How to manage a cold during Covid 19 and a review of treatment advice .pdf
From the Canadian Association of Pharmacists – so you can’t read this too carefully – anything in italics are my own additions
Revised: April 2020
Peer Review: March 2020
Introduction
Even more detailed information on the rapidly evolving (mis)understanding of the epidemiology and pathophysiology ofcoronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, can be found
at:
■ Public Health Agency of Canada (PHAC) (reading time approximately 2 hours)
■ World Health Organization (WHO) (reading time approximately 2 months)
■ Centers for Disease Control and Prevention (CDC) (reading time 2.5 minutes)
This chapter provides information on:
■ Management of select common symptoms of COVID-19: fever, cough, headache/myalgia
■ Experimental treatments being used in acute-care settings using live human guinea pigs so take with a pinch of salt
Goals of Therapy
■ Alleviate symptoms and think positive
■ Prevent complications at all costs
Therapeutic Choices – summary: limited evidence based material
Fever
There is no evidence regarding the management of fever due to COVID-19 specifically, but the Association of Pharmacists has found the following information regarding management of patients experiencing fever in general very helpful.
See also .
■ Children <6 months of age with a fever should be assessed by an appropriate health-care practitioner ie. not a herbalist
■ In a pregnant patient who is in her first trimester, the goal of antipyresis is protection of the fetus.
■ There are many arguments against treating a fever:[4][5][6][7][8]
– Fever is an important defence mechanism; it enhances the immune response; it is the immune response and it tells mom when to call a doctor.
– Fever is usually self-limiting and, though sometimes distressing, the associated symptoms of fever (mild dehydration, discomfort, febrile delirium, febrile seizures) are usually not harmful – unless you are unfortunate enough to suffer with febrile seizures in which case ignore all of the above advice.
– Use of antipyretics may impair the use of temperature as an important clinical tool for monitoring the progress of an infection or response to antibiotics – ie. the absence of a fever after giving little Johnny tylenol does not mean he is cured, even if he is running up and down stairs playing hide and seek with his cousins.
Nonpharmacologic Choices
General interventions for reduction of fever and associated discomfort include:[1]
■ Removal of excess clothing and bedding – but leave the mattress
■ Increased fluid intake to replace insensible water loss during fever
■ Maintenance of ambient temperatures around 20–21°C
■ Avoidance of physical exertion –
Physical methods for heat reduction use convection, evaporation or conduction to counteract the body’s attempt to maintain a higher temperature set-point (fever). Pharmacologic methods are
preferred because they lower the hypothalamic set-point.[9] In the rare instance where core temperatures exceed 41–42°C, physical methods may be used in addition to pharmacologic methods. but please call me or your doctor if it goes over 39°C and I don’t know Fahrenheit.
■ Sponging with tepid or cold water uses evaporation to dissipate body heat. Sponging with alcohol is not recommended as it may be absorbed through the skin, inhaled or accidentally ingested by the
patient; it has also been associated with hypoglycemia, intoxication and coma.[10][11] alcohol is for the exclusive use of your doctor.
■ Ice packs or cooling (hypothermia) blankets may be applied to the skin to lower body temperature by conduction.
■ Circulating fans, sometimes directed over ice before reaching the patient, use convection to transfer heat away from the skin surface.
Pharmacologic Choices
The decision to use antipyretics must be individualized. The goal should be reduction of fever rather than “normal” body temperature. Assessment of the patient should not depend solely on the elevation of temperature.
■ Acetaminophen is safe and effective in children and adults.[12]
■ ASA, ibuprofen and naproxen are also effective antipyretics and may be used in the treatment of
fever due to COVID-19, keeping the following in mind:
– Evidence to date suggests that older people (>60 y) and those with underlying medical
conditions are at higher risk of severe COVID-19. As NSAIDs should be used with caution in
these populations, it is reasonable to avoid NSAIDs in the elderly and in those with comorbid
conditions (e.g., cardiovascular disease, renal disease, chronic respiratory disease). If the use of
an NSAID is unavoidable in these patients, it should be at the lowest effective dose and for the
shortest duration.[12]
– ASA is not recommended in children or adolescents because of the potentially increased risk of Reye syndrome.[13]
– Naproxen is not approved/recommended in children <12 years of age.
