The Cough - mypharmacyacademy.com€¦ · asthma and colds. As stipulated in Section 22A subsection...

Module 1

The Cough

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SmokingAsthma Some types of medication

1. Nose

2. Trachea

3. Bronchial tubes

4. Bronchi

5. Bronchiole

6. Alveoli

7. Mucus

8. Cilia

Dust and bacteria are inhaled and trapped by mucus and the fine hairs of the nasal membranes2a.

Bacteria that get past these hairs stick to the mucous membranes of the trachea or windpipe, or are swept upward by the cilia or hairs of the lower respiratory tract2b.

However, when the lungs are compromised or not working to full capacity, the body will develop a sneeze or cough to help rid itself of bacteria3.

The lungs are well protected by mucus and keep giving off tracheobronchial sputum that has natural bactericidal action (kills bacteria)2c.

Viruses/bacteria that lead to respiratory tract infections such as colds or flu

IntroductionA cough is your body’s way of keeping your throat and lungs clear of foreign particles, microbes, irritants, fluids and mucus1.

CausesSome of the most common causes of coughs include:

How to diagnose a cough effectively4

A careful scrutiny of the patient’s cough will help determine a diagnosis or even a cause. Ask questions to both the patient and any accompanying family members, since patients can be unaware of the characteristics of their cough or may underestimate its frequency and duration.

Next, we take a look at how to distinguish between different types of coughs, and how to treat them:

The Different Kinds of Cough: Wet vs. Dry5a

Patients may develop one of the following coughs when they have a case of the flu or a cold:

Cough

Coughs up mucus

Persistent/Constant

tickle

Any combination of the features of a wet

and dry coughWheezingSensitive

throat

Chest tightnessHacking Difficulty

breathingNo mucus expelled

Dry/Tickly/ Non-productive

Wet/Chesty/ Productive

Wet & Dry Cough (Combination)/

Non-specific

Did You Know?Coughs are one of the most common ailments seen by doctors, but exact causes can be found for less than 50% of these conditions5b.

As stipulated in Section 22A subsection 4 and 5 of the Medicines and Related Substances Act 101 of 1965, product recommendations can only be made by Pharmacists and Pharmacist Assistants acting under the personal supervision of a pharmacist (S1 – S2). Any customer seeking medical advice from a Front Shop Assistant should be referred to the Pharmacist on duty.


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Module 1 The Cough

The Different Kinds of Cough: Acute vs. Chronic6

Coughs are not only classified according to type, but also according to the length of time a patient has it:

SymptomsSymptoms CausesCauses

Lasts longer than 2-3 weeks

Begins suddenly

Lasts 2-3 weeks

Comes and goes

Chronic bronchitis,

asthma, smoking,

allergies & medicines

Colds, flu & acute

bronchitis

Acute Chronic

Cough

Did You Know? Post-nasal drip – where mucus drips down the back of the patient’s throat because of sinus complications – causes about 7% of coughs5c. Thin mucus naturally drips down the back of the throat unnoticed on a daily basis, but when the mucous lining of the throat becomes irritated it could lead to inflammation of the respiratory tract, which in turn leads to dry, tickly coughs5c.

See Module 3 for more on sinus complications.

How Symptoms of a Cold or Flu Develop

Patients may experience different stages as their flu or cold symptoms emerge7.

Stage 1 & 2

• Patient may experience lack of energy, body aches, dry/tickly coughs, symptoms that affect breathing, and a sore throat8a.

• Patient complains of an itchy or sore throat, or tickly cough.

• Recommend: a cough remedy that soothes the back of the throat.

Stage 3 & 4

• Patients may experience either wet, chesty coughs or dry, hacking coughs8b.

• Recommend: a cough remedy that targets multiple symptoms and various cough conditions.

Stage 1:

Something is different

Stage 2:

Something is wrong

Stage 3:

Full-blown

cold or flu

Time

Seve

rity

Stage 4:

Extended throat or chest problems

Chesty cough vs. Dry hacking cough

Sore throat Dry/tickly cough



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Module 1 The Cough

Treatment of Coughs

The alleviation of wet, dry and combination (wet and dry) coughs calls for specific treatments.

