Community Course 2012

1) Cold
General notes

2) Flu

Upper Respiratory Tract (URT) Diseases 3] Allergic rhinitis

Types of allergic rhinitis: a) Seasonal rhinitis b) Perennial rhinitis Symptoms may start by any age (common in children & young adults). Improves or resolves as child gets older. Inflammatory response initiated by allergens deposited on the nasal mucosa lead to histamine release. Fungal spores Slightly late often until September. Start in April when pollens appear peaks btn may & July when grass pollen levels are highest. House-dust mite, animal danders & feathers.

4] Cough

5] Sore throat
Most sore throat which present in pharmacy will caused by viral infections (90%) & bacterial infections (10%). Most infections are self-limiting. Streptococcal (bacterial) sore throat is more likely in children of school age. Detect choice of ttt & if referral is necessary. Most sore throats are self-limiting & will be better within 7-10 days if more Referral. Severity: If the sore is being severe painful especially in absence of cold, cough & catarrhal symptoms (if there are no improvement within 24-48 hrs) Referral.

a) Information to collect

Difference between Cold & Flu [Viral infection]: a) Cold b) Flu Child or adult (children more susceptible to URT infectn > adults). Age Infants < 30 days Referred immediately.1 Affect Localized at URT. Affects all body. Gradual (symptoms Onset Rapid 1. last for 7-14 days) Fever Rare High (3-4 days) Aches & pain Slight Severe Fatigue & Slight Prominent Weakness Early & Exhaustn Never prominent Headache Rare Prominent Sneezing Usual Sometimes Sore throat1 Irritated not red 1 Sore & red 1 Productive May persist after Common can become severe Cough the cold is over. Stuffy nose Common Sometimes Prevention No Possible Sinus congestion or Bronchitis or Complication earache pneumonia 1] Runny nose (Rhinorhea / blocked nose) Definition: Initially Clear Watery Fluid, Followed by Thicker Tenacious (viscous) Mucus. Due to: Dilatation of the nasal blood vessel swallowing of the lining surfaces of the nose narrowing of the nasal passage mucosa blocked nose. 2] Cough & Sneezing Symptoms a) Cough b) Sneezing Due to pharynx or bronchus Due to nasal passages irritation by post-nasal drip. irritation & congestion. 3] Sore throat: The throat feels dry & irritated. Sore & red Not inflamed & not red 4] Temperature 2] Earache A common complication Presence of temp indicates flu. of colds in children. Flu starts with: hot & Under normal cold shivery feelings, circumstances the middle muscular aches, pains in ear is an air-containing limbs, sore throat, dry compartment. cough & high temp. Due to: blocking of the The symptoms resolve Eustachian tube due to over 3-5 days "dry nasal catarrh lead to cough may persist for the ear can no longer be some time (2 days)". cleared by swallowing 5] Muscular & joint lead to the middle ear aches: Malaise. filled up with fluids which is an ideal site for bacterial infection otitis media "2ry infection" (feel uncomfortable & deaf) Referral. N.B: when this occurs usually requires ABs.

Allergen

Cough is a protective reflex action caused when the airway (especially larynx & lung) is being irritated or obstructed. Purpose: to clear the airway so that breathing can continue normally. Majority of coughs (90%) presenting in the pharmacy caused by UR viral infection. They will be associated with other cold symptoms & self limited. Children are more susceptible to respiratory infections. Establish who is the patient (child or adult) will influence the choice of ttt & if referral is necessary. Most coughs are self-limiting and will be better within few days with or without treatment. A cough > 2 weeks Referral.

1) Age

Age

Present all the year & worse in summer. People can suffer from what they think mild cold symptoms for long period without knowing they have perennial rhinitis. Nature of cough 1] Unproductive 2] Productive cough cough Nature Dry, tickly, tight. Chesty, loose. Sputum Without sputum. Sputum is produced. Different causes determined Viral infection (cold, flu or Cause irritation). & self limiting. by sputum color. Sputum colors & causes: Color Cause Action Non-colored Un-infected (normal or mucoid) self Respond Clear or white limiting. Green, Viral infection or chest infection yellow or (Pneumonia or bronchitis) rusty Heart failure and mitral stenosis. Due to congestion of blood vessels in Pink and lung leakage of blood in the air frothy or space and appear in sputum. bright red Symptoms: Breathlessness (especially in night) and swollen ankles. Blood in sputum (Haemoptysis): a) Minor b) Serious problem Problem Pink to Pulmonary deep red emphysema Violent cough Burst cancer, T.B & capillaries. chronic bronchitis.

