OTC Circumstances: September 2022

September 28, 2022

This month’s OTC circumstances options anemia.

CASE 1: Iron Deficiency

Q: RH is a 48-year-old girl who’s in search of iron dietary supplements. After feeling fatigue and weak point, she not too long ago visited her doctor, who did blood work and located that RH has low iron and vitamin D ranges, although she is in any other case wholesome. Her doctor prescribed vitamin D dietary supplements and recommended she take an OTC iron complement however didn’t specify the dosage. What iron complement and dosage ought to the pharmacist advocate?

A: Some situations might warrant sufferers utilizing intravenous (IV) iron as a substitute of oral dietary supplements. These situations embody anemia brought on by most cancers, inflammatory bowel illness, menorrhagia, nondialysis-dependent persistent kidney illness, and obstetrics.1 As a result of RH’s scenario is just not difficult, she will use any OTC iron complement, resembling ferrous sulfate, fumarate, or gluconate. Elemental iron at a dosage of 60 mg is really helpful a couple of times every day. RH ought to begin with 325 mg of ferrous sulfate a couple of times every day to see how she tolerates the treatment. Some sufferers expertise adversarial results, resembling constipation, darkish stools, or nausea.2,3 If she can’t tolerate these, RH ought to seek the advice of her primary-care supplier to see if she will use an alternate formulation or swap to IV iron.

CASE 2: Vitamin B

Q: KJ is a 31-year-old girl who’s in search of a vitamin B12 complement. Her endocrinologist stated her vitamin B12 ranges are low. The doctor initially really helpful vitamin B12 photographs, however KJ advised him she prefers oral treatment. KJ takes insulin glargine 10 items at bedtime and metformin 1000 mg twice every day, as she has had kind 2 diabetes for 10 years. What suggestions ought to the pharmacist give KJ relating to vitamin B12 and dosage?

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A: Sufferers may be screened for vitamin B12 deficiency if they’re excessive danger, which incorporates people who’re older than 75 years, people who’ve gastric or small gut resections or inflammatory bowel illness, sufferers who’ve taken metformin for greater than 4 months or have used histamine H2 blockers or proton pump inhibitors for greater than 12 months, or those that are vegan or vegetarian.4 KJ ought to take 1000 to 2000 mcg every day.4 If she experiences extreme deficiency or neurologic signs, she ought to as a substitute think about intramuscular vitamin B12 supplementation.5 As a result of vitamin B12 is water-soluble, excessive doses usually don’t trigger adversarial well being results.5

CASE 3: Influenza Vaccines

Q: GL is a 69-year-old man who needs a flu shot. He was hospitalized for COVID-19 2 months in the past as a result of he was having hassle respiration. Whereas on the hospital, the doctor additionally discovered that GL had coronary heart failure exacerbation with fluid overload and made a analysis of iron deficiency anemia. GL takes aspirin 81 mg every day, carvedilol 25 mg twice every day, ferrous sulfate 325 mg every day, and lisinopril 20 mg every day. He is aware of you will need to get his flu shot however is confused about which one to get primarily based on his medical situations. What ought to the pharmacist inform GL?

A: On June 30, 2022, the CDC’s Advisory Committee on Immunization
Practices (ACIP) suggested that people 65 years and older preferentially obtain 1 of the next influenza vaccines: quadrivalent adjuvanted inactivated influenza vaccine, quadrivalent high-dose inactivated influenza vaccine, or quadrivalent recombinant influenza vaccine.6 As a result of GI is older than 65 years, he ought to obtain 1 of those, no matter his medical situations. If not one of the 3 vaccines is accessible, any age-appropriate influenza vaccine may be administered.6 The ACIP really helpful this primarily based on a evaluate of obtainable research on this age group, which demonstrates these vaccines are more practical than standard-dose, unadjuvanted flu vaccines. The pharmacist ought to let GL know that in scientific research, the adversarial impact profiles of those vaccines was much like standard-dose vaccines.

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CASE 4: Folic Acid

Q: RT is a 27-year-old girl who’s in search of a folic acid complement as a result of she has learn that it’s helpful throughout being pregnant and for her hair. She and her husband plan to attempt to conceive within the subsequent few months. RT needs data on folic acid supplementation. What suggestions ought to the pharmacist give her?

A: In response to the CDC, all ladies of reproductive age ought to devour 400 mcg of folic acid every day. Folic acid helps create new cells, which is helpful for hair, nails, and pores and skin and helps forestall neural tube defects, resembling anencephaly and spina bifida, throughout early being pregnant. Those that have had infants with neural tube defects might have 4000 mcg of folic acid every day 1 month earlier than changing into pregnant and thru the primary 3 months of being pregnant.7 As a result of RT is just not on this scenario, 400 mcg of folic acid every day is enough. The pharmacist must also advise RT to speak to her main care supplier or obstetrician about beginning on an OTC or prescription prenatal vitamin.

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About The Authors

Rupal Mansukhani, PharmD, FAPhA, CTTS, is a scientific affiliate professor at Ernest Mario Faculty of Pharmacy at Rutgers, The State College of New Jersey in Piscataway, and a transitions-of-care scientific pharmacist at Morristown Medical Heart in New Jersey.

Ammie Patel, PharmD, BCACP, is a scientific assistant professor of pharmacy observe and administration at Ernest Mario Faculty of Pharmacy at Rutgers, The State College of New Jersey in Piscataway, and an ambulatory care specialist at RWJBarnabas Well being Main Care in Shrewsbury and Eatontown, New Jersey.


1. Gozzard D. When is high-dose intravenous iron repletion wanted? Assessing new therapy choices. Drug Des Devel Ther. 2011;5:51-60. doi:10.2147/DDDT.S15817

2. Camaschella C. Iron deficiency: new insights into analysis and therapy. Hematology Am Soc Hematol Educ Program. 2015;2015:8-13. doi:10.1182/asheducation-2015.1.8

3. Pavord S, Myers B, Robinson S, et al. UK tips on the administration of iron deficiency in being pregnant. Br J Haematol. 2012;156(5):588-600. doi:10.1111/j.1365-2141.2011.09012.x

4. Vitamin B12. NIH Workplace of Dietary Dietary supplements. Accessed August 6, 2022. Up to date March 29, 2022. https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/#h5

5. Langan RC, Goodbred AJ. Vitamin B12 deficiency: recognition and administration. Am Fam Doctor. 2017;96(6):384-389.

6. Advisory Committee on Immunization Practices. CDC. Up to date September 1, 2022. Accessed September 5, 2022. https://www.cdc.gov/vaccines/acip/index.html

7. Folic acid. NIH Workplace of Dietary Dietary supplements. Up to date June 15, 2022. Accessed August 6, 2022. https://www.cdc.gov/ncbddd/folicacid/about.html