OSPAP Programme MPHM13 Respiratory OTC Seminar

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Gerard Gaines
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1 OSPAP Programme MPHM13 Respiratory OTC Seminar Slide 1 of 41 MPH14 OSPAP OTC Respiratory

2 Learning Objectives: By the end of this session, you should be able to: Recognise signs and symptoms of common respiratory OTC patient complaints Question patients appropriately allowing for accurate history taking Recognise when to refer certain patients and the associated danger symptoms Be aware of appropriate treatments available OTC Provide correct advice and counselling for patients Slide 2 of 41 MPH14 OSPAP OTC Respiratory

3 Common Respiratory Conditions Cough Cold & Flu Sore Throat Hay fever Slide 3 of 41 MPH14 OSPAP OTC Respiratory

4 Getting a broad view of the scenario: History Taking Self Age Medications Extra medicines already tried Time/Duration of symptoms History of the condition/ Causes & contributing factors Other symptoms Danger symptoms (refer) Slide 4 of 41 MPH14 OSPAP OTC Respiratory

5 Instructions for each scenario As per previous seminar: Split into groups of 3 Person 1: Patient Person 2: Pharmacist Person 3: Marker 7 minutes for each scenario Answers and feedback to be provided at the end of the session Slide 5 of 41 MPH14 OSPAP OTC Respiratory

6 Instructions for case studies Patient: Will be given a case study Do not show the case study to the pharmacist You are to read the scenario at the top of the page Then allow the pharmacist to question/ counsel you as appropriate Do NOT volunteer any information given in the case study unless asked/ however if you are asked information and you do not have an answer on the case you may need to make up a valid answer Do not give an opinion on any interventions suggested Your job is to be the patient- and nothing else Slide 6 of 41 MPH14 OSPAP OTC Respiratory

7 Instructions for case studies Pharmacist: You are to take an accurate history from the patient before making any recommendations Answer the query as a qualified pharmacist, not as a student, pre reg, etc Check reference sources when needed Incorrect information given that will potentially harm a patient is an instant fail You will be given a communication mark for the way you relate to the patient Try not to rely too heavily on the Boots OTC book as can be confusing and is not aimed at pharmacists Slide 7 of 41 MPH14 OSPAP OTC Respiratory

8 Instructions for case studies Marker/Assessor: You should use a blank marking sheet and give one mark for each relevant question asked. Make any relevant notes along the way too. Ensure you can also see the case study so that you know what to mark against If there is anything the pharmacist says that you are unsure ofwrite this in the comments box Award an appropriate communications mark based on the flow of the conversation and the pharmacists communication skills Be realistic- you might want to score your friends highly but the examiner will not be so lenient This exercise will also test your knowledge on right/wrong recommendations Slide 8 of 41 MPH14 OSPAP OTC Respiratory

9 Case Study Slide 9 of 41 MPH14 OSPAP OTC Respiratory

10 Case 1 Mrs Thompson comes into your pharmacy asking for something for her husband (aged 53). She thinks he has the symptoms of a cold and wishes to purchase an oral decongestant because he used one before and it worked well for him. He takes simvastatin and lisinopril Slide 10 of 41 MPH14 OSPAP OTC Respiratory

11 Case 1 It is not unusual for patients to come to the pharmacy requesting products which they may have used before Never assume a product is suitable for a patient simply because they request it by name or have used it before.circumstances may change and so full questioning is still essential. Slide 11 of 41 MPH14 OSPAP OTC Respiratory

12 The Common Cold: Usually lasts 7-10 days and will resolve itself, there is no cure treatment aims to relieve symptoms Gradual onset (flu-rapid onset) Symptoms: Runny/blocked nose Cough- which may persist for a few days after other symptoms have cleared Feeling warm but NO fever Sore throat Aches and pains Headache Cough which may persist for a number of days after the cold has passed Slide 12 of 41 MPH14 OSPAP OTC Respiratory

13 Case 1: Treatment Options for a cold 1. Oral Analgesics - Paracetamol may be used in order to relieve symptoms of the cold such as headache, aches, pains and sore throat - Maximum dose of 1g four times daily in adults - NSAIDs such as ibuprofen or aspirin (over 16 s only) may also be considered Slide 13 of 41 MPH14 OSPAP OTC Respiratory

blood vessels - Stimulatory action which may cause sleep disturbances if taken at night - Tablets: licenced for use in patients over

