Rupal Patel Mansukhani, PharmD, CTTS, FAPHA

: JS is a 58-year-old woman who is interested in taking black cohosh. She said that her hot flashes are “out of control” and frequently cause intense heat and redness to show up on her face and neck. JS says that although the problem is worse at night, she gets hot flashes during the day, as well. A friend suggested JS try black cohosh. JS, who is otherwise relatively healthy, has not yet spoken to her doctor but wants to try this herb. What recommendations do you have regarding black cohosh for menopause?

: JS appears to be suffering from menopausal symptoms but should go to her physician to be assessed and diagnosed. Black cohosh has been shown to reduce symptoms of menopause. However, the evidence varies depending on the formulation. One proprietary preparation that has proven beneficial is Remifemin. The extract is standardized to 1 mg of triterpene glycosides, calculated as 27-deoxyactein, per 20-mg extract tablet.

 Common adverse effects include gastrointestinal issues, headaches, rash, and weight gain. Some case reports have also shown acute hepatitis when using black cohosh. Advise JS to monitor for these symptoms if she plans to use it. Also, safety has not been demonstrated in long-term studies, so she should not use it for more than 6 months.

: BB is a 58-year-old woman who is looking for a calcium supplement. She has been taking a multivitamin for years but is a vegan and recently realized that she is still not getting enough calcium. BB says that she typically does not like to take too many medications but wants to make sure she is taking care of herself as she gets older. She has no medical conditions. What recommendations do you have?

: Advise BB that everyone can benefit from appropriate calcium intake. Based on her age, she should get 1200 mg per day of calcium. Adults who are younger than 50 years should take about 1,000 mg of calcium per day, and women 51 years and older should take 1200 mg per day. Experts also recommend a daily intake of about 600 international units of vitamin D up to age 70 years.

OTC calcium typically comes in 500 or 600 mg, so let BB know that she may need to take 2 tablets to meet her daily recommended intake. Many formulations have calcium with vitamin D, so she can get a combination tablet. BB should separate the dosing to achieve the maximum benefit. Because she is vegan, she can try to increase her dietary calcium by eating oatmeal, soybeans, and tofu. Patients who are not vegan can increase their calcium intake by having milk and yogurt.3 If BB is trying to obtain her calcium through her diet, it is important to stress that she should have a consistent daily intake. BB should also consider following up with a physician to discuss her bone health.

: RD is a 40-year-old woman who, while refilling her prescription, mentions that she got sunburned the day before after not using sunscreen. Her mild sunburn is visible on her face and shoulders. RD says that she is under the impression that sunblock does not work well in the water. She has wellcontrolled diabetes, and is otherwise healthy. What recommendations do you have regarding sunscreen?

: Inform RD that sunblock can be used in the water, and if she plans to swim outside frequently, she should purchase a water-resistant product. It is important to reapply water-resistant sunblock every 40 to 80 minutes and non—water-resistant sunblock every 2 hours. If RD plans on being outdoors and is concerned about insects, she can apply the sunblock and then spray the insect repellent if needed but not rub it in. Let her know that the sun’s rays are most dangerous between 10:00 am and 4:00 pm. During that time, RD should wear protective clothing and apply sunblock with an SPF of 15 or higher. She should consider buying products that contain octocrylene, meradimate, titanium dioxide, benzophenones, or avobenzone with padimate O, which protect against ultraviolet A and B rays.

: PA is a 30-year-old man who wants to start taking vitamin C to prevent the coronavirus disease 2019 (COVID-19). PA works in a grocery store and is concerned about his exposure to other people. He is healthy, with no medical conditions and does not take any medication or vitamins. PA’s friend recommended that he start taking vitamin C, but he does not know which dose to take. What recommendations do you have?

: Vitamin C has a lot of properties that can be beneficial for treating viral infections.

 Therefore, many people use vitamin C to prevent common colds. However, the jury is out. The results of 1 study showed that vitamin C 50 mg/kg intravenous every 6 hours for 96 hours did not significantly alter C-reactive protein levels, disease severity scores, or thrombomodulin levels compared with a placebo in patients with acute respiratory distress syndrome and sepsis. The study results did show that the 28-day all-cause mortality and intensive care unit—free days were significantly lower in both.

