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115 – TABLES FROM OTC BOOK – Annie Ho
BREAKDOWN OF QUESTIONS
Dr Stan-Ugbene
Dr Wagner
Dr Norton
30 questions
30 questions
10 questions
PRE-MIDTERM TOPICS COVERED:
COUGH, COLD, ALLERGY, ORAL DISCORDERS, DENTAL DISORDERS, FEVER, PAIN, HOME TESTING/MONITORING DEVICES,
SEXUALLY TRANSMITTED DISEASES AND PREGNANCY PREVENTION
 Table 5-3
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 Table 5-8
[from first study guide]: Please focus just on primary ingredients without actual doses for Advil Cold and Sinus, Aleve-D, Alka-Seltzer
Plus Sinus, Excedrin Migraine and Excedrin Tension Headache
 Advil cold/sinus: ibuprofen, pseudoephedrine
 Aleve-D: naproxen sodium, pseudoephedrine
 Alka-Seltzer Plus Sinus: acetaminophen, phenylephrine
 Excedrine Migraine: acetaminophen, asprin, caffeine
 Excedrine tension HA: acetaminophen, caffeine
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Table 7-2 – Exclusions to self treatment of musculoskeletal Disorders
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(I think that Oby meant FIGURE 7-2, because TABLE 7-2 is “comparison of musculoskeletal disorders, which does not include
anything about exclusions to self-tx)
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 Table 7-3
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 Figure 6.1- Exclusions to self treatment of fever
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 Table 11-5 Only study dosing for adults/children more than 12 years
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 Table 11-8
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 Table 12-3
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Pharmacological therapy for cough
Cough suppressants (systemic antitussives)
– Dextromethorphan
• Codeine analog
• Increases cough threshold
• 10-20 mg every 6-8 hours
• 120 mg maximum
– Codeine
• Gold standard
• Increases cough threshold
• 10-20 mg every 4-6 hours
• 120 mg maximum
– Diphenhydramine
• First generation antihistamine
• Anticholinergic effects
• 38 mg every 4 hours
• 225 mg maximum
– Topical
• Camphor
• Menthol
Topical antitussives
Expectorants (protussives)
Guaifenesin
 Loosens and thins lower respiratory tract secretions to effectively remove mucus
 200-400 mg every 4 hours
 2.4 g maximum
Lecture slides 9-15: cough, cold, allergic rhinitis
DEXTROMETHORPHAN
• Drug of choice for non productive cough
• Non- Opioid (non addictive)
• Codeine analog (a control substance)
• Acts centrally in the medulla to increase cough threshold
• For cough resulting from chemical/mechanical irritation
• Dose related toxicities
• Overdose: nervousness, confusion, irritability psychosis, mania, respiratory depression
• AE (adverse effect) - drowsiness, N,V, stomach discomfort, constipation
• Not to be used within 14 days of using MAOI (Monoamine oxidase inhibitor) Inhibitors (phenylalidine)  serotonin syndrome (increase BP,
hyperpyrexia, arrhythmias, myoclonus)
• Abuse potential
• Supplied as syrups, liquids, liquid-filled gelcaps, oral disintegrating strips, oral sprays, lozenges, extended release oral suspensions (delsome)
CODEINE
• Gold standard antitussive
• Controlled Substance
• Acts centrally on the medulla to increase cough threshold
• Supplied as oral solutions and syrup
• Lethal adult dose - 0.5 to 1g (respiratory depression, cardiopulmonary arrest)
• AE - N,V, sedation, dizziness, constipation
• CI (contraindication): During labor with anticipation of preterm labor, codeine allergy
• DDI (drug-drug interaction): Alcohol, barbiturates, sedatives -> additive CNS depression
DIPHENHYDRAMINE (aspirin, Benadryl)
• Non selective first generation antihistamine (causes drowsiness)
• Acts centrally in the medulla to increase cough threshold
• Action related to anticholinergic effects
• Onset of action – 15 mins, helps to clear the cough
• Hepatic metabolism (not for patients with liver problem)
• For cough due to chemical/mechanical irritation
• Supplied as syrups, liquids, oral disintegrating strips
• AE: drowsiness, blurred vision, dry mouth, urinary retention, excitability in children
• Caution: glaucoma, hyperthyroidism, asthma (due to anticholingergic effect)
TOPICAL COUGH SUPPRESSANTS
• Oral camphor (topical treatment, ex. Vicks)
• Oral menthol
• MOA (mechanism of action) – Stimulate sensory nerve endings within the nose and mucosa creating a local anesthetic effect with a sense of
increased air flow
• Lethal in large doses
GUAIFENESIN (mucefnix)
• Drug of choice for coughs consisting of thick, tenacious secretions which are difficult to expel (thins the mucous and helps to expel it)
• Loosens and thins lower respiratory tract secretions to effectively remove mucous
• Relatively harmless
• FDA approved for acute productive cough
• Few adverse effects
– Stomach pain, diarrhea, nausea, HA
• No reported drug interactions
• Oral solutions, syrups, immediate and extended release tablets
• Alcohol free, sucrose free and dye-free
Slide 8 -12: oral and dental disorder
Pharmacological therapy
• Chemical management of plaque
– Aid mechanical removal directly or by disrupting components of plaque
– Characteristics include:
• agents with selective antibacterial activity
• substantivity (retention in the mouth)
• compatibility with dentifrice ingredients (toothpaste)
• reduced adverse effects
• non interference with natural mouth flora
– FLUORIDE
• Mostly for orthodontic pts, pts with reduced salivary flow or at risk for caries
