Exam 2 Flashcards
Cold symptoms
Limited to upper respiratory tract
-Pharynx, nasopharynx, nose, and sinuses
Main cold season is Aug through early April
Cold risk factors
High population density such as shared workspaces
Respiratory allergies
Smoking
Sedentary lifestyle
Sleep deprivation
Getting Chilled –> common misconception
Cold symptom timeline
Day 1-3: sore throat first then nasal dominate days 2 & 3
-Red pharynx, nasal obstruction, mildly tender sinuses
-Nasal drainage: clear thing and watery
Days 4-5
-Cough in under 20% of people
-Secretions thicken and color may change to yellow/green
*Color due to myeloperoxidase
Day 6 and onward
Secretions return to clear as cold resolves
*Low grade fever possible especially in children
When to refer a patient for a cold
Oral temp greater than 100.4 F
Chest pain
Shortness of breath
Worsening of symptoms or new symptoms occur during self-care
Concurrent health conditions (asthma, COPD, CHF)
AIDs or chronic immunosuppressive therapy
Frail older adults of advanced age
Infants <3 months of age
Goals of therapy in Colds
Prevent transmission of cold viruses
Reduce bothersome symptoms
Treatment strategies
Nondrug therapies
Single entity OTC products to treat specific symptoms-because combo products because symptoms peak and resolve at different times no need to put chemicals in body if its not going to be helpful
Complementary and non pharmacologic options
Hydration: water, juice, broth, chicken soup (limited anti-inflammatory evidence), ice pop
Adequate rest
Nutritious diet: no evidence that withholding dairy decreases cough or congestion
Increased humidification:
-Humidifiers
-saline nasal spray or drops
-Saline gargles (1/4 - 1/2 tsp of table salt in 8 oz of warm water)
-Steamy showers
Aromatic oils: camphor, menthol, eucalyptus
Zinc and Vitamin C
Breathe right nasal strips: Temp relieve congestion
Antiviral disinfectant: helps prevent transmission
-hand hygiene
-body positioning
-nasal bulb syringe (can’t blow nose till age 4 and regularly clean bulb, soften mucous)
Zinc
-Method of action: Inhibits rhinovirus binding and replicating in the nasal mucosa thereby suppressing inflammation
-When administered within 24 hours of cold symptom onset, zinc reduces duration and severity
-Dosing: 1 lozenge (at least 13 mg/lozenge) every 2 hours while awake, initiate at first sign of cold
-Side effects: nausea, upset stomach, diarrhea, irritation of oral mucosa, distortion of taste, copper deficiency (high doses)
Vitamin C
Method of Action: antioxidant properties, stimulate neutrophil and monocyte activity
Efficacy for prophylaxis and treatment of colds has been debated for > 70 years
Preventative, high dose > 2 grams/day
(not helpful to prevent colds in general pop, except patients with severe physical stress)
Side effects: diarrhea, GI upset at 4 g/day or more
OTC treatment options
Congestion/rhinorrhea: saline nasal spray, decongestants, 1st gen antihistamine
Aches/pains: systemic analgesics
Pharyngitis: saline gargles or local anesthetic sprays/lozenges, systemic analgesics
Sleeplessness: nasal decongestant spray and 1st gen antihistamine or alcohol containing product
Follow up with Primary care provider if:
Sore throat longer than several days
Symptoms worse during OTC
Symptoms persist/worse, Fever greater than 101.5
Pseudoephedrine
Mechanism of action: alpha adrenergic agonists that constrict blood vessels, decreasing sinusoid vessel engorgement and mucosal edema or swelling
Indication: temporary relief of nasal and eustachian tube congestion and cough associated with post nasal drip
Pharmacodynamics: Immediate release
Onset- within 30 minutes
Duration- 4-6 hours
Side Effects: CV (elevated BP and HR, palpitations, arrythmias), CNS (tremor, insomnia, anxiety, irritability, dizziness, HA), other (rebound nasal congestion, nausea/anorexia, difficulty urinating)
Drug interactions: ergot derivatives, linezolid, MAOIs, SNRIs
Avoid: if taking MAOIs
Pseudoephedrine with Pregnanacy and Lactation
