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CNS OTC Flashcards

1
Q

what are OTC analgesics used to treat?

A
  • Mild to moderate pain
  • Somatic pain
  • Headache
  • Dysmenorrhoea
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2
Q

what are the OTC analgesics?

A
  • Paracetamol
  • Aspirin
  • Ibuprofen
  • Codeine/dihydrocodeine
    combination products
  • Naproxen
  • Topical formulations (rubefacients, NSAIDs,
    freezing agents and local anaesthetics)
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3
Q

what are the different types of headache?

A
  • Migraine
  • Tension headache
  • Cluster headaches
  • Temporal arteritis
  • Trigeminal neuralgia
  • Chronic daily headache
  • Sinusitis
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4
Q

what is a migraine?

A

Migraine is a primary episodic headache disorder. It is characterised by episodic severe headaches (commonly, but not always unilateral, and often described as throbbing or
pulsating), with associated symptoms such as photophobia phonophobia and nausea and vomiting

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5
Q

what are the characteristics of a migraine with aura?

A
  • With neurological symptoms
  • Alterations in vision (prodromal phase)
  • Tingling/numbness (paraesthesia)
  • Nausea or vomiting
  • Relief from lying in a darkened room
  • 3 x more common in women than men
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6
Q

what are the characteristics of a migraine without aura?

A

Absence of neurological symptoms
* No pro-dromal phase
* Both sides of head may be affected.
* GI symptoms may occur

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7
Q

what are the common trigger factors for a migraine?

A
  • Dietary
  • Hormonal
  • Physical
  • Environmental
  • Psychological
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8
Q

what are the 3 phases of a migraine?

A

1- prodromal phase/ aura
2- attack
3- resolution phase/ postdromal phase

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9
Q

what are the initial prodromal symptoms of a migraine?

A
  • Mood variation
  • Yawning
  • Food cravings
  • Fluid retention
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10
Q

what are the aura symptoms of a migraine? how long does it last?

A

– last <1 hour
* Flashing lights/arc of light
* Blind spot
* Numbness and tingling sensation
* Weakness
* Clumsiness

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11
Q

what are the symptoms during a migraine attack?

A
  • Severe headache
  • Throbbing/pulsing pain
  • Usually unilateral
  • Nausea & vomiting
  • Photophobia
  • Phonophobia
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12
Q

symptoms during resolution of a migraine?

A
  • Symptoms fade slowly
  • Headache becomes less
    severe
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13
Q

what are the postdromal symptoms of a migraine?

A
  • Hangover effect
  • Fatigue
  • Depressed mood
  • Migraine is also associated with an increased risk of depression, bipolar affective disorder, anxiety disorder, and
    panic disorder
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14
Q

what is the prophylactic treatment for a migraine?

A
  • Fever few/Riboflavin/Magnesium/Aspirin 75mg daily
  • There is very little/no evidence base to support any of these!
  • Recommended prophylactic treatment on prescription include: topiramate (note: teratogenic), propranolol or amitriptyline
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15
Q

What are the OTC analgesics used to treat migraines?

A
  • paracetamol
  • aspirin
  • ibuprofen
  • codeine, dihydrocodeine
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16
Q

why should we be cautious when giving codeine/ DHC?

A

as it can contribute to gastric status- can cause constipation

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17
Q

what anti-emetics are there for migraines?

A
  • buclizine (pink Migraleve)
  • prochloperazine (Bucastem M) - blocks
    the chemoreceptor trigger zone, quelling N&V
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18
Q

what is a migraine specific treatment?

A
  • Triptans or selective 5-HT agonists
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19
Q

how do triptans work?

A
  • Constrict blood vessels that are dilated during an attack
    Acts on four common symptoms – headache,
    photophobia, phonophobia and nausea
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20
Q

what is the supply criteria for sumatriptan?

