NHS Cumbria Minor Ailments Service. Formulary and Prescribing Notes

Transcription

1 NHS Cumbria Min Ailments Service Fmulary and October 2015

2 GASTROINTESTINAL (a) INDIGESTION Adult Antacids First choice: co-magaldrox (Mucogel ) Alginates First choice: compound alginic acid preparations (Peptac suspension Gastrocote tablets) H2 recept antagonists First choice: ranitidine Child Alginates First Choice: compound alginic acid preparations (Peptac suspension) Mucogel (magnesium hydroxide 195mg, dried aluminium hydroxide 220mg/5mL) suspension (500mL): adults, 10-20mL, 20 minutes-1 hour after meals, and at bedtime when required Peptac suspension 500mL (sodium alginate 250mg, sodium bicarbonate 133.5mg, calcium carbonate 80mg per 5mL): children aged 6-12 years, 5-10mL after meals and at bedtime; adults and children aged over 12 years, 10-20mL after meals and at bedtime Gastrocote (alginic acid 200mg, dried aluminium hydroxide gel 80mg, magnesium 40mg sodium bicarbonate 70mg) tablets (20): adults, 1-2 tablets chewed 4 times daily after meals and at bedtime ranitidine 75 mg tablets (12): adults, 1 tab PRN up to maximum of 2 in 24 hours. - Peptac is the most cost effective liquid compound alginic acid preparation - Liquid fmulations of antacids are me effective than tablets capsules - Compound alginic acid preparations are less powerful antacids than co-magaldrox but may be me effective f heartburn - Refer to pregnancy section f advice in pregnancy - Ranitidine should only be used sht term, if the problem persists refer to GP. - Advise patient to lose weight if overweight, stop smoking, avoid trigger foods. - Child under 6 years - Difficulty swallowing - Symptoms are persistent (longer than 5 days) recurrent - Pain is severe radiating - Blood in vomit stools - Pain wsens on efft - Persistent vomiting - Treatment has failed (no improvement in symptoms after 5 days) - Adverse drug reaction is suspected - Associated weight loss - First episode at age over 40 (b) INFANT COLIC Child No treatment see prescribing notes - Colic usually resolves within 4 months - Try helpful strategies of gentle motion, bathing in warm water, if breast feeding avoid spicy foods, alcohol, caffeine and foods with high dairy content, if bottle feeding ensure crect size holes on teat, if too large baby may gulp in air - Advise parents to take a break if possible, get friends family to help - Trials on effectiveness of simeticone showed no significant improvement in symptoms therefe it has not been included in the MAS. - Failure to thrive - Frequent recurrent vomiting - Feeding difficulties - Possible post-natal depression colic is often associated with parental anxiety (c) CONSTIPATION Adult First choice: dietary manipulation Second choice: ispaghula husk senna NHS Cumbria Min Ailments Service - Page 2 of 17

3 Child First choice: dietary manipulation Second choice: lactulose Fybogel (ispaghula husk) 3.5g sachets (30): adults, 1 sachet in water twice daily preferably after meals lactulose g/5mL solution (200mL, 500mL): children aged 1-5 years, 2.5mL twice daily with meals (may be diluted with water juice); children aged 5-10 years, 10mL twice daily with meals (may be diluted with water juice); adults and children 11 years and older, 15mL twice daily, adjust dose accding to patients needs senna 7.5mg 20 tablets: adults, 2-4 tablets at night - Ispaghula may take several days to act - Stimulant laxatives become less effective with long-term use - If bulk-fming and stimulant laxatives are unsuitable, consider at least 30mL daily of lactulose; this may take 48 hours to act - Refer to pregnancy section f advice in pregnancy - The use of laxatives in children should be discouraged unless recommended by a doct but lactulose may be given if needed sht term until dietary measures take effect - Dietary measures include increasing: fluid, fruit and fibre intake, avoid too many caffeine containing drinks - Regular exercise improves bowel habits - Lactulose may take up to 48 hours to act and should be used with caution in lactose intolerant patients - Stimulant laxatives should only be used sht-term - After an episode of acute constipation, maintenance therapy may be required f several months longer until regular bowel habit is established. - New wsening symptoms without adequate explanation - Persistent change in bowel habit - Abdominal pain, blood in stools, weight loss, nausea and vomiting - Prescribed medication suspected of causing symptoms - Failure of OTC medication (no relief of symptoms within 7 days) - Child feeling weak dizzy - Marked anal pain on defecation (d) DIARRHOEA Adult First choice: al rehydration therapy (Electrolade ) Second choice: loperamide Child First choice: al rehydration therapy (Electrolade ) Electrolade (sodium chlide 236mg, potassium chlide 300mg, sodium bicarbonate 500mg, anhydrous glucose 4g/sachet) al powder 6 sachets: reconstitute one sachet with 200mL of water (freshly boiled and cooled f infants): children aged 1 month 1 year, 1-1½ times usual feed volume; children aged 1-12 years, 200mL after every loose motion; adults and children aged over 12 years, mL after every loose motion loperamide 2mg capsules (12): adults and children over 12 years, 4mg then 2mg after each loose stool f up to 5 days. Max. 12mg daily. - First-line treatment f acute diarrhoea is to prevent dehydration, advise 3L fluids in 24 hours if not eating, 2L fluids in 24 hours if eating - Any unused solution should be discarded no later than 1 hour after preparation unless sted in a fridge when it can be kept f maximum of 24 hours - Eat as nmally as possible. Ideally include fruit juices and soups which will provide sugar and salt and also foods high in carbohydrate such as bread, pasta, etc. - Always wash hands after going to the toilet/changing nappies - Antidiarrhoeal drugs should not be given in acute inflammaty bowel disease pseudomembranous colitis, as they may increase the risk of developing toxic megacolon, n in acute infective diarrhoea with bloody stools. - Children <1 year: diarrhoea of duration greater than 1 day - Children 1-3 years: diarrhoea of duration greater than 2 days - Adults and children >3 years: duration of diarrhoea greater than 3 days - Concerns about dehydration e.g. not passing much urine NHS Cumbria Min Ailments Service - Page 3 of 17

