Mary Bama Bridgeman, PharmD, BCPS, CGP

BF, a 22-year-old woman, comes to the pharmacy seeking something to help boost her immune system. She says she always gets colds during the year and wants to use zinc daily to prevent colds. Her friend has been using zinc for the past few years and has not gotten sick at all. BF was thinking about using zinc lozenges daily to help prevent colds for the upcoming cold and flu season. She said that she has tried to increase the number of times she washes her hands and is willing to try other nonpharmacologic techniques to prevent the spread of germs. BF has no medical conditions and no drug allergies, but she takes a multivitamin daily. What recommendations about zinc do you have for BF?

 Zinc is an essential nutrient, which can help with growth and immunity. BF should be told that the evidence that zinc prevents colds is conflicting, and many of the clinical studies have poor designs. One study evaluated patients who used daily zinc lozenges, and the results showed that the number of colds per year and antibiotic use decreased.

 However, the results of most studies show that zinc does not help prevent colds. BF should also be told that zinc lozenges appear to help treat the common cold. Most trials have had patients use zinc lozenges every 2 hours while awake as soon as symptoms begin. Most of the studies show a symptom reduction of 3 days.

 Therefore, BF should start zinc lozenges as soon as her symptoms begin to help decrease the length of illness. But based on the data, it appears that taking zinc daily will not help prevent a cold. In addition to her nonpharmacologic way of preventing infection, BF should ensure that all her vaccinations are up to date, which can prevent any vaccine-preventable illnesses. 

 MR, a 48-year-old woman, visits the pharmacy asking for something to help prevent influenza. She says that a distant family member recently died from influenza. MR was surprised to learn that the flu can be fatal because she always thought that people recover. Since she heard the news, she has been thinking about getting a flu vaccination. As the pharmacist, you recommend that MR get the vaccine today because it is flu season. She says that she is allergic to eggs and has never received the vaccine before. Upon questioning, MR says that her normal reaction to eggs is to break out in hives. She has never used epinephrine and has never needed to seek urgent medical attention for her allergy. What recommendations do you have for MR?

MR should be told that the recommendation for flu vaccination for those with an egg allergy changed last season. It is now recommended that a patient who breaks out in hives after contact with eggs receive any licensed flu vaccine, whether it is the inactivated influenza vaccine or the recombinant influenza vaccine. Therefore, MR should receive the vaccination either at the pharmacy today or at her physician's office, as it is the best way to protect against influenza. Patients with egg allergies, who have symptoms such as angioedema, respiratory distress, lightheadedness, or recurrent emesis, or who in the past required epinephrine or another emergency medical intervention, may also receive any licensed influenza product. However, these patients should receive the vaccine at an inpatient or outpatient medical facility. In addition, the vaccine is contraindicated for anyone who has had a previous severe allergic reaction.

MR should also be told that the influenza vaccine is not 100% effective. However, if she does get the flu, it will be a milder version. MR should be told that the vaccine takes up to 14 days to kick in, so if she comes in contact with the influenza virus before then, it could have no benefit during that time. 

TA, a 28-year-old woman, comes to the pharmacy to inquire about whooping cough. She is 30 weeks pregnant and was advised by a friend to get the vaccine for whooping cough, which is also known as pertussis. There is currently an outbreak of pertussis in the state where she lives. She says she does not want to harm her baby, so she would like to wait until she gives birth. TA does not understand why she needs to get the vaccine while she is pregnant. In addition, she does not want a combination vaccine but one for pertussis only. What recommendations do you have for TA?

TA should be told that whooping cough is a contagious respiratory disease that can be deadly for babies younger than 12 months.  It is caused by bacteria, and symptoms include an uncontrollable cough that makes is difficult to breathe. The best way to help TA’s baby is by getting vaccinated during the third trimester of pregnancy. When the vaccine is given during pregnancy, some of the antibodies pass to the baby before birth, offering protection until the baby can get his or her own pertussis vaccination at 2 months. Because TA is already 30 weeks pregnant, she can get a one-time dose of Tdap today. The pertussis vaccine only comes as a combination vaccine of DTaP for children and Tdap for adolescents and adults. It is recommended that pregnant women get vaccinated between weeks 27 and 36. The recommendations only recommend Tdap post-pregnancy if the mother has never received the vaccination before or if her vaccination status is unknown.

