From Prescription to OTC Sapna N. Patel UCSF Pharm. D. Candidate 2008 Preceptor Dr. Craig S. Stern Febuary 29, 2008

Significance Unable to track usage Difficult to obtain patient’s entire medication profile Many potential DDIs unidentified May be more cost-effective for employers/patients to switch to OTC usage Many insurances do not cover OTC products Pts more likely to postpone seeking medical treatment PUD/GERD represent 2 of the Top 5 most expensive conditions to treat

Prescription Drug Categories now OTC Non-Sedating Antihistamines Loratadine (Claritin®, Claritin D®) Loratadine (Alavert®, Alavert D®) Cetirizine (Zyrtec®, Zyrtec D®) Histamine Receptor Blockers Cimetidine (Tagamet®) Famotidine (Pepcid®) Nizatidine (Axid®) Ranitidine (Zantac®) Proton Pump Inhibitors Omeprazole (Prilosec®)

Peptic Ulcer Disease Definition: Open sores on the inside lining of the stomach, small intestine, or esophagus Causes: Helicobacter pylori infection (90%) Long-term use of NSAIDs Common Symptoms: Epigastric pain Weight loss Bloating N/V Feels “better” after eating

Peptic Ulcer Disease (cont.) Treatment: NEVER self treat See MD to be tested for H. pylori

Role of OTC Proton Pump Inhibitors (PPI) MOA: Inhibits acid formation by inhibiting H+/K+ ATPase pump Available: Prilosec Administration: 20mg daily before breakfast Place in Therapy: H. pylori (-): 4-8 week regimen under supervision of MD ADRs: Acid rebound, abdominal pain, diarrhea, headache, pneumonia Must know why before breakfast. Rx Strength: 20mg twice daily

Patient Counseling Minimize fatty foods, spicy foods and caffeine Smoking cessation Minimize alcohol consumption Use NSAIDs only if absolutely necessary Eat smaller meals more often vs. large meals Weight loss

GERD (Gastroesophageal Reflux Disease) Definition: Movement of stomach contents into the esophagus Causes: Big meals Fatty foods Alcohol/Smoking Lying down after a meal Obesity Common Symptoms: Difficulty Swallowing Acidic taste in mouth Coughing Roughness of voice Chocolate, onions, spicy food

H2 Receptor Blockers MOA: Stops histamine from stimulating the gastric parietal cell, therefore inhibiting acid secretion Available: Cimetidine (Tagamet®), Famotidine (Pepcid®), Nizatidine (Axid®), Ranitidine (Zantac®) Administration: Before meals Place in Therapy: Mild Severity: Infrequent symptoms and short duration (< 2x/week) ADRs: N/V/D, constipation, dry mouth, drowsiness, dizziness Refer if symptoms more than 2x a week

Patient Counseling Weight loss Decrease fatty food intake Smoking cessation Decreasing alcohol intake Avoid laying down for 3 hours after meals

Allergic Rhinitis Definition: Immune reaction due to exposure to allergens Risk Factors: Family history Male Firstborn status Early use of antibiotics Exposure to indoor allergens High IgE levels Common Symptoms: (perennial or seasonal) Conjuctival, nasal, pharyngeal itching Rhinorrhea Sneezing

Role of OTC Anti-histamines MOA: Blocks peripheral histamine H(1)-receptor activity Available: Claritin®, Alavert®, Zyrtec® Administration: Variable Place in Therapy: Mild or intermittent allergic rhinitis symptoms Combined with the decongestant, pseudoephedrine, provide better symptom relief ADRs: Dry mouth, headache, drowsiness, fatigue ADRs for pseudoephedrine sulfate: hypertension, insomnia, irritability, and headache Histamine H1 receptor location, all come in “D” forms, Asthma: (allergic asthma) 10 to 20 mg ORALLY once daily has been used for up to 8 weeks Idiopathic urticaria, chronic: 10 mg ORALLY once daily , The second-generation agents appear to be similarly efficacious to each other

Patient Counseling Allergen Identification: Skin testing (by MD) Avoid Allergens Pollens Insects Animal allergens Molds Molds: (which are difficult to differentiate from other perennial allergens by history alone)

Summary Globally, PUD/GERD represent expensive conditions to treat Many prescription medications are now found OTC Benefits may include a more cost-effective choice for employers/patients Downfalls include information lost regarding patient’s medication profile leading to suboptimal medication management Non-coverage of OTC products by insurances may lead to patient not purchasing medication Possible worsening of outcomes due to lack of treatment

References http://www.acg.gi.org/ patients/ pdfs/ UnderstandGIBleednew.pdf 281k 27/Jan/2008 Antossian T, Madera X, Stern C. Peptic Ulcer Disease, California Pharmacist 9/2005 pp 25-30. Stern C, Antossian T, Choo C. Gastroesophageal Reflux Disease, California Pharmacist 6/2005 pp25-30. Micromedex Drugdex Evaluations-Pepcid, copyright 2006 by Thomson MICROMEDEX. Micromedex Drugdex Evaluations-Loratadine, copyright 2006 by Thomson MICROMEDEX. Micromedex Drugdex Evaluations-Cetirizine, copyright 2006 by Thomson MICROMEDEX. UpToDate-Allergic Rhinitis, copyright 2007 by deShazo R, Kemp S. Kasper D, Braunwald E, Fauci A Harrison’s Principles of Internal Medicine 16th edition, copyright 2005.