Professional Documents
Culture Documents
For
Condition Page
Eye Infections............................................................................................. 3
Sulphacetamide Eye Drops
Cough........................................................................................................... 6
Sedating Antihistamines
Choline Theophyllinate + Guaiphenesin
Insomnia........................................................................................................ 15
Diphenhydramine
Doxylamine Succinate
Salicylamide + Diphenhydramine
Mouth Ulcers................................................................................................. 19
Triamcinolone Oral Paste
Pain — Musculoskeletal.............................................................................. 23
Diclofenac
Pain — Migraine............................................................................................ 25
Paracetamol + Metoclopramide
Thrush — Oral............................................................................................... 28
Miconazole
Nystatin
Thrush — Vaginal......................................................................................... 32
Imidazole & Nystatin Vaginal Creams/Pessaries
Fluconazole Tablets
Warts.............................................................................................................. 37
Podophyllin
2
© Pharmacy Guild of New Zealand (Inc) 2006
Eye Infections
Sulphacetamide Eye Drops
Any symptoms involving the eyes require careful assessment. While some
problems involving the eye can be safely and effectively treated with OTC
medicines, others should be referred for further investigation or treatment with
prescription medicines.
Conjunctivitis
Types
• Bacterial — Usually affects both eyes. Redness, painful gritty sensation, with
a sticky discharge, eyelids often stuck together on awakening. Usually self-
limiting, clearing after 7 – 10 days. However treatment can shorten the
duration of the infection, increase patient’s comfort and prevent spread of the
infection.
• Allergic — Redness, intense itching, eyelid swelling, dark rings under eyes,
watery discharge, typically seasonal in nature or patient has a history of
allergies. Consider oral or topical antihistamines, or sodium cromoglycate
drops.
• Viral — Redness, soreness, with a clear watery discharge. There may be
other viral symptoms present, eg fever or sore throat.
Keratitis
Inflammation of the cornea, usually with symptoms of deep pain and
photophobia in addition to red-eye. There may be a discharge and vision may be
affected.
Blepharitis
Chronic inflammation and crusting of the eyelids and eyelashes. Symptoms
include itching, and red, inflamed eyelids.
Blocked tear ducts are common an infants but don’t usually produce symptoms
until about 3 –12 weeks after birth while chlamydial or gonococcal infections
produce symptoms within a few days to a week from birth.
1
McKellar M. Sinister paediatric eye conditions. New Zealand GP. 17 Oct.2001:p27
2
Wagner R. Eye infections and abnormalities: Issues for the paediatrician.
Contemporary Pediatrics. June 1997
3
© Pharmacy Guild of New Zealand (Inc) 2006
Elderly people are more prone to eye problems such as dry eye and are more
likely to be taking medicines that affect the eye.
Symptoms?
Note: Contact lenses should not be worn during treatment with sulphacetamide
eye drops. It is safe to wear lenses again 24 hours after the last sulphacetamide
drops were used.
Glaucoma
• Patient is likely to be using eye drops, some of which can cause an eye
irritation
• A painful red eye is one of the symptoms of acute glaucoma and urgent
medical attention may be required. Refer if glaucoma has been diagnosed but
the patient hasn’t had the condition checked recently.
Diabetes
• Retinopathy, cataracts, and glaucoma are conditions commonly associated
with diabetes. Eyes should be checked 2 yearly.
Rheumatoid arthritis
• May be associated with Sjogren’s Syndrome, a condition that causes dryness
of the mouth and eyes due to an insufficiency in the glands that supply tears
and saliva.
4
© Pharmacy Guild of New Zealand (Inc) 2006
Pregnant?
Be aware that systemic absorption of medicines can occur after medicines have
been used in the eye. When administered systemically, sulphonamides cross the
placenta and may cause jaundice and haemolytic anaemia in the newborn.3
Breastfeeding?
• Incorrect usage, storage, or using eye drops after the expiry date may
predispose to eye irritation or infection.
• Steroid eye drops - possibility of a rise in intra-ocular pressure in a small
number of people or a lesser rise in intra-ocular pressure in more people
when used for longer than a few weeks. Long term use has been associated
with thinning of the cornea.
• Sulphacetamide is anionic so can cause precipitation if used with other eye
drops (most other eye drops are cationic).
Allergies to medicines?
3
Data sheet. Acetopt eye drops. July 1999
4
Briggs G, Freeman R, Yaffe S. Drugs in Pregnancy and Lactation. 6th Ed. 2002
5
American Pharmaceutical Association. Drug Information Handbook. 9th Ed. 2001-
2002:1143
5
© Pharmacy Guild of New Zealand (Inc) 2006
Cough
Choline Theophyllinate + Guaiphenesin
Sedating Antihistamines
Acute cough — The origin is usually a viral respiratory tract infection and the
duration is generally two weeks or less. An acute cough is often associated with
other symptoms of upper respiratory tract infection.
