Pharmacy First Scheme Protocols

Transcription

1 Pharmacy First Scheme Protocols Reference: Minor ailment Page No: MAS1 Allergic rhinitis. 2 MAS2 Athletes foot. 4 MAS3 Bacterial conjunctivitis 6 MAS4 Upper respiratory infections 8 MAS5 Constipation 11 MAS6 Diarrhoea 13 MAS7 Dermatitis 14 MAS8 Head lice. 16 MAS9 Insect bites and stings. 18 MAS10 Mouth ulcers 20 MAS11 Vaginal thrush 22 Pharmacy First quick formulary list 24 Reference: British National formulary Acknowledgement : Dr Hanna, Dr Uncle, Dr Goriparthi, Shaista Hussain, Jan Tomes and Nakul Arora 1

2 MAS 1 ALLERGIC RHINITIS Definition/Criteria for inclusion. Allergic rhinitis is classified as: Seasonal allergy, when symptoms occur at the same time each year. Such as allergy to pollen and mould spores. Perennial,when symptoms occur throughout the year. For instances allergies to pet hairs and house dust mite droppings. Occupational, when symptoms are due to exposure to allergens at work, for example, flour allergy in a baker. Some of the most common allergens include: house dust mites, grass and tree pollens, pet hair, or skin flakes, fungal or mould spores, Materials that people us in their work such as latex gloves, flour dust, and wood dust Criteria for INCLUSION Age range: Clients aged over 1 year old Patients with previously diagnosed with an allergy requiring symptomatic treatment to: sneezing, runny nose, itchy eyes, ears, lips throat and palate (roof of mouth), Criteria for EXCLUSION Patients < 1 years Patients<18yr who require beclomethasone Pregnancy, breast feeding mothers Associated wheeze and tightness of chest Action for excluded patients and non-complying patients Referral to General Practitioner Recommended Treatments Chlorphenamine syrup Adults: 10ml every 4 to 6 hourly (daily max: 24 mg i.e. 60ml) Children aged 6-12 years: 5ml every 4 to 6 hourly (daily max: 12 mg i.e. 30ml) Children aged 2-5 years: 2.5ml every 4 to 6 hourly (daily max: 6 mg i.e. 15ml) Children aged 1-2 years: 2.5ml twice daily Chlorphenamine tabs 4mg Adults: One tablet every four to six hours ( Daily max six tablets 24mg) 2

3 Loratadine liq 5mg/5ml Adults and children over 12 years of age : 10mg once daily (10ml (10mg) once daily). Children 2 to 12 years of age are dosed by weight: Bodyweight more than 30kg : 10mg once daily (10ml (10mg) of the syrup once daily). Bodyweight 30kg or less : 5ml (5mg) of the syrup once daily. Loratadine 10mg tablets Adults and children over 12 years of age: Take one tablet once daily. Children 2 to 12 years of age are dosed by weight: Body weight more than 30 kg: Take one tablet once daily with a glass of water, with or without food. Cetirizine liq 1mg/ml Adults and children aged 6 years and over: 2 x 5ml once daily or 5 ml taken twice daily (mo Children between 2 and 6 years. 5ml (5mg) once daily or 2.5ml (2.5mg) twice daily. Cetirizine tabs 10mg Children aged from 6 to 12 years: 5mg twice daily (a half tablet twice daily) Adults and adolescents over 12 years if age: 10 mg once daily (1 tablet once daily). Sodium Cromoglycate eye drops One or two drops in each eye four times a day Beclomethasone nasal spray Adults aged 18 and over: The recommended dosage is two sprays into each nostril morning and evening and reduce to one spray into each nostril morning and night when control of symptoms have been achieved. Follow-up and Advice Avoidance measures. For instance Check weather reports for the pollen count, and stay indoors when it is high. Wear wrap-around sunglasses to protect you eyes from pollen. Keep doors and windows shut during mid-morning and early evening because this is when there is most pollen in the air. Avoid grassy areas, such as parks and fields. Get someone else to cut the grass for you. Do not use eye drops if wearing contact lenses Side effects and their management Chlorphenamine causes sedation if affected, do not drive or operate machinery. Cetirizine is much less likely to do so but patients should be advised it may occur. Beclomethasone can cause dryness, irritation of the nose and throat, headache, smell and taste disturbances Special considerations/concurrent medication Glaucoma (antihistamines contra-indicated) Patients on anti-arrhythmic drugs (antihistamines contra-indicated) Hepatic disease and renal impairment (antihistamines) Patients on anti-arrhythmic drugs (antihistamines contra-indicated) Avoid excessive amounts of alcohol with antihistamines Avoid inhaled corticosteroid in the presence of untreated nasal infection and after recent nasal surgery Systemic absorption may follow prolonged treatment with inhaled corticosteroids 3

