There are over 200 subtypes of the common cold (British Medical Journal (BMJ), 2022). Most people experience at least one cold a year, which is usually self-limiting and lasts less than a week (BMJ, 2022). It involves inflammation of the upper respiratory tract mucosa, which may affect the nose, throat, sinuses and larynx, producing sore throat, sneezing, blocked or runny nose, headaches, cough, malaise and low-level fever. However, frailer patients are at higher risk of a more severe degree of illness from a cold.
Flu (also known as influenza) is a more severe illness that has similar symptoms to the common cold and can have a detrimental effect on the vulnerable. Influenza is categorised as type A, B or C. Type A is more virulent and frequent, B involves milder disease but can still cause outbreaks and C causes mild or no symptoms that are similar to the common cold (National Institute for Health and Care Excellence (NICE), 2022a). With flu, you may see more extreme fatigue, chills, fever and myalgia, and there may be a dry cough and nasal congestion. Complications of flu include bronchitis, secondary bacterial pneumonia, and may at times be cardiac or neurological in presentation (NICE, 2022a).
At-risk groups of the complications of flu include: children under 6 months, pregnant females and those up to 6 weeks post-partum, adults over 65 years, patients with long-term conditions involving respiratory, renal, hepatic, neurological or cardiac disease, diabetes, or morbid obesity (above 40 kg/m2 body mass index), as well as those who are severely immunocompromised (NICE, 2022a).
Treating cold and flu
As we make our way through cold and flu season, nurses in the community are likely to encounter many patients with varying degrees of illness from these viruses.
Many individuals may worriedly think they need prescriptions for antibiotics but it is only when a bacterial infection is likely that they should receive this, and may need reminding of the risks of taking antibiotics unnecessarily. Others may be at risk of complications owing to the virus and may benefit from antivirals. Others may simply want advice on over-the-counter medications.
If the patient is not frail and at risk of complications, reassurance should be given, rest advised, and advice on a good nutrient and liquid intake, as well as on the use of the basic analgesics (BMJ, 2022). Paracetamol and ibuprofen can be used to reduce symptoms of fever, but caution is advised for the many decongestants sold over the counter, as these can have significant unwanted side effects resulting from sympathetic nervous system activation.
The BMJ (2022) notes, however, that efficacy of decongestants is not absolutely proven due to limited evidence, although some evidence supports short-term use. Nonetheless, the mental side effects of such a medication should be noted.
Oseltamivir
According to World Health Organization (WHO) (2022), oseltamivir should be prescribed as soon as possible, preferably within 48 hours following the onset of symptoms, for a 5-day course of treatment. Corticosteroids (unless for asthma and other specific illnesses) should be avoided as these have been found to prolong the viral clearance, and can also cause immunosuppression that results in a bacterial or fungal super-infection (WHO, 2022). All influenza viruses are now confirmed to be resistant to antivirals such as amantadine and rimantadine, so these are no longer recommended for use for this purpose. It is advisable to check the WHO website as they provide regular updates about resistance among antivirals to the influenza virus.
However, it is important to be cautious when prescribing oseltamivir. A study published by Chung and Joung (2010) reports neuropsychiatric events that have been observed from giving oseltamivir, although the authors do note that the drug is generally well tolerated. However, they highlight cases of severe depression reported following administration, but note that most adverse effects are gastrointestinal in nature. In some patients, there have been reports of delirium, behavioural disturbance, delusions, panic attacks, convulsions, loss of consciousness, and the most serious of all being suicide. It is likely that some groups are more at risk of these effects than others and concerns should be discussed with the patient's general practitioner and their psychiatrist if they have one for preexisting mental disorders.
Over-the-counter medications
Over-the-counter medicines are frequently purchased for cold and flu viruses discussed in this article, but they carry risks that many people are unaware of. Where possible, it is important to give the right advice and correct warnings about drugs prescribed such as the many available decongestants, which can in some cases do more harm than good.
Harvard Health Publishing (2021) summarises the harm to the heart that stimulant decongestants can do. Day Nurse, Sudafed and Lemsip have preparations of stimulant medication for nasal decongestion. Pseudoephedrine, for example, is found in Day Nurse, and works by constricting blood vessels in the nose and sinuses, to shrink the swelling and drain fluid, allowing easier breathing. However, something the person at the counter frequently might not mention when selling this popular medication, is that it can also induce a significant rise in blood pressure, and neuropsychiatric symptoms. Where blood pressure is controlled, the rise can be minimal (Harvard, Health Publishing 2021), although some can experience a significant episode of hypertension. Harvard Health Publishing (2021) also report that millions do use pseudoephedrine, but there have been reports of myocardial infarction, stroke, arrhythmia and other cardiovascular episodes linked to its use. It is a drug that tightens vessels throughout the body, not just around the nasal cavity, and this is what can lead to the issues reported in those more at risk to complications of the drug.
Another common stimulant congestion relief medication is phenylephrine, which is found in Lemsip day and night. This also carries the risk of causing multiple significant effects, such as anxiety, confusion, hypertension, headache, hypoxia, insomnia, nausea, and even psychosis (NICE, 2022b).
Conclusion
Turning straight to medications has been normalised in our medicalised society without consideration for the negative effects this may have and the positive effect of perhaps allowing our bodies to fight off infections as they have been designed to do. In patients where medication may do harm, or simply is not recommended, it is best to avoid them. More natural ways to decongest the airways can be pursued if this is deemed the safest option on balance. NICE (2022c) recommends steam inhalation, vapour rubs, gargling salt water, and saline nasal drops to relieve congestion. Most importantly, there is no substitute for simple rest, adequate hydration and good nutrition.