Drug Quizz #3 OTC Flashcards
Meclizine
Trade Name: Dramamine Less Drowsy; Bonine
Class: Antihistamine; Antiemetic
Self-Care indication: Motion sickness
Self-Care Monitoring Parameters:
Improvement in nausea or vertigo symptoms. Seek medical attention for signs of severe CNS toxicity.
Key Patient Counseling Points:
More effective if taken 30-60 min prior to anticipated motion sickness than for acute treatment. Can be taken daily for consistent exposure to environments that make cause motion sickness. May cause drowsiness; avoid driving and operating machinery until the effects of meclizine are known. Avoid alcohol and other CNS depressants. Caution in adults >65 y of age.
Clinical Pearls:
Meclizine is available OTC in many different products and by prescription. A number of products named Dramamine are available, with different active ingredients. Check packaging to confirm active agent.
Magnesium Oxide
Trade Name: Mag-200
Class: Mineral Supplement
Self-Care indications: Dietary Supplementation
Self-Monitoring Parameters:
Primary efficacy monitoring is via clinical laboratory testing. Patients may self-monitor for resolution of symptoms, including muscle weakness and arrhythmias. Seek medical attention if severe diarrhea, nausea, or vomiting occurs.
Key Patient Counseling Points:
Take with food and at least 240 mL of water. Whole grains, legumes, and dark-green leafy vegetables are dietary sources of magnesium.
Clinical Pearls:
Magnesium chloride is also used for magnesium supplementation and is available in a sustained-release formulation which enhances absorption. Avoid with other magnesium-containing products including magnesium citrate used as saline laxative. Thiazide and loop diuretics, as well as PPIs, are a common cause of hypomagnesemia. If discontinuation of thiazide or loop diuretics is impractical, a potassium-sparing diuretic can be added to increase magnesium reabsorption in the kidney. Magnesium hydroxide also available as an antacid.
Menthol Oral
Trade Name: Halls Cough Drops
Class: Cough Suppressant
Self-Care indications: Cough and throat irritation
Self-Care Monitoring Parameters:
Relief from cough. Seek medical attention if cough does not improve in 7 d or if severe skin rash or flank pain occurs.
Key Patient Counseling Points:
Advise patients to get adequate rest and hydration. Take with plenty of noncaffeinated liquids. Note that most cough drops contain glucose syrup and should be used with caution in patients with diabetes.
Clinical Pearls:
Also used in a wide variety of topical products, with other active ingredients, as a moisturizer, topical analgesic (as a counterirritant), topical decongestant, and for many other applications. Forms a eutectic mixture when triturated with camphor, phenol, and many other substances. Major component of peppermint oil, a common natural product, believed to have value for a wide range of indications with little evidence supporting efficacy.
Moisturizers
Trade Name: Eucerin; Lubriderm; Cetaphil
Class: Topical Moisturizers
Self-Care indications: Dry skin
Self-Care Monitoring Parameters:
Improvement in dry skin symptoms. Seek medical attention for rash or signs of hypersensitivity.
Key Patient Counseling Points:
Do not use on injured skin (lacerated or burned) or on skin infections. Avoid contact with eyes; if contact occurs, flush with copious amounts of clean water until irritation subsides. Selection of product is dependent on personal preference.
Clinical Pearls:
While petrolatum is the most effective moisturizing ingredient, its major drawback is significant greasiness, which is undesirable to many patients. Silicone products (such as dimethicone) also reduce moisture loss from the skin, but are not as greasy. Combinations of petrolatum and dimethicone represent the most common ingredients in OTC moisturizers. Humectants, such as glycerine, are added to many moisturizers to draw moisture to the skin in the event the moisture barrier formed by protectant agents (petrolatum, dimethicone) is compromised. Many products with the same name have very different active ingredients and uses; select products carefully. Many moisturizers contain sunscreens at various SPF (sun protection factor) values. Some sunscreen products can bleach fabric and hair.
Magnesium Hydroxide
Trade Name: Milk of Magnesia
Class: Laxative; Antacid
Self-Care indications: Antacid; Laxative
Self-Monitoring Parameters:
Relief from constipation or relief from heartburn. Diarrhea, cramps, and abdominal pain may occur; if severe, seek medical attention.
Key Patient Counseling Points: Lifestyle interventions (increasing exercise, intake of water, and dietary fiber) are generally first-line management of constipation. Take product with 240 mL of water. Product available in combination with other therapies for acid reflux including H2RAs and antacids. Multiple formulations of magnesium exist; ensure use of appropriate salt form.