A

o Migraine must be diagnosed by a doctor or pharmacist
o Simple analgesics tried and ineffective
o Plus….
* Aged 18 – 65 years
* Established and stable pattern of migraine, with or without aura…..
* Migraine for at least one year
* Had at least 5 or more attacks

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21
Q

when should you be precautious about using a triptan?

A

– SSRI/SNRI
– St John’s wort (Hypericum perforatum)
– combined oral contraceptives
* Heart disease risk factors (contraindicated in
patients who have three or more risk factors
i.e. diabetes, high cholesterol levels,
smoking/use of NRT)

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22
Q

who is contraindicated for triptans?

A
  • Those under 18 or over 65,
  • Pregnant or breastfeeding,
  • CV disease or hypertension and those with 3 or more CV risk factors, history of stroke, renal or hepatic impairment,
  • Epilepsy or history of seizures,
  • MAOIs in last 2 weeks,
  • Known triptan allergy.
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23
Q

how should you use sumatriptan?

A
  • 1 tablet should be taken ASAP at the first signs of a migraine headache.
  • Symptoms return after initial relief - a 2nd tablet may be taken after at least 2hrs.
  • Max 2 tablets in 24hrs and no more than 2 tablets to be taken for same attack.
  • If the 1st tablet does not give any relief then a 2ndshould not be taken (this means it’s a headache not a migraine).
  • Warn patients not to take as a prophylactic
    treatment!
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24
Q

what counselling should you give for a migraine?

A
  • Avoid trigger factors
  • Immediate analgesic use
  • Sleep
  • Dark & quiet environment
  • Hot/cold compress
  • Prescribed treatment & prophylaxis
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25
Q

what are the causes of a tension headache?

A
  • Posture
  • Emotional stress
  • Anxiety
  • Prolonged
    concentration
  • Fatigue
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26
Q

what are the symptoms of a tension headache?

A
  • dull persistent pain
  • Pressure/tight band
    around head
  • dizziness
  • fatigue
  • sweating
  • mild nausea
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27
Q

what OTC treatments are available for tension headache?

A
  • Simple analgesics
  • Syndol Tablets
  • syndol headache relief (doxylamine succinate)
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28
Q

how should you counsel someone on a tension headache?

A
  • Identifying causes – eg. computer screens???
  • stress management
  • Exercise/yoga
  • massage
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29
Q

what are the characteristics of a cluster headache?

A
  • severe boring pain around eye
  • more common in men and tend to start their 30s or 40s
  • unilateral pain
  • blocked nostril
  • hot, reddened cheek
  • last 15mins-3 hrs
  • similar time of day
  • Refer to GP
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30
Q

what are the characteristics of temporal arteritis?

A
  • severe pain around temples
  • continuous/intermittent
  • throbbing/steady
  • red, prominent temporal artery
  • jaw pain
  • partial or complete loss of vision
  • immediate referral
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31
Q

what are the characteristics of trigeminal neuralgia?

A
  • nerve pain
  • unilateral
  • sudden & severe
  • shooting pain
  • lasts for up to 2 mins
  • several attacks per day
  • painful to touch
  • Refer for treatment with
    carbamazepine/pregabalin
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32
Q

how would you define a chronic daily headache?

A

> 4 hours on > 15 days per month

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33
Q

what causes a chronic daily headache?

A

Analgesic/opioid/caffeine dependence
Rebound withdrawal symptoms

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34
Q

how do you treat chronic daily headache?

A

Restrict opioid analgesic use to up to 3 days to
prevent these headaches
* Break the cycle of analgesic use - slow steady
reduction in opioid dose

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35
Q

what is sinusitis?

A

Defined as symptomatic inflammation of the paranasal sinuses…ie swelling of the mucosal lining

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36
Q

what triggers sinusitis?

A

Usually triggered by viral infection - a secondary bacterial infection could potentially develop (2% of cases)

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37
Q

what are the characteristics of sinusitis?

A
  • Pressure buildup which causes pain.
  • Usually unilateral or central, behind and between the eyes.
  • Worse on bending forwards or lying down
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38
Q

how do you treat sinusitis?

