OTC Case Studies: Guiding Patients in Self-Care

Case 1—Anxiety Management

BP is a 32-year-old man who asks for your recommendation for an OTC supplement for alleviating the symptoms of jet lag. BP reports he has been traveling back and forth across the country on business for the past few weeks and that he can’t seem to acclimate to the time zone changes and adjust his sleep patterns accordingly. He reports experiencing insomnia and excessive daytime sleepiness, which are impacting his work performance. BP reports suffering from a sulfa allergy and takes loratadine 10 mg daily as needed for allergic rhinitis and ibuprofen 200 mg as needed for occasional tension headaches. What herbal supplement is indicated for the prevention of “jet lag”? Is BP a candidate for the use of this product?

Answer

Jet lag is a temporary condition associated with air travel across 3 more time zones that can result in poor sleep or delayed sleep onset (after traveling east), early awakening (after traveling west), poor mental alertness in the new time zone, fatigue, irritability, and impaired concentration. Symptoms of jet lag can be alleviated through various nonpharmacologic means prior to travel, including eating a balanced diet and allowing for plenty of rest prior to travel and adjusting the timing of sleep to a few hours earlier or later (depending on the direction of air travel) several days prior to a trip. During travel, travelers should be counseled to avoid excessive meals, alcohol, and caffeine intake, keep hydrated,and sleep during long flights.

Regarding the use of OTC remedies for alleviating and preventing symptoms of jet lag, melatonin is an herbal supplement that works to regulate sleep and circadian rhythms. When taken in proximity to the hour of sleep, melatonin may induce drowsiness and make it easier to fall asleep; however, its use for the prevention of jet lag remains controversial. A recent meta-analysis did find the use of melatonin may reduce symptoms of jet lag in individuals traveling across 5 or more time zones.

Doses of 0.5 to 5 mg of melatonin can be taken in the evening on the day of arrival and at bedtime for up to 5 days after. Rare side effects include nausea, vomiting, tachycardia, and a morning “hangover” effect. Although theoretical, the sedative effects of this herb may increase the sedative properties of antihistamines, of which BP should be reminded.

Case 2—Headache Relief

MD is an 18-year-old woman seeking an OTC medication for the treatment of headaches. She describes experiencing moderate headaches each month just prior to the onset of her menstrual period, and that the headaches are usually accompanied by fatigue, irritability, nausea, and mild abdominal pain. She usually takes acetaminophen for symptom relief, and is wondering if there’s another medication that might work “better.” She has no medication allergies and takes an oral contraceptive tablet each day for birth control, which she has been taking for several years. Describe counseling points you would want to reiterate to MD for the treatment of her premenstrual headaches and to alleviate her symptoms of premenstrual syndrome (PMS).

Answer

PMS is a cyclic disorder characterized by physical and emotional changes that occur during the luteal phase of a woman’s menstrual cycle just before the onset of menses. Although the etiology of PMS is not completely understood, it is believed that fluctuations in the hormones estrogen and progesterone may be the trigger for these cyclic symptoms. There are at least 200 different symptoms of PMS. Only some of the symptoms are routinely assessed and identified, however. The most common symptoms of PMS include tension and anxiety; depression; abdominal bloating and lower extremity edema; mastalgia and breast tenderness; headache and irritability.

In the case of MD, treatment goals include resolution of or significant improvement in her symptoms, providing her with education about her symptoms and expectations for treatment, and limiting the impact of her symptoms on daily activities. Treatment of mild-to-moderate symptoms of PMS can include both nonpharmacologic and pharmacologic interventions.

For MD, consider recommending routine exercise, which has been shown to reduce the behavioral symptoms of PMS; dietary modification, including reduction in caffeine consumption, which can worsen irritability; consuming a balanced diet rich in complex carbohydrates and whole grains; and practicing stress-reducing relaxation techniques.

For headache relief, because her symptoms occur in a cyclic pattern in conjunction with the onset of menses, recommend she use a nonsteroidal anti-inflammatory drug, such as naproxen or ibuprofen, on a scheduled basis (rather than as needed) at the onset of symptoms and for the first few days of menstruation. Either ibuprofen or naproxen are appropriate agents to alleviate headache pain associated with PMS; if she also experiences muscle/joint pains, abdominal cramping, or symptoms of dysmenorrhea, this drug class may also help to alleviate these symptoms. Naproxen may be administered at a dose of 220 mg every 8 to 12 hours whereas ibuprofen is dosed 200 to 400 mg every 4 to 6 hours, not to exceed 1200 mg per 24-hour period. Remind her to take the selected agent with food to minimize gastric upset.

Case 3—Dry Eye

ML is a 38-year-old woman who comes to the pharmacy complaining of her eyes feeling tired. She states they feel like they have sand in them. Upon examination, you notice they are mildly red. She claims they are often red and feel like they are dry. ML states she has no medical conditions and takes a multivitamin daily. She has no allergies and would like a recommendation for her dry eyes.

