Yvette C. Terrie, BSPharm, RPh

Dry eye disease (DED), also known as dry eye syndrome, dysfunctional tear syndrome, and keratoconjunctivitis sicca, is a chronic multifactorial disease of the ocular surface characterized by hyperosmolarity, inadequate production and/or instability of the tear film, and ocular surface damage and inflammation.

Data from a recent National Health and Wellness Survey show that an estimated 16.4 million adults in the United States (6.8% of the population) have received diagnoses of DED to some degree.

 Considered the most common disorder affecting the anterior eye, DED can be mild, moderate, or severe

 and often correlates with ocular discomfort, fatigue, and visual disturbance that can significantly affect quality of life.

Although the most common clinical symptom is a sandy, gritty sensation in the eye, DED can also cause blurry vision, discharge, excessive tearing, redness, inflammation, and photophobia.

Research results have established DED is often associated with aging and women are twice as likely as men to develop it. DED commonly occurs during pregnancy, menopause, and postmenopause and with Bell palsy, corneal defects, diabetes, loss of lid tissue turgor, lupus, Parkinson disease, rheumatoid arthritis, rosacea, Sjogren syndrome, thyroid-related eye disorders, and vitamin A deficiency.

 DED is also an adverse effect of some pharmacological agents, including antidepressants, antihistamines, beta-blockers, decongestants, diuretics, and oral contraceptives.

 Some study results have indicated an increased risk of DED in those with sleep apnea who use continuous positive airway pressure therapy.

Results of numerous cross-sectional studies have shown duration of digital screen use correlates with severe symptoms of DED in adults and long-term screen times are linked to greater risk of DED in school-aged children.

 Allergens, environmental factors, and laser eye surgery can also contribute to or exacerbate DED.

 As frontline health care professionals, pharmacists can be instrumental in identifying medical conditions and/or pharmacological agents that increase the risk of DED. They can counsel patients about nonprescription products that provide symptomatic relief of mild to moderate DED and encourage those with undiagnosed or severe DED to seek evaluation by an ophthalmologist.

Without timely diagnosis and treatment, DED may damage ocular tissues, especially the corneal surface.

 The primary goals of therapy are to prevent or alleviate symptoms, maintain or reestablish tears, minimize dryness and related discomfort, and support overall eye health.

First-line treatment often entails nonpharmacological measures to decrease the incidence of DED and treat any inflammation of the eye- lids or eye surface that contributes to DED.

 These measures include applying warm compresses to the eyes, avoiding smoky environments, discontinuing (if possible) medications that cause DED, getting enough sleep, limiting screen time, staying hydrated, using a humidifier, and wearing sunglasses outdoors.

Artificial tears and nonmedicated gels and ointments are the main self-treatments.

 Mild DED cases may be treated with less viscous products, and severe ones with products that are more viscous.5 When no contraindications are present, some ophthalmologists may also recommend omega-3 fatty acid supplements.

Adhere to manufacturer directions and recommendations.

Apply ocular ointments at bedtime to keep eyes moist while sleeping and prevent blurry, dry eyes upon waking.

If you have questions, ask pharmacists and/or primary health care providers.

Discuss frequency of use with primary health care provider. Artificial tears are typically used once or twice daily, in the morning and at bedtime.

Note that artificial tears without preservatives are less likely than those with preservatives to cause allergic reactions and/or irritate ocular surface.

Refrigerate artificial tears for additional relief.

Before applying ocular gels, ointments, or drops, wash hands thoroughly with soap and water and remove contact lenses, if applicable.

Whenever possible, pharmacists should ascertain whether self-treatment is appropriate and, if it isn’t, suggest patients seek medical care. They should tell patients whose symptoms don’t improve or worsen with OTC products to ask an ophthalmologist for prescription medications like lifitegrast or cyclosporine ophthalmic emulsion. They should encourage patients with red or painful eyes, severe DED, or signs of ocular infection to see an ophthalmologist immediately. And they should recommend that patients visit www. allaboutvision.com.

, is a consulting pharmacist and medical writer in Haymarket, Virginia.

1. Dry eye. National Institutes of Health. Updated April 8, 2022. Accessed August 1, 2022. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/dry-eye

2. Labetoulle M, Benitez del Castillo JM, Barabino S, et al. Artificial tears: biological role of their ingredients in the management of dry eye disease. 

. 2022;23(5):2434. doi:10.3390/ ijms23052434

3. Bron AJ, de Paiva CS, Chauhan SK, et al. TFOS DEWS II pathophysiology report. 

. 2017;15(3):438-510. doi:10.1016/j.jtos.2017.05.011

4. Farrand KF, Fridman M, Stillman IÖ, Schaumberg DA. Prevalence of diagnosed dry eye disease in the United States among adults aged 18 years and older. 

