OTC Agents Flashcards
Antacid Medications
- three common ingredients
- when/how they should be used
- how they work
- specifics of magnesium and aluminum preparations
Antacid Medications
how they work = they are buffering agents; which change the pH in the lower esophagus, stomach and duodenal bulb to decrease aciditiy
Relief = within 5 minutes, last for 20/30 quick onset
Indications = for mild, infrequent heartburn pt. using these more than 2x a week or regularly for more thant 2 weeks should see a provider for workup
Agents: Ingredents
Calcium Carbonate
Magnesium
Aluminum
Sodium bicarbonate
magnesium and aluminum = liquid preparations which covera greater surface area
chloride will react with cations, hydrogen will react with anions
Side Effects of the following Antacid Medications
- calcium carbonate
- magnesium
- aluminum
- sodium bicarbonate
renal dosing consideration
adsorbition/chelation consideration
Calcium Carbonate
- Beltching and flatulence
Magnesium
- Diarrhea
Aluminum
- Constipation
Sodium Bicarbonate
- Fluid Retention (watch in fluid overload/edematous; CHF,tc.)
- flatuence and beltching
Renal Impairment
- watch all these in those with CrCL < 30 ml/min
Chelation Consideration
- can adsorb to other medications
- separate from ABX (tetracycline, azithro & florquinolones) by 2 hours
- separate from levothyroxine by 4 hours
- separate from fungal oral agents by 2 hours
Histamine Type 2 Receptor Antagonists Medications
- names (which to use over others)
- how do they work
- when are they used/onset
Histamine Type 2 Receptors Antagonists
- famotadine : preferred agent
- cimetidine (not used)
- rantidine (off market)
How they work
- they bind to H2 receptors on parietal cells within the stomach to decrease the activation (not entirely eliminate) of parietal cells in producing HCL
When they are used
- they are good for mild-moderate heartburn prophylatically before the heartburn occurs
- take 30-45 mins to work; last 8-10 hours
- good for nighttime symptoms
Histamine 2 Receptor Antagonists
Pearls (when to refer)
renal considerations
D-D interations
Pearls
- should not use more thant 2x daily
- if using them PRN; they will work less
- if they need this more than 2 weeks of use = refer to be worked up
Renal Considerations
- adjust dose in those with CrCL < 50
- adjust in older pt.
D-D interactions
- most with cimitidine : so just avoid the med all together
Proton Pump Inhibitors
- how long can they be taken before needing eval.
- how long to wait betweedn a d/c PPI and started OTC antacids
- which PPI’s are offered OTC
PPIs
- can be used for 14 days without a rx. before they need to be evaluated for underlying disease (can use like a trial of PPI to dx. ulcer or self treatement of acid reflux)
- must wait 4 months between the d/c of a PPI and using antacids
if pt. needs relief sooner than 4 months, theres something going on and they need to see a provider
PPIs offered OTC
- omeprazole
- esomeprazole
- lansoprozaole
PPIs (OTC)
- how do they work & when used
- onset and duration
OTC PPI
- omeprazole
- esomeprazole
- lansoprozole
How they Work
- they irreversibly bind to the proton pump within the stomach: thus completely supressing the gastric acid secretion
- they will only bind to actively secreting proton pumps, so need to take them 30-60 mins before a meal
Onset & Duration
- slow onset 2-3 hours
- peak effect 3-4 days of thearpy
cannt be crushed, they wont work
PPI ADRs
- short term side effects
- longer term side effects
- chronic use side effects
Drug interactions via CYP 2C19
Short Term
- diarrhea, constipation
- headaches
Long term
- osteoporosis & fracture risk increases
Chronic use
- increased infection risk CAP and C. diff
- malabsorbition!!! : VitB12, iron, calcium & Mg (because working in stomach)
acid rebound can occur if continued use for > 8 weeks
Drug Interactions
- watch with clopidogrel: its a prodrug, so these meds will prevent conversion of clopidogrel to its active form: especially omeprazole and esomeprazole
Alpha-galactosidase (Beano)
- when is it used
- how does it work
- what is the gold standard in this class of meds
- caution in…
Alpha-glactosidase
when is it used
- to reduce gas: prophylatic for foods which contain oligosaccharides (complex carbs)
How it works
- galactosidase is the enzyme needed to breakdown complex carbs
Gold Standard: is simethicone (a surfactant med which probably is gold standard)
lactose intolerace? give them lactase enzymes (lactaid)
do not use in….
