Transcript OTC Meds MATA 2016x

OTC Medications:
Need to Know Info for the
ATC
(how not to let Walgreens kill
somebody)
MATA Annual Meeting 2016
P. Brent Smith, MD, MSc, FAAFP
Primary Care Sports Medicine
Family Medical Clinic Cleveland, MS
Objectives
Review the “schedules” for classifying drugs
Review the practical difference between prescription and “Over
the Counter” (OTC) Meds
Review the professional and legal ramifications of
providing/administering OTC medications to athletes with or
without physician oversight
Review the most common types of over the counter medications
including their common dosing, benefits, adverse effects, and
interactions
Review potential areas of misuse of over the counter medications
Disclosures
I have no professional relationships, conflicts of interests,
etc… to disclose.
I do shameless steal images off the internet....which is why
there are so many pictures coming up.
I tried to avoid deep biochemistry/pharmacology jargon
However, I’m always open to new potential conflicts of
interest.
Why you ask?
In all seriousness….
All that follows are suggestions.
The dispensing of medication of any type by an ATC is
a tricky proposition. (more on this later)
Advice #1: If you’re giving it for more than 24-72you
need to be talking about it with a doctor
Advice #2: Have a primary care (preferably primary
care sports medicine doctor) who loves you enough to
give you their phone number.
What makes a drug available
over the counter…?
Many drugs are available over the counter (OTC), but
can also be prescribed
Many dangerous drugs are available over the counter,
in fact some drugs are available OTC and prescription
Many OTC drugs have potentially dangerous side
effects…
Drug Schedules
Originally began as a method to control addictive substances.
Schedule I- illegal
No Medically accepted use (Heroin)
Schedule II- Highly addictive
No refills (Norco)
Schedule III- Addictive
Considered less addictive than I and II (Ultram)
Schedule IV- Potentially addictive
Xanax
Schedule V- Minimally addictive
Lyrica
Food and Drug Administration
A division of the Department of Health and Human
Services (Which also administers medicare/medicaid)
800 approved ingredients that are combined to create
over 100000 OTC drugs
Founded in 1906
Approximately 15000 employees in their headquarters
and 223 field offices
What does the FDA regulate…?
Food
Drugs
Biologics
Medical Devices
Electronic products that give off radiation
Cosmetics
Veterinary Products
Tobacco Products
OTC versus Prescription
Prescription- regulated by the FDA New Drug
Application Process, prescribed by physician/NP/PA,
available at a pharmacy, intended for one person
OTC- regulated by the FDA through OTC Drug
Monographs
FDA Process for New Drugs
Discovery of new drug molecule
Patent filed (10 year timeline)
Continued development
FDA Trials
Released to Public
1-800-BadDrug
The Pain Relievers
Aspirin
NSAID’s
Advil (Ibuprofen)
Aleve (Naproxen)
Acetaminophen (Tylenol)
Aspirin (The OG NSAID)
Acetysalycilic acid (ASA)
Analgesis, anti-pyretic, anti-inflammatory
Also decreases platelet activity (this is why we use it for
heart attack patients)
Inhibits Cyclooxygenase (more COX 1 than COX 2)
Derived from willow tree bark, properties known for
more than 2 millenia, first isolated in 1763, synthesized
in 1897
Reye’s Syndrome
Encephalopathy, brain edema, and fatty liver. Rare but
occurs when given to children with viral illnesses.
Varying recommendations for age at which it is safe to
give… 12-16 yo.
NSAID’s
Non-Steroidal Anti-inflammatories
Acts on prostaglandin and thromboxane synthesis
Less adverse effects than steroids (weight gain, brittle
bones, suppression of natural corticosteroid production)
Principal adverse effects are gastric upset (10-20%) and
renal damage
Ibuprofen (Advil) and Naproxen (Aleve)
Same drug OTC and prescription, difference is in
strength
NSAID’s continued
Naproxen sold in 220 mg tablets, prescription is 250 or
500 mg tablets
Ibuprofen 200 mg tablets sold in packs of two or
advised to take 2 from bottle.
Prescription is up to 800 mg.
Max dose is 800mg every 8 hours
Anti-inflammatory effects kick in above 600 mg.
