Drug Quizz #2 OTC

Question 1

Dextromethorphan

Answer 1

Trade Name: Delsym
Robitussin
Triaminic

Class: Cough Suppresant

Self-Care indications: Cough

Self-Care Monitoring Parameters:
Relief from cough. Seek medical attention if cough does not improve in 7 d, or if severe skin rash, headache, fever, or flank pain occurs.

Key Patient Counseling Points:
Shake extended release suspension well before use. Advise patients to get adequate rest and hydration. Take with plenty of noncaffeinated liquids. Only use the measuring cup provided with individual product.

Clinical Pearls:
Multiple products available, often in combination with other active ingredients. Dextromethorphan can cause varying degrees of euphoria, hallucinations (usually at doses of 100-400 mg), temporary psychosis, alterations in consciousness, and out-of-body experiences (usually at doses >600 mg), which makes it a potential drug of abuse. Many pharmacies voluntarily only allow purchases by adults >18 y of age to reduce abuse. Not for persistent or chronic cough or for self-care in children <4 y of age, serotonin syndrome possible with concomitant use of proserotonergic drugs.

Question 2

Dimenhydrinate

Answer 2

Trade Name: Dramamine Original Formula

Class: Antihistamine
Antiemetic

Self-Care indications: Motion sickness, prevention and treatment

Self-Care Monitoring Parameters:
Improvement in nausea or vertigo symptoms. Seek medical attention for signs of severe CNS toxicity.

Key Patient Counseling Points:
May cause drowsiness and impair physical or mental abilities; avoid driving and operating machinery. Avoid alcohol and other CNS depressants. Avoid use in elderly patients due to risk of anticholinergic effects. Tablets are scored for pediatric dosing.

Clinical Pearls:
Dimenhydrinate is available OTC in many different products, and some brand name products with the same name contain meclizine instead of dimenhydrinate. Read product labeling carefully to confirm active ingredient. For best effect, take 30-60 min before, and continuously during travel or other activities producing nausea; product is more effective as prevention than for treatment. Parenteral formulation is available for IM or IV administration by HCP if symptoms are severe.

Question 3

Diphenhydramine Topical

Answer 3

Trade Name: Benadryl

Class: Antihistamine

Self-Care indications: Pruritus

Self-Care Monitoring Parameters:
Improvement in urticaria symptoms.

Key Patient Counseling Points:
Unlikely to cause any systemic adverse effects unless applied to large area of skin; advise patients to apply sparingly. Avoid other diphenhydramine-containing products (including oral). Avoid contact with eyes and do not ingest by mouth. Do not wrap or occlude treated area. Do not use for >7 d.

Clinical Pearls:
Used for temporary relief of pain or itching due to insect bites, sunburn, scrapes, minor skin irritations, minor burns, or rash due to poison ivy, oak, or sumac. Oral and parenteral formulations are also available. Topical products should not be used on chicken pox or measles. Topical hydrocortisone, calamine lotion, moisturizers, or cool compresses for minor skin reactions are usually preferred as use of diphenhydramine topically is known to cause sensitization.

Question 4

Docosanol

Answer 4

Trade Name: Abreva

Class: Topical Antiviral

Self-Care indications: Herpes simplex

Self-Monitoring Parameters:
Healing of cold sore, reduction in size and duration of lesion. If used at first symptoms, may prevent visible lesion from forming. Adverse effects are rare and not serious. Seek medical attention if severe local burning or hypersensitivity reaction occurs or worsens, or if lesion is not healed after 10 d of treatment.

Key Patient Counseling Points:
Counsel patient to keep infected area clean, wash hands before and after use, and do not share products. Initiate therapy at the first sign of cold sore and continue until lesion is completely healed; early treatment is more effective. Do not use inside mouth or on lesions anywhere on the body except for lips and around mouth (not for use in genital areas); avoid eyes. Use 5 times daily for maximum effectiveness. Monitor lesion for signs of secondary bacterial infection.

Clinical Pearls:
Prescription antivirals (eg, acyclovir, oral and topical) available with very clear evidence of efficacy; less evidence supports efficacy of docosanol, but no comparative data exist. Docosanol may be preferred in patients intolerant to oral antivirals or who have mild and infrequent cold sores. Concealing patch, Abreva Conceal, is nonmedicated and alternates between not adhering to skin and falling off or adhering so well that skin comes off when removed.

Question 5

Docusate

Answer 5

Trade Name: Colace

Class: Stool Softener

Self-Care indications: Constipation

Self-Monitoring Parameters:
Relief from occasional constipation and discomfort/straining caused by hard stools. Cramps, diarrhea, and abdominal pain may occur; if severe, seek medical attention.

Key Patient Counseling Points:
Lifestyle interventions (increasing exercise, intake of water and dietary fiber) generally first-line management of constipation. May require several days of treatment before stool softening is noticeable. Discontinue and contact an HCP if rectal bleeding occurs or bowel movement fails to occur after appropriate use. Do not use with products containing mineral oil.