Chronic cough — A cough that lasts for more than two weeks can be
considered chronic. Potential causes are:
- Post nasal drip
- Sinusitis
- Bronchitis
- Asthma
- Gastro-oesophageal reflux
- Smoking
- Congestive heart failure
- Emphysema
- Lung cancer
- Side effects of medication eg ACE Inhibitors
Assessing a cough
Refer if the patient is a child under 2 years of age. Coughing in infants and very
young children may be an indication of
• asthma (persistent dry cough which is worse at night)
• congenital abnormality where milk gets into the airway during feeding
• an inhaled object
• the result of a near choking episode
Type of cough:
A productive cough is chesty and produces phlegm/sputum. It should be
encouraged as secretions retained in the lower respiratory tract impair breathing
and can cause infection. Clear sputum is generally uninfected, but thick, yellow
or green secretions may indicate an infection.
6
Stenson N. Coughs and Colds. IPU Review 2005;10:25-31
6
© Pharmacy Guild of New Zealand (Inc) 2006
Croup
Suspect croup if the patient is a child with a continuous cough that sounds like a
barking seal. The cough may begin at night after the child has been sleeping but
may occur during the day as well. The child may also have troubled breathing.7
Whooping cough
Can appear in people of all ages but is most serious in infants. Initial symptoms
are similar to those of a cold lasting for 1 to 2 weeks followed by a cough. The
cough may follow the distinctive pattern of bursts of coughing followed by a
deep gasp, producing a ‘whooping’ sound but this is not always the case.
Infants and young children appear very distressed and may turn blue as a result
of breathing difficulty or vomit as a result of intense coughing.
Phlegm/Sputum
The presence and nature of sputum can be a useful indicator of the cause of the
cough and need for further investigation.
The majority of coughs are self-limiting. Coughs lasting longer then 10-14 days
may need further investigation.
7
Virtual Childrens Hospital:
http://www.vh.org/pediatric/patient/pediatrics/cqqa/cough.html
Medline Plus: http://www.nlm.nih.gov/medlineplus/print/ency/article/003072.htm
http://familydoctor.org/858.xml?printxml all accessed 31.10.2005
7
© Pharmacy Guild of New Zealand (Inc) 2006
• Wheezing can be a symptom of bronchitis especially in children, of asthma or
heart failure.
• A persistent high temperature for 3 days or more may indicate the presence
of bacterial infection.
• Extreme tiredness accompanied by loss of appetite and fever can be
symptoms of pneumonia.
Smoker?
Many smokers have a chronic cough. Apart from the obvious intervention to
assess the smoker’s readiness to quit, look for any change to the cough as an
indication that there is a more serious cause.
A child who is experiencing a chronic cough and is under the care of a specialist
for any reason or who has asthma or gastro-oesophageal reflux should be
referred to their GP.
Heart failure
One of the symptoms that a patient with heart failure may experience is a
chronic cough that occurs especially when he/she is lying flat in bed. Worsening
cough may be an indication of drug therapy failure.
Epilepsy
Because there have been occasional reports of convulsions in patients taking
antihistamines, Martindale cautions against recommending antihistamines to
patients with epilepsy.
Diabetes
In short term acute conditions, the amount of sugar in cough medicines is now
considered unimportant when used for short periods, since diabetic control is
often upset during infections.8
8
Blenkinsopp A&J, Paxton P. Symptoms in the Pharmacy. Blackwell Publishing. Oxford.
2005:37
8
© Pharmacy Guild of New Zealand (Inc) 2006
Taking any medicines?
Other advice
Demulcents such as glycerine, lemon and honey are popular for their soothing
effects. They do not contain any active ingredients and although they have high
syrup content, their pleasant taste makes them suitable for children.
Children who are regularly exposed to second hand smoke have more difficulty
recovering from upper respiratory tract infections and are more prone to chronic
coughs.
9
© Pharmacy Guild of New Zealand (Inc) 2006
SEDATING ANTIHISTAMINES
Thus the following cough and cold medicines containing sedating antihistamines
are restricted medicines:
The sedative effects of antihistamines may prove troublesome for daytime use,
but may be a short-term advantage for night coughs.
Non-sedating antihistamines are less effective in the symptomatic treatment of
coughs and colds because of their less pronounced anticholinergic actions.10
9
Martindale: The Complete Drug Reference. Electronic version, Accessed 6 December
2005
10
Blenkinsopp A&J, Paxton P. Symptoms in the Pharmacy 2005:36
10
© Pharmacy Guild of New Zealand (Inc) 2006
Overdosage
Sedating antihistamines have additive effects with alcohol and other CNS
depressants.
11
Martindale. The Complete Drug Reference. Electronic version. Accessed 6 December
2005
11
© Pharmacy Guild of New Zealand (Inc) 2006
CHOLINE THEOPHYLLINATE + GUAIPHENESIN
Reclassification of theophylline
Theophylline has a narrow margin between the therapeutic dose and the toxic
dose. Brondecon and Broncelix deliver a relatively small dose of theophylline
when taken at the recommended doses; however there is a potential risk of
toxicity for people in whom the theophylline half-life is increased.
