumonia, which most commonly involves Streptococus pneumoniae . Other causes include Mycoplasma pneumoniae, Chlamydia, Legionella species and Haemophilus influenzae . Initially, the cough is non-productive and painful (first 24–48 hours) but it rapidly becomes productive, with the sputum being stained red. The intensity of the redness varies depending on the causative organism. The cough tends to be worse at night. The patient will be unwell, with a high fever, malaise, chills and headache, and will experience pleuritic pain (inflammation of the pleural membranes, manifested as sharp pain in the chest) that worsens on inspiration. Other investigations, including chest X-rays and sputum culture, help guide the diagnosis and treatment.

Carcinoma of the lung
A chronic cough is a common symptom of carcinoma of the lung. The possibility of carcinoma increases in long-term cigarette smokers who have had a cough for a number of months or who develop a marked change in the character of their cough. The cough produces small amounts of sputum that might be blood streaked. Other symptoms that can be associated with the cough are dyspnoea, weight loss and fatigue.

Legionnaire's disease
Legionnaire's disease is caused by Legionellae sp., a gram-negative bacillus. It is transmitted by inhalation of contaminated water or dust. A common source of outbreak is water towers associated with air-conditioning in public buildings such as shopping centres. Less commonly it can be caused by inhaling dust from potting mixtures. The incubation time is 2 to 10 days, and the presentation is similar to a severe case of the flu, with a fever, chills and a dry cough. Middle-aged to elderly people are most likely to be susceptible.

Non-productive coughs

Gastro-oesophageal reflux disease
Gastro-oesophageal reflux disease (GORD) does not usually present with cough but patients with this condition might cough when recumbent (lying down). Other symptoms of GORD are usually present such as heartburn, regurgitation, or sour mouth. The cough may result from cough receptors being activated by the refluxate, acid-induced laryngitis, or aspiration of the refluxate into the lungs, and treatment with high-dose proton pump inhibitor for 8–12 weeks can help ( Gibson et al 2010 ). It should always be considered in all cases of unexplained chronic cough.

Lung abscess
A typical presentation is of a non-productive cough with pleuritic pain and dyspnoea. Signs of infection such as malaise and fever can also be present. Later the cough produces large amounts of purulent and often foul-smelling sputum.

Spontaneous pneumothorax (collapsed lung)
Rupture of the bullae (the small air or fluid filled sacs in the lung) can cause spontaneous pneumothorax, although there is normally no underlying cause. Spontaneous pneumothorax affects approximately 7 to 18 per 100,000 males and 1 to 6 per 100,000 females ( Sahn & Heffner 2000 ). It typically occurs in tall, thin men aged between 20 and 40 years. Cigarette smoking and a family history of pneumothorax are contributing risk factors. This can be a life-threatening disorder causing a non-productive cough and severe respiratory distress. The patient experiences sudden sharp chest pain that worsens on chest movement. The symptoms often begin suddenly and can occur during rest or sleep. Figure 1.1 will aid the differentiation between serious and non-serious conditions of cough in adults.

Fig. 1.1
Primer for differential diagnosis of cough in adults. Duration of cough Most acute, self-limiting coughs usually resolve within 2 weeks; conditions with sinister pathology are more likely the longer the cough has been present. However, not all coughs that have lasted 2 weeks have to be referred automatically. UACS caused by conditions such as allergies can persist for weeks and can be managed by community pharmacists once other causes have been ruled out. Referral symptoms Certain symptoms warrant direct referral to the GP or even the emergency department. For example, shortness of breath, breathlessness (possible asthma), chest pain (possible cardiovascular cause) or pain on inspiration ( pleurisy or pneumothorax). Sputum colour Sputum colour can be helpful in deciding when to refer. However, there is a common misconception that patients who present with green-yellow or brown sputum have a bacterial infection; this is not normally the case and may indicate the body is fighting a viral infection. If the cough has persisted for more than 7 to 10 days it is possible that an initial viral infection has become secondarily infected with a bacterial infection. This could indicate referral, especially if the symptoms are debilitating or if the patient is elderly. Symptoms associated with infection The patient might have associated symptoms of fever, chills, rhinorrhoea and sore throat. Haemoptysis Blood in the sputum requires further investigation, especially if the person has had the symptoms for a period of time. Trigger factors Certain atmospheric factors can trigger cough. These factors include air temperature changes, pollution (e.g. cigarette smoke) and dry atmospheres (e.g. air conditioning).

Evidence base for non-prescription medicines
Cough can be trivialised by some healthcare practitioners, but coughing can impair quality of life and cause anxiety to parents of children with cough ( Dicpinigaitis et al 2009 ). There is an overwhelming range of non-prescription medicines to treat cough. However, growing evidence of the lack of demonstrable efficacy and potential safety concerns of these products, in particular in children, means the pharmacist must ensure that the most appropriate medicine is selected for the patient.
  Trigger Points indicative of referral Cough

• >Chest pain

• >Cough that recurs on a regular basis

• >Cough associated with severe flu-like symptoms

• >Duration longer than 2 weeks

• >Haemoptysis

• >Pain on inspiration

• >Persistent nocturnal cough in children

• >Wheeze and/or shortness of breath

A number of active ingredients have been formulated to help expectoration, including guaifenesin (guaiphenesin), ammonium salts, ipecacuanha, creosote and squill. The majority of products marketed in Australia for productive cough contain guaifenesin, although products containing ipecacuanha (Ipecacuanha and Tolu Mixture) and ammonium salts are available. The clinical evidence available for any active ingredient is limited. Older ingredients such as ammonium salts, ipecacuanha and squill were traditionally used to induce vomiting as it was believed that at sub-emetic doses they would cause gastric irritation, triggering reflex expectoration. This has never been proven and belongs in the annals of folklore. At best they offer a placebo effect and should not be recommended. Guaifenesin is the only active ingredient that has any evidence of effectiveness. A Cochrane Review ( Smith et al 2008 ) identified two studies using guaifenesin. The larger study (n = 239) found that more people taking guaifenesin reported reduced cough frequency and intensity compared with placebo (75% vs 31%). However a smaller study (n = 65), examining it as a cough suppressant rather than an expectorant, found guaifenesin to be no different from placebo in terms of cough frequency or severity, but it did reduce sputum thickness in 96% of patients compared with 54% with placebo.

Mucolytics increase the sputum volume and decrease the sputum viscosity. Bromhexine is used orally as a mucolytic and is reported to act by breaking down mucolytic fibres, enhancing ciliary activity, and by increasing exocrine gland secretion. A Cochrane Review ( Smith et al 2008 ) identified one study involving bromhexine, which found a 50% reduction in frequent coughing (coughing every two to five minutes) with bromhexine compared with placebo (8% vs 15%). It should be noted that the study was over 40 years old, and the absolute benefit is small.

Based on evidence, guaifenesin and bromhexine should be recommended as first-line treatment for productive coughs in adults. Although lacking rigorous trials, keeping well hydrated, unless contraindicated such as in heart failure, may also help thin and remove the mucous.

Cough suppressants (antitussives)
Most cough suppressants work directly on the cough centre to suppress the cough reflex. The effectiveness of antitussives has been investigated in acute and chronic cough as well as citric-acid-induced cough. Although trials on healthy volunteers – in whom coughing was induced by citric acid – allowed reproducible conditions to assess the activity of antitussives, they are of little value because they do not represent physiological cough. Of greatest relevance to non-prescription medicine are trials investigating acute cough, because patients suffering from chronic cough should be referred to the GP. While codeine was previously available without a prescription as a single agent (e.g. codeine linctus), its abuse potential led to it being re-scheduled to a Controlled drug. However, it can be given in combination with paracetamol, although evidence would suggest pholcodine and dextromethorphan have fewer side-effects and less potential for abuse ( Anonymous 2010 ). It is important that cough suppressants are not used in productive coughs, or in patients with asthma or chronic obstructive pulmonary disease.

Pholcodine has been the subject of limited clinical trials, with the majority being either animal models or citric-acid-induced cough studies in humans. These studies have shown pholcodine to have antitussive activity. A review by Findlay (1988) concluded that, on balance, pholcodine appears to possess antitussive activity but advocated the need for better, well-controlled studies.

Trial data for dextromethorphan, like that for pholcodine, are limited. A Cochrane Review ( Smith et al 2008 ) identified three studies comparing dextromethorphan with placebo. Two studies found an improvement in cough counts and cough effort, which in one study equated to a difference of up to 8–10 coughing bouts every 30 minutes. The third study found no difference between dextromethorphan and placebo in terms of cough frequency and subjective cough scores. It appears to have limited abuse potential and fewer side-effects than codeine.

Dihydrocodeine is a synthetic derivative of codeine. Like codeine, it has potential for abuse and has a similar range of adverse effects. This is only available on prescription in New Zealand.

Antihistamines have been included in cough remedies for decades. Their mechanism of action is thought to be through the anticholinergic-like drying action on the mucous membranes and not via histamine. There have been numerous clinical trials involving antihistamines for the relief of cough and cold symptoms, most notably with diphenhydramine.
Citric-acid-induced cough studies have demonstrated significant antitussive activity compared with placebo and results from chronic cough trials support an antitussive activity for diphenhydramine. However, trials that showed a significant reduction in cough frequency suffered from having small patient numbers, thus limiting their usefulness. Additionally, the poor methodological design of trials investigating the antitussive activity of diphenhydramine in acute cough, makes assessment of its effectiveness difficult. A recent review concluded ‘Presumptions about efficacy of diphenhydramine against cough in humans are not univocally substantiated in literature’ ( Bjornsdottir et al 2007 ).
Less sedating antihistamines have also not been shown to have any benefit in treating coughs associated with the common cold compared with placebo ( Smith et al 2008 ). They may have a role if allergies are causing UACS.

Demulcents, such as Simple Linctus APF, which is mainly a sugar syrup with some citric acid, or sucking on hard lollies (preferably sugar-free), are pharmacologically inert and are used on the theoretical basis that they reduce irritation by coating the pharynx and so prevent coughing. There is no evidence for their efficacy and they are used mainly for their placebo effect. They are a suitable recommendation for adults and children who cannot take other cough suppressants.

Antitussives have traditionally been evaluated for efficacy in animal or cough-induced models on healthy volunteers. This presents serious problems in assessing their effectiveness because support for their antitussive activity does not come from patients with acute cough associated with upper respiratory tract infection. Indeed, a recent systematic review of trial data of any cough medicine for acute cough in adults concluded that evidence of efficacy was lacking. Furthermore, there appear to be no comparative studies of sound study design that allow judgments to be made on their comparable efficacy. Compounding these problems is the self-limiting nature of acute cough, which further hinders differentiation between clinical efficacy and normal symptom resolution.
Antitussives therefore probably have a limited role in the treatment of acute non-productive cough in adults. Patients should be encouraged to drink more fluids and told that their symptoms will resolve in time on their own. If medicine is required then any active ingredient could be recommended; side-effect profile, abuse tendency, and potential drug interactions rather than clinical efficacy will drive the choice. On this basis the Australian Medicines Handbook recommends dextromethorphan and pholcodine as first-line therapy as they have a low incidence of side-effects and less risk of dependence. Antihistamines should not be used routinely, unless night-time sedation is perceived as an additional benefit to help the patient sleep.

Combination cough mixtures
Many of the non-prescription cough preparations are combinations of agents. Some of these include ingredients targeting other aspects of a common cold such as decongestants. It should be noted that some combination products contain sub-therapeutic doses of the active ingredients, while a few contain illogical combinations such as cough suppressants with an expectorant, or an antihistamine with an expectorant. If possible, these should be avoided.

Cough medicine for children
Very few well-designed studies have been conducted in children. A review published in the Drug and Therapeutics Bulletin identified just five trials of sound methodological design ( Anonymous 1999 ). However, of these five trials, one study used illogical drug combinations (expectorant combined with suppressant) and the remainder used combination products that are not available in Australia. A Cochrane Review examining the treatment of acute cough in both adults and children concluded there was no good evidence to support the effectiveness of cough medicines in acute cough ( Smith et al 2008 ). In addition, there has been growing evidence of the potential harm that these agents can pose to young children, either due to adverse effects, or from accidental inappropriate dosing ( Isbister et al 2010 ; Vassilev et al 2010 ). Based on the lack of efficacy and potential harm, the Australian Therapeutics Goods Administration and the New Zealand Medsafe are reviewing the use of cough and cold mixtures in children under 6 years of age. Therefore, the best treatment for children is non-pharmacological including increasing water intake, and the use of sugar-free hard lollies to help with dry coughs.

Practical prescribing and product selection
Prescribing information relating to the cough medicines reviewed in the section ‘Evidence base for non-prescription medicines’ is discussed and summarised in Table 1.2 and useful tips relating to patients presenting with cough are given in Hints and Tips Box 1.1 .
Table 1.2   Practical prescribing: Summary of cough medicines Medicine Use in children Likely side-effects Drug interactions of note Patients in whom care should be exercised Pregnancy Cough expectorants Guaifenesin >6 years; use should be discouraged None None None Single agents are category A; combination products with a sympathomimetic are category B2 and should be avoided Mucolytics Bromhexine >6 year; use should be discouraged Minor gastrointestinal upset None None Single agents are category A; combination preparations with a sympathomimetic are category B2 and should be avoided Cough suppressants Pholcodine Dextromethorphan Dihydrocodeine Codeine >6 years; use should be discouraged Possible sedation Increased sedation with alcohol, opioid analgesics, anxiolytics, hypnotics and antidepressants; dextromethorphan is contraindicated in patients taking MAOI People with asthma Single agents are category A; combination preparations with a sympathomimetic are category B2 and should be avoided Antihistamines Brompheniramine Chlorpheniramine Diphenhydramine >6 years; use should be discouraged Dry mouth and constipation Increased sedation with alcohol, opioid analgesics, anxiolytics, hypnotics and antidepressants Glaucoma, prostate enlargement Single agents are category A; combination preparations with a sympathomimetic are category B2 and should be avoided Promethazine >6 years; use should be discouraged Category C: avoid Demulcents Simple Linctus APF >2 years None None None OK
Hints and tips box 1.1 Cough

Insulin-dependent diabetes People with insulin-dependent diabetes who develop a cough secondary to a viral infection should be asked to monitor their blood glucose more frequently because insulin requirements increase during acute infections Alternative delivery routes Dextromethorphan is available as a lozenge. This is a useful alternative for those patients who find carrying a bottle of liquid around with them difficult. However, there is potential for overdose if patients take them frequently because they are seen as like throat lollies and taken whenever needed Avoid illogical combinations Very few cough remedies now have illogical medicine combinations. However, there are still a few on the market and these are best avoided. For example, combinations of expectorants and suppressants

Cough expectorants

A number of manufacturers include guaifenesin in their cough product ranges. The recommended dose for adults must be 200   mg four times a day. Some products deliver suboptimal doses or the quantity taken in a single dose would be so large that the product would last only 2 or 3 days. It is therefore advisable to check the label of any branded guaifenesin product before recommendation to ensure the patient is receiving appropriate treatment. Guaifenesin-based products have no major side-effects; they are also free from clinically significant drug interactions and so can be given safely with prescribed medicine. Sugar-free versions are available for patients with diabetes.

Mucolytics (bromhexine)
Several products include bromhexine, either alone or in combination with guaifenesin. Adults should take 8   mg three times a day and can increase the dose to 16   mg three times a day for the first 7 days. Bromhexine can occasionally cause gastrointestinal side-effects including nausea, vomiting and diarrhoea; there do not appear to be any clinically relevant drug interactions with bromhexine.

Cough suppressants
Pholcodine, dextromethorphan, codeine and dihydrocodeine are opiate derivatives and therefore – broadly – have the same interactions, cautions in use and side-effect profile. They interact with prescription-only and non-prescription medicines that cause CNS depression (e.g. first-generation antihistamines). Their combined effect is to potentiate sedation and it is important to warn the patient of this, although short-term use of cough suppressants with the interacting medicine is unlikely to warrant dosage modification. Dextromethorphan may increase the risk of serotonin syndrome if given with other drugs that contribute to serotonin syndrome such as monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs) and tramadol, and manufacturers specifically warn against the combination with MAOIs. Care should be exercised when giving cough suppressants to patients with asthma because, in theory, cough suppressants can cause respiratory depression in adults and children. However, in practice this is very rarely observed. Other side-effects can occur such as constipation. If a cough suppressant is unsuitable, for example in late pregnancy and children, then a demulcent can be offered.

