CPD 71: THE 123 OF SORE THROAT This module was brought to you by RB Ireland, for full list of papers and studies used please see references at the end of the article.
1. REFLECT - Before reading this module, consider the following: Will this clinical area RB Strip.indd be relevant to my practice. 2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area. 3. PLAN - If I have identified a knowledge gap
- will this article satisfy those needs - or will more reading be required? 1
4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result? Have I identified further learning needs?
After completing this module you should be able to: • Acknowledge the causes, symptoms and duration of sore throat • Recognise the patient’s need for symptom relief and reassurance • Advise patients on how to effectively manage their symptoms WHY CPD? Continuing profession educational development (CPD) is a legal requirement for pharmacists. Journal-based educational programmes are an important means of keeping up to date with professional developments and from a significant element of your CPD.
will usually resolve without antibiotics, and discomfort can be reduced by over-the-counter medication. The WHO warns that antibiotic resistance hampers the control of infectious diseases, increases the cost of healthcare and jeopardises the healthcare gains made in the last 100 years, threatening a return to the pre-antibiotic era.8 Sore Throat Signs & Symptoms The HSE advises that symptoms and signs of a sore throat include: • swollen tonsils (two small glands found at the back of your throat, behind the tongue) • enlarged and tender glands in your neck • a painful, tender feeling at the back of your throat
• discomfort when swallowing
Sore throat is usually one of the first signs of an upper respiratory tract infection (URTI) such as the common cold,1 which affects adults approximately two to four times a year.2 The vast majority of sore throats are caused by viral infections so antibiotics are ineffective and inappropriate for most cases, and do not help to relieve the symptoms.3,4 However, antibiotics continue to be overused for sore throat.5,6,7 Because sore throats are usually mild and not serious, the pharmacy team is ideally placed to help manage this condition with options for symptomatic relief.
If patients have a sore throat, they may also experience a number of other symptoms that are associated with common infectious conditions, such as:
The World Health Organization (WHO) has highlighted antibiotic resistance as a complex threat, with many driving factors, that requires urgent global action8. The pharmacy team has an important role in advising patients about symptomatic treatment without the need for antibiotics. For instance, sore throat
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5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings.
The 1-2-3 of Sore Throat LEARNING OBJECTIVES
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• a high temperature (fever) of 38C (100.4F) or over • aching muscles • a headache • tiredness • a cough • a runny nose These other symptoms will depend on what infection is causing your sore throat.
60 Second Summary Sore throat is a common condition, affecting adults about two to four times a year.2 Sore throat is a symptom of inflammation occurring in the pharynx, tonsils or nasopharynx, most frequently caused by a viral upper respiratory tract infection.2 About 10% of sore throats in adults are caused by bacteria and the vast majority of these are uncomplicated and self-limiting.3,9 For both viral or bacterial sore throats, symptoms resolve on their own, generally within 3 to 7 days.4 During this time, patients with sore throat can experience a range of symptoms including throat pain, difficulty swallowing and a swollen throat.13 Symptoms can vary in severity but sore throat is rarely serious. Patients should be recommended treatments for symptomatic relief that are tailored to their needs and preferences. Special attention needs to be paid to ‘red flag’ symptoms that may warrant further investigation/ antibiotic treatment or populations that may be at increased risk of complications e.g. Elderly or Immunocompromised patients.20
CPD 71: THE 123 OF SORE THROAT of antibiotics for treating these is not well established.2 Antibiotics should only be prescribed where the origin is bacterial or where GP deems it to be appropriate on case by case basis. Non-Infectious Factors Non-infectious factors can also cause sore throat – these include allergies, pollution, smoking, cold temperatures, dry air, occupational irritants, medications, snoring, overusing the voice, and tracheal intubation.11, 12 Infectious and non-infectious factors can all trigger the four signs of inflammation, the underlying cause of sore throat symptoms.1,10,11 2. Be Vigilant – Assess Severity Key symptoms in sore throat are a painful throat, swollen throat and difficulty swallowing.13 Most sore throats are not serious and the risk of complications is low.3 In addition to sore throat, it is common for other symptoms to be present. These include:14 • Runny nose • Sneezing
The vast majority of sore throats are due to a viral URTI. Viruses are responsible for 85-95% of sore throats in adults, 95% in children younger than 5 years and 70% in children aged 5-16 years.3 Common cold viruses, influenza viruses and adenoviruses are common viral causes of sore throat.9 In adolescents, sore throat may also be caused by infectious mononucleosis (glandular fever), caused by Epstein–Barr virus.10 Bacterial Factors A small proportion of sore throats are caused by bacteria. Group A β-haemolytic streptococcus (GABHS) is the only commonly occurring bacterial cause of sore throat that can cause complications, albeit rarely. Other bacterial causes include groups C and G β-haemolytic streptococci, Mycoplasma pneumonia and Chlamydia pneumoniae, although the value
There are several general measures that can be taken to provide relief: • Get plenty of rest • Drink plenty of fluids • Eat cool, soft food and drink cool or warm liquids
• Dry cough
• Gargle with warm, salty water
Reassure patients that these types of symptoms commonly accompany a sore throat and are usually nothing to worry about.