2) Duration

Duratn N.B

Pollens

Any one presenting with summer cold for several weeks may suffer from hay fever.

1] Sneezing (Specific)
Case Severe symptoms of symptoms Cause

1) In morning 2) In evening 3) Windy days 4) After rain 5) Damp weather

9 9 9 9 9

Pollen rises after being released. Pollen settles at night. As pollen scattered. As pollen clears. Fungal spores

3) Symptoms

2] Rhinorhea (Specific) The discharge is often thin, clear & watery but can change to thicker, colored & purulent one 2ry infection no need for antibiotics. 3] Nasal congestion (Non-specific) The inflammatory response caused by allergen produces V.D of the nasal blood vessels nasal congestion. Severe congestion may result in headache, earache or 2ry infection as Otitis media & sinusitis. 3] Nasal itching (Specific) Irritation on the roof of the mouth. 4] Eye symptoms (allergic conjunctivitis) The eyes may be itchy & watery. Causes: 1. Irritation of the nose by pollen. 2. Direct effect of pollen grains in the eye (inflammatory response) tear duct congestion. People suffer from severe symptoms may be hypersensitive to bright light (photophobic) & find wearing dark glasses is helpful. Summer cold = Nasal congestion + Sneezing + Irritant watery eyes.

Appearance of throat Appearance Indicate Bacterial White spots, exudates or pus on tonsils infection Red, inflamed swollen Viral or bacterial throat Fungal infection Thrush (white plaques all over the oral cavity) (candidiasis) Inflamed with creamy Glandular fever exudates 1] Thrush Most commonly seen in babies or the very elderly & in younger adults (immunecompromised due to: leukemia, HIV, AIDS or taking steroid therapy. Require Referral. 2] Glandular fever Viral infection caused by Epstein-Barr virus (kissing virus) Referral. Incidence: Occurs in teenagers & young adults between the ages of 14 & 21. Symptoms: glands in the neck & axillary is enlarged, fever, malaise, severe sore throat & Dysphagia (difficulty in swallowing). Diagnosis: blood tests (+ve after a week of infection). Treatment: 1. Antibiotics of no value if Ampicillin is given during the infection measles type rash will develop. 2. Treatment is aimed to symptomatic relief. Referral is need for accurate diagnosis.

Referral

Colored

Community Course 2012 1] Facial pain / Frontal headache (Referral) May be due to: sinusitis. Sinuses "air-containing spaces adjacent in bony structure". In a cold inflamed and swollen produce catarrh secretions drain into the nasal cavity block drainage passage fluids build up in the sinus secondarily infected with bacteria. There are 2 types: a) Maxillary b) Frontal sinusitis sinusitis Above the Adjacent to the eye nose (most Frontal commonly headache involved) (worse by Facial pain & bending swelling in the forwards area of face or lying next to nose. down) 2] Earache (above row) 4) Complications or Symptoms of direct Referral 5) Previous history

1) Pneumonia Flu is complicated by 2ry lung infection (pneumonia). Warnings of complications: - Dry cough productive cough. - Persisting temperature - Pleuritic-type chest pain or delirium, - Dry throat. Complications may occur in: - Very young & very old. - Patients have preexisting heart or lung disease (Chronic bronchitis).

Symptoms of direct referral 1 1] Wheezing Difficulty in breathing, tightness of chest or coughing may indicate asthmatic attack or seasonal Asthma Referral. 2] Earache & facial pain Allergic Rhinitis 2ry bacterial infection Otitis media or Sinusitis Referral. 3] Purulent conjunctivitis Allergic conjunctivitis is a complicated by a 2ry infection. The eye becomes more painful (gritty sensation) and Redder. The discharge change from clear to colored ( )and sticky (purulent) Referral is needed.

3) T.B Nature Affect Associated symptoms Alcoholics, elderly & poor Chronic fever, night sweat & weight loss.

4) Whooping cough Bacterial infection Children < 5 years. Occur at regular interval of time (hourly) with plug of thick sputum & sometimes vomiting. Whoop sound produce when breathing after a paroxysm of coughing as bouts of coughing prevent normal breathing & the whoop represent the desperate attempt to breath in. Characteristic whoop isnt present in early stages of infection. Vaccines have no effect on it.