. 2017;182:90-98. doi:10.1016/j.ajo.2017.06.033

5. Fiscella RG, Jensen MK. Ophthalmic disorders. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. 

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

. 20th ed. American Pharmacists Association; 2020:507-530.

Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II epidemiology report. 

. 2017;15(3):334- 365. doi:10.1016/j.jtos.2017.05.003

7. Matossian C, Song X, Chopra I, Sainski-Nguyen A, Ogundele A. The prevalence and incidence
of dry eye disease among patients using continuous positive airway pressure or other nasal mask therapy devices to treat sleep apnea. 

. 2020;14:3371-3379. doi:10.2147/OPTH. S274949

8. Al-Mohtaseb Z, Schachter S, Shen Lee B, Garlich J, Trattler W. The relationship between dry eye disease and digital screen use. 

. 2021;15:3811-3820. 2021. doi:10.2147/OPTH.S321591

9. Muntz A, Turnbull PRK, Kim AD, et al. Extended screen time and dry eye in youth. 

. 2021;101541. doi:10.1016/j.clae.2021.101541

10. Dry eye. American Optometric Association. Accessed August 1, 2022. https://www.aoa.org/healthy-eyes/eye-and-vision-conditions/dry-eye?sso=

Articles

Pharmacists should ascertain whether self-treatment is appropriate and suggest medical care if it isn’t.

Help Patients Prevent and Treat Dry Eye

Pharmacists can provide advice to patients who are seeking guidance on how to prevent and treat atopic dermatitis (AD), given the many topical nonprescription products on the market, such as antihistamines, low-potency topical hydrocortisone products, moisturizers, and skin cleansers.

Self-management using a combination of OTC products and non- pharmacological measures is appropriate for most patients with mild to moderate AD. However, encourage patients who exhibit severe signs of or worsening AD to seek further medical evaluation and treatment.

The American Academy of Dermatology (AAD) indicates that AD is a chronic, pruritic inflammatory dermatological condition that occurs most commonly in pediatric patients but also affects many adults.

 AD is often seen in patients with a personal or family history of allergic rhinitis and asthma.

AD is the most common form of eczema, affecting more than 9.6 million pediatric patients and an estimated 16.5 million adults in the United States, according to the National Eczema Association (NEA).

Its pathogenesis is often multifaceted and may involve environmental factors, epidermal and immunologic barrier dysfunction, and a genetic predisposition.

 An estimated 50% of patients receive a diagnosis within the first year of life, and up to 85% present with symptoms before the age of 5 years.

Patients with AD often experience flare-ups that may exacerbate their conditions. Common triggers include dry skin, exposure to environmental or food allergens, exposure to extreme temperatures, skin irritants, and stress.

More than 85% of those with AD experience itching on a daily basis, which can also cause pain and sleep issues, according to the NEA.

Investigators attempted to compare the clinical effectiveness and safety of the 4 primary emollient types used for pediatric eczema, which are creams, gels, lotions, and ointments. The study involved 550 participants aged 6 months to 12 years. The subjects were randomly assigned to use 1 of the 4 types of emollients, and parents reported their observations weekly for 16 weeks and followed up every 4 weeks for 52 weeks.

 indicated that there was no difference regarding the efficacy and safety among the 4 primary types of emollients commonly used in pediatric eczema. The authors also noted that the total number of adverse events did not significantly vary between the treatment groups, though stinging was less common with ointments than with creams, gels, or lotions.

 The Journal of Allergy and Clinical Immunology: In Practice 

indicated that although having a history of food allergies is common among pediatric patients with AD, only a small percentage of subjects in the study had food-triggered AD (FTAD). FTAD, defined by a physician-noted sustained improvement in AD after removal of a food, appeared uncommon, occurring in just 3% of the total cohort and 2% of patients with mild AD, 6% of those with moderate AD and 4% with severe AD.

Journal of the American Academy of Dermatology

 indicate that individuals with AD exhibited a small but increased risk of incident dementia compared with the general population, and AD severity was correlated with a greater risk. The study involved individuals aged 60 to 99 years. In the adjusted Cox proportional-hazard models, patients with AD exhibited a 27% enhanced risk of dementia, and the incidence of dementia was 57 per 10,000 person-years among those with AD during follow-up compared with 44 per 10,000 person-years in the control group.

The investigators also noted that the correlation persisted even after adjusting for the use of systemic corticosteroids and potential mediators, and severe eczema was associated with a greater risk of dementia.

Establishing a routine skin care regimen is critical to maintaining healthy, hydrated skin, and incorporating preventive measures can help prevent or reduce flare-ups.

