Drug Quizz #4 OTC Flashcards
Ranitidine
Trade Name: Zantac
Class: Histamine H2 Antagonist
Self-Care Indication: Indigestion; Heartburn
Self-Monitoring Parameters:
Resolution of GI discomfort. Seek medical attention for severe blistering skin rash, chest pain, irregular heartbeat, or seizures.
Key Patient Counseling Points:
Avoid triggers, including alcohol, caffeine, and smoking. Avoid high-fat, acidic or spicy foods, and large meals. Maintain healthy weight and avoid tight-fitting clothes. Elevate the head by using blocks under bed legs or foam pillow wedge; do not stack traditional pillows. Take 30-60 min before meals or at bedtime with full glass of water. May take with antacids, if needed. Other PPI and H2-antagonists are available OTC; warn patients not to take multiple products concurrently to avoid additive risk of adverse effects. Cool mint formulation has no therapeutic effect on indigestion or heartburn.
Clinical Pearls:
All patients should attempt lifestyle modifications. Antacids are first-line therapy for moderate and infrequent heartburn. H2-antagonists are first-line therapy for moderate heartburn. Ranitidine is the H2-antagonist of choice in pregnancy with HCP. Ranitidine HCl 160 mg is equivalent to ranitidine 150 mg base. Trace contaminants in some ranitidine formulations reported in October 2019. Recalls of many products are ongoing.
Saccharomyces Boulardii
Trade Name: Florastor
Class: Probiotic
Self-Care indication: Diarrheal illness
Self-Monitoring Parameters:
Improvement in symptoms of abdominal discomfort and/or diarrhea. Probiotics are generally well tolerated after the first few days of therapy.
Key Patient Counseling Points:
Gas and bloating are common adverse effects at the start of treatment but generally diminish over several days of treatment. For antibiotic-associated diarrhea, start within 3 d of using antibiotics and continue for 3 d afterward. Product should be taken bid 2 h after an antibiotic dose to prevent loss of potency. Product should be stored in its original packaging at room temperature to prevent loss of potency; do not use if broken or unsealed. Capsules may be opened and sprinkled into drinks or onto food (eg, applesauce, yogurt, pudding). May be taken with or without food, but do not mix with carbonated, alcoholic, or hot beverages.
Clinical Pearls:
As a dietary supplement, no FDA oversight or review is required for this product. Nonpathogenic yeast use in immunocompromised patients has been linked to fungemia and should be avoided. Recommended often for antibiotic-associated diarrhea but has been studied for a wider range of GI disorders, including Crohn disease and ulcerative colitis. Pediatric formulation is available; however, it has the same strength and dosing as the adult formulation; the difference is flavoring (tutti-frutti).
Salicylic Acid
Trade Name: Oxy pads; Compound W
Class: Antiacne; Wart Remover
Self-Care indication: Acne vulgaris; Wart removal
Self-Monitoring Parameters:
Resolution of acne lesions and reduced redness of skin. If excessive dryness, irritation, or skin peeling occurs, discontinue use temporarily (until symptoms resolve) and restart applying smaller amounts less often, or consider using different salicylic acid product, a different formulation, a lower-concentration product, or select an alternative medication.
Key Patient Counseling Points:
Avoid sun exposure or use sunscreen. For acne, wash the affected area and/or shave 20 min before applying topical product to minimize irritation. Acne may worsen prior to improving as microcomedones are drawn to the surface of skin as treatment begins. If possible, eliminate mechanical causes of acne (contact with sports equipment such as headbands, chin straps, etc). Avoid cosmetics and other topical products that are comedogenic. Start treatment with lowest effective concentration possible and increase to maximum effect. Recommend nighttime administration and (if patient does not have oily skin type) daily moisturizer to reduce redness. For warts, may soak the affected area for 5 min before application. Apply amount sufficient to cover the affected area, let dry, and cover with a bandage or appropriate dressing. May leave on overnight. Use a debriding device such as a pumice stone to gently debride the affected area in the morning, then repeat treatment. Avoid contact with eyes; if exposed, flush with water for 15 min. May required 12 wk of treatment for full effectiveness.
Clinical Pearls:
Available in a wide range of OTC products with different excipients and inactive ingredients. If acne is not resolved with OTC products, various prescription antiacne products are available. Salicylic acid is also available in shampoo formulation for dandruff. Case reports of severe adverse effects from the topical agent including death have been reported when applied to broken skin.
