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This winter, with the combination of a flu outbreak, ongoing Covid cases and increased numbers of respiratory viruses, community pharmacies are likely to see many customers complaining of a sore throat. And as research indicates there is still widespread misunderstanding of the role of antibiotics in sore throat treatment, it’s more important than ever that pharmacy teams are armed with the correct advice.
A sore throat is among the most common reasons for customers to visit a community pharmacy. And across the UK, almost 10 per cent of patients see their GP each year for a sore throat, while 8 per cent of all acute prescribing relates to sore throat.
It’s important for pharmacy staff to understand the different causes of sore throat and the signs that a customer may have Covid, flu or a Strep A infection. Keeping up to date with the latest treatment guidance and educating customers about the safe use of antibiotics will help encourage them to manage their own symptoms, minimise antibiotic misuse, and understand when there may be cause for concern.
Managing sore throat
A sore throat is a symptom, not a condition. Soreness on swallowing may be accompanied by fever, headache, rhinitis and/or cough. Most sore throats are caused by a viral infection, such as rhinovirus, coronavirus or flu. The most common bacterial cause is group A beta-haemolytic streptococcus (GABHS), which causes tonsillitis, pharyngitis and scarlet fever. In children, this causes 20-40 per cent of sore throats and 10 per cent in adults.
Whether they are caused by a viral or bacterial infection, most sore throats resolve within two weeks, and in 40 per cent of people by three days. After one week, 85 per cent of people are likely to be feeling better.
A fever of 38oC is common in people with tonsillitis, along with inflamed tonsils and swollen glands in the neck. A cough is not a symptom of tonsillitis. If your customer also has a cough, it’s likely that the cause is another virus, such as a coronavirus or rhinovirus. Other common non-Strep causes of sore throat include:
- Common cold
- Flu
- Pharyngoconjunctival fever (other signs include fever, conjunctivitis, headache and rhinitis)
- Glandular fever (other symptoms include a high fever and chills, swollen glands in the neck, extreme fatigue and tonsillitis that doesn’t improve).
Sue Snelling, Oxford Online Pharmacy manager, says: “Some customers are still not aware a sore throat could be a symptom of Covid, so pharmacy staff are still educating patients and advising them to wear masks if feeling unwell.”
“At Numark, we are seeing an uplift in winter virus symptoms and are seeing how important it is that customers are advised to rule out Covid before attending a pharmacy,” says Lucy Morris, Numark patient services manager.
Red flags
A severe sore throat and fever, muffled voice, drooling and stridor indicates epiglottitis. This is a medical emergency, and the throat should not be examined as this could cause the airway to close. Fever, neck pain, trismus, muffled voice, displaced uvula, enlarged and displaced tonsils indicates quinsy, a condition that is most common in two- to four-year-olds.
Treatment
Pharmacy teams can reassure customers that most sore throats resolve within a week and don’t need antibiotics. However, if group A Strep has been confirmed or is strongly suspected, antibiotics may be prescribed – although some studies have found that they only shorten duration by a day.
To relieve pain and/or fever, paracetamol or ibuprofen can be recommended, as appropriate for the sufferer. They should also ensure adequate fluid intake to avoid dehydration. Throat sprays containing a local anaesthetic, NSAID and antiseptic ingredients can give relief, as can lozenges or pastilles with these ingredients.
“We’ve seen that people are happy to pay a little more for a product that has natural ingredients”
Jacquie Lee, Numark medication safety officer and information pharmacist, adds: “Pharmacy staff should advise customers treating sore throats at home to take ibuprofen or paracetamol if appropriate; drink plenty of fluids, eat cool or soft foods; get plenty of rest; gargle with warm, salty water; use medicated lozenges and throat sprays to ease pain.”
Managing laryngitis in the pharmacy
Laryngitis causes inflammation of the voice box or vocal cords. It is normally triggered by a viral infection such as a common cold or flu, and may accompany bronchitis. Over-use of the voice or allergies and irritants such as cigarette smoke can also cause laryngitis, as can gastroesophageal reflux.