 Patients treated in China with moderate to severe COVID-19 with large doses of intravenous vitamin C (10,000 to 20,000 mg/d) had shorter lengths of hospital stays than untreated patients with COVID-19. However, these data have not been published and therefore cannot be recommended. Advise PA that there is no evidence for patients taking vitamin C to prevent COVID-19. If he is really concerned, he should take a multivitamin for overall health and follow guidance to appropriately wash hands often and keep a safe distance from other people.

, is a clinical assistant professor of pharmacy practice and administration at the Ernest Mario School of Pharmacy at Rutgers, the State University of New Jersey, and an ambulatory care specialist at RWJBarnabas Health in New Jersey.

Rupal Patel Mansukhani, PharmD, CTTS, FAPhA

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

Liske E, Hanggi W, Henneicke-von Zepelin HH, Boblitz NN, Wustenberg P, Rahlfs VW. Physiological investigation of a unique extract of black cohosh (cimicifugae racemosae rhizoma): a 6-month clinical study demonstrates no systemic estrogenic effect. 

 2002;11(2):163-174. doi: 10.1089/152460902753645308

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 2005;105(5 pt 1):1074-1083. doi: 10.1097/01.AOG.0000158865.98070.89

Calcium and vitamin D: important at every age. National Institutes of Health. National Institute of Arthritis and Musculoskeletal and Skin Disease. Accessed May 27, 2020. 

bones.nih.gov/health-info/bone/bone-health/nutrition/calcium-and-vitamin-d-important-every-age

Crosby KM, O’Neal KS. Prevention of sun-induced skin disorders. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. 

 19th ed. American Pharmacists Association; 2017.

Kashiouris MG, L’Heureux M, Cable CA, Fisher BJ, Leichtle SW, Fowler AA. The emerging role of vitamin C as a treatment for sepsis. 

Hemilä H, Chalker E. Vitamin C for preventing and treating the common cold. 

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Fowler AA, Truwit JD, Hite RD, et al. Effect of vitamin C infusion on organ failure and biomarkers of inflammation and vascular injury in patients with sepsis and severe acute respiratory failure: the CITRIS-ALI randomized clinical trial. 

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Coronavirus disease (COVID-19) advice for the public. World Health Organization. Updated April 29, 2020. Accessed May 28, 2020. 

who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public

Articles

Four OTC cases are presented for women's health.

OTC Case Studies: Women's Health

Q: RD, a 23-year-old man, asks for something to treat a scaly, itchy rash between his toes. He has been running outdoors since the weather got warmer and thinks that the humidity may be causing the rash. RD is training for a marathon in a few months and does not want to stop running. He got new running shoes, but the itchiness continued. RD is otherwise healthy and does not take any medications. He would prefer to use an OTC treatment and heard about powders that absorb humidity. What recommendations do you have?

A: It appears that RD has athlete’s foot, or tinea pedis. The fungus that typically causes the infection can grow in humid conditions. If the area is kept clean, it can be treated over the counter, as long as there is no medical condition or secondary infection. RD can purchase an OTC product that includes at least 1 of the following ingredients: butenafine, clotrimazole 1%, miconazole 2%, tolnaftate 1%, or undecylenic acid. Depending on the ingredient and manufacturer, the product can be applied once or twice daily for up to 4 weeks. It is important to advise RD that he should follow the package directions, because the products differ in duration of treatment and formulation. He should try to avoid using powders or sprays, which are typically less effective because they are not rubbed into the skin.

 RD runs every day, so he may benefit from wearing moisture-wicking socks that keep the fungus from growing. If the infection persists or worsens, he should seek medical attention.

Q: MJ is a 26-year-old woman who is looking for a vitamin D supplement. She says that a friend is taking vitamin D because she thinks that it prevents coronavirus disease 2019 (COVID-19). MJ works at an assisted-living center and often gets sick, so she wants to take something natural that will help her avoid being infected by the virus. She has no medical conditions, she is healthy, and her immunizations are up-to-date. MJ denies taking anything over the counter, including natural products or vitamins. What recommendations do you have regarding prevention of COVID-19 with vitamin D?

A: Some evidence supports the role of vitamin D in reducing viral infections. One study’s findings showed that vitamin D could interfere with viral replication.

