Community Pharmacy - PPP 516 PDF

Community Pharmacy – PPP 516 “Management of Minor Ailments” Obstetrics and Gynecology TABLE OF CONTENTS 01 02 03 Vaginal Symptoms, Premenstural Dysmenorrhea Hygiene, and Syndrome Infections 04 05 Contraception Pregnancy and...

Community Pharmacy – PPP 516 “Management of Minor Ailments” Obstetrics and Gynecology TABLE OF CONTENTS 01 02 03 Vaginal Symptoms, Premenstural Dysmenorrhea Hygiene, and Syndrome Infections 04 05 Contraception Pregnancy and Fertility Testing  01 Vaginal Symptoms, Hygiene and Infections -The vagina is a fibromuscular structure that connects the external genitalia, or vulva, with the internal cervix - and uterus. The healthy vagina is host to several microorganisms including lactobacilli, Candida albicans -Normally, the organisms live in balance in the vaginal environment without adverse effects. -When this harmony is disrupted, overproduction of host organisms or colonization by acquired pathogens can occur. These changes set the stage for the development of vaginitis.  Potential predisposing factors for vulvovaginal candidiasis TREATMENT GOALS 01 03 Relieve Prevent symptoms recurrence 02 04 Cure the Prevent misdiagnosis infection and delayed treatment of another condition Urgent Referral (fever, pain, hematuria…)  Non-pharmacological Management - Good genital hygiene measures are important to keep the tissue healthy and free from irritation. - Vaginal deodorants, douches, harsh soaps and perfumed products for genital use should be avoided, as irritation or allergic reactions may occur. - regular use of panty liners has not been shown to promote the occurrence of vulvovaginal candidiasis Pharmacological Management Vaginal antifungals or oral fluconazole  Drug Dosage Adverse Drug Interactions Effects Fluconazole Uncomplicated infection: 150 mg Headache, Inhibitor of CYP2C9, CYP2C19 and CYP3A4. PO × single dose Recurrent nausea, Decreases serum concentration of clopidogrel’s Diflucan infection: 100 mg, 150 mg or 200 abdominal pain, active metabolites mg every 72 h PO × 3 doses; then diarrhea, Decreases metabolism of atorvastatin, 100 mg, 150 mg or 200 mg weekly dyspepsia, benzodiazepines, calcium channel blockers, PO × 6 months dizziness. clarithromycin,… Co-administration with warfarin is associated with increased risk of bleeding. Clotrimazole Uncomplicated infection: Local May diminish therapeutic effect of vaginal 200 mg/vaginal tablet: 1 tablet daily hypersensitivity. progesterone; avoid concomitant use. Canesten PV × 3 days or 500 mg/vaginal tablet: 1 tablet PV × single dose or 1% vaginal cream: 1 daily PV × 7 days 2% vaginal cream: 1 daily PV × 3 days 10% vaginal cream: 1 PV × single dose Recurrent infection: intravaginal azole × 7–14 days to achieve mycologic remission, followed by clotrimazole 500 mg/vaginal tablet once monthly × 6 months  Drug Dosage Adverse Drug Interactions Effects Miconazole Uncomplicated infection Local may cause increased INRs and bleeding in women 400 mg/ovule: 1 ovule daily PV × hypersensitivity taking warfarin. If necessary to use together, Miconaz 3 days consider more frequent INR monitoring, 2% vaginal cream: 1 applicatorful May diminish therapeutic effect of vaginal daily PV × 7 days progesterone; avoid concomitant use Terconazole Uncomplicated infection: 0.4% Local May diminish therapeutic effect of vaginal vaginal cream: 1 applicatorful hypersensitivity. progesterone; avoid concomitant use. Gynoconazol daily PV × 7 days  Monitoring of Therapy for Vulvovaginal Candidiasis Symptoms Monitoring Endpoint Actions of Therapy Vulvovaginal Patient: daily for 7-10 days Eradication of If symptoms still present 1 week after start of itching and Healthcare practitioner: after 7 days symptoms therapy, patient requires further evaluation and burning, or next pharmacy visit therapy. dyspareunia, discharge Increased irritation Patient: daily for 7-10 days Eradication of Increased severity of symptom(s) should be (may indicate Healthcare practitioner: after 7 days symptoms assessed promptly; discontinue therapy and ensure adverse reaction or next pharmacy visit. patient receives further evaluation by appropriate to product or healthcare practitioner. inappropriate therapy)  Vulvovaginal Candidiasis Tips to prevent yeast infections Refrain from Avoid irritant wearing tight or perfumed pants and Wear cotton Ironing or products such jeans underwear that tumble-drying as vaginal won’t irritate the underwear deodorants or your skin may also kill soaps any residual fungal spores  