FINAL EXAMINATION GUIDE



115 – TABLES FROM OTC BOOK – Annie Ho

BREAKDOWN OF QUESTIONS

Dr Stan-Ugbene 30 questions

Dr Wagner 30 questions

Dr Norton 10 questions

PRE-MIDTERM TOPICS COVERED:

COUGH, COLD, ALLERGY, ORAL DISCORDERS, DENTAL DISORDERS, FEVER, PAIN, HOME TESTING/MONITORING DEVICES, SEXUALLY TRANSMITTED DISEASES AND PREGNANCY PREVENTION

▪ Table 5-3

▪ [pic]

▪ Table 5-8

[from first study guide]: Please focus just on primary ingredients without actual doses for Advil Cold and Sinus, Aleve-D, Alka-Seltzer Plus Sinus, Excedrin Migraine and Excedrin Tension Headache

• Advil cold/sinus: ibuprofen, pseudoephedrine

• Aleve-D: naproxen sodium, pseudoephedrine

• Alka-Seltzer Plus Sinus: acetaminophen, phenylephrine

• Excedrine Migraine: acetaminophen, asprin, caffeine

• Excedrine tension HA: acetaminophen, caffeine

[pic]

▪ Table 7-2 – Exclusions to self treatment of musculoskeletal Disorders

▪ (I think that Oby meant FIGURE 7-2, because TABLE 7-2 is “comparison of musculoskeletal disorders, which does not include anything about exclusions to self-tx)

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▪ Table 7-3

▪ [pic]

▪ Figure 6.1- Exclusions to self treatment of fever

▪ [pic]

▪ Table 11-5 Only study dosing for adults/children more than 12 years

▪ [pic]

▪ Table 11-8

▪ [pic]

▪ Table 12-3

▪ [pic]

Pharmacological therapy for cough

Cough suppressants (systemic antitussives)

– Dextromethorphan

• Codeine analog

• Increases cough threshold

• 10-20 mg every 6-8 hours

• 120 mg maximum

– Codeine

• Gold standard

• Increases cough threshold

• 10-20 mg every 4-6 hours

• 120 mg maximum

– Diphenhydramine

• First generation antihistamine

• Anticholinergic effects

• 38 mg every 4 hours

• 225 mg maximum

– Topical

• Camphor

• Menthol

Topical antitussives

Expectorants (protussives)

Guaifenesin

▪ Loosens and thins lower respiratory tract secretions to effectively remove mucus

▪ 200-400 mg every 4 hours

▪ 2.4 g maximum

Lecture slides 9-15: cough, cold, allergic rhinitis

DEXTROMETHORPHAN

• Drug of choice for non productive cough

• Non- Opioid (non addictive)

• Codeine analog (a control substance)

• Acts centrally in the medulla to increase cough threshold

• For cough resulting from chemical/mechanical irritation

• Dose related toxicities

• Overdose: nervousness, confusion, irritability( psychosis, mania, respiratory depression

• AE (adverse effect) - drowsiness, N,V, stomach discomfort, constipation

• Not to be used within 14 days of using MAOI (Monoamine oxidase inhibitor) Inhibitors (phenylalidine) ( serotonin syndrome (increase BP, hyperpyrexia, arrhythmias, myoclonus)

• Abuse potential

• Supplied as syrups, liquids, liquid-filled gelcaps, oral disintegrating strips, oral sprays, lozenges, extended release oral suspensions (delsome)

CODEINE

• Gold standard antitussive

• Controlled Substance

• Acts centrally on the medulla to increase cough threshold

• Supplied as oral solutions and syrup

• Lethal adult dose - 0.5 to 1g (respiratory depression, cardiopulmonary arrest)

• AE - N,V, sedation, dizziness, constipation

• CI (contraindication): During labor with anticipation of preterm labor, codeine allergy

• DDI (drug-drug interaction): Alcohol, barbiturates, sedatives -> additive CNS depression

DIPHENHYDRAMINE (aspirin, Benadryl)

• Non selective first generation antihistamine (causes drowsiness)

• Acts centrally in the medulla to increase cough threshold

• Action related to anticholinergic effects

• Onset of action – 15 mins, helps to clear the cough

• Hepatic metabolism (not for patients with liver problem)

• For cough due to chemical/mechanical irritation

• Supplied as syrups, liquids, oral disintegrating strips

• AE: drowsiness, blurred vision, dry mouth, urinary retention, excitability in children

• Caution: glaucoma, hyperthyroidism, asthma (due to anticholingergic effect)

TOPICAL COUGH SUPPRESSANTS

• Oral camphor (topical treatment, ex. Vicks)

• Oral menthol

• MOA (mechanism of action) – Stimulate sensory nerve endings within the nose and mucosa creating a local anesthetic effect with a sense of increased air flow

• Lethal in large doses

GUAIFENESIN (mucefnix)

• Drug of choice for coughs consisting of thick, tenacious secretions which are difficult to expel (thins the mucous and helps to expel it)

• Loosens and thins lower respiratory tract secretions to effectively remove mucous

