Rupal Patel Mansukhani, PharmD, FAPhA, NCTTP

: RD is a 35-year-old man who is looking for an OTC 

 inhaler. He received a diagnosis of mild intermittent asthma 20 years ago, and the physician recommended an inhaler. RD’s symptoms, typically chest tightness, appear every few months. He occasionally also experiences shortness of breath and wheezing that require medical care, though he has never been hospitalized as a result. The asthma does not interrupt his sleep. RD recently lost his medications, including an inhaler, on a trip. What should the pharmacist recommend?

A: Because RD has received a diagnosis of mild intermittent asthma and has no warning symptoms, it would be appropriate to recommend an OTC inhaler. Primatene Mist is FDA approved for mild symptoms of intermittent asthma, such as chest tightness, shortness of breath, and wheezing. It contains epinephrine 0.125 mg, which acts like a bronchodilator. Patients 12 years
and older can use 1 oral inhalation when experiencing symptoms. Remind RD to wait at least 4 hours between doses and wash the inhaler mouthpiece after each use. Advise him to seek medical care immediately if he has more than 2 asthma attacks in a week, he is not feeling better within 20 minutes, he needs more than 8 inhalations in 24 hours, or his symptoms worsen.

1. Primatene Mistdrug facts. Accessed March 10, 2022. https://www.primatene.com/drug-facts.aspx

CASE 2: Allergy Avoidance in Asthma Patients

: NM is a 22-year-old woman who is seeking advice on ways to treat her allergies and asthma. She takes fluticasone propionate 250 mcg/salmeterol 50 mcg, loratadine 10 mg daily, and montelukast 10 mg daily and uses an albuterol inhaler as needed. NM says her asthma is well controlled and she has not used the inhaler in 6 months. However, she is concerned because her allergies worsen every spring and she is frequently hospitalized for asthma exacerbation. NM said she enjoys being outside and would like to be able to open the windows in the spring before it is too hot. She is allergic to pollen and wants to know if there is anything else she can do to alleviate her asthma symptoms before pollen season starts. What should the pharmacist advise?

: Advise NM to avoid pollen, if possible, by looking at forecasts and staying indoors during peak times. Although she enjoys the spring weather, she can help decrease pollen exposure by keeping windows closed and using air-conditioning. If NM really wants to be outdoors, she can avoid touching her eyes and wash her face when she comes inside. She should change her clothes after being outdoors and shower if possible.

 In addition, NM should consider talking to her primary care provider, who may add another medication for allergies, such as an intranasal corticosteroid.

2. Pollen and your health.CDC. August 21, 2020. Accessed March 12, 2022. https://www.cdc.gov/climateandhealth/effects/pollen-health.htm

CASE 3: Allergic Rhinitis in Asthma Patients

: HH is a 42-year-old woman who is looking for an OTC nasal spray for her allergies. She takes fluticasone propionate 100 mcg/ salmeterol 50 mcg, cetirizine 10 mg daily and uses an albuterol inhaler as needed. HH recently visited her physician because she has itchy eyes, postnasal drip, and a runny nose. She has been experiencing these symptoms for the few weeks since it got warmer outside. HH’s primary care provider recommended that she start using a nasal spray for allergies. What recommendations should the pharmacist provide?

: Intranasal corticosteroids are very effective for allergy symptoms. Multiple nonprescription formulations are available, such as budesonide (Rhinocort Allergy Spray), fluticasone furoate (Flonase Sensimist), fluticasone propionate (Flonase Allergy Relief), and triamcinolone acetonide (Nasacort Allergy 24HR).

 Advise HH that though intranasal corticosteroids are generally well tolerated, some patients experience a cough, nasal bleeding or discomfort, or sneezing. She can purchase any formulation. However, HH should continue to take her other medications, including the cetirizine 10 mg daily.

3. Over-the-counter allergy nasal steroid sprays -what does it mean for patients? American Academy of Allergy, Asthma, and Immunology. Updated September 28, 2020. Accessed March 12, 2022. https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/triamcinolone-nasal-spray

: SM is a 22-year-old woman who is looking for a COVID-19 home test after being exposed 2 days ago to someone who had tested positive. SM is concerned because she takes medications to control her asthma, though she does not have any COVID-19 symptoms, such as chills, a cough, fatigue, a fever, or loss of smell or taste. She has had 2 doses of a mRNA COVID-19 vaccine, with the second in May 2021. Although she knows a polymerase chain reaction test is most accurate, she wants quick results. What should the pharmacist recommend?

