OTC Case Studies: Stomach Issues

Case 1: Fiber Adverse Effects

Q: NM is a 41-year-old man who comes into the pharmacy complaining of bloating and flatulence. He says he was recently given a diagnosis of diabetes, and his doctor started him on medication. In addition, the doctor asked NM to increase his fiber, as he gets very little in his diet, and recommended an OTC fiber supplement. NM says he got a powder supplement that contains psyllium. The directions on the package recommended taking it 3 times a day. NM says that the bloating and discomfort started when he began the psyllium. What recommendations do you have?

A: Increasing dietary fiber can lead to bloating and flatulence. The Academy of Nutrition and Dietetics recommends about 38 g of fiber per day.¹ NM should have slowly increased his fiber intake to avoid symptoms such as bloating and gas. Importantly, advise him that he can also try to increase his fiber through his diet. Foods high in fiber include beans, fruits, legumes, nuts, and vegetables. Because NM is already taking psyllium, he can try to titrate up slowly to avoid the bloating and flatulence. If that does not work, he can try a soluble, semisynthetic fiber supplement, such as calcium polycarbophil. Calcium polycarbophil is an “inert synthetic polymer (compound) with water-absorbing ability, which is higher than natural fibers such as psyllium or carboxymethylcellulose.”²

Case 2: Ginger for Morning Sickness

Q: LL is a 32-year-old woman who comes into the pharmacy complaining of morning sickness. She is 16 weeks pregnant and is nauseated every morning when she wakes up. LL has tried acupressure wristbands, which she used during her past pregnancy. However, the wristbands have provided no relief during this pregnancy. LL is healthy overall but has been feeling this way since becoming pregnant. LL’s friend recommended ginger, but LL does not like the taste and is looking for a natural supplement that she can take to reduce her nausea. She denies vomiting or any other symptoms. Currently, LL is taking a prenatal multivitamin. What recommendations do you have?

A: Morning sickness can vary in severity and can be treated with nonpharmacologic or pharmacologic treatment. For most pregnant women, symptoms of nausea resolve by 20 weeks. However, LL appears to be in discomfort and would like to take something natural to help relieve her symptoms. During pregnancy, women can use ginger in many forms, including capsules, ginger ale, preserves, and teas. According to the American Academy of Family Physicians, one study showed that 1g a day of ginger was more effective than a placebo in reducing the symptoms of nausea. Although no safety data from clinical studies are available, many cultures use ginger as part of their daily diet. It is considered relatively healthy. In addition, LL should be advised about vitamin B6, which, as well as pyridoxine, has also been shown to reduce nausea during pregnancy and can be used alone or in combination with doxylamine. The results of one study showed that small doses of 75 mg a day were more effective than a placebo in reducing symptoms. LL can try either agent, but she should discuss her options with her physician before she starts any new medication, even if it is natural.³

Case 3: Dysmenorrhea

Q: RD is a 24-year-old woman who comes in looking for an OTC option to decrease her menstrual pain. She has had

pain every month during her menstrual cycle for the past 10 years. RD typically takes ibuprofen before and during her menstrual cycle to decrease pain. She complains of a dull ache with spasmodic cramping in her midabdominal area. RD has seen a physician, who gave her a diagnosis of primary dysmenorrhea around her menstrual cycle. He recommended that she take ibuprofen as needed for pain. RD read online that fish oil, in addition to being good for heart health, can help decrease menstrual pain. What recommendation do you have regarding fish oil?

A: Omega-3 fish oil has proven benefits in patients who suffer from high triglycerides. In addition, limited data are

available on its use for many other conditions, including attention-deficit/hyperactivity disorder, bipolar disorder, dysmenorrhea, heart failure, and hypertension. Regarding dysmenorrhea, the results of one study evaluated the use of fish oil compared with a placebo. The authors concluded that the intensity and duration of pain decreased with fish oil compared with a placebo.⁴ Another study evaluated omega-3 fish oil as well as vitamin E compared with a placebo. The study results showed that both supplements effectively relieved menstrual pain. However, the combination reduces the pain significantly (P <.05).⁵ Overall, individuals can safely use fish oil in doses of 3 g a day and less. It has been generally recognized as safe in the United States.⁶ Therefore, RD can try taking fish oil to see whether it helps with her dysmenorrhea.