5) Croup Viral infection (larynx & trachea. Infants. Difficulty in breathing. Inspiratory stridor (noise in throat on breathing in) has harsh barking quality. Cause edema & airway narrowing.

Sound of cough

N.B Action

Referral

Associated symptoms Cold, sore throat, temperature, generalized muscle aches & catarrh may be associated with cough (due to viral infection) Respond. Post-nasal drip is a common cause of cough (may be due to sinusitis). Chest pain, shortness of breath (SOB) or wheezing Referral. History of 1] Chronic bronchitis 2] Asthma 3] HF 4] Gastroesophageal 5] Smoking Case Patient diagnosed by doctor. Patient doesnt diagnosed by doctor. A recurrent night cough can indicate asthma (especially in children) Heart disease with persisting cough. Gastro-esophageal reflux can cause cough. Smoking should be stopped Action

Symptoms of direct referral 1 1] Hoarseness a. Laryngitis: Inflammation of the vocal cords in larynx (viral infection self limited). ABs of no value & symptomatic advice (resting the voice) should be given. b. Croup (< 5 years): Viral infection in babies, infants or small children croup. Difficulty in breathing & stridor Referral. c. Laryngeal cancer: persistent hoarseness. N.B: When hoarseness persists > 3 weeks & isnt associated with acute infection Referral. 2] Dysphagia (difficulty in swallowing) a. Tonsillitis: Abscess develops in the tonsils region. Hospital admission operation to drain abscess & then dose parenteral ABs. b. Glandular fever: as above. Associated symptoms Cold, cough, catarrh (inflammation of mucus membrane), fever & general pains (self-limiting viral infection) Respond. 1. 2. 3. Recurrent bouts of infection (tonsillitis) Referral. If the patient is diabetic sugar-free medication might be preferred. Smoking habit: will exacerbate a sore throat.

a) Chronic bronchitis patients Definition: Chronic cough & mucus production for at least 3 months on at least 2 consecutive years when other causes of chronic cough have been excluded. If they have a bad cold or flu-like infection as it is often complicated by 2ry chest infection Referral.

b) Asthmatic patients Ask to inhaler using to prevent attacks Respond 1 to patient if this measure fails Referral.

Perennial rhinitis can be distinguished from seasonal rhinitis by questioning about the timing & the occurrence of symptoms.

Respond Referral

Respond
Drug Steroid inhalers (Beclomethasone or Budesonide) 1 Problem Immuno suppressant immunity in throat causes hoarseness & candidiasis of throat & mouth. Rare side effect agranulocytosi s ( WBCs cause autoimmune disease) Action 1) Rinse the mouth with H2O after use. 2) Tell the pt the right way to use the inhaler or use spacer as (Poor technique with metered-dose inhalers lead to amount of the drug deposited in throat).

6) Present medication

Be aware of any medication being taken by the patient to avoid interaction. In most cases of colds & flu OTC treatment will be appropriate. If medication has been tried for relief of cold symptoms with no improvement Referral.

To avoid drug-drug interaction. To avoid using un-effective product which may be experienced by patient.

It is essential to establish medicines currently being taken which includes: 1. Prescribed by a doctor. 2. Any OTC product. It is important to remember possibility of interactions with cough medicines. Medication causing cough: Ace inhibitors (Enalapril, Captopril & Lisinopril) Cause Dry, irritating & persistent cough (female > male) Within days of starting the treatment or after a period of few Developed weeks or even months. 1. Cough may resolve. 2. Cough may persist (troublesome) ACEI should be Solution discontinued. Any patient in whom medication is suspected as the cause of cough Referred to their doctors. Medication treating cough: 1. Inappropriate preparation may be taken as cough suppressant for a productive cough. 2. If 1 or more appropriate remedies have been tried without success Referral. If cough not improved after 14 days Referral.

Carbimazole (hyper thyroidism) 1

+ Sore throat Referral.

c) ttt time scale

If symptoms not improved within a week Referral

If symptoms not improved after 5 days Referral.

If sore throat improved within 5 days Referral.

