mtm essentials for cold, ﬂ u, and sinusitis management · 10/10/2018 · 36 drug topics october...

36 Drug topics October 2015 DrugTopics.com

EARN CE CREDIT FOR THIS ACTIVITY AT WWW.DRUGTOPICS.COM

Goal: The goal of this activity is to compare and contrast the common cold, infl uenza, and sinusitis and discuss the role of the pharmacist as the medication expert for various treatment options and as a source to triage patients when needed.

After participating in this activity, pharmacists will be able to:

● Compare the clinical presentations of the

common cold, fl u, and sinusitis

● Describe nonpharmacologic and

pharmacologic therapy for the common cold,

fl u, and sinusitis

● Summarize the effi cacy and safety of

popular herbal products for the common

cold, fl u, and sinusitis

● Discuss essentials of pharmacist triage

for the patient with cold, fl u, and sinusitis

symptoms

● Compare differences between adult and

pediatric populations as they relate to the

common cold, fl u, and sinusitis

The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider

of continuing pharmacy education.Pharmacists are eligible to participate in the knowledge-based activity, and will receive up to 0.2 CEUs (2 contact hours) for completing the activity, passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the CPE Monitor online system and your participation will be recorded with CPE Monitor within 72 hours of submission.

ACPE# 0009-9999-15-035-H01-P

Grant Funding: This activity is supported by an inde-pendent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.

Supported by an educational grant from Genentech

Novartis Pharmaceuticals Corporation

Activity Fee: There is no fee for this activity.

Initial release date: October 10, 2015

Expiration date: October 10, 2018

To obtain CPE credit, visit www.drugtopics.com/cpe and click on the “Take a Quiz” link. This will direct you to the UConn/Drug Topics website, where you will click on the Online CE Center. Use your NABP E-Profi le ID and the session code: 15DT35-PTK48 to access the online quiz and evaluation. First-time users must pre-register in the Online CE Center. Test results will be displayed immediately and your participation will be recorded with CPE Monitor within 72 hours of com-pleting the requirements.

For questions concerning the online CPE activities, e-mail: [email protected].

CREDIT: 2.0

educationaL oBJectiVeS

MtM essentials for cold, fl u, and sinusitis management

Faculty: danielle M. Miller, Pharmd, and tayla n. Rose, PharmdDr. Miller is an assistant clinical professor at Northeastern University School of Pharmacy, Boston, Mass., and an ambulatory care clinical pharmacy specialist at Boston Medical Center, Boston, Mass. Dr. Rose is an assistant clinical professor at Northeastern University School of Pharmacy, Boston, Mass., and an ambulatory care clinical pharmacy specialist at Lynn Community Health Center, Lynn, Mass.

Faculty Disclosure: Dr. Miller and Dr. Rose have no actual or potential confl ict of interest associated with this article.

Disclosure of Discussions of Off-Label and Investigational Uses of Drugs: This activity may contain discussion of unlabeled/unapproved use of drugs in the United States and will be noted if it occurs. The content and views presented in this educational program are those of the faculty and do not necessarily repre-sent those of Drug Topics or University of Connecticut School of Pharmacy. Please refer to the offi cial information for each product for discussion of approved indications, contraindications, and warnings.

AN ONGOING CE PROGRAM OF THE UNIVERSITY OF CONNECTICUT SCHOOL OF PHARMACY AND DRUG TOPICS

Continuing Education

AbstractThe common cold, in� uenza (� u), and sinusitis are common upper respiratory tract infections (URIs) that frequently result in unnecessary primary care of� ce visits, missed school days among children, and missed work days among adults. Because of their viral etiology (except in less common cases of bacterial sinusitis), these illnesses are considered to be self-limiting. Treatment recommendations are focused on symptom management, including pharmacologic, nonpharmacologic, and/or complementary alternative medicine options. Community pharmacists are uniquely positioned healthcare providers adequately trained to assess patients’ symptoms and triage care. Serving as the initial healthcare provider, pharmacists are able to identify whether patients are eligible for self-care or whether they require a referral to a primacy care provider. In the setting of self-care, pharmacists serve as medication experts to recommend over-the-counter (OTC) pharmacologic options and/or nonpharmacologic options for symptom management.

Danielle M. Miller, PharmDASSISTANT CLINICAL PROFESSOR, NORTHEASTERN UNIVERSITY SCHOOL OF PHARMACY, BOSTON, MASS., AND AMBULATORY CARE CLINICAL PHARMACY SPECIALIST, BOSTON MEDICAL CENTER, BOSTON, MASS.

Tayla N. Rose, PharmDASSISTANT CLINICAL PROFESSOR, NORTHEASTERN UNIVERSITY SCHOOL OF PHARMACY, BOSTON, MASS., AND AMBULATORY CARE CLINICAL PHARMACY SPECIALIST, LYNN COMMUNITY HEALTH CENTER, LYNN, MASS.

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continuing education

October 2015 Drug topics 37DrugTopics.com

introductionThe common cold, infl uenza (fl u), and sinus-itis are commonly encountered upper respi-ratory tract infections (URIs) that comprise a majority of visits to primary care offi ces and are often inappropriately treated with a prescription antibiotic.1,2 In addition to prescription drug use, there are an abun-dance of nonprescription products, includ-ing herbal and complementary alternative medicine (CAM) products, available to treat symptoms related to the common cold, fl u, and sinusitis.3 Community pharmacists are aptly placed as fi rst-line healthcare provid-ers able to assess patients’ symptoms, determine self-care eligibility, and make nonpharmacologic and/or pharmacologic recommendations as appropriate.

symptoms associated with the common cold, fl u, and sinusitisThe common cold, often simply referred to as a cold, is a viral infection of the up-per respiratory tract. While there are nu-merous viruses that may cause a cold, rhinovirus is the most common. Although relatively benign in nature, colds are the primary reason for missed school and workdays for children and adults, respec-tively.4 Colds often develop slowly, with a one- to three-day incubation period after viral exposure, and begin with a sore or “scratchy” throat and rhinorrhea, followed by sneezing and cough. Other symptoms commonly associated with a cold include itchy or watery eyes (Table 1).5-7 Systemic symptoms such as headache, fever, my-

algia, and general malaise are less com-mon with a cold and more indicative of the fl u.8 The average duration of a cold varies from seven to 10 days, with the exception of the cough, which can last up to three weeks and is often considered the most bothersome symptom for patients.4,8 Colds are generally considered to be self-limiting; however, because they are often a reason for children and adults staying home from school or work, affl icted individuals may fi nd themselves turning to various over-the-counter (OTC) products to help alleviate their symptoms. Some patients may visit the doctor’s offi ce in search of an antibiot-ic despite the viral nature of the infection.8

