Chapter 1 Viral Rhinitis

Home , Rhinitis medicamentosa, Rhinorrhea, Symptomatic treatment

Chapter 1: Viral Rhinitis 1

Chapter 1 ViralChapter 1 Rhinitis Timothy P. Lynch, MD, FRCPC Revised: May 2018 Peer Review: March 2017 Goals of Therapy ■ Prevent infection ■ Lessen interference with activities of daily living ■ Reduce the discomfort and emotional distress of rhinorrhea ■ Relieve the discomfort of nasal congestion ■ Minimize the potential adverse effects of pharmacologic agents ■ Prevent person-to-person transmission Investigations ■ Diagnosis of the common cold, which is most commonly due to a rhinovirus infection, requires no specific laboratory investigation ■ History with particular attention to intensity, frequency and severity of symptoms – early symptoms of a cold include headache, chills, sneezing and sore throat. Later symptoms include nasal discharge, nasal obstruction, cough and malaise. Symptoms may last from a few days to 2 weeks[1] – symptoms of the flu are more severe than those of colds and typically include abrupt onset of fever, severe myalgias, anorexia, sore throat, headache and cough[2] (see Influenza) – symptoms of a sinus headache, difficulty breathing or chest pain suggest bacterial infection Therapeutic Choices Viral rhinitis is usually a benign, self-limited condition. Typical symptoms of rhinorrhea and nasal congestion resolve untreated in 7–10 days. There is no evidence that treatment of the rhinitis lessens the risk of developing a complication such as middle ear effusion, otitis media, sinusitis, febrile seizure or asthma exacerbation.[3] To improve these symptoms and the patient’s quality of life, nonpharmacologic and pharmacologic approaches are available. Each pharmacologic agent employed should be directed against a specific symptom. Nonpharmacologic Choices ■ Avoid close contact with someone who has a cold as a key to prevention.[3] ■ Limit the risk of inoculation and transmission by adhering to strict hand-washing techniques;[4][5] abstaining from touching eyes or nose; and sneezing or coughing into the elbow or into a facial tissue, which is then discarded immediately. ■ Maintain usual fluid intake.[6] ■ Rest.

Copyright © 2019 . All rights reserved. 2 Pharmacologic Choices Figure 1 provides an approach to the symptomatic treatment of viral rhinitis. Dosing information for the medications discussed can be found in Table 1.

Analgesics and Antipyretics Nonsteroidal anti-inflammatory drugs have not been shown to improve respiratory symptoms associated with the common cold, but may improve pain-related symptoms.[8] Acetaminophen or ibuprofen may be helpful for fever or headache in preschool children. ASA should not be used in children due to the increased incidence of Reye syndrome associated with its use during influenza virus infections.[9]

Antibiotics Antibiotic use is not effective in the treatment of the common cold in children or adults. Gastrointestinal adverse effects are significantly increased in adults who take antibiotics for their colds.[10] In addition, their use may contribute to antibiotic resistance in the community.

Anticholinergic Agents Intranasal ipratropium blocks cholinergic-mediated vasodilatation. It is effective for rhinorrhea and relief of sneezing, but does not improve nasal congestion.[11] Adverse effects include nasal dryness, blood-tinged mucous and epistaxis.

Antihistamines The anticholinergic effects of some first-generation antihistamines may reduce nasal secretions, but there is no evidence in children or adults that they improve recovery time from colds when used as monotherapy. In addition, the incidence of sedation is higher than with placebo for these medications.[12] Antihistamine/decongestant combinations have been shown to improve short-term nasal symptoms in adolescents and adults with viral rhinitis.[13] Second-generation or nonsedating antihistamines have no anticholinergic activity.[3] There is no evidence to support their use alone in controlling rhinorrhea or nasal congestion secondary to viral rhinitis.[14]

