In practice (II)
IN PRACTICE
Mark, a 45-year-old with a history of hay fever, comes in to ask for your advice. He usually takes a daily antihistamine when his symptoms start to appear but this year, he seems to be suffering more than usual, particularly with nasal congestion. He is wondering if there is an alternative product. What advice could you give to help Mark?
Advise him that as his symptoms have worsened it might be better if he makes an appointment with his GP to be on the safe side
INCORRECT - you could find out a bit more about his symptoms and if appropriate, recommend OTC treatment options without having to send him to the GP
Explain the types of products available and how they differ so that he can make the right choice
CORRECT - this will help reduce any confusion he may have on the various options available in the pharmacy and also help build rapport to encourage him to come back for future advice
Inform him that there are products such as Benacort® Nasal Spray (budesonide) available which can help prevent and relieve symptoms of hay fever, including nasal congestion
CORRECT - Products such as Benacort® Nasal Spray (budesonide) can also be recommended and effectively relieve nasal hay fever symptoms
Tell him that it can take a while for antihistamines to take effect, and to be patient and persevere with treatment for a few more days
INCORRECT - antihistamines such as acrivastine start to work within 15 minutes but generally within one day. If his symptoms have not been relieved by his usual medication, advise him of alternative options such as budesonide-containing products like Benacort Nasal Spray, which can help to alleviate symptoms including congestion
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22. Benadryl Allergy Relief SPC. Available at www.medicines.org.uk/emc/product/1473/smpc
23. www.nhs.uk/medicines/acrivastine/
24. Barnes PJ, Adcock IM. How do corticosteroids work in asthma? Ann Intern Med. 2003 Sep 2;139(5 Pt 1):359-70
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28. Benacort 64 micrograms Nasal Spray Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/product/8876
29. Benacort Hayfever Relief Spray for adults Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/product/12041/smpc#gref
Online references last accessed March 2021
Benacort® 64 micrograms Nasal Spray (budesonide) Presentation: Nasal spray, suspension. Each actuation contains 64mcg budesonide Uses: Prevention and treatment of seasonal allergic rhinitis (hay fever). Dosage (adults): Once daily dosing: 128mcg into each nostril in the morning. Twice daily dosing: 64mcg into each nostril morning and evening. If good effect is achieved, 64 micrograms into each nostril each morning. Full effect not achieved until after a few days treatment. Treatment of seasonal rhinitis should start, if possible, before exposure to the allergens. If symptoms are not controlled, or persist for longer than 2 weeks of treatment, medical advice must be sought. Benacort should not be used continuously for longer than 3 months. Paediatric population: not be used in children and adolescents under 18 years of age. Contraindications: Hypersensitivity to active ingredient or to any of the excipients. Warnings and precautions: If symptoms are not controlled or persist for longer than 2 weeks of treatment, medical advice must be sought. Patients should consult a physician before use if: they are using a corticosteroid for other conditions, they currently have or have been exposed to tuberculosis, chicken pox or measles, they have severe or frequent nose bleed or have/had nose ulcers, nose surgery or injury, they have ever been diagnosed with glaucoma or cataracts, they have an eye infection or diabetes. Special care needed: when treating patients transferred from oral steroids, where disturbances of hypothalamic- pituitary-adrenal (HPA) axis could be expected; in patients with fungal and viral infections of the airways. Reduced liver function affects the elimination of corticosteroids, may lead to higher systemic exposure and possible systemic side effects. Systemic effects of nasal corticosteroids may occur, particularly at high doses prescribed for prolonged periods. CYP3A inhibitors may increase systemic exposure to budesonide. Raised plasma concentrations and enhanced effects of corticosteroids have been observed in women treated with oestrogens and contraceptive steroids. No effect observed during concomitant intake of low dose oral contraceptives. As adrenal function may be suppressed this may lead to false results in ACTH stimulation test for diagnosing pituitary insufficiency. Contains Potassium sorbate (E202) which may cause local skin reactions, (e.g. contact dermatitis). Pregnancy and lactation:Avoid during pregnancy unless benefit outweighs risk. No effects on breast fed child are expected at therapeutic doses. Side effects: Consult SmPC for full list of side effects Common: Haemorrhagic secretion and epistaxis. Nasal Irritation (sneezing, stinging and dryness). Uncommon: Immediate and delayed hypersensitivity reactions including erythema, urticaria, rash, dermatitis, angioedema and pruritus. Muscle spasms. Rare: Anaphylactic reaction, signs and symptoms of systemic corticosteroid effects, including adrenal suppression and growth retardation, nasal septum perforation, nasal ulcer and dysphonia. Blurred vision. Contusion. Very rare: Ulceration of mucous membrane. Not known: Raised intraocular pressure or glaucoma and cataract. In rare cases, signs or symptoms of glucocorticosteroid-side effects such as Cushing’s syndrome, Cushingoid features, psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children) may occur. Acute overdose even in excessive doses, is not expected to be a clinical problem. RRP (excl. VAT): 120 actuations: £8.74 Legal category: P PL holder: McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG PL number: 15513/0404 Date of preparation: 23 February 2021.