RM, a 35-year-old woman visits the pharmacy looking for something to prevent colds. She works in a daycare center and over the past month has had 3 colds. Every time RM has gotten a cold, she cannot go to work and does not get paid. Although she has tried to increase her vitamin C intake and now takes a multivitamin, it has not helped. RM is looking for an immune booster. She heard that echinacea can help prevent colds. RM does not take any other prescription medication and has no other medical conditions. What recommendations do you have for RM?

 RM should be told that though echinacea is a natural supplement, strong randomized clinical trials are lacking. Data on the use of echinacea is conflicting, though some research suggests that it may help prevent and treat the common cold. The results of a study showed that echinacea taken on the first day of a cold and continued for 6 days can reduce symptom scores by 23% compared with a placebo. Results of another study showed that it could decrease cold symptoms by day 4, compared with day 7 with a placebo.

Some research also suggests that echinacea can reduce the incidence of colds by 45% to 58%.

 Although some of the data show that echinacea may be beneficial, there is also conflicting research suggesting that there is no benefit over a placebo. Therefore, RM should be told that she can try echinacea, but it may not benefit her. Depending on the product she selects, she should follow the package directions. In addition, RM may benefit from good hand-washing techniques. She should wash her hands frequently and keep the soap on her hands for 20 to30 seconds before rinsing with water. In addition, RM should make sure that her immunizations are up to date. 

Dr. Mansukhani is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and a transitions-of-care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey.

Dr. Bridgeman is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. 

McElroy BH, Miller SP. An open-label, single-center, phase IV clinical study of the effectiveness of zinc gluconate glycine lozenges (Cold-Eeze) in reducing the duration and symptoms of the common cold in school-age subjects. 

Hemila H, Petrus EJ, Fitzgerald JT, Prasad A. Zinc acetate lozenges for treating the common cold: an individual patient data meta-analysis. 

 2016 ;82(5):1393-1398. doi: 10.1111/bcp.13057.

Zinc lozenges reduce the duration of common cold symptoms. 

CDC. Flu vaccine and people with egg allergies. https://www.cdc.gov/flu/protect/vaccine/egg-allergies.htm. Updated September 2, 2016.Accessed August 7, 2017.

CDC. Tdap (tetanus, diptheria, pertussis) VIS. cdc.gov/vaccines/hcp/vis/vis-statements/tdap.html. Updated October 16, 2016. Accessed August 7, 2017.

Goel V. Lovlin R, Barton R, et al.  Efficacy of a standardized echinacea preparation (Echinilin) for the treatment of the common cold: a randomized, double-blind, placebo-controlled trial. 

Goel V, Lovlin R, Chang C, et al. A proprietary extract from the echinacea plant (Echinacea purpurea) enhances systemic immune response during a common cold. 

Shah SA, Sander S, White CM, et al. Evaluation of echinacea for the prevention and treatment of the common cold: a meta-analysis. 

Schoop R, Klein P, Suter A, Johnston SL. Echinacea in the prevention of induced rhinovirus colds: a meta-analysis. 

Articles

Which OTC products should these pharmacists recommend?

Self-Care for Immunizations

 AM is a 35-year-old woman who comes to the pharmacy seeking advice on her dry, nonproductive cough, which has bothered her for the past few days along with a tickle in her throat. She has been coughing intermittently throughout the day, but it gets worse when she lies down, which has made it difficult for her to sleep. Therefore, AM wants something to suppress her cough while she sleeps. She otherwise reports feeling well and does not have any medical problems or allergies to medications. What suggestions for cough relief can you recommend to AM so she can sleep better?

 AM’s cough could to be related to an upper respiratory tract infection or allergies. Typically, first-line treatment for a dry, nonproductive cough is a first-generation antihistamine. This can be with or without a decongestant for nasal congestion and naproxen for pain or fever. A product such as diphenhydramine would be appropriate to recommend; a common adverse effect is drowsiness, which could help AM sleep through the night. Many patients seek a product that is nonsedating; however, second-generation antihistamines lack antitussive properties and should be avoided for managing cough. Dextromethorphan is another option for patients who want to suppress their cough during waking hours. AM should be counseled to follow up with her primary care provider (PCP) if her cough worsens or lasts more than 7 days or if she develops a fever.

