OTC Case Studies: Winter Colds

CASE 1: Oral Phenylephrine and Hypertension

JM is a man aged 57 years with a past medical history of hypertension and diabetes who presents to the pharmacy with complaints of nasal congestion for the past 3 days. He has not tried any OTC medications and is requesting assistance selecting an OTC medication for relief. He is interested in trying oral phenylephrine because he recently saw a commercial advertising its benefits for nasal congestion.

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Q: What counseling points should the pharmacist provide JM regarding the use of OTC phenylephrine?

A: Because of JM’s history of hypertension, he should be counseled to avoid oral phenylephrine because it can increase blood pressure due to vasoconstriction properties within the nasal mucosa.¹ Additionally, recent data suggest oral phenylephrine is not effective for cough and cold relief.²

However, the pharmacist can recommend the use of a nasal decongestant such as oxymetazoline spray (Afrin; Bayer). Oxymetazoline is also a vasoconstrictor agent, but it works more selectively in the nasal pathway and has fewer systemic adverse effects compared with oral decongestants, with less impact on blood pressure. The pharmacist should counsel JM to use 2 to 3 sprays of oxymetazoline in each nostril twice daily. JM should also be counseled to limit oxymetazoline use to 3 days because it can cause rebound congestion when used for longer duration. If JM does not have any improvement in his symptoms after 3 to 5 days of oxymetazoline use, he should be seen by a medical provider for alternative therapies. Other common adverse effects with oxymetazoline include nasal irritation, nasal dryness, and burning.³

CASE 2: Cough and Congestion

KD is a woman aged 83 years who comes to the pharmacy seeking help with a persistent, productive cough and chest congestion that she has had for the past 2 days. She says she feels as though there is mucus in her chest but is struggling to cough it out. The only thing she has tried so far to help is cough drops. Her past medical history includes hypothyroidism and diabetes, for which she takes levothyroxine (Synthroid; AbbVie) and metformin. She says she has no drug allergies.

Q: What would be an appropriate OTC agent for the pharmacist to recommend for KD’s cough?

A: Because KD has a productive cough with difficulty clearing mucus, an expectorant such as guaifenesin (Mucinex; Reckitt) would be an appropriate OTC recommendation. Guaifenesin helps reduce mucous viscosity, providing loose, thin secretions that are easier to clear from the lungs. Guaifenesin extended-release products should be taken as 1 to 2 tablets every 12 hours with a maximum dose of 2400 mg per day, as needed, to reduce chest congestion and help cough up mucous. Additionally, the pharmacist should counsel KD to ensure adequate hydration while taking guaifenesin to promote better thinning and clearing of mucous. KD should also be counseled to see her primary care provider if her symptoms do not resolve within 7 days of onset, as this may indicate the need for additional medications for management.⁴

CASE 3: Acetaminophen and Cold Products

LP is a woman aged 43 years who approaches the pharmacy counter for help selecting an OTC medication to manage her symptoms of a dry, hoarse cough; headache; and fevers. Her past medical history includes rheumatoid arthritis for which she is currently taking hydroxychloroquine (Plaquenil; Sanofi) 200 mg twice daily and acetaminophen (Tylenol; Johnson & Johnson) 650 mg every 8 hours for pain. She says she has no drug allergies. She brings a combination cough and cold product she found to the pharmacy counter and wonders whether the pharmacist has any additional recommendations. The product contains the following in each 15 mL of syrup: phenylephrine 5 mg, acetaminophen 325 mg, dextromethorphan 10 mg, and guaifenesin 200 mg. The product directions state to take 30 mL by mouth every 4 hours as needed for cough and cold symptoms.

Q: What recommendations should the pharmacist make regarding LP’s selection?

A: The pharmacist should recommend against the use of this combination cough and cold medicine due to her acetaminophen use. The patient should be counseled that the cough and cold product contains acetaminophen, which LP is already taking throughout the day. If she were to take the product as directed with 30 mL every 4 hours, LP would consume approximately 3900 mg of acetaminophen within 24 hours from the cough and cold product alone, in addition to the scheduled acetaminophen she takes for her rheumatoid arthritis. The pharmacist should counsel LP that the maximum recommended dose of acetaminophen is 3000 mg when taken at home without the supervision of a health care professional.^5,6

CASE 4: Pseudoephedrine and Hypertension

HB is a man aged 79 years with diabetes and hyperlipidemia, for which he takes sitagliptin (Januvia; Merck) and atorvastatin (Lipitor; Viatris) daily. He also has a known penicillin allergy. He calls the pharmacy from home requesting assistance with selection of an OTC product for postnasal drip associated with a sore throat. He has not tried any medications because he is worried about interactions with his existing health conditions and other medications.

Q: How should the pharmacist advise HB?

A: The pharmacist should counsel HB on the options to manage his symptoms. Based on his past medical history of hypertension, HB should be counseled to avoid decongestants containing pseudoephedrine and phenylephrine because those have the potential to affect his blood pressure.⁷ Alternatively, HB could consider oral antihistamines such as diphenhydraminecontaining products to assist in drying up his postnasal drip. Because diphenhydramine can produce drowsiness, HB should be counseled to utilize these products before bedtime to assist with his symptoms.⁸ To help with his postnasal drip during the daytime, HB should be counseled to consider intranasal sprays such as fluticasone, which reduces inflammation in the nasal passages. For his sore throat, HB can consider topical anesthetics such as menthol-containing lozenges or throat sprays, in addition to warm fluids such as soup and tea to help ease his symptoms.^9,10

About the Authors

Kylie Helfenbein, 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.

Rupal Patel Mansukhani, PharmD, CTTS, FAPHA, is a clinical associate 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.

References

1. Biorphen. Prescribing information. Eton Pharmaceuticals; 2022. Accessed November 5, 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/212909s000lbl.pdf
2. FDA clarifies results of recent advisory committee meeting on oral phenylephrine. News release. FDA. September 14, 2023. Accessed December 18, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-clarifies-results-recent-advisory-committee-meeting-oral-phenylephrine
3. Afrin. Prescribing information. Bayer HealthCare LLC; 2019. Accessed November 5, 2023. https://www.accessdata.fda.gov/spl/data/c35038ef-b42e-329e-e053-2a95a90a30f1/c35038ef-b42e-329e-e053-2a95a90a30f1.xml
4. Mucinex Adult. Prescribing information. Reckitt Benckiser; 2013. Accessed November 5, 2023. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=0129f47d-abc2-414c-b4e1-1064c5d6a623&type=display
5. Tylenol 8 Hour Arthritis Pain. Prescribing information. McNeil Consumer Healthcare Division; 2019. Accessed November 5, 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/019872Orig1s048lbl.pdf
6. Dextromethorphan hydrobromide. Prescribing information. Spirit Pharmaceuticals; 2022. Accessed November 5, 2023. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7f24f63c-812c-4050-8743-9295093f62bd
7. Pray WS. Nonprescription products to avoid with hypertension. U.S. Pharmacist. February 19, 2010. Accessed November 5, 2023. https://www.uspharmacist.com/article/nonprescription-products-to-avoid-with-hypertension
8. Benadryl. Prescribing information. McNeil Consumer Healthcare Division; 2018. Accessed November 5, 2023. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=702f9786-7ce9-43e4-921d-e1db09612127
9. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis. Otolaryngol Head Neck Surg. 2015;152(1 suppl):S1-S43. doi:10.1177/0194599814561600
10. Cold and cough medicines. MedlinePlus. Accessed November 5, 2023. https://medlineplus.gov/coldandcoughmedicines.html