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Transcript
Gastrointestinal Medication
Used in specific disease states:
1. GERD – Gastro-esophageal Reflux Disease
2. PUD – Peptic Ulcer Disease
a. Duodenal
b. Gastric
c. Stress induced
d. Drug induced
3. Gastritis
a. Acute
b. Chronic
GERD
Gastro – esophageal reflux Disease
(Reflux of gastric content in lower esophageal sphincter)
1. General
a. Problem with the lower esophageal sphincter (it is
incompetent & does not close properly)
b. Acid & food contents can reflux back into the esophagus
c. Regurgitation may be present (not vomiting)
d. Laying down – worsen the condition
e. Goal of therapy: to decrease acid production & increase
tone - Give Metoclopramide (Reglan) – Reglan &
propaisid?
2. Symptoms
a. Gastric burning
b. Esophageal ulceration
c. Coughing during the night
d. Sore throat upon wakening
e. Shortness of breath (dyspenea)
f. Wheezing & chest pain
g. Mouth irritations
1
h. Food regurgitation – chocking & aspiration possible,
difficulty in swallowing (dysphasia)
i. Acid regurgitation
j. Barretts Esophagus – A condition of pre-cancerous cell
formation upon repeated exposure of the esophagus to acid
reflux ( Acid destroys cells)
3. Atypical presentation
a. NO NORMAL COMPLAINTS
b. NO - GI burning
c. NO – Acid regurgitation
d. Tightening of throat : Patient may feel a tightness at the
base of the neck which is actually an upper esophageal
spasm (protective mechanism)
e. tone = Constrict
f.  tone = Reflux
4. Proper diagnosis
a. An Endoscopy should be performed
5. Life Style Changes
a. Allow 3 hrs between eating & bedtime
b. If the patient does fall asleep before 3 hrs, they should be
sitting up
c. Recommended putting blocks under the bed to increase
the incline
d. AVIOD:
i. Overeating (eat small meals)
ii. Chocolates (decreases tone of the esophageal
sphincter)
iii. Caffeine (decreases tone of the esophageal sphincter)
iv. Mint (decreases tone of the esophageal sphincter)
v. Acidic drinks (Ex. OJ & Soda)
2
vi. Fatty food (b/c of delayed digestion & gastric
emptying time)
vii. Smoking
6. Complications
a. Burret’s Esophagus
b. Esophageal strictures
c. Ulcer
7. Medication ( Drug therapy, Therapeutic Management)
a. D/C PPt factors
b. Drug options – NSAIDS
c. H2 Analysist
d. Proton pump inhibitors
ACIDIC PRODUCTION AT NIGHT BECAUSE
PARASYMPTHETIC NERVUS SYSTEM TAKES OVER.
3
Gastritis
(Indigestion)
Acute Vs. Chronic
Acute
1. Food
2. Alcohol
3. Drugs – NSAIDS
Chronic
1. Alcohol
2. Chronic Drug Therapy
(Motrin, Advil)
1. Sx:
a. Burning
b. Pain (Substrnal)
2. Complications
a. Bleeding
i. IF bleeding from upper GI / Pt. taking iron =
Feces – Black
ii. Bleeding from Lower GI (rectal/ stomach)= feces
– Black & Red
b. Vomiting – Coffee Brown
3. General
a. AKA sour stomach or indigestion
b. ASA, NSAIDS, spicy food, alcohol can cause gastritis
c. No ulceration formed, but bleeding can occur
4
PUD
Peptic Ulcer Disease
1. General
a. Any ulceration of the GI tract where pepsin is involved
in the pathogenesis
b. Acid (produced by the parietal cells) & Pepsin ( a
proteolytic enzyme produced by the chief cells) can
break down the protective lining of the GI
c. Acid breaks down pepsinogen to pepsin, which is
autolytic
Pepsin is a protolytic enzyme which breaks down
protein from pepsinogen which is broken down to
pepsin by acid.
d. The vast majority of ulcers are
i. Duodenal ulcer 80%
ii. Gastric 10%
iii. Esophageal
iv. Jejunum
e. Some ulcers are drug induced: ASA, NSAIDS (no safe
NSAID in market), corticosteroids (prednisone) &
some antihypertensive (Reserpine)
2. Proper Diagnosis
a. Gastroscopy (out patient basis)
b. Give BZP
c. Midazolam ( Versed) – Produce temporary amnesia
d. Meperidine (Demerol) – Relives pain & discomfort
3. Symptoms
a. Continual burning pain located in the mid-gastric,
substernal region
b. If patient eat & get pain – duodenal ulcer
5
c. Pain can be relieved by eating because acid will be
digested food, not aggravate the ulcer. Food can
aggravate gastric ulcer because stomach will stretch
4. Etiology
a. Drugs : aspirin, NSAIDS, Ibuprofen, Prednisone
b. Alcohol
c. Stress
d. Familial
e. Infection (H pylori)
5. Complications
a. Tar black stools
i. The blood has been digested
ii. Fe is oxidized
iii. Fe supplements may case black stools
b. Bleeding
i. Upper GI bleeds produce – Black stool
ii. Lower GI bleeds produce - red stool or blood on
toilet paper
iii. Other reasons for lower GI bleed- hemorrhoids,
colon cancer or inflammatory bowel disease
iv. RED/ BLACK stool = condition life threatening,
most likely there is a major artery involved &
blood rushes through the GI – surgery may
required
c. Perforation
i. Disruption of the GI lining that forms a hole
through all tissues
ii. Life threatening
iii. Acid content leak into the peritoneal cavity
d. Penetration
i. Contents exit the GI through a perforation &
penetrate a neighboring organ & cause damage
Ex. Liver of Pancreas damage
6
e. By treating PUD, perforation can be allowed to heal &
 PH
i. Sucralfate (Carafate) – coats the stomach & has
an affinity for the ulcer crater
7
Antacids
Goal:  PH > 4 b/c pepsid needs to be neutralize
* Pepsinogen  pepsin  protein breakdown
* 4 or 5 basic ingredients
* OTC antacid products are just mixtures of these ingredients
1. Sodium Bicarbonate (Baking soda)
a. NEVER be used on a chronic basis, TO BE USED
ONLY ONE TIME
b. NEVER GIVE SODIUM BICARBONATE TO Pt. W/
i. CHF
ii. HTP
iii. RENEAL FAILURE
c. NaHCo3  HCl  NaCl  H2O  CO2
Advantages
1. Inexpensive
2. Fast acting (minutes)
3. High neutralizing capacity
Disadvantages
1. Short duration (20 -30
min)
2. Cause metabolic alkalosis:
treatment – D/C
Bicarbonate
3. Cause Hypernatremia:
Treatment: –
* Free H2O deficit = TBW –
(TBW*140/Na)
* Give D5W, ½ 1st 24 hours
finish the rest over 1 -2 days,
* Fluid overload
* Avoid in patients with
edema & Na restriction
(CHF)
Disadvantages >>>>>>>>>>>>>>> Advantages
8
2. Calcium Salts
a. NEVER be used on a chronic basis, TO BE USED
ONLY ONE TIME
b. NEVER GIVE CA SLATS TO Pt. W/
i. CHF
ii. HTP
iii. RENEAL FAILURE
c. Calcium Carbonate (Tums): also used as a Ca
supplement for osteoporosis but not for chronic use for
the gastritis
Advantages
1. High neutralizing capacity
2. Rapid onset
3. Longer duration than
NaHCO3 = > 1hr
1.
2.
3.
4.
disadvantages
Hypercalcemia 
Constipation (in case of
constipation -  fiber
intake 25-30g/day & drink
more fluid
Milk Alkali Syndrome:
Taking bicarbonate with
milk, Ca will cause a
rebound secretion of H
production, acid rebound
wound up causing hyper
secretion of acid; end
result was Hypeercalcemia
with Metabolic Alkalosis
Metastatic Calcification (
if Ca ppt & deposit into
the soft tissue like brain &
kidney
Constipation
3. Magnesium Salts
a. Laxatives & antacids
9
b. Magnesium Hydroxide Mg(OH)2 – Milk of Magnesiahighest neutralizing capacity
c. Magnesium Sulfate MgSO4 – Epsom salts (laxative &
food soaking)
d. For the laxative affect they act osmotically - H2O
shifts into the GI, distends the Luman Increases
Peristalsis
e. Problem = Diarrhea due to the laxative action
f. Advantages:
i. Moderate neutralizing capacity
ii. Can be used CHRONICALLY EXCEPT
1. Pt. W/ Renal Insufficiency
2. CrCl < 30 = accumulate Mg
3. CrCl = (140 – Age) * Kg / 72 * sCr NOTE
: FEMALE *0.85
4. Diarrhea
4. Aluminum Salts
a. Can be used chronically (not absorbed)
b. Al(OH)3 = Aluminum hydroxide  salts = Rolaids
(Amphagel or Alteragel)
c. Possible deposition in the CNS may be linked to
Alzheimer’s
- Found in Antiperspirants as an astringent
- Deodorant alone contains fragrances
d. Advantages:
i. Chronic use for PUD
ii. Counteracts diarrhea from Mg salts
iii. Used therapeutically in combo products b/c
Al = constipation
10
iv. Maalox = combo of Magnesium hydroxide &
Aluminum hydroxide
v. Maalox Plus = contains Simethicone (Mylicon) –
Antigas causes small gas bubbles to come
together to form larger bubbles so they can be
easily passed
vi. Maalox TC = therapeutic concentrate – smaller
dosage
vii. Mylanta = Simethicone  Magnesium hydroxide
 Aluminum hydroxide
viii. Mylanta II = Doubled the concentration of
everything – lower dosage
5. Additional Ingredients in Antacids
a. Simethicone (Mylicon)
- Anti flatulent
- Aids in the passing of gas
- Good for infants
b. Alginic acid (Gavison):
- Tablet
- Main ingredient found in Gaviscon
- Marketed for GERD management: Bz it hits
esophagus & not acid
- Dissolve & make layer & fluid expand and flow
on top
- Contraindicated in pt w/ narrow esophagus
- DON’T TAKE IF PROBLEM WITH
SWALLOWING
- TAKE WITH 8 OZ OF H2O
- The alginic acid swells & floats on top of the
gastric contents
- When a patient has reflux, alginic acid comes into
contact with the esophagus & not the acid
- It swells when it comes in contact with fluid
11
- It should be taken with plenty of water to avoid
lodging in the esophagus
- Alginic acid is contraindicated in patient with a
narrow esophagus
- Could be a problem in GERD patients because
they have a narrow esophagus (the damaged areas
thicken)
- It should be avoided in patient with diagnosed
GERD
12
Drug Interaction with Antacids
1. Tetracyclines & Antacids
a. Chelation Occurs
i. Divalent & trivalent ions (Al+3, Ca+2, Mg+2)
ii. Tetracycline are loaded with – OH group
iii. Antacids bind Tetracycline & ↓ absorption
b. Keep separate (2 hr)
c. Toxicity Sx: Infection get worst, more fever
d. Doxcycline & Minocycline are OK to use due to
decreased binding
e. Mainly get problems with older tetracyclines
i. Tetracycline HCL
ii. Oxytetracycline
2. Quinidine Sulfate and Antacids
a. Is a salt : comes from weak base & strong Acid (SO4
strong acid & Qunidine weak base
b. Unionized drug: Cross mem. & go to blood
c. Salt either
i. SB + WA
ii. WB + SA
d. Need to avoid NaHCO3 antacids
i. Basic drug + Basic medium = Drug in ionized
state (↑ blood level)
ii. The NaHCO3 makes the urine basic & the drug
gets reabsorbed
iii. Alk seltzer contains NaHCO3
e. Develop Qunidine toxicity
i. Similat to ASA toxicity
ii. Cinchonism side effect
f. Sx of Qunidine toxicity
i. Headache
ii. GI distrubance
3. Digoxin & Antacids:
Bind to digoxin & ↓ absorption
13
Toxicity Sx: worsen heart failure, more congestion,
getting tired, edema
4. Sucralfate (Carafate) & Antacids
a. Carafate = affinity for the Ulcer crater
b. It clings to the crater & protects the exposed tissue from
stomach acid
c. Carafate needs an acidic environment to dissociate
properly
d. Give Carafate at least 30 minute before the patient takes
the antacids
5. Enteric coated Aspirine & Antacids
ASA dissolves in alkaline environment & bypass
ASA Dissolve in stomach & cause irritation
6. Ketoconazole & Antacids
Antifungal
Required acidic environment/media to dissolve
properly
Antacids ↓ absorption of it as well as ↑ PH
Separate 2 hrs
14
Dosage for antacids
Did not go over this
1. Pt should utilize dosages on the package label
2. Neutralizing capacity – All antacids won’t neutralize the
same amount of acid
a. Mg(OH)2 from one company may not neutralize the
