Pharmaceutical care when Pharmaceutical care when dispensing OTCdispensing OTC

drugs for symptomatic drugs for symptomatic treatment and treatment and

prevention of coldsprevention of colds

A fever is any body temperature elevation over

100°F (37.8°C).A healthy person’s body temperature

fluctuates between 97°F (36.1°C) and 100°F (37.8°C), with the average being 98.6°F (37°C). The body maintains stability within this range by balancing the heat produced by the metabolism with the heat lost to the environment. The “thermostat” that controls this process is located in the hypothalamus, a small structure located deep within the brain. The nervous system constantly relays information about the body’s temperature to the thermostat, which in turn activates different physical responses designed to cool or warm the body, depending on the circumstances.

A dramatic rise in body temperature often includes the following symptoms: A. Loss of fluid results in dehydration. B.The

hypothalamic set-point is increased, raising metabolism. C. Blood vessels in skin dilate. D. Sweat glands produce excess

perspiration. E. Increased pulse rate. F. Increased hypothalmic set-point may introduce chills and shivering to promote heat

production from muscles. G. Skin becomes more heat-sensitive

Causes and symptoms

Fevers are primarily caused by viral or bacterial infections, such as pneumonia or influenza.Conditions that can induce a fever:

Allergic reactions; autoimmune diseases; trauma, such as breaking a bone; cancer; excessive exposure to the sun; Intense exercise; hormonal imbalances; certain drugs; damage to the hypothalamus.

Causes and symptoms (cont’d)

Malignant hyperthermia is a rare, inherited condition in which a person develops a very high fever when given certain anesthetics or muscle relaxants in preparation for surgery.

Causes and symptoms (cont’d)

Most fevers caused by infections are acute, appearing suddenly and then dissipating as the immune system defeats the infectiousagent. An infectious fever may also rise and fall throughout the day, reaching its peek in the late afternoon or early evening. A low-grade fever that lasts for several weeks is associated with autoimmune diseases such as lupus or with some cancers, particularly leukemia and lymphoma.

Fever. Causes in kidsInfections (bacterial, viral, fungal)Infections (bacterial, viral, fungal)

OverheatingOverheating

StressStress

ToothingToothing

Allergic reactionsAllergic reactions

Water-electrolite dysbalanceWater-electrolite dysbalance

VaccinationsVaccinations

"Threatenings" symptoms"Threatenings" symptoms

A fever requires emergency treatment under the following circumstances:

• newborn (three months or younger) with a fever over 100.5°F (38°C)

• infant or child with a fever over 103°F (39.4°C)

• fever accompanied by severe headache, neck stiffness, mental confusion, convulsions, or severe swelling of the throat

Threatening symptoms (cont’d)Threatening symptoms (cont’d)

A very high fever in a small child can trigger seizures (febrile seizures) and therefore should be treated immediately.

A fever accompanied by the above symptoms can indicate the presence of a serious infection, such as meningitis, and should be brought to the immediate attention of a physician.

A fever over 100.5°F (38°C) 3 days and longer

A fever over 37,5°C 2 weeks and longer

Fever of unknown origin (FUO)

– When temperature elevation occurs for an extended period of time and no cause is found, the term FUO is then used. The far majority of these patients are eventually found to have one of several diseases:

– Tuberculosis remains an important cause, especially when it occurs outside the lungs.

– Allergies to medications can also cause prolonged fever (sometimes patients will have other symptoms suggesting an allergic reaction, such as a rash).

– HIV is a potential cause of fever. (Patients with HIV are an especially difficult problem, as they often suffer from many unusual infections).

Treatment

Drugs to lower fever (antipyretics) can be given if a patient (particularly a child) is uncomfortable. These include aspirin, acetaminophen (Tylenol), and ibuprofen (Advil). Aspirin should not be given to a child or adolescent with a fever since this drug has been linked to an increased risk of Reye’s syndrome (A disorder principally affecting the liver and brain, marked by the rapid development of life-threatening neurological symptoms)Bathing a patient in cool water can also help alleviate a high fever.

Treatment (cont’d)Antipyretic

Aspirin is the prototype of the analgesic–antipyretic–anti-inflammatory drugs and the most commonly used salicylate.