: Advise SM that COVID-19 home tests can provide results within a few minutes compared with laboratory-based tests, which can take a few days. She can use any OTC, FDA-approved COVID-19 home test, a list of which is available on the FDA’s website. SM should take her home test at least 5 days after exposure and if it is negative, she should consider retesting 1 to 2 days after the initial test. If she is positive, she should stay home for at least 5 days and follow local and state guidelines. She should also wear a well-fitted mask around others until she is confirmed as negative.

 If SM experiences symptoms, such as shortness of breath, she should seek medical care. In addition, once she is confirmed as negative, she should consider scheduling a booster dose for the COVID-19 vaccine. Adults should receive a booster dose of either Pfizer-BioNTech or Moderna (mRNA COVID-19 vaccines) at least 5 months after the last dose in their primary series.

4. Self-testing at home or anywhere. CDC. Updated March 9, 2022. Accessed March 13, 2022. https://www.cdc.gov/coronavirus/2019-ncov/testing/self-testing.html4 / 4125%

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

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

Articles

This month's OTC case studies focuses on asthma.

OTC Cases: April 2022

 SD is a 51-year-old woman who calls seeking advice. She was diagnosed with type 2 diabetes 2 years ago and had been taking metformin to keep her HbA1c level at the goal up until a few months ago. SD’s physician told her that her HbA1c level had increased, and it was time for her to add another antidiabetic medication. SD asked the physician for time to think about it and to implement the recommended lifestyle modifications. A friend recommended cinnamon capsules to SD, explaining that cinnamon has been proven to help regulate blood glucose and manage diabetes. Otherwise, SD is healthy and does not take any other medications. What information should the pharmacist provide to SD regarding taking cinnamon capsules for diabetes?

 Cinnamon has been used as a dietary supplement to regulate glucose in type 2 diabetes for several years. Study results from 2003 through 2007 show a significant impact of cinnamon supplementation on HbA1c, lipid, and serum glucose levels. The most studied dose was 2 g daily. Cinnamon 2000-mg capsules are available OTC. The theoretical explanation of the benefits is that cinnamon increases insulin sensitivity and intracellular movement of glucose. More recently, meta-analyses were conducted to assess the impact of cinnamon on diabetes. The meta-analyses results show conflicting data regarding taking cinnamon for diabetes. The results of 1 meta-analysis of 10 trials showed no impact of cinnamon on HbA1c or serum glucose levels, whereas the results of another meta-analysis of 8 trials show a significant impact of cinnamon on serum glucose in type 2 diabetes. Given that the data are inconclusive, pharmacists should not recommend cinnamon use for diabetes treatment.

SD was impressed with the information the pharmacist provided regarding cinnamon as a dietary supplement for diabetes. To follow up, she asks about chromium supplementation for diabetes. What information should the pharmacist provide regarding chromium supplementation for diabetes?

Chromium is an essential mineral that is present in foods
in small amounts. The theoretical explanation of the mechanism of benefits is that chromium may improve glucose tolerance by decreasing insulin resistance. Chromium picolinate is available OTC in doses ranging from 200 to 1000 μg. Studies have investigated the impact of chromium on glucose control. Although some study results show chromium plays a role in reducing blood glucose levels and improving tolerance, others show chromium has no impact. Dietary supplementation with chromium picolinate has not consistently demonstrated benefit in glucose control for type 2 diabetes. Therefore, it is not listed in diabetes guidelines.

DP is an 84-year-old man with type 2 diabetes who recently had blood work done. DP was informed that his glycated hemoglobin (HbA1c) level was 14%, indicating that his diabetes is not well controlled. His physician asked DP whether he tests his blood glucose levels at home. In addition, the physician planned to initiate a long-acting insulin and would like to titrate the dose up as needed per the fasting blood glucose results. DP would need to provide blood glucose data from home to achieve this. DP had been reluctant to check his glucose levels at home because of the painful fingerstick and dexterity requirements of a traditional glucometer. He is seeking information about the FreeStyle Libre 2 continuous glucose monitoring (CGM) device. What information can the pharmacist provide?

As opposed to a monitor that measures glucose in the blood via a fingerstick, FreeStyle Libre 2 measures the glucose in the patient’s interstitial fluid, which lies below the skin but above the blood vessel layer. Following the ingestion of carbohydrates in meals and snacks, glucose first enters the blood stream in vessels and is then absorbed into the interstitial fluid. As such, a glucose reading from the FreeStyle Libre 2 CGM is slightly delayed compared with blood glucose readings via a fingerstick. To overcome this barrier, the CGM has a trend indicator on the reader that shows whether the glucose is trending up, down, or staying consistent to predict outcomes.

