OTC Cases: Influenza

CASE 1: Influenza with Echinacea

RD is a 66-year-old woman who is looking for echinacea to prevent influenza. She is relatively healthy and does not take any medications. What should the pharmacist recommend to RD?

Although RD has no medical conditions, she is considered high risk for influenza complications based on her age.¹ Let her know that studies show that obtaining the annual vaccine is the most effective way to prevent influenza.² There are conflicting data related to the use of echinacea for the prevention of influenza. The results of 1 study show that echinacea can help with influenza vaccine response in patients with respiratory conditions³ and may be beneficial to take with the vaccine. Results from another study showed that echinacea with elderberry reduced the rate of influenzarelated respiratory complications like oseltamivir, the gold standard of influenza treatment. However, the sample size included 473 patients and did not have a placebo group.⁴ Based on the literature, RD should probably try other methods of prevention, such as avoiding individuals who are sick, cleaning and disinfecting surfaces, washing her hands regularly with soap and water, and wearing a mask.²

CASE 2: Aspirin

RA is a 56-year-old woman who asks about her OTC aspirin 81 mg daily, which she started taking a few years ago, because she heard it has heart benefits, though she never discussed the matter with a health care provider. She has diabetes but no history of a heart attack, stomach bleeding, or strokes. RD does not drink alcohol and has never smoked. She exercises regularly and has a healthy diet. What recommendation should the pharmacist give?

RA has no secondary prevention indication for aspirin use. The guidance on the use of aspirin for the primary prevention of cardiovascular disease in patients with diabetes is controversial. The results of 1 meta-analysis with 13 studies showed that aspirin reduces the incidence of cardiovascular events.⁵ However, the results of another meta-analysis with 11 studies showed no reduction in all-cause mortality.⁶ The results of both meta-analyses showed a higher rate of gastrointestinal (GI) bleeding. Although the data are conflicting, the American Diabetes Association recommends that patients with diabetes use aspirin if they are older than 50 years of age and have any of the following risk factors: albuminuria/chronic kidney disease, dyslipidemia, family history of premature atherosclerotic cardiovascular disease, hypertension, or smoking. It is important to assess that patients taking aspirin are not at risk for GI bleeding before initiating aspirin therapy. Although RA is older than 50 years, she has no additional risk factors and therefore, based on the guidelines, should not take aspirin for primary prevention.^7,8

CASE 3: Lice

MG, is a 33-year-old woman who is looking for a lice treatment. Her 5-year-old daughter, SG, came home from school and was complaining of an itchy scalp. Upon examination, MG noticed live lice and nit casings on SG’s head. MG is looking for a recommendation for an OTC product. In the past, when SG has had lice, MG has used permethrin and pyrethrin. What recommendation should the pharmacist provide?

In October 2020, the FDA approved ivermectin (Sklice) lotion, 0.5% for the treatment of head lice infestation in patients 6 months of age and older to be converted from prescription to OTC status.⁹ The results of 1 study showed that patients using ivermectin were louse-free on day 2 (94.9%), day 8 (85.2%), and day 15 (73.8%).¹⁰ When treating head lice, it is important to use nondrug strategies with OTC medications.¹¹ For example, any clothing that was worn within the time frame of infestation should be machine-washed in hot water or sealed in a plastic bag and stored for 2 weeks. Soak brushes and combs in hot water and vacuum floors. Use a fine-tooth comb to remove dead lice or nits. Sklice lotion can be applied directly to dry hair and the scalp.¹² It is important to rub the lotion throughout the entire head so that all lice and eggs are exposed to it. Use the entire tube. An adult must apply Sklice for children. Let the lotion stay on the head for 10 minutes, and then completely rinse using only water. SG should wait 24 hours before using shampoo. Avoid exposure of Sklice to eyes, but if it does get accidentally get in the eyes, gently flush with water. Adverse effects include burning sensation on the skin, dandruff, and eye redness or soreness. Do not use Sklice lotion again without talking to SG’s health care provider first.

CASE 4: COVID-19 With Zinc

AS is a 49-year-old man who is looking for zinc as he wants to lower his chance of getting the coronavirus disease 2019 (COVID-19). He has a history of diabetes and hypertension. AS heard from his co-workers that zinc supplements boost the immune system, so they will provide protection against the virus. What recommendations should the pharmacist make?