The main signs are a change of voice, such as hoarseness or quieter voice, or voice loss. A sore or tickly throat, fever, difficulty swallowing and a need to constantly clear the throat are other common symptoms.
Red flags
Patients with breathing difficulties should receive urgent medical help. Anyone aged 45-plus with persistent unexplained hoarseness or a lump in their neck should be referred for examination for possible laryngeal cancer.
Treatment
Gargling with salt water can help, and paracetamol or ibuprofen can relieve pain and fever. A cough syrup can be recommended to ease cough symptoms, while throat lozenges should also give relief. Advise customers to ensure they get plenty of fluids. Steam inhalation will also help to keep the throat moist.
Market drivers
Mintel reports that homemade remedies such as hot lemon and honey are increasingly popular for treating sore throats. “Considering the popularity of homemade remedies, brands can innovate in add-ins, concentrates or syrups that can be diluted, blurring the line between an OTC and a homemade remedy,” says the Mintel report Cough, Cold & Flu Remedies, 2022.
In the last year, 48 per cent of people asked by Mintel said they had taken an OTC remedy for a sore throat or cough; 17 per cent had used a homemade remedy, and six per cent a prescription remedy. Mintel sees a gap in the UK market for more topical remedies to treat sore throat, such as sprays and products to keep throats hydrated overnight.
Andy Richman, managing director of Ricola UK, is already seeing a busier season than last year. “We are extending our distribution where we can and have increased production, as we know from Australian data that we are likely to have a lot of flu cases this year,” he says.
Ricola has seen increased demand for products with natural ingredients to treat sore throats. “Natural ingredients are what people want,” he says. “Our product sits between medicated brands such as Strepsils and the cheaper mass produced ‘sweets’ for sore throats, coughs and colds.”
Ricola has seen value sales increase by 181 per cent in the last year (Nielsen, Oct ’22). “We’ve seen that people are happy to pay a little more for a product that has natural ingredients,” Mr Richman says.
Alphega’s Vinay Patel adds that cough syrups, lozenges and throat sprays are driving market growth. “Customers will often purchase multiple products – syrups for use at home, lozenges or sprays for when they’re out and about.”
Improve your category
When it comes to making the most out of potential sales in this category, Mr Richman says: “It’s important to display products well and to learn about them so you can advise your customers appropriately. Be proactive in offering advice and recommending products for sore throats. Ensure that your shelves are well stocked in advance of peak winter virus season and offer a good selection of ranges in different price points.”
Ms Lee adds the following advice: “Pharmacies should stock a range of sore throat products including hard lozenges, soft pastilles and throat sprays. Linctus containing glycerine, honey and lemon can also give relief.”
“Stock the key brands, especially those that have national advertising campaigns,” says Mr Patel. “Ensure products are prominently displayed and encourage your teams to support self care. Use supplied point of sale materials.”
Sore throat test & treat service update
An NHS funded sore throat test & treat service (STTT) was originally piloted in Wales in 2018-19 in a small number of pharmacies. Following successful evaluation, it was then rolled out in 2019-20, but suspended in March 2020 due to Covid-19. It was reintroduced at the end of 2021/2022 by some local health boards.
“The aims of the service were to transfer the care of patients with uncomplicated sore throats from GPs to community pharmacy, improve antimicrobial stewardship, reduce the number of emergency out of hours appointments and provide service user education,” says an analysis published in the Journal of Antimicrobial Chemotherapy (October ’22).
The analysis looked at more than 11,300 consultations in community pharmacies between November 2018 and February 2020. Pharmacists managed 91 per cent of these consultations in the pharmacy and referred only 9.3 per cent to a GP and 0.2 per cent to A&E.