- glactosemia pt.
- those with DM
Laxitives
MOA accoding to each medication
Psyllium
Docusate sodium
mineral oil
polyethylene glycol
senna
Milk of Mag.
Psyllum
- a bulk forming laxative: increaes the stool’s retention of water, thus increasing rate of transit
Docusate Sodium
- stool softener: mixes aqueous and fatty substances together in the intestinal tract
Mineral Oil
- coats/lubercates stool to prevent colonic absorbtion & slide through GI tract
PEG
- osmotic laxitivate : pulls water into the RECTUM, thus facilating the passing of stool
Senna & Biascodyl
- stimulant laxitive: increases peristalsis by local irritation of nerves to increase movement in the GI
Milk of Magnesia
- fastest clearance: saline: most potent lax
- like a bowel prep for colonoscopy
- not for chronic manamagement
Laxitives
onset of action
psyllium
docusate sodium
mineral oil
polyethylene glycol
senna
Psyllium
- 12-72 hours
- bulk forming
Docusate sodium
- 12-72 hours
- softener
Mineral Oil
- 6-8 hours
- lubricant
PEG
- 12-72 hours
- osmostic agent
Senna
- 6-10 hours
- stimulant
Loperamide: Treatment of Diarrhea
MOA
dosing considerations (max)
role in therapy/when is it used
Loperamide (Imodium A-D)
- anti-diarrhea agent
- MOA: works as a synthetic mu opioid agonist: which opiods decrease the intestinal motility & thus decrease the diarrheal symptoms –: allowing more absoroption of electrolytes and water
Dosing Considerations
-NO more than 8 mg/day
shouldnt use for more thatn 48hours
Role in Thearpy
- should be used first-line gold standard for acute diarrhea (think IBS-D or traveler’s diarreha with abx.)
- not for kids < 6
NEVER USED IN C. DIFF PTS!!!! :toxic megacolon risk
ADR
- constipation
Prevention of Traveler’s Diarrhea
- medication to use
- how it works
- other indiciations for this medication
- adverse reactions
Medication for prophylatic traveler’s diarrhea : Bismuth Subsalicylate (pepto-bismol)
MOA: reacts with HCL to form bismuth oxycholride and salyclyic acid
- the bismuth has antimicrobial effects (locally in GI)
- the salicylic acid has antisecretory (antinflammatory- systemic) effects
- in traveler’s diarrhea, the salcyliate activity here seems to prevent the effect from occuring if contaminated
Role in Therapy
- for prophlyatic traveler’s diarrhea
- heartburn
- upset stomach
- indigestion
- nausea
Guidelines
- NEVER FOR KIDS: salycliate!!! reye’s syndrome
- not for this with asprin allergy: salycilayte
- not for pregnant: salycilate
ADR
- black stool or darkening of the tongue : will resolve
Lactaid
used for those with lactose intolerant
helpful to take with dairy products: help decrase the osmotic diarrheal effect
Antihistamines: H1 antagonists
First generations
second generations
how they work & their differences
First Generations Oral Antihistamines
- more drowsy, cross BBB
- Diphenhydramine
- chlorpheniramine
- celmastine
Second Generations Oral Antihistamins
less drowsy, peripherally selective
- loradidine (claratin)
- desloradidine (clarinex)
- cetirizine (zyrtec)
- levocitirizine (xyzal)
- fexofenadine (allegra)
MOA
- H1 histamine antagonists: to help decrease histamine response of sneezing, rhinorrhea, itchy & eye symmptoms
- better for prevention that relief: aim to take before exposure
Adverse Effects of Oral Antihistamines
ranking in order of most sedating to least
Drowsy & performane impairment
- HA
- loss of appetite
- N/V
- epigastric distress
anticholenergic effects
- dry mouth
- urinary retention
- constipation
- CV effects
Ranking
Most sedation = diphenhydramine
cholrpheniramine
minimally = cetirizine, levocitirazine
least = fexofenidine, loratadine
some antihistmianes come in opthalmic forms – which
Opthalmic = only controllong the eye symptoms
- olopatadine
- azelastine
- ketofien
intranasal formualtions also avalible
Decongestants
medication
MOA
ADR
Medication: alpha adrenergic agonists
MOA
- work to vasoconstrict: decreasing the vessel enlargement and mucosal edema: allowing pt. to feel less congested
Meds
oral
- phenylephrine, pseudoephedrine
intranasal
- naphazoline, oxymetazoline (afrin), phenylephrine, terahydrdozline
