Exam 2 Compilation - Clin Pharm 161 2024-2025

EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 OUTLINE i. MEBENDAZOLE...

EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 OUTLINE i. MEBENDAZOLE SUMMARY LESSON 4 - INFECTIONS LESSON 5 - CNS A. CHICKENPOX AND MEASLES I. PAIN I. CHICKENPOX (Varicella) A. ACUTE PAIN i. CLINICAL COURSE B. CHRONIC PAIN ii. CLINICAL MANIFESTATIONS C. PAIN ASSESSMENT iii. REACTIVATION TO SHINGLES D. TREATMENT OPTIONS (Herpes Zoster) i. ORAL ANALGESICS II. MEASLES 1. ASPIRIN AND IBUPROFEN i. CLINICAL COURSE 2. DICLOFENAC ii. CLINICAL MANIFESTATIONS 3. NAPROXEN III. CHICKENPOX VS MEASLES 4. PARACETAMOL IV. RED FLAGS FOR REFERRAL 5. ADDITIONAL INGREDIENTS V. LIFESTYLE ADVICE ii. TOPICAL ANALGESICS I. CHICKENPOX 1. TOPICAL NSAIDS ii. MEASLES 2. RUBEFACIENTS VI. IMMUNIZATION SCHEDULE (COUNTERIRRITANTS) VARICELLA AND MEASLES VACCINE 3. LOCAL ANESTHETICS VI. TREATMENT OPTIONS 4. FREEZE SPRAY B. IMPETIGO AND COLD SORES II. HEADACHE I. IMPETIGO A. TREATMENT OPTIONS I. CLINICAL MANIFESTATIONS B. CLINICAL PEARLS II. COLD SORES III. NAUSEA, VOMITING AND MOTION SICKNESS I. CLINICAL MANIFESTATIONS A. NAUSEA AND VOMITING III. RED FLAGS FOR REFERRAL I. RED FLAGS FOR REFERRAL IV. LIFESTYLE ADVICE i. MEDICINE-INDUCED N/V I. IMPETIGO i. TREATMENT OPTIONS ii. COLD SORES i. DOMPERIDONE IV. TREATMENT OPTIONS i. FDA CIRCULAR 2024-001 i. ACYCLOVIR B. MOTION SICKNESS V. IMPETIGO: ANTIMICROBIAL PRESCRIBING i. LIFESTYLE ADVICE C. THREADWORM AND ROUNDWORM i. STEPS TO PROPERLY USE SE-BAND ACUPRESSURE WRIST BANDS I. THREADWORM i. TREATMENT OPTIONS I. CLINICAL MANIFESTATIONS i. MECLIZINE II. ROUNDWORM ii. CLINICAL PEARLS I. CLINICAL MANIFESTATIONS IV. Musculoskeletal Conditions III. RED FLAGS FOR REFERRAL A. Acute Low Back Pain IV. LIFESTYLE ADVICE i. PQRST IV. TREATMENT OPTIONS ii. Red Flags for Referral COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 1 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 iii. Lifestyle Advice v. LIFESTYLE ADVICE iv. Treatment Options TREATMENT OPTIONS B. Soft Tissue Injuries i. CHLORAMPHENICOL i. Red Flags for Referral ii. TETRAHYDROZOLINE ii. Treatment Options C. SORE, TIRED AND DRY EYES V. INSOMNIA I. SORE AND TIRED EYES A. RED FLAGS FOR REFERRAL II. DRY EYES B. WELLNESS AND HEALTH PROMOTION i. RED FLAGS FOR REFERRAL TECHNIQUES ii. LIFESTYLE ADVICE i. COGNITIVE BEHAVIORAL THERAPY iii. TREATMENT OPTIONS FOR INSOMNIA i. HYPROMELLOSE I. STIMULUS CONTROL iv. OTHER TREATMENT OPTIONS ii. RELAXATION i. POLYVINYL ALCOHOL 1.4% iii. GOOD SLEEP HYGIENE ii. CARBOMER 940 C. MEDICINE-INDUCED INSOMNIA iii. HYALURONATE 0.1% D. TREATMENT OPTIONS C1. BLEPHARITIS AND STYES i. ANTIHISTAMINES I. BLEPHARITIS ii. MELATONIN RECEPTOR AGONISTS II. STYES OR HORDEOLA VI. OBESITY i. RED FLAGS FOR REFERRAL A. Lifestyle Advice ii. LIFESTYLE ADVICE B. Treatment Options iii. TREATMENT OPTIONS i. Orlistat III. EYE DROPS VII. SMOKING CESSATION IV. EYE OINTMENT A. NIcotine Dependence V. CLINICAL PEARLS B. Role of the Pharmacists (5 A’s) D. EAR HEALTH C. Treatment Options I. EAR ACHE i. Oral NRT i. TREATMENT OPTIONS i. Transdermal NRT i. ORAL ANALGESICS VIII. SUMMARY ii. OTIC ANALGESICS LESSON 6 - EYES, EARS AND ORAL HEALTH II. EAR WAX IMPACTION A. EYES, EARS, AND ORAL EXAMINATION i. RED FLAGS I. EYE EXAMINATIONS ii. LIFESTYLE ADVICE II. EAR EXAMINATIONS iii. TREATMENT OPTIONS III. ORAL EXAMINATIONS i. DOCUSATE B. EYE HEALTH iv. CLINICAL PEARLS I. CONJUNCTIVITIS III. OTITIS EXTERNA i. CAUSE OF CONJUNCTIVITIS i. CAUSES OF OTITIS EXTERNA ii. DIFFERENT TYPES OF ii. QUESTION AND RELEVANCE FOR CONJUNCTIVITIS OTITIS EXTERNA iii. QUESTIONS TO ASK FOR PATIENTS iii. RED FLAGS FOR REFERRAL WHO HAVE CONJUNCTIVITIS iv. LIFESTYLE ADVICE iv. RED FLAGS FOR REFERRAL COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 2 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 v. TREATMENT OPTIONS A. CHICKENPOX AND MEASLES IV. ADMINISTERING EAR DROPS I. CHICKENPOX (Varicella) E. ORAL HEALTH Highly infectious viral disease (varicella zoster virus), 🔉 which can be fatal. I. TEETHING AKA bulutong i. LIFESTYLE ADVICE ○ Most common infectious disease of childhood (12 y/o) Promethazine is available as a syrup or as a tablet, 6.5 to 12.5mg TID or 25 mg HS (> 2y/o) May make the child drowsy, and can be useful at night-time COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 6 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 🔉 During reactivation, the virus actively replicates which leads to lesions and distribution in the affected nerve Transmitted via direct contact