Benacort® Hayfever Relief for Adults 64 micrograms (budesonide). Presentation: Nasal spray, suspension. Each actuation contains 64mcg budesonide Uses: Treatment of seasonal allergic rhinitis (hay fever). Dosage (adults): Initially: Two sprays (128mcg) into each nostril in the morning. Once symptoms are under control, use a maintenance dose of one spray (64 micrograms) into each nostril each morning. No more than four sprays in one day. Full effect not achieved until after a few days treatment. If symptoms are not controlled, or persist for longer than 7 days of treatment, medical advice must be sought. Benacort should not be used continuously for longer than 1 month without medical advice. Paediatric population: not be used in children and adolescents under 18 years of age. Contraindications: Hypersensitivity to active ingredient or to any of the excipients, and patients taking HIV medications. See the SmPC for further details. Warnings and precautions:Patients should consult a physician before use if: they are using a corticosteroid for other conditions, they currently have or have been exposed to tuberculosis, chicken pox or measles, they have fungal or viral infections of the airways, they have severe or frequent nose bleeds or have/had nose ulcers, nose surgery or injury, they have ever been diagnosed with glaucoma or cataracts, they have an eye infection or diabetes. Patients should consult a pharmacist or doctor if they develop signs or symptoms of an infection, such as persistent fever, while taking this medicine. Reduced liver function affects the elimination of corticosteroids, may lead to higher systemic exposure and possible systemic side effects. Systemic effects of nasal corticosteroids may occur, particularly at high doses used for prolonged periods. Co-treatment with CYP3A inhibitors including cobicistat-containing products is expected to increase the risk of systemic side effects. In cases of clinically significant adrenal suppression, additional systemic corticosteroid cover should be considered during periods of stress or elective surgery. Raised plasma concentrations and enhanced effects of corticosteroids have been observed in women treated with oestrogens and contraceptive steroids, but no effect has been observed during concomitant intake of low dose combination oral contraceptives. As adrenal function may be suppressed this may lead to false results in ACTH stimulation test for diagnosing pituitary insufficiency. See the SmPC (summary of product characteristics) for full details. Contains Potassium sorbate (E202) which may cause local skin reactions, (e.g. contact dermatitis). Pregnancy and lactation: Avoid during pregnancy unless benefit outweighs risk. No effects on breast fed child are expected at therapeutic doses. This medicine should not be used during pregnancy or breast-feeding without first consulting a doctor or pharmacist. Side effects: Consult SmPC for full list of side effects Common: Haemorrhagic secretion, epistaxis. Nasal discomfort (sneezing, stinging and dryness). Uncommon: Immediate and delayed hypersensitivity reactions including erythema, urticaria, rash, dermatitis, angioedema and pruritus. Muscle spasms. Rare: Anaphylactic reaction, signs and symptoms of systemic corticosteroid effects, including adrenal suppression and growth retardation, nasal septum perforation, nasal ulcer and dysphonia. Blurred vision. Contusion. Very rare: Ulceration of mucous membrane. Not known: Raised intraocular pressure or glaucoma, cataract. In rare cases, signs or symptoms of glucocorticosteroid-side effects such as Cushing’s syndrome, Cushingoid features, psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children) may occur. Acute overdose even in excessive doses, is not expected to be a clinical problem. RRP (excl. VAT): 60 actuations: £6.39. Legal category: GSL PL holder: McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG PL number: 15513/0409 Date of preparation: 23 Feb 2021