Clinical Pearls:
Magnesium hydroxide is the laxative of choice for children 2-5 y of age. Generally, produces bowel movement within 1-6 h of oral administration. Magnesium accumulates and may become toxic in patients with renal failure. Also at risk are patients with advanced age, heart failure, or use of diuretics; use of magnesium hydroxide should be avoided in these cases. Also available as magnesium citrate, a carbonated beverage that produces bowel movement very quickly. Magnesium oxide also available as nutritional supplement.
Melatonin
Trade Name: N-acetyl-5-methoxytryptamine; Midnite
Class: Hypnotic; Analgesic
Self-Care indications: Insomia; Jet lag; Pain
Self-Care Monitoring Parameters:
Improvement in insomnia. Alleviation of symptoms in jet lag (eg, correction of disturbed sleep, reduced daytime tiredness). Discontinue use and seek medical attention for signs of severe adverse effects.
Key Patient Counseling Points:
Administer 30 min before going to bed. Good sleep hygiene and avoidance of caffeine, alcohol, and nicotine 4 h before bedtime should be recommended in addition to self-management of insomnia. Identifying underlying medical or medication causes is most effective at relieving sleep disturbances. Do not use for >2 wk without discussing with HCP. For overnight eastward travel, start treatment during flight, 30 min prior to planned bedtime at destination. For example, when traveling to a destination with a 12-h time difference, if the target bedtime is 10 PM, melatonin should be taken at 9:30 AM local time. For westward travel, start treatment the evening of arrival, 30 min prior to bedtime.
Clinical Pearls:
A meta-analysis demonstrated that melatonin is significantly better than placebo in prolonging sleep duration; however, the clinical significance is questionable as the mean duration of additional sleep was <10 min. However, melatonin appears to be quite effective in reducing jet lag. According to a Cochrane review published in 2002, immediate-release melatonin 0.5-5 mg, taken close to the target bedtime at the destination (10 PM to midnight), decreased jet lag with minimal adverse effects.
Miconazole
Trade Name: Desenex; Lotrimin AF
Class: Antifungal
Self-Care indication: Skin fungal infections (jack itch, ringworm of the body, athlete’s foot), Vulvovaginal candidiasis.
Self-Care Monitoring Parameters:
Resolution of infection. For skin infections, improvement in erythema and pruritus usually occurs within 3-5 d. Seek medical attention if no improvement is seen after 1 wk of treatment for tinea corporis, or after 2 wk of treatment for tinea cruris or tinea pedis, or if infection appears to worsen after application. For vaginal infections, symptoms usually improve in 1-2 d; seek medical attention if not resolved after treatment. Seek medical attention for severe skin irritation or rash.
Key Patient Counseling Points:
Wash and dry area before applying. For athlete’s foot, allow shoes to dry between wearing (leather shoes may take up to 3 d to dry). Change of socks several times daily to keep the foot dry. Use shower shoes in public showers. For jock itch, change to looser fitting boxer shorts instead of briefs to allow better air circulation. All topical skin infections are contagious; avoid skin-to-skin contact with infected area to prevent spread. Vaginal products are petrolatum based, which weakens condoms; use an alternative form of birth control. 7 d or 3 d formulations may be more effective than 1 d preparations, but ease of 1-time administration may be preferred by some patients.
Clinical Pearls:
Ringworm (tinea corporis) typically occurs on smooth skin and appears as a small red, round, scaly, and itchy lesions. Athlete’s foot (tinea pedis) is usually between the toes and is either white and macerated or red and scaly. Application area should be 1-2 in beyond the rash. May consider treatment for 1-2 wk after the area has healed to avoid reoccurrence. For vaginal candidiasis, all topical imidazole antifungals are considered equivalent to one another, but more effective than nystatin. Oral product is also available via prescription for oropharyngeal candidiasis.
Minoxidil Topical
Trade Name: Rogaine
Class: Alopecia Agent
Self-Care indications: Hair growth
Self-Care Monitoring Parameters:
Growth of hair. Seek medical attention if severe adverse effects occur.
Key Patient Counseling Points:
Apply topically. Avoid contact with eyes, mouth, nose, or other mucous membranes. Do not use if scalp is red, inflamed, infected, or painful. Avoid with other topical medicines or medicated shampoos on the scalp. Topical solution is flammable; keep away from fire or flame. May cause changes in hair color and/or texture. May require 4 mo to 1 y of continuous bid treatment for treatment effect to be noticeable.
Clinical Pearls:
Not intended for frontal baldness or receding hairline or in patients with no family history of hair loss. While topical use does not result in significant systemic absorption, use with caution in patients with cardiovascular disease. Not for use in children <18 y of age. Exceeding the recommended dosage does not result in greater or faster hair growth but may increase adverse effects.