 In addition, supplementing with vitamin D prior to infections was shown to reduce expression of angiotensin-converting enzyme 2, which may be beneficial in patients with viral infections.

 Although a few studies have shown that supplementation may be helpful, no well-controlled clinical trials have been conducted, especially in patients with COVID-19. Advise MJ that vitamin D is fat soluble and can lead to toxicity. An overabundance of vitamin D can lead to anorexia, heart arrhythmias, polyuria, and weight loss, as well as damage to the blood vessels, heart, and kidneys. However, during winter months, many patients can be deficient in vitamin D. It is important to let MJ know that the recommended dietary allowance is 600 IU daily for patients aged 19 to 70 years. Patients over 70 years can increase to 800 IU daily.

 A health care provider can recommend an appropriate prescription product for a vitamin D deficiency. If MJ is concerned about COVID-19, the best way to protect herself is by practicing good hygiene. She should avoid touching her face, cough and sneeze into an elbow or a tissue, disinfect surfaces at the office, and wash her hands frequently.

 She should also follow her workplace guidelines on personal protective equipment when she is with patients.

Q: LS, a 54-year-old man, stops in to discuss acetaminophen. He has been taking ibuprofen 600 mg twice daily for several years to treat his arthritis. A few years back, his doctor recommended taking an anti-inflammatory medication for pain that, at the time, was not controlled. Since then, LS says, his pain has been well managed, and he has no complaints. However, he heard a news report that made him concerned that taking ibuprofen will increase his chances of being infected with the COVID-19 virus. LS has not spoken with his physician but would like to know your thoughts on discontinuing ibuprofen and taking acetaminophen instead. What information can you provide on ibuprofen and the coronavirus?

A: The Infectious Diseases Society of America released guidelines on the treatment of COVID-19, addressing statements by the FDA and World Health Organization that no available data suggest that nonsteroidal anti-inflammatory drugs (NSAIDs) worsen COVID-19—related infections. At this time, the data are limited, but the virus is thought to use angiotensin-converting enzyme 2 to cause infections. This enzyme can be upregulated by medications, such as ibuprofen. However, no substantial evidence shows a link to ibuprofen or any NSAIDs harming patients by this process.

 In addition, advise LS that no data connect ibuprofen to an increased risk of being infected by the COVID-19 virus. However, NSAIDs have cardiovascular, gastrointestinal, and renal risks associated with them, so patients should be counseled about the potential for adverse events.

 If LS wants to discontinue his ibuprofen, he should speak with his health care provider to discuss the best OTC or prescription alternative.

Q: TY is a 38-year-old woman in search of a way to treat her eyes, which have been itchy the past few days. She recently started working at a landscaping company and has been outside a lot. TY thinks that she is allergic to pollen, but she has never been tested. Before working at this job, she did not spend much time outdoors, especially in the spring. TY’s physician recommended using OTC eye drops. TY has no other medical conditions and does not take any medication. What recommendations do you have?

A: Avoiding allergens is the best way to treat allergies, but because TY’s work requires her to be outside, that is not an option for her. She should, however, try to stay indoors as much as possible when not at work, keep car windows closed when driving, wear sunglasses, and shower when she gets home to remove some of the pollen. First-line treatment for allergic conjunctivitis is artificial tears, which TY can use according to the package instructions. Gel formulations can be beneficial overnight. If her symptoms do not improve within a few days, she can try using ketotifen ophthalmic solution twice daily, which works directly on the eyes, not systemically. However, if her symptoms persist, she should consider speaking with her health care professional to evaluate and rule out an eye infection.

 TY can use an OTC oral antihistamine such as cetirizine, fexofenadine, levocetirizine, or loratadine if infections have been ruled out.

Gardner A, Walkup N. Fungal skin infections. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. 

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

Teymoori-Rad M, Shokri F, Salimi V, Marashi SM. The interplay between vitamin D and viral infections. 

Xu J, Yang J, Chen J, Luo Q, Zhang Q, Zhang H. Vitamin D alleviates lipopolysaccharide-induced acute lung injury via regulation of the renin-angiotensin system. 

 2017;16(5):7432-7438. doi:10.3892/mmr.2017.7546

Vitamin D. National Institutes of Health. Updated March 24, 2020. Accessed April 18, 2020. 

https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

How to protect yourself and others. CDC website.