Community Course 2012 1] Antihistamines a) Types: a) Older antihistamines 1st generation (Sedating) b) Newer antihistamines 2 generation (Non-Sedating) 1
nd

b) Effectiveness: Examples

a) Effective in b) Not effective in Sneezing & rhinorrhoea. Nasal congestion. Promethazine (t1/2 = 8-12 hrs), 1) Astemizole 2) Acrivastine 3) Loratedine 4) Cetrizine c) Mechanism of action: Anticholinergic action of antihistamines drying of secretions. Diphenhydramine (t1/2 = 5-8 Examples Once daily t1/2 3 Dosage / day Once daily dosage d) Uses: hrs) & Chlorpheniramine. For children > 12 years. > 2 years. > 6 years. a) Used for b) Nor used for Anticholinerg st More pronounced. Less pronounced. 1. 1 line treatment for allergic rhinitis symptoms. 1. Nasal congestion. ic effects 2. Diphenhydramine in cold remedies antitussive. 2. Cough with Diphenhydramine has less sputum. 3. For dry cough with cough suppressants. N.B Less effective in cough & colds. morning hang over/ f) Contraindications: drowsiness than promethazine. 1. Glaucoma. 2. Prostatic hypertrophy. e) Problems: 3. Epileptic patients. 4. Liver diseases. Problem Not recommended for Aggravating factors g) Interactions: Older types (At NORMAL doses) 1. Alcohol. 1. Anyone who drive. 1. Alcohol, sedatives, TCADs & anxiolytics effect of antihistamines. 1 Cause drowsiness (CNS depression) so 2. Impaired level of consciousness 2. Drugs cause CNS (BDZs, 2. Chlorpheniramine inhibit liver metabolism serum Phenytoin (operators of machinery) Phenothiazines & barbiturates). taken at bed time. level Phenytoin toxicity. 2 At HIGH doses CNS stimulation. Reports of fits at very doses. Epileptic patients 3. Antihistamines antagonize Betahistine. Older types Anticholinergic adverse 4. Anticholinergics (hyoscine) anticholinergic side effects. 1. Glaucoma patients. 3 effects (dry mouth, blurred vision, 5. Erythromycin, Ketconazole, Terfenadine & Diuretics with antihistamines 2. Prostatic hypertrophy patients. constipation & urinary retention). arrhythmias. 2] Nasal decongestant (Sympathomimetics) a) Types: b) Mechanism of action: Work on receptors of the dilated blood vessels in the nasal mucosa V.C. a) Short acting (old generation) b) Long acting (new generation) Shrinkage of the nasal membrane drainage of the mucus & circulation of Ephedrine & Pseudoephedrine. Examples Oxymetazoline & Xylometazoline (up to 6 hrs). air are improved. Rebound congestion Rebound congestion. Less likely to cause rebound congestion. d) Uses: c) Route of administration: 1. Nasal congestion alone or in combination with antihistamines. a) Orally b) Topically 2. Allergic rhinitis: in patients used a preventer as Cromoglycate or Dosage forms Tablets & syrups (e.g. Pseudoephedrine). Nasal sprays & drops (e.g. Oxymetazoline). Corticosteroids [N.B: used before the preventer as the congestion can prevent the drug from reaching the nasal mucosa]. Rebound congestion Rebound congestion after 7 days of use. No rebound congestion. 3. Allergic rhinitis: eye drops containing antihistamines & sympathomimetics e) Problems with ORAL decongestants: combination for eye symptoms. Problem Solution 4. Orally ONLY (e.g. Pseudoephedrine) commonly included in cough remedies for Some drugs as Ephedrine (more likely to produce this problem) when Avoid taking dose near the their bronchodilator & decongestant actions for chesty productive cough. 1 taken orally cause CNS stimulation (keep patient awake). bed time. f) Advices: Interaction between sympathomimetics + MAOIs (phenelzine) Avoid taking BOTH (Oral & Topical decongestants (ONLY) shouldnt be used more than 7 days due hypertensive crisis. Topical "also can induce this to rebound congestion (rebound medicamentosa) can occur due to receptor 2 This can occur up to 2 weeks after stop taking of MAOI the effect" sympathomimetics) in down-regulation [not with ORAL decongestants). 1 patient treated with MAOI. pharmacist must know any recently discontinued medication. g) Contraindications: Avoid taking Orally 1. Can cause stimulation in the heart & blood pressure not 1. HTN 2. Diabetes 3. Heart Diseases 4. Hyperthyroidism sympathomimetics BUT Topical used in heart diseases patients "Hypertensive patients" & 5. Eye drops containing sympathomimetics in patients with glaucoma or whom 3 Hyperthyroidism patient "more vulnerable to heart irregularity". agents (drops or sprays) can be wear soft contact lenses. used or use saline nasal drops. h) Interactions: -blockers, MAOIs (phenelzine) & Tricyclic antidepressants. 2. Blood glucose level not used in diabetics patients. 3] Cough suppressants (Dry cough) 3] Sodium cromoglycate 3] Zinc, Echinacea & Vitamin C Forms Echinacea immunity response & Drops or sprays for eyes & nose. a) Codeine b) Pholcodine c) Dextro Vitamin C in high dose > 1 g / day duration of Class Mast cell stabilizer. Class Centrally acting drugs (on cough centers in CNS). symptoms by 15% or 1 day. Uses Effective as a prophylactic if used correctly. Effectiveness Effective cough suppressants. Less potent. 4] Sore throat products, Cough remedies Should be started 2 to 3 weeks before the hay Constipat At OTC doses Less NO n How to & Analgesics fever season is likely to begin then Resp use? continued through the season. depression At higher doses Regimen Used 4 times daily (every 6 hours). Addiction Less NO Side No significant side effects. Drowsiness NO effect Avoided in ttt of For children > 2 yrs Useful for Children. children & never Usage (5 mg) & Adults (15 Contain the preservative Benzalkonium Cl used < 1 year old. mg) 3-4 times daily. Warning so shouldnt be used by wearers of soft Has long t1/2 Pharmacists not contact lenses. N.B recommend it. twice daily dosage. Side effects