The AAD and NEA provide several tips that patients can use to manage and prevent AD symptoms. These include the following

Bathe daily, taking a 5- to 10-minute bath or shower in lukewarm, but never hot, water.

Identify triggers to AD flare-ups and avoid when feasible.

Eat a healthy diet, manage stress, and obtain sufficient sleep.

Moisturize after bathing and when skin feels dry.

Protect the skin from extreme temperatures.

Seek care from a dermatologist if symptoms do not improve or if they worsen.

Select fragrance-free skin care products.

Test all skin care products before using them.

Wash new clothing in detergent that is dye- and fragrance-free before wearing.

Wear clothing that is loose fitting and 100% cotton, as cotton is less irritating and lets the skin breathe.

More information can be found on the AAD website (https://www.aad.org/ public/diseases/eczema/atopic-dermatitis-coping).

The NEA also has a helpful application called EczemaWise to keep track of symptoms and triggers (https://nationaleczema.org/turn-your-whys-into- wise-with-eczemawise/).

To effectively counsel patients, pharmacists should be familiar with guidelines for the management and treatment of AD that were published in early 2022 by the AAD (https://www.aad.org/member/clinical-quality/guidelines/atopic-dermatitis).

Pharmacists can educate patients about the best OTC products for AD and the importance of using OTC skin care products that contain ceramides, which can be beneficial in maintaining, protecting, and restoring the natural skin barrier function and overall dermatological health. Pharmacists can also direct patients to the NEA website that lists skin care products for AD that have received the NEA Seal of Acceptance (https://nationaleczema.org/ eczema-products/about-nea-seal-of-acceptance/).

 is a consulting pharmacist and medical writer in Haymarket, Virginia.

1. Davis DMR, Drucker AM, Alikhan A, et al. American Academy of Dermatology Guidelines: awareness of comorbidities associated with atopic dermatitis in adults. 

. 2022;86(6):1335-1336.e18. doi:10.1016/j.jaad.2022.01.009

2. Atopic dermatitis. National Eczema Association. 2022. Accessed June 28, 2022. https://nationaleczema.org/eczema/types-of-eczema/atopic-dermatitis/

3. Kim BE, Leung DYM. Significance of skin barrier dysfunction in atopic dermatitis. 

. 2018;10(3):207-215. doi:10.4168/aair.2018.10.3.207

4. Benner KW. Atopic dermatitis and dry skin. In: Krinsky DL, Ferreri SP, Hemstreet BA, Hume AL, Rollins CJ, Tietze KJ[NL1] , eds. 

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

 20th ed. American Pharmacists Association; 2021:689-699.

5. Kim J, Kim BE, Leung DYM. Pathophysiology of atopic dermatitis: clinical implications. 

. 2019;40(2):84-92. doi:10.2500/aap.2019.40.4202

6. Eczema causes and triggers. National Eczema Association. Accessed June 28, 2022. https://nationaleczema.org/eczema/causes-and-triggers-of-eczema/

7. Ridd MJ, Santer M, MacNeill SJ, et al. Effectiveness and safety of lotion, cream, gel, and ointment emollients for childhood eczema: a pragmatic, randomised, phase 4, superiority trial. 

. 2022;6(8):522-532[NL2] . doi:10.1016/S2352-4642(22)00146-8

8. Li JC, Arkin LM, Makhija MM, Singh AM. Prevalence of food allergy diagnosis in pediatric patients with atopic dermatitis referred to allergy and/or dermatology subspecialty clinics. 

 2022;S2213-2198(22)00577-3. doi:10.1016/j.jaip.2022.05.028

9. Magyari A, Ye M, Margolis DJ, et al. Adult atopic eczema and the risk of dementia: a population-based cohort study

. 2022;87(2):314-322. doi:10.1016/j.jaad.2022.03.049

10. Eczema types: atopic dermatitis: tips for coping. American Academy of Dermatology. Accessed June 28, 2022. 

https://www.aad.org/public/diseases/eczema/atopic-dermatitis-coping

Guidelines provide information on the management and treatment of this common skin condition.

Prevent or Reduce Atopic Dermatitis Flare-Ups

Recent research suggests that climate change is making things worse for patients who suffer from allergies, which can cause symptoms including a cough resulting from postnasal drip, to headache, itchy eyes and throat, nasal congestion, sneezing, and watery eyes.

Left unmanaged, these symptoms can significantly affect an individual’s quality of life and productivity. An estimated 60 million individuals deal with allergy symptoms annually, according to the CDC. Up to 30% of the general population experiences ocular allergies and up to 70% experiences allergic rhinitis.