Updated April 24, 2020. Accessed April 30, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html

Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19. Infectious Diseases Society of America. Published April 11, 2020. Accessed April 18, 2020. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/

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Systane Aaditor Antihistamine Eye Drops ingredients and usage. Alcon. Accessed April 1 2020. 

https://systane.myalcon.com/eye-care/systane/products/systane-zaditor/ingredients/

Four case studies about skin and eye health.

OTC Case Studies: Skin and Eye Health

: RC is a 34-year-old male truck driver who is seeking information about the use of e-cigarettes. He reports that his primary care physician, who is treating RC’s diabetes, recommended smoking cessation. RC mentions that his friends have been trying to quit cigarette smoking via e-cigarettes. He is skeptical but asks about the latest recommendations. What recommendations do you have?

: Based on the symptoms reported, BA likely has a common cold, for which antibiotics would not be a cure.1 He should try nonpharmacologic and single-ingredient OTC medications to provide supportive care for the symptoms. BA should also increase fluid intake and rest and consider increased humidification with a humidifier, steam, or a vaporizer.

 Per CDC recommendations, encourage him to use alcohol-based hand sanitizer and wash his hands frequently.

BA should start taking a nonsedating antihistamine, such as cetirizine, fexofenadine, levocetirizine, or loratadine. Antihistamines may help alleviate a runny nose.

 Instruct BA to monitor for worsening symptoms; if they present, a medical referral will be necessary.

: RS is a 40-year-old woman who smokes. She has fatigue, fever, and a severe sore throat with inflamed lymph nodes. RS has tried natural remedies that her sister recommended, but she finds that the symptoms have continued, and she has also developed a cough with green and yellow sputum. RS stops by to ask about combination cold and cough products. What recommendations do you have?

: Given this patient’s symptoms of a productive and worsening cough with a persistent fever, she cannot self-treat. Refer RS to her primary care physician, as she may be suffering from a bacterial respiratory infection and requires further evaluation in case she needs an antimicrobial agent.

 For supportive care, advise RS to avoid cigarette smoking, drink hot honey and lemon tea for sore throat relief, increase fluid intake, and rest.

: RP is a 31-year-old man who asks about complementary and natural products for cold and respiratory infection prevention. He has heard about Echinacea purpurea and vitamin C but is unsure of the evidence. What information can you provide?

 : Of the products RP listed, prophylactic high-dose vitamin C (at least 2000 μg) has been shown to reduce the duration and severity of a cold. The results of the same meta-analysis compared the use of prophylactic vitamin C in study participants under physical stress, such as marathon runners and skiers, with use in community participants. Study results showed that vitamin C was effective in preventing colds in participants under stress.

 If RP expects physical stress during his trip, vitamin C may be an appropriate choice for him.

 has been shown to decrease mucin production and symptoms of respiratory infections. Its anti-inflammatory and immune stimulatory effects may be responsible for its efficacy. No standardized dose for 

 exists, and each product may be labeled per concentration and formulation.

 to be more effective in preventing recurrent infections than a placebo. If RP were to choose 

, he should take it at the onset of cold symptoms.

Similarly, elderberry (Sambucol) has been shown to exhibit anti-inflammatory and antiviral properties. Results of a study comparing elderberry with placebo showed a shortened duration of cold symptoms and fever in patients with the influenza virus.

 Additionally, the use of rescue medications, such as analgesics (acetaminophen and nonsteroidal inflammatory drugs) and nasal sprays, was decreased with the use of elderberry compared with a placebo.

Finally, zinc has been shown to reduce the incidence of colds in healthy people. The results of a meta-analysis showed that zinc was effective in reducing the duration and symptoms of the common cold when administered every 2 hours at the onset of symptoms.

Commonly advertised products Airborne and Emergen-C are not proven therapeutics for respiratory infections. However, they include proprietary blends of the above-mentioned complementary therapies.

: PP is a 22-year-old male college student who stops in to purchase nasal decongestant spray Afrin. He moved into a carpeted apartment this semester and suffers from dust mite allergies. PP stopped taking his antihistamine loratadine, as it had stopped working well for him. He has a cough, a postnasal drip, and a stuffy nose with trouble breathing through his nose. He asks whether he should know anything in particular about Afrin. What information can you provide?