If DP were to obtain a prescription for FreeStyle Libre 2, the supplies provided would be a reader and sensors. The sensors would be applied to the back of his arm and are approximately the size of a quarter. Sensors include a microfilament that lays in the interstitial fluid to continuously track glucose. The sensor should be changed every 14 days. To allow for remote monitoring, DP would create an account where he can agree to share the CGM data with his physician’s office so insulin changes can be made accordingly.

The data and scanning can be completed on the reader or via a smartphone application that is available for both Android and iOS devices.

RJ is a 66-year-old man with type 2 diabetes who is seeking advice. He takes insulin glargine and metformin for his diabetes. RJ’s physician recently prescribed Admelog for mealtime injection. RJ has been injecting his 4-unit dose approximately half an hour prior to each meal, but he has been experiencing an inability to concentrate, lightheadedness, and sweating. His friend who has diabetes mentioned that RJ may be experiencing hypoglycemia. What advice should the pharmacist give?

 The insulin regimen RJ described includes both long- and rapid-acting insulins. When administered correctly with relation to meals and with consistent diet, rapid-acting insulin is less likely to cause hypoglycemia. RJ is injecting his Admelog too early in relation to his meals. The correct time to inject the Admelog would be within 15 minutes of meals. One strategy is to inject the dose while sitting down to eat, immediately before the first bite of food. This ensures the medication has not started to reduce blood glucose levels before a patient has ingested food.

For symptomatic hypoglycemia that he described, instruct him to check his blood glucose and eat 15 g of simple carbohydrates if the glucose reading is less than 70 mg/dL. Examples of simple carbohydrates that may be found at home include 8 oz of milk, 4 oz of orange juice or regular soda, 5 to 6 Life Savers candies, or 1 tbsp of honey or sugar. After 15 minutes, the patient should check the blood glucose reading again to ensure it has risen to above 70 mg/dL. If not, he should repeat eating 15 g of simple carbohydrates. Once blood glucose rises to 70 mg/dL, instruct patients to eat a small snack and inform a medical provider in case changes to the diabetes regimen are needed.

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

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

1. Khan A, Safdar M, Ali Khan MM, KhattakKN, Anderson RA. Cinnamon improves glucose and lipids of people with type 2 diabetes. 

.2003;26(12):3215-3218. doi:10.2337/diacare.26.12.3215

2. Leach MJ, Kumar S. Cinnamon for diabetes mellitus. 

.2012;2012(9):CD007170. doi:10.1002/14651858.CD007170.pub2

3. Davis PA, Yokoyama W. Cinnamon intake lowers fasting blood glucose: meta-analysis. 

.2011;14(9):884-889. doi:10.1089/jmf.2010.0180

4. Anderson RA, Polansky MM, Bryden NA, Canary JJ. Supplemental-chromiumeffects on glucose, insulin, glucagon, and urinary chromium losses in subjects consuming controlled low-chromium diets. 

.1991;54(5):909-916. doi:10.1093/ajcn/54.5.909

5. Balk EM, Tatsioni A, Lichtenstein AH, Lau J, Pittas AG. Effect of chromium supplementation on glucose metabolism and lipids: a systematic review of randomized controlled trials. 

.2007;30(8):2154-2163. doi:10.2337/dc06-0996

6. Haak T, Hanaire H, Ajjan R, Hermanns N, Riveline JP, RaymanG. Flash glucose-sensing technology as a replacement for blood glucose monitoring for the management of insulin-treated type 2 diabetes: a multicentre, open-label randomised controlled trial. 

.2017;8(1):55-73.doi:10.1007/s13300-016-0223-6

7. Unger J, Kushner P, Anderson JE. Practical guidance for using the FreeStyle Libre flash continuous glucose monitoring in primary care. 

. 2020;132(4):305-313. doi:10.1080/00325481.2020.1744393

8. Donnelly LA, Morris AD, Frier BM, et al. Frequency and predictors of hypoglycaemia in type 1 and insulin-treated type 2 diabetes: a population-based study. 

.2005;22(6):749-755. doi:10.1111/j.1464-5491.2005.01501.x

9. Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. 

.2003;26(6):1902-1912. doi:10.2337/diacare.26.6.1902

10. Carlson JN, Schunder-Tatzber S, Neilson CJ, Hood N. Dietary sugars versus glucose tablets for first-aid treatment of symptomatic hypoglycaemiain awake patients with diabetes: a systematic review and meta-analysis. 