4 - In severe cases referral should be recommended immediately - Associated with severe vomiting and fever - Suspected drug-induced reaction to prescribed medicine - Histy of change in bowel habit - Presence of blood mucus in the stools - Drowsiness confusion e) HAEMMORHOIDS Adult First Choice: Anusol Plus HC Dosage Regimen and Fmulations Anusol Plus HC (containing benzyl benzoate, bismuth oxide, bismuth subgallate, hydroctisone, peru balsam, zinc oxide) ointment with rectal nozzle (15g), supposities (12): adults, apply ( insert 1 supposity) night, mning and after defecation, f up to 7 days. - Anusol Plus HC can be used to provide symptomatic relief of haemrhoids and pruritus ani - Provide lifestyle advice to minimise constipation and straining - Keep anal area clean, perhaps use moist wipes - Warm baths may soothe - Refer to pregnancy section f advice in pregnancy. - Haemrhoids in children - Duration of longer than 3 weeks - Presence of blood in the stools - Change of bowel habit (persisting alteration from nmal bowel habit) - Suspected drug-induced constipation - Associated abdominal pain/vomiting OROPHARYNX (a) ORAL ULCERATION AND INFLAMMATION Adult First choice: benzydamine hydrochlide (Difflam ) +/- chlhexidine gluconate Second choice: hydroctisone sodium succinate lozenge Child First choice: benzydamine hydrochlide spray (Difflam ) Difflam (benzydamine hydrochlide) 0.15% al rinse (200mL): adults, rinse gargle with 15mL (diluted with water if stinging occurs) every 1½-3 hours as required, usually f not me than 7 days Difflam (benzydamine hydrochlide) 0.15% spray (30mL): children aged under 6 years, 1 puff per 4kg body-weight to max. 4 puffs onto affected area every 1½-3 hours; children aged 6-12 years, 4 puffs onto affected area every 1½-3 hours; adults and children over 12 years, 4-8 sprays onto affected area every 1½-3 hours chlhexidine gluconate 0.2% mouthwash (300mL): adults, rinse mouth with 10mL f about 1 minute twice daily Csodyl (chlhexidine gluconate) 0.2% al spray (60mL): adults, apply as required to tooth and gingival surfaces using up to a maximum of 12 actuations (approximately 0.14mL/actuation) twice daily hydroctisone sodium succinate 2.5mg lozenges (20): adults, 1 lozenge 4 times daily, allowed to dissolve slowly in the mouth in contact with the ulcer. Use f a maximum of 5 days. - There is some evidence that chlhexidine gluconate may reduce the duration and severity of each episode of ulceration - Benzydamine mouthwash can be used 10 minutes befe meals to relieve pain in patients suffering from mouth ulcers. /dental practitioner - Duration of longer than 3 weeks - Associated weight loss - Involvement of other mucous membranes - Rash - Suspected adverse drug reaction - Diarrhoea NHS Cumbria Min Ailments Service - Page 4 of 17

5 (b) TEETHING Child First choice: self care - rub gum with clean finger, allow infant to bite on a clean, cool object Second choice: lidocaine dental gel (Dentinox ) Dosage Regimens Dentinox (lidocaine hydrochlide 0.33% w/w and cetylpyridium chlide 0.1% w/w) teething gel (15g): children, place a small quantity of gel on a clean fingertip cotton wool pad and rub gently onto the baby s gums. Can be repeated after 20 minutes if necessary. - Oral analgesics might be helpful in managing the pain associated with teething, see CNS section f detail - Petroleum jelly aqueous cream applied around the mouth and chin may prevent rashes and seness from excessive dribbling. (c) ORAL FUNGAL INFECTION (thrush) Adult and Child First Choice: miconazole gel Daktarin (miconazole) 24mg/mL al gel (15g): prevention and treatment of al fungal infections: children aged 4 months 2 years, 2.5mL twice daily; children aged 2-6 years, 5mL twice daily; children aged 6 years-12 years, 5mL 4 times daily; adults and children over 12 years, 5-10mL 4 times daily. Place in the mouth after food and retain near lesions. Localised lesions, smear small amount on affected areas with clean finger 4 times daily f 5-7 days. - Avoid concomitant use in patient taking warfarin, simvastatin and sulphonylureas - Dental prostheses should be removed at night and brushed with gel - Treatment is continued f 48 hours after lesions have resolved - Pre-term slower developing babies should not be given miconazole gel until they are 5-6 months old, as detailed in the product literature - Never put the whole dose in the mouth of a child at once divide each dose into smaller applications. The gel should be placed in the front of the mouth, never put a large ption of gel in the back of the throat. - Child under 4 months - Duration of longer than 3 weeks - Associated weight loss - Involvement of other mucous membranes - Rash - Suspected adverse drug reaction - Diarrhoea RESPIRATORY & NASAL (a) HAY FEVER/RHINITIS Adult Allergic rhinitis First choice: beclometasone Antihistamines First choice: cetirizine chlphenamine Second choice: latadine Child Non drowsy antihistamines First choice: cetirizine Sedating antihistamines First choice: chlphenamine beclometasone dipropionate 50micrograms/puff nasal spray (180 dose): adults, 100 micrograms (2 sprays) into each nostril twice daily 50 micrograms (1 spray) into each nostril 3-4 times daily; max total 400 micrograms (8 sprays) daily; when symptoms controlled, reduce dose to 50 micrograms (1 spray) into each nostril twice daily cetirizine 10mg tablets (30); 5mg/5mL al liquid (200mL): children aged 2-6 years, 5mg daily 2.5mg twice daily; adults and children aged 6 years and over, 10mg daily 5mg twice daily latadine 10mg tablets (30): adults, 10mg daily NHS Cumbria Min Ailments Service - Page 5 of 17

