CASE 1: Headache
AB is a 30-year-old man presenting to the pharmacy asking for help choosing an OTC option for a headache. He explains that the headache is mild, has lasted about an hour, and is located behind his left temple. He denies sensitivity to light or sounds, as well as nausea or vomiting. When asked about the frequency of his headaches, he reports that he experiences a headache only about once a month. The only medication he has taken today is losartan (Cozaar; Organon LLC) for his high blood pressure.
Q: What pharmacologic recommendations and counseling should the pharmacist give AB?
A: Differentiating between headaches and migraines can help determine which patients should be referred to a physician. The American Headache Society defines migraine as at least 5 headaches that last 4 to 72 hours; meet 2 of the following 4 criteria: unilateral location, pulsating quality, moderate or severe pain intensity, or aggravation by routine physical activity; and occur in conjunction with nausea and vomiting or photophobia and phonophobia.1 Based on the described features, AB is not presenting with a migraine. Combination medications that include caffeine or nonsteroidal anti-inflammatory drugs would not be appropriate due to his hypertension. AB can try acetaminophen 325 mg to 650 mg orally every 4 to 6 hours as needed for headache. AB should be counseled to avoid doses of acetaminophen above 4 g per day and should be informed of adverse effects including nausea, vomiting, skin rashes, or allergic reactions. If AB begins to experience more frequent headaches of worsening severity, he should be advised to see his physician.1
CASE 2: Herbal Supplements for Osteoarthritis
BK is a 60-year-old woman who presents to the pharmacy in search of a supplement for her knee osteoarthritis. She reports that she is newly diagnosed and because her symptoms are mild, she would prefer to try an oral herbal supplement rather than pharmacologic therapy. She has no other pertinent medical history and does not take any medications.
Q: What recommendations can you offer BK?
A: The American College of Rheumatology and the Arthritis Foundation provide guidance regarding supplements for the management of knee osteoarthritis. Most herbal supplements are strongly recommended against due to lack of data. Glucosamine is strongly recommended against in patients with hand, knee, or hip osteoarthritis on the basis of data from clinical trials showing a lack of efficacy and large placebo effect. Chondroitin is also strongly recommended against in patients with knee or hip osteoarthritis but is conditionally recommended for hand osteoarthritis due to results from a single trial suggesting efficacy without evidence of harm. Fish oil has shown some benefit although the guidelines recommend against its use due to lack of efficacy evidence. Additionally, vitamin D is recommended against; trials in osteoarthritis have mixed results from small effect sizes to no benefit.2 Although no herbal supplements are recommended in the guidelines, the pharmacist can recommend nonpharmacologic options to BK. Specific to knee osteoarthritis, the guidelines recommend exercise such as walking, strengthening, neuromuscular training, and aquatic exercises; heat and cooling therapy; and use of a knee brace, balance training, and acupuncture.2
About the Authors
Brielle Stawicki, PharmD, is a PGY-1 pharmacy resident at Atlantic Health System in Morristown, New Jersey.
Deanna Fox, PharmD, is a PGY-2 pharmacy resident at Atlantic Health System in Morristown, New Jersey.
Kylie Helfenbein, PharmD, is a PGY-2 pharmacy resident at Atlantic Health System in Morristown, New Jersey.
Rupal Patel Mansukhani, PharmD, FAPhA, NCTTP, is a clinical professor of pharmacy practice and administration 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.
CASE 3: Capsaicin
TM is a 63-year-old man who presents to the pharmacy requesting a recommendation for an OTC product for nerve pain relief. He says that about 4 months prior, he was diagnosed with shingles after a maculopapular rash appeared on his legs. The rash has resolved, but he has been experiencing burning pain in both legs daily.
Q: He saw a commercial for a medication called Zostrix (Prestige Consumer Healthcare, Inc) and would like to know if the pharmacy sells it. He has no other pertinent medical history and does not take any medications.
A: Postherpetic neuralgia is a common complication of herpes zoster and is defined as dermatologic pain that is sustained for at least 90 days after the initial rash. Pharmacologic therapies include topical or systemic treatments. Systemic treatments include prescription agents such as the anticonvulsants gabapentin and pregabalin, or tricyclic antidepressants. Lidocaine patches or capsaicin can be used topically and are available OTC.3
Zostrix cream contains capsaicin 0.075% and can appropriately be recommended to TM. He should be counseled to apply the cream 4 times daily to the painful areas. Capsaicin is made from peppers and can burn or tingle when applied in some patients. TM should wash his hands immediately after applying and he should avoid contact with his eyes, wounds, and damaged skin.3
CASE 4: Pain Relief Creams
RA is a 35-year-old man presenting to the pharmacy with multiple topical pain relievers looking for assistance in selecting one. He states that he pulled a muscle in his shoulder at work and would like to try a topical product for relief. He presents Aspercreme Arthritis Pain Relief Gel, Motrin Arthritis Pain Relief Topical Gel, and Voltaren Arthritis Pain Relief Gel.
Q: He would like to know how the products differ and which would provide him the most relief.
A: All 3 of the products RA presented contain the same active ingredient, diclofenac 1%, highlighting the importance of educating patients on how to read drug facts labels to determine active ingredients. Diclofenac is a topical nonsteroidal anti-inflammatory drug (NSAID) that is approved by the FDA to treat acute pain, including musculoskeletal pain. Per the American College of Physicians and American Academy of Family Physicians, topical NSAIDs with or without menthol gel are recommended as first-line therapy to reduce or relieve acute pain secondary to non–low back, musculoskeletal injuries. Any of the 3 options RA presented can be recommended, and he should be counseled to apply up to 4 g (using the dosing card) of the gel up to 4 times daily to the affected shoulder. The gel should be applied to clean, dry, intact skin, avoiding open wounds, eyes, or mucous membranes; his hands should be washed immediately after application. The area should not be covered with an occlusive dressing.4
