OTC Exam #2

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OTC Exam #2
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  1. Constipation
    • most common digestion-related complaint in the world
    • it is a decrease in the frequencey of fecal elimination and is characterized by the difficult passage of hard, dry stools
    • three bowel movements/day to as a few as 3 bowel movements/week is considered normal
    • patients with a frequency below 3 bowel movements per week may experience discomfort commonly associated with constipation
  2. Prevalence and Epidemiology of Constipation
    • ~63 million people experience
    • common in all age groups, but mainly a problem with elderly patients
    • almost half of all patients over 65 use laxatives regularly due to immobility, chronic illnesses, medication use, poor nutrition, reduced fluid intake, and age-related changes in gut motility
  3. Etiology of Constipation
    Includes travel, lifestyle factors (inadequate fiber intake, inadequate exercise, inadequate fluid intake), pregnancy, pain, medical conditions, medication-induced
  4. Travel
    • common during travel
    • eating habits, prolonged sitting, bathroom facilities, and interrupted time from activities
  5. Lifestyle Factors
    • inadequate fluid intake: patients should drink at least 8 glasses (8-10 oz each) of non-caffeinated fluids daily
    • inaqeduate fiber intake: fiber shortens time it takes to pas material through the bowel and bulks up the stools; patients should try to eat at least 10g to 25 g of fiber daily
    • inadequate exercise: aerobic exercise recommended to prevent constipation by promoting bowel motility
  6. Pregnancy
    high in pregnant women due to a lack of exercise, vitamin use, and pressure against colon
  7. Pain
    pain during defecation could lead to avoidance and constipation (hemorrhoids, anal fissures, passage of hard stools)
  8. Medical Conditions
    a wide variety of medical conditions can cause constipation (cancer, irritable bowel syndrome, diabetes, chronic renal failure, neurological disorders)
  9. Medication-Induced (CONSTIPA)
    • Calcium channel blockers
    • Opiates (narcotic analgesics)
    • Nsaids
    • Stomach (Antacids, aluminum, calcium)
    • Tricyclic antidepressants
    • Iron supplements
    • P (Diuretics)
    • Anticholinergics
  10. Signs and Symptoms of Constipation
    • infrequent stools (< 3 per week)
    • straining while passing stools
    • pain when attempting to defecate
    • a feeling that the bowel has not been completely emptied after actual or attempted defecation
    • a lack of urgency to evacuate
    • Rome III Diagnostic Criteria = physicians will use this if patient has serious constipation
  11. Constipation Treatment
    • constipation should be intially managed by adjusting the diet, accompanied by some form of exercise
    • pharmacologic intervention can be used in conjunction with lifestyle modifications if more immediate relief is desired
    • laxative agent should be selected according to age and health status of the patient
    • treatment with laxatives should be short term (less than ONE week)
  12. Treatment Goals
    • relieve constipation and re-establish normal bowel function
    • establish dietary and exercise habits that will aid in preventing recurrences
    • promote the safe and effective habits that will aid in preventing recurrences
    • promote the safe and effective use of laxative products
    • avoid the overuse of laxative products (stimulants especially by women)
  13. Exclusions for Self-treatment
    • children < 2 years of age (need a physician's recommendation)
    • marked abdominal pain or significant distention or cramping
    • fever
    • nausea/vomiting
    • paraplegia or quadriplegia
    • daily laxative use
    • unexplained changes in bowel habits (esp. if accompanied by weight loss)
    • blood in stool, or dark/watery stool
    • any bowel symptoms that recur after lifestyle changes or laxative use
    • history of inflammatory bowel disease, Chron's disease, Ulcerative Colitis
  14. Non-pharmacologic Therapy
    • establish a routine time for defecation
    • drink at least 8 glasses of non-caffeinated fluids daily
    • increase fiber content of the diet (avoid hihg fat, greasy foods)
    • limit intake of foods with little or no fiber
    • obtain regular aerobic exercise
    • avoid laxatives that cause dependence (stimulants) and medication-induced constipation
  15. Selection of Dosage Forms -Enemas: fasting acting product
    • solution that is administered into the rectum with the use of an enema syringe
    • may need diluted if using a concentrated solution
    • allow the solution to flow into the rectum slowly