6 chlphenamine 2mg/5mL syrup (150mL); 4mg tablets (30); (NB: syrup not licensed f use in children under 1 year; tablets not licensed f use in children under 6 years): children 1-2 years, 1mg twice daily; children 2-6 years, 1mg every 4-6 hours, max 6mg daily; children 6-12 years, 2mg every 4-6 hours, max 12mg daily; adults and children 12 years and over 4mg every 4-6 hours, max 24mg daily - F seasonal allergic rhinitis, prophylaxis should begin 1 week befe the start of the pollen season and continue throughout - Beclometasone nasal spray will not give instant relief of symptoms; maximum efficacy is achieved after a few days. Patient must be over 18 and maximum use of 3 months - Non-sedating antihistamines may be of value in the treatment of nasal allergies, especially hay fever, and vasomot rhinitis. They reduce rhinrhoea and sneezing but are usually less effective f nasal congestion - Cetirizine causes less sedation than chlphenamine but is me expensive - See also section - Eyes (b) Hayfever symptoms - Refer to pregnancy section f advice in pregnancy. - Wheezing shtness of breath, tightness of chest - Suspected drug allergy - Persisting painful ear sinuses - Purulent conjunctivitis - Failed medication (no improvement in symptoms after 10 days) (b) COUGH/NASAL CONGESTION Adult & Child Cough suppressants First choice: no treatment Expectants/demulcents First choice: no treatment Second choice: simple linctus BP ( paediatric) Topical decongestant First choice: sodium chlide 0.9% nasal drops Second choice: ephedrine nasal drops (N.B. not under 6 years) Systemic decongestant First choice: pseudoephedrine (N.B. not under 6 years) simple linctus BP (citric acid monohydrate 2.5%) sugar-free al solution (200mL): adults and children 12 years and over, 5mL 3 4 times daily simple linctus paediatric BP (citric acid monohydrate 0.625%) sugar-free al solution (200mL): children under 12 years of age, 5-10mL 3-4 times daily; children over 12 years use adult preparation sodium chlide 0.9% nasal drops (10mL): adults and children, instil 1-2 drops into each nostril when necessary ephedrine 0.5% nasal drops (10mL): adults and children over 6 years, instil 1-2 drops into each nostril up to 3 4 times daily when required. (max. 7 days) pseudoephedrine hydrochlide 60mg tablets (12): adults and children over 12 years 1 tablet 4 times daily pseudoephedrine hydrochlide 30mg/5mL al solution (100mL): children aged 6-12 years, 5ml every 4-6 hours up to 4 times daily; over 12 years, 10mL every 4-6 hours (up to 4 times daily). - Inhalation of warm moist air is useful in the treatment of symptoms of acute infective conditions - None of the remedies available f the management of cough (cough suppressants, expectants demulcents) are proven to provide any benefit - F persistent cough lasting over 2 weeks, the underlying cause should be established - Sodium chlide 0.9% nasal drops may relieve congestion by liquefying mucous secretions - F al pseudoephedrine recommendations refer to current MHRA/BNF guidance - Topical nasal decongestants are of limited value because they can give rise to rebound congestion on withdrawal. These products should not be used f me than 7 days - Ephedrine nasal drops are the safest sympathomimetic preparation - Systemic decongestants provide sht term (3-10 hour) relief of congestive symptoms - Systemic decongestants should be used with caution in patients with diabetes - Oral antihistamines may improve runny nose and sneezing but provide no significant difference in overall symptoms - Refer to pregnancy section f advice in pregnancy. - Cough lasting 2 weeks me - Sputum yellow, green, rusty blood stained - Chest pain NHS Cumbria Min Ailments Service - Page 6 of 17