Generally ok for pregnancy in first trimester but it could possibly raise BP and cause digestive issues
In lactating women it can reduce the flow of milk
Pseudoephedrine on BP and HR
Effects on BP and HR infrequently clinically relevant
Only raise BP by 1 mmHg
Naphazoline, oxymetazoline, phenylephrine, propylhexedrine
MOA: alpha adrenergic agonists that constrict blood vessels, decreasing sinusoid vessel engorgement and mucosal edema or swelling
Indication: temporary relief of nasal and eustachian tube congestion and cough associated with post nasal drip
Pharmacodynamics:
onset - within a few minutes
duration - varies by agent between 4-12 hours
Side effects:
Rebound nasal congestion (limit to 3 days to avoid rhinitis) , nasal burning/stinging, nasal dryness
Drug interactions: Albuterol
Avoid: Getting spray in eyes
*Pregnancy: Ok to use Oxymetazoline poorly absorbed so preferred
*Lactation: Likely ok to use
Oxymetazoline (afrin)
Adults and children >= 12 years
NMT every 10-12 hours Max 2 doses/24 hours
Children 6 to <12 years
NMT every 10-12 hours Max 2 doses/24 hours
Propylhexedrine (Benzedrex)
Adults and children >= 12 years
2 inhalations each nostril NMT every 2 hours
Children 6 to < 12 years
2 inhalations each nostril NMT every 2 hours
Brompheniramine, chlorpheniramine, diphenhydramine
MOA: Blocks histaminic and muscarinic receptors in medulla
Indication: relieve runny nose and sneezing due to common cold
Pharmacodynamics:
Onset - 15 to 30 min
Duration - 4 to 6 hours
Side effects: Sedation, dry mouth/nose/throat, nausea, dizziness, difficult urination, constipation, blurred vision, cognitive problems, excitation
Drug interactions: duloxetine, alprazolam, MAOI, Parkinson’s medications
Avoid: Alcohol, driving or operating machinery
*Pregnancy: Avoid brompheniramine, caution with diphenhydramine, likely ok to use chlorpheniramine
*Lactation: Avoid brompheniramine, low doses as needed chlorpheniramine, Short term use of diphenhydramine is ok
Acetaminophen, ibuprofen, naproxen
Indication: relief of aches or fever or sore throat
Medications:
Acetaminophen-> 325 -1000mg every 4-6 hours PRN (max is 3250 mg/day)
Ibuprofen-> 200-400 mg every 4-6 hours PRN (max 1200 mg/24 hours)
Naproxen-> 220 mg every 8-12 hours PRN (may take 2 tab = 440 mg to start)
Avoid: aspirin in children younger than 18 due to Rye’s syndrome
Pregnancy: Acetaminophen preferred
Lactation: All 3 likely ok for short term use
Benzocaine, dyclonine HCL, phenol, menthol
MOA: local anesthetic effect to provide pain relief
Indication: temporary relief of sore throat
Pharmacodynamics
Onset->Within minutes
Duration–> 2-4 hours
Dosing-> every 2-4 hours
Side effects: altered taste sensation, nausea
Drug interactions: none
Avoid: if allergic to anesthetics
Pregnancy and lactation is likely ok to use
Colds and older adults
More sensitive to side effects of systemic decongestants
May exacerbate diseases sensitive to adrenergic stimulation
Ex: HTN, DM, CAD, BPH, glaucoma
Colds and young children
OTC cold products not recommended in young children (<6 years old)
-Recommend non drug therapies
-Avoid combo products
-Avoid use of siblings topic decongestant meds for younger children
Nondrug therapies for infants
-Upright positioning to enhance nasal drainage
-Maintain adequate fluid intake
-Increase humidity of inspired air
-Irrigate nose with saline drops
-Carefully clear nasal passageways with bulb syringe
Presenting symptoms
Description:
Productive
Wet and chesty
Effective -> easy to expel
Ineffective -> hard to expel
Nonproductive
Dry or hacking (viral, atypical bacteria, GERD, CV, some meds)
Classification:
acute-> viral URTI, bacterial sinusitis, pertussis, allergic rhinits, COPD, pnuemonia, environmental irritants
Subaccute: post infection, CHF/fluid
Chronic: asthma, GERD, COPD, chronic bronchitis
Common cough complications
Exhaustion, sleep deprivation, social discomfort, MSK pain, hoarseness, excessive perspiration, urinary incontinence
Appearance:
URTI –> clear
Bacterial –> purulent
When is a patient not a candidate for self-care?
