OTCs (Student View 2025) PDF
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2025
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This document provides an overview of over-the-counter (OTC) medications, focusing on common drugs, their uses, and considerations. Key aspects of various medication types covered include objectives, headaches, and their associated treatments and warnings.
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Over-the-Counter (OTC) Objectives For common OTC drugs, you should be able to identify: Pathophysiology of diseases / disorders MOA of drugs Adverse effects Drug interactions For common vitamins, minerals, enzymes & herbs, you should be able to identify: Dise...
Over-the-Counter (OTC) Objectives For common OTC drugs, you should be able to identify: Pathophysiology of diseases / disorders MOA of drugs Adverse effects Drug interactions For common vitamins, minerals, enzymes & herbs, you should be able to identify: Diseases / disorders and acceptable products MOA (if noted in slides) Headaches Headaches Primary Tension (episodic or chronic) Migraine (without or with aura) Cluster Secondary Stroke Substance abuse Infection Others… Headaches Tension Myofascial tissues & pericranial nociceptors Episodic peripheral nervous system Chronic central nervous system 15 or more days per month for at least 3 months Migraine Without aura Pain pathways are stimulated and messenger molecules are involved, including nitric oxide, serotonin, and calcitonin gene–related peptide Stimulation (by an axon reflex) of trigeminal sensory fibers in the large cerebral and dural vessels causes neuropeptide release with concomitant neurogenic inflammation, vasodilation, and activation of platelets and mast cells With aura Neuronal depolarization that spreads slowly across the cerebral cortex Magnesium deficiency may contribute to this state Sinus headaches Estrogen withdrawal headaches What is the max adult dose of APAP & ibuprofen per day? Why do children start taking adult doses at Rx doses age 12? will be higher than OTC doses Headaches Acetaminophen (Tylenol / APAP) Central inhibition of prostaglandin synthesis FDA requires manufacturers to include a boxed warning on acetaminophen products that addresses its potential to cause hepatotoxicity Metabolized by the cytochrome P450 enzyme system to a hepatotoxic intermediate metabolite that is detoxified by glutathione (Phase II conjugation) May be treated with activated charcoal or acetylcysteine to supplement glutathione Headaches Acetaminophen (Tylenol / APAP) Blackbox warnings Headaches Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Relieve pain through central and peripheral inhibition of cyclooxygenase (COX) with consequent inhibition of prostaglandin synthesis Ibuprofen (Advil) and naproxen (Aleve) Adverse effects GI ulceration, perforation, and bleeding NSAID use is associated with increased risk for myocardial infarction (MI), heart failure, hypertension, and stroke Sodium and water retention causing edema Nephropathy with chronic use Drug interactions Methotrexate decreased methotrexate clearance P2Y12 inhibitors & SSRIs increased risk of bleeding Bisphosphonates increased risk of GI bleeding / ulceration Digoxin decreased renal clearance monitor Phenytoin and ibuprofen displacement from protein-binding sites monitor Headaches Salicylates Aspirin Inhibit prostaglandin synthesis from arachidonic acid by inhibiting both isoforms of the COX enzyme (COX-1 and COX-2) Intolerance is uncommon and consists of two types: cutaneous (manifesting as urticaria and angioedema) and respiratory (manifesting as bronchospasm, laryngospasm, and rhinorrhea) May produce a positive result on fecal occult blood testing, so its use should be discontinued at least 3 days before testing Should be avoided in patients with a history of gout or hyperuricemia because of dose-related effects on renal