Case 1: Astepro
Q: SK is a 32-year-old woman who recently moved into a carpeted apartment building. She has had symptoms of rhinitis in the past, including a runny and stuffy nose, along with itching and sneezing. In the past, SK has used 10 mg of loratadine per day during the allergy season for symptoms of rhinitis. She said it’s unusual to experience symptoms outside of allergy season and thinks the carpeting and ventilation in her new building may play a role in causing the rhinitis. SK has been taking loratadine for the past week, but it has not relieved her symptoms. She used a prescription nasal spray with antihistamines a few years ago that was helpful, but her doctor isn’t here tonight to prescribe the medication. What OTC Medication Options Should the Pharmacist Recommend?
A: SK has taken azelastine (Astepro) in the past. As of early 2022, azelastine is the only FDA-approved OTC intranasal antihistamine. In some studies, intranasal antihistamines have shown greater efficacy and safety compared to oral antihistamines. In addition, intranasal azelastine has shown relief when oral antihistamines fail.1-3
Instruct SK to initiate OTC azelastine and use 2 sprays intranasally once per day or 1 spray in each nostril twice daily for a maximum of 4 sprays per day. Although azelastine is generally well tolerated, common side effects include a bitter taste in the mouth, headache, and a runny nose. Some patients experience sedation, similar to some oral antihistamines, with azelastine, so SK may want to take the drug at bedtime. Instruct her to avoid alcohol and other sedative medications while taking azelastine.1.2
Case 2: Nasal administration technique
Q: SK calls the pharmacy later in the day to inquire about the antihistamine nasal spray and wants to make sure she’s using it correctly. She asks to be guided through an appropriate nasal spray administration technique. What guidance should the pharmacist provide?
A: Instruct SK to clean her nasal passages first and always wash her hands before and after using the nasal spray. Before first use, remove the blue plastic safety clip. Then prime the spray by spraying it into the air 6 times or until a fine spray appears. Then gently press 1 side of the nose with a finger to close the nostril. Tilt the head down, insert the tip of the bottle into the open nostril and hold the bottle upright while pointing the spray tip toward the back of the nose. Sniff deeply while pressing the pump once, keeping the head forward and downward. Repeat in the other nostril with the same steps. Clean the tip of the spray with a dry tissue. Wait a few minutes after using the drug before blowing the nose. Prime the spray each time the device is cleaned and if it is not used for 3 or more days.1
Case 3: Systemic Nasal Decongestants
Q: RP is a 34-year-old man with a stuffy nose. He shares that he is otherwise healthy, but has not been able to treat his stuffy nose in recent days. RP has tried a saline nasal spray and some non-pharmacological measures, including nasal strips (Breathe Right) and humidifiers. He wants to learn about other options, including oral tablets, which are nasal decongestants. What information should the pharmacist share with RP?
A: Decongestants treat nasal and sinus congestion by stimulating -adrenergic receptors. This leads to narrowing of blood vessels and thereby to a decrease in the edema and swelling of the sinus vessels. Nonprescription systemic decongestants include phenylephrine and pseudoephedrine. In general, phenylephrine has low bioavailability and pseudoephedrine is well absorbed. Although approved for short-term use for the temporary relief of congestion, the decongestants have adverse effects that can be exacerbated with excessive use. These can include anxiety, increased blood pressure, insomnia, and tachycardia. RP can buy pseudoephedrine as a single agent or in combination with some over-the-counter antihistamines or antipyretics. Phenylephrine, on the other hand, can be bought without a prescription. Instruct him to follow the dosage information on the package and avoid exceeding the maximum daily dose of 60 mg for phenylephrine and 240 mg for pseudoephedrine.4
Case 4: Non-pharmacological therapy for infants
Q: NK calls to inquire about the care of his little nephew, MK, who he is babysitting. The child’s mother gave NK a bulb syringe to relieve the child’s stuffy nose, but he doesn’t know how to use it. What information can the pharmacist provide?
A: NK rightly uses non-pharmacological strategies to relieve its cousin’s congestion, as most drugs cannot be used on children under 2 years of age. Advise NK to hold MK upright at first to improve nasal drainage. Because the buildup of mucus would interfere with MK’s eating and sleeping routine, it’s important to clear the nasal passages. Instruct NK to squeeze the large end of the bulb first before gently inserting the tip of the syringe into the nose. Then he must slowly release the compression pressure in an attempt to suck fluid out. After the pressure is released, NK should remove the syringe from MK’s nose, compress the bulb in a napkin or towel to remove the accumulated fluid and mucus, then repeat the steps on the other side.5
About the author
Ammie Patel, PharmD, BCACP, is a clinical assistant professor of pharmacy practice and administration at the Ernest Mario School of Pharmacy in Rutgers, The State University of New Jersey in Piscataway, and an ambulatory care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.
Rupal Mansukhani, PharmD, FAPhA, CTTS, is a clinical associate professor at the Ernest Mario School of Pharmacy in Rutgers, the State University of New Jersey at Piscataway, and a clinical care pharmacist at Morristown Medical Center in New Jersey.
1. Colds: protect yourself and others. CDC. Updated November 29, 2021. Accessed June 7, 2022. https://www.cdc.gov/features/rhinoviruses/
2. Jacobs SE, Lamson DM, St George K, Walsh TJ. Human Rhinoviruses. Clin Microbiol ds. 2013;26(1):135-162. doi:10.1128/CMR.00077-12
3. Cohen S, Janicki-Deverts D, Doyle WJ. Self-rated health in healthy adults and susceptibility to the common cold. Psychosom Med. 2015;77(9):959-968. doi:10/1097/PSY.000000000000232
4. Part 341 – Cold, Cough, Allergy, Bronchodilator and Anti-asthmatic Drugs for Over-the-Counter Human Use. Code of Federal Rules. Updated June 21, 2022. Accessed June 15, 2022. https://www.ecfr.gov/current/title-21/chapter-I/subchapter-D/part-341
5. Suction the nose with a bulb syringe. Cincinnati Children’s Hospital Medical Center. Updated March 2019. Accessed June 24, 2022. www.cincinnatichildrens.org/health/info/newborn/home/suction/htm