Wk 14 OTC 1 2023 (SG) PDF

WEEK 13 OTC Medicines (1) Susan Gault Dale 121 [email protected] ttpoll.eu Session ID: OTC1 Slide 1 of 21 PHA113 MPharm WEEK 13 Learning Outcomes • Recognising the causes, signs and symptoms of common minor ailments • Recognising when to treat and when to refer • Recognising and...

WEEK 13 OTC Medicines (1) Susan Gault Dale 121 [email protected] ttpoll.eu Session ID: OTC1 Slide 1 of 21 PHA113 MPharm WEEK 13 Learning Outcomes • Recognising the causes, signs and symptoms of common minor ailments • Recognising when to treat and when to refer • Recognising and understanding red flag symptoms • Common OTC products and doses 3 PHA113 MPharm WEEK 13 Sales value of OTC medicines in Great Britain in 2022, by medicine category https://www.statista.com/statistics/415963/over-the-counter-otc-medicine-breakdown-of-sales-in-great-britain/ 4 PHA113 MPharm WEEK 13 Common Respiratory Minor Ailments 5 PHA113 MPharm WEEK 13 6 Common Cold Causes Signs and Symptoms • A mixture of viral upper respiratory tract infections • Generally gradual onset • Transferred via the inhalation of infected droplets through the mouth or nose • Self-limiting • Begin 2-3 days after infection • Last 2-14 days, usually resolve after 7 days • Runny/blocked nose • Cough (may persist for a few days after other symptoms have cleared) • Sore throat • Aches and pains • Headache PHA113 MPharm WEEK 13 Common Cold (cont.) Red flag/referral symptoms OTC Treatment • Wheezing / Shortness of breath • Pain on breathing or coughing • Earache • Blood stained mucus • Symptoms for 3 weeks or longer • Neck stiffness • Chest pain 7 • Self-limiting but patients often opt for symptomatic relief • Decongestants • Demulcents PHA113 MPharm WEEK 13 Coughs Causes Signs and Symptoms • Reflex action of the body due to infection, inflammation or irritation of the airway • Categorised as: • Self-limiting • Symptoms generally improve better within a few days with or without treatment. • Productive/chesty • Phlegm is produced and the cough reflex expels the phlegm • Non-productive/dry • No phlegm production 8 PHA113 MPharm WEEK 13 Coughs (cont.) Red flag/referral symptoms OTC Treatment • Longer than 3 weeks’ duration and not improving • Regularly recurring cough • Shortness of breath • Chest pain/pain on breathing • Coughing up blood • Yellow, green, brown stained phlegm • Offensive or foul smelling phlegm • Fever 9 PHA113 • Self-limiting but patients often opt for symptomatic relief • Expectorants • Suppressants • Demulcents MPharm WEEK 13 Sore Throats Causes Signs and Symptoms • Usually a symptom of an acute upper respiratory tract infection. • May occur alone or be accompanied by other symptoms such as sinusitis, cough and headache. • May be viral or bacterial in origin • Usually self-limiting • Symptoms generally improve within 7 days • Pain in the back of the throat • Swollen lymph glands may be felt under the chin or neck • Pain upon swallowing • No evidence that duration or severity is significantly different in either case. • Clinical examination is unlikely to be able to differentiate between bacterial and viral sore throat. • Other causes of sore throat may be GORD, physical or chemical irritation 10 PHA113 MPharm WEEK 13 Sore Throats (cont.) Red flag/referral symptoms OTC Treatment • Dysphagia (difficulty in swallowing) • Self-limiting but patients often opt for symptomatic relief • Fever • Longer than 14 days • Demulcents • Hoarseness persisting for more than three weeks • Local anaesthetics • Analgesics • Sore throat with a skin rash • White spots, exudate or pus on the tonsils with a high temperature and swollen glands NB: Where there is bacterial infection, antibiotics make little difference on outcome, so treatment with antibiotics is unnecessary in most cases. • Recurrent bouts of infection • Failed treatment • Breathing difficulties 11 PHA113 MPharm WEEK 13 General Advice for Common Respiratory Minor Ailments • Smoking • Consider referring the patient in to a stop smoking service • Hand hygiene • Use of alcohol gels and effective hand washing to prevent transmission • Flu vaccination 13 PHA113 MPharm WEEK 13 When you have had a cough, cold or sore throat what have you used to help make it better? Slide 14 of 21 PHA113 MPharm WEEK 13 OTC Treatment for Common Respiratory Minor Ailments Decongestants (E.g. pseudoephedrine, phenylephrine, oxymetazoline) • Work by constricting the