Communication workshop OTC advice

Question 1

How to choose the correct product

Answer 1

Patient charcateristics
Indication and contra-indications
Formulation
Dose
Patient preference
Red flag symptoms
Evidence base
Licensing considerations
Referral criteria (conditional vs unconditional)

Question 2

What information should you provide?

Answer 2

If a product is recommended: What is it?
Instructions for use
Possible side effects
Special storage instructions
What to do if symptoms get worse/ don’t improve (with a clear timeline)
If patient is referred: Explain why you are making a referral
Emphasise importance- be assertive

Question 3

Pain perception

Answer 3

The sensation of pain is increased by: discomfort, fatigue, fear, sadness, boredom, insomnia, anxiety, anger, depression, loneliness
The sensation of pain is decreased by: sleep sympathy, companionship, rest, understanding, diversional activities, antidepressants (if appropriate)

Question 4

Acute pain

Answer 4

Usually rapid in onset
usually identifiable cause
Limited duration
Tends to get better
Biological significance

Question 5

Chronic pain

Answer 5

Not necessarily an identifiable cause
Large emotional component
Unpredictable duration
Does not get better
None or negative meaning

Question 6

Pain is transmitted through three different levels:

Answer 6

Nociception: peripheral activation and release of pain mediators
Travel through primary nociceptors, C and Ad fibres
Pain gating: dorsal horn of the spinal cord
Travels through ascending and descending secondary fibres
Pain perception: The brain (thalamus, limbic and cortical systems)

Question 7

Nociceptive pain

Answer 7

Stimulation of receptors that respond to heat, vibration, stretch and chemical stimuli released from damaged cells

Question 8

Non-nociceptive pain

Answer 8

From within peripheral and CNS, no specific receptors, but nerve cells dysfunction

Question 9

Treatment of somatic pain

Answer 9

NSAIDs, weak and strong opioids

Question 10

Treatment of visceral pain

Answer 10

NSAIDs, weak and strong opioids

Question 11

Treatment of neuropathic pain

Answer 11

Anti-depressants, anti-convulsants, anti-arrhythmics

Question 12

What happens when tissues are damaged?

Answer 12

Release of chemical mediators e.g. bradykinin, histamine, 5-HT and inflammatory mediators e.g. prostaglandins
Activation of C fibres
Inflammation- a protective mechanism, moving plasma and leucocytes from blood into injured tissues, results is swelling, heat and pain, no beneficial function

Question 13

Prostaglandins

Answer 13

Chemical messengers made from fatty acids that play a role in influencing pain signals, and regulation of inflammation
Transmission of pain information to the brain
Modulation of the hypothalamic thermostat
Inflammation

Question 14

Cyclooxygenase (COX)

Answer 14

Enzyme responsible for formation of prostaglandins
COX 1- always present in most cells
COX 2- induced in inflammatory cells

Question 15

Vascular events of acute inflammation

Answer 15

Prostaglandins and histamine cause dilatation of the small arterioles
Causes increased blood flow
Causes stasis of the blood
Causes increase in permeability of postcapillary venules
Exudation of fluid- plasma and leukocytes into damaged area
Causes activation of the complement system, fibriolytic system, coagulation system and kinin system

Question 16

NSAIDs

Answer 16

Most have three major types of effect:
Anti-inflammatory effects
Analgesic effect- decrease production of the prostaglandins that sensitise noiciceptors to inflammatory mediators such as bradykinin
Antipyretic effect- NSAIDs reset the thermostat by inhibition of E-type prostaglandin production in the hypothalamus
he primary action of NSAIDs is the inhibition of COX, most NSAIDs inhibit both isoenzymes but vary in he degree of inhibition of each

Question 17

Anti-inflammatory effects of NSAIDs

Answer 17

NSAIDs reduce mainly those components of the inflammatory and immune response in which products of COX II action play a significant part, namely:
Decrease vasodilation
Decrease oedema (indirectly, the vasodilatation facilitates the action of mediators such as histamine which increase permeability of postcapillary venules)
Decreases pain

Question 18

Common unwanted effects

Answer 18

Gastrointestinal disturbance, dyspepsia, nausea and vomiting due to effects on gastric mucosa
Skin reactions e.g. rash
Reversible renal insufficiency
Can trigger asthma attacks
NSAIDs should be avoided in the elderly because this group of patients already suffer mild renal dysfunction

Question 19

Aspirin

Answer 19

Non-selective and irreversibly inhibits both COX 1 and COX 2
Inhibits prostaglandins, to combat inflammation and pain (300-900mg every 4-6h)
Blocks the formation of thromboxane in platelets, producing an inhibitory effect on platelet aggregation
Anticoagulant property makes aspirin useful for reducing the incidence of heart attacks (75mg)

Question 20

Ibuprofen

Answer 20

Non-selective COX inhibitor (200/400mg-400mg 3x per day)
Milder antiplatelet effect
The analgesic, antipyretic, and anti-inflammatory activity of NSADs is achieved mainly through inhibition of COX-2
Inhibition of COX-1 would be responsible for unwanted effects on platelet aggregation and the gastrointestinal tract

Question 21

Paracetamol

Answer 21

COX-3, found in the brain and spinal cord is selectively inhibited by paracetamol, relieving pain and reducing fever without having unwanted gastrointestinal side effects
Anti-pyretic effect- a centre in the hypothalamus regulates temperature, fever occurs when there is a disturbance of this thermostat, causing sweating and dilatation of superficial blood vessels&raquo_space; paracetamol works as a thermoregulator in the hypothalamus
First step on WHO analgesic ladder
Can cause fatal hepatoxicity, but is safe when dosage kept within therapeutic guidelines