As sore throat can be worrying for some patients, it is important for the pharmacy team to provide reassurance regarding the duration and severity of the condition. Recognising the patient’s main concern(s) and providing suitable communication and guidance should help ease the patient’s anxiety.
• Avoid smoking and smoky environments
• Redness of throat or roof of mouth
Inflammatory pathways are activated when the throat lining is damaged by infectious or non-infectious factors, leading to the production of inflammatory mediators such as prostaglandins. It is the action of these inflammatory mediators that causes the pain and discomfort of sore throat.
3. COUNSEL ON EFFECTIVE SELF-MANAGEMENT
• Dullness of hearing
1. Causes of Sore Throat
The HCP needs to be vigilant and identify patients who may require antibiotic treatment or further clinical assessment. Patients with ‘red flag’ symptoms may have a serious infection that warrants antibiotic treatment, and a visit to their General Practitioner should be recommended.
Sore throat usually begins with relatively mild symptoms such as a dry or irritated throat but can progress to a more painful condition. Patients can describe troublesome symptoms such as difficulty swallowing (dysphagia), pain on swallowing (odynophagia) or the sensation of a swollen throat.17 Sore throat and associated symptoms can have a considerable emotional effect, such as impairment of concentration and impact on normal daily activities16 but complications are rare in most developed countries.18; 19
Over-the-counter treatments In addition to these general measures, several national and international organisations recommend the self-management of sore throat with over-the-counter (OTC) symptomatic treatments (see www.hse.ie). Furthermore, most patients with sore throat want symptom relief,20 so HCPs should be prepared to give advice on treatment options, tailored to the patient’s needs.21 OTC sore throat treatments are available in a variety of formats and contain different active ingredients with different mechanisms of action.22 Guidelines often recommend ibuprofen or paracetamol for symptomatic relief2 these drugs are usually delivered systemically (liquid, tablet or capsule format).
Examples of Patients at High risk of Complications
Examples of Red Flag Symptoms
• Children <2 years old or born prematurely
• Shortness of breath
• Adults>65 years old • Those with compromised immune systems (e.g. receiving chemotherapy or who have HIV) • Those with a pre-existing medical condition such as diabetes, cystic fibrosis or chronic lung disease
• Coughing up blood
• Unilateral neck swelling unrelated to lymph nodes • Great difficulty swallowing • Very high temperature (>39°C) or night sweats • Drooling or muffled voice • Wheezing sounds when breathing • Patients appearing severely unwell
CPD 71: THE 123 OF SORE THROAT Active Ingredient
Mechanism of Action
McNally et al, 2010; Wade et al, 2011
McNally et al, 2010; Wade et al, 2011
Benzocaine Local Anaesthetic
Kagan et al, 1982; Busch et al, 2010; Chrubasik et al, 2012
Cingi et al, 2010; Cingi et al, 2011
Watson et al, 2000; Benrimoj et al, 2001; Blagden et al, 2002; Schachtel et al, 2014a; Schachtel et al, 2014b; Shephard et al, 2014; Russo et al, 2014a
Antiseptic, Local Anaesthetic
McNally et al, 2012
Kryukov et al, 1999; McNally et al, 2012
Lozenges, sprays and gargles are common examples of locally delivered formats which have the advantage of targeting the active ingredient(s) directly to the throat.25 22 Treatments that have anti-inflammatory effects can be of particular interest as inflammation is the underlying cause of sore throat symptoms.1, 11, 12 Lozenges The use of lozenges forms a reservoir of active ingredient(s) in the throat as the lozenge dissolves.25 Lozenges with a non-steroidal anti-inflammatory drug (NSAID) have been shown to provide effective relief of sore throat by providing pain relief, reducing throat swelling and making it easier to swallow.26, 27 All lozenges have a demulcent effect which may provide initial throat pain reduction during treatment.30 Sprays Sore throat sprays can provide targeted relief by delivering the active ingredient directly to the site of pain25,22 but vary with respect to spray characteristics. This affects delivery of the active ingredient to the throat. Characteristics considered by consumers to be of high importance include even product distribution, precision and delivery of spray as a gentle mist.31 A recently available sore throat treatment is a throat spray containing a low dose of the NSAID flurbiprofen (8.75 mg in three sprays). The spray format means that it targets the throat directly25 while the flurbiprofen acts in the affected area to reduce inflammation.32 A randomised controlled clinical trial with 505 patients has shown that flurbiprofen 8.75 mg spray is well tolerated and provides fast and sustained relief for throat soreness, sore throat pain, difficulty swallowing and the sensation of a swollen throat for up to 6 hours.33, 34
