OTC Cases: Strep Throat

CASE 1: Sore Throat/Fever

Q: RY is a 34-year-old woman looking for something to treat her daughter’s fever. Her daughter, HY, is 6 years old. She has a sore throat that started very quickly, a fever for the past 2 days, and pain when swallowing. Her oral temperature has been 101 °F to 103 °F. What recommendations does the pharmacist have for RY to treat HY’s fever?

A: In most cases, viruses are the cause of sore throats. In some cases, Group A Streptococcus can cause a throat infection. The only way to identify Group A Streptococcus is by taking a rapid strep test.¹ Therefore, RY should be referred to a health care practitioner who can test HY for the virus. In terms of her fever, no evidence suggest that fever worsens illness or causes other complications. Therefore, fever reducers should only be used to reduce HY’s discomfort. If she is uncomfortable, RY can give her acetaminophen or ibuprofen. Data show there is no difference between the efficacy and safety of acetaminophen or ibuprofen in otherwise healthy children. Acetaminophen typically works within 2 hours at the recommended dosage of 10 to 15 mg/kg every 4 to 5 hours. Advise RY not to give more than 5 doses in a 24-hour period. The recommended dosage for ibuprofen is 5 to 10 mg/kg every 6 to 8 hours, with a maximum of 4 doses per day.² HY should stay hydrated as long as the fever persists.

CASE 2: Hypoglycemia Diabetes

Q: MR is a 58-year-old man who is looking for something to manage his blood sugar. He has hypertension and type 2 diabetes. MR started taking insulin approximately 6 months ago. He has been doing well on it, but he felt dizzy the previous evening, so he checked his blood sugar. It came back low, so MR ate dinner to raise his blood sugar level. He wants to buy OTC glucose tablets. What recommendations should the pharmacist give MR for managing his low blood sugar?

A: MR likely had an episode of hypoglycemia. The signs and symptoms of hypoglycemia can vary and may include blurred or impaired vision, chills, confusion, dizziness, fainting, fast heartbeat, weakness, headaches, or sweating. The best way to determine if a patient is experiencing hypoglycemia is to check their blood sugar level. Encourage MR to use the 15-15 rule if he is experiencing hypoglycemia. The rule of 15 starts with checking his blood sugar level. If it is low, then MR should take 15 g of carbohydrates to raise it. After 15 minutes, he should recheck his blood sugar level. If it is still lower than 70 mg/dL, he should take another 15 g of carbohydrates, which can include glucose gels or tablets. MR can also have 4 oz (1/2 cup) of juice or regular soda (not diet), hard candy, or 1 tbsp of corn syrup, honey, or sugar. Once his glucose returns to normal, he should have a small snack if it is not near mealtime to prevent another episode.³

CASE 3: Pneumococcal Vaccine

Q: MB is a 55-year-old woman who wants to know if there are OTC options to prevent pneumococcal disease. MB has had breast cancer, diabetes, and high cholesterol. She is being treated with chemotherapy and other medications. What recommendations should the pharmacist make?

A: The best way for MB to prevent pneumococcal disease, which can cause meningitis, pneumonia, and sepsis, is to get the pneumococcal vaccination. The CDC recommends the pneumococcal vaccination for children younger than 2 years and adults 65 years or older. In certain situations, older children and other adults also can receive the pneumococcal vaccines. There are 2 pneumococcal vaccines on the market: PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23). The recommendations for PCV13 include children younger than 2 years and patients 2 years of age and older with certain medical conditions. PPSV23 is recommend for patients 65 years and older, individuals 2 to 64 years with certain medical conditions, and adults who smoke cigarettes. MB is eligible for both PCV 13 and PPSV23, because she is immunocompromised due to chemotherapy. The CDC recommends that PCV13 should be followed by a dose of PPSV23 a year later in all immunocompetent persons aged 65 years or older who have not previously received the pneumococcal vaccine. Because MB is immunocompromised, the interval between doses would be shortened to 8 weeks.⁴

CASE 4: Heart Health

Q: RD is a 58-year-old woman who is looking for an OTC option to prevent heart failure (HF). She has been taking prescription medications for the past year for HF. RD’s friend recommended she try coenzyme Q10 (CoQ10). What recommendations should the pharmacist give to RD?

A: Because RD has HF, she should discuss treatment with her health care providers before initiating therapy. If she can take CoQ10 safely without drug interactions, it is important to look at longterm efficacy and safety. A meta-analysis demonstrated that patients with HF who took CoQ10 at doses of 30 to 300 mg or 2 mg/kg daily for up to 2 years showed improvements. Improvements included ability to exercise, fewer deaths, and reduced hospitalizations compared with a placebo. Although benefits were seen, all patients were taking conventional therapies in addition to CoQ10. Other markers, such as cardiac output, ejection fraction, and New York Heart Association Functional Classification, did not improve.⁵ Advise RD to continue taking her prescription medications.

AMMIE J. PATEL, PHARMD, BCACP, is a clinical assistant professor of pharmacy practice and administration at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway, and an ambulatory care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.RUPAL PATEL MANSUKHANI, PHARMD, FAPHA, NCTTP, is a clinical associate professor at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, and a transitions-ofcare clinical pharmacist at Morristown Medical Center in New Jersey.

REFERENCES

• CDC. Strep throat: all you need to know. Updated January 12, 2021. Accessed January 20, 2021. https://www.cdc.gov/groupastrep/diseases-public/strep-throat.html
• Section on Clinical Pharmacology and Therapeutics, Committee on Drugs, Sullivan JE, Farra HC.Fever and antipyretic use in children. Pediatrics. 2011;127(3):580-587.doi:10.1542/peds.2010-3852
• American Diabetes Association. Hypoglycemia (low blood sugar). Accessed January 20, 2021. https://www.diabetes.org/healthy-living/medication-treatments/blood-glucose-testing-and-control/hypoglycemia
• CDC. Pneumococcal ACIP vaccine recommendations. Updated November 21, 2014.Accessed January 20, 2021.https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html
• Lei L., Liu Y. Efficacy of coenzyme Q10 in patients with cardiac failure: ameta-analysis of clinical trials. BMC Cardiovasc Disord. 2017;17(1):196. doi:10.1186/s12872-017-0628-9