A Pharmacist's Guide to OTC Therapy

NOVEMBER 01, 2006
Monica Holmberg, PharmD, and Melinda K. Schott, RPh, PharmD

Nearly everyone has suffered from either a stuffy nose or a painful cold sore. Luckily, OTC treatment options are available to decrease the bothersome symptoms of both conditions. Appropriate choice and use of these products can help decrease the discomfort of these nagging situations.

Nasal Decongestants

Oral Decongestants

Oral decongestants work to relieve nasal congestion by constricting the blood vessels of the nasal passages, resulting in a decreased swelling of the nasal passages and an increased size of the nasal cavity.1 Until recently, pseudoephedrine had been the only option in oral decongestant therapy. Changes in law enforcement and retail policies, however, have restricted the sale of pseudoephedrine nationwide. These changes arose from the potential for pseudoephedrine to be illegally manufactured into methamphetamine. Effective September 30, 2006, the FDA has restricted the sale of all pseudoephedrine to behind the counter and requires patients to provide proper identification and a current address prior to purchasing the product.2

Pseudoephedrine is available in a myriad of preparations, including regular-release (30-mg tablets, dosed as 2 tablets every 4 -6 hours) and sustained-release tablets (120-mg tablets, dosed as 1 tablet every 12 hours; and 240-mg tablets, dosed as 1 tablet every 24 hours). The maximum daily dose of pseudoephedrine should not exceed 240 mg.2

Although pseudoephedrine is still available and offers tried-and-true efficacy as a nasal decongestant, people may find its limited availability inconvenient. Because it cannot be manufactured into methamphetamine, many manufacturers have begun marketing phenylephrine as another option in oral nasal decongestant therapy. Phenylephrine offers an equivalent product to people 12 years and older and is available over the counter without restrictions. The 10-mg phenylephrine tablets should be taken every 4 hours as needed, with a maximum daily dose of 60 mg.2

Topical Decongestants

Topical decongestants, available as drops or sprays, offer quick and effective relief by acting directly on the tissue of the nasal passageways to decrease the swelling and congestion.1 Due to their speed and efficacy, topical decongestants are often a popular choice for people with nasal congestion (Table 13).

Appropriate use of topical decongestants is extremely important. These products should never be used for more than 72 consecutive hours. Topical decongestants have been associated with a "rebound effect," which is described as a worsening of the congestion when the decongestant wears off. As a result, the user may increase the dose or frequency of the product, only to have even worse congestion when the increased dose wears off. The only way to break this cycle is to stop using the spray or drops altogether?even though it may take several days for the nasal passageways to return to normal.4

Patient Education

Neither oral nor topical decongestants should be used in people with the following disease states: heart disease, hypertension, thyroid disease, diabetes, or enlarged prostate. Decongestants should not be used during pregnancy or while breast-feeding unless under the advice of a physician.4

People using a monoamine oxidase inhibitor should not use nasal decongestants.1

Oral decongestants should not be used for longer than 7 days without consulting a physician. Sustained-release products should be swallowed whole. Side effects of oral decongestants include an increase in blood pressure, nervousness, insomnia, palpitations, tremor, difficulty urinating, and decreased appetite.1

Cold Sore Products

Herpes simplex virus type 1 or 2 causes herpes labialis, commonly known as cold sores or fever blisters. They occur on the lips, nostrils, chin, or fingers and are often confused with canker sores, which occur inside the mouth. Symptoms include prodrome pain, which is an itching or tingling preceding the lesion by 1 to 2 days, as well as fluid-filled blisters on a raised, red, painful skin area.The blisters form a yellow crust that sloughs off to show pink skin that heals without a scar in 7 to 14 days.5,6

Treatment Options

Although no medication can get rid of the viral infection completely, some treatments can shorten the duration of the sore and decrease pain. OTC topical anesthetics do not affect the duration of the sore, but many people find them useful to minimize discomfort. Most nonprescription anesthetic products available contain benzocaine, camphor, phenol, alcohol, or any combination of those ingredients in various topical vehicles, such as creams, gels, and lotions.7

The only nonprescription medication available that actually has antiviral properties is docosanol 10% cream (Abreva). Docosanol may shorten healing time when used soon after the onset of symptoms. People using docosanol should wash their hands before and after application and gently and completely rub the cream in a thin layer 5 times a day until the sore is healed8 (Table 27).

In addition to topical anesthetics and docosanol, OTC oral pain relievers may be useful in reducing pain. Options include aspirin, acetaminophen, or ibuprofen. Some people may find ice or warm applications effective at easing pain.6

Patient Education

Here are a few tips to avoid spreading the virus responsible for cold sores:

  • Avoid touching the lesion. If contact is made, be sure the hands are washed immediately.
  • Avoid sharing utensils, towels, and other items that come in contact with the virus
  • Avoid touching other parts of the body
  • Avoid skin contact with others, as well as kissing
  • Avoid common cold sore triggers, such as too much sun exposure, stress, not getting enough sleep, and fever
  • Do not squeeze or pick at the blister. Instead, care for the lesion by washing it gently with soap and water.

Self-treatment may not be appropriate for everyone. People with an immunosuppressive disorder, severe symptoms, frequent recurrence of cold sores, eye irritation, or a cold sore that lasts for over 1 or 2 weeks should see their physician for appropriate medical treatment for the cold sore.5

Dr. Holmberg is a pharmacist with Phoenix Children's Hospital, Phoenix, Ariz. Dr. Schott is a pharmacist with Stop and Shop, Meriden, Conn.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Rybovic, Pharmacy Times, Ascend Media Healthcare, 103 College Road East, Princeton, NJ 08540; or send an e-mail request to: arybovic@ascendmedia.com.