same amount of acid the Mg(OH)2 from another
company will
b. Maalox with Mg(OH)2 & Aluminum Hydroxide = 5
meq/ml
c. At the present time, most drug companies have
reformulated their antacids so the patient only has to
take 30 ml to get adequate neutralization
d. Interval of dosing for Ulcer if the patient desires round
the clock therapy with an antacid
e. Prior to 1970 = Anticholinergics
f. After 1970 = proton pump inhibitors
15
H2 Antagonist
1. Cimetidine (TAGAMET)
a. Dose – 200 mg Bid
b. MORE DRUG INTERACTION – NOT USED MUCH
c. Inhibitor of P450 therefore most problems & most drug
interactions
d. Inhibition leads to accumulation of drugs –
Theophylline & Phenytoin
e. Theophylline toxicity = vomiting, seizures, sever nausia
f. Dilantin toxicity = ataxia & nystagmaus (uncontrollable
rolling of the eyes)
2. Famotidine (Pepsid AC)
a. Dose = 10 mg Bid
b. Short term use
3. Nizatidine (Axid AR)
a. Dose = 75mg Bid
4. Ranitidine (Zantac 75)
a. Dose = 75 mg Bid
b. Could cause mental confusion if patient is renally
insufficient (Due to accumulation)
5. Omeparazole (Prilosec)
a. Proton pump inhibitor
6. These drugs are not cost effective to be taken for long periods
of time ITC
7. The patient should get a prescription strength so their
insurance company will pay
16
Constipation
*** ↓ frequency & difficulty in bowel movement (BM)
Change in normal bowl movement habits
Associate with hard stool
Causes of Constipation
1. Poor diet
2. Anatomical
a. Disease state
b. Obstruction eg. Colon cancer
c. Irritable Bowl Syndrome(IBS) – alteration in
constipation & diarrhea
d. Thyroid disorder
3. Drug: any drug that impairs peristalsis (Eg. Loparimide)
a. Iron supplements – black stool
b. Ca++ supplements
c. Verapamil
d. Anticholinergics
e. Narcotics (Morphine, Meperidine etc.)
i. Problem with long term use
f. Laxatives; if abused
i. Laxatives abuse syndrome = especially with
stimulant laxatives such as Casanthronol & Senna
( Senokot). Stimulant laxatives stimulate the
nerves to ↑ peristalsis
ii. After prolonged use, damage to the nerves occur
causing ↓ peristalsis Hypokalemia can also
develop causing ↓ tone of the muscle
4. Foods
a. Cheese
b. Processed food
c. Peanut butter
5. Inadequate fluid intake
6. Lack of fiber (Poor diet)
17
a. Normal fiber intake = 20-25g
b. Fiber lowers the incidence of colon, prostate & breast
cancer
c. Carbohydrate 27g, fiber 2g insoluble, fiber 4g soluble
so net carbohydrate = 27-2-4 = 21g
7. Pregnancy
i. Estrogen can cause smooth muscle relaxation of
GI, ↓ peristalsis
ii. May need to give a stool softener
8. Cancer
i. Can cause constipation or diarrhea
ii. Ages 50& older should be tested annually for
colon cancer
iii. Hemoccult – screening test for blood in the stool
Prevention of constipation
1. Exercise
2. Side note – a person needs 25 -30Kcal/Kg/day to maintain
weight
3. Drink adequate fluid
i. 6 -8 glass of water/day – 8oZ
4. Increase fiber intake
i. 25 -30 g/day – based on a 2000 calorie diet
ii. fruits & vegetables
iii. All Bran – 60% in one bowl
iv. oatmeal
18
The use of laxative OTC has become abusive in
- People who are trying to control their weight
Models & Eating disorders (anorexia)
- Elderly
They have ↓ GI motility & frequency of BM
Often use castor oil (stimulant) as a home remedy
- Anyone trying to establish regularity
Especially young & middle aged women
Elderly
Management of constipation
1. The best treatment is ↑ water & fiber intake
2. Bulk Laxatives: Natural Laxative, act like vegetables
a. Psyllium (Metamucil)
b. Polycarbophil(Equalactin) – for both diarrhea &
constipation
c. Malt soup extract (Maltsuprex)
d. These products swell & become a bulky mass which
stimulates peristalsis
e. They mimic fiber
f. Onset is within 72hrs
g. No electrolytes or water loss
h. No griping pain or cramps or abdominal pain
i. Can be used on a chronic basis
j. Chronically used with patients of:
i. Cardiac Disorders
ii. Rectal Surgery
iii. Pregnancy
iv. Drug induced like cancer chemotherapy &
Anemic Fe deficiency
k. Used when straining at the stool is unwanted
i. MI – straining at the stool could cause death
ii. Pregnancy
iii. Hemorrhoids
19
iv. Trauma
v. aneurysm
3. Stool Softener: Emollenenats
a. Incorporate intestinal fluids into the feces to soften
b. Docusate sodium (colace)
c. Docusate calcium (Surfak)
d. 12 -72 hrs onset
e. They are surfactants – mix oil & water
f. Can be used chronically in same situation as with the
bulk laxatives
g. No griping or cramping
h. No electrolytes or water loss
i. Good for ling term basis
j. Can use chronically
k. If restricted to Na than use Docusate Calcium
4. Mineral Oil
a. Lubricates
b. NO CHRONIC USE
c. No griping or cramping
d. No electrolytes or water loss
e. Easier for feces to pass
f. Can be combined with bulk laxatives
g. Take 8 hrs to lubricate
h. Should not be used on a daily basis because of the
development of lipid pneumonia & ↓ absorption of fat
soluble vitamins (vit. D, E, A, K)
i. Lipid pneumonia – drops of oil can coat the back
of the throat & collect bacteria
ii. These drops can then drip into the lungs & cause
an infection
i. Usually used for fecal impaction
i. A back up of feces into the colon
ii. A regular laxative may cause tearing
20
5. Osmotic Laxatives: (Saline Laxative)
a. Mg++ salts & phosphate salts – BEST FOR ONE
TIME USE ONLY
b. Electrolyte loss & abdominal pain or discomfort
c. They work osmotically in the intestines
d. Cause H2O to shift into the intestines
e. The intestines become distended & peristalsis is ↑
f. Cause cramping in excess
g. Dose dependent ( the more you take the more catharsis)
Mg++ Salts
PO4- Salts
1. Don’t use it with renal Pt.
1. Na+ phosphate, Na
2. HIGHER THE DOSE
monophosphate, Na
GREATER THE
dibasic & Na+
LAXATIVE EFF
Biophosphate
3. ECT
2. Used in combo
4. Magnesium hydroxide
3. Brand: fleets or Fleets
(M.O.M)
phosposoda (oral / rectal)
5. Magnesium sulfate
4. Very powerful laxatives
(Epsom salts)
5. Retention enema – the
6. Magnesium citrate ( little
patient must hold the
green bottle)
enema inside the rectum
7. ONSET 4-6 hrs
for as long as possible &
the time of onset is ~ 2 -5
min
6. Time of onset for oral ~ 4 6 hrs
h. Used often for evacuations before surgical procedures
i. Problems
i. Should be avoided in renal insufficiency
ii. If the CrCl <30, then the Mg++ & Ph will
accumulate
iii. Avoid phosphate salts with people on Na+
restricted diets
21
iv. Don’t want to take on a chronic basis due to fluid
& electrolyte loss
6. Hyperosmotic Laxative
a. Glycerin
b. Irritates the lower part of the intestines & causes a loose
stool
c. Commonly used in children & infants
d. Works within a few minutes
e. Comes in suppositories
i. Insert rectally & hold
f. No fluid & electrolyte problem
g. If infants are receiving a formula containing iron, which
can constipate, parents should put some Karo syrup or
Malt Soup Extract in the bottle
Gly Suppository
MAO: Osmotic effect & also act as local irritation effect to the
rectam
 Children & adult affect
 Children > 6yr = adult dose
 <6 yr = pediatric dose
 Onset time within few min
7. Stimulant Laxatives
a. Bisacodyl (Dulcolax)
i. Tablet form
ii. Used before scoping with Na+phosphate & an
enema (soap suds enema)
iii. Stimulates the nerves to ↑ peristalsis
iv. Abdominal cramping
v. Should be used on a chronic basis
vi. Fluid & electrolyte loss
vii. Possible laxative abuse syndrome
22
b. Senna(Senokot)
i. In the anthraquinone class
ii. Same problem as dulcolax
iii. Should be used on a one time only basis & not
chronically
c. Ex-lax
i. Used to contain phenolphthalein (powerful
stimulant)
ii. It would color the feces red & had the possibility
for allergic rection
iii. Has now been reformulated with Dulcolax
d. Castrol oil
i. Active ingredient: Ricinoleic acid
ii. Bacteria in the gut break down the castor oil
iii. Ricinoleic acid stimulates the nerves
iv. Onset time of 6-8hrs
8. For chronic use, Bulk laxatives & stool softeners should be
the drug of choice
Stimulant Laxative:
1. Anthraquinone:
o Onset 6-12 hr
o Cascara
o Cascara segrada
o Casnthranol
o Senna(senokot: liquid for children)
o Ex-lax
o perdium
2. Diphenylmethane
o Bisacodyl (Dulcolax: tablet & syrup)
o Onset 15-60min
o PO 6-10hrs also depend upon patient
o Take at night
3. Castrol oil
23
 Converted into the small intestine by pencriatic lipase
to ricinoleic acid to increase fluid secretion through
Camp
 Onset 2-6hrs
 Begins work in small intestine can grater loss of fluid &
electrolytes
MAO
Increase proposive peristaltic activity of the intestine by local
irritation of mucosa also may stimulate nerves in intestinal smooth
muscle to increase contraction & also secretion of the water &
electrolytes.
Indications:
1. use to evacuate bowl prior to endoscopic or radiological
evaluation of GI
2. not fro chronic use
3. fluid & electrolyte loss
4. abdominal pain or discomfort
5. Can be use for initial drug therapy simple constipations
6. should not be used more than week
Adverse effect:
1. sever cramping
2. fluid & electrolyte loss or deficiency
3. mal absorption due to excessive motility
4. hypokalemia
Drug interactions
1. Bisacodyl
a. Avoid taking within 1hr w/ NSACIDS, cimetedine,
formitidine or milk restricted bz interic coating of drug
can be dissolved & result in gastric or dudodnal
irritation
b. Increase pH = H2 antagonist proton pump inhibitor,
Nacids
c. Don’t break down or crush tablet
2. senna: urine pink/red/brown
24
Considerations
1. avoid using in pt. with sever abdominal pain
2. avoid in pergency
3. avoid in rectal bleed pts
ASK Pt.
1. why do you feel u need laxative?
2. fluid & fiber intake
3. r u experiencing any abd.pain, discomfort, bleeding,
weight loss n/v? if yes than go to the doctor
4. has he appearance of stool change
5. recommend mild laxative first – bulk /stool softeners 1st
then advise to increase fluid & fiber intake
25
Antidiarrhea
Normal water in feces = 100 – 150 ml/day
Diarrhea = 3000 - 10,000 ml/day + loss of electrolytes
Diarrhea:
 water reabsorbing capacity of colon inhibited
 Ascending & Transverse colon = Grater water reab.
 Descending & Segmental colon = Feces stored
 Loss of Na, K, HCO3-, Cl- causes hypo( NA, CL, K)
Complications:
1. Dehydration
2. Circulatory Collapse (shock) – don’t have enough blood in
the circulation
3. Electrolytes loss
4. Acute renal problems
Cause & Etiology:
1. Bacterial food poisoning – infectious diarrhea
a. Staph
i. G+ bacterial
ii. Found in poultry, salad with mayonnaise, dairy
products & cream desserts
iii. Happens after 1st couple hrs of eating food
b. Ecoli
i. Enteric bacteria
ii. Found in beef products/meats (poultry & red)
iii. Has been a problem with mass contamination (Ex.
Jack in the box restaurant)
iv. Effect salad bars
c. Salmonella
i. Found in chicken(poultry)/meat – consider it
infectious
ii. Found also in egg
26
iii. It can penetrate the muscle linings of the colon &
be present for weeks
iv. Diarrhea can contain Pus & blood
v. The health department is informed
vi. If the patient works in food prep or is a kid in