Theophylline is metabolised by the liver. Its clearance and consequently its half-
life are affected by a variety of factors including age of the patient, disease
states, and concurrent drug therapy.
12
Medsafe. Medicines Reclassification Committee. Minutes of the 24th meeting, Nov.
2000.
13
Adis International. New Ethicals Compendium, 7th Edition, 2000:261-262.
12
© Pharmacy Guild of New Zealand (Inc) 2006
Other health problems?
Refs14, 15
Look for
• Medicines that may cause a cough as an adverse effect eg. ACE inhibitors and
Beta-blockers although this type of cough is typically irritating and non-
productive.
• Other theophylline containing medicines or Xanthines eg. caffeine (in large
doses) which with the additive effect of choline theophyllinate may cause
toxicity.
• Medicines with the potential to increase the plasma concentration of
theophylline.
14
Martindale. The Complete Drug Reference. Electronic version. Accessed 6 December
2005
15
British National Formulary 41, March 2001.
16
American Pharmaceutical Association. Drug Information Handbook. 6th Edition,
1998 – 99.
13
© Pharmacy Guild of New Zealand (Inc) 2006
Pregnant or breastfeeding?
Theophylline crosses the placenta and also enters breast milk. The Australian
Drug Evaluation Committee lists both theophylline derivatives and guaiphenesin
as category A 17 ie Drugs which have been taken by a large number of pregnant
women and women of childbearing age, without any proven increase in the
frequency of malformations or other direct or indirect harmful effects on the
foetus having been observed.
Adverse effects
The most common side effects are gastric irritation and headache. Gastric
irritation can be minimised by taking the dose immediately after food.
17
Australian Drug Evaluation Committee. Prescribing medicines in pregnancy. 4th
Edition, 1999:38
14
© Pharmacy Guild of New Zealand (Inc) 2006
Insomnia
Diphenhydramine, Doxylamine Succinate
Salicylamide+ Diphenhydramine
Definition
A sleep disorder or difficulty exists when the inability to sleep well produces
impaired daytime functioning or excessive sleepiness. This difficulty typically
takes the form of waking unrefreshed, difficulty falling asleep, frequent night-
time awakenings or awakening too early.18 Many people have never discussed
their sleep difficulties with their doctor, so direct questioning about the pattern
and possible cause is important.
Duration
Insomnia is classified as
• Transient – lasting 2 to 3 days
• Short term – lasting up to 3 weeks and typically due to emotional trauma or
physical illness
• Chronic – occurring most nights for more than 3 weeks
• Stress
• Anxiety/depression
• Shift work or change in surrounding environment
• Sleep/wake schedule changes eg jet lag
• Having a high intake of beverages containing caffeine
• Medication side effects
• Alcohol - the sleep cycle is disturbed by continuous or heavy alcohol
consumption
• Uncomfortable sleep environment eg room too hot or too cold,
uncomfortable bed, noisy
• Snoring associated with sleep apnoea
• Chronic health conditions involving pain, breathing difficulties, frequent
night time urination or depression
Irregular sleep patterns are common in babies and toddlers but these can
usually be modified using sleep retraining techniques. Suggesting a self help
book or referral to the local Plunket nurse for assistance may be appropriate.
People over 60 years of age may need less sleep at night, especially those who
have daytime naps. For some, all that may be needed is reassurance that they
are having sufficient sleep. As sleep physiology changes with age, older people
spend less time in deep sleep, the duration of sleep becomes shorter and sleep
becomes shallower. Older people tend to be more easily woken by noise and
other environmental factors.
18
Gowan J, Roller L. Practical Disease State Management for Pharmacists. 2004: 21
15
© Pharmacy Guild of New Zealand (Inc) 2006
Some patients may need treatment for an underlying problem in order to sleep
better. Sleep can be disrupted by conditions where pain or discomfort is a factor
such as angina, oesophageal reflux, arthritis, or cancer, conditions where
breathing difficulties are common such as asthma, heart failure, and COPD, or
other conditions such as hyperthyroidism, and Parkinson’s disease.
One of the reasons that sedating antihistamines used to treat insomnia are
classified as Pharmacist Only Medicines is the risk of tolerance developing. An
initial focus on sleep hygiene and careful explanation that sedating anti-
histamines are for short-term use are therefore important.
When recommending treatment for an older patient bear in mind that older
people are more susceptible to the adverse effects of sedating antihistamines
and may be more prone to hangover like effects of sedating antihistamines.
Allergies to medicines?
19
National Heart, Lung and Blood Institute. Facts about Insomnia. 1995: 1
16
© Pharmacy Guild of New Zealand (Inc) 2006
Diphenhydramine and doxylamine are both classified as Category A 20 i.e. Drugs
which have been taken by a large number of pregnant women and women of
childbearing age without any proven increase in the frequency of malformations
or other direct or indirect harmful effects on the foetus having been observed.
