OTC Cases: March 2021 PT Retail

Case 1: Rhinovirus in Children

Q: LS calls the pharmacy with questions regarding the rhinovirus, or the common cold, which her 2 boys contracted at school. Her children are aged 5 and 7 years and have had low-grade fevers, malaise, and nasal congestion for the past few days. What should the pharmacist recommend?

A: In children, the common cold is a mild viral illness, usually precipitated by rhinoviruses. Because the common cold is self-limiting and the data with OTC antihistamine, antitussives, and decongestants are lacking for children, the risks of starting OTC medications for children with rhinovirus outweigh the benefits. Nonpharmacologic treatment, including nasal saline irrigation, has been shown to relieve upper respiratory–tract infection symptoms and decrease school absences.^1,2 When choosing pharmacologic treatment for colds in children, data are limited to analgesics or antipyretics. If the symptoms of fever are bothersome, LS can give her children antipyretics acetaminophen or ibuprofen. Advise her to avoid combination products for the common cold in children.³

Case 2: Common Cold During Pregnancy

Q: VK is a 29-year-old pregnant woman who asks about self-care for her cold symptoms, which started with a sore throat and then a runny nose. Her husband had the same symptoms a few days earlier, and Alka Seltzer Plus PowerMax helped him. VK had a low-grade fever earlier in the day and the previous night. She asks if she can use the same medication as her husband. What advice should the pharmacist give VK about Alka Seltzer Plus PowerMax?

A: Pharmacologic management of the common cold in pregnant patients is dependent on the availability of human data. Overall recommendations for pregnant patients are to target specific symptoms using nonpharmacologic and/or single-ingredient pharmacologic treatment. Advise to avoid combination, extra-strength, and long-acting OTC products. Alka Seltzer Plus PowerMax is a combination of dextromethorphan and phenylephrine for day and dextromethorphan, doxylamine, and phenylephrine for night. Given that VK has not reported a cough, she should avoid the cough suppressant dextromethorphan. VK should also avoid systemic decongestants, such as phenylephrine and pseudoephedrine, as they have been linked with malformations, such as abdominal wall defects, hip dislocation, and inguinal hernia.⁴ Advise her to use acetaminophen to address the fever. Intranasal cromolyn is considered a first-line treatment for a runny nose during pregnancy. Cromolyn is a mast cell stabilizer that treats rhinitis. Of note, antihistamines chlorpheniramine and diphenhydramine are also considered compatible with pregnancy.⁴ In addition to pharmacologic recommendations, VK should increase fluid intake and strive for adequate rest and a nutritious diet. Also advise her to increase humidity via humidifiers, steamy showers, or vaporizers. Hot tea with honey and lemon and salt water gargles may help ease her sore throat.⁴

Case 3: Intranasal Spray

Q: JP is a 24-year-old man who has a common cold and has been suffering from a headache, nasal congestion, and a sore throat for a few days. His physician recommended that he try Flonase Allergy Relief OTC nasal spray. JP brings Flonase to the pharmacy counter and asks how he should use it. How should the pharmacist counsel him?

A: Advise JP to first clear his nasal passages and always wash hands before and after use. If this is a new Flonase device or has not been in used in a week or more, he will need to prime the nozzle. To prime, aim the bottle away from the face, and hold the bottle with the nozzle placed between the first 2 fingers and the thumb placed on the bottom of the bottle. JP should pump until a fine mist is visible. If pumped 6 times and a mist is not visible, the Flonase spray nozzle may be clogged and would need to be cleaned. After priming, JP should prepare for use. To begin, he should gently press the opposite side of the nose with a finger to block off the passage. Next, JP should tilt his head forward and aim the tip of the Flonase delivery device away from nasal septum (center) to avoid damage. He should sniff deeply while pressing down on the pump once and repeat in the other nostril. JP should then breathe through his mouth and wait a few minutes after using the medication before blowing his nose. Remind him to avoid sharing nasal sprays and to discard the medication if discolored or expired or if contamination is suspected. Advise JP to remove caps before use and replace tightly after each use.⁵

Case 4: Zinc

Q: MP is a 54-year-old woman with hypertension who is asking about supplements to treat a cold and is specifically interested in zinc. Her OTC medication options are limited because she has hypertension. What information should the pharmacist provide about the use of zinc for the common cold?

A: Zinc has been studied in vitro for its antiviral properties, and it may provide modest antiviral efficacy. It is reported that high local concentrations of zinc block the adhesion of human rhinovirus to the nasal epithelium. It also thought that zinc inhibits viral replication by disrupting viral capsid formation. The results of a meta-analysis concluded that zinc lozenges or syrup at 75 mg or more per day are effective in decreasing cold duration or symptoms if started within 24 hours of the first symptom and administered every 2 hours. The study results applied regardless of the zinc salt. In terms of prevention, the study results showed that if zinc is used for 5 months or longer, there is a potential for decreased risk of cold. A variety of formulations of zinc are available, including capsules, chews, lozenges, oral sprays, syrups, and tablets. There was previously a nasal formulation of zinc, but it has been removed from the market due to reports of lost sense of smell with intranasal cold remedies containing zinc. Advise MP to take oral formulations of zinc with food because it may be associated with gastrointestinal adverse effects, such as bitter taste, nausea, or upset stomach if taken on an empty stomach.⁶

REFERENCES

• OTC cough and cold products: not for infants and children under 2 years of age. FDA. Updated January 7, 2008. Accessed March 2, 2021. https://www.fda.gov/consumers/consumer-updates/otc-cough-and-cold-products-not-infants-and-children-under-2-years-age
• King D, Mitchell B, Williams CP, Spurling GK. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database Syst Rev.2015;(4):CD006821. doi:10.1002/14651858.CD006821.pub3
• Slapak I, Skoupá J, Strnad P, Horník P. Efficacy of isotonic nasal wash (seawater) in the treatment and prevention of rhinitis in children. Arch Otolaryngol Head Neck Surg. 2008;134(1):67-74. doi:10.1001/archoto.2007.19
• Briggs GG, Freeman RK. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. 10th ed. Wolters Kluwer Health; 2015.
• Krinsky DL. Patient self-care and allergic rhinitis: new and emerging issues. Pharmacy Today. 2016;22(2):14. Accessed March 2, 2021. https://www.pharmacytoday.org/article/S1042-0991(16)00250-4/fulltext
• Singh M, Das RR. Zinc for the common cold. Cochrane Database Syst Rev. 2011;(2):CD001364. doi:10.1002/14651858.CD001364.pub4

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.