4 MAS 2 ATHLETE'S FOOT Definition/Criteria Tinea Pedis Criteria for INCLUSION On examination, red itchy broken skin at first, later turning white with maceration and soreness between toes. Always involves the interdigital space of the foot but may spread to sole and upper foot Criteria for EXCLUSION Patients under 1 years Appears in the 1 st and 2 nd web spaces, or no involvement of interdigital space Toenails becoming black or discoloured Fungal infection starts to spread under the nails or to other areas of the body Evidence of bacterial infection / history of eczema Diabetic patients Persistent infection not responsive to treatment Action for excluded patients and non-complying patients Referral to General Practitioner. Recommended Treatments Frequency of administration and maximum dosage Clotrimazole Cream 1%(20g) apply thinly 2 to 3 times daily continuing for at least 2 weeks after lesions have healed Miconazole Cream 2% (15g) apply twice daily continuing for 10 days after lesions have healed Terbinafine Cream 1% (7.5g) ( For clients over 16 years of age) Apply thinly locally once a day for 7 days. Follow-up and Advice Advise if symptoms do not begin to resolve within 7 days to make an appointment to see a GP Feet should be washed and dried thoroughly, especially between the toes, before applying the cream. Advise patient to use dusting powders in shoes and socks a preventative measure, since boiling socks will not kill fungal spores. Side Effects and their Management Redness, itching and scaling and rarely, sensitivity to Imidazoles (discontinue) Cream may sting on application 4

5 When and how to refer to GP Referral: On 3 rd occurrence If lesions do not start to heal whilst using miconazole Signed of generalised infection especially in the immuno-compromised Eczema Psoriasis Candidasis Bacterial infection Consider supply, but patient should be advised to make an appointment to see the GP: Differential diagnosis Special considerations/concurrent Medication Pregnancy: Manufacturer advises avoid unless essential Breast feeding: use with caution Avoid contact with eyes and mucous membranes 5

6 MAS 3 BACTERIAL CONJUNCTIVITIS Definition/Criteria Acute bacterial conjunctivitis Criteria for INCLUSION Red eye with discharge either mucopurulent or watery Eye discomfort usually described as burning, gritty, minimal pain present Minimal photophobia Eyes stuck together by discharge after sleep Blurred vision due to discharge, which clears with blinking Absence of itching No history of recent episode of conjunctivitis Criteria for EXCLUSION Children under 2 years Pregnancy and lactation Pupil fixed and mid-dilated or distorted form previous attacks Headache History of hypersensitivity to chloramphenicol or to any other ingredients of the drops Family history of blood dyscrasias Patients who have experienced myelosupression during previous exposure to chloramphenicol Previous conjunctivitis in the recent past Copious discharge that re-accumulates after being wiped away Affected vision or pain the eye, Foreign body in eye / eye injury Patients with glaucoma or dry eye syndrome or who have had eye surgery or laser treatment in the past 6 months Contact lens users Patient taking bone marrow suppressant drugs Enlarged lymph nodes in front of the ears (associated with Chlamydia / adenoviral type) Disturbed vision Photophobia Eye inflammation associated with a rash on the scalp or face. The eye looks cloudy Suspected foreign body in the eye Glaucoma Dry eye syndrome Eye surgery or laser treatment in the last 6 months Current use of other eye drops or eye ointment. Action for excluded patients and non-complying patients: Refer to GP Contact lens practitioner for contact lens user. 6

7 Recommended Treatments Chloramphenicol eye drops The recommended dosage for adults (including the elderly), and children aged 2 years and over is one drop to be applied to the affected eye every two hours for the first 48 hours and 4 hourly thereafter. To be used during waking hours only. Treatment should continue for 5 days, even if symptoms improve. Follow-up and Advice The course of treatment is 5 days, if symptoms persist make an appointment to see a GP. To be used during waking hours only. Blurred vision can occur, do not driver or operate machinery unless vision is clear Store eye drops in a refrigerator, discard any remaining solution after 5 days. Advise on measures to reduce the spread of infection. Side Effects and their Management Transient burning or stinging sensations may occur with the use of chloramphenicol eye drops Discontinue of hypersensitivity type reactions occur 7

