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  • 1. COMMUNITY PHARMACY AND PHARMACY PRACTICE CODE: 903 Fourth YearCompiled by the Clinical Pharmacy Department Staff Faculty of Pharmacy Cairo University 2008-2009
  • 2. Table of ContentPRESCRIPTION AND OVER-THE COUNTER (OTC) MEDICATIONS 1RESPONDING TO SYMPTOMS 3COLD AND FLU 13COUGH 20SORE THROAT 27ALLERGIC RHINITIS 32MOUTH ULCERS 37HEART BURN 42INDIGESTION 46NAUSEA AND VOMITING 52CONSTIPATION 54DIARRHOEA 59HAEMORRHOIDS 65ECZEMA/DERMATITIS 70ACNE 72ATHLETE’S FOOT 79WARTS AND VERRUCAE 84SCABIS 89COMMON CHILDHOOD RASHES 94HEADACHE 97MUSCULOSKELTAL PROBLEMS 105EYE PROBLEMS 112COMMON EAR PROBLEM 114DRUG USE IN SPECIAL POPULATIONS 117 DRUG USE IN PAEDIATRICS 117 DRUG USE IN PREGNANT PATIENTS 122 DRUG USE IN GERIATRIC PATIENTS 128COMMUNICATION SKILLS 131PATIENT COUNSELLING 138THE ROLE OF THE PHARMACIST IN FAMILY PLANNING 146SMOKING CESSATION 159PHYSICAL ASSESSMENT SKILLS 171ETHICS AND LAW 183PRACTICAL NOTES 217
  • 3. Prescription and Over-The Counter (OTC) MedicationsMedications include Over-The-Counter medications (OTC) as well as prescriptionmedications. People often think medications that do not require a doctor’s prescription cannotbe harmful. This is not true. Over-the-counter medications also can create problems if usedimproperly or used at the same time as prescription medications. Because over-the-countermedications are used so frequently and can have harmful effects, it is important to know thedifferences between prescription and over-the-counter medications. Prescription Medications Over-the-Counter Medications■ Require a written order or prescription from ■ Can be bought without a prescription.a physician, dentist, or nurse practitioner. Thisprescription authorizes a pharmacist todispense a particular medication.■ Are prescribed for the treatment of a ■ Are intended for relief of minor ailments.specific medical problem.■ Are usually more powerful and have more ■ Are considered safe if warnings andside effects than OTC medications. directions are followed. • Over-the-counter medications differ from prescription medications in that the particular ingredient, or mix of ingredients, and the recommended doses are considered relatively safe and problems are relatively unlikely. However, many OTCs contain strong agents. • If taken in large quantities, some OTCs would be equal in strength to medications normally available only by prescription.Prescription Labels • Prescription medications include important label instructions and must be followed carefully to ensure safe and effective use. • Sometimes, however, the labels can be confusing because instructions are not clear. For example: ■ Take as directed. (What were the directions?) ■ Take 4 times a day. (Around the clock or just during waking hours?) ■ Take as needed. (What determines need?) ■ Take before bedtime. (Immediately before sleeping or 1-2 hours before?) • For the patient’s health and well-being, the patient needs to know exactly what the directions on the medication labels mean and not to be satisfied with vague instructions. • The health care provider, doctor, or pharmacist can advise the patient on the best time and the best way to take medication to get the most benefit.
  • 4. In What Ways Can Over-the- Counter Medications be Harmful? OTC medications can change the effect of prescribed medications OTC medications can affect the action of prescribed medications. For example, making them stronger or less effective. Patient should ask the doctor before taking any OTC medication at the same time as prescribed medication. OTC medications can mask symptoms of disease. OTC medications, especially when taken regularly, can reduce or completely dispel symptoms that warn of a more serious medical problem. For example, antacids taken for “upset stomach” may cover symptoms of ulcer disease, so diagnosis and treatment may be delayed. OTC medications can lead to overdose. An OTC, when taken in excess or combined with prescribed medication, may lead to symptoms of drug overdose. Once again, patient should consult with a doctor or pharmacist before combining both OTC and prescribed medications. OTC medications can be harmful.If misused, even common OTCs, such as aspirin, vitamins, or cold remedies can be harmful.Examples are:■ Laxatives. Habitual use of laxatives can lead to loss of normal bowel function.■ Antacids. May produce magnesium toxicity in patients with renal problems or maycontribute sodium to the diet (examples: Alka Seltzer).
  • 5. Responding to SymptomsResponding to symptoms is a major activity for the community pharmacist. Pharmacistreceives every day loads and loads of requests for advice about symptoms and the pharmacistsupervises a much greater number of over the counter (OTC) medicine sales. This role hasalways been important for the community pharmacist. • It was always being criticized that pharmacists were not performing their role to a satisfactory standard. • It was argued that in many cases pharmacists were not asking enough or appropriate questions and therefore had insufficient information to advice optimally the patient about their symptoms. • It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patients’ symptoms and they fail to differentiate between a symptom that might suggest a more serious pathology or one which can be easily managed with an OTC product.For all these reasons, guidelines were issued outlining a structured approach when dealingwith a patient requesting advice on symptoms. It is essential for all pharmacists to be familiarwith these guidelines. • When called upon by a member of the public to advice on symptoms, the request should be dealt with by the pharmacist or a suitably trained member of staff. • Arrangements should ensure that an intervention by a pharmacist can be made at an appropriate stage.The following steps should be taken: • Obtain sufficient information to enable a proper assessment of the situation to be made. - This should include information about who has the problem, what are the symptoms, how long has the condition persisted, has any action been taken, and which medicines the patient concerned is already taking. • Decide whether the symptoms might be strongly associated with a serious condition, and in such circumstances refer the patient for immediate medical advice. • In the case of other symptoms, give appropriate advice with/without the sale of medicine. • When medicines are supplied, make records when appropriate and advise the inquirer to consult a doctor should the symptoms persist beyond a stated time.
  • 6. A structured response to symptoms • In a busy pharmacy, interruptions may interfere with dialogue between pharmacist and patient and the use of a mnemonic to remind the pharmacists of the critical steps involved in assessing the clinical significance of symptoms is helpful. • Use of a mnemonic will minimize the risk of missing important information about the patient’s condition. • There are three such methods which have been suggested. AS METHOD WHAM ENCORE The AS METHOD techniqueThe AS METHOD mnemonic identifies some of the main questions which should be asked ofeach patient requesting advice on symptoms. AS METTHOD translates as:A Age of the patient?S Self or for someone else?M Medicines the patient is taking?E Extra medicines tried for the current symptoms?T Time or duration of the symptoms?T Taken anything for it or seen the doctor?H History of any disease or condition?O Other symptoms being experienced?D Danger symptoms (which require referral to the doctor)? • The AS METHOD technique will be helpful to establish necessary information to provide the basis for a possible primary diagnosis. • The order in which questions are asked is not important. • Some of the questions suggested will not need to be asked as their answers may be implicit, such as the age group of the patient, which in many cases will be obvious. It is best to use the mnemonic as a checklist to ensure that all the points are covered. • Patient’s response will suggest additional aspects of the symptom which will need investigation. The WWHAMThe WHAM mnemonic was developed mainly for use by counter assistants when respondingto symptoms. It is shorter than the other techniques. The basis of this mnemonic is:W Who is the patient and what are the symptoms?H How long have the symptoms been present?A Action taken: what medicines have been tried?
  • 7. M Medicines being taken for other problems? The ENCORE- ENCORE was developed as a structured approach to responding to symptoms, in response to perceived shortcomings of community pharmacists in this area of activity.- Deficiencies highlighted by several surveys have included: • Inadequate knowledge about specific therapies and products • Suboptimal exploration with the patient of the symptoms • Insufficient attention given to drug-drug interactions • Omission of advice about referral to other experts when justified • Generally insufficient communication with the patient.
  • 8. N ature of symptoms O btain identiy of patientE XPLORE C oncurrent medication E xclude possibility of a serious disease O ther associated symptomsN O MEDICATION Remember that in many instances a medication is not necessary and may indeed be contraindicated G eriatric patientsC ARE P aediatric patients P regnant women L actating mothers O ther tell-tale signsO BSERVE D emeanor of patient D ramatisation by patient P otentially serious caseR EFER P ersistant symptoms P atients at increased risk Discuss with patients why aE XPLAIN particular course of action is suggested
  • 9. The basic mnemonic ENCORE identifies six major steps in the patient-pharmacist interview E XPLORE • In other words make sure that pharmacist has as much information about Nature of the symptoms, Obtain identity of the patient, Concurrent medication being taken. • The pharmacist must Exclude the possibility of a serious disease and must identify Other associated symptoms. • The Latin word NOCEO have been used (to harm) to remind the pharmacist of these substeps.N O MEDICATIONJust like doctors, pharmacists have often been accused of being too ready to recommend uselessmedications in situations where no medication is justified.C ARE • This is to remind the pharmacist that the elderly (Geriatric), the very young (Paediatric), Pregnant women and Lactating mothers need special care. • The mnemonic GPPL (good pharmacy practice for life) is being used to remind the pharmacists of those special ‘at risk’ group of patients. O BSERVE • Careful observation often gives useful diagnostic information. Look for Other tell-tale signs. • A truly ill patient rarely looks well. Pharmacist should be alert to such features as dilated pupils, smell, flushing and sweating, all of which can suggest illness. • Consider the Demeanor of the patient. The sound of a cough can give valuable information about its source. • The Dramatisation by the patient is a further clue.R EFER • The pharmacist should not hesitate to Refer to other experts for a second opinion. The sooner a patient who needs help gets it, the better. • The pharmacist should refer all Potentially serious cases, Persistent symptoms, and Patients at increased risk.E XPLAIN • The pharmacist should Explain to the patients why a particular course of action is being recommended.
  • 10. • This way they are much more likely to heed the advice. The pharmacist should avoid jargon when explaining.E XPLOREA) Nature of symptoms The exact nature & site of the symptoms will often need clarification. • Dyspepsia and indigestion are used by patients to explain diverse non-specific complaints. • Establishing the exact site of the gastric pain or discomfort would be important. Pain in the region of the abdomen just below the sternum usually indicates that its origin is the upper elements of the GIT (oesophagus, stomach and upper small intestine). A burning pain in this region radiating towards the throat would be indicative of oesophagus. • “Sharp” may indicate a precisely-located pain, originating from a gastric or peptic ulcer. • “Burning” may refer to gastric or oesophagitis. • Symptoms felt in the central region of the abdomen are indicative of a condition further down the gut such as gastro-enteritis and constipation.B) Obtain identity of patient • It is always necessary to establish who the request is for. Assuming the person asking for advice is the person suffering the symptoms is not always correct. - For example, a wife may be requesting advice on a symptom which her husband is experiencing, or vice versa. Although their ages are similar, the symptoms of gastritis would be of greater concern in a male since he will have a greater chance of suffering from coronary heart disease than his wife. Conversely, gallstones conditions. • Parents or grandparents will report the symptoms on behalf of a child. It is important to be aware of this if a medicine is to be recommended, since many preparations are contraindicated in children.C) Concurrent Medication • It is essential to establish if the patient is taking any medicines, whether prescribed by a doctor or purchased OTC. • There are four obvious reasons for this: 1. A medicine may be causing the symptoms 2. A medicine may indicate a disease state which could have a bearing on management 3. The patient may already be taking a medicine the pharmacist is about to recommend and which is not providing relief. 4. Medications that are recommended may interact with existing treatment.
  • 11. • This information will be very helpful in formulating the recommendation. • It is important to remember that many patients do not regard OTC remedies, such as milk of Magnesia. Therefore, it is important to enquire about ‘simple remedies’. • Drugs which cause gastric irritation can lead to gastric pain and discomfort. More importantly, ‘upset stomach’ may be a sign of drug toxicity. • If the patient has tried one or more preparations and/or has seen the doctor but has not obtained relief, this may indicate that the initial diagnosis was wrong. It is certainly would suggest that recommendation of a similar preparation would be of a little use.D) Exclude possibility of a serious disease • Knowing if the patient has a history of disease may give important information. • Obese patients tend to suffer more frequently from gastritis than non-obese people. This is often due to physical pressure on the stomach. • Large meals can cause symptoms due to the physical distension of the stomach. • Hiatus hernia is a condition in which the lower oesophagus or part of the stomach slides through the diaphragm. This situation leads to more reflux of gastric acid.E) Other Associated symptoms • Other symptoms being experienced can help in the verification or rejection of a ‘working diagnosis’. • An ‘upset stomach’ may be a complex array of symptoms which include: epigastric discomfort, pain, bloating, belching, feeling of fullness, heartburn and nausea. It may also be associated with vomiting but care must be taken in such situations where vomiting is present since this may indicate a blockage or, if the vomit is found to contain blood; it might indicate a bleeding ulcer. Both of these conditions would require referral. • The severity of pain must be established. Pain which awakens the patient out of sleep is indicative of peptic ulcer for example. • Discomfort on swallowing food or drinks may be experienced in gastritis. When a real difficulty in swallowing (dysphagia) is experienced, the patient must be referred to the doctor. This may indicate a physical blockage due to carcinoma or due to the production of scar tissue from repeated gastric reflux. • Loss of weight in someone suffering from an ‘upset stomach’ must be concerned as it may indicate carcinoma or bleeding ulcer. - Blood produced from bleeding ulcer can lead to the production of ‘tarry’ stool which is difficult to pass. • The aggravation of symptoms when bending down or on some sudden physical exertion is usually indicative of dyspepsia. - Lying down allows acid to enter the oesophagus and aggravate the symptoms which is why patients are sometimes recommended to raise the head of the bed.
  • 12. • Smoking worsens dyspepsia, due to the effect of nicotine on sphincter muscle tone and gastric acid. • Eating large meals or drinking alcohol may trigger the symptoms mainly due to physical distension of the stomach. Indeed, symptoms are noticeably worsen just before or after a meal.N O MEDICATIONIf over indulgence of specific foods or alcohol can be identified as a possible cause, then advice toavoid them may be all that is necessary.C ARESpecial Care GroupCertain groups of patients, because of their vulnerability to the complications of disease or theirsusceptibility to adverse drug reactions, will require special consideration before a managementstrategy is decided. The four main groups are:1. The Geriatric Patient • The elderly are a heterogeneous group and therefore it is very difficult to make predictions about individuals within the group. • However, caution should be exercised in this age group when responding to symptoms. • They suffer from many more diseases than younger people and therefore receive more medication than other groups of patients. • Eight five percent of the elderly (arbitrarily defined as those over retirement age) suffer from at least one chronic condition and the average number of drugs taken by an elderly patient is 3.2. • It is not unusual to see some elderly patient receiving 10 to 12 preparations and consequently the risk of adverse drug reactions is very much greater in the elderly. • Pharmacist should always be aware that prescribing an OTC without proper consideration of the patient’s current medication could worsen the condition through drug interaction. • The aging CNS makes elderly more susceptible to the effect of some drugs and the physiological changes in various organs reduce the excretion of drugs from the body (e.g., digoxin excretion). • In this patient group, many symptoms may be a result of social stress. Treating such symptoms with medicines would be a poor substitute for effective social measures.2. The Paediatric Patients • Very young children, especially those in their first months of life are particularly susceptible to the complications of what in older children would be regarded as ‘minor condition’. • Neonates have a larger surface area to volume ratio compared to older children and adults and are for example, at particular risk of dehydration from diarrhoea.
  • 13. • Additionally, all children differ from adults in their response to medicines. • Pharmacist will have difficulties in obtaining accurate information about the symptoms since this will often be imparted by parents on the children’s behalf, and often in their absence. • The assessment will be very subjective, reflecting the parents’ anxiety or alternatively a lack of appreciation of the severity of the condition.3. The Pregnant Patients • All drugs can potentially have an effect on the foetus during pregnancy. • In the first three months of gestation the effects tend to be most devastating, with the risk of malformation being highest from week three to week 11. • During the second and third trimesters, the effects of drugs tends to be on growth and functional development of the foetus. • Drugs taken just before term or during labour can have an effect on the neonate after delivery. Many women do take medicines during pregnancy as the condition is often associated with frequent symptoms. • The pharmacist should inform the patient that there is a lack of information on the effect of most OTC medicines in pregnancy. • Certain medicines are known to cause definite adverse effects and therefore should be avoided.4. Lactating Mothers • All mothers are being actively encouraged to breast-feed their babies. • Toxicity can occur in the infant if drugs are excreted in the breast milk. • Drugs which appear in milk in significant amounts to cause effect include Aspirin, sedating antihistamines, caffeine, iodides, phenolphthalein and vitamin A. Products containing these drugs, therefore, should be avoided in breast-feeding mother.O BSERVE • A very important rule when dealing with patients presenting with symptoms is to observe their general appearance. ‘Does the patient look ill?’. This is the most valuable physical sign. • A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia. • Non-verbal dramatisation, such as facial grimacing or the beating of a clenched fist onto the area where discomfort or pain is being experienced, can give useful information. - For example, a clenched fist beat onto an area indicates a sharp pain, whereas a flattened hand rubbed around a general area would indicate discomfort.
  • 14. R EFER• Potentially serious cases such as patients with peptic ulcer disease (associated with pain) and gastric malignancy (associated with anorexia) should be referred to a doctor. Tarry stools may be seen in both conditions.• Recurrent and persistent symptoms require referral to the doctor. Generally, if a symptom has lasted more than 10-14 days, the patient will require referral.This recommendation will not apply in every case.• Someone suspected to be suffering from a heart condition should be referred immediately. On the other hand, a patient who is under constant supervision of a doctor will not need further referral unless there is a clear condition deterioration.• Patients over the age of 40 are at increased risk of both peptic ulcer disease and malignancy.
  • 15. RESPIRATORY DISEASES
  • 16. COLD AND FLU .The common cold comprises a mixture of upper respiratory tract viral infections. Although coldsare self-limiting, many patients choose to buy OTC medicines for symptomatic relief. Some of theingredients of OTC remedies may interact with prescribed therapy, occasionally with seriousconsequences. Therefore, careful attention needs to be given to taking medication history andselecting appropriate product. - Information to be collected Age • Establishing who the patient is – child or adult – is important. • This will influence the pharmacist’s decision about the necessity of referral to the doctor and the choice of treatment. • Children are more susceptible to upper respiratory tract infection than adults. Duration • Flu: Patients may describe a rapid onset of symptoms which is said to be more commonly true of flu. • Common cold: Patients may describe a gradual onset over several hours - The symptoms of the common cold usually last for about 7 days. - Some symptoms, such as a cough, may persist after the worst of the cold is over. Such guidelines are general rather than definitive. SymptomsA Runny/blocked nose • Most patients will experience a runny nose (rhinorrhoea) “This is initially a clear watery fluid which is followed by the production of thicker and more tenacious mucus”. • Nasal congestion occurs because of dilation of blood vessels, leading to swelling of the lining surfaces of the nose. • This narrows the nasal passages which are blocked by increased mucus production.B Summer Colds • These are where the main symptoms are nasal congestion, sneezing and irritant watery eyes, and are more likely to be due to allergic rhinitis.C Sneezing/coughing • Sneezing occurs because the nasal passages are irritated and congested. • Cough may be present either because the pharynx is irritated or due to irritation of the bronchus caused by post-nasal drip.
  • 17. D Aches and pains/ headache • Headache may be experienced due to inflammation and congestion of the nasal passages and sinuses. • A persistent or worsening frontal headache may be due to sinusitis. • People with flu often report muscular and joint aches. • This is more likely to occur with flu than with cold.E High temperature • Cold sufferers often complain of feeling hot, but in general, high temperature will not be present. • The presence of fever may be an indication of flu rather than a cold. - Flu often starts abruptly with hot and cold shivery feelings, muscular aches and pains in the limbs, a dry sore throat, cough and high temperature. - These symptoms resolve over 3-5 days. There is a period of generalized weakness and malaise following the worst of the symptoms. - A dry cough may persist for some time. - Warning that complications are developing may be given by severe or productive cough, persisting high temperature, pleuritic-type chest pain or delirium. - Flu can be complicated by secondary lung infection (pneumonia). Complications are much more likely to occur in the very young, the very old and those who have pre- existing heart or lung disease (chronic bronchitis).F Sore throatThe throat often feels dry and sore during a cold and may be the first sign that a cold is imminent.G Earache • Earache is a common complication of colds, especially in children. • When nasal catarrh is present, the ear can feel blocked. This is due to middle ear to the back of the nasal cavity. - Under normal circumstances the middle ear is an air-containing compartment. - However, if the Eustachian tube is blocked the ear can no longer be ‘cleared’ by swallowing and may feel uncomfortable and deaf. - This situation often resolves spontaneously, but decongestants and inhalations can be helpful. Sometimes the situation worsens when the middle ear fills up with fluids. - This is an ideal site for secondary infection” otitis media” to settle. - When this does occur the ear becomes acutely painful and usually requires antibiotics.H Facial pain/ frontal headache • It may signify sinusitis. - Sinuses are air-containing spaces in bony structure adjacent to the nose (maxillary sinuses) and above the eyes (frontal sinuses).
  • 18. - In a cold, their lining surfaces become inflamed and swollen, producing catarrh. The secretions drain into the nasal cavity. If the drainage passage becomes blocked, fluid builds up in the sinus and can be secondarily infected with bacteria. If this happens, persistent pain arises in the sinus areas. - The maxillary sinuses are most commonly involved, causing pain and swelling in the area of the face next to the nose. - When the frontal sinuses are infected, the sufferer may complain of a frontal (forehead) headache. The pain of sinusitis may be worsened by bending forwards or lying down. Previous history • Chronic bronchitics may be advised to see their doctors if they have a bad cold or flu- like infection, as it is often complicated by a secondary chest infection. • Also, many asthmatic attacks are triggered by upper respiratory tract viral infections. • Certain medications are best avoided in those with heart diseases, hypertension and diabetes. Present medication • The pharmacist must be aware of any medicines being taken by the patient. It is important to remember that interactions might occur with some of the constituents of commonly used medicines. • If medication has already been tried for relief of cold symptoms with no improvement and if the remedies tried were appropriate, referral to the doctor may be considered. In most cases of colds and flu, OTC treatment will be appropriate. - Treatment timescale If symptoms have not improved within a week, the patient should see the doctor. - Management- The use of OTC medicines in the treatment of cold and flu is widespread.- The pharmacist’s role is to select appropriate treatment based on the patient’s symptoms.- Polypharmacy abounds in the area of cold treatment, and patients should not be ‘over treated’. 1 Decongestants: Sympathomimetics • Sympathomimetics (e.g., pseudoephedrine or phenylpropanolamine) can be effective in reducing nasal congestion. • Nasal decongestions work by constricting the dilated blood vessels in the nasal mucosa. • The nasal membranes are effectively shrunk, so the drainage of mucus and circulation of air are improved and the feeling of nasal stuffiness is relieved. • These medicines can be given orally or topically. • Tablets and syrups are available, as are nasal sprays and drops.