and through vesicular exudate I. CLINICAL MANIFESTATIONS 🔉 To differentiate from Impetigo, look at the stage of progression and appearance of the lesion Lesions on the lips (common in lips), may sometimes appear on the nose and around the mouth, which eventually dry up to form yellow crust ○ Prodrome of itching, burning pain, or tingling Bullous impetigo symptoms hours to days prior to vesicle eruption ○ Flaccid, fluid-filled bullae ○ Crusting happens within 24 hours ○ Rupture ○ Lesions spontaneously resolve in 7 to 10 days ○ Leaves a thin brown crust Usually last 14 days from the recognition of ○ Often located on trunk prodromal symptoms to symptom resolution Take note of prodrome period of cold sores as it is essential in treatment I. CLINICAL MANIFESTATIONS Rash occurring mostly on face, chiefly around nose and mouth ○ May sometimes affect the limbs ○ Begins with small red itchy patch of inflamed skin → vesicles that rupture and weep → drying of exudate → yellow-brown crusted lesions ○ Infectious until lesions have dried up Stages of Blisters II. COLD SORES 🔉 Viral infection caused by herpes simplex virus (HSV1) Similar to impetigo since it also affects mouth area but different since 🔉 Impetigo:Bacterial ; Cold Sores:Viral 🔉 HSV1: almost always causes a cold sore HSV2: most commonly implicated in genital lesions (genital herpes) ○ 50% of adults may have been infected, although not all 🔉 are symptomatic Since viral, it can be reactivated Primary infection most commonly contracted by preschool children (asymptomatic) Once contracted, the infection lasts the lifetime of the host III. RED FLAGS FOR REFERRAL Infects nerve endings which travels to the Papular rash (papules - flat like lesions; sometimes palpable sensory ganglia where it lies dormant in the - slightly elevated), with or without vesicles and crusting, in dorsal root ganglia of the trigeminal nerve the beard area of men (located in the face, associated with the ○ May indicate sycosis barbae (bacterial infection) or 🔉 control of mouth) until reactivation tinea barbae infection (fungal infection) If bacterial or fungal, will require antibiotics/antifungals which are Rx COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 7 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 Widespread non-bullous impetigo, or bullous impetigo ○ Aciclovir 5% cream (Rx in PH, but OTC in EU) and Cold sores located within the mouth Penciclovir 1% cream (not available in PH) Patient suffering from atopic eczema who has come into First-line therapy for treatment and prevention of contact with an active cold sore cold sores ○ Life-threatening due to increased risk of widespread Reduces total healing time by 0.5 to 1 day herpetiform eczema when applied during prodromal stage Skin lesions accompanied by fever and malaise Oral formulation are effective against HSV, but 🔉 ○ May indicate infection which might require antibiotic topical formulations are less conclusive therapy But topicals are still recommended since Immunocompromised patients, or those taking these are localized, to prevent systemic side 🔉 immunosuppressants effects(which orals have) Since they will experience more severe factors and Miscellaneous Products slower healing time ○ Ammonia, Zinc, Phenol No evidence of efficacy, but may dry up cold sore IV. LIFESTYLE ADVICE lesions and prevent secondary bacterial infections I. IMPETIGO ○ Local Anesthetics (Lidocaine), Choline Salicylate Do not scratch lesions to prevent scarring and transmission For pain relief for cold sores ○ Keep fingernails short Antibiotics Prevent contact with other people until the lesions clear ○ For localized non-bullous impetigo with 1% Hydrogen General hygiene measures Peroxide Cream not suitable ○ Do not share towels and clothing ○ For widespread and progressed non-bullous impetigo, ○ Wash affected area with soapy water or bullous impetigo ○ Wash hands thoroughly after touching affected area, and after applying antibiotic creams ii. COLD SORES Do not touch affected area, unless treatment is being applied to the area General hygiene measures ○ Do not share items which come into contact with lesions (eating utensils, lipstick, towels) ○ Wash hands thoroughly after touching affected area, and after applying treatment 🔉 Acyclovir is safe for children of all ages and in pregnant women ○ Avoid kissing until lesions are healed (risk of transmission is highest during first 4 days of symptoms) ○ Do not burst blisters i. ACYCLOVIR Children with cold sores can attend school as normal Mechanism Use