Benadryl® Allergy Children’s 1mg/mL Oral Solution (Cetirizine dihydrochloride 1mg/ml solution) Presentation: Clear and Colourless liquid. Uses: Symptomatic treatment of allergic rhinitis and chronic idiopathic urticaria. Dosage: 2-6 years: 2.5mL twice daily; 6-12 years: 5mL twice daily; 12 years and above: 10ml once daily. Contraindications: Hypersensitivity, severe renal impairment, hereditary fructose intolerance. Precautions: Renal impairment: dosage adjustment required - refer to SPC. Caution with concomitant alcohol consumption, in epilepsy and those at risk of convulsions, in patients with predisposing factors of urinary retention. Do not drive or operate machinery until familiar with response to drug. Wash-out period of 3 days is recommended before performing an allergy skin test. Pregnancy and Lactation: On health care professional advice only. Side effects: Common: Somnolence, fatigue, dizziness, headache, abdominal pain, dry mouth, nausea, pharyngitis, diarrhoea, rhinitis. Rare: Hypersensitivity, aggression, confusion, depression, hallucination, insomnia, convulsions, movement disorders, tachycardia, hepatic function abnormal, urticaria, oedema, weight increased. Very rare: thrombocytopenia, anaphylactic shock, tics, dysgeusia, dystonia, dyskinesia, angioneurotic oedema, fixed drug eruption, syncope, tremor, accommodation disorder, blurred vision, oculogyration, eye swelling, cough, dysuria, enuresis, feeling abnormal, nausea. Uncommon: agitation, paraesthesia, diarrhoea, pruritus, rash, asthenia, malaise. Not known: increased appetite, suicidal ideation, amnesia, memory impairment, vertigo, urinary retention, eye pain, erectile dysfunction, nightmares, acute generalised exanthematous pustulosis (AGEP), arthralgia, pruritus upon withdrawal. RRP (ex VAT): 100ml £4.99 Legal category: P PL Holder: McNeil Products Ltd, Foundation Park, Maidenhead, Berks, SL6 3UG. PL Number: PL 15513/0138 Date of prep: 14th August 2019.
Benadryl® Allergy Liquid Release 10mg Capsules (cetirizine) Presentation: Soft capsules containing 10mg cetirizine. Uses: For the relief of nasal and ocular symptoms of seasonal and perennial allergic rhinitis. Also for the relief of symptoms of chronic idiopathic urticaria. Dosage: 12 years and above: 10mg once daily. Under 12 years: Not recommended. Contraindications: Hypersensitivity to cetirizine, hydroxyzine or any piperazine derivatives, to soya, peanut, or to any of the excipients listed in section 6.1 of the SPC. Moderate to severe renal impairment. Precautions: Caution with concomitant alcohol consumption. Patients with both liver and kidney disease should consult a physician before use. Caution in epilepsy patients and those at risk of convulsions. Caution in patients with predisposition factors of urinary retention. Allergy skin tests are inhibited by antihistamines and a wash-out period (of 3 days) is required before performing them. Pruritus and/or urticaria may occur when cetirizine is stopped, even if those symptoms were not present before treatment initiation. Pregnancy and Lactation: Consult a physician before use. Side effects: Common: Somnolence, fatigue, dizziness, headache, abdominal pain, dry mouth, nausea, pharyngitis, diarrhoea, rhinitis. Uncommon: agitation, paraesthesia, diarrhoea, pruritus, rash, asthenia, malaise. Rare: Hypersensitivity, aggression, confusion, depression, hallucination, insomnia, convulsions, tachycardia, hepatic function abnormal, urticaria, oedema, weight increased. Very rare: thrombocytopenia, anaphylactic shock, tics, dysgeusia, dystonia, dyskinesia, angioneurotic