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Questions and Answers
What is a major risk associated with codeine use as indicated by the black box warning?
What is a major risk associated with codeine use as indicated by the black box warning?
Which of the following CYP2D6 inhibitors can lead to a reduced effect of codeine?
Which of the following CYP2D6 inhibitors can lead to a reduced effect of codeine?
What metabolite is formed when codeine undergoes O-methylation?
What metabolite is formed when codeine undergoes O-methylation?
What are common street names for codeine syrup when mixed with soft drinks or alcohol?
What are common street names for codeine syrup when mixed with soft drinks or alcohol?
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Which of the following statements about extensive metabolizers of codeine is true?
Which of the following statements about extensive metabolizers of codeine is true?
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What is the reason NSAIDs are contraindicated in the third trimester of pregnancy?
What is the reason NSAIDs are contraindicated in the third trimester of pregnancy?
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What is the relevant infant dose percentage of Acetaminophen for a lactating mother?
What is the relevant infant dose percentage of Acetaminophen for a lactating mother?
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At what age is Ibuprofen approved for use in children?
At what age is Ibuprofen approved for use in children?
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How would you determine the acceptable dose of ibuprofen for a 7-month-old patient weighing 18 lbs using the dosage of 5 mg/kg?
How would you determine the acceptable dose of ibuprofen for a 7-month-old patient weighing 18 lbs using the dosage of 5 mg/kg?
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What is the FDA-approved dose range for Clindamycin in treating periorbital cellulitis in an 8-year-old patient?
What is the FDA-approved dose range for Clindamycin in treating periorbital cellulitis in an 8-year-old patient?
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What effect does Miralax have on the alimentary canal?
What effect does Miralax have on the alimentary canal?
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What physiological process occurs as a result of Miralax's action in the alimentary canal?
What physiological process occurs as a result of Miralax's action in the alimentary canal?
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What is the primary use of Loperamide (Imodium)?
What is the primary use of Loperamide (Imodium)?
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Which of the following is a potential issue with Loperamide use?
Which of the following is a potential issue with Loperamide use?
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What is an effect of Bismuth subsalicylate (Pepto-Bismol)?
What is an effect of Bismuth subsalicylate (Pepto-Bismol)?
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Which herb is known for its use in treating insomnia and anxiety?
Which herb is known for its use in treating insomnia and anxiety?
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What is the primary benefit of glucosamine and chondroitin?
What is the primary benefit of glucosamine and chondroitin?
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Which supplement is recognized for its potential liver damage risks?
Which supplement is recognized for its potential liver damage risks?
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What is the effect of probiotics as mentioned?
What is the effect of probiotics as mentioned?
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Which of the following herbs is commonly associated with treatment for menopause symptoms?
Which of the following herbs is commonly associated with treatment for menopause symptoms?
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Which vitamin is known for its role in preventing and treating colds?
Which vitamin is known for its role in preventing and treating colds?
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What is the primary use of Echinacea?
What is the primary use of Echinacea?
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Which interaction is most likely to occur with antidepressants?
Which interaction is most likely to occur with antidepressants?
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What is the mechanism by which pyrantel pamoate paralyzes adult worms in the GI tract?
What is the mechanism by which pyrantel pamoate paralyzes adult worms in the GI tract?
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What should be considered when dosing pyrantel pamoate for a patient weighing 70 kg?
What should be considered when dosing pyrantel pamoate for a patient weighing 70 kg?
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Which agent can be used to treat excess cerumen?
Which agent can be used to treat excess cerumen?
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What is the primary characteristic of atopic dermatitis?
What is the primary characteristic of atopic dermatitis?
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What is the use of benzoyl peroxide in acne treatment?
What is the use of benzoyl peroxide in acne treatment?
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Which OTC treatment can be recommended for tinea pedis?
Which OTC treatment can be recommended for tinea pedis?
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How should hydrocortisone 1% be used for treating dermatologic conditions?
How should hydrocortisone 1% be used for treating dermatologic conditions?
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Which product is contraindicated in photoaging treatment?
