Nonprescription Products

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CHAPTER 26 Nonprescription Products

A. Nonprescription or over-the-counter (OTC) products are medicines that can be bought without a prescription. They are relatively safe and effective when directions on the label are followed and when used as the prescriber or health care professional directs.

B. These products are regulated by the Food and Drug Administration (FDA).

C. Reasons consumers self-diagnose and use OTC products

1. Products readily available in pharmacies and grocery stores

2. High insurance costs (for medication or doctor’s visits) or no insurance

3. Availability of information on the web (i.e., WebMD.com)

4. Time constraints (e.g., doctor’s visits, travel time, missed time from work)

D. There are more than 80 therapeutic categories of OTC drugs, ranging from acne drug products to weight-control drug products.

F. Special considerations when using OTC products

1. Drug interactions (drug-disease, drug-drug, drug-food, drug-herbal)

A. The common cold may involve the nose, throat, sinuses, eustachian tubes (connects the ears to the throat), trachea (windpipe), larynx (voice box), and bronchial tubes (airways).

B. The cause of developing a cold is due to a viral infection, including rhinoviruses (most common), coronaviruses, adenoviruses, echoviruses, respiratory syncytial viruses (RSV), and coxsackieviruses.

C. In response to infection, the immune system triggers a series of events, including release of inflammatory cytokines (a group of proteins that help regulate inflammation, blood cell production, and immunity), such as interleukin-6 (IL-6), interleukin-8 (IL-8), and granulocyte-macrophage colony-stimulating factor (GM-CSF), fluid leakage (runny nose), mucous membrane swelling (stuffy nose), increased mucous production, and stimulation of sneeze and cough reflexes.

1. Symptoms usually appear about 1 to 3 days after exposure to a cold virus. Nasal symptoms can begin as early as 2 hours after exposure; cough and sore throat symptoms usually begin 10–12 hours after exposure to the virus.

2. Signs and symptoms may include runny or stuffy nose, itchy or sore throat, dry cough, facial pressure due to sinuses (hollow bones in the front of the face), slight body aches or a mild headache, sneezing, itchy, watery eyes, low-grade fever (less than 102 °F), and mild fatigue (tiredness).

3. Nasal discharge may become thicker as the cold runs its course.

4. Colds last on average for 1 week. Mild colds may last only 2 or 3 days; severe colds may last a maximum of 2 weeks. Cough due to a cold can last hours or days.

D. Risk factors

1. Social activity

a) Being around children (teachers, day care workers)

b) Traveling in airplanes or buses

c) Being around people who are sneezing and coughing

d) Touching public railings and doors

e) Workplace

f) Healthcare workers

2. Age

a) Infants’ immune systems not fully developed

b) Colds generally occur less frequently with age

3. Seasonal changes

a) In cold months, air is dry and heating dries air even more.

b) In hot months, air conditioning dries air.

c) Dry air dehydrates the mucous membranes in the nose and throat, which are the first line of defense against the viruses. This allows the viruses to attack the tissue in the nose and throat.

4. Environmental toxins

a) Injure airways and damage the cilia

(1) Cigarette smoke

(2) Industrial smoke

(3) Other air pollutants

5. Lowered immunity

6. HIV

7. Cancer

8. Medications (e.g., corticosteroids, chemotherapy)

9. Stress

10. Too much exercise

11. Malnutrition

12. Lack of sleep

E. Treatment

1. There is no cure for the common cold.

2. OTC cold preparations may be used for symptoms.

a) Annually Americans spend about $2.9 billion on OTC drugs in addition to $400 million on prescription medicines for symptomatic relief from colds.

F. Pharmacological therapy

1. Pain relievers and fever reducers

a) Indication: fever, sore throat, body aches, and headache

b) Examples: acetaminophen (Tylenol), ibuprofen (Advil, Motrin)

c) Considerations

(1) Acetaminophen (Tylenol)

(a) Does not affect platelet function or increase blood clotting time

(b) Does not cause gastrointestinal (GI) irritation

(d) May be used in patients with gout taking probenecid

(e) Caution with use in patients with hepatic disease

(f) Acetaminophen can cause liver damage, especially if taken chronically, or in doses that exceed 4 grams daily

(2) NSAID (e.g., aspirin, ibuprofen)

(a) Upper GI disturbances are common

(b) Risk for increased bleeding

(d) Caution with use in patients with stomach ulcers, poor kidney function

(e) Duration of antipyretic effect may be slightly longer (3–4 versus 5 hours)

(f) It is recommended never to give aspirin to children ages 3 to 12 years old. Aspirin may play a role in causing Reye syndrome, a rare but potentially fatal illness in children with concomitant viral illness.

