colds and flu€¦ · colds and flu are both classified as viral infections1a. the definition of a...

Module 2

Colds and Flu

IntroductionColds and flu are both classified as viral infections1a.

The Definition of a Virus

A virus is a small infectious organism – much smaller than a fungus or bacterium – that invades a living cell to reproduce (replicate)1b.

Virus invading cell. Adapted from Porter RS (Ed.) Viral Infections: Overview of Viral Infections1b

The virus enters a cell.

Once inside, it takes control.

The virus forces the cell to duplicate

the virus.

The cell dies as it cannot return

to its natural function.

This leads to the unpleasant symptoms

we associate with a cold or the flu.

The Lifecycle of a Virus

The Common Cold

The common cold is a viral infection of the membranes of the nose, sinuses and throat2a. It usually leaves the patient with unpleasant symptoms, but is not usually accompanied by a fever and the condition is self-limited and resolves itself when it has run its course3a.

The rhinovirus is most often the culprit when it comes to the common cold2b and it specifically infects the cells of the upper respiratory tract, which leads to symptoms such as a runny nose, coughing and a sore throat3a.

How does a head cold – and its symptoms – come about?

The pathophysiology of key head cold symptoms4-8

Nasal congestion can lead to the feeling of a stuffy head4

Solution: Target your patients’ most bothersome cold symptoms for maximum benefit.

Infection with cold virus

Nasal congestion Sinus Pain

Headache

Inflammatory mediators

Pressure changes in sinuses

• Vasodilation/oedema

• Swelling of the nasal venous tissue

• Difficulty breathing

• Possible occlusion of the ostia

Local mediators

Local mediators

Systemic mediators

As stipulated in Section 22A subsection 4 and 5 of the Medicines and Related Substances Act 101 of 1965, product recommendations can only be made by Pharmacists and Pharmacist Assistants acting under the personal supervision of a pharmacist (S1 – S2). Any customer seeking medical advice from a Front Shop Assistant should be referred to the Pharmacist on duty.


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Module 2 Colds and Flu

How to Spot a Cold

Take precautions: wash your hands after being in contact with a person with a runny nose/mild cough2d

Day 1 Day 3Day 2 Day 4 Day 5

Symptoms appear 1 – 3 days after exposure9a

Cold is most contagious 1 – 2 days after symptoms develop2c

!

Key Symptoms

of a Cold

Cough – generally mild and can last up to 2 weeks3b

Discharge from the nose may become thick and yellow or green as the cold progresses2e

Runny or congested nose2e

Itchy or sore throat2e

Occasional low-grade fever2e

Mild fatigue9b

Sneezing9b

Slight body aches or a mild headache9b

How to Treat a Cold

Because antibiotics do not affect the course of a viral infection10, symptoms are usually treated2f.

Most Bothersome Cold Symptoms4-8

Occlusion of the ostia can affect sinus ventilation and drainage leading to:

• Pressure changes• Fluid/mucus accumulation

Inflammatory mediators and pressure changes in the sinus can result in:

• Sinus Pain• Headaches

• The cold virus triggers the release of inflammatory mediators, leading to vascodilation and swelling of the nasal mucosa

• This can cause nasal congestion and difficulty breathing

• Excess mucus can exacerbate nasal congestion

of cold sufferers experienced head or nasal congestion, while 85% or more reported headache or sinus pressure1190%

OverAs stipulated in Section 22A subsection 4 and 5 of the Medicines and Related Substances Act 101 of 1965, product recommendations can only be made by Pharmacists and Pharmacist Assistants acting under the personal supervision of a pharmacist (S1 – S2). Any customer seeking medical advice from a Front Shop Assistant should be referred to the Pharmacist on duty.


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Cold symptoms affect how patients feel mentally

34% reduction in mental alertness amongst cold sufferers vs. healthy individuals12

A larger reduction means a greater negative impact on the individual.

