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Helping people with diabetes navigate the OTC aisle
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In this issue, Susan Weiner, MS, RDN, CDE, FAADE, talks with Mandy Reece, PharmD, CDE, BC-ADM, BCACP, FAADE, about helping people with diabetes choose over-the-counter products for common nondiabetes ailments. Many of these therapies have effects on glucose and diabetes complications.
What are some common conditions for which people with diabetes seek out OTC medications?
Reece: The most common reasons for shopping for OTC products are pain, gastrointestinal issues (heartburn, upset stomach, diarrhea, constipation), allergies, colds and coughs. Often, people prefer to stop in the OTC aisle for minor conditions (eg, knee pain, headaches) with troublesome symptoms that do not require a physician visit. Also, some people will opt for OTC products due to lack of health insurance, inability to afford an office visit copay or simply lack of time to visit a primary care provider.
What are some examples of OTC medication recommendations for people with diabetes?
Reece: For pain (eg, occasional headache), acetaminophen is preferred over an NSAID such as ibuprofen or naproxen sodium. The recommended dosing is below:
- acetaminophen 325 mg to 1,000 mg every 4 to 6 hours as needed (maximum daily dose 4,000 mg);
- ibuprofen 200 mg to 400 mg every 4 to 6 hours as needed (maximum daily dose 1,200 mg); and
- naproxen sodium 220 mg every 8 to 12 hours as needed (maximum daily dose 660 mg).
There are a few precautions for people with diabetes to consider when using OTC pain relievers. Avoid ibuprofen when chronic kidney disease or NSAID-induced peptic ulcer disease is present. Acetaminophen can interfere with the DexCom G5 continuous glucose monitoring system, but that is not an issue with the DexCom G6 system.
When experiencing heartburn, dyspepsia, diarrhea or constipation, it is key to identify possible causes before purchasing an OTC medication. Antacids are a great option for treating heartburn and indigestion. The dosing for antacids is chewing two to four tablets as symptoms occur (maximum daily dose depends on the specific product). Bismuth subsalicylate (Pepto-Bismol) can treat diarrhea, heartburn, nausea and upset stomach. The dosing is 30 mL every 30 minutes to 1 hour as required (maximum daily dose depends on specific product). Heads up — it can cause black tongue and black tarry stool. Loperamide can treat diarrhea. The dosage is 4 mg (30 mL) initially followed by 2 mg (15 mL) after each loose stool, not to exceed 8 mg (60 mL) per day. If food poisoning is suspected, seek out medical care rather than taking these medications.
What are the considerations before taking an OTC medicine in terms of impact on glucose?
Reece: Many OTC liquid medications, especially syrups, contain carbohydrates (sugar), which can substantially elevate blood glucose. Cough drops are another OTC product that contain carbohydrates that could lead to serious elevation if a person were to consume multiple drops. It is important to advise people with diabetes to select sugar-free liquids and cough drops to avoid unnecessary hyperglycemia.
What are the considerations before taking an OTC medication if a person with diabetes also has hypertension or CKD?
People with diabetes and hypertension should strive to keep their blood pressure under control and check BP before taking an OTC product. They also should learn which symptoms might be associated with uncontrolled BP, diabetes and diabetes complications. They should specifically avoid decongestants if they have hypertension or uncontrolled BP, and avoid nephrotoxic drugs, such as NSAIDs, if they have CKD. Acetaminophen is a good alternative to NSAIDs for people with diabetes.
Always ask the pharmacist at the pharmacy when in doubt.
As diabetes educators, what guidance can we provide people with diabetes before they step into the OTC aisle?
Reece: Advise people with diabetes to pause and identify the symptoms before rushing to the local pharmacy to purchase an OTC medication. Provide patients with a list of red flag symptoms, such as black or tarry stools, blood in sputum or urine, sudden sharp pain, vomiting or diarrhea lasting for more than 6 hours, unexplained dizziness that indicates the need to call a diabetes educator or primary care provider or go to urgent care.
Having diabetes often precludes self-treatment with OTC products as diabetes that is not well-controlled or diabetes with complications can contribute to symptoms that person is experiencing. Also, encourage patients to opt for sugar-free cold and cough preparations, especially liquids, and select products with least number of primary ingredients (more is not always better). Most OTC medications should not be used for more than 7 consecutive days without provider supervision. Caution must be used to ensure not overdoing acetaminophen, especially when using combination pain, allergy, cold and cough products — advise patients to not take additional acetaminophen if it is already included in a combination. Share with patients the maximum daily dose of acetaminophen.
- For more information:
- Sara (Mandy) Reece, PharmD, CDE, BC-ADM, BCACP, FAADE, is vice chair and associate professor of pharmacy practice, director of interprofessional education with Georgia Campus–Philadelphia College of Osteopathic Medicine School of Pharmacy. She can be reached at sararee@pcom.edu.
- Susan Weiner, MS, RDN, CDE, FAADE, is the 2015 AADE Diabetes Educator of the Year and author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com.
Disclosures: Reece reports no relevant financial disclosures. Weiner reports she is a clinical adviser to Livongo Health.