uric acid Contraindicated in patients with hypoprothrombinemia, vitamin K deficiency, hemophilia, history of any bleeding disorder The American Academy of Pediatrics, FDA, the Centers for Disease Control and Prevention, and the Surgeon General have issued warnings that aspirin and other salicylates (including bismuth subsalicylate and nonaspirin salicylates) should be avoided in children and teenagers who have influenza or chicken-pox due to the risk of Reye’s syndrome. Drug interactions Similar to NSAIDs Valproic acid displacement of valproic acid from protein-binding sites and inhibition of valproic acid metabolism Sulfonylureas increased risk of hypoglycemia *APAP analgesic pathway not as well understood… probably inhibits COX per Micromedex Arachidonic acid (AA) metabolism. This figure also illustrates some of the major differences between cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). Phospholipase A (PLA) is stimulated by physical, chemical, inflammatory, and mitogenic stimuli and releases AA from cell membranes. The COX- 1 enzyme synthesizes prostaglandins (PGs) that maintain cellular and vascular homeostasis. The COX-2 enzyme produces PGs within activated macrophages and endothelial cells that accompany inflammation. Whereas nonsteroidal antiinflammatory drugs (NSAIDs) reversibly inhibit both COX isoforms, selective COX-2 inhibitors inhibit the COX-2 isoform. Some authors suggest that inhibiting the COX enzymes shunts AA metabolism toward the production of chemotactic-vasoactive leukotrienes. Glucocorticoids inhibit PLA and down regulate induced expression of COX-2. ASA = acetylsalicylic acid; 5-HPETE, hydroperoxy eicosatetraenoic acid; GI = gastrointestinal; PGI2 = prostacyclin; PGD = prostaglandin D; PGE2 = prostaglandin E2; PGF = prostaglandin F; PGH2 = prostaglandin H2; PLT = platelet; RBF = renal blood flow; TXA2 = thromboxane. Citation: Chapter 35 Nonsteroidal Antiinflammatory Drugs, Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. Goldfrank's Toxicologic Emergencies, 11e; 2019. Available at: https://accesspharmacy.mhmedical.com/content.aspx?bookid=2569§ionid=210270683 Accessed: January 24, 2021 Copyright © 2021 McGraw-Hill Education. All rights reserved Headaches Combination products available that contain caffeine, nasal decongestants or diphenhydramine Why might caffeine be problematic? Caution use of OTC analgesics for patients that use blood thinners or drink alcohol What happens with concomitant EtOH and APAP or NSAIDs? Headaches Pregnancy APAP NSAIDs contraindicated in third trimester Delayed parturition, prolonged labor, and increased postpartum bleeding Premature closure of the ductus arteriosus Avoid aspirin Lactating Ibuprofen; relevant infant dose is 0.6 – 0.9% Acetaminophen; relevant infant dose is 3.98% Avoid aspirin Pediatrics APAP safe for all ages 160 mg / 5 mL suspension Rx max depends on age & weight Ibuprofen approved >= 6 months 100 mg / 5 mL suspension Rx max depends on age & weight Dosing 7-month-old patient weighing 18 lbs. What is an acceptable dose (X) of ibuprofen using 5 mg / kg? Ibuprofen comes in a 100 mg / 5 mL standard concentration. How many mL will each dose be? Dosing Eight-year-old patient with ICD-10 code L03213 International Statistical Classification of Diseases and Related Health Problems provided by WHO Periorbital cellulitis – patient weighs 62 lbs. Clindamycin (Cleocin) 75 mg / 5 mL FDA-approved dose is 8 – 20 mg / kg / day divided into 3 – 4 doses Prescriber used 20 mg / kg / day TID dosing for 10 days How many mL should you prescribe? Fever Fever Core body temperature is controlled by the hypothalamus and regulated by a feedback system involving information transmitted between the thermoregulatory center in the anterior hypothalamus and the thermosensitive neurons in the skin and central nervous system (CNS) Pyrogens, either exogenous or endogenous, are fever- producing