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ترجمه مقاله و پروژه های دانشجویی - مطالب اسفند 1393

ترجمه مقاله انگلیسی Using a sustainability index to assess energy technologies for rural electrification استفاده از شاخص پایداری برای ارزیابی فناوری های برق رسانی برای روستاها

ترجمه مقاله انگلیسی


Using a sustainability index to assess energy technologies for rural
electrification

استفاده از شاخص پایداری  برای ارزیابی فناوری های برق رسانی برای روستاها



تعداد صفحات انگلیسی: 15 صفحه
تعداد صفحات ترجمه فارسی: 10 صفحه

تامین انرژیِ قابل اعتماد ، مقرون به صرفه  و عمومی باید در راستای اهداف توسعه (NDG ) قرار بگیرد . از یک طرف چالش در راستای دسترسی به انرژی های قابل اعتماد و پاک به 8/2 میلیارد از مردم جهان وجود دارد و باید برق به 2/1 میلیارد مردم جهان برسد . از سوی دیگر چالش برای مقابله با تغییرات آب و هوایی جهانی وجود دارد




برچسب ها: ترجمه مقاله انگلیسی Using a sustainability index to assess energy technologies for rural electrification استفاده از شاخص پایداری برای ارزیابی فناوری های برق رسانی برای روستاها تعداد صفحات انگلیسی: 15 صفحه تعداد صفحات ترجمه فارسی: 10 صفحه دانلود متن انگلیسی تامین انرژیِ قابل اعتماد، مقرون به صرفه و عمومی باید در راستای اهداف توسعه (NDG ) قرار بگیرد . از یک طرف چالش در راستای دسترسی به انرژی های قابل اعتماد و پاک به 8/2 میلیارد از مردم جهان وجود دارد و باید برق به 2/1 میلیارد مردم جهان برسد . از سوی دیگر چالش برای مقابله با تغییرات آب و هوایی جهانی وجود دارد،  

تاریخ : سه شنبه 26 اسفند 1393 | 02:15 ق.ظ | نویسنده : sinister | نظرات

ترجمه مقاله انگلیسی A GA–DE hybrid evolutionary algorithm for path synthesis of four-bar linkage الگوریتم تکاملی ترکیبی GA-DE برای سنتز مسیر ارتباطی چهارخطی:

ترجمه مقاله انگلیسی
A GA–DE hybrid evolutionary algorithm for path synthesis of four-bar linkage

الگوریتم تکاملی ترکیبی GA-DE برای سنتز مسیر ارتباطی چهارخطی:


تعداد صفحات انگلیسی: 12 صفحه
تعداد صفحات ترجمه فارسی: 9 صفحه

مقدمه:
سنتز یک مسیر چهار خطه به طور فعال در طول پنجاه سال گذشته مورد مطالعه تعداد زیادی قرار گرفته است. تعداد زیادی مطالعات در مورد این موضوع با استفاده از روش های مختلف انجام شده است. این موارد شامل تحلی،برنامه نویسی غیر خطی،شیب دقیق،منحنی تابع جفت زاویه و روش های انحنای منحنی انجام شده است. مشکل روش سنتز ارتباطی یک مسیر چهارخطه این است که نقطه  می تواند به مسیر متصل شده و یا نقطه هدف مورد نظر را بدون هیچ تحلیل ردیابی کند. راه حل مشکل به طور کلی در اهداف بیش از پنج نقطه است.



برچسب ها: ترجمه مقاله انگلیسی A GA–DE hybrid evolutionary algorithm for path synthesis of four-bar linkage الگوریتم تکاملی ترکیبی GA-DE برای سنتز مسیر ارتباطی چهارخطی: تعداد صفحات انگلیسی: 12 صفحه تعداد صفحات ترجمه فارسی: 9 صفحه دانلود متن انگلیسی مقدمه: سنتز یک مسیر چهار خطه به طور فعال در طول پنجاه سال گذشته مورد مطالعه تعداد زیادی قرار گرفته است. تعداد زیادی مطالعات در مورد این موضوع با استفاده از روش های مختلف انجام شده است. این موارد شامل تحلی، برنامه نویسی غیر خطی، شیب دقیق، منحنی تابع جفت زاویه و روش های انحنای منحنی انجام شده است. مشکل روش سنتز ارتباطی یک مسیر چهارخطه این است که نقطه می تواند به مسیر متصل شده و یا نقطه هدف مورد نظر را بدون هیچ تحلیل ردیابی کند. راه حل مشکل به طور کلی در اهداف بیش از پنج نقطه است.، ترجمه مقاله انگلیسی A GA–DE hybrid evolutionary algorithm for path synthesis of four-bar linkage الگوریتم تکاملی ترکیبی GA-DE برای سنتز مسیر ارتباطی چهارخطی:، ترجمه مقاله انگلیسی A GA–DE hybrid evolutionary algorithm for path synthesis of four-bar linkage الگوریتم تکاملی ترکیبی GA-DE برای سنتز مسیر ارتباطی چهارخطی:t t،  

تاریخ : سه شنبه 26 اسفند 1393 | 02:13 ق.ظ | نویسنده : sinister | نظرات

ترجمه مقاله انگلیسی BRIEF NOTE CREEP-STABILITY ANALYSIS OF VISCOELASTIC CYLINDRICAL SHELLS مروری مختصر بر تحلیل خزش، ثبات ویسکو الاستیک در پوسته های استوانه ای

ترجمه مقاله انگلیسی


BRIEF NOTE

CREEP-STABILITY ANALYSIS OF VISCOELASTIC

CYLINDRICAL SHELLS


مروری مختصر بر تحلیل خزش، ثبات ویسکو الاستیک در پوسته های استوانه ای



تعداد صفحات انگلیسی: 12 صفحه
تعداد صفحات ترجمه فارسی: 9 صفحه

مقدمه :
ثبات خزش پوسته های دایره ای استوانه توسط پژوهش گران متعددی مورد مطالعه با استفاده از مفاهیم مختلف و قوانین اساسی انجام شده است. تعدادی از تحقیقات با استفاده از روش عیوب به این نتیجه رسیده اند. که در شرایط خزش عیوب اولیه با گذشت زمان توسعه یافته و منجر به فروپاشی ساختار می شود. مهم در این تجزیه و تحلیل این است که معمولا تغییر شکل نامحدود و تا نرخ آن بی نهایت تعریف می شود. برخی از این مطالعات متوسط هوفی و کویشن در سال های اخیر توجه زیادی را توسط برنامه های کاربردی به پژوهش در زمینه خزش متمرکز کرده است.




برچسب ها: ترجمه مقاله انگلیسی BRIEF NOTE CREEP-STABILITY ANALYSIS OF VISCOELASTIC CYLINDRICAL SHELLS مروری مختصر بر تحلیل خزش، ثبات ویسکو الاستیک در پوسته های استوانه ای تعداد صفحات انگلیسی: 12 صفحه تعداد صفحات ترجمه فارسی: 9 صفحه دانلود متن انگلیسی مقدمه : ثبات خزش پوسته های دایره ای استوانه توسط پژوهش گران متعددی مورد مطالعه با استفاده از مفاهیم مختلف و قوانین اساسی انجام شده است. تعدادی از تحقیقات با استفاده از روش عیوب به این نتیجه رسیده اند. که در شرایط خزش عیوب اولیه با گذشت زمان توسعه یافته و منجر به فروپاشی ساختار می شود. مهم در این تجزیه و تحلیل این است که معمولا تغییر شکل نامحدود و تا نرخ آن بی نهایت تعریف می شود. برخی از این مطالعات متوسط هوفی و کویشن در سال های اخیر توجه زیادی را توسط برنامه های کاربردی به پژوهش در زمینه خزش متمرکز کرده است.، ثبات ویسکو الاستیک در پوسته های استوانه ای، ثبات ویسکو الاستیک در پوسته های استوانه ای t t،  

تاریخ : سه شنبه 26 اسفند 1393 | 02:13 ق.ظ | نویسنده : sinister | نظرات

ترجمه مقاله انگلیسی NONLINEAR CREEP BUCKLING ANALYSIS OF INITIALLY IMPERFECT SHALLOW SPHERICAL SHELLSt خزش غیر خطی و تحلیل کمانش کم عمق: پوسته کروی ناقص:

ترجمه مقاله انگلیسی

NONLINEAR CREEP BUCKLING ANALYSIS OF
INITIALLY IMPERFECT SHALLOW
SPHERICAL SHELLSt

خزش غیر خطی و تحلیل کمانش کم عمق: پوسته کروی ناقص:


تعداد صفحات انگلیسی: 12 صفحه
تعداد صفحات ترجمه فارسی: 22 صفحه


مقدمه :
به خوبی شناخته شده است که ساختار دیواره نازک مواد در اثر تغییر شکل ناشی از خزش در راستای وجود بارهای ثابت در زمان کافی بوده است. برای پوسته کروی یکنواخت وقتی بارگذاری انجام می شود. آن به زمان بستگی داشته و شکست بستگی به طور زمان دارد. زمان به عنوان عامل شکست نیز می تواند نام گذاری شود چرا که خزش در زمان مشخص در حین اعمال بار بوده و شکست ساختار اتفاق می افتد. محاسبه بار همراه با تغییر شکل خزش برای پوسته کروی کم عمق متقارن دلیل اصلی تحقیق زیر می باشد.



برچسب ها: ترجمه مقاله انگلیسی NONLINEAR CREEP BUCKLING ANALYSIS OF INITIALLY IMPERFECT SHALLOW SPHERICAL SHELLSt خزش غیر خطی و تحلیل کمانش کم عمق: پوسته کروی ناقص: تعداد صفحات انگلیسی: 12 صفحه تعداد صفحات ترجمه فارسی: 22 صفحه دانلود متن انگلیسی مقدمه : به خوبی شناخته شده است که ساختار دیواره نازک مواد در اثر تغییر شکل ناشی از خزش در راستای وجود بارهای ثابت در زمان کافی بوده است. برای پوسته کروی یکنواخت وقتی بارگذاری انجام می شود. آن به زمان بستگی داشته و شکست بستگی به طور زمان دارد. زمان به عنوان عامل شکست نیز می تواند نام گذاری شود چرا که خزش در زمان مشخص در حین اعمال بار بوده و شکست ساختار اتفاق می افتد. محاسبه بار همراه با تغییر شکل خزش برای پوسته کروی کم عمق متقارن دلیل اصلی تحقیق زیر می باشد.، ترجمه مقاله انگلیسی NONLINEAR CREEP BUCKLING ANALYSIS OF INITIALLY IMPERFECT SHALLOW SPHERICAL SHELLSt خزش غیر خطی و تحلیل کمانش کم عمق: پوسته کروی ناقص:،  

تاریخ : سه شنبه 26 اسفند 1393 | 02:12 ق.ظ | نویسنده : sinister | نظرات

ترجمه مقاله انگلیسی Therelationshipbetweenshearwavevelocity,temperature,attenuationandviscosityintheshallowpartofthemantle مقاله عمران زلزله رابطه سرعت برشی,درجه حرارت ،روابط کاهندگی و ویسکوزیته در قسمت کم عمق از گوشته

ترجمه مقاله انگلیسی

Therelationshipbetweenshearwavevelocity,temperature,attenuationandviscosityintheshallowpartofthemantle

 مقاله عمران زلزله

رابطه سرعت برشی,درجه حرارت ،روابط کاهندگی و ویسکوزیته در قسمت کم عمق از گوشته




تعداد صفحات انگلیسی: 14 صفحه
تعداد صفحات ترجمه فارسی: 13 صفحه


مقدمه:
ارتباط سرعت موج برشی در مقابل افزایش کاهندگی کاهش کی یابد و کاهش ویسکوزیته در گوشته فوقانی زمین تقریبا در  90 سال گذشته شناخته شده است.(گوتنبرگ 1950.ص76) این اثرات در آستونسفر بیشتر آشکار می باشد که در  آن درجه حرارت گوشته به درجه حرارت ذوب می رسد. شکل 1-A یک حالت ثابت ژئوترم را نشان می دهد. لایه ی نزدیک به سطح که در آن گرما از طریق هدایت منتقل می شود به عنوان یک لایه مرزی مکانیکی شناخته شده است(MBL) این است که توسط یک فاصله در لایه مرزی حرارتی (TBL) بخشی از حرارت به صورت هم رفتی از گوشته فوقانی منتقل می شود. در اعماق بیشتر گرادیان دما در ایزونتروپیک همرفتی است.



برچسب ها: temperature، attenuationandviscosityintheshallowpartofthemantle مقاله عمران زلزله رابطه سرعت برشی، درجه حرارت، روابط کاهندگی و ویسکوزیته در قسمت کم عمق از گوشته تعداد صفحات انگلیسی: 14 صفحه تعداد صفحات ترجمه فارسی: 13 صفحه دانلود متن انگلیسی مقدمه: ارتباط سرعت موج برشی در مقابل افزایش کاهندگی کاهش کی یابد و کاهش ویسکوزیته در گوشته فوقانی زمین تقریبا در 90 سال گذشته شناخته شده است.(گوتنبرگ 1950.ص76) این اثرات در آستونسفر بیشتر آشکار می باشد که در آن درجه حرارت گوشته به درجه حرارت ذوب می رسد. شکل 1-A یک حالت ثابت ژئوترم را نشان می دهد. لایه ی نزدیک به سطح که در آن گرما از طریق هدایت منتقل می شود به عنوان یک لایه مرزی مکانیکی شناخته شده است(MBL) این است که توسط یک فاصله در لایه مرزی حرارتی (TBL) بخشی از حرارت به صورت هم رفتی از گوشته فوقانی منتقل می شود. در اعماق بیشتر گرادیان دما در ایزونتروپیک همرفتی است.، ترجمه مقاله انگلیسی Therelationshipbetweenshearwavevelocity،  

تاریخ : سه شنبه 26 اسفند 1393 | 02:10 ق.ظ | نویسنده : sinister | نظرات

ترجمه مقاله انگلیسی Probabilistic Issue of Reliability for Power Machinery Operating in Coal Fired Power Plants میزان احتمالات قابلیت اطمینان برای توان ماشین آلات با سوخت زغال چوب

ترجمه مقاله انگلیسی

Probabilistic Issue of Reliability for Power
Machinery Operating in Coal Fired Power
Plants

میزان احتمالات قابلیت اطمینان برای توان ماشین آلات با سوخت زغال چوب



تعداد صفحات انگلیسی: 7 صفحه
تعداد صفحات ترجمه فارسی: 12 صفحه


مقدمه :
عمل تعمیر و نگهداری نشان می دهد كه تعداد خطلا از اجزای واحدهای قدرت چند برابر بالاتر از دیگر اجزای سیستم قدرت مانند خطوط هوایی، ترانسفورماتور، تابلوها، سیستم های كنترل و حفاظت است . عناصر دستگاه و همچنین ضرورت در نگهداری دستگاه بر مبنای تعمیر واحد قدرت در نظر گرفته می شود تأثیر اقتصادی واحد قدرت خاموش بستگی به قدرت میزان شكستها و مدت زمان تعمیر و دوره سال آن دارد كه در آنبسته به میزان آن محاسبه می شود این یك مسأله بسیار مهم است.



برچسب ها: ترجمه مقاله انگلیسی Probabilistic Issue of Reliability for Power Machinery Operating in Coal Fired Power Plants میزان احتمالات قابلیت اطمینان برای توان ماشین آلات با سوخت زغال چوب، ترجمه مقاله انگلیسی Probabilistic Issue of Reliability for Power Machinery Operating in Coal Fired Power Plants میزان احتمالات قابلیت اطمینان برای توان ماشین آلات با سوخت زغال چوب تعداد صفحات انگلیسی: 7 صفحه تعداد صفحات ترجمه فارسی: 12 صفحه دانلود متن انگلیسی مقدمه : عمل تعمیر و نگهداری نشان می دهد كه تعداد خطلا از اجزای واحدهای قدرت چند برابر بالاتر از دیگر اجزای سیستم قدرت مانند خطوط هوایی، ترانسفورماتور، تابلوها، سیستم های كنترل و حفاظت است . عناصر دستگاه و همچنین ضرورت در نگهداری دستگاه بر مبنای تعمیر واحد قدرت در نظر گرفته می شود تأثیر اقتصادی واحد قدرت خاموش بستگی به قدرت میزان شكستها و مدت زمان تعمیر و دوره سال آن دارد كه در آنبسته به میزان آن محاسبه می شود این یك مسأله بسیار مهم است.،  

تاریخ : سه شنبه 26 اسفند 1393 | 02:07 ق.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th




Smoking cessation – tips for customers about quitting
 Set a quit date, prepare for it and stick to it.
 Get support and advice from friends, family and health professionals.
 Consider NRT for the first few weeks.
 Avoid situations where you will find it difficult not to smoke.
 Change your routine to distract yourself from times and places you
associate with smoking.
 Stop completely if you can, rather than cut down.
 Get rid of all cigarettes, lighters and ashtrays before your quit date.
 Ask people not to smoke around you and tell everyone you are quitting.
 Keep busy, especially when cravings start.
 Reward yourself for not smoking.
 Calculate how much money you will save and plan how you will
now spend it.
A range of NRT products are available. They vary in the ease and
frequency of use, the speed of nicotine release and the amount of behavioural
replacement provided. There are no conclusive studies to
show that one formulation is any more effective than another at achieving
cessation. All products will increase the chances of success if used
correctly.
Nicotine replacement therapy – formulation options
Patches
Discreet – easy to wear and forget about, but watch for skin irritation
Continuous nicotine release – suitable for regular smokers
16-h patch (removed at night) – reduced insomnia
24-h patch – good for early morning cravings
Three strengths – allows a step-down reduction programme.
Gum
Flexible regimen – controls cravings as they occur
Various flavours – allows customer preference
Various strengths – allows step-down reduction programme
Chewed slowly – to release nicotine and then ‘park’ gum between
cheek and gum.
Nasal spray
Fast-acting – helpful for highly dependent smokers
Local side-effects (sore throat and rhinitis) – usually pass after first
few days.
PREVENTION OF HEART DISEASE 333
Sublingual tablet
Discrete – placed under tongue and dissolves over 20 min
Dose variation – one or two (2-mg) tablets may be used per hour
Sublingual – sucking or chewing the tablet will reduce its effectiveness.
Inhalator
Cigarette substitute – useful for smokers who miss hand-to-mouth
action
Reduce usage over time – the recommended period is 12 weeks.
Lozenge
Various strengths – allows step-down reduction programme
Highest strength (4 mg) – good for smokers who start within 30 min
of waking
Sucked until taste is strong – lozenge then ‘parked’ between cheek
and gum.
Licensed indications for OTC nicotine replacement therapy
NRT can be recommended for adults and children aged 12 years or
over, for pregnant women and those who are breastfeeding.
Some NRT products are licensed to aid smoking reduction with
the eventual aim of smoking cessation (‘reduce to quit’). The smoker
should attempt to quit when he or she is ready – but not later than 6
months after reducing the cigarette consumption. Young people (aged
12–18 years) should attempt “reduce to quit” only after consulting a
health care professional.
Positive messages for new non-smokers
 Giving up smoking reduces the risk of developing smoking-related
illness.
 Eight hours after quitting, nicotine and carbon monoxide levels in
the blood are reduced by half and oxygen levels return to normal.
 After 24 h, carbon monoxide is eliminated.
 After 48 h, nicotine is eliminated.
 After 3 days, breathing becomes easier.
 After 2–12 weeks, circulation is improved and smokers’ coughs start
to get better.
 After 6 months, lung efficiency will have improved by 5–10%.
 After 5 years, the risk of having a heart attack is half of that of a
smoker.
 After 10 years, the risk of heart attack is the same as that of a nonsmoker.
334 PREVENTION OF HEART DISEASE
Table 9 Benefits of 5- to 10-kg weight loss.
Condition Health benefit
Mortality 20–25% fall in overall mortality
30–40% fall in diabetes-related deaths
40–50% fall in obesity-related cancer deaths
Blood pressure 10 mm Hg fall in diastolic and systolic pressures
Diabetes Up to a 50% fall in fasting blood glucose
Reduces risk of developing diabetes by over 50%
Lipids Fall of 10% TC, 15% LDL and 30% triglycerides
Increase of 8% HDL
 After 10–15 years, the risk of developing lung cancer is only slightly
greater than that of a non-smoker.
 Research has shown that people who stop smoking before the age of
35 years survive about as well as lifelong non-smokers.
Weight management
Being overweight increases the chance of having a heart attack. This
is in part because obese individuals are more likely to have high blood
pressure, diabetes and high blood fats. Less fat, sugar and alcohol in
the diet is helpful for weight control. In order to achieve a healthy body
weight, it is also important to build regular, moderate exercise into a
daily routine.
Pharmacy staff should counsel customers whose BMI is >25 kg/m2 on
an appropriate plan for weight loss. A 3-month programme of weight
reduction should aim for a 5- to 10-kg weight loss over 3 months or
0.5 kg per week (combining diet, exercise and behavioural strategies;
see Table 9 for benefits of weight loss).
Pharmacy staff can give advice on a healthy diet. The recommended
calorie intake should be between 1200 and 1600 kcal per day. People
should be advised to moderate fat intake by eating less fatty meat, fatty
cheese, full-cream milk, fried food, lard, etc., and to reduce the amount
of sugar. They should consider eating more vegetables, fruit, cereals,
wholegrain bread, poultry, fish, rice, skimmed or semi-skimmed milk,
grilled food, lean meat, pasta, etc.
If the customer does fry food, suggest choosing a vegetable oil high
in polyunsaturates (‘good fats’), such as sunflower or rapeseed oil.
Suggest considering a low-fat spread that contains plant stanol esters.
Such plant stanol-containing supplements have been shown to reduce
cholesterol levels and may be useful adjuncts in lowering cholesterol
levels. Reducing cholesterol levels is possible through dietary manipulation.
However, the magnitude of such reductions is modest, even
with strict adherence to a diet plan. In addition, many patients will
find it hard to sustain a strict dietary regimen.
PREVENTION OF HEART DISEASE 335
Physical inactivity is an important contributor to CHD. CV benefits
of regular physical activity include reduced blood pressure and less
likelihood of obesity, which help to reduce the risk of developing CHD.
At least 30 min of steady activity for 5 or more days a week is recommended.
This time can be accumulated during the day in periods of
10 min or more.Walking, jogging, swimming, cycling and dancing are
all excellent choices. Remember to advise patients to start slowly and
gradually build up their exercise.
OTC orlistat in the USA
Orlistat has been available on prescription in the UK for several years.
The USA Food and Drug Administration approved the drug product
orlistat 60-mg capsule (trade name Alli) in 2007 for OTC marketing
as a weight-loss aid. A similar application for OTC status in the UK
and mainland Europe is anticipated; hence, we include this section on
its use.
In the USA, OTC orlistat is to be used only in conjunction with a
weight-loss programme that includes a reduced calorie diet, a low-fat
diet and an exercise programme. It is approved for OTC use in adults
18 years and older.
The amount of weight loss achieved with orlistat varies. In 1-year
clinical trials, between 35 and55%of subjects achieved a5%or greater
decrease in body mass, although not all of this mass was necessarily fat.
Between 16 and 25% achieved at least a 10% decrease in body mass.
After orlistat was stopped, a significant number of subjects regained
weight – up to 35% of the weight they had lost.
The main side-effects of orlistat are gastrointestinal (GI) related.
Side-effects are most severe when beginning therapy, and in trials they
decreased in frequency with time, with nearly half of side-effects lasting
less than a week, but some persisting for over 6 months. Because
orlistat’s main effect is to prevent dietary fat from being absorbed,
the fat is excreted unchanged in the faeces and so the stool may become
oily or loose (steatorrhoea). Increased flatulence is also common.
Bowel movements may become frequent or urgent, and cases of faecal
incontinence have been seen in clinical trials. To minimise these effects,
foods with high fat content should be avoided; the manufacturer
advises consumers to follow a low-fat, reduced-calorie diet.
Patients should be advised to wear dark trousers and take a change of
clothes with them to work. Oily stools and flatulence can be controlled
by reducing the dietary fat content to somewhere in the region of 15
g per meal, and it has been suggested that the decrease in side-effects
over time may be associated with long-term compliance with a low-fat
diet.
Absorption of fat-soluble vitamins and other fat-soluble nutrients
is inhibited by the use of orlistat. A multivitamin tablet containing
336 PREVENTION OF HEART DISEASE
vitamins A, D, E, K and beta-carotene should be taken once a day, at
least 2 h before or after taking the drug.
OTC simvastatin
The goal of OTC simvastatin 10 mg is to reduce the risk of a first major
coronary event (i.e. non-fatal MI and CHD deaths) in people who are
likely to be at moderate risk of CHD.
Men aged 55 years and above are likely to be at moderate risk of
CHD (approximately 10–15% 10-year risk of a first major coronary
event). In addition, men aged 45–54 years and women aged 55 years
and above are likely to be at moderate risk of CHD if they have one
or more of the following risk factors:
 Family history of CHD in a first-degree relative (parent or sibling);
CHD in male first-degree relative below 55 years or female first-degree
relative below 65 years
 Smoker (is currently or has been a smoker in the last 5 years)
 Overweight (BMI >25 kg/m2) or truncal obesity (waist 40 in or 102
cm in men and 35 in or 88 cm in women)
 Of South Asian ethnic origin
OTC simvastatin should be taken as part of a programme of actions
designed to reduce the risk of CHD. People aged over 70 years should
start OTC simvastatin following advice from their doctor. These include
cessation of smoking, eating a healthy diet, weight loss and regular
exercise. Simvastatin treatment can be initiated simultaneously with
diet, exercise and smoking cessation.
In an essentially normal population it is reasonable to use the lowest
effective dose to achieve the proportionately greatest benefit. The rare
adverse events (e.g. muscular pain) associated with statin use are dose
related and linked in many cases to drug–drug interactions that increase
statin effects. The risk of such events with simvastatin 10 mg is very low
and therefore the risk-to-benefit ratio for the self-medicating individual
is favourable.
Pharmacists and their staff should encourage customers to read the
patient information leaflet carefully, paying particular attention to the
section on side-effects. Research with the general public suggests that
their understanding of the frequency of adverse events is at variance
with statutory definitions. For example, the European Union (EU) definition
of a rare adverse event would suggest a frequency of between
0.01 and 0.1%. When Berry et al. (Lancet 2002; 359: 853–854) asked
200 people what frequency ‘rare’ might suggest to them, a figure of
8% was reported.
The possibility of rare but important side-effects – liver disease, myopathy
(unexplained generalised muscle pain, tenderness or weakness,
e.g. muscle pain not associated with flu, unaccustomed exercise or
PREVENTION OF HEART DISEASE 337
recent strain or injury) and allergic reactions – should be explained
and discussed with customers.
The BNF reports that statins are rarely associated with altered liver
function including drug-related hepatitis. Reversible myositis is also
a rare but significant side-effect of the statins. Both these reactions
are thought to be dose related. Some patients may ask about these
issues following the withdrawal of cerivastatin from the market. Rash
and hypersensitivity reactions (including angioedema and anaphylaxis)
have also been rarely reported.
If taken regularly, simvastatin 10 mg will reduce an individual’s LDL
cholesterol by 27% on average. The relationship between simvastatin
dose and LDL cholesterol reduction is log-linear in nature: a doubling
of dose from 10 to 20 mg increases the relative reduction of LDL
cholesterol from around 27 to 32%, and doubling the dose again to
40 mg produces a further 5% improvement.
In addition, the absolute reduction of LDL cholesterol achievable
with 10-mg simvastatin, if sustained, will produce around 30% relative
reduction in CHD risk. This will result in a worthwhile absolute risk
reduction in those at moderate risk and if the individual also modifies
other risk behaviours (such as stopping smoking, weight reduction and
regular exercise), the benefits will be considerable.
Aspirin 75 mg
Low-dose aspirin tablets may be sold as a P medicine in packs of up
to 100 tablets. They are currently licensed for the secondary prevention
of thrombotic strokes, transient ischaemic attacks (TIAs or ‘ministrokes’),
heart attacks or unstable angina.
Low-dose aspirin is recommended by the BNF, for primary prevention
of vascular events, as antiplatelet therapy in patients who have
an estimated 10-year CHD risk greater than or equal to 15%. Patients
with hypertension should have their blood pressure controlled
to minimise the risk of antiplatelet therapy contributing to the risk of
cerebrovascular bleeding. Patients should be assessed for contraindications
to aspirin therapy and patients at increased risk of GI bleeding
may require cover with a gastroprotective agent. There is no compelling
evidence to currently support the use of aspirin in low-risk subjects,
such as middle-aged males with no other risk factors.
Preventing heart disease in practice
Case 1
A man who looks as if he is in his mid-fifties asks to speak to the
pharmacist. He says, ‘I’ve been wondering if I should take them junior
aspirins. A few of the lads at the snooker club are on them – and they
say it can stop you having a heart attack?’ He asks what you think and
338 PREVENTION OF HEART DISEASE
if it is true that the aspirin tablets can prevent heart attacks. He does
not appear to be overweight.
The pharmacist’s view
I would first ask this man why he thinks he might need aspirin. That
will give me an idea of how he has assessed his risk and it will be a good
starting point. I would need to assess this man’s risk of heart disease
by asking about his family history, smoking, diet, physical activity and
medication (looking particularly for diabetes and hypertension). On
the basis of this assessment, I would decide whether he needed to be
referred to the general practitioner (GP). If he were a smoker, I would
prioritise that and discuss his readiness to quit. Then I would decide
what to do next.
The doctor’s view
I would agree with the pharmacist about checking his overall risk factors,
his understanding of these factors and the areas he needs to work
on. Aspirin is mainly used for secondary CHD prevention but if the
10-year risk for CHD is 15% or more, then it can be used for primary
prevention. If he hasn’t had a blood pressure or cholesterol test in the
last year or so, then it would make sense for this to be done. Some
pharmacies provide this service. In most GP surgeries further assessment
and information can be gleaned from seeing the practice nurse.
The most important aspect of advice is to cover all the risk factors and
not just focus on one area. A follow-up review is often helpful to see
how lifestyle has changed and what difficulties have been experienced.
Case 2
A woman in her forties comes in asking for some patches to help her
give up cigarettes. The pharmacist finds out that she is a heavy smoker,
20–30 per day, and has smoked for 25 years. She knows that she is overweight
and struggles to keep it down. She managed to stop smoking
for about 3 months once, but put on weight. She has a family history
of diabetes and two of her grandparents died of heart attack in their
seventies. Her uncle who is 60 years has angina. She saw her GP about
1 year ago who told her that her cholesterol level was mildly raised at
6 and her blood pressure was borderline. She was supposed to go back
for a review but hasn’t done so yet.
The pharmacist’s view
I would ask this woman to tell me about her previous attempt to quit,
including whether she used NRT that can be bought OTC; in many
parts of the UK, pharmacies are part of local NHS smoking cessation
services and can provide treatment. Many people are concerned that
they will put on weight when they stop smoking and I would talk
PREVENTION OF HEART DISEASE 339
with her about this. The health benefits of stopping smoking far outweigh
any additional risk from being overweight, and discussing the
figures can get this point across. Talking about what happened after
she stopped smoking last time including her diet and eating patterns
might provide some ideas about minimising weight gain this time.
The doctor’s view
It is very encouraging that she wants to do something about her smoking,
especially as she has several risk factors for CHD. I think the
pharmacist is in a good position to counsel and perhaps advise an appropriate
NRT. It would be useful to ascertain how she managed to
stop last time and the reasons for starting cigarettes again. The pharmacist
is also in a position to offer advice about her weight and find
out about her level of physical exercise. It would also be helpful to suggest
a review at her GP’s surgery to follow up her blood pressure and
cholesterol. It is likely that the GP would want to do some blood tests:
fasting lipid profile, fasting blood glucose, electrolytes and renal function,
and liver profile. In addition, a urine test checking for proteinuria
and glycosuria would be useful and, possibly, an electrocardiogram. If
after three readings she remained hypertensive, medication such as an
angiotensin-converting enzyme inhibitor may be advised. Of course, if
she were able to lose weight and increase exercise, this would also help
to lower her blood pressure.
340 PREVENTION OF HEART DISEASE
Appendix: Summary of Symptoms for
Direct Referral
Chest
Chest pain
Shortness of breath
Wheezing
Swollen ankles
Blood in sputum
Palpitations
Persistent cough
Whooping cough
Croup
Sputum mucoid, coloured
Gut
Difficulty with swallowing
Blood in vomit
Bloody diarrhoea
Vomiting with constipation
Weight loss
Sustained alteration in bowel habit
Eye
Painful red eye
Loss of vision
Double vision
Ear
Pain
Discharge
Deafness
Irritation
Tinnitus
Vertigo
Genitourinary
Difficulty in passing urine
Blood in urine
Abdominal/loin/back pain with cystitis
Temperature with cystitis
Urethral discharge
APPENDIX 341
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5
Vaginal discharge
Vaginal bleeding in pregnancy
Other
Neck stiffness/rigidity with temperature
Vomiting (persistent)
Non-blanching skin rash (purpura)
342 APPENDIX
Index
abdominal pain
atypical angina 85–6
gallstones 85
gastro–oesophageal reflux 36, 74–82
irritable bowel syndrome 85, 122
ulcers 84–5, 91–2
Acanthamoeba keratitis 266
Accident & Emergency departments 13–14
accidents
major/minor 13–14
ACE see angiotensin-converting enzyme
aciclovir 162, 163–4
acne 148–53
age 148–9
antibiotics 152–3
benzoyl peroxide 150–1
diet 152
make-up 153
management 150–3
severity 149
acrivastine 56
actions (WHAM mnemonic) 9
acupressure 99
acupuncture 215
acute laryngotracheitis 35
adverse drug reactions (ADRs)
see also drug interactions
ibuprofen for dysmenorrhoea 237–8
paracetamol 198
sodium/potassium citrate 228
sumatriptan 203
WHAM mnemonic 9
advice-giving criteria 1–2
age of patient 10–11
agranulocytosis 46
alcohol 95, 200, 329
alcoholic lotions 299–300
alginates 77
allergic conjunctivitis 264–5
allergic dermatitis 139–47
allergic rhinitis 52–60
age 52–3
allergic conjunctivitis 264–5
case reports 59–60
duration 53
eczema/dermatitis 141
failed medication 55
management 56–9
medication 55–9
symptoms 53–4
alopecia 180–3
alternative therapy see complementary
medicine
aluminium salts 88
alverine citrate 123, 124, 126
amoebic dysentery 113
amorolfine 158
amoxicillin 120, 248–9, 273
amprenavir 57
anal fissure 135
anal irritation 129
analgesics
see also individual analgesics; oral analgesics
topical 71, 213, 217
angina 81–2, 85–6
angiotensin-converting enzyme (ACE)
inhibitors 37
anogenital warts 167
antacids 77, 87–9
anti-inflammatory agents 214–15
see also individual anti-inflammatory drugs
antibiotics
acne 152–3
colds and flu 30
cystitis 228–9, 231, 232
eczema/dermatitis 145
napkin rash 292
oral thrush 308
otitis media 273
productive cough 34
sore throat 50
vaginal thrush 245, 248–9
anticholinergics 25–6, 98
antidiarrhoeals 125
antifungals 292, 309
see also azoles
vaginal thrush 242, 246, 248, 249
antihistamines
allergic rhinitis 56–7
colds and flu 25–7
cough remedies 40
insomnia treatment 317, 320
motion sickness 97–8
antipruritics 143–4
antiseptics
acne 152
haemorrhoids 132
mouth ulcers 70, 71
napkin rash 292
antispasmodics 123–4, 126
antivirals 29–30, 32, 162, 163–4
anxiety, chest pain 62
aphthous ulcers 67–73
appearance of patient 10–11
aqueous lotions 299–300
aromatherapy 317
arthralgia 210, 218
ASMETHOD mnemonic 10–12
aspirin
colds and flu 31
dysmenorrhoea 238, 240
headache 197, 199–200
heart disease 338
ibuprofen sensitivity 199
INDEX 343
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5
assessment of patients 8–14
asthma
colds and flu 22
cough 36, 42, 43
eczema/dermatitis 141
ibuprofen sensitivity 237–8
shortness of breath 62
wheezing 63
astringents 132
athlete’s foot 154–60
appearance 154–5
case reports 159–60
footwear 157–8
history taking 155
location 155
management 156–9
medication 155
referral to doctor 155
ringworm 157, 158
transmission 158
atorvastatin 32
atypical angina 85–6
aura 192, 193, 194, 201
azelastine 59
azithromycin 228–9, 231
azoles
athlete’s foot 156
dandruff 178
napkin rash 292
oral thrush in babies 309
threadworms 305
vaginal thrush 242, 246, 248–9
babies
colic 285–7
napkin rash 289–94
oral thrush 307–11
teething 288
bacillary dysentery 112, 113
back pain 210–11, 216–17, 258
bacterial diarrhoea 112
baldness 180–3
bathing 319
beclometasone 58, 60
behavioural therapy for colic 287
Behc¸et’s syndrome 69
benzocaine 48, 72, 131
benzodiazepines 317
benzoyl peroxide 150–1
benzydamine mouthwash/spray 48, 71
beta-blockers 331
betamethasone 146
bisacodyl 103, 106
blanching 282–3
bland creams 164
blepharitis 265
bloating 122
blood
see also haem...
bleeding 129, 200
cystitis 225
diarrhoea 114
pressure 24–5, 40, 329
stool 101
BMI see body mass index
BNF see British National Formulary
body mass index (BMI) 328–9, 334–5
bottle feeding 286–7
bowel cancer 101, 108–9
bowel habit 100–9, 122, 130
breastfeeding 146, 147
British National Formulary (BNF)
eczema/dermatitis 141
effectiveness of treatments 6–7
heart disease risk 327
pyridoxine 236
sympathomimetics 24
bronchitis 22, 35, 36, 62, 63
bruising 209
buclizine 201
bulk laxatives 104
bulking agents 124–5
bursitis 210
caffeine 197, 201, 238–9, 319
calamine lotion 284
calcipotriol 186
calcium carbonate 88
Campylobacter 112, 113
cancer
bowel 101, 108–9
hoarseness 46
oral 68–9, 73
skin 170
warts 170
Candida see oral thrush; vaginal thrush
capsaicin 214
capsicum 214
captopril 37
carbaryl 299–300
carbimazole 46
cardiac pain 61–2
cardiac respiratory problems 62, 63
cardiovascular disease (CVD) 36, 202,
326–33
cascara 104
castor oil 104, 291–2, 293
CDH see chronic daily headache
cefalexin 232
cetirizine 56
CHD see coronary heart disease
chest pain 61
chesty cough 34–5
chickenpox 279–80
childhood conditions 277–311
chickenpox 279–80
colic 285–7
constipation 104–5
fifth disease 281
German measles 281–2
head lice 295–302
measles 280–1
meningitis 282
napkin rash 289–94
oral thrush 47, 290, 292, 307–11
rashes 279–84
roseala infantum 281
teething 288
threadworms 303–6
Chinese herbal medicine 125–6, 144
Chlamydia 224–5, 228–9, 230–1
chloramphenicol 264, 267, 268
chlorhexidine gluconate 70, 71, 292
chlorphenamine 25, 26, 57, 284
344 INDEX
cholesterol 329–30
chondroitin 215
chronic bronchitis 62
chronic daily headache (CDH) 194
chronic obstructive pulmonary disease
(COPD) 22
ciclosporin 253
cigarettes see smoking habit
cimetidine 57, 78
CKS see Clinical Knowledge Service
classic migraine 192, 193–4, 203–4, 207
Clinical Evidence (BMJ Publishing Group)
6
clinical guidelines 6–7, 251–2
Clinical Knowledge Service (CKS)
280
clobetasone 140, 142, 143, 146
closed-angle glaucoma 26, 27
Clostridium difficile 120
clothing 79
clotrimazole 156, 292
cluster headache 195
coal tar 178–9
codeine 38–9, 197, 200–1
cold sores 161–5
colds and flu 19–32
antihistamines 25–7
case reports 31–2
flu differentiation 22
flu prevention 28–9
management 23–30
pandemics 29
colic 285–7
combined oral contraceptive (COC) 196,
206
comedones 148, 149
Commission on Human Medicines 9
Committee on Safety of Medicines (CSM)
243, 317
common migraine 194
communication skills 1–5
Community Pharmacy Contractual
Framework (CPCF) 6
complementary medicine
cold sores 164
colic 287
cystitis 228
eczema/dermatitis 144
insomnia treatment 317
irritable bowel syndrome 125–6
low back pain 215
motion sickness 98, 99
computer systems 5, 6, 7
confidentiality 14
conjunctivitis 55, 263–5, 266
constipation 100–9
associated symptoms 101
case reports 106–9
drugs causing 103
elderly people 105
haemorrhoids 130
management 103–5
medication 102–3
pregnancy 105, 258
referral to doctor 102, 108–9
timescales 103
consultations 7–12
contact dermatitis 139–47
contact lenses 266
contraception 196, 206, 251–7
COPD see chronic obstructive pulmonary
disease
corneal ulcers 265
coronary heart disease (CHD) 326–33
corticosteroids
see also hydrocortisone
topical 71, 72, 140, 142–6
cough 33–43
associated symptoms 35–6
asthma 36, 43
case reports 42–3
expectorants 39–40
management 38–42
referral to doctor 35, 36, 37
suppressants 38–9
types 34–5
counterirritants 132, 213
cow’s milk 286–7
CPCF see Community Pharmacy Contractual
Framework
cranberry juice 228
cromoglycate see sodium cromoglycate
crotamiton 143
croup 35
cryotherapy 169
CSM see Committee on Safety of
Medicines
CVD see cardiovascular disease
cyclophosphamide 227
cystitis 223–32
age/gender 224
blood in urine 225
case reports 229–32
Chlamydia 224–5, 228–9, 230–1
fluid intake 229
management 227–9
postmenopausal women 226
pregnancy 224, 258
referral to doctor 227
symptoms 224, 225–6
cytotoxic drugs 181, 187
dandruff 176–9
decision making 3, 5, 12–13
decongestants 24–5, 40–1, 57–8
demulcents 38, 39
dentures 69
depression
constipation 106–7
insomnia 321–3
St John’s wort 318, 321–3
dermatitis
allergic 139–47
napkin rash 289–94, 308, 309
vaginal 243
detergent sensitivity 294
dextromethorphan 39
diabetes
colds and flu treatments 27
cough medicines 32, 40, 41
cystitis 226
heart disease 329–30
sympathomimetics 24–5, 40
vaginal thrush 245
INDEX 345
diarrhoea 110–20
age 110
amoxicillin 120
case reports 117–20
causes 112–14
chronic 113–14
Clostridium difficile 120
irritable bowel syndrome 113–14
management 115–17
medication 114
referral to doctor 115
symptoms 111
diclofenac 90–1, 197–99, 206
diet
constipation 101–2, 106
heartburn 79
irritable bowel syndrome 125
rehydration therapy 115–16, 118
weight control 334–7
digoxin 95
dihydrocodeine 197, 201
dimeticone 88–9, 291, 297–8
diphenhydramine
allergic rhinitis 56–7
colds and flu 25, 26
insomnia treatment 317, 320
diphenoxylate/atropine 116
discharge
vaginal 243–4, 259
dithranol 186–7
doctors
see also referral to doctor
working with 14–15
docusate sodium 104
domperidone 89–90
doxycycline 231
doxylamine succinate 197, 201
drug interactions
antacids 89
antihistamines 26, 40
ciclosporin/levonorgestrel 253
cimetidine 78
ibuprofen 199
St John’s wort 318
sumatriptan 203
sympathomimetics 24–5, 41
theophylline 41
dry cough 34
duct tape 169
duodenal ulcers 84–5
dysmenorrhoea 233–41
age 233
case reports 240–1
endometriosis 234–5, 240
management 237–40
premenstrual syndrome 235–6
primary/secondary 234–5
referral to doctor 237, 240
dyspareunia 244
dyspepsia see indigestion
dysphagia 46, 75
dysuria 244
ear problems 270–5
allergic rhinitis 55
case reports 274–5
colds and flu 21
earplugs 274
glue ear 273–4
otitis externa 271–2
otitis media 272–4
referral to doctor 274–5
wax 270–1
earplugs 274
eating disorders 107–8
echinacea 27
eczema herpeticum 165
eczema/dermatitis 139–47
age 139–40
aggravating factors 141
case reports 144–7
history taking 140–1
management 142–4
medication 141
napkin rash 294
occupational contact 140
referral to doctor 141
effectiveness 6–7, 23–4, 38
EHC see emergency hormonal
contraception
elderly patients 105, 212
embarrassment 12, 14
emergency hormonal contraception (EHC)
251–7
age 251, 256
case reports 255–7
management 253–5
emollients 142–3, 291
emphysema 62
enalapril 37
endometriosis 234–5, 240
Entamoeba histolytica 113
Enterobius vermicularis 303–6
ephedrine 24–5
epilepsy 26, 27
Epsom salts 104
erythema infectiosum 281
erythromycin 152, 273, 274
Escherichia coli 112, 223
Eumovate cream 146, 147
evening primrose oil 236
exercise 319, 329
expectorants 38, 39
eye drops 57, 58
eye problems 261–9
allergic conjunctivitis 264–5
allergic rhinitis 54
blepharitis 265
case reports 266–9
conjunctivitis 263–5, 266, 268–9
contact lenses 266
glaucoma 266
iritis 265–6
styes 266–8
uveitis 265–6
eye tests 196
face masks 30
facial pain 21, 55
family doctors 14–15
family history 328
famotidine 77, 78, 89
346 INDEX
felbinac
topical 214
fever 20, 283
feverfew 203
fibromyalgia 210
fifth disease 281
first-aid 215–16
flu see colds and flu
fluconazole 242
fluid intake
constipation 102
coughs and colds 42
cystitis 229
diarrhoea 115–16, 117, 118
fluticasone 58, 60
footwear 157–8
formaldehyde 169
formulations 299
Framingham Heart Study 330
frozen shoulder 210
fungal infections see athlete’s foot;
onychomycosis; oral thrush; vaginal
thrush
furosemide 120
gallstone 85
gargles 49
gastric irritation 199–200
gastrointestinal tract problems 65–135
constipation 100–9
diarrhoea 110–20
haemorrhoids 128–35
heartburn 74–82
indigestion 83–92
irritable bowel syndrome 121–7
motion sickness 96–9
mouth ulcers 67–73
nausea and vomiting 93–5
gastro–oesophageal reflux 36, 74–82,
85
German measles (rubella) 281–2
Giardia lamblia 113
ginger 98–9
glandular fever 46, 47, 49–50
Glauber’s salts 104
glaucoma 266
glipizide 32
glucosamine 215
glue ear 273–4
glutaraldehyde 169
glycerin suppositories 104, 105, 108
glycogen 242–3
goserelin 240
guaifenesin 39–40
guttate psoriasis 185
H2 antagonists 77–8
haematuria 225
Haemophilus influenzae 282
haemoptysis 35, 64
haemorrhoids 128–35
case reports 133–5
management 131–3
pregnancy 258
referral to doctor 131
symptoms 129–30
hair loss 180–3
hay fever see allergic rhinitis
HDL see high-density lipoprotein
head injury 209
head lice 295–302
age 295
case reports 302
itching 296–7
management 297–302
wet combing method 302
headache 191–207
age 191–2
case reports 203–7
causes 195–6
chronic daily 194
cluster headache 195
colds and flu 21
frequency 192–3
history taking 193
management 197–203
migraine 192, 193–4, 203–4, 207
nature/site of pain 192
oral analgesics 197–203
pregnancy 259
referral to doctor 197
sinusitis 195
temporal arteritis 195
tension 205–6
heart disease
age 327
aspirin 338
case reports 338–40
diabetes 329–30
drugs exacerbating 330–1
mortality 326
obesity 328–9
orlistat 336–7
prevention 324–33
risk factors 327–31
simvastatin 337–8
smoking habit 328, 331–5
sympathomimetics 40
heart failure 35, 36, 62
heart stimulation 24–5
heartburn 74–82
age 74
case reports 80–2
causes 61
management 77–9
pregnancy 259
referral to doctor 76, 81–2
symptoms 75–6
heat 216, 319
Helicobacter pyloris 78, 81, 85
heparinoid 215
herpetiform ulcers 67, 68, 69
hexamine 227
high temperature 20, 283
high-density lipoprotein (HDL) 330
HIV infection 308, 310
hoarseness 46
holiday diarrhoea 111, 118–19
holiday travel 111, 118–19, 304, 320
honeymoon cystitis 226
hordeolum (stye) 267
hormonal contraception 196, 206, 251–7
how-to-use this book 1–15
hyaluronidase 215
INDEX 347
hydrocortisone
topical
athlete’s foot 157
eczema/dermatitis 140, 142–6
haemorrhoids 134
mouth ulcers 71, 72
napkin rash 292, 294
hygiene 133, 153, 290
hyoscine 98, 238
hypericum see St John’s wort
hypersensitivity 200
hypertension 24–5, 40, 329
hyperventilation syndrome 62–3
IBS see irritable bowel syndrome
ibuprofen
childhood fevers 283
cystitis 227
dysmenorrhoea 237–8, 239
headache 198–9
indigestion 198
musculoskeletal pain 212, 214, 218
identity of patient 8–9, 218
IHD see ischaemic heart disease
imidazole 242
immunocompromised 47, 245
immunosuppressives 308
indigestion 83–92
age significance 84
antacids 87–9
aspirin 199–200
atypical angina 85–6
case reports 90–2
gallstones 85
gastro–oesophageal reflux 85
ibuprofen 198
irritable bowel syndrome 85
questions and answers 84–7
referral to doctor 87, 91–2
ulcers 84–5
infective conjunctivitis 263–4, 268–9
influenza and colds 19–32
information gathering 3–5, 8–14
injuries
major/minor 13–14
insecticides 174, 297–301
insomnia 312–23
age 314–15
case reports 320–3
depression 318, 321–3
drugs causing 316
history taking 315–16
management 317–19
nasal plasters for snoring 318
referral to doctor 321, 322
St John’s wort 318, 321–3
symptoms 315
interactions see drug interactions
International Headache Society 194
iodine 49
iritis 265–6
irritable bowel syndrome (IBS) 121–7
age 121
case reports 126–7
diarrhoea 113–14
history 122–3
indigestion 85
management 123–6
referral to doctor 123
symptoms 122
irritant effects 217
see also allergic...
ischaemic heart disease (IHD) 326
ispaghula 104
itching
childhood rashes 283
head lice 296–7
nasal 54
pregnancy 260
scabies 172–5
threadworms 303–4
vaginal thrush 243, 249
joint pain 210, 218
kaolin and morphine 116, 117, 131
Kaposi’s varicelliform eruption 165
keratolytics 150–1
ketoconazole 156, 178
ketoprofen 214
key skills 1–15
lactic acid 168
lactobacilli 247
lactulose 104
lanolin 291
laryngitis 46
laryngotracheitis 35
laxatives 102–5, 107, 108, 132
LDL see low-density lipoprotein
levonorgestrel 252, 253
lidocaine 72, 131
lisinopril 37
listening skills 3–4
Listeria monocytogenes 112, 113
lithium 199
live yoghurt 247–8
liver toxicity 198
local anaesthetics 48, 72, 131, 246
lodoxamide eye drops 265
loose cough 34–5
loperamide 116, 119, 125
loratadine 56–7
low-density lipoprotein (LDL) 330
low-dose aspirin 338
lozenges
throat 49
magnesium salts 88
major accidents 13–14
make-up
acne 153
Malassezia furfur 176, 177
malathion 174, 298–300
measles 280–1
measles, mumps, rubella (MMR) vaccine
280
mebendazole 305
mebeverine hydrochloride 123, 124, 126
melatonin 318
meningitis 282
meningococcal meningitis 282
menthol 214
metformin 32
348 INDEX
methenamine hippurate see hexamine
methotrexate 187
methyl salicylate 213
methylcellulose 104
metronidazole 248–9
miconazole 156, 292, 309
migraine
buclizine 201
case reports 203–4, 207
sumatriptan 201–3, 207
symptoms 192, 193–4
migrainous neuralgia see cluster headaches
minor accidents 13
minoxidil 182, 183
misoprostol 91
mittelschmerz 234
MMR see measles, mumps, rubella vaccine
monoamine oxidase inhibitors (MAOIs) 24,
25
morning sickness 259–60
morphine 116–17
mortality
heart disease 326
motion sickness 96–9
alternative medicines 98, 99
anticholinergic agents 98
antihistamines 97–8
ginger 98–9
mouth ulcers 67–73
case reports 72–3
history taking 69
management 70–2
referral to doctor 70
mouthwashes 48–9, 71
multiple warts 167
muscle pain 209
musculoskeletal problems 208–19
age 208
case reports 217–19
first-aid 215–16
management 212–17
medication 212
referral to doctor 212
symptoms 208–12
nail infections 158–9
named product requests 2–3
napkin rash 289–94, 308, 309
naproxen 237
nasal congestion 53
nasal itching 54
nasal plasters 318
nasal sprays 28, 58, 60
National Service Framework (NSF) 326–7
nausea and vomiting 93–5, 259–60
nedocromil eye drops 265
NHS Direct 5, 7, 14
nicotinamide 151
nicotinates 214
nicotine replacement therapy (NRT) 331–3
nits 296, 300
nocturnal cough 43
nonsteroidalanti-inflammatorydrugs(NSAIDs)
see ibuprofen, naproxen, diclofenac
non-pigmented warts 170
NRT see nicotine replacement therapy
NSAIDs see ibuprofen, naproxen, diclofenac
NSF see National Service Framework
nurse colleagues 14–15
obesity
heart disease 328–9
heartburn 79
orlistat 336–7
smoking cessation 334–5
weight control 334–5, 336–7
occupational exposure 140
OE see otitis externa
omeprazole 77, 78
onychomycosis 158–9
oral analgesics 31, 48
childhood fevers 283
codeine 38–9, 197, 200–1
cystitis 227
dysmenorrhoea 237–8
headache 196, 197–203
indigestion 198
sore throat 31, 48
teething 288
oral cancer 68–9, 73
oral contraceptives 196, 206, 331
oral rehydration therapy 115–16, 118
oral thrush 307–11
case reports 309–11
management 309
napkin rash 290, 292, 308, 309
throat 47
orlistat 336–7
osmotic laxatives 104
otitis externa (OE) 271–2
otitis media 272–4
outcomes 3, 7
oxymetazoline 24
painful conditions 189–219
haemorrhoids 129
headache 191–207
heartburn 74–82
indigestion 84
musculoskeletal problems 208–19
red eye 263–9
painful periods see dysmenorrhoea
pandemics
flu 29
papillary conjunctivitis 266
paracetamol
childhood fevers 283
cystitis 227
dysmenorrhoea 238
headache 197–8
musculoskeletal pain 218
partner treatment 244, 247, 249
partnership with patients 2
pastilles
throat 49
patent foramen ovale (PFO) 193
patient assessment 8–14
Patient Group Directions (PGD) 254, 256
patient identity 8–9
pelvic inflammatory disease (PID) 235
penciclovir 163, 164
peppermint oil 123, 124, 126
peptic ulcers 84–5, 91–2
permethrin 174, 298–9
INDEX 349
pertussis 35
PFO see patent foramen ovale
PGD see Patient Group Directions
pharmacy patient medication records 3, 6, 15
phenothiazines 40
phenothrin 298–9, 300
phenylpropanolamine (PPA) 25
pholcodine 38–9
PID see pelvic inflammatory disease
pigmented skin lesions 170
piles 4–5, 128–35
see also haemorrhoids
piperazine 305–6
piroxicam 214
PMR system see pharmacy patient medication
records
PMS see premenstrual syndrome
pneumonia 30, 63
pompholyx 160
POP see progestogen-only pill
postmenopausal women 226
postnasal drip 35
posture 79
potassium citrate 228, 231
PPA see phenylpropanolamine
pregnancy
common symptoms 258–60
constipation 105
cystitis 224
emergency contraception 251–70
haemorrhoids 130
heartburn 76
ibuprofen 199
nausea and vomiting 94
vaginal thrush 244–5
premenstrual syndrome (PMS) 235–6
preventive medicine
flu 28–9
heart disease 324–33
motion sickness 97–9
recurrent back pain 216–17
vaginal thrush 248
primary care system 5, 7, 14–15
primary dysmenorrhoea 234, 241
privacy 14, 247
productive cough 34–5
progestogen-only pill (POP) 255
promethazine 40, 56–7, 317, 320
Propionibacterium acnes 149, 152
prostaglandins 237, 238
prostatic hypertrophy 26, 27
Proteus mirabilis 223
proton pump inhibitors 77, 78
pruritus
childhood rashes 283–4
head lice 296–7
nasal 54
pregnancy 260
scabies 172–5
threadworms 303–4
vaginal thrush 243, 249
pseudoephedrine 24–5, 40–1
Pseudomonas 272
psoriasis 176, 177, 184–7
psychological factors 62, 165, 184–5
purulent conjunctivitis 55
pyridoxine 236
ramipril 37
ranitidine 77, 78, 89
rashes
childhood 279–84
record-keeping 6, 15
red eye
painful 263–9
referral to doctor
age and appearance assessment
10
allergic rhinitis 54–5
ASMETHOD mnemonic 12
athlete’s foot 155
childhood thrush 310
cold sores 163
constipation 102, 108–9
cough 35, 36, 37, 50–1
cystitis 227
diarrhoea 115
dysmenorrhoea 237, 240
ear problems 274–5
eczema/dermatitis 141, 145
elderly patient with musculoskeletal pain
218–19
guidelines 15
haemorrhoids 131
headache 197
heartburn 76, 81–2
indigestion 87, 91–2
insomnia 321, 322
irritable bowel syndrome 123,
127
meningitis 282, 283
migraine 202
mouth ulcers 70
musculoskeletal pain 212
otitis externa 271
otitis media 273
respiratory symptoms 61–4
risk assessment 12–13
scabies 173
sore throat 46–7
subarachnoid haemorrhage 192
symptoms summary 342–3
regurgitation 75–6
rehydration therapy 115–16, 118
repetitive strain disorder 211
respiratory problems 17–64
allergic rhinitis 52–60
colds and flu 19–32
cough 33–43, 50–1
direct referral needed 61–4
sore throat 44–51
rhinitis
allergic 52–60
rhinorrhoea 20, 53
RICE mnemonic 216
ringworm 157, 158
risk assessment 12–13
ritonavir 57
roseala infantum 281
roundworms 305
Royal Pharmaceutical Society of Great Britain
(RPSGB) guidance 254
rubefacients 213
rubella 281–2
runny nose 20
350 INDEX
safety
see also adverse drug reactions; drug
interactions; referral to doctor; side
effects
direct referral 61–4, 342–3
pyridoxine 236
respiratory direct referral 61–4
risk assessment 12–13
sumatriptan 202–3
sympathomimetics 24–5
SAH see subarachnoid haemorrhage
St John’s wort (SJW) 318, 321–3
sale restrictions 25
salicylic acid 168, 169–70
Salmonella 112, 113
Sarcoptes scabiei 172–5
scabies 172–5
secondary dysmenorrhoea 234–5, 240
selenium sulphide 2.5 178
senna pods 104, 108
sennosides 103
sexually transmitted diseases 244, 245, 247,
249–50
shampoos 178–9, 300
shark liver oil 132
Shigella 112
shortness of breath 62–3
sickness and vomiting 93–5
side effects
constipation 103
diarrhoea 114, 120
drugs exacerbating heart disease
330–1
hair loss 181
liver toxicity 198
mouth ulcers 70
nausea and vomiting 95
simvastatin 337–8
simeticone 286
simvastatin 337–8
sinuses 21, 195
SJW see St John’s wort
skin conditions 137–87
acne 148–53
athlete’s foot 154–60
cancer 170
childhood rashes 279–84
cold sores 161–5
dandruff 176–9
eczema/dermatitis 139–47
hair loss 180–3
history taking 11
napkin rash 289–94
pregnancy rashes 260
psoriasis 184–7
scabies 172–5
warts/verrucae 166–71
skin protectors 131–2
sleep hygiene 316, 319
sleep problems 312–23
smoking habit
cough 36
giving up 331–5
heart disease 328
heartburn 79
indigestion 86
sore throat 45
sneezing
allergic 54
snoring 318
sodium bicarbonate 88
sodium citrate 228, 231
sodium cromoglycate 56, 57, 58, 264, 265
sore throat 44–51
associated symptoms 45
case reports 49–51
colds and flu 21
direct referral symptoms 46–7
management 48–9
sprains 209, 215–16
sputum 34, 35, 63
Staphylococcus spp.
cystitis 223
diarrhoea 112, 113
eczema 145
otitis externa 272
styes 268
statins 337–8
steam inhalations 28, 41–2
sterculia 104
steroids
see also hydrocortisone; individual steroids
topical
acne 153
allergic rhinitis 58
athlete’s foot 157
haemorrhoids 132, 134
mouth ulcers 71, 72
psoriasis 186
stimulant laxatives 103–4
stomach ulcers 84–5
strains 209, 211, 215–16, 218
stress 165, 184–5
strokes 25, 324–33
styes (hordeolum) 266–8
subarachnoid haemorrhage (SAH) 192
sumatriptan 201–3, 207
summer colds 20
sunlight 152, 164–5
sunscreens 164–5
surgical face masks 30
swimming pools 170–1
sympathomimetics 24–5, 40–1, 57–8
symptom-based requests for help 3
symptoms for direct referral 61–4, 342–3
tacalcitol 186
TB see tuberculosis
teething 288
temporal arteritis 195
tenosynovitis 211
TENS see transcutaneous electrical nerve
stimulation
tension headache 205–6
terbinafine 156
tetracyclines 152
theophylline 41
threadworms 244, 303–6
throat 44–51
thrush see oral thrush; vaginal thrush
tickly cough 34
tight cough 34
tinea pedis 154–60
tolnaftate 156, 157
INDEX 351
topical treatments
analgesics 71, 213, 217
antihistamines 59
antivirals 162, 163–4
headache 203
NSAIDs 212, 214–15
steroids
acne 153
athlete’s foot 157
eczema/dermatitis 140, 142–6
haemorrhoids 132, 134
mouth ulcers 71, 72
psoriasis 186
transcutaneous electrical nerve stimulation
(TENS) 239
trauma 196
travel 111, 118–19, 304, 320
treatment recommendations 5–7
triage process 3, 5, 14
triamcinolone 58, 60, 72
tricyclic antidepressants 40
trimethoprim 152, 232
tuberculosis (TB) 35
ulcers 67–73, 84–5, 91–2
undecenoates 156, 157
unproductive cough 34
urinary tract infection (UTI) 223–32
uveitis 265–6
vaginal discharge 242–50, 260
vaginal thrush 242–50
age 242–3
case reports 248–50
dyspareunia 244
dysuria 244
history taking 244–5
management 246–8
pregnancy 244–5
symptoms 243–5
varicella 279–80
verrucae 166–71
viral diarrhoea 112
viral upper respiratory infections
19
vitamin C 27, 31
volunteering information 12, 14
vomiting see nausea and vomiting
waist measurement 328–9
warts/verrucae 166–71
age 166
appearance 166–7
history taking 167
location 167
management 168–71
multiple 167
skin cancer 170
wax in ears 270–1
websites
clinical guidelines 7
weight control 334–7
wet combing 296, 297, 302
WHAM mnemonic 8–9
wheezing 54–5, 63
whiplash injuries 211
whooping cough 35
women’s health 221–60
cystitis 223–32
dysmenorrhoea 233–41
emergency contraception 251–7
pregnancy symptoms 258–60
xylometazoline 24
Yellow Cards 9
zanamivir 32
zinc 27, 131, 178, 291, 293
352 INDEX

برچسب ها: Smoking cessation – tips for customers about quitting  Set a quit date، prepare for it and stick to it.  Get support and advice from friends، family and health professionals.  Consider NRT for the first few weeks.  Avoid situations where you will find it difficult not to smoke.  Change your routine to distract yourself from times and places you associate with smoking.  Stop completely if you can، rather than cut down.  Get rid of all cigarettes، lighters and ashtrays before your quit date.  Ask people not to smoke around you and tell everyone you are quitting.  Keep busy، especially when cravings start.  Reward yourself for not smoking.  Calculate how much money you will save and plan how you will now spend it. A range of NRT products are available. They vary in the ease and frequency of use، the speed of nicotine release and the amount of behavioural replacement provided. There are no conclusive studies to show that one formulation is any more effective than another at achieving cessation. All products will increase the chances of success if used correctly. Nicotine replacement therapy – formulation options Patches Discreet – easy to wear and forget about،  

