Case 1: Overactive Bladder
BJ is a 68-year-old female inquiring about a treatment for urinary incontinence. BJ reports that she has been using panty liners for several months due to urine leakage when she coughs, sneezes, or exerts herself. She recently saw an advertisement for a new OTC product for overactive bladder (OAB) and would like to know whether she could use the product. BJ has hypertension, diabetes, gastroesophageal reflux disease, and arthritis and takes lisinopril/hydrochlorothiazide 20/25 mg daily, glyburide/metformin 5/500 mg twice daily, omeprazole 40 mg daily, and acetaminophen 650 mg as needed for pain. She has no known allergies. How should BJ self-treat her symptoms?
OAB is characterized by urinary urgency, with or without incontinence, and by increased urinary frequency and nocturia.1
This condition occurs more frequently in women than in men. OAB should not be regarded as a normal part of aging and should be evaluated in patients of all ages who present with symptoms that affect their daily activities and quality of life.2
If an underlying drug or medical condition is identified as a cause of symptoms, the condition should be recognized and treated.3
It is prudent to ask BJ about her antihypertensive regimen and remind her to take her lisinopril/hydrochlorothiazide early in the day to alleviate nocturnal symptoms. Lifestyle modifications (fluid consumption, avoiding caffeine and alcohol) and behavioral therapy (pelvic floor muscle exercises) should be initiated in patients with OAB. These interventions in conjunction with pharmacotherapy may result in synergistic symptomatic improvement.
The OTC oxybutynin transdermal patch is an option for women who have had OAB symptoms for at least 3 months. The patch is applied to clean, dry, unbroken skin for 4 days at a time. Based on BJ’s episodic symptoms of incontinence associated with sneezing and coughing, which are consistent with stress incontinence, the patch is not a prudent option; advise BJ to follow up with her primary care provider.4
Case 2: Pain Management for Arthritis
UR is an 83-year-old female looking for a recommendation regarding OTC pain medication. Upon questioning, she states that the arthritis pain in her hand joints is noticeably worse in cold weather and that she is looking for something stronger than the acetaminophen she has been taking for pain relief. She currently takes aspirin 81 mg, clopidogrel 75 mg, atorvastatin 40 mg, and ramipril 2.5 mg daily, and metoprolol 12.5 mg twice daily; she has no known medication allergies. What therapeutic alternatives for pain relief can UR consider?
Osteoarthritis is characterized by destruction of cartilage between joint spaces, usually affecting the hip, knee, lower back, and hands, resulting in alterations in the architecture of these spaces.5
The pain associated with osteoarthritis is usually dull, localized to the affected joints, and accompanied by joint stiffness, and is estimated to affect more than 27 million Americans.6
Pain management approaches aimed at alleviating the pain and stiffness associated with this condition involve nonpharmacologic and pharmacologic therapies. Nonpharmacologic strategies to provide relief of osteoarthritis pain include exercising the affected joints to increase lubrication and to help strengthen the affected muscle and ligament groups surrounding the affected area. Topical counterirritants, which exert their analgesic effect by stimulating a local inflammatory reaction, represent reasonable alternatives to consider in patients unable to tolerate other pharmacologic treatment options. OTC agents in this class include ingredients such as methyl salicylate, camphor, menthol, and capsicum, all of which may provide temporary localized pain relief and need to be reapplied 3 or 4 times daily. Systemic analgesics, including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), represent the next step in pharmacologic treatment of pain. Scheduled, rather than as needed, use of these products may provide more adequate relief of pain for individuals with chronic symptoms.5
Based on her antiplatelet agent use and presumed underlying cardiac condition, UR is not a candidate for OTC NSAID use at this time. She can consider use of topical OTC analgesic creams or should be referred to her primary care provider for a prescription-only alternative (eg, tramadol, opioid) for pain relief.
Case 3: Sleep Aids
WD is an 81-year-old man seeking a pharmacist’s advice on what he can do to sleep better. He reports having difficulty falling asleep and staying asleep throughout the night, the latter of which he attributes to frequent urination during the night. He has a history of heart failure, hypertension, and diabetes, for which he has been prescribed furosemide 20 mg, metolazone 10 mg, metoprolol succinate 50 mg, and insulin glargine 20 units subcutaneously once daily, respectively. On questioning, he denies having prostate issues; however, he doesn’t recall whether his prostate health has ever been evaluated by his primary care provider. What recommendations can you give WD to improve his sleep behaviors?
Insomnia, one of the most common sleep disorders, can be characterized by abnormal sleep behaviors including difficulty falling or staying asleep, early morning awakening with trouble falling back asleep, and disturbed quality of sleep.7
This condition is particularly prevalent in the elderly, with an estimated 50% of adults older than 65 years having symptoms.8
Treatment of insomnia includes environmental and behavioral modification in conjunction with judicious use of pharmacologic therapies.