: PP’s symptoms are consistent with allergic rhinitis that progressed to congestion and postnasal drip. He should resume a nonsedating antihistamine. If loratadine no longer works, he can try cetirizine, fexofenadine, or levocetirizine.

 For topical decongestant oxymetazoline (Afrin), he should limit use to 2 doses every 24 hours for a maximum duration of 72 hours.

 Rebound congestion has been associated with overuse of oxymetazoline. The therapy duration is controversial because results of some studies have shown a treatment duration up to 8 weeks to be safe without rebound congestion. Counsel PP on appropriate nasal spray technique, as ingestion of oxymetazoline may result in adverse effects, including coma, drooling, hyperthermia, and nausea.

, is a clinical assistant professor of pharmacy practice and administration at the Ernest Mario School of Pharmacy and an ambulatory care specialist at RWJBarnabas Health in New Jersey.

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

Buensalido JAL, Valencia JCB, Rhinovirus (RV) Infection (common cold) clinical presentation. Medscape website.

emedicine.medscape.com/article/227820-clinical

. Updated July 30, 2019. Accessed March 15, 2020.

Common colds: protect yourself and others. CDC website. 

. Updated February 11, 2019. Accessed March 15, 2020.

De Sutter AI, van Driel ML, Kumar AA, Lesslar O, Skrt A. Oral antihistamine-decongestant-analgesic combinations for the common cold. 

 2012;(2):CD004976. doi: 10.1002/14651858.CD004976.pub3. 

Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. 

 2016;164(6):425-434. doi: 10.7326/M15-1840.

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Hudson JB. Applications of the phytomedicine 

 (purple coneflower) in infectious diseases. 

 2012;2012:769896. doi: 10.1155/2012/769896.

Schapowal A, Klein P, Johnston SL. Echinacea reduces the risk of recurrent respiratory tract infections and complications: a meta-analysis of randomized controlled trials. 

 2015;32(3):187-200. doi: 10.1007/s12325-015-0194-4.

Zakay-Rones Z, Varsano N, Zlotnik M, et al. Inhibition of several strains of influenza virus 

 and reduction of symptoms by an elderberry extract (

 L.) during an outbreak of influenza B Panama

 1995;1(4):361-369. doi: 10.1089/acm.1995.1.361.

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. 

 2004;32(2):132-140. doi: 10.1177/147323000403200205.

Singh M, Das RR. Zinc for the common cold. 

 2011;(2):CD001364. doi: 10.1002/14651858.CD001364.pub3.

Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis. 

 2015;152(suppl 1):S1-S43. doi: 10.1177/0194599814561600.

Cold, cough, allergy, bronchodilator, and antiasthmatic drug products for over-the counter human use. Electronic Code of Federal Regulations website. 

ecfr.gov/cgi-bin/text-idx?SID=694f58669bc9c39632fe5305dd2358e6&mc=true&node=pt21.5.341&rgn=div5#se21.5.341_172

. Updated March 23, 2020. Accessed March 25, 2020.

Mortuaire G, de Gabory L, Francois M, et al. Rebound congestion and rhinitis medicamentosa: nasal decongestants in clinical practice. Critical review of the literature by a medical panel. 

2013;130(3):137-144. doi: 10.1016/j.anorl.2012.09.005.

US Department of Justice. CMEA (Combat Methamphetamine Epidemic Act 2005). Drug Enforcement Administration website. 

Case studies focusing on infectious disease.

OTC Case Studies(April 2020)

RC is a 34-year-old male truck driver who is seeking information about the use of e-cigarettes. He reports that his primary care physician, who is treating RC’s diabetes, recommended smoking cessation. RC mentions that his friends have been trying to quit cigarette smoking via e-cigarettes. He is skeptical but asks about the latest recommendations. What recommendations do you have?

Let RC know that a study conducted in the United Kingdom compared the rates of smoking cessation using a particular brand of e-cigarettes versus nicotine replacement therapy. The 1-year abstinence rate was 18.0% in the e-cigarette group and 9.9% in the nicotine-replacement group.

