Craig I. Coleman, PharmD
Dr. Coleman is an assistant professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.
Heliobacter pylori Eradication
HP is a 42-year-old man who comes to the pharmacy counter at a major grocery store
pharmacy with prescriptions for clarithromycin 500 g twice daily, metronidazole 500
mg twice daily, and lansoprazole 30 mg twice daily for 14 days. HP had just come from
his physician's office across the street, where he was told that he was infected with a
bacterium called Helicobacter pylori. The pharmacist fills the prescription and starts
to counsel HP on the importance of completing the entire course of antibiotic therapy
when she notices a 6-pack of beer in HP's shopping cart.
What should the pharmacist do next? What would an alternative regimen contain?
Nasal Congestion
RM is a 33-year-old man who comes to the pharmacy counter with 2 boxes of phenylephrine
nasal drops. The pharmacy technician asks the patient if there is anything
else she can help him with today, and in a very congested voice, RM asks if he could
speak with a pharmacist. When the pharmacist comes over to the counter, RM asks
"are there any stronger nasal decongestants than these?" Upon questioning by the
pharmacist, RM admits to using the phenylephrine nasal drops for the past week or
so, noting "initially they worked great, but now not so much."
How should the pharmacist respond to RM's question?
ANSWERS
Heliobacter pylori Eradication
It is very important that the pharmacist make HP aware that it can be extremely dangerous to drink alcohol while taking metronidazole, because the 2 can
interact, resulting in severe nausea and vomiting, headache, abdominal cramps, flushing, and palpitations, and, in severe cases, may even be fatal (disulfiram-like reaction).
HP should be told not to consume alcohol (including from cough and cold preparations) for at least 3 days after he has completed therapy. A number of 2-antibiotic regimens,
along with a proton pump inhibitor or histamine-2 antagonist, have been studied to eradicate H pylori infections. Replacing the metronidazole in the above regimen with
amoxicillin 1 g twice daily results in an effective and commonly used regimen referred to as CAP and is marketed under the brand name Prevpac.
Nasal Congestion
The pharmacist should explain to RM that he is likely suffering from rebound congestion (rhinitis medicamentosa). This can occur due to prolonged (>3-5 days)
nasal decongestant use and often results in decreased benefit from the spray despite increased use. Treatment of rebound congestion entails either "cold turkey" withdrawal
or weaning off of the nasal decongestant. The former is generally a less comfortable method than the latter, but may result in relief of congestion faster (typically in 1-2 weeks).
If the pharmacist recommends weaning off of the nasal product, he should explain to RM that the nasal decongestant should be discontinued in only one nostril initially, with
continued use as often as desired in the other nostril. Once the rebound phenomenon subsides in one nostril, total drug withdrawal should then be suggested. The pharmacist
also could suggest that RM contact his physician to get a prescription for a nasal corticosteroid to use while weaning off of the nasal decongestant, as they have been shown
to increase the time to congestion relief.