تاریخ : دوشنبه 25 اسفند 1393 | 11:57 ب.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th




Oral thrush
Thrush (candidosis) is a fungal infection, which occurs commonly in
the mouth (oral thrush), in the nappy area in babies and in the vagina
(see p. 242). Oral thrush in babies can be treated by the pharmacist.
What you need to know
Age
Infant, child, adult, elderly
Affected area
Appearance
Previous history
Medication
Significance of questions and answers
Age
Oral thrush is most common in babies, particularly in the first few
weeks of life. Often, the infection is passed on by the mother during
childbirth. In older children and adults, oral thrush is rarer, but may
occur after antibiotic or inhaled steroid treatment (see ‘Medication’
below). In this older group it may also be a sign of immunosuppression
and referral to the doctor is advisable.
Affected areas
Oral thrush affects the surface of the tongue and the insides of the
cheeks.
Appearance
Oral thrush
When candidal infection involves mucosal surfaces, white patches
known as plaques are formed, which resemble milk curds; indeed, they
may be confused with the latter by mothers when oral thrush occurs
in babies. The distinguishing feature of plaques due to Candida is that
they are not so easily removed from the mucosa, and when the surface
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
ORAL THRUSH 307
of the plaque is scraped away, a sore and reddened area of mucosa will
be seen underneath, which may sometimes bleed.
Napkin rash
In the napkin (nappy) area, candidal infection presents differently, with
characteristic red papules on the outer edge of the area of nappy rash,
so-called satellite papules. Another feature is that the skin in the folds
is nearly always affected. Candidal infection is thought to be an important
factor in the development of nappy rash (see p. 242).
Previous history
In babies recurrent infection is uncommon, although it may sometimes
occur following reinfection from the mother’s nipples during breastfeeding
or from inadequately sterilised bottle teats in bottle-fed babies.
Patients who experience recurrent infections should be referred to
their doctor for further investigation.
Human immunodeficiency virus infection
Persistence of oral thrush and/or thrush of the nappy area after the
neonatal period may be the first sign of HIV infection.
Medication
Antibiotics
Some drugs predispose to the development of thrush. For example
broad-spectrum antibiotic therapy can wipe out the normal bacterial
flora, allowing the overgrowth of fungal infection. It would be useful to
establish whether the patient has recently taken a course of antibiotics.
Immunosuppressives
Any drug that suppresses the immune system will reduce resistance
to infection, and immunocompromised patients are more likely to get
thrush. Cytotoxic therapy and steroids predispose to thrush. Patients
using inhaled steroids for asthma are prone to oral thrush because
steroid is deposited at the back of the throat during inhalation, especially
if inhaler technique is poor. Rinsing the throat with water after
using the inhaler may be helpful.
The pharmacist should identify any treatment already tried. In a
patient with recurrent thrush it would be worth enquiring about previously
prescribed therapy and its success.
When to refer
Recurrent infection
All except babies
Failed medication
308 CHILDHOOD CONDITIONS
Treatment timescale
Oral thrush should respond to treatment quickly. If the symptoms have
not cleared up within 1 week, patients should see their doctor.
Management
Antifungal agents
Miconazole
The only specially formulated product currently available for sale OTC
to treat oral thrush is miconazole gel. Preparations containing nystatin
are also effective but are restricted to prescription-only status.
Miconazole gel is an orange-flavoured product, which should be
applied to the plaques using a clean finger four times daily after food
in adults and children over 6 years, and twice daily in younger children
and infants. For young babies, the gel can be applied directly to the
lesions using a cotton bud or the handle of a teaspoon. The gel should
be retained in the mouth for as long as possible. Treatment should be
continued for 2 clear days after the symptoms have apparently gone,
to ensure that all infection is eradicated.
Miconazole gel should not be recommended for patients taking anticoagulants.
There is evidence of an interaction with warfarin leading
to an increase in bleeding time.
Practical points
Oral thrush and nappy rash
If a baby has oral thrush, the pharmacist should check whether nappy
rash is also present. Where both oral thrush and candidal involvement
in nappy rash occur, both should be treated at the same time. An antifungal
cream containing miconazole or clotrimazole can be used for
the nappy area.
Breastfeeding
Where the mother is breastfeeding, a small amount of miconazole gel
applied to the nipples will eradicate any fungus present. For bottle-fed
babies, particular care should be taken to sterilise bottles and teats.
Oral thrush in practice
Case 1
Helen Jones, a young mother, brings her daughter, Jane, to see you. Mrs
Jones wants you to recommend something for Jane’s mouth, which has
white patches on the tongue and inside the cheeks. Jane is 8 years old
and is not currently taking any medicines. She has not recently had any
ORAL THRUSH 309
antibiotics or other prescribed medicines. Jane does not have any other
symptoms.
The pharmacist’s view
Jane should be referred to her doctor, since thrush is rare in children
other than infants. There is no apparent precipitating factor such as
recent antibiotic therapy and Jane should see her doctor for further
investigation.
The doctor’s view
Helen Jones should be advised to take Jane to the doctor. The description
is certainly suggestive of oral thrush. If there were any doubt as
to the diagnosis, a swab could be taken for laboratory examination.
If Jane did have thrush, then treatment such as miconazole oral gel or
nystatin oral suspension might be prescribed. Treatment is enhanced by
cleaning the white plaques off with a cotton bud prior to application.
The next concern would be to determine a precipitating cause. General
enquiries about Jane’s health would be necessary. The doctor
would be in a good position to know of previous medical history including
any transfusions and family history. A general physical examination
would be carried out, looking, in particular, for signs of anaemia, any
rashes or bruising, enlargement of lymph nodes (glands), enlargement
of abdominal organs (e.g. liver or spleen) or any other masses. The doctor
would be looking for signs of a malignancy such as leukaemia or
lymphoma. Almost certainly blood tests would be arranged. The doctor
would also make an assessment of any HIV risk factors and counsel
Helen and Jane accordingly before initiating any further action.
Case 2
A young mother asks for something to treat her baby son’s mouth. You
look inside the baby’s mouth and see white patches on the tongue and
inside the cheeks. The baby is 8 weeks old and has had the patches
for 2 days: at first his mother thought they were milk curds. He had
some antibiotic syrup last week for a chest infection and finished it
yesterday. The baby is not taking any other medicines and his mother
has not given him anything to treat the symptoms yet. He has no other
symptoms.
The pharmacist’s view
You could recommend the use of miconazole oral gel for this baby. He
has a thrush infection following antibiotic therapy that should respond
well to the imidazole antifungal. His mother should use 2.5 mL of gel
twice daily after feeds, applying it to the inside of the mouth and tongue.
Treatment should be continued for 2 days after the problem has cleared
310 CHILDHOOD CONDITIONS
up. If the symptoms have not gone after 1 week, the baby should be
seen by the doctor.
The doctor’s view
Oral thrush seems the most likely diagnosis. It would be reasonable for
the pharmacist to institute treatment in view of the baby’s age alone,
although in this case antibiotic treatment is an additional precipitating
factor. If there were any doubt as to the diagnosis, his mother could
seek the advice of the health visitor. It might be useful to ask the mother
whether or not she was breastfeeding in case any gel needed applying
to the nipples. When applying the gel to the mouth, the plaques should
be scraped off, if possible, to increase the effectiveness of the treatment.
ORAL THRUSH 311
Insomnia
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5


Insomnia
It is estimated that over 8 million people in the UK have problems sleeping.
Temporary insomnia is common and can often be managed by the
pharmacist. The key to restoring appropriate sleep patterns is advice on
sleep hygiene. Over-the-counter (OTC) products to aid sleep (the antihistamines
diphenhydramine and promethazine) can help during the
transition period and can also be useful in periodic and transient sleep
problems. These products are advertised direct to the public and pharmacists
report difficulties in declining sales for continued use. An initial
focus on sleep hygiene and careful explanation that antihistamines are
for short-term use are therefore important.
What you need to know
Age
Symptoms
Difficulty falling asleep
Waking during the night
Early morning waking
Poor sleep quality
Snoring
Duration
Previous history
Previous episodes
Contributory factors
Shift working, being away from home
Current sleep hygiene
Medication
Significance of questions and answers
Age
In elderly people the total duration of sleep is shorter and there is less
deep stage 4 sleep. Nocturnal waking is more likely because sleep is
generally more shallow. However, people may still feel that they need
more sleep and wish to take a medicine to help them sleep. Elderly
INSOMNIA 315
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5
people may nap during the day and this reduces their sleep need at
night even further.
Many babies, toddlers and infants have poor sleep patterns, which
understandably can cause anxiety to parents. In these situations referral
to the health visitor or doctor can be helpful. There are also some
helpful self-help books and pamphlets available.
Symptoms
It is important to distinguish between the different types of sleep problems:
Difficulty in falling asleep (sleep latency insomnia)
Waking during the night
Early morning waking
Poor sleep quality
Snoring.
Depression is an important cause of insomnia. Early morning waking
is a classic symptom of depression. Here the patient may describe no
problems in getting to sleep but waking in the early hours and not being
able to get back to sleep. This pattern requires referral to the doctor
for further investigation.
The onset of symptoms of bipolar disorder may be associated with
lack of sleep. It is possible that insufficient sleep may actually trigger
an episode of mania in bipolar disorder.
Anxiety can also cause insomnia. This is usually associated with
difficulty in getting off to sleep because of an overactive mind. This
is something that many people experience, particularly before an important
occasion, e.g. an examination. If, however, this occurs as a
more regular pattern, referral to the general practitioner (GP) should
be offered.
Duration
Sleep disorders are classified as follows:
Transient (days)
Short term (up to 3 weeks)
Chronic (longer than 3 weeks).
All chronic cases should be referred to the doctor.
Previous history
It is worth asking whether this is the first time problems in sleeping
have occurred or whether there is a previous history. Where there is a
previous history, it is helpful to know what treatments have been tried.
316 INSOMNIA
It is also useful to be aware of a history of depression or anxiety or
some other mental health problem.
Contributory factors
1 Shift work with changing shifts is a classic cause of sleep problems.
Those who work away from home may experience difficulty in getting a
good night’s sleep because of the combination of travelling and staying
in unfamiliar places.
2 Alcohol – while one or two drinks can help by decreasing sleep
latency, the sleep cycle is disturbed by heavy or continuous alcohol
consumption.
3 Life changes can cause disrupted sleep, e.g. change or loss of job,
moving house, bereavement, loss or separation or the change of life
(i.e. menopause).
4 Other stressful life events might include examinations, job interviews,
celebrations (e.g. Christmas) and relationship difficulties.
5 Obesity can be associated with sleep apnoea and snoring, both of
which can interrupt sleeping.
Current sleep hygiene
It is worth asking about the factors known to contribute to effective
sleep hygiene (see ‘Practical points’ below).
Medication
Some drugs can cause or contribute to insomnia, including decongestants,
fluoxetine, monoamine oxidase inhibitors, corticosteroids, appetite
suppressants, phenytoin and theophylline. Medical problems can
be associated with insomnia through pain (e.g. angina, arthritis, cancer
and gastro-oesophageal reflux) or breathing difficulties (e.g. heart failure,
chronic obstructive airways disease and asthma). Other medical
conditions such as hyperthyroidism and Parkinson’s disease can also
cause insomnia.
When to refer
Suspected depression
Chronic problem (longer than 3 weeks’ duration)
Children under 16 years
Treatment timescale
There should be an improvement within days: refer after 1 week if the
problem is not resolved.
INSOMNIA 317
Management
Antihistamines (diphenhydramine and promethazine)
Antihistamines reduce sleep latency (the time taken to fall asleep) and
also reduce nocturnal waking. They should be taken 20–30 min before
bedtime and can be recommended for adults and children over
16 years. Tolerance to their effects can develop and they should not
be used for longer than 7–10 consecutive nights. Diphenhydramine
has a shorter half-life than promethazine (5–8 h compared with 8–
12 h). Following a 50-mg dose of diphenhydramine there is significant
drowsiness for 3–6 h. These antihistamines have anticholinergic sideeffects,
including dry mouth and throat, constipation, blurred vision
and tinnitus. These effects will be enhanced if the patient is taking
another drug with anticholinergic effects (e.g. tricyclic antidepressants
and phenothiazines) but patients taking these drugs would be better
referred anyway. Prostatic hypertrophy and closed-angle glaucoma are
contraindications to the use of diphenhydramine and promethazine.
Diphenhydramine and promethazine should not be recommended for
pregnant or breastfeeding women.
Benzodiazepines
Despite the UK Committee on Safety of Medicines (CSM) statement
on the use of benzodiazepines, recommending that these drugs are for
short-term use only and should not be used for longer than 3 weeks,
pharmacists are well aware that patients continue to be on these drugs
for long periods of time. Research shows that success rates in weaning
patients off benzodiazepines can be high. This is an area where
pharmacists and doctors can work together and discussions with local
doctors can initiate this process.
Complementary therapies
Some patients prefer alternative treatments for insomnia, perceiving
them as more natural. Herbal remedies have been traditionally used
for insomnia, with valerian and hops being the most commonly used
ingredients. They are not recommended for pregnant or breastfeeding
women. In studies, side-effects have been mild and transient and with
no differences from placebo.
Aromatherapy
Lavender oil has been shown to induce a sense of relaxation, as has
camomile. One or two drops of the essential oil sprinkled on a pillow
or three or four drops in a warm (not hot) bath can be recommended.
318 INSOMNIA
Melatonin
Melatonin is currently available only as prescription-only medicine in
the UK; however, it is widely used in the USA to treat insomnia. Melatonin
is produced by the body’s pineal gland during darkness and is
thought to regulate sleep. Studies have shown that melatonin levels are
lower in the elderly. Supplementation with melatonin can raise levels
and help to restore the sleep pattern. Melatonin has a short half-life
(2–3 h) and is subject to first-pass metabolism. Sublingual, controlledrelease
products are therefore popular in the USA.
St John’s wort (hypericum)
St John’s wort (SJW), a herbal remedy, is commonly used in the selftreatment
of depression and pharmacists will encounter people who
come into the pharmacy to buy it and those who seek the pharmacist’s
opinion about whether to take it or not. In a recent study among people
with depression one in three had tried SJW.
A recent systematic review and meta-analysis found that overall
the evidence relating to SJW is inconsistent and complex. In mild-tomoderate
depression, SJW preparations and standard antidepressants
appear to show similar effects. In major depression, SJW preparations
had only small benefits over placebo; in older studies in patients with
mild-to-moderate depression, Hypericum perforatum preparations appear
to be of more benefit than placebo. Pharmacists should bear in
mind that there is heterogeneity not only among the trials and their
results, but also among the different manufacturers’ products tested.
Products may differ considerably in their pharmaceutical quality and
cannot be considered equally effective. Lack of standardisation of the
amount of active ingredient is an issue and preparations are not standardised.
Pharmacists will make their own decisions about whether they will
recommend SJW, and they need to be prepared to answer requests
for advice about its use and to be aware of the emerging evidence.
SJW is an inducer of drug-metabolising enzymes and there are some
important drug interactions (see the British National Formulary for
a full current listing). The CSM has advised that SJW should not be
taken with other medicines. Pharmacists are an important source of
information for patients about possible interactions.
Nasal plasters for snoring
These adhesive nasal strips work by opening the nostrils wider and
enabling the body to become accustomed to breathing through the
nose rather than through the mouth. A plaster is applied each night
for up to 1 week to retrain the breathing process. The strips have been
suggested for use in night-time nasal congestion during pregnancy.
INSOMNIA 319
Practical points
Sleep hygiene
Key points are as follows:
Establish a regular bedtime and waking time
Consciously create a relaxation period before bedtime
No meals just before bedtime
No naps during the daytime
No caffeine after early afternoon
Reduce extraneous noise (use earplugs if necessary)
Get up if you can’t sleep – go back to bed when you feel ‘sleepy,
tired’
Restrict alcohol intake to 1–2 units a day or less
Restrict nicotine intake immediately before bedtime
Exercise
There is evidence that regular exercise is beneficial in reducing depressive
symptoms. The National Institute for Health and Clinical Excellence
guideline 23 on depression states that there is evidence that a
structured exercise programme, 45 min to 1 h up to three times weekly,
can be beneficial in those with mild-to-moderate depression and those
with low mood.
The Mental Health Foundation has run a campaign encouraging
exercise in people with depression. Their website (www.mentalhealth.
org.uk) gives free access to booklets aimed at both professionals and
patients.
Alternatives to medication are important especially as there is evidence
that antidepressants are overall not beneficial in mild depression.
Bathing
A warm bath 1–2 h (not immediately) before bedtime can help induce
sleep.
Using heat
An electric blanket can help sleep by relaxing the muscles and increasing
brain temperature. The effect is not needed throughout the night,
only in inducing sleep. Using a timer to switch off the blanket after 1
or 2 h is sensible.
Caffeine
The stimulant effect of caffeine in coffee, tea and cola drinks is considerable.
Avoiding caffeine in the late afternoon and evening is sensible
advice.
320 INSOMNIA
Insomnia in practice
Case 1
Chris Jenkins, a 20-year-old student, comes into the pharmacy requesting
some tablets to help him sleep. He says that he has had problems
sleeping ever since he returned from Indonesia 10 days ago. He says
that he cannot get off to sleep because he does not feel tired. When he
eventually does fall asleep, he sleeps fitfully and finds it difficult to get
up in the morning. He has never suffered from insomnia before. He
is otherwise well, is not taking any medicines and does not have any
other problems or difficulties.
The pharmacist’s view
Long-haul travel can result in disruption of the sleep pattern and some
people are more affected by it than are others. It would be reasonable
to recommend that Chris take an antihistamine (diphenhydramine or
promethazine) for 4–5 days until the problem resolves. An alternative
would be one of the herbal products to aid sleep. He should find that
his normal sleep pattern is re-established within 1 week.
The doctor’s view
This is quite likely to be a short-term problem due to his recent travelling.
A very short course of antihistamines may re-establish a better
pattern. Many people who complain of insomnia do not always admit
to other problems in their lives. It is therefore important to be alert
to this possibility. If his insomnia does not resolve quickly, or if the
pharmacist were to notice that Chris seemed low or anxious, a referral
would be appropriate.
Case 2
Maureen Thomas, aged about 50 years, comes in asking for something
to help her sleep. She says she has seen an advertisement for some
tablets that will help. Maureen explains that her sleep has been bad ever
since she had her children, but over the last week it has got worse. She
says she has had problems in getting off to sleep and recently has been
waking early and not getting back to sleep. She says that she has had
some worries at work and her Mum has been unwell . . . ‘but that’s all,
no more than usual. I’ve had to put up with a lot worse and managed! I
just need a few days’ good sleep and I’ll be OK.’ Otherwise she reveals
that she is not on any other medication and has never troubled anyone
before with her sleeping problem.
The pharmacist’s view
This patient is experiencing a number of sources of stress and difficulty
that are likely to be contributing to her sleep problems. In addition to
INSOMNIA 321
having trouble getting to sleep, she is also waking early and unable
to get back to sleep, indicating that the sleep disturbance is extensive.
Early waking can also be a symptom of depression. It would be best for
her to see the doctor and this will need a careful, persuasive explanation
from the pharmacist. It would also be useful to talk about sleep hygiene
to see if there are any practical actions that she could take to alleviate
the problem. While the use of an antihistamine or herbal medicine
for a few days would not be harmful, it may prevent her from seeking
advice from the doctor. Therefore it would be better not to recommend
a medicine on this occasion.
The doctor’s view
Ideally, this woman should be advised to make an appointment to
see her doctor. It is possible that she would be reluctant to do so, as
she gives the impression that she thinks she should be able to cope
and should not have to trouble anyone else with her problems. If the
pharmacist could persuade her that it is completely acceptable to seek
advice from her doctor, this would be the best course of action. She
may be depressed and it would be helpful for a doctor to make a full
assessment. This would include how she is feeling, how her life is being
affected and what other symptoms she may have. It may be that she is
also distressed by changes associated with the menopause.
Just the ability to talk to a good, attentive, accepting listener can be
very beneficial. She may benefit from seeing a counsellor or a cognitive–
behaviour therapist which the GP could arrange. She may benefit from
an exercise programme and a change in her diet. It is thought that having
a diet with adequate essential fatty acids, e.g. omega 3 and omega 6,
complex rather than refined carbohydrates and foods containing sufficient
vitamins (B1, B3, B6, B12, C and folic acid) and trace elements
(zinc, magnesium and selenium) are necessary for good mental health.
She might benefit from an assessment from a nutritionist. If she were
to have moderate or severe depression then most doctors would offer
her antidepressants.
Case 3
A man whom you do not recognise as a regular customer asks to speak
with you. He tells you that he has been feeling rather stressed lately in
his job. (He is an estate agent and works locally.) He says he is having
trouble sleeping and feels that things are getting on top of him. He
isn’t getting much exercise these days – he used to play football and go
training regularly but since a knee injury he has given it up. He thinks
he might be depressed but doesn’t want to see his doctor because he
doesn’t want to end up on antidepressants. He read an article in the
paper yesterday about SJW and would like to try it. He asks what you
think and if it’s safe.
322 INSOMNIA
The pharmacist’s view
This is not an uncommon query. If someone just asks to buy SJW,
I’d sell it to them after checking about other medication and asking
whether they wanted to discuss anything. But if they ask for my view
or advice, I would discuss it with them. I find that some people don’t
want to see the doctor even when they think they’re depressed. In
this case it’s because of a dislike of the idea of taking antidepressants.
Although there is evidence that they work, especially in severe depression,
it’s not so clear-cut for mild-to-moderate depression. Cognitive
therapy would be another option. There’s good evidence to support
it but its availability varies. Also some people want to try to manage
their depression themselves rather than get into the formal health
system.
I would take this man to a quiet part of the pharmacy.
If he decided to try SJW, I would explain that it could take 3–4 weeks
to work. I would tell him that it does have some sedative effect and
that taking it at night could be helpful.
If it were a woman of childbearing age, I would always ask
whether she was on the pill, because SJW interacts with the oral
contraceptive pill and makes it less effective. If she still wanted to
take SJW, I would give some advice about using extracontraceptive
protection.
The doctor’s view
The evidence on the effectivenesss of SJW is variable. Some trials
show benefit and others no benefit when compared to placebo.
The pharmacist could suggest that he goes to see his GP anyway
whether he takes the SJW or not, and it could be pointed out that it
would be his choice whether to take antidepressants.
If this man were to come to his GP, which would be very reasonable, it
would be important to hear more about how he is being affected by his
problem, i.e. what it is like for him, what is the impact on his life, how
he feels, etc. It would be useful to hear about his understanding of the
problems and how he thinks he can be helped, and whether he would be
prepared to see a counsellor. The GP would need to do a risk assessment
and check whether he is feeling suicidal and, if so, whether he has
specific plans as to how he might kill himself. Once an initial assessment
has been made, it can often be useful to delay starting medication or
making a referral at the first consultation and instead offer to review
him in the next few days or week to see how he is. Just the fact of
coming to see the GP, being listened to and taken seriously can be
helpful, and the problem may be viewed in a different or better light
on subsequent follow-up. In his case it probably would be best to advise
a non-pharmacological approach. Even if he were to take SJW or an
antidepressant, the conditions triggering his depression are likely to be
INSOMNIA 323
still there when he stops the medication. He could be referred for brief
intervention counselling/therapy or cognitive–behavioural therapy if
he were in agreement.
Another way to help him could be to enable him to get back to some
exercise as this is known to improve depression. When he presented at
the pharmacy he mentioned that he was unable to play football because
of a knee injury. It might be really helpful to have this reassessed by
the GP. Perhaps a referral to an orthopaedic surgeon or physiotherapist
might be useful. It sounds as though a return to exercise could help him
deal with some of his stress. It might be that he could try swimming as
another form of exercise.
The customer’s view
It was useful to know more about whether SJW works or not. The
pharmacist made me feel as though it was my choice and told me that
if I went to the doctor, I could say that I didn’t want antidepressants.
I decided to try SJW wort for a few weeks and see how it goes.
324 INSOMNIA

Prevention of Heart Disease
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5
Prevention of heart disease
This chapter is different from the others in this book, which are primarily
concerned with responding to a symptom. Here the pharmacist
is unlikely to be dealing with symptoms and is instead assessing risk
and advising on preventive treatment. The development of cardiovascular
disease (CVD) is largely asymptomatic up to the point where an
‘event’ (such as a heart attack or stroke) occurs. The pharmacists can
make interventions to prevent the development of CVD while assisting
people who are largely symptom free but at increased risk of developing
heart disease in the future. These interventions are called primary
prevention. Here the individual is not a patient because he or she does
not have any disease or condition. Once a person has experienced an
event and has ongoing disease, the prevention of subsequent events is
termed secondary prevention.
CVD can be subdivided into stroke and coronary heart disease
(CHD). CHD occurs because of narrowing and/or blockage of the
coronary arteries. It may be sufficient to cause myocardial ischaemia –
ischaemic heart disease (IHD) – and can be present without symptoms.
CHDmay remain asymptomatic until it manifests as myocardial infarction
(MI), sudden death or cardiac dysfunction (such as arrhythmias
or cardiac failure). Some patients may therefore suffer consequences of
myocardial ischaemia without any history of warning symptoms.
CHDis a leading cause of mortality and morbidity in the UK. Despite
a fall in CHD mortality in recent years, the UK death rate in 2006 is
still high at 173 for men and 58 per 100,000 for women per year. This
equates to someone in the UK having a heart attack every 2 min. In
addition, it is estimated that more than 1.3 million people over the age
of 35 years in the UK have, or have had, angina.
Preventing CHD is a national priority. The National Service
Framework (NSF) for CHD in England sets out plans to ensure that
the best care, in terms of prevention, diagnosis and treatment, is available
to everyone. The NSF also defines the government target of cutting
mortality from heart disease by 40% in people less than 75 years by
2010.
However, the NSF has prioritised for intervention those individuals
at greatest risk. This includes patients with established CVD
PREVENTION OF HEART DISEASE 327
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5
(secondary prevention) and those with a high risk of developing the
disease (primary prevention). The NSF currently defines a ‘high-risk’
threshold for intervention as a CHD event risk greater than 30% over
10 years but recognises that those with a greater than 15% risk should
be progressively targeted as resources allow. The British National Formulary
(BNF) includes a table to determine risk produced by the Joint
British Societies Coronary Risk Prediction Chart. It is anticipated that
the NSF targets may change in the future and that this will increase the
number of people targeted by the NHS.
The causes of CHD are multifactorial and are often termed ‘risk
factors’. The summation of these risk factors will provide an assessment
of absolute CV risk, which should be the starting point for discussions
with patients, and a reduction in absolute risk should be the goal of
interventions.
What you need to know
Age, gender
Ethnic origin
Family history of CHD
Smoking history
Waist circumference/body mass index
Diet
Physical activity
Alcohol intake
Medical history (blood pressure, diabetes and cholesterol/lipid profile)
Medication
Significance of questions and answers
Assessment of an individual’s risk of developing CHD involves the
summation of both modifiable and non-modifiable risk factors for developing
the disease. Non-modifiable risk factors include age, gender,
ethnic origin and family history of CHD. These risk factors cannot
be altered. Interventions to reduce absolute CHD risk are focused on
modifiable risk factors.
Age and gender
With age the risk of developing CHD increases. Around 80% of people
who die from heart disease are aged 65 years or over. It is commoner in
men than in women. (The lifetime risk of developing it at age 40 years
is one in two for a men and one in three for a women.) Postmenopausal
women have a CV risk similar to that of men.
328 PREVENTION OF HEART DISEASE
Ethnic origin
Heart disease in the UK is commoner in Afro-Caribbean people and
those from the Asian subcontinent (Bangladesh, India, Pakistan and
Sri Lanka).
Family history of CHD
Risk of developing CHD increases if an individual has a close relative
(father, mother, brother or sister) with the disease. A family history of
premature CHD (i.e. a father or brother who had a coronary event
before the age of 55 years, or a mother or sister before the age of 65
years) is an even stronger indicator of risk.
Smoking history
Currently in the UK, 25% of men and 23% of women smoke. Smoking
tobacco has been shown to increase the risk of MI. This effect is related
to the number of cigarettes smoked; heavy smokers (more than 20 per
day) increase their risk of MI by two- to fourfold over non-smokers.
No level of smoking has been demonstrated to be safe. Those who have
recently stopped smoking remain at a higher risk for as long as 5 years
after stopping, but the risk begins to decline within a few months of
stopping.
Waist circumference/body mass index
Obesity is associated with an increased risk of stroke, CHD, type 2
diabetes, hypertension and dyslipidaemia, i.e. raised total cholesterol
(TC), high low-density lipoprotein (LDL) cholesterol and high triglyceride
levels. Abdominal obesity (apple-shaped body) is particularly significant,
and waist circumference may be a better predictor of susceptibility
to CHD than BMI. A waist circumference of more than 94 cm
in men or 80 cm in women is associated with a relatively increased
risk of CHD. Waist circumference may be a better way of assessing
risk, especially in the Asian population compared to body mass index
(BMI).
BMI is calculated by dividing an individual’s weight (kilogrammes)
by height (metre) squared. The normal range of BMI is between 18.5
and 25 kg/m2. Overweight is defined as a BMI >25 kg/m2 and obesity
is defined as a BMI >30 kg/m2.
Men in the UK increase their risk of CHD by 10% with every 1
kg/m2 increase in BMI above 22 kg/m2. Waist circumference >94 cm
in men and 80 cm in women identifies a CHD risk equivalent to that
of a BMI >25 kg/m2. For a circumference greater than 102 cm in men
and 88 cm in women the risk is equivalent to that of a BMI >30 kg/m2.
About 47% of men and 33% of women in theUKare overweight and
an additional 23% of men and 24% of women are obese. Overweight
and obesity increase with age. Overweight and obesity are increasing.
PREVENTION OF HEART DISEASE 329
The percentage of adults who are obese has roughly doubled since the
mid-1980s. Frequent fluctuations in weight are also associated with an
increased risk of developing CHD.
Physical activity
Regular aerobic exercise has been proved to assist weight loss and reduce
blood pressure. Physical inactivity is associated with an increased
incidence of developing hypertension (a CHD risk factor).
Alcohol intake
Drinking more than 21 units of alcohol per week is associated with
an increase in blood pressure, which can be reversed if the intake
is reduced. Alcohol can affect most parts of the body and, in addition
to causing liver damage, can cause infertility, skin damage,
heart damage, cancer and strokes. Many accidents, episodes of violence
and risk-taking behaviour, e.g. unprotected sex, are associated
with alcohol. Excess alcohol in those under the age of 20 years can
damage the brain while it is still developing. Small amounts of alcohol
(such as one glass of red wine per day with a meal) may slightly
reduce the chances of developing CHD. Safe drinking limits are 3–
4 units per day for men and 2–3 units per day for women. Most
experts advise at least two alcohol-free days each week. For information
on the number of units of alcohol in different drinks see
http://www.knowyourlimits.gov.uk/stay safe/units.html.
Medical history (hypertension, diabetes and cholesterol/lipid profile)
Raised blood pressure (>140/90 mm Hg) has been shown to be a risk
factor for the development of stroke and CHD. Diastolic pressures of
90–109 mm Hg are found in about 20% of the middle-aged adult population.
In younger people the prevalence is lower, and in elderly people
it is higher. Current estimates suggest that in the UK around 40% of
men and women have raised blood pressure. In addition, undertreated
hypertension is common, with up to half of all people with diagnosed
hypertension not reaching recommended targets.
Contributing factors to hypertension should be identified. These include
obesity, excessive alcohol intake (3 units/day), high salt intake
and physical inactivity.
Diabetes
Developing diabetes has the equivalent effect on increasing an individual’s
CHD risk as having a heart attack. It increases CHD mortality by
two to three times in men and four to six times in women. Eighty per
cent of type 2 diabetics (the commonest type of diabetes, by a ratio of
9:1) are obese. This has led to the coining of the term ‘diabesity’, which
cleverly combines the two conditions. Patients with type 2 diabetes
330 PREVENTION OF HEART DISEASE
have a two- to fourfold increased risk of, and a fourfold increase in,
mortality from CHD. Intensive glycemic control has a more modest
effect on reducing macrovascular than microvascular complications.
This is because the development of CVD is multifactorial, and hyperglycaemia
is only one of many risk factors.
Epidemiological data suggest that a glycosylated haemoglobin
(HbA1c) level of 7% or less is reasonable to avoid or minimise the
complications associated with type 2 diabetes. Studies have shown that
there is an increased risk of CV mortality even before the onset of type
2 diabetes.
Many studies, including the Framingham Heart Study, have clearly
established that high TC levels are associated with increased risk of developing
CHD. CHD is caused when the blood vessels to the heart (the
coronary arteries) become narrowed by a gradual build-up of fatty material
within their walls – a condition called atherosclerosis. Atheroma
develops when LDL cholesterol is oxidised and is taken up by cells
in the coronary artery walls where the narrowing process begins. On
the other hand, high-density lipoprotein (HDL) cholesterol removes
cholesterol from the circulation and appears to protect against CHD.
So the ratio of HDL to LDL is important. The goal is to have a low
level of LDL (>3 mmol/L) and a high level of HDL (>1 mmol/L).
As a general rule, the higher the TC level, the greater is the risk to
health. A TC level of less than 5 mmol/L is often a target aimed for.
However, more than half of adults in the UK have a TC level above
this figure. Increasing importance is being placed on LDL rather than
TC; from long-term epidemiological studies and intervention studies
with statins, it is clear that reductions in LDL levels correlate closely
with reduction in CHD risk. This relationship (plotted on a logarithmic
or doubling scale) is a straight line with no threshold below, which
a reduction in LDL does not produce a further reduction in risk. This
means that if someone has an absolute level of risk that justifies treatment,
reducing the LDL will reduce that risk, whatever their starting
level of cholesterol.
The level of LDL cholesterol in the blood tends to rise, and HDL
falls, with the amount of saturated fat that is eaten. On the other hand,
unsaturated fats have a good effect as they tend to lower LDL levels.
A high level of triglycerides also increases the risk of CHD and stroke.
Medication
A full medication history is important as some medicines can affect
CHD risk either positively or negatively. The potential contribution of
over-the-counter (OTC) medicines should also be considered. Medications
with a positive effect on CHD risk will be considered later in
the chapter. Factors predisposing to CV toxicity include existing heart
disease, uncorrected electrolyte abnormalities and poor renal function.
PREVENTION OF HEART DISEASE 331
Sympathomimetic drugs such as adrenaline, noradrenaline, dobutamine,
dopamine and phenylephrine can all cause systemic hypertension
and precipitate heart failure. Other commonly prescribed
medicines with CV side-effects include thyroxine, tricyclic antidepressants
and triptans.
Sudden withdrawal of beta-blockers may induce unstable angina, MI
and sudden death. This is thought to be due to an increased myocardial
oxygen consumption caused by an increase in heart rate subsequent to
the removal of beta-blockers. This effect is more commonly seen after
short-acting beta-blockers are stopped.
Epidemiological studies have demonstrated that combined oral contraceptives
increase the risk of CVD. Oral contraceptives have complex
effects on blood pressure, platelet function, blood coagulation, carbohydrate
metabolism and lipid metabolism. Similarly, current evidence
suggests that hormone replacement therapy (HRT) should not be used
for the prevention of CHD postmenopause.
Managing heart disease risk in the pharmacy
The modifiable risk factors forCHDare generally accepted as smoking,
cholesterol/lipid imbalance, hypertension, poor diet, obesity, excessive
alcohol intake, physical inactivity and inadequate diabetes control. A
recent literature review demonstrated the contribution of communitypharmacy-
based services to the reduction of risk behaviours and risk
factors for CHD. The evidence supports the wider provision of smoking
cessation and lipid management through community pharmacies.
Both primary and secondary prevention of CHD involve similar interventions.
Smoking cessation and nicotine replacement therapy
In recent years smoking cessation has become an increasingly important
focus for the National Health Service (NHS) and the UK can now
boast a world-leading smoking cessation service. Nonetheless, there
are still around 13 million tobacco users in the UK and their cost to
the NHS is £1.7 billion per year.
Research suggests that around 70% of smokers would like to give up,
but only 2–3% of smokers manage to quit using willpower alone. Nicotine
replacement therapy (NRT) is an effective aid to smoking cessation
for those smoking more than 10 cigarettes a day. Smokers are about
twice as likely to stop long-term smoking when prescribed NRT and
are up to six times more likely to succeed when NRT and behavioural
support are combined. The current National Institute for Health and
Clinical Excellence (NICE) guidelines recommend that NRT should
only be prescribed for a smoker who commits to a target stop date.

برچسب ها: Oral thrush Thrush (candidosis) is a fungal infection، which occurs commonly in the mouth (oral thrush)، in the nappy area in babies and in the vagina (see p. 242). Oral thrush in babies can be treated by the pharmacist. What you need to know Age Infant، child، adult، elderly Affected area Appearance Previous history Medication Significance of questions and answers Age Oral thrush is most common in babies، particularly in the first few weeks of life. Often،  

تاریخ : دوشنبه 25 اسفند 1393 | 11:56 ب.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th




The pharmacist can then explain how to make weekly checks for
lice using wet combing with a fine-toothed comb and a light-coloured
sheet of paper. If any signs are found, the parent should return to the
pharmacy, at which time the pharmacist will recommend an insecticide.
The doctor’s view
The advice given by the pharmacist is very helpful. It would have certainly
been a lot quicker and more convenient, but inappropriate, to
have sold the mother an insecticide preparation. Hopefully, the information
given by the pharmacist will allay her anxiety regarding hygiene
and lice. This demonstrates an important role of health education that
can be provided in the pharmacy.
302 CHILDHOOD CONDITIONS
Threadworms (pinworms)
Infection with threadworms (Enterobius vermicularis) is common in
young children, and parents may seek advice from the pharmacist.
As with head lice infections, many parents feel embarrassed about
discussing threadworms and feel ashamed that their child is infected.
Pharmacists can give reassurance that this is a common problem. In addition
to recommending OTC antihelminthic treatment, it is essential
that advice be given about hygiene measures to prevent reinfection.
What you need to know
Age
Signs of infection
Perianal itching
Appearance of worms
Other symptoms
Duration
Recent travel abroad
Other family members affected
Medication
Significance of questions and answers
Age
Threadworm infection is very common in schoolchildren.
Signs of infection
Usually the first sign that parents notice is the child scratching his
or her bottom. Perianal itching is a classic symptom of threadworm
infection and is caused by an allergic reaction to the substances in
and surrounding the worms’ eggs, which are laid around the anus.
Sensitisation takes a while to develop, so in someone infected for the
first time itching will not necessarily occur.
Itching is worse at night, because at that time the female worms
emerge from the anus to lay their eggs on the surrounding skin. The
eggs are secreted together with a sticky irritant fluid onto the perianal
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
THREADWORMS (PINWORMS) 303
skin. Persistent scratching may lead to secondary bacterial infection. If
the perianal skin is broken and there are signs of weeping, referral to
the doctor for antibiotic treatment would be advisable.
Loss of sleep due to itching may lead to tiredness and irritability during
the day. Itching without the confirmatory sighting of threadworms
may be due to other causes, such as an allergic or irritant dermatitis
caused by soaps or topical treatments used to treat the itching. In some
patients, scabies or fungal infection may produce perianal itching.
Appearance of worms
The worms themselves can be easily seen in the faeces as white- or
cream-coloured thread-like objects, about 10 mm in length and less
than 0.5 mm in width. Males are smaller than females. The worms can
survive outside the body for a short time and hence may be seen to be
moving. Sometimes the worms may be seen protruding from the anus
itself.
Other symptoms
In severe cases of infection, diarrhoea may be present and, in girls,
vaginal itch.
Duration
If a threadworm infection is identified, the pharmacist needs to know
how long the symptoms have been present and to consider this information
in the light of any treatments tried.
Recent travel abroad
If any infection other than threadworm is suspected, patients should
be referred to their doctor for further investigation. If the person has
recently travelled abroad, this information should be passed on to the
doctor so that other types of worm can be considered.
Other family members
The pharmacist should enquire whether any other member of the family
is experiencing the same symptoms. However, the absence of perianal
itching and threadworms in the faeces does not mean that the
person is not infected; it is important to remember that during the early
stages, these symptoms may not occur.
Medication
The pharmacist should enquire about the identity of any treatment already
tried to treat the symptoms. For any antihelminthic agent, correct
use is essential if treatment is to be successful. The pharmacist should
therefore also ask how the treatment was used, in order to establish
whether treatment failure might be due to incorrect use.
304 CHILDHOOD CONDITIONS
When to refer
Infection other than the threadworm suspected
Recent travel abroad
Medication failure
Management
When recommending treatment for threadworms, it is important that
the pharmacist emphasise how and when the treatment is to be used. In
addition, advice about preventing recurrence can be given, as described
under ‘Practical points’ below. The BNF states that mebendazole is the
treatment of choice for patients of all ages. If symptoms do not remit
after correct use of an appropriate preparation, patients should see
their doctor.
Mebendazole
Mebendazole is the preferred treatment for threadworms and is an
effective, single-dose treatment. It is also active against whipworm,
roundworm and hookworm. Compliance with therapy is high because
of the single dose. The drug is formulated as a suspension or a tablet,
which can be given to children aged 2 years and over and to adults.
Reinfection is common and a second dose can be given after 2–3 weeks.
Occasionally, abdominal pain and diarrhoea may occur as side-effects.
Mebendazole is not recommended for pregnant women.
Piperazine
Piperazine is effective against threadworm and roundworm. It is available
in granular form in sachets. The mode of action of piperazine
seems to be paralysis of the threadworms in the gut. The incorporation
of a laxative (senna) in the sachet preparation helps to ensure that
the paralysed worms are then expelled with the faeces.
Instructions
One dose is followed by another 2 weeks later to destroy any worms
that might have hatched and developed after the first dose. Only two
doses are required.
Side-effects
Side-effects of piperazine include nausea, vomiting, diarrhoea and colic
but these are uncommon. Adverse effects on the central nervous system
include headaches and dizziness but these are rare.
THREADWORMS (PINWORMS) 305
Contraindications
Piperazine can be recommended OTC for children from 3 months onwards.
It should not be recommended for pregnant women because,
although a direct causal relationship has not been established, some
cases of fetal malformations have been reported. Its use is contraindicated
in epileptic patients since it has been shown to have the potential
to induce fits in patients with grand mal epilepsy. In some European
countries, piperazine has been removed from the market because of
concern about adverse effects. The most common adverse effects are
gastrointestinal with nausea vomiting and diarrhoea.
Practical points
1 Parents are often anxious and ashamed that their child has a threadworm
infection, thinking that lack of hygiene is responsible. The pharmacist
can reassure parents that threadworm infection is extremely
common and that any child can become infected; infection does not
signify a lack of care and attention.
2 All family members should be treated at the same time, even if only
one has been shown to have threadworms. This is because other members
may be in the early stages of infection and thus asymptomatic. If
this policy is not followed, reinfection may occur.
3 Transmission and reinfection by threadworms can be prevented by
the following practical measures:
(a) Cutting fingernails short to prevent large numbers of eggs being
transmitted. Hands should be washed and nails brushed after going
to the toilet and before preparing or eating food, since hand-to-mouth
transfer of eggs is common. Eggs may be transmitted from the fingers
while eating food or onto the surface of food during preparation. Eggs
remain viable for up to 1 week.
(b) Children wearing pyjamas to reduce the scratching of bare skin
during the night. Underpants can be worn under pyjama bottoms.
(c) Affected family members having a bath or shower each morning to
wash away the eggs that were laid during the previous night.
306 CHILDHOOD

برچسب ها: The pharmacist can then explain how to make weekly checks for lice using wet combing with a fine-toothed comb and a light-coloured sheet of paper. If any signs are found، the parent should return to the pharmacy، at which time the pharmacist will recommend an insecticide. The doctor’s view The advice given by the pharmacist is very helpful. It would have certainly been a lot quicker and more convenient، but inappropriate، to have sold the mother an insecticide preparation. Hopefully، the information given by the pharmacist will allay her anxiety regarding hygiene and lice. This demonstrates an important role of health education that can be provided in the pharmacy. 302 CHILDHOOD CONDITIONS Threadworms (pinworms) Infection with threadworms (Enterobius vermicularis) is common in young children، and parents may seek advice from the pharmacist. As with head lice infections،  

تاریخ : دوشنبه 25 اسفند 1393 | 11:56 ب.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th




to the back of the throat. Within the middle ear are tiny bones that
transmit the sound wave vibrations of the eardrum to the inner ear.
An infection typically starts with a common cold, especially in children,
which leads to blockage of the Eustachian tube and fluid formation
within the middle ear. The fluid can then be secondarily infected
by a bacterial infection.
Symptoms
The symptoms of otitis media are pain and temporary deafness. Sometimes
the infection takes off so quickly that the eardrum perforates,
releasing the infected fluid. When this occurs, a discharge will also be
present and be associated with considerable lessening of pain.
As with OE, referral is usually necessary so that the eardrum can
be examined. Treatment may involve a course of oral antibiotics (e.g.
amoxicillin (amoxycillin), penicillin or erythromycin). However, the
use of antibiotics is being increasingly questioned. It appears that many
cases of otitis media settle spontaneously and the effect of taking antibiotics
possibly provides some benefit in symptoms after the first 24 h
only when symptoms are already resolving. A meta-analysis of the research
done on the value of antibiotics shows the number needed to
successfully treat one patient is seven. In other words, six of every
seven children treated for otitis media do not need antibiotics or show
no response to them. Pharmacists can explain this to parents. Other
concerns with the use of antibiotics are increasing bacterial resistance
and adverse effects, such as diarrhoea, which occurs in about 10% of
cases. Research has shown that it is reasonable to delay starting antibiotics
for 72 h and starting only if symptoms persist at that time.
‘Delayed prescriptions’ are used where either the patient is given a
postdated prescription which is ‘cashed’ only if needed or the patient
can return to the surgery after a specified length of time to collect a
prescription if needed. Sometimes topical or oral decongestants are
used in addition to antibiotics. These can be useful if air travel is to
be undertaken after such an infection. If the Eustachian tube is still
blocked during a flight, pain can be experienced due to the change in
air pressure. Decongestants would make this less likely.
Glue ear
Some children who are subject to recurrent otitis media develop glue
ear. This occurs because the fluid that forms in the middle ear does
not drain out completely. The fluid becomes tenacious and sticky. One
method of dealing with this common problem is a minor operation in
which the fluid is sucked out through the eardrum. After this it is usual
to insert a small grommet into the hole in the drum. The grommet has
a small hole in the middle, which allows any further fluid forming to
drain from the middle ear. The grommet normally falls out within a
COMMON EAR PROBLEMS 273
few months and the small hole in the drum closes over. The long-term
effectiveness of this procedure is debatable.
Earplugs. Some children are advised not to get water into the ear
after the insertion of a grommet. One method is to use earplugs that
can be purchased in the pharmacy. However, this is often unnecessary
and bathing and swimming can be undertaken without using plugs, although
it is sensible to avoid deep diving as water may enter the middle
ear under pressure, which will impair hearing and may predispose to
infection.
Ear problems in practice
Sue Moorhouse is a woman in her twenties. She and her parents have
been regular customers for years and you know she recently went to
Kenya on holiday. It is Saturday afternoon and Sue tells you that her
ear problem has returned. She has had antibiotics to treat it on four
previous occasions during the last 3 years. She tells you she recognises
the signs. Her face started to swell this morning. Her outer ear now
feels swollen and her jaw is painful when she moves it. She knows from
experience that if she can take some antibiotics within 24 h, the ear infection
will not be so bad. In the past the doctor has had trouble inserting
the otoscope because the inside of her ear had been so swollen and
painful. The problem causes a feeling of intense pressure inside the ear
and she then has a discharge from the ear, which seems to ease the pain.
When you check your patient medication record, you find that you have
dispensed four courses of erythromycin for Sue in the last 3 years.
The pharmacist’s view
It is typical that a problem like this happens on a Saturday afternoon
when it is less easy to refer to the doctor. I could send Sue to the walk-in
centre (if there is one) or to accident and emergency (A&E) department.
Using the framework used in other parts of this book, I can think about
possible actions I could take. There is no way I would consider leaving
her to see the doctor on Monday.
Potential
harm to
patient
from not
supplying
Potential
harm to
patient
from
supplying
Potential
benefit to
patient
from
supplying
Consequences
for pharmacist of
supplying/not
supplying
What would I do if
the patient were
me/my spouse/my
parent/my child? Is
this decision
different from the
one I have reached
for the patient?
Why?
274 EYE AND EAR PROBLEMS
The doctor’s view
Sue needs referral to the emergency on-call GP service or, failing that,
to the local A&E department. It sounds like she has recurrent OE with
cellulitis. She is likely to need high-dose antibiotic treatment. As this
is her fifth episode in the last 3 years, she would need some followup,
possibly with an ENT surgeon. If on resolution of this infection
there were exudate and debris present in the outer ear canal, she could
benefit from cleaning of the ear using microsuction. This would reduce
the possibility of recurrence.
COMMON EAR PROBLEMS 275
Childhood Conditions
Childhood problems understandably create significant parental anxiety.
This can affect the interchange with the pharmacist. If the pharmacist
has children, this will be well understood. Whether the pharmacist
is confident about childhood problems or not the most important
method of dealing with this is to listen well, not just to the presenting
complaints but also to the specific concerns of the parent. Sometimes
people will be more open with their concerns and sometimes it will be
necessary to ask them about their concerns more than once. Just sharing
a concern can literally diminish the perceived problem and make
the rest of the consultation with the pharmacist more effective.
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5