.2017;34(2):100-106. doi:10.1136/emermed-2015-205637

This month's OTC cases focus on cinnamon, chromium, glucose monitoring, and hypoglycemia.

OTC Cases: February 2022

Q: JW is a man, age 46 years, filling his prescription for baloxavir. He has been feeling unwell for the past 24 hours with body aches, fatigue, fever, headache, runny nose, and sore throat. JW asks about OTC medications to help him feel better in addition to the baloxavir. He does not take any other medications and is relatively healthy. JW went to urgent care the previous night and they ruled out COVID-19, but a test for influenza came back positive. What recommendations should the pharmacist give him?

A: Because JW is being treated with an antiviral medication, the pharmacist can help him manage symptoms OTC. Based on JW’s symptoms, he can use an antipyretic product, such as acetaminophen or ibuprofen, for his body aches, fever, and sore throat. If he experiences breakthrough sore throat pain, he can consider using a lozenge that includes a benzocaine and/or menthol as well. For a runny nose, JW can use a first-generation antihistamine, such as diphenhydramine. Based on his symptoms, he can either buy the products in combination or individually. Because JW has a fever, he should also be educated about staying hydrated. If he experiences fever for longer than 48 hours, he should follow up with his primary care physician. JW should also consider staying away from others or wearing a mask while he is sick to prevent transmission.

Q: KL is a woman, age 68 years, looking for elderberry supplements. She has had body aches, chills, and fever; she tested negative for COVID-19 but positive for influenza. She did not have time to get a flu vaccination this year and is concerned about complications from influenza. KL asks whether elderberry would help treat the flu. She does not take any and is relatively healthy. What should the pharmacist recommend?

A: Advise KL that there are several published studies of elderberry with influenza treatment. The study results show that elderberry could reduce influenza by 4 days compared with the placebo.

 Elderberry is safe for patients; a double-blind, placebo-controlled, randomized trial (NCT03410862) showed no difference in duration or severity of symptoms between the elderberry and placebo groups.

 Because her age puts KL at high risk for influenza complications, she should consider taking oseltamivir 75 mg twice daily for 5 days. She should contact her primary-care provider immediately to get started on antiviral treatment.

If KL has a high fever, she should also consider taking an antipyretic such as acetaminophen or ibuprofen. The pharmacist should also advise her to get an influenza vaccination as soon as she recovers.

Q: MT is a woman, age 35 years, who has a cough with phlegm, fatigue, and fever. She went out a few times over the weekend and because she lives with her elderly parents wants to rule out COVID-19. MT is planning on taking a polymerase chain reaction (PCR) COVID-19 test. However, she wants to know whether there is anything OTC that provides faster results. MT is healthy and has no medical conditions. What should the pharmacist recommend?

A: The OTC Abbott BinaxNOW rapid antigen test has a sensitivity of 64.2% and a high specificity of 92.6% in symptomatic patients, according to the CDC. The high specificity in symptomatic patients, with a very quick turnaround time of just 15 to 30 minutes, can help patients who are symptomatically infectious to isolate and reduce transmission by testing at home rather than going to a crowded testing center where the virus could be transmitted to other individuals. Additionally, it reduces the chance of MT being infected by another individual at the testing center. She can purchase BinaxNOW to determine whether she is sick with COVID-19. Advise MT to follow the package directions; she should have results within 15 to 30 minutes. Additionally, it is important to emphasize that the most accurate test for COVID-19 is a PCR test, and she should still follow up and have one. If MT’s results come back positive from BinaxNOW, she should follow quarantine guidelines and consult a provider if she feels worse.5 Individuals 50 years and older should receive the nonlive herpes zoster vaccine, Shingrix.

Q: SS is a man, age 61 years, who wants COVID-19 and influenza vaccinations. He has diabetes and takes metformin 1000 mg twice daily. SS has never had a reaction to a vaccine and feels healthy. What should the pharmacist recommend?

A: The CDC says COVID-19 and influenza vaccinations can be given at the
same time. Patients with diabetes are at higher risk for both COVID-19 and influenza complications, so SS should get the vaccinations as soon as possible.6 If he experiences any common adverse effects, such as arm pain, chills, or fever, he can take OTC medications such as acetaminophen or ibuprofen for pain relief. In addition, advise SS to stay hydrated. SS should contact his physician if symptoms persist more than a few days.