7 - Shtness of breath wheezing - Whooping cough croup - Recurrent nocturnal cough - Suspected adverse drug reaction (e.g. ACE inhibits) - Failed medication (no improvement in symptoms after 5 days) CENTRAL NERVOUS SYSTEM (a) PAIN/INFLAMMATION Adult Mild pain First choice: paracetamol ibuprofen Mild to moderate pain First choice: paracetamol +/- ibuprofen Child Mild pain First choice: paracetamol ibuprofen Mild to moderate pain First choice: paracetamol +/- ibuprofen paracetamol 120mg/5mL al suspension (100mL, 200ml); 250mg/5mL al suspension (200mL), 500mg tablets (32); soluble tablets (24): children aged 3-6 months, 60mg every 4-6 hrs; children aged 6-24 months, 120mg every 4-6 hrs; children aged 2-4 years, 180mg every 4-6 hrs; children aged 4-6 years, 240mg every 4-6 hrs; children aged 6-8 years, 250mg every 4-6 hrs; children aged 8-10 years, 375mg every 4-6 hrs; children aged years, 500mg every 4-6 hrs; children aged years, 750mg every 4-6 hrs; adults and children aged 15 years and over, 1g every 4-6 hrs. Maximum 4 doses in 24 hrs ibuprofen 100mg/5mL suspension (100mL); 200mg tablets (24); 400mg tablets (24): children aged 3-6 months (over 5kg), 50mg 3 times daily; children aged 6-12 months, 50mg 3 times daily; children aged 1-4 years, 100mg 3 times daily; children aged 4-7 years, 150mg 3 times daily; children aged 7-10 years, 200mg 3 times daily; children aged years, 300mg 3 times daily; adult and children aged 12 years and over, mg 3 times daily. (Maximum 30mg/kg daily in 3 divided doses) - Children under 6 months should not be given paracetamol and ibuprofen concomitantly, without pri medical assessment - If symptoms suggest fever in a child refer to NICE Guideline 47 which contains a traffic light system f symptoms and referral guidance - Aspirin should not be given to children under 16 because of the risk of Reye's syndrome - Relative contra-indications to NSAIDs include renal impairment, histy of gastro intestinal bleeding, heart failure, hypertension, coagulation defects; absolute contra-indications include proven hypersensitivity to aspirin any NSAID - Assess the hydration status of the patient befe prescribing NSAIDs. There is a risk of precipitating renal failure if NSAIDs are administered to patients who are dehydrated - NSAIDs may wsen asthma; they are contra-indicated if aspirin any other NSAID has precipitated attacks of asthma, although this occurs rarely in children - Compound analgesics containing an opioid may produce opioid side-effects and can complicate treatment of an overdose. After consideration of the potential f abuse they have been excluded from the Cumbria fmulary - Approximately 10% of patients are unable to convert codeine to mphine, therefe it may be an inefficient analgesic in some patients - Refer to pregnancy section f advice in pregnancy. - Child under 6 months not improving on paracetamol alone - Headache in children under 12 years old - Headache associated with injury/trauma - Severe headache of me than 4 hours duration - Severe occipital headache (across the back of the head) - Headache which is wse in the mning then improves - Suspected adverse drug reaction - Associated drowsiness, visual disturbances vomiting - Neck stiffness NHS Cumbria Min Ailments Service - Page 7 of 17

8 INFECTION (a) FUNGAL VAGINAL CANDIDIASIS (thrush) Adult First choice: clotrimazole pessary 500mg +/- clotrimazole 2% cream Second choice: fluconazole +/- clotrimazole 2% cream clotrimazole 500mg pessary (1): adults, insert 1 at night as a single dose clotrimazole 2% cream (20g): adults, apply to anogenital region 2-3 times daily fluconazole 150mg capsule (1): adults, 150mg as a single dose. - There is no evidence that treating an asymptomatic partner(s) of women suffering from candidiasis is helpful - Patients who are inserting intravaginal cream pessaries into the vagina, may also apply topical clotrimazole cream to the vulva - Clotrimazole may damage latex condoms and diaphragms - Fluconazole may be used f women aged years. - Children - Pregnancy - Recurrent episodes of infection - Signs of bacterial infection - Unresponsive to appropriate treatment - Diabetic patients - Vulva pain (b) FUNGAL/SKIN Adult First choice: clotrimazole Second choice: terbinafine Child First choice: clotrimazole clotrimazole 1% cream (20g): adults and children, apply 2 3 times daily continuing f at least 14 days after disappearance of infection terbinafine 1% (Lamisil AT cream) cream (15g): adult and children aged 15 years and over, apply thinly 1-2 times daily f up to 1 week in tinea pedis and 1-2 weeks in tinea cruris - The licences f OTC terbinafine differ depending on the preparation. All versions are licensed to treat tinea pedis (athlete s foot) and tinea cruris (Jock itch) and the spray and gel are licensed f tinea cpis (ringwm) - Terbinafine is not licensed f patients under 15 years old. - Severe widespread infection of the foot - Recurrent episodes of infection - Signs of bacterial infection - Unresponsive to appropriate treatment - Diabetic patients - Involvement of toenails - Immunocompromised patient c) VIRAL COLD SORES (herpes simplex) Adult & Child First Choice: aciclovir aciclovir 5% cream (2g): adults and children, apply to lesions every 4 hours (5 times daily) f 5-10 days, starting at first sign of attack. NHS Cumbria Min Ailments Service - Page 8 of 17

9 - It is best applied at the earliest possible stage, when prodromal changes of sensation are felt in the lip and befe vesicles appear - Wash hands regularly to prevent spread of infection - Limited absption from topical aciclovir therefe, use in pregnancy if benefit outweighs risk. - Babies and young children - Child with fever - Failure of an established se to resolve - Severe wsening se - Histy of frequent cold ses - Se lasting longer than 2 weeks - Painless se - Patients with atopic eczema - Eye affected - Uncertain diagnosis - Immunocompromised patient (d) VIRAL WARTS (verrucas) Adult First choice: salicylic acid Child (2 years and over) First choice: no treatment Second choice: salicylic acid Occlusal (salicylic acid 26% in a polyacrylic solution) application with applicat (10mL): adults and children aged 2 years and over, apply daily Salactol (salicylic acid 16.7%, lactic acid 16.7% in flexible collodion) paint with applicat (10mL): adults and children aged 2 years and over, apply daily. - These preparations are contra-indicated in facial genital warts - The skin surface should be rubbed with a file pumice stone and the surrounding skin protected befe each application. If application becomes painful treatment should be withheld f a few days then recommenced - Avoid application to broken skin - Molluscum contagiosum usually resolve spontaneously refer if concerned. - Changed appearance of lesions: size, colour - Bleeding itching - Genital warts - Facial warts - Immunocompromised patients (e) PARASITIC THREADWORM Adult First choice: mebendazole Child First choice: mebendazole mebendazole 100mg tablet (1): adults and children aged 2 years and older, 100mg tablet as a single dose - Anthelmintics should be used in combination with hygiene measures (e.g. washing hands befe eating, keeping nails sht, washing around anal area) to break the cycle of autoinfection. All members of the family should be treated. - One dose of mebendazole is usually sufficient f treatment of threadwms. If reinfection is suspected, a second dose can be given after 2 to 3 weeks. - Mebendazole is not licensed f children under 2 years; - Refer to pregnancy section f advice in pregnancy. - Infection other than threadwm suspected - Recent travel abroad - Medication failure NHS Cumbria Min Ailments Service - Page 9 of 17