AL is a 28-year-old woman who presents to the pharmacy seeking advice on cold prevention. She recently started a new job at a local daycare and is concerned about getting sick. At her last job where she worked with children, she was sick every week. She says some of her coworkers take elderberry to prevent colds. They claim a teaspoonful a day will help prevent a cold. She otherwise reports feeling well and does not have any medical problems or allergies to medications. She is interested in a holistic approach to preventing colds and would like to avoid taking prescription products because she heard they are unsafe. What suggestions for cold prevention can the pharmacist provide?

 AL should be educated that good hand hygiene is important for preventing transmission of viruses and bacteria, so she should be instructed on how to wash her hands properly throughout the day. If she does not have access to a sink, she can use hand sanitizers. No medications are approved to prevent colds; however, the results of a few studies have shown elderberry may be effective if taken within 48 hours of flu-like symptom onset.

 If AL decides to take elderberry for flulike symptoms, she should follow the package instructions for dosing because there are many formulations and the dosing can vary. AL should be encouraged to avoid taking something daily for preventing colds because there are no data to support any claims. In addition, if she is considering taking elderberry to reduce flulike symptoms, she may also benefit from getting an annual influenza vaccination, which is recommended in anyone 6 months and older. Because influenza is associated with complications, such as secondary infection, hospitalization, and death, patients presenting with signs of influenza should be referred to their PCP.

 RD is a 40-year-old man who comes to the pharmacy looking for a nasal irrigation system. He has suffered from seasonal allergies since he was a child and today is complaining of congestion, runny nose, and watery eyes. He takes loratadine 10 mg daily during hay season to reduce his symptoms. His sister, who also suffers from allergies, recommended he try a nasal irrigation system for the congestion. He otherwise reports feeling well and does not have any medical problems or allergies to medications. What suggestions do you have for RD regarding nasal irrigation?

 RD should be told that some study results show that hypertonic saline nasal irrigation 3 times daily can reduce symptoms after 3 to 6 weeks of treatment.

 Intranasal corticosteroids, such as triamcinolone acetonide (Nasacort Allergy 24 HR) and fluticasone propionate (Flonase Allergy Relief), have also been proven more effective than saline nasal irrigation. However, both isotonic and hypertonic saline nasal irrigation can improve symptoms of allergic rhinitis.

 RD should be educated on the OTC options, which include intranasal corticosteroids, second-generation antihistamines, and nasal irrigation. If he would like to try nasal irrigation, he should follow the package instructions. In addition, he should be educated on keeping the products sterile, the instructions for which vary by product.

NG is a 30-year-old man who comes to the pharmacy looking for a home testing kit for allergies. He recently used a CardioChek testing kit and was amazed because it measured his total cholesterol, high-density lipoprotein cholesterol, triglyceride, glucose, and ketone levels at home, the convenience of which he appreciated. After he used the home testing kit, he sent the results to his physician. Recently, his allergies have been worse, so he started taking loratadine 10 mg daily. He has had seasonal allergies for more than 10 years, but never had allergy testing to find out exactly what he should avoid. Now that his allergies are worsening, he wants to see if there is an OTC test like CardioChek for allergies. What recommendations would you have for NG?

 If NG is suffering from allergies and wants to know their cause, he should see his PCP who can refer him for testing and investigate why his allergy symptoms are worsening. There are 2 methods of allergy testing: skin tests give fast results and typically cost less; blood tests are helpful because they involve a single needle prick, although it takes longer to get the results.

 A home testing kit called “My Allergy Test” is no longer available and no other OTC product exists. The best option for NG would be to discuss with his PCP whether he should have allergy testing and which test would be best for him.

Dr. Bridgeman is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

Zakay-Rones Z, Varsano N, Zlotnik M, et al. Inhibition of several strains of influenza virus in vitro and reduction of symptoms by an elderberry extract during an outbreak of influenza B Panama. J Altern Complement Med 1995;1:361-9.

Zakay-Rones Z, Thom E, Wollan T, Wadstein J. Randomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections. J Int Med Res 2004;32:132-40

Garavello W, DiBerardino F, Romagnoli M, et al. Nasal rinsing with hypertonic solution: an adjunctive treatment for pediatric seasonal allergic rhinoconjunctivitis. Int Arch Allergy Immunol 2005;137:310-4.