Ammie J. Patel, PharmD, BCACP, BCPS, is a clinical assistant professor
of pharmacy practice and administration at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, in Piscataway, and an ambulatory
care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.

1. Treatment: what you need to know. CDC. Updated August 31, 2021. Accessed December 2, 2021. 

https://www.cdc.gov/flu/treatment/treatment.htm

2. 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

3. Macknin M, Wolski K, Negrey J, Mace S. Elderberry extract outpatient influenza treatment for emergency room patients ages 5 and above: a randomized, double-blind, placebo-controlled trial. 

 2020;35(11):3271-3277. doi:10.1007/s11606-020-06170-w

4. People at higher risk of flu complications. CDC. Updated November 18, 2021. Accessed December 2, 2021. 

https://www.cdc.gov/flu/highrisk/index.htm

5. Evaluation of Abbott BinaxNOW rapid antigen test for SARS-CoV-2 infection at two community-based testing sites—Pima County, Arizona, November 3-17, 2020. CDC. Updated January 28, 2021. Accessed December 2, 2021. https://www.cdc.gov/mmwr/volumes/70/wr/mm7003e3.htm

6. Frequently asked influenza (flu) questions: 2021-2022 season. CDC. Updated December 8, 2021. Accessed December 22, 2021. 

https://www.cdc.gov/flu/season/faq-flu-season-2021-2022.htm#Seasonal-Flu-and-COVID-19

7. Possible side effects after getting a COVID-19 vaccine. CDC. Updated December 16, 2021. Accessed December 22, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html

This month's OTC Cases focus on influenza.

OTC Cases: January 2022

RS is a 38-year-old woman who has nasal congestion and typically has seasonal allergies. RS has been taking loratadine 10 mg daily for the past few weeks but has had no relief. She wants to know if there is anything stronger she can take over the counter. What recommendations should the pharmacist make?

Typically, RS can use antihistamines, decongestants, or intranasal corticosteroids to treat her symptoms. Because she is already taking an antihistamine, she should try an intranasal corticosteroid. The FDA has approved the following intranasal corticosteroids for nasal symptoms: budesonide (Rhinocort Allergy Spray), fluticasone furoate (Flonase Sensimist), fluticasone propionate (Flonase Allergy Relief), and triamcinolone acetonide (Nasacort Allergy 24HR).

 RS can try any of these intranasal corticosteroids, as all of them are once-daily medications. Both formulations of fluticasone are approved for ophthalmic symptoms, such as watery eyes. If her symptoms do not improve, RS should see her primary care provider.

CASE 2: Nasal Congestion With Vaccination

BL is a 10-year-old girl who comes to the pharmacy with her mother RL complaining about a runny nose, though she has no other symptoms.

BL was tested by her pediatrician for COVID-19 influenza, and streptococcus, but all the test results came back negative. RL was planning on getting BL vaccinated with the newly approved pediatric COVID-19 vaccine. Although she would like BL to receive the vaccination today, she is concerned about her runny nose. What should the pharmacist advise?

The CDC says that vaccines do not affect mild illnesses, such as a cold, cough, ear infection, low-grade fever, or runny nose. In addition, the pharmacist should advise RL that mild illnesses do not affect how well the body responds to a vaccine. Vaccines have a small amount of the bacteria and viruses with which BL would normally come in contact. Therefore, her immune system can handle getting vaccinated today and fighting off her runny nose at the same time. Let RL know that vaccines can cause mild adverse effects (AEs), such as a low-grade fever or soreness or swelling at the injection site. AEs typically resolve within 24 hours, but BL can place a cool, wet washcloth on the sore area. If symptoms persist, she can also take fever- or pain-reducing medications, such as acetaminophen or ibuprofen. RL should follow package instructions on pediatric dosing.

LH is a 54-year-old man who has a dry cough and nasal congestion. He has felt sick for the past few days, so he went to see his health care provider. LH’s COVID-19 and flu tests came back negative. His physician recommended he buy an OTC medication to treat his cold and cough. LH would like a sugar-free medication, as he recently received a diagnosis of diabetes. He does not take any medications. What should the pharmacist recommend to LH?

LH is complaining of 2 symptoms: dry cough and nasal congestion. Most dry coughs are caused by postnasal drip; therefore, he can take a first-generation antihistamine, such as diphenhydramine.

 For the nasal congestion, LH may benefit from the antihistamine but can also use nasal decongestants, such as pseudoephedrine. If he chooses to use a nasal decongestant, he should monitor his blood glucose closely, as it may raise his blood sugar level.

