When to call MD for > 3 months
Rectal temp > 104 or equivilant
Ibuprofen PEDIATRIC OTC Dose
7.5mg /kg / dose
to
MAX 30mg/kg/day
Digital Thermometers
GENERALLY THE BEST CHOICE
- 10-60 seconds for a reaing
- Can be used for Oral / Rectal / Axillary
-
Use Watersoluble LUBRICATION for rectal
- not vaseline = too thick
Naproxen Dosing
220mg q8-12 hours
first dose can be 220 or 440
MAX DOSE = 660mg/day
Glucosamine + Chondroitin indications
Indicated to manage pain in Osteoarthritis
for moderate to severe pain
- not too much for mild pain*
- no evidence for effectiveness in RA*
Osteo Bi-flex
- Glucosamine + Chondroitin
- MSM + Bosweilla serrata extract
- Vitamins + Herbs + Melatonin
NSAID Patient Counseling
- Avoid other NSAIDS + ASA** **+ Alcohol
- Take w/ food or milk
- minimum full glass of water
- Notify MD if:
- weight gain / edema / rash
- signs of bleeding
-
Do not take for >10 days for PAIN
- >3 days for fever w/o talking to your doctor
Choosing Ibuprofen vs APAP
Ibuprofen has longer duration of action
–> can use overnight / less dosing
BUT - Ibu has side effects including GI distress
Can you use Chondroitin / Glucosamine if pregnant?
NO
Also avoid in Kids
Oral Fever Temperature
> 99.5
Temporal Fever Temperature
for 0-2 months
>100.7
Do not take NSAIDS for ___ days
>10 days for PAIN
>3 days for FEVER w/o talking to MD
Advantage of NAPROXEN > other NSAIDS (ibuprofen)
Longer duration of Action
Up to 12 hours
Can take less frequently
but no anti-pyretic effect
Acetaminophen Max Daily Dosage
FDA < 4 Grams a day
Tylenol botles say < 3 grams per day for extra strength
Regular < 3250mg/day
How long can an adult use APAP?
<10 days for PAIN
<3 days for FEVER
Symptoms that EXCLUDE self-treatment
“see doctor”
- Spots / Rash
-
CANT DRINK FLUIDS
- refuses fluids / vomiting
- Fever >3 days w or w/o treatment
- Diarrhea
- Stiff neck
- History of Siezures
NSAID Increased risk of adverse effects
- >60 yrs old
- Taking oral steroids / warfarin / diuretics
- ASA sensitivity
- >3 alcoholic drinks every day while using product
- History of:
- bleeding problems
- stomach problems like heartburn or ulcers
- CHF / High BP / Heart Disease / Kidney Disease
Heart & Stroke Warning for NSAIDS
EXCEPT FOR ASPIRIN (salicylate)
NSAIDS increase risk of heart attack / failure / stroke
patients with risk for CV disease should AVOID NSAIDS
use lowest dose & shortest durations
When to use oral antipyretics for ADULTS / Older Children?
Oral temp > 101
and/or fever is ACCOMPANIED by DISCOMFORT
Glucosamine
500mg TID
VERY SLOW ONSET OF ACTION
compared to NSAIDS, takes up to 4-6 months for FULL effects
Appears to be safe short-term
Beware of SHELLFISH ALLERGIES
diabetic patients should monitor glucose-amino sugar
Axillary Temperature Measurement
- Inaccurate due to environmental temperatures and physiologic factors
- Armpit
- >99.3
- Fever may shunt blood AWAY from skin, so can be NORMAL when fever is present
What to recommend if patient has history of GI upset with ASA or IBU?
Acetaminophen
Enteric Coated Salicylate (if anti-inflammatory needed)
Asperin indications
Analgesic (equivilant to APAP)
Antipyretic (equivilant to APAP)
Anti-inflammatory
Ibuprofen Pediatric Safety
5-10mg/kg/dose
Boston Uni Fever Study
Looked at GI bleeding / renal failure / anyphylaxis / REYE’s
No Difference in risk for SERIOUS adverse effects
Buffered ASA
Alka-Seltzer
- No REAL evidence that they are better or faster
- May DECREASE GI UPSET and local Gastric damage
- pH may be INCREASED by antacids
- increase dissolution + absorption
-
Only rec if patient can NOT swallow tablets
- avoid in patients w/ High BP & CHF
- Sodium restricted = HIGH SODIUM LOAD
Temporal Fever Temperature
>4 y/o
>100.1
Glass Thermometers
- Mercury w/ scale
- AVOID GLASS, can break in rectum
- Oral = 4 min
-
Rectal = 3 minutes
- negative is HOW LONG it takes to get reading
-
Ibuprofen Infant Dose
for 6 mo-23mo
2x more concentrated than Childrens
50mg/1.25ml vs 100mg/5ml
How long can Children use APAP?
