Wk 16 OTC 3 2023 (SG) PDF

WEEK 15 OTC Medicines (3) Susan Gault Dale 121 [email protected] Slide 1 of 39 PHA113 MPharm WEEK 15 Learning Outcomes • Responding to symptoms • Recognising the causes, signs and symptoms of common minor ailments • Recognising when to treat and when to refer • Recognising and...

WEEK 15 OTC Medicines (3) Susan Gault Dale 121 [email protected] Slide 1 of 39 PHA113 MPharm WEEK 15 Learning Outcomes • Responding to symptoms • 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 4 PHA113 MPharm WEEK 15 Common Minor Ailments 5 PHA113 MPharm WEEK 15 Ear Wax Causes Signs and Symptoms • Earwax is a normal physiological substance in the ear canal. • The wax (cerumen) aids removal of skin debris from the ear canal • • • • • Cleans, lubricates and protects the lining • Has antibacterial properties. Temporary deafness Discomfort A sensation that the ear is blocked. Symptoms should come on gradually • Usually soft and works its way out of the ear, but excessive build-up of hard earwax can develop • Cotton wool buds should never be poked into the ear to clean or clear it as wax is pushed further in and it is possible to damage the eardrum. 6 PHA113 MPharm WEEK 15 Ear Wax (cont.) Red flag/referral symptoms • • • • • 7 OTC Treatment Dizziness/tinnitus Fever or general malaise Foreign body in the ear canal OTC medication failure Pain PHA113 • Cerumenolytics • Oil based • Peroxide based • Water based MPharm WEEK 15 General Advice for Ear Wax Removal • Warn the patient that instilling ear drops may cause transient hearing loss, discomfort, dizziness and irritation of the skin. • Some ear wax treatments contain arachis oil and/or almond oil • Always check for a nut allergy before selling • If this is a recurrent issue they should see their GP to have their inner ear examined. • Other treatments include irrigation of the ear or syringing/suctioning of the wax 8 PHA113 MPharm WEEK 15 OTC Treatment for Ear Wax Cerumenolytics (agents that soften hardened cerumen and make it easier to be removed from the ear) E.g. Cerumol, hydrogen peroxide and urea, sodium bicarbonate, olive oil • Prescribe ear drops for 3– 5 days initially, to soften wax and aid removal. • Pour a few drops into the affected ear. • Lie with the affected ear uppermost when putting in drops. • Stay like this for 2– 3 min to allow the drops to soak into the ear and the earwax. 9 PHA113 MPharm WEEK 15 MPharm PHA113 11 WEEK 15 Mouth Ulcers Causes Signs and Symptoms • Trauma to the inside of the mouth or tongue • Minor aphthous ulcers • Ill-fitting dentures may produce ulceration, • Can precede the start of the menstrual period • Stress and emotional factors • Food allergies • The cause can remain unclear • Major aphthous ulcers • E.g. biting the inside of the cheek while chewing food. 12 PHA113 • • • • • • • • Most common 2– 10 mm in diameter Round or oval Uncomfortable but eating not affected Usually over 10 mm in diameter Round or oval Prolonged and painful ulceration eating may become difficult • Herpetiform • Least common • Pinhead sized coalesce to form irregular shape as they enlarge • May be very painful MPharm WEEK 15 Mouth Ulcers (cont.) Red flag/referral symptoms OTC Treatment • Painless ulcers should be referred – often a sign of cancer • Lasting more than 14 days • More than 10 ulcers present • Ulcer greater than 1cm in diameter • Signs of systemic illness • Children under 10 13 PHA113 • • • • Chlorhexidine mouthwash Anaesthetic or analgesic gels Orabase protective paste Hydrocortisone mucoadhesive buccal tablet MPharm WEEK 15 OTC Treatment for Mouth Ulcers Anaesthetic/analgesic gels • Local anaesthetics e.g. lidocaine (Anbesol range, Calgel) • Short duration of action • No known interactions • Limited side effects • Local analgesics e.g. choline salicylate (Bonjela) • Licensed from 16yrs+ • Bonjela teething and Bonjela Jnr have different licensing 14 PHA113 MPharm WEEK 15 OTC Treatment for Mouth Ulcers Chlorhexidine Mouthwash • Reduces duration and severity of ulceration. • Helps prevent secondary bacterial infection frequently occurs. • Regular use can stain teeth brown • Should be used twice a day, for 1 min, and continued for 48 h after symptoms