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Reduces solubility of dental enamel, enhancing remineralization while reducing glycolysis of sugar hence inhibiting acid
formation
OTC fluoride rinses ( Oral B Anti cavity rinse, ACT for Kids)
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Should not be used more than once daily
Brush with fluoride toothpaste prior to using fluoride treatment
Swish specified amount around the teeth for about 1 minute
Do not swallow
Do not eat or drink for about 30 minutes after fluoride treatment
Supervise children < 12 yrs for proper use of agent
Refer children < 6 yrs to PCP or dentist prior to treatment initiation
Fluorosis may occur with overdose of fluoride (makes pits in your teeth)
Fluoride therapy
Dentifrices
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Used with a toothbrush to clean accessible tooth surfaces
Types - Fluoride, Tartar control, antiplaque/gingivitis, whitening/antistain
Available in paste, powders and gel (aquafresh, Colgate, ultrabrite, biotene, sensodyne, crest)
Low - abrasive types contain low concentration of silica while high- abrasive types contain more of aluminum salts
Antiplaque agents contains triclosan ( Colgate Total)
Whitening agents differ from bleaching agents and may contain chemicals such as aluminum oxide, citrate salts, papain (
Rembrandt Whitening toothpaste)
MOUTH RINSES AND GELS
• Adjunct to brushing and flossing
• Contain alcohol without abrasive as well as glycerin, benzoic acid and zinc chloride - Crest Pro-Health, Listerine, Scope
• Contain aromatic oils for antibacterial activity and local anesthetics – menthol, eucalyptus and thymol as well as agents for
antimicrobial activity – cetylpyridinium chloride
PLAQUE CONTROL CHEWING GUM AND LOZENGES
• Between dental gum, Biotene (mainly for dry mouth)
Gingivitis
• Inflammation of the gingiva (gum) without loss or migration of epithelial attachment
• Swollen red gum as well as engorged capillaries
• Main cause of tooth loss in adults > 45yrs
• Closely associated with oral hygiene
• Etiology: plaque build up, hormonal changes, blood dyscrasias (leukemia), mucocutaneous disease and viral infections, AIDS, medicationsCCB (calcium channel blockers), BB (beta-blockers), Anti depressants, Phenytoin, Cyclosporine, tobacco, pregnancy
• Reversible
• Asymptomatic – bleeding, swollen gums
• May lead to periodontal disease
• Prevention - brushing, flossing, gum massage
Slides 19-24
TOOTH HYPERSENSITIVITY
• Exposure of dentin due to enamel or gingival recession
• Causes: bruxism (grinding), teeth whitening products, dental treatments,
• Stimulus (heat, cold, pressure, acid,) stimulate exposed dentin or open tubule pain
• Treatment goals- alter damaged tooth surface using proper toothbrush and paste, stop abrasive toothbrush practices
• Differentiation of tooth hypersensitivity & Toothache[Table 32-1]
• Nonpharmacological treatment - removing predisposing factors, proper brushing techniques, standard fluoride dentifrice
• Pharmacological treatment: use of desensitizing dentifrices containing a potassium salt [Table 32-2]. Common ingredients include sodium
fluoride + potassium nitrate 5% containing products (Colgate sensitive maximum strength, Sensodyne)
– At least 1 inch strip required
– Pts should not rinse mouth after use
– 2- 4 wks of treatment may be required
– Not for children < 12 yrs
Teething discomfort
• Mostly in babies
• Characterized by mild pain, irritation, reddening, swelling and excessive drooling, irritability and sleep disturbance
• Treatment goal - relieve pain and discomfort
• Non pharmacological treatment – massaging the gums, frozen pacifiers or cold wet cloth
• Pharmacological treatment
– FDA approved topical analgesics containing benzocaine 5% to 10% ( Baby Oragel)
– Systemic analgesics for pediatrics
Recurrent Aphthous Stomatitis
• Also known as RAS or canker sores
• May be precipitated by stress and local trauma, may be genetic
• Associated with smoking, SLE, allergy, IBD, HIV, iron, folic acid or Vit B1,B2,B6 or B12 deficiency
• Epithelial ulceration on nonkeratinized mucosal surfaces
• Treatment Goals: control ulcer pain, promote healing, prevent recurrence and prevent secondary infection
• Exclusions to self care [Figure 32-2]
• Nonpharmacological treatment
– Vitamin/mineral supplementation
– Avoiding acidic, spicy food
– Eliminating offending allergy causing agent
– Applying ice in 10 minute increments
• Pharmacological
– Oral debriding and wound cleansing agents, topical oral analgesics/anesthetics/protectants and rinses provide symptomatic relief
(GlyOxide oral cleanser, carmex lip balm, canker cover, listerine rinse, abreva [Table 32-5]
• Minor Oral Mucosal Injury/Irritation May be caused by dental procedures, biting/abrasion of the cheek, irritations in the mouth or gum
• Treatment goal: control discomfort and pain, aid healing and prevent secondary bacterial infection
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Nonpharmacological treatment
– ice application in 10 minute increments
– sodium bicarbonate (baking soda ½ to 1tsp in 4 oz of water)
– saline rinse(1-3 tsp in 4-8 oz of water)
• Pharmacological treatment: same as in RAS, and astringents (cleaning to get rid of bacteria) may also be used [Table 32-5]
• Should resolve in 7-10 days or else refer to PCP
HERPES SIMPLEX LABIALIS
• Also known as HSL, cold sore, fever blister
• Viral
– HSV-1 – oral and labial sores
– HSV-2 – genital sores? Oral sex?
