Case 1: Chronic Dry Cough
JV is a 55-year-old male who reports experiencing a bothersome dry cough for the past 3 months that hasn’t responded to any of the medications he’s tried, including cough suppressants and expectorants. He reports that his symptoms are worse at night and when lying in bed. He has a medical history significant for hyperlipidemia, hypertension, and gastroesophageal reflux disease, for which he takes simvastatin 20 mg daily, amlodipine 10 mg daily, chlorthalidone 50 mg daily, and omeprazole 40 mg daily. He has no known allergies to medications, but reports he was initially prescribed lisinopril for his blood pressure, which got changed to amlodipine once he experienced worsening cough. Is JV a candidate for self-care? What recommendations can you give him?
More than 23 million Americans each year see their physicians for evaluation and treatment of cough.1
Cough may be acute (lasting fewer than 3 weeks), subacute (lasting 3 to 8 weeks), or chronic (lasting longer than 8 weeks), and may be a symptom of myriad medical conditions, including viral or bacterial infections, asthma or chronic obstructive pulmonary disorder, heart failure, or sinusitis.2
Chronic cough is most often related to 3 specific medical conditions in adults: postnasal drip, asthma, or acid reflux.2
Postnasal drip is associated with accumulation of nasal secretions in the back of the throat, which can result in irritation and coughing. With asthma, airway constriction may be triggered by environmental exposure and may result in coughing, wheezing, or shortness of breath. Individuals with acid reflux experience a backflow of stomach acid into the esophagus that can result in chronic irritation of the throat and pharynx.2
In JV’s case, the duration of his cough and his history of reflux disease warrant that he be instructed to follow up with his primary care clinician for evaluation. Remind JV to continue to take his omeprazole as prescribed and implement nonpharmacologic strategies for symptom relief (eg, avoid eating within 2 to 3 hours of bedtime, avoid trigger foods and excessive alcohol, elevate the head of the bed 6 inches).3
Case 2: Prevention of Colds
EN is a 42-year-old female nursery school teacher who is seeking a recommendation for prevention of colds. She and her colleagues have been swapping home remedy secrets for keeping well, and she is interested in purchasing a high-dose vitamin C supplement because her friend reports “never getting sick” since taking this vitamin. EN has a penicillin allergy and a history of asthma, which is controlled with use of an inhaled steroid twice daily and her albuterol inhaler as needed. She also utilizes a triphasic hormonal oral contraceptive for birth control. What can you recommend to EN at this time? Is there evidence to support the use of vitamin C for prevention of the common cold?
Vitamin C supplementation for prevention and treatment of the common cold has been evaluated by more than 30 clinical trials in more than 10,000 patients, with ongoing debate as to its efficacy for alleviating symptoms of this common condition.4
The overwhelming evidence does not support the use of vitamin C supplementation as being effective for preventing symptoms of the common cold in adults, although oral supplementation of 2 g or more per day may decrease the duration of cold symptoms by 1 to 1.5 days.4,5
Other studies have failed to show any benefit of supplementation on duration of cold symptoms, even with doses up to 3 g per day.6
High-dose vitamin C, beyond its mixed efficacy results for reducing the duration of cold symptoms, may be associated with significant dose-related adverse effects, including nausea, vomiting, and heartburn; doses above 1 g per day may increase the risk of kidney stone formation.5
Further, large doses have been associated with deep vein thrombosis formation; a potential drug interaction between vitamin C supplementation and hormonal contraceptives may further increase this risk because vitamin C, when used concomitantly with estrogen therapies, may increase plasma estrogen levels by as much as 55%.5
Instruct EN that the data are not compelling to support routine supplementation with vitamin C and that her risk of adverse effects may outweigh any possible benefits; instruct her on good hand washing, the need for immunization, and other best practices for infection control to keep her well during cold and influenza season.
Case 3: Symptom Relief
GN is a 57-year-old businessman who comes to the pharmacy seeking a recommendation for symptom relief. He is traveling tomorrow morning and describes suffering from a constellation of symptoms, including itchy, red, irritated eyes; sneezing; nasal irritation; and a dry cough, all of which have kept him awake the past few evenings. He does not want to be bothered by these symptoms while away. He reports experiencing similar symptoms each fall but has never had a medical evaluation for these complaints, as they seem to subside in 2 to 3 weeks. He has no known medication allergies but is diabetic and takes insulin for glycemic control, an angiotensin-converting enzyme inhibitor for blood pressure and kidney protection, and a low-dose aspirin each day. What condition is GN most likely suffering from? What OTC remedy or remedies can be recommended for symptomatic relief?