VAGINAL DRYNESS (ATROPHIC VAGINITIS) Lack of oestrogen can cause a thinning and reduction in elasticity of the vaginal walls and a reduction in the glands which produce lubricating mucus. Many post-menopausal women develop a dry vagina, and other symptoms around the genital area. Pain during Discomfort sex Vaginal dryness Symptoms hormonal chemotherapy Urinary contraceptive use Itch problems Danger cigarette smoking radiation therapy Sjörgen’s syndrome, an autoimmune disease causes dry mouth and eyes as well as vaginal dryness. Patients with symptoms of dry eyes, dry mouth and atrophic vaginitis should be referred to their GP  VAGINAL DRYNESS (ATROPHIC VAGINITIS) Vaginal Douching Douching is a process of instilling fluid into the vagina and flushing the cavity. There are no substantiated benefits to routine douching and it can be associated with significant Adverse outcomes: Douching may disrupt the normal vaginal environment, increasing the risk of irritation or infection. Similarly, perfumed soaps and bath products that may be irritant should be avoided  Treatment OTC POM Lubricating gels Hormone replacement Water-based lubricants, such as KY jelly®, lubricate the vagina for several hours and can therapy (HRT) be applied to the vaginal opening to prevent Oestrogen cream pain on intercourse. Vaginal moisturizers Replens MD® is a non-hormonal drug-free bioadhesive vaginal moisturizer which has been compared to topical oestrogens over a 12- week period. It is a safe and effective treatment exhibiting statistically significant increases in vaginal moisture, vaginal fluid volume and vaginal elasticity and a return of premenopausal pH state. 02 Premenstrual Syndrome (PMS) - The term PMS refers to the cyclic recurrence of physical and/or cognitive (behavioural) symptoms during the luteal phase of the menstrual cycle (after ovulation) that ameliorate upon onset of menses. Premenstrual dysphoric disorder (PMDD) is a severe subtype of PMS that includes significant distress and interference with daily activities. PMS symptoms occur in 90% of women of reproductive age at some point in their life, whereas PMDD affects only 3–8% of women. 02 Premenstrual Syndrome Risk Factors for PMS - Obesity - Physical or emotional trauma - depression - Sedentary lifestyle - Improper diet - Smoking 02 Premenstrual Syndrome A diagnosis of PMS is generally agreed upon if symptoms: - Are present during the luteal phase of the menstrual cycle - Reach their peak shortly before the beginning of menstruation and remit at the onset of menses or shortly thereafter - interfere with daily functioning and interpersonal relationships - Are absent during the follicular phase of the menstrual cycle  A daily symptom calendar can be used to determine whether the woman’s symptoms are cyclical and are confined to the luteal phase. Pharmacological Treatment  Drug Dosage Adverse Effects Drug Interactions Calcium 1200 mg daily in divided Constipation, caution in Decrease absorption of bisphosphonates, iron, doses PO severe renal impairment levothyroxine, phenytoin, phosphate, quinolones, Citrate tetracyclines. Antacid effect may alter absorption of other medications; calcium dosing should be separated from other medications by 2 hours. May decrease therapeutic effect of CCBs. May enhance inotropic effects of digoxin and lead to arrhythmias. Thiazide diuretics decrease excretion of calcium and may increase risk of hypercalcemia Magnesium, 200-400 mg daily PO Diarrhea, asthenia, Magnesium salts decrease GI absorption of drugs dizziness dosed concomitantly; dosing should be separated by 2 hours. Pyridoxine 50-100 mg daily PO Nausea, headache, Metabolism of levodopa increase; effect prevented Do not exceed 200 paresthesia when levodopa combined with carbidopa. mg/day Sensory neuropathy High doses (80-200 mg/day) may increase (ataxia, numbness of metabolism of phenytoin and barbiturates. hands and feet) has Estrogen therapy increases pyridoxine requirements. occurred with chronic use of large doses  03 Dysmenorrhea Dysmenorrhea: painful menstruation and can be primary or secondary. Primary dysmenorrhea is attributed to uterine contractions with no underlying pathology Secondary dysmenorrhea is due to pelvic disease such as endometriosis, inflammatory disease or uterine polyps.  03 Dysmenorrhea Dysmenorrhea occurs as prostaglandins are released from lysing endometrial cells in the luteal phase of an ovulatory cycle. Menstrual pain occurs a few hours before or just after menstruation begins and usually lasts for 48–72 hours. Cramping is most intense over the lower abdomen, but it may radiate to the back and inner thighs.  