Clinical Pearls:
Does not act to stimulate or otherwise cause defecation but reduces straining during defecation. Less effective in dehydrated patients. Often combined with other laxatives (eg, Peri-Colace and generics with senna). Calcium and sodium salts are available and are clinically indistinguishable. Onset may occur within 12 h but requires 72 h of treatment for full effect. PEG 3350 is the laxative of choice for patients with constipation from opiates. Docusate is the laxative of choice in patients who should avoid straining after surgery, AMI, etc.

Question 6

Doxylamine

Answer 6

Trade Name: Unisom Sleep Tabs

Class: H1 Antagonist

Self-Care indications: Sleep

Self-Care Monitoring Parameters:
Improvement in insomnia. Seek medical attention for signs of severe CNS toxicity.

Key Patient Counseling Points:
Administer 30 min before going to bed. Avoid alcohol and other CNS depressants. May cause drowsiness and impair physical or mental abilities; avoid driving and operating machinery. Avoid use in elderly patients due to risk of anticholinergic effects. Good sleep hygiene (including avoidance of caffeine, alcohol, and nicotine) should be recommended in addition to self-management of insomnia. Do not use for >2 wk without discussing with an HCP.

Clinical Pearls:
Several manufacturers market products with the same name, but with different active ingredients; some Unisom products contain diphenhydramine instead of doxylamine. Read product labeling carefully to confirm active ingredient. Doxylamine in combination with pyridoxine is recommended for the treatment of nausea and vomiting in pregnancy. Diphenhydramine is generally considered a more effective OTC treatment for insomnia.

Question 7

Diphenhydramine Systemic

Answer 7

Trade Name: Benadryl
ZzzQuil

Class: Antihistamine
Antitussive
Antiemetic
Hypnotic

Self-Care indications: Allergic reactions
Cough
Sleep
Motion sickness

Self-Care Monitoring Parameters:
Improvement in allergic symptoms, cough, nausea, or insomnia. Seek medical attention for signs of severe CNS toxicity.

Key Patient Counseling Points:
May cause drowsiness and impair physical or mental abilities; avoid driving and operating machinery. Avoid alcohol, other CNS depressants, and other diphenhydramine-containing products (including topical). Avoid use in elderly patients due to risk of anticholinergic effects. May cause paradoxical excitability in children. If used for sleep, good sleep hygiene (including avoidance of caffeine, alcohol, nicotine) should be recommended. ZzzQuil packing resembles Nyquil, but active ingredients differ. Do not use for >2 wk without discussing with an HCP.

Clinical Pearls:
Diphenhydramine is available in a wide range of OTC and prescription products, alone and in combination with other cough and cold products. Avoid confusion as 50 mg/30 mL concentration is only indicated for insomnia. When used for motion sickness, initiate dosing 30 min prior to departure or activity that may cause nausea. Should be used only occasionally for sleep; avoid chronic use. When used for sleep, recommend intermittent use for 3 d with an “off” night to evaluate ability to sleep. Approved ages of treatment will vary; consult product-specific labeling. Not recommended for self-care for children <6 y of age for any indication, but may be used in children 2-6 y of age if advised by an HCP. Other indications include treatment of anaphylaxis and parkinsonism under care of HCP. Also available in parenteral formulation.

Question 8

Echinacea

Answer 8

Trade Name: Coneflower
Echinafresh

Class: Immune Stimulant

Self-Care indications: Upper respiratory tract infections

Self-Monitoring Parameters:
Relief from cold symptoms. Seek medical attention if symptoms are severe or no improvement after 7 d, or if severe hypersensitivity occurs.

Key Patient Counseling Points:
Advise rest and plenty of fluids. Initiate treatment at the first sign of illness. Not recommended for use >10 d in otherwise healthy individuals.

Clinical Pearls:
A Cochrane review concludes there is little to no evidence to suggest that Echinacea is effective for decreasing the incidence or duration of colds. Some evidence exists for the efficacy of zinc, which may be a preferred alternative. Not for use in children, no evidence of efficacy, but evidence of an increased risk of rash. Avoid use in patients with ragweed allergy as cross-sensitivity is possible. Avoid use during pregnancy due to lack of safety data. Avoid use in women trying to get pregnant as Echinacea may decrease fertility. Multiple adulterants have been documented in supplements; elevated lead levels have been reported with long-term use of Echinacea.

Question 9

Esomeprazole

Answer 9

Trade Name: Nexium

Class: Proton Pump Inhibitor

Self-Care indications: Treatment of frequent heartburn

Self-Monitoring Parameters:
Resolution of GI discomfort (complete resolution may not be noted for up to 4 d). Seek medical attention for new bone pain, severe skin rash, severe diarrhea, abdominal pain, or worsening of symptoms.

Key Patient Counseling Points:
Avoid triggers, including alcohol, caffeine, and smoking. Avoid high-fat, acidic or spicy foods, and large meals. Maintain healthy weight and avoid tight-fitting clothes. Elevate the head by using blocks under bed legs or foam pillow wedge; do not stack traditional pillows. May take with food or antacids if needed. Best taken 30-60 min before breakfast with full glass of water or before the largest meal of the day q24h for maximum effect. Capsules may be opened and contents mixed with 1 tablespoon of applesauce. Other PPIs and H2-antagonists are available OTC; warn patients not to take multiple products concurrently to avoid additive risk of adverse effects. Note OTC dose is half of prescription dose for patients who lack insurance coverage. Do not take for >14 d but may repeat 14 d course every 4 mo. Refer to an HCP if symptoms recur before 4 mo. May require 1-4 d for full effect.