Cold present for at least 24 hours but no longer than 96 hours.

N=189.

Adapted from Smith AP, 2012.

Alertness of subject with and without a cold

Mea

n ch

ang

e fr

om

bas

elin

e in

al

ertn

ess

sco

re (

%)

5

-5

0

-10

-15

-25

-20

-30

-35

-34,8

2,4


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• Anna has come to the pharmacy to ask for advice

• She tells you that her nose is blocked and that she is experiencing some facial pain

• She also cannot smell anything and her head is aching

• She’s also feeling tired and is having trouble focusing on her tasks.

• What can she take that will make her feel better, but won’t make her sleepy as she has to mark test papers at home?

Case Study 1 Anna, 39, Primary School Teacher

Ask the following questions: • How long have the symptoms

lasted for?

• Where is she experiencing facial pain?

• Does she have toothache?

• Does she have a fever?

• Does she have a cough?

• Does she have discoloured nasal discharge?

• Is she experiencing a feeling of fatigue?

• Does she have a post nasal drip?

Anna says that the symptoms started for the first time 48 hours before she came to your pharmacy. She is feeling fatigued and a bit shivery and she says her face aches underneath her eyes, but she does not have discoloured discharge or a post nasal drip.

Diagnosis: You establish that it’s a cold that has likely lead to mild sinusitis, but that it’s not a severe case as she doesn’t have discoloured nasal discharge. It’s also an acute case as it only recently started and she doesn’t have a postnasal drip.

Inability to think clearly is one of the most important impairments12

Top 5 functional impairments in order of importance

90% of sufferers reported an influence on clear thinking12

Top 5 functional impairments in order of frequency

Top 5 out of 10 functional impairments in order of frequency.

N=230 people with a common cold. Adapted from Barrett B, et al. 2009.

Patients were asked to rate the importance of selected cold symptoms on a 5-point scale with the descriptors “Not”, “Somewhat”, and “Very” aligned with the numbers 1, 3 and 5.

Top 5 out of 10 functional impairments in order of importance.

N=230 people with a common cold. Adapted from Barrett B, et al. 2009.

An increase in symptom severity was significantly associated with a decrease in alertness12

95,7%

91,3%

90,0%

90,0%

88,7%

Breathe Easily

Sleep Well

Think Clearly

Accomplish Daily

Activities

Live Your Personal Life

4,59%

4,47%

4,35%

4,28%

4,26%


As stipulated in Section 22A subsection 4 and 5 of the Medicines and Related Substances Act 101 of 1965, product recommendations can only be made by Pharmacists and Pharmacist Assistants acting under the personal supervision of a pharmacist (S1 – S2). Any customer seeking medical advice from a Front Shop Assistant should be referred to the Pharmacist on duty.40 41


Treatment

Since Anna needs to stay awake, the best products to recommend would be Sinutab® Sinus Pain Non-Drowsy and /or Sinutab® 3-Way as both have a non-drowsy formula.

If the congestion is severe and a hindrance to her, she can use the Sinutab® Nasal Spray to alleviate this.

Top Tip: Home Care2g,13a,14

Remind your patient that when he/she has a cold he/she can do the following to help speed up the recovery process:

Inhale steam (from a vaporiser

to loosen secretions)

Rest at home (if you have a fever or

more severe symptoms)

Drink lots of fluids

(with added electrolytes)

Avoid stressful situations (which can

tire out your immune system)

Ease high temperatures

with OTC remedies (such as ibuprofen and paracetamol)

Stay warm and

comfortable

Sinutab® Sinus Pain Non-DrowsySymptomatic relief of head cold symptoms:

• Nasal congestion• Pressure• Headache

Sinutab® Nasal SpraySymptomatic relief of:

• Nasal congestion caused by colds, hay fever, allergic rhinitis and sinusitis

Sinutab® 3-WaySymptomatic relief of head cold symptoms:

• Nasal congestion• Pressure• Headache• Inflammation

Active ingredients:

• Pseudoephedrine Hydrochloride 30 mg per tablet

• Paracetamol 500 mg per tablet

Dosage

• Adults & children over 12 years: 2 tablets every 4 – 6 hours. Do not exceed 8 tablets in 24 hours.