    • patient should be laying on their side and after drugs is administered they should stay there for drug to get into the system
    • retain the enema until definite lower abdominal cramping is felt (5-7 minutes)
    • enemas act within 2-15 minutes
  16. Selection of Dosage Forms - Suppositories
    • solid medication that's administered in rectum
    • remove suppository from wrapping
    • dip in lukewarm water for a few seconds to soften the exterior
    • gently insert, and continue to lie down for a few minutes
    • most effective when the bowel is empty
  17. Selection of Dosage Forms - Liquids
    • can be made more palatable if mixed with juices/milk
    • chilling the oral form or taking it with ice also seems tom ake the product more palatable
  18. Pharmacologic Therapy - Bulk Therapy
    • most utilized medications
    • most are derived from agar, plantago (psyllium) seed, kelp (alginates), and plant gums
    • the synthetic cellulose derivatives - methylcellulose and carboxymethyl cellulose sodium are also commonly used
    • these agents are the recommended choice as intital therapy for most forms of constipation
    • the 7-day use limitation doesn't apply to this class because often they are used for preventative purposes
    • MOA: dissolve or swell in the intestinal fluid, forming gles that faciltate passage of the intestinal contents
    • Onset of action: 12-24 hours, but may be dealyed as long as 72 hours
    • Exceeding the recommended doses could lead to increased amounts of flatulence and to obstruction if appropriate fluid intake if not maintained
    • common adverse effects include abdominal cramping and flatulence (esophogeal obstruction has been seen in certain patients)
    • when taken properly, these agents have few systemic side effects because they're not systemically absorbed
    • bulk-forming products are not appropriate for individuals wiht intestinal obstruction, intestinal ulcerations, or patients who must restrict their fluid intake
    • Methylcellulose (Citrucel), Wheat dextrin (Benefiber), Pysllium (Metamucil), and Polycarbophil (Fibercon, Equalactin)
  19. Pharmacologic Therapy - Stool Softners (Emollinets)
    • MOA: they increase the wetting efficiency of intestinal fluid and facilitate a mixture of aqueous and fatty substances to soften the fecal mass
    • Onset of Action: 1-2 days, but may take as long as 3-5 days
    • emollients can also be used to prevent constipation but are of little or no value in treating long-standing constipation
    • Stool softeners are frequently used along with a stimulant (senna or bsacodyl) as a long-term treatment for opiates-induced constipation
    • generally well tolerated, with little to no side effects or drug interactions
    • docusate sodium (Colace) or docusate calcium (Sulfolax, Sur-Q-Lax)
  20. Pharmacologic Therapy - Mineral Oil (Lubricants)
    • NOT RECOMMENDED much due to side effects
    • MOA: soften fecal contents by coating them, thus preventing colonic absorption of fecal water
    • Onset of Action: 6-8 hours after oral administration and 5-15 minutes after rectal administration
    • Routine use or prevention of constipation is not an appropriate use for mineral oil
    • Excessive dosage increases the possibility of loss of fat-soluble nutrients from the GI tract and enhances the likelihood of product aspiration (must take mineral oil in the upright position) -> dangerous b/c patient can't sit up
    • Avoid in patients taking anticoagulants (warfarin), bedridden patients, or in individuals witih dysphagia
    • Dose: 15-45 mL daily/adults
  21. Pharmacologic Therapy - Saline Laxatives (Osmotics)
    • Magnesium and phosphate; relatively non-absorbable cations and anions such as magnesium and sutlfate ions
    • MOA: draws water into the intestine, causing an increase in intraluminal pressure; the pressure therefore exerts a mechanical stimulus that increases intestinal motility
    • Onset of action: 30 minutes-3 hours for oral doses and between 2-5 minutes for rectal doses
    • dehydration is a big problem with these drugs
    • indicated for use only when acute evacuation of the bowel is required (endoscopic examination) no place in long-term management of constipation
    • excessive dosage may lead to hypermagnesemia (in the magensium products) and hyperphosphatemia (in the phosphorous products)
    • Adverse effects inlcude abdominal cramping, excessive diuresis, nausea, vomiting, dehydration, and electrolyte abnormalities
    • drug interactions include oral anticoagulants and tetracyclines
    • contraindicated in patients with dehydration symdromes, renal function, impairment, or congestive heart failure