sunblock (may be additional revenue of the pharmacy), ○ Inhibits herpes virus DNA polymerase as there are cold sores that can be triggered by sun Counseling Points exposure (on your face or butt) ○ Should be used as soon as symptoms exist to gain and maximize benefits which is reduced healing time ○ May cause initial stinging when applied IV. TREATMENT OPTIONS Product Topical Antiseptics ○ Aciclovir 5% Cream (Zovirax®) ○ 1% Hydrogen Peroxide Cream Applied 5x daily at approximately 4h-interval for at least 5 days 🔉 For localized non-bullous impetigo If bullous na, will require antibiotics May be continued for up to 10 days if healing 🔉 Others do not have sufficient evidence has not occurred Antiviral Preparations Difference with Penciclovir: Penciclovir has more frequent application and for only 4 days COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 8 of 40  EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 🔉 Only impetigo has NO PRODROMAL STAGE V. IMPETIGO: ANTIMICROBIAL PRESCRIBING 🔉 Retroinfection infection occurs when larvae hatch and travel 🔉 Threadworm eggs are highly resistant to environmental back to the large intestine factors and can easily be transferred to clothing, bed linen, toys, etc. resulting in inhalation infections I. CLINICAL MANIFESTATIONS Night-time perianal itching ○ Due to mucus produced by females when laying eggs C. THREADWORM AND ROUNDWORM ○ Highly suggestive of threadworm in children Part of phylum Nematoda May be confirmed with stool examination 🔉 May be dermatitis if in adult if there is no recent family history, no affected I. THREADWORM nearby people, no visible worms in stool, it is Also known as pinworm or Enterobius vermicularis, which most likely dermatitis due to irritating clothing enterobiasis may cause ○ May also include local tickling sensation, acute pain, ○ Most common helminth infection irritability and tiredness More common in pre-school children vs adults ○ May ask whether perianal skin is broken or weeping to ○ Transmitted via fecal-oral retroinfection, and inhalation check for excoriation and secondary bacterial infection route, due to persistent scratching Eggs → breakdown by duodenal fluid → release of larvae → migration into the small and large II. ROUNDWORM intestines → females migrate to the anus, usually at Also known as ascaris or Ascaris lumbricoides, which may 🔉 night → laying of eggs(can cause itching) Counselling pharmacist must reassure patient that cause ascariasis contracting this does not automatically mean that they are ○ Less common, more serious, and more difficult to unhygienic, since it can be transmitted through inhalation identify vs threadworm and not just the fecal-oral route ○ Transmitted via ingestion of contaminated food, water, or soil COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 9 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 Eggs hatching in the intestine → larvae pass into 🔉 Areas for urination and vaginal discharge are close to the bloodstream → migration into the lungs, liver, each other. Since the roundworm can migrate, it can 🔉 trachea, and esophagus → intestine affect these nearby areas when they hatch and lay 🔉 Coz it can migrate around these areas, there eggs. can be symptoms that manifest in these areas Refer to physician Accompanied by vomiting, diarrhea, or unexplained weight 🔉 loss Can manifest as GI symptoms 🔉 Recent travel abroad 🔉 There may be other worms that infested the patient There may be worms endemic to specific countries IV. LIFESTYLE ADVICE 🔉 Hygiene Measures Good and strict hygiene practice is the most important lifestyle advice. General hygiene advice ○ Ensure nails are kept short and washed regularly ○ Always wash hands after using the bathroom 🔉 ○ Do not bite nails and avoid putting hands in the mouth Keeping hands clean reduces fecal-oral transmission. ○ Avoid sharing of towels 🔉 ○ Daily vacuuming to remove eggs NOTE: Not everyone has access to vacuums. Thus, recommend other cleaning methods that are more I. CLINICAL MANIFESTATIONS feasible for them (e.g. sweeping, mopping, etc.). Light infestations are usually asymptomatic At the time of treatment Heavy infestations produce GI and respiratory symptoms, ○ Wash all bed linen, sleepwear, towels, and any toys that and sometimes fatal children have in bed with them ○ Persistent cough, SOB, wheezing ○ Thoroughly clean the house and ensure that cloth is ○ Vague abdominal pain, N/V, diarrhea or bloody stools thrown out after use ○ Ensure that the bathroom is cleaned and all towels are 🔉 ○ Malnutrition Heavy infestations - hatching of larvae and mature to washed For the next 2 weeks 🔉 adult worms, laying of eggs and propagate They are more likely to survive and migrate to other ○ Wear loose-fitting clothes in bed and change in the morning 🔉 areas of the body If the round worm is in chronic manifestation, it can ○ If particularly itchy at night, consider wearing gloves present as malnutrition. The roundworms are able to Wear underpants under pajamas at night to survive a longer period of time. They are like pests that prevent them from transferring eggs to their try to compete for nutrients in the body. fingers if they scratch during sleep ○ Ensure that children and adults are fully bathed in the morning III. RED FLAGS FOR REFERRAL 🔉 Medication failure IV. TREATMENT OPTIONS Refer to doctor if the worms remain Mebendazole 🔉 Secondary infection of perianal skin due to scratching Other infections may be present = refer for antibiotics ○ First-line therapy for threadworms Fever with bedwetting or pain when urinating, and vaginal Higher cure rates for roundworm vs threadworm discharge in young women (60% to 82%) COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 10 of 40  EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 Requires medical supervision if to be used for Repeat dose 14 days later often recommended 🔉 roundworm to ensure complete eradication ○ Available as OTC Children do NOT need to be excluded from school, as long Piperazine as they follow strict hygiene practices ○ Less evidence, less cure rate vs Mebendazole Probably due to its mechanism where Piperazine SUMMARY only paralyzes the worm Chickenpox and measles usually present as lesions If paralysis wears off, the worm might be able to 🔉 affecting the trunk area of the body migrate back into the colon and cause treatment 🔉 Difference: failure Chickenpox: starts at trunk and is elevated and Co-formulated with Senna to optimize worm 🔉 blisterous clearance Measles: start at forehead/face and is flat and ○ OTC in other countries, but not available in PH erythematous ○ Tx: Antipyretics(ex. paracetamol is often recommended), analgesics, antipruritics(topical calamine), and antihistamines(ex. chlorphenamine & promethazine) may be useful Avoid aspirin and other NSAIDS as it can cause severe skin complications ○ Referral is recommended/required for measles to prevent outbreak 🔉 Both are avoided in pregnancy due to its teratogenic ○ Vaccination is the key to prevent incidence! Impetigo and cold sores usually present as lesions in the 🔉 Both are reported not to transfer in milk, which makes properties (i.e. can cause fetal deformities). 🔉 face 🔉 breastfeeding alright. Difference: Impetigo: bacterial infection and has NO prodromal 🔉 stage i. MEBENDAZOLE Cold Sores: viral infection and has prodromal stage Mechanism ○ 1% Hydrogen peroxide cream may be recommended ○ Inhibits worms’ uptake of glucose → disrupts energy for localized non-bullous impetigo, otherwise, refer for 🔉 metabolism → death within 3 days of administration antibiotic treatment Patients report that worms will be seen in stool, this ○ Acyclovir cream is recommended as first-line therapy simply means that the worms have been successfully for cold sores, but would require prescription eradicated and eliminated through the stool Should be started at the onset of symptoms Counseling Points (prodrome) to reduce healing time ○ Strict personal complementary to pharmacological 🔉 Threadworms and roundworms usually affect children treatment Remember common routes of transmission ○ Ideally should be given to all family members, and not ○ Mebendazole is the first-line therapy, although its use 🔉 only to the patient in roundworms would require medical supervision vs Since it is possible that they are already OTC for threadworms infected but just asymptomatic ○ Strict personal hygiene is complementary to ○ Potentially teratogenic pharmacological treatment Therefore alternative recommendation can be to For the patient, and every household; and ideally follow strict personal hygiene measures for 6 should have repeat dose after 14 days weeks Products LESSON 5 - CNS ○ Mebendazole 20mg/mL Suspension or 100mg tablet (Vermox®, Antiox®) I. PAIN Single 100mg dose Most common symptom among patients COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 11 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 ○ Acute Pain Arises from muscles, bones, joints, or Arises from tissue damage, inflammation, or connective tissues disease process that is of relatively