Nsouli TM. Long-term use of nasal saline irrigation: harmful or helpful (abstract 32). Ann Allergy Asthma Immunol 2009;103(5 Suppl 3):A27-8.

American College of Allergy, Asthma, and Immunology. Overview. Available at: http://acaai.org/allergies/treatment/allergy-testing. Accessed March 1, 2017.

What OTC products should these pharmacists recommend?

Self-Care for Respiratory Disorders

LM is a 38-year-old woman who comes to the pharmacy to fill her prescription for an antibiotic. She has been feeling sick for the past week, and her physician said she has a bacterial infection. The last time an antibiotic was prescribed to her, she had diarrhea. To prevent diarrhea, her physician recommended she take a probiotic, which she could pick up at a pharmacy. LM is healthy with no other medical conditions. She wants to know if you recommend a probiotic or if she could just eat yogurt to prevent diarrhea. She is not taking anything else for her illness. What recommendation do you have for LM regarding the use of probiotics to prevent diarrhea?

Many probiotics have been studied for preventing diarrhea with antibiotic use. Antibiotics remove the normal flora in the gastrointestinal tract, so replenishing the flora makes sense. Lactobacillus spp, Bifidobacterium spp, and Saccharomyces boulardii have been studied to reduce the risk of diarrhea by 42% to 47%.

 LM should be educated that any product containing one of these probiotics can be beneficial. Other ways to help prevent diarrhea include increasing consumption of foods that commonly contain probiotics, such as yogurt and cheese. However, it is difficult to achieve the optimal dose with foods without supplementation with probiotics. If LM decides to increase her yogurt intake, she must do so for the course of her antibiotic therapy. If she decides to use probiotic supplementation, she should be educated to follow the package instructions because dosing of probiotic supplements varies greatly. Common brand names of probiotics include Florastor, Florajen, ProViva, and BioGaia. Any one of them would be sufficient to help LM prevent diarrhea associated with antibiotic use.

JP is a 45-year-old woman who comes to the pharmacy looking for something to relieve her constipation. She states she has been constipated for the past several months. On questioning, she states she has breast cancer and is currently undergoing chemotherapy. In addition, she is taking multiple pain medications. She started feeling constipated when she began her pain medication. She has tried to increase her intake of leafy green vegetables and other high-fiber foods, however, this has not been beneficial. JP was avoiding adding more medications to the ones she already takes, but her constipation is getting worse. She denies having a fever or any other symptoms. What recommendations do you have for JP?

JP appears to be suffering from opioid-induced constipation, which is the most common adverse effect of opioid use. Opioids bind to the bowel receptors and decrease gastrointestinal (GI) motility. The degree of constipation depends on the dose and duration of therapy; therefore, patients on long-term opioid therapy should be given a prophylaxis or treatment for constipation. JP should be referred to her health care practitioner who is prescribing her opioid therapy. The practitioner should evaluate JP to see if there are alternatives for managing her pain that cause less constipation, such as a patch formulation. Typically, opioid-induced constipation is treated with stimulant laxatives, such as senna or bisacodyl, which promote GI motility. When GI motility is slow, stool in the GI tract can lose water and harden. Docusate can be used in combination with a stimulant laxative to help loosen stool. JP should be educated that she can also help prevent constipation by increasing her water and fiber intake.

NM is a 34-year-old woman who comes to the pharmacy looking for something to help relieve her heartburn. For the past few months, she has been feeling a burn in her stomach and feels like she has regurgitation. She says this happens 3 or 4 times a week, typically 30 to 60 minutes after she eats. She tries to drink milk whenever she has heartburn, but it does not help that much. She says her symptoms are bothersome but do not interfere with her daily activities. On questioning, she states she has not tried treating her symptoms with anything besides milk. She travels a lot for work and tends to eat out most days of the week, so her diet is inconsistent. She has no medical conditions. What can you recommend for NM?