 There are specific OTC formulations with less sugar, such as Diabetic Tussin syrup or Robitussin sugar free. However, these products would not be appropriate for LH because he does not need an expectorant at this time. If he needs cough drops or lozenges for the sore throat, he could consider sugar-free lozenges, such as those from Cepacol, Cold-Eeze, or Ricola.

TY is a 38-year-old man who has had a fever and nasal congestion for the past 3 days. He also complains of occasional shortness of breath. TY went to a local pharmacy to get tested for COVID-19, but his results were negative. He still feels sick and wants recommendations on how to treat the fever and nasal congestion. What recommendations should the pharmacist provide?

Because TY is complaining of fever and shortness of breath, he should be referred to his primary care provider to be evaluated. Although he tested negative for COVID-19, he should also get tested for influenza and other viruses that may be circulating. Patients who have a fever lasting more than 3 days should be referred to a physician. Other patients who should be referred include those who complain of a cough that gets worse or lasts more than 7 days, dizziness, nasal congestion, new onset of symptoms, pain, redness, or sleeplessness.

 TY should also stay hydrated and use an OTC electrolyte supplement with low sugar.

Rupal Patel Mansukhani, PharmD, FAPhA, NCTTP, 

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

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

Over-the-counter allergy nasal steroid sprays - what does it mean for patients? American Academy of Allergy, Asthma, and Immunology. Updated September 28, 2020. Accessed November 7, 2021. 

https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/triamcinolone-nasal-spray

Vaccines when your child is sick. CDC. Updated September 7, 2021. Accessed November 8, 2021. 

https://www.cdc.gov/vaccines/parents/visit/sick-child.html

Benich JJ 3rd, Carek PJ. Evaluation of the patient with chronic cough. 

Sudafed dosage information. Sudafed.com. Accessed November 8, 2021. 

www.sudafed.com/products/sudafed-dosage-information

Tylenol Cold + Flu Severe for day and night time relief of fever, pain, cough & congestion. Tylenol.com. Accessed November 8, 2021. 

www.tylenol.com/products/tylenol-cold-flu-severe-day-night-caplets

Case Studies: Nasal Congestion

MP is a 54-year-old woman who has worked as an office manager at a desk all day for 25 years and who has a sedentary lifestyle. She also commutes 30 minutes each way to her office. MP does not engage in physical activity other than short evening walks after dinner when weather permits. MP helped her adult son move into a new home the day prior and lifted boxes and furniture. That caused lower back pain, and she thinks she may have strained her muscles. MP inquires about rest, ice, compression, and elevation (RICE) as a nonpharmacological approach to managing the back pain. What should the pharmacist advise?

Although acute back pain may be self-limiting, a nonpharmacological approach with RICE may help decrease the inflammation associated with muscle injury and promote recovery. The RICE method is best applied in the first 72 hours of injury and may be applied with or without pharmacological interventions.

It is recommended that MP rest her back for 24 to 48 hours to promote healing. She should refrain from weight-bearing activities during this time. Encourage MP to apply ice to her back for 15 minutes 3 to 4 times daily for 24 to 72 hours. Compression can be applied to the back using an elastic bandage or wrap. To prevent future back pain due to bursts of activity, MP should aim for moderate physical activity and stretch to strengthen muscles.

JR is picking up acetaminophen for pain relief for his wife, MR,
a 66-year-old woman with osteoarthritis. She has been experiencing lower back pain due to osteoarthritis of the hips. JR says that MR does not have a significant medical history apart from the osteoarthritis. She has been taking acetaminophen for many years, but it has not relieved her back pain. JR asks about other nonprescription relief for back pain resulting from osteoarthritis of the hip. What should the pharmacist recommend?

In previous years, acetaminophen was recommended as a first-line analgesic for arthritic pain relief instead of nonsteroidal anti-inflammatory drugs (NSAIDs) in relieving pain. In recent years, evidence-based guidelines have steered away from acetaminophen and changed the first-line recommendation for osteoarthritic pain. The 2019 American College of Rheumatology/ Arthritis Foundation (ACR/AF) guidelines, for example, strongly recommend oral NSAIDs as first-line agents for this patient population. Similarly, the Osteoarthritis Research Society International (OARSI) 2019 guidelines removed oral acetaminophen for all forms of osteoarthritis. The caution taken in recommending NSAIDs as first-line pain relief is understandable, given the risk of serious adverse effects (AEs) such as cardiac events, gastrointestinal (GI) bleeding and ulcers, and nephropathy. Despite the risks, the ACR/AF and OARSI guidelines considered the benefits versus risks and recommended the use of NSAIDs first. Furthermore, the OARSI guidelines recommend the addition of a proton pump inhibitor to lessen the risk of GI ulcerations in cases where a patient is at high risk for AEs and if nonselective NSAIDs will be used continuously. Like the ACR/AF and OARSI guidelines, American College of Physicians guidelines on treatment of all chronic back pain recommend oral NSAIDs first rather than oral acetaminophen for pharmacological treatment.

