Responding to Symptoms for Special Patient Groups

Objectives: Revise and build upon aspects of 'Responding to Symptoms' from Year 1 with relation to special patient groups Identify products which are not suitable for particular patient groups Identify products which can be safely recommended in pregnancy and breastfeeding Special Groups Common patient groups or conditions that need special consideration when responding to symptoms include: Pregnancy and breastfeeding Infants and children Cardiovascular disease sthma !iabetes "pilepsy Renal impairment #epatic impairment "lderly patients Prostatic hypertrophy $laucoma thletes

Pregnancy and Breastfeeding %hen responding to patients who are pregnant or breastfeeding& a number of considerations need to be ta'en( ccording to )IC" guidelines& pregnant women should use *+C medicines as little as possible( ,edicines should only be recommended in pregnancy and breastfeeding if they are essential and the benefits outweigh the ris's to the baby( +he greatest ris' to the baby is between the third and the eleventh wee' of pregnancy as during this period congenital malformations can occur( !uring the second and third trimesters there still e-ists ris's to growth& functional development and to-icity( .or the ma/ority of *+C medicines& the ris's of use outweigh the benefits( In breastfeeding& we need to consider whether the medicine will pass into the mil' or not& and if so& if the medicine will it harm the baby( ,etronida0ole will be present in breast mil' and can affect the taste of it( +his should be ta'en into account as putting off the baby from feeding could be detrimental( lso we need to as' if the medicine will affect the supply of the mil' and any potential conse1uences this can cause( Some drugs can increase or decrease the volume of mil' the mother is producing( Pseudoephedrine& present in many *+C products used to treat colds& can dramatically decrease the supply of mil' to the child( %here medicines are not contraindicated& often the best time for the mother to ta'e the medicine is after a feed( +he lowest effective dose should be used over the shortest duration possible( ll these measures are to minimise how much of the drug will reach the baby(

ntiemetics:

,orning sic'ness is common in early pregnancy but unfortunately nothing is available over2the2counter to treat it( $P's may prescribe antihistamine2based antiemetics such as cycli0ine but only if it is essential( Cycli0ine is available as a P2medicine but is not licensed for morning sic'ness& so can't be sold for this purpose( $inger and peppermint tea are supposedly effective in treating sic'ness& as is peppermint tea3 both are suitable to be used in pregnancy and breastfeeding( +ravel bands can also be helpful( ,aintaining fluids should be a priority(

nalgesics:

In pregnancy& paracetamol is fine to recommend if it is essential( )S I!'s should be avoided& especially in the third trimester( In breastfeeding3 paracetamol& ibuprofen and diclofenac are fine to use as long as it is essential( spirin must not be ta'en in either instance& due to the inherent ris' of Reye's Syndrome(

nthelmintics:

+hreadworm is a common condition in children and can easily spread around a household( *+C products such as pipera0ine and mebenda0ole are not recommended in pregnancy or breastfeeding( +he only effective way of combatting threadworm is by following strict and stringent hygiene rules for four to si- wee's3 the length of the threadworm life cycle(

ntacids:

#eartburn is common in pregnancy& especially in the later stages when there is more pressure on the stomach( lginates& such as $aviscon& and other antacids are *4 in pregnancy and breastfeeding although aluminium2based products may aggravate constipation( lginates are high in sodium so should be used with caution by patients with high blood pressure( #5 antagonists and PPIs cannot be given over the counter to patients who are pregnant or breastfeeding (

6a-atives:

Constipation is also common in pregnancy& again due to the high amount of pressure around the intestines( +he first line of treatment should be dietary changes& such as an increased consumption of foods high in fibre( If dietary changes prove to be ineffective& bul'2forming la-atives and osmotic agents can be used( n e-ample of a bul'2forming la-ative is .ibrogel& and an e-ample of an osmotic agent is lactulose( Senna& docusate and bisacodyl are not recommended over2the2counter in pregnant patients as they wor' by causing smooth muscle contractions 7 uterine muscle is an e-ample of smooth muscle( +hey are also 'nown to cause diarrhoea and colic in breastfed infants(

#aemorrhoids:

#aemorrhoids are another condition common in pregnancy( +he licensing of *+C products should be chec'ed carefully before they are recommended( #ydrocortisone2containing products should not be recommended( +he patient should be referred if the haemorrhoids are very painful or the symptoms are severe(

!iarrhoea:

6operamide is not recommended in either pregnancy or breastfeeding( *ral2rehydration products should be recommended providing the product in 1uestion is licensed(

Coughs and Colds:

Cough suppressants3 e-pectorants and decongestants are not licensed to be used by pregnant or breastfeeding patients( Steam inhalation can be recommended for congestion( Sterimar is a branded saline nasal spray that can be used to treat congestion and nasal dryness( $lycerol2based syrups are fine but may not be very effective( Patients should be advised to drin' lots of fluids(

"c0ema:

+opical hydrocortisone 18 is not licensed for use in pregnancy( .or patients who are breastfeeding& the licensing for each individual product should be chec'ed(

ntifungals:

Pregnancy can increase the ris' of contracting thrush( *ral thrush can be common in infants and easily contracted by mothers( *ver2the2counter antifungals are not recommended in pregnancy( Clotrima0ole can be prescribed if it is deemed essential( ,icona0ole gel for oral thrush is not licensed for breastfeeding mothers(

Cystitis:

Patients with symptoms suggesting cystitis should be referred to their $P and advised to drin' plenty of fluids( +he first line of treatment is allergen avoidance( 9:arrier; treatments such as Prevalin& <aseline and #ayma- coat the nasal mucosa and prevent allergens reaching receptors( Sedating and non2sedating antihistamines should be avoided in pregnancy and breastfeeding( If they are essential they should be prescribed( +opical cromoglicate could be considered but the licensing should be chec'ed for each individual product before it is recommended(

#ayfever:

ntimalarials:

If travelling to malarial areas can't be avoided& a $P can prescribe chloro1uine and proguanil where P. Faciparum strains are sensitive( .olic acid =mg should be prescribed with proguanil& to prevent defects in the neural tube >the embryo's spinal cord?( +he licensing of any repellents should be chec'ed carefully before being sold(

#ead 6ice:

#edrin& which contains the active ingredient dimeticone& is licensed in pregnancy and breastfeeding so is the first line treatment( +he licensing for individual products should be chec'ed carefully before being sold(

Infants and Children %hen considering over2the2counter products for infants and children& a few important things points need to be remembered( %ith a lot of products& the licensing dictates that the medicine is not to be ta'en by children under a certain age( #owever& a lot of the same products can be dispensed to children under the set age if it is prescribed by a doctor( If this is the case& the patients mother can be signposted to their child's doctor or a nearby out2of2 hours clinic to ma'e sure the child gets the most appropriate medication(

lso& a lot of medicines& such as paracetamol and ibuprofen that are suitable for children in certain circumstances& have varying doses in different ages( +his can be an issue when there are children of different ages living in the same household( +he parent's attention should be drawn to this and the dosing regime should be highlighted before the product is sold( It is also a good idea to suggest a policy where only one parent agrees to give the child the medicine( +his arrangement can help the parents prevent the child being overdosed due to slight miscommunications( nother thing to bear in mind is that the time until referral with children is often a lot shorter than with adults( s an e-ample& an adult who is suffering from diarrhoea should be referred to their $P if the problem has been present for longer than two days3 with children the referral time is reduced to 5@ hours(

nalgesicsA ntipyretics:

Paracetamol can be administered if the child is over three months of age( If it is to treat vaccination2associated pyre-ia& paracetamol can be given if the child is over two months of age( +he child's weight should be chec'ed to confirm the appropriate dose( Ibuprofen can only be administered if the child is over three months of age( spirin should not be given to anyone under the age of si-teen due to the associated ris's of the child developing Reye's syndrome( +he ,#R has said that codeine2containing products are not to be used in children under the age of twelve( Some brands of products containing codeine are licensed for children over the age of twelve( +he licensing should always be chec'ed beforehand(

Chic'en Po-:

If a child is presented with chic'en po-2li'e symptoms& other illnesses should be ruled out before recommending anything( Paracetamol can be given to treat fever and headaches associated with chic'en po- if the child is over the age of B months( Calamine lotion is no longer recommended( +his is due to the lotion leaving a powdery residue on the s'in that can aggravate the itchiness( 1ueous calamine can still be recommended though( lso& newer products& such as <irasoothe $el and Po-Clin ,ousse& are available to help cool the s'in though these can be 1uite e-pensive(