8 MAS 4 UPPER RESPIRATORY INFECTION Definition/Criteria Adults and older children presenting acute symptoms of: sore throat; nasal irritation, congestion, sneezing and nasal discharge; cough; headache; muscular pain; a general feeling of malaise. Fever is unusual in adults and if present low-grade. Younger children and babies presenting acute symptoms of: nasal congestion that interferes with breathing, feeding, and sleeping; restlessness or irritation; coughing; fever (usually < 39 C), inflamed throat, or swollen lymph glands. Criteria for INCLUSION Any of the above symptoms Criteria for EXCLUSION Patients under 3 months Upper airway distress may be a result of obstruction and is characterized by stridor, drooling, or an inability to swallow. Lower airway distress is characterized by laboured breathing (moderate or severe dyspnoea) and may be a sign of pneumonia, an acute exacerbation of asthma or chronic obstructive pulmonary disease, or the presence of a foreign body. Severe headache may be an early sign of meningitis or a serious vascular disorder, such as subarachnoid haemorrhage. It may be described as the 'worst ever' and be accompanied by a rigid neck, altered mental state, and focal neurological symptoms. Symptoms of meningitis: Symptoms can appear in any order, but the first symptoms are usually fever, vomiting, headache and feeling unwell, just like many mild illnesses. Be alert for the early warning symptoms of fever and any of the following symptoms: the child complains of severe pain in their legs or hands, their hands and feet are unusually cold, and/or their skin becomes pale and their lips may appear blue. Please refer to attached guide from the Meningitis Research Foundation. Patients under one year, when the child is unwell and is associated with either high temperature, poor feeding. Cough productive of green / yellow / blood stained sputum Asthmatics presenting with wheeze or reduced peak-flow. For Ibuprofen: history of hypersensitivity to aspirin or other NSAIDs / history of GI ulcers/ Warfarin/ Lithium/ SSRI/ pregnancy / heart failure/ renal impairment /Hepatic impairment. Action for excluded patients and non-complying patients Referral to General Practitioner. The presence of fever and any early warning symptoms for meningitis should be taken extremely serious. Phone 999 and ask for an ambulance. 8

9 Recommended Treatments, Frequency of administration and maximum dosage Fever/ Temperature Formulary Paracetamol tablets 500mg(32) Paracetamol suspension SF 250mg / 5ml(100ml) Paracetamol susp SF 120mg / 5ml(100ml) By mouth Adult dose: g every 4 6 hours to a max. of 4 g daily; 3 months 1 year mg, 1 6 years mg, 6 12 years mg; these doses may be repeated every 4 6 hours when necessary (max. of 4 doses in 24 hours) Formulary Ibuprofen 200mg tablets (24) Ibuprofen suspension 100mg/5ml (100ml) By mouth ADULT and CHILD over 12 years, initially mg 3 4 times daily; CHILD 3 6 months (body-weight over 5 kg), 50 mg 3 times daily CHILD 6 months 1 year, 50 mg 3 4 times daily ; CHILD 1 4 years, 100 mg 3 times daily (max. 30 mg/kg daily in 3 4 divided doses); CHILD 4 7 years, 150 mg 3 times daily (max. 30 mg/kg daily in 3 4 divided doses); CHILD 7 10 years, 200 mg 3 times daily (up to 30 mg/kg daily (max. 2.4 g) in 3 4 divided doses); CHILD years, 300 mg 3 times daily (up to 30 mg/kg daily (max. 2.4 g) in 3 4 divided doses) ADULT and CHILD over 16 years Aspirin 300mg soluble tablets (32) Use one tablet in water four times a day to gargle Nasal Congestion Formulary Sodium chloride nose drops (10ml) Follow-up and Advice The natural history of the common cold is one of rapid onset, with symptoms peaking after 3 5 days. Most symptoms resolve completely after 7 14 days, although a mild cough may persist for longer No treatments are available that reliably shorten the duration of the common cold. In particular, antibiotics are ineffective; cause adverse effects; and increase the risk of bacterial resistance in the community, which may affect treatment of other diseases Adequate fluid should be taken during the course of the illness to compensate for 9