The adult dose is 10–15   mg (10–15   mL) three or four times a day. For children aged 6 to 12 years the dose is 5–10   mg (5–10   mL) up to four times daily. Pholcodine dose for children aged 2 to 5 years is 2.5–5 mg up to four times daily. Sugar-free versions are available for patients with diabetes.

The adult dose is 30   mg. For children aged 6 to 12 years it is 15   mg, and for children aged 2 to 5 years it is 7.5   mg. Doses are taken three to four times a day with a maximum of four doses in 24 hours. The dose of the lozenges for adults is two lozenges every 3 hours; the dose for children 6 years to 12 years is one lozenge every 3 hours.

The adult dose is 5–10   mL every 4 to 6 hours. For children aged 6 to 12 years the dose is 2.5–5   mL up to six times a day. Abuse potential is high with dihydrocodeine and use should be closely monitored.

The adult dose is 15–30   mg three or four times a day. For children over 6 years the dose is 0.25–0.5   mg/kg/dose every 6 to 8 hours.

Routine use of antihistamines is unjustified in treating non-productive cough. However, the sedative side-effects from antihistamines can, on occasion, be useful to allow patients an uninterrupted night's sleep.
All antihistamines included in cough remedies are first-generation antihistamines and associated with sedation. They interact with other sedating medicine, resulting in potentiation of the sedative properties of the interacting medicines. They also possess antimuscarinic side-effects, which commonly result in dry mouth and possibly constipation. It is these antimuscarinic properties that mean that patients with closed-angle glaucoma and prostate enlargement should ideally avoid their use, because it could lead to increased intraocular pressure and precipitation of urinary retention. The vast majority of products that contain an antihistamine for coughs are combination products, usually with a cough suppressant and a sympathomimetic.

Demulcents are a safe alternative for at-risk patient groups such as the elderly, pregnant women, young children and those taking multiple medicines. If recommended they should be given three or four times a day, although theoretically they could be used as often as needed.


Anonymous, Cough medications in children , Drug and Therapeutics Bulletin 37 ( 1999 ) 19 – 21 .
Anonymous, About Asthma in New Zealand , Online. Available ( 2002 ) ; [1 January 2011] .
Anonymous, Drugs for Cough , In: (Editor: Rossi, S) Australian Medicines Handbook ( 2010 ) Australian Medicines Handbook Pty Ltd , Adelaide , pp. 791 – 794 .
Australian Centre for Asthma Monitoring, Asthma in Australia 2008. AIHW Asthma Series no. 3. Cat. no. ACM 14 . ( 2008 ) AIHW , Canberra .
Australian Lung Foundation, Statistics , [Online] Available at ( 2010 ) ; [17 January 2011] .
AIHW 2010 Australia's health 2010. AIHW cat. no. AUS 122
Barry, C; Konstantinos, A, Tuberculosis notifications in Australia, 2007 , Communicable Diseases Intelligence 33 ( 3 ) ( 2009 ) 304 – 315 .
Bjornsdottir, I; Einarson, TR; Guomundsson, LS, Efficacy of diphenhydramine against cough in humans: a review , Pharmacy World & Science 29 ( 6 ) ( 2007 ) 577 – 583 .
Britt, H; Miller, GC; Charles, J; et al. , General practice activity in Australia, 2008–09. General practice series no. 25. Cat. no. GEP 25 . ( 2009 ) AIHW , Canberra .
Dicpinigaitis, P; Colice, G; Goolsby, M; et al. , Acute cough: a diagnostic and therapeutic challenge , Cough 5 ( 1 ) ( 2009 ) 11 .
Findlay, J W A, Review articles: pholcodine , Journal of Clinical and Pharmacological Therapy 13 ( 1988 ) 5 – 17 .
Gibson, PG; Chang, AB; Glasgow, NJ; et al. , CICADA: Cough in Children and Adults: Diagnosis and Assessment. Australian Cough Guidelines summary statement , Medical Journal of Australia 192 ( 5 ) ( 2010 ) 265 – 271 .
Isbister, GK; Prior, F; Kilham, HA, Restricting cough and cold medicines in children , Journal of Paediatrics and Child Health ( 2010 ) .
Sahn, S; Heffner, J, Spontaneous Pneumothorax , New England Journal of Medicine 342 ( 2000 ) 868 – 874 .
Smith SM, Schroeder K, Fahey T 2008 Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub3
Vassilev, ZP; Kabadi, S; Villa, R, Safety and efficacy of over-the-counter cough and cold medicines for use in children , Expert Opinion on Drug Safety 9 ( 2 ) ( 2010 ) 233 – 242 .
World Health Organization, Table A-1 Estimated epidemiological burden of TB, all forms, 1990–2008: Western Pacific , Available ( 2009 ) ; [1 August 2010] .

Further reading

Eddy, NB; Friebel, H; Hahn, KJ; et al. , Codeine and its alternatives for pain and cough relief . ( 1970 ) World Health Organization , Geneva .

Web sites

National Tobacco Campaign, .
Action on Smoking and Health, .
The Australian Lung Foundation, .
Asthma and Respiratory Foundation of New Zealand, .
National Asthma Campaign, .

The common cold

Colds, along with coughs, represent the largest caseload for primary healthcare workers. Because the condition has no specific cure and is self-limiting in nature it would be easy to dismiss the differential diagnosis as unimportant. However, because of the very high number of cases seen it is essential that pharmacists have a thorough understanding of the condition so that severe symptoms or symptoms suggestive of influenza are identified.

Prevalence and epidemiology
The common cold is extremely prevalent. Upper respiratory tract infections are the most common affliction that affects the general population, with people on average suffering between 3 and 12 colds per year, depending on their age. Children aged between 4 and 8 years are most likely to contract a cold and it can appear to a child's parents that one cold follows another with no respite. By the age of 10 the number of colds contracted is half that observed in preschool children. In Australia, the peak times for the common cold are spring and winter.

More than 200 different virus types can produce symptoms of the common cold, including rhinoviruses, adenoviruses and the influenza virus – rhinoviruses accounting for almost half of all cases. Transmission is primarily by the virus coming in contact with the hands, which then touch the nose, mouth and eyes (direct contact transmission). Droplets shed from the nose of an infected person cover surfaces such as door handles and telephones. The cold viruses can remain viable on these surfaces for several hours, and when a non-infected person touches these surfaces, the transmission occurs. Direct spread by droplets from sneezing or coughing is only a secondary mechanism. This is why good hygiene (washing hands frequently and using disposable tissues) remains the cornerstone of reducing the spread of a cold.
Once the virus is exposed to the mucosa, it invades the nasal and bronchial epithelia, attaching to specific receptors and causing damage to the ciliated cells. This results in the release of inflammatory mediators, which in turn leads to inflammation of the tissues lining the nose. Permeability of capillary cell walls increases, resulting in oedema, which is experienced by the patient as nasal congestion and sneezing. Fluid might drip down the back of the throat, spreading the virus to the throat and upper chest and causing cough and sore throat.

Arriving at a differential diagnosis
It is extremely likely that someone presenting with cold symptoms will have a viral infection. Most people will accurately self-diagnose a common cold and it is the pharmacist's role to confirm this self-diagnosis and assess the severity of the symptoms as some patients, for example the elderly, infirm and those with existing medical conditions, might need greater support and care. In the first instance, the pharmacist should make an overall assessment of the person's general state of health. Anyone with debilitating symptoms that effectively prevent him or her from doing their normal day-to-day routine should be managed more carefully. While it is likely that a patient will have a common cold, severe colds can mimic the symptoms of flu, which is the main condition of any real significance that has to be eliminated before treatment can be given. Asking symptom-specific questions will help the pharmacist to determine if referral is needed ( Table 1.3 ) .
Table 1.3   Specific questions to ask the patient: Cold Question Relevance Onset of symptoms

• >Peak incidence of flu is in the winter months; the common cold occurs any time throughout the year

• >Flu symptoms tend to have a more abrupt onset than the common cold – a matter of hours rather than 1 or 2 days

• >'Summer colds’, which occur in warmer months, are common but they must be differentiated from seasonal allergic rhinitis (hayfever) Nature of symptoms •   Marked myalgia, chills and malaise are more prominent in flu than the common cold. Loss of appetite is also common with flu Aggravating factors •   Headache/pain that is worsened by sneezing, coughing and bending over suggests sinus complications. If ear pain is present, especially in children, middle ear involvement is likely

Clinical features of the common cold
The symptoms of the common cold are well known. However, the nature and severity of symptoms will be influenced by factors such as the causative agent and the patient's age and underlying medical condition. Following an incubation period of between 1 and 3 days the patient develops a sore throat and sneezing, followed by profuse nasal discharge and congestion. Cough and UACS commonly follow. In addition headache, mild to moderate fever (<38.5°C) and general malaise might be present. Most colds resolve in a week, but it is not unusual for a common cold to last for 14 days or more.

Conditions to eliminate

Patients often use the word ‘flu’ when describing a common cold. However, subtle differences in symptoms between the two conditions should allow differentiation. It is helpful to remember that the ‘flu’ season tends to be in winter, whereas the common cold, while more common in winter and spring, can strike at any time. The onset of influenza is sudden and the typical symptoms are shivering, chills, malaise, marked aching of the limbs, insomnia, a non-productive cough (cough in the common cold is usually productive) and loss of appetite. Influenza is therefore normally debilitating and a person with flu is much more likely to send a third party to the pharmacy for medicine than present in person.

A blocked or stuffy nose, whether acute or chronic in nature, is a common complaint. Rhinitis is covered in more detail on page 24 and the reader is referred to this section for differential diagnosis of rhinitis from the common cold.

Acute rhinosinusitis
Rhinosinusitis, previously called sinusitis, is inflammation of one or more of the paranasal sinuses. Between 0.5 and 2% of patients will develop acute sinusitis as a complication of the common cold ( Heikkinen & Jarvinen 2003 ). Anatomically the sinuses are described in four pairs: frontal, ethmoid, maxillary and sphenoid ( Figure 1.2 ). All are air-filled spaces that drain in to the nasal cavity. Following a cold, sinus air spaces can become filled with nasal secretions, which stagnate because of a reduction in ciliary function of the cells lining the sinuses. Bacteria – commonly Streptococcus and Haemophilus – can then secondarily infect these stagnant secretions. Acute rhinosinusitis is characterised by two or more symptoms, one of which should be either nasal blockage or nasal discharge, with or without facial pain and reduction or loss of smell lasting less than 3 months ( Anonymous 2010 ). The pain in the early stages tends to be relatively localised, usually unilateral and dull, but becomes bilateral and more severe the longer the condition persists. Bending down, moving the eyes from side to side, coughing or sneezing often exacerbates the pain. If the ethmoid sinuses are involved, retro-orbital pain (behind the eye) is often experienced. Analgesics can be used for pain relief, and oral or nasal sympathomimetics can be tried to remove the nasal secretions, but if this fails then referral is needed because appropriate antibiotic therapy will probably be needed.

Fig. 1.2
Location of the sinuses.

Otitis media
This is commonly seen in children following a common cold and results from the virus spreading to the middle ear via the Eustachian tube. The overriding symptom is pain due to an accumulation of pus within the middle ear or inflammation of the tympanic membrane (eardrum), but in young children this may manifest as the child rubbing or tugging at the ear. Rupture of the eardrum causes purulent discharge and relieves the pain. Referral to the GP would be appropriate for auroscopical examination . GPs may prescribe antibiotic treatment, although the importance of antibiotics in speeding the resolution of otitis media has not been definitively established, as 60% of placebo-treated patients are pain free in 24 hours. Because of this, ‘delayed prescribing’ has been trialled where the doctor either writes a prescription for an antibiotic and tells the patient to wait and see if the symptoms improve before filling the prescription or asks the patient to come back for a prescription if the symptoms do not improve. A systematic review found that not prescribing an antibiotic on the initial visit and asking the patient to return if symptoms persist leads to a reduction in antibiotic use and no difference in outcomes compared with prescribing antibiotics ( Spurling et al 2007 ). Therefore, pharmacists can play a role by educating patients about the benefits of avoiding antibiotics unless needed. However, irrespective of whether the doctor provides an antibiotic or not, the pharmacist should offer symptomatic relief of pain.
  Trigger Points indicative of referral: The common cold

• >Acute sinus involvement

• >Ear pain originating from the middle ear

• >Patients with symptoms indicative of flu

• Vulnerable patient groups, such as the very elderly

Evidence base for non-prescription medicines
Many of the active ingredients found in cold remedies are also constituents of cough products. In many cases they are combined and marketed as cough and cold or flu remedies. For information relating to cough ingredients the reader is referred to the sections on non-prescription medicine for coughs ( page 6 ).

Data from a Cochrane Review conducted by De Sutter et al (2003) showed that antihistamines when used as monotherapy did not have significant benefit clinically in nasal congestion, rhinorrhoea or sneezing in older children and adults. Additionally, they appeared not to influence subjective improvement. Only two trials were evaluated in young children, the results of which were conflicting. However, the larger study, which was more robustly conducted, showed no beneficial effect of antihistamines on the common cold.
Trials that used antihistamines in combination with other products such as decongestants and antitussives did show some beneficial global effects in adults and older children. Unfortunately, in most trials it was not possible to assess the clinical significance of these benefits because of insufficient data.

Systemic and topical sympathomimetics
Sympathomimetics help to clear nasal passages and are clinically effective. A Cochrane Review ( Taverner & Latte 2007 ) identified seven trials that met their inclusion criteria that involved topical oxymetazoline, oral pseudoephedrine and oral phenylpropanolamine (no longer used in Australia or New Zealand). The authors found a small (6%) but significant improvement in symptoms of nasal congestion in adults. However, data were lacking in children under 12 years. A systematic review of single-dose phenylephrine studies found a statistically significant improvement in nasal airway resistance at 60 minutes compared with placebo ( Kollar et al 2007 ). However, the studies did not measure clinical outcomes (e.g. subjective improvement in symptoms), the difference was small (16% at 60 minutes), and four of the eight studies showed no benefit for phenylephrine compared with placebo. Importantly, the manufacturers of phenylephrine conducted this review and the studies included were from an FDA submission and have not been subject to peer review. A review by Eccles, also published in 2007 , concluded that there was limited evidence for the efficacy of phenylephrine as a nasal decongestant ( Eccles 2007 ).

Multi-ingredient preparations
There is no shortage of cold and flu remedies marketed. Many combine three or more ingredients. In the majority of cases either the patient will not require all the active ingredients to treat symptoms or the ‘drug cocktail’ administered will not contain active ingredients that have proven efficacy. A more sensible approach to medicine management would be to match symptoms with active ingredients with known evidence of efficacy. In many cases this can be achieved by providing the patient with monotherapy or a product containing two active ingredients. Preparations with multiple ingredients therefore have a very limited role to play in the management of coughs and colds.

Alternative therapies
Many products are advocated to help treat cold symptoms. Three products in particular have received much attention and are widely used.

Zinc lozenges
The argument for zinc as a plausible treatment in ameliorating symptoms of the common cold can be traced back to 1984. A number of studies have investigated whether zinc lozenges can decrease the severity and duration of the common cold. A meta-analysis conducted in 2000 concluded that there was insufficient evidence to establish efficacy and that any benefit would probably be modest ( Marshall 2000 ). A further trial, which was published after the meta-analysis, did show zinc lozenges significantly decrease the duration and severity of the common cold, although numbers in the study were low ( Prasad et al 2000 ). This latter study provides important additional evidence that zinc lozenges might have a beneficial effect. However, a structured review in 2007 found there was a lack of evidence of efficacy for zinc when considering high-quality studies, with only one out of the four studies that met all the criteria for valid experimental design showing a positive effect ( Caruso et al 2007 ). Further, it has been proposed that it is ionic zinc, not bound zinc, that is the active moiety, and this is dependent on the form of zinc used ( Eby 2010 ). Therefore, larger studies examining the different salts are needed to establish the role of zinc in the common cold.