Chlorpheniramine is licensed to be used in children over the age of one year to reduce the itchiness in chic'en po-( nother treatment that can be recommended is adding sodium bicarbonate to the child's bath water( Colic: Infacol and !entino-& which both contain dimethicone3 and Colief& which contains lactase& are all licensed to be used from birth( $ripe water can be used from the age of one month( Constipation: +he age ranges for different products should always be chec'ed( !ietary changes& such as increasing fibre& should be the first line treatment( !iarrhoea: *ral Rehydration sachets can be sold over2the2counter for patients above the age of two years( 6operamide can be sold over2the2counter for patients above the age of twelve years( If the child is under the age of two years& boiled and cooled water can be used for rehydration( If the diarrhoea lasts longer than 5@ hours the child should be referred to his or her $P( ntispasmodics such as alverine and mebeverine are not recommended in children( )appy Rash: <arious products are available to treat nappy rash( +he licensing of these products should be chec'ed( It is also useful to as' the parent what treatment options have been tried already( :acterial and fungal infections should be ruled out aswell( $P's can occasionally prescribe steroid creams but these can't be sold over2the2counter( "c0ema: "mollients are the first line treatment for ec0ema over2the2counter and should be used as a preventative measure as well( +he amount of emollient to be used is specified in the :).(

Steroid creams have age limitations( #ydrocortisone can be used from the age of ten years3 clobetasone and aclometasone can be used from the age of twelve years( nthelmintics: .or the treatment of threadworm& mebenda0ole can be sold over2the2 counter for patients over the age of two( Pripsen& which contains pipera0ine and senna& is licensed for the use in patients over the age of three months( Stringent hygiene measures are to be recommended( >see Pregnancy and breastfeeding? #eadlice: +he age restrictions for individual products should be chec'ed( lcohol based lotions are not suitable to s'in that suffers with or is prone to ec0ema( ntifungals: .or oral thrush& oral micona0ole gel can be used from the age of four months( +his is because it presents a cho'ing ha0ard to children younger than this( +opical antifungals are not licensed for vaginal candidiasis in patients under the age of si-teen( Cystitis: Cystitis can occur in children but unfortunately no products are licensed for patients under the age of si-teen( Children with cystitis should be referred to their $P( +he patient should be advised to drin' plenty of fluids( Regular occurrence of cystitis could possibly suggest a child protection issue( Coughs and Colds: +he age ranges for products should always be carefully chec'ed( ,enthol rubs specifically designed for children& such as 4arvol& tend to be licensed from the age of three months( )ormal saline nasal drops can be used from birth( It is recommended that the child is 'ept well hydrated and humidifiers can be used if the room is too dry( Cough sweets should be used with caution due to the cho'ing ha0ard(

+eething:

+eething gels are typically licensed from three months onward( :on/ela teething gel should not be confused with :on/ela dult due to the adult formulation containing salicylates(

"ye Infections:

:rolene eye drops have no lower age restriction but should be used with care in children under the age of one year( Chloramphenicol can be sold for use in patients over the age of two years but can be prescribed for the use in patients younger than two( :oiled and cooled water with a small amount of salt added can be used as a natural antiseptic( +his is suitable for patients of all ages(

lderly Patients s people get older& the changes in physiology that occur can change how drugs are handled inside the body( +his means certain drugs may have more pronounced effects& so in these cases e-tra care should be ta'en when recommending products to elderly patients( +he increased age of the patient can also mean there is an increased ris' of certain disease states( Symptoms being presented in the pharmacy could be indicative of a more serious condition( Pharmacists should be wary of such symptoms in elderly patients( "lderly patients are also more li'ely to have medical conditions or be on medicines& meaning some over2the2counter products could be contraindicated in the given cirumstances( n good awareness of medical conditions and e-tra vigilance should be deployed when selling P2medicines to the elderly( nalgesics: Paracetamol is often suitable to sell to elderly patients but it is worth chec'ing if the patient is already ta'ing any other paracetamol containing product( %hen ta'ing )S I!s& elderly patients are at a greater ris' of the gastric side2effects and ulcerations that these drugs are associated with( If the patient is presenting for pain relief due to a fall& it is worth chec'ing for any medication the patient is currently on that could have contributed to the accident( +his 'ind of information is available at the front of the :).(

ntihistamines:

"lderly patients are at greater ris' to the sedative effects of sedating antihistamines( +his should be ta'en into account when recommending these products( :enadryl and :enadryl Plus should not be sold to patients over the age of C= as they contain acrivastine(

ntifungals:

+opical antifungals are not licensed for vaginal candidiasis in patients over the age of si-ty( +he patient should be referred to her $P( +his is due to the symptoms being similar to vaginal prolapse(

Cystitis:

Sodium and potassium citrate sachets can be recommended as they have no upper age limit but elderly patients are much more prone to complications( +hey should be used with caution in patients who are ta'ing C" inhibitors due to the ris' of developing hyper'alemia( Cystitis may also be a sign of diabetes(

