OTC Drugs PDF

# OTC Drugs ## Otic, Buccal and Ophthalmic medications Presented by Dr. Fatma M Mady ### Supporting reference for studying: - **Non-prescription Medicines** Fourth Edition Alan Nathan - **PSC Patient Self-Care** First Edition Helping patients make therapeutic decisions ### Learning objectives...

# OTC Drugs ## Otic, Buccal and Ophthalmic medications Presented by Dr. Fatma M Mady ### Supporting reference for studying: - **Non-prescription Medicines** Fourth Edition Alan Nathan - **PSC Patient Self-Care** First Edition Helping patients make therapeutic decisions ### Learning objectives: - Understand causes and treatment of different ear, eye and oral conditions - Identifying as a pharmacist how you can assess and manage these conditions by selecting proper pharmacologic/Non pharmacologic therapy - Guide your patient for proper use of his eye or ear drops - Distinguish when you have to ask your patient to see a doctor and when you can advise him/her with beginning treatment ## Ear Problems - Ear problems offer little scope for pharmacists to advise on treatment. - Patients' descriptions of their symptoms and their own self-diagnoses may be misleading. - Medical examination is usually necessary for accurate diagnosis. ### Ear Problems - Earache - Ear wax - Otitis Externa ## Earache - In adults, earache may sometimes be associated with an upper respiratory tract infection. As long as the pain is not severe, the earache can be treated with oral analgesics for up to 48 hours before referral if the condition does not improve. - Earache in children should always be referred, as otitis media is fairly common and repeated attacks can lead to permanent damage if it is not managed properly. Use of an oral analgesic can be advised until the patient can see a doctor. Analgesic ear drops are available without prescription but are not generally recommended. ## You should refer the patient to the physician if: - Ear pain associated with: - Ear drainage - Pruritus - Tenderness with ear movement - Fever - Hear loss - Persist for more than 2 days. ## Choline salicylate (Rx Earex) - Is an analgesic constituent available without prescription. The product is use for the relief of earache and the softening of ear wax. - Choline salicylate is used as a local analgesic. It has a counterirritant effect and is also hydrolysed by cutaneous esterases to produce salicylic acid, which probably exerts some anti-inflammatory effect by blocking prostaglandin formation. - Some other brands of ear drops contain constituents with counterirritant or local analgesic properties, such as camphor oil, chlorbutol, turpentine oil and terpineol, which may have some analgesic effects. ## Ear wax - Cerumen (ear wax) is a complex oily fluid secreted by sebaceous and apocrine glands in the external auditory canal, which combines with exfoliated skin cells to form a protective waxy layer. This is normally moved outwards by movement of the jaw in speaking and chewing, and then removed by washing. - In some individuals, excessive cohesive cerumen is produced. This forms a waxy plug that affects hearing and causes discomfort. The prophylactic use of a cerumenolytic preparation is sometimes recommended. - Syringing is necessary to remove ear wax, although cerumenolytics can be used in advance to soften, loosen and partially dissolve the wax. ## Cerumenolytics - May soften ear wax and make it easier to remove by syringing, but they are unlikely on their own to dissolve and remove compacted plugs. - Several approaches are taken to loosening and dissolving wax in the ear, including the use of aqueous and oily solvents and surfactants, and oxygen generation (e.g H2O2) to facilitate penetration of water into the plug. - Constituents of cerumenolytic products include fixed and volatile oils, glycerol, docusate, urea, hydrogen peroxide and paradichlorobenzene. However, ear-wax-softening agents have been found to be no more effective than using warm water or saline shortly before syringing. ## Otitis Externa - Inflammation of the external auditory canal (acute or chronic) - The acute form is commonly caused by bacterial infection, but it may also be fungal or viral. - The chronic form is eczematous and may be atopic or a contact dermatitis. Dermatitis may become infected, and the two types of otitis externa can exist together. ### Symptoms: - Ear pain worse with motion of the ear e.g chewing - Feeling of ear fullness and hearing loss ### Non pharmacological therapy: - Adequate cleaning of the canal by the physician. ## Hydrocortisone cream - For mild eczematous otitis externa affecting the pinna. ## Aluminium acetate - Is astringent and hygroscopic and produces an acidic environment that is hostile to pathogenic bacteria. ## Acetic acid - Has antibacterial activity and is reported to be active against Haemophilus, Pseudomonas, Candida and Trichomonas species. - A 2% solution of acetic acid is available as a pump-action spray for adults and children over the age of 12 years. It is used 3-8times daily until 2 days after symptoms have disappeared, for up to a maximum of 7 days. - Use should be discontinued and medical advice sought if symptoms do not improve within 48 hours of starting treatment. ## The recommended technique for the most effective use of ear drops - It is best to have another person instill the ear drops. - Before use, the drops should be warmed slightly by holding in the hands for a few minutes. - The patient should lay their head