Which OTC products should these pharmacists recommend?
Case 1: Dental Pain
MG is a 15-month-old baby whose mother comes to the pharmacy looking for something to relieve MG’s teething pain. The mother says MG has been teething for the past few days, is crankier than usual, has been waking up at night screaming in pain, but has not had fevers or vomiting. MG finds relief when chewing on a toy or sucking her thumb. The mother has not given MG any medication, but her pediatrician recommended she try an OTC product. The mother can see that MG has 2 molars coming in. What recommendations do you have for the mother?
A: There are many approaches to relieving teething pain in babies. Nonpharmacologic treatment, such as massaging the gums or applying something cold (eg, a cold teething ring) in the affected area can be helpful. Topical oral analgesics, such as benzocaine, can be helpful for relieving dental pain; however, these products are not recommended for use in children younger than 2 years, and are, therefore, not recommended for treating teething pain.
Topical products, such as benzocaine gels and liquids can lead to a condition called methemoglobinemia, a disorder in which the amount of oxygen carried through the bloodstream is greatly reduced.1 Oral nonprescription analgesics such as acetaminophen have been shown to reduce teething pain and can be beneficial. Acetaminophen is dosed based on weight for pediatric patients; therefore, MG’s weight would need to be known to determine the appropriate dose. It is important to educate MG’s mother on the importance of following the package instructions, and not exceeding 5 doses in 24 hours. In addition, if MG experiences any symptoms, such as vomiting, diarrhea, fever, or other symptoms not typical of teething discomfort, the mother should take MG to her pediatrician.
Case 2: TENS
LG is a 38-year-old woman who comes to the pharmacy with a box of Icy Hot Smart Relief. She started an exercise program 2 weeks ago, and her back has been hurting ever since. She tried OTC analgesics, but they do not seem to help. LG went to her physician, who recommended an OTC product called transcutaneous electrical nerve stimulation (TENS). He said Icy Hot Smart Relief has TENS therapy, which can be helpful for exercise pain. LG has never heard of TENS, so she wants to know if you can tell her what it is and how it works. On questioning, LG denies having any other medical problems, has no allergies, and is not taking any medications. What advice can you give LG about TENS therapy?
A: TENS therapy applies mild electrical impulses to the skin for pain relief. The Icy Hot Smart Relief device is a battery-powered TENS device that transmits mild electrical impulses to underlying nerve fibers and muscles. It is indicated for pain associated with sore and aching muscles due to exercise, which is what LG is suffering from. The electrical current from the device should interfere with the ability of nerves to transmit pain signals, thereby confusing the pain signal. LG should follow the instructions on the package and be instructed to follow the package directions. She should be shown where to snap the control unit to the electrode pad, and how to turn on the power. She should then apply the adhesive pad to the back. The Icy Hot Smart Relief device is not recommended for patients who have a pacemaker, implanted defibrillator, or other implanted metallic or electronic devices. If the pain persists, LG should follow up with her physician.2
Case 3: Fibromyalgia
RD is a 38-year-old woman who comes to the pharmacy looking for something natural to help with her fibromyalgia. She complains of fatigue, as well as sleep, memory, and mood issues. Her physician told her that these are classic symptoms of fibromyalgia. She is taking ibuprofen for pain and fluoxetine for depression. She has tried other analgesics, such as naproxen sodium, but prefers ibuprofen. She says OTC analgesics help, but she wants to try something natural. She heard that a product called S-adenosylmethionine (SAMe) is helpful for reducing pain. What recommendations do you have for RD regarding SAMe?
A: SAMe, a chemical found naturally in the body, has been used for depression and pain. SAMe could be beneficial for helping RD control her pain. The results of one study showed SAMe improved symptoms of fibromyalgia better than transcutaneous electrical nerve stimulation, or placebo. SAMe 800 mg daily in 2 divided doses for 6 weeks has been used for treating fibromyalgia.3 RD should be educated that SAMe is slow acting, possibly taking several days to several weeks to improve symptoms. The long-term safety of SAMe is unknown because most of the clinical trials have been short term. The results of one study, that lasted 2 years, showed SAMe to be safe, with no serious adverse effects reported. However, patients should be cautious if they have bipolar disorder or are taking serotonergic agents because they can lead to serotonin syndrome. Because RD is taking fluoxetine, it would be advisable for her not to take SAMe. If she decides to stop taking fluoxetine, taking SAMe could be an option for her. Before she stops taking a medication, she should discuss her options with her primary care physician.
Case 4: Menstrual Pain
GG is a 24-year-old woman who comes to the pharmacy seeking a product to relieve her menstrual pain. She says she has cramping that produces a continuous dull ache. She feels the pain and cramping near the middle of her abdomen. She has had these cramps for years, but they usually only last for the first day of her cycle. She has tried taking acetaminophen in the past but usually takes ibuprofen 400 mg 1 or 2 times on the first day of her menstrual cycle, and it relieves her pain. Her friend finds relief from menstrual cramps by using an OTC heat patch. GG wants to know if you can give her more information about the heat patch. She likes the idea of not having to take ibuprofen if she does not need it. What recommendations do you have for GG?
A: Many women experience pain during their menstrual cycles. The results of one study demonstrated that patients found relief from nonpharmacologic measures, such as hot baths or a heating pad. The use of heat has been shown to provide better relief than placebo. In addition, heat can provide a faster onset of relief than conventional analgesics. Study results have also shown that heat can be beneficial as an add-on therapy with analgesics. GG can see if she finds relief with a heating pad or a Thermacare patch, which can provide temporary relief of minor menstrual cramp pain and associated backache. If GG decides to use the Thermacare patch, she should be advised not to wear it while sleeping because it can cause burns. She should attach the patch firmly over the painful area with the adhesive side against underwear—not against the skin. She should be educated that it may take up to 30 minutes for the patch to reach the therapeutic temperature. She should not use the patch for more than 8 hours in a 24-hour period.4 If her pain persists after the 8 hours, she can take an analgesic such as ibuprofen to relieve her discomfort.
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.