Therapy Goals are to relieve symptoms, minimize time lost from activities and identify patients who may have secondary dysmenorrhea and require further medical assessment Non-pharmacological Management Pharmacological Management - Regular aerobic exercise can also decrease stress, which may be a contributing factor. Analgesics (e.g. NSAIDs) Decreasing fat intake Hormone therapies Combined oral contraceptive, Warm baths or applying a heating contraceptive patch, vaginal ring, pad, heat patch or hot water bottle to progestin only pill the abdomen may reduce discomfort. - Alternative approaches for Behavioural interventions such as managing dysmenorrhea include massage with aromatic oils magnesium supplements,omega-3 fatty acids, …. ibuprofen 200-400 mg Q6-8h PO Maximum dose for self-care: 1200 mg/day PO Usual maximum dose: 2400 mg/day PO naproxen Loading dose 500 mg PO; then 250 mg Q6-8h PO or 500 mg BID PO Maximum daily dose: 1250 mg/day PO - Take with food to minimize GI upset - Caution in asthmatic or ASA-sensitive patients - Avoid in patients at risk of peptic ulcer and with renal impairment  04 Contraception Contraception is the act of preventing pregnancy. This can be a device, a medication, a procedure or a behavior. Contraception allows a woman control of her reproductive health  04 Contraception Non-hormonal contraception Hormonal contraception Condoms Help prevent pregnancy and some sexually transmitted infections (STIs), including HIV/AIDS, when used correctly every time. For protection from STIs/HIV, some couples use condoms along with other family planning methods. Easy to use with a little practice. Effective if used correctly every time. Often not used every time, however. Some people object that condoms interrupt sex, reduce sensation, or embarrass them. Talking with partner can help  Contraceptive Implants One or 2 small rods placed under the skin of a woman's upper arm. There is little to do once implants are in place. Very effective for 3 to 5 years, depending on which implant. Can be used at any age and whether or not a woman has had children. A woman can have a trained provider take out the implants at any time. Then she can become pregnant with no delay. Unexpected light bleeding or spotting may occur, or monthly bleeding may stop. Not harmful. Safe during breastfeeding.  Hormonal Contraceptive Methods Preventing ovulation Thickening cervical Thinning endometrium mucus Advantages Disadvantages - Ease of access and use - Must remember to take pills at SAME - Regular, lighter and shorter menses TIME EVERY DAY - Decrease cramps - Decrease uterine, ovarian, colon cancer  Combined Oral Contraceptives (COCs) Taking 1 pill every day & start new packs on time = greatest effectiveness. Unexpected bleeding or spotting may occur, especially at first. Not harmful. Monthly bleeding is lighter & more regular in a few months. Some women have mild headaches, weight change, upset stomach, especially at first. These often go away. Serious complications are very rare. used at any age whether or not a woman has had children. Help prevent menstrual cramps, heavy bleeding, anemia (low blood iron), and other conditions  Injectable Contrceptives Three types: DMPA—injection every 3 months (13 weeks); NET EN—injection every 2 months; Cyclo-Fem and others—injection every month. Can still get next injection even if 4 weeks late for DMPA, 2 weeks late for NET EN, or 1 week late for monthly injectables. Effective and safe. Private. Others cannot tell you are using it. Can be used at any age and whether or not you have had children. DMPA and NET EN are safe during breastfeeding, starting 6 weeks after childbirth. Monthlies not advised. With monthly injectables, monthly bleeding usually becomes lighter, shorter or less frequent. Spotting and unexpected bleeding can occur. When injections stop, a woman can get pregnant again. After DMPA, it may take a few more months  Hormonal Contraceptive Methods Preventing ovulation Slowing tubal motility Thinning Thickening cervical endometrium mucus Advantages Disadvantages - Ease of access and use - Must remember to take pills at SAME - Safety (to be used in cases of TIME EVERY DAY contraindications to estrogen) - Increase risk of unscheduled bleeding  Progestin Only Oral Contraceptives It is a good choice for breastfeeding mothers who want pills. Very effective during breastfeeding and reversible without delay. Taking one pill every day produces greatest effectiveness. If not breastfeeding, spotting and unexpected light bleeding are common. Not harmful  05 Pregnancy Testing Once an ovum is fertilized, it takes an average of 9 days (6–12 days) before it is implanted in the endometrium. Human chorionic gonadotropin (hCG) is detectable in the blood and urine once the ovum is fertilized and implanted.  