A Pharmacist's Guide to OTC Therapy

Antiemetics

Because nausea and vomiting aresymptoms of various medical conditions,the objectives for treating them shouldinclude identifying the underlying causeas well as providing symptomatic relief.The 3 most prevalent causes of nauseaand vomiting are motion sickness, morningsickness associated with pregnancy,and viral gastroenteritis. Examples ofother causes include stress, certain medications,food poisoning, certain diseasestates, and abdominal distention due toovereating.¹

Treatment

OTC antiemetics should be used onlyto prevent or treat the symptoms of mild,occasional, self-treatable episodes ofnausea and vomiting. Products availablefor the treatment of these conditionsinclude antihistamine products, bismuthsubsalicylate, antacids, histamine² antagonists,and phosphorated carbohydratesolution. Also available for the treatmentof nausea are nondrug products such asthe Sea-Band wristband, which utilizesthe principles of acupressure. In addition,complementary products such as ginger,peppermint, and chamomile are utilizedfor the treatment of nausea and vomiting.¹

OTC antihistamines are indicated forthe prevention and treatment of nausea,vomiting, and dizziness associated withmotion sickness (Table 1). It is recommendedthat antihistamines be taken atleast 30 to 60 minutes before travelstarts to allow sufficient time for theonset of action and for the continuationof the action during travel. Patientsshould be informed of the adverseeffects, such as drowsiness, blurredvision, dry mouth, and urinary retention.Patients with certain medical conditions(eg, asthma, narrow-angle glaucoma,benign prostatic hypertrophy) shouldbe advised not to use these productsunless directed by their physician.¹

Patients should be made aware of theincreased sedative effect that may occurwhen antihistamines are used in conjunctionwith central nervous systemdepressants, such as alcohol, tranquilizers,and hypnotics. Caregivers should beinformed that the use of antihistaminesmay cause paradoxical stimulation inchildren and agitation and confusionamong geriatric patients.¹

Key Counseling Points

Whereas many cases of nausea andvomiting are mild and self-treatable,they sometimes can be symptoms ofmore serious medical conditions, suchas intestinal blockage, appendicitis, andmigraine headaches. Individuals withchronic medical conditions alwaysshould be referred to their physiciansfor the management of nausea andvomiting. Therefore, prior to recommendingany of the OTC products, it isimperative that pharmacists ascertainwhether self-treatment is appropriate(Table 2).

Pharmacists should ensure thatpatients clearly understand the properuse of the OTC products and that theyshould seek immediate medical care ifthe nausea and vomiting is prolonged(lasting >24-48 hours) or if symptomsworsen. When appropriate, pharmacistsalso can encourage patients to drinkclear liquids such as electrolyte-replacementsolutions (eg, Pedialyte) and maintainfluid intake to avoid possible dehydration. Pregnant or lactating womenexperiencing nausea and vomitingshould always consult their physiciansprior to using any medication.

Pharmacists also can play a key role inassisting pediatric patients, because antihistamineproducts, such as dimenhydrinateand diphenhydramine, should notbe used by children under the age of 2.Cyclizine should not be used by childrenunder the age of 6, and meclizine shouldnot be used by children under the age of12.¹ In addition, bismuth subsalicylateshould not be used in children under theage of 12.

Pharmacists can have a vital role inidentifying possible contraindicationsand drug interactions in individuals withpreexisting medical conditions and inthose currently taking other medications.Those patients should be encouraged toconsult their primary health care providerprior to using any of the products.Because possible dehydration and electrolyteimbalance are common concernswith episodes of vomiting, patients,especially pediatric patients, should beassessed for signs of dehydration andshould be encouraged to seek medicalattention when warranted. Please visitwww.pharmacytimes.com for a tablegiving examples of signs of dehydrationin children.

Heartburn Products

Pyrosis, commonly known as heartburn,typically is characterized by a burningor painful sensation in the substernalarea that radiates toward the neck orthroat. Heartburn occurs when the loweresophageal sphincter does not open andclose properly, thus allowing the reflux ofgastric juices into the esophagus.^1,2

Many individuals who experienceinfrequent mild-to-moderate episodes ofheartburn can be treated effectively withOTC medications, in conjunction withlifestyle modifications. Heartburn that isrecurrent and persistent (for =3 months)however, may be a symptom of gastroesophagealreflux disease, which, if leftuntreated, can cause long-term complications,such as esophagitis, gastrointestinalbleeding, Barrett's esophagus,and esophageal cancer.^1,3 It is essentialthat pharmacists encourage individualswho experience severe symptoms toseek medical care immediately (Table 1).

Causes of Heartburn

The severity and frequency of heartburnare different for every individual.Common risk factors are as follows^1,4:

• Certain foods and beverages (eg,tomato sauce, chocolate, peppermint,coffee, alcohol, carbonatedbeverages, spicy or fatty foods)
• Overeating
• Eating <2 hours before bedtime
• Reclining too soon after eating
• Pregnancy
• Smoking
• Excessive weight
• Certain medications (Table 2)
• Stress
• Certain disease states (scleroderma,peptic ulcer disease, Zollinger-Ellisonsyndrome)

Pharmacologic Therapy

Currently a variety of OTC products areavailable for the treatment of mild-tomoderateheartburn (Table 3). Pleasevisit www.pharmacytimes.com for amore complete table.

Bismuth subsalicylate, found in brandname products such as Pepto-Bismol ornewer products such as Maalox TotalStomach Relief, also is approved forheartburn.

Pharmacists can assist patients in theselection of products by carefully assessingthe nature of the patients'symptomsas well as the frequency and duration ofepisodes.

