Offer Patients OTC Pointers

Over 80 autoimmune diseases affect an estimated 14.7 million to 23.5 million people in the United States.

The mainstays of therapy consist of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and anti–tumor necrosis factor (TNF)–α biologics, but various products over the counter also help relieve symptoms. Pharmacists can help patients select the appropriate OTC medications in light of special considerations related to their conditions.

NSAIDs: An Important Part of Therapy

For rheumatoid arthritis (RA) and other autoimmune diseases, NSAIDs can be a good starting point for relieving pain and inflammation, said Wendy Ramey, BSPharm,RPh,CSP,clinicalpharmacist with a specialty in inflammatory conditions at University of Kentucky’s specialty pharmacy and infusion services in Lexington. For some conditions, such as ankylosing spondylitis, most insurance companies require that patients try OTC or prescription NSAIDs before being approved to move on to biologics, she said.

Ramey recommends that patients limit OTC NSAID use to short periods. “If they need to go beyond 2 or 3 weeks of everyday use, then they’re going to need to talk to us about some other kind of treatment to take care of their pain,” she said.

Community pharmacists who notice patients with autoimmune diseases consistently buying these OTC products should initiate a discussion regarding use, said Jessica Farrell, PharmD, clinical pharmacist at the Center for Rheumatology at the Albany College of Pharmacy and Health Sciences in New York. “If [patients are] using lots of NSAIDs consistently with a DMARD-methotrexate, hydroxychloroquine, sulfasalazine-or a TNF inhibitor...then maybe that DMARD or biologic is not adequate,” Farrell said. Patients should be advised to speak with their provider about trying a different therapy. Patients also should take a histamine-2 receptor blocker or proton pump inhibitor (PPI) because of gastrointestinal toxicities related to NSAIDs, she advised.

Other Helpful OTCs

Pharmacists can recommend other OTC products to manage symptoms. For patients with inflammatory arthritis, Farrell encourages use of OTC topical pain-relief prod- ucts such as lidocaine patches and diclofenac gel. “These are great options for patients who have more mild disease or in smaller joints or for small flares that don’t require systemic therapy,” she said.

Pharmacists also can guide patients toward OTC products to treat the dry mouth and eyes associated with Sjögren syndrome. “Many of our patients [with] other au- toimmune diseases have overlap Sjögren syndrome,” Farrell reported. Various products treat dry mouth, including mouthwashes, gums, and toothpastes, and it often takes trial and error to find what works best for each patient, she said. Patients with Sjögren may need help finding the right eye drops, whether they need a preservative-free product or one for sensitive eyes. Gel-like drops can be particularly helpful for patients with severe nighttime dryness that interferes with sleep, Farrell said.

Mild injection site reactions in patients on injectable therapies can be treated with OTC topical steroids or antihistamines, according to Farrell.

For patients who complain of insomnia, which can be caused by an autoimmune disease or its treatment, Ramey recommends melatonin products rather than antihistamines, which can have other unwanted effects.

Supplementary Sources

Various nutritional supplements also play a role in managing autoimmune diseases. Folic acid supplementation is crucial to reduce the gastrointestinal and liver toxicities of methotrexate therapy in patients with RA. Although most patients take prescription folic acid, Farrell said, some use the OTC version. Recommendations on amounts vary, but common regimens consist of 1 mg daily or 5 mg once weekly.

Some data suggest that cherries and cherry extract products have antioxidant properties and reduce inflammation in patients with gout. Farrell commonly adds those products as an adjunct for patients taking uric acid–lowering therapies, such as allopurinol and febuxostat, who need additional urate-lowering therapy but for whom adverse effects preclude increased doses.

Check the Fine Print

Patients taking NSAIDs should be taught to carefully check labels of OTC combination products to prevent overdosing on NSAIDs, Farrell said. “That’s one of the things that I teach my patients a lot about: reading labels and how to recognize if they’re taking products that have multiple drugs in them, so they’re not double dosing on ibuprofen or taking ibuprofen and naproxen at the same time,” she said.

Patients with Sjögren should be ad- vised to avoid OTC products containing decongestants and first-generation antihistamines, which can exacerbate dryness, Farrell said: “Sometimes patients take Tylenol PM; they don’t realize that it has diphenhydramine, so it’s drying them out even more.” For relief from seasonal allergy symptoms, second-generation antihistamines are preferable, she said.

Patients with RA who are looking for immune-boosting supplements also need to scrutinize labels. Ingredients such as zinc and vitamin C are fine to take, Farrell said, but pharmacists should warn patients to steer clear of products that contain astragalus, an herb that increases TNF-ɑ.

Avoid Interactions

An important drug interaction in this population occurs between immuno-suppressant mycophenolate mofetil and PPIs, Farrell noted. PPIs can reduce absorption of mycophenolate mofetil, which requires an acidic environment for optimal absorption, so patients should take mycophenolate mofetil at least 90 minutes before the PPI. Pharmacists are in an ideal position to alert patients about this interaction, she said, because physicians might not be aware that their patients are taking OTC PPIs.

To avoid toxicity, acetaminophen use should be limited to 2 g per day in patients taking drugs that are metabolized by the liver, Ramey said. Farrell noted that in patients taking hydroxy- chloroquine, any OTC product potentially associated with increased risk of QTc prolongation, such as pseudo-ephedrine, could be problematic.

“For the most part, we [in the field of rheumatology] are very lucky to have drugs that don’t cause us very many [drug interaction] problems,” Ramey said.

Pharmacy software might flag an interaction between methotrexate and NSAIDs, but that is not clinically relevant in this patient population, Farrell said. NSAIDS can prevent excretion of methotrexate, which is used in high doses in oncology, and result in toxicity, but that is not an issue at the doses used in autoimmune diseases, she said.

Infection Control

Because so many patients with autoimmune disease take immunosuppressants, pharmacists counseling them should be on the lookout for infections.

“If a patient with an autoimmune disease is coming in looking for something to treat a possible infection, like [OTC] bactericidal ointments or creams, that would be the first clue that something needs to be addressed with their doctor,” Ramey said. “Because most of our medications increase the risk of infection, we always want to know if a patient has a cut or a bug bite that is starting to look infected; that is our biggest concern.”

Patients on immunosuppressants who want to buy OTC cough or cold products should be reminded that their current treatments prevent them from fighting infections. “If they’re on methotrexate, sometimes, if it’s a very mild infection, we might not have to hold it, but if they’re on biologics, they definitely should hold during an infection.”