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688 Cards in this Set
- Front
- Back
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Neonate Age
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First month
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Infant age
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1 month - 12 years
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Neonate Age
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First month
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Infant age
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1 month - 12 years
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Child age
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1 - 12 years
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Adolescent age
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12-18 years
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What are APAP and IBU used for with infants and pediatrics?
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Reduce fever and relieve minor aches and pains
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How do APAP and IBU work? (MOA)
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Inhibition of synthesis of prostaglandins
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Does APAP decrease prostaglandin synthesis centrally or peripherally?
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Centrally
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Does IBU decrease prostaglandin synthesis centrally or peripherally?
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Peripherally
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APAP dosing in infants
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10-15 mg/kg every 4-6 hours
Do not exceed 5 doses in one day |
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Standard APAP concentration of infants and children
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Oral liquid 160mg/5mL
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Are APAP rectal dosing forms generally recommended for infants/peds?
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No
Variable absorption of APAP rectally |
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APAP rectal dosing vs. oral dosing
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Rectal dose is typically either the same as the oral dose or 1.5 times the oral dose
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What age group is IBU used for?
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6 months or older
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IBU dose for peds
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5-10 mg/kg every 6-8 hrs
Do not exceed 4 doses/day Do not give for more than 3 days |
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What IBU dose is given for a fever <102.5?
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5 mg/kg
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What IBU dose is given for a fever >/= 102.5?
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10 mg/kg
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Max number of consecutive days to give IBU to infant/ped
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3 days
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Max number of doses/day for peds
APAP vs. IBU |
APAP: 5 doses/day
IBU: 4 doses/day |
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IBU peds concentration
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Concentrated oral drops for infants: 50mg/1.25mL
Oral liquid for children: 100mg/5mL |
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True or False.
APAP = IBU in efficacy. |
True
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T/F.
Alternating APAP and IBU has been shown to be of benefit. |
False
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What is the most common symptom of disease in children?
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Fever
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T/F
Peds presenting with fever pose extreme danger. |
False
Unless fever is extremely high |
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What does a fever mean for the body?
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Sign that body is mounting immune response to infection or immunization
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T/F
Fever = bacterial infection (need for antibiotics. |
False
Does not always mean this |
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What does accuracy of measuring body temp in infants depend on?
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Measurement of core body temp
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What devices should not be recommended to measure body temp in infants?
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Glass thermometers
Temperature strips |
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T/F.
An oral thermometer can be used to measure temperature rectally. |
False
May perforate rectum |
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Fever:
Oral Temp |
>37.8 C (100 F)
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Fever:
Axillary Temp |
>37.2 C (99 F)
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Fever:
Rectal Temp |
>38 C (100.5 F)
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When does a fever require urgent attention?
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< 3 months old with any fever
6-24 months with rectal temp >38.9 C (102 F) + abnormal WBC Any child with a temp >/= 41 C (105.8 F) Any fever + immunocompromised or asplenic |
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Treatment of Fever
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1. Antipyretic therapy (APAP/IBU) indicated to alleviate parent patient discomfort
2. Adequate hydration 3. Dress child in lightweight clothing 4. Lightweight bedding 5. Keep room comfortably cool 6. Discourage vigorous physical activity |
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When should a parent call a pediatrician when their child has a fever?
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Child < 3 months
Looks ill, unusually drowsy, very fussy Additional symptoms (stiff neck, severe HS, severe sore throat, severe ear pain, unexplained rash, repeat V/D Immunosuppressed Seizure Child 3-6 months w/ fever >101 F Child >6 months w/ fever >103 F Fever persists >3 days Child dehydrated Child delirious/unresponsive |
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Which is perceived as more effective for treating pain? APAP or IBU?
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IBU
longer dosing interval |
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Longer dosing interval: APAP vs. IBU
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IBU
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T/F
IBU/APAP dosing is based on amount of pain. |
False
Always use weight based dosing |
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Infant Medication Measuring Devices
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Medication cups
cylindrical dosing spoons Oral dosing syringes Oral droppers |
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Most accurate infant medication measuring device
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Calibrated oral syringe
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Are oral droppers very accurate?
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No
In order to make dosing more precise, droppers are now being marked by age range of child However, makes dosing by weight difficult |
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Are household spoons accurate dose measuring devices?
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No
Household teaspoons volumes vary from 2.5-10 mL |
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Counseling Points:
Fever/Pain |
Correct dose, frequency, duration, and specific strenght/formulation
Base dose on child's weight, not age Caution - do not exceed recommended daily dosage/duration Emphasize importance of reading labels Demonstrate measuring Explain that many preparations contain APAP and IBU Follow=up and when to contact PCP |
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First line treatment for infants with constipation
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Glycerin suppositories
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What products should be avoided in infants for treatment of constipation?
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Avoid enemas, mineral oil, saline, and stimulant laxatives
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What products may help to alleviate infant constipation? Why?
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Breast milk/formula - Karo syrup
Prune/apple juice - contains sorbitol (increases frequency/water content of stool) |
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What juice ingredient increases frequency of bowel movements and increases water content of stool?
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Sorbitol
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Symptoms of teething
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Sleep disturbance, irritability, excessive drooling, reddening/swelling of gums, loose stools
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Nonpharmacologic treatments for teething
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Frozen teething ring/pacifier
Cold wet cloth |
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Pharmacologic treatments for teething
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Topical analgesics
Teething tablets/herbal gel Benadryl applied to gums Systemic analgesics |
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Topical analgesics use with teething
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Benzocaine 5-20%
If 4 months or older Do not use more than 4 times daily Only use topical analgesics designed for infants (adult doses may cause overdoses in infants) |
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Teething tablets/Herbal gel
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Combination of herbals (belladonna, coffee, chamomile, calcium)
Tablets dissolve rapidly under tongue or can dissolve in 1 tsp of water |
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T/F
Benadryl is effective as a topical analgesic for teething. |
True
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Can systemic analgesics aid in treating pain caused by teething?
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Yes
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Causes of diaper dermatitis
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Occlusion, moisture, bacteria, alkaline pH of skin, chafing/friction, enzymes and bile salts from GIT, fungus, etc
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Factors that increase risk for diaper dermatitis
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Child's age (peak 6-12 months)
Presence of atopic dermatitis Diarrhea Type of diaper (cloth diapers/tight fitting diapers) Infrequent diaper changes |
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How many diaper changes do most infants need in a day?
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6
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Clinical manifestations of diaper dermatitis
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Baby cries when cleansed at changing
Erythema of skin/shiny patches Butt, upper inner thighs, abdomen, pubic regions Could be inflamed, exhibit lesions, mild scaling |
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Candida-infected diaper dermatitis
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Sharp border
Satellite lesions Intense, beefy-red erythema Child will often begin violent crying just following urination/defecation |
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Nonpharmacologic treatment of Diaper dermatitis
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air dry skin
good hygiene change diapers frequently (after each wetting/soiling) |
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Pharmacologic treatment of diaper dermatitis
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Skin protectants (zinc oxide)
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T/F
Skin protectants (zinc oxide) treat AND prevent diaper dermatitis. |
True
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How do skin protectants work?
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Serve as a physical barrier between the skin and external irritants
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Most commonly used protectant
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Zinc oxide
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Why is zinc oxide the best recommendation for deaper dermatitis treatment?
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Has antiseptic and astringent properties
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When should diaper dermatitis not be self-treated?
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Condition present longer than 7 days
Signs of bacterial/fungal infection Skin broken Child crying violently after urination/defecation |
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How often should diapers be changed with diaper dermatitis?
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At least 8 times a day
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T/F
Talcum powder can be used to treat diaper dermatitis. |
False
Should be avoided due to risk of pulmonary damage |
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Examples of skin protectants
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A + D ointment
Aveeno Destin Zinc oxide |
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Causes/contributing factors of colic
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Intestinal gas
Lactose intolerance Dairy allergy Maternal diet (if breastfeeding) GI disorders Parental/Child environment factors |
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Colic Manifestations
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Usually within first 3 months of life (otherwise healthy, happy, thriving infant
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Colic Symptoms
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Violent paroxysms of irritability
Unexplained fussing Full-force crying/screaming (often worsens in early evening hours) |
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Colic vs. fussy
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Symptoms:
Last more than 3 hours/day Occur on more than 3 days in any 1 week Continue for at least 3 weeks |
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Colic treatment
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Underlying cause must be addressed
Comfort infant until crying is over Simethicone (if gas related) Herbal remedies (Gripe water) Probiotics |
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Treatment for gas-related colic
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Simethicone 20mg/0.3mL
Ex. Infant mylicon, little tummy gas relief drops |
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Absorption of simethicone drops for colic
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Virtually nonabsorbed
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Simethicone ADEs
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None
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Colic Symptoms
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Violent paroxysms of irritability
Unexplained fussing Full-force crying/screaming (often worsens in early evening hours) |
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Simethicone dose
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Children <2: 20 mg
Children >2: 40 mg |
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Colic vs. fussy
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Symptoms:
Last more than 3 hours/day Occur on more than 3 days in any 1 week Continue for at least 3 weeks |
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Simethicone concentration
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20 mg/0.3 mL
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Colic treatment
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Underlying cause must be addressed
Comfort infant until crying is over Simethicone (if gas related) Herbal remedies (Gripe water) Probiotics |
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Treatment for gas-related colic
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Simethicone 20mg/0.3mL
Ex. Infant mylicon, little tummy gas relief drops |
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When is simethicone given? What is the max amount it can be given?
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Given after meals and at bedtime
Maximum of 12 doses/day |
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Absorption of simethicone drops for colic
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Virtually nonabsorbed
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Gripe water
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Combination of herbals to help soothe stomach muscles
ginger root extract, fennel seed extract, chamomile flower |
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Simethicone ADEs
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None
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Simethicone dose
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Children <2: 20 mg
Children >2: 40 mg |
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Simethicone concentration
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20 mg/0.3 mL
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When is simethicone given? What is the max amount it can be given?
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Given after meals and at bedtime
Maximum of 12 doses/day |
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Gripe water
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Combination of herbals to help soothe stomach muscles
ginger root extract, fennel seed extract, chamomile flower |
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Probiotics used for colic treatment
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Lactobacillus reuteri
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T/F
FDA approval of cold meds (decongestants, expectorants, suppressants, antihistamines) is based on the evidence of safety/effectiveness of products in children. |
False
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Recommendation for OTC cough/cold meds for child use
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Do not recommend cough suppressants and other OTC cough meds for young children
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Age recommendations for OTC cough med product use (AAP vs. FDA vs. CHPA)
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AAP( american academy of pediatrics): Do not use under age of 6
FDA: do not use if less than 2 years old CHPA (consumer healthcare products association): do not use under 4 years old |
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Alternatives to OTC cough meds for treating children cold
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drink plenty of fluids
pain/fever relievers vaporizers/humidifiers Vicks VapoRub Honey |
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Treatment for congestion in infants/peds
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Keep upright
Gentle nasal suctioning saline nose drops |
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Vaporizers vs humidifiers
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Both moisten the air
Humidifiers release cool moisture Vaporizers boil water to release warm moisture |
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How often should water be replaced in vaporizers/humidifiers?
