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Sep 13 2010

Pique the Geek 20100912: Cold and Flu Season

Well, summer will be officially over on or around 20100921, the autumnal equinox.  This is the day when the nights begin to grow longer than the days, just like the vernal equinox, when the nights grow shorter than the days.  It all has to do with the unique orbit of our wonderful spaceship earth as it orbits the sun.  Perhaps near that date I cam elaborate.

This time, however, we shall discuss the beginning of the cold and flu season, and how to deal with it.  I have only two rules, and they are important.  Observe them and you will have fewer of them, I suspect.

A cold is usually caused by a rinovirus that infects the upper respiratory system.  A cold is unpleasant, with symptoms including fever, cough, sneezing, a copious nasal discharge, and just all around feeling bad.  Colds rarely cause mortality, just some superficial mobidity.

The flu (short for influenza), on the other hand, is an extremely serious infection that can kill outright.  I have had the flu twice in my life, and thought that I would die (when I really felt badly, HOPED that I would) from it.  For most people, the flu is the most unpleasant infectious disease that they will ever have.  For the very young and the very old, it can be, and often is, fatal.  I should mention the anomalous flu that was pandemic just after The Great War (WW I).  It infected hundreds of millions of people, and was atypical in that it was often the young and strong who died from it.  As a matter of fact, my Great Uncle Walter died from it after returning from The Great Was unscathed.  Hopefully we will not see that one again, so this discussion is confined to the “normal” one.

Before we get in any deeper, here is my opinion about “flu shots”, the immunization against influenza.  I do NOT take them, although the government advocates them.  I choose not to take them for many reasons, the most important being my superstition that stimulating the immune system every year for something that few folks get is a bad idea.  That is JUST a superstition, and I have not a whit of scientific evidence to back it.  Most health officials advocate getting the shot, especially for the population at risk because of young or old age or other factors such as respiratory trouble.  It is up to YOU to decide whether or not to get one, and I take NO position except for my personal opinion on that question.

The thrust of this post concerns the over the counter drugs that one can buy and take to alleviate the symptoms of a cold (mostly), the flu (rarely), and the very common seasonal allergies that occur in the fall of the year (probably most common).  We are entering that season right now, and here are my thoughts.  Please feel free to disagree if you wish.

Right now, ragweed (Ambrosia species) are beginning to bloom.  These plants are ubiquitous, give off LOTS of pollen, and are responsible for more allergic reactions than most others combined.  I am fortunate in that I am not sensitive to pollen as an allergen, but do succumb to it if it overwhelms my system.  In my case, it is an irritant, but that is different.  When I lived in southeastern Arkansas I would often become ill from the pine pollen for a couple of weeks in the spring.  The pollen is so thick that it coats automobiles and washes off into yellow puddles after a rain.  In some woods, when the breeze blows it looks like yellow smoke grenades being used.

Another fall plant commonly blamed for allergies is goldenrod (Solidago species), but in fact they are rarely responsible.  Ragweed in the fall is the primary culprit.

Sometimes it is difficult to tell allergies from a cold, since many of the symptoms are similar.  The flu is quite different. Colds and allergies make you feel bad, cough quite a bit (more so with colds than with allergies).  Fever and minor aches and pains are common in both, as is a nasal discharge.  The main difference in symptoms is that in allergies, the nasal discharge is usually clear and watery, while in a cold it is often very viscous and colored (greenish usually; if yellow you likely have a staph infection).

The flu is quite different, with nasal symptoms not necessarily being very noticeable.  Severe body aches, deep muscle pain, and high fever are hallmarks of the flu, and often severe pulmonary symptoms are present.  In my experience the body aches and muscle pain was extreme, to the point that “even my hair hurt”.  The deadly thing about the flu is that it often predisposes people to pneumonia, and that is often what kills the old and the very young.

There are no cures for any of these conditions.  For allergies there are some treatments that reduce sensitivity in some people, but the best remedy is removal of the allergen.  This is not always practical.  For colds and the flu, time is the only real cure, but some recent antiviral drugs seem to reduce both the severity and duration in many people.  What we are left with, then, are treatments that lessen the symptoms of these ailments.  These treatments fall into several categories, and most of them are drugs, but not all.  Let us look at these conditions symptom by symptom, and see what can be done for them.

Fever is often the most uncomfortable symptom.  Modern drugs do a pretty good job of controlling fever, but what did we do before them?  Not much, really, except for giving hot drinks like mulled wine and the like while keeping the patient well covered to induce sweating, hoping that the sweating would then bring the fever when the covers were removed.  Unless quite a bit of wine was given, the patient rarely felt much improvement!  However, there was one drink treatment that actually worked, and that was willow bark tea.  Willows, of the genus Salix, contain in combination with sugars, a compound called salicylic acid, a proven antipyretic.  Unfortunately, salicylic acid is way too irritating to take directly by mouth (it is used in OTC wart removers), so a German pharmaceutical outfit named Bayer developed a derivative that was not nearly as irritating and worked well.  Since the late 19th century we have had acetylsalicylic acid, known the world over as aspirin.  (Aspirin was originally a trade name, but became part of the public domain).

