Case 1: Fungal Infection
JM is a 67-year-old male complaining of painful white lesions in his mouth and on his tongue that occasionally bleed when he pokes or scrapes them with his toothbrush. He first noticed symptoms several days after starting a new inhaler medication to control his chronic obstructive pulmonary disease (COPD). He has never experienced symptoms like this in the past and would like a recommendation for an OTC product to get rid of them. He has a history of diabetes, hypertension, chronic kidney disease, and COPD, for which he takes aspirin 81 mg, atorvastatin 20 mg, lisinopril 20 mg daily, amlodipine 5 mg daily, glipizide XL 10 mg once daily, tiotropium 18 mcg once daily, fluticasone/salmeterol 250/50 mcg twice a day, and albuterol 2 puffs every 4 hours as needed for shortness of breath; he has no known medication allergies. Is JM a candidate for self-care? What treatment options can you recommend?
JM’s symptoms are consistent with the presentation of oral thrush, which is characterized by overgrowth of Candida albicans
fungal species in the mouth. This condition is likely to affect individuals who are immunocompromised, wear dentures, or use inhaled corticosteroids.1
Symptoms of thrush can include cottage cheese–like, white discolorations or plaques on the mouth structures, oral pain, minimal bleeding with irritation, taste disturbances, or difficulty swallowing if the lesions have spread and have affected the esophagus.1
JM’s risk factors for developing thrush may include recently starting a combination inhaled corticosteroid/long-acting beta2
-agonist for the treatment of COPD and having diabetes, poor control of which may result in this infection.
Counsel JM to avoid self-care at this time and to follow up with his primary care provider, as JM will likely need a topical oral antifungal agent, such as clotrimazole troches, available by prescription only, to cure this condition. Salt water gargles are the safest remedy for providing some symptomatic relief while waiting to see his physician. Take this opportunity to reinforce proper inhaler technique, including the importance of rinsing the mouth after each use.
Case 2: Omega-3 Fatty Acid Supplementation
TJ is a 45-year-old male who is seeking information on omega-3 fatty acids. He’s heard and seen a lot of news extolling the benefits of the omega-3s for heart health is and wondering if supplementation is a natural way for him to lower his cholesterol without medications. TJ has a sulfa allergy and is currently taking atorvasta- tin 40 mg once daily for dyslipidemia, lisinopril 40 mg daily and chlorthalidone 50 mg daily for hypertension, and escitalopram 10 mg daily for depression. What can you recommend for TJ? What information can you give him about the benefits of dietary intake and supplementation with omega-3 fatty acids?
Omega-3 fatty acids have received much attention in the press and been the subject of several large-scale clinical research studies on heart health and cholesterol reduction in recent years. The major dietary forms of this type of fatty acid include docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), and alpha-linolenic acid (ALA). DHA and EPA are primarily found in animal products, particularly from dietary seafood sources (oily fish and shellfish) and from fish oil capsules. ALA is more often derived from vegetable oils and dietary sources such as flax seeds, walnuts, and dairy products. Omega-3 fatty acids may reduce triglycerides and blood pressure and improve immune function, among many other potential health bene- fits. Consuming 1 or 2 servings of fish per week may additionally reduce the risk of heart disease, particularly sudden cardiac death.
Much like the use of vitamin and mineral supplements for promoting health and wellness, it is generally recognized that dietary intake of the omega-3 fatty acids has been shown to have a benefit in promoting cardiac wellness, while the benefits of omega-3 supplements to the diet remain less certain. The Dietary Guidelines for Americans, 2010, has been updated to include a recommendation that most American adults should consume 8 or more ounces of seafood per week to ensure adequate intake of these heart-healthy nutrients; pregnant women and children usually require less than this amount.2
A recent study published in 2012 found that supplementing EPA and DHA may not have the same protective effect on heart function as food sources of these nutrients.3
For TJ, counsel him on the importance of dietary consumption and on foods rich in omega-3s for heart health promotion.