10 (f) PARASITIC HEAD LICE Adult & Child First choice: dimeticone Second choice: malathion dimeticone (Hedrin ) 4% lotion (150mL): adults and children aged over 6 months, rub into dry hair and scalp, allow to dry naturally, shampoo after a minimum of 8 hours, repeat application after 7 days malathion (Derbac-M ) 0.5% liquid in an aqueous basis (50mL, 200mL): adults and children aged over 6 months, rub into dry hair and scalp, allow to dry naturally, shampoo after 12 hours, repeat application after 7 days - Refer to Public Health guidelines f the treatment of head lice - Head lice should be treated with lotion, liquid cream rinse fmulations; shampoos are diluted too much during use to be effective and should not be used - Alcohol fmulations are preferred because of improved success rates except in asthmatic patients and patients with severe eczema where aqueous fmulations are safer - A rotational policy f insecticides is outmoded; a mosaic strategy is suggested whereby if a course of treatment fails then a different insecticide is used f the next course - Malathion should not be applied at intervals of less than 1 week f me than 3 consecutive weeks since effectiveness is not increased. (g) PARASITIC - SCABIES Adult & Child First choice: permethrin Second choice: malathion permethrin (Lyclear ) 5% dermal cream (30g): adults and children aged 2 years and over, apply over whole body and wash off after 8-12 hours, repeat application after 7 days. If hands are washed with soap within 8 hours of application, they should be treated again with cream. In young children and those who have experienced treatment failure, application may need to be extended to the face, neck, scalp and ears malathion (Derbac-M ) 0.5% aqueous liquid (200mL): adults and children aged 6 months and older, and older apply over whole body and wash off after 24 hours, repeat application after 7 days. If hands are washed with soap within 24 hours they should be retreated. In young children and those who have experienced treatment failure, application may need to be extended to the face, neck, scalp and ears. - Aqueous preparations are preferable to alcoholic lotions - All members of the household and close contacts should be treated - Clothes and bedlinen should be washed at 50 o C above at time of treatment - Apply to cool dry skin (i.e. not after a hot bath) - Consider sedating antihistamine f night time if itch interferes with sleep - Crotamiton (Eurax ) cream may help soothe itch which may last f 2-3 weeks after treatment. (h) PARASITIC CRAB LICE Adult First choice: malathion Second choice: permethrin malathion (Derbac-M ) 0.5% aqueous liquid (50mL, 200mL): adults, apply over whole body, allow to dry naturally, wash off after 12 hours overnight, repeat application after 7 days permethrin (Lyclear ) 5% dermal cream (30g): adults, apply over whole body, allow to dry naturally, wash off after 12 hours overnight, repeat application after 7 days - Aqueous preparations and dermal cream are preferred rather than alcoholic preparations due to irritation of exciated skin and genitalia. (i) URINARY - CYSTITIS Adult First choice: No treatment (see prescribing notes) Second choice: potassium citrate (see prescribing notes) sodium citrate (see prescribing notes) NHS Cumbria Min Ailments Service - Page 10 of 17

11 potassium citrate mixture BP (potassium citrate al solution containing potassium citrate 30%, citric acid monohydrate 5% in a suitable vehicle with a lemon flavour) solution (200mL): adults, 10mL 3 times daily well diluted with water potassium citrate 3g sachets (6): adults, one sachet dissolved in water 3 times daily f 48 hours sodium citrate 4g sachets (6): adults, one sachet dissolved in water 3 times daily f 48 hours - Symptoms nmally resolve in 2-4 days - Paracetamol ibuprofen may be taken to ease discomft - Little evidence to suppt use of alkalinising products - Drink nmally i.e. 2 litres of water per day - Avoid alcohol, tea and coffee as can irritate the bladder - Drinking cranberry juice may help prevent recurrence - Hot water bottle may help relieve discomft - Potassium containing products are best avoided in patients with hyperkalaemia, renal cardiac impairment and in patients taking potassium sparing diuretics, ACE inhibits and aldosterone antagonists. - All men and children - Fever, nausea/vomiting - Loin pain and tenderness - Haematuria - Vaginal discharge - Duration longer than 2 days - Pregnancy - Recurrent cystitis - Failed medication SKIN (a) ACNE Adult & Child First choice: benzoyl peroxide (twelve years and over) benzoyl peroxide 2.5% aquagel (40g): adults and children, apply 1-2 times daily benzoyl peroxide 5% aquagel (40g): adults and children, apply 1-2 times daily benzoyl peroxide 10% aquagel (40g): adults and children, apply 1-2 times daily. - Topical treatment takes at least 30 days to become effective - Benzoyl peroxide should be used in increasing strengths regularly to the entire acne-prone area - May bleach clothing - Wash with mild soap and lukewarm water, no me than twice a day - May cause dry skin. If necessary use a water-based moisturiser. - Acne in the very young - Severe acne - Acne causing scarring - Failed medication (no improvement in 2 months) - Suspected drug-induced acne (b) ECZEMA Adult & Child Emollient First choice: ointment base - white soft paraffin 50%/liquid paraffin 50% (preservative-free) Hydromol ointment (preservative-free) emulsifying ointment (preservative-free) First choice: cream base: Diprobase cream Aveeno cream Bath/shower products First choice: Oilatum emollient Second choice: Balneum bath oil E45 emollient bath oil NHS Cumbria Min Ailments Service - Page 11 of 17