Clinical Pearls:
All patients should attempt lifestyle modifications. Antacids are first-line therapy for moderate and infrequent heartburn. H2-antagonists are first-line therapy for moderate heartburn. PPIs can be used if H2-antagonists are ineffective. Long-term use of PPIs can lead to bone fractures, magnesium, and vitamin B12 deficiencies. CYP2C19 poor metabolizer frequency varies by ethnicity, ranging between 3-20%; if known, consider 20 mg dose. Esomeprazole magnesium dihydrate 22 mg is equivalent to 20 mg of esomeprazole base.

Question 10

Evening Primrose Oil

Answer 10

Trade Name: Suncups
Sun drops
Efamol

Class: Hormonal Modulator

Self-Care indications: Eczema

Self-Monitoring Parameters:
Relief from eczema symptoms. Seek medical attention if symptoms are severe or no improvement is seen after 8 wk, or if seizures or increased bleeding occur.

Key Patient Counseling Points;
Advise patient to avoid triggers by avoiding heat, perspiration, dry skin, stress, and anxiety. Low-water-content creams (Eucerin) and ointments (Vaseline and Aquaphor) are recommended for all patients. First generation antihistamines may be used to control itching and sleep disturbances secondary to itching. Topical corticosteroids are the mainstay of therapy for mild disease. If taking evening primrose oil, avoid alcohol or NSAIDs as the combination may increase the risk of bleeding.

Clinical Pearls;
A recent Cochrane review suggests no difference in efficacy between placebo and evening primrose oil for the treatment of eczema. Adverse effects were more common in the evening primrose group, although they were usually mild GI distress. Evening primrose oil is also used for breast pain, menstrual symptoms, diabetic nephropathy, and rheumatoid arthritis, despite the lack of evidence as to its efficacy. Current evidence does not support the use of primrose oil for any health condition.

Question 11

Famotidine

Answer 11

Trade Name: Pepcid

Class: Histamine H2 Antagonist

Self-Care indications: Indigestion and heartburn

Self-Monitoring Parameters:
Resolution of GI discomfort. Seek medical attention for severe blistering skin rash, chest pain, irregular heartbeat, or seizures.

Key Patient Counseling Points:
Avoid triggers, including alcohol, caffeine, and smoking. Avoid high-fat, acidic or spicy foods, and large meals. Maintain healthy weight and avoid tight-fitting clothes. Elevate the head by using blocks under bed legs or foam pillow wedge; do not stack traditional pillows. Take 10-60 min before meals or at bedtime. May take with food or antacids if needed. Other PPI and H2-antagonists available OTC; warn patients not to take multiple products concurrently to avoid additive risk of adverse effects. Note combination chewable tablet contains multiple antacids in addition to H2-antagonist. Tablets should not be chewed; chewable tablets should not be swallowed whole.

Clinical Pearls:
All patients should attempt lifestyle modifications including weight loss. Antacids are first-line therapy for moderate and infrequent heartburn. H2-antagonists are first-line therapy for moderate heartburn

Question 12

Ferrous Sulfate

Answer 12

Trade Name: Feosol
For-in-sol

Class: Mineral Supplement

Self-Care indications: Anemia, iron deficiency treatment and prevention

Self-Care Monitoring Parameters:
Improvement in nutritional status, resolution of symptoms of anemia (fatigue, shortness of breath, exercise intolerance). Seek medical attention if severe GI distress occurs.

Key Patient Counseling Points:
May require several weeks for maximum effect. Stools will turn black. Take on empty stomach, if possible, to maximize absorption. May take with food if significant nausea occurs. Avoid calcium-containing food and antacids as this decreases iron absorption. Keep out of reach of children; accidental ingestion may be fatal. Do not crush or chew any formulations.

Clinical Pearls:
GI distress is associated with amount of elemental iron dose absorbed; decreasing iron dose will decrease GI distress. Sustained-release products may reduce adverse effects, but only as result of lower iron absorption as iron is absorbed proximal to the jejunum. Vitamin C enhances absorption, but avoid orange juice containing calcium. Various prescription and OTC products, as well as other iron salts that contain different amounts of elemental iron, are available; confirm appropriate elemental iron for dosing purposes. Contraindicated in patients with iron overload, such as those with hereditary hemochromatosis or transfusion-dependent anemias.

Question 13

Fexofenadine

Answer 13

Trade Name: Allegra Allergy

Class: Antihistamine

Self-Care indications: Upper respiratory allergies
Seasonal/perennial allergic rhinitis

Self-Monitoring Parameters:
Improvement in rhinitis symptoms. Seek medical attention for signs of severe fatigue, fast or irregular heartbeat, rash, or shortness of breath.