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Daily
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Vicks VapoRub
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Combination of menthol, camphor, eucalyptus oil
Gives perception of increased airflow across nostrils |
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Age limitations for Vicks VapoRub
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Not for children <2
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Honey
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Recommended to reduce cough in children > 12 months
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Honey age limitations
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Not for children < 1 year
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Honey dosing
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Children 2-5 years: 1/2 tsp
6-11 years: 1 tsp 12-18 years: 2 tsp |
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Menstruation
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Monthly cycling of femal reproductive hormones
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Menstrual cycle
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time between onset of one menstrual flow and the beginning to the next
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Length of menstrual cycle
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Usually 28 days (varies between 21-40 days)
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Average age of onset of first menstrual cycle
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12 (ranges from 10-16)
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Menses
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menstrual flow, blood loss occurs
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Length of menses
When does most blood loss occur? |
Lasts of average of 4 days, most blood loss occurs on days 1 to 2
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Components of menstrual fluid
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endometrial cellular debris and blood
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Average blood lost during menstruation
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30-80 mL
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Abnormal menstruation
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Menses lasting > 7 days
and/or blood loss > 80 mL |
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Primary dysmenorrhea
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idiopathic, crampy abdominal pain not addociated with pelvic disease
Onset generally 6-12 months after first menarche amenable to self-treatment |
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Can primary dysmenorrhea be self-treated?
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Yes
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Secondary dysmenorrhea
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associated with pelvic disease or pathology (endometriosis, PID, IUD)
onset may initially occur years after menarche May be related to irregular menstrual cycles or pain at times other than around time of menses Refer for treatment |
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Can secondary dysmenorrhea be self-treated?
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No
Refer for treatment by MD |
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Primary dysmenorrhea prevalence
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Prevalence highest in adolescence
Prevalence decreases after age of 25 (could be due to OC use, uterine adrenergic nerve-damage during pregnancy) |
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What levels are associated with primary dysmenorrhea?
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Prostaglandin levels
Leukotrienes and vasopressin may also play a role in dysmenorhea pain |
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What produces prostaglandin that is relative to menses?
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Endometrium
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When are prostaglandin levels highest during the menstrual cycle?
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First 2 days of menses
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Pathophysiology of primary dysmenorrhea
|
As progesterone levels decrease at the end of the luteal phase of menstruation, arachidonic acid levels increase
Prostaglandins cause uterine contractions which help expel menstrual fluids Increased levels of prostaglandins lead to stronger uterine contractions and vasoconstriction, leading to uterine ischemia and pain |
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Prostaglandins and leukotriene precursor
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Arachidonic acid
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Increased levels of prostaglandins lead to:
Causing: |
Lead to stronger uterine contractions and vasoconstriction
Causing uterine ischemia and pain |
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Primary dysmenorrhea signs/symptoms
|
continuous dull, aching pain and/or spasmodic cramping in lower abdomen, lower back, upper thighs
circulating prostaglandins may also cause N/V, fatigue, dizziness, irritability, diarrhea, H/A |
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When do symptoms of primary dysmenorrhea occur?
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Usually occur at menses onset and last 48-72 hours
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When should pain with menses be referred?
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Secondary dysmenorrhea
sexually active adolescents patients not responding to self-treatment |
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Nonpharmacologic treatment of primary dysmenorrhea
|
Heat (heating pad/heat patches)
Rest |
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Heat patches use with APAP or IBU
|
Heat patches provide additional benefit when used with oral IBU
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Aspirin and primary dysmenorrhea
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Should not be recommended because when used at low doses it has a minimal effect on prostaglandin production
Increases risk of Reye's syndrome in adolescents May increase menstrual flow |
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APAP and primary dysmenorrhea
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Should only be used for mild symptoms
less effective than NSAIDs Does not effect peripheral prostaglandin production |
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NSAIDs and primary dysmenorrhea
|
DOC for dysmenorrhea
Ibuprofen, naproxen effect production and action of prostaglandins peripherally |
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DOC for dysmenorrhea
|
NSAIDs
Ibuprofen, naproxen |
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NSAID dosing/schedule for dysmenorrhea
|
Start dosing at menses onset or 1-2 days before if pain is severe
Take on schedules basis vs. waiting for pain to occur If try one NSAID and no relief, may get relief from another IBU: 200-400mg q4-6h Naproxen: 220mg q8-12h |
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T/F
Using more than the max recommended OTC dose may provide additional pain relief. |
False
Will also increase risk of ADEs |
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PMS
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Premenstrual Syndrome
Combination of physical and emotional symptoms that occur during the luteal phase of the menstrual cycle |
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When does PMS resolve?
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after the first few days of menstrual flow
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PMDD
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Premenstrual dysphoric disorder
severe form of PMS that causes functional impairment |
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Trigger of PMS
|
cyclic hormone fluctuations
Serotonin levels may play a role (have been found to decrease with PMS) |
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PMS pathophysiology
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Ovarian hormone fluctuations cause biochemical changes in neurotransmitters (serotonin)
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PMS signs/symptoms
|
bloating/weight gain
breast swelling/tenderness fatigue anxiety irritability depression acne H/A swelling of extremeties appetite changes |
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PMS vs. PMDD symptoms
|
same symtpms
PMDD symptoms more sever |
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Nonpharmacologic treatment for PMS
|
aerobic exercise, diet modifications (balanced diet w/ alcohol, salt, simple sugar, and caffeine avoidance
cognitive-behavioral therapy |
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What should be avoided from diet during PMS?
|
alcohol, salt, simple sugar, caffeine
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Pharmacologic treatment for PMS
|
Pyridoxine
Vitamin E Calcium Magnesium NSAIDs Diuretics |
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Pyridoxine for PMS
|
=vitamin B6
100 mg QD doses >100mg may cause neurotoxicity |
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Vitamin E for PMS
|
400 IU used for breast tenderness
|
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Calcium for PMS
|
600mg BID
Side effects rare - include N, kidney stones |
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Magnesium for PMS
|
360mg QD may help reduce symptoms
ADEs: diarrhea |
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Diuretics for PMS
|
Most patients will not get relief with diuretics b/c usually experience a fluid shift with PMS instead of retention
Ex. Ammonium chloride, caffeine, pamabrom |
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T/F
Fluid shift is associated with fluid retention. |
False
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Ammonium chloride
|
diuretic
short duration of effect up to 3g/day do not take >6 consecutive days May cause metabolic acidosis with renal/hepatic impairment |
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Caffeine
|
diuretic
inhibits renal tubular reabsorption of Na and water 100-200mg q3-4h Tolerance may develop ADEs: anxiety, tachycardia, GI irritation, insomnia |
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Pamabrom
|
diuretic
derivative of theophylline up to 200mg/day (50mg QID) active ingredient in many combo products (Midol, Pamprin) |
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Combo products for PMS treatment
|
Ex. pamprin, midol
contain APAP, pamabrom, pyrilamine, caffeine, and/or magnesium salicylate |
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Should combo products be recommended for PMS relief? Why or why not?
|
No, APAP does not provide adequate pain relief for PMS symptoms other than H/A
no evidence for using pyrilamine for PMS most patients don't need a diuretic due to no weight gain |
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Toxic Shock Syndrome
|
severe, life threatening multisystem disease
caused by staph aureus or strep pyogenes symptoms occur as a response to enterotoxins release by bacteria |
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TSS risk factors
|
tampon use (especially higher absorbency tampons)
use of barrier contraceptives (sponge, diaphragms, cervical caps, IUDs) |
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TSS signs/symptoms
|
prodromal symptoms occur prior to illness (malaise, myalgias, chills)
early in illness: GI symptoms (V, D, abdominal pain) Later symptoms: high fever, myalgias, V, D, erythroderma, decreased urine output, severe hypotension, shock, H/A, seizures, *rash, desquamation of skin* |
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T/F.
A patient with TSS symptoms does not need to be referred if she has not been menstruating. |
False
|
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How long do antifungals remain in vaginal fluid?
|
At least 3 days afer 1 day treatment
|
|
|
Possible interactions:
Warfarin + antifungals |
May increase INR
|
|
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Antifungals:
Systemic absorption - high or low? |
Very little
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Antifungals:
ADEs |
vaginal burning, itching, irritation
|
|
|
Most effective dosage form of antifungals for vulvovaginal candidiasis
|
Cream
|
|
|
When should vulvovaginal cadidiasis be referred?
|
girls < 12 yo
pregnant women women experiencing yeast infection for the first time unclear symptoms |
|
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Counseling for antifungal use with vulvovaginal candidiasis
|
insert product high in vagine
also apply externally if vulvar symptoms are present complete entire course of treatment |
|
|
Antifungal duration of treatment when pregnant
Why? |
7 days
estrogen levels are high which increases the risk of vulvovaginal candidiasis infections may be resistant to treatment |
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|
Atrophic vaginitis
|
inflammation of vagina related to atrophy of mucosa due to decreased estrogen levels
May occur as a result of menopause, postpartum period, during breastfeeding |
|
|
Atrophic vaginitis:
Signs and symptoms |
Decrease in vaginal lubrication, vaginal irritation, dryness, burning, itching, dyspareunia
|
|
|
When should atrophic vaginitis be referred?
|
severe vaginal dryness
dyspareunia bleeding long standing atrophic vaginitis |
|
|
Atrophic vaginitis:
Treatment |
vaginal lubricants
|
|
|
What type of vaginal lubricants should be used to treat atrophic vaginitis?
|
water-soluble product
temporarily moisten vaginal tissues and provide relief form burning/itching, ease intercourse Ex. astroglide, KY Jelly, replens |
|
|
Counseling for vaginal lubricant use with atrophic vaginitis
|
Use a large quantity of lubricant initially, then tailor to individual needs
Do not use petroleum jelly warming lubricants also avaialbe. |
|
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Is petroleum jelly a good treatment option for atrophic vaginitis? Why or why not?
|
NO
difficult to remove breaks down latex condoms |
|
|
Douching:
AEs |
increased risk of PID
reduced fertility ectopic pregnancy vaginal infections STDs/STIs, cervical cancer, local irritation, contact dermatitis imbalance in normal vaginal flora |
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|
Patient counseling for douching
|
Do not recommend unless prescribed by physician for medical purposes
Do not forcefully eject fluid Do not douche immediately after intercourse if a spermicide was used |
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Is douching recommended for the treatment of vaginal infections?
|
NO
|
|
|
OTC vaginal antifungal agents MOA
|
Imidazole agents - increase cell permeability of susceptible fungi
|
|
|
Examples of OTC vaginal antifungal agents (active ingredient)
|
butoconazole nitrate
clotrimazole miconazole nitrate tioconazole |
|
|
Vulvovaginal candidiasis:
self-treatable? |
YES
|
|
|
Vulvovaginal candidiasis:
symptoms |
thich, white, "cottage cheese" discharge with no odor or a yeasty odor
normal pH |
|
|
Vulvovaginal candidiasis:
unique symptoms |
erythema
itching edema absence of malodor thick discharge |
|
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Vulvovaginal candidiasis:
organism(s), risk factors |
C. albicans, C. glabrata, C. tropicalis
May occur as result of treatment with antibiotics, immunosuppressants |
|
|
Vulvovaginal candidiasis:
Complications |
increased risk of other secondary infections
|
|
|
Vulvovaginal candidiasis:
Treatment |
vaginal antifungals (OTC or Rx)
butoconazole, clotrimazole, miconazole, tioconazole |
|
|
Vulvovaginal candidiasis:
Treatment for male partners |
Male partners not typically treated
|
|
|
Vulvovaginal candidiasis:
% of vaginal infections |
Causes 20-25% of vaginal infections
|
|
|
Bacterial vaginosis:
self-treatable |
NO
|
|
|
Bacterial vaginosis:
symptoms |
Thin, off-white or discolored (green, gray, tan) sometimes foamy discharge
unpleasant "fishy odor" vainal pH higher than normal |
|
|
What vaginal infection causes a "fishy" odor?
|
Bacterial vaginosis
|
|
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Bacterial vaginosis:
unique symptoms |
vaginal irritation, dysuria, malodor
|
|
|
Bacterial vaginosis:
organism(s) |
Polymicrobial infection a result of imbalance of normal flora (G. vaginalis and anaerobes)
|
|
|
What patients are at a higher risk of bacterial vaginosis?
|
new sexual partner, AA race, use of IUD, douching, receptive oral sex, tobacco use, prior pregnancy
|
|
|
T/F.
