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OTC FOCUS CASE STUDIES CASE 2: WEIGHT LOSS RECOMMENDATIONS A 48-year-old obese woman asks about treatment options for weight loss. She recently had an annual physical exam with her internist, who, after examining her blood work, indicated she has an abnormal fasting blood glucose value of 115 mg/dL, along with a gly- cated hemoglobin level of 6.2%, indicating she is at an increased risk of developing diabetes. Additionally, she has high blood pressure, which is currently controlled with a combination of lisinopril /hydrochlorothiazide 20 mg/25 mg once daily by mouth. She describes having a strong family history of heart disease and diabetes and is committed to changing her lifestyle to prevent developing complications. Her internist referred her for nutrition and dietary counseling and has encouraged her to engage in low-impact physical activity. The patient wonders if there is an OTC medi- cation or supplement she should take to help her lose weight more quickly. What recommendations should the pharmacist provide? ANSWER Diet, exercise, and behavior modification play sig- nificant roles in managing obesity. Drug therapy can augment the effects of these lifestyle modifications and may be indicated, in conjunction with lifestyle modification, in certain patient groups. However, the effects of drug therapies, whether prescription or over the counter, are usually limited; lost weight may return after cessation of medication use, and use of these agents alone will not "cure" obesity. This patient is already taking appropriate steps to modify her lifestyle to reduce her weight and improve her overall health. The pharmacist can work with her to determine her overall weight-loss goals and educate her on the availability of OTC weight-loss products, such as orlistat, that may augment her multicompo- nent approach to changing her lifestyle. Unlike other prescription-only weight-loss drugs, orlistat is a reason- able first-line pharmacologic intervention that is virtu- ally free of cardiovascular adverse effects (AEs), and may reduce the blood cholesterol level as a second- ary benefit. 1,2 The pharmacist can also encourage the patient to discuss other prescription-only medications with her internist at her next follow-up appointment. These medications could be indicated for the patient based on her body mass index, and as a next step depending on the effectiveness of dietary modifica- tion and exercise. CASE 1: DENTAL HEALTH FOR THE CARDIAC PATIENT A 78-year-old man approaches the phar- macy counter for advice. He reports that he recently underwent mitral valve replace- ment surgery and subsequently began taking warfarin. He has multiple medical comorbidities, including heart failure, dyslipid- emia, and hypertension. In addition to taking warfarin, he is taking several other antihypertensive and lipid-lowering medications. After having heart surgery, he recalls receiving infor- mation on the importance of good dental hygiene, but he cannot remember why or what, specifically, he should be doing to ensure good dental health. What information should the pharmacist provide regarding the importance of dental hygiene in this patient, and strategies to ensure healthy gums? ANSWER The results of clinical trials have suggested that pre- venting gum disease may reduce the risk for cardiovas- cular disease, although research is limited as to wheth- er treating gum disease actually reduces the incidence of cardiovascular events. Because this patient has undergone a valve repair, he may be at increased risk for infective endocarditis; therefore, oral hygiene and regular dental care are particularly important. Encourage this patient to seek the care of a dental health professional, who, prior to performing routine dental care, should be notified that the patient is tak- ing warfarin. Remind the patient to discuss his need for prophylactic antibiotics with his cardiologist and his dentist, prior to dental procedures. Dr. Bridgeman is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. Dr. Mansukhani is a clinical assistant professor at the Ernest Mario School of Pharmacy, Rutgers University, and a transitions-of-care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey. Rupal Patel Mansukhani, PharmD Mary Barna Bridgeman, PharmD, BCPS, CGP Self-Care for Heart Health 26 PharmacyTimes.com December 2015