Saline Nasal
Trade Name: Ayr; Ocean
Class: Sodium Salt
Self-Care indication: Nasal Congestion
Self-Monitoring Parameters:
Relief from dry nasal passages or nasal congestion. Seek medical attention if no improvement in 7 d.
Key Patient Counseling Points:
Blow nose prior to use. Do not share; can spread infection. Discard after cold episode. Rinse bottle tip with hot water and wipe with a clean towel after each administration. To use, squeeze bottle gently holding in desired direction. If the bottle is held upright, it will deliver a mist; if horizontal, a stream; and if upside down, a drop will be delivered. Put drops in each nostril and have the child remain on their back for 1-2 min. Available in gel formulation; may be used as often as needed with dry nostrils due to CPAP, dryness, or low humidity.
Clinical Pearls:
Nasal solution is not sterile. Do not use in the eyes or intravenously. There is a product named Afrin, which contains only saline. Read label to determine active ingredients and do not rely on recognition of brand name. Nasal saline should be considered first line in children <6 y of age for treatment of nasal congestion as systemic decongestants are not recommended.
Saw Palmetto
Trade Name: Serena repens; Serena serrulata
Class: Antiandrogen
Self-Care indication: Benign prostatic hyperplasia
Self-Care Monitoring Parameters:
Improvement in signs and symptoms of BPH (urinary urgency, frequency, incontinence, etc). Discontinue use and seek medical attention for any severe adverse effects.
Key Patient Counseling Points:
Stomach upset caused by saw palmetto may be reduced by taking it with food.
Clinical Pearls:
As a dietary supplement, no FDA oversight or review is required for this product. 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. While generally safe, a recent systematic review evaluating the results of 32 well-designed trials has shown that saw palmetto is no better than placebo at resolving urinary symptom scores, measures of urinary flow, or prostate size in patients with BPH. Saw palmetto is also less effective than finasteride in relieving chronic prostatitis and does not affect prostate-specific antigen (PSA) levels.
Simethicone
Trade Name: Gas-X; Mylicon
Class: Antiflatulent
Self-Care indication: Relief from gas
Self-Monitoring Parameters:
Reduction in frequency and severity of bloating sensation, flatulence, and abdominal pain after meals containing legumes, fruit, and other products containing nondigestible complex carbohydrates.
Key Patient Counseling Points:
Shake suspension before administration. Mix liquid formulations with as little other liquid (eg, water, infant formula, etc) as possible (eg, 30 mL) before administration. May be administered directly into the mouth without diluting in other liquids; administer toward the cheek to avoid infant spitting out dose. Take after meals. To reduce gas formation, avoid carbonated beverages and other gas-producing foods.
Clinical Pearls:
Often used postoperatively for abdominal procedures and for coalescing gas and reducing gas shadowing during colonoscopy, GI imaging, and ultrasonography. Can be used safely in newborns and infants for colic, although little evidence exists supporting its effectiveness in this indication. Simethicone does not reduce or prevent the formation of gas in the GI tract; rather, it hastens its exit from the GI tract.
Sodium Phosphate Enema
Trade Name: Fleet Enema
Class: Laxative
Self-Care indication: Laxative
Self-Monitoring Parameters:
Relief from constipation. 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) generally first-line management of constipation. Use care to administer the correct volume/formulation in younger children. Do not use >1 enema per day.
Clinical Pearls:
Saline laxatives can be considered in patients with GI obstruction if recommended by an HCP. Rectal enema generally produces bowel movement within 3-5 min of administration. Rectal formulations should be used no more often than once per day, and with caution in patients at risk for renal failure and electrolyte disturbances. The FDA has issued frequent warnings regarding the risks of oral sodium phosphate use as a laxative, citing severe dehydration, electrolyte disturbances leading to acute phosphate nephropathy and deaths. In 2008, Fleet Phospho-Soda was removed from the market, but several generic oral formulations are still available. Oral use should be strongly discouraged.
ST. JOHN’S WORT
Trade Name: Hypericum perforatum
Class: Antidepressant
Self-Care indication: Mild to moderate depression
Self-Care Monitoring Parameters:
Improvement in symptoms of depression. Discontinue use and seek medical attention for any severe adverse effects.
Key Patient Counseling Points:
Warn patients to discuss concurrent drug use before starting any new prescription or OTC product. May increase sensitivity to sunlight, use sunscreen, or avoid sun exposure.
