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1
Q

Let’s talk about 💩…

What is constipation?

A

Passing of dry, hard stools less frequently than a person’s normal bowel habit.

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2
Q

What is typical of a ‘normal’ bowel habit?

A

2-3 times/day to 1-2 times/week

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3
Q

When would you consider referring someone who presented with constipation?

A

1) dark red/black stools - especially if associated with other symptoms such as weight loss –> indicative of something more sinister like bowel Cancer
2) bright red blood seen on passing stools or when wiping –> ?haemorrhoids
3) > 14 days with no identifiable cause
4) pain when trying to pass stools
5) constipation in addition to following symptoms lethargy, weight gain, mood swings, coarse hair or dry skin –> ? Hypothyroidism
6) drug induced –> opioids, Hyoscine, SSRIs, TCAs, verapamil, propranolol, aluminium containing antacids, iron, chlorphenamine, bendroflumethiazide
7) continuous use of laxatives –> loss of bowel muscle activity –> induces constipation

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4
Q

What lifestyle advice would you give to a patient presenting with constipation?

A

Increase fruit and veg intake
Increase wholemeal food intake I.e wholemeal cereals
Increase fluids
Increase regular exercise

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5
Q

What is the recommended amount of exercise?

A

150 minutes of moderate aerobic exercise/ week

E.g cycling, brisk walking

Activities which get your heart rate up

+

2 days of strength exercises e.g weights to help maintain strong bones and muscle function

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6
Q

What is the treatment protocol for constipation?

A

1st line: lifestyle advice

2nd line: osmotic or bulk forming laxatives

3rd line: stimulant laxatives

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7
Q

How do osmotic laxatives exert their therapeutic effect and name some examples which can be purchased from the pharmacy?

A

MOA: increase osmotic pressure in the large bowel by drawing water into the bowel or helping to retain the fluid that is already there.

E.g
lactulose
Macrogols - movicol or laxido

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8
Q

What are the main S/E of osmotic laxatives?

A

S/E particularly with lactulose (20% of people experience the following):

Flatulence
Abdominal cramps

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9
Q

How do bulk forming laxatives exert their therapeutic effect and name some examples which can be purchased from the pharmacy?

A

MOA: human body does not naturally possess the enzymes to break down active ingredients of bulk forming laxatives –> e.g ispaghula, methylcellulose. This allows the laxative to pass straight through and increase the mass in the large bowel to help stimulate peristalsis. The hydrated material also allows bacteria naturally found in the gut to colonise and help soften stools.

E.g
fybogel - ispaghula
Celevac - methylcellulose

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10
Q

How do stimulant laxatives exert their therapeutic effect and name some examples which can be purchased from the pharmacy?

A

MOA: directly stimulates the mucosa of large bowel and rectum; promoting peristalsis and accumulation of water and electrolytes into the intestinal mucosa

E.g
Senokot- Senna
Dulcolax - Bisacodyl

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11
Q

What is important to counsel a patient on when they are taking bulk forming laxatives?

A

Drink plenty of fluids to avoid oesophageal and intestinal obstruction

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12
Q

How long do the following laxatives take to exert a therapeutic effect?

Osmotic
Bulk forming
Stimulant

A

Osmotic -> 2-3 days
Bulk forming -> 24hrs to 3days
Stimulant -> 6-12hours

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13
Q

Ages for use of laxatives in Children.

Osmotic
Bulk forming
Stimulant
Stool softeners

A

Osmotic:
Lactulose > 1yo
Movicol paediatric > 2yo

Bulk forming:
Ispaghula > 6yo
Methylcellulose > 7yo

Stimulant:
Senna > 2yo
Bisacodyl > 4yo
Glycerol suppositories -> infant onwards

Stool softeners
Docusate sodium > 6months

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14
Q

What is diarrhoea?

A

Increased bowel movements of watery or abnormally soft stools.

Usually accompanied by abdominal cramps, nausea and vomiting and lethargy may also occur.

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15
Q

When should you refer patients presenting with diarrhoea?

A

1) patients > 50yo with a LONG TERM change in bowel habit
2) diarrhoea following recent travel to tropical/ sub-tropical climates
3) duration > 2-3 days in children and elderly
4) patients unable to drink fluids with signs of dehydration
5) blood/mucus in stools
6) severe abdominal pain
7) steatorrhoea - fatty stools

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16
Q

What is the treatment protocol for diarrhoea?

A

1st line: oral rehydration therapy - preventing dehydration

E.g diarolyte sachets

1 sachet in 200mL of water
Contains sodium, glucose, potassium, chloride, citrate

Keep well hydrated

2nd line: loperamide 2mg tablets
Opioid receptor analogue/ anti-propulsive

E.g Imodium

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17
Q

What is the MOA of loperamide?