daycare, than the patient must remain at home
vii. The patient needs 2 consecutive negative stool
sample to be considered cured enteric bacteria
viii. Pus & Bleed in Stool
d. Shigella
i. Entreic bacteria
ii. Found in meats
iii. In Raw Oysters
iv. Pus & Bleed in Stool worst bz effect lining or
muscle of the GI
e. Camplobacteril
i. Well water
f. Vibrio Cholera
i. Found in oysters (raw)
ii. Can cause fever, diarrhea, arthralgia & myalgia
iii. The infection can go systemic
iv. Oysters must be cooked to kill vibrio
v. The reason for contamination is bz the oysters
filter debris
vi. Arthralgia – pain in joint w/o swelling or other
signs of arthritis
27
2. Drugs
a. Cholinergics
i. Bethanechol, Carbachol, Mehtacholine,
Pilocarpine, Physostigmine, Neostigmine,
Endrophonium
ii. Beside diarrhea the patient may present with:
Miosis, ↑BP & Bradycardia
b. Antibiotics
i. Distrupt the normal flora which upsets the balance
in the GI allowing disease causing bacteria to
overgrow
ii. Takes ~ 3 – 5 days to happen
iii. Can lead to an overgrowth of Clostridium dificile
which causes bloody diarrhea & must be treated
with vancomycin
iv. Some antibiotics undergo enterohepatic
recirculation
v. Intestine – Liver – Blood – Liver – Bile – GI
vi. This can irritate the GI & would occur quickly
within the 1 day of administration
vii. No bloody diarrhea seen
viii. Erythromycin is involved in enterohepatic
recirculation & can cause diarrhea
c. Laxatives
i. Ex-lax
ii. Mg²+ salts are antacids & laxatives
Traveler’s Diarrhea
iii. Caused by Ecoli (Enterotoxigenic)
iv. Can use Pepto Bismol &/or Tertacyclines
v. Drink bottoled water or boil the existing water
vi. Prevention:
1. Don’t drink tap water Don’t use ice made
with tap water
28
3.
4.
5.
6.
2. Avoid raw fruits & vegetables especially
lettuce & fruit salad
3. Use things that you can pill
4. No raw meat
5. No food from street vendors
Viral Diarrhea
a. Self limiting
b. Can last up to 2 - 3 weeks
c. Seen frequently in children & infantile diarrhea is often
caused by a virus (may go on for weeks)
d. Serious = viral diarrhea secondary to immunocompromised disorders(AIDS)
e. Signs of acute HIV infection
i. 50 -70% of patients will have a variety of
symptoms
ii. Diarrhea, malaise, swollen lymph nodes
iii. Comparable to the flu
iv. Disappears after 2 -3 weeks
v. The body makes antibodies & ↓ the amount to
virus present
Protozoal – txypiescrtion only
a. Giardi Lambia
i. Must treat with prescription drugs
ii. Blood appears in the stool
iii. Treat with Metronidazole (Flagyl)
iv. Found in well water, bad seafood & meat
v. Could have relapse episodes
Entamoeba Histolytical – Rx Only
a. Amoeba (protozoal)
b. Causes dysentery
c. Treated with Flagyl
Immuno-compromised Diarrhea
a. AIDS or Cancer
b. Protozoal
i. Cryptsporidia
29
ii. Isospora
iii. They can cause a secretory diarrhea (↑ H2O; not
isotonic diarrhea)
iv. Not candidate for OTC management
Patient management for Diarrhea
If
 temperature is to high >101.5 F
 Child is < 3yrs old
 Diarrhea more than 48 hr
NO OTC ANTIDIARRHEA
DON’T USE OTC ANTIDIARRHEA MORE THAN 48 HRS.
1. Fluid intake: Depend upon type or amount of diarrhea
a. Dileamma; the more you drink, the worst the diarrhea
gets
b. Slip on fluids periodically to avoid exacerbation
c.
i. 1st 24 hr
1. Slip on clear fluid
2. No meat or vegs
3. Can have vegetable broth, chicken broth,
jello or gelatin, Gatorade, water, Gingeral
cola drink
4. Can use tea or coffee but in some Pt. it may
cause cramp
nd
ii. 2 24 hr
1. Assuming subsiding
2. Crackers, potatoes, bread, softer food
3. IF DIARRHEA STILL WORST GO TO Dr.
d. Gatorade, Pedialyte or water
i. Sugar could worsen diarrhea (Gatorade should
diluted with water)
30
ii. Patients often use Karo syrup for infants who
become constipated
iii. It relieves constipation osmotically
2. Food intake needs to be delayed until diarrhea subsides in
acute cases
a. If > 2 days – the patient needs to see a doctor
b. The patient should eat light meals (Ex. Soup with pasta)
bz heavy meals may irritate GI
3. Meds
a. Adsorbants
i. Adsorbants actually bind to the cause of diarrhea
(ex. Bacterial toxin or virus)
ii. The adsorbent & cause will then be excreted
through the feces
iii. Bismuth subsalicylate (Pepto Bismol,
Kaoprectate)
1. darken the stool
2. work as adsorbant: bz abs virus toxins that
cause diarrhea
3. Pepto Bismol: each tab. spoon contains
130mg salicylate
4. Pepto Bismol:
a. take 2 tab. Spoon 30-60ml Prn
b. Max. no more than 8 dose/day
c. Drug of choice in Traveler’s Diarrhea
5. BE CAREFUL WITH SALICYLATE:
a. Be careful to whom do you
recommend that
b. Don’t give if diarrhea/fever in children
bz can cause Reye’s Syndrome
c. Reye’s syndrome :
i. hepatomegaly
ii. hepatotoxicity
iii. brain swelling
31
iv. kidney failure
6. ASA can be absorbed with continued use
7. could cause drug interactions
8. 15-30ml after ease loose stool
iv. FDA warning – Don’t use for more than 48 hrs or
in the presence of high fever (>101.5F) or in
children under 3 yrs of age
v. Side note – Dehydretion can cause a mild fever
(100F)
vi. Kaolin + pectin (Kao – Pectate) :
1. Adsorbants
2. Stick to toxin & virus that cause diarrhea
3. very effective
4. no systemic absorbtion
5. 4-8 tsp after each loose stool
6. given 15 – 60ml after each loose stool
b. Loperamide HCL (Immodium AD)
i. Very powerful
ii. Liquid
1. 4 tsp after 1st episode of diarrhea
2. 2 tsp after each stool
3. Not more than 8 tsp/day
iii. IF PATIENT IS < 6Yrs CONSULT Dr.
iv. Loperamide
1. ↓ Peristalsis movement of GI
2. ↓ Propulsive movement of GI
3. ↓ motality of the GI throught its narcotic like
action
v. Side effects include drowsiness, sedation &
constipation
vi. It should not be used in diarrhea where
penetration has occurred for example in
Salmonella, Ecoli or Shigella exposure
a. Blood & pus in stool
b. The patient should see a physician
32
vii. It should not be used in patients who have
Crohn’s disease or ulcerative colitis – can cause
toxic megacolon
viii. Inflammatory Bowel Disease
1. Crohn’s Disease – can be form mouth to
anus
2. Ulcerative Colitis
a. Inflammation & ulcers are confined to
the intestine
b. The danger is toxic megacolon, where
all peristalsis stops & the intestines fill
with air (surgery needed)
3. Side notes
a. Lomotil (Diphenoxylate with
Atropine)
b. Rx Product (schedule V)
c. The diphenocylate is a narcotic that
prevents the diarrhea
d. The atropine prevents abuse (not
enough for anti diarrheal)
c. Absorbents
i. Absorbs water
ii. Polycarbophil (equalactin)
1. can absorb up to 60x its weight in water
2. can be used for constipation or diarrhea
3. absorbs excessive water & leaves a more
formed BM
4. for constipation , it will distend the lumen &
stimulate peristalsis
5. can be used for irritable bowel syndrome
6. can be used daily if necessary
33
4. Other notes on Diarrhea
a. The major problem with diarrhea is fluid & electrolyte
loss
b. 100 -150ml of fluid is lost daily in a normal stool
c. In diarrhea 3 – 10L can be lost per day
d. This can become an emergency situation in children &
the elderly
e. Problems
i. Dehydration
ii. Renal failure = ↓renal blood flow = cellular death
iii. Electrolyte imbalances
iv. Shock leading to circulatory collapse
f. The reason children & the elderly are so affected by
diarrhea is due to:
i. The majority of an infant’s body weight is water
ii. The elderly lack physiological compensation
g. Patients should drink clear fluids:
i. If it is pure water then the patient will receive no
electrolyte replacement
ii. Approved liquids include water , broth, Gatorade,
flat sodas, pedialyte, Non – solidified Jello
(Gelatine)
34
Internal Analgesics
 Used for more than analgesia, also indicated for antiinflammatory (except Acetaminophen) & anti pyretic
action
 Self treatment for mild  moderate pain
Categories:
1. Salicylates
2. Acetamonophen
3. NSAIDS – ibuprofen
Self treatment for mild to moderate pain
Headache
Could be caused by hypoglycemia, hangover, or sinus
infection
Ask patient where it hurts, how long has it been
occurring?
Acute Headache: OTC medication does well
a. Sinus infection - headache
1. The location of the pain & Sx presented are
important
ii. Often is the maxillary sinuses
iii. Pain occurs around the eyes, frontal, maxillary,
face & possibly the teeth (gum may ache)
iv. A fever may or may not present
v. Areas of pain will usually contain
1. Nasal congestion
2. Rihorrhea (post nasal drip = discolored) may
occur
vi. Sinusitis could be life threatening bz bacteria from
sinuses can gain access to ear & brain
1. colored discharge
35
2. foul smelling
3. caused by anaerobes (release sulfur)
vii. Bacteria may cause ear infection & meningitis if it
gets into brain
viii. Metabolism of anaerobes result in constant smell
ix. Will require more than Tylenol & the patient
needs to see a doctor bz ANTIBIOTIC MAY BE
NEEDED
b. Tension headache
1. Caused by stress
2. Due to spasm of the musculature of the scalp
& base of the neck
3. Even by removing the source of the tension,
the headaches can last for days
4. Don’t expect to see with any other Sx
Chronic headache: Rx NEEDED
 Should be referred to a Dr bz no one should have
chronic headaches
 If Sx associated with chronic headache are N/V,
Photophobia, fever, dizziness, stiff neck, blurred vision
& focusing NEED TO GO SEE Dr. bz it represent that
there is a mass in the brain.
 Migrains:
1. Need prescription meds. OTC DON’T
WORK WELL
2. Vasodialtion result in Intense throbbing
3. in blood circulation could lead to stroke
4. Pt. can usually sense when headache is
coming
5. Pain may last for days & may include
vomiting
6. Patient gets an aura sensation – light can
hurt eyes
36
7. Could be caused by being too hot or cold ,
fatigued
8. Give Somatropin(lmitrex) or Erot Alkaloids
iii. Cluster headaches
1. unexplained headaches for days-wks - occur
ever so often
2. probably due to sympathetic nervous system
dysfunction
3. propranolol(inderal) – works well for short
term
iv. High blood pressure
1. Serious when Pt. has headache
2. Silent Killer – Pt. may have  BP & not
know
3. drugs that cause vasodilation may cause
headache
4. Rx treatment include Lmitrex & DRE 45
v. Cancer headaches
1. Tumors can press upon nerves as they grow
larger
Hypertension that causes vasodialtion that
leads to a headache is a life threatening
situation bz of damage & stroke possibility
Myalgias: muscle pain
Arthralgias :
 These drugs not for RA or sever Inflammation
 Don’t use Acetaminophen bz does not deal with
infection bz not anti-inflammatory)
Neurological:
 Pain from nerve
 Don’t respond to this drugs
 Trigeminal neuralgia (intense facial pain) =
response to this drug analgesics for other neuralgias
use Antidepressent or antipsychotic
37
Hunger headache: result of  glucose
Hypoglycemia,Hangover & Caffine headache
Any drugs that cause vasodilation can cause a headache (Ex.
Diazoxide, Hydralazine)
Dysmenorrhea:
 Aspirin works initially
 DOC- Peopionic acid derivatives
38
AntiPyretics
Fever:




