Headache and Fever

What is the role of the pharmacist in the realm of self care?

- investigate patients problem

- differentiate self treatable conditions from those requiring medical intervention

- advise/counsel: recommend no treatment, self therapy, or refer to provider

- triage

7 pillars of self care

1. knowledge of health literacy

2. mental well being

3. physical activity

4. healthy eating

5. risk avoidance

6. good hygiene

7. rational use of products and services

Pure Food and Drug Act of 1906

standards for strength, quality, and purity

1938 Federal Food, Drug and Cosmetic Act (FFDCA)

standards for safety

1951 Durham-Humphrey Amendment

differentiates between prescription and OTC products

1962 Kefauver-Harris Amendment

mandates drug efficacy

How can prescriptions be switched to OTC?

1. the FDA OTC drug review process

2. Manufacturer requests switch via supplemental application to its approved NDA

3. manufacturer or other party petitions FDA

7 required components on the Drug Facts Label:

- active ingredients

- purpose

- uses

- warnings

- directions

- other information

- inactive ingredients

QuEST

-Quickly and accurately assesses the patient

- Establish the patient is an appropriate self care candidate

- Suggest appropriate self care strategies

- Talk with the patient

SCHOLAR MAC

Symptoms, Characteristics, History, Onset, Location, Aggravating Factors, Remitting Factors, Medications, Allergies, Conditions

Sign

objective, what the provider observes/sees/measures, contributes to diagnosis

ex. fever and runny nose

Symptom

subjective, not observed by another person, what the patient is experiencing

ex. pain, loss of taste/smell

Normal Body Temp

98.6 F (37 C)

What causes a fever?

virus, bacteria, allergic rxn, exercise, drugs

PYROGENS

endogenous pyrogens

-already within the body

-immune cytokines, interleukins, interferons, tumor necrosis factor

-increase hypothalamic temp. set point

exogenous pyrogens

-external toxins

- cannot independently increase hypothalamic temp set point

-1st stimulate release of endogenous pyrogens

Stages of Fever

1. Prodromal

2. Chill (temp rises)

3. Flush

4. Defervescence

Fever

- temp over 100 F

-usually self limited, regulated by hypothalamus

hyperpyrexia

-temp over 106 F

-serious complications more likely: seizures, mental changes, dehydrated

hyperthermia

-temp over 100F

-malfunctions of normal thermoregulatory process by hypothalamus

-caused by excessive heat exposure or production

Rectal Temperature

Normal: 97.9-100.4

Fever:>100.4

Age: all (under 3 months)

Oral Temp

Normal: 95.9-99.5

Fever: >99.5

Age: 3mo-3 yr use pacifier, greater then 3 years

Axillary temp

Normal: 94.5-99

Fever: >99

Age: All

Tympanic temp

Normal: 96.3-100.4

Fever: >100.4

Age: over 6 months (don't want to damage ear)

Temporal temp

Normal: 97.9-100.1

Fever: 0-2 months: >100.7

3-47 months: >100.3

over 4 yrs: >100.1

Age: All

Ruling Out Self Treatment for Fever

- patients > 3 months with rectal temp > 104

- children <3 months with rectal temp > 100.4

- children <2 yrs. with persistent fever >24 hrs

- patients >2 yrs with fever that persist >3 days with or without treatment

-fever that repeatedly rises above 104

- risk for hyperthermia

-impaired oxygen utilization

-impaired immune function

-CNS damage

-children with : history of febrile seizures, stiff neck, rash/spots, refusing to drink liquids, irritable, very sleepy, hard to wake, vomiting, repeated diarrhea

Nonpharmacologic Therapy (Fever)

-adequate fluid intake

-lightweight clothes, remove blankets, comfortable room temp

-body sponging

Pharmacologic Treatment for Fever

-Antipyretics: inhibit PGE2 synthesis, decreases feedback between thermoreg. neurons and hypothalamus, reducing body temp. set point

-inhibits COX enzyme, decreasing prostaglandin synthesis

-NSAIDS, aspirin, Acetaminophen

Pediatric Ibuprofen Dosing

- 5-10 mg/kg/dose q 6-8 hours

- max: 300mg per dose or 40 mg/kg/day (MAX 4 DOSES/DAY)

Pediatric Acetaminophen Dosing

- 10-15 mg/kg q4-6h

- max: 480 mg per dose up to 5 doses or 75mg/kg/day

Nonsalicylate NSAID: Ibuprofen

-dose forms: IR tablets, ER tablets, capsules, liquid suspension

- metabolized by kidney absorbed from GI

- onset 30 min

duration 6-8 hrs

- GI side effects

Acetaminophen (Tylenol)

- dosage forms: IR tablets, liquid, rectal suppositories

- metabolized by liver, absorbed from GI

-onset oral: 30 min, duration: 4 hrs

-max dose 4g daily

Salicylate NSAIDS: Aspirin

-dosage forms: IR tablets, EC tablets, ER cap

- metabolized by liver

-onset 4-6 hrs

- side effects: worse GI effects

- DO NOT use in children

Adult Dosing: Acetaminophen

Regular strength: 2 tablets q 4-6 hrs (limit 10 tabs/day)

Extra strength: 2 tablets q 6hrs (limit to 6 per day)

ER: 2 tablets q 8 hrs (limit to 6 per day)

Adult Dosing: Ibuprofen

200-400 mg every 4-6 hours (1200mg)

minimum age 6 months

Adult Dosing: Naproxen

220mg q 8-12 hrs (660mg)

minimum age 12 years

Adult Dosing: Aspirin

325-1000mg q 4-6 hrs (4000mg)

minimum age 15 years

Tension Type HA

-stress headache

-most common

-nociceptors

Migraine HA

-most severe

-with or w/o aura

-trigeminal nerve activation

Sinus HA

-something else going on

-sinusitis

-analgesic + decongestant

medication overuse HA

- overuse of same meds that treat HA

-excessive analgesic use >3 months

Exclusions for self treatment (HA)

- severe head pain

-headache with rapid onset of max pain

-concerning change in headache pattern

- persists for 10 days with or without treatment

- age < 8 years

- high fever or signs of serious infection

-neck stiffness

-neurologic change

- high risk comorbid conditon

- last trimester of pregnancy

- new headache during pregnancy

- secondary headache

- symptoms consistent w/ migraine, not no formal diagnosis of migraine

- history of liver disease of consumption of > 3 alcoholic drinks per day

Non-Pharmacologic HA Treatment

-headache diary

-trigger avoidance (MSG, caffeine, tyramine, phenylalanine, chocolate)

-hydration

-cognitive behavior interventions

-acupuncture

-PT

DDI: Acetaminophen and Alcohol

increased risk of hepatotoxicity

DDI: Acetaminophen and Warfarin

Increased risk of bleeding

DDI: Ibuprofen and Aspirin

Decreased antiplatelet effect of aspirin

DDI: Salicylates + NSAIDs and anticoagulants/alcohol

Increased risk of bleeding (especially GI)