Self-Care for Heart Health

CASE 1: SELECTING COMPRESSION STOCKINGS FOR CHRONIC DEEP VEIN THROMBOSISQ: A 66-year-old man approaches the pharmacy counter looking for the pharmacist’s advice following a medical evaluation for pain and swelling in his right calf. Although he attributed these symptoms to a recent mechanical fall, medical workup revealed the presence of a chronic deep vein thrombosis (DVT) as the likely cause. He has no known medical comorbidities and takes only aspirin 325 mg daily at the advice of his physician; he denies smoking cigarettes, but does report smoking the occasional cigar. His physician told him that he does not need prescription anticoagulants, but has suggested he purchase an OTC DVT treatment stocking. What information should the pharmacist provide regarding the selection and use of thromboembolic stockings in this gentleman?

A: Patients recovering from a DVT may experience residual lower extremity swelling as part of the postthrombotic syndrome. Medical compression stockings come in a number of types (eg, OTC pantyhose, compression hose, prescription-strength compression hose) and lengths (eg, knee-high, thigh-high, full-length).¹ Selecting a stocking length depends on a patient’s symptoms, with swelling below the calf generally responding to a knee-high stocking and swelling that involves the thigh necessitating a thigh-high or full-length stocking.¹ The degree of support and level of compression (eg, light, mild, moderate, firm) varies with the type of product selected, with prescription compression hose offering the greatest level of support and a customized fit. In this patient’s case, compression stockings may help reduce any pain and alleviate swelling, as indicated by his physician. Following a DVT, often a stocking offering 30 to 40 mm Hg of compression is commonly recommended for use.¹ Recommend he talk to his physician about how long he should expect to wear this product and the level of support he should select. 

CASE 2: OTC ANALGESICS AND HEART FAILUREQ: A 53-year-old obese woman is inquiring about OTC treatment options for her knee pain. She has a medical history significant for atrial fibrillation, congestive heart failure, dyslipidemia, anxiety, and insomnia. She is currently taking several medications, including digoxin, metoprolol, furosemide, spironolactone, aspirin, atorvastatin, buspirone, and melatonin; she cannot recall the doses. She is wondering if there is an OTC medication that would be best to alleviate her pain, given her medical history and current medication use. What recommendations should the pharmacist provide?

A: Nonsteroidal anti-inflammatory drugs (NSAIDs), although an appropriate option for alleviating pain and inflammation associated with osteoarthritis, should be avoided in this patient’s case, given her comorbid heart failure. OTC NSAIDs, including ibuprofen and naproxen, may exacerbate sodium and fluid retention and worsen heart failure symptoms. The sodium and water retention are thought to be a result of a compensatory mechanism to combat the effects of the NSAIDs on the inhibition of renal prostaglandins and reduced glomerular filtration and may contribute to impaired cardiovascular homeostasis.² In addition, the combination of cardioprotective aspirin and NSAID may increase the risk of bleeding; aspirin should be taken 2 hours after an NSAID, if used concomitantly, to preserve its antiplatelet effect.³ For this patient’s knee pain, recommend a trial of acetaminophen and refer her to her primary care provider for further evaluation.

CASE 3: AN OTC CARDIAC MONITORING DEVICE

Q: A 57-year-old man would like information about a new OTC cardiac rhythm monitor his physician suggested he purchase. The patient has a history of chronic atrial fibrillation and has been experiencing occasional episodes of dizziness and lightheadedness after the recent addition of diltiazem to his medication regimen. He takes multiple other medications and is concerned these effects could be secondary to low blood pressure or another cardiac abnormality. Although his cardiologist reduced the diltiazem dose based on these symptoms, he informed the patient that new technology is available, suggesting he purchase a cardiac monitor and try to capture his rhythm when symptoms occur. What advice would be reasonable to share with the patient at this time?

A: In yet another example of the use of smartphones and the evolution of technology to promote wellness and disease-state self-management, a mobile electrocardiogram device is now available from AliveCor.⁴ Although many self-monitoring devices to capture heart rate and/or blood pressure are available, there is now a relatively inexpensive device that can also be used to remotely monitor cardiac rhythms and detect abnormalities outside a health care provider’s office. Remind this patient that he should not self-adjust his antiarrhythmic or antihypertensive medications based on the results obtained from this device. If he believes he is experiencing an arrhythmia or other cardiac event, he should seek medical help immediately.

CASE 4: HEMORRHOIDS AND HYPERTENSION

Q: A 63-year-old woman is seeking a recommendation for self-treatment of her hemorrhoids. She has suffered from external hemorrhoids intermittently throughout her life and, because it has been a while since she visited the pharmacy in need of treatment, she would like to know her best options to relieve the this flare-up. She was recently given a diagnosis of hypertension and has been told to monitor her diet because her most recent blood work suggests she may be at risk for developing diabetes. She has started taking a combination medication for her blood pressure and metformin to help with her blood sugar level. What recommendations or education on the self-treatment of hemorrhoids should the pharmacist offer this patient?

A: Hemorrhoids are a common anorectal disorder, likely affecting more than half the population at some point, according to the American Society of Colon and Rectal Surgeons.⁵ Hemorrhoids are inflamed blood vessels, and symptoms can include bleeding during bowel movements, pruritus, pain, and sensitivity.^5,6 Cornerstones of self-management and self-care include recommending sufferers maintain soft stools, through the use of nonprescription stool softeners or dietary modification by increasing fluid and fiber intake, to prevent straining to have a bowel movement. Good toileting habits, such as not suppressing the need to defecate, should be advocated as other nondrug approaches to alleviate and prevent symptoms. Numerous nonpre- scription and prescription-only drug treatment options exist, including topical anesthetics, vasoconstrictors, astringents, protectants, antipruritics, and corticosteroids. In this patient’s case, any of these options, with the exception of topical preparations containing phenylephrine or epinephrine—vasoconstrictors that could exacerbate her underlying hypertension—could be considered. The pharmacist would need to eval- uate the patient’s preference for dosage form (eg, applicator, locally applied cream, suppository) and cost in helping to select an appropriate treatment option. The patient should also be reminded to follow up with her physician if symptoms have not resolved within 7 days with appropriate self-care.⁶

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

References:

• Patient education blog: compression stocking use following DVT. patientblog.clotconnect.org/2012/05/01/compression-stocking-use-following-dvt/. Accessed October 7, 2016.
• Bleumink GS, Feenstra J, Sturkenboom MC, Stricker BH. Nonsteroidal anti-inflammatory drugs and heart failure. Drugs. 2003;63(6):525-534.
• Horn JR, Hansten PD. Antiplatelet effects of aspirin: which NSAIDs interact? Pharmacy Times website. pharmacytimes.com/publications/issue/2013/may2013/antiplatelet-effects-of-aspirin-which-nsaids-interact. Accessed October 7, 2016.
• AliveCor. alivecor.com/en/. Accessed October 7, 2016.
• American Society of Colon and Rectal Surgeons. fascrs.org/patients/disease-condition/hemorrhoids. Accessed October 6, 2016.
• Chan J. Anorectal disorders. In: Krinsky DL, ed. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 18th ed. Washington, DC: American Pharmacists Association; 2015.