Common childhood rashes
Most childhood rashes are associated with self-limiting viral infections.
Some of these rashes fit well-described clinical pictures (e.g. measles)
and are described below. Others are more difficult to label. They may
appear as short-lived fine flat (macular) or slightly raised (papular) red
spots, often on the trunk. The spots blanch with pressure (erythematous).
There is usually associated cold, cough and raised temperature.
These relatively minor illnesses occur in the first few years of life and
settle without treatment. Any rash in early childhood, particularly during
the first year, can be alarming and frightening for parents. Advice,
reassurance and referral are needed as appropriate.
What you need to know
When did it start?
Where did it start?
Where did it spread?
Any other symptoms?
Infectious diseases
Chickenpox
Measles
Roseola infantum
Fifth disease
German measles
Meningitis
Rashes that do not blanch
Chickenpox (also known as varicella)
This is most common in children under 10 years. It can occur in adults
but is unusual. The incubation time (i.e. time between contact and development
of the rash) is usually about 2 weeks (11–21 days). Sometimes
the rash is preceded by a day or so of feeling unwell with a
temperature. The rash is characteristic and difficult to diagnose when
only very few spots are present. Typically it starts with small red lumps
that rapidly develop into minute blisters (vesicles). The vesicles then
COMMON CHILDHOOD RASHES 279
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5
burst, forming crusted spots over the next few days. The spots mainly
occur on the trunk and face but may involve the mucous membranes of
the mouth. They tend to come out in crops for up to 5 days. The rash is
often irritating. Once the spots have all formed crusts, the individual is
no longer contagious. NHS Clinical Knowledge Service (CKS) advises
that exclusion from school or work is not necessary after 6 days from
the onset of the rash. The whole infection is usually over within 1 week
but it may be longer and more severe in adults. Sometimes the spots can
become infected after scratching, so it can be helpful to advise cutting
the child’s fingernails short to reduce the chance of this possibility.
Measles
This is now a less common infection in the more developed countries
but a significant cause of childhood mortality on a large scale in developing
countries. A combined measles, mumps, rubella (MMR) vaccine
is given between the ages of 12 and 15 months. The uptake of MMR
in England was about 85% in 2006. The ideal is 95%. In 2007 there
were 769 cases of measles confirmed up to the end of October. Many
of these occurred in unvaccinated children, which included some in the
travelling communities (see Table 7 for the nature and risk of complications
from measles). At the time of introduction of the MMR there
were about 86,000 cases per year.
Measles has an incubation period of about 10 days. The measles
rash is preceded by 3–4 days of illness with symptoms of cold, cough,
conjunctivitis and fever. After the first 2 days of this prodromal phase,
small white spots (Koplik spots), like grains of salt, can be seen on the
inner cheek and gums. The measles rash then follows. It starts behind
the ears, spreading to the face and trunk. The spots are small, red
Table 7 Nature and risk of complications of measles.
Complications Risk
Diarrhoea 1 in 6
Ear infection 1 in 20
Pneumonia/chest infection 1 in 25
Fits 1 in 200
Meningitis/encephalitis 1 in 1000
Death 1 in 2500–5000
Serious brain complication years
later (subacute sclerosing
panencephalitis)
1 in 8000 (of children who have measles
under 2 years)
From www.medinfo.co.uk.
280 CHILDHOOD CONDITIONS
patches (maculae), which will blanch if pressed. Sometimes there are
so many spots that they merge together to form large red areas.
In most cases the rash fades after 3 days, at which time the fever
also subsides. If, however, the fever persists, the cough becomes worse
or there is difficulty in breathing or earache, then medical attention
should be sought as complications may be developing. Someone with
measles is infectious for about 5 days after the rash appears.
Roseola infantum
Roseola infantum is a viral infection occurring most commonly in the
first year of life (but also between 3 months and 4 years of age). It can
be confused with a mild attack of measles. There is a prodromal period
of 3–4 days of fever followed by a rash similar to measles but which
is mainly confined to the chest and abdomen. Once the rash appears
there is usually an improvement in symptoms, in contrast to measles,
and it lasts only about 24 h.
Fifth disease (erythema infectiosum)
Fifth disease is another viral infection (parvovirus B19), which usually
affects children. It does not often cause systemic upset but may cause
fever, headache and, rarely, painful joints. The rash characteristically
starts on the face. It particularly affects the cheeks and gives the appearance
that the child has been out in a cold wind. Fifth disease is
sometimes called ‘slapped cheek’ disease because of the appearance
of reddened cheeks. The rash then appears on the limbs and trunk as
small red spots that blanch with pressure. The infection is usually short
lived.
Fifth disease can have adverse effects in pregnancy. If the infection
occurs in the first 20 weeks of gestation, there is an increased chance
of miscarriage and a small chance the developing baby will become
anaemic.
German measles (rubella)
German measles is a viral infection that is generally very mild, its main
significance being the problems caused to the fetus if the mother develops
the infection in early pregnancy. The incubation time for German
measles is 12–23 days. The rash is preceded by mild catarrhal symptoms
and enlargement of glands at the back of the neck. It usually starts
on the face and spreads to the trunk and limbs. The spots are very fine
and red. They blanch with pressure. They do not become confluent as
in measles. In adults rubella may be associated with painful joints. The
rubella rash lasts for 3–5 days.
COMMON CHILDHOOD RASHES 281
Table 8 Warning symptoms.
Meningitis symptoms in children
Meningitis symptoms in babies and adults
High temperature, fever, possibly with
cold hands and feet
High temperature, fever, possibly with cold
hands and feet
Vomiting or refusing feeds Vomiting, sometimes diarrhoea
High-pitched moaning, whimpering cry Neck stiffness (unable to touch chin to
chest)
Blank, staring expression Joint or muscle pains, sometimes stomach
cramps
Pale blotchy complexion Dislike of bright lights
May be floppy, may dislike being
handled, may be fretful
Drowsiness
Difficult to wake or lethargic Fits
Fontanelle (soft spot) may be tense or
bulging
Confusion or disorientation
May have rash May have rash
Taken from the Meningitis Trust website. (There is no particular order for these symptoms to occur, not
all have to be present and there may be others not mentioned.)
Meningitis
Meningitis is a very serious infection that can be caused by bacterial,
viral or fungal infections. The bacterial causes, which are much more
serious than viral causes, include meningococcus, Haemophilus and
pneumococcus infections. In the UK there are now vaccines routinely
given for meningococcus C and Haemophilus influenzae B. Meningococcus
can cause a septicaemia (infection spreading throughout the
body in the blood) in addition to meningitis alone, causing a typical
rash. Meningococcal septicaemia usually presents with flulike symptoms
that may rapidly worsen (see Table 8). There may be an associated
rash that appears as tiny purplish red blotches or bruises. (Very small
bruises are called petechiae and larger ones, purpura and ecchymoses).
These bruises do not blanch with pressure. The spots will start as a few
tiny pinpricks and progress to widespread larger ones which coalesce
together. The tumbler or glass test can be used to determine whether
or not the rash is serious. The side of a glass tumbler should be pressed
firmly against the skin. If the spots are the small bruises of septicaemia,
they will not fade when the tumbler is pressed against the skin. Any
suspicion of this condition requires emergency medical help.
Rashes that do not blanch
As a general rule all rashes that do not blanch when pressed (use glass
tumbler test described in section on meningitis) ought to be referred to
282 CHILDHOOD CONDITIONS
a doctor. These rashes are caused by blood leaking out of a capillary,
which may be caused by a blood disorder. It could be the first sign of
leukaemia or a much less serious condition. Blanching is not a concept
that parents are familiar with. It is important to explain what is meant
by blanching and how parents can check for it.
When to refer
Suspected meningitis (see Table 8)
Flulike symptoms
Vomiting
Headache
Neck stiffness
Rash
Small widespread spots or bruises that do not blanch when pressed
Rashes that do not blanch when pressed
Management
Fever
Moderate fever (raised temperature up to 40◦C from normal 36.5–
37.5) is usually not harmful and some experts believe it could even have
beneficial effects in some illnesses. The question of whether and when
an antipyretic medicine should be given remains a matter of debate.
The National Institute for Health and Clinical Excellence Guideline on
Feverish Illness in Children advises against routine use of antipyretic
to solely reduce temperature if the child is otherwise well.
Parents often want to reduce a child’s temperature where there is a
fever. There is no clear evidence that reducing a raised temperature is
harmful and doing so may reduce the child’s discomfort and distress.
Sponging with lukewarm water used to be recommended as a method
of reducing fever but can cause goosebumps and shivering and is now
viewed as potentially causing discomfort to the child.
Paracetamol or ibuprofen can be used if a high temperature is
present.
Many babies develop a raised temperature after immunisation. Some
preparations containing paracetamol or ibuprofen can be used over the
counter (OTC) to reduce post-immunisation fever. Product licences
vary, so check the labels.
Itching
The itching caused by childhood rashes such as chickenpox can be
intense, and the pharmacist is in a good position to offer an antipruritic
COMMON CHILDHOOD RASHES 283
cream, ointment or lotion. Crotamiton cream or lotion may help to
soothe itchy skin. Calamine lotion has been used traditionally but it is
now thought that the powdery residue it leaves may further dry and
irritate itchy dry skin. If itching is very severe, chlorpheniramine can
be effective in providing relief, can be given to children 1 year and over
and is licensed for use OTC in chicken pox rash. Such treatment would
be likely to make the child drowsy but may be useful at night time.
284 CHILDHOOD CONDITIONS
Colic
The cause of colic is unknown and it may affect between one in twenty
and one in five babies. Although infantile colic is not harmful, it is
stressful for both the baby and parents. It generally begins in the first
few weeks after the baby is born and resolves by the time the baby is
3–4 months old. The formal definition is ‘crying for at least 3 h a day,
on at least 3 days a week and for at least 3 weeks’.
What you need to know
Age
Symptoms
Feeding
Does the mother smoke?
Any advice already sought?
Age
Colic generally starts in the early weeks and may last up to the age of
3–4 months.
Symptoms
Mothers usually describe crying that occurs in the late afternoon and
evening, where the baby cannot be comforted, becomes red in the face
and may draw the knees up. Passing wind and difficulty in passing
stools may also occur.
It is important to be aware that colic is not the only cause of crying
and discomfort. If a baby becomes inconsolable and cannot be comforted,
the parent should be advised to consult the general practitioner
(GP). Rarely, problems such as volvulus (twisting of the intestines) can
occur and cause incessant and loud crying.
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John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
COLIC 285
Feeding
Establish whether the baby is bottle- or breastfed (or a combination)
and the type of formula milk being used.
Does the mother smoke?
There does seem to be an association between maternal smoking and
colic in the baby.
Any advice already sought?
It is useful to ask whether advice has been sought already either from
health professionals or from lay sources. The pharmacist can assess the
relevance and appropriateness of advice already received.
Management
There is no good evidence to support any of the commonly tried approaches
to management. It is important to reassure parents that colic
is not their fault and that the baby will ‘grow out of it’.
Simeticone
Simeticone has been commonly used to treat infantile colic and is included
in several proprietary preparations. However, only three small
trials were found in systematic reviews, and the evidence of benefit is
uncertain. A trial of simeticone drops for 1 week could be suggested
if other strategies are unsuccessful and the parents would like to try
treatment.
Feeding
For breastfed infants it may be worth the mother considering the exclusion
of cow’s milk from her diet. There is a theoretical rationale for
this in that breast milk contains intact cow’s milk proteins. However,
there is no good evidence of benefit. A trial of cow’s milk exclusion
for 1 week could be suggested. This means that the mother needs to
stop eating all forms of dairy produce. If there appears to be some
improvement, referral to the health visitor for further advice on diet is
appropriate.
Where the baby is being bottle-fed and symptoms are severe and
persistent, the mother might consider trying hypoallergenic formula
(caseinogen (casein) hydrolysate) milk. Studies indicate that this may
reduce crying by over 20%. A trial of such milk for 1 week could be
suggested. If there appears to be a response, referral for further advice
on diet from the health visitor is appropriate. Evidence is less strong for
286 CHILDHOOD CONDITIONS
whey hydrolysate formula. There is limited evidence of effectiveness of
soya milk in reducing crying. There is no evidence to support the use
of low-lactose or fibre-enriched milk.
Complementary therapies
A study of herbal tea in colic showed a large reduction in crying but
there are concerns over the study design. Furthermore, the safety of
herbal teas in infants has been questioned, probably because of issues
around standardisation of ingredients and questions about the possible
presence of other ingredients.
Behavioural approaches
In the past it was thought that overstimulation of the baby might be
a cause of colic. Therefore there have been studies to test avoiding
carrying or holding the baby unnecessarily and not intervening too
rapidly when the baby cries. These studies did not show a significant
effect.
Baby massage
Although baby massage seems to have become more popular as a
method of managing colic, the evidence of benefit is uncertain.
Other health professionals
Health visitors can advise and support families on infant feeding and
other problems.
COLIC 287
Teething
Teething can start as early as 3 months and continue up to 3 years. The
association of discomfort and physical change associated with teething
is a matter of some debate. Some health professionals and parents
incorrectly associate symptoms of agitation, fever and diarrhoea with
teething. A study showed that the number of symptoms ascribed to
teething was paediatricians (2.8), dentists (4.4), GPs (6.5), pharmacists
(8.4) and nurses (9.8). The more contemporary view of teething is
that it is a local phenomenon that may account for symptoms such as
dribbling, drooling, reddened cheeks, inflamed gums, biting objects and
increase in general irritability but is not itself a cause of infection. One
theory is that bottle-fed babies receive fewer antibodies than those who
are breastfed, and this may result in an association between teething
and systemic symptoms. An important point about associating systemic
problems with teething is that a more serious underlying cause may be
overlooked.
The appropriate management of teething is local discomfort relief
using application of cold and the use of analgesics (paracetamol suspension)
or topical gels. There is a homoeopathic teething product
available as granules, and some parents may prefer complementary
therapies. Parents should be encouraged to clean their baby’s teeth
from their first appearance using a baby toothbrush. Dummies should
be avoided, but if used then it is important not to dip them or teething
rings into honey, fruit juices or syrups. Further advice on prevention
of teething problems can be obtained from the health visitor.
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
288 CHILDHOOD CONDITIONS
Napkin rash
Most babies will have napkin (nappy) rash at some stage during their
infancy. Contributory factors include contact of urine and faeces with
the skin, irritant effect of soaps and wetness and maceration of skin due
to infrequent nappy changes and inadequate skin care. Advice from the
pharmacist is important in both treating and preventing recurrence of
the problem.
What you need to know
Nature and location of rash
Severity
Broken skin
Signs of infection
Duration
Previous history
Other symptoms
Precipitating factors
Skin care and hygiene
Medication
Significance of questions and answers
Nature and location of rash
Nappy rash, sometimes called napkin dermatitis, appears as an erythematous
rash on the buttock area. Other areas of the body are not
involved, in contrast to infantile seborrhoeic dermatitis, where the scalp
may also be affected (cradle cap). In infantile eczema, other body areas
are usually involved. The initial treatment of nappy rash would be the
same in each case.
Severity
In general, if the skin is unbroken and there are no signs of secondary
bacterial infection, treatment may be considered. The presence
of bacterial infection could be signified by weeping or yellow crusting.
Secondary fungal infection is common in napkin dermatitis and
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John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
NAPKIN RASH 289
the presence of satellite papules (small, red lesions near the perimeter
of the affected area) would indicate such an infection. Referral to the
doctor would be advisable if bacterial infection were suspected, since
topical or systemic antibiotics might be needed. Secondary fungal infection
could be treated by the pharmacist using one of the azole topical
antifungal preparations that are available.
Duration
If the condition has been present for longer than 2 weeks, the pharmacist
might decide that referral to the doctor would be the best option,
depending on the nature and severity of the rash.
Previous history
The pharmacist should establish whether the problem has occurred
before and, if so, what action was taken, e.g. treatment with OTC
products.
Other symptoms
Napkin dermatitis sometimes occurs during or after a bout of diarrhoea,
when the perianal skin becomes reddened and sore. The pharmacist
should therefore enquire about current or recent incidence of
diarrhoea. Diarrhoea may occur as a side-effect of antibiotic therapy
and this may be the cause. Sometimes thrush in the nappy area may be
associated with oral thrush, which causes a sore mouth or throat (see
p. 308). If this is suspected, referral to the doctor is advisable.
Precipitating factors
Skin care and hygiene
At one time napkin dermatitis was thought to be a simple irritant dermatitis
due to ammonia, produced as a breakdown product of urine in
soiled nappies. However, other factors are now known to play a part
in the development of the condition. These include irritant substances
in urine and faeces, sensitivity reactions to soaps and detergents and
antiseptics left in terry nappies after inadequate rinsing and sensitivity
reactions to ingredients in some topical preparations, e.g. lanolin
(although purified versions of wool fat have reduced the problems previously
caused by wool fat and lanolin). The major factor thought to
influence the incidence of nappy rash is the constant wetting and rewetting
of the skin when left in contact with soiled nappies. Maceration of
the skin ensues, leading to enhanced penetration of irritant substances
through the skin and the breakdown of the skin. Wearing occlusive
plastic pants exacerbates this effect. Frequent changes of nappy together
with good nappy-changing routine and hygiene are essential
(see ‘Practical points’ below).
290 CHILDHOOD CONDITIONS
Medication
The identity and effectiveness of any preparations used for the current
or any previous episode, either prescribed or purchased OTC, should be
ascertained by the pharmacist. The possibility of a sensitivity reaction
to an ingredient in a topical product already tried should be considered
by the pharmacist, especially if the rash has worsened.
When to refer
Broken skin, severe rash
Signs of infection
Other body areas affected
Treatment timescale
A baby with nappy rash that does not respond to skin care and OTC
treatment within 1 week should be seen by the doctor.
Management
Treatment of napkin dermatitis and the prevention of further episodes
can be achieved by a combination of OTC treatment and advice on
care of the skin in the nappy area.
Emollient preparations
Emollient preparations are the mainstay of treatment. The inclusion
of a water repellent such as dimeticone is useful in theory but there
is no convincing evidence that such products are more effective. The
choice of individual preparation may sometimes depend on customer
preference and many preparations are equally effective. Most pharmacists
will have a particular favourite, which they usually recommend.
Some of the ingredients included in preparations for the treatment and
prevention of nappy rash and their uses are described below.
Zinc
Zinc acts as a soothing agent.
Lanolin
Lanolin emollient hydrates the skin. It can sometimes cause sensitivity
reactions, although the high grades of purified lanolin used in many of
today’s products should reduce the problem.
Castor oil/cod liver oil
Castor oil and cod liver oil provide a water-resistant layer on the skin.
NAPKIN RASH 291
Antibacterials (e.g. chlorhexidine gluconate)
These may be useful in reducing the number of bacteria on the skin.
Some antibacterials have been reported to produce sensitivity reactions.
Antifungals
Secondary infection with Candida is common in napkin dermatitis and
the azole antifungals would be effective. Miconazole or clotrimazole
applied twice daily could be recommended by the pharmacist with
advice to consult the doctor if the rash has not improved within 5 days.
If an antifungal cream is advised, treatment should be continued for
4 or 5 days after the symptoms have apparently cleared. An emollient
cream or ointment can still be applied over the antifungal product.
Hydrocortisone
Prescription-only medicine
Hydrocortisone cream or ointment cannot be sold by pharmacists for
the treatment of nappy rash because its use OTC is restricted to children
over 10 years. Topical steroids are effective treatments for napkin
dermatitis and other preparations containing steroids may well be prescribed
by the doctor for this purpose. Pharmacists can give valuable
advice about the correct method of use.
Method of use
Firstly, the preparation should be applied thinly and sparingly; the pharmacist
can reassure the parents that only a small amount is needed for
effectiveness. Secondly, the absorption of corticosteroids from topical
vehicles is increased when the skin is occluded by wearing plastic
pants. Occasionally, there are systemic side-effects as a result of
large quantities of topical steroids being applied followed by occlusion
under waterproof pants. The more potent the steroid, the higher is
the chance that such adverse effects will be produced. Parents should
be reminded that if the condition does not respond quickly to treatment
(within 10 days), further advice should be sought from the
doctor.
Practical points
1 Nappies should be changed as frequently as necessary. Babies up to
3 months old may pass urine as many as 12 times a day.
2 Nappies should be left off wherever possible so that air is able to
circulate around the skin, helping the affected skin to become and
remain dry. Lying the baby on a terry nappy or towel with a waterproof
sheet underneath will prevent the soiling of furniture or bedding.
3 Waterproof pants create an occlusive barrier, which prevents the
evaporation of moisture and can worsen napkin dermatitis. They
should only be used for short periods of time, if at all.
292 CHILDHOOD CONDITIONS
4 The washing routine for terry nappies is important. If a sanitising
solution is used to soak the nappies, thorough rinsing is needed before
washing. The nappies should be rinsed well after washing to ensure
that no chemicals are left in the fabric that might irritate the baby’s
skin. Towelling nappies may be bleached occasionally before washing,
but thorough rinsing is essential.
5 At each nappy change the skin should be cleansed thoroughly by
washing with warm water or using a proprietary lotion or wipes. The
skin should then be carefully and thoroughly dried. The use of talcum
powder can be helpful, but the clumping of powder can sometimes
cause further irritation. Talcum powder should always be applied to
dry skin and should be dusted lightly over the nappy area. The regular
use of an emollient cream or ointment, applied to clean dry skin, can
help to protect the skin against irritant substances.
Napkin rash in practice
Case 1
Jane Simmonds, a young mother, asks you to recommend a good cream
for her baby daughter’s nappy rash. The baby (Sarah) is 3 months
old and Mrs Simmonds tells you that the buttocks are covered in a
red rash. The skin is not broken and there is no weeping or yellow
matter present. On further questioning, you find that the rash is also
affecting the upper back and neck and there are signs of its appearance
around the wrists. The rash seems to be itchy, as Sarah keeps trying
to scratch the affected areas. Mrs Simmonds uses disposable nappies,
which she changes frequently, and zinc and castor oil cream is applied
at each nappy change, after cleansing the skin. The baby has no other
symptoms and is not taking any medicines.
The pharmacist’s view
Mrs Simmonds’ nappy-changing and skin-care routine seems to be
adequate, but the baby has nappy rash and the rash has affected other
areas of the body. It is possible that Sarah has infantile eczema and
referral to the doctor would be the best course of action.
The doctor’s view
It is quite likely that Sarah does have eczema, which could be the cause
of her nappy rash. It is also possible that an eczematous rash can be
complicated by a secondary infection. Referral to the doctor or health
visitor for further assessment would be wise. Such skin problems can
be upsetting for the mother and it is important that Mrs Simmonds
should be given an opportunity to air her understanding and concerns
about the problem and, in return, that the doctor offer an appropriate
explanation. The management would be to reinforce all the above
NAPKIN RASH 293
practical points and possibly prescribe a weak topical steroid, such
as 1% hydrocortisone, with or without an antifungal or antibacterial
agent.
Case 2
Mrs Lesley Tibbs is worried about her baby son’s nappy rash, which,
she tells you, seems to have appeared over the last few days. The skin
is quite red and looks sore and she has been using a proprietary cream,
but the rash seems to be even worse. The baby has never had nappy
rash before and is about 5 months old. Mrs Tibbs is using towelling
nappies, which she soaks in a proprietary solution before washing in
an automatic washing machine. She has recently changed the washing
powder she uses, on a friend’s recommendation. The rash affects only
the napkin area and the baby has no other symptoms.
The pharmacist’s view
The history gives two clues to the possible cause of the problem. This
baby has not had nappy rash before and this episode has coincided
with a change in detergent, so it is possible that a sensitivity reaction
is occurring due to residues of detergent in the nappies after washing.
The second factor is the cream that Mrs Tibbs has been using to treat
the problem, with no success. The ingredients of the product should be
carefully considered by the pharmacist to see if any might be potential
sensitisers.
Initial advice to Mrs Tibbs might be to revert to her original detergent
and to use a different treatment. Advice on nappy-changing routine
could be given and if the rash has not started to resolve within 1 week,
or has become worse, referral to the doctor should be indicated.
The doctor’s view
The advice given by the pharmacist should clear up the problem
quickly. It would be quite reasonable to refer Mrs Tibbs and her baby
to the health visitor for further advice if the rash does not settle down.
294 CHILDHOOD CONDITIONS
Head lice
Head lice infection is common in young children. Effective treatments
are available, but treatment failure may occur if products are not used
correctly. It is therefore important for the pharmacist to explain how
products should be used, since more patients are now being directed to
pharmacies to obtain treatment. The pharmacist has a valuable health
education role in explaining how to check children’s hair for lice and in
discouraging prophylactic use of insecticides. Parents are often embarrassed
to seek advice, particularly if the child has head lice. Pharmacists
can reassure parents that the condition is common and does not in any
way indicate a lack of hygiene. The term infection is preferred to infestation
because of the unpleasant image associated with infestation.
What you need to know
Age
Child, adult
Signs of infection
Live lice
Checking for infection
Nits
Scalp itching
Previous infection
Medication
Treatments used
Significance of questions and answers
Age
Head lice infection is most commonly found in children, particularly
at around 4–11 years, with girls showing a higher incidence than boys.
Older children and adults seem to be less prone to infection. Adult
women occasionally become infected, but head lice infection is rare in
adult men because, as men lose hair through male pattern baldness,
the scalp offers less shelter to lice.
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John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
HEAD LICE 295
Signs of infection
Unless infection has been confirmed by a nurse or doctor who has conducted
wet combing of the hair or inspected the scalp, the pharmacist
should ask whether any check has been made to confirm the presence
of head lice. Parents often worry that their children may catch lice and
want the pharmacist to recommend prophylactic treatment. Insecticides
should never be used prophylactically, since this may accelerate
resistance. Treatment should be reserved for infected heads.
Checking for infection
Wet combing of the hair is a more reliable detection method than scalp
inspection. Parents can easily check for infection by combing the child’s
hair over a piece of white- or light-coloured paper, using a fine-toothed
comb (tooth spacing of less than 0.3 mm). The hair should be damp or
wet to make the combing process easier and less painful. Also, dry hair
can produce static that causes lice to be repelled from the comb, making
detection less likely. After each stroke the comb should be wiped on
a white tissue or cloth. The hair should be combed one section at a
time. The hair at the nape of the neck and behind the ears should
be thoroughly checked. These spots are preferred by lice because they
are warm and relatively sheltered. Such a check should be carried out
regularly, say once a week, and perhaps more often when infection is
known to have occurred in other children at school or playgroup.
If live lice are present, some will be combed out of the hair and onto
the paper, where they will be seen as small beige, black, greyish or
brown-coloured specks. Cast shells are discarded as the louse grows
and appear yellowish in colour. Louse faeces may be seen as small
blackish specks on pillows and collars.
Nits
The presence of empty eggshells – the cream- or white-coloured nits
attached to the hair shafts – is not necessarily evidence of current infection
unless live lice are also found. Parents sometimes think that
treatment has failed because nits can still be seen in the hair. It is therefore
important for the pharmacist to explain that the empty shells are
firmly glued to the hair shaft and will not be removed by the lotion
used in treatment. A fine-toothed comb can be used to remove the nits
after treatment.
Itching
Contrary to popular belief, itching is not experienced by everyone with
a head lice infection. In fact, as few as one in five cases present with
itching, perhaps because detection now occurs at an earlier stage than
used to be the case. Where it occurs, itching of the scalp is an allergic
response to the saliva of the lice, which is injected into the scalp in
296 CHILDHOOD CONDITIONS
small amounts each time the lice feed. Sensitisation does not occur
immediately and it may take weeks for itching to develop. It has been
estimated that thousands of bites from the lice are required before the
reaction develops. The absence of itching does not mean that infection
has not occurred. In someone who has previously been infected and
becomes reinfected, itching may quickly begin again.
Previous infection
The pharmacist should establish whether the child has been infected
before. In particular, it is important to know whether there has been
a recent infection, as reinfection may have occurred from other family
members if the whole family was not treated at the same time. Head-tohead
contact, between family members and also among young children
while playing, is responsible for the transmission of head lice from one
host to the next. The pharmacist could ask whether the parent was
aware of any contact with infected children, e.g. if there is currently a
problem with head lice at the child’s school.
Medication
While it is possible that treatment failure may occur, this is unlikely if
a recommended insecticide has been used (see ‘Management’ below)
correctly. Careful questioning will be needed to determine whether
treatment failure has occurred. The identity of any treatment used and
its method of use should be elicited.
Management
Having established that infection is present, the pharmacist can go on
to recommend an appropriate treatment. Depending on the parent’s
preference:
 Dimeticone
 Insecticide
 Wet combing (‘bug busting’).
Dimeticone and the insecticides malathion, permethrin and phenothrin
are available OTC, while carbaryl is a prescription-only
medicine (POM). All are effective treatments for head lice. If insecticide
treatment fails then another preparation from a different class of
insecticides is used next.
Bug busting, a method of wet combing, has been used as an alternative
strategy to treatment with insecticides. Bug busting generally
involves meticulous combing with a plastic detection comb after hair
conditioner or vegetable oil has been applied. The hair is combed for
about 30 min every 4 days for a minimum of 2 weeks.
Herbal treatments (e.g. teatree oil) and aromatherapy have been tried
but there is little evidence of their effectiveness.
HEAD LICE 297
Teamwork between pharmacists, GPs and nurses (particularly those
involved in prescribing for head lice) is important to ensure consistency
of messages and treatment information. Pharmacists can also liaise
with health visitors and school nurses to communicate with schools in
the area and ensure the accuracy and currency of information given to
parents and children.
There is still a stigma attached to head lice infection and many parents
feel ashamed if their children become infected, feeling that infection
must be a sign of poor hygiene. Of course this is not so and
pharmacists can reassure their customers that head lice infection is not
only extremely common, but equally likely to occur in clean as in dirty
hair. Head-to-head contact means that lice are easily transferred from
one person to the next.
Dimeticone and isopropyl myristate/cyclomethicone
There is evidence of efficacy from randomised clinical trials for
dimeticone and for isopropyl myristate/cyclomethicone. Dimeticone
is thought to coat the lice and prevent the insects from excreting excess
water. It is applied to dry hair and scalp, left for 8 h and then rinsed
off. A second application is used after 7 days. Detection combing at 4
and again at 8–10 days is recommended. Dimeticone has a good safety
profile. Adverse effects are not common and include itchy or flaky scalp
and irritation if it gets into the eyes. It is particularly useful for people
with eczema or asthma as it is less irritant to the scalp. Isopropyl myristate/
cyclomethicone solution also has a physical effect on the lice. It
is applied to dry hair and washed out after 10 minutes.
Insecticides
Few comparative studies of insecticides have been conducted. It is
therefore not possible to definitively state comparative effectiveness.
CKS suggests aqueous lotions first line because they do not have the
potential for adverse effects of alcoholic lotions. The lotion or liquid
should be applied to dry hair and scalp and left for a minimum contact
time of 12 h (or overnight). A repeat application 7 days after the
initial treatment should be recommended. This second application will
kill any lice that have emerged from eggs in the meantime. Eggs take
around 7 days to hatch. A detection comb should be used at 4 and
again at 8–10 days. The British National Formulary (BNF) does not
recommend shampoos, cream rinses and mousses because of their short
contact time.
Malathion, permethrin and phenothrin
Malathion, permethrin and phenothrin can be recommended OTC.
The BNF recommends the use of lotions and liquids but not of permethrin
cream rinse and phenothrin mousse formulations (the reason
298 CHILDHOOD CONDITIONS
being that the contact time is too short). It is generally recommended
that all members of the family should be treated at the same time to
prevent reinfection from another family member. Another approach is
to treat only those in whom infection has been confirmed and to check
the hair of all family members on a regular basis to look for infection.
However, the latter requires a high level of motivation. Checking the
hair by combing over white paper and visual inspection should confirm
who is infected. Contact tracing is important to track the source of the
infection and also to identify who might have become infected.
Family sized treatment packs are available for some products. The
pharmacist can advise doctors and nurse prescribers about the amount
of lotion necessary to treat each person. This is sometimes underestimated
by prescribers and should be 50–100 mL per person. Using
too little treatment has been a cause of treatment failure in the past,
necessitating repeated treatment.
Carbaryl
Carbaryl is now available only as POM in the UK. Data from animal
studies indicated the possibility of carcinogenicity, and the theoretical
risk to humans led to the change in legal classification in 1996.
Which formulation?
There are two issues to consider when choosing a formulation: the first
is the concentration of insecticide that will be in contact with the scalp;
the second is the length of time the insecticide will be in contact with
the scalp.
Lotions are the preferred treatment for head lice. A lotion is applied
to the scalp and the hair left to dry for 12 h or overnight to increase the
likelihood that eggs are killed. The insecticide is therefore in contact
with the hair for a long period of time and at a high concentration.
By contrast, a cream rinse or shampoo is diluted by water, so that
the concentration of insecticide is lower. After shampooing, the hair is
rinsed so that the insecticide is in contact with the scalp for only a short
time. Because several applications of shampoo are needed, compliance
may not be achieved and treatment failure can result. A cream rinse is
left on for 10 min and a foam (mousse) for 30 min before shampooing
off, so the contact time is short.
Alcoholic and aqueous lotions
Malathion and carbaryl are available as alcoholic and aqueous lotions.
Alcohol-based formulations are generally useful but are not suitable for
all patients because they can cause two types of problems. Firstly, alcohol
can cause stinging when applied to scalps with skin broken as
a result of scratching. Babies and other patients with eczema affecting
the scalp may also experience stinging. Secondly, in patients with
HEAD LICE 299
asthma, it is thought that alcohol-based lotions are best avoided, as the
evaporating alcohol might irritate the lungs and cause wheezing, perhaps
even precipitating an attack of asthma. Such reactions are likely
to be extremely rare, but caution is still advised. The NHS Clinical
Knowledge Service recommends that aqueous lotions should be used
first line because of their lower potential for adverse effects.
Indications for shampoo
Shampoos are not recommended. Their clinical effectiveness is less than
that of lotion and cream rinse formulations. In the past, shampoos
were an alternative where alcoholic lotions were not suitable. However,
aqueous versions of treatments are now available.
Method of use and advice
Malathion and carbaryl
Malathion and carbaryl lotions should be rubbed gently into dry hair
and care should be taken to ensure that the scalp is thoroughly covered;
the wet hair is then combed. The most effective method of application
is to sequentially part sections of the hair and then apply a few drops
of the treatment, spreading it along the parting into the surrounding
scalp and along the hair. Approximately 50–55 mL of lotion should
be sufficient for one application, although people with very thick or
long hair may need more. A towel or cloth can be placed over the eyes
and face to protect them from the lotion. When applying the product,
particular attention should be paid to the areas at the nape of the neck
and behind the ears, where lice are often found. The hair should then
be left to dry naturally. Hair driers or other heat sources should not
be used with carbaryl and malathion because both are inactivated by
heat. In addition, where an alcoholic lotion is used, the hair should be
kept away from fire and naked flames.
Phenothrin lotion
Phenothrin lotion is formulated as an aqueous or alcoholic preparation.
The lotion is sprinkled onto dry hair and rubbed gently until hair and
scalp are soaked. The hair is then left to dry naturally. The aqueous
and alcoholic lotion is left on for 12 h or overnight. Phenothrin is not
inactivated by chlorine in swimming pools.
Removing eggs and nits
After using a lotion or shampoo, a fine-toothed dust comb can be used
to remove the eggs and empty shells (nits), which will have remained
glued to the hair shafts. Combing is best done the next time the hair is
washed while it is wet.
300 CHILDHOOD CONDITIONS
Residual effect
A residual effect from insecticides can occur after the use of lotions,
but not shampoos. The effect takes several hours of contact to develop
when using carbaryl and malathion and the level of residual action
varies from person to person. Once established, the effect may last
for several weeks. In the case of carbaryl and malathion, contact with
chlorinated water during swimming will reduce any residual effect, as
will the application of heat via hairdryers.
Treatment failure
The most likely cause of treatment failure is emerging lice that have
not been killed by the initial application. Resistance to the insecticide
is responsible for a minority (30%) of cases of treatment failure.
Wet combing method
Wet combing, or bug busting, is used to remove lice without using
chemical treatments. Recent evidence suggests it may cure in about half
the cases it is used in. Effectiveness of this method is very dependent
on repeated use over a fortnight. The procedure is as follows:
 Wash the hair as normal.
 Apply conditioner liberally. (This causes the lice to lose their grip on
the hair.)
 Comb the hair through with a normal comb first.
 With a fine-toothed nit comb, comb from the roots along the complete
length of the hair and after each stroke check the comb for lice
and wipe it clean. Work methodically over the whole head for at least
30 min.
 Rinse the hair as normal.
 Repeat every 3 days for at least 2 weeks.
(Source: NHS Clinical Knowledge Summaries)
Head lice in practice
Case 1
A young mother, who often comes into your pharmacy to ask for advice
and buy medicines for her children, asks for a product to prevent head
lice. Her children have not got head lice but she wants to use a treatment
‘just to be on the safe side’. On questioning, you find out that the
children are aged 5 and 7 years and that there are no signs of infection
such as itching scalps. The children’s heads have not been checked for
lice. She is not sure how to go about making such a check. There has
not been any communication from the children’s school to indicate
that head lice is a current problem at the school. This lady explains
HEAD LICE 301
that she is very hygiene conscious and would hate her children to get
nits.
The pharmacist’s view
Insecticides should never be recommended unless there is evidence of
infection. From what this mother has said, it seems unlikely that her
children have head lice and there is no evidence of a current problem
at school. The pharmacist can therefore reassure her that infection
is unlikely. In cases such as this where parents with their children’s
interest at heart seek to use insecticides to prevent infection, careful
explanation from the pharmacist is required. Firstly, the parent can
be reassured that head lice and hygiene have absolutely nothing to do
with each other and that lice actually prefer clean heads. Head lice
are easily transferred from one head to another, particularly among
schoolchildren. It is important to stress that chemical treatments will
be ineffective in preventing infection and may even contribute to the
development of resistant lice. The ritual use of insecticides, which was
a feature of some parents’ own childhood, was both unnecessary and
ineffective.


برچسب ها: to the back of the throat. Within the middle ear are tiny bones that transmit the sound wave vibrations of the eardrum to the inner ear. An infection typically starts with a common cold، especially in children، which leads to blockage of the Eustachian tube and fluid formation within the middle ear. The fluid can then be secondarily infected by a bacterial infection. Symptoms The symptoms of otitis media are pain and temporary deafness. Sometimes the infection takes off so quickly that the eardrum perforates، releasing the infected fluid. When this occurs، a discharge will also be present and be associated with considerable lessening of pain. As with OE، referral is usually necessary so that the eardrum can be examined. Treatment may involve a course of oral antibiotics (e.g. amoxicillin (amoxycillin)، penicillin or erythromycin). However،  

تاریخ : دوشنبه 25 اسفند 1393 | 11:55 ب.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th




The GP’s view
It would probably be best for Julie Parker to go back and see her GP
who has already given her two courses of treatment and taken a swab.
She needs to find out exactly what the GP has been treating her for,
what the swab result is and to be able to explain to her GP what her
current symptoms are. Metronidazole is often prescribed for bacterial
vaginosis. It could be that she has also developed thrush especially as
she has been taking amoxycillin. It is always important for patients to
know how and when they can get their results. Often patients understandably
assume that if they don’t hear from their doctors’ surgery,
the result is negative or normal. This is potentially dangerous and it is
always important for the person taking laboratory samples to explain
clearly how and when the results will be available and agree this with
their patient. In this situation it is also important for the prescriber
to explain the need for the prescription that has been left out at the
surgery.
Case 2
Helen Simpson is a student at the local university. She asks one of your
assistants for something to treat thrush and is referred to you. You
walk with Helen to a quiet area of the shop where your conversation
will not be overheard. Initially, Helen is resistant to your involvement,
asking why you need to ask all these personal questions. After you
have explained that you are required to obtain information before
selling these products and that, in any case, you need to be sure that
the problem is thrush and not a different infection, she seems happier.
She has not had thrush or any similar symptoms before but described
her symptoms to a flatmate who made the diagnosis. The worst symptom
is itching, which was particularly severe last night. Helen has noticed
small quantities of a cream-coloured discharge. The vulval skin
is sore and red. Helen has a boyfriend, but he hasn’t had any symptoms.
She is not taking any medicines and does not have any existing
illnesses or conditions. Since arriving at the university a few months
ago she has not registered with the university’s health centre and has
therefore come to the pharmacy hoping to buy a treatment.
The pharmacist’s view
The key symptoms of itch and cream-coloured vaginal discharge make
thrush the most likely candidate here. Helen has no previous history
of the condition and, unfortunately, the regulations preclude the recommendation
of an intravaginal azole product or oral fluconazole in
such a case. An azole cream would help to ease the itching and soreness
of the vulval skin. As her boyfriend is not experiencing symptoms he
does not need treatment. However, because external treatment alone
VAGINAL THRUSH 249
is unlikely to prove effective in eradicating the infection, it would be
best for Helen to see a doctor.
She would be well advised to register at the university health centre.
You can explain to her that she can seek treatment on a temporary
resident basis but that it would be best to get proper medical cover.
The doctor’s view
The history is very suggestive of thrush and treatment should include
an appropriate intravaginal preparation. The case history highlights
some of the difficulties of asking personal questions about genitalia and
sexual activity. These difficulties are also likely to occur in the doctor’s
surgery. It is important for the doctor to carefully explore the patient’s
ideas, understanding, concerns and preconceptions of her condition.
Many doctors would prescribe without an examination with such a
clear history and examine and take appropriate microbiology samples
only if treatment fails.
250 WOMEN’S HEALTH
Emergency hormonal contraception
Dealing with requests for emergency hormonal contraception (EHC)
requires sensitive interpersonal skills from the pharmacist. Enabling
privacy for the consultation is essential and the wider availability of
consultation areas and rooms has improved this. Careful thought needs
to be given to the wording of questions. Some 20% of women will go to
a pharmacy other than their regular one because they want to remain
anonymous.
What you need to know
Age
WhyEHC is needed – confirmation that unprotected sex or contraceptive failure
has occurred
When unprotected sex/contraceptive failure occurred
Could the woman already be pregnant?
Other medicines being taken
Significance of questions and answers
Age
EHC can be supplied OTC as a P medicine for women aged 16 years
and over. For women under 16 years the pharmacist can refer to the
doctor or family planning service. In the NHS, EHC may be supplied
under patient group directions (PGDs) according to a locally agreed
protocol. Some of these schemes include community pharmacies and
if the PGD so states, supply can be made to a woman under 16 years.
Why EHC is needed
The most common reasons for EHC to be requested are failure of a
barrier contraceptive method (e.g. condom that splits), missed contraceptive
pill(s) and unprotected sexual intercourse (UPSI). In the
case of missed pills the pharmacist should follow the guidance of the
Faculty of Family Planning and Reproductive Health Care Clinical
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
EMERGENCY HORMONAL CONTRACEPTION 251
Effectiveness Unit (Emergency Contraception: Guidance, April 2006
at www.ffprhc.org.uk). Note: At the time of writing the BNF is more
cautious and recommends EHC after 2 or more missed combined pills.
Recommendations for use of EHC (FFPRHC 2006)
Combined pills If three or more, 30- to 35-μg or two or more 20-μg (21 active
tablets) ethinyloestradiol pills have been missed in the first week
of pill taking (i.e. days 1–7) and UPSI occurred in week 1 or the
pill-free week
Progestogen-only pills
(POPs)
If one or more POPs have been missed or taken >3 h late
(>12 h late for Cerazette) and UPSI has occurred in the 2 days
following this
Progestogen-only
injectable
If the contraceptive injection is late (>14 weeks from the
previous injection for medroxyprogesterone acetate or
>10 weeks for norethisterone enantate) and UPSI has occurred
Barrier methods If there has been failure of a barrier method
When unprotected sex/contraceptive failure occurred
EHC needs to be started within 72 h of unprotected intercourse. The
sooner it is started, the higher is its efficacy. If unprotected sex took
place between 72 h and 5 days ago, the woman can be referred to
have an intrauterine device (IUD) fitted as a method of emergency
contraception.
Requests are sometimes made for EHC to be purchased for use in
the future (advance requests, for example, to take on holiday just in
case). This is considered below.
Could the woman already be pregnant?
Any other episodes of unprotected sex in the current cycle are important.
Ask whether the last menstrual period was lighter or later than
usual. If in doubt, the pharmacist can suggest that the woman has a
pregnancy test. EHC will not work if the woman is pregnant. There is
no evidence that EHC is harmful to the pregnancy.
Other medicines being taken
Medicines that induce specific liver enzymes have the potential to increase
the metabolism of levonorgestrel and thus to reduce its efficacy.
Women taking the following medicines should be referred to an alternative
source of supply of EHC:
Anticonvulsants (carbamazepine, phenytoin, primidone, phenobarbital
(phenobarbitone))
Rifampicin and rifabutin
Griseofulvin
Ritonavir
St John’s wort.
252 WOMEN’S HEALTH
There is an interaction between ciclosporin and levonorgestrel. Here,
the progestogen inhibits the metabolism of ciclosporin and increases
levels of the latter. A woman requesting EHC who is taking ciclosporin
should be referred.
Treatment timescale
EHC must be started within 72 h of unprotected intercourse.
When to refer
Age under 16 years
Longer than 72 h since unprotected sex
Taking a medicine that interacts with EHC
Requests for future use
Management
Dosage
Levonorgestrel EHC is taken as a dose of one 1.5-mg tablet as soon as
possible after unprotected intercourse.
Side-effects
The most likely side-effect is nausea, which occurred in about 14% of
women during clinical trials of levonorgestrel EHC. Far fewer women
(1%) actually vomited. Although the likelihood of vomiting is small,
absorption of levonorgestrel could be affected if vomiting occurs within
3 h of taking the tablet. Another dose is needed as soon as possible.
Women who should not take EHC
The product licence for the P medicine states that it should not be
taken by a woman who is pregnant (because it will not work), has
severe hepatic dysfunction or has severe malabsorption (e.g. Crohn’s
disease).
Advice to give when supplying EHC
1 Take the tablet as soon as possible.
2 About one in seven women feels sick after taking levonorgestrel EHC
but only one in every hundred is actually sick.
3 If the woman is sick within 3 h of taking the tablet, she should obtain
a further supply.
4 The next period may start earlier, on time or later than usual. If it is
lighter, shorter or more than 3 days later than usual, the woman should
see her doctor or family planning adviser to have a pregnancy test.
EMERGENCY HORMONAL CONTRACEPTION 253
5 If the woman takes the COC, she and her partner should use condoms
in addition to continuing the pill, until she has taken it for 7
consecutive days.
6 EHC does not equate to ongoing contraception, nor does it offer
protection against STD.
Practical points
1 A PGD is available in many areas for pharmacists to supply EHC on
the NHS. The PGD was introduced to enable quicker access for EHC
to women who are not covered by the OTC product licence (e.g. those
under 16 years) and to overcome the difficulties faced by some women
in relation to the cost ofOTCEHC(currently around £22). Pharmacists
supplying under a PGD undertake additional training, follow a closely
defined protocol and keep records of their supplies.
2 Pharmacists need to know local sources of family planning services
and their opening hours so that they can refer if, for some reason, it
is not appropriate for the P EHC to be supplied. Knowledge of local
services is also important for advice to women who may wish to obtain
regular contraception and information about STDs.
3 EHC can be used on more than one occasion within the same menstrual
cycle but this is likely to disrupt the cycle. There are no safety
concerns about repeated use of EHC but a woman doing so would
find it difficult to keep track of her cycle because of the changes EHC
can cause. Some women may believe that repeated courses of EHC are
a substitute for other contraceptive methods. EHC used in this way
is less effective than other methods of contraception and the risk of
becoming pregnant is higher.
4 On advance supply of EHC, RPSGB guidance states that ‘if faced
with a request for advanced supply of EHC the pharmacist should use
their professional judgement to decide the clinical appropriateness of
the supply’. RPSGB suggests the following:
Declining repeated requests for advance supply and advising clients
to seek more reliable methods of contraception
Providing reminders to ensure that any prospective use of EHC is
safe, effective and appropriate.
The following points are suggested for inclusion in counselling:
(a) Read the patient information leaflet (PIL) again before taking
the product to ensure that it is still suitable for you.
(b) EHC efficacy decreases with time and will be effective only if
taken within 72 h (3 days) of unprotected sex/intercourse or failure
of a contraceptive method.
(c) IUDs can be fitted up to 120 h (5 days) after unprotected sex or
within 5 days of expected ovulation.
254 WOMEN’S HEALTH
(d) Pregnancy is a contraindication for EHC. If you have had unprotected
sex which was more than 72 h ago, and since your last
period, you may already be pregnant and the treatment won’t work.
Refer to your doctor or pharmacist for advice.’
In a trial of wider access to EHC involving over 2000 women, those
who had advance supplies at home were more likely to use EHC when
required, without compromising regular contraceptive use or increasing
risky sexual behaviour.
EHC in practice
Case 1
A customer whom you recognise as a regular comes into the pharmacy
and asks to speak to the pharmacist. She says that she thinks she needs
EHC and you move to a quiet area of the pharmacy. On questioning,
you find out that she takes the POP but was away from home on
business earlier this week and missed one pill, as she forgot to take
them with her. The packet says that other contraception will be needed
for 7 days. She had sex last night and says she had not had the chance
to get any condoms. She is not taking any medicines other than the pill
and is not taking any herbal remedies. Her last period was normal and
there have been no other episodes of unprotected sex.
The pharmacist’s view
Many of the women who request EHC are aged between 20 and 30
years and are regular users of contraception but something has gone
wrong. This woman needs to take EHC and the pharmacist can go
through the PIL with her to advise on timing of doses and what to
do about side-effects should they occur. The pharmacist can also sell
condoms/spermicide and reinforce the advice about continuing other
contraceptive methods until the pill has been taken for 7 consecutive
days as well as taking her POP.
The doctor’s view
The pharmacist’s approach is appropriate. It is likely that the consultation
was made easier because the pharmacist already had a professional
relationship with the patient and it would have easier for her to seek
advice in the first place. It would be useful for the customer to review
the appropriateness of her POP and whether she has missed pills before.
She could be advised to have a follow-up with her pill prescriber.
Case 2
It is a Saturday afternoon about 4.30 p.m. A young woman comes into
your pharmacy, asks your counter assistant for EHC and is referred to
EMERGENCY HORMONAL CONTRACEPTION 255
you. You move to consultation area of the pharmacy and in response to
your questions she tells you that she had intercourse with her boyfriend
last night for the first time. No contraception was used. She is not taking
any medicines or herbal remedies. Her periods are fairly regular about
every 30 days. You think the woman may be under 16 years.
The pharmacist’s view
This woman had unprotected sex 12–18 h ago. If she is under 16 years,
the use of P EHC would be outside the terms of the product licence
and the pharmacist could ask her age. Some pharmacies can supply
EHC on the NHS to under-16s through a PGD. If the area does not
have a PGD, the pharmacist will have to consider what other methods
of access are available. A walk-in centre, GP out-of-hours centre or
Accident and Emergency Department might be available. If all other
avenues proved unfeasible, the pharmacist might have to weigh the
benefits and risks of referral versus supplying outside the terms of the
OTC licence. While there is time for it to be started within 72 h of
unprotected sex, the earlier EHC is taken, the more likely it is to be
effective. The pharmacist should tactfully suggest that she could get
advice on regular contraception and discuss whether she would prefer
to get this from her GP or local family planning service.
The doctor’s view
Referral does depend on her age, which can be difficult to assess, and
whether or not there is a local PGD. One of the problems here is the day
and time of presentation. It is unlikely that the local family planning
service would be open late on a Saturday. She could wait until Monday
but that would be getting close to the 72-h deadline. Clearly, it would
be better to take the EHC as soon as possible. Her best option would
be to phone the on-call GP service. This could probably be done in the
pharmacy and she could discuss what to do with the duty GP or nurse.
If she turns out to be under age, the GP has a duty to encourage her to
discuss this with her parents. The General Medical Council guidance
is that the GP can prescribe contraceptives to young people under 16
years without parental consent or knowledge, provided that:
(a) They understand all aspects of the advice and its implications.
(b) You cannot persuade the young person to tell their parents or to
allow you to tell them.
(c) In relation to contraception and sexually transmitted infections, the
young person is very likely to have sex with or without such treatment.
(d) Their physical or mental health is likely to suffer unless they receive
such advice or treatment.
(e) It is in the best interests of the young person to receive the advice
and treatment without parental knowledge or consent.
256 WOMEN’S HEALTH
Case 3
A woman asking for EHC is referred to you. She thinks that she may be
pregnant as she takes the combined OCP and missed one pill 2 days ago
during the second week of the packet. Her brand of pill contains 20μg
ethinyloestradiol. She had sex last night. Her last period was normal.
The pharmacist’s view
The Faculty of Family Planning Guidelines state that EHC is not needed
unless the woman has missed two or more pills during the first week of
taking it. The woman should use an additional contraceptive method
such as condoms until pills have been taken on 7 consecutive days. The
pharmacist should discuss this with the woman. If she continues to be
concerned and still wants to take EHC, the pharmacist could supply
it as there are no safety concerns. The timing of the next period may
be disrupted. The pharmacist should also suggest that she buys some
condoms and spermicide.
The doctor’s view
The pharmacist’s advice is appropriate. It would be useful to know if
she has had similar problems before. If she has, she may benefit from
discussion with her GP or adviser at the contraceptive clinic whether
or not she decides to take EHC this time.
Case 4
It was the week before I was due to go travelling in South America with
my boyfriend for six months during my gap year. We’re used to using
condoms but I’m worried in case one splits while we’re away. So I’m
going to a pharmacy to see if I can buy the emergency contraception
pill to take with me. I don’t want to go to the doctors to ask for it.
This woman is now in your pharmacy asking to purchase EHC. Use
the chart below to use your professional judgement and decide how to
deal with the request.
Potential
harm to
patient from
not
supplying
Potential
harm to
patient from
supplying
Potential
benefit to
patient from
supplying
Consequences for
pharmacist of
supplying/not
supplying
What would I do if
the patient were
me/my spouse/my
parent/my child? Is
this decision
different from the
one I have reached
for the patient?
Why?
EMERGENCY HORMONAL CONTRACEPTION 257
Common symptoms in pregnancy
Constipation (see p. 100)
Constipation can occur in pregnancy because of the effect of hormonal
changes. These changes reduce the contractility of the intestines, slowing
down the transit of waste products. This in turn allows more fluid
to be extracted through the bowel wall drying and hardening the faecal
matter. Some women are also taking oral iron preparations for
anaemia, which can aggravate constipation. It makes sense to try to
prevent this problem by attention to diet (fruit, vegetables and wholegrain
cereal, lentils and pulses) and increased fluid intake. If the constipation
is aggravated by iron tablets, it may be worthwhile discussing
a change of preparation with the GP.
Haemorrhoids (see p. 128)
Haemorrhoids can be aggravated by constipation, and in pregnancy
relaxation of the muscles in the anal veins can lead to dilation and
swelling of the veins (haemorrhoids or piles). The venous dilatation
occurs under the influence of the pregnancy hormones. Later in pregnancy,
as the baby’s head pushes down into the pelvis, further pressure
is exerted on these veins aggravating piles.
In the management of haemorrhoids it is important to avoid constipation,
take regular exercise to improve circulation, avoid standing
for long periods and discuss with the pharmacist, midwife or GP an
appropriate OTC treatment.
Backache
As pregnancy progresses the ligaments of the lower back and pelvis
become softer and stretch. Posture also changes leading to an increased
forward curve in the lumbar (lower) spine, which is called a lordosis.
The change in the ligaments and the lordosis can lead to low backache.
Commonsense techniques avoiding heavy lifting, awkward bending
and twisting are advisable, as is a good supportive mattress. Further
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
258 WOMEN’S HEALTH
help may be gained from an obstetric physiotherapist and chiropractor
or osteopath.
Cystitis (see p. 223; reason for referral)
Increased frequency of urination is common in pregnancy and, although
inconvenient, is medically unimportant. When it is associated
with any signs of cystitis such as discomfort on urination, discolouration
or offensive smell of urine, referral to the GP is important. When
cystitis occurs in pregnancy, the infection can move upwards from the
bladder to the kidneys, causing a much more serious infection. If there
is any doubt about cystitis being present, it is important to have the
urine sent for analysis.
Headache
Headaches can be a common problem for some women in pregnancy.
It is best to have a balance of exercise, rest and relaxation. Occasional
paracetamol can be taken but it is generally best to avoid medication
during pregnancy. Occasionally persistent or severe headaches are due
to raised blood pressure. It is important to get the midwife or GP to
check for this.
Heartburn (see p. 74)
Heartburn is caused by the relaxation of the muscles in the lower oesophagus,
allowing the acid stomach contents to regurgitate upwards.
This acid reflux causes inflammation of the oesophagus and heartburn.
It is aggravated as pregnancy progresses by pressure on the stomach
from the growing baby. It can be reduced by raising the head of the
bed, eating small meals and not eating prior to going to bed. A glass
of milk may help. If treatment is to be recommended, the pharmacist
will need to consider the sodium content and avoid any medicine with
a high sodium level.
Nausea/vomiting (morning sickness)
Nausea and vomiting is very common, especially in early pregnancy:
nausea affects 70% and vomiting 60%. It is sometimes misleadingly
called morning sickness as it actually can occur anytime during the day.
Vomiting ceases by the sixteenth week in 90% of women. It may be
caused by the change in hormone levels. It is important to take plenty of
rest and get up in the mornings slowly, drink plenty of fluids, avoid food
and smells that aggravate and eat bland foods. Ginger may be helpful.
There are some trials which suggest that ginger reduces nausea and
COMMON SYMPTOMS IN PREGNANCY 259
vomiting but they all involve small numbers of people. One crossover
trial assessed 27 women with severe nausea during pregnancy.Women
were given ginger 250 g four times daily or placebo for 4 days. Nausea
was significantly reduced in the ginger group compared to the placebo
one. The evidence for P6 acupressure is at present inconclusive, with
some trials showing benefit and others that it is less effective than
placebo. A recent trial suggests that acupuncture is effective, although
the numbers involved were too small to draw firm conclusions.
Vaginal discharge
Vaginal discharge occurs in most women during pregnancy. Providing
the discharge is clear and white and non-offensive, it is a normal
response to pregnancy. If, however, the discharge has an unpleasant
odour, is coloured or is associated with symptoms such as soreness or
irritation, referral to the midwife or GP is advised. The most common
infection is thrush and is usually managed with topical and intravaginal
azoles.
Irritation
Mild skin irritation is common in pregnancy. It is caused by increased
blood flow to the skin and by the stretching of the abdominal skin.
Wearing loose clothing may help as may perhaps the use of an emollient/
moisturising cream. Rarely if the itching is severe, a more serious
cause may be revealed, i.e. obstetric cholestasis. This condition may be
associated with jaundice and can have a deleterious effect on the baby.
It is important to refer patients who complain of severe itching.
260 WOMEN’S HEALTH
Eye and Ear Problems
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5

Eye problems: the painful red eye
Conjunctivitis is one cause of a painful red eye. There are other serious
causes of painful red eyes and there are several causes of conjunctivitis.
Accurate diagnosis of these causes is of vital importance and requires
specific knowledge and skills. Notes on some of the causes of painful
red eyes are provided below.
What you should know
Causes of painful red eye
Conjunctivitis
Infective
Allergic
Corneal ulcers
Keratitis
Other causes
Iritis/uveitis
Glaucoma
One or both eyes affected?
What is the appearance of the eye?
What are the symptoms – pain, gritty feeling, photophobia?
Is vision affected?
Any discharge from the eye(s) – purulent, watery?
Does the patient wear contact lenses?
Significance of questions and answers
Conjunctivitis
The term conjunctivitis implies inflammation of the conjunctiva, which
is a transparent surface covering the white of the eye. It can become
inflamed due to infection, allergy or irritation.
Infective conjunctivitis
Both bacteria and viruses can cause conjunctivitis. The symptoms are
a painful gritty sensation and a discharge. The discharge is sticky and
purulent in bacterial infections and more watery in viral infections. It
EYE PROBLEMS: THE PAINFUL RED EYE 263
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5
nearly always affects both eyes. Conjunctivitis occurring in only one eye
suggests the possible presence of a foreign body or another condition
accounting for the red eye.
Management. Acute infective conjunctivitis is frequently selflimiting.
A systematic review found that 65% of cases resolved within
2–5 days when treated with placebo. Gentle cleansing of the affected
eye(s) with cotton wool soaked in water can be recommended regardless
of whether treatment is also being suggested.
There is some evidence that infective conjunctivitis treated with
antibacterial eye drops and ointment resolves more quickly. Chloramphenicol
eye drops 0.5% every 2 h for the first 24 h and then four
times daily or chloramphenicol eye ointment 1% can be used over the
counter (OTC) for the treatment of acute bacterial conjunctivitis in
adults and children aged 2 years or over.
People with infective conjunctivitis or those treating someone who
is infected should wash their hands regularly and avoid sharing towels
and pillows. Contact lenses should not be worn until the infection
has completely cleared and until 24 h after any treatment has been
completed.
Medical advice is urgently needed if the eye(s) become markedly
painful, there is photophobia, marked redness or vision is affected.
NHS Clinical Knowledge Service advises that if symptoms persist for
longer than 2 weeks further investigation is needed.
Other conditions with similar symptoms
Allergic conjunctivitis
This produces irritation, discomfort and a watery discharge. It typically
occurs in the hay fever season. It is sometimes difficult to differentiate
between infection and allergy and therefore referral is important if
there is any doubt.
Management. In seasonal allergic conjunctivitis, decongestant and
antihistamine drops can be helpful and sodium cromoglicate (sodium
cromoglycate) eye drops is an effective, safe treatment. Mast cell stabilisers
help to prevent the onset of allergic reactions by blocking the
attachment of immunoglobulin/allergen complexes to mast cells. They
do not provide the rapidity of relief associated with topical antihistamines
but are effective when used for longer periods of time. In recurrent
seasonal allergies it is appropriate to use a mast cell stabiliser
for 4 weeks before the start of an allergy season.
If there is prolonged exposure to allergens in perennial allergic conjunctivitis,
then the continued use of a topical antihistamine becomes
inappropriate and it is better to recommend drops containing a mast
cell stabiliser such as Sodium cromoglicate. Sodium cromoglicate 2%
eye drops can be recommended OTC for the treatment of both seasonal
264 EYE AND EAR PROBLEMS
and perennial allergic conjunctivitis. A number of proprietary brands
are available.Warn patients that they might experience a mild transient
burning or stinging sensation after administering these products.
A more chronic form of allergic conjunctivitis is called vernal keratoconjunctivitis.
It usually occurs in atopic individuals. It is an important
diagnosis to make, as untreated it can lead to corneal scarring.
It would normally be managed by an ophthalmologist. Steroid drops
may be used in the management of more severe cases.
Blepharitis may present with similar symptoms to allergic conjunctivitis.
However, it is often the case that pruritis (itching) is less prominent
with blepharitis. This is also the case with dry eye syndrome
(keratoconjunctivitis sicca). Blepharitis is an infection along the lid
margin. Its management usually requires removal of the crusty matter
from between the lashes with a cotton wool bud.
Corneal ulcers
These may be due to an infection or a traumatic abrasion. The main
symptom is that of pain. There may be surrounding conjunctival inflammation.
An abrasion can be caused by wearing contact lenses.
Early diagnosis is important as the cornea can become permanently
scarred, with loss of sight. If a corneal ulcer is suspected, the eye is
examined after instilling fluorescein drops, which will colour and highlight
an otherwise invisible ulcer. The cornea is the transparent covering
over the front of the eye and early ulcers are not visible.
Keratitis (inflammation or infection of the cornea) often presents
with a unilateral, acutely painful red eye and the patient complaining
of photophobia. It may be caused by herpes simplex virus or, occasionally,
a bacterial infection. Acanthamoeba keratitis is commoner in soft
contact lens wearers and is associated with poor lens hygiene, extended
wear and swimming whilst wearing lenses. Both these conditions need
to be referred.
Management. This is obviously determined by the cause of the ulcer.
Specialist referral is invariably required.
Other causes
Iritis/uveitis
Iritis is inflammation of the iris and surrounding structures. It may
occur in association with some forms of arthritis, sarcoidosis or tuberculosis.
It may occur as an isolated event with no obvious cause.
The inflammation causes pain, which is felt more within the eye than
is the superficial gritty pain of conjunctivitis, and there is no discharge.
The affected eye is red and the pupil small and possibly irregular. Urgent
specialist referral is necessary for accurate diagnosis. Treatment is with
topical steroids to reduce inflammation.
EYE PROBLEMS: THE PAINFUL RED EYE 265
Glaucoma
Glaucoma occurs when the pressure of the fluids within the eye becomes
abnormally high. This may either happen suddenly or develop
slowly and insidiously; two different abnormalities are involved. It
is the sudden onset type (acute closed-angle glaucoma) that causes a
painful red eye. Emergency hospital referral is necessary in order to prevent
permanent loss of sight. The pain of acute glaucoma is severe and
may be felt in and around the eye. There may be associated vomiting.
As the pressure builds up the cornea swells, becoming hazy, causing
impaired vision and a halo appearance around lights. Treatment involves
an operation to lower the pressure to prevent it from developing
again. Acute closed-angle glaucoma is rare, whereas 2% of people over
40 years suffer from primary open-angle glaucoma (chronic simple
glaucoma). This condition starts slowly and insidiously, without
warning symptoms. As the intraoccular pressure builds up, the optic
nerve is damaged, which leads to loss of visual field and blindness if not
treated. Chronic glaucoma can be detected by an examination at the
optician. Regular check-ups are advised if there is a family history of
glaucoma, especially in those over 40 years. Free eye tests are available
to those over the age of 40 years who have a close relative with
glaucoma.
Contact lenses
There are two main types of lens: hard (gas-permeable) and soft (hydrogel).
Soft lenses are the most popular because of their comfort.
One-day disposable lenses, which are worn once and require no maintenance
or storage, are becoming increasingly popular. However, this
can lead to patients keeping lenses in for longer periods of time. Extended
wear involves much greater risks and increases the chances of
complications, such as ulcerative keratitis, Acanthamoeba keratitis and
papillary conjunctivitis.
Contact lenses should not be worn if the patient has conjunctivitis
or is using eye drops. Soft contact lenses can absorb the preservative
benzalkonium chloride used in eye drops. Consequently, soft lenses
should not be worn within 24 h of instilling eye drops containing this
preservative.
Eye problems in practice
Paul Greet is a man in his forties who comes into your pharmacy on his
way home from work wanting treatment for a stye. He asks to speak
to the pharmacist. It is Friday night and you are just about to close.
Your pharmacy is in the city centre. He asks if you would make him an
emergency supply of chloramphenicol eye ointment, which his doctor
266 EYE AND EAR PROBLEMS
usually prescribes for him. OTC chloramphenicol is licensed only for
the treatment of acute bacterial conjunctivitis. What would you do?
Pharmacist’s view
This sort of dilemma sometimes happens. Unless this man’s general
practitioner (GP) surgery is open in the morning, he will not be able
to get a prescription until Monday, by which time his stye may have
worsened. In areas where community pharmacies can supply chloramphenicol
eye ointment through a patient group direction, the pharmacist
can, following a protocol, supply treatment for a style (hordeolum)
where appropriate. In areas that have an NHS walk-in centre,
he could be directed there for treatment. If his surgery is open for emergencies
in the morning, he could be seen then. If none of these apply,
he could be advised to go to casualty or to call his GP out-of-hour
service.
As for making an emergency supply, it is up to the pharmacist to
decide whether this constitutes an emergency, which requires the pharmacist
to satisfy him- or herself that ‘there is an immediate need for
the POM requested to be sold or supplied and it is impracticable in
the circumstances to obtain a prescription without undue delay’. Patients’
and pharmacists’ views of what constitutes an emergency do
not always coincide. A possible framework for making such decisions
is shown below.
Potential
harm to
patient
from not
supplying
Potential
harm to
patient
from
supplying
Potential
benefit to
patient
from
supplying
Consequences
for pharmacist of
supplying/not
supplying
What would I do if
the patient were
me/my spouse/my
parent/my child? Is
this decision different
from the one I have
reached for the
patient? Why?
However, the pharmacist will take into account the consequences
of not making a supply, including suffering and any potential harm
from delayed treatment. If, in the pharmacist’s view, the circumstances
constitute an emergency, the requirements for emergency supplies are
set out in Medicines, Ethics and Practice (Royal Pharmaceutical Society
of Great Britain, 2003).
The doctor’s view
Most styes are self-limiting. A stye can be an external one: a localised
infection of the hair follicles of the eyelid margin; or an internal stye:
an infection of meibomian glands on the inner surface of the lid.
EYE PROBLEMS: THE PAINFUL RED EYE 267
Staphylococcus aureus is the infection responsible in nearly all cases.
If left untreated, the stye will point and discharge and resolve spontaneously.
The stye can be encouraged to point by the regular application
of heat. A way of doing this would be to dip a cotton-wool bud in hot
water and then gently press it against the stye. Often chloramphenicol
ointment is prescribed more to protect the eye from any discharge
rather than actually treat the stye. It would probably help Paul Greet
to understand the natural course of styes; although if he has used chloramphenicol
ointment in the past, he is not likely to be happy without
a further supply this time. It would be useful for his GP to review
him as the styes have been recurrent. Sometimes recurrent styes can be
associated with blepharitis, diabetes or raised lipids.
If there is inflammation surrounding the stye on the eyelid, then this
would be a reason for referral to the GP, as systemic antibiotics may be
indicated. Very occasionally, styes need incision and drainage to speed
up their resolution.
Eye problems in practice
Kate Cosattis is a mum in her late thirties who wants advice about a
problem with her daughter’s eyes. Both of Ellie’s eyes were sticky in
the morning with ‘yellow stuff’ yesterday and today. The child is 18
months old and her eyes seem to be bothering her because she has been
rubbing them.
Pharmacist’s view
I couldn’t recommend chloramphenicol for this child because she’s under
2 years. In any case I’m not convinced that it offers any benefit in
infective conjunctivitis in children. So I explained to Kate that if she
gently bathed the eyes to keep them clean over the next few days it
was likely that the infection would go by itself. She wanted to get some
treatment, so I referred her to the GP.
The doctor’s view
I agree with the pharmacist’s opinion. The available evidence suggests
that there is no advantage in prescribing chloramphenicol eye drops
compared to placebo drops even in those who are subsequently shown
to have bacterial infections on laboratory testing. In other words, most
infections resolve spontaneously. In Ellie’s situation it would be important
to find out her mum’s ideas, concerns and expectations about
conjunctivitis and its management. She may be very insistent on a prescription
and many GPs would be persuaded by her wishes and issue
one, especially given the time pressures of a consultation. If possible,
time spent listening to her concerns and addressing them could avoid
a prescription and a rerun of this scenario in the future.
268 EYE AND EAR PROBLEMS
The parent’s view
I wasn’t happy with the pharmacist. I come here a lot for advice and
usually he’s really good. But this time he told me that the infection
would probably go away by itself without treatment. And in any case
he said he couldn’t sell me anything and I would have to take Ellie to
the doctor. I was worried that the infection might get worse or even
damage Ellie’s eyesight for the future. Anyway the doctor gave me some
eye ointment and the infection cleared up in a few days. I don’t see why
the pharmacist couldn’t have done the same.
EYE PROBLEMS: THE PAINFUL RED EYE 269
Common ear problems
Although the treatment of common ear problems is straightforward, it
does depend on accurate diagnosis and may require a prescription. It
is not always possible to determine the problem from the story. A key
issue for the pharmacist is the potential risk from not examining the
inside of the ear and seeing how the ear looks. Unless the pharmacist is
trained in clinical examination of the ear, diagnosis is best made by the
doctor, who can examine the ear with an auriscope or otoscope. Referral
to the doctor is therefore advisable for ear problems. Ear problems
that commonly present are described below.
What you need to know
Wax
Otitis externa
Otitis media
Glue ear
One or both ears affected?
Symptoms – pain, itching
Is there any hearing loss?
Significance of questions and answers
Wax
Symptoms
Wax blocking the ear is one of the commonest causes of temporary
deafness. It may also cause discomfort and a sensation that the ear is
blocked.
Management
Ear drops. The ear can be unblocked by using ear drops such as
olive oil and various proprietary drops containing urea and hydrogen
peroxide. A systematic review found that oil-based and water-based
preparations are equally effective at clearing ear wax and for softening
ear wax before syringing. The drops should be warmed before use
(ideally to body temperature).With the head inclined, five drops should
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
270 EYE AND EAR PROBLEMS
be instilled. A cotton-wool plug should be applied to retain the fluid
and be kept in for at least 1 h or overnight. This procedure should
be repeated at least twice a day for 3–5 days. The use of these drops
can worsen the deafness initially and appropriate warning should be
given. Cotton-wool buds should not be poked into the ear as wax is
just pushed further in and it is possible to damage the eardrum.
Syringing ears. If any wax remains despite this treatment, referral to
the doctor is advisable so that irrigation of the ear and possible syringing
can be considered. Syringing is now less frequently used than
it used to be. One of the problems of syringing can be to trigger an infection
(otitis externa, OE). The use of drops for 3–5 days to soften the
wax prior to syringing the ears is recommended to make the procedure
more effective.
Otitis externa
OE involves inflammation and infection of the skin in the ear canal
(meatus). One in ten people experience it at some time in their life. OE
may be localised or diffuse. In the former (due to a furuncle or boil),
the main symptom is ear pain and, in the latter, a combination of some
or all of pain, itching, hearing loss and discharge. Sometimes it is a site
of eczema, which may become secondarily infected.
OE can be precipitated by ear trauma (scratching, foreign bodies and
use of cotton buds), swimming (especially in polluted water), chemicals
(hairspray, hair dyes, shampoo and ceruminolytics), ear syringing and
skin conditions (eczema, seborrhoeic dermatitis and psoriasis). OE is
five times more common in swimmers than in non-swimmers. It is more
frequent in hot and humid environments and is 10 times more common
in summer than winter.
Symptoms
The symptoms of OE are usually pain and discharge. Referral to the
doctor may be necessary for accurate diagnosis. It is possible that the
same symptoms can arise from a middle ear infection (otitis media)
with a perforated eardrum. In such a situation, which usually involves
a child, the middle ear infection is likely to be associated with an upper
respiratory tract infection. As the middle ear infection develops, so does
the pain. It is often intense and remains so until the drum perforates
alleviating the pressure and pain and leading to a discharge.
Management
A good history is essential, including questions about any previous OE
and recent foreign travel (association with swimming pools). Patients
with OE should be referred to their local surgery, where they may be
seen by a GP or a nurse. Some surgeries have a policy of taking a swab to
COMMON EAR PROBLEMS 271
enable treatment with an antibiotic to which the responsible bacterium
is sensitive, rather than treating on a trial-and-error basis, which may
lengthen time to healing. Thorough cleansing of the external ear canal
is needed in many cases of OE. This is performed under direct vision
using microsuction or with a probe covered with cotton wool.
Acute localised otitis externa
Acute localised OE is caused by a boil in the outer third of the external
auditory meatus. If there is spreading cellulitis associated, then
systemic antibiotics should be started and flucloxacillin would be the
treatment of choice. Regular analgesics help and effective pain relief
can be achieved using paracetamol. This can be combined with codeine
when the pain is more severe, although the evidence of benefit is not
definitive. Applying heat by holding a hot flannel against the ear can
help to relieve pain.
Diffuse otitis externa
Approximately 90% of diffuse OE cases are bacterial. Pseudomonas
infections account for two-thirds and Staphylococcal are the next most
common. The remaining 10% of infections are fungal and Aspergillus
is the most common form. Topical treatments containing an antibiotic
alone or in combination with a corticosteroid are effective.
For people who are prone to recurrent OE, the following advice is
helpful:
 Try not to let soap or shampoo get into your ear canal. While having
a shower, you can do this by placing a piece of cotton wool coated in
soft white paraffin (e.g. Vaseline) in the outer ear.
 Silicone rubber earplugs may be helpful to keep the ears dry whilst
you swim.
 Do not use corners of towels or cotton buds to dry any water that
does get in the ear canal. This will push things further in. Let it dry
naturally.
 Try not to scratch or poke the ear canal with fingers, cotton wool
buds, towels, etc.
 Do not clean the ear canal with cotton buds. They may scratch and
irritate, and push wax or dirt further into the ear. The ear cleans itself,
and bits of wax will fall out now and then.
Otitis media
Otitis media is an infection of the middle ear compartment. The middle
ear lies between the outer ear canal and the inner ear. Between the outer
ear and the middle is the eardrum (tympanic membrane). The middle
ear is normally an air-containing compartment that is sealed from the
outside apart from a small tube (the Eustachian tube), which connects
272 EYE AND EAR PROBLEMS
to the back of the throat. Within the middle ear are tiny bones that
transmit the sound wave vibrations of the eardrum to the inner ear.
An infection typically starts with a common cold, especially in children,
which leads to blockage of the Eustachian tube and fluid formation
within the middle ear. The fluid can then be secondarily infected
by a bacterial infection.
Symptoms
The symptoms of otitis media are pain and temporary deafness. Sometimes
the infection takes off so quickly that the eardrum perforates,
releasing the infected fluid. When this occurs, a discharge will also be
present and be associated with considerable lessening of pain.
As with OE, referral is usually necessary so that the eardrum can
be examined. Treatment may involve a course of oral antibiotics (e.g.
amoxicillin (amoxycillin), penicillin or erythromycin). However, the
use of antibiotics is being increasingly questioned. It appears that many
cases of otitis media settle spontaneously and the effect of taking antibiotics
possibly provides some benefit in symptoms after the first 24 h
only when symptoms are already resolving. A meta-analysis of the research
done on the value of antibiotics shows the number needed to
successfully treat one patient is seven. In other words, six of every
seven children treated for otitis media do not need antibiotics or show
no response to them. Pharmacists can explain this to parents. Other
concerns with the use of antibiotics are increasing bacterial resistance
and adverse effects, such as diarrhoea, which occurs in about 10% of
cases. Research has shown that it is reasonable to delay starting antibiotics
for 72 h and starting only if symptoms persist at that time.
‘Delayed prescriptions’ are used where either the patient is given a
postdated prescription which is ‘cashed’ only if needed or the patient
can return to the surgery after a specified length of time to collect a
prescription if needed. Sometimes topical or oral decongestants are
used in addition to antibiotics. These can be useful if air travel is to
be undertaken after such an infection. If the Eustachian tube is still
blocked during a flight, pain can be experienced due to the change in
air pressure. Decongestants would make this less likely.
Glue ear
Some children who are subject to recurrent otitis media develop glue
ear. This occurs because the fluid that forms in the middle ear does
not drain out completely. The fluid becomes tenacious and sticky. One
method of dealing with this common problem is a minor operation in
which the fluid is sucked out through the eardrum. After this it is usual
to insert a small grommet into the hole in the drum. The grommet has
a small hole in the middle, which allows any further fluid forming to
drain from the middle ear. The grommet normally falls out within a
COMMON EAR PROBLEMS 273
few months and the small hole in the drum closes over. The long-term