GN’s ocular and nasal symptoms and cough secondary to postnasal drip are all characteristic complaints of seasonal allergic rhinitis. Symptoms of allergic rhinitis can be classified as seasonal or perennial and mild to severe.7
The most common symptoms of this bothersome condition include pruritus of the eyes, nose, and/or mouth; runny nose; watery eyes; and congestion. Symptoms may be alleviated in part by allergen avoidance: avoiding triggers and irritants known to exacerbate symptoms.8
From a pharmacologic standpoint, the use of oral antihistamine therapy represents a reasonable OTC treatment option for mild, intermittent relief of allergic rhinitis symptoms. These agents work by blocking the allergic activity of histamine from binding to H1 receptors.
Based on the type of symptoms (eg, ocular and nasal irritation), GN would benefit from recommendation of an OTC second-generation antihistamine, such as cetirizine (Zyrtec; McNEIL-PPC, Inc), loratadine (Claritin; MSD Consumer Care, Inc), or fexofenadine (Allegra; Chattem, Inc). These agents can be taken on a daily basis, as long as symptoms persist, or as needed for symptomatic relief; the most recent guidelines suggest the use of these agents over first-generation antihistamines, such as diphenhydramine, due to their favorable efficacy and reduced risk of sedation.7,8
Counsel GN on the potential side effects, most notably sedation, associated with the use of these agents, particularly if cetirizine is recommended.
Case 4: Nasal Congestion
RD is a 32-year-old female who is seeking the advice of her pharmacist. She has a 6-week-old daughter and reports suffering from unbearable nasal congestion for the past few days, which she attributes to a change in the weather. She is concerned about which OTC decongestants are safest for her to use while she is breast-feeding and would like a recommendation for symptomatic relief. She has no known allergies to medication and reports taking only a prenatal vitamin once daily along with ibuprofen or acetaminophen as needed for pain relief. What OTC product and self-care advice can you recommend to RD at this time?
Managing nasal congestion can be particularly challenging, especially if an affected woman is pregnant or lactating. As a general treatment approach, recommendation of nonpharmacologic therapies to afford symptomatic relief without systemic effects is a prudent option for this patient population.
In the case of RD, getting adequate rest, ensuring adequate hydration, and using a humidifier or increasing humidification by taking a hot shower are all nondrug strategies that may mitigate cold symptoms and alleviate RD’s nasal congestion.9
Additionally, use of an isotonic or a hypertonic saline nasal spray several times throughout the day may alleviate her nasal irritation and provide a local, temporary anti-inflammatory effect in the upper airways. For pharmacologic relief, RD could consider use of an intranasal or systemic decongestant. For systemic treatment, pseudoephedrine is generally considered safe and preferred. For topical relief, intranasal oxymetazoline or phenylephrine is also poorly absorbed and is considered safe to recommend.9
Remind RD that use of these agents should be limited to 3 to 5 days to reduce the risk of rebound congestion. Use of decongestant therapy may also result in a reduction in milk production by reducing serum prolactin levels; this risk is greatest with systemic therapy.10
Mothers should be cautioned to monitor their milk supply and keep hydrated to minimize this effect; mothers whose milk supply is not yet established or who have difficulty with milk production should consider an alternate therapy.11
Dr. Bridgeman is an internal medicine clinical pharmacist in New Brunswick, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.
Mayo Clinic finds effective test to determine treatment for chronic cough. www.eurekalert.org/pub_releases/2006-09/mc-mcf082906.php. Accessed September 16, 2013.
Chung KF, Pavord ID. Prevalence, pathogenesis, and causes of chronic cough. Lancet. 2008;371:1364-1374.
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.
Hemilä H, Chalker E, Douglas B. Vitamin C for preventing and treating the common cold. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD000980. DOI: 10.1002/14651858.CD000980.pub3.
Vitamin C (ascorbic acid). Natural Medicines Comprehensive Database [Internet]. http://naturaldatabase.therapeuticresearch.com/nd/Search.aspx?cs=&s=ND&pt=100&id=1001&fs=ND&searchid=43500628. Accessed October 17, 2013.
Audera C, Patulny RV, Sander BH, Douglas RM. Mega-dose vitamin C in treatment of the common cold: a randomized controlled trial. Med J Aust. 2001;175:359-362.
Brozek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic rhinitis and its impact on asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126:466-476.
Bahls C. In the clinic: allergic rhinitis. Laine C, Goldman DR, Wilson JF, eds. Allergic rhinitis. Ann Intern Med. 2007;146:ITC4-16.
Scolaro KL. Disorders related to colds and allergy. 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.
Aljazaf K, Hale TW, Ilett KF, et al. Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin Pharmacol. 2003;56:18-24.
Drugs and Lactation Database. National Library of Medicine. http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT. Accessed September 16, 2013.