Case 4: Heartburn

Q: FG is a 39-year-old woman who is looking for something for her heartburn. She recently started a diet and has

been eating healthier. FG gave up regular soda and replaced it with diet soda. She likes it so much that she is drinking 8 to 10 cups of diet soda daily. In addition, FG has been eating salads with spicy jalapen&#771;o dressing. These dietary changes often cause a burning sensation. FG’s physician recommended she take an OTC product to alleviate her heartburn, but she does not know which product to select. What recommendations do you have?

A: Because FG has changed her dietary habits significantly, she should seek counseling on lifestyle modifications.

Many foods can trigger heartburn, especially spicy foods. FG should try to avoid alcohol, caffeinated drinks, citrus fruits, coffee, peppermint, and tomatoes. She should also replace her diet soda with regular water or at least noncaffeinated beverages to see whether her symptoms decrease or resolve. In addition, FG can try eating smaller meals or eating more frequently. OTC medications that might help include antacids, such as calcium carbonate; a histamine 3 receptor antagonist, such as cimetidine, famotidine, or ranitidine; and a proton pump inhibitor (PPI), such as esomeprazole, lansoprazole, or omeprazole. She can start with a histamine 2 receptor agonist (H2RA) as needed when she has symptoms. FG can escalate to a PPI if symptoms do not resolve with H2RAs. If her symptoms persist or worsen, she should be reevaluated by a physician.⁷

Rupal Patel Mansukhani, PharmD, CTTS, FAPhA, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.Caitlyn Bloom, PharmD, BCACP, AE-C, is a clinical assistant professor at the Ernest Mario School of Pharmacy at Rutgers University and an ambulatory care clinical pharmacist at RWJBarnabas Health, part of the Barnabas Health Medical Group in Eatontown, New Jersey.Ammie J. Patel, PharmD, BCACP, is a clinical assistant professor of pharmacy practice at the Ernest Mario School of Pharmacy at Rutgers University and an ambulatory care specialist at RWJBarnabas Health, part of the Barnabas Health Medical Group.

REFERENCES

• US Department of Health and Human Services, US Department of Agriculture. Dietary guidelines for Americans 2015-2020. Office of Disease Prevention and Health Promotion website. health.gov/dietaryguidelines/2015/guidelines/. Accessed June 17, 2019.
• Frequently asked questions. FiberCon website. fibercon.com/faqs. Accessed June 19, 2019.
• Quinla JD, Hill DA. Nausea and vomiting of pregnancy. Am Fam Physician. 2003;68(1):121-128.
• Hosseinlou A, Alinejad V, Alinejad M, Aghakhani N. The effects of fish oil capsules and vitamin B1 tablets on duration and severity of dysmenorrhea in students of high school in Urmia-Iran. Glob J Health Sci. 2014;6(spec 7):124-129. doi: 10.5539/gjhs.v6n7p124.
• Sadeghi N, Paknezhad F, Rashidi Nooshabadi M, Kavianpour M, Jafari Rad S, Khadem Haghighian H. Vitamin E and fish oil, separately or in combination, on treatment of primary dysmenorrhea: a double-blind, randomized clinical trial. Gynecol Endocrinol. 2018;34(9):804-808. doi: 10.1080/09513590.2018.1450377.
• GRAS notices. FDA website. www.accessdata.fda.gov/scripts/fdcc/index.cfm?set=GRASNotices&sort=Substance&order=ASC&startrow=1&type=basic&search=fish%20 oil. Updated June 14, 2019. Accessed June 17, 2019.
• Heartburn and dyspepsia. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 18th ed. Washington, DC: American Pharmacists Association, 2018.