Which product is contraindicated in photoaging treatment?
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What are common symptoms of tinea pedis?
What are common symptoms of tinea pedis?
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What is an effective treatment for minimizing scarring?
What is an effective treatment for minimizing scarring?
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What is the primary mechanism of action of dextromethorphan?
What is the primary mechanism of action of dextromethorphan?
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Which adverse effect is associated with the use of magnesium-containing antacids?
Which adverse effect is associated with the use of magnesium-containing antacids?
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What potential risk is linked to the use of pseudoephedrine during the first trimester of pregnancy?
What potential risk is linked to the use of pseudoephedrine during the first trimester of pregnancy?
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Which drug is an H2 receptor antagonist that may cause antiandrogenic effects?
Which drug is an H2 receptor antagonist that may cause antiandrogenic effects?
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What is a common side effect of proton pump inhibitors (PPIs) with long-term use?
What is a common side effect of proton pump inhibitors (PPIs) with long-term use?
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What is the effect of large doses of guaifenesin?
What is the effect of large doses of guaifenesin?
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Which statement about drug interactions of antacids is true?
Which statement about drug interactions of antacids is true?
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What should be avoided during pregnancy due to safety concerns?
What should be avoided during pregnancy due to safety concerns?
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Which of the following are symptoms of dyspepsia?
Which of the following are symptoms of dyspepsia?
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Which antihistamine is preferred for mild to moderate treatment during pregnancy?
Which antihistamine is preferred for mild to moderate treatment during pregnancy?
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What adverse effect is specifically linked with long-term use of cimetidine?
What adverse effect is specifically linked with long-term use of cimetidine?
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Which laxative category does polyethylene glycol 3350 belong to?
Which laxative category does polyethylene glycol 3350 belong to?
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What should be avoided in antacids when renal impairment is present?
What should be avoided in antacids when renal impairment is present?
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Which drug interactions can omeprazole cause?
Which drug interactions can omeprazole cause?
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Study Notes
Over-the-Counter (OTC) Drugs
- Objectives for common OTC drugs include identifying the pathophysiology of diseases/disorders, mechanism of action (MOA) of drugs, adverse effects, and drug interactions.
- Objectives for common vitamins, minerals, enzymes, and herbs involve identifying diseases/disorders and acceptable products, along with MOA (if noted).
- Handbook of Nonprescription Drugs (20th Edition) is an interactive approach to self-care, authored by Daniel L. Krinsky, Stefanie P. Ferreri, Brian A. Hemstreet, Anne L. Hume, Carol J. Rollins, and Karen J. Tietze.
Headaches
- Primary headaches include tension (episodic or chronic), migraine (without or with aura), and cluster headaches.
- Secondary headaches stem from stroke, substance abuse, infection, and other causes.
- Tension headaches involve myofascial tissues and pericranial nociceptors, episodic peripheral nervous system, and chronic central nervous system involvement (15 or more days per month for at least 3 months).
- Migraine headaches involve stimulated pain pathways with messenger molecules like nitric oxide, serotonin, and calcitonin gene-related peptide. Stimulus involves the trigeminal sensory fibers in cerebral and dural vessels, causing neuropeptide release, inflammation, vasodilation, and platelet/mast cell activation. In Aura-type migraines, neuronal depolarization spreads slowly across the cerebral cortex, potentially influenced by magnesium deficiency.
- Sinus headaches and estrogen withdrawal headaches are other types.
Table 5-1: Characteristics of Tension-Type, Migraine, and Sinus Headaches
- Tension-type headaches are bilateral, diffuse, mild-moderate, and gradual onset. The duration is 30 minutes to 7 days, aggravated by stress and anxiety. Non-headache-related symptoms are scalp tenderness, neck pain, and muscle tension.
- Migraine headaches are usually unilateral, throbbing/pulsating, moderate-severe in intensity, and sudden in onset. Duration is 4-72 hours, aggravated by physical activity, light, sound, nausea, vomiting, and aura. Symptoms can include pressure behind eyes or face, or dull bilateral pain; non-headache symptoms include nausea, vomiting and aura.