on a flat surface such as a table, with the affected ear uppermost. - The auricle (pinna) should be lifted upwards and backwards in adults, or downwards and backwards in children, to straighten the ear canal. - The requisite number of drops should be instilled. - The tragus (the small projection in front of the external opening) should be pressed gently once or twice to assist the drops down the ear canal and to expel air bubbles. - The patient should remain with their head down for at least 5 minutes. A cotton-wool plug moistened with the drops should be placed into the ear. - Unless directed otherwise, the drops should be used night and morning for 3 or 4 days before syringing. # Eye conditions ## Minor eye conditions for which nonprescription medication is available are: - Bacterial and allergic conjunctivitis - Styes - Sore and 'tired' eyes - Dry eyes - Blepharitis ## Bacterial Conjunctivitis "pinkeye" and Styes - Bacterial conjunctivitis is a infectious condition affecting one or both eyes, in which the conjunctiva become inflamed. The infecting organism is most often Staphylococcus aureus, but several other bacteria may also be responsible. - Symptoms: feeling of itchiness or grittiness, and there is often also a discharge. There is no pain, and vision is not affected, except for blurring caused by the discharge. - **Note**: Viruses are also common causative agents of infective conjunctivitis, and it may be clinically difficult to distinguish a viral from a bacterial infection. However, over-the-counter (OTC) treatment of any infective conjunctivitis with an antibacterial agent is considered appropriate, as it may help to prevent secondary bacterial infection if the condition is of viral origin. - Stye (Hordeolum) is an infection of the lash follicle of the eyelid, producing pustules. The most common infecting agent is S. aureus. ## Non-Pharmacologic Therapy: - Warm compresses for 10-15 min 3-4 times for 2 days. - Hard boiled egg wrapped in a compress is a convenient method to apply heat to the eyelid. The same egg can be re-boiled prior to each application. - Irrigation with sterile or eye wash. - Contact lens wearers should stop lens wear and referred to a physician to avoid serious infections. ## Chloramphenicol - Is considered the gold standard. - Chloramphenicol penetrates well into the aqueous humour of the eye after topical application and has low ocular surface toxicity. Development of resistance is rare - Chloramphenicol eye drops and eye ointment are used in adults and children aged 2 years and over. - In the pharmacy, chloramphenicol eye drops should be stored in a refrigerator at 2-8°C and eye ointment at room temperature. ## Propamidine isethionate 0.1% eye drops and dibromopropamidine isethionate 0.15% eye ointment - Both can be used for adults and children. - The ointment persists longer on the corneal surface and needs to be applied only twice daily, but it can cause stickiness and blurring of vision. It is suitable for the treatment of both conjunctivitis and styes. ## Sore and 'tired' eyes - Redness and mild irritation in the eyes can be caused by activities such as driving and close work, and environmental pollutants. Several products, based mainly on astringents and vasoconstrictors, are available. ## Witch Hazel - Several products contain distilled witch hazel (hamamelis water), which contains flavonoids and tannins. Witch hazel has astringent and anti-inflammatory properties. ## Vasoconstrictor - Naphazoline, a decongestant vasoconstrictor, is included in some ophthalmic preparations to shrink the dilated blood vessels that cause redness. - Naphazoline is a sympathomimetic agent with marked alpha adrenergic activity, with a rapid and prolonged action when applied topically. It is documented as being effective in constricting conjunctival blood vessels and in reducing discomfort associated with ocular inflammation. ## Dry Eyes - A chronic condition characterized by dryness of the surface of the eye. It is caused by either a deficiency of conjunctival mucus, due to the absence or significant impairment of the mucin-producing goblet cells of the conjunctiva, or tear deficiency. The latter is often associated with rheumatoid arthritis. ### Symptoms: - Eyes feel like they are burning, itchy or tired - Sandy or scratchy sensation of the eye. ### Non Pharmacological Therapy: - Avoid smoking and smoky area - A moistened gauze placed inside the goggles helps maintain a moist environment. - A cool, moist wash-cloth placed over closed eyelids may provide short term relief. ## Tear substitutes (artificial tears) - Hypromellose (hydroxypropyl methylcellulose) is a mixed cellulose ether with viscosity-enhancing properties, which prolongs the persistence of the water in the drops, containing it on the surface of the eye. - Carmellose (1% carboxymethylcellulose) - Polyvinyl alcohol (PVA) also promotes wetting of the ocular surface and is useful to help spread the water content of the drops over the eye when the mucus layer is deficient and tear film distribution is patchy. - Carbomer 940 is an acrylic acid polymer that is formulated as a liquid gel for the treatment of dry eye. - Sodium hyaluronate - Hydrophobic ocular lubricants. ## In sever cases: - Oral Pilocarpine - Topical Acetylcysteine - Topical Methylprednisolone - Topical Cyclosporine - Topical Estradiol ## Blepharitis - Blepharitis is inflammation of the margins of the eyelids, often accompanied by crusting. In many cases the