Wet/Productive Wet/Productive

Broncholytic

Agent that dilates/opens the bronchial tubes/passages9

Anti-inflammatory

Substance or treatment that reduces inflammation or swelling11

Demulcent

Substance which provides a soothing protective coating on mucous membranes of mouth and throat12

Mucolytic

Agent that liquifies thick mucus/phlegm and is usually used to help relieve respiratory difficulties10

Cough calming

Agent that helps to sooth and reduce an irritating cough8d

Anti-inflammatory

Substance or treatment that reduces inflammation or swelling11

Expectorant

Aid in clearance of mucus/phlegm from the passages of the lungs8c

Dry Cough Alleviation

Distinct Cough Types Call for Targeted Remedies

Active ingredients are specifically targeted to relieve the symptoms of distinct cough types13,14,15:

• Guaifenesin improves the ease of expelling sputum in a productive cough

• Dextromethorphan acts centrally to suppress a non-productive cough

How the active ingredients work

Productive

Acute cough

Key active ingredient: Guaifenesin

Associated with mucus production

Non-productive

Associated with dry or hacking cough

Key active ingredient: Dextromethorphan

Without Dextromethorphan

When you don't wear sunglasses you are exposed to the full glare of the sun's rays. Without protection you can't control the urge to squint. This is the same when you have a cough. You need to enhance your tolerance to resist the urge to cough.

Without Guaifenesin

Thick mucus or phlegm, difficult to clear.

With Dextromethorphan

Dextromethorphan may be compared to sunglasses filtering the sun’s rays. It increases the tolerance to nervous impulses, suppressing their effects so that the urge to cough is reduced.

With Guaifenesin

Loosening of mucus or phlegm by increasing its volume make it easier to clear from the airways.

One, or a combination of the solutions above, can be used to treat a variety of different coughs. Expectorants are ideal to treat wet coughs8c, while antitussives are used to soothe or calm dry coughs8d.



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Module 1 The Cough

Some herbal extracts also provides alleviation for the causes

of coughs, and the treatment of cold and flu symptoms:

Glycyrrhiza glabra (Liquorice Root)16

Helps to loosen and thin mucus in airways. Used as an expectorant and suppressant to accelerate tracheal mucus secretion, a demulcent to treat sore throats, and an anti-inflammatory agent.

Zingiber officinale (Ginger)17,18

Employed in the treatment of colds and flu. Used as an anti-inflammatory agent to treat headaches and upper respiratory tract infections, coughs and bronchitis.

Emblica officinalis (Indian Gooseberry)19,20

Used as an anti-viral and anti-bacterial substance, an expectorant and an antioxidant.

Levomenthol (Mint)21,22,23

Used as a decongestant and expectorant agent to thin mucus, as well as for its soothing and cooling properties.

Ocimum sanctum (Holy Basil)24,25,26

Used as an expectorant, anti-asthmatic and anti-catarrhal, and in the treatment of bronchitis, the common cold, fever, flu and catarrh.

Curcuma longa (Turmeric)27,28

Used for the treatment of headaches, bronchitis, the common cold and respiratory infections.

Adhatoda vasica (Malabar Nut)29

Used as an expectorant to loosen chest congestion and as a bronchodilatory agent to open the breathing tubes (bronchi).

Solanum indicum (Indian Nightshade)30,31

Used as an expectorant and treatment against bronchitis, and to treat dry and spasmodic coughs.

Inula racemosa (Indian Elecampane)32,33

Known for its antiseptic, anti-bacterial and anti-inflammatory properties. Used to treat respiratory diseases such as coughs, bronchial asthma and bronchitis.

Piper cubeba (Cubeb Pepper)34

Used for its expectorant qualities, stimulating effect on the mucous membranes of the respiratory tract and ability to ease the symptoms of chronic bronchitis.

Terminalia bellerica (Bahera Fruit)35

Used as an expectorant to treat respiratory conditions, including respiratory tract infections, coughs and sore throats.

Aloe barbadensis (Aloe Vera)36,37 Its anti-inflammatory properties help treat

asthma and colds.



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Module 1 The Cough

A combination of herbal extracts that works. Naturally.

Broncholytic

Mucolytic

Expectorant

Cough Calming

Anti-inflammatory

Demulcent

Effective for wet and dry coughs

For coughs associated with colds and flu

Available in syrup and lozenges

For day and night use

Alcohol free

DOKTOR MOM® helps the body naturally defend against infections by assisting the activity of tracheobronchial secretion to relieve coughs.

