There are over 200 subtypes of the common cold (British Medical Journal (BMJ), 2022) and most people experience one cold in a year, which is usually self-limiting and lasts less than a week (BMJ, 2022). This 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 is a more severe illness that has similar symptoms to the common cold, and can have a detrimental impact 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 which are similar to the common cold (British National Formulary (BNF), 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 (BNF, 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 (BNF, 2022a).
Treating cold and flu
As we make our way through cold and flu season, prescribers are likely to encounter many patients with varying degrees of illness from these viruses.
Many may worriedly think they need prescriptions for antibiotics, but it must be only where 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 provided on a good nutrient and liquid intake, as well as 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 unless a natural sea-water-based decongestant is used (Jiang et al, 2021).
The BMJ (2022) notes that efficacy of decongestants is not absolutely proven due to limited evidence, although some evidence supports short-term use. However, the mental side effects of such a medication should be noted and will be discussed herein.
Antivirals are often used to treat and for post-exposure prophylaxis of influenza although these come with some risk. Oseltamivir and zanamivir are commonly used; however, the BNF (2022a) highlights the risk that some strains of influenza can develop resistance to oseltamivir.
The UK Health Security Agency (2022) published the report for week 49 on the influenza and COVID-19 viruses, noting that hospitalisations and intensive care admissions due to COVID-19 have gone up slightly, being highest in the over-85s, and influenza admissions were highest in the 75-84-year-olds and those below the age of 5. Flu-like emergency department visits increased while those with COVID-like symptoms stayed at medium intensity, which represents the virulence and intensity of the flu virus currently. Many vulnerable patients will be at risk, but 62.4% of those over 50 have already (by week 48) had their autumn booster for the flu vaccine.
The World Health Organization (2022) advises that the main treatment for those who are not medically compromised would be to manage the fever and give antivirals to those at risk as appropriate. Those urgently requiring antiviral treatment include patients who have severe or progressive clinical illness linked to suspected or confirmed influenza virus infection, such as those with a clinical presentation of pneumonia, sepsis, or exacerbation of chronic underlying disease (WHO, 2022).
Oseltamivir
The WHO (2022) recommends that oseltamivir should be prescribed as soon as possible, preferably within the 48 hours following onset of symptoms, for a 5-day course of treatment, and 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 superinfection (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 in Psychiatry Investigations 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. However, 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 GP and their psychiatrist if they have one for preexisting mental disorders.
Over-the-counter medications
Over-the-counter medicines are frequently purchased for the 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 summarises the harm to the heart that stimulant decongestants can do (Harvard, 2021). Day Nurse, Sudafed and Lemsip have preparations of stimulant medication for nasal decongestion. Pseudoephedrine for example is found in Day Nurse, and works but 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, 2021), although some can experience a significant episode of hypertension. Harvard (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.
Glowacka and Wiela-Hojenska (2021) summarise the risks and benefits of pseudoephedrine, noting that the drug stimulates the sympathetic nervous system and thus can also lead to fight-or-flight reactions, speeding up breathing inducing hypertension, tachycardia, vessel constriction peripherally, bronchodilation, hyperglycaemia, central nervous system stimulation and producing a surge in energy. Some may find it in fact improves their mood although others may experience severe panic attacks, among other psychiatric symptoms. Patients who may be hypersensitive to the drug should be advised to avoid taking it, and those who are vulnerable to anxiety disorders, depressive thoughts and insomnia should be advised to be cautious. It is best to avoid a drug if there exists the potential to do harm. Some patients may also find it addictive, which leads to problems coming off the drug, and also can lead to rebound nasal congestion, which is why people should only really take this for 3 days.
Such drugs can be bought over the counter; however, they carry many contraindications. Those listed for pseudoephedrine include hypersensitivity to the drug, cardiovascular diseases (hypertension and coronary artery disease), impaired function of organs responsible for elimination of the drug (severe liver dysfunction, moderate or severe renal dysfunction), hyperthyroidism, narrow-angle glaucoma, benign prostatic hyperplasia, diabetes mellitus, mental agitation and treatment with monoamine oxidase inhibitors (MAO inhibitors) currently or in the last two weeks (Glowacka and Wiela-Hojenska, 2021).
Another common stimulant congestion relief medication is phenylephrine, for example, 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 (BNF, 2022b).
Conclusion
Immediate use of medication has been normalised in our over-medicalised society without consideration of potential negative effects while overlooking the potential positive effect of supporting our bodies to fight off infections as they have been designed to do. In patients where medication may do harm or 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. The National Institute for Health and Care Excellence (2022) recommends steam inhalation, vapour rubs, gargling salt water, and saline nasal drops to relieve congestion. It must be noted however that there is no substitute for simple rest, adequate hydration and good nutrition.