A

Opioid receptor analogue. Also known as anti-propulsive.

Binds to opioid receptors in the gut and reduces peristalsis, increases gut transit time and enhancing resorption of water and electrolytes.
Loperamide also increase tone of anal sphincter which helps reduce faecal incontinence and urgency.

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18
Q

What counselling points would you give to patients presenting with diarrhoea?

A

1) hand hygiene- always wash hands with soap and dry well with a clean towel
2) avoid drinking fizzy drinks, milk (as temporary lactose intolerance occurs due to damage to intestinal lining cells), fruit as these may all prolong diarrhoea
3) reconstitute powders with boiled and cooled water (recommended)
4) avoid sharing water or drinking untreated water if abroad
5) avoid shellfish and fish unless fresh and from freshwater
6) eat fresh foods, no uncooked meat

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19
Q

What is a cough?

A

A natural protective reflex action which is triggered by an irritation or blockage in the airways - to help clear airways.

In a productive cough, excess sputum is secreted in response to irritation of the airways.

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20
Q

When should you refer someone who presents with a cough?

A

1) cough lasting for more than 3 weeks
2) coloured sputum (indicative of chest infection)
3) blood in sputum (haemoptysis)
4) cough associated with persistent fever and night sweats and haemoptysis - indicated TB
5) persistent harsh barking cough - croup (viral infection which is common in young children)
6) difficulty breathing
7) chest pain
8) recurrent night time cough - indicative of asthma
9) ACEIs

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21
Q

What OTC treatments are available for dry coughs?

A

Cough suppressant -

Dextromethorphan - e.g. Robitussin

Pholcodeine

Codeine

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22
Q

What OTC preparations are available for mucus/ productive chesty coughs?

A

Expectorants

guifenasin - e.g benylin mucus cough

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23
Q

What can demulcent preparations be used for?

A

*demulcent = relieves irritation/inflammation and provides a protective film

Used to smooth any type of cough

E.g simple linctus, honey and lemon

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24
Q

What OTC antihistamine preparations are available that may help to relieve coughs?

A

*antihistamines are thought to help dry up secretions that may be triggering the cough

Examples include:

Diphenhydramine- benylin chesty cough (original)

Promethazine (night nurse)

Triprolidine (actifed)