Regardless of the treatment that patients seek, it is important to keep in mind that symptom management is the preferable treatment for colds, as there is no cure for the causative virus. The common cold is a contagious virus spread primarily via self-inoculation through the nasal mucosa or conjunctival membranes. Spread of the infection can be prevented by proper hand washing, disinfecting frequently touched objects such as toys or door handles, and avoiding close contact with others.4

The fl u is a highly contagious respira-tory infection caused by the infl uenza vi-rus. Two types of infl uenza virus, Type A and Type B, cause disease in humans. Type A is further divided into various subtypes based on the genetic makeup of the viral surface proteins.9,10 Infl uenza Type A is con-sidered more pathogenic than Type B and is responsible for most outbreaks.5 The strains vary yearly and are often unpredict-

able. Yearly vaccination is prudent because of the constant variability in virus strains caused by “antigenic shift” and “antigenic drift.”11 Although some symptoms of the fl u are similar to those of a cold, fl u symptoms are more abrupt in onset and more severe in nature. Symptoms typically include a high fever (≥100-102°F), chills, myalgia, fatigue, sore throat, stuffy or runny nose, and headache (Table 1).5-7 Most individu-als who are otherwise healthy will recover from the fl u in a few days. However, the World Health Organization (WHO) estimates that 250,000 to 500,000 deaths are re-lated to the fl u each year. The incubation period of the virus is 18 to 72 hours, but viral shedding begins 24 hours before the onset of symptoms and may last for fi ve to

Welcome to the CPE series, Medication Therapy Management for the Patient with Respiratory Disease, which was designed for pharmacists who take care of patients with respiratory disease. Beginning in April 2015 and continuing through December 2015, pharmacists can earn up to 18 hours of CPE credit with 9 monthly knowledge-based activi-ties from the University of Connecticut School of Pharmacy and Drug Topics.

This series kicked off in April and May with MTM essentials for asthma manage-ment—Part 1 and Part 2. In June and July, the focus shifts to MTM essentials for chronic obstructive pulmonary dis-ease (COPD) management. The August CE activity is a primer on inhalers and nebulizers. In September, pharmacists have the opportunity to learn about al-lergic rhinitis management. In October, the CE activity covers MTM essentials

for cold, fl u, and sinusitis management. The November CE activity includes drug-induced pulmonary disease recognition and management and idiopathic pulmo-nary fi brosis. The series concludes in De-cember with a focus on MTM essentials for cough management.

The series also offers application-based and practice-based activities in 2016.

cpE sEriEs: MtM For tHE pAtiENt WitH rEspirAtorY DisEAsE

The best way to prevent the � u is to receive the � u vaccine each year, ideally before � u season, as antibodies against the virus develop approximately two weeks after vaccination.



10 days. The virus is easily spread among individuals, entering the respiratory tract of the host where it begins to proliferate.5 The best way to prevent the fl u is to receive the fl u vaccine each year, ideally before fl u sea-son, as antibodies against the virus develop approximately two weeks after vaccination. Flu season may begin as early as October, may peak in January and February, and may continue to persist until May. The Centers for Disease Control and Prevention (CDC) therefore recommends that all individuals over the age of six months be vaccinated as early as possible. However, it is appropri-ate to receive the vaccination at any point during fl u season.12

Acute rhinosinusitis, or sinusitis for short, is defi ned as an infl ammation of the mucosal lining of the nasal passage and paranasal sinuses and is usually consid-ered to be mild to moderate in nature.2

Most acute sinusitis cases are viral (90%-98%), with the rhinovirus and coronavirus as causative agents. However, bacterial eti-ology does occur less commonly (2%-10% of cases).13 URIs, although mostly viral in nature, often precede the development of acute bacterial rhinosinusitis (ABRS).

Organisms commonly responsible for ABRS include Streptococcus pneumoniae, Hae-mophilus infl uenzae, and Moraxella catarrha-lis.14 Clinical presentation will therefore vary depending on the etiology of the infection. Symptoms commonly associated with si-nusitis include nasal discharge beginning as clear and watery and becoming more thick and discolored by day four or fi ve, conges-tion, cough, and sore or “scratchy” throat (Table 1).5-7 Fever and/or myalgias are pos-sible in the fi rst 24 to 48 hours. Bacterial sinusitis is usually distinguished from viral sinusitis based on the duration of symp-toms, severity of symptoms, or worsening of symptoms (Table 2).6 According to the In-fectious Diseases Society of America (IDSA) Clinical Practice Guidelines for Acute Bacte-rial Rhinosinusitis in Children and Adults, a patient presenting with any one of the three criteria in Table 2 is clinically considered to have ABRS.6 Duration of sinusitis also varies based on etiology. Viral sinusitis is shorter in duration, lasting approximately fi ve to 10 days with a peak in symptoms around days three to six, whereas bacte-rial sinusitis usually persists for more than seven to 10 days.6

symptomatic treatment for the common coldThe widespread prevalence of the com-mon cold results in many consumers pur-chasing OTC products for self-treatment. These OTC medications are viable options for the treatment of cold symptoms such as cough, nasal congestion, runny nose, watery eyes, myalgia, and general malaise. As there are more than 200 available OTC cough/cold products, many formulated as combination products, it is imperative for patients to choose the most appropriate product based on their symptoms.8 Phar-macists are able to quickly and accurately assess a patient’s symptoms with respect to characteristics, history, onset, and any aggravating/remitting factors and estab-lish whether patients are eligible to self-treat. This approach is better known as QuEST SCHOLAR (Figure 1).15

Essential pharmacologic treatment op-tions for cough/cold symptoms include analgesic/anti-inflammatory agents, anti-histamines, decongestants, expectorants, and antitussive products. Analgesics such as aspirin, acetaminophen, ibuprofen, and naproxen are commonly employed for both their analgesic and anti-infl ammatory prop-erties, with acetaminophen most commonly found in OTC cold products.8 It is thought that respiratory symptoms arise secondary to an infl ammatory process caused by the virus, most notably via the prostaglandin E2 mediator, supporting the use of nonsteroidal anti-infl ammatory drugs (NSAIDs).16-19