برچسب ها: The GP’s view It would probably be best for Julie Parker to go back and see her GP who has already given her two courses of treatment and taken a swab. She needs to find out exactly what the GP has been treating her for، what the swab result is and to be able to explain to her GP what her current symptoms are. Metronidazole is often prescribed for bacterial vaginosis. It could be that she has also developed thrush especially as she has been taking amoxycillin. It is always important for patients to know how and when they can get their results. Often patients understandably assume that if they don’t hear from their doctors’ surgery، the result is negative or normal. This is potentially dangerous and it is always important for the person taking laboratory samples to explain clearly how and when the results will be available and agree this with their patient. In this situation it is also important for the prescriber to explain the need for the prescription that has been left out at the surgery. Case 2 Helen Simpson is a student at the local university. She asks one of your assistants for something to treat thrush and is referred to you. You walk with Helen to a quiet area of the shop where your conversation will not be overheard. Initially، Helen is resistant to your involvement، asking why you need to ask all these personal questions. After you have explained that you are required to obtain information before selling these products and that، in any case، you need to be sure that the problem is thrush and not a different infection،  

تاریخ : دوشنبه 25 اسفند 1393 | 11:54 ب.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th





Medication
Cystitis can be caused by cytotoxic drugs such as cyclophosphamide
and also by methenamine hippurate (hexamine) (because of formaldehyde
release). It has been claimed that the incidence of cystitis is higher
in women who are on the pill; however, no causative effect has ever
been shown. It has been suggested that since women taking the pill
are more likely to be sexually active, this may explain the difference in
incidence of cystitis.
When to refer
All men, children
Fever, nausea/vomiting
Loin pain or tenderness
Haematuria
Vaginal discharge
Duration of longer than 2 days
Pregnancy
Recurrent cystitis
Failed medication
The identity of any preparations already taken to treat the symptoms
is therefore important. The pharmacist may then decide whether
an appropriate remedy has been used. Failed medication would be a
reason for referral to the doctor.
Treatment timescale
If symptoms have not subsided within 2 days of beginning the treatment,
the patient should see her doctor.
Management
For pain relief, offer paracetamol or ibuprofen for up to 2 days. A high
temperature will also be reduced, bearing in mind that a level above
38.5◦C is more characteristic of pyelonephritis. The pharmacist can
also recommend a product that will alkalinise the urine and provide
symptomatic relief, although there is no good evidence of its effectiveness.
Other OTC preparations are of doubtful value. In addition
to treatment, it is important for the pharmacist to offer advice about
fluid intake (see ‘Practical points’ below). For women in whom cystitis
is a recurrent problem, self-help measures can sometimes prevent
recurrence. Literature can be offered on this subject.
CYSTITIS 227
Potassium and sodium citrate
Potassium and sodium citrate work by making the urine alkaline. The
acidic urine produced as a result of bacterial infection is thought to
be responsible for dysuria; alkalinisation of the urine can therefore
provide symptomatic relief. While easing discomfort, alkalinising the
urine will not produce an antibacterial effect, and it is important to
tell patients that if symptoms have not improved within 2 days, they
should see their doctor. Proprietary sachets are more palatable than
potassium citrate mixture.
Contraindications
There are some patients for whom such preparations should not be recommended.
For potassium citrate these would include anyone taking
potassium-sparing diuretics, aldosterone antagonists or angiotensinconverting
enzyme inhibitors, in whom hyperkalaemia may result.
Sodium citrate should not be recommended for hypertensive patients,
anyone with heart disease or pregnant women.
Advice
Potassium citrate mixture tastes unpleasant, despite its fruity lemon
smell, and patients should be advised to dilute the mixture well with
cold water.
Warning
Patients should be reminded not to exceed the stated dose of products
containing potassium citrate: several cases of hyperkalaemia have been
reported in patients taking potassium citrate mixture for relief from
urinary symptoms.
Complementary therapies
Cranberry juice has been recommended as a folk remedy for years as
a preventive measure to reduce UTI. A systematic review of evidence
showed that drinking cranberry juice on a regular basis (300 mL per
day) has a bacteriostatic effect. The mechanism for this is unknown and
the full clinical implications have not been elucidated. Cranberry juice
is unlikely to be effective in the treatment of acute cystitis. For women
who are prone to cystitis, drinking cranberry juice is not harmful and
might help.
Trimethoprim and nitrofurantoin
At the time of writing it has been proposed that trimethoprim and
nitrofurantoin should be deregulated from prescription-only medicine
control for the treatment of uncomplicated acute bacterial cystitis.
228 WOMEN’S HEALTH
Azithromycin and chlamydial infection
At the time of writing it has been proposed that the antibiotic
azithromycin should be deregulated from prescription-only medicine
control for the treatment of asymptomatic chlamydial infection following
a positive test result (nucleic acid amplification test, NAAT).
Two 500-mg tablets of azithromycin would be given as a single-dose
treatment. Symptomatic cases of Chlamydia would be referred since
they have an increased risk of complications. Some pharmacists already
supply azithromycin for chlamydial infection via a patient group
direction.
Practical points
1 There is little evidence to support much of the traditional advice
that has been given to women with cystitis, and the list below can be
discussed with the woman to consider acceptability.
(i) Drinking large quantities of fluids should theoretically help in cystitis
because the bladder is emptied more frequently and completely
as a result of the diuresis produced; this is thought to help flush the
infecting bacteria out of the bladder. However, this may cause more discomfort
where dysuria is severe and may be better as advice to prevent
recurrence rather than to use during treatment.
(ii) During urination the bladder should be emptied completely by
waiting for 20 s after passing urine and then straining to empty the
final drops. Leaning backwards is said to help to achieve a complete
emptying of the bladder than the usual sitting posture.
(iii) After a bowel motion wiping toilet paper from front to back
may minimise transfer of bacteria from the bowel into the vagina and
urethra.
(iv) Urination immediately after sexual intercourse will theoretically
flush out most bacteria from the urethra but there is no evidence to
support this.
2 There are several paperbacks published on the subject of cystitis,
including Angela Kilmartin’s The Cystitis Solution.
3 Reduced intake of coffee and alcohol may help because these substances
seem to act as bladder irritants in some people.
Cystitis in practice
Case 1
Mrs Anne Lawson, a young woman in her twenties, asks to have a
quiet word with you. She tells you that she thinks she has cystitis. On
questioning, you find that she is not passing urine more frequently
than normal, but that her urine looks dark and smells unpleasant. Mrs
Lawson has back pain and has been feeling feverish during today. She
CYSTITIS 229
is not taking any medicine from the doctor and has not tried anything
to treat her symptoms.
The pharmacist’s view
This woman has described symptoms that are not of a minor nature.
In particular, the presence of fever and back pain indicates an infection
higher in the urinary tract. Mrs Lawson should see her doctor as soon
as possible.
The doctor’s view
Referral is advisable. She may have a UTI, possibly in the kidney. However,
there is insufficient information to make a definite diagnosis. It
would be useful to know if she has pain on passing urine and the site
and nature of her back pain. Her symptoms could in fact be accounted
for by a flulike viral infection in which the backache is caused by muscular
inflammation and the urine altered because of dehydration. The
GP is likely to check the urine in the surgery with a multistix test and
also sends a sample (midstream specimen of urine) to the laboratory for
miscroscopy and culture. If the multistix test were positive for leucocytes
and nitrites, an urinary infection would be likely, and the patient
would be started on antibiotics awaiting laboratory confirmation of
the bacteria responsible. She may subsequently require further investigations
of her renal tract, e.g. an ultrasound of her kidneys and possibly
an intravenous urogram. Severe cases of kidney infection require emergency
hospital admission for intravenous antibiotics.
Case 2
A young man asks if you can recommend a good treatment for cystitis.
In response to your questions, he tells you that the medicine is
for him: he has been having pain when passing urine since yesterday.
He otherwise feels well and does not have any other symptoms. No
treatments have been tried already and he is not currently taking any
medicines.
The pharmacist’s view
This man should be referred to the doctor because the symptoms of
cystitis are uncommon in men and may be the result of a more serious
condition.
The doctor’s view
Referral is necessary for accurate diagnosis. A urine sample will need to
be collected for appropriate analysis. If it shows that he has a urinary
infection, then treatment with a suitable antibiotic can be given and
a referral to a specialist for further investigation made. The reason
for referral is that urinary infection is relatively uncommon in men
230 WOMEN’S HEALTH
compared to women and may be caused by some structural problem
within the urinary tract.
If in addition to discomfort on passing urine he develops a urethral
discharge, he is most likely to be suffering from a sexually transmitted
infection, such as Chlamydia (previously called non-specific urethritis)
or gonorrhoea. Chlamydia is the more prevalent of the two
and can be treated using azithromycin or doxycycline. Chlamydia can
be complicated by an infection around the testis which becomes very
painful swollen and red. It may also lead to reduced fertility. Another
complication of Chlamydia is the development of a reactive arthritis
(Reiters), which often affects the knees and feet often associated with
a conjunctivitis.
Case 3
It is Saturday afternoon and a young woman whom you do not recognise
as a regular customer asks for something to treat cystitis. On
questioning, you find out that she has had the problem several times
before and that her symptoms are frequency and pain on passing urine.
She is otherwise well and tells you that her doctor has occasionally prescribed
antibiotics to treat the problem in the past. She is not taking
any medicines.
The pharmacist’s view
This woman represents a common situation in community pharmacy.
She has had these symptoms before and is unlikely to be able to see her
doctor before Monday. Since only half of all cases of cystitis are caused
by an infection, antibiotic treatment without a urine culture is now discouraged.
She should see her doctor on Monday if the symptoms have
not improved and the pharmacist could suggest that she take a urine
sample with her, although in practice the GP may prescribe without test
results. In the meantime, she is experiencing considerable discomfort.
It would be reasonable to recommend the use of an alkalinising agent,
such as sodium or potassium citrate, over the weekend. Proprietary
formulations are more pleasant tasting than is the potassium citrate
mixture and they are very acceptable to patients. You could advise her
to drink plenty of fluids but with minimum consumption of tea, coffee
and alcohol, all of which may cause dehydration and make the problem
worse.
The doctor’s view
The story is suggestive of cystitis. Symptomatic treatment with potassium
citrate may help until after the weekend. It would be interesting
to know how her infections usually resolve. If her symptoms did not
ease with an alkalinising agent, she could be advised to speak to the
on-call general practitioner (GP). If she had severe symptoms, it would
CYSTITIS 231
be reasonable to start treatment with an antibiotic. If she brought a
urine sample, the GP could test it immediately with a multistix dip
test, which would determine the presence or not of protein, red blood
cells, leucocytes and nitrite. Positive results for the latter two would be
very suggestive of a bacterial infection. It would be important to check
whether she is pregnant or on the combined oral contraceptive pill
before prescribing antibiotics. Changing patterns of resistance mean
that first line antibiotics vary according to local protocols.
232 WOMEN’S HEALTH
Dysmenorrhoea
It has been estimated that as many as one in two women suffer from dysmenorrhoea
(period pains). Up to one in ten of those affected will have
severe symptoms, which necessitate time off school or work. Many of
these women will try self-medication, seeking advice from their doctor
only if this treatment is unsuccessful. Pharmacists should remain
aware that discussing menstrual problems is potentially embarrassing
for the patient and should therefore try to create an atmosphere of
privacy.
What you need to know
Age
Previous history
Regularity and timing of cycle
Timing and nature of pains
Relationship with menstruation
Other symptoms
Headache, backache
Nausea, vomiting, constipation
Faintness, dizziness, fatigue
Premenstrual syndrome (PMS)
Medication
Significance of questions and answers
Age
The peak incidence of primary dysmenorrhoea occurs in women between
the ages of 17 and 25 years. Primary dysmenorrhoea is defined
as pain in the absence of pelvic disease, whereas secondary dysmenorrhoea
refers to pain, which may be due to underlying disease. Secondary
dysmenorrhoea is most common in women aged over 30 years and is
rare in women aged under 25 years. Common causes of secondary dysmenorrhoea
include endometriosis or PID. Primary dysmenorrhoea is
uncommon after having children.
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
DYSMENORRHOEA 233
Previous history
Dysmenorrhoea is often not associated with the start of menstruation
(menarche). This is because during the early months (and sometimes
years) of menstruation, ovulation does not occur. These anovulatory
cycles are usually, but not always, pain free and therefore women sometimes
describe period pain that begins after several months or years
of pain-free menstruation. The pharmacist should establish whether
the menstrual cycle is regular and the length of the cycle. Further
questioning should then focus on the timing of pains in relation to
menstruation.
Timing and nature of pains
Primary dysmenorrhoea
Primary dysmenorrhoea classically presents as a cramping lower abdominal
pain that often begins during the day before bleeding starts.
The pain gradually eases after the start of menstruation and is often
gone by the end of the first day of bleeding.
Mittelschmerz. Mittelschmerz is ovulation pain which occurs midcycle,
at the time of ovulation. The abdominal pain usually lasts for a
few hours, but can last for several days and may be accompanied by
some bleeding.
Secondary dysmenorrhoea
The pain of secondary or acquired dysmenorrhoea may occur during
other parts of the menstrual cycle and can be relieved or worsened by
menstruation. Such pain is often described as a dull, aching pain rather
than being spasmodic or cramping in nature. Often occurring up to 1
week before menstruation, the pain may get worse once bleeding starts.
The pain may occur during sexual intercourse. Secondary dysmenorrhoea
is more common in older women, especially in those who have
had children. In pelvic infection, a vaginal discharge may be present
in addition to pain. If, from questioning, the pharmacist suspects secondary
dysmenorrhoea, the patient should be referred to her doctor
for further investigation.
Endometriosis. Endometriosis mainly occurs in women aged between
30 and 45 years, but can occur in women in their twenties. The
womb (uterus) has a unique inner lining surface (endometrium). In
endometriosis, pieces of endometrium are also found in places outside
the uterus. These isolated pieces of endometrium may lie on the
outside of the uterus or ovaries, or elsewhere in the pelvis. Each section
of endometrium is sensitive to hormonal changes occurring during
the menstrual cycle and goes through the monthly changes of thickening,
shedding and bleeding. This causes pain wherever the endometrial
234 WOMEN’S HEALTH
cells are found. The pain usually begins up to 1 week before menstruation
and both lower abdominal and lower back pain may occur. The
pain may also be non-cyclical and may occur with sexual intercourse
(dyspareunia). Endometriosis may cause subfertility. Diagnosis can be
confirmed by laparoscopy.
Pelvic inflammatory disease. Pelvic infection can occur and may be
acute or chronic in nature. It is important to know whether or not
an intrauterine contraceptive device (coil) is used. The coil can cause
increased discomfort and heavier periods, but also may predispose to
infection. Acute pelvic infection occurs when a bacterial infection develops
within the fallopian tubes. There is usually severe pain, fever
and vaginal discharge. The pain is in the lower abdomen and may be
unrelated to menstruation. It may be confused with appendicitis.
Chronic PID may follow on from an acute infection. The pain tends
to be less severe, associated with periods and may be experienced during
intercourse. It is thought that adhesions that develop around the
tubes following an infection may be responsible for the symptoms in
some women. In others, however, no abnormality can be found and
pelvic congestion is assumed to be the cause. In this situation psychological
factors are thought to be important.
Other symptoms
Women who experience dysmenorrhoea will often describe other associated
symptoms. These include nausea, vomiting, general GI discomfort,
constipation, headache, backache, fatigue, feeling faint and
dizziness.
Premenstrual syndrome
The term premenstrual syndrome (PMS) describes a collection of symptoms,
both physical and mental, whose incidence is related to the menstrual
cycle. Symptoms are experienced cyclically, usually from 2 to
14 days before the start of menstruation. Relief from symptoms generally
occurs once menstrual bleeding begins. The cyclical nature, timing
and reduction in symptoms are all important in identifying PMS. Some
women experience such severe symptoms that their working and home
lives are affected.
Sufferers often complain of a bloated abdomen, increase in weight,
swelling of ankles and fingers, breast tenderness and headaches.
Women who experience PMS describe a variety of mental symptoms
that may include any or all of irritability, tension, depression, difficulty
in concentrating and tiredness.
If PMS is considered to be a possibility, advising the woman to keep
a diary of symptoms recording when they occur and remit is useful,
especially if the pharmacist later decides referral is needed.
DYSMENORRHOEA 235
Treatment of the symptoms of PMS is a matter for debate and there
is a high placebo response to therapy of mood changes, breast discomfort
and headaches when taken from 2 weeks before the period starts
or throughout the cycle. There is some evidence that pyridoxine may
reduce symptoms but the quality of clinical trials was poor and the
evidence thus not definitive. The mechanism of action of pyridoxine in
PMS is unknown. However, women should be advised to stick to the
recommended dose; higher doses of pyridoxine are reported to have led
to neuropathy. The British National Formulary states that ‘prolonged
use of pyridoxine in a dose of 10 mg daily is considered safe but the
long-term use of pyridoxine in a dose of 200 mg or more daily has been
associated with neuropathy. The safety of long-term pyridoxine supplementation
with doses above 10 mg daily has not been established’.
The Royal Pharmaceutical Society of Great Britain (RPSGB) has advised
that pharmacists should consider how to advise customers requesting
preparations containing higher doses and that they should
decide their own policy on the display of products containing more
than 10 mg per daily dose of pyridoxine. The practical effect of this
advice is that pharmacists are likely to ask their customers about the
dose of pyridoxine they are planning to take.
Evening primrose oil has been used to treat breast tenderness associated
with PMS. However, there are no good-quality trials to support its
use and therefore is of unknown effectiveness. The mechanism of action
of evening primrose oil in such cases is thought to be linked to effects
on prostaglandins, particularly in increasing the level of prostaglandin
E, which appears to be depleted in some women with PMS. The active
component of evening primrose oil is gamma-linolenic (gamolenic)
acid, which is thought to reduce the ratio of saturated to unsaturated
fatty acids. The response to hormones and prolactin appears to be
reduced by gamma-linolenic acid.
Medication
The pain of dysmenorrhoea is thought to be linked to increased
prostaglandin activity, and raised prostaglandin levels have been found
in the menstrual fluids and circulating blood of women who suffer from
dysmenorrhoea. Therefore, the use of analgesics that inhibit the synthesis
of prostaglandins is logical. It is important, however, for the
pharmacist to make sure that the patient is not already taking an nonsteroidal
anti-inflammatory drug (NSAID).
Women taking oral contraceptives usually find that the symptoms
of dysmenorrhoea are reduced or eliminated altogether and so any
woman presenting with the symptoms of dysmenorrhoea and who is
taking the pill is probably best referred to the doctor for further investigation.
236 WOMEN’S HEALTH
When to refer
Presence of abnormal vaginal discharge
Abnormal bleeding
Symptoms suggest secondary dysmenorrhoea
Severe intermenstrual pain (mittelschmerz) and bleeding
Failure of medication
Pain with a late period (possibility of an ectopic pregnancy)
Presence of fever
Treatment timescale
If the pain of primary dysmenorrhoea is not improved after two cycles
of treatment, referral to the doctor would be advisable.
Management
Simple explanation about why period pains occur, together with sympathy
and reassurance, is important. Treatment with simple analgesics
is often very effective in dysmenorrhoea.
NSAIDs (Ibuprofen, diclofenac and naproxen) (see also p. 198)
NSAIDs can be considered the treatment of choice for dysmenorrhoea,
provided they are appropriate for the patient (i.e. the pharmacist has
questioned the patient about previous use of aspirin, and history of GI
problems and asthma). NSAIDs inhibits the synthesis of prostaglandins
and thus have a rationale for use. Most trials have studied the use
of NSAIDs at the onset of pain. One small study compared treatment
started premenstrually against treatment from onset of pain:
both strategies were equally effective. Sustained-release formulations
of ibuprofen are also available.
Doses for ibuprofen and diclofenac are on p. 198. Naproxen 250mg
tablets can be used by women aged between 15 and 50 years for primary
dysmenorrhoea only. Two tablets are taken initially then one
tablet 6–8 hours later if needed. Maximum daily dose is 750mg and
maximum treatment time is 3 days.
Contraindications
Care should be taken when recommending NSAIDs which can cause
GI irritation and should not be taken by anyone who has or has had
a peptic ulcer. All patients should take NSAIDs with or after food to
minimise GI problems (see also p. 198).
NSAIDs should not be taken by anyone who is sensitive to aspirin
and should be used with caution in anyone who is asthmatic, because
such patients are more likely to be sensitive to NSAIDs. The pharmacist
DYSMENORRHOEA 237
can check if a person with asthma has used a NSAID before. If they
have done so without problems, they can continue.
Aspirin
Aspirin also inhibits the synthesis of prostaglandins but is less effective
in relieving the symptoms of dysmenorrhoea than is ibuprofen. One
review found the number needed to treat was 10 for aspirin compared
with 2.4 for ibuprofen. Aspirin can cause GI upsets and is more irritant
to the stomach than NSAIDs. For those who experience symptoms
of nausea and vomiting with dysmenorrhoea, aspirin is probably best
avoided. Soluble forms of aspirin will work more quickly than traditional
tablet formulations and are less likely to cause stomach problems.
Patients should be advised to take aspirin with or after meals.
The pharmacist should establish whether the patient has any history
of aspirin sensitivity before recommending the drug.
Paracetamol
Paracetamol has little or no effect on the levels of prostaglandins involved
in pain and inflammation and so it is theoretically less effective
for the treatment of dysmenorrhoea than either NSAIDs or aspirin.
However, paracetamol is a useful treatment when the patient cannot
take NSAIDs or aspirin because of stomach problems or potential sensitivity.
Paracetamol is also useful when the patient is suffering with
nausea and vomiting as well as pain, since it does not irritate the stomach.
The pharmacist should remember to stress the maximum dose that
can be taken.
Hyoscine
Hyoscine, a smooth muscle relaxant, is marketed for the treatment of
dysmenorrhoea on the theoretical basis that the antispasmodic action
will reduce cramping. In fact, the dose is so low (0.1-mg hyoscine)
that such an effect is unlikely. The anticholinergic effects of hyoscine
mean that it is contraindicated in women with closed-angle glaucoma.
Additive anticholinergic effects (dry mouth, constipation and blurred
vision) mean that hyoscine is best avoided if any other drug with anticholinergic
effects (e.g. tricyclic antidepressants) is being taken.
Caffeine
There is some evidence (from a trial comparing combined ibuprofen
and caffeine with ibuprofen alone and caffeine alone) that caffeine may
enhance analgesic effect. OTC products contain 15–65 mg of caffeine
per tablet. A similar effect could be achieved through drinking tea,
238 WOMEN’S HEALTH
coffee or cola. A cup of instant coffee usually contains about 80-mg
caffeine, a cup of freshly brewed coffee about 130 mg, a cup of tea 50
mg and a can of cola drink about 40–60 mg.
Non-drug treatments
High-frequency transcutaneous electrical nerve stimulation (TENS)
may be of benefit. It seems to work by altering the body’s ability to
receive or perceive pain signals. High-frequency TENS has pulses of
50–120 Hz at low intensity and, when compared with placebo in seven
small randomised controlled trials, was found to be effective for pain
relief in primary dysmenorrhoea. Low-frequency TENS is also available
and has pulses of 1–4 Hz delivered at high intensity. Although
low-frequency TENS was better than placebo, the evidence is less convincing
than for high frequency.
Acupuncture may be helpful and was found in a small, but welldesigned,
study to be more effective than its placebo equivalent (sham
acupuncture, where the needles are positioned away from the ‘real’
acupuncture sites). The treatments were given once a week for 3 weeks
per month over a 3-month period. Women receiving ‘real’ acupuncture
gained significant pain relief. While further research is needed to
confirm this effect, some women may want to try it.
Locally applied low-level heat may also help pain relief. Results from
one study showed that the time to noticeable pain relief was significantly
reduced when ibuprofen was combined with locally applied
heat, as compared with ibuprofen alone.
Fish oil (omega-3 fatty acids) compared with placebo in one study
showed the use of additional pain relief to be significantly lower in the
treatment group. There were significantly more adverse effects in the
women treated with fish oil, but these were not serious.
Pyridoxine alone and combined with magnesium showed some benefit
in reducing pain, compared with placebo.
Practical points
1 Exercise during menstruation is not harmful, as some ‘old wives
tales’ would have people believe. In fact, exercise may well be beneficial,
since it raises endorphin levels, reducing pain and promoting a feeling
of well-being. There is some evidence that moderate aerobic exercise
can improve symptoms of premenstrual syndrome.
2 There is some evidence that a low-fat, high-carbohydrate diet reduces
breast pain and tenderness.
3 NHS Clinical Knowledge Service gives the following advice to
women taking analgesics for dysmenorrhoea:
(i) Take the first dose as soon as your pain begins or as soon as the
bleeding starts, whichever comes first. Some doctors advise to start
DYSMENORRHOEA 239
taking the tablets on the day before your period is due. This may prevent
the pain from building up.
(ii) Take the tablets regularly, for 2–3 days each period, rather than
‘now and then’ when pain builds up.
(iii) Take a strong enough dose. If your pains are not eased, ask your
doctor or pharmacist whether the dose that you are taking is the maximum
allowed. An increase in dose may be all that you need.
(iv) Side-effects are uncommon if you take an anti-inflammatory for
just a few days at a time, during each period. (But read the leaflet that
comes with the tablets for a full list of possible side-effects.)
Dysmenorrhoea in practice
Case 1
Linda Bailey is a young woman aged about 26 years, who asks your
advice about painful periods. From your questioning, you find that
Linda has lower abdominal pain and sometimes backache, which starts
several days before her period begins. Her menstrual cycle used to be
very regular, but now tends to vary; sometimes she has only 3 weeks
between periods. The pain continues throughout menstruation and is
quite severe. She has tried taking aspirin, which did not have much
effect.
The pharmacist’s view
This woman sounds as though she is experiencing secondary dysmenorrhoea.
The pain begins well before her period starts and continues
during menstruation. Her periods, which used to be regular, are no
longer so and she has tried aspirin which has not relieved the pain. She
should be referred to her doctor.
The doctor’s view
Referral does seem appropriate in this situation. Further information
needs to be gathered from history taking (how long overall has she
experienced pain and what it is like, effect on her life, any pregnancies,
does she use contraception, any history of pelvic infection, her concerns
and ideas about her problem, the sort of help is she expecting,
etc.), examination and preliminary investigations. It is quite possible
that the patient has endometriosis and referral to a gynaecologist may
be indicated. The diagnosis of endometriosis can be confirmed by a
laparoscopy. The range of treatment options includes other NSAIDs,
hormone treatments and surgery. The hormonal treatments that can
be used are progestogens, antiprogestogens, combined oral contraceptives
and gonadotrophin-releasing hormone analogues (GnRH).
GnRH preparations such as goserelin work by suppressing the hormones
to create an artificial menopause. They can be used for up to
240 WOMEN’S HEALTH
6 months (not to be repeated) and may have to be used with hormone
replacement therapy to offset menopausal-like symptoms.
Case 2
Jenny Simmonds is a young woman aged about 18 years who looks
rather embarrassed and asks you what would be the best thing for
period pains. Jenny tells you that she started her periods about 5 years
ago and has never had any problem with period pains until recently.
Her periods are regular – every 4 weeks. They have not become heavier,
but she now gets pain, which starts a few hours before her period. The
pain has usually gone by the end of the first day of menstruation and
Jenny has never had any pain during other parts of the cycle. She says
she has not tried any medicine yet, is not taking any medicines from
the doctor and can normally take aspirin without any problems.
The pharmacist’s view
From the results of questioning it sounds as though Jenny is suffering
from straightforward primary dysmenorrhoea. She could be advised to
take a NSAID. She could be recommended to follow this regimen for
2 months and invited back to see if the treatment has worked.
The doctor’s view
Jenny’s pain is most likely due to primary dysmenorrhoea. An explanation
of this fact would probably be very reassuring. The treatment
recommended by the pharmacist is sensible. If her pain was not helped
by a NSAID, she could be advised to discuss further management with
her GP. Sometimes the combined oral contraceptive pill can be helpful
in reducing painful periods.
DYSMENORRHOEA 241
Vaginal thrush
Women often seek to buy products for feminine itching and may be embarrassed
to seek advice or answer what they see as intrusive questions
from the pharmacist. Vaginal pessaries, intravaginal creams containing
imidazole antifungals and oral fluconazole are effective treatments. Before
making any recommendation it is vital to question the patient to
identify the probable cause of the symptoms. Advertising of these treatments
direct to the public means that a request for a named product
may be made. It is important to confirm its appropriateness.
What you need to know
Age
Child, adult, elderly
Duration
Symptoms
Itch
Soreness
Discharge (colour, consistency, odour)
Dysuria
Dyspareunia
Threadworms
Previous history
Medication
Significance of questions and answers
Age
Vaginal candidiasis (thrush) is common in women of childbearing age,
and pregnancy and diabetes are strong predisposing factors. This infection
is rare in children and in postmenopausal women because of the
different environment in the vagina. In contrast to women of childbearing
age, where vaginal pH is generally acidic (low pH) and contains
glycogen, the vaginal environment of children and menopausal women
tends to be alkaline (high pH) and does not contain large amounts of
glycogen.
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
242 WOMEN’S HEALTH
Oestrogen, present between adolescence and the menopause, leads
to the availability of glycogen in the vagina and also contributes to the
development of a protective barrier layer on the walls of the vagina. The
lack of oestrogen in children and postmenopausal women means this
protective barrier is not present, with a consequent increased tendency
to bacterial (but not fungal) infection.
In the UK, the Committee on Safety of Medicines (CSM) recommends
that women under 16 or over 60 years complaining of symptoms
of vaginal thrush should be referred to their doctor. Child abuse may
be the source of vaginal infection in girls, making referral even more
important. Vaginal thrush is rare in older women and other causes of
the symptoms need to be excluded.
Duration
Some women delay seeking advice from the pharmacist or doctor because
of embarrassment about their symptoms. They may have tried
an OTC product or a prescription medicine already (see ‘Medication’
below).
Symptoms
Itch (pruritus)
Dermatitis. Allergic or irritant dermatitis may be responsible for vaginal
itch. It is worth asking whether the patient has recently used any
new toiletries (e.g. soaps, bath or shower products). Vaginal deodorants
are sometimes the source of allergic reactions. Women sometimes
use harsh soaps, antiseptics and vaginal douches in overenthusiastic
cleansing of the vagina. Regular washing with warm water is all that
is required to keep the vagina clean and maintain a healthy vaginal
environment.
Candidiasis (thrush). The itch associated with thrush is often intense
and burning in nature. Sometimes the skin may be excoriated and raw
from scratching when the itch is severe.
Discharge
In women of childbearing age, the vagina naturally produces a watery
discharge and cervical mucus is also produced, which changes consistency
at particular times of the menstrual cycle. Such fluids may
be watery or slightly thicker, with no associated odour. Some women
worry about these natural secretions and think they have an infection.
The most common infective cause of vaginal discharge is candidiasis.
Vaginal candidiasis may be (but is not always) associated with a
discharge. The discharge is classically cream-coloured, thick and curdy
in appearance but, alternatively, may be thin and rather watery. Other
vaginal infections may be responsible for producing discharge but are
VAGINAL THRUSH 243
markedly different from that caused by thrush. The discharge associated
with candidal infection does not usually produce an unpleasant
odour, in contrast to that produced by bacterial infection. Infection
leading to discharge described as yellow or greenish is more likely to be
bacterial in origin, e.g. bacterial vaginosis, chlamydia or gonorrhoea.
Partner’s symptoms
Men may be infected with Candida without showing any symptoms.
Typical symptoms for men are an irritating rash on the penis, particularly
on the glans.
Dysuria (pain on urination)
Dysuria may be present and scratching the skin in response to itching
might be responsible, although dysuria may occur without scratching.
Sometimes the pain on passing urine may be mistaken for cystitis by the
patient. If a woman complains of cystitis, it is important to ask about
other symptoms (see p. 225). The Commission on Human Medicines
(CHM) advises that lower abdominal pain or dysuria are indications
for referral because of their possible link with kidney infections.
Dyspareunia (painful intercourse)
Painful intercourse may be associated with infection or a sensitivity
reaction where the vulval and vaginal areas are involved.
Threadworms
Occasionally, threadworm infestation can lead to vaginal pruritus and
this has sometimes occurred in children. The patient would also be
experiencing anal itching in such a case. The pharmacist should refer
girls under the age of 16 years to the doctor in any case of vaginal
symptoms.
Previous history
Recurrent thrush is a problem for some women, often following antibiotic
treatment (see below). Recurrent infections are defined as ‘four
or more episodes of symptomatic candidosis annually’. The CSM advice
is that any woman who has experienced more than two attacks
of thrush during the previous 6 months should be referred to the doctor.
Repeated thrush infections may indicate an underlying problem or
altered immunity and further investigation is needed.
Pregnancy
During pregnancy almost one in five women will have an episode of
vaginal candidiasis. This high incidence has been attributed to hormonal
changes with a consequent alteration in the vaginal environment
244 WOMEN’S HEALTH
leading to the presence of increased quantities of glycogen. Any pregnant
woman with thrush should be referred to the doctor.
Diabetes
It is thought that Candida is able to grow more easily in diabetic patients
because of the higher glucose levels in blood and tissues. Sometimes
recurrent vaginal thrush can be a sign of undiagnosed diabetes
or, in a patient who has been diagnosed, of poor diabetic control.
Sexually transmitted diseases
In the UK, the CHM insists that women who have previously had a
sexually transmitted infection should not be sold OTC treatments for
thrush. The thinking behind this ruling is that with a previous history
of sexually transmitted disease (STD), the current condition may not
be thrush or may include a dual infection with another organism.
Pharmacists may be concerned about how patients will respond to
personal questions. However, it should be possible to enquire about
previous episodes of these or similar symptoms in a tactful way, e.g.
by asking ‘have you ever had anything like this before?’ and if ‘yes’,
‘tell me about the symptoms.Were they exactly the same as this time?’
and about the partner, ‘has your partner mentioned any symptoms
recently?’
Oral steroids
Patients taking oral steroids may be at increased risk of candidal infection.
Immunocompromised patients
Patients with HIV or AIDS are prone to recurrent thrush infection
because the immune system is unable to combat them. Patients undergoing
cancer chemotherapy are also at risk of infection.
Medication
Oral contraceptives
It has been suggested that the oral contraceptive pill (OCP) is linked to
the incidence of vaginal candidiasis; however, oral contraceptives are
no longer considered a significant precipitating factor.
Antibiotics
Broad-spectrum antibiotics wipe out the natural bacterial flora (lactobacilli)
in the vagina and can predispose to candidal overgrowth. Some
women find that an episode of thrush follows every course of antibiotics
they take. The doctor may prescribe an antifungal at the same
time as the antibiotic in such cases.
VAGINAL THRUSH 245
Local anaesthetics
Vaginal pruritus may actually be caused by some of the products used
to relieve the symptom. Creams and ointments advertised for ‘feminine’
itching often contain local anaesthetics – a well-known cause of
sensitivity reactions. It is important to check what, if any, treatment
the patient has tried before seeking your advice.
When to refer
The UK Committee on Safety of Medicines list
First occurrence of symptoms
Known hypersensitivity to imidazoles or other vaginal antifungal products
Pregnancy or suspected pregnancy
More than two attacks in the previous 6 months
Previous history of STD
Exposure to partner with STD
Patient under 16 or over 60 years
Abnormal or irregular vaginal bleeding
Any blood staining of vaginal discharge
Vulval or vaginal sores, ulcers or blisters
Associated lower abdominal pain or dysuria
Adverse effects (redness, irritation or swelling associated with treatment)
No improvement within 7 days of treatment
Management
Single-dose intravaginal and oral azole preparations are effective in
treating vaginal candidiasis and give 80–95% clinical and mycological
cure rates. A Cochrane review found them to be equally effective. Topical
preparations give quicker initial relief, probably due to the vehicle.
They may sometimes exacerbate burning sensations initially, and oral
treatment may be preferred if the vulva is very inflamed. Oral therapies
are effective, but it may be 12–24 h before symptoms improve. Some
women find oral treatment more convenient. Patients find single-dose
products very convenient and compliance is higher than with treatments
involving several days’ use. The patient can be asked whether
she prefers a pessary, vaginal cream or oral formulation. Some experts
argue that oral antifungals should be reserved for resistant cases.
Pharmacists will use their professional judgement together with patient
preference in making the decision on treatment.
The pharmacist should make sure that the patient knows how to
use the product. An effective way to do this is to show the patient the
manufacturer’s leaflet instructions. Where external symptoms are also
246 WOMEN’S HEALTH
a problem, an azole cream (miconazole or clotrimazole) can be useful
in addition to the intravaginal or oral product. The cream should be
applied twice daily, morning and night.
The azoles can cause sensitivity reactions but these seem to be
rare. Oral fluconazole interacts with some drugs: anticoagulants, oral
sulphonylureas, ciclosporin (cyclosporin), phenytoin, rifampicin and
theophylline.
The effects of single-dose fluconazole rather than continuous therapy
with the drug in relation to interactions are not clear. Theoretically,
single-dose use is unlikely to cause problems but in a small study of
women taking warfarin the prothrombin time was increased.
Reported side-effects from oral fluconazole occur in some 10% of
patients and are usually mild and transient. They include nausea, abdominal
discomfort, flatulence and diarrhoea. Oral fluconazole should
not be recommended during pregnancy or for nursing mothers because
it is excreted in breast milk.
Practical points
Privacy
Patients seeking advice about vaginal symptoms may be embarrassed,
fearing that their conversation with the pharmacist will be overheard. It
is therefore important to try and ensure privacy. Requests for a named
product may be an attempt to avoid discussion. However, a careful
response is needed to ensure that the product is appropriate.
Treatment of partner
Men may be infected with Candida without showing any symptoms.
Typical symptoms for men are an irritating rash on the penis, particularly
on the glans. While expert opinion is that male partners without
symptoms should not be treated, this remains an area of debate. Symptomatic
males with candidal balanitis (penile thrush) and whose female
partner has vaginal thrush should be treated. An azole cream can be
used twice daily on the glans of the penis, applied under the foreskin
for 6 days. Oral fluconazole can also be used.
‘Live’ yoghurt
Live yoghurt contains lactobacilli, which are said to alter the vaginal
environment, making it more difficult for Candida to grow. It has been
suggested that women prone to thrush should regularly eat live yoghurt
to increase the level of lactobacilli in the gut. However, data are inconclusive
as to the effectiveness of Lactobacillus-containing yoghurt,
administered either orally or vaginally, in either treating or preventing
thrush. Direct application of live yoghurt onto the vulval skin and
into the vagina on a tampon has been recommended as a treatment for
VAGINAL THRUSH 247
thrush. This process is messy and some women have reported stinging
on application, which is not surprising if the skin is excoriated
and sore. It is otherwise harmless, although evidence of effectiveness is
lacking.
Prevention
Thrush thrives in a warm environment. Women who are prone to attacks
of thrush may find that avoiding nylon underwear and tights and
using cotton underwear instead may help to prevent future attacks.
The protective lining of the vagina is stripped away by foam baths,
soaps and douches and these are best avoided. Vaginal deodorants
can themselves cause allergic reactions and should not be used. If the
patient wants to use a soap or cleanser, an unperfumed, mild variety is
best.
Since Candida can be transferred from the bowel when wiping the
anus after a bowel movement, wiping from front to back should help
to prevent this.
Vaginal thrush in practice
Case 1
Julie Parker telephones your pharmacy to ask for advice because she
thinks she might have thrush. She tells you she didn’t want to come
to the pharmacy as she was concerned that the conversation might be
overheard. When you ask why she thinks she may have thrush, she tells
you that she was recently prescribed a week’s course of metronidazole.
She had her first baby about 6 months ago and has had some skin
irritation following an episiotomy. When she went back to the GP
after taking the metronidazole, she was prescribed a second course
of metronidazole plus a course of amoxicillin for 1 week and a swab
was taken. She didn’t hear anything further for about 2 weeks until
the surgery rang her and asked if she had been told the results of the
swab (she hadn’t). She was asked to go and collect a prescription from
the surgery. She hasn’t brought it in yet to be dispensed but it is for a
pessary.
The pharmacist’s view
This sort of query is difficult to deal with because the pharmacist does
not have access to diagnosis or test results. It sounds as though there
may have been a communication problem initially and a delay in the
test results being dealt with. I would ask what the name of the pessary
on the prescription is and then explain what it’s used for. I would
explain that thrush sometimes happens after a

برچسب ها: Medication Cystitis can be caused by cytotoxic drugs such as cyclophosphamide and also by methenamine hippurate (hexamine) (because of formaldehyde release). It has been claimed that the incidence of cystitis is higher in women who are on the pill; however، no causative effect has ever been shown. It has been suggested that since women taking the pill are more likely to be sexually active، this may explain the difference in incidence of cystitis. When to refer All men، children Fever، nausea/vomiting Loin pain or tenderness Haematuria Vaginal discharge Duration of longer than 2 days Pregnancy Recurrent cystitis Failed medication The identity of any preparations already taken to treat the symptoms is therefore important. The pharmacist may then decide whether an appropriate remedy has been used. Failed medication would be a reason for referral to the doctor. Treatment timescale If symptoms have not subsided within 2 days of beginning the treatment، the patient should see her doctor. Management For pain relief، offer paracetamol or ibuprofen for up to 2 days. A high temperature will also be reduced،  

تاریخ : دوشنبه 25 اسفند 1393 | 11:53 ب.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th





Dihydrocodeine
Dihydrocodeine is related to codeine and has similar analgesic efficacy.
A combination product containing paracetamol and dihydrocodeine
is available with a dose per tablet of 7.46-mg dihydrocodeine. The
product is restricted to use in adults and children over 12 years. Sideeffects
include constipation and drowsiness. Like codeine, the drug may
cause respiratory depression at high doses.
Caffeine
Caffeine is included in some combination analgesic products to produce
wakefulness and increased mental activity. It is probable that
doses of at least 100 mg are needed to produce such an effect and
that OTC analgesics contain 30–50 mg per tablet. A cup of tea or
coffee would have the same action. Products containing caffeine are
best avoided near bedtime because of their stimulant effect. It has been
claimed that caffeine increases the effectiveness of analgesics but the
evidence for such claims is not definitive. Caffeine has an irritant effect
on the stomach.
Doxylamine succinate
Doxylamine is an antihistamine whose sedative and relaxing effects are
probably responsible for its usefulness in treating tension headaches.
Like other older antihistamines, doxylamine can cause drowsiness and
patients should be warned about this. Doxylamine should not be recommended
for children under 12 years.
Buclizine
Buclizine is an antihistamine and is included in an OTC compound
analgesic for migraine because of its antiemetic action.
Sumatriptan
Sumatriptan 50-mg tablets can be usedOTCfor acute relief of migraine
with or without aura and where there is a ‘clear diagnosis of migraine’.
It can be used by people aged between 18 and 65 years. A 50-mg tablet
is taken as soon as possible after the migraine headache starts. A second
dose can be taken at least 2 h after the first if symptoms come back.
A second dose should be taken only if the headache responded to the
first dose.
Practice guidance from Royal Pharmaceutical Society of Great
Britain (RPSGB) suggests that if the patient has previously received
sumatriptan on prescription and the pharmacy holds their patient medication
record, then OTC supplies can be made, provided there has
been no change in the condition. If the person has not used sumatriptan
before, the pharmacist needs to determine their suitability for the
treatment. They must have an established pattern of migraine and the
HEADACHE 201
pharmacist needs to identify any other symptoms or relevant medical
conditions as well as any medication.
The following patients should be referred for medical assessment:
 Those aged under 18 years or over 65 years
 Those aged 50 years or over and experiencing migraine attacks for
the first time. If a doctor confirms a diagnosis of migraine they can be
considered for OTC sumatriptan
 Patients who had their first ever migraine attack within the previous
12 months
 Patients who have had fewer than five migraine attacks in the past
 Patients who experience four or more attacks per month. The patient
is potentially suitable for OTC sumatriptan but should be referred to
a doctor for further evaluation and management
 If migraine headache lasts for longer than 24 h. The patient is potentially
suitable for OTC sumatriptan but should be referred to a doctor
for further evaluation and management
 Patients who do not respond to treatment
 Patients who have a headache (of any type) on 10 or more days per
month
 Women with migraine who take the combined oral contraceptive
pill have an increased risk of stroke, so should be referred if the onset
of migraine is within the previous 3 months, if migraine attacks are
worsening or if they have a migraine with aura
 Patients who do not recover fully between attacks
 Pregnant or breastfeeding migraine sufferers
 Patients with three or more cardiovascular risk factors.
(Source: Practice Guidance – OTC Sumatriptan. RPSGB, 2006.)
Cautions
People with three or more of the following cardiovascular risk factors
are not suitable for OTC sumatriptan: men aged over 40 years;
post-menopausal women; hypercholesterolaemia; regular smoker (10
or more daily); obesity – body mass index more than 30 kg/m2; diabetes;
family history of early heart disease – either father or brother
had a heart attack or angina before the age of 55 years or mother or
sister had a heart attack or angina before the age of 65 years.
Contraindications
Sumatriptan must not be used prophylactically. It should not be used
in people with known hypertension, a previous myocardial infarction,
ischaemic heart disease, peripheral vascular disease, coronary
vasospasm/Prinzmetal’s angina, cardiac arrhythmias (includingWolff–
Parkinson–White syndrome), hepatic or renal impairment, epilepsy, a
202 PAINFUL CONDITIONS
history of seizures, a history of cerebrovascular accident or transient
ischaemic attack.
Adverse effects
Common adverse effects include nausea and vomiting, disturbances
of sensation (including tingling), dizziness, drowsiness, flushing, warm
sensation, feeling of weakness and fatigue and feelings of heaviness,
pain or pressure in any part of the body.
Interactions
These include monoamine oxidase inhibitors (either current or within
the last 2 weeks), ergot and St John’s wort (may increase serotonin
levels). It has been suggested that an interaction between sumatriptan
and selective serotonin reuptake inhibitors or serotonin noradrenaline
reuptake inhibitors may occur, causing ‘serotonin syndrome’ and a
small number of cases have been reported in the USA.
Feverfew
Feverfew is a herb that has been used in the prophylaxis of migraine.
Some clinical trials have been conducted to examine its effectiveness,
but results have been conflicting. Adverse effects that have been reported
from the use of feverfew include mouth ulceration involving
the oral mucosa and tongue (which seems to occur in about 10% of
patients), abdominal colic, heartburn and skin rashes. These effects
occur both with feverfew leaves and when the herb is formulated in
capsules. The herb has a bitter taste, which some patients cannot tolerate.
Feverfew was used in the past as an abortifacient and it should
not be recommended for pregnant women with migraine.
Topical headache treatments
These have a cooling action and can be used in children over 12 years
and adults. They can be applied to the forehead, back of the neck and
temples.
Headaches in practice
Patient perspectives
I have suffered from migraine for about 14 years now. At the beginning
I didn’t get much advice or medical help, but since then I’ve actively
worked to find out what triggers my attacks. I have found that I have
to eat at regular intervals; skipping meals can often trigger an attack.
I need to drink at least 2 L of water a day and in the summer often
much more. Caffeine was a trigger for me and I have stopped drinking
coffee and tea now although I enjoy herbal teas. It is really worth
experimenting with these as you will find one to your taste, eventually!
HEADACHE 203
I cut various things (cheese, red wine) out of my diet for a while to
confirm if they were a problem. Other things that I know will set off
an attack are lack of sleep and strong perfume.
Most people, when hearing the word ‘migraine’ think of headache.
But people who get migraines know that these are not ordinary
headaches. The pain associated with migraine can be debilitating, even
disabling – but a lot of people, including healthcare professionals, still
don’t understand. Sometimes I wish people who think migraines are
just a bad headache would have a migraine themselves so they’d know
how mistaken they are. Just one migraine for every doctor and pharmacist
who will ever treat a migraine patient.
Case 1
For several years Sandra Brown, a young mother, has purchased combination
analgesics for migraine from your pharmacy every few months.
She has suffered from migraine headaches since she was a child. Today
she asks if you have anything stronger; the tablets do not seem to work
like they used to. She is not taking any medicines on prescription. (You
check whether she is taking the contraceptive pill and she is not.) Sandra
tells you that she now suffers from migraines two or three times a
month and they are making her life a misery. Nothing seems to trigger
them and the pain is not more severe than before. She has read about
feverfew and wonders whether she should give it a try.
The pharmacist’s view
This woman has successfully used an OTC product to treat her migraines
for a long time. Many patients who suffer migraines report
that they get relief from OTC analgesics. Sandra’s migraines have become
more frequent for no apparent reason. Referral to the doctor is
needed to exclude any serious cause of her headaches before considering
further treatments.
The doctor’s view
It makes sense for her to be reviewed by her GP as the headaches are so
frequent and making her life a misery. It would be helpful to get more
details of her experience of headaches and associated symptoms, e.g.
any preceding visual symptoms, nature and site of headache, duration;
other useful information would include her understanding of migraine,
any specific concerns she may have and what sort of treatment she
would be prepared to try. There is some evidence that headaches improve
more quickly if patients’ expectations and concerns are addressed
adequately in the consultation. It would also be useful to explore what
level of stress she was experiencing. A limited examination would be
usual, e.g. blood pressure and fundoscopy to look for signs of raised
intracranial pressure.
204 PAINFUL CONDITIONS
Prophylactic treatments (e.g. propranolol) for migraine are available
and are worth considering in patients who report attacks more
than four times a month. There is inconclusive evidence supporting
the use of feverfew as a migraine prophylaxis. Sodium valproate has
good evidence of efficacy in migraine prophylaxis but is not licensed for
this indication. Although prophylactic treatments may reduce the frequency
of migraine attacks, their adverse effects can make them unacceptable
to some people. Valproate can cause fetal malformations and
other problems if taken during pregnancy. 5HT1 agonists, e.g. sumatriptan,
zolmitriptan and naratriptan, are effective acute treatments for
migraine, producing relief from a headache within 1 or 2 h for many
patients. They are contraindicated in those with ischaemic heart disease
or poorly controlled hypertension. Research evidence shows that one
of every three patients treated with oral sumatriptan will have his or
her headache cured or substantially improved, which would not have
happened had he or she been treated with placebo. This is the same
success rate demonstrated for treatment with a combination of oral
aspirin and metoclopramide.
Case 2
Wei Lin, a woman aged about 30 years, has asked to speak to you.
She tells you that she would like you to recommend something for the
headaches that she has been getting recently. You ask her to describe
the headache and she explains that the pain is across her forehead
and around the back of the head. The headaches usually occur during
the daytime and have been occurring several times a week, for several
weeks. There are no associated GI symptoms and there is no nasal
congestion. No medicines are being taken, apart from a compound
OTC product containing aspirin, which she has been taking for her
headaches. On questioning her about recent changes in lifestyle, she
tells you that she has recently moved to the area and started a new job
last month. In the past she has suffered from occasional headache, but
not regularly. This lady does not wear glasses and says she has not had
trouble with her eyesight in the past. She confides that she has been
worried that the headaches might be due to something serious.
The pharmacist’s view
From the information obtained, it sounds as though this woman is
suffering from tension headaches. The location of the pain and lack
of associated symptoms lead towards this conclusion. The timing of
the headaches indicates that this woman’s recent move and change of
employment are probably responsible for the problem. The pharmacist
should obtain information about the current headaches in relation to
the patient’s past experience. This patient is worried that the headaches
may signal a serious problem, but the evidence indicates this would be
HEADACHE 205
unlikely. The pharmacist could recommend the use of paracetamol,
ibuprofen or diclofenac. If the headaches do not improve within 1
week, she should see her doctor.
The doctor’s view
The pharmacist’s assessment makes sense. A tension headache is the
most likely explanation. If her symptoms do not settle within 1 week, it
would be very reasonable to be reviewed by her GP. The most important
aspect of the GP’s assessment would be to determine what her concerns
about the headache were; e.g. many people with headaches become
concerned that they might have a brain tumour. Hopefully, providing
appropriate information and explanation will put her mind at rest.
Case 3
Monowarar Ahmed is a regular visitor to your shop. She is a young
mother, aged about 25 years, and today she seeks your advice about
headaches that have been troubling her recently. The headaches are of
a migraine type, quite severe and affecting one side of the head. Mrs
Ahmed had her second child a few months ago, and when you ask
if she is taking any medicines she tells you that she recently started
to take the COC pill. In the past she has suffered from migraine-type
headaches, but only occasionally and never as severe as the ones she
has been experiencing during the past weeks. The headaches have been
occurring once or twice a week for about 2 weeks. Paracetamol has
given some relief, but Mrs Ahmed would like to try something stronger.
The pharmacist’s view
Mrs Ahmed should be referred to her doctor immediately. Her history
of migraine headaches associated with the COC is a cause for concern;
in addition, you have established that she has suffered from migraine
headaches in the past.
The doctor’s view
The pharmacist should recommend referral to the doctor. Someone
who develops a first migraine attack whilst taking the pill should be told
to discontinue it. If there is a previous history of migraine, the pill may
sometimes be used, but if the frequency, severity or nature (especially
onset of focal neurological symptoms) of the migraines worsens on the
pill, then once again the pill should be discontinued. The reason for this
advice is that the migraine could herald a cerebral thrombosis (stroke),
which could be prevented by stopping the pill.
Case 4
Ben Jones, a 35-year-old man, comes in asking whether he could have
something stronger for his migraines. He tells you that he has had
206 PAINFUL CONDITIONS
migraines since he was a teenager. The attacks are not that frequent
but are quite disabling when they come on. He is particularly concerned
that he travels a lot in his job as an IT consultant and cannot afford to
be laid up when he is working away from home. Last year he saw his
GP who encouraged him to continue with soluble paracetamol and also
prescribed domperidone to reduce his nausea. The GP mentioned that
he might benefit from a ‘triptan’ if this was not helping him enough.
Ben explains that his migraine starts with a small area of wavy vision
in the centre of his visual field, which is then followed about half an
hour later by a throbbing headache above his left eye with nausea and
vomiting. He says he feels so bad that he has to lie down in a darkened
room. He goes on to say that he usually falls asleep after an hour so
and then sleeps fitfully until the next day when he is better.
He is otherwise fit and well, plays regular sports, is a non-smoker
and doesn’t take any other medication.
He goes on to say, ‘Can I buy the triptan or do I need to go back to
the doctor?’
The pharmacist’s view
This patient’s history of migraines shows an established pattern and
falls within the indications for OTC sumatriptan. Since he does not
have any indication for referral to the GP, it would be reasonable for
him to try sumatriptan. I would ask him to come back and let me know
how the treatment went.
The doctor’s view
The pharmacist’s recommendation is reasonable since Ben is fit and
healthy and has a long-established pattern of headaches previously
diagnosed by his GP.
HEADACHE 207
Musculoskeletal problems
Pharmacists are frequently asked for advice about muscular injuries,
sprains and strains. Simple practical advice combined with topical or
systemic OTC treatment can be valuable. Sometimes patients who are
already taking prescribed medicines for musculoskeletal problems will
ask for advice. Here a careful assessment of compliance with prescribed
medicines and the need for referral is important.
What you need to know
Age
Child, adult, elderly
Symptoms
Pain, swelling, site, duration
History
Injury
Medical conditions
Medication
Significance of questions and answers
Age
Age will influence the pharmacist’s choice of treatment, but other reasons
make consideration of the patient’s age important. In elderly patients,
a fall is more likely to result in a fracture; elderly women are
particularly at risk because of osteoporosis. Referral to the local casualty
department for X-rays may be the best course of action in such
cases.
Symptoms and history
Injuries commonly occur as a result of a fall or other trauma and
during physical activity such as lifting heavy loads or taking part in
sport. Exact details of how the injury occurred should be established
by the pharmacist.
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
208 PAINFUL CONDITIONS
Sprains and strains
Sprains. A sprain injury involves the overstretching of ligaments
and/or the joint capsule, sometimes with tearing. The most common
sprain involves the lateral ankle ligament. Referral is the best course of
action, so that the family practitioner or casualty department doctor
can examine the affected area and consider whether a complete tearing
of ligaments has occurred, particularly for knee injuries.With a partial
tear the knee is often swollen and the patient experiences severe pain
on movement. A complete tear may involve the tearing of the capsule
itself. If this occurs, any blood or fluid can leak out into the surrounding
tissues, so the knee may not appear swollen.
Strains. Strains are injuries where the muscle fibres are damaged by
overstretching and tearing. Sometimes the fibres within the muscle
sheath are torn; sometimes the muscle sheath itself ruptures and bleeding
occurs. Strains are most common in muscles that work over two
joints, e.g. the hamstring. When the strain heals, fibrosis can occur,
and the muscle becomes shortened. The muscle is then vulnerable to
further damage.
Early mobilisation, strengthening exercises and coordination exercises
are all important after both sprains and strains. The return to full
activity must occur gradually.
Muscle pain
Stiff and painful muscles may occur simply as a result of strenuous
and unaccustomed work, such as gardening, decorating or exercise,
and the resulting discomfort can be reduced by treatment with OTC
medicines.
Bruising
Bruising as a result of injury is common and some products that minimise
bruising are available OTC. The presence of bruising without
apparent injury, or a description by the patient of a history of bruising
more easily than usual, should alert the pharmacist to the possibility of
a more serious condition. Spontaneous bruising may be symptomatic
of an underlying blood disorder, e.g. thrombocytopaenia or leukaemia,
or may result from an adverse drug reaction or other cause.
Head injury
Pain occurring as a result of head injury should always be viewed with
suspicion and such patients, particularly children, are best referred for
further investigation.
Bursitis
Other musculoskeletal problems about which the pharmacist’s advice
might be sought include bursitis, which is inflammation of a bursa.
MUSCULOSKELETAL PROBLEMS 209
(This is the name given to tissues around joints and where bones move
over one another. The function of a bursa is to reduce friction during
movement.) Examples of bursitis are housemaid’s knee and student’s
elbow.
Fibromyalgia
Fibromyalgia refers to chronic widespread pain affecting the muscles
but not the joints. Tender spots can be discovered in the muscles and
the condition can be associated with a sleep disturbance. Brain wave
studies often show a loss of deep sleep. This condition may be precipitated
by psychological distress and physical trauma. The symptoms
can be similar to those of myalgic encepalopathy (encephalomyelitis).
Referral to the GP for assessment would be advisable. An empathetic
approach from the doctor is important as many patients have felt rejected
or that their problems have not been taken seriously by the health
professional. Medication (e.g. tricylics, NSAIDs and gabapentin) is of
limited benefit in these situations.
Frozen shoulder
Frozen shoulder is a common condition where the shoulder is stiff
and painful. It is more prevalent in older patients. The shoulder pain
sometimes radiates to the arm and is often worse at night. Patients can
sometimes relate the problem to injury, exertion or exposure to cold,
but frozen shoulder may occur without apparent cause. The pain and
limitation of movement are usually so severe that referral to the doctor
is advisable.
Painful joints
Pain arising in joints (arthralgia) may be due to arthritis, for which there
are many causes. The pain may be associated with swelling, overlying
inflammation, stiffness, limitation of movement and deformity of the
joint. A common cause of arthritis is osteoarthritis (OA), which is due
to wear and tear of the joint. This often affects the knees and hips, especially
in the older population. Another form of arthritis is rheumatoid
arthritis (RA), which is a more generalised illness caused by the body
turning its defences on itself. Other forms of arthritis can be caused by
gout or infection. A joint infection is rare but serious and occasionally
fatal. It is often difficult to distinguish between the different causes and
it is therefore necessary to refer to the doctor except in mild cases.
Back pain
Lower back pain affects 60–80% of people at some stage in their lives
and is often recurrent. Non-serious acute back problems need to be
treated early, with mobilisation and exercise thought to be particularly
important in the prevention of chronic low back pain. Acute back
pain is generally regarded as lasting less than 6 weeks, subacute for
210 PAINFUL CONDITIONS
6–12 weeks and chronic longer than 12 weeks. The main cause is a
strain of the muscles or other soft structures (e.g. ligaments and tendons)
connected to the vertebrae. Sometimes it is the cushion between
the bones (intervertebral disc) which is strained and which bulges out
(herniates) and presses on the nearby nerves (as in sciatica). Lower back
pain that is not too severe or debilitating and comes on after gardening,
awkward lifting or bending may be due to muscular strain (lumbago)
and appropriate advice may be given by the pharmacist.
Bed rest is not recommended for simple low back pain. The emphasis
is on maintaining activity, supported by pain relief. There is evidence
from RCTs that advice to stay active results in increased rate of recovery,
reduced pain, reduced disability and reduced time off work
compared with advice to rest. If there is no improvement within 1
week, referral is advisable.
Pain that is more severe, causing difficulty with mobility or radiating
from the back down one or both legs, is an indication for referral. A
slipped disc can press on the sciatic nerve (hence sciatica), causing pain
and sometimes pins and needles and numbness in the leg. Low back
pain associated with any altered sensation in the anal or genital area
or bladder symptoms requires urgent referral to the GP.
Back pain that is felt in the middle to upper part of the back is less
common, and if it has been present for several days, it is best referred
to the doctor. Kidney pain can be felt in the back, to either side of the
middle part of the back just below the ribcage (loin area). If the back
pain in the loin area is associated with any abnormality of passing urine
(discolouration of urine, pain on passing urine or frequency), then a
kidney problem is more likely.
Repetitive strain disorder
Repetitive strain disorder covers several arm conditions, mainly affecting
the forearm. Tenosynovitis is the term that has been used to refer
to conditions around the wrist, which sometimes occur in computer
operators. The condition presents as swelling on the back of the forearm.
There may be crepitus (a creaking, grating sound) when the wrist
is moved. Sometimes the symptoms disappear on stopping the job, but
they may return when the work is restarted.
Whiplash injuries
Neck pain following a car accident can last for a long period – up to
2 years in some cases. Good posture is important and keeping both
the back and the head straight has been shown to reduce pain and
help recovery. A physiotherapist’s advice would probably include the
recommendation to sleep with only one pillow to facilitate extension
of the neck.
MUSCULOSKELETAL PROBLEMS 211
Medication
Prescribed medication
Sufferers, for example, of RA or chronic back pain are likely to be
taking painkillers or NSAIDs prescribed by their doctor. Although the
recommendation of a topical analgesic would produce no problems in
terms of drug interactions, if the patient is in considerable and regular
pain despite prescribed medication, or the pain has become worse,
referral back to the doctor would be appropriate.
Side-effects. In elderly patients, it should be remembered that falls
may occur as a result of postural hypotension, dizziness or confusion
as adverse effects from drug therapy. Any elderly patient reporting falls
should be carefully questioned about current medication, and the pharmacist
should contact the doctor if an adverse reaction is suspected.
Self-medication
The pharmacist should also enquire about any preparations used in
self-treatment of the condition and their degree of effectiveness.
When to refer
Suspected fracture
Possible adverse drug reaction: falls or bruising
Head injury
Medication failure
Arthritis
Severe back pain
Back pain (and/or pins and needles/numbness) radiating to leg
Back pain in the middle/upper back (especially in the older patient)
Treatment timescale
Musculoskeletal conditions should respond to treatment within a few
days. A maximum of 5 days’ treatment should be recommended, after
which patients should see their doctor.
Management
A wide range of preparations containing systemic and topical analgesics
is available (see p. 197 for a discussion of systemic analgesics).
The oral analgesic of choice would usually be an NSAID, such as
ibuprofen, provided there were no contraindications. Taking the analgesic
regularly is important to obtain full effect and the patient needs
to know this. Topical formulations include creams, ointments, lotions,
sticks and sprays.
212 PAINFUL CONDITIONS
Topical analgesics
There is a high placebo response to topical analgesic products. This is
probably because the act of massaging the formulation into the affected
area will increase blood flow and stimulate the nerves, leading to a
reduction in the sensation of pain.
Counterirritants and rubefacients
Counterirritants and rubefacients cause vasodilatation, inducing a feeling
of warmth over the area of application. Counterirritants produce
mild skin irritation, and the term rubefacient refers to the reddening
and warming of the skin. The theory behind the use of topical analgesics
is that they bombard the nervous system with sensations other
than pain (warmth and irritation) and this is thought to distract attention
from the pain felt. Simply rubbing or massaging the affected
area produces sensations of warmth and pressure and can reduce pain.
Massage is known to relax muscles and it has also been suggested that
massage may disperse some of the chemicals that are responsible for
producing pain and inflammation by increasing the blood flow. The
mode of action of topical analgesics is therefore twofold: one effect
relying on absorption of the agent through the skin, while the other
on the benefit of the massage. There is no published evidence on the
effectiveness of counterirritants and rubefacients. This is not surprising
as many of the active ingredients and formulations have been available
for many years.
There are many proprietary formulations available, often incorporating
a mixture of ingredients with different properties. Most pharmacists
and customers have their own favourite product. For customers
who live alone, a spray formulation, which does not require massage,
can be recommended for areas such as the back and shoulders. Generally,
patients can be advised to use topical analgesic products up to
four times a day, as required.
Methyl salicylate
Methyl salicylate is one of the most widely used and effective counterirritants.
Wintergreen is its naturally occurring form; synthetic versions
are also available. A systematic review concluded that salicylates may
be effective in acute pain but that the clinical trials were not of good
quality. The agent is generally used in concentrations between 10 and
60% in topical analgesic formulations.
Nicotinates
Nicotinates (e.g. ethyl nicotinate and hexyl nicotinate) are absorbed
through the skin and produce reddening of the skin, increased blood
flow and an increase in temperature. Methyl nicotinate is used
at concentrations of 0.25–1.0% to produce its counterirritant and
MUSCULOSKELETAL PROBLEMS 213
rubefacient effects. There have been occasional reports of systemic adverse
effects following absorption of nicotinates, such as dizziness or
feelings of faintness, which are due to a drop in blood pressure following
vasodilatation. However, systemic adverse effects are rare, seem
to occur only in susceptible people and are usually due to use of the
product over a large surface area.
Menthol
Menthol has a cooling effect when applied to the skin and acts as a mild
counterirritant. Used in topical formulations in concentrations of up
to 1%, menthol has antipruritic actions, but at higher concentrations
it has a counterirritant effect. When applied to the skin in a topical
analgesic formulation, menthol gives a feeling of coolness, followed by
a sensation of warmth.
Capsaicin/capsicum
The sensation of hotness from eating peppers is caused by the excitation
of nerve endings in the skin, body organs and airways. Capsicum
preparations, e.g. capsaicin capsicum and capsicum oleoresin, produce
a feeling of warmth when applied to the skin. They do not cause reddening
because they do not act on capillary or other blood vessels.
Capsaicin (available on prescription) has been the subject of research
in clinical trials as an analgesic for postherpetic pain and this work is
continuing. Studies in patients with arthritis have also shown effectiveness.
Capsaicin has few side-effects. A small amount needs to be rubbed
well into the affected area. Patients should always wash their hands after
use; otherwise they may inadvertently transfer the substance to the
eyes, causing burning and stinging.
Topical anti-inflammatory agents
Topical gels, creams and ointments containing NSAIDs are widely used
in the UK. Clinical trials have shown them to be as effective as oral
NSAIDs in relieving musculoskeletal pain. There have been no comparative
trials with counterirritants and rubefacients.
Ibuprofen, felbinac, ketoprofen and piroxicam are available in a
range of cream and gel formulations. The drug is absorbed into the
bloodstream and appears to become concentrated in the affected
tissues. Topical NSAIDs (except benzydamine) should not be used
by patients who experience adverse reactions to aspirin, such as
asthma, rhinitis or urticaria. Because of the higher likelihood of aspirin
sensitivity in patients with asthma, caution should be exercised when
considering recommending a topical NSAID. Several reports of bronchospasm
have been received following the use of these products.
Rarely, GI side-effects have occurred, mainly dyspepsia, nausea and
diarrhoea.
214 PAINFUL CONDITIONS
Heparinoid and hyaluronidase
Heparinoid and hyaluronidase are enzymes that may help to disperse
oedematous fluid in swollen areas. A reduction in swelling and bruising
may therefore be achieved. Products containing heparinoid or
hyaluronidase are used in the treatment of bruises, strains and sprains.
Glucosamine and chondroitin
There is some evidence that glucosamine sulphate and chondroitin improve
the symptoms of OA in the knee and that glucosamine may have
a beneficial structural effect on joints. The research shows that glucosamine
may be as effective as NSAIDs in reducing pain. However
the quality of some trials is poor. Most trials used a daily dose of 1500
mg of glucosamine. Adverse effects are uncommon and include abdominal
discomfort and tenderness, heartburn, diarrhoea and nausea.
There is insufficient information about pharmaceutical quality and actual
content of glucosamine to enable pharmacists to make informed
choices between available products. Some are produced from natural
sources (the shells of crabs and other crustaceans), while others are
synthesised from glutamic acid and glucose. A licensed glucosamine
product became available in 2007, initially limited to prescription use
only. The 2008 NICE guideline suggested that patients wanting to try
OTC glucosamine could be helped by advice on how to evaluate their
pain before starting and to review at 3 months.
Acupuncture
There are no RCTs of acupuncture in acute low back pain and thus
no evidence of effectiveness. For chronic low back pain, 8 of 11 RCTs
found acupuncture to be no more effective than placebo.
In OA of the knee, acupuncture has been shown to be of benefit in
pain relief and improvement in function. The effect size of acupuncture
in OA knee is similar to NSAIDs and exercise.
Practical points
First-aid treatment of sprains and strains
The priority in treating sprains and soft-tissue injuries is to apply
compression, cooling and elevation immediately, and this combination
should be maintained for at least 48 h. Although cooling has generally
been the priority in the past, latest research evidence suggests that
compression is the first priority. The aim of the treatment is to prevent
swelling. If swelling is not minimised, the resulting pain and pressure
will limit movement, lead to muscle wasting, cause pain and delay
recovery. Ice packs by themselves will reduce metabolic needs of the
tissues, reduce blood flow and result in less tissue damage and swelling,
but will not prevent haemorrhage.
MUSCULOSKELETAL PROBLEMS 215
The area should be wrapped around with a cotton-wool pad and
held in place with a crepe bandage.
Once the injury has been protected and a compression bandage applied,
an ice pack should be used. Its function is to produce vasoconstriction,
thus preventing further blood flow into the injured area
from the torn capillaries and, in turn, minimising further bruising and
swelling. Proprietary cold packs are available, but in emergencies various
items have been brought into service. For example, a bag of frozen
peas is an excellent cold pack for the knee or ankle because it can be
easily applied and wrapped around the affected joint.
The affected limb should be elevated to reduce blood flow into the
damaged area by the effect of gravity. This will, in turn, reduce the
amount of swelling caused by oedema. Finally, the injured limb should
be rested to facilitate recovery. The acronym RICE is a useful aidememoire
for the treatment of sprains and strains.
R – Rest
I – Ice/cooling
C – Compression
E – Elevation
Heat
The application of heat can be effective in reducing pain. However,
heat should never be applied immediately after an injury has occurred,
because heat application at the acute stage will dilate blood vessels and
increase blood flow into the affected area – the opposite effect to what
is needed. After the acute phase is over (1 or 2 days after the injury),
heat can be useful. The application of heat can be both comforting and
effective in chronic conditions such as back pain.
Patients can use a hot-water bottle, a proprietary heat pack or
an infrared lamp on the affected area. Heat packs contain a mixture
of chemicals that give off heat and the packs are disposable.
Keeping the joints and muscles warm can also be helpful and wearing
warm clothing, particularly in thin layers that can retain heat, is
valuable.
Prevention of recurrent back pain
Good posture, lifting correctly, a good mattress and losing excess
weight can help. Paying attention to posture and body awareness is
important, and classes to relearn good posture may help some patients
(e.g. Feldenkrais method and Alexander technique). The additional
pressure on the spine caused by excess weight may lead to structural
compromise and damage (e.g. injury and sciatica). The lower back is
particularly vulnerable to the effects of obesity, and lack of exercise
leads to poor flexibility and weak back muscles.
216 PAINFUL CONDITIONS
Irritant effect of topical analgesics
Preparations containing topical analgesics should always be kept well
away from the eyes, mouth and mucous membranes and should not be
applied to broken skin. Intense pain and irritant effects can occur following
such contact. This is due to the ready penetration of the irritant
topical analgesics through both mucosal surfaces and direct access, via
the broken skin. When preparations are applied to thinner and more
sensitive areas of the skin, irritant effects will be increased and hence,
the restrictions on the use of topical analgesics in young children recommended
by some manufacturers for their products. Therefore, the
manufacturer’s instructions and recommendations should be checked.
Sensitisation to counterirritants can occur; if blistering or intense irritation
of the skin results after application, the patient should discontinue
use of the product.
Musculoskeletal problems in practice
Case 1
Charan Gogna, a regular customer in his late twenties, comes into your
pharmacy. He asks what you would recommend for a painful lower
back following his weekend football game; he thinks he must have
pulled a muscle and says he has had the problem before in the same
spot. On questioning, you find out that he has not taken any painkillers
or used any treatment. He is not taking any other medicines.
The pharmacist’s view
Mr Gogna could take an oral analgesic regularly until the discomfort
subsides.Atopical analgesic could also be useful if gently massaged into
the affected area. Since the back is hard to reach, a spray formulation
might be easier than a rub. Evidence shows that bed rest does not speed
up recovery, and Mr Gogna should be advised to continue his usual
daily routine.
The doctor’s view
His low back pain should settle in a few days. As he has had recurrent
bouts of pain he could be reviewed by his GP. A more detailed
history of his problem describing his occupation would be useful with
an examination of his back. Depending on the findings, he might be
advised to see a physiotherapist or an osteopath. His posture and way
of moving might be less than ideal and might be putting him at risk of
future problems. If this is so, he might benefit from attending classes
with an Alexander or Feldenkrais teacher.
MUSCULOSKELETAL PROBLEMS 217
Case 2
Amiddle-aged man comes into your shop. He is wearing a tracksuit and
training shoes and asks what you can recommend for an aching back.
On questioning, you find out that the product is in fact required for his
wife, who was doing some gardening yesterday because the weather
was fine and who now feels stiff and aching. The pain is in the lower
back and is worse on movement. His wife is not taking any medicines
on a regular basis but took two paracetamol tablets last night, which
helped to reduce the pain.
The pharmacist’s view
In this case it would have been very easy for the pharmacist to assume
that the man in the shop was the patient whereas, in fact, he was making
a request on his wife’s behalf. This emphasises the importance of
establishing the identity of the patient. The history described is of a
common problem: muscle stiffness following unaccustomed or strenuous
activity – in this case, gardening. The pharmacist might recommend
a combination of systemic and topical therapy. If there were an
adequate supply of paracetamol tablets at home, the woman could continue
to take a maximum of two tablets four times daily until the pain
resolved. Alternatively, an oral or topical NSAID or a topical rub or
spray containing counterirritants could be advised. The woman should
see her doctor if the symptoms have not improved within 5 days.
The doctor’s view
The story is suggestive of simple muscle strain, which should settle
with the pharmacist’s advice within a few days. It would be helpful to
enquire whether or not she has had backaches before and, if so, what
happened. It would also be worth checking that she did not have pain
or pins and needles radiating down her legs. If these symptoms were
present, then she might have a slipped disc and referral to her doctor
would be advisable.
Case 3
An elderly female customer who regularly visits your pharmacy asks
what would be the best thing for ‘rheumatic’ pain, which is worse now
that the weather is getting colder. The pain is in the joints, particularly
of the fingers and knees. On further questioning, you find out that she
has suffered from this problem for some years and that she sees her
doctor quite regularly about this and a variety of other complaints. On
checking your patient medication records, you find that she is taking
five different medicines a day. Her regular medication includes a combination
diuretic preparation, sleeping tablets and analgesics for her
218 PAINFUL CONDITIONS
arthritis (co-dydramol plus an NSAID). The joint pains seem to have
become worse during the recent spell of bad weather.
The pharmacist’s view
It would be best for this customer to see her doctor. She is already taking
several medicines, including analgesics for arthritis. It would therefore
be inappropriate for the pharmacist to consider recommendation
of a systemic anti-inflammatory or analgesic because of the possibilities
of interaction or duplication. Indeed, the recent worsening of the
symptoms indicates that consultation with the doctor would be wise.
Perhaps this woman is not taking all her medicines; the pharmacist
could explore any compliance problems with her before referring her
back to the doctor.
The doctor’s view
Referral to the doctor is advisable. She may have OA, RA or even some
other form of arthritis and the doctor would be in the best position to
advise further treatment. The GP is already likely to have made an assessment
of her joint pains. OA most commonly affects the end joints
of the fingers, whereas RA affects the other small joints of the fingers
and knuckles. Knees can be affected by both OA and RA, whereas in
the case of the hip, OA is most common. A feature of RA is morning
joint stiffness. Blood tests and X-rays can assist the diagnosis. An appointment
with the GP would also give an opportunity to review her
medication. She may not have been taking her medicines regularly. It
would be helpful to find out whether she is experiencing adverse effects
and to renegotiate her treatment.
MUSCULOSKELETAL PROBLEMS 219
Women’s Health
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5