10 excess water lost through fever (sweating) and mucous secretion (e.g. rhinorrhoea). The following remedies may help to relieve symptoms in some people: Steam inhalation may help to relieve congestion. However, care should be taken to avoid scalding. Sitting in the bathroom with a running hot shower is a safe option. Vapour rubs may soothe respiratory symptoms in infants and small children when applied to the chest and back (avoid application to the nostril area for safety reasons). Gargling with salt water or sucking menthol sweets may help to relieve sore throat or nasal congestion. Nasal saline drops may help relieve nasal congestion. One or 2 drops applied to the nostrils of infants has been reported to help feeding. Sterile sodium chloride 0.9% nasal drops are available on prescription or over the counter. Enquire about concurrent analgesic usage: Paracetamol daily dose - other products containing Paracetamol Other NSAIDs prescribed or OTC Fever should also be treated with temperature reducing methods such as tepid bathing NB overuse of analgesics can cause headaches Asthmatics: any degree of worsening of asthma related to ingestion of NSAIDs History of renal, cardiac or hepatic impairment, coagulation defects, allergic disorders Side Effects and their Management Side effects are experienced rarely with the occasional use of paracetamol Ibuprofen should be taken with / immediately after food to avoid GI side effects When and how to refer to GP Referral: If cough and other symptoms persist beyond 10 days the patient should consult the GP Constant chest pain or chest pain on normal inspiration Difficulty breathing, worsening asthma Green or rusty sputum If pain related to exertion Marked visual symptoms & / or vomiting (see above exclusion criteria) No response within 48 hours, rising temperature and deterioration of general symptoms Presence of a petechial rash (associated with meningitis) Photophobia, neck stiffness, drowsiness Travel to a tropical area in the last 3 months 10

11 MAS 5 Constipation Definition/Criteria for inclusion. Increased difficulty and reduced frequency of bowel evacuation compared to normal short term Criteria for INCLUSION Acute onset in adults only Criteria for EXCLUSION Children under 12 years. Give advice about keeping the bowels healthy such as healthy eating, drinking plenty of fluids, and improving on the physical activity. Drinks containing naturally containing sorbitol such as apple, prune or pear should be encouraged, as they are a natural stool softener. Adults > 75 years Significant variation from normal bowel evacuation, which has not improved following adjustments to diet and other lifestyle activities (see below). Patients currently receiving laxatives as part of their regular medication. Pharmacists should exercise their professional judgement to implement dosage alteration to existing laxative regime Past history of allergy to medication listed below. New or worsening constipation without explanation, blood in the stools, weight loss, nausea and vomiting. Intestinal obstruction, such as faecal impaction. Symptoms usually colicky pain abs spurious diarrhoea. Action for excluded patients and non-complying patients Referral to General Practitioner Referral to Health Visitor for Children (<12 years) and Babies Recommended Treatments and Route Frequency of administration and maximum dosage Senna tabs (20), Oral route, Take two at night. Fybogel sachets (10), Oral route, Take one sachet in water twice a day. Lactulose (500ml), Oral route,take three 5ml spoonful (15mls) twice a day initially, then adjusted according to patient needs. Glycerol suppositories 4g, insert one when required.( Use if other treatments have failed) Follow-up and Advice Regular doses of laxatives are rarely required and can cause a lazy bowel. Drink six to eight glasses of water. Avoid drinks that are caffeine containing as this may worsen constipation. Eat foods rich in fibre. For example fruit, vegetables, wholegrain cereals. Bran is an easy way of introducing fibre into the diet as it is tasteless, although some people may not like the texture. Take regular exercise. Consider walking, gardening, swimmining. Senna should not be used in pregnancy Lactulose takes 2/3 days to start working, after which you may be able to reduce dose Lactulose can be taken straight from the spoon / measuring cup or you can mix with fruit juice or water. 11

12 Ispaghula husk should not be taken immediately before going to bed; adequate fluid intake should be maintained to prevent intestinal obstruction. Contra-indicated if there is difficulty swallowing. Constipation due to medication investigate 12

13 MAS 6 DIARRHOEA Definition/Criteria for inclusion. Diarrhoea is frequently passing of watery stools Criteria for INCLUSION Sudden onset of above symptoms Criteria for EXCLUSION Patients with chronic diarrhoea problems (i.e. lasting > 2 weeks). Blood y diarrhoea. Children under the age of 1year Signs of shock such as decreased level of consciousness, pale or mottled skin, and cold extremities. Action for excluded patients and non-complying patients Referral to General Practitioner Recommended Treatments ADULT(16yrs & over) Loperamide caps (12) Two capsules used initially and then one after each loose motion. Maximum of eight capsules in 24 hours CHILD (1yr & over) Dioralyte Sachets (6) Patient information: Continue to take normal fluids as well. Follow the preparation instructions on the pack and reconstitute one sachet in 200ml of water. Once prepared, the solution can be kept in the fridge for 24 hours; otherwise any solution remaining after an hour should be discarded. Follow-up and Advice Food intake is recommended if the person wishes to eat. Breast feeding and other milk in infants should continue. Encourage fluid intake( but discourage fruit juices and carbonated drinks) Patient should only be given clear fluids for hours until the symptom resolves.. Good hygiene to prevent infectious diarrhoea, such as washing hands after being to the toilet, before preparing food, before eating food, not sharing towels/ flannels, wearing gloves at nappy change and washing soiled cloths/bed lining separately at highest temperature possible for the product.. Side Effects and their Management Loperamide can cause abdominal pain and bloating When and how to refer to GPReferral: If symptoms persist beyond 48 hours, consult the GP. If accompanied by other symptoms, such as. drowsiness / confusion or blood in stools Food handlers Pregnancy Consider supply, but patient should be advised to make an appointment to see the GP: Patients taking medication with recognised diarrhoea effect Infection caught abroad 13

