Case 1
Simethicone for Gas
CM is a 37-year-old woman presenting to the pharmacy looking for an OTC product for gas relief. She has been experiencing bloating and gas for the past 3 days and is uncomfortable. She has not tried any OTC medications so far. Her medical history includes hypothyroidism and hypertension, for which she takes levothyroxine (Synthroid; AbbVie) and lisinopril (Prinivil; Merck). She has no known drug allergies.
Q: What OTC product can the pharmacist recommend to CM for gas relief?
A: An appropriate OTC medication for CM is simethicone (Gas-X; Haleon), an oral agent that relives gas by decreasing the surface tension of gas bubbles and helping to prevent gas pockets. The pharmacist should recommend simethicone 40 mg to 125 mg by mouth 4 times daily after meals and at bedtime.1 The pharmacist can also advise CM to avoid foods and beverages that may cause gas, such as beans, lentils, some vegetables, and carbonated beverages.2
About the Authors
Deanna Fox, PharmD, is an acute care clinical pharmacist in emergency medicine and clinical care at Geisinger.
Kylie Helfenbein, PharmD, is a critical care clinical pharmacist at Overlook Medical Center in Summit, New Jersey.
Rupal Patel Mansukhani, PharmD, FAPhA, NCTTP, is a clinical professor of pharmacy practice and administration 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.
Case 2
Bismuth Subsalicylate for Upset Stomach
JT is a 78-year-old woman with a medical history of hypertension, diabetes, and heart failure. Her medications include sacubitril-valsartan (Entresto; Novartis), metformin (Glucophage; Merck), dapagliflozin (Farxiga; AstraZeneca), carvedilol (Coreg; Waylis Therapeutics LLC), and spironolactone (CaroSpir; CMP Pharma). She comes to the pharmacy counter complaining of occasional indigestion associated with upset stomach, nausea, and heartburn, especially after eating large meals. Her primary care provider recommended that she try OTC products to manage her symptoms. She approaches the counter with liquid bismuth subsalicylate (Pepto-Bismol; Procter & Gamble) and wants to speak to a pharmacist about whether this is a good option and how to use it for her symptoms.
Q: What counseling points should be provided by the pharmacist in regard to the use of this OTC product?
A: The pharmacist should reassure JT that bismuth subsalicylate products are used for several gastrointestinal symptoms, including nausea, heartburn, indigestion, and upset stomach, as well as diarrhea. Additionally, before making further recommendations, the pharmacist should confirm that JT does not have an allergy to salicylates such as aspirin and is not taking any other salicylate-containing products. The pharmacist should advise JT that a dose cup is included in the package. A single dose is 30 mL and can be taken every 30 minutes as needed for symptom relief. However, JT should be advised not to exceed 8 doses in a 24-hour period or to take bismuth subsalicylate for longer than 2 days without notifying her physician if symptoms persist or worsen. Lastly, the pharmacist should counsel JT that a common adverse effect of this medication is darkening of her stool and/or tongue.3
Case 3
Acid Reflux
LH is a 64-year-old man with a medical history of hypertension for which he takes amlodipine (Norvasc; Viatris) and losartan (Cozaar; Organon) each morning with breakfast. He presents to the pharmacy complaining of heartburn that worsens after eating and when lying down. LH explains that he saw his doctor for these symptoms and it was recommended that he trial lifestyle modifications and OTC medications for management of gastroesophageal reflux disease. He asks to speak with a pharmacist regarding recommendations for an OTC product he can take once daily with his other medications to manage his acid reflux symptoms.
Q: What recommendation should the pharmacist provide LH?
A: The pharmacist should recommend that LH try an OTC proton pump inhibitor, such as esomeprazole (Nexium; AstraZeneca), for management of his acid reflux.4,5 The pharmacist should explain to LH that medications in this class are recommended for OTC management of acid reflux because they help reduce production of stomach acids that cause heartburn and other symptoms.4,5 The pharmacist should counsel LH that esomeprazole comes as either a delayed-release capsule or an oral suspension, both of which can be taken once daily with his other medications.6 LH should also be counseled to seek advice of his physician if his symptoms persist or worsen while taking esomeprazole.
Case 4
MiraLAX for Constipation
EY is a 28-year-old woman with no known medical history. She comes to the pharmacy asking to speak with a pharmacist about OTC medications for management of constipation. EY explains that she has been experiencing abdominal bloating and infrequent dry, hard stools.
Q: What OTC agents should the pharmacist recommend to EY at this time?
A: The pharmacist should recommend an OTC osmotic laxative such as polyethylene glycol 3350 powder (MiraLAX; Bayer), which will help keep water in the intestine and assist with the softness of stool to minimize EY’s symptoms.7,8 The pharmacist should counsel EY that she can take 1 capful of polyethylene glycol 3350 powder mixed into 4 to 8 oz of water once daily to produce a bowel movement in 1 to 3 days. EY should be counseled not to use this product for more than 7 days without consulting her physician.9
REFERENCES
1. Gas-X. Prescribing information. Haleon; 2024. Accessed November 7, 2024. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f553374b-c20e-4c92-a8c0-cef0aeda8d1c
2. Controlling intestinal gas. International Foundation for Gastrointestinal Disorders. Accessed November 7, 2024. https://iffgd.org/gi-disorders/symptoms-causes/intestinal-gas/
3. Pepto-Bismol. Prescribing information. Procter & Gamble; 2024. Accessed November 7, 2024. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=67006e82-870d-8d63-e053-2991aa0a02d1
4. Acid reflux/GERD (gastroesophageal reflux disease). American College of Gastroenterology. Accessed November 7, 2024. https://gi.org/topics/acid-reflux/#tabs2
5. Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenter. 2022;117(1):27-56. doi:10.14309/ajg.0000000000001538
6. Nexium. AstraZeneca; 2024. Accessed November 7, 2024. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/022101s014021957s017021153s050lbl.pdf
7. Constipation and defecation problems overview. American College of Gastroenterology. Updated August 2022. Accessed November 7, 2024. https://gi.org/topics/constipation-and-defection-problems/
8. Chang L, Chey WD, Imdad A, et al. American Gastroenterological Association-American College of Gastroenterology clinical practice guideline: pharmacological management of chronic idiopathic constipation. Gastroenterology. 2023;164(7):1086-1106. doi:10.1053/j.gastro.2023.03.214
9. Miralax. Prescribing information. Bayer; 2023. Accessed November 7, 2024. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d69ce3d4-7ca4-4fe3-b49e-6655e48d6963