Runny nose, itchy/watery eyes, and sneezing respond well to the use of antihis-tamines, as these symptoms are thought to result from histamine release caused by an infl ammatory response to the causative virus.20 First-generation antihistamines such as chlorpheniramine and doxylamine are effi cacious in reducing nasal symptoms as monotherapy but are considered to be more effi cacious in treating cold symptoms when combined with other agents.21 Drowsiness is a well-known side effect of fi rst-genera-tion antihistamines because of their ability to cross the blood-brain barrier. Due to this troublesome side effect, first-generation antihistamines should be used with caution in certain patient populations, such as the elderly and those who require mental alert-ness. Nonsedating second-generation anti-histamines such as loratadine, fexofenadine,

MtM eSSentiaLS FoR coLd, FLu, and SinuSitiS ManageMent

TABLE 1 CLiniCAL PResentAtion oF CoMMon ResPiRAtoRY inFeCtions

Common cold Infl uenza Sinusitis

Common symptoms:Sore/scratchy throat, cough, nasal congestion, rhinorrhea, itchy/watery eyes, sneezing

Common symptoms:Fever, myalgia, headache, rhinitis, sore throat, cough, general body aches/fatigue

Common symptoms:Nasal congestion and/or discharge, facial pain, cough, fever

Possible symptoms:Low-grade fever, chills, headache, myalgia, general malaise

Possible symptoms:Nausea, vomiting, diarrhea

Possible symptoms:Sore throat, cough, laryngitis, headache, loss of smell, tooth pain

Onset of symptoms:Slowly over the course of 1-3 days

Onset of symptoms:Sudden

Onset of symptoms:Evolves over days

Source: Ref 5-7

TABLE 2 ACute BACteRiAL RHinosinusitis CLiniCAL PResentAtion

Patient must meet any one of the following criteria:

• Symptoms of acute sinusitis persisting ≥10 days without signs of improvement• Severe signs/symptoms characterized by high fever ≥102°F and purulent nasal discharge or

facial pain lasting ≥3 to 4 consecutive days beginning at symptom onset• Worsening symptoms, such as new-onset fever, headache, or increase in nasal discharge after

initial improvement (“double sickening”)Source: Ref 6

DrugTopics.com October 2015 Drug topics 39


and cetirizine lack this side effect but unfor-tunately have not been shown to effectively treat histamine-mediated cold symptoms.22

Nasal congestion is caused by swelling in the nasal mucosa tissue and obstruc-tion of the airways due to vasodilation and increased vascular permeability as a result of the infl ammatory processes associated with the common cold.23,24 Phenylephrine (PE) and pseudoephedrine (PDE) are FDA-approved oral decongestants that constrict dilated blood vessels in the nasal mucosa, thereby relieving nasal congestion. Although still available without a prescription, PDE has been moved to behind pharmacy counters to regulate sales because of its role in the illegal production of methamphetamine.25

This barrier in accessibility led to the refor-mulation, or brand-name extension, of many products to replace PDE with PE, therefore keeping decongestants readily available in the aisles. The addition of “PE” to com-monly known brands was used to distin-guish the replacement of PDE with PE.26

Unfortunately, the recommended PE single dose of 10 mg is considered less effective than PDE single dose of 60 mg because PE undergoes extensive systemic metabolism, leading to low bioavailability.27,28 In addition to the low bioavailability, the two agents also differ in duration of action. Because of a shorter half-life (2–3 hours), PE is dosed ev-ery four hours compared to PDE, which has a longer half-life and can be dosed every four to six hours.29,30 Following product reformula-tion, concern grew for the low bioavailability of PE (38%), compared to PDE (90%), resulting in the Citizen’s Petition of February 1, 2007, which was fi led with the FDA to increase the maximum allowable PE dose from 10 mg to 25 mg.31 However, following the meeting of the Nonprescription Drug Advisory Committee in December 2007, it was concluded that 10 mg of oral PE is safe and effective as an OTC nasal decongestant in adults and that insuffi -cient evidence exists to increase the dose to 25 mg.32 While there is a plethora of literature to support the effi cacy of a single 60-mg oral PDE dose for nasal congestion, there is a

lack of literature available to support the use of PE at a higher dose. Even more confl icting, one study concluded that 10 mg of oral PE was no more effective than placebo in the treatment of nasal symptoms.27,33 Patients should therefore be educated accordingly as brand-name products they had previously used may now contain a different chemical ingredient, increasing concern for potential drug-drug or drug-disease interactions, and differences in effi cacy.

Cough is often the most irritating and longest lasting symptom associated with the common cold, lingering for up to three weeks. Airway infl ammation, excess mucus produc-tion, and postnasal drip are mechanisms re-sponsible for cough.34,35 Treatment of cough depends on whether the cough is productive or nonproductive. Productive coughs may warrant the use of an expectorant such as guaifenesin, whereas nonproductive coughs may warrant the use of an antitussive such as dextromethorphan. However, combining the two ingredients can be useful in certain situations to alleviate not only cough frequen-cy but also the physical symptoms of chest discomfort associated with excess mucus. Although many studies have demonstrated effi cacy with dextromethorphan alone for non-

productive, dry cough, others have found no difference between dextromethorphan and placebo.36-38 The American College of Chest Physicians recommends the combination of brompheniramine, a fi rst-generation antihista-mine, and PDE for acute cough.39

As most people do not typically suffer from just one symptom, cold relief products generally contain a combination of multiple medications targeted at alleviating an array of cold symptoms. This strategy can be benefi -cial for patients, as evidenced by a placebo-controlled trial that found that acetaminophen and PDE used in combination provided better relief of URI-associated pain and congestion than either agent used as monotherapy.40

However, the use of combination products can also be harmful for patients by exposing them to unnecessary medications and their associated adverse effects. Pharmacists can help patients choose the right product by educating them to properly read OTC prod-uct packaging and to select certain agents based on individualized symptoms. Not only is it imperative for patients to understand the symptoms that they are treating, but they must also understand the directions for use, including maximum daily intake of individual medications. OTC products are considered safe when used in recommended amounts; nevertheless, these agents are associated with adverse events that can worsen when dose limitations are exceeded.8

Because of the similarity between cold and fl u symptoms (Table 1), patients should be counseled to seek medical attention if

pause&ponder

Which herbal supplements have you recently seen in the media claiming to prevent and/or treat upper respiratory tract infections?