– Cytomegalovirus, Epstein-Barr virus
– At age 40, 84% of US population have antibodies for HSV-1. Recurrent infection in 30 to 40% of patients
• Contagious via direct contact
• Triggers for reactivation of virus – UV radiation, stress, fatigue, cold, windburn, dental work, fever, immunotherapy
• Lesions on the lips, lip borders or in the mouth
• Treatment similar to RAS
• Treatment goals: cleansing affected area, protecting the lesions from infection, relieving discomfort of itching, burning and pain
• Exclusions to self care [Figure 32-4]
• Nonpharmacological treatment
– Proper hand washing, keeping lesions moist and avoiding triggers
• Pharmacological treatment
– Topical skin protectants
– Analgesic/anesthetic in emollient vehicles
– Abreva
– Antibiotic ointments for secondary bacterial infection
• Infection is self limiting
Xerostomia
• aka dry mouth
• Entails limited or completely stopped salivary flow
• Disposing factors: DM (diabetic) , autoimmune disorders, depression, crohn’s disease, anticholinergic medications, diuretics (dry mouth),
sedatives, antipsychotics, antidepressants, old age, autoimmune disorders, alcohol, tobacco, caffeine, mouth breathing
• Treatment goals- relieve discomfort, prevent/treat infection, reduce risk of caries
• Exclusions to self care [ Figure 32-5]
• Counseling tips
– Professional dental management in addition to self care
– Good oral hygiene
– Adequate water intake
– Complications include gingivitis, caries, periodontal disease
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Nonpharmacological treatment: avoid substances that dry mouth, modify medication schedules to at least 1 hr prior to meals, limit sugar
intake to avoid tooth decay, gum sweetened with sugar alcohol (xylitol) may be beneficial and increased water intake
Pharmacological
– Artificial saliva
• Viscosity - carboxymethylcellulose and glycerin
• Mineral content – calcium and phosphate ions, some fluoride
• Palatability – mint or lemon flavor sweetened with xylitol or sorbitol
– Biotene, Salivart [Table 32-6]
Self Care Slides 7-13
Problems with self care
• Product confusion – marketing strategies
• Therapeutic duplication
• Therapeutic failure
• Poor self care choices
• Incorrect dosing
• Drug interactions
• Uncertainty regarding duration of therapy
• Patients assumptions that OTC medications are not “real drugs”
Conditions commonly treated with self care
• Pain (78%)
• Cough/cold/flu/sore throat (52%)
• Allergy/sinus problems (45%)
• Heartburn, indigestion (37%)
• Constipation/diarrhea/gas (21%)
• Minor infection (12%)
• Skin problems (10%)
Patient self care behavior
• Some patients using prescription medications are concurrently using herbal supplements
• Common indications for OTC therapy include headache, skin problems, heartburn/indigestion, cold, cough, flu, sore throat, allergy or sinus
problems
• Primary source of information include family and friends
• Special populations often overlooked when reading labels - pregnant women, diabetics, hypertension patients, and the elderly
OTC drug label facts
• Active Ingredients
• Uses
• Warnings
• Directions
• Other information
• Inactive ingredients
• Caution about pregnancy/breastfeeding
• Storage information
• Questions?
Benefit of pharmacist assisted related health care
• Reduced ER and physician office visits
• Reduced medical errors
• Reduced health care costs
• Improved quality of care
• Increased productivity and reduced absenteeism from work
• Saves patients time
• Increased patient education and awareness
• Increased patient satisfaction
Goals of pharmaceutical care for self treatment
• Proper patient evaluation for self care vs. referral
• Developing and implementing a care plan
• Scheduling follow–up care to evaluate therapeutic outcomes
• Implementing modifications as necessary
Missing: lectures slides on contraception and Home Testing Devices