Heart Health OTC Cases: March 2023

Case 1: Omega-3 Fatty Acid

Q: AG is a 67-year-old man with heart failure (HF) and hypertension. He visits the pharmacy to pick up a medication refill for furosemide. AG tells the pharmacist that he has been experiencing more shortness of breath during his daily morning walks around his neighborhood. His doctor classified his HF as New York Heart Association (NYHA) Class II. AG isinterested in improving his heart health and asks the pharmacist if there are any OTC agents that may help. How should the pharmacist respond?

A: In addition to continuing his other guideline-directed prescription medication therapy for HF, AG can consider taking omega-3 polyunsaturated fatty acid (PUFA) supplements. Study results have shown that PUFA supplementation may reduce cardiovascular events in patients with HF.^1,2 The 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America Guideline for the Management of Heart Failure states that PUFA supplementation may be reasonable to use as an adjunct therapy to reduce morbidity and mortality in patients with NYHA Class II to IV symptoms.³ Common adverse effects of PUFA supplementation are mild and may include headaches, unpleasant taste, or upset stomach.⁴

Case 2: Smoking Cessation

Q: ZH is a 36-year-old man who visits the pharmacy after his primary care appointment. He shares that his blood pressure level was elevated and his physician encouraged him to quit smoking to improve his cardiovascular health. ZH smokes a pack of cigarettes daily. He recognizes that smoking is bad for his health and wants to quit. This is his first attempt at quitting, and the physician told him to purchase nicotine patches from the local pharmacy. ZH is overwhelmed by the selection of nicotine products available for smoking cessation and asks for the pharmacist’s support choosing the best agent. What should the pharmacist recommend?

A: Nicotine patches are available over the counter in a variety of brands and doses in 3 strengths: 7, 14, and 21 mg. Selecting the appropriate dose is dependent on the number of cigarettes smoked daily. Patients who smoke 10 or more cigarettes per day should start using the highest strength, the 21-mg patch. Patients who smoke less than 10 cigarettes daily should start with the 14-mg patch. Because ZH smokes a pack of cigarettes daily, the pharmacist should recommend the 21-mg patch. If the patient continues to have cravings or withdrawal symptoms while using the patch, he can consider combining the patch with a short acting nicotine replacement therapy, such as gum or lozenges. ZH may also consult his physician to see if he would be a candidate for a prescription medication for smoking cessation.^5,6

Case 3: Coenzyme Q10

Q: MB is a 38-year-old woman with no significant past medical history who brings a bottle of coenzyme Q10 (CoQ10) to the pharmacy consultation window. She tells the pharmacist that a coworker said CoQ10 can improve heart health. MB asks the pharmacist how CoQ10 works and would like to know about the benefits and risks associated with this supplement. What advice can the pharmacist provide?

A: CoQ10 is a naturally occurring antioxidant found in the body that is involved in many important biological pathways.⁷ It is available as an oral dietary supplement that can be purchased over the counter. The pharmacist can inform MB that this supplement may have a small degree of efficacy in improving cardiovascular health; however, results are inconclusive.8A literature analysis found CoQ10 treatment may be associated with a reduction in all-cause mortality in patients with heart failure. The same analysis found inconclusive data regarding the supplement’s effect on heart attack or stroke risk. Larger, controlled trials are needed before definitive conclusions can be reached.⁹ CoQ10 is generally well tolerated, and adverse effects may include abdominal discomfort. CoQ10 may interact with medications such as warfarin, so patients should inform a health care professional before taking the supplement.⁸

Case 4: Cold and Cough

Q: LV is a 50-year-old man who comes to the pharmacy with complaints of a cold. The patient tells the pharmacist he has been experiencing symptoms including body aches, a dry cough, and a runny nose over the past 48 hours. LV has a mild fever of 100.4 °F and his COVID-19 test result was negative. He has had uncontrolled hypertension and hypercholesterolemia, for which he is taking amlodipine (Norvasc), atorvastatin (Lipitor), hydrochlorothiazide, and losartan (Cozaar). He asks the pharmacist for OTC recommendations that would be safe given his high blood pressure level and concomitant prescription medications. What should the pharmacist recommend?

A: Certain cold medications that contain decongestants or nonsteroidal anti-inflammatory drugs (NSAIDs) may increase blood pressure level and should be used with caution in patients with hypertension. Decongestants such as phenylephrine and pseudoephedrine should be avoided in uncontrolled hypertension, and alternatives include antihistamines, intranasal corticosteroids, and nasal saline. Acetaminophen is a safer alternative to NSAIDs.¹⁰ When recommending a medication for cold and cough, pharmacists should evaluate the components of each OTC option. Certain brands, such as Coricidin HBP, formulate products with these considerations.¹¹ To target LV’s specific symptoms, the pharmacist can recommend a product containing acetaminophen, an antihistamine, and dextromethorphan. The acetaminophen helps relieve body aches and fever, antihistamine (eg, chlorpheniramine) can help with a runny nose, and dextromethorphan is a cough suppressant.