Canada's Trusted Reference for Minor Ailments

44 Pages·2016·2.09 MB·English

CTMA 2
Canada’s Trusted Reference for
Minor Ailments

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Created by Canadian experts for
Canadian healthcare practitioners
treating Canadian patients
CANADIAN CURRENT COMPREHENSIVE CONVENIENT
www.pharmacists.ca
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Table of Contents
EditorialAdvisoryCommittee................................................................................................vii
Authors...........................................................................................................................viii
Reviewers........................................................................................................................ix
Editor'sMessage ................................................................................................................x
EditorialPolicy,DescriptionandLimitationsofInformation...........................................................xi
HowtoUseCompendiumofTherapeuticsforMinorAilments......................................................xii
PatientAssessments.........................................................................................................xiii
CommunicatingWithPatients
1 EffectivePharmacist-patientInteractions,BarbaraJ.Farrell...................................................1
2 FacilitatingBehaviourChange,LisaDolovich....................................................................12
3 PharmacistAssessmentoftheSelf-treatingPatient,NardineNakhla......................................21
PsychiatricConditions
4 Depression,RicM.ProcyshynandAlasdairM.Barr............................................................27
5 Insomnia,RicM.ProcyshynandAlasdairM.Barr...............................................................38
6 SmokingCessation,KristinePetraskoandManjitBains.......................................................52
CentralNervousSystemConditions
7 Fever,YvonneM.Shevchuk..........................................................................................82
8 Headache,IreneWorthington........................................................................................99
9 Heat-relatedDisorders,DorothyTscheng........................................................................117
10 Tinnitus,YvonneM.Shevchuk.....................................................................................128
11 VertigoandDizziness,YvonneM.Shevchuk...................................................................132
EyeCare
12 AssessmentofPatientswithEyeConditions,AnneM.Friesen............................................139
13 Conjunctivitis,AnneM.Friesen....................................................................................140
14 ContactLensCare,DavidS.WingandKenGellatly.........................................................148
15 DryEye,AnneM.Friesen...........................................................................................162
16 EyelidConditions:Hordeolum,ChalazionandBlepharitis,AnneM.Friesen...........................169
EarConditions
17 AssessmentofPatientswithHearingLoss,EarPainandEarDrainage,YvonneM.
Shevchuk................................................................................................................187
18 ComplicationsAffectingtheEar:EarPiercing,ForeignBodiesandBarotrauma,YvonneM.
Shevchuk................................................................................................................193
19 ImpactedEarwax,YvonneM.Shevchuk.........................................................................198
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20 OtitisMediaandOtitisExterna,YvonneM.Shevchuk.......................................................206
RespiratoryConditions
21 AcuteCough,DanielJ.G.Thirion..................................................................................217
22 AllergicRhinitis,JenniferKendrick................................................................................226
23 AssessmentofPatientswithUpperRespiratoryTractSymptoms,DanielJ.G.Thirion..............249
24 ViralRhinitis,Influenza,RhinosinusitisandPharyngitis,DanielJ.G.Thirion...........................254
MetabolicandCardiovascularConditions
25 DiabetesCare,LoriMacCallum....................................................................................273
26 DiabetesCareDevices,RonaldSilver...........................................................................293
27 LifestyleManagementandDiseasePrevention,L.MariaGutschi........................................302
GastrointestinalConditions
28 AssessmentofPatientswithAbdominalPain,PeterThomson............................................323
29 Constipation,JaneBowles-Jordan................................................................................327
30 Diarrhea,AntoniettaForrester......................................................................................353
31 DyspepsiaandGERD,CoQ.D.Pham..........................................................................378
32 GastrointestinalGas,CoQ.D.Pham.............................................................................390
33 Hemorrhoids,JoyceChan...........................................................................................398
34 InfantColic,ShelitaDattani.........................................................................................407
35 IrritableBowelSyndrome,LynetteKosar........................................................................420
36 NauseaandVomiting,ChristineHughes........................................................................429
37 OstomyCare,MarieBerry...........................................................................................448
38 PerianalSymptomAssessment,JoyceChan..................................................................463
39 Pinworms,JoyceChan...............................................................................................465
Nutrition
40 InfantNutrition,JoanBrennan-Donnan..........................................................................472
41 SpecialDiets,ShirleyHeschuk.....................................................................................491
42 SportsNutrition,ShirleyHeschuk..................................................................................506
43 WeightManagement,ShirleyHeschuk...........................................................................519
MusculoskeletalConditions
44 DrugUseandAbuseinSports,LilyLum.........................................................................547