It provides support through:

Anti-inflammatory38a effects – which assists with wound healing

Immunoregulatory38b effects – which helps the immune system fight off infections

Iron-chelating39 activities – which make it difficult for bacteria to survive

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Herbal Cough Solutions: DOKTOR MOM®

DOKTOR MOM® Herbal Cough Syrup

Age

Indication

Active

Size

For the relief of wet & dry coughs

DOKTOR MOM® Herbal Cough Lozenges

For cough relief on the go

12+

• Effective partner in assisting in cough relief associated with colds and flu

• Relieves wet and dry coughs• Soothes the throat• Loosens mucus• Opens airways• Ideal for use day and night• Helps the body naturally

defend against infections to relieve cough

• Alcohol and tartrazine free

The syrup contains 11 herbal extracts already mixed for the patient’s convenience:

Aloe | Indian Elecampane | Turmeric | Mint | Cubeb Pepper | Ginger | Holy Basil | Indian Nightshade | Liquorice Root | Bahera Fruits | Malabar Nut

100 ml

12+

• Relieves coughs

• Soothes the throat• Ideal for use day and night• Alcohol and tartrazine free• Effective partner in assisting

in cough relief associated with colds and flu

The lozenges are made from a blend of 4 herbal extracts:

Liquorice Root | Ginger | Indian Gooseberry | Mint

20 lozenges

Available in 4 soothing flavours:

Lemon | Pineapple | Berries | Mixed Fruit

S0 DOKTOR MOM® HERBAL COUGH SYRUP (ALCOHOL, TARTRAZINE & COLOURANT FREE). Each 10 ml contains: Ocimum sanctum 100 mg, Glycyrrhiza glabra 60 mg, Curcuma longa 50 mg, Zingiber officinale 10 mg, Adhatoda vasica 60 mg, Solanum indicum 20 mg, Inula racemosa 20 mg, Piper cubeba 10 mg, Terminalia belerica 20 mg, Aloe barbadensis 50 mg, Menthol 6 mg; Contains Sugar.

S0 DOKTOR MOM® HERBAL COUGH LOZENGES (ALCOHOL, TARTRAZINE & COLOURANT FREE). Each lozenge contains: Dry extracts derived from: Liquorice root (Glycyrrhiza glabra) 15 mg, Common ginger rhizome (Zingiber officinale) 10 mg, Indian gooseberry fruits (Emblica officinalis) 10 mg, Levomenthol 7 mg; Contains Sugar.



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Module 1 The Cough

Benylin® Wet Cough

Benylin®

Wet Cough Menthol

Benylin® Children’s

Wet Cough

Benylin® Bronchospect

Benylin® Chesty

2+ 12+ 2+ 3+ 2+

Thins mucus, making it easier to get rid of thick, stubborn phlegm

Solution for the whole family, 2 years and older

Sugar, colourant and alcohol free



Sugar, alcohol and colourant free

Eases a tight, wheezy chest

Loosens phlegm

For relief of tight chests and stubborn phlegm

Bronchodilator and mucolytic

Alcohol and sugar free

Guaifenesin 100 mgGuaifenesin

50 mg

Terbutaline Sulphate 1,5 mg, Guaifenesin 66,5 mg

Orciprenaline Sulphate 5 mg, Bromhexine Hydrochloride 4 mg

50 ml & 100 ml

50 ml & 100 ml 100 ml 200 ml 100 ml

Benylin® Dry Cough

Benylin® Paediatric

Benylin® with Codeine

5+ 6+ 6+

For effective relief from an irritating dry cough

Sugar and alcohol free

For a dry cough driven by seasonal allergies and hay fever

Nighttime cough suppressant

Dextromethorphan 15 mg

Diphenhydramine Hydrochloride 7 mg

Diphenhydramine hydrochloride 12,5 mg, Codeine phosphate 10 mg, Ammonium chloride 125 mg

100 ml & 200 ml 100 ml 100 ml

Benylin® Original

6+

Alleviates cough

Diphenhydramine Hydrochloride 12,5 mg, Ammonium chloride 125 mg

100 ml & 200 ml

Wet Cough Dry Cough Wet & Dry Cough

Cough Solutions: Benylin®

S2 Benylin® Original. Each 5 ml contains Ammonium Chloride 125 mg and Diphenhydramine HCI 12,5 mg. Ref. No. G829 (Act 101/1965).