Worsens after 3-5 days
Persists are 2-3 weeks
Children younger than 4 years old
Temp >=100.4 F
Temp >= 100 F for more than 3 days
Complementary and non-pharmacologic options
- Honey
- Nonmedicated lozenges/hard candies
-Stimulate saliva and decrease throat irritation - Humidification
-Increases inspired air moisture to soothe airways
-Vaporizer: humidifier with well/cup for volatile inhalants - Nasal drainage techniques
-Adults: variety of drainage systems but saline solution most notable
-Babies and young children: rubber bulb syringe; positioning via baby sleep in your arm, raise head of bed if little child - Hydration
-Promotes less viscous secretions; consider other health conditions
honey and cough
MOA: unknown maybe it increases salivation, soothes airway
Do not recommend honey use in children < 1 year due to risk for botulism
Cough frequency –> Cochrane review
Honey > placebo or no treatment
Honey = dexomethorphan
Honey > diphenhydramine
Dosing:
-2.5 to 5 ml in oral syringe or diluted in liquid (tea/juice)
-Can corn syrup by substituted? Yes
Saline for nasal irrigation
Water
-Warmed to body temp
-Distilled, sterile, or boiled (never TAP)
-1 to 2 cups or 8 to 16 oz
Salt
-1/4 to 1/2 tsp uniodized
-Non iodized
Baking soda
-Pinch
OTC treatment options for cough
1.Antitussives
Oral
-Codeine
-Dextromethorphan
-Diphenhydramine
Topical
-Camphor
-Menthol
2. Protussives (expectorants)
-Guaifenesin
3. No combination products
Follow up recommendations for cough
Follow up with primary care provider if:
-Symptoms worsen after treatment
-No improvement after 7 days
*Continue self care:
If cough improves but not gone within 7 days
Codeine
Schedule V narcotic
MOA: works centrally on the medulla to increase cough threshold
Indication: Suppression of NONPRODUCTIVE cough
Pharmacodynamics:
Onset–> 15-30 minutes
Duration–> 4-6 hours
Side effects: N/V, sedation, dizziness, constipation, respiratory depression; risk of addiction/abuse/misuse
Drug interactions: CNS depressants, alcohol
Avoid: codeine hypersensitvity (allergy, impaired respiratory reserve (people who have asthma or COPD)
*Avoid prolonged use during pregnancy (addiction issues to fetus)
*Avoid during lactation because of excretion into breast milk
Dextromethorphan
MOA: works centrally on the medulla to increase cough threshold
Indication: Suppression of NONPRODUCTIVE cough
Pharmacodynamics:
Onset-> 15-30 minutes
Duration-> 3-6 hours
Side effects: Slight drowsiness, N/V, stomach discomfort, constipation
Drug interactions:
-Strong CYP2D6 inhibitors
-SSRIs
-MAO inhibitors: Serotonergic syndrome (BP increase, Body temp increase)
Avoid: DM hypersensitivty, prior DM dependence, interacting drugs
*Pregnancy: no fetal risk in first trimester
*Lactation: no evidence its excreted through milk
Dextromethorphan, Robotripping
Abuse potential due to phencyclidine like euphoric effect
Abuse associated with psychosis and mania
S/Sx of intoxication:
-Tachycardia, HTN, vomiting,
-Hallucinations and zombie like walking, agitation, somnolence
Diphenhydramine
MOA: works centrally on the medulla to increase cough threshold
Indication: Suppression of NONPRODUCTIVE cough
Pharmacodynamics:
Onset: 15 minutes
Duration: 4-6 hours
Side effects: Drowsiness, disturbed coordination, respiratory depression, blurred vision, urinary retention, dry mouth, dry respiratory secretions
Drug interactions: CNS depressants and narcotics, alcohol, benzodiazepines, other tranquilizing agents
Avoid: hx hypersensitivity, medical conditions that can be exacerbated by anticholinergic effects such as people who have narrow angle glaucoma
*Pregnancy: no fetal risk, 3rd trimester caution
*Lactation: decrease flow of milk
Codeine dosing (less preferred option)
Adults >= 12 yrs
10-20 mg every 4-6 hours
*120 mg
Children 6 to < 12 yrs
5-10 mg every 4-6 hours
*60 mg
Dextromethorphan dosing
Adults/children >= 12 yrs
10-20 mg every 4 hours or 30 mg every 6-8 hours
*120 mg
Children 6 to < 12 yrs
5-10 mg every 4 hours or 15 mg every 6-8 hrs
*60 mg
Diphenhydramine dosing
Adults/children >= 12 yrs
25 mg every 4 hours
*150 mg
Children 6 to < 12 yrs
12.5 every 4 hours
*75 mg
Camphor and menthol
MOA: Inhaled vapors create local anesthetic sensation in sensory nerve endings in nose and mucosa for sense of improved air flow
Indication: Suppression of NONPRODUCTIVE cough
Pharmacodynamics unknown
Side effects: skin, nose or eye burning/irritation
Drug interactions: warfarin (possible with menthol –> decreased INR)