Cystitis
Cystitis is a term used to describe a collection of urinary symptoms including
dysuria, frequency and urgency. The urine may be cloudy and
strong smelling; these may be signs of bacterial infection. In 50% of
cases no bacterial cause is found. When infection is present, the common
bacteria are Escherichia coli, Staphylococcus saprophyticus and
Proteus mirabilis, and the source is often the gastrointestinal (GI) tract.
About half of cases will resolve within 3 days even without treatment.
Cystitis is common in women but rare in men; it has been estimated
that more than one in two women will experience an episode of cystitis
during their lives. The pharmacist should be aware of the signs that
indicate more serious conditions. Over-the-counter (OTC) products
are available for the treatment of cystitis, but are recommended only
when symptoms are mild, or for use until the patient can consult her
doctor.
What you need to know
Age
Adult, child
Male or female
Symptoms
Urethral irritation
Urinary urgency, frequency
Dysuria (pain on passing urine)
Haematuria (blood in the urine)
Vaginal discharge
Associated symptoms
Back pain
Lower abdominal (suprapubic) pain
Fever, chills
Nausea/vomiting
Duration
Previous history
Medication
CYSTITIS 223
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5
Significance of questions and answers
Age
Any child with the symptoms of cystitis should always be referred to the
doctor for further investigation and treatment. Urinary tract infections
(UTIs) occur in children, and damage to the kidney or bladder may
result, particularly after recurrent infections.
Gender
Cystitis is much more common in women than in men for two reasons:
1 Cystitis occurs when bacteria pass up along the urethra and enter
and multiply within the bladder. As the urethra is much shorter in
females than in males, the passage of the bacteria is much easier. In
addition, the process is facilitated by sexual intercourse.
2 There is evidence that prostatic fluid has antibacterial properties,
providing an additional defence against bacterial infection in males.
Referral
Any person who presents with the symptoms of cystitis requires medical
referral because of the possibility of more serious conditions such
as kidney or bladder stones or prostate problems.
Pregnancy
If a pregnant woman presents with symptoms of cystitis, referral to the
doctor is the best option, because bacteruria (presence of bacteria in the
urine) in pregnancy can lead to kidney infection and other problems.
Symptoms
Cystitis sufferers often report that the first sign of an impending attack
is an itching or pricking sensation in the urethra. The desire to pass
urine becomes frequent and women with cystitis may feel the need to
pass urine urgently, but pass only a few burning, painful drops. This
frequency of urine occurs throughout the day and night. Dysuria (pain
on passing urine) is a classical symptom of cystitis. After urination, the
bladder may not feel completely empty, but even straining produces no
further flow. The urine may be cloudy and strong smelling; these may
be signs of bacterial infection.
Chlamydial infection
Chlamydial infection is a sexually transmitted infection and is most
commonly seen in women aged 16–24 years. About 1 in 10 women
under the age of 25 years have chlamydial infection. Unfortunately,
most women with it (about 80%) do not have any symptoms. Those
that do can have symptoms of cystitis, an alteration in vaginal
discharge or lower abdominal pain. Chlamydial infection can cause
224 WOMEN’S HEALTH
pelvic inflammatory disease (PID) and infertility. It is important that
the infection be detected and treated. There is currently a National
Chlamydia Screening Programme operating in England. Women
under 25 years attending health clinics (contraceptive clinics, general
practice, young peoples services, antenatal clinics, etc.) for any reason
are offered screening and in some areas community pharmacies offer
a screening (and sometimes treatment) service. Each woman is offered
a urine test and given a vulvovaginal swab to self-collect. Women can
choose how to receive their results, e.g. phone, post, etc. Those with
positive results are offered treatment with azithromycin and advised
about informing their sexual partner(s). The use of condoms can
prevent the infection from being spread.
Blood in urine
Haematuria (presence of blood in the urine) is an indication for referral
to the doctor. It often occurs in cystitis when there is so much
inflammation of the lining of the bladder and urethra that bleeding occurs.
This is not serious and responds quickly to antibiotic treatment.
Sometimes blood in the urine may indicate other problems such as a
kidney stone. When this occurs, pain in the loin or between the loin
and groin is the predominant symptom. When blood in the urine develops
without any pain, specialist referral is required to exclude the
possibility of a tumour in the bladder or kidney.
Vaginal discharge
The presence of a vaginal discharge would indicate local fungal or
bacterial infection and would require referral.
Associated symptoms
When dealing with symptoms involving the urinary system, it is best to
think of it as divided into two parts: the upper (kidneys and ureters) and
the lower (bladder and urethra). The pharmacist should be aware of
the symptoms that accompany minor lower UTI and those that suggest
more serious problems higher in the urinary tract, so that referral for
medical advice can be made where appropriate.
Upper UTI symptoms
Systemic involvement, demonstrated by fever, nausea, vomiting, loin
pain, and tenderness are indicative of more serious infection such as
pyelitis or pyelonephritis and patients with such symptoms require
referral.
Other symptoms
Cystitis may be accompanied by suprapubic (lower abdominal) pain
and tenderness; pain is sometimes felt in the lower back.
CYSTITIS 225
Duration
Treatment with OTC preparations is reasonable for mild cystitis of
short duration (less than 2 days).
Previous history
Women with recurrent cystitis should see their doctor. One in two
episodes of cystitis is not caused by infection and the urethral syndrome
is thought to be responsible for these non-infective cases. The anxiety
produced by repeated occurrences of cystitis is itself thought to be a
contributory factor.
It has been estimated that one in ten cases of UTI is followed by
relapse (the same bacterium being responsible) or reinfection (where a
different organism may be involved). The remaining nine cases clear
up without recurrence.
Diabetes
Recurrent cystitis can sometimes occur in diabetic patients and therefore
anyone describing a history of increasing thirst, weight loss and a
higher frequency of passing urine than normal should be referred.
Honeymoon cystitis
Sexual intercourse may precipitate an attack (honeymoon cystitis) due
to minor trauma or resulting infection when bacteria are pushed along
the urethra.
Other precipitating factors
Other precipitating factors may include the irritant effects of toiletries
(e.g. bubble baths and vaginal deodorants) and other chemicals (e.g.
spermicides and disinfectants). Lack of personal hygiene is not thought
to be responsible, except in extreme cases.
Postmenopausal women
Oestrogen deficiency in postmenopausal women leads to thinning of
the lining of the vagina. Lack of lubrication can mean the vagina and
urethra are vulnerable to trauma and irritation and attacks of cystitis
can occur. For such women, painful intercourse can also be a problem
and this can be treated with OTC lubricants or prescribed products
(e.g. oestrogen creams). Lubricant products are available OTC and
newer formulations mean that a single application can remain effective
for several days. Should this approach be unsuccessful, or if other
troublesome symptoms be present, referral to the doctor would be advisable

برچسب ها: Dihydrocodeine Dihydrocodeine is related to codeine and has similar analgesic efficacy. A combination product containing paracetamol and dihydrocodeine is available with a dose per tablet of 7.46-mg dihydrocodeine. The product is restricted to use in adults and children over 12 years. Sideeffects include constipation and drowsiness. Like codeine، the drug may cause respiratory depression at high doses. Caffeine Caffeine is included in some combination analgesic products to produce wakefulness and increased mental activity. It is probable that doses of at least 100 mg are needed to produce such an effect and that OTC analgesics contain 30–50 mg per tablet. A cup of tea or coffee would have the same action. Products containing caffeine are best avoided near bedtime because of their stimulant effect. It has been claimed that caffeine increases the effectiveness of analgesics but the evidence for such claims is not definitive. Caffeine has an irritant effect on the stomach. Doxylamine succinate Doxylamine is an antihistamine whose sedative and relaxing effects are probably responsible for its usefulness in treating tension headaches. Like other older antihistamines، doxylamine can cause drowsiness and patients should be warned about this. Doxylamine should not be recommended for children under 12 years. Buclizine Buclizine is an antihistamine and is included in an OTC compound analgesic for migraine because of its antiemetic action. Sumatriptan Sumatriptan 50-mg tablets can be usedOTCfor acute relief of migraine with or without aura and where there is a ‘clear diagnosis of migraine’. It can be used by people aged between 18 and 65 years. A 50-mg tablet is taken as soon as possible after the migraine headache starts. A second dose can be taken at least 2 h after the first if symptoms come back. A second dose should be taken only if the headache responded to the first dose. Practice guidance from Royal Pharmaceutical Society of Great Britain (RPSGB) suggests that if the patient has previously received sumatriptan on prescription and the pharmacy holds their patient medication record، then OTC supplies can be made، provided there has been no change in the condition. If the person has not used sumatriptan before، the pharmacist needs to determine their suitability for the treatment. They must have an established pattern of migraine and the HEADACHE 201 pharmacist needs to identify any other symptoms or relevant medical conditions as well as any medication. The following patients should be referred for medical assessment:  Those aged under 18 years or over 65 years  Those aged 50 years or over and experiencing migraine attacks for the first time. If a doctor confirms a diagnosis of migraine they can be considered for OTC sumatriptan  Patients who had their first ever migraine attack within the previous 12 months  Patients who have had fewer than five migraine attacks in the past  Patients who experience four or more attacks per month. The patient is potentially suitable for OTC sumatriptan but should be referred to a doctor for further evaluation and management  If migraine headache lasts for longer than 24 h. The patient is potentially suitable for OTC sumatriptan but should be referred to a doctor for further evaluation and management  Patients who do not respond to treatment  Patients who have a headache (of any type) on 10 or more days per month  Women with migraine who take the combined oral contraceptive pill have an increased risk of stroke، so should be referred if the onset of migraine is within the previous 3 months،  

تاریخ : دوشنبه 25 اسفند 1393 | 11:52 ب.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th




than the traditional ones but some people still find the smell of coal tar
unacceptable. Coal tar can cause skin sensitisation and is a photosensitiser.
Practical points
Continuing treatment
Patients need to understand that the treatment will not cure their dandruff
permanently and that it will be sensible to use the treatment on
a less frequent basis to prevent their dandruff from coming back.
Treating the scalp
It is the scalp that needs to be treated rather than the hair. The treatment
should be applied to the scalp and massaged gently. All products need
to be left on the scalp for 5 min before rinsing for the full effect to be
gained.
Standard shampoos
There is debate amongst experts as to whether dandruff is caused by
infrequent hairwashing. However, it is generally agreed that frequent
washing (at least three times a week) is an important part of managing
dandruff. Between applications of their treatment the patients can
continue to use their normal shampoo. Some may wish to wash their
hair with their normal shampoo before using the dandruff treatment
shampoo.
Hair products
Gel, mousse and hairspray can still be used and will not adversely affect
treatment for dandruff.
DANDRUFF 179
Hair loss
The two major types of hair loss are diffuse hair loss and alopecia
areata. Alopecia androgenetica (male pattern baldness, sometimes
known as common baldness because it can affect women) is the most
common cause of diffuse hair loss. Other causes of diffuse hair loss
include telogen effluvium, hypothyroidism, severe iron deficiency and
protein deficiency. Occasionally, diffuse hair loss is seen after pregnancy,
in chronic renal failure and with certain drugs and chemical
agents.
Alopecia androgenetica may be treatable, but there are currently no
treatments that the pharmacy can offer for alopecia areata. Although
hair loss has been largely regarded as a cosmetic problem, the psychological
effects on sufferers can be substantial. A sympathetic approach
is therefore essential.
What you need to know
Male or female
History and duration of hair loss
Location and size of affected areas
Other symptoms
Influencing factors
Medication
Significance of questions and answers
Male or female
Men and women both may suffer from alopecia androgenetica or
alopecia areata. Alopecia areata can affect people at any age.
History and duration of hair loss
Alopecia androgenetica is characterised by gradual onset. In men the
pattern of loss is recession of the hairline at the front and/or loss of
hair on the top of the scalp. In women the hair loss is generalised
and there is an increase in the parting width. Another pattern of hair
loss in women in the 20+ age group is increased shedding of hair but
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
180 SKIN CONDITIONS
without any increase in the parting width. This latter pattern is not
due to alopecia androgenetica and it is thought that the cause may be
nutritional. Hair loss in women is increasingly recognised as a problem.
Alopecia areata may be sudden and result in patchy hair loss. The
cause of alopecia areata remains unknown but it is thought that the
problem may be autoimmune in origin.
Telogen effluvium usually occurs 2–3 months after significant physical
or emotional stress. The rate of hair loss increases significantly
for a period of time before resolving spontaneously and returning to
normal. Typically this can occur following major surgery or illness.
Location and size of affected area
If the affected area is less than 10 cm in diameter in alopecia androgenetica,
then treatment may be worth trying.
Other symptoms
Coarsening of the hair and hair loss can occur as a result of hypothyroidism
(myxoedema) where other symptoms might include a feeling
of tiredness or being run down, a deepening of the voice and weight
gain.
Inflammatory conditions of the scalp such as ringworm infection
(tinea capitis) can cause hair loss. Other symptoms would be itching
and redness of the scalp with an advancing reddened edge of the infected
area. Referral would be needed in such cases.
In women excessive bleeding during periods (menorrhagia) could
lead to iron deficiency and anaemia, which in turn could cause diffuse
hair loss or aggravate alopecia androgenetica. Absent or very
infrequent periods are sometimes due to polycystic ovary disease or
elevated prolactin levels, which in both cases can result in alopecia
androgenetica.
Influencing factors
Hormonal changes during and after pregnancy mean that hair loss is
common both during pregnancy and after the baby is born. While this
is often distressing for the woman concerned, it is completely normal
and she can be reassured that the hair will grow back. Treatment is not
appropriate.
Medication
Cytotoxic drugs are well known for causing hair loss. Anticoagulants
(coumarins), lipid-lowering agents (clofibrate) and vitamin A
(in overdose) have also been associated with hair loss. Such cases
should be referred to the doctor. Other medications include allopurinol,
beta-blockers, bromocriptine, carbamazepine, colchicine, lithium
and sodium valproate.
HAIR LOSS 181
When to refer
Alopecia areata
Suspected drug-induced hair loss
Suspected hypothyroidism
Menstrual disorders
Suspected anaemia
Treatment timescale
Treatment with minoxidil may take up to 4 months to show full effect.
Management
Minoxidil
The only treatment licensed for use in hair loss is minoxidil, available as
a 2 or5%lotion with the drug dissolved in an aqueous alcohol solution.
Propylene glycol is included to enhance absorption. The mechanism of
action of minoxidil in baldness is unknown. The earlier minoxidil is
used in balding, the more likely it is to be successful. Treatment is most
likely to work where the bald area is less than 10 cm in diameter, where
there is still some hair present and where the person has been losing
hair for less than 10 years. The manufacturers of minoxidil say that the
product works best in men with hair loss or thinning at the top of the
scalp and in women in a generalised thinning over the whole scalp –
both manifestations of alopecia androgenetica. Up to one in three users
in such circumstances report hair regrowth of non-vellus (normal) hair
and stabilisation of hair loss. A further one in three are likely to report
some growth of vellus (fine, downy) hair. The final third will not see
any improvement.
It is important that patients understand the factors that make successful
treatment more or less likely and believe that their expectations
are realistic. Some patients may still want to try the treatment, even
where the chances of improvement are small.
After 4–6 weeks, the patient can expect to see a reduction in hair
loss. It will take 4 months for any hair regrowth to be seen, and
some dermatologists suggest continuing use for 1 year before abandoning
treatment. Initially, the new hair will be soft and downy but it
should gradually thicken to become like normal hair in texture and
appearance.
Application
The lotion should be applied twice daily to the dry scalp and lightly
massaged into the affected area. The hair should be clean and dry and
182 SKIN CONDITIONS
the lotion should be left to dry naturally. The hair should not be washed
for at least 1 h after using the lotion.
Caution
Irritant and allergic reactions to the alcohol/propylene glycol vehicle
sometimes occur. A small amount (approximately 1.5%) of the drug
is absorbed systemically and there is the theoretical possibility of a
hypotensive effect, but this appears to be unlikely in practice. Minoxidil
is also known to cause a reflex increase in heart rate. While
this is a theoretical risk where such small amounts of the drug are involved,
tachycardia and palpitations have occasionally been reported.
The manufacturers advise against use in anyone with hypertension,
angina or heart disease without first checking with the patient’s doctor.
Although no specific problems have been reported, the manufacturers
advise against use when pregnant or breastfeeding.
It is important to explain to patients that they will need to make a
long-term commitment to the treatment should it be successful. Treatment
must be continued indefinitely; new hair growth will fall out 2–3
months after treatment is stopped. One year’s treatment costs about
£350.
Minoxidil should not be used in alopecia areata or in hair loss related
to pregnancy.
HAIR LOSS 183
Psoriasis
People with psoriasis usually present to the doctor rather than the
pharmacist. At the time of first presentation, the doctor is the most
appropriate first line of help and pharmacists should always refer cases
of suspected, but undiagnosed, psoriasis. The diagnosis is not always
easy and needs confirming. In the situation of a confirmed diagnosis in
a relatively chronic situation, the pharmacist can offer continuation of
the treatment where the products are available OTC.
This is a condition where continued management and monitoring
by the pharmacist is reasonable, with referral back to the doctor when
there is an exacerbation or for periodic review. Jointly agreed guidelines
between pharmacist and doctors are valuable here.
Psoriasis occurs worldwide with variation in incidence between different
ethnic groups. The incidence for white Europeans is about 2%.
Although there is a genetic influence, environmental factors are thought
to be important.
What you need to know
Appearance
Psychological factors
Diagnosis
Medication
Significance of questions and answers
Appearance
In its most common form there are raised, large, red, scaly
patches/plaques over the extensor surfaces of the elbow and knee
(Plate 12). The patches are symmetrical and sometimes there is a patch
present over the lower back area. The scalp is often involved (see
Plate 13). Psoriasis can affect the soles of the feet.
Psychological factors
In some people these patches are very long standing and show little
change.With others, the skin changes worsen and spread to other parts
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
184 SKIN CONDITIONS
of the body, often in response to a stressful event. This is particularly
distressing for the person involved who then has to cope with the stress
of having a relapse of psoriasis as well as the precipitating event.
The psychological impact of having a chronic skin disorder such as
psoriasis must not be underestimated. There is still a significant stigma
connected with skin disease. There can be a mistaken belief that the
rash is contagious. There is a cultural pressure to have a perfect body as
defined by the fashion industry and media. Psoriasis can understandably
cause loss of self-esteem, embarrassment and depression. This
is further compounded by the fact that there is no cure for psoriasis,
although treatment will usually result in remission to some extent. Various
creams and ointments are available, but many of these are messy,
smelly, stain clothes and are time consuming to apply. The treatments
do not always work, and can cause sore skin and stain normal skin
around the psoriatic plaque. The prospect of spending 1 h before going
to bed applying creams, clearing up the skin scales from the floor
and getting into bed with smelly ointments is not an attractive one.
Diagnosis
The diagnosis of psoriasis can be confusing. In the typical situation
described above, it is straightforward. In addition to affecting the
extensor surfaces, psoriasis can typically involve the scalp (also see
p. 177). Often the fingernails show signs of pitting, which is a useful
diagnostic guide. However, psoriasis can present with differing patterns
that can be confused with other skin disorders. In guttate psoriasis a
widespread rash of small, scaly patches develops abruptly, affecting
large areas of the body. This most typically occurs in children or young
adults and may be triggered by a streptococcal sore throat. In general
practice the most common differential diagnosis to guttate psoriasis is
pityriasis rosea. This latter condition is self-limiting and usually settles
down within 8 weeks.
Psoriasis can also involve the flexor surfaces, the groin area, palms,
soles and nails. The most common alternative diagnostic possibilities
in these situations include eczema or fungal infections. In 7% of people
who have psoriasis there is an associated arthritis, which usually affects
a single joint but can be more severe and identical to rheumatoid
arthritis.
Medication
It is worthwhile enquiring about routine medications taken as lithium,
beta-blockers, non-steroidal anti-inflammatory drugs and antimalarials
can exacerbate psoriasis.
PSORIASIS 185
Management
Management is dependent on many factors, e.g. nature and severity
of psoriasis, understanding the aims of the treatment, ability to apply
creams and whether the person is pregnant. (Some treatments are
teratogenic.) As always, it is particularly important for the doctor to
deal with the person’s ideas, concerns and expectations to appreciate
how that person’s life is affected by the condition to give a relevant,
understandable explanation and to mutually agree whether to treat or
not, and, if so, how.
Topical treatments
The doctor is likely to offer a topical treatment, usually an emollient
alone or in conjunction with active therapy. Emollients are important
in psoriasis and may be underused. The pharmacist can ask the patient
when and how they are being used.
Calcipotriol or tacalcitol
Vitamin D derivatives are available as calcipotriol or tacalcitol. This
does not smell or stain and has been widely used in the treatment of
mild-to-moderate psoriasis. A systematic review has shown it to be
as beneficial in efficacy as dithranol. If overused, there is a risk of
causing hypercalcaemia. It is available as a scalp application as well as
an ointment.
Topical steroids
Topical steroids should generally be restricted to use in the flexures
or on the scalp. Although effective in suppressing skin plaques on the
body, large amounts are required over time as the condition is a chronic
one, resulting in severe steroid side-effects (striae, skin atrophy and
adrenocortical suppression). Also, stopping steroid preparations can
result in a severe flare-up of the psoriasis.
There is a combination cream with betamethasone and calciptriol,
which is effective but licensed for use only on up to 30% of body
surface for up to 4 weeks.
Dithranol
Dithranol has been a traditional, effective and safe treatment for psoriasis
and is available as proprietary creams (0.1–2.0%) which can be
used for one short-contact (30-min) period each day and removed using
an emollient. Some people are very sensitive to dithranol as it can
cause quite severe skin irritation. It is usual to start with the lowest
concentration and build up slowly to the strongest that can be tolerated.
Users should wash their hands after application. It should not be
186 SKIN CONDITIONS
applied to the face, flexures or genitalia. There are some people who
are unable to tolerate it at all.
Second-line treatment
Referral by a doctor to a dermatologist may be necessary when
there is diagnostic uncertainty, when the doctor’s treatment fails
or in severe cases. Second-line treatment may include phototherapy
or systemic therapy with methotrexate, etretinate or ciclosporin
(cyclosporin). Unfortunately, all of these have potentially serious sideeffects.
Methotrexate has been shown to be effective in non-randomised
trials but relapse usually occurs within 6 months of discontinuation.
Long-term methotrexate treatment carries the risk of liver damage.
PSORIASIS 187
Painful Conditions
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5


Headache
The most common types of headache that the community pharmacist
is likely to encounter are tension headache, migraine and sinusitis.
Careful questioning can distinguish causes that are potentially more
serious so referral to the doctor can be advised.
What you need to know
Age
Adult, child
Duration
Nature and site of pain
Frequency and timing
Previous history
Fits, faints, blackouts
Associated symptoms
Nausea, vomiting, photophobia
Precipitating factors
Foods, alcohol, stress, hormonal
Recent trauma or injury
Falls
Recent eye test
Medication
Significance of questions and answers
Age
The pharmacist would be well advised to refer any child with a
headache to the doctor, especially if there is an associated history of
injury or trauma to the head, e.g. from a fall. Children with severe pain
across the back of the head and neck rigidity should be referred immediately.
Elderly patients sometimes suffer a headache a few days after
a fall involving a bang to the head. Such cases may be the result of a
slow bleed into the brain, causing a subdural haematoma, and require
immediate referral.
HEADACHE 191
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5
It is unusual for patients to present with their first migraine episode
over the age of 40 years and such patients should be referred. The peak
incidence of migraine without aura in males is between ages 10 and
11 years and in females between ages 14 and 17 years. The incidence of
migraine with aura peaks in males at age 5 years and females between
ages 12 and 13 years.
Duration
Any headache that does not respond to over-the-counter (OTC) analgesics
within a day requires referral.
Nature and site of pain
Tension headaches are the most common form. The pain is often described
as being around the base of the skull and the upper part of the
neck. Sometimes the pain extends up and over the top of the head to
above the eyes. It is not associated with any neck stiffness. The suboccipital
muscles can feel tender to touch. The pain may be described
like a band around the head. The pain is usually of a dull nature rather
than the pounding or throbbing sensation associated with migraines.
However, the nature of the pain alone is not sufficient evidence on
which to decide whether the headache is likely to be from a minor or
more serious cause.
A steady, dull pain that is deep seated, severe and aggravated by
lying down requires referral, since it may be due to raised intracranial
pressure from a brain tumour, infection or other cause. This is rare
and usually there would be other associated symptoms such as altered
consciousness, unsteadiness, poor coordination and, in the case of an
infection, a raised temperature.
Classic migraine is unilateral, affecting one side of the head, especially
over the forehead.
Rarely, a sudden severe pain that develops at the back of the head
may signify a subarachnoid haemorrhage (SAH). The incidence rate
for SAH in the general population is 6 cases per 100,000 person-years.
It occurs when a small blood vessel at the base of the brain leaks blood
into the cerebrospinal fluid surrounding the brain. It may be associated
with raised blood pressure. Emergency medical referral is essential.
Sometimes sudden headaches at the back of the head are related to
exercise (exertional headaches). These are not dangerous but may need
differentiation from haemorrhagic ones by computed tomography and
magnetic resonance angiography.
Frequency and timing of symptoms
Pharmacists should regard a headache that is worse in the morning
and improves during the day as particularly serious, since this may
192 PAINFUL CONDITIONS
be a sign of raised intracranial pressure. Cluster headaches typically
happen daily for 2–3 months and each episode of pain can last up to
3 h. A person who has headaches of increasing frequency or severity
should be referred.
Previous history
It is always reassuring to know that the headache experienced is the
usual type for that person. In other words, it has similar characteristics
in nature and site but not necessarily in severity to headaches
experienced over previous years. This fact makes it much less likely
to be from a serious cause, whereas new or different headaches (especially
in people over 45 years) may be a warning sign of a more serious
condition. Migraine patients typically suffer from recurrent episodes
of headaches. In some cases the headaches occur in clusters. The pain
may be present daily for 2–3 weeks and then be absent for months or
years.
Associated symptoms
Children and adults with unsteadiness and clumsiness associated with
a headache should be referred.
Migraine
Migraine affects over 15% of the UK population and two-thirds of
sufferers are women. There are two common types of migraine: migraine
without aura (common migraine), which occurs in 75% cases,
and migraine with aura (classic migraine).
Classic migraine. Classic migraine is often associated with alterations
in vision before an attack starts, the so-called prodromal phase. Patients
may describe seeing flashing lights or zigzag lines. During the prodromal
phase, patients may experience tingling or numbness on one side
of the body, in the lips, fingers, face or hands. Migraines are also associated
with nausea and sometimes vomiting. Patients often get relief
from lying in a darkened room and say that bright light hurts their
eyes during an attack of migraine. Classic migraine is three times more
common in women than in men.
Common migraine. In common migraine there is no prodromal phase
(no aura); the headache maybe one sided but both sides of the head
may be affected and gastrointestinal (GI) symptoms such as nausea and
vomiting may occur.
The International Headache Society has published diagnostic pointers
for migraine.
HEADACHE 193
International Headache Society’s diagnostic pointers for migraine
Migraine without aura (common migraine)
At least five previous episodes with
Attacks lasting 4–72 h
At least two of the following headache characteristics
Pulsating/throbbing
Pain of moderate-to-severe intensity
Pain aggravated by movement
Unilateral pain
At least one associated symptom
Nausea and/or vomiting
Photophobia and phonophobia
Migraine with aura (classic migraine)
At least three of the following characteristics
One or more transient focal neurological aura symptoms
Gradual development of aura symptoms during up to 5 min or several
symptoms in succession
Aura symptoms lasting 5–60 min
Headache following or accompanying aura within 60 min
Source: Cephalalgia, 2004; 24(suppl 1): 1–150.
Chronic daily headache
Chronic daily headache (CDH) is defined as headache that is present
on most days, i.e. more than 15 days a month, typically occurring
over a 6-month period or longer, and it can be daily and unremitting.
In some patients, an episode of chronic headache resolves in
a much shorter time; it can occur in children and in the very old.
Twice as many men have it compared to women. Chronic headache
is characterised by a combination of background, low-grade musclecontraction-
type symptoms, often with stiffness in the neck and superimposed
migrainous symptoms. It is possible that daily use of simple
analgesics and combinations containing codeine causes CDH. Any
frequent headache needs referral to the general practitioner (GP) for
assessment.
Cluster headaches (previously called migrainous neuralgia)
Cluster headaches involve, as their name suggests, a number of
headaches one after the other. A typical pattern would be daily episodes
of pain over 2–3 months, after which there is a remission for anything
up to 2 years. The pain can be excruciating and often comes
on very quickly even waking the sufferer from sleep. Each episode
194 PAINFUL CONDITIONS
of pain can last from 1/2 to 3 h and the pain is usually experienced
on one side of the head, in the eye, cheek or temple. A cluster
headache is often accompanied by a painful, watering eye and a
watering or blocked nostril on the same side as the pain. Any recurrent,
persistent or severe headache needs referral to the GP for a
diagnosis.
Sinusitis
Sinusitis may complicate a respiratory viral infection (e.g. cold) or allergy
(e.g. hay fever), which causes inflammation and swelling of the
mucosal lining of the sinuses. The increased mucus produced within
the sinus cannot drain, a secondary bacterial infection develops and the
pressure builds up, causing pain. The pain is felt behind and around
the eye and usually only one side is affected. The headache may be associated
with rhinorrhoea or nasal congestion. The affected sinus often
feels tender when pressure is applied. It is typically worse on bending
forwards or lying down.
Temporal arteritis
Temporal arteritis usually occurs in older patients; the arteries that
run through the temples become inflamed. They may appear red
and are painful and thickened to the touch. However, these signs
are not always present. Any elderly patient presenting with a severe
frontal or temporal headache that persists and is associated with a
general feeling of being unwell should be referred immediately. Temporal
arteritis is a curable disease and delay in diagnosis and treatment
may lead to blindness, because the blood vessels to the eyes are
also affected by inflammation. Treatment usually involves high-dose
steroids and is effective, provided the diagnosis is made sufficiently
early.
Precipitating factors
Tension (psychogenic) headache and migraines may be precipitated
by stress, e.g. pressure at work or a family argument. Some migraine
sufferers experience their attacks after a period of stress, e.g. when on
holiday or at weekends. Certain foods have been reported to precipitate
migraine attacks, e.g. chocolate and cheese. Migraine headaches may
also be triggered by hormonal changes. In women, migraine attacks
may be associated with the menstrual cycle.
Recent trauma or injury
Any patient presenting with a headache who has had a recent head
injury or trauma to the head should be referred to the doctor immediately
because bruising or haemorrhage may occur, causing a rise in
HEADACHE 195
intracranial pressure. The pharmacist should look out for drowsiness
or any sign of impaired consciousness. Persistent vomiting after the
injury is also a sign of raised intracranial pressure.
Recent eye test
Headaches associated with periods of reading, writing or other close
work may be due to deteriorating eyesight and a sight test may be
worth recommending to see whether spectacles are needed.
Medication
The nature of any prescribed medication should be established,
since the headache might be a side-effect of medication, e.g. nitrates
used in the treatment of angina.
It is also known now that headaches can occur because of medication
overuse. Up to 4% of the population suffers from CDH. This
is when headaches occur on more than 15 days per month. The
headaches may be tension or sometimes associated with superimposed
migraine. Sometimes the headaches may actually be caused by taking
too much medication, as it is possible to develop tolerance and then
rebound headaches. It is therefore important to determine what medication
has been taken for headaches, in what dose and with what
frequency.
Contraceptive pill
Any woman taking the combined oral contraceptive (COC) pill
and reporting migraine-type headaches, either for the first time
or as an exacerbation of existing migraine, should be referred to
the doctor, since this may be an early warning of cerebrovascular
changes.
Occasionally, a headache is caused by hypertension but, contrary
to popular opinion, such headaches are not common and
occur only when the blood pressure is extremely high. Nevertheless,
the pharmacist should consider the patient’s medication carefully.
In drug interactions which have led to a rise in blood pressure,
e.g. between a sympathomimetic such as pseudoephedrine and
a monoamine oxidase inhibitor, a headache is likely to occur as a
symptom.
The patient may already be taking a non-steroidal anti-inflammatory
drug (NSAID) or other analgesic on prescription and duplication
of treatments should be avoided, since toxicity may result. If OTC
treatment has already been tried without improvement, referral is
advisable.
196 PAINFUL CONDITIONS
When to refer
Headache associated with injury/trauma
Severe headache of more than 4-h duration
Suspected adverse drug reaction
Headache in children under 12 years
Severe occipital headache (across the back of the head)
Headache that is worse in the morning and then improves
Associated drowsiness, unsteadiness, visual disturbances or vomiting
Neck stiffness
Frequent migraines requiring prophylactic treatment
Frequent and persistent headaches
Treatment timescale
If the headache does not respond to OTC analgesics within a day,
referral is advisable.
Management
The pharmacist’s choice of oral analgesic comprises three main agents:
paracetamol, NSAIDs (ibuprofen and diclofenac) and aspirin. These
may be combined with other constituents such as codeine, dihydrocodeine,
doxylamine and caffeine. OTC analgesics are available
in a variety of dosage forms and, in addition to traditional tablets and
capsules, syrups, soluble tablets and sustained-release dosage forms are
available for some products. The peak blood levels of analgesics are
achieved 30 min after taking a dispersible dosage form; after a traditional
aspirin tablet, it may take up to 2 h for peak levels to be reached.
The timing of doses is important in migraine where the analgesic should
be taken at the first sign of an attack, preferably in soluble form, since
GI motility is slowed during an attack and absorption of analgesics delayed.
Combination therapy may sometimes be useful, e.g. an analgesic
and decongestant (systemic or topical) in sinusitis.
Sumatriptan 50-mg tablets can be used for acute relief of migraine
with or without aura and where there is a ‘clear diagnosis of migraine’.
Paracetamol
Paracetamol has analgesic and antipyretic effects but little or no antiinflammatory
action. The exact way in which paracetamol exerts its
analgesic effect remains unclear, despite extensive research. However,
the drug is undoubtedly effective in reducing both pain and fever. It
is less irritating to the stomach than is aspirin and can therefore be
recommended for those patients who are unable to take aspirin for
HEADACHE 197
this reason. Paracetamol can be given to children from 2 or 3 months
old, depending on the product licence. Check the individual packs for
doses. A range of paediatric formulations, including sugar-free syrups,
is available. Evidence for the effectiveness of paracetamol in the management
of migraine is limited.
Liver toxicity
At high doses, paracetamol can cause liver toxicity and damage may
not be apparent until a few days later. All overdoses of paracetamol
should be taken seriously and the patient referred to a hospital casualty
department.
NSAIDs (ibuprofen and diclofenac)
Ibuprofen and diclofenac have analgesic, anti-inflammatory and antipyretic
activity and causes less irritation and damage to the stomach
than does aspirin. The dose required for analgesic activity is 200–400
mg and that for anti-inflammatory action 300–600 mg (total daily dose
of 1600–2400 mg). The maximum daily dose allowable for OTC use is
1200 mg and ibuprofen tablets or capsules should not be given to children
under 12 years. Ibuprofen suspension 100 mg in 5 mL is available
OTC. Differences in product licences mean that some ibuprofen suspensions
can be used in children 3 months and over. Check individual
product details for doses.
Diclofenac 12.5mg tablets can be used in adults and children aged
14 years and over. Two tablets should be taken initially, then one or
two tablets every 4–6 hours as needed. The maximum daily dose in
75mg.
Indigestion
NSAIDs can be irritating to the stomach, causing indigestion, nausea
and diarrhoea, but less so than aspirin. Gastric bleeding can also occur.
For these reasons, it is best to advise patients to take NSAIDs with or
after food, and they are best avoided in anyone with a peptic ulcer
or a history of peptic ulcer. Elderly patients seem to be particularly
prone to these effects. NSAIDs can increase the bleeding time due to
an effect on platelets. This effect is reversible within 24 h of stopping
the drug (whereas reversibility may take several days after stopping
aspirin).
Ibuprofen and diclofenac seem to have little or no effect on whole
blood clotting or prothrombin time, but it is still not advised for patients
taking anticoagulant medication for whom paracetamol would
be a better choice.
198 PAINFUL CONDITIONS
Hypersensitivity
Cross sensitivity between aspirin and NSAIDs occurs, so it would be
wise for the pharmacist not to recommend them for anyone with a
previous sensitivity reaction to aspirin. Since asthmatic patients are
more likely to have such a reaction, the use of NSAIDs in asthmatic
patients should be with caution.
Contraindications
Sodium and water retention may be caused by NSAIDs and they are
therefore best avoided in patients with congestive heart failure or renal
impairment and during pregnancy, particularly during the third
trimester. Breastfeeding mothers may safely take ibuprofen and diclofenac,
since it is excreted in only tiny amounts in breast milk.
Interactions
There is evidence of an interaction between NSAIDs and lithium.
NSAIDs may inhibit prostaglandin synthesis in the kidneys and reduce
lithium clearance. Serum levels of lithium are thus raised, with
the possibility of toxic effects. Lithium toxicity manifests itself as GI
symptoms, polyuria, muscle weakness, lethargy and tremor.
Caution
NSAIDs is best avoided in aspirin-sensitive patients and should be used
with caution in asthmatics. Adverse effects are more likely to occur in
the elderly and paracetamol may be a better choice in these cases.
Aspirin
Aspirin is analgesic, antipyretic and also anti-inflammatory if given in
doses greater than 4 g daily. About half of migraine sufferers show
significant improvement in their headache 2 h after taking aspirin. It
should not be given to children under 16 years because of its suspected
link with Reye’s syndrome. Reports indicate that some parents are still
unaware of the contraindication in children under 16 years. Analgesics
are often purchased for family use and it is worth reminding parents
of the minimum age for the use of aspirin. It has been suggested that in
addition to its use in the symptomatic treatment of headaches, doses
of aspirin on alternate days may be effective in the prophylaxis of
migraine but evidence is limited.
Indigestion
Gastric irritation (indigestion, heartburn, nausea and vomiting) is
sometimes experienced by patients after taking aspirin, and for this
reason the drug is best taken with or after food. When taken as soluble
tablets, aspirin is less likely to cause gastric irritation and it is
HEADACHE 199
also available as an enteric-coated version which is designed so that
the aspirin is released lower down the GI tract to try and prevent
adverse effects. However, evidence indicates that enteric coating does
not reduce the risk of aspirin-induced gastric bleeding. The pharmacist
should also remember that enteric-coated preparations will not be
released quickly and so they are inappropriate where rapid pain relief
is required. The local use of aspirin, e.g. dissolving a soluble tablet
near an aching tooth, is best avoided, since ulceration of the gums may
result.
Bleeding
Aspirin can cause GI bleeding and should not be recommended for
any patient who either currently has or has a history of peptic ulcer.
Aspirin affects the platelets and clotting function, so bleeding time
is increased, and it has been suggested that it should not be recommended
for pain after tooth extraction for this reason. The effects of
anticoagulant drugs are potentiated by aspirin, so it should never be
recommended for patients taking these drugs.
Alcohol
Alcohol increases the irritant effect of aspirin on the stomach and also
its effects on bleeding time. Concurrent administration is therefore best
avoided.
Pregnancy
Aspirin is best avoided in pregnancy.
Hypersensitivity
Hypersensitivity to aspirin occurs in some people; it has been estimated
that 4% of asthmatic patients have this problem and aspirin should be
avoided in any patient with a history of asthma. When such patients
take aspirin, they may experience skin reactions (rashes and urticaria)
or sometimes shortness of breath, bronchospasm and even asthma attacks.
Codeine
Codeine is a narcotic analgesic; a systematic review of evidence from
clinical trials showed that a dose of at least 15 mg is required for
analgesic effect. Codeine is commonly found in combination products
with aspirin, paracetamol or both. Constipation is a possible side-effect
and is more likely in elderly patients and others prone to constipation.
Codeine can also cause drowsiness and respiratory depression

برچسب ها: than the traditional ones but some people still find the smell of coal tar unacceptable. Coal tar can cause skin sensitisation and is a photosensitiser. Practical points Continuing treatment Patients need to understand that the treatment will not cure their dandruff permanently and that it will be sensible to use the treatment on a less frequent basis to prevent their dandruff from coming back. Treating the scalp It is the scalp that needs to be treated rather than the hair. The treatment should be applied to the scalp and massaged gently. All products need to be left on the scalp for 5 min before rinsing for the full effect to be gained. Standard shampoos There is debate amongst experts as to whether dandruff is caused by infrequent hairwashing. However، it is generally agreed that frequent washing (at least three times a week) is an important part of managing dandruff. Between applications of their treatment the patients can continue to use their normal shampoo. Some may wish to wash their hair with their normal shampoo before using the dandruff treatment shampoo. Hair products Gel، mousse and hairspray can still be used and will not adversely affect treatment for dandruff. DANDRUFF 179 Hair loss The two major types of hair loss are diffuse hair loss and alopecia areata. Alopecia androgenetica (male pattern baldness، sometimes known as common baldness because it can affect women) is the most common cause of diffuse hair loss. Other causes of diffuse hair loss include telogen effluvium، hypothyroidism، severe iron deficiency and protein deficiency. Occasionally، diffuse hair loss is seen after pregnancy،  

تاریخ : دوشنبه 25 اسفند 1393 | 11:51 ب.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th




