Which OTC products should these pharmacists recommend?
CASE 1: MEAL REPLACEMENT OPTIONS
A middle-aged man approaches the pharmacy wanting a recommendation for a meal replacement preparation. On questioning, he says he is the primary caregiver for his elderly mother who is in her nineties. Over the past several years, his mother has had consecutive medical setbacks: a broken hip, hospitalization for pneumonia, and a recent stay in a long-term care facility for rehabilitation after a debilitating lowerextremity wound. She is now home, but has a poor appetite, eating only 1 small meal for dinner each day. He is concerned she is not receiving adequate nutrition and would like to give her a dietary supplement, at the advice of her physician, but is not sure which type to purchase. What information should the pharmacist provide regarding the use of a nonprescription meal replacement formulation for this gentleman’s aged mother?
Several enteral nutrition formulations, intended as oral nutritional supplements, are available over the counter and may be useful for older adults whose dietary intake is reduced due to medical comorbidities or poor functional status. A variety of forms, including liquid beverages and nutrition bars, are available and may be considered based on patient preference.1 It is important to realize that most formulations that are readily available without a prescription are polymeric (ie, appropriate for use in individuals with normal digestive capabilities and formulated to contain a balance of macronutrients, including proteins, carbohydrates, and fats). Other additives, including fiber, and alternative formulations—such as those specially formulated for individuals with diabetes or concentrated to contain less water—are available, as are supplements containing single macronutrients.1
In counseling this gentleman about a supplement for his elderly mother, instruct him on how to interpret the nutrition label on various preparations in order to estimate his mother’s nutritional intake. Suggest he offer the supplement after the main meal of the day or as a snack between meals. Recommend that the son offer various flavors to avoid taste fatigue and identify which ones his mother prefers. Suggest refrigeration of the products to improve the patient’s tolerance. Remind the son that unfinished liquid meal replacements should be refrigerated immediately and used within 24 hours or discarded.1
CASE 2: MANAGING CHRONIC CONSTIPATION
An 88-year-old woman approaches the pharmacist seeking a recommendation. She has been suffering from constipation for the past several weeks and has not found relief with the remedies she has tried, including eating prunes and using a daily fiber supplement. On reviewing her pharmacy profile, the pharmacist confirms she is taking multiple long-term medications, including ones to treat hypertension, diabetes, thyroid disease, osteoporosis, and asthma. She has no known allergies to medications. What can the pharmacist recommend to alleviate this patient’s acute constipation and prevent recurrence?
Elderly individuals may suffer from constipation for numerous reasons, including medical comorbidities and the use of medications; psychological and physical conditions, including dehydration and physical inactivity; and lifestyle habits.2 In this patient’s case, it is reasonable to review her dietary and physical habits and recommend (1) a balanced daily diet that includes high-fiber foods such as vegetables, fruits, and whole grains; (2) increased fluid intake, as permitted, given the patient’s comorbidities; and (3) increased physical activity, with physician oversight.2 These interventions are long-term interventions intended to reduce the risk of constipation recurrence; they are not likely to alleviate the patient’s acute constipation.
For the patient’s acute symptoms, recommend the use of a hyperosmotic laxative, such as polyethylene glycol 3350. If this agent is selected, inform the patient that the adverse effects commonly associated with it include bloating and abdominal discomfort or cramping. A bowel movement should be expected within 12 to 72 hours after administration of the product.2 The patient may want to review her medication list with her prescriber at her next scheduled office appointment in order to determine if adjustment of her medications is warranted.
CASE 3: HERBAL SUPPLEMENTS FOR BONE HEALTH
A 74-year-old man comes to the pharmacy for a recommendation for a supplement to support bone health. At a recent routine checkup, his general practitioner told him he has low bone density, or osteopenia. Although the patient does not have osteoporosis, he is concerned about his risk for developing it and that a bone fracture would impair his ability to function independently. He is currently taking low-dose bisphosphonate and a calcium supplement that contains vitamin D, but he is wondering if there are natural products he could also take. What advice would be reasonable to give the patient?
Beyond the use of pharmacotherapy, supplementation with calcium and vitamin D is paramount to supporting healthy skeletal function. A daily calcium intake of 1200 mg/day is recommended for adults 50 years and older; in addition, 600 to 800 IU of vitamin D is recommended for adults 60 years and older.3 A reasonable first step in evaluating this patient’s total daily calcium intake is to evaluate how many servings of foodstuffs containing calcium and/or vitamin D he is consuming each day. Educating him on how to interpret calcium content on nutrition labeling may help him to determine if the daily calcium plus vitamin D formulation he is using is adequate for meeting his daily requirements. Another suggestion is for the patient to ask his prescriber about the indication for checking his vitamin D blood level and whether a high-dose, prescription vitamin D supplement may be indicated for him.
Beyond these interventions, routine weight-bearing exercise, with physician approval, may help to improve the patient’s bone mass and balance, as well as reduce the risk of osteoporosis. Although several natural products, including black tea, boron, chromium, copper, and dehydroepiandrosterone, are touted for improving bone health, clinical data are limited; therefore, the effectiveness of these interventions for improving bone density is unclear.3
CASE 4: VACCINE NEEDS IN THE ELDERLY
A 78-year-old woman wants to speak to the pharmacist about whether she should receive the pneumococcal vaccine this year. She has seen a lot of press about a new pneumococcal vaccine formulation and is wondering if this product is better than the formulation she received several years ago when she was discharged from the hospital after a heart attack. However, she does not want to receive the vaccine unless it is necessary. She is allergic to sulfa drugs and takes several medications for chronic heart failure and hypertension. What recommendation or education regarding the pneumococcal vaccine should the pharmacist offer?
Streptococcus pneumoniae is a bacterial pathogen responsible for thousands of infections in the United States each year, including meningitis, bacteremia, and pneumonia.4 Two pneumococcal vaccines are currently licensed for use in the United States: a 13-valent pneumococcal conjugate vaccine (PCV13) and a 23-valent pneumococcal polysaccharide vaccine (PPSV23). According to recommendations from the Advisory Committee on Immunization Practices (ACIP), all adults 65 years and older should be immunized with both vaccines to ensure the broadest protection against the various strains of this type of bacteria and to reduce the incidence of invasive pneumococcal disease in this at-risk population.5
The administration guidelines have recently changed: for individuals who have not been previously vaccinated, a single-dose of PCV13 is recommended for all adults 65 years and older, followed by a singledose of PPSV23 1 year or more after the PCV13 vaccination.6 In this patient’s case, because she received a single dose of PPSV23 more than 1 year ago, it would be appropriate for her to receive a single dose of PCV13. It is also prudent to educate her on the risks and benefits of immunization and the risks of disseminated pneumococcal disease. Additionally, pharmacists should be mindful that guidelines for the use of these vaccines in other patient populations may vary and review of the most recent immunization schedules from the CDC or ACIP is prudent.
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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. 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.