A

Treat OTC with pain killers/decongestants/saline nasal wash or
drops

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39
Q

what is the headache red flags?

A
  • migraine with COC
  • frequent migraine/treatment failure
  • severe headache of > 4 hrs duration
  • suspected ADR
  • associated neck stiffness, visual disturbance
  • associated with injury/trauma
  • children under 12 years
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40
Q

what is RA? what are the symptoms?

A

Inflammation of synovial
lining of peripheral joints
Symptoms
* starts at any age
* joint pain…can be extreme
* polyarthritis
* affects other systems eg. eyes
* swelling
* prolonged morning stiffness
* Reduced mobility

41
Q

what is the OTC treatment for RA?

A
  • Simple analgesics
  • NSAIDs
  • Topical formulations
42
Q

how would you counsel someone of RA?

A
  • support to adapt to
    disability
  • avoid analgesic over use
  • caution with NSAIDs
  • advise about DMARDs,
    cytotoxics,
    corticosteroids
  • information about
    corticosteroid injections
43
Q

what is osteoarthritis?

A

Slow progressive disorder of articular cartilage and bone affecting joints of peripheral and spinal skeleton

44
Q

what are the symptoms of osteoarthritis?

A
  • over age 55 years
  • monoarticular
  • joint pain
  • Stiffness after prolonged rest
  • functional impairment
45
Q

what are the OTC treatments for osteoarthritis?

A
  • simple analgesics
  • NSAIDs
  • topical formulations
  • glucosamine
    1500mg/day
  • chondroitin
    1200mg/day
46
Q

how do you counsel someone with OA?

A
  • joint protection
  • weight loss
  • Keep active - exercise
    little and often
  • physiotherapy
47
Q

what is GOUT?

A

A disorder of purine metabolism characterised by a raised uric acid level in the blood (hyperuricaemia) and the deposition of
urate crystals in joints and other tissues, such as soft connective tissues or the urinary tract.

48
Q

how would someone with GOUT present?

A
  • inflammatory arthritis of single joint
  • extremely painful & red
  • skin may peel
  • Gout tends to attack joints in
    the extremities
49
Q

what are the 3 distinct phases of GOUT?

A

A long period of asymptomatic hyperuricaemia before gout manifests.

‘interval gout’, or ‘intercritical gout’
A period with acute attacks of gouty arthritis which are followed by variable intervals (months to years) when there are no symptoms

The final period of chronic tophaceous gout, where people have nodules affecting joints.

50
Q

what are the risk factors for gout?

A
  • Uric acid - end-product of the breakdown of purines (adenine and guanine), and exists as sodium urate in extracellular fluid.
  • Impaired renal excretion can lead to….
  • Hyperuricaemia is the single most important risk factor for developing gout
  • Duration and magnitude of hyperuricaemia correlates with the likelihood of subsequent development of gouty arthritis, uric acid kidney stones, and age of onset.
  • Hyperuricaemia - risk factors include CVD, renal disease, diabetes, obesity, metabolic syndrome, dyslipidaemia, severe psoriasis, alcoholism, and use of certain drugs (eg. diuretics)
51
Q

who is GOUT more common in?

A

More common in men (30–60 years of age)
and in older people

52
Q

what are the complications of GOUT?

A
  • Tophi - create problems with ADL (preparing food, dressing), become inflamed and exude tophaceous material
  • Development of secondary infection.
  • Hyperuricaemia-induced renal disease may occur, such as acute and chronic urate nephropathy
53
Q

how is GOUT diagnosed?

A

based on the clinical history and examination – no specific criteria used in the UK.
* Investigations -limited use as serum uric acid level can be normal during an acute attack

54
Q

what physical examinations would you do for gout?

A
  • Maximal inflammation developing within 1 day of onset.
  • Monoarthritis attack (90% of initial attacks).
  • Redness over affected joint.
  • Unilateral attack on the first metatarsophalangeal (big toe) joint or tarsal joint.
  • Tophus (proven or suspected).
  • Hyperuricaemia (not visible)
55
Q

how would you assess GOUT OTC?