14 Case 1: Treatment Options for a cold 2. Oral Sympathomimetics - eg: pseudoephedrine, phenylephrine - Useful in clearing a blocked nose and congestion due to dilation of blood vessels - Stimulatory action which may cause sleep disturbances if taken at night - Tablets: licenced for use in patients over 12 years - Liquid: licenced for use in patients over 6 years - Avoid in patients with the following conditions Diabetes, hypertension, hyperthyroidism, coronary heart disease licensing!! Slide 14 of 41 MPH14 OSPAP OTC Respiratory

15 Treatment Options in this case This patient was taking lisinopril for hypertension and so an oral decongestant is not suitable. The lady should be counselled that although her husband has used one in the past, it is not suitable to be sold now. Recommend steam inhalation with an inhalant as an alternative or possibly a topical decongestant (max 7 days use rebound congestion) Slide of 41 MPH14 OSPAP OTC Respiratory

16 Case 2: Mrs O Hara (aged 40) comes into your pharmacy requesting something for a cough she has had for the past 2 days. From the information gathered it can be concluded that Mrs O Hara is type 2 diabetic and has a productive chesty cough Mrs O Hara currently takes metformin, aspirin, atorvastatin and ramipril Slide 16 of 41 MPH14 OSPAP OTC Respiratory

17 Case 2: Sell or Refer? When to Refer??? - Persistent cough lasting longer than 2 weeks - Purulent sputum (yellow/green/brown) - Haemoptysis - Chest pain - Wheezing/problems breathing None of the referral points are relevant in this case. Slide 17 of 41 MPH14 OSPAP OTC Respiratory

18 Case 2.Mrs O Hara has a non- purulent cough which has lasted for 2 days Care should be taken when choosing a cough remedy for diabetic patients as a lot of products contain sugar which may affect diabetic control (although the illness itself is likely to have a greater impact) A sugar free preparation should be chosen to eliminate any risk (eg: Robitussin) Guaifenesin is an expectorant (eg: Robitussin Chesty Cough Medicine), this should relieve chesty coughs by stimulating bronchial mucus secretion, leading to increased liquefying of sputum making it easier for the patient to cough up. Slide 18 of 41 MPH14 OSPAP OTC Respiratory

Case 2 Mrs O Hara is not displaying any other symptoms of cold or flu If the patient had shown signs of systemic infection (eg: fever and shivering), this would require direct referral to the GP

19 Case 2 Mrs O Hara is not displaying any other symptoms of cold or flu If the patient had shown signs of systemic infection (eg: fever and shivering), this would require direct referral to the GP Systemic infection/flu in diabetic patients can lead to uncontrolled blood glucose levels as well as increased risk of complications such as diabetic ketoacidosis (more relevant in type 1 diabetics) Sugar free lozenges may also be recommended to soothe her sore throat as this is most likely caused by her persistent cough Slide 19 of 41 MPH14 OSPAP OTC Respiratory

20 Case 3 Mrs Smith comes into your pharmacy and would like something for her eyes as they are red and itchy. Symptoms are worse in the evening She also has a runny nose and thinks she may be getting a cold Slide 20 of 41 MPH14 OSPAP OTC Respiratory

21 Case 3 Mrs Smith is presenting with symptoms of seasonal rhinitis (hay fever) Hay fever may be either seasonal or perennial During the spring and summer months it is common for patients to present to the pharmacy with such symptoms This is because the pollen count is higher during these months Symptoms: - Itchy, red, watery eyes - Runny nose - Sneezing - Cough (due to postnasal drip) - An itchy throat, mouth, nose Slide 21 of 41 MPH14 OSPAP OTC Respiratory

22 Case 3: OTC Treatment Options 1. Lifestyle Advice - Minimise exposure to pollen - Avoid the outdoors when pollen counts are high eg: dusk and dawn - Keep windows and doors closed - Use a physical barrier, such as petroleum jelly around the nose to prevent the inhalation of pollen - Sunglasses may also be used to protect the eyes from exposure to irritating pollen Slide 22 of 41 MPH14 OSPAP OTC Respiratory

23 Case 3: OTC Treatment Options 2. Oral Antihistamines may be of some benefit - There are a variety of oral anti-histamines available OTC, and the efficacy of each varies from patient to patient Chlorphenamine; has some sedative side effects however these may be taken advantage of in patients experiencing sleep disturbances due to their symptoms. Usual dose is 4mg four times daily Loratadine and cetirizine may be given once daily. While both claim to be non-sedating, loratadine is the least likely to cause drowsiness out of the two Acrivastine; may cause some drowsiness in certain patients. It requires three times daily doses. It is available in liquid form for patients over 2, and in tablet form for patients over 12. Slide 23 of 41 MPH14 OSPAP OTC Respiratory

Mrs Smith should be advised that the effect is not immediate and may take up to 2 weeks 4.