Answer

ML appears to be suffering from dry eyes and has no warning signs; therefore, she is a candidate for OTC treatment. Because her dry eyes appear to be mild, an ocular lubricant would be warranted. Cellulose ethers are common in formulations of lubricant eye drops, including hydroxypropyl methylcellulose 0.3% to 0.8% and carboxymethylcellulose 0.5% and 1.0%. Other vehicles could be polyvinyl alcohol (PVA) 1.4% or povidone 0.6%. Many OTC lubricant eye drops contain these vehicles, which can increase the viscosity, thereby increasing the drug’s action. Most patients with a mild case of dry eye, including ML, would instill drops once or twice daily in the affected eye.

Case 4—Dry Skin

RN is a 38-year-old woman who comes to the pharmacy complaining of dry skin. She states that her skin is very dry, even though she’s been applying lotion for a week. She doesn’t regularly use lotion, but her skin has been so dry lately that it’s cracking, so she started applying lotion. RN has no medical conditions and takes no medications. She wants to know if there is a lotion that works better than the one she is currently using. What lotion would you recommend for her dry skin?

Answer

Dry skin is very common, especially in the dry climates. It is important to educate RN about daily moisturizing. RN should not use hot water when showering, and should instead shower with water no more than 3°F above body temperature. In addition, she should stay in the water for only 3 to 5 minutes.

Within 3 minutes of getting out, RN should pat her body dry and apply a body lotion. It is recommended that she apply body lotion at least 3 or more times during the day to the whole body or at least the affected areas. For more severe cases of dry skin, products containing urea and lactic acid can enhance hydration. Also, increasing her water intake to at least 8 glasses per day can be beneficial.

Case 5—Contraception

JL is a 19-year-old woman who wants your advice on OTC contraceptives. She reports she is sexually active with a new partner and that he had been using latex condoms for prevention of pregnancy. After using these condoms for several weeks, JL developed a painful skin reaction around her genital area, for which her gynecologist evaluated her to rule out infection. After concluding JL was likely experiencing a reaction to the latex in her partner’s condoms, the doctor recommended an alternative condom type if JL decided to continue to use this form of contraception. JL cannot remember the type of condom she was instructed by her doctor to purchase and would like your recommendation.

Answer

Condoms represent one of the most effective methods of contraception and prevention of sexually transmitted infection. The many varieties available— male or female; latex, polyurethane, or natural membrane; various colors, sizes, styles, and shapes—mean many options for individuals who choose to utilize this method of birth control.

Because JL has likely had a reaction to the latex of her partner’s condom, recommend she purchase a synthetic type of condom made from polyurethane or polyisoprene, in either the male or female variety. Polyurethane condoms are available in the same widths and thicknesses as latex condoms but tend to conduct heat better than the latex variety. Polyurethane condoms are also less sensitive to degradation than their latex counterparts and thus tend to have a longer shelf life and may also be used with oil-based lubricants. Polyurethane condoms are not as stretchy as the latex variety, however, and may be more likely to slip or break.

Another option would be to purchase condoms made of polyisoprene, which are more elastic than polyurethane condoms but cannot be used with oilbased lubricants. Both varieties are more expensive than latex condoms. Natural lamb membrane condoms, while effective at preventing pregnancy, may not be a desirable option for JL if she is intending to prevent sexually transmitted infection. The tiny pores in this type of condom may allow the passage of viruses like HIV and Hepatitis B.

If still unsatisfied with this method of contraception, recommend JL speak with her primary care provider to obtain a prescription contraceptive.

Case 6: Dysmenorrhea

BR is a 32-year-old woman who inquires about treatment options for menstrual cramp pain relief. Recently, she reports experiencing new-onset lower abdominal pain that worsens with the onset of menstruation. She has a history of uterine fibroids and reports experiencing particularly heavy and prolonged menstrual bleeding. BR reports no known medication allergies and reports taking only an iron supplement every day to prevent anemia. Is she a candidate for OTC treatment? What would you recommend?

Answer

BR’s lower abdominal pain requires evaluation by a primary care provider. Her symptoms are consistent with secondary causes of dysmenorrhea (eg, age at onset older than 25 years, continuous pain or pain at times other than menses, heavy and prolonged menses) that are associated with a pelvic pathology, notably her history of uterine fibroids. She should not consider using OTC remedies for cramp relief, as these agents may mask the underlying problem and delay medical evaluation. Further, nonsteroidal antiinflammatory drugs—the treatment of choice for primary dysmenorrhea symptoms—may exacerbate BR’s anemia and increase her risk of bleeding.

Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Bridgeman is an internal medicine clinical pharmacist in Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University