substances that activate the body’s host defenses, resulting in an increase in the set point Treat with APAP or ibuprofen… may consider alternating both Musculoskeletal Injuries and Disorders Musculoskeletal Injuries and Disorders Somatic pain occurs when pain impulses are transmitted from peripheral nociceptors to the central nervous system Inflammatory response develops through participation of multiple mediators, including histamine, bradykinin, serotonin, leukotrienes, and prostaglandin E Musculoskeletal Injuries and Disorders Topicals Menthol 2 – 16% Stimulates cutaneous receptor response (i.e., acts as a counterirritant) Activates the transient receptor potential (TRPM8) menthol receptor, triggering the sensation of cold Camphor 3.2% Stimulates nerves Produces cooling sensation Capsaicin 0.1 – 0.15% Elicits a transient feeling of warmth through stimulation of the TRPV1 receptor and ↑ depletion of substance P Histamine dihydrochloride 0.025% Vasodilator Trolamine salicylate 10% Inhibits prostaglandin synthesis Methyl salicylate 10 – 30% Rubefacients (increase blood flow) Inhibits prostaglandin synthesis Lidocaine 4% Inhibits the conduction of nerve impulses Diclofenac sodium 1% NSAID Genitourinary System Genitourinary System Vulvovaginal Candidiasis (VVC) Azoles Topical – 1 to 7 days of therapy 7-day therapy preferred if pregnant Clotrimazole Miconazole Tioconazole These drugs inhibit cytochrome P450 (CYP) enzymes in the cell membrane of the infecting pathogen, thereby decreasing synthesis of the fungal sterol ergosterol. The reduced membrane content of ergosterol is accompanied by an increase in lanosterol-like methylated sterols. These sterols cause structural damage to fungal membranes, resulting in the loss of normal membrane function. Genitourinary System Vaginal itching and irritation Hydrocortisone 1% Benzocaine 5 – 10% / resorcinol 2 – 3% Rare risk of methemoglobinemia associated with benzocaine-containing products Others Genitourinary System Atrophic vaginitis Vaginal dryness, burning, itching, and dyspareunia (if vaginal dryness is the cause of painful sexual intercourse) Lubricants Glycerin Propylene glycol Mineral oil Others Genitourinary System Overactive bladder Oxybutynin patches (Oxytrol) MOA: antimuscarinic Respiratory System Respiratory System Colds Rhinoviruses, coronaviruses, parainfluenza, respiratory syncytial virus, adenoviruses, and human metapneumovirus A virus binds to intercellular adhesion molecule-1 receptors on respiratory epithelial cells in the nose and nasopharynx Infected cells release chemokine “distress signals,” and cytokines then activate inflammatory mediators and neurogenic reflexes Inflammatory mediators and parasympathetic nervous system reflex mechanisms cause hypersecretion of watery nasal fluid Respiratory System Allergic rhinitis Sensitization phase Allergen stimulates beta-lymphocyte–mediated IgE production Early phase Rapid release of preformed mast cell mediators (e.g., histamine, proteases), as well as the production of additional mediators (e.g., prostaglandins, kinins, leukotrienes, neuropeptides) Cellular recruitment Leukocytes, especially eosinophils, are attracted to the nasal mucosa and release more inflammatory mediators Late phase Mucus hypersecretion secondary to submucosal gland hypertrophy and congestion Respiratory System Cough Initiated by stimulation of chemically and mechanically sensitive, vagally mediated bronchopulmonary and extrapulmonary sensory nerves in the pharynx, larynx, esophagus, and tracheobronchial airway epithelium Productive cough Clear usually acute bronchitis Purulent usually bacteria Putrid malodor usually anerobic bacteria Smoker's cough purulent usually chronic bronchitis from smoking Nonproductive cough May be associated with viral and atypical bacterial infections, gastroesophageal reflux disease (GERD), cardiac disease (e.g., congestive heart