Over-the-counter case: April 2022

CASE 1: Inhalers

Q: RD is a 35 year old male looking for an over the counter asthma inhaler. He was diagnosed with mild intermittent asthma 20 years ago, and the doctor recommended an inhaler. Symptoms of RD, usually chest tightness, appear every few months. He also occasionally suffers from shortness of breath and wheezing which requires medical attention, although he has never been hospitalized for this reason. Asthma does not interrupt his sleep. RD recently lost his medication, including an inhaler, while traveling. What should the pharmacist recommend?

A: Since RD has been diagnosed with mild intermittent asthma and has no warning symptoms, it would be appropriate to recommend an over-the-counter inhaler. Primatene Mist is FDA-approved for mild symptoms of intermittent asthma, such as chest tightness, shortness of breath, and wheezing. It contains 0.125 mg of epinephrine, which acts as a bronchodilator. Patients 12 years old
and older can use 1 oral inhalation if symptomatic. Remind RD to wait at least 4 hours between doses and to wash the mouthpiece of the inhaler after each use. Advise him to see a doctor immediately if he has more than 2 asthma attacks in a week, if he does not feel better within 20 minutes, if he needs more than 8 inhalations in 24 hours or if his symptoms worsen.¹

Reference

1. Facts about Primatene Mistdrug. Accessed March 10, 2022. https://www.primatene.com/drug-facts.aspx

CASE 2: Allergy avoidance in asthmatic patients

Q: NM is a 22 year old female seeking advice on how to manage her allergies and asthma. She takes fluticasone propionate 250 mcg/salmeterol 50 mcg, loratadine 10 mg daily and montelukast 10 mg daily and uses an albuterol inhaler as needed. NM says her asthma is well controlled and she has not used the inhaler for 6 months. However, she is worried because her allergies get worse every spring and she is frequently hospitalized for an exacerbation of her asthma. NM said she loves being outdoors and wishes she could open the windows in the spring before it gets too hot. She is allergic to pollen and wants to know if she can do anything else to relieve her asthma symptoms before the start of pollen season. What should the pharmacist advise?

A: Advise NM to avoid pollen, if possible, by checking the forecast and staying indoors during peak hours. Although she loves the spring weather, she can help reduce pollen exposure by keeping windows closed and using air conditioning. If NM really wants to be outside, she can avoid touching her eyes and wash her face when she comes inside. She should change clothes after being outdoors and take a shower if possible.² Additionally, NM should consider talking to her primary care provider, who may add another allergy medication, such as an intranasal corticosteroid.

Reference

2. Pollen and your health. CDC. August 21, 2020. Accessed March 12, 2022. https://www.cdc.gov/climateandhealth/effects/pollen-health.htm

CASE 3: Allergic rhinitis in asthmatic patients

Q: HH is a 42 year old female looking for an over-the-counter nasal spray for her allergies. She takes fluticasone propionate 100 mcg/salmeterol 50 mcg, cetirizine 10 mg daily and uses an albuterol inhaler as needed. HH recently visited her doctor because she has itchy eyes, post nasal drip and a runny nose. She has been experiencing these symptoms for a few weeks since it has been warmer outside. HH’s primary care provider recommended that she start using a nasal spray for allergies. What recommendations should the pharmacist provide?

A: Intranasal corticosteroids are very effective for allergic symptoms. Several over-the-counter formulations are available, such as budesonide (Rhinocort Allergy Spray), fluticasone furoate (Flonase Sensimist), fluticasone propionate (Flonase Allergy Relief), and triamcinolone acetonide (Nasacort Allergy 24HR).³ Advise HH that although intranasal corticosteroids are generally well tolerated, some patients experience coughing, nasal bleeding or discomfort, or sneezing. She can buy any formulation. However, HH should continue to take his other medications, including cetirizine 10mg daily.

Reference

3. Over-the-counter allergy steroid nasal sprays – what does this mean for patients? American Academy of Allergy, Asthma and Immunology. Updated September 28, 2020. Accessed March 12, 2022. https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/triamcinolone-nasal-spray

CASE 4: Asthma and home testing for COVID-19

Q: SM is a 22 year old woman seeking a home COVID-19 test after being exposed 2 days ago to someone who tested positive. SM is worried because she takes medication to control her asthma, although she has no symptoms of COVID-19, such as chills, cough, fatigue, fever or loss of smell or disgust. She received 2 doses of a COVID-19 mRNA vaccine, the second in May 2021. Although she knows a polymerase chain reaction test is the most accurate, she wants results fast. What should the pharmacist recommend?

A: Inform SM that COVID-19 home tests can provide results in minutes compared to lab tests, which can take days. She can use any over-the-counter, FDA-approved COVID-19 home test, a list of which is available on the FDA’s website. SM should take her home test at least 5 days after exposure and if negative she should consider retesting 1-2 days after the initial test. If positive, she should stay home for at least 5 days and follow local and national guidelines. She should also wear a tight-fitting mask around others until she is confirmed negative.⁴ If SM has symptoms, such as shortness of breath, she should see a doctor. Additionally, once she is confirmed negative, she should consider scheduling a booster dose for the COVID-19 vaccine. Adults should receive a booster dose of Pfizer-BioNTech or Moderna (COVID-19 mRNA vaccines) at least 5 months after the last dose of their primary series.

Reference

4. Self-test at home or anywhere. CDC. Updated March 9, 2022. Accessed March 13, 2022. https://www.cdc.gov/coronavirus/2019-ncov/testing/self-testing.html4/4125%

Rupal Mansukhani, PharmD, FAPhA, NCTTPis an Associate Clinical Professor at Ernest Mario School of Pharmacy at Rutgers, State University of New Jersey at Piscataway, and a clinical pharmacist specializing in care transitions at Morristown Medical Center in New Jersey.

ammie J. Patel, PharmD, BCACP, BCPSis a Clinical Assistant Professor of Pharmacy Practice and Administration at Ernest Mario School of Pharmacy at Rutgers, State University of New Jersey at Piscataway, and an outpatient
care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.