Decongestants (Alpha-Adrenergic Agents) Decongestants are used to relieve nasal congestion and improve rhinorrhea. They help most adults by improving nasal air flow. There may be a small positive effect on nasal congestion in adults with the common cold who take multiple doses of decongestants; however, the effectiveness of a single-dose of decongestant is unknown.[15] There is insufficient evidence to support their use in children under 12 years of age.[16] Decongestants are available in oral or intranasal dosage forms. Pseudoephedrine is an effective oral treatment for nasal congestion in adults.[17][18] Multiple doses of pseudoephedrine over a 3-day period are safe.[18] Evaluations of the effectiveness of oral phenylephrine have yielded conflicting results.[19][20] Prolonged use (usually over 5 days) of topical nasal decongestants is associated with rebound congestion (rhinitis medicamentosa).[21]

Saline Nasal Irrigation Nasal irrigation with saline may offer some relief of the symptoms of acute upper respiratory tract infections (e.g., reduced nasal secretion and obstruction, reduced need for decongestants) in children and adults.[22]

Copyright © 2019 . All rights reserved. Chapter 1: Viral Rhinitis 3 Vitamin C Daily vitamin C (ascorbic acid) supplementation is not effective in the prevention of colds in the general population, but may be useful in those exposed to brief periods of extreme physical stress (e.g., marathons, Arctic expeditions).[23] Daily supplementation (1 g) is associated with a reduction in duration and possibly severity of symptoms.[23] Ingestion of high “treatment” doses (4–8 g) at the onset of cold symptoms has not been shown to reduce the duration of cold symptoms or their severity.[23]

Vitamin D Randomized controlled trials have not shown a benefit of regular vitamin D supplementation on the incidence, severity or duration of upper respiratory tract infections.[24][25]

Zinc Lozenges A meta-analysis of 3 randomized placebo-controlled trials demonstrated that the use of zinc lozenges shortened the average duration of the common cold by just under 3 days.[26] It is difficult to make recommendations with respect to dose and duration. Zinc has an unpleasant taste and may cause nausea.

Natural Health Products Camphor, Eucalyptus and Menthol Inhaled menthol does not seem to affect nasal airflow;[27] however, it is associated with increased patient perception of nasal patency. No significant reduction in cough is observed.[28] A study in 138 children found that parents reported superior relief of their children’s nocturnal cough, congestion and sleep difficulty caused by upper respiratory tract infection with vapor rub ointment (containing menthol, camphor and eucalyptus) compared with petrolatum and no treatment. The vapor rub was applied to the child’s chest and neck before bedtime.[29] Due to concerns of increased production and decreased clearance of mucus potentially leading to respiratory distress in children, menthol and camphor rubs should never be placed directly under or in the nostrils.[30] In addition, menthol and camphor rubs should not be used in children <2 years of age. Camphor-containing products can pose a risk of toxicity in children when used inappropriately.[31] Chinese Herbal Medicines There are no studies to support the use of Chinese herbal medicines in the treatment of the common cold.[32] Echinacea Echinacea products are extracted from different species and parts of the plant, making it difficult to compare studies. A Cochrane review found that although none of the 12 individual prevention studies using various Echinacea products demonstrated a significant difference in participants experiencing a cold, a significant 10–20% relative risk reduction was observed when the studies were pooled.[33] While statistically significant, it is unclear if this small decrease is of clinical relevance. In the same review, treatment trials were mixed with no clear conclusions. In addition, conclusions regarding use of Echinacea in children could not be drawn from this review; however, 1 study reported a 5% increase in rash in the Echinacea treatment group. Garlic There is no evidence to support the use of garlic in the treatment of the common cold.[34]

North American Ginseng Extract A systematic review of 5 heterogeneous trials found insufficient evidence that North American ginseng extract (Panax quinquefolius), or COLD-FX (see Table 1), reduces the incidence or severity of the common cold when used acutely; however, if used daily for up to 4 months, ginseng may reduce the total time with upper respiratory tract symptoms by about 6 days.[36] The main side effect was GI upset. There are no efficacy studies for use of ginseng in children or for treatment of the common cold. In conclusion, evidence is insufficient to recommend ginseng for the prevention or treatment of the common cold. Probiotics Low-quality evidence exists that probiotics may be beneficial in preventing upper respiratory tract infections when compared with placebo.[37]

