I'm Not Feeling Well

Pharmacy Times, November 2014 Cough & Cold, Volume 80, Issue 11

I'm not feeling well..." These are the words every parent, spouse, and employer dreads hearing on a weekday morning. School is back in session, and more time indoors means cough and cold season is upon us. It's time to stock up on lozenges, Kleenex, and hand sanitizer. No matter how frequently health care professionals encourage patients to get their annual flue shot (if they are eligible), cover their mouths when they cough or sneeze, and thoroughly wash their hands, we know that some patients won't follow this advice.

Pharmacists have the opportunity to have a positive impact in identifying and helping patients with flu-like symptoms. While patients frequently visit multiple physician specialists for various conditions, pharmacists are highly accessible health care providers within communities. Knowing your patients and their ailments are essential when recommending an OTC cough and cold reliever for short-term use. Knowing your patients and their ailments are essential when recommending an OTC cough and cold reliever for short-term use.

Cough and Cold Control

SB is a 22-year-old female who has been having her prescriptions filled at your pharmacy during the past year. You know from past counseling sessions that she is a student at the local university and works at the health center on campus SB is browsing the cough and cold aisle in your pharmacy, picking up boxes to view labels and ingredients. She is wiping her nose frequently and is periodically coughing. When SB comes to collect her monthly prescription refill, she smells of cigarette smoke and she hands you a basket filled with various OTC medications. You ask her how she is feeling and what you can do to help. SB explains that she feels “pretty stuffed up inside,” and that she just “can’t stop coughing up stuff.” She mentions how her boss dismissed her from work and insisted she go home, rest, and not come back to work until she is well. She is a bit stressed about missing work, so she is looking for something to relieve her symptoms.

You ask SB if she would be interested in participating in a brown bag session. You explain what it entails, telling SB that you are interested in reviewing her medications, reeducating her on them, and possibly saving her money. SB appreciates the opportunity to talk with you. She is worried about missing school and work and wants to start feeling better as soon as possible. She appreciates your time and would appreciate your advice and feedback about her health.

When reviewing SB’s current medication profile, you find the following:

Escitalopram 5 mg daily

Sumatriptan 100 mg as needed (refill overdue)

Loestrin Fe daily

Ibuprofen 600 mg every 6 hours as needed (usually filled 3 or 4 days early)

Hydrocodone/acetaminophen 5/500 mg every 4 to 6 hours daily as needed

You have some questions and suggestions about SB’s medications and health. During your discussion, SB admits that she recently started smoking. She understands the consequences of smoking but explains that it helps her relax, reduces her stress, and eases periodic depression. You ask SB about her stress, and she attributes it to her workload, demands at school, lack of exercise, and the fact that she has not been eating or sleeping much lately. You explain how stress and depression can lead to illness, and insist that she learn to manage her stress without the crutch (and long-term effects) of smoking. SB agrees to explore healthy stress management options and to talk with her primary care physician about the dosing of her escitalopram, which has never been titrated.

You review the OTC medications in SB’s basket and pull out multiple combination products. You explain to SB that she does not need anything with additional ibuprofen or acetaminophen because of the potential for drug toxicity. You also explain that the hydrocodone in the acetaminophen combination product should be helping to suppress her cough. SB tells you she has been taking her prescription ibuprofen and hydrocodone/acetaminophen on a regular basis because of frequent headaches. Despite this increase in use, the hydrocodone has not reduced her coughing episodes. SB admits to being nonadherent to her sumatriptan prescription and agrees to follow up with her primary care provider about her headaches.

You tell SB that because she is taking an antidepressant, you would not recommend taking any OTC product with dextromethorphan without her primary care provider’s permission. You suggest a single-use guaifenesin product, a decongestant, and an antihistamine instead. You see that SB has also selected some throat lozenges, a topical throat and chest aromatic, and a compact humidifier. You agree with her nonpharmacologic choices and tell her it’s important to drink lots of water. SB agrees to check in with you tomorrow after she contacts her primary care provider, and thanks you for providing her with some temporary relief. She promises to visit an urgent care center if her cough becomes more frequent and serious.

How would you help SB?

Dr. Drury works as a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin. She earned her doctor of pharmacy from Midwestern University College of Pharmacy. Her blog, Compounding in the Kitchen, appears on www.PharmacyTimes.com.