Use of oral contraceptives, female hormones, and condoms may be protective against bacterial vaginosis. |
True
|
|
|
Bacterial vaginosis:
Complications |
PID, UTI, cervicitis, endometriosis, infections after gynecologic surgery, may facilitate HIV spread
In pregnant women, may cause preterm labor and low birth weight |
|
|
Bacterial vaginosis:
Treatment |
vaginal clindamycin or vaginal metronidazole
PO metronidazole Probiotics |
|
|
Bacterial vaginosis:
Treatment of male partners |
Male partner not routinely treated
|
|
|
What % of vaginal infections are caused by vulvovaginal candidiasis, Bacterial vaginosis, and trichomoniasis?
|
vulvovaginal candidiasis: 20-25%
Bacterial vaginosis: 33% Trichomoniasis: 15-20% |
|
|
Trichomoniasis:
self-treatable? |
NO
|
|
|
Trichomoniasis:
Symptoms |
Copious, malodorous, yellow-green discharge, pruritis, vaginal irritation, dysuria
About 50% of women are asymptomatic initially |
|
|
Trichomoniasis:
Unique symptoms |
Yellow discharge
erythema edema |
|
|
Trichomoniasis:
organism(s) |
Organism: protozoan Trichomonas vaginalis
|
|
|
Trichomoniasis:
Risk factors |
multiple sex partners
new sex partner failure to use barrier contraceptives presence of other STDs |
|
|
Trichomoniasis:
Complications |
may facilitate HIV transmission
For pregnant women, may increase risk of pre-term labor, low birth weight infants, tubal infertility |
|
|
Trichomoniasis:
Treatment |
PO metronidazole or PO tinidazole
|
|
|
Trichomoniasis:
Treatment of male partners |
Partners must also be treated
Do not resume sex until patient and partners have completed the full course of treatment |
|
|
Itching and thick discharge are telling symptoms of what vaginal infection?
|
Vulvovaginal candidiasis
|
|
|
Malodor is a telling symptoms of what vaginal infection?
|
Bacterial vaginosis
|
|
|
Yellow discharge is a telling symptoms of what vaginal infection?
|
Trichomoniasis
|
|
|
If unable to tell by symptoms, what can you use to distinguish between vulvovaginal candidiasis and bacterial candidiasis?
|
Use the Fem-V home test kit, VH Essentials home test for BV, or Vagisil Screening Kit
|
|
|
How do you determine if medications should be used during pregnancy?
|
Only use meds after weighing risk vs. benefit to patient and fetus
|
|
|
Doses during pregnancy
|
Lowest doses for shortest period of time possible
|
|
|
Combo products during pregnancy
|
Avoid
|
|
|
1st trimester and meds
|
drug use is most risky during this time
development of fetus' neurological system and major organs |
|
|
What do you worry most about during 3rd trimester?
|
ductus arteriosus
|
|
|
FDA Pregnancy categories
|
A: remote risk, no risk shown in any trimester
B: safe in animals + no human data OR animal risk + safe human data C: risk to animals and no human data OR no data on either (benefit vs. risk) D: risk in human; benefits may outweigh risk X: CI in women who are/may become pregnant |
|
|
What vitamin is necessary to protect closure of the neural tube?
|
Folic acid
|
|
|
When does the neural tube close?
|
Within first 4 weeks of pregnancy
|
|
|
When should folic acid be taken to reduce neural tube defects?
|
Prior to and during pregnancy
|
|
|
Folic Acid dosing
|
All women of childbearing age should take 400 mcg of folic acid daily
Prior pregnancy w/ neural tube defect = 4000mcg qd |
|
|
How much folic acid should be taken if a prior pregnancy resulted in a neural tube defect?
|
4000 mcg QD
|
|
|
Calcium daily requirement
|
1200 mg/day
|
|
|
T/F.
Pregnancy can cause bone loss. |
True
|
|
|
Why is iron needed during pregnancy?
|
Increase production of RBCs for mom and fetus
|
|
|
How much dose maternal volume increase during pregnancy?
|
50%
|
|
|
When are fetal needs highest?
|
Third trimester
|
|
|
Iron supplement in 2nd and 3rd trimester
|
27 mg elemental iron/day
|
|
|
Iron supplement for women who are anemic (Hct <33%)
|
60-120 mg/day
|
|
|
First line treatment for pain during pregnancy
|
Non-drug measures (heat patches, ice pack, massage, braces, rest)
|
|
|
DOC for pain during pregnancy
Dose? |
APAP regular strength - 650 mg up to QID
|
|
|
NSAIDs during pregnancy
|
May be used second line with MD approval
Do NOT use during 3rd trimester |
|
|
NSAIDs pregnancy category
|
1st/2nd trimester: Preg Cat C
3rd trimester: Preg Cat D |
|
|
What risk do NSAIDs pose during pregnancy?
|
Premature closure of ductus arteriosus
|
|
|
ASA during pregnancy
|
Should not be recommended
|
|
|
ASA pregnancy category
|
All salicylates are category D in all trimesters
|
|
|
ASA risks during pregnancy
|
Increase risk of perinatal mortality, neonatal hemorrhage, decreased birth weight, birth defects
|
|
|
First line treatment for cold/allergy during pregnancy
|
Nonpharmacologic treatment
Lozenges/sprays, vicks vapo rub, humidifier/vaporizer, saline nasal spray, drink plenty of fluids |
|
|
Lonzenges/sprays used during pregnancy
|
Menthol and camphor
Risk is undetermined Low conc. of menthol so low risk |
|
|
Safest recommendations for cold/allergy during pregnancy
|
peppermint candy
chloraseptic throat spray (benzocaine) Luden's cough drops (Pectin) |
|
|
Vicks vapo rub during pregnancy
|
Retrospective studies
No developmental toxicity associated with exposures during pregnancy Do not ingest product orally |
|
|
Nasal decongestants during pregnancy
|
Oxymetazoline, phenylephrine, xylometazoline
Preg cat C amount of fetal exposure minimal b/c small systemic absorption recommended for cough due to post-nasal drip |
|
|
Oxymetazoline during pregnancy
|
nasal decongestant
No increased risk for malformations 2-3 sprays/nostril q10-12h (max 2 doses/day) |
|
|
Zinc with a cold
|
used to reduce the signs/symptoms of the common cold when given within 24 hrs of cold symptom onset
|
|
|
Zinc during pregnancy
|
zinc supplementation in vitamins during pregnancy may improve fetal development?
Doses studied </= 40mg/day or 3 drops/day for OTC zinc lozenges |
|
|
Vitamin C with a cold
|
may decrease symptoms of cold by < 24 hrs
Dose: 1-3 g/day Higher dose = N, D |
|
|
Vitamin C during pregnancy
|
max of 2 g/day
|
|
|
What antihistamine is first line during pregnancy?
|
loratadine
|
|
|
What sedating antihistamine is first line during pregnancy?
|
chlorpheniramine
|
|
|
nasal steroids for allergic rhinitis during pregnancy
|
Refer to MD
|
|
|
Guafenesin during pregnancy
|
may be unsafe if used in 1st semester - may lead to inguinal hernia
avoid LA/ER products and those with alcohol Use sparingly due to questionable efficacy for cough due to common cold |
|
|
Recommendations of guafenesin use (ACOG, Briggs, NCCWCH)
|
ACOG (Am. college of OBs and GYNs) - no recommendation
Briggs - low risk to fetus NCCWCH (National collaborating centre wor womens/childrens health) - use sparingly |
|
|
Dextromethorphan during pregnancy
|
Preg cat C
1st trimester - no increased risk of malformations detected Use sparingly due to questionable efficacy for cough due to common cold |
|
|
Guafenesin and Dextromethorphan for cough due to common cold
|
Neither have been proved effective
|
|
|
Pseudoephedrine/Phenylephrine during pregnancy
|
Pseudoephedrine considered safe short-term (2-3 days)
Avoid if pt's BP high Preg cat C |
|
|
Oral decongestants during pregnancy
|
Avoid during first trimester
Increased risk of gastroschisis (intestines outside body) May lead to vasoconstriction = maternal hypertension = impaired blood flow to fetus Ok during 2nd/3rd trimesters IM dosage - take min. effective dose for shortest duration possible 30-60mg q4-6h PRN (max 240mg/day) |
|
|
What is usually the first symptom of pregnancy?
|
N,V
|
|
|
How can N/V be avoided during pregnancy?
|
Avoided if prenatal vitamins taken daily from time of conception
|
|
|
When does N/V usually occur with pregnancy? When does it resolve?
|
Usually occurs in AM in 1st trimester of pregnancy
Usually resolves around week 12 |
|
|
What may cause N/V during pregnancy?
|
Vit. B6 deficiency, surging hormones, low BG in AM
|
|
|
When should morning sickness be referred?
|
dehydration symptoms
vomiting blood weight loss >/= 2 pounds |
|
|
Hyperemesis gravidarum
|
prolonged, severe vomiting leading to dehydration or malnutrition
rare may last entire pregnancy |
|
|
Treatment for morning sickness
|
Vit. B6 (pyridoxine) supplementation - 10mg q8h in combo with doxylamine
Doxylamine (unisom) - 1/2 of a 25mg tab TID Emetro - 5-10mL qAM and q3-4h PRN Ginger sometimes recommended - incorporate into diet |
|
|
Bismuth subsalicylate during pregnancy
|
Avoid - salicylate absorption
|
|
|
Loperamide during pregnancy
|
anti-diarrheal
preg cat B avoid in 1st trimester |
|
|
What may be helpful for regulating bowels throughout pregnancy?
|
bulk forming laxatives
|
|
|
Why does peristalsis slow during pregnancy?
|
progesterone levels, reduced intestinal muscle tone, decreased motility
|
|
|
T/F.
Growing fetus compresses colon. |
True
|
|
|
Prenatal vitamins for constipation
|
iron
calcium |
|
|
Constipation nonpharm. treatment during pregnancy
|
Lifestyle modifications - drink water, high fiber diet, activity unless CI
|
|
|
Constipation pharmacologic treatment of choice during pregnancy
|
Bulk forming laxatives (psyllium, soluble fiber)
|
|
|
Is docusate safe to use during pregnancy?
|
Yes - safe to prevent constipation and soften stools
|
|
|
Is simethicone safe to use during pregnancy?
|
Yes - for flatulence
|
|
|
Can MiraLax be used during pregnancy?
|
Yes - can be used daily - not systemically absorbed
|
|
|
What types of laxatives should not be used during pregnancy?
|
stimulant laxatives
osmotic laxatives mineral oil |
|
|
When is heartburn/GERD worst during pregnancy? Why?
|
3rd trimester
less intra-abdominal space, pressure on stomach |
|
|
Recommended lifestyle modifications for heartburn/GERD during pregnancy
|
avoid eating before bedtime
raise head of bed avoid alcohol/smokiing (duh) avoid trigger foods (chocolate, peppermint, etc) |
|
|
Heartburn/GERD during pregnancy: preferred pharmacologic treatment
|
Calcium carbonate (TUMS)
also a great source of calcium may cause constipation |
|
|
What should be added if constipation is an issue with use of calcium carbonate to relieve heartburn during pregnancy?
|
magnesium
|
|
|
H2 antagonists during pregnancy
|
Recommend if antacids ineffective
Avoid during 1st trimester |
|
|
Preferred H2 antagonist during pregnancy
|
Ranitidine
preg. cat. B |
|
|
PPIs during pregnancy
|
Use for persistent uncontrolled symptoms
|
|
|
Preg. Cat.
