PHAR-241 OTC Meds

Exclusions - Constipation

• Sever abdominal pain , distention

• Flatulence of unknown etiology

• N&V

• Unintentional Weight Loss

• Blood in Stool

• Daily laxative use

• Symptoms persit >2 wks or recur within

• Anorexia

• < 2 years old

General Pharmacotherapy - Constipation

• Most relieve symptoms 3-72 hrs

• Enema : Evacuation within minutes

• Avoid within 2 hrs of medications

• Opioid Induced Constipation : Stimulant + Emollient Laxative

Bulk Forming Laxatives

• Methylcellulose , Psyllium, Polycarbophil

  • >6 yrs old

  • Relief - Short term for pts with:

    • Low fiber

    • Postpartum woman

    • Older adults

    • Colostomies, IBS, Diverticulitis

  • Onset 12-24 hrs

  • Adverse Effects:

    • Abdominal Cramping

    • Flatulence

  • Avoid if

    • Dysphagia (Difficulty Swallowing)

    • Fluid Restrictions

    • Intestinal Ulcer/Obstructions

    • Immobile

Emollient Laxatives (Stool Softeners)

• Docusate Sodium : 50-100 mg Capsule

  • 50-300 mg in single or divided doses

  • Increase wetting efficiency of intestine

  • Onset : 12-72 hrs, Up to 3-5 days

  • Avoid w/Mineral Oil

Stimulant Laxatives

• Senna (Senakot), Biscodyl (Dulcolax), Fletchers Laxative for Kids

  • Biscodyl (Dulcolax) : 5 mg Tab , 1-3 Tab daily (2 Usually)

    • Oral onset (6-10hrs, Up to 24 hr ,Suppository (15-60min)

  • Inc. intestinal motility and secretion of water + e-lytes into intestine

  • With Emollient for Opioid Induced Constipation

Hyperosmotic Laxatives

• Polyethylene glycol 3350/PEG-3350 (Miralax) , glycerin (Fleet glycerin Suppository)

  • PEG-3350 (Miralax) : 17 g capful in 4-8 oz of beverage

    • >17 yrs old

    • Contain large molecule, poorly absorbed ions to draw water into colon/rectum, stimulating bowel mvmnt

  • Avoid in patients with E-lyte imbalances

  • Help pts to who should avoid straining(Heart Attack or Surgery)

Saline Laxative

• Magnesium Citrate , Magnesium Hydroxide , Magnesium Sulfate Di/Monobasic Sodium

  • No dosing required

  • Draw water into small/large intestine/rectum by osmosis , increase intraluminal pressure and GI motility

  • Oral Liquid, Chewable, or Enema

Lubricant Laxatives

Generally Avoid, Lots of adverse effects, DDI

Laxative Overuse

Common in

• Elderly

• Those who fear constipation

• Eating Disorders

Causes

• Vomiting , Diarrhea , Hypokalemia

Non-pharm care first line in pregnancy

• Limit stimulant + hyperosmotic laxatives to short term if needed

Exclusions for Diarrhea

• < 6 months or < 17.5 lbs

• Persistant Fever >102.2 F

• Blood , Pus, Mucus in Stool

• Persistant Vomiting/Diarrhea

• Severe Abdominal Pain

• Pregnancy

• Intolerance to Oral Rehydration

Loperamide

• Loperamide (Imodium), Imodium Advanced

  • Comes in Liquid snd Capulet Formulations

  • Do not exceed 8mg / 60 mL a day

    • 9-11 yr olds : 6 mg/day

    • 6-8 yr olds : 4 mg/day

  • Imodium Advanced (2 mg Loperamide + 125 mg Simethicone)

    • Do not exceed 3 cap in 24 hrs

Bismuth Subsalicylate (BSS) - Diarrhea

• Kaopectate (Antidiarrheal Caplets or Flavored Liquid), Maalox Total Relief flavored liquid.

  • 525 mg Q30-60 min no more than 4200 mg (8 dose)

  • Duration of Use : 2 days

  • Interacts with acid in stomach

    • Bismuth: Antimicrobial against pathogens in diarrhea

    • Salicylate : Antisecretory, Decrease fluid and e-lyte loss

  • For acute/travelers diarrhea , Adjuvant to antibiotics in H.Pylori treatment

  • > 12 years

  • May darken tongue or stool

  • Is a salicylate , increase bleeding risk when taken with other meds (NSAID, Anticoagulants , >3 alcoholic bev)

Lactase Replacement

• Lactase, Lactaid, Lac-Dose

  • Mostly chewable tablets

  • Use : Prevention of gas, bloating, diarrhea related to dairy

    • Dose : 3000-18000 at first bite of lactose

Exclusions for Self-care - Heartburn

• Frequent heartburn lasting > 3 mo

• Heartburn despite taking H2RA and PPI’s

• Dysphagia or Odynophagia

• GI Bleed

• Unintentional Weightloss

• Continuos N&V or Diarrhea

• Chest pain radiating to other areas with SOB

• Children <2 yrs Antacids, <12 yrs H2RAs <18 PPIs

Non-Pharm Therapy - Heartburn

Avoid

• Alcohol

• Caffeine

• Carbonated Drinks

• Citrus food/drinks

• Chocolates

• Fatty/Spicy Foods

• Garlic , Onions, Mint

Life Mods

• Smaller , Less fatty meals

• Avoid eating 3 hrs before bed

• Raise head of bed 6-8 in

• Avoid Smoking

• Replacing meds that increase risk

Antacids

• For mild infrequent heartburn, neutralize gastric acid

• Onset : <5 min, Duration 20-60 min (Within 1 hr of meal : 3 hrs)