failure), and some medications Respiratory System Colds, allergic rhinitis & cough Decongestants Adrenergic agonists (sympathomimetics) Stimulation of alpha-adrenergic receptors constricts blood vessels, thereby decreasing sinusoid vessel engorgement and mucosal edema Directly bind to adrenergic receptors Phenylephrine (Sudafed PE) Found in solo and combination products FDA 2023 – product is ineffective; not officially removed from market as of 1/6/25 Oxymetazoline (Afrin nasal spray) Limit use to three consecutive days due to rhinitis medicamentosa (RM) Respiratory System Colds, allergic rhinitis & cough Decongestants Direct binding and displacement of norepinephrine from storage vesicles in prejunctional nerve terminals (tachyphylaxis can develop as stored neurotransmitter is depleted) Pseudoephedrine (Sudafed D) Found in solo and combination products Limit use for patients with hypertension (HTN) If blood pressure is under control, may use 30 mg tablets at lowest frequency possible for 3 days Purchase limits imposed to reduce illegal methamphetamine manufacturing Drug interactions Increased risk of hypertension Linezolid, MAOIs & ergot derivatives Increased risk of tachycardia SNRIs Respiratory System Colds, allergic rhinitis and cough Antihistamines Compete with histamine at central and peripheral histamine type 1 (H 1) receptor sites, preventing the histamine receptor interaction and subsequent mediator release Additionally, second-generation antihistamines inhibit the release of mast cell mediators and may decrease cellular recruitment First generation Diphenhydramine (Benadryl) Has antitussive effect not seen with second generation antihistamines Chlorphenamine Doxylamine (Unisom) More sedating more anticholinergic, antiserotonin, and anti–alpha-adrenergic effects Highly lipophilic molecules that readily cross the blood–brain barrier Adverse effects associated with cholinergic blockage include dryness of the eyes and mucous membranes (mouth, nose, vagina), blurred vision, urinary hesitancy and retention, constipation, and reflex tachycardia Sedating antihistamines are contraindicated in newborns or premature infants, lactating women, and patients with narrow-angle glaucoma Drug Interactions – increased risk of ulcers with potassium chloride Respiratory System Colds, allergic rhinitis and cough Antihistamines Second generation Loratadine (Claritin) Cetirizine (Zyrtec) – most sedating second generation antihistamine Levocetirizine (Xyzal) Fexofenadine (Allegra) Respiratory System Colds, allergic rhinitis and cough Antihistamines Nasal spray New to OTC market (2022) Azelastine 0.15 % (Astepro) Respiratory System Diphenhydramine muscarinic receptor antagonism will cause anticholinergic effects: dry mouth blurry vision Blue = cholinergic nerves constipation Red = noradrenergic nerves urinary retention (rarely) Ach = acetylcholine D = dopamine Epi = epinephrine M = muscarinic receptors N = nicotinic receptors NE = norepinephrine Agonist – elicits receptor activity Antagonist – blocks access to receptor activity Clozapine is a muscarinic agonist Produces lots of saliva Respiratory System Colds, allergic rhinitis and cough Intranasal corticosteroids Inhibit multiple cell types and mediators, including histamine, and effectively stop the “allergic cascade” Budesonide (Rhinocort) Fluticasone (Flonase) Triamcinolone (Nasacort) Adverse effects Epistaxis Long-term use has been linked to changes in vision, glaucoma, cataract formation, increased risk of fungal infections, and growth inhibition in children Avoid concomitant use with protease inhibitors May lead to Cushing’s syndrome (rapid weight gain, obesity, facial hirsutism and swelling) Respiratory System Colds, allergic rhinitis and cough Cromolyn sodium Mast cell stabilizer Blocks the influx of calcium into mast cells, thereby preventing degranulation and leukotriene release Must be administered one