Non-Rx

Headache, Fever, and Musculoskeletal Pain

Headache - Exclusions for Self Care (7)

1. Severe headache (intolerable, unlike any other headache)

2. Headache lasting > 10 days w/ or w/o treatment

3. Women in last trimester of pregnancy

4. Children < 8 years of age

5. High fever or signs of infections disease

6. Headache due to head trauma or stroke

7. Symptoms of migraine without a prior diagnosis of migraine

Headache - Pharmacotherapy

• Acetaminophen (APAP)

  • Analgesic (++)

  • Antipyretic (++)

  • Anti-inflammatory (+)

  • liver toxicity

• Non-steroidal anti-inflammatory drugs (NSAIDs)

  • Analgesic (++)

  • Antipyretic (+++)

  • Anti-inflammatory (+++)

  • Cardiac, GI, renal toxicity

  • Avoid naproxen in Children < 12 y/o

• Aspirin (ASA) or salicylates

  • Analgesic (++)

  • Antipyretic (++)

  • Anti-inflammatory (++)

  • GI toxicity

  • Avoid in Children with influenza or chickenpox

Headache - APAP (acetaminophen/tylenol)

• inhibits COX-2 in CNS

• analgesic, antipyretic effects

• extensively metabolized by liver, eliminated by kidneys

• Onset: 30 minutes after oral intake

• Duration: 4 hrs; 6-8 hrs for XR

• Potentially toxic > 4 grams/day

  • especially with chronic use

• liver toxicity with overdose

Headache - NSAIDs (ibuprofen/Motrin naproxen/aleve)

• nonselective, reversible inhibition of COX enzymes to inhibits prostaglandin synthesis

• analgesic, antipyretic, anti-inflammatory effects

• metabolized by liver through glucuronidation, eliminated by kidneys

• Onset: 30 minutes

• Duration: 6-8 hr for Ibuprofen; 12hrs for Naproxen

• GI toxicity, cardiac toxicity, renal toxicity

OTC Analgesics: Drugs of Choice for Children < 12 y/o

APAP or Ibuprofen

OTC Analgesics: Drugs of Choice for Pregnancy or breastfeeding mothers

APAP

OTC Analgesics: Drugs of Choice for Heart disease, GI ulcers or bleeding, kidney disease, or on ASA for cardiac protection

APAP

OTC Analgesics: Drugs of to AVOID for Children < 12

Naproxen or Salicylates

OTC Analgesics: Drugs of to AVOID for Children/Teens recovering from chickenpox or influenza

Aspirin or Salicylates

OTC Analgesics: Drugs of to AVOID for Pregnancy or breastfeeding mothers

Aspirin or NSAIDs

OTC Analgesics: Drugs of to AVOID for GI ulcers, gout, recent surgery, uncontrolled HTN, heart failure, kidney disease

NSAIDs or salicylates

OTC Analgesics: Drugs of to AVOID for Liver disease, 3 or more alcoholic drinks/day, poor nutritional diet

APAP

APAP (Acetaminophen/Tylenol) dosing in Adults & Children 12 years or older - Dose, Dose Schedule, Max Daily Dose

• Dose

  • 325 - 1000mg

• Dose Schedule

  • Q 4 - 6 hrs PRN

  • Extra Strength Q 6 - 8 hrs

• Max Daily Dose

  • 3250 mg (10 tabs regular strength)

  • 3000 mg (6 tabs extra strength)

  • < 4000 mg (6 tabs of 650 mg)

Ibuprofen (Motrin/Advil) Dosing in Adults & Children 12 years or older - Dose, Dose Schedule, Max Daily Dose

• Dose

  • 200 - 400 mg

• Dose Schedule

  • Q 4 - 6 hrs PRN

• Max Daily Dose

  • 1200 mg

Naproxen (Aleve) Dosing in Adults & Children 12 years or older - Dose, Dose Schedule, Max Daily Dose

• Dose

  • 220 mg

• Dose Schedule

  • Q 8 - 12 hrs PRN

• Max Daily Dose

  • 660 mg (do not exceed 2 doses within 12 hrs)

APAP (Acetaminophen/Tylenol) Dosing in Children Younger Than 12 Years - Wt based dosing, Dose schedule, Max per dose, Max daily dose

• weight based dosing

  • 10 - 15 mg/kg

• Dose schedule

  • Q 4 - 6 hrs PRN

• Max per dose

  • 480 mg/dose

• Max daily dose

  • 5 doses (2400 mg/day)

Ibuprofen Dosing in Children Younger Than 12 Years - Wt based dosing, Dose schedule, Max per dose, Max daily dose

• weight based dosing

  • 5 - 10 mg/kg

• dose schedule

  • Q 6 - 8 hrs PRN

• max per dose

  • 300 mg/dose

• Max daily dose

  • 4 doses (1200 mg/day)

What OTC analgesic should Children younger than 12 years AVOID and why

AVOID salicylates due to risk of Reye’s Syndrome

What is Reye’s Syndrome

• rare, serious condition of swelling in liver and brain

  • present with confusion/seizures, unconsciousness

What OTC analgesic is NOT indicated for Children younger than 12 years

naproxen (aleve)

OTC Pediatric Oral Suspension Availability - APAP

Availability - 160mg/5mL

OTC Pediatric Oral Suspension Availability - Ibuprofen

100mg/5mL

APAP - Patient Education

• read and follow medication labels and dosing

• be aware of labeling - Acetaminophen = APAP = Tylenol

• know active ingredient in OTC and Rx (e.g. Tylenol #2, #3, #4; Fioricet, Norco, Percocet) medications