<5 Days for pain
<3 days for FEVER w/o MD advice
Tympanic Fever Temperature
>100
Temporal Fever Temperature
for 3-47 months
>100.3
ASA (salicylate) Contraindications
DO NOT TAKE ASA IF:
- Do not take ASA if:
- PUD / GI bleeding / Hemophilia
-
Gout
- <2 grams per day can increase URIC ACID levels
- ASTHMA
- ASA hypersensitivty
- PREGNANCY / BREASTFEEDING
-
KIDS / TEENS W/ VIRAL INFECTIONS
- -> Reye’s syndrome
ASA Suppositories
for patients who are Vomitting or Can’t Swallow
APAP Drug Interactions
Generally no significant interactions
Can still increase risk of Anticoag Effects (monitor INR carefully)
Still Preferred analgesic for patients on blood thinners
Rectal temperature measuring
- MOST ACCURATE MEASURE OF CORE TEMP
- <1 inch from rectum
- Preferred for <3 mo
- Core temperature is HIGHER vs oral
- >100.4 vs >99.5
Reye’s Syndrome
- Acute Nerological Disorder
- Vomiting / CNS Dmg / hepatic injury / hypoglycemia
-
Virus + ASA ingestion in Children
- or even a history of RECENT viral illness
Enteric Coated ASA
Bayer / Ecotrin
-
May prevent Gastric distress
- dissolution is in GI instead of stomach
-
Delayed Onset of Action
- takes longer to work, indicated for Long term treatment
- DO NOT TAKE W/
- Antiacids / PPI / H2 agonist
- -> increase pH, NEGATES enteric coating
- Antiacids / PPI / H2 agonist
Tympanic Thermometers
-
NOT Recommended for Children <6 months
- ear canals are NOT developed
- Ear wax / infections can affect reading
Caffeine Patient Counseling
- Dose = About as much as a CUP OF COFFEE
- D/C if:
- fast pulse
- dizziness
- Pounding heartbeat
- Avoid if taking medications that contain caffeine:
- cns stimulants
- MAO inhibitors
- HTN / PUD can be aggrevated
APAP Side Effects
Steven Johnson Syndrome
watch for SKIN REACTIONS
blisters / rash / reddening
see doctor right away
Motrin (NSAID) Pediatric Dosing
There is dosing for >6mo children
12-17lbs / 6-11 mos = 1.25mL
18-23lbs / 12-23 mos = 1.875mL
ASA (salicylate) Risk Factors
-
GI risk factors
- >60 years old
- h/o of PUD = ulcer disease
- Gastric ulceration
- taking blood thinner or Steroid
- alcoholic liver disease
What duration should you exclude SELF CARE for pain?
Adults > 10 days
Children > 5 days
go see a doctor
Rectal Fever Temperature
>100.4
OTC NSAIDS:
Ibuprofen / Naproxen
Analgesic
Anti inflammatory
Anti-pyretic
Naproxen is not used for anti-pyretic
Can APAP be used during pregnancy / breastfeeding?
YES
used SPARINGLY during either
Anacin
Aspirin 400mg
Caffeine 32mg
What age of children are rectal assessment MOST accurate?
< 3 months old!
Children / Adults -> oral or tympanic can be appropriate if proper
Axillary Fever Temperature
>99.3
ASA (salicylate) Side Effects
-
Hematologic
- Bleeding
-
Local GI Damage
-
systemic effect from prostaglandin inhibition
- -> can effect other parts of body not just GI
- Ulceration
-
systemic effect from prostaglandin inhibition
Tympanic Temperature measurement
- Infrared technolagy to measure blood supply inside
- Ear Canal
-
5 Second measurement
- >100
-
Can be affected by ambient temperature
- wait 15 minutes before measuring if child was Outside
APAP and ALCOHOL Counseling
Issue is more with Chronic Alcoholics:
<4g per day for <2 days is still okay
Magnesium Salicylate
Doans / Percogesic
650-100mg Q4-6 hours
Approved OTC for MINOR ACHES & PAINS
associated w/ backache + Muscular aches
- Lower incidense of GI upset*
- can cause magnesium toxicity in pts w/ renal insufficiency*
Two Types of ASA Allergy/Intolerance
-
CUTANEOUS
-
uticarial / angioedema
- -> RASH / Skin issues
-
uticarial / angioedema
-
RESPIRATORY
- bronchospasm / laryngospasm / rhinorrea
- 10% of asthma patients have ASA sensitivity
- Shortness of breath
- Usually occurs within 3 hours of ASA ingestion
When to call MD for Children < 3mo
>100.4 RECTAL
How long to wait for fevers for children < 2 years?