Tylenol
Acetaminophen (paracetomol)
Antipyretic, analgesic, not very anti-inflammatory
(blocks COX 2 in the brain)
Discovered in 1877, exact mechanism still unclear
High doses can cause liver damage (4 grams in adults)
Most effective for pain, fever reduction is mainly for
higher temps. Commonly used in conjunction with
opiates
Excedrin
Recommendations
Keep a bottle of Tylenol and Ibuprofen (gel caps) in
your bag/cabinet
Give under 18 with parents permission
Give over 18 x 1-2 days, before reconsidering
Keep a bottle of chewable 325 mg Aspirin in your bag.
Tape the lid on it. Hope it expires before you have to
use it.
Cough and Cold
Antihistamines
Decongestants
Anti-tussives
Expectorants (Mucinex)
Often combinations with or without tylenol/ibuprofen
Anti-histamines
Stabilize histamine cells (H1 cells) making you less
reactive to antigens and reduces the inflammatory
cascade
Claritin (loratidine), Allegra (fexofinadine), Zyrtec
(ceterizine)
Roughly equal efficacy, sometimes mixed with
pseudoephedrine (Claritin-D)
Decongestants
Vaso-constrictors
Can be intranasal or oral
Stinging/burning sensation after use. Help with nose
bleeds too. But can also cause nose bleeds with
continuous use.
Sudafed PE
Pseudoephedrine
Stronger and more effective decongestant
Now prescription strength in MS, because it can be
used in the manufacture of Methamphetamine
Is still available OTC in neighboring states, though
behind the counter and monitored
It is ILLEGAL to buy and bring it back into MS even if
just for personal use.
Anti-tussives
Dextromethorphan (Robitussin DM)
Diphendyramine (Benadryl)
Effective but principle side effect is sleepiness and has
an abuse potential
Remember that benadryl potentiates the affects of
some other medications
Recommendations
Pick one decongestant and one cough suppressant,
keep it in your bag.
Give to minors with parents permission
Give to Adults for up to 72 hours
Consider keeping saline nasal spray and Afrin Nasal
Spray in your bag
Reflux Medications
Proton pump inhibitors (Nexium), Histamine 2
blockers (Zantac) and acid neutralizers (Tums)
Globally, there is no difference between OTC and Rx
formulations, the Rx is just stronger
OTC’s are safe and can be used for long periods of
time, except frequent use of the acid neutralizers
Milk-Alkali syndrome results from pH alterations and
excess calcium and can lead to kidney failure or death
Diuretics and Bowel Meds
Anti-diarrheals
Laxatives
Diuretics
Anti-diarrheal
Work by slowing gastric motility, or by changing the
pH of the gastric contents.
Milk of Magnesia
Bismuth subsalcylate (Pepto Bismol)
Loperamide (Immodium)
Main aim of treatment is stop/prevent dehydration
Remember that not all diarrhea is bad….
Laxatives
Stimulant versus bulk/osmotic
Be very careful when using laxatives, especially
stimulant laxatives
Stimulant laxatives can negatively affect your
electrolytes, can damage the colon over time, and can
be abused for weight management purposes.
Diuretics
Most feature some form of caffeine
Weight control, menstrual bloating
“Family Planning”
Plan B- Emergency birth control
Levonorgestrel- which is a common ingredient in oral
birth controls and is the hormone present in Mirena
Vitamins and Supplements
In some ways the trickiest category we will discuss,
simply because some of these are not FDA
approved/studied.
Rules and Regulations related to ATC’s
High Points
Clearly defined policy regarding who can give OTC
meds, how they are dispensed and what meds are
stocked and how they are stored
Avoidance of distribution to minors without parental
consent
My Recommendations
Have a clearly defined, written and signed policy
statement that covers drug administration in the
training room and elsewhere
Keep locked up, stored properly, and clearly labeled
Keep a log of who, what, when and where
Be strict about time limits for dispensing medications
Have a team physician involved in your process
Areas of Abuse
Overuse of NSAID’s and tylenol
Using laxatives to maintain weight, body image
Using diuretics for the same
Caffeine
Cough syrup
Thank you
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