  • never take more than one APAP containing products at the same time

• Avoid in pts with liver disease, consume >/= 3 alcoholic drinks/day

• limit OTC analgesic for headache to 3 days per week to prevent medication overuse

• Dispense measuring device with calibration (e.g. measuring cup, syringe) to ensure accurate dosing in pediatric

NSAIDs - Patient Education

• read and follow medication labels and dosing

• be aware of labeling - may be labeled as NSAIDs

  • Ibuprofen - Motrin, Advil

  • Naproxen - Aleve

• Take NSAIDs with food or milk to reduce upset stomach

• Avoid in pts taking ASA for cardiac protection, heart disease, stomach ulcers or bleeding, and kidney disease or for those undergoing surgery

• Avoid taking NSAIDs or salicylates with concomitant anticoagulants, due to increased bleeding risk

• Dispense measuring device with calibration (e.g. measuring cup, syringe) to ensure accurate dosing in pediatrics

Fever - exclusions for self care

• Children

  • > 6 moths with rectal temp >/= 104*F (40*C)

  • < 6 months with rectal temp > 101*F (38*C)

  • who develop rash, refuse to drink fluids, very sleepy or irritable, hard to wake, or vomiting

  • history of febrile seizures or seizures

• Fever persisting > 3 days w/ or w/o treatment

• severe COPD, heart failure, respiratory distress

• Impaired immune function (cancer, HIV)

• CNS damage (head trauma, stroke)

Fever - Pharmacotherapy of Antipyretics - MOA

• Antipyretics decrease production of prostaglandin by inhibiting COX enzymes in central (NSAIDs, APAP) and peripheral (NSAIDS) nervous system

  • Decrease feedback between thermoregulatory neurons and the hypothalamus, thereby decreasing hypothalamic set point

Fever - Pharmacotherapy of Antipyretics - How long can they be used

Generally, antipyretics should not be used for more than 3 days

Fever - Pharmacotherapy of Antipyretics - what antipyretics are not recommended before or immediately after vaccination

Prophylactic antipyretics before and immediately after vaccination are not recommended

Fever - Pharmacotherapy of Antipyretics - What should not be combined with antipyretics

• Avoid combining antipyretics with cold/cough products which contain APAP or NSAIDs

  • always read labels, follow appropriate dosing

Calculation of Pediatric Dose
- A 44 lb child is prescribed Motrin every 8 hours for fever. How many teaspoons (min and max) would you recommend for the caregiver to administer to this child?

• Know: concentration of Children’s Motrin Oral Suspension is:

  • 100 mg/5 mL

• Know Pediatric Dose for Ibuprofen is:

  • 5 - 10 mg/kg

  • 1 dose Q 6 - 8 hrs, do not exceed 1200 mg/day

• Calculate amount to give this child

  • 1 -2 tsp Q 6 - 8 hrs PRN for fever

Musculoskeletal Pain - exclusions for self care

• moderate to severe pain

  • e.g. pain score > 6, on severity scale of 0-10

• pain lasting > 10 days

• pain continuing > 7 days after treatment with topical analgesic

• increased in pain intensity, w/ or w/o self treatment

• pelvic or abdominal pain

• pain accompanying N/V/F or other S/S or systemic infection

• visually deformed joint or abnormal movement from pain

• third trimester of pregnancy

• Children < 2 yrs of age

Musculoskeletal Pain - Pharmacotherapy - Systemic analgesics: NSAIDs & APAP

• NSAIDs are generally more efficacious; if one NSAID does not work, may alter to another

• Limit to 10 days of self-care use

• Chronic NSAIDs use may lead to GI ulcerations & bleeding, cardiac risk, nephropathy

• If NSAIDs are used chronically, consider proton pump inhibitor of GI protection

Musculoskeletal Pain - Pharmacotherapy - Topical analgesics: counterirritants & topical anesthetics

• use for temporary relief of mild to moderate aches and pains or muscle and joints

• Counterirritants - camphor, capsaicin, methyl salicylate, methyl nicotine

• Topical anesthetics -topical lidocaine cream and patches

• Topical NSAIDs - diclofenac (Voltaren topical fel 1%)

  • OTC in Feb 2020

Musculoskeletal Pain - Topical Analgesics - Counterirritants

• Capsaicin, camphor, menthol, methyl salicylate, methyl nicotine

  • e.g. Capzasin-HP, Bengay, Tiger Balm

• Applied to skin to relieve pain by causing another less severe, distracting pain

• Applied to affected area 3-4 times daily (TID - QID)

• Adverse Effects: skin irritations, rash, erythema, blistering

• Well tolerated for short term use, lack of evidence to support efficacy for acute or chronic musculoskeletal pain

Musculoskeletal Pain - Topical Analgesics - Topical Anesthetics

• topical lidocaine cream and patches

  • e.g. Icyhot

• for nerve pain

• do not exceed 3 applications per day

• adverse effects: rash, itching, skin irritation

  • remove and clean area, if occurs

Musculoskeletal Pain - Topical Analgesics - Topical NSAID

Diclofenac (Voltaren) topical gel 1%

Musculoskeletal Pain - Patient Education

1. Wash hands before and after applying all topical analgesics

2. Discontinue immediately and seek medical attention

   1. If burning or blistering

3. Should not apply (cream or patches) to broken or damaged skin

4. Avoid contact to the eyes or mucous membranes

5. If using with heat or wrapping, separate their use by several hours

6. Keep out of reach of children