 NM appears to be suffering from gastroesophageal reflux disease. Because her diet is inconsistent, it may be beneficial for her to keep a diary of her food intake. Then she can document when she has heartburn to identify foods that trigger it. Once she identifies possible triggers, she should try avoiding them in order to decrease the frequency of her heartburn. In addition, because her symptoms occur more than 2 days per week, she may benefit from using an OTC proton pump inhibitor (PPI) once daily for 14 days. Many PPI brands are available over the counter, including Prilosec OTC and generic equivalents, Zegerid OTC, Prevacid 24HR and generic equivalents, and Nexium 24HR. Because NM does not have any other conditions or medications, she can choose any treatment option. She should be encouraged not to exceed 14 days of treatment—and no more frequently than every 4 months. If heartburn continues while an OTC PPI is taken, persists for more than 2 weeks, or recurs within 4 months, a medical evaluation is recommended.

Dr. Mansukhani is a clinical assistant professor at the Ernest Mario School of Pharmacy, Rutgers University, and a transitions-of-care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey. 

		Probiotics. Natural Medicines website. naturaldatabase.therapeuticresearch.com/ce/ceCourse.aspx?s=ND&cs=naturalstandard&pm=5&pc=13-103. Accessed May 26, 2016.

		Constipation. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. 

Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care

. 18th ed. Washington, DC: American Pharmacists Association, 2015.

		Heartburn and dyspepsia. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. 

. 18th ed. Washington, DC: American Pharmacists Association; 2015.

		Ginger. Rutgers University Libraries website. naturalmedicines-therapeuticresearch-com.proxy.libraries.rutgers.edu/databases/food,-herbs-supplements/professional.aspx?productid=961#safety. Accessed May 26, 2016.

Self-Care for Digestive Health

MG is a 28-year-old woman who comes to the pharmacy questioning which vitamins are important in pregnancy. She says she is trying to get pregnant and wants to start taking a multivitamin. She is confused by the many different combinations of vitamins in each brand and wants your opinion on which vitamins should definitely be in her prenatal vitamin. What recommendations do you have for MG?

Vitamins and minerals play an important role in health, especially during pregnancy. Depending on the formulation, prenatal vitamins can include folic acid, iron, calcium, and vitamin D. Folic acid can help prevent major birth defects, called neural tube defects, to a fetus’s brain and spine. The recommended dose is 400 mcg daily. Iron plays a role in pregnancy by helping the body make more blood to supply oxygen to the fetus. The daily recommended dose of iron during pregnancy is 27 mg. Patients can also obtain iron from their diet by eating foods such as lean red meat, poultry, fish, beans and peas, and iron-fortified cereal, and drinking prune juice.

Calcium is used to build the fetus’s bones and teeth. All women 19 years and older, including those who are pregnant, should get 1000 mg of calcium daily. Diets high in milk and other dairy products, such as yogurt, are the best sources of calcium. Vitamin D works with calcium to help the fetus’s bones and teeth develop and is also essential for healthy skin and eyesight. All women, including those who are pregnant, need 600 IU of vitamin D a day; good sources are milk fortified with vitamin D and fatty fish, such as salmon. Exposure to sunlight converts a chemical in the skin to vitamin D.

If adding food sources of vitamins, such as fish, MG should discuss with her health care provider what is safe to eat during pregnancy. Because vitamins other than the ones discussed here are also important during pregnancy, MG should be encouraged to obtain them by taking a multivitamin, rather than separately.

SG is a 28-year-old woman who comes to the pharmacy to purchase an ovulation test. She says her husband and she are trying to get pregnant, and she wants to predict when to do so. She has tried the basal body temperature method but is interested in using the urine test. What recommendations do you have for SG?

 SG should be educated that ovulation tests detect a surge in luteinizing hormone (LH). A positive test result typically indicates that a woman’s chance of conceiving in the next 48 hours is higher. SG should follow the package instructions. Testing morning urine after a full night of sleep is typically recommended because it is more concentrated.

SG should also be educated on when to use the ovulation test. Most women ovulate between days 10 and 17; therefore, testing should occur 2 to 4 days before the estimated day of ovulation. If SG is unaware of when she is ovulating, she can try to use more test sticks for the first few months. Ovulation kits show a positive result (an LH surge) with a darkening line or with a smile icon. If SG gets a positive test result, she should be encouraged to have intercourse because ovulation will occur within 48 hours. Ovulation predictor tests are not recommended because they can produce false-positive results in patients who take fertility medications, have polycystic ovary syndrome, are in menopause, or are pregnant.