2. Decongestants help open swollen mucous membranes of the nasal passages so the individual can breathe easier.

a) Indication: nasal or sinus congestion

b) Decongestants include tablets, sprays, inhalers, and nose drops.

d) Side effects

(1) Stinging, burning, sneezing, increased nasal discharge, drying of the nostrils, and altered taste may occur.

(2) Other side effects include rapid or pounding heartbeat, dizziness, trouble sleeping, shaking of the hands, and tremors.

e) Caution

(1) Nasal decongestants are safe for most patients, except people with heart disease, high blood pressure, thyroid disease, glaucoma (increased pressure in the eyes), diabetes, seizure disorders, or enlarged prostate, or by individuals using a monoamine oxidase inhibitor (MAOI).

f) Contraindications

(1) Nasal decongestants are not safe in individuals using a MAOI. Healthcare professionals recommend not using decongestants while pregnant or breastfeeding.

g) Counseling points

(1) Over time, decongestant nose drops, inhalers, and sprays can actually cause rebound congestion, which means the nasal passages are not able to function normally without using these medications.

(2) Prolonged use can also cause chronic inflammation of the mucous membranes.

(3) Decongestant nasal drops and sprays are not to be used for more than 3 days, which helps to stop the potential of nasal rebound.

(4) If symptoms worsen, a doctor may need to evaluate the situation.

4. Cough syrups

a) Indication: for symptomatic relief of cough associated with a cold.

b) Examples (Figure 26-1)

(1) Various combinations of antihistamines, decongestants, and cough suppressants

(2) If the cough is productive (brings up mucus), the ingredient guaifenesin can help break up the chest congestion (water intake is also important).

(3) If the cough is dry and hacking, a cough suppressant (dextromethorphan) can stop the cough.

c) Considerations

(1) Dextromethorphan

(a) Can use in pregnancy

(b) Less constipation than with use of opiate

(2) Codeine

(a) Can use in pregnancy

d) Caution

(1) Many doctors strongly discourage the use of these combination cough syrups for any child younger than 2 years old, in whom accidental overdoses could be fatal.

e) Counseling points

(1) Coughs associated with a cold usually last less than 2–3 weeks. If a cough lasts longer than 3 weeks, the patient should see a doctor.

(2) Cough due to colds in adults may be safely treated for as long as 7 days.

(3) The American Academy of Pediatrics highly recommends the use of calibrated measuring devices for the administration of all liquid medications to children and infants.

G. Nonpharmacological therapy can help reduce cold symptoms and is recommended by healthcare professionals for all infants younger than 9 months.

1. Rest and increased intake of fluids

2. Saline nasal drops

3. Nasal bulb aspirator

4. Elevating the head

5. Humidification

6. Petroleum jelly

III. Otics

A. Otic preparations (ear drops) are commonly used in adults and children and may be used to relieve pain, itching, and inflammation in the ear caused by ear infections, for example. Otic preparations can also be used to remove cerumen (ear wax) and to clear water from the clogged ear (ear drying aid).

B. They are made as solutions and suspensions.

C. Anti-infective

1. Indication: external ear infections, all are prescription-only medications

2. Examples

a) Neomycin and polymyxin B (AK-Spore HC, Cortisporin, and Otocort)

D. Anesthetics

1. Indication: ear pain, prescription only

2. Examples

a) Benzocaine (Americaine Otic and Otocain)

b) Combination of antipyrine (an anti-inflammatory) and benzocaine (Auralgan, Auroto, Otocalm)

E. Ear wax removal

1. Indication: to soften, loosen, and remove excessive ear wax

2. Examples

a) Carbamide peroxide (Murine, Debrox)

b) Carbamide peroxide with anhydrous glycerin (Physicians’ Choice Ear Drops Ear Wax Removal Kit)

c) Hypertonic seawater (EARinse)

F. Ear drying aid

1. Indication: water-clogged ear after swimming, showering, washing the hair

2. Examples

a) Isopropyl Alcohol (95%) in Anhydrous Glycerin (5%) (Auro-Dri and Swim-Ear)

5. Swelling or other sign of irritation in or around the ear not present before use of this medicine

H. Counseling points

1. It is best to warm the ear drops to body temperature (37 °C or 98.6 °F) by holding the bottle in the hand for a few minutes and gently rolling the bottle before using the medicine. This helps to lessen the pain in the ear.

