Pharmacist Prescribing Flashcards
What is the number one prescribing situation for pharmacists?
Cold Sores
What is useful to pharmacists regarding prescribing for cold sores?
50% if individuals will get prodromal symptoms –> Tingling
- Helps us out a lot as far as prescribing
What is Lysine +? Efficacy in cold sores?
Amino Acid - Not very effective
Asterix on package - probably tested in test tube (cuts healing time in half)
Much more expensive compared to name brand chap stick
How is Lysine+ suppose to be used as indicated by the manufacturer?
For the relief of cold sores
Apply ointment every 2 hours until cold sore resolves
Up to 10 applications per day
Apply using a clean fingertip
Are cold sores always on the lip? What is another issue with cold sores?
Can deviate away from the lip
Can make diagnosis hard
Rare to see an MD; often MD comes into play when 5 to 6 cold sore a summer for a child
What are some benefits in cold sore prescribing regarding the individual?
Self-diagnosed –> Easy to do as has seen them before
–> legalistic approach, but we double check
–> not much can go wrong on thus front
Prodromal Symptoms may be present and helps with clueing into cold sore
What is cold-sore Fx? Efficacy?
Bee pollen/wax
- A bit better than other agents but still not that great of an agent
- Bee stuff has loads of good stuff in it
- Still just a chapstick
When do people commonly get cold sores? Describe the pattern between age and cold sores?
Virus of cold sores can infect people of all ages
Exposure to the virus typically occurs in childhood
Many people catch HSV-1 by the time they are 5 years old
One can develop a cold sore at any age although having a chnacde of an outbreak decraeses after the age of 35
Describe the typical progression of a cold sore
Typical - 2 days in:
- Will crust over (keep it soft with some normal chapstick) and will have some leakage
- Takes about a week to be taken care of
Describe the stages of a cold sore? Differential?
Stage 1: Tingling, itching, or burning
Stage 2: Blister formation - 12-24 hours later (red, swollen, pain)
Stage 3: Blister bursts - Lasts 2-3 days
Stage 4: Scab formation (may crack and bleed)
Stage 5: Healing stage
Stages of a cold sore can help differentiate from angular chelitis
Differential of cold sores
ANgular Chelitis –> Tx is to keep it soft
Impetigo - Age is usually 2-5
- Tears in the skin can lead to a staph infection
Describe cold sores
Usually form an and around the mouth and lips
Genuinely look the same from person to person
Begin with a tingle or an itch, form a small fluid blister or cluster of blisters, then pop and scab over
Describe the difference between cold sores and impetigo regaridng presnetation
Distinguishing a visual difference between the non-bullous form of impetigo and cold sores cane be difficult
Some cases, non-bollus impetigo blisters form in much larger cluster and burst more quikcly than cold sores
Impetigo often looks worse than it feels
Non bollus impetigoo does not cause much, if any, pain ; however, can experience some itchiness once blisters burst and crust over
Describe the difference between cold sores and impetigo in regards to treatment and duration of disease
Impetigo can be treated with antibiotiics, and when identidfied early, heal within a week
- Once treated, child will not experience a recurrence unless they contact the bacteria again (bacteria will not stay in child’s system for a significnat length of time)
When a child suffers cold sores, they are more likely to develop pain and itchiness throughout the stages of an outbreak
- May ecome ill during their first cold sor eoutbreak
- No cure for HSV-1 or 2, children with cold sores are mor elikely to suffer recurring outbreaks
Do cold sores cause systemic symptoms?
Not usually
The symptoms are usually the most severe the first time yoy get cold sores
A first-time cold sore can make a child seriously ill
Cold sore vs angular chelitis
Cold sores typically begin as an itchy or painful area that turns into one or a group of small painful blisters
Over time, they may weep, scab over, and finally heal
Angular Chelitis - Begins as a patch of dry, irritated, or cracked skin at one or both corners of the mouth
Desribe some of the OTC cold sore medications that may be used? Efficacy?
1) Docosonal (Abreva)
- Medicated - use in prodromal symptoms
- If used after sores burst, use chapstick
- 20$
2) Propolis - COldSoreFX
3) Camphor/Phenol - CArmex
- Some people swear by it
- Anasthetic
- TLC
4) Heparin/ZN SO4 - Lipactin
- definetly heparin receptors in the body
- not therapeutic; not out go to
5) Lysine+
6) Benzyl Alcohol - Zilactin
- Anasthetic
- Drying agent
7) Benzocaine - Orajel
- Totatlly fine to use to numb the area
8) Ice cube in Facecloth
- Anti-inflammatory
9) Thin Colloid Patch - Not avai;able anymore
- Unmedicated silicone patch - cosmetic
- Great agents
Dogs and puppies chase chickens, catch happy little bugs, zooming by outside.