  • 19. • If nasal sprays/drops are to be recommended, the pharmacist should advise the patient not to use the product for more than 7 days. • Rebound congestion (rhinitis medicamentosa) can occur with topically applied, but not oral Sympathomimetics. • The decongestant effects of topical products containing oxymetazoline or xyloetazoline are longer lasting (up to 6 hours) than those of other preparations such as ephedrine. The longer acting topical decongestants are said to be less likely to cause rebound congestion. The pharmacist can give useful advice about the correct way to administer nasal drops and sprays. • PROBLEMS:1. The pharmacist should be aware that some of these drugs (e.g., ephedrine, pseudoephedrine),when taken orally, have the potential to keep patients awake, because of their CNS stimulatingeffects. Generally, ephedrine is more likely to produce this effect than the other members.- Solution: It may therefore be reasonable to suggest that the patient avoids taking dose of the medicine near bedtime.2. Sympathomimetics can cause heart stimulation and an increase in blood pressure, and mayaffect diabetes control because they increase blood glucose levels. They should not be used by diabetic patients, those with heart disease or hypertension, or with hyperthyroidism. Hyperthyroid patients’ hearts are more vulnerable to irregularity, so that stimulation of the heart is undesirable. Sympathomimetics are most likely to cause these unwanted effects when taken orally and are unlikely to do so when used topically.- Solution: Nasal drops and sprays containing sympathomimetics can therefore be recommended for those patients in whom the oral drugs are to be avoided.- Saline nasal drops or the use of inhalations would be other possible choice for the patients in this group.3. The interaction between sympathomimetics and MAOIs (phenelzine) is potentially serious – ahypertensive crisis can be induced, and several deaths have occurred in such cases. This interaction can occur up to 2 weeks after a patient has stopped taking the MAOI, so the pharmacist must establish any recently discontinued medication.- Solution: There is a possibility that topically applied sympathomimetics could induce such a reaction in a patient taking MAOI. It is therefore advisable to avoid both oral and topical sympathomimetics in patients taking MAOIs.
  • 20. 2 Antihistamines • They can reduce some of the symptoms of a cold as runny nose (rhinorrhoea) and sneezing. These effects are due to anticholinergic action of antihistamines. • The older drugs (e.g., chlorpheniramine, promethazine) have more pronounced anticholinergic actions than do the non-sedating antihistamines (e.g., astemizole, terfenadine, loratidine). Antihistamines are not so effective to reduce nasal congestion. • Some (e.g., diphenhydramine) may also be included in cold remedies for their supposed antitussive action. • PROBLEMS:1. The problem of using antihistamines, particularly the older types, is that they can causedrowsiness. - Alcohol will increase this effect, as well drugs which have the ability to cause drowsiness or CNS depression e.g., benzodiazepines, phenothiazines or barbiturates. - Solution: antihistamines with known sedative effects should not be recommended for anyone who is driving, or in whom an impaired level of consciousness may be dangerous (e.g., operators of machinery).2. Because of their anticholinergic activity, the older antihistamines may produce the sameadverse effects as anticholinergics, i.e., dry mouth, blurred vision, constipation, urinary retention. - These effects are more likely if antihistamines are given with anticholinergics such as hyoscine, or with drugs which have anticholinergic action such as TCADs. - Solution: They should be avoided in glaucoma and prostatic hypertrophy because of possible anticholinergic side effects. Increased intra-ocular pressure is one of such side effects; hence antihistamines are best avoided in patients with closed-angle glaucoma. Anticholinergics can precipitate acute urinary retention in predisposed patients, for example, men with prostatic hypertrophy. While the probability of such adverse effects is low, the pharmacist should be aware of the origin of possible adverse effects from OTC medicines.3. At high doses, antihistamines can produce stimulation rather than depression of the CNS.4. There have been reports of fits being induced at very high doses of antihistamines, and it is forthis reason it has been argues that they should be avoided in epileptic patients.5. Chlorpheniramine has been reported to cause elevated serum phenytoin levels and therecould be the risk of toxic effects when the two are given concurrently.6. Antihistamines can antagonise the effect of betahistine.
  • 21. 3- Cough remedies4- Analgesics5- Products for sore throatAll these will be discussed later - Practical PointsA. DiabeticsIn short term use for acute conditions the sugar contents of OTC remedies is less important.B. Steam inhalations • These may be useful in reducing nasal congestion and soothing the air passages, particularly if a productive cough is present. • Inhalation which can be used on handkerchiefs, bedclothes and pillowcases are available. These usually contain aromatic ingredients such as eucalyptus. • Such products can be useful in providing some relief but are not as effective as steam- based inhalation.C. Nasal spray or drops • Nasal sprays are preferable for adults and children aged over 6 years. - Because the small droplets in the spray mist reach a large surface area. - Drops are more easily swallowed, which increases the possibilities of systemic effects. • For children under 6 years, drops are to be preferred because in young children the nostrils are not sufficiently wide to allow the effective use of sprays. • Paediatric versions of nasal drops should be used when appropriate. • Manufacturers of paediatric drops advise consultation with the doctor for children less than 2 years.
  • 22. COUGH .Coughing is a protective reflex action caused when the airway is being irritated or obstructed. Itspurpose is to clear the airway so that breathing can continue normally. The majority of coughspresenting in the pharmacy will be caused by upper respiratory viral infection. They will often beassociated with other symptoms of cold. - Information to be collected Age • Establish who the patient – child or adult is. • This will influence the choice of treatment and whether referral is necessary. Duration • Most coughs are self-limiting and will be better within few days with or without treatment. • In general, a cough of longer than 2 weeks’ duration should be referred to the doctor. Nature of cough1 Unproductive (dry, tickly or tight) • In an unproductive cough no sputum is produced. • These coughs are usually cause by viral infection and are self-limiting.2 Productive (chesty or loose) • In productive cough, sputum is produced. • Coloured sputum (green, yellow or rusty coloured thick mucus) may indicate a chest infection such as bronchitis or pneumonia and require referral. • Sometimes blood may be present in the sputum (haemoptysis) giving a colour ranging from pink to deep red. - Blood may be an indication of a minor problem such as burst capillaries following a bout of violent coughing during an acute infection but may be a warning of more serious problems. Therefore, haemoptysis is an indication of referral. • Non-coloured (clear or whitish) sputum is un-infected and known as ‘mucoid’. • In heart failure and mitral stenosis, the sputum is described as ‘pink and frothy’ or can be bright red. - Confirming symptoms would be breathlessness (especially in bed during the night) and swollen ankles.3 Tuberculosis (TB)Chronic cough with haemoptysis associated with chronic fever and night sweats are classicalsymptoms.
  • 23. 4 Croup • This usually occurs in infants. • It develops a day or so after the onset of cold-like symptoms. • The cough has a harsh barking quality. It is associated with difficulty in breathing and an inspiratory stridor (noise in throat on breathing in). Referral is necessary.5 Whooping cough • This starts with catarrhal symptoms. • The characteristic whoop is not present in the early stages of infection. • The whoop is the sound produced when breathing in after a paroxysm of coughing. • The bouts of coughing prevent normal breathing and the whoop represents the desperate attempt to get a breath in. Referral is necessary. Associated Symptoms • A cold, sore throat and catarrh may be associated with a cough. • Often there may be a temperature and generalized muscular aches present. This would be in keeping with a viral infection and be self-limiting. • Chest pain, shortness of breath or wheezing is all indications for referral. • Post-nasal drip: Post nasal drip is a common cause of cough and may be due to sinusitis. Previous historyA Chronic bronchitis • Questioning may reveal a history of chronic bronchitis which is being treated by the doctor with antibiotics. • In this situation, further treatment may be possible with an appropriate cough medicine.B AsthmaA recurrent night-time cough can indicate asthma, especially in children, and should be referred.C Cardiovascular • Coughing can be symptom of heart failure. • If there is a history of heart disease, especially with a persisting cough, then referral is advisable.D Gastro-oesophogeal • Gastro-oesophogeal reflux can cause cough. Sometimes such reflux is asymptomatic apart from coughing. Certain cough remedies are best avoided in diabetics and anyone with heart disease or hypertension.
  • 24. E Smoking Habit • Smoking will exacerbate a cough and can cause coughing since it is an irritant to the lungs. • One in three long-term smokers develop chronic cough. • If coughing is recurrent and persistent the pharmacist is in a good position to offer health education advice about the benefits of stopping smoking. • However, on stopping, the cough may initially become worse as the cleaning action of the cilia is re-established during the first few days, so appropriate warnings should be given. Present medication - It is essential to establish which medicines are currently being taken. - This includes those prescribed by a doctor and any bought over the counter. - It is important to remember the possibility of interactions with cough medicines. ACE inhibitors • Chronic cough (Typically, the cough is irritating, non-productive and persistent) may occur in patients taking ACEIs such as enalapril, captopril, and lisinopril, particularly in women. • The problem is now well recognized and patients may develop the cough within days of starting the treatment of after a period or a few weeks or even months. • Any ACEI may induce cough, and there seem to be little advantage to be gained in changing from one to another. • The cough may resolve or may persist; in some patients the cough is so troublesome and distressing that ACEI therapy may have to be discontinued. • Any patient in whom medication is suspected as the cause of a cough should be referred to their doctors. • It is also useful to know which cough medicines have been tried already.The pharmacist may decide that an inappropriate preparation has been taken, for example a cough suppressant for a productive cough. If one or more appropriate remedies have been tried without success then referral is advisable. - Treatment timescale If the cough has not improved after 5 days, the patient should see the doctor. - Management - The choice of treatment depends on the type of the cough. - Suppressants (e.g. pholcodine) are effective in treating unproductive coughs, while expectorants (e.g. guaiphenesin) in theory should be effective in the productive cough. - Demulcents which soothe the throat, are particularly useful in children and pregnant women as they contain no active ingredients. - Productive cough should not be treated with cough suppressants because the results is pooling and retention of mucus in the lungs and a higher chance of infection, especially in chronic bronchitis.
  • 25. - There is no logic in using expectorants and suppressants together as they have opposing effects. Therefore, products which contain both are not therapeutically sound.A Cough Suppressants1. Codeine/pholcodine • Both are effective cough suppressants. • Pholcodine has several advantages over the codeine, in that: a) It produces fewer side effects (at OTC doses codeine can cause constipation and at higher doses, respiratory depression) b) Pholcodine is less liable to abuse.For these reasons, codeine is best avoided in the treatment of children’s coughs and should never be used in children under a year old. • Both pholcodine and codeine can induce drowsiness, although in practice this does not appear to a problem. Nevertheless it is sensible to give an appropriate warning. • Codeine is well known as a drug of abuse and many pharmacists choose not to recommend it. • Dose: - Pholcodine can be given at a dose of 5 mg to children over 2 years. - Adults may take doses of up to 15 mg up to 3-4 times daily. - The drug has a long half-life and may be more appropriately given as a twice daily dose.2. Dextromethorphan • This is an effective but less potent cough suppressant than codeine and pholcodine. • It is non-sedating and has few side effects. • Occasionally drowsiness has been reported, but, as pholcodine, this does not seem to be a problem in practice. • Dextromethorphan can be given to children of 2 years and over. • Dextromethorphan was generally thought to have a low potential for abuse. However, there have been rare reports of mania following abuse and consumption of very large quantities, and pharmacists should be aware of this possibility if regular purchase is made.3. Demulcents • Preparations such glycerine, lemon and honey are popular and useful for their soothing effects. • They don’t contain active ingredients and are safe in children and pregnant women. • Their pleasant taste makes them suitable for children but their high syrup content preclude their use in diabetics.B ExpectorantsTwo mechanisms have been proposed for expectorants: 1. They may act directly by stimulating bronchial mucus secretion, leading to increased liquefying sputum, making it easier to cough up.
  • 26. 2. They may act indirectly via irritation of the GIT which has a subsequent action on the respiratory system causing increased mucus secretion. The latter theory has less evidence.1. Guaiphenesin • This is commonly found in cough remedies. • In adults, the dose required to produce expectoration is 100-200 mg, so in order to have a theoretical chance of effectiveness any product recommended should contain a sufficiently high dose. • Some OTC preparations contain sub-therapeutic doses.2. Ipecacuanha • This is has been used as an expectorant for many years and is found in several formulary preparations. • Such preparations have now fallen out of favour.3. Ammonium salts • Ammonium chloride and ammonium bicarbonate were traditionally used as expectorants. • Problems which can ensue from the use of ammonium chloride include vomiting and acidosis.C Cough remedies – other constituents1. Antihistamines • Examples used in OTC include diphenhydramine and promethazine. • In theory, they reduce the frequency of coughing and have a drying effect on secretions, but in practice they also induce drowsiness. • Combinations of antihistamines with expectorants are illogical and best avoided. • A combination of antihistamine and cough suppressant may be useful in that antihistamines can help to dry up secretions, and when the combination is given as a night- time dose if the cough is disturbing sleep, a good night’s sleep will invariably follow – one of the rare occasions when a side effect proves useful. • The non-sedating antihistamines are less effective in symptomatic treatment of coughs and colds because of their less pronounced anticholinergic actions. • Interactions: alcohol, hypnotics and sedatives.2. Sympathomimetics • Examples include pseudoephedrine and phenylpropanolamine. • These are commonly included in cough and cold remedies for their bronchodilatory and decongestant actions. • Phenylpropanolamine is a weaker bronchodilator than ephedrine and pseudoephedrine. • They may be useful in productive coughs. • All three have a stimulant effect which lead to a sleepless night if taken close to bedtime. • These drugs can cause raised blood pressure, stimulation of the heart and alterations in diabetic control.
  • 27. • Oral sympathomimetics should not be recommended for patients with diabetes, coronary heart disease (angina), hypertension and hyperthyroidism. The last 3 points have been mentioned before in cold and flu can we remove them?3. Theophylline • This is sometimes included in the cough remedies for its bronchodilatory effect. • Interaction: - OTC medicines containing theophylline should not be taken at the same time as prescribed medicines since toxic blood levels and side effects may occur. - The action of theophylline can be potentiated by some drug, for example, cimetidine and erythromycin. - Levels of theophylline in the blood are reduced by smoking and drugs such as carbamazepine, phenytoin and rifampicin which induce liver enzymes, so that metabolism of theophylline is increased and lower serum levels result. • Side effects: include GI irritation, nausea, palpitations, insomnia and headache. • Dose: the adult dose is typically 120 mg 3-4 times daily. It is not recommended for children. • Before selling any OTC product containing theophylline, check that the patient is not already taking the drug on prescription. If the patient is, do not recommend a product containing theophylline. - Practical PointsA. Diabetics • Current thinking is that in short-term acute conditions, the amount of sugar in cough medicines for short-term use is relatively unimportant. • Diabetic control is often upset during infections and the additional sugar is not now considered to be a major problem. • Nevertheless many diabetic patients may prefer a sugar-free product, as will many other customers who wish to reduce sugar intake for themselves and for their children. • As part of their contribution to improving dental health, pharmacists can ensure that they stock and display a range of sugar-free medicines.B. Steam inhalations • These can be very useful, especially in productive cough. • The steam helps to liquify lung secretions, and patients find the warm moist air comforting. • While there is no evidence that the addition of medications to the water produces better clinical effect than steam alone, some may prefer to add a preparation such as menthol and eucalyptus. • One teaspoonful of inhalation should be added to a pint of hot (not boiling) water and inhaled. Apart from the risk from scalding, boiling water volatilizes the constituents too quickly. • A cloth/towel can be put over the head to trap the steam.
  • 28. C. Fluid intake • Maintaining a high fluid intake helps to hydrate the lungs and hot drinks can have soothing effect. • General advice with coughs and cold should be to increase fluid intake by around 2 litres a day.
  • 29. SORE THROAT .Most sore throat which present in the pharmacy will be caused by viral infection, with only one inten being due to bacterial infections. Clinically, it is almost impossible to differentiate between thetwo. Most infections are self-limiting. - Information to be collected Age • Establishing who the patient is will influence the choice of treatment and whether referral is necessary. • Streptococcal (bacterial) sore throat is more likely in children of school age. Duration • Most sore throats are self-limiting and will be better within 7-10 days. • If a sore throat has been present for longer, then the patient should be referred. SeverityIf the sore throat is being extremely painful, especially in the absence of cold, cough andcatarrhal symptoms, then referral should be recommended if there is no improvement within 24-48 hours. Associated symptoms • A cold, catarrh and a cough may be associated with a sore throat. • There is may also be a fever and general aches and pains. These are in keeping with a minor self-limiting viral infection. • Hoarseness of longer than 3 weeks duration and difficulty in swallowing (dysphagia) are both indications for referral. Previous history • Recurrent bouts of infection (tonsillitis) would mean that referral is best. • If the patient is diabetic, sugar-free medication might be preferred. Smoking habitSmoking will exacerbate a sore throat, and the patient smokes it can be a good time to offeradvice and information about quitting. Present medication • The pharmacist should establish whether any medication has been tried already to treat the symptoms. • If one or more medicines have been tried without improvement, then referral to the doctor should be considered.
  • 30. • Current prescriptions are important and the pharmacist should question the patient carefully about them. • Steroid inhalers (beclomethasone or budesonide) can cause hoarseness and candidal infections of the throat and the mouth. Generally, they tend to do this at high doses. - Such infections can be prevented by rinsing the mouth with water after using the inhaler. - It is also worthwhile checking the inhaler technique. Poor technique with metered-dose inhalers can lead to a large amount of the inhaled drug being deposited at the back of the throat. • Any patient taking carbimazole and presenting with a sore throat should be referred. A rare side effect of carbimazole is agranulocytosis. - The same principle applies to any drug which can cause agranulocytosis. - A sore throat in such patients can be the first sign of a life-threatening infection. - Symptoms for direct referral1 Hoarseness • This is caused when there is inflammation of the vocal cords in the larynx, Laryngitis is typically caused by a self-limiting viral infection. • It is usually associated with a sore throat and a hoarse, diminished voice. • Antibiotics are of no value and symptomatic advice, which includes resting the voice, should be given. • The infection usually settles within a few days and referral is necessary. • When this infection occurs in babies, infants or small children it can cause croup and present with difficulty in breathing and stridor. In this situation referral is essential. • When hoarseness persists for more than 3 weeks, especially when it is not associated with an acute infection, referral is necessary. - There are many causes of persistent hoarseness, some of which are serious. For example, laryngeal cancer can present and hoarseness may be the only early symptom.2 Dysphagia • Difficulty in swallowing can occur in severe throat infections. • It can happen when an abscess develops in the region of the tonsils as a complication of tonsillitis. This will usually result in a hospital admission where an operation to drain abscess may be necessary and high-dose parenteral antibiotics may be given. • Glandular fever is one of the viral causes of sore throat, which often produces marked discomfort and may cause dysphagia. Referral is necessary for accurate diagnosis. • Most bad sore throats will cause discomfort on swallowing but not true difficulty and do not necessarily need referral unless there are other reasons for concerns. • Dysphagia when not associated with a sore throat always needs referral.
  • 31. 3 Appearance of throat • It is commonly thought that the presence of white spots, exudates or pus on the tonsils is an indication for referral or a means of differentiating between viral and bacterial infection. • But this is not always so. Unfortunately the appearance can be the same in both types of infection and sometimes the throat can appear almost normal without exudates in a streptococcal infection.A) Thrush • An exception not to be forgotten is candidal (thrush) infection which produces white plaques. • However, these are rarely confined to the throat alone and are most commonly seen in babies or the very elderly. • It is an unusual infection in younger adults and may be associated with more serious disorders which interfere with the body’s immune system for example leukaemia, human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), or with immunosuppressive therapy (steroids). • The plaques may be seen in the throat and on the gums and tongue. When they are scraped off the surface is raw and inflamed. • Referral is advised if thrush is suspected and the throat is sore and painful.B) Glandular fever • This is a viral infection caused by Epstein-Barr virus. • It is well known because of its tendency to leave its victims deliberated for some months afterwards and its association with the controversial condition ME (myalgic encephalomyelitis). The infection typically occurs in teenagers and young adults, with peak incidence between the ages of 14 and 21. • It is known as ‘kissing disease’. • A severe sore throat may follow a week or two of general malaise. • The throat may become very inflamed with creamy exudates present. • There may be difficulty in swallowing because of the painful throat. • Glands in the neck and axillae may be enlarged and tender. • The diagnosis can be confirmed with a blood test, although this may not become positive until a week or after the onset of the illness. • Antibiotics are of no value; in fact if ampicillin is given during the infection a measles- type rash is likely to develop. • Treatment is aimed at symptomatic relief. - Treatment timescaleIf the sore throat has not improved within 5 days, the patient should see the doctor.
  • 32. - ManagementA Mouthwashes and sprays1. Antiseptics • A range of antiseptic mouthwashes is available over the counter, and research suggests that some preparations are more effective than others. • Those containing chlorhexidine, hexetidine, povidone-iodine and cetylpyridinium chloride have been shown to have an effective antimicrobial action. - Such preparations are unlikely to have antiviral activity, but would be useful where there was bacterial involvement. • Mouthwashes and gargles are popular treatments.2. Anti-inflammatory • Benzydamine is an anti-inflammatory agent which is absorbed through the skin and mucosa and has been shown to be effective in reducing pain and inflammation in conditions of the mouth and throat. • Side effects have occasionally been reported and include numbness and stinging of the mouth and throat. • Benzydamine spray can be used in children of 6 and over, whereas the mouthwash may be only recommended for children aged over 12.3. Local anaesthetic • Phenol has a local anaesthetic effect when applied to the mucosa and can be effective in reducing pain in sore throat. • Phenol-based mouthwashes and sprays are available over the counter. Benzocaine is available as a throat spray.B Lozenges and pastillesThese can be divided into three categories:1- Antiseptic (cetylpyridinium chloride)2- Antifungal (dequalinium) • Lozenges and pastilles are commonly used over the counter treatments for sore throats, and where viral infections is the cause, the main use of antibacterial and antifungal preparations is to soothe and moisten the throat. • Lozenges containing cetylpyridinium chloride have been shown to have an effective antibacterial action.3- Local anaesthetic (Benzocaine) • Local anaesthetic lozenges will numb the tongue and throat and can help to ease soreness and pain. • Benzocaine can cause sensitization. • Caution: Iodized throat lozenges should be avoided in pregnancy because they have the potential to affect the thyroid gland of the foetus.