A
  • Severity? (No. of joints affected? Patients ability to mobilise? Impact on work and functioning?)
  • Previous attacks?
  • Which drugs (if any) the person is taking or tried? (inc NSAIDs, or urate-lowering drugs such as allopurinol).
  • Assess risk factors - (eg. diuretics), alcohol, diet, and obesity.
  • Associated conditions? (hypertension, diabetes, and CVD)
  • Advise to get CV risk assessment (usually after the attack has settled).
  • Ideally if had first acute attack pt should have serum uric acid level measured 4–6 weeks later
56
Q

how do you treat GOUT?

A
  • Mild symptoms – SELF CARE
  • 1st Line - NSAIDs - Ibuprofen OTC asap and continue until 48 hours after the attack has resolved.
  • If required regularly -refer for co-prescribing of PPI
57
Q

when do you refer GOUT?

A
  • Mild symptoms – SELF CARE
  • 1st Line - NSAIDs - Ibuprofen OTC asap and continue until 48
    hours after the attack has resolved.
  • If required regularly -refer for co-prescribing of PPI
58
Q

when should you stop allopurinol/ febuxostat?

A

Do not stop allopurinol or febuxostat during an acute attack of gout if already established on these drugs

59
Q

what is the GOUT self care/ advice?

A
  • Rest and elevate the limb. - Avoid trauma to joint.
  • Keep the joint cool by not covering (with a sock, shoe, or bed clothing) and using an ice pack.
  • Aim for an IBW - Take regular exercise — but avoid intense muscular exercise and trauma to joints.
  • Restrict amount of red meat and avoid a high protein intake.
  • Drink alcohol sensibly — avoid binge drinking alcohol
    consumption = 14 units, at least 2 alcohol-free days a week.
  • Avoid dehydration
  • Stop smoking
60
Q

what is used for GOUT prevention?

A
  • Allopurinol (POM) - after 2+ attacks within a year or
    after 1st attack in people at higher risk
  • Start 1–2 weeks after the inflammation has settled
  • Titrate dose every few weeks until the serum uric
    acid (SUA) level is <300 micromol/L.
  • When starting allopurinol, a low dose NSAID (+PPI) is often co-prescribed; or low-dose colchicine, for at
    least 1 month to prevent acute attacks
61
Q

what is second line treatment for prophylaxis of GOUT?

A

febuxostat

61
Q

what is second line treatment for prophylaxis of GOUT?

A

febuxostat

62
Q

when may acute attacks of GOUT occur?

A

Allopurinol or febuxostat may cause acute attacks of
gout just after initiating treatment, and for some
weeks afterwards

63
Q

when would you refer GOUT?

A
  • Uncertain diagnosis or underlying systemic illness
    (eg. RA or connective tissue disorder)
  • Pregnancy or <25 yrs of age.
  • Allopurinol or febuxostat is at maximum dose but a person is still having recurrent attacks of gout.
  • Persistent symptoms during an acute attack despite
    maximum doses of anti-inflammatory medication
  • CI to NSAIDs or available OTC treatment
63
Q

when would you refer GOUT?

A
  • Uncertain diagnosis or underlying systemic illness
    (eg. RA or connective tissue disorder)
  • Pregnancy or <25 yrs of age.
  • Allopurinol or febuxostat is at maximum dose but a person is still having recurrent attacks of gout.
  • Persistent symptoms during an acute attack despite
    maximum doses of anti-inflammatory medication
  • CI to NSAIDs or available OTC treatment
63
Q

when would you refer GOUT?

A
  • Uncertain diagnosis or underlying systemic illness
    (eg. RA or connective tissue disorder)
  • Pregnancy or <25 yrs of age.
  • Allopurinol or febuxostat is at maximum dose but a person is still having recurrent attacks of gout.
  • Persistent symptoms during an acute attack despite
    maximum doses of anti-inflammatory medication
  • CI to NSAIDs or available OTC treatment
64
Q

when would you refer GOUT?