Avoid: using 1 hours before or 30 min after bath/shower; eye/nostril contact; heat/microwave; use with tight bandages; damaged skin
*Ok with lactation and pregnancy
Guaifenesin
*very limited data for efficacy so drink water instead
MOA: loosens and thins lower respiratory tract secretions
Indication: symptomatic relief of acute, ineffective productive cough
Pharmacodynamics: Not well understood
Onset: unknown
Duration: unknown
Side effect: nausea vomiting, dizziness, HA, rash, diarrhea, drowsiness, stomach pain
Drug interactions: none reported
Avoid: Guaifenesin hypersensitivity
*Pregnancy is ok to use
*Lactation it is not recommended for use
Guaifenesin dosing (as needed)
Adults and adolescents >= 12 years
200-400 mg every 4 hours as needed
Max: 2.4 g in 24 hours
Children 6 to < 12 years
100-200 mg every 4 hours as needed
Max: 1.2 g in 24 hours
Children 2 to < 6 years
50-100 mg every 4 hours as needed
Max: 600 mg in 24 hours
Product selection
little evidence that oral antitussives and expectorants are effective at treating acute cough
Large placebo response of 85%
Start with nondrug measures first
(water)
Cough and older adults
Golden rule: avoid cough meds
Diphenhydramine–> side effects more pronounced
Codeine and DM—> more susceptible to sedating effects
start at lower doses and titrate up
*cough is a symptom of many acute and chronic conditions
Administration guidelines for OTC Topical Antitussives (adults and children >= 2 years)
Ointments: Apply thick layer on throat and chest; repeat as needed up to 3 times daily, loosen clothing around throat and chest so vapors reach the nose and mouth
*Do not use in the nostrils, under the nose, by the mouth, on damaged skin or with tight bandages
Lozenges: Allow lozenge to slowly dissolve in mouth; repeat hourly or PRN
Inhalation: For products intended to be added to cold water for use in steam vaporizer–> add measured solution to cold water, place in vaporizer, breathe in vapors 3 times daily PRN
*For hot steam vaporizer–> same as above by no adding to cold water
Physical assessment of patient with cold symptoms
- Observe patient (look for signs of chronic conditions)
- Obtain vital signs
- Palpate sinuses and neck, observe for any pain/tenderness
- Visually examine throat for redness or exudates. Run strep test if strep throat suspected
- Auscultate chest to detect wheezing, crackles, and rapid or irregular heartbeat
Administration guidelines for Nasal dosage formulations
General instructions:
-Clear nasal passages before administering the product
-Wash your hands before and after use
-Gently depress the other side of the nose with finger to close off the non-receiving nostril
Administration for Nasal Sprays
Gently insert bottle tip into one nostril
-Keep head upright and sniff deeply while squeezing bottle, repeat with other nostril
Administration for nasal inhalers
-Warm the inhaler in hand just before use
-Gently insert the tip in one nostril
-Wipe the inhaler after each use, discard after 2-3 months
Do oral decongestants have a clinically significant effect on BP in patients with hypertension?
It is unclear
Pseudoephedrine causes an avg increase of 1.2 mmHg in systolic BP in patients with controlled hypertension
*However studies not adequately powered to provide evidence
Acute wounds
Usually from injury
Types:
Punctures: sharp objects pierces epidermis and lodges in dermis or deeper tissues
Abrasions: rubbing or friction injury to the epidermis may extend to upper layer
Lacerations: a cut in the skin
Burns: due to heat/chemical damage
*Can require up to a month to heal in otherwise healthy people
*Usually ok to self-treat if wounds do not extend below the dermis
Chronic wounds
anything other than acute wounds
*Older adult in nursing facility
Require triage and medical treatment
Beyond scope of this lecture
Exclusions to wound self care
-Deeper puncture wounds
+/- animal bites (Rabies and other bacteria)
-Gaping wounds that might need stitches
-Wounds showing fat/muscle/bone
-Wounds containing foreign material despite cleansing
-Severe pain or numbness
-Inability to move structures below wound
-New wounds in patients with bleeding disorders or diabetes (might need special treatment, slow healing)
-Chronic wounds
-Infected wound (swelling, redness, warmth, pus, red streaks radiating from wound
Minor wounds
Superficial - they happen to the outer layer of your skin, the epidermis
*not near the natural openings of your body
-Not heavy bleeders
-Small (size of a coin)
Stopping bleeding
What is the purpose of bleeding?
*Nature’s way of cleaning the wound
Which wounds bleed more?
