Help patients navigate the pharmacy analgesic aisle

LAS VEGAS — Clinicians should make specific product recommendations to patients for over-the-counter topical pain medications to help prevent confusion among hundreds of analgesic choices at the pharmacy.

During his presentation at PAINWeek 2022, Mark P. Garofoli, PharmD, MBA, BCGP, CPE, CTTS, clinical assistant professor and clinical pain management pharmacist at the West Virginia University Schools of Pharmacy and Medicine, reviewed the ingredients and uses of many of the currently available topical analgesics.

“There’s a lot of confusion and concern out there for things that are not opioids,” he said. “The OTC aisle is overwhelming to people.”

His advice: Remember the basics. “Topical means ‘apply here, works here,’” he said. “Transdermal means ‘apply here, works everywhere.’”

Garofoli presented a chart that broke down topical ingredients into four categories: counterirritants, numbing, anti-inflammation and other.

Counterirritants can be divided into hot and cold treatments, he said. Heat causes vasodilation and should be used for muscle tension or knots. Cold creates vasoconstriction and should be used for muscle spasms.

Methyl salicylates, which are warm counterirritants, are available in OTC combination form in products from Salonpas (Hisamitsu), Tiger Balm (Haw Par Corp.), Bengay (Johnson & Johnson) and Icy Hot (Sanofi). Products also containing trolamine salicylates include Aspercreme (Sanofi) and Sportscreme (Chattem).

Capsaicin, another warm counterirritant, can be found in Capzasin (Chattem) and Zostrix (Prestige). Some Salonpas and Tiger Balm products contain capsaicin along with camphor, menthol and essential oils.

A prescription capsaicin product, the Qutenza 8% patch (Averitas Pharma), is FDA-approved for use in patients with diabetic peripheral neuropathy of the foot and postherpetic neuralgia.

Cool counterirritants include products containing camphor, menthol and essential oils, Garofoli said. Some Salonpas, Bengay and Tiger Balm combination products feature these ingredients, and some Tiger Balm and Aspercreme combination products also contain essential oils, he said.

Topical numbing agents contain lidocaine and include products from Salonpas, Bengay, Icy Hot, Aspercreme and a number of other brands.

Topical anti-inflammatories may contain CBD or diclofenac, Garofoli said. Flector (diclofenac 1.3% patch, IBSA) is FDA-approved for acute pain due to minor strains, sprains and contusions, while Licart (diclofenac 1.3% patch, IBSA) is FDA-approved for topical treatment of acute pain due to minor strains, sprains and contusions. Pennsaid (diclofenac sodium 1.5% solution, Horizon) is FDA-approved for osteoarthritis of the knee.

Voltaren gel (diclofenac sodium 1% topical gel, GlaxoSmithKline), intended for osteoarthritis joint pain, was approved by the FDA for nonprescription status in 2020.

Garofoli’s “other” topical analgesic is the antidepressant Zonalon (doxepin 5% cream, Doak Dermatologics), which can be used for itching or neuropathic pain.

Garofoli said emu products, which contain omega-3, omega-6 and omega-9, are becoming popular for use with arthritis, hypocholesterolemic effect, mucositis, irritable bowel disease, cancer chemotherapy-induced bone loss, hair loss and short-term mosquito repellent.

Additional topical analgesics include Bio Freeze (menthol, Reckitt), Deep Heat (methyl salicylate, Mentholatum Australasia), Vicks VapoRub (menthol, camphor, eucalyptus oil) and Mineral Ice (menthol, Crown Therapeutics).