Case Studies: Nasal Congestion

CASE 1: Allergy-Related Nasal Congestion

RS is a 38-year-old woman who has nasal congestion and typically has seasonal allergies. RS has been taking loratadine 10 mg daily for the past few weeks but has had no relief. She wants to know if there is anything stronger she can take over the counter. What recommendations should the pharmacist make?

A: Typically, RS can use antihistamines, decongestants, or intranasal corticosteroids to treat her symptoms. Because she is already taking an antihistamine, she should try an intranasal corticosteroid. The FDA has approved the following intranasal corticosteroids for nasal symptoms: budesonide (Rhinocort Allergy Spray), fluticasone furoate (Flonase Sensimist), fluticasone propionate (Flonase Allergy Relief), and triamcinolone acetonide (Nasacort Allergy 24HR).¹ RS can try any of these intranasal corticosteroids, as all of them are once-daily medications. Both formulations of fluticasone are approved for ophthalmic symptoms, such as watery eyes. If her symptoms do not improve, RS should see her primary care provider.¹

CASE 2: Nasal Congestion With Vaccination

BL is a 10-year-old girl who comes to the pharmacy with her mother RL complaining about a runny nose, though she has no other symptoms.

BL was tested by her pediatrician for COVID-19 influenza, and streptococcus, but all the test results came back negative. RL was planning on getting BL vaccinated with the newly approved pediatric COVID-19 vaccine. Although she would like BL to receive the vaccination today, she is concerned about her runny nose. What should the pharmacist advise?

A: The CDC says that vaccines do not affect mild illnesses, such as a cold, cough, ear infection, low-grade fever, or runny nose. In addition, the pharmacist should advise RL that mild illnesses do not affect how well the body responds to a vaccine. Vaccines have a small amount of the bacteria and viruses with which BL would normally come in contact. Therefore, her immune system can handle getting vaccinated today and fighting off her runny nose at the same time. Let RL know that vaccines can cause mild adverse effects (AEs), such as a low-grade fever or soreness or swelling at the injection site. AEs typically resolve within 24 hours, but BL can place a cool, wet washcloth on the sore area. If symptoms persist, she can also take fever- or pain-reducing medications, such as acetaminophen or ibuprofen. RL should follow package instructions on pediatric dosing.²

CASE 3: Cold or Cough With Diabetes

LH is a 54-year-old man who has a dry cough and nasal congestion. He has felt sick for the past few days, so he went to see his health care provider. LH’s COVID-19 and flu tests came back negative. His physician recommended he buy an OTC medication to treat his cold and cough. LH would like a sugar-free medication, as he recently received a diagnosis of diabetes. He does not take any medications. What should the pharmacist recommend to LH?

A: LH is complaining of 2 symptoms: dry cough and nasal congestion. Most dry coughs are caused by postnasal drip; therefore, he can take a first-generation antihistamine, such as diphenhydramine.³ For the nasal congestion, LH may benefit from the antihistamine but can also use nasal decongestants, such as pseudoephedrine. If he chooses to use a nasal decongestant, he should monitor his blood glucose closely, as it may raise his blood sugar level.⁴ There are specific OTC formulations with less sugar, such as Diabetic Tussin syrup or Robitussin sugar free. However, these products would not be appropriate for LH because he does not need an expectorant at this time. If he needs cough drops or lozenges for the sore throat, he could consider sugar-free lozenges, such as those from Cepacol, Cold-Eeze, or Ricola.

CASE 4: Fever and Nasal Congestion

TY is a 38-year-old man who has had a fever and nasal congestion for the past 3 days. He also complains of occasional shortness of breath. TY went to a local pharmacy to get tested for COVID-19, but his results were negative. He still feels sick and wants recommendations on how to treat the fever and nasal congestion. What recommendations should the pharmacist provide?

A: Because TY is complaining of fever and shortness of breath, he should be referred to his primary care provider to be evaluated. Although he tested negative for COVID-19, he should also get tested for influenza and other viruses that may be circulating. Patients who have a fever lasting more than 3 days should be referred to a physician. Other patients who should be referred include those who complain of a cough that gets worse or lasts more than 7 days, dizziness, nasal congestion, new onset of symptoms, pain, redness, or sleeplessness.⁵ TY should also stay hydrated and use an OTC electrolyte supplement with low sugar.

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, in Piscataway, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

Ammie J. Patel, PharmD, BCPS, 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.

REFERENCES

1. Over-the-counter allergy nasal steroid sprays - what does it mean for patients? American Academy of Allergy, Asthma, and Immunology. Updated September 28, 2020. Accessed November 7, 2021. https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/triamcinolone-nasal-spray
2. Vaccines when your child is sick. CDC. Updated September 7, 2021. Accessed November 8, 2021. https://www.cdc.gov/vaccines/parents/visit/sick-child.html
3. Benich JJ 3rd, Carek PJ. Evaluation of the patient with chronic cough. Am Fam Physician. 2011;84(8):887-892.
4. Sudafed dosage information. Sudafed.com. Accessed November 8, 2021. www.sudafed.com/products/sudafed-dosage-information
5. Tylenol Cold + Flu Severe for day and night time relief of fever, pain, cough & congestion. Tylenol.com. Accessed November 8, 2021. www.tylenol.com/products/tylenol-cold-flu-severe-day-night-caplets