Key Patient Counseling Points:
Avoid allergic triggers. Use scheduled doses instead of prn. Symptoms should improve after 3-4 d but may require 2-4 wk for full benefit. Use provided measuring device with oral suspension. Patients should avoid activities requiring mental alertness or coordination until drug effects are known as drug may cause dizziness or sedative effects. Avoid alcohol.

Clinical Pearls:
Product is available OTC in several dosage forms. Oral disintegrating tablet not for use in children <6 y of age. Glucocorticoid nasal sprays are considered first line therapy for allergic rhinitis; however, many patients prefer oral antihistamines for management to avoid intranasal medication administration. Orange, grapefruit, and apple juice can decrease effectiveness; separate at least 4 h. Oral antihistamines are considered first-line therapy for urticaria under care of an HCP. Topical product of the same name contains diphenhydramine as the active ingredient. Read product labeling carefully to confirm active ingredient. Available in extended-release combination with pseudoephedrine (12 and 24 h)

Question 14

Flaxseed Oil

Answer 14

Trade Name: Linux usitatissimum
Omega 3

Class: Antihyperlipidemic

Self-care indications: Lipid lowering

Self-Care Monitoring Parameters:
Home cholesterol monitoring tests are available and are generally accurate, but they only evaluate total cholesterol, HDL, and triglycerides, and do not replace cholesterol panels performed by HCPs. Seek medical attention if severe rash, chest pain, heart palpitations, or shortness of breath occur.

Key Patient Counseling Points:
Swallow the whole capsule. Take with food and a full glass of water. Do not eat raw flaxseeds.

Clinical Pearls:
Flaxseed is a plant source of Omega 3, fish oil is another well-studied source of Omega 3 and effective in lowering triglycerides. Small clinical trials suggest that flaxseed oil reduces LDL and TG. Further study is needed before flaxseed oil can be routinely recommended. Flaxseed contains fiber that is generally used to treat constipation. Flaxseed is being studied as a treatment for cancer, diabetes, dry skin, constipation, and various other conditions; however, there is no conclusive evidence of efficacy.

Question 15

Fluticasone Nasal

Answer 15

Trade Name: Flonase

Class: Intranasal Adrenal Glucocorticosteroid

Self-Care indications: Upper respiratory allergies

Self-Monitoring Parameters:
Improvement in nasal rhinitis symptoms. Seek medical attention for signs of severe fatigue, fast or irregular heartbeat, rash, or shortness of breath. While only small amounts of fluticasone reach systemic circulation, bone mineral density and growth and rate of development in children should be monitored. Routine ophthalmologic examinations should be performed. Monitor for signs and symptoms of adrenal suppression and infection.

Key Patient Counseling Points:
Avoid allergic triggers. Children ≤12 y of age should be supervised by an adult. For administration, bottle must be primed and shaken well prior to first use or if it has not been used in >14 d; avoid spraying in face. Patients should clear nasal passages by blowing nose prior to use. Press against outside of 1 nostril to close off. Employ the “nose to the toes” technique of tilting the head slightly downward to avoid overspray into the esophagus while inhaling to avoid bad taste. Aiming the spray away from the nasal septum toward the ears slightly inserted into the nostril can help minimize irritation and nosebleeds. Medication may take 24-72 h to take full effect. Sniff gently as you pump the bottle. Do not blow nose for at least 15 min after use. Brief stinging or sneezing may occur immediately after use. Wipe nozzle with tissue and replace cap. Nozzle only can be cleaned with tap water if pump does not spray properly; follow included instructions. Should not be shared to treat multiple people to reduce spread of infection.

Clinical Pearls:
Other fluticasone nasal products, as well as oral inhalation and topical dosage forms of fluticasone are also available by prescription for treatment of other allergic disorders. Twice-daily dosing was not more effective than once-daily dosing. While oral antihistamines (either OTC or prescription) remain the mainstay for treatment of rhinitis, nasal steroids are a recommended option if symptoms are severe, unresolved with oral antihistamines, or if oral antihistamines cause undesirable adverse effects. Do not use for common cold.

Question 16

Garlic

Answer 16

Trade Name: Allium
Alho

Class: Antihyperlipidemic

Self-Care indications: Hyperlipidemia
Hypertension

Self-Care Monitoring Parameters:
Home cholesterol monitoring tests are available and are generally accurate, but they only evaluate total cholesterol, HDL, and triglycerides, and do not replace cholesterol panels performed by HCPs. Lipid levels and blood pressure should be monitored carefully as treatment with garlic is small and not as effective as conventional medications, and patients using garlic without other treatments are unlikely to achieve therapeutic goals. Seek medical attention if severe rash, chest pain, heart palpitations, or shortness of breath occur.

Key Patient Counseling Points:
May take with food or milk to reduce GI upset. Odorless formulations are available, although this may influence the efficacy of the garlic. Garlic may increase your risk of bleeding; discontinue 10 d prior to elective surgery.

