OTC Cases: April 2022

CASE 1: Inhalers

Q: RD is a 35-year-old man who is looking for an OTC asthma inhaler. He received a diagnosis of mild intermittent asthma 20 years ago, and the physician recommended an inhaler. RD’s symptoms, typically chest tightness, appear every few months. He occasionally also experiences shortness of breath and wheezing that require medical care, though he has never been hospitalized as a result. The asthma does not interrupt his sleep. RD recently lost his medications, including an inhaler, on a trip. What should the pharmacist recommend?

A: Because RD has received a diagnosis of mild intermittent asthma and has no warning symptoms, it would be appropriate to recommend an OTC inhaler. Primatene Mist is FDA approved for mild symptoms of intermittent asthma, such as chest tightness, shortness of breath, and wheezing. It contains epinephrine 0.125 mg, which acts like a bronchodilator. Patients 12 years
and older can use 1 oral inhalation when experiencing symptoms. Remind RD to wait at least 4 hours between doses and wash the inhaler mouthpiece after each use. Advise him to seek medical care immediately if he has more than 2 asthma attacks in a week, he is not feeling better within 20 minutes, he needs more than 8 inhalations in 24 hours, or his symptoms worsen.¹

Reference

1. Primatene Mistdrug facts. Accessed March 10, 2022. https://www.primatene.com/drug-facts.aspx

CASE 2: Allergy Avoidance in Asthma Patients

Q: NM is a 22-year-old woman who is seeking advice on ways to treat her allergies and asthma. She takes fluticasone propionate 250 mcg/salmeterol 50 mcg, loratadine 10 mg daily, and montelukast 10 mg daily and uses an albuterol inhaler as needed. NM says her asthma is well controlled and she has not used the inhaler in 6 months. However, she is concerned because her allergies worsen every spring and she is frequently hospitalized for asthma exacerbation. NM said she enjoys being outside and would like to be able to open the windows in the spring before it is too hot. She is allergic to pollen and wants to know if there is anything else she can do to alleviate her asthma symptoms before pollen season starts. What should the pharmacist advise?

A: Advise NM to avoid pollen, if possible, by looking at forecasts and staying indoors during peak times. Although she enjoys the spring weather, she can help decrease pollen exposure by keeping windows closed and using air-conditioning. If NM really wants to be outdoors, she can avoid touching her eyes and wash her face when she comes inside. She should change her clothes after being outdoors and shower if possible.² In addition, NM should consider talking to her primary care provider, who may add another medication for allergies, such as an intranasal corticosteroid.

Reference

2. Pollen and your health.CDC. August 21, 2020. Accessed March 12, 2022. https://www.cdc.gov/climateandhealth/effects/pollen-health.htm

CASE 3: Allergic Rhinitis in Asthma Patients

Q: HH is a 42-year-old woman who is looking for an OTC nasal spray for her allergies. She takes fluticasone propionate 100 mcg/ salmeterol 50 mcg, cetirizine 10 mg daily and uses an albuterol inhaler as needed. HH recently visited her physician because she has itchy eyes, postnasal drip, and a runny nose. She has been experiencing these symptoms for the few weeks since it got warmer outside. HH’s primary care provider recommended that she start using a nasal spray for allergies. What recommendations should the pharmacist provide?

A: Intranasal corticosteroids are very effective for allergy symptoms. Multiple nonprescription formulations are available, such as budesonide (Rhinocort Allergy Spray), fluticasone furoate (Flonase Sensimist), fluticasone propionate (Flonase Allergy Relief), and triamcinolone acetonide (Nasacort Allergy 24HR).³ Advise HH that though intranasal corticosteroids are generally well tolerated, some patients experience a cough, nasal bleeding or discomfort, or sneezing. She can purchase any formulation. However, HH should continue to take her other medications, including the cetirizine 10 mg daily.

Reference

3. Over-the-counter allergy nasal steroid sprays -what does it mean for patients? American Academy of Allergy, Asthma, and Immunology. Updated September 28, 2020. Accessed March 12, 2022. https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/triamcinolone-nasal-spray

CASE 4: Asthma and COVID-19 Home Test

Q: SM is a 22-year-old woman who is looking for a COVID-19 home test after being exposed 2 days ago to someone who had tested positive. SM is concerned because she takes medications to control her asthma, though she does not have any COVID-19 symptoms, such as chills, a cough, fatigue, a fever, or loss of smell or taste. She has had 2 doses of a mRNA COVID-19 vaccine, with the second in May 2021. Although she knows a polymerase chain reaction test is most accurate, she wants quick results. What should the pharmacist recommend?

A: Advise SM that COVID-19 home tests can provide results within a few minutes compared with laboratory-based tests, which can take a few days. She can use any OTC, FDA-approved COVID-19 home test, a list of which is available on the FDA’s website. SM should take her home test at least 5 days after exposure and if it is negative, she should consider retesting 1 to 2 days after the initial test. If she is positive, she should stay home for at least 5 days and follow local and state guidelines. She should also wear a well-fitted mask around others until she is confirmed as negative.⁴ If SM experiences symptoms, such as shortness of breath, she should seek medical care. In addition, once she is confirmed as negative, she should consider scheduling a booster dose for the COVID-19 vaccine. Adults should receive a booster dose of either Pfizer-BioNTech or Moderna (mRNA COVID-19 vaccines) at least 5 months after the last dose in their primary series.

Reference

4. Self-testing at home or anywhere. CDC. Updated March 9, 2022. Accessed March 13, 2022. https://www.cdc.gov/coronavirus/2019-ncov/testing/self-testing.html4 / 4125%

Rupal Mansukhani, PharmD, FAPhA, NCTTP, is a clinical associate professor 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.

Ammie J. Patel, PharmD, BCACP, BCPS, is a clinical assistant professor of pharmacy practice and administration at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway, and an ambulatory
care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.