S0 Benylin® Wet Cough. (Alcohol, Sugar & Colourant Free Liquid). Each 10 ml contains: Guaifenesin 200 mg. Reg. No. 37/10.1/0061.

S0 Benylin® Wet Cough Menthol. Each 10 ml contains Guaifenesin 200 mg. Reg. No. 28/10.1/0374.

S0 Benylin® Children’s Wet Cough (Alcohol, Sugar & Colourant Free Liquid). Each 5 ml contains Guaifenesin 50 mg. Reg. No. 35/10.1/0266.

S2 Benylin® Bronchospect. Each 5 ml contains: Guaifenesin 66,5 mg; Terbutaline Sulphate 1,5 mg. Reg. No. 31/10.1/0487.

S2 Benylin® Chesty. Each 5 ml contains: Bromhexine Hydrochloride 4 mg; Orciprenaline Sulphate 5 mg. Reg. No. 29/10.1/0288.

S2 Benylin® Dry Cough. Each 5 ml contains Dextromethorphan HBr 15 mg. Reg. No. Z/10.1/5.

S2 Benylin® Paediatric. Each 5 ml contains Diphenhydramine HCI 7 mg. Reg. No. H/10.1/12.

S2 Benylin® With Codeine. Each 5 ml contains Ammonium Chloride 125 mg; Codeine Phosphate 10 mg; Diphenhydramine HCI 12,5 mg. Ref. No. G830 (Act 101/1965).

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Module 1 The Cough

Product Summary

Herbal offering

Non-herbal offering

Dry cough

Benylin® Paediatric (Age 6+)

Benylin® Dry Cough (Age 5+)

Wet cough

Benylin® Children’s Wet Cough (Age 2+)


(Age 3+)

Benylin® Chesty (Age 2+)

Wet & Dry cough (combination)

Benylin® Original (Age 6+)

CHILDREN2 - 12 YEARS

Dry cough

Benylin® Dry Cough


DOKTOR MOM® Cough Syrup

DOKTOR MOM® Cough Lozenges

Wet cough

Benylin® Wet Cough

Benylin® Wet Cough Menthol



Wet & Dry cough (combination)

Benylin® Original



ADULTS12+ YEARS

HERBAL AND NON-HERBAL COUGH TREATMENT SOLUTION



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Module 1 The Cough

• Linda has come to your pharmacy to ask for advice.

• She tells you that she has a cough that’s been getting worse over the last few days.

• She also tells you that she’s experiencing wheezing and tightness in her chest.

• She would like to know which over-the-counter (OTC) product she can take to help with her symptoms.

Case Study 1 Linda, 25, Assistant Editor

• Was the start of the cough sudden?

• Was there a cause for the cough to start?

• How long has the cough been present?

• Is the cough persistent or does it come and go?

• How often does a single coughing spell happen?

• How long does a coughing spell last?

• Can she tell where the cough or the sputum come from – is it from the throat or deeper in the chest? (Is it dry or wet?)

• Is phlegm easily expelled when she coughs?

• Is the cough an isolated symptom, or is she aware of any other respiratory or non-respiratory symptoms?

Ask the following questions4

Continued on next page

Linda says that the cough started only four days before. It grew from a tickle in her throat, along with her feeling tired, to her experiencing tightness in her chest and coughing up mucus. The phlegm seems to come from deeper in her chest and some of it is expelled when she coughs. On average she has a coughing fit every two hours, which lasts for a few minutes. She doesn’t smoke and hasn’t had a cough in recent years.

Diagnosis: You establish that she has a wet cough.

• Has she been exposed to any irritants, such as smoke, that may inflame her respiratory tract?

• What time of the day or night is the cough or sputum production worse?

• Has the pattern of the cough or nature of the sputum changed recently?

• Has she had a similar problem with coughing in the past?

TreatmentSince Linda has a wet cough you can recommend the following products within the Johnson & Johnson portfolio:

Top Tip: Since DOKTOR MOM® is a herbal cough remedy, it can also be recommended to patients like Linda by front shop assistants.

For the relief of coughs

• Soothes the throat

• Loosens mucus

• Opens airways


Benylin® Wet Cough Menthol


• Fresh, menthol flavour

HERBAL

OFFERING



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Module 1 The Cough


For convenient cough relief on the go

Benylin® Original

Alleviates cough by facilitating elimination of mucus

Benylin® Chesty


Benylin® Wet Cough


Other recommendations

Depending on your patient’s preference, or what is in stock at your pharmacy, you can also recommend:

Case Study 2 Bheki, 2, Toddler

• Bheki’s mother has come to your pharmacy for advice with her toddler.