Clinical Pearls:
A randomized, placebo-controlled trial compared 3 different garlic preparations (raw, powdered, and aged garlic extracts at a daily dose approximately equivalent to one 4 g clove) demonstrating no reduction in LDL. Garlic has also been studied for preventing cancer, reducing blood pressure, preventing colds and a variety of other indications with limited clinical success, and is generally not recommended. Most studies are of poor quality, as the odor of the supplement is unmistakable making it difficult to conduct trials with blinded controls.

Question 17

Guaifenesin

Answer 17

Trade Name: Mucinex

Class: Expectorant

Self-Care indications: Cough, due to minor throat and bronchial irritation

Self-Care Monitoring Parameters:
Relief from cough. Seek medical attention if cough worsens or does not improve in 7 d or if severe skin rash or flank pain occurs.

Key Patient Counseling Points:
Advise patients to get adequate rest and hydration. Take with plenty of noncaffeinated liquids. Tastes awful; do not chew or crush the extended-release formulations. Not for persistent cough or OTC use in children <2 y of age, ER formulation not for children <12 y of age.

Clinical Pearls:
According to a recent Cochrane review, there is little evidence to support the effectiveness of guaifenesin for relief from acute coughs in adults or children; however, there are few adverse effects, and it may be beneficial in some patients. Multiple combination products are available, including guaifenesin/codeine syrup that can be dispensed OTC by pharmacists in a majority of states; double-check for therapeutic duplication. Labeling of various OTC products list varying minimum age limits for this product, many manufacturers voluntarily relabeled products to state “do not use in children <4 years of age,” but data exist for dosing down to 2 y of age.

Question 18

Goldenseal

Answer 18

Trade Name: Berberine

Class: Anti-infective

Self-Care indications: Traveler’s diarrhea

Self-Monitoring Parameters:
Resolution of diarrhea. Seek medical attention if severe or bloody diarrhea, diarrhea persisting longer than 3 d.

Key Patient Counseling Points:
No significant research exists on goldenseal for traveler’s diarrhea has been published. Prevent traveler’s diarrhea with appropriate food choices. Water must be boiled or filtered to be safe to drink; tea, coffee, and other hot drinks are generally safe. Freezing does not kill bacteria. Drink bottled water; avoid ice. Use bottled water for tooth brushing. Avoid condiments that are on the table and used by multiple individuals, food served in steam tables, fruit salads, chicken salads, or lettuce salads. Fruit that can be peeled before eating is generally safe. Avoid undercooked meat and other proteins (eggs). If you observe meat stored or transported at room temperature as a general practice, avoid meat consumption. In most cases, antibiotics are brought on trip and started for acute treatment of traveler’s diarrhea and not used as prophylaxis. Avoid contact of goldenseal with mucous membranes.

Clinical Pearls:
Appropriate antibiotics, loperamide, and bismuth subsalicylate are commonly prescribed for traveler’s diarrhea. Goldenseal is best taken daily 7 d before travel, while traveling, and for 7 d after travel. Goldenseal is also being studied for hyperlipidemia, diabetes, infection, and cancer with some evidence for efficacy, although there are currently inadequate data to recommend it over standard treatments. Goldenseal has not been shown to reduce the duration or intensity of common cold or infection. Goldenseal reduces B vitamin absorption and patients with patients on CYP3A4/5 substrates should not take goldenseal. Multiple adulterants have been documented in supplements, specifically Chinese goldthread and Oregon grape have been found in goldenseal.

Question 19

Ginkgo Biloba

Answer 19

Trade Name: Tebonin
EGG 761

Class: Antioxidant

Self-Care indications: Dementia
Memory improvement
Tinnitus and vertigo
Peripheral vascular disease

Self-Monitoring Parameters:
Absence of dementia, improved memory. Seek medical attention if bleeding, seizures, or palpitations occur.

Key Patient Counseling Points:
Normal age-related changes usually cause minor difficulties in short-term memory and a slowed ability to learn and process information. These changes are usually mild and do not worsen greatly overtime in normal aging, nor should they interfere with a person’s day-to-day functioning. Discontinue prior to elective surgery and dental procedures to reduce the risk of bleeding. Consuming raw ginkgo seeds may be poisonous.

Clinical Pearls:
According to recent meta-analyses, there is no evidence that ginkgo has a clinically significant benefit for any disease including patients with peripheral arterial disease, tinnitus, dementia, or memory loss. Similarly, there is no significant evidence that ginkgo helps with memory improvement in otherwise healthy adults. Small, uncontrolled trials suggest that ginkgo may improve depression, sexual functioning, macular generation, and vertigo; however, large trials are required to demonstrate efficacy. Multiple adulterants have been documented in ginkgo supplements, specifically colchicine. Elevated lead levels have been reported with long-term use of ginkgo.

Question 20

Hydrogen Peroxide

Answer 20

Trade Name: Peroxyl

Class: Antiseptic

Self-Care indications: Topical wound irrigation
Recurrent aphthous ulcers

Self-Monitoring Parameters:
Healing of oral ulcers, reduction in infection risk in skin wounds. If any adverse effects occur, discontinue use and report concern to HCP.