*Head wounds (most high vascularize area of body)
Procedure
-Pressure
*Duration of pressure? Elevated above heart level steady pressure for 15 min
-Clean tissue/cloth/gauze
-Remove clothing/jewelry b/c wound may swell
*What if blood soaks through? Put another layer on
Wound cleansing
What (only use other methods when wound contaminated)
-Tap water with sufficient pressure (most suffice)
-Washcloth (around the wound)
-Soap
-Alcohol
Hydrogen Peroxide
-Iodine
*Wound only needs to be cleaned once
*clean around wound as needed
Antibiotic ointment
Purpose of antiseptics/antibiotics
-Prevent infection
Max amount of time to use: until wound is healed
Single/double/triple antibiotics
-Risk of allergic contact dermatitis from bacitracin
-Recommend single antibiotic because of antibiotic resistance
How to use
-Apply within 4 hours of injury
-Apply 1-3 times per day
How do you know if the wound is infected?
-Inflamed, thick/creamy drainage, red streaks, warm
*Avoid triple antibitoics
*Might have allergic reaction or neomycin hypersensitivity
Local Anesthetics and pain control
Use only if unbroken skin
Combination antibiotic and anesthetic products
Can use NSAID
Super adhesive polymer (MOA: seal off nerve endings, and reduce pain)
Alternatives: cold/ice pack (20 min on/off)
Wound dressing Primary
Primary
-Purpose
1. Light absorbency
2. Protection
3. Aesthetics
-How to apply?
1. Apply over wound
2. Secure with tape/gauze
-Types
1. Gauze
2. Nonadherent gauze type
Wound dressing secondary
-Purpose
1. Mod heavy absorbency
2. Compression
3. Enhanced protection
-How to apply?
1. Over primary dressing
-Who uses?
1. Not for self care
2. Surgical patients
Tape
4 types (plastic (least expensive), paper, cloth, waterproof (most expensive))
Residue removal: alcohol or nail polish
remover on a cotton ball
Allergy issues
-Worse: plain waterproof tape, plastic
-Better: fabric cloth, paper
Waterproof tape best for joints
Cloth is best for allergies
Liquid bandages
Cyanoacrylate polymers:
-Avoid with cream/ointment
-If cover with bandage : change bandage daily/apply loosely
-Protect from sun and tanning booth lotion
-Cautions:
*May sting
*Clean affected area and air dry for 15 min
*May stain surfaces
*Limit to 1 week of used
*Avoid infected or drainage wounds
How to apply and remove liquid bandage
- Apply and spray light amount over the area 1-3 x/day and let dry
- Second coating may be applied for extra protection
- If apply to knee/elbow/knuckle bend the joint during application and drying
- To remove, apply light coat and quickly wipe off
*if wound reopens take L bandage off
animal bite care-part 1
Wash with soap and water
Apply pressure if bleeding
Antibiotic ointment after bleeding stops
Cover with bandage/sterile gauze or telfa
Systemic analgesic, if desired
Animal Bite care part 2
Seek immediate medical care if:
-Animal
-Bite breaks skin
-Bite on face, head, neck, hand, foot, near joint
-Bite area infected
-Tetanus shot not updated
*call healthcare provider clinic anyways after acute wound is cleansed/dressed
Scab care
Purpose: protect wound from debris
*Leave them alone
Stitches care
Usually wash after 1-3 days (dry well)
If drains clear, yellowish fluid–> cover with primary dressing like Telfa pad
Elevate if possible for a few days
1. decrease pain
2. decrease swelling
3. enhance/speed of healing
Antibiotic ointment
-usually cover stitches
-reduces thickness of scab
-reduces scarring
Post-healing
-broad spectrum sunscreen (30-50 Spf) x 60 min
-can burn more easily cause of skin burn susceptibility
Plastic tape
Least expensive
Really strong adhesive (lots of residue)
Movable parts of the body
*no joints
Paper tape
2nd least expensive
Really weak adhesive
Little residue
Short term use
Cloth tape
In between paper and plastic tape in terms of adherence and residue
More preferrable for sensitivity
More expensive
Good for allergy
Waterproof tape
Really strong adherence
Leaves a lot of residue
Most likely to cause a skin reaction (allergy)
*no joints
*most sticky
Myalgia
Generalized muscle pain
Muscle cramp: prolonged muscle spasm causing pain
Symptoms:
-Dull, ongoing ache
-Weakness
-Muscle fatigue
-Worse with contraction of the muscle affected
Causes:
-Diffuse (general)
-Localized
Tendonitis
Inflammation of tendon: acute injury or overuse
Signs: erythema, swelling, warmth near joints
Symptoms:
-Mild to severe pain, usually after use
-Loss of range of motion