  • 33. - Practical Points1. Diabetics • Mouthwashes and gargles are suitable, and can be recommended. • Sugar-free pastilles are available but the sugar content of such products is now not considered so important in short-term use.2. Mouthwashes and gargles • Patients should be reminded that mouthwashes and gargles should not be swallowed. • The potential toxicity of OTC products of this type is low and it is unlikely that problems would result from swallowing small amounts. • However, there is small risk of systemic toxicity from swallowing products containing iodine. • Manufacturers’ recommendations about whether to use the mouthwash diluted or undiluted should be checked and appropriate advice given to the patient.
  • 34. Allergic Rhinitis s- The symptoms of allergic rhinitis (hey fever) occur after an inflammatory response involving the release of histamine which is initiated by allergens being deposited on the nasal mucosa. Allergens include grass and tree pollens, and fungal mould spores.- Perennial allergic rhinitis occurs when symptoms are present all year around, and is caused by the house-dust mite, animal dander and feathers.- Some patients may suffer from perennial rhinitis which becomes worse in the summer. - Information to be collected Age • Symptoms may start by any age, although its onset is commoner in children and young adults. There is frequently a family history of atopy in allergic rhinitis sufferers. Thus children of allergic rhinitis sufferers are more likely to have the condition. • The condition improves or resolves as the child gets older. • The age of the patient must be taken into account if any medicine is recommended. Duration • Sufferers will often present with seasonal rhinitis as soon as the pollen count becomes high. Symptoms may start in April when pollens appear. • Hay fever peaks between May and July, when grass pollen levels are highest. • Anyone presenting with ‘summer cold’, perhaps for several weeks, may be suffering from hay fever. • Fungal spores are also a cause and are present slightly later, often until September. • People can suffer from what they think are mild cold symptoms for a long period, without knowing they have perennial rhinitis. Symptoms A Sneezing • In hay fever, the allergic response starts with sneezing, then rhinorrhoea, progressing to nasal congestion. • Classically, symptoms of hay fever are more severe in the morning and in the evening. This is because pollen rises during the day after being released in the morning, and then settles at night. - Patients may describe a worsening of the condition on windy days as pollen is scattered, and a reduction in symptoms when it rains or after rain, as the pollen clears. • Conversely, in those allergic to fungal mould spores, the symptoms worsen in damp weather.
  • 35. B Rhinorrhoea • A runny nose is a commonly experienced symptom of allergic rhinitis. • The discharge is often thin, clear and watery, but can change to thicker, coloured, purulent one. • This suggests a secondary infection, although the treatment for allergic rhinitis is not altered. • There is no need for antibiotics.C Nasal congestion • The inflammatory response caused by the allergen produces vasodilation of the nasal blood vessels so results in nasal congestion. • Severe congestion may result in headache and occasionally earache. • Secondary infection such as otitis media and sinusitis can occur.D Nasal itching • This commonly occurs. Irritation is sometimes experienced on the roof the mouth.E Eye symptoms • The eyes may be itchy and also watery; it is thought these symptoms are a result of tear duct congestion, and also a direct effect of pollen grains being caught in the eye, setting off a local inflammatory response. • Irritation of the nose by pollen probably contributes to eye symptoms too. • People who suffer severe symptoms of allergic rhinitis may be hypersensitive to bright light (photophobic) and find that wearing dark glasses is helpful. Previous history • There is commonly a history of hay fever going back over several years. • It can occur at any age, so the absence of any previous history does not necessarily indicate that allergic rhinitis is not a problem. • The incidence of hay fever has risen during the last decade. • Pollution, particularly in urban areas, is thought to be at least partly responsible for the trend. • Perennial rhinitis can usually be distinguished from seasonal rhinitis by questioning about the timing and the occurrence of symptoms. • People who have had hay fever before will often consult the pharmacist when symptoms are exacerbated in the summer months. Danger symptoms
  • 36. •When tightness of the chest, wheezing, shortness of breath or coughing are present, then immediate referral is advised. • These symptoms may herald the onset of an asthmatic attack.A Wheezing • Difficulty with breathing, possibly with cough, suggests an asthmatic attack. • Some sufferers only experience asthma attacks during the hay fever season (seasonal asthma). These episodes can be quite severe and require referral. • Seasonal asthmatics often do not have appropriate medication at hand as their attacks occur so infrequently, which puts them at greater risk.B Earache and facial pain • Allergic rhinitis can be complicated by secondary bacterial infection in the middle ear (otitis media) or the sinuses (sinusitis). • Both these conditions cause persisting severe pain.C Purulent conjunctivitis • Irritant watery eyes are a common accompaniment to allergic rhinitis. • Occasionally this allergic conjunctivitis is complicated by a secondary infection. - When this occurs the eye become more painful (gritty sensation) and redder, and the discharge changes from being clear and water to coloured and sticky (purulent). - Referral is needed. Medication • The pharmacist must establish any prescription or OTC medicines are being taken by the patient. - Potential interactions between prescribed medication and antihistamines can therefore be identified. • It would be useful to know if any medicines have been tried already to treat the symptoms, especially where there is a previous history of allergic rhinitis. • In particular, the pharmacist should be aware of the potentiation of drowsiness by some antihistamines combined with other medicines. This can lead to increased danger in certain occupations and driving. • Failed medication - If symptoms are not controlled with OTC preparations then an appointment with the doctor may be worthwhile. - Such an appointment is useful to explore the patient’s beliefs and preconceptions about the hay fever and its management. - It is also an opportunity to suggest ideas for the next season. - Treatment timescale • Improvement in symptoms should occur within a few days.
  • 37. • If no improvement is noted after 5 days, the patient might be referred to the doctor. - Management - Management include antihistamines, nasal decongestants and sodium cromoglycate. - Over the counter antihistamines can be very effective in the treatment of allergic rhinitis. - It is reasonable for the pharmacist to recommend treatment for hay fever. - Patients with symptoms which do not respond to OTC products can be referred to the doctor at a later stage. - Pharmacists also have an important role in ensuring that patients know how to use any prescribed medicines correctly (e.g., steroid nasal sprays, which must be used continuously for the patients to benefit).1 Antihistamines • Most pharmacists would consider these drugs to be the first line for symptoms of allergic rhinitis. They are effective in reducing sneezing and rhinorrhoea, less so in reducing nasal congestion. • Non-sedating OTC antihistamines including astemizole, loratadine, and terfenadine. Astemizole and Loratadine Terfenadine• long duration of action and requires only • Terfenadine can be given as a once – or once daily dosage, as does loratadine twice daily dose• For sale over the counter , astemizole and • For sale over the counter, terfenadine can loratadine for children over 12 be recommended for children over 6 years• loratadine may be recommended for other • Terfenadine may be recommended for allergic disorders such as perennial rhinitis other allergic disorders such as perennial and urticaria, while currently astemizole is to rhinitis and urticaria be recommended for hay fever only• Astemizole has a long half-life and its full effects may take a day or longer to develop.• This drug may be most effective when taken continuously during the hay fever season, since its long half-life may make intermittent treatment of symptoms less effective.- All are effective in reducing the troublesome symptoms of hay fever and have the advantage of causing less sedation than some of the older antihistamines.- While drowsiness is an extremely unlikely side-effect of any of the three drugs, patients might be well advised to try the treatment for day before driving or operating machinery. • Older antihistamines, such as promethazine and diphenhydramine, have a greater tendency to produce sedative effects.
  • 38. • The shorter t1/2 of diphenhydramine (5-8 hours compared to promethazine’s 8-12 hours) should mean less likelihood of a morning hangover/drowsiness. • Other older antihistamines are relatively less sedative, such as chlorpheniramine and clemastine. • Patients may develop tolerance to their sedation effects after regular use. • Antihistamines competitively block histamine release at receptor level, and also have anticholinergic activity. • Anticholinergic activity is very much lower among the newer. • Interactions: The potential sedative effects of older antihistamines are increased by alcohol, sedatives and anxiolytics. Both terfenadine and astemizole have the potential to induce ventricular arrhythmias. - Concurrent administration with certain drugs (erythromycin, oral ketoconazole, antiarrythmics, neuroleptics (chlorpromazine), tricyclic antidepressants (amitriptyline) and drugs which may cause electrolyte imbalance, such as diuretics.) predisposes to cardiotoxicity. - Patients should always be reminded not to exceed the recommended dose of these antihistamines. There have been reports of an interaction between phenytoin and chlorpheniramine, in which the phenytoin levels were raised to toxic levels while the patients were taking chlorpheniramine. - It has been suggested that antihistamines might inhibit liver metabolism of phenytoin. Antihistamines can antagonize the effects of betahistine. • Side effects: The major side effect of the older antihistamines is their potential to cause drowsiness. Their anticholinergic activity may result in a dry mouth, blurred vision, constipation and urinary retention. - These effects will be increased if the patient is taking another drug with anticholinergic effects (TCADs, neuleptics). - Antihistamines are best avoided by patients with closed angle glaucoma, since the anticholinergic effects produced can cause an increase in intra-ocular pressure. - They should be used with caution in patients with liver disease or prostatic hypertrophy. At very high doses, antihistamines have CNS excitatory effects. - Such effects seem to be more likely to occur in children. - At toxic levels, there have been reports of fits being induced. - As a result, so antihistamines should be used with care in epileptic patients.2 Nasal decongestants
  • 39. • Decongestants may be used to reduce nasal congestion alone or in combination with an antihistamine. • They are useful in patients using a ‘preventer’ such as cromoglycate or beclomethasone where congestion can prevent the drug from reaching the nasal mucosal. • Topical decongestant can cause rebound congestion, especially with prolonged use. - They should not be used for more than a week. - Since there is best restricted to 7 days or fewer, they will be inappropriate if the symptoms continue. - The decongestants are sympathomimetics such as pseudoephedrine and phenylpropanolamine. - Eye drops containing an antihistamine and sympathomimetic combination may be of value in troublesome eye symptoms. - The sympathomimetic acts as vasoconstrictor, reducing irritation and redness. - Some patients find that the vasoconstrictor causes painful stinging when first applied. - Eye drops which containing a vasoconstrictor should not be used in patients who have glaucoma or who wear soft contact lenses.3 Sodium cromoglycate • It can be effective as a prophylactic if used correctly. • It should be started 2 to 3 weeks before the hay fever season is likely to begin, and then used continuously through the season. • It seems to have no significant side effects, although nasal irritation may occasionally occur.
  • 40. GIT DISEASES
  • 41. MOUTH ULCERS sMouth ulcers are extremely common. They are classified as aphthous (minor or major) orherpetiform ulcers. Most cases are minor aphthous ulcers, which as self-limiting. Ulcers may bedue to a variety of causes including infection, trauma and drug allergy. However, occasionallymouth ulcers appear as a symptom of serious disease such as carcinoma. - Information to be collected Age • Patients may describe a history of recurrent ulceration which began in childhood and has continued ever since. • Minor apthous ulcers are commoner in women, and occur more often between the ages of 10 and 30. Nature of the ulcers TYPE Minor aphthous ulcers Major aphthous ulcers Herpetiform ulcers • Occur in crops of 1-5. • Major aphthous ulcers • More numerous and The lesions may be up to are uncommon severe smaller than 5 mm in diameter and variants of the minor aphtous appear as a white or ones.APPEARANCE yellowish centre with an • These ulcers, which inflamed red outer edge may be as large as 30 mm in diameter, can occur in crops of up to 10. • Common sites are the • Sites involved are the • In addition to the tongue margin and lips, cheeks, tongue, sites involved with inside the lips and pharynx and palate. aphthous ulcers, SITE cheeks. • They are more may affect the floor common in sufferers of the mouth and of ulcerative colitis. the gums. • Systemic conditions such as Behcet’s syndromes and erythrema multiform may produce mouth ulcers, but other symptoms would generally be present. Duration • Minor apthous ulcers : usually heal in less than a week • Major apthous ulcers take longer time than minor aphtous (10-30 days). • Herpetiform ulcers occur, fresh crops of ulcers tend to appear before the original crop has healed, which may lead patients to think that the ulceration is continuous.
  • 42. Oral cancer• Any mouth ulcer which has persisted for longer than 3 weeks requires immediate referral because an ulcer of such longer duration may indicate serious pathology such as carcinoma.• The development of cancer may be preceded by a premalignant lesion, including erythroplasia (red) and leucoplakia (white), or a speckled leucoplakia.• The key point to raise suspicion would be a lesion which last for several weeks or longer. Oral cancer is commoner in smokers.Previous history• There is often a family history of mouth ulcers.• Minor apthous ulcers often recur, with the same characteristic features of size, numbers, appearance and duration before healing. - The appearance of these ulcers may follow trauma to the inside of the mouth or tongue, such as biting the inside of the cheek while chewing food. - Ill-fitting dentures may produce ulceration, and if this is suspected as a cause, the patient should be refereed back to the dentist so that the dentures can be re-fitted. - However, trauma is not always a feature of the history, and the cause of minor apthous ulcers remains unclear.• In women, minor apthous ulcers often precede the start of the menstrual period.• The occurrence of ulcers may cease after pregnancy, suggesting hormonal involvement.• Stress and emotional factors may precipitate a recurrence or delay in healing but do not seem to be causative.• Deficiency of iron, folate or vitamin B12 may be a contributory factor in apthous ulcers and may also lead to glossitis (a condition where the tongue becomes sore, red and smooth) and angular stomatitis (where the corners of the mouth become sore, cracked and red).• Food allergy is occasionally the causative factor.Other symptoms• The severe pain associated with major apthous or herpetiform ulcers may mean that the patient finds it difficult to eat and, as a consequence, weight loss may occur. - Weight loss would therefore be an indication for referral.• In most cases of recurrent mouth ulcers the disease eventually burns itself out over a period of several years. - Occasionally, as in Behcet’s syndrome, there is progression with involvement of sites other than the mouth.• Most commonly the vulva and vagina and the eye are affected, with genital ulceration and iritis.
  • 43. • Behcet’s syndrome can be confused with erythema multiforme although in latter there is usually a distinctive rash present on the skin. - Erythema multiforme is sometimes precipitated by an infection or drugs (e.g., sulphonamides or barbiturates). • Mouth ulcers may be associated with inflammatory bowel disorders or with celiac disease. - Therefore, if persistent or recurrent diarrhoea is present then referral is essential. Medication • The pharmacist should establish the identity of any current medication. Since mouth ulcers may be produced as a side effect of drug therapy. • Drugs which have been reported to cause the problem include aspirin and other NSAIDs, cytotoxic drugs and sulphasalazine. • Radiotherapy may also induce mouth ulcers. • It would also be useful to ask the patient about any treatment tried either previously or on this occasion, and the degree of relief obtained. The pharmacist can then recommend an alternative. - Treatment timescale • If there is no improvement after a week, the patient should see the doctor. - Management- Symptomatic treatment of minor apthous ulcers can be recommended by the pharmacist.- Active ingredients include antiseptics, local anaesthetics and anti-inflammatory agents.- Commonly used preparations include gels, liquids, mouthwashes, pastilles and tables.- Gels and liquids may be more accurately applied using cotton bud, providing the ulcer is readily accessible.- Mouthwashes can be useful where ulcers are difficult to reach 1 Local anaesthetics • Local anaesthetic gels form one of the most popular treatments for mouth ulcers. - Although they are effective in producing pain relief, maintenance of gels and liquids in contact with the ulcer surface is difficult. - Reapplication of the preparation may be made when necessary. • Tablets and pastilles can be kept in contact with the ulcer by the tongue, and can be very useful when just one or two ulcers are present. • Any preparation containing a local anaesthetic becomes difficult to use when the lesions are located in inaccessible parts of the mouth. • Both lignocaine and Benzocaine have been reported to produce sensitization, but cross-sensitivity seems to be rare, probably because the two agents are from two different chemical groupings.
  • 44. - Thus, if a patient has experienced a reaction to one agent in the past, the alternative could be tried.2 Topical analgesics • Choline salicylate dental gel is frequently recommended for the symptomatic treatment of mouth ulcers. - Again, while it is effective in relieving pain, retention of the gel in contact with the ulcer is difficult, and reapplication will be necessary. • Although aspirin is no longer recommended for children under 12 years old because of the possible links with Reye’s syndrome, choline salicylate dental gel produces low levels of salicylate and can, therefore, be recommended for children.3 Antibacterials • The rationale for the use of antibacterial agents (cetylpyridiniukm chloride, povidone-iodine, chlorhexidine gluconate) in the treatment of mouth ulcers is that secondary bacterial infection frequently occurs. - Such infection can increase discomfort and delay healing. • Preparations available include mouthwash, pastilles and pellets. • Mouthwashes are especially useful where there are several lesions, or where ulcers are located in parts of the mouth which are difficult to each. • Products containing Chlorhexidine may discolour the tongue and teeth.4 Anti-inflammatory agents • Hydrocortisone pellets act locally on the ulcer to reduce inflammation and pain. - To exert its effect, a pellet must be held in close proximity to the ulcer until dissolve. - This can be difficult when ulcer is in an inaccessible spot. - One pellet is used four times a day. - The pharmacist should explain to the patient that the pellets should not be sucked, but dissolved in contact with the ulcer. • Benzylamine is available as a mouthwash and can be useful when ulcers are located in inaccessible areas, or where there are several lesions. - Benzylamine has been reported to cause numbness and tingling of the mouth as adverse effect in small number of users. - Benzylamine mouthwash is not recommended for children under 12 years. • Carbenoxolone is available as an oral gel, which is applied in a thick layer to the ulcers after meals and before going to bed.5 Protective agents • Carmellose dental paste forms a protective mechanical barrier when applied to ulcers, and can be reapplied as needed.
  • 45. - The preparation is even more effective when the corticosteroids triamcinolone is added, particularly when used during the prodromal phase (before the ulcer appears, where the affected areas feel sensitive and tingling).6 Other substances • Alum was a traditional remedy for mouth ulcers because of its astringent action. - However, it is now known to have the potential actually to damage tissue, thus delaying healing. • Tincture of myrrh has been used in the past as an ingredient of mouthwashes in the treatment of mouth ulcers. - As more effective treatments are now available, its use has been superseded.
  • 46. HEART BURN S- Symptoms of heartburn are caused when there is reflux of gastric content, particularly acid, in the oesophagus, which irritate the sensitive mucosal surface (oesophagitis).- Patients will often describe the symptoms of heartburn – typically a burning discomfort/pain felt in the stomach passing upwards behind the breastbone. - Information to be collected Age • The symptoms of reflux and oesophagitis occur more commonly in patients aged over 55. • Heartburn is not a condition normally experienced in childhood, although symptoms can occur in young adults and particularly in pregnant women. • Children with symptoms of heart burn should therefore be referred to the doctor. Symptoms/associated factors • A burning discomfort is experienced in the upper part of the stomach (epigastrium), and the burning feeling tends to move upwards behind the breastbone. • The pain may be felt only in the lower retrosternal area, on occasion be felt right up to the throat, causing an acid taste in the mouth. • Deciding whether or not someone is suffering from heartburn can be greatly helped by enquiring about precipitating or aggravating factors. • Heartburn is often brought on by bending or lying down. It is more likely to occur in the overweight and can be aggravated by a recent increase in weight. • It is also more likely to occur after a large meal. • It can be aggravated and even caused by belching. - Many people develop a nervous habit of swallowing to clear the throat. Each time this occurs, air is taken down into the stomach, which becomes distended. - This causes discomfort which is relieved by belching but which in turn can be associated with acid reflux. • Severe pain - Sometimes the pain can come on suddenly and severely and even radiate to the back and arms. - In this situation differentiation of symptoms is difficult as the pain can mimic a heart attack, and urgent medical referral is essential. - Sometimes, patients who have been admitted to hospital apparently suffering a heart attack are found to have oesophagitis instead. • Difficulty in swallowing (dysphagia) - This must always be regarded as a serious symptom. - Difficulty may either be discomfort as food or drink is swallowed or a sensation of food or liquids sticking in the gullet. Both require referral.
  • 47. - It is possible that discomfort may be secondary to oesophagitis from acid reflux, especially when it occurs whilst swallowing hot drinks or irritant fluids (alcohol or fruit juice). - A history of a sensation that food sticks as it is swallowed or that it does not seem to pass directly into the stomach (dysphagia) is an indication for immediate referral. It may be due to obstruction of the oesophagus – by a tumour for example.• Regurgitation - It can be associated with difficulty in swallowing. - It occurs when recently eaten food sticks in the oesophagus and is regurgitated without passing into the stomach. - This is due to a mechanical blockage in the oesophagus. This can be caused by cancer or by less serious conditions such as a peptic stricture which is caused by long- standing acid reflux with oesophagitis. - The continual inflammation of the oesophagus causes scarring. Scars contract and can cause narrowing of the oesophagus. - This can be treated by dilatation using a fibre optic endoscope. - However, medical examination and further investigations are necessary to determine the cause of regurgitation.• Pregnancy - It has been estimated that as many as half of all pregnant women suffer from heartburn. - Pregnant women aged over 30 are more likely to suffer from the problem. - The symptoms are caused by an increase in intra-abdominal pressure, and incompetence of the lower oesophageal sphincter. - It is thought that hormonal influences, particularly progesterone, are often important in the lowering of sphincter pressure. - Heartburn often begins in mid – to late pregnancy, but may happen at any stage. - The problem may sometimes be associated with stress. Medication • The pharmacist should establish the identity of any medication which has been tried to treat symptoms. • Any other medication being taken by the patient should also be identified; some drugs can cause the symptoms of heartburn – for example, anticholinergic agents (hyoscine), and drugs with anticholinergic action (TCADs and phenothiazines). • Calcium channel blockers, nitrates, theophylline and aminophylline can also aggravate heartburns, as can caffeine. • Failure to respond to antacids and pain radiating to the arms could mean that the pain is not caused by acid reflux. Acid reflux is still a possibility but other causes such as ischaemic heart disease and gall bladder disease have to be considered.
  • 48. - Treatment timescale • If symptoms have not responded to treatment after 1 week, the patient should see the doctor. - ManagementThe symptoms of heartburn respond well to treatments which are available over the counter, andthere is also a role for the pharmacist to offer practical advice about measures to preventrecurrence of the problem.1 Antacids • These can be very effective in controlling the symptoms of heartburn and reflux. • Choice of antacid can be made by the pharmacist. • Preparations which are high in sodium should be avoided in pregnant women and people with heart disease or taking antihypertensive medication.2 Alginates • Preparations containing alginates work on the principle that a raft is formed which sits on the surface of the stomach contents and prevents reflux. • Some alginates – based products are high in sodium because their formulation includes sodium bicarbonate. - The function of the sodium bicarbonate, in addition to its antacid action, is to cause the release of carbon dioxide gas in the stomach, enabling the raft to float on top of the stomach content. - If a preparation low in sodium is required, the pharmacist can recommend one containing potassium bicarbonate instead. - Alginates with a low sodium contents are useful in pregnancy and in hypertensive patients.3 H2 antagonists (ranitidine, famotidine) • These H2 antagonists have been deregulated from prescription only control for short – term treatment (up to 2 weeks) of dyspepsia. • The 2-week treatment limit is intended to ensure that patients do not self-medication with these drugs for long periods. • It is therefore important that pharmacists and their staff adhere to the 2-week period and advise referral where needed. • Where food is known to precipitate symptoms, the H2 antagonist should be taken an hour before food. • Headache, dizziness, diarrhoea and skin rashes have been reported as adverse effects but they are not common.
