Which OTC products should these pharmacists recommend?
Case 1: Hair Loss
RG is a 40-year-old man who comes to the pharmacy looking for something to help his hair, which has been falling out slowly over the past decade. RG is starting to notice patches of hair loss on his scalp. He heard he could use an OTC product to prevent hair loss. He has changed his shampoos a few times but has not noticed much of a difference. His dad also suffers from balding and wants to prevent complete hair loss. What recommendations do you have for RG?
A: RG appears to be suffering from hair loss. Minoxidil is FDA approved as a self-care treatment and is available in many formulations. Minoxidil reinvigorates shrunken hair follicles to regrow thicker hair over time. It can be applied as a spray, drops, or a rub. The topical minoxidil formulation for men is available as a 2% or 5% solution or foam.1 In studies, the most effective OTC therapy is minoxidil 5%. The most common adverse effect (AE) is excessive hair growth, typically on the cheeks and forehead. Patients should be educated that the solution may cause more irritation than the foam. RG should be told that, after he begins treatment, his hair loss may initially increase, but he should see an improvement over time. Hair regrowth can take a few months to notice.1 RG should be educated to follow the package directions based on the product he selects. In addition, he can try scalp massage to see if it stimulates hair growth.
Case 2: Athletic Performance
MG is a 35-year-old man who comes to the pharmacy looking for a natural way to improve his athletic ability. He has been out of shape for years and decided to start working out 6 months ago. He complains that he needs more energy when lifting and running. He also wants something to help him recover after workouts so he does not feel as sore. His friends at the gym recommended he take creatine every day. He is concerned about the AEs of taking something natural. He has no medical problems and takes no medication. He has an annual physical, and all his blood values are within normal limits. What can you tell MG about taking creatine to improve athletic performance?
A: Creatine has become a very popular athletic performance agent, with sales more than $400 million each year. Patients typically use it for performance during high-demand situations. Creatine is a natural part of skeletal muscle. Increasing the body’s creatine level can improve energy and the recovery phase after physical exertion. Clinical studies have shown that creatine enhances muscle performance during high-intensity workouts, such as weightlifting or cycling. The use of creatine has been shown to decrease recovery time after weightlifting, but not after sprinting or cycling. Although muscle strength improves with the use of creatine, it does not necessarily increase lean body mass, but does increase water weight within muscles. The most common dose of creatine is 20 g/day for 5 days. Individuals complain of gastrointestinal upset and muscle cramping when taking creatine. MG should be educated to increase his fluid intake to reduce cramping and prevent dehydration.2 MG can also try obtaining creatine naturally in foods such as milk, meat, and fish.
Case 3: Saw Palmetto for Benign Prostatic Hyperplasia in a Patient with Diabetes
NM is a 55-year-old man who comes to the pharmacy looking for something natural to treat his benign prostatic hyperplasia (BPH). His physician recently told him he has an enlarged prostate and wants to start him on a prescription medication. NM tries to limit the number of prescription medications he takes because of AEs and medication interactions. He wants to know if he could take something natural for his prostate. His friend recommended saw palmetto, which is natural, and said it would help improve his urgency to urinate. NM has diabetes and hypertension and is taking insulin and lisinopril daily. What recommendations do you have for him?
A: Saw palmetto is commonly discussed for treating BPH; however, study results show contradictory information regarding the use of saw palmetto for treating BPH. The results of a few studies have shown improvements in BPHrelated urinary symptoms, such as frequent urination, hesitancy, urgency, obstructive symptoms, and prostate size. However, the studies have had small numbers of participants and have been short in duration. The results of 1 study, sponsored by the National Institutes of Health, concluded that saw palmetto 160 mg twice daily was ineffective for reducing symptoms in men with moderate to severe symptoms of BPH after a year of treatment.3 The results of another study showed that saw palmetto in doses of 320 mg to 960 mg daily for 72 weeks did not significantly improve symptoms compared with placebo.4 Although some study results have suggested improvement of symptoms, it appears that saw palmetto does not improve symptoms in long, well-designed clinical trials.
Because the safety of saw palmetto is not a concern, if NM wants to try it for a few months, he can. However, he should be advised to have his physician monitor him for improvement of symptoms. NM’s diabetes and hypertension are not contraindications for the use of saw palmetto.
Case 4: Smoking Cessation
OO is a 50-year-old man who comes to the pharmacy looking for something to help him quit smoking. Upon questioning, he has been smoking 1 pack per day for the past 20 years. He has tried several times to quit smoking “cold turkey,” but he is now looking for something to assist him. His father recently received a diagnosis of lung cancer, so OO is finally motivated to quit smoking. What recommendations do you have for OO?
A: Most smokers are like OO in that they attempt to quit on their own without pharmacologic assistance. Approximately 95% of individuals who attempt to quit cold turkey resume smoking. Assisting patients with pharmacologic treatment can help improve outcomes and prevent smoking relapse. The Clinical Practice Guideline for Treating Tobacco Use and Dependence recommends counseling patients for smoking cessation on 5 key areas, known as the 5 As, which include (1) ask patients whether they use tobacco, (2) advise tobacco users to quit, (3) assess patients’ readiness to quit, (4) assist patients with quitting, and (5) arrange follow-up care.5 Because OO is already at step 4, he should be assisted through pharmacologic treatment. Nicotine replacement products include a variety of dosage forms. The difference between dosage forms is based on the site of administration and the rate of absorption. The onset is highest with the nasal spray, followed by the gum, lozenge, inhaler, and patch. The gum, lozenge, and patch are all available over the counter. In addition, bupropion and varenicline are available as prescription medications. OO should be educated on the various products to assist him in smoking cessation. He should be educated that although pharmacologic agents can help, follow-up counseling improves quit rates, so he should speak to a smoking cessation counselor.
Dr. Mansukhani is a clinical assistant professor at the Ernest Mario School of Pharmacy, Rutgers University, and a transitions-of-care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey. Dr. Bridgeman is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.