>24 hours call doctor for <2yearsold
Oral Temperature Measurement
-
>99.5
- ~ 1 degree less than rectal
- Wait 20-30 minutes after drinking or eating
- Best temp below tongue as far back as possible
Midol (teen)
APAP 500mg
Pamabrom (diuretic) 25mg
no caffeine
NSAIDS & Pregnancy
DO NOT USE IN 3rd TRIMESTER
Compatible w/ Breast Feeding
First line is APAP
Pacifier Thermometer
- Useful for infants who Cannot hold probe under tongue
-
3-8 minute reading
- wait 20-30 min after drinking or eating
OTC NSAID (naproxen) SIDE EFFECTS
- GI intolerance
- Hemtalogic
- -> inhibit platelet function
-
CNS
- dizziness / headache / drowsy / nervousness
-
Renal
- renal function decrease
- NA/water retention
- Dehydration
Acetaminophen Infant dose
IS NOW THE SAME AS CHILDRENS
160/5ml
but drops might still be at HOME so ASK!
Ibuprofen Dose / Max per day
Max 1.2 grams per day
FOR OTC
200-400 mg q46
ASA (salicylate) Patient Counseling
- Take w/ food or milk
- Take w/ full glass of water
- Avoid LYING DOWN 15-30 min after taking
- Do not use ASA if it has a strong vinegar odor
- do not use ASA if drinking >3 alcoholic drinks / day
- notify provider if Tinnitus or Signs of bleeding
- if difficulty in swallowing > use film coated tabs
Ibuprofen vs APA
in antipyretic / analgesic efficacy in CHILDREN
APAP 15mg/kg/dose
comparible in efficacy to
Ibuprofen 10mg/kg/dose
Percogesic
APAP 325mg
Diphenhydramine 12.5mg
Do NOT use Naproxen if…?
in 3rd Trimester of pregnancy
MSM
Used for chronic pain of OSTEOARTHRITIS
use for <3months
- No data support MSM in creams or lotions (poorly absorbed)*
- little date support Oral MSM*
ASA DOSING
Adults: 2-3 (325mg) tablets q-4-6 hours
- RARELY USED IN CHILDREN*
- NEVER IN OTC SETTING*
- typically dosed by age/weight*
Infrared Thermometer
- Infrared -> heat from ARTERIAL blood supply
- Tympanic Artery / Temporal Artery
- tympanic = in ear
- temporal = temples
- <5 seconds
- dirty lens / bad placement –> innacurate reading
Excedrin Migraine
ASA 250mg
APAP 250mg
Caffeine 65mg
Pediatric APAP Dose
10-15 mg/kg/dose
<5 doses per day
no doses for children <2 y/o on label
Temporal Thermometer
- Forehead Scan
- Conflicting results -> RECTAL themometer still gold standard
- Let thermometer adjust to room temp for >30 minutes
- Remain in contact with skin at ALL times
Chondroitin
Some commercial products made from cow trachea
Similar to Heparin
be cautious w/ pts on ASA or warfarin, check INR
•400mg TID
with food if nausea / GI upset
Midol Complete
APAP 500mg
Caffeine 60mg
Pyrilamine (antihistamine) 15mg
PAIN SCORE
What is an EX-ST
Mild = 1-3
Moderate = 4-6
Severe = 7-10
EXST if > 6
Questions to ask for PAIN
WHERE is the pain?
Does it RADIATE?
Is it Constant or Sporadic?
What is your PAIN SCORE?
(>6 =exst)
What other meds have you tried?
how much / how often
How LONG?
>10days for adults / >5 days children = EXST
Current medications / conditions
gout / ulcers / allergies / bleeding issues / GI UPSET
ALCOHOL / pregnant/BF
Questions to ask for FEVER
HOW did yo take the temprature?
What symptoms are present & how long?
What medications have you tried / what dose?
Allergies?
Is the patient drinking fluids?
Other disease states = SEIZURES / HIV / CANCER