Clinical Pearls:
As a dietary supplement, no FDA oversight or review is required for this product. 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. While systematic reviews have shown St. John’s wort to be superior to placebo and equivalent to TCAs and SSRIs for depression, other reviews have concluded that it is no more effective than placebo. Trials showing results similar to active pharmaceuticals are often small, unblinded, and not well conducted. Guidelines published by the American Psychiatric Association find insufficient evidence to support use of St. John’s wort for the treatment of depression. It has been studied for ADHD, IBS, and smoking cessation with poor evidence; St. John’s wort should not be used for these conditions. Given its uncertain efficacy, the risk of serious interactions with a large number of prescription drugs, the value of St. John’s wort is questionable.
Senna
Trade Name: Ex-Lax; Senokot
Class: Laxative; Stimulant
Self-Care indication: Constipation
Self-Monitoring Parameters:
Relief from constipation. 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. Often administered at bedtime (“dose in the PM for a BM in the AM”). Decrease dose after bowel movement and should not be used for chronic treatment.
Clinical Pearls:
Generally produces bowel movement within 6-24 h of oral administration. Formulations resembling chocolate pose poisoning risk and should be kept out of reach of the young children. Should not be taken with mineral oil. Available in combination with docusate (eg, Peri-Colace and generics). Senna leaf extract syrup is a dietary supplement that is not interchangeable on an mL-to-mL basis with other OTC senna products.
Terbinafine Topical
Trade Name: Lamisil At
Class: Antifungal
Self-Care indication: Skin fungal infections (athlete’s foot, ringworm of the body, jock itch)
Self-Care Monitoring Parameters:
Resolution of infection. 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 cruris or tinea corporis, or after 2 wk of treatment for tinea pedis, or if severe skin irritation or rash occurs.
Key Patient Counseling Points:
Wash with soap 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. Spray contains alcohol and is flammable. Recommend use of creams and solutions that may be rubbed into affected areas (vs sprays and powders, which are useful as adjuncts for prevention of infection). Location of athlete’s foot (tinea pedis) dictates treatment duration: 1 wk for between the toes only, 2 wk for bottom or sides of foot. Use product for full recommended course for full resolution of infection, and advise patients not to discontinue after itching or other symptoms resolve.
Clinical Pearls:
Oral terbinafine product is available by prescription. Ringworm typically occurs on smooth care skin and appears as a small red, round, scaly, and itchy lesions. Athlete’s foot is usually between the toes and is either white and macerated or red and scaly. Jock itch occurs in groin area and is typically well demarcated, not diffuse. Topical antifungals, including terbinafine, are the treatment of choice. 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. Not formulated for vaginal candidiasis; select an alternative antifungal.
Tetrahydrozoline Ophthalmic
Trade Name: Visine
Class: Alpha-adrenergic Agonist; Ophthalmic Decongestant
Self-Care indication: Redness of the eye due to minor irritation
Self-Monitoring Parameters:
Improvement in redness symptoms. Seek medical attention if changes in vision, eye pain, symptoms not improved after 3 d, or 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 and replace cap after use.
Clinical Pearls:
Accidental ingestion by children <6 y of age can result in coma, bradycardia, respiratory depression, sedation and death. Seek emergency medical attention if accidental ingestions occur, and keep out of the reach of children and pets. A number of products named Visine are available, with different active ingredients and in combination. Check packaging to determine active agent. May cause pupils to dilate temporarily after use. Assess indication for use (allergic conjunctivitis, infection, etc) as product does not address underlying causes of redness. Using more than qid or beyond 3 consecutive d can result in rebound congestion (increased eye redness).
Tolnaftate
Trade Name: Tinactin
Class: Antifungal
Self-Care indication: Skin fungal infection (jock itch, ringworm of the body, athlete’s foot).
Self-Care Monitoring Parameters:
Resolution of infection. Improvement in erythema and pruritus usually occurs within 3-5 d. Seek medical attention if no improvement is seen after 2 wk or if severe skin irritation or rash exists.
Key Patient Counseling Points:
Wash with soap and dry area before applying. Keep skin clean and dry during treatment and avoid sharing personal items that may come into contact with the infected area. 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. Spray contains alcohol and is flammable. Recommend use of creams and solutions that may be rubbed into affected areas (vs sprays and powders, which are useful as adjuncts for prevention of infection). Adherence is important to eradicate infection; use product for full recommended course, and advise patients not to discontinue after itching or other symptoms resolve.