Vitamin C
Vitamin C has been widely recommended as a ‘cure’ for the common cold by many sources – both medical and non-medical. However, controversy still remains as to whether it is an effective weapon in combating the common cold. A large number of clinical trials have investigated the effect of vitamin C on the prevention and treatment of the common cold. A Cochrane Review examining the role of vitamin C at doses above 200   mg per day in preventing and treating the common cold identified 29 studies involving 11,306 subjects ( Hemilä et al 2010 ). The review found that vitamin C prophylaxis had no effect on the incidence of the common cold in the general community, and a small effect on the duration of a cold (equivalent to approximately one day less per year for adults and four days for children) in this population. However, they found a halving of the incidence of the common cold in people undergoing high physical stress (marathon runners, skiers and soldiers on subarctic exercises) with the prophylactic use of vitamin C. The review found the use of vitamin C once a cold had started had no consistent effect on the duration or the severity of the cold. The authors concluded that routine prophylaxis with vitamin C in the general community is unjustified, but could be beneficial to those exposed to brief periods of severe physical exercise.

The herbal remedy echinacea is marketed as a treatment for upper respiratory tract infections, including the common cold. Several reviews have reported echinacea's effect as inconsistent. This is in part due to the limited number of trials that are comparable, as different echinacea species are used as well as differing plant parts and extraction methods. A Cochrane Review ( Linde et al 2006 ) has attempted to take these factors into consideration and found some evidence that aerial parts of Echinacea purpurea (either alcoholic extract or pressed juice) might be effective in the early treatment of colds in adults. Following on from the Cochrane Review, Shah et al (2007) conducted a further review, which also included experimentally induced colds. From the 14 trials that met the inclusion criteria, results drawn showed that treatment with echinacea reduced the chance of developing a cold by about half and the duration of colds was reduced by 1.4 days. The authors did, however, acknowledge various limitations of the study, including variability in product composition and plant species used, possible bias and problems with heterogeneity.

Vapour inhalation
Steam inhalation has long been advocated to aid symptoms of the common cold, usually with the addition of menthol crystals. Current trial data has shown mixed results with vapour inhalation in relieving the symptoms of the common cold ( Singh 2006 ). However, it is cheap and does not carry any significant risks for adults apart from minor discomfort and irritation of the nose. Direct steam inhalation is not recommended for young children because of the risk of burns. However, vaporisers can be used to increase humidity in the air. Steam is the key to symptom resolution, and not any additional ingredient that is added to the water. Also, some additives used with vaporisers, such as eucalyptus oil and menthol, can be toxic if swallowed and care must be taken to keep them out of the reach of children.

Saline sprays
Saline sprays have been shown to work in observational studies. A Cochrane Review exploring the use of saline irrigation on acute upper respiratory tract infections, identified three randomised controlled trials involving 618 participants ( Kassel et al 2010 ). The studies generally found no difference between saline treatment and control. Although there was some limited evidence of benefit in adults in some studies, the review was constrained by the different interventions used (e.g. nasal irrigations, drops and sprays) and the variety of outcomes measured. The authors noted that there were no serious side-effects, but saline irrigation could cause minor irritation and discomfort, with up to 40% of babies not tolerating saline nasal drops. Some saline nasal sprays boast being preservative-free, which they claim gives advantages in terms of not affecting cilia in the nasal passages. However, head-to-head comparisons with standard saline sprays (containing benzalkonium chloride) are lacking.

General summary
Evidence of efficacy for Western and complementary medicines in preventing and treating the common cold are weak. Decongestants used on a when needed basis probably have the strongest evidence base in treating symptoms in adults, although recent studies suggests that echinacea might well have beneficial effects. There is limited evidence of efficacy for decongestants in children under 12 years, and simple options such as steam inhalation and saline nasal drops/sprays are probably the safest options.

Practical prescribing and product selection
Prescribing information relating to the cold medicines reviewed in the section ‘Evidence base for non-prescription medicines’ is discussed and summarised in Table 1.4 and useful tips relating to patients presenting with a cold are given in Hints and Tips Box 1.2 .
Table 1.4   Practical prescribing: Summary of cold medicines MAOI: monoamine oxidase inhibitor; TCA: trycyclic antidepressant. Medicine Use in children Likely side-effects Drug interactions of note Patients in whom care should be exercised Pregnancy Antihistamines Brompheniramine Chlorpheniramine Diphenhydramine Tripolidine >6 years; use should be discouraged Dry mouth, sedation and constipation anxyiolytics Increased sedation with alcohol, opioid analgesics, combination hypnotics and antidepressants Closed-angle Glaucoma, prostate enlargement > 12 years Single agents are category A; preparations with sympathomimetics are category B2 and should be avoided Promethazine Category C: avoid Systematic Sympathomimetics Phenylephrine Pseudoephedrine >6 years; use should be discouraged Insomnia is most likely. Possibly causes tachycardia Avoid concomitant use with MAOIs because of risk of hypertensive crisis. Avoid in patients taking beta blockers and TCAs Patients with high blood pressure, heart disease or hyperthyroidism should avoid. Control of hypertension and diabetes might be affected but a short treatment course is unlikely to be clinically important Category B2: avoid Topical Sympathomimetics Oxymetazoline >2 years Possible local irritation in ~5% of patients Avoid concomitant use with MAOIs because of risk of hypertensive crisis None Not investigated but probably OK Xylometazoline >2 years Tramazoline >6 years Phenylephrine >12 years
Hints and tips box 1.2 The common cold

Limiting viral spread

• >Use disposable tissues rather than handkerchiefs

• >Wash hands frequently; the NH&MRC recommends washing for 10 seconds, rinsing for 10 seconds, and then drying with a paper towel – antibacterial washes are not required

• >Do not share hand towels

• >Try and avoid touching your nose Stuffy noses in babies •   Saline nose drops can be used from birth to help with congestion. This would be a more suitable and safer alternative than a topical sympathomimetic Unscheduled cold remedies •   Products such as Lemsip contain paracetamol. It is important to ensure patients are not taking excessive doses of paracetamol unknowingly Administration of nasal drops •   The best way to administer nose drops is to have the head in the downwards position, facing the floor. Tilting the head backwards and towards the ceiling is incorrect because it facilitates swallowing the drops. However, most patients will find the latter way of putting drops into the nose much easier than the former

Antihistamines, especially first-generation antihistamines, are included in many cough and cold remedies and further information on antihistamines can be found on page 26 .

Sympathomimetics constrict dilated blood vessels and swollen nasal mucosa, easing congestion and helping breathing. However, they interact with MAOIs (e.g. phenelzine, tranylcypromine and moclobemide), which can result in a fatal hypertensive crisis. The danger of the interaction persists for up to 2 weeks after treatment with MAOIs is discontinued. In addition, systemic sympathomimetics can also increase blood pressure, which might, although unlikely with short courses of treatment, alter control of blood pressure in hypertensive patients and disturb blood glucose control in patients with diabetes. Care should be taken with patients who have cardiovascular or cerebrovascular histories (e.g. angina or stroke), and are best avoided. However, coadministration of medicines such as beta-blockers is probably clinically unimportant and does not preclude patients on beta-blockers taking a sympathomimetic. However, a topical sympathomimetic could be given to such patients to negate this potential interaction, and to patients with angina or stroke. The most likely side-effects of sympathomimetics are insomnia, restlessness and tachycardia. Patients should therefore be advised not to take a dose just before bedtime because their mild stimulant action can disturb sleep.
Owing to concerns over illicit manufacture of methyl amphetamine (crystal meth or ‘ice’) from non-prescription cold preparations, the sale of all products containing pseudoephedrine are now restricted. In Australia, since 2006, small quantities (packets with less than 720   mg of pseudoephedrine in total = 12 standard tablets) are pharmacist-only medicines, while larger quantities are prescription-only. In New Zealand in 2009 it was announced that all pseudoephedrine and ephedrine products are to be made prescription-only. In Australia, an on-line recording system for pseudoephedrine has been developed called Project STOP ( ). The web-based system provides real-time information to pharmacists and police on the sales of pseudoephedrine in pharmacies across the country. Although only compulsory in some States and Territories, all pharmacists are encouraged to participate.

Systemic sympathomimetics

Phenylephrine is available in a number of proprietary cold remedies, in doses ranging between 5 and 10   mg to be given three or four times a day. The dosage for children aged 6 to 12 years is 5   mg three or four times a day.

Pseudoephedrine is available as either a single ingredient or in multi-ingredient products in cold and cough remedies. The standard adult dose is 60   mg four times a day and half the adult dose is suitable for children between 6 and 12 years of age.

Topical sympathomimetics
Topical administration of sympathomimetics represents the safest route of administration. They can be given to most patient groups, including children, pregnant women after the first trimester and patients with pre-existing heart disease, diabetes, hypertension and hyperthyroidism. However, a degree of systemic absorption is possible, especially when using drops, as a small quantity might be swallowed, and they should therefore be avoided in patients taking MAOIs. No topical decongestant should be used for longer than 5 days because rhinitis medicamentosa (rebound congestion) can occur.

Ephedrine and phenylephrine
Both are short acting and need to be administered four times a day. Ephedrine can be given to babies from 6 months (0.25% nasal drops, one or two drops up to four times a day). Adults can use 0.5% or 1% ephedrine nasal drops. Ephedrine nasal drops are only available as extemporaneously prepared products. Phenylephrine nasal spray is only indicated for adults and children over 12 years of age. Both ephedrine and phenylephrine are less likely to cause rebound congestion than oxymetazoline/xylometazoline.

Oxymetazoline, xylometazoline and tramazoline
Oxymetazoline and xylometazoline are longer acting than ephedrine and phenylephrine and require only twice-daily dosing; tramazoline is used up to four times a day. Oxymetazoline and xylometazoline are made by a number of manufacturers. Paediatric drops can be given to children over 2 years of age. Tramazoline is only available as a metered dose spray. These agents must only be used for no more than three to five days at a time to prevent rebound congestion.


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Caruso, TJ; Prober, CG; Gwaltney, J J M, Treatment of Naturally Acquired Common Colds with Zinc: A Structured Review , Clinical Infectious Diseases 45 ( 5 ) ( 2007 ) 569 – 574 .
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Eccles, R, Substitution of phenylephrine for pseudoephedrine as a nasal decongeststant. An illogical way to control methamphetamine abuse , British Journal of Clinical Pharmacology 63 ( 1 ) ( 2007 ) 10 – 14 .
Heikkinen, T; Jarvinen, A, The common cold , The Lancet 361 ( 9351 ) ( 2003 ) 51 – 59 .
Hemilä H, Chalker E, Douglas B 2010 Vitamin C for preventing and treating the common cold. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD000980. DOI: 10.1002/14651858.CD000980.pub3
Kassel J C, King D, Spurling G K P 2010 Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD006821. DOI: 10.1002/14651858.CD006821.pub2
Kollar, C; Schneider, H; Waksman, J; et al. , Meta-analysis of the efficacy of a single dose of phenylephrine 10   mg compared with placebo in adults with acute nasal congestion due to the common cold , Clinical therapeutics 29 ( 6 ) ( 2007 ) 1057 – 1070 .
Linde K, Barrett B, Bauer R et al 2006 Echinacea for preventing and treating the common cold. Cochrane Database of Systematic Reviews Issue 1. Art. No.: CD000530. DOI: 10.1002/14651858.CD000530.pub2
Marshall I 2000 Zinc for the common cold. Cochrane Database of Systematic Reviews 2:CD001364
Prasad, AS; Fitzgerald, JT; Bao, B; et al. , Duration of symptoms and plasma cytokine levels in patients with the common cold treated with zinc acetate. A randomized, double-blind, placebo-controlled trial , Annals of Internal Medicine 133 ( 2000 ) 245 – 252 .
Shah, S; Sander, S; White, CM; et al. , Evaluation of echinacea for the prevention and treatment of the common cold: a meta-analysis. Lancet , Infectious Diseases 7 ( 7 ) ( 2007 ) 473 – 480 .
Singh M 2006 Heated, humidified air for the common cold. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD001728. DOI: 10.1002/14651858.CD001728.pub3
Smith, MB; Feldman, W, Over-the-counter cold medications. A critical review of clinical trials between 1950 and 1991 , Journal of the American Medical Association 269 ( 1993 ) 2258 – 2263 .
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Taverner D, Latte J 2007 Nasal decongestants for the common cold. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD001953. DOI: 10.1002/14651858.CD001953.pub3

Further reading

Damoiseaux, RA; van Balen, FA; Hoes, AW; et al. , Antibiotic treatment of acute otitis media in children under two years of age: evidence based? British Journal of , General Practice 48 ( 1998 ) 1861 – 1864 .
Mossad, SB, Treatment of the common cold , British Medical Journal 317 ( 1998 ) 33 – 36 .
Thibodeau, GA; Patton, KT, Anatomy and physiology . ( 2003 ) Mosby , St Louis .

Web sites

Healthinsite Healthinsite, .
The National Institute for Health, .

Sore throat

Any part of the respiratory mucosa of the throat can give rise to symptoms of throat pain. This includes the pharynx (pharyngitis) and tonsils (tonsillitis) yet clinical distinction between pharyngitis and tonsillitis is unclear and the term sore throat is commonly used. Pain can range from scratchiness to severe pain. Sore throats are often associated with the common cold. However, in this section, people who present with sore throat as the principal symptom are considered.

Prevalence and epidemiology
Sore throats are often associated with the common cold and therefore the prevalence of sore throat is extremely common. Throat complaints are the second most common reason people presented to GPs after cough and represent 3 in every 100 encounters ( Britt et al 2009 ). The average adult experiences two or three sore throats each year. Streptococcal sore throat is more commonly associated with people under the age of 30, particularly those of school age (5 to 15). Other causes of sore throat such as candidiasis (oral thrush) and herpes simplex are more common in children, and glandular fever is most prevalent in adolescents and young adults.

Viral infection accounts for between 70 and 90% of all sore throat cases. Remaining cases are nearly all bacterial; the most common cause being group A beta-haemolytic Streptococcus (also known as Streptococcus pyogenes ). A fuller account of the aetiology of viral and bacterial pathogens that affect the upper respiratory tract appears on page 11 .

Arriving at a differential diagnosis
Pharmacists must try to differentiate between viral infection and other causes of sore throat. Unfortunately, differentiation between viral and bacterial causes of sore throat is extremely difficult. A number of marker symptoms that might point to sore throat of bacterial origin can be identified, but these are by no means fool-proof. Asking symptom-specific questions will help the pharmacist to determine the cause and whether referral is needed ( Table 1.5 ). After questioning, the pharmacist should inspect the mouth and cervical glands (located just below the angle of the jaw) to substantiate the differential diagnosis ( Figure 1.3 ). Using a good light source (e.g. pen torch) ask the patient to say ‘ah’; this should allow you to see the pharynx well. When examining the mouth, pay particular attention to the fauces and tonsils – are they red and swollen? Is any exudate present? Is there any sign of ulceration?
Table 1.5   Specific questions to ask the patient: Sore throat Question Relevance Age

• >The likely cause of sore throat is influenced by the age of the patient:

• >Streptococcal infections are rare in children under 3 years, and more prevalent in school-aged children (5–15 years of age)

• >Viral causes are the most common cause of sore throat in adults

• >Glandular fever is most prevalent in adolescents

• >Oral thrush affects the very young and very old Tender cervical •   On examination, patients suffering from glandular fever and streptococcal sore throat often have markedly swollen glands. This is less so in viral sore throat Presence of tonsillar exudate •   Marked tonsillar exudate is more suggestive of a bacterial cause than a viral cause Ulceration •   Herpetiform and herpes simplex ulcers can also cause soreness in the mouth, especially in the posterior part of the mouth. For further information see Chapter 6 , page 124

Fig. 1.3
Major structures of the mouth.