■ Some clinicians recommend alternating acetaminophen and ibuprofen administration to reduce
fever; however, there is insufficient evidence to support this as a routine practice and it is not
recommended.[2][14][15] No difference was found in patient discomfort in 2 trials that assessed it.[15]
Potential risks of prescribing 2 antipyretics may include confusion and dosing errors with
associated toxicity.
For more detailed information on medications used in the management of fever, see Table 2.
Cough
There is no evidence regarding the management of cough due to COVID-19 specifically, but the
following general information regarding management of patients experiencing acute cough may be helpful.
Nonpharmacologic Choices
■ Avoid exposure to inhaled irritants such as smoke, dust, pollutants and allergens, which can further
exacerbate any cough.
■ Although evidence is lacking, hydration with oral liquids and humidification of room air may be
beneficial. Room humidifiers used as preventive measures should be well cleaned to avoid
aerosolizing mould.
Pharmacologic Choices
Overall, there is little evidence for or against the effectiveness of nonprescription cough medicines.[16]
■ Nonprescription antitussives act centrally to suppress cough. Antitussives are not recommended
when a cough performs a useful function. If used by a patient with a productive cough, more mucus
is retained.[17]
– Dextromethorphan and codeine are commonly used to treat cough related to upper respiratory
tract infections, although there is little evidence for efficacy.[16] The American College of Chest
Physicians does not recommend centrally acting cough suppressants for cough secondary to
upper respiratory tract infections.[18]
■ Expectorants are reported to reduce sputum viscosity, permitting more effective removal of
secretions from the respiratory tract. There is a lack of evidence to support the efficacy of
expectorants: they do not thin sputum nor increase sputum volume, even at doses higher than
recommended.[17]
– Guaifenesin is purported to enhance cough effectiveness by promoting the clearance of airway
secretions.[19]
– Adequate hydration with oral liquids and inhalation of humidified air is perhaps the best
protussive or “expectorant” measure.
– Note that the cough associated with COVID-19 infection has generally been reported as dry in
most patients, further limiting the already questionable usefulness of expectorants.
■ Various other agents have been used for the management of cough, generally based on limited and/
or poor-quality evidence.
– Honey has demulcent, antioxidant and antibacterial effects. It is proposed that the demulcent
effect may act to decrease cough. It may be an effective cough suppressant in children; no
studies in adults are available.[19][20]
– Zinc lozenges have been used to alleviate cough due to the common cold. However, metaanalyses
have concluded there is insufficient evidence to recommend zinc preparations.[19] In
addition, zinc can be associated with unpleasant taste, mouth irritation and nausea.
– Anesthetic lozenges containing ingredients such as benzocaine, phenol and menthol may
reduce the sensitivity of peripheral nociceptors. They have been used as antitussives, but
evidence for efficacy is poor. Rarely observed side effects include tingling or irritation at the site
of administration and hypersensitivity reactions.
– Bronchodilators such as salbutamol or formoterol are recommended only for cough due to
obstructive lung disease such as asthma or COPD.[21]
For more detailed information on medications used in the management of cough, see Table 2.
Headache and myalgias
There is no evidence regarding the management of headache and/or myalgia due to COVID-19
specifically, but the following general information regarding management of patients experiencing these symptoms may be helpful. See also in the Compendium of Therapeutics for Minor Ailments as
well as , and in the Compendium of Therapeutic Choices
Nonpharmacologic Choices
■ Simple measures such as resting in a dark, quiet room and applying a cold cloth/ice pack to the
head are helpful for headache, although not evidence-based.