Methyl Salicylate and Menthol Topical
Trade Name: Bengay; Icy Hot
Class: Topical Analgesic
Self-Care indications: Pain
Self-Care Monitoring Parameters. Decreased pain. Stinging or burning may occur in an area where product is applied. Discontinue use and seek medical attention if severe skin irritation, rash, or burns occur.
Key Patient Counseling Points:
Apply topically, for external use only. Do not apply to wounds, rashes, damaged skin, mucous membranes, or right after bathing. Do not use a heating pad after application. Available in a variety of formulations; following package-specific instructions for appropriate administration. Avoid contact with eyes. Use with caution in patients with diabetes and patients with sensitivity to aspirin.
Clinical Pearls:
Some formulations also contain camphor for topical analgesia. Other products replace methyl salicylate with camphor (in combination with menthol) and are used for dry, itchy skin (eg, Mentholatum, Sarna, etc) and for nasal congestion (Vicks VapoRub). Methyl salicylate is absorbed after topical application. While risks in patients with hepatic or renal failure, or drug interactions common with salicylates, are not included in most standard drug references, caution is warranted in patients with renal or hepatic failure, particularly after regular, chronic use. Patch formulation (Salonpas Pain Relief Patch) has higher likelihood of systemic absorption of salicylate and includes label warnings for patients who are at risk of salicylate toxicity. Patch should be used with caution for those patients and for no more than 3 d in any patient.
Milk Thistle
Trade Name: Silymarin; Silibinin; Legalon; Livergol
Class: Hepatoprotectant
Self-Care indications: Hepatoprotectan(hepatitis C)
Self-Care Monitoring Parameters:
Improvement in signs and symptoms of hepatic dysfunction. Discontinue use and seek medical attention for any severe adverse effects.
Key Patient Counseling Points:
Avoid use with alcohol and hepatotoxic drugs. Avoid use of above-ground parts of the plant in women with hormone-sensitive conditions (breast, uterine, ovarian cancers, endometriosis, etc) due to the extract’s possible estrogenic effects. Use with caution in patients with diabetes. Avoid in patients with allergy to plants in the Asteraceae/compositae family.
Clinical Pearls:
A Cochrane review reported in 2007 assessed the influence of milk thistle on alcoholic and/or hepatitis B or C virus liver diseases compared to placebo or no intervention demonstrating no benefit in mortality, complications of liver disease or liver histology. Efficacy for a wide range of disorders has been claimed, yet evidence for most indications is absent or weak. A wide variety of products are marketed, with no FDA oversight over product content, quality, or labeling. Milk thistle may lower blood sugar levels. Caution is advised in people with diabetes and in those taking drugs that affect blood sugar.
Naphazoline Ophthalmic
Trade Name: Clear Eyes
Class: Alpha-Agonist
Self-Care indications: Relief from redness of the eyes due to minor irritation
Self-Monitoring Parameters:
Improvement in redness symptoms. Seek medical attention if symptoms not improved after 3 d or if severe hypersensitivity occurs.
Key Patient Counseling Points:
Do not use if solution is discolored or has particulates. The solution contains benzalkonium chloride, which can be absorbed by contacts; therefore, remove contact lens before use and may put back in 15 min after use. Wash hands before and after use. To administer, tilt your head back and place 1-2 drops in corner of eye without touching the bottle tip to your eye, and use finger to apply pressure to the inside corner of the eye. Close eye for a few minutes after administration. Avoid touching the tip of container to eye to avoid contamination.
Clinical Pearls:
Accidental ingestion by children <6 y of age can result in coma, bradycardia, respiratory depression, and sedation. Seek emergency medical attention if accidental ingestions occur and keep out of the reach of children and pets. Not intended to treat allergic conjunctivitis as monotherapy. Use may lead to rebound congestion. Patients may notice temporary change in pupil size. Does not treat underlying cause of redness (allergic conjunctivitis, etc); these causes may require additional or different treatment.
Naproxen
Trade Name: Aleve
Class: NSAID
Self-Care indications: Fever; Pain; Headache
Self-Monitoring Parameters:
Decreased pain, fever. If fever does not resolve in 3 d or pain in 10 d, seek medical attention. Seek medical attention if severe skin rash, black tarry stools, hematemesis, chest pains, yellowing of eyes or skin, or changes in urination occur.
Key Patient Counseling Points:
Take with food or milk to decrease GI upset. Drink a full glass of water with each dose.
Clinical Pearls:
NSAIDs are associated with an increased risk of adverse cardiovascular thrombotic events, including fatal AMI and stroke. Use with caution in patients with renal dysfunction. Patients <12 y of age should use ibuprofen if an NSAID is indicated. Various OTC NSAID products are available; caution patients not to duplicate dosing with multiple NSAID products.