If a drug has been used successfully and appropriately before, suggest the
same. Ensure that the patient is aware of advice and lifestyle changes that
make a difference.
Management of insomnia
20
Australian Drug Evaluation Committee. Prescribing Medicines in Pregnancy. 4th
Edition. 1999:40
17
© Pharmacy Guild of New Zealand (Inc) 2006
Non-Pharmacological advice
• Blenkinsopp, A. & J. & Paxton, P. Symptoms in the pharmacy. 5th Ed. 2005:
279-285
• Gowan, J & Roller, L. Practical disease state management for pharmacists.
2004:21-26
• Li Wan Po, A. & Li Wan Po, G. OTC Medications. 2nd Ed. 1997: 202-203
• Pharmaceutical Society of Australia. Counselling guide for non-prescription
medicines. 2003. 19-21
• Pharmacy Today. Healthcare handbook. 2004: 114-115, 240
21
Gowan, J & Roller, L. Practical disease state management for pharmacists. 2004: 22
18
© Pharmacy Guild of New Zealand (Inc) 2006
Mouth Ulcers
Triamcinolone Oral Paste
Mouth ulcers are seen in all age groups from childhood onwards and are slightly
more common in females. There are three main clinical types of mouth ulcer:
1. Minor aphthous ulcers
2. Major aphthous ulcers
3. Herpetiform ulcers
Minor aphthous ulcers are either round or oval, often crater-like, usually small
(< 5mm) in diameter and appear suddenly either singly or in groups. The centre
of the ulcers is yellowish grey and the outside edge may be surrounded by a
reddish halo. They occur most commonly on the lining mucosa of the cheeks,
lips and underside of the tongue and are usually painful. These ulcers usually
heal within 7 to 14 days.
Major aphthous ulcers are not as common, and are larger (> 1 cm diameter).
These ulcers are quite deep and painful and are slower to heal some taking a
month or more.
Contributing factors
Mouth ulcers occur often in people with immune deficiencies due to bone marrow
damage eg leukaemia, viral infection eg HIV, bacterial infection eg TB,
autoimmune disease eg systemic lupus or as a result of radiation therapy to the
head /neck or chemotherapy.
19
© Pharmacy Guild of New Zealand (Inc) 2006
Ulcers elsewhere?
Ulcers on other mucous membranes such as the genital area or the eyes require
urgent referral.
Other symptoms?
Accompanying symptoms such as fever, fatigue, muscle and joint pain, swollen
lymph nodes, and weight loss could indicate a systemic condition such as lupus
erythematosus and should be referred. The autoimmune skin diseases bullous
pemphigoid and pemphigus vulgaris present as blistering skin eruptions that
may also involve ulceration of the mouth.
A patient with any mouth ulcer lasting more than two to three weeks should be
referred to his or her doctor for further investigation to exclude malignancy or
other serious conditions.
Anyone with weight loss associated with the ulcer(s) due to the inability to eat
should be referred.
Pregnant?
22
Data sheet. Oracort Paste,Topical. April 1998
23
Australian Drug Evaluation Committee. Prescribing medicines in pregnancy. 4th
Edition. 1999:24
20
© Pharmacy Guild of New Zealand (Inc) 2006
Breastfeeding?
For a drug to cause mouth ulcers through direct contact requires prolonged
exposure to drugs such as potassium chloride, aspirin, captopril and pancreatic
enzyme preparations. 24 Patients taking these medicines should be instructed to
swallow the tablets/capsules as quickly as possible.
Feverfew, a herbal remedy popular for treating headache has been has been
known to cause mouth ulcers.26 This seems to be a problem when people take
the raw leaf rather than an encapsulated formulation.
Systemic effects
The small amount of steroid released when triamcinolone oral paste is used as
recommended makes systemic effects very unlikely. However systemic effects
are possible when topical corticosteroid preparations are used in the mouth for
prolonged periods.
Adverse effects
24
Barrons R. Treatment strategies for recurrent oral aphthous ulcers. Am J Health-
System Pharm. 2001;58(01):41-53
25
Walker R, Edwards C. Drug-induced blood disorders. Clinical Pharmacy and
Therapeutics. Chapter 46.1994
26
University of Maryland Medical Centre. Alternative/Complementary medicine.
http://www.umm.edu/altmed/ConsHerbs/Feverfewch.html Accessed 28 Feb 2006
21
© Pharmacy Guild of New Zealand (Inc) 2006
General Reference Sources
22
© Pharmacy Guild of New Zealand (Inc) 2006
PAIN – MUSCULOSKELETAL
Diclofenac
NSAIDs should be used with caution in the elderly due to the increased risk of
serious side effects.27 In this group of patients the lowest possible dose should
be used.
Severity/location/duration/causes of pain?
Pain that is severe and/or causes mobility problems is an indication for referral.
Middle to upper back pain with no history of injury or strain could indicate kidney
problems and should be referred.