FIGURE 1

QuEST SCHOLAR Mnemonic for assessing self-care among patients

Source: Ref 15 (Used with permission of the American Pharmacists Association)

• Symptoms: What are the main and associated/related symptoms?• Characteristics: What are the symptoms like?• History: What has been done so far? Has this ever happened

and was prior treatment successful?• Onset: When did this particular problem start? • Location: Where is the problem? • Aggravating factors: What makes it worse?• Remitting factors: What makes it better?

• Quickly and accurately assess the patient.• Establish that the patient is an appropriate

self-care candidate.• Suggest appropriate self-care strategies.• Talk with the patient.QuEST

SCHOLAR


Continuing Education MtM eSSentiaLS FoR coLd, FLu, and SinuSitiS ManageMent

symptoms do not resolve within seven to 10 days. Pharmacists can also educate patients about nonpharmacologic treatment recom-mendations such as saline nasal irrigation, gargling with warm salt water, increased fl uid intake (such as hot tea with lemon and honey and chicken noodle soup), adequate rest, and increased humidifi cation with mist vaporizers or hot showers.7

treatment recommendations for infl uenzaAccording to the CDC, WHO, and IDSA, patients presenting with fl u-like symptoms should be diagnosed clinically. There are, however, rapid infl uenza diagnostic tests available. Unfortunately, while the speci-fi city of these tests is high (>95%), rapid fl u tests have variable sensitivity, ranging from 10% to 70%, and negative results cannot rule out the fl u. Real-time reverse transcriptase polymerase chain reaction tests and viral cultures are available, but these techniques take more than 24 hours

to produce results.5 Because of the gen-erally self-limiting course of the fl u virus, antiviral treatment is recommended only for certain patient populations. Prophy-lactic treatment is also available and rec-ommended for individuals who may have been in close contact with someone with the fl u (Figure 2).5

There are two antiviral drug classes in-dicated for the treatment and prevention of infl uenza: neuraminidase (NA) inhibitors and adamantanes. Only two antiviral drugs, both belonging to the NA inhibitor medication class, are FDA approved for the prevention and treatment of the fl u in the outpatient setting: oseltamivir (Tamifl u) and zanamivir (Relenza) (Table 3).41,42 NA inhibitors prevent the release of virions from an infected host by inhibiting the enzyme neuraminidase, thereby reducing viral spread. NA inhibitors work on both infl uenza subtypes.43 Initiation of NA inhibitors within 36 to 48 hours of symptom onset has been associated with a statistically signifi cant reduction in the time to symptom resolution. Initiating these agents in a timely manner is important be-cause they have not shown effectiveness in patients who have been experiencing symp-toms for longer than 48 hours. According to a systematic review and meta-analysis of the two NA inhibitors, use of these agents within two days of symptom onset in chil-dren resulted in symptom resolution 0.5 to 1.5 days sooner than in those not receiving

a NA inhibitor.44,45 In contrast, the adaman-tanes, rimantadine and amantadine are not routinely recommended in clinical practice. Drug resistance, side effects, and lack of effi cacy against infl uenza Type B virus limit their use.46 Young, healthy individuals are excluded from antiviral therapy and instead should be educated about nonpharmaco-logic treatment options such as rest and adequate hydration. Specific symptoms may be treated with OTC antipyretic and/or anti-infl ammatory agents. The use of aspi-rin or aspirin-containing products should be avoided in children and teenagers because of the risk of Reye’s syndrome.47

treatment recommendations for sinusitisPharmacologic recommendations for the treatment of sinusitis vary depending on the cause: bacterial or viral. In general, an-tibiotics should not be routinely prescribed for acute mild to moderate sinusitis as it is often viral in nature. Pharmacists may help to reassure patients during this watch-ful waiting period and counsel patients to contact their primary care provider if symp-toms last for more than seven days, if symptoms worsen after initial improvement, or if symptoms are accompanied by a high fever (≥102°F), excruciating facial/dental pain, or pain/tenderness over the sinuses.2

Overall, acute sinusitis is a self-limiting viral infection that often co-occurs with a URI or the common cold. Nonpharmacologic treat-ment recommendations include applying a warm compress over the face or breathing in steam from a hot shower to help allevi-ate sinus pain and facilitate mucus drain-age. Nasal irrigation can also help to clean out the nasal passages. Patients should maintain adequate hydration to dilute mu-cus buildup and promote drainage. Patients should also elevate the head of the bed when sleeping to prevent congestion and should obtain plenty of sleep to help fi ght off the infection.

However, if a clinical diagnosis of ABRS is made, empiric antibiotic treatment should be initiated immediately. Amoxicillin-clavu-lanic acid is considered a fi rst-line option for ABRS in both children and adults. In adults with a penicillin allergy, alternative fi rst-line options include doxycycline or a respiratory fluoroquinolone (levofloxacin

FIGURE 2

Source: Ref 5 (Adapted with permission)

*Close contact: Self-inoculation of mucosal surfaces after droplet exposure to respiratory secretions (coughing or sneezing) from an infectious person.§Infectious period: One day before fever until 24 hours after resolution.

Indications for antiviral agents for the treatment and prophylaxis of the infl uenza virus

• Hospitalized patients with severe, complicated influenza-like illness or laboratory-confirmed influenza

• Patients with influenza-like illness or laboratory-confirmed influenza who are at risk of complications in the outpatient setting

• Patients with severe, complicated influenza-like illness or laboratory-confirmed influenza in the outpatient setting

Indications to prescribe antiviral

treatment

• Healthcare workers• Persons at risk of influenza-related complications • Pregnant women

Indications to consider

antiviral prophylaxis if close contact* has occurred with an infected person

during the infectious period§

pause&ponderHow can you more effectively counsel patients on the selection of appropriate combination cough and cold products?



or moxifloxacin). Because of increased resistance against S. pneumoniae and S. pneumoniae plus H. infl uenzae, macrolides and trimethoprim-sulfamethoxazole, respec-tively, are no longer recommended for initial treatment. In uncomplicated ABRS, the du-ration of therapy is fi ve to seven days in adults and 10 to 14 days in children. An ad-juvant intranasal corticosteroid can be used with antibiotics, particularly in patients with a history of allergic rhinitis. However, the use of topical or systemic decongestants and antihistamines should not be recom-mended as adjuvant therapy. These agents may dry out the nasal mucosa and prevent normal clearance of secretions.6

Herbal products: Do they work and are they safe?Various vitamins, supplements, and herbal remedies are promoted as “natural” options for the prevention and treatment of URIs. Because of the plethora of these products available on pharmacy shelves, pharmacists will often be asked to provide a recommen-dation. As such, pharmacists must be well informed regarding the safety and effi cacy of these products. Several commonly encoun-tered products are reviewed below.