- Sinus headaches are positioned on the facial/forehead/periorbital area, pressure behind the eyes, and dull bilateral pain. The intensity is mild-severe, the onset is sudden, and duration is days which resolves with sinus symptoms. Aggravating factors include nasal congestion. Non-headache related symptoms include nasal congestion, nasal discharge.
Table 5-3: Recommended Dosages of Nonprescription Analgesics for Adults and Children (12 years and older)
- Acetaminophen (Tylenol/APAP) dosages vary from 325-1000 mg every 4-6 hours (3000 or 4000 mg with supervision of HCP) for immediate-release products or 650-1300 mg every 8 hours (3000, or 4000 mg with supervision of HCP) for extended-release products, as needed.
- Ibuprofen dosages range from 200-400 mg every 4-6 hours (max 1200 mg) as needed.
- Naproxen sodium dosages vary from 220 mg every 8-12 hours (660 mg), with initial dose of 2 tablets within first hour.
- Aspirin dosages vary from 325-1000 mg every 4-6 hours (max 4000mg) as needed.
- Maximum daily dosages may vary depending on product type (regular-strength, extra-strength, extended-release).
Acetaminophen (Tylenol/APAP)
- Acetaminophen (Tylenol/APAP) inhibits prostaglandin synthesis centrally.
- A boxed warning on acetaminophen products addresses its potential for hepatotoxicity.
- It's metabolized by the cytochrome P450 enzyme system resulting in a hepatotoxic intermediate metabolite detoxified by glutathione conjugation.
- Activated charcoal or acetylcysteine may be used to supplement glutathione.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
- NSAIDs relieve pain through central and peripheral inhibition of cyclooxygenase (COX), leading to prostaglandin synthesis inhibition. Common examples include ibuprofen (Advil) and naproxen (Aleve).
- Adverse effects include GI ulceration, perforation and bleeding, increased risk for myocardial infarction (MI), heart failure, hypertension, and stroke, sodium/water retention causing edema, and nephropathy with chronic use.
- Drugs interacting with NSAIDs include methotrexate (decreasing clearance), P2Y12 inhibitors & SSRIs (increased risk of bleeding), bisphosphonates (increased GI risk), digoxin (decreased renal clearance), and phenytoin (displacement from protein-binding sites).
Salicylates (Aspirin)
- Aspirin inhibits prostaglandin synthesis from arachidonic acid by inhibiting COX-1 and COX-2 enzymes.
- A positive result on fecal occult blood testing is possible after use, requiring discontinuation for at least 3 days before testing.
- Aspirin use or salicylate use is contraindicated in patients with gout, hyperuricemia, hypoprothrombinemia, vitamin K deficiency, hemophilia, and bleeding disorders.
- Warnings from the American Academy of Pediatrics, FDA, the Centers for Disease Control and Prevention, and the Surgeon General caution against aspirin/salicylate use in children and teens with influenza or chickenpox due to Reye's syndrome risk.
Combination OTC Products
- Combination products for headaches containing caffeine, nasal decongestants or diphenhydramine are available.
- Caffeine use may be problematic.
- Caution is advised for OTC analgesic use in patients taking blood thinners or consuming alcohol.
- Concomitant use of ethanol (EtOH) with APAP or NSAIDs requires caution.
Pregnancy/Lactation/Pediatrics
- Pregnancy: NSAIDs are contraindicated in the third trimester due to potential delayed parturition, prolonged labor, and increased postpartum bleeding. Premature ductus arteriosus closure is also a risk. APAP is safe.
- Lactating: Ibuprofen's infant dose ranges from 0.6%-0.9%, and acetaminophen's dose is 3.98%. Avoid aspirin.
- Pediatrics: APAP is safe for all ages. Ibuprofen doses are age and weight-dependent. Doses for acetaminophen are also age & weight dependent.
Dosing Considerations
- Various dosing scenarios are presented, involving calculation of appropriate medication amounts and volumes for different age groups and weights.