Using the 1 — 10 scale of pain intensity is a useful tool for gauging the severity
of pain. Ask the patient how bad the pain is on a scale of 1 to 10 where 1 is
very mild and 10 is unbearable.
Note; like other NSAIDs diclofenac may mask signs and symptoms of infection
due to its pharmacodynamic properties.28 If you suspect there may be infection
present refer the patient for medical attention.
• Asthma
Between 8 — 20% of adult asthmatics experience bronchospasm following
ingestion of aspirin or other NSAIDs. Asthmatics with chronic rhinitis or a
history of nasal polyps are at greater risk.29
• Stomach ulcers
Diclofenac may aggravate existing problems.
Note: Do not give diclofenac to someone who is dehydrated due to the potential
risk of renal damage.
27
British National Formulary (BNF) 41. September 2001
28
Data Sheet. Voltaren. September 1999.
http://www.medsafe.govt.nz/Profs/Datasheet/v/Voltarentab.htm
29
Sturtevant J. NSAID – induced bronchospasm – A common and serious problem.
Prescriber Update No 18, June 1999
23
© Pharmacy Guild of New Zealand (Inc) 2006
Allergies to medicines or previous reactions to aspirin or other NSAIDs?
Pregnant or breastfeeding?
The Voltaren data sheet states that following oral doses of 50mg every 8 hours
diclofenac passes into breast milk in such small quantities that no undesirable
effects on the infant are expected. This is confirmed by the BNF where it states
that the amount that passes into breast milk is too small to be harmful.
Alcohol should not be taken at the same time as diclofenac due to the potential
to increase GI irritation.
30
Australian Drug Evaluation Committee. Prescribing medicines in pregnancy. 4th
Edition. 1999:21
31
American Pharmaceutical Association. Drug Information Handbook. 9th Ed. 2001-2002
24
© Pharmacy Guild of New Zealand (Inc) 2006
PAIN - MIGRAINE
Paracetamol + Metoclopramide
The key to clinical evaluation of an acute headache is to make sure that all
potentially serious causes of the symptoms are ruled out.
While children as young as five can get migraines it is advisable to refer children
with migraine symptoms to a doctor for the initial diagnosis.
Many people also get a warning prior to the aura that an attack is coming. They
may feel irritable and withdrawn, crave certain foods, or yawn a lot.
Refer anyone with the following symptoms for medical assessment 33:
• Sudden, severe pain accompanied by nausea/vomiting – possible sub
arachnoid haemorrhage
• Severe frontal or temporal pain in a patient > 50
• Nausea, vomiting, fever, stiff neck – may be symptoms of meningitis
• Drowsiness, double vision, limb weakness/loss of feeling, pins and needles –
possibly a serious neurological condition
• Eye pain, visual disturbance, nausea vomiting – could be glaucoma
• Headache triggered by exertion, coughing or bending
• A change in headache pattern
• New onset of headaches from middle age onwards
• Any headache that follows a head injury
32
Blenkinsopp A&J, Paxton P. Symptoms in the Pharmacy. 3rd Ed. 1998
25
© Pharmacy Guild of New Zealand (Inc) 2006
What is the pain like?
For a useful indication of how bad the pain is ask the patient to rank the pain on
a scale of one to ten where one is mild and ten is unbearable.
Migraine triggers
A wide variety of food, environmental and lifestyle factors are known to trigger
migraines. Most migraine sufferers know what their ‘triggers’ are and it makes
sense to avoid these if at all possible. If the triggers haven’t been identified a
good idea is to keep a headache diary recording the characteristics, date, length,
pre-headache symptoms, of the migraine plus the foods eaten and the
environment immediately prior to the attack.
In some women migraine attacks may be associated with the menstrual cycle.
In alcoholics or patients with chronic liver disease paracetamol doses may need
to be lowered due to the increased risk of liver damage. 36
33
Nordenberg T. United States Food and Drug Administration. Heading off migraine
pain.
http://www.fda.gov/fdac/features/1998/398_pain.html
34
Data Sheet. Paramax. June 1999
http://www.medsafe.govt.nz/Profs/Datasheet/p/Paramaxtab.htm
35
British National Formulary (BNF) 41. 2001
26
© Pharmacy Guild of New Zealand (Inc) 2006
Taking any medicines?
• Check that the patient is not taking any other medications containing
paracetamol that would result in ’double dosing’.
• Keep in mind that the absorption of any concurrently administered oral
medication may be modified by the effect of metoclopramide on gastric
motility.
• Refer immediately any patient on combined oral contraceptives who has an
unusually severe or prolonged headache. Refer also any patient who has
had migraines in the past but since taking a combined oral contraceptive has
experienced an increase in the number, severity or length of migraines.
• Since extrapyramidal reactions may occur with both metoclopramide and
phenothiazines, taking both together may increase the risk of such adverse
reactions.
• Headaches are a common adverse effect of many medicines. Medicines that
have been particularly implicated include vasodilators (nitrates, calcium
channel blockers, alpha-adrenoceptor blockers), oestrogen and oral
contraceptives.
