Self-Care for Respiratory Health

CASE 1: INTRANASAL CORTICOSTEROIDS

RP is a 30-year-old woman who comes to your pharmacy complaining of allergic rhinitis. She was diagnosed with allergies when she was younger and has been taking something for them every subsequent spring, when they tend to be at their worst. She usually takes loratadine 10 mg daily, and her physician also prescribes a nasal spray. Today, when she called her physician for a refill, he told her both medications were available over the counter. She takes no other medications and denies any other conditions. What recommendations do you have for RP?

ANSWER:

RP appears to be suffering from seasonal allergies. Since she does not take her allergy medications year round, instruct RP to start taking them at least 1 week prior to symptoms appearing. Loratadine 10 mg has been available over the counter for many years; however, intranasal corticosteroids, such as triamcinolone acetonide (Nasacort Allergy 24HR) and fluticasone propionate (Flonase), have only recently become available over the counter. Typically, intranasal corticosteroids are shown to be effective for most allergic rhinitis symptoms. Both sprays are approved to treat nasal allergy symptoms: triamcinolone acetonide is approved for individuals 2 years and older, and fluticasone propionate is approved for use in individuals 4 years and older.¹ Depending on the formulation, you would recommend 1 or 2 sprays in each nostril daily. Also let RP know that each time she uses the medication, she should shake the bottle well. She can take the nasal spray with her loratadine since there are no drug interactions with the products and can use her normal pattern of allergies to determine when she should stop using it.

Minor adverse effects (AEs), such as nasal bleeding or sneezing, are common. Serious AEs include glaucoma, changes in vision, cataracts, and chance of infection. Inform RP of both. If she feels she is experiencing a serious AE or if her allergies worsen, she should call her physician immediately.

CASE 2: VITAMIN C

MJ is a 40-year-old woman who comes to your pharmacy seeking information regarding using vitamins for a cold. She states she has been using vitamin C for more than 15 years at the onset of cold symptoms such as sore throat, runny nose, and cough. When feeling ill, she typically supplements her intake with orange juice and an additional 200 mg of vitamin C once daily. She says sometimes this helps, and her cold is cured, but not always. She is concerned with taking vitamin C so often, having heard natural products could be unsafe. She has no medical conditions and no allergies to medications. She wants to know what your thoughts are on the use of vitamin C for colds.

ANSWER:

Vitamin C (ascorbic acid) is a water-soluble vitamin that has been used for the treatment of colds for many years. Since MJ has used vitamin C for many years, she already knows that it is not always beneficial. The published clinical evidence has been consistent. A Cochrane review on vitamin C for preventing and treating the common cold examined the therapeutic response of the vitamin, using doses of 200 mg or more at the onset of symptoms for the first 3 to 5 days of illness. The authors concluded that although a small subset of patients did benefit, vitamin C generally failed to reduce the incidence of colds for the general population, and certain populations should still be cautious when using it. Patients taking more than 2000 mg per day experienced diarrhea and gastrointestinal upset. However, since vitamin C has an overall favorable safety profile, it can still be recommended to treat symptoms of a cold.² If it is recommended, educate patients that it may not reduce the duration of a cold.

CASE 3: COLD WITH FEVER

LM is a 26-year-old woman who comes to your pharmacy complaining of fever, body aches, chills, congestion, and cough. She claims her roommate was sick last week and passed the illness to her. She initially had a fever of 102.1°F, with fluctuations from 101.9°F to 103.6°F for the past 48 hours; her current temperature is 102.3°F. She does not like to take medication, but feels awful and can hardly move. LM states she has not tried anything yet, but wants something to lower her fever. She also is having difficulty sleeping, so she wants a medication to help her sleep through the night. She is confused because there are so many OTC products, and she doesn’t know what to take. Her immunizations are up-to-date, but she did not receive the seasonal flu vaccine. What recommendations do you have for LM?

ANSWER:

Reasons patients should not self-treat for a cold include shortness of breath, chest pain, worsening of symptoms, AIDS, advanced age, and a history of cardiopulmonary diseases, such as chronic obstructive pulmonary disease or chronic heart failure.³ Since LM has a fever and does not seem to be improving, she could be suffering from the flu or have a bacterial infection, which requires antibiotics. Since her temperatures for the past 48 hours have been above 101.5°F, you could recommend that LM see her physician. You could also recommend acetaminophen to help reduce her fever, an oral rehydration fluid since her fever has been present for 2 days, and the seasonal flu vaccine once she feels better (since she has not received it). Although the flu vaccine is not contraindicated for LM right now, because she has a high fever and does not feel well, it may be advisable to wait until she recovers.

CASE 4: ELDERBERRY

RG is a 30-year-old woman who comes to your pharmacy looking for information to help flu-like symptoms. She states her mother got the flu a few weeks ago and that her mother’s symptoms included fever, body aches, chills, and congestion. Based on a friend’s recommendation, her mother tried elderberry fruit extract (Sambucol, Nature’s Way) to self-treat her flu. Her mother claims that it helped cure her flu symptoms. RG woke up this morning with a cough—she denies fever, chills, or body aches—and her mother recommended that she try elderberry. RG has no chronic conditions and is not taking any medications. What recommendations do you have for RG?

ANSWER:

A few small studies have demonstrated that elderberry extracts could reduce flu-like symptoms and the duration of influenza infections when given within 2 days of initial symptoms. Most patients report symptom relief within 2 to 4 days of treatment.^4,5 Typically, doses of 15 mL were given 4 times daily. Since influenza has complications, such as secondary infection, hospitalization, and death, patients presenting with signs of the flu should be referred to their physician. Because RG does not appear to have signs of influenza, elderberry would not be considered as a treatment option. If she did have the flu, however, and wanted to try something natural, she could discuss elderberry use with her physician. Currently, her cough should be evaluated to discuss OTC treatment options, such as a first-generation antihistamine or dextromethorphan (depending on the type of cough). If her cough is related to postnasal drip, a first-generation antihistamine should be considered. Dextromethorphan can be considered in patients trying to reduce coughing that interferes with their sleep or daily life.

Dr. Mansukhani is clinical assistant professor at the Ernest Mario School of Pharmacy, Rutgers University, and transitions of care clinical pharmacist at Morristown Medical Center, Morristown, New Jersey. Dr. Bridgeman is clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and internal medicine clinical pharmacist at Robert Wood Johnson University Hospital, New Brunswick, New Jersey.

References

• Drugs@FDA. FDA website. www.accessdata.fda.gov/scripts/cder/drugsatfda. Accessed March 6, 2015.
• Hemila, H. and Chalker, E. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev. 2013;1:CD000980. doi: 10.1002/14651858.CD000980.pub4.
• Scolaro, K. Colds and allergy. In: Krinsky DL, Ferreri SP, Hemstreet B, et al (eds). Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 18th ed.. Washington, DC: American Pharmacists Association; 2015:Figure 11-1.
• Zakay-Rones Z, Varsano N, Zlotnik M, et al. Inhibition of several strains of influenza virus in vitro and reduction of symptoms by an elderberry extract (Sambucus nigra L) during an outbreak of influenza B Panama. J Altern Complement Med. 1995;1(4):361-369.
• 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.