Zinc is important in maintaining cellular homeostasis and can potentially prevent viral replication in the nasal mucosa.¹³ The National Institutes of Health’s (NIH) recommended dietary allowance is 11 mg daily for men and 8 mg for nonpregnant women.¹⁴ With the surge of COVID-19 cases in 2020, some have considered using zinc as prophylaxis for the disease. However, a retrospective study of azithromycin and hydroxychloroquine with or without zinc showed no differences in outcomes.¹⁵ Because there are limited studies with COVID-19 and the use of zinc, the NIH guidelines recommend against the use of zinc.¹⁶ Additionally, excess zinc consumption is associated with long-term adverse effects, such as anemia, ataxia, copper deficiency, leukopenia, myelopathy, and spasticity.^17,18

AMMIE J. PATEL, PHARMD, BCACP, 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.RUPAL PATEL MANSUKHANI, PHARMD, FAPHA, NCTTP, is a clinical associate professor at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, and a transitions-ofcare clinical pharmacist at Morristown Medical Center in New Jersey.

REFERENCES

• CDC. People at high risk for flu complications. December 1, 2020. Accessed December 4, 2020. https://protect-us.mimecast.com/s/hW5hCZ6RoRi5g5ryUzUjjn?domain=cdc.gov
• CDC. Preventivesteps. September 25, 2020. Accessed December 3, 2020. https://protect-us.mimecast.com/s/r89-C1wDnDuMGM2KiGB9Ye?domain=cdc.gov
• Di Pierro F, Rapacioli G, Ferrara T, et al. Use of a standardized extract from Echinacea angustifolia (Polinacea) for the prevention of respiratory tract infections. Altern Med Rev. 2012;17(1):36-41.
• Raus K, Pleschka S, Klein P, et al. Effect of an echinacea-based hot drink versus oseltamivir in influenza treatment: a randomized, double-blind, double-dummy, multicenter, noninferiority clinical trial. Curr Ther Res Clin Exp.2015;77:66-72. doi:10.1016/j.curtheres.2015.04.001
• Zheng SL, Roddick AJ. Association of aspirin use for primary prevention with cardiovascular events and bleeding events: a systematic review and meta-analysis. JAMA.2019;321(3):277-287.doi:10.1001/jama.2018.20578
• Mahmoud AN, Gad MM, ElgendyAY, et al. Efficacy and safety of aspirin for primary prevention of cardiovascular events: a meta-analysis and trial sequential analysis of randomized controlled trials. Eur Heart J. 2019;40(7):607-617.
• The ASCEND Study Collaborative Group. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med.2018;379(16):1529-1539.
• American Diabetes Association. Standards of Medical Care in Diabetes-2020 abridged for primary care providers. Clin Diabetes. 2020;38(1):10-38.doi: 10.2337/cd20-as01
• FDA approves lotion for nonprescription use to treat head lice. News release. FDA.October 27, 2020: Accessed December 4, 2020.https://www.fda.gov/news-events/press-announcements/fda-approves-lotion-nonprescription-use-treat-head-lice
• Pariser DM, Meinking TL, Bell M, et al. Topical 0.5% Ivermectin lotion for treatment of head lice. N Engl J Med. 2012;367:1687-1693. doi:10.1056/NEJMoa1200107
• CDC. Parasites. October 15, 2019. Accessed December 4, 2020.https://www.cdc.gov/parasites/lice/head/treatment.html
• Sklice. Package insert.Sanofi Pasteur;2012.Accessed January 8, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/202736Orig1s000lbl.pdf
• Read SA, Obeid S, Ahlenstiel C, Ahlenstiel G. The role of zinc antiviral immunity. Adv Nutr.2019;10(4): 696-710.doi:10.1093/advances/nmz013
• US Department of Health & Human Services. Zinc. National Institutes of Health. Accessed January 8, 2021. https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/
• Carlucci P, Ahuja T, Petrilli CM, Rajagopalan H, Jones S, Rahimian J. Zinc sulfate in combination with a zinc ionophore may improve outcomes in hospitalized COVID-19 patients. J Medical Microbiology.2020. doi:10.1099/jmm.0.001250
• National Institutes of Health. COVID-19 treatment guidelines. Updated December 17, 2020. Accessed January 8, 2020.https://www.covid19treatmentguidelines.nih.gov
• Myint ZW, Oo TH, Thein KZ, et al. Copper deficiency anemia: review article. Ann Hematol.2018;97(9):1527-1534.
• Kumar N. Copper deficiency myelopathy (human swayback). Mayo Clin Proc. 2006;81(10):1371-1384. doi:10.4065/81.10.1371