dilated blood vessels in the nasal mucosa • Nasal membranes are effectively shrunk, so drainage of mucus and circulation of air are improved and the feeling of nasal stuffiness is relieved. • Stimulatory action may cause sleep disturbances if taken at night • Can be given orally or applied topically. • Tablets: licensed for 12yrs + • Liquids: licensed for 6yrs + • Nasal spays/drops: licensed for 12yrs + • Rebound congestion can occur with topically applied • Max. use 7 days 15 PHA113 MPharm WEEK 13 OTC Treatment for Common Respiratory Minor Ailments Expectorants (E.g. guaifenesin, squill extract) • In theory produce expulsion of bronchial secretions, although, there is no evidence that they can specifically facilitate expectoration. • BNF states that they are more likely to have a placebo effect and in general are inexpensive, so may be useful to offer to some patients who feel the need to take something. • Given orally • Liquids: licensed for 6yrs + 16 PHA113 MPharm WEEK 13 OTC Treatment for Common Respiratory Minor Ailments Suppressants (aka anti-tussives) (E.g. codeine, dextromethorphan) • Suppress the cough reflex • Not to be used if clearance of phlegm if needed • Those codeine or opioid derivatives are not ideal because of the high incidence of side effects, such as constipation and dependence. • Pholcodine has fewer side effects than codeine. • Dextromethorphan (a non-sedating opiate) and menthol have both been shown to suppress the cough reflex without the adverse effects of codeine and pholcodine • Given orally • Liquids: licensed for 6yrs + • Those containing opioid derivatives are not recommended for those 12-18 yrs old with breathing problems 17 PHA113 MPharm WEEK 13 OTC Treatment for Common Respiratory Minor Ailments Demulcents (e.g. glycerine, lemon & honey, simple linctus) • Definition: a substance that relieves irritation of the mucous membranes in the mouth by forming a protective film. • Do not contain any active ingredient • Considered to be safe in children and pregnant women. • Now the treatment recommended for children under 6 years old. • Given orally: • Liquids: paediatric and adult versions available • Lozenges: avoid use in young children as they pose a choking hazard 18 PHA113 MPharm WEEK 13 OTC Treatment for Common Respiratory Minor Ailments Analgesics (e.g. paracetamol, ibuprofen) • Paracetamol has analgesic and antipyretic effects • Max. adult dose 1000mg four times in any 24hr period • Is contained in many OTC cough/cold remedies, care must be taken to avoid duplicate doses • Ibuprofen has analgesic, anti-inflammatory and antipyretic activities • Classed as a non-steroidal anti-inflammatory (NSAID) • Causes less irritation and damage to the stomach than does aspirin. • Adult dose required for analgesic activity is 200– 400 mg and that for anti-inflammatory action 300– 600 mg 19 PHA113 MPharm WEEK 13 OTC Treatment for Common Respiratory Minor Ailments Local Anaesthetics (e.g. benzocaine, lidocaine) • Should not be used if sensitivity reactions are suspected • Should not be used for longer than five days. • Given topically: • Throat spray: licensed for 12yrs + • Lozenges: licensing varies depending on active ingredients usually 6yrs + 20 PHA113 MPharm WEEK 13 Gastro-intestinal Minor Ailments 22 PHA113 MPharm WEEK 13 Dyspepsia Causes Signs and Symptoms • Describes a collection of symptoms including: • Caused when there is reflux of gastric contents, particularly acid, into the oesophagus, which irritate the sensitive mucosal surface • Burning discomfort/pain felt in the stomach, passing upwards behind the breastbone • Unpleasant acid taste in the mouth • Often related to eating • Other symptoms may include nausea, fullness in the upper abdomen or belching • upper abdominal discomfort and pain • Heartburn • acid reflux • nausea and vomiting related to eating • Non-ulcer dyspepsia • diagnosis made by endoscopy • GORD • Peptic ulcer disease • gastric or duodenal • A hiatus hernia. 