Nonprescription Cough and Cold Medications There is no evidence to support the use of these agents for the symptomatic treatment of cough in children and adults.[38] Furthermore, Health Canada now requires manufacturers to label nonprescription cough and cold medications to indicate they should not be used by children <6 years of age.[39][40]

Appropriate Treatment for Specific Age Groups Breast- or bottle-fed infants who are obligate nose breathers may benefit from regular administration of normal saline drops, which aid in cleaning the nose and may improve mucociliary clearance in young infants.[9] Studies examining the use of antihistamines, decongestants or antihistamine/ decongestant combinations in children <6 years of age have failed to show benefit.[41][42] In addition, accidental ingestion and dosing errors with these products can do much harm. There have been few trials in school-aged children. An antihistamine/decongestant/antitussive combination is superior to an antihistamine/expectorant combination in reducing nasal symptoms.[13] There are no published trials that evaluate topical nasal decongestants in children. Antihistamine/ decongestant combinations may be of benefit, but risks of treatment should be carefully considered.[12] In adolescents and adults, decongestants (topical or oral) and antihistamine/decongestant combinations have been shown to improve short-term nasal symptoms.[13] Oral decongestants are associated with an increased number of adverse effects.[13] Anticholinergic agents have also been shown to improve rhinorrhea.[14] A short course of topical decongestants or topical anticholinergic agents is first-line therapy. Choices during Pregnancy and Breastfeeding Women may experience symptoms of the common cold with increased frequency during their pregnancy.[43] The common cold in the 1st trimester may be a modest risk factor for birth defects.[44] Few trials have studied the effects of viral rhinitis treatment during pregnancy. First-generation antihistamines, including brompheniramine, chlorpheniramine and diphenhydramine, are considered safe.[45][46][47][48] Due to conflicting reports of possible malformations with 1st-trimester use of oral decongestants (phenylephrine and pseudoephedrine),[47][49][50][51][52] more evidence is required before a clear recommendation can be made regarding their use during the 1st trimester. Although data are limited and conflicting,[53][54] oxymetazoline and xylometazoline are considered safe during pregnancy for short-term use.[43][55] The extent of systemic absorption of nasally administered topical decongestants is unknown[43] and systemic side effects have been reported with

Copyright © 2019 . All rights reserved. Chapter 1: Viral Rhinitis 5 the use of xylometazoline nasal spray.[56] There are no published data regarding the use of anticholinergics during pregnancy for patients with asthma or rhinitis.[57] The recommended dietary allowance of vitamin C increases in pregnancy (80–85 mg/day) and adequate intake is an important consideration in pregnancy.[58] However, a higher incidence of intrauterine growth restriction was observed in women taking vitamin C (1 g) in combination with vitamin E (400 units) in a study designed to evaluate their role in prevention of pre-eclampsia.[59][60] This brings into question the safety of high-dose vitamin C in pregnancy and that its use is not recommended for this self-limiting condition. The safety of Echinacea use during pregnancy has not been established.[61][62] The active component of ginseng, ginsenoside Rb1, was teratogenic in animal studies; therefore, caution is advised in pregnancy.[63] There are no published studies of zinc therapy for viral rhinitis during pregnancy. Caution is advised with Echinacea and ginseng during breastfeeding due to insufficient data. Many nonprescription products are compatible with breastfeeding. Pseudoephedrine has been linked to irritability in the infant and decreased milk production at commonly used doses.[64][65] Intranasal saline and topical decongestants (oxymetazoline, xylometazoline) are preferred over oral agents. A discussion of general principles on the use of medications in these special populations can be found in Drug Use during Pregnancy and Drug Use during Breastfeeding. Other specialized reference sources are also provided in these appendices. Therapeutic Tips

■ Hand hygiene and cough hygiene (coughing into sleeve or tissue that is discarded) are key to reducing the spread of viral rhinitis. ■ The incubation period for rhinovirus illness is short, generally 1–2 days; virus shedding coincides with the onset of illness or may begin shortly before symptoms develop. ■ There is insufficient evidence to support the practise of inhaling steam.[66] ■ There is evidence that multiple-dose oral or nasal decongestants are effective for the relief of congestion in adults.[15][41] ■ There is no evidence to support the use of intranasal corticosteroids for the treatment of the common cold.[67]