Now days, in addition to aspirin, we have ibuprofen and acetaminophen as well as several others.  Here is my take on them.  Aspirin is a wonder drug, if you can tolerate it.  It works well, works fast, and has an extremely wide safety margin compared to most others.  However, it causes gastric upset in some folks, and some people are allergic to it (as are many people with asthm ).  People with bleeding disorders should not take it because it has an anticlotting effect.  Children and teens suspected of having the flu should NEVER use aspirin because of the link with Reye Syndrome, an extremely serious condition in that age group specifically seen almost exclusively in these individuals who both have the flu AND take aspirin.  However, if you are an otherwise healthy adult, aspirin is in my opinion the drug of choice for fever.  By the way, there are no stable water based aspirin products since water hydrolyses it back to salicylic acid in a few hours.  The effervescent tablets are dry and when dissolved in water are consumed immediately, not giving enough time for hydrolysis.

Ibuprofen is the next best drug, and for children and teens is the drug of choice because of Reye’s.  Fewer people are intolerant of ibuprofen than are of aspirin, and it does a good job on fever.  In addition, it is stable in water solution, so liquid preparations are available making it easy to administer to children.  It is not nearly as likely as aspirin to cause gastric upset or to trigger asthma.  A few people are allergic to it, but that can be said for almost any drug, or food for that matter.

Then comes acetaminophen.  This drug has been heavily promoted as the “safe” alternative to aspirin.  In my opinion, nothing could be further from the truth.  First of all, it is not particularly potent.  Second of all, the range between therapeutic and toxic dose is very narrow.  Third, the toxic effect of acetaminophen is on the liver, which is a bad thing indeed.  As a matter of fact, the leading cause of hospitilization for liver failure is due to overuse of acetaminophen.  I wrote a long post about the dangers of this drug about a year ago.  I shall restate my bottom line about this drug:  it should be prescription only.  Only people who can not tolerate the safer drugs should even consider it, and then use it with extreme caution.  Alcohol drinkers should not take it at all, in my opinion.  By the way, if you look at the warning statements on aspirin, ibuprofen, and acetaminophen they all have a warning about “people who consume three or more alcoholic drinks per day…”.  This warning is really intended for acetaminophen, but the manufactures lobbied FDA to have it included on other products as well.  NEVER use it for a hangover.  Since it produces stable aqueous solutions, it is widely marketed as a product to use with children.  Give them ibuprofen instead.

Aches and pains are the next most annoying symptom, and the antipyretics are for the most part good analgesics as well.  Ibuprofen seems to have a bit of an edge in this category, so instead of aspirin you might consider it if your aches and pains are particularly severe.  I cracked a couple of ribs a few years ago, and aspirin would not even begin to ease the pain, but with ibuprofen I could sleep.

Nasal symptoms are extremely bothersome, and range from constant running to completely stuffed.  Runny noses are generally caused by allergies (especially if the discharge is clear and watery) and can be treated with a wide range of OTC antihistamines.  These drugs block the action of histamine and reduce the runniness.  Some of them also have a slight anticholinergic action that has an additional drying effect.  The most well known is diphenhydramine (Benedryl is the popular brand name).  This is a very old drug with a proven track record for safety and effectiveness, but is not particularly potent.  A typical dose is 50 mg, and at that level can be quire sedating.  As a matter of fact, it is usually the active ingredient in OTC sleep aids as well.  There are a dozen different antihistamines, so you may have to shop around until you find the one best for you.  Some claim to be nonsedating, and some people are more sensitive than others.  As a matter of practical use, antihistamines are not very useful for a cold, but are quite effective for allergies.  However, it is possible to have both at the same time.

For stuffy noses, decongestants are used.  There are a wide variety of them, and almost all of them are pressor amines, meaning that they stimulate the sympathetic nervous system because they mimic the neurotransmitter norepinephrine.  This can have serious consequences for those with hypertension or other heart related conditions and probably should be avoided by those individuals, at least for the tablets for oral use.  There are topical products (“nose sprays”) that can be used with less danger since they are absorbed systemically to a much less extent.  However, it is possible to become dependent on those sprays in a fairly short time, so only use them when you really need them.  The most common oral decongestant, or at least it used to be, is pseudoephedrine.  It is effective, fast, and cheap.  I said “used to be” because it is now a “behind the counter” drug, if not prescription only, in most states.  This is because that meth cookers use it as starting material, so states are controlling it.  In many OTC preparations it has been replaced by phenylephrine, which is not as good, but is more available.  There used to be on the market a drug called phenylpropanolamine, and it was terrible.  It was removed because of meth as well, but also because it was a dangerous drug.  For the topical sprays there is a wide variety of active ingredients, so you will have to shop around until you find one that works best for you.

Interestingly, the old chicken soup remedy is excellent for congestion.  The hot water vapor, the spices (especially pepper), and the warmth tend to open the nasal passages.  The garlic is also an immune booster, so it is good all the way around.  Besides, sick people need easy to digest nutrition, and chicken soup fills the bill.

