MAPs

MAP#1 GI Gas

How is excess gas removed?

flatulence or eructation (belching)

What are common symptoms?

ab discomfort, distention or pain, bloating, burping, flatulence

What are the main sources of GI gas?

• air swallowing (aerophagia)

• by intestinal bacteria

• movement between lumen and blood

What causes eructation (belching)?

aerophagia (excessive air swallowing), carbonated beverages

Name factors that can cause aerophagia.

eating fast, chewing gum, smoking, ill fitted dentures, excess salivation, anxiety

What is abdominal discomfort?

bloating, cramping, pain

What causes ab discomfort?

may be on its own or sign of underlying condition (IBD, GERD, colon cancer, eating disorder)

What is considered excessive flatulence?

> 25 times a day

What causes flatulence?

normal metabolic byproducts of nonabsorbable food digested by intestinal bacteria

What are the 5 primary components of flatus?

N, H, CO2, CH4, O

What causes the odour of flatus?

trace gases (skatoles, indoles, sulfur)

What are common dietary sources of intestinal gas?

lactose, fiber, nonabsorbable carbs

What are the goal(s) of therapy?

reduce/eliminate symptoms (belching, pain, bloating, flatulence)

minimize odour and social embarassment

identify and refer patients with red flags

What are red flag symptoms that require referral? (8)

mod to severe ab pain and distention

sudden change in bowel movement

blood in stool/vomit

dysphagia

dyspepsia

fever or chills

nausea or vomiting

unintentional weight loss

What is the 1st line for GI gas?

nonpharm (diet, lifestyle)

What are nonpharm options for eructation?

educate patient to stop gulping air

adjust poorly fitting dental apparatus

reduce gum chewing

reduce smoking

lower consumption of carbonated drinks

eat slowly

breathing exercises

What are nonpharm options for GI discomfort?

eat smaller meals earlier in the day

physical activity

What are nonpharm options for flatulence?

eat small more frequent meals

physical activity

What is the FODMAPs diet?

diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols

T/F there is lots of evidence that supports FODMAPs making it a strong recommendation

F

What are examples of food rich in FODMAPs?

apples, cauliflower, garlic, honey, mangoes, milk, watermelon

T/F there is limited evidence for pharm treatments of GI gas and there is no consensus for guidelines

T

What are the 1st line pharm options for GI gas?

simethicone

alpha-D-galacotosidase

lactase enzyme

What does simethicone do?

treat flatulence and bloating

prevent bubbling in stomach

can be used with loperamide (acute diarrhea)

What does alpha-D-galactosidase do?

treat flatus and discomfort associated with nonabs. carbs

do not put on hot food or enzyme become inactive

What are the 2nd line pharm options for GI gas?

bismuth subsalicylate

probiotic

When should lactase enzyme supplements be used?

in individuals with suspected lactase deficiency, consume before or with lactose products

What is bismuth subsalicylate for?

AKA pepto bismol

short term flatulence relief (<4 weeks)

long term use = salicylate toxicity

What are common side effects of bismuth salicylate?

constipation, nausea, tongue discolouration, grey/black stool

Is bismuth salicylate safe to use in pregnancy?

avoid in 2nd half of pregnancy

MAP #2 Acute Cough

What are the 3 categories of cough?

acute (<3 weeks)

subacute (3-8 weeks)

chronic (>8 weeks)

What are red flags for acute rough that need referral?

prolonged (>72h) or high (>40.5*C) fever

cough present > 3 weeks

discomfort/difficulty breathing

vomiting/choking from cough

earache (children)

barking cough

What are underlying conditions in a patient with acute cough that require referral?

B pertussis or B parapertussis infection

acute bacterial sinusitis

chronic bronchitis

allergic rhinitis

pneumonia

What are the 1st line options for acute cough?

dextromethorphan

simple demulcents (sugar-free lozenges)

honey (1-2 tsp, age >1y)

What are 2nd line options for acute cough?

guaifenesin

ipratropium nasal spray

acetaminophen or ibuprofen

menthol/eucalyptus (rub on chest)

What are 3rd line options for acute cough?

short acting B2 agonist

inhaled corticosteroid

PPI (GERD related cough)

antibiotics (bacterial infection)

What should never be recommended for acute cough?

OTC codeine or dextromethorphan prods for children <6y

1st gen antihistamine + decongestant unless benefit > risk

What are some precautions for dextromethorphan?

avoid in <6y

use with caution in asthma/COPD/productive cough

may cause drowsy/dizzy

risk of misuse in teens

What are some precautions for menthol/eucalyptus rubs?

avoid in <2y

What are some precautions for honey?

avoid <1y (botulism)

can raise blood sugar in diabetes

When should the pharmacist follow up with the patient?