• Children 6 – 12 years: A half to 1 tablet every 6 hours. Do not exceed 4 tablets in 24 hours.

• Children under 6 years: Not recommended.

Active ingredients:

• Xylometazoline – local vasoconstrictor to help open nasal passages and relieve congestion and a runny nose

Dosage

• Adults & children over 12 years: One spray into each nostril 2 – 3 times per day, as required. Do not exceed 3 sprays per day.

• Do not use for more than three days.

Active ingredients:

• Pseudoephedrine Hydrochloride 30 mg per tablet

• Ibuprofen 200 mg per tablet

Dosage

• Adults & children over 12 years: 1 tablet every 4 – 6 hours.

• If symptoms do not respond to 1 tablet, a second may be taken.

• Do not exceed 6 tablets per day.

• Do not recommend for children under 12 years.Daytime solution:

Non-Drowsy

S2 SINUTAB® Sinus Pain Non-Drowsy. Each tablet contains: Pseudoephedrine Hydrochloride 30 mg, Paracetamol 500 mg. Reg. No. 37/5.8/0138.

S2 SINUTAB® 3-Way. Each tablet contains: Pseudoephedrine Hydrochloride 30 mg, Ibuprofen 200 mg. Reg. No. 36/5.8/0207.

S1 SINUTAB® Nasal Spray. Xylometazoline Hydrochloride 1 mg per ml (0,1 % w/v). Reg. No. P/16.1/184.



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The Flu

Flu is a viral infection of the lungs and airways by an influenza virus15a.

How to spot the flu

Symptoms tend to be more severe than those of a cold. They usually appear about 1 to 4 days after the patient has been exposed to the virus15b.

Flu becomes contagious 1 day before symptoms develop and can stay contagious for up to a week after the person becomes sick17.

Pneumonia is the most common complication of flu. This can present as a viral or bacterial infection15c. Key symptoms are a worsened cough, difficulty breathing, persistent fever, and blood in the sputum15c.

Key Symptoms of

Influenza15d

Chills or chilly sensations (usually the first symptom)

Severe headaches and light sensitivity may occur

Fatigue and weakness

Scratchy sore throat

Body aches and pains

Dry cough, which may develop into a wet cough

Runny nose and watering eyes

Burning sensation in the chest

Fever (up to 39°C)

Warm, flushed skin

Fast Fact

When it comes to the flu, the time from infection to illness, known as the incubation period, is about 2 days16a.

Diagnosis: The Difference between Colds and Flu13b,15d

It can be difficult to assist patients who aren’t feeling well and are not quite sure about all the facts regarding their condition. It is especially tricky since colds and flu share many of the same common symptoms.

The table below will help you to ask your patients exactly the right questions, so you can quickly distinguish between the two ailments, and offer an effective solution.

Symptom Cold Flu

Sore throat (often scratchy)

Cough (mild and short duration) (can last for weeks)

Headache (usually mild) (usually more severe)

Discomfort in the eyes

(watering eyes)(often light sensitivity and painful eyes)

General malaise or tiredness

(watering eyes)(often accompanied by weakness)

Sneezing/runny nose/blocked nose

(often one of the first symptoms to appear)

General aches and pains in the body

(mild or not at all)

Fever (usually not)

Appears suddenly (appears gradually)(appears quickly within hours)



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Ask the following questions

Case Study 2 Kagiso, 29, Banker

• Kagiso has come to your pharmacy to ask for advice

• He says that he has body aches and pains and that he is feeling very tired

• He also tells you that he has a runny nose and watering eyes

• He says that he has taken a sick day and will be going home to get some rest and that he would like to know which over-the-counter (OTC) product he can take to help him get better

• How long has he had the symptoms?