12 Soap Substitutes First choice: aqueous cream emulsifying ointment Hydromol ointment Oilatum shower gel Topical cticosteroids First choice: hydroctisone 1% (NB over 10 years only) Emollients & soap substitutes: 50:50 (white soft paraffin 50%/liquid paraffin 50%) ointment (250g): adults and children, apply as often as required Hydromol ointment (yellow soft paraffin 30%, emulsifying wax 30%, liquid paraffin 40%) (125g, 500g): adults and children, massage into skin as often as required; may be used as a soap substitute Emulsifying ointment (emulsifying wax 30%, white soft paraffin 50%, liquid paraffin 20%) (500g): adults and children, massage into skin as often as required; may be used as a soap substitute Diprobase cream (cetomacrogol 2.25%, cetostearyl alcohol 7.2%, liquid paraffin 6%, white soft paraffin 15%) (50g, 500g): adults and children, apply as often as required Aveeno cream (colloidal oatmeal in emollient basis) (100mL): adults and children, apply as often as required. Bath/shower products: Oilatum emollient bath additive (acetylated wool alcohols 5%, liquid paraffin 63.4%) (250mL): adults and children, add 5-15 ml to each bath Balneum bath oil (soya oil 84.75%) (200mL): adults and children, add 20mL to each bath E45 Emollient bath oil (cetyl dimeticone 5%, liquid paraffin 91%) (250mL): adults and children, add 15mL to each bath. Soap Substitutes: aqueous cream BP (emulsifying ointment 30%, phenoxyethanol 1% in freshly boiled and cooled purified water) (100g, 500g): adults and children, massage into skin 2-3 times daily; may be used as a soap substitute Oilatum shower gel (light liquid paraffin 70%) (125ml): adults and children, apply to wet skin as a shower gel as frequently as necessary Topical cticosteroids: hydroctisone 1% cream (15g): adults and children aged 10 years and over, apply thinly 1-2 times daily f a maximum of 7 days, not f use on face, broken skin, anogenital areas in pregnancy. - The choice of emollient is guided by individual patient tolerance, preference and ease of use - Emollients soothe, smooth and hydrate the skin and are indicated f all dry scaling disders - Emollients should be applied regularly to maintain improvement; most are best applied after a shower bath - Aqueous cream and emulsifying ointment are preferred as soap substitutes. Most emollients may be used as soap substitutes by firstly wetting the skin, washing with the cream ointment, then rinsing off - Aqueous cream should not be used as an - When using as a soap substitute emulsifying ointment and Hydromol may be applied as soap balls these are made by putting a scoop of ointment into tubinette stockinette - Topical cticosteroids are not recommended in urticaria, rosacea, acne undiagnosed, possibly infective disders - To minimise risk of side-effects with topical cticosteroids, the smallest effective amount should be used, reducing strength and frequency of application as the condition settles. The risk of systemic side-effects increases with prolonged use - When using topical cticosteroids wait 30 minutes befe applying emollients to prevent diluting the steroid. - Once only trial of emollient, if need to use regularly if no improvement (c) ALLERGY/ITCH Adult & Child First choice: calamine cream lotion crotamiton cream calamine in aqueous cream (100g); lotion (200mL): adults and children, apply as often as required crotamiton (Eurax ) 10% cream (30g, 100g): adults and children 3 years and over: apply 2-3 times daily. - Emollient preparations may be useful f pruritus due to dry skin - Sedating al antihistamines may also be helpful f itching in patients over 1 year of age - Crotamiton is useful f pruritus persisting after treatment of scabies. NHS Cumbria Min Ailments Service - Page 12 of 17