Clinical features of sore throat
Patients can present with a sore throat as an isolated symptom or as part of a cluster of symptoms that include rhinorrhoea, cough, malaise, fever, headache and hoarseness (laryngitis). Symptoms are relatively short-lived with 40% of people being symptom-free after 3 days and 85% of people symptom-free after 1 week.

Conditions to eliminate

Streptococcal sore throat
Differentiating between bacterial and viral sore throat is plagued with difficulty. However, the probability that the sore throat is bacterial in origin rises if the patient is aged 5 to 15 years of age, has marked tonsillar exudate, tender cervical glands, a fever over 38°C, and no cough. However, even in patients with all five of these features, 40% or more will not have a Streptococcal infection. Some indigenous populations living in lower socio-economic areas (Aboriginal from central and northern Australia, some Mãori and Pacific Islander groups) are at greater risk of developing complications of streptococcal sore throat such as rheumatic fever and should be referred for further investigation even if only a few of these signs and symptoms are present. Table 1.6 summarises the potential distinguishing features of viral and bacterial infection. If bacterial infection is suspected then referral to the GP is appropriate. The use of antibiotics in such situations is debatable as a Cochrane Review ( Del Mar et al 2004 ) found that the absolute benefit of antibiotics was modest. The maximum benefit was seen by day 3 of treatment, with an average reduction in illness time of 1 day.
Table 1.6 Features of viral and bacterial sore throat Age Tonsillar/pharangyl exudates Duration Cervical glands Cough present Other symptoms Viral infection Any age Possible but generally limited 3–7 days Normal Common Low grade fever, headache Bacterial infections School children Often present and can be substantial 3–7 days Swollen Rare Highgrade fever possible

Glandular fever (infectious mononucleosis)
Glandular fever is caused by the Epstein–Barr virus and is often called the ‘kissing disease’ because transmission occurs primarily via saliva. It has a peak incidence in adolescents and young adults. The signs and symptoms of glandular fever often mimic those of streptococcal sore throat. It is characterised by pharyngitis (occasionally with exudate), fever, cervical lymphadenopathy and fatigue. The person can also suffer from general malaise prior to the start of the other symptoms, and a macular rash can also occur in a small number of patients. A correct diagnosis is important as the use of penicillins, in particular amoxycillin, can result in a non-allergic rash in most patients with glandular fever, and this can result in patients erroneously being labelled as ‘penicillin allergic’.

Trauma-related sore throat
Occasionally patients develop a sore throat from direct irritation of the pharynx. This can be due to substances such as cigarette smoke, a lodged foreign body or from acid reflux.

Medicine-induced sore throat
A rare complication associated with certain medicines is agranulocytosis , which can manifest as a sore throat. The patient will also probably present with signs of infection, including fever and chills. Medicines known to cause this adverse event are listed in Table 1.7 .
  Trigger Points indicative of referral: Sore throat

• >Adverse drug reaction

• >Associated skin rash

• >Duration of more than 2 weeks

• >Dysphagia and/or dysphonia

• >Indigenous patients aged 2 to 25 from remote or rural settings

• >Marked tonsillar exudate accompanied by a high temperature and swollen glands
Table 1.7 Examples of medicines known to cause agranulocytosis




Neuroleptics, e.g. clozapine



Sulfur-containing antibiotics

Laryngeal and tonsillar carcinoma
Both these cancers have a strong link with smoking and excessive alcohol intake, and are more common in men than women. Sore throat and dysphagia are the common presenting symptoms. In addition, patients with tonsillar cancer often develop referred ear pain. Any person, regardless of age, who presents with dysphagia should be referred.
Figure 1.4 will help in the differentiation of serious and non-serious conditions in which sore throat is a major presenting complaint.

Primer for differential diagnosis of sore throat. Duration longer than 2 weeks The overwhelming majority of cases resolve spontaneously in this time; it is therefore prudent to refer these cases for further investigation. Dysphagia True difficulty in swallowing (i.e. not just caused by pain but by a mechanical blockage) should be referred. Most patients with sore throat will find it less easy to swallow but this has to be differentiated from actual difficulty in swallowing. Severe inflammation of the throat can cause restriction of the airways and thus hinder breathing. Additionally, rare causes of sore throat also have associated dysphagia symptoms, such as peritonsillar abscess, thyroiditis, acute epiglottitis, and oesophageal carcinoma. Signs of agranulocytosis A severe reduction in the number of white blood cells can result in neutropenia, which is manifested as fever, sore throat, ulceration and small haemorrhages under the skin. Mouth ulceration and Candida (oral thrush) primers See Chapter 6 and Figs 6.6 & 6.7 for further differentiation of these conditions. Trauma related Simple acts of drinking fluids that are too hot can give rise to ulceration of the pharynx. It is worth asking whether any such factors could have triggered the sore throat.

Evidence base for non-prescription medicines
The majority of sore throats are viral in origin and self-limiting. Medicine therefore aims to relieve symptoms and discomfort while the infection runs its course. Lozenge and spray formulations incorporating anti-bacterials and anaesthetics provide the mainstay of treatment, and there is no shortage of these on the market. In addition, systemic analgesics will help reduce the pain associated with sore throat.

Local anaesthetics
Lignocaine and benzocaine are the two local anaesthetics included in a number of marketed products. Very few published clinical trials involving products marketed for sore throat have been conducted yet local anaesthetics have proven efficacy. It therefore appears that manufacturers are using trial data on local anaesthetic efficacy for conditions other than sore throats to substantiate their effect.

Antibacterial, antifungal, and antiviral agents
Antibacterial agents include chlorhexidine and benzalkonium chloride. In vitro testing has shown that many of the proprietary products do have antibacterial activity, and some inhibit the growth of Candida albicans . In vivo tests have also shown antibacterial effects. The use of antibacterial and antifungal agents should not be routinely recommended because the vast majority of sore throats are caused by viral infections, against which these agents have no action. As adverse effects are rare and stimulation of saliva from sucking the lozenge can confer symptomatic relief, the use of such products may be justified.
Povidone iodine is available as a throat gargle. Although reported to have activity against bacteria, viruses, fungi, protozoa, and spores, there is no published evidence of its clinical efficacy in sore throat.

Benzydamine is available as a lozenge, spray or mouthwash and has proven efficacy in relieving pain associated with sore throat ( Thomas et al 2000 ). Flurbiprofen lozenges have also been shown to be more effective than placebo in reducing pain associated with sore throat. However, the clinical significance of the benefit is uncertain, and comparisons with active treatments are lacking. In a review in Prescrire in 2007 the conclusion was that ‘flurbiprofen lozenges have a negative risk-benefit balance…it is better to suck real sweets and, if necessary, take paracetamol’ ( Anonymous 2007 ).

There is good evidence to show that simple systemic analgesia, for example paracetamol, aspirin and ibuprofen, is effective in reducing the pain associated with sore throat. Thomas et al (2000) undertook a review of treatments other than antibiotics for sore throats. They identified 22 trials, 13 of which involved NSAIDs (primarily ibuprofen) or paracetamol, and found both NSAIDs and paracetamol were effective. However, the authors noted that patients took the medicines regularly in the studies, not on an ‘as needed’ basis, and this should be stressed to patients presenting with sore throats.

Aspirin and salt water gargles
Gargling with aspirin or salt water is a common lay remedy for sore throat. No trials appear to have been conducted on their effectiveness. While there is likely to be little harm, there are other options with proven benefit and minimal side-effects that could be recommend.

Practical prescribing and product selection
Prescribing information relating to the sore throat medicines reviewed in the section ‘Evidence base for non-prescription medicines’ is discussed and summarised in Table 1.8 and useful tips relating to patients presenting with a sore throat are given in Hints and Tips Box 1.3 .
Table 1.8   Practical prescribing: Summary of sore throat medicines Medicine Use in children Likely side-effects Drug interactions of note Patients in whom care should be exercised Pregnancy Local anaesthetics Lignocaine >6 years Can cause sensitisation reactions None Caution with hot foods and drinks because of altered perception of heat OK Benzocaine Antiinflammatories Benzydamine >6 years Oral rinse may cause stinging None None Category B2: avoid Flurbiprofen >12 years Mild abdominal symptoms None Pregnancy and breast feeding Category C: avoid
Hints and tips box 1.3 Sore throat

Stimulation of saliva production Sucking a lozenge or pastille promotes saliva production, which will lubricate the throat and thus exert a soothing action Gargles or lozenges? Gargles have very short contact time with inflamed mucosa and therefore any effect will be short-lived. A lozenge or a pastille is preferable, as contact time will be longer

Local anaesthetics (lignocaine, benzocaine)
All local anaesthetics have a short duration of action and frequent dosing is required to maintain the anaesthetic effect, whether formulated as a lozenge or spray. They appear to be free from any drug interactions, have minimal side-effects and can be given to most patients, including pregnant women, and women who are breast feeding. A small number of patients might experience a hypersensitivity reaction with either ingredient; this appears to be more common with benzocaine. Because of differences in their chemical structure, cross-sensitivity is unusual and therefore if a patient experiences side-effects with one, then the other can be tried. Most products contain a sugar base but the amount of sugar is too small to affect blood glucose control and the products can therefore be recommended to patients with diabetes. Because they cause anaesthesia of the mouth including the tongue, patients need to be warned to take care with hot drinks and food.

Lignocaine is available as lozenges in combination with antibacterials and antiinflammatory agents such as benzydamine. Lignocaine products are licensed for adults and children over 6 years and are best taken on a when-needed basis (every 2 hours). Patients should be told that a maximum of eight lozenges are allowed in any 24 hours.

Benzocaine can also be given to adults, and children from 6 years of age. Lozenges and gargle/solution are available. The recommended dose is 1 lozenge every 2 hours (maximum of eight lozenges per day), or 40–60   mg (10 to 15   mL) of the solution, gargled and expelled, every 2 hours.

Antiinflammatories (benzydamine and flurbiprofen)
Antiinflammatories have the advantage over local anaesthetics in that they do not generally anaesthetise the entire mouth. This reduces the risks with hot foods and liquids. However, some preparations also contain a local anaesthetic.

Benzydamine is available as a lozenge, solution and throat spray, and should be used every 1 to 2 hours for maximum benefit. It has no drug interactions of note, can be used by all patient groups and only occasionally does the solution cause stinging, in which case it can be diluted with water. The manufacturers advise that the product should be stored in the box away from direct sunlight; however, the stability of the product is not known to be affected by sunlight. Benzydamine is probably the treatment of choice for adults and children over the age of 6 years who wish to use a non-systemic treatment. The dose of the spray is four to eight sprays for adults, and four sprays for children over 6 years of age. The dose of the rinse is 22.5   mg (15   mL) for adults, and 7.5–22.5   mg (5–15   mL) for children over 6 years of age. Benzydamine preparations are all sugar-free.

Flurbiprofen lozenges can only be given to adults and children over the age of 12. The dose is one lozenge to be sucked every 3 to 6 hours with a maximum of eight lozenges in 24 hours. They are contraindicated in patients with peptic ulceration, asthma patients sensitive to NSAIDs, and those patients allergic to flurbiprofen, and must be used with caution in pregnant and breastfeeding women. Flurbiprofen has the same interactions as other NSAIDs (see Chapter 8 , page 254) Some lozenges are available as sugar-free lozenges.


Anonymous, Flurbiprofen: new indication. Lozenges: NSAIDs are not to be taken like sweets! , Prescrire International 16 ( 87 ) ( 2007 ) 13 .
Britt, H; Miller, GC; Charles, J; et al. , General practice activity in Australia, 2008–09. General practice series no. 25. Cat. no. GEP 25 . ( 2009 ) AIHW , Canberra .
Del Mar CB, Glasziou PP, Spinks AB 2004 Antibiotics for sore throat. Cochrane Database of Systematic Reviews, issue 2
Thomas, M; Del Mar, C; Glasziou, P, How effective are treatments other than antibiotics for acute sore throat? British Journal of General Practice 50 ( 2000 ) 817 – 820 .

Further reading

Turnidge, J, Responsible prescribing for URTIs , Current therapeutics 43 ( 7 ) ( 2002 ) 50 – 59 .
Middleton, DB, Pharyngitis , Primary Care 23 ( 1996 ) 719 – 739 .
Watson, N; Nimmo, WS; Christian, J; et al. , Relief of sore throat with the antiinflammatory throat lozenge flurbiprofen 8.75   mg: a randomised, double-blind, placebo-controlled study of efficacy and safety , International Journal of Clinical Practice 54 ( 2000 ) 490 – 496 .

Web sites

Sinus Care Center, .


Rhinitis is simply inflammation of the nasal lining. It is characterised by rhinorrhoea , nasal congestion, sneezing and itching. The majority of cases that present in a community pharmacy will be either viral infection (see page 12 ), colds or allergic rhinitis, which can either be intermittent (sometimes called hay fever) or year-round (persistent rhinitis). Previously allergic rhinitis was defined as either seasonal or perennial. The current classification is now based on the timing of the symptoms and is divided into intermittent (occurring on less than four days per week and less than four weeks at a time) or persistent (occurring on more than four days per week and more than four weeks at a time). Rhinitis has a significant impact on quality of life, impairing performance at work and school, and disrupting sleep.

Prevalence and epidemiology
The prevalence of allergic rhinitis has dramatically increased since the 1970s, with studies confirming a doubling of prevalence over this time. Allergic rhinitis affect roughly 25% of working-age adults in Australia, with the life time prevalence as high as 41% ( Walls et al 2005 ). However, this might be an underestimate because many people do not consult their doctor and choose to self medicate. Allergic rhinitis also affects young people, with 10 to 20% of the adolescent population suffering from the condition. In addition, a person is more likely to suffer from allergic rhinitis if there is a family history of asthma and eczema. It has also been reported that patients with asthma have up to an 80% chance of developing allergic rhinitis.

Allergic rhinitis is a mucosal reaction in response to an allergen. Initially, the patient must be exposed to an allergen; for intermittent allergic rhinitis this is usually pollen or fungal spores. The pollen season can last from early spring (tree pollen) through to the end of the summer months (grass pollen); fungal spores are prominent in the autumn. However, in some areas of Australia, particularly Queensland, it may be difficult to identify the pollen season, and therefore the symptoms may be persistent not intermittent. The house dust mite is the allergen most responsible for persistent allergic rhinitis, although animal dander, particularly from cats, can also give rise to symptoms. The allergen lodges within the mucous blanket lining the nasal membranes and activates immunoglobulin E (IgE) antibodies (formed from previous allergen exposure) on the surface of the mast cells. Potent chemical mediators – primarily histamine, but also leukotrienes, kinins and prostaglandins – are released, which exert their action via neural and vascular mechanisms. This immediate response to an allergen is known as the early-phase allergic reaction and gives rise to nasal itch, rhinorrhoea, sneezing and nasal congestion. A late-phase reaction then occurs 4 to 12 hours after allergen exposure with nasal congestion being the main symptom.
Also of importance is the phenomenon of nasal priming. After a period of continuous allergen exposure, patients can find that they experience the same level of severity in symptoms with lower levels of allergen exposure. Similarly, symptoms will be worse than previously experienced when levels of the allergen are the same. This explains why patients complain of worsening symptoms the longer the season goes on. Table 1.9 highlights the main allergens responsible for allergic rhinitis.
Table 1.9 Allergens responsible for rhinitis * timing of symptoms in northern areas of Australia (e.g. Queensland, Northern Territory, northern Western Australia) may not follow these dates due to their climate and may occur any time in the year When Causative allergen Intermittent * allergic rhinitis September to December Tree pollen December to March Grass pollen March to June Fungal spores Persistent allergic rhinitis Year round House dust mite, animal dander (especially cats)

Arriving at a differential diagnosis
Rhinitis is not difficult to diagnose. Within the community pharmacy setting the majority of patients who present with rhinitis will be suffering from a cold or intermittent allergic rhinitis. Diagnosis is largely dependent upon the patient having a family history of atopy , clinical symptoms and worsening symptoms at a particular time of year. Asking symptom-specific questions will help the pharmacist to determine the cause and whether referral is needed ( Table 1.10 ).
Table 1.10   Specific questions to ask the patient: Rhinitis Question Relevance Seasonal variation •   Symptoms in the summer months suggest intermittent rhinitis; year-round symptoms suggest persistent rhinitis History of asthma, eczema or hayfever in the family •   If a first-degree relative suffers from atopy then hayfever is much more likely Triggers

• >Pollen is the main allergen in intermittent rhinitis, therefore symptoms are worse when pollen counts are high

• >Infective and vasomotor rhinitis will be unaffected by pollen count

• >Patients with persistent rhinitis might suffer from worsening symptoms when pollen counts are high, but symptoms should persist when indoors, unlike intermittent rhinitis sufferers who usually see improvement of symptoms when away from pollen

Clinical features of intermittent allergic rhinitis
The patient will experience a combination or all four of the classical rhinitis symptoms of nasal itch, sneeze, rhinorrhoea and nasal congestion. However, in addition the patient might also suffer from ocular irritation, giving rise to allergic conjunctivitis. The symptoms should occur intermittently (i.e. times of pollen exposure) and tend to be worse in the morning and evening as pollen levels peak at this time, as they do when the weather is hot and humid.