• Does he have a headache and how severe is it?

• Is he experiencing any sensitivity to light?

• Does he have a fever? • Does he have a cough?• Does he have any allergies?• Does he have any other medical

conditions?• Is he short of breath?• Is he experiencing pain in his chest

or difficulty breathing? • Has he experienced any dizziness

or confusion? • Is he on any other medication?

Kagiso says that his symptoms started two days ago. He does not have a cough, but he is experiencing sensitivity to light. He might have a fever, since he is feeling hot and chilly. He does not have any allergies, does not have problems breathing and has not experienced any confusion or dizziness.

Diagnosis: You have established that Kagiso has the flu without a cough. (A cough may still develop, but has not yet.)

He does not describe any warning signs that are a cause for concern.

How to Avoid the Flu

Getting a yearly flu shot is advised. It typically takes 2 weeks for the influenza vaccine to become effective15e, so it is essential for the patient to be extra vigilant and boost their immune system during this time. Here are some of the things that can be done to avoid getting sick:

How to Treat the Flu

The majority of people recover from fever and other symptoms in about 7 days without needing medical attention16b, though coughing, wheezing, weakness, sweating and fatigue may continue for days or weeks15d. At the pharmacy, treatment is aimed at relieving symptoms and OTC remedies overlap with those used to treat symptoms of the common cold15g.

Wash your hands frequently18. It is recommended to wash your hands for 20 seconds at a time19, to make sure you get rid of any unwanted micro-organisms.

Avoid people who are coughing or sneezing – as with the cold, the flu virus can be transmitted through air or by touch15f.

Eat plenty of fruits and vegetables. A balanced diet with lots of vitamins and minerals will boost the body’s immune system, making it easier to fight off viruses. Make sure you eat a good mixture of green, red and yellow vegetables and a variety of fruit to get the maximum benefit20a.

Do aerobic exercises. Any activity that gets your heart pumping helps increase the natural virus-killing cells in your body20b.

Drink plenty of warm drinks in the winter months21. This helps you stay hydrated, it soothes the throat and also washes it clear of potentially harmful intruders.


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Since Kagiso has a flu without a cough and can go home to rest and recover, his pharmacist can confidently recommend the following Benylin® product:

Treatment

Benylin® 4 Flu Tablets and LiquidFor relief of symptoms associated with colds and flu, including:

• Coughing

• Fever

• Headache

• Minor aches and pains

• Nasal congestion

Benylin® Daytime Flu TabletsFor the relief of symptoms associated with colds, sinusitis and flu, including:

• Fever

• Headache

• Body aches and pains


Active ingredients

• Paracetamol (1000 mg per 20 ml / 500 mg per tablet) – reduces pain and fever

• Pseudoephedrine (45 mg per 20 ml / 22,5 mg per tablet) – for nasal congestion and runny nose

• Diphenhydramine HCl (25 mg per 20 ml / 12,5 mg per tablet) – starts to work in 15 min. and lasts up to 12 hours – relieves cough

Note: Because this product contains Diphenhydramine HCl, Kagiso may experience drowsiness.

Dosage

Benylin® 4 Flu Tablets

Adults and children over 12 years: 2 tablets 4 times daily. Do not exceed 8 tablets within 24 hours.

Children (6 – 12 years): 1 tablet 4 times daily. Do not exceed 4 tablets within 24 hours.

Do not recommend for children under 6 years.

Benylin® 4 Flu Liquid

Adults and children over 12 years: 20 ml 4 times daily.

Kagiso has a choice between Benylin® 4 Flu Tablets and Benylin® 4 Flu Liquid if he does not like swallowing tablets.