oedema, fixed drug eruption, syncope, tremor, accommodation disorder, blurred vision, oculogyration, eye swelling, cough, dysuria, enuresis. Not known: increased appetite, suicidal ideation, amnesia, memory impairment, vertigo, urinary retention, eye pain, erectile dysfunction, nightmares, hepatitis, acute generalised exanthematous pustulosis (AGEP), arthralgia, pruritus upon withdrawal. Consult SPC for additional side effects. RRP (ex VAT): 7s £4.41 Legal category: GSL PL Holder: McNeil Products Ltd, Foundation Park, Maidenhead, Berks, SL6 3UG. PL Number: 15513/0378 Date of prep: 12/11/2019
Benadryl® One A Day Relief / Benadryl® Allergy One A Day 10 mg Tablets, Cetirizine Presentation: Cetirizine dihydrochloride 10mg film-coated tablets with breakline and Y-Y logo. Excipients with known effect: lactose monohydrate. Uses: Symptomatic treatment of allergic rhinitis and chronic idiopathic urticaria. Dosage: 12 years and above: 10mg once daily. Contraindications: Hypersensitivity to ingredients, hydroxyzine or piperazine derivatives; severe renal impairment, galactose intolerance, total lactase deficiency or glucose-galactose malabsorption. Precautions: Renal impairment: dosage adjustment required - refer to SPC. Caution with concomitant alcohol consumption, in epilepsy and those at risk of convulsions. Caution in patients with predisposition factors of urinary retention (e.g. spinal cord lesion, prostatic hyperplasia). Do not drive or operate machinery until familiar with response to drug. Severe skin reactions such as acute generalised exanthematous pustulosis (AGEP) have been reported very rarely with cetirizine-containing products – refer to SPC. Fertility, Pregnancy and Lactation: Caution should be exercised when prescribing to pregnant or lactating women. Side effects: Common: Somnolence, fatigue, dizziness, headache, abdominal pain, dry mouth, nausea, pharyngitis, rhinitis. Uncommon: agitation, paraesthesia, diarrhoea, pruritus, rash, asthenia, malaise. Rare: Hypersensitivity, aggression, confusion, depression, hallucination, insomnia, convulsions, tachycardia, hepatic function abnormal, urticaria, oedema, weight increased. Very rare: thrombocytopenia, anaphylactic shock, tics, dysgeusia, syncope, tremor, dystonia, dyskinesia, accommodation disorder, blurred vision, oculogyration, angioneurotic oedema, dysuria, enuresis, fixed drug eruption. Not known: increased appetite, suicidal ideation, amnesia, memory impairment, eye pain, vertigo, urinary retention, erectile dysfunction, acute generalised exanthematous pustulosis (AGEP), arthralgia, pruritus upon withdrawal. RRP (ex-VAT)/NHS Cost: 7s £4.41; 14s £6.31; 30s £8.33. UK/BN/15-5847(8) Legal category: GSL. PL Holder: McNeil Products Ltd, Foundation Park, Maidenhead, Berks, SL6 3UG PL Number(s): 15513/0118. Date of prep: 11 July 2019
Benadryl® Allergy Relief Plus Decongestant Capsules, Presentation: Acrivastine 8mg and pseudoephedrine 60mg capsules. Uses: Symptomatic relief of allergic rhinitis. Dosage: Adults and children 12 - 65 years: One capsule as necessary, up to three times a day. Contraindications: Hypersensitivity to the active substances, triprolidine or to any of the excipients. Cardiovascular disease including hypertension, concomitant use of beta blockers or other sympathomimetic decongestants, diabetes mellitus, phaeochromocytoma, closed angle glaucoma, hyperthyroidism, significant or severe renal impairment. in patients who are taking or have taken MAOI’s in the preceding 14 days. Contains lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine. Precautions: Severe hepatic impairment, moderate to severe renal impairment or occlusive vascular disease. Effects of alcohol or other CNS depressants may be enhanced. Patients taking sympathomimetics, antihypertensives, anticholinergic