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Copyright © 2019 . All rights reserved. Chapter 1: Viral Rhinitis 9 Suggested Readings Allan GM, Arroll B. Prevention and treatment of the common cold: making sense of the evidence. CMAJ 2014;186(3):190-9. Arroll B. Non-antibiotic treatments for upper-respiratory tract infections (common cold). Respir Med 2005;99(12):1477-84. Gentile DA, Skoner DP. Viral rhinitis. Curr Allergy Asthma Rep 2001;1(3):227-34. Smith MB, Feldman W. Over-the-counter cold medications. A critical review of clinical trials between 1950 and 1991. JAMA 1993;269(17):2258-63. References 1. Eccles R. Understanding the symptoms of the common cold and influenza. Lancet Infect Dis 2005;5(11):718-25. 2. Monto AS, Gravenstein S, Elliott M et al. Clinical signs and symptoms predicting influenza infection. Arch Intern Med 2000;160(21):3243-7. 3. Fireman P. Pathophysiology and pharmacotherapy of common upper respiratory diseases. Pharmacotherapy 1993;13(6 Pt 2):101S-9S. 4. Allan GM, Arroll B. Prevention and treatment of the common cold: making sense of the evidence. CMAJ 2014;186(3):190-9. 5. Ryan MA, Christian RS, Wohlrabe J. Handwashing and respiratory illness among young adults in military training. Am J Prev Med 2001;21(2):79-83. 6. Guppy MP, Mickan SM, Del Mar CB et al. Advising patients to increase fluid intake for treating acute respiratory infections. Cochrane Database Syst Rev 2011;(2):CD004419. 7. U.S. Food and Drug Administration. FDA Drug Safety Communication: Serious adverse events from accidental ingestion by children of over- the-counter eye drops and nasal sprays. Available from: www.fda.gov/drugs/drugsafety/ucm325257.htm. Accessed April 25, 2018. 8. Kim SY, Chang YJ, Cho HM et al. Non-steroidal anti-inflammatory drugs for the common cold. Cochrane Database Syst Rev 2015;(9): CD006362. 9. Jones NS. Current concepts in the management of paediatric rhinosinusitis. J Laryngol Otol 1999;113(1):1-9. 10. Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev 2013;(6):CD000247. 11. Albalawi ZH, Othman SS, Alfaleh K. Intranasal ipratropium bromide for the common cold. Cochrane Database Syst Rev 2013;(6):CD008231. 12. Sutter AI, Lemiengre M, Campbell H et al. Antihistamines for the common cold. Cochrane Database Syst Rev 2003;(3):CD001267. 13. De Sutter AI, van Driel ML, Kumar AA et al. Oral antihistamine-decongestant-analgesic combinations for the common cold. Cochrane Database Syst Rev 2012;(2):CD004976. 14. Luks D, Anderson MR. Antihistamines and the common cold. A review and critique of the literature. J Gen Intern Med 1996;11(4):240-4. 15. Deckx L, De Sutter AI, Guo L et al. Nasal decongestants in monotherapy for the common cold. Cochrane Database Syst Rev 2016;10:CD009612. 16. Taverner D, Latte J. Nasal decongestants for the common cold. Cochrane Database Syst Rev 2007;(1):CD001953. 