1-2 days to assess side effects/safety

1—3 weeks to check cough severity/intensity

MAP #3 Dandruff and Seborrheic Dermatitis

What is dandruff?

mild, noninflammatory form of SD, limited to scalp

What is seborrheic dermatitis?

inflammatory, erythematous and scaling eruptions, at sebaceous glands (scalp, face, upper trunk)

How can you differentiate between dandruff and seborrheic dermatitis?

dandruff: non inflam, mostly cosmetic

SD: in seborrheic areas, mostly in immunocompromised (HIV)

What is the proposed pathophysiology?

malassezia yeast overgrowth

T/F women are more likely to have SD due to estrogen

F, males & androgen

What are aggravating factors?

genetics (psoriasis, allergy)

HIV/AIDS

Parkinson disease

30-50y

environment (humidity, cold/dry weather)

stress/poor sleep/sweat

What population is at higher risk of developing SD?

immunocompromised

Parkinson’s disease

How can you differentiate from psoriasis?

slivery white scales, elbows/knees

How can you differentiate from blepharitis?

red, crusty eyelid margins

How can you differentiate from tinea capitis?

patchy hair loss, more common in children

How can you differentiate from atopic dermatitis?

intense itching, history of atopic triad

How can you differentiate from contact dermatitis?

link to allergen exposure

How can you differentiate from yeast infection?

bright red moist patches, satellite pustules

How can you differentiate from rosacea?

facial flushing, not on scalp

How can you differentiate from tinea corporis?

ring shaped lesions with central clearing

How can you differentiate from tinea cruris?

red itchy rash in groin

What are goals of therapy for dandruff?

reduce/eliminate scales and flaking

prevent recurrence by improving scalp hygiene

What are goals of therapy for seborrheic dermatitis?

prevent progression

reduce fungus and associated scaling and inflammation

relieve signs and symptoms (pruritis)

eliminate environmental triggers

What are 1st line options for dandruff/SD?

medicated shampoos (ciclopirox, ketoconazole)

topical antifungals (ketoconazole, ciclopirox olamine)

How long should you leave the shampoo in?

up to 20 mins, depend on product

T/F ketoconazole and ciclopirox olamine show similar efficacy

T

What are 2nd line options?

topical corticosteroids (hydrocortisone, betamethasone)

antifungals (Selenium sulfide; shampoo/lotion)

keratolytic/antiproliferatives (salicylic aicd, sulfur, coal tar)

T/F you can stop corticosteroids once pruritus and erythema resolve

T

What are 3rd line options?

oral itraconazole/ketoconazole

topical calcineurin inhibitor (tacrolimus) if topical corticosteroid no work

NHPs (tea tree, aloe)

UV light therapy

What is the comparative efficacy of the pharm options? (rank 1 = best)

1. ketoconazole

2. hydrocortisone

3. selenium sulfide

4. zinc pyrithione

5. keratolytic

6. coal tar

What are some nonpharm measures?

gentle shampoos and brushing to remove scales (infants)

avoid aggravating factors

keep hair short

avoid hot water

use cool air humidifier

exposure to sunlight

nonmedicated shampoos

When should you refer?

failure to respond to 1st line after 4 weeks

signs of secondary changes (bacterial infection, spread)

systemic symptoms

rapid onset of symptoms

vision changes due to intense swelling around eyes

When should pharm follow up?

2-3 weeks

MAP #4 fungal skin infections

What are dermophytes?

umbrella term, survive on dead keratin (epidermis), do not invade living tissue

infection = ringworm or tinea

What is pityriasis versicolour yeast infection caused by?

malassezia species, affect stratum corneum layer (sebaceous glands)

What is cutaneous candidiasis yeast infection caused by?

candida yeasts (normal flora)

What are the goals of therapy?

eliminate/reduce causative organism

heal lesion and relieve symptoms

prevent spread and recurrence

prevent secondary complications (scarring, pigmentation)

How does tinea barbae present?

unilateral

beard/mustache hair loss

pustules

How does tinea capitis present?

scalp hair loss

“black dots” or “grey patch”

How does tinea corporis present?

round scaly patch with central clearing

raised border

How does tinea cruris present?

itchy ring rash in groin (not on scrotum)

How does tinea mannum present?

dry/thickening of one palm

How does pityriasis versicolour present?

hypo/hyperpigmentation patches that do not tan

How does cutaneous candidiasis present?

moist, red rash, satellite pustules

What are the 1st line options?

azoles (clotrimazole, miconazole, ketoconazole)

terbinafine

What is the main difference between azoles and terbinafine?

azoles have shorter therapy duration (1 week vs. 4 weeks)

What are 2nd line options?

ciclopirox, tolnaftate, undecylenic acid

What are 3rd line options?

corticosteroids

systemic antifungals

What are some non pharm options?

keep skin clean and dry

wear loose fitting clothes

nonmedicated powders (no evidence)

prevent spread (avoid sharing personal items)

For a pregnant person, what are the best/1st line options?

clotrimazole and miconazole

Assessment of Perianal Symptoms

Who is at risk for colorectal cancer?

>50y

history of colorectal cancer

family history of adenomatous polyposis or Lynch syndrome

IBD

strong family history

How would you assess a child <12y of age?

possible pinworms

sexual abuse

congenital abnormality

REFER

When should you refer a patient with perianal symptoms?

patient at risk of colorectal cancer

rectal bleeding

mass or protrusion

fever

rectal pain

If a patient presents with predominant itching symptom and there is a child in the household, what can you infer?

possible pinworms

If a patient presents with itching, irritation, swelling, lots of bright red blood on outer part of stool, what can you infer?

possible hemorrhoids