Author: Rupal Patel Mansukhani, PharmD, and Mary Barna Bridgeman, PharmD, BCPS, CGP
Case 1—Occasional Constipation
ML is a 68-year-old man who comes to the pharmacy asking how he can stay regular. Upon questioning, ML does not report suffering from constipation right now, but says he passes hard stools from time to time. He also reports infrequent episodes of straining to have a bowel movement. He has no medical conditions or allergies and is not taking any medication. What would you recommend to ML to prevent constipation?
Prevention and treatment of constipation are common reasons patients, especially elderly ones, use OTC laxative products. In the elderly population, it is important to identify medical conditions and medications that may be contributing to symptoms of constipation. In ML’s case, medications are not an issue.
Nonpharmacologic therapy can be used to treat and prevent episodes of acute constipation. ML should increase his dietary fiber intake, his daily fluid intake, and his level of physical activity. Fiber promotes regularity by increasing the water content and bulk of stool within the intestine. According to the American Dietetic Association, adults should consume 20 to 35 g of fiber each day.1
Counsel ML on gradually increasing his consumption of whole grains, bran, fruits, nuts, and vegetables to prevent potential undesired gastrointestinal adverse events such as bloating and flatulence. Fiber supplements work best when taken with adequate amounts of fluid, and increasing fluid intake can also help alleviate symptoms of constipation. If ML is unable to increase his fiber intake from dietary sources, bulk-forming fiber supplements can also be considered.
Increasing water intake to 6 to 8 glasses per day may help soften the stool. Physical activity may also help alleviate constipation, as a sedentary lifestyle has been shown to be associated with constipation.2
Due to ML’s advanced age, recommend that he check with his physician before starting a physical activity program. Finally, maintaining good toileting habits, including allowing adequate time for using the toilet and attempting to defecate first thing in the morning or after meals, when bowel motility is the greatest, may help condition bowel habits.
Case 2—Seasonal Depression
GM is an 83-year-old woman who comes to the pharmacy looking for a recommendation regarding which brand of St. John’s wort she should use. Upon questioning, she says she has been feeling a little down lately, especially since the holidays are over. She says she gets a little down every January and that her friend recommended she take OTC St. John’s wort to help her feel better. She currently takes lisinopril 10 mg, hydrochlorothiazide 25 mg, and clopidogrel 75 mg. What would you suggest that GM do regarding her depression?
Depression is the second-most common condition in the United States. Especially after the holidays, many patients feel down and may come to the pharmacy seeking OTC products to help improve their mood. St. John’s wort is thought to work in a manner similar to conventional antidepressants. There are conflicting findings on whether St. John’s wort is effective, but the majority of evidence suggests that it helps improve mood in patients with mild to moderate depression.3
St. John’s wort could help treat GM’s symptoms, but it isn’t necessarily the best choice for therapy. For instance, it has the potential to interact with the clopidogrel that GM is currently taking. Because she has not formally been diagnosed with depression, it is probably best for GM to be evaluated by a physician before taking any medication to attempt to improve her mood. She and her physician can then discuss which treatment option would be most appropriate.
SM is a 43-year-old man who comes to the pharmacy to fill a prescription for omega-3-acid ethyl esters (Lovaza). Lovaza is not covered under his insurance; therefore, he wants a recommendation for OTC omega-3 fish oil. His physician prescribed Lovaza because his triglycerides are high. His lab work shows the following: total cholesterol = 220 mg/dL, low-density lipoprotein (LDL) = 120 mg/dL, high-density lipoprotein = 60 mg/dL, and triglycerides = 200 mg/dL. SM says that his primary care physician recommended omega-3 fish oils to lower his LdL and triglycerides. He is not taking any other medications and has no medical conditions. Would you recommend that he initiate OTC omega-3 fish oil?
Lovaza is indicated as an adjunct to diet to reduce triglyceride levels in adult patients with severe (≥500 mg/dL) hypertriglyceridemia. Lovaza contains a high concentration of omega-3 fish oils (840 mg/capsule); therefore, patients with triglycerides greater than 500 mg/dL should be encouraged to take Lovaza.4
Because SM’s triglycerides are not greater than 500 mg/dL, it might be appropriate for him to take OTC fish oil. Clinical trials show that fish oil in doses between 1 and 5 g/day can reduce triglycerides by 20% to 50%. However, they are not effective in reducing LDL or total cholesterol. If SM wants to take an OTC omega-3 fish oil, it is recommended that he take a high concentration of omega-3 in a fish oil that that is verified by the United States Pharmacopeia (USP). USP products are high quality and verified to be free of contaminants such as pesticides.
Case 4—Diabetes and Aspirin
RM is a 33-year-old man who comes to the pharmacy with a refill prescription of lisinopril 10 mg, atenolol 10 mg, and metformin 500 mg. He says his doctor recommended that he take a baby aspirin every day. His friend told him that the doctor recommended it because everyone with diabetes should be taking baby aspirin. He has no other medical conditions and has not had any previous cardiac events. Would RM be a candidate for aspirin therapy?
Primary prevention of aspirin therapy (75-162 mg/ day) is recommended in patients with diabetes at an increased cardiovascular risk. This includes men 50 years and older or women 60 years and older who have at least 1 additional risk factor. Risk factors include a family history of cardiovascular disease (CVD), hypertension, smoking, dyslipidemia, or albuminuria.
Because RM is 33 years old, he is not a candidate for primary prevention with aspirin. Patients who are candidates would take aspirin 81 mg daily for primary prevention; however, it is important to discuss with a primary care physician prior to initiation of aspirin. Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (10-year CVD risk <5%, such as in men 50 years or older and women 60 years or older with no major additional CVD risk factors), because the potential adverse effects from bleeding likely offset the potential benefits.
Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Bridgeman is an internal medicine clinical pharmacist in New Brunswick, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University
Marlett JA, McBurney MI, Slavin JL. Position of the American Dietetic Association: health implications of dietary fiber. J Am Diet Assoc. 2002;102:993-1000.
Everhart JE, Go VL, Johannes RS, Fitzsimmons SC, Roth HP, White LR. A longitudinal survey of self-reported bowel habits in the United States. Dig Dis Sci. 1989;34:1153-1162.
Linde K, Mulrow CD, Berner M, Egger M. St. John’s Wort for depression. Cochrane Database Syst Rev. 2008;(4):CD000448.
Lovaza prescribing information. GSK Source website. www.gsksource.com/gskprm/en/US/adirect/gskprm?cmd=ProductDetailPage&product_id=1336506912652&featureKey=603462#i4i_indications_id_de09a191-bc3b-49b7-9925-a4534d8bdbda. Accessed November 20, 2012.