OTC analgesics are very effective
Body is kept heated to fight infection
Fever may resut in malaise & drug like feeling
 in body temperature indicates something going on in
the body
 Darvocet ~ 400mg of ibuprofen
 Normally body temperature = 98.6 °F
 A high temperature is >101.5°F, caused by infection,
dehydration or meds.
 Children >104°F – seizures are possible
 In adults a fever of >105 °F has the potential to cause
brain damage
vi. Seen frequently with heat stroke
vii. Elderly population is the most susceptible bz they
have the tendency to have a ↓ hypothalamic
regulatory functioning of body temperature (poor
regulatory mechanism)
1. they drink less fluids due to a ↓ thirst
response
2. tend to run air conditioners less frequently
3. heat stroke is normally not self detected
4. Heat stroke result of ↑ humidity & thrist or
strenuous sports
 Certain drugs can ↑ the body temperature
Antipsychotics (Haloperidol & Phenothiazine) –
malignant hyperthermia
Anticholinergics (↑slightly)
Dantroline
THIS DRUGS CAUSE MALIGNANT HYPERTHERMIA  TO
GET IMMEDIATE RELIEF USE COLD WATER WITH ICE TO
GET IMMEDIATE DECREASE IN THE BODY
TEMPERATURE
39
If fever for couple days than do see Dr.
Non pharmacologic treatment for fevers:
1. Bath in lukewarm water (not cold)
 cold water lead to chills , shivering & ↑temp even more
 Tylenol should be given before
 Emergency situation – temperature 108 -110°F ice bath
should be given & then towel to prevent chills
 If temperature is too high in certain situation like drug
induced hyperthermia & overheated in summer use
cold water with ice to reduce temperature
2. Alcohol rubs (70% isopropyl Alcohol)
 Evaporates quickly & feels cool but fumes cause
toxicity therefore NOT RECOMMENDED
 Temporary relief
 The danger is form the fumes/vapor becoming toxic &
irritating to the nasal mucosa
 Should not be used for sustained reduction in fever
3. ↑ fluid intake
Salicylates:
Aspirin (ASA)
 Oldest of internal analgesics
 Prototype
 Good antipyretic & anti - inflammatory
 325 – 650mg po q 4-6hr
 4gm/day max
 Baby ASA 81mg
 single dose maximum = 975 to 1000 mg/day
 single dose = max ~ 3 tablet (bz ↑serum level – don’t want to
use up all the glycine in liver)
40
 Single dose is limited bz of rate limited metabolism
 Glycine is metabolite that combines with aspirin &
inactivates it
 At critical doses glycine is saturated & dose of aspirin sky
rockets
 Michaelis – Menton : non linear pharmacokinetics
 Zero-order kinetic
o Overdose → saturation of glycine → ASA will
accumulate in bloodstream →ASA will ↑ with next
dose (not proportional)
ASPIRIN SHOULD BE AVOIDED IN CHILDREN W/
VIRAL ORIGIN FEVER (CHICKEN POX) GIVE
ACETAMNOPHEN
Adverse Effects:
1. Gastrointestinal
a. Includes GI hemorrhage, irritation, gastritis, PUD,
ulceration & bleeding (can occult bleeding after 2 tabs
that is not seen), Associated w/ RENAL FAILURE
 To find out occult bleeding do HEMOCCULT &
STOOLL QUATE TEST
b. Sx are likely to ↓ when taken with food
c. Avoid in pt w/ GERD & PUD bz in GERD esophagus
is already irritated
d. Iron Deficiency anemia (Also w/ Advil & Motrin)
2. Platelet Effect: ↓ platelets aggression – may either GOOD or
BAD
a. GOOD: ASA inhibits aggregation & ↓ possibility of
heart attack, MI/stroke
b. BAD: May cause excessive bleeding bz blood takes
longer to coagulate
3. Toxicity
a. Tinnitus – ringing in the ears
41
b. Diplopia – double vision
c. Hypothrombinemia
 ↑ bleeding time by not allowing clot to form
 Prothrombin → thrombin → fibrinogen →
fibrin(CLOT)
 Prothrombin forms platelet aggregation; it
converts fibrin, ↓in it fibrin will not form clot
d. Acid/base disturbance - Metabolic acidosis &
respiratory alkalosis
 Excess of ASA → ↑ pH → Renal excretion of
HCO3 & K to overcome Metabolic Acidosis
 Direct medullar stimulation
a. Loss of CO2 – Hyperventilation
b. ↑ pH → Respiratory Alkalosis
 Uncoupling of oxidative phosphorylation
e. Paradoxical headache
4. Uric acid: Low dose of ASA causes ↑ in uric acid
a. Low 1-2 g/day leads to uric acid retention =  uric acid
BZ inhibit tubular renal secretion
b. Moderate 3-4g/day = NO EFFECT
c. High > 4 g/day = uricousric (↑ amount of uric acid
excreted in urine)
d. In gout pts. Treating a cold with ASA can make gout
worst therefore Pt. W. GOUT SHOULD NOT TAKE
LOW DOSE OF ASA
5. Reye’s Syndrome: rare disorder occurring in childhood – NO
Tx but Sx can be treated
a. Sx develop in recovery phase of a viral infection; Ex.
Chicken Pox - give ASAP
b. Sx:
 Hepatomegaly & Encephalopathy
 Brain swelling – cause lots of neurological
problems - Death
 Seizures
42
 Renal failure
c. Death occurs from brain swelling & liver damage
d. ASA may be the cause of this condition & should be
avoided in children under 12 yrs of age
e. Encephalopathy is treated with Mannitol
6. Allergic Reactions
a. ↑ Incidence in asthma pts
b. includes shortness of breath & angioedema ( swelling
of throat leading to closure & sever rash)
Biopharmaceutical Consideration for Decreasing GI Side
Effect
1. Enteric Coated Aspirin (Ecotrin)
a. Will not dissolve until reaches alkalinity in small
intestine/duodnum
b. Reduces breakdown by acid of stomach
c. Onset is longer than normal
d. Drugs which  pH will cause immature dissolving
2. Buffered Aspirin
a. They don’t use enough antacids to neutralize acid but ↑
dissolution rate
b. Commonly used to ↓ GI bleeding bz quickly abs.
c. Contains antacids – Mg hydroxide. Al hydroxide, Mg
carbonate
d. Antacids or other agents ↑ the dissolution rate of the
tablet therefore go into sol’n fast
e. If dissolve in fluid & ↑ed pH layer = dissolve fast
f. ASA in chunks (sitting in stomach) cause irritation
g. EX: Bufferin (contains MgCO2) , Ascriptin, Ascriptin
AD(contains Maalox)
h. Bufferin = ASA + Mg2+ carbonate &
i. Alka Seltzer = ASA + Na Bicarbonate
j. MAO: ↑pH around ASA → ↑Dissolution rate → ↑abs
43
k. Bufferin & Ascriptin has GI irritation but less irritation
& bleeding
3. Aspirin Complexes
a. Choline Salicylate(Arthropan) – less aspirin per dose –
less irritation
b. Magnesium Salicylates (Doan’s Pill) – less salicylate
per dose – less irritation
Drug Interaction
1. Warfarin(Cumadin)
a. Major interaction – protein displacement, GI irritation
& Hypoprothrombia
b. Can be given together but prothrombin time must be
monitored
c. Low dose of ASA can be used for pts needing it for MI
or stroke
2. Captopril (Capoten)
a. Mild to moderate interaction
b. ASA inhibits PG synthesis
c. ASA inhibits blood pressure lowering effects &
formation of Angiontensin II- Lose some of blood
pressure control
d. Long term ASA use inhibits vasodialting properties of
Capropril
3. Sulfonylurase
a. 1st generation oral hypoglycemic agents
(Acetohexamide, Tolbutamide)
b. Stimulate pancreas to secret more insulin - cause
protein displacement – hypoglycemia – drug
availability ↑ bz ↓ in serum glucose
c. pt. may experience anxiety, sweating, & tachycardia bz
of ↑Epi release
d. Epienphrine → Glycogenolysis
e. Manage by giving sugar, OJ, candy etc.
44
Acetaminophen