14 MAS 7 Dermatitis Definition/Criteria for inclusion. Mild eczema, Itchy inflamed areas in a person with dry skin Contact dermatitis is an inflammatory skin reaction (dermatitis) that occurs in response to an external agent acting as either an irritant (For example washing up liquid) or an allergen ( for example latex gloves). Criteria for EXCLUSION Signs of weeping, crusty skin or thickening of the skin. Seborrhoeic eczema or other types of eczema. Affected areas on the face and genitalia. Untreated bacterial, fungal or viral skin lesion. Action for excluded patients and non-complying patients Referral to General Practitioner Recommended Treatments. Aqueous cream Apply to skin frequently and liberally, as often as required.. Supply 500 grams Emulsifying ointment Apply to skin frequently and liberally, as often as required. Supply 500 grams. Hydrocortisone 1% cream (Do not use in Children younger than 10 years old and pregnant women.) Apply to the affected area(s) once or twice a day. Client s one fingertip quantity should cover an area of their flat hand need to be used. Supply 15 grams.. Treatment should be continued for 48 hours after the flare has been controlled. Follow-up and Advice Avoid scratching their eczema (if possible), keep nails short (use anti-scratch mittens in babies) and rub with fingers to alleviate itch. Avoid trigger factors known to exacerbate eczema such as clothing (do not wear synthetic fibres), soaps or detergents (use emollient substitutes), animals, and heat (keep rooms cool). It is essential to provide education on the correct use of emollients, with clear demonstrations where appropriate People with dry skin should avoid the use of soaps, detergents, and bubble bath when washing; instead a suitable soap substitute should be used, for instance an ointment dissolved in hot water or lotion in warm water Advise the person to use their emollient first, and then wait 30 minutes before applying the topical corticosteroid (only after the emollient has been fully absorbed). Advise if symptoms do not start to resolve within 7days to make an appointment to see a GP 14

15 Do not use hydrocortisone for more than 7 days Advise emollient even if condition improves Identify and avoid known irritants and trigger factors or use a barrier between skin and irritant Signpost to the Eczema Society for information: Side Effects and their Management Hypersensitivity to the above recommended medication When and how to refer to GP Referral: If the areas are not healing after 7 days of using the appropriate treatment Recurrent eczema Severe eczema Discoid eczema Infected, weeping eczema Where there is associated scabies Consider supply, but patient should be advised to make an appointment to see the GP: Contact dermatitis where cannot identify an allergen/irritant Gravitational eczema 15

16 MAS 8 HEAD LICE Definition/Criteria for inclusion. Head lice infestation (also known as pediculosis capitis) is the condition caused by the parasitic insect Pediculus capitis, which lives on, and among, the hair of the scalp and neck of humans. Live lice can be found anywhere on the scalp; the eggs are most commonly found behind the ears and at the back of the neck Criteria for INCLUSION Diagnosis of head lice Use detection combing (systematic combing of wet or dry hair with a detection comb) to confirm the presence of lice: Wet combing Wash the hair in the normal way with ordinary shampoo. Rinse out the shampoo and put on lots of ordinary conditioner. Comb the hair with a normal comb to get rid of tangles. When the hair is untangled switch to a detection comb. This is a special fine-toothed comb. Slot the teeth of the detection comb into the hair at the roots so it is touching the scalp. Draw the detection comb through to the tips of the hair. Make sure that all parts of the hair are combed by working around the head. Check the comb for lice after each stroke. A magnifying glass may help. If you see any lice, clean the comb by wiping it on a tissue or rinse it before the next stroke. After the whole head has been combed, rinse out the conditioner. Repeat the combing procedure in the wet hair to check for any lice that might have been missed the first time. Dry combing Straighten and untangle the dry hair using an ordinary comb. Once the comb moves freely through the hair without dragging. Starting from the base or the side of the scalp, comb the hair from the scalp down to the end of the hair. Comb each section of hair 3-4 times before moving to an adjacent section. Look for lice as the comb is drawn through the hair. If a possible louse is seen, trap it against the face of the comb using the thumb. This avoids the risk of the louse being repelled by static electricity as the comb is withdrawn from the hair. Continue combing the hair section by section until the whole head of hair is combed through Advise the person (or the child's parent) that all members of the household should also be checked Lice found using a detection combing need to be attached to sticky tape and brought to the consultation to aid diagnosis. 16