Clinical Pearls:
Ringworm typically occurs on smooth care skin and appears as a small red, round, scaly, and itchy lesions. Topical antifungals are the treatment of choice. Athlete’s foot is usually between the toes and is either white and macerated or red and scaly. Fissures may also be present. If white, soggy, and has fissures, aluminum chloride 20% is recommended first line to reduce sweating; use topical antifungal after fissures have healed. Jock itch occurs in groin area and is typically well demarcated, not diffuse. Topical antifungals are the treatment of choice. Tolnaftate should be considered second line as time to effect is longer compared to other antifungals.
Triamcinolone Nasal
Trade Name: Nasacort Allergy 24HR
Class: Nasal corticosteroid
Self-Care indication: Perennial or Seasonal allergic rhinitis
Self-Monitoring Parameters:
Improvement in nasal rhinitis symptoms. Seek medical attention for signs of severe fatigue, fast or irregular heartbeat, rash, or shortness of breath. While only small amounts of triamcinolone reach systemic circulation, bone mineral density and growth and rate of development in children should be monitored. Routine ophthalmologic examinations should be performed. Monitor for signs and symptoms of adrenal suppression and infection.
Key Patient Counseling Points:
Avoid allergic triggers. Children ≤12 y of age should be supervised by an adult. For administration, bottle must be primed and shaken well prior to first use or if it has not been used in >14 d; avoid spraying in face. Patients should clear nasal passages by blowing nose prior to use. Press against outside of 1 nostril to close off. Employ the “nose to the toes” technique of tilting the head slightly downward to avoid overspray into the esophagus while inhaling to avoid bad taste. Aiming the spray away from the nasal septum toward the ears slightly inserted into the nostril can help minimize irritation and nosebleeds. Medication may take 24-72 h to take full effect. Sniff gently as you pump the bottle. Do not blow nose for at least 15 min after use. Brief stinging or sneezing may occur immediately after use. Wipe nozzle with tissue and replace cap. Nozzle only can be cleaned with tap water if pump does not spray properly; follow included instructions. Should not be shared to treat multiple people to reduce spread of infection.
Clinical Pearls:
Injectable, oral inhalation, and topical dosage forms of triamcinolone are also available by prescription for treatment of other allergic disorders. While oral antihistamines (either OTC or prescription) remain the mainstay for treatment of rhinitis, nasal steroids are a recommended option if symptoms are severe, unresolved with oral antihistamines, or if oral antihistamines cause undesirable adverse effects. Do not use for common cold.
Undecylenic Acid
Trade Name: Fungi-Nail
Class: Antifungal
Self-Care Indication: Ringworm of the body and athlete’s foot
Self-Care Monitoring Parameters:
Resolution of infection. Improvement in erythema and pruritus usually occurs within 3-5 d. Seek medical attention if no improvement is seen after 4 wk or if severe skin irritation or rash.
Key Patient Counseling Points:
Wash with soap and dry area before applying. Keep skin clean and dry during treatment and avoid sharing personal items that may come into contact with the infected area. 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 and wear well-ventilated shoes. Use shower shoes in public showers. All topical skin infections are contagious; avoid skin-to-skin contact with infected area to prevent spread. Adherence to bid regimen required for maximum efficacy. Continue use for 2 wk after symptoms have resolved. May be used daily to prevent athlete’s foot.
Clinical Pearls:
A number of topical products marketed for application to toenails and fingernails for nail fungus (onychomycosis) are available. Less than 10% of patients experience clinical benefit with these agents even after 48 wk of use. This product treats only the area around the nail and does not penetrate the keratin of the nail, so use is not recommended. Oral antifungals are effective and preferred agents for the treatment of onychomycosis. This product is effective in treating ringworm of body and athlete’s foot.
Vitamin A and D topical
Trade Name: A + D Original
Class: Protectant
Self-Care Indication: Protectan
Self-Monitoring Parameters:
Maintenance of clear skin or resolution of irritated skin or rash. If irritation worsens and becomes severe, discontinue use.
Key Patient Counseling Points:
Clean the affected area before use and allow skin to dry. Advise patients to change wet or soiled diapers quickly to avoid diaper rash. Apply liberally and rub in gently after each diaper change, especially at bedtime or potential prolonged exposure, to promote healing if inflamed skin and protect healthy skin. For external use only. Avoid contact with eyes or mucous membranes. Do not use on animal bites, serious burns, or deep puncture wounds.
Clinical Pearls:
Available in a wide range of OTC products in combination with other active ingredients (eg, lanolin, petrolatum, etc) and with different excipients and inactive ingredients. Cod liver oil is a common source of vitamins A and D. May be used for protective effect again chafed, cracked, or wind-burned skin.
