CASE 1: INTRANASAL CORTICOSTEROID USE
BT is a 25-year-old woman who comes to the pharmacy seeking advice about her “runny nose.” She notes that this symptom always seems to occur in the fall in conjunction with the change of seasons and states that it is accompanied by itchy eyes and a sore throat. She says that her symptoms are particularly bothersome, to the point of interrupting her sleep. She has previously tried OTC cetirizine and fexofenadine for symptom relief but reports that these agents left her feeling groggy the next day. She has no significant past medical history and only uses ibuprofen as needed for headache relief. What self-care recommendations can you provide to BT at this time?

ANSWER:
BT’s “runny nose” and the seasonal occurrence of her complaint are characteristics consistent with allergic rhinitis, symptoms of which include watery rhinorrhea, sneezing, nasal obstruction, and nasal pruritus with or without ocular symptoms such as irritation and watery eyes.1 A successful treatment plan for alleviating BT’s symptoms combines both pharmacologic treatment and nonpharmacologic measures to prevent or reduce allergen exposure. In the case of seasonal symptoms, nonpharmacologic strategies for reducing allergen exposure may include minimizing exposure to pollen or mold by keeping windows and doors closed during pollen season and limiting time spent outdoors, when possible, during peak pollen times. Based on BT’s symptoms and poor experience with cetirizine and fexofenadine, recommend that she consider taking an alternative second-generation antihistamine such as loratadine and using this agent on a scheduled basis rather than as needed for symptomatic relief. Another reasonable recommendation would be to use an inhaled corticosteroid such as triamcinolone acetonide (Nasacort AQ). Intranasal corticosteroids (ICs) are a potent treatment option and work best for alleviating symptoms of nasal congestion, rhinorrhea, sneezing, and ocular irritation. ICs work comparatively slower than oral antihistamines; onset of therapeutic effect may take several hours, with maximal benefit not seen for several days with continuous use.2 Localized nasal irritation and epistaxis have been reported with use of ICs; thus when counseling patients, be sure to describe the proper inhalation technique to minimize these adverse events.2 Rupal Patel Mansukhani, PharmD Mary Barna Bridgeman, PharmD, BCPS, CGP For references, go to www.PharmacyTimes.com/publications/issue.

CASE 2: HERBALS FOR PREVENTION OF THE COMMON COLD
JS is a 44-year-old woman who would like some information about taking a natural supplement to reduce her risk for contracting a cold. JS travels frequently for work and is concerned about illness due to her exposure to so many other people in airports and on airplanes. She remembers reading an article about the potential benefits of echinacea and zinc supplements in cold prevention and would like to know your thoughts on the use of these supplements. JS has a history of depression and currently takes sertraline 100 mg daily; she has no known medication allergies. How do you respond?

ANSWER:
Colds are viral infections that can be spread either through contact with airborne respiratory droplets from infected individuals or through physical contact, such as shaking hands with someone infected with a cold. Numerous herbal products, including ginseng, echinacea, garlic, goldenseal, vitamins C and E, and zinc, have been touted to stimulate the immune system to help prevent colds. Echinacea has been shown to stimulate the immune system by promoting production of interleukins and beta-interferon, but results of clinical studies have shown this supplement to be ineffective in preventing the common cold.3 Similarly, although there is evidence that zinc supports an inhibitory effect on rhinovirus replication in vitro, results of clinical studies on the use of zinc supplementation have failed to show efficacy of this nutrient in preventing the common cold.3 Remind JS that there is no “magic bullet” for prevention of the common cold, but that proper and frequent hand washing or use of alcohol-based hand sanitizers may help to mitigate transmission.

CASE 3: COUGH IN THE PEDIATRIC PATIENT
GE is a 2-year-old girl who comes to the pharmacy with her mother, who would like the pharmacist’s recommendation for treating her daughter’s cough. GE received the live attenuated intranasal influenza vaccine 2 days earlier at her pediatrician’s office and subsequently developed a runny nose and bothersome cough that has kept her awake the past 2 nights. GE has no medication allergies and takes no medications. What advice can you provide to GE’s mom at this time?

ANSWER:
Cough is a bothersome symptom that frequently sends adults and children to pharmacies and primary care providers seeking treatment. Due to the risks for adverse effects and the potential for unintentional overdose, nonprescription cough and cold medications containing ingredients such as dextromethorphan, guaifenesin, phenylephrine, pseudoephedrine, chlorpheniramine, and diphenhydramine are no longer recommended for use in children younger than 4 years.4 GE is likely suffering from a cough and runny nose secondary to receipt of the live attenuated intranasal flu vaccine, or she may simply have contracted a cold. Take this opportunity to remind GE’s mom that the live attenuated vaccine cannot cause influenza, because this vaccine contains weakened forms of influenza viruses. For symptomatic relief, suggest to GG’s mom that she use a saline nasal spray to clear mucus from her daughter’s nose. Using a pillow in bed to prop up her daughter’s head, placing a humidifier in her daughter’s room, and increasing her daughter’s fluid intake to thin respiratory secretions may also help provide relief of her congestion.4 If GE develops a fever, shortness of breath, or worsening symptoms, physician referral is warranted. For references, go to www.PharmacyTimes.com/publications/issue.

CASE 4: COUGH AND COLD AND THE PREGNANT WOMAN
BF is a 36-year-old kindergarten teacher who approaches the pharmacy counter seeking professional advice. Over the past 24 hours, she has developed symptoms that include a sore throat and runny nose but has no fever, chills, or systemic complaints. She is currently 25 weeks pregnant with her second child and indicates that many of the children in her class have been ill with upper respiratory complaints over the past few weeks. She would like to treat her symptoms as soon as possible to minimize her absence from work. She has no allergies to medication and currently takes only a prenatal vitamin once daily. What recommendations can you provide to BF at this time?

ANSWER:
Cough and cold are common and bothersome complaints, including during pregnancy. Nonpharmacologic interventions (eg, increasing hydration, using a humidifier, wearing nasal strips to mechanically open the airways, and/or using a saline nasal spray) are all reasonable and can be used alone, in combination with one another, or in conjunction with pharmacotherapy to help to mitigate symptoms. The classes of nonprescription agents that are frequently sought for symptomatic cold relief include antihistamines, decongestants, expectorants, and antitussives. Most agents in these classes fall into the FDA’s pregnancy category B or C regarding their safe use in pregnancy. For BF’s sore throat and runny nose, recommending chlorpheniramine would be appropriate if she is looking for an agent to augment the effectiveness of nonpharmacologic intervention. Chlorpheniramine is a pregnancy category B medication that clinical studies have not found to be associated with fetal malformation.5 This is an older, first-generation agent, so counsel her on the potential for anticholinergic side effects and sedation. Additionally, it is always prudent to remind a pregnant patient to double-check with her prenatal care provider before self-medicating with any nonprescription agent.

References

  1. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy. 2008;63(suppl 86):8-160.
  2. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122:S1-S84.
  3. Natural medicines in the clinical management of colds and flu. In: Natural Medicines Comprehensive Database [Internet]. Stockton, CA: Therapeutic Research Faculty. http://naturaldatabase.therapeuticresearch.com/ce/ceCourse.aspx?&pm=5&pc=12-108. Updated October 6, 2014. Accessed October 7, 2014.
  4. Tietze KJ. Cough. In: Krinsky DL, Berardi RR, Ferreri SP, et al (eds). Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2011.
  5. Hansen WF, Peacock AE, Yankowitz J. Safe prescribing practices in pregnancy and lactation. J Midwifery Womens Health. 2002;47:409-421.