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Cold
Symptoms – sore throat, sneezing, runny/blocked nose, cough, mild fever, pressure in ears, headache, myalgia (pain in muscles)
Duration – 1-2 weeks, symptoms peak 2-3 days, incubation period 10-12 hrs
Referral criteria – suspected flu, earache not responding to analgesia, sinus pain not responding to decongestants, no improvement after 10-14 days self-medication
Complications - immunocompromised, who smoke, and with comorbidities such as diabetes mellitus, congestive heart failure, asthma, chronic obstructive pulmonary disease, cystic fibrosis, and sickle-cell disease
Sinusitis – prolonged nasal congestion and facial pain
LRTI - acute bronchitis, acute exacerbation of asthma or chronic obstructive pulmonary disease (COPD), and community-acquired pneumonia
Acute otitis media – common in younger patients
Differential diagnosis
Meningitis – high fever, drowsiness, blank expression, vomiting, loss of appetite, high pitched screaming, non-blanching rash, photophobia, severe headache, malaise
Upper airway obstruction – noisy breathing, drooling, inability to swallow.
Nasal foreign body – persistent discharge from 1 nose with no other symptoms
Management – paracetamol or ibuprofen for headache, muscle pain or fever – only continue use if distressed, change to other agent if not alleviated, don’t give both together
Paracetamol contraindicated in – liver/kidney problems, epileptic
Ibuprofen contraindicated in – pregnancy, perforated stomach, increased bleeding, severe HF, kidney or liver problems, high BP, asthma, hay fever
Intranasal decongestants – improve breathing and promote sleep and has fewer S/E than oral decongestants. Ephedrine HCL 0.5% nasal drops for 12 and older p 1-2 drops 4x daily for 1 week – contraindicated – diabetes, hypertension, hyper thyroidism, CVD, high BP, MAOI in last 2 weeks
Oral decongestants – relieve nasal congestion (phenylephrine) – max 1 week
Antitussive (cough) – dextromethorphan
Expectorants (guaifenesin)
Chlorphenamine or Beecham’s (contains phenylephrine and paracetamol) (Sedating antihistamine – dries up secretions)
Counselling points
Go to GP if
fever for more than 3 days
symptoms worsening after 5 days
symptoms not better after 10 days
follow up meeting
risk and complicated patients within the week
young children – 1 week
Headaches
Types of headaches
Primary – not associated with other conditions – migraines, tension types, cluster
Secondary – associated with other conditions – trauma/injury, vascular disorders, hyper-tension, withdrawal such as opioids, analgesics, or alcohol. Bacterial or viral infection.
Features of serious headache – referral
New severe or unexpected headache – sudden onset reaching max intensity 5 mins and new onset in over 50s
Progressive or persistent headaches that changed dramatically
Associated features – fever, impaired consciousness, seizure, stiffness, photophobia, neurological deficit, cognitive dysfunction, atypical aura (greater than 1 hour) or aura 1st time in patients using combined oral contraceptives.
Dizziness, visual disturbance, vomiting. Head trauma up to 3 months prior, triggered by coughing, sneeze, or physical exertion. Worsened by standing or lying down.
Compromised immunity
Diagnosis
Migraine without aura – at least 5 attacks lasting 4-72 hrs with unilateral location (half the face), pulsating, moderate to severe pain and aggravated by or causing avoidance of routine physical activity. Attack comes with nausea and/or vomiting, photophobia and phonophobia
Migraine with aura – 2 attacks with visual aura (zigzag lines or blind spots), pins and needles, speech/language symptoms, motor weakness, vertigo.
One aura spreading gradually for 5 mins and 2 or more occurring after
Each aura lasts for 5-60mins which is unilateral
Management – stop combined oral anticontraception – contraindicated
Ibuprofen 400mg, paracetamol 1g, advise med to be taken at start of attack – follow up 2 weeks
Tension type – recurrent episodes lasting 30 mins – 7 days with NO nausea or vomiting. May have phot/phono phobia
Bilateral (across head landscape), pressing or tight (not pulsating), mild to moderate pain, not aggravated by physical activity
Management – simple analgesia – paracetamol or NSAID
Identify comorbidities such as stress, mood disorders, chronic pain, sleep disorders to manage
Cluster headache – 5 attacks of severe/very severe unilateral orbital (around ONE eye), forehead or temporal pain lasting 15 mins to 3 hrs with nasal congestion, runny nose, eyelid oedema, sweating, facial slushing, fullness in ear or restlessness
Attacks occur between one every other day and 8 per day for more than half the time the disorder is active
Management – REFER
Advise to avoid triggers and risk of medication overuse, identify and manage comorbidities – insomnia, depression, and anxiety
Medication – occurs 15 days per month and have a pre-existing headache disorder. Regular overuse of drugs for 3 months
Management – withdrawal from medication and advice around this
Sinusitis
Sinusitis usually follows a cold and lasts less than 12 weeks
If over 12 weeks becomes chronic – risk groups are allergic rhinitis, asthma, immunosuppression
Symptoms
Adults
Nasal blockage (obstruction/congestion), nasal discharge, facial pain/pressure, frontal headache, loss, or reduction of smell, altered speech indicating nose blocked. Tenderness, swelling. Redness over cheekbone, cough, headache worse when bending or lying down. Toothache.
Children
Nose block, discoloured nasal discharge, facial pain, pressure and or cough at day or night-time
Bacterial sinusitis
More than 10 days, discoloured, pussy discharge (from 1 nose), severe local pain (1 side), fever over 38 degrees, deterioration after milder sickness
Refer to hospital immediately
If they have symptoms of acute sinusitis and;
Severe systemic infection
Intraorbital or periorbital complications, including periorbital oedema or cellulitis, displaced eyeball, double vision, or new reduced vision
Intracranial complications, including swelling over frontal bone, symptoms or signs of meningitis, severe frontal headache, or focal neurological signs
Refer to GP
Severe symptoms, painkillers don’t work, symptoms worsen, symptoms don’t improve after 1-week, recurrent infection, sudden worsening, antibiotic failure, unusual or resistant bacteria, recurrent episodes, immunocompromised, allergic cause
Treatment
Acute with symptoms less than 10 days
DON’T OFFER ANTIBIOTIC, assure that it usually self resolves without bacterial complications. Symptoms managed
Paracetamol or ibuprofen for pain, headache, and fever
Use nasal saline spray or decongestants spray
Clean nose with saltwater solution (boil 1 pint of water and add 1 teaspoon of salt and bicarbonate soda. Wash hands, stand over sink, cup the palm of 1 hand and pour small amount of solution into it. Sniff water into 1 nostril at a time, breath through mouth and allow water to pour into sink, don’t let it go into your throat. Do 3x daily)
Acute for 10 days or more with no improvement
High dose nasal corticosteroid for 2 weeks for over 12s (mometasone 200mcg 2x daily)
Counsel that It may improve symptoms but won’t make the infection any shorter, could have systemic effects, may be difficult to use correctly.
Symptoms should get better 3-5 days of treatment – REFER if not
1st line antibiotic for adult
If not life threatening - phenoxymethylpenicillin 500 mg four times a day for 5 days.
Is systemically unwell, symptoms of more serious illness or high risk of complications - co-amoxiclav 500/125 mg three times a day for 5 days.
Allergic or intolerant to penicillin - clarithromycin 500 mg twice a day for 5 days.
Pregnant or intolerant to penicillin - erythromycin 250 mg to 500 mg four times a day or
Children 1st line
Phenoxymethylpenicillin
1 to 11 months, 62.5 mg four times a day for 5 days.
1 to 5 years, 125 mg four times a day for 5 days.
6 to 11 years, 250 mg four times a day for 5 days.
12 to 17 years, 500 mg four times a day for 5 days.
If very unwell - co-amoxiclav
1 to 11 months, 0.25 mL/kg of 125/31 suspension three times a day for 5 days.
1 to 5 years, 5 mL of 125/31 suspension three times a day or 0.25 mL/ kg of 125/31 suspension three times a day for 5 days
6 to 11 years, 5 mL of 250/62 suspension three times a day or 0.15 mL/kg of 250/62 suspension three times a day for 5 days.