Has taken over for ASA
Dose 325 – 650mg po q 4 to 6 hrs, maximum 4g/day
Extra strength 500mg; single dose max 1g
Alternated with ASA for fever control to ↓toxic effect
Adv

Less irritating to the GI

Variety of dosage forms –
tablet & liquid

Less drug interaction

Can be used in kids
w/fever
Disadv

Avoid in Pt. w/
Hepato toxicity/liver dysfxn &
Isoniazid(INH)

Alcoholic/ ppl with liver
disease should not take or use

Hepatocites convert
acetaminophen to toxic
metabolite

Metabolite is very
reactive; has affinity for
sulfhydro group (SH)

SH group provided by
________in liver – inactivates
metabolite

_____________saturation
occurs & cause liver damage

IF OVERDOSE :
hepatotoxicity is delayed for 3-5
days → coma

N – acetyl cystein
(Mucomyst) – given po for
emergency situation
Heptatoxicity:
 Sx skin discoloration, icteric sclera (yellow eyes)
45
 Takes 3-5x as much to get response of toxicity
 Reactive metabolite binds to Cysteine which has –SH group
 In overdose cysteine is over saturated so it attaches to liver –
liver necrosis
 Go to ER & they will give Nacetylcysteine for the next 2448hrs continuously (has to be given early to work)
 Have to alternate acetaminophen with Ibuprofen to avoid
toxicity
NSAIDS/Proprionic Acid Derivatives
 Cause Na+ & water retention so make CHF worst AVOID IN
Pt. W/CHF
 Can have irreversible Hear Damage w/ continuous use at
normal dose
 Some GI irritation
 No stroke or MI prevention like ASA
 Very Good analgesics for mild to moderate pain
 Must stick to OTC doses; usually ½ Rx dose
 Ibuprofen (Advil, Motrin IB) – 200-400mg q 4-6hr; max
1200mg/day - liquid
 Ketoprofen (Orudis KT) – 12.5mg q 4-6 hr; max 75mg/day
 Naproxen (Aleve) – 200 mg q 8-12 hr; max 600mg/day
46
External Analgesics









Apply to skin
Counterirritant
Brand names – Icy Hot, Bengay
MOA: Deflect ur perception on pain
Methylsalicylate
o Oil of wintergreen
Camphor
o Rubifacient – warm sensation upon rubbing
Menthol
o Cool sensation upon rubbing
Icthammol
Capsaicin
o Contains irritating oleoresin – ingredient in hot peppers
o Causes burning sensation upon initial application
o 3-4 days for optimum relief
o Relieves pain associated with RA
o MOA: depletes & Prevents reaccumulation of substance
P
47
Otic Products
Otic products are used for Tx of:
1. Mild, external, ear
disorders affecting the
auricle (visible part of ear)
2. The external ear canal
Otic products have 2 indications for OTC use:
1. Cerumen removing agents
2. External otitis
Two common problems with Ear:
1. Impacted Cerumen
(Earwax) – Stuck Earwax
2. External Otitis – Use OTC
Cerumen/Wax:
 Secreted by Ceruminous Gland
o Ceruminous gland
 Constantly produce cerumen – earwax
 Fxnal throughout life
 Older ppl have fewer # of them bz Atropy
 Combination of lipids & phospholipids
 Lubricates the ear canal (pH of the ear canal – slightly acidic
- ↑ pH favor bacterial infection in ear canal)
 Protecting Barrier
o Trap foreign products like dust & bacteria that get into
ear
o Prevents harm to the middle ear & eardrum
 Migrate constantly outward
o Which is facilitated by talking & chewing
o Ear wax can be cleaned off with a cloth once it has
exited the canal – aesthetic purpose only
48
4 Reasons for impacted Serum:
Wax become thick – dry & will not migrate
Impaction can impair Hearing
1. Sticking foreign object into the ear
2. Overactive ceruminous gland
3. Abnormally shaped external auditory canal
4. Secretion of abnormally dry wax
Cerumen Removing Agents
 Help to soften the wax
 Get Syringe bulb to remove Wax after it softens
 Olive oil (Sweet Oil) –
o Soften the wax – use few drops
o Relatively inexpensive
o Place few drops on cotton swabs - place oil on outside
of ear canal & allow to drain into ear or use dropper,
allow to sit there for 5-10 min , remove wax that has
become softened by oil by rinsing ear with warm water
via a bulb syringe
o Can be used for
 itching & burning of the ear canal
 kill bugs that have crawled into ear canal
 3% Hydrogen Peroxide (H2O2)
o Use in 1:1 Ratio with H2O bz ↑ [ ] affects skin of inner
ear & could predispose to infection
o H2O2 placed in ear canal will fizz & Release nascent
O2 which will disorganize wax n make it easier to
remove with a bulb syringe
o Has weak antiseptic action
 6.5% Carbamide Peroxide (Debrox, Murine)
o Only FDA approved OTC softening agent
o H2O2 attached to urea molecule - Carrier for H2O2
o Effervescence mechanically breaks up cerumen & urea
helps debride (remove dead tissue) skin
49
o Instill 5 drops into affected ear, allow to sit for
15minutes & rinse with warm water via bulb syringe
 Glycerin
o Serves as a vehicle for deliver
o Helps to soften wax
External Otitis (Water Clogged Ears): Rx ONLY
 Skin of the external auditory canal is H2O resistant with a pH
bw 5-7.2 acidic, which prevents pathologic bacterial growth
 Prolonged exposure to moisture tends disrupt epithelia cells,
providing a fertile environment for bacterial growth & tends
to raise pH which promotes growth of fungi & bacteria
 Pseudomonas, Staphylococcus, Bacillus & Proteus –
causative org.
 Infection may develop down to auditory canal, across
tympanic membrane & into middle ear
 Sx may develop following attempts to clean or scratch ear w/
cotton swabs, hairpins, matchsticks, finger etc. these attempts
may damage upper layer of skin & allow microorg access to
underlying tissue
 Sx
o Pain , burning, itching, swollen, red ear
o Painful chewing & extremely tender ears
o 1 way of differentiating from otitis media is painful
auricle & swollen auditory canal
 OTC Product prevent infection from occurring
 If infected canal – Go to Dr. & get ear drops
 If water into the ear dry it out bz gives favorable environment
to grow bacteria
 Swimmer’s Ear
o Type of external otitis –External auditory canal
Infection- result from frequent swimming
50
o Accumulation of H2O in tympanic recess may macerate
skin & raise pH
o Water & wax is trapped in ear
o Patient usually has itching. Pain, redness, or burning of
ear
o Must see physician for antibiotic eardrop
(Corticosporin)
o OTC products are used for preventative methods
o pH is usually acidic & OTC products provide
environment so bacteria doesn’t grow
Otic Media:
 More systemic problems like fever, ear ache
 Infants have ↑ed irribility, vomiting, dizzness
 Caused by: Strep ( + bacilli) & Hemophilus (- bacilli)
OTC Products:
 Maintain acidic environment – want ~ 2.5% acidic
 Acetic acid & Boric acid (SwimEar®, Aquaotic B®) - 22.5% acidity
o Reduce redness, inflammation & edema thereby
relieving Sx of external otitis & swimmer’s ear
o Bacterial & fungicidal properties when used in right [ ]
& ↓ pH of ear canal, inhibiting microbial growth
o Propylene Glycol
 Viscous therefore acetic acid will stay in contact
w/ epithelium longer
o 70% Isopropyl Alcohol
 alone or mixed w/ acetic acid has antimicrobial
activity - prevent bacteria from growing
 alcohol’s astringent properties help drying ear
canal
o 5% Vinegar
 5%acetic acid in it
51
 given with water in 1:1 ratio
 Aluminum Acetate (Burow’s Sohition) - Domboro®
o Acidic
o Astringent, antimicrobial & anti – pruritic propertied
o Effective when ear canal is swollen bz it causes the
contraction & wrinkling of skin
o Also toughens skin to prevent reinfection
DO NOT TREAT INFECTION ONLY FOR
PREVENTION
52
Ophthalmic Products:
Common eye problems
1. Conjunctivits
2. Dry Eyes
Conjunctivitis:
 Inflammation of the conjunctiva – lining become infected &/
irritated resulting in conjunctivitis
 Conjunctiva is
o Thin , transparent membrane covering anterior eyeball
& lining the eyelid
o Contains vascular & lymphatic tissue of the anterior eye
o Source of redness during ocular irritation &
inflammation
 Types:
 Bacterial (Pink Eye)
 Allergic
 Chemical
 Viral
1. Bacterial (Pink eye) – Rx ONLY
 Very contagious caused by many organisms
(Streptococcal, Staph, Hemophilus etc.)
 Auto inoculate other eye
 SX: feels like foreign body in the eye, itching,
burning & pain, red appearance – eyelid begin to
turn red (light red)
 Patient usually wakes up with eye shut with crust
bz of bacterial secretion – purulent exudates
 Starts in one eye & then spread to next eye
 Self limiting – goes away in 7-10days
 CANN’T USE OTC PRODUCTS BZ they will
mask problem
 OTC makes eye wider – ONLY treat Sx of red
eye
 Rx antibiotics make go away in a few days
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 Rx Eye drops – Sulfacetamide (sulmyd®)
2. Viral: Rx ONLY
 Most common form of conjunctivitis
 Present w/ pink eye & watery discharge –
contagious
 Low grade of fever present
 Self limiting w/ Sx resolving over 1-3 wks
 ↑ In immunosuppressive Pt.
 Diagnosis by exclusion
 Must be referred to physician to determine
cause/origin
 Tx – symptomatic – artificial tears &
decongestants
VIRAL & BACTERIAL CONJUNCTIVITIS ARE
CONTAGIOUS THEREFORE Pt. SHOULD BE COUNSELED
ON THE IMPORTANCE OF WASHING HANDS, NOT
SHARING TOWELS & PROPERLY DISPOSING OF TOWELS
USED TO BLOT EYE
3. Allergic – OTC
 CAN USE OTC PRODUCTS.
 Affected either both or one eye
 Caused by allergies like pollen, seafood, pine etc
 Eye is red swollen, red, itchy (sever), tear –
watery discharge
 Vision may not impair
 Pt. also suffer w/ rhinitis
 Other Sx: include rhinorrhea, post nasal drip,
nasal congestion, sneezing bz cause mast cell to
release Histamine - ↑ vasodilation
 OTC – sympathomimetic –Vasoconstrictiors
 Tx: helps relieve Sx
o Ocular decongestants
54
o Ocular decongestant antihistamine prep
o Oral antihistamines
4. Chemical: OTC
 Chemical irritates eye & results in inflammation
 Hair spray, Cigarette smoke
Drugs:
 Sympathomimetics
o Phenylephrine
o Imidazoline der. like
o Tetrahydrozoline (Visine)
o Naphazoline
Vasoconstrictors(Decongestants):
 Cause vasoconstriction of ocular blood vessels,
resulting in ↓ed Sx of red eye
 Rebound congestion of conjunctiva may result w/
prolonged use, therefore use should be limited to
72hrs (ESPECIALLY W/ PHENYLEPHRINE)
Whiten the eye
1. Oxynetazoline (ocuClear)
2. Tetrahydroozline (VisineTM ) – more stable
3. Naphazoline (Naph Con) – more stable
a. Can be combined with zinc sulfate which serves as an
astringent (Visine AC)
b. Sodium Benzoate & Benzoic Acid – buffer that
balances the pH
c. Sodium Bisulfite/Metasulfitee – Anti-oxidant to prevent
change in color
d. Cloudiness is due to bacteria
1&2
 work quickly
 One time use only situation
 Don’t use more than 3-4x a day bz rebound
decongestion (rebound vasodilatation)
55
Naphazoline, Tetrahydrozoline, Oxymetazoline:
 agonists that cause v.constriction of ophthalmic
vessels
 less likely to cause pupil dilation that
phenylephrine
 less likely to cause rebound congestion that
phenylephrine
 Naphazoline (Naph-ConTM is preferred bz it has
lowest incidence of SE
 Oxymetazoline can last up tp 4-6hrs, others 14hrs
4. Visine AC
a. Zinc Sulfate – 0.25%
b. Helps keep eye dry
c. Prevent tearing
d. Estrigent
5. Phenylephrine (0.125%)
a. Should not be used
b. More stable to oxidation
c. Acts on adrenergic receptors in ophthalmic vessels
resulting in constriction & resolution of red eye
d. May be absorbed into underlying tissue & cause pupil
dilation
Antihistamines:
 Indicated for rapid relief of Sx associated w/
seasonal or atopic conjunctivits
 Agents are PHENIRAMINE ( Naphcon-ATM ) &
Antazoline(Vasocon-ATM )
 Effective individually, all histamine preparations
contains the decongestant agents, naphazoline
56
(use of decongestant w/ antihistamine is more
effective than either agents alone)
 SE w/ antihistamines include burning, stinging
& discomfort on instillation – may cause pupil
dilation (mydriasis) in ppl w/ light colored iris
Dry Eyes:
 Common disorder of anterior eye
 Lacrimal glands stop producing tears – elderly  lacrimal
gland
 Characterized by white/mildly red eye; sandy, gritty feeling
or complaint of something in eye
 Often accompanied by excess tearing; however tears
produced are too watery & don’t properly lubricate the eye
resulting in above Sx
 May need artificial tears
 Mostly seen in elderly
 Drugs like Antihistamine, anticholinergics, antidepressants
have DRY EYE AS side effects
 Maintain moisture in eye 1-2days
 Tx – instillation of nonprescription artificial tears &
lubricants
 Wet compress of sol’n may be applied to auricle for swelling
or drops may be instilled
 DomeboroTM - tablet or packets dissolved in 500ml of water
 Lubricants:
o Used 3-4x daily or hourly if necessary
o Cellulose (ethers) Derivatives:
 Preferred bz stay in eye longer 1-2 gtts qd - bid
 Mehtylcellulose
o Most common
o 0.25% or any other cellulose der,
 Hydrocypropyl methylcellulose
 Hydroxyehtycellulose
57
 Hydroxypropylcellulose
 Carboxymethylcellulose
 Stabilizing tear film & prevent evaporation
 Non irritating & non toxic
 All of the ethers have different viscosities
 All form colorless sol’n
o Polyvinyl alcohol 1.4%
 tid more expensive up to 3X daily
 Not as effective as Methyl der.
 Enhances stability of tear film w/out irritating eye
 PVA less viscous than methylcellulose
Stye (Hordeolum):
 Staph infection eyelash follicle
 Inflammation of either hair follicle(external stye, most
common type) or sebaceous gland (internal stye) that may
occur on upper or lower eyelid
 Self limited – clear within week
 Sx: pain, redness, swelling, inflammation, itching & dryness
at site of infection - Painful & results in a bump
 Bump is a result of plugging of glands in the eyelid
 Bump must be drained by applying warm compress (towel or
washcloth) q 15 min for 15 min
 Warmth will also give patient comfort
 Types:
o External
 Warm compresses, styeTM - consist of mineral oil
& petrolatum
 Used to lubricate stye & helps to relieve itching &
dryness
 Does not cause faster resolution of stye
o Internal
 More severe, painful & may lead to closure of eye
 Sever may require RX
58