Causes:
-Trauma such as hyperextension injury
-Overexertion
-Drug induced
-Inflammatory diseases
Bursitis
Inflammation of bursa sack in joints
Signs:
Warmth
Swelling
Redness
Crepitus
Symptoms:
Constant pain that worsens with movement or application of external pressure over the joint
Causes:
Acute: trauma, sometimes infection
Chronic: excessive use
Sprains
Stretching or tearing of ligament
Characterized by grade
*Grade I = excessive stretching
*Grade II = partial tear
*Grade III = complete tear of tissue
Signs:
-Bruising
Symptoms:
-Initial severe pain; ongoing pain with joint use
-Joint instability and loss of function
Strain
Overextension of muscle or tendon
Signs
-Swelling, bruising
Symptoms
-Muscle weakness
-Some loss of function
Exclusions for self-care
Pain score more than 6 (0-10)
Pain longer than
-10 days total (know)
-7 days with treatment (Know)
with topical analgesic
Increased intensity or change in pain
Associated n/v, fever or infection
Visual deformity, abnormal movement, weakness, numbness, or possible fracture
OTC intolerances
Achille tendonitis
Pregnancy
<2 years of age (know)
Ice and heat
Nonpharmacologic option
ICE: as soon as possible following injury, 3-4 times daily x for up to 72 hours
HEAT: 15-20 minutes, 3-4 times daily (not within 48 hours of injury due to possible leakage and damage from vasodilation)(NONINFLAMMATORY CONDITIONS ONLY)
*Avoid use with other topical agents or with broken skin
RICE
Rest
*After injury & until pain decreases
Ice
*As soon as possible
*10-15, 3-4 times daily
Compression
*Elastic support/bandage
*Proper size
*Wrap distal to injury
*Overlap previous layer by 1/2-1/3
Elevate
*At or above heart 2-3 hours per day
Pharmacologic treatments
Systemic analgesics: acetaminophen, NSAIDS
Initial: scheduled doses
Over 1-3 days: decreasing dose and increasing interval
Max 10 days
Topical counterirritants
-Apply up to 3-4 times/day
-Max 7 days
Acetaminophen
Central (no anti inflammatory) inhibitor of prostaglandin synthesis
Metabolized in the liver
Onset of action: 30 minutes
Duration 4 hours (6-8 hours for extended release)
10-15 mg/kg every 4-6 hrs
3250 mg max dose daily
*No longer than 3 days for FEVER
Hepatotoxicity with doses > 4 grams/day
NSAIDS
Peripheral (anti inflammatory) COX inhibitors
and subsequent inhibition of prostaglandin synthesis
-Should be taken with food and full glass of water
Adverse effects:
GI ulceration
-Age > 60
-Prior ulcer
-Concurrent anticoagulant use
-Higher dose and duration
-Moderate high use of alcohol
*increase change of a MI or stroke, BP, edema
Oral OTC NSAID agents
Ibuprofen 200 mg tablets
-Dose: 200-800 mg QID, max OTC dose 1200 mg/day
Naproxen 220 mg
-Dose 220 mg BID, max dose 660 mg/day
Diclofenac gel 1%
Apply up to QID, NMT 2 spots on body
Upper Body-> apply 2 g or 2.25 in
Lower Body -> apply 4 g or 4.5 in
MDD = 32 g/day
~6% topical diclofenac absorbed systemically
-Avoid showering and bathing for an hour after application
-Avoid direct sunlight
Topical counterirritants
Relieve pain through nerve stimulation rather than depression
Four categories
-Rubefacients
-Cooling agents
-Vasodilation
-Irritants
Interactions
-Avoid combination of drugs with same MOA
-Combo with local anesthetics
-Combo with skin products
OTC counterirritants
Apply nmt TID-QID prn < 7 days (remember duration)
Rubefacients
*Ammonia water (1-2.5%)
*Methyl salicylate (10-60%)
Cooling Agents
*Camphor (3-11%)
*Menthol (1.25-16%)
Vasodilation
*Histamine Dihydrochloride
(0.025 - 0.1%)
*Methyl nicotinate
(0.25 - 1%)
Apply TID-QID for duration of pain
Irritant (take longer to see effects)
*Capsicum (0.025-0.25)
*Capsicum oleoresin (0.025-0.25)
*Capsaicin (0.025 - 0.25)
Methyl salicylate
MOA: Rubefacient
“hot”
-Vasodilation of cutaneous blood vessels
Central and peripheral inhibition
-Related to Aspirin through a category of salicylates
SE of Methyl Salicylate
Allergy
Blistering, erythema
Prevent skin problems:
-Avoid occlusive dressings
-Avoid concomitant heating pad use
-Avoid in children, asthma, nasal polyps
-Do not use on open wounds
-Lower concentrations
-Combination products ok but avoid dual
Camphor
MOA: Cooling sensation
Concentrations > 3%
-Stimulates skin nerve endings to mask deeper pain
Menthol
MOA: Cooling sensation
Concentrations > 1.25%
Cooling sensation distracts from pain sensation
*Safer
SE:
Can sensitize some people
-Stop using if rash, irritation, swelling, etc.
