Dr. Rolita: Over-the-Counter Medications and You

Adults use as much as one-third of all prescription drugs and 40% of non-prescription medications, with over 80% of older adults using over-the-counter (OTC) medications– twice as many as younger adults.

This widespread availability is driven in part by the deregulation of more than 600 preparations from prescription-only to OTC status over the past 20 years. While this trend enhances patient autonomy and reduces healthcare costs, it also elevates the risk of misdiagnosis, dosing errors, and adverse reactions.

Navigating the pharmacy aisle means sifting through approximately 100,000 OTC products, where brand-name options actively compete using flashy, colorful packaging.

However, this attractive branding frequently conceals complex multi-ingredient combination formulas, steering consumers away from simpler generic alternatives. Although generic medications frequently feature plain, black-and-white labeling that is straightforward to read, consumers often avoid them because the plain packaging feels intimidating—ironically choosing brand-name drugs that may pose greater health risks.

The average person over the age of 65 takes six to nine concurrent medications, dramatically increasing polypharmacy risks. This danger is amplified by age-related physiological changes including altered ability to metabolize medications, impaired kidney and liver function, changes in receptor sensitivity due to aging, increased medical conditions, decreased lean body mass, and increased body fat.

Consequently, the chances of a serious drug reaction or interaction are greatly increased, not to mention concerns about misdiagnosis, overdosage, underdosage, adverse reactions, and polypharmacy are raised. Adverse drug reactions are up to seven times more common in individuals aged 70 to 79 than in those aged 20 to 29, accounting for 15% to 23% of hospital admissions.

Even if appropriately dosed, it is important to be aware that when drugs are tested in clinical trials, older adults are usually grossly underrepresented, which results in unpredictability of recommended dosages for this population from available clinical literature. 

Older adults’ medication use should be a careful, informed process. I will attempt to lay out some of the common OTC meds and possible issues that can arise from their use.

Cough & Cold Medications

Decongestants: Oral forms like pseudoephedrine (Sudafed) stimulate adrenergic receptors to constrict sinus blood vessels, drying up secretions and reducing nasal congestion and cough. Short-term risks include hypertension, arrhythmia, and stroke. They should not be combined with beta blockers or digoxin, which can trigger arrhythmias.

Topical alternatives like Afrin (oxymetazoline) or Neo-Synephrine (phenylephrine) can cause rebound swelling (rhinitis medicamentosa), leading to tolerance and increased nasal stuffiness. They also produce significant hypertension in those who take them. Caution should be exercised when using both topical and oral decongestants in those who have heart disease, hypertension, thyroid disease, diabetes, benign prostatic hypertrophy, or urinary retention.

Antihistamines

First-generation antihistamines like diphenhydramine (Benadryl) carry heavy anticholinergic loads. They disrupt central nervous system function, causing confusion, delirium, blurred vision, and impaired motor reflexes, which significantlyincrease the risk of automobile accidents, falls, and hip fractures. Many studies have verified impaired cognitive function from long-term use as well.

Second-generationantihistamines like loratadine (Claritin) have fewer side effects but do not effectively treat coughs.

Cough-Specific Drugs

Robitussin® (guaifenesin) is used for cough symptoms. Its goal is to thin secretions, making them easier to clear by coughing.

Although the side effects of guaifenesin are very rare and mild, its effectiveness is not well documented. One common ingredient in OTC cough preparations is dextromethorphan. It is a morphine derivative and works by centrally suppressing the cough reflex. Side effects are rare and include occasional dizziness, drowsiness, and nausea. The effectiveness of this ingredient is also not well documented.

Vitamin C & Zinc

Vitamin C has been shown to significantly decrease the duration of episodes and the severity of symptoms of a cold by an average of 23%.

Few side effects are associated with taking vitamin C. However, patients should be warned against this therapy if they are prone to kidney stones. Some studies have shown that zinc can shorten the duration of a cold. Although nausea and bad taste sometimes accompany this treatment, these are usually quite mild and well tolerated.

Pain Medications

Nonsteroidal Anti-Inflammatory Drugs: NSAIDs include Bayer (aspirin), Advil (ibuprofen), and Aleve (naproxen).

Despite side effects of tinnitus, diarrhea, and nausea, the major risk factor of NSAIDs is gastrointestinal (GI) bleeding, which rises sharply with age and alcohol use. They also can compromise renal function, threatening patients with heart failure or those taking diuretics.  

Acetaminophen (Tylenol)

Avoids GI bleeding but carries risks of liver toxicity and accidental overdose due to its presence in multiple combination products. It can also interact dangerously with anticoagulants like warfarin. 

Dyspepsia & Heartburn Medications

Antacids, H2 blockers, or proton pump inhibitors (PPIs) are frequently used for heartburn. 

While effective, these medications risk masking symptoms of serious underlying illnesses like esophageal cancer. Antacids can cause diarrhea or constipation and interfere with drug absorption, while blockers like cimetidine carry extensive drug interaction risks, including potential Parkinsonism symptoms when combined with certain antidepressants. It is important to use them as per packaging instructions, as PPIs do not work unless taken on an empty stomach followed by food within 30 min of ingestion. 

Diarrhea & Constipation Medications

Antidiarrheal agents like bismuth subsalicylate can discolor stool, potentially masking internal bleeding. Overuse of laxatives for constipation can result in severe electrolyte imbalances or a dependency condition known as cathartic colon, making proper dietary fiber the safest first-line approach.

In Summary

Misuse of OTC drugs often stems from misleading commercial packaging, small-print labeling, and the misconception that OTC drugs are inherently safe. Furthermore, adverse drug reactions frequently present as subtle symptoms - such as confusion, fatigue, or frequent falls. Clinicians may mistakenly treat these symptoms with additional medications, triggering a harmful “prescribing cascade.”  I recommend everyone review their medication history, including their OTC regimen, with their health care provider and/or their pharmacist to improve safety and prevent adverse reactions.