13 (d) BARRIER PREPARATIONS (urinary nappy rash) Adult & Child First choice: zinc and cast oil ointment (contains peanut oil) Contotrane cream Second choice: Metanium ointment (nappy rash only) zinc and cast oil BP (zinc oxide 7.5%, cast oil 50%, arachis (peanut) oil 30.5%, white beeswax 10%, cetostearyl alcohol 2%) ointment (100g): adults and children, f nappy and urinary rash and eczematous conditions, apply several times daily as necessary after each nappy change Conotrane (benzalkonium chlide 0.1%, dimeticone %) cream (100g): adults and children, apply several times daily as necessary Metanium (titanium dioxide 20%, titanium peroxide 5%, titanium salicylate 3% in a basis containing dimeticone, light liquid paraffin, white soft paraffin, and benzoin tincture) ointment (30g): adults and children, apply several times daily as necessary after each nappy change. - Do not apply too liberally as may prevent moisture absption by the nappy - Urinary (nappy) rash may clear if skin is left exposed to air - An ingredient of zinc and cast oil ointment is arachis oil, it should not be used if there is a known allergy to peanut soya - If associated with yeast (candida) infection an antifungal such as clotrimazole is useful, should be applied two three times daily and used f 7-10 days after rash has cleared. - If standard treatments fail nappy rash persists - If sign of infection eczema (e) SCALP DISORDERS Adult First choice: ketoconazole shampoo coconut oil containing shampoo Second choice: T-Gel shampoo Polytar liquid (contains peanut oil) Child First choice: ketoconazole shampoo Second choice: Polytar liquid Cradle Cap First choice: no treatment Second choice: coconut oil containing shampoo Capasal (coconut oil 1.0%. salicylic acid 0.5%, distilled coal tar 1.0% containing) shampoo (250mL): adults and children, apply accding to product infmation Polytar (arachis (peanut) oil extract of crude coal tar 0.3%, cade oil 0.3%, coal tar solution 0.1%, oleyl alcohol 1%, tar 0.3%) liqiud (250mL): adults and children, scalp disders, including psiasis, sebrhoea, eczema, pruritus and dandruff, apply 1 2 times weekly ketoconazole 2% shampoo (60mL, 100mL): adults and children, f sebrhoeic dermatitis and dandruff, apply twice weekly f 2 4 weeks T-Gel (coal tar 2% extract) shampoo (125ml, 250ml): adults and children, scalp psiasis, sebrheic dermatitis and dandruff, apply 2-3 times weekly. - Treatment depends on the severity of the condition. Shampoo fmulations are preferred f moderate scaly scalp conditions whereas me severe conditions may require an ointment - Ketoconazole shampoo is often helpful f sebrhoeic dermatitis of the scalp - Removal of thick crusts and scales from the scalp using warm mineral olive oil befe using antifungal shampoo may improve effectiveness - Cradle cap is often a self-limiting condition and causes no discomft - Frequent shampooing (unless medicated) and harsh brushing should be avoided. NHS Cumbria Min Ailments Service - Page 13 of 17

14 EYES (a) TEAR DEFICIENCY/OCULAR LUBRICANTS Adult Eye drops First Choice: hypromellose 0.3% Second Choice: polyvinyl alcohol (Liquifilm Tears ) carbomer 980 (Viscotears ) Eye ointments First Choice: Lacri-Lube hypromellose 0.3% eye drops (10mL): adults, may need to be instilled frequently e.g. hourly, f adequate relief polyvinyl alcohol (Liquifilm Tears ) 1.4% eye drops (15mL): adults, may need to be instilled frequently e.g. hourly, f adequate relief carbomer 980 (Viscotears ) eye drops (10g): adults, apply 3-4 times daily as required Lacri-Lube eye ointment (3.5g): adults, usually applied at night. All available lubricant eye ointments contain lanolin. - The severity of the condition and patient preference will often guide the choice of preparation - Chronic seness of the eyes due to reduced/abnmal tear secretion often responds to tear replacement therapy - Frequent instillation of drops (e.g. hourly hypromellose) may cause a sensitivity reaction to the preservative in the drops. - If condition lasts longer than 2 weeks - Pain signs of infection i.e. purulent discharge (b) HAYFEVER (EYE) SYMPTOMS Adult & Child Prophylaxis First Choice: sodium cromoglicate 2% Acute treatment First Choice: Otrivine-Antistin sodium cromoglicate 2% eye drops (10mL): adult and children, apply 4 times daily Otrivine-Antistin (antazoline 0.5%, xylometazoline 0.05%) eye drops (10mL): adults and children 12 years and over - apply 2-3 times daily f no me than 7 days. - Sodium cromoglicate is used to treat allergic conjunctivitis. It has a prophylactic action and must be used regularly even when symptoms improve - Otrivine-Antistin eye drops may be used to treat acute allergic conjunctivitis as a sht-term measure. Long-term use should be avoided because of rebound hyperaemia - See also section - Respiraty & Nasal (a) Hayfever/rhinitis (c) BACTERIAL CONJUNCTIVITIS Adult & Child Eye drops First Choice: no treatment Second Choice: chlamphenicol chlamphenicol 0.5% eye drops (10mL): adults and children 2 years and over, 1 drop usually every 2 hours f 2 days then every 4 hours during waking hours. Usual treatment course of 5 days. Keep in fridge chlamphenicol 1% eye ointment (4g): adults and children 2 years and over, apply 3-4 times daily f 5 days. - Most cases of acute bacterial conjunctivitis are self-limiting. Treatment should be given if the condition has not resolved spontaneously after 5 days - Clean away infected secretions from eyes with cotton wool soaked in cooled boiled water - Remove contact lenses until all symptoms have resolved and any treatment completed f 24 hours - Wash hands regularly and avoid sharing towels. - Patient under 2 years of age - Suspected feign body in the eye eye injury - Pupil looks unusual i.e. irregular, dilated non-reactive to light - Photophobia NHS Cumbria Min Ailments Service - Page 14 of 17

