IPN 2022 October

Management and Treatment of – Cough

Following on from the September issue Continuing Professional Development on the Management of Cough, this 5-Minute Learning Module is designed to enhance the community pharmacy team understanding and ask further questions as to how you can support and advise patients.

Learning ObjectivesAfter studying this module, pharmacy teams will:

• Understand that cough is a common symptom and complaint, and is associated with a wide variety of aetiologies and clinical conditions.

• Be aware of the different types of presenting cough (acute, subacute or chronic) and identify the correct pharmacy treatments

• Identify red flags and/ or danger symptoms, and know when a patient needs to be referred to the GP or seek urgent medical attention.

• Be aware of any potential drug-drug interactions or contraindications, considerations and questions to ask the patient before supplying OTC or prescribed cough medication

After completing this module, you should recognise the varying types of cough that may present to the pharmacy and the OTC treatments available for each. Where pharmacy management is appropriate you will be able to explain to patients the nature of their type of cough and suggest possible solutions. You will be able to give advice on current recommendations symptom management and know how to signpost to relevant resources. Where a patient wishes to purchase OTC treatments, you should be able to support that person to make appropriate choices.

Cough is a common symptom and complaint, particularly during the winter months, and is associated with a wide variety of aetiologies and clinical conditions. A cough is one of the most common medical complaints, and is the most common symptom for which people seek advice at their community pharmacy.

Coughs are classified as acute, subacute or chronic. A cough is considered ‘acute’ if it is present for less than 3 weeks. A ‘subacute’ cough, is one lasting 3 to 8 weeks, most often due to a recent

respiratory infection. A cough of greater than 8-week duration is considered a ‘chronic’ cough.

Most coughs are self-limiting and will usually self-resolve within 3 weeks, however, it is important for the person to see or be referred to the GP, if the cough lasts more than 3 weeks, or if the person is coughing up blood (haemoptysis).

Smoking is a leading risk factor for coughs, and additional common causes of an acute cough include acute rhinosinusitis, pertussis, acute exacerbations of COPD, allergic rhinitis, asthma, congestive heart failure, pneumonia, aspiration syndromes, and pulmonary embolism. An acute cough is also a main symptom of SARS-CoV-2 (Covid-19) infection, and this must always be considered when a patient presents with a cough, and investigated and treated appropriately.

Those presenting to the pharmacy with a cough should be referred to their GP if they:

• Are finding it difficult to breathe

• Are short of breath or have a wheeze

• Are coughing up blood (Haemoptysis)

• Have a hacking cough or cannot stop coughing and it is getting worse

• Have a recurrent nocturnal cough

Coughs and colds in children are frequent and usually self-limiting, and there is no clear evidence to support the use of these products in children under six. Children under six years should not be given OTC cough and cold medicine containing;

• brompheniramine, chlorphenamine maleate, diphenhydramine, doxylamine, promethazine or triprolidine (antihistamines)

• dextromethorphan or pholcodeine (cough suppressants)

• guaifenesin or ipecacuanha (expectorants)

• phenylephrine hydrochloride, pseudoephedrine hydrochloride, ephedrine hydrochloride, oxymetazoline, or xylometazoline hydrochloride (decongestants)

Certain cough remedies however, made with mainly natural ingredients including traditional herbal medicinal products (THRs) are licenced for sale in Ireland, available in pharmacies nationwide, and suitable to use for children over 12 months old. A range of products are specifically formulated for children from 1 year of age, and can be used to treat dry or chesty coughs.

Opioid derivatives are commonly sold as cough suppressants / antitussives to suppress the cough reflux from the medulla in the brain stem to provide relief from frequent coughing. Common drugs include dextromethorphan, pholcodine, dihydrocodeine, and codeine. Preparations may be sold as syrups, medicated lozenges, tablets or capsules.

Medication licensed for the management of productive coughs fall into two categories: expectorants (protussives) and mucolytics. Like antitussives, these drugs come as syrups, medicated lozengers, tablets or capsules.

Herbal medicines are popular in the treatment of minor medical conditions, including coughs. Herbal medicines are those with active ingredients made from plant extracts such as leaves, roots and flowers. Like conventional medicines, herbal medicines have an effect on the body, and can be potentially harmful if not used correctly. While traditional herbal remedies are safe to use for most people, some herbal medicines may not be suitable for certain individuals including; those taking other medicines; people with serious health conditions, such as kidney or liver disease; people who are undergoing surgery; pregnant or breastfeeding women; some older people and children.

There are a wide variety of herbal remedies available for coughs in pharmacies. Consumers should check for a traditional herbal registration (THR) marking on the product packaging, which means the medicine complies with quality standards relating to safety and manufacturing, and provides information about how and when to use it.

Now I should:

• Update my knowledge of the signs, symptoms, causes and treatment of cough

• Reassess my and my staffs’ ability to do a risk assessment

• Train my pharmacy counter assistants to ensure they can meet the points in the training checklist