cause is unknown, but it is sometimes associated with seborrhoea of the scalp. ### Symptoms: - Irritation and itching of lid margin - A foreign-body sensation in the eye. - Sandy or gritty sensation in the eye that is worse upon awakening. ### Non Pharmacological Therapy: - Melt solidified material in the gland through: - Warm compresses, to closed eyelid for 5-10 min - Gentle scrubbing of the lid margin with warm water and a commerical eyelid scrub (e.g Eye scrub®, lid-care® or Blepharoshampoo®) - A few drops of baby shampoo in a small amount of warm water. ## Topical antibiotics - Used after eyelid cleansing, such as Bactracin and Erythromycin. ## Ointments - Applied on the lid margins, are preferred to drops because of increased contact time between the drug and tissues. ## In case of association with seborrhoea, treatment of the scalp with an antidandruff shampoo containing pyrithione zinc, selenium sulphide or ketoconazole may resolve the condition # Administration of eye drops and ointment - Wash hands thoroughly - Tilt head backwards. - Gently grasp lower outer eyelid just below the lashes and pull the eyelid away from the eye. - Place the dropper or ointment tube directly over the eye by looking directly at it. ### With drops: - Just before applying a drop, look up. - After applying a single drop, look down for several seconds. - Release the eyelid slowly. - Keep eyes closed for 1-2 minutes - With a finger, gently press over the opening of the tear duct in the inner corner of the eye. - Blot excess liquid from around the eye. ### With ointment: - With a sweeping motion, insert 1-2 cm of ointment inside the lower lid. - Release the eyelid slowly. - Keep eyes closed for 1-2 minutes. - Blot excess ointment from around the eye. # Oral Thrush (oral candidiasis) - An infection caused by a yeast-like fungus, Candida albicans. Oral thrush is common in newborn babies because they can pick up the organism during passage through an infected birth canal. Oral thrush can also be contracted by users of inhaled corticosteroids or following antibiotic treatment; such patients should be referred to a physician, as infection may indicate reduced immune status. ### Symptoms: - Creamy-white patches on the oral mucosa, which may be mistaken for milk curds. The patches are difficult to remove and, if scraped away, reveal inflamed patches that may bleed ## Miconazole oral gel - For infants is miconazole oral gel, which has been shown to be effective and can be recommended by pharmacists. Adults may be referred back from the doctor to the pharmacist for treatment, as the product costs less than a prescription charge. Miconazole has been shown to be fetotoxic, although not teratogenic, in animal studies. The oral gel is not licensed for use in pregnant women without prescription. ## You should refer the patient to the physician if: - Patient is an infant or is elderly. - Patient has a history of receiving: - Broad spectrum antibiotics - Inhaled corticosteroids. - Chemo- or radiation-therapy. - Patient has: - Malignancy. - Diabetes - Nutritional deficiency. - Immunosuppression. - Terminal illness. ## You can help prevent Oral thrush - Prevent your mouth to become dry e.g don't use a mouthwash that has a high alcohol content for long time - Keep your mouth clean e.g if you wear a dentures, take them out at night and clean them properly. - If you use an inhaled corticosteriods rinse your mouth with water after using it and use a spacer. ## When you have Oral thrush - You should throw out your old toothbrush and start using a new one. # Canker Sore (Mouth Ulcers) - Mouth ulcers (recurrent aphthous Ulcer) are a common condition of the oral mucosa. Both adults and children can be affected. About 75% of cases are minor aphthous ulcers that are self limiting (usually within 7-14 days) and can usually be treated without a doctor visit. - Aphthous ulcers are painful, shallow ulcers occurring singly or in groups of up to five lesions on the tongue or the mucosal surfaces of the lips and cheeks. Aphthous ulcers usually **appear suddenly**, the ulcers disappear just as abruptly. - The cause of aphthous stomatitis remains unknown; although several causes have been suggested, including stress, trauma of the oral mucosa, infection, vitamin B or iron deficiency and hormonal changes. Several drugs also appear to induce mouth ulcers. ## As the cause is unknown, treatment can only be symptomatic; anti-inflammatories (including corticosteroids) seem to be the most effective treatment, but a wide range of products containing local anaesthetics, antiseptics and astringents is also available. ## Hydrocortisone sodium succinate - Mouth ulcer tissue is intensely inflamed and corticosteroids would therefore be expected to be helpful. ## Benzydamine hydrochloride - Benzydamine hydrochloride is a NSAID, available for the treatment of mouth ulcers as an oral rinse and spray. ## Chlorhexidine gluconate(digluconate) - A antimicrobial agent, effective against a wide range of bacteria, viruses, fungi and yeasts. - The inclusion of local anaesthetic and analgesic agents seems reasonable, as they should be useful in reducing pain and discomfort until lesions resolve. ## You should refer the patient to the physician if: - It is still there after 14 days. - It has gotten larger or more have developed - Pain is not controlled by medications - There is: - Fever - Pain in joints - Watery bowel movements - Irritated eyes - Difficulty in chewing or swelling.