  • 49. - Practical PointsA) Obesity • If the patient is overweight, weight reduction should be advised. • Most patients will find that their symptoms will cease when they attain their ideal weightB) Food • Small meals, eaten frequently, are better than large meals; reducing the amount of food in the stomach and therefore reducing gastric distension will help to prevent reflux. • Gastric emptying is slowed when there is a large volume of food in the stomach; this can also aggravate symptoms. • The patient’s evening meal is best taken several hours before going to bed.C) Aggravating factors • Smoking, alcohol, caffeine, chocolate and fatty food can all make the oesophageal sphincter less competent by reducing its pressure, and therefore contribute to symptoms. • The pharmacist is in a good position to offer advice about how to stop smoking, perhaps offering a smoking cessation product where appropriate. • The knowledge that the discomfort of heartburn will be reduced can be a motivating factor in giving up smoking.D) Posture • Bending and even slumping in an armchair can provoke symptoms, and should be avoided where possible. • It is better to squat rather than bend down. • Since the symptoms are often worse when the patient lies down, raising the head of the bead may help. • Using extra pillows is often recommended but this is not as effective as raising the head of the bed. The reason for this is that using extra pillow raises only the upper part of the body, with bending at the waist, which can result in increased pressure on the stomach content.
  • 50. INDIGESTIONIndigestion (dyspepsia) is commonly presented in community pharmacies, and is often self-diagnosed by patients, who use the term to include anything from pain in the chest and upperabdomen to lower abdominal symptoms. The pharmacist must establish whether such a self-diagnosis is correct and exclude the possibility of serious disease.Information to collectThe symptoms of typical indigestion include poorly localized upper abdominal (the area betweenthe belly button and the breastbone) discomfort which may be brought on by particular foods, byexcess food, alcohol, or by medication, e.g. aspirin.AgeIndigestion is rare in children, who should be referred to the GP. Abdominal pain, however, is acommon symptom in children and is often associated with an infection. OTC treatment is notappropriate for abdominal pain of unknown cause and referral to the doctor would be advisable.Details of painIf the pharmacist can obtain a good description of the pain, then the decision whether to advisetreatment or referral is much easier. A few medical conditions which may present as indigestionbut which require referral are described below.UlcersUlcers may occur in the stomach (gastric ulcer), or, in the first part of the small intestine leadingfrom the stomach (duodenal ulcer). Duodenal ulcers. Duodenal ulcers are more common and have different symptoms to gastric ulcers. Typically, the pain of a duodenal ulcer is localized to the upper abdomen, slightly to the right of the midline. It is often possible to point to the site of pain with a single finger. The pain is dull and is most likely to occur when the stomach is empty, especially at night. It is relieved by food (although it may be aggravated by fatty foods) and by antacids. Gastric ulcers. The pain of a gastric ulcer is also in the same area, but less well localized. It is often aggravated by food and may be associated with nausea and vomiting. Appetite is usually reduced and the symptoms are persistent and severe. Both types of ulcer may be exacerbated or precipitated by smoking and by nonsteroidal anti-inflammatory drugs.Gall stones
  • 51. Single or multiple stones can be formed in the gall bladder which is situated beneath the liver. Thegall bladder stores bile. It periodically contracts to squirt bile through a narrow tube (bile duct) intothe duodenum to aid digestion of food, especially fat. Stones can become temporarily stuck in theopening to the bile duct as the gall bladder contracts. This causes severe pain (biliary colic) in theupper abdomen below the right rib margin. Sometimes this pain can be confused with that of aduodenal ulcer. Biliary colic may be precipitated by a fatty meal.Acid refluxWhen a person eats, food passes down the gullet (oesophagus) into the stomach. Acid isproduced by the stomach. The lining of the stomach is resistant to the irritant effects of acid,whereas the lining of the oesophagus is readily irritated by acid. There is usually a valve systemoperating between the stomach and the oesophagus preventing acid reflux. When this valvesystem is weak, e.g. in the presence of an hiatus hernia, or where sphincter muscle tone isreduced by drugs such as anticholinergics, the acid contents of the stomach can leak backwardsinto the oesophagus. The symptoms are typically described as heartburn; this is a pain arising inthe upper abdomen passing upwards behind the breastbone. It is precipitated by a large meal, orbending and lying down. Heartburn can be treated by the pharmacist.Irritable bowel syndromeThis is a common, non-serious, but troublesome condition in which symptoms are caused bycolon spasm. There is an alteration in bowel habit, often with alternating constipation anddiarrhoea. The diarrhoea is typically worse first thing in the morning. Pain is usually present; it isoften lower abdominal (below and to the right or left of the belly button), but may be upper andconfused with indigestion. Any persistent alteration in normal bowel habit is an indication forreferral.Atypical anginaAngina is usually experienced as a tight painful constricting band across the middle of the chest.Atypical angina pain may be felt in the lower chest or upper abdomen. This is likely to beprecipitated by exercise or exertion. If this occurs, then referral is necessary.More serious disordersPersisting upper abdominal pain especially when associated with anorexia and weight loss mayherald an underlying cancer of the stomach or pancreas. Ulcers sometimes start bleeding.Thismay present with blood in the vomit (haematemesis) or in the stool (melaena). In the latter thestool becomes tarry and black. Urgent referral is necessary.Duration/previous history
  • 52. Indigestion which is persistent or recurrent should be referred to the GP, after considering theinformation gained from questioning. Any patient with a previous history of the symptom which hasnot responded to treatment, or which has worsened, should be referred.DietFatty foods and alcohol can cause indigestion, aggravate ulcers and precipitate biliary colic.Smoking habitSmoking predisposes to, and may cause indigestion and ulcers. Ulcers heal more slowly andrelapse more often during treatment in smokers. The pharmacist is in a good position to offerantismoking advice.MedicationMedicines already triedAnyone who has tried one or more antacids without improvement, or whose initial improvement insymptoms is not maintained should see the doctor.Other medicines being takenGastrointestinal side effects can be caused by many drugs, so it is important for the pharmacist toascertain any medication which the patient is taking.Nonsteroidal anti-inflammatory agents such as ibuprofen, indomethacin and piroxicam maycause symptoms of indigestion and have been implicated in the causation of ulcers, and withbleeding ulcers. Elderly patients are particularly prone to these problems, and pharmacists shouldbear this in mind when dealing with patients. Indigestion in any patient taking a nonsteroidal anti-inflammatory agent is an indication for referral to the GP.Treatment timescaleIf symptoms have not improved within 5 days, the patient should see the doctor.ManagementOnce the pharmacist has excluded serious disease, treatment with antacids may berecommended and is likely to be effective. The preparation chosen should be selected on thebasis of the individual patients symptoms. Smoking, alcohol and fatty meals can all aggravatesymptoms, so the pharmacist can advise appropriately.AntacidsIn general, liquids are more effective antacids than are solids; they are easier to take, work morequickly and have a greater neutralizing capacity. Their small particle size allows a large surfacearea to be in contact with the gastric contents. Some patients find tablets more convenient, andtablets should be well chewed before swallowing for the best effect. It might be appropriate for the
  • 53. patient to have both: the liquid can be taken before and after working hours and tablets forconvenience during the day. Antacids are best taken about an hour after meals, because the rateof gastric emptying has slowed, and the antacid will therefore remain in the stomach for longer.Taken at this time, antacids may act for up to 3 hours compared to half an hour to an hour if takenbefore meals.Sodium bicarbonateThis is the only absorbable antacid that is useful in practice. It is water-soluble, acts quickly, and isan effective neutralizer of acid, with a short duration of action. It is often included in OTCformulations in order to give a fast-acting effect, in combination with longer-acting agents.However, antacids containing sodium bicarbonate should be avoided in patients if sodium intakeshould be restricted (for example, pregnant women and hypertensive patients). The contents ofOTC products should therefore be carefully scrutinized, and pharmacists should be aware of theconstituents of some of the traditional formulary preparations. For example, magnesium trisilicatemixture contains sodium bicarbonate and is therefore relatively high in sodium. In addition, long-term use of sodium bicarbonate may lead to systemic alkalosis and renal damage. In short-termuse, however, it can be a valuable and effective antacid. Its use is more appropriate in acuterather than chronic dyspepsia.Aluminium and magnesium salts (e.g. aluminium hydroxide, magnesium trisilicate)Aluminium based antacids are effective; they tend to be constipating, and this can be a usefuleffect in patients if there is slight diarrhoea. However, the use of aluminium antacids is betteravoided in anyone who is constipated, and in elderly patients, who have a tendency to be so.Magnesium salts are more potent acid neutralizers than aluminium. They tend to cause osmoticdiarrhoea as a result of the formation of insoluble magnesium salts and are therefore useful inpatients who are slightly constipated. Combination products containing aluminium and magnesiumsalts cause minimum bowel disturbance and are therefore valuable preparations forrecommendation by the pharmacist.Calcium carbonateThis is commonly included in over-the-counter formulations. It acts quickly and has a prolongedaction, and is a potent neutralizer of acid. It can cause acid rebound and if taken over longperiods, can cause hypercalcaemia, so should not be recommended for long-term use. Calciumcarbonate and sodium bicarbonate can, if taken in large quantities, with a high intake of milk,result in the milkalkali syndrome. The syndrome involves hypercalcaemia, metabolic alkalosis andrenal insufficiency; its symptoms are nausea, vomiting, anorexia, headache and mental confusion.Simethicone
  • 54. Simethicone is sometimes added to antacid formulations because of its defoaming properties.Theoretically, it reduces surface tension and allows easier elimination of gas from the gut bypassing flatus or eructationInteractions with antacidsBecause they raise the gastric pH, antacids can interefere with enteric coatings on tablets whichare intended to release their contents further along the GIT. The consequences of this may be thatrelease of the drug is unpredictable; adverse effects may occur if the drug is in contact with thestomach. Enteric coatings are sometimes used to protect a drug which may be inactivated by thelow pH in the stomach, so concurrent administration of antacids may result in such inactivation.Sucralfate works best in an acid medium, so concurrent administration with antacids should beavoided. Excretion of flecainide, mexiletine and quinidine may be reduced, and plasma levelsincreased if the urine is alkaline, and antacids may increase urinary pH. Antacids may reduce theabsorption of tetracyclines, ketoconazole, penicillamine, chlorpromazine, diflunisal, ciprofloxacin,pivampicillin, and rifampicin. Sodium bicarbonate may increase the excretion of lithium and lowerthe plasma level, so that a reduction in lithiums therapeutic effect may occur. Antacids containingsodium bicarbonate should not be recommended for patient on lithium.The changes in pH which occur after antacid administration can result in a decrease in ironabsorption if iron is taken at the same time. The effect is caused by the formation of insoluble saltsdue to pH change. Taking iron and antacids at different times should prevent the problem.Interactions: chlorpromazine; ciprofloxacin; diflunisal; enteric coated tablets; flecainide;ketoconazole; lithium; mexiletine; penicillamine; pivampicillin; quinidine; rifampicin; sucralfate;tetracyclines.
  • 55. NAUSEA AND VOMITINGNausea and vomiting are symptoms which have many possible causes. From thepharmacist’s point of view, while there are treatments available to prevent nausea andvomiting, there is no effective OTC treatment once vomiting is established.Information to collectAgeThe very young and elderly are most at risk from dehydration as a result of vomiting.Vomiting of milk in infants less than a year old may be due to infection or feeding problems,or, rarely, to an obstruction such as pyloric stenosis. In the latter there is thickening of themuscular wall around the outlet of the stomach which causes a blockage. It typically occursin the first few weeks of life in a first-born male. The vomiting is frequently projectile in thatthe vomit is forcibly expelled a considerable distance. The condition can be cured by a simpleoperation. The pharmacist must distinguish, by questioning, between vomiting (the forcedexpulsion of gastric contents through the mouth) and regurgitation (where food is effortlesslybrought up from the throat and stomach). Regurgitation sometimes occurs in babies, where itis known as ‘posseting’ and is a normal occurrence; and also in adults, where it is associatedwith oesophageal disease, and hence difficulty in swallowing. Nausea is associated withvomiting but not regurgitation, and this can be employed as a feature during questioning.PregnancyNausea and vomiting are very common in pregnancy, usually begins after the first missedperiod, and occurs early in the morning. Pregnancy should be considered as a possiblecause of nausea and vomiting in any woman of child-bearing age who presents at thepharmacy complaining of nausea and vomiting. Nausea and vomiting are commoner in thefirst pregnancy than in subsequent ones.DurationGenerally, adults should be referred to the doctor if vomiting has been present for longer than2 days. Infants and children under 2 years are referred whatever the duration because of therisks from dehydration. Anyone presenting with chronic vomiting should be referred sincesuch symptoms may indicate the presence of a peptic ulcer or gastric carcinoma.SymptomsGastroenteritis
  • 56. An acute infection is often responsible for vomiting, and in these cases, diarrhoea may alsobe present. Careful questioning about food intake during the previous 2 days may give a clueas to the cause. In young children, the rotavirus is the commonest cause of gastroenteritis,and it is highly infectious, so it is not unusual for more than one child in the family to beaffected. In such situations there are usually associated cold symptoms.Vomiting bloodThe vomiting of blood may indicate serious disease and is an indication for referral, since itmay be caused by haemorrhage from a peptic ulcer or gastric carcinoma. Sometimes thetrauma of vomiting can cause a small bleed, due to a tear in the gut lining. Vomit with afaecal smell means that the GIT may be obstructed and required referral urgently.MigraineNausea and vomiting may be associated with migraine.MedicationPrescribed and OTC medicines may make patients feel sick, and it is important to determinewhich medicines the patient is currently taking. Aspirin and NSAIDs are common causes.Some antibiotics may cause nausea and vomiting – for example, doxycycline. Oestrogens,steroids and narcotics may also produce these symptoms. Symptoms can be improved bytaking the medication with food, but if they continue, the patient should be referred. Digoxintoxicity may show itself by producing nausea and vomiting, and such symptoms in a patienton digoxin, specially an elderly person, should prompt immediate referral where questioninghas not produced an apparent cause for the symptoms. Vomiting, with loss of fluids andpossible electrolyte imbalance, may cause problems in elderly people taking digoxin anddiuretics.Previous historyAny history suggesting chronic nausea and vomiting would indicate referral. Any history ofdizziness or vertigo should be noted, as it may point to inner ear disease as a cause ofnausea.ManagementPatients who are vomiting should be referred to the doctor, who will be able to prescribe ananti-emetic if needed. The pharmacist can initiate rehydration therapy in the meantime.
  • 57. CONSTIPATIONConstipation is a condition which is difficult to define and is often self-diagnosed by patients.Generally it is characterized by a decreased frequency of defaecation and the passage ofhard, dry stools. It is important for the pharmacist to find out what the patient means by‘constipation’, and to establish what (if any) change in bowel habit has occurred.Information to collectDetails of bowel habitMany people believe that a daily bowel movement is necessary for good health, andlaxatives are taken and abused as a result. In fact, the ‘normal’ range may vary from 3movements in 1 day to 3 in 1 week. There is an important health education role for thepharmacist in reassuring patients that their frequency of bowel movement is ‘normal’.Patients who are constipated will usually complain of hard stools which are difficult to passand less frequent than usual.The determination of any change in bowel habit is essential, particularly any prolongedchange. A sudden change which has lasted for 2 weeks or more would be referred.Associated symptomsAbdominal discomfort, bloating and nauseaConstipation is often associated with abdominal discomfort, bloating and nausea. In somecases constipation can be severe as to obstruct the bowel. This obstruction usually becomesevident by causing colicky abdominal pain, abdominal distension and vomiting. Whensymptoms suggestive of obstruction are present, urgent referral is necessary as hospitaladmission is the usual course of action. Constipation is only one of many possible causes ofobstruction. Other causes such as bowel tumours or twisted bowels (volvulus) require urgentsurgical intervention.Blood in the stoolThe presence of blood in the stool can be associated with constipation and although alarmingis not necessarily serious. In such situations blood may arise from piles or small crack in theskin on the edge of the anus (fissure). Both these conditions are thought to be caused by alow residue diet which tends to produce constipation. The bleeding is characteristically notedon toilet paper after defaecation. The bright red blood may be present on the surface of themotion (not mixed in with the stool), and splashed around the toilet pan. If piles are presentthere is often discomfort on defaecation. The piles may drop down (prolapse) and protrudethrough the anus. A fissure, however, tends to cause less bleeding but much more severe
  • 58. pain on defaecation. Medical referral is usually advisable as there are other serious causesof bloody stool, especially where the blood is mixed in with the motion.Bowel cancerBowel cancer may also present with a persisting change in bowel habit. Early diagnosis andintervention can dramatically improve the prognosis. Bowel cancer is most common in thoseover 50 years old but can, rarely, also occur in younger age groups.DietInsufficient dietary fibre is a common cause of constipation. An impression of the fibrecontent of the diet can be gained by asking what would normally be eaten during 1 day,looking particularly for the presence of wholemeal cereals and bread, and of freshvegetables.Changes in diet and lifestyle, for example, following a job change, loss of work or retirement,or travel may result in constipation. An inadequate intake of food and fluid, for example, insomeone who has been ill, may be responsible.MedicationOne or more laxatives may already have been taken in an attempt to treat the symptoms.Failure of such medication may indicate that referral to the doctor is the best option. Previoushistory of the use of laxatives is relevant. Continuous use, especially of stimulant laxatives,can result in a vicious circle where the contents of the gut are expelled, causing asubsequent cessation of bowel actions for 1 or 2 days. This then leads to the falseconclusion that constipation has recurred and more laxatives are taken, and so on.Chronic overuse of stimulant laxatives can result in loss of muscular activity in the bowel wall(an atonic colon) and thus further constipation.Drugs which may cause constipationAnalgesics and opiates Dihydrocodeine, codeineAntacids Aluminium saltsAnticholinergics HyoscineAnticonvulsants PhenytoinAntidepressants AmitriptylineAntihistamines Chlorpheniramine, promethazineAntihypertensives Clonidine, prazosin, methyldopaAnti-parkinson agents LevodopaBeta blockers PropranololDiuretics BendrofluzideIronLaxative abuseMonoamine oxidase inhibitors PhenelzinePsychotropics Chlorpromazine
  • 59. Treatment timescaleIf one week’s use of treatment does not produce relief of symptoms, the patient should seethe doctor. If the pharmacist feels that it is only necessary to give dietary advice, then itwould be reasonable to leave it for about two weeks to see if the symptoms settle.ManagementConstipation which is not caused by serious pathology will usually respond to simplemeasures which can be recommended by the pharmacist; increasing the amount of dietaryfibre; maintaining fluid consumption; and taking regular exercise. In the short term, a laxativemay be recommended to ease the immediate problem.Stimulant laxatives (senna, bisacodyl)These work by increasing peristalsis. All stimulant laxatives can produce griping/crampingpain. It is advisable to start at the lower end of the recommended dosage range, increasingthe dose if needed. The intensity of the laxative effect is related to the dose taken. Stimulantlaxatives work within 6-12 hours. They should be used for a maximum of 1 week.The use of senna and cascara which is non-standardized should be discouraged becausethe doses, and therefore actions, are unpredictable. Phenophthalein should be avoidedaltogether because it is absorbed and can produce unpleasant side effects. Absorbedphenolphthalein is excreted with bile back into the GIT, where a laxative effect will beexerted. The cycle continues, and the laxative action of phenolphthalein last for 3-4 days.Adverse effects including albuminuria, rashes, and haemoglobinuria may also occur.Bisacodyl, taken orally, will act within 6-10 hours. If it is given as a suppository, the effectusually occurs within an hour, and sometimes as soon as 15 minutes after insertion.Castor oil is a traditional remedy for constipation. Evacuation of the bowel occurs within 2-6hours. Castor oil works best if taken on an empty stomach but it has an unpleasant taste andcan cause griping pain. Its use is best avoided when other preparations can berecommended.Bulk laxatives (Ispaghula, methylcellulose, sterculia)These are the laxatives which most closely copy the normal physiological mechanismsinvolved in bowel evacuation, and are considered by many to be the laxative of choice. Suchagents are especially useful where patients cannot or will not increase their intake of dietaryfibre. Bulk laxatives work by swelling in the gut and increasing faecal mass so that isstimulated. The laxative effect can take several days to develop.
  • 60. The sodium content of bulk laxatives should be considered in those requiring a restrictedsodium intake.When recommending the use of a bulk laxative, the pharmacist should advise that anincrease in fluid intake will be necessary. In the form of granules or powder, the preparationshould be mixed with a full glass of liquid before taking. Fruit juice can mask the bland tasteof the preparation. Intestinal obstruction may result from inadequate fluid intake in patientstaking bulk laxatives, particularly those whose gut is not functioning properly as a result ofabuse of stimulant laxatives.Lubricant laxatives (liquid paraffin)Liquid paraffin works by coating and softening the faeces; it prevents further absorption ofwater in the colon. Long-term use can result in impaired absorption of fat-soluble vitamins.Leakage of liquid paraffin through the anal sphincter may occur, causing embarrassment. Ifliquid paraffin is inadvertently inhaled into the lungs lipid pneumonia can develop. Inhalationcould occur during vomiting or if acid reflux is present.Osmotic laxatives (Lactulose, Epsom salts, Glauber’s salts)Epsom salts (magnesium sulphate) and Glauber’s salts (sodium sulphate) act by drawingwater into the gut; the increased pressure which results increases intestinal motility. A doseof either salt usually produces a bowel movement within a few hours. Glauber’s salts shouldbe avoided in those whose sodium intake needs to be restricted. Occasional use of Epsomsalt or Glauber’s salts can be useful where a rapid evacuation of the bowel is needed, butthey are unsuitable for long-term use because their repeated use can lead to dehydration.Lactulose works by maintaining the volume of fluid in the bowel. It may take 1-2 days to work.Glycerin suppositories have both osmotic and irritant effects, and act within an hour. Theymay cause rectal discomfort. Moistening the suppository before use will make insertioneasier.Constipation in childrenParents sometimes ask for laxatives for use in children. Fixed ideas about ‘regular’ bowelhabits are often responsible for such requests. Numerous factors can cause constipation inchildren, including a change in diet, and emotional causes. Simple advice about sufficientdietary fibre may be all that is needed.