SE Camphor
High doses can cause nausea, vomiting –> convulsions death
Infant nostrils –> respiratory collapse
Histamine Hydrochloride
Vasodilation mediated by prostaglandin biosynthesis
Other effects:
Reduces reactive oxygen species
Suppresses pro inflammatory
Increases blood flow
-Usually in combo with other counterirritants
Capsaicin
Wash hands really well after use
MOA: Indirect vasodilation causes feelings of warmth
*Isolated from hot peppers
Depletes substance P
Use regularly
SE: Redness, burning, coughing
Avoid if allergic
Counterirritant interactions
NSAIDs (prostaglandin inhibitor) and histamine dihydrochloride
Avoid with same MOA and local anesthetic
Avoid combo with skin protectants (oppose counterirritants make less effective)
How to approach tendonitis
Onset is gradual and worsened by joint movement
-Prefer nondrug (stretching, rest, Ice (early), Heat (later-48 hours and on))
-Use an NSAID cause of peripheral action
Topical anesthetic
Lidocaine
Max use 7 days
Apple every 6 hours NMT 3 times per day
Apply only to intact skin
Found in unexpected brand name prod:
-4% lidocaine and 1% menthol (cooling)
-4% lidocaine topical (warming)
How to approach bursitis
Onset is acute and worsened by joint movement
Non-drug measures
*Rest
*Immobilization
OTC
*NSAIDs, counterirritants, topical analgesics
How to approach sprains and strains
Acute at time of injury
Nondrug measures:
RICE
Stretching
Protection
OTC:
Systemic analgesics and Topical counterirritants
How to approach shin splints
Pain is from knee to ankle
Affects runners, walkers and anyone who overuses hard surfaces
Nondrug
RICE
Orthotic Shoes
Medical referral
Drug
Systemic analgesics
Patient counseling
If they exceed 7 days have them see their PCP
Fever
Regulated rise in body temps maintained by hypothalamus is response to a pyrogen
‘
Morning > 98.9
Afternoon > 99.9
Rectal > 100.4
Oral > 99.7
Axillary > 99.3
Tympanic > 100
Temperature regulation
Temp controlled by thermoregulatory center in the anterior hypothalamus
-Older adults = lower body temps
Normal variation up to 1 degree
Febrile Seizures
Seizure with fever in infants / children without intracranial infection, metabolic disturbance, or a defined cause
No prophylaxis with antiepileptics
Antipyretics don’t reduce risk
Pyrogens
Exogenous - infectious
Endogenous - cytokines
Trigger elevation of PGE2 levels
Elevated PGE2
leads to vasoconstriction
Blood shunted away from periphery to internal organs
Treating fevers
Except in rare cases there is no benefit to allowing a fever to persist
*Always
Exclusion for self treatment of inflammation and fever
Patients with really high fevers
Severe symptoms
Complications (HIV, Cancer, COPD, etc.)
Fevers beyond 3 days
Fever treatment options
Nondrug
Rest
Drink Water
No baths!
Maintain comfortable temps
Drug
Use acetaminophen (central action)
No corticosteroids
Can use NSAIDS too or both
Ibuprofen
5-10 mg per kg every 6-8 hours
Peripheral action (so good for inflammation + fever)
Max is 1200 mg/day
100mg / 5 mL in Children
50mg/1.25 mL in infants
Naproxen
Only available in tablets
220 mg every 8-12 hours, do not exceed 660 mg daily
Wakefullness
Block histamine with Anti-histamine to promote sleep
Sleep
Block adenosine with caffeine which promotes wakefulness
Sleep stages
Non-REM - 75% of sleep
REM sleep - 25% of sleep
Insomnia
Difficulty initiating/maintaining sleep
Daytime consequences (irritability, anxiety, etc.)