17. Latte J, Taverner D, Slobodian P et al. A randomized, double-blind, placebo-controlled trial of pseudoephedrine in coryza. Clin Exp Pharmacol Physiol 2004;31(7):429-32. 18. Eccles R, Jawad MS, Jawad SS et al. Efficacy and safety of single and multiple doses of pseudoephedrine in the treatment of nasal congestion associated with common cold. Am J Rhinol 2005;19(1):25-31. 19. Hatton RC, Winterstein AG, McKelvey RP et al. Efficacy and safety of oral phenylephrine: systematic review and meta-analysis. Ann Pharmacother 2007;41(3):381-90. 20. Kollar C, Schneider H, Waksman J et al. Meta-analysis of the efficacy of a single dose of phenylephrine 10 mg compared with placebo in adults with acute nasal congestion due to the common cold. Clin Ther 2007;29(6):1057-70. 21. Graf P. Rhinitis medicamentosa: aspects of pathophysiology and treatment. Allergy 1997;52(40 Suppl):28-34. 22. King D, Mitchell B, Williams CP et al. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database Syst Rev 2015;(4):CD006821. 23. Hemila H, Chalker E. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev 2013;(1):CD000980. 24. Murdoch DR, Slow S, Chambers ST et al. Effect of vitamin D3 supplementation on upper respiratory tract infections in healthy adults: the VIDARIS randomized controlled trial. JAMA 2012;308(13):1333-9. 25. Rees JR, Hendricks K, Barry EL et al. Vitamin D3 supplementation and upper respiratory tract infections in a randomized, controlled trial. Clin Infect Dis 2013;57(10):1384-92. 26. Hemilä, H, Petrus, EJ, Fitzgerald, JT et al. Zinc acetate lozenges for treating the common cold: an individual patient data meta-analysis. Br J Clin Pharmacol 2016;82(5):1393-8. 27. Pereira EJ, Sim L, Driver H et al. The effect of inhaled menthol on upper airway resistance in humans: a randomized controlled crossover study. Can Respir J 2013;20(1):e1-4. 28. Kenia P, Houghton T, Beardsmore C. Does inhaling menthol affect nasal patency or cough? Pediatr Pulmonol 2008;43(6):532-7. 29. Paul IM, Beiler JS, King TS et al. Vapor rub, petrolatum, and no treatment for children with nocturnal cough and cold symptoms. Pediatrics 2010;126(6):1092-9. 30. Abanses JC, Arima S, Rubin BK. Vicks VapoRub induces mucin secretion, decreases ciliary beat frequency, and increases tracheal mucus transport in the ferret trachea. Chest 2009;135(1):143-8. 31. Camphor revisited: focus on toxicity. Committee on Drugs. American Academy of Pediatrics. Pediatrics 1994;94(1):127-8. 32. Wu T, Zhang J, Qiu Y et al. Chinese medicinal herbs for the common cold. Cochrane Database Syst Rev 2007;(1):CD004782. 33. Karsch-Völk M, Barrett B, Kiefer D et al. Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev 2014;(2):CD000530. 34. Lissiman E, Bhasale AL, Cohen M. Garlic for the common cold. Cochrane Database Syst Rev 2014;(11):CD006206. 35. 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(9):1043-8.