45 LowBackPain,KellyGrindrod,JasonKiellyandCarloMarra.............................................554
46 Osteoarthritis,KellyGrindrod,JasonKiellyandCarloMarra...............................................569
47 Osteoporosis,LalithaRaman-WilmsandAnneMarieWhelan.............................................590
48 SportsInjuries,LilyLum..............................................................................................608
FootConditions
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20 OtitisMediaandOtitisExterna,YvonneM.Shevchuk.......................................................206
RespiratoryConditions
21 AcuteCough,DanielJ.G.Thirion..................................................................................217
22 AllergicRhinitis,JenniferKendrick................................................................................226
23 AssessmentofPatientswithUpperRespiratoryTractSymptoms,DanielJ.G.Thirion..............249
24 ViralRhinitis,Influenza,RhinosinusitisandPharyngitis,DanielJ.G.Thirion...........................254
MetabolicandCardiovascularConditions
25 DiabetesCare,LoriMacCallum....................................................................................273
26 DiabetesCareDevices,RonaldSilver...........................................................................293
27 LifestyleManagementandDiseasePrevention,L.MariaGutschi........................................302
GastrointestinalConditions
28 AssessmentofPatientswithAbdominalPain,PeterThomson............................................323
29 Constipation,JaneBowles-Jordan................................................................................327
30 Diarrhea,AntoniettaForrester......................................................................................353
31 DyspepsiaandGERD,CoQ.D.Pham..........................................................................378
32 GastrointestinalGas,CoQ.D.Pham.............................................................................390
33 Hemorrhoids,JoyceChan...........................................................................................398
34 InfantColic,ShelitaDattani.........................................................................................407
35 IrritableBowelSyndrome,LynetteKosar........................................................................420
36 NauseaandVomiting,ChristineHughes........................................................................429
37 OstomyCare,MarieBerry...........................................................................................448
38 PerianalSymptomAssessment,JoyceChan..................................................................463
39 Pinworms,JoyceChan...............................................................................................465
Nutrition
40 InfantNutrition,JoanBrennan-Donnan..........................................................................472
41 SpecialDiets,ShirleyHeschuk.....................................................................................491
42 SportsNutrition,ShirleyHeschuk..................................................................................506
43 WeightManagement,ShirleyHeschuk...........................................................................519
MusculoskeletalConditions
44 DrugUseandAbuseinSports,LilyLum.........................................................................547
45 LowBackPain,KellyGrindrod,JasonKiellyandCarloMarra.............................................554
46 Osteoarthritis,KellyGrindrod,JasonKiellyandCarloMarra...............................................569
47 Osteoporosis,LalithaRaman-WilmsandAnneMarieWhelan.............................................590
48 SportsInjuries,LilyLum..............................................................................................608
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FootConditions
49 AssessmentofFootSymptoms,AnneMallin...................................................................621
50 Athlete'sFoot,AnneMallin..........................................................................................623
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51 Corns,Calluses,BunionsandIngrownToenails,AnneMallin..............................................631
52 PlantarWarts,AnneMallin..........................................................................................641
DermatologicConditions
53 ASummaryofCommonSkinConditions,PennyF.Miller...................................................648
54 Acne,DebraSibbald..................................................................................................653
55 Atopic,Contact,andStasisDermatitis,DebraSibbald.......................................................682
56 BacterialSkinInfections:Impetigo,FurunclesandCarbuncles,PennyF.Miller.......................716
57 Burns,NancyKleiman................................................................................................730
58 DandruffandSeborrheicDermatitis,DebraSibbald..........................................................740
59 DiaperDermatitis,DebraSibbald..................................................................................760
60 Dressings,MarieBerry...............................................................................................779
61 Drug-inducedSkinReactions,SandraKnowles...............................................................786
62 DrySkin,NancyKleiman............................................................................................802
63 Frostbite,NancyKleiman............................................................................................809
64 FungalNailInfections(Onychomycosis),PennyF.Miller....................................................818
65 FungalSkinInfections,PennyF.Miller...........................................................................827
66 HairCareandHairGrowth,NancyKleiman....................................................................842
67 InsectBitesandStings,NancyKleiman.........................................................................861
68 MinorCutsandWounds,NancyKleiman........................................................................877
69 ParasiticSkinInfections:LiceandScabies,PennyF.Miller................................................886
70 PerspirationandBodyOdour,NancyKleiman.................................................................904
71 Psoriasis,DebraSibbald.............................................................................................915