12 to 17 years, 250/125 mg three times a day or 500/125 mg three times a day for 5 days.
If allergic or intolerant to penicillin – clarithromycin
Under 8 kg, 7.5 mg/kg twice a day for 5 days.
8 to 11 kg, 62.5 mg twice a day for 5 days.
12 to 19 kg, 125 mg twice a day for 5 days.
20 to 29 kg, 187.5 mg twice a day for 5 days.
30 to 40 kg, 250 mg twice a day for 5 days.
12 to 17 years, 250 mg twice a day or 500 mg twice a day for 5 days.
2nd line – if symptoms are still worsening after 1st line treatment for 2-3 days
Adults – co-amoxiclav 500/125mg TD x 5 days
Children – specialist advice
ANTIHISTAMINES can be prescribed for allergic triggered sinusitis
Diabetes type 1
Body stops making insulin and the blood sugar (glucose) level goes extremely high - persistent hyperglycaemia (random plasma glucose of 11mmol/l or more). We must control glucose level with insulin injections, healthy diet and reduce the risk of other health complications. Typically occurs in children and young adults.
Symptoms of T1D- Frequently thirsty, pass a lot of urine, tiredness, weight loss and feeling generally unwell. Develops quite quickly, over days or weeks, as the pancreas stops making insulin.
Pathophysiology of T1D- Autoimmune disease (environmental & genetic factors). Antibodies attach to the beta cells in the pancreas destroying the cells that make insulin (pancreatic islet cells).
Diagnosing T1D- Simple dipstick test to detect glucose in a sample of urine BUT only way to confirm the diagnosis is to have a blood test to look at the level of glucose in your blood (level of 11.1 mmol/L or more in the blood sample indicates that you have diabetes) PLUS a fasting blood glucose level is taken (level of 7.0 mmol/L or more indicates that you have diabetes).
Management- Should be offered multiple daily injection basal-bolus insulin regimens as the first-line choice. Twice-daily insulin detemir should be offered as the long-acting basal insulin therapy. Once-daily insulin glargine may be prescribed if insulin detemir is not tolerated, or if a twice-daily regimen is not acceptable to the patient. Insulin detemir may also be offered as an alternative once-daily regimen. There are multiple types of insulin…
Rapid Acting- Insulin Aspart (Novorapid®), Lispro (Humalog®) and Glulisine (Apidra®)
Short Acting- Soluble insulin (Actrapid®)
Intermediate Acting- Isophane (Insulatard® or Humulin I®) & NPH - neutral protamine Hagedorn
Long Acting- Insulin glargine (Lantus®), detemir (Levemir®)
Combination insulins (biphasic)- e.g., Novomix 30®, Humalog Mix 25®, Humalog Mix 50®, Humulin M3® and Insuman Comb 50®
Diet & Lifestyle- Diet low in fat, salt, and sugar and high in fibre and with plenty of fruit and vegetables. If you are overweight try to lose weight, increase your physical activity even if it’s only going for a walk (community groups)
Other Health Complications- Get regular checks with your GP, podiatrist, and optometrist. Also get the flu jab every year.
Complications – microvascular, macrovascular (MI, stroke), metabolic (diabetic ketoacidosis) and hypoglycaemia (blood glucose less than 3.5mmol/l)
Psychological complications – anxiety, depression, and eating disorders and those at increased risk of developing autoimmune diseases
Suspect DKA in diabetics – greater than 11mmol/L
Increased thirst and urine frequency, inability to tolerate fluids, persistent vomiting, diarrhoea, visual disturbance, lethargy, fruity smell on breath, deep sighing when breathing and dehydrated
Management
HbA1c levels target of 48mmol/mol or lower - Measure 3-6 months but more often if not controlled
Self-monitoring – need glucose monitor, lancet, finger pricking device and testing strips
Taught at diagnosis and review technique 1 yearly.
Before breakfast, 2 hours after meals, during illness, before driving, if they feel hypo – at least 4 times a day including before and after meals and before bed.
More frequency required (up to 10x daily) if
Target HbA1c not achieved, frequency of hypo increases, during illness, before, during and after sports, planning, during and while breastfeeding.
Target glucose readings
Fasting plasma glucose level of 5–7 mmol/L on waking.
Plasma glucose level of 4–7 mmol/L before meals at other times of the day.
For adults who choose to test after meals, plasma glucose level of 5–9 mmol/L at least 90 minutes after eating.
Agree bedtime target plasma glucose levels with the person. This should:
Consider the timing of the last meal and its related insulin dose.
Be consistent with the recommended fasting level on waking.
Provide information of effects of food and drinks – carbohydrate training (match carb quantities to insulin doses)
Educate to be careful of body weight and diets, feasting and fasting, fibre and protein intake, diabetic foods and sweeteners, alcohol intake, matching carbs with insulin and physical activity
Advice on alcohol – avoid drinking on empty stomach, eat carb snack before and after drinking (extra insulin not required). Measure glucose more regularly and maintain it with carb intake. Alcohol can exacerbate or prolong hypoglycaemic effect.
Exercise – lower glucose levels and reduces CVD risk and can help weight
Sick day rules – never stop or skip insulin – dose may need altering seek advice. Check blood more frequently – 1-2 hours including in the night. Check blood or urine ketone levels – 3-4 hours including night and if 2+ or 3mmol/l or higher then contact GP immediately.
Maintain normal meal pattern where possible if not then replace meals with carb rich drinks, milk, fruit juices and sugary drinks. Aim to drink at least 3L of fluid to prevent dehydration.
Offer multiple daily injection basal-bolus insulin regimens as the first-line choice to all adults with type 1 diabetes.
Offer twice-daily insulin detemir as the long-acting basal insulin therapy
Offer a rapid-acting insulin analogue injected before meals for mealtime insulin replacement
If a multiple daily injection basal–bolus insulin regimen is not possible and a twice-daily mixed insulin regimen is preferred
Insulin pump therapy is recommended as a treatment option for adults with type 1 diabetes mellitus if condition isn’t controlled by treatment
Diabetes type 2
The body still makes insulin however, you do not make enough insulin for your body's needs OR the cells in your body do not use insulin properly (insulin resistance means you need more insulin than normal make to keep glucose levels down. Occurs mainly in people aged > 40 but inc diagnosed in younger people, commonly associated with obesity, physical inactivity, raised blood pressure, dyslipidaemia, and a tendency to develop thrombosis (CV risk).
Symptoms of T2D- Gradual (weeks-months) and can be quite vague at first. Frequent thirst, passing large amounts of urine, tiredness, which may be worse after meals. Some people also develop blurred vision and frequent infections, such as recurring thrush.
Management- Metformin HCl 1st choice for treatment of all patients (à weight loss, red risk of hypoglycaemic events and long-term CV benefits). Has an anti-hyperglycaemic effect, lowering both basal and postprandial blood-glucose conc. It does not stimulate insulin secretion and therefore, when given alone, does not cause hypoglycaemia. If metformin contra-indicated/not tolerated trial MR formulation or initial treatment should be a sulfonylurea e.g. gliclazide OR a dipeptidyl peptidase-4 inhibitor e.g. linagliptin OR Pioglitazone.
Insulin- can be added if intensification of treatment needed. If needed, bedtime basal insulin should be initiated, and the dose titrated against morning (fasting) glucose.
Diet & Lifestyle- Avoid foods heavy in saturated/trans fats, beef and processed meats, sugary drinks, high-fat dairy products and salty/fried foods & have fibrous fruits and vegetables, high omega-3 fatty acid food and poly/monosaturated fats. Lose weight and inc physical activity (min 5 x 30 min brisk walk / week) and smoking cessation. Also see optician regularly in case of damage to retina, GP and podiatrist.
EXTRA INFO FOR BOTH
Holiday- Pack about x3 the amount of insulin needed, test strips, lancets, needles or glucose tablets you would use, in case you need it (take cool bag to avoid insulin getting too hot). Carry your medicine in your hand luggage just in case checked-in bags go missing or get damaged (insulin can freeze and render it unusable). If injecting (i.e. will have needles/sharps) get a letter from your GP that says you need it to treat diabetes. If you use a pump or CGM, check with your airline before you travel about taking it on board as may require paperwork for medical equipment. If you use a pump, pack insulin pens in case it stops working. Take plenty of snacks in case there are any delays. Do not put your pump through the hand luggage scanner – let airport security know so they can check it another way.
