Author: Rupal Patel Mansukhani, PharmD, and Mary Barna Bridgeman, PharmD, BCPS, CGP
Case 1: Heartburn
MG is a 34-year-old woman who comes to the pharmacy complaining of a burning sensation after eating. She says she has been dating a new man who loves to eat spicy food, and they have been eating out quite frequently over the past few weeks. She typically experiences the burning symptoms 1 or 2 hours after she eats, 3 to 4 days per week. She has tried antacids, but they only help soothe the immediate burning. She never had problems with heartburn prior to beginning to eat spicy foods regularly and wants to know if there is anything preventive she can take to avoid the burning. What would you recommend for MG?
When counseling heartburn patients, first determine whether there is any reason they should be excluded from self-treatment. Heartburn patients should be referred to a physician if they are pregnant or have severe heartburn or dyspepsia, nocturnal heartburn, or difficulty eating, or have frequent heartburn for more than 3 months, heartburn while taking recommended dosages of nonprescription or prescription medicine, or heartburn that continues after 2 weeks of treatment.1
Since MG does not meet any of these exclusion criteria, she qualifies for self-treatment. Episodic heartburn can typically be treated with antacids or histamine h2 antagonists. However, MG has frequent heartburn (symptoms that appear more than 2 days per week), so she should take a proton pump inhibitor. She can try omeprazole 20 mg or an equivalent product every day for 14 days, taking 1 tablet with a glass of water before eating in the morning. Advise MG that she will need to take the medicine for 1 to 4 days to see maximal benefit. In addition, since MG never suffered from heartburn before beginning to eat spicy foods, avoiding these foods when possible may be the most effective way to prevent the burning. If MG’s heartburn persists despite 14 days of treatment, a physician should evaluate her and recommend a treatment course.
Case 2: Motion Sickness
GG comes to the pharmacy looking for something to treat her 8-year-old daughter LM’s motion sickness. They are going on a 5-day cruise to the Bahamas, and the last time LM went on a cruise she was nauseous for the first 2 days. On the third day, the captain gave LM some medicine that helped. GG does not remember the medication’s name but says it made her daughter drowsy. They considered not going on the cruise but decided they really wanted to visit the Bahamas. LM has no other medical conditions or allergies to medication, but GG says she does not swallow medication, so she needs a chewable formulation. What would you recommend for LM?
Since LM has nausea due to motion sickness, it may be beneficial to recommend nonpharmacologic in addition to pharmacologic self-treatment. Avoiding food before getting on a boat trip can help control motion sickness, but it would be difficult for LM to avoid food for 5 days. Nonetheless, it may be helpful to reduce the amount of food LM consumes per sitting. Staying toward the top of the ship, where the motion cannot be felt as strongly, and wearing an acupressure wristband may also help minimize LM’s symptoms.
Antihistamines are typically recommended to prevent motion sickness. There are many different formulations available, but most contain dimenhydrinate, diphenhydramine, or cyclizine. They are recommended for motion sickness in children 2 years and older (dimenhydrinate or diphenhydramine) and 6 years or older (cyclizine). Products such as meclizine should not be used in children younger than 12 years. Since LM needs a chewable formulation, you can give her dimenhydrinate 50 mg. She should take one-half to 1 chewable tablet every 6 to 8 hours. GG should not give LM more than 1.5 tablets in a 24-hour period unless her doctor instructs her to do so. The most common side effect of the medication is drowsiness.
Case 3: Pediatric Gas
LM is a 28-year-old man who comes to the pharmacy looking for something to help his 6-month-old baby boy with gas. He says his infant has been keeping him and his wife up at night. Previously, the baby slept through the night, but the past week has been horrible. The pediatrician said the baby is most likely teething, but said it is possible his fussiness is related to gas. The pediatrician recommended that LM pick up an over-the-counter treatment for gas to see if it would help. LM is overwhelmed by the number of products available as well as when to give them to his baby, but found a possible product that contains simethicone 20 mg. What would you recommend?
Gas is generally caused by swallowed air or undigested food. Infants typically cry and swallow more air, so they may be particularly prone to having gas. Over-the-counter products such as simethicone gas drops, which are safe for infants, contain 20 mg per 0.3 ml. Although these products have been marketed for decades for gas relief, their efficacy is questionable. One study reported that simethicone was not superior to placebo in preventing or treating gas.2
If LM chooses to try simethicone gas drops, his baby boy (who is under 2 years of age) should be dosed at 0.3 ml as needed. Gripe water, which usually consists of a mixture of herbs and water, is another over-the-counter remedy commonly used to treat gas. It is also said that the alcohol content of gripe water provides a soothing effect for colic.3
However, no clinical data support the use of gripe water. Since the baby may or may not have gas, it may be beneficial for LM to see whether the fussiness is related to teething before trying an over-the-counter medication. If LM feels that medication is necessary, he can try simethicone gas drops or gripe water to see if they produce any relief.
Case 4: Fiber Supplementation
GM is a 58-year-old woman who comes to the pharmacy to refill her medication for diabetes. She says she has recently started seeing a diabetes educator because her blood sugar level has been high. The educator wants her to lose weight and modify her diet, including increasing her fiber intake to 30 grams per day. She has tried to increase her fiber intake through dietary changes, but she is struggling to find products that contain fiber and has failed to reach her goal. A friend told her about over-the-counter psyllium fiber supplements, and she wants to know your thoughts on them. How would you counsel GM?
Most patients do not get adequate fiber from the foods in their diet. Fiber can safely be recommended in doses of 25 to 30 grams each day.4
Foods that are high in fiber include oats, barley, whole-grain cereals, brown rice, beans, peas, lentils, nuts, fruits, and vegetables. It may be helpful to give GM a list of high-fiber foods and ask her to recalculate her intake before trying the psyllium products. If GM continues to feel she cannot get adequate fiber from her diet, it may be helpful to recommend a psyllium fiber product such as Metamucil or an equivalent product.
It is important to stress that psyllium fiber products should be taken in addition to dietary fiber. In other words, the patient’s diet must include some fiber in order to reach 30 grams per day. Since psyllium fiber products come in many dosage forms, including powdered drinks, wafers, and capsules, patient preference should be considered. GM prefers the powder drink, so she should take 8 ounces of liquid 3 times daily. This will provide 3 grams of fiber per serving for a total of 9 supplementary grams of fiber per day. In addition, GM should be instructed to titrate from once daily to 3 times daily to avoid flatulence or abdominal pain.
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 Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.
Zweber A, Berardi R. Heartburn and dyspepsia. In: Krinsky DL, Berardi RR, Ferreri SP, et al (eds). Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2011.
Metcalf TJ, Irons TG, Sher LD, et al. Simethicone in the treatment of infant colic: a randomized, placebo-controlled, multicenter trial. Pediatrics. 1994;94(1):29-34.
Illingworth RS. Infantile colic revisited. Arch Dis Child. 1985,60:981-985.
American Diabetes Association. Carbohydrates. www.diabetes.org/food-and-fitness/food/what-can-i-eat/carbohydrates.html. Accessed May 17, 2013.