24 Case 3: OTC Treatment Options 3. Topical treatment for nasal symptoms Beclomethasone nasal spray; treatment should be initiated at the start of the hay fever season and used daily as a preventative measure. Mrs Smith should be advised that the effect is not immediate and may take up to 2 weeks 4. Topical treatment for eye symptoms Sodium cromoglycate eye drops (also available in nasal spray) is available and acts as a mast cell stabiliser to prevent eye symptoms. This would definitely be appropriate for this patient as she has clearly described eye symptoms! o The patient should be advised that she may take both an oral and topical treatment concurrently in order to maximise hay fever treatment Slide 24 of 41 MPH14 OSPAP OTC Respiratory

25 Case 4 Mrs Scott comes into your pharmacy and wants to buy something for her 16 year old son s sore throat. He is home in bed and wants something effective as soon as possible He has tried some Strepsil lozenges and paracetamol but they re not helping. Slide 25 of 41 MPH14 OSPAP OTC Respiratory

26 Case 4 90% of sore throats are caused by a virus and are usually self-limiting with patients feeling better within 7 days from the onset of symptoms One in ten are caused by bacteria and may require treatment with an antibiotic Slide 26 of 41 MPH14 OSPAP OTC Respiratory

27 Case 4: Treatment Options for Sore Throat 1. Oral Analgesics First line- control the pain and discomfort associated with sore throats 2. Mouthwash/ Sprays Anti-Inflammatory (e.g. Benzydamine - Difflam ) Reduces local pain and inflammation in the mouth and throat Spray- used in children 6 years and over Mouthwash- used in children over 12 years Local anaesthetic (e.g. Benzocaine Ultra Chloraseptic) For adults and children over 6 dose age dependent Numbs the throat and hence relieves pain..care with swallowing difficulties and when eating hot food/drinks Slide 27 of 41 MPH14 OSPAP OTC Respiratory

28 Case 4: Treatment Options for Sore Throat 3. Lozenges - Eg: Tyrozets (benzocaine and tyrothricin) - Benzocaine is a local anaesthetic and tyrothricin is an antibacterial, helping to treat infection - Licenced for use in those over 3 years old - Dose: 1 lozenge every 3 hours; max 8 in 24 hours Slide 28 of 41 MPH14 OSPAP OTC Respiratory

29 Case 4 Mrs Scott s son s symptoms appear to be severe as he is ill enough to be in bed The patient has a history of tonsillitis and is also displaying symptoms of dysphagia and pyrexia Dysphagia can signal a severe throat infection and possibly an abscess on the throat as a complication of tonsillitis Hence, this patient requires referral to his GP. In the meantime the patient should be recommended to continue paracetamol - the analgesic and antipyretic effects would be useful in this case A soluble form of paracetamol may be beneficial for this patient due to his difficulty swallowing Slide 29 of 41 MPH14 OSPAP OTC Respiratory

30 Case 5 Mr Kelly comes into the pharmacy requesting a cough medicine as he has been up all night with a dry cough. He hasn t tried anything yet but is anxious to get something which will help stop the cough and help him get some sleep. Slide 30 of 41 MPH14 OSPAP OTC Respiratory

31 Case 5 Most coughs are self limiting and will improve within in approximately 7-10 days without treatment Mr Kelly is complaining of a dry, unproductive cough where no sputum is being produced but it is severe enough to keep him awake at night A variety of products are available OTC which suppress the cough and aid sleep. Lack of sleep may often be the most distressing aspect of the complaint. Slide 31 of 41 MPH14 OSPAP OTC Respiratory