<18 & Diabetic- Paediatric diabetes care team until 18 will help w injecting insulin, testing blood glucose levels, and diet. They can give advice on school or nursery and talk to your child's teachers and carers. Initially, every 1 - 2 weeks but will eventually be every 3 months.
Check Ups Needed- Annually get feet checked by podiatrist to check for loss of feeling in your feet, and for ulcers and infections. Get your eyes checked to check for any damage to blood vessels in the eyes, and checks for high blood pressure, heart, and kidney disease by your GP, also ensure to book in annually for a flu jab. Every 3 months have a blood sugar test (HbA1C test) checks your average blood sugar levels and how close they are to normal when newly diagnosed, then every 6 months once you're stable (~48-53 mmol/mol recommended).
Education- free education courses to help you learn more about and manage your diabetes, your GP will need to refer you. Diabetes UK run local charities for extra support, their website plus the NHS website offers a lot of diabetes information and advice. Maybe invest in a medical ID to carry w you.
Extra Lifestyle Advice- Eat a meal w carbs (e.g. pasta) before you drink alcohol and make sure people around you can recognise a hypo, choose diet soft drink mixers where possible, check your blood glucose regularly/before bed/the next day, drink plenty of water the next day. Avoid hypos by eating the right amount of carbs before, during and after exercise, adjust your insulin and check your blood glucose regularly, drink plenty of water. Recommended to have HbA1c <48mmol/mol when pregnant as high blood glucose levels can harm your baby, especially in the first 8 weeks of pregnancy, also a risk of having a large baby, which can cause complications during labour. Speak to your diabetes team If you're planning to get pregnant or if you get pregnant unexpectedly.
Item for disposal
Method of disposal
Needles
Sharps bin
Lancets
Sharps bin
Used blood test strips
Sharps bin
Leftover/expired insulin
Sharps bin/return to pharmacy
DVLA- tell the DVLA you’re diabetic or you could get fined due to hypoglycaemia/low sugar levels crisis. Check your blood glucose no longer than 2 hours before driving, check your blood glucose every 2 hours if you're on a long journey, travel with sugary snacks and snacks with long-lasting carbs, like a cereal bar or banana. If you feel your levels are low: stop the car when it's safe, remove the keys from the ignition, get out of the driver's seat, check your blood glucose, and treat your hypo, don't drive for 45 minutes from when you feel normal again.
Sharps Removal- Patients issued a sharps bin from the diabetes clinic/hospital on first diagnosis. Some pharmacies offer this sharps disposal service, or the diabetes clinic do too. Can arrange w GP/LHB for sharps collection (Cardiff Council does NOT offer kerbside sharps disposal)
Other Technologies- Insulin Pump (attached to skin via tiny tube which is replaced every 2-3 days & pump moved to diff part of body) will deliver a set background amount of insulin into blood day and night, can add your extra mealtime insulin using the pump. Continuous glucose monitoring (CGMs) means you can check your sugar levels at any time (see patterns in your levels, sends an alert if glucose too high/low) but as interstitial fluid sugar readings are a few mins behind your blood sugar levels you'll still need to do finger-prick checks every now and then. It’s a sensor you attach to your abdomen which needs replacing every 7 days, but some models can be worn for months. Free Style Libre is a flash glucose monitoring system measures your glucose levels continuously throughout the day via interstitial fluid (few mins behind). Attach sensor to your arm and a reader will scan to see your sugar levels (can also use a smartphone app to scan the sensor), sensors usually last for 14 days.
Testing blood glucose
Glucose monitor, specific in-date test strips, primed lancing device and cotton wool pad.
PRIMING LANCET
Twist cap off lancing device
Place fresh lancet into device so grooves line up and twist off the cover, so the needle is visible – change lancet every time so you don't get skin infections
Replace device cap - it should click and then adjust the depth metre – how far the needle will puncture – this is personal preference
Pull sliding barrel at bottom of device back to prime the lancet
CALIBRATING MONITOR
Turn on monitor – put new in-date test strip inside it and test it with in-date control solution – to make sure readings are correct
Do this every time you open a new pack of test strips, if you damage your monitor and if you think the readings are wrong.
TESTING process
Wash hands with warm water and soap and dry. Then rub hands for 10 seconds – warms hands to improve blood flow to fingers
Turn on monitor and place strip inside and wait for it say it’s ready for blood
Place device firmly on side of the finger (less nerves so less painful) and press release button then remove device from site. - change fingers regularly to stop hardening of skin.
Wipe first drop of blood away with cotton pad, use second one to test make sure by touching the blood onto the test strip
If successful wipe blood with cotton pad and apply plaster
Note readings
Remove cap of device exposing lancet. Place lancet cover on table and press lancet hard into this blue plastic cover – this will cover the needle and make it easy to remove
Place lancet and cotton pad in bin
Injecting insulin
Inject in stomach, thighs, or buttocks. Inject an inch away from previous site. Prevents lumps – this reduces absorption of insulin.
check that its correct insulin and is in date. Always check manufacturer’s instructions.
Wash hands with soap and warm water
Attach needle to pen – peel back cover, screw cap onto pen, remove white outer cover and the green cover to expose needle – change needle every time
Dial to 2 units and push plunger so you can see insulin coming out – to make sure no air stuck in there – can take multiple goes in new pens
Set correct dose
Press directly into skin and inject slowly – count to 10
Remove needle straight without bending it
Use the white outer cap to remove the needle and dispose in yellow sharps bin
Asthma
Symptoms – episodic, worse at night/early morning, triggered by exercise, infection and exposure to cold air or allergens. Triggered by emotion and laughter in children. In adults by NSAIDS and BB use.
Common with atopic eczema, dermatitis and allergic rhinitis and family history
ACUTE EXACERBATION OF ASTHMA IN ADULTS
First-line treatment for acute asthma is a high-dose inhaled short-acting beta2 agonist (such as salbutamol) given as soon as possible. For patients with mild to moderate acute asthma, a pressurised metered-dose inhaler and spacer can be used. For patients with acute severe or life-threatening symptoms, administration via an oxygen-driven nebuliser is recommended, if available. If the response to an initial dose of nebulised short-acting beta2 agonist is poor, consider continuous nebulisation with an appropriate nebuliser. Intravenous beta2 agonists are reserved for those patients in whom inhaled therapy cannot be used reliably.
In all cases of acute asthma, patients should be prescribed an adequate dose of oral prednisolone. Continue usual inhaled corticosteroid use during oral corticosteroid treatment. Parenteral hydrocortisone or intramuscular methylprednisolone are alternatives in patients who are unable to take oral prednisolone.
IN CHILDREN OVER 2
First-line treatment for acute asthma is an inhaled short-acting beta2 agonist (such as salbutamol) given as soon as possible. For children with mild to moderate acute asthma, a pressurised metered-dose inhaler and spacer device is the preferred option. The dose given should be individualised according to severity and adjusted based on response. For children with acute severe or life-threatening symptoms, administration via an oxygen-driven nebuliser is recommended, if available. Parents/carers of children with acute asthma at home, should seek urgent medical attention if initial symptoms are not controlled with up to 10 puffs of salbutamol via a spacer; if symptoms are severe, additional bronchodilator doses should be given as needed whilst awaiting medical attention. Urgent medical attention should also be sought if a child's symptoms return within 3-4 hours; if symptoms return within this time, a further or larger dose (maximum of 10 puffs of salbutamol via a spacer) should be given whilst awaiting medical attention.