Pharmacologic Choices
The following medications are effective for alleviating headache and myalgia:
■ Acetaminophen can be used for mild to moderate pain. Compared with full-dose NSAIDs,
acetaminophen has fewer adverse effects and drug interactions but is less effective and has no antiinflammatory
action.[22]
■ ASA, ibuprofen and naproxen are effective anti-inflammatory analgesics. They may be useful for
the treatment of headache and myalgia in patients with COVID-19, keeping the following in mind:
– Evidence to date suggests that older people (>60 y) and those with underlying medical
conditions are at higher risk of severe COVID-19. As NSAIDs should be used with caution in
these populations, it is reasonable to avoid NSAIDs in the elderly and in those with comorbid
conditions (e.g., cardiovascular disease, renal disease, chronic respiratory disease). If the use of
an NSAID is unavoidable in these patients, it should be at the lowest effective dose and for the
shortest duration.[12]
– ASA is not recommended in children or adolescents because of the potentially increased risk of
Reye syndrome.[13]
– Naproxen is not approved/recommended in children <12 years of age.
■ Headache and myalgia due to COVID-19 seem to respond adequately to acetaminophen or
NSAIDs; it is unlikely that stronger analgesics such as opioids would be required.
For more detailed information on medications used in the management headaches/myalgias, see
Table 2.
Experimental therapies for COVID-19
Numerous medications are being used on an experimental basis for the management of COVID-19.
Use of any of these medications for the prevention or treatment of confirmed or suspected COVID-19
outside of a clinical trial or acute-care setting on the advice of an infectious disease specialist is
inappropriate.[27]
Experimental therapies are being used in the acute-care setting in severely ill patients as well as in
uninfected patients or earlier in the illness in attempts to prevent spread or progression of the disease.
Information about COVID-19-related clinical trials being conducted in Canada can be found at Canada
COVID-19 Therapeutic Clinical Trials.
Information about the rationale for use, dosage, adverse effects and drug interactions of select trial
medications can be found in Table 1.
Choices during Pregnancy and Breastfeeding
Management of COVID-19 during pregnancy
General information on what is known thus far with respect to COVID-19 and pregnancy can be found
on the Society of Obstetricians and Gynecologists of Canada website.
Fever, headache, myalgia: acetaminophen is considered the drug of choice. ASA and NSAIDs may
be considered as alternatives during the first or second trimester, but are not recommended in the third
trimester.[28]
Cough: codeine has the most evidence of safety during pregnancy and dextromethorphan can be
considered as an alternative.[28] Available data do not support an association between guaifenesin use
during pregnancy and congenital defects. Liquid products containing guaifenesin may contain high
alcohol content. Products with high alcohol content should be avoided during pregnancy.[36] Honey is
safe to consume during pregnancy. Zinc is considered safe in pregnancy, provided the recommended
daily maximum zinc intake (40 mg)[37] is not exceeded. The safety of other ingredients in any zinc based lozenges must also be assessed.
Management of COVID-19 during breastfeeding
General information on breastfeeding and COVID-19 can be found through the WHO and the PHAC.
Continuation of breastfeeding is recommended, as breast milk is considered an insignificant route of transmission for other respiratory viruses. If the mother is infected, wearing a mask, respiratory
etiquette and hand hygiene are recommended.[38]
Fever, headache, myalgia: acetaminophen is considered the drug of choice. Anti-inflammatory doses
of ASA are not recommended during breastfeeding due to possible excretion of salicylic acid into
breast milk and risk of Reye syndrome. NSAIDs have been shown to be present in breast milk in small
amounts and are considered safe to use. The use of short-acting drugs, such as ibuprofen, may be
preferred over those with a longer half-life, such as naproxen.[39]
Cough: the transfer of dextromethorphan and guaifenesin into breast milk is unknown. It is unlikely
that usual maternal doses would harm a nursing infant, especially in those over 2 months of age;
however, liquid products containing dextromethorphan or guaifenesin may contain high alcohol
content. Products with high alcohol content should be avoided while breastfeeding.[30][36] Use codeine
with caution at the lowest effective dose for a maximum of 2–3 days in a breastfeeding mother. If
codeine is used, monitor the infant for increased sleepiness, difficulty breastfeeding, breathing
difficulties and limpness.[29] Honey is safe to consume during breastfeeding. Zinc is considered safe in
breastfeeding, provided the recommended daily maximum zinc intake (40 mg)[37] is not exceeded. The
safety of other ingredients in any zinc-based lozenges must also be assessed.