Describe Abreva and its efficcay
Docosonal
- Can be used if early enough (<48 hours) and have effect
Cold sore usually lasts around 7 days
Manufacturer claims to cleave off 3 days - –> Astronomical
Fake –> 4.1 vs 4.8 days in a lab –> 0.7 of a day
Describe cold sore patches
Abreva Conceal
- Non-medicated patch that covers your cold sore and provdies a smooth surface for applying makeup
Lip Clear - Cold Sore Banadage
- Hard to find in pharamcy
- Non-medical - Cosmetic agent -> Wear for 12 hours
Describe the prescrbing symptom history section of med-sask guidelines for cold sores? Issues?
Describe the treatment options of cold sores
Describe the issues associated with topical and oral therapy of cold sores?
Topical Agents - Hard to know where lesion will form and therefore can be hard to hit the prodromal phase
Oral Agnets –> Not an issue
What are the treatment options of a cold sore once prodromal phase is over?
Describe cold sores and the concern in elderly patients
After 35 and 50 years old, have titres to fight off cold sores and become rare-ish
Nervous about squamish cells or basal cell carcinoma
–> Guidelines say 14 days
- Basal - lowest invasive skin cancer
- Melanoma is the worry
Worried in older individuals
When can a pharmacist prescribe preventative therapy for cold sores?
4-6x times per year; can give prevention therapy a thought
- If just in summer, only do prevention therapy in the summer
- Agents are safe (no s/e)
- If used all year, maybe worried about the liver
Describe why HSV-1 can lead to recurrences?
Virus remains in the body and lies dormant in a bundle of nerves called the trigeminal ganglion and stops causing infection
The virus can become active agein and cause recurrent cold sores
Cods sores typically recure three to four times a year, although some people may develop more than one cold sore per month
Describe pharmacist prescribing of birth control
Women pharmacist know this areas - Know your limits; especially of a man
- Do you smoke, then try one. If side effects, try soemthing else
Low level therapeutics
- Estrogen levels are getting lower vs historically (50 mg historically increased side ffects)
Describe a situation that may be an adverse effect bit also treatment with birth control
Acne - Sometimes worsens intially but usually improves in the long term
Acne as an adverse effect occurs with progesterone component
Ethinyl Estradiol (estrogen) can help acne
Describe why prescribing of birth control is considered safe for pharamcists?
- Low level worries about prescribing birth control in a pharamcist setting
Opill - Norgesterol Tablet
–> OTC in USA
- First ever OTC birth control
- Progestin-only pills are safer compared to the combined birth control pills that contain both estrogen and progesting
- Progestin only pills do not have the same risk of blood clots or stroke as combination pills
OTC Birth Control
LAtin America and Europe has been doing this for awhile
Leading medical organizations have affirmed that a prescription is not clinically necessart for acess ro the pill
No toxic, addictive and has no risk of oberdose, meeting FDA criteria for oTC acess
Other OTC products such as cold, flu and allergy sumptoms carry higher risks
What can be a diagnostic criteria for a migraine?
If an individual thinks they have a migraine, try a triptan
- If it helps, diagnosis via treatment
Describ ethe difference between a tension headache and migraine
Tension - Once or few times a week or continous for several days
- Generalized
Migraine - Svere, intense throbbing pain with pulsating charcter mostly localized on one side of the head
–> Typically unilater
Why is it hard to differntiate a migraine and a tension headache? Mangement?
Enough overlap between the two that can make it hard to diagnose
Just try a triptan
Describe the phases of a migraine
Prodorome Sx - 25% of people with migraines will have
- Few hours to days
Aura - 5-60 mins
Migraine Attack
- 4 to 72 hours
- Nauseau, vomitting (still can occur in tension headaches)
Post-drome - 24-48 hours
- Can occur in a tension headache as well
Describe some concerns regarding migraines and a stroke
Although symptoms can overlap, if even the slightest chance of being a stroke, call 911
If you are over 40 and never had a migraine, assume its something more serious
If you are young, more likely a migraine. If you. are older, more likely a stroke.
People who get migraines typically have had them before; rare to get 1st one when older
Describe the difference in symptoms between a stroke and a migraine/headache
If grey hairs - it may be a stroke - if first migraine/headache, lean towards a stroke (usually exoerience early in life)
Stroke - Lose (loss of function)
–> Diminishes vision
Migraine - Add on Sx
–> Added on visual stimuli
Its possible to have a firts migraine at any age, it’s more typical to begin having them as a child - Most will also recognize their aura
Describe med-sask red flags for migraine? When to refer?