Omeprazole, pantoprazole, esomeprazole, lansoprazole |
Omeprazole: cat. C
Pantoprazole: Cat B Esomeprazole: Cat B Lansoprazole: Cat. B |
|
|
Why are yeast infections common during pregnancy?
|
increased estrogen levels
|
|
|
When should patients be referred for yeast infection during pregnancy?
|
If this is their first yeast infection
|
|
|
DOC for yeast infections during pregnancy
|
Clotrimazole
|
|
|
Duration of treatment for yeast infection during pregnancy
|
7 days
|
|
|
Imidazole and tioconazole during pregnancy for yeast infections
|
imidazole - probably safe
tioconazole (vagistat) - no data |
|
|
T/F.
Onset of atopic dermatitis and psoriasis common during pregnancy. |
True
|
|
|
T/F.
Skin is more sensitive during pregnancy. |
True
|
|
|
What can be recommended for dermatologic issues during pregnancy?
|
Mild non-soap cleansers
Moisturize with Cetaphil cream of Aquaphor ointment on extremely dry areas May use hydrocorisone short term (<3 days), after that refer to MD |
|
|
Smoking during pregnancy
|
Harmful to fetus
Causes growth retardation, premature birth, fetal neurotoxicity, ect |
|
|
Nicotine Preg. Cat
|
Preg. Cat. D (smoking more harmful)
|
|
|
Smoking cessation during pregnancy
|
Recommend non-pharmacologic approaches
If nicotine replacement is necessary, consider gum/lozenge |
|
|
Other considerations to offer during pregnancy
|
Wear seatbelt across legs
Do not change cat litter (toxoplasmosis) Omega-3 supplementation Calcium supplementation Folic acid 1g daily Iron supplement (iron stores reduced) Limit caffeine intake! (<300mg daily) NO herbal meds during pregnancy and lactation |
|
|
How much folic acid should be taken daily during pregnancy?
|
1 gram
|
|
|
How much caffeine during pregnancy?
|
< 300mg daily
|
|
|
What herbal meds can be used during pregnancy? Lactation?
|
NONE
|
|
|
Tinea capitis:
Definition Self-treatable? Fungi responsible |
Ringworm of the scalp
NOT self-treatable Trichophyton, Microsporum |
|
|
Tinea crusis:
Definition Self-treatable? Fungi responsible |
Jock itch
YES self-treatable Epidermophyton |
|
|
Tinea corporis:
Definition Self-treatable? Fungi responsible |
Ringworm of the body
YES self-treatable Trichophyton, microsporum, epidermophyton |
|
|
Tinea pedis:
Definition Self-treatable? Fungi responsible |
Athlete's foot
YES self-treatable Epidermoophyton |
|
|
Tinea unguium:
Definition Self-treatable? Fungi responsible |
Ringworm of the nail
NOT self-treatable Trichophyton, microsporum, epidermophyton |
|
|
Anthropophilic
|
Transmission of fungal infections via people
|
|
|
Zoophilic
|
Transmission of fungal infections via animal
|
|
|
Geophilic
|
Transmission of fungal infections via soil
|
|
|
Fomites
|
Transmission of fungal infections via infected combs, hats, etc
|
|
|
Signs and Symptoms of fungal skin infection
|
mild itching and scaling
sever, exudative inflammatory process (denudation, fissuring, crusting, discoloration) |
|
|
Tinea cruris:
Location Appearance/characteristics |
Location: medial and upper parts of the thighs and pubic area
Appearance: bilateral; pruritic, scaly lesions |
|
|
Acute vs. Chronic tinea cruris appearance
|
Acute: small bright red vesicles
Chronic: hyperpigmented appearance |
|
|
Tinea corporis:
Location Appearance/characteristics |
Location: glabrous (smooth and bare) skin
small circular, erythematous, scaly lesions; borders may contain vesicles or pustules; spreads peripherally |
|
|
Location of tinea corporis:
zoophilic vs. anthropophilic dermatophytes |
Zoophilic: neck, face, arms
anthropophilic: occluded areas, areas of trauma |
|
|
Tinea pedis:
Location |
feet
|
|
|
Appearance of chronic, intertriginous tinea pedis
|
fissured, scaled, macerated interdigital spaces, malodor, pruritus, stinging
|
|
|
Appearance of chronic, papulosquamous tinea pedis
|
both feet, mild inflammation and diffuse, moccasin-like scaled feet
|
|
|
Appearance of vesicular tinea pedis
|
small vesicles or vesicopustules near instep and on mid-anterior plantar surface, scaling
|
|
|
Appearance of acute, ulcerative tinea pedis
|
macerated, denuded, weeping ulcerations on the sole of the foot, white hyperkeratosis, pungent odor, pain
|
|
|
Pharmacologic treatment of fungal skin infections
|
clotrimazole and miconazole nitrate
terbinafine HCl butenafine HCl tolnaftate Undecylenic acid Salts of aluminum |
|
|
Inflammatory phase of wound healing
|
prepares wound for tissue development
|
|
|
Proliferative phase of wound healing
|
wound is filled with new connective tissue and covered with new epithelium
|
|
|
Maturation phase of wound healing
|
continual collagen synthesis and breakdown
|
|
|
Phases of wound healing
|
1. Inflammatory phase
2. Proliferative phase 3. Maturation phase |
|
|
Factors that affect wound healing
|
tissue perfusion and oxygenation
infection nutrition age weight DM meds |
|
|
Wound depth classification
|
Stage I: reddened, unbroken skin
Stage II: blister or partial-thickness skin loss involving epidermis and part of dermis Stage III: full-thickness skin loss; damage may be down to subcutaneous tissue; REFER Stage IV: stage III with underlying muscle/tendon/bone involvement; REFER |
|
|
What wounds should be referred for treatment (excluded from self-treatment)
|
Stage III or IV wound depth
wounds containing foreign matter after irrigation chronic wounds wounds secondary to animal/human bite wound with sign of infection wounds that involve face, mucous membrane or genitalia deep, acute wounds |
|
|
Minor wound treatment for stage I or II wounds
|
wound irrigants
antiseptics first aid antibiotics |
|
|
Wound irrigants
|
normal saline or water
|
|
|
antiseptics
|
applied around wound for disinfectant purposes to decrease the rate of infection
Hydrogen peroxide, ethyl alcohol, isopropyl alcohol, iodine, povidine-iodine, camphorated phenol |
|
|
Hydrogen peroxide
|
limited bactericidal effect
effervescent cleansing action occurs due to enzymatic release of oxygen Do NOT use in abscesses Wound should be dry before dressings are applied Recommend for wounds with broken skin and contamination with debris only |
|
|
When should hydrogen peroxide be recommended?
|
Recommend for wounds with broken skin and contamination with debris only
|
|
|
Ethyl alcohol
|
20-70%
good bactericidal activity may cause tissue irritation and skin dehydration, esp. at high concentrations |
|
|
Isopropyl alcohol
|
70%
stronger bactericidal activity than ethyl alcohol may have cytotoxic effects on open skin |
|
|
Stronger bactericidal activity: ethyl vs. isopropyl alcohol
|
Isopropyl alcohol
|
|
|
Iodine
|
broad antimicrobial spectrum against bacteria, fungi, virus, spores, protozoa, and yeast
Do not apply bandage after iodine application Will stain skin, may irritate tissue and may cause allergic rxns in sensitive individuals Solution preferred over tincture (tincture irritating to skin) |
|
|
Iodine: solution vs. tincture
|
Solution preferred over tincture (tincture irritating to skin)
|
|
|
T/F.
Bandages should be applied after iodine application. |
False
|
|
|
Povidine-iodine (betadine)
|
Rapid bactericidal activity
Not irritating to skin or mucous membranes absorbed systemically when used on open wounds When used on large areas for long periods of time, iodine absorption could lead to thyroid dysfunction, esp. in pts with renal dysfunction |
|
|
Can povidine-iodine (betadine) be absorbed systemically?
|
Yes if used on open wounds
|
|
|
T/F
Povidine-iodine use can lead to thyroid dysfunction. |
True
If used on large areas for long periods |
|
|
Camphorated phenol
|
contain high conc. of phenol which may be caustic when applied to wet skin
Apply to DRY skin only Do not apply bandages after application |
|
|
T/F
Bandages should be applied after camphorated phenol application. |
False
|
|
|
Should camphorated phenol be applied to dry or wet skin?
|
DRY
|
|
|
First aid antibiotics
|
prevent infection in minor cuts, wounds, scrapes, burns
Apply up to TID Bacitracin, Neomycin, Polymyxin B sulfate |
|
|
Bacitracin MOA
|
inhibits cell-wall synthesis in gram + organisms
|
|
|
Neomycin MOA
|
irreversible binds to 30s ribosomal subunit to inhibit protein synthesis in gram - organisms and some staph species
|
|
|
Polymyxin B sulfate MOA
|
polypeptide antibiotic that alters cell wall permeability of gram - organisms
|
|
|
Neosporin:
active ingredients considerations |
Bacitracin, polymyxin B, neomycin
Hypersensitivity from neomycin |
|
|
Neosporin Plus:
active ingredients considerations |
Polymyxin B, neomycin, pramoxine
Pramoxine (topical anesthetic) |
|
|
Polysporin:
active ingredients |
Polymyxin B, bacitracin
|
|
|
Wounds that do not require triple wound dressing
|
Minor abrasions and lacerations
Puncture wounds |
|
|
Treatment for minor abrasions and lacerations
|
Adhesive gauze-type bandage
Hydrocolloid-based bandages Liquiderm |
|
|
Treatment for puncture wounds
|
Inspect for foreign objects
Irrigate Soak with soapy water for 30 minutes QID Hydrocolloid or hydrogel dressing |
|
|
Moist Wound Healing
|
1. Dressings that absorb moisture in inflammatory phase
2. Dressings that maintain moisture in proliferative phase 3. Dressings that provide moisture in maturation phase |
|
|
Dressings that absorb moisture in inflammatory phase
|
Foam
Alginate Carbon-impregnated Composite |
|
|
Dressings that maintain moisture in proliferative phase
|
Hydrocolloid
Transparent Film |
|
|
Dressings that provide moisture in maturation phase
|
Amorphous Hydrogels
|
|
|
Scar Treatment
|
Mederma
Silicone Vitamin E |
|
|
Mederma:
active ingredient considerations |
active ingredient - onion extract
No proven benefits |
|
|
Silicone
|
Works by improving wound hydration or preventing dessication and fibroblast formation
Works best on immature hypertrophic scars Sheeting worn 12-24 hrs daily, rinsed, and reapplied Use for 3-6 months |
|
|
What types of scars does silicone work best for?