The authors concluded: “This is the largest description of a pharmacy-led STTT service to date and suggests it can be delivered at scale to align with a pre-specified pathway that promotes appropriate use of RADT (rapid antigen detection testing) and antibiotics. The service could substantially reduce workload from a common illness in other heavily pressurised areas of primary and emergency care. The service was well received by both pharmacists and patients, with patient satisfaction not found to be correlated to antibiotic supply.”
Judy Thomas of Community Pharmacy Wales says: “The Clinical Community Pharmacy Service specification allows the inclusion of the STTT service as part of the Common Ailments Service from November 1 (once PGDs are released), so we are expecting an increase in the number of contractors providing it in the near future.”
“Pharmacy teams have an important role in antibiotic stewardship and sore throats, where antibiotics are not always required”
A recent Cochrane review of rapid testing for sore throat in primary care suggested antibiotic prescribing rates might reduce by 25 per cent when RADT is used. NICE has acknowledged that further research is needed to assess the value of RADT on antibiotic prescribing for sore throat in different healthcare settings.
In England, the service was paused due to the pandemic, but a few pharmacies are starting it up again, says the NPA, which has produced a sore throat ‘red flag’ fact sheet for its members.
“Pharmacies are considering how they can support their customers over the winter, including the delivering of an STTT service,” says Lucy Morris, Numark patient services manager. “Offering this service will ensure customers can treat their ailment appropriately without the need to visit their GP.”
Vinay Patel, services and contract pharmacist at Alphega Pharmacy, adds: “STTT services are increasing in popularity, particularly where these can rule out the possibility of Covid infection and confirm the presence of a bacterial infection.”
In Northern Ireland, there is no commissioned STTT service, although some pharmacies may offer a private service. There is a commissioned Pharmacy First service, but the winter pressures component only ran until end of March. It may be reintroduced, but has not been confirmed yet.
An NHS service is not yet available in Scotland either. “A sore throat service is on the roadmap for Pharmacy First, but it is likely to be beyond 2023,” says Matt Barclay of Community Pharmacy Scotland. “Pharmacy teams have an important role in antibiotic stewardship and sore throats, where antibiotics are not always required, and this is a classic example of where their expertise can be deployed when having conversations with patients.”
Views of the P3pharmacy category panel
This is one of our biggest OTC categories as customers don’t want to wait for an appointment. If we are asked whether antibiotics are needed, we educate about viral and bacterial infections and why antibiotics are not usually necessary for a sore throat. Lozenges used to be first line, but then throat sprays became more popular. Now brands such as Difflam and Chloraseptic produce lozenges as well. Sprays are good as they target the precise area. Difflam, Chloraseptic and Strepsils are popular, but there is a large range of remedies to choose from. Most products can go on display, so keep these in an easy access area.
Lila Thakerar, Shaftesbury Pharmacy, Harrow
This is a really important category this season. There seem to be many more viruses around with sore throat and cough symptoms. It’s important for staff to ask customers about their symptoms and how long they’ve had them for to try and work out the cause – Covid, flu, or something else? When asked for something to relieve a sore throat and a cough, we tend to recommend a throat spray such as Chloraseptic or Difflam, which have an anaesthetic. These are very effective and have become more popular recently. An oral rinse is a good alternative for people who don’t like throat sprays.
Hardik Desai, Ticehurst Pharmacy, East Sussex
Sore throats, although mainly self-limiting, offer pharmacy a great way to engage patients. With Covid still in mind, questions revolve around how to tell if it’s Covid or not. Strepsils are prominent for self selection; we offer a generic benzydamine spray (Difflam for those who prefer brands) to optimise relief. We make sure vaccination messaging and lifestyle advice is central to our engagement. With more sore throats than usual, keeping on top of stock is paramount. Locate products next to other cough and cold remedies. And include BreathEasy tissues for extra sales to benefit both patients and pharmacy.
Gareth Evans, Wansford Pharmacy, Peterborough
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