Symptoms of migraine in med-sask prescribing algorithm
TX recommendations of migraines MedSask
If tripatn helps, diatgnostic
Describe the benefit of pharamcists prescribing for migraines
Pharamcists can help to close the treatment gap
- Not trying to be diagnosticians but can help decrease the tx gap
Migraines remain underdiagnosed, undertreated and under-estimated
When should acute medications for migraines be taken?
Take acute medications ASAP (within 30 mins of mild pain)
How should triptans be dosed?
If needing repeat dosing over 24 hours, taking the max dose once is more effective than a low dose twice
If prodrome phase, give high dose of triptan
What is considered an adequate trial of a triptan?
Ensure an adequate trial of a triptan
Try a triptan over 3 attacks, with re-dosing if needed and/or increase dose
If still fialure, try greater than or equal to other triptans
Migraine and Combination Therapy
More effective than monotherapy (e.g. triptan + NSAID vs triptan alone) but also consider potential for AE –> MAx of 9 days/month to prevent MOH (> 10 days)
Describe the speed of triptans in a migraine? Is it effective?
Onset of tablet and ODT formulations are similar, but ODT can be convienient and discreet
ODT also useful if water exacetbates nauseau
If require speed, use an ODT –> if faster relief is desired
Drug Interactions of Triptans
Triptans and Ergots (rarely used)
Risk of serotonin syndrome with triptans, even with triptans + SSRI’s, is low
Describe the effcacy of migraine medications
Triptans - 74%
Ergots - 65% - Specialized meds - Strong vasoactive compound
- Don’t know if incraesed dilation or incraesed sensitivity in migraine
Anti-emetics - 59% - Treating symptoms of migraines
NSAID’s - Give it a try
What are the best migraine medications regarding efficacy?
Triptans, ergots and entiemetics had the highest efficacy
–> TRIPTANSSSSSS
Individual medications with the highest patient-reported effectiveness were eletriptan, zolmitriptan and sumatriptan - Just try one
Describe Ibuprofen usage in migraines
400 mg - ceiling effect of analgesia
Don’t know if migraines have inflammatory effect - can try 800 mg but may be overkill
Whatever works for patient
Make sure someone is monitoring
Make sure they try triptans
Ibuprofen and Speed in mIgraines Tips
Ibuprofen liquid gel and diclofenac K+ (expensive) often 10-20 min quicker onset
Avoid enetric coated and slow release tabs
Avoid taking NSAIDs with food in acute migraine
(delays absorption)
GI effect is low with NSAIDs
What are some symptoms of cystitis?
Symptoms of UTI in Men
Is urine sterile?
Urine in healthy individuals naturally comtaines bacteria and urine is not a sterile substance
Describe statistics of UTI in CAnada
A UTI is the 8th most common cause of ambulatory care visists
Almost half of all women will experience a UTI before the age of 33
Uncomplicated UTIs can be empiraclly treated with oral natibiotics
What are some key factors that support an uncomplicated UTI?
What are some red flags of a UTI?
red flag symptoms of UTI’s MedSask prescribing algorithm
Leaning more towards pyelonephritis here
Symptoms of acute uncomplicated cystitis - Med Sask
Standard therapy for UTI - MedSask
Describe the main therapy for a UTI CI
UTI’s in Elderly and Concern
UTI is one of the most common infections in odler aduts
- Constitues approximately 25% of all infx in older audlts
- Would need to be worried about creatinine clearence at this age
Counselling for a UTI Key Points
recurrence happens in about 25% of patients
The ppainful urination should resolve within a few hours of starting the medication
Sx should improve within 48-72 hours and resolve within 7 days
Preventative Tips to COusnel a Patient on to prevent UTIs
Is viral and bacterial conjuctivitis easily distinguishable?
NO - Hard to tell the difference
Will be right about 50% of the time
Describe the diferrences between viral and bacterial conjuctivitis
Describe the course of viral conjuctivitis? WHat does it commonly occur after?
starts in 1 eye – moves to 2nd eye in approx 1/3 of cases
often follows a cold
Describe how to diffren6tiate betwen viral, bacterial and allergic conjuctivitis?
Overall summary between viral and bacterial conjuctivitis?
What type of conjuctivitis is most common in children?
Bacterial
When is bacterial conjuctivit more likely?
