By Andy Skean, Senior Editor, Physician’s Weekly

 

The over-the-counter (OTC) medication aisle can be overwhelming for patients, especially when trying to select from the more than 300,000 products marketed in the United States in 80 therapeutic categories. Add a chronic medical condition, like diabetes, and the selection process can become even more difficult. Choosing the right OTC medication can be challenging for patients with diabetes, because many contain carbohydrates that can affect blood glucose levels, as well as ingredients that can interact with the prescription medications they are taking. In addition, diabetes is often listed in the “warnings” section of the Drug Facts label as a condition requiring the patient to consult with a doctor before use.

Unfortunately, unlike the Nutrition Facts label, the Drug Facts label does not list the amount of carbohydrates contained within the medication. Carbohydrate content can vary significantly between medications. Reviewing the inactive ingredients can help patients to identify if the medication contains carbohydrates, but will not provide how much.

Following are seven key points to consider when recommending OTC medications to patients with diabetes.

 

  1. Well-managed diabetes allows for more OTC options: When A1C and blood glucose values are near or within goal ranges, many OTC medications can be taken safely, regardless of whether they contain carbohydrates. This is especially true if the medication is taken for short-term symptom management, as blood glucose levels rise during illness due to the stress on the body and subsequent release of catecholamines.
  2. Emphasize active ingredients over brand name products: Many brand name OTC manufacturers produce product line extensions, allowing the manufacturer to capitalize on an existing product’s name recognition in order to market additional products. The products may contain new strengths, formulations, combinations of active ingredients, or entirely different active ingredients of the brand name product that was originally marketed. In addition, brand name products are often reformulated, meaning the active ingredients may change from time to time. Selecting a specific active ingredient that addresses the patient’s symptoms removes confusion and inappropriate medication selection if they cannot find the exact brand name recommended.
  3. Recommend only the necessary active ingredients: Many OTC medications are combination products that contain multiple active ingredients. Each active ingredient should treat a current symptom. Cough syrups often contain a suppressant and an expectorant, but it does not make sense to take both. In addition, multiple products contain acetaminophen. If the patient does not have pain or fever, there is no indication for this ingredient. Both of these examples result in the patient taking a medication they do not need.
  4. Tablet and capsule formulations are preferred over liquids, when possible: Liquid medications often contain added sugar or sweeteners to enhance the palatability. Without the carbohydrate content listed on the Drug Facts label, it is difficult for clinicians and their patients to determine the amount of carbohydrate in the medication. Only a few resources are available to determine the carbohydrate content of OTC medications. Calling the manufacturer provides the most current information and accounts for any medication formulation changes. The website com lists carbohydrate content in prescription and—a limited number of—OTC medications. The site was last updated in May 2014 and therefore may contain outdated information. A literature search identified one journal article containing the carbohydrate content of prescription and—again, a limited selection of—OTC medications from 2001. However, the article does not include manufacturer names, making it difficult to determine the carbohydrate content from different generic companies. The Table includes examples of the carbohydrate content in select OTC medications.

Alcohol is also often added to liquid OTC medications, to serve as a solvent, vehicle, and preservative. For example, NyQuil Cold and Flu contains 10% alcohol, the equivalent of a 20 proof beverage or as much alcohol as some glasses of beer or wine. Patients with diabetes should be notified that alcohol can cause hypoglycemia.

  1. Special diabetes formulated products are not always the only choice: If patients are concerned about the effects of an OTC medication on their blood glucose levels, medications labeled as “sugar-free” or “for people with diabetes” can be recommended. The Drug Facts label must be reviewed to determine that the active ingredients within the medication will appropriately treat the patient’s symptoms. Otherwise, a product that does not state “sugar-free” but does have active ingredients to treat the symptoms would be more appropriate.
  2. Talk to patients about OTC medications before they are sick: Part of diabetes self-management includes proper sick day care and monitoring. Ideally, clinicians and patients should discuss appropriate OTC medication selection before the patient gets sick. This discussion can also include plans to increase blood glucose monitoring and diabetes treatment medication doses if the carbohydrate content in the OTC medication increases blood glucose levels.
  3. Ask the pharmacist: Pharmacists are OTC medication experts and can help clinicians and their patients select appropriate OTC medications to treat patients’ specific symptoms. Additionally, pharmacists can check for drug interactions between prescription and other OTC medications the patient takes.

References

FDA. Drug applications for over-the-counter (OTC) drugs.  Available at:  www.fda.gov/drugs/developmentapprovalprocess/howdrugsaredevelopedandapproved/approvalapplications/over-the-counterdrugs/default.htm.

Rickert E. Legal and regulatory issues in self-care pharmacy practice.  In: Krinsky D, Ferreri S, Hemstreet B, et al. Handbook of nonprescription drugs: an interactive approach to self-care. American Pharmacists Association. 2015;49-60.

Institute for Safe Medication Practices. Maalox brand name extension may cause confusion. Medication Safety Alert! 2005;4:1-2.

McGhee B, Katyal N. Avoid unnecessary drug-related carbohydrates for patients consuming the ketogenic diet.  J Am Diet Assoc. 2001;101:87-101.