1. 2. 3.

1] Oral analgesic Paracetamol each 4 hrs. Aspirin & ibuprofen each 8 hrs. Flurbiprofen lozenges: Contain 8.75 mg Flurbiprofen. Used for adults & children > 12 yrs One sucked/3-6 hrs up to max 5 lozenges. Used up to 3 days.

The patient should take the analgesic REGULARLY to sustain relief of pain "a regular full dose" is better than "now & then"

d) Management

Use of analgesic

2] 2nd Line involve 4 Pharmacological classes: 1. Antifungal 2. Antiseptic 3. Anti-inflammatory 4. Local anesthetic Pharmaceutical forms: a) Sucking b) Liquid Lozenges Mouthwashes. Pastilles Sprays & gargles. N.B: Local anesthetic & Present in both forms. antiseptics AntiMouthwashes & gargles. inflammatory Antifungal Lozenges & pastilles. A) Mouthwashes, sprays & gargles a) Antiseptic Hexetidine, Povidoneiodine & Cetyl pyridinium chloride Antimicrobial action b) Local anesthetic 1) Phenol, 2) Benzocaine & Legnocaine (commonly used as throat sprays). Pain. Sensitization reaction may occur with Benzocaine or Legnocaine but NO cross sensitization.

Examples

Effect

N.B

NO antiviral activity

c) Anti-inflammatory Example MOA Side effects Suitable for Benzydamine Absorbed from skin & mucosa pain & inflammation in conditions of mouth & throat Numbness & stinging of the mouth & throat. I) Spray Children 6 years Mouthwash or gargles ONLY for children > 12 years.

Community Course 2012 4] Steroidal nasal sprays Bechlomethasone & Fluticasone nasal spray. Anti-inflammatory. 1. Treatment of seasonal allergic rhinitis. 2. Treatment of choice for moderate to Uses severe continuous nasal symptoms. 1. Regular use essential for full benefit & ttt continued through season. How to 2. If symptoms already present pt must use? know that it will take several days before the full ttt effect is reached. Regimen Up to 3 months. Dryness, irritation of nose & throat, nose Side effect bleeding. Useful for Patients > 18 years. Not recommended for: Children, Warning pregnant women or patients with glaucoma. Forms Class MOA Example Advantage Not suitable 1. 2. 4] Demulcents They coat the inflamed mucosa. Soothing & hydration of the mucus membrane irritatn. Glycerin, lemon & honey. 1. Dont contain active ingredients for children & pregnant. 2. Pleasant taste suitable for children. Diabetic patients (pleasant taste). 5] Expectorants (chesty cough) a) Direct MOA b) Indirect B) Lozenges (Circular) & pastilles (tetra hexagonal) a) Antifungal Examples Effect Dequalinium Moisten the throat. Used in viral sore throat to avoid 2ry fungal infection. c) Antiseptic Example Effect Cetylpyridinium chloride Effective antibacterial action. b) Local anesthetic Benzocaine Numb the tongue & the throat soreness & pain.