Conditions to eliminate

Persistent allergic rhinitis
Persistent allergic rhinitis is much less common than intermittent allergic rhinitis. As its name suggests, the problem tends to be continual and does not exhibit seasonality. However, it must be remembered that patients suffering from persistent allergic rhinitis might also be allergic to pollen and experience worsening symptoms in the summer months. Besides not having a seasonal cause, there are a number of other clues to look out for that aid differentiation. Nasal congestion is much more common, which often leads to hyposmia (poor sense of smell) and ocular symptoms are uncommon. Additionally, persistent allergic rhinitis sufferers also tend to sneeze less frequently and experience more episodes of chronic sinusitis. The house dust mite, moulds and animal dander (particularly from cats and dogs) are the main allergens. It is therefore prudent to ask about pets in the home when trying to establish the cause.

Infective rhinitis
This is normally viral in origin and associated with the common cold. Nasal discharge tends to be more mucopurulent than in allergic rhinitis and nasal itching is uncommon. Sneezing tends not to occur in paroxysms and the condition resolves more quickly, whereas allergic rhinitis lasts for as long as the person is exposed to the allergen. Other symptoms, such as cough and sore throat, are much more prominent in infective rhinitis than allergic rhinitis.

Vasomotor rhinitis (intrinsic rhinitis)
Vasomotor rhinitis is thought to be due to either an overactive parasympathetic nervous system response, or hypoacitve sympathetic nervous system response to irritants such as dry air, pollutants, or strong odours. The symptoms can be similar to allergic rhinitis yet an allergy test will be negative. Itching and sneezing are less common and patients might experience worsening nasal symptoms in response to climatic factors, such as a sudden change in temperature. Patients appear to fall into to two groups: those with ‘wet’ rhinorrhoea as the dominant symptom; and, those with ‘dry’ symptoms where nasal congestion dominates.

Non allergic rhinitis with eosinophillia syndrome (NARES)
This accounts for up to 20% of cases of rhinitis ( Ramakrishnan and Meyers 2010 ). The symptoms are very similar to persistent allergic rhinitis and include nasal congestion, rhinorrhoea, sneezing and hyposmia. The distinguishing feature is the presence of a large number (up to 20% or more) of eosinophils on a nasal smear. The cause of NARES is unknown and it is thought to be a precursor in patients who develop the triad of asthma, nasal polyps and aspirin sensitivity.

Rhinitis of pregnancy
It is thought that this occurs because of hormonal changes, however evidence is lacking ( Wallace et al 2008 ). It usually starts after the second month of the pregnancy, and resolves spontaneously after childbirth. Nasal congestion is the prominent feature.

Rhinitis medicamentosa and drug-induced rhinitis
Rhinitis medicamentosa is due to prolonged use of topical decongestants (more than 5 to 7 days), which causes rebound vasodilatation of the nasal arterioles leading to further nasal congestion. Although the exact mechanism is still uncertain, it is thought to be due to de-sensitisation of the alpha adrenoceptors as a result of constant stimulation. Therefore, patients should always be questioned about the use of topical nasal decongestants. A number of oral medicines are implicated in causing rhinitis through other mechanisms, including angiotensin-converting enzyme inhibitors, alpha adrenoceptor antagonists (e.g. prazosin), phosphodiesterase-5 inhibitors (e.g. sildenafil), aspirin, montelukast, and other non-steroidal antiinflammatory drugs.

Nasal blockage
In the absence of rhinorrhoea, nasal itch and sneezing it is possible that the problem is mechanical or anatomical. A continuous and unilateral blockage might relate to a deviated nasal septum in adults. This might develop or be a result of trauma. Referral is needed and surgery is recommended. If the obstruction is bilateral this could relate to nasal polyps in adults. Nasal obstruction is progressive and is often accompanied by hyposmia. Referral is needed for corticosteroids or surgery.

Nasal foreign body
A trapped foreign body in a nostril commonly occurs in young children, often without the parents’ knowledge. Within a matter of days of the foreign body being lodged, the patient experiences an offensive nasal discharge. Any unilateral discharge, particularly in a child, should be referred for nasal examination because it is highly likely that a foreign body is responsible.
Figure 1.5 will aid in differentiating the different types of rhinitis.
  Trigger Points indicative of referral: Rhinitis

• >Failed treatment with medicines

• >Medicine-induced rhinitis

• >Nasal obstruction that fails to clear

• >Unilateral discharge, especially in children

Fig. 1.5
Primer differential diagnosis of rhinitis Nasal obstruction Nasal obstruction differs from nasal congestion in that obstruction refers to a physical blockage of the nasal passage and is normally due to an anatomical fault, whereas congestion refers to the nasal passages being temporarily blocked by nasal secretions that can easily be cleared by nose blowing. Obstruction therefore warrants referral. Unilateral discharge Any one-sided nasal discharge must be viewed with suspicion. Accidental lodging of a foreign body by young children is the usual cause. Nasal itch and sneeze prominent Nasal itching and sneezing are classically associated with intermittent allergic rhinitis, although these symptoms are also associated with persistent rhinitis, but to a lesser extent. Sneezing is often said to occur in multiple bouts, which is unlike infective rhinitis. Coughing can occur but is infrequent. Treatment of vasomotor rhinitis As the causes are usually environmental, not allergens, then avoidance is the best treatment. Nasal decongestants, nasal corticosteroids, and ipratropium nasal spray can be tried.

Evidence base for non-prescription medicines
Before treatment is started it is important to try and identify the causative allergen. If this can be achieved then measures to limit the exposure to the allergen will help to reduce the symptoms experienced by the patient. This is more easily accomplished in persistent allergic rhinitis than in intermittent allergic rhinitis.

Allergen avoidance
Avoiding pollen is almost impossible but if the patient obeys a few simple rules then exposure to pollen can be diminished. Patients can choose to stay indoors when pollen counts are high. Windows should be closed (both when in the house and when travelling in cars) and ‘wrap around’ sunglasses worn. Patients should avoid walking in areas with the potential for high pollen exposure (grassy fields, parks and gardens), as well as areas such as city centres, because many intermittent allergy sufferers will have increased sensitivity to other irritants such as car exhaust fumes and cigarette smoke. However, these measures are often impractical for many patients.
The two main causative agents of persistent allergic rhinitis – house dust mite and animal dander – can be avoided more easily. The offending pet can be banished from certain parts of the house, such as living areas and bedrooms. Using allergen-impermeable bed linen and acaricidal sprays can reduce house dust mite. Replacing carpeted rooms with wooden flooring will also help reduce both animal dander and house dust mite. Acaricidal sprays and strict bedroom cleaning regimes have shown to be of some benefit in reducing rhinitis symptoms ( Sheikh et al 2010 ).

Pharmacists now possess a wide range of therapeutic options to treat both intermittent and persistent allergic rhinitis. A number of down-scheduled prescription-only products enable the vast majority of sufferers to be managed appropriately without the need for referral to the GP. Management of allergic rhinitis falls broadly into two categories: systemic and topical.

Systemic therapy: antihistamines
Both sedating and less-sedating antihistamines are clinically effective in reducing the symptoms associated with allergic rhinitis ( Sheikh et al 2006 ). However, sedating antihistamines should not be recommended routinely because of their sedative effects when compared with second- and third-generation, less-sedating antihistamines.
Of the second- and third-generation antihistamines, the community pharmacist has a choice between cetirizine, levocetirizine (the more active enantiomer of cetirizine), loratadine, desloratadine (the active metabolite of loratadine) and fexofenadine (the active metabolite of terfenadine, a second-generation antihistamine now withdrawn from the market due to adverse events). All are equally effective and are considered to be less-sedating than first-generation antihistamines. Loratadine has been shown to have the lowest affinity for histamine receptors in the brain, and a review investigating sedation with second-generation antihistamines, showed loratadine and fexofenadine to be least sedating of the less-sedating antihistamines ( Mann et al 2000 ). In comparison cetirizine was 3.5 times more likely to cause sedation than loratadine. On this basis, loratadine, desloratadine and fexofenadine would be the antihistamines of choice for many patients.

Topical therapy
A range of topically administered medicine is available to combat nasal congestion and ocular symptoms, including antihistamines, corticosteroids, mast cell stabilisers, anticholinergics and decongestants. All can be administered intranasally but corticosteroids and anticholinergics cannot be administered ocularly.

Intranasal medicine

Intranasal corticosteroids (budesonide, beclomethasone, triamcinolone and fluticasone) are the medicines of choice for nasal congestion and have been recommended by the World Health Organization (WHO) as first-line therapy for allergic rhinitis because a number of clinical trials have confirmed their efficacy. Additionally, they have demonstrated superiority to antihistamines in the treatment of allergic rhinitis for all nasal symptoms, and equivalence for ocular symptoms ( Wallace et al 2008 ). There is no difference in efficacy between the different intranasal corticosteroids. Although the maximum clinical efficacy may take several days of regular use, they can be used on an ‘as needed’ basis in some patients. Patients who regularly suffer intermittent allergic rhinitis should be encouraged to commence therapy before exposure to the allergen to maximise symptom control.

Two nasally administered antihistamines are currently available without a prescription: azelastine and levocabastine. Clinical trials have proved their efficacy and a meta analysis concluded that azelastine was more effective than placebo and equivalent to oral antihistamines ( Lee & Pickard 2007 ). This finding seems to be equally applicable to levocabastine.

Mast cell stabilisers
Sodium cromoglycate is a prophylactic agent. However, the effect of sodium cromoglycate is only partial – it is less effective than corticosteroids, although it is not clear why. A further drawback with nasal cromoglycate is the frequency of administration; between four and six times a day. Although no data are available for compliance with such a regimen it is likely to be poor and result in inadequate symptom control. The place of mast cell stabilisers in nasal symptoms of allergic rhinitis is therefore limited.

Ipratropium is an anticholinergic agent that is structurally similar to atropine. When applied topically ipratropium acts on the serous and seromucous glands lining the nasal mucosa to reduce secretions, with few systemic effects. Ipratropium has no effect on the underlying allergic response. However, ipratropium may be useful if rhinorrhoea is the predominant symptom.

Topical decongestants are clinically effective in the treatment of nasal congestion. However, they are of limited value in allergic rhinitis as prolonged use is associated with rebound congestion (see rhinitis medicamentosa). Their place in therapy is probably best reserved for when nasal congestion needs to be treated quickly to provide symptom relief while corticosteroid therapy is initiated and has time to begin to exert its action.

Ocular medicine

Mast cell stabilisers (sodium cromoglycate, lodoxamide)
Mast cell stabilisers have proven efficacy and are significantly better than placebo ( Lindsay-Miller 1979 ; Richard et al 1998 ). However, cromoglycate requires four- to six-times-a-day dosing, and lodoxamide four-times-a-day dosing, and compliance might be a problem. Further, cromoglycate takes 4 to 6 weeks to reach maximal response; lodoxamide may act faster, but still requires 2 or more weeks to reach peak effectiveness. Thus, mast cell stabilisers alone only have a role when patients can predict well in advance the onset of the symptoms.

Antihistamines (levocabastine, antazoline, pheniramine, azelastine, ketotifen)
Trial data have shown levocabastine to be an effective and well-tolerated treatment in controlling ocular symptoms. Comparative trials have shown it to be significantly better than placebo and at least as effective as sodium cromoglycate ( Azevado et al 1991 ).
Antazoline and pheniramine are available in combination with naphazoline. There appears to be little trial data in the public domain regarding decongestant/antihistamine combinations, although one trial found the combination of antazoline and naphazoline significantly reduced itching, redness and chemosis following an allergen challenge ( Abelson et al 1990 ). At best it should be used short term to avoid possible rebound conjunctivitis caused by naphazoline.
Azelastine and ketotifen have both been shown in clinical trials to be superior to placebo, and as effective as levocabastine in treating allergic conjunctivitis ( Canonica et al 2003 ; Kidd et al. 2003 ). Azelastine and ketotifen also have mast-cell stabilising properties, and this may result in a slightly faster onset of action compared with other antihistamines ( Giede et al 2000 ).

Sympathomimetics (naphazoline, tetrahydrozoline)
Non-prescription ocular sympathomimetics are commonly used to control ocular redness and discomfort. There appear to be no significant differences between ocular decongestants on the basis of their vasoconstrictive effectiveness. Like nasal sympathomimetics they should be restricted to short-term (less than 5 days) use to avoid rebound effects. However, their efficacy has been questioned, and the possibility of rebound redness can lead to overuse ( Anonymous 2010 ).

Loratadine, desloratadine or fexofenadine should be recommended as first-line therapy if the patient suffers from mild intermittent general symptoms such as nasal itching, sneezing, rhinorrhoea and associated ocular symptoms. If this fails to control all symptoms then a topical eye drop (antihistamine or mast cell stabiliser) or nasal spray (corticosteroid) should be added to the regimen. If a patient has moderate to severe intermittent symptoms, or persistent allergic rhinitis then regular topical nasal corticosteroids are recommended as first-line treatment, with antihistamines added if there is a poor response. Other agents can be used in conjunction with first-line treatments to target specific symptoms such as rhinorrhoea (consider inhaled anticholinergics) and allergic conjunctivitis (consider topical antihistamines without a decongestant). The Allergic Rhinitis and its Impact on Asthma (ARIA) group, working in collaboration with the World Health Organization, has produced a guideline for pharmacists on the management of allergic rhinitis (see Web sites ).