Given the absence of significant risk of GI bleeding for MR and the data available, the pharmacist should recommend that she switch to NSAIDs for back pain relief.

PM is a 27-year-old woman who calls the pharmacy for advice on treating lower back pain due a recent sprain from a new workout class. She has tried acetaminophen, oral NSAIDs, and RICE therapy. PM does not want to continue taking systemic medications. She says she felt some relief when using 1 of her mother’s leftover prescription-strength Lidoderm patches. PM asks whether a similar OTC product is available. What information can the pharmacist provide?

PM has tried the first-line recommendations for acute back pain: oral NSAIDs and RICE. Like the prescription-strength transdermal patch, lidocaine is available over the counter, as is topical lidocaine, as a cream, gel, lotion, and ointment. The maximum OTC strength of lidocaine is 4%.

Remind PM that topical lidocaine should not be applied more than 3 times daily for a maximum of a week. The absorption of lidocaine will increase with exercise, heat application, and skin moisture. PM should wash her hands after each application and avoid contact with mucous membranes. She should avoid applying lidocaine to areas with skin injury and discontinue if irritation occurs and clean the skin. If PM starts using the OTC patch, she can wear it on clean, dry skin for up to 8 hours.

EP is a 57-year-old woman with lower back pain and a history of osteoarthritis. She calls the pharmacy with questions regarding her back pain and stiffness. EP reports that she tried the RICE method last week after acute pain onset and has not yet felt relief. She has heard that heat may also be a potential intervention for this type of pain. What information can the pharmacist provide to EP regarding heat therapy for back pain?

For acute back pain
and stiffness that is not inflammatory in nature, thermotherapy may deliver relief. Unlike ice therapy, heat should not be applied when inflammation is present, as the heat could perpetuate vascular leakage and vasodilation. The ACR/AF guidelines also recommend thermotherapy as a nonpharmacological treatment for osteoarthritic pain. Applying heat can decrease muscle spasms, increase blood flow to the affected area, and relieve stiffness. Different forms of heat applications studied include heating pads, hot-water bottles, and warm compresses. Newer products include heat-generating pads and wraps.

Apply the heat for 15-minute periods 3 to 4 times daily. Overall, heat therapy should not be applied on areas of broken skin or recent injury, as this may increase the risk of skin burn. Ready-to-use heat wraps can be applied to the back for a maximum of 8 to 12 hours, depending on the product label. The adhesives should be applied to clean, dry skin. EP should avoid using lotions or topical analgesics underneath the heat application, as this may also increase the risk of skin burns. If she experiences burning, itching, or pain upon application of heat, she should remove the heat immediately.

Qaseem A, Wilt T, McLean R, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. 

 2017;166(7):514-530. doi:10.7326/M16-2367

Sprains and strains. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Updated January 2015. Accessed October 17, 2021. 

https://www.niams.nih.gov/health-topics/sprains-and-strains

Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. 

 2020;72(2):149-162. doi:10.1002/acr.24131

Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. 

 2019;27(11):1578-1589. doi:10.1016/j.joca.2019.06.011

Osteoarthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. October 2019. Accessed October 31, 2021. 

https://www.niams.nih.gov/health-topics/osteoarthritis

External analgesic drug products for over-the-counter human use: tentative final monograph. FDA. 

 1983;48(27):5852. Accessed October 18, 2021. 

http://cdn.loc.gov/service/ll/fedreg/fr048/fr048027/fr048027.pdf#page=138

Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: the Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative. 

OTC Case Studies: Back Pain

GN is a 21-year-old man with a close relative who has inflammatory bowel disease (IBD). GN has heard about the potential protective effects of vitamin D supplementation for Crohn disease development. Although he has not developed Crohn disease, he is aware that his risk for development of the disease is 4 to 20 times higher because of genetics. What information can the pharmacist provide regarding vitamin D supplementation in Crohn disease?