Additionally, individuals with respiratory issues such as asthma usually are more sensitive to pollen.

Pharmacists can guide patients in selecting OTC products for the prevention and treatment of seasonal allergies, such as intranasal corticosteroids, mast cell stabilizers, ocular and oral antihistamines, and oral and topical decongestants. Pharmacists also can counsel patients about the proper use of these products and make clinical recommendations based on a patient’s medical and medication history while taking into consideration factors such as cost, ease and frequency of use, potential adverse effects, and route of administration. They should direct patients to seek further evaluation and medical care from allergy specialists when warranted.

Results of a study by investigators from the University of Michigan (UM) showed that allergy season will likely become longer and more intense because of climate change.

 The investigators noted that the annual amount of pollen emitted each year could increase by up to 200% because of rising temperatures and expanding carbon dioxide levels. Hotter temperatures may increase the amount of pollen produced by grass, trees, and weeds. By the end of the century, they noted, pollen emissions could start 40 days earlier in the spring than observed between 1995 and 2014 and allergy season may last an additional 19 days before high pollen counts wane. The investigators developed a predictive model that assessed 15 of the most common pollen types and how their production will be affected by projected changes in precipitation and temperatures. They combined climate data with socioeconomic scenarios, correlating their modeling with data from 1995 through 2014. They then used their model to predict pollen emissions for the first 2 decades of the 21st century.

“Pollen-induced respiratory allergies are getting worse with climate change. Our findings can be a starting point for further investigations into the consequence of climate change on pollen and corresponding health effects,” Yingxiao Zhang, a UM graduate student research assistant in climate and space sciences and engineering and lead author of the study,

“The modeling developed by the team could eventually allow for allergy season predictions targeted to different geographical regions,” said Allison Steiner, the study’s other author and a professor of climate and space sciences at UM.

The National Science Foundation supported the project.

In other news, on March 17, 2022, Perrigo announced that its intranasal corticosteroid, Nasonex 24HR Allergy, had received final FDA approval for OTC use. Nasonex 24HR Allergy is indicated for the management of nasal symptoms of allergic rhinitis, nasal congestion associated with seasonal allergic rhinitis, nasal polyps, and the prophylaxis of seasonal allergic rhinitis. This is the first OTC formulation for Nasonex, and it will be available in full prescription strength. Each nasal spray delivers 50 g of mometasone furoate monohydrate. Perrigo expects the OTC product to be available later in 2022.

On March 15, 2022, Allergan announced that Lastacaft (alcaftadine ophthalmic solution 0.25%) now is available without a prescription for the estimated 40% of Americans with ocular allergies. The FDA approved the switch to OTC in December 2021. The histamine receptor antagonist is indicated in patients 2 years and older for the temporary relief of itchy eyes resulting from animal hair, dander, pollen, and ragweed allergies. In clinical trials, 1 drop of Lastacaft worked in as little as 3 minutes to provide relief from itchy eyes and lasted
for 16 hours. Lastacaft is available in a 5-mL multidose bottle containing a 60-day supply, as well as a twin pack with two 5-mL multidose bottles for a 120-day supply.

Meanwhile, the American College of Allergy, Asthma & Immunology (ACAAI) said recently that because COVID-19 symptoms, especially for the Omicron variant, often resemble symptoms commonly associated with allergies, patients should get tested if they suspect they have the virus. The ACAAI noted that allergies rarely cause a fever. The ACAAI also suggested that individuals with seasonal allergies identify their triggers if possible and discuss other therapies if OTC allergy medications are not managing symptoms.

 The ACAAI provides tips for managing spring allergies on its website.

Pharmacists can suggest the use of various mobile applications that monitor the pollen counts across the United States to help patients manage symptoms.

Pharmacists can help patients with seasonal allergy symptoms select and properly use nonprescription products. They can also counsel patients about the most efficacious means of preventing or reducing allergy symptoms. In addition, pharmacists can screen for potential contraindications and drug/drug interactions before recommending the use of OTC allergy medications. Patients with other medical conditions and/or those taking prescription medications should consult their primary health care providers to ascertain appropriateness of use. Pharmacists should encourage patients with severe or unmanaged allergy symptoms to seek further care from their primary health care providers.

Treatment of allergy symptoms may include a combination of allergen avoidance and environmental control measures when feasible, as well as immunotherapy and pharmacologic therapy. Many patients try several options before finding the most effective treatment.

1. Allergens and pollen. CDC. August 21, 2020. Accessed March 28, 2022. https://cdc.gov/climateandhealth/effects/allergen.htm

2. Zhang Y, Steiner AL. Projected climate-driven changes in pollen emission season length and magnitude over the continental United States. 