have gone. Orabase Protective Gel • Gelatin, pectin, carmellose paste • Sticks when it comes into contact with mucosal surfaces • Dose not contain pain relieving agents • Works by protecting the ulcer from further abrasion 15 PHA113 MPharm WEEK 15 OTC Treatment for Mouth Ulcers Hydrocortisone Mucco-adhesive Buccal Tablet (e.g. Corlan pellets) • Acts locally on the ulcer to reduce inflammation and pain • Thought to shorten healing time (although evidence is weak) • For use by adults and children over 12. • A tablet is held in close proximity to the ulcer until dissolved. • One tablet is used four times a day. • Explain that the tablet should not be sucked, but dissolved in contact with the ulcer. • Can be difficult when the ulcer is in an inaccessible spot. 16 PHA113 MPharm WEEK 15 Warts Verrucas 18 PHA113 MPharm WEEK 15 Warts and Verrucas Causes Signs and Symptoms • Cutaneous warts • Can appear anywhere on the skin • small, rough growths that are caused by infection of skin cells with certain strains of the human papillomavirus (HPV). • A verruca (also known as a plantar wart) is a wart on the sole of the foot. • Most common on the hands and feet. • More common in children • Peak incidence is 12-16 yrs old • Warts appear as raised fleshy lesions on the skin with a roughened surface • Most common type is said to resemble a cauliflower. • Appearance can vary, mostly related to where they occur on the body. • Verrucas occur on the weightbearing areas of the sole and heel • different appearance from warts • pressure from the body’s weight pushes the lesion inwards, sometimes producing pain when weight is applied during walking. 19 PHA113 MPharm WEEK 15 Warts and Verrucas (cont.) Red flag/referral symptoms OTC Treatment • Changed appearance of lesions • • • • • 20 • Once immunity to the infecting virus is sufficiently high, the lesions will disappear • size and colour Bleeding Itching Genital warts Facial warts Immunocompromised patients • 6months- 2yrs • Many patients and parents prefer active treatment. • Acids • Cryotherapy PHA113 MPharm WEEK 15 General Advice for Warts and Verrucas • Many preparations are available OTC, and correct use is required to break down hard skin and to prevent damage to surrounding healthy skin • Continuous application of the selected preparation for several weeks or months is needed, and it is important to explain this to the patient for any benefit to be achieved. • OTC wart products CANNOT be used on: • the face or skinfolds (such as the groin or axillae). • moles or birthmarks, or lesions with red edges, or an unusual colour. • open wounds, irritated or reddened skin or any area that appears to be infected. 21 PHA113 MPharm WEEK 15 OTC Treatment for Warts and Verrucas Acid Treatments (e.g. salicylic acid, lactic acid) • Act by softening and destroying the lesion by chemically burning, thus mechanically removing affected tissue. • Forms: • Gels / paints / plasters • Applied once a day, usually at night. • helped by prior soaking of the affected hand or foot in warm water for 5– 10 min to soften and hydrate the skin, increasing the action of the salicylic acid. • Main risk is causing chemical burns and irritation to healthy skin. • Use petroleum jelly to prevent the treatment from making contact with healthy skin. • Application of the liquid or gel using an applicator will help to confine the substance to the lesion itself. 22 PHA113 MPharm WEEK 15 OTC Treatment for Warts and Verrucas Cryotherapy (e.g. Dimethyl ether propane) • Can be used to freeze warts and is available in an application system for home use for adults and children over 4. • There is little evidence from which to judge its effectiveness in home use rather than when applied by a doctor. • Doctors usually use liquid nitrogen which freezes to a much lower temperature • Should not be used by people with diabetes or by pregnant women. 