COPD
Symptoms - persistent respiratory symptoms and airflow obstruction, which is usually progressive and not fully reversible, exertional breathlessness, chronic/recurrent cough, or regular sputum production, wheeze
Treatment – education on condition and risk factors, smoking cessation, pneumococcal and flu vaccination yearly, treatment of associated comorbidities
1st line – SABA or SAMA to relieve breathlessness and improve exercise tolerance – reviewing medication, adherence, and inhaler technique regularly
THEN IF they have NO asthmatic features or no features of steroid responsiveness – offer LABA AND LAMA
If they continue to have day-to-day symptoms, consider 3-month trial of LABA+LAMA+ICS
If NO improvement go back to LAMA+LABA only but if it works continue and review annually
If they have asthmatic or steroid responsiveness features offer LABA+ICS if they have day to day symptoms of 1 severe or 2 moderate exacerbations a year, then offer LABA+LAMA+ICS
WITH ICS DISCUSS RISK OF USING ICS including pneumonia
Acute exacerbation of COPD – triggered by infections, smoking and environmental pollutants
Severe breathlessness, increased cough, increased sputum production and change in colour, increased wheeze, and chest tightness, cold or sore throat, reduced exercise tolerance, ankle swelling, increased fatigue, and acute confusion
FOR SEVERE exacerbation – ADMISSION
FOR non-severe – increase dose or freq of SABA and maybe change to nebuliser for ease of admission
If no contraindications with significant increase in breathlessness – offer 30mg oral prednisolone OD x 5 days or if caused by infection then amoxicillin 500mg TD x 5 days, doxycycline 200mg day 1, 100mg OD x 5 days, or clarithromycin 500mg BD X 5 days
Epilepsy
Cause – abnormal excessive or synchronous brain activity
Symptoms
Short-lived (less than 1 minute), abrupt, generalised muscle stiffening with rapid recovery — suggestive of tonic seizure.
Generalised stiffening and subsequent rhythmic jerking of the limbs, urinary incontinence, tongue biting —suggestive of a generalised tonic-clonic seizure.
Behavioural arrest — indicative of absence seizure.
Sudden onset of loss of muscle tone — suggestive of atonic seizure.
Brief, 'shock-like' involuntary single or multiple jerks —suggestive of myoclonic seizure.
Management
During seizure – protect from injury by placing in recovery position. If tonic-clonic seizure is prolonged (more than 5 mins) or recurrent – emergency buccal midazolam or emergency admission
Annually reviewed – assess seizure control, how it’s affecting QOL, adverse effects and compliance with drug
Women of childbearing age – 13 to 60
Epileptic women not treated with drugs or on non-enzyme inducing antiepileptic (except lamotrigine) – contraceptive options are same as general population
Woman on exyzme-inducing drugs – drug can reduce effectiveness of combined hormonal contraception, progestogen-only pills, transdermal patches, the vaginal ring, and progestogen-only implants. OFFER medroxyprogesterone acetate injections or an intrauterine method (copper intrauterine device or the levonorgestrel-releasing intrauterine system)
Woman on lamotrigine – oestrogen containing contraceptive reduces efficacy of lamotrigine
USE progesterone only instead but educate them to report signs of lamotrigine toxicity
Category 1 (ensure the person is maintained on a specific manufacturer's product) — phenytoin, carbamazepine, phenobarbital, primidone.
S/E – common and usually mild, advise to report and can usually be fixed with dose adjustment or change of drug
Sedation and dizziness, suicidal thoughts and behaviour, acute psychotic reactions, weight gain and loss, skin rashes.
Safe in pregnancies – lamotrigine (Lamictal) and levetiracetam (Keppra) are safest options
Anxiety
Uncontrollable widespread worry and range of cognitive and behavioural symptoms
Slow onset and symptoms don’t usually improve but are better controlled with intervention
Diagnosis – worry associated with restlessness, insomnia and muscle tension, fatigue, poor concentration, irritable. ALWAYS ask about alcohol and drug use including OTC
Treatment
Establish diagnosis and severity of anxiety and any other comorbidities (usually insomnia and depression and whichever is the most pressing is treated first) – explaining the disorder and treatment opportunities and starting them with active monitoring of symptoms either self or through regular meetings
Offer CBT – non-facilitated self-help for 6 weeks, individual guided self-help, educational groups
High intensity CBT, applied relaxation or drug therapy
Drug therapy – 1st line is SSRI (sertraline, paroxetine, or escitalopram) 2nd line SNRI (duloxetine or venlafaxine). If both contraindicated or intolerable then Pregabalin.
Review effectiveness and ADR every 2-4 weeks during first 3 months then every 3 months.
Counsel on common effects during treatment initiation (suicidal thoughts and worsening of anxiety) but importance of reporting this instead of withdrawing from drug
SSRI – don’t take NSAIDS or if prescribed take with PPI
For pregnant women step 3
DO NOT give benzo or antipsychotics in primary care
Benzodiazepines (SCH 3 and 4)
Most commonly used anxiolytics and hypnotics
Short rem relief (2-4 weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress
use to treat short-term ‘mild’ anxiety is inappropriate
Sch 4 CDs, apart from temazepam
Sch 3 (CD no register) and midazolam
Pharmacological effects of benzodiazepines
Sedation, sleep induction
sleep, but can still cause arousal
decreased anxiety, amnesia at higher doses
muscle relaxation (both midbrain and spinal effects)
anticonvulsant activity
Reduced aggression
Depression
Persistent low mood and/or loss of pleasure in most activities and range of emotional, cognitive, physical, and behavioural symptoms
Diagnosis
Low mood
Loss of interest/pleasure from normally pleasurable activities (anhedonia)
Reduced energy (fatigue)
Low self-esteem; feelings of guilt
Inability to think/concentrate
Altered psychomotor activity
Sleep disturbance; early morning wakening
Altered appetite
Suicidal thoughts
Diagnosis requires 2 core symptoms plus 2 or more others present for most of the day on most days for the last 2 weeks
Differential diagnosis
Ensure symptoms are not caused by physical illness, alcohol, medication, or illicit drug use
The symptoms aren’t caused by normal grief (death of family) – maybe consider very long grief
Never been a manic (severe levels of high mood) or hypomanic (to a reduced level) episode
Treatment
Dependant on accurate assessment and diagnosis of depression
Psychological
CBT, behavioural activation, interpersonal psychotherapy, problem solving therapy
Social
Identify stressors and work on strategies/signposting to other supporting organisations
Biological – moderate to severe
Antidepressant therapy or antidepressant and antipsychotic combination therapy in psychotic depression
Drug classes
Tricyclic antidepressants (TCAs) e.g., amitriptyline
Selective serotonin reuptake inhibitors (SSRIs) e.g., fluoxetine
Serotonin and NA uptake inhibitors (SNRIs) e.g., venlafaxine
Monoamine oxidase inhibitors (MAOIs)
Irreversible e.g., phenelzine (MAO-A and B)
Reversible e.g., Moclobemide
Atypical antidepressants e.g., Mirtazapine
Noradrenaline reuptake inhibitors (NRIs) e.g., Atomoxetine
TCA - S/E – Short lasting (days) sedation, confusion, and Incoordination in both normal and depressed patients, antimuscarinic effects, dry mouth, blurred vision, decreased mucus production. Dangerous CV effects in OD
Severe depressive at risk of suicide shouldn’t be given TCA
Interactions – potentiation of the effects of alcohol – alcohol is a depressant and will only compound the depressive effects
SSRI’s - S/E – nausea, anorexia, insomnia, and loss of sexual function
Less anticholinergic side-effects and less dangerous in OD than TCAs. Prolonged QTc – cardiovascular complications risk with citalopram interactions – NSAIDs, Anticoagulants, triptans
SNRI’s - S/E – significant withdrawal effects – have short half-lives so need to be taken regularly to avoid these effects. Complex nature of TCAs makes them difficult to prescribe to complex patients unlike SNRIs
Interactions – NSAIDs and anticoagulants
MAOIs - S/E – antimuscarinic effects, restlessness as a result of CNS excitation
Interactions – serious food and drug reactions e.g., cheese (tyramine from food such as cheese is broken down by MAO. The lack of breakdown from MAOIs can lead to tyramine actively displacing neurotransmitters such as 5HT, DA, NA – causing hypertensive crisis
VERY IMPORTANT COUNSELLING POINTS
No other drugs or illicit drugs with this
Side effects
Drug and food interactions are unacceptable.
“Cheese reaction”: this occurs when amines that are generated during fermentation, like tyramine, are ingested and absorbed from the gut. (The main danger is ripe cheese, yeast products - Marmite).