72 PreventionandTreatmentofSun-InducedSkinDamage,NancyKleiman..............................939
73 ViralSkinInfections:CommonandFlatWarts,PennyF.Miller............................................956
74 ViralSkinRashes,SandraKnowles...............................................................................968
Reproductive,GynecologicandGenitourinaryHealth
75 BenignProstaticHyperplasiaandAssociatedLowerUrinaryTractSymptoms,CherylA.
Sadowski................................................................................................................985
76 Contraception,AnneMarieWhelan...............................................................................999
77 Dysmenorrhea,ThomasE.R.Brown............................................................................1031
78 MaleSexualDysfunction,TomSmiley..........................................................................1041
79 MenopauseandPerimenopause,ThomasE.R.Brown.....................................................1054
80 PregnancyandFertilityTesting,MarieBerry...................................................................1067
81 PremenstrualSyndrome,ThomasE.R.Brown................................................................1074
82 PrenatalandPostpartumCare,CarlaDillon...................................................................1090
83 UrinaryIncontinence,CherylA.Sadowski.....................................................................1132
84 VaginalSymptoms,HygieneandInfections,Laura-LynnPollock.........................................1145
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DentalHealth
85 DentalConditions,MichelleBourassa...........................................................................1167
86 OralHygiene,DentalPlaqueandCaries,MichelleBourassa.............................................1176
87 PeriodontalConditions:GingivitisandPeriodontitis,MichelleBourassa...............................1188
88 Teething,MichelleBourassa.......................................................................................1201
MouthConditions
89 AphthousUlcers(CankerSores),AdelineT.ChauMarkarian.............................................1209
90 ColdSores(HerpesLabialis),JamesS.Conklin.............................................................1220
91 DryMouth,VictoriaKletas..........................................................................................1232
92 Halitosis,ShirinAbadi...............................................................................................1242
93 OralCandidiasis,KarenWlock....................................................................................1249
GeneralAppendices
I ComplementaryandAlternativeTherapies,CynthiaRichardandPaulA.Spagnuolo..............1258
II HomeTesting,MarieBerry.........................................................................................1278
III InformationfortheTraveller,MarkKearney....................................................................1289
IV MedicalDevicesandAidstoDailyLiving,MarieBerry......................................................1304
V PregnancyandBreastfeeding:Self-careTherapyforCommonConditions,MylaE.
Moretti...................................................................................................................1320
VI NutritionalSupplements,L.MariaGutschi.....................................................................1329
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206 EarConditions
EarConditions
Chapter 20
COhatpitetri2s0 Media and Otitis Externa
YvonneM.Shevchuk, BSP,PharmD, FCSHP
Otitis Media
Pathophysiology
Acuteotitismedia(AOM)isaninfectionofthemiddleearcavityandisoneofthemostcommon
bacterialinfectionsinchildhood.1Seventy-fivepercentofchildrenexperienceatleast1episodeprior
toenteringschool.2TodiagnoseAOM,3criterianeedtobemet:1)signsandsymptomsofmiddleear
inflammation2)thepresenceofmiddleeareffusionand3)acuteonset(oftenabrupt)ofsignsand
symptomsofmiddleearinflammationandeffusion.1Symptomsincludeacuteearpain(often