23 PHA113 MPharm WEEK 15 Conjunctivitis Causes Signs and Symptoms • Describes inflammation of the conjunctiva, a membrane covering the anterior white part of the eye (sclera) and the inside of the eyelids. • Viral conjunctivitis is often accompanied by other signs of viral respiratory tract infection, such as cough and cold. • Main symptoms of conjunctivitis • Can become inflamed due to infection, allergy or irritation. • Infection can be caused by either viruses or bacteria • Viral conjunctivitis is the most common and does not require treatment • Allergic conjunctivitis • Seasonal • Associated with allergic rhinitis symptoms 25 PHA113 • redness or ‘pinkness’ • uncomfortable gritty sensation • a discharge. • Sticky and purulent discharge = bacterial infection • Watery discharge = viral infection • Only one eye may be affected initially, but symptoms usually spread to the 2nd eye MPharm WEEK 15 PHA113 MPharm 26 WEEK 15 Conjunctivitis (cont.) Red flag/referral symptoms OTC Treatment • Clouding of the cornea • Associated vomiting • Possible foreign body in the eye • Irregular pupil shape • Photophobia • Eye pain • Changes in vision • Bacterial • No improvement within 48hrs of treatment 27 PHA113 • Viral • No specific OTC preparations • Symptoms may be eased by bathing the eyelids to remove any discharge and using lubricant eye drops. • Bacterial • Chloramphenicol • Allergic (see wk 12 lecture) • Antihistamines • Sodium Cromoglicate MPharm WEEK 15 General Advice for Infective Conjunctivitis • Viral and bacterial causes are highly contagious • A patient will remain infectious until the redness and weeping resolve (usually in 10–12 days) • Self-help and hygiene measures should be recommended and include the following: • Bathe the eyelids with lukewarm water to remove any discharge. • Use tissues to wipe the eyes and throw away immediately. • Wash hands regularly and avoid sharing pillows and towels. • Contact lenses should not be worn • New lenses should be used after infection has cleared 28 PHA113 MPharm WEEK 15 OTC Treatment for Bacterial Conjunctivitis Chloramphenicol (available as drops or ointment) • licensed for use in children older than 2 years. • Drops: One drop every 2 hours for the first 48 hours and then reducing to four times a day for a maximum of 5 days of treatment. • Ointment: should be used three or four times a day. • Suitable for most patient groups, but always check the license • Pregnancy: not recommended, so hygiene measures should be adopted. • Breastfeeding: only if absolutely necessary 29 PHA113 MPharm WEEK 15 Common Childhood Minor Ailments 30 PHA113 MPharm WEEK 15 Head Lice Causes Signs and Symptoms • Most prevalent: 4-11 yrs, more in girls/those with long hair • Head lice can occur at any time, no seasonal variation. • Only be transmitted by head to head contact. • Observation of live lice is diagnostic. • Fleeting contact not sufficient • Once transmitted lice begin to reproduce • Wet combing • Scalp itching • Presence of empty eggshells • Cream or white-coloured attached to the hair shafts • not necessarily evidence of current infection unless live lice are also found. • Adults live for approx. 1 month. • Females lay eggs at the base of a hair shaft each night. • Eggs hatch after 7-10 days, leaving the egg case attached to the hair 31 PHA113 MPharm WEEK 15 Head Lice (cont.) Red flag/referral symptoms • • • • 32 OTC Treatment Psoriasis Secondary Infection Allergy treatment Symptoms without observed live lice PHA113 • Wet combing • Insecticides • Physical • Chemical MPharm WEEK 15 General Advice for Head Lice • Detection combing is the best way to confirm the presence of live lice. • Systematic combing of wet or dry hair using a fine-toothed (0.2–0.3 mm apart) head lice detection comb. • A person should only be treated if a live head louse is found. All affected household members should also be treated on the same day. • Treatments are most successful if done correctly and if affected patients are treated on the same day. • Children who are being treated for head lice can still attend school. • No evidence that head lice have a preference for either clean or dirty hair. • No need to treat clothing/bedding that has been in contact with lice • Lice only live for 1 –2 days once detached from a human head. • Essential oil-based treatments and herbal treatments are not recommended due to the lack of good-quality evidence • Not possible to prevent head lice infestation. • Children of primary school age should be examined regularly at home (using a detection comb) to identify infestation early. 