OTC Cases: September 2022

CASE 1: Iron Deficiency

Q: RH is a 48-year-old woman who is looking for iron supplements. After feeling fatigue and weakness, she recently visited her physician, who did blood work and found that RH has low iron and vitamin D levels, though she is otherwise healthy. Her physician prescribed vitamin D supplements and suggested she take an OTC iron supplement but did not specify the dosage. What iron supplement and dosage should the pharmacist recommend?

A: Some conditions may warrant patients using intravenous (IV) iron instead of oral supplements. These conditions include anemia caused by cancer, inflammatory bowel disease, menorrhagia, nondialysis-dependent chronic kidney disease, and obstetrics.¹ Because RH’s situation is not complicated, she can use any OTC iron supplement, such as ferrous sulfate, fumarate, or gluconate. Elemental iron at a dosage of 60 mg is recommended once or twice daily. RH should start with 325 mg of ferrous sulfate once or twice daily to see how she tolerates the medication. Some patients experience adverse effects, such as constipation, dark stools, or nausea.^2,3 If she cannot tolerate these, RH should consult her primary-care provider to see if she can use an alternative formulation or switch to IV iron.

CASE 2: Vitamin B

Q: KJ is a 31-year-old woman who is looking for a vitamin B12 supplement. Her endocrinologist said her vitamin B12 levels are low. The physician initially recommended vitamin B12 shots, but KJ told him she prefers oral medication. KJ takes insulin glargine 10 units at bedtime and metformin 1000 mg twice daily, as she has had type 2 diabetes for 10 years. What recommendations should the pharmacist give KJ regarding vitamin B12 and dosage?

A: Patients can be screened for vitamin B12 deficiency if they are high risk, which includes individuals who are older than 75 years, individuals who have gastric or small intestine resections or inflammatory bowel disease, patients who have taken metformin for more than 4 months or have used histamine H2 blockers or proton pump inhibitors for more than 12 months, or those who are vegan or vegetarian.⁴ KJ should take 1000 to 2000 mcg daily.⁴ If she experiences severe deficiency or neurologic symptoms, she should instead consider intramuscular vitamin B12 supplementation.⁵ Because vitamin B12 is water-soluble, high doses typically do not cause adverse health effects.⁵

CASE 3: Influenza Vaccines

Q: GL is a 69-year-old man who wants a flu shot. He was hospitalized for COVID-19 2 months ago because he was having trouble breathing. While at the hospital, the physician also found that GL had heart failure exacerbation with fluid overload and made a diagnosis of iron deficiency anemia. GL takes aspirin 81 mg daily, carvedilol 25 mg twice daily, ferrous sulfate 325 mg daily, and lisinopril 20 mg daily. He knows it is important to get his flu shot but is confused about which one to get based on his medical conditions. What should the pharmacist tell GL?

A: On June 30, 2022, the CDC’s Advisory Committee on Immunization
Practices (ACIP) advised that individuals 65 years and older preferentially receive 1 of the following influenza vaccines: quadrivalent adjuvanted inactivated influenza vaccine, quadrivalent high-dose inactivated influenza vaccine, or quadrivalent recombinant influenza vaccine.⁶ Because GI is older than 65 years, he should receive 1 of these, regardless of his medical conditions. If none of the 3 vaccines is available, any age-appropriate influenza vaccine can be administered.⁶ The ACIP recommended this based on a review of available studies in this age group, which demonstrates these vaccines are more effective than standard-dose, unadjuvanted flu vaccines. The pharmacist should let GL know that in clinical studies, the adverse effect profiles of these vaccines was similar to standard-dose vaccines.

CASE 4: Folic Acid

Q: RT is a 27-year-old woman who is looking for a folic acid supplement because she has read that it is beneficial during pregnancy and for her hair. She and her husband plan to try to conceive in the next few months. RT wants information on folic acid supplementation. What recommendations should the pharmacist give her?

A: According to the CDC, all women of reproductive age should consume 400 mcg of folic acid daily. Folic acid helps create new cells, which is beneficial for hair, nails, and skin and helps prevent neural tube defects, such as anencephaly and spina bifida, during early pregnancy. Those who have had babies with neural tube defects may need 4000 mcg of folic acid each day 1 month before becoming pregnant and through the first 3 months of pregnancy.⁷ Because RT is not in this situation, 400 mcg of folic acid daily is sufficient. The pharmacist should also advise RT to talk to her primary care provider or obstetrician about starting on an OTC or prescription prenatal vitamin.

About The Authors

Rupal Mansukhani, PharmD, FAPhA, CTTS, 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 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.

References

1. Gozzard D. When is high-dose intravenous iron repletion needed? Assessing new treatment options. Drug Des Devel Ther. 2011;5:51-60. doi:10.2147/DDDT.S15817

2. Camaschella C. Iron deficiency: new insights into diagnosis and treatment. Hematology Am Soc Hematol Educ Program. 2015;2015:8-13. doi:10.1182/asheducation-2015.1.8

3. Pavord S, Myers B, Robinson S, et al. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol. 2012;156(5):588-600. doi:10.1111/j.1365-2141.2011.09012.x

4. Vitamin B12. NIH Office of Dietary Supplements. Accessed August 6, 2022. Updated March 29, 2022. https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/#h5

5. Langan RC, Goodbred AJ. Vitamin B12 deficiency: recognition and management. Am Fam Physician. 2017;96(6):384-389.

6. Advisory Committee on Immunization Practices. CDC. Updated September 1, 2022. Accessed September 5, 2022. https://www.cdc.gov/vaccines/acip/index.html

7. Folic acid. NIH Office of Dietary Supplements. Updated June 15, 2022. Accessed August 6, 2022. https://www.cdc.gov/ncbddd/folicacid/about.html