Large rise in systemic tyramine indirectly results in a large release
of catecholamines
Hypertensive crisis characterised by throbbing
headache, tachycardia & cardiac arrhythmias.
Same can occur with drugs (Pseudoephedrine)
Atypical antidepressants - S/E- sedation, weight gain, increased appetite – good in patients with anorexia or depression causing loss of appetite or weight
Blood disorders – counselling
Withdrawal issues
Can be used with other antidepressants that cause sleep issues
Interactions – alcohol
FDA black box warning – suicide
Treatment
Mild symptoms – psychological therapy
Persistent mild symptoms or moderate to severe symptoms – combination of psychological and drug therapy
1st line treatment usually SSRIs
2nd line switch to alternate SSRI
3rd line switch to different class (normally an SNRI)
Practical issues
Initiating an antidepressant can cause feelings of anxiety consider co-prescribing short course of benzodiazepines to counteract the anxiety
During the first few weeks of antidepressant treatment can have worsening suicidal thoughts with improved motivation so ensure counselling and regular reviews
Consider prescribing limited supply of meds to reduce chance of OD
Side effects often transient and improve with time
Caution when switching antidepressants – table of different half-lives and how to taper them
Treatment approach
If no response to 3 antidepressants, then check concordance, review diagnosis, and consider if social problems are maintaining depression
Consider augmentation – addition of drug to the current therapy
Mirtazapine – sleep
Quetiapine – mood
Aripiprazole
Lithium – mood stabiliser
Lamotrigine – mood stabiliser
Electroconvulsive therapy
Response
2-4 weeks usually for response to be seen (longer in elderly)
Improvement greatest during weeks 1-2
If no response during 2–4-week period, consider first increase in dosage then if again limited efficacy, then switch to alternative
Extended duration if treatment trial will lead to additional benefit in some
Differences between drugs
Mirtazapine, escitalopram, venlafaxine, and sertraline
more efficacious than
duloxetine, fluoxetine, fluvoxamine, paroxetine and reboxetine
Reboxetine less effective overall
Escitalopram and sertraline
better tolerated than
duloxetine, venlafaxine, fluvoxamine, paroxetine and reboxetine
Preventing relapse
Relapse rate 3-6 months post remission is 50% with no drug treatment
A/D treatment reduces absolute risk of relapse by about 50%
After 1st episode continue for 6-9 months
After 2nd episode continue for 12 months
After 3rd episode continue for 2 years
Insomnia – difficulty in getting to sleep or staying asleep long enough to feel refreshed the next morning
Causes
Recreational drugs
caffeine, nicotine, alcohol, cannabis)
Medicinal drugs
anticonvulsants, antipsychotics, b-blockers, SSRIs, MAOIs, steroids, decongestants, Alpha agonists and antagonists, narcotic analgesics
Drug withdrawal
from CNS depressants (eg alcohol, anxiolytics/hypnotics)
Physiological
Diet, late night exercise, shift work (night and evening work)
Environmental
Noise, bright lights, extremes of temperature
Medical conditions
Psychological - anxiety, depression, grief, stress
Non-psychological eg chronic pain, gastric reflux, asthma, sleep apnoea
Types of insomnia
Primary insomnia - insomnia not attributable to a medical psychiatric or environmental cause
Secondary insomnia- insomnia secondary to another condition
Transient (2-3 days) – caused by changes in routine (for eg. change in time zone, alteration of shift work)
Short term (<3 weeks) – may result from temporary environmental stress
Chronic insomnia (>3 weeks) –usually secondary to other conditions
Treatment
FIRST LINE IS ALWAYS NON-DRUG treatments e.g., lifestyle changes and CBT
Drug therapy – Hypnotics
Benzodiazepines
Benzodiazepine-like drugs (Z-class)
melatonin
BEFORE hypnotic is prescribed the cause of insomnia must be established and where possible, underlying factors should be treated
NICE recommends
if hypnotic medicine is the appropriate way to treat one for only short periods of time and strictly according to the licence for the drug. (Usually, 1-2 weeks and max 4 weeks) and should be prescribed on a weekly basis
Benzodiazepines
Most benzodiazepines
decrease time taken to get to sleep
in individuals who habitually sleep <6hr, the drug increases duration of sleep
Few short-acting BDZs recommended for insomnia (short-term treatment – max 2-4 weeks)
Should only be used when SEVERE, DISABLING or causing EXTREME DISTRESS
Benzodiazepine – like drugs
Z -Hypnotics – Zaleplon, zopiclone, zolpidem (Short acting – t1/2 < 8 hr)
Short term use only (2-4 weeks)
Lack of anxiolytic effects –drowsiness or dizziness - just induce sleep
Melatonin treatment
Prolonged release melatonin available for primary insomnia in over 55yr olds (can be used up to 3 weeks)
Antihistamine gen 1 – can cause drowsiness
Anxiolytics
Kalms, Kalms day, Karma, Karmamood, Potters Newrelax, Relaxherb, Stressless
Hops, valerian, passionflower, passiflora, vervain, St John’s Wort
Sedatives
Kalms night, Kalms sleep, Dormesean, Niteherb, Nytol herbal, Potters Nodoff, sominex herbal
Hops, valerian, vervain, skullcap, wild lettuce, passiflora
Some herbal remedies do contain active ingredients so be careful of interactions
Lifestyle changes – promote sleep hygiene
establishing fixed times for going to bed and waking up
trying to relax before going to bed
maintaining a comfortable sleeping environment avoiding napping during the day
avoiding caffeine, nicotine, and alcohol late at night
avoiding exercise within four hours of bedtime
avoiding eating a heavy meal late at night
avoiding watching or checking the clock throughout the night
using the bedroom mainly for sleep if possible
avoid going on phone, looking at screens immediately before bed or whilst in bed
ADHD
Persistent developmentally with inappropriate levels of over reactivity, inattention and/or impulsivity
Diagnosis – based on observation there are no biomed tests
Symptoms – 9 symptoms across 2 domains
Hyperactivity/impulsivity
Inattention
Can be combined type or dominant in one
ADHD – Predominantly inattentive type
Fails to give close attention to details or makes careless mistakes.
Has difficulty sustaining attention.
Does not appear to listen.
ADHD – predominantly Hyperactive/impulsive type
Fidgets with hands or feet or squirms in chair.
Acts as if driven by a motor.
Blurts out answers before questions have been completed.
Difficulty waiting or taking turns.
Interrupts or intrudes upon others.
ADHD – Combined type
Patient meets both sets of inattention and hyperactive/impulsive criteria
ADHD – Differential diagnosis
Sensory impairment – leading to under or over-sensitivity to triggers
Epilepsy and related states – could present as inattention
Effects of head injury
Acute or chronic medical illness
Poor nutrition – linked to poor behavior – not directly linked to ADHD
Sleep disorders – linked to poor behavior – not directly linked to ADHD
Side effects of medication
School or classroom difficulties – bullying or other factors
Large links to exposure to smoking and drinking during pregnancy, childhood illness such as meningitis or other viral infection, low birthweight/prematurity. HIGH heritability
Treatment
Mild-moderate –1st line - parent-training/education programmes with parent and child, group based or individual sessions. Teachers receive ADHD training and offer intervention in schools.
2nd line – CBT or social skills training
3rd line – DRUG THERAPY ONLY FOR SEVERE and should be offered along with psychological, behavioural, and educational interventions
Drug therapy
Methylphenidate – generally first choice
Atomoxetine - if other tics, Tourette's syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present
D-amphetamine – ONLY if other drugs ineffective at raised doses – CD2 high risk in addiction and dependence and misuse so used as last resort
Decide which drug treatment to use based on:
their different adverse effects
potential problems with compliance (for example, if a mid-day dose is needed at school)
potential for drug diversion (taken by others) and misuse
preferences of the child or young person and their parent or carer
When a decision has been made to treat children or young people with ADHD with drugs, healthcare professionals should consider: –
methylphenidate for ADHD without significant comorbidity
methylphenidate for ADHD with comorbid conduct disorder
methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present
atomoxetine if methylphenidate has been tried and has been ineffective at the max dose, or the child intolerant to low or moderate doses of methylphenidate.