  • 61. If the problem is of recent origin and there are no significant associated signs, a singleglycerine suppository together with dietary advice may be appropriate. Referral to the doctorwould be best if these measures were unsuccessful.Constipation in pregnancyConstipation is a common problem in pregnancy; hormonal changes are responsible. Dietaryadvice concerning the intake of plenty of high-fibre foods and fluid can help. Oral iron, oftenprescribed for pregnant women, may contribute to the problem.Stimulant laxatives are best avoided during pregnancy; bulk-forming laxatives are preferable,although they may cause some abdominal discomfort to women when used in pregnancy.Constipation in the elderlyConstipation is a common problem in elderly patients for several reasons; elderly patients areless likely to be physically active and they often have poor natural teeth or false teeth so mayavoid high-fibre foods which are more difficult to chew. Multi-drug regimens are more likely inelderly patients, who may therefore suffer from drug-induced constipation. Fixed ideas aboutwhat constitutes a ‘normal’ bowel habit are common in older patients. If a bulk laxative is tobe recommended for an elderly patient, it is important that the pharmacist gives advice aboutmaintaining fluid intake to prevent the possible development of intestinal obstruction.Laxative abuseTwo groups of patients are likely to abuse laxatives; those with chronic constipation who getinto vicious circle by using stimulant laxatives, which eventually results in damage to thenerve plexus in the colon; and those who take laxatives in the belief that they will controlweight- for example, those who are dieting or, more seriously, women with eating disorders(anorexia nervosa or bulimia), who take very large quantities of laxatives.
  • 62. DIARRHOEACommunity pharmacists may be asked by patients to treat existing diarrhoea, or to offeradvice on what course of action to take should diarrhea occur, for example to holidaymakers.Diarrhea is defined as an increased frequency of bowel evacuation, with the passage ofabnormally soft or watery faeces. The basis of treatment is fluid and electrolyte replacement;in addition, anti-diarrheals are useful in adults and older children.Information to collectAgeParticular care is needed in the very young and the very old. Infants (younger than 1 yearold) and elderly patients are especially at risk of becoming dehydrated.DurationMost cases of diarrhoea will be acute and self-limiting. Because of the dangers ofdehydration, it would be wise to refer infants with diarrhoea of longer than 1 days duration tothe doctor.SeverityThe degree of severity of diarrhoea is related to the nature and frequency of stools. Boththese aspects are important, since misunderstandings can arise, especially in self-diagnosedcomplaints. Elderly patients who complain of diarrhoea may, in fact, be suffering from faecalimpaction. They may pass liquid stools, but with only one or two bowel movements a day.SymptomsAcute diarrhoea is rapid in onset and produces watery stools which are passed frequently.Abdominal cramps, flatulence and weakness or malaise may also occur. Nausea andvomiting may be associated with diarrhoea, as may fever. The pharmacist should questionthe patient about food intake, and also about whether other family members or friends aresuffering from the same symptoms, since acute diarrhoea is often infective in origin. Often,there are minor outbreaks of gastroenteritis locally, when the pharmacist may be askedseveral times for advice and treatment by different patients during a short period of time.Types of infective diarrhoea are discussed later in the chapter.The presence of blood or mucus in the stools is an indication for referral. Diarrhoea withsevere vomiting or with a high fever would also require medical advice.
  • 63. Previous historyA previous history of diarrhoea or prolonged change in bowel habit would warrant referral forfurther investigation, and it is important that the pharmacist distinguishes between acute andchronic conditions. Chronic diarrhoea (more than 3 weeks duration) may be caused bybowel conditions such as Crohns disease, irritable bowel syndrome or ulcerative colitis andrequires medical advice.Recent travel abroadDiarrhoea in a patient who has recently travelled abroad requires referral, since it might beinfective in origin.Causes of diarrhoeaInfectionsMost cases of diarrhoea are short lived, the bowel habit being normal before and after. Inthese situations the cause is likely to be infective (viral or bacterial). • Viral. Viruses are common culprits of gastroenteritis. In infancy, the virus causing such problems is often one which gains entry into the body via the respiratory tract (rotavirus). Associated symptoms are those of a cold and perhaps a cough. The infection starts abruptly and vomiting often precedes diarrhoea. The acute phase is usually over within 2-3 days, although diarrhoea may persist. Sometimes diarrhoea returns when milk feeds are reintroduced. This is due to the fact that one of the milk digestive enzymes is temporarily inactivated. Milk therefore passes through the bowel undigested causing diarrhea. The health visitor or GP would need to give further advice in such situations. Whilst in the majority the infection is usually not too severe and self-limiting, it should be remembered that rotavirus infection can be fatal. This is most likely in those already malnourished and living in poor social circumstances that have not been breast fed. • Bacterial. These infections are the cause of food poisoning. This typically occurs when poultry is undercooked, or contaminated food is reheated insufficiently. Two commonly-seen types of infection are Campylobacter and Salmonella. In the latter, symptoms may arise 12-48 hours after ingesting the infected food. There is an abrupt onset of frequent diarrhea, occasionally with
  • 64. abdominal pain and vomiting, whereas in campylobacter infection there may be a longer incubation period and colicky abdominal pain is more common. The mainstay of treatment is fluid replacement. The infection is usually self-limiting and eliminated quickly from the bowel. Occasionally, infection can persist in the bowel although symptoms have resolved (carrier state). This is of little consequence unless the carrier is the school cook or a restaurant chef. Sometimes it is necessary to treat campylobacter infection with antibiotics (erythromycin) when it is severe or not settling down. Antibiotics for salmonella are best avoided, except in extreme situations when hospitalization is necessary, as they may paradoxically prolong the carrier state. • Parasitic/protozoan. These infections are uncommon in Western Europe but may occur in travelers returning from further afield. Examples include amoebic dysentery and a worm infection, strongyloidiasis. Diagnosis is made by sending stool samples to the laboratory.Chronic diarrhoeaRecurrent or persistent diarrhoea may be due to an irritable bowel or, more seriously, due toa bowel tumor, an inflammation of the bowel, e.g. ulcerative colitis or Crohns disease, aninability to digest or absorb food (malabsorption), e.g. coeliac disease, or diverticular disease.Irritable bowel syndromeThis non-serious but troublesome condition is one of the commoner causes of recurrentbowel dysfunction in adolescents and young adults. The stools are typically variable innature, often loose and semi-formed. They may be described as being like rabbit droppingsor as pencil shaped. The frequency of bowel action is also variable, as the diarrhoea mayalternate with constipation. Often the bowels are open several times in the morning beforeleaving for work. The condition is more likely to occur at times of stress; it may be associatedwith anxiety and occasionally it may be triggered by a bowel infection. Inadequate dietaryfibre may also be of significance. It is possible that certain foods can irritate the bowel, but isdifficult to prove.There is no blood present within the motion in an irritable bowel. The presence of bloodydiarrhea may be as a result of an inflammation or tumor of the bowel. The latter is more likelywith increasing age (from middle age onwards).Medication
  • 65. Medicines tried alreadyThe pharmacist should establish any medication which has already been taken to treat thesymptoms, to assess its appropriateness.Other medicines being takenDetails of any other medication being taken (both over-the-counter and prescribed) are alsoneeded, as diarrhoea may be drug-inducedSome drugs which may cause diarrhoeaAntacids: magnesium saltsAntibioticsAntihypertensives: guanethidine (commonly); methyldopa, beta blockers (rarely)Digoxin (toxic levels)Diuretics (e.g. frusemide)Iron preparationsLaxativesNonsteroidal anti-inflammatory drugsOver-the-counter medicines should be considered; commonly-used medicines such asmagnesium-containing antacids and iron preparations are examples of such medicines whichmay induce diarrhoea. Laxative abuse should be considered as a possible cause.Treatment timescaleOne day in children, otherwise 2 days.ManagementOral rehydration therapyThe risk of dehydration from diarrhoea is greatest in babies, and rehydration therapy isconsidered to be the standard treatment for acute diarrhoea in babies and young children.Oral rehydration sachets may be used with antidiarrhoeals in older children and adults.Rehydration may still be initiated if referral to the GP is advised. Sachets of powder forreconstitution are available. These contain sodium as chloride and bicarbonate, glucose andpotassium.The absorption of sodium is facilitated in the presence of glucose. A variety of flavours isavailable. It is essential that appropriate advice is given by the pharmacist about howreconstitution should be performed. Patients should be reminded that only water should beused to make the solution (never fruit juice or fizzy drinks), and that boiled and cooled watershould be used for children younger than 1 year old. Boiling water should not be used, as itwould cause the liberation of carbon dioxide. The solution can be kept for 24 hours if storedin a refrigerator. Fizzy, sugary drinks should never be used to make rehydration fluids - they
  • 66. will produce a hyperosmolar solution which may exacerbate the problem. The sodiumcontent of such drinks as well as the glucose content may be high.Home-made salt and sugar solutions should not be recommended, since the accuracy ofelectrolyte content cannot be guaranteed and is essential, especially in infants, youngchildren and elderly patients. Special measuring spoons are available; their correct usewould produce a more acceptable solution, but their use should be reserved for the treatmentof adults, where electrolyte concentration is less crucial.Amount of rehydration solution to be offered to patientsAge Quantity of solution (per watery stool)Children up to 1 year 50 ml1-5 years 100 ml (half a glass)6-12 years 200 mI (one glass)Adults 400 ml (two glasses)Quantities. Patients sometimes ask how much rehydration fluid should be given to children.The following simple rules can be used for guidance; the amount of solution offered to thepatient is based on the number of watery stools which are passed.Other therapyLoperamideThis was transferred from the prescription only category in 1983 and made available for saleover the counter. Loperamide is an effective antidiarrheal treatment for use in older childrenand adults. When recommending loperamide, the pharmacist-should remind patients to drinkplenty of extra fluids. Oral rehydration sachets may be recommended. Loperamide may notbe recommended for use in children under 12 years old.KaolinThis has been used as a traditional remedy for diarrhoea for many years. Its use was justifiedon the theoretical grounds that it would absorb water in the GI tract, and would adsorb toxinsand bacteria onto its surface, thus removing them from the gut. The latter has not beenshown to be true, and the usefulness of the former is questionable. The use of kaolin-basedpreparations has largely been superseded by oral rehydration therapy, although patientscontinue to ask for various products containing kaolin.MorphineMorphine, in various forms, has been included in antidiarrheal remedies for many years. Thetheoretical basis for its inclusion is that morphine, together with other narcotic drugs such ascodeine, is known to slow the action of the GI tract; indeed constipation is a well-recognizedside effect of such drugs. However, at the doses included in most over-the-counter
  • 67. preparations, it is unlikely that such an effect would be produced. Kaolin and morphinemixture remains a popular choice for some patients, despite the lack of evidence of itseffectiveness. However, such mixture should not be given to children under 12 years.Practical points 1. Patients with diarrhoea should be advised to drink plenty of clear, non-milky fluids, such as water and diluted squash. 2. Advice to eat no solid food for 24 hours may be appropriate. Bottle-fed infants should not be given any milk for 24 hours; milk should then be reintroduced gradually over a period of 1-2 days, beginning with quarter strength milk and gradually increasing to full strength. Breast-fed infants can continue to be fed. 3. Patients with diarrhoea should avoid milk, because during diarrhoea, the enzyme in the gut which digests milk (lactase) is inactivated. Temporary lactose intolerance can therefore be produced, which makes the diarrhoea worse.
  • 68. HAEMORRHOIDSHaemorrhoids (known as piles) can produce symptoms of itching, burning, pain, swellingand discomfort in the perianal area and anal canal, and of rectal bleeding. Haemorrhoids areswollen veins, rather like varicose veins, which protrude into the anal canal (internal piles).They may swell so much that they hang down outside the anus (external piles).Haemorrhoids are often caused or exacerbated by inadequate dietary fibre or fluid intake.The pharmacist must, by careful questioning, differentiate between this minor condition andthe others which may be potentially more serious.Information to collectDurationAs an arbitrary guide, the pharmacist might consider treating haemorrhoids of up to 3 week’sduration. It would be useful to establish whether the patient has a previous history ofhaemorrhoids, and if the doctor has been seen about the problem. A recent examination bythe doctor which has excluded serious symptoms would indicate that treatment of symptomsby the pharmacist would be appropriate.SymptomsThe term ‘haemorrhoids’ includes internal and external piles, which can be further classifiedas: those which are confined to the anal canal and cannot be seen; those which prolapsethrough the anal sphincter on defaecation, then reduce by themselves or are pushed backthrough the sphincter after defaecation by the patient; and those which remain persistentlyprolapsed and outside the anal canal. These three types are sometimes referred to as first,second and third degree respectively. Predisposing factors for haemorrhoids include diets,sedentary occupation and pregnancy, and there is thought to be a genetic element.PainPain is not always present; if it is, it may take the form of a dull ache, and may be worsewhen the patient is having a bowel movement. A severe sharp pain on defaecation mayindicate the presence of an anal fissure, which tear in the skin of the anal canal. It is usuallycaused by constipation and can often be managed conservatively by correcting this andusing local anaesthetic-containing cream or gel. In severe cases a minor operation issometimes necessary.Irritation
  • 69. The most troublesome symptom for many patients is itching and irritation of the perianal arearather than pain. Persistent or recurrent irritation which does not improve is sometimesassociated with rectal cancer and should be referred.BleedingBlood may be deposited onto the stool from internal piles as the stool passes through theanal canal. This fresh blood will appear bright red. It is typically described as being splashedaround the toiled pan and may be seen on the surface of the stool or on the toilet paper. Ifblood is mixed with the stool, it must have come from higher up the GIT, and will be dark incolour (altered). If rectal bleeding is present, the pharmacist would be well advised to suggestthat the patient sees the doctor so that an examination can be performed to exclude moreserious pathology such as tumour or polyps. Colorectal cancer can cause rectal bleeding.The disease is unusual in patients aged under 50, and the pharmacist should be alert for themiddle aged patient with rectal bleeding. This is particularly so if there has been a significantand sustained alteration in bowel habit.ConstipationConstipation is a common causatory or exacerbatory factor in haemorrhoids. Insufficientdietary fibre and inadequate fluid intake may be involved, although the pharmacist shouldalso consider the possibility of drug-induced constipation.Straining at stool will occur if the patient is constipated; this increases the pressure in thehaemorrhoidal blood vessels in the anal canal and haemorrhoids may result. If piles arepainful, the patient may try to avoid defaecation, and ignoring the call to open the bowels willmake the constipation worse.Bowel habitA persisting change in bowel habit is an indication for referral, as it may be caused by abowel cancer. Seepage of faecal material through the anal sphincter can produce irritationand itching of the perianal area, and may be caused by the presence of tumour.PregnancyPregnant women have a higher incidence of haemorrhoids than non-pregnant women. Thisis thought to be due to pressure on the haemorrhoidal vessels due to gravid uterus.Constipation in pregnancy is also a common problem and can exacerbate symptoms ofhaemorrhoids. Appropriate dietary advice can be offered by the pharmacist.
  • 70. Other symptomsSymptoms of haemorrhoids remain ‘local’ to the anus. They do not cause abdominal pain,distension or vomiting. Any of these more ‘widespread’ symptoms suggest other problemsand require referral. Tenesmus (the desire to defaecate when there is no stool present in therectum) sometimes occurs when there is a tumour in the rectum. The patient may describe afeeling of often wanting to pass a motion but no faeces being present.MedicationPatients may already have tried one or more preparations to treat their symptoms. Some ofthese products are advertised widely, wince the problem of haemorrhoids is perceived aspotentially embarrassing, and such advertisements may sometimes discourage patients fromdescribing their symptoms. It is therefore important for the pharmacist to identify the exactnature of the symptoms being experienced and details of any product used already. If thepatient is constipated, the use of any laxative should be established.Present medicationHaemorrhoids may be exacerbated by drug-induced constipation, and the patient should bequestioned about current medication, including prescription and OTC medicines. Rectalbleeding in a patient taking warfarin or another anticoagulant is an indication for referral.Treatment timescaleIf symptoms have not improved after a week, patients should see their doctor.ManagementSymptomatic treatment of haemorrhoids can provide relief from discomfort, but if present, theunderlying cause of constipation must be addressed. The pharmacist is in a good position tooffer dietary advice, in addition to treatment, to prevent recurrence of symptoms in the future.Local anaesthetics (e.g., Benzocaine, lignocaine)These can help to reduce the pain and itching associated with haemorrhoids. There is apossibility that local anaesthetics may cause sensitization, and their use is best limited to amaximum of 2 weeks.Skin protectorsMany haemorrhoidal products are bland, soothing preparations containing skin protectors(e.g., zinc oxide and kaolin). These products have emollient and protective properties.Protection of the perianal skin is important, because the presence of faecal matter can cause
  • 71. symptoms such as irritation and itching. Protecting agents form a barrier on the skin surface,helping to prevent irritation and loss of moisture from the skin.AstringentsAstringents such as zinc oxide, hamamelis and bismuth salts are included in products on thetheoretical basis that they will cause precipitation of proteins when applied to mucousmembranes or skin which is broken or damaged. A protective layer is then thought to beformed, helping to relieve irritation and inflammation. Some astringents also have aprotective and mild antiseptic action (e.g., bismuth).AntisepticsThese are among the ingredients of many antihaemorrhoidal products, including themedicated toiled tissues. They do not have specific action in the treatment of haemorrhoids.Resorcinol has antiseptic, antipruritic and exfoliative properties. The exfoliative action isthought to be useful by removing the top layer of skin cells and aiding penetration ofmedicaments into the skin. Resorcinol can be absorbed systemically via broken skin if thereis prolonged use, and its antithyroid action can lead to the development of myxoedema(hypothyroidism).Counter-irritantsCounter-irritants such as menthol are sometimes included in antihaemorrhoidal products onthe basis that their stimulation of nerve endings gives a sensation of cooling and tinglingwhich distracts from the sensation of pain. Menthol and phenol also have antipruritic action.Shark liver oil/live yeastThese agents are said to promote healing and tissue repair, but there is no scientificevidence to support such claims.LaxativesThe short-term use of a laxative to relieve constipation might be considered. One or twodays’ supply of stimulant laxatives should help to deal with the immediate problem whiledietary fibre and fluids are being increased. For patients who cannot or choose not to adapttheir diet, bulk laxatives may be used long term.Practical pointsSelf-diagnosisPatients may say that they have piles, or think they have piles, but careful questioning by thepharmacist is needed to check whether this self-diagnosis is correct. If there is any doubt,referral is the best course of action.
  • 72. HygieneThe itching of haemorrhoids can often be improved by a good anal hygiene, since thepresence of small amounts of faecal matter can cause itching to occur. The perianal areashould be washed with warm water as frequently as is practicable, ideally after each bowelmovement. Soap will tend to dry the skin and could make itching worse, but a mild soapcould be tried if the patient wishes to do so. Moist toilet tissues are available and these canbe very useful where washing is not practical. These tissues are better used with a pattingrather than rubbing motion, which might aggravate symptoms. Many people withhaemorrhoids find that a warm bath soothes their discomfort.An increased intake of dietary fibre will increase bowel output, so that patients can be welladvised to take care in wiping the perianal area, and to use soft toilet paper to avoidsoreness after wiping.How to use OTC productsOintments and creams can be used for internal and external piles, and should be applied inthe morning and at night, and after each bowel movement. Suppositories can berecommended for internal piles. After removing the foil or plastic packaging, a suppositoryshould be inserted night and morning and after each bowel movement. Insertion is easier ifthe patient is crouching or lying down.
  • 73. ECZEMA/DERMATITISEczema is a term used synonymously with dermatitis; the latter tending to be used when anexternal precipitating factor is present (contact dermatitis). The rash- produced has similarfeatures but the distribution on the body varies and can be diagnostic.The rash of eczema typically has dry flaky skin which may be inflamed and may include smallred spots. The skin may be cracked and weepy and sometimes becomes thickened. Eczemais an irritant rash.Information to collectAge/distributionThe distribution of the rash tends to vary with age. In infants, it is usually present around thenappy area, neck and back of scalp, face, and back of wrists.In children, the rash is most marked behind the knees, on the inside of the elbow joint,around wrists, ankles and neck, the hands and around the eyes.In adults, the neck, the back of the hands, the groin and around the anus, the ankles and feetare the most common sites.Occupation/contactContact dermatitis may be caused by substances which irritate the skin or which spark off anallergic reaction. Substances which can irritate the skin include: alkaline cleansing agents,degreasing agents, solvents and oils, oxidizing and reducing agents (e.g. as used byhairdressers when perming hair). Such substances either cause direct and rapid damage tothe skin, or in cases of weaker irritants, exert their irritant effect after continued exposure.Classic examples of irritant dermatitis include housewives eczema, due to continuedexposure to detergents and wetting, and napkin dermatitis.In other cases the contact dermatitis is caused by an allergic response to substances whichinclude chromates (present in cement and rust preventive paint), nickel (in costume jewelleryand as plating on scissors, for example), rubber and resins (two-part glues, and the resincolophony in adhesive plasters), dyes and certain plants (for example, primula). Eye make-up and perfumes can cause allergic contact dermatitis.