week prior to exposure of allergens Takes two weeks to work for perennial rhinitis Respiratory System Colds, allergic rhinitis and cough Antitussives Codeine (Cheratussin AC [codeine 10mg / guaifenesin 100 mg / 5 mL]) Acts centrally on the medulla to increase the cough threshold CYP2D6 polymorphisms lead to unpredictable clinical response and potential toxicity in affected persons. Poor metabolizers may not benefit from codeine. Extensive metabolizers are at increased risk for sedation and respiratory depression. Black box warning for codeine includes the risk of serious, life-threatening, or fatal respiratory depression and the risk of opioid addiction, abuse, and misuse Drug interactions CYP2D6 inhibitors bupropion, fluoxetine & paroxetine Reduce effect of codeine because codeine is a prodrug Codeine syrup containing the antihistamine promethazine hydrochloride (Rx only), when mixed with soft drinks and/or alcohol and sometimes candy (common street names include “purple drank,” “sizzurp,” “syrup,” and “lean”) Opiate and opioid metabolism. Codeine is O-methylated to morphine, N-demethylated to norcodeine, or glucuronidated to codeine-6-glucuronide (codeine- 6-G). Morphine is N-demethylated to normorphine or glucuronidated to either morphine-3-glucuronide (morphine-3-G) or morphine-6-glucuronide (morphine-6-G). Heroin is converted to morphine by a two-step process involving plasma cholinesterase and two human liver carboxylesterases known as human carboxylesterase-1 and human carboxylesterase-2. Citation: Chapter 36 Opioids, Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. Goldfrank's Toxicologic Emergencies, 11e; 2019. Available at: https://accesspharmacy.mhmedical.com/content.aspx?bookid=2569§ionid=210270754 Accessed: January 24, 2021 Copyright © 2021 McGraw-Hill Education. All rights reserved Respiratory System Colds, allergic rhinitis and cough Antitussives Dextromethorphan (Robitussin or Delsym) Noncompetitively antagonizes N-methyl-D-aspartate (NMDA) and glutamate-induced excitation and excitotoxicity in the CNS and spinal regions D-isomer of the codeine analog of levorphanol – no analgesic or addictive properties Drug interactions CYP2D6 inhibitors bupropion, fluoxetine & paroxetine May decrease dextromethorphan metabolism, increasing the psychoactive effects of dextromethorphan SSRIs & MAOIs May increase the risk of serotonergic (psychoactive) effects of dextromethorphan Dextromethorphan is abused for its phencyclidine-like euphoric effect (“robo- tripping”) Respiratory System Colds, allergic rhinitis and cough Expectorants Guaifenesin (Mucinex) Loosens and thins lower respiratory tract secretions, making minimally productive coughs more productive Large doses of this agent, either alone or in combination with ephedrine or pseudoephedrine, have been associated with development of renal calculi Mucinex D – guaifenesin and pseudoephedrine Mucinex DM – guaifenesin and dextromethorphan Respiratory System Colds, allergic rhinitis and cough Pregnancy Intranasal cromolyn is considered compatible with pregnancy and is a first-line option Oxymetazoline preferred 1st-line nasal decongestant if there is severe congestion Phenylephrine during the first trimester has been associated with minor malformations (e.g., inguinal hernia, congenital hip dislocation) Pseudoephedrine has been linked to abdominal wall defects (gastroschisis) in newborns ACOG says do not use pseudoephedrine during the first trimester Diphenhydramine (severe symptoms + antitussive effect) and chlorpheniramine (mild/mod) are preferred antihistamines Second generation antihistamines (eg, loratadine and cetirizine) can be used, too INCS are considered compatible with pregnancy – but systemic use of these drugs is associated with cleft lip and palate and low birth weight Lactation American Academy of Pediatrics has found pseudoephedrine (RID = 6.7%) to be compatible with