Conjuctivitis vs Blepharitis: Location opf exudate
Blepharitis - Older individuals - Seborhhea - Exudate from the lid margin
Bacterial Conjuctivitis - Exudate from the eye
What is blephritis
Eyelid disorder
CAn lead to probelms with dry eyes
Crusting at the base of the eye lashes
REFER
Describe the etyiology of Blepharitis
Blepaharitis Symptoms
Allergic Conjuctivitis Sx
ITCHING
Nasal Symptoms at play?
Agents for Allergic COnjuctivitis
Agent of Choice - PAtaday OD
Murine can help to wash stuff out of the eyes
Visine for allergic eyes - Not a good idea
Describe Infectious conjuctivitis in adults
Viral causes are more common - 7 days of sx
Both are slef limiting heree
MDS correct 50% of the time
Describe the effect of an antibiotic in bacvteria conjuuctivitis
Antibiotic shortens the course by 1-3 days
Decreased spreading
Should see improvement within 2 days
What is another strategy that can used for infectious conjuctiviytis?
Watchful Wiating - If not better 3 days after sx begin, consider an antibiotic
Treatment of Viral COnjuctivitis
Most references suggest symptomatic care
Lubricating eye drops - None of them are better than the otehr one
Just go with one here
Are presverative sin eye drops toxic? How often to apply?
NOOO
QID - Should go presverative free
May be irritating but not toxic
Most wi;ll become preservative free
Hylo Eye Drops
Bacteria cannot get back into the bottle
Expensive with no special ingredients
Still a trial and error
Homeopathic {Pink Eye Relief
NOOOOO
Bacterial Conjutcivitis Treatment
3 day Windo - Watchful waiting
Use an antibiotic
Polysporin Eye Drops (totally fine to use)
Polysporin Eeye Drop Usage Directions
Great agent
1-2 Drops QID
Is treatment necessary for bacterial conjuctivitis?
Almost all cases of bacterial conjuctivitis are self limiting and will clear within 10 days without treatment
TX of Subconjuctival hemorrhage
Visine decongestant is not effective here
ACnnot decongestant a broken vessel
Greater the size may be worrying but not worried on this front
More so worried if it occured due to trauma
Whn does BP work best for acne?
BP works best for acne if ther eis inflammation occuring
Differentails Acne
PCOS - HAirs, wacky p-eriods and acne - Worried
Roscea/Perioral Derm -
Roscea Diffrential pof Acne
Acne-like lesions at same stage
Starts at 30 years of age
Facial Flushing, Teleangiectasis, Eye Druness
No black heads or white heads and older womken - Roscea
Describe the age of Acne and its prevalence
80% of teenagers; can last till early 30’s
20% tennager and stops at w0 and comes back later - More conerned - Adult onset
peri-oral Dermatitis Differntail
- Dermatitis that occurs around the. mouth
Lesions clustered around the mouth and nasal fold
Women > Men
History of topical steroid use
No blackheads
TX of peri-oral Dermatitis
Low level antibiotics here - Inherrent antiflammatory
What combination therapy for acne is recommended?
BP + Retinoi d
BP + antibio
retinoid + Antibio
Does not matter which one we choose
Describe when ceratin acne agents sghould he used regarding lesisons?
Pimps - Inflammatory Response - BP
White/Blackheads - No anti-inflammatory - Retinoids stop the inflammation from starting
How to apply retinoid?
1 pea sized dab spread over 4 spots - not the more the merrier here
prescribing for Acne
TActuo - Adapalen BP
Clindoxyl - Clindamycoin 1% OD
RX Prescribing and COmbination Products
Pharamcists cannot prescribe for antibio and BP combination prpducts
Not indicated for mild acne
e.g. TActupump
Other age nt for acne? Efficacy?
Not a listed benefit of the Saskatchewan Drug Plan. Pharmacists may prescribe
& assessment fee may be claimed.
Dapsone gel 5% - Aczone
TRASHHHH
Describe ongoing care of Acne and agents
Topical antibiotics (if being used) should be d/c after resolution of inflammatory symptoms
Drop down to retinoid monotx
Referall Situation Acne
Acne ofn the back
Rare Agent for Acne and Its indication
Aklief Trifarotene 0.005%
Indicated for chest, shoudkers and back - MD only
Targeted trunkal acne - Not going to pentrate retinoid market
Still a standard retinoid that also works on the face
Tinea Capitis
Common infection in childrem
Not topical monotthearpy here
Scalp is hard to pentrate - Need oral tx
Descrobe the ytreatment of tinea
Diaper Rash Applicatuon
1/2 FTU should be enough HC 0.5-1%
Treatment of Diaper RAsh Fungal
