Help your patients: Tips for effective patient counseling in the treatment of URIs (Part 5 of 6)

Clinical Associate Professor, University of New Mexico School of Medicine, Editor in Chief, Alternative Therapies in Health and Medicine, Board of Trustees, American Holistic Medical Association, Founder, Integrative Medicine Institute, Santa Fe, NM

This e-newsletter installment, the 5^th of a 6-part series about management of upper respiratory infections (URIs), is designed to help you better manage patient perceptions regarding the etiology of—and best management practices for—URI symptoms, focusing on patient education concerning herbal products and nutritional supplements.

  Addressing patient misconceptions about colds

Patients who visit your office for symptom relief from URIs often have misconceptions about the causes of, and effective treatments for, URIs. For example, some patients may believe that low environmental temperature, dampness, or being wet or chilled initiate or affect the severity of a cold. They may also believe that antibiotics prevent colds.¹ They may not understand that simple measures such as hand washing will prevent the spread of many viral infections. The first newsletter of this series described patient education strategies for URI prevention.

Additionally, brief patient counseling concerning the viral origin of most URIs may provide your patients with insight into why some remedies may be effective—and why other treatments may not alleviate symptoms. The potential importance of patient counseling and increased awareness about URIs—their causes and treatments—may affect how patients view the care you provide.

In addition, many of your patients may use herbal or nutritional supplements, as well as over-the-counter medications, to help them manage the symptoms of URIs. They may believe that such products prevent or cure URIs. This e-newsletter installment gives you practical information that can help you counsel your patients about the complementary and alternative medicine products that your patients may be using—or that might be useful to consider—and thus help them to manage their symptoms.

Key points for patients:

• Symptoms appear 1 to 2 days after exposure; initial symptoms may be characterized by a tickling or soreness in the throat, sneezing, cough, runny nose, nasal congestion, and headache.

• Resolution usually occurs within 10 days, regardless of treatment.²

• Rest and hydration are often advised.²

• As most URIs are caused by viral infections, antibiotics will have no benefit.

• Nonprescription cold remedies, such as decongestants and cough suppressants, may relieve some symptoms but will not prevent or shorten duration of URIs. These agents often have side effects, such as drowsiness, dizziness, insomnia, or upset stomach. Patients should use them with care.²

• Common OTC products (eg, pseudoephedrine, phenylephedrine) can dry nasal secretions, which may increase the risk of infection in the nasopharynx and sinuses. Long-term use of nasally administered vasoconstrictors may result in a rebound effect, worsening symptoms because of mucosal dependence on the agent. Vasoconstrictors may also result in side effects that include elevated blood pressure, tachycardia, and arrhythmias.

The following sections briefly review the medical literature concerning nutritional supplements and herbal agents for the treatment of URIs. It may aid your efforts to counsel your patients concerning alternative therapies. You may wish to inform your patients that, in its regulation of supplements and herbal products,³ the US Food & Drug Administration does not verify effectiveness claims about these and other alternative medicine products, nor does it require the same toxicology and efficacy data that it requires for approval of a new drug. The medical literature, however, provides guidance that may assist you and your patients in making informed choices regarding these agents.

Zinc. The medical literature regarding zinc is inconsistent. The variations in effects may result from the various formulations used in studies, and these may differ from those available in the marketplace. Still, it may help your patients to know that some studies have shown that zinc lozenges help speed symptom resolution. For example, in one double-blind, placebo-controlled study, 65 individuals were followed. At 7 days, 86% of patients in the active treatment group were symptom-free, compared with 46% in the placebo group.⁴ However, it is equally important to let your patients know that other studies have shown no benefit.^5,6 Likewise, conflicting data are reported for nasal zinc preparations. Although some studies have found zinc nasal gel spray effective in shortening the duration of colds (2.3 days with treatment vs 9 days with placebo in one trial⁷ and 4.3 days with treatment vs 6 days with placebo in another⁸), others have found no difference between treatment with zinc nasal spray and placebo in cold duration or severity.⁹ Anosmia following intranasal use of zinc has been reported^10,11; however, no strong evidence to date supports a negative effect of zinc on sense of smell in humans.¹¹

Vitamin C. Overall, studies have shown that vitamin C may be useful to reduce the duration and severity—but not the incidence—of colds. A meta-analysis of 30 controlled trials evaluating 11,350 study participants demonstrated that vitamin C prophylaxis had a greater effect in children (14%) than adults (8%); however, the authors questioned the practical relevance of their findings.¹² Interesting data concerning cold incidence was reported in an evaluation of 642 very active patients or those experiencing significant physical stress: vitamin C prophylaxis demonstrated a 50% reduction in incidence in that population.^12,13 It should be noted that the dosages used in some trials ranged from 500 mg/wk to 8 g at onset of symptoms.^12,13 While very few reports of severe harm have been noted, high dosages may result in gastrointestinal symptoms.

Echinacea. Echinacea purpurea, although commonly used for the treatment of URIs in children, is not effective in treating URI symptoms in patients age 2 to 11 years. Its use has been associated with an increased risk of rash.^14,15 However, in adults, this herbal remedy has produced mixed results. One randomized, double-blind, placebo-controlled study of 282 patients revealed that total daily symptom severity scores were 23.1% lower in the echinacea group than in the placebo group.¹⁶ Another study of 80 patients showed that the duration of symptoms was 6 days with echinacea, compared with 9 days with placebo.¹⁷ Conversely, other studies have found that echinacea has no, or only minor, effects on cold symptoms or severity.^18-21

Pelargonium sidoides. This agent has been discussed in previous installments of this series. P sidoides is well tolerated both by children 2 years of age and older as well as adults.²² A number of detailed randomized clinical trials previously described in this series have shown that it reduces the severity and duration of colds.