ADR
ORAL AGENTS = systemic response of CNS stimulation (sympathomimemic) and CV stimulation
- increase BP, tachycardia, palpataions
- restlnessness, insomnia, anxiety, tremor
INTRANASLA = local reaction
- burning, itchy, dry nose
- RHINITIS MEDICAMENTOSA: rebound congestion due to use 3-5 days +
Intranasal Steroids
MOA
names
when are they used
ADR
Intranasal Steroids
MOA
- reduce inflammation by suppressing the immune resonse and edema with vasoconstriction and steroid effect locally
When to use
- best if used BEFORE the syptoms: example like before the season changes for allergies
- frorm allergy sx.; congestion, sneezing, runny nose, itchy watery eyes
- COUNCELING POINT: can take up to 7 days to get best response: wont work immediately
Names
- beclomethasone
- budesonide
- fluticasone (OTC)
- momentasone (OTC)
ADR
- sneezing, stinking HA andnose bleed
- no much systemic steroid impact as they are intranasal
Antitussive agents
medication name
MOA
ADE
caution use in
Antitussive: for the cough (NON PRODUCTIVE!!) just the dry cough - not the mucus
Medication: Dextamethoraphan (the DM of musinex or robotissin)
ADE
- drowsy, N/V, stomach upset and constipation
- if OD: can have hallucinations and euphoria: irritability and nervouness: risk of respiratory depression
- has an additive CNS depression response with others (alcohol)
DO NOT USE WITH
- MAOIs: serotonin syndrome
another option if codine, but not used/for sale in PA and has addictive properties - opioid but dextamethorophan = effectiveness
Antitussive agents
medication name
MOA
ADE
caution use in
Antitussive: for the cough (NON PRODUCTIVE!!) just the dry cough - not the mucus
Medication: Dextamethoraphan (the DM of musinex or robotissin)
ADE
- drowsy, N/V, stomach upset and constipation
- if OD: can have hallucinations and euphoria: irritability and nervouness: risk of respiratory depression
- has an additive CNS depression response with others (alcohol)
DO NOT USE WITH
- MAOIs: serotonin syndrome
another option if codine, but not used/for sale in PA and has addictive properties - opioid but dextamethorophan = effectiveness
Expectorant (protussive) agents
names
MOA
Expectorants: helps to break up the mucous
Names: guaifenesin (musinex)
- take with water!!! lots
Topical Antitussive agents
names
how they work
Topical Antitussive
- Camphor and menthol
- remember: camphor cannot be ingested: leathal (only topical)
WOrk
- they are a local anestheti cwhich helps improve sensation of airflow
creams, lotions
steam + cough drop = menthol
Nicotine Replacement Therapy
Products & Formualtion
release of nicotine in these v. in a cigarrette
NRT
Gums: Nicorette, Nicotine gum
Lozenge: nicorette & generic
Transdermal patch: NicoDerm or generic
Nasal Spray (Rx.): NIcotrol
Inhaled (Rx.): Nicotrol
Nicotine release
- immediate and hgihest release with a cig. (obv)
- but the issue is no replacement thearpy really comes CLOSE to this concentration even if they start acting quickly, they’re much less concentration
everything is first line in managemnet of nicotine replacement
Combination NRT
- long acting formulation (patch) + short acting (gum, inhaler, spray)
Buproprion SR + Nicotine Patch
NRT:
patients you need to be cautious with
Caution in…. CVD patients
- MI within 2 weeks
- serious arrythmias
- serious or worsening angina
Nicotine Replacing Gum
dosage 2 v 4 mg : who gets what
Nicotine Gum
- sugar free gum with buccal buffer to help in nicotine absorbtion
Time To First Cigarette (TTFC)
- if you smoke within 30 minutes of waking = give 4mg gum
- if you smoke more thant 30 minutes after waking = give 2 mg gum
then you taper down the dosage over 12 weeks - no more than 24 pieces in 24 hours
Counceling
- chew until peppery/tingly = then park it in the gum and let the nicotine absorb = then continue to chew
- dont eat/drink 15 minutes before gum
- some foods/drinks (coffee, wine, soda) decrease effectiveness
- chew too rapidly = get ightheaded, irritation and N/V = dont swallow the nicotine
SE
- sore mouth and jaw
- hiccups
- dyspepsia
- can stick to dental work!