Practical prescribing and product selection
Prescribing information relating to the rhinitis medicines reviewed in the section ‘Evidence base for non-prescription medicines’ is discussed and summarised in Table 1.11 and useful tips relating to patients presenting with rhinitis are given in Hints and Tips Box 1.4 .
Table 1.11   Practical prescribing: Summary of rhinitis medicines MAOI: monoamine oxidase inhibitor * The use of the fastmelts is only recommended in children over 12 years of age, and the use of the tablets in children over 6 years of age ** the use of tablets is only recommended for children over 12 years of age *** Only available in combination with naphazoline **** Budesonide is licensed for children over 12 years for intermittent allergic rhinitis, but only for adults > 18 years for the treatment of persistent allergic rhinitis Medicine Use in children Likely side-effects Drug interactions of note Patients in whom care should be exercised Pregnancy Systemic antihistamines Cetirizine >1 year * Sedation, but most likely with cetirizine and levocetirizine None Moderate to severe renal failure Avoid in pregnancy; first generation antihistamines, except promethazine and trimeprazine, are preferred Desloratadine >12 years None Fexofenadine >6 years Severe renal impairment Levocetirizine >12 years Severe renal impairment Loratadine >1 year ** Severe hepatic impairment Ocular antihistamines Antazoline *** >12 years Local irritation, bitter taste Avoid concomitant use with MAOIs due to risk of hypertensive crisis Avoid in glaucoma Safety in pregnancy not established, but probably OK Pheniramine *** >12 years Local irritation and pupil dilation Azelastine >4 years Local irritation None None Category B3: avoid Ketotifen >3 years Local irritation None None Category B1: avoid Levocabastine >6 years Local irritation, blurred vision None None Category B3: avoid Nasal antihistamines Azelastine >5 years Nasal irritation (5%), bitter taste (3%) None None Category B3: avoid Levocabastine >6 years Nasal irritation, headache Severe renal impairment Category B3: avoid Nasal corticosteroids Beclomethasone >12 years **** Nasal irritation, bitter taste, nosebleeds None Avoid in glaucoma Category B3: avoid Budesonide Fluticasone Triamcinolone Nasal anticholinergics Ipratropium >12 years Nasal dryness, nose bleeds, dry mouth None Avoid in glaucoma Category B1: avoid Ocular and nasal mast cell stabilisers Sodium cromoglycate ocular No lower age stated Local irritation, blurred vision None None OK Sodium cromoglycate nasal Rare wheezing and shortness of breath Lodoxamide >4 years Stinging on instillation Category B1: avoid Ocular sympathomimetics Naphazoline Not recommended Local irritation Avoid concomitant use with MAOIs and because of risk of hypertensive crisis None OK for short-term use Phenylephrine No lower limit stated Category B2: avoid Tetrahydrozoline >6 years OK for short-term use
Hints and tips box 1.4 Rhinitis

Levocabastine Eye Drops and Nasal Spray These are microsuspensions and the bottle should be shaken before each application Corticosteroid nasal sprays These are suspensions and the bottle should be shaken before use. Regular usage is essential for full therapeutic benefit. It should also be explained that maximum relief might not be obtained for several days. However, most begin to act in 3–7   h Breakthrough symptoms with once-a-day antihistamines Patients who suffer breakthrough symptoms using a once-daily preparation (loratadine, cetirizine) might benefit from changing to fexofenadine, because twice-a-day dosing may confer better symptom control

Systemic antihistamines (cetirizine, levocetirizine, loratadine, desloratadine and fexofenadine)
Systemic antihistamines selectively inhibit histamine H 1 receptors and suppress many of the vascular effects of histamine. They have rapid onset of action (approximately 30 minutes to 1 hour) and relieve ocular symptoms, rhinorrhoea and nasal irritation, but have little effect on nasal congestion. For maximum effect they are best taken on a regular basis but will have an effect if taken when required. Patient response is variable among the different antihistamines and more than one type may have to be tried to provide symptom control. They possess very few side-effects and can be given safely with other prescribed medicines. They can also be prescribed to all patient groups, although manufacturers advise against prescribing to the elderly. First-generation, sedating anthistamines are generally the preferred antihistamines in pregnancy as the risk of foetal toxicity appears low, with dexchlorpheniramine being the medicine of choice. Of the non-sedating antihistamines loratadine is the most widely studied and data available do not indicate an increased risk of teratogenicity, yet manufacturers advise avoidance (presumably on the basis of being outside their product licences). The Australian Medicines Handbook states that less-sedating antihistamines are safe to use in breastfeeding, although the manufacturers advise against their use.

Cetirizine is available as tablets, fastmelts (orodispersible tablet) or solution. The solution can be given to children aged over 1 year of age. For children aged 1 to 2 years the recommended dose is 0.125   mg/kg twice a day. For children aged 2 to 6 years the dose is 2.5–5   mg daily, and for children 6 to 12 years 5   mg twice a day. The dose for adults and children 12 years and over is one tablet or fastmelt (10   mg) daily.

The dose of levocetirizine in adults and children over 12 years is 5   mg once a day. Dose reduction is required in moderate to severe renal failure: moderate (GFR 30–49   mL/min) – 5   mg on alternate days; severe (GFR 10–29   mL/min) – 5   mg every three days. Alternative may be preferred in these situations.

Loratadine is available as a tablet, syrup, or effervescent tablet. The dose for people aged over 12 years is one tablet (10   mg) each day. The syrup (1   mg/mL) can be given to children aged between 2 and 12 years old (<30   kg) at a dose of 5   mg (5   mL) each day. Children aged 1 to 2 years can be given 2.5   mg (2.5   mL) once a day.

Desloratadine is available as a tablet for adults and children aged over 12 years of age. The recommended dose is 5   mg daily.

Fexofenadine is available as 30   mg, 60   mg and 120   mg tablets. The dose for children aged 6 to 11 years is 30   mg twice a day. The adult dose (and children 12 years and over) is 120   mg daily in one or two divided doses.

Nasal corticosteroids (beclomethasone, fluticasone, budesonide, triamcinolone)
Currently beclomethasone, fluticasone, triamcinolone and budesonide are available for sale to the public. In addition, mometasone has pharmacy-only medicine status; the manufacturers have not marketed a non-prescription product. Because of the concerns about the effect of steroids on growth and development, these products should not be used in children under 12 years except on prescription. They can be used in most patient groups, although avoidance in patients with glaucoma is recommended. The manufacturers recommend that they are not used in pregnancy or lactation, although the Australian Medicine Handbook suggests they are probably safe in both situations. The main side-effects with all inhaled corticosteroids are nasal irritation, sore throat, dry mouth, and cough, and they can occasionally cause epistaxis.

This is approved for adults and children over 12 years old, although it can be given to children over the age of 3 on prescription. The recommended dose is two sprays into each nostril twice daily (400   mcg/day). Once symptoms have improved it might be possible to decrease the dose to one spray twice daily. However, should symptoms recur, patients should revert to the standard dosage.

In common with beclomethasone, fluticasone is licensed for adults and children over 12 years old. The dose is two sprays into each nostril once daily (200   mcg/day). Once symptoms are controlled the dose can be decreased to one spray per nostril per day.

Budesonide is approved for adults and children over the age of 12 years for the treatment of seasonal (intermittent) allergic rhinitis, and in adults aged over 18 years for the treatment of perennial (persistent) allergic rhinitis, although it can be used in younger patients on prescription. The initial dose is 256   mcg/day given as either 128   mcg (four sprays) in each nostril once a day, or 64   mcg (two sprays) in each nostril twice a day. The maintenance dose is one to two sprays in each nostril once a day.

Triamcinolone is licensed for adults and children over 12 years old. The initial dose is two sprays into each nostril once daily (220   mcg/day). Once symptoms are controlled the dose can be decreased to one spray per nostril per day.

Nasal antihistamines
Intranasal antihistamines are useful in treating mild or intermittent nasal symptoms, and work more quickly than systemic antihistamines (15 minutes). Although the risk is lower intranasal antihistamines may cause drowsiness in some individuals. However, they do not appear to have any significant drug interactions. Although systemic absorption of intranasal antihistamines is likely to be limited, both azelastine and levocabastine are not recommended for use in pregnancy. Manufacturers also caution against their use in lactation, however the Australian Medicines Handbook indicates they are probably safe.

Azelastine can be given to adults and children over 5 years of age. The dose is one spray in each nostril twice daily (0.56   mg of azelastine hydrochloride).

Levocabastine is only recommended for adults and children over the age of 6 years. The usual dose is two sprays per nostril twice daily. The dose can be increased to three to four times daily, if necessary.

Ocular antihistamines
Ocular antihistamines are useful in treating allergic conjunctivitis related to intermittent rhinitis. Newer antihistamines are available as single agents (azelastine, ketotifen and levocabastine), while older antihistamines are used in combination with the sympathomimetic naphazoline (antazoline and pheniramine). Local irritation is the main side-effect with all ocular antihistamines.

Antazoline and pheniramine
Both antazoline and pheniramine can be used in adults and children over 12 years old. The usual dose is one or two drops instilled three of four times a day. As both antihistamines are administered with naphazoline they should not be used in patients with glaucoma, and because of potential interactions with MAOI, they should not be used in patients receiving such treatment or within 14 days of ceasing therapy.

Azelastine, ketotifen, levocabastine
Levocabastine can be used in adults and children over 6 years of age, while azelastine can be used from 4 years of age, and ketotifen from 3 years of age. All are administered twice a day, and azelastine and levocabastine can be used up to four times a day. They have no significant drug interactions and can be used in nearly all patient groups, but should be avoided in pregnancy. All three appear to be safe to use in patients who are breastfeeding, although the manufacturers advise against their use.

Mast cell stabilisers
Treatment with mast cell stabilisers is best started up to four weeks before exposure to an allergen, and should be continued for at least two to four weeks before evaluating their effectiveness. They are well tolerated and can be used in all groups of patients, and do not appear to have any significant drug interactions.

Ocular and nasal sodium cromoglycate
Sodium cromoglycate can be given intranasally (Rynacrom) or ocularly. It is not known to be teratogenic and can be used in breast feeding. The dose for the eye drops and the 2% nasal spray is one drop/spray four to six times a day, and the 4% nasal spray is used two to four times a day.

Lodoxamide eye drops
The dose is one drop in each eye four times a day. The manufacturer recommends starting lodoxamide at least one week prior to the allergy season. However, given the delay in reaching their maximum efficacy, it is best to start using the drops four weeks before.

For general information about sympathomimetics and product information on nasally administered products, see page 17 .

Ocular sympathomimetics
Ocular products contain either a combination of a sympathomimetic and an antihistamine or a sympathomimetic alone (e.g. naphazoline 0.1%). They should be limited to short-term use (less than 5 days) to avoid rebound effects, and their routine use should be discouraged. Like all sympathomimetics they can interact with MAOIs and should not be used by patients receiving such treatment or within 14 days of ceasing therapy. Sympathomimetics should also be avoided in patients with narrow angle glaucoma. They are reported to be safe for short-term use in pregnancy, although phenylephrine has a B2 pregnancy category.

The use of products containing naphazoline is restricted to adults. One to two drops should be administered into the eye three to four times a day. The benefit of hamamelis water (witch-hazel) added as an astringent is uncertain.

Although no lower age limit is stated for these products, they are probably best avoided in children. The recommended dose is one to two drops three times a day.

The recommended dose in adults and children over the age of six years is one or two drops up to four times a day.

Complementary therapies
Butterbur is promoted as having antiallergic properties. Two clinical trials have reported favourable outcomes of butterbur in controlling symptoms. Both trials found butterbur to be as effective as its comparator drug (cetirizine and fexofenadine, respectively) although another trial found it to be no better than placebo.


Anonymous, Vasoconstrictors , In: (Editor: Rossi, S) Australian Medicines Handbook 2010 ( 2010 ) Australian Medicines Handbook , Adelaide , pp. 454 – 455 .
Abelson, M; Paradis, A; George, M; et al. , Effects of Vasocon-A in the allergen challenge model of acute allergic conjunctivitis , Archives of Ophthalmology 108 ( 1990 ) 52 – 524 .
Azevedo, M; Castel-Branco, M; Oliveira, J; et al. , Double-blind comparison of levocabastine eye drops with sodium cromoglycate and placebo in the treatment of seasonal allergic conjunctivitis. Clinical and Experimental , Allergy 21 ( 1991 ) 689 – 694 .
Canonica, GW; Ciprandi, G; Petzold, U; et al. , Topical azelastine in perennial allergic conjunctivitis , Current Medical Research and Opinion 19 ( 4 ) ( 2003 ) 321 – 329 .
Giede, C; Metzenauer, P; Petzold, U; Ellers-Lenz, B, Comparison of azelastine eye drops with levocabastine eye drops in the treatment of seasonal allergic conjunctivitis , Current medical research and opinion 16 ( 3 ) ( 2000 ) 153 – 163 .
Kidd, M; McKenzie, SH; Steven, I; Cooper, C; Lanz, R, Efficacy and safety of ketotifen eye drops in the treatment of seasonal allergic conjunctivitis , British Journal of Ophthalmology 87 ( 10 ) ( 2003 ) 1206 – 1211 .
Lee, TA; Pickard, AS, Meta-analysis of azelastine nasal spray for the treatment of allergic rhinitis , Pharmacotherapy 27 ( 6 ) ( 2007 ) 852 – 859 .
Lindsay-Miller, A C M, Group comparative trial of 2% sodium cromoglycate (Opticrom) with placebo in treatment of seasonal allergic conjunctivitis , Clinical Allergy 9 ( 1979 ) 271 – 275 .
Mann, RD; Pearce, GL; Dunn, N; et al. , Sedation with ‘non-sedating’ antihistamines: four prescription-event monitoring studies in general practice , British Medical Journal 320 ( 2000 ) 1184 – 1186 .
Ramakrishnan, VJ; Meyers, AD, Nonallergic rhinitis , eMedicine [online] Available at ( 2010 ) ; Cited 19 August 2010 .
Richard, C; Trinquand, C; Bloch-Michel, E; et al. , Comparison of topical 0.05% levocabastine and 0.1% lodoxamide in patients with allergic conjunctivitis , European Journal of Ophthalmology 8 ( 1998 ) 207 – 216 .
Sheikh, A; Panesar, SS; Dhami, S, Seasonal Allergic Rhinitis. British Medical Journal Clinical Evidence , [Online] Available ( 2006 ) ; [1 February 2007] .
Sheikh A, Hurwitz B, Nurmatov U, van Schayck C P 2010 House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD001563. DOI: 10.1002/14651858.CD001563.pub3
Wallace, DV; Dykewicz, MS; Bernstein, DI; Blessing-Moore, J; Cox, L; Khan, DA; et al. , The diagnosis and management of rhinitis: an updated practice parameter , Journal of Allergy and Clinical Immunology 122 ( 2S ) ( 2008 ) 1 – 84 .
Walls, RS; Heddle, RJ; Tang, M L K; et al. , Optimising the management of allergic rhinitis: an Australian perspective , Medical Journal of Australia 182 ( 1 ) ( 2005 ) 28 – 33 .

Further reading

Anonymous, Hayfever , MeReC Bulletin 6 ( 1995 ) 13 – 16 .
Anonymous, Drugs for allergic and inflammatory eye conditions , In: (Editors: Rossi, S; Hurley, E; Vitry, A; et al. ) Australian Medicines Handbook ( 2010 ) Australian Medicines Handbook Pty Ltd , Adelaide , pp. 454 – 458 .
Anonymous, Drugs for rhinitis and sinusitis , In: (Editors: Rossi, S; Hurley, E; Vitry, A; et al. ) Australian Medicines Handbook ( 2010 ) Australian Medicines Handbook Pty Ltd , Adelaide , pp. 385 – 390 .
Jones, NS; Carney, AS; Davis, A, The prevalence of allergic rhinosinusitis: a review. Journal of Laryngology and , Otolaryngology 112 ( 1998 ) 1019 – 1030 .
Respiratory Expert Group, Rhinitis , In: Therapeutic guidelines: respiratory. Version 4 ( 2009 ) Therapeutic Guidelines Limited , Melbourne , pp. 99 – 103 .
Slater, JW; Zechnich, AD; Haxby, DG, Second-generation antihistamines: a comparative review , Drugs 57 ( 1999 ) 31 – 47 .
Soparkar C N S, Wilhelmus, KR; Douglas, D; et al. , Acute and chronic conjunctivitis due to over-the-counter ophthalmic decongestants , Archives of Ophthalmology 115 ( 1997 ) 34 – 38 .
Walls, RS; Heddle, RJ; Tang, M L K; et al. , Optimising the management of allergic rhinitis: an Australian perspective , Medical Journal of Australia 182 ( 1 ) ( 2005 ) 28 – 33 .

Web sites

Allergic Rhinitis and its Impact on Asthma (ARIA) resources for pharmacists, .
Australasian Society of Clinical Immunology and Allergy, .