32 Case 5: Treatment Options 1. Cough Suppressants - Are useful in unproductive coughs especially where sleep is being disturbed Pholcodine Linctus - May cause drowsiness - Adults 10ml, 3 to 4 times daily Dextromethorphan - Less potent than pholcodine - Sedation less likely Slide 32 of 41 MPH14 OSPAP OTC Respiratory

33 Case 5: Treatment Options Demulcents (eg. honey and lemon, glycerin, simple linctus) Have no active ingredient but are used for their soothing effect Safe for use in children, adults and pregnancy 2. Antihistamines A number of OTC cough suppressants now contain an antihistamine such as diphenhydramine or promethazine They are added for their ability to dry up secretions They induce drowsiness, therefore when given at night they aid a restful sleep..be alert for abuse of such products for this effect!!! Slide 33 of 41 MPH14 OSPAP OTC Respiratory

34 Case 5: Treatment for Mr Kelly The patient is not taking any other medications and is otherwise healthy We can recommend a cough suppressant which also contains an anti-histamine as Mr Kelly s main concern was the sleep disturbance as a result of his dry cough A product such as Benylin Dry Cough Original (diphenhydramine and dextromethorphan) would be suitable Counsel the patient regarding drowsiness and to take caution if driving etc. Slide 34 of 41 MPH14 OSPAP OTC Respiratory

35 Case 6 Mr Wong comes into your pharmacy and asks you for a cough suppressant for his daughter (aged 4). She has had a cough for almost a month now and it is worse at night. It disturbs her sleep and Mr Wong has growing concerns about it, he would like something that will suppress his daughter s cough which will also help her sleep? Slide 35 of 41 MPH14 OSPAP OTC Respiratory

36 Case 6 Mr Wong is requesting a cough suppressant in this case such a product would be unsuitable..symptoms of night cough can often be the first presenting symptom of asthma in children! Symptoms of Asthma in Children - Vary from mild to severe - Dry cough which worsens at night (sometimes this is the only presenting symptom) - Chest tightness - Shortness of breath - Tiring quickly when exercising - Wheezing Slide 36 of 41 MPH14 OSPAP OTC Respiratory

37 Case 6 Referral is necessary in this case for a number of reasons: - Cough present for longer than 2 weeks, with no signs of improvement - Persistent dry cough at night - Treatment failure no other product licensed OTC for under 6 years Asthma cannot be treated OTC and the patient should be referred to the GP in order to get a definitive diagnosis and appropriate treatment Slide 37 of 41 MPH14 OSPAP OTC Respiratory

38 Case 7 A middle aged man comes into the pharmacy seeking advice about his wife s sore throat. She has had a hoarse voice for just over 1 month and has tried a number of different lozenges but none are effective. On further questioning you find out that Mrs Jones has smoked 20 cigarettes a day for over 30 years. Slide 38 of 41 MPH14 OSPAP OTC Respiratory

39 Case 7: Sell or Refer? As a pharmacist it is crucial to consider all factors when deciding whether to sell or refer a patient Mrs Jones should be referred to her GP - This patient has a long term history of smoking - Various failed OTC products This is not a typical case of inflamed vocal cords (laryngitis). Laryngitis will usually resolve itself within about 3 weeks, Mrs Jones has been experiencing hoarseness for over a month. These symptoms may (or may not) be related to something more serious eg. laryngeal cancer. This should be investigated further. Slide 39 of 41 MPH14 OSPAP OTC Respiratory

40 Case 8 A female patient (aged 40) would like something to help with a chesty cough. She describes the cough as productive with a lot of thick sputum that is a green/brown colour. Slide 40 of 41 MPH14 OSPAP OTC Respiratory

41 Case 8: Sell or Refer? Treatment of a chesty cough as per case 2 treatment of choice is Guaiphenasin. However Refer???...Red flag symptoms are present - Persistent cough >2 weeks - Purulent sputum (yellow/green) - Haemoptysis - Chest pain - Wheezing This patient is describing symptoms that indicate a possible bacterial infection and she should be referred as it is likely she will need treatment with an antibiotic. Advise steam inhalation in the short term until she can see her GP. This will help to help liquefy secretions and help clear the chest. Slide 41 of 41 MPH14 OSPAP OTC Respiratory

throats in the breastfeeding mum

Treating coughs, colds and sore throats in the breastfeeding mum Wendy Jones PhD MRPharmS Breastfeeding and Medication Pharmacist and Grandmother 1 Colds and flu The average adult has 2-4 colds a year