Active ingredients

• Ibuprofen (200 mg per tablet) – reduces pain and fever

• Pseudoephedrine Hydrochloride (30 mg per tablet) – for nasal congestion and runny nose

Dosage

Adults and children over 12 years: 1 tablet every 4 – 6 hours. If symptoms do not respond to 1 tablet, a second may be taken. Do not exceed 6 tablets in 24 hours.

A daytime, non-drowsy option



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Your adult patients should seek further medical advice if they answer yes to any of the following questions25a,26:

• Are you experiencing shortness of breath or difficulty breathing?

• Do you have pain or pressure in the chest or abdomen?

• Have you felt suddenly dizzy?

• Are you confused?

• Have you been experiencing severe or ongoing vomiting?

• Have you had an improvement in symptoms followed by a return of the fever and a worse cough?

• Have you been coughing up blood?

• Have you recently been in hospital?

• Has your cough lasted for more than 3 weeks?

• Have you felt unwell with a prolonged fever?

• Do you have conditions such as chronic bronchitis, heart disease, diabetes or asthma?

Advise the customers to take their child to a doctor when the answer is yes to any of the following questions25b:

• Is he/she breathing rapidly or finding it difficult to breathe?

• Is his/her skin bluish or grey in colour?

• Is he/she not drinking enough fluids?

• Is he/she experiencing severe or ongoing vomiting?

• Is he/she not waking up/not interacting?

• Is he/she irritable or does he/she not want to be held?

• Has he/she experienced an improvement in symptoms, followed by a return of the fever and a worse cough?

! Urgent Assistance

Benylin® 4Flu Liquid

Benylin® 4Flu Tablets

Benylin® Daytime Flu Tablets

Age 12+ 6+ 12+

Indications

For the relief of symptoms associated with colds and flu, including:

• Coughing

• Fever

• Headache

• Minor aches and pains


Warning: May cause drowsiness Do not use for more than 10 days

For the relief of symptoms associated with colds, sinusitis and flu, including:

• Fever

• Headache

• Body aches and pains


Warning: Do not use continuously for colds for more than 7 days or for fever for more than 3 days unless directed by a doctor

Active Ingredients

Paracetamol 1000 mg, Diphenhydramine 25 mg, Pseudoephedrine 45 mg

Paracetamol 500 mg, Diphenhydramine 12,5 mg, Pseudoephedrine 22,5 mg

Ibuprofen 200 mg, Pseudoephedrine Hydrochloride 30 mg

Pack Sizes 100 ml & 200 ml 24 tablets 20 tablets

S2 Benylin® Four Flu Liquid. Each 20 ml contains Diphenhydramine HCI 25 mg; Paracetamol 1 000 mg; Pseudoephedrine HCI 45 mg. Reg. No. 33/5.8/0345.

S2 Benylin® Four Flu Tablets. Each tablet contains Diphenhydramine HCI 12,5 mg; Paracetamol 500 mg; Pseudoephedrine HCI 22,5 mg. Reg. No. 33/5.8./0509.

S2 Benylin® Daytime Flu Tablets. Each tablet contains Pseudoephedrine Hydrochloride 30 mg; Ibuprofen 200 mg. Reg. No. 36/5.8/0206.



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Symptomatic relief of head cold symptoms:


• Pressure

• Headache

Age: 6+

Active ingredients

Pseudoephedrine: Decongestant – helps clear congested nasal passages through vasoconstriction

• Starts to work in 30 mins27

• Lasts up to 8 hours27

Paracetamol: An analgesic and antipyretic – active chiefly in the central nervous system, and is effective in a wide variety of mild to moderate pain conditions and in conditions associated with fever

• Starts to work in 30 – 60 mins28

• Lasts 4 – 6 hours28

Symptomatic relief of head cold symptoms:


• Pressure

• Pain and fever

• Inflammation

Age: 12+

Active ingredients

Pseudoephedrine: Decongestant – helps clear congested nasal passages through vasoconstriction

• Starts to work in 30 mins27


Ibuprofen: Non-steroidal, anti-inflammatory drug (NSAID) that is used to reduce fever and treat pain or inflammation

• Starts to work within 1 hour28

• Lasts 6 – 8 hours28

Sinutab® Sinus Pain Non-Drowsy

Sinutab® 3-Way

S2 SINUTAB® 3-Way. Each tablet contains: Pseudoephedrine Hydrochloride 30 mg, Ibuprofen 200 mg. Reg. No. 36/5.8/0207.