A
  • Uncertain diagnosis or underlying systemic illness
    (eg. RA or connective tissue disorder)
  • Pregnancy or <25 yrs of age.
  • Allopurinol or febuxostat is at maximum dose but a person is still having recurrent attacks of gout.
  • Persistent symptoms during an acute attack despite
    maximum doses of anti-inflammatory medication
  • CI to NSAIDs or available OTC treatment
65
Q

what is tendonitis?

A

A tendon is the fibre which attaches muscle to bone
sudden stress may rupture tendons causing severe
pain, inflammation and loss of movement eg. common example is the Achilles heel

66
Q

what is bursitis? how should you treat?

A
  • inflammation of bursa
  • Sacs of fluid protecting
    adjacent structure
  • Treat with rest and cooling, and then after 48hrs apply heat.
  • If this does not help - refer
67
Q

what is fibritis/ fibromyalgia? how is it treated?

A
  • Aching at multiple sites with no abnormalities
  • stiffness
  • lethargy
  • tension headache
  • IBS
  • Steroid injection at local
    sites may give short
    term relief
68
Q

what is a sprain/ strain?

A
  • sprain (ligament injury)
  • severe pain on movement
  • swelling
  • strain (muscle fibre damage)
69
Q

what is first aid injury- PRICE?

A

protection
* Protect from further injury (for example by using a support or high-top, lace-up shoes)
* Functional brace
Rest
* Avoid further harm
* Avoid activity for the first 48–72 hours following injury and consider the use of crutches Ice
* Apply ice wrapped in a
damp towel
* 15-20 mins every 2-3 hours
* For 48-72 hrs following injury
* Do not leave ice on while asleep.
* Increases pain threshold
* Reduces inflammatory
response & swelling
Compression
* Tubigrip
* Snug, but not tight
* first 2-3 days
* Remove before going to sleep
Elevation
* above level of heart
* first 48 hrs
* reduces swelling

70
Q

what does it mean - avoid HARM?

A
  • Avoid HARM in the first 72 hours after the injury:
  • Heat (eg. hot baths, saunas, heat packs).
  • Alcohol (increases bleeding and swelling and decreases healing).
  • Running (or any other form of exercise which may cause further damage)
  • Massage (may increase bleeding and swelling).
71
Q

what analgesia should be given for MSK?

A

topical NSAIDS

72
Q

what is whiplash?

A
  • A neck injury caused by a sudden movement of the head forwards, backwards or sideways.
  • Often occurs after a sudden impact such as a RTA.
  • The vigorous movement of the head damages the ligaments and tendons in the neck.
73
Q

what are the common symptoms of whiplash?

A
  • Neck pain and stiffness
  • Tenderness/reduced, painful neck movements
  • Headaches
  • Symptoms can be delayed - (6-12 hours) post event.
74
Q

what is the treatment for whiplash?

A
  • Head and neck straight initially
  • Early mobilisation
  • Sleep with rolled towel in neck crease
  • Analgesics
75
Q

what is carpal tunnel syndrome?

A
  • Commonest cause of hand pain
  • Fluid retention
  • Symptom of RA
  • Numbness & tingling
  • Sense of swelling
  • Wrist splint at night
  • Corticosteroid injection
  • surgery
76
Q

what are leg cramps?

A

‘a spasmodic, painful, involuntary contraction of skeletal muscle’
* Common cause of leg pain

77
Q

who are leg cramps common in?

A
  • Muscle cramps are common in children, especially at night.
  • Common in the elderly
78
Q

what metabolic disturbances are leg cramps associated with?

A
  • Hyponatraemia (acute or chronic diarrhoea/
    Excessive heat and sweating causing Na+ depletion)
  • Hypokalaemia and hyperkalaemia
  • Hypocalcaemia (Hypothyroidism/ Hyperthyroidism)
  • Hypomagnesaemia
  • Hypoglycaemia
79
Q

what drugs can cause cramps?