15 EAR - Severe pain within the eye changes in vision - Pain swelling around the eye face, with without, an associated rash - Eye surgery laser treatment in the past 6 months - Pregnant breastfeeding - No improvement is seen after 48 hours symptoms becoming wse (a) EAR WAX Adult & Child First Choice: almond oil sodium bicarbonate Second Choice: Exterol sodium bicarbonate 5% ear drops (10mL): adults and children, 3 to 4 drops into the affected ear(s) three to four times a day f 3 to 5 days. Allow the drops to warm to room temperature befe use almond oil (50mL): adults and children, apply twice a day f 3-4 days. Allow to warm to room temperature befe use Exterol (thick solution containing urea hydrogen peroxide 5%, 8-hydroxyquinoline and glycerol) ear drops (8mL): adults and children, instil up to 5 drops into the ear. Retain drops in ear f several minutes by keeping the head tilted and then wipe away any surplus. Repeat once twice daily f 3 to 4 days. Allow the drops to warm to room temperature befe use. - Ear wax needs to be removed only if it causes symptoms of discomft hearing loss - The ear is a self-cleaning system and cotton buds should not be used to try to clear the ear canal, as wax is likely to be pushed back against the ear drum and become me impacted - After instilling the ear drops, the person should lie with the affected ear uppermost f 5-10 minutes - Sodium bicarbonate ear drops may cause dryness of the ear canal. - Otitis media in the last 6 weeks - Histy of ear drum perfation - Severe ear pain pain lasting f me than 2 days PREGNANCY (a) MORNING SICKNESS (PREGNANCY) - There are no OTC medicines that are licensed specifically f the treatment of mning sickness - Although there is no research-based evidence, it is common practice to recommend: - Small, frequent meals high in carbohydrate and low in fat - Eating cold meals rather than hot meals, which may prevent any smell-related nausea, as cold food does not seem to give off as much smell as hot food - Eating plain ( ginger) biscuits about 20 minutes befe getting up - Glucose tablets to possibly help prevent blood sugar levels from dropping (low blood sugar levels may cause nausea) - Avoiding any foods smells that trigger symptoms - Avoiding drinking cold, tart sweet beverages - Avoiding caffeine and alcohol to prevent dehydration. (b) HEARTBURN (PREGNANCY) Adult First Choice: co-magaldrox (Mucogel ) Second Choice: compound alginic acid preparations (Peptac suspension) Mucogel (magnesium hydroxide 195mg, dried aluminium hydroxide 220mg/5mL) suspension (500mL): adults, 10-20mL, 20 minutes-1 hour after meals, and at bedtime when required Peptac (sodium alginate 250mg, sodium bicarbonate 133.5mg,calcium carbonate 80mg per 5mL) suspension (500mL): adults and children 12 years and over, 10-20mL after meals and at bedtime. - Liquid fmulations of antacids are me effective than tablets capsules - Compound alginic acid preparations are less powerful antacids than co-magaldrox but may be me effective f heartburn. - See main section NHS Cumbria Min Ailments Service - Page 15 of 17

16 (c) CONSTIPATION (PREGNANCY) Adult First choice: ispaghula husk Second choice: lactulose Fybogel (ispaghula husk) 3.5g sachets (30): adults, 1 sachet in water twice daily preferably after meals lactulose g/5ml solution (200mL, 500mL): adults and children aged over 12 years, 15ml twice daily, adjust dose accding to patient needs. - Encourage me fluids and an increased level of fibre in the diet - Ispaghula may take several days to act - Lactulose may take 48 hours to act. - See main section (d) HAEMORRHOIDS (PREGNANCY) Adult First choice: Anusol Anusol (containing bismuth oxide, bismuth subgallate, Peru balsam, zinc oxide) ointment with rectal nozzle (25g): adults, apply mning and night and after defecation, f up to 7 days. - Anusol an ice pack can be used to provide symptomatic relief of haemrhoids. - See main section (e) COUGHS/COLDS (PREGNANCY) Adult Cough suppressants First choice: no treatment Expectants/demulcents First choice: no treatment Second choice: simple linctus, BP Topical decongestant First choice: sodium chlide 0.9% simple linctus BP (citric acid monohydrate 2.5%) sugar-free al solution (200mL): adults and children aged 12 years and older, 5mL 3 4 times daily sodium chlide 0.9% nasal drops (10mL): adults and children, instil 1-2 drops into each nostril when necessary. - Inhalation of warm moist air is useful in the treatment of symptoms of acute infective conditions - None of the remedies available f the management of cough (cough suppressants, expectants demulcents) are proven to provide any benefit - F persistent cough lasting 2 weeks me refer to GP. - See main section (f) VAGINAL CANDIDIASIS (PREGNANCY) - OTC antifungal treatments cannot be supplied to pregnant women refer to GP. (g) HEADACHES/BACKACHE (PREGNANCY) Adult Mild pain First choice: non-pharmacological measures Second choice: paracetamol paracetamol 250mg/5mL al suspension (200mL); 500mg tablets (32); 500mg soluble tablets (24): children aged years, 750mg every 4-6 hrs; adults and children aged 15 years and over, 1g every 4-6 hrs. Maximum 4 doses in 24 hrs NHS Cumbria Min Ailments Service - Page 16 of 17

17 - Where possible, non-pharmacological measures (e.g. reassurance, rest, stress management, ice, massage) should be tried befe paracetamol - Paracetamol is generally regarded as being safe f use in pregnancy - Frequency and intensity of migraines may diminish during pregnancy. - See main section (h) HAY FEVER (PREGNANCY) Adult Nasal symptoms First choice: no treatment Ocular symptoms First choice: sodium cromoglicate 2% (prophylaxis) sodium cromoglicate 2% eye drops (10mL): adults and children, apply 4 times daily. - Nasal steroids and al antihistamines may be used in pregnancy but only on medical advice - See main section (i) PARASITIC INFECTION (PREGNANCY) - THREADWORM - During pregnancy, hygiene methods alone are preferred. Mebendazole is best avoided during pregnancy - Threadwm infection can be treated solely by meticulous attention to hygiene f 6 weeks. The wms in the intestine will die within this time, and, if no eggs are swallowed, no new wms will replace them. (j) PARASITIC INFECTION (PREGNANCY) - HEAD LICE - During pregnancy, malathion in an aqueous basis is preferred. - See main section NHS Cumbria Min Ailments Service - Page 17 of 17