    • Magnesium citrate (Citroma)
    • Magnesium hydroxide (Phillips Milk of Magnesia)
    • Sodium phosphate (Fleet Ready to Use Enema, Fleet Phospho-Soda, OsmoPrep tablets, Visicol tablets)
  22. Pharmacologic Therapy - Hyperosmotics
    • MOA: draws water into the rectum to stimulate a bowel movement
    • Onset of Action: suppositories usually produce a bowel movement within 30 minutes; powder produces a bowel movement within 1-4 days
    • Glycerin is available as rectal suppositories (3 g daily/adults and 1.5 g daily children less than 6 years of age) and liquid (5-15 mL daily/adults)
    • Polyethylene Glycol (Miralax powder) 17 g = one heaping tbsp of powder in 120-240 mL of fluid given PO QD
    • Works with body's natural rhythm without harsh side effects
    • reduces cramps and gas
    • produces bowel movement within 1-3 days
    • max dose for adults/elderly is 34 g/day PO
    • no dosage adjustments needed for kidney or liver impairment
    • Pregnancy Category C can recommend
    • no special considerations exist for the use in geriatric patients
    • generic products available now
  23. Pharmacologic Therapy - Stimulants
    • MOA: increases the propulsive peristaltic activity of the intestine by local irritation of the mucosa; stimulation of water secretion in either the large or small intestine has also been noted
    • Onset of action: 6-12 hours but may require 24 hours
    • may be used as initial drug therapy in patients with simple constipation, but they should not be used for more than a week
    • intensity of their activity is proportional to the dose used
    • overdose situations may lead to sudden vomiting, nausea, diarrhea, or severe abdominal cramping
    • adverse effects include severe cramping, electrolyte and fluid deficiencies and enteric loss of protein
    • Senna may color urine pink to red, red to violet, or red to brown
    • senna or sennosides (Ex-Lax, Senokot)
    • bisacodyl (Dulcolax)
    • cascara sagrada (Nature's Remedy)
    • Castor oil
    • combination products that include both a stimulant (senna) and stool softner (docusate) include Senna-S and Peri-Colace
  24. Special Populations - Children
    • encourage a regular pattern of bowel movements, and to avoid withholding of stools when the urge occurs
    • always consider age and any previous laxative use
    • if medications are indicated in children younger than 5, glycerin suppositories may initiate defecations within 15-60 mintues
    • Enemas are not usually recommended for children younger than 2
    • Stimulants shoudl probably be avoided
    • Pedia-Lax, Fleet Pedia-Lax - quick dissovling stimulant strips (senna laxative)
  25. Special Populations - Elderly
    • sensitive to shifts in fluids and electrolytes (use caution with saline-type laxatives)
    • bulk forming agents are generally preferred for older paitents, and onset is usually in 2-3 days
    • adequate fluid intake is necessary to avoid worsening constipation from bulk-forming laxatives
  26. Special Populations - Pregnancy
    • dietary measures should be attempted as an initial measure in most patients
    • bulk-forming laxatives are the common first-line choice b/c of thier safety and effectiveness
    • if bulk-forming laxatives are ineffective, emoillient laxatives, senna, or bisacodyl may relieve symptoms
    • some prenatal vitamins such as PrimaCare and PreCare Premier have docusate sodium included in tablet form
  27. Constipation- Evaluation of Patient Outcomes
    • dietary changes/exercise and the use of bulk-forming laxatives may take several days to weeks to provide relief
    • stimulant laxatives usually provide results within 24 hours; osmotic laxatives provide more immediate relief, usually within 15 minutes to 3 hours for oral preparations
    • laxative enemas can produce evacuation within minutes
    • if an adequate response is not achieved within one week, chronic constipation should be considered
  28. Constipation Conclusions
    • constipation is a decrease in the frequency of fecal elimination characterized by the difficult passage of hard, dry stool; successful treatment depends on careful identification of the cause
    • for most cases of simple constipation, proper diet, exercise, and adquate fliud intake should be helpful; therapy with any laxative should be limited to short-term use
    • bulk laxatives are the safest when ingested with adeqaute water; stool softeners also have a low incidence of adverse reactions
    • special circumstances and patient characteristics should be considered when assessing the need for self-medication
  29. Prevalence and Epidemiology of Diarrhea
    • A disease of worldwide incidence, diarrhea strikes virutally everyone at some point
