/publications/issue/2009/2009-03/2009-03-10049

Counseling Patients on Their OTC Treatment Options

Author: Craig I. Coleman, PharmD


Dr. Coleman is an assistant professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.


Increasingly, pharmacies are becoming a destination for patients looking for health care services and advice-not only on the myriad Rx and OTC medications, but also on ways to prevent illness and promote better health.

Test your clinical skills with these cases featuring topics patients frequently ask about.

Constipation

The pharmacist at the local independent pharmacy notices SB, a 52-year-old woman in the laxative aisle reading the back of boxes and realizes that this is a good opportunity to do some patient counseling. Upon questioning, SB explains to the pharmacist that she has been having infrequent bowel movements for the past 2 weeks and now is suffering from abdominal discomfort, bloating, and a feeling of fullness. SB notes no important changes in her health but mentions that she started taking diphenhydramine a few weeks back because of her seasonal allergies. What other questions should the pharmacist ask SB? What should the pharmacist recommend for SB's constipation?

The pharmacist should ask SB whether her diet contains enough crude fiber (>10 g/day) from fruits, vegetables, and cereals. This level of intake is often sufficient to prevent constipation in the majority of patients, but it may take as long as 1 month to work. The infrequent use of laxatives (less than every few weeks) is typically acceptable, but bulk-forming agents should be tried first. If ineffective, sennosides, bisacodyl, or saline laxatives can be tried. SB should be counseled that if a laxative is required for longer than 1 week, she should consult her physician. Because the anticholinergic effects of diphenhydramine could be contributing to her constipation, SB may want to contact her doctor if her seasonal allergies are troublesome to get a seasonal allergy therapy that will not contribute to her constipation, such as a nasal steroid.

Cold Sores

HS, a 23-year-old man comes to the pharmacy and after stopping in the natural products aisle, walks to the counter with a bottle of L-lysine capsules, and asks to talk with the pharmacist. HS reveals that he is a lifeguard at a local beach and suffers from frequent cold sores during the summer. HS says he knows that a cold sore is coming when he feels a tingling and burning sensation near the edge of his lip. He notes that he is feeling these symptoms now and is hoping that, if he acts quickly, the cold sore will not be as bad. HS claims a friend told him that L-lysine can help with cold sores. He wants to know if it really works. What should the pharmacist tell HS?

The pharmacist should inform HS that, according to the FDA, neither L-lysine nor any other oral OTC medication are effective in curing cold sores, but that typically cold sores resolve on their own within 7 to 10 days. The pharmacist could recommend HS apply docosanol 10% to the tingling site. Because HS's cold sore is still in the "prodrome" (presore) stage, administration of docosanol may decrease its duration and reduce symptoms. If a cold sore appears and is painful, the pharmacist could recommend HS try acetaminophen or ibuprofen as well as a topical anesthetic agent (such as benzocaine). Additional recommendations might include keeping the site clean and applying petroleum jelly to the cold sore to prevent cracking and subsequent infection. Perhaps most importantly, HS should use sunscreen in the future, as cold sores are commonly triggered by sun exposure.

Head Lice

PC is a 32-year-old mother of twin, 10-year-old girls. She comes into the pharmacy with a distraught look and proceeds to tell the pharmacist that she has just received a call from the school nurse asking her to come and pick up one of the girls, who-after a routine head check-was found to have head lice. She proclaims how embarrassed she is about the situation and swears that "her girls aren't dirty." How should the pharmacist handle this situation?

The pharmacist should reassure PC that head lice (Pediculus capitis) is a common problem in school children up to 12 years of age and is not related to poor hygiene and then advise PC to wash hairbrushes, combs, toys, cloths, linens, and towels in hot water. Items that cannot be washed should be thrown away or sealed in a plastic bag for 2 weeks. PC can choose from a variety of OTC treatment options for her daughter. These include products containing pyrethrin or permethrin, as well as therapies that are pesticidefree, such as dimethicone. PC should use the products as directed along with a nit comb. If lice persist after 2 courses of therapy or after 2 weeks, PC should call her daughter's pediatrician. PC's other daughter was not found to have head lice; therefore, she does not need to be treated, but all members of the family should be checked periodically.

Acne

AV, a 14-year-old girl, comes into the pharmacy looking sad. The pharmacist notices 5 or so mild acne lesions on her face. She tells him that her junior high school prom is in a little more than a month, and she is worried about her complexion. She wants to get an OTC product to treat her current acne lesions and prevent future breakouts, but is afraid that such a product will dry out her skin. What should the pharmacist recommend?

Benzoyl peroxide creams, lotions, gels, and soaps are effective OTC treatments for AV's mild acne. Benzoyl peroxide is broken down on the skin, producing oxygen-free radicals, killing bacteria (Propionibacterium acnes), and causing epithelia skin cells of the acne lesions to slough off. The pharmacist might recommend that AV use a benzoyl peroxide product that does not contain alcohol (because these are less likely to cause skin to dry out) at a lower potency- 2.5%. The concentration could then be titrated up to 5% or 10% as needed. Alternatively, the frequency of administration could be increased from every other day to daily and to twice daily to get optimal results while minimizing the risk of drying or irritating skin. Benzoyl peroxide also should not be applied to moist skin, because this will increase the risk of her skin drying out. It is important that she wait at least one half hour after washing her face.