OTC Case Studies: Cardiovascular Disease Conundrum

Case One—Aspirin Use or No?

CF is 45-year-old woman who comes to the pharmacy to refill her metformin prescription. CF states that her friend is taking baby aspirin because she has diabetes. She asks whether she should also be taking a baby aspirin every day. Her medication profile shows that she is currently prescribed metformin 500 mg by mouth twice daily and glyburide 5 mg by mouth once a day. She has no other risk factors or medical conditions, and takes no other OTC medications. Would you recommend CF take a baby aspirin for primary prevention of a first heart attack or stroke?

Answer

The recommendations that patients with diabetes receive low-dose aspirin therapy (75-162 mg per day) for primary prevention of cardiovascular disease has recently been revised, according to the American Diabetes Association’s Standards of Medical Care in Diabetes — 2010.1 Aspirin therapy should be considered for preventing primary stroke, myocardial infarction (MI), or other cardiovascular events in those patients with either type 1 or type 2 diabetes who have an increased cardiovascular risk, defined as a 10-year risk of greater than 10%. These revised recommendations include use of aspirin for most diabetic men aged 50 years or older or diabetic women aged 60 years or older, who have 1 or more additional major coronary heart disease risk factors (ie, family history of heart disease, hypertension, smoking, dyslipidemia, or albuminuria). Routine aspirin use for secondary prevention of a subsequent stroke or MI is still warranted.

In this case, CF does not fall within warranted use of low-dose aspirin for primary prevention, because she has no additional risk factors for coronary disease and is only 45 years of age. Suggest that CF follow up with her primary care provider if she has any additional questions about her risk factors for cardiovascular disease.

Case Two—High Blood Pressure and a Cold

JD is a 58-year-old man with hypertension (usual systolic blood pressure range, 140-150 mm Hg; usual diastolic blood pressure range, 80-90 mm Hg), for which he is currently taking hydrochlorothiazide 25 mg daily and amlodipine 10 mg daily. He reports a history of dyslipidemia, for which he takes simvastatin 20 mg daily, and depression, for which he takes sertraline 50 mg daily. He presents to your pharmacy complaining of sinus congestion, a runny nose, and sneezing, which he attributes to having a cold. He remembers his doctor told him to avoid taking certain OTC medications because of his high blood pressure, but cannot remember which he should avoid. What recommendations can you give JD to help alleviate his current symptoms, considering his other medical co-morbidities and concomitant prescription medications?

Answer

To reduce the risk of spreading the cold virus, recommend JD wash his hands or use an alcohol-based hand scrub frequently, and cover his nose and mouth when he sneezes. It is preferable that individuals experiencing the common cold sneeze into the crux of the elbow rather than into the hands to reduce the spread of infected respiratory droplets.²

Other nonpharmacologic measures, such as keeping hydrated, consuming a balanced diet, and getting adequate sleep, may help JD recover from his acute illness. To alleviate his sinus congestion, recommend JD increase the humidification of the air he breathes by taking a steamy shower or through the use of a humidifier. Nasal adhesive strips, such as Breathe Right Nasal Strips (GlaxoSmithKline), which hold the nasal passages open and allow patients experiencing nasal congestion to breathe more easily, offer patients another option for treating cold symptoms.

Counsel JD to avoid the use of systemic decongestants, such as pseudoephedrine and phenylephrine. JD’s blood pressure is uncontrolled, and use of these products may cause further blood pressure elevations secondary to their vasoconstrictive effects. JD should also avoid combination products containing systemic decongestants. Although intranasal decongestants are minimally absorbed, the safest recommendation for treating JD’s symptoms would be to use a saline nasal spray to flush his sinuses. PT

Dr. Bridgeman is an internal medicine clinical pharmacist in Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Patel is a clinical pharmacist in North Brunswick, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.