33 PHA113 MPharm WEEK 15 OTC Treatment for Head Lice Wet combing • Inexpensive, and the kits are reusable. • Time-consuming/labour intensive; • may be a drawback when treating young children or if several people are to be treated at the same time. • Ineffective if an unsuitable comb or incorrect method is used. • Cure rates are lower than other methods. • The recommended regimen is four sessions spaced over 2 weeks (on days 1, 5, 9, and 13). • Detailed information on wet combing is provided on the Community Hygiene Concern website (www.chc.org) 34 PHA113 MPharm WEEK 15 OTC Treatment for Head Lice Physical Insecticides (e.g. dimeticone [Hedrin], Isopropyl myristate & cyclomethicone [Full marks]) • Now considered ‘first line’ as they have few adverse effects, and lice do not develop resistance to them. • Dimeticone is thought to work by coating the lice internally and externally, leads to disruption in water excretion, causing the gut of the lice to rupture • Isopropyl myristate works by blocking the breathing system & coating the lice with a thin film of fluid • Check directions and indications of products • Hedrin: 6 months + • Full Marks: 2 yrs + 35 PHA113 MPharm WEEK 15 OTC Treatment for Head Lice Chemical Insecticides (e.g. malathion, permethrin) • Main insecticide: malathion • usually reserved for second-line use as physical insecticides are more effective and do not cause resistance to develop • Permethrin is not now generally recommended because of its short contact time and because resistance rates are high in the United Kingdom. • Malathion: available as alcoholic & aqueous lotions. • Alcohol-based formulations are not suitable for patients with asthma or eczema 36 PHA113 MPharm WEEK 15 Colic Causes Signs and Symptoms • Defined for as repeated episodes of excessive and inconsolable crying in an infant who otherwise appears to be healthy and thriving. • Cause is unknown • Generally begins in the first few weeks after the baby is born • May affect between 1 in 20 and 1 in 5 babies. • Seems to be multifactorial. • Linked to GI disorder, where spasmodic contraction of smooth muscle causes pain and discomfort, possibly caused by allergy to cow’s milk, lactose intolerance, or inadequate amounts of lactobacilli. 38 PHA113 • Usually resolves by the time the baby is 3– 4 months old. • Excessive and inconsolable crying • Facial flushing and drawing up of the legs. • Clenching of the fists and arching of the back is common. • Passing wind and difficulty in passing stools may also occur. • Attacks appear to be more common in the early evening MPharm WEEK 15 39 Colic (cont.) Red flag/referral symptoms OTC Treatment • Infant not thriving • Symptoms not improving or worsening over age of 4months • Overanxious parents – may need further support • No good evidence for any OTC interventions but parents may still wish to try them • Simeticone • Lactase PHA113 MPharm WEEK 15 General Advice for Colic • Has the feeding technique been reviewed? • Underfeeding the baby can result in excessive sucking and in air being swallowed, leading to colic-like symptoms. • If bottle feeding, the teat size of the bottle should be checked. • Important to reassure parents that colic is not their fault and that the baby will ‘grow out of it’. • Check on the wellbeing of the parents, do they have a good support network? • Signpost for support to their health visitor or Support For Crying And Sleepless Babies | Home | Cry-sis 40 PHA113 MPharm WEEK 15 OTC Treatment for Colic Simeticone (e.g. infacol) • Commonly used to treat infantile colic but evidence of benefit is uncertain. • A trial of simeticone drops for 1 week could be suggested if other strategies are unsuccessful and the parents would like to try treatment. • Pharmacologically inert • No side effects, drug interactions or precautions in its use and can therefore be safely prescribed to all infants. 41 PHA113 MPharm WEEK 15 OTC Treatment for Colic Simeticone (e.g. infacol) • Commonly used to treat infantile colic but evidence of benefit is uncertain. • A trial of simeticone drops for 1 week could be suggested if other strategies are unsuccessful and the parents would like to try treatment. • Pharmacologically inert • No side effects, drug interactions or precautions in its use and can therefore be safely prescribed to all infants. 