It is effective in pain of low to moderate intensity, involving the skin, muscles, joints, and other connective tissue.

It is useful in inflammatory disorders, such as arthritis, but many people prefer drugs that cause less gastric irritation.

Treatment (cont’d) Propionic acid derivatives

ibuprofen (Motrin, Advil), ketoprofen (Orudis), naproxen (Naprosyn)

are available OTC

these drugs are usually better tolerated than aspirin, they are much more expensive and may cause all the adverse effects associated with aspirin and other prostaglandin inhibitors

AcetaminophenAcetaminophen is available in tablet, liquid, and rectal suppository forms and is in numerous combination products marketed as analgesics and cold remedies. It is often prescribed with codeine, hydrocodone, or oxycodone for added analgesic effects.

Treatment (cont’d)

Acetaminophen can cause liver damage; ibuprofen is a relative of aspirin that can cause gastrointestinal upset and bleeding. Total daily dosage should not be excessive (with Tylenol, above four doses of 1000 mg each; with ibuprofen, above 2400 mg).

The following The following guidelinesguidelines are provided to help are provided to help consumers make more informed choices consumers make more informed choices

when selecting OTC products:when selecting OTC products:Always read the labels and know the ingredients in the Always read the labels and know the ingredients in the products. Never take more than the recommended products. Never take more than the recommended dose. dose. Do not use aspirin-containing medicines for children Do not use aspirin-containing medicines for children and teenagers with influenzaand teenagers with influenza, , chickenpoxchickenpox or other viral or other viral illnesses. Rare cases of illnesses. Rare cases of ReyeReye syndromesyndrome have been have been associated with the use of aspirin in this population. associated with the use of aspirin in this population. Reye syndrome is a serious illness characterized by Reye syndrome is a serious illness characterized by liver damage, vomiting, and sometimes coma. It has a liver damage, vomiting, and sometimes coma. It has a 50% mortality rate, and those who survive can be left 50% mortality rate, and those who survive can be left with permanent brain damagewith permanent brain damage. . Therefore, Therefore, acetaminophen-containing products are acetaminophen-containing products are recommended for children with fever. NSAIDs may be recommended for children with fever. NSAIDs may be used in children over six months of age.used in children over six months of age.

GGuidelinesuidelinesAspirin and NSAIDs can cause ulcers and increase the Aspirin and NSAIDs can cause ulcers and increase the risk of bleeding, and should be avoided by people with risk of bleeding, and should be avoided by people with known known ulcer disease or certain blood diseasesulcer disease or certain blood diseases. People . People who are scheduled for elective surgeries should inform who are scheduled for elective surgeries should inform their doctors that they are taking aspirin or NSAIDs.their doctors that they are taking aspirin or NSAIDs.A true aspirin A true aspirin allergyallergy is rare. Aspirin allergy consists of is rare. Aspirin allergy consists of hives, occasionally difficulty breathing, and rarely shock, hives, occasionally difficulty breathing, and rarely shock, within three hours of taking aspirin.within three hours of taking aspirin. Aspirin Aspirin can precipitate bronchoconstriction (“aspirin asthma,” pseudoallergy) due to inhibition of PGE2 synthesis and overproduction of leukotrienes. Aspirin allergy is most common among Aspirin allergy is most common among individuals who have individuals who have asthma, urticaria, and nasal polypsasthma, urticaria, and nasal polyps. . Individuals with aspirin allergy should also avoid NSAIDs Individuals with aspirin allergy should also avoid NSAIDs because they are chemically similar to aspirin.because they are chemically similar to aspirin.Aspirin can cause complications during pregnancy and Aspirin can cause complications during pregnancy and should be avoided during pregnancyshould be avoided during pregnancy..Aspirin can increase the effectiveness of blood thinning by Aspirin can increase the effectiveness of blood thinning by Coumadin and may increase the risk of Coumadin and may increase the risk of bleedingbleeding..