The results of several studies have shown vitamin D deficiencies in patients with IBD. However, a causative relationship with vitamin D deficiency and onset of IBD has not been established in studies. The study results do show that vitamin D deficiency is more common in individuals with Crohn disease and ulcerative colitis (UC) than in the general population. Theoretical explanations for the protective effects of vitamin D have been established. Vitamin D regulates proteins that are involved in the maintenance of the gastrointestinal barrier. As such, vitamin D may be associated with protection of the gut microbiota. Another well-known property of vitamin D is its ability to ameliorate inflammation. With both the barrier protection and anti-inflammatory properties, vitamin D is thought to slow disease progression of IBD.

Experts suspect the vitamin D deficiency in IBD may be correlated to its mechanism, including decreased exposure to the sun, impaired gastrointestinal absorption of nutrients, and restricted dietary intake.

JM is a 33-year-old man with ulcerative colitis (UC) who is having more frequent and looser bowl movements. He is also experiencing abdominal cramping and has asked his fiancé to pick up antidiarrheals, as they are on vacation and have lost track of JM’s medication. What guidance can the pharmacist offer on loperamide for UC, including the administration, adverse effects, dosing, mechanism of action, and warnings?

Loperamide (Imodium) is an antidiarrheal that works by binding to mu opioid receptors on intestinal neurons, leading to decreased gastrointestinal (GI) motility and loss of electrolytes and fluids. Loperamide decreases fecal volume while increasing viscosity of stool. Loperamide also has been thought to increase anal sphincter tone, which may lead to improved fecal continence. The adverse effects of loperamide are primarily related to the GI mechanism: abdominal pain, bloating, constipation, nausea, and vomiting.

The pharmacist should offer counseling on loperamide dosing. Patients should take 2 mg after each loose stool, up to a maximum of 16 mg per day. At typical therapeutic doses, loperamide does not cross the blood-brain barrier, but when supratherapeutic doses are taken, loperamide may cross the blood-brain barrier and cause opioidlike effects. At higher-than-recommended doses, loperamide may lead to life-threatening cardiac adverse events, including arrythmias, QTc prolongation, sudden death, and syncope.

PJ is a 27-year-old woman who is on immunosuppressive therapy for inflammatory bowel disease (IBD). She wants to speak to the pharmacist about vaccinations. PJ’s physician had recommended vaccines but she is unclear about her needs. What vaccines should the pharmacist recommend to PJ?

Given that PJ is on immunosuppressant therapy, it should be noted that the overall response to vaccinations may be suppressed by the IBD medications. Even so, patients with IBD on immune system suppressing medications should be vaccinated against infections as they are at a higher risk of contracting them. All patients with IBD should receive only nonlive vaccines, as their immunosuppressed state puts them in danger of infection from strains of live virus or bacteria from the vaccines, according to the Advisory Committee on Immunization Practices of the CDC and the Infectious Diseases Society of America.

Adult patients with IBD should receive the annual inactivated influenza intradermal or intramuscular vaccine. Evidence suggests that patients with IBD who develop the influenza infection are more likely to be coinfected with pneumonia and hospitalized. Patients with IBD on immunosuppressants should receive the pneumococcal conjugate vaccine, followed by the pneumococcal polysaccharide vaccine (PPSV23) 8 weeks later. PPSV23 should be repeated 5 years after the first dose and once again after age 65. For hepatitis vaccines, a patient’s immunity should be assessed via blood work. If the patient’s titers confirm that she is not immune to hepatitis A, a 2-dose series should be administered, with the second dose 6 to 12 months after the first. Similarly, if the patient’s titers confirm that she is not immune to hepatitis B, a 3-dose series should be administered, with the second and third doses occurring 1 and 6 months after the first dose, respectively. Patients with IBD who are older than 50 years should receive the nonlive herpes zoster vaccine, Shingrix.

SP is a 37-year-old man with Crohn disease. He has been on immunosuppressant medications for Crohn disease but has not been able to quit smoking. SP has questions about smoking, including that he has heard that smoking is protective, and if he quits smoking, his inflammatory bowel disease (IBD) will flare up and his symptoms will be worse. What information should the pharmacist provide to SP?

Data suggest that for patients with IBD, smoking is associated with the development and progression of the disease as well as poor outcomes. The results of a meta-analysis and several studies show a significant increased risk for development of Crohn disease. Moreover, some study results show that smoking is related to poor response to IBD treatment.

Additionally, the results of a prospective study of patients with Crohn disease showed that after smoking cessation, the risk of IBD flare-ups in those who quit smoking did not differ from that of those who were nonsmokers and was lower than in those who continued smoking. Encourage SP to quit smoking.

How would you answer these patients' questions?