17 Criteria for EXCLUSION No evidence of lice brought in by the client. Note: infestation is not indicated by the presence of nits [hatched and empty egg shells] Children under the age of six months Action for excluded patients and non-complying patients Referral to General Practitioner Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage Treat the person only if a live head louse is found Ensure all affected individuals in a household are treated simultaneously Choice of treatment depends on the preference of the individual or parent and what has been previously tried Dimeticone 4% lotion (Hedrin lotion) Suitable for all ages, those with skin conditions, and those with asthma. It should be applied twice, with 7 days between applications. Dimeticone is left on the hair and scalp for 8 hours or overnight, and is then washed out using shampoo. Wet combing using the Bug Buster comb. Suitable for all ages, those with skin conditions, and those with asthma Unlike other treatment options, the Bug Buster comb is reusable; one comb can be used to treat the whole family Treatment involves methodically combing wet hair with the fine-toothed Bug Buster comb to remove lice. This is undertaken for four sessions over 2 weeks. Wet combing should be continued until no lice have been seen for three consecutive sessions Malathion 0.5% aqueous liquid, a traditional insecticide Apply to dry hair so that the scalp and roots of the hair are saturated (one bottle is usually enough). Allow to dry naturally. Leave on the hair for 12 hours or overnight. Then wash hair. Repeat treatment after 7 days. Use detection combing 2-3 days after final treatment, and again 9-10 days after the final treatment to check that treatment has been successful. All infested contacts must be treated t the same time to prevent reinfestation. Follow-up and Advice Hair should be allowed to dry naturally avoid flames. Do not use hair dryers Not suitable for prophylaxis Advise people to check whether treatment was successful by detection combing on day 2 or day 3 after completing a course of treatment, and again after an interval of 7 days (day 9 or day 10 after completing a course of treatment). Itching can persist for days to weeks after head lice eradication. If treatment has been repeated because the first treatment course was unsuccessful: Advise people to consider detection combing 5 days after the first application of treatment, and 2 days after the second application of treatment, and again after a further 7 days. Wet combing using the Bug Buster comb. The Bug Buster comb and method has been successful if no lice are found on day 17. If lice are found on day 17, continue use of the Bug Buster comb until no lice have been found on three consecutive sessions Side Effects and their Management Side effects are experienced rarely 17

18 MAS 9 INSECT BITES AND STINGS Definition/Criteria for inclusion. Insect bites are puncture wounds, or lacerations, caused by insects. In the UK, insects that bite include midges, gnats, mosquitoes, flies, fleas, and bedbugs. Many insects sting as a defence mechanism, by injecting venom into the skin. In the UK, stinging insects include bees (honeybees and bumblebees), wasps, and hornets. Criteria for INCLUSION Reactions to insect bites or stings present with localized pain, swelling, and erythema at the site of the bite or sting. Criteria for EXCLUSION Children under 1 year Pregnancy Affected area is face or anogenital region Secondary bacterial infection may occur as a result of scratching or may be introduced at the time of the bite. It can present as impetigo, folliculitis, cellulitis, or lymphangitis. Insect bite with fever Action for excluded patients and non-complying patients Refer to their General Practitioner. Recommended Treatments Analgesia Paracetamol tablets 500mg Paracetamol suspension SF 250mg / 5ml Paracetamol susp SF 120mg / 5ml By mouth Adult dose: g every 4 6 hours to a max. of 4 g daily; 1 6 years mg, 6 12 years mg; these doses may be repeated every 4 6 hours when necessary (max. of 4 doses in 24 hours) Ibuprofen 200mg tablets Ibuprofen suspension 100mg/5ml By mouth ADULT and CHILD over 12 years, initially mg 3 4 times daily; CHILD 1 4 years, 100 mg 3 times daily (max. 30 mg/kg daily in 3 4 divided doses); CHILD 4 7 years, 150 mg 3 times daily (max. 30 mg/kg daily in 3 4 divided doses); CHILD 7 10 years, 200 mg 3 times daily (up to 30 mg/kg daily (max. 2.4 g) in 3 4 divided doses); CHILD years, 300 mg 3 times daily (up to 30 mg/kg daily (max. 2.4 g) in 3 4 divided doses) Topical corticosteroid Hydrocortisone 1% cream ( for over 10 year olds) Apply thinly to the affected area 1 to 2 times a day. Use for a maximum of 7 days. Sedating oral antihistamines (for itch at night) Chlorphenamine syrup Children aged 6-12 years: 5ml every 4 to 6 hourly (daily max: 12 mg i.e. 30ml) 18