. 2022;13(1):1234. doi:10.1038/s41467-022-28764-0

3. Longer, more intense allergy seasons could result from climate change. University of Michigan. March 16, 2022. Accessed March 28, 2022. https://news.umich.edu/longer-more-intense-allergy-seasons-could-result-from-climate-change/

4. Perrigo announces US FDA approval for OTC use of Nasonex 24hr Allergy. Perrigo. News release. March 17, 2022. Accessed March 18, 2022. https://www. prnewswire.com/news-releases/perrigo-announces-us-fda-approval-for-otc-use-of-nasonex-24hr-allergy-301505410.html

5. Now available over the counter, Lastacaft provides eye allergy itch relief in minutes that lasts through 16 hours. AbbVie. News release. March 15, 2022. Accessed March 15, 2022. https://www.prnewswire.com/news-releases/now-available-over-the-counter-lastacaft-provides-eye-allergy-itch-relief-in-minutes-that-lasts-through-16-hours-301501288.html

6. Covid’s not gone, and spring allergies could hit hard. American College of Allergy, Asthma, & Immunology. February 22, 2002. Accessed March 28, 2022. https:// acaai.org/news/what-allergists-want-you-to-know-about-the-2022-spring-allergy-season/

With climate change potentially affecting pollen counts, new OTC products can relieve symptoms.

Help Patients Prepare for Allergy Season

Although cardiovascular disease (CVD) continues to be the leading cause of death among all ethnic groups globally, including in the United States, many cases are preventable. “Heart disease is 90% treatable. Everyone can prevent heart disease anywhere in the world, especially by eating foods that are low in salt and cholesterol, exercising regularly, and not smoking. Even if a person has a family history of heart disease, we can still prevent and treat heart disease, thanks to incredible advances in medicine,” Leslie Cho, MD, section head for preventive cardiology and cardiac rehabilitation at Cleveland Clinic in Ohio, said recently.

Because many individuals take proactive roles in their overall health, pharmacists can help them select and use nutritional supplements marketed for cardiovascular health. Examples include coenzyme Q10 (CoQ10), garlic, omega-3 fatty acids, and plant sterols, as well as specialty mineral and multivitamin supplements that are formulated with a blend of essential nutrients specifically targeted for cardiovascular health.

Research results show some supplements may decrease the risk of CVD, whereas others may cause harm to individuals with CVD risk factors. Findings from clinical trials have also produced mixed results.

Manufacturer Piper Biosciences recently released clinical data demonstrating the efficacy of its Cholesterol Wellness gummies, which contain plant sterols that help lower cholesterol. Results show that among participants who completed the 3-month study, there was a statistically significant (P =.03) reduction in low-density lipoprotein cholesterol (LDL-C) of 5.8%, and more than 90% of participants indicated interest in using the gummies long term if recommended by their physicians. The investigators concluded that supplementation with plant sterols can be effective in lowering LDL-C levels.

Another recent publication on the Cleveland Clinic website explored the benefits associated with cardiovascular health supplements based on clinical data. The cardiologist featured in the article indicated that patients should always discuss the use of these supplements with their primary health care providers to ascertain appropriateness. The cardiologist also indicated that although some supplements may not be harmful, some may carry risks that can affect cardiac function.

The results of a study assessing the use of CoQ10 in individuals with congestive heart failure show that participants who took 100 μg per day had fewer major adverse cardiac events than those who took a placebo.

 Although other studies that involved a small number of patients indicate that use of CoQ10 was associated with improvements in cardiovascular risk factors, such as blood glucose control, hyperlipidemia, and hypertension, more research is warranted.

 indicated that individuals with vitamin D deficiency are more likely to have CVD and hypertension. The findings show that for participants with the lowest concentrations of vitamin D, the risk of CVD was more than double than in those with sufficient concentrations.

However, the results of a meta-analysis of clinical trials and prospective cohort studies conducted by the American Heart Association (AHA) showed that mineral/multivitamin supplementation does not improve cardiovascular outcomes in the general population.

 The results of another AHA study showed that no effect was observed for commonly used multivitamins, vitamins C and D, calcium, and, to date, there is no conclusive evidence for the benefits of supplements. The authors of the study also noted that consuming plant-based food is a safe approach to increasing micronutrient intake.

An article in Current Cardiology Reports noted that, despite the popular use of supplements, there is no evidence to support the routine supplementation of oral multivitamins and minerals for the prevention or treatment of CVD.