Case 3: 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, 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.4
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.5
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.4
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 4: Anxiety
GM is a 38-year-old female who comes to the pharmacy looking for something natural to control her anxiety. She says she becomes anxious from time to time and feels like she wants to take something to control her anxiety. She says her anxiety is mild according to her doctor. Typically, her anxiety occurs when she is in social situations. GM usually starts sweating and gets tachycardia when she is around people she doesn’t know. She is very embarrassed because most people can tell that she is acting oddly. Her doctor recommended that she try relaxation techniques. GM says that her next-door neighbor takes kava for anxiety. The neighbor said that kava is the natural solution to anxiety and that GM should try it. The neighbor said that kava doesn’t have the scary side effects that prescription medications have. GM has no other medical conditions and takes no other medication. She has no other complaints. What are your recommendations for GM regarding her anxiety?
It appears that GM suffers from social anxiety disorder. The evidence supporting the use of kava is conflicting. Some studies have shown improvement of mild anxiety in patients who took kava; however, there have not been studies in patients with social anxiety. It is important to educate GM that although kava may help her neighbor, it may not necessarily help GM’s type of anxiety. GM should be made aware that kava could increase her risk for liver toxicity. On August 20, 2013, the FDA issued a statement that included the following: “Kava-containing products have been associated with liver-related injuries, including hepatitis, cirrhosis, and liver failure.”6
Most natural supplements have not been shown to help with social anxiety. For social anxiety disorder, GM should be referred to her physician for a prescription of a selective serotonin reuptake inhibitor or venlafaxine. Both are considered first-line treatments for social anxiety disorder. She could also try relaxation techniques and behavior modification.
Case 5: Self-Treatment of Acne
DD is a 16-year-old female who stops by the pharmacy with her mother while out shopping. DD’s mother wants to know which OTC face wash would be best for helping DD treat and prevent blackheads on her forehead, nose, and cheeks. DD’s mother reports that her daughter suffers from occasional acne flares that seem to worsen with the onset of menses; however, her blackheads are a constant problem that seem to make DD anxious and self-conscious about her appearance. DD has not yet seen a dermatologist for evaluation of her condition, but her mother is hoping to improve DD’s condition with self-care. What products and self-care recommendations can you share with DD?
DD’s acne vulgaris is a common problem in adolescents and in some adults. This bothersome skin condition is thought to result from genetic, hormonal, and environmental influences, although the exact cause remains unknown.7
DD’s self-identified blackheads represent a type of noninflammatory lesion; papules, pustules, and nodules are inflammatory lesions associated with this condition. The goals of self-care for this often self-limiting condition include reducing the appearance of lesions and minimizing scarring.7
Topical retinoids are considered the gold standard treatment for moderate to severe acne, although their availability is limited by their prescription-only status.7
In the case of DD, consider recommending that she use an OTC face wash containing benzoyl peroxide in a concentration of 2.5% to 10%. The concentration does not seem to affect product efficacy; higher-strength formulations have similar antimicrobial effects and greater potential for causing adverse effects compared with their lower-strength counterparts.7,8
Counsel DD that topical application of benzoyl peroxide may result in redness and scaling of the skin that should subside within 1 to 2 weeks with continued use. If severe redness or suspected allergic reaction occurs, recommend discontinuation of the product and prompt physician follow-up for further evaluation.
Case 6: 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 that 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 exposure. 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.9
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.
Oral thrush. Mayo Foundation for Medical Education and Research website. www.mayoclinic.org/diseases-conditions/oral-thrush/basics/causes/con-20022381. Accessed January 10, 2014.
US Department of Agriculture, US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: US Government Printing Office; December 2010. www.cnpp.usda.gov/dgas2010-policydocument.htm. Accessed November 18, 2013.
Kwak SM, Myung SK, Lee YJ, Seo HG. Efficacy of omega-3 fatty acid supplements (eicosapentaenoic acid and docosahexaenoic acid) in the secondary prevention of cardiovascular disease: a meta-analysis of randomized, double-blind, placebo-controlled trials. Arch Intern Med. 2012;172:686-694.
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.
Safety: kava (Piper methysticum). FDA website. www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm154577.htm. Accessed February 2, 2014.
Foster KT, Coffey CW. Acne. 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.
Federman DG, Kirsner RS. Acne vulgaris: pathogenesis and therapeutic approach. Am J Managed Care. 2000;6:78-87.
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.