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Phm Sci 438: OTC > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Cold symptoms

A

Limited to upper respiratory tract
-Pharynx, nasopharynx, nose, and sinuses
Main cold season is Aug through early April

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2
Q

Cold risk factors

A

High population density such as shared workspaces
Respiratory allergies
Smoking
Sedentary lifestyle
Sleep deprivation
Getting Chilled –> common misconception

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3
Q

Cold symptom timeline

A

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

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4
Q

When to refer a patient for a cold

A

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

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5
Q

Goals of therapy in Colds

A

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

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6
Q

Complementary and non pharmacologic options

A

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)

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6
Q

Zinc

A

-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)

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7
Q

Vitamin C

A

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

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8
Q

OTC treatment options

A

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

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9
Q

Pseudoephedrine

A

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

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10
Q

Pseudoephedrine with Pregnanacy and Lactation

A

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

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11
Q

Pseudoephedrine on BP and HR

A

Effects on BP and HR infrequently clinically relevant
Only raise BP by 1 mmHg

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12
Q

Naphazoline, oxymetazoline, phenylephrine, propylhexedrine

A

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

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13
Q

Oxymetazoline (afrin)

A

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

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14
Q

Propylhexedrine (Benzedrex)

A

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

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15
Q

Brompheniramine, chlorpheniramine, diphenhydramine

A

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

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16
Q

Acetaminophen, ibuprofen, naproxen

A

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

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17
Q

Benzocaine, dyclonine HCL, phenol, menthol

A

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

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18
Q

Colds and older adults

A

More sensitive to side effects of systemic decongestants
May exacerbate diseases sensitive to adrenergic stimulation
Ex: HTN, DM, CAD, BPH, glaucoma

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19
Q

Colds and young children

A

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

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20
Q

Nondrug therapies for infants

A

-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

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21
Q

Presenting symptoms

A

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

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22
Q

When is a patient not a candidate for self-care?