breastfeeding – may decrease milk production Intranasal cromolyn and INCS are probably compatible Antihistamines contraindicated Avoid long-acting or max dose products Dextromethorphan, guaifenesin, benzocaine, camphor (topical), and menthol (topical) each carry a low risk of birth defects and have been found to be compatible with breastfeeding Gastrointestinal System Gastrointestinal System Heartburn Acidic stomach contents regurgitate through lower esophageal sphincter and stimulates mucosal chemoreceptors Alarm symptoms Dysphagia, odynophagia, vomiting, GI bleeding, and unexplained weight loss Dyspepsia – orginiating from stomach / duodenal area Symptoms Persistent postprandial fullness, early satiation, epigastric pain, and epigastric burning Gastrointestinal System Antacids Onset – 5 minutes MOA: buffering agents Different mixtures of sodium bicarbonate, calcium carbonate, aluminum hydroxide, magnesium hydroxide & bismuth subsalicylate Adverse effects Magnesium – diarrhea – avoid if CrCl < 60 mL / min Aluminum – constipation – avoid chronic use for patients with renal failure Calcium – renal calculi possible if preexisting renal impairment Sodium bicarbonate – alkalosis possible if preexisting renal impairment Drug interactions Chelation via divalent cations (e.g., Ca2+ or Mg2+) Doxycycline, ciprofloxacin, levofloxacin and others Gastrointestinal System Histamine Type 2 Receptor Antagonist (H2RA) Onset – 30 – 45 minutes Inhibiting histamine on the H2 receptor of the parietal cell (site of HCl production) Cimetidine (Tagamet) & Famotidine (Pepcid) Ranitidine (Zantac) – removed from marked due to N-nitrosodimethylamine (NDMA) Adverse effects Cimetidine – antiandrogenic effect (decreased libido, impotence, or gynecomastia in men) Drug interactions Cimetidine – Inhibits CYP450 1A2, 2C19 Phenytoin, warfarin, amiodarone, clopidogrel, nifedipine, theophylline, tricyclic antidepressants, opioids and others Gastrointestinal System Proton Pump Inhibitors (PPI) Onset – 60 minutes … make take several days for full efficacy Inhibits hydrogen potassium ATPase (the proton pump), thereby irreversibly blocking the final step in gastric acid secretion Omeprazole (Prilosec), Esomeprazole (Nexium), Lansoprazole (Prevacid) Others like Pantoprazole (Protonix) are available Rx only Adverse effects Clostridium difficile infection Patients with ascites secondary to cirrhosis are at an increased risk of spontaneous bacterial peritonitis Long-term and multiple daily dose PPI therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist or spine Drug interactions Omeprazole – Inhibition of CYP2C19 Citalopram, clopidogrel, warfarin, tacrolimus, mycophenolate and others Gastrointestinal System Take all heartburn / dyspepsia meds on an empty stomach Increasing the pH of the stomach will cause lots of drug interactions Azoles, protease inhibitors, fluoroquinolones, thyroxine, digoxin and others Lifestyle modifications Weight loss, elevate head of bed 6 – 8 inches, avoid eating 2 – 3 hours before bed, Mediterranean diet, symptom diary and smoking cessation Pediatrics Age: 2 – 12 – calcium carbonate Age: 12 – 17 – antacids and H2RAs Bismuth subsalicylate not recommended due to Reye syndrome Pregnancy 1.Lifestyle modifications 2.Calcium antacids 3.H2RAs Avoid PPIs – needs more safety data to recommend Gastrointestinal System Constipation Polyethylene glycol 3350 (Miralax) Hyperosmotic Wheat dextrin (Benefiber) Fiber supplement Docusate (Colace) Emollient (aka stool softener) Magnesium citrate Saline laxative Bisacodyl (Dulcolax) Simulant laxative Osmolality – concentration of solutes per kg of water 1. Miralax will increase alimentary canal osmolality > 300 mOsm 2. Water will diffuse into alimentary canal to equalize hyperosmotic state 3. Results in relief of constipation Physiological relations between plasma osmolality, plasma AVP concentrations, urine volume, and urine