OTC Flashcards
What is the CKS definition of constipation?
Passing stool less than 3 times a week
What is the referral criteria for constipation?
- Blood in stools
- black terry and mixed in stool: upper GI bleed?
- bright red blood: anal fissure/ haemorrhoids - Unexplained weight loss of appetite loss
- colorectal cancer? - Patients over 40 with a sudden change in bowel habit
- Medication ADR
- Constipation, lethargy, weight gain, hair-thinning, dry skin
- signs of hypothyroidism - Stimulant laxative abuse
- overuse = lazy bowel - Obstruction - abdominal distension, vomiting and colic pain
- Constipation >2 weeks
Which classes of medication can cause constipation?
Opioids
Iron
TCAs
Antimuscarinics
Diuretics
Aluminium antacids
Verapamil
Antihistamines
What is 1st line for constipation and what are their age limits?
Bulk-forming laxatives:
- ispaghula husk e.g. fybogel 6+
- sterculia e.g. normacol 6+
- methylcellulose
Works by increasing faecal mass
How long does it take for bulk-forming laxatives to work and what are the side effects of it?
2-3 days
SE: oesphageal or intestinal obstruction
abdominal distension and flatulence
What counselling is given with bulk-forming laxatives?
Swallow with water
Do not take immediately before bed
Maintain adequate fluid intake
What are the examples of osmotic laxatives and their age restrictions?
Ideal for hard stools - they increase water in colon
Macrogol e.g. laxido
Lactulose - 3+
Magnesium sulphate e.g. epsom salts - 12+
How long does it take for osmotic laxatives to work?
2-3 days
48 hours for lactulose
What are the side effects of osmotic laxatives?
Discomfort
Flatulence
Cramps
What type of constipation are stimulant laxatives suitable for?
Soft stool that is hard to pass
What is the maximum usage of stimulant laxatives?
1 week
What are examples of stimulant laxatives and their age restrictions?
Senna - 12+ (colours urine brown)
Bisacodyl e.g. dulcolax 10+
Sodium picosulfate - 10+
Docusate sodium 18+ (stool softener too)
Glycerin suppositories - 4g for adults, 2g for children under 12, 1g for infants
What are the side effects of stimulant laxatives?
Abdominal cramps
Excessive use: hypokalaemia, diarrhoea, lazy bowel
What counselling should be provided for stimulant laxatives?
- Take at night to go in the morning
- Senna colours urine yellow-brown
How do you treat constipation in pregnant women?
1st line: bulk-forming or lactulose
AVOID STIMULANT
How do you treat constipation in elderly?
Take caution recommending bulk-forming laxatives - risk of gut obstruction and difficult to increase fluid intake
How do you treat constipation in children?
1st line: lactulose
How do you treat opioid-induced constipation?
Lactulose + stimulant laxative
AVOID bulk-forming - can cause obstruction
What is the referral criteria for diarrhoea
- babies under 3 months
- children under 1, diabetic patients or elderly patients if they have had diarrhoea for >1 day
- children under 3 who have had diarrhoea for >3 days
- if the patient has signs of dehydration e.g. dry skin/reduced turgor, sunken eyes, dry tongue, drowsiness/light-headedness, less/ dark urine, sunken fontanelle
- blood or mucus in the stool
- gastric bleeding, bowel cancer, IBD? - long-standing change in bowel habit in those >50 and weight loss
- colorectal cancer? - suspected faecal impaction in elderly
- poorly formed stools still difficult to pass? - severe vomiting, high-grade fever
- recent travel abroad
- chronic diarrhoea >3 days
What medication can cause diarrhoea?
Magnesium antacids
NSAIDs
Iron (laxating or constipating)
Laxatives - overuse
Antibiotics
Digoxin
PPIs
Diuretics
SSRIs
How is diarrhoea treated?
1st line: ORT - all ages
- 1-2 sachets after each loose stool motion
2nd line: loperamide (12+)
- 2 capsules after each loose motion (max. 8 a day)
- not recommended in pregnancy or breast-feeding
Bismuth salicylate - 16+
- can also be used for dyspepsia and vomiting
- avoid in aspirin hypersensitivity
- causes black stools and tongue
How do you reconstitute ORT?
1 sachet in 200ml water (no fizzy drinks fruit juices)
- must use boiled and cooled water for babies <1 years
- must be reconstituted immediately before use but can be stored in the fridge for 24 hours
What lifestyle advice should be given for babies with diarrhoea?
Dilute formula to 1/4 of regular strength
- build back up to normal over 3 days
- diarrhoea causes temporary lactose intolerance
- feed more frequently than normal and supplement with ORT
What are the characteristics of GORD?
Burning sensation behind breast-bone and bitter acid taste
What are the symptoms of dyspepsia?