• He’s struggling with a cough.

• He’s irritable, because his cough and difficulty breathing means he does not sleep well.

• She wants to know what OTC product will be effective for his cough, but gentle enough for a toddler.

Ask the following questions4

• How long has he been coughing for?

• Was there a cause for the cough to start?

• Does he suffer from any other illnesses or allergies that she is aware of?

• Does he have a fever?

• Is he regularly in the company of someone who smokes?

• Does Bheki cough persistently, or is it worse at certain times of the day?

• Can she tell whether it is a chesty cough that produces sputum, or a dry, hacking cough?

• Does he have trouble breathing? And when he sleeps? Can she detect a wheezing sound?

HERBAL

OFFERING



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Module 1 The Cough

Bheki’s mother says the coughing started about a week ago, mainly at night and in the morning. When Bheki sleeps, his chest is wheezy, and he coughs up phlegm especially in the morning. He doesn’t have a fever and no allergies that she is aware of.

Diagnosis: You establish that Bheki does not have the flu, but that he is struggling with a wet cough.

TreatmentSince Bheki has a wet cough, and is only two years old, you can recommend:

Benylin® Children’s Wet Cough

Thins mucus, making it easier to get rid of thick, stubborn phlegm.

Sugar, alcohol and colourant free.



For children 3+

While this isn’t suitable for Bheki, children aged 3 and over can also use:

Benylin® Chesty



Eases a tight, wheezy chest and loosens phlegm

Benylin® Wet Cough


Case Study 3 Mandy, 28, mother, with Nina, 6, daughter

• Nina and her mother have come to your pharmacy to ask for advice.

• Nina’s mother explains that both her and Nina have a cough.

• She’d like to know which over-the-counter (OTC) product each of them can take to help with their symptoms.

Ask the following questions4 • How long has each of them had

the symptoms?

• Does either of them have a fever?

• Does either of them have any allergies

• Is her cough dry or productive? And Nina’s?

• Does either of them have any other medical conditions?

• Is she or Nina short of breath?

• Is she experiencing pain in her chest or difficulty breathing? How about Nina?

• Has she experienced any dizziness or confusion?

Nina’s mom tells you that they seem to be suffering from the same thing, as their symptoms are similar. It

Strawberry flavourIdeal for children



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Module 1 The Cough

TreatmentBoth of them will find relief for a dry, tickly cough using the following:

NEW Benylin® Paediatric

For a dry cough driven by seasonal allergies and hay fever.

Suitable for children aged 6+, as well as adults.

Benylin® Dry Cough

For effective relief from an irritating dry cough




Nighttime cough suppressant

Benylin® Original

Relief of a wet or dry cough



For Mandy only:

Test Your KnowledgeYou’ve reached the end of the module. You can test your knowledge right away while the info is fresh, or you can complete the full Class Test in one go once you reach the end of this Study Pack. See the back page of the booklet for more details on how to complete and submit your test.

Below are the questions from the Class Test that applies to the module you just finished. The full Class Test appears on the Fax Sheet included separately.

1 A mucolytic is an agent which:

a Liquifies thick mucus

b Helps clear mucus from the passages of the lungs

c Reduces inflammation

d All of the above

2 Which of the following would not cause a chronic cough?

a Smoking

b Some medicines

c Allergies

d Acute bronchitis

3 Which Benylin® product is recommended for a non-specific/combination wet and dry cough?

a Benylin® Chesty

b Benylin® Brochospect

c Benylin® Original

d Benylin® Paediatric

seems to be a dry cough, since neither of them is coughing up phlegm. The coughing appears intermittently and sometimes at different times from each other, without any other symptoms, except for a tickly throat. Mandy says she’s always had a slight allergic reaction to pollen, dust and animal dander, and she suspects Nina may suffer from the same.

Diagnosis: Both Mandy and Nina are suffering from a dry cough. Since the pollen count is high, it seems likely that the cough is due to allergies.