A

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

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23
Q

Complementary and non-pharmacologic options

A
  1. Honey
  2. Nonmedicated lozenges/hard candies
    -Stimulate saliva and decrease throat irritation
  3. Humidification
    -Increases inspired air moisture to soothe airways
    -Vaporizer: humidifier with well/cup for volatile inhalants
  4. 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
  5. Hydration
    -Promotes less viscous secretions; consider other health conditions
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24
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
25
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
26
OTC treatment options for cough
1.Antitussives Oral -Codeine -Dextromethorphan -Diphenhydramine Topical -Camphor -Menthol 2. Protussives (expectorants) -Guaifenesin 3. No combination products
27
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
28
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
29
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
30
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
31
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
32
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
33
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
34
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
35
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
36
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
37
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
38
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)
39
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
40
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
41
Physical assessment of patient with cold symptoms
1. Observe patient (look for signs of chronic conditions) 2. Obtain vital signs 3. Palpate sinuses and neck, observe for any pain/tenderness 4. Visually examine throat for redness or exudates. Run strep test if strep throat suspected 5. Auscultate chest to detect wheezing, crackles, and rapid or irregular heartbeat
42
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
43
Administration for Nasal Sprays
Gently insert bottle tip into one nostril -Keep head upright and sniff deeply while squeezing bottle, repeat with other nostril
44
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
45
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
46
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
47
Chronic wounds
anything other than acute wounds *Older adult in nursing facility Require triage and medical treatment Beyond scope of this lecture
48
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
49
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)
50
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
51
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
52
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
53
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)
54
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
55
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
56
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
57
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
58
How to apply and remove liquid bandage
1. Apply and spray light amount over the area 1-3 x/day and let dry 2. Second coating may be applied for extra protection 3. If apply to knee/elbow/knuckle bend the joint during application and drying 4. To remove, apply light coat and quickly wipe off *if wound reopens take L bandage off
59
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
60
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
61
Scab care
Purpose: protect wound from debris *Leave them alone
62
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
63
Plastic tape
Least expensive Really strong adhesive (lots of residue) Movable parts of the body *no joints
64
Paper tape
2nd least expensive Really weak adhesive Little residue Short term use
65
Cloth tape
In between paper and plastic tape in terms of adherence and residue More preferrable for sensitivity More expensive Good for allergy
66
Waterproof tape
Really strong adherence Leaves a lot of residue Most likely to cause a skin reaction (allergy) *no joints *most sticky
67
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
68
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
69
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
70
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
71
Strain
Overextension of muscle or tendon Signs -Swelling, bruising Symptoms -Muscle weakness -Some loss of function
72
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)
73
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
74
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
75
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
76
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
77
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
78
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
79
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
80
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
81
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)
82
Methyl salicylate
MOA: Rubefacient "hot" -Vasodilation of cutaneous blood vessels Central and peripheral inhibition -Related to Aspirin through a category of salicylates
83
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
84
Camphor
MOA: Cooling sensation Concentrations > 3% -Stimulates skin nerve endings to mask deeper pain
85
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.
86
SE Camphor
High doses can cause nausea, vomiting --> convulsions death Infant nostrils --> respiratory collapse
87
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
88
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
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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)
90
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
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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)
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How to approach bursitis
Onset is acute and worsened by joint movement Non-drug measures *Rest *Immobilization OTC *NSAIDs, counterirritants, topical analgesics
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How to approach sprains and strains
Acute at time of injury Nondrug measures: RICE Stretching Protection OTC: Systemic analgesics and Topical counterirritants
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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
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Patient counseling
If they exceed 7 days have them see their PCP
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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
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Temperature regulation
Temp controlled by thermoregulatory center in the anterior hypothalamus -Older adults = lower body temps Normal variation up to 1 degree
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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
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Pyrogens
Exogenous - infectious Endogenous - cytokines Trigger elevation of PGE2 levels
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Elevated PGE2
leads to vasoconstriction Blood shunted away from periphery to internal organs
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Treating fevers
Except in rare cases there is no benefit to allowing a fever to persist *Always
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Exclusion for self treatment of inflammation and fever
Patients with really high fevers Severe symptoms Complications (HIV, Cancer, COPD, etc.) Fevers beyond 3 days
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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
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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
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Naproxen
Only available in tablets 220 mg every 8-12 hours, do not exceed 660 mg daily
106
Wakefullness
Block histamine with Anti-histamine to promote sleep
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Sleep
Block adenosine with caffeine which promotes wakefulness
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Sleep stages
Non-REM - 75% of sleep REM sleep - 25% of sleep
109
Insomnia
Difficulty initiating/maintaining sleep Daytime consequences (irritability, anxiety, etc.) *Occurs in the absence of other underlying sleep disorder or problem Ex: Sleep Apnea
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Causes of sleep impairment
Most insomnia patients have a psychiatric disorder (40%) Medical Drug induced Environmental Social
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Some diseases that cause insomnia
BPH --> have to pee all the time Chronic Pain GERD --> Acid reflux Anxiety Respiratory diseases --> Trouble breathing
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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)
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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
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What OTC and supplements to not use for insomnia
-Diphenhydramine -Melatonin -L-Tryptophan -Valerian
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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
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Diphenhydramine (Insomnia)
Two forms 38 mg citrate = 25 mg of HCL -"safe and effective" -Antihistaminic and Anticholinergic effects
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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
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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
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Diphenhydramine precautions
Do not use longer than 14 nights Avoid alcohol and other CNS depressants
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Diphenhydramine adverse effects
Sedation hangover Impaired daytime function, confusion Anticholinergic effects Avoid in late pregnancy, lactation, and elderly adults
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Doxylamine
Not as useful as diphenhydramine
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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
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melatonin interactions
Warfarin - increased risk of bleeding Nifedipine - increased BP Fluvoxamine - increased CNS depression Corticosteroids - reduced efficacy of steroids
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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
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Valerian root drug interactions
Barbiturates Benzodiazepines Ethanol Opioid Analgesics
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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
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Alcohol
Decreases sleep latency at first but then disrupts sleep cycle with glutamine rebound *Never a sleep aid!
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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
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Fatigue
Doesn't respond to caffeine well
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Sleepiness
Nondrug: Better sleep hygiene OTC: Caffeine, Taurine, and Guarana
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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
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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
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Caffeine precautions
Can have dependence and withdrawal symptoms Minimize use in pregnancy Osteoporosis - decreases reabsorption of calcium No children < 12 yr
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Alertness inhalers
Smelling salts *Do not use these! Adverse events: shortness of breath, seizures, migraines, vomiting, diarrhea, fainting

Phm Sci 438: OTC (4 decks)

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