Athlete’s foot Apply once or
twice daily for 1
week
Apply once daily
for one week
Apply once
between the toes
and to the soles
and sides of the
feet. Leave in
contact for 24 h.
Apply once daily
for one week
Dhobie itch
(‘jock itch’)
Apply once or
twice daily for
1–2 weeks
Apply once daily
for one week
— Apply once daily
for one week
Ringworm — Apply once daily
for one week
— Apply once daily
for one week
Tolnaftate
Tolnaftate is available in powder, cream, aerosol and solution formulations
and is effective against athlete’s foot. It has antifungal, but not
antibacterial, action. It should be applied twice daily and treatment
should be continued for up to 6 weeks. Tolnaftate may sting slightly
when applied to infected skin.
Undecenoates (e.g. zinc undecenoate, undecenoic acid and methyl and
propyl undecylenate)
Undecenoic acid is an antifungal agent, sometimes formulated with
zinc salt to give additional astringent properties. Treatment should be
continued for 4 weeks.
Hydrocortisone cream or ointment
Hydrocortisone may be sold OTC for allergic and irritant dermatitis,
insect bites or stings and mild-to-moderate eczema. The pharmacist
may not recommend the use of topical hydrocortisone in athlete’s foot
because, although it would reduce inflammation, it would not deal with
the fungal infection, which might then worsen. Combination products
containing hydrocortisone together with an antifungal agent are, however,
available OTC for use in athlete’s foot and intertrigo (described
as ‘sweat rash’ on product packaging and information). Treatment is
limited to 7 days.
Practical points
Footwear
Sweating of the feet can produce the kind of hot, moist environment
in which the fungus is able to grow. Shoes that are too tight and that
are made of synthetic materials make it impossible for moisture to
evaporate. If possible, the patient should wear leather shoes, which
will allow the skin to breathe. In summer, open-toed sandals can be
helpful, and shoes should be left off where possible. The wearing of
ATHLETE’S FOOT 157
cotton socks can facilitate the evaporation of moisture, whereas nylon
socks will prevent this.
Foot hygiene
The feet should be washed and carefully and thoroughly dried, especially
between the toes, before the antifungal preparation is applied.
Transmission of athlete’s foot
Athlete’s foot is easily transmitted and is thought to be acquired by
walking barefoot, e.g. on changing-room floors in workplaces, schools
and sports clubs. There is no need to avoid sports but wearing some
form of footwear such as rubber sandals is advisable.
Prevention of reinfection
Care should be taken to ensure that shoes and socks are kept free of
fungus. Socks should be changed and washed regularly. Shoes can be
dusted with a fungicidal powder to eradicate the fungus. The use of a
fungicidal dusting powder on the feet and in the shoes can be a useful
prophylactic measure and can also help to absorb moisture and prevent
maceration. Patients should be reminded to treat all shoes, since fungal
spores may be present.
Ringworm
Ringworm of the body (tinea corporis) is a fungal infection, which
occurs as a circular lesion that gradually spreads after beginning as a
small, red papule. Often there is only one lesion and the characteristic
appearance is of a central, cleared area with a red advancing edge
(Plate 5). Topical azoles such as miconazole are effective treatments for
ringworm.
Ringworm of the groin (tinea cruris) presents as an itchy red area
in the genital region and often spreads to the inside of the thighs. The
problem is more common in men than in women and is commonly
known as jock itch in the USA. Treatment consists of topical antifungals;
the use of powder formulations can be particularly valuable
because they absorb perspiration.
Ringworm of the scalp (tinea capitis) is most common in preadolescent
children, although it can occur in adolescents and adults.
There may be associated hair loss and affected hairs come out easily
(see Plate 6). Treatment is with oral antinfungals and referral is required
(see also ‘Hair loss’).
Fungal nail infections (onychomycosis)
Onychomycosis is a fungal infection in which mild cases involve the
nail plate and sometimes the nail bed that lies underneath (see Plate
7). A nail lacquer containing 5% amorolfine can be used for the
158 SKIN CONDITIONS
treatment of mild infection involving one or two nails in people aged
over 18 years. Plate 8 shows an onychomycotic nail. The lacquer should
be applied to the affected finger or toenails once weekly. Treatment
length is 6 months for fingernails and 9–12 months for toenails. Refer
where there is a predisposing condition such as diabetes, peripheral
circulatory problems and immunosuppression. Amorolfine should not
be used by pregnant or breastfeeding women. Reported adverse effects
include nail discolouration and broken or brittle nails. (These can also
be effects of the infection itself.) A burning sensation of the skin is
rarely experienced, as is contact dermatitis from amorolfine.
Fungal infections in practice
Case 1
John Chen, the local plumber, is in his early twenties and captains
the local football team on Sunday mornings. Today he wants to buy
something for his athlete’s foot, which he just can’t get rid of. His
girlfriend bought him some cream a few days ago but it doesn’t seem
to be having any effect. The skin between the third and fourth toes and
between the second and third toes is affected. John tells you the skin is
itchy and that it looks flaky. He tells you that he has had athlete’s foot
before and that it keeps coming back again. He wears trainers most of
the time (he has them on now) and has used the cream his girlfriend
bought on most days.
The pharmacist’s view
From the answers he has given, it sounds as though John has athlete’s
foot. Once you have ascertained the identity of the cream he has been
using, it might be appropriate to suggest the use of one of the azoles
or terbinafine. Advice is also needed about foot hygiene and footwear
and about regular use of treatment. If the problem has not cleared up
after 2 weeks, John should see his doctor.
The doctor’s view
He probably does have athlete’s foot (tinea pedis), although it is unusual
for the skin not to be affected between the fourth and fifth toes.
Athlete’s foot usually starts with the skin being affected in this area.
If his symptoms don’t settle with the pharmacist’s suggested treatment
and management then he should see his GP. The GP could confirm
the diagnosis. It would be helpful to know whether he has a history
of other skin problems such as eczema or dermatitis, and it would be
important to examine his foot. If the diagnosis was in doubt, a swab
could be taken to identify whether or not it was a fungal infection.
ATHLETE’S FOOT 159
Case 2
Linda Green asks if you can recommend anything for athlete’s foot.
She tells you that it affects her toes and the soles and top of her feet,
and is extremely itchy. When asked about the skin between her toes,
she tells you she does not think the rash is between the toes. She says
the skin is dry and red and has been like this for several days. Ms Green
has not tried any medication to treat it.
The pharmacist’s view
The symptoms that Linda Green has described do not sound like those
of athlete’s foot. The skin between the toes is not affected, so dermatitis
is a possibility. Rather than recommend a product without being able
to identify the cause of the problem, it would be better to refer Ms
Green to her doctor.
The doctor’s view
The description that the pharmacist has obtained does not sound like
athlete’s foot, which usually involves the cleft between the fourth and
fifth toes. Referral to the doctor for diagnosis would be sensible. It is
possible she may have pompholyx and/or eczema. It would be helpful to
know if she suffers, or has suffered, from any skin problems elsewhere
on the body, e.g. psoriasis or eczema. Pompholyx is also known as
vesicular or dyshidrotic eczema and typically affects the hands and
feet. An early feature of pompholyx is the development of tiny blisters
deep in the skin of the fingers palms or toes. This can progress to
scaling, cracking or crusting. About half of sufferers have a history of
allergy or eczema. It appears more common in conditions that lead
to increased sweating, such as a hot humid climate and stress. The
condition tends to come and go and is often not a problem for long
periods of time. Treatment is similar to that for ordinary eczema and
may include emollients, topical steroids and, if the pompholyx has
become infected, topical or systemic antibiotics.
Psoriasis can also affect the soles of the feet and cause thickened dry
skin associated with deep painful cracks. The differential diagnosis is
made easier if there are signs of psoriasis present elsewhere, such as
thickened, reddened skin around the knee caps and elbows.
160 SKIN CONDITIONS
Cold sores
Cold sores (herpes labialis) are caused by one of the most common
viruses affecting humans worldwide. The virus responsible is the herpes
simplex virus (HSV) of which there are two major types: HSV1
and HSV2. HSV1 typically causes infection around or in the mouth,
whereas HSV2 is responsible for genital herpes infection. Occasionally,
however, this situation is reversed with HSV2 affecting the face
and HSV1 the genital area.
What you need to know
Age
Duration
Symptoms and appearance
Tingling
Pain
Location (current and previous)
Precipitating factors
Sunlight
Infection
Stress
Previous history
Medication
Significance of questions and answers
Age
Although initial infection, which is usually subclinical and goes unnoticed,
occurs in childhood, cold sores are most commonly seen in
adolescents and young adults. Following the primary attack, the virus
is not completely eradicated and virus particles lie dormant in nerve
roots until they are reactivated at a later stage. Although herpes infection
is almost universal in childhood, not all those affected later
experience cold sores, and the reason for this is not fully understood.
Recurrent cold sores occur in up to 25% of all adults and the frequency
declines with age, although cold sores occur in patients of all ages. The
incidence of cold sores is slightly higher in women than in men.
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
COLD SORES 161
In active primary herpes infection of childhood, the typical picture
is of a febrile child with a painful ulcerated mouth and enlarged lymph
nodes. The herpetic lesions last for 3–6 days and can involve the outer
skin surface as well as the inside of the mouth. Such patients should be
referred to the doctor.
Duration
The duration of the symptoms is important as treatment with aciclovir
(acyclovir) is of most value if started early in the course of the infection
(during the prodromal phase). Usually the infection is resolved within
1–2 weeks. Any lesions that have persisted longer need medical referral.
Symptoms and appearance
The symptoms of discomfort, tingling or irritation (prodromal phase),
may occur in the skin for 6–24 h before the appearance of the cold sore.
The cold sore starts with the development of minute blisters on top of
inflamed, red, raised skin. The blisters may be filled with white matter.
They quickly break down to produce a raw area with exudation and
crusting by about the fourth day after their appearance. By around
1 week later, most lesions will have healed.
Cold sores are extremely painful and this is one of the critical diagnostic
factors. Oral cancer can sometimes present a similar appearance
to a cold sore. However, cancerous lesions are often painless and their
long duration differentiates them from cold sores. Another cause of a
painless ulcer is that of a primary oral chancre of syphilis. Chancres
normally occur in the genital area but can be found on the lips. The
incidence of syphilis has increased since 1997 in major cities in Europe,
North America and Australia. In the UK outbreaks have occurred in
Bristol, London, Manchester, Nottingham and Newcastle upon Tyne.
When a cold sore occurs for the first time, it can be confused with a
small patch of impetigo. Impetigo is usually more widespread, does not
start with blisters and has a honey-coloured crust. Impetigo tends to
spread out to form further patches and does not necessarily start close
to the lips. It is less common than cold sores and tends to affect children.
Since impetigo requires either topical or oral antibiotic treatment, the
condition cannot be treated by the pharmacist. If there is any doubt
about the cause of the symptoms, the patient should be referred.
Location
Cold sores occur most often on the lips or face. Lesions inside the
mouth or affecting the eye need medical referral.
Precipitating factors
It is known that cold sores can be precipitated by sunlight, wind,
fever (during infections such as colds and flu) and menstruation, being
162 SKIN CONDITIONS
rundown and local trauma to the skin. Physical and emotional stress
can also be triggers. Whilst it is often not possible to avoid these factors
completely, the information is usually helpful for the sufferer.
Previous history
The fact that the cold sore is recurrent is helpful diagnostically. If a sore
keeps on returning in the same place in a similar way, then it is likely
to be a cold sore. Most sufferers experience one to three attacks each
year. Cold sores occur throughout the year, with a slightly increased
incidence during the winter months. Information about the frequency
and severity of the cold sore is helpful when recommending referral
to the doctor, although the condition can usually be treated by the
pharmacist.
In patients with atopic eczema, herpes infections can be severe and
widespread. Such patients must be referred to their doctor.
Medication
It is helpful to enquire what creams and lotions have been used so far,
what was used in previous episodes and what, if anything, helped last
time.
Immunocompromised patients, e.g. those undergoing cytotoxic
chemotherapy, are at risk of serious infection and should always be
referred to their doctor.
When to refer
Babies and young children
Failure of an established sore to resolve
Severe or worsening sore
History of frequent cold sores
Sore lasting longer than 2 weeks
Painless sore
Patients with atopic eczema
Eye affected
Uncertain diagnosis
Immunocompromised patient
Management
Aciclovir and penciclovir
Aciclovir cream and penciclovir creams are antivirals that reduce time
to healing by one half to 1 day and reduce pain experienced from the
lesion. Treatment should be started as soon as symptoms are felt and
before the lesion appears. Once the lesion has appeared, evidence of
effectiveness is less convincing. The treatments are therefore a helpful
COLD SORES 163
recommendation for patients who suffer repeated attacks and know
when a cold sore is going to appear. Such patients can be told that they
should use treatment as soon as they feel the characteristic tingling or
itching which precedes the appearance of a cold sore.
Aciclovir cream can be used by adults and children and should be
applied 4-hourly during waking hours (approximately five times a day)
to the affected area for 5 days. If healing is not complete, treatment can
be continued for up to 5 more days, after which medical advice should
be sought if the cold sore has not resolved. Penciclovir can be used by
those aged 12 years and over and is applied 2-hourly during waking
hours (approximately eight times a day) for 4 days. Some patients
experience a transient stinging or burning sensation after applying the
creams. The affected skin may become dry and flaky.
Bland creams
Keeping the cold sore moist will prevent drying and cracking, which
might predispose to secondary bacterial infection. For the patient who
suffers only an occasional cold sore, a simple cream, perhaps containing
an antiseptic agent, can help to reduce discomfort.
Hydrocolloid patch
This patch is applied as soon as symptoms start and replaced as needed.
The thin hydrocolloid patch is used for its wound healing properties.
Complementary therapies
Balm mint extract and tea tree oil applied topically may have an effect
on pain, dryness and itching. There is insufficient evidence to assess
whether they have an effect on healing, time to crusting, severity
of an attack or rate of recurrence. Low-energy, non-thermal narrowwaveband
light within the infrared spectrum may have an effect on
cold sores, although there is insufficient evidence currently.
Practical points
Preventing cross infection
Patients should be aware that HSV1 is contagious and transmitted by
direct contact. Tell patients to wash their hands after applying treatment
to the cold sore.Women should be careful in applying eye makeup
when they have a cold sore to prevent infection affecting the eye.
It is sensible not to share cutlery, towels, toothbrushes or face flannels
until the cold sore has cleared up. Oral sex with someone who has a
cold sore means a risk of genital herpes and should be avoided until
the cold sore has gone.
164 SKIN CONDITIONS
Use of sunscreens
Sunscreen creams (SPF 15 or above) applied to and around the lips
when patients are subject to increased sun exposure (e.g. during skiing
and beach holidays) can be a useful preventive measure.
Stress
Sources of stress in life could be looked at to see if changes are possible.
It might be worthwhile to recommend a discussion with the doctor
about this.
Eczema herpeticum (Kaposi’s varicelliform eruption)
Patients with atopic eczema are very susceptible to herpetic infection
and show an abnormal response to the virus with widespread lesions
and sometimes involvement of the central nervous system. These patients
should avoid contact with anyone who has an active cold sore.
Impetigo
In some parts of the UK pharmacists now assess and treat impetigo
using a Patient Group Direction (PGD). Localised crusted impetigo is
usually treated with topical fusidic acid. Washing the hands with soap
and water after applying treatment, and not sharing face cloths and
towels can help to prevent spread.
COLD SORES 165
Warts and verrucae
Warts and verrucae are caused by a viral infection of the skin and have a
high incidence in schoolchildren. Once immunity to the infecting virus
is sufficiently high, the lesions will disappear, but many patients and
parents prefer active treatment for cosmetic reasons. Effective preparations
are available OTC, but correct use is essential if damage to
surrounding skin is to be minimised.
What you need to know
Age
Adult, child
Appearance and number of lesions
Location
Duration and history
Medication
Significance of questions and answers
Age
Warts can occur in children and adults; they are more common in
children and the peak incidence is found between the ages of 12 and
16 years. The peak incidence is thought to be due to higher exposure
to the virus in schools and sports facilities. Warts and verrucae both
are caused by the human papilloma virus, differing in their location.
Appearance
Warts appear as raised lesions with a roughened surface that are usually
flesh coloured. Plantar warts occur on the weight-bearing areas of the
sole and heel (verrucae). They have a different appearance from warts
elsewhere on the body because the pressure from the body’s weight
pushes the lesion inwards, eventually producing pain when weight is
applied during walking. Warts have a network of capillaries and, if
pared, thrombosed, blackened capillaries or bleeding points will be
seen. The presence of these capillaries provides a useful distinguishing
feature between callouses and verrucae on the feet: if a corn or callous
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
166 SKIN CONDITIONS
is pared, no such dark points will be seen; instead layers of white keratin
will be present. The thrombosed capillaries are sometimes thought,
incorrectly, to be the root of the verruca by the patient. The pharmacist
can correct this misconception when explaining the purpose and
method of treatment (discussed below).
Multiple warts
Warts may occur singly or as several lesions. Molluscum contagiosum
is a condition in which the lesions may resemble warts and where another
type of viral infection is the cause. Closer examination shows
that the lesions contain a central plug of material (consisting of viral
particles), which can be removed by squeezing. The location of molluscum
contagiosum tends to differ from that of warts – the eyelids,
face, armpits and trunk may be involved. Such cases are best referred
to the doctor, since self-treatment would be inappropriate.
Location
The palms or backs of the hands are common sites for warts, as is
the area around the fingernails. People who bite or pick their nails are
more susceptible to warts around them.Warts sometimes occur on the
face and referral to the doctor is the best option in such cases. Since
treatment with OTC products is destructive in nature, self-treatment
of facial warts can lead to scarring and should never be attempted.
Parts of the skin that are subject to regular trauma or friction are
more likely to be affected, since damage to the skin facilitates entry of
the virus. Plantar warts (verrucae) are found on the sole of the foot and
may be present singly or as several lesions.
Anogenital
Anogenital warts are caused by a different type of human papilloma
virus and require medical referral for examination, diagnosis and treatment.
They are sexually transmitted and patients can self-refer to their
local genitourinary clinic.
Duration and history
It is known that most warts will disappear spontaneously within a
period of 6 months to 2 years. The younger the patient, the more
quickly the lesions are likely to remit.
Any change in the appearance of a wart should be treated with suspicion
and referral to the doctor is advised. Skin cancers are sometimes
mistakenly thought to be warts by patients, and the pharmacist can
establish how long the lesion has been present and any changes that
have occurred. Signs related to skin cancer are described in ‘Practical
points’ below.
WARTS AND VERRUCAE 167
Medication
Diabetic patients should not use OTC products to treat warts or verrucae
since impaired circulation can lead to delayed healing, ulceration
or even gangrene. Peripheral neuropathy may mean that even extensive
damage to the skin may not provoke a sensation of pain.
Warts can be a major problem if the immune system is suppressed
by either disease (e.g. HIV infection and lymphoma) or drugs (e.g.
ciclosporin (cyclosporin) to prevent rejection of a transplant).
The pharmacist should ask whether any treatment has been attempted
already and if so, its identity and the method of use. Commonly,
treatments are not used for a sufficiently long period of time
because patients’ expectations are often of a fast cure.
When to refer
Changed appearance of lesions: size and colour
Bleeding
Itching
Genital warts
Facial warts
Immunocompromised patients
Treatment timescale
Treatment with OTC preparations should produce a successful outcome
within 3 months; if not, referral is necessary.
Management
Treatment of warts and verrucae aims to reduce the size of the lesion
by gradual destruction of the skin. Continuous application of the selected
preparation for several weeks or months may be needed and it
is important to explain this to the patient if compliance with treatment
is to be achieved. Surrounding healthy skin should be protected during
treatment (see ‘Practical points’ below).
Salicylic acid
Salicylic acid may be considered to be the treatment of choice for warts;
it acts by softening and destroying the skin, thus mechanically removing
infected tissue. Preparations are available in a variety of strengths,
sometimes in collodion-type bases that help to retain the salicylic acid
in contact with the wart. Lactic acid is included in some preparations
with the aim of enhancing availability of the salicylic acid. It is a keratolytic
and has an antimicrobial effect. Ointments, gels and plasters
containing salicylic acid provide a selection of methods of application.
168 SKIN CONDITIONS
Preparations should be kept well away from the eyes and applied with
an orange stick or other applicator, not with the fingers.
Cryotherapy
Dimethyl ether propane can be used to freeze warts and is available
in an application system for home use for adults and children over 4.
There is little evidence from which to judge its effectiveness in home
use rather than when applied by a doctor. The treatment should not be
used by people with diabetes or by pregnant women. The wart should
fall off about 10 days after application.
Duct tape
Application of a piece of duct tape to the wart has been widely used
in the USA and little used in the UK. The tape is left in place for up
to 6 days at a time after which the wart is soaked in warm water for
5 min and then gently abraded with an emery board. Treatment takes
up to 8 weeks. A randomised controlled trial (RCT) comparing duct
tape with OTC cryotherapy found similar effectiveness.
Formaldehyde
Formaldehyde is used for the treatment of verrucae; it is considered to
be less suitable for warts on the hands because of its irritant effect on
the skin. The thicker skin layer on the sole of the feet protects against
this irritant action. A gel formulation is available for the treatment of
verrucae and is applied twice a day. Both formaldehyde and glutaraldehyde
have an unpredictable action and are not first-line treatments for
warts, though they may be useful in resistant cases.
Glutaraldehyde
Glutaraldehyde is used in a 5 or 10% gel or solution to treat warts; it
is not used for anogenital warts and is generally used for verrucae. Its
effect on viruses is variable. Patients should be warned that glutaraldehyde
will stain the skin brown, although this will fade after treatment
has stopped.
Practical points
Application of treatments
Treatments containing salicylic acid should be applied daily. The treatment
is helped by prior soaking of the affected hand or foot in warm
water for 5–10 min to soften and hydrate the skin, increasing the action
of the salicylic acid. Removal of dead skin from the surface of the
wart by gentle rubbing with a pumice stone or emery board ensures
that the next application reaches the surface of the lesion. Occlusion
of the wart using an adhesive plaster helps to keep the skin macerated,
maximising the effectiveness of salicylic acid.
WARTS AND VERRUCAE 169
Protection of the surrounding skin is important and can be achieved
by applying a layer of petroleum jelly to prevent the treatment from
making contact with healthy skin. Application of the liquid or gel using
an orange stick will help to confine the substance to the lesion
itself.
Warts and skin cancer
Premalignant and malignant lesions can sometimes be thought to be
warts by the patient. There are different types of skin cancer. They can
be divided into two categories: non-pigmented (i.e. skin-coloured) and
pigmented (i.e. brown).
Non-pigmented. In this group, which is more likely to occur in the
elderly, the signs might include a persisting small ulcer or sore that
slowly enlarges but never seems to heal. Sometimes a crust forms but
when it falls off, the lesion is still present. In the case of a basal cell
carcinoma (rodent ulcer), the lesion typically has a circular, raised and
rolled edge.
Pigmented. Pigmented lesions or moles can turn malignant. These can
occur in patients of a much younger age than the first group. Changes
in nature or appearance of pigmented skin lesions that warrant referral
for further investigation include:
Increase in size
Irregular outline (surface and edge)
Colour change, especially to black
Itching or bleeding
Satellite lesions (near main lesion).
Plates 9 and 10 show a melanoma and a superficial spreading
melanoma.
Length of treatment required
Several weeks’ continuous treatment is usually needed up to 3 months
for both warts and verrucae. Patients need to know that a long period
of treatment will be required and that they should not expect instant
or rapid success. An invitation to come back to see the pharmacist and
report progress can help the pharmacist to monitor the treatment. If
treatment has not been successful after 3 months, referral for removal
using liquid nitrogen may be required.
Verrucae and swimming pools
Viruses are able to penetrate moist skin more easily than dry skin, and
it has been suggested that the high level of use of swimming pools has
170 SKIN CONDITIONS
contributed to the high incidence of verrucae. Theoretically, walking
barefoot on abrasive surfaces by the pool or changing area can lead to
infected material from the verruca being rubbed into the flooring. There
has been controversy about whether wearing rubber socks can protect
against the spread of verrucae. Also, the wearing of this conspicuous
article might in itself create stigma for the child involved.
WARTS AND VERRUCAE 171
Scabies
Infestation by the scabies mite, Sarcoptes scabiei, causes a characteristically
intense itching, which is worse during the night. The itch of
scabies can be severe and scratching can lead to changes in the appearance
of the skin. It is therefore necessary to take a careful history.
Scabies goes through peaks and troughs of prevalence, with a peak
occurring every 15–20 years, and pharmacists need to be aware when
a peak is occurring.
What you need to know
Age
Infant, child, adult
Symptoms
Itching, rash
Presence of burrows
History
Signs of infection
Medication
Significance of questions and answers
Age
Scabies infestation can occur at any age from infancy onwards. The
pharmacist may feel it best to refer infants and young children to the
doctor if scabies is suspected.
Symptoms
The scabies mite burrows down into the skin and lives under the surface.
The presence of the mites sets up an allergic reaction, thought to
be due to the insect’s coat and exudates, resulting in intense itching.
A characteristic feature of scabies is that itching is worse at night and
can lead to loss of sleep.
Burrows can sometimes be seen as small thread-like grey lines. The
lines are raised, wavy and about 5–10 mm long. Commonly infested
sites include the web space of the fingers and toes, wrists, armpits,
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
172 SKIN CONDITIONS
buttocks and genital area. Patients may have a rash that does not always
correspond to the areas of infestation. The rash may be patchy and
diffuse or dense and erythematous. It is more commonly found around
the midriff, underarms, buttocks, inside the thighs and around the
ankles.
In adults, scabies rarely affects the scalp and face, but in children
aged 2 years or under and in the elderly, involvement of the head is
more common, especially the postauricular fold.
Burrows may be indistinct or may have been disguised by scratching
which has broken and excoriated the skin. Scabies can mimic other skin
conditions and may not present with the classic features. The itch tends
to be generalised rather than in specific areas. In immunocompromised
or debilitated patients (e.g. the elderly), scabies presents differently.
The affected skin can become thickened and crusted. Mites survive
under the crust and any sections that become dislodged are infectious
to others because of the living mites they contain.
History
The itch of scabies can take several (6–8) weeks to develop in someone
who has not been infested previously. The scabies mite is transmitted
by close personal contact, so patients can be asked whether anyone
else they know is affected by the same symptoms, e.g. other family
members, boyfriends and girlfriends.
Signs of infection
Scratching can lead to excoriation, so secondary infections such as impetigo
can occur. The presence of a weeping yellow discharge or yellow
crusts would be indications for referral to the doctor for treatment.
Medication
It is important for the pharmacist to establish whether any treatment
has been tried already and, if so, its identity. The patient should be
asked about how any treatment has been used, since incorrect use can
result in treatment failure. The itch of scabies may continue for several
days or even weeks after successful treatment, so the fact that itching
has not subsided does not necessarily mean that treatment has been
unsuccessful.
When to refer
Babies and children
Infected skin
Treatment failure
Unclear diagnosis
SCABIES 173
Management
There is relatively little evidence from RCTs of scabies treatment. Permethrin
cream is an effective scabicide (acaricide) and malathion can
be used where permethrin is not suitable. Two treatments are recommended,
7 days apart. Aqueous lotions are used in preference to alcoholic
versions because the latter sting and irritate excoriated skin.
Medical supervision is required for the treatment of scabies in children
under 2 years.
The treatment is applied to the entire body including the neck, face,
scalp and ears in adults. Particular attention should be paid to the
webs of fingers, toes and soles of the feet, and under the ends of the
fingernails and toenails.
Permethrin
The cream formulation is used in the treatment of scabies. For a single
application in an adult, 30–60 g of cream (one to two 30-g tubes) is
needed. The cream is applied to the whole body and left on for 8–12 h
before being washed off. If the hands are washed with soap and water
within 8 h of application, cream should be reapplied to the hands.
Medical supervision is required for its use in children under 2 years
and in elderly patients (aged 70 years and over). Permethrin can itself
cause itching and reddening of the skin.
Malathion
Malathion is effective for the treatment of scabies and pediculosis (head
lice). For one application in an adult, 100 mL of lotion should be
sufficient. The aqueous lotion should be used in scabies. The lotion
is applied to the whole body. The lotion can be poured into a bowl
and then applied on cool, dry skin using a clean, broad paintbrush or
cotton wool. The lotion should be left on for 24 h, without bathing,
after which it is washed off. If the hands are washed with soap and
water during the 24 h, malathion should be reapplied to the hands.
Skin irritation may sometimes occur. Medical supervision is needed
for children under 6 months.
Practical points
1 The itch will continue and may become worse in the first few days
after treatment. The reason for this is thought to be the release of
allergen from dead mites. Patients need to be told that the itch will not
stop straightaway after treatment. Crotamiton cream or lotion could be
used to relieve the symptoms, provided the skin is not badly excoriated.
An oral antihistamine such as promethazine may be considered if the
itch is severe.
174 SKIN CONDITIONS
2 The treatment should be applied to cool, dry skin. Good advice
would be to apply the treatment immediately before bedtime (leaving
time for the cream to be absorbed or the lotion to dry). Because the
hands are likely to be affected by scabies, it is important not to wash the
hands after application of the treatment and to reapply the preparation
if the hands are washed within the treatment period.
3 All members of the family or household should be treated, preferably,
on the same day. Because the itch of scabies may take several weeks
to develop, people may be infested but symptomless. It is thought that
patients may not develop symptoms for up to 8 weeks after infestation.
The incubation period of the scabies mite is 3 weeks, so reinfestation
may occur from other family or household members.
4 The scabies mite can live only for around 1 day after leaving its host
and transmission is almost always caused by close personal contact. It
is possible that reinfestation could occur from bedclothes or clothing
and this can be prevented by washing them at a minimum temperature
of 50◦C after treatment.
5 Other possible infestations include those caused by pet fleas and
bedbugs. Pet fleas are common and patients may present with small,
reddened swellings, often on the lower legs and around the ankles
where the pet has come into contact with the skin. Questioning may
reveal that a pet cat or dog has recently been acquired or that a pet
has not been treated with insecticide for some time. Regular checks
for fleas and use of insecticides will prevent the problem occurring
in the future. A range of proprietary products is available to treat
either the pet or bedding and carpets. A second treatment should be
applied 2 weeks after the first to eradicate any fleas that have hatched
since the first application. Pet flea bites can be treated with topical
hydrocortisone in anyone over 10 years. Alternatively, an antipruritic
such as crotamiton (with or without hydrocortisone) or calamine cream
can be recommended.
SCABIES 175
Dandruff
Dandruff is a chronic relapsing condition of the scalp, which responds
to treatment but returns when treatment is stopped. The condition
usually appears during puberty and reaches a peak in early adulthood.
Dandruff has been estimated to affect one in two people aged between
20 and 30 years and up to four in ten of those aged between 30 and
40 years. Dandruff is considered to be a mild form of seborrhoeic
dermatitis, associated with the yeast Malassezia furfur. Diagnosis is
straightforward and effective treatments are available OTC.
What you need to know
Appearance
Presence of scales
Colour and texture of scales
Location: scalp, eyebrows, paranasal clefts and others
Severity
Previous history
Psoriasis
Seborrhoeic dermatitis
Aggravating factors
Medication
Significance of questions and answers
Appearance
Dandruff is characterised by greyish-white flakes or scales on the scalp
and an itchy scalp as a result of excessive scaling. In dandruff the epidermal
cell turnover is at twice the rate of those without the condition.
A differential diagnosis for severe dandruff could be psoriasis. In the
latter conditions, both the appearance and the location would be different.
In more severe cases of seborrhoeic dermatitis the scales are
yellowish and greasy looking and there is usually some inflammation
with reddening and crusting of the affected skin (Plate 11). In psoriasis
the scales are silvery-white and associated with red, patchy plaques and
inflammation (Plate 12).
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
176 SKIN CONDITIONS
Location
In dandruff the scalp is the only area affected. More widespread seborrhoeic
dermatitis affects the areas where there is greatest sebaceous
gland activity, so it can affect eyebrows, eyelashes, moustache,
paranasal clefts, behind the ears, nape of neck, forehead and chest.
In infants seborrhoeic dermatitis is common and occurs as cradle
cap, appearing in the first 12 weeks of life.
Psoriasis can affect the scalp but other areas are involved. The knees
and elbows are commonly involved but the face is rarely affected. This
latter point distinguishes psoriasis from seborrhoeic dermatitis, where
the face is often affected.
Severity
Dandruff is generally a mild condition. However, the itching scalp may
lead to scratching, which may break the skin, causing soreness and the
possibility of infection. If the scalp is very sore or there are signs of
infection (crusting or weeping), referral should be indicated.
Previous history
Since dandruff is a chronic relapsing condition there will usually be a
previous history of fluctuating symptoms. There is a seasonal variation
in symptoms, which generally improve in summer in response to UVB
light. M. furfur is unaffected by UVA light.
Aggravating factors
Hair dyes and perms can irritate the scalp. Inadequate rinsing after
shampooing the hair can leave traces of shampoo causing irritation
and itching.
Psoriasis can be exacerbated by drugs (e.g. chloroquine).
Medication
Various treatments may already have been tried. It is important to
identify what has been tried and how it was used. Dandruff treatments
need to be applied to the scalp and be left for at least 5 min for best
effect. However, if an appropriate treatment has been correctly used
with no improvement, referral should be considered.
When to refer
Suspected psoriasis
Signs of infection
Unresponsive to appropriate treatment
DANDRUFF 177
Treatment timescale
Dandruff should start to improve within 12 weeks of beginning treatment.
Management
The aim of the treatment is to reduce the level of M. furfur on the scalp;
therefore, agents with antifungal action are effective. Ketoconazole,
selenium sulphide, zinc pyrithione and coal tar are effective. The results
from studies suggest that ketoconazole is the most and coal tar is the
least effective. All treatments need to be left on the scalp for 3–5 min
for full effect.
Ketoconazole
Ketoconazole 2% shampoo is used twice a week for 2–4 weeks, after
which usage should reduce to weekly or fortnightly as needed to
prevent recurrence. It is considered first line in moderate-to-severe dandruff.
The shampoo can also be used in seborrhoeic dermatitis. Whilst
shampooing the lather can be applied to the other affected areas and
left before rinsing.
Ketoconazole is not absorbed through the scalp and side-effects are
extremely rare. There have been occasional reports of allergic reactions.
Zinc pyrithione
Zinc pyrithione is effective against dandruff and has a cytostatic effect.
It should be used twice weekly for the first 2 weeks and then once
weekly as required.
Selenium sulphide 2.5%
Selenium sulphide has been shown to be effective and works by reducing
the cell turnover rate (cytostatic effect). Twice-weekly use for
the first 2 weeks is followed by weekly use for the next 2 weeks; then
it can be used as needed. The hair and scalp should be thoroughly
rinsed after using selenium sulphide shampoo; otherwise discoloration
of blond, grey or dyed hair can result. Frequent use can make the scalp
greasy and therefore exacerbate seborrhoeic dermatitis. Products containing
selenium sulphide should not be used within 48 h of colouring
or perming the hair. Contact dermatitis has occasionally been reported.
Selenium sulphide should not be applied to inflamed or broken skin.
Coal tar
Findings from research studies indicate that coal tar is the least effective
of the antidandruff agents. Modern formulations are pleasanter

برچسب ها: Athlete’s foot Apply once or twice daily for 1 week Apply once daily for one week Apply once between the toes and to the soles and sides of the feet. Leave in contact for 24 h. Apply once daily for one week Dhobie itch (‘jock itch’) Apply once or twice daily for 1–2 weeks Apply once daily for one week — Apply once daily for one week Ringworm — Apply once daily for one week — Apply once daily for one week Tolnaftate Tolnaftate is available in powder، cream، aerosol and solution formulations and is effective against athlete’s foot. It has antifungal، but not antibacterial، action. It should be applied twice daily and treatment should be continued for up to 6 weeks. Tolnaftate may sting slightly when applied to infected skin. Undecenoates (e.g. zinc undecenoate، undecenoic acid and methyl and propyl undecylenate) Undecenoic acid is an antifungal agent، sometimes formulated with zinc salt to give additional astringent properties. Treatment should be continued for 4 weeks. Hydrocortisone cream or ointment Hydrocortisone may be sold OTC for allergic and irritant dermatitis،  

تاریخ : دوشنبه 25 اسفند 1393 | 11:51 ب.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th




The most likely cause is an irritant dermatitis caused by increased recent
exposure to water and detergents. There are no signs of infection and
it would be reasonable to recommend treatment with topical hydrocortisone
or clobetasone. The skin is dry, so an ointment formulation
would be helpful. Wearing rubber gloves to protect the skin would
help. Regular and frequent use of an emollient will also be helpful.
The doctor’s view
If his skin does not settle with the pharmacist’s advice over the next
week or two, it would be appropriate to suggest seeing his GP. In the
consultation with the GP, it would be helpful to find out what his understanding
of the problem is, how he thinks it is caused and what
concerns he may have. He might, for example, think that it is caused
solely by an infection and be contagious. Similarly his expectations of
what can be done to help need to be explored. He might, for instance, be
expecting a complete cure; some people expect oral medication rather
than topical creams. Exploration of his ideas, concerns and expectations
will lead to a more satisfactory outcome. He will be more likely
to adhere to the advice and treatment.
In this case he might benefit from a stronger steroid cream (0.1%
betamethasone) and a change of emollient. The most important aspect
for the future would be prevention by protection from frequent contact
with detergents.
Case 4
You are asked to speak to a patient on the phone about some cream she
purchased at your pharmacy earlier today. The patient says she bought
146 SKIN CONDITIONS
some Eumovate eczema and dermatitis cream for a rash caused by a
new deodorant. However, when she got back home and read the patient
information leaflet (PIL), she discovered that it should not be used by
breastfeeding mothers without medical advice. She had her first baby
4 months ago and is breastfeeding.
The pharmacist’s view
I didn’t realise that the PIL for Eumovate said this about breastfeeding,
so this phone call put me on the spot. I thought about the possible risk
and decided it was very small. The treatment was going to be used
only for a few days and the amount of steroid that might be absorbed
through the skin would be absolutely tiny. However, I didn’t want
to undermine her confidence. I was also a bit worried about where I
stood if I gave advice that was different from the PIL. But in the end I
decided to use my own judgement. I told her that I would explain why
the warning is in the leaflet, would give her my opinion and then see
what she wanted to do. I said that if she would prefer it, she could use a
simple soothing cream on the rash. I also said that if it was inconvenient
for her to come back to the pharmacy, I could arrange for the other
cream to be delivered by our prescription delivery van.
The patient’s view
I was really worried when I got home and read the leaflet. You don’t
expect that putting something on a rash might mean you can’t breastfeed.
I thought maybe something in the cream could be dangerous to
my baby. The pharmacist spent time talking it through with me and
in the end I decided to go for the soothing cream instead, to be on the
safe side.
The doctor’s view
It is unlikely that Eumovate would cause any problems for the baby,
especially as the treatment is going to be very short term. The advice
given about corticosteroids and breastfeeding in the BNF states that
‘maternal doses of up to 40-mg prednisolone daily by mouth are unlikely
to cause any systemic effects in infants’. As so little of this topical
moderate-potency steroid is likely to be absorbed, the chances of any
problems are unlikely. It is probable that the warning is included in the
PIL because there is no research evidence available in this situation.
ECZEMA/DERMATITIS 147
Acne
The incidence of acne in teenagers is extremely high and it has been
estimated that over half of all adolescents will experience some degree
of acne. Most acne sufferers resort, at least initially, to self-treatment.
Mild acne often responds well to correctly used OTC treatments. Acne
has profound effects on patients, and pharmacists should remember
that even mild acne is seen as stigmatising for teenagers and moderateto-
severe acne can be a major problem and a source of depression for
some. A sympathetic response to requests for help, together with an
invitation to return and report progress, can be as important as the
treatment selected.
What you need to know
Age
Severity
Mild, moderate, severe
Affected areas
Duration
Medication
Significance of questions and answers
Age
Acne commonly occurs during the teenage years and its onset is most
common at puberty, although it may start to appear a year or so earlier.
Acne can persist for anything from a few months to several years;
with onset at puberty, acne may continue until the late teens or even
early twenties. The hormonal changes that occur during puberty, especially
the production of androgens, are thought to be involved in
the causation of acne. Increased keratin and sebum production during
adolescence are thought to be important contributory factors; the increased
amount of keratin leads to blockages of the follicles and the
formation of microcomedones. A microcomedone can develop into a
non-inflammatory lesion (comedone), which may be open (blackhead)
or closed (whitehead), or into an inflammatory lesion (papule, pustule
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
148 SKIN CONDITIONS
or nodule). Excess sebum encourages the growth of bacteria, particularly
Propionibacterium acnes, which are involved in the development
of inflammatory lesions. Acne can thus be non-inflammatory or inflammatory
in nature.
Very young
Acne is extremely rare in young children and babies and any such cases
should be referred to the doctor for investigation since an androgensecreting
(hormone-producing) tumour may be responsible.
Older
For patients in whom acne begins later than the teenage years, other
causes should be considered, including drug therapy (discussed below)
and occupational factors. Oils and greases used at work can precipitate
acne and it would be worth asking whether the patient comes into contact
with such agents. Acne worsens just before or during menstruation
in some women; this is thought to be due to changes in progesterone
levels.
Severity
OTC treatment may be recommended for mild acne. Comedones may
be open or closed; the sebum in closed comedones cannot reach the
surface of the skin. The plug of keratin, which is at the entrance to the
follicle in a comedone, is initially white (a whitehead), later becoming
darker coloured because of the accumulation of melanin (a blackhead).
However, sebum is still produced, so swelling occurs and the comedone
eventually ruptures, discharging its contents under the skin’s surface.
The released sebum causes an inflammatory response; if the response
is not severe, small red papules appear. In more severe acne, angrylooking
red pustules are seen and referral to the doctor for alternative
forms of treatment such as topical or systemic antibiotics is needed.
Affected areas
In acne, affected areas may include the face, neck, centre of the chest,
upper back and shoulders, i.e. all areas with large numbers of sebaceous
glands. Rosacea is a skin condition that is sometimes confused with
acne (Plate 3). Occurring in young and middle-aged adults, rosacea
has characteristic features of reddening, papules and pustules. Only
the face is affected.
Duration
The information gained here should be considered in conjunction with
facts about medication (prescribed or OTC) tried already and other
medicines being taken. Acne of long duration where several OTC
ACNE 149
preparations have been correctly used without success indicates referral
to the doctor.
Medication
The pharmacist should establish the identity of any treatment tried
already and its method of use. Inappropriate use of medication, e.g.
infrequent application, could affect the chances of success.
Information about current therapy is important, since acne can
sometimes be drug induced. Lithium, phenytoin and the progestogens,
levonorgestrel and norethisterone (e.g. in the combined oral contraceptive
pill), may be culprits. If acne is suspected as a result of drug
therapy, patients should be advised to discuss this with their doctor.
When to refer
Severe acne
Failed medication
Suspected drug-induced acne
Treatment timescale
A patient with mild acne, which has not responded to treatment within
8 weeks, should be referred to the doctor.
Management
Dozens of products are marketed for the treatment of acne. The pharmacist
can make a logical selection based on knowledge of likely efficacy.
The general aims of therapy are to remove follicular plugs so
that sebum is able to flow freely and to reduce the number of bacteria
on the skin. Treatment should therefore reduce comedone formation.
The most useful formulations are lotions, creams and gels. Gels with
an alcoholic base dry quickly but can be irritating. Those with an
aqueous base dry slower but are less likely to irritate the skin. A noncomedogenic
moisturiser can help if the skin becomes dry as a result
of treatment.
Benzoyl peroxide
Benzoyl peroxide has both antibacterial and anticomedogenic actions
and is the first-line OTC treatment for inflammatory and noninflammatory
acne. Anti-inflammatory action occurs at all strengths.
Anticomedogenic action is low and has the greatest effect at higher
strengths. It has a keratolytic action, which increases the turnover of
skin cells, helping the skin to peel. Regular application can result in
150 SKIN CONDITIONS
improvement of mild acne. At first, benzoyl peroxide is very likely to
produce reddening and soreness of the skin, and patients should be
warned of this (see ‘Practical points’ below). Treatment should start
with a 2.5 or 5.0% product, moving gradually to the 10.0% strength
if needed. Gels can be helpful for people with oily skin and creams for
those with dry skin. Washing the skin with a mild soap or cleansing
product rinsed off with water before applying benzoyl peroxide can
help by reducing the amount of sebum on the skin.
Benzoyl peroxide prevents new lesions forming rather than shrinking
existing ones. Therefore it needs to be applied to the whole of the
affected area, not just to individual comedones, and is best applied to
skin following washing. During the first few days of use, the skin is
likely to redden and may feel slightly sore. Stinging, drying and peeling
are likely. Warning should be given that such an irritant effect is likely
to occur; otherwise treatment may be abandoned inappropriately.
One approach to minimise reddening and skin soreness is to begin
with the lowest strength preparation and to apply the cream, lotion
or gel sparingly and infrequently during the first week of treatment.
Application once daily or on alternate days could be tried for a week
and then frequency of use increased to twice daily. After 2 or 3 weeks,
a higher strength preparation may be introduced. If irritant effects do
not improve after 1 week or are severe, use of the product should be
discontinued.
Sensitisation
Occasionally, sensitisation to benzoyl peroxide may occur. The skin
becomes reddened, inflamed and sore, and treatment should be discontinued.
Bleaching
Warning should be given that benzoyl peroxide can bleach clothing
and bedding. If it is applied at night, white sheets and pillowcases are
best used and patients can be advised to wear an old T-shirt or shirt to
minimise damage to good clothes. Contact between benzoyl peroxide
and the eyes, mouth and other mucous membranes should be avoided.
Other keratolytics
Other keratolytics include potassium hydroxyquinoline sulphate and
salicylic acid. They are second-line treatments.
Nicotinamide
Topical nicotinamide has a mild anti-inflammatory action and is applied
twice daily. There is limited evidence of effectiveness. Side-effects
may include skin dryness and/or irritation.
ACNE 151
Antibacterials
Skin washes and soaps containing antiseptic agents such as chlorhexidine
are available. Such products may be useful in acne by degreasing
the skin and reducing the skin flora. There is limited evidence of effectiveness.
Practical points
Information on acne for teenagers
The website www.teenagehealthfreak.com is a useful source of practical
information for teenagers with health concerns including acne.
As well as explaining what acne is and what can be used to treat it,
site users can read other teenagers’ queries about acne and Dr Ann’s
replies.
Diet
There is no evidence to link diet with acne, despite a common belief
that chocolate and fatty foods cause acne or make it worse.
Sunlight
It is commonly believed that there are beneficial effects of sunlight on
acne, thought to be due to its peeling effect, which helps to unblock
follicles, and its drying or degreasing effect. A systematic review found
that ‘convincing direct evidence for a positive effect of sunlight exposure
on acne is lacking’.
Antibiotics
The resistance of Propionibacterium acnes to antibiotics is increasing.
The pharmacist is in a good position to ensure that acne treatments
are used correctly. Oral antibiotic therapy usually consists of tetracyclines
(minocycline is more commonly used as there is less resistance,
better absorption and it needs a dose only once daily) and patients
should be reminded not to eat or drink dairy products up to 1 h before
or after taking the antibiotic. The same rule applies to antacid or
iron preparations. Evidence suggests that failure of antibiotic therapy
in acne in the past may have been due to subclinical levels of antibiotic
because of chelation by metal ions in dairy products or antacids.
Other antibiotics used orally include erythromycin and trimethoprim.
Bacterial resistance to erythromycin is now high, so it may not be effective.
Trimethroprim is sometimes used when acne is resistant to other
bacterials, although it is an unlicensed indication.
Topical antibiotics are used as an alternative to oral antibiotics but
are not as effective. They are useful in inflammatory acne. Topical
erythromycin combined with benzoyl peroxide or zinc may induce less
bacterial resistance than does oral therapy alone.
152 SKIN CONDITIONS
Continuous treatment
Acne is notoriously slow to respond to treatment and a period of up to
6 months may be required for maximum benefit. It is generally agreed
that keratolytics such as benzoyl peroxide require a minimum of 6–
8 weeks’ treatment for benefit to be shown. Patients should therefore
be encouraged to persevere with treatment, whether with OTC or prescription
products, and told not to feel discouraged if results are not
immediate. Research has shown that many teenagers have unrealistic
expectations of the time needed for improvement to be seen, perhaps
created by the advertising for some treatments. The patient also needs
to understand that acne is a chronic condition and continuous treatment
is needed to keep the problem under control.
Skin hygiene
Acne is not caused by poor hygiene or failure to wash the skin sufficiently
often. Regular washing of the skin with soap and warm water
or with an antibacterial soap or skin wash can be helpful as it degreases
the skin and reduces the number of bacteria present. However the evidence
for face cleansing in the management of acne is mostly from
poor-quality studies.
Since personal hygiene is a sensitive area, an initial enquiry about
the kind of soap or wash currently being used might be a tactful way
to introduce the subject. Dermabrasion with facial scrubs removes the
outer layer of dead skin and must be done gently. There is no evidence
of effectiveness of this approach in acne.
Topical hydrocortisone and acne
The use of topical hydrocortisone is contraindicated in acne because
steroids can potentiate the effects of androgenic hormones on the sebaceous
glands, hence making acne worse.
Make-up
Heavy, greasy make-up can only exacerbate acne. If make-up is to
be worn, water-based rather than oily foundations are best, and they
should be removed thoroughly at the end of the day.
ACNE 153
Athlete’s foot
The incidence of athlete’s foot (tinea pedis) is not, as its name might suggest,
limited to those of an athletic disposition. The fungus that causes
the disease thrives in warm, moist conditions. The spaces between the
toes can provide a good growth environment and the infection therefore
has a high incidence. The problem is more common in men than
in women and responds well to OTC treatment.
What you need to know
Duration
Appearance
Severity
Broken skin
Soreness
Secondary infection
Location
Previous history
Medication
Significance of questions and answers
Duration
Considered together with its severity, a long-standing condition may
make the pharmacist decide to refer the patient. However, most cases
of athlete’s foot are minor in nature and can be treated effectively with
OTC products.
Appearance
Athlete’s foot usually presents as itchy, flaky skin in the web spaces
between the toes. The flakes or scales of skin become white and macerated
and begin to peel off. Underneath the scales, the skin is usually
reddened and may be itchy and sore. The skin may be dry and scaly or
moist and weeping. (see Plate 4).
Severity
Athlete’s foot is usually a mild fungal infection, but occasionally the
skin between the toes becomes more macerated and broken and deeper
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
154 SKIN CONDITIONS
and painful fissures may develop. The skin may then become inflamed
and sore. Once the skin is broken, there is the potential for secondary
bacterial infection to develop. If there are indications of bacterial involvement,
such as weeping, pus or yellow crusts, then referral to the
doctor is needed.
Location
Classically, the toes are involved, the web space between the fourth
and fifth toes being the most commonly affected. More severe infections
may spread to the sole of the foot and even to the upper surface
in some cases. This type of spread can alter the appearance of the condition
and severe cases are probably best referred to the doctor for
further investigation. When other areas of the foot are involved, the
appearance can be confused with that of allergic dermatitis. However,
in eczema or dermatitis, the spaces between the toes are usually spared,
in contrast to athlete’s foot.
If the toenails appear to be involved, referral to the doctor may be
necessary depending on how many toenails are affected and severity.
Systemic antifungal treatment may be required to deal with infection
of the nail bed where OTC treatment is not appropriate.
Previous history
Many people occasionally suffer from athlete’s foot. The pharmacist
should ask about previous bouts and about the action taken in response.
Any diabetic patient who presents with athlete’s foot is best
referred to the doctor. Diabetics may have impaired circulation or innervation
of the feet and are more prone to secondary infections in
addition to poorer healing of open wounds.
Medication
One or more topical treatments may have been tried before the patient
seeks advice from the pharmacist. The identity of any treatment and
the method of use should be established. Treatment failure may occur
simply because it was not continued for sufficiently long enough.
However, if an appropriate antifungal product has been used correctly
without remission of symptoms, the patient is best referred to the doctor,
especially if the problem is of long duration (several weeks).
When to refer
Severe, affecting other parts of the foot
Signs of bacterial infection
Unresponsive to appropriate treatment
Diabetic patients
Involvement of toenails
ATHLETE’S FOOT 155
Treatment timescale
If athlete’s foot has not responded to treatment within 2 weeks, patients
should see their doctor.
Management
Many preparations are available for the treatment of athlete’s foot. Formulations
include creams, powders, solutions, sprays and paints. A systematic
review of clinical evidence compared topical allylamines (e.g.
terbinafine), azoles (e.g. clotrimazole, miconazole and ketoconazole),
undecenoic acid and tolnaftate. All are more effective than placebo.
Topical allylamines have been tested against topical azoles; cure rates
were the same. However, terbinafine was more effective in preventing
recurrence. Terbinafine and ketoconazole have a 1-week treatment
period, which some patients may prefer.
Pharmacists should instruct patients on how to use the treatment
correctly and on other measures that can help to prevent recurrence
(see ‘Practical points’ below). Regular application of the recommended
product to clean, dry feet is essential and treatment must be continued
after symptoms have gone to ensure eradication of the fungus. Individual
products state the length of treatment and generally advise use for
1–2 weeks after the disappearance of all signs of infection.
Azoles (e.g. clotrimazole, ketoconazole and miconazole)
Topical azoles can be used to treat many topical fungal infections, including
athlete’s foot. They have a wide spectrum of action and have
been shown to have both antifungal and antibacterial activity. (The latter
is useful as secondary infection can occur.) The treatment should be
applied two or three times daily. Formulations include creams, powders
and sprays. Miconazole, clotrimazole and ketoconazole have occasionally
been reported to cause mild irritation of the skin. Ketoconazole
has a 1-week treatment period.
Terbinafine
Terbinafine is available as cream, solution, spray and gel formulations.
Their licensed indications and treatment schedules are shown in the
table below. There is evidence that terbinafine is better than the azoles
in preventing recurrence, so it will be useful where frequent bouts
of athlete’s foot are a problem. Terbinafine can cause redness, itching
and stinging of the skin; contact with the eyes should

برچسب ها: The most likely cause is an irritant dermatitis caused by increased recent exposure to water and detergents. There are no signs of infection and it would be reasonable to recommend treatment with topical hydrocortisone or clobetasone. The skin is dry، so an ointment formulation would be helpful. Wearing rubber gloves to protect the skin would help. Regular and frequent use of an emollient will also be helpful. The doctor’s view If his skin does not settle with the pharmacist’s advice over the next week or two، it would be appropriate to suggest seeing his GP. In the consultation with the GP، it would be helpful to find out what his understanding of the problem is، how he thinks it is caused and what concerns he may have. He might، for example، think that it is caused solely by an infection and be contagious. Similarly his expectations of what can be done to help need to be explored. He might،  

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کتاب علائم در داروخانه Symptoms in the Pharmacy 6th




told she had IBS. The doctor said it was all due to stress, which had
upset her. Over the last year she has started a new job and moved into
new accommodation. She eats a healthy diet and exercises regularly.
The pharmacist’s view
The history here is not straightforward and although Jane’s symptoms
are indicative of IBS, which she says she has had before, the symptoms
are different on this occasion. The best course of action is to refer her
to the doctor for further investigation.
The doctor’s view
Jane probably has IBS but there is insufficient information so far to
make that diagnosis. It is not uncommon to have upper abdominal
pain with IBS, but other possibilities need to be considered. It sounds
as though Jane thinks it is coming from her stomach. She may fear that
she has an ulcer. She also mentions urinary frequency, which may well
be associated with IBS but could be a urinary infection. A referral to her
doctor is sensible to make a complete assessment of her symptoms. It is
likely that the assessment would just involve listening to her description
of her problem, gathering more information and a brief examination
of her abdomen. A urine sample would show whether or not she had a
urinary infection. If there was still doubt about the diagnosis, a referral
to a gastroenterologist at the local hospital could be made. Between 20
and 50% of referrals to gastroenterologists turn out to be due to IBS.
The main purpose of referral is for a diagnosis.
If the doctor thinks Jane has IBS, an explanation of the syndrome
would be helpful in addition to dealing with her concerns about a
stomach ulcer. Whether or not psychological factors cause IBS there is
no doubt that the stresses of life can aggravate symptoms. It therefore
makes sense to help sufferers to make this connection, so they can
consider different ways of dealing with stress.
Often the above approach is effective treatment in itself. However,
if Jane did want some medication, a bulk bowel regulator to help her
constipation plus some antispasmodic tablets would be of value.
IRRITABLE BOWEL SYNDROME 127
Haemorrhoids
Haemorrhoids (commonly known as piles) can produce symptoms of
itching, burning, pain, swelling and discomfort in the perianal area
and anal canal and rectal bleeding. Haemorrhoids are swollen veins,
rather like varicose veins, which protrude into the anal canal (internal
piles). They may swell so much that they hang down outside the anus
(external piles). Haemorrhoids are often caused or exacerbated by inadequate
dietary fibre or fluid intake. The pharmacist must, by careful
questioning, differentiate between this minor condition and others that
may be potentially more serious.
What you need to know
Duration and previous history
Symptoms
Itching, burning
Soreness
Swelling
Pain
Blood in stools
Constipation
Bowel habit
Pregnancy
Other symptoms
Abdominal pain/vomiting
Weight loss
Medication
Significance of questions and answers
Duration and previous history
As an arbitrary guide, the pharmacist might consider treating haemorrhoids
of up to 3 weeks’ duration. It would be useful to establish
whether the patient has a previous history of haemorrhoids and if the
doctor has been seen about the problem. A recent examination by the
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
128 GASTROINTESTINAL TRACT PROBLEMS
doctor that has excluded serious symptoms would indicate that treatment
of symptoms by the pharmacist would be appropriate.
Symptoms
The term haemorrhoids includes internal and external piles, which can
be further classified as (1) those which are confined to the anal canal
and cannot be seen; (2) those which prolapse through the anal sphincter
on defaecation and then reduce by themselves or are pushed back
through the sphincter after defaecation by the patient; (3) those which
remain persistently prolapsed and outside the anal canal. These three
types are sometimes referred to as first, second and third degree, respectively.
Predisposing factors for haemorrhoids include diet, sedentary
occupation and pregnancy and there is thought to be a genetic
element.
Pain
Pain is not always present; if it is, it may take the form of a dull ache
and may be worse when the patient is having a bowel movement. A
severe, sharp pain on defaecation may indicate the presence of an anal
fissure, which can have an associated sentinel pile (a small skin tag
at the posterior margin of the anus) and requires referral. A fissure
is a minute tear in the skin of the anal canal. It is usually caused by
constipation and can often be managed conservatively by correcting
this and using a local anaesthetic-containing cream or gel. In severe
cases a minor operation is sometimes necessary.
Irritation
The most troublesome symptom for many patients is itching and irritation
of the perianal area rather than pain. Persistent or recurrent
irritation, which does not improve, is sometimes associated with rectal
cancer and should be referred.
Bleeding
Blood may be deposited onto the stool from internal haemorrhoids as
the stool passes through the anal canal. This fresh blood will appear
bright red. It is typically described as being splashed around the toilet
pan and may be seen on the surface of the stool or on the toilet paper.
If blood is mixed with the stool, it must have come from higher up the
GI tract and will be dark in colour (altered blood). If rectal bleeding
is present, the pharmacist would be well advised to suggest that the
patient see the doctor so that an examination can be performed to
exclude more serious pathology such as tumour or polyps. Colorectal
cancer can cause rectal bleeding. The disease is unusual in patients
under 50 and the pharmacist should be alert for the middle-aged patient
HAEMORRHOIDS 129
with rectal bleeding. This is particularly so if there has been a significant
and sustained alteration in bowel habit.
Constipation
Constipation is a common causatory or exacerbatory factor in haemorrhoids.
Insufficient dietary fibre and inadequate fluid intake may be
involved, and the pharmacist should also consider the possibility of
drug-induced constipation.
Straining at stool will occur if the patient is constipated; this increases
the pressure in the haemorrhoidal blood vessels in the anal canal and
haemorrhoids may result. If piles are painful, the patient may try to
avoid defaecation and ignoring the call to open the bowels will make
the constipation worse.
Bowel habit
A persisting change in bowel habit is an indication for referral, as it may
be caused by a bowel cancer. Seepage of faecal material through the
anal sphincter (one form of faecal incontinence) can produce irritation
and itching of the perianal area and may be caused by the presence of
a tumour.
Pregnancy
Pregnant women have a higher incidence of haemorrhoids than nonpregnant
women. This is thought to be due to pressure on the haemorrhoidal
vessels due to the gravid uterus. Constipation in pregnancy is
also a common problem because raised progesterone levels mean that
the gut muscles tend to be more relaxed. Such constipation can exacerbate
symptoms of haemorrhoids. Appropriate dietary advice can be
offered by the pharmacist (see the chapter on ‘Women’s health’).
Other symptoms
Symptoms of haemorrhoids remain local to the anus. They do not cause
abdominal pain, distension or vomiting. Any of these more widespread
symptoms suggest other problems and require referral.
Tenesmus (the desire to defaecate when there is no stool present in
the rectum) sometimes occurs when there is a tumour in the rectum.
The patient may describe a feeling of often wanting to pass a motion
but no faeces being present. This symptom requires urgent referral.
Medication
Patients may already have tried one or more proprietary preparations
to treat their symptoms. Some of these products are advertised
widely, since the problem of haemorrhoids is perceived as potentially
embarrassing and such advertisements may sometimes discourage patients
from describing their symptoms. It is therefore important for
130 GASTROINTESTINAL TRACT PROBLEMS
the pharmacist to identify the exact nature of the symptoms being experienced
and details of any products used already. If the patient is
constipated, the use of any laxatives should be established.
Present medication
Haemorrhoids may be exacerbated by drug-induced constipation and
the patient should be carefully questioned about current medication,
including prescription and OTC medicines. A list of drugs that may
cause constipation can be found on p. 103. Rectal bleeding in a patient
taking warfarin or another anticoagulant is an indication for referral.
When to refer
Duration of longer than 3 weeks
Presence of blood in the stools
Change in bowel habit (persisting alteration from normal bowel habit)
Suspected drug-induced constipation
Associated abdominal pain/vomiting
Treatment timescale
If symptoms have not improved after 1 week, patients should see their
doctor.
Management
Symptomatic treatment of haemorrhoids can provide relief from discomfort
but, if present, the underlying cause of constipation must also
be addressed. The pharmacist is in a good position to offer dietary advice,
in addition to treatment, to prevent the recurrence of symptoms
in the future.
Local anaesthetics (e.g. benzocaine and lidocaine (lignocaine))
Local anaesthetics can help to reduce the pain and itching associated
with haemorrhoids. There is a possibility that local anaesthetics may
cause sensitisation and their use is best limited to a maximum of 2
weeks.
Skin protectors
Many antihaemorrhoidal products are bland, soothing preparations
containing skin protectors (e.g. zinc oxide and kaolin). These products
have emollient and protective properties. Protection of the perianal skin
is important, because the presence of faecal matter can cause symptoms
such as irritation and itching. Protecting agents form a barrier on the
HAEMORRHOIDS 131
skin surface, helping to prevent irritation and loss of moisture from the
skin.
Topical steroids
Ointment and suppositories containing hydrocortisone with skin protectors
are available. The steroid reduces inflammation and swelling to
give relief from itching and pain. The treatment should be used each
morning and at night and after a bowel movement. The use of such
products is restricted to those over 18. Treatment should not be used
continuously for longer than 7 days.
Astringents
Astringents such as zinc oxide, hamamelis (witch hazel) and bismuth
salts are included in products on the theoretical basis that they will
cause precipitation of proteins when applied to mucous membranes or
skin which is broken or damaged. A protective layer is then thought to
be formed, helping to relieve irritation and inflammation. Some astringents
also have a protective and mild antiseptic action (e.g. bismuth).
Antiseptics
These are among the ingredients of many antihaemorrhoidal products,
including the medicated toilet tissues. They do not have a specific action
in the treatment of haemorrhoids. Resorcinol has antiseptic, antipruritic
and exfoliative properties. The exfoliative action is thought to be
useful by removing the top layer of skin cells and aiding penetration
of medicaments into the skin. Resorcinol can be absorbed systemically
via broken skin if there is prolonged use and its antithyroid action can
lead to the development of myxoedema (hypothyroidism).
Counterirritants
Counterirritants such as menthol are sometimes included in antihaemorrhoidal
products on the basis that their stimulation of nerve endings
gives a sensation of cooling and tingling, which distracts from the sensation
of pain. Menthol and phenol also have antipruritic actions.
Shark liver oil/live yeast
These agents are said to promote healing and tissue repair, but there is
no scientific evidence to support such claims.
Laxatives
The short-term use of a laxative to relieve constipation might be considered.
A stimulant laxative (e.g. senna) could be supplied for 1 or 2
days to help deal with the immediate problem while dietary fibre and
fluids are being increased. For patients who cannot or choose not to
adapt their diet, bulk laxatives may be used long term.
132 GASTROINTESTINAL TRACT PROBLEMS
Practical points
Self-diagnosis
Patients may say that they have piles, or think they have piles, but
careful questioning by the pharmacist is needed to check whether this
self-diagnosis is correct. If there is any doubt, referral is the best course
of action.
Hygiene
The itching of haemorrhoids can often be improved by good anal hygiene,
since the presence of small amounts of faecal matter can cause
itching. The perianal area should be washed with warm water as frequently
as is practicable, ideally after each bowel movement. Soap will
tend to dry the skin and could make itching worse, but a mild soap
could be tried if the patient wishes to do so. Moist toilet tissues are
available and these can be very useful where washing is not practical,
e.g. at work during the daytime, and some patients prefer them. These
tissues are better used with a patting rather than a rubbing motion,
which might aggravate symptoms. Many people with haemorrhoids
find that a warm bath soothes their discomfort.
An increased intake of dietary fibre will increase bowel output, so
patients should be advised to take care in wiping the perianal area and
to use soft toilet paper to avoid soreness after wiping.
How to use OTC products
Ointments and creams can be used for internal and external haemorrhoids
and should be applied in the morning, at night and after each
bowel movement. An applicator is included in packs of ointments and
creams and patients should be advised to take care in its use, to avoid
any further damage to the perianal skin.
Suppositories can be recommended for internal haemorrhoids. After
removing the foil or plastic packaging (patients have been known to try
and insert them with the packaging left on), a suppository should be
inserted in the morning, at night and after bowel movements. Insertion
is easier if the patient is crouching or lying down.
Haemorrhoids in practice
Case 1
Tom Harris, a customer whom you know quite well, asks if you can
recommend something for his usual problem. You ask him to tell you
more about it: Mr Harris suffers from piles occasionally; you have
dispensed prescriptions for Anusol HC and similar products in the past
and have previously advised him about dietary fibre and fluid intake.
He has been away on holiday for 2 weeks and says he hasn’t been eating
the same foods he does when at home. His symptoms are itching and
HAEMORRHOIDS 133
irritation of the perianal area but no pain and he has a small swelling,
which hangs down from the anus after he has passed a motion, but
which he is able to push back again. He is a little constipated, but he
is not taking any medicines.
The pharmacist’s view
Mr Harris has a previous history of haemorrhoids, which have been
diagnosed and treated by his doctor. It is likely that his holiday and
temporary change in diet have caused a recurrence of the problem,
so he now has a second-degree pile, and it would be reasonable to
suggest symptomatic treatment for a few days. You could recommend
the use of an ointment preparation containing hydrocortisone and skin
protectors for up to 1 week and remind Mr Harris that the area should
be kept clean and dry. You might consider recommending a laxative to
ease the constipation until Mr Harris’s diet gets back to normal (you
advise that he returns to his usual high-fibre diet) and makes sure his
daily fluid intake is sufficient; a small supply of a stimulant laxative
(perhaps a stimulant/stool softener such as docusate sodium) would be
reasonable. He should see his doctor after 1 week if the problem has
not cleared up.
The doctor’s view
The treatment suggested by the pharmacist should settle Mr Harris’s
symptoms within 1 week. The treatment is, of course, symptomatic and
not curative. If he continues to suffer from frequent relapse, referral
should be considered. His doctor could advise whether or not to refer
him for injection or removal of the piles.
Case 2
Mr Briggs is a local shopkeeper in his late fifties who wants you to
recommend something for his piles. He tells you that he has had them
for quite a while – a couple of months. He has tried several different
ointments and suppositories, all to no avail. The main problem now
is bleeding, which has become worse. In fact he tells you, somewhat
embarrassed, that he has been buying sanitary towels because this is
the only way he can prevent his clothes from becoming stained. He is
not constipated and has no pain.
The pharmacist’s view
Mr Briggs should be referred to his doctor at once. His symptoms have
a history of 2 months and there must be quite profuse rectal bleeding,
which may well be due to a more serious disease. He has already tried
some OTC treatments, with no success. His age and the description of
his symptoms mean that further investigation is needed.
134 GASTROINTESTINAL TRACT PROBLEMS
The doctor’s view
Mr Briggs should be advised to see his doctor. This is not a typical
presentation of piles. He will need a more detailed assessment by his
doctor who will need to look for a cancer of the colon or rectum. Piles
can bleed at times other than when defaecating, but this is uncommon.
The doctor would gather more information by questioning and from
an examination. The examination would usually include a digital rectal
assessment to determine whether or not a rectal tumour is present. It is
quite likely that this man would require outpatient hospital referral for
further investigations, which would involve sigmoidoscopy and barium
enema.
Case 3
Caroline Andrews is a young woman in her mid-twenties, who works
as a graphic designer in a local art studio. She asks your advice about
an embarrassing problem: she is finding it very painful to pass motions.
On questioning, she tells you that she has had the problem for
a few days and has been constipated for about 2 weeks. She eats a
diet that sounds relatively low in fibre and has been eating less than
usual because she has been very busy at work. Caroline says she seldom
takes any exercise. She takes the contraceptive pill but is not taking any
medicines and has no other symptoms such as rectal bleeding.
The pharmacist’s view
Caroline would probably be best advised to see her doctor, since the
symptoms and pain which she has described might be due to an anal
fissure, though they may be caused by a haemorrhoid.
The doctor’s view
An anal fissure would be the most likely cause of Caroline’s problem.
An examination by her doctor should quickly confirm this. Correction
of the constipation and future preventative dietary advice could
well solve the problem. The discomfort could be helped by a local
anaesthetic-containing cream or gel. If this is applied prior to a bowel
action, the discomfort would be less. In severe cases that are not settling,
referral to a specialist surgeon is necessary in order to release one
of the muscles in spasm for rapid relief of pain. Topical nitrate (e.g.
GTN 0.2–0.3% ointment) is now also used by hospital specialists to
treat anal fissure (unlicensed indication).
HAEMORRHOIDS 135
Skin Conditions
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5