Pregnant or breastfeeding?
The Paramax data sheet states that ‘adequate human data on use during
pregnancy is not available. However, animal studies have not identified any risk
to pregnancy or embryo-foetal development’.
36
Australian Drug Evaluation Committee. Prescribing medicines in pregnancy. 4th
Edition. 1999: 13 & 20
27
© Pharmacy Guild of New Zealand (Inc) 2006
Thrush - Oral
Miconazole, Nystatin
Candidiasis (thrush) in the mouth appears as curd like white or cream slightly
raised patches on the inside of the mouth, gums and/or tongue. The patches
are relatively easily removed to reveal a red, raw underlying base which may be
tender.
Infant
Oral thrush is frequently seen in babies. Newborn infants often pick up candida
from the mother during the birth process. Thrush can also pass through the
baby’s digestive system and cause a fungal nappy rash. Reinfection from the
mother’s nipples during feeding may occur. To prevent this, a small amount of
the oral antifungal medicine being given to the baby can be applied to the
mother’s nipples. Babies bottles, teats and pacifiers should be well sterilised
between use to prevent reinfection.
Adult
Oral thrush in adults however should be considered abnormal and in most cases
indicative of a depressed immune system.
• If a baby has oral thrush check whether the nappy area is affected also. If it
is, treat both oral thrush and thrush of the nappy area at the same time. If
the baby is breastfed advise the mother to check her nipples and treat if
necessary.
• If a woman has oral thrush ask if she has vaginal thrush as well. Both sites
should be treated at the same time with appropriate medication.
28
© Pharmacy Guild of New Zealand (Inc) 2006
Denture wearer?
Poor fitting dentures may predispose to oral thrush and the patient should be
referred to the dentist.
Denture wearers should remove dentures before taking each dose of oral
antifungal medicine to allow contact with all areas of the oral mucosa and gums.
As an additional measure, the Daktarin Oral Gel package insert advises denture
wearers to apply a thin layer of gel directly to the dentures after removing them
in the evening, leave the gel on overnight and wash it off in the morning.
Medicines that dry the mouth may predispose to oral thrush. Classes of
medicines that commonly cause dry mouth include:
Treatment choices
Nystatin is not absorbed from the GI tract when used buccally so medicine
interactions are not a concern. However when miconazole is used locally in the
mouth a small amount may be absorbed so potential interactions need to be
considered.
29
© Pharmacy Guild of New Zealand (Inc) 2006
Medicines which may interact with miconazole
The chart below lists a number of potential interactions between miconazole oral
gel and other medicines. It should be noted that there is documented evidence
for only some of the interactions. Others listed are theoretical, and based on
documented interactions involving ketoconazole or itraconazole rather than
miconazole.
Use your clinical judgement when advising patients about these potential
interactions.
The data sheet recommends that if Daktarin Oral Gel and anticoagulants are to
be used concomitantly the anticoagulant effect should be carefully monitored
and titrated. Similarly it recommends monitoring phenytoin levels if it is to be
used at the same time as miconazole.
37
Data sheet. Daktarin Oral Gel. October 2000
38
Stockley I. Drug Interactions. 4th Edition. 1996
30
© Pharmacy Guild of New Zealand (Inc) 2006
Pregnant?
Miconazole and Nystatin are both listed by the ADEC as category A 39, ie drugs
which have been taken by a large number of pregnant women and women of
childbearing age without any proven increase in the frequency of malformations
or other direct or indirect harmful effects on the foetus having been observed.
Breastfeeding?
Nystatin – It is not known whether nystatin is excreted into human breast milk
but as it is poorly absorbed from the GI tract40,41, excretion into breast milk
would be expected to be insignificant.
39
Australian Drug Evaluation Committee. Prescribing medicines in pregnancy. 4th
Edition. 1999: 13 & 20
40
Data sheet. Mycostatin Oral. May 2004
41
Data sheet. Nilstat. May 2002
31
© Pharmacy Guild of New Zealand (Inc) 2006
Thrush Vaginal
Imidazole and Nystatin Vaginal Creams/Pessaries
Fluconazole Oral Tablets
Vaginal thrush is rare before puberty or in post menopausal women because the
high levels of circulating oestrogen necessary to create the conditions (vaginal
glycogen production) that favour growth of candida albicans are lacking.
Therefore patients who have not yet reached puberty or are over 60 years
should be referred. In these two age groups vaginal infections are more likely to
be bacterial rather than fungal and in older women the possibility of malignancy
needs to be ruled out. In girls under the age of 16 referral is advisable as
thrush like symptoms are likely to be caused by poor hygiene, contact
dermatitis, threadworms, diabetes or bacterial infections and the possibility of
sexual abuse as the source of vaginal infection may need to be investigated.
There are other common conditions that produce similar symptoms to VVC eg
bacterial vaginosis, trichomoniasis and contact dermatitis.