Key Patient Counseling Points:
When used topically, solution should be dried before covering area with bandage. Patients should be advised not to swallow or instill product into body cavities that would prevent release of gas formed by hydrogen peroxide. Concentrated product is caustic and should not be used clinically for any purpose. Use “swish and spit” technique for oral ulcers. Patients with oral ulcers should be counseled on good oral hygiene, avoidance of irritants (foods, etc.), and if pain is present, on the use of topical analgesics. If oral ulcers persist for >7 d, seek medical attention.

Clinical Pearls:
For canker sores, use after meals. Patients can also make their own rinse by mixing equal parts of water and hydrogen peroxide 3% for oral use. Various formulations are also available for tooth whitening. Concentrated solution available OTC is used most often for bleaching hair. High-concentration topical solution (40%) is also available by prescription for seborrheic keratosis. Solution decomposes and loses effectiveness upon standing, upon repeated agitation, or when in contact with oxidizing or reducing substances. Provides little benefit over soapy water as an antiseptic for wounds. Has been used in diluted formulations to loosen earwax but is not FDA approved commercially for this purpose and can leave excess water in the ear canal

Question 21

Hydrocortisone Topical

Answer 21

Trade Name: Cortizone-10
Preparation-H

Class: Topical Corticosteroid

Self-Care indications: Pruritus

Self-Care Monitoring Parameters:
Improvement in clinical signs of skin disorder. Seek medical attention if severe skin irritation, symptoms worsen after administration, symptoms reoccur after treatment, or do not resolve in 7 d.

Key Patient Counseling Points:
Apply thin layer to affected area of skin. Skin should be clean and intact at site of application. Avoid contact with eyes and do not ingest by mouth. Avoid occlusive dressings or tight-fitting clothes over site of administration.

Clinical Pearls:
Large number of dosage preparations both by prescription and OTC are available; do not use multiple products. Application to large surface areas, broken skin, prolonged use, and occlusive dressings may increase risk of systemic absorption and toxicity; pediatric patients are more susceptible to systemic absorption. Not for use for self-care of diaper rash or in children <12 y of age for anal or genital itching. Preparation-H cream contains hydrocortisone, but preparation-H suppositories contain phenylephrine; important to verify active ingredients of various products before making treatment recommendations. First-line agent for minor skin irritations; preferred over topical antihistamines, which can lead to sensitization as well as superior efficacy. Potency varies based on hydrocortisone salt used in preparation and the type of vehicle used. Use may mask signs and symptoms of skin infection.

Question 22

Ibuprofen

Answer 22

Trade Names: Motrin
Advil

Class: NSAID

Self-Care indications: Fever, pain, headache, menstrual cramps, blackache, muscular aches, common cold and toothaches

Self-Monitoring Parameters:
Decreased pain, fever. If fever does not resolve in 3 d or pain in 10 d, seek medical attention. Seek medical attention if severe skin rash, black tarry stools, chest pains, yellowing of eyes or skin, change in urination occur. All pediatric formulations contain a sore throat warning accompanied by fever, headache, nausea, and vomiting, and should not be used >2 d or children <3 y of age without consulting an HCP.

Key Patient Counseling Points:
Take with food or milk to decrease GI upset. Always use the dose measuring device provided with ibuprofen solutions; note the difference in concentration for children (100 mg/5 mL) versus infants (50 mg/1.25 mL) to reduce pediatric dosing errors.

Clinical Pearls:
Elderly patients are at increased risk of GI ulceration. All NSAIDs are associated with an increased risk of adverse cardiovascular thrombotic events, including fatal MI, heart failure, and stroke. Use lowest effective dose for shortest possible duration; after observing initial response, adjust dose and frequency to meet individual patient’s needs. NSAIDs are also associated with renal adverse events, especially in patients with preexisting CKD, nephrotic syndrome, liver disease, and patients who are volume depleted. Various OTC ibuprofen products and combinations are available; caution patients not to duplicate dosing with multiple ibuprofen products.

Question 23

Ketoconazole Shampoo

Answer 23

Trade Name: Nizoral A-D

Class: Imidazole Antifungal

Self-Care indications: Dandruff

Self-Care Monitoring Parameters:
Resolution of dandruff. Improvement usually seen within 1-2 wk. Seek medical attention if severe skin irritation or rash occurs or if no improvement is seen in 2-4 wk.

Key Patient Counseling Points:
Avoid contact with eyes. Contact time with the skin is an important predictor of efficacy. Ensure application is to wet area and skin, and after adequate lather, shampoo should be left on skin for 3-5 min before rinsing.

Clinical Pearls:
More effective if used intermittently after initial course of therapy (weekly). Malassezia is fungi found on the skin of most humans and is thought to be a primary etiology of dandruff and other skin conditions, making topical antifungals the treatment of choice. Oral formulation (which has multiple drug-drug interactions) and topical cream, foam and gel, as well as increased strength of shampoo (2%) are also available by prescription.

Question 24

Ketotifen Ophthalmic

Answer 24

Trade Name: Zaditor
Alaway
Claritin Eye
Zyrtec Itchy Eye

Class: Antihistamine

Self-Care indications: Allergic conjunctivitis

Self-Monitoring Parameters:
Improvement symptoms of ocular rhinitis (itchy, watery eyes). Seek medical attention if symptoms not improved after 3 d, increased redness, or if changes in vision or eye pain occur.

