A Pharmacist's Guide to OTC Therapy

Yvette C. Terrie, BSPharm, RPh
Published Online: Tuesday, May 1, 2007
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Antiemetics

Because nausea and vomiting are symptoms of various medical conditions, the objectives for treating them should include identifying the underlying cause as well as providing symptomatic relief. The 3 most prevalent causes of nausea and vomiting are motion sickness, morning sickness associated with pregnancy, and viral gastroenteritis. Examples of other causes include stress, certain medications, food poisoning, certain disease states, and abdominal distention due to overeating.1

Treatment

OTC antiemetics should be used only to prevent or treat the symptoms of mild, occasional, self-treatable episodes of nausea and vomiting. Products available for the treatment of these conditions include antihistamine products, bismuth subsalicylate, antacids, histamine2 antagonists, and phosphorated carbohydrate solution. Also available for the treatment of nausea are nondrug products such as the Sea-Band wristband, which utilizes the principles of acupressure. In addition, complementary products such as ginger, peppermint, and chamomile are utilized for the treatment of nausea and vomiting.1

OTC antihistamines are indicated for the prevention and treatment of nausea, vomiting, and dizziness associated with motion sickness (Table 1). It is recommended that antihistamines be taken at least 30 to 60 minutes before travel starts to allow sufficient time for the onset of action and for the continuation of the action during travel. Patients should be informed of the adverse effects, such as drowsiness, blurred vision, dry mouth, and urinary retention. Patients with certain medical conditions (eg, asthma, narrow-angle glaucoma, benign prostatic hypertrophy) should be advised not to use these products unless directed by their physician.1

Patients should be made aware of the increased sedative effect that may occur when antihistamines are used in conjunction with central nervous system depressants, such as alcohol, tranquilizers, and hypnotics. Caregivers should be informed that the use of antihistamines may cause paradoxical stimulation in children and agitation and confusion among geriatric patients.1

Key Counseling Points

Whereas many cases of nausea and vomiting are mild and self-treatable, they sometimes can be symptoms of more serious medical conditions, such as intestinal blockage, appendicitis, and migraine headaches. Individuals with chronic medical conditions always should be referred to their physicians for the management of nausea and vomiting. Therefore, prior to recommending any of the OTC products, it is imperative that pharmacists ascertain whether self-treatment is appropriate (Table 2).

Pharmacists should ensure that patients clearly understand the proper use of the OTC products and that they should seek immediate medical care if the nausea and vomiting is prolonged (lasting >24-48 hours) or if symptoms worsen. When appropriate, pharmacists also can encourage patients to drink clear liquids such as electrolyte-replacement solutions (eg, Pedialyte) and maintain fluid intake to avoid possible dehydration. Pregnant or lactating women experiencing nausea and vomiting should always consult their physicians prior to using any medication.

Pharmacists also can play a key role in assisting pediatric patients, because antihistamine products, such as dimenhydrinate and diphenhydramine, should not be used by children under the age of 2. Cyclizine should not be used by children under the age of 6, and meclizine should not be used by children under the age of 12.1 In addition, bismuth subsalicylate should not be used in children under the age of 12.

Pharmacists can have a vital role in identifying possible contraindications and drug interactions in individuals with preexisting medical conditions and in those currently taking other medications. Those patients should be encouraged to consult their primary health care provider prior to using any of the products. Because possible dehydration and electrolyte imbalance are common concerns with episodes of vomiting, patients, especially pediatric patients, should be assessed for signs of dehydration and should be encouraged to seek medical attention when warranted. Please visit www.pharmacytimes.com for a table giving examples of signs of dehydration in children.


Heartburn Products

Pyrosis, commonly known as heartburn, typically is characterized by a burning or painful sensation in the substernal area that radiates toward the neck or throat. Heartburn occurs when the lower esophageal sphincter does not open and close properly, thus allowing the reflux of gastric juices into the esophagus.1,2

Many individuals who experience infrequent mild-to-moderate episodes of heartburn can be treated effectively with OTC medications, in conjunction with lifestyle modifications. Heartburn that is recurrent and persistent (for =3 months) however, may be a symptom of gastroesophageal reflux disease, which, if left untreated, can cause long-term complications, such as esophagitis, gastrointestinal bleeding, Barrett's esophagus, and esophageal cancer.1,3 It is essential that pharmacists encourage individuals who experience severe symptoms to seek medical care immediately (Table 1).

Causes of Heartburn

The severity and frequency of heartburn are different for every individual. Common risk factors are as follows1,4:

  • Certain foods and beverages (eg, tomato sauce, chocolate, peppermint, coffee, alcohol, carbonated beverages, spicy or fatty foods)
  • Overeating
  • Eating <2 hours before bedtime
  • Reclining too soon after eating
  • Pregnancy
  • Smoking
  • Excessive weight
  • Certain medications (Table 2)
  • Stress
  • Certain disease states (scleroderma, peptic ulcer disease, Zollinger-Ellison syndrome)

Pharmacologic Therapy

Currently a variety of OTC products are available for the treatment of mild-tomoderate heartburn (Table 3). Please visit www.pharmacytimes.com for a more complete table.

Bismuth subsalicylate, found in brand name products such as Pepto-Bismol or newer products such as Maalox Total Stomach Relief, also is approved for heartburn.

Pharmacists can assist patients in the selection of products by carefully assessing the nature of the patients'symptoms as well as the frequency and duration of episodes.