    • strikes as many as 27% of Americans monthly
    • characterized by increased frequency of defecation
    • loose, watery stools; three or more loose stools during a 24-28 hour period
    • If dehydration results, the patient may experience electrolyte imbalances
    • diarrhea is a symptom, not a disease
  30. Etiology of Diarrhea - Chronic Diarrhea
    • diarrhea present for more than one month
    • most frequent causes are: infections, dietary intolerance/allergies, serious medical conditions, laxative abuse
  31. Etiology of Diarrhea - Acute Diarrhea
    • often causes additonal symptoms as flatulence, cramping, abdominal pain, bloating, and N/V
    • most frequent causes are: infections (bacterial, viral, parasite-induced), diet, medications, traveling
  32. Infectious Diarrhea
    • most deaths and hospitalizations resulting from diarrhea involve an actue infections agents
    • day-care centers, nursing homes, prison, and multifamily dwellings contribute to the spread of diarrheal illnesses
    • bacterial diarrhea
    • viral diarrhea
    • parasite-induced diarrhea
  33. Bacterial Diarrhea
    • most often contracted through ingestion of contaminated food/drink
    • Salmonella organisms may be ingested with infected poultry, eggs, beef, raw fruits/vegetables, and milk
    • Campylobacter jejuni-induced diarrhea is acquired from undercooked chicken, milk, or contaminated water
    • other bacteria producing diarrhea include E. coli, Clostridium, Shigella, and Staphylococcus aureus
  34. Viral Diarrhea
    • viruses may cause up to 80-85% of all episodes of acute gastroenteritis in the U.S>
    • viral diarrhea seldom requires therapy other than electrolyte maintenance
    • Rotavirus is the most common viral cause of pediatric gastroenteritis; contracted through fecal-oral trasmission and contaminated water
  35. Parasite-induced diarrhea
    • Giardia lamblia and Entamoeba histolytica are protozoa associated with acute diarrhea
    • contracted through ingestion of water or food contaminated with animal or human feces
  36. Dietrary Diarrhea
    causes inlcude: lactose intolerance, large amounts of salty drinks or foods (especially seeds), some enteral diets
  37. Medication-related diarrhea
    • drug-induced diarrhea is a frequent adverse outcome of therapy, comprising of 7% of all adverse drug events
    • several groups of medications cause diarrhea including the following:
    • Antibiotics (ampicillin, amoxicillin-clavulanate, cephalosporins, clindamycin, and tetracyclines); the cause of 25% of drug-induced diarrhea
    • chemotherapeutic agents
    • colchicine- used for gout
    • metformin- HIV
    • protease inhibitors
    • magnesium (antacids)
    • Dose reduction of these agents may resolve the problem; or patient may build tolerance to diarrhea as well
  38. Traveler's Diarrhea
    • an acute diarrhea caused by bacteria that the patient contacted when traveling, usually to a foreign country
    • almost 1/2 of the 50 million people traveling from industrialized nations to tropical/less developed countries will experience it
    • most important variable for it's development is the level of risk of the destination
    • most common causative agent is E. coli, and diarrhea is caused by ingestion of contaminated food or water
    • symptoms usually subside over 3-5 days
  39. Osmotic diarrhea
    unabsorbed solutes in the intestines increase the osmotic load in the lumen and retard the absorption of fluids
  40. Secretory diarrhea
    net flow of electrolytes and fluids commonly caused by bacterial and viral infections
  41. Exudative diarrhea
    inflammatory states or bacterial infection
  42. Motor diarrhea
    intestinal transit time is abnormally rapid
  43. Complications of Diarrhea
    • fluid and electrolyte imbalance is the major complication of diarrheal illnesses
    • signs and symptoms of dehydration are associated with the severity of the diarrhea and are related to the etiology/degree of fluid and electrolyte losses
    • Mild diarrhea: slightly dry buccal mucous membranes, increased thirst, slight decrease in urine output, wt loss
    • Moderate diarrhea: sunken eyes loss of skin turgor, dry buccal mucous membranes, restlessness, 6-9% wt loss
    • Severe diarrhea: same signs as moderate including a > or equal to 10% wt loss, rapid pulse/breathing, lethargy
  44. Diarrhea - Goals of Tx
    • prevent or correct fluid and electrolyte loss and acid-base disturbances
    • relieve symptoms
    • identify and treat the cause
    • prevent acute morbidity and mortality
  45. Diarrhea - General Tx Approach
    • symptomatic relief and correction of fluid and electrolyte loss are generally adequate for mild to moderate, uncomplicated diarrhea
