What would you recommend?

THIS MONTH: INFLUENZA

Lisa Berg wants to know what she can take to get rid of the flu. She came down with a high fever a couple of days ago, and it’s getting worse. Lisa, a physiotherapist at the local hospital, suspects she contracted the infection from one of her patients. She adds that she didn’t get a flu shot this year, because she believes that last year’s vaccination caused a flu infection.

When you pull up her profile you see the following:

When you ask Lisa to describe her symptoms, she says that she came down with a fever and chills a couple of days ago. Then she developed a headache that has persisted. She explains that over the last day or two she has developed a cough that is both dry and hacking. She has very little nasal congestion and her throat is a little sore. She has muscle aches all over her body and she has generally felt so bad that she has had trouble getting out of bed over the last couple of days.

Upon further questioning, you discover:

• Lisa has no known medical conditions.
• She says that many of her patients have had colds lately.
• Her symptoms began about two-and-a-half days ago.
• She heard that the flu can lead to severe pneumonia and even death and she wants to know what she can do to prevent more serious problems.
• Lisa asks about the new flu medications that she has seen advertised on television and wonders if they would be a good choice for her.

What would you recommend for Lisa?

CASE WORKUP

Influenza is a common infection that can affect anyone. The incidence of influenza tends to peak in the winter. The symptoms are typically headache, chills, dry cough, body aches and fever.

The fever starts to decline after the second or third day, and upper respiratory symptoms such as nasal congestion and sore throat may begin to develop. The major concern with influenza is that it places patients at higher risk of more serious infections such as pneumonia.

Until recently, our main goal in flu treatment was to help patients manage their symptoms. This would include the recommendation of an analgesic to manage the headache, malaise and fever. Good choices include acetaminophen, ibuprofen or acetylsalicylic acid (ASA), although ASA should not be recommended for children, due to the affiliation with Reye’s syndrome. A dextromethorphan-based cough suppressant is also often suggested to help with the cough.

With the release of zanamivir (Relenza) and oseltamivir phosphate (Tamiflu, not yet approved in Canada) we have a new option for the treatment of flu.

Zanamivir is available in a breath-actuated inhaler format and is taken twice daily for a total of five days. The drug shortens the duration of flu symptoms by one to three days, and is well tolerated. However it must be initiated within two days of the onset of symptoms.

Although these drugs look promising, it is important to educate patients that they do not replace flu vaccination.

This patient shares one of the common misconceptions of flu vaccination; that the flu vaccine can cause influenza. Patients need to understand that the flu vaccine cannot cause a flu infection, since it contains only inactivated virus. Following vaccination, it takes several weeks for the patient to develop sufficient antibodies to the vaccine; therefore it’s important to immunize patients prior to the peak flu season. Use of the vaccine can drastically decrease the incidence of influenza. It is important to clarify that it was more likely a cold she developed, or she may have contracted an influenza infection too close to vaccination, before she developed sufficient antibody levels.

CARE PLAN

Lisa is suffering many of the classic symptoms of an influenza infection. Her occupation puts her at much higher risk of developing this type of infection. Although she does not have any medical conditions to warrant flu vaccination, her constant contact with patients would make it a good idea. She has had her symptoms for more then two days, therefore treatment with anti-viral drugs is not indicated.

Our focus should be on patient education and treatment of her symptoms. It’s important to correct her misconception about flu vaccination and encourage Lisa to have the injection every year. We should let her know that new influenza treatments are available. If she does develop another episode of the flu, she should see a physician promptly, since these treatments must be started within 48 hours to be effective. We should counsel her to monitor for signs of influenza complications, such as symptoms of pneumonia: chills, chest pain when breathing and a productive cough with yellow or greenish colour sputum.

Finally, we should encourage Lisa to drink plenty of fluids and rest until her symptoms improve.

Michael Boivin, B.Sc.Phm., is a community pharmacist and consultant in Sudbury, Ont.

PATIENT PROFILE

Lisa Berg D.O.B. 12/09/62

ALLERGIES: None