|
Immature hypertrophic scars
|
|
|
Vitamin E
|
Not effective for scar treatment
May cause dermatitis |
|
|
Clotrimazole and miconazole nitrate:
Indication |
tinea pedis
tinea cruris tinea corporis |
|
|
Clotrimazole and miconazole nitrate:
Frequency/duration |
Apply BID for up to 4 weeks
|
|
|
Clotrimazole and miconazole nitrate:
MOA |
Inhibits biosynthesis of ergosterol and damage fungal cell wall membrane
--> alter membrane permeability --> essential intracellular elements lost |
|
|
Clotrimazole and miconazole nitrate:
ADEs |
mild irritation, burning, stinging
|
|
|
Clotrimazole and miconazole nitrate:
Products |
Cruex, Desenex, Lotrimin, Micatin
|
|
|
Terbinafine HCl:
Indication |
tinea pedis (interdigital)
tinea cruris tinea corporis |
|
|
Terbinafine HCl:
Frequency/Duration |
Apply BID for up to 4 weeks
|
|
|
Terbinafine HCl:
MOA |
Inhibits squalene epoxidase
--> ergosterol deficiency --> accumulation of squalene within fungal cell --> cell death |
|
|
Terbinafine HCl:
ADEs |
Irritation
Burning Itching Dryness |
|
|
Terbinafine HCl:
Products |
Lamisil
|
|
|
Butenafine HCl:
Indications |
tinea pedis (interdigital)
tinea cruris tinea corporis |
|
|
Butenafine HCl:
Frequency/Duration |
Tinea pedis: Apply BID x 1 week, then QD x 4 weeks
Tinea cruris/corporis: Apply QD x 2 weeks |
|
|
Butenafine HCl:
MOA |
Inhibits squalene epoxidase
--> ergosterol deficiency --> accumulation of squalene within fungal cell --> cell death |
|
|
Butenafine HCl:
ADEs |
low incidence of ADEs
|
|
|
Butenafine HCl:
Products |
Lotrimin Ultra
|
|
|
Tolnaftate:
Indications |
tinea pedis (treatment and prevention)
|
|
|
Tolnaftate:
Frequency/Duration |
Apply BID x 2-4 weeks
|
|
|
Tolnaftate:
MOA |
Not reported
Distorts hyphae and stunts mycelial growth of fungi |
|
|
Tolnaftate:
ADEs |
stinging
|
|
|
Tolnaftate:
Products |
Tinactin
|
|
|
Undecylenic acid:
Indications |
tinea pedis
|
|
|
Undecylenic acid:
Frequency/Duration |
Apply BID x 2-4 weeks
|
|
|
Undecylenic acid:
MOA |
Not reported
|
|
|
Undecylenic acid:
ADEs |
Burning
|
|
|
Undecylenic acid:
Products |
Cruex
|
|
|
Salts of aluminum/aluminum acetate:
Indications |
wet tinea pedis (adjuvant)
lesions with inflammation |
|
|
Salts of aluminum/aluminum acetate:
Frequency/Duration |
Dilute with water and immerse foot for 20 minutes daily (up to TID) x 6 days
|
|
|
Salts of aluminum/aluminum acetate:
MOA |
anti-inflammatory properties
|
|
|
Salts of aluminum/aluminum acetate:
ADEs |
tissue necrosis
|
|
|
Salts of aluminum/aluminum acetate:
Products |
Burow's solution
|
|
|
Aluminum chloride:
Indications |
wet soggy tinea pedis +/- deep fissures (adjuvant)
|
|
|
Aluminum chloride:
Frequency/Duration |
Apply BID until signs/symptoms are gone, then QD to control signs/symptoms
|
|
|
Aluminum chloride:
MOA |
Anti-inflammatory properties
|
|
|
Aluminum chloride:
ADEs |
tissue necrosis
|
|
|
Aluminum chloride:
Products |
Burow's solution
|
|
|
Burow's solution
|
Made from utilizing Domeboro powder packets and varying amounts of water to alter the conc. of the solution)
Acetate 10 parts to 40 parts water Chloride 20-30% (with very deep fissures chonsider diluting to 10%) |
|
|
Tissue perfusion and oxygenation with wound healing
|
poor vascularization delays wound healing and reduces resistance to infection
|
|
|
Infections and wound healing
|
delays collagen synthesis and epithelialization
prolongs inflammatory phase |
|
|
Nutrition and wound healing
|
protein, carbs, vitamins, and trace elements are needed for collagen production and cellular energy
|
|
|
Age and wound healing
|
delays inflammatory response
increases capillary fragility |
|
|
Weight and wound healing
|
obesity leads to poor perfusion and delays wound healing
|
|
|
Diabetes and wound healing
|
reduces collagen synthesis
impairs wound contraction delays epidermal migration |
|
|
Medications and wound healing
|
corticosteroids: suppress inflammation
antineoplastics: interfere with cell divisioin anticoagulants: interfere with inflammatory phase |
|
|
Hemorrhoid
|
abnormally large, swollen conglomerate of blood vessels, supporting tissues, and overlying mucous membranes or skin in the anorectal region
|
|
|
Causes of hemorrhoids
|
Weakened muscle fibers within vascular cushions around anal canal
Increased downward pressure with defecation High resting anal pressure |
|
|
Risk factors for hemorrhoids
|
Increased age
Prolonged standing or sitting Lack of dietary fiber Constipation or diarrhea Heavy lifting with straining Pregnancy |
|
|
Signs/symptoms of hemorrhoids
|
itching, discomfort, irritation, burning, inflammation, swelling
|
|
|
Internal hemorrhoids
|
often painless (due to lack of sensory fibers(
may present with bleeding or prolapsed mass degree of prolapse graded I-IV |
|
|
External hemorrhoids
|
may present with mild discomfort to severe pain
visible swelling or lump possibly bluish in color |
|
|
Exclusions for self-treatment of hemorrhoids
|
Patients < 12 yo
diagnosed with GI diseases associated with colorectal bleeding family history of colon cancer history of potentially serious anorectal disorders previously diagnosed by PCP symptoms that persist > 7 days Anorectal s/sx: acute onset of severe pain, bleeding, seepage, prolapse, thrombosis, black tarry stools; moderate-to-severe itching, burning, inflammation, swelling, discomfort |
|
|
Non-pharmacologic treatments of hemorrhoids
|
increase dietary fiber intake
proper bowel habits good anal hygiene surgical or nonsurgical procedures |
|
|
Pharmacologic treatment of hemorrhoids
|
local anesthetics
vasoconstrictors protectants astringents keratolytics analgesics/anesthetics/antipruritics corticosteroids |
|
|
Local anesthetics and hemorrhoids:
MOA |
relieve itching, irritation, burning, discomfort, pain through reversibly blocking transmission of nerve impulses
External use only |
|
|
Local anesthetics and hemorrhoids:
ADEs |
burning
itching contact dermatitis |
|
|
Local anesthetics and hemorrhoids:
Products and Frequency |
Benzocaine, benzyl alcohol, dyclonine, lidocaine - use up to 6 times daily
Dibucaine - use up to 4 times daily Pramoxine - use up to 5 times daily |
|
|
Vasoconstrictors and hemorrhoids:
MOA |
relieve itching, discomfort, and irritation through constriction of arterioles resulting in transient reduction of swelling
|
|
|
Vasoconstrictors and hemorrhoids:
Intrarectal Vasoconstrictors |
Ephedrine, phenylephrine
Administer up to QID ADEs: increased BP, cardiac contractility, HR, and bronchodilation Use caution in patients with DM, thyroid disease, hypertension, angina pectoris, or enlarged prostate, and those taking antidepressants, antihypertensive agents, or cardiac meds |
|
|
Vasoconstrictors and hemorrhoids:
Topical vasoconstrictors |
ephedrine, epinephrine, phenylephrine
administer up to QID ADEs: nervousness, tremor, insomnia, N, loss of appetite |
|
|
Protectants and hemorrhoids:
MOA |
prevent irritation and water loss by forming physical barrier
external or internal use (except glycerin - external only) |
|
|
Protectants and hemorrhoids:
Products |
Petrolatum/white petrolatum: use as often as needed
Starch, cocoa butter, glycerin, mineral oil, zinc oxide, calamine: use up to 6 times daily or after each bowel movement |
|
|
Protectants and hemorrhoids:
ADEs |
minimal systemic absorption, minimal side effects
|
|
|
Astringents and hemorrhoids:
MOA |
relieve itching, irritation, and burning by promoting coagulation of skin cells and protecting underlying tissue
|
|
|
Astringents and hemorrhoids:
Products, frequency |
Calamine, zinc oxide - external or internal use
witch hazel - external use only administer up to 6 times daily or after each bowel movement |
|
|
Protectants and hemorrhoids:
ADEs |
Side effects typically uncommon
Long term use of internal zinc oxide can lead to zinc toxicity = N, V, lethargy, severe pain |
|
|
Signs/symptoms of zinc toxicity
|
N, V, lethargy, severe pain
|
|
|
Keratolytics and hemorrhoids:
MOA |
relieve itching and discomfort by promoting cell turnover and debridement of epidermal surface cells
|
|
|
Keratolytics and hemorrhoids:
Products, frequency |
Resorcinol - external use only; use up to 6 times daily or after each bowel movement
|
|
|
Keratolytics and hemorrhoids:
ADEs |
see ADEs with long-term use
tinnitus, tachycardia, sweating, SOB, methemoglobinemia, circulatory collapse, unconsciousness, convulsions |
|
|
Analgesics/anesthetics/antipruritics and hemorrhoids:
MOA |
relieve pain, itching, burning, or discomfort by producing local sensation that distracts from anorectal symptoms
External use only |
|
|
Analgesics/anesthetics/antipruritics and hemorrhoids:
Products, frequency |
Menthol, juniper tar, camphor
Use up to 6 times daily |
|
|
Corticosteroids and hemorrhoids: MOA
|
act as vasoconstrictor and antipruritic
|
|
|
Corticosteroids and hemorrhoids: Products, frequency
|
Hydrocortisone - use up to 4 times daily
Max conc. 1% delayed onset but longer DOA may mask bacterial and fungal infection symptoms |
|
|
Product selection guidelines for hemorrhoid treatment
|
combo products
dosage form considerations pregnant/breast-feeding (only use external products and internal protectants) Patients with CVD, HTN, DM, thyroid disease, difficulty urinating, or antidepressant use (do not use vasoconstrictors) |
|
|
What products should be used for pregnant/breast-feeding patients with hemorrhoids
|
Only use external products and internal protectants
|
|
|
When are vasoconstrictors not recommended for treatment of hemorrhoids?
|
Patients with CVD, HTN, DM, thyroid disease, difficulty urinating, or antidepressant use
|
|
|
What is the only helminthic infection with an approved OTC treatment option?
|
pinworm infections
|
|
|
How are pinworm infections transmitted?
|
Most common route: ingestion of infective eggs by direct anus-to-mouth transfer
Embryonated eggs also can be transferred from perianal region to clothes, bedding, or bathroom fixtures and dust |
|
|
How long do pinworm eggs remain viable?
|
20 days (esp. in humid conditions)
|
|
|
T/F.
