Over the Counter Medications for common ailments and possible overdoses Rhynn Malloy, Cynthia Herrera, Katrina Karpowitch PGY-1 Pharmacy Residents Northwestern Memorial Hospital The speaker has no potential or actual conflicts of interest with this presentation

What can be treated? Pain The common Flu/Cold Heartburn/Upset stomach 2

Pain

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Ibuprofen (Advil, Motrin) Naproxen (Naprosyn, Aleve) Aspirin Uses:  Fevers  Rheumatoid arthritis/Gout/Osteoarthritis pain/inflammation  Musculoskeletal pain/Bone pain  Dysmenorrhea pain  Migraines 4

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Contraindications:  Peptic Ulcer Disease  Renal/Kidney Disease  Hypertension/Heart Failure  Coronary Artery Disease (CAD)  Cardiovascular Disease (CVD) Alternative if you have Peptic Ulcer Disease or increased bleeding risk: Celebrex 5

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Doses:  Ibuprofen: 200mg every 4-6 hours as needed Max dose: 1,200mg in 24 hours Treatment >10 days not recommended  Aspirin: 325mg every 4-6 hours as needed Max dose: 4,000mg in 24 hours  Naproxen (sodium): 220 mg every 8-12 hours Max dose: 660mg in 24 hours 6

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Side Effects:  Dyspepsia (indigestion)  Ulcers  Nausea  Gastrointestinal bleeding  Rash/Itching  Kidney damage 7

Acetaminophen (Tylenol) Uses:  Fevers  Injury/Trauma pain  Cramping, aches Contraindications: liver disease Doses: 325mg every 4-6 hours  Max dose: 4,000mg in 24 hours  Overdose = #1 cause of acute liver failure in the US 8

Insomnia

Melatonin Uses:  Insomnia  Limited evidence that it is effective Dose: 0.3mg to 5mg at bedtime Side effects: largely unknown 10

Valerian Root Uses:  Insomnia  Limited evidence that it is effective  May take weeks of nightly use to be effective Dose: mg at night Side effects: if withdrawn abruptly, may cause heart complications and withdrawal sympmtoms 11

Antihistamines Diphenhydramine Uses  Insomnia  Allergic reactions (skin rashes, hives)  Congestion 12

Antihistamines Contraindications:  Urinary retention  Prostate enlargement  Angle closure glaucoma  Cardiovascular disease  Patients of advanced age- may interact with medications and will increase fall risk 13

Antihistamines Doses:  Diphenhydramine: 25-50mg before bed Max use: do not exceed 14 days of nightly use May develop tolerance in 2-3 nights 14

Antihistamines Side effects:  Sedation – extending into morning after  Dry mucous membranes  Elevated body temperature  Constipation  Blurred vision  Urinary retention 15

Cold/Flu Management

Antihistamines Diphenhydramine Doxylamine Uses:  Sinus and nasal congestion, allergy relief  Insomnia 17

Decongestants Contraindications:  Hypertension/Heart Failure  Coronary Artery Disease (CAD)  Cardiovascular Disease (CVD)  Asthma  Chronic Obstructive Pulmonary Disease (COPD) Alternative agents to use in hypertension:  Antihistamines: desloratadine (Clarinex), fexofenadine (Allegra), cetirizine (Zyrtec) 18

Decongestants Doses:  Phenylephrine HCl: 10mg every 4 hours as needed Max dose: 60mg in 24 hours  Pseudoephedrine: 60mg every 4-6 hours as needed Max dose: 240mg in 24 hours Nasal sprays:  Ephedrine 0.5%: 2-3 drops not more often than every 4 hours 19

Decongestants Side effects:  Elevated blood pressure  Palpitations, arrhythmias, fast heart beat  Restlessness, insomnia  Anxiety  “Rebound congestion” Occurs within 3-5 days of continuous use 20

Antitussives and Protussives (Expectorants) Dextromethorphan (antitussive) Guaifenasin (expectorant) Uses:  Cough related to post-nasal drip  Chest congestion 21

Contraindications:  Hypertension/Heart Failure  Coronary Artery Disease (CAD)  Cardiovascular Disease (CVD)  Asthma, chronic bronchitis  Chronic Obstructive Pulmonary Disease (COPD) 22 Antitussives and Protussives (Expectorants)

Doses:  Dextromethorphan: 10-20mg every 4 hours or 30mg every 6-8 hours Max dose: 120mg in 24 hours  Guaifenasin (expectorant): mg every 4 hours Max dose: 2,400mg (2.4g) in 24 hours CAUTION: beware of combination products! 23

Antitussives and Protussives (Expectorants) Side effects:  Drowsiness OR excitation, nervousness  Dizziness  Headache  Stomach discomfort, nausea, constipation  Respiratory depression in high doses 24

Heartburn

Heartburn-antacids Symptomatic treatment of heartburn and indigestion  Tums©, Milk of Magnesia©, Maalox©, Mylanta©, Rolaids©

Heartburn-antacids Things to watch out for:  Drug interactions  Constipation or diarrhea  Nausea and/or vomiting  Muscle twitching  Confusion  Irregular heartbeat

Heartburn-H2RAs Symptomatic Prevention or Treatment of acid reflux/peptic ulcer disease:  Pepcid© (famotidine), Zantac© (ranitidine), Tagamet© (cimetidine), Axid© (nizatidine)

Heartburn-H2RAs Things to look out for:  Drug interactions [Cimetidine]  Diarrhea  Abnormal heartbeat  Flushing and/or sweating  Nausea and/or vomiting  Slurred speech Dosing:  Famotidine: 10-20mg once to twice daily  Ranitidine: mg once to twice daily  Cimetidine: mg once to twice daily  Nizatidine: 75mg once to twice daily **CAUTION in patients with kidney dysfunction**

Heartburn-PPIs Treatment for chronic acid reflux, GERD, and PUD  Prilosec© (omeprazole), Prevacid© (lansoprazole)

Heartburn-PPIs Things to look out for:  Nausea and/or vomiting  Bone pain  Sedation  Muscle twitching  Abnormal heart beats  Diarrhea Dosing:  Omeprazole: 20mg once daily  Lansoprazole: 15mg once daily **CAUTION in patients with osteoporosis**

Nausea

Pepto-Bismol© (bismuth subsalicylate)  Symptomatic relief of upset stomach, nausea, indigestion, diarrhea Dramamine© (meclizine)  Symptomatic and preventive treatment of motion sickness

Nausea Things to watch out for with Pepto-Bismol©  Breathing problems  Stomach bleed  Hearing loss  Aspirin allergy Dosing  30 mL every minutes for maximum of 8 doses/day **DO NOT USE WITH STOMACH ULCERS**

Nausea Things to watch out for with meclizine:  Urinary retention  Closed angle glaucoma  Dry mouth  Drowsiness  Flushing Dosing:  25-50mg one hour prior to traveling. Maximum dose of 50mg in 24 hours.

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