They should ascertain the appropriatenessof self-treatment and screen forpossible drug-drug interactions or contraindications.They should encourageindividuals with preexisting medical conditions,pregnant or nursing women, andpatients <12 years of age to seek advicefrom their primary health care provider.

Pharmacists should inform patientsutilizing OTC products to seek immediatemedical care if their symptoms worsenor if they show no signs of improvementafter 14 days. These products should notbe used for more than 2 weeks unlessdirected by a physician. In addition tocounseling patients on the appropriateuse and adverse effects associated withthe use of these products, pharmacistsshould counsel patients on possible nondrugmeasures that can be incorporatedinto their treatment plans, such as modificationsto diet and lifestyle.

For more information on heartburn,visit the following Web sites:

National Heartburn Alliance: www.heartburnalliance.org

National Digestive Diseases Information Clearinghouse: www.digestive.niddk.nih.gov

American College of Gastroenterology: www.acg.gi.org

Oral Care Products

Good oral hygiene is a fundamentalcomponent of overall health. The 2 mostcommon oral health problems are dentalcaries (tooth decay) and periodontaldisease (gum disease; Table 1). Otheroral health problems include formationof plaque and tartar, halitosis, discomfortfor denture wearers, and tooth sensitivity.

Gum Disease

It is estimated that 80% of adults in theUnited States have some degree of periodontaldisease.^1-3 This disease can rangefrom gingivitis, which is the mildest formand is reversible, to periodontitis, whichcan result in irreversible major damageto soft tissue and the bone structure ofthe teeth. Periodontitis is considered tobe the primary cause of tooth lossamong adults >45 years of age.¹Furthermore, the results of several studiessuggest that periodontal disease mayexacerbate certain health conditions,including stroke, cardiovascular disease,and respiratory disease and can lead togiving birth to preterm low-weightbabies.^2-5

In addition, more than 90% of all systemicdiseases have oral manifestations,and many diseases can be diagnosed intheir early stages through an oral examination.² The goals of proper oral hygieneare removing or preventing plaque andtartar buildup, preventing dental cariesand gingivitis, and decreasing the incidenceof halitosis.

Currently a plethora of oral care productsare on the market. Dentifrices areavailable in various formulations, whichinclude antiplaque/antigingivitis, tartarcontrol, sensitive teeth, and whiteningproducts. Also available are various flossingproducts, topical fluoride products,and cosmetic and therapeutic mouthrinses (Table 2).

The Role of the Pharmacist

Pharmacists are in a crucial position toincrease awareness regarding the benefitsof good oral health care (see sidebar).They can emphasize the importance ofadhering to a daily preventive oral careregimen, as well as being a source ofinformation on the selection and properuse of OTC oral hygiene products.

Through routine monitoring, pharmacistscan recognize patients who may besusceptible to dental problems associatedwith certain medical conditions. Somemedications also can cause adverse dentaleffects, such as xerostomia, tooth discoloration,abnormal bleeding, or inflammationof the gum tissue. Pharmacistsshould recommend that patients seekadvice from a dental professional whenwarranted.

Ms. Terrie is a clinical pharmacy writerbased in Haymarket,Va.

For more information on oral healthcare, visit the following Web sites:

American Dental Association: www.ada.org

Centers for Disease Control 2007Report on Oral Health: Preventing Cavities, Gum Disease and Tooth Loss:www.cdc.gov/nccdphp/publications/aag/oh.htm

Academy of General Dentistry: www.agd.org

National Institute of Dental and Craniofacial Research:www.nidr.nih.gov (site maintained by the National Institutes of Health)

References

Antiemetics

1. McWhorter LS, Fermo J. Nausea and vomiting. In: Berardi RR, Kroon LA, McDermott JH, et al, eds.Handbook of Nonprescription Drugs, 15th ed. Washington, DC: American Pharmacists Association; 2006: 381-401.

2. Nausea and vomiting. Medline Plus. Available at:www.nlm.nih.gov/medlineplus/ency/article/003117.htm.

Heartburn Products

1. Zweber A, Berardi RR. Heartburn and dyspepsia. In: Berardi RR, Kroon LA, McDermott JH, et al,eds. Handbook of Nonprescription Drugs. 15th ed. Washington, DC: American PharmacistsAssociation; 2006. Chapter 14.

2. Berardi R, et al. Medications That May Contribute to Heartburn. National Heartburn Alliance Website. Available at: www.heartburnalliance.org/nosection/medthatcontribute.jsp.

3. Long-term complications of GERD. The Cleveland Clinic Health Information Center Web site.Available at: www.clevelandclinic.org/health/health-info/docs/2500/2565.asp?index=9615.

4. Get Heartburn Smart: Self Care Strategies for Heartburn Sufferers. National Heartburn Alliance Website. Available at: www.heartburnalliance.com/brochure.pdf.

5. www.drugstore.com.

Oral Care Products

1. Klasser G, Colvard M. Prevention of hygiene related oral disorders. In: Berardi RR, Kroon LA,McDermott JH, et al, eds. Handbook of Prescription Drugs, 15th ed. Washington, DC: AmericanPharmacists Association; 2006:649-676.

2. The importance of oral health. Academy of General Dentistry Web site. Available at:www.agd.org/consumer/topics/overallhealth/main.asp.

3. Billingsley J. Gum Disease Can Harm Much More Than Your Teeth. MedicineNet Web site. Availableat: www.medicinenet.com/script/main/art.asp?articlekey=62522.

4. Controlled Diabetics Have New Reason to Smile. American Academy of Periodontology Web site.Available at: www.perio.org/consumer/diabetes.htm.

5. New Study Confirms Periodontal Disease Linked to Heart Disease. American Academy of PeriodontologyWeb site. Available at: www.perio.org/consumer/bacteria.htm.