Nicotine Lozenge
key pearls
2mg v 4mg
dosing pearls
Nicotine Lozenge
- delivers 25% more than the gum
- contains buffer to protect buccal too
Dosing
-2mg if you wait > 30 mins after waking for first cig.
- give 4 mg if you ahve firsti cig within 30 mins of waking
- taper dose over 12 weeks
- do not use more thatn 20 lozenges in 1 day
Couceling
- park the drop in the mouth and let is dissolve slowly
- dont chew/swallow it
- rotate to different areas
- dont eat/drink 15 mins. before use = decrease efficacy
SE
- nausea
- heartburn
- HA
- insomnia
Transdermal NIcotine Patch
- how it works and why
- strengths & who gets what strength
Patches
- nicontine is well absorbed across the skin- goes to the systemic circulation and bypasses first pass
- plasma concentrations are lower but fulctuant less
Strengths of Patches
- come in 7, 14 & 21 mg
- smoke < 10 per day = go 14 to 7 mg taper
- smoke > 10 per day = go 21, 14 to 7 taper
Nicotine Patch
- application techniques
Application
- cannot cut it! or smoke with it on!
- clean, dry, hairless non irritated skin
- roate application sites = cant apply for 1 week then can put on same spot
- put it on and press for 10 seconds
- wash hands!! can sting eyes/nose
- dont leave on longer than 24
- can bathe, shower, etc. with it on
- remove before MRI
Side Effects
- itchy
- burning, tingiling at site
- Vivid dreams/sleep disturbances
- HA
- skin can be red after removal fo 24 hours
- some pt. can have local skinreaction (avoid if derm condtion pt. liks psoriasis)
OTC Pain Relievers
APAP
NSAIDS
Salicylates
APAP: acetaminophen
- Tylenol
NSAIDS: non-steroidal anti-inflamma
- Ibuprofen (motrin, advil)
- naproxen (aleve)
Salicylates
- acetylated: asprin (ASA)
- non-acetylated: magnesium salicylate, sodium salyclyate
APAP (Acetominophen) : Tylenol
- what is is indicated for
- MOA
- formulations avalible
Acetominophen
Indicated for
- analgesic (mild-moderate pain)
- antipyretic (fever)
- NO ANTI-INFLAMMATION
MOA
- inhibit prostaglandins centrally during synthesis
Formulations: lots (tablets, gels, liquid, etc.)
- regular or extended release
- comes in combo with other meds! think excedrine and percocept
APAP (acetaminophen) dosing
kids
adults
alcoholics
Kids
- weight based dosing
Adults
- MAX DOSE is 3000 mg (3g) a day: 4g if medical supervision stick to 3g
- regular strength is 325 (Extra is 500)
Alcoholics or liver disease pt.
- hepatotoxic: max dose is 1500-2000 mg
Acetaminophen
overdose & toxicity points
SE
Overdose and Toxicity
- going over 4mg (3mg) = hepatotoxicity
- councel on the combo products!
- leading cause of acute liver failure in the US
- avoid alcohol use with tylenol
Drugs
- D-D interactions: Warfarin: cin high doses of APAP - increased INR: need to adjuts warfarin
SE
- NO AFFECT on platelet aggregation: its the most safe out of NSAIDS and asprin on bleeding risk pt.