2. The individual must lie down or tilt the head so that the infected ear faces up.

3. The earlobe is gently pulled up and back for adults (down and back for children) to straighten the ear canal.

4. The medicine is then dropped into the ear canal as directed, keeping the ear facing up for approximately 5 minutes to allow the medicine to coat the ear canal.

a) For young children and other patients who cannot stay still for 5 minutes, keeping the ear facing up for at least 1 or 2 minutes may be best.

b) Watching television can also help keep children from moving around.

5. Cotton may be placed in the ear canal to keep the medicine from running out.

6. Keep the medicine as germ-free as possible, do not touch the dropper to any surface (including the ear), and keep the container tightly closed.

7. To help clear up the infection completely, the patient should keep using this medicine for the full time of treatment, even if the symptoms have disappeared, and do not miss doses.

8. Ask a doctor before use if a patient has:

a) Ear drainage or discharge

b) Ear pain

c) Irritation or rash in the ear

d) Dizziness

e) An injury or perforation (hole) of the eardrum

f) Recently had ear surgery

9. Stop use and ask a doctor if:

a) A patient needs to use more than 4 days

b) Excessive earwax remains after use of this product

IV. Ophthalmics

A. Ophthalmic products include eye drops and lubricants. They are commonly used to relieve redness, dryness, itching, and inflammation in the eye caused by seasonal allergies or from working in front of a computer, to name a few examples. Some ophthalmic products can also be used to rinse the eye of debris.

D. Lubricants

1. Indication: For the temporary relief of burning, irritation, and discomfort due to dryness of the eye or exposure to wind or sun

3. Considerations

a) Tear production may decrease with age so that fewer tears are available to keep the surface of the eye moist. Both of these changes explain why older people are more likely to have dry eyes.

4. Counseling points

a) In treating dry eye, the first thing to do is to remove or reduce the cause. Reducing contact lens wear time and taking breaks from intense visual work are two examples.

b) If the individual has chronic dry eye, it is important to use the drops even when the eyes feel fine to keep them lubricated.

c) If the eyes dry out while sleeping, there are thicker lubricants, such as ointments, that can be used at night.

E. Eye rinses

1. Sodium chloride

a) Indication: Temporary relief of corneal edema

b) Examples

(1) Sodium chloride (5%) (Bausch & Lomb Muro 128® 5% ointment)

F. Counseling points

1. The proper way for a patient to use eye drops or ointments is:

a) Wash your hands.

b) Shake the container.

c) Tilt your head back and look up.

d) Gently pull your lower lid away from the eye, forming a pouch (Figure 26-2).

e) Into the pouch place one drop or 1/4 to 1/2 inch of ointment. Do not touch the eye or eyelid with the container or dropper.

f) For drops

(1) For 5 minutes the patient should:

(a) Either close an eye, or with the eye open press a finger against the inner corner of the eyelid and the side of the nose (see Figure 26-2). This prevents the medication from entering the tear duct and draining away.

g) For ointment

(1) Simply close the eye. Vision may be blurred for several minutes.

h) Repeat with the other eye if needed.

i) Replace the cap or dropper on the bottle or tube; tighten.

j) It takes 5 minutes for most of an eye drop to be absorbed into the eye. Wait at least 5 minutes before instilling a second drop or between applying other eye medications.

V. Pain and Fever

A. Fever

1. For infants and very young children, even a slight increase in body temperature may indicate a serious infection. If a baby younger than 12 months old has a temperature higher than 100 °F, a healthcare provider should be consulted immediately.

2. Adults and children who have temperatures higher than 102 °F that are not responding to medications, such as ibuprofen (Motrin, Advil), aspirin, or acetaminophen (Tylenol), should visit their doctors.

