Managing Cold and Flu Symptom Relief in Patients With Hypertension

SEPTEMBER 06, 2017
Sponsored by Procter & Gamble.
Hypertension, commonly known as high blood pressure (BP), affects approximately 34% of adults 20 years or older in the United States.1,2 It has been estimated that less than half (46%) of patients with hypertension achieve BP control.2 With adults generally suffering 2 to 4 colds each year,3 pharmacists are frequently asked to recommend treatment for the relief of common cold, often in patients who may also have elevated BP. In patients with hypertension, the use of certain medications that may raise BP should be avoided.4 It is important for pharmacists to raise awareness of considerations for their patients with high BP, and to counsel them on appropriate treatment options that provide cold and flu symptom relief without adversely affecting their BP.

Cold and Flu: Multiple, Concurrent, Bothersome Symptoms
To understand how symptoms present over the course of a typical cold or flu, Vicks®, the makers of NyQuilTM and DayQuilTM, conducted a prospective cold surveillance study among employee volunteers. Data were gathered on community-acquired cold illness episodes over a 4-year period. The study is unique because most subjects were enrolled within 24 hours of the start of cold symptoms.5 Self-reported cold symptoms over the first 7 days, assessed at 9 AM, 3 PM, and 9 PM are shown in Figure 1.5,6 In a further analysis, cold symptoms of nasal congestion and cough were assessed independently; other symptoms were grouped according to their proximate pathophysiology, including secretory symptoms (runny nose, sneezing, watery eyes), and pain and feverish symptoms (sore/scratchy throat, headache, muscle aches and pains, feverishness and chilliness). Over the first 4 days of illness, the combination of secretory symptoms, cough, and pain/fever symptoms were present in 48% to 61% of episodes evaluated, with the combination of nasal congestion, secretory symptoms, cough, and pain/fever symptoms presenting in 44% to 58% of episodes (Figure 2).5

Rationale for Using Multi-Symptom Relief Products
Although cold and flu illnesses are self-limited and gradually resolve within 7 to 10 days, the multiple symptoms are unpleasant and disruptive to everyday life and daily or nightly activities.7 To help patients feel better, they should rest and drink plenty of fluids. In addition, OTC medicines can help relieve symptoms.8 As the typical cold and flu manifest with concurrent symptoms, it is appropriate to consider multi-symptom relief products that manage several symptoms simultaneously by combining various classes of active ingredients (eg, antihistamines, nasal decongestants, cough suppressants, expectorants and analgesics/antipyretics).9 According to the results of a recent survey of adults who have used a cough, cold, or flu product in the past 24 months, patients prefer to use NyQuil for nighttime cough, cold, and flu symptoms versus leading brands, and DayQuil for non-drowsy relief of cough, cold, and flu symptoms versus leading brands (based on top brands from November 2016, among those who expressed a preference).10
Properties of Nasal Decongestants
For hypertensive patients seeking cold and flu symptom relief, it is important to consider the impact of nasal decongestants on BP. To understand why decongestants may increase BP, it is important to recognize that nasal congestion is caused by dilation of the blood vessels within the nasal tissues, resulting in excess fluid buildup and swelling that restricts air flow.11 Nasal decongestant sympathomimetic amines, such as phenylephrine and pseudoephedrine, exert their primary action through alpha-adrenergic activation of blood vessels of the nasal mucosa. The resulting vasoconstriction shrinks swollen and inflamed nasal tissue, thereby reducing congestion severity to allow freer breathing.11
Evidence for an Effect of Decongestants on Hypertension
While vasoconstriction helps open congested nasal passageways, the potential for increasing BP exists in some patients. A 2005 meta-analysis found that pseudoephedrine increased systolic BP by approximately 1 mm Hg, and heart rate by approximately 3 beats per minute, with no effect on diastolic BP.12 BP increases also were associated with higher doses and immediate-release formulations of pseudoephedrine.12 There is a lack of consistent effect of phenylephrine on BP at doses of 25 mg or less.13
Because some OTC medications may contain active ingredients that can elevate BP, such as nasal decongestants, the American Heart Association urges patients with hypertension to read the labels of all OTC medications before use.4 Cold and flu products containing an oral nasal decongestant include a labeled warning instructing patients with high BP to consult with their physician on the product usage before administration.14-17 Patients may not understand which ingredient(s) to avoid, relevance for acute use, and their level of hypertension; patients may decide to either use the product regardless of consulting with their physician, or decide not to self-treat. For patients with high BP seeking cold and flu multi-symptom relief, pharmacists may consider recommending products specially labeled for easy self-selection and formulated without an oral nasal decongestant, such as Vicks NyQuil HBP and Vicks DayQuil HBP.
Topical Decongestants
Available topical decongestants for intranasal use include naphazoline, oxymetazoline, xylometazoline, and phenylephrine.18 Although there are sparse data on the connection between use of topical decongestants and elevations in BP, all OTC topical decongestants carry a warning for use in patients with high BP.14-17 Other warnings that apply to topical nasal decongestants include avoiding use for more than 3 days, as long-term use carries the risk of rhinitis medicamentosa (rebound rhinitis).14-17,19 In this condition, worsening symptoms may result in user dependency.19 Notably, the topical decongestants levmetamfetamine and propylhexedrine do not carry a warning for use in patients with hypertension.20,21
Nonpharmacologic Treatment Options
It is important to consider other strategies for helping reduce nasal congestion, such as drinking water to thin mucus,22 increasing environmental humidity with a humidifier to loosen mucus, and using a saline nasal spray to soothe and moisten the sinuses.23

