Clarence D. Moore, PharmD, BCPS

Nearly 33% of adults in the United States have the typically symptomless disease known as “hypertension.”

 When health care providers treat ailments in these individuals, caution should be exercised, as several medications are contraindicated. For example, because decongestants, which are frequently used to manage nasal congestion, can increase blood pressure (BP), their use is a concern in patients with hypertension.

Nasal congestion, often referred to as a “stuffy nose,” is a typical symptom of the common cold, occurring when nasal and adjacent tissues and blood vessels become swollen with excess fluid.

 This symptom has been described as the most bothersome by adults with allergies.

 Individuals with nasal congestion are encouraged to drink plenty of fluids to thin mucus and promote nasal drainage. Getting plenty of rest and limiting activities are also warranted for affected patients.

 In addition, OTC medications are often used to manage symptoms; however, they do not shorten the duration of illness and only offer temporary relief.

Individuals with hypertension should be made aware that decongestants can elevate their BP. Various medical guidelines characterize hypertension in adults as a systolic BP of 140 mm Hg or higher or a diastolic BP of 90 mm Hg or higher.

 Hypertension is treated by using various methods to decrease BP to a predetermined target. The American Heart Association warns all individuals with hypertension, including those being treated for it, to read the labels on all OTC medications prior to use.

Nasal decongestants are vasoconstrictors that belong to the pharmacologic class sympathomimetic amines. They exert their primary action by activating alpha-adrenergic receptors on blood vessels of the nasal mucosa. This results in vasoconstriction, which decreases blood flow through the nasal mucosa and shrinks tissue.

 Decongestants are available in multiple formulations with varying degrees of systemic effects, including potential elevation of BP.

The decongestants pseudoephedrine and phenylephrine may offer mild relief from nasal congestion associated with the common cold.

 These medications are administered alone or in combination with antihistamines, which minimize other symptoms associated with the common cold.

Pseudoephedrine is a common ingredient in more than 135 medications and has proved effective in treating nasal congestion. The drug was found to elevate BP in a 2005 meta-analysis that showed it significantly increased systolic BP (0.99 mm Hg) and heart rate (2.83 beats/min). However, the results revealed no effect on diastolic BP. Higher BP increases were associated with higher doses and immediate-release formulations of pseudoephedrine.

Studies comparing phenylephrine with placebo showed no significant improvement in measures of nasal congestion. There is a lack of data on phenylephrine’s effect on BP.

Phenylephrine and pseudoephedrine have been described as safe and effective for treating nasal congestion.

 However, as a result of the Combat Methamphetamine Epidemic Act of 2005, pseudoephedrine products are kept “behind the counter” and have certain restrictions regarding their purchase.

Naphazoline, oxymetazoline, and phenylephrine are commonly used topical decongestants. Although these agents are expected to promote local activity, the FDA requires their instructions to contain a warning for individuals with high BP; however, the data on the connection between their use and hypertension are sparse. Unlike other topical decongestants, propylhexedrine is a topical OTC decongestant that is not required to carry a warning against unsupervised use in patients with hypertension.

 The use of topical nasal decongestants for more than 5 days is associated with the development of rhinitis medicamentosa, also known as “rebound rhinitis,” which can lead to user dependency.

A 2003 Cochrane review concluded that monotherapy with antihistamines does not alleviate nasal congestion to a clinically significant degree. In that review, first-generation antihistamines were found to have greater adverse effects than placebo, with neither first- nor second-generation antihistamines increasing BP. Antihistamines can be used in combination with decongestants; however, they should not be used in small children.

Saline has been used to relieve congestion and is thought to thin mucus in the sinus cavities. Increasing humidity in the environment of patients with nasal congestion may also provide relief; therefore, the use of humidifiers is recommended. A third solution, nasal strips may help open the nostrils and, therefore, improve breathing in patients with congestion.