A
  • Salbutamol and terbutaline (hypokalaemia)
  • Raloxifene
  • Opiate withdrawal
  • Diuretics cause electrolyte loss
  • Nifedipine
  • Phenothiazines
  • Penicillamine
  • Nicotinic acid
  • Statins (myopathy
80
Q

how do you manage cramps?

A
  • Review drugs - eg, use of diuretics and electrolyte imbalance.
  • The severity of symptoms/impact on sleep, mood, and QOL will determine whether treatment is required
  • Passive stretching and massage of affected muscle
  • Using a pillow to raise the feet through the night, or raising the foot of the bed may help to prevent attacks in some people.
  • The value of massage, over and above sychological benefit, is also questionable
81
Q

why is quinine sulphate not recommended for cramps?

A
  • Extensive SE profile
82
Q

when would you refer pain?

A
  • Severe Arthritis
  • Back pain associated with abnormal urination
  • Back pain radiating to leg
  • Suspected fracture
  • Head injury
  • Treatment failure
  • Suspected Adverse Drug Reaction
83
Q

what is insomnia and what are the risk factors?

A

“complaint of poor quality or inadequate sleep”
Risk Factors
* female
* divorced, widowed, separated
* lower socio-economic status
* increased age

84
Q

what are the classifications of sleep disorders?

A
  1. Transient (days)
  2. Short-term (up
    to 3 weeks)
  3. Chronic (>3
    weeks)….Always
    refer
85
Q

what are the causes of sleep disorders- 5PS?

A
  • physical
  • physiological
  • psychological
  • psychiatric
  • pharmacological
86
Q

what are the different types of sleep problems?

A
  1. difficulty falling asleep (sleep latency insomnia)
  2. difficulty in staying asleep
    - multiple waking through night
    - early morning waking
  3. poor quality sleep -day time drowsiness
    -inability to concentrate
87
Q

what are the treatment options for insomnia?

A
  • Non-pharmacological - relaxation techniques
  • sleep hygiene measures
  • OTC remedies - sedative antihistamines
  • complementary therapies
  • Prescribed hypnotics
88
Q

what are some relaxation techniques for insomnia?

A
  • deal with physical
    tension
  • deal with worry
  • deal with difficult
    situations
89
Q

what are some sleep hygeine measures for insomnia?

A
  • keep sleep diary
  • light exercise if early evening
  • wind down during evening
  • avoid caffeine, meals, alcohol close to bed time
  • go to bed only when tired
  • Relax/temp of bedroom
  • get up at same time every morning
90
Q

how would you counsel someone of antihistamines for insomnia?

A
  • diphenhydramine, promethazine
  • 20-30 mins before bedtime
  • not longer than 14 consecutive nights
  • side effects - anticholinergic, hang over effect
  • contraindications - prostatic hypertrophy, closed
    angle glaucoma, pregnancy & breast feeding
91
Q

what is the advice surrounding prescribed hypnotics for insomnia?

A
  • lowest dose
  • short course
  • withdraw gradually
  • benzodiazepines e.g nitrazepam, temazepam
  • zopiclone, zolpidem, zaleplon
  • chloral hydrate
  • chlomethiazole
92
Q

what are the counselling points surrounding hypnotics?

A
  • SE- day time drowsiness, driving hazard, elderly
    prone to falls & injury
  • Dependence - even after short term use
  • Withdrawal - BNF guidelines
  • symptoms: include anxiety,
    insomnia, loss of appetite, headache,
    nausea & vomiting
93
Q

what is melatonin?

A

Produced by the body’s pineal gland during darkness and is thought to regulate sleep
* Levels are lower in the elderly
* Supplementation can raise levels and aid restoration of sleep pattern

94
Q

who is melatonin licensed for?

A

Is available on prescription (but is only licensed for
patients aged 55+.)

95
Q

when would you refer someone for insomnia?

A
  • Suspected depression
  • Chronic problem
  • Age under 16 year

MO1 (50 decks)

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