Pharmacy Times

JAN 2015

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For references, go to www publications/issue. MORE @ WWW. PHARMACY TIMES.COM Community-Acquired Pneumonia Individuals older than 75 years are 50 times more likely to acquire commu- nity-acquired pneumonia than younger adults and are significantly more likely to die as a result. 7 Although multiple pathogens cause commu- nity-acquired pneumo- nia, rhinoviruses (there are 99 recognized types of human rhinovirus) are often involved as a caus- ative agent or precursor. Consider this: researchers studied 191 patients with pneumococcal pneumo- nia, stratifying them into 2 groups. Patients with a Pneumonia Severity Index score of 91 or high- er (n = 99) were consid- ered to have severe ill- ness, whereas those with a score less than 91 (n = 92) were considered to have non- severe illness. Forty-eight patients (52%) had RVIs before developing pneumonia, and about 10% of those infections were rhinoviruses. Having a preceding RVI doubled the likelihood of developing severe pneumococcal pneumonia. 9 Asthma Respiratory viruses, especially rhinovi- ruses, have been linked to the develop- ment and exacerbation of asthma. Patients with allergic sensitization are especially at risk. Rhinovirus can precipitate asthma attacks, and roughly 20% of adults with mild to moderate asthma develop wheez- ing and increased bronchial reactivity when infected. 3 Researchers suspect that after viral infection, immunoglobulin E– mediated pathways block critical type I interferon responses, allowing viruses and allergens to induce asthmatic disease cooperatively and synergistically. 10 Chronic Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) is an inflammatory lung con- dition that is associated, in large part, with the cumulative effect of years of smoking. Thus, it is a disease of older adults. Rhinovirus exacerbates COPD, and patients with COPD are at increased risk for bacterial infection following rhinovirus infection. In patients with COPD who develop rhinovirus infection, it appears that bacteria already present in the lung proliferate. (This bacterial burden has not been noted in otherwise healthy individuals.) Rhinovirus seems to precipitate secondary bacterial infec- tions and hospitalization in those with COPD. 8,11,12 Allergic Rhinitis Symptoms of viral upper respiratory infec- tion (URI) overlap with those of allergic rhinitis. Patients with allergic rhi- nitis often mistake repeat- ed viral infections for allergies, and vice versa. The relationship between these 2 conditions is not fully understood. Some researchers believe that allergen-induced inflammation and nasal and paranasal mucosal swelling may make patients with allergic rhinitis more susceptible to viral infections. A pro- spective case–control study compared 58 adults with perennial allergic rhinitis with 61 adults without allergy for 1 year. Among patients with perennial allergic rhinitis, 43% developed URI compared with 25% of control patients. Rhinovirus accounted for the majority of URIs in patients with allergic rhinitis, suggesting these patients are at increased risk for this specific infection. 13 On the other hand, results of a recent study showed that after intranasal inocu- lation with rhinovirus, patients with AR had fewer and less severe cold symptoms if allergic inflammation was induced before viral inoculation. These results suggest that allergy may attenuate respi- ratory viral disease. 14 Conclusion During a typical 74-year life span, humans will experience cold symptoms for about 1800 days (approximately 5 years). Because most patients are not tested for a specific virus when they con- tract a cold, pharmacists need to assume the condition is viral and that about half of the infections are due to rhinovirus. Preventing or actively managing rhino- virus infections in elderly patients can reduce complications (Table 2). 8,10,11 n Rhinoviruses— which manifest as the common cold—cause the greatest number of respiratory viral illnesses. January 2015 33 TABLE 1: CLINICAL CHARACTERISTICS OF RHINOVIRUS INFECTION Rhinovirus is seen year-round, but the peak incidence in northern hemispheres occurs in August and September. Rhinovirus causes approximately 50% of all colds. Most patients develop symptoms within 1.5 to 4.5 days after exposure and have the cold for 7 to 10 days. Approximately one-third of patients develop low-grade fever. Almost all patients report cough, rhinor- rhea, malaise, and sore throat. Roughly one-half to three-fourths of patients report headache, chills, produc- tive cough, and myalgia. Patients who develop severe illness requiring hospitalization are at high risk for death from the complications (illness severity is comparable to influenza). Adapted from references 2-5. TABLE 2: MANAGEMENT CONSIDERATIONS FOR RHINOVIRUS IN THE ELDERLY Encourage elders to wash their hands often with warm, soapy water. Review a patient's complete drug regi- men before selecting and recommend- ing OTC products. Encourage seniors to receive a yearly influenza vaccination and a pneumococ- cal pneumonia vaccination as indicated. Smoking increases risk for complications considerably, so promote smoking ces- sation. In patients who have asthma, clinicians should target allergic inflammation to prevent virus-induced exacerbations using inhaled corticosteroids and b-agonists. Forewarn asthma patients to watch for wheezing or dyspnea. Warn patients with chronic obstruc- tive pulmonary disease that rhinovirus infection may increase the possibility of secondary bacterial complications, and counsel them on the signs of rhinovirus (coughing, fever, increased sputum pro- duction). Refer any elderly patient who presents with any of the following signs or symp- toms to a primary care or urgent care provider: fever higher than 102 o F; severe pain in the face, forehead, or ear; short- ness of breath or wheezing; a cold that lasts for more than 10 days; ear drain- age; or coughing that produces blood. Adapted from references 3, 8, 10 and 11. | page 30

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