In addition, given the variability in the composition of e-cigarette products and insufficient evidence supporting the use of e-cigarettes, the 2020 US Surgeon General’s Report on Oral Health does not make generalizations about the efficacy of e-cigarettes for smoking cessation. However, the report does acknowledge that findings from clinical trials suggest that e-cigarettes containing nicotine are associated with increased smoking cessation compared with e-cigarettes that contain no nicotine. Also, more frequent use of e-cigarettes is associated with increased smoking cessation compared with less frequent use. The report summarizes that if smokers were to use e-cigarettes, they would need to stop smoking cigarettes and other tobacco products completely before switching to e-cigarettes, with the ultimate goal of stopping using e-cigarettes as well.

Although e-cigarettes contain fewer toxic chemicals than burned tobacco products, they still carry carcinogenic chemicals and tiny particles that reach deep into the lungs via aerosolization of the liquid. Furthermore, the FDA has not approved the use of nicotine-containing e-cigarettes for smoking cessation. FDA-approved agents for smoking cessation include nicotine replacement therapy using gum; an inhaler; lozenges; nasal spray; prescription medicines, such as bupropion and varenicline; and the transdermal patch.

VH is a 40-year-old woman who recently discussed smoking cessation with her primary care physician (PCP) and is picking up nicotine replacement patches and gum. Although her PCP had informed her about nicotine replacement therapy products and how they work, she asks if there is anything she can use on her smartphone, or alerts she can arrange to help her manage cravings and adhere to her quit plan. What recommendations do you have?

Tell VH that one option is to call the “quitline” 1-800-QUIT-NOW (1-800-784-8669), which is staffed by coaches who are trained in smoking cessation. Another option is the free quitSTART app for smartphones. This app, created by the FDA and the National Cancer Institute, assists the user in getting back on the road to cessation after a slipup by managing cravings, monitoring progress, and staying on track. A third option is SmokefreeTXT, a texting service that asks users screening questions about their smoking history and quit plans. After the questions are answered, the user receives 3 to 5 texts per day for 6 to 8 weeks to assist with smoking cessation. Topics discussed on SmokefreeTXT include cravings, nicotine withdrawal, triggers, and weight gain. Users can sign up by texting QUIT to 47848. Finally, there are a number of social media discussion groups on Facebook, Pinterest, Twitter, and YouTube where VH can find support.

CASE 3: MEDICATIONS AND SMOKING CESSATION

HS is a 42-year-old man who is picking up his clozapine prescription. He has been smoking 10 cigarettes per day for 15 years and is interested in quitting. HS asks about nicotine replacement products. What advice do you have?

Tell HS about smoking cessation, but also counsel him on the importance of speaking with the clozapine prescriber about his plan to quit smoking. Given that tobacco smoking induces cytochrome P450 1A2, patients who smoke require much higher doses of clozapine (a medication metabolized by 1A2) to achieve therapeutic levels.

 If HS were to quit smoking, he would be at risk for clozapine toxicity because of reduced 1A2 induction and increased serum concentration of clozapine if he continued taking the same dosage. The clozapine prescriber and HS should be urged to consider a clozapine dose reduction, monitor changes in smoking habits, and obtain baseline clozapine levels prior to smoking cessation. Inform HS that he could develop symptoms of clozapine toxicity 2 to 3 weeks after smoking cessation if he is not monitored appropriately.

CL is a 32-year-old woman who recently bought nicotine gum from the pharmacy to aid in smoking cessation and manage cravings. She returns a week later with complaints of hiccups and indigestion. These adverse effects are disrupting CL’s workday, and she asks for advice. What do you tell her?

Tell CL that the hiccups and indigestion may be a result of excessive nicotine release from chewing the gum too quickly. Inform her that it is not like regular gum and is meant for buccal absorption. Counsel CL on the chew-and-park method: First, chew the gum slowly until it begins to tingle; then place it between the cheek and gums until the tingle goes away; finally, repeat this process until the tingle is gone after 30 to 60 minutes. Remind CL that the gum’s effectiveness may be reduced by beverages or food, so she should not drink or eat anything 15 minutes before or while using the gum.

 is a clinical assistant professor of pharmacy practice and administration at the Ernest Mario School of Pharmacy and an ambulatory care specialist at RWJBarnabas Health in New Jersey.

Rupal Patel Mansukhani, PharmD, CTTS, FAPhA,

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

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Handling e-cigarettes, technological solutions to smoking, and more.