osmolality in healthy humans.60 Note that the osmolality at which the secretion of vasopressin is stimulated is below that at which thirst is stimulated. (Adapted with permission from Robinson AG: Disorders of Antidiuretic Hormone Secretion, Clin Endocrinol Metab 1985 Feb;14(1):55–88.) Citation: Chapter 9 Posterior Pituitary and Disorders of Water Metabolism, Allen DB, Nadeau K, Kappy MS, Geffner ME. Pediatric Endocrinology: Principles and Practice, 3e; 2020. Available at: https://accesspediatrics.mhmedical.com/content.aspx?bookid=2947§ionid=250004121 Accessed: January 25, 2021 Copyright © 2021 McGraw-Hill Education. All rights reserved Gastrointestinal System Diarrhea Replenish fluids Loperamide (Imodium) Peripheral mu opioid agonist Potential for abuse Bismuth subsalicylate (Pepto-Bismol) Antisecretory antidiarrheal effects Gastrointestinal System Pin worms (E. vermicularis) Pyrantel pamoate (Pin-X) Depolarizing neuromuscular agent that stimulates the release of acetylcholine and inhibits cholinesterase, thereby paralyzing adult worms in the gastrointestinal (GI) tract Paralyzed adult worms loosen their hold on the intestinal wall and are subsequently passed out in the stool OTC labeled for two years and up Weight-based dosing starting at 11 mg / kg not to exceed 1 gram pyrantel base (formulation dependent) 1 mg of pyrantel base equivalent to 2.88 mg of pyrantel pamoate salt Ophthalmic and Otic Products Ophthalmic and Otic Products Dry eye and allergic conjunctivitis products available Ophthalmic and Otic Products Excess cerumen Carbamide peroxide 6.5% in anhydrous glycerin (Debrox) Excess water Isopropyl alcohol 95%; anhydrous glycerin 5% (Swim-Ear Drops) Dermatologic Disorders Dermatologic Disorders Atopic dermatitis Eczema in which the skin is chronically scaly, erythematous, edematous, papular, and crusty Atopic skin is inflamed owing to overexpression of cytokines (the interleukins IL-4 and IL-13) and chemokines produced by T-helper 2 cells Hydrocortisone 1% Topical corticosteroid Limit use to two weeks with a week off Xerosis Dry skin Moisturizers Creams, ointments and lotions Dermatologic Disorders Acne Multifactorial disorder of pilosebaceous glands Adapalene (Differin Gel) Retinoid May cause irritation at first – results take 6 – 12 weeks Benzoyl peroxide 2.5 – 10% Keratolytic and antibacterial properties Can bleach clothing, bedding and other fabrics Salicylic acid 0.5 – 2% Comedolytic Inhibits ultraviolet B (UVB) radiation–induced formation of “sunburn cells” Sulfur 3 – 10% Keratolytic and antibacterial properties Dermatologic Disorders Photoaging Glycolic acid Alpha hydroxy acid Retinol Vitamin A derivative Can use Differin Gel, however efficacy studies are based on tretinoin 0.5% cream Minimizing scarring Silicon sheets or gels – preferred Vitamin E liquid Can find as a liquid or can puncture a vitamin E capsule Dermatologic Disorders Tinea pedis – athlete’s foot Fissuring, scaling, or maceration in the interdigital spaces; malodor; pruritus; and/or a stinging sensation on the feet Tinea unguium – nail infection Thick, rough, yellow, opaque, and friable nails OTC options are typically ineffective – consider terbinafine (Rx) Tinea corporis – ring worm Most often, lesions which involve glabrous (smooth and bare) skin, begin as small, circular, erythematous, scaly areas Tinea capitis Four clinically different fungal infections of the head Go to PCP or dermatologist – consider griseofulvin (Rx) Dermatologic Disorders OTC treatment for tinea pedis / tinea corporis Clotrimazole & miconazole Inhibits the biosynthesis of ergosterol and other sterols and by damaging the fungal cell wall membrane, thereby altering its permeability and resulting in the loss of essential intracellular elements Tolnaftate Allylamine antifungal agent that inhibits squalene epoxidase, a key enzyme in fungal sterol biosynthesis Which drug formulation would you