brief Examples: Polymyositis, dermatitis, duration and linear nature arthritis, sickle cell disease, statin induced Treatment include short-term symptomatic myopathy relief using NSAIDs and opiates Phantom pain is most commonly ○ Chronic Pain associated with amputation where they Persists for extended periods of time (>3 still feel pain. months) that tends to be circular in nature NOTE Statin induced myopathy is usually Treatment include not only symptom relief, but associated with people with high also amelioration of suffering and disability cholesterol. Side effects of taking using regular analgesics + adjuvants statins are usually muscular pain. (anticonvulsants, benzodiazepines, and antidepressants [such as TCAs]) C. PAIN ASSESSMENT Pain Interview Acute pain has a duration of Blocks the enzyme COX → prevents formation of Paracetamol 1000mg = Aspirin 650mg prostaglandin from arachidonic acid → no local Dental Pain inflammation, pain, or fever ○ Ibuprofen 400mg > Paracetamol 1000mg = Aspirin ○ Paracetamol 650mg ○ Additional ingredients: Codeine, Caffeine Dysmenorrhea Topical Analgesics ○ NSAIDs (Naproxen > Ibuprofen) > Paracetamol ○ NSAIDs, Rubefacients, Local Anesthetics, Freeze Back Pain and Muscular Pain Spray ○ NSAIDs (Ibuprofen > Aspirin) > Paracetamol All classes of topical analgesics have been Pain and Fever in Children shown to be effective for short-term treatment ○ Ibuprofen > Paracetamol of musculoskeletal pain NSAIDs have the best evidence of efficacy 1. ASPIRIN AND IBUPROFEN Topical NSAIDs can produce the same For mild to moderate pain (dental, musculoskeletal, adverse effects and side-effects as oral dysmenorrhea) NSAIDs in sensitive individuals Side Effects ○ Aspirin > Ibuprofen Paracetamol is not considered NSAIDs GI irritation and bleeding because it has little to no Reduced by taking with or after food anti-inflammatory properties Hypersensitivity reactions in asthma or allergy NOTE Patients taking topical NSAIDs can still patients experience the same side effects May impair liver and renal functions compared to when they opt to take oral Delays onset of labor, affects late-stage or systemic development of fetus, and may increase hemorrhage during labor COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 13 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 Reye’s Syndrome with aspirin in 1 month), may be at higher risk of ○ NSAIDS (Ibuprofen) dehydration Cluster ○ Inhaled oxygen i. MEDICINE-INDUCED N/V ○ SC Sumatriptan (Not in PH) Cytotoxics Opiates B. CLINICAL PEARLS Iron Ask the patient Antibiotics (Doxycycline) ○ They often know what works for them (Concept of Aspirin and NSAIDs Autonomy) ○ Most common cause If asked for recommendation, FIRST CHOICE is Potassium supplements IBUPROFEN Digoxin toxicity Combination of products with Codeine Topical NSAIDs are unlikely to interact with other drugs i. TREATMENT OPTIONS ○ They must not be used by people sensitive to Domperidone aspirin and other NSAIDs ○ For N/V of less than 48 hours and for relief of ○ Rubefacients containing salicylates are also post-prandial (after meals) symptoms contraindicated Better vs placebo ○ Available as OTC until March 5, 2024 in PH (still OTC III. NAUSEA, VOMITING AND MOTION SICKNESS in other countries); now requires Rx in PH Prochlorperazine COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 16 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 ○ For N/V associated with migraine years, patients taking daily doses greater than 30 mg, ○ Available as OTC in other countries (oral) but and patients concurrently taking QT-prolonging drugs requires Rx in PH (solution for injection) (e.g. disopyramide, quinidine, amiodarone, dofetilide, Oral rehydration solutions dronedarone, ibutilide, sotalol, haloperidol, pimozide, ○ Pharmacists may initiate rehydration therapy in sertindole, citalopram, escitalopram) or CYP3A4 the meantime for patients who are vomiting inhibitors (e.g. clarithromycin, erythromycin, itraconazole, oral ketoconazole, posaconazole, ritonavir, saquinavir, telithromycin, telaprevir and voriconazole). B. MOTION SICKNESS Form of vertigo Symptom complex characterized by nausea, pallor, vague abdominal discomfort, and occasionally i. DOMPERIDONE vomiting Mechanism of Action ○ Affects any individual and involve any form of ○ Dopamine antagonist → reduced input in the movement chemoreceptor trigger zone (CTZ) → Reduced ○ Most common in age 2 to 12 y/o, and due to vomiting reflex moving vehicles, fairground rides Counseling Points ○ Inability of brain