Cardiovascular Conditions ,any cardiovascular conditions and the medications used to treat them can be aggravated by over2the2counter medicines( Symptoms being presented in the pharmacy could also be signs of a C<S condition getting worse or they could be the side2effects of the medicine being used to treat the C<S( Coughs: *ver2the2counter cough medicines do not interact with C<S medicines or C<S conditions( persistent chesty cough with a watery& frothy sputum may indicate the worsening of heart failure( If the patient has a persistent dry cough& it should be investigated whether or not the patient is ta'ing an C" inhibitor( Sympathomimetic !econgestants: Sympathomimetic decongestants have a vasoconstrictive effect so can increase blood pressure( Phenylephrine& pseudoephedrine and ephedrine should not be recommended for anyone with high blood pressure( +he chemical structures of these drugs are very similar to adrenaline so can affect heart rate(

+hese drugs are unsuitable for people with arrhythmias( +he licensing for topical and nasal sprays should be chec'ed and used with caution as there can still be some systemic absorption( nalgesics: Paracetamol and codeine are both fine to recommend to patients with C<S conditions provided there are no other contraindications( )S I!s cause sodium and water retention so they should be avoided in patients with congestive heart failure( )S I!S can also affect clotting so they should be avoided in patients ta'ing warfarin& anticoagulants and antiplatelets& especially if the patient is over the age of si-ty2five years( Sumatriptan: Sumatriptan is contraindicated in patients with more than three C<S ris' factors& or have been diagnosed with hypertension& previous heart attac's& ischaemic heart disease or angina( If migraines are bad& the patient should be referred to their $P( ,igraleve& paracetamol and co2codamol can also be recommended( ,ino-idil: ,ino-idil& 'nown by the brand name Regaine& is used to encourage hair growth( It was originally developed as an antihypertensive( +hough it is applied topically& there is still the potential for it to reach the systemic circulation resulting in lower blood pressure( .or this reason it should not be used by patients suffering from hypertension& and patients suffering from other C<S conditions should first be referred to their $P( Indigestion: +he sodium content of all indigestion products should be chec'ed before they are recommended( 6ow2sodium products can be identified and are preferable in congestive heart failure( Cystitis: Sodium citrate& which is present in numerous products aimed at helping patients with cystitis& is high in sodium so is contraindicated in patients with high blood pressure or heart disease(

Potassium citrate& which is also present in these products& should not be ta'en by patients who are also ta'ing C" inhibitors& aldosterone antagonists and potassium sparing diuretics( +his is due to an increased ris' of hyper'alemia( "ffervescent products: "ffervescent products are very high in sodium& so should be avoided li'e the fuc'ing plague by patients with high blood pressure and heart failure( lot of vitamins and herbal supplements can interact with warfarin and other anticoagulants so care should be ta'en if patients want to start& stop or alter the dose of any of these( "-amples include cod liver oil tablets& garlic e-tract& vitamin 42 containing products and cranberry e-tracts( In some of these cases& there may also be the opportunity to advise the patient of lifestyle changes such as weight2loss& smo'ing cessation and dietary changes( !sthmatic Patients ,any medicines& including over2the2counter medicines& can aggravate asthma or interact with the medicines used to treat it( +he symptoms presenting in a pharmacy may be indicative of the asthma e-acerbating or possibly the side2effects of the medicines used to treat the condition( nalgesics: Paracetamol should always be the first line of treatment( Some asthmatic patients are sensitive to )S I!s and aspirin& as they have the potential to trigger an asthma attac'( If the patient has used them before and had no problems they can be used with caution( If not& it is best to recommend something else( Systemic absorption is still possible with topical )S I!s so the same cautions should be applied( Coughs: Codeine and pholcodine containing products should be used with caution due to the ris' of respiratory depression( !emulcents such as glycerin are fine to recommend( Children with persistent night time coughs should be referred to their $P(

<itamins and Supplements:

Colds:

Sympathomimetic decongestants >both local and systemic? can increase the side2effects of salbutamol inhalers( If side2effects manifest& the patient should cease using the decongestant( Steam inhalation with essential oils can trigger an attac' so should not be recommended(

#eadlice:

lcohol2based lotions should be avoided as they can irritate the lungs( %ater2based products should be recommended instead(

"c0ema and #ayfever:

Patients with asthma are more prone to ec0ema and hayfever( +his is 'nown as atopy 7 a predisposition to allergic responses( +here are mi-ed reports about the suitability of sedative antihistamines used to treat hayfever(

+heophylline:

+heophylline is a prescription2only medicine that is used in the treatment of asthma( +his drug has a particularly narrow therapeutic inde-& so is very dangerous at to-ic levels( +heophylline is also present in some over2the2counter medicines such as Chest2"0e( sthmatics should always chec' with their $P before ta'ing these medicines( Patients ta'ing theophylline that wish to stop smo'ing should always consult their $P before hand as smo'ing alters the body's levels of theophylline(