  • 74. Clues to whether or not a contact problem is present can be gleaned from knowledge of: siteof rash, details of job and hobbies, onset of rash and agents handled, improvement of rashwhen away from work or on holiday.Previous historyPatients may ask the pharmacist to recommend treatment for eczema which has beendiagnosed by the GP. In cases of mild eczema, it would be reasonable for the pharmacist torecommend the use of emollients and to advise on skin care. However, where exacerbationsof eczema have occurred, the patient is best referred to the GP. It should be rememberedthat topical hydrocortisone preparations cannot be recommended where the condition hasbeen diagnosed as eczema (which may be interpreted here as eczema with no identifiablecause). Thus the pharmacist may not sell hydrocortisone cream or ointment to such patients,even those who have obtained it previously on prescription.Hay fever/asthmaA large number of eczema sufferers have associated hay fever and/or asthma. There is oftena family history of eczema, hay fever or asthma. Eczema occurring in such situations iscalled atopic eczema. The pharmacist can enquire during questioning about family history ofthese conditions.Aggravating factorsAtopic sufferers may be worsened during the hay fever season, and with house dust oranimal danders. Factors which dry the skin, such as soaps, detergents and cold wind canaggravate eczema. Certain clothing, such as woollen material, can irritate eczema. In a smallminority (less than 5%), certain foods which include cows milk, eggs and food coloring(tartrazine) have been implicated. Emotional factors, stress and worry can sometimesexacerbate eczema. Antiseptic solutions applied directly to the skin or added to the bathwater can irritate the skin.MedicationContact dermatitis may be caused or made worse by sensitization to topical medicaments.The pharmacist should ask which treatments have already been used. Topically applied localanesthetics, antihistamines, antibiotics and antiseptics can all provoke allergic dermatitis.Lanolin has been a common cause of allergic reactions; .and is present in many over-the-counter treatments and in cosmetic moisturizers and hand creams. Some preservatives may
  • 75. cause sensitization. Information about different preparations and their formulations can beobtained from the local drug information pharmacist, or from the manufacturer of the product.If the patient has used a preparation which the pharmacist considers appropriate for thecondition, but there has been no improvement or the condition has worsened, the patientshould see the doctor.Treatment timescaleIrritant and allergic dermatitis should respond to skin care and treatment with over-the-counter products. If no improvement has been noted after a week, referral to the GP isadvisable.ManagementSkin rashes tend quite understandably to cause much anxiety. There is also a social stigmaassociated with skin disease. Therefore, many patients will have been seen by their GP.Pharmacists are most likely to be involved where the diagnosis has already been made, orwhen the condition first presents but is very mild. However, as much of the managementinvolves advice and the use of emollients, the pharmacist is in a good position to help. Wherethe pharmacist is able to identify a cause of irritant or allergic dermatitis, topicalhydrocortisone may be recommended.EmollientsThese are medically inert creams and ointments which can be used to soothe the skin,reduce irritation, prevent the skin from drying, act as a protective layer, and as a soapsubstitute. They may be applied directly to the skin or added to the bath water. E45 creamand Unguentum Merck are popular general purpose emollients. Emulsifying ointment andOilatum emollient are commonly used in the bath. Emulsifying ointment should first be mixedwith water (1 or 2 tablespoonfuls of ointment in a bowl of hot water) before adding to the bathto ensure distribution in the bath water.There are many different types of emollient preparation which vary in their degree ofgreasiness. The greasy preparations such as white soft paraffin are often the most effective,especially with very dry skin, but have the disadvantage of being messy and unpleasant touse. Those preparations containing lanolin should be avoided for long-term use, as skinsensitization can occur.
  • 76. Emollient preparations should be used as often as is needed to keep the skin hydrated andmoist. Several and frequent applications each day may be required to achieve this.Topical hydrocortisoneHydrocortisone cream and ointment can be sold over the counter, but only for a limited rangeof indications: irritant and allergic dermatitis, and insect bites. OTC hydrocortisone may notbe sold for eczema or any other skin condition. Its use is contra-indicated where the skin isinfected (e.g. athletes foot, cold sores), in acne, on the face and anogenital areas. Onlychildren over the age of 10 years can be treated, and any course must not be longer than 1week. Only proprietary over-the-counter brands of topical hydrocortisone can be used;dispensing packs may not be sold.AntipruriticsAntipruritic preparations are sometimes useful. Aqueous calamine cream is extremely usefulfor this purpose and its effectiveness is increased by adding 1 % menthol to give additionalantipruritic and cooling actions. Crotamiton is an excellent agent for reducing the discomfortof Itchy skin, and is available in cream and lotion forms.AdviceThis could include identification of possible aggravating or precipitating factors. If the historyis suggestive of an occupationally associated contact dermatitis, then GP referral isadvisable. The GP in turn may feel that referral to a dermatologist is appropriate. It issometimes necessary for a specialist to perform patch testing to identify the cause of acontact dermatitis.Further advice could be given regarding the use of soaps, which tend to dry the skin, andtheir alternatives. If steroid creams have been prescribed and emollients are to be used, thepharmacist is in a good position to check that the patient understands the way in which theyshould be used.
  • 77. ACNEThe incidence of acne in teenagers is extremely high, and it has been estimated that overhalf of all adolescents will experience some degree of acne. Most acne sufferers resort, atleast initially, to self-treatment. Mild acne often responds well to correctly used over-the-counter treatments. Pharmacists should remember that self-conscious teenagers regardacne as a major problem, and that a sympathetic response to requests for help, together withan invitation to return and report progress, can be as important as the treatment selected.Information to collectAgeAcne commonly occurs during the teenage years, and its onset is commonest at puberty,although it may start to appear a year or so before puberty. Acne can persist for anythingfrom a few months to several years; with onset at puberty, acne may continue until the lateteens or even early twenties. The hormonal changes which occur during puberty, especiallythe production of androgens, are thought to be involved in the causation of acne. Increasedkeratin and sebum production during adolescence are thought to be important contributoryfactors, the increased amount of keratin leading to blockages of the follicles and theformation of comedones (a corned one is a mass of keratin and sebum).Very youngAcne is extremely rare in young children and babies and any such cases should be referredto the doctor, since an androgen secreting (hormone producing) tumor may be responsible.OlderFor patients in whom acne begins later than the teenage years, other causes should beconsidered, including drugs and occupational factors. Oils and greases used at work canprecipitate acne, and it would be worth asking whether the patient comes into contact withsuch agents. Acne worsens just before or during menstruation; this is thought to be due tochanges in progesterone levels.DurationThe information gained here should be considered in conjunction with facts about medication(prescribed or over-the-counter) tried already, and about other medicines being taken. Acneof long duration where several over-the-counter preparations had been correctly used withoutsuccess would indicate referral to the GP.
  • 78. SeverityOTC treatment may be recommended for mild acne. Comedones may be open or closed;the sebum in closed comedones cannot reach the surface of the skin. The plug of keratinwhich is at the entrance to the follicle in a comedone is initially white (a whitehead), laterbecoming darker coloured because of the accumulation of melanin (a blackhead). However,sebum is still produced, so that swelling occurs, and the corned one ruptures, discharging itscontents under the skin.The released sebum causes an inflammatory response; if the response is not severe, smallred papules appear. In more severe acne angry-looking red pustules are seen and referral tothe GP for alternative forms of treatment, such as topical or systemic antibiotics, is needed.Affected areasIn acne these may include the face, neck, centre of the chest, upper back and shoulders - allareas with large numbers of sebaceous glands. Rosacea is a skin condition which issometimes confused with acne. Occurring in young and middle-aged adults, thecharacteristic features of rosacea are reddening, papules and pustules. Only the face isaffected.MedicationThe pharmacist should establish the identity of any treatment tried already, and its method ofuse. Inappropriate use of medication, for example infrequent application, could affect thechances of success. Information about current therapy is important, since acne cansometimes be drug-induced. Lithium, phenytoin and progestogens (for example, in the oralcontraceptive pill) may be culprits. If acne is suspected as a result of drug therapy, thepatients should be advised to discuss this with their doctor.Treatment timescaleA patient with mild acne which has not responded to treatment within 8 weeks should bereferred to the GP.ManagementDozens of products are marketed for the treatment of acne. The pharmacist can make alogical selection based on knowledge of likely efficacy. The general aims of therapy are to
  • 79. remove follicular plugs so that sebum is able to flow freely, and to reduce the numbers ofbacteria on the skin. Treatment should therefore reduce come done formation.Benzoyl peroxideBenzoyl peroxide can be considered the first-line over-the-counter treatment for acne. It hasa keratolytic action, helping peeling of the skin, and also has antibacterial properties whichshould help to reduce the skin flora. Regular application can result in improvement of mildacne. At first, benzoyl peroxide is very likely to produce reddening and soreness of the skin,and patients should be warned of this (see Practical points below).SensitizationOccasionally, sensitization to benzoyl peroxide may occur. The skin becomes reddened,inflamed and sore, and treatment should be discontinued.BleachingWarning should be given that benzoyl peroxide can bleach clothing and bedding. If used atnight, white sheets and pillowcases are best used, and patients can be advised to wear anold T-shirt or shirt to minimize damage to good clothes. Contact between benzoyl peroxideand the eyes, mouth and other mucous membranes should be avoided.Other keratolyticsThese include potassium hydroxyquinoline sulphate, sulphur, resorcinol and salicylic acid.Potassium hydroxyquinoline sulphate also has antibacterial activity. Sulphur has someantiseptic activity in addition to its keratolytic effect. There seems to be evidence that sulphurcan itself be comedogenic, that is, it can lead to comedone formation, so would not beconsidered a first-line treatment.Prolonged application of resorcinol can affect thyroid function, so continued use of productscontaining resorcinol is not advisable, although the relative risk in acne is probably smallunless large areas of skin are involved. The use of resorcinol in black-skinned patients is notadvisable because it may lead to skin discoloration. Salicylic acid has some antibacterial andantifungal actions.AntibacterialsSkin washes and soaps are available containing antiseptic agents such as chlorhexidine.Such products can be useful in acne by degreasing the skin, and by reducing the skin flora.
  • 80. One combination product is available containing benzoyl peroxide together with miconazole,an antifungal agent with antibacterial activity. Such a combination should fulfil both aims ofacne treatment, i.e. to unblock follicular plugs and reduce numbers of bacteria on the skin.Practical pointsDietThere is absolutely no evidence to link diet with acne, despite a common belief that chocolateand fatty foods cause acne or make it worse.SunlightUltraviolet light can be helpful in acne, and advice can be given to spend more time in thesun. The beneficial effects of sunlight are thought to be due to its peeling effect, which helpsunblock follicles, and the drying or degreasing effect of the sun on the skin may also bevaluable. The use of artificial forms of ultraviolet light such as sun beds is not to beencouraged, since evidence suggests that the risk of melanoma is increased.KeratolyticsAll keratolytics make the skin peel, and can therefore be useful in acne. They should beapplied to the whole of the affected area, not just to individual comedones, and are bestapplied to skin following washing. During the first few days of use, the skin is likely to becomereddened and may feel slightly sore. Warning should be given that such an irritant effect islikely to occur, otherwise treatment may be abandoned inappropriately.One approach to minimize reddening and skin soreness is to begin with the lowest strengthpreparation and to apply the cream, lotion or gel sparingly and infrequently during the firstweek of treatment. Once-daily application or application on alternate days could be tried for aweek, and then frequency of use increased. After 2 or 3 weeks, a higher strength preparationmay be introduced. If irritant effects continue after a week, or are severe, use of the productshould be discontinued.AntibioticsThe pharmacist is in a good position to ensure that acne treatments are used correctly.Oral antibiotic therapy usually consists of tetracyclines, and patients should be reminded notto eat or drink dairy products up to an hour before or after taking the antibiotic. The same ruleapplies to antacid or iron preparations.
  • 81. Evidence suggests that failure of antibiotic therapy in acne in the past may have been due tosub-clinical levels of antibiotic due to chelation by metal ions in dairy products or antacids.Continuous treatmentAcne is notoriously slow to respond to treatment and a period of up to 6 months may berequired for maximum benefit. It is generally agreed that keratolytics such as benzoylperoxide require a minimum of 6 weeks treatment for benefit to be shown. Patients shouldtherefore be encouraged to persevere with treatment, whether with over-the-counter orprescription products, and told not to feel discouraged if results are not immediate.Skin hygieneAcne is not caused by poor hygiene, or by failure to wash the skin sufficiently often.However, regular washing of the skin with soap and warm water, or preferably with anantibacterial soap or skin wash can be helpful by degreasing the skin and reducing thenumbers of bacteria present.Topical hydrocortisoneThe use of topical hydrocortisone is contra-indicated in acne because steroids can potentiatethe effects of androgenic hormones on the sebaceous glands, hence making acne worse.Removal of comedonesComedone expressors can be bought to remove blackheads. They are applied to the cornedone and have a small hole through which the corned one is extracted when pressure isapplied. Steam will aid the removal of comedones. However, some dermatologists adviseagainst attempts to remove comedones, because the application of pressure may damagethe follicles and also spread sebum and pus to previously unaffected skin areas, leading toinfection, inflammation and possible scarring. Certainly the squeezing of comedones andspots with the fingers is to be discouraged for the same reasons.Make-upHeavy, greasy make-up can only exacerbate acne. If make-up is to be worn, water basedrather than oily foundations are best, and should be removed thoroughly at the end of theday.
  • 82. ATHLETE’S FOOTThe incidence of this condition is not, as its name suggests, limited to those of an athleticdisposition. Tinea pedis, the fungus which causes the disease, thrives in warm, moistconditions and the infection is therefore widespread. The problem is more common in menthan in women and responds well to over-the-counter treatment.Information to collectDurationConsidered with severity, a long-standing condition may make the pharmacist decide to referthe patients to their GP. However, most cases of athletes foot are minor in nature and canbe treated effectively with products available over the counter.AppearanceAthletes foot usually presents as itchy, flaking skin in the web spaces between the toes. Theflakes or scales of skin become white and macerated and begin to peel off. Underneath thescales, the skin is usually reddened and may be itchy and sore. The skin may be dry andscaly or moist and weeping.SeverityAthletes foot is usually a mild fungal infection, but occasionally the skin between the toesbecomes more macerated and broken, and deeper and painful fissures may develop. Theskin may then become inflamed and sore. Once the skin is broken, there is potential forsecondary bacterial infection to develop. If there are indications of bacterial involvement:weeping, pus or yellow crusts, then referral to the doctor is needed.LocationClassically, the toes are involved, the web space between the fourth and fifth toes being themost affected. More severe infections may spread to the sole of the foot and even to theupper surface in some cases. This type of spread can alter the appearance of the condition,and severe cases are probably best referred to the doctor for further investigation. Whenother areas of the foot are involved, the appearance can be confused with that of allergicdermatitis. However, in eczema or dermatitis, the spaces between the toes are spared, incontrast to athletes foot.
  • 83. If the toenails appear to be involved, referral to the doctor will be necessary, becausesystemic antifungal treatment may be required to deal with infection of the nail bed. Evenwith systemic treatment it is not always possible to eradicate such infections.Previous historyMany people suffer occasionally from athletes foot. The pharmacist should ask aboutprevious bouts, and about the action taken in response. Any diabetic patient who presentswith athletes foot is best referred. Diabetics may have impaired circulation or innervation ofthe feet and are more prone to secondary infections in addition to poorer healing of openwounds.MedicationOne or more topical treatments may have been tried before the patient seeks advice from thepharmacist. The identity of any treatment should be established, and the method of use.Treatment failure may occur simply because it was not continued sufficiently long. However,if an antifungal product has been used correctly without remission of symptoms, the patient isbest referred to the doctor, especially if the problem is of long duration (several weeks).Treatment timescaleIf athletes foot has not responded to treatment within 2 weeks, the patient should see theirGP.ManagementMany preparations are available for the treatment of athletes foot. Formulations includecreams, powders, solutions, sprays and paints. Some older antifungal agents are lesseffective than those more recently introduced. Pharmacists should instruct patients on how touse the treatment correctly, and on other measures which can help to prevent recurrence(see Practical points, below). For successful treatment, regular application of therecommended product to clean and dry feet is essential, and treatment must be continuedafter symptoms have gone, to ensure eradication of the fungus.Imidazoles (e.g. miconazole, clotrimazole)The imidazoles constitute the most effective group of antifungal agents, and can be used totreat many topical fungal infections, including athletes foot. Imidazoles have a wide spectrumof action and miconazole has been shown to have both antifungal and antibacterial activity.Formulations include creams, powders and sprays. Miconazole and clotrimazole have
  • 84. occasionally been reported to cause mild irritation of the skin. The imidazoles can beconsidered to be the treatment of choice for topical fungal infections.TolnaftateTolnaftate is available in powder, cream, aerosol and solution formulations, and is effectiveagainst athletes foot. Tolnaftate may sting slightly when applied to infected skin.Undecenoates (e.g. zinc undecenoate, undecenoic acid, methyl and propyl undecylenate)Undecenoic acid is an antifungal agent sometimes formulated with its zinc salt, to giveadditional astringent properties. The astringent action of zinc can help to reduce irritation andinflammation of the skin.Whitfields ointmentThis preparation, also known as compound benzoic acid ointment, contains benzoic acid withsalicylic acid. The rationale for its use is that the keratolytic action of salicylic acid exfoliatesthe upper layers of skin, allowing the antifungal benzoic acid to penetrate the infected layers.However, the effectiveness of benzoic acid as an antifungal agent is questionable. Whitfieldsointment has been successfully used to treat athletes foot for many years. The developmentof the imidazoles has meant that effective antifungals are now available in formulations whichare more pleasant to use. Whitfields ointment stings on application, and the ointmentformulation is rather greasy. Its use has now been largely superseded by newer products.Potassium permanganate lotionThis was a traditional treatment to dry wet or weeping areas of skin. In athletes foot,permanganate foot baths or soaks were used for their oxidizing and astringent action to drysoggy skin before applying topical treatments. However, potassium permanganate stains theskin and any container which is used to soak the feet, and its use is less popular now.ChlorphenesinChlorphenesin is an older agent used in some preparations for athletes foot. There seems tobe little evidence of its effectiveness as an antifungal agent, but it may be useful forprophylaxis.Hydrocortisone cream or ointmentThe only conditions for which hydrocortisone may be sold over the counter are allergic andirritant dermatitis and insect bites or stings. The pharmacist may not recommend the use oftopical hydrocortisone in athletes foot, since it would reduce inflammation, but would not dealwith the fungal infection which might then worsen. Combination products containing
  • 85. hydrocortisone together with an antifungal agent are available, but only on prescription at thepresent time.Practical pointsFootwearSweating of the feet can produce the kind of hot, moist environment in which the fungus isable to grow. Shoes which are too tight and which are made of synthetic materials make itimpossible for moisture to evaporate. If possible, the patient should wear leather shoes,which will allow the skin to breathe. In summer, open-toed sandals can be helpful, andshoes should be left off where possible. The wearing of cotton socks can facilitate theevaporation of moisture, whereas nylon socks will prevent this.Foot hygieneThe feet should be washed and carefully and thoroughly dried, especially between the toes,before applying the antifungal preparation.Transmission of athletes footAthletes foot is easily transmitted, and is thought to be acquired by walking barefoot onchanging-room floors in workplaces, schools and sports clubs, for example. The wearing ofsome form of footwear such as rubber sandals can therefore be useful.Prevention of reinfectionCare should be taken to ensure that shoes and socks are kept free of the fungus. Socksshould be changed and washed regularly. Shoes can be dusted with a fungicidal powder toeradicate the fungus. The use of a fungicidal dusting powder on the feet and in the shoescan be a useful prophylactic measure, and can also help to absorb moisture and preventmaceration. Patients should be reminded to treat all shoes, since fungal spores may bepresent.Frequency and length of treatmentProducts should be applied to clean, dry feet twice daily, in the morning and the evening. Anytreatment should be continued for 2 weeks after the symptoms of athletes foot havedisappeared, to ensure that the infection is eradicated. A total treatment time of 2-4 weeksmight be expected. If the condition has not improved after 2 weeks, referral to the doctor isadvisable.RingwormRingworm of the body (tinea corporis) is a fungal infection which occurs as a circular lesionthat gradually spreads after beginning as a small, red, papule. Often there is only one lesion,
  • 86. and the characteristic appearance is of a central, cleared area with a red advancing edge.Topical imidazoles such as miconazole are effective treatments for ringworm. Ringworm ofthe groin (tinea cruris) presents as an itchy red area in the genital region, and often spreadsto the inside of the thighs. The problem is commoner in men than in women and is commonlyknown as Jock Itch in the USA. Treatment consists of topical antifungals, and the use ofpowder formulations can be particularly valuable because they absorb perspiration.
  • 87. WARTS AND VERRUCAEWarts and verrucae are caused by a viral infection of the skin and have a high incidence inschool children. Once immunity to the infecting virus is sufficiently high, the lesions willdisappear, but many patients and parents prefer active treatment for cosmetic reasons.Effective preparations are available over the counter, but correct use is essential if damageto surrounding skin is to be minimized.Information to collectAgeWarts can occur in children and adults; they are commoner in children and peak incidence isfound in 12-16-year-olds. The peak incidence is thought to be due to higher exposure to thevirus in schools and sports facilities. Warts and verrucae are both caused by the humanpapilloma virus, differing in their location.AppearanceWarts appear as raised lesions with a roughened surface; the lesions are usually flesh-coloured. Plantar warts on the sole of the foot (verrucae) have a different appearance towarts elsewhere on the body because the pressure from the bodys weight pushes the lesioninwards, eventually producing pain when weight is applied during walking.Warts have a network of capillaries and if pared, thrombosed, blackened capillaries orbleeding points will be seen. The presence of these capillaries provides a usefuldistinguishing feature between calluses and verrucae on the feet - if a corn or callus is pared,no such dark points will be seen; instead layers of white keratin are present. The thrombosedcapillaries are sometimes thought, incorrectly, to be the root of the verruca by the patient.The pharmacist can correct this misconception when explaining the purpose and method oftreatment.NumberWarts may occur singly, or as several lesions. Molluscum contagiosum is a condition inwhich the lesions may resemble warts and where another type of viral infection is the cause.Closer examination shows that the lesions contain a central plug of material (consisting ofviral particles) which can be removed by squeezing. The location of molluscum contagiosumtends to differ from that of warts - the eyelids, face, armpits and trunk may be involved. Suchcases are best referred to the doctor, since self-treatment would be inappropriate.