• Relatively harmless

• FDA approved for acute productive cough

• Few adverse effects

– Stomach pain, diarrhea, nausea, HA

• No reported drug interactions

• Oral solutions, syrups, immediate and extended release tablets

• Alcohol free, sucrose free and dye-free

Slide 8 -12: oral and dental disorder

Pharmacological therapy

• Chemical management of plaque

– Aid mechanical removal directly or by disrupting components of plaque

– Characteristics include:

• agents with selective antibacterial activity

• substantivity (retention in the mouth)

• compatibility with dentifrice ingredients (toothpaste)

• reduced adverse effects

• non interference with natural mouth flora

– FLUORIDE

• Mostly for orthodontic pts, pts with reduced salivary flow or at risk for caries

• Reduces solubility of dental enamel, enhancing remineralization while reducing glycolysis of sugar hence inhibiting acid formation

• OTC fluoride rinses ( Oral B Anti cavity rinse, ACT for Kids)

Fluoride therapy

• Should not be used more than once daily

• Brush with fluoride toothpaste prior to using fluoride treatment

• Swish specified amount around the teeth for about 1 minute

• Do not swallow

• Do not eat or drink for about 30 minutes after fluoride treatment

• Supervise children < 12 yrs for proper use of agent

• Refer children < 6 yrs to PCP or dentist prior to treatment initiation

• Fluorosis may occur with overdose of fluoride (makes pits in your teeth)

Dentifrices

• Used with a toothbrush to clean accessible tooth surfaces

• Types - Fluoride, Tartar control, antiplaque/gingivitis, whitening/antistain

• Available in paste, powders and gel (aquafresh, Colgate, ultrabrite, biotene, sensodyne, crest)

• Low - abrasive types contain low concentration of silica while high- abrasive types contain more of aluminum salts

• Antiplaque agents contains triclosan ( Colgate Total)

• Whitening agents differ from bleaching agents and may contain chemicals such as aluminum oxide, citrate salts, papain ( Rembrandt Whitening toothpaste)

• MOUTH RINSES AND GELS

• Adjunct to brushing and flossing

• Contain alcohol without abrasive as well as glycerin, benzoic acid and zinc chloride - Crest Pro-Health, Listerine, Scope

• Contain aromatic oils for antibacterial activity and local anesthetics – menthol, eucalyptus and thymol as well as agents for antimicrobial activity – cetylpyridinium chloride

• PLAQUE CONTROL CHEWING GUM AND LOZENGES

• Between dental gum, Biotene (mainly for dry mouth)

Gingivitis

• Inflammation of the gingiva (gum) without loss or migration of epithelial attachment

• Swollen red gum as well as engorged capillaries

• Main cause of tooth loss in adults > 45yrs

• Closely associated with oral hygiene

• Etiology: plaque build up, hormonal changes, blood dyscrasias (leukemia), mucocutaneous disease and viral infections, AIDS, medications- CCB (calcium channel blockers), BB (beta-blockers), Anti depressants, Phenytoin, Cyclosporine, tobacco, pregnancy

• Reversible

• Asymptomatic – bleeding, swollen gums

• May lead to periodontal disease

• Prevention - brushing, flossing, gum massage

Slides 19-24

TOOTH HYPERSENSITIVITY

• Exposure of dentin due to enamel or gingival recession

• Causes: bruxism (grinding), teeth whitening products, dental treatments,

• Stimulus (heat, cold, pressure, acid,)( stimulate exposed dentin or open tubule( pain

• Treatment goals- alter damaged tooth surface using proper toothbrush and paste, stop abrasive toothbrush practices

• Differentiation of tooth hypersensitivity & Toothache[Table 32-1]

• Nonpharmacological treatment - removing predisposing factors, proper brushing techniques, standard fluoride dentifrice

• Pharmacological treatment: use of desensitizing dentifrices containing a potassium salt [Table 32-2]. Common ingredients include sodium fluoride + potassium nitrate 5% containing products (Colgate sensitive maximum strength, Sensodyne)

– At least 1 inch strip required

– Pts should not rinse mouth after use

– 2- 4 wks of treatment may be required

– Not for children < 12 yrs

Teething discomfort

• Mostly in babies

• Characterized by mild pain, irritation, reddening, swelling and excessive drooling, irritability and sleep disturbance

• Treatment goal - relieve pain and discomfort

• Non pharmacological treatment – massaging the gums, frozen pacifiers or cold wet cloth

• Pharmacological treatment

– FDA approved topical analgesics containing benzocaine 5% to 10% ( Baby Oragel)

– Systemic analgesics for pediatrics

Recurrent Aphthous Stomatitis

• Also known as RAS or canker sores

• May be precipitated by stress and local trauma, may be genetic

• Associated with smoking, SLE, allergy, IBD, HIV, iron, folic acid or Vit B1,B2,B6 or B12 deficiency

• Epithelial ulceration on nonkeratinized mucosal surfaces

• Treatment Goals: control ulcer pain, promote healing, prevent recurrence and prevent secondary infection