- no GI irritation (like NSAIDS)
- can use in aspring allergy
NSAIDS
- indication for use
- MOA
NSAIDS
Indications
- analgesics (mild-moderate pain relief)
- antipyretic
- anti-inflammaotry
- anti-platelet (not used for this but it happens)
Names
- Ibuprofen (motrin or advil) max dose 1200mg
- Naproxen (Aleve) max dose 660mg
MOA
- peripheral inhibition of COX1 and COX2 AND prostoglandin synthesis (so fever and anti-inflamm)
NSAIDS
- avoid in what pt. populations
avoid in
- pt. with intolerance to asprin or any NSAID
- renal dysfunction
- heart faiure: can worsen edema
- uncontrol HTN can worsen (inc. BP since it holds onto water
- those with active ulcer disease
- those in 3rd trimester
NSAIDS
adverse effects
- gastric irritation: peptic uclerc & bleeding (dyspepsia, heartburn, nausea)
- Bleeding risk!! : blood thinning possible due to platelet aggregation inhibition
- fluid retention (avoid in HTN and HF)
- can increase CVD and CVA events
- increase bleed with warfarin pt.
- can decrease effectiveness of antihypertensive
- decrease platelet effect of ASA (asprin) : space dosing
counceling
- dont take with alcohol (GI bleed risk)
- take with food and full galss of water
- dont crush
Salicylates
MOA
names
indications
Names: asprin, magnesium salicylate
Indications
- analgesic
- antipyretic
- anti-inflammatory
- Asprin = anti-platelet
MOA
- inhibit both forms of the COX1 and COX2: thus inhibiting formation of prostoglabins, thromboxane A2 and prostocyclin
- prostoglins to brain = fever
- prostoglandins to tissue = inflammation
Acetylated Salicylate = Asprin
- irreversible inhibition to platlet aggregation
Non-acetylated Salicylate = MAgnesium salicylate
- no platlet aggregation
max dose 4000mg
Clinical use and indications for when asprin is used
formations
Aspring (acetylated salicylate)
- mild-moderate pain releif
- fevers
- prevention and treatement of CVD: stroke and MI : because of the antiplatlet effect
avoid in children: Reye’s syndrome
and in pregnant 3rd trimester
Formations
- enteric-coated: tablets to decrease GI irritation and risk of bleeding
Salicylates
toxicity
ADR
true asprin allergy
conceling
Toxicity
- tinnitus
- HA
- dizzy
- confusion
- N/V
ADR
- gastric ulcer/bleed
- dyspepsia
- bleeding
some people are alergic to asprin….
- hievs, angioedema and other anaphlaytic rxn
- increase risk in those with asthma and nasal polyps = Samtners triad AERD
true aspring alelrgy = can ahve cross-reactivity with NSAIDS (tylenol ok)
Conceling
- no alcohol
- dont use with warfarin unless recoemmedn by dr.
- dont crush or chew: take with water
how long should pt. take fever reducing medications before seeking medical attention
do not use longer tha 3 days
Capsicum Preparations
how is it used
what does it do
names
How its used: the hot chili peper oil works at nerve endings to fire substance P until “empty” then pain relief
- get warm feeeling throughout stimulating TRPV1 receptors
NAmes
- capzasin cream
- Zostrix
Indications
- minor aches and pains of joints/muscles
- will relieve the nerve pain; just but eliciating a less severe pain to counter the more intesne painful feeling
- apply no more thant 4 daily x 7 days
Rubefacients
what is it
Rubefacients: Bengay
- methly salicylate
- naturally: wintergreen oil or sweet birtch
- produces mild local inflammation reaction
- gives “hot” feeling
- for MSK pains
camphor& menthol : used as cooling sensation
Camphor (JointFlex pain relief cream) or Menthol (Icy Hot)
- depresses cutaneous receptors at lower concentrations (< 1%)
- in higher concentrations, stimulates nerve endings to relieve pain and discomfory by masking the pain of visercal deep pain (organs) (joints?)