A comprehensive medication profile review may reveal medications attributable to symptoms of insomnia. In the case of WD, inquiring about the use and timing of his diuretic medications may help to ascertain whether they may be contributing to nocturnal symptoms. Educate WD on best practices to ensure optimal sleep hygiene (eg, establish a sleep schedule; ensure a comfortable environment for sleep; avoid daytime napping, stimulants like caffeine, or clock watching if you can’t fall asleep) and encourage a trial of behavior modification before initiating drug therapy.7,8
OTC treatments for insomnia fall into two categories: antihistamines and complementary or herbal supplements. Given WD’s unclear medical history regarding his prostate health, avoidance of antihistamine-containing OTC sleep aids would be reasonable at this time. Encourage medical evaluation in lieu of a trial using an herbal supplement because of issues regarding quality control, timing of administration, dosing, and clinical efficacy.
Case 4: Herbal Supplement Use for Memory
EB is a 65-year-old female who would like to know which herbal products can improve memory. She reports experiencing occasional episodes of forgetfulness (eg, “I can’t find my keys!”), which she attributes to long days and busy hours at the office and is looking for a natural product to help boost her memory and energy level. She has no known medication allergies and reports taking a daily senior multivitamin and an OTC omega-3 fish oil supplement for cholesterol and heart health. Is EB a candidate for an herbal supplement for memory loss at this time?
Numerous herbal supplements, including huperzine, ginkgo, and choline, have been touted to treat age-related memory loss. Of these agents, ginkgo leaf has the most clinical evidence and data to support its safety and efficacy for this indication.9
The ginkgo leaf and its extracts contain several different flavonoids, including isorhamnetin, quercetin, and proanthocyanidins, which are touted to scavenge free radicals and to function as antioxidants to reduce oxidative stress in the central nervous system. The chemicals known as the terpenoids, the ginkgolides, and bilobalide function to competitively inhibit platelet aggregation and reduce free radical production. These compounds may work synergistically to reduce inflammation and increase cerebral blood flow and thus may be attributed to ginkgo’s efficacy on memory and cognitive function in elderly patients with mild to moderate age-related memory impairment.9
Like all supplements and drug products, ginkgo is not without risk. Although this agent is generally well tolerated when administered by mouth, side effects can include headache, gastrointestinal upset, dizziness, heart palpitations, increased bleeding risk, and allergic skin reactions.9
Individuals using anticoagulants, antiplatelets, or NSAIDs should be counseled on the potential for an increased risk of bleeding when using ginkgo due to its platelet-inhibiting properties. Further, individuals with seizure disorders should use ginkgo with extreme caution; ginkgo seeds contain ginkgotoxin, a compound associated with reduction of the seizure threshold at high doses.9
In the case of EB, given her limited medical history and use of few other concomitant medications, a trial of a ginkgo leaf supplement at a dose of 120 to 240 mg per day, divided into 2 or 3 doses, may be reasonable.9
Encourage her to discuss her symptoms with her physician at her next appointment.
Dr. Bridgeman is an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital, New Brunswick, New Jersey, and clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers University. Dr. Mansukhani is a clinical pharmacist at Morristown Medical Center in Morristown, New Jersey, and clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers University.
Abrams P, Artibani W, Cardozo L, et al. Reviewing the ICS 2002 Terminology Report: the ongoing debate. Neurourol Urodyn. 2009;28:287.
Sexton CC, Coyne KS, Thompson C, et al. Prevalence and effect on health-related quality of life of overactive bladder in older Americans: results from the epidemiology of lower urinary tract symptoms study. J Am Geriatr Soc. 2011;59:1465-1470.
Ouslander JG. Management of overactive bladder. N Engl J Med. 2004;250:786-799.
Oxytrol for Women package label. www.Oxytrolforwomen.com/pdf/OXYTROL_LABEL_HORIZONTAL_v2.pdf. Accessed December 3, 2013.
Olenak JL. Musculoskeletal injuries and disorders. 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.
What is osteoarthritis? Arthritis Foundation website. www.arthritis.org/what-is-osteoarthritis.php. Accessed December 3, 2013.
Kirkwood CK, Melton ST. Insomnia, drowsiness, and fatigue. 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.
Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. Am J Med. 2006;119:463-469.
Ginkgo. In: Natural Medicines Comprehensive Database. www.therapeuticresearch.net. Stockton, CA: Therapeutic Research Faculty; c1995-2013. Accessed December 5, 2013.