    • attention should also be given to dietray considerations
    • pharmacists should make patients aware that a physician evaluation is needed in many cases
    • although there are many OTC products available, they must not be used if symptoms worsen or if diarrhea has lasted for more than 2 days
  46. Exclusions for self-tx
    • chrnoic diarrhea
    • < six months of age
    • severe dehydration
    • > or equal to six months of age with persisten high fever, blood/mucus/pus in the stool, protracted vomiting, severe abdominal pain
    • risk for significant complications (cancer chemotherapy, AIDS patients, organ transplant recipients)
    • pregnancy
  47. Non-pharmacologic tx - fluid & electrolyte managment
    • oral rehydration therapy (ORT) is the preferred tx
    • oral sugar-electrolyte solution can be absorbed during diarrhea; contains low concentrations of glucose or dextrose and electrolytes (sodium, chloride, citrate, and potassium)
    • these products don't reduce number of stools, nor do they shorten the duration of the condition
    • Products: Pedialyte, Pedialyte Freezer Pops, Rehydralyte Solution, KaoLectrolyte Powder Packets, and Infalyte Solution
  48. Non-pharmacologic tx - Dietary Management
    • Children with normal hydration: increase fluid intake along with an age-appropriate diet, including breast milk
    • children with dehydration: ORT and reinstituion of an age-appropriate diet
    • no evidence that fasting or dietary modification influences outcomes of acute diarrhea in adults
    • diet should consist of complex carbohydrate-rich food (rice, potatoes, bread, cereals), lean meats, fruits, and vegetables; AVOID fatty foods, simple sugars, spicy foods, caffeinated drinks
  49. Non-pharmacologic tx - Preventative Measures
    • isolating the individual with diarrhea (in congregate living conditions)
    • washing hands and other hygenic practices
    • strict food handling
  50. Diarrhea Pharmacologic Treatment Options
    • loperamide
    • bisumuth subsalicylate
    • digestive enzymes
  51. Diarrhea - loperamide (Imdoium)
    • a synthetic opiod agonist that produces antidiarrheal effects by stimulating opoid recpetors: slows intestinal motility and allows absorption of electrolytes and water
    • effective antidiarrheal agent in traveler's diarrhea, acute diarrhea, or chronic diarrhea associated with inflammatory bowel disease
    • caution against use if patient has a fever
    • few side effects include occasional dizziness, dry mouth, abdominal pain/distention
    • Products: Imodium A-D (loperamide caplets and liquid) and Imodium Advanced Formula Caplets (loperamide and simethicone)
    • caplets (2 mg), liquid (1 mg/5 mL)
    • don't exceed 16 mg/day
    • not recommended for children younger than 6
  52. Diarrhea - Bismuth subsalicylate (BSS) (Pepto-Bismol)
    • reacts with HCl in stomach to form bisumuth oxychloride and sailcyclic acid
    • both of these moieties are pharmacologically active
    • reduce the frequency of unformed stools, increase stool consistency, decrease N/V, and relieve symptoms of abdominal cramping
    • therapeutic effects of BSS in traveler's diarrhea are attributed to direct antimicrobial effects
    • indicated for symptomatic relief of mild, nonspecific diarrhea and indigestion (FDA approved for acute diarrhea and traveler's diarrhea)
    • used as an adjuvant agent to antibiotics for treating Helicobacter pylori-associated peptic ulcer disease
    • Adverse effects:
    • toxic levels of salicylate may be reached (in patients taking asprin or other salicylate-containing drugs)
    • mild tinnitus
    • asprin-indcued Reye's syndrome (especially children with chicken pox or flu symptoms)
    • neurotoxicity (tremor, myoclonus, and ataxia in overdose situations)
    • harmless black staining of stool or tongue
    • contraindicated for nursing or pregnant women and patients with AIDS
    • drug interactions include those agents that potentially interact with asprin (warfarin, valproic acid, methotrexate, tetracyclines, quinolones)
    • products: Kapectate, Pepto-Bismol (caplets, chewable tablets, original strength liquid, maximum strength liquid) Children's Pepto (mainly Tums) contains calcium carbonate 400 mg and the dose is based on the child's age and weight
    • Pepto-Max = 525 mg/15 mL; Pepto Regular = 262 mg/15 mL
    • max is 8 doses/day
    • not recommended for children less than 12 years old
  53. Diarrhea - Digestive enzymes
    • take with each consumption of dairy
    • for patients with lactase GI enzyme deficiency, lactase enzyme preparations are available
    • taken with milk at meal times to prevent osmotic diarrhea