TM is 38-year-old woman who comes to the pharmacy looking for weight loss medications. She says her mother recently passed away from a heart attack. TM is obese, with a body mass index (BMI) of 32. She wants to try to lose weight and be healthier. She recently heard about an OTC medication that can help with losing weight. She says she eats out a lot because she tends to work late. Most days, she picks up fast food; however, she is willing to try to cook at home more. She does not engage in physical activity. What recommendations do you have for TM?

 TM can try to lose weight with lifestyle modifications and pharmacologic therapy. She should be educated to minimize eating out. She may also benefit from nutritional education from a dietician on how to make healthier choices when she eats out and how to cook healthier when she eats at home.

In addition to dietary changes, she should exercise for 30 minutes most days of the week. If she prefers to exercise fewer days, she can increase the time she works out to 60 minutes for 3 days a week. In addition to lifestyle modifications, TM can try taking a pharmacologic agent such as nonprescription Alli (orlistat), which can be recommended for patients with a BMI greater than 25. The recommended dosage of Alli is 60 mg with each calorie- reduced meal, which should contain no more than 15 g of fat. In clinical studies of orlistat, patients lost 5 to 10 lb over 6 months. Orlistat can interfere with the absorption of fat-soluble vitamins; therefore. multivitamins should be taken at least 2 hours before or after taking orlistat. TM should be warned that orlistat may cause flatulence or oily stools when high-fat foods are eaten.

RG is a 58-year-old woman who comes to the pharmacy looking for something for her hot flashes. She says over the past few months, she has experienced redness in her face and heat radiating down her neck. She has also had irregular menstruation. Her friend recommended she take a soy supplement to help with her hot flashes. The friend said the supplements are natural and safe. RG has no other medical issues and is not taking any medications. What recommendations do you have for RG?

 RG appears to be suffering from menopausal symptoms. Soy has been studied in patients who are in menopause and have hot flashes. Washburn and colleagues demonstrated that 20 g of soy protein decreased the severity and frequency of hot flashes.

 Although the results of some clinical studies have shown soy could be beneficial, others have shown no benefit with soy. Most studies have shown that a dose up to 60 g per day is generally safe; however, the effects of high doses are unclear.

 Soy appears to work similar to estrogen and has been shown to increase the risk of developing blood clots. It is not recommended in patients with hormone-sensitive cancers.

Because RG has not been given a formal diagnosis of menopause, she should be encouraged to see her primary care provider to determine whether pharmacologic therapy would be a better option than soy. If RG wants to try something natural, she can increase her soy intake to see if it helps her symptoms.

		Nutrition during pregnancy. American College of Obstetricians and Gynecologists website. acog.org/-/media/For-Patients/faq001.pdf?dmc=1&ts=20160428T2256140523. Published April 2015. Accessed May 1, 2016.

		Ophthalmic disorders. In: Krinsky DL, Ferreri SP, Hemstreet B, et al (eds). 

		Your Alli brand startup guide. Myalli.com website.myalli.com/content/dam/global/Alli/PDF/alliBrandStartupGuide.pdf. Accessed May 6, 2016.

		Washburn S, Burke GL, Morgan T, Anthony M. Effect of soy protein supplementation on serum lipoproteins, blood pressure, and menopausal symptoms in perimenopausal women. 

Self-Care for Women's Health

A 35-year-old man comes to the pharmacy looking for a product for his dry eyes. He says that for the past few weeks, his eyes have felt very tired, as he has been using a computer more at his work. He went to an eye doctor, who said he is suffering from mild dry eyes. The doctor recommended he use something over-the-counter. The patient is not taking any medications and has no other medical conditions. He is confused about which product to take. What would you recommend to help relieve this patient’s dry eyes?

Most patients who come to the pharmacy with dry eyes typically have not gotten a diagnosis of the condition. Therefore, we typically look for symptoms such as tired or red eyes. Because this patient has been given a diagnosis of dry eyes, we can recommend any ophthalmic lubricant, such as Systane, Teargen II, Soothe, Tears Naturale, or GenTeal Lubricant Eye Gel. A few formulations are on the market. Drops are typically used during the day, and formulations made with gels are recommended for use at night and are typically reserved for more severe cases.1 The patient should follow the package’s directions for use, which typically recommend application of drops 1 or 2 times daily for mild dry eyes. If he has severe dry eyes, he can use the drops up to 4 times daily, and overnight gel therapy should be recommended. In addition to using drops, the patient could decrease or avoid computer use, as it can lead to dry eyes. Warm compresses and protective eye equipment may also help decrease his dry eyes.