- Vague abdominal pain over the bellybutton
- bloating, belching and flatulence
- fullness
- N/V
- heartburn
What is the referral criteria for dyspepsia?
Anaemia (iron deficiency)
Loss of weight
Anorexia
Recently changes or new dyspepsia in >55
Malaena, haemostasis, persistent vomiting, dysphagia
- Peptic ulcers
- Cardiovascular problems
- pain radiating to the jaw, back and arms
- pain precipitated by exercise and not relieved by antacids - symptomatic treatment after 4 or more weeks
- previous gastric ulcer or GI surgery
- children
- regurgitation
7, jaundice or severe liver disease
How do you rule out peptic ulcer?
You must rule out peptic ulcer before treating:
- persistent gnawing, boring pain from one point of the abdomen indicates peptic ulcer
Gastric ulcer:
- pain aggravated by food, usually 30 minutes after a meal
Duodenal ulcer:
- pain when stomach empty
- pain 2-3 hours after eating
- awakening at night
When would you refuse a PPI or H2RA for dyspepsia?
Due endoscopy or C-urea test in 14 days because it can result in a false negative
What salt in antacids is constipating?
Aluminium
What salt in antacids is laxating?
Magnesium
What drugs do antacids impair the absorption of?
Do not take at the same time - leave 2 hour gap
- tetracyclines
- quinolones
- bisphosphonates
Avoid giving with enteric coated medication as can alter the pH of the stomach acid
What drugs and conditions should you avoid with antacids due to the high sodium content?
Hypertension
Heart, kidney or liver failure
Avoid in sodium-restricted diets e.g. lithium or CHD
Low sodium preparations = mucogel and maalox
What is the MOA, onset of action of and duration of action of H2RA?
MOA: acid suppressor
Onset of action: 1 hour
Duration of action: 9 hours
What is the age restrictions and maximum usage for H2RA?
E.g. ranitidine 16+
- maximum use 14 days
How do you take ranitidine?
1 x 75mg tablet when symptoms occur
- if symptoms persist for more than one hour or return = take another tablet
- maximum of 4 tablets in 24 hours
What are the side effects of H2RA?
Headaches
Rashes
Dizziness
Diarrhoea
Masks symptoms of gastric cancer
NOT recommended in pregnancy and breastfeeding
Provide some information about OTC PPIs
Onset 1-3 days
Lasts 24 hours
Omeprazole 20mg (boots acid reflux)
Esomeprazole 20mg (nexium)
Pantoprazole 20mg (pantoloc control)
Age: 18+
Max supply: 14 days
Not recommended in pregnancy and breast-feeding
What is the referral for PPIs?
> 2 weeks OTC failure
4 weeks continuous use
What are the side effects of PPIs?
Abdominal pain
N/V
Diarrhoea
Flatulence
Masks symptoms of gastric cancer
What drugs does omeprazole interact with?
Omeprazole is an enzyme inhibitor so:
- warfarin = enhances anticoagulation
- phenytoin = toxicity
- clopidogrel = reduced antiplatelet effect
What are the symptoms of IBS?
Lower abdominal spasms
Bloating
Alternating between constipation or diarrhoea
Aggravated by stress, depression and anxiety and lack of dietary fibre
- commonly affects young adult women
What is the referral criteria for IBS?
- children
- > 45 first time symptoms
- blood in stools
- bowel obstruction
- unexplained weight/ appetite loss
- fever, N/V, severe abdominal pain
- pregnant women
- suspected depression
How do antispasmodics work and what are their age restrictions?
Relaxes guts smooth muscles to reduce abdominal spasms
Mebeverine - 18+ (colofac IBS)
Alverine - 12+ (spasmonal)
Peppermint oil - 15+ (Colpermin)
Common SE of peppermint oil - heartburn
How do antimuscarinics work and what are their age restrictions?
Anticholinergic effect relaxes smooth gut muscle
Hyoscine - 12+ (buscopan)
Dicycloverine - 12+
What do antimuscarinics interact with?
Additive anticholinergic effect:
- Antihistamines
- TCAs
- Antipsychotics
Avoid in glaucoma and prostatic enlargement
How is constipation in IBS treated?
Bulk-forming laxatives
How is diarrhoea treated in IBS?
Loperamide 18+
- previously diagnosed IBS
What BMI must a patient have before they can have OTC orlistat?
BMI equal to or more than 28kg/m2
What drugs are contraindicated with orlistat?
- Levothyroxine: reduced control of hypothyroidism
- Amiodarone: decreased plasma levels
- Ciclosporin: decreased plasma levels
- Warfarin + NOACs: INR affected by low vitamin K
- Acarbose
- Antiepileptics: increased risk of convulsions
What vitamins does orlistat impact?