19 Children aged 2-5 years: 2.5ml every 4 to 6 hourly (daily max: 6 mg i.e. 15ml) Children aged 1-2 years: 2.5ml twice daily Chlorphenamine tabs 4mg Adults: One tablet every four to six hours ( Daily max six tablets 24mg) Follow-up and advice Use of insect repellent products for future potential exposure If a person has been stung and the stinger is still in place: o Remove it as soon as possible by flicking or scraping with a fingernail, piece of card, or knife blade. o Never squeeze the stinger or use tweezers, as this will cause more venom to go into the skin. Remove ticks as soon as possible. Wash the area of the bite or sting with soap and water Apply ice to reduce swelling, if present. Do not scratch, as this will cause the site to swell and itch more, and increase the chance of infection. If there are signs of a severe allergic reaction (generalized symptoms, breathing difficulties, and/or hypotension) seek urgent medical help. Bites from fleas, mites, and bedbugs may be due to an infestation. The source of the infestation should be confirmed and then eliminated. Side Effects and their Management Chlorphenamine causes sedation if affected, do not drive or operate machinery Emergency referral (call 999 or 112) If the patient experiences shortness of breath or fever If the patient has symptoms of a severe allergic reaction: swollen lips and eyelids, difficulty in breathing (wheezing), becoming pale, fainting, generalised itchiness, aches/ pains, feeling unwell If stung in the mouth suck on an ice cube, or sip cold water and seek immediate medical attention If have a known allergy to bites and stings seek medical attention 19

20 MAS 10 MOUTH ULCERS Definition/Criteria for inclusion. Mouth ulcers are painful, clearly defined, round, or oval sores which form in the mouth and are not associated with systemic disease. Criteria for INCLUSION Oral trauma. Such as damage to the mouth from a sharp tooth, or filling, toothbrush injury, thermal burns, ill fitting dentures History of recurrent mouth ulcers. History of up to 14 days. Criteria for EXCLUSION Ulcer has been present for more than 3 weeks Oral swellings persisting for more than 3 weeks Associated systemic symptoms Patient is taking immunosuppressant drugs or is immunocompromised Lesions including any lump, thickening, red or white patches. Ulcers affecting extra-oral sites (e.g. genitalia) Ulcers affecting atypical sites in the mouth (e.g. palate) Any sore that bleeds Child under 6 years Suspected adverse drug reaction. Pregnancy. Action for excluded patients and non-complying patients Referral to a patient s general practitioner. Recommended Treatments Chlorhexidine gluconate 0.2% mouthwash. (Clients over 12 years old) Rinse the mouth with 10ml for about 1 minute twice a day. Hydrocortisone 2.5mg oromucosal tablets (Clients over 12 years old) Place one tablet over the affected area and allow it to dissolve slowly, four times a day. Benzydamine 0.15% oromucosal spray Age 6 to 12 yrs 11 mths: Spray four times onto the affected area every 3 hours when required for pain relief. Increase to every one and a half hours if required. Age 13 yrs onwards: Spray 4 to 8 times onto the affected area every 3 hours when required for pain relief. Increase to every one and a half hours if required. Not to use this spray continuously for more than 7 days. Follow-up and Advice The course of treatment is 5 days, if symptoms persist or ulcer(s) returns make an appointment to see a GP Suggest the patient limits the use of sharp foods (e.g. crisps) spicy foods, hot fluids and carbonated drinks, and uses a softer toothbrush To prevent getting mouth ulcers, try to avoid becoming run down by making sure that you eat a balanced diet, take regular exercise, and learn to effectively manage stress. If you are prone to recurrent ulcers, try to avoid damaging the inside of your mouth by using a softer toothbrush and avoiding hard, brittle, or sharp-edged foods Make sure 20

21 that your teeth are in good order by regularly visiting your dentist. Side Effects and their Management Chlorhexidine gluconate 0.2% mouthwash When used regularly, this mouthwash may stain teeth brown but this is not usually permanent. Brushing the teeth before using the mouthwash can minimize the staining but make sure that you rinse your mouth well with water before you rinse with the mouthwash. Do not use this mouthwash continuously for more than 1 month. When and how to refer to GP Referral: As per exclusion criteria Refer to dentist for ulcers caused by ill-fitting dentures or sharp surfaces on dentures, prostheses, orthodontic braces, tooth restorations or foodstuffs 21