In this study, a single dose of flurbiprofen 8.75 mg spray reduced all these symptoms significantly more than a placebo from the time of the first post-dose assessment (5 minutes for throat soreness and difficulty swallowing, 20 minutes for sore throat pain intensity, 30 minutes for swollen throat) to 6 hours.33 Symptomatic treatments like flurbiprofen spray that are clinically proven to provide relief from the first dose and can be used as a first-line treatment in the initial few days when symptoms are at their most painful. Flurbiprofen 8.75 mg is also available in a lozenge format. As with the spray, flurbiprofen 8.75 mg lozenge has been shown to be well tolerated and efficacious in clinical trials.35, 27, 36, 37 In addition, flurbiprofen 8.75 mg lozenge has demonstrated efficacy in patients with particularly severe sore throat symptoms,38 patients complaining of a swollen and inflamed throat39 and patients with and without streptococcal infection. Note: Flurbiprofen Lozenges indicated for children over 12 years and Flurbiprofen Spray indicated for adults over 18 years. Patient Preferences Patient preferences are important when recommending products for symptomatic relief. Given that oral NSAIDs are available in tablets, caplets, dissolvable tablets or liquid-filled capsules, and the patient may have a regular formulation that they use. The following questions will help identify patient preferences: â€˘ Do you only need relief at the site of pain or do you feel generally unwell in addition to your sore throat? â€˘ Would you like to try a product containing a local anaesthetic which has a numbing effect?
CPD 71: THE 123 OF SORE THROAT • Do you have any swelling or inflammation, or is pain your only symptom? • Are you able to take tablets easily or would you prefer a medicated lozenge to suck?
• Are you over 18? • Do you have any other preferences for relief of your sore throat? • Are you on any other medications? • Do you suffer from any other medical conditions?
• Are you pregnant or breastfeeding? Select medication and formulations that best meet the patient’s needs and preferences. Remember to advise caution with hot food and drink if the formulation offered contains a local anaesthetic, as the numbing effect may prevent them from realising something is too hot.
In addition, please consider any concomitant medications the patient may be on and any special warnings or precautions that need to be taken into account. Please also take age of patient into consideration.
Eccles R. Mechanisms of symptoms of the common cold and influenza. Br J Hosp Med (Lond) 2007;68:71–5 ESCMID Sore Throat Guideline Group, Pelucchi C, Grigoryan L, Galeone C, Esposito S, Huovinen P, Little P, Verheij T. Guideline for the management of acute sore throat. Clin Microbiol Infect 2012;18:1–28 Worrall GJ. Acute sore throat. Can Fam Physician 2007;53:1961–2 Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev 2013;11:CD000023 Kuehn BM. Excessive antibiotic prescribing for sore throat and acute bronchitis remains common. JAMA 2013;310:2135– Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997–2010. JAMA Intern Med 2014;174:138–40. Hawker JI, Smith S, Smith GE, Morbey R, Johnson AP, Fleming DM, Shallcross L, Hayward AC. Trends in antibiotic prescribing in primary care for clinical syndromes subject to national recommendations to reduce antibiotic resistance, UK 1995-2011: analysis of a large database of primary care consultations. J Antimicrob Chemother 2014. [Epub ahead of print]. World Health Organisation. Antimicrobial Resistance, 2012, Accessed 21.09.16 www.who.int/mediacentre/factsheets/ fs194/en Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C. Clinical practice guideline for the diagnosis and management of group A
streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012;55:1279–82. Ebell MH. Epstein-Barr virus infectious mononucleosis. Am Fam Physician 2004;70:1279–87. Renner B, Mueller CA, Shephard A. Environmental and non-infectious factors in the aetiology of pharyngitis (sore throat). Inflamm Res 2012;61:1041–52 Renner B, Kettenmann B, Shephard A. Tonic stimulation of the pharyngeal mucosa causes pain and a reversible increase of inflammatory mediators. Inflamm Res 2013;62:1045–51. Schachtel, et al. J Pain. 2012;13:S6, Abstract 122 Milford C, Anuku S. Sore throat. ENT UK. 2011. Accessed 20.08.12. https://entuk. org/ent_patients/throat_conditions/sore_ throat Schachtel BP, Fillingim JM, Beiter DJ, Lane AC, Schwartz LA. Subjective and objective features of sore throat. Arch Intern Med 1984;144:497–500. Addey D, Shephard A. Incidence, causes, severity and treatment of throat discomfort: a four-region online questionnaire survey. BMC Ear Nose Throat Disord 2012;12:9. Schachtel B, Aspley S, Berry P, Shephard A, Sanner K, Shea T, Smith G, Schachtel E. Chief complaint: the therapeutogenic stimulus as the primary, individualized endpoint in clinical trials. J Pain 2012a;13:S6 Hanna BC, McMullan R, Gallagher G, Hedderwick S. The epidemiology of peritonsillar abscess disease in Northern Ireland. J Infect 2006;52:247–53. Rodriguez-Iturbe B, Musser JM. The current state of poststreptococcal glomerulonephritis. J Am Soc Nephrol 2008;19:1855–64 Van Driel ML, De Sutter A, Deveugele M, Peersman W, Butler CC, De Meyere M, De Maeseneer J, Christiaens T. Are sore throat patients who hope for antibiotics actually asking for pain relief? Ann Fam Med 2006;4:494–9 Essack S, Pignatari AC. A framework for the non-antibiotic management of upper respiratory tract infections: towards a global change in antibiotic resistance. Int J Clin Pract 2013;67(Suppl 180):4–9. Farrer F. Sprays and lozenges for sore throats. S Afr Fam Pract 2012;54:120–2. Sedinkin AA, Balandin AV, Dimova AD. Results of an open prospective controlled randomised comparative trial of efficacy & tolerance of sublingual tablets of flurbiprofen (Strepfen) & paracetamol in patients with sore throat pain in acute infectious inflammatory diseases of the upper respiratory tract. Vestn Otorhinolaryngol 2004;5:52–4. Mehlisch DR, Sykes J. Ibuprofen blood plasma levels and onset of analgesia. Int J Clin Pract Suppl 2013;67(Suppl 178):3–8.
25. Limb M, Connor A, Pickford M, Church A, Mamman R, Reader S, Shephard A, Aspley S, Goulder MA. Scintigraphy can be used to compare delivery of sore throat formulations. Int J Clin Pract 2009;63:606–12. 26. Schachtel B, et al. Int J Pharm. 2010;34:143-258. 27. Benrimoj SI, et al. Clin Drug Invest. 2001;21(3):183-193. 28. Wade AG, et al. BMC Fam Pract. 2011;12:6. 29. Oxford JS, Leuwer M. Int J Clin Pract. 2011;65:524-30 30. Schachtel B, et al. Int J Clin Pharm. 2012;34:143-258 31. Kansei study market research, RB data on file 32. Sefia E, Mann A, Lambkin R, Balasingham S, Oxford J, Simpson M, Shephard A, Goulder M. Flurbiprofen lozenges rapidly reduce levels of the inflammatory mediator prostaglandin E in human respiratory cells in vitro. Annual Scientific Meeting of the British Pain Society, 24–27 April 2007, Glasgow, Scotland. 33. Russo M, de Looze F, Bloch M, Montgomery B, Smith G, Shephard A, Aspley S. Effects of a single dose of flurbiprofen spray for the treatment of sore throat. Int J Clin Pharm 2014a: in press. 34. Russo M, de Looze F, Bloch M, Montgomery B, Smith G, Shephard A, Aspley S. Safety and efficacy of flurbiprofen spray for the treatment of sore throat. Int J Clin Pharm 2014b: in press. 35. Watson N, Nimmo WS, Christian J, Charlesworth A, Speight J, Miller K. Relief of sore throat with the anti-inflammatory throat lozenge flurbiprofen 8.75 mg: a randomised, double-blind, placebocontrolled study of efficacy and safety. Int J Clin Pract 2000;54:490–6. 36. Schachtel B, Aspley S, Shephard A, Shea T, Smith G, Sanner K, Savino L, Rezuke J, Schachtel E. Onset of action of a lozenge containing flurbiprofen 8.75mg: a randomized, double-blind, placebocontrolled trial with a new method for measuring onset of analgesic activity. Pain 2014a;155:422–8. 37. Schachtel B, Aspley S, Shephard A, Shea T, Smith G, Schachtel E. Utility of the sore throat pain model in a multipledose assessment of the acute analgesic flurbiprofen: a randomized controlled study. Trials 2014b;15:263. 38. Aspley S, Schachtel B, Berry P, Shephard A, Shea T, Smith G, Schachtel E. Flurbiprofen lozenges in patients with a “bad sore throat”. J Pain 2013;14:S59. 39. Schachtel B, Aspley S, Berry P, Shephard A, Shea T, Sanner K, Smith G, Schachtel E. Efficacy of flurbiprofen 8.75mg lozenges in patients with swollen/inflamed sore throat. Abstract presented at the 14th World Congress on Pain, 27–31 August 2012b, Milan, Italy.