 If stye occludes vision, Dr. may lance stye
causing it to drain than give Rx antibiotic
(ointment, eye drops, systemic antibiotic such as
erythromycin)
Camphor & Menthol are usually in OTC products that are
sold
These products only________________ patient from the
perception of pain
Camphor provides Aruba Facia (Warmth)
Menthol provides coolness
Patient must be sent to the doctor for any penetrating wound
to the eye
Blepharitis:
 Inflammation of eyelid margins
 Commonly caused by Staph infection & present as red, sclay,
thinkened eyelids with loss of eyelashes
 Itching & burning – common
 Tx – topical antibiotic
 May be a chronic condition, prevention of which results by
using lid scrubs such as baby shampoo to keep eyelids clean
Lice infestation of Eyelids:
 May result from head lice or pubic lice (crabs)
 Don’t apply agents such as NixTM or RidTM to eyelid
 Vaseline applied to eyelashes & eyebrows for 10 days is
effective bz it suffocates louse & deprives eggs of oxygen
Opthalmic Products:
 Used to relieve minor Sx of burning, stinging, itching &
watering
 Self – medication may be effective in managing hordeolum
(Stye), Blepharitis, conjunctivitis, tear insufficiency (Dry
eye) & external inflammation or irritation of eye
59
 Self medication should not exceed 72hrs without consulting
Dr.
General Information for Patient:
1. Rebound Congestion
a. Vasoconstrictors are not for chronic use
2. Proper Administration
a. Color of solution must be clear
i. If not clear Bacterial growth or degradation of the
drug
ii. Benzyl acetate – preservative
iii. Benzoic acid – Na Benzoate & Ascorbic acid –
Na Ascorbate = used as buffer
iv. Na Bisulfite & Na metabisulfite = Antioxidant
v. If oxiodise than color changes light pink to Dark
Brown
vi. Preservative free products should be discarded
after 12hr
b. Slightly pink color is due to oxidization
c. Tilt heat back, drop in corner & message into eye
d. Don’t touch eye b/c may override effects of
preservative
e. Yellow Mercuric oxide – OTC ointment
f. Sodium Sulamyde (Sulfacetamide) – Rx for
conjunctivitis
g. Avoid putting tip of the product to the eye
h. Handling more than one drop –
i. 1st drop and close eye gently massage it & put 2nd
drop
i. Wash eye with warm water or Boric acid
60
Contraceptives
Condoms – Vagina; contraceptives – Spermacidal Agents
HIV INFECTION:
 Human Immuno Deficiency Virus
 HIV I
 HIV II – more in other countries
 Found 1st in1979 - more in homosexual white men
 Now 50% AA – fastest rising group & 1/3~ 27% Hispanic
 No sexual Activity is safe
 Only 50% ppl will have Sx
 Get Infected by - Anal, viginal, transmission of IV, stuck by
needle, large amount of infected blood splash on eye,
artificial sexual transmission
 Fever, swollen Lymph node, generalized lymphatonomy,
diarrhea – After few weeks go away
 It effect T1 helper cell -  HIV RNA (viral load) -  CD4
helper cell
 Normal CD4 = >1000 cells/nm³
 After infection CD4 starts to Drop
 By therapy CD4 can - never go to normal & cause
opportunistic infection
 may take 3-6 weeks for CD4 to  again
 Goal of therapy = CD4 > 350 & viral load = 0
 ELISA test – enzyme linked Immuno sorbent Assay
 CD4> 350 no opportunistic infection – Pneumocystis carinill,
Oral candidiasis etc
61
Syphilis:
 Treponema Pallidum
 Female it is hard to see bz it can be inside layer of vagina
 1º Sx = formation of chancre can occur in mouth, under leap,
finger & general areas - Chancre
 2º Sx – Chancre spreads - skin - skin infection
 3º Sx
o Sx might not der. 30 yrs later – more in older pt.
o Neurosyphilis – demensia, organic, hallucination
 VDRL – measures Treponema Pullidum concentration in the
blood stream
 Condoms can prevent transmission of disease
  HIV infection
Gonorrhea:
 Neisseria Gonorrhea
 Start of w/ Purulent discharge (PUS), dysurea
(burning/pain/pus)
 Cause Polyarthritis – spreads to joints – more than one joint
 Use condoms to prevent Gonorrhea
 It is not obvious in female – can have coexisting anal
infection
 No long term problem so if treated initially no problem later
on
62
CONDOMS
3 types
1. Latex condoms
2. Lamb cecum (Skin) – don’t prevent HIV
3. Poluarethane types – reaction to Pt. w/ infection
General Guideline for Use of Condom:
 Use only condoms that are fresh & not previously open
 Check expiration dates
 Store in cool, dry palace – Not in wallet or Glove
compartment
 Be aware of long fingernails/Jewelry as they may tear the
condom
 Unroll condom onto an erect penis. If a reservoir tipped is
used, leave ½ inch of space bw end of condom & tip of the
penis by pinching top of condom as it is being unrolled. This
leaves space for ejaculated &  risk of breakage
 After ejaculation, hold onto the rim of condom to avoid
slipping off
 If a tear has occurred, immediately insert spermicidal foam or
jelly containing a  concentration of spermicide into the
vagina
63
Male Condoms
Latex condom: Trojan-Enz, Sheik, Lifestyle
 used properly to stop spread of infection
 can have pin holes – holes that you can’t see – electric
testing/ fill condom w/ water
 Inexpensive
 Prevent pregnancy by preventing ejaculated semen to escape
during intercourse into cervix
 Very IMP barrier contraceptive for prevention of spread of
STD’s
 DISADV
o User related
o Storage – don’t keep in wallet or glove compartment
(HOT TEMP.)
o Proper placement
o Use of other lubricant
 DON’T USE PATROLEUM PRODUCTS,
LOTION, VASALINE
 USE KYJELLY
 ADV.
o Reduce transmission of STD’s
o Inexpensive
o Grater variety like
 lubricated vs. non-lubricated
 Plain ended vs. receptacle end
 Rib vs. non-rib
Polyurethane Condoms: Avanti, Avanti Super Thin
 Used for Pt. w/ Latex allergies
 Is available prelubricated, conduct heat well & is not subject
to degradation by oil based products
 More expensive than latex
 Less elastic; have no reserve tip
64
Lamb Cecum Condoms: Fourex, Naturalamb
 Good for Pregnancy prevention only
 More expensive
 Made from lamb cecum (Intestine) & has pores in the
membrane which allow for passage of viral Org, HIV &
Hepatitis B
 Conduct heat well & very strong
 Come lubricated & plain ended
 Don’t use for prevention of HIV transmission
65
Female Contraceptives
 Female condoms are available to be placed intravaginally to
capture ejaculated sperm
 These condoms are generally more expensive & not used as
much as male condoms
o Product Name : REALITY
o Made polyurethane rather than latex
o Comes pre-lubricated & resist degradation by Oil based
lubricants
o These condom consist of an outer ring, a pouch that fits
over the vaginal mucosa & an inner ring that secures
the pouch by fitting like a diaphragm over the cervix, it
is designed for once time use only
 Vignal Spermacides
o Surface active agents that act to immobilize & kill by
disrupting sperm membranes
o Spermicidles includes:
 Octoxynol – 9
 Ortho Options Ortho Gynol
 nonoxynol - 9
 Emko, Conceptrol, Koromex, Ortho Gynol
II
o Available in a wide variety of dosage forms including
gels (jellies), foams, suppositories. Use ↑ conc.
Products if not using with a diaphragm
66
o The onset & DOA varies for dosage forms & the
instruction for each product should read. Once these
products are used, they should not be removed for at
least 6 hrs after intercourse to avoid leaving behind
viable sperm that can cause pregnancy
67
Administration Guideline for Vaginal Spermicidal Products:
 Foams
o Insert full dose near cervix as directed
o Effective immediately & last 1 hr
o Should be inserted up to 1 hr before intercourse
o Reapply if intercourse repeated
 Suppository
o Insert into cervix
o Effective in 10-15min & last 1hr
o Insert 10min prior to intercourse
o Reapply in intercourse repeated
 Gel
o Insert full dose near cervix
o Effective immediately & last 1hr
o Insert up to 30-60min prior to intercourse
o Reapply in intercourse repeated
 Vaginal gel used with a diaphragm
o Fill device ⅓ full wit gel & place near cervix
o Effective immediately & last 6hr (if cervical cap is used
it will last 48hr)
o Apply up to 1hr prior to intercourse
 Sponge
o Moisten sponge with 2 tbsp of water & insert sot that
concave side covers cervix
o Leave in place for 6-8 hrs after intercourse
o Effective immediately & last 24hr
o Insert up to 24 hrs prior to intercourse & insert new
sponge if 24hrs has passed
o Adverse Effect
 Local irritation may occur & if it does the user
should switch product
 Sponge has been associated with toxic shock
syndrome & women should take care to wash
their hands before inserting the sponge
68
 Should not use the sponge during menstruation or
postpartum
 Should not leave the sponge in for more than
24hrFrequent sponge use has been associated with
↑ed incidence of vaginal & cervical ulcers
69
Topical Antiinfectivs
General Antiseptics
Broad Spectrum Antiseptics
Antifungal
Virginal Infection
1. General Antiseptics
 Creates difficult environment for bacteria to grow
 Prevent infection - DON’T TREAT IT
 Iodine Products
o Iodine sol’n – Sodium Iodine & Sodium Iodide in
WATER
o Iodine tincture – Sodium Iodine & Sodium Iodide in
ALCOHOL
o Get in cell disrupt mem & kill bacteria
o Bacteria can’t grow in ↑ concentration of this drug
o Most effective antiseptic – prevent infection –
DON’T TREAT INF.
o It can sensitize allergic Rxn
 Don’t have allergy to Iodine but after repeated
use Pt. get allergy to Iodine
 Ex. Seafood (Shrimp, Crab), certain exam like
IVP for kidney intravenous Pylogram Fxn
o Dis adv:
 stain cloths & skin
 irritating - don’t bandage wound w/iodine bz ↑
irritation
 Minor cuts & brushes
 Povidine Iodine (Betadine)
o Less irritation – most widely used – leaves residue
o Contains 9-12% Iodine – water soluble complex –
can be absorbed sys
o Iodine is attached to Povidine so slowly release
o Pt. allergic to iodine can’t use this product
70
 Ethanol (Ethyl Alcohol)
o Used in drinking alcohol- denatured so it can’t be
swallowed
o Don’t apply directly to wound bz it can be irritation
 Alcohol - 70% isopropyl – rubbing alcohol
o Commonly used antiseptic
o Has stronger bactericidal activity than ethanol –
destroys membrane of bacteria – leaves residue – kill
bacteria
o Used to sterilize medical equipment
o Lipid soluble & dries skin
o Very irritating feels like burn
o Don’t use on open wound bz of irritation
 Chlorhexidine Gluconate
o Hibiclens – like soap
o 4% []
o strong antimicrobial activityNo allergic reaction
o Once use it – wash it and dry - It leaves a thin film
on hand
o Used to sterilize hands in pre-surgical procedures
o Has stained action & can be used as an deodorant
o OTC ask for it bz not on self BEHIND COUNTER
 Sodium Hypochloride (Bleach)
o Used in 0.25 – 0.50% full strength
o Skin infection – very good antiseptic
o Used for wound dressing for Tx of Decubutis
wounds
o Sodium carbonate used to make – more stable
o Chloride – good antiseptic
o Wash cloths 0.5% or lower for pool water
 Mercurial
o Poor antiseptic
o Very irritating
o Denatured by proteins
71
 AgNO3
o 0.25-0.5% - Stain the skin
o Use for AgNO3 sticks
 chancre sore - Prevent inf. in wound
 Newborn – put it in the eyes to preven
infection.
2. Broad Spectrum Antiseptics
 3% H2O2
o Release of free o2 (nascent o2)
o Most widely used – prevention
o Fizzing due to oxygen release
o When fizzing is over that is when antimicrobial action
stops
o Use only when there is no fear of infection
o Nonspecific
 Phenol Der.:
o Old antiseptic, anesthetic, Antipruritic
o ↑ con. – disinfectant
o Stops itching
o Camphophenique, Cresol, Resorcinol
o Found in Listerine, throat lozenges
 4° ammonium compound
o Food preservatives & drug preservatives (eye drops)
o Benzakonium CL (Bactin)
o Bensothonium CL
o Hexylresorcinol
 Mouth wash
 Burning sensation
 G +/ Very good antiseptic
o Triclosan
 Antibacterial soaps – weak antimicrobial action
 Hand washes
72
 Active ingredient in safeguard soap
THESE PROCUDTS ARE FOR MINOR CUTS & BRUSES
Topical Antibiotics
 Bacitracin
 Neomycin (Neosporin)
 Polymyxin B Sulfate (Polycycin)
73
Skin Conditions
Tx of common skin problems
1. minor cuts & abrasives
 Use antiseptic
 Qualification for when to see DR. – NO ANTISEPTIC
USE ANTIBIOTICS
o Swollen & red skin – Lots of it refer to Dr. bz
ANTISEPTIC IS ONLY FOR PREVENTION
o Pus
o Some antibiotic cream can cause CELLULILUS
o Suspect stitches
 Some level of swelling with it
 Skin pull & if don’t touch back than need to
take stitches
2. Cellutlitis
 Tissue infection
 Don’t use OTC
 Cause by bacteria – Erisupilas: strep cellulites (spread
quickly)
 Swollen, warm, red
3. Paronychia – nail infection
 Staph inf
 Nail starts becoming lose - come off
 Pus from side of nails – press it & if pus come out
than need oral antibiotic – Penicillin 1st Generation
Cephalosporin
 Pain in nail - pus
 Get antibiotic that kill Staph
 1st generation cephalosphorin /penicillin
 fungal infection - 1°
 Bacterial infection - 2°
4. Furuncles(Bacteria in Hair follicle)
5. Carbuncles (Mostly in hairy area of body)
74
 (3-4) Don’t squze boil bz go to another layer of
skin
 Life threatening
 Damage many layers of skin
 Involve under layer of tissue
6. Impetigo
 Vulqaris – sever, contagious, anywhere in the body
 Start w/ vesicle – filled w/ fluid - yellow
amber color
 vesicle rapture – Yellow/Brown crust
 some vesicle – amber color mix with yellow
& brown crust
 common in children
 Tx oral antibiotic (cure in 10 days),
alterative OTC antibiotic ointment (may
take 21 days to treat)
 Use Amoxicillin, Penicillin B, Amplicillin
7. Hidradentitis suppurtiva
 Sweat gland Inf
 Chronically inflamed sweat gland
 Very painful
 Antibiotic – Corticoster9oid injected there –
underneath arm ar9ound nipples
8. Fungal
 Caused by microsporum trichopyton
 Tinea Pedis (Athlete’s foot)
 Tinea Cruris (Jock Itch)
 Tinea Corporis/ Cicinata– ring warm on skin
 Tinea Unguium – ring warm on nail
 Tinea Pedis: (Athlete’s Foot)
 Signs – macerated, boggy, whitened, thick,
foul odor, purities
75