unilateralanddevelopingoverafewhours),feverandreducedhearing.1Tuggingorpullingontheears
isoftendescribed,butthisisaverynonspecificsign.1Childrentooyoungtocomplainofpainor
pressureintheearsmaydisplayirritability,excessivefussiness,poorfeedinganddisruptedsleep
patterns.Acuteotitismediaismorecommoninthewintermonths.Arecenthistoryofviralupper
respiratorytractinfectionisoftenpresent.2ThemicroorganismsmostcommonlyassociatedwithAOM
areStreptococcuspneumoniae,HaemophilusinfluenzaeandMoraxellacatarrhalis.1,2
AOMhasahighspontaneousrecoveryrate;80%ofchildrenexperiencespontaneoussymptomatic
reliefwithplaceboornodrugtherapy.3,4Forthisreason,theconceptof“watchfulwaiting”is
advocatedafterappropriatehealthcarepractitionerassessmentanddiagnosisofAOM.Ratherthan
immediateinitiationofantibiotictherapy,appropriatelyselectedchildrenaremanagedwithanalgesic
therapyforthefirst24–48hours.Thisincludeschildren>6monthsofagewithnocraniofacial
abnormalitieswhohaveuncomplicatedAOM(normalhost,nootorrhea,nohistoryofchronicor
recurrentAOM)withoutseverepainorsystemicillness,andwhosecaregiversareabletorecognize
severeillness,takethechildforimmediateassessment,andprovideaccesstofollow-upcare.1,2
Goals of Therapy
■ Relievesymptomsoffever,painandirritability
■ Eliminatebacteriafromthemiddleear
■ Ensureappropriatetherapytoreducetheriskofresistantpathogensanddrug-relatedadverseeffects
suchasantibiotic-associateddiarrhea
■ Preventcomplications,e.g.,mastoiditis,intracranialinfection,facialparalysis
Nonpharmacologic Therapy
Comfortmeasures,suchaswarmedoils,warmorcoldcompressesandheatingpadshavebeenusedby
parentsandcaregiversforyears,althoughtherearenostudiesevaluatingtheireffectiveness.Iftried,
heattherapyshouldbeusedcautiouslyandwithclosesupervisioninchildren,toavoidburns.Ayoung
childshouldneversleepwithahotwaterbottleorheatingpad.Questionthecaregiveraboutwhether
therehasbeenanydrainagefromtheearpriortorecommendinganytopicaltherapy.Warmedoil
shouldnotbeusedifthereisachanceofperforationoranysuspicionofdrainage.Warmingofdrops
oroilshouldbedonebyrollingthebottlebetweenthepalms;othermethodssuchasplacingthebottle
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Ear Conditions
Chapter20:OtitisMediaandOtitisExterna 207
inaglassofwarmwaterorusingthemicrowaveovenshouldbeavoidedasseriousburnshavebeen
reported.
Pharmacologic Therapy
Formoreinformationonmanagementofacuteotitismedia,consulttheCompendiumofTherapeutic
Choices:AcuteOtitisMediainChildhood.
■ Ifantibioticsareused,systemictherapyisrequired;topicalagentsarenotusedinAOM.
■ Adequateanalgesiawithusualdosesofacetaminophenoribuprofenisimportant(seeChapter7:
Fever,Table5).
■ Topicalanalgesicsmayprovideshort-termanalgesiainchildrenwithAOM,butshouldnotreplace
oralanalgesics.5,6Topicalanalgesicsmaycauselocalhypersensitivityreactions.
■ Decongestantsandantihistamines,whichwererecommendedinthepast,donotspeedthe
resolutionofeffusionandcanhavesignificantadverseeffectsinchildrenandthereforeshouldnot
beused.7,8
Foramorecompletediscussionofacuteotitismedia,seeSuggestedReadings.
Otitis Externa
Pathophysiology
Otitisexternaisdefinedasinflammationoftheexternalauditorycanal(EAC)andmayalsoinvolve
thepinnaortympanicmembrane(TM).Otitisexternaisoftenduetoinfection.9,10,11,12TheEACis
warm,darkandpronetobecomingmoist.Thisprovidesanexcellentenvironmentforbacteriaorfungi
toproliferate,particularlyiftheEACistraumatized.Otitisexternacanbecategorizedasacutediffuse,
acutelocalized,chronic,eczematousornecrotizing.12Themainfocusofthischapterisacutediffuse
otitisexterna.
AcuteDiffuseOtitisExterna
Predisposingfactorsforacutediffuseotitisexternainclude:9,10,11,13
■ Toolittlecerumen—cerumenprovidesantibacterialactionbyphysicallyprotectingthecanaland
maintainingalowpH
■ Toomuchcerumen,whichcanleadtoocclusionandmaceration
■ Moisture(swimming,bathing,watersports,perspiration,increasedhumidity)—macerates
underlyingskinandraisespH
■ TraumatoEAC(fingernails,cotton-tippedswabs,otherforeignobjects,overzealouswaxremoval)
—abrasionandlacerationallowinginoculationoforganisms
■ Chronicdermatologicdisorders
■ Hearingaids
■ Narrow,hairyearcanal.