Experimental therapies: see Table 1.
A discussion of general principles on the use of medications in these special populations can be found
in and . Other specialized reference sources are also provided in these appendices.
References
- Canadian Paediatric Society. Caring for kids. Fever and temperature taking [internet]. CPS. October 2015. Available from:
www.caringforkids.cps.ca/handouts/fever_and_temperature_taking. Accessed March 26, 2020. - Section on Clinical Pharmacology and Therapeutics, Committee on Drugs, Sullivan JE et al. Fever and antipyretic use in children. Pediatrics
2011;127(3):580-7. - Russell FM, Shann F, Curtis N et al. Evidence on the use of paracetamol in febrile children. Bull World Health Organ 2003;81(5):367-72.
- Sajadi MM, Mackowiak PA. Temperature regulation and the pathogenesis of fever. In: Bennett JE, Dolin R, Blaser MJ, editors. Mandell,
Douglas, and Bennett’s principles and practice of infectious diseases. 8th ed. Philadelphia (PA): Churchill Livingstone/Elsevier; 2015. p. 708-
20. - Mackowiak PA. Concepts of fever. Arch Intern Med 1998;158(17):1870-81.
- Aronoff DM, Neilson EG. Antipyretics: mechanisms of action and clinical use in fever suppression. Am J Med 2001;111(4):304-15.
- Styrt B, Sugarman B. Antipyresis and fever. Arch Intern Med 1990;150(8):1589-97.
- El-Radhi AS. Why is the evidence not affecting the practice of fever management? Arch Dis Child 2008;93(11):918-20.
- Meremikwu M, Oyo-Ita A. Physical methods for treating fever in children. Cochrane Database Syst Rev 2003;(2):CD004264.
- Axelrod P. External cooling in the management of fever. Clin Infect Dis 2000;31(Suppl 5):S224-S229.
- Garrison RF. Acute poisoning from use of isopropyl alcohol in tepid sponging. J Am Med Assoc 1953;152(4):317-8.
- Canadian Pharmacists Association: Use of NSAIDs in patients with COVID-19: what is the evidence? [PDF file]. Available from:
www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/Use-of-NSAIDs-in-patients-with-COVID-19-FINAL-EN.pdf. Accessed: March
26, 2020. - Committee on Infectious Diseases, Fulginiti VA, Brunell PA et al. Aspirin and Reye syndrome. Pediatrics 1982;69(6):810-2.
- National Institute for Health and Care Excellence. Fever in under 5s: assessment and initial management [internet]. NICE. August 2017.
Available from: www.nice.org.uk/guidance/CG160. Accessed April 19, 2018. - Wong T, Stang AS, Ganshorn H et al. Combined and alternating paracetamol and ibuprofen therapy for febrile children. Cochrane Database
Syst Rev 2013;(10):CD009572. - Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings.
Cochrane Database Syst Rev 2014;11:CD001831. - Irwin RS, Curley FJ, Bennett FM. Appropriate use of antitussives and protussives. A practical review. Drugs 1993;46(1):80-91.