A 29-year-old mother comes to the pharmacy looking for treatment for lice for her 6-year-old daughter. This is the first time this mother has had lice in her household and she feels very overwhelmed. She thinks her daughter got it from school and says her daughter has been complaining about itching on her head. When she tried to remove what looked like dandruff from her daughter’s hair, the gray/ white speck was firmly attached to the hair shaft. Her friend said it is lice, but she is not sure. What recommendation do you have for this mother?

Lice are easily identified by their firm attachment to the hair shaft. Head lice are common in school-age children and appear to be white or gray. Two ingredients— pyrethrin and permethrin&mdash;are available for treating lice. Pyrethrins are typically used in combination with piperonyl butoxide to help kill lice. Patients should be educated to follow the directions on the package. Both treatments are typically left on the hair for 10 minutes. Whereas pyrethrin requires a second application 7 to 10 days later to kill nits that may have hatched since the first treatment, permethrin is not applied again unless active lice are detected. Because the products do not kill 100% of the nits, a nit comb should be used with these products, many of which come with the comb. The adverse effects of both products are similar; however, permethrin is more effective after one treatment.

A 32-year-old woman comes to the pharmacy looking for a product to protect her from sunburn. Her family is planning on going to Hawaii next week. She says that the last time they went on vacation, she forgot to buy sunscreen; her family got sunburnt on the first day, and the trip was ruined. She also worries about the exposure causing cancer. She wants to know what you recommend for her if she is planning on being in the water some of the time, but also lying out in the sun. She wants to know if you recommend a specific SPF for sunscreen and which products are effective?

It is most important to educate this customer on avoiding or minimizing her sun exposure. The sun’s rays are most damaging between 10 am and 4 pm. She should try to avoid the sun during this time; however, it sounds like she will be exposed to the sun most of the day. If she cannot avoid it, she should try to wear protective clothing, such as hats and long-sleeve shirts, or use protective equipment, such as a beach umbrella. An SPF of 15 or higher provides the greatest protection. She should consider buying a product that protects against ultraviolet A and B rays. These products contain octocrylene, meradimate, titanium dioxide, benzophenones, or avobenzone with padimate O. She should be taught to apply sunblock at least 15 minutes before sun exposure. If she is planning to go into the water, she should buy a water-resistant product and apply it every 40 to 80 minutes. Non—water-resistant products can be applied every 2 hours. Reapplication is the best way to protect her family against the sun’s rays.

		Ophthalmic disorders. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. 

		Insect bites and stings and pediculosis. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. 

Self-Care for Skin and Eye Disorders

A 40-year-old man presents to the pharmacy seeking advice for his allergies, from which he has suffered for years. He has been taking loratadine 10 mg daily during his seasonal outbreaks. He saw a commercial for a nasal spray that is now available over the counter. He did some research and found that the nasal spray is more effective. What education and recommendation can a pharmacist provide regarding OTC intranasal steroids?

The American Academy of Allergy, Asthma & Immunology and the American College of Allergy, Asthma and Immunology rate intranasal corticosteroids as the most effective class of medication for controlling nasal symptoms of allergic rhinitis.

 Because loratadine is not controlling this patient’s symptoms, he may benefit from an inhaled corticosteroid. Intranasal corticosteroids work best when used every day. Patients should be informed that they need to use the product for several days before relief will be seen, however.

The FDA has approved 2 intranasal corticosteroids for the switch from prescription to over the counter: Nasacort (triamcinolone acetonide) and Flonase (fluticasone propionate) have been available over the counter since July 2014.

 The efficacy profiles of these nasal sprays are similar, but patient preference should be considered when a recommendation is made. Many inhaled corticosteroids contain alcohol, which can affect odor and dryness. Triamcinolone acetonide nasal spray does not include alcohol; therefore, it is free of odor and taste. Fluticasone propionate contains phenylethyl alcohol. If patients are complaining of dryness or odor, this may play a role in education. Otherwise, both nasal sprays are effective in controlling seasonal allergies.

Depending on the formulation, 1 to 2 sprays in each nostril daily can be recommended. Each time the patient uses the medication, he should shake the bottle well. He should be educated that minor adverse effects (AEs), such as nasal bleeding and sneezing, are common. Serious AEs include glaucoma, cataracts, infection, and changes in vision.

