Case 1: Seasonal Allergies
GR is a 38-year-old female who comes to the pharmacy complaining of a runny nose, congestion, and sneezing. She says her allergies have been acting up the last few weeks. She is currently taking cetirizine (Zyrtec) 10 mg daily, with no relief. She says she normally uses cetirizine and it controls her symptoms, but for a few weeks in the season, her symptoms are bad and cetirizine does not help. She has been diagnosed with seasonal allergies, and high pollen counts worsen her allergies. She denies having a fever and does not have other complaints at this time. What recommendations do you have for GR?
GR is suffering from seasonal allergies. When oral antihistamines such as cetirizine are not controlling symptoms, it may be beneficial to use another class of agents. Nasacort Allergy 24HR (triamcinolone acetonide) is now available over the counter for patients 2 years and older. Corticosteroids is the most effective class for treating moderate to severe allergies.1
Nasacort is a nasal formulation with minimal adverse effects compared with those of systemic corticosteroids. GR should be counseled on how to administer the medication and instructed to shake it with each use. Priming is only recommended when the bottle is new or the nasal spray has not been used for more than 2 weeks. Adults 12 years and older should use it once daily, spraying 2 times into each nostril while sniffing gently.
Once the allergy symptoms improve, GR should be instructed to reduce the dose to 1 spray in each nostril per day. She can continue to take cetirizine with Nasacort until symptoms have resolved. Once the pollen count decreases, she can go back to once-daily cetirizine and can use Nasacort when her symptoms are not controlled by cetirizine. Because Nasacort is a corticosteroid, parents of children younger than 12 years should be educated that using it for more than 2 months should be discussed with a physician because it can affect growth rates in some children.
Case 2: Perennial Allergies and Asthma
NN is a 24-year-old female who comes to the pharmacy complaining of runny nose, congestion, watery eyes, and shortness of breath. She says she has been having difficulty breathing the past few days because her allergies have gotten so bad. She says she is allergic to dust and has not needed to take anything for it in the past. She was first diagnosed with her dust allergy when she was diagnosed with asthma as a child. She is usually careful not to expose herself to dusty areas, but the past few weeks, she has been cleaning houses and her allergies have gotten worse. She is currently taking Advair (fluticasone/salmeterol) and using an albuterol inhaler as needed. She denies taking anything for her allergies and has not tried anything. She claims she has used her albuterol around the clock for the past few days but feels her shortness of breath is not improving. She is looking for something to treat her dust allergy. What recommendations would you have for NN?
NN appears to be suffering from allergies and asthma. Her asthma may not be controlled because her allergies have worsened. Therefore, NN should be referred to a physician for evaluation of her asthma and shortness of breath. Many patients suffer from both allergies and asthma. It is important to remember than when patients have shortness of breath or wheezing, they should be instructed to get medical care immediately. NN should also be educated on allergy avoidance. If possible, she should avoid cleaning houses because it predisposes her to more dust. She should be educated to seek immediate medical care if her shortness of breath does not improve after she uses albuterol. Other patients who would not be candidates for self-treatment of allergies include children younger than 12 years, pregnant or lactating patients, patients who appear to have an infection, or patients who use an OTC medication that is not effective or causes side effects.2
Case 3: Asthma
MG is a 30-year-old female who comes to the pharmacy looking for an OTC product for her asthma. She says a few years ago she was using a product called Primatene Mist. At that time, her asthma symptoms were controlled and she did not experience any shortness of breath. Because the product went off the market, her doctor put her on fluticasone propionate (Flovent) and albuterol sulfate (ProAir HFA). She says she went traveling through Europe last month and lost her albuterol inhaler. She has been using her fluticasone for the past month when she is short of breath; however, she is still having symptoms. She experiences shortness of breath once every few weeks. She wants to see if Primatene Mist was replaced by another OTC product because she does not want to make a doctor’s appointment. What would you recommend to MG?
Primatene Mist was taken off the market on December 31, 2011, to phase out chlorofluorocarbons in inhalers. In 2013, Primatene Mist was reformulated into Primatene Mist HFA. In February 2014, the FDA’s Nonprescription Drugs Advisory Committee and the Pulmonary-Allergy Drugs Advisory Committee evaluated the data on Primatene Mist HFA. Eighteen members of the advisory committee voted against granting marketing approval for OTC use of Primatene Mist HFA due to safety concerns with self-treatment of asthma and using the device.
Therefore, MG should be educated that nothing is available over the counter for her symptoms. She should be educated to use fluticasone daily to prevent shortness of breath instead of waiting to use it when she is already short of breath. She should have a short-acting beta-agonist to control her shortness of breath. She should be referred to her primary care physician to obtain a prescription for albuterol and instructed to use albuterol only when short of breath. If MG continues to have shortness of breath, additional drug therapy or increasing her dose of fluticasone may be necessary.
Case 4: Fish Oil for Asthma?
NS is a 31-year-old female who comes to the pharmacy looking for fish oil. She states she is very health conscious and exercises daily. She was diagnosed with asthma as a child but has not needed to take anything for it in years. She claims she just started working out again and wants to train for a marathon. She has been running 3 to 5 miles a day and occasionally feels short of breath. On average, she is short of breath 2 times a week.
Her mother told her that she saw on the news that fish oil is recommended for asthma patients. Her mom said all her friends take fish oil and that NS should start as well. NS has heard of fish oil being used for high triglyceride levels, but never for asthma. Because her mother said it might work, NS thought she would try it for a few weeks to see if it improves her symptoms. Even if it does not improve her shortness of breath, she says she may continue to take it for overall health. What recommendations would you have for NS?
Omega-3 fatty acids can have some antiinflammatory effects. Some evidence shows that fish oil may improve peak flow and reduce medication use in pediatric patients. In adults, “Fish oil does not improve forced expiratory volume in 1 second (FEV1), peak flow rate, asthma symptoms, asthma medication use, or bronchial hyperreactivity.” 3
Even though there is no evidence to support the use of fish oil in asthma patients, NS can be instructed to eat 1 to 2 servings of fatty fish to increase her fish oil levels for overall health. Because NS just started exercising again, a physician should evaluate her for exercise-induced asthma. Because she is experiencing shortness of breath 2 times a week, a physician may prescribe a preventive medication for use prior to exercise.
Dr. Mansukhani is clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers University, and transitions of care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey. Dr. Bridgeman is clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers University, and internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.
Bousquet J, Khaltaev N, Cruz AA, et al. ARIA (allergic rhinitis and its impact on asthma) 2008 update (in collaboration with the World Health Organization, GA2LEN and AllerGen). Allergy. 2008;63(suppl 86):8-160.
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.
Woods RK, Thien FC, Abramson MJ. Dietary marine fatty acids (fish oil) for asthma in adults and children. Cochrane Database Syst Rev. 2002;(2):CD001283.