42 PHA113 MPharm WEEK 15 OTC Treatment for Colic Lactase Enzyme (e.g. colief) • Evidence of benefit is uncertain • Some babies may have difficulty in fully digesting the lactose in milk. This can be an important factor in some babies with colic. • Colief Infant Drops helps to break down the lactose in a baby’s usual milk before the baby is fed, making the milk more easily digestible • Pharmacologically inert • No side effects, drug interactions or precautions in its use and can therefore be safely prescribed to all infants. 43 PHA113 MPharm WEEK 15 Teething Causes Signs and Symptoms • Teething is the process in which deciduous teeth (sometimes known as milk teeth or baby teeth) emerge through the gums causing usually mild and localized symptoms. • Most infants start teething around 6 months of age. • Teething should be suspected in an infant/child up to3 years old if alternative causes have been excluded and there are clinical features which start approx. 3–5 days before each tooth eruption • Some start before 4 months old or after 12 months old • A full set of milk teeth has usually emerged through the gums when the child reaches 2–3 years of age. 45 PHA113 • pain, increased biting and chewing, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite, disturbed sleep, and mild pyrexia. • Signs of gum swelling, redness, and tenderness on palpation just before tooth eruption. MPharm WEEK 15 Teething (cont.) Red flag/referral symptoms OTC Treatment • Exclude any alternative • Teething rings (nonconditions which may cause pharmaceutical) similar symptoms, especially if the child is systemically • Ibuprofen/paracetamol unwell or severely distressed. • Lidocaine containing • Seeking urgent medical review if the infant or child products becomes systemically unwell, is severely distressed, or has prolonged symptoms. NOT RECOMMENDED • Oral salicylate gels • Homeopathic gels/powders 46 PHA113 MPharm WEEK 15 General Advice for Teething • Baby’s teeth should be brushed from their first appearance using a baby toothbrush. • Children should have their first dentist appointment at around 6 months old. • Self-care measures to relieve teething symptoms • Gentle rubbing of the gum with a clean finger; allowing the infant to bite on a clean and cool object; cuddling and reassuring the child; wiping away excess saliva regularly to reduce the risk of facial rash. • Considering the use of over-the-counter paracetamol and/or ibuprofen to provide symptom relief in infants three months of age or older, if self-care measures have not helped. 47 PHA113 MPharm WEEK 15 OTC Treatment for Teething Analgesics (e.g. ibuprofen or paracetamol) • For infants 3 months of age or older if required • Give either paracetamol or ibuprofen alone. • If the child does not respond, • check their adherence and that an appropriate dose is being taken. • If adherence and dose are appropriate, switch analgesic: • If the child does not respond sufficiently to appropriate doses of either drug alone, consider alternating paracetamol and ibuprofen. • Care needs to be taken not to exceed the maximum doses of either drug in 24hrs. • Remember to use the sugar free versions 48 PHA113 MPharm WEEK 15 OTC Treatment for Teething Lidocaine (e.g. anbesol, calgel, detinox gel, bonjela) • No longer available as GSL but will be P meds • Third line treatment option • Apply a pea sized blob of gel (see circle shown in the patient information leaflet) to a clean fingertip and spread gently onto the sore area of the gum. If necessary, repeat the dose after 3 hours. Do not use more than 6 times in one day (24 hour period). 49 PHA113 MPharm WEEK 15 51 Any Questions PHA113 MPharm WEEK 15 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 4: Pg 83-87 Chapter 7: Pg 162-168 Chapter 8: Pg 258-264 Chapter 3: Pg 57-65 Chapter 10: Pg 323-327, 329-331 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 52 PHA113 MPharm WEEK 15 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 53 PHA113 MPharm