36. Seida JK, Durec T, Kuhle S. North American (Panax quinquefolius) and Asian Ginseng (Panax ginseng) preparations for prevention of the common cold in healthy adults: a systematic review. Evid Based Complement Alternat Med 2011;2011:282151. 37. Hao Q, Dong BR, Wu T. Probiotics for preventing acute upper respiratory tract infections. Cochrane Database Syst Rev 2015;(2):CD006895. 38. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database Syst Rev 2014;(11):CD001831. 39. Government of Canada. Healthy Canadians. Health Canada releases decision on the labelling of cough and cold products for children. Ottawa (ON): Health Canada; 2008. Available from: www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2008/13267a-eng.php. Accessed April 25, 2018. 40. Shefrin AE, Goldman RD. Use of over-the-counter cough and cold medications in children. Can Fam Physician 2009;55(11):1081-3. 41. Arroll B. Non-antibiotic treatments for upper-respiratory tract infections (common cold). Respir Med 2005;99(12):1477-84. 42. Clemens CJ, Taylor JA, Almquist JR et al. Is an antihistamine-decongestant combination effective in temporarily relieving symptoms of the common cold in preschool children? J Pediatr 1997;130(3):463-6. 43. Erebara A, Bozzo P, Einarson A et al. Treating the common cold during pregnancy. Can Fam Physician 2008;54(5):687-9. 44. Zhang J, Cai WW. Association of the common cold in the first trimester of pregnancy with birth defects. Pediatrics 1993;92(4):559-63. 45. Seto A, Einarson T, Koren G. Evaluation of brompheniramine safety in pregnancy. Reprod Toxicol 1993;7(4):393-5. 46. Seto A, Einarson T, Koren G. Pregnancy outcome following first trimester exposure to antihistamines: meta-analysis. Am J Perinatol 1997;14(3):119-24. 47. Aselton P, Jick H, Milunsky A et al. First-trimester drug use and congenital disorders. Obstet Gynecol 1985;65(4):451-5. 48. Heinonen OP, Shapiro S, Slone D. Birth defects and drugs in pregnancy. Littleton (MA): Publishing Sciences Group; 1977. 49. Werler MM, Mitchell AA, Shapiro S. First trimester maternal medication use in relation to gastroschisis. Teratology 1992;45(4):361-7. 50. Torfs CP, Katz EA, Bateson TF et al. Maternal medications and environmental exposures as risk factors for gastroschisis. Teratology 1996;54(2):84-92. 51. Zierler S, Rothman KJ. Congenital heart disease in relation to maternal use of Bendectin and other drugs in early pregnancy. N Engl J Med 1985;313(6):347-52. 52. Källén BA, Olausson OP. Use of oral decongestants during pregnancy and delivery outcome. Am J Obstet Gynecol 2006;194(2):480-5. 53. Rayburn WF, Anderson JC, Smith CV et al. Uterine and fetal Doppler flow changes from a single dose of a long-acting intranasal decongestant. Obstet Gynecol 1990;76(2):180-2. 54. Baxi LV, Gindoff PR, Pregenzer GJ et al. Fetal heart rate changes following maternal administration of a nasal decongestant. Am J Obstet Gynecol 1985;153(7):799-800. 55. Ferreira E, Martin B, Morin C. Grossesse et allaitement: guide thérapeutique. 2nd ed. Montréal (QC): CHU Sainte-Justine; 2013. 56. CPS online. Ottawa (ON): Canadian Pharmacists Association; 2018. Xylometazoline [CPhA monograph]. Available from: www.e- therapeutics.ca. Accessed April 25, 2018. Subscription required. 57. National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program Asthma and Pregnancy Working Group. NAEPP expert panel report. Managing asthma during pregnancy: recommendations for pharmacologic treatment-2004 update. J Allergy Clin Immunol 2005;115(1):34-46. 58. Health Canada. Dietary reference intakes tables. Available from: www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/ dietary-reference-intakes/tables.html. Accessed April 25, 2018. 59. Goh YI, Ungar W, Rovet J et al. Mega-dose vitamin C and E in preventing FASD: the decision to terminate the study prematurely. J FAS Int 2007;5:e3. Available from: www.motherisk.org/JFAS_documents/JFAS7002_5_e3.pdf. Accessed April 25, 2018. 60. Poston L, Briley AL, Seed PT et al. Vitamin C and vitamin E in pregnant women at risk for pre-eclampsia (VIP trial): randomised placebo- controlled trial. Lancet 2006:367(9517):1145-54. 61. Gallo M, Sarkar M, Au W et al. Pregnancy outcome following gestational exposure to echinacea: a prospective controlled study. Arch Intern Med 2000;160(20):3141-3. 62. Perri D, Dugoua JJ, Mills E et al. Safety and efficacy of echinacea (Echinacea angustifolia, e. purpurea and e. Pallida) during pregnancy and lactation. Can J Clin Pharmacol 2006;13(3):e262-7. 63. Liu P, Xu Y, Yin H et al. Developmental toxicity research of ginsenoside Rb1 using a whole mouse embryo culture model. Birth Defects Res B Dev Reprod Toxicol 2005;74(2):207-9. 64. Ito S, Blajchman A, Stephenson M et al. Prospective follow-up of adverse reactions in breast-fed infants exposed to maternal medication. Am J Obstet Gynecol 1993;168(5):1393-9. 65. Aljazaf K, Hale TW, Ilett KF et al. Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin Pharmacol 2003;56(1):18-24. 66. Singh M, Singh M. Heated, humidified air for the common cold. Cochrane Database Syst Rev 2013;(6):CD001728. 67. Hayward G, Thompson MJ, Perera R et al. Corticosteroids for the common cold. Cochrane Database Syst Rev 2012;(8):CD008116.