Patients with preexisting medical conditions and/or those taking other medications should always consult their primary health care providers before using any supplements. Encourage patients to discuss individual nutritional needs based on their medical and medication history. During counseling, pharmacists can remind patients about the importance of knowing about and discussing their modifiable and nonmodifiable CVD risk factors, including blood pressure values, family history, and lipid levels with their primary health care providers. Pharmacists can also encourage patients to implement healthy dietary and lifestyle measures into their daily routine, lose weight if needed, and maintain routine health care visits, which are essential to overall cardiovascular health. It is also important to remind patients who use prescription medications for the prevention and treatment of CVD to adhere to these medications as directed by their primary health care providers.

, is a consulting pharmacist and a medical writer in Haymarket, Virginia.

1. 90 percent of heart disease is preventable through healthier diet, regular exercise, and not smoking. News release. Cleveland Clinic; September 29, 2021. Accessed January 12, 2022. https://newsroom.clevelandclinic.org/2021/09/29/90-percent-of-heart-disease-is-preventable-through-healthier-diet-regular-exercise-and-not-smoking/

2. Clinical study shows gummy containing plant sterols significantly lowers cholesterol. News release. Piper Biosciences; September 27, 2021. Accessed January 12, 2022. https://www.prnewswire.com/ news-releases/clinical-study-shows-gummy-containing-plant-sterols-significantly-lowers-cholesterol-301385051.html

3. Do heart health vitamins work? Cleveland Clinic. December 23, 2021. Accessed January 12, 2022. https://health.clevelandclinic.org/ heart-health-vitamins-ally-or-false-friend/

4. Mortensen AL, Rosenfeldt F, Filipiak KJ. Effect of coenzyme Q10 in Europeans with chronic heart failure: a sub-group analysis of the Q-SYMBIO randomized double-blind trial. 

. 2019;26(2):147- 156. doi:10.5603/CJ.a2019.0022

5. Ayers J, Cook J, Koenig RA, Sisson EM, Dixon DL. Recent developments in the role of coenzyme Q10 for coronary heart disease: a systematic review. 

. 2018;20(6):29. doi:10.1007/ s11883-018-0730-1

6. Zhou A, Selvanayagam JB, Hyppönen E. Non-linear Mendelian randomization analyses support a role for vitamin D deficiency in cardiovascular disease risk. 

. Published online December 5, 2021. doi:10.1093/eurheartj/ehab809

7. Kim J, Choi J, Kwon SY, et al. Association of multivitamin and mineral supplementation and risk of cardiovascular disease: a systematic review and meta-analysis. 

. 2018;11(7):e004224. doi:10.1161/CIRCOUTCOMES.117.004224

8. Jenkins DJA, Spence JD, Giovannucci EL, et al. Supplemental vitamins and minerals for cardiovascular disease prevention and treatment: JACC Focus Seminar. 

. 2021;77(4):423-436. doi:10.1016/j.jacc.2020.09.619

9. Ingles DP, Cruz Rodriguez JB, Garcia H. Supplemental vitamins and minerals for cardiovascular disease prevention and treatment.

. 2020;22(4):22. doi:10.1007/s11886-020-1270-1

Taking appropriate doses of vitamins and minerals may aid in lowering the risk of cardiovascular disease.

Help Patients Navigate Array of Heart Health Supplements

The severity of annual cold and flu season can be very unpredictable from year to year.

Each year, millions of individuals use the various nonprescription medications marketed for the management and treatment of symptoms that are generally associated with colds and influenza. Pharmacists can be indispensable resources in aiding patients in the selection and proper use of these products. For the management of mild to moderate common cold and influenza symptoms, nonprescription products include analgesics, anesthetics, antihistamines, antipyretics, antiseptics, cough suppressants, decongestants, and expectorants, available in multi-ingredient or single-entity formulations.

Findings from 2 recently published studies predicted the impact of the 2021-2022 flu season. According to the results from one, there could be 100,000 to 400,000 more influenza hospitalizations in the 2021-2022 flu season compared with a typical season. But the investigators found that the predicted increase in those hospitalizations could be avoided if the percentage of Americans vaccinated against influenza increased from the typical 50% to 75%.

 In the second study, investigators suggested that the 2021-2022 season could see a 20% increase in cases compared with a typical season and that children younger than age 2 would be particularly at risk for influenza because they are unlikely to have any previous exposure to the virus.

 The results of both studies suggested that a flu season with high activity could be avoided if vaccination rates increased by 20% to 50% compared with those in a typical year.

On November 1, 2021, Reckitt, the manufacturer of the OTC cold, cough, and influenza product Mucinex, announced the launch of a new product line called Mucinex InstaSoothe, which includes lozenges and spray designed to numb, relieve, and soothe sore throat pain. The new products are Mucinex InstaSoothe
Sore Throat + Cough Relief Lozenges, Mucinex InstaSoothe Sore Throat + Pain Relief Spray, and Mucinex InstaSoothe Sore Throat + Soothing Comfort Lozenges.