23 PHA113 MPharm WEEK 13 Dyspepsia (cont.) Red flag/referral symptoms OTC Treatment • Gastro-intestinal bleeding • ‘coffee grounds’ in vomit • Black/tarry stools • Dysphagia (difficulty swallowing) • Progressive unintentional weight loss • Persistent vomiting • Severe pain • Pain radiating to other areas of body e.g. arm • Failed treatment 24 PHA113 • Antacids • Alginates • Proton pump inhibitors MPharm WEEK 13 General Advice for Gastro-intestinal Minor Ailments • Dyspepsia: • Eating smaller, more frequent meals can help • Raise the head end of your bed, so your chest and head are above the level of your waist, which can stop stomach acid travelling up towards your throat • Smoking • Consider referring the patient into a stop smoking service • Weight loss • Avoid trigger foods • E.g. chocolate, alcohol, caffeine, rich/spicy/fatty foods 25 PHA113 MPharm WEEK 13 OTC Treatment for Gastro-intestinal Minor Ailments Antacids (e.g. calcium carbonate, magnesium and aluminium salts, Rennie) • Limited evidence on their efficacy • However, symptomatic relief is often reported • Best given when symptoms occur or are expected, ie after meals and at bedtime. • Remain in the stomach for longer at these times, and therefore have longer to act. • Should not be taken at the same time as other drugs as they may impair absorption • Combination antacid products, containing both magnesium and aluminium salts are less likely to cause gastro-intestinal upset. • Magnesium salts alone may cause diarrhoea • Aluminium salts alone may cause constipation 26 PHA113 MPharm WEEK 13 OTC Treatment for Gastro-intestinal Minor Ailments Alginates (e.g. sodium alginate, potassium alginate, Gaviscon) • Form a ‘raft’ on the stomach contents, providing symptomatic relief of reflux and protecting the oesophageal mucosa • Some products are a combination of alginates and antacids • Use potassium based alginates in patients on a restricted sodium diet. 27 PHA113 MPharm WEEK 13 OTC Treatment for Gastro-intestinal Minor Ailments Proton pump inhibitors (e.g. omeprazole, esomeprazole) • Generally accepted as being the most effective treatment for heartburn • Can take up to 24hrs to become effective • Inhibit gastric acid secretion by blocking the hydrogen potassium adenosine triphosphatase enzyme system (the proton pump) of the gastric parietal cell. • Omeprazole • Licensed for short-term relief of reflux, 18yrs + for a max. of four weeks. • Esomeprazole • Licensed for 18 years + for a maximum of 14 days treatment. 28 PHA113 MPharm WEEK 13 30 Constipation Causes Signs and Symptoms • • • • • Reduced frequency of defecation compared to what is normal for that person Poor fibre intake Poor fluid intake Sedentary lifestyle Other medication • Straining and passage of small, hard stools • Abdominal discomfort • Abdominal cramps • Feeling of incomplete emptying of bowels after going to the toilet PHA113 MPharm WEEK 13 Constipation (cont.) Red flag/referral symptoms OTC Treatment • Blood in the stools • Pain on defecation • With abdominal pain, vomiting or bloating • Unexplained weight loss • Failed treatment • Change in bowel habit of more than 2 weeks • Adults with new or worsening constipation without adequate explanation 31 PHA113 • Laxatives • Bulk forming • Osmotic • Stimulant • Stool softener MPharm WEEK 13 32 Constipation in special patient groups Children Pregnancy and Breastfeeding • Normally resolves without treatment • Tummy ache, pain when attempting to pass stools, upset/ anxious about going to the toilet • Fruit juice will help • Referral to a GP if not resolved and danger symptoms present • If the constipation becomes regular, referral for prescribed treatment may be appropriate. • ‘Toilet phobia’ needs to be avoided • Bulk forming and osmotic laxatives are the safest options as they are not absorbed • Senna enters the breast milk, so may cause colic and diarrhoea in the infant. PHA113 MPharm WEEK 13 General Advice for Gastro-intestinal Minor Ailments • Constipation: • • • • 33 Drink eight glasses of fluid a day (about two litres) Too much caffeine can worsen constipation Eat foods high in fibre Remain physically active PHA113 MPharm WEEK 13 OTC Treatment for Gastro-intestinal Minor Ailments Laxatives • Bulk forming (e.g. ispaghula) • Act by retaining water in the gut and increasing faecal mass, therefore stimulating peristalsis. • Have a delayed onset and therefore are not suitable for acute occasional relief • They must be taken with adequate fluids to avoid intestinal obstruction • Side effects may be bloating, distension and flatulence; should settle with regular use. • Dissolve sachet in water and drink • Licensed for 6yrs + 34 PHA113 MPharm WEEK 13 OTC Treatment for Gastro-intestinal Minor Ailments Laxatives • Osmotic (e.g. lactulose, macrogol) • Act by increasing the absorption of water into the large bowel • Can take up to 