Although there is still a great deal of uncertainty associated with the global coronavirus disease 2019 (COVID-19) pandemic, frontline health care providers, including pharmacists, remain essential providers of clinical information for patients.

During this pandemic, pharmacists are likely to encounter patients seeking counsel on the use of nonprescription drugs for the symptomatic relief of some of the common mild symptoms associated with COVID-19 that may be amenable to self-treatment.

The CDC reports that individuals with COVID19 may present with a plethora of symptoms that range from mild to severe. These symptoms may include chills, difficulty breathing or shortness of breath, dry cough, fatigue or general feeling of malaise, fever, headache, muscle pain, new loss of smell or taste, repeated shaking with chills, and sore throat.1

The CDC also has a convenient self-checker guide that patients can use to ascertain if they should seek appropriate medical care (https://www.cdc.gov/coronavirus/2019-ncov/ symptoms-testing/symptoms.html).

Patients exhibiting mild symptoms associated with COVID-19 may elect to consider using OTC analgesic/antipyretics, cough suppressants/expectorants, and decongestants to treat mild symptoms. Pharmacists are in a pivotal position to ensure that patients make appropriate product selections from the many nonprescription products available. Prior to recommending any of these agents, pharmacists should always review a patient’s allergies, medical history, and drug profile to screen for contraindications or drug-drug interactions. During patient counseling, pharmacists should ensure that patients clearly understand the proper use of the medication and the correct recommended dosage, especially for the pediatric population. They should remind patients to use the dosing devices that are supplied with some liquid formulations to ensure accuracy of the dosage measurement or purchase calibrated medication-dosing devices.

Recent Clinical Studies and News
There have been recent conflicting reports about the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for those with COVID-19. There were a number of reports showing that NSAIDs may exacerbate symptoms in patients with COVID-19.2 Russell et al gathered information available in published articles to detect any evidence behind these claims with the goal of guiding clinicians on how to best treat patients. This review found no published evidence for or against the use of NSAIDs in patients with COVID-19.2

On March 19, 2020, the FDA issued a statement clarifying its stance on the use of NSAIDs for patients with COVID-19, stating that “The FDA is not aware of scientific evidence connecting the use of NSAIDs, like ibuprofen, with worsening COVID-19 symptoms.”3 This FDA clarification is related to a recent article published in The Lancet on March 11, 2020, which hypothesized that an enzyme is increased by NSAIDs and could aggravate COVID-19 symptoms.3 The statement indicated that the agency is investigating further and will communicate publicly when more information is available.3 The FDA also stated that patients should speak to their primary health care providers if concerned about NSAIDs. The full statement from the FDA can be found at https://www.fda.gov/drugs/drug-safety-and-availability/ fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19.

The latest OTC agent being investigated for use in COVID19 is the histamine-2 receptor antagonist, famotidine. Pharmacists should remind patients that this agent is under investigation and needs further validation. According to an article in Science, the use of this agent is being explored to treat hospitalized patients with severe COVID-19 cases.4,5 Science reported online about in vivo testing of famotidine at an intravenous dose 9 times that of the heartburn dose at Northwell Health, a 23-hospital system in New York City. The author noted that to protect the drug supply and avert hasty speculation about efficacy, investigators kept quiet about their study, which was launched based on early evidence from China and promising models showing that famotidine might be associated with reduced mortality in patients with COVID-19.4,5 The double-blind, randomized study, which began on April 7, 2020, has enrolled 187 participants to date but plans to expand to a total of 1174 individuals in critical status, including many on ventilators, because of the virus. Science indicated that reports from China and molecular modeling results imply that the drug, which seems to bind to a key enzyme in severe acute respiratory syndrome coronavirus 2, could make a difference.4 Thus far, researchers report that in inspecting the medical records of 6212 patients with COVID-19, the doctors observed that many survivors had been suffering from chronic heartburn and were on famotidine rather than omeprazole.4,5 They also noted that hospitalized COVID-19 patients on famotidine seemed to be dying at a rate of about 14% compared with 27% for those not on the drug, although the analysis was an approximation, and the result was not statistically noteworthy.4,5 It is important to note that not much is known about this study, and it warrants further investigation. More information on this study can be found at https://www.sciencemag.org/ news/2020/04/new-york-clinical-trial-quietly-tests-heartburn-remedy-against-coronavirus#.

The Role of the Pharmacist
As the gatekeepers of promoting and ensuring the proper and safe use of pharmacological agents, it is imperative that during counseling, pharmacists should seize every possible opportunity to provide patients with guidance on the correct use of medications, including nonprescription drugs. Pharmacists can also make nonpharmacological recommendations that may be beneficial, such as obtaining adequate hydration, proper nutrition, and rest. Clinical interventions from pharmacists may allow patients to make informed decisions regarding their health and provide them with pertinent information about the proper use of these OTC products.

The world is inundated hourly with news about COVID-19, and as frontline health care providers, pharmacists should advise patients to always obtain information from reliable and reputable sources. They should remind patients not to believe every possible remedy that they hear about, particularly because many are not safe. As we all learn more and more about this pandemic, it is vital that pharmacists remind patients to always seek guidance from their primary health care providers about the best measures to manage mild COVID-19 symptoms and also when to seek medical care for concerning or severe symptoms.

Additionally, patients who take other medications or those with preexisting medical conditions should contact their primary health care providers if they have any concerns. During counseling, pharmacists should advise patients to immediately seek medical attention if they are experiencing severe symptoms. The CDC recommends that patients seek immediate medical attention if experiencing any of the following emergency warning signs of COVID-19: bluish face or lips; new confusion or inability to wake or stay awake; persistent pain or pressure in the chest; and severe difficulty breathing or shortness of breath.2

Keep in mind that the CDC mentions that this list of symptoms is not all inclusive, and patients should always consult with their primary health care providers for symptoms that are severe or worrisome.
 
Yvette Terrie, BS Pharm, RPh, is a consultant pharmacist and medical writer based in Haymarket, Virginia.


REFERENCES
  1. Symptoms of coronavirus. Centers for Disease Control and Prevention. Updated May 8, 2020. Accessed May 11, 2020. https://www. cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
  2. Russell B, Moss C, Rigg A, Van Hemelrijck M. COVID-19 and treatment with NSAIDs and corticosteroids: should we be limiting their use in the clinical setting? ecancermedicalscience. 2020;14:1023. doi:10.3332/ecancer.2020.1023
  3. FDA advises patients on use of NSAIDs for COVID-19. Published March 19, 2020. Accessed April 29, 2020. https://www.fda.gov/drugs/ drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19
  4. Borrell B. New York clinical trial quietly tests heartburn remedy against coronavirus. Science. April 26, 2020. Accessed May 11, 2020. https://www.sciencemag.org/news/2020/04/new-york-clinical-trial-quietly-tests-heartburn-remedy-against-coronavirus
  5. Worcester S. COVID-19 daily: office visits decimated, no US ‘vaccine nationalism.’ Medscape. April 26, 2020. Accessed April 28, 2020. https:// medscape.com/viewarticle/929402#vp_2