Further resources for this chapter are available online at:
Self-assessment questions
The following questions are intended to supplement the text. Two levels of questions are provided: multiple choice questions and case studies. The multiple choice questions are designed to test factual recall and the case studies allow knowledge to be applied to a practice setting.
Multiple choice questions

1.1 Which respiratory condition is characterised by shortness of breath and bronchoconstriction?

a Acute bronchitis

b Heart failure

c Asthma

d Chronic bronchitis

e Pneumonia

1.2 What course of action would be most appropriate if a baby was suffering with croup-like symptoms?

a Refer the patient to a physician

b Put the infant into a steamy room

c Give the infant paracetamol

d Give the infant a cough suppressant

e Give the infant an antihistamine

1.3 Which patient group is most at risk of pneumothorax?

a Elderly women

b Young men

c Young women

d Elderly men

e None of the above

1.4 Which ONE of the following medicines can cause rebound congestion with overuse?

a Pseudoephedrine tablets

b Guaifenesin cough mixture

c Oxymetazoline nasal spray

d Chlorpheniramine tablets

e Pholcodine linctus

1.5 Which medicine IS the drug of choice for nasal congestion caused by persistent allergic rhinitis?

a Loratadine

b Nasal sodium cromoglycate

c Nasal levocabastine

d Nasal beclomethasone

e Chlorpheniramine

1.6 Which patient group is most likely to suffer from infectious mononucleosis?

a Infants

b Children

c Adolescents

d Adults

e The elderly

1.7 What symptoms are commonly associated with acute sinusitis?

a Dull, localised unilateral pain that is often worse on bending down

b Dull, localised unilateral pain that often eases on bending down

c Dull, diffuse bilateral pain that is often worse on bending down

d Dull, diffuse bilateral pain that often eases on bending down

e Sharp, localised bilateral pain that often eases on bending down

1.8 The most likely cause of acute cough in children is:

a Bacterial infection

b Viral infection

c Upper airways cough syndrome

d Croup

e Asthma

Questions 1.9 to 1.11 concern the following conditions:

A Tuberculosis

B Left ventricular failure

C Chronic bronchitis

D Pneumonia

E Acute bronchitis

Select in which of the above conditions (A to E):

1.9 Is shortness of breath often the main presenting symptom

1.10 Is cigarette smoking the main cause of the condition

1.11 A higher prevalence is seen in ethnic groups

Questions 1.12 to 1.14 concern the following medicines:

A Codeine

B Dextromethorphan

C Pholcodine

D Beclomethasone

E Benzydamine

Select, from A to E, which of the above medicines:

1.12 Should be avoided by patients taking beta-blockers

1.13 Is most frequently abused by patients

1.14 May increase the risk of developing serotonin syndrome if used with MAOIs

1.15 Which of the following symptoms are not associated with sinusitis:

a Localised pain

b Pain is worsened on bending over

c Pain is described as dull

d Loss of taste

e Nasal discharge

1.16 A pharmacist should refer patients when the following symptoms are associated with the common cold:

a Duration of more than 5–7 days

b If fever is present

c If middle ear involvement is suspected

d If nasal discharge is coloured

e If symptoms occur outside of winter

1.17 Which of the following precautions should a patient take if he or she suffers from persistent rhinitis:

a Avoid contact with animals, especially household pets

b Cover bare floorboards with carpets or rugs

c Close the windows when in the house

d Avoid excessive cleaning

e Use an air-conditioner in the house

1.18 Which of the following medicines is not associated with causing a sore throat:

a Carbimazole

b Penicillin

c Sulfasalazine

d Methotrexate

e Sulfamethoxazole

1.19 Which of the following statement is true regarding intermittent rhinitis:

a Is commonly caused by animal dander

b Is common in the winter months

c Is associated with a mucopurulent discharge

d Can be linked to a family history of asthma or eczema

e Loratadine would be first-line treatment for moderate to severe symptoms

1.20 Which of the following statement is true regarding pholcodine:

a Is a good choice for young children

b Should not be used in combination with moclobemide

c Is more effective than codeine

d Should be avoided during pregnancy

e Sugar-free formulations are available
Case studies

Case Study 1.1

Ms NR, a female patient (about 30 years old), presents to the pharmacist complaining of a bothersome sore throat. The following information is gained from the patient. Information Gathering Data Generated Presenting complaint (possible questions) What symptoms have you got? Pain when trying to swallow How long have you had the symptoms? Had for the last 2   days Do you have any other symptoms? Headache Additional questions asked Do you have a temperature? Not sure Do you have true difficulty swallowing? No Previous history of presenting complaint? Had cough and cold a few months ago Past medical history? Eczema Drugs (non-prescription, Rx, and compliance)? Nothing currently Allergies? None known Social history No questions asked in relation to social history Smoking Alcohol Drugs Employment Relationships Family history N/A Examination Throat appears normal. No ulceration or pus obviously visible using pen torch. Glands do not feel swollen. Running low fever (38°C)
Epidemiology of sore throat suggests that viral sore throat is the most likely cause of sore throat in primary care for all ages. However, other conditions are possible and are noted below: Probability Cause Most likely Viral infection Likely Streptococcal infection Unlikely Thrush, glandular fever, trauma Very unlikely Carcinoma, medicines
Using the information gained from questioning and linking this with known epidemiology on sore throat it should be possible to make a differential diagnosis.
Diagnostic Pointers with respect to symptom presentation
Below summarises the expected findings for questions when related to the different conditions that can be seen by community pharmacists. Age Tonsillar/pharyngeal exudates Duration Cervical glands Cough present Other symptoms Viral Infection Any age Possible but generally limited 3–7 days Normal Common Low grade fever, headache Bacterial Infection School children Often present and can be substantial 3–7 days Swollen Rare High grade fever, possible rash Thrush Young and old No 5–14 days? Normal No No Glandular fever Adolescents Unlikely >   14 days Swollen No Lethargy Trauma Any age Unlikely Varies depending on cause Normal No None Carcinoma Older people None >   14 days Normal? No? Dysphagia, ear pain Medicines Adults None depends Normal No
When this information is applied to the information gained from our patient we see that her symptoms most closely match viral infection or trauma. As epidemiology indicates viral infection is the most prevalent cause of sore throat it seems likely that this is the cause of her symptoms. Trauma appears less likely due to having no systemic symptoms – a supplementary question about precipitating factors should exclude trauma as a cause. Age Tonsillar/pharyngeal exudate Duration Cervical glands swollen Cough present Absence of dysphagia Systemic upset present Viral Infection ✓ ✓? ✓ ✓ ✗ ✓ ✓ Bacterial Infection ✗ ✗ ✓ ✗ ✗? ✓ ✓? Thrush ✗ ✓ ✗? ✓ ✓ ✓ ✗ Glandular fever ✗ ✓ ✗ ✗ ✓ ✓ ✗ Trauma ✓ ✓ ✓? ✓ ✓ ✓ ✗ Carcinoma ✗ ✓ ✗ ✓ ✓ ✗ ✗ Medicines N/A N/A N/A N/A N/A N/A N/A

Danger Symptoms/signs (Trigger Points for referral)
As a final double check it might be worth making sure the person has none of the referral signs or symptoms. This is the case with this patient. Adverse drug reaction ✗ Associated skin rash ✗ Duration of more than 2 weeks ✗ Dysphagia ✗ Marked tonsillar exudate accompanied with a high temperature and swollen glands ✗
Case study 1.2

Mr JL, a man in his early sixties (slightly overweight), wants something for his persistent cough. He has tried some stuff from the supermarket but it did not work. The following information is gained from the patient. Information gathering Data generated Presenting complaint (possible questions) Describe symptoms Cough with a little bit of phlegm How long have you had the symptoms? Weeks. Just been there in the background. Not really bothered by it but just doesn't seem to want to go. Saw the GP about 6 weeks ago and was given antibiotics. Seemed to help but the cough came back again Nature of sputum Not a lot there really. Seems green/brown Onset/timing Not noticed it being better or worse at any time Other symptoms/provokes Generally feels off colour and has done for a while Additional questions No blood in sputum noticed; no weight loss Previous history of presenting complaint Gets coughs and colds from time-to-time but not constantly Past medical history GORD, hypothyroidism Drugs (non-prescription, Rx and compliance) Pantoprazole 40   mg daily Thyroxine 100   mcg daily Allergies No allergies known Social history Smoking Smokes 20–40 a day Alcohol Drinks most nights down the club Drugs Employment Unemployed currently Relationships Lives on own Family history N/A On examination GORD, gastro-oesophageal reflux disease
Epidemiology of cough suggests that viral sore throat is the most likely cause of cough in primary care for all ages. However, other conditions are possible and are noted below: Probability Cause Most likely Viral infection Likely Post-nasal drip, allergies, acute bronchitis Unlikely Croup, chronic bronchitis, asthma pneumonia, Very unlikely Heart failure, bronchiectasis, tuberculosis, cancer, pneumothorax, lung abscess, nocardiasis, GORD, ACE inhibitor ACE, angiotensin converting enzyme; GORD, gastro-oesophageal reflux disease
Using the information gained from questioning and linking this with known epidemiology on cough it should be possible to make a differential diagnosis.

Diagnostic Pointers with respect to symptom presentation
Below summarises the expected findings for questions when related to the different conditions that can be seen by community pharmacists. Acute or chronic Sputum Sputum colour Age Systemic symptoms Worse at any particular time of day? Viral Acute Sometimes White to green or yellowy Any Yes pm Post-nasal drip Acute No N/A Adults No None Allergy Either No N/A Any No pm Acute bronchitis Acute Sometimes White to green or yellowy Adults Yes None Croup Acute No N/A Young children No pm Chronic bronchitis Chronic Yes Mucopurulent >40 No am Asthma Chronic Sometimes Yellow Any No pm Pneumonia Acute Yes Rust tinged >50 Yes pm Medicines Either No N/A Adults No None Heart failure Chronic Yes Pink tinged Elderly No pm Bronchiectasis Chronic Yes Mucopurulent Adults No am & pm Tuberculosis Chronic Yes Blood present Any Yes None Carcinoma Chronic Yes Dark red >50 No None Pneumothorax Acute No N/A Young adults No None Lung abscess Chronic No N/A Elderly Yes None Nocardiasis Chronic Yes Mucopurulent Adults Yes None
When this information is applied to the information gained from our patient we see that the conditions that most closely fit with the man's symptoms are chronic bronchitis, tuberculosis or nocardiasis. Based on epidemiology, nocardiasis seems highly unlikely so is it chronic bronchitis or tuberculosis? The man does smoke heavily and this fits with chronic bronchitis but he says that he does not have a repeated history of cough. The patient has felt unwell for ‘a while’ and this suggests systemic involvement. Although rare, tuberculosis appears to be a possibility and it would seem sensible to refer him to his GP because of the long-standing nature of the symptoms coupled with his general malaise. Acute or chronic Sputum Sputum colour (productive only) Age Systemic symptoms Worse at any particular time of day (non-specific answer?) Viral ✗ ✓ ? ✗ ? ✓ ✓ ? Post-nasal drip ✗ ✗ N/A ✓ ✗ ? Allergy ✗ ? ✗ N/A ✓ ✗ ? Acute bronchitis ✗ ✓ 7? ✓ ✓ ? Croup ✗ ✗ N/A ✗ ✗ ? Chronic bronchitis ✓ ✓ ✓ ✓ ✗ ? Asthma ✓ ✓ ? ✓ ? ✓ ✗ ? Pneumonia ✗ ✓ ✓ ? ✓ ✓ ? Medicines ✗ ? ✗ N/A N/A N/A ? Heart failure ✓ ✓ ✗ ✗ ✗ ? Bronchiectasis ✓ ✓ ✓ ? ✓ ✗ ? Tuberculosis ✓ ✓ ✓ ? ✓ ✓ ? Carcinoma ✓ ✓ ✓ ? ✓ ✗ ? Pneumothorax ✗ ✗ N/A ✓ ✓ ? Lung abscess ✓ ✗ N/A ✓ ✓ ? Nocardiasis ✓ ✓ ✓ ? ✓ ✓ ?
Case study 1.3

Mr RT has asked to speak to the pharmacist because he has a troublesome cough.

a Discuss the appropriately worded questions you will need to ask Mr RT to determine the seriousness of the cough and to establish whether he can be treated or must be referred. Explain your rationale for each question.
Discussion with Mr RT indicates he has a productive cough that appeared a few days ago and that the sputum is white. His nose is ‘a bit blocked’. He has a headache and he does not have any chest pain. Before you can make a recommendation for the symptoms you identify he is taking the following medicines:

• >Moclobemide 150   mg bd – he has taken this for over 6 months

• >Bimatoprost drops daily – he has used this for 2 years

• >Paracetamol 2 qid prn – for lower back pain

b Compare and contrast the different products available to treat Mr RT's symptoms and indicate which you consider would be the most beneficial to him and which are contraindicated.
A few weeks later Mr RT returns to the pharmacy complaining that he is still having trouble clearing his blocked nose. A friend at work recommended Otrivin nasal spray (xylometazoline) and he has been using it 2 to 3 times a day for about 10 days.

c The use of local decongestants is associated with the phenomenon known as rhinitis medicamentosa. Explain what this is and what advice you would give to Mr RT to remedy this.
Case study 1.4

Mr SJ, a 26-year-old man, comes into the pharmacy asking for something for flu. He has tried a product containing phenylephrine and the paracetanol he bought from the supermarket. He looks visibly well.

a What questions do you need to ask to determine whether the patient has flu?
Further details you obtain from him are:

• >He has had the symptoms for 5 to 7 days.

• >He has a productive cough but this is not bothering him too much.

• >He aches a little and has hot and cold spells.

• >He takes salbutamol on a when-needed basis but has been using it a little more than normal.

• >He has recently come back from a holiday in India.

b What do you think is wrong with Mr SJ?

c What course of action are you going to take?
Answers to multiple choice questions
1.1 = c 1.2 = a 1.3 = b 1.4 = c 1.5 = d 1.6 = c 1.7 = a 1.8 = b 1.9 = B 1.10 = C
1.11 = A 1.12 = B 1.13 = A 1.14 = B 1.15 = d 1.16 = c 1.17 = a 1.18 = b 1.19 = d 1.20 = e
Answers to case study questions – see page 307

Chapter 2. Ophthalmology

In this chapter

Background 43

General overview of eye anatomy 43

History taking and the eye exam 44

Red eye 44

Eyelid disorders 52

Dry eye 55

Self-assessment 60

The eye is one of the most important and complex organs of the body. Vision is taken for granted and only when our sight is threatened do we truly appreciate what we have. Because of its complicated and intricate anatomy, many things can and do go wrong with the eye, and these manifest as ocular symptoms to the patient.
It is the pharmacist's role to differentiate between minor self-limiting and serious sight-threatening conditions. For pharmacists to undertake this role they need to be familiar with the gross anatomy of the eye, be able to take an eye history and perform a simple eye examination.
In addition, pharmacists can play a major role in health promotion towards eye care. Patients who present with repeat prescriptions for degenerative conditions, such as glaucoma, could have regular contact with the pharmacist, who could check patient concordance, ability to administer eye drops and ointments correctly and, potentially, discover any deterioration of the patient's condition.

General overview of eye anatomy
A basic understanding of the main eye structures is useful to help pharmacists assess the nature and severity of the presenting complaint. Figure 2.1 highlights the principal eye structures.

Fig. 2.1
Anatomy of the eye. Above: side view; below: front view.

The eyelids
The eyelids consist mainly of voluntary muscle with a border of thick connective tissue, known as the tarsal plate. This plate is felt as a ridge when everting the eyelid to remove a foreign body. Covering the inner aspect of the eyelids is the conjunctiva, which continues over the surface of the eye.

The sclera and cornea
The sclera encircles the eye, apart from a small ‘window’ at the very front of the eye where the cornea is located. The sclera is often referred to as the ‘white of the eye’. The transparent cornea allows light to enter the eye and helps to converge light on to the retina.

The iris, pupil and ciliary body
The iris is the coloured part of the eye. It is an incomplete circle, with a hole in the middle of the iris, which forms the pupil. The iris attaches to the ciliary body, which serves to hold the lens in place. The ciliary body produces the aqueous humour, a watery solution that bathes the lens. This is manufactured behind the iris and travels through the posterior chamber and the pupil before draining at the anterior chamber angle (where the iris meets the cornea). If this exit becomes blocked then the intraocular pressure of the eye becomes elevated.

The lens
The lens is responsible for ‘fine focusing’ light onto the retina. It possesses the ability to vary its focusing power. However, this variable focus power is lost with increasing age as the lens grows harder and less elastic. This is the reason many people require reading glasses as they get older.

The retina
The retina is the light-sensitive layer of the eye; it is the reason for the presence of all the other eye structures. The functioning of the retina can be compromised by many factors, such as underlying disease states and foreign bodies causing retinal damage and detachment.

