Mary Barna Bridgeman, PharmD Rupal Patel Mansukhani, PharmD
NF is a 54-year-old man who visits your pharmacy to inquire about a remedy to help with daytime fatigue. He works as a bus driver and covers a busy shift from 7 am to 3:30 pm each day. Although he usually begins the day feeling refreshed, he feels fatigued after his noontime lunch break and has difficulty focusing his attention on his job for the latter part of his workday. He denies medication allergies and reports taking atorvastatin 40 mg daily for dyslipidemia, metformin 1000 mg twice daily for weight loss and glucose control, and a men’s multivitamin once daily for health maintenance. Describe lifestyle modifications NF can implement to improve his condition. What pharmacologic therapy can be recommended for NF for symptomatic relief of his fatigue?
Daytime drowsiness and fatigue are common symptoms that send individuals to the pharmacy seeking self-treatment. These symptoms are usually attributed to inadequate duration of sleep or poor sleep quality. They can be exacerbated by the presence of underlying medical conditions (eg, overactive bladder, depression, cancer, and chronic pain), or by the use of certain medications or drugs, including anxiolytics, antidepressants, alcohol, and caffeine.1 In the case of NF, goals of treatment should include identifying and treating the underlying cause and restoring mental alertness so that he can continue to function in his current occupation.
In evaluating NF for contributing factors, he should be questioned about his dietary and lifestyle habits, including current caffeine consumption, and evaluated for the presence of underlying medical conditions. Additionally, questioning NF about his current sleep practices is prudent to identify potential counseling points. Reiterate the importance of good sleep hygiene practices, such as pursuing relaxing activities prior to bedtime; avoiding alcohol or caffeine intake or consuming a large amount of food in the hours before sleep; assuring the bedroom environment is comfortable for sleep; and limiting the use of the bedroom to sleeping or intimacy.1,2
OTC caffeine supplements could also be considered in the case of NF after ruling out the presence of underlying cardiovascular disease. Regarding pharmacologic interventions, caffeine is the only FDA-approved stimulant product available without a prescription for the treatment of occasional drowsiness. Although many individuals will “self-medicate” with caffeine in its dietary forms, it is important to counsel individuals on the development of tolerance that rapidly occurs with persistent use.
In addition, the OTC or dietary forms are not intended as substitutes for good sleep behavior. If he chooses to purchase a caffeine supplement, counsel NF to take 100 to 200 mg every 3 to 4 hours as needed. Additionally, if recommending an OTC supplement, remind NF to avoid excessive dietary intake of caffeine through consumption of caffeinated beverages or other supplements, because excessive caffeine intake can result in exaggerated physiologic effects, including worsening of insomnia, transient increases in heart rate, and anxiety.
AG is a 43-year-old woman who inquires at the pharmacy about a supplement for treating symptoms of depression. Over the past 6 months, AG reports experiencing feelings of guilt and persistent sadness, new-onset insomnia, and appetite changes that have contributed to a significant, 10-lb weight loss, all of which started after her father’s death. Although she attributed these symptoms initially to grief and expected that they would resolve on their own, she is now contemplating using an herbal supplement to boost her mood. AG has a penicillin allergy and takes an oral contraceptive tablet each day, a women’s health multivitamin supplement, and an OTC fish oil supplement 3 times daily for heart health and cholesterol maintenance. What is your recommendation for alleviating AG’s symptoms at this time?
Because AG’s symptoms have interfered with her activities of daily living and have resulted in physical and physiological manifestations (ie, weight loss, insomnia), they are consistent with those of major depressive disorder or major depression. Regarding AG’s inquiry for an OTC herbal supplement, St John’s wort is the herbal product with the most research and experience to support its use for the treatment of depression. The antidepressant properties of this herbal agent have been attributed to hypericin and hyperforin compounds found in the plant, which may work to modulate the effects of serotonin, dopamine, and norepinephine to stabilize mood.
It is important to point out to AG, however, that clinical trials have not shown St John’s wort to be any more effective than placebo in treating moderate symptoms of major depression.2 Further, there is a potential for this herb to interact with AG’s oral hormonal contraceptive tablets, resulting in decreased efficacy and possible unintended pregnancy. Self-treatment of a condition as severe as depression could result in a delay in seeking professional medical evaluation, and AG should be encouraged to seek an evaluation by a physician rather than self-medicate to improve her symptoms.
Dr. Bridgeman is an internal medicine clinical pharmacist in Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.