22 MAS 11 VAGINAL THRUSH Definition Vaginal candidiasis (Thrush) is a fungal infection (mycosis) of any of the Candida species, of which Candida albicans is the most common. Infection may cause severe itching, burning, soreness, irritation, and a whitish or whitishgrey discharge, often with a curd-like appearance. Criteria for INCLUSION Vaginal candidiasis (Thrush) occurring in adult females with a previous diagnosis of Thrush who are confident it is a recurrence of the same condition. Criteria for EXCLUSION Experiencing symptoms for the first time. Client is under 16 or over 60 years of age. Client is pregnant. Client has lower stomach pain, or pain /burning sensation on passing urine. Client has sores, ulcers or blisters on the vulva or vagina. Client has had two cases of thrush within six months. Client has reacted badly to an antifungal treatment in the past, or if they were ineffective. Client or partner has been exposed to a sexually transmitted disease. Client has abnormal or irregular vaginal bleeding or blood stained discharge. Action for excluded patients and non-complying patients Refer to the General Practitioner. Recommended treatments and frequency of administration and maximum dosage Clotrimazole Cream 2% 20g Apply thinly twice to three times daily for at least 2 weeks Clotrimazole Pessary 500mg insert one pessary at night Clotrimazole 500mg pessary/ 2% cream Combination Pack Follow-up and Advice The symptoms of the skin infection, such as itching or soreness, should improve within a few days of treatment although signs such as redness and scaling may take longer to disappear. Make aware sexual partners should be treated concurrently. May cause damage to latex contraceptives. Consequently the effectiveness of such contraceptives may be reduced. Patients should be advised to use alternative precautions for at least five days after using this product. Advise if symptoms get worse or persist to make an appointment to see a GP. How to avoid future recurrences: Wear cotton knickers and loose clothing. Wash daily. After going to the toilet, wipe yourself from the front to back as a thrush infection may 22

23 be transferred from the bowel. Change your sanitary protection regularly. Try to avoid wearing tights, nylon knickers and close fitting jeans. Try to avoid washing with perfumed soaps or using vaginal deodorants. Do not wash or rub yourself hard with sponges or flannels. Side Effects and their Management Sensitivity to Imidazoles. When and how to refer to GP Referral: On 3 rd occurrence Allergy to Clotrimazole Presence of loin pain. Fever. If blood present in discharge Consider supply, but patient should be advised to make an appointment to see the GP: Post-menopausal women Patient with diabetes. 23

24 Pharmacy First quick formulary list Minor ailment Pharmacy first medication Allergic Rhinitis Cetirizine Solution 1mg/1ml (200ml) Cetirizine 10mg Tablets (30) Chlorphenamine syrup ( 150ml) Chorphenamine tablets 4mg (30) Loratadine Liq. 5mg/5ml (100ml) Loratadine 10mg tablets (30) Beclomethasone nasal spray (180 doses) Athlete s Foot Clotrimazole cream 1 % (20g) Miconazole cream 2% ( 15g) Terbinafine cream 1 % ( 7.5g) Bacterial Conjunctivitis Chloramphicol eye drops (10ml) Constipation Fybogel sachets (10) Glycerol suppositories 4g (12) Lactulose Solution (500ml) Senna tabs (20) Dermatitis Aqueous cream (500g) Emulsifying ointment (500g). Hydrocortisone 1% cream (15g) Diarrhoea Loperamide caps (12) Dioralyte Sachets (6) Head lice Dimeticone 4% lotion (2x50ml) Wet combing using the Bug Buster comb. Malathion 0.5% aqueous liquid ( 2 x 50ml) Insect bites and stings Chlorphenamine syrup ( 150ml) Chorphenamine tablets 4mg (30) Hydrocortisone 1% cream (15g) Ibuprofen 100mg/5ml Suspension (100ml) Ibuprofen 200mg tablets (24) Paracetamol tablets 500mg (32) Paracetamol susp. 120mg/5ml (100ml) Paracetamol susp 250mg/5ml ( 100ml) Mouth ulcers Chlorhexidine gluconate 0.2% mouthwash.(300ml) Hydrocortisone 2.5mg oromucosal tablets (20) Benzydamine 0.15% oromucosal spray (30ml) Upper Respiratory Infection Vaginal Thrush Aspirin 300mg soluble 300mg tablets Ibuprofen 100mg/5ml Suspension (100ml) Ibuprofen 200mg tablets (24) Paracetamol tablets 500mg (32) Paracetamol susp. 120mg/5ml (100ml) Paracetamol susp 250mg/5ml ( 100ml) Sodium chloride nose drops (10ml) Clotrimazole Cream 2% 20g Clotrimazole Pessary 500mg Clotrimazole 500mg pessary/ 2% cream pack 24