August 2021: OTC Case Studies
How would you answer these patients' questions?
Case 1: Decongestants
Q: GR, aged 38 years, has had congestion for the past few days and wants something to help open her airways. She says she usually uses pseudoephedrine but was recently diagnosed with high blood pressure (HBP), which she is trying to control through diet and exercise. Her blood pressure (BP) readings for the past week have been 138-156/90-98. GR does not take other medications. What should the pharmacist recommend?
A: Pseudoephedrine can be used as a decongestant. However, it can cause a slight increase in BP. In patients with controlled hypertension, the results of one meta-analysis showed that BP increased by 1 mm Hg. Patients who took higher doses had even higher increases.1 Because GR has uncontrolled BP, she should avoid pseudoephedrine. Patients with hypertension should use decongestants only if advised to do so by their physicians, and they should monitor their BP during use. OTC products that are marketed for patients with hypertension often do not include decongestants. GR can try to use a dehumidifier and nasal saline and see whether her congestion improves.
Case 2: BP Monitoring
Q: HH is a 48-year-old man looking for a BP monitor. He was recently diagnosed with hypertension, and his physician recommended that he monitor his BP at home. HH is looking for a wrist monitor because he wants a small device that is portable for work. He takes hydrochlorothiazide 25 mg and lisinopril 10 mg daily for HBP. HH is otherwise healthy. What should the pharmacist recommend?
A: The American Heart Association recommends home monitoring for all patients with HBP to help assess and modify treatment. Finger and wrist BP monitors are not recommended because the readings may not be reliable.2 When choosing a monitor, it is important to assess appropriate cuff size; the cuff bladder should encircle 80% or more of the patient's arm circumference. HH should be seated comfortably with his back supported, a bare upper arm, and his legs uncrossed.3 Advise him not to drink caffeine, exercise, or smoke 30 minutes before measuring his BP. It is also important to take the reading at a similar time each day to see trends. HH can take his BP multiple times throughout the day to assess whether his medications are working. He should be familiar with his goal BP and contact a health care professional if the reading is elevated.
Case 3: DASH Diet
Q: LM is a 55-year-old woman who would like a multivitamin. She was recently diagnosed with hypertension. LM was prescribed 2 medications, but her physician said she should also diet and exercise. Her medications include amlodipine 5 mg and losartan 50 mg daily and atorvastatin 20 mg at bedtime. LM began going to a gym a few days a week but is having trouble adhering to a diet and is tired of eating salads. She asks about a diet that can help reduce her BP. What should the pharmacist recommend?
A: The Dietary Approaches to Stop Hypertension (DASH) diet can help patients reduce their BP level. DASH recommends eating fruits, vegetables, and whole grains instead of refined grains. In addition, the diet suggests incorporating beans, fat-free or low-fat dairy products, fish, nuts, poultry, and nontropical vegetable oils to replace foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils (coconut, palm kernel, and palm oils).4 LM should also limit sugar-sweetened drinks and sweets. In addition, encourage her to limit her salt intake to less than 2300 mg daily, or approximately 1 teaspoon, because data show that less than 1 teaspoon of salt per day can lower BP by 2 to 8 mm Hg.5 However, if LM can tolerate less than 1500 mg per day, her BP will likely be even lower. LM should also speak with a dietician to assess daily caloric intake and learn how to read food labels.
Case 4: Stevia
Q: GG is a 48-year-old woman who wants to refill her medication for lisinopril 10 mg daily. She has had hypertension for 5 years but has been able to control it with diet, exercise, and medication. A friend suggested GG use stevia instead of sugar in her coffee because it can lower BP. Should she try the stevia to help control her hypertension?
A: Advise GG that the data are conflicting regarding the use of stevia for hypertension. The results of 1 study showed that taking stevioside, a constituent of stevia, had a 12 mm Hg mean reduction in systolic BP and an 8 mm Hg reduction in diastolic BP.6 However, results of another study showed no reduction in BP when using stevioside in doses up to 15 mg/kg daily.7 Although stevia has conflicting data, its safety profile is relatively safe. Therefore, if GG wants to use stevia in her coffee, she can certainly try it. Advise her to monitor her BP daily and contact a health care professional if it increases.
Rupal Patel Mansukhani, PharmD, FAPHA, NCTTP, is a clinical associate professor at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.
Ammie J. Patel, PharmD, BCACP, BCPS, is a clinical assistant professor of pharmacy practice and administration at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, in Piscataway, and an ambulatory care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.
1. Salerno SM, Jackson JL, Berbano EP. Effect of oral pseudoephedrine on blood pressure and heart rate: a meta-analysis. Arch Intern Med. 2005;165(15):1686-1694. doi:10.1001/archinte.165.15.1686
2. Monitoring your blood pressure at home. American Heart Association. Updated November 30, 2017. Accessed July 20, 2021. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home
3. Smith L. New AHA recommendations for blood pressure measurement. Am Fam Physician. 2005;72(7):1391-1398.
4. DASH eating plan. National Heart, Lung, and Blood Institute. Accessed July 20, 2021. https://www.nhlbi.nih.gov/health-topics/dash-eating-plan
5. Lenfant C, Chobanian AV, Jones DW, Roccella EJ; Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7): resetting the hypertension sails. Hypertension. 2003;41(6):1178-1179. doi:10.1161/01.HYP.0000075790.33892.AE
6. Chan P, Tomlinson B, Chen YJ, Liu JC, Hsieh MH, Cheng JT. A double-blind placebo-controlled study of the effectiveness and tolerability of oral stevioside in human hypertension. Br J Clin Pharmacol. 2000;50(3):215-220. doi:10.1046/j.1365-2125.2000.00260.x
7. Ferri LAF, Alves-Do-Prado W, Yamada SS, Gazola S, Batista MR, Bazotte RB. Investigation of the antihypertensive effect of oral crude stevioside in patients with mild essential hypertension. Phytother Res. 2006;20(9):732-736. doi:10.1002/ptr.1944