With their training in OTC medications, pharmacists can play a major role in managing decongestion in their patients. No product can be recommended to provide safe and effective relief of congestion in all patients with hypertension. Therefore, pharmacists’ medication knowledge, coupled with their keen ability to obtain valuable information from patients, can ensure optimal drug selection for individuals with hypertension.

Clarence D. Moore, PharmD, BCPS, BCOP, is Assistant Professor at Bernard J. Dunn School of Pharmacy, Shenandoah University, in Ashburn, Virginia.

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Articles

Nearly 33% of adults in the United States have the typically symptomless disease known as hypertension.

Decongestants and Hypertension: Dangerous Together

Although the prostate plays an important role in the male reproductive system, many individuals are unaware of its purpose. The prostate is a small walnut-sized gland that rests low in the pelvis, below the bladder and just in front of the rectum. This gland assists in producing semen, a milky fluid that nourishes and protects sperm. During ejaculation, the muscles of the prostate ensure that semen is forcefully pushed into the urethra and expelled outward.

The prostate is prone to 3 diseases that generally occur at different stages of life. Prostatitis is more common among younger men, whereas benign prostatic hyperplasia (BPH) is more common among middle-aged and older men. Older men are more at risk for developing prostate cancer, and the risk increases with age.

This is a common problem that affects approximately 1 in 6 men and initiates nearly 2 million visits with health care providers annually. Prostatitis is a broad diagnosis that has 4 classifications: acute or chronic bacterial, chronic prostatitis, chronic pelvic pain syndrome, and asymptomatic.

 Along with having inflammation of the prostate, patients with prostatitis experience urinary problems such as dysuria, urgency, difficult or painful ejaculation, and pain in the perineum or the back.

The treatment for prostatitis is based on its classification. Bacterial prostatitis is categorized as acute or chronic. Acute bacterial prostatitis is typically addressed in the outpatient setting and, if left untreated, can lead to severe complications. 

 is the primary cause identified; however, other gram-negative organisms and 

 have also been isolated. Oral antibiotics, frequently fluoroquinolones and trimethoprim- sulfamethoxazole, are used for 4 to 6 weeks to treat individuals with mild to moderate cases. Complicated or resistant cases may require hospitalization and intravenous antibiotics.

Chronic bacterial prostatitis is defined as persistent infection of the prostate for more than 3 months. As with acute bacterial prostatitis, 

is most commonly isolated in patients with chronic bacterial prostatitis. For management, fluoroquinolones are usually administered for 6 weeks and often preferred over trimethoprim-sulfamethoxazole because of their good penetration into prostatic tissue.

Chronic pelvic pain syndrome does not have a clear etiology, which makes it difficult to treat. There are no clear-cut signs of infection, and there is no consensus on first-line treatment. Treatment often includes the use of antibiotics, alpha-blockers, 5-alpha-reductase inhibitors, and anti-inflammatory medications, with the latter 2 classes having only modest benefits.

Asymptomatic prostatitis is usually diagnosed during urologic evaluation for other reasons.5 Treatment should be based on the primary reason for urologic evaluation.

BPH has an abrupt effect on affected patients’ quality of life. BPH is progressive and usually presents as lower urinary tract symptoms. Patients must be evaluated to determine whether their symptoms are secondary to BPH or another cause, such as diabetes, bladder cancer, or a medication (Table

Historically, BPH has been treated with surgery; however, the development of new medications over the past decade has changed treatment. Untreated BPH can lead to a urinary tract infection and, in severe cases, kidney damage. When medication is warranted, alpha-blockers and 5-alpha-reductase inhibitors are used alone or in combination to manage the effects of the disease.

Alpha-blockers are used first-line to relax the smooth muscle in the prostate. This drug class is divided into nonselective and selective types, with the latter being more targeted toward prostate tissue and having fewer systemic effects. Although the adverse effects (AEs) of alpha- blockers vary, dizziness and orthostatic hypotension are seen with both types.

