What should these pharmacists do?
Case 1: Croup
Q: : TY is a 26-year-old mother who comes to the pharmacy for her son, PO, who is 2 years old. She says that he has been coughing for the past week, and she is looking for something to treat his cough. TY says she thinks it may be croup. She says that her daughter had croup once, and it required just symptom management. TY says that in the past 24 hours, PO has been making a high-pitched breathing sound and has had difficulty breathing. TY thinks if she gives him a cough suppressant, it may be beneficial and allow him to breathe more easily. What recommendations do you have?
A: Croup is an infection of the bronchial tubes (bronchi), the vocal cords (larynx), and the windpipe (trachea). It is considered a severe lower respiratory illness that can lead to difficulty breathing and hospitalization. TY should be advised to take PO to his primary care doctor or the emergency department to be evaluated. The symptoms he is exhibiting mean that she should not try to treat him herself.1
Case 2: Immune Booster Echinacea
Q: DD is a 56-year-old woman who is looking for something to boost her immune system. She recently started a job that requires her to travel by plane weekly. Since beginning her job, DD has been getting sick every week. Whenever she gets sick, she cannot go to work and is worried about being fired because she is new. DD began taking a multivitamin, but it has not helped much. Her coworker suggested that she take Echinacea. DD is looking for something to prevent colds and wants your thoughts on Echinacea. She is healthy and takes no medications besides her daily multivitamin. What recommendations do you have?
A: DD should be advised that the data on Echinacea are conflicting. It is categorized as a natural supplement, and therefore, there are no multicentered, randomized clinical trials. Some data have shown that Echinacea may be beneficial to not only treat but also prevent the common cold. Results of studies have shown that individuals who begin taking Echinacea as soon as symptoms begin can see a 3-day reduction in the duration of their symptoms.2,3 Other study results have shown that the incidence of colds can be reduced by almost 50%.4-6 Although the results from these trials have shown benefit, there are others that demonstrate no clinical benefit of taking Echinacea. DD can tryEchinacea to see whether it helps her because she has no medical conditions and is not taking any medications. She should follow the package directions because they may vary by manufacturer. In addition, DD should ensure that she practices good handwashing habits and wipes down surfaces that may be contaminated while traveling.
Case 3: Acute Cough
Q: AM is a 35-year-old woman who comes to the pharmacy seeking advice on her dry, nonproductive cough, which has bothered her for the past few days along with a tickle in her throat. She has been coughing intermittently throughout the day, but it gets worse when she lies down, which has made it difficult for her to sleep. Therefore, AM wants something to suppress her cough while she sleeps. She otherwise reports feeling well and does not have any medical problems or allergies to medications. What suggestions for cough relief can you recommend to AM so she can sleep better?
A: AM’s cough could to be related to an upper respiratory tract infection or allergies. Typically, first-line treatment for a dry, nonproductive cough is a first-generation antihistamine. This can be with or without a decongestant for nasal congestion and naproxen for pain or fever. A product such as diphenhydramine would be appropriate to recommend; a common adverse effect is drowsiness, which could help AM sleep through the night. Many patients seek a product that is nonsedating; however, second-generation antihistamines lack antitussive properties and should be avoided for managing cough. Dextromethorphan is another option for patients who want to suppress their cough during waking hours. AM should be counseled to follow up with her primary care provider (PCP) if her cough worsens or lasts more than 7 days or if she develops a fever.
Case 4: Influenza VaccineQ: NM is a 28-year-old woman who comes to the pharmacy asking for something to help prevent influenza. She says that she is really scared of needles, so she has not gotten the influenza vaccine for the past 2 years. Previously, NM received the nasal spray formula, but it was taken off the market. She knows that flu season is beginning, so she wants to protect herself. NM is healthy and has no medical conditions. What recommendations do you have?
A: NM should be advised that the best way to prevent influenza is by getting vaccinated. For the 2018-2019 season, live attenuated influenza vaccine (LAIV) will be available, and the ACIP voted on February 21, 2018, to include it this year. Previously, the ACIP had recommended against the use of the vaccine because it provided low protection, about 3%, against H1N1 in the 2013-2014 and 2014-2015 seasons. The manufacturer reformulated the vaccine to include a different H1N1 virus. In clinical trials, it was found that the antibody response grew 4-fold in 45% of participants after the second dose.7 LAIV comes in a single-dose sprayer unit. Half of the dose is sprayed into each nostril. Therefore, NM should not be concerned about receiving it. LAIV does not contain thimerosal or any other preservative and is approved for use only in healthy, nonpregnant people between ages 2 and 49 years. Therefore, prior to administration, the pharmacist must confirm NM’s healthy status and that she is not expecting.
Mary Barna Bridgeman, PharmD, BCPS, BCGP, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.Rupal Patel Mansukhani, PharmD, is a clinical associate professor at the Ernest Mario School of Pharmacy and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.