To gain a better understanding about the impact of sore throat pain on patient quality of life, Reckitt conducted a random double opt-in survey of 2005 Americans between August 26 and August 30, 2021.

The results showed that sore throat pain is 1 of the top 3 most incapacitating symptoms, alongside fever and migraine. Despite this, 55% of individuals are most likely to “power through” a sore throat, meaning that they continue completing housework, going to school, running errands, and working while dealing with difficult sore throat pain.

Prior to recommending any OTC cold and cough products, pharmacists should always screen for a patient’s allergy and medical history and medication profile
to check for possible contraindications or interactions. Individuals with medical conditions and/or who are taking other medications should always consult with their primary health care providers before using any nonprescription medications to ascertain appropriateness. During counseling, pharmacists should remind patients to read labels prior to self-administration and to check for expiration dates and ingredients, particularly if using multiple products, to avoid therapeutic duplications or excessive dosing. Pharmacists should also remind patients to adhere to the recommended administration guidelines, dosages, and duration of use.

Additionally, remind caregivers and parents to always read all labels prior to administering medications to children and use the calibrated drug measuring devices provided with the selected OTC products when administering liquid medications to ensure proper accuracy and dosage. Caregivers and parents should only give children those OTC products manufactured specifically for the pediatric population, and when in doubt regarding the appropriateness or dose of a medication should consult their pediatricians or pharmacists.

During counseling, pharmacists should stress the importance of obtaining an annual influenza vaccination, as well as suggest various nonpharmacologic measures that may provide relief of cold and influenza symptoms. These include humidifiers, nonmedicated nasal strips, saline nasal sprays, and vaporizers. Patients should also maintain adequate hydration and rest. Encourage patients to seek medical attention from their primary health care provider if a cough lasts more than 14 days, a fever is high, a sore throat persists, symptoms linger or worsen, or there are signs of infection. Study results have shown that the implementation of various preventive measures, such as avoiding direct contact with an individual with a cold or influenza, routine handwashing, and use of hand sanitizers when soap and water are not available, is effective for decreasing or preventing the transmission of colds and influenza.

1. Rettner R. Flu season will be bad this year, research predicts. LiveScience. September 1, 2021. Accessed November 3, 2021. https://www. livescience.com/flu-season-comeback-covid-2021-2022.html

2. Lee K, Jalal H, Raviotta JM, et al. Predicting the impact of low influenza activity in 2020 on population immunity and future influenza season in the United States. medRxiv. Preprint posted online August 30, 2021. doi:10.1101/2021.08.29.21262803

3. Krauland MG, Galloway DD, Raviotta JM, Zimmerman RK, Roberts MS. Agent-based investigation of the impact of low rates of influenza on next season influenza infections. medRxiv. Preprint posted online August 26, 2021. doi:10.1101/2021.08.18.21262185

4. Painful sore throats meet their match  -Mucinex introduces Mucinex InstaSoothe, a new line of lozenges and spray to help fight against sore throat pain and irritation. News release. Mucinex. November 1, 2021. Accessed November 3, 2021. https://www.prnewswire.com/ news-releases/painful-sore-throats-meet-their-match-mucinex-introduces-mucinex-instasoothe-a-new-line-of-lozenges-and-spray-to-help-fight-against-sore-throat-pain-and-irritation-301412676.html

Help patients prepare for these winter ailments and choose the appropriate nonprescription medications.

Here Comes Cold and Flu Season

Patients commonly self-treat pain with nonprescription analgesics, and pharmacists can help them choose the correct OTC products.

Acute pain typically initiates abruptly and can often be attributed to a known cause such as an injury or surgery.

 Chronic pain typically lasts for 3 or more months and can be caused by a condition, disease, inflammation, an injury, medical treatment, or an unknown reason.

Pain is a complex symptom that affects individuals differently, and therapy should be tailored to the individual’s needs. Left untreated, pain may affect quality of life, including cognitive, emotional, and physical functions.

Because of the opioid crisis in the United States, many health care professionals are exploring alternative approaches to pain relief, such as cognitive therapy, cold and heat treatments, physical therapy, and OTC oral and topical analgesics.

Many individuals frequently use nonprescription oral and topical analgesics to self-treat mild to moderate pain because the products are accessible, easy to use, and reasonably priced. Consumers spent $4.5 billion on oral analgesics and $1.1 billion on topical analgesics in 2020, according to a Consumer Healthcare Products Association report.