• Separate with other meds by 2-4 hrs

Adverse Effects:

• Mg2+ / Al3+ : Cause Diarrhea

• Al3+/Ca2+ : Constipation

• NaHCO3 : Fluid retention

  • Caution in Renal failure, Cirrhosis , CHF, Pregnancy

Bismuth Subsalicylate BSS - Heartburn

• Bismuth Subsalicylate

  • Heartburn, Upset stomach , Indegestion

  • 262-525 mg Q30-60 min

  Adverse

  • Avoid in children recovering from flu or chickenpox

  • Darkens stool/Blacken Tongue

  • Can Increase Bleeding Risk with other medications

H2RA’s

• Famotidine 10/20 mg

  • Take with 1 glass of water, 2 tablets max daily

    • Onset 30-45 min , Duration 4-10 hrs , Limit use to 2 wks (Only as needed, Tolerance w/daily use)

  • Inhibits H2 receptors on parietal cells , decrease acid secretion and gastric volume

    • For mild or moderate infrequent episodic heartburn , or prevention due to indigestion

  • Adverse :

    • HA, Constipation , Diarrhea , Drowsy, Thrombocytopenia

    • Avoid in elderly (CNS Effects)

  • Can combine with antacid

  • Take 30min-1hr before anticipated Heartburn

PPI’s

• Omeprazole (Prilosec) DR 20 mg , Omprazole 20mg/NaHCO3 1110 (Zegrid), Lansoprazole 15 mg (Prevacid) , Esomeprazole (20 mg Nexium)

  • Take 1 tab with glass of water, 30 min (1hr Zegrid) before morning meal, Daily for 14 days

  • Treat patients with symptoms more than 2 days/week

    • If symptoms more than 2 weeks or reoccur in 4 month, refer

    • Crush/Chew decrease efficacy

  • Adverse effects

    • Diarrhea , HA, Constipation, C.diff

Exclusions for self care - Insomnia

• <12 yrs or >65 yrs

• Pregnant

• Frequent nocturnal or early morning awakenings

• Chronic Insomnia (>3 weeks)

• Sleep disturbance due to psych disorders

Non-Pharm Therapy - Insomnia

• Cognitive Behavioral Therapy

• Sleep hygiene

  • Limit function of bed

  • Comfortable bed environment

  • Relax prior to bedtime

  • Exercise 4hrs before bed

  • Light snack 2 hrs before bed

  • Avoid Electronics

  • Avoid Daytime nap

  • Avoid Caffeine , Alcohol , Nicotine

  • Avoid Clock Watching

Antihistamines - Insomnia

• Diphenhydramine (Unisom SleepGels), Doxylamine (Unisom SleepTablets)

  • Gels: 50 mg , Tablets 25 mg , 30 min before bedtime

  • Do not exceed 7-10 consecutive nights

  • Onset 3-6 hrs

  • Adverse Effects

    • Anticholinergic Effects

  • Contraindications

    • BPH, Narrow Angle Glaucoma, CVD, Diarrhea

Melatonin

Complimentary Therapy

• Conflicting evidence in insomnia

  • 2-3 mg some 5 -10 mg

• Adverse Effects

  • HA, Dizziness, Drowsiness

Preventative Care - Motioin Sickness

Prevention N&V- Motion Sickness

Avoid:

• Reading during travel

• Excess food or alcohol before travel

• Strong Odors

Should

• Stay where motion is least or drive the vehicle

• Focus vision straight ahead

N&V Pregnancy (NVP)

Avoid -

• Greasy, fatty, spicy foods

• Sensory stimuli

• Iron supp

• Excess heat/humidity

Should

• Dry crackers and relax 10-15 before getting out of bed

• Small meals, avoid full stomach

• Dry bland high protein foods

• Small sips of carbonation / fruit juice

• Fresh air

• Multivitamin x 3 mo before pregnancy

Non-Pharm Therapy - NVP

• Ginger

  • Mixed efficacy in NVP

  • 250 mg - 2g daily in 3-4 doses (target 1g daily)

  • Adverse Effects

    • Heartburn

    • Diarrhea

    • Mouth Irritation

• Pyridoxine

  • Water soluble vitamin B6, mixed efficacy in NV , off-label NVP

  • NVP: 10-25 mg TID

  • Large & Prolong Use cause

    • Peripheral Neuropathy

    • Weakness

    • Lethargy

Antihistamines - NV/NVP

• Dimenhydrinate (Dramamine), Diphenhydramine (Benadryl), Meclizine (Dramamine All Day Less Drowsy) , Doxylamine [NVP Offlabel Use]

  • Dimenhydrinate: 50-100 mg Q4-6 hrs (400mg)

    • 6-12 yrs: 25-50 mg Q6-8 hrs (150 mg)

    • 2-6 yrs: 12.5-25 mg Q6-8 hrs (75 mg)

  • Diphenhydramine: 25-50 mg Q6-8 hrs (300mg)

  • Meclizine: 25-50 mg 1 hr before travel (50mg)

  • Doxylamine: 10-12.5 mg w-w/o pyridoxine Q8 hrs

• Take 30 - 60 min before travel and during , do not exceed max

• Drowsiness , Sedation w/2nd Gen Antihistamine