  • 88. LocationThe palms or backs of the hands are common sites for warts, as is the area around thefingernails. People who bite or pick their nails are more susceptible to warts around the nails.Warts sometimes occur on the face and referral to the doctor is the best option in suchcases. Since treatment with over-the-counter products is destructive in nature, self-treatmentof facial warts can lead to scarring and should never be attempted.Parts of the skin which are subject to regular trauma or friction are more likely to be affected,since damage to the skin facilitates entry of the virus. Plantar warts (verrucae) are found onthe sole of the foot and may be present singly or as several lesions.Anogenital wartsAnogenital warts are caused by a different type of the human papilloma virus and requiremedical referral for examination, diagnosis, and also for treatment.Duration and historyIt is known that most warts will disappear spontaneously in a time period of between 6months and 2 years. The younger the patient, the more quickly the lesions are likely to remit.Any change in the appearance of a wart should be treated with suspicion, and referral to theGP advised. Skin cancers are sometimes mistakenly thought to be warts by patients, and thepharmacist can establish how long the lesion has been present, and any changes whichhave occurred. Signs which are related to skin cancer are described in Practical pointsbelow.MedicationDiabetic patients should not use OTC products to treat warts or verrucae since impairedcirculation can lead to delayed healing, ulceration and even gangrene. Peripheral neuropathymay mean that even extensive damage to the skin may not provoke a sensation of pain.The pharmacist should ask whether any treatment has been attempted already and if so, itsidentity and the method of use. Commonly, treatments are not used for a sufficiently longperiod of time because patients expectations are often of a fast cure.Treatment timescaleTreatment with over-the-counter preparations should produce a successful outcome within 3months; if not, referral is necessary.Management
  • 89. Treatment of warts and verrucae aims to reduce the size of the lesion by gradual destructionof the skin. Continuous application of the selected preparation for several weeks or monthsmay be needed and it is important to explain this to the patient if compliance with treatment isto be achieved. Surrounding, healthy skin should be protected during treatment.Salicylic acidSalicylic acid may be considered to be the treatment of choice for warts and acts by softeningand destroying the skin. Preparations are available in a variety of strengths, sometimes incollodion type bases which help retain the salicylic acid in contact with the wart. Ointments,gels and plasters provide a selection of methods of application. Preparations should be keptwell away from the eyes and applied using a stick or other applicator, not with the fingers.PodophyllumPodophyllum has an antimitotic action, preventing cell division. Its main uses are in verrucaeand anogenital warts. Strongly irritant to the skin and to mucous membranes, care must betaken to ensure that application is restricted to the wart itself. Application of preparationscontaining podophyllum to the wart twice weekly will be sufficient.Pregnant women should not use preparations containing podophyllum because of the risk ofdamage to the fetus which may occur following absorption of podophyllum. The toxicity ofpodophyllum means that adverse systemic effects have been reported after topical use.However, the risk of such effects is low providing the area of skin treated is small.Formaldehyde and glutaraldehydeFormaldehyde is used for the treatment of verrucae; it is considered to be less suitable forwarts on the hands because of its irritant effect on the skin. The thicker skin layer on the soleof the feet protects against this irritant action. Formalin soaks are sometimes used forverrucae and it is important to tell the patient to protect the skin between the toes using whitesoft paraffin, otherwise cracking and soreness will result.Glutaraldehyde is used in a 5-10% gel or solution to treat warts; it is not used for anogenitalwarts, and is used for verrucae. Patients should be warned that glutaraldehyde will stain theskin brown. Both formaldehyde and glutaraldehyde have an unpredictable action, and are notfirst-line treatments for warts, though they may be useful in resistant cases.Practical pointsApplication of treatment
  • 90. Treatment containing salicylic acid should be applied daily and is helped by prior soaking ofthe affected hand or foot in warm water for 5-10 minutes to soften and hydrate the skin,increasing the action of salicylic acid. Removal of dead skin from the surface of the wart bygentle rubbing with a pumice stone or emery board ensures that the next application reachesthe surface of the lesion. Occlusion of the wart using an adhesive plaster helps to keep theskin macerated, maximizing the effectiveness of salicylic acid.Protection of the surrounding skin is important and can be achieved by applying a layer ofpetroleum jelly to prevent the treatment from making contact with healthy skin. Application ofthe liquid or gel using an orange stick will help to limit the substance to the lesion itself.Warts and skin cancerPremalignant and malignant lesions can sometimes be thought to be warts by the patient.There are different types of skin cancer. They can be divided into two categories: those notpigmented, i.e. skin coloured, and those pigmented, i.e. brown.Non-pigmented: In the first group, which are more likely to occur in the elderly, the signsmight include a persisting small ulcer or sore which slowly enlarges but never seems to heal.Sometimes a crust forms but when it falls off the lesion is still present. In the case of a basalcell carcinoma (rodent ulcer) the lesion typically has a circular, raised and rolled edge.Pigmented lesions or moles can turn malignant. These can occur at a much younger agethan in the first group. Changes in nature or appearance of pigmented skin lesions whichwarrant referral for further investigation include: increase in size; irregular, wavy outline;colour change, especially to black; itching or bleeding.Length of treatment requiredSeveral weeks continuous treatment is usually needed, up to 3 months in some cases.Patients need to know that a long period of treatment will be required, and that they shouldnot expect instant or rapid success. An invitation to come back to see the pharmacist andreport progress can help the pharmacist to monitor the treatment. If treatment has not beensuccessful after 3 months, referral for removal using liquid nitrogen may be required.Verrucae and swimming poolsViruses are able to penetrate moist skin more easily than dry skin, and it has been suggestedthat the high level of use of swimming pools has contributed to the high incidence of
  • 91. verrucae. There has been controversy about whether the wearing of protective rubber sockscan protect against the spread of verrucae.
  • 92. SCABIESInfestation by the scabies mite, Sarcoptes scabiei, causes a characteristically intenseitching, which is worse during the night. The itch of scabies can be severe, and scratching ofthe skin can lead to changes in the appearance of the skin. It is necessary to take a carefulhistory.Information to collectAgeScabies infestation can occur at any age, from infancy onwards. The pharmacist may feel itbest to refer infants and young children to the GP if scabies is suspected.SymptomsThe scabies mite burrows down into the skin, and lives under the surface of the skin. Thepresence of the mites sets up an allergic reaction, thought to be due to the insects coat andexudates, resulting in intense itching. A characteristic feature of scabies is that itching isworse at night and can lead to loss of sleep.Burrows can sometimes be seen as small, thread-like grey lines. The lines are raised, wavyand about 5-10 mm long. Commonly infested sites include the web spaces of the fingers andtoes, wrists, armpits, buttocks and genital area. Patients may sometimes have a rash, whichdoes not always correspond to the areas of infestation. In adults, scabies rarely affects thescalp and face, but in infants, involvement of the head is more common.HistoryThe itch of scabies can take several weeks to develop in someone who has not beeninfested previously. The scabies mite is transmitted by close personal contact, so the patientcan be asked whether anyone else they know is affected by the same symptoms, forexample, other family members, boyfriends and girlfriends.Signs of infectionScratching can lead to excoriation, so that secondary infections such as impetigo can occur.The presence of weeping, yellow discharge or yellow crusts would be indications for referral.Medication
  • 93. It is important for the pharmacist to establish whether any treatment has been tried already,and its identity. The patient should be asked how any treatment has been used, sinceincorrect use can result in treatment failure. The itch of scabies may continue for severaldays or even weeks after successful treatment, so the fact that itching has not subsided doesnot necessarily mean that treatment has been unsuccessful.ManagementFor adults, gamma benzene hexachloride (lindane) lotion and benzyl benzoate applicationare effective scabicides. Monosulftram lotion is preferred for babies and children. Thetreatment is applied to the entire body, from the neck downwards, but not to the neck, faceand scalp, since these are not usually involved in the infestation in adults, although they maybe in infants.Patients are sometimes unsure about how to apply the lotion they have been told to use, andsimple advice is that they should pour the preparation into a bowl, and then apply it using aclean, broad paintbrush, cotton wool or a shaving brush. Patients should be told to apply thepreparation to the whole body, not just to the areas where burrows have been found. Asecond application may be necessary, and guidelines are given below for each preparation.Gamma benzene hexachloride (lindane)Lindane is used in the treatment of scabies, and also in body and pubic lice. Lindane is anextremely effective treatment for scabies. After application, the lotion should be left on theskin for at least 6 hours and preferably for 24 hours.Lindane is not irritant to the skin but because it is an organochlorine insecticide, it can beabsorbed through the skin, and CNS toxicity and side effects have been reported. Thepossibility of such toxicity means that lindane is best avoided in children, and its use shouldbe restricted to a maximum of two applications during anyone infestation in adults. Thecontinuing itch of scabies after successful treatment has led some patients to believe thattheir infestation is still present, and to use several repeat applications of gamma benzenehexachloride, with consequent development of toxicity.ToxicityReported signs of toxicity include headache, loss of appetite, muscle feakness and tremor. Itis therefore important for the pharmacist to stress that successful treatment will not removethe itching immediately. At one time, lindane was used in the treatment of head lice, but it isno longer recommended because reports of resistance have been received.
  • 94. Gamma benzene hexachloride is available as a 1 % lotion, shampoo or cream. The lotion isgenerally preferred for the treatment of scabies.Benzyl benzoate applicationThis preparation is a 25% strength application, which is used solely in the treatment ofscabies.Irritant natureBenzyl benzoate is irritant in nature, and can cause stinging, itching and burning of the skinand occasional skin rashes. For this reason, it is not recommended for babies and children; ifit is used, the application should be diluted before use with 1 volume of water for children and3 volumes of water for babies. Because of its irritant nature, its application should not beused for patients with eczema or with scratched and broken skin, in whom stinging mayoccur.ApplicationAfter applying the application to the whole body, but not the head and neck, the preparationshould be left to dry on the skin.A second application should be made on the next day, without bathing or washing off thefirst. The second application is washed off 24 hours later. Benzyl benzoate is extremelyirritant to the eyes and mucous membranes; it should be kept well away from the eyes.CrotamitonThis is an effective antipruritic which is also a scabicide. It appears to be less effective intreating scabies than other agents. The preparation is available as a cream or lotion, and isless commonly used than benzyl benzoate application or gamma benzene hexachloridelotion. Crotamiton can be useful for its antipruritic action when itch is troublesome aftertreatment.MonosulfiramMonosulfiram is available as alcoholic solution which should be diluted with 2-3 parts of waterbefore use, and is particularly suitable for scabies in babies and children. The solution shouldbe diluted in the same manner for adults. Monosulfiram is sometimes used in adults.Reaction with alcoholIf monosulfiram is used, the patient should be warned that ingestion of alcohol can cause adisulfiram-type reaction, with flushing, headache, sweating, nausea and vomiting. Adults
  • 95. should be advised to avoid alcohol for 2 days before and after using monosulfiram. Thediluted solution should be applied to the whole body, from the neck downwards, rubbed inand left to dry. Drying will take about 10-15 minutes. Repeat applications can be made oneach of the next 2-3 days if needed.Practical points1. Patients with scabies are usually advised to have a hot bath before applying their treatment. The theory is that a hot bath willopen up the mites burrows, making it easier for the scabicide to reach the mites. This advice is no longer recommended - there is no evidence that a hot bath increases the effectiveness of scabicides, but there is a real possibility that increased absorption of the scabicide could occur through warm, hydrated skin with resultant toxic effects.2. All members of the family or household should be treated, preferably on the same day. Because the itch of scabies may take several weeks to develop, people may be infested but symptomless. It is thought that patients may not develop symptoms for up to 8 weeks after infestation. The incubation period of the scabies mite is 3 weeks, so reinfestation may occur from other family or household members.3. The scabies mite can only live for about 1 day after leaving its host, and transmission is almost always caused by close personal contact. It is unlikely that infestation could occur from bedclothes or clothing. After treatment for scabies, bedclothes and clothing should be washed, but there is no need for disinfection.4. Other possible infestations include problems caused by pet fleas and bed bugs. Pet fleas are common and patients may present with small reddened swellings on the lower legs and around the ankles where the pet has come into contact with the skin. Questioning may reveal that a pet cat or dog has recently been aquired or that a pet has not been treated with insecticide for some time. Regular checks for fleas and use of insecticides will prevent the problem. A range of proprietary products is available to treat either the pet or bedding and carpets. A second treatment should be applied 2 weeks after the first to eradicate any fleas which have hatched since the first application. Pet flea bites can be treated with topical hydrocortisone in anyone over 10 years old. Alternatively, an antipruritic such as crotamiton or aqueous calamine cream can be recommended.
  • 96. COMMON CHILDHOOD RASHESMost childhood rashes are associated with self-limiting viral infections. Some of theserashes fit well described clinical pictures, e.g. measles and are described below. Others aremore difficult to label. They may appear as short-lived fine flat (macular), or slightly raised(papular) red spots often on the trunk. The spots blanch with pressure (erythematous). Thereis usually an associated cold, cough and raised temperature. These relatively minor illnessesoccur in the first few years of life and settle without treatment.ReferralIn very rare situations a rash may be associated with meningococcal septicaemia. This veryserious infection causes meningitis. It usually presents with flu-like symptoms which progresswith vomiting, headache, and neck stiffness. There may be an associated rash present whichappears as small widespread bruises (very small bruises are called petechiae, larger onesecchymoses). Bruises do not blanch with pressure. This condition requires emergencymedical help.As a general rule, all rashes which do not blanch when pressed ought to be referred to a GP.These rashes are caused by blood leaking out of a capillary, which may be caused by ablood disorder. It could be the first sign of leukaemia.Infectious diseasesChicken poxThis is most common in children under 10 years. It can occur in adults but is unusual. Theincubation time, i.e. between contact and development of rash is usually about 2 weeks (11-21 days). Sometimes the rash is preceded by a day or so of feeling off colour with atemperature. The rash is characteristic and only difficult to diagnose when very few spots arepresent. Typically it starts with small red lumps which rapidly develop into minute blisters(vesicles). The vesicles then burst, forming crusted spots over the next few days. The spotsmainly occur on the trunk and face but may involve the mucous membranes of the mouth.They tend to come out in crops for up to 5 days. The rash is often irritant. Once the spotshave all formed crusts, the individual is no longer contagious. The whole infection is usuallyover within a week, but may be longer and more severe in adults.The symptoms may be eased with calamine lotion and paracetamol if a high temperature ispresent. Warm salt baths may be comforting.
  • 97. MeaslesThis is now a less common infection in the more developed countries. All infants have beenroutinely offered the measles vaccine at about 13 months of age. This has now beensuperseded by the introduction of MMR, a combined measles, mumps and rubella vaccinebetween the ages of 1-2 years.Measles has an incubation period of about 10 days. The measles rash is preceded by 3-4days of illness with cold symptoms, cough, conjunctivitis and fever. After the first 2 days ofthis prodromal phase small white spots (Kopliks spots), like grains of salt, can be seen onthe inner cheek and gums. The measles rash then follows. It starts behind the ears,spreading to the face and trunk. The spots are small red patches (macules) which will blanchif pressed. Sometimes there are so many spots that they merge together to form large redareas.ComplicationsAt present there are about 10 deaths a year in England and Wales from encephalitis(inflammation of the brain) which is a rare complication of measles. In most cases, the rashfades after 3 days at which time the fever also subsides. If however the fever persists, thecough becomes worse, there is difficulty in breathing, or earache, then medical attentionshould be sought.Roseola infantumThis is a viral infection occuring most commonly in the first year of life (3 months-4 years). Itcan be confused with a mild attack of measles. There is a prodromal period of 3-4 days offever, followed by a rash similar to measles but which is mainly confined to the chest andabdomen. Once the rash appears there is usually an improvement in symptoms, in contrastto measles, and it only lasts about 24 hours.Fifth disease (erythema infectiosum)This is another viral infection which usually affects children. It does not often cause systemicupset but may cause fever, headache and painful joints. The rash characteristically starts onthe face. It gives an appearance that the cheeks have been slapped, or, the child has beenout in a cold wind. The rash then appears on the limbs and trunk as small red spots whichblanch with pressure. The infection is usually short-lived.
  • 98. German measles (rubella)This viral infection is generally very mild, its main significance being the problems caused tothe foetus if the pregnant mother develops the infection in early pregnancy. The rash ispreceded by mild catarrhal symptoms and enlargement of glands at the back of the neck. Itusually starts on the face and spreads to the trunk and limbs. The spots are very fine andred. They blanch with pressure. They do not become confluent as in measles. In adults,rubella may be associated with painful joints. Rubella rash lasts 3-5 days.TreatmentThe itching caused by childhood rashes such as chicken pox can be intense and thepharmacist is in a good position to offer an antipruritic cream, ointment or lotin. Aqueouscalamine cream is an excellent preparation to soothe itchy skin and its effectiveness can beincreased further by adding 1% menthol. The addition of menthol provides an antipruritic andcooling effect which can be very comforting for irritated skin. Calamine lotion is an effectiveantipruritic and leaves a soothing layer of powder on the skin once the liquid vehicle hasevaporated. Some patients find calamine lotion messy to use. Aqueous calamine cream isnon-greasy and easily absorbed and is preferred by many patients.If itching is very severe, a systemic antihistamine such as promethazine can be effective inproviding relief. Such treatment would be likely to make the child drowsy but may be useful atnight time.
  • 99. HEADACHEThe community pharmacist is often asked to recommend an analgesic for headache. Themost common types of headache which the community pharmacist is likely to encounter aretension headache, migraine and sinusitis.Information to collectAgeThe pharmacist would be well advised to refer any child with headache to the GP, especiallyif there is an associated history of injury or trauma to the head, from a fall, for example.Children with severe pain across the back of the head, and neck rigidity should be referredimmediately because of the possibility of meningitis.Duration of headacheAny headache which lasts for longer than a few hours requires referral.Nature and site of painTraditionally, tension (psychogenic) headache has been described as a dull ache, while theheadache of migraine has been described as a pounding or throbbing pain. However, thenature of the pain alone is not sufficient evidence on which to decide whether the headacheis likely to be of minor or more serious cause. A steady, dull pain which feels deep-sited andis severe and aggravated by lying down, requires referral, since it may be due to raisedintracranial pressure from a brain tumor, infection or other cause.Classical migraine is unilateral, affecting one side of the head, especially over the forehead.Tension headache may be described as a weight pressing on top of the head, a band acrossthe fore head, around the head or at the back of the head and neck.Rarely, a sudden severe pain which develops at the back of the head may signify asubarachnoid haemorrhage. The sufferer may describe the onset of the pain as thoughhaving been struck on the back of the head with a brick. It occurs when a small blood vesselat the base of the brain leaks blood into the cerebrospinal fluid surrounding the brain. It maybe associated with raised blood pressure. Urgent medical referral is essential.Previous historyIt is always reassuring to know that the headache experienced is the usual type for thatperson. In other words it has similar characteristics in nature and site but not necessarily
  • 100. severity to headaches experienced over previous years. This fact makes it much less likely tobe of a serious cause, whereas new or different headaches especially in the over 45-year-oldmay be a warning sign of a more serious condition. Migraine sufferers typically suffer fromrecurrent episodes of their headaches. In some cases the headaches Occur in clusters. Thepain may be present daily for 2-3 weeks, then be absent for months or years.Associated symptomsChildren with unsteadiness and clumsiness associated with head ache should be referred.Classical migraineClassical migraine is often associated with alterations in vision before an attack starts, theso-called prodromal phase. Patients may describe seeing flashing lights or zig-zag lines.During the prodromal phase, patients may experience tingling or numbness on one side ofthe body, in the lips, fingers, face or hands. Migraine is also associated with nausea andsometimes vomiting. Patients often get relief from lying in a darkened room, and say thatbright light hurts their eyes during an attack of migraine. Classical migraine is three timesmore common in women than in men.Common migraineThere are other forms of migraine which do not fit the classical description above. In commonmigraine, there is no prodromal phase, both sides of the head may be affected, andgastrointestinal symptoms such as nausea and vomiting may occur.SinusitisSinusitis may complicate a respiratory viral infection, e.g. cold, or allergy, e.g. hay fever,which causes inflammation and swelling of the mucosal lining of the sinuses. The increasedmucus production within the sinus cannot drain, a secondary bacterial infection develops,and the pressure builds up causing pain. The pain is felt behind and around the eye, andusually only one side is affected. The headache may be associated with rhinorrhoea or nasalcongestion. The affected sinus often feels tender when pressure is applied. It is typicallyworse on bending forwards or lying down.Temporal arteritisIn temporal arteritis, which usually occurs in older patients, the arteries which run through thetemples become inflamed. They may appear red and are painful and thickened to the touch.However these signs are not always present. Any elderly patient presenting with a severefrontal or temporal headache which persists and is associated with a general feeling of being
  • 101. unwell should be referred immediately. Temporal arteritis is a curable disease and delay indiagnosis and treatment may lead to blindness. This is because the blood vessels to theeyes are also affected by inflammation.Frequency and timing of symptomsPharmacists should regard a headache which is worse in the morning and which improvesduring the day as particularly serious, since this may be a sign of raised intracranial pressure.Precipitating factorsTension (psychogenic) headache may be precipitated by stress, for example, pressure atwork, or a family argument. Certain foods have been reported to precipitate migraine attacks,e.g. chocolate and cheese. Migraine headaches may also be triggered by emotional andpsychological factors, and by hormonal changes. In women, migraine attacks may beassociated with the menstrual cycle.Recent trauma or injuryAny patient with headache who has had a recent head injury or trauma to the head should bereferred to the doctor immediately because bruising or haemorrhage may occur, causing arise in intracranial pressure. The pharmacist should look out for drowsiness or any sign ofimpaired consciousness. Persistent vomiting after the injury is also a sign of raisedintracranial pressure.Recent eye testHeadaches associated with periods of reading, writing or other close work may be due todeteriorating eyesight, and a sight test may be worth recommended to see whetherspectacles are needed.MedicationThe nature of any prescribed medication should be established, since the headache might bea side effect of medication, for example, nitrates used in the treatment of angina.Contraceptive pillAny woman taking the combined oral contraceptive pill and reporting migraine-typeheadaches, either for the first time, or an exacerbation of existing migraine should be referredto the GP, since this may be an early warning of cerebrovascular changes.Occasionally, headache is caused by hypertension, but such headaches are not commonand only occur when the blood pressure is extremely high. Nevertheless, the pharmacist
  • 102. should consider the patients medication carefully. In drug interactions which have led to arise in blood pressure, for example, between a sympathomimetic such asphenylpropanolamine and a monoamine oxidase inhibitor, headache is likely to occur as asymptom.The patient may already be taking a nonsteroidal anti-inflammatory drug or other analgesicon prescription, and duplication of treatments should be avoided, since toxicity may result.If OTC treatment has already been tried without improvement, referral is advisable.Treatment timescaleIf the headache does not respond to over-the-counter analgesics within a day, referral isadvisable.ManagementThe pharmacists choice of oral analgesics is limited to three main agents: aspirin,paracetamol and ibuprofen. These are often combined with other constituents such ascodeine, doxylamine and caffeine. OTC analgesics are available in a variety of dosageforms, and in addition to traditional tablets and capsules, syrups, soluble tablets andsustained release dosage forms are available for some products. The peak blood levels ofanalgesics are achieved 30 minutes after taking a soluble dosage form; after a traditionalaspirin tablet, it may take up to 2 hours for peak levels to be reached.The timing of doses may be important. In migraine, the analgesic should be taken at the firstsign of an attack, since gastrointestinal motility is slowed during an attack, and absorption ofanalgesics delayed. Combination therapy may sometimes be useful, for example, ananalgesic and decongestant (systemic or topical) in sinusitis.AspirinAspirin is analgesic, antipyretic and also anti-inflammatory if given at doses greater than 4 gdaily. It should not be given to children under 12 years old because of its suspected link withReyes syndrome. In addition to its use in the symptomatic treatment of headache, it hasbeen suggested that alternate day doses of aspirin may be effective in the prophylaxis ofmigraine.Indigestion
  • 103. Gastric irritation (indigestion, heartburn, nausea, vomiting) is sometimes experienced bypatients after taking aspirin, so the drug is best taken with or after food. When taken assoluble tablets, aspirin is less likely to cause irritation. It is also available as an enteric-coatedversion, which is designed to release aspirin lower down the GI tract, to try to preventadverse effects.The pharmacist should remember though that enteric-coated preparations will not bereleased quickly, so are inappropriate where rapid pain relief is required. The local use ofaspirin, for example, dissolving a soluble tablet near an aching tooth is best avoided, sinceulceration of the gums may result.BleedingAspirin can cause gastrointestinal bleeding, and should not be recommended for any patientwho currently has, or has a history of peptic ulcer. Aspirin affects the platelets and clottingfunction so that bleeding time is increased, and it has been suggested that it should not berecommended for pain after tooth extraction. The effects of anticoagulant drugs arepotentiated by aspirin, which should never be recommended for patients taking these drugs.AlcoholAlcohol increases the irritant effect of aspirin on the stomach, and also increases the effectsof aspirin on bleeding time. Concurrent administration is therefore best avoided.PregnancyAspirin is best avoided in pregnancy.HypersensitivityHypersensitivity to aspirin occurs in some people; it has been estimated that 4% of asthmaticpatients have this problem, and aspirin should be avoided in any patient with this history.When such patients take aspirin, they may experience skin reactions (rashes, urticaria), orsometimes shortness of breath, bronchospasm and even asthma attacks.ParacetamolParacetamol has analgesic and antipyretic effects but little or no anti-inflammatory action.The exact way in which paracetamol exerts its analgesic effect remains unclear, despiteextensive research. However, the drug is undoubtedly effective both in reducing pain andfever. Paracetamol is now the analgesic of choice for children under 12 years, and can begiven to children from 3 months onwards. It is less irritant to the stomach than aspirin, andcan therefore be recommended for those patients who are unable to take aspirin for thisreason. A range of paediatric formulations including sugar-free syrups is available.