BreathingBreathing

SwallowingSwallowing

Separating Separating (channelization)(channelization)

Speech Speech (articulation)(articulation)

INFLAMMATORY DISORDERS OF INFLAMMATORY DISORDERS OF THE PHARYNXTHE PHARYNX

Inflammatory disorders of the pharynx most Inflammatory disorders of the pharynx most commonly present as throat or neck pain. commonly present as throat or neck pain. Disphagia, odynophagia, and airway Disphagia, odynophagia, and airway obstruction are other frequent complaints. obstruction are other frequent complaints. The pharynx is a dynamic conduit for The pharynx is a dynamic conduit for inspired air and ingested matter, responsible inspired air and ingested matter, responsible for diverting each into the trachea or for diverting each into the trachea or esophagus, respectively. This process may esophagus, respectively. This process may be impaired by anything which obstructs or be impaired by anything which obstructs or restricts the mobility of the pharynx.restricts the mobility of the pharynx.

EVALUATIONEVALUATION Key historical considerations Key historical considerations – Age of patient Age of patient – Onset and duration Onset and duration – History of recent trauma (including possible foreign History of recent trauma (including possible foreign

body) body) – Inflammatory symptoms - fever, pain, malaise, Inflammatory symptoms - fever, pain, malaise,

malodorous breath malodorous breath – Status of nasal airway: congestion, obstruction, Status of nasal airway: congestion, obstruction,

rhinorrhea, purulent discharge, allergic history, snoring rhinorrhea, purulent discharge, allergic history, snoring – Reflux symptoms such as heartburn or water brash Reflux symptoms such as heartburn or water brash – Associated ear pain Associated ear pain – Disphagia or odynophagia Disphagia or odynophagia – Dyspnea or stridor Dyspnea or stridor – Other associated symptoms Other associated symptoms – Recent exposure to infectious discharge Recent exposure to infectious discharge – Cancer risk factors: smoking historyCancer risk factors: smoking history

Strep throatStrep throat

Strep often produces Strep often produces white patches in the white patches in the throat and on the throat and on the tonsils, as well as red, tonsils, as well as red, swollen tonsils. Pus swollen tonsils. Pus may be seen in the may be seen in the back of the throat.back of the throat.

Strep throat may Strep throat may cause the lymph cause the lymph nodes in the neck to nodes in the neck to become swollen and become swollen and tender. tender.

Pharyngitis.Pharyngitis. Symptoms   Symptoms   sore throatsore throat additional symptoms are dependent on the underlying additional symptoms are dependent on the underlying microorganisms microorganisms

step throat may be accompanied by fever, headache, step throat may be accompanied by fever, headache, swollen lymph nodes in the neck swollen lymph nodes in the neck

viral pharyngitis may be associated with runny nose viral pharyngitis may be associated with runny nose (rhinorrhea) and postnasal discharge (rhinorrhea) and postnasal discharge

severe cases of pharyngitis may be accompanied by severe cases of pharyngitis may be accompanied by difficulty swallowing and rarely difficulty breathingdifficulty swallowing and rarely difficulty breathing

Signs and tests.    A physical exam with attention to Signs and tests.    A physical exam with attention to the pharynx to assess whether drainage/coating the pharynx to assess whether drainage/coating (exudates) are present, as well as skin, eyes, neck (exudates) are present, as well as skin, eyes, neck lymph nodes is frequently done. lymph nodes is frequently done.

OropharyngoscopyOropharyngoscopy

•Swollen, erythematous mucosa of the oropharynx and hypopharynx, often with edema of the uvula and soft palate.•Swollen cyanotic lymphatic follicles on the posterior wall•Mucous or purulent discharges on the posterior wall

Complications   Complications   complications of strep throat: complications of strep throat:

rheumatic fever, rheumatic fever,

glomerulonephritis (kidney inflammation),glomerulonephritis (kidney inflammation),

chorea,chorea,

bacteremia (bloodstream infection) and rarely bacteremia (bloodstream infection) and rarely streptococcal shock syndrome streptococcal shock syndrome

in some severe forms of pharyngitis (e.g., in some severe forms of pharyngitis (e.g., severe mononucleosis-pharyngitis) severe mononucleosis-pharyngitis)

airway obstruction may occur airway obstruction may occur

peritonsillar abscess, retropharyngeal abscessperitonsillar abscess, retropharyngeal abscess