Andrographis paniculataAndrographis paniculata (andrographis) is an herb with a long history of use in traditional Indian, Chinese, and Thai medicine.48 In addi-tion to its use in many other ailments, it is be-lieved to prevent and treat the common cold. A Swedish formulation of andrographis, Kan Jang, when used prophylactically at a dose of 100 mg twice daily fi ve days per week for a minimum of two months, may reduce the risk of the common cold by twofold.49 In terms of common cold treatment, one particular an-drographis product, KalmCold, demonstrated a statistically signifi cant reduction in symp-toms versus placebo at a dose of 100 mg twice daily for fi ve days.50 Patients had been symptomatic for fewer than three days upon taking the fi rst dose.

Andrographis is generally well tolerated but may cause diarrhea, vomiting, nosebleed, and itchy rash.48,50 Caution should be used in patients taking immunosuppressive, anti-hypertensive, or anticoagulant medications as andrographis may stimulate the immune system, and increase the risk of bleeding and hypotension.48

Take away: Andrographis, in the form of Kan Jang and KalmCold, may be effec-tive in the prevention and treatment of the common cold, respectively. Results are not generalizable to all andrographis products. If this agent is used for treatment, patients should start taking the medication within 72 hours of symptom onset.

EchinaceaEchinacea refers to a genus of North Ameri-

can fl owering plants in the Asteraceae family. Echinacea species are promoted as immune system stimulants and protectors against the common cold. Three species of Echina-cea (purpurea, angustifolia, and pallida) are used in herbal products.51 These products may include the aerial (above-ground) and/or root portions of the plant in varying propor-tions. Additionally, these products come in various formulations, including oral tablets and capsules, liquid extracts, juices, and teas. These differences in composition and formulation lead to a high degree of variabil-ity among products. It is important to con-sider these inconsistencies and how they might affect the safety and effi cacy of the various products.

A systematic review conducted in 2013 evaluated a variety of Echinacea products versus placebo for the prevention and treat-ment of the common cold.52 Investigators concluded that Echinacea is not effective for the treatment of colds. Prophylactic Echinacea did not signifi cantly reduce the incidence of cold; however, a nonsignifi cant trend toward prevention was observed. Other studies have found that Echinacea purpurea may decrease the duration and severity of cold symptoms when initiated shortly after symptom onset; however, Echi-nacea angustifolia is not benefi cial.1

Echinacea may cause nausea and head-ache and is known to have a poor taste.51

It has also been associated with rashes, particularly in children.52 Echinacea may inhibit cytochrome P450 1A2 and induce cytochrome P450 3A4, leading to poten-

pause&ponder

How often do you use the QueSt ScHoLaR method when triaging patient symptoms?

TABLE 3 neuRAMiniDAse inHiBitoRs FoR tHe tReAtMent AnD PReVention oF inFLuenZA

Antiviral agent FDA-approved indications Treatment (by mouth twice daily for 5 days) Prevention (by mouth once daily for 10 days)*

Oseltamivir • Prophylaxis in patients aged ≥1 year• Treatment of acute, uncomplicated fl u

in patients aged ≥1 year who have not been symptomatic for >48 hours

Children aged 1-12 years:• ≤15 kg: 30 mg• >15-23 kg: 45 mg • >23-40 kg: 60 mg• >40 kg: use adult dosage

Children aged ≥13 years and adults:• 75 mg• CrCl <30 mL/min: 75 mg once daily

for 5 days

Children aged 1-12 years:• ≤15 kg: 30 mg• >15-23 kg: 45 mg • >23-40 kg: 60 mg• >40 kg: use adult dosage

Children aged ≥13 years and adults:• 75 mg • CrCl <30 mL/min: 75 mg every other

day for ≥10 days

Zanamivir • Prophylaxis in patients aged ≥5 years• Treatment of acute, uncomplicated fl u

in patients aged ≥7 years who have not been symptomatic for >48 hours

Children aged ≥7 years and adults: • 2 inhalations (10 mg) via the Diskhaler

Children aged ≥5 years and adults:• 2 inhalations (10 mg) via the Diskhaler

Abbreviations: CrCl, creatinine clearance.*Oseltamivir may be used prophylactically for up to 6 weeks and zanamivir for up to 4 weeks during community influenza outbreaks. Source: Ref 41,42

DrugTopics.com42 Drug topics October 2015


tial drug-drug interactions.51 The clinical impact of these interactions is unclear. Additionally, it may stimulate the immune system and should be avoided in patients who are immunosuppressed, including those taking immunosuppressive medica-tions. Patients should be counseled on the possibility of an allergic reaction, especially those with a history of atopy.

Take away: Echinacea products should not be recommended for the prevention or treatment of the common cold because of the lack of consistency among products and the lack of compelling evidence. If pa-tients do elect to use an Echinacea prod-uct, Echinacea purpurea may have greater benefi t than other species.

ElderberryElderberry (Sambucus nigra) is marketed for the treatment of infl uenza. Elderberry is thought to stimulate the immune system by signifi cantly increasing the production of cy-tokines.53 One study showed that patients with the fl u who used elderberry extract four times daily experienced pronounced symp-tom improvement after 3.1 days versus 7.1 days in patients taking placebo.54 Patients included in this study had been symptomat-ic for less than 48 hours. It is important to note that this study was conducted using a specifi c product (Sambucol, Nature’s Way); results should not be extrapolated to allelderberry products. Another study found that elderberry lozenges taken four times daily for two days signifi cantly improved in-fl uenza symptoms within 48 hours when patients took the fi rst dose within 24 hours of symptom onset.55 Both of these studies were small, with each including approxi-mately 60 patients; therefore, results may not be generalizable to the entire popula-tion.

Elderberry is well tolerated in supple-mental form. Patients should be warned that eating raw elderberries may cause nausea, vomiting, and diarrhea. Cook-ing the elderberries eliminates this risk.56

Elderberry may stimulate the immune sys-tem and should be avoided in patients with autoimmune disease and those taking im-munosuppressants.

