Case 1: Fungal Infection
Q: RD, a 23-year-old man, asks for something to treat a scaly, itchy rash between his toes. He has been running outdoors since the weather got warmer and thinks that the humidity may be causing the rash. RD is training for a marathon in a few months and does not want to stop running. He got new running shoes, but the itchiness continued. RD is otherwise healthy and does not take any medications. He would prefer to use an OTC treatment and heard about powders that absorb humidity. What recommendations do you have?

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

Case 2: Vitamin D with Coronavirus
Q: MJ is a 26-year-old woman who is looking for a vitamin D supplement. She says that a friend is taking vitamin D because she thinks that it prevents coronavirus disease 2019 (COVID-19). MJ works at an assisted-living center and often gets sick, so she wants to take something natural that will help her avoid being infected by the virus. She has no medical conditions, she is healthy, and her immunizations are up-to-date. MJ denies taking anything over the counter, including natural products or vitamins. What recommendations do you have regarding prevention of COVID-19 with vitamin D?

A: Some evidence supports the role of vitamin D in reducing viral infections. One study’s findings showed that vitamin D could interfere with viral replication.2 In addition, supplementing with vitamin D prior to infections was shown to reduce expression of angiotensin-converting enzyme 2, which may be beneficial in patients with viral infections.3 Although a few studies have shown that supplementation may be helpful, no well-controlled clinical trials have been conducted, especially in patients with COVID-19. Advise MJ that vitamin D is fat soluble and can lead to toxicity. An overabundance of vitamin D can lead to anorexia, heart arrhythmias, polyuria, and weight loss, as well as damage to the blood vessels, heart, and kidneys. However, during winter months, many patients can be deficient in vitamin D. It is important to let MJ know that the recommended dietary allowance is 600 IU daily for patients aged 19 to 70 years. Patients over 70 years can increase to 800 IU daily.4 A health care provider can recommend an appropriate prescription product for a vitamin D deficiency. If MJ is concerned about COVID-19, the best way to protect herself is by practicing good hygiene. She should avoid touching her face, cough and sneeze into an elbow or a tissue, disinfect surfaces at the office, and wash her hands frequently.5 She should also follow her workplace guidelines on personal protective equipment when she is with patients.
 

Case 3: Ibuprofen and COVID-19
Q: LS, a 54-year-old man, stops in to discuss acetaminophen. He has been taking ibuprofen 600 mg twice daily for several years to treat his arthritis. A few years back, his doctor recommended taking an anti-inflammatory medication for pain that, at the time, was not controlled. Since then, LS says, his pain has been well managed, and he has no complaints. However, he heard a news report that made him concerned that taking ibuprofen will increase his chances of being infected with the COVID-19 virus. LS has not spoken with his physician but would like to know your thoughts on discontinuing ibuprofen and taking acetaminophen instead. What information can you provide on ibuprofen and the coronavirus?

A: The Infectious Diseases Society of America released guidelines on the treatment of COVID-19, addressing statements by the FDA and World Health Organization that no available data suggest that nonsteroidal anti-inflammatory drugs (NSAIDs) worsen COVID-19–related infections. At this time, the data are limited, but the virus is thought to use angiotensin-converting enzyme 2 to cause infections. This enzyme can be upregulated by medications, such as ibuprofen. However, no substantial evidence shows a link to ibuprofen or any NSAIDs harming patients by this process.6 In addition, advise LS that no data connect ibuprofen to an increased risk of being infected by the COVID-19 virus. However, NSAIDs have cardiovascular, gastrointestinal, and renal risks associated with them, so patients should be counseled about the potential for adverse events.6 If LS wants to discontinue his ibuprofen, he should speak with his health care provider to discuss the best OTC or prescription alternative.
 

Case 4: Allergic Conjunctivitis
Q: TY is a 38-year-old woman in search of a way to treat her eyes, which have been itchy the past few days. She recently started working at a landscaping company and has been outside a lot. TY thinks that she is allergic to pollen, but she has never been tested. Before working at this job, she did not spend much time outdoors, especially in the spring. TY’s physician recommended using OTC eye drops. TY has no other medical conditions and does not take any medication. What recommendations do you have?

A: Avoiding allergens is the best way to treat allergies, but because TY’s work requires her to be outside, that is not an option for her. She should, however, try to stay indoors as much as possible when not at work, keep car windows closed when driving, wear sunglasses, and shower when she gets home to remove some of the pollen. First-line treatment for allergic conjunctivitis is artificial tears, which TY can use according to the package instructions. Gel formulations can be beneficial overnight. If her symptoms do not improve within a few days, she can try using ketotifen ophthalmic solution twice daily, which works directly on the eyes, not systemically. However, if her symptoms persist, she should consider speaking with her health care professional to evaluate and rule out an eye infection.7,8 TY can use an OTC oral antihistamine such as cetirizine, fexofenadine, levocetirizine, or loratadine if infections have been ruled out.

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

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



REFERENCES
  1. Gardner A, Walkup N. Fungal skin infections. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 19th ed. American Pharmacists Association; 2017.
  2. Teymoori-Rad M, Shokri F, Salimi V, Marashi SM. The interplay between vitamin D and viral infections. Rev Med Virol. 2019;29(2):e203 doi:10.1002/rmv.2032
  3. Xu J, Yang J, Chen J, Luo Q, Zhang Q, Zhang H. Vitamin D alleviates lipopolysaccharide-induced acute lung injury via regulation of the renin-angiotensin system. Mol Med Rep. 2017;16(5):7432-7438. doi:10.3892/mmr.2017.7546
  4. Vitamin D. National Institutes of Health. Updated March 24, 2020. Accessed April 18, 2020. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/
  5. How to protect yourself and others. CDC website. Updated April 24, 2020. Accessed April 30, 2020. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
  6. Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19. Infectious Diseases Society of America. Published April 11, 2020. Accessed April 18, 2020. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
  7. Bielory L. Ocular allergy overview. Immunol Allergy Clin North Am. 2008; 28(1):1-23,v. doi:10.1016/j.iac.20012.011
  8. Systane Aaditor Antihistamine Eye Drops ingredients and usage. Alcon. Accessed April 1 2020. https://systane.myalcon.com/eye-care/systane/products/systane-zaditor/ingredients/