In patients who are unable to tolerate alpha-blockers or do not have an adequate response to them, 5-alpha-reductase inhibitors are an option. These agents can be used as monotherapy or in combination with alpha-blockers. 5-Alpha-reductase inhibitors inhibit the conversion of testosterone to dihydrotestosterone, which is the primary androgen involved in prostate growth. These agents have been shown to decrease prostatic volume; however, it may take up to 6 months for results to be seen. Pregnant women should wear gloves while handling these medications because they may pose a risk to unborn male fetuses. Sexual dysfunction and decreased libido are other AEs associated with this class of medications.

Anticholinergic agents and phosphodiesterase-5 have also been used to treat symptoms of BPH.

This is the second-leading cause of cancer death for men in the United States. The tests commonly used for screening prostate cancer are the digital rectal exam and the prostatic-specific antigen test.

 Treatment of prostate cancer varies based on disease stage and patient-specific factors. Individuals with advanced disease often require medications for management. Hormone therapy, also known as androgen deprivation therapy (ADT), is used to reduce the androgen level in the body in order to disrupt the growth of prostate cancer cells. ADT can be achieved by surgical or medical castration. Medical castration is often achieved using luteinizing hormone—releasing hormone (LHRH) agonists, LHRH antagonists, or antiandrogens. Hot flashes are the most common AE of these medications.

Although these agents are effective for some time, patients eventually develop resistance to them. In castration-resistant cases, chemotherapy and other novel strategies are used to continue managing the disease.

 These agents have been shown to improve overall survival and quality of life of patients. Enzalutamide and abiraterone acetate are newer oral agents that must be taken daily. Appropriate management of patients is based on patient-specific factors.

The 3 diseases discussed in this article can greatly affect patients’ quality of life. Medications can be integral to managing the complications, allowing pharmacists to play a pivotal role in each case. Pharmacists can ensure that pharmacotherapy needs are met by assisting in drug selection, educating patients, and providing comprehensive patient care.

Clarence D. Moore, PharmD, BCPS, BCOP, is assistant professor at Bernard J. Dunn School of Pharmacy, Shenandoah University, in Ashburn, Virginia. 

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		The importance of prostate health. Health Advantage, Inc website. healthmd.com/ps-1.htm. Accessed July 15, 2016.

		Prostatitis: inflamed prostate can be a vexing health problem. Harvard University website. harvardprostateknowledge.org/prostatitis-inflamed-prostate-can-be-a-vexing-health-problem. Accessed July 23, 2016.

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		Charalabopoulos K, Karachalios G, Baltogiannis D, Charalabopoulos A, Giannakopoulos X, Sofikitis N. Penetration of antimicrobial agents into the prostate. 

		Anothaisintawee T, Attia J, Nickel JC, et al. Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis. 

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		Prostate cancer: treatment options. Cancer.Net website. cancer.net/cancer-types/prostate-cancer/treatment-options. Published January 2016. Accessed August 1, 2016.

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Although the prostate plays an important role in the male reproductive system, many individuals are unaware of its purpose.

The Prostate: Prone to 3 Diseases

Nausea is defined as the unpleasant, painless urge to vomit. Generally an intended protective mechanism, vomiting is an organized, autonomic response resulting in the forceful ejection of stomach contents through the mouth. Nausea and vomiting are symptoms of many different conditions, such as infection, food poisoning, motion sickness, concussion, appendicitis, and various other disease states. Although nausea and vomiting are frequently discussed together, nausea can occur without vomiting or may precede or follow it.

Individuals often experience nausea accompanied by autonomic symptoms, such as pallor, altered heart rate, diaphoresis, and salivation.

 Vomiting involves a series of events leading to the expulsion of the gastric and, often, the small intestinal contents. The pathophysiologies of nausea and vomiting are poorly understood, as there are many contributing factors to each.

The brain’s vomiting center, located in the medulla, can induce vomiting when it is stimulated. This center can be activated directly or indirectly following input from the gastrointestinal tract, the cerebral cortex and thalamus, the vestibular region, or the chemoreceptor trigger zone. Because the vomiting center is not protected by the bloodbrain barrier, it is easily permeated by irritants.