Eczema/dermatitis
Eczema is a term used synonymously with dermatitis. The latter is
more commonly used when an external precipitating factor is present
(contact dermatitis). The rashes produced have similar features but the
distribution on the body varies and can be diagnostic. Atopic eczema
affects up to 20% of children, in many of whom it disappears or greatly
improves with age such that 2–10% of adults are affected. Atopy is a
term that has been used to describe a group of diseases, e.g. eczema,
asthma and hay fever, which run in families.
The rash of eczema typically presents as dry flaky skin that may be
inflamed and have small red spots (Plate 1). The skin may be cracked
and weepy and sometimes becomes thickened. The rash is irritating
and can be extremely itchy. Many cases of mild-to-moderate eczema
can be managed by the patient with support from the pharmacist.
What you need to know
Age
Distribution of rash
Occupation/contact
Previous history
History of hay fever/asthma
Aggravating factors
Medication
Significance of questions and answers
Age/distribution
The distribution of the rash tends to vary with age. In infants, it is
usually present around the nappy area, neck, back of scalp, face, limb
creases and backs of the wrists (Plate 2).
In white children, the rash is most marked in the flexures: behind
the knees, on the inside of the elbow joints, around the wrists, as well
as the hands, ankles, neck and around the eyes. In black and Asian
children, the rash is often on the extensor surface of the joints and may
have a more follicular appearance.
ECZEMA/DERMATITIS 139
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5
In adults, the neck, the backs of the hands, the groin, around the
anus, the ankles and the feet are the most common sites. The rash of
intertrigo is caused by a fungal infection and is found in skinfolds or
occluded areas such as under the breasts in women and in the groin or
armpits.
Occupation/contact
Contact dermatitis may be caused by substances that irritate the skin
or spark off an allergic reaction. Irritant contact dermatitis is most
commonly caused by prolonged exposure to water (wet work). Typical
occupations include cleaning, hairdressing, food processing, fishing
and metal engineering. Substances that can irritate the skin include
alkaline cleansing agents, degreasing agents, solvents and oils. Such
substances either cause direct and rapid damage to the skin or, in the
case of weaker irritants, exert their irritant effect after continued exposure.
Napkin dermatitis is an example of irritant dermatitis and can
be complicated by infection, e.g. thrush.
In other cases, the contact dermatitis is caused by an allergic response
to substances which include chromates (present in cement and
rust-preventive paint), nickel (present in costume jewellery and as
plating on scissors), rubber and resins (two-part glues and the resin
colophony in adhesive plasters), dyes, certain plants (e.g. primula), oxidising
and reducing agents (as used by hairdressers when perming hair)
and medications (including topical corticosteroids, lanolin, neomycin
and cetyl stearyl alcohol). Eye make-up can also cause allergic contact
dermatitis.
Clues as to whether or not a contact problem is present can be
gleaned from knowledge of site of rash, details of job and hobbies,
onset of rash and agents handled and improvement of rash when away
from work or on holiday.
Previous history
Patients may ask the pharmacist to recommend treatment for eczema,
which has been diagnosed by the doctor. In cases of mild-to-moderate
eczema, it would be reasonable for the pharmacist to recommend the
use of emollients and to advise on skin care. Topical hydrocortisone
and clobetasone preparations can be recommended for the treatment
of mild-to-moderate eczema. However, where severe or infected exacerbations
of eczema have occurred, the patient is best referred to the
doctor.
Occasionally, pharmacists receive requests for topical hydrocortisone
or clobetasone products from patients on the recommendation of
their doctors. It can be difficult to explain why such a sale cannot legally
be made if the product is for use on the face or anogenital area or for
severe eczema. Pharmacists can minimise such problems by ensuring
140 SKIN CONDITIONS
that local family doctors (especially those in training) are aware of the
restrictions that apply to the sale of hydrocortisone and clobetasone
over the counter (OTC).
History of hay fever/asthma
Many eczema sufferers have associated hay fever and/or asthma. There
is often a family history (in about 80% of cases) of eczema, hay
fever or asthma. Eczema occurring in such situations is called atopic
eczema. The pharmacist can enquire about the family history of these
conditions.
Aggravating factors
Atopic eczema may be worsened during the hay-fever season and by
house dust or animal danders. Factors that dry the skin such as soaps
or detergents and cold wind can aggravate the condition. Certain clothing
such as woollen material can irritate the skin. In a small minority
of sufferers (less than 5%), cow’s milk, eggs and food colouring (tartrazine)
have been implicated. Emotional factors, stress and worry can
sometimes exacerbate eczema. Antiseptic solutions applied directly to
the skin or added to the bathwater can irritate the skin.
Medication
Contact dermatitis may be caused or made worse by sensitisation to
topical medicaments. The pharmacist should ask which treatments
have already been used. Topically applied local anaesthetics, antihistamines,
antibiotics and antiseptics can all provoke allergic dermatitis.
Some preservatives may cause sensitisation. Information about different
preparations and their formulations can be obtained from the local
pharmacist or from the manufacturer of the product. The British National
Formulary (BNF) is also a good source of information on this
subject, with a list of additives for each topical product and excipients
that may be associated with sensitisation.
If the patient has used a preparation, which the pharmacist considers
appropriate for the condition, correctly but there has been no
improvement or the condition has worsened, the patient should see the
doctor.
When to refer
Evidence of infection (weeping, crusting, spreading)
Severe condition: badly fissured/cracked skin, bleeding
Failed medication
No identifiable cause (unless previously diagnosed as eczema)
Duration of longer than 2 weeks
ECZEMA/DERMATITIS 141
Treatment timescale
Most cases of mild-to-moderate atopic eczema, irritant and allergic
dermatitis should respond to skin care and treatment with OTC products.
If no improvement has been noted after 1 week, referral to the
doctor is advisable.
Management
Skin rashes tend, quite understandably, to cause much anxiety. There
is also a social stigma associated with skin disease. Many patients will
therefore have been seen by their doctor. Pharmacists are most likely
to be involved when the diagnosis has already been made or when the
condition first presents but is very mild.
However, with increasing recognition that patients can manage mildto-
moderate eczema, and as much of the management involves advice
and the use of emollients, the pharmacist is in a good position to help,
with short-term use of OTC topical steroids where needed. Where the
pharmacist is able to identify a cause of irritant or allergic dermatitis,
topical hydrocortisone or clobetasone may be recommended.
Emollients
Emollients are the key to managing eczema and are medically inert
creams and ointments which can be used to soothe the skin, reduce
irritation, prevent the skin from drying, act as a protective layer and
be used as a soap substitute. They may be applied directly to the skin
or added to the bathwater.
There are many different types of emollient preparations that vary in
their degree of greasiness. The greasy preparations such as white soft
paraffin are often the most effective, especially with very dry skin, but
have the disadvantage of being messy and unpleasant to use. Patient
preference is very important and plays a major part in compliance with
emollient treatments. Patients will understandably not use a preparation
they find unacceptable. Patients may need to try several different
emollients before they find one that suits them, and they may need to
have several different products (e.g. for use as a moisturiser, for use in
the bath and for use as a soap substitute when washing or showering).
Emollient preparations should be used as often as needed to keep the
skin hydrated and moist. Several and frequent applications each day
may be required to achieve this.
Standard soaps have a drying effect on the skin and can make eczema
worse. Aqueous cream can be used as a soap substitute. It should be
applied to dry skin and rinsed off with water. Proprietary skin washes
are also available. Adding emulsifying ointment or a proprietary bath
oil to the bath is helpful. Emulsifying ointment should first be mixed
142 SKIN CONDITIONS
with water (one or two tablespoonfuls of ointment in a bowl of hot
water) before being added to the bath to ensure distribution in the bathwater.
Some patients with eczema believe, incorrectly, that bathing will
make their eczema worse. This is not the case, provided appropriate
emollient products are used and standard soaps and perfumed bath
products are avoided, and in fact, bathing to remove skin debris and
crusts is beneficial.
Advice
This could include the identification of possible aggravating or precipitating
factors. If the history is suggestive of an occupationally associated
contact dermatitis, then referral is advisable. The doctor may in
turn feel that referral to a dermatologist is appropriate. It is sometimes
necessary for a specialist to perform patch testing to identify the cause
of contact dermatitis.
Further advice could be given regarding the use of ordinary soaps
that tend to dry the skin and their alternatives (soap substitutes). If
steroid creams have been prescribed and emollients are to be used, the
pharmacist is in a good position to check that the patient understands
the way in which they should be used.
Topical corticosteroids
Hydrocortisone cream and ointment and clobetasone 0.05% can be
sold OTC for a limited range of indications. Topical hydrocortisone
OTC is licensed for the treatment of irritant and allergic dermatitis,
insect bites and mild-to-moderate eczema. OTC hydrocortisone is contraindicated
where the skin is infected (e.g. athlete’s foot or cold sores,
in acne, on the face and anogenital areas). Children aged over 10 years
and adults can be treated, and any course must not be longer than 1
week. Only proprietary OTC brands of topical hydrocortisone can be
used; dispensing packs may not be sold.
Topical clobetasone 0.05% can be used for the short-term treatment
and control of patches of eczema and dermatitis in people aged 12 years
and over. The indications include atopic eczema and primary irritant
or allergic dermatitis and exclude seborrhoeic dermatitis.
Antipruritics
Antipruritic preparations are sometimes useful, although evidence of
effectiveness is lacking. The itch of eczema is not histamine related,
so the use of antihistamines other than that of sedation at night is
not indicated. Calamine or crotamiton can be used in cream or lotion.
A combination product containing crotamiton with hydrocortisone is
available. Indications for use are the same as those for topical hydrocortisone
for contact dermatitis (irritant or allergic), insect bites or stings
ECZEMA/DERMATITIS 143
and mild-to-moderate eczema. The same restrictions on use apply (see
‘Topical corticosteroids’ above).
Support for patients
The National Eczema Society provides information and support
through its website www.eczema.org, a telephone helpline and written
information.
Eczema and dermatitis in practice
Patients’ perspectives
I have lived with eczema all my life. I am now 33. My father had eczema
and asthma. And the youngest of my three children also suffers with
eczema. I know the heartache of this disease well. I have learned to
control my eczema through my lifetime, but it takes quite a lot of trial
and error to find the things that work and to avoid the things that set it
off. Parents of kids with eczema need to listen to them and be patient
with them because they are probably miserable, like I was as a child.
By the time I was about 18 or 19 my eczema had practically gone.My
skin is still very sensitive and quite dry but is mostly OK. I go through
phases where it breaks out behind my knees, on my forearms, on the
back of my neck and on my lower back. When this happens, extra moisturiser
and OTC hydrocortisone cream bring it under control again.
Managing atopic dermatitis is like taking care of the family car.
When the car breaks down, you take it to the mechanic and get it
fixed. That’s like managing a flare-up of eczema with topical steroids
. . . but the maintenance is still needed. Your car may be mended, but
you still have to put oil in it regularly or the engine will seize up. And,
like your car, you can do everything right – change the oil when you’re
supposed to – and it can still break down on you.
Case 1
Sandra Thompson asks your advice about her 4-year-old daughter Janine
whose eczema has worsened recently. She tells you that she has
been using Chinese herbs, which have proved very helpful until the last
week or so. The eczema has flared up especially on her arms and legs.
She would like to use a safe cream but not a steroid cream as she has
heard about its side-effects. Janine is not with her mother.
The pharmacist’s view
Chinese herbal treatments have become popular for eczema. Their exact
contents and the amounts of their constituent active ingredients
are difficult to identify. Ironically, analysis of some of these herbal
treatments showed them to contain active ingredients with steroidal
effects. Janine should be seen by the family doctor as the eczema has
144 SKIN CONDITIONS
flared up and without seeing the child it is difficult to assess its severity.
However, the mother’s comments and the history indicate that medical
assessment would be helpful.
The doctor’s view
The flare-up of her eczema could be due to an infection. The dry flaky
skin can be an ideal site for infections to thrive. If that happens, the
eczema is further worsened. It would be advisable for Janine to be
referred to her general practitioner (GP). The GP might take a skin
swab to confirm an infection and start oral antibiotics with a steroid
cream, which could be combined with a topical antibiotic. In this case,
it would be necessary to check out Ms Thompson’s concerns about
steroid creams. With appropriate information she may well be persuaded
to try one. It would be best to advise her to discontinue the
Chinese herbs as they are not subject to quality control and regulation.
Case 2
Ray Timpson is a local man in his mid-thirties and a regular customer.
Today, he wants to buy some hydrocortisone cream for his eczema,
which has worsened. He has had eczema for many years and usually
obtains his hydrocortisone cream on a repeat prescription from his
doctor. As a child, Mr Timpson was asthmatic and both asthma and
hay fever are present in some members of his family. He has just seen
an advert for a proprietary OTC hydrocortisone cream and says he
would prefer to buy his supplies from you in the future to save both
himself and the doctor some time. The eczema affects his ankles, shins
and hands; the skin on his hands is cracked and weeping.
The pharmacist’s view
Mr Timpson needs to see his doctor because the eczema on his hands
is infected. Topical steroids, including hydrocortisone, should not be
used on infected skin.
The doctor’s view
The description given suggests widespread atopic eczema with an area
of infection on his hands. Although he has had this problem for many
years, it would make sense for him to be referred to the GP, especially
in view of the likely infection. It would be helpful for the GP to gain an
understanding of Mr Timson’s ideas, concerns and expectations about
his eczema and its management. It would be useful to identify any aggravating
factors, e.g. pets, soaps, washing powders, working environment
and stress. It would be helpful to enquire which emollients have
been used and how helpful they have been. It could be useful to take
a swab to confirm the infection, which is most likely due to Staphylococcus
aureus. In this situation, a 10-day course of flucloxacillin,
ECZEMA/DERMATITIS 145
or erythromycin if penicillin sensitive, is indicated. If he is subject to
repeated infection, he could try an antiseptic bath oil and emollient.
It might be appropriate for him to use a potent topical steroid, e.g.
betamethasone 0.1% for a short period to control symptoms, rather
than persist with a weaker one in the long term. Once his symptoms
are under control, he could continue with hydrocortisone as required
plus his usual emollient.
Case 3
Romiz Miah, a young adult, asks your advice about his hands, which
are sore and dry. The skin is flaky but not broken and there is no sign
of secondary infection such as weeping or pus. He says the problem is
spreading and now affecting his arms as well. He has occasionally had
the problem before but not as severely. On further questioning, you
discover that he has recently started working in his family’s restaurant
and has been doing a lot of washing up and cleaning.
The pharmacist’s view be avoided.

برچسب ها: told she had IBS. The doctor said it was all due to stress، which had upset her. Over the last year she has started a new job and moved into new accommodation. She eats a healthy diet and exercises regularly. The pharmacist’s view The history here is not straightforward and although Jane’s symptoms are indicative of IBS، which she says she has had before، the symptoms are different on this occasion. The best course of action is to refer her to the doctor for further investigation. The doctor’s view Jane probably has IBS but there is insufficient information so far to make that diagnosis. It is not uncommon to have upper abdominal pain with IBS، but other possibilities need to be considered. It sounds as though Jane thinks it is coming from her stomach. She may fear that she has an ulcer. She also mentions urinary frequency، which may well be associated with IBS but could be a urinary infection. A referral to her doctor is sensible to make a complete assessment of her symptoms. It is likely that the assessment would just involve listening to her description of her problem، gathering more information and a brief examination of her abdomen. A urine sample would show whether or not she had a urinary infection. If there was still doubt about the diagnosis،  

تاریخ : دوشنبه 25 اسفند 1393 | 11:50 ب.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th





Constipation in pregnancy
Constipation commonly occurs during pregnancy; hormonal changes
are responsible and it has been estimated that one in three pregnant
women suffers from constipation. Dietary advice concerning
the intake of plenty of high-fibre foods and fluids can help. Oral
iron, often prescribed for pregnant women, may contribute to the
problem.
Stimulant laxatives are best avoided during pregnancy; bulk-forming
laxatives are preferable, although they may cause some abdominal discomfort
to women when used late in pregnancy (see the chapter on
‘Women’s health’).
Constipation in the elderly
Constipation is a common problem in elderly patients for several reasons.
Elderly patients are less likely to be physically active; they often
have poor natural teeth or false teeth and so may avoid high-fibre foods
that are more difficult to chew; multidrug regimens are more likely in
elderly patients, who may therefore suffer from drug-induced constipation;
fixed ideas about what constitutes a normal bowel habit are
common in older patients. If a bulk laxative is to be recommended for
an elderly patient, it is of great importance that the pharmacist give advice
about maintaining fluid intake to prevent the possible development
of intestinal obstruction.
Laxative abuse
Two groups of patients are likely to abuse laxatives: those with chronic
constipation who get into a vicious circle by using stimulant laxatives
(see p. 103), which eventually results in damage to the nerve plexus
in the colon, and those who take laxatives in the belief that they will
control weight, e.g. those who are dieting or, more seriously, women
with eating disorders (anorexia nervosa or bulimia), who take very
large quantities of laxatives. The pharmacist is in a position to monitor
purchases of laxative products and counsel patients as appropriate.
Any patient who is ingesting large amounts of laxative agents should
be referred to the doctor.
Constipation in practice
Case 1
Mr Johnson is a middle-aged man who occasionally visits your pharmacy.
Today he complains of constipation, which he has had for several
weeks. He has been having a bowel movement every few days;
normally they are every day or every other day. His motions are hard
and painful to pass. He has not tried any medicines as he thought the
problem would go of its own accord. He has never had problems with
CONSTIPATION 105
constipation in the past. He has been taking atenolol tablets 50 mg
once a day, for over 1 year. He does not have any other symptoms,
except a slight feeling of abdominal discomfort. You ask him about his
diet; he tells you that since he was made redundant from his job at a
local factory 3 months ago, he has tended to eat less than usual; his
dietary intake sounds as if it is low in fibre. He tells you that he has
been applying for jobs, with no success so far. He says he feels really
down and is starting to think that he may never get another job.
The pharmacist’s view
Mr Johnson’s symptoms are almost certainly due to the change in his
lifestyle and eating pattern. Now that he is not working he is likely to
be less physically active and his eating pattern has probably changed.
From what he has said, it sounds as if he is becoming depressed because
of his lack of success in finding work. Constipation seems to be
associated with depression, separately from the constipating effect of
some antidepressant drugs.
It would be worth asking Mr Johnson if he is sleeping well (signs of
clinical depression include disturbed sleep: either difficulty in getting
to sleep or difficulty in waking early and not being able to get back
to sleep). Weight can change either way in depression. Some patients
eat for comfort, while others find their appetite is reduced. Depending
on his response, you might consider whether referral to his doctor is
needed.
To address the dietary problems, he could be advised to start the day
with a wholegrain cereal and to eat at least four slices of wholemeal
bread each day. Baked beans are a cheap, good source of fibre. Fresh
vegetables are also fibre rich. It would be important to stress that fluid
intake should also be increased. A high-fibre diet means patients should
increase their fibre intake until they pass one large, soft stool each day;
the amount of fibre needed to produce this effect will vary markedly
between patients. The introduction of dietary fibre should be gradual;
too rapid an increase can cause griping and wind. Mr Johnson also
needs to make sure he is drinking the recommended daily fluid intake
of 2.5 litres each day.
To provide relief from the discomfort, a suppository of glycerin
or bisacodyl could be recommended to produce a bowel evacuation
quickly; in the longer term, dietary changes provide the key. He should
see the doctor if the suppository does not produce an effect; if it works
but the dietary changes have not been effective after 2 weeks, he should
go to his doctor. Mr Johnson’s medication is unlikely to be responsible
for his constipation because, although beta-blockers can sometimes
cause constipation, he has been taking the drug for over 1 year with
no previous problems.
106 GASTROINTESTINAL TRACT PROBLEMS
The doctor’s view
The advice given by the pharmacist is sensible. It is likely that Mr Johnson’s
physical and mental health have been affected by the impact of
a significant change in his life. The loss of his job and the uncertainty
of future employment is a major and continuing source of stress. The
fact that the pharmacist has taken time to check out how he has been
affected will in itself be therapeutic. It also gives the pharmacist the
opportunity to refer to the doctor if necessary. Many people are reluctant
to take such problems to their doctor but a recommendation from
the pharmacist might make the process easier. Hopefully, the advice
given for constipation will at least improve one aspect of his life. If the
constipation does not resolve within 2 weeks, Mr Johnson should see
his doctor.
Case 2
Your counter assistant asks if you will have a word with a young
woman who is in the shop. She was recognised by your assistant as
a regular purchaser of stimulant laxatives. You explain to the woman
that you will need to ask a few questions because regular use of laxatives
may mean an underlying problem, which is not improving. In
answer to your questions she tells you that she diets almost constantly
and always suffers from constipation. Her weight appears to be within
the range for her height. You show her your pharmacy’s BMI (body
mass index) chart and work out with her where she is on the chart,
which confirms your initial feeling. However, she is reluctant to accept
your advice, saying that she definitely needs to lose some more weight.
You ask about her diet and she tells you that she has tried all sorts of
approaches, most of which involve eating very little.
The pharmacist’s view
Unfortunately this sort of story is all too common in community
pharmacy, with many women who seek to achieve weight below the
recommended range. The pharmacist can explain that constipation
often occurs during dieting simply because insufficient bulk and fibre
is being eaten to allow the gut to work normally. Perhaps the
pharmacist might suggest that she joins a local group, either weight
watchers or a self-help group. (The local health promotion unit will
know what is available.) Despite the pharmacist’s advice, many customers
will still wish to purchase laxatives and the pharmacist will
need to consider how to handle refusal of sales. Offering stimulant
laxatives for sale by self-selection can only exacerbate the problems
and make it more difficult to monitor sales and refuse them when
necessary.
CONSTIPATION 107
The doctor’s view
This is obviously a difficult problem for the pharmacist. It is inappropriate
for the young woman to continue taking laxatives and she
could benefit from counselling. However, a challenge from the pharmacist
could result in her simply buying the laxatives elsewhere. If, as
is likely, she has an eating disorder, she may have very low self-esteem
and be denying her problem. Both these factors make it more difficult
for the pharmacist to intervene most effectively. An ideal outcome
would be appropriate referral, which would depend on local resources
but which might initially be to the doctor, or she could be advised
about the Beating Eating Disorders helpline 0845 6341414, which
can be accessed 10.30 a.m.–8.30 p.m. Monday–Friday, Saturdays 1.00
p.m–4.30 p.m., Sundays closed, bank holidays 11.30 a.m.–2.30 p.m.
(www.b-eat.co.uk).
If she is seen by the doctor, an empathic approach is necessary. The
most important thing is to give her full opportunity to say what she
thinks about the problem, how it makes her feel and how it affects her
life. Establishing a supportive relationship with resultant trust between
patient and doctor is the major aim of the initial consultation. Once this
has been achieved, further therapeutic opportunities can be discussed
and decided on together.
Case 3
A man comes into the pharmacy and asks for some good laxative
tablets. Further questioning by the pharmacist reveals that the medicine
is for his dad who is aged 72 years. He does not know many details except
that his dad has been complaining of increasing constipation over
the last 2–3 months and has tried senna tablets without any benefit.
The pharmacist’s view
Third-party or proxy consultations are often challenging because the
person making the request may not have all of the relevant information.
However, in this case the decision is quite clear. The patient needs to
be referred to the doctor because of the long history of the complaint
and the unsuccessful use of a stimulant laxative.
The doctor’s view
Referral to the GP should be recommended in this situation. A glycerin
suppository is a safe treatment to use in the meantime. Clearly,
more information is needed to make an opinion and diagnosis. A prolonged
and progressive change in bowel habit is an indication for referral
to hospital for further investigations as the father could have a
large bowel cancer. The GP would need to gather more information
about his symptoms and would perform an examination that would include
abdominal palpation and a digital rectal examination. This latter
108 GASTROINTESTINAL TRACT PROBLEMS
examination could confirm the presence of a rectal tumour. It is likely
that an urgent referral would then be made for further investigations
as an outpatient. At hospital the investigations could include
sigmoidoscopy plus a barium enema X-ray and/or a colonoscopy. In
colonoscopy a flexible fibre-optic tube is passed through the anus and
then up and around the whole of the large bowel to the caecum.
CONSTIPATION 109
Diarrhoea
Community pharmacists may be asked by patients to treat existing
diarrhoea or to offer advice on what course of action to take should
diarrhoea occur, e.g. to holidaymakers. Diarrhoea is defined as an increased
frequency of bowel evacuation, with the passage of abnormally
soft or watery faeces. The basis of treatment is electrolyte and fluid replacement;
in addition, antidiarrhoeals are useful in adults and older
children.
What you need to know
Age
Infant, child, adult, elderly
Duration
Severity
Symptoms, associated symptoms
Nausea/vomiting
Fever
Abdominal cramps
Flatulence
Other family members affected?
Previous history
Recent travel abroad?
Causative factors
Medication
Medicines already tried
Other medicines being taken
Significance of questions and answers
Age
Particular care is needed in the very young and the very old. Infants
(younger than 1 year) and elderly patients are especially at risk of
becoming dehydrated.
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
110 GASTROINTESTINAL TRACT PROBLEMS
Duration
Most cases of diarrhoea will be acute and self-limiting. Because of the
dangers of dehydration it would be wise to refer infants with diarrhoea
of longer than 1 day’s duration to the doctor.
Severity
The degree of severity of diarrhoea is related to the nature and frequency
of stools. Both these aspects are important, since misunderstandings
can arise, especially in self-diagnosed complaints. Elderly
patients who complain of diarrhoea may, in fact, be suffering from
faecal impaction. They may pass liquid stools, but with only one or
two bowel movements a day.
Symptoms
Acute diarrhoea is rapid in onset and produces watery stools that
are passed frequently. Abdominal cramps, flatulence and weakness or
malaise may also occur. Nausea and vomiting may be associated with
diarrhoea, as may fever. The pharmacist should always ask about vomiting
and fever in infants; both will increase the likelihood that severe
dehydration will develop. Another important question to ask about
diarrhoea in infants is whether the baby has been taking milk feeds
and other drinks as normal. Reduced fluid intake predisposes to dehydration.
The pharmacist should question the patient about food intake and
also about whether other family members or friends are suffering from
the same symptoms, since acute diarrhoea is often infective in origin.
Often there are localised minor outbreaks of gastroenteritis, and the
pharmacist may be asked several times for advice and treatment by
different patients during a short period of time. Types of infective diarrhoea
are discussed later in this chapter.
The presence of blood or mucus in the stools is an indication for
referral. Diarrhoea with severe vomiting or with a high fever would
also require medical advice.
Previous history
A previous history of diarrhoea or a prolonged change in bowel habit
would warrant referral for further investigation and it is important
that the pharmacist distinguish between acute and chronic conditions.
Chronic diarrhoea (of more than 3 weeks’ duration) may be caused by
bowel conditions such as Crohn’s disease, IBS or ulcerative colitis and
requires medical advice.
DIARRHOEA 111
Recent travel abroad
Diarrhoea in a patient who has recently travelled abroad requires referral
since it might be infective in origin. Gardiasis should be considered
in travellers recently returned from South America or the Far East.
Causes of diarrhoea
Infections
Most cases of diarrhoea are short lived, the bowel habit being normal
before and after. In these situations the cause is likely to be infective
(viral or bacterial).
Viral. Viruses are often responsible for gastroenteritis. In infants the
virus causing such problems often gains entry into the body via the
respiratory tract (rotavirus). Associated symptoms are those of a cold
and perhaps a cough. The infection starts abruptly and vomiting often
precedes diarrhoea. The acute phase is usually over within 2–3
days, although diarrhoea may persist. Sometimes diarrhoea returns
when milk feeds are reintroduced. This is because one of the milkdigestive
enzymes is temporarily inactivated. Milk therefore passes
through the bowel undigested, causing diarrhoea. The health visitor
or doctor would need to give further advice in such situations.
Whilst in the majority the infection is usually not too severe and
is self-limiting, it should be remembered that rotavirus infection can
cause death. This is most likely in those infants already malnourished
and living in poor social circumstances who have not been breastfed.
Bacterial. These are the food-borne infections previously known as
food poisoning. There are several different types of bacteria that can
cause such infections: Staphylococcus, Campylobacter, Salmonella,
Shigella, pathogenic Escherichia coli, Bacillus cereus and Listeria
monocytogenes. The typical symptoms include severe diarrhoea and/or
vomiting, with or without abdominal pain. Two commonly seen infections
are Campylobacter and Salmonella, which are often associated
with contaminated poultry, although other meats have been implicated.
Contaminated eggs have also been found to be a source of Salmonella.
Kitchen hygiene and thorough cooking are of great importance in preventing
infection.
Table 4 summarises the typical features of some of the following
infections:
– Bacillary dysentery is caused by Shigella. It can occur in outbreaks
where there are people living in close proximity and may occur in
travellers to Africa or Asia.
– B. cereus is usually associated with cooked rice, especially if it has
been kept warm or has been reheated. It presents with two different
clinical pictures, as shown in Table 4.
112 GASTROINTESTINAL TRACT PROBLEMS
Table 4 Features of some infections causing diarrhoea.
Infection Incubation Duration Symptoms
Staphylococcus 2–6 h 6–24 h Severe, short lived;
especially vomiting
Salmonella 12–24 h 1–7 days Mainly diarrhoea
Campylobacter 2–7 days 2–7 days Diarrhoea with
abdominal colic
B. cereus 1–5 h 6–24 h Vomiting
B. cereus (two types
of infection)
8–16 h 12–24 h Diarrhoea
L. monocytogenes 3–70 days Flulike, diarrhoea
– E. coli infections are less common but can be severe with toxins being
released into the body, which can cause kidney failure.
– L. monocytogenes can cause gastroenteritis or a flulike illness. On
occasion it can be more severe and cause septicaemia or meningitis.
Pregnant woman are more susceptible to it but it is still a rare infection
occurring in 1 in 20,000 pregnancies. Infection during pregnancy can
cause miscarriage, still birth or an infection of the newborn. Foods to
be avoided during pregnancy include unpasteurised cheese, soft ripe
cheeses, blue-veined cheeses, pates, cold cuts of meat and smoked fish.
Pregnant women with diarrhoea or fever should be referred to their
midwife or GP.
Antibiotics are generally unnecessary as most food-borne infections
resolve spontaneously. The most important treatment is adequate fluid
replacement. Antibiotics are used for Shigella infections and the more
severe Salmonella or Campylobacter ones. Ciprofloxacin may be used
in such circumstances.
– Protozoan infections are uncommon in Western Europe but may
occur in travellers from further afield. Examples include Entamoeba
histolytica (amoebic dysentery) and Giardia lamblia (giardiasis). Diagnosis
is made by sending stool samples to the laboratory.
Chronic diarrhoea
Recurrent or persistent diarrhoea may be due to an irritable bowel or,
more seriously, a bowel tumour, an inflammation of the bowel (e.g.
ulcerative colitis or Crohn’s disease), an inability to digest or absorb
food (malabsorption, e.g. coeliac disease) or diverticular disease of the
colon.
Irritable bowel syndrome (see p. 121). This non-serious, but troublesome,
condition is one of the more common causes of recurrent bowel
DIARRHOEA 113
dysfunction in adolescents and young adults. The patient usually describes
the frequent passage of small volumes of stool rather than true
diarrhoea. The stools are typically variable in nature, often loose and
semiformed. They may be described as being like rabbit droppings or
pencil shaped. The frequency of bowel action is also variable as the
diarrhoea may alternate with constipation. Often the bowels are open
several times in the morning before the patient leaves for work. The
condition is more likely to occur at times of stress, it may be associated
with anxiety and, occasionally, it may be triggered by a bowel infection.
Inadequate dietary fibre may also be of significance. It is possible
that certain foods can irritate the bowel, but this is difficult to prove.
There is no blood present within the motion in an irritable bowel.
Bloody diarrhoea may be a result of an inflammation or tumour of
the bowel. The latter is more likely with increasing age (from middle
age onwards) and is likely to be associated with a prolonged change
in bowel habit; in this case diarrhoea might sometimes alternate with
constipation.
Medication
Medicines already tried
The pharmacist should establish the identity of any medication that
has already been taken to treat the symptoms in order to assess its
appropriateness.
Other medicines being taken
Details of any other medication being taken (bothOTCand prescribed)
are also needed, as the diarrhoea may be drug induced (Table 5). OTC
medicines should be considered; commonly used medicines such as
magnesium-containing antacids and iron preparations are examples
Table 5 Some drugs that may cause diarrhoea.
Antacids: Magnesium salts
Antibiotics
Antihypertensives: methyldopa; beta-blockers (rare)
Digoxin (toxic levels)
Diuretics (furosemide)
Iron preparations
Laxatives
Misoprostol
Non-steroidal anti-inflammatory drugs
Selective serotonin reuptake inhibitors
114 GASTROINTESTINAL TRACT PROBLEMS
of medicines that may induce diarrhoea. Laxative abuse should be
considered as a possible cause.
When to refer
Diarrhoea of greater than
1 day’s duration in children younger than 1 year
2 days’ duration in children under 3 years and elderly patients
3 days’ duration in older children and adults
Association with severe vomiting and fever
Recent travel abroad
Suspected drug-induced reaction to prescribed medicine
History of change in bowel habit
Presence of blood or mucus in the stools
Pregnancy
Treatment timescale
One day in children; otherwise 2 days.
Management
Oral rehydration therapy
The risk of dehydration from diarrhoea is greatest in babies, and rehydration
therapy is considered to be the standard treatment for acute
diarrhoea in babies and young children. Oral rehydration sachets may
be used with antidiarrhoeals in older children and adults.
Rehydration may still be initiated even if referral to the doctor is
advised. Sachets of powder for reconstitution are available; these contain
sodium as chloride and bicarbonate, glucose and potassium. The
absorption of sodium is facilitated in the presence of glucose. A variety
of flavours are available.
It is essential that appropriate advice be given by the pharmacist
about how the powder should be reconstituted. Patients should be
reminded that only water should be used to make the solution (never
fruit or fizzy drinks) and that boiled and cooled water should be used
for children younger than 1 year. Boiling water should not be used, as it
would cause the liberation of carbon dioxide. The solution can be kept
for 24 h if stored in a refrigerator. Fizzy, sugary drinks should never be
used to make rehydration fluids, as they will produce a hyperosmolar
solution that may exacerbate the problem. The sodium content of such
drinks, as well as the glucose content, may be high.
DIARRHOEA 115
Table 6 Amount of rehydration solution to be offered
to patients.
Quantity of solution
Age (per watery stool)
Under 1 year 50 mL (quarter of a glass)
1–5 years 100 mL (half a glass)
6–12 years 200 mL (one glass)
Adult 400 mL (two glasses)
Home-made salt and sugar solutions should not be recommended,
since the accuracy of electrolyte content cannot be guaranteed, and
this accuracy is essential, especially in infants, young children and elderly
patients. Special measuring spoons are available; their correct
use would produce a more acceptable solution, but their use should be
reserved for the treatment of adults, where electrolyte concentration is
less crucial.
Quantities
Parents sometimes ask how much rehydration fluid should be given
to children. The following simple rules can be used for guidance; the
amount of solution offered to the patient is based on the number of
watery stools that are passed. Table 6 provides the volumes required
per watery stool.
Other therapy
Loperamide
Loperamide is an effective antidiarrhoeal treatment for use in older
children and adults. When recommending loperamide the pharmacist
should remind patients to drink plenty of extra fluids. Oral rehydration
sachets may be recommended. Loperamide may not be recommended
for use in children under 12 years.
Diphenoxylate/atropine (Co-phenotrope)
Co-phenotrope can be used as an adjunct to rehydration to treat diarrhoea
in those aged 16 years and over.
Kaolin
Kaolin has been used as a traditional remedy for diarrhoea for many
years. Its use was justified on the theoretical grounds that it would
absorb water in the GI tract and would absorb toxins and bacteria
onto its surface, thus removing them from the gut. The latter has not
been shown to be true and the usefulness of the former is questionable.
The use of kaolin-based preparations has largely been superseded by
oral rehydration therapy, although patients continue to ask for various
products containing kaolin.
116 GASTROINTESTINAL TRACT PROBLEMS
Morphine
Morphine, in various forms, has been included in antidiarrhoeal remedies
for many years. The theoretical basis for its inclusion is that
morphine, together with other narcotic drugs such as codeine, is known
to slow the action of the GI tract; indeed, constipation is a wellrecognised
side-effect of such drugs. However, at the doses included
in most OTC preparations, it is unlikely that such an effect would be
produced. Kaolin and morphine mixture remains a popular choice for
some patients, despite the lack of evidence of its effectiveness.
Practical points
1 Patients with diarrhoea should be advised to drink plenty of clear,
non-milky fluids, such as water and diluted squash.
2 NHS Clinical Knowledge Service (CKS) says that the patient can be
advised to continue their usual diet but that fatty foods and foods with
a high sugar content might be best avoided as they may not be well
tolerated.
3 Breast- or bottle feeding should be continued in infants. The severity
and duration of diarrhoea are not affected by whether milk feeds
are continued. A well-nourished child should be the aim, particularly
where the infant is poorly nourished to begin with and where the
withholding of milk feeds may be more detrimental than in a wellnourished
infant, where temporary withdrawal is unimportant. Some
doctors continue nevertheless to advise the discontinuation of milk,
especially bottle, during the acute phase of infection.
Diarrhoea in practice
Case 1
Mrs Robinson asks what you can recommend for diarrhoea. Her son
David, aged 11 years, has diarrhoea and she is worried that her other
two children, Natalie, aged 4 years, and Tom, aged just over 1 year,
may also get it. David’s diarrhoea started yesterday; he went to the
toilet about five times and was sick once, but has not been sick since.
He has griping pains, but is generally well and quite lively. Yesterday
he had pie and chips from the local takeaway during his lunch break
at school. No one else in the family ate the same food. Mrs Robinson
has not given him any medicine, but has some kaolin and morphine
mixture at home and wants to know if David could take some, and
also if the other children could take it if necessary.
The pharmacist’s view
It sounds as if David has a bout of acute diarrhoea, possibly caused by
the food he ate yesterday during lunchtime. He has vomited once, but
now the diarrhoea is the problem. The child is otherwise well. He is
DIARRHOEA 117
11 years old, so the best plan would be to start oral rehydration with
some proprietary sachets, with advice to his mother about how they
should be reconstituted. Kaolin and morphine mixture should not be
given to children under 12, and in any case it is not considered first-line
treatment for diarrhoea. If either or both the other children get diarrhoea,
they can also be given some rehydration solution. David should
see the doctor the day after tomorrow if his condition has not improved.
The doctor’s view
David’s diarrhoea could well be due to food poisoning. Oral rehydration
is the correct treatment. He should also be told not to eat anything
for the next 24 h or so until the diarrhoea has settled. If he wants to
drink other fluids in addition to the electrolyte mixture, he should be
told to avoid milk.
His symptoms should settle down over the next few hours. If they
persist or he complains of worsening abdominal pain, particularly in
the lower right side of the abdomen, his mother should contact the
doctor. An atypical acute appendicitis may present with symptoms of
a bowel infection.
Case 2
Mrs Choudry is collecting her regular repeat prescription for antihypertensive
treatment. You ask how she and the family are, and she tells
you that several members of the family have been suffering with diarrhoea
on and off. You know that the family recently returned from a
trip to India where they had been visiting relatives to attend a family
wedding. In answer to your questions, Mrs Choudry tells you that the
problem with the diarrhoea started after they returned.
The pharmacist’s view
Referral to the GP is needed here as the diarrhoea may be related to
the recent travel.
The doctor’s view
Referral is a sensible course of action. Clearly, more information is
required, e.g. date of onset of symptoms and date of return to the
UK. It does not sound as if any of the family are acutely ill but it
would be necessary to ensure that no one is dehydrated. If the diarrhoea
is persisting, it would be helpful to send stool samples to the local
public health laboratory for analysis. It is possible that they may be
suffering from giardiasis, which can be treated with metronidazole.
Sometimes stool samples come back showing no signs of infection, in
which case the diarrhoea is considered as being due to postinfection
irritability of the bowel. This usually resolves spontaneously with no
specific treatment.
118 GASTROINTESTINAL TRACT PROBLEMS
Case 3
Mrs Jean Berry wants to stock up on some medicines before her family
sets off on their first holiday abroad; they will be going to Spain next
week. Mrs Berry tells you that she has heard of people whose holidays
have been ruined by holiday diarrhoea and she wants you to recommend
a good treatment. On questioning, you find out that Mr and Mrs
Berry and their two boys aged 10 and 14 years will be going on the
holiday.
The pharmacist’s view
Holiday diarrhoea can often easily be dealt with. Mrs Berry could be
advised to buy some loperamide capsules, which would be suitable
treatment for her, Mr Berry and their 14-year-old son. In addition, she
should purchase some oral rehydration sachets for the younger son.
The sachets could also be used by other family members.
The pharmacist could also give some valuable advice about the
avoidance of potential problems by the Berry family on their first foreign
holiday. Fresh fruit should be peeled before eating and hot food
should not be eaten other than in restaurants. Roadside snack stalls
are best avoided. The question of the quality of drinking water often
crops up. Good advice to travellers would be to check with the tour
company representative as to the advisability of drinking local water.
If in doubt, bottled mineral water can be drunk; such water (the still
variety) could also be used to reconstitute rehydration sachets. Ice in
drinks may be best avoided, depending on the water supply.
Holiday diarrhoea is usually self-limiting, but if it is still present after
several days, medical advice should be sought. If the diarrhoea persists
or is recurrent after returning home, the doctor should be seen. Finally,
patients would be well advised to be wary of buying OTC medicines
abroad. In some countries, a large range of drugs including oral steroids
and antibiotics can be purchased OTC. Each year, patients return to
Britain with serious adverse effects following the use of oral chloramphenicol,
for example, which has been prescribed or purchased.
The doctor’s view
The pharmacist has covered all the important points. The most likely
cause of diarrhoea would be contaminated food or water. The best
treatment of acute diarrhoea is to stop eating and to drink bottled
mineral water (with or without electrolyte reconstitution powders). It
would be sensible to take an antidiarrhoeal such as loperamide.
Case 4
Mr Radcliffe is an elderly man who lives alone. Today, his home help
asks what you can recommend for diarrhoea, from which Mr Radcliffe
has been suffering for 3 days. He has been passing watery stools quite
DIARRHOEA 119
frequently and feels rather tired and weak. He has sent the home help
because he dare not leave the house and go out of reach of the toilet.You
check your PMRs (patient medication records), which confirm your
memory that he takes several different medicines: digoxin, furosemide
and paracetamol. Last week you dispensed a prescription for a course
of amoxicillin. The home help tells you that he has been eating his
usual diet and there does not seem to be a link between food and his
symptoms.
The pharmacist’s view
Mr Radcliffe’s diarrhoea may be due to the amoxicillin, which he
started to take a few days ago. It would be best to call the patient’s
doctor to discuss the appropriate course of action because Mr Radcliffe’s
other drug therapy means that fluid loss and dehydration may
cause electrolyte imbalance and put him at further risk. The doctor
may decide to stop the amoxicillin.
The doctor’s view
It is likely that the amoxicillin has caused the diarrhoea. The most important
consideration in management is to ensure adequate fluid and
electrolyte replacement. This is particularly so as the elderly (and babies)
are not as resilient to the effects of dehydration. In Mr Radcliffe’s
case things are further complicated by his other medication: furosemide
and digoxin. He is not on any potassium supplement or a potassiumsparing
diuretic. Although there may be good reason for this, diuretics
such as furosemide can lower the plasma potassium level and make
digoxin dangerously toxic. Unfortunately, potassium can also be lost
in diarrhoea, further aggravating this problem. It is therefore reasonable
to ask for the doctor to visit and assess.
There is also a possibility that the diarrhoea could be due to a bacterium
(Clostridium difficile) in the colon. It is thought that antibiotics
(Mr Radcliffe was given amoxicillin) upset the normal bowel flora allowing
C.difficile to flourish. This condition can be caused by most
antibiotics, but has been reported most often with clindamycin, ampicillin,
amoxicillin and the cephalosporins. The condition is more likely
to occur in those over the age of 65 years. It is now most commonly
seen in hospitals where it is thought that the infection is spread by
health workers.
The diarrhoea of a C. difficile infection can range from mild selflimiting
symptoms to severe protracted or recurrent episodes and can
sometimes be fatal. There is often a low-grade fever, and abdominal
pain/cramps may occur. The symptoms usually begin within 1 week
of starting antibiotic treatment but may start up to 6 weeks after a
course of antibiotics. It is sometimes necessary to treat severe cases
with metronidazole or vancomycin.
120 GASTROINTESTINAL TRACT PROBLEMS
Irritable bowel syndrome
Irritable bowel syndrome (IBS) is defined as a chronic, functional bowel
disorder in which abdominal pain is associated with intermittent diarrhoea,
sometimes alternating with constipation, and a feeling of abdominal
distension. IBS is estimated to affect 20% of adults in the
industrialised world, most of whom (up to three quarters) do not consult
a doctor. More women with IBS consult a health professional than
do men and the incidence of the condition appears to be higher in
women. The cause is unknown. IBS can sometimes develop after a
bout gastroenteritis. It often seems to be triggered by stress, and many
IBS sufferers have symptoms of anxiety and depression. Some sufferers
have food intolerances which trigger their symptoms.
What you need to know
Age
Child, adult
Symptoms
Gastrointestinal
Abdominal pain
Abdominal distension/bloating
Disturbed bowel habit; diarrhoea and/or constipation
Nausea
Other symptoms
Urinary symptoms, especially frequency
Dyspareunia (pain during intercourse)
Significance of questions and answers
Age
Because of the difficulties in diagnosis of abdominal pain in children,
it is best to refer.
IBS usually develops in young adult life. If an older adult is presenting
for the first time with no previous history of bowel problems, a referral
should be made.
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
IRRITABLE BOWEL SYNDROME 121
Symptoms
IBS has three key symptoms: abdominal pain (which may ease following
a bowel movement), abdominal distension/bloating and disturbance
of bowel habit.
Abdominal pain
The pain can occur anywhere in the abdomen. It is often central or left
sided and can be severe. When pain occurs in the upper abdomen, it
can be confused with peptic ulcer or gall-bladder pain. The site of pain
can vary from person to person and even for an individual. Sometimes
the pain comes on after eating and can be relieved by defaecation.
Bloating
A sensation of bloating is commonly reported. Sometimes it is so severe
that clothes have to be loosened.
Bowel habit
Diarrhoea and constipation may occur; sometimes they alternate. A
morning rush is common, where the patient feels an urgent desire to
defaecate several times after getting up in the morning and following
breakfast, after which the bowels may settle. There may be a feeling
of incomplete emptying after a bowel movement. The motion is often
described as loose and semiformed rather than watery. Sometimes it is
like pellets or rabbit droppings, or pencil shaped. There may be mucus
present but never blood.
Other symptoms
Nausea sometimes occurs; vomiting is less common.
Patients may also complain of apparently unrelated symptoms such
as backache, feeling lethargic and tired. Urinary symptoms may be
associated with IBS, e.g. frequency, urgency and nocturia (the need to
pass urine during the night). Some women report dyspareunia.
Duration
Patients may present when the first symptoms occur or may describe
a pattern of symptoms, which has been going on for months or even
years. If an older person is presenting for the first time, referral is most
appropriate.
Previous history
You need to know whether the patient has consulted his/her doctor
about the symptoms and, if so, what they were told. A history of travel
abroad and gastroenteritis sometimes appears to trigger an irritable
bowel. Referral is necessary to exclude an unresolved infection. Any
history of previous bowel surgery would suggest a need for referral.
122 GASTROINTESTINAL TRACT PROBLEMS
Aggravating factors
Stress appears to play an important role and can precipitate and exacerbate
symptoms.
Caffeine often worsens symptoms and its stimulant effect on the
bowel and irritant effect on the stomach are well known in any case.
The sweeteners sorbitol and fructose have also been reported to aggravate
IBS. Other foods that have been implicated are milk and dairy
products, chocolate, onions, garlic, chives and leeks.
Medication
The patient may already have tried prescribed or OTC medicines to
treat the condition. You need to know what has been tried and whether
it produced any improvement. It is also important to know what other
medicines the patient is taking. IBS is associated with anxiety and depression
in many patients, but it is not known whether this is cause or
effect.
When to refer
Children
Older person with no previous history of IBS
Pregnant women
Blood in stools
Unexplained weight loss
Caution in patients aged over 45 years with changed bowel habit
Signs of bowel obstruction
Unresponsive to appropriate treatment
Treatment timescale
Symptoms should start to improve within 1 week.
Management
Antispasmodics
Antispasmodics are the mainstay of OTC treatment of IBS and research
trials show some improvement in abdominal pain with smooth muscle
relaxants. Alverine citrate, peppermint and mebeverine are used.
They work by a direct effect on the smooth muscle of the gut, causing
relaxation and thus reducing abdominal pain. The patient should see
an improvement within a few days of starting treatment and should
be asked to return to you in 1 week, so you can monitor progress. It
is worth trying a different antispasmodic if the first has not worked.
Side-effects from antispasmodics are rare.
IRRITABLE BOWEL SYNDROME 123
All antispasmodics are contraindicated in paralytic ileus, a serious
condition that fortunately occurs only rarely (e.g. after abdominal
operations and in peritonitis). Here the gut is not functioning and is
obstructed. The symptoms would be severe pain, no bowel movements
and possibly vomiting of partly digested food. Immediate referral is
needed.
Alverine citrate
Alverine citrate is given in a dose of 60–120 mg (one or two capsules)
up to three times a day. Remind the patient to take the capsules with
water and not to chew them. Side-effects are rare, but nausea, dizziness,
pruritus, rash and headache have occasionally been reported. The drug
should not be recommended for pregnant or breastfeeding women or
for children. Alverine citrate is also available in a combination product
with sterculia (see ‘Bulking agents’ below).
Peppermint oil
Peppermint oil has been used for many years as an aid to digestion
and has an antispasmodic effect. Capsules containing 0.2 mL of the oil
are taken in a dose of one or two capsules three times a day, 15–30
min before meals. They are enteric coated, with the intention that the
peppermint oil is delivered beyond the stomach and upper small bowel.
Patients should be reminded not to chew the capsules as not only will
this render the treatment ineffective, it will also cause irritation of the
mouth and oesophagus.
This treatment should not be recommended for children. Occasionally,
peppermint oil causes heartburn and so is best avoided in patients
who already suffer from this problem. Allergic reactions can occur
and are rare; rash, headache and muscle tremor have been reported
in such cases. One trial involving 110 people showed improvement in
symptoms of abdominal pain, distension and stool frequency.
Mebeverine hydrochloride
Mebeverine hydrochloride is used at a dose of 135 mg three times a day.
The dose should be taken 20 min before meals. The drug should not
be recommended for pregnant or breastfeeding women, for children
under 10 or for patients with porphyria.
Bulking agents
Traditionally, patients with IBS were told to eat a diet high in fibre, and
raw wheat bran was often recommended as a way of increasing the fibre
intake. Bran is no longer recommended in IBS (see ‘Practical points:
Diet’). Bulking agents such as ispaghula containing soluble fibre can
help some patients. It may take a few weeks of experimentation to find
the dose that suits the individual patient. Remind the patient to increase
fluid intake to take account of the additional fibre. Bulking agents are
124 GASTROINTESTINAL TRACT PROBLEMS
also available in combination with antispasmodics. The evidence for
benefit is not strong, as studies have involved small numbers of patients.
Possible positive benefit has been shown for ispaghula husk.
Antidiarrhoeals
Patients who complain of diarrhoea may be describing a frequent urge
to pass stools, but the stools may be loose and formed rather than
watery. Use of OTC antidiarrhoeals such as loperamide is appropriate
only on an occasional, short-term basis. In two studies involving a total
of 100 patients, loperamide improved diarrhoea, including frequency
of bowel movements, but not abdominal pain or distension.
Practical points
Diet
Patients with IBS should follow the recommendations for a healthy
(low-fat, low-sugar, high-fibre) diet. Bran (which contains insoluble
fibre) used to be widely recommended but it tends to ferment in the
bowel and can lead to feelings of bloating and discomfort, and can
make symptoms worse. Dietary sources of soluble fibre can be recommended
including oats and pulses.
Some patients find that excluding foods which they know exacerbate
their symptoms is helpful (see ‘Aggravating factors’ above). The sweeteners
sorbitol and fructose can make symptoms worse and they are
found in many foods the patient needs to check labels at the supermarket.
Cutting out caffeine, milk and dairy products and chocolate may
be worth trying. Although some patients benefit from the withdrawal
of milk and dairy products, there is no evidence of lactase deficiency in
IBS. Remind patients that caffeine is included in many soft drinks and
so they should check labels.
Complementary therapies
Some patients find relaxation techniques helpful. Videos and audio
tapes are available to teach complementary therapies.
Studies have shown that hypnotherapy is of benefit in IBS. If patients
want to try this, they should consult a registered hypnotherapist. Others
may benefit from traditional acupuncture, reflexology, aromatherapy
or homoeopathy.
Irritable bowel syndrome in practice
Case 1
Joanna Mathers is a 29-year-old woman who asks to speak to the
pharmacist. She has seen an advertisement for an antispasmodic for
IBS and wonders whether she should try it. On questioning, she tells
you that she has been getting stomach pains and bowel symptoms for
several months, two or three times a month. She thinks her symptoms
IRRITABLE BOWEL SYNDROME 125
seem to be associated with business lunches and dinners at important
meetings and include abdominal pain, a feeling of abdominal fullness,
diarrhoea, nausea and sometimes vomiting. In answer to your specific
question about morning symptoms, Joanna says that sometimes she
feels the need to go to the toilet first thing in the morning and may have
to go several times. Sometimes she has been late for work because she
felt she couldn’t leave the house due to the diarrhoea. Joanna tells you
that she works as a marketing executive and that her job is pressurised
and stressful when there are big deadlines or client meetings. Joanna
drinks six or seven cups of coffee a day and says her diet is ‘whatever
I can get at work and something from the freezer when I get home’.
She is not taking any other medicines and has not been to the doctor
about her problems as she didn’t want to bother him.
The pharmacist’s view
The picture that has emerged indicates IBS. She has the key symptoms
and there is a link to stress at work. It would be worth trying an
antispasmodic (alverine, peppermint oil or mebeverine) for 1 week and
asking Joanna to come back at the end of that time. She also needs a
careful explanation of aggravating factors for IBS and might want to
try a gradual reduction in her intake of coffee over the next few days.
If there is no improvement, a different antispasmodic could be tried
for a further week, with referral then if needed.
The doctor’s view
Joanna gives a clear history of IBS. Her symptoms are likely to settle
with the pharmacist’s advice and treatment. There is up to a 60%
placebo response rate in IBS sufferers, so it would be surprising if she
did not improve when next reviewed. If there were no improvement,
then a referral would be sensible. A referral would give her doctor an
opportunity to deal with her concerns about what was wrong, confirm
the diagnosis and give her an appropriate explanation of IBS.
She could also be given some time to consider how she might tackle
her work pressures. Plenty of information is available on the web,
which she could be advised to look at, e.g., www.nhsdirect.nhs.uk and
www.theguttrust.org.
Case 2
Jane Dawson asks to see the pharmacist. She is in her early twenties and
says she has been getting some upper abdominal pain after food. She
wants to try a stomach medicine. On further questioning she says that
she has had an irritable bowel before but this is different, although she
does admit that her bowels have been troublesome recently and she has
noticed some urinary frequency. Jane says that she has been constipated
and felt bloated. She says that she went to her doctor last year and was
126 GASTROINTESTINAL TRACT PROBLEMS

برچسب ها: Constipation in pregnancy Constipation commonly occurs during pregnancy; hormonal changes are responsible and it has been estimated that one in three pregnant women suffers from constipation. Dietary advice concerning the intake of plenty of high-fibre foods and fluids can help. Oral iron، often prescribed for pregnant women، may contribute to the problem. Stimulant laxatives are best avoided during pregnancy; bulk-forming laxatives are preferable، although they may cause some abdominal discomfort to women when used late in pregnancy (see the chapter on ‘Women’s health’). Constipation in the elderly Constipation is a common problem in elderly patients for several reasons. Elderly patients are less likely to be physically active; they often have poor natural teeth or false teeth and so may avoid high-fibre foods that are more difficult to chew; multidrug regimens are more likely in elderly patients، who may therefore suffer from drug-induced constipation; fixed ideas about what constitutes a normal bowel habit are common in older patients. If a bulk laxative is to be recommended for an elderly patient، it is of great importance that the pharmacist give advice about maintaining fluid intake to prevent the possible development of intestinal obstruction. Laxative abuse Two groups of patients are likely to abuse laxatives: those with chronic constipation who get into a vicious circle by using stimulant laxatives (see p. 103)، which eventually results in damage to the nerve plexus in the colon،  

