What over-the-counter (OTC) medications are recommended for an elderly patient with COVID-19, experiencing a runny nose and cough, with potential underlying health conditions such as impaired renal function or heart failure?

OTC Medications for Runny Nose and Cough in Elderly COVID-19 Patients

For elderly COVID-19 patients with runny nose and cough, use honey as first-line therapy for cough suppression, and consider short-term codeine-based products only if cough is severely distressing; avoid routine use of antihistamines or decongestants given the lack of guideline support and potential cardiovascular/renal risks in this population. 1

Cough Management

First-Line Approach

• Start with honey (for patients over 1 year old) as the initial simple measure for cough suppression. 1
• Encourage patients to avoid lying flat on their back, as this position makes coughing ineffective and worsens symptoms. 1

Prescription Options for Distressing Cough

• Consider short-term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution only when cough is significantly distressing and impacting quality of life. 1, 2
• These opioid-based agents should be used cautiously and for limited duration given the elderly population and potential for respiratory depression. 1

Runny Nose Management

Why Standard OTC Options Are Problematic

• No guideline evidence supports routine use of antihistamines or decongestants for COVID-19 rhinorrhea in elderly patients with comorbidities. 1
• While one observational study suggested antihistamines (loratadine, cetirizine, dexchlorpheniramine) may have benefit, this was a small retrospective analysis without controlled comparison and cannot guide treatment in patients with heart failure or renal impairment. 3

Specific Contraindications in Your Patient Population

Pseudoephedrine (decongestant) should be avoided because: 4

• Increases blood pressure and heart rate, potentially destabilizing heart failure
• Can precipitate arrhythmias in elderly patients with cardiovascular disease
• May worsen renal perfusion in patients with impaired kidney function

Antihistamines carry significant risks: 5

• First-generation antihistamines cause sedation, confusion, and falls in elderly patients
• Anticholinergic effects can cause urinary retention, constipation, and cognitive impairment
• No established benefit for COVID-19 rhinorrhea in guideline-based evidence

Critical Medication Adjustments for Elderly Patients

Dose Reduction Requirements

• All COVID-19 medications must be reduced to 1/2 of standard adult doses for patients over 80 years old due to deteriorated liver and kidney function with low drug clearance rates. 1, 2
• For patients aged 60-80 years, use 3/4 to 4/5 of standard adult doses. 1

Polypharmacy Review

• Immediately review all current prescriptions to minimize polypharmacy and prevent dangerous drug-drug interactions, which carry significantly higher risk in elderly patients with multiple comorbidities. 1, 2
• Engage pharmacists in medication reconciliation to identify potential interactions between any new symptomatic treatments and existing heart failure or renal medications. 1, 2

Supportive Care Measures

Hydration and Positioning

• Advise regular fluid intake to thin secretions and prevent dehydration, but limit to no more than 2 liters daily to avoid fluid overload in heart failure patients. 1, 2
• Position patient sitting upright and leaning forward with arms bracing to improve ventilatory capacity and facilitate secretion clearance. 1, 2

Breathing Techniques

• Teach controlled breathing techniques including pursed-lip breathing (inhale through nose for several seconds, exhale slowly through pursed lips for 4-6 seconds) to manage breathlessness that may accompany cough. 1, 2
• Encourage relaxing and dropping shoulders to reduce the hunched posture associated with respiratory distress. 1

Monitoring Requirements for High-Risk Patients

Watch for Disease Progression

• Monitor oxygen saturation closely, as elderly patients with comorbidities are at higher risk of developing severe pneumonia leading to respiratory failure. 1
• Aggressively monitor for secondary bacterial infections, as elderly COVID-19 patients demonstrate significantly higher neutrophil ratios indicating greater infection susceptibility. 1, 2, 6

Cardiovascular and Renal Surveillance

• Closely monitor for signs of heart failure decompensation (increased dyspnea, edema, weight gain), as COVID-19 can precipitate acute cardiac injury through multiple mechanisms including cytokine storm and direct myocardial involvement. 7, 8
• Track renal function parameters, as acute kidney injury occurs commonly in severe COVID-19 and associates with increased mortality, particularly in patients with baseline renal impairment. 9, 8, 10
• Monitor D-dimer levels and coagulation parameters given significantly elevated thromboembolic risk in elderly COVID-19 patients. 1, 2, 6

What NOT to Use

Avoid These Medications

• Do not use NSAIDs for symptom relief; paracetamol is preferred for fever and discomfort in COVID-19 patients. 1, 2
• Do not use high-flow nasal oxygen or non-invasive ventilation for symptomatic rhinorrhea management, as these are reserved for hypoxemic respiratory failure. 1
• Avoid combination cold products containing multiple active ingredients, as these increase risk of drug interactions and adverse effects without proven benefit. 1, 2

Common Pitfalls

• Pitfall: Using multiple OTC medications simultaneously without considering cumulative anticholinergic burden, sedation risk, and cardiovascular effects in elderly patients with heart failure. 1, 2
• Pitfall: Failing to adjust doses for age and renal function, leading to drug accumulation and toxicity. 1, 2
• Pitfall: Not recognizing that rhinorrhea and cough may signal disease progression requiring escalation of care rather than just symptomatic treatment. 1
• Pitfall: Overlooking fluid restriction needs in heart failure patients when recommending increased hydration for upper respiratory symptoms. 1, 2