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25
What is dyspepsia?
Dyspepsia is an umbrella term which covers the following: 1) non-ulcer dyspepsia/ functional dyspepsia (indigestion) 2) GORD/ heartburn 3) gastritis 4) duodenal ulcers 5) gastric ulcers Pain may be felt in the upper abdomen all the way up to the oesophagus. Heartburn may also be associated with an acid taste in the mouth.
26
What cough medicines should you NOT give to people presenting with a productive/ chesty cough?
Cough suppressants as these may lead to accumulation of mucus in the lungs and a higher chance of infection.
27
An unproductive cough (dry, tickly) is usually caused by what?
Viral infection - self limiting
28
Define 'sore throat'
Constant or varying levels of pain from the back of the throat. Swollen lymph glands may be felt under the chin or in the neck. Pain may be experienced upon swallowing (dysphagia)
29
Sore throats are commonly caused by viral or bacterial infections?
90% viral | 10% bacterial
30
When would you consider referring someone who presents with a sore throat?
1) lasting longer than 10days 2) extreme pain - especially in absence of cold/cough and symptoms lasting for greater than 1-2days 3) dysphagia 4) red and swollen tonsils/ swollen lymph glands 5) drugs - e.g methotrexate, carbimazole (agranulocytosis), steroid inhalers 6) oral thrush - white plaques in the throat, gums and/or tongue
31
Which types of drugs may cause the symptoms of heartburn?
Tricyclic antidepressants NSAIDs CCBs Caffeine
32
When would you consider referring someone who presents with symptoms of heartburn/indigestion?
Children Pain which radiates Dysphagia Drug induced Persistent pain originating from one point in the abdomen (may indicate gastric/duodenal ulcer) New onset symptoms in patients > 55yo Patients taking OTC heartburn remedies regularly/ greater than 4 weeks symptomatic treatment Patient with hepatic impairment/ jaundice
33
Antacids normally contain which TWO types of compounds?
Aluminium or magnesium based compounds
34
Magnesium compounds have been found to be constipating or inducing a laxative type effect?
Laxative effect
35
Aluminium based antacid compounds have been found to be constipating or laxative type inducing?
Constipating
36
How do aluminium/ magnesium based antacids exert their therapeutic effect?
Both are relatively insoluble in water. Bind with H+ in HCl and thus lowers gastric pH and reduce acid delivery to duodenum.
37
Which drugs are antacids known to interact with?
tetracyclines, vitamins, ciprofloxacin, ketoconazole, levothyroxine, hydroxychloroquine, chloroquine, chlorpromazine, rifampicin, cefdinir, cefpodoxime, rosuvastatin. Although none of these reactions are generally 'black-dot/ severe' Patients should be counselled to take medicines at least 2 to 3 hours apart
38
Why is aluminium based antacids not recommended in renal impairment?
Due to aluminium based compounds being insoluble in water and mainly excreted in urine, accumulation may occur in the kidneys in patients with renal impairment. Possibility of aluminium toxicity.
39
How do alginates exert their therapeutic effect?
Form a raft which sits on the surface of the stomach contents and prevents reflux. Some alginate based products contains bicarbonate causes the release of carbon dioxide in the stomach which allows the raft to float more easily on top of the stomach contents.
40
How does ranitidine/famotidine exert their therapeutic effect to reduce the symptoms of heartburn/indigestion?
Both are H2 receptor antagonists. Prevents the release of histamine which consequently reduces the effect of H+/K+ ATPase pump - reducing gastric acid secretion
41
How long is the maximum supply for OTC H2 receptor antagonists like ranitidine?
Max. 14 days supply
42
How do proton pump inhibitors exert their therapeutic effect?
PPIs directly inhibit gastric acid secretion by specifically inhibiting H+/K+ ATPase acid pump in the parietal cell.
43
How long do PPIs take to exert their full therapeutic effect?
1-3 days
44
What are the most common side effects of PPIs?
Abdominal pain, constipation, diarrhoea, flatulence, GI-disturbances, nausea, vomiting
45
For pregnant women, elderly or those with hypertension, which type of OTC indigestion/ heartburn remedy medication would you advise?
Low sodium/ sodium free antacid preparation containing an alginate. E.g
46
What is the maximum dose of Ranitidine (for dyspepsia) which can be supplied OTC, for how long and which patient group(s) is the use of OTC ranitidine contra-indicated in?
75mg OD for 14days. Not for the supply to: - children aged <16yo - pregnant/ breastfeeding women
47
Which types of patients would be eligible to receive OTC orlistat?
Adults aged 18 and over | BMI >28
48
What is the OTC dose for orlistat; how long is the recommended initial treatment and how should it be taken?
60mg TDS Trialled for 3 months Taken immediately before, during or up to 1 hour after each main meal.
49
What % of body weight should be lost within the initial period for therapy with orlistat to continue?
5-10%
50
What are the suggestive signs that a baby may have colic?
- the baby will begin crying suddenly; the crying is high-pitched and nothing the parent does seems to help - the crying begins at the same time each day, usually in the afternoon or evening - the baby might draw their legs up when they cry, and their tummy might look swollen - the baby might clench their hands - the baby’s face flushes - the crying can last for minutes or hours - the crying often calms down when the baby is exhausted or when they have passed wind or a stool
51
What is colic?
Colic is excessive crying in an otherwise healthy baby and is defined as being present when babies cry for at least three hours a day, for three days a week, for at least three weeks.