 Can develop 2° bacterial infection –
vesicular inflammation
 Fungal in moist
 Moist environment – public shower, retain
moisture, heavy boots in summer
 More in men
 Present in 4 forms
Present mild itching & scale be toe & intertriqtnous
Skin begin to tear & fissures
Chronic Pauploswuamous type
bw & beyond digit & go under the sole
hard to treat
Nail infection as well
Toe nail serve as reservoir
All 3 type + fluid filled vesicles
Vesicular type – fluid fill vesicular
Ulcerative – bw toes , bottom of sole – ulcer forms
Infected to pseudomonase
 Tinea Cruris: (Jock Itch)
 Signs – lesions – inflamed
 Center of lesion is reddish brown
 Jock Itch – male & female
 Found in Groin area – in skin folds
 Inside of the thigh & grow upword to groin
area – can spread to thigh or rectum
 Bz not enough air – warm or moist
environment
 Can lead to 2° infection
 Seen in summer - Excessive tight clothsMore in older Pt.
 Under arm, under breast
 Same Sx everywhere - Itching, slaing,
vesicle form
 Get infected w/ bacteria
 Use PO or Topical antibiotics
76
 Tinea Corporis/ Cicinata– ring warm on skin
 Signs smooth bare skin, crusty or dry
appearance, red itchy
 Ring worm of body
 Contact transmission
 Animal spread
 Doesn’t need warm, moist environment
 Common in kids
 Ring worm:
 Contagious
 Not bz of moisture
 Those area hair will fall out
 Use same medication for all these fungal
infection
 Ring warm on skin – discoloration of skin &
that’s fungal
 Tinea Capitus:
 Signs – patchy, dry or scaly skin, alopecia in
restricted area, non-inflammatory dermatosis
 Ring worm of the scalp
 Can be picked up by direct contact brushes,
combs, clothing
 Occlusive hair dressing
 Animal spread
 Tinea versicolor:
 Pig of skin change
 Systemic antifungal agent
 Rx drug – oral
SEE Dr IN THESE SITUATION – Rx NEEDED
 Nail infection:
 OTC don’t work well
 Oral antifungal needed
 Toe nails, fingernails
77
 Nail bed is cribected
 Take long time to get rid off
 Oozing vesicles:
 Releasing pus (puralent material)
 Automatic bacteria
 Foul smelling:
 Anerobic neumonia – caugh
 Smell like sulfur
 Inflammation:
 Area is swollen
Topical Antifungal Agents:
 Tolnaftate 1% (Tinactin, Aftate)
 Spray, cream, liquid, powder
 Apply several times a day
 Keep area dry
 Use several wks – 2 wks after Sx disappear
 Tinea Pedia & Tinea Corporis – use 4 wks
 Undecyclenate (Desenex, Curex)
 Clotrimazole (Lotrimin)
 Treeminafine (lamisil)
 Grater activity
 Cost more
 Miconazole (Micatin)
MODEL AFTER FATTY ACID SO ANTIFUNGAL
CHARACTRIS PROPERTIES;  FATTY ACID…….
General Use Rules:
 Starts with clean area & dry it well
 If lisian is oozing- Plain water & soap
78
 Burrow soln 1:40 ratio – aluminum acerate
(Dornbro®)
 Slight acidic & slightly antibacterial
 Than put some of thick cream – cover area , thin
layer on finger & rub it
 Sole take long time
 2-3x day
 use at least 1-2 week after Sx is completely make
sure gone
 itching & burning has stop very well dry
 Put powder or in the soak to keep feet dry
 Need extra pair of soak for Pt. who use whole day
 Best thing is to expose to the air
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Drowsiness
Etiology: Lack of sleep
1. Sleep Apnea
 During the night sometimes stop breathing completely
for moment
 Many Episodes 50 or 20***
2. Narcolepsy
 Go to sleep all the time
3. Depression
 For all these DO NOT GIIVE OTC
 REFER TO Dr.
4. Chronic Pain
 Cancer
 Intractable back pain
 Dental procedure
ONLY AVIABLE OTC PRODUCT – CAFFEINE
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Coffee 502*** - 50-80mg dependent on coffee
Decafe – significantly less only 3-5mg
Tea – lower in caffeine – 502*** - 20-90mg
Soda type – 54mg/derving
Coke – 45-50mg/serving
100-200mg/dose give max. Stimulation begin to
develop problem if it is ↑ than that
 Red bull – 100mg
 Chocolate – 5-10mg from few O2***
 Hot chocolate – 50mg/cup – real coco
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Caffeine – Nodose tab – Generic tablet Caffeine
1. CNS
 ↑ Alertness
 Counteract fatigue
 ↑ nervousness at high dose
 ↑ tremors
2. Cardic
 ↑ HR – can become tolerant to that
 >200 mg/single does – arrhythmias
 ↑ BP – varies – not consistence
 ↑ release of NE, Epi – not consist elevation
3. Diuresis
 Can be caused by caffeine
 *** ________short limited so should not be dependent
on it
4. Dependence
 Get HA*** withour it
 ↑ irritability
 Everyday for 7 days your body develop dependence
 Fatigue, restless, irritated throbbing***
 Last 1-2 days
Caffeine Toxicity:
 Insomnia
 HA
 ↑ restleness
 Become delirious & cause seizure
 Sustain release product should be taken
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Insomnia
Cause: Lifestyle
Etiology:
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
Menopause
Sleep pattern chance
Depression
Some ppl get sedated but some ppl have insomnia
Altered life style contributes
1. Drinking caffeinated products too close to
bed time
2. Exercise - ↑ adrenal too high
 If have problem w/ sleeping
1. Reserve bedtime for sleeping activity
2. If can’t sleep within 20-30min – get up & do
some relacing activities
3. Should engage in relaxing activity before
you go to bed
4. Don’t eat large meal before go to bed – in
real it is not a bad idea to eat before go to
sleep but can ↑ weight & other problem –
depend upon individual
TX:
 Antihistamine
1. Diphenhydramin (ethanolamine)
2. Some have compoz***nitol +
acetamenophene so minex****
 Problem w/ diphenhydramin
1. abuse
2. Re-sedation
3. Anticholinergic activity – dry mouth,
constipation – Give some eye – hard
candy****
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4. Tachycardia
5. ↓ urination
6. Urinary retention in men w/BPH**** can
occur at any age
7. Gluacoma
AVIOD IN Pt. W/ BPH & GLUACOMA
Make sure Pt. not take med. When he/she has to be alert
1. Melatoran*** - 1-3mg, alter – rhythm – natural product no
FDA approval for sleep management
2. L-triptophan – AA supplement now – no FDA approval- cause
esoinophilia mylagia syndrome
DON’T RECOMMAND THIS DRUGS
22YRS F IS DIAGNOSED W/ VAGINAL YEAST
INFECITON BY A Dr AT A CLINIC HE TELLS HER TO
OBTAIN OTC Rx
1. WHAT Sx WHOULD UOU EXCEPT?
2. RECOMMAND AT LEAST 2 PRODUCTS THAT CAN
HELP HER WITH DOSAGE?
3. COMPARE Sx & Tx W/ TRICHOMONIASIS &
BACTERIAL VAGINASIS?
83
Cough Prepration
1. Antitussives
2. Expectorants
W or w/o sympathomametic
* Need to listen to Pt. & determine what type
Antisussives:
1. Dextromethorphan (Robitussin DM, Delsym)
2. Guaifenesin – Ecpectrant
1. Cough dry, non productive
a. No cough up any sputum have to look at frequency only
happen 3-4X day – no drug
b. ↑ frequency – nacking*** cough – duration 10min –
annoying cough
2. Congested – non productive***********
a. Load with sputum but don’t come out
b. Need to broken up
c. Use expectorants – break it up – antitussive – to slow it
down
d. Can develop bacteria
e. Cigarette smoke
f. Certain drugs – ACE inhibitors
g. So when they cough , cough come out
h. Expectronats -↓ viscosity of the flam – helps to break
flam up
i. Expectant – can use pure water – 6-8 Oz or 8glass/day
– good advice make sure enough water or
guafenesin********
3. Congested productive cough
a. Do nothing only drink fluid
b. Still concern about – 5min********
c. Small dose of antitussive ******* - do cough but not
frequent******
d. Antitussive – big problem in teenagers
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e.
f.
g.
h.
Isomer equal to – levorphanol (**********charcotic)
They take large amount of it
Go through period – get sick & vomit
Get addicted
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
sneezing
Nasal congestion
Cough
Sore throat
Lug congestion – post nasal drip – virus
itself***********
Sx:
ROBITUSSIN CF:
 Have Guafenacin & also sympathomimetics
Pseudoepriedrine
 Have runny nose
 Non productive cough
