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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 53 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 79 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 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 80 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 81 Insomnia Cause: Lifestyle Etiology: 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**** 82 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 84 e. f. g. h. Isomer equal to – levorphanol (**********charcotic) They take large amount of it Go through period – get sick & vomit Get addicted 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*************************** 85 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 86 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 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