Take away: Elderberry may be benefi -cial, in addition to other supportive care, in patients with the fl u. However, patients at high risk of complications should be

referred to their primary care provider for evaluation and potential treatment with antiviral agents.

GarlicGarlic is believed to have antibacterial and antiviral properties and therefore is often used for prevention and treatment of the common cold. One small study evaluated the effect of garlic on the occurrence of the common cold when taken once daily for 12 weeks during cold season.57 Re-sults indicated that garlic taken prophy-lactically may decrease the incidence of cold compared to placebo. However, in pa-tients who did develop cold, there was no difference in the duration of symptoms.

Patients may be hesitant to use garlic on a long-term basis because of the side effects of bad breath, body odor, and rash.57

Garlic may decrease plasma concentrations of isoniazid and saquinavir and should not be used concomitantly with these medica-tions. Garlic may have antiplatelet and anti-coagulant activity and should be used with caution in patients taking warfarin.58

Take away: Prophylactic use of garlic may reduce the incidence of colds, how-ever, side effects may be intolerable.

GinsengBoth American ginseng and Panax gin-seng have been studied for use in URIs. Patients may not be aware of the distinc-tion between these two products. This is an important starting point for discussion, as their use differs signifi cantly.

One specifi c extract of American gin-seng, CVT-E002, has shown possible effi cacy in three randomized controlled trials.59-61 Combined results suggest that American ginseng taken daily for three to four months during fl u season

may decrease the risk of contracting the common cold and fl u in adults and may decrease the severity of symptoms in those patients who do develop URI. Fur-thermore, the use of this product appears to decrease the likelihood of contracting more than one cold in a given season.60

American ginseng is well tolerated, with headache being the most commonly re-ported adverse effect.62

Panax ginseng may also be referred to as Asian ginseng. One small study evalu-ated the effect of Panax ginseng taken daily for 12 weeks on immune response to influenza vaccination.63 Patients re-ceived the infl uenza vaccine during the fourth week of the study. Results showed a signifi cant increase in antibody titers and a decrease in the occurrence of fl u. The most common adverse effect asso-ciated with Panax ginseng is insomnia.64

Both types of ginseng appear to de-crease the effi cacy of warfarin and should not be used concomitantly.62,64 Women with estrogen-sensitive cancers and con-ditions should avoid ginseng due to its po-tential estrogenic activity. Additionally, gin-seng may increase risk of hypoglycemia in patients taking antidiabetic medications.

Take away: Prophylactic American ginseng used during fl u season may de-crease the incidence and severity of URIs. Panax ginseng may improve response to infl uenza vaccination.

Pelargonium sidoidesPelargonium sidoides, also known as Umckaloabo, is a species of a South Afri-can fl owering plant related to the gerani-um.65 The active ingredient used in herbal supplements is derived from the root of the plant. It has been evaluated for use in the common cold and sinusitis. A ran-

Pharmacists should use the QuEST SCHOLAR technique for all patients presenting with symptoms of URIs to elicit pertinent information, formulate an assessment, determine eligibility for self-care, and create a treatment or referral plan as appropriate.




domized controlled trial evaluated the ef-fect of 1.5 mL of liquid P. sidoides extract taken three times daily for 10 days ver-sus placebo for treating symptoms of the common cold.66 Patients in the treatment group experienced less severe symptoms and fewer days until clinical cure versus those patients taking placebo. A small, unpublished study suggested that pa-tients who take 60 drops of Umckaloabo extract three times daily for 21 days may experience decreased duration of sinusitis symptoms.67

Umckaloabo is well tolerated, but po-tential adverse effects include itchy rash, gastrointestinal upset, and conjunctivi-tis.65 It is believed to have stimulatory ef-fects on the immune system and should be avoided in patients taking immunosup-pressant medications and those with au-toimmune diseases.

Take away: P. sidoides may be effec-tive for the treatment of the common cold. Further study is needed to determine the effectiveness of Umckaloabo for treating the symptoms of sinusitis.

Vitamin C Vitamin C supplementation is often per-ceived by patients to boost the immune system and to prevent the common cold. Unfortunately, evidence indicates that daily vitamin C supplementation does not in fact decrease the risk of cold. However, in patients who do contract the common cold, a Cochrane review showed that those who regularly use vitamin C as a daily supplement experience a decreased duration of cold: 8% shorter in adults and 14% shorter in children.68 The value of this marginally shortened duration should be weighed against the associated cost and pill burden. Patients may also believe that large doses (1-3 g) of vitamin C are benefi-cial in treating the symptoms of the com-mon cold. There is no evidence to support the use of high-dose therapeutic vitamin C once a cold has started.68

Although vitamin C is generally well tol-erated at doses used for daily supplemen-tation, at high doses, it may cause gas-trointestinal symptoms (such as nausea, vomiting, and diarrhea) and urinary tract stones.69 Patients should be encouraged to avoid using more than the recommended upper intake level of 2000 mg per day.

Take away: Daily vitamin C supplemen-tation may help to decrease the duration of colds in adults and children; however, high-dose vitamin C should not be recom-mended for treatment of the common cold.

Zinc Zinc has been shown to inhibit rhinoviral replication in in-vitro studies and there-fore is often marketed to the public as an effective agent for prevention and treat-ment of the common cold. Overall, data do not strongly support the prophylactic use of zinc.70 If zinc is taken prophylacti-cally for at least five months, children may experience a decreased incidence of the common cold and associated absences from school.71 In terms of treatment, two systematic reviews have demonstrated that zinc lozenges at doses greater than 75 mg/day reduce the duration of symp-toms (nasal discharge, congestion, sneez-ing, sore throat, hoarseness, cough, and muscle ache) by approximately one day when treatment is initiated within 24 hours of symptom onset.70,71 It is impor-tant to counsel patients that to achieve the efficacious dose, one lozenge must be used every two to three hours, depending on the product. This frequency of adminis-tration may be burdensome for patients.

Oral zinc is normally well tolerated; however, patients may complain of bad taste and nausea.72 Agents used to im-prove the flavor of zinc-containing prod-ucts, including citric acid and sugar alco-hols (sorbitol, mannitol) may chelate zinc, and therefore decrease efficacy. Zinc interacts with quinolone and tetracycline antibiotics, resulting in reduced absorp-tion of both agents. Patients should be counseled to take antibiotics two hours before or four hours after zinc.