Atomoxetine
Closely observe children or young people taking atomoxetine for agitation, irritability, suicidal thinking, and self-harming behavior, particularly during the initial months of treatment, or after a dose change.
Liver damage in rare cases (usually presenting as abdominal pain, unexplained nausea, malaise, darkening of the urine or jaundice).
Treatment of adults
In adults, methylphenidate normally first line treatment
Consider atomoxetine or dexamphetamine if symptoms do not respond to methylphenidate or the person is intolerant to it ~6 weeks.
Selection of appropriate medication
Immediate-release preparations if more flexible dosing is required or during initial titration to using methylphenidate, consider determine correct dosing levels
If there is a choice of more than one drug, use the drug of lowest overall cost
modified-release preparations for convenience…
their pharmacokinetic profile,
improving adherence,
reducing stigma (because the drug does not need to be taken at school)
reducing problems of storing and administering controlled drugs in schools
abuse liability
AUTISM
Symptoms
Socialization
Impaired use of non-verbal behaviors to regulate interactions
Delayed peer interactions, few or no friendships, and little interaction
Absence of seeking to share enjoyment and interests
Delayed initiation of interactions
Little or no social reciprocity and absence of social judgment
Communication
Delay in verbal language without non-verbal compensation (gestures)
Impairment in expressive language and conversation, and disturbance in pragmatic language use
Treatments
NEED early diagnosis and defined biomarkers
Currently intervention is through family and educational support
Only some specific programs have an evidence base
Aim is to ‘improve the functional status…through skill acquisition in core areas’
Eg developing relationships
Achieving social and environmental milestones through play
Positive reinforcement of social communication
Pharmacological treatments for co-morbidities
Developmental
Hyperactivity/impulsivity (see ADHD)
Psychiatric
SSRIs, other antidepressants for depression
atypical antipsychotics for OCD
SSRI or a2 agonists for anxiety
Behavioural
Atypical antipsychotics (irritability, aggression)
Sensory
Neurological
anticonvulsants and fits, a2 agonists for tics
Gastrointestinal
Sleep disruption
melatonin and clonidine
Dementia
Symptoms –
Higher cognitive function affected
Memory, thinking, comprehension, learning capacity, language (speaking and understanding it)
Daily living activities/emotional behaviour (non-cognitive symptoms)
Behavioural and psychological symptoms of dementia (BPSD) – include agitation, apathy, depression, anxiety, delusions, hallucinations, irritability, and wandering
Treatment -
Acetylcholinesterase (AChE) inhibitors (donepezil, galantamine, and rivastigmine) — as monotherapies for managing mild to moderate Alzheimer's disease.
Memantine (a N-methyl-D-aspartic acid receptor antagonist):
As monotherapy for managing Alzheimer's disease for people with moderate Alzheimer's disease who are intolerant of, or have a contraindication to, AChE inhibitors, or for people with severe Alzheimer's disease.
In addition to an AChE for people with established moderate or severe Alzheimer's disease who are already taking an AChE
For people with non-Alzheimer's dementia the use of AChE inhibitors or memantine is unlicensed, but they may be prescribed by a specialist for people with:
Mild to moderate dementia with Lewy bodies:
Donepezil or rivastigmine are recommended first line.
Galantamine is an option if donepezil and rivastigmine are not tolerated.
Severe dementia with Lewy bodies:
Donepezil or rivastigmine are recommended.
Vascular dementia:
AChE inhibitors or memantine are options if the person has suspected comorbid Alzheimer's disease, Parkinson's disease dementia, or dementia with Lewy bodies.
Risperidone and haloperidol are the only antipsychotics licensed for treating non-cognitive symptoms of dementia, although other antipsychotics are often prescribed off-label for this purpose.
Acetylcholinesterase inhibitors
NMDA receptor antagonist
Cholinesterase inhibitors for mild to moderate AD (eventually stop working)
NMDA receptor antagonist for severe AD and moderate AD in some cases
Treatment must be started only by a specialist clinician
Rheumatoid arthritis
Inflammatory disease causing persistent symmetric joint synovitis
Presents as pain and joint stiffness with heat and swelling progressing at rest and after periods of inactivity with malaise, fatigue, fever, and weight loss
Risk factors – smoking, eating large amounts of red meat, drinks excessive coffee
Symptoms
Joints
Pain
Swelling
Stiffness
Systemic
Fatigue, depression, irritability
Anaemia
Flu-like symptoms, such as feeling generally ill, hot, and sweating
Pain worse in morning
Treatment
Drugs, mild exercise (enhance flexibility of joint and muscle strength), lifestyle changes (rich antioxidant diet, no smoking)
Main types of RA meds
NSAIDs (short term symptomatic relief) – reduce inflammation. OTC (ibuprofen, naproxen). POM (celecoxib, etoricoxib)
S/E – GI irritation, ulcers (use at lowest dose and take with food, use PPI to lessen effects)
Caution – asthmatics and renal impairment and patients with increased CV risk
Disease-modifying anti-rheumatic drugs (DMARDs) – 1ST LINE for active RA (methotrexate, sulfasalazine)
S/E – Nausea, diarrhoea, oral ulceration, alopecia, cough, SOB, bone marrow suppression – CAN BE REDUCED by co-prescribing FOLIC acid 1mg daily
Biological therapies (type of DMARD) – used when DMARDS don’t control RA
Glucocorticoids – short term treatment when starting new DMARD for rapid symprom control - also used in flares
Analgesics (painkillers)
Drug Treatment Schedule
Start two DMARD regime once diagnosed, using titration regimens
Use anti-inflammatories (NSAIDs), paracetamol with or without corticosteroids until effective
Review after 6 months: increase dose or switch as clinical condition determines.
Patient counselling in RA
Place of drugs in therapy
Onset of action
Side effects
Immunosuppression
Regular painkillers
Regular monitoring including blood tests
Dexterity aids, prescription services
Osteoarthritis
Predominantly non-inflammatory and caused by cartilage loss from synovial joints and bone remodelling due to excessive and repeated overloading on weight bearing joints or stress of a joint over tome and specific injuries
Risk factors – genetic, age, gender, obesity, damage, occupational, and stress
Symptoms
Pain – tends to be worse when using the joint and at end of the day (Worsens on use, resolves at rest)
Stiffness – feel stiff after rest, usually wears off as you get moving
Grating or grinding sensation (crepitus) – joints creak or crunch as you move
Swelling – may be caused by osteophytes (bone outgrowth) or caused by synovial thickening and extra fluid
Muscles around joint look thin/wasted
Unable to use joint normally – doesn’t move as freely or far as normal
Joints give way – muscles have weakened, and joint is less stable
Management
Provide information on sources of advice and support
Advice on self-care strategies such as;
Weight loss, local muscle strengthening exercises and aerobic fitness training
Appropriate footwear, local heat, or cold packs
Odder psychosocial support – career and occupational health assessments if needed
Advice on simple analgesia
Arranging regular reviews to assess response to treatment
MANAGEMENT GOAL – pain reduction and symptomatic relief
First line:
Paracetamol regularly – 4g daily
Topical NSAIDs
Additional treatment:
Oral NSAIDs– not first line
-Start with ibuprofen
-Monitor for side effects
-Possible place for topical therapy
Topical capsaicin – adjunct and helpful in knee and hand – works by stimulating then decreasing the pain sensation
Corticosteroid injection: â pain and inflammation of flare-up
Role of pharmacist
Counselling:
dosage regimen
side effects
warnings
Monitoring for side effects
Weight loss advice
Physiotherapy advice
Compliance aids & living aids
Gout
Type of inflammatory arthritis – causes severe pain and damage to joints
Caused by abnormal high levels of uric acid in blood which deposits urate crystals in joints and tissue
3 phases
Asymptomatic hyperuricaemia – can remain in this stage for life
Acute attack of gouty arthritis – can vary from months to years before another attack
Final period of chronic tophaceous gout – nodules effecting joints
Treatment
Acute
Ice
Rest affected joint
NSAIDs – short term, 7-14 days, high dose, for pain relief and anti-inflammatory
Colchicine (Dose: 500mcg 2-4 x daily until symptomatic relief or SE (stomach cramps, diarrhoea, vomiting)), steroids (used when NSAID and colchine is contraindicated or not useful)
Choice of drug dependant on comorbidities and renal function (NSAID cause fluid retention whereas colchicine doesn’t)
Colchicine use limited as it can have sudden toxicity at higher conc
Combination treatment can be used as well if monotherapy isn’t controlling the attack
Long term treatment to reduce urate
Lifestyle modifications (reduce dietary intake)
Drug therapy: Allopurinol (1st line – offer to all, 100mg od, increased in 100mg increments every 2-3 weeks) S/E – rashes
Febuxostat (2nd line only use when allopurinol intolerant or contraindicated – 60mg OD dose)
Monitor urate level – aim for < 360 μmol/L or 6 mg/dl (critical level)
Muscoskeletal
Sprain
Commonly ankle, wrist, thumb, knees – pain, swelling, tenderness, bruising, disabled use and no weight
Strain
Common in legs and lower back – pain, swelling, bruising, red, and reduced function
BOTH
Self-limiting gets better in 4-6 weeks and full recovery in 12 weeks
Non-pharma advice
PRICE (Protect, Rest (48-72hrs), Ice immediately after, Compression bandages and Elevate to reduce swelling
Reduce HARM (Heat, alcohol, running and massaging for 72hrs.