Symptomatic relief of:

• Nasal congestion caused by colds, hay fever, allergic rhinitis and sinusitis

Age: 12+

Active ingredients

Xylometazoline: Local vasoconstrictor to help open nasal passages and relieve congestion and a runny nose

• Starts to work in 10 minutes29


Symptomatic relief of:

• Cleans and moisturises nasal passages

• Supportive treatment for nasal congestion

Age: All, incl. infants & toddlers

Active ingredients

Isotonic saline solution: Physiological salt solution – flushes, soothes and moisturises nasal passages

Sinutab® Nasal Spray

Sinutab® Saline Spray

S1 SINUTAB® Nasal Spray. Xylometazoline Hydrochloride 1 mg per ml (0,1 % w/v). Reg. No. P/16.1/184.

S2 SINUTAB® Sinus Pain Non-Drowsy. Each tablet contains: Pseudoephedrine Hydrochloride 30 mg, Paracetamol 500 mg. Reg. No. 37/5.8/0138.



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Test Your KnowledgeYou’ve reached the end of the module. You can test your knowledge right away while the info is fresh, or you can complete the full Class Test in one go once you reach the end of this Study Pack. See the back page of the booklet for more details on how to complete and submit your test.

Below are the questions from the Class Test that applies to the module you just finished. The full Class Test appears on the Fax Sheet included separately.

1 Which of the following is not a key symptom of the common cold?

a Mild cough

b Runny nose

c Mild fatigue

d Skin rash

2 For which of the following cold symptoms can Sinutab® Sinus Pain Non-Drowsy be used?

a Nasal congestion

b Pressure

c Headache

d All of the above

3 Your patient has the flu with no cough. Which one of the following products would you recommend?

a Benylin® Original

b Benylin® with Codeine

c Benylin® 4Flu Liquid

d Benylin® Bronchospect

4 When do flu symptoms appear?

a 1 to 4 days after the patient has been exposed to the virus

b 5 to 7 days after the patient becomes sick

c Within 12 hours of exposure

d Exactly 3 days after being exposed to the virus

5 Which OTC remedy would you recommend to a parent with a child aged between 6 and 12 years who is suffering from flu symptoms?

a Benylin® Daytime Flu Tablets

b Benylin® 4 Flu Tablets

c Sinutab® 3-Way

d Sinutab® Nasal Spray



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References 1. Porter RS (Ed). Viral Infections: Overview of Viral Infections. The Merck Manual Home Health Handbook. Available at www.

merckmanuals.com/home/infections/viral-infections/overview-of-viral-infections. Accessed on 20 December 2017

2. Porter RS (Ed). Viral Infections: Common Cold. The Merck Manual Home Health Handbook. Available at www.merckmanuals.com/home/infections/viral-infections/common-cold. Accessed on 20 December 2017.

3. Porter RS (Ed). Respiratory Viruses: Common Cold. The Merck Manual of Diagnosis and Therapy. Available at www.merckmanuals.com/professional/infectious-diseases/respiratory-viruses/common-cold. Accessed on 20 December 2017.

4. Graf P, et al. Expert Opin Pharmacother 2009;10:889-908.

5. Eccles R, et al. Curr Med Res Opin 2010;26:889-899.

6. Eccles R. Am J Rhinol 2000;14:335-338.

7. Eccles R. Rhinology 2011;49:131-138.

8. Eccles and Weber (ed). Common Cold. Birkhäuser Advances in Infectious Diseases. 2009 Birkhäuser. Verlag Basel/Switzerland.