False Results Errors leading to false results include: Using an expired testing kit Not following the timing recommendations (waving the stick through the urine stream too quickly) Testing too early after conception when hCG levels are too low to be detected Testing too late (after 60–70 days when hCG levels decline) Soap residue, blood or protein in the urine sample Cloudy, pink or red urine Strong urine odour Case I 35 -years- old Female comes to your Pharmacy complaining from vaginal itching, crude like discharge, external dysuria which is not for the first time 1) Mention 2 reasons required referral. 2) Mention some predisposing factors that may exacerbate this case 3) Mention some non pharmacological treatment to be done 4) What are treatment options and monitoring parameters for this case?  Potential predisposing factors for vulvovaginal candidiasis  Non-pharmacological Management - Good genital hygiene measures are important to keep the tissue healthy and free from irritation. - Vaginal deodorants, douches, harsh soaps and perfumed products for genital use should be avoided, as irritation or allergic reactions may occur. - The regular use of products such as panty liners has not been shown to promote the occurrence of vulvovaginal candidiasis Pharmacological Management Vaginal antifungals or oral fluconazole  Drug Dosage Adverse Drug Interactions Effects Fluconazole Uncomplicated infection: 150 mg Headache, Inhibitor of CYP2C9, CYP2C19 and CYP3A4. PO × single dose Recurrent nausea, Decreases serum concentration of clopidogrel’s Diflucan infection: 100 mg, 150 mg or 200 abdominal pain, active metabolites One, mg every 72 h PO × 3 doses; then diarrhea, Decreases metabolism of atorvastatin, CanesOral, 100 mg, 150 mg or 200 mg weekly dyspepsia, benzodiazepines, calcium channel blockers, PO × 6 months dizziness. clarithromycin,… generics Co-administration with warfarin is associated with increased risk of bleeding. Clotrimazole Uncomplicated infection: Local May diminish therapeutic effect of vaginal 200 mg/vaginal tablet: 1 tablet daily hypersensitivity. progesterone; avoid concomitant use. Canesten PV × 3 days or Vaginal, 500 mg/vaginal tablet: 1 tablet PV × generics single dose or 1% vaginal cream: 1 daily PV × 7 days 2% vaginal cream: 1 daily PV × 3 days 10% vaginal cream: 1 PV × single dose Recurrent infection: intravaginal azole × 7–14 days to achieve mycologic remission, followed by clotrimazole 500 mg/vaginal tablet once monthly × 6 months  Drug Dosage Adverse Drug Interactions Effects Miconazole Uncomplicated infection Local may cause increased INRs and bleeding in women 400 mg/ovule: 1 ovule daily PV × 3 hypersensitivity taking warfarin. If necessary to use together, Monistat, days consider more frequent INR monitoring, generics 2% vaginal cream: 1 applicatorful May diminish therapeutic effect of vaginal daily PV × 7 days progesterone; avoid concomitant use Terconazole Uncomplicated infection: 0.4% Local May diminish therapeutic effect of vaginal vaginal cream: 1 applicatorful daily hypersensitivity. progesterone; avoid concomitant use. Terazol 7, PV × 7 days generics  Monitoring of Therapy for Vulvovaginal Candidiasis Symptoms Monitoring Endpoint Actions of Therapy Vulvovaginal Patient: daily for 7-10 days Eradication of If symptoms still present 1 week after start of itching and Healthcare practitioner: after 7 days symptoms therapy, patient requires further evaluation and burning, or next pharmacy visit therapy. dyspareunia, discharge Increased irritation Patient: daily for 7-10 days Eradication of Increased severity of symptom(s) should be (may indicate Healthcare practitioner: after 7 days symptoms assessed promptly; discontinue therapy and ensure adverse reaction or next pharmacy visit. patient receives further evaluation by appropriate to product or healthcare practitioner. inappropriate therapy)  Case II 34 –year- old Female with High Blood pressure comes to your Pharmacy telling you What is the best method for contraception for her? ( mention 2 can be used and 2 not to be used) (chart)”””” High Bp _Monthly injectables and COC not advisable Thank You