Key Patient Counseling Points:
Ophthalmic use only. Do not use if solution is discolored or has particulates. After ketotifen use, soft contact lens wearers should wait at least 10 min before putting their lenses in. Do not contaminate dropper tip or solution when placing drops in eyes. Wash hands before use. To administer, tilt your head back, pull down the lower eyelid to make a pouch, and place 1-2 drops in corner of eye without touching the bottle tip to your eye; look downward and gently close your eyes and hold for 1-2 min.

Clinical Pearls:
Not appropriate for the treatment of contact lens-related irritation. Oral formulation is available outside the United States. Note most formulations contain the preservative benzalkonium (BAK) chloride, and if patients require preservative-free eye drops, consider alternative treatment for allergic conjunctivitis. Ophthalmic formulation may be a good alternative for older adults with suffering from allergic conjunctivitis at risk for higher anticholinergic burden from systemic antihistamines.

Question 25

Lactobacillus

Answer 25

Trade Name: Lactinex
Culturelle
Floranex
VSL #3

Class: Probiotic

Self-Care indications: Diarrheal illness’s
Irritable bowel syndrome

Self-Monitoring Parameters:
Improvement in symptoms of abdominal discomfort and/or diarrhea. Probiotics are generally well tolerated after the first few days of therapy.

Key Patient Counseling Points:
Gas and bloating is a common adverse effect at the start of treatment but generally diminishes over several days of treatment. Product should be stored in its original packaging to prevent loss of potency, and refrigeration of some products is required. Over time, potency of product within an individual package will decline, and patients may need to increase dose to maintain therapeutic effect. Various products may be crushed, chewed, or sprinkled into drinks or onto food including cereal; consult package labeling for administration techniques.

Clinical Pearls:
Data on use of probiotics in children is limited but has been used safely in many trials (eg, for mild acute diarrhea associated with rotavirus infection). Lactobacillus has been studied for radiation-induced diarrhea. Individual effects of Lactobacillus vary by strain and product and consistency in product recommendations may affect efficacy. Data are not conclusive on which strains are most efficacious for a given condition. If one product fails to produce desired effect, alternative product with different mix of strains may still be beneficial. For antibiotic-associated diarrhea, take at least 2 h after the antibiotic dose to ensure survival, and continue 7-14 d after completion of antibiotic regimen. Refrigeration requirements vary by product; products that require refrigeration can generally be stored at room temperature for up to 1 wk.

Question 26

Lansoprazole

Answer 26

Trade Name: Prevacid 24HR

Class: Proton Pump Inhibitor

Self-Care indications: Treatment of frequent heartburn

Self-Monitoring Parameters:
Resolution of GI discomfort. Seek medical attention for new bone pain, severe skin rash, severe diarrhea, or abdominal pain.

Key Patient Counseling Points:
Avoid triggers, including alcohol, caffeine, smoking, and high-fat meals. Maintain healthy weight and avoid tight-fitting clothes. Elevate the head by using blocks under bed legs or foam pillow wedge; do not stack traditional pillows. May take with food or antacids if needed. Best taken 30 min before breakfast or the largest meal of the day with large glass of water. Other PPIs and H2-antagonists are available OTC and by prescription; warn patients not to take multiple products concurrently to avoid additive risk of adverse effects. If prescription dose of medication is no longer covered, note the OTC dose is one-half of the prescription dose. Do not take for >14 d but may repeat 14 d course every 4 mo. May require 1-4 d for full effect.

Clinical Pearls:
All patients should attempt lifestyle modifications. Antacids are first-line therapy for moderate and infrequent heartburn. Long-term use of PPIs can lead to bone fractures, magnesium, and vitamin B12 deficiencies. H2-antagonists are first-line therapy for infrequent mild-moderate heartburn. PPIs can be used if H2-antagonists ineffective.

Question 27

Loperamide

Answer 27

Trade Name: Imodium A-D

Class: Antidiarrheal

Self-Care indications: Chronic diarrhea
Acute diarrhea
Travelers diarrhea

Self-Monitoring Parameters:
Relief from diarrhea. Constipation and abdominal pain may occur; if severe, seek medical attention.

Key Patient Counseling Points:
Oral rehydration therapy for mild, uncomplicated diarrhea must accompany treatment with loperamide. Max dose OTC is 8 mg for adults and children >12 y of age and 4 mg for children ≥6 y of age. Do not use in children <2 y of age.

Clinical Pearls:
Treats symptoms, but not cause, of diarrhea. Loperamide, with or without antibiotic, is the preferred treatment of traveler’s diarrhea. Should not be used as the primary therapy for bacterial enterocolitis, dysentery, pseudomembranous colitis associated with the use of broad-spectrum antibiotics, or acute ulcerative colitis (other primary therapy required). High doses (up to 60 mg) have been used without medical supervision for opioid withdrawal, leading to CNS depression and intestinal blockage, and should not be recommended for OTC use. Special alert issued June 2016 regarding cardiac events caused by use of higher than recommended doses, including through abuse or misuse of the product.