Avoid NSAIDs for 72hrs
Exercises for sprains
Gently move joint in all directions to increase and maintain flexibility (lack of movement can delay recovery BUT severe sprains with complete lack of movement rest for 10 days first)
Treatment – topical and oral analgesics
Refer – severe pain, possible break or fracture, no alleviation with OTC meds
Lower back pain
Symptoms – pain, tension, soreness, stiffness without underlying cause
6 weeks usual recovery can be up to 12 weeks
Advice
Back exercises, improve posture, yoga, avoid lying or sitting for too long, remain active.
Sleep in different positions, pillows between legs, under knees, hot baths, hot water bottles, ice packs.
Treatment
OTC – topical analgesics or co-codamol if still painful
Refer
No improvement in 3 days, continues for more than 6 weeks, pain travels higher, pain after injury, younger than 20, older than 50, pain affects sleep, unsteady on feet, unexplained weight loss
EMERGENCY
Pins and needles in back, genital, bum, both legs, lose urine or bowel control
Conjunctivitis
Symptoms
Bacterial
Viral
Allergic
Eyes affected
1 or 2
Both
Both
Discharge
Pussy
Watery
watery
Sensation
Gritty
Gritty
Itchy
Co-presenting symptoms
None
Cough/cold
Rhinitis
If pussy, red or gritty it is contagious – allergic ISNT contagious
Advice
Don’t wear contacts, hold cold flannel on eyes for few mins to cool them, use FBC water to gently wipe lashes and clean off crust and clean with cotton wool pad. Use a different one for each eye
Control spread by – reg wash hands with hot soapy water, cover mouth and nose when sneezing, don’t share towels or pillows and don’t rub eyes
Refer
Baby less than 28 days old with red eyes, allergic reaction, or spots on eyelids. For all – symptoms not resolved after 2 weeks
111 - Severe pain, sensitive to light, sudden changes to vision
Treatment
Viral – self-limiting, use hygiene and non-pharma advice
Allergic – Opticrom eye drops (Adults and child – 1-2 drops in each eye up to 4x daily)
Bacterial – over 2, chloramphenicol drops/ointment (Optrex Bacterial Conjunctivitis 1%w/w Eye Ointment) - apply a small amount of ointment in the affected eye 3-4 times daily for 5 days
Blepharitis
Symptoms
NOT contagious, rims of eyelids are inflamed, burning, soreness or stinging in the eyes, crusty lashes that stick together, itchy eyelids
Advice
Clean eyelids at least 1x daily, clean eyes even if symptoms clear, don’t wear contacts, or eye makeup
Cleaning eyes – soak a clean flannel/cotton wool in warm water and place on eye for 10 mins, gently massage eyelids for 30 secs, clean lids using cotton wool. Baby shampoo at 10:1 ratio good.
Refer
No improvement after 2 weeks of cleaning eyes
Treatment OTC
Brolene eye drops – 1-2 drops in each eye up to 4 x daily. If not better in 2 days refer
Dry eyes
Symptoms
Dry feeling, sensation of something in eye, burning, grittiness, itching, light sensitivity, over-blinking, redness, excess tears (randomly tearing)
Causes – over 50, contacts, digital screens, AC, windy/cold/dry/ dusty environment, smoking, alcohol, meds (antidepressants/BP) medical conditions (blepharitis)
Refer
Treatment failure after 2 weeks, change in eyelid shape
111 – severe pain and red, contact wearer with red eyes (could be an infection)
999 A&E – sudden change in sight, bursts of light sensitivity, severe headache/nausea, dark red eyes, injured/pierced eye, something stuck in eye
Advice
Clean eyes daily, take breaks when using screens, use screens below eye level, use humidifier, wear glasses instead of contacts
Treatment
Light lubricant – Optrex Double Action Drops for Dry and Tired Eyes - Apply 1-2 drops in each eye.
Hyaluronic Acid - Artelac Rebalance Drops, long lasting relief - Place 1 drop into the conjunctival sac 3-5 times daily or more frequently if required.
Hypromellose drops – 1-2 drops 3 x daily
Excessive ear wax
Symptoms – hearing loss, earache, noise/ringing, vertigo, dizziness, and nausea
Causes – narrow/damaged canals, hairy canal, skin condition affecting scalp around ear, inflammation of ear canal
Refer – not cleared in 5 days, badly blocked, severe, complete loss of hearing, likely infection
Advice – don’t use fingers or cotton buds to remove wax
Treatment
Olive oil drops – 2-3 drops in affected ear and massage around outside of ear BD x 7 days
Use dropper when lying down with head to one side to allow oil into ear, over 2 weeks then lumps should fall out, but symptoms should be better within 5 days
Otitis externa
Symptoms - pain, discharge, itch, irritation, external ear/canal appears red, swollen, eczema, deafness, skin swells, tender to touch
Refer – ear pain in children, inflamed pinna, unsuccessful treatment (after 4 days), hearing aids, excessive discharge (wax or pus), high fever, vomiting, fatigue, confusion, dizzy, stiff neck, rash, slurred speech, fits, light sensitivity
Advice – avoid under/over dressing feverish child, lower heating, offer regular fluids, avoid dummies when lying flat, give paracetamol/ibuprofen if child is unwell/distressed (not together)
Treatment
Acute localised (furunculosis) – infected hair follicles in outer-ear causing swelling and irritation
Treatment – hot flannel, oral analgesics, antibiotics if severe
Acute diffuse (over 3 months – more widespread inflammation of skin, bacterial/fungal infection or contact dermatitis due to irritant/allergens
Treatment – earwax plus or EarCalm
Otitis media
Symptoms – earache, discharge, hot, irritable, sleeplessness, ear pulling/rubbing, crying, temporary deafness
Refer – recurrent infections, no improvement in 3 days
Treatment
Self-limiting should be better in 3 days, single analgesics for pain
Hyperthyroidism
Too much thyroid hormones produced naturally
Symptoms
Tremor, warm sweaty palms, weigh loss despite increasing appetite, heat intolerance, diffused alopecia, hair thinning, tachycardia, diarrhoea
Advice
Healthy diet with foods rich in antioxidants, green leafy vegetables (broccoli, cabbage etc)
Vitamin D, omega 3 fatty acids and calcium rich foods. Smoking cessation
Treatment
Carbimazole (adjunct B blocker propylthiouracil for adrenergic symptoms) – block and replace regime
Combo of fixed high dose carbimazole and levothyroxine
Radioactive iodine destroys thyroid cells, surgery to remove some thyroid
Hypothyroidism
Thyroid gland doesn’t produce enough hormones caused by immune system attacking thyroid gland and damaging ait or by damage to thyroid that occurs during treatments for a hyperthyroidism or thyroid cancer
Symptoms
Fatigue, muscle pain, weakness, weight gain, sensitive to cold, dry skin, brittle hair, nails, depression, reduced libido
Advice
Eat antioxidant rich food, seeds and nuts, tyrosine (meat, dairy, legumes)
Avoid – soy, iodine rick food, leafy green vegs, caffeine, alcohol – quit smoking, alcohol.