    • Produts: Lactaid (caplets, extra strength caplets, ultra caplets, Lactrase capsules)
    • Lactaid Milk is also available; real milk that's 100% lactose free
  54. Diarrhea - Probiotics
    • live organisms that are similar to beneficial microorganisms found in the human gut
    • called "good bacteria" and available mainly in the form of dietrary supplements and foods
    • used to prevent and treat certain illnesses and support general wellness
    • Ex. Align (daily dosing) and Dannon Activia yogurt
  55. Diarrhea conclusions
    • diarrhea is often considered a trivial disorder, but i can be a symptom of a more serious underlying disease
    • actue diarrhea is characterized by a suddne onset of loose stools in a previously healthy patient; whereas, chronic diarrhea is persisten or recurrent episodes of loose stools accompanied by anorexia, weight loss, and weakness
    • oral hydration products may be helpful in preventing dehydration, and may be purchased in the forms of solutions, freezer pops, or powders for reconstitution
    • uncomplicated, actue diarrhea can usually be treated by supportive care and/or hydration product or OTC drug
    • if a nonspecific antidiarrheal is recommended, you should review label instructions, maximum doses per 24 hours, potential drug interactions, side effects, and contraindications
  56. Wart epidemiology
    • approximately 7-10% of kids/young adults and 16% of the general population
    • peak incidence = 12-16 years old
    • warts are usually not permanent
    • persence of warts is a risk factor for developing additional warts
  57. How are warts caused?
    HPV
  58. 3 criteria must be met to develop a wart:
    • virus must be present
    • open avenue must exist
    • immune system must be susceptible
  59. warts may be spread
    • person-to-person
    • autoinoculation - spreading warts to yourself
    • indirect exposure
  60. Signs and symptoms of warts
    • rough, cauliflower-like appearance
    • slightly scaly, rough papules or nodules that appear alone or grouped
    • may have black dots scattered across surface
    • warts are defined according to location
  61. Common warts (verruca vulgaris)
    • hands and fingers; knees in kids
    • single/grouped
  62. Periungal and sublingual warts
    • around and underneath the nail beds
    • proudce abnormalities in nail growth
  63. Juvenile or flat warts (verruca plana)
    • face, neck, hands, and legs
    • small size; appear tan/pink to gray or brown
  64. Venereal warts (condyloma lata and acuminate)
    • genitalia region
    • STDs
  65. Plantar warts (verruca plantaris)
    • soles of feet
    • cause pain when walking
  66. Warts- Tx Goals
    • remove the wart
    • prevent autoinoculation or transmission to others
  67. Warts - exclusions for self-tx
    • face, toenails/fingernails, genitalia involved
    • extensive warts at one body site
    • painful plantar warts
    • one or more chronic, debilitating diseases (diabetes, peripheral vascular disease) which contraindicate use of foot care products
    • physical/mental impairments that make following product directions difficult
    • immunosuppressive medications that contraindicate use of salicyclic acid
  68. Warts - Non-pharmacologic therapy
    • wash hands before and after treating our touching wart area
    • avoid skin-to-skin contact with infected individuals
    • a specific towel should be used only for dyring the affected area after cleaning
    • never share any possible infected objects
    • don't probe, poke, or cut the wart area
    • don't walk barefoot if warts are present on the sole of foot
  69. Warts Pharmacologic therapy - Salicylic Acid
    • topical salicylic acid (common/plantar)
    • 12-40% in plaster vehicle
    • 5-17% in a collodion-like vehicle
    • 15% in a karaya gum-glycol plaster vehicle
    • patients should notice visible improvement within the 1st or 2nd week of tx
    • plantar warts should be treated with a higher concentration of salicyclic acid (up to 40%)
    • if wart remains after a full course of tx, contact primary physician
  70. Warts Pharmacologic therapy - plaster/pads
    • using plaster: trim the plaster to follow the contours of the wart; apply to skin and cover with adhesive tape
    • if using disks with pads: apply appropriately sized disk directly on area, then cover with pad
    • apply and remove every 48 hours as neeed up to 12 weeks
  71. Warts Pharmacologic therapy - collodion vehicle
    • apply product no more than twice daily
    • apply solution one drop at a time; don't overuse product
    • wash off solution that touches healthy skin
    • allow solution to harden; repeat procedure for up to 12 weeks