HERBAL

OFFERING


As stipulated in Section 22A subsection 4 and 5 of the Medicines and Related Substances Act 101 of 1965, product recommendations can only be made by Pharmacists and Pharmacist Assistants acting under the personal supervision of a pharmacist (S1 – S2). Any customer seeking medical advice from a Front Shop Assistant should be referred to the Pharmacist on duty. 27

Module 1 The Cough

4 Which of the following does DOKTOR MOM® not support?

a Anti-inflammatory effects

b Immunoregulatory effects

c Iron-chelating activities

d Depletion of tracheobronchial substances

5 Which Benylin® product would you recommend for a toddler aged 2 with a wet cough?

a Benylin® Original

b Benylin® Children’s Wet Cough

c Benylin® with Codeine

d Benylin® Wet Cough Menthol

6 Which of the following statements about DOKTOR MOM® is true?

a Effective for dry coughs only

b For coughs associated with colds and flu

c Available only in lozenge form

d Only for use during the day

7 Which of the following statements is true about Benylin® Chesty?

a Contains Guaifenesin

b Available in a 200 ml bottle

c Contains menthol

d Alcohol and sugar free

8 Which of the following is not a typical trait of a wet/productive cough:

a Coughing up mucus

b Wheezing

c Persistent/Constant tickle

d Difficulty breathing



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Module 1 The Cough

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overview. Accessed on 13 December 2017.

2. Immune Defense against Bacterial Pathogens. Online Textbook of Bacteriology. Available at textbookofbacteriology.net/innate_3.html. Accessed on 13 December 2017.

3. Zakharova I.N. et al. Doktor Mom herbal cough syrup in combination therapy of acute respiratory infections in children. Paediatrics Appendix to Consilum Medicum. Volume 06/N 2/2004

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5. Health Freedom Alliance. 8 Different Coughs, Their Symptoms And What Each Means For Your Health. Available at http://www.healthfreedoms.org/8-different-coughs-their-symptoms-and-what-each-means-for-your-health/ Accessed on 13 December 2017

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13. Benylin Mucus Cough Menthol SPC

14. Benylin Dry Coughs Night SPC

15. Benylin Dry Coughs 7.5 mg / 5 ml Syrup SPC

16. WHO Monographs on Selected Medicinal Plants – Volume 1. Radix Glycyrrhizae. Available at apps.who.int/medicinedocs/en/d/Js2200e/20.html#Js2200e.20. Accessed on 14 December 2017.

17. WHO Monographs on Selected Medicinal Plants – Volume 1. Rhizoma Zingiberis. Available at apps.who.int/medicinedocs/en/d/Js2200e/30.html#Js2200e.30 Accessed on 14 December 2017.

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20. Health Canada. Monograph: Amla - Phyllanthus emblica. Available at webprod.hc-sc.gc.ca/nhpid-bdipsn/monoReq.do?id=841&lang=eng. Accessed on 14 December 2017.

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22. Livestrong.com. Medicinal Properties of Menthol. Available at www.livestrong.com/article/164443-medicinal-properties-of-menthol/ Accessed on 14 December 2017.

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27. WHO Monographs on Selected Medicinal Plants – Volume 1. Rhizoma Curcumae Longae. Available at apps.who.int/medicinedocs/en/d/Js2200e/14.html#Js2200e.14. Accessed on 14 December 2017.

28. Natural Medicines Comprehensive Database. Turmeric. Available at naturaldatabase.therapeuticresearch.com/nd/Search.aspx?pt=100&id=662. Accessed on 14 December 2017.

29. Natural Medicines Comprehensive Database. Malabar Nut. Available at naturaldatabase.therapeuticresearch.com/nd/Search.aspx?cs=&s=ND&pt=100&sh=1&id=1. Accessed on 14 December 2017.

30. Mother Herbs. Solanum Indicum. Available at www.motherherbs.com/solanum-indicum.html. Accessed on 14 December 2017.

31. HolisticOnline.com. Indian Nightshade. Available at http://holisticonline.com/herbal-med/_Herbs/h136.htm. Accessed on 14 December 2017.

32. Easy Ayurveda. Pushkarmool – Inula Racemosa. Available at easyayurveda.com/2013/09/18/pushkarmool-inula-racemosa-benefits-usage-dose-side-effects/. Accessed on 14 December 2017.

33. Mother Herbs. Inula Racemosa. Available at www.motherherbs.com/inula-racemosa.html. Accessed on 14 December 2017.

34. Mother Herbs. Piper Cubeba. Available at www.motherherbs.com/piper-cubeba.html. Accessed on 14 December 2017.

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