Pinworm reinfections can readily occur. |
True
|
|
|
Pinworm infections:
symptoms |
often asymptomatic
perianal itching at night most common Symptoms of major infection: abdominal pain, insomnia, restlessness, anorexia, D, intractable localized itching |
|
|
What can scratching lead to during pinworm infections?
|
secondary bacterial infection of the perianal and perineal area
|
|
|
Exclusions for self-treatment of pinworm infections
|
liver disease, pregnancy, breast-feeding, < 2 yo, < 25 pounds, vague symptoms and negative visual inspection, helminthic infections other than pinworms, hypersensitivity to pyrantel pamoate, need for repeat dosing
|
|
|
Pinworm infections:
Non-pharmacologic treatment |
Wash bed linens, towels, sleeping clothes, and underwear daily
Open blinds or cutrains in affected room Take morning showers Use disinfectants on toilet seats Vacuum area around beds, curtains, etc., in bedroom Maintain proper hand hygiene, esp. before meals and after using toilet |
|
|
Pinworm infections:
Pharmacologic Treatment |
Pyrantel pamoate
|
|
|
Who should be treated for pinworm infections?
|
Everyone in household (unless excluded from self-treatment)
|
|
|
Pyrantel:
MOA, dose, ADEs |
MOA: depolarizing neuromuscular agent
Dose: 11 mg/kg single dose (max 1 g) (dose off pyrantel base in product) Take with or without food Repeat dose in 2 weeks (after referral) if symptoms don't improve ADEs: N, V, D, tenesmus, anorexia, abdominal cramps |
|
|
Pyrantel:
formulations |
Liquid formulations: 50mg pyrantel base/mL
Pin-X chewable tab: 250mg pyrantel base/tablet Reese's Pinworm caplet: 62.5 mg pyrantel base/tab |
|
|
Maximum dose of pyrantel
|
1 gram
|
|
|
Heartburn/GERD/dyspepsia:
pathophysiology |
Lower esophageal sphincter relaxes which allows reflux of gastric contents into lower esophagus
lower esophageal epithelium is not as tolerant to acid as stomach lining, so esophageal tissue may become inflamed, eroded, or ulcerated |
|
|
T/F
Lower esophageal epithelium is as tolerant to stomach acid as stomach lining. |
False
|
|
|
Heartburn
|
symptom of GERD
burning sensation arising from substernal are and moves up toward neck or throat (sometimes perceived as cardiac issue) |
|
|
Dyspepsia
|
symptom of GERD
"bad digestion" belching, bloating, N after meals |
|
|
GERD
|
gastroesophageal reflux disease
condition which develops when reflux of stomach contents causes troublesome symptoms and/or complications |
|
|
Complications of GERD
|
esophagitis
esophageal strictures Barrett's esophagus adenocarcinoma |
|
|
Typical symptoms of GERD
|
burning sensation in epigastric region that may move up toward the neck/throat
|
|
|
Atypical symptoms of GERD
|
asthma, chronic laryngitis, hoarsness/cough, globus sensation, noncardiac chest pain, dental erosions, sleep apnea
Referral required |
|
|
Alarming symptoms of GERD
|
dysphagia, odynophagia, chest pain, upper GI bleeding, unexplained weight loss, continuous N/V/D
Referral required |
|
|
Risk factors of GERD
|
diet, obesity, smoking, stress, pregnancy, genetics, diseases, drugs, H. pylori
|
|
|
Diet risk factors of GERD
|
fatty foods, spicy foods, chocolate, garlic/onion, mint, alcohol (white wine>red wine), caffeine/carbonation, acidic foods
|
|
|
Heartburn inducing drugs
|
bisphosphonates, ASA/NSAIDs, Iron, tetracyclines, anticholinergics, hormones, narcotic analgesics, TCAs, CCBs, albuterol
|
|
|
Heartburn symptoms in pediatric patients
|
Symptoms vary in this population
Infants: poor weight gain, excessive crying, disturbed sleep/feeding, recurrent ear infections Older children: intermittent vomiting, abdominal pain, cough, hoarseness |
|
|
T/F.
Recurrent ear infections may be a symptom of GERD in infants. |
True
|
|
|
T/F
Risk for GERD increases with age. |
True
|
|
|
Tissue injury/symptoms due to GERD
|
Risk of tissue injury greater in elderly but symptoms often milder than in younger population
|
|
|
Presentation of GERD in the elderly
|
primarily chronic respiratory complaints, poor dentation
Patient more likely to be taking GERD-causing meds |
|
|
GERD:
Nonpharmacologic treatment |
Institue these either before or at same times as pharmacotherapy
elevate head of bed, avoid lying down after eating, weight loss, avoid known triggers, eat small meals, avoid alcohol/tobacco/caffeine, drink water or chew gum, take PO meds with plenty of water |
|
|
GERD:
Pharmacologic treatment options |
antacids
bismuth subsalicylate H2 antagonists |
|
|
Antacids:
Indication, MOA |
For mild, infrequent or situational heartburn, sour stomach
Neutralize gastric acid |
|
|
Least expensive GERD treatment option
|
antacids
|
|
|
Antacids:
active ingredients |
magnesium salts
calcium carbonate sodium bicarbonate aluminum salts |
|
|
T/F.
Liquid antacids have a faster onset than other formulations |
True
|
|
|
Antacids:
Duration of action |
depends on dose timing
duration prolonged if taken with a meal Na bicarb < Mg < Ca = Al |
|
|
Which antacid(s) have the longest duration of action? Shortest?
|
Longest: calcium and aluminum
Shortest: sodium bicarb |
|
|
ANC
|
acid neutralizing capacity
|
|
|
Antacids:
drug interactions |
cations may bind some meds
|
|
|
T/F.
Antacids are not absorbed systemically. |
False - some absorbed
|
|
|
Antacids:
ADEs |
depends on active ingredient
|
|
|
ADEs of Na bicarbonate antacids
|
belching
flatulence may cause fluid retention/edema |
|
|
ADEs of magnesium antacids
|
dose related diarrhea
no belching or flatulence |
|
|
ADEs of aluminum antacids
|
constipation
hypophosphatemia no belching or flatulence |
|
|
ADEs of calcium antacids
|
constipation
belching flatulence hypercalcemia |
|
|
Which antacids do not cause belching or flatulence?
|
magnesium and aluminum antacids
|
|
|
Ingredients commonly included with antacids (why?)
|
Simethicone - decreases discomfort related to flatulence
Antireflux agent (alginic acid) - forms viscous layer over stomach contents; works well for dyspepsia |
|
|
Bismuth Subsalicylate:
Indications MOA ADEs |
indicated for heartburn, upset stomach, indigestion, N, D
MOA: topical protective effct on stomach mucosa May turn stool or tongue black |
|
|
What antacid product may turn tongue/stool black?
|
bismuth subsalicylate
|
|
|
H2 antagonists:
Indications |
treatment of mild to moderate infrequent (<2x weekly), episodic heartburn and for prevention of acid indigestion and sour stomach
Works well for nocturnal GERD symptoms |
|
|
H2 antagonists:
MOA |
block H2 receptors to decrease gastric acid secretion, decrease volume of secreted acid
|
|
|
H2 antagonists:
Products |
cimetidine (Tagamet)
ranitidine (Zantac) famotidine (Pepcid) nizatidine (Axid) |
|
|
H2 antagonists:
Duration of action, frequency |
Onset slower than antacids but duration longer
Dosed QD or BID |
|
|
Onset:
antacids vs. H2 antagonists |
H2 antagonists have a slower onset than antacids
|
|
|
H2 antagonists:
Counseling Points |
Best when taken 30 minutes - 1 hr before meal
Should not use > 14 days without consulting MD |
|
|
PPIs:
Indications |
frequent heartburn (>/= 2 x weekly)
|
|
|
PPIs:
Products |
omeprazole
lansoprazole omeprazole + Na bicarb (Zegrid) |
|
|
PPIs:
MOA |
Irreversibly shuts down ATPase proton pump
Blocks gastric acid secretion Inhibits basal and meal-time acid secretion |
|
|
PPIs:
Administration |
administered as enteric coated, DR acid labile prodrug
activated in acidic compartment of parietal cell Exception: zegrid (not enteric coated) - Na bicarb in formulation to protect drug |
|
|
PPIs:
Dosing |
Daily on an empty stomach 1 hour before a meal
No dosage adjustments necessary for renal/hepatic impairment |
|
|
PPIs:
onset of action |
2-3 hrs
Complete relief in 1-4 days Duration up to 24 hrs (T 1/2 1.5 hrs) |
|
|
PPI referral
|
symptoms continue while taking PPI, persist > 2 weeks, or recurs before 4 months after 1st treatment regimen
|
|
|
PPIs:
ADEs |
rare
H/A, abdominal discomfort, D bone fracture? |
|
|
PPIs:
Drug interactions |
potential for interactions - Cyp2C19
|
|
|
Onset of relief:
antacids vs. H2 antag. vs. H2 antag+antacid vs. PPI |
antacid: <5 minutes
H2 antag: 30-45 min. H2 antag + antacid: <5 min PPI: 2-3 hrs |
|
|
Duration of relief:
antacids vs. H2 antag. vs. H2 antag+antacid vs. PPI |
antacid: 20-30 min (longer if taken with food)
H2 antag: 4-10 hrs H2 antag + antacid: 8-10 hrs PPI: 12-24 hrs |
|
|
Symptomatic relief:
antacids vs. H2 antag. vs. H2 antag+antacid vs. PPI |
antacid: excellent
H2 antag: excellent H2 antag + antacid: excellent PPI: superior |
|
|
Screening questions for GERD treatment
|
How old is patient?
Does pt have renal impairment? Does pt have heart disease? Does pt have other GI symptoms? How long has pt had current symptoms? How often? Have they already tried OTC meds? |
|
|
Pediatrics pts with GERD
|
refer ages < 12 yo
Children >/= 12 yo may take calcium or magnesium antacids or H2 antagonists PPIs for ages >/= 18 |
|
|
Pregnant pts with GERD
|
calcium or magnesium antacids (cat. B)
H2 antags (cat. B) - check with OB b/c cross placenta (best to avoid in 1st trimester) |
|
|
Elderly with GERD
|
consider comorbidities (renal disease), other meds (interactions) before recommendation
|
|
|
Possible signs of heartburn (to help vary from angina/heart attack)
|
sharp, burning sensation just below breastbone/ribs
pain generally dose not rediate to shoulders, neck or arms, but can pain usually comes soon after meals or upon lying down symptoms may respond quickly to liquid antacids rarely accompanied by a cold sweat |
|
|
Most common conditions that involve N/V
|
motion sickness
pregnancy viral gastroenteritis |
|
|
motion sickness
|
rarely occurs in ages <2 or >50
women more susceptible |
|
|
N/V of Pregnancy (NVP)
|
usually subsides by 16th week of pregnancy (go with 12th week - Dr. Williams)
|
|
|
Viral gastroenteritis
|
acute transient attacks of V with D
usually self-limiting most common pathogens: norovirus and rotavirus can affect any age |
|
|
T/F.