"iabetic Patients %hen responding to symptoms in diabetic patients& a few factors must be ta'en into consideration( Some medicines can alter blood glucose levels& so the upmost care must be ta'en in these cases( !iabetics also have poor circulation( +his should also be ta'en into account when recommending certain products( Symptoms being presented in the pharmacy could be indicative of uncontrolled diabetes or a side2effect of medicines being ta'en to control the condition( !iabetics also tend to suffer from other conditions aswell such as hypertension and renal problems( Sympathomimetics: Sympathomimetics should be used with caution in diabetic patients for a number of reasons( +hey can increase blood glucose levels(

+hey can act as vasoconstrictors( +his is of importance because diabetic patients are prone to having poor circulation( lso& diabetics are prone to having high blood pressure( safer alternative for treating congestion is the inhalation of steam and inhalant oils( Sumatriptan: !iabetes increases the ris' of cardiovascular disease( *ver2the2counter sumatriptan is contraindicated in patients with more than three cardiovascular ris' factors 7 diabetes being one of them( Patients with more than three ris' factors should be referred to their $P( Indigestion: Indigestion and nausea can be a side2effect of antidiabetic drugs& especially metformin when the treatment is first initiated( Patients should be reminded that this can happen& Side2effects are reduced when the sustained release form of metformin is used( Recurrent infections such as cystitis and thrush may be a warning sign of undiagnosed diabetes and may also be a sign of poor control in previously diagnosed diabetes( !iabetic patients also suffer from delayed wound healing( +he poor circulation associated with diabetes delays healing& especially at the e-tremities( )europathy can also mean the patient does not notice the worsening of conditions due to the reduced feeling of pain( .or these reasons& any slow healing wounds and foot problems should be referred to the patient's $P( lso& heat pads should not be recommended for pain relief( pileptic Patients Certain medicines are not recommended for patients with epilepsy( Sumatriptan: Sumatriptan is contraindicated in patients with epilepsy or a history of sei0ures( Pipera0ine >Pripsen? is used to treat threadworm and has the potential to induce fits( .or this reason it is contraindicated in epilepsy(

Pipera0ine:

nti2histamines:

ntihistamines can be used in epileptic patients with caution( #igh doses of antihistamines have been 'nown to induce fits so they should be avoided if possible( +he licensing of individual brands and medicines should be chec'ed before they are recommended(

"mergency Contraception:

Some anti2epileptics can affect the absorption of levonorgestrel( +he patient should be chec'ed to see if they are currently ta'ing any en0yme inducers such as phenytoin& carbema0epine and any barbiturates( If the patient is ta'ing any of the above medication& a double dose of levonorgestrel will be re1uired( +his is not licensed to be sold over2 the2counter so the patient should be referred to their $P or a family planning clinic(

Renal Impairment Certain medicines are not recommended to be used by patients suffering from renal impairment( +hese include: Sumatriptan >contraindicated? Pipera0ine >contraindicated? Indigestion products that are high in sodium >alternatives can be found in the :).? "ffervescent products >due to the high sodium levels? Cystitis treatments containing sodium or potassium )S I!S >due to the increased water and sodium retention associated with them? Sympathomimetics >in severe impairment? #epatic Impairment Certain medicines are not recommended to be used by patients suffering from hepatic impairment( +hese include: Sumatriptan >contraindicated? Pipera0ine >contraindicated? )S I!S )S I!S can precipitate renal failure in patients with liver failure( Paracetamol should be used as the first2line treatment(

Glaucoma Certain medicines are not recommended to be used by patients suffering from glaucoma( +his is mostly due to the potential of these medicines to increase to increase ocular pressure( ,edicines not to be used by patients with glaucoma include: ntihistamines and hyoscine >due to the anticholinergic effect these drugs have? Sympathomimetic decongestants Prostatic #ypertrophy Prostatic hypertrophy is the enlargement of the prostate( Patients suffering from this condition should not use: ntihistamines and hyoscine >the anticholinergic effect of these drugs can precipitate urinary retention? Sympathomimetic decongestants Sports !thletes Sports people who may have to undergo drug testing need to be cautious as to which medicines they ta'e( +hese patients should be referred to the D4 nti !oping >D4 !? website as recommended by the :).( thletes should chec' the status of licensed drugs with the $lobal !rug Reference *nline( n e-ample of an over2the2counter medicine that can cause issues with drug testing is pseudoephedrine( Pseudoephedrine is only allowed under certain levels in the patients urine(