Stimulating bronchial mucous secretion Irritation of GIT (subsequent liquefying sputum making it easier action on the respiratory system mucus secretion. to cough up. 1] Epicacuahna Guaiphenesin GIT irritation stimulation of In adults the dose required to produce respiratory system (Subexpectoration is 100-200 mg so emetic effect). any product should contain a sufficiently dose. 2] Ammonium salts Some OTC preparations contain sub(NH4Cl.NH4HCO3) cause vomiting & acidosis. therapeutic doses. 6] Mycolytic It dissolves various chemical bonds within secretion which in turn MOA can viscosity by alternating mucin-contaning components. E.Xs Acetylcysteine, Carbocysteine, methylcysteine HCl & ambroxol. Used Treatment of respiratory diseases with phlegm production due to for their capacity to facilitate sputum elimination. N.B Have anti-oxidant & anti-inflammatory effects. 7] Other remedies (Theophylline) Class From xanthine family & they are bronchodilator. b) Theophylline levels Smoking, Carbamazepine, Cimetidine & erythromycin Phenytoin & rifampicin. Liver enzymes & metabolism Liver enzymes & metabolism OTC medicines contain theophylline shouldnt be taken at same time with prescribed medicines as toxic blood levels may occur Therapeutic drug monitoring should be done (theophylline has narrow therapeutic index) NOT for Children. a) Theophylline levels

N.B

Example

Caution 1 Iodized throat lozenges avoided in pregnancy potential effect on the fetus thyroid gland.

Intera ctions

N.B

1] Diabetes In short term use for acute conditions the sugar contents of OTC remedies is less important. Nevertheless many diabetic patients may prefer sugar-free product. 2] Steam inhalation Useful in: nasal congestion & soothing the air passages, particularly with productive cough (hydration and dilution of the secretion of mucus membrane) may contain eucalyptus or menthol. Procedures: one teaspoonful of inhalation should be added to a pint of hot (not boiling scalding & volatilizes the constituents too quickly) water & inhaled. A cloth/towel put over the head to trap the steam. Inhalation which can be used on handkerchiefs, bedclothes & pillowcases are available. 3] Nasal spray & drops 3] Fluid intake Maintaining a high fluid intake helps to hydrate the lungs. a) Nasal spray b) Nasal drops Hot drinks can have soothing effect. Example Phenylephrine, Ephedrine & Naphazoline. General advice with coughs & cold to fluid intake by around 2 L/day. Preferred for Adults and children aged over 6 years. Children under 6 years. Combinations 1 In young children the nostrils are not sufficiently wide to Because It reaches a large surface area. a) Rational Mixtures b) Irrational Mixtures allow the effective use of sprays. Antihistamines + Suppressants night-time N.B: Expectorants + Suppressants. dose if cough is disturbing the sleep. 1. Drops are more easily swallowed possibility of systemic side effects. Bronchodilator + Suppressants. Expectorants + Antihistamines. 2. Manufacturers of pediatric drops advise consultation with the doctor for children < 2 years. 1. 2. 3. 4. 5. 6. Symptoms persist > 7-14 days. Ear ache > 48 hrs or if there is discharge (Otitis). Very young & Very old (> 80 years). Wheezing, difficulty in breathing (SOB) & Delirium. Facial pain & Frontal headache (Sinusitis). Persisting fever , Productive cough & CB. 1. 2. 3. 4. 5. Wheezing, difficulty in breathing or SOB. Facial pain & Frontal headache (Sinusitis). Ear ache. Purulent conjunctivitis. Symptoms persist > 5 days. 1. Symptoms persist > 14 days. 3. Difficulty in breathing or SOB. 5. Colored sputum. 7. Whooping cough & croup. 9. . Heart failure history. 11. Gastro-esophageal reflux cough. 2. Wheezing chest. 4. Dry night time cough. 6. Wight loss. 8. Chronic bronchitis. 10. ACE inhibitors cough.

1] Diabetes Mouthwashes & gargles are suitable & can be recommended. Sugar-free pastilles are available but the sugar content of such products isnt considered important in short term use. 2] Mouthwashes & gargles Pts should be reminded that mouthwashes & gargles shouldnt be swallowed. The potential toxicity of OTC products of this type is low & it is unlikely that problems would result from swallowing small amount: 1. There are small risk of systemic toxicity from swallowing products contain iodine. 2. Not used for pregnant (risk on fetus). Hoarseness or Dysphagia . Dysphagia without sore throat. Symptoms > 10 days. Glandular fever (swollen tender gland) Carbimazole. Tonsillitis.

e) Practical points

1. 2. 3. 4. 5. 6.

f) Referral