  • 104. At high doses, paracetamol can cause liver toxicity, and this can be a problem after overdosewith paracetamol, since damage may not be apparent until a few days afterwards. Alloverdoses of paracetamol should be taken seriously and referred to a hospital casualtydepartment.IbuprofenIbuprofen was transferred from the prescription only medicines list in 1984, and becameavailable for sale over the counter. It has analgesic, anti-inflammatory and antipyretic activity.The dose required for analgesic activity is 200-400 mg, that for anti-inflammatory action 300-600 mg. The maximum daily dose allowable for over-the-counter use is 1200 mg andibuprofen should not be given to children under 12 years. Ibuprofen causes less irritation anddamage to the stomach than does aspirin.IndigestionIbuprofen can be irritant to the stomach, causing indigestion, nausea and diarrhoea, but lessso than aspirin. Gastric bleeding can also occur. For these reasons, it is best to advisepatients to take it with or after food, and ibuprofen is best avoided in anyone with a pepticulcer or history of peptic ulcer. Elderly patients seem to be particularly prone to these effects,and pharmacists should exercise care if recommending ibuprofen for such patients.Ibuprofen can increase the bleeding time, due to an effect on platelets. This effect isreversible within 24 hours of stopping the drug (whereas reversibility may take several daysafter stopping aspirin). Ibuprofen seems to have little or no effect on whole blood clotting orprothrombin time, but is still not advised for patients taking anticoagulant medication, in whichparacetamol would be a better choice.HypersensitivityCross-sensitivity between aspirin and ibuprofen occurs, so it would be wise for thepharmacist not to recommend its use for anyone with a previous sensitivity reaction toaspirin. Since asthmatic patients are more likely to have such a reaction, the use of ibuprofenis best avoided in asthmatic patients.Contra-indicationsSodium and water retention may be caused by ibuprofen, and it is therefore best avoided inpatients with congestive heart failure or renal impairment.Ibuprofen is best avoided during pregnancy, particularly during the third trimester.Breastfeeding mothers may safely take ibuprofen, since it is excreted in only tiny amounts inthe breast milk.
  • 105. InteractionsThere is evidence of an interaction between ibuprofen and lithium. Ibuprofen may inhibitprostaglandin synthesis in the kidneys and reduce lithium clearance. Serum levels of lithiumare thus raised, with the possibility of toxic effects. Lithium toxicity manifests itself asgastrointestinal symptoms, polyuria, muscle weakness, lethargy and tremor. This interactiondoes not seem to occur between lithium and aspirin.CautionIbuprofen is best avoided in aspirin sensitive and asthmatic patients. Adverse effects aremore likely to occur in the elderly and paracetamol may be a better choice in these cases.CodeineCodeine is a narcotic analgesic, and a dose of at least 15 mg is required for analgesic effect.Codeine is commonly found in combination products with aspirin, paracetamol or both.Constipation is a possible side effect, although might be considered unlikely at the relativelysmall doses found in over-the-counter analgesics. However, in elderly patients and othersprone to constipation, codeine may be constipating.CaffeineCaffeine is included in some combination analgesic products to produce wakefulness andincreased mental activity. It is probable that doses of at least 100 mg are needed to producesuch an effect, and it could be argued that a strong cup of tea or coffee would have the sameaction. Caffeine has an irritant effect on the stomach.Doxylamine succinateDoxylamine is an antihistamine whose sedative and relaxing effects are probably responsiblefor its usefulness in treating tension headache. Like other older antihistamines, doxylaminecan cause drowsiness, and patients should be warned about this. Doxylamine should not berecommended for children under 12 years.BuclizineBuclizine is an antihistamine which is mainly used for its antiemetic action. For this reason,buclizine is included in some preparations for the treatment of migraine, where nausea andvomiting are a problem.Feverfew
  • 106. Feverfew is a herb which has been used in the prophylaxis of migraine. Some clinical trialshave been conducted to examine its effectiveness, but results have been conflicting. Adverseeffects which have been reported from the use of feverfew include mouth ulceration, GI tractupsets and skin rashes. Feverfew was used in the past as an abortifacient, and it should notbe recommended for pregnant women with migraine.
  • 107. MUSCULOSKELTAL PROBLEMSPharmacists are frequently asked for advice about muscular injuries, sprains and strains.Simple practical advice combined with topical or systemic over-the-counter treatment can bevaluable. The pharmacist requires guidelines about when apparently minor injuries mayindicate a more serious problem, so that appropriate referral to the GP can be made.Information to collectAgeAge will influence the pharmacists choice of treatment: a consideration of the patients age isimportant. In elderly patients, a fall is more likely to result in a fracture; elderly women areparticularly at risk because of osteoporosis. Referral to the local casualty department for X-rays may be the best course of action in such cases.Symptoms and historyInjuries commonly occur as a result of a fall or other trauma, and during physical activity suchas lifting heavy loads, and taking part in sport. Exact details of how the injury happenedshould be established by the pharmacist.Sprains and strainsSprains occur where the ligaments or capsule of a joint are damaged, while strains areinjuries where the muscle is torn or damaged. Minor sprains and strains may be reasonablytreated by the pharmacist, but if in any doubt the patients should be referred to their doctor orlocal casualty department.Muscle painStiff and painful muscles may occur simply as a result of strenuous and unaccustomed worksuch as gardening, decorating or exercise, and the resulting discomfort can be reduced bytreatment with over-the-counter medicines.BruisingBruising as a result of injury is common, and some products are available for over-the-counter treatment to minimize bruising. The presence of bruising without apparent injury, or adescription by the patient of a history of bruising more easily than usual, should alert thepharmacist to the possibility of a more serious condition. Blood disorders may occur as anadverse drug reaction, and symptoms may include spontaneous bruising.Head injury
  • 108. Pain occurring as a result of head injury should always be viewed with suspicion, and suchpatients, particularly children, are best referred for further investigation.Other problemsBursitisOther musculoskeletal problems about which the pharmacists advice might be soughtinclude bursitis, which is inflammation of bursae (the name given to tissues around joints andwhere bones move over one another. The function of bursae is to reduce friction duringmovement). Examples of bursitis are housemaids knee and students elbow.FibrositisFibrositis refers to muscular pain which may involve the lower back, base of the neck,shoulders, elbows and knees. This condition is thought to have a psychogenic component,and may be aggravated by stress.Frozen shoulderFrozen shoulder is a common condition where the shoulder is stiff and painful, and is moreprevalent in older patients. The shoulder pain sometimes radiates to the arm and is oftenworse at night. Patients can sometimes, but not always, relate the problem to injury, exertionor exposure to cold, but frozen shoulder may occur without apparent cause. The pain andlimitation of movement are usually so severe that referral to the GP is advisable.Painful jointsPain arising in joints (arthralgia) may be due to arthritis, of which there are many causes. Thepain may be associated with swelling, overlying inflammation, stiffness, limitation ofmovement and deformity of the joint.A common cause of arthritis is osteoarthritis which is due to wear and tear of the joint. Thisoften affects the knees and hips, especially in the older population. Another form of arthritis isrheumatoid arthritis, which is a more generalized illness caused by the bodys defensesturning upon itself. Other forms of arthritis can be caused by gout or infection. A joint infectionis rare but potentially fatal. It is often difficult to distinguish between the different causes andit is therefore necessary to refer to the GP.Back painLower back pain probably affects most people at some stage in their lives, often recurrently.Low back pain which is not too severe or debilitating that comes on after gardening, awkwardlifting or bending may be due to muscular strain (lumbago) and appropriate advice may be
  • 109. given by the pharmacist. If there is no improvement within a week following such advice thenreferral is advisable.Pain that is more severe, causing difficulty with mobility or radiating from the back down oneor both legs, is an indication for referral. A slipped disc can press upon the sciatic nerve(hence sciatica) causing pain and sometimes pins and needles and numbness to be felt inthe leg.Back pain which is felt in the middle to upper part of the back is less common, and if it hasbeen present several days, is best referred to the GP. Kidney pain can be felt in the back, toeither side of the middle part of the back just below the ribcage. If the back pain is associatedwith any abnormality of passing urine (discoloration of urine, pain on passing urine, orfrequency) then a kidney problem is more likely.MedicationPrescribed medicationSufferers of, for example, rheumatoid arthritis or chronic back pain are likely to be takingpainkillers or nonsteroidal anti-inflammatory drugs prescribed by their GP. Although therecommendation of a topical analgesic would produce no problems in terms of druginteractions, if the patient is in considerable and regular pain despite prescribed medication,or the pain has be come worse, referral back to the doctor would be appropriate.Side effects. In the context of elderly patients, it should be remembered that falls may occuras a result of postural hypotension, dizziness or confusion as adverse effects from drugtherapy. Any elderly patient reporting falls should be carefully questioned about currentmedication, and the pharmacist might contact the GP about an adverse reaction besuspected.Self-medicationThe pharmacist should also enquire about any preparations used in self-treatment of thecondition and their degree of effectiveness.Treatment timescaleMusculoskeletal conditions should respond to treatment within a few days. A maximum of 5days treatment should be recommended, after which the patients should see their doctor.
  • 110. ManagementA wide range of preparations containing systemic and topical analgesics is available (seeheadache section). Topical formulations include creams, ointments, lotions, sticks andsprays.Topical analgesicsCounter-irritants and rubefacientsSuch agents act as rubefacients and counter-irritants, causing vasodilatation and inducing afeeling of warmth over the area of application. Counter-irritants produce mild skin irritationand the term rubefacient refers to reddening and warming of the skin.The theory behind the use of topical analgesics is that they bombard the nervous system withsensations other than pain (warmth, irritation), and this is thought to distract attention fromthe pain felt.Simply rubbing or massaging the affected area produces sensations of warmth and pressure,and can itself reduce pain. Massage is known to relax muscles and it has also beensuggested that massage may disperse some of the chemicals which are responsible forproducing pain and inflammation by increasing blood flow.The mode of action of topical analgesics is therefore two-fold, one effect relying onabsorption of the agent through the skin, the other on the effect of massage. There are manyproprietary formulations available, often incorporating a mixture of ingredients, with differentproperties. Most pharmacists and customers have their own favorite product. For customerswho live alone, a spray formulation which does not require massage can be recommendedfor areas such as the back and shoulders.Generally, patients can be advised to use topical analgesic products up to 4 times a day, asrequired.Methyl salicylateMethyl salicylate is one of the most widely-used and effective counter-irritants. Wintergreen isthe naturally-occurring form of methyl salicylate; synthetic versions are also available. Theagent is generally used in concentrations of between 10% and 60% in topical analgesicformulations.NicotinatesNicotinates, e.g. ethyl nicotinate, hexyl nicotinate, are absorbed through the skin and produceskin reddening, increased blood flow and an increase in temperature. Methyl nicotinate is
  • 111. used at concentrations of 0.25-1% to produce its counter-irritant and rubefacient effects.There have been occasional reports of systemic adverse effects following absorption ofnicotinates. Such effects may include dizziness or feelings of faintness and are due to a dropin blood pressure following vasodilatation. However, systemic adverse effects are rare; theyseem to occur only in susceptible people and are usually due to use of the product over alarge surface area.MentholMenthol has a cooling effect when applied to the skin, and acts as a mild counter-irritant.Used in topical formulations in concentrations of up to 1 %, menthol has antipruritic actions,but at higher concentrations it has a counter-irritant effect. When applied to the skin in atopical analgesic formulation, menthol gives a feeling of cooling, followed by a sensation ofwarmth.CamphorIn concentrations up to 3%, camphor has antipruritic actions; in higher concentrations it actsas a counter-irritant and rubefacient. Camphor is highly toxic if swallowed, and problems oftoxicity led to the withdrawal from sale of some well-known formulations, includingcamphorated oil.CapsicumWhen applied to the skin, capsicum causes reddening and a feeling of burning, but does notappear to induce changes in blood flow.Turpentine oilTurpentine oil has counter-irritant and rubefacient actions, and is a traditional ingredient ofmany topical analgesic formulations. It is the main ingredient of white liniment BP. It is usedin concentrations of between 6% and 50%.Topical anti-inflammatory agentsBenzydamine and ibuprofen are available for sale over the counter in cream formulations andhave been found to be effective in reducing muscular pain when applied topically.Heparinoid and hyaluronidaseThese are enzymes which may help to disperse oedematous fluid in swollen areas. Areduction in swelling and bruising may therefore be achieved. Products containing heparinoidor hyaluronidase are used in the treatment or bruising, strains and sprains.
  • 112. Practical pointsFirst aid treatment of sprains and strainsAs soon as possible after the injury has occurred, an ice-pack should be applied. Its functionis to produce vasoconstriction, thus preventing further blood flow into the injured area, and inturn minimizing further bruising and swelling. Proprietary cold packs are available, but inemergencies various items have been brought into service. A bag of frozen peas, forexample, is an excellent cold-pack for the knee or ankle because it can be easily applied andwrapped round the affected joint.The affected limb should be elevated to reduce blood flow into the damaged area by theeffect of gravity. This will, in turn, reduce the amount of swelling caused by oedema. Thethird piece of advice which the pharmacist can give is to apply compression of the injuredarea using a bandage. Finally, the injured limb should be rested to facilitate recovery. Theacronym RICE is a useful aide-memoire for the treatment of sprains and strains - Rest, Ice,Compression, Elevation.HeatThere is no doubt that the application of heat can be effective in reducing pain, and is asimple method of pain relief. Patients can use a hot water bottle, a proprietary heat pack oran infra-red lamp on the affected area. Heat packs contain a mixture of chemicals which giveoff heat, and the packs are disposable. Keeping the joints and muscles warm can also behelpful, and the wearing of warm clothing, particularly thin layers which can retain heat, isvaluable.Irritant effect of topical analgesicsPreparations containing topical analgesics should always be kept well away from the eyes,mouth and mucous membranes, and should not be applied to broken skin. Intense irritanteffects and pain can occur following such contact due to the ready penetration of the irritanttopical analgesic, which occurs through mucosal surfaces and by direct access throughbroken skin. It should be remembered that when applied to thinner and more sensitive areasof skin, irritant effects will be increased, hence the restrictions on the use of topicalanalgesics in young children recommended by some manufacturers for their products.Therefore, the manufacturers instructions and recommendations should be checked.Sensitization to counter-irritants can occur; if blistering or intense irritation of the skin resultsafter application, the patient should discontinue use of the product.
  • 113. EYE PROBLEMSThe painful red eyeConjunctivitis is one cause of a painful red eye. There are other serious causes of painful redeyes and there are several causes of conjunctivitis. Accurate diagnosis of these causes is ofvital importance, requiring medical knowledge and skills. GP referral is therefore essential.Below are notes on some of the causes of painful red eyes.ConjunctivitisThe term conjunctivitis implies inflammation of the conjunctiva, which is a transparent surfacecovering the white of the eye. It can become inflamed due to infection, allergy or irritation.InfectionBoth bacteria and viruses can cause conjunctivitis. The symptoms are that of a painful grittysensation and a discharge. The discharge is sticky and purulent in bacterial infections andmore watery in viral. It nearly always affects both eyes. Conjunctivitis occurring in only oneeye should alert the doctor to the presence of a foreign body or another diagnosis to accountfor the red eye.Treatment. Infective conjunctivitis is treated with antibacterial eye drops and ointment. Bothbacterial and viral infections are treated in the same way. In viral infections, the drops willprevent secondary infection. Quite often it is difficult for the doctor to differentiate betweenthe two types of infection, and it is safer to assume that it is bacterial. A typical course oftreatment would be chloramphenicol eye drops hourly for the first 24 hours, decreasing to 4times daily, and chloramphenicol eye ointment at night for a week.AllergyThis produces irritation, discomfort and a watery discharge. It typically occurs in the hay feverseason. It is sometimes difficult to differentiate between infection and allergy, so GP referralis important.Treatment. Sodium cromoglycate eye drops is an effective, safe treatment. Alternativelydecongestant and antihistamine drops can be helpful. Steroid drops are rarely used becauseof their possible side effects of cataract and glaucoma.
  • 114. Corneal ulcersThese may be due to an infection or a traumatic abrasion. The main symptom is that of pain.There may be surrounding conjunctival inflammation. An abrasion can be caused by contactlens wear. Early diagnosis is important as the cornea can become permanently scarred withloss of sight. If a corneal ulcer is suspected, the eye is examined after instilling fluoresceindrops, which will color and highlight an otherwise invisible ulcer. (The cornea is thetransparent covering over the front of the eye and early ulcers are not visible.)Treatment. This is obviously determined by the cause of the ulcer and invariably requiresspecialist referral.Other causesIritisIritis is the inflammation of the iris and surrounding structures. It may occur in associationwith some forms of arthritis, sarcoidosis or tuberculosis. It may occur as an isolated eventwith no obvious cause. The inflammation causes pain, felt more within the eye than thesuperficial gritty pain of conjunctivitis, and there is no discharge. The affected eye is red andthe pupil small and possibly irregular. Urgent specialist referral is necessary for accuratediagnosis.Treatment is with topical steroids to reduce inflammation.GlaucomaGlaucoma occurs when the pressure of the fluids within the eye becomes abnormally high.This may happen suddenly or develop slowly and insidiously by two different abnormalities. Itis the former (acute angle closure glaucoma) which causes a painful red eye. Emergencyhospital referral is necessary in order to prevent permanent loss of sight. The pain of acuteglaucoma is severe and may be felt in and around the eye. There may be associatedvomiting. As the pressure builds up, the cornea swells, becoming hazy and causing impairedvision and haloes around lights.Treatment involves an operation to lower the pressure and prevent it from developing again. COMMON EAR PROBLEMAlthough the treatment of common ear problems is straightforward, it does depend uponaccurate diagnosis and may require a prescription. It is not always possible to determine theproblem from the story. Diagnosis is best made by the GP who can examine the ear with an
  • 115. auroscope or otoscope. Referral to the GP is therefore advisable with ear problems. Beloware three ear problems commonly presenting to the GP. WaxSymptomsWax blocking the ear is one of the commonest causes of temporary deafness. It may alsocause discomfort and a sensation that the ear is blocked.TreatmentEardropsThe ear can be unblocked using eardrops, e.g. olive oil and various proprietary drops. Thedrops should be warmed before use (ideally at body temperature). With the head inclined, 5drops should be instilled. A cotton wool plug should be applied to retain the fluid and be keptin for at least an hour or overnight. This procedure should be repeated at least twice a day for3 days. The use of these drops can worsen the deafness initially and an appropriate warningshould be given. Cotton wool buds should not be poked into the ear as wax is just pushedfurther in and it is possible to damage the ear drum.Syringing earsIf any wax remains despite this treatment, then referral to the GP is advisable so the wax canthen be syringed out. The prior use of drops to syringing the ears is in any caserecommended to make the procedure more effective. Otitis externaDescriptionOtitis externa is inflammation of the outer ear canal. This is the skin-lined canal which leadsinto the ear as far as the eardrum.The inflammation is most commonly caused by an infection. Sometimes it is a site of eczemawhich may become secondarily infected.SymptomsThe symptoms of otitis externa are usually that of pain and discharge. Referral to the GP isnecessary for accurate diagnosis. It is possible that the same symptoms can arise from amiddle ear infection (otitis media) with a perforated eardrum.Treatment
  • 116. Treatment may involve the use of astringent ear drops, e.g. aluminium acetate orantibacterial drops, e.g. neomycin, polymyxin and anti-inflammatory drops, e.g.hydrocortisone. In addition any debris or discharge should be removed. This may beachieved by gently syringing, removal under direct vision with a special probe, or theinsertion of a ribbon gauze wick soaked in glycerin and icthammol. Occasionally oralantibiotics are used. Otitis mediaDescriptionThis is an infection of the middle ear compartment. The middle ear lies between the outer earcanal and the inner ear. Between the outer ear and the middle is the eardrum (tympanicmembrane). The middle ear is normally an air-containing compartment which is sealed fromthe outside apart from a small tube (Eustachian tube) which connects to the back of thethroat. Within the middle ear are tiny bones which transmit the sound wave vibrations of theeardrum to the inner ear.An infection typically starts with a common cold, especially in children, which leads toblockage of the Eustachian tube and fluid formation within the middle ear. The fluid can thenbe secondarily infected by a bacterial infection.SymptomsThe symptoms of otitis media are pain and temporary deafness. Sometimes the infectiontakes off so quickly that the eardrum perforates, releasing the infection. When this occurs adischarge will also be present, and associated with considerable lessening of pain.TreatmentAs with otitis externa, GP referral is necessary. Treatment is usually a course of oralantibiotics, e.g. ampicillin, amoxycillin, penicillin, erythromycin, trimethoprim or cotrimoxazole.Sometimes topical or oral decongestants are used in addition to antibiotics.These can be useful if an airplane flight is to be undertaken after such an infection. If theEustachian tube is still blocked during a flight, then pain can be experienced due to thechange