B. Pain

1. OTC analgesics are indicated for mild to moderate pain.

C. Pharmacological therapy may include:

1. Acetaminophen (Tylenol)

a) Considerations

(1) Acetaminophen can cause liver damage, especially if taken chronically, or in doses that exceed 4 g daily

2. Aspirin (Ecotrin, Bayer, Aspergum, Aspirtab, Easprin, Ecpirin)

a) Considerations

(1) Aspirin may interact with asthma, a bleeding disorder, congestive heart failure (CHF), diabetes mellutis (DM), gout, hemophilia, elevated blood pressure, kidney or liver disease, thyroid disease, or a peptic ulcer.

(2) Alcohol intake should be limited when taking aspirin because it increases the risk of stomach irritation and bleeding.

4. NSAID: ibuprofen (Motrin, Advil), naproxen (Naprosyn)

5. Pain patches

6. Hot and cold therapy

7. Rubs and ointments

D. Nonpharmacological therapy includes:

1. Application of ice and/or heat

2. Cool compress

3. Cool liquids

4. Sponge bath

5. Psychological measures (such as biofeedback and cognitive therapy)

VII. First Aid

A. Burn first aid

1. To care for a burn victim with a first- or second-degree burn, first remove the burning agent to keep it from inflicting further damage.

a) For example, fires are extinguished, and smoldering clothing that may be covered with hot tar or soaked with chemicals is immediately removed.

b) Any constricting jewelry, such as rings, are removed.

2. It is important to note that all third-degree burns and complicated location burns, such as the airway and eyes, need immediate evaluation by a doctor, and burnt clothing and/or burning agents should not be removed without the supervision of a healthcare provider.

4. Affected area can be cleansed gently with an antiseptic solution, if a first degree (mild) burn.

6. First-degree thermal burns can be treated with local skin care such as aloe vera. Many topical antibiotics (such as Neosporin or Bacitracin) and antiseptics are available.

7. Keeping the burned area clean is important because the damaged skin is easily infected.

a) Cleaning may be accomplished by gently running water over the burns periodically.

b) Wounds are cleaned and bandages are changed one to three times per day.

c) Bandaging

(1) The burn can be covered with a sterile gauze bandage.

(2) The gauze should be wrapped loosely to avoid putting pressure on burned skin.

(3) Bandaging keeps air off the burned skin, reduces pain, and protects blistered skin.

8. Minor burns usually heal without further treatment.

a) They may heal with pigment changes, meaning the healed area may be a different color from the surrounding skin.

10. Avoid re-injuring or tanning if the burns are less than a year old.

a) Tanning may cause more extensive pigmentation changes.

VIII. Topical Agents for Common Skin Conditions

B. Skin rashes

1. Oral and topical antihistamines like diphenhydramine (Benadryl) have been used to treat skin rashes caused by an allergic reaction.

a) Antihistamines decrease redness and itchiness associated with the rash.

2. Baking soda

a) A solution of baking soda and water may help treat allergic skin reactions caused by poisonous plants.

b) Three teaspoons of baking soda can be mixed with one teaspoon of water and applied to affected areas of the skin.

3. Calamine lotion

a) Calamine lotion (Calamox) can be applied to the skin to reduce itching and blistering caused by exposure to a poisonous plant.

4. Cool compress

a) Applying a cool compress to affected areas of the skin may help relieve itching and swelling associated with rashes.

5. Topical corticosteroids

a) Topical corticosteroids are the most common and effective treatments for rashes caused by atopic dermatitis. They are used until the rash clears. Low-strength topical corticosteroids should be used on the face.

b) Hydrocortisone (Bactine, Cortaid, Dermolate, or Aveeno anti-itch cream) is a low-strength corticosteroid cream that has been used to treat young children.

6. Zinc oxide creams

a) Ointments that contain zinc oxide (like Desitin or Diaparene) may help relieve diaper rash in babies. The ointment is applied to affected areas of the skin each time the baby’s diaper is changed.

C. Itching

1. Hydrocortisone cream has been applied to the affected area to temporarily relieve itching associated with allergic reactions and exposure to poisonous plants.