A 35-year-old woman comes to the pharmacy complaining of red, itchy eyes; frequent sneezing; and congestion. She says she has not had a fever and has not tried any medications. She says her symptoms are worst when awakening and improve during the day. She has no chronic conditions and no other diagnoses. She currently takes a prenatal vitamin daily and has no drug allergies. On questioning, she reveals she is currently 22 weeks pregnant. A few years ago, she was taking cetirizine hydrochloride for her allergies, but stopped taking it because her physician said it may not be safe while she is pregnant. She has come to the pharmacy looking for relief from her symptoms. What recommendations can you make?

She appears to be suffering from allergic rhinitis, of which pregnancy is a common cause. Therefore, she should be referred to her primary care physician for an evaluation and a recommendation. If allergic rhinitis is confirmed, many treatment options are available.

 Typically, the FDA categorizes medications based on pregnancy categories. For Category B, animal reproduction studies have failed to demonstrate a risk to the fetus, and there are no adequate and well-controlled studies in pregnant women. Many of the medications used during pregnancy fall into Category B. Cetirizine (Zyrtec), loratadine (Claritin), diphenhydramine (Benadryl), and Cromolyn (NasalCrom) are all Category B medications for allergic rhinitis. Because fexofenadine (Allegra) and nasal corticosteroids are Category C, they are not preferred for use during pregnancy.

The patient should be educated to avoid symptom triggers by keeping doors and windows closed. She should also be instructed on the use of medications for occasional symptom relief and to follow up with her obstetrician for product recommendations.

A 66-year-old woman comes to the pharmacy complaining of fever, body aches, chills, congestion, and cough. She claims she has not been feeling well over the past week and has not been able to eat. Her temperature has ranged from 101ºF to 102.7ºF for the past 24 hours. She is also short of breath and has chronic obstructive pulmonary disease (COPD). She has been taking acetaminophen around the clock, which temporarily reduces her fever. She has not had any vaccinations because she thinks they do not work. What would you recommend for this patient’s fever and cold?

Infection, due either to the influenza virus or to bacteria, is the likely cause of this patient’s condition. Because she has COPD and shortness of breath, it is recommended that she go to a physician for evaluation. Other reasons patients should not self-treat for a cold include fevers higher than 101.5ºF for more than 48 hours, chest pain, worsening of symptoms, cardiopulmonary diseases (eg, chronic heart failure), an acquired immunodeficiency syndrome, or advanced age.

This patient can continue to take acetaminophen; however, she should not take more than the recommended 4000 mg per day. She should be encouraged to contact her primary care physician immediately, especially because she is short of breath, and educated on the importance of vaccinations for preventing illness. Although nonlive vaccinations are not a contraindication for her, because she is not feeling well, it may be advisable for her to recover from her illness before getting a vaccination.

A 26-year-old woman comes to the pharmacy to refill her prescription for a multivitamin. She states she recently quit smoking because she heard it is harmful to inhale the chemicals in cigarettes, in addition to nicotine. She decided to try the vape pens her friends use. Use of these pens is known as vaping. To her surprise, she has not felt the urge or need to smoke a cigarette in 7 days, and she had been smoking 2 packs per day for 9 years. She wants to know if you have heard anything about vape pens and you have recommendations for her.

According to the CDC, electronic cigarettes (e-cigarettes) are an emerging challenge for public health because the long-term benefits and risks associated with their use are unknown. Currently, e-cigarettes are unregulated in the United States. The FDA has proposed regulating e-cigarettes as tobacco products, but this has not yet happened.

The patient should be educated that nicotine is an addictive chemical and that because e-cigarettes are not regulated, their use is not recommended for smoking cessation. She should be encouraged to discuss with her physician or pharmacist other ways to quit smoking, such as nicotine replacement therapy or drug therapy.

One study found no difference between e-cigarettes and nicotine patches.

 Therefore, because e-cigarettes are not regulated, it may be safer to recommend nicotine replacement products in the form of gum, lozenges, or patches. These can all be obtained over the counter and are effective for smoking cessation.

Got an interesting question regarding OTC medications? Contact the authors at otccasestudies@pharmacy.rutgers.edu and share the details. Your case could be featured in an upcoming column!

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