15.1 Minor Ailments I: Allergic Rhinitis, Colds & Influenza, Eye and Ear Conditions

Minor Ailments I: Allergic Rhinitis, Colds & Influenza, Eye and Ear Conditions

Self-care and minor-ailment assessments are among the most common pharmacist interactions in Canada. Several provinces also allow pharmacists to prescribe for these conditions (section 2.2). The exam tests three things: choosing the most effective, safest option; knowing the product limits (age, duration, contraindications); and recognizing red flags that need referral.

1. Allergic Rhinitis

• Intranasal corticosteroids (INCS) (fluticasone, mometasone, budesonide, triamcinolone, ciclesonide) are the most effective single therapy. They relieve congestion, rhinorrhea, sneezing and itch, and also improve eye symptoms.
  • Benefit begins within a day but peaks after 1 to 2 weeks of regular use. For seasonal allergies, start before the season.
  • Technique: shake, look slightly down, aim the spray away from the septum (right hand to the left nostril and vice versa), and sniff gently. This reduces nosebleeds.
• Second-generation oral antihistamines (cetirizine, loratadine, desloratadine, fexofenadine, bilastine, rupatadine) help sneezing, itch and rhinorrhea but do little for congestion. Cetirizine causes the most sedation of the group.
• Avoid first-generation antihistamines (diphenhydramine, chlorpheniramine): sedation, impaired driving, and anticholinergic effects in older adults.
• Topical decongestants (xylometazoline, oxymetazoline) are limited to 3 to 5 days to prevent rhinitis medicamentosa (rebound congestion).
• Oral decongestants: pseudoephedrine raises blood pressure and heart rate. Caution or avoid it with uncontrolled hypertension, coronary disease, hyperthyroidism, BPH with retention, angle-closure glaucoma, and MAO inhibitors. Oral phenylephrine is poorly absorbed and of doubtful benefit.
• Other options: saline irrigation; ipratropium nasal spray for watery rhinorrhea; and allergen immunotherapy (subcutaneous, or sublingual tablets for grass, ragweed and house dust mite) for patients who are not controlled.
• Pregnancy: saline, budesonide or fluticasone INCS, and loratadine or cetirizine are commonly recommended.

2. The Common Cold and Cough

• Colds are viral, last 7 to 10 days, and do not respond to antibiotics. Supportive care: fluids, rest, saline drops or spray, humidified air, and acetaminophen or ibuprofen for fever and aches.
• Honey (for children over 1 year) modestly reduces night-time cough. Never give honey to infants under 1 year (botulism).
• Non-prescription cough and cold products:
  • Children: not for children under 6 years (Health Canada labelling).
  • Dextromethorphan: a serotonergic and abuse risk with MAO inhibitors and at high doses.
  • Codeine-containing products: Schedule II, and avoided in children under 12.
• Refer the patient with:
  • shortness of breath, chest pain, wheeze or hemoptysis;
  • fever above about 39°C or fever lasting more than 3 days;
  • symptoms lasting longer than 10 to 14 days, or worsening after initial improvement;
  • a cough lasting longer than 3 weeks;
  • a patient who is immunocompromised or frail.

3. Influenza

• Vaccination: annual vaccination for everyone 6 months and older is the main prevention (section 16.1).
• Antiviral treatment (oseltamivir 75 mg twice daily for 5 days) works best within 48 hours. It is still recommended beyond 48 hours for patients who are at high risk (for example, with asthma, chronic heart or lung disease, pregnancy, or age 65 and older), hospitalized, or worsening. PEBC sample items choose oseltamivir for a patient with asthma who is worsening 72 hours after onset.
• Inhaled zanamivir can cause bronchospasm and is avoided in asthma and COPD. Amantadine is not used because of resistance.
• Renal dosing: reduce the oseltamivir dose when CrCl is below 60 mL/min.

4. Eye Conditions

5. Ear Conditions

• Acute otitis externa ("swimmer's ear"): ear canal pain that worsens when the tragus or pinna is pulled, itch and discharge. It is treated with topical drops (antibiotic with or without a corticosteroid, such as ciprofloxacin/dexamethasone, or acidifying drops). Oral antibiotics are not needed unless infection spreads beyond the canal.
• If the eardrum may be perforated (or the patient has ear tubes), avoid potentially ototoxic drops such as neomycin or aminoglycoside-containing products. Use fluoroquinolone drops.
• Prevention: dry the ears after swimming; acetic acid or alcohol-based drying drops for people prone to recurrence.
• Earwax (cerumen) impaction: softening drops (carbamide peroxide, or olive or mineral oil) for several days, then gentle irrigation if appropriate. Never use cotton swabs in the canal. Refer when there is pain, discharge, hearing loss, dizziness, a perforation history or ear tubes.
• Acute otitis media in children is assessed by a prescriber (section 11.1).