The several neurotransmitters involved in the nausea and vomiting process are not limited to dopamine, histamine, substance P, and serotonin. Although medications are used to target these pathways in the prevention and treatment of nausea or vomiting, many medications may induce nausea or vomiting, as well (Table 1

Nausea is a subjective feeling that is sometimes given minimal attention by health care providers who may view it as an annoying side effect and not as a notable issue that requires treatment.

 Vomiting can lead to serious consequences, such as aspiration pneumonia. In addition, severe and repetitive vomiting can result in disturbances in the acid-base balance, dehydration, malnutrition, and electrolyte depletion. Continual vomiting may result in the erosion of tooth enamel, thereby increasing tooth sensitivity.

Although many cases of nausea and vomiting may be self-eliminating, some may warrant the use of medications. For serious cases, prescription medications are often recommended; however, OTC treatment options are often used, as well, with patients consulting pharmacists for recommendations regarding nausea and vomiting. In addition to serving as a medication reference, pharmacists should also be knowledgeable about common conditions that may require referral for further investigation (Online Table 2

Table 2. Conditions and Patient Presentations Requiring Referral

				Severe abdominal pain in the middle or right lower quadrant

				Bleeding ulcer or other serious condition, such as cancer

				Blood-stained vomit and/or black, tarry stools

				Children younger than 1 year who are not urinating, or are listless, lethargic, or crying

				Dark urine and/or yellow discoloration of the skin or eyes, along with cold and flu symptoms

				Headache or stiff neck; normal light hurts the eyes

				If an in-home pregnancy test produces a positive result, refer the patient to a physician for confirmation

				History of recent head injury, headache, blurred vision, numbness, or tingling

				Acute myocardial infarction, bulimia nervosa, congestive heart failure, gastroparesis, pyelonephritis, migraine headache, pancreatitis, jaundice, urinary tract infection, seizure, and stroke

				If suspected, these conditions require referral

The OTC agents used to treat or prevent nausea and vomiting include various antihistamine products. These agents are typically effective, especially when the nausea or vomiting is due to vestibular causes such as motion sickness.

 Patients receiving these medications should be notified of their potential anticholinergic adverse effects, such as drowsiness, blurred vision, dry mouth, and urinary retention. Because of these effects, these medications should be used with caution in patients with asthma, glaucoma, or enlargement of the prostate gland. In addition, these medications may impair the mental and/or physical abilities required for performing tasks such as driving or operating machinery. The concomitant use of alcohol or other central nervous system depressants may have an additive effect. Age restrictions apply to these medications and should be reviewed prior to administration (Online Table 3

Nausea and vomiting are symptoms of many different conditions, such as infection, food poisoning, motion sickness, concussion, appendicitis, and various other disease states. 

Nausea and Vomiting: Not Always in Sync

Infertility has been defined as “the inability to conceive after 12 months of unprotected intercourse.” Women aged 35 or older, who are unable to conceive after 6 months, are generally considered infertile, as well.

 According to the CDC, 6.1% of married women are considered infertile, with nearly 7 million of them receiving some form of infertility services during their lifetime.

 The use of fertility-enhancing medications has increased drastically over the past 30 years, with the role of the pharmacist continuing to expand within that specific niche of pharmacy.

The causes of infertility are often complex, with several factors contributing to the inability to conceive. One or both partners may contribute to a couple’s infertility, with male issues accounting for one-third of infertility cases.

 Male infertility is often the result of a hormonal imbalance or blockage of sperm movement.

 An enlarged vein in the testicle, known as a varicocele, is thought to be the most common cause of male infertility, although this theory is controversial.

 Several factors affecting a man’s overall health and lifestyle may reduce his sperm quality and quantity, resulting in an increased risk of infertility (Table 1

). Approximately one-third of infertility is caused by a combination of problems or is unexplained, and one-third of cases of infertility can be attributed to the female partner.

 Ovulatory disorders, abnormalities of the uterus or outflow tract, and tubal disease or dysfunction account for the majority of female infertility cases.