52
What OTC treatment options are there for colic?
Anti-foaming agents, e.g. simethicone, contained in Dentinox® and Infacol®. (There is little evidence to show that these drops help in colic.) It is not systemically absorbed and therefore is safe from birth and may be an option to a parent who is keen to give a treatment.
53
What is IBS?
Irritable bowel syndrome (IBS) is a chronic non-inflammatory bowel condition in which there is recurrent abdominal pain associated with a change in bowel habit. It may appear as alternating constipation and diarrhoea, abdominal discomfort, passage of mucus, bloating and constipation or faecal urgency and diarrhoea.
54
How long before a diagnosis of IBS can be made if the following symptoms are present: Abdominal pain Change in bowel habit Bloating
6 months
55
What are the trigger points for referral: IBS
- blood in stools - fever, N&V - severe abdominal pain - children under 16 or adults over 45 with a recent change in bowel habit - steatorrhea (fatty stools - may be related to malabsorption)
56
What types of OTC medication are available for symptomatic treatment of IBS?
Tx dependent on dominant symptoms. Constipation: bulk-forming laxatives (fybogel) Diarrhoea: anti-motility drugs (loperamide) Use of antispasmodics may be helpful for relief of abdominal pain E.g Mebeverine (Colofac) or alverine (Spasmonal) Hyoscine butylbromide (buscopan) may also be useful
57
What is allergic rhinitis and what are the symptoms?
Allergic rhinitis is characterized by paroxysms of sneezing, rhinorrhea, nasal obstruction, and itching of the eyes, nose, and palate. It is also frequently associated with postnasal drip, cough, irritability, and fatigue.
58
What is acute sinusitis and symptoms of it?
inflammation (swelling) of the lining of the sinuses and nose. Thick, yellow to green discharge from the nose ●Nasal congestion or blockage ●Facial pain, pressure, or fullness - localised unilateral pain worse on bending down
59
Why should breastfeeding women avoid taking pseudoephedrine based products?
May suppress lactation
60
What is blepharitis and what are the symptoms?
Chronic eye condition categorised by inflammation of the eyelids. Symptoms include: ``` ●Red eyes ●Gritty sensation ●Burning sensation ●Excessive tearing ●Itchy eyelids ●Red, swollen eyelids ●Crusting or matting of eyelashes in the morning ●Flaking or scaling of the eyelid skin ●Light sensitivity ●Blurred vision ```
61
What is the Tx option for patients with blepharitis?
1) good eye hygiene
62
What is a chalazion?
painless lump in the eyelid. It is caused by a blockage in a gland that makes tears.
63
How do you treat someone with a chalazion?
applying warm, wet compress with slight amount of pressure QDS Do not squeeze it - may become infected Should subside on its own, if it doesn't go after 4 weeks referral to GP is advised
64
What is uveitis and symptoms of it?
Intra-ocular inflammation (middle eye) Symptoms include: A red eye ●Eye pain ●Being very uncomfortable looking at bright lights ●A small pupil – The pupil is the dark, round area at the center of the eye. ●Blurred vision
65
What is glaucoma and the symptoms associated with it?
Elevated intro-ocular pressure Symptoms (angle closure glaucoma) include: ``` ●Decreased vision ●Halos around lights ●Headache ●Severe eye pain ●Nausea and vomiting ```
66
Which organism is bacterial conjunctivitis most commonly caused by?
Staph. aureus
67
Which viral pathogen normally causes viral conjunctivitis?
Adenovirus
68
Omeprazole is usually a POM, however at what age, strength, duration and indication can omeprazole be sold to the General public for?
10mg for the short term relief of heartburn/ reflux-like symptoms. Max 4 weeks use only for > 18yo
69
What are haemorrhoids?
Swollen veins which protrude into the anal canal (internal) or extend outside the anus (external) together with itching, pain, swelling, burning and soreness in the perianal area and anal canal. May also be associated with rectal bleeding (bright red blood, often seen on wiping)
70
When would you refer someone presenting with haemorrhoids?
Symptoms lasting longer than 3 weeks Unresponsive to 1 week of OTC treatment Blood in stools (dark in colour) Abdominal pain, nausea and vomiting as other symptoms
71
What OTC treatments are available for the treatment of haemorrhoids?
Soothing preparations containing astringents - zinc oxide, bismuth, hamamelis (cause a protective layer across mucous membranes providing symptomatic relief) Local anaesthetics (e.g benzocaine, lidocaine) - can be absorbed through rectal mucosa so excessive application should be avoided Topical corticosteroids (e.g hydrocortisone) - reduces inflammation and swelling
72
What is the maximum recommended use of local anaesthetics for the treatment of haemorrhoids?
2 weeks - local anaesthetics cause sensitisation therefore prolonged use is not recommended
73
What is the maximum OTC recommended use of topical steroids for the treatment of haemorrhoids?
7 days - only used in >18yo
74
What symptoms relate to differentiating between bacterial vaginosis, trichomoniasis and vaginal thrush?
Bacterial vaginosis - white discharge with strong fishy odour. Odour is worse after sexual intercourse and may worsen during menses Trichomoniasis - frothy green-yellow discharge accompanied by vulvar itching is typical Thrush - curd or cottage cheese like discharge with vulval itching
75
When can fungal nail infections be treated OTC?
- If the infection is only beneath nail tips or the sides of the nail - no more than 2 nails affected - patient has no other underlying medical conditions which may predispose them to fungal nail infections e.g immunocompromised or diabetic - patient is > 18yo