The absorption of fat-soluble vitamin ADEK - take vitamins at night or 2 hours after orlistat
What are the restrictions for orlistat, how do you take it and what are the side effects?
18+
maximum treatment: 6 months - in conjunction with hypocaloric lower-fat diet
MOA: potent lipase inhibitor - prevents absorption of dietary fat
How to take:
60mg capsule TDS before 3 main meals or up to 1 hour after
- omit dose if missed meal or meal did not contain fat
SE: oily stools and faecal incontinence
What are the symptoms of haemorrhoids?
Swollen veins
- protrudes into anal canal
- prolapses outside anus
Dull pain on defecation or sitting
Slight rectal bleeding - bright red blood
Perianal itching and burning
Swelling and soreness in perineum
What is the haemorrhoids referral criteria?
- Black, terry stools
- Abdominal pain, N/V, fever, malaise, loss of appetite
- Altered bowel habit
- Urge to defecate when stool not there
- Symptoms >3 weeks
- > 1 week OTC failure
- Constipating medication
What OTC products are available for haemorrhoids?
Soothing agents e.g. Anusol
- zinc oxide, benzyl benzoate, allatoin, peru balsam
Mild astringents e.g. preparation H
- bismuth, zinc oxide, witch hazel
Local anaesthetics 12+ e.g. germaloids
- lidocaine
Products with hydrocortisone 18+ e.g. anusol plus HC
- max 7 day use
- avoid in pregnancy and breastfeeding
(pregnancy increases risk of haemorrhoids)
What is the referral criteria for cold and flu?
- 2 weeks and no improvement
- Middle-ear pain not improving
- otitis media? - persistent chesty cough or high fever
- 3-6 month old = 24 hours
- 6+ month old = 72 hours
- fever = 38 degree and + in younger than 3 months
- fever = 39 degrees and + in 3-6 months - Vulnerable patients
- COPD, asthma, kidney disease, diabetes, immunocompromised, infants, elderly
What nasal decongestants are recommended in cold and flu?
Xylometazoline & oxymetazoline - maximum 7 day treatment
Phenylephrine & pseudoephedrine - maximum 720mg
What conditions should you avoid nasal decongestants in?
Hypertension
Diabetes
CVD
Hyperthyroidism
Glaucoma
Benign prostatic hyperplasia
What drugs do nasal decongestants interact with?
TCAs
MOAI
BB
What is the MHRA warning for pseudoepherdrine?
Posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome
- C/I: severe/uncontrolled hypertension, severe kidney disease, RF
- counselling: stop and report signs of sudden severe headache or thunderclap, N/V, confusion, seizures, visual
What is the age restriction for nasal decongestants?
6+
ages 6-12: for 5 days
- second line to best practice
- only 1 cough or cold remedy
What is the referral criteria for a cough?
- 3 weeks and no improvement
- medication ADR or OTC failure
- chest pain, wheezing and dyspnoea
- significant fever or malaise
- distressing cough in elderly or frail
- pain on inspiration
- whopping cough
- night time cough
- croup
- green, yellow or brown sputum
- blood in sputum
- pink and froth = HF?
- rust = cap?
- dark red = TB?
What is recommended for dry coughs?
Antitussive 6+
- dextromethorphan
What is recommended for chesty cough?
Expectorants 6+
- guaifenasin
- ipecacuanha
- squill
- ammonium chloride
What is the referral criteria for hayfever?
- Chest tightness
- wheezing
- SOB
4 cough - purulent conjunctivitis
- painful ear of sinuses
Which antihistamines are non-sedating and what are their age restrictions?
Cetirizine - 6+ OD (2+ for liquid)
Loratadine - 2+
Acrivastine (benadryl) - 12-65 years
Which antihistamines are sedating and what are their age restrictions?
Chlorphenamine (piriton) - 6+ (1+ for liquid)
Promethazine (phenergan) - 5+ (2+ for liquid)
In what conditions should you avoid antihistamines?
Bengin prostatic hyperplasia (urinary retention)
Glaucoma (raises intracrainal pressure)
Epilepsy (risk of seizures)
Which class of drugs is contraindicated with antihistamines?
MAOI - during treatment and up to 14 days after MAOI stopped
What anti-inflammatories are recommended in sore throat and what are their age restrictions?
Benzydamine (difflam oral rinse - 12+, spray - 6+)
Flurbiprofen (strefen lozenges - 12+)
- max use for 3 days
- every 3-6 hours
- max 5 lozenges per day
Gargling dispersible aspirin - 16+
What local anaesthetics are recommended for sore throat and what are their age restrcitions?
Lidocaine - 12+
Benzocaine - lozenges 3+
- throat spray 6+
Hexylresorcinol - strepsil extra triple action 6+
What is the referral criteria for insomnia?