    • store product away from sunlight or heat
  72. Warts Pharmacologic therapy - Karaya Gum-Glycol Vehicle
    • apply plaster to wart at bedtime, and leave on for at least 8 hours
    • remove and discard plaster in the morning
    • repeat every 24 hours as needed for up to 12 weeks
  73. Cryotherapy for warts
    • causes irritation leading the host to mount an immune response against the virus
    • mixture of dimethyl ether and propane (DMEP) that enables patients to treat warts at home
    • Cryotherapy devices consist of 2 parts: pressurized spray can and applicator
  74. Patient Education and Counseling Points for warts
    • warts are contagiouis and can spread to other parts of the body
    • there are differences in how salicylic acid products are applied
    • stress contraindications, warnings, and precautions for topical salicylic acid products
    • warts may reappear months after the inital treatment
    • educated both non-pharmacologic and pharmacologic measures
    • alleviation of the symptoms wil not occur overnight
  75. Evaluation of Patient Outcomes - warts
    • wart removal can take from 4-12 weeks, therefore the first follow-up on the patient's progress should be after 4 weeks of tx
    • reevaluation every 4 weeks is appropriate for persistent warts
    • refer to primary care provider for any warts that persist after 12 weeks of self-tx
  76. three distinct groups of patients often encounter foot problems
    • children with a congenital malformation or deformation
    • adolescents who experience rapid growth
    • older patients who encounter foot problems b/c of aging and disease
  77. Epidemiology of foot disorders
    • diabetes contributes to over 50% of non-traumatic lower extremity amputations
    • indivudals who exercise regular are also at risk for foot disorders
  78. Chronic Diseases and Foot Disorders
    • diabetes mellitus
    • peripheral vascular disease - poor ciruclation
    • arthritis
  79. Corns
    • on top of toes
    • small, raised, sharply demarcated lesions
    • can be hard or soft
    • usually found on/between the toes
  80. Calluses
    • diffuse thickening of the skin; indefinite borders
    • ranges from a few millimeters to several centimeters
    • forms from joints and weight bearing areas
  81. Treatment of Corns and Calluses - Non-pharmacological therapy
    • daily soaking the affected area for at least 5 minutes in warm water
    • dead tissue should be removde gently with a rough towel, callus file, or pumice stone
    • use of a pad (Dr. Scholl's) to relieve painful pressure
    • wear well-fitting, nonbinding footwear
  82. Treatment of Corns and Calluses - Pharmacologic Therapy - Salicylic Acid
    • 12-40% in plaster vehicle
    • 12-17.6% in a collodionlike vehicle
  83. Patient Counseling on Foot Disorders
    • eliminate predisposing that contributed to foot problem in beginning
    • OTC products that removes corns and calluses are not recommended for patients with diabetes or circulatory problems (also, don't use on irritated, infected, reddened skin)
    • patient progress should be checked after 2 weeks of tx (refer to physician after 14 days if poor results)
  84. Bunions
    • 10 times more common in women than in men
    • positive family history in as many as 60% of patients
    • prolonged pressure associated with shoe irritation may result in painful inflammation and swelling over the bony joint structure
    • asymptomatic, but may become painful, swollen, and tender
  85. Bunion Tx
    • not amenable to topical drug therapy
    • refer patient to podiatrist/physician
    • routine, chronic use of oral analgesics is not recommended
    • routine, chronic use of oral analgesics is not recommended
    • management of the bunion should address the cause:
    • avoid high-heeled shoes
    • use protective padding
    • take oral analgesics on a short-term basis
    • bunion pads/cushions (Bunion gaurd, bunion cushion)
  86. Ingrown toenails
    • most frequent cause is incorrect trimming of the nails
    • wearing pointed-toe or tight shoes has also been implicated
    • education is the best way to prevent the development
    • oral analgesics may be used to relieve the pain and inflammation
    • Dr. Scholl's ingrown toenail pain reliever (sodium sulfide nonahydrate 1% in a gel vehicle)
  87. Mosquitoes
    • found in abundance worldwide, particularly humid, warm climates
    • can transmit diseases such as malaria and West Nile virus
    • bites usually occur on exposed body parts
    • injects a salivary secretion containing an anticoagulant and antigenic component
  88. Fleas
    • tiny, wingless insects that are also found worldwide
    • transmits diseases such as bubonic plauge and endemic typhus