History taking and the eye exam
A detailed history should be sought from the patient when attempting to decide on the presenting complaint. Pay attention to vision, the severity and nature of discomfort and the presence of discharge. You should also ask about whether there has been any trauma to the eye or head (e.g. a blow to the eye socket), or whether they were doing anything that could have resulted in a foreign body in the eye (e.g. woodwork or metalwork). Do not forget to ask about any family history of eye disease (e.g. glaucoma) and the person's previous eye and medication history. Answers to these various questions should enable the pharmacist to build up a picture of the problem and arrive at a tentative differential diagnosis.
The history gained should then be supplemented by performing an eye exam. A great deal of information can be learned from a close inspection of the eye. For example, you can check the size of the pupils, their comparative size and reaction to light, the colour of the sclera, the nature of any discharge and if there is any eyelid involvement. It is impossible to agree with a patient's self-diagnosis or for you to differentially diagnose any form of conjunctivitis from behind a counter, Pharmacists should conduct a simple eye examination before making any recommendations on treatment.
The eye can only be examined in good light. This might mean asking the patient to move to an area within the pharmacy where the exam can be performed. Before performing an eye exam seek the patients consent and ensure you explain fully what you are about to do.

• First, wash your hands.

• Next, ask the patient to look straight ahead. This allows you to view the pupil, cornea and sclera.

• Then, gently pull down the lower lid and ask the patient to look upwards and to both the left and the right. This enables you to examine the conjunctiva.

• Now ask the patient to look directly in to a near light and then back at you. This is best performed using a pen-torch. This enables you to examine the reaction of the pupils to light. Any abnormal pupil reaction in the presence of ocular symptoms should always be treated seriously.
You should also endeavour to assess the visual acuity of the patient. Snellen charts (standard charts used to assess visual acuity) will not be available in most community pharmacies, and most pharmacists are not trained in their use, although some pharmacists may have them. It is possible to test a person's visual acuity by getting them to read print from a book.

Red eye

Conjunctivitis simply means inflammation of the conjunctiva and is characterised by varying degrees of ocular redness, irritation, itching and discharge. Redness of the eye and inflammation of the conjunctiva has been reported as being the most common ophthalmic problem encountered in the Western world. As conjunctivitis (bacterial, viral and allergic forms) is the most common ocular condition encountered by community pharmacists, this section concentrates on recognising the different types of conjunctivitis and differentially diagnosing these from more serious ocular disorders.

Prevalence and epidemiology
The exact prevalence of conjunctivitis is not known, although the prevalence of intermittent allergic conjunctivitis (hayfever) may be increasing. Statistics from Australian GPs indicate that eye complaints make up 1.6% of reasons for people presenting, and infectious conjunctivitis represent 0.5% of problems managed by GPs ( Britt et al 2009 ). Conjunctivitis seems to affect the sexes equally and can present in any age of patient, although it is more common in the very young and the elderly. All three types of conjunctivitis are essentially self-limiting, although viral conjunctivitis can be recurrent and persist for many weeks.

The various pathogens that cause bacterial conjunctivitis vary between adults and children. In adults Staphylococcus species are most common (over 50% of cases), followed by Streptococcus pneumoniae (20%), Moraxella species (5%) and Haemophilus influenzae (5%). In children, Streptococcus, Moraxella and Haemophilus are most common. The adenovirus is most commonly implicated in viral conjunctivitis and pollen usually causes intermittent allergic conjunctivitis.

Arriving at a differential diagnosis
Red eye is a presenting complaint of both serious and non-serious causes of eye pathology. Community pharmacists must be able to differentiate between those conditions that can be managed and those that need referral.
Redness of the eye can occur alone or present with accompanying symptoms of pain, discomfort, discharge and loss of visual acuity. A number of eye specific questions should always be asked of the patient to aid in diagnosis ( Table 2.1 ).
Table 2.1   Specific questions to ask the patient: Red eye Question Relevance Discharge present Most commonly seen in conjunctivitis. Can vary from watery to mucopurulent, depending on the form. Mucopurulent discharge is more suggestive of bacterial conjunctivitis especially if the eyes are glued together by discharge in the absence of itching Visual changes Any loss of vision or haloes around objects should be viewed with extreme caution, especially if scleral redness is also present Pain/discomfort/itch True pain is generally associated with conditions requiring referral, e.g. scleritis, keratitis and acute glaucoma. Pain associated with conjunctivitis is often described as a gritty/foreign-body-type pain Location of redness Redness concentrated near or around the coloured part of the eye can indicate sinister pathology, for example uveitis. Generalised redness and redness toward the fornices (corners of the eyes) is more indicative of conjunctivitis. Localised scleral redness can indicate scleritis or episcleritis Duration Minor eye problems are usually self-limiting and resolve within a few days. Any ocular redness, apart from subconjunctival haemorrhage, and allergic conjunctivitis that lasts more than 1 week requires referral Other symptoms Signs and symptoms of an upper respiratory tract infection point towards a viral cause of conjunctivitis; vomiting suggests glaucoma

Clinical features of conjunctivitis
The overwhelming majority of patients presenting to the pharmacy with red eye will have some form of conjunctivitis. Each of the three types of conjunctivitis has similar but varying symptoms. Each presents with the three main symptoms of redness, discharge and discomfort. Table 2.2 and Fig. 2.2 , Fig. 2.3 and Fig. 2.4 highlight the similarities and differences in the classic presentations of the three conditions.
Table 2.2 Symptoms that help to distinguish between the different types of conjunctivitis Bacterial Viral Allergic Eyes affected Both, but one eye often affected first by 24–48 hours Both Both Discharge Purulent Watery Watery Pain Gritty feeling Gritty feeling Itching Distribution of redness Generalised and diffuse Generalised Generalised but greatest in fornices Associated symptoms None commonly Cough and cold symptoms Rhinitis (might also have family history of atopy)

Fig. 2.2
Bacterial conjunctivitis.
Reproduced from Handbook of Ocular Disease Management by Joseph W Sowka OD, Andrew S Gurwood OD and Alan Kabat OD, Jobson Publishing, with permission.

Fig. 2.3
Viral conjunctivitis.
Reproduced from Handbook of Ocular Disease Management by Joseph W Sowka OD, Andrew S Gurwood OD and Alan Kabat OD, Jobson Publishing, with permission

Fig. 2.4
Allergic conjunctivitis.
Reproduced from Handbook of Ocular Disease Management by Joseph W Sowka OD, Andrew S Gurwood OD and Alan Kabat OD, Jobson Publishing, with permission

Conditions to eliminate

The episclera lies just beneath the conjunctiva and adjacent to the sclera. If this becomes inflamed the eye appears red, which is segmental affecting only part of the eye ( Figure 2.5 ). The condition affects only one eye in the majority of cases and is usually painless or a dull ache might be present. It is most commonly seen in young women and is usually self-limiting, but it could take 6 to 8 weeks before symptoms resolve.

Fig. 2.5
Reproduced from Clinical Ophthalmology, 2003, by J Kanski, Butterworth–Heinemann, with permission

Inflammation of the sclera – Scleritis – presents with similar symptoms as episcleritis but the condition is much less common than episcleritis and more painful. It is often associated with autoimmune diseases, for example, in 20% of cases the patient has rheumatoid arthritis. It presents similarly to episcleritis but pain is a predominant feature and vision can be affected. Discharge is rare or absent in both episcleritis and scleritis.

Keratitis (corneal ulcer)
Inflammation of the cornea often results from recent trauma (e.g. eye abrasion) or administration of long-term steroid drops. Over wear of soft contact lenses has also been implicated in causing keratitis. Pain, which can be very severe, is a prominent feature. The patient usually complains of photophobia accompanied by a watery discharge. Redness of the eye tends to be worse around the iris. Immediate referral to a medical practitioner is needed as loss of sight is possible if left untreated.

Uveitis describes inflammation involving the uveal tract (iris, ciliary body and choroid). The likely cause is an antigen–antibody reaction, which can occur as part of a systemic disease such as rheumatoid arthritis or ulcerative colitis. Photophobia is a prominent feature and pain is moderate to severe and might keep the person awake. Usually, only one eye is affected and the redness is often localised to the limbal area (known as the ciliary flush). On examination, the pupil will appear irregularly shaped and constricted ( Figure 2.6 ). The patient might also complain of impaired reading vision. Immediate referral to a medical practitioner is needed.

Fig. 2.6
Reproduced from Handbook of Ocular Disease Management by Joseph W Sowka OD, Andrew S Gurwood OD and Alan Kabat OD, Jobson Publishing, with permission

Subconjunctival haemorrhage
The rupture of a blood vessel under the conjunctiva causes subconjunctival haemorrhage. A segment, or even the whole eye, will appear bright red ( Figure 2.7 ). It occurs spontaneously but can be precipitated by coughing, straining or lifting. The suddenness of symptoms and the brightness of the blood invariably means patients present very soon after they have noticed the problem. There is no pain and the patient should be reassured that symptoms will resolve in 10 to 14 days without treatment. However, a patient with a history of trauma should be referred to exclude ocular injury.

Fig. 2.7
Subconjunctival haemorrhage.
Reproduced from Clinical Ophthalmology, 2003, by J Kanski, Butterworth–Heinemann, with permission

Acute closed-angle glaucoma
There are two main types of glaucoma:

• chronic open-angle glaucoma, which does not cause pain

• acute closed-angle glaucoma, which can present with a painful red eye.
The latter requires immediate referral to the GP or even casualty. It is the result of inadequate drainage of aqueous fluid from the anterior chamber of the eye, which results in an increase in intraocular pressure. The onset can be very quick and characteristically occurs in the evening. The eye appears red and may be cloudy ( Figure 2.8 ). Vision is blurred and the patient might also notice haloes around lights. Vomiting is often experienced because of the rapid rise in intraocular pressure.

Fig. 2.8
Acute closed-angle glaucoma.
Reproduced from ABC of Eyes, 1999, by P Khaw and A Elkington, with permission of BMJ Books
Figure 2.9 can be used to help differentiation between serious and non-serious red eye conditions.

Fig. 2.9
Primer for differential diagnosis of red eye Generalised redness Most episodes of conjunctivitis will show generalised redness, although the intensity of redness tends to be worse towards the corners of the eye or away from the pupil. Occasionally, severe conjunctivitis can have marked redness throughout the eye; these cases are best referred. Contact lens wearers Contact lens wearers are more predisposed to keratitis because the space between the contact lens and cornea can act as an incubator for bacteria and enhance mechanical abrasion. This is especially true if patients sleep with their lenses in, because contact time for abrasion to occur is prolonged. True pain It is important to distinguish true pain from ocular irritation. Red eye caused by conjunctivitis causes discomfort, often described as a gritty or a ‘foreign body’ sensation. It does not normally cause true eye pain. True pain would indicate more serious ocular pathology, such as scleritis, uveitis or keratitis. It is important to encourage the patient to describe the sensation carefully to enable an accurate assessment of the type of pain experienced. Acute, close-angle glaucoma This is more common in people aged over 50 years and long-sighted people. Dim light can precipitate an attack. It is a medical emergency and immediate referral is needed. Viral conjunctivitis Associated symptoms of an upper respiratory tract infection might be present (e.g. cough and cold). Viral conjunctivitis often occurs in epidemics and it is not unusual to see a number of cases in a very short space of time.

  Trigger points indicative of referral Red eye

• Associated vomiting

• Clouding of the cornea

• Distortion of vision

• Irregular shaped pupil or abnormal pupil reaction to light

• Photophobia

• Redness caused by a foreign body

• Redness localised around the pupil

• True eye pain

Evidence base for non-prescription medicines

Viral conjunctivitis
Currently, there are no specific non-prescription preparations available to treat viral conjunctivitis. The recommended treatment is the use of lubricant eye drops (see Dry Eye ). As differentiation between bacterial and viral causes of conjunctivitis can be difficult, the use of an antibacterial preparation might be of benefit if uncertainty exists as to the cause of the problem. Viral conjunctivitis is highly contagious and the pharmacist should instruct the patient to follow strict hygiene measures (e.g. washing hands frequently and not sharing towels), which will help to control the spread of the virus. A patient will remain infectious until the redness and weeping resolves (usually 10–12 days) and Australian NH&MRC guidelines recommend that children be excluded from school or childcare until any discharge has stopped. A similar exclusion for adults from work may also be beneficial to stop the spread.

Bacterial conjunctivitis
Bacterial conjunctivitis is regarded as self-limiting – 65% of people will have clinical cure in 2 to 5 days with no treatment – yet antibiotics are routinely given by medical practitioners as they are considered clinically desirable to speed recovery and reduce relapse.
Up until recently the non-prescription ocular antibiotics consisted of dibromopropamidine isethionate, propamidine and sulfacetamide. All three compounds are active against a wide range of organisms, including those responsible for bacterial conjunctivitis. However, clinical trials are lacking to substantiate their effectiveness and a further possible limitation is that their licensed dosage regimen (four times a day for drops) has been reported to be too infrequent to achieve sufficient concentrations to kill or stop the growth of the infecting pathogen. Older preparations contained mercuric oxide. However, these have been discontinued because of lack of efficacy and potential toxicity.
In 2010 chloramphenicol eye drops and ointment were included as a Pharmacist-only/Restricted medicine. Chloramphenicol has proven efficacy and can be used for all cases of bacterial conjunctivitis, although mild cases can be treated with propamidine according to the Australian Therapeutic Guidelines. Rose et al (2005) questioned whether antibiotics were needed in children as no significant difference was seen in the cure rate after 7 days; 86% of the children were clinically cured in the antibiotic group compared with 83% in the placebo group. Even in those children who only had bacterial infection, there was still no significant difference in cure rates. The authors concluded that antibiotics were not needed in children.
Despite the findings from Rose et al the most recent Cochrane Review ( Sheikh & Hurwitz 2006 ) concluded that antibiotics are associated with significantly improved clinical rates of remission. However, they also note that clinical remission occurred within 2 to 5 days in 65% of patients receiving placebo.
Bacterial conjunctivitis, like viral conjunctivitis, is contagious and patients should follow good hygiene including washing their hands regularly, using disposable tissues to wipe the eye, and only using their own washer and towels on their face. Also like viral conjunctivitis, children should be excluded from school until the discharge from the eye has stopped.

Allergic conjunctivitis
Avoidance of the allergen will, in theory, result in control of symptoms. However total avoidance is almost impossible and the use of prophylactic medicine is usually advocated.
The evidence base for mast cell stabilisers, antihistamines and sympathomimetics is discussed in Chapter 1 (pages 26–28).

Practical prescribing and product selection
Prescribing information relating to medicine for conjunctivitis reviewed in the section ‘Evidence base for non-prescription medicines’ is discussed and summarised in Table 2.3 and useful tips relating to treatment are given in Hints and Tips Box 2.1 .
Table 2.3   Practical prescribing: Summary of medicines for conjunctivitis MAOI: monoamine oxidase inhibitor. * Only available in combination with naphazoline. Medicine Use in children Likely side-effects Drug interactions of note Patients in whom care should be exercised Pregnancy Drugs for allergic conjunctivitis Mast cell stabilisers Sodium cromoglycate No lower age limit stated Local irritation, blurred vision None None OK Lodoxamide >4 years Stinging on instillation Category B1: avoid Sympathomimetics Naphazoline Not recommended Local irritation Avoid concomitant use with MAOIs and because of risk of hypertensive crisis None OK for short-term use Phenylephrine No lower age limit stated Category B2: avoid Tetrahydrozoline >6 years OK for short-term use Antihistamines Antazoline * >12 years Local irritation, bitter taste Avoid concomitant use with MAOIs due to risk of hypertensive crisis Avoid in glaucoma Safety in pregnancy not established, but probably OK Pheniramine * >12 years Local irritation and pupil dilation Azelastine >4 years Local irritation None None Category B3: avoid Ketotifen >3 years Local irritation None None Category B1: avoid Levocabastine >12 years Local irritation, blurred vision None None Category B3: avoid Antiba

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