They should ascertain the appropriateness of self-treatment and screen for possible drug-drug interactions or contraindications. They should encourage individuals with preexisting medical conditions, pregnant or nursing women, and patients <12 years of age to seek advice from their primary health care provider.

Pharmacists should inform patients utilizing OTC products to seek immediate medical care if their symptoms worsen or if they show no signs of improvement after 14 days. These products should not be used for more than 2 weeks unless directed by a physician. In addition to counseling patients on the appropriate use and adverse effects associated with the use of these products, pharmacists should counsel patients on possible nondrug measures that can be incorporated into their treatment plans, such as modifications to diet and lifestyle.

For more information on heartburn, visit the following Web sites:

National Heartburn Alliance: www.heartburnalliance.org

National Digestive Diseases Information Clearinghouse: www.digestive.niddk.nih.gov

American College of Gastroenterology: www.acg.gi.org


Oral Care Products

Good oral hygiene is a fundamental component of overall health. The 2 most common oral health problems are dental caries (tooth decay) and periodontal disease (gum disease; Table 1). Other oral health problems include formation of plaque and tartar, halitosis, discomfort for denture wearers, and tooth sensitivity.

Gum Disease

It is estimated that 80% of adults in the United States have some degree of periodontal disease.1-3 This disease can range from gingivitis, which is the mildest form and is reversible, to periodontitis, which can result in irreversible major damage to soft tissue and the bone structure of the teeth. Periodontitis is considered to be the primary cause of tooth loss among adults >45 years of age.1 Furthermore, the results of several studies suggest that periodontal disease may exacerbate certain health conditions, including stroke, cardiovascular disease, and respiratory disease and can lead to giving birth to preterm low-weight babies.2-5

In addition, more than 90% of all systemic diseases have oral manifestations, and many diseases can be diagnosed in their early stages through an oral examination.2 The goals of proper oral hygiene are removing or preventing plaque and tartar buildup, preventing dental caries and gingivitis, and decreasing the incidence of halitosis.

Currently a plethora of oral care products are on the market. Dentifrices are available in various formulations, which include antiplaque/antigingivitis, tartar control, sensitive teeth, and whitening products. Also available are various flossing products, topical fluoride products, and cosmetic and therapeutic mouth rinses (Table 2).

The Role of the Pharmacist

Pharmacists are in a crucial position to increase awareness regarding the benefits of good oral health care (see sidebar). They can emphasize the importance of adhering to a daily preventive oral care regimen, as well as being a source of information on the selection and proper use of OTC oral hygiene products.

Through routine monitoring, pharmacists can recognize patients who may be susceptible to dental problems associated with certain medical conditions. Some medications also can cause adverse dental effects, such as xerostomia, tooth discoloration, abnormal bleeding, or inflammation of the gum tissue. Pharmacists should recommend that patients seek advice from a dental professional when warranted.

Ms. Terrie is a clinical pharmacy writer based in Haymarket,Va.

For more information on oral health care, visit the following Web sites:

American Dental Association: www.ada.org

Centers for Disease Control 2007 Report on Oral Health: Preventing Cavities, Gum Disease and Tooth Loss: www.cdc.gov/nccdphp/publications/aag/oh.htm

Academy of General Dentistry: www.agd.org

National Institute of Dental and Craniofacial Research: www.nidr.nih.gov (site maintained by the National Institutes of Health)


References

Antiemetics

1. McWhorter LS, Fermo J. Nausea and vomiting. In: Berardi RR, Kroon LA, McDermott JH, et al, eds. Handbook of Nonprescription Drugs, 15th ed. Washington, DC: American Pharmacists Association; 2006: 381-401.

2. Nausea and vomiting. Medline Plus. Available at: www.nlm.nih.gov/medlineplus/ency/article/003117.htm.

Heartburn Products

1. Zweber A, Berardi RR. Heartburn and dyspepsia. In: Berardi RR, Kroon LA, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 15th ed. Washington, DC: American Pharmacists Association; 2006. Chapter 14.

2. Berardi R, et al. Medications That May Contribute to Heartburn. National Heartburn Alliance Web site. Available at: www.heartburnalliance.org/nosection/medthatcontribute.jsp.

3. Long-term complications of GERD. The Cleveland Clinic Health Information Center Web site. Available at: www.clevelandclinic.org/health/health-info/docs/2500/2565.asp?index=9615.

4. Get Heartburn Smart: Self Care Strategies for Heartburn Sufferers. National Heartburn Alliance Web site. Available at: www.heartburnalliance.com/brochure.pdf.

5. www.drugstore.com.

Oral Care Products

1. Klasser G, Colvard M. Prevention of hygiene related oral disorders. In: Berardi RR, Kroon LA, McDermott JH, et al, eds. Handbook of Prescription Drugs, 15th ed. Washington, DC: American Pharmacists Association; 2006:649-676.

2. The importance of oral health. Academy of General Dentistry Web site. Available at: www.agd.org/consumer/topics/overallhealth/main.asp.

3. Billingsley J. Gum Disease Can Harm Much More Than Your Teeth. MedicineNet Web site. Available at: www.medicinenet.com/script/main/art.asp?articlekey=62522.

4. Controlled Diabetics Have New Reason to Smile. American Academy of Periodontology Web site. Available at: www.perio.org/consumer/diabetes.htm.

5. New Study Confirms Periodontal Disease Linked to Heart Disease. American Academy of Periodontology Web site. Available at: www.perio.org/consumer/bacteria.htm.




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