A Pharmacist's Guide to OTC Therapy

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

Head Lice Treatments

Table

Inspection for Head Lice

• Examine each member of the household for lice or nits by using a magnifying glass and bright light

• Look for nits near the scalp starting at the beginning of the neck and behind the ears

• Look for small white-to-yellow specks the size of poppy seeds, and for adult lice moving quickly away from the light

• Examine only a small section of the hair at a time

• If evidence of lice/nits is present, consult a pharmacist or physician for possible treatment options

Adapted from references 3-5.

Pediculus humanus capitis, commonlyreferred to as head lice, affectsan estimated 10 million to 12 millionindividuals in the United Statesannually and is most prevalent amongchildren aged 3 to 12 years.¹ Althoughhead lice can occur at any time duringthe year, the peak times for outbreaksare typically between August andNovember.¹ Head lice can be transmittedvia direct contact with an infestedindividual or through indirect contactwith a contaminated item, such as ahat, hairbrush, or towel.^1,2

OTC pediculicides currently on themarket for the treatment of head licecontain permethrins and synergizedpyrethrins. Both of these products arecontraindicated for use in individualswho have hypersensitivities or allergiesrelated to chrysanthemums, ragweed,or pyrethrins.¹

Pyrethrin

Pyrethrin products should be appliedto the hair for 10 minutes and thenrinsed with warm water or shampooedas directed, followed by combingthrough the hair with a lice comb toremove nits. This procedure shouldbe repeated in 7 to 10 days to kill anyremaining nits. Pyrethrin products areavailable in various formulations, suchas shampoos, lotions, and mousses. Inaddition, many of these products typicallycontain a nit removal comb.

Table

Removal of Head Lice/Nits

• Use disposable gloves when removing nits and work in a well-lit area

• Part hair into 4 sections starting at the top of the head. Hair should be damp If hair dries, rewet with water.

• Using a 1- to 2-in strand of hair, place comb close to scalp and comb firmly away from the scalp

• Pin back area that has been combed and proceed with other sections of the hair

• Clean comb often while combing by using a tissue to wipe away nits and discard the tissue in a sealed plastic bag

• Check hair daily for lice or nits

• Always clean comb after each use

Adapted from references 3-5.

Permethrin

After the hair has been shampooedwith regular shampoo without conditioner,rinsed, and towel dried, permethrincream rinses should be appliedto the hair for 10 minutes and then rinsedwith warm water. The hair should thenbe combed with a lice comb. The rinsehas a residual effect for up to 10 days.¹ Asecond application of permethrin creamrinses should only be used after 7 to10 days if active lice are still detected.¹Products containing permethrin areavailable as 1% cream rinses.

Counseling Points

When used as directed, OTC productscan be very effective in treatinghead lice. Patients/caregivers shouldbe reminded to adhere to the directionsgiven by the manufacturer ofthe selected product and inspect theinfested area routinely for nits, usingthe appropriate combing technique forremoval of nits. If all nits are not goneafter the first treatment, a secondapplication should be applied.

Table

Lice Removal Combs

Nix Premium Metal Two-Sided Lice Comb

LiceGuard Robi Electronic Lice Comb

LiceMeister Comb

RID Dual Combing System

Adapted from references 3-5.

The scalp and hair should be thoroughlyexamined for at least 7 to 10days. If head lice infestation persistsafter a second application, individualsshould consult their health care providerimmediately for other treatmentoptions. As a result of concerns aboutan increase in lice resistance to pediculicides,it is important for pharmaciststo remind patients about theoveruse of these products, noting thatresistance may be caused by improperuse, excess use, or insufficient contacttime.^1,2 Patients also should be remindedto avoid unnecessary use of theseproducts. Individuals with signs of asecondary dermatologic infection inthe infested area and women who arepregnant or lactating should always bereferred to their primary health careprovider for treatment before usingany of these products.¹

Table

Miscellaneous Products

Brand Name

Active Ingredient(s)

Hair Clean 123 Completely Natural Lice Kit

coconut oil, anise oil, ylang ylang oil, isopropyl alcohol

Lice Free Hair Gel

natrum muriaticum 1X (sodium chloride USP)

LiceGuard Lice Treatment System

purified water, sodium laureth sulfate, quaternium-80, polyquaternium-11, panthenol, allantoin, disodium EDTA, fragrances, glycol distearate, sodium laureth sulfate, cocamide MEA

RID Lice Control Spray (for nonwashable items)

permethrin 0.5%

RID Pure Alternative: Head Lice Remedy

dimethicone

Nix Lice Control Spray for the Home

permethrin 0.25%

Pharmacists can assist patients inthe selection of the various OTC productscurrently on the market, as wellas be instrumental in ensuring thatthese products are used properly byproviding the patient with adequatecounseling. When counseling patientsabout these products, pharmacistsshould relay the importance of nonpharmacologicmeasures to preventtransmission of head lice to anotherindividual and prevent possible reinfestation.Examples of these measuresinclude^1,2:

• Adequately clean personal items bywashing brushes, combs, hats, andtoys with very hot water (≥130° F)for at least 10 minutes
• Ensure appropriate cleaning ofthe living environment by vacuumingcarpets, rugs, mattresses, andupholstered furniture
• All linens should be laundered inhot (130° F) soapy water. Dry theseitems on the hottest dryer setting,if possible.
• Seal objects that cannot be launderedin plastic bags for at least2 weeks
• Refrain from sharing items suchas combs, brushes, hats, helmets,and towels

For more information on head lice,please visit the National PediculosisAssociation at www.headlice.org.