Fever
- Body temperature is regulated by the hypothalamus through a feedback system involving the anterior hypothalamus and thermosensitive CNS neurons.
- Pyrogens (exogenous or endogenous) activate the body's immune defenses and increase the set point, resulting in fever.
- Treating fever involves APAP or ibuprofen, potentially alternating use of both.
Musculoskeletal Injuries and Disorders
- Somatic pain is transmitted from peripheral nociceptors to the central nervous system causing pain.
- Inflammatory responses occur through multiple mediators such as histamine, bradykinin, serotonin, leukotrienes, and prostaglandin E.
Genitourinary System
- Common vaginal infections (bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis) are discussed using a table differentiating their classic signs, differentiating findings, and etiology/epidemiology.
- OTC treatments for vulvovaginal candidiasis (VVC) like azoles (topical, 7-day therapy preferred if pregnant—Clotrimazole, Miconazole, Tioconazole) are discussed.
- Vaginal itching and irritation are addressed with topicals such as hydrocortisone (1%), and benzocaine (5-10%)/resorcinol (2-3%).
Respiratory System
- Common respiratory conditions (colds, allergic rhinitis, cough), decongestants (adrenergic agonists like phenylephrine and oxymetazoline), antihistamines (first-generation—diphenhydramine, and second-generation—loratadine, cetirizine, levocetirizine, and fexofenadine), nasal spray (azelastine), cough suppressants (codeine, dextromethorphan), expectorants (guaifenesin), and intranasal corticosteroids (budesonide, fluticasone, and triamcinolone).
- Mechanism of action, adverse effects, precautions (including pregnancy and lactation) and drug interactions are described for these categories.
Gastrointestinal System
- Common gastrointestinal issues (heartburn, dyspepsia, diarrhea, constipation) and treatments (antacids, H2 blockers, proton pump inhibitors, and laxatives).
- Lifestyle modifications for gastrointestinal health, including weight loss, diet changes, and medication usage considerations, particularly in pregnancies and children.
- Specific details on the mechanism of action, adverse effects, warnings, and drug interactions for various medication categories are provided for the conditions.
Ophthalmic and Otic Products
- Dry eye and allergic conjunctivitis treatment options (decongestants such as phenylephrine, naphazoline, oxymetazoline, and tetrahydrozoline) and antihistamine/mast cell stabilizers (olopatadine and ketotifen).
- OTC treatments for excess cerumen (carbamide peroxide 6.5% with glycerin) and ear drops (isopropyl alcohol with glycerin) are discussed .
Dermatologic Disorders
- Common skin conditions such as atopic dermatitis (eczema), xerosis (dry skin), acne, photoaging, warts, alopecia (minoxidil), and pediculosis capitis (lice) are discussed.
- Treatments include topical corticosteroid (e.g., Hydrocortisone 1%), moisturizers (creams, ointments, and lotions), retinoids (adapalene), benzoyl peroxide, salicylic acid for acne, glycolic acid and retinol for photoaging, cryotherapy, and antiparasitic agents (permethrin and ivermectin).
Vitamins, Minerals, Enzymes & Herbs
- Various vitamins, minerals, enzymes, and herbs are discussed, along with their intended uses, mechanisms, cautions, and potential interactions. Topics include: B12 and B9, calcium and vitamin D, iron, coenzyme Q10, fish oil, red yeast rice, niacin, gingko biloba, melatonin, St. John's wort, valerian root, kava, kratom, CBD, cannabis sativa, echinacea, sambucus nigra (elderberry), vitamin C, zinc, probiotics (e.g., Florajen, VSL), glucosamine & chondroitin, saw palmetto, and other herbal remedies.
Natural Medicines in the Library
- Resources for researching natural medicines within a library.
Updates/Important Note
- Recent approvals of Narcan and Opill for OTC use in 2023.
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Description
Test your knowledge on pharmacology, including the risks associated with codeine use and the implications of various medications. This quiz covers metabolism, dosing guidelines for children, and contraindications during pregnancy. Enhance your understanding of drug interactions and their effects on different populations.