76
What treatment is available OTC for the treatment of fungal nail infections?
Amorolfine 5% nail lacquer
77
How is amorolfine nail lacquer used?
Applied once a week after filing and cleaning the surface of the infected nail
78
What it the MOA of amorolfine?
Fungicidal - primarily works by inhibiting fungal sterol biosynthesis
79
How long does treatment need to continue with amorolfine?
Tx needs to continue until the infected nail has grown out (6 months for fingernails, 9 months for toenails)
80
When would you refer someone presenting with fungal nail infection?
< 18yo - have predisposing factors (immunocompromised, diabetic, have peripheral circulatory issues) - nail psoriasis (fine pitting on the surface of the nail) - yellow nail syndrome (affects all nails, indicative of lung disorders) - nail trauma - pregnancy and breast-feeding
81
What is scabies caused by?
Scabies mites, burrowing underneath the skin - their coat and exudates result in intense itching. Burrows can lead to appearance of small thread-like grey lines, most visible in the webs of the fingers and toes
82
When would you refer someone with scabies?
Treatment failure Secondary infection of the skin Severe and extensive symptoms Suspected dermatitis
83
What OTC treatment options are there for scabies?
Permethrin Benzyl benzoate Malathion
84
What is the licensed age for permethrin to be used?
> 2months
85
What is the licensed age for malathion to be used?
> 6months
86
What is the licensed age for benzyl benzoate to be used?
> 12yo
87
How long should permethrin be kept on after application for Tx of scabies?
8-12 hours before being washed off
88
How long after should treatment be repeated with permethrin or malathion for scabies?
7 days
89
How long should malathion be kept on after application for Tx of scabies?
24 hours
90
Where should permethrin, malathion or benzyl benzoate be applied for the Tx of scabies?
UK guidelines state the Tx should be applied to the whole body including scalp, neck, face and ears
91
What counselling points should you tell patients regarding permethrin, malathion or benzyl benzoate for scabies?
- Do not apply after a hot bath, as this increases systemic absorption and removes drug from treatment site - hygiene measures - wash clothes and bedding > 50degrees to prevent reinfestation
92
Should the whole family in the household and/or close contacts be treated for scabies?
Yes
93
Defiine cluster headache?
Unilateral headache which most commonly affects frontal, orbital or temporal regions. Also associated with a water eye (on affected site) and watery nose. Pain is described as a piercing, boring, searing eye pain which is worse on lying down Headaches often occur in clusters at the same time of day/night and can last up to 2-3 hours
94
Define migraine?
Unilateral (in about 70% of patients) headache which may change from side to side. Headache is often described as a severe throbbing pain. Headaches are often associated with certain times and may have certain triggers e.g menses, after periods of stress, upon eating cheese, chocolate or citrus fruits
95
Define tension-type headache?
Bilateral headache which commonly affects the frontal or occipital areas. Described as a 'tight band' across the front or back of the head
96
What is dysmenorrhea?
Cyclical, lower abdominal or pelvic pain which may radiate to the back and thighs. Occuring before/during menses. Can be broken down to primary and secondary dysmenorrhea
97
What is primary dysmenorrhea?
First appears 6-12 months from onset of menarche. Usually affects women during adolescence and early 20's. Symptoms most severe on the day preceding menses or first 24-48 hours of menstrual flow and pain is described as 'cramping pains' Other symptoms may include - headache, nausea, vomiting, diarrhoea, dizziness
98
What is secondary dysmenorrhea?
Implies underlying pelvic pathology causing pain e.g PID, endometriosis, fibroids later onset than primary dysmenorrhea, affecting women > 30yo and pain usually starts a few days before the onset of menses Pain lasts throughout menses and other symptoms may be present e.g intermenstrual bleeding, postcoital bleeding and is described as a 'dull, continuous diffuse' type pain
99
Can a pregnant woman be sold an OTC product for vaginal thrush?
No, although products such a clotrimazole cream and pessary are perfectly safe to use in pregnancy, hormonal changes during pregnancy may mean eradication of Candida could be more difficult, therefore referral is needed
100
Which drugs may predispose women to thrush, and therefore would require referral?
Broad-spec antibiotics, corticosteroids, immunosupressants, COC, HRT
101
What advice should be given to someone who is using Lacri-Lube and is having to use another occular medication?
Leave 5 minutes in between both medications
102
What is the best method to take a child's temperature?
Rectal temperature is the most accurate
103
For children > 5yo, how can their temperature be taken?
Although rectal temperature measurements are the most accurate, accurate temperatures can be taken by mouth. Thermometers (glass) should be kept in the child's mouth for about 3-4minutes
104
Warts and verucae are caused by which virus?
Human Papilloma Virus (HPV)
105
What treatment options OTC are available for warts and verucae?
Topical salicylic acid (5-15%) applied daily for up to 12 weeks Cyrotherapy with liquid nitrogen (max. of 6 treatments)
106
True or False: warts and verucae can spontaneously resolve
True - usually over a period of about 2 years
107
What age group has the highest incidence of warts and verucae?
Adolescents

Pharmacy (35 decks)

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