OTC Cases: January 2022

CASE 1: Influenza OTC Symptom Relief

Q: JW is a man, age 46 years, filling his prescription for baloxavir. He has been feeling unwell for the past 24 hours with body aches, fatigue, fever, headache, runny nose, and sore throat. JW asks about OTC medications to help him feel better in addition to the baloxavir. He does not take any other medications and is relatively healthy. JW went to urgent care the previous night and they ruled out COVID-19, but a test for influenza came back positive. What recommendations should the pharmacist give him?

A: Because JW is being treated with an antiviral medication, the pharmacist can help him manage symptoms OTC. Based on JW’s symptoms, he can use an antipyretic product, such as acetaminophen or ibuprofen, for his body aches, fever, and sore throat. If he experiences breakthrough sore throat pain, he can consider using a lozenge that includes a benzocaine and/or menthol as well. For a runny nose, JW can use a first-generation antihistamine, such as diphenhydramine. Based on his symptoms, he can either buy the products in combination or individually. Because JW has a fever, he should also be educated about staying hydrated. If he experiences fever for longer than 48 hours, he should follow up with his primary care physician. JW should also consider staying away from others or wearing a mask while he is sick to prevent transmission.¹

CASE 2: Elderberry for Influenza

Q: KL is a woman, age 68 years, looking for elderberry supplements. She has had body aches, chills, and fever; she tested negative for COVID-19 but positive for influenza. She did not have time to get a flu vaccination this year and is concerned about complications from influenza. KL asks whether elderberry would help treat the flu. She does not take any and is relatively healthy. What should the pharmacist recommend?

A: Advise KL that there are several published studies of elderberry with influenza treatment. The study results show that elderberry could reduce influenza by 4 days compared with the placebo.² Elderberry is safe for patients; a double-blind, placebo-controlled, randomized trial (NCT03410862) showed no difference in duration or severity of symptoms between the elderberry and placebo groups.³ Because her age puts KL at high risk for influenza complications, she should consider taking oseltamivir 75 mg twice daily for 5 days. She should contact her primary-care provider immediately to get started on antiviral treatment.⁴ If KL has a high fever, she should also consider taking an antipyretic such as acetaminophen or ibuprofen. The pharmacist should also advise her to get an influenza vaccination as soon as she recovers.

CASE 3: BinaxNOW at-Home COVID-19 Test

Q: MT is a woman, age 35 years, who has a cough with phlegm, fatigue, and fever. She went out a few times over the weekend and because she lives with her elderly parents wants to rule out COVID-19. MT is planning on taking a polymerase chain reaction (PCR) COVID-19 test. However, she wants to know whether there is anything OTC that provides faster results. MT is healthy and has no medical conditions. What should the pharmacist recommend?

A: The OTC Abbott BinaxNOW rapid antigen test has a sensitivity of 64.2% and a high specificity of 92.6% in symptomatic patients, according to the CDC. The high specificity in symptomatic patients, with a very quick turnaround time of just 15 to 30 minutes, can help patients who are symptomatically infectious to isolate and reduce transmission by testing at home rather than going to a crowded testing center where the virus could be transmitted to other individuals. Additionally, it reduces the chance of MT being infected by another individual at the testing center. She can purchase BinaxNOW to determine whether she is sick with COVID-19. Advise MT to follow the package directions; she should have results within 15 to 30 minutes. Additionally, it is important to emphasize that the most accurate test for COVID-19 is a PCR test, and she should still follow up and have one. If MT’s results come back positive from BinaxNOW, she should follow quarantine guidelines and consult a provider if she feels worse.5 Individuals 50 years and older should receive the nonlive herpes zoster vaccine, Shingrix.^5-7

CASE 4: COVID-19 and Flu Vaccines

Q: SS is a man, age 61 years, who wants COVID-19 and influenza vaccinations. He has diabetes and takes metformin 1000 mg twice daily. SS has never had a reaction to a vaccine and feels healthy. What should the pharmacist recommend?

A: The CDC says COVID-19 and influenza vaccinations can be given at the
same time. Patients with diabetes are at higher risk for both COVID-19 and influenza complications, so SS should get the vaccinations as soon as possible.6 If he experiences any common adverse effects, such as arm pain, chills, or fever, he can take OTC medications such as acetaminophen or ibuprofen for pain relief. In addition, advise SS to stay hydrated. SS should contact his physician if symptoms persist more than a few days.⁷

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, 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.

References

1. Treatment: what you need to know. CDC. Updated August 31, 2021. Accessed December 2, 2021. https://www.cdc.gov/flu/treatment/treatment.htm

2. Zakay-Rones Z, Thom E, Wollan T, Wadstein J. Randomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections. J Int Med Res. 2004;32(2):132-140. doi:10.1177/147323000403200205

3. Macknin M, Wolski K, Negrey J, Mace S. Elderberry extract outpatient influenza treatment for emergency room patients ages 5 and above: a randomized, double-blind, placebo-controlled trial. J Gen Intern Med. 2020;35(11):3271-3277. doi:10.1007/s11606-020-06170-w

4. People at higher risk of flu complications. CDC. Updated November 18, 2021. Accessed December 2, 2021. https://www.cdc.gov/flu/highrisk/index.htm

5. Evaluation of Abbott BinaxNOW rapid antigen test for SARS-CoV-2 infection at two community-based testing sites—Pima County, Arizona, November 3-17, 2020. CDC. Updated January 28, 2021. Accessed December 2, 2021. https://www.cdc.gov/mmwr/volumes/70/wr/mm7003e3.htm

6. Frequently asked influenza (flu) questions: 2021-2022 season. CDC. Updated December 8, 2021. Accessed December 22, 2021. https://www.cdc.gov/flu/season/faq-flu-season-2021-2022.htm#Seasonal-Flu-and-COVID-19 [RP4]

7. Possible side effects after getting a COVID-19 vaccine. CDC. Updated December 16, 2021. Accessed December 22, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html