2. Hydrocortisone 1% cream, which is available OTC, has anti-inflammatory effects and relieves swelling and redness in addition to itching.

3. Prescription hydrocortisone has been used to relieve itching, redness, dryness, crusting, scaling, inflammation, and discomfort associated with the reaction.

D. Dry skin

1. Ammonium lactate

a) Used for dry, scaly skin conditions like xerosis and ichthyosis vulgaris

b) A thin layer should be applied to the affected areas of the skin, usually twice daily.

c) It should be rubbed thoroughly into the skin.

E. Poison ivy

1. Aloe vera gel

a) Applied to affected areas of the skin to relieve itching and help rashes heal

b) Should not be applied to open cuts, blisters, or sores on the skin

2. Baking soda

a) A solution of baking soda and water may help treat allergic skin reactions caused by poisonous plants.

b) Three teaspoons of baking soda can be mixed with one teaspoon of water and applied to affected areas of the skin.

3. Calamine lotion

a) Calamine lotion (Calamox) can be applied to the skin to reduce itching and blistering.

4. Cool showers

a) Taking cool showers can help relieve itching associated with the allergy.

b) Also, soaking affected areas in cool water with baking soda or oatmeal may help reduce itching and dry blisters.

(1) Colloidal oatmeal (Aveeno Oatmeal Bath) has been shown to relieve itching a maximum of 7 hours.

5. Cool compress

a) Applying a cool compress to affected areas of the skin may help relieve itching.

6. Hydrocortisone

a) Hydrocortisone cream may be applied to the affected area to temporarily relieve itching.

b) Hydrocortisone 1% cream, which is available OTC, has anti-inflammatory effects and relieves swelling and redness in addition to itching.

c) Prescription hydrocortisone has been used to relieve itching, redness, dryness, crusting, scaling, inflammation, and discomfort associated with the reaction.

IX. Antihistamines

A. Indications: symptoms like runny or stuffy nose, itchy or sore throat, sneezing, itchy, watery eyes

D. Considerations

1. First generation agents are less expensive compared to newer agents.

2. Best when taken ~1–2 hours before exposure to offending allergen.

3. If patient becomes tolerant, switch to an antihistamine in a different class.

E. Caution

1. Antihistamines can cause confusion and increased risk of falls if administered to elderly patients, especially first generation agents

2. Caution with use in patients with increased intraocular pressure, hyperthyroidism, and cardiovascular disease.

X. Constipation, Diarrhea, Nausea, Vomiting

A. Antidiarrheals

3. Antisecretory agent

a) Enzymes (lactase)

(1) Helpful for patients with lactose intolerance

(2) Lactase is needed for carbohydrate digestion and is needed for patients who have diarrhea after eating dairy products,.

(3) To be used each time a diary product is eaten, such as milk or ice cream

b) Bacterial replacement

(1) Lactobacillus acidophilus, Lactobacillus bulgaricus

(2) Replaces colonic microflora; restores intestinal functions; suppresses the growth of pathogenic microorganisms

4. Nonpharmacologic

a) Stopping solid foods for 24 hours

b) Avoiding dairy products

c) Start bland diet as bowel movements decrease

d) Oral rehydration fluids

B. Laxatives

2. Agents that cause watery evacuation

a) Effects seen in 1–6 hours

(1) Magnesium sulfate

(2) Magnesium hydroxide

(a) Milk of magnesia used for acute constipation.

3. Aloe

4. Polycarbophil

(1) FDA recommends as effective adsorbent

(2) Adsorbs 60× its weight in water

(3) Treats both diarrhea and constipation

(4) 500-mg chewable tablets

(5) Nonabsorbable, safe, may be taken four times per day, to a maximum of 6 g in adults

5. Irritants and stimulants

a) Effects seen in 6–12 hours

a) Bowel movement within 1–3 hours after use

b) Caution

(1) Because it has a strong purgative action, it should not be used regularly.