Rotavirus vaccine is part of childhood immunizations. |
True
|
|
|
Acute complications of V
|
dehydration
electrolyte abnormalities aspiration malnutrition diaphragm hernia esophageal tears |
|
|
Treatment goals for N/V
|
identify and correct underlying cause
most cases are self-limiting and resolve spontaneously severe cases necessitate further evaluation |
|
|
Treatment approach for N/V
|
Population, cause, and severity determine therapy
Use caution in pregnancy and breast-feeding Children warrant special consideration |
|
|
Exclusions for self-treatment of N/V
|
N/V with fever and/or D
suspected food poisoning that doesn't clear in 12 hours blood in vomit severe abdominal pain in middle or right lower quadrant severe right upper quadrant pain after eating fatty foods yellow skin or eye discoloration and dark urine stiff neck and sensitivity to brightness diabetic with high BG and signs of dehydration head injury with blurry vision or numbness/tingling drug-induced (ADE, toxic dose, ethanol, chemo) psychogenic induced (bulimia, anorexia) chronic disease induced (gastroparesis, GERD) |
|
|
Additional exclusions for self-treatment of children with N/V
|
< 6months or weights < 8 kg
vomiting > 8 hrs vomiting with each feeding vomit contains red, black, green fluid sever dehydration is present (weight loss > 9%, lack urination in past 8 hours, sunken fontanel, absence of tears when crying, unusually sleepy or restless) |
|
|
Nonpharmacologic therapy of N/V
|
accupressure wristbands
battery-powered acustimulation band |
|
|
Accupressure wristbands
|
used in motion sickness, pregnancy, chemo
Stimulates P6 acupuncture point by pressure |
|
|
Battery-powered acustimulation band
|
FDA approved for pregnancy and motion sickness
Stimulates P6 acupunture point by electricity |
|
|
Recommendations for N/V due to motion sickness
|
avoid reading during travel
focus vision straight ahead avoid excess food/alcohol before travel avoid strong odors stay where motion is least |
|
|
Recommendations for N/V due to pregnancy
|
plenty of fresh air
eat crackers before rising and before breakfast get out of bed slowly eat 4-5 small meals/day no fluids with meals or soups drink small sips between meals try carbonated drinks or juices no greasy, spicy, or acidic food eat food that is chilled |
|
|
Pharmacologic therapy of N/V
|
antihistamines
antacids H2 antagonists PPIs bismuth subsalicylate (BSS) pshophorated carbohydrate (CHO) solution |
|
|
Antihistamines for N/V:
MOA |
1st generation antihistamines cross BBB and depress histamine release in brain caused by certain motions
|
|
|
Antihistamines for N/V:
Administration |
Take 30-60 minutes before departure
Continue during travel Do not combine with other CNS depressants (sedatives, alcohol) |
|
|
Antihistamines for N/V:
ADEs |
anticholinergic (drowsiness)
paradoxical stimulation in children |
|
|
Antihistamines for N/V:
Avoidance, Caution |
Avoid use: < 2 yo, elderly, lactating
Use caution: respiratory conditions, glaucoma, enlarged prostate |
|
|
Antihistamines for N/V:
Products |
cyclizine
dimenhydrinate diphenhydramine meclizine |
|
|
cyclizine dosing for N/V
|
2 - 6 yo: not recommended
6 -12 yo: 25mg q6-8h >/= 12 yo: 50 mg q4-6h |
|
|
dimenhydrinate dosing for N/V
|
2 - 6 yo: 12.5-25 mg q6-8h
6 -12 yo:25-50 mg q4-8h >/= 12 yo: 50-100 mg q4-6h |
|
|
diphenhydramine dosing for N/V
|
2 - 6 yo: 6.25 mg q4h
6 -12 yo: 12.5-25 mg q4h >/= 12 yo: 25-50 mg q4h |
|
|
meclizine dosing for N/V
|
2 - 6 yo: Not recommended
6 -12 yo: Not recommended >/= 12 yo: 25-50 mg one hour before travel |
|
|
Antacids for N/V
|
efficacy for N/V is marginal
|
|
|
H2 receptor blockers for N/V
|
Efficacy for N/V is uncertain
|
|
|
PPIs for N/V
|
data insufficient to support use in treating N/V
|
|
|
Probiotics for N/V
|
role, strain, and doses for N/V is undetermined
|
|
|
Bismuth subsalicyate:
MOA |
acts by topical effect on stomach mucosa
|
|
|
Bismuth subsalicyate:
Indications |
used for various GI complaints, including nausea associated with indigestion, heartburn, and gas
|
|
|
Bismuth subsalicylate:
Dosing |
262-525 mg q30-60min PRN
Max 4200 mg/day or 8 doses/day |
|
|
Bismuth subsalicylate:
ADEs |
Darkening of stool or tongue
Overdosage can cause neurotoxicity Tinnitus is a dose-related side effect |
|
|
Bismuth subsalicylate:
drug interactions |
any drug that may interact with ASA
|
|
|
Bismuth subsalicylate:
contraindications |
pregnancy/lactation
ASA sensitivity AIDS (increased risk of neurotoxicity) |
|
|
Difference in children's Bismuth subsalicylate formulation
|
Contains calcium carbonate
Avoid salicylates in children < 12 |
|
|
Phosphorated carohydrate (CHO) solution:
formulation |
mixture of levulose, dextrose, and phosphoric acid
|
|
|
Phosphorated carohydrate (CHO) solution:
MOA |
hyperoxmolar solutions decrease smooth muscle contraction and delay gastric emptying time
Dose-related effect |
|
|
Phosphorated carohydrate (CHO) solution:
Indications |
Nausea with upset stomach caused by intestinal/stomach influenza or diet indescretions
|
|
|
Phosphorated carohydrate (CHO) solution:
Dosing |
15-30 mL q15min until vomiting ceases
Do not consume other liquids for 15 min after dose Max 5 doses/hr Pregnancy: 15-30 mL on arising and q3h |
|
|
Complementary therapies for N/V
|
ginger
chamomile peppermint |
|
|
Ginger
|
used for N/V, NVP, motion sickness
SE: heartburn, worsening colic with gallstones, bleeding |
|
|
Chamomile
|
Used for gastric complaints, sedation
Interacts with Asteraceae allergy and antiplatelet drugs |
|
|
Peppermint
|
used for dyspepsia
SE: bronchial spasms in high doses, worsening heartburn |
|
|
Second-line treatment for NVP
|
Pyridoxine (vit. B6): 10-15 mg TID-QID (side effects are rare)
Doxylamine: only antihistamine used in pregnancy (cat. A) - 12.5 mg TID-QID |
|
|
Oral Rehydration Solution (ORS)
|
contain electrolyte mixtures
avoid sports drinks, fruit juices, soft drinks dosing based on severity measured by weight loss <3%: minimal to no dehydration. If <10kg, give 60-120mL for each episode. If > 10kg, administer 120-240 mL for each episode 3-9%: mild to moderate dehydration. 50-100mL/kg over 2-4 hrs >9%: severe dehydration. medical emergency = IV fluid replacement |
|
|
Evaluation of patient w/ N/V
|
Obtain medical, medication, and diet history
Similar s/sx in family members? Exclusions for self-treatment? Taking an antiemetic? What are symptoms related to? Motion sickness, pregnancy, overeating, food poisoneing, medication use |
|
|
Treatment for adult N/V due to motion sickness
|
antihistamines
|
|
|
Treatment for adult N/V due to pregnancy
|
phosphorated CHO solution, doxylamine, pyridoxine, or ginger
Rest, diet/environmental changes, or acupressure/acustimulation |
|
|
Treatment for adult N/V due to Overeating or disagreeable foods
|
bismuth products or phosphorated CHO solution
Avoid disagreeable foods, coffee, tea, alcohol, smoking, NSAIDs |
|
|
Treatment for adult N/V due to food poisoning
|
ORS
eat bland diet or fast if symptoms are excessive Explain signs/symptoms of dehydration |
|
|
Treatment for adult N/V due to medication use
|
advise taking med with food or changing timing
consult with physician and DC/decrease dose |
|
|
Treatment for children N/V due to motion sickness
|
antihistamines
avoid precipitating factor |
|
|
Treatment for children N/V due to gastroenteritis
|
dehydration present = refer
initiate ORS avoid antiemetics stop all feedings for 1 hr restart feeding with formula and light solids, as tolerated restart therapy with clear liquids if vomiting occurs continue breast-feeding of breast-fed infants |
|
|
Treatment for children N/V due to episodic/situational (otherwise healthy)
|
phosphorated CHO solution
|
|
|
When is diarrhea considered abnormal?
|
> 3 bowel movements per day
|
|
|
Acute diarrhea
|
< 14 days
|
|
|
Persistent diarrhea
|
14 days - 4 weeks
|
|
|
Chronic diarrhea
|
> 4 weeks
|
|
|
Highest prevalence of diarrhea
|
children < 5 yo
|
|
|
Most common causes of D
|
viral and food-borne illnesses
|
|
|
Risk factors for D
|
day care
caregiver congregate living conditions unsafe foods |
|
|
Viral gastroenteritis
|
norovirus from contaminated water/food
Rotavirus from fecal-oral route and common in infants during winter months |
|
|
Bacterial gastroenteritis
|
Caused by Campylobacter, Salmonella
Contaminated food --> outbreaks traced to processing plants E. coli most common cause for traveler's diarrhea |
|
|
Most common cause of traveler's diarrhea
|
E. coli
|
|
|
Protazoal diarrhea
|
caused by Giardia
NOT self-treatable |
|
|
Food induced diarrhea
|
food allergy, excessibely fatty/spicy foods, high amounts of roughage or seeds
|
|
|
Drug induced diarrhea
|
25% caused by antibiotics
C.diff |
|
|
C. diff
|
overgrowth leads to pseudomembranous colitis
Symptoms: green, watery, mucoid stools NEVER give anti-motility agents in bacterial diarrhea due to risk of trapping toxins in GIT (=tociv megacolon) |
|
|
How long before acute cases of diarrhea improve? Complications?
|
24-48 hours
Major complication is fluid and electrolyte imbalance |
|
|
Stool characteristics with diarrhea due to small intestine disease
|
undigested food particles
|
|
|
Stool characteristics with diarrhea due to upper GI bleeding
|
black, tarry
|
|
|
Stool characteristics with diarrhea due to colonic disorder
|
many, small-volume
|
|
|
Stool characteristics with diarrhea due to liver disorder
|
yellowish (presence of bilirubin)
|
|
|
Stool characteristics with diarrhea due to fat malabsorption disease
|
Whitish
|
|
|
Stool characteristics with diarrhea due to lower bowel or hemorrhoidal bleeding, foods (beets), drugs (rifampin)
|
Red
|
|
|
Diarrhea treatment goals
|
prevent or correct fluid/electrolyte loss and acid-base disturbances
relieve symptoms identify and treat cause prevent acute morbidity and mortality |
|
|
Diarrhea treatment approach
|
Infectious diarrhea is often self-limiting
Self-care should focus on fluid-electrolyte replacement Severe diarrhea is a medical emergency |
|
|
Exclusions for diarrhea self-treatment
|
>48 hrs since onset
fever > 102.2 F >6 unformed stools/day stool contains blood or mucus signs of severe dehydration >9% loss of body weight low BP/dizziness severe abdominal pain protracted vomiting <6 months old pregnancy diarrhea due to chronic medication antibiotic induced with C. diff presentation risk for significant complications (DM, severe CVD, renal disease, immunosuppressed) |
|
|
Nonpharm. treatment for diarrhea
|
fluid/electrolyte management
dietary management preventative measures |
|
|
Two phases of fluid/electrolyte management
|
Rehydration: replaces water/electrolyte deficits over 3-4 hrs
Maintenance: maintains normal composition and resumes dietary intake |
|
|
ORS use in adults; use with diarrhea
|
Little evidence to support use in adults
Use of ORS has no effect on duration of diarrhea |
|
|
ORS formulations
|
powders or premixed solutions
all available ORSs equally safe and effective |
|
|
When should ORS be used as diarrhea treatment?
|
Only use sports drinks, soda, and juices if >5 yo and diarrhea is mild
|
|
|
Oral rehydration therapy:
6 months - 5 years |
<3% dehydration: increase intake of fluids, continue regular diet
3-9%: begin ORT at 50-100 mL over 3-4 hrs; replace each loose stool with 10 mL/kg >/= 10% dehydration: hospitalize |
|
|
Oral rehydration therapy:
> 5 years old |
<3% dehydration: increase intake of fluids, continue regular diet
3-9% dehydration: begin ORT at 2-4L over 3 hrs; replace ongoing losses >/= 10% rehydration: referral |
|
|
Dietary management with diarrhea
|
oral intake dose not worsen diarrhea
bowel rest is not necessary reintroduce normal diet once rehydrated avoid fatty foods, foods rich in simple sugars, spicy foods, and caffeine |
|
|
T/F.