drugs such as tricyclic antidepressants, oxytocin, cardiac glycosides, ergot alkaloids, moclobemide, anaesthetic agents, ketoconazole, erythromycin or grapefruit juice. Patients experiencing difficulty in urination due to enlargement of the prostate, or patients with thyroid disease who are receiving thyroid hormones should not take pseudoephedrine unless directed by a physician. Patients with the following conditions should be advised to consult a physician before using acrivastine: a respiratory condition such as emphysema, chronic bronchitis, or acute or chronic bronchial asthma, prostate hyperplasia with urinary retention. If any of the following occur, this product should be stopped: hallucinations, restlessness, sleep disturbances. Severe skin reactions such as acute generalized exanthematous pustulosis (AGEP) may occur with pseudoephedrine containing products. Some cases of ischaemic colitis have been reported with pseudoephedrine. Cases of ischaemic optic neuropathy have been reported with pseudoephedrine. Pseudoephedrine should be discontinued if sudden loss of vision or decreased visual acuity such as scotoma occurs. Rare cases of posterior reversible encephalopathy syndrome (PRES) / reversible cerebral vasoconstriction syndrome (RCVS) have been reported with sympathomimetic drugs, including pseudoephedrine. Pregnancy & lactation: Not recommended. Side effects: Hypersensitivity (including dyspnoea and face swelling), cross-sensitivity with other sympathomimetics, insomnia, nervousness, anxiety, euphoric mood, excitability, hallucinations, irritability, paranoid delusions, restlessness, sleep disorder, headache, somnolence, dizziness, cerebrovascular accident, posterior reversible encephalopathy syndrome (PRES)/reversible cerebral vasoconstriction syndrome (RCVS), psychomotor hyperactivity, dysrhythmias, myocardial infarction/myocardial ischaemia, palpitations, tachycardia, hypertension, dry mouth, nausea, ischaemic colitis, ischaemic optic neuropathy, vomiting, angioedema, pruritus, rash, severe skin reactions, including acute generalised exanthematous pustulosis (AGEP), dysuria, urinary retention in men in whom prostatic enlargement could have been an important predisposing factor. RRP (ex-VAT): 12s £5.41 Legal cat: P PL holder: McNeil Products Ltd, Foundation Park, Maidenhead, Berks, SL6 3UG. PL no: 15513/0017 Date of prep: 15 June 2020.
Benadryl® Allergy Relief (Acrivastine 8 mg) Presentation: Acrivastine 8 mg capsules.Uses: Symptomatic relief of allergic rhinitis. Also chronic idiopathic urticaria.Dosage: Adults and children aged 12 - 65 years: One capsule up to 3 times a day.Contraindications: Hypersensitivity to acrivastine or triprolidine or any excipients listed in section 6.1 of the SPC. Severe renal impairment. Rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption. Precautions: Concomitant administration of acrivastine with CNS depressants may produce additional impairment in mental alertness in some individuals. Patients with renal impairment should consult with a physician before use.This product may cause drowsiness. Acrivastine may cause dizziness and somnolence- caution when engaging in activities which require mental alertness until familiar with response to drug. Caution when taking with ketoconazole, erythromycin or grapefruit juice. Pregnancy and Lactation: Not recommended Side effects: Very common: somnolence. Co mmo n: dry mouth, dizziness. Unknown: hypersensitivity (including dyspnoea and face swelling), rash. RRP (ex VAT): 12s £4.58, 24s £7.78, 48s: £14.16 Legal category: 12s GSL, 24s GSL, 48s P PL Holder: McNeil Products Ltd, 50 – 100 Holmers Farm Way, High Wycombe, Buckinghamshire, HP12 4EG, UK PL Number: 12s & 24s 15513/0128, 48s 15513/0035 Date of prep: 07/12/2020