Themostcommonetiologyofacuteotitisexternaisbacterialinfection.Fungalovergrowthoccurs
rarely,andprimarilyinpatientswhohavereceivedpriorantibiotictherapy.The2mostcommon
microorganismscausingacuteotitisexternaarePseudomonasaeruginosa(20–60%)and
Staphylococcusaureus(10–70%).10,11
Bacterialotitisexternaproducesearpainordiscomfort(otalgia),otorrhea,pruritusandtenderness,
especiallyonmanipulationoftheear.10,11Thesesymptomsmaybemoreintensethanthoseseenwith
fungalotitisexterna.Cellulitisofthepinnaandregionallymphadenopathymaybepresent.10Fungal
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Chapter 20: Otitis Media and Otitis Externa
208 EarConditions
otitisexternamaybeasymptomaticormayproducepruritusandfullnessintheear.Itclassically
occursafterprolongedtreatmentofbacterialotitisexternawithantibioticswhichalterthebacterial
floraoftheEAC.TheEACmaycontainblack,grey,bluishgreen,yelloworwhitefungalelementsand
debris.
AcuteLocalizedOtitisExterna(Furunculosis)
Thisisanacutelocalized“boil”(infectedhairfollicle)intheearcanalusuallyduetoS.aureus.It
produceslocalizedpain,itching,edema,erythemaandpossiblyafluctuanceorabscess.Thepain
subsideswhentheboilcomestoaheadandbursts.Topicalmupirocinorfusidicacidcanbeusedfor
mildcases.14Incisionanddrainagemayberequiredforsomepatients.Patientsappearingtoneed
incisionanddrainageshouldbeseenbyahealthcarepractitionerwithappropriatetraining.Inmore
severecases,systemicantibioticsactiveagainstS.aureusshouldbeconsidered.10
ChronicOtitisExterna
ChronicotitisexternaischaracterizedasathickeningoftheEACskinsecondarytolow-grade
infectionandinflammation.Thereisusuallyunrelentingpruritus,milddiscomfortanddry,flakyskin
intheEACwithlackofcerumen.Thisisoftenduetononbacterialcausesincludingallergiccontact
dermatitis.9
EczematousOtitisExterna
Eczematousotitisexternamaybeduetoavarietyofskinconditions,includingatopic,seborrheicor
contactdermatitis,psoriasis,lupuserythematosus,neurodermatitisandinfantileeczema.Lesions
typicallyoccurelsewhereonthebody,especiallytheheadandneck,aswellastheauricleandEAC.
Appearancemayrangefrommilderythemaandscalingwithatopicdermatitistothetypicaladherent
scalesofpsoriasis(seeChapter55:Atopic,Contact,andStasisDermatitis;Chapter58:Dandruffand
SeborrheicDermatitis;andChapter71:Psoriasisforamorecompletedescriptionofthelesions).The
mostcommonsymptomispruritus,althougherythema,edema,crustingandoozingmaybepresent.
Thelesionsmaybecomesecondarilyinfectedwithbacteriaorfungi.Treatmentisprimarily
managementoftheunderlyingcondition.15
Necrotizing(Malignant)OtitisExterna
Thisisaninfectionthatextendstothemastoidortemporalboneandisusuallyseenin
immunocompromisedpatientsorthosewithdiabetes.Urgentreferralandsystemicantimicrobial
therapyarerequired.10,11
Thischapterfocusesonthemanagementofacutediffuseotitisexterna.
Goals of Therapy
■ Eliminatepathogenicmicroorganisms
■ Controlpain
■ Restorethecanaltonormalhealthsoitresistsinfection—returntonormalacidicpHandadequate
cerumen
Patient Assessment
Acuteotitisexternaischaracterizedbyotalgia(70%ofcases),itching(60%)orfullness(22%)withor
withouthearingloss(32%)anddischargeinorcomingfromtheear(otorrhea).10,16Incidencepeaksin
childrenage7–12yearsanddeclinesaftertheageof50.16Itisunilateralin90%ofcases.16The
discomfortcanrangefrompruritustoseverepain.Thepainisoftenworsewithmotionoftheear
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Ear Conditions
Chapter20:OtitisMediaandOtitisExterna 209
(pushingthetragusorpullingthepinna),10includingmovementcausedbychewing.11Determiningthe
typeofotitisexterna(infectiousvs.noninfectious)canbeassistedbythedescriptionofthesignsand
symptomsaboveandthepresenceofcontributingfactors(e.g.,historyofswimmingortraumatothe
EAC),orthepresenceofdermatologicconditionsonareasofthebodyotherthantheEAC.