Niacin (Vitamin B3)
Trade Name: Niacin-50; SLO-Niacin
Class: Antihyperlipidemic; Water-Soluble Vitamin
Self-Care indications: Coronary arteriosclerosis; hypercholesterolemia; Vitamin Supplement
Self-Care Monitoring Parameters:
Resolution of signs and symptoms of vitamin B deficiency. Home cholesterol monitoring tests are available and are generally accurate, but they only evaluate total cholesterol, HDL, and triglycerides, and do not replace cholesterol panels performed by HCPs. Niacin reduces total cholesterol and increases HDL. Seek medical attention for signs/symptoms of rhabdomyolysis (myalgias, dark urine, arthralgias, fatigue), yellowing of eyes or skin, severe abdominal pain.
Key Patient Counseling Points:
Start with a low dose and titrate based on tolerability (primarily flushing). If discontinued for several days, may need to restart on a lower dose and re-titrate. Avoid alcohol and warm beverages with niacin to reduce flushing. Aspirin or NSAID 30 min prior to niacin may reduce flushing. Pectin, a component in applesauce, has been studied to reduce the incidence and severity of flushing when administered 30 min of niacin.
Clinical Pearls:
Various extended-release versions of niacin have different release profiles. The wax-matrix extended-release product decreases flushing and is bioavailable and effective. Inositol hexanicotinate (“no-flush niacin”) does not cause flushing but is not bioavailable and is ineffective in lowering lipids; should not be recommended. Lifestyle modification, including maintaining a healthy weight and exercise, should be recommended to all patients. Niacin is regulated as a dietary supplement OTC and may have varying levels of naicin; prescription formulations are available if indicated. Statins are first-line agents for the management of hypercholesterolemia.
Nicotine
Trade Name: Nicorette; Nicoderm CQ
Class: Smoking Cessation Aid
Self-Care indications: Tobacco cessation, gum, or lozenge; Tobacco cessation, patch
Self-Monitoring Parameters:
Cessation of smoking. Discontinue use and seek medical attention if chest pain or irregular heartbeat occurs.
Key Patient Counseling Points:
Encourage patients to quit by emphasizing that quitting smoking is one of the best things they can do for their health. Select a quit day and start patch 12 h prior or lozenges or gum on quit day. Do not chew or swallow lozenge; allow to slowly dissolve in mouth. Chew gum until tingle, then park between cheek and gum. When tingle subsides, chew again until tingle starts. Repeat for about 30 min. Apply patch to clean, dry hairless skin, and rotate site daily. If vivid dreams, may remove at bedtime. Do not cut patches or wear >1 at a time. Do not wear more than 24 h. Rash is common due to adhesive; may treat with OTC hydrocortisone. Avoid in patients with underlying eczema. Keep out of reach of children and pets; fold patch on itself before discarding; accidental ingestion may be fatal.
Clinical Pearls:
Behavioral therapy and pharmacologic interventions are first-line therapies for smoking cessation. All patients should be offered counseling (free nationwide quit line, 1-800-QUIT-NOW). First-line pharmacologic therapy for smokers includes nicotine replacement therapy, bupropion, or varenicline. Choice based on patient characteristics. Patches can be supplemented with lozenges and gum prn. Prescription-only oral and nasal inhaler formulations are also available for nicotine replacement therapy. Cigarette smoking produces combustion by-products that may induce CYP1A2; conversion to nicotine replacement may stop induction of drugs metabolized by that pathway, requiring dose reduction.
Orlistat
Trade Name: Alli
Class: Weight Loss
Self-Care indications: Obesity
Self-Care Monitoring Parameters:
Successful weight loss. Seek medical attention if signs of liver failure (eg, jaundice, dark urine, right upper quadrant pain, etc), or if other severe adverse effects occur.
Key Patient Counseling Points:
Advise patients that use of orlistat should be accompanied by lifestyle changes (improved diet, increase in exercise) to reach weight-loss goals. Patients should continue lifestyle changes even if discontinuing orlistat due to intolerance. Orlistat must be taken with low-fat diet to avoid significant GI adverse effects. Patients should take a multivitamin high in fat-soluble vitamins 2 h before or after dose of orlistat (eg, at bedtime).
Clinical Pearls:
Weight loss may increase the risk of cholelithiasis. Cases of severe liver failure (some requiring transplant or fatal) have been reported. May increase urinary oxalate and cause renal failure and/or nephrolithiasis. Patients with diabetes should be monitored closely and have medications adjusted as needed. As with all weight-loss products, risk of misuse (eg, in patients with anorexia nervosa or bulimia) should be considered. In clinical trials of orlistat with diet changes, actual weight loss has been minimal (only 2-5 kg). Essentially behavioral therapy, as without fat intake reduction, product results in incredibly unpleasant adverse effects. Also available in prescription form (Xenical) that contains 120 mg/capsule.