- chronic insomnia >3 weeks
- suspected depression
- under 16
- medication ADR
- MAOI
- fluoxetine
- phenytoin
- corticosteroids
- theophylline
What can be used to treat insomnia OTC?
Diphenhydramine (nytol) - 16+
Promethazine HCI (sominex and phenergan) - 16+
What is the referral criteria for headaches/ migraines?
- unresponsive to analgesics in 1 day
- combined contraceptives and experiencing migraine
- recurring headache
- stiff neck
- children under 12
- severe headache >4 hours
- recent trauma/ injury
- increasing severity and frequency
- severe deep pain; worse when lying down
What is the symptom history for sumatriptan?
Refer if:
- 1st migraine attack in patients ages 50+
- 4 or more attacks in a month
- a headache for 24 hours or more
- migraine symptoms have changed
Which conditions should you avoid sumatriptan in?
Renal impairment
Liver impairment
CVD
Epilepsy
Which antiemetics are recommended for migraines?
Prochlorperazine - buccastem M
Buclizine - migraleve pink
What is the sumatriptan licensing?
Age: 18-65
For migraine with or without an aura
- previously tried simple analgesics
- established patter: 5 or more attacks a year
- previously diagnosed
How do you take sumatriptan?
one 50mg tablet asap after migraine onset
- do not take a 2nd dose for the same attack
- a second dose can be taken after 2 hours if migraine recurs
- max 2 tablets in 24 hours
What is the referral criteria for motion sickness?
Symptoms that continue after travelling
Taking other anticholinergic drugs
What are the age restrictions, and duration of action for motion sickness antimuscarinics?
For journey under 4 hours =
Hyoscine: lasts 6 hours
(take 30 mins before travel)
- kwells: 10+
- kwells kids: 4+
- joy-ride: 3+
For journey more than 24 hours =
Hyoscine: lasts 72 hours
(Take 5-6 hours before journey or evening before)
- scopoderm patches: 10+
What conditions is hyoscine contraindicated in?
Glaucoma
Prostatic enlargement
What antihistamines can be used for motion sickness?
Journey 4-8 hours:
- cinnarizine (sturgeron)
–> lasts 8 hours
–> take 2 hours before
- promethazine (phenergan)
–> lasts 6-8 hours
–> take night before
Which preparations are insecticides for head lice?
Physical insecticide - dimeticone (hedrin)
- isopropyl myristate and cyclomethicone solution (Full Marks Solution)
Chemical/ tradition insecticide - Malathion 0.5% aqueous liquid (Derbac-M) but resistance has been reported
What is recommended for treatment of head lice in pregnant women, breastfeeding women, young children aged 6 months to 2 years, and people with asthma or eczema?
wet combing or dimeticone 4% lotion (hedrin)
What is the referral criteria for scabies?
- Secondary bacterial infection caused by scratching
- Treatment failure
- unclear diagnosis
- Babies and children
What are the treatment options for scabies?
Permethrin cream (lyclear) - 2+
- adult application 30-60g
- leave on 8-12 hours before washing
Malathion (derbac) - 6 months +
- adult single application = 100ml
- leave on for 24 hours before washing
2 treatments 7 days apart
Apply to the entire body
Treat all close contacts at the same time
What is the referral criteria for threadworm?
- recent travel abroad
- secondary bacterial infection
- treatment failure
What is the treatment for threadworm?
Mebenazole (ovex) - 2+
- 100mg single dose
- repeat dose after 14 days to prevent reinfection
- treat all family
- contraindicated in pregnancy
- pregnant and young children: strict hygeine measures for 6 weeks
What is the maximum usage for OTC tamsulosin?
6 weeks (400mcg tablets)
- if patients symptoms have not resolved after 14 days = refer to the doctor
- initially supply 14 days worth, if improvement is seen = supply 28 days further
What ages is tamsulosin OTC licensed for?
45-75 years
How should sildenafil be taken?
One tablet 1 hour before sexual intercourse
- can be taken up to 4 hours before if required
- can take 30-60 mins to take effect
- fatty meals delay its absorption and hence effect
- grapefruit juice lead to higher levels of sildenafil
What is the referral criteria for a sore throat?
- > 1 week
- dysphagia
- hoarse voice >3 weeks
- extremely painful and no improvement within 24-48 hours
- medication ADRs:
- bone marrow suppress: carbimazole, methotrexate, clozapine, sulfasalazine - white puss red swollen tonsils
What are the side effects of stool softener laxatives?
e.g. liquid paraffin 3+ - no longer recommended due to harsh side effects
SE:
- anal seepage
- lipoid pneumonia
- malabsorption of fat-soluble vitamins ADEK
What is the onset of action for stimulant laxatives?
6-12 hours
Glycerin suppositories - 15-30 minutes