32
© Pharmacy Guild of New Zealand (Inc) 2006
Typical symptoms of Trichomoniasis:
(Some women do not have any symptoms at all but where symptoms are
present they may include)
• Green frothy discharge
• Painful urination
The presence of sores, blisters or ulcers is not generally associated with thrush
and may be a sign of genital herpes.
Keep in mind the possibility of STIs, especially if the patient has a history of STIs
or could have been exposed to a partner with an STI.
42
Risk factors for the presence of STIs include
Unlike the vagina, the skin of the penis does not provide ideal conditions for the
growth of candida. Current thinking on whether male sexual partners of women
who suffer from recurrent bouts of thrush should be routinely treated supports
only treating the male partner if he is experiencing symptoms such as local
itching or skin irritation of the penis. 43,44
Pregnant?
There is some debate over whether a pregnant woman with symptoms of vaginal
thrush should be referred to her doctor for confirmation of diagnosis or whether
pharmacists should go ahead and sell an OTC treatment. Essentially it is up to
the pharmacist’s professional judgement, taking into consideration:
a) the patient’s history, specific clinical circumstances and evidence to
support safety and efficacy of the product in pregnancy;
42
Mitchell H. Vaginal Discharge, causes, diagnosis and treatment. ABC of Sexually
Transmitted Infections. BMJ 29 May 2004;328:1306-1308
43
Sparrow M. Vaginal thrush and its association with the male partner. New Zealand
Pharmacy July 1997: 31-34
44
Ringdahl E. Treatment of recurrent vulvovaginal candidiasis. American Family
Physician. June 2000
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b) the patient’s agreement to accept the pharmacist’s recommendation after
receiving adequate information on risk v benefit.
Keep the following points in mind when deciding on your course of action:
• If this is the first time the woman has experienced symptoms typical of
vaginal thrush, she should be referred to her doctor (this applies to non-
pregnant women also).
• While systemic absorption from vaginal application of imidazole
antifungals is relatively low, the data sheets for the topical vaginal
products carry a precaution that these products should be used in the first
trimester of pregnancy only under the supervision of a medical
practitioner and when the physician considers its use essential to the
welfare of the patient.45,46
• Gestational diabetes may predispose a pregnant woman to vaginal thrush.
• If the woman has a previous history of STIs or is at risk of STIs then
referral to confirm diagnosis is advisable as STIs that remain untreated
can cause birth defects, pre-term birth, low birth weight or be passed on
the to the infant at birth.
Topical Imidazoles
Oral Fluconazole
When the New Zealand Medicines Classification Committee considered the safety
of fluconazole in pregnancy they concluded that the risks associated with a
single 150mg dose would be minimal.47 This view is supported by the Australian
Drug Evaluation Committee. The ADEC provides the following guidance:
‘Single dose therapy (150mg) does not appear to cause adverse pregnancy
effects. Repeated doses of fluconazole (400-800mg daily) have been
associated with a consistent pattern of birth defects similar to those seen in
animal studies.’ 48
45
Data sheet. Pevaryl Pessaries. November 2003
46
Data sheet. Clotrimaderm Vaginal Cream. April 1998
47
Minutes of the 31st meeting of the Medicines Classification Committee.
48
Australian Drug Evaluation Committee. Prescribing Medicines in Pregnancy. 4th Edition.
1999:30
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The manufacturer of Diflucan recommends that pregnant women check with
their doctor before taking Diflucan.
Breastfeeding?
Intravaginal imidazole products are considered safe to use by women who are
breastfeeding. As systemic absorption of these products via the intravaginal
route is relatively low, secretion into breast milk is likely to be low. 50,51
• Creams containing local anaesthetic that are applied vaginally can sometimes
cause a sensitivity reaction that resembles symptoms of thrush.
• Broad-spectrum antibiotics are well known for causing vaginal thrush in
susceptible women.
Interactions
While clinical drug interactions with single dose fluconazole are unlikely, the
following drugs either have the potential to or have been documented as
interacting with fluconazole (with repeated or high doses): Cisapride;
terfenadine; astemizole; midazolam; phenytoin; theophylline; sulphonylureas;
warfarin; rifabutin; zidovudine; cyclosporine; tacrolimus.
50
The use of fluconazole with cisapride is contraindicated.
Vegetable and mineral oils in the bases of antifungal creams or pessaries may
damage the latex rubber of condoms and diaphragms thereby reducing their
contraceptive efficacy.
Allergies to medicines?
The use of oral fluconazole is contraindicated in people who have had a previous
allergic reaction to any azole antifungal formulation.
Although systemic absorption from vaginal imidazoles is only 3 to 10% this could
be enough to cause a reaction in people sensitive to azole compounds. Therefore
the use of topical azoles should be avoided in people who have had an allergic
response to the oral formulations.
49
Data sheet. Diflucan May 2004
50
Data sheet. Gyno Pevaryl. May 1999
51
Data sheet. Clocreme. January 1999
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© Pharmacy Guild of New Zealand (Inc) 2006
Side effects
Fluconazole oral
Common side effects: headache; nausea; abdominal pain; dyspepsia; diarrhoea.