A sore throat A sore throat caused by a cold viruscaused by a cold virus usually usually resolves in resolves in one to two weeks without one to two weeks without treatmenttreatment. On the other hand, a sore throat . On the other hand, a sore throat caused by the streptococcus bacteriumcaused by the streptococcus bacterium (strep throat) (strep throat) should be treated with should be treated with antibiotics to prevent damage to the heart antibiotics to prevent damage to the heart valvesvalves ( (phenoxymethylpenicillin 500 mg four times a day or cefaclor 250 mg three times daily).. Generally, Generally, streptococcus bacteria cause a more severe streptococcus bacteria cause a more severe sore throat and a higher fever than viral sore sore throat and a higher fever than viral sore throats.throats.In some cases, strep may cause In some cases, strep may cause

nausea, a lack of appetite, nausea, a lack of appetite,

or pain in the head and abdomen.or pain in the head and abdomen.

A less common sign of strep infection is a A less common sign of strep infection is a rash that appears on the neck and chest, rash that appears on the neck and chest, eventually spreading to the rest of the eventually spreading to the rest of the body. When this rough, sandpaper-like body. When this rough, sandpaper-like rash develops, the infection is known as rash develops, the infection is known as scarlet feverscarlet fever. Although the full body rash . Although the full body rash may be alarming, it will start to fade after a may be alarming, it will start to fade after a few daysfew days

Sneezing, runny nose, and cough more Sneezing, runny nose, and cough more frequently accompany sore throats due frequently accompany sore throats due to a cold virus, rather than to a cold virus, rather than streptococcus infections. Sometimes, a streptococcus infections. Sometimes, a throat culture is necessary to establish throat culture is necessary to establish the cause of the sore throat.the cause of the sore throat.

Antibiotic treatment may Antibiotic treatment may lessen symptoms lessen symptoms and duration of illness and duration of illness and decrease and decrease

the chance for complicationsthe chance for complications

Acute TonsillitisAcute Tonsillitis

The most common organism is The most common organism is beta beta hemolytic streptococcushemolytic streptococcus, but viral organisms , but viral organisms can also cause exudative tonsillitis. Other can also cause exudative tonsillitis. Other causative organisms include staphylococcus causative organisms include staphylococcus aureus, streptococcus viridans, and various aureus, streptococcus viridans, and various hemophilus species. hemophilus species.

Catharal and Follicular TonsilitisCatharal and Follicular Tonsilitis

•The tonsils are red, enlarged and painfulnesswith an exudate or studded with white follicles. •Tender, firm cervical adenopathy is often present

Tonsillar hypertrophyTonsillar hypertrophy

TTreatmentreatment

Taking antibiotics Taking antibiotics unnecessarily can unnecessarily can contribute to the contribute to the growing problem of growing problem of microbial resistance. microbial resistance. When bacteria are When bacteria are frequently exposed to frequently exposed to antibiotics, they may antibiotics, they may become "superbugs" become "superbugs" that can't be treated that can't be treated with standard with standard medications.medications.

TTreatmentreatment

Since fever and painful Since fever and painful swallowing can lead to swallowing can lead to dehydration, it's dehydration, it's important to increase important to increase intake of fluids to intake of fluids to combat it. Water and combat it. Water and ginger ale are good ginger ale are good choices. A patient choices. A patient should avoid citrus should avoid citrus drinks which can irritate drinks which can irritate an inflamed throat.an inflamed throat.

TTreatmentreatment

Medications that are available OTC for Medications that are available OTC for the temporary relief of sore throat due to the temporary relief of sore throat due to the common cold usually contain the common cold usually contain anesthetics such as anesthetics such as benzocainebenzocaine and and dycloninedyclonine or or mentholmenthol and come in the and come in the form of form of

lozenges, lozenges,

gargles, gargles,

sprays. sprays.

TTreatmentreatmentPain RelieversPain RelieversOver-the-counter pain Over-the-counter pain relievers, like relievers, like acetaminophen, acetaminophen, ibuprofen, or naproxen, ibuprofen, or naproxen, can temporarily dull the can temporarily dull the pain of a sore throat. pain of a sore throat. (Do not give aspirin to (Do not give aspirin to children and teenagers children and teenagers because of the risk of because of the risk of the rare but potentially the rare but potentially fatal Reye's syndrome.)fatal Reye's syndrome.)