    • bites are usually multiple and grouped; occur on the legs and ankles (intense itching)
  89. Scabies
    • "the itch"
    • contagious parasitic skin infection
    • inflammation and intense itching
  90. Bedbugs
    • hide and deposit their eggs in crevices of walls, floors, bedding, and furniture
    • become active at night and bite sleeping victims
    • reaction may range from irritation at the site of the bite to a small dermal hemorrhage
  91. Ticks
    • feed on the blood of humans and animals; holds on firmly to the host
    • may cause intense itching and nodules if the tick is aggressively removed from skin; remove tick intact by using fine tweezers
    • can transmit diseases such as Rocky Mountain spotted fever and Lyme disease
  92. Chiggers
    • live in shrubbery, trees, and grass
    • insert their mouth into the skin and secrete a digestive fluid that causes cellular disintegration and intense itching
  93. Spiders
    • an estimated 60 species of spiders in the U.S. have the ability to bite humans
    • the black widdow and brown recluse are two varieties whose bites are serious
  94. Insect bite tx
    • external analgesics are labeled for use in treating minor insect bites; however, NOT EFFECTIVE for treating scabies
  95. Tx goals for insect bites
    • relieve symptoms
    • prevent future insect bires and secondary bacterial infections
  96. General tx for insect bites
    • application of an ice pack
    • self-treatment with an OTC is appropriate if the rxn is confined to the site and if the patient is older than 2 years of age
  97. Exclusions for self-tx
    • hypersensitivity to insect bites, resulting in systemic symptoms or symptoms away from bite areas
    • less than 2 years of age
    • history of tick and bite and systemic effects
    • suspected spider bite requiring medical attention
    • signs of secondary infection of bite area
  98. Non-pharmacologic therapy for insect bites - avoiding insects
    • covering the skin with clothing, hats, shoes
    • avoiding swamps, dense woods, and brush
    • keeping pets away from pests
  99. Non-pharmacological therpay for insect bites - Using repellents
    useful in preventing bites from mosquitoes, fleas, and ticks but NOT effective in repelling insect stings (wasps, hornets, bees)
  100. DEET insect repellant
    • in concentrations ranging from 7-40%
    • the higher the concentrations, the longer the duration
    • doesn't kill insects: the volatile repellent releases vapors that tend to discourage the approach of insects
    • applied to skin or clothing no more frequent than 4-8 hours
    • concentrtaions below 10% = children
    • DEET on children less than 2 discouraged
    • concentrations of 50-100% DEET are reserved for high risk individuals
    • skin irritation is the most frequent adverse effect; can be toxic if ingested
    • examples include Cutter Backwoods, Off Insect Repellent, Repel Ultra Roll On
    • Alternative products include citronella, soybean oil, eucalyptus oil, and fragranced moisturizers in mineral oil (Skin So Soft)
  101. Pharmacological Therapy insect bites - local anesthetics
    • used in topical preparations for the relief of itching and irritation
    • cause a reversible blockade of conduction of nerve impulses at the stie of aplication, thereby producing a loss of sensation
    • approved for burns, sunburns, minor cuts, insect bites, minor skin irritation
    • generally applied to the bite area up to 3-4 times daily for no longer than 7 days
    • allergic contact dermatitis may occur with these products; pramoxine and benzyl alcohol don't commonly cause adverse effects and exhibit less cross-sensitivity
    • Examples: benzocaine, pramoxine, benzyl alcohol, lidocaine, dibucaine, and phenol
  102. Pharmacological Therapy insect bites - Topical anithistamines
    • diphenhydramine HCl in concentrations of 0.5% to 2% is the agent used in most products
    • exert an anesthetic effect by depressing cutaneous receptors , thereby relieving pain and itching
    • approved for temporary relief of pain and itching due to minor burns, sunburns, insect bites, poison oak, ivy, and sumac
    • generally applied to the bite area up to 3-4 times daily for no longer than 7 days
    • topical antihistamines are not absorbed in sufficient quantities to cause systemic side effects (unless used over a large body area, espeically children)
    • oral histamines are not often used in treating itching related to insect bites, but this is not a label indication
  103. Pharmacological Therapy insect bites - Counterirritants
    low concentrations of camphor (0.1% to 3%)

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