Question 28

Levocetirizine

Answer 28

Trade Name: Xyzal Allergy 24HR Children’s
Xyzal Allergy 24HR

Class: Antihistamine

Self-Care indications: Allergic rhinitis

Self-Monitoring Parameters:
Improvement in rhinitis symptoms. Seek medical attention for signs of severe fatigue, fast or irregular heartbeat, rash, or shortness of breath.

Key Patient Counseling Points:
Avoid allergic triggers. Use scheduled doses at night instead of prn. Symptoms should improve after 3-4 d but may require 2-4 wk for full benefit. Patients should avoid activities requiring mental alertness or coordination until drug effects are known, as drug may cause dizziness or sedative effects. For older children and adults, dose of 2.5 mg (one-half tablet) daily is often sufficient to provide symptomatic relief.

Clinical Pearls:
While OTC product is not FDA approved for urticaria (as is its parent compound, cetirizine), the prescription formulation does have that labeled indication. If used for urticaria, recommend topical therapy as first-line therapy, but oral levocetirizine may be useful in some patients. Package labeling recommends referral to HCP for adults ≥65 y of age; consider starting at 2.5 mg to reduce sedation risk.

Question 29

Levonorgestrel

Answer 29

Trade Name: Afteral
                         My Choice
                         New Day
                         Option One-step
                         Plan B One-step

Class: Progestin
Contraceptive

Self-Care indication: Emergency contraception

Self-Monitoring Parameters:
Monitor menstrual period, if delayed by >7 d pregnancy may have occurred. If severe vaginal bleeding or abdominal pain, see an HCP.

Key Patient Counseling Points:
There are no age or gender restrictions for purchase. Ideally, take this drug within 72 h of unprotected sex although it may be used up to 120 h after unprotected sex. If vomiting occurs within 2 h of the dose, repeat dose. Not intended for routine contraception and not effective for terminating a pregnancy. Does not protect against sexually transmitted diseases or future episodes of unprotected sex. Use effective birth control for preventing pregnancy. Breast-feeding women should pump and discard breast milk for 24 h after use of levonorgestrel.

Clinical Pearls:
Levonorgestrel is most effective within 72 h, but data suggest efficacy for up to 5 d after unprotected sex. It is more efficacious taken as soon as possible after unprotected sex. Prescription emergency contraception methods include ulipristal and copper intrauterine devices (IUDs). IUDs have the added advantages of being the most effective emergency contraception methods with pregnancy rates of 0.1% as well as being an ongoing contraception method. Pregnancy rates for ulipristal are 1.8%, compared to 2.6% with levonorgestrel. Levonorgestrel may be less effective in obese women

Question 30

Lidocaine Topical

Answer 30

Trade Name: Solarcaine
LMX4

Class: Local Anesthetic

Self-Care indications: Skin pain or itching
Pretreatment for minor dermal procedures

Self-Care Monitoring Parameters:
Relief from pain. Seek medical attention if burn worsens after 2 d or is not healed after 7 d or if severe skin reactions occur.

Key Patient Counseling Points:
Shake spray well prior to use. Hold can 6 in from burn and spray for 1-3 s. If applying to face, spray in palm first and gently apply; avoid contact with open eyes. Do not apply to broken skin or ingest, may lead to systemic absorption and toxicity, particularly cardiac dysfunction. Do not use on large areas of the body. Formulation may contain alcohol and may be flammable; avoid smoking. Since topical anesthetics like lidocaine work for up to 1 h and can only be used 3-4 times/d, pain relief is not continuous and oral pain relievers like acetaminophen or ibuprofen should be considered. Avoid scratching or rubbing treated area until sensation returns. Advise sunburned patient to use sun protection in future.

Clinical Pearls:
Cool burn with cool (not cold or ice) running water, cover with sterile gauze, and wrap lightly to protect burn from contact (do not use tight or occlusive dressings). Do not break blisters, or use ointments, butter, honey, or other home remedies on burns as these trap heat (increasing severity of burns) and increase risk of infection. Products may contain combination with aloe vera that has mixed efficacy on sunburns in small trials but is generally well tolerated.

Question 31

Loratadine

Answer 31

Trade Name: Claritin
Children’s Claritin
Alavert

Class: Antihistamine

Self-Care indications: Perennial or seasonal allergic rhinitis urticaria

Self-Monitoring Parameters:
Improvement in rhinitis or urticaria symptoms. Seek medical attention for signs of severe fatigue, fast or irregular heartbeat, rash, or shortness of breath.

Key Patient Counseling Points:
Avoid allergic triggers. Use scheduled doses instead of prn, and symptoms should improve after 3-4 d but may require at least 14 d for full benefit. Patients should avoid activities requiring mental alertness or coordination until drug effects are known as drug may cause dizziness or sedative effects at higher than the usual dose. Concurrent sedation with alcohol and other medications; use with caution in patients with severe hepatic or renal dysfunction.

Clinical Pearls:
Product is available OTC in several dosage forms, including extended-release product in combination with pseudoephedrine for rhinitis with congestion.