Table

OTC Pediculicide Products

Brand Name

Active Ingredient(s)

A 200 Lice Treatment

Kit Shampoo: pyrethrum extract equivalent to 0.33% pyrethrins; piperonyl butoxide 4%

Lice Spray: permethrin 0.50%

Nix Crème Rinse

Permethrin 1%

Nix Combing Gel and Metal Comb

Permethrin 1%

Nix Complete Lice Removal Kit

Permethrin 1%

Pronto Lice Killing Shampoo 0.33%

Piperonxyl butoxide 3%; pyrethins

Pronto Plus Maximum Strength Lice Killing Mousse Shampoo Kit Plus Vitamin E

Pyrethrum extract pyrethrins 0.33%; Piperonyl butoxide 4%

Pronto Plus Lice Killing Warm Oil Treatment & Conditioner

Pyrethrum extract pyrethrins 0.33% piperonyl butoxide 4%

Pronto Plus Complete Lice Removal System (contains lice killing shampoo and lice egg remover plus antiseptic)

Shampoo: pyrethrum extract pyrethrins 0.33%; piperonyl butoxide 4%

Lice Egg Remover Plus Antiseptic: benzalkonium chloride 0.1%

Pronto Plus Maximum Strength Lice Killing Hair & Scalp Masque Apple with Herbal Scent

Pyrethrum extract pyrethrins 0.33%— piperonyl butoxide 4%

RID Lice Shampoo Piperonxyl

butoxide 3%; pyrethins 0.33%

RID Unique Three Step Lice Elimination System Complete Kit

Shampoo: piperonyl butoxide 4%; pyrethrins 0.33%

Comb-Out Gel: water, glycerin, hydroxyethylcellulose, behenamidopropyl dimethylamine behenate, cabbage extract

Home Control Spray: permethrin 0.50% (3-phenoxphenyl) methyl cix/trans3-(2-2 dichloroethenyl) 2,2 dimethylcyclopropanecarboxylate

References

• Buff W, Fuhrman C. Insect Bites and Stings and Pediculosis. In: Berardi R, Kroon L, Newton G, et al, eds. Handbook of Nonprescription Drugs. 15th Edition. Washington, DC: American Pharmacists Association; 2006:794-800.
• National Pediculosis Association Web site. www.headlice.org.
• Rid Lice Products. Bayer Health Web site. www.ridlice.com/healthcare.html.
• Nix Lice Treatment. Insight Pharmaceuticals Web site. www.nixlice.com
• Pronto Plus Products. Del Pharmaceuticals Web site. www.prontoplus.com/index.cfm.

Herbal Supplements

The use of herbal supplements hasincreased in the last 10 to 15 years, andan estimated 25% of adults use oneor more herbal supplements to treat amedical condition.¹ Herbal supplementsare defined as dietary supplementsderived from a plant source, includingthe leaves, stems, flowers, roots, andseeds.¹ Herbal supplements are availableas single-entity or combination products.In addition, some multivitamin/mineralsupplements are now formulated withherbal supplements, such as ginkgo bilobaand ginseng.

According to an article by Bent andKo, published in the April 2004 issue ofthe American Journal of Medicine, of the10 most frequently used herbal supplementsin the United States in 2001,only 4 herbs—garlic, ginkgo biloba, sawpalmetto, and St. John's wort—have systematicreviews that report statisticallysignificant evidence of efficacy.¹

Many patients may assume that herbalsupplements are generally safe becausethey are derived from natural sources;however, many patients with preexistingmedical conditions and/or those patientsconcurrently taking other medications—including prescription and OTC agents—may not be awaretematic reviews thatreport statistically significant evidenceof effi of the potential for drug–herbalsupplement interactions.

Examples of Possible Herbal Supplement–Drug Interactions

• Supplements such as garlic,ginkgo, ginseng, St. John's wort,and evening primrose oil mayincrease the international normalizedratio in individuals takingwarfarin, thus increasing the incidenceof bleeding

• Ginkgo may reduce the effectivenessof anticonvulsants

• Ginseng may intensify the effectsof antihypergylcemic drugs, thusincreasing incidence of hypoglycemia

• St. John's wort can cause adecrease in the plasma concentrationsof agents such as amitriptylinecyclosporine, digoxin,and theophylline. In addition,St. John's wort also may causebreakthrough bleeding anddecrease the effectiveness of oralcontraceptives

• Valerian may produce anincreased sedative effect whenused with alcohol and other centralnervous system depressants

• Kava may reduce the efficacy oflevodopa and is contraindicatedfor use with other agents andherbs that may cause hepaticdamage

• Garlic supplements may intensifythe effects of some antihypertensiveagents

Adapted from references 1, 2, 5, and 6.