9. Mayo Clinic Patient Care & Health Info. Common Cold: Symptoms. Available at www.mayoclinic.org/diseases-conditions/common-cold/basics/symptoms/con-20019062. Accessed on 20 December 2017.

10. Web MD Cold, Flu, & Cough Health Center. Coughs: Age 12 and Older. Available at www.webmd.com/cold-and-flu/tc/coughs-topic-overview. Accessed on 20 December 2017.

11. Barrett B, et al. Health Qual Life Outcomes 2009;7(76).

12. Smith AP. Brain Behav Immun 2012;26:1072-1076.

13. NHS Choices. Coping With Colds and Flu. Available at www.nhs.uk/Livewell/coldsandflu/Pages/Coldcomfort.aspx. Accessed on 20 December 2017.

14. Boots WebMD. Flu guide. Available at www.webmd.boots.com/cold-and-flu/flu-guide/five-days-of-flu. Accessed on 20 December 2017.

15. Porter RS (Ed). Viral Infections: Influenza. The Merck Manual Home Health Handbook. Available at www.merckmanuals.com/home/infections/viral-infections/influenza-flu. Accessed on 20 December 2017.

16. World Health Organization. WHO Facts Sheets: Influenza (Seasonal). Available at www.who.int/mediacentre/factsheets/fs211/en/. Accessed on 20 December 2017.

17. How Flu Spreads. Centers for Disease Control and Prevention. Available at www.cdc.gov/flu/about/disease/spread.htm. Accessed on 20 December 2017.

18. WebMD. Cold, Flu & Cough Health Center. Coughs, Age 12 and Older – Prevention. www.webmd.com/cold-and-flu/tc/coughs-prevention. Accessed on 20 December 2017.

19. Centers for Disease Control and Prevention. When and How to Wash Your Hands. www.cdc.gov/handwashing/when-how-handwashing.html. Accessed on 20 December 2017.

20. WebMD. Cold, Flu & Cough Health Center. 8 Natural Tips to Help Prevent a Cold. Available at www.webmd.com/cold-and-flu/11-tips-prevent-cold-flu. Accessed on 20 December 2017.

21. Daily Mail. 10 Ways to Avoid Colds and Flu This Winter. Available at http://www.dailymail.co.uk/health/article-86521/Ten-ways-avoid-colds-flu-winter.html. Accessed on 20 December 2017.

22. Nurses Drug Handbook. 2010, Jones and Bartlett Pub. 9th Edition, pp. 332 – 333.

23. Donaldson, M., Gizzarelli, G. & Chanpong, B. 2007, Oral Sedation: A Primer on Anxiolysis for the adult patient. Anaesth Prog. 54: pp. 118 – 129.

24. Goodman and Gilman’s. 2011, The Pharmacological Basis of Therapeutics, Twelfth Edition, Diphenhydramine HCl. p. 921: Table 32-2.

25. The National Institute for Communicable Diseases (NICD) in collaboration with The South African National Department of Health and World Health Organization (WHO). Healthcare Workers Handbook On Influenza (last updated: May 2014). Available at www.nicd.ac.za/assets/files/Healthcare%20Workers%20Handbook%20on%20Influenza%20in%20SA%20_12%20May%202014(1).pdf. pp 17. Accessed on 20 December 2017.

26. Morice AH et al. Thorax 2006;61(Suppl 1):i1−i24

27. http://www.drugs.com/monograph/pseudoephedrine.html.

28. Tucci J, Bandiera E, Darwiche R, Medos Z, Nashed R, Trinh D. Paracetamol and Ibuprofen for Paediatric Pain and Fever. Jnl Pharmacy Practice Research. 2009; 39(3):223-225.

29. Martindale, The Complete Drug Reference, 32nd Edition, page 1071.

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colds and flu€¦ · colds and flu are both classified as viral infections1a. the definition of a...

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