60yrs old make Sx Phinorrhea, sneezing, post nasal drip, frequent
non productive cough, congestion ↑ BP
Lasix 20 PO q d
**** can take antishis. Cardyra 2m po – do you have prostate
problem?
Treat – Dextromethorphan bz frequent cough ec[ectrant
No anticholinergic drug be used***************************
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3. Cold
Caused by virus invading nasal epitheliumhoping to end up in
lungs
1. Rhinorrhea
a. Vasodialtion
b. Inflammation that contains mediators
c. Mediators include slow reaction substrate anaphylaxis,
bradykinins, leukotrines, histamines
2. Nasal congestion
3. Sneezing – body tries to rid itself of substance causing the
problem
4. Sore Throat (Pharyngitis) – from cold or bacteria must
determine source
a. Streptococcal – white spots in back of throat are
exudates from bacteria
i. Pt. may also have fever throat may have a beefy,
red appearance difficult to swallow
b. Cold – develops bz irritation of virus or allergy & post
nasal drip
i. If post nasal drip - disappears when runny nose is
treated
5. Cough – result of virus irritating bronchioles & post nasal
drip
6. Production of Sputum
a. Mucous glands put out mucus & coughs become more
productive
b. Color may indicate infection if pt. also have a fever
7. Myalgias – more sever than influenza; is usually minor in a
cold
8. Fever – mild with colds; if high may be bacterial component
9. Malaise
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Allergies
Same Sx like cold excluding the last 3
The mediator released is Histamine
1. Rhinorrhea
a. Vasodialtion
b. Inflammation that contains mediators
c. Mediators include slow reaction substrate anaphylaxis,
bradykinins, leukotrines, histamines
2. Nasal congestion
3. Sneezing – body tries to rid itself of substance causing the
problem
4. Sore Throat (Pharyngitis) – from cold or bacteria must
determine source
a. Streptococcal – white spots in back of throat are
exudates from bacteria
i. Pt. may also have fever throat may have a beefy,
red appearance difficult to swallow
b. Cold – develops bz irritation of virus or allergy & post
nasal drip
i. If post nasal drip - disappears when runny nose is
treated
5. Cough – result of virus irritating bronchioles & post nasal
drip
6. Production of Sputum
a. Mucous glands put out mucus & coughs become more
productive
b. Color may indicate infection if pt. also have a fever
87
1.
2.
3.
4.
Complication of cold
Happens as a result of a cold
Bacterial Pneumonia
a. Initial Sx: runny nose/ sore throat 1st
b. Later Sx: chest pain, fever, breathing problem
c. Virus paves way for bacterial infection b/c impairing
immune system in respiratory tract is more susceptible
for infection
d. Ciliary bodies impair????
Sinusitis
a. Major complication
b. Usually bacterial & may be chronic
c. Left over fluid gets into sinus & causes infection
d. Sx include HA (frontal, facial, Toothache), odor, bz
anaerobe bacteria produces sulfur as byproduct
Otitis Media
a. Fluid sits in Eustachian tubes(thin, narrow) & lead to
infection
b. Infection in middle of ear
c. Affects speech, social ability & behavioral
d. If chronic – may have to be drained
Asthma
a. Aggravated by cold b/c dripping of fluid into lungs &
irritates bronchioles causing then to spasm
88
1.
2.
3.
4.
Medications
Oral Decongestants – sympathomimetics stimulate 1
receptor → vasodialtion
Pseudophedrine (Sudafed)
Phenylephrine – Varity of combination products
Phenopropynolamine
a. Take off market b/c ↑ risk of stroke
b. Should have considered HTN, lipid problems &
diabetes pts. Before taken off the market
Adverse Effects/ Contraindications
1. CNS
a. ↑irritability
b. insomnia
c. if overdose can lead to seizures
2. Cardic
a. CHF
i. Can exacerbate condition bz cause tachycardia
ii. Output drops bz of fast heartbeat
iii. Heart will maintain between 50 & 150 beats/min
iv. If HR > 150 beats/min ventricles won’t fill
properly
b. Arrythmias
c. Coronary Artery Disease (CAD)
i. Leads to angina pectoris : drugs ↑ HR & CO → ↑
workload of heart
ii. Oxygen demand exceeds oxygen supply &
worsen angina
d. ↑ BP causes vasoconstriction
3. Thyroid Disorders
a. Hyperthyroidism leads to ↑ BP , ↑HR etc
4. Prostate Disorders
a. Benign Prostatic Hypertrophy – leads to urinary
retention & cause infection
89
b. Problem with antihistamine bz they cause urinary
retention
5. Avoid use within 2 weeks of MAOI
6. Diabetes Mellitus
a. Potential to ↑ glucose
b. EPi → stimulate Glycogenolysis → ↑ blood sugar
90
Topical Decongestants
Nasal Drops & Sprays
Can have system effects
Very intense vasoconstrictors
 Phenylephrine (Neosynephrine) q 6-8hr
 Oxymetazoline (Afrin)
q 12hr
 Xylometazoline(Neosynephrine 12º)
Adverse Effects
Rebound Congestion
o ↑ risk if used for more than 4 days
o Nose is dry & breathing hurts
o 0.65% NaCl spray is given & topical decongestant is
discontinues
o Give oral decongestant bz they don’t cause rebound
congestion
91
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Antihistamines
Don’t work as well as decongestants
Chlorpheniramine (Chlor-Trimeton) – Less sedation
Brompheniramine (Dimetapp)
Diphenhydramine (Benadryl)
Doxylamine (Nyquil)
Diphenhydramine (Benadryl) & Doxylamine (Nyquil) - MOSTLY
USED & HAVE SIMILAR SEDATION
Problems with Antihistamine
1. CNS depressant – sedation, loss of consciousness,
Drowsiness
2. Prostate Hypertrophy – retain more urine, ↑ chances of
infection, BPH
3. Paradocixal effect - opposite effect to use, especially in
children, can become CNS stimulant
Cough Preparations
Antitussives:
 Slows down frequency of cough
 Works centrally & at peripheral nerve endings
o Dextrometorphan (Delsym)
Expectorants:
 loosens phlegm in lung & chest making it easier to bring up
 ↑ respiratory secretions
o Guafenesin (Robitussin)
o Water (BEST)
92
Types of Cough
1. Congested, Productive Cough
a. Brings up phlegm with cough
b. Use EXPECTORANT
2. Congested, Nonproductive Cough
a. Phlegm sits in chest even though there is cough
b. Use EXPECTORANT
3. Dry, Nonproductive Frequent Cough
a. Seen in smokers
b. Use ANTITUSSIVE
Robitussin
Active Ingredient: Gualfenesin 100mg –Expectorant
Inactive Ingredient: Caramel, Citric acid, FD & C red no 40,
flavor, glucose, glycerin, high fructose corn syrup, menthol,
saccharin sodium, sodium benzoate, water
Robitussin DM
Active Ingredient: Gualfenesin 100mg –Expectorant,
Dextromethorphan 10mg cough (suppressant)
Inactive Ingredient: Caramel, Citric acid, FD & C red no 40,
flavor, glucose, glycerin, high fructose corn syrup, menthol,
saccharin sodium, sodium benzoate, water
Robitussin CF
Active Ingredient: Gualfenesin 100mg –Expectorant,
Dextromethorphan 10mg, Pseudoephedrine 30mg (nasal
decongestant)
Inactive Ingredient: Caramel, Citric acid, FD & C red no 40,
flavor, glucose, glycerin, high fructose corn syrup, menthol,
saccharin sodium, sodium benzoate, water
93
Robitussin CF
Active Ingredient: Gualfenesin 100mg –Expectorant, Codeine
10mg – antitussive, Alcohol 3.5%
Inactive Ingredient: Caramel, Citric acid, FD & C red no 40,
flavor, glycerin, Saccharine sodium, sodium benzoate, Sorbitol,
Purified water
Nyquil
Active Ingredient: Acetaminophen 500mg – pain reliever/ fever
reducer, Pseudophedrine 30mg – nasal decongestant,
Dextromethorphan 15mg, Doxylamine Succinate 6.25mg antihistamine
Inactive Ingredient: Alcohol, blue 1, citric acid, flavor, high
fructose corn syrup, polyethylene glycol, propylene glycol,
purified water, red 40, saccharin sodium, sodium citrate
Comtrex
Active Ingredient: Acetaminophen 500mg. brompheniramine
maleate 2mg – antihistamine, pseudophedrine 30mg
Inactive Ingredient: Benzoic acid, carnauba wax, corn starch,
croscarmellose sodium, FD&C#40 lake, hydroxyl proply methyl
cellulose, magnesium stearate, methyl paraben, microcrystalline
cellulose, polyethylene glycol, polysorbate 80. propylparaben,
stearic acid, titanium oxide
94