Inform GP if pregnant (needs treatment and monitoring during)
Treatment
Levothyroxine 1st line – dose depends on blood test and progression – take tablet at same time every day (MORNING) If taking too much causes sweating, chest pain, headaches, diarrhoea, vomiting. Supressing thyroid supressing hormone with high doses causes atrial fibrillation, stroke, osteoporosis
Cold sores
Symptoms
Simplex - Pain, burning, itching, tingling before lesions and lasts 6-48 hrs
Crops of vesicles burst and crust over and heal, commonly on lower lip and ends of mouth
Gingivostomatitis – fever, malaise, sore throat, painful nodules in cervix or under jaw, excessive salivation. Painful vesicles on a red swollen base that rupture to form ulcers inside mouth, covered with yellow/grey membranes
Refer – immunocompromised, unable to swallow, risk of dehydration, severe infection, complication, pregnant, recurrent
Treatment
Paracetamol/ ibuprofen for symptoms
Topical acyclovir/penciclovir OTC – use from onset of symptoms before lesions until lesions heal
OTC topical anaesthetic or analgesics, mouthwashes, or lip barriers – topical analgesics aren’t licensed in children
DON’T prescribe oral antiviral for healthy people
Consider prescribing oral antiviral for healthy people with episode of primary oral herpes simplex, recurrent labialis if lesions are severe, frequent, or persistent and recurrent
And for those who are immunocompromised
Should take at onset and until lesions have healed – minimum of 5 days
Choice of aciclovir or valaciclovir based on preference, dose, regimen, and adherence
Advice
Reassure its usually self-limiting and heals without scarring
Adequate fluid intake
Offer leaflets or websites for more info
Avoid kissing, oral until lesions fully healed, don’t share pillows, makeup, or lip balms. Don’t touch lesions other than when applying treatment – dab instead of rubbing. Wash hands after touching.
Athletes foot
Interdigital — most common; affects the lateral toe web spaces first; usually caused by Trichophyton rubrum.
Moccasin or dry — diffuse chronic scaling and hyperkeratosis affecting the sole and lateral foot; usually caused by Trichophyton rubrum.
Vesicobullous — least common; multiple small vesicles and blisters mainly on the arches and soles of the feet; usually caused by Trichophyton interdigital.
Risk – hot, humid, occlusive footwear excessive sweating, contaminated surfaces, immunocompromised
Advice
Wear well fitting, open footwear that keep feet cool and dry, replace old shoes that may be contaminated. Maintain good foot hygiene – wear different pair of shoes every 2-3 days. Wear cotton, absorbent socks, don’t scratch skin, after washing feet dry then well and between toes, don’t share towels and wash towel freq.
Treatment
Topical antifungal cream in mild, non-extensive disease
Terbinafine 1% cream (12 and over – apply thinly to affected area 1 or 2 daily for 7 days) or clotrimazole 1% cream (2-3 times daily and continue for 4 weeks minimum) okay for kids – OTC for some ages
Additional mild topical corticosteroid if there’s inflammation
Hydrocortisone 1% cream (OD for max 7 days)
Adult severe or extensive – oral antifungal with confirmed fungal infection
1st choice – terbinafine (250 mg once daily for 2–6 weeks, depending on the severity of infection)
2nd – itraconazole, Griseofulvin if not tolerated or contraindicated
Refer
Treatment failure, severe pain, got, painful and red (indicative of serious infection), infection spreads, diabetic patient, immunocompromised
Warts and verrucae
Warts – small, rough growths caused by infection of skin with HPV, form anywhere on skin most commonly on hand and feet
Verruca – (plantar wart) wart on sold of feet
Spread by direct contact, occur and clear spontaneously at any time or may take years
Common warts are firm and raised with a rough surface that resembles a cauliflower (common on knuckles, knees, and fingers).
Periungual warts are common warts around the nails that can be painful and disturb nail growth — nail biting is a risk factor.
Plane warts are usually round, flat-topped, and skin coloured or greyish yellow (common on the backs of hands).
Filiform warts have a finger-like appearance and may have a stalk (more common on the face and neck).
Palmar and plantar warts grow on the palms and the soles of the feet (verrucae). They often have central dark dots (thrombosed capillaries) and may be painful.
Mosaic warts occur when palmar or plantar warts coalesce into larger plaques on the hands and feet.
Not harmful and don’t come with symptoms and resolve with treatment
Advice
Reducing transmission and limit spread, keep feet dry, wear slippers or waterproof plaster in shower and communal areas. don’t share towels, socks, shoes. Don’t scratch lesions, bite nails or suck fingers with warts
Refer
Painful, facial, uncertain diagnosis, immunocompromised, extensively infected
Treatment
Only treated if painful, cosmetically unsightly, or patient request and persistent as the treatment is long and can have side effects.
Topical salicylic acid – up to 12 weeks
Duofilm® (salicylic acid 16.7% plus lactic acid 16.7%) — licensed for plantar and mosaic warts.
Bazuka® extra strength gel (salicylic acid 26%) — licensed for warts and verrucae.
Occlusal® (salicylic acid 26%) — licensed for common and plantar warts.
Salactol® (salicylic acid 16.7% plus lactic acid 16.7%) — licensed for warts, plantar warts, and verrucae.
Apply OD at night, file and soften area by soaking in warm water for 5-10 mins, peel of remaining film before administering next dose, don’t apply on healthy skin
Cryotherapy – every 2 weeks for max 6 treatments
Liquid nitrogen – only for older children and adults
Corns and calluses
Hard or thick areas of skin that can be painful
Corns – lumps of hard skin on knuckles and joints of toes
Callouses – larger patches of rough, thick skin
Both can be tender and painful
Refer
Diabetic, heart disease, circulation issues. Bleeding or puss, treatment failure after 3 weeks, severe pain
Advice
Wear thick, cushioned socks, wear wide, comfortable shoes with low heel and soft sole, use insoles or heel pads, soak corns and calluses in warm water to soften them, use pumice stone regularly or foot file to remove hard skin. Moisturise.
Don’t try to cut them, walk, or stand for long period, wear high heels or tight pointy shoes, go barefoot
Treatment
Heel pads and insoles, OTC products, pain relief
Carnation brand caps for both – adhesive dressing
Fungal nail infection
Caused by dermatophyte and non-dermatophyte moulds and yeasts
Symptoms
Discoloured, abnormal, small flaky white patches and pits on top of nail and becomes rough and eroded. Nail lifted, wite or yellow opaque streaks on one side of nail, scaling, thickening
Refer
Diabetic, severe, treatment failure, spread to other nails
Advice
Keep nails trimmed short and filed, don’t share clippers and files. Well-fitting shoes, cotton socks, maintain good foot hygiene, weak shoes in communal places, avoid nail trauma
Treatment
Not needed if patient not troubled by appearance and infection is asymptomatic
Advise antifungal treatment if – walking uncomfortable, distress, cosmetic, co-morbid complication, or complication
If dermatophyte or candida infection conformed – topical antifungal treatment 0f 50% of nail involved, 2 nails infected, contraindication to oral antifungal
Topical – amorolfine 5% mail lacquer – OTC apply 1 or 2 weekly to affected nail after gentle nail filing – 6 months minimum for fingernails, 12 months for toenails
If dermatophyte nail infection is confirmed:
Prescribe oral terbinafine first-line.
250 mg once a day for between 6 weeks and 3 months for fingernails, and for 3–6 months for toenails
Oral itraconazole if an alternative drug is indicated.
Prescribe as pulsed therapy 200 mg twice a day for 1 week, with subsequent courses repeated after a further 21 days.
If Candida or non-dermatophyte nail infection is confirmed:
Prescribe oral itraconazole first-line.
Prescribe as pulsed therapy 200 mg twice a day for 1 week, with subsequent courses repeated after a further 21 days.
Prescribe oral terbinafine if an alternative drug is indicated.
Prescribe 250 mg once a day for between 6 weeks and 3 months for fingernails, and for 3–6 months for toenails.
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