48hrs to be effective • Lactulose • Liquid • Licensed for use in babies • Macrogol • Sachets, paediatric sachets and liquid • All require dilution before use • Licensed from 2yrs + depending on formulation 35 PHA113 MPharm WEEK 13 OTC Treatment for Gastro-intestinal Minor Ailments Laxatives • Stimulant (e.g. senna, bisacodyl) • Act by stimulating colonic nerves to increase intestinal motility • They take effect within 8 to 12 hours, so the dose is usually taken at night. • Frequent use can lead to fluid and electrolyte imbalance • Given orally • Senna: Licensed for 18yrs + • Bisacodyl: Licensed for 12yrs + 36 PHA113 MPharm WEEK 13 OTC Treatment for Gastro-intestinal Minor Ailments Stool Softener (e.g. docusate, glycerol) • Act by reducing surface tension and increasing penetration of intestinal fluids into the faeces. • Both are also stimulant laxatives. • Docusate • Given orally as liquid or capsules • Licensing depends on formulation • Glycerol • • • • 37 Given rectally Licensed for use in children Size of suppository used depends on age Useful for rapid relief (work within approx. 30mins) PHA113 MPharm WEEK 13 39 Diarrhoea Causes Signs and Symptoms • Viral or bacterial infections e.g. E.Coli, Salmonella, Cryptosporidium • Diseases of the GI tract e.g. IBS • Defined as an increased frequency of bowel evacuation, with the passage of abnormally soft or watery faeces. • Usually acute and selflimiting • Abdominal cramps, flatulence, weakness/malaise may also occur PHA113 MPharm WEEK 13 Diarrhoea (cont.) Red flag/referral symptoms OTC Treatment • Drowsiness or confusion • Signs of dehydration e.g. passing little urine, dry mouth and tongue • Cool hands or feet • Sunken fontanelle in babies/young infants • Blood or mucus in the stools • Persistent vomiting • Lasting longer than 3 days in adults • Recent travel abroad 40 PHA113 • Basis of treatment is electrolyte and fluid replacement • Anti-diarrhoeals (a.k.a. antimotility drugs) may be useful in some adults and older children. MPharm WEEK 13 General Advice for Gastro-intestinal Minor Ailments • Diarrhoea • Drink plenty of normal drinks if possible. • Eat as normally as possible. • Ideally include fruit juices and soups, which will provide sugar and salt, and also foods that are high in carbohydrate, • There is little evidence to support the need to avoid solid food for 24 hours. • Always wash your hands after going to the toilet (or changing nappies). • Regular cleaning of the toilet, including the flush handle and toilet seat is advisable. • Specialist advice is required for those whose job involves handling food 41 PHA113 MPharm WEEK 13 OTC Treatment for Gastro-intestinal Minor Ailments Oral Rehydration sachets (e.g. dioraltye) • Rehydration sachets are considered the standard treatment for acute diarrhoea in babies and young children • Sachets or tablets are dissolved in water and should be taken with each loose stool, in addition to taking other fluids throughout the day • Licensing will vary based on preparation 42 PHA113 MPharm WEEK 13 OTC Treatment for Gastro-intestinal Minor Ailments Anti-motility drugs (e.g. loperamide, imodium) • Helps reduce the duration of diarrhoea and improves symptoms • Increases stool consistency • Should only be used when symptom control is necessary • Should not be used routinely to treat diarrhoea • Patients should still drink plenty of fluids 43 PHA113 MPharm WEEK 13 44 Any Questions PHA113 MPharm WEEK 13 Follow Up Reading • Rutter, P. (2021) Community pharmacy : symptoms, diagnosis and treatment. Fifth edition. Amsterdam: Elsevier. (Available online from the library and as a hard copy) • Chapter 2: Pg 9-34 • Chapter 7: Pg 174-196 OR • Blenkinsopp, A., Duerden, M. and Blenkinsopp, J. (2023) Symptoms in the pharmacy : a guide to the management of common illnesses. Ninth edition. Hoboken, NJ: John Wiley & Sons Ltd. (Available from the library as a hard copy) • Read relevant chapters on topics covered in this lecture 45 PHA113 MPharm WEEK 13 Useful Resources • Common Clinical Conditions and Minor Ailments. NHS Education for Scotland. www.cppe.ac.uk [Accessed 04/10/2022] • Blenkinsopp, A, Duerden, M, & Blenkinsopp, J 2018, Symptoms in the Pharmacy : A Guide to the Management of Common Illnesses, John Wiley & Sons, Incorporated, Newark. Available from: ProQuest Ebook Central. [4 October 2022]. • Guidelines: summarising clinical guidelines for primary care 46 PHA113 MPharm