Intranasal zinc has been associated with permanent loss of smell, and as such, popular formulations were discon-tinued in 2009.73 However, these products may still be available online, so patients should be strongly advised to avoid the use of intranasal zinc.

Take away: Patients interested in using zinc should be counseled that it does not prevent the common cold. Although zinc may decrease symptoms in patients with the common cold, this benefit is achieved only if treatment is started almost immedi-

ately and the lozenges are taken every two to three hours.

Other productsPatients may inquire about the use of apple cider vinegar as a holistic treatment for a multitude of health concerns, including si-nusitis.74 It is believed to have antibacterial properties. At this time, however, there is no clinical evidence to support its use in sinusitis. Bromelain is a digestive enzyme found in pineapple.75 When taken orally, this agent is believed to decrease swelling in the sinus cavity, however, there is no reli-able evidence to support its use in sinus-itis. The aforementioned products should not be recommended for the prevention or treatment of URIs.

Herbal supplements should be avoided in children and women who are pregnant or breastfeeding. Pharmacists should con-sult the Natural Medicines database for information regarding the safety, efficacy, and drug-drug interactions associated with herbal products and other CAMs.

pharmacist’s referral: is self-care appropriate? As the most accessible healthcare pro-fessionals, pharmacists are in a strong position to decrease the unnecessary use of urgent care services by accurately triag-ing patients’ symptoms. If a pharmacist can recognize the pattern of a viral illness and recommend appropriate symptomatic self-care treatment, he or she may pre-vent a costly trip to the doctor’s office and a potentially inappropriate antibiotic prescription. However, it is equally impor-tant that a pharmacist be able to identify patients who need further medical evalu-ation. Therefore, pharmacists should use the QuEST SCHOLAR technique for all pa-tients presenting with symptoms of URIs to elicit pertinent information, formulate an assessment, determine eligibility for self-care, and create a treatment or refer-ral plan as appropriate.

ColdPatients presenting with symptoms of the common cold should first be evalu-ated for appropriateness of self-care. The following patients should be referred to their primary care provider for further evaluation: those presenting with chest

DrugTopics.com44 Drug topics October 2015


pain, shortness of breath, or a tempera-ture above 101.5°F; patients with chronic diseases that involve the respiratory and immune systems (eg, asthma, chronic ob-structive pulmonary disease, congestive heart failure, AIDS); frail elderly patients; children aged less than nine months; and patients with worsening symptoms despite appropriate self-treatment.15 If self-care is deemed appropriate, patients should be educated on the nature of viral illness, mainly that curative therapies are not available and that treatment should focus on individual symptoms that are bothersome. Pharmacists should offer to assist the patient in selecting an appropri-ate product and counsel the patient on the appropriate use of the product. Finally, patients should be educated on strategies to prevent the spread of the virus to oth-ers, such as appropriate hand hygiene. All patients should be encouraged to seek medical evaluation if symptoms have not resolved within seven to 14 days.15

FluPharmacists should interview patients with suspected infl uenza to identify those at high risk for developing complications. High-risk patients include pregnant wom-en, Alaskan natives and American Indians, individuals aged younger than fi ve or older than 65 years, patients aged younger than 19 years who are receiving aspirin thera-py, residents of long-term care facilities, immunocompromised patients, morbidly obese patients, and those with chronic disease.76 Patients meeting the afore-mentioned criteria should be referred to their primary care provider for evaluation and possible treatment with a NA inhibitor. For patients not at high risk for compli-cations, pharmacists should recommend appropriate supportive care and discuss strategies to prevent spread of the infec-tion to others, such as using appropriate hand hygiene, staying home from school/work until 24 hours after temperature re-turns to normal, and wearing a facemask if patients must go out.77 Adult patients should be encouraged to seek medical care if they experience chest pain or trou-ble breathing, confusion or dizziness, or persistent vomiting. Children should see a doctor if they experience increased irri-tability, unusual fatigue, abnormal breath-

ing, fever with rash, or dehydration. All patients should seek care if symptoms initially improve before worsening.

SinusitisPatients presenting with symptoms of sinus-itis should be evaluated for the presence of symptoms indicative of bacterial illness (Table 2).6 Patients meeting these criteria should be referred to their primary care pro-vider for evaluation and antibiotic therapy. In patients who present with symptoms in-dicative of viral illness, pharmacists should explain the likelihood of viral infection and recommend watchful waiting and symptom-atic treatment (nasal irrigation and intranasal corticosteroids). Patients should be encour-aged to avoid antihistamines and deconges-tants and to seek medical care if improve-ment is not seen in seven to 10 days or if they experience “double sickening”.6

the common cold, fl u, and sinusitis in pediatric populations: Are they the same?As with all medications, it is important to remember that pediatric patients often require different doses of medication.

In 2007, manufacturers voluntarily with-drew infant preparations of cough and cold medications, and in 2008, the FDA recom-mended that OTC cough and cold prod-ucts should no longer be used in children aged younger than two years.78,79 These changes came as a result of reports of serious adverse effects, such as seizures, tachycardia, loss of consciousness, and in some cases, death. Additionally, these agents had not demonstrated efficacy in patients aged younger than six years. Later in 2008, manufacturers voluntarily further restricted the use of OTC cough and cold products, with labels changed to state that these products should not be used in children aged younger than four years.80 Additionally, improved packaging and measuring devices were developed to prevent accidental overdose. After these changes, emergency department visits for adverse events related to these medica-tions decreased signifi cantly.79 It is crucial that pharmacists counsel patients that OTC cough and cold medications are not appropriate for children aged younger than four years. It is also important to educate

parents regarding age- or weight-based dosing of specific products, as parents may plan to use the same agent for mul-tiple children. Parents should be taught to read ingredient labels on combination products to ensure that maximum doses are not exceeded and that aspirin is not inadvertently administered to children.

There are many other important consid-erations that pharmacists must take into account when triaging pediatric patients with URIs. Disease presentation may be different from that in adults, as well as po-tential complications. For example, children with the fl u are more likely to present with vomiting and diarrhea compared to adults, and subsequently they are at increased risk of hospitalization.9, 76 Herbal supplements do not have suffi cient data to support their use in the pediatric population and there-fore should not be recommended for use in children. Additionally, OTC and prescription medications may need dose adjustments based on the age or weight of the patient.

conclusionThe high prevalence and viral etiology of the common cold, fl u, and sinusitis among both pediatric and adult populations afford community pharmacists the opportunity to assess for self-care eligibility. As highly ac-cessible, uniquely positioned healthcare providers, community pharmacists play a key role in decreasing primary care visits, patient costs, and inappropriate antibiotic use. As medication experts, pharmacists are adequately trained to provide OTC phar-macologic treatment recommendations, as well as nonpharmacologic options for symptom management when appropri-ate. Pharmacists play a role not only in determining self-care eligibility, but also in identifying patients ineligible for self-care, warranting a referral.