7. Stool softeners

a) Emollient: surfactant agents

(1) Docusate sodium

(2) Increase water and electrolyte secretion in the small and large bowel

(3) To prevent, not treat, constipation

(4) Effect seen in 1–3 days

8. Glycerin suppositories are used for acute constipation

a) Effect seen in 30 minutes

b) Considered to be a safe laxative but can sometimes cause rectal irritation

9. Enemas

10. Nonpharmacologic

a) Tap water enema used for acute constipation; bowel movement can be seen in 30 minutes

b) Regular exercise

c) Dietary measures such as increasing fiber (20–35 g each day including more fruits and uncooked vegetables), more water, and more whole grain breads and cereals are helpful.

d) For individuals who get gas or bloating from whole grains, a fiber substitute such as psyllium (a natural soluble fiber) may help. If gas is still a problem, methylcellulose (Citrucel) or polycarbophil (FiberCon) may be beneficial. These products do not undergo bacterial fermentation, therefore creating less gas.

XI. Smoking Cessation

A. There is evidence that combining the nicotine patch with nicotine gum or nicotine nasal spray increases long-term quit rates compared with using a single type of nicotine replacement therapy. Nicotine gum, in combination with nicotine patch therapy, may also reduce withdrawal symptoms better than either medication alone. A doctor or pharmacist can provide more information.

B. Pharmacological therapy

1. Nicotine gum

c) Side effects

(1) Bad taste in the mouth

(2) A tingling feeling on the tongue while chewing the gum

(3) Hiccups

(4) Upset stomach (nausea) or heartburn

(5) Nausea and light-headedness are possible signs of overdose and warrant dose reduction.

d) Counseling points

(1) Nicotine gum might not be appropriate for people with temporomandibular joint (TMJ) disease, or popping of the jaw, or for those with dentures or other dental work such as bridges.

(2) Nicotine gum is generally used for 12 weeks.

(3) It should be chewed slowly until a peppery or minty taste emerges and then parked between the cheek and the gums for absorption through the oral mucosa. The gum should be chewed slowly and intermittently and parked for about 30 minutes or until the taste dissipates.

2. Nicotine lozenge

a) Nicotine lozenge comes in the form of a hard candy and releases nicotine as it slowly dissolves in the mouth. Eventually, the quitter uses fewer and fewer lozenges during the 12-week program until he or she is completely nicotine-free.

b) Side effects

(1) Soreness of the teeth and gums

(2) Indigestion

(3) Throat irritation

(4) Nausea and light-headedness are possible signs of overdose and warrant dose reduction.

c) Counseling points

(1) There is no eating or drinking within 15 minutes before using or while the lozenge is in the mouth.

(2) Each lozenge will last about 20–30 minutes, and nicotine will continue to leach through the lining of the mouth for a short time after the lozenge has disappeared.

(3) No more than five lozenges in 6 hours, or more than 20 lozenges total per day are used.

(4) One lozenge after another is not used because this may cause hiccups, heartburn, nausea, or nervousness.

(5) Biting or chewing the lozenge will cause more nicotine to be swallowed quickly and may result in indigestion and/or heartburn.

3. Nicotine patches

a) Nicotine patch looks like an oversized adhesive bandage. The outer part of the patch sticks to the skin, while the inner portion presses against and slowly releases nicotine into the skin.

b) Side effects

(1) Sleep disruption

(2) Skin irritation because of the adhesive, not the nicotine

(3) Nausea and light-headedness are possible signs of overdose and warrant dose reduction

c) Counseling points

(1) The patch is used on a clean, dry, nonhairy area of skin on the upper body or the outer part of the arm.

(2) Skin that is very oily, burned, broken out, cut or irritated in any way may cause the patch not to stick.

(3) Men with excess hair can apply the patches on the underside of the arms or clip excess hair from the back or chest.

(4) The patch may stay in place if it is placed over joints, such as the shoulder.

(5) Most individuals prefer the patch placed on an area that is not visible to others.

(6) The patch should not be removed from the sealed, protective pouch until it is ready to be used.

(7) There are instructions in the package regarding opening, such as where to cut the package so as not to cut the patch.

(8) After opening the package, the patch is immediately applied to the skin, pressing firmly against the skin with the palm for about 10 seconds.

(9) Healthcare professions recommend rotating the site of patch application.

(10) Apply the patch on a different place on the skin daily.

(11) The nicotine patch may not be a good choice for individuals with skin problems or allergies to adhesive tape.

(12) It should not be worn for more than 24 hours because it may irritate the skin.