• Exclusions to self care [Figure 32-2]

• Nonpharmacological treatment

– Vitamin/mineral supplementation

– Avoiding acidic, spicy food

– Eliminating offending allergy causing agent

– Applying ice in 10 minute increments

• Pharmacological

– Oral debriding and wound cleansing agents, topical oral analgesics/anesthetics/protectants and rinses provide symptomatic relief (GlyOxide oral cleanser, carmex lip balm, canker cover, listerine rinse, abreva [Table 32-5]

• Minor Oral Mucosal Injury/Irritation May be caused by dental procedures, biting/abrasion of the cheek, irritations in the mouth or gum

• Treatment goal: control discomfort and pain, aid healing and prevent secondary bacterial infection

• Nonpharmacological treatment

– ice application in 10 minute increments

– sodium bicarbonate (baking soda ½ to 1tsp in 4 oz of water)

– saline rinse(1-3 tsp in 4-8 oz of water)

• Pharmacological treatment: same as in RAS, and astringents (cleaning to get rid of bacteria) may also be used [Table 32-5]

• Should resolve in 7-10 days or else refer to PCP

HERPES SIMPLEX LABIALIS

• Also known as HSL, cold sore, fever blister

• Viral

– HSV-1 – oral and labial sores

– HSV-2 – genital sores? Oral sex?

– Cytomegalovirus, Epstein-Barr virus

– At age 40, 84% of US population have antibodies for HSV-1. Recurrent infection in 30 to 40% of patients

• Contagious via direct contact

• Triggers for reactivation of virus – UV radiation, stress, fatigue, cold, windburn, dental work, fever, immunotherapy

• Lesions on the lips, lip borders or in the mouth

• Treatment similar to RAS

• Treatment goals: cleansing affected area, protecting the lesions from infection, relieving discomfort of itching, burning and pain

• Exclusions to self care [Figure 32-4]

• Nonpharmacological treatment

– Proper hand washing, keeping lesions moist and avoiding triggers

• Pharmacological treatment

– Topical skin protectants

– Analgesic/anesthetic in emollient vehicles

– Abreva

– Antibiotic ointments for secondary bacterial infection

• Infection is self limiting

Xerostomia

• aka dry mouth

• Entails limited or completely stopped salivary flow

• Disposing factors: DM (diabetic) , autoimmune disorders, depression, crohn’s disease, anticholinergic medications, diuretics (dry mouth), sedatives, antipsychotics, antidepressants, old age, autoimmune disorders, alcohol, tobacco, caffeine, mouth breathing

• Treatment goals- relieve discomfort, prevent/treat infection, reduce risk of caries

• Exclusions to self care [ Figure 32-5]

• Counseling tips

– Professional dental management in addition to self care

– Good oral hygiene

– Adequate water intake

– Complications include gingivitis, caries, periodontal disease

• Nonpharmacological treatment: avoid substances that dry mouth, modify medication schedules to at least 1 hr prior to meals, limit sugar intake to avoid tooth decay, gum sweetened with sugar alcohol (xylitol) may be beneficial and increased water intake

• Pharmacological

– Artificial saliva

• Viscosity - carboxymethylcellulose and glycerin

• Mineral content – calcium and phosphate ions, some fluoride

• Palatability – mint or lemon flavor sweetened with xylitol or sorbitol

– Biotene, Salivart [Table 32-6]

Self Care Slides 7-13

Problems with self care

• Product confusion – marketing strategies

• Therapeutic duplication

• Therapeutic failure

• Poor self care choices

• Incorrect dosing

• Drug interactions

• Uncertainty regarding duration of therapy

• Patients assumptions that OTC medications are not “real drugs”

Conditions commonly treated with self care

• Pain (78%)

• Cough/cold/flu/sore throat (52%)

• Allergy/sinus problems (45%)

• Heartburn, indigestion (37%)

• Constipation/diarrhea/gas (21%)

• Minor infection (12%)

• Skin problems (10%)

Patient self care behavior

• Some patients using prescription medications are concurrently using herbal supplements

• Common indications for OTC therapy include headache, skin problems, heartburn/indigestion, cold, cough, flu, sore throat, allergy or sinus problems

• Primary source of information include family and friends

• Special populations often overlooked when reading labels - pregnant women, diabetics, hypertension patients, and the elderly

OTC drug label facts

• Active Ingredients

• Uses

• Warnings

• Directions

• Other information

• Inactive ingredients

• Caution about pregnancy/breastfeeding

• Storage information

• Questions?

Benefit of pharmacist assisted related health care

• Reduced ER and physician office visits

• Reduced medical errors

• Reduced health care costs

• Improved quality of care

• Increased productivity and reduced absenteeism from work

• Saves patients time

• Increased patient education and awareness

• Increased patient satisfaction

Goals of pharmaceutical care for self treatment

• Proper patient evaluation for self care vs. referral

• Developing and implementing a care plan

• Scheduling follow–up care to evaluate therapeutic outcomes

• Implementing modifications as necessary

Missing: lectures slides on contraception and Home Testing Devices

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