Treatment choice
Topical nystatin requires a longer treatment period (two weeks) than topical
azoles; however it can be useful in women who have failed to respond to azole
antifungals.
52
Watson MC, Grimshaw JM, Bond CM, Mollison J, Ludbrook A. Oral versus intra-vaginal
imidazole and triazole antifungal treatment of uncomplicated vulvovaginal candidiasis
(thrush). Cochrane Review. The Cochrane Library, Issue 2, 2004
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© Pharmacy Guild of New Zealand (Inc) 2006
WARTS
Podophyllin
Warts and varrucae are caused by Human Papilloma Viruses (HPV). There are
over 60 types of HPV and a variety of different presentations.
Warts are more common in children and teenagers than in adults and are spread
by direct contact or self infection (auto-inoculation). If a wart is picked or
scratched viral particles can be spread to other areas.
Types of warts
Common warts Seen on the fingers, backs of hands, around the nails and on
the legs. Usually have a rough ‘cauliflower like’ surface. Can
occur at the site of a scratch or injury.
Plantar warts Located on the soles of the feet. The pressure of walking on
them flattens them and pushes them into the skin. Can be
painful. When plantar warts grow in clusters they are known
as mosaic warts. There may be pinpoint black dots visible
(clotted blood vessels).
Flat warts Small smooth growths that appear in groups, most often on
the face.
Anogenital warts Occur in the anogenital region including the mucosal surface
of the vagina, anus or urethra. Often transmitted sexually.
Filoform warts Long narrow thin growths that commonly appear on the
eyelids face or neck.
(Ref sources53,54)
Skin cancers are sometimes mistaken for warts so ask about the history of the
wart particularly any change in appearance ie shape, size, colour and if there
has been any bleeding.
53
Dept of Dermatology, St Vincent’s Hospital. Dermatology within the Pharmacy. 1998
54
NZ Dermatological Society Website, Dermnet. www.dermnet.org.nz
55
Martindale. The Complete Drug Reference. Micromedex via www.pgnz.org.nz
56
Data Sheet. Posafilin. New Ethicals Compendium. 8th Edition 2004
37
© Pharmacy Guild of New Zealand (Inc) 2006
Location?
Refer
• Warts on the face as self treatment may lead to scarring.
• Warts in the anogenital region require medical referral for examination,
diagnosis and treatment.
• Warts covering a large area or multiple warts.
• Any wart-like lesion that changes colour or size.
Pregnant or breastfeeding?
Wart treatments containing podophyllin should not be used by women who are
pregnant or considering pregnancy. Cases of congenital malformations following
the topical use of podophyllin during pregnancy have been reported.57
Refer if self treatment for three months or more has been unsuccessful.
Applying podophyllin
• Soften the wart in a bath or bowl of hot soapy water. Remove any hard
skin from the surface of the wart using a pumice stone or emery board.
• Protect the surrounding skin by applying Vaseline or zinc oxide plaster.
Apply the podophyllin product directly to the wart.
• Do not apply to healthy skin.
• Do not apply to broken skin.
• If treatment makes the area sore, stop treatment until discomfort settles
then try again.
• Repeat the treatment daily if using paint or every 2-3 days if using
ointment, removing dead skin between applications.
57
Briggs G, Freeman R, Yaffe S. Drugs in Pregnancy and Lactation. 5th Edition. 1998
38
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is not recommended for patients with large, rapidly multiplying or painful warts
or warts that have been present for more than two years.
Only a small number of warts should be treated at any one time due to the risk
of systemic toxicity. 56
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APPENDIX
A: Drugs which have been taken by a large number of pregnant women and
women of childbearing age without any proven increase in the frequency of
malformations or other direct or indirect harmful effects on the foetus having
been observed.
B1: Drugs which have been taken by only a limited number of pregnant women
and women of childbearing age without an increase in the frequency of
malformation or other direct or indirect harmful effects on the human foetus
having been observed. Studies in animals have not shown evidence of an
increased occurrence of foetal damage.
B2: Drugs which have been taken by only a limited number of pregnant women
and women of childbearing age without an increase in the frequency of
malformations or other direct or indirect harmful effects on the human foetus
having been observed. Studies in animals are inadequate or may be lacking, but
available data show no evidence of an increased occurrence of foetal damage.
B3: Drugs which have been taken by only a limited number of pregnant women
and women of childbearing age without an increase in the frequency of
malformations or other direct or indirect harmful effects on the human foetus
having been observed. Studies in animals have shown evidence of an increased
occurrence of foetal damage, the significance of which is considered uncertain in
humans.
D: Drugs which have caused, are suspected to have caused or may be expected
to cause, an increased incidence of foetal malformations or irreversible damage.
These drugs may also have adverse pharmacological effects.
X: Drugs which have such a high risk of causing permanent damage to the
foetus that they should not be used in pregnancy or when there is a possibility of
pregnancy.
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