Coughing is another symptom that bothers lots of folks, and right off the bat let me say that preparations containing dextromethorphan are essentially worthless and downright dangerous in some cases.  Do not use it.  I suspect that it will be off the market before too long because it is abused, being a dissociative analgesic, like PCP and ketamine, but less potent.

There are two kinds of coughs:  the wet, productive ones that rid the lungs of nasty material, and the dry, unproductive ones that just irritate the throat.  Productive coughing is to be encouraged, because it is helping the body rid itself of infection.  There is a drug that thins these secretions, a little, and makes a productive cough more so.  It is called guiafenisen and is available in several brands and store brands too.  As long as you are not coughing up blood, try not to use a cough suppressant.

However, if you have an unproductive cough, about the only things that work are true narcotics.  Codeine is the most often used one, but hydrocodone is more effective and less apt to cause nausea.  (I can not take codeine because it makes me throw up almost every time).  In some states codeine containing cough suppressants are behind the counter products, available without prescription but you have to sign for it, just like pseudoephedrine.  In others a prescription is required.  I know of no state where you can get hydrocodone without a prescription, but if you are really in distress it may be worth a visit to your doctor.

There are a lot of quack remedies and preventions for colds.  Avoid anything that calls itself homeopathic, even though it may be billed as having “no side effects”.  The reason for no side effects is that these remedies have no effects at all, any active ingredient being so diluted that it has nothing but the placebo effect.  Another thing to avoid are the zinc products that are hyped by a well known wingnut radio personality.  There is no clinical evidence that they are effective, and the nasal swabs were even recalled a couple of years ago because of documented relationships with total and permanent loss of smell.

There are some things that you can do to prevent colds and flu, mainly just common sense things like a good diet, plenty of water, and avoiding bad habits like smoking.  In my personal experience, it seems to me that vitamin C and zinc supplements help a little to reduce the severity and duration of a cold, but this is only my personal feeling.  Clinical results are conflicting.  The best way to avoid a cold or flu is to avoid people ill with them, but that is not always possible.  Since research shows that most colds and flu are transmitted via the hands, lots of handwashing is prudent.  Some of the alcohol based hand sanitizers are better than nothing, but soap and hot water works the best.

If you have a cold, try to stay away from people.  That is not always possible because of work or school, but with the flu there is no choice.  You will be down.  I remember one day when I had the flu that my big accomplishment was getting from the bed to the bathroom.  After a rest, I got back to the bed.  Wash you hands often if you must be with other people when you have a cold, and use lost of tissues, since some infections are airborne.  DO NOT shake hands with people.  I remember once when I had a cold I had to hand out awards to my entire staff of over 50 people.  Handshakes are customary on these occasions, but we decided that bumping elbows would suffice.  Everyone got a kick out it, and I think that they were happy that I was thinking of their health.

Well, you have done it again!  You have wasted another perfectly good batch of photons reading this sick post.  And even though Megyn Kelly looses her harsh attorney facial expression when she reads me say it, I always learn much more than I could possibly hope to teach writing this series.  Please keep questions, comments, corrections, and any other thoughts coming.  Remember, no science or technology issue is off topic in the comments.

Warmest regards,

Doc

Crossposted at Docudharma.com and at Dailykos.com

7 comments

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  1. Translator, aka Dr. David W. Smith

    for staying healthy?

    Warmest regards,

    Doc

  2. TMC

    remedies that contain codeine are regulated very tightly under the Controlled Substances Act and is dependent on the amount of codeine in the preparation. Even those preparations that contain very small amounts that are permitted to be sold without a prescription are subject to tight state regulation and kept mostly behind the counter. The pharmacists must keep very precise dispensing records. There are only 12 states that allow these remedies to be sold OTC.

    As to allergies, some can result in life threatening reactions such as anaphylaxis and anaphylactoid reactions that need immediate emergency intervention. Many people with common pollen allergies develop asthma later in life. While medication like Chlor-Trimeton, Dimetane and Zyrtec may give the patient some relief, sometimes when allergies get more severe or interfere with the patients ability to function, it is necessary to consult the family doctor or specialist.

    As for the season flu shot, it is recommended that everyone get one, especially young children, persons with chronic diseases, all health care workers and older adults who are more likely to succumb to the infection. The oddity of H1N1 was not that it was any more lethal than any other influenza virus but the high mortality among healthy young adults and pregnant women and that it showed up after the “traditional” flu season had ended. The increased awareness of how the virus was spread resulted in the increased use of hand sanitizers and frequent hand washing. I wouldn’t tell you not to get the shot but if your healthy and use precautions, you can most likely safely pass it up.

    One other point is antibiotics. They don’t work for a viral infection. In really severe infections they should only be prescribed to prevent a secondary bacterial infection like strep due to immunosuppression. Antibiotics have been over used and have created problems like super bugs such as MRSA.

    Otherwise, nicely done, Doc, with good information about the OTC remedies. Thanks.

     

  3. BobbyK

    I received a few days before giving blood that caused me to come up with a messed up ARC blood test many years ago.  

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