Oral intake may worsen diarrhea. |
False
|
|
|
T/F.
Bowel rest is necessary for diarrhea treatment. |
False
|
|
|
Diarrhea preventative measures
|
Isolate individual with diarrhea
hand washing and sterile technique Strict food handling and sanitation prophylaxis is NOT recommended |
|
|
When is prophylaxis recommended for diarrhea?
|
Never
|
|
|
Pharmacologic therapy for diarrhea
|
loperamide
BSS |
|
|
Complementary therapies for diarrhea treatment
|
Probiotics
Zinc |
|
|
Loperamide:
MOA |
stimulates micro-opiod receptors in intestinal muscles
slows intestinal motility and allows absorption of water and electrolytes |
|
|
Loperamide:
effects |
decrease fecal volume
increase viscosity increase bulk volume decrease fluid/electrolyte loss |
|
|
Loperamide:
Dose |
4mg initially then 2mg after each loose stool
Max of 8 mg/day or 48 hrs of use Avoid in children < 6 yo |
|
|
Loperamide:
ADEs |
dizziness
constipation |
|
|
Loperamide:
when to discontinue |
abdominal distension
constipation (risk of toxic megacolon) |
|
|
Loperamide:
drug interactions |
additive dizziness with sedatives, anxiolytics, antidepressants
|
|
|
BSS dose for diarrhea treatment
|
525 mg q30-60min PRN
Max 4200 mg/day or 48 hrs treatment |
|
|
BSS effects on diarrhea
|
decrease # of stools
increase stool consistency relieves abdominal cramping decreases N/V |
|
|
BSS + HCl for diarrhea (MOA)
|
bismuth oxychloride + salicylic acid
Bismuth moeity has antimicrobial effects against E. coli Salicylate moeity exerts antisecretory effects |
|
|
Probiotics with diarrhea
|
Lactobacillus, Bifidobacteria, Saccharomyces
MOA: improve microflora balance in the GIT Used for diarrhea secondary to antibiotics or infection NOT recommended for uncomplicated diarrhea |
|
|
Zinc with diarrhea
|
zinc deficiency impairs water/electrolyte absorption
NOT recommended in US |
|
|
Treatment for children < 5 yo with diarrhea
|
self-care limited to ORSs
|
|
|
Diarrhea treatment for elderly patients
|
diarrhea more likely to be severe or fatal
medical referral |
|
|
Diarrhea treatment during pregnancy
|
consult with provider first
Loperamide: cat. B BSS: contraindicated |
|
|
Patient counseling with diarrhea
|
Most episodes of diarrhea stop after 48 hours
Preventing dehydration is most important Appropriate use of ORS and diet management |
|
|
Deciding treatment for diarrhea
|
Treatment based on etiology, symptoms, drug interactions, and contraindications
BSS preferred when vomiting present Travelers need clean water if useing dry powder ORS |
|
|
Constipation
|
decrease in the frequency of fecal elimination characterized by the difficult passage of hard, dry stools
|
|
|
Normal bowel movements
|
3 per week or up to 3 per day considered normal
|
|
|
Causes of constipation
|
low activity level
inadequate fluid/fiber intake pregnancy nerve damage pain prolonged colon transit time IBS meds Medical conditions diets low in fiber/carbs |
|
|
What meds may cause constipation?
|
opiates, anticholinergics, benzos, diuretics, CCBs, B-blockers, NSAIDs, calcium, aluminum AAs, iron
|
|
|
What medical conditions may cause constipation?
|
diabetes, hypothyroidism, hemorrhoids, anal fissures, colorectal carcinoma
|
|
|
S/Sx of constipation
|
abdominal pain
cramping swelling bloating gas back pain |
|
|
What should constipation be referred?
|
sudden changes in stool
recent weight loss presence of abdominal pain blood in stool fever anorexia N/V failure to have BM after lifestyle modifications and laxative use |
|
|
Long term risks of constipation
|
fecal impaction
bowel obstruction fecal incontinence colon rupture toxic megacolon |
|
|
Nonpharm. treatments of constipation
|
increase fiber
increase fluids exercise establish routine limit foods known to cause constipation take advantage of gastrocolic reflex digital manipulation of anal sphincter chew sugarless gum containing sorbitol or mannitol |
|
|
When are nonpharm. treatment options effective for constipation?
|
For occasional constipation
Not as effective for chronic constipation |
|
|
Goal for fiber intake per day
|
20-35 g/day
|
|
|
Pharm. treatment of constipation
|
bulk laxatives
stool softeners/emollients lubricants saline laxatives stimulant laxatives hyperosmotic laxatives enemas |
|
|
Laxative of choice for constipation
|
Bulk laxatives
*unless rapid effect is necessary |
|
|
Laxative of choice during pregnancy
|
Bulk laxatives
|
|
|
How often and for how long can bulk laxatives be used?
|
1-3 times daily
May be used long term (will not cause dependence) |
|
|
Bulk laxatives effects on stool
|
increase stool frequency and weight (attract water)
softens stool |
|
|
What types of patients should take bulk laxatives?
|
Only those with adequate fluid intake
|
|
|
Bulk laxatives:
ADEs |
gas
not absorbed systemically so only GIT effects |
|
|
Methylcellulose bulk laxatives
|
synthetic
may cause less gas than natural products |
|
|
Psyllium bulk laxatives
|
natural
May cause esophageal obstruction Hypersensitivity may occur |
|
|
Which class is more effective for prevention rather than for treating constipation?
|
Stool softeners/emollients
|
|
|
Stool softeners/emollients:
MOA |
surfactant brings water into fecal mass to soften stool
|
|
|
Better option:
bulk laxatives vs. stool softeners |
bulk laxatives
|
|
|
Stool softeners/emollients:
Products |
docusate sodium
|
|
|
Stool softeners/emollients:
Target patients |
Patients with hard, difficult to pass stools, hemorrhoids, hernias
Not useful alone for pts with motility disorder or those < 2 yo |
|
|
Stool softeners/emollients
Adult dose |
50-360 mg QD
|
|
|
Can Stool softeners/emollients be used during pregnancy?
|
Yes
|
|
|
Mineral oil recommendation
|
Not generally recommended due to ADEs and fat soluble vitamin malabsorption
|
|
|
Lubricants:
MOA |
coats fecal matter with oil to lubricate and prevent water loss
|
|
|
Lubricants:
Products |
mineral oil
|
|
|
Can Lubricants be used during pregnancy?
|
No
|
|
|
Lubricants:
ADEs |
anal leakage
anal itching aspiration pneumonia |
|
|
Lubricants:
duration/frequency |
Avoid repeated and prolonged use
|
|
|
Lubricants:
Dosages |
Take PO 30-60 min before HS
6-12 yo: 10-15 mL/day >12 yo: 15-45 mL/day |
|
|
When are saline laxatives useful?
|
for quick, complete evaculation
often used before bowel surgery/procedures |
|
|
saline laxatives:
MOA |
contains Na or Mg
draw water into intestine |
|
|
saline laxatives
Counseling |
Must drink 8 oz water with each dose
Take on empty stomach |
|
|
saline laxatives:
frequency/duration |
Not for chronic use
|
|
|
Can saline laxatives be used during pregnancy?
|
No
|
|
|
saline laxatives
contraindications |
renal dysfunction
Oral form not for < 6 yo enema not for < 2 yo pregnancy |
|
|
saline laxatives:
ADEs |
Too much magnesium absorption may lead to hypotension, muscle weakness, CNS depression
|
|
|
saline laxatives:
Dosage |
Magnesium citrate: 150-300 mL
Magnesium hydroxide (Milk of Mag): 30-60 mL |
|
|
Stimulant laxatives:
MOA |
increase colonic activity (peristalsis) to force colon emptying
|
|
|
Stimulant laxatives:
Products |
Senna
Bisacodyl |
|
|
Senna
|
increases volume and pressure in intestines
SE: pink/red colored urine |
|
|
Bisacodyl
|
stimulates entire colon by causing contractions
Used for evacuation of bowel before procedure Avoid giving oral form w/in 1 hr AAs, H2 blockers, milk |
|
|
What is a good option for pts on opiods with constipation?
|
stimulant laxatives
|
|
|
Can Stimulant laxatives be used during pregnancy?
|
See MD advice - may cause uterine contractions
|
|
|
Stimulant laxatives:
ADEs |
abdominal cramping
watery stools |
|
|
Stimulant laxatives:
Duration |
Do not use for > 7 days
May lead to abuse/dependence |
|
|
Stimulant laxatives:
Dosage |
Bisacodyl: 10-30 mg QD
Senn: 187-374 mgQD |
|
|
Laxative of choice for children
|
Hyperosmotic laxatives
|
|
|
Hyperosmotic laxatives:
Products |
rectal glycerin
MiraLax |
|
|
Hyperosmotic laxatives:
MOA |
draws water into feces and has local irritant effect
|
|
|
What are Hyperosmotic laxatives good for?
|
lower bowel emptying
|
|
|
Hyperosmotic laxatives:
ADEs |
cramping
rectal discomfort |
|
|
Hyperosmotic laxatives:
Dosages |
Glycerin (children < 6 yo): 1-1.5g suppository or 2-5 mL rectal liquid
Glycerin (adult): 3g suppository or 5-15 mL rectal liquid Miralax: 17g powder dissolved in 4-8 oz beverage QD |
|
|
Who is MiraLax approved for?
|
adults and children 17 and older
safe for use in younger children under MD care |
|
|
Miralax: Duration
|
No longer than 7 days
|
|
|
Enemas:
Use |
cleans only the distal colon if used properly
|
|
|
Enemas:
ADEs |
fluid and electrolyte imbalance
spasms of intestinal wall abrasion of anus/rectum |
|
|
Enemas:
Products |
Sodium phosphate
sodium biphosphate Avoid soapsuds, tap water, saline enemas Use bisacodyl suppositories over enemas Only use when absolutely necessary and with caution |
|
|
Onset of action:
bulk laxatives - stool softeners/emollients - lubricants - saline laxatives - stimulant laxatives - hyperosmotic laxatives - enemas - |
bulk laxatives - 12-72 hrs
stool softeners/emollients - 24-72 hrs lubricants - 6-8 hrs saline laxatives - Oral 30min-3hrs; enema 2-5 min stimulant laxatives - Oral 6-10hr Supp. 1hr hyperosmotic laxatives - rectal glycerin 15-60min MiraLax 1-3 days enemas - up to 1 hr |
|
|
Signs/symptoms of gas
|
belching
abdominal discomfort cramping bloating glatulence |
|
|
Causes of gas
|
lactose initolerance
GI motility disorders foods meds |
|
|
Treatment of gas (before gas formation)
|
Beano (alpha-galactosidase)
Lactaid (lactose) |
|
|
Treatment of gas (after gas formation)
|
simethicone
activated charcoal (caution - will absorb everything, including meds) |
|
|
Simethicone:
MOA |
silicone polymers-defoaming agent
reduces surface tension of gas bubbles so they can be expelled |
|
|
Simethicone:
Dosage |
125-250mg after meals and at bedtime
Max 500 mg/day Safe in infants/children (not systemically absorbed) |