(13) Leaving a patch on for 24 hours may cause sleep disturbance, such as difficulty sleeping or vivid dreams.

(14) Removing the patch in the evening around 8 p.m. may stop sleep problems.

(15) Use of nicotine patches usually lasts 8 to 10 weeks, but this can vary with the individual and the brand of patch.

(16) There appears to be little benefit in using the patch for more than 8 weeks.

C. Nonpharmacological therapy

1. “Cold turkey”

2. Support and counseling

Figure 26-1 Sample front and back of cough expectorant product.

(From Donjon RP, Goeckner BJ: Mosby?s OTC drugs: an over-the-counter drug resource for health professionals. St. Louis, 1999, Mosby.)

Figure 26-2 Examples of giving eye medication. A, Cleansing the eye from the inner to outer canthus prior to giving the eye medication. B, Insert the eyedrop into the lower conjunctival sac. C, Application. D, Applying gentle pressure against the nasolacrimal duct after application.

(From Lilley LL, Harrington S, Snyder JS: Pharmacology and the nursing process, ed. 5. St. Louis, 2007, Mosby.)

PATIENT PROFILE

Allergies: No known drug allergies (NKDA)

Current Health Conditions:

No chronic health conditions

Pharmacy Medication Profile:

No current active medications

Pharmacy Consult: BH is seriously trying to lose weight after several failed efforts with diet and exercise alone. She would like more information regarding orlistat (Alli). She recently had an appointment with a registered dietician at the hospital where she works as a nurse and joined a Weight Watchers support group. The dietician encouraged her to consider Alli treatment as an adjunct to diet and exercise.

PATIENT PROFILE QUESTIONS

1. What is BH’s body mass index (BMI)?

a. 44 kg/m²

b. 32 kg/m²

c. 28 kg/m²

Answer: b. The BMI is a calculated index that uses the patient’s weight and height. A common formula to calculate BMI is:

Obesity is defined as a BMI >30 kg/m². BH is considered obese.

2. Is Alli, which is a nonprescription diet aid, an appropriate treatment option for BH?

a. Yes

b. No

Answer: b. Nonprescription use of Alli is aimed at those who are mild or moderately overweight (BMI 25–28 kg/m²). BH should be encouraged to talk to her doctor about treatment options, including prescription use of orlistat.

3. BH confers with her doctor, who agrees that a trial of Alli, combined with current weight loss strategies, is warranted, rather than expose BH to potentially intolerable prescription strength doses of orlistat (Xenical). What are important counseling points for BH before taking Alli?

I. Gastrointestinal side effects include loose or frequent stools that may be hard to control, an urgent need to go to the bathroom, and flatulence that may cause oily spotting.

II. Side effects should diminish with time but may recur if the patient is not compliant with a reduced fat intake in the diet.

III. Take one Alli capsule three times per day with each main meal containing fat. If a meal is skipped, that dose of Alli should also be skipped.

IV. It may take several months for noticeable results.

V. A multivitamin containing the fat-soluble vitamins A, D, E, and K is recommended; however, the dose should be separated from a dose of Alli by at least 2 hours.

Answer: d. All of the above are pertinent counseling points. Patients should note that for some patients, weight loss with Alli might not be significantly greater than that obtained with diet and exercise efforts alone. Compliance with dietary recommendations is essential for weight loss and for limiting embarrassing and uncomfortable side effects. Although short-term treatment with orlistat at nonprescription doses has not reduced the absorption of fat-soluble vitamins, experts generally recommend multivitamin supplementation.

REVIEW QUESTIONS

(Answers and Rationales on page 381.)

1. Which of the following is the preferred form of iron for the treatment of iron deficiency anemia?

e. A combination of b and c

2. OTC products containing minoxidil include:

3. True or False: Clotrimazole is available for administration as an oral troche, topical cream, topical solution, and vaginal cream.

a. True

b. False

4. Clotrimazole:

a. is excreted predominantly in the feces.

b. is absorbed into systemic circulation after topical application.

c. has a time to peak serum concentration of 1–2 days after oral troche.

d. a and b

e. a, b, and c

5. True or False: Oxymetazoline nasal spray should be used for at least 2 weeks in order for the patient to experience relief.

a. True

b. False

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