Colds and Flu
Combination cold
and flu medicines for
special populations
Patients suffering from flu may have cold-like symptoms,
but may also experience headaches, muscle aches, fatigue
and weakness. Some flu symptoms last for more than two
weeks.
Combination products for colds and flu
Fae Farrer, BPharm
Amayeza Info Centre
Introduction
Every year, patients consult doctors and pharmacists
for advice on colds and flu. Combination cold and flu
medications are available to relieve the symptoms of these
conditions, but some products are not suitable in certain
patients.
The product’s package insert usually lists medical
conditions that limit the use of particular medicines in
patients who suffer from those conditions, or who are
taking other medication that would interfere with the
ingredients in the cold and flu remedy. This article will
briefly examine combination cold and flu medication, and
highlight patients needing careful evaluation before the
selection of a suitable product.
More about colds and flu
More than 200 viruses cause colds. Flu is the result of
three types of virus: influenza A, B or C. These viruses
are capable of mutating, causing new influenza outbreaks
every year.
The symptoms of colds and flu are quite similar. Patients
suffering from a cold may complain of a sore throat, malaise
and slight fever (pyrexia) at onset. Nasal congestion or a
runny nose (rhinorrhoea) may develop later. The symptoms
of a cold usually last for 7-10 days.
Each ingredient in a combination product is included
therein in order to treat a different symptom. Each separate
ingredient has its own set of side-effects too.
“Combination cold and flu
medications are available to
relieve the symptoms of these
conditions, but some products
are not suitable in certain
patients.”
Decongestants are used to relieve nasal congestion
associated with cold symptoms. Decongestants include
ephedrine, phenylephrine and pseudoephedrine.
Antihistamines are included in cold preparations for their
mucus-drying properties. Antihistamines in cold and flu
remedies relieve a runny nose and sneezing, but side-effects
include sedation and drying of the eyes, nose and mouth,
which may prevent some patients from choosing these
preparations. Antihistamines that are used in cold and
flu remedies include chlorpheniramine, diphenhydramine,
mepyramine,
pheniramine,
phenyltoloxamine
and
triprolidine. Newer antihistamines, which cause less
sedation, include loratadine, desloratadine, cetirizine,
levocetirizine and fexofenadine, but these are not effective
in the treatment of cold and flu symptoms, and are indicated
for the relief of nasal symptoms caused by allergies, such
as allergic rhinitis.
SA Pharmacist’s Assistant [Winter 2014]
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Colds and Flu
Codeine, an opioid-type analgesic, may be included in some
preparations as it also has antitussive properties, which
help to soothe a dry cough. It may also assist in alleviating
Antihistamines in cold and flu remedies may cause
sedation, but may also cause unusual excitement,
nervousness and restlessness in children.
aches and pains, and has additive analgesic effects when
used with paracetamol, aspirin and a nonsteroidal antiinflammatory drug (NSAID), such as ibuprofen.
Analgesics and antipyretics, such as paracetamol, aspirin
and ibuprofen, are included in many preparations to treat
headaches, muscle aches and pains associated with cold
and flu symptoms.
“Once the symptoms
experienced by a patient have
been identified, and medication
needs selected, various patient
factors need to be evaluated.”
Caffeine may be added to some preparations to counteract
the sedative effects produced by other ingredients, such
as antihistamines. The side-effects of caffeine include
sleeplessness, anxiety and irritability.
Certain cold and flu preparations are available in syrup
form. Some of these preparations contain sugar in order to
improve the taste. Others contain alcohol as a preservative.
Patients should be made aware of these ingredients, as
certain conditions such as diabetes mellitus or alcoholism,
may limit their use.
It is important that patients are aware that the medication
is a combination product.They should be advised not to use
any more products until the ingredients have been checked
to prevent accidental duplication, e.g. taking a combination
cold and flu product and a cough syrup that contains an
antihistamine may result in excessive antihistamine intake.
Elderly patients
With advancing age, there is the possibility that patients
may have other conditions, and therefore take other
medicines. The pharmacist’s assistant should enquire if
elderly patients are taking other medicines, with specific
reference to medication for blood pressure (BP), glaucoma
and prostate problems.