recommend for tinea pedis? Cream or spray? Dermatologic Disorders Warts HPV infection of the basal keratinocytes Salicylic acid 17 – 40% Cryotherapy Nitrous oxide Dimethyl ether and propane Dermatologic Disorders Alopecia Minoxidil 2 – 5% (Rogaine) Vasodilator Increases cutaneous blood flow, promotes and maintain vascularization of hair follicles, and directly stimulates follicular hypertrophy No effect on hemodynamics reported in clinical trials due to limited absorption into systemic circulation Dermatologic Disorders Pediculosis capitis (Lice) Pediculus humanus capitis Permethrin 1% (Nix) Acts on the nerve cell membrane to disrupt the sodium channel current by which the polarization of the membrane is regulated Ivermectin 0.5% (Sklice) Opens glutamate-sensitive chloride channel currents in helminths Approved OTC in 2020 Vitamins, Minerals, Enzymes & Herbs Vitamins, Minerals, Enzymes & Herbs Vitamin B12 (cyanocobalamin) Macrocytic anemia Decreased intrinsic factor (age > 50 or taking metformin) Vitamin B9 (folic acid) Reduction of neural tube defects Calcium and vitamin D Osteoporosis Vitamin D should no longer be dosed in IU (international units) … but it still is Ergocalciferol (D2) is Rx and cholecalciferol (D3) is OTC Iron Microcytic anemia Vitamin E Used topically for scar minimization Vitamins, Minerals, Enzymes & Herbs Coenzyme Q10 Rate-limiting cofactor in mitochondrial adenosine triphosphate (ATP) formation Reduction of statin-associated adverse effects Fish oil Omega-3 fatty acids DHA / EPA Hypertriglyceridemia and inflammatory conditions Red yeast rice Molecular structure similar to statins Hypercholesteremia Niacin (Vitamin B3) NAD & NADP precursor for mitochondrial redux reactions Hypercholesteremia Vitamins, Minerals, Enzymes & Herbs Gingko biloba Neuroprotective properties Alzheimer’s disease (AD), vascular dementia, attention-deficit/hyperactivity disorder (ADHD), tardive dyskinesia, intermittent claudication, tinnitus, acute mountain sickness, and age-related macular degeneration Melatonin Hormone and potent antioxidant produced by the pineal gland Insomnia and jetlag St. John’s wort Hypericum perforatum flower Depression, anxiety and OCD Valerian root Valeriana officinalis Insomnia and anxiety Vitamins, Minerals, Enzymes & Herbs Kava Piper methysticum Ceremonial tranquilizer for Pacific Islanders May cause severe liver damage Kratom Mitragyna speciosa Psychoactive with both stimulant and opioid-like effects CBD Cannabis sativa Used for everything??? Use proliferated after passage of the 2018 Farm Bill Vitamins, Minerals, Enzymes & Herbs Prevent and treat colds – may decrease duration of infection Echinacea Sambucus nigra (elderberry) Vitamin C (ascorbic acid) Zinc Vitamins, Minerals, Enzymes & Herbs Probiotics GI flora restorations Refrigerated products are preferred by gastroenterologist Florajen (≈$30) and VSL (≈$60) Glucosamine and chondroitin Stimulates chondrocytes to produce cartilage and synoviocytes to produce synovial fluid and hyaluronic acid, inhibits matrix metalloproteinase, and modulates activities of inflammatory cytokines; also serves as “building blocks” for cartilage Osteoarthritis Vitamins, Minerals, Enzymes & Herbs Saw palmetto Inhibits 5-alpha-reductase and cytosolic androgen receptor BPH Black cohosh Cimicifuga racemose Premenstrual syndrome, dysmenorrhea, and menopause Evening primrose oil Oenothera biennis PMS and menopause Vitamins, Minerals, Enzymes & Herbs GRAS Generally regarded as safe Drug interactions Mostly likely to occur with antidepressants and blood thinners United States Pharmacopeia Sterile and non-sterile compounding standards USP 795, 797, 800 guidelines What is Natural Medicines in the South College library? Can cranberry juice treat or prevent a urinary tract infection? Updates Narcan and Opill were approved for OTC use in 2023 Discussed during Q4 with pain management and contraception