- Irwin RS, Baumann MH, Bolser DC et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice
guidelines. Chest 2006;129:1S-23S. - Malesker MA,Callahan-Lyon P, Ireland B et al. Pharmacologic and nonpharmacologic treatment for acute cough associated with the common
cold: CHEST Expert Panel report. Chest 2017;152(5):1021-37. - Oduwole O, Udoh EE, Oyo-Ita A et al. Honey for acute cough in children. Cochrane Database Syst Rev 2018;10(4):CD007094.
- Becker LA, Hom J, Villasis-Keever M et al. Beta2-agonists for acute cough or a clinical diagnosis of acute bronchitis. Cochrane Database
Syst Rev 2015;9:CD001726. - Nonopioid drugs for pain. Med Lett Drugs Ther 2018;60(1540):25-32.
- Lopes RD, Horowitz JD, Garcia DA et al. Warfarin and acetaminophen interaction: a summary of evidence and biologic plausibility. Blood
2011:118(24):6269-73. - Kanabar D, Dale S, Rawat M. A review of ibuprofen and acetaminophen use in febrile children and the occurrence of asthma-related
symptoms. Clin Ther 2007;29(12):2716-23. - Antman EM, Bennett JS, Daugherty A et al. Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from
the American Heart Association. Circulation 2007;115(12):1634-42. - Government of Canada. Health Canada recommends that children and youth not use cough and cold products that contain opioids [internet].
February 2019. Available from: www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2019/69080a-eng.php. Accessed February 22,
2019. - Ontario Pharmacists Association, Ontario Medical Association, Registered Nurses Association of Ontario. A joint message to Ontario’s
doctors, nurse practitioners and pharmacists. Statement on the use of hydroxychloroquine and azithromycin for COVID-19 prophylaxis
[internet]. March 2020. Available at: https://ipolitics.ca/wp-content/uploads/2020/03/2020-03-23-OPA-OMA-RNAO-Statement-to-Membersv2-
2.pdf. Accessed March 31, 2020. - Diav-Citrin O, Koren G. Drug use during pregnancy. In: Canadian Pharmacists Association. Compendium of Pharmaceuticals and Specialties
(CPS) 2019. Toronto: Webcom; 2019. p. L11-L15. - Brochet MS, Ito S. Drug use during breastfeeding. In: Canadian Pharmacists Association. Compendium of Pharmaceuticals and Specialties
(CPS) 2019. Toronto: Webcom; 2019. p. L16-L26. - Drugs and Lactation Database (LactMed). Bethesda (MD): U.S. National Library of Medicine; 2016. Available from: toxnet.nlm.nih.gov.
Accessed April 2, 2020. - APILM (Association for Promotion of and Cultural and Scientific Research into Breastfeeding). E-lactancia [internet]. Available at: www.elactancia.
org. Accessed April 1, 2020. - Indraratna PL, Virk S, Gurram D et al. Use of colchicine in pregnancy: a systematic review and meta-analysis. Rheumatology (Oxford)
2018;57(2):382-7. - Park-Wyllie L, Mazzotta P, Pastuszak A et al. Birth defects after maternal exposure to corticosteroids: prospective cohort study and metaanalysis
of epidemiological studies. Teratology 2000:62(6):385-92. - Antiretroviral Pregnancy Registry Steering Committee. 2019. Antiretroviral Pregnancy Registry Interim Report for 1 January 1989 – 31 July
- Executive Summary [PDF file]. Wilmington (NC): Registry Coordinating Center. Available from: http://www.apregistry.com/forms/
exec-summary.pdf. - Dörnemann J, Burzio C, Ronsse A et al. First newborn baby to receive experimental therapies survives Ebola virus disease. J Infect Dis
2017;215(2):171-4. - CPS online. Ottawa (ON): Canadian Pharmacists Association; 2016. [product monograph]. Available from: www.e-therapeutics.ca.
Subscription required. - National Institutes of Health. Office of Dietary Supplements. Zinc: fact sheet for consumers [internet]. Available from: https://ods.od.nih.gov/
factsheets/Zinc-Consumer/#h8. Accessed March 30, 2020.