Older patients may also demonstrate an increase in
sensitivity to the side-effects of certain ingredients found
in cold and flu medicines.They are more likely to experience
dizziness, confusion, drowsiness, problems with urination,
or dryness of the mouth when taking antihistamines, than
younger patients.
Decongestants may cause more incidences of confusion,
hallucination or convulsion in older patients
These products may also increase BP in elderly patients.
Patient factors to consider
Once the symptoms experienced by a patient have been
identified, and medication needs selected, various patient
factors need to be evaluated.
Patient age
Paediatric patients
It is recommended that children under
the age of four years should not be
given medication for colds and flu,
except on the advice of a medical
doctor. Children are more sensitive
to the side-effects of medication.
Dosages should be checked carefully
on the package insert if a combination
product is selected for a child.
Aspirin and salicylates should not be
administered to children aged 16 years
and younger, especially if they have a
viral infection, as these ingredients
have been linked to Reye’s syndrome
in this age group.
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SA Pharmacist’s Assistant [Winter 2014]
Antihistamines may worsen the symptoms of glaucoma
and prostate problems.
Older patients are more prone to the adverse effects of
NSAIDs, such as ibuprofen.
Colds and Flu
“Decongestants are best
avoided in pregnancy and
during lactation.”
Pregnancy and breastfeeding
Paracetamol is considered to be safe in pregnancy and
lactation. Aspirin should be avoided. The use of aspirin,
salicylates or NSAIDS, such as ibuprofen, in the last
trimester of pregnancy may cause bleeding problems,
prolonged pregnancy and prolonged labour.
Regular use of codeine or related products during
pregnancy may cause the foetus to become dependent on
the medication and to experience withdrawal after birth.
The amount of codeine excreted in breast milk in usual
therapeutic doses is considered to be too small to be
harmful to the breastfed baby.
Antihistamines, such as chlorpheniramine and diphenhydramine, have not been shown to cause problems in
pregnancy when used in recommended doses. Small
amounts of some antihistamines may pass into the breast
milk and cause unusual excitement or irritability in babies.
Antihistamines can also decrease the flow of breast milk.
Alcohol use during pregnancy has been implicated in birth
defects. Certain cold and flu or cough preparations contain
alcohol which should be avoided in pregnancy. Alcohol
passes into the breast milk, but the amounts contained in
over-the-counter products used at recommended dosages
should not affect the breastfed infant.
Cardiovascular disease
Decongestants and medications containing large amounts
of caffeine should be avoided by patients with hypertension,
as well as patients with cardiovascular disease, such as
ischaemic heart disease and heart rhythm disorders.
Asthma
Patients with asthma, and who are allergic to aspirin and
NSAIDs, are advised to avoid taking these medicines.
Asthmatic patients should check the ingredients in
cough preparations to prevent an accidental overdose of
bronchodilator medicines, such as theophylline.
Thyroid disease
Patients with thyroid problems must avoid taking products
containing decongestants.
Lifestyle
Patients who spend their work days operating machinery
or driving should exercise caution if there is the potential
for drowsiness with the ingredients contained in the cold
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SA Pharmacist’s Assistant [Winter 2014]
and flu medicine. Drowsiness may be aggravated with the
simultaneous intake of alcohol and certain cold and flu
medicines that contain antihistamines or codeine.
Conclusion
Combination cold and flu products are useful for treating
the symptoms of these conditions. Identification of the
ingredients of a particular product, together with an
evaluation of the patient, ensures that the most suitable
selection is made.
Bibiography
1. Cough and cold combinations (oral route). Mayo Clinic [homepage on the Internet]. 2013.
c2014. Available from: http://www.mayoclinic.org/drugs-supplements/cough-and-coldcombinations-oral-route/before-using/drg-20061164
2. Kid’s cold medicines: new guidelines. WebMD [homepage on the Internet]. 2013. c2014.
Available from: http://www.webmd.com/cold-and-flu-guide/kids-cold-medicines-newguidelines
3. Pregnancy and medicine. WebMD [homepage on the Internet]. 2013. c2014. Available
from: http://www.webmd.com/women/pregnancy-medicine