to process conflicting information ○ Side effects are rare from sensory nerve terminals involving movement Galactorrhea (milk/fluid secretions in breast) and position Gynecomastia (abnormal breast enlargement) ○ Tend to resolve over prolonged exposure to motion Reduced libido due to adaptation Dystonia (problem in postural tone) Rash i. LIFESTYLE ADVICE Products Minimizing motion ○ Domperidone 10 mg Tablet or 1mg/mL suspension ○ Identify mode of travel (Motilium®) Planes – sit over the wing One tablet QID (4x a day), preferably after Ships – sit in the middle close to the water line meals Cars – sit in the front Avoid rear-facing seats in any form of transport i. FDA CIRCULAR 2024-001 Increasing focus on objects to help settle the brain’s receipt of conflicting messages Focus on stationary objects Elevate seating position so patients can see out of the car Playing games during travel Avoid reading Avoid alcohol or overeating before journeys Ensure good ventilation (opening of window) Use of alternatives ○ Acupressure The FDA conducted a literature review to assess the Available as OTC, but conflicting evidence safety of Domperidone considering regulatory actions regarding benefits made by other countries in response to an ○ Ginger epidemiological study showing that this drug is Has probable antiemetic activity, with better associated with an increased risk of serious efficacy in motion sickness vs placebo (similar ventricular arrhythmias or sudden cardiac death. A with pharmacological agents); but studies are higher risk was observed in patients older than 60 not robust COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 17 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 ○ Might be worth trying for drivers or pregnant ○ Has antihistamine and antimuscarinic activity, and women probable anti-dopaminergic effect → decreased input on the vomiting center i. STEPS TO PROPERLY USE SE-BAND ACUPRESSURE WRIST Counseling Points BANDS ○ Most effective when given prophylactically Only Promethazine has shown utility for treatment of motion sickness (vs others which are for prevention) ○ May experience dry mouth as side effect May suck sweets to stimulate saliva production Products ○ Meclizine 12.5mg or 25mg Tablet/Chewable Tablet (Bonamine®) Age 2 to 12 years: 12.5mg OD i. TREATMENT OPTIONS Adult: 25mg OD 1st Generation Antihistamines Must be taken the previous evening or 1h ○ Better vs placebo before exposure to motion, vs: Meclizine available as OTC, least sedating, has Promethazine (for prophylaxis): previous long duration of action (~24h) evening or 1h before, OD. If for treatment, Available as OTC in other countries take it immediately. Cinnarizine, but requires Rx in PH Cinnarizine (for prophylaxis): 2h before, Promethazine (oral), but requires Rx in PH then q8h (IM/IV) Hyoscine (for prophylaxis): 20 minutes ○ Most sedating, has long duration of before, then q6h action (~24h) ii. CLINICAL PEARLS Cyclizine, but not available in PH since Match up product with length of journey prone to abuse ○ If longer than 8 hours: Meclizine and Promethazine Anticholinergics (duration of action is 24 hours) ○ Better vs placebo, probably more effective vs ○ If 4 to 8 hours: Cinnarizine (taken once) antihistamines, but short-duration and more ○ If 1 week → refer in pain relief and functional improvement ○ Accurate history taking is important from advice to stay active compared to advice to rest in bed Exercise programs can help with acute back A. Acute Low Back Pain pain and have been shown to reduce Self-limiting, with 90% of patient getting better within recurrence 6 weeks Use of complementary therapy Most commonly seen in: ○ Acupuncture ○ Age 30 – 55 y/o No benefit in acute LBP, more effective in pain ○ Pregnant women relief for chronic LBP vs no treatment ○ Patients with occupation risk factors ○ Massage therapy ○ Patients engaged in sports May be beneficial in non-specific back pain Acupuncture massage may be better than traditional massage ○ Superficial heat and cold Heat wrap therapy may reduce pain and disability in the short-term to a small extent No conclusive evidence for cold therapy iv. Treatment Options Oral Analgesics ○ NSAIDs (Ibuprofen > Aspirin) > Paracetamol for 7 to i. PQRST 10 days Paracetamol may still be used as first-line due to fewer S/E Advise to seek GP if symptoms fail to improve after 7 days ○ Compound analgesics such as Paracetamol/Codeine, Aspirin/Codeine, Paracetamol/Dihydrocodeine should be avoided May still be perceived better due to placebo response ○ Caffeine may be added at doses 100mg or more, for little additional benefit ii. Red Flags for Referral Must be avoided before going to bed Topical Analgesics ○ Topical NSAIDs may be beneficial for lesser S/E vs oral NSAIDs ○ Rubefacients = topical placebo in acute and chronic LBP; except for capsaicin Others ○ Enzymes (heparinoids and hyaluronidase) may disperse fluids in swollen areas → reduction in swelling and bruising; but unproven ○ Glucosamine > chondroitin for iii. Lifestyle Advice osteoarthritis-associated low back pain COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 19 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 Pain felt in the small, fluid-filled sacs (bursa), which cushions the bones, tendons, and B. Soft Tissue Injuries muscles near the joints Usually activity—related or sports-related affecting the shoulder, elbow, knee, ankle and foot ○ Patients usually go directly to GP or physiotherapist ○ May be: Sprain - Forcing of joint into abnormal position that overstretches or twists ligaments Strains - Tearing of muscle fibers, which can be partial or complete, and is usually a result of over-exertion when muscle is stretched beyond usual limits Shoulder-specific Conditions ○ Rotator Cuff Syndrome Rubbing of the combined tendons of the scapula muscles → pain Most often seen in patients over the age of 40 and is associated with repetitive overhead activity Knee-specific Conditions ○ Frozen Shoulder ○ Ligament Damage Used to describe the shoulder when it has Injury due to twisting (damage to the medial marked restriction in all the major ranges of meniscus) is less serious vs injury due to blow motion at the back of the knee (damage to anterior Relatively uncommon cause of shoulder pain cruciate ligament) accounting for 2% of cases ○ Runners Knee (Chondromalacia) Pain is experienced usually at the front of the knee or behind the kneecap Most commonly seen in recreational joggers increasing their mileage Ankle- and Foot-specific Conditions ○ Ankle Sprains Patients usually describe an accident when they ‘went over their ankle’ Most patients will walk with a limp because the ankle cannot support their full weight ○ Achilles Tendon Injuries Pain usually felt behind the heel, just above Elbow-specific Conditions the calcaneus, and progressively worsens the ○ Golfer’s Elbow (Medial epicondylitis) longer the injury lasts Pain felt on the inner side of the elbow and can Usually seen in runners or athletes involved in radiate down the forearm jumping sports ○ Tennis Elbow (Lateral epicondylitis) ○ Plantar Fasciitis Pain and tenderness felt over outer aspect of Pain felt along the plantar surface of the foot the elbow joint that might also spread up the and heel, which can progressively worsen upper arm Muscle Strains ○ Student’s Elbow (Bursitis) ○ Thigh Strains COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 20 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 Commonly due to tears of the quadriceps ○ Young adults complain about difficulty falling (front of the thigh) and hamstring (back of the asleep thigh) ○ Middle-aged and elderly complain about Patients will not always be able to recall a middle-of-night awakenings or early morning specific event that has caused the strain awakenings Pain and discomfort worsened when patient Self-medication is as high as 40% tries to use the muscle i. Red Flags for Referral Acute injuries which show immediate swelling and severe pain Children under 12 and elderly patients Decreased range of motion in all direction involving the shoulder Excessive range of movement in any joint ○ May suggest major ligament disruption Patients unable to bear any weight on an injured ankle/foot Suspected fracture Treatment failure ii. Treatment Options Same with low back pain, but non-drug treatment plays a vital and major role in the treatment of soft tissue injuries (RICE) ○ Rest Allows immobilization, enhancing healing and reducing blood flow ○ Ice Should be applied whilst the injury feels warm to the touch Apply until the skin becomes numb and repeat at hourly intervals Bags of frozen peas wrapped in a towel are ideal to use on the injury as they conform to body shape and provide even distribution of cold ○ Compression A crepe bandage provides a minimum level of compression. Tubular stockings (e.g. Tubigrip) A. RED FLAGS FOR REFERRAL are convenient and easy to apply but fail to Children under 12 give adequate compression Duration of more than 3 weeks (chronic) ○ Elevation Insomnia for which no cause can be ascertained