تاریخ : دوشنبه 25 اسفند 1393 | 11:48 ب.ظ | نویسنده : sinister | نظرات

کتاب علائم در داروخانه Symptoms in the Pharmacy 6th






Calcium carbonate
Calcium carbonate is commonly included in OTC formulations. It acts
quickly, has a prolonged action and is a potent neutraliser of acid. It can
cause acid rebound and, if taken over long periods at high doses, can
cause hypercalcaemia and so should not be recommended for longterm
use. Calcium carbonate and sodium bicarbonate can, if taken
in large quantities with a high intake of milk, result in the milk–alkali
syndrome. This involves hypercalcaemia, metabolic alkalosis and renal
insufficiency; its symptoms are nausea, vomiting, anorexia, headache
and mental confusion.
Dimeticone (dimethicone)
Dimeticone is sometimes added to antacid formulations for its defoaming
properties. Theoretically, it reduces surface tension and allows
88 GASTROINTESTINAL TRACT PROBLEMS
easier elimination of gas from the gut by passing flatus or eructation
(belching). Evidence of benefit is uncertain.
Interactions with antacids
Because they raise the gastric pH, antacids can interfere with enteric
coatings on tablets that are intended to release their contents further
along the GI tract. The consequences of this may be that release of
the drug is unpredictable; adverse effects may occur if the drug is in
contact with the stomach. Alternatively, enteric coatings are sometimes
used to protect a drug that may be inactivated by the low pH in the
stomach, so concurrent administration of antacids may result in such
inactivation. Taking the doses of antacids and other drugs at least 1 h
apart should minimise the interaction.
Antacids may reduce the absorption of tetracyclines, azithromycin,
itraconazole, ketoconazole, ciprofloxacin, dipyridamole, norfloxacin,
rifampicin and zalcitabine. Absorption of angiotensin-converting
enzyme (ACE) inhibitors, phenothiazines, gabapentin and phenytoin,
may also be reduced (see the BNF for a full current
list).
Sodium bicarbonate may increase the excretion of lithium and lower
the plasma level, so a reduction in lithium’s therapeutic effect may
occur. Antacids containing sodium bicarbonate should not therefore
be recommended for any patient on lithium therapy.
The changes in pH that occur after antacid administration can result
in a decrease in iron absorption if iron is taken at the same time. The
effect is caused by the formation of insoluble iron salts due to the
changed pH. Taking iron and antacids at different times should prevent
the problem (see the BNF for a detailed listing of interactions with
antacids).
Famotidine and ranitidine
Famotidine and ranitidine can be used for the short-term treatment
of dyspepsia and heartburn (see also p. 77). Treatment with ranitidine
is limited to a maximum of 2 weeks and with famotidine to
6 days.
Discussing the use ofH2 antagonists with local family doctors would
be valuable. Agreeing general guidelines or a protocol for their use
could be a feature of the discussion.
Domperidone
Domperidone 10 mg can be used for the treatment of postprandial
stomach symptoms of excessive fullness, nausea, epigastric bloating
and belching, occasionally accompanied by epigastric discomfort and
heartburn. It increases the rate of gastric emptying and transit time in
INDIGESTION 89
the small intestine, and also increases the strength of contraction of
the oesophageal sphincter. Domperidone can be used in patients aged
16 years and over. The maximum dose is 10 mg and the maximum
daily dose 40 mg. When used as a prescription-only medicine (POM)
medicine, domperidone is used to treat nausea and vomiting, but these
indications are not included in the pharmacy (P) licence and patients
with these symptoms would need to be referred.
Indigestion in practice
Case 1
Mrs Johnson, an elderly woman, complains of indigestion and an upset
stomach. On questioning, you find out she has had the problem for a
few days; the pain is epigastric and does not seem to be related to food.
She has been feeling slightly nauseated. You ask about her diet; she has
not changed her diet recently and has not been overdoing it. She tells
you that she is taking four lots of tablets: for her heart, her waterworks
and some new ones for her bad hip (diclofenac modified release 100 mg
at night). She has been taking them after meals, as advised, and has not
tried any medicines yet to treat her symptoms. Before the diclofenac she
was taking paracetamol for the pain. She normally uses paracetamol as
a general painkiller at home; she tells you that she cannot take aspirin
because it upsets her stomach.
The pharmacist’s view
It sounds as though this woman is suffering GI symptoms as a result
of her NSAID. Such effects are more common in elderly patients. She
has been taking the medicine after food, which should have minimised
any GI effects, and the best course of action would be to refer her back
to the doctor. It would be worth asking Mrs Johnson about the dose
and frequency with which she took the paracetamol to see whether she
took enough for it to be effective.
The doctor’s view
Referral back to her doctor is the correct course of action. Almost
certainly her symptoms have been caused by the diclofenac. A large
clinical trial showed that risk factors for serious complications with
oral NSAIDs were: age 75 years or more, history of peptic ulcer, history
of GI bleeding and history of heart disease. If this woman were over
75 years and taking tablets for heart problems, she has two significant
risk factors. The model predicts that for patients with none of the four
risk factors, 1-year risk of a complication is 0.8%. For patients with
all four risk factors, the risk is 18%.
She should be advised to stop the diclofenac. A blood test for H.
pylori would be helpful and whilst awaiting the results she could be
90 GASTROINTESTINAL TRACT PROBLEMS
started on a PPI, such as lansoprazole. If the H. pylori test came back
positive, she would also benefit from H. pylori eradication therapy.
Control of her primary symptom (hip pain) will then be a problem.
NSAIDs should be avoided if possible. It may be possible to change
the paracetamol to a compound preparation containing paracetamol
and codeine or dihydrocodeine. If an NSAID is necessary to control the
pain and there is a documented history of peptic ulceration, an NSAID
can be given with a PPI. The NSAID can also be given concomitantly
with misoprostol. Misoprostol is a prostaglandin analogue that protects
the gastric mucosa and may limit damage from NSAIDs. Research
evidence shows that omeprazole was more effective than misoprostol
in preventing unwanted effects.
Failure to control hip pain due to osteoarthritis (OA) may require
referral to an orthopaedic surgeon to consider a hip replacement.
Case 2
Ken Jones is a local milkman in his early fifties and he comes in to ask
your advice about his stomach trouble. He tells you that he has been
having the problem for a couple of months but it seems to have got
worse. The pain is in his stomach, quite high up; he had similar pain a
few months ago, but it got better and has now come back again. The
pain seems to get better after a meal; sometimes it wakes him during
the night. He has been taking Rennies to treat his symptoms; they did
the trick but do not seem to be working now, even though he takes a
lot of them. He has also been taking some OTC ranitidine tablets. He
is not taking any other medicines.
The pharmacist’s view
Mr Jones has a history of epigastric pain, which remitted and has now
returned. At one stage his symptoms responded to an antacid but they
no longer do so, despite his increasing the dose. This long history, the
worsening symptoms and the failure of medication warrant referral to
the doctor.
The doctor’s view
It would be sensible to recommend referral to his doctor as the information
obtained so far does not permit diagnosis. It is possible that
Mr Jones has a stomach ulcer, acid reflux or even a stomach cancer,
but further information is required. An appropriate examination and
investigation will be necessary.
The doctor would need to listen carefully, first by asking open questions
and then by asking more direct, closed questions to find out more
information; e.g. how does the pain affect him? What is the nature of
the pain (burning, sharp, dull, tight or constricting)? Does it radiate (to
back or chest, down arms, up to neck/mouth)? Are there any associated
INDIGESTION 91
symptoms (nausea, difficulty in swallowing, loss of appetite, weight
loss or shortness of breath)? Are there any other problems (constipation
or flatulence)? What are the aggravating/relieving factors? How
is his general health? What is his diet like? How are things going for
him generally (personally/professionally)? Does he smoke? How much
alcohol does he drink? What does he think might be wrong with him?
What are his expectations for treatment/management?
92 GASTROINTESTINAL TRACT PROBLEMS
Nausea and vomiting
Nausea and vomiting are symptoms that have many possible causes.
From the pharmacist’s point of view, while there are treatments available
to prevent nausea and vomiting, there is no effective OTC treatment
once vomiting is established. For that reason, this section will deal
briefly with some of the causes of these symptoms and then continue in
the next section to consider the prevention of motion sickness, where
the pharmacist can recommend effective treatments to help prevent the
problem.
What you need to know
Age
Infant, child, adult, elderly
Pregnancy
Duration
Associated symptoms
Has vomiting started?
Abdominal pain
Diarrhoea
Constipation
Fever
Alcohol intake
Medication
Prescribed
OTC
Previous history
Dizziness/vertigo
Significance of questions and answers
Age
The very young and the elderly are most at risk of dehydration as a
result of vomiting. Vomiting of milk in infants less than 1 year old
may be due to infection or feeding problems or, rarely, an obstruction
such as pyloric stenosis. In the latter there is thickening of the
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
NAUSEA AND VOMITING 93
muscular wall around the outlet of the stomach, which causes a blockage.
It typically occurs in the first few weeks of life in a first-born
male. The vomiting is frequently projectile in that the vomit is forcibly
expelled a considerable distance. The condition can be cured by an
operation under general anaesthetic lasting about half an hour called a
pyloromyotomy. The pharmacist must distinguish, by questioning, between
vomiting (the forced expulsion of gastric contents through the
mouth) and regurgitation (where food is effortlessly brought up from
the throat and stomach). Regurgitation sometimes occurs in babies,
where it is known as posseting and is a normal occurrence. When regurgitation
occurs in adults, it is associated with oesophageal disease
with difficulty in swallowing and requires referral (see p. 75). Nausea
is associated with vomiting but not regurgitation and this can be
employed as a distinguishing feature during questioning.
Pregnancy
Nausea and vomiting are very common in pregnancy, usually beginning
after the first missed period and occurring early in the morning.
Pregnancy should be considered as a possible cause of nausea and vomiting
in any woman of childbearing age who presents at the pharmacy
complaining of nausea and vomiting. Nausea and vomiting are more
common in the first pregnancy than in subsequent ones.
Duration
Generally, adults should be referred to the doctor if vomiting has been
present for longer than 2 days. Children under 2 years are referred
whatever the duration because of the risks from dehydration. Anyone
presenting with chronic vomiting should be referred to the doctor since
such symptoms may indicate the presence of a peptic ulcer or gastric
carcinoma.
Associated symptoms
An acute infection (gastroenteritis) is often responsible for vomiting
and, in these cases, diarrhoea (see p. 110) may also be present. Careful
questioning about food intake during the previous 2 days may give
a clue as to the cause. In young children, the rotavirus is the most
common cause of gastroenteritis; this is highly infectious and so it is
not unusual for more than one child in the family to be affected. In
such situations there are usually associated cold symptoms.
The vomiting of blood may indicate serious disease and is an indication
for referral, since it may be caused by haemorrhage from a
peptic ulcer or gastric carcinoma. Sometimes the trauma of vomiting
can cause a small bleed, due to a tear in the gut lining. Vomit with a
faecal smell means that the GI tract may be obstructed and requires
urgent referral.
94 GASTROINTESTINAL TRACT PROBLEMS
Nausea and vomiting may be associated with a migraine. Any history
of dizziness or vertigo should be noted as it may point to inner ear
disease, e.g. labyrinthitis or Meniere’s disease as a cause of the nausea.
Alcohol intake
People who drink large quantities of alcohol may vomit, often in the
morning. This may be due to occasional binge drinking or chronic
ingestion of alcohol. Alcoholic patients often feel nauseous and retch in
the morning. The questioning of patients about their intake of alcohol
is a sensitive area and should be approached with tact. Asking about
smoking habits might be a good way of introducing other social habits.
Medication
Prescribed and OTC medicines may make patients feel sick and it is
therefore important to determine which medicines the patient is currently
taking. Aspirin and NSAIDs are common causes. Some antibiotics
may cause nausea and vomiting, e.g. doxycycline. Oestrogens,
steroids and narcotic analgesics may also produce these symptoms.
Symptoms can sometimes be improved by taking the medication with
food, but if they continue, the patient should see the doctor. Digoxin
toxicity may show itself by producing nausea and vomiting, and such
symptoms in a patient who is taking digoxin, especially an elderly
person, should prompt immediate referral where questioning has not
produced an apparent cause for the symptoms. Vomiting, with loss
of fluids and possible electrolyte imbalances, may cause problems in
elderly people taking digoxin and diuretics.
Previous history
Any history that suggests chronic nausea and vomiting would indicate
referral.
Management
Patients who are vomiting should be referred to the doctor, who will be
able to prescribe an antiemetic if needed. The pharmacist can initiate
rehydration therapy in the meantime.
NAUSEA AND VOMITING 95
Motion sickness and its prevention
Motion sickness is thought to be caused by a conflict of messages to the
brain, where the vomiting centre receives information from the eyes,
the GI tract and the vestibular system in the ear. Symptoms of motion
sickness include nausea and sometimes vomiting, pallor and cold
sweats. Parents commonly seek advice about how to prevent motion
sickness in children, in whom the problem is most common. Any form
of travel can produce symptoms, including air, sea and road. Effective
prophylactic treatments are available OTC and can be selected to
match the patient’s needs.
What you need to know
Age
Infant, child, adult
Previous history
Mode of travel: car, bus, air, ferry, etc.
Length of journey
Medication
Significance of questions and answers
Age
Motion sickness is common in young children. Babies and very young
children up to 2 years seem to only rarely suffer from the problem and
therefore do not usually require treatment. The incidence of motion
sickness seems to greatly reduce with age, although some adults still
experience symptoms. The minimum age at which products designed
to prevent motion sickness can be given varies, so for a family with
several children careful product selection can provide one medicine to
treat all cases.
Previous history
The pharmacist should ascertain which members of the family have
previously experienced motion sickness and for whom treatment will
be needed.
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
96 GASTROINTESTINAL TRACT PROBLEMS
Mode of travel/length of journey
Details of the journey to be undertaken are useful. The estimated length
of time to be spent travelling will help the pharmacist in the selection
of prophylactic treatment, since the length of action of available drugs
varies.
Once vomiting starts there is little that can be done, so any medicine
recommended by the pharmacist must be taken in good time before
the journey if it is to be effective. The fact that it is important that
the symptoms are prevented before they can gain a hold should be
emphasised to the parents. If it is a long journey, it may be necessary to
repeat the dose while travelling and the recommended dosage interval
should be stressed.
The pharmacist can also offer useful general advice about reducing
motion sickness according to the method of transport to be used. For
example, children are less likely to feel or be sick if they can see out of
the car, so appropriate seats can be used to elevate the seating position
of small children. This seems to be effective in practice and is thought
to be because it allows the child to see relatively still objects outside the
car. This ability to focus on such objects may help to settle the brain’s
receipt of conflicting messages.
For any method of travel, children are less likely to experience symptoms
if they are kept occupied by playing games as they are therefore
concentrating on something else. However, again, it seems that looking
outside at still objects remains helpful and that a simple game, e.g.
‘I spy’, is better than reading in this respect. In fact, for many travel
sickness sufferers, reading exacerbates the feeling of nausea.
Medication
In addition to checking any prescription or OTC medicines currently
being taken, the pharmacist should also enquire about any treatments
used in the past for motion sickness and their level of success or failure.
Management
Prophylactic treatments for motion sickness, which can be bought
OTC, are effective and there is usually no need to refer patients to
the doctor.
Anticholinergic activity is thought to prevent motion sickness and
forms the basis of treatment by anticholinergic agents (e.g. hyoscine)
and antihistamines, which have anticholinergic actions (e.g. cinnarizine
and promethazine).
Antihistamines
Antihistamines include cinnarizine, meclozine and promethazine. Anticholinergic
effects are thought to be responsible for the effectiveness
MOTION SICKNESS AND ITS PREVENTION 97
of antihistamines in the prophylaxis of motion sickness. All have the
potential to cause drowsiness and promethazine appears to be the most
sedative. Meclozine and promethazine theoclate have long durations
of action and are useful for long journeys since they need to be taken
only once daily. Cinnarizine and promethazine theoclate are not recommended
for children younger than 5 years, whereas meclozine can be
given to those over 2 years. The manufacturers of products containing
these drugs advise that they are best avoided during pregnancy.
Anticholinergic agents
The only anticholinergic used widely in the prevention of motion sickness
is hyoscine hydrobromide, which can be given to children over
3 years. Anticholinergic drugs can cause drowsiness, blurred vision,
dry mouth, constipation and urinary retention as side-effects, although
they are probably unlikely to do so at the doses used in OTC formulations
for motion sickness. Children could be given sweets to suck to
counteract any drying of the mouth.
Hyoscine has a short duration of action (from 1 to 3 h). It is therefore
suitable for shorter journeys and should be given 20 min before
the start of the journey. Anticholinergic drugs and antihistamines with
anticholinergic effects are best avoided in patients with prostatic hypertrophy
because of the possibility of urinary retention and in glaucoma
because the intraocular pressure might be increased.
Pharmacists should remember that side-effects from anticholinergic
agents are additive and may be increased in patients already taking
drugs with anticholinergic effects, such as tricyclic antidepressants (e.g.
amitriptyline), butyrophenones (e.g. haloperidol) and phenothiazines
(e.g. chlorpromazine). It is therefore important for the pharmacist to
determine the identity of any medicines currently being taken by the
patient. Table 2 summarises recommended doses and length of action
for the treatments discussed.
Alternative approaches to motion sickness
Ginger
Ginger has been used for many years for travel sickness. Clinical trials
have produced conflicting findings in travel sickness. No mechanism of
action has been identified, but it has been suggested that ginger acts on
the GI tract itself rather than on the vomiting centre in the brain or on
the vestibular system. No official dosage level has been suggested, but
several proprietary products containing ginger are available. Ginger
would be worth trying for a driver who suffered from motion sickness,
since it does not cause drowsiness, and might be worth considering
for use in pregnant women, for whom other antiemetics such as anticholinergics
and antihistamines are not recommended. Ginger has
98 GASTROINTESTINAL TRACT PROBLEMS
Table 2 Treatments for motion sickness.
Timing of
Minimum first dose in Recommended
age for Adult relation to dose interval
Ingredient use (year) Children’s dose dose journey (h)
Cinnarizine 5 15 mg 30 mg 2 h before 8
Hyoscine
hydrobromide
3 3–4 years: 75 μg 300 μg 20 min before 6
4–7 years: 150 μg
7–12 years:
150–300 μg
Meclozine 2 2–12 years:
12.5 mg
25 mg Previous
evening or 1 h
before
24
Promethazine
theoclate
5 5–10 years:
12.5 mg
Over 10 years:
25 mg
25 mg Previous
evening or
1 h before
24
been shown to be effective in a research trial in nausea and vomiting
associated with pregnancy (see the chapter on ‘Women’s health’).
Acupressure wristbands
Elasticated wristbands that apply pressure to a defined point on the
inside of the wrists are available. Evidence of effectiveness is equivocal.
Such wristbands might be worth trying for drivers or pregnant women.
MOTION SICKNESS AND ITS PREVENTION 99
Constipation
Constipation is a condition that is difficult to define and is often selfdiagnosed
by patients. Generally, it is characterised by the passage of
hard, dry stools less frequently than by the person’s normal pattern. It
is important for the pharmacist to find out what the patient means by
constipation and to establish what (if any) change in bowel habit has
occurred and over what period of time.
What you need to know
Details of bowel habit
Frequency and nature of bowel actions now
When was the last bowel movement?
What is the usual bowel habit?
When did the problem start?
Is there a previous history?
Associated symptoms
Abdominal pain/discomfort/bloating/distension
Nausea and vomiting
Blood in the stool
Diet
Any recent change in diet?
Is the usual diet rich in fibre?
Medication
Present medication
Any recent change in medication
Previous use of laxatives
Significance of questions and answers
Details of bowel habit
Many people believe that a daily bowel movement is necessary for good
health and laxatives are often taken and abused as a result. In fact, the
normal range may vary from three movements in 1 day to three in 1
week. Therefore an important health education role for the pharmacist
is in reassuring patients that their frequency of bowel movement is
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
100 GASTROINTESTINAL TRACT PROBLEMS
normal. Patients who are constipated will usually complain of hard
stools which are difficult to pass and less frequent than usual.
The determination of any change in bowel habit is essential, particularly
any prolonged change. A sudden change, which has lasted for 2
weeks or longer, would be an indication for referral.
Associated symptoms
Constipation is often associated with abdominal discomfort, bloating
and nausea. In some cases constipation can be so severe as to obstruct
the bowel. This obstruction or blockage usually becomes evident by
causing colicky abdominal pain, abdominal distension and vomiting.
When symptoms suggestive of obstruction are present, urgent referral
is necessary as hospital admission is the usual course of action. Constipation
is only one of many possible causes of obstruction. Other
causes such as bowel tumours or twisted bowels (volvulus) require
urgent surgical intervention.
Blood in the stool
The presence of blood in the stool can be associated with constipation
and, although alarming, is not necessarily serious. In such situations
blood may arise from piles (haemorrhoids) or a small crack in the
skin on the edge of the anus (anal fissure). Both these conditions are
thought to be caused by a diet low in fibre that tends to produce constipation.
The bleeding is characteristically noted on toilet paper after
defaecation. The bright red blood may be present on the surface of
the motion (not mixed in with the stool) and splashed around the toilet
pan. If piles are present, there is often discomfort on defaecation.
The piles may drop down (prolapse) and protrude through the anus. A
fissure tends to cause less bleeding but much more severe pain on defaecation.
Medical referral is advisable as there are other more serious
causes of bloody stools, especially where the blood is mixed in with the
motion.
Bowel cancer
Large bowel cancer may also present with a persisting change in bowel
habit. This condition kills about 16,000 people each year in the UK.
Early diagnosis and intervention can dramatically improve the prognosis.
The incidence of large bowel cancer rises significantly with age. It is
uncommon among people under 50 years. It is more common amongst
those living in northern Europe and North America compared with
southern Europe and Asia. The average age at diagnosis is 60–65 years.
Diet
Insufficient dietary fibre is a common cause of constipation. An impression
of the fibre content of the diet can be gained by asking what would
normally be eaten during a day, looking particularly for the presence
CONSTIPATION 101
of wholemeal cereals, bread, fresh fruit and vegetables. Changes in diet
and lifestyle, e.g. following a job change, loss of work, retirement or
travel, may result in constipation. An inadequate intake of food and
fluids, e.g. in someone who has been ill, may be responsible.
An adequate fluid intake is essential for well-being, and, for both
prevention and treatment of constipation. It is thought that an inadequate
fluid intake is one of the commonest causes of constipation.
Research shows that by increasing fluid intake in someone who is
not well hydrated the frequency of bowel actions is increased. It is
particularly effective when it is increased alongside an increase in
dietary fibre. The recommended daily amount of fluid is 2.5 litres a
day for adults and not all of this needs to be in the form of water. Tea
and coffee can be counted towards daily fluid intake.
Medication
One or more laxatives may have already been taken in an attempt
to treat the symptoms. Failure of such medication may indicate that
referral to the doctor is the best option. Previous history of the use of
laxatives is relevant. Continuous use, especially of stimulant laxatives,
can result in a vicious circle where the contents of the gut are expelled,
causing a subsequent cessation of bowel actions for 1 or 2 days. This
then leads to the false conclusion that constipation has recurred and
more laxatives are taken and so on.
Chronic overuse of stimulant laxatives can result in loss of muscular
activity in the bowel wall (an atonic colon) and thus further constipation.
Many drugs can induce constipation; some examples are listed in
Table 3. The details of prescribed and OTC medications being taken
should be established.
When to refer
Change in bowel habit of 2 weeks or longer
Presence of abdominal pain, vomiting, bloating
Blood in stools
Prescribed medication suspected of causing symptoms
Failure of OTC medication
Treatment timescale
If 1 week’s use of treatment does not produce relief of symptoms, the
patient should see the doctor. If the pharmacist feels that it is necessary
to give only dietary advice, then it would be reasonable to leave it for
about 2 weeks to see if the symptoms settle.
102 GASTROINTESTINAL TRACT PROBLEMS
Table 3 Drugs that may cause constipation.
Drug group Drug
Analgesics and opiates Dihydrocodeine, codeine
Antacids Aluminium salts
Anticholinergics Hyoscine
Anticonvulsants Phenytoin
Antidepressants Tricyclics, selective serotonin reuptake
inhibitors
Antihistamines Chlorpheniramine, promethazine
Antihypertensives Clonidine, methyldopa
Anti-Parkinson agents Levodopa
Beta-blockers Propranolol
Diuretics Bendroflumethiazide
Iron
Laxative abuse
Monoamine oxidase inhibitors
Antipsychotics Chlorpromazine
Management
Constipation that is not caused by serious pathology will usually respond
to simple measures, which can be recommended by the pharmacist:
increasing the amount of dietary fibre, maintaining fluid consumption
and doing regular exercise. In the short term, a laxative may
be recommended to ease the immediate problem.
Stimulant laxatives (e.g. sennosides and bisacodyl)
Stimulant laxatives work by increasing peristalsis. All stimulant laxatives
can produce griping/cramping pains. It is advisable to start at
the lower end of the recommended dosage range, increasing the dose if
needed. The intensity of the laxative effect is related to the dose taken.
Stimulant laxatives work within 6–12 h when taken orally. They should
be used for a maximum of 1 week. Bisacodyl tablets are enteric coated
and should be swallowed whole because bisacodyl is irritant to the
stomach. If it is given as a suppository, the effect usually occurs within
1 h and sometimes as soon as 15 min after insertion.
Docusate sodium appears to have both stimulant and stool-softening
effects and acts within 12 days.
The use of senna pods and cascara, which is non-standardised,
should be discouraged because the dose and therefore action are unpredictable.
Castor oil is a traditional remedy for constipation, which is
no longer recommended since there are better preparations available.
CONSTIPATION 103
Bulk laxatives (e.g. ispaghula, methylcellulose and sterculia)
Bulk laxatives are those that most closely copy the normal physiological
mechanisms involved in bowel evacuation and are considered by many
to be the laxatives of choice. Such agents are especially useful where
patients cannot or will not increase their intake of dietary fibre. Bulk
laxatives work by swelling in the gut and increasing faecal mass so
that peristalsis is stimulated. The laxative effect can take several days
to develop.
The sodium content of bulk laxatives (as sodium bicarbonate) should
be considered in those requiring a restricted sodium intake.
When recommending the use of a bulk laxative, the pharmacist
should advise that an increase in fluid intake would be necessary. In
the form of granules or powder, the preparation should be mixed with
a full glass of liquid (e.g. fruit juice or water) before taking. Fruit juice
can mask the bland taste of the preparation. Intestinal obstruction may
result from inadequate fluid intake in patients taking bulk laxatives,
particularly those whose gut is not functioning properly as a result of
abuse of stimulant laxatives.
Osmotic laxatives (e.g. lactulose, Epsom salts and Glauber’s salts)
Lactulose works by maintaining the volume of fluid in the bowel. It
may take 1–2 days to work. Lactitol is chemically related to lactulose
and is available as sachets. The contents of the sachet are sprinkled on
food or taken with liquid. One or two glasses of fluid should be taken
with the daily dose. Lactulose and lactitol can cause flatulence, cramps
and abdominal discomfort.
Epsom salts (magnesium sulphate) is a traditional remedy that, while
no longer recommended, is still requested by some older customers. It
acts by drawing water into the gut; the increased pressure results in increased
intestinal motility. A dose usually produces a bowel movement
within a few hours. Repeated use can lead to dehydration.
Glycerin suppositories have both osmotic and irritant effects and
usually act within 1 h. They may cause rectal discomfort. Moistening
the suppository before use will make insertion easier.
Constipation in children
Parents sometimes ask for laxatives for their children. Fixed ideas about
regular bowel habits are often responsible for such requests. Numerous
factors can cause constipation in children, including a change in
diet and emotional causes. Simple advice about sufficient dietary fibre
and fluid intake may be all that is needed. If the problem is of recent
origin and there are no significant associated signs, a single glycerin
suppository together with dietary advice may be appropriate. Referral
to the doctor would be best if these measures are unsuccessful

برچسب ها: Calcium carbonate Calcium carbonate is commonly included in OTC formulations. It acts quickly، has a prolonged action and is a potent neutraliser of acid. It can cause acid rebound and، if taken over long periods at high doses، can cause hypercalcaemia and so should not be recommended for longterm use. Calcium carbonate and sodium bicarbonate can، if taken in large quantities with a high intake of milk، result in the milk–alkali syndrome. This involves hypercalcaemia، metabolic alkalosis and renal insufficiency; its symptoms are nausea،  

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کتاب علائم در داروخانه Symptoms in the Pharmacy 6th





Respiratory symptoms for direct referral
Chest pain
Respiratory causes
A knifelike pain is characteristic of pleurisy. It is a localised pain which
is aggravated by taking a breath or coughing. It is usually caused by a
respiratory infection and may be associated with an underlying pneumonia.
Less commonly, it may be caused by a pulmonary embolus (a
blood clot which has lodged in a pulmonary artery after separating
from a clot elsewhere in the circulation).
A pain similar to that experienced with pleurisy may arise from
straining the muscles between the ribs following coughing. It may also
occur with cracked or fractured ribs following injury or violent coughing.
Another less common cause of pain is due to a pneumothorax
where a small leak develops in the lung causing its collapse.
The upper front part of the chest may be very sore in the early
stages of acute viral infections that cause inflammation of the trachea
(tracheitis). Viral flulike infections can be associated with non-specific
muscular pain (myalgia).
Non-respiratory causes
Heartburn
Heartburn occurs when the acid contents of the stomach leak backwards
into the oesophagus (gullet). The pain is described as a burning
sensation, which spreads upwards towards the throat. Occasionally, it
can be so severe as to mimic cardiac pain.
Cardiac pain
Cardiac pain typically presents as a tight, gripping, vicelike, dull pain
that is felt centrally across the front of the chest. The pain may seem to
move down one or both arms. Sometimes the pain spreads to the neck.
When angina is present, the pain is brought on by exercise and relieved
by rest. When a coronary event such as a heart attack (myocardial
infarction) occurs, the pain is similar but more severe and prolonged.
It may come on at rest.
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
RESPIRATORY SYMPTOMS FOR DIRECT REFERRAL 61
Anxiety
Anxiety is a commonly seen cause of chest pain in general practice.
The pain probably arises as a result of hyperventilation. Diagnosis can
be difficult as the hyperventilation may not be obvious.
Shortness of breath
Shortness of breath may be a symptom of a cardiac or respiratory
disorder. Differential diagnosis can be difficult. It is usually a sign of a
serious condition, although it can be due to anxiety.
Respiratory causes
Asthma
Occasionally, asthma may develop in later life, but it is most commonly
seen in young children or young adults. The breathlessness is typically
associated with a wheeze, although in mild cases the only symptom
may be a recurrent nocturnal cough. Most asthmatics have normal
breathing between attacks. The attacks are often precipitated by viral
infections such as colds. Some are worsened in the hay fever season,
others by animal fur or dust. The breathlessness is often worse at night.
Chronic bronchitis and emphysema
Chronic bronchitis and emphysema are usually caused by cigarette
smoking and give rise to permanent breathlessness, especially on exertion,
with a productive cough. The breathing worsens when an infective
episode develops. At such times there is also an increase in coloured
sputum production.
Cardiac causes
Heart failure
Heart failure may develop gradually or present acutely as an emergency
(usually in the middle of the night). The former (congestive cardiac
failure) may cause breathlessness on exertion. It is often associated
with ankle swelling (oedema) and is most common in the elderly. The
more sudden type is called acute left ventricular failure. The victim is
woken by severe breathlessness and has to sit upright. There is often a
cough present with clear frothy sputum.
Other causes
Hyperventilation syndrome
Hyperventilation syndrome occurs when the rate of breathing is too
high for the bodily requirements. Paradoxically, the subjective experience
is that of breathlessness. The sufferer complains of difficulty in
taking in a deep breath. The experience is frightening but harmless. It
may be associated with other symptoms such as tingling in the hands
62 RESPIRATORY PROBLEMS
and feet, numbness around the mouth, dizziness and various muscular
aches. It may be caused by anxiety.
Wheezing
Wheezing sounds may be heard in the throat region in URTIs and
are of little consequence. They are to be differentiated from wheezing
emanating from the lungs. In this latter situation, there is usually some
difficulty in breathing.
Wheezy bronchitis
Wheezing occurs in infants with wheezy bronchitis. It is caused by a
viral infection and is completely different from chronic bronchitis seen
in adults. The infection is self-limiting but requires accurate diagnosis.
Children who have a history of recurrent wheezy bronchitis are more
likely to develop asthma.
Asthma
Wheezing is a common feature of asthma and accompanies the shortness
of breath. However, in very mild asthma it is not obvious and may
present with just a cough. At the other extreme, an asthma attack can
be so severe that so little air moves in and out of the lungs there is no
audible wheeze.
Cardiac
Wheezing may be a symptom associated with shortness of breath in
heart failure.
Sputum
Sputum may be described as thick or thin and clear or coloured. It is
a substance coughed up from the lungs and is not to be confused with
saliva or nasal secretions.
Bronchitis
Clear thick sputum may be coughed up in chronic bronchitis or by regular
cigarette smokers. It has a mucoid nature and may be described as
white, grey or clear with black particles. Chronic bronchitics are prone
to recurrent infective exacerbations during which sputum production
increases and turns yellow or green.
Pneumonia
Coloured mucoid sputum may be present in other lung infections such
as pneumonia. Rust-coloured sputum is characteristic of pneumococcal
(lobar) pneumonia.
RESPIRATORY SYMPTOMS FOR DIRECT REFERRAL 63
Cardiac
Clear thin (serous) sputum may be a feature of heart failure (left ventricular
failure). The sputum forms as a result of pulmonary oedema,
which characteristically awakens the patient in the night with shortness
of breath.
Haemoptysis
The presence of blood in sputum is always alarming. Small traces of
blood can result from a broken capillary caused by coughing and is
harmless. However, it can be a symptom of serious disease such as
lung cancer or pulmonary TB, and should always be referred for further
investigation. Occasionally, blood is coughed up after a nosebleed and
is of no consequence.
64 RESPIRATORY PROBLEMS
Gastrointestinal Tract Problems
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton
and J. Blenkinsopp © 2009 Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. ISBN: 978-1-405-18079-5

Mouth ulcers
Mouth ulcers are extremely common, affecting as many as one in five
of the population, and are a recurrent problem in some people. They
are classified as aphthous (minor or major) or herpetiform ulcers. Most
cases (more than three quarters) are minor aphthous ulcers, which are
self-limiting. Ulcers may be due to a variety of causes including infection,
trauma and drug allergy. However, occasionally mouth ulcers
appear as a symptom of serious disease such as carcinoma. The pharmacist
should be aware of the signs and characteristics that indicate
more serious conditions.
What you need to know
Age
Child, adult
Nature of the ulcers
Size, appearance, location, number
Duration
Previous history
Other symptoms
Medication
Significance of questions and answers
Age
Patients may describe a history of recurrent ulceration, which began
in childhood and has continued ever since. Minor aphthous ulcers are
more common in women and occur most often between the ages of 10
and 40 years.
Nature of the ulcers
Minor aphthous ulcers usually occur in crops of one to five. The lesions
may be up to 5 mm in diameter and appear as a white or yellowish
centre with an inflamed red outer edge. Common sites are the tongue
margin and inside the lips and cheeks. The ulcers tend to last from 5
to 14 days.
MOUTH ULCERS 67
Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp
Paul Paxton and John Blenkinsopp © 2009 Blackwell Publishing Ltd, ISBN: 978-1-4051-8079-5
Table 1 The three main types of aphthous ulcers.
Minor Major Herpetiform
80% of patients 10–12% of patients 8–10% of patients
2–10 mm in diameter
(usually 5–6 mm)
Usually over 10 mm in diameter;
may be smaller
0.5–3.0 mm in diameter
Usually 1–5 mm in
diameter
Usually 10–20 mm in diameter or
more
0.05–1.0 mm in
diameter
Round or oval Round or oval Round or oval, coalesce
to form irregular shape
as they enlarge
Usually not very painful Prolonged and painful ulceration;
may present patient with great
problems – eating may become
difficult
May be very painful
Other types of recurrent mouth ulcers include major aphthous and
herpetiform. Major aphthous ulcers are uncommon, severe variants of
the minor ones. The ulcers which may be as large as 30 mm in diameter
can occur in crops of up to 10. Sites involved are the lips, cheeks,
tongue, pharynx and palate. They are more common in sufferers of
ulcerative colitis.
Herpetiform ulcers are more numerous, smaller and, in addition to
the sites involved with aphthous ulcers, may affect the floor of the
mouth and the gums. Table 1 summarises the features of the three
main types of aphthous ulcers.
Systemic conditions such as Behc¸et’s syndrome and erythema multiforme
may produce mouth ulcers, but other symptoms would generally
be present (see below).
Duration
Minor aphthous ulcers usually heal in less than 1 week; major aphthous
ulcers take longer (10–30 days). Where herpetiform ulcers occur, fresh
crops of ulcers tend to appear before the original crop has healed,
which may lead patients to think that the ulceration is continuous.
Oral cancer
Any mouth ulcer that has persisted for longer than 3 weeks requires
immediate referral to the dentist or doctor because an ulcer of such long
duration may indicate serious pathology, such as carcinoma. Most oral
cancers are squamous cell carcinomas, of which one in three affects
the lip and one in four affects the tongue. The development of a cancer
may be preceded by a premalignant lesion, including erythroplasia
(red) and leucoplakia (white) or a speckled leucoplakia. Squamous cell
carcinoma may present as a single ulcer with a raised and indurated
68 GASTROINTESTINAL TRACT PROBLEMS
(firm or hardened) border. Common locations include the lateral border
of the tongue, lips, floor of the mouth and gingiva. The key point
to raise suspicion would be a lesion that had lasted for several weeks
or longer. Oral cancer is more common in smokers than non-smokers.
Previous history
There is often a family history of mouth ulcers (estimated to be present
in one in three cases). Minor aphthous ulcers often recur, with the
same characteristic features of size, numbers, appearance and duration
before healing. The appearance of these ulcers may follow trauma to
the inside of the mouth or tongue, such as biting the inside of the cheek
while chewing food. Episodes of ulceration generally recur after 1–4
months.
Ill-fitting dentures may produce ulceration and, if this is a suspected
cause, the patient should be referred back to the dentist so that the
dentures can be refitted. However, trauma is not always a feature of
the history, and the cause of minor aphthous ulcers remains unclear
despite extensive investigation.
In women, minor aphthous ulcers often precede the start of the menstrual
period. The occurrence of ulcers may cease after pregnancy, suggesting
hormonal involvement. Stress and emotional factors at work
or home may precipitate a recurrence or a delay in healing but do not
seem to be causative.
Deficiency of iron, folate, zinc or vitamin B12 may be a contributory
factor in aphthous ulcers and may also lead to glossitis (a condition
where the tongue becomes sore, red and smooth) and angular stomatitis
(where the corners of the mouth become sore, cracked and red).
Food allergy is occasionally the causative factor and it is worth enquiring
whether the appearance of ulcers is associated with particular
foods.
Other symptoms
The severe pain associated with major aphthous or herpetiform ulcers
may mean that the patient finds it difficult to eat and, as a consequence,
weight loss may occur. Weight loss would therefore be an indication
for referral.
In most cases of recurrent mouth ulcers the disease eventually burns
itself out over a period of several years. Occasionally, as in Behc¸et’s
syndrome, there is progression with involvement of sites other than
the mouth. Most commonly, the vulva, vagina and eyes are affected,
with genital ulceration and iritis (see p. 265).
Behc¸et’s syndrome can be confused with erythema multiforme, although
in the latter there is usually a distinctive rash present on the
skin. Erythema multiforme is sometimes precipitated by an infection
or drugs (e.g. sulphonamides or barbiturates).
MOUTH ULCERS 69
Mouth ulcers may be associated with inflammatory bowel disorders
or with coeliac disease. Therefore, if persistent or recurrent diarrhoea is
present, referral is essential. Patients reporting any of these symptoms
should be referred to their doctor.
Rarely, ulcers may be associated with disorders of the blood including
anaemia, abnormally low white cell count or leukaemia. It would
be expected that in these situations there would be other signs of illness
present and the sufferer would present directly to the doctor.
Medication
The pharmacist should establish the identity of any current medication,
since mouth ulcers may be produced as a side-effect of drug therapy.
Drugs that have been reported to cause the problem include aspirin
and other non-steroidal anti-inflammatory drugs (NSAIDs), cytotoxic
drugs and sulphasalazine (sulfasalazine). Radiotherapy may also induce
mouth ulcers. It is worth asking about herbal medicines because
feverfew (used for migraine) can cause mouth ulcers.
It would also be useful to ask the patient about any treatments tried
either previously or on this occasion and the degree of relief obtained.
The pharmacist can then recommend an alternative product where
appropriate.
When to refer
Duration of longer than 3 weeks
Associated weight loss
Involvement of other mucous membranes
Rash
Suspected adverse drug reaction
Diarrhoea
Treatment timescale
If there is no improvement after 1 week, the patient should see the
doctor.
Management
Symptomatic treatment of minor aphthous ulcers can be recommended
by the pharmacist and can relieve pain and reduce healing time. Active
ingredients include antiseptics, corticosteroids and local anaesthetics.
There is evidence from clinical trials to support use of topical corticosteroids
and chlorhexidine mouthwash. Gels and liquids may be more
accurately applied using a cotton bud or cotton wool, provided the
70 GASTROINTESTINAL TRACT PROBLEMS
ulcer is readily accessible. Mouthwashes can be useful where ulcers are
difficult to reach.
Chlorhexidine gluconate mouthwash
There is some evidence that chlorhexidine mouthwash reduces duration
and severity of ulceration. The rationale for the use of antibacterial
agents in the treatment of mouth ulcers is that secondary bacterial infection
frequently occurs. Such infection can increase discomfort and
delay healing. Chlorhexidine helps to prevent secondary bacterial infection
but it does not prevent recurrence. It has a bitter taste and is
available in peppermint as well as standard flavour. Regular use can
stain teeth brown – an effect that is not usually permanent. Advising
the patient to brush the teeth before using the mouthwash can
reduce staining. The mouth should then be well rinsed with water as
chlorhexidine can be inactivated by some toothpaste ingredients. The
mouthwash should be used twice a day, rinsing 10 mL in the mouth
for 1 min and continued for 48 h after symptoms have gone.
Topical corticosteroids
Hydrocortisone and triamcinolone act locally on the ulcer to reduce
inflammation and pain and to shorten healing time. The former is used
as pellets, the latter as a protective paste. To exert its effect a pellet
must be held in close proximity to the ulcer until dissolved. This can
be difficult when the ulcer is in an inaccessible spot. One pellet is used
four times a day. The pharmacist should explain that the pellets should
not be sucked, but dissolved in contact with the ulcer. These treatments
are best used as early as possible. Before an ulcer appears, the affected
area feels sensitive and tingling – the prodromal phase – and treatment
should start then. They should be applied three to four times daily.
They have no effect on recurrence, but should be restarted at the first
signs of a new outbreak.
Local analgesics
Benzydamine mouthwash or spray and choline salicylate dental gel
are short acting but can be useful in very painful major ulcers. The
mouthwash is used by rinsing 15 mL in the mouth three times a day.
Numbness, tingling and stinging can occur with benzydamine. Diluting
the mouthwash with the same amount of water before use can
reduce stinging. The mouthwash is not licensed for use in children under
12. Benzydamine spray is used as four sprays onto the affected area
three times a day. Although aspirin is no longer recommended for children
under 16 years because of possible links with Reye’s syndrome,
choline salicylate dental gel produces low levels of salicylate and can
therefore be used in children.
MOUTH ULCERS 71
Local anaesthetics (e.g. lidocaine (lignocaine) and benzocaine)
Local anaesthetic gels are often requested by patients. Although they
are effective in producing temporary pain relief, maintenance of gels
and liquids in contact with the ulcer surface is difficult. Reapplication
of the preparation may be done when necessary. Tablets and pastilles
can be kept in contact with the ulcer by the tongue and can be of value
when just one or two ulcers are present. Any preparation containing a
local anaesthetic becomes difficult to use when the lesions are located
in inaccessible parts of the mouth.
Both lidocaine and benzocaine have been reported to produce sensitisation,
but cross sensitivity seems to be rare, probably because the
two agents are from different chemical groupings. Thus, if a patient has
experienced a reaction to one agent in the past, the alternative could
be tried.
Mouth ulcers in practice
Case 1
Anthony Jarvis, a man in his early fifties, asks you to recommend something
for painful mouth ulcers. On questioning, he tells you that he
has two ulcers at the moment and has occasionally suffered from the
problem over many years. Usually he gets one or two ulcers inside the
cheek or lips and they last for about 1 week. Mr Jarvis is not taking
any medicines and has no other symptoms. You ask to see the lesions
and note that there are two small white patches, each with an angrylooking
red border. One ulcer is located on the edge of the tongue and
the other inside the cheek. Mr Jarvis cannot remember any trauma or
injury to the mouth and has had the ulcers for a couple of days. He
tells you that he has used pain-killing gels in the past and they have
provided some relief.
The pharmacist’s view
From what he has told you, it would be reasonable to assume that Mr
Jarvis suffers from recurrent minor aphthous ulcers. Treatment with
hydrocortisone pellets (one pellet dissolved in contact with the ulcers
four times a day), with triamcinolone in carmellose dental paste, or
with a local anaesthetic or analgesic gel applied when needed, would
help to relieve the discomfort until the ulcers healed. Mr Jarvis should
see his doctor if the ulcers have not healed within 3 weeks.
The doctor’s view
Mr Jarvis is most likely suffering from recurrent aphthous ulceration.
As always, it is worthwhile enquiring about his general health, checking,
in particular, that he does not have a recurrent bowel upset or
72 GASTROINTESTINAL TRACT PROBLEMS
weight loss. These ulcers can be helped by a topical steroid preparation.
Case 2
One of your counter assistants asks you to recommend a strong treatment
for mouth ulcers for a woman who has already tried several
treatments. The woman tells you that she has a troublesome ulcer that
has persisted for a few weeks. She has used some pastilles containing
a local anaesthetic and an antiseptic mouthwash but with no improvement.
The pharmacist’s view
This woman should be advised to see her doctor for further investigation.
The ulcer has been present for several weeks, with no sign of
improvement, suggesting the possibility of a serious cause.
The doctor’s view
Referral is correct. It is likely that the doctor will refer her to an oral
surgeon for further assessment and probable biopsy as the ulcer could
be malignant. Cancer of the mouth accounts for approximately 2% of
all cancers of the body in Britain. It is most common after the sixth
decade and is more common in men, especially pipe or cigar smokers.
Cancer of the mouth is most often found on the tongue or lower lip. It
may be painless initially.
MOUTH ULCERS 73
Heartburn
Symptoms of heartburn are caused when there is reflux of gastric contents,
particularly acid, into the oesophagus, which irritate the sensitive
mucosal surface (oesophagitis). Patients will often describe the symptoms
of heartburn – typically a burning discomfort/pain felt in the
stomach, passing upwards behind the breastbone (retrosternally). By
careful questioning, the pharmacist can distinguish conditions that are
potentially more serious.
What you need to know
Age
Adult, child
Symptoms
Heartburn
Difficulty in swallowing
Flatulence
Associated factors
Pregnancy
Precipitating factors
Relieving factors
Weight
Smoking habit
Eating
Medication
Medicines tried already
Other medicines being taken
Significance of questions and answers
Age
The symptoms of reflux and oesophagitis occur more commonly in
patients aged over 55 years. Heartburn is not a condition normally experienced
in childhood, although symptoms can occur in young adults
and particularly in pregnant women. Children with symptoms of heartburn
should therefore be referred to their doctor.
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
74 GASTROINTESTINAL TRACT PROBLEMS
Symptoms/associated factors
A burning discomfort is experienced in the upper part of the stomach
in the midline (epigastrium) and the burning feeling tends to move
upwards behind the breastbone (retrosternally). The pain may be felt
only in the lower retrosternal area or on occasion right up to the throat,
causing an acid taste in the mouth.
Deciding whether or not someone is suffering from heartburn can be
helped by enquiring about precipitating or aggravating factors. Heartburn
is often brought on by bending or lying down. It is more likely to
occur in those who are overweight and can be aggravated by a recent
increase in weight. It is also more likely to occur after a large meal. It
can be aggravated and even caused by belching. Many people develop
a nervous habit of swallowing to clear the throat. Each time this occurs,
air is taken down into the stomach, which becomes distended.
This causes discomfort which is relieved by belching but which in turn
can be associated with acid reflux.
Severe pain
Sometimes the pain can come on suddenly and severely and even radiate
to the back and arms. In this situation differentiation of symptoms
is difficult as the pain can mimic a heart attack and urgent medical referral
is essential. Sometimes patients who have been admitted to hospital
apparently suffering a heart attack are found to have oesophagitis
instead. For further discussion about causes of chest pain, see p. 61.
Difficulty in swallowing (dysphagia)
Difficulty in swallowing must always be regarded as a serious symptom.
The difficulty may be either discomfort as food or drink is swallowed
or a sensation of food or liquids sticking in the gullet. Both require
referral (see ‘When to refer’ box below). It is possible that discomfort
may be secondary to oesophagitis from acid reflux (gastro-oesophageal
reflux disease (GORD)), especially when it occurs whilst swallowing
hot drinks or irritant fluids (e.g. alcohol or fruit juice). A history of a
sensation that food sticks as it is swallowed or that it does not seem to
pass directly into the stomach (dysphagia) is an indication for immediate
referral. It may be due to obstruction of the oesophagus, e.g. by
a tumour.
Regurgitation
Regurgitation can be associated with difficulty in swallowing. It occurs
when recently eaten food sticks in the oesophagus and is regurgitated
without passing into the stomach. This is due to a mechanical blockage
in the oesophagus. This can be caused by a cancer or, more fortunately,
by less serious conditions such as a peptic stricture. A peptic stricture is
HEARTBURN 75
caused by long-standing acid reflux with oesophagitis. The continual
inflammation of the oesophagus causes scarring. Scars contract and
can therefore cause narrowing of the oesophagus. This can be treated
by dilatation using a fibre-optic endoscope. However, medical examination
and further investigations are necessary to determine the cause
of regurgitation.
Pregnancy
It has been estimated that as many as half of all pregnant women suffer
from heartburn. Pregnant women aged over 30 years are more likely
to suffer from the problem. The symptoms are caused by an increase in
intra-abdominal pressure and incompetence of the lower oesophageal
sphincter. It is thought that hormonal influences, particularly progesterone,
are important in the lowering of sphincter pressure. Heartburn
often begins in mid-to-late pregnancy, but may occur at any stage. The
problem may sometimes be associated with stress.
Medication
The pharmacist should establish the identity of any medication that has
been tried to treat the symptoms. Any other medication being taken by
the patient should also be identified; some drugs can cause the symptoms
of heartburn, e.g. those with anticholinergic actions, such as tricyclic
antidepressants and calcium channel blockers and caffeine in
compound analgesics or when taken as a stimulant.
Failure to respond to antacids and pain radiating to the arms could
mean that the pain is not caused by acid reflux. Although it is still a
possibility, other causes such as ischaemic heart disease (IHD) and gall
bladder disease have to be considered.
When to refer
Failure to respond to antacids
Pain radiating to arms
Difficulty in swallowing
Regurgitation
Long duration
Increasing severity
Children
Treatment timescale
If symptoms have not responded to treatment after 1 week the patient
should see a doctor.
76 GASTROINTESTINAL TRACT PROBLEMS
Management
The symptoms of heartburn respond well to treatments that are available
over the counter (OTC), and there is also a role for the pharmacist
to offer practical advice about measures to prevent recurrence of the
problem. Pharmacists will use their professional judgement to decide
whether to offer antacids/alginates,H2 antagonists or the proton pump
inhibitor (PPI) omeprazole as first-line treatment. The decision will also
take into account customer preference.
Antacids
Antacids can be effective in controlling the symptoms of heartburn and
reflux, more so in combination with an alginate. Choice of antacid can
be made by the pharmacist using the same guidelines as in the section
on indigestion (see p. 87). Preparations that are high in sodium should
be avoided by anyone on a sodium-restricted diet (e.g. those with heart
failure or kidney or liver problems).
Alginates
Alginates form a raft that sits on the surface of the stomach contents
and prevents reflux. Some alginate-based products contain sodium bicarbonate,
which, in addition to its antacid action, causes the release
of carbon dioxide in the stomach, enabling the raft to float on top of
the stomach contents. If a preparation low in sodium is required, the
pharmacist can recommend one containing potassium bicarbonate instead.
Alginate products with low sodium content are useful for the
treatment of heartburn in patients on a restricted sodium diet.
H2 antagonists (famotidine and ranitidine)
Famotidine and ranitidine can be used for the short-term treatment of
dyspepsia, hyperacidity and heartburn in adults and children over 16
(see also p. 89). The treatment limit is intended to ensure that patients
do not continuously self-medicate for long periods. Pharmacists and
their staff can ask whether use has been continuous or intermittent
when a repeat purchase request is made. The H2 antagonists have both
a longer duration of action (up to 8–9 h) and a longer onset of action
than do antacids.
Where food is known to precipitate symptoms, the H2 antagonist
should be taken an hour before food. H2 antagonists are also effective
for prophylaxis of nocturnal heartburn. Headache, dizziness, diarrhoea
and skin rashes have been reported as adverse effects but they are not
common.
Manufacturers state that patients should not take OTC famotidine
or ranitidine without checking with their doctor if they are taking other
prescribed medicines.
HEARTBURN 77
Famotidine
Famotidine does not affect the cytochrome P450 system and therefore
does not cause the same range of interactions as cimetidine. The drug
is licensed for OTC use at a maximum dose of 10 mg and a maximum
daily dose of 20 mg. Famotidine is available as a tablet in combination
with the antacids magnesium hydroxide and calcium carbonate. The
idea behind this is to provide rapid symptom relief from the antacid and
longer action from famotidine. The maximum continuous treatment
period is six days.
Ranitidine
Ranitidine is licensed for OTC use in a dose of 75 mg with a maximum
daily dose of 300 mg. Ranitidine does not affect the cytochrome P450
system. It can be used for up to two weeks.
Proton pump inhibitors
Omeprazole can be used for the relief of heartburn symptoms associated
with reflux in adults. PPIs, including omeprazole, are generally
accepted as being amongst the most effective medicines for the relief
of heartburn. It may take a day or so for them to start being fully
effective. During this period a patient with ongoing symptoms may
need to take a concomitant antacid. Omeprazole works by suppressing
gastric acid secretion in the stomach. It inhibits the final stage of gastric
hydrochloric acid production by blocking the hydrogen–potassium
ATPase enzyme in the parietal cells of the stomach wall (also known
as the proton pump).
Two 10-mg tablets once daily is the initial starting dose. Subsequently,
symptomatic relief from heartburn can be achieved in some
subjects by taking 10 mg once daily, increasing to 20 mg if symptoms
return. The lowest effective dose should always be used and the
maximum daily dose is two tablets. Patients taking omeprazole should
be advised not to take H2 antagonists at the same time. The tablets
should be swallowed whole with plenty of liquid prior to a meal. It is
important that the tablets are not crushed or chewed. Alcohol and food
do not affect the absorption of omeprazole.
If no relief is obtained within 2 weeks, the patient should be referred
to the doctor. Omeprazole should not be taken during pregnancy or
whilst breastfeeding. Drowsiness has been reported but rarely. Treatment
with OTC omeprazole may cause a false-negative result in the
‘breath test’ for helicobacter.
78 GASTROINTESTINAL TRACT PROBLEMS
Practical points
Obesity
If the patient is overweight, weight reduction should be advised (see
weight management p. 335). There is some evidence that weight loss
reduces symptoms of heartburn.
Food
Small meals, eaten frequently, are better than large meals, as reducing
the amount of food in the stomach reduces gastric distension, which
helps to prevent reflux. Gastric emptying is slowed when there is a
large volume of food in the stomach; this can also aggravate symptoms.
High-fat meals delay gastric emptying. The evening meal is best taken
several hours before going to bed.
Posture
Bending, stooping and even slumping in an armchair can provoke
symptoms and should be avoided where possible. It is better to squat
rather than bend down. Since the symptoms are often worse when the
patient lies down, there is evidence that raising the head of the bed can
reduce both acid clearance and the number of reflux episodes. Using
extra pillows is often recommended but this is not as effective as raising
the head of the bed. The reason for this is that using extra pillows
raises only the upper part of the body, with bending at the waist, which
can result in increased pressure on the stomach contents.
Clothing
Tight, constricting clothing, especially waistbands and belts, can be an
aggravating factor and should be avoided.
Other aggravating factors
Smoking, alcohol, caffeine and chocolate have a direct effect by making
the oesophageal sphincter less competent by reducing its pressure
and therefore contribute to symptoms. The pharmacist is in a good position
to offer advice about how to stop smoking, offering a smoking
cessation product where appropriate (see the chapter on ‘Prevention of
heart disease’). The knowledge that the discomfort of heartburn will
be reduced can be a motivating factor in giving up cigarettes.
HEARTBURN 79
Heartburn in practice
Patient perspectives
I’ve been having trouble with heartburn. In fact, it is one of the reasons
I wanted to lose weight. I used to get it every once in a while, but then
it started to get more frequent. It used to be only in the evening, but
then it started happening in the middle of the day. A burning feeling
in my chest and coming up into my throat. Leaving a horrible taste in
the back of my throat. Because I started getting it during the day, I had
to start carrying antacid tablets around in my handbag. I haven’t been
to a doctor. I found that getting my weight down to a certain level (out
of the overweight range) got rid of my heartburn. It seems it doesn’t
take much excess weight to push on the contents of your stomach and
cause them to go up in the wrong direction.
Case 1
Mrs Amy Beston is a woman aged about 50 years who wants some
advice about a stomach problem. On questioning, you find out that
sometimes she gets a burning sensation just above the breastbone and
feels the burning in her throat, often with a bitter taste, as if some food
has been brought back up. The discomfort is worse when in bed at
night and when bending over whilst gardening. She has been having
the problem for 1 or 2 weeks and has not yet tried to treat it. Mrs Beston
is not taking any medicines from the doctor. To your experienced eye
this lady is at least a stone overweight. You ask Mrs Beston if the
symptoms are worse at any particular time and she says they are worst
shortly after going to bed at night.
The pharmacist’s view
This woman has many of the classic symptoms of heartburn: pain
in the retrosternal region and reflux. The problem is worse at night
after going to bed, as is common in heartburn. Mrs Beston has been
experiencing the symptoms for about 2 weeks and is not taking any
medicines from the doctor.
It would be reasonable to advise the use of an alginate antacid product
about 1 h after meals and before going to bed or an H2 antagonist.
Practical advice could include the tactful suggestion that Mrs Beston’s
symptoms would be improved if she lost weight. If your pharmacy
provides a weight management service you could ask if Mrs Beston is
interested in participating. Alternatively advice on healthy eating and
contact with a local weight watchers group could be given. Mrs Beston
could also try cutting down on tea, coffee and, if she smokes, stopping.
This is a long list of potential lifestyle changes. It might be a good idea
to explain the contributory factors to Mrs Beston and negotiate with
80 GASTROINTESTINAL TRACT PROBLEMS
her as to which one she will begin with. Success is more likely to be
achieved and sustained if changes are introduced one at a time.
Menopausal women are more prone to heartburn, and weight gain
at the time of the menopause will exacerbate the problem.
The doctor’s view
The advice given by the pharmacist is sensible. Acid reflux is the most
likely explanation for her symptoms. It is not clear from the presentation
whether she was seeking medication or simply asking for an
opinion about the cause of her symptoms, or both. It is always helpful
to explore a patient’s expectations in order to produce an effective
outcome to a consultation. In this instance the interchange between
the pharmacist and Mrs Beston is complex as a large amount of information
needs to be given, both explaining the cause of the symptoms
(providing an understandable description of oesophagus, stomach, acid
reflux and oesophagitis) and advising about treatment and lifestyle. It
is often sensible to offer a follow-up discussion to check on progress
and reinforce advice. If her heartburn was not improving, it would
provide an opportunity to recommend referral to her doctor.
The doctor’s next step would be very much dependent on this information.
If a clear story of heartburn caused by acid reflux were obtained,
then reinforcement of the pharmacist’s advice concerning posture,
weight, diet, smoking and alcohol would be appropriate. If medication
was requested, antacids or alginates could be tried. If the symptoms
were severe, an H2 antagonist or omeprazole would be treatment
options. In the case of persistent symptoms or diagnostic uncertainty,
referral for endoscopy would be necessary. Helicobacter pylori eradication
is not thought to play a role in the management of heartburn.
Case 2
You have been asked to recommend a strong mixture for heartburn
for Harry Groves, a local man in his late fifties who works in a nearby
warehouse. Mr Groves tells you that he has been getting terrible heartburn
for which his doctor prescribed some mixture about 1 week ago.
You remember dispensing a prescription for a liquid alginate preparation.
The bottle is now empty and the problem is no better. When
asked if he can point to where the pain is, Mr Groves gestures across
his chest and clenches his fist when describing the pain, which he says
feels heavy. You ask whether the pain ever moves and Mr Groves tells
you that sometimes it goes to his neck and jaw. Mr Groves is a smoker
and is not taking any other medicines. When asked if the pain worsens
when bending or lying down, Mr Groves says it does not, but he tells
you he usually gets the pain when he is at work, especially on busy
days.
HEARTBURN 81
The pharmacist’s view
This man should see his doctor immediately. The symptoms he has described
are not those that would be typical of heartburn. In addition,
he has been taking an alginate preparation, which has been ineffective.
Mr Groves’ symptoms give cause for concern; the heartburn is associated
with effort at work and its location and radiation suggest a more
serious cause.
The doctor’s view
Mr Groves’ story is suggestive of angina. He should be advised to contact
his doctor immediately. The doctor would require more details
about the pain, such as duration and whether or not the pain can come
on without any exertion. If the periods of pain were frequent, prolonged
and unrelieved by rest, it would be usual to arrange immediate
hospital admission as the picture sounds like unstable or crescendo
angina.
If an urgent inpatient referral is not required, the doctor would carry
out a fuller assessment that would usually include an examination,
electrocardiogram (ECG), urine analysis and blood test. This in turn
could lead to medication, e.g. aspirin and glyceryl trinitrate (GTN),
possibly a beta-blocker, a long acting nitrate or a rate-limiting calcium
channel blocker being prescribed and an urgent outpatient referral to
a cardiologist. Mr Groves would be strongly advised to stop smoking.
More detailed tests are likely to be arranged in hospital. These would
probably include an exercise cardiogram and an angiogram. This latter
test allows visualisation of the blood vessels supplying the heart muscle
and assessment of whether surgery would be advisable.
82 GASTROINTESTINAL TRACT PROBLEMS
Indigestion
Indigestion (dyspepsia) is commonly presented in community pharmacies
and is often self-diagnosed by patients, who use the term to
include anything from pain in the chest and upper abdomen to lower
abdominal symptoms. Many patients use the terms indigestion and
heartburn interchangeably. The pharmacist must establish whether
such a self-diagnosis is correct and exclude the possibility of serious
disease.
What you need to know
Symptoms
Age
Adult, child
Duration of symptoms
Previous history
Details of pain
Where is the pain?
What is its nature?
Is it associated with food?
Is the pain constant or colicky?
Are there any aggravating or relieving factors?
Does the pain move to anywhere else?
Associated symptoms
Loss of appetite
Weight loss
Nausea/vomiting
Alteration in bowel habit
Diet
Any recent change of diet?
Alcohol consumption
Smoking habit
Medication
Medicines already tried
Other medicines being taken
Symptoms in the Pharmacy, 6th edition. By Alison Blenkinsopp, Paul Paxton and
John Blenkinsopp. Published 2009 by Wiley-Blackwell. ISBN: 978-1-4051-8079-5.
INDIGESTION 83
Significance of questions and answers
Symptoms
The symptoms of typical indigestion include poorly localised upper
abdominal (the area between the belly button and the breastbone) discomfort,
which may be brought on by particular foods, excess food,
alcohol or medication (e.g. aspirin).
Age
Indigestion is rare in children, who should be referred to the doctor.
Abdominal pain, however, is a common symptom in children and is
often associated with an infection. OTC treatment is not appropriate
for abdominal pain of unknown cause and referral to the doctor would
be advisable.
Be cautious when dealing with first-time indigestion in patients aged
45 years or over and refer them to the general practitioner (GP) for a
diagnosis. Gastric cancer, while rare in young patients, is more likely
to occur in those aged 50 years and over. Careful history taking is
therefore of paramount importance here.
Duration/previous history
Indigestion that is persistent or recurrent should be referred to the doctor,
after considering the information gained from questioning. Any patient
with a previous history of the symptom which has not responded
to treatment, or which has worsened, should be referred.
Details of pain/associated symptoms
If the pharmacist can obtain a good description of the pain, then the
decision whether to advise treatment or referral is much easier. A few
medical conditions that may present as indigestion but which require
referral are described below.
Ulcer
Ulcers may occur in the stomach (gastric ulcer) or in the first part of the
small intestine leading from the stomach (duodenal ulcer). Duodenal
ulcers are more common and have different symptoms from gastric
ulcers. Typically the pain of a duodenal ulcer is localised to the upper
abdomen, slightly to the right of the midline. It is often possible to
point to the site of pain with a single finger. The pain is dull and is
most likely to occur when the stomach is empty, especially at night. It
is relieved by food (although it may be aggravated by fatty foods) and
antacids.
The pain of a gastric ulcer is in the same area but less well localised.
It is often aggravated by food and may be associated with nausea and
vomiting. Appetite is usually reduced and the symptoms are persistent
84 GASTROINTESTINAL TRACT PROBLEMS
and severe. Both types of ulcers are associated with H. pylori infection
and may be exacerbated or precipitated by smoking and NSAIDs.
Gallstones
Single or multiple stones can form in the gall bladder, which is situated
beneath the liver. The gall bladder stores bile. It periodically contracts
to squirt bile through a narrow tube (bile duct) into the duodenum to
aid the digestion of food, especially fat. Stones can become temporarily
stuck in the opening to the bile duct as the gall bladder contracts.
This causes severe pain (biliary colic) in the upper abdomen below the
right rib margin. Sometimes this pain can be confused with that of a
duodenal ulcer. Biliary colic may be precipitated by a fatty meal.
Gastro-oesophageal reflux
When a person eats, food passes down the gullet (oesophagus) into the
stomach. Acid is produced by the stomach to aid digestion. The lining
of the stomach is resistant to the irritant effects of acid, whereas the
lining of the oesophagus is readily irritated by acid. A sphincter (valve)
system operates between the stomach and the oesophagus preventing
reflux of stomach contents.
When this valve system is weak, e.g. in the presence of a hiatus
hernia, or where sphincter muscle tone is reduced by drugs such as
beta-blockers, anticholinergics and calcium channel blockers, the acid
contents of the stomach can leak backwards into the oesophagus. The
symptoms arising are typically described as heartburn but many patients
use the terms heartburn and indigestion interchangeably. Heartburn
is a pain arising in the upper abdomen passing upwards behind
the breastbone. It is often precipitated by a large meal or by bending
and lying down. Heartburn can be treated by the pharmacist but
sometimes requires referral (see p. 76).
Irritable bowel syndrome
Irritable bowel syndrome (IBS) is a common, non-serious, but troublesome,
condition in which symptoms are caused by colon spasm (also
see p. 121). There is usually an alteration in bowel habit, often with alternating
constipation and diarrhoea. The diarrhoea is typically worse
first thing in the morning. Pain is usually present. It is often lower
abdominal (below and to the right or left of the belly button) but it
may be upper abdominal and therefore confused with indigestion. Any
persistent alteration in normal bowel habit is an indication for referral.
Atypical angina
Angina is usually experienced as a tight, painful constricting band
across the middle of the chest. Atypical angina pain may be felt in
INDIGESTION 85
the lower chest or upper abdomen. It is likely to be precipitated by
exercise or exertion. If this occurs, referral is necessary.
More serious disorders
Persisting upper abdominal pain, especially when associated with
anorexia and unexplained weight loss, may herald an underlying cancer
of the stomach or pancreas. Ulcers sometimes start bleeding, which
may present with blood in the vomit (haematemesis) or in the stool
(melaena). In the latter the stool becomes tarry and black. Urgent referral
is necessary.
Diet
Fatty foods and alcohol can cause indigestion, aggravate ulcers and
precipitate biliary colic.
Smoking habit
Smoking predisposes to, and may cause, indigestion and ulcers. Ulcers
heal more slowly and relapse more often during treatment in smokers.
The pharmacist is in a good position to offer advice on smoking
cessation, perhaps with a recommendation to use nicotine replacement
therapy.
Medication
Medicines already tried
Anyone who has tried one or more appropriate treatments without
improvement or whose initial improvement in symptoms is not maintained
should see the doctor.
Other medicines being taken
Gastrointestinal (GI) side-effects can be caused by many drugs, so it
is important for the pharmacist to ascertain any medication that the
patient is taking.
NSAIDs have been implicated in the causation of ulcers and bleeding
ulcers, and there are differences in toxicity related to increased doses
and to the nature of individual drugs. Sometimes these drugs cause
indigestion. Elderly patients are particularly prone to such problems
and pharmacists should bear this in mind. Severe or prolonged indigestion
in any patient taking an NSAID is an indication for referral.
Particular care is needed in elderly patients, when referral is always
advisable. A study looked at emergency admissions to two hospitals in
two areas of England for GI disease. When the results were extrapolated
to the UK, the number of NSAID-associated emergency admissions
in the UK per year would be about 12,000, with about 2500
deaths.
86 GASTROINTESTINAL TRACT PROBLEMS
OTC medicines also require consideration; aspirin, ibuprofen and
iron are among those that may produce symptoms of indigestion. Some
drugs may interact with antacids (see ‘Interactions with antacids’ below).
When to refer
Age over 45 years if symptoms develop for first time
Symptoms are persistent (longer than 5 days) or recurrent
Pain is severe
Blood in vomit or stool
Pain worsens on effort
Persistent vomiting
Treatment has failed
Adverse drug reaction is suspected
Associated weight loss
Children
Treatment timescale
If symptoms have not improved within 5 days, the patient should see
the doctor.
Management
Once the pharmacist has excluded serious disease, treatment of dyspepsia
with antacids or anH2 antagonist may be recommended and is likely
to be effective. The preparation should be selected on the basis of the
individual patient’s symptoms. Smoking, alcohol and fatty meals can
all aggravate symptoms, so the pharmacist can advise appropriately.
Antacids
In general, liquids are more effective antacids than are solids; they are
easier to take, work quicker and have a greater neutralising capacity.
Their small particle size allows a large surface area to be in contact
with the gastric contents. Some patients find tablets more convenient
and these should be well chewed before swallowing for the best effect.
It might be appropriate for the patient to have both; the liquid could be
taken before and after working hours, while the tablets could be taken
during the day for convenience. Antacids are best taken about 1 h after
a meal because the rate of gastric emptying has then slowed and the
antacid will therefore remain in the stomach for longer. Taken at this
time antacids may act for up to 3 h compared with only 30 min–1 h if
taken before meals.
INDIGESTION 87
Sodium bicarbonate
Sodium bicarbonate is the only absorbable antacid that is useful in
practice. It is water soluble, acts quickly, is an effective neutraliser of
acid and has a short duration of action. It is often included in OTC
formulations in order to give a fast-acting effect, in combination with
longer acting agents. However, antacids containing sodium bicarbonate
should be avoided in patients if sodium intake should be restricted
(e.g. in patients with congestive heart failure). Sodium bicarbonate
increases excretion of lithium, leading to reduced plasma levels. The
contents of OTC products should therefore be carefully scrutinised and
pharmacists should be aware of the constituents of some of the traditional
formulary preparations. The relative sodium contents of different
antacids can be found in the BNF. In addition, long-term use of
sodium bicarbonate may lead to systemic alkalosis and renal damage.
In short-term use, however, it can be a valuable and effective antacid.
Its use is more appropriate in acute rather than chronic dyspepsia.
Aluminium and magnesium salts (e.g. aluminium hydroxide and
magnesium trisilicate)
Aluminium-based antacids are effective; they tend to be constipating
and this can be a useful effect in patients if there is slight diarrhoea.
Conversely, the use of aluminium antacids is best avoided in anyone
who is constipated and in elderly patients who have a tendency to be
so. Magnesium salts are more potent acid neutralisers than are aluminium
salts. They tend to cause osmotic diarrhoea as a result of the
formation of insoluble magnesium salts and are therefore useful in patients
who are slightly constipated. Combination products containing
aluminium and magnesium salts cause minimum bowel disturbance
and are therefore valuable preparations for recommendation by the
pharmacist..

برچسب ها: Respiratory symptoms for direct referral Chest pain Respiratory causes A knifelike pain is characteristic of pleurisy. It is a localised pain which is aggravated by taking a breath or coughing. It is usually caused by a respiratory infection and may be associated with an underlying pneumonia. Less commonly، it may be caused by a pulmonary embolus (a blood clot which has lodged in a pulmonary artery after separating from a clot elsewhere in the circulation). A pain similar to that experienced with pleurisy may arise from straining the muscles between the ribs following coughing. It may also occur with cracked or fractured ribs following injury or violent coughing. Another less common cause of pain is due to a pneumothorax where a small leak develops in the lung causing its collapse. The upper front part of the chest may be very sore in the early stages of acute viral infections that cause inflammation of the trachea (tracheitis). Viral flulike infections can be associated with non-specific muscular pain (myalgia). Non-respiratory causes Heartburn Heartburn occurs when the acid contents of the stomach leak backwards into the oesophagus (gullet). The pain is described as a burning sensation، which spreads upwards towards the throat. Occasionally، it can be so severe as to mimic cardiac pain. Cardiac pain Cardiac pain typically presents as a tight، gripping، vicelike، dull pain that is felt centrally across the front of the chest. The pain may seem to move down one or both arms. Sometimes the pain spreads to the neck. When angina is present،  

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