The Role of the Pharmacist
Pharmacists must regularly communicate several key patient counseling points regarding cold and flu management (Table8,24). In addition, for patients with comorbidities, such as hypertension, pharmacists can counsel patients to raise awareness that some OTC medicines may not be appropriate for patients with high BP, and they may recommend specially formulated multi-symptom fixed-dose combination OTC cold and flu medicines that are labeled for use in patients with high BP. In addition to multi-symptom relief products, pharmacists should encourage patients to read each product label, use products only as directed, consider all contraindications for use of therapies, and keep medications out of reach of children.
Through appropriate recommendations for patients with hypertension, pharmacists can help patients achieve optimal outcomes in managing the bothersome and disruptive symptoms of cold and flu.

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  6. Procter & Gamble. Data on file. Study #87-213.
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  8. CDC, National Center for Immunization and Respiratory Diseases. The flu: caring for someone sick at home. Published December 2010. Accessed June 2017.
  9. FDA. Cold, cough, allergy, bronchodilator, and antiasthmatic drug products for over-the-counter human use; proposed amendment of monograph for over the counter nasal decongestant drug products. Government Publishing website. . Published November 2, 2004. Accessed June 2017.
  10. Procter & Gamble. Data on file.DQ/NQ Equity Survey-2016.
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  12. Salerno SM, Jackson JL, Berbano EP. Effect of oral pseudoephedrine on blood pressure and heart rate: a meta-analysis. Arch Intern Med. 2005;165(15):1686-1694.
  13. Hatton RC, Winterstein AG, McKelvey RP, Shuster J, Hendeles L. Efficacy and safety of oral phenylephrine: systematic review and meta-analysis. Ann Pharmacother. 2007;41(3):381-390. doi: 10.1345/aph.1H679.
  14. Naphazoline hydrochloride liquid [package insert]. Torrance, CA: Sato Pharmaceuticals; 2011.
  15. Oxymetazoline hydrochloride spray [package insert]. Whippany, NJ: Bayer HealthCare, LLC; 2016.
  16. Xylometazoline HCl spray [package insert]. New York, NY: JGL North America; 2012.
  17. Phenylephrine hydrochloride spray [package insert]. Parsippany, NJ: Novartis Consumer Health; 2014.
  18. May JR, Smith PH. Chapter 104: Allergic Rhinitis. In: Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York, NY: McGraw-Hill; 2011.
  19. Ramey JT, Bailen E, Lockey RF. Rhinitis medicamentosa. J Investig Allergol Clin Immunol. 2006;16(3):148-155.
  20. Propylhexedrine inhalant [package insert]. Lenexa, KS: BF Ascher and Co; 2014.
  21. Vapor Inhaler (levmetamfetamine) [package insert]. Deerfield, IL:Walgreen Co; 2016.
  22. Saketkhoo K, Januszkiewicz A, Sackner MA. Effects of drinking hot water, cold water, and chicken soup on nasal mucus velocity and nasal airflow resistance. Chest. 1978;74(4):408-410.
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  24. CDC, National Center for Emerging and Zoonotic Infectious Diseases, Division of Global Migration and Quarantine. Do your part to slow the spread of flu. Accessed June 2017.