Treatment of infertility depends on several factors, including diagnosis, duration of infertility, and age. Any underlying factors affecting fertility should be managed accordingly.

 Assisted reproductive technologies (ART) are often used to help affected individuals achieve pregnancy. These procedures are frequently done in combination with the use of medications to improve pregnancy success rates (Table 2

Clomiphene citrate is the most commonly prescribed ovulation medication and is primarily prescribed for women who have rare or absent ovulation. This oral medication works by competitively inhibiting estrogen receptors, resulting in increased levels of follicle- stimulating hormone (FSH) and luteinizing hormone (LH), which subsequently promotes follicle development and ovarian stimulation.

Clomiphene citrate induces ovulation in approximately 80% of cases and should not be given for more than 6 cycles. Women should be informed that conception while taking clomiphene is associated with a 30% chance of delivering twins. Women who have ovulation abnormalities due to hypothalamic disorders or very low estrogen levels generally do not respond well to clomiphene. The adverse effects (AEs) of clomiphene are considered mild, with 10% of women experiencing hot flashes.

Gonadotropins are injectable fertility medications containing exogenous FSH and LH. These medications are often used in women who have failed clomiphene therapy and are used to induce development of multiple follicles for procedures such as intrauterine insemination or ART. Human chorionic gonadotropin is another injectable gonadotropin that is used to trigger the release of mature eggs. This group of medications is associated with multiple births, an increased incidence of miscarriage and premature delivery, mood swings, breast tenderness, and injection-site reactions.

Polycystic ovary syndrome (PCOS) is a common hormonal condition in which women produce an increased amount of androgens, resulting in irregular, or a lack of, ovulation. Metformin has been shown to restore cyclic ovulation and menses in some women who suffer from PCOS, while lowering elevated blood glucose levels. AEs of metformin include increased gastrointestinal discomfort, and the medication is contraindicated in certain patients with renal dysfunction.

Some women ovulate irregularly because their body secretes an increased amount of prolactin, which inhibits the release of FSH and LH and, in turn, prevents ovulation. This class of agents reduces excess amounts of prolactin released by the pituitary gland and is thought to normalize prolactin levels in most patients. These oral medications often cause fatigue, headaches, fainting, nausea, and vomiting, and should be discontinued during pregnancy.

Gonadotropin-releasing hormone (GnRH) is released from the hypothalamus and stimulates the pituitary gland to secrete LH and FSH. In the absence or improper release of GnRH, women are unable to ovulate regularly. GnRH analogs are synthetic agents that have a structure similar to that of natural GnRH. This class of medications is used to prevent spontaneous ovulation in women receiving gonadotropins for in vitro fertilization. AEs often seen with the use of GnRH antagonists and agonists include hot flashes, mood swings, and vaginal dryness. These AEs are thought to subside once these medications are discontinued.

The pharmacist is an excellent resource for patients using these medications for the treatment of infertility.

 The regimens are often complicated and require a sound understanding for optimal results. Pharmacists can answer questions regarding administration and safety of the medications, while discussing treatment options and assisting with referrals, if needed.

Clarence D. Moore, PharmD, BCPS, is assistant professor at Howard University College of Pharmacy.

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		Moy I, Ekpo G. Clomiphene citrate use for ovulation inductions: when, why, and how? Contemporary OB/GYN website. contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/clinical/clinical-pharmacology/clomiphene-citrate-use-ovulation-induction-wh?page=full. Accessed February 18, 2016.

		What are gonadotropins? American Society for Reproductive Medicine website. asrm.org/FACTSHEET_Side_effects_of_injectable_fertility_drugs_gonadotropins/. Accessed February 18, 2016.

		Infertility and polycystic ovary syndrome. WebMD.com website. webmd.com/infertility-and-reproduction/polycystic-ovary-syndrome?page=2. Accessed February 19, 2016.

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The use of fertility-enhancing medications has increased drastically over the past 30 years, with the role of the pharmacist continuing to expand within that specific niche of pharmacy.