*Occurs in the absence of other underlying sleep disorder or problem
Ex: Sleep Apnea
Causes of sleep impairment
Most insomnia patients have a psychiatric disorder
(40%)
Medical
Drug induced
Environmental
Social
Some diseases that cause insomnia
BPH –> have to pee all the time
Chronic Pain
GERD –> Acid reflux
Anxiety
Respiratory diseases –> Trouble breathing
Non-Pharmacologic Therapy for Insomnia
Maintain good sleep hygiene
-Wake up at the same time
-Exercise a lot (not before bed)
-Comfortable sleep environment
*Dark, quiet, free of intrusions (television)
-Stimulus control
*only go to bed when sleepy
-CBT (go to a therapist)
Pharmacotherapy for insomnia
Indicated for short term insomnia and for difficulty initiating sleep
*not for chronic insomnia
*Max duration is 2 weeks but really 4-7 days because of body getting used to drowsy effects
What OTC and supplements to not use for insomnia
-Diphenhydramine
-Melatonin
-L-Tryptophan
-Valerian
Exclusions to self-treatment
*Refer if not responding to treatment after 2 weeks
< 12 years of age (kids)
> 65 years of age (older adults)
Pregnant or breastfeeding
Chronic insomnia
Significant sleep disorder
Diphenhydramine (Insomnia)
Two forms
38 mg citrate = 25 mg of HCL
-“safe and effective”
-Antihistaminic and Anticholinergic effects
anticholinergic side effects
Brain: drowsiness, dizziness, confusion, hallucinations
Heart: tachycardia
Bladder: Urine retention
Skin: Skin flushing, overheating
Bowel: Constipation
Mouth: Dry mouth
Eyes: Blurred vision, dry eyes
Diphenhydramine
MOA: H1 and M1 blocking mechanism
Produces sedation and anticholinergic effects
Metabolized in liver
Clear drug less quickly as older
Build up tolerance after 4-7 days
Diphenhydramine precautions
Do not use longer than 14 nights
Avoid alcohol and other CNS depressants
Diphenhydramine adverse effects
Sedation hangover
Impaired daytime function, confusion
Anticholinergic effects
Avoid in late pregnancy, lactation, and elderly adults
Doxylamine
Not as useful as diphenhydramine
Melatonin
Secreted by pineal gland during darkness
*not a sedative
Useful for treatment of circadian rhythm disorders
Not that useful in treating insomnia / no effect on sleep latency in people with primary insomnia
Caution in patients with renal and/or hepatic impairment
melatonin interactions
Warfarin - increased risk of bleeding
Nifedipine - increased BP
Fluvoxamine - increased CNS depression
Corticosteroids - reduced efficacy of steroids
Valerian
Valerian root contains all 3 components
-Increases release of GABA
-Can dose in a tea, tincture, extract (all oral)
*May improve sleep quality but the studies are poor
Valerian root drug interactions
Barbiturates
Benzodiazepines
Ethanol
Opioid Analgesics
Other agents used to treat insomnia
Kava - do not use (hepatoxicity)
L-Tryptophan - Eosinophilic Myalgia Syndrome
Passionflower, Chamomile, Lavendar, GABA - NO EVIDENCE
CBD doesn’t work either compared to placebo
Alcohol
Decreases sleep latency at first but then disrupts sleep cycle with glutamine rebound
*Never a sleep aid!
Fatigue vs sleepiness
Central fatigue: Described as “mental exhaustion” with impaired concentration or thinking ability
Physical Fatigue: Fatigue from physical effort
Sleepiness: A person feels the urge to sleep in the absence of fatigue
Fatigue
Doesn’t respond to caffeine well
Sleepiness
Nondrug: Better sleep hygiene
OTC:
Caffeine, Taurine, and Guarana
Fatigue/Sleepiness exclusions to self treatment
< 12 yr old
Taking meds
Chronic fatigue
Women who are pregnant or breastfeeding
Heart Disease or High BP
Anxiety
Caffeine
MOA: Antagonizes adenosine receptors
Half life is 4-5 hours
Metabolized by liver
Well absorbed orally
*partial tolerance 4-5 days
Adverse effects:
Insomnia, caffeinism, tremor/muscle twitching, tachycardia
Caffeine precautions
Can have dependence and withdrawal symptoms
Minimize use in pregnancy
Osteoporosis - decreases reabsorption of calcium
No children < 12 yr
Alertness inhalers
Smelling salts
*Do not use these!
Adverse events: shortness of breath, seizures, migraines, vomiting, diarrhea, fainting