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October 2015 Drug topics 45DrugTopics.com

test questions

1. Which of the following correctly pairs the upper respiratory infection with its most common causative agent? a. Influenza: influenza B b. Bacterial sinusitis: M. catarrhalis c. Common cold: rhinovirus d. Viral sinusitis: S. pneumoniae

2. Which of the following pairs best matches the upper respiratory infection with its typical clinical course? a. Influenza: sore throat followed by

rhinorrhea and cough lasting 10 to 14 days b. Bacterial sinusitis: fever, body aches, and

fatigue lasting up to 14 days c. Common cold: headache, facial pain, and

fever lasting less than 10 days d. Viral sinusitis: nasal congestion, scratchy

throat, and cough lasting five to 10 days

3. Which of the following clinical presentations suggests a patient is likely to have bacterial, rather than viral, sinusitis? a. Symptoms lasting more than 10 days b. Cough c. Fever lasting less than 48 hours d. Nasal discharge

4. Which of the following patient-reported symptoms suggests the presence of influenza versus the common cold? a. Body aches b. Runny nose c. Productive cough d. Stuffy nose

5. JG is a 42-year-old woman diagnosed with acute bacterial rhinosinusitis. She has no history of recent hospitalization, immunodeficiency, or penicillin allergy and has not used antibiotics in the past month. Which of the following treatment options is the most appropriate recommendation for JG? a. Azithromycin 500 mg on day one, then

250 mg daily on days two to five b. Sulfamethoxazole-trimethoprim

800 mg/160 mg twice daily for 10 days c. Amoxicillin-clavulanate 875 mg/125 mg

twice daily for five days d. Levofloxacin 750 mg daily for 10 days

6. Which of the following statements regarding influenza antiviral medications is true? a. Influenza antiviral medications are usually

prescribed for 14 days. b. Antiviral medications should be

recommended for all patients with influenza. c. Oseltamivir should not be recommended

in patients with asthma and COPD. d. Influenza antiviral medications are

most effective if started within 48 hours of symptom onset.

7. Which of the following nonpharmacologic recommendations would be most appropriate to help alleviate sinus pain in a patient with sinusitis? a. Nasal irrigation b. Warm facial compress

c. Gargling with warm salt water d. Increased hydration

8. All of the following antihistamines have been shown to be effective for treating cold symptoms as monotherapy or in combination with other agents except for: a. Doxylamine b. Loratadine c. Chlorpheniramine d. Brompheniramine

9. Andrographis products may decrease symptoms of the common cold if initiated within __ hours of symptom onset: a. 24 b. 36 c. 48 d. 72

10. Which of the following is true regarding daily supplemental use of vitamin C? a. Vitamin C may prevent the common cold,

but it has no effect on symptom duration in patients with the common cold.

b. Vitamin C may decrease symptom duration in patients with the common cold, but it does not prevent the common cold.

c. Vitamin C may be effective in both preventing the common cold and decreasing symptom duration in patients with the common cold.

d. Vitamin C is not effective in either preventing the common cold or decreasing symptom duration in patients with the common cold.

11. Which of the following is the most important counseling point regarding the use of zinc? a. Intranasal zinc may result in permanent

loss of smell. b. Zinc lozenges are effective when taken

two to three times daily. c. Zinc has no effect on the duration of the

common cold. d. Prophylactic use of zinc sulfate may

reduce the risk of the common cold if taken daily for at least five weeks before exposure.

12. Which herbal product may be effective in decreasing the duration of influenza symptoms? a. Elderberry b. Garlic c. P. sidoides d. Ginseng

13. Community pharmacists may employ the QuEST SCHOLAR method to gather patient information in order to: a. Diagnose the patient’s complaint b. Recommend an OTC product c. Determine self-care eligibility d. Accurately fill the prescription

14. Which of the following statements regarding community pharmacists is true? a. They are unable to provide OTC

recommendations without a physician-diagnosed problem.

b. Their job consists solely of pouring pills from big bottles into smaller bottles.

c. They are unable to provide recommendations regarding herbal supplements.

d. They are uniquely positioned healthcare providers equipped to accurately triage patients’ symptoms.

15. The role of pharmacist triage for patients presenting with symptoms of acute sinusitis may include all of the following except: a. Preventing an unnecessary primary care

physician visit b. Filling an antibiotic prescription in less

than 15 minutes c. Counseling the patient regarding watchful

waiting d. Decreasing patient cost (eg, copays)

16. NC is a 27-year-old woman who is 35 weeks pregnant with her first child and presents to the pharmacy counter while you are on duty. She reports that her husband was diagnosed with the flu yesterday and has been running a fever all day today. She wants to know what she can do to remain healthy. Which of the following is the most appropriate recommendation for NC at this time? a. Refer her to her primary care physician, as

she may be eligible for prophylactic treatment. b. Wish her luck, as she is most likely going

to catch the flu. c. Counsel her to avoid further contact with

her husband until symptoms resolve. d. Reassure her she is in the clear, as he is

not contagious after 24 hours.

17. Current product labeling states that OTC cough and cold medications should not be used in patients aged younger than: a. One year b. Two years c. Three years d. Four years

18. Which of the following is the best agent to recommend for a three-year-old patient with past medical history of asthma diagnosed with influenza? a. Oseltamivir b. Amantadine c. Zanamivir d. Rimantadine

19. Aspirin and aspirin-containing products should be avoided in children and teenagers with flu-like symptoms because of the concern for: a. Raynaud disease b. Rhinoviral replication c. Reye’s syndrome d. Respiratory depression

20. Which of the following most appropriately represents the correct duration of antibiotic therapy for ABRS in pediatric patients? a. Five to seven days b. Five to 10 days c. 10 to 14 days d. 14 to 21 days

DrugTopics.com


Drug topics 2015

MtM eSSentiaLS FoR coLd, FLu, and SinuSitiS ManageMent

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