Selecting an appropriate nonprescription product may be overwhelming for many patients, especially if they have other medical conditions and/or are taking other medications. Therefore, pharmacists are in a critical position to advise patients on oral and topical nonprescription analgesics, as well as direct them to seek counsel from their primary health care providers when warranted. That is especially important if further evaluation is needed, the pain is severe, or self-treatment is not appropriate.

The American Academy of Family Physicians and the American College of Physicians (ACP) in August 2020 recommended the use of topical nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy for treating acute, non–low back pain from musculoskeletal injuries in outpatient settings.

 Evidence has shown that topical NSAIDs are among the most effective options for pain reduction, physical function, symptom relief, and treatment satisfaction, and they have not been linked with any considerable adverse effects. The ACP guidelines suggest other treatment options when appropriate, including oral NSAIDs to diminish or relieve symptoms and acupressure and transcutaneous electrical nerve stimulation to decrease pain.

“These types of injuries and associated pain are common, and [as physicians] we need to address them with the best treatments available for the patient,” Jacqueline W. Fincher, MD, MACP, president of the ACP, said. “The evidence shows that there are quality treatments available for pain caused by acute musculoskeletal injuries that do not include the use of opioids. There are a number of recommended interventions that are not opioids to choose from, and topical NSAIDs should be the first line of treatment.”

 indicated that pain has been frequently described as a clinical feature of COVID-19, and the main pain syndromes that have been linked with the acute phase of the virus are arthritis, headaches, myalgia, and neuropathic pain.

issued a consensus statement cautioning against the use of nonprescription acetaminophen during pregnancy. The authors warned of possible links to adverse fetal development outcomes, called for additional investigation, and encouraged additional precautions prior to use in pregnancy.

However, some experts have indicated that more research is warranted and that the findings from the study should not change clinical decision-making.

In response to the publication, medical societies including the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine have made statements continuing to encourage the safe administration of acetaminophen to patients who need it during pregnancy.

National Health Interview Survey data published in Pain stated that 50.2 million, or 20.5%, of adults in the United States in 2019 experienced chronic pain.

 The estimated total value of lost productivity due to chronic pain is nearly $300 billion annually.

Pharmacists should advise patients about the proper use of the selected product, including adherence to manufacturer directions, dosage, potential adverse effects, and recommended duration of use. Pharmacists also serve as excellent resources in identifying possible drug-drug contraindications and interactions. Patients taking other medications and those with chronic medical conditions should always consult their primary health care providers before taking any nonprescription drugs. Pharmacists can also make recommendations about using nonpharmacological measures to alleviate joint and muscle pain.

For example, the RICE protocol (rest, ice, compression, elevation) helps diminish inflammation and swelling associated with acute joint and muscle injuries, and localized heat therapy may be beneficial for patients with noninflammatory pain.

Encourage patients with continual, severe, or recurring pain to seek additional care from their primary health care providers, especially if pain worsens or they see no signs of progress after using nonprescription analgesics. Advise patients to limit the use of systemic analgesics to 10 days unless otherwise directed by their primary health care providers. 

1. Safely and effectively managing pain without opioids. CDC. June 11, 2021. Accessed October 14, 2021. https://www.cdc.gov/drugoverdose/ featured-topics/pain-management.html

2. OTC use statistics. Consumer Healthcare Products Association. Accessed October 28, 2021. https://www.chpa.org/about-consum- er-healthcare/research-data/otc-use-statistics

3. ACP, AAFP release new guideline for treatment of non-low back pain from musculoskeletal injuries in adults. American College of Physicians. August 17, 2020. Accessed October 14, 2021. https://www. acponline.org/acp-newsroom/acp-aafp-release-new-guideline-for- treatment-of-non-low-back-pain-from-musculoskeletal-injuries-in

4. Oguz-Akarsu E, Gullu G, Kilic E, et al. Insight into pain syndromes in acute phase of mild-to-moderate COVID-19: frequency, clinical characteristics, and associated factors. Eur J Pain. Published online October 8, 2021. doi:10.1002/ejp.1876

5. Bauer AZ, Swan SH, Kriebel D, et al. Paracetamol use during pregnancy - a call for precautionary action. Nat Rev Endocrinol. Published online September 23, 2021. doi:10.1038/s41574-021-00553-7

6. D’Ambrosio A. Warning on Tylenol in pregnancy no cause for alarm. MedPage Today. October 11, 2021. Accessed October 12, 2021.https:// www.medpagetoday.com/obgyn/pregnancy/94967

7. Yong RJ, Mullins PM, Bhattacharyya N. Prevalence of chronic pain among adults in the United States. Pain. Published online April 2, 2021. doi:10.1097/j.pain.0000000000002291

Pharmacists Can Provide Advice on Pain Products’ Directions, Dosage, and Duration of Use