Sood et al reported that the potentialfor significant drug–herbal supplementinteractions appears to be mostcommon in the following drug classes:antithrombotic medications, sedatives,antidepressant agents, and antidiabeticagents. These accounted for an estimated94% of the potential clinicallysignificant interactions.² The drug mostcommonly documented for a potentialdrug–herbal supplement interactionis warfarin.² Furthermore, Sood et alreported that the 5 most common herbalsupplements associated with potentialdrug interactions are garlic, valerian,kava, ginkgo, and St. John's wort.²

Results from a national survey revealthat an estimated 18.⁴% of patients usingprescription medications also used herbalremedies.² In addition, many patientsdo not report the use of these herbalsupplements, making it more difficultto screen for possible drug–supplementinteractions or contraindications. Resultsfrom another survey reported that anestimated 63% of participants did notinform their primary health care providerabout their use of dietary supplements.³Sood et al concluded that, although thepotential for interactions between prescriptiondrugs and herbal supplementsappears to be high, the actual potentialfor harm is relatively low.²

Pharmacists can be a fundamentalsource of information for patients seekingguidance about the safety and efficacyof herbal supplements. When counselingpatients about prescription andOTC medications, pharmacists shouldascertain if the patient is currently usingherbal supplements in order to assessfor possible drug interactions or contraindications.Likewise, when assistingpatients in the selection of herbal supplements,pharmacists should screenfor possible drug interactions and contraindications.

Factors to be considered when evaluatingthe clinical significance of an herbalsupplement–drug interaction includethe particular herb, the drug, and themedical history of the patient.⁴ Patientsshould be reminded to discuss the useof herbal supplements with their primaryhealth care provider prior to using themand to always include these supplementsas part of their medication profile.Women who are pregnant or lactatingshould never use an herbal supplementwithout consulting their primary healthcare provider.

In addition, it is important to remindpatients to always use herbal supplementsfrom reputable manufacturersand to adhere to the patient instructionsprovided. Patients also should bereminded that if they experience anyadverse effects to report them to theirprimary health care provider immediately.

For more information regarding herbalsupplements, please visit the NationalInstitutes of Health's National Centerfor Complementary and AlternativeMedicine at nccam.nih.gov.

Table

Most Commonly Used Herbal Supplements

Herbal Supplement

Examples of Common Uses

Potential Adverse Effects

Echinacea

Immune stimulant to prevent and treat colds and other upper respiratory infections

Fatigue, dizziness, headache, and GI symptoms

Garlic

Hypercholesterolemia, hypertension, peripheral arterial disease

Nausea; burning sensation in mouth; throat, and stomach; halitosis; and body odor

Ginko biloba

Cognitive impairment, vascular dementia, tinnitus

Nausea, dyspepsia, headache, and heart palpitations

Saw palmetto

BPH

Headache and diarrhea

Ginseng

Mental and physical stress, anemia, diabetes, and insomnia

Anorexia, rash, changes in blood pressure, and headache

Grape seed extract

Chronic venous insufficiency, diabetic retinopathy, and atherosclerosis

No adverse effects reported in literature

Green tea

Protections against cancer, cardiovascular disease, and hepatic disorders

Insomnia, anxiety, and tachycardia

St. John's wort

Depression, pain, anxiety, and insomnia

Photosensitivity, xerostomia, dizziness, and confusion

Bilberry

Vision impairment

No adverse effects reported in literature

Aloe

Aloe Topical aloe: promotion of wound healing and dermatitis

Oral aloe: digestive disorders wash stimulation

Allergic reactions and urticaria. The use of topical aloe is contraindicated in individuals with allergy to plants in the Liliaceae family.

GI = gastrointestinal; BPH = benign prostatic hypertrophy.

Adapted from references 1, 5, and 6.

References

• Bent S, Ko R. Commonly used herbal medicines in the United States: a review. Am J Med. 2004;116(7):478-485.
• Sood A, Sood R, Brinker FJ, Mann R, Loehrer LL, Wahner-Roedler DL. Potential for interactions between dietary supplements and prescription medications. Am J Med. 2008;121(3):207-211.
• McQueen C, Hume A. Introduction to Botanical and Nonbotanical Medicines. In: Berardi R, Kroon L, Newton G, et al, eds. Handbook of Nonprescription Drugs.15th Edition. Washington, DC: American Pharmacists Association; 2006:1095.
• Hu Z, Yang X, Ho PC, et al. Herb-drug interactions: a literature review. Drugs. 2005;65(9):1239-1282.
• Hume, Anne and Strong, Kathryn. Botanical Medicines. In: Berardi R, Kroon L, Newton G, et al, eds. Handbook of Nonprescription Drugs.15th Edition. Washington, DC: American Pharmacists Association; 2006:1104-1136.
• Dermatological Disorders. In: Beers M, ed: The Merck Manual of Diagnosis and Therapy.18th Edition. Rahway, NJ: Merck Publishing; 2006:2724-2728.