Thedrugmustbedeliveredtotheinfectedtissueiftopicaltherapyistobesuccessful.10,16Cleansing
mustbedonebyahealthcarepractitionerwithappropriatetraining.Therefore,ifthereissignificant
edemaordebrisintheEAC,thepatientmayneedtobereferredsothatauraltoiletcanbeperformed
orforawicktobeplaced.10Inmildcases,atopicalproductmaybeinitiatedwithoutcleansing;
recommendationsforpainmanagementareimportant.
Nonpharmacologic Therapy
Adequatecleansingoftheearcanalwithremovalofdebrismayberequiredfrequentlysothattopical
therapycanbeeffective.9,10Ifthecanalisnotpatent,earwicksmaybeinsertedbyahealthcare
practitionertoreduceedemaandswellingandprovideamechanismfordrugdeliverytothecanal.10,11
Thesemayremaininplacefor2–5days.
Pharmacologic Therapy
Forcomparativeingredientsofnonprescriptionproducts,consulttheCompendiumofProductsfor
MinorAilments—AnalgesicProducts:InternalAnalgesicsandAntipyretics;OticProducts.
Topicaltreatmentisthemainstayoftherapy,althoughinmoreseverecases,wheninfectionhasspread
beyondtheEAC,whenotitismediacoexists,orifthepatienthasaconditionsuchasdiabetesor
immunodeficiency,systemicantibioticsmayberequired.10Inuncomplicatedcases,systemictherapy
doesnotimproveoutcomescomparedwithtopicaltherapyandincreasestheriskofadverseeffectsand
antibioticresistanceandtimetoclinicalcure.17Topicaltherapyoptionsincludeacidifyingagents,
antibioticsaloneorantibiotic/corticosteroidcombinations(seeTable1).Comparativetrialsshow
similaroutcomesamongapproaches;therefore,thechoiceisdeterminedbyhealthcarepractitionerand
patientpreference,thesideeffectprofileoftheagentsandcost.10,11,12,18,19Onetrialdemonstratedthat
corticosteroiddrops(witheitheraceticacidorantibiotic)aremoreeffectivethanaceticacidaloneand
recommendedthataceticacidalonenotbeusedinadultpatients.20Inpatientswhosesymptomslast
longerthanaweek,aceticacidmaybelesseffectivethananantibiotic/corticosteroidcombination;
efficacyat1weekissimilar.18Advantagesanddisadvantagesofthevariousproductsareoutlinedin
Table1.
Antibioticdropsareavailableasbothoticandophthalmicpreparations.Bothnonprescriptionand
prescriptionproductsareavailable.Oticproductsaremoreacidicthanophthalmicpreparationsand
maycauseburningoninstillation.Ifapatientcannottolerateoticpreparations,ophthalmic
preparationsmaybemorecomfortable.21Preparationsfortreatmentofotitisexternamaycontain
corticosteroids,whichreduceinflammationandedemaandmayresolvesymptomsmorequickly;
however,thishasnotbeenshowninallstudiesandcorticosteroidsmayoccasionallybetopical
sensitizers.18
Oneparticularconcernwithtopicaltherapyofacuteotitisexternaisthepotentialototoxicityof
aminoglycosides.22Thisisadocumentedadverseeffectofsystemicallyadministered
aminoglycosides.Ifthetympanicmembraneisintact,theriskwithtopicaladministrationisextremely
small.Riskfactorsforototoxicityincluderupturedtympanicmembrane,useoftheproductformore
than1weekandcontinueduseafterotorrheahassubsided.Topicalfluoroquinoloneshavenotbeen
associatedwithototoxicity.
Enoughliquidtofillthecanal(3–4drops)shouldbeinstilled3–4timesdaily(mostproductsexcept
fluoroquinolones).Symptomswilllastforapproximately6daysaftertreatmentbegins;however,
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