Garlic and ginseng. Other agents, such as garlic and ginseng, have been evaluated in a very small number of studies, all of which reported an improvement in symptoms. In one study, participants taking an allicin-containing garlic supplement experienced cold symptoms for 1.5 days, compared with 5.0 days with placebo.²³ And in another study, patients taking ginseng were 12.8% less likely to develop a cold, and their symptom severity and duration were reduced by 31% and 34.5%, respectively.²⁴

Disclosure

Dr Riley reports that he has no conflict of interest to disclose.

This e-newsletter is supported by a grant from Abkit and Nature’s Way, manufacturers of the only products available in the United States that contain the active P sidoides extract used in clinical trials. These products are available as a rapid melt tablet (Zucol™, ColdCare, Abkit) as well as in liquid and chewable tablet forms (Umcka® ColdCare, Nature’s Way).

References

1. Braun BL, Fowles JB, Solberg L, et al. Patient beliefs about the characteristics, causes, and care of the common cold. J Fam Pract. 2000;49:153–156.
2. National Institutes of Health. National Institute of Allergy and Infectious Diseases. Common cold. http://www3.niaid.nih.gov/topics/commonCold/treatment.htm. Accessed March 16, 2009.
3. US Food and Drug Administration. Center for Food Safety and Applied Nutrition. Dietary supplements. http://www.cfsan.fda.gov/~dms/supplmnt.html. Accessed March 16, 2009.
4. Eby GA, Davis DR, Halcomb WW. Reduction in duration of common colds by zinc gluconate lozenges in a double-blind study. Antimicrob Agents Chemother. 1984;25:20–24.
5. Jackson JL, Lesho E, Peterson C. Zinc and the common cold: a meta-analysis revisited. J Nutr. 2000;130(5S suppl):1512S–1515S.
6. Macknin ML, Piedmonte M, Calendine C, et al. Zinc gluconate lozenges for treating the common cold in children: a randomized controlled trial. JAMA. 1998;279:1962–1967.
7. Hirt M, Nobel S, Barron E. Zinc nasal gel for the treatment of common cold symptoms: A double-blind, placebo-controlled trial. Ear Nose Throat J. 2000;79:778–780, 782.
8. Mossad SB. Effect of zincum gluconicum nasal gel on the duration and symptom severity of the common cold in otherwise healthy adults. QJM. 2003;96:35–43.
9. Belongia EA, Berg R, Liu K. A randomized trial of zinc nasal spray for the treatment of upper respiratory illness in adults. Am J Med. 2001;111:103–108.
10. Alexander TM, Davidson TM. Intranasal and anosmia: the zinc-induced anosmia syndrome. Laryngoscope. 2006;116:217–220.
11. Kim K-J. Zinc: Combats the common cold? Consumer Health Information Corporation. 2006. http://www.consumer-health.com/services/cons_take48.htm. Accessed February 23, 2008.
12. Hemilä H, Chalker E, Treacy B, et al. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev. 2007;(3):CD000980.
13. Anderson TW, Suranyi G, Beaton GH. The effect on winter illness of large doses of vitamin C. CMAJ. 1974;111:31–36.
14. Linde K, Barrett B, Bauer R, et al. Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev. 2006;(1):CD000530.
15. Taylor JA, Weber W, Standish L, et al. Efficacy and safety of echinacea in treating upper respiratory tract infections in children: A randomized controlled trial. JAMA. 2003;290:2824–2830.
16. Goel V, Lovlin R, Barton R, et al. Efficacy of a standardized echinacea preparation (Echinilin) for the treatment of the common cold: a randomized, a randomized, double-blind, placebo-controlled trial. J Clin Pharm Ther. 2004;29:75–83.
17. Schulten B, Bulitta M, Ballering-Brühl B, et al. Efficacy of Echinacea purpurea in patients with a common cold. A placebo-controlled, randomised, double-blind clinical trial. Arzneimittelforschung. 2001;51:563–568.
18. Grimm W, Muller HH. A randomized controlled trial of the effect of fluid extract of Echinacea purpurea on the incidence and severity of colds and respiratory infections. Am J Med. 1999;106:138–143.
19. Turner RB, Bauer R, Woelkart K, et al. An evaluation of Echinacea angustifolia in experimental rhinovirus infections. N Engl J Med. 2005;353:341–348.
20. Schwarz E, Parlesak A, Henneicke-von Zepelin HH, et al. Effect of oral administration of freshly pressed juice of Echinacea purpurea on the number of various subpopulations of B- and T-lymphocytes in healthy volunteers: results of a double-blind, placebo-controlled cross-over study. Phytomedicine. 2005;12:625–631.
21. Yale SH, Liu K. Echinacea purpurea therapy for the treatment of the common cold: a randomized, double-blind, placebo-controlled clinical trial. Arch Intern Med. 2004;164:1237–1241.
22. Timmer A, Günther J, Rücker G, et al. Pelargonium sidoides extract for acute respiratory tract infections. Cochrane Database Syst Rev.2008(3):CD006323.
23. Josling P. Preventing the common cold with a garlic supplement: a double-blind, placebo-controlled survey. Adv Ther. 2001;18:189–193.
24. Predy GN, Goel V, Lovlin R, et al. Efficacy of an extract of North American ginseng containing poly-furanosyl-pyranosyl-saccharides for preventing upper respiratory tract infections: a randomized controlled trial. CMAJ. 2005;173:1043–1048.

The Journal of Family Practice ©2009 Dowden Health Media