Ideally the injured part should be elevated Previous undiagnosed medical conditions above the heart to help fluid drain away from Symptoms suggestive of anxiety or depression the injury V. INSOMNIA Inability to initiate or maintain sleep, and can be associated with problems during the daytime COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 21 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 Avoid drinking large quantities of liquids in the evening C. MEDICINE-INDUCED INSOMNIA Stimulants (caffeine, theophylline, sympathomimetics) Anti-epileptics (phenytoin, carbamazepine) Alcohol ○ Low to moderate can promote sleep, but when taken in excess may disturb sleep Beta-blockers (propranolol) ○ Can cause nightmares Diuretics ○ Ensure doses are not taken after midday to stop nocturia (pag-ihi sa gabi) B. WELLNESS AND HEALTH PROMOTION TECHNIQUES D. TREATMENT OPTIONS i. COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA Pharmacotherapy First-line agent, more effective in >55 y/o vs ○ Indicated for all forms of insomnia BUT as an pharmacotherapy (CBTI has no side effect) adjunct only (first-line is CBTI) INVOLVES: Stimulus control therapy, sleep restriction, ○ Barbiturates and non barbiturates (chloral relaxation therapy, cognitive therapy, paradoxical hydrate), benzodiazepines, Z drugs (zolpidem, intention, biofeedback, and education on good sleep zaleplon, es/zopiclone), melatonin agonists hygiene (ramelteon, tasimelteon), dual orexin receptor Administered over a 5-hr period over the course of 4-6 antagonist (suvorexant), antihistamines weeks and can be a maintenance I. STIMULUS CONTROL Maintain regular bedtimes and awakenings Sleep long enough to avoid feeling tired, but no more Do not go to bed unless you are sleepy If you cannot go back to sleep do not stay in bed more than 15-20 minutes; get up and do something else until you are sleepy i. ANTIHISTAMINES do not go to bed hungry, do no stuff yourself before Usually both sedating and anticholinergic bed; try a small snack ○ Diphenhydramine 50 mg PO 30 minutes before Avoid activities in the bedroom except for sleeping and bedtime (50 mg requires Rx vs 25 mg OTC) sex ○ Others: Doxylamine, Hydroxyzine, Promethazine Avoid naps during the day Effective and safe in mild insomnia ○ Not as effective vs Benzodiazepines (BZDs), but ii. RELAXATION can be an alternative if BZD is C/I Slow contraction and relaxation of muscles (superior ○ Higher incidence of daytime sedation parts to inferior) ○ Caution in elderly → anticholinergic effect → iii. GOOD SLEEP HYGIENE worsening of dementia and other conditions (like Exercise routinely (3 to 4x weekly) during the day, but glaucoma and prostate enlargement) not close to bedtime ○ Regular use not recommended → do not use for >10 Optimize the bedroom conditions (e.g. light, days to avoid tolerance temperature, noise) Increasing dose will not produce a linear Develop a bedtime ritual that allows you to unwind increase in response Avoid blue spectrum light from TV, smart phones, ii. MELATONIN RECEPTOR AGONISTS tablets, and other mobile devices Melatonin Avoid alcohol, caffeine, and nicotine since they have ○ Exogenous stimulant effects COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 22 of 40 EXAM 2 COMPILATION Clin Pharm 161 (PHARMACY WELLNESS AND HEALTH PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 ○ Prolonged-release improves sleep onset latency free fatty acids and monoglycerides → elimination and quality in patients >55 years old of fat via feces ○ Limited clinical data on use for chronic insomnia Counseling Points ○ May be beneficial to patients with delayed sleep ○ Indicated for weight loss in adults (>=18 y/o) who phase syndrome and in a subgroup patients with are overweight (BMI ≥28 kg/m2) and SHOULD BE low melatonin level TAKEN IN CONJUNCTION with a mildly Limit use to a maximum of 3 months hypocaloric, lower-fat diet ○ May possibly reduce absorption of fat-soluble VI. OBESITY medications Growing epidemic which increases CV and DM risks → ○ Limited data in pregnancy and breastfeeding shorter life-spans women → not recommended ○ Main cause include increased consumption of Side Effects energy-dense foods high in fats and sugars, and ○ GI in nature reduced physical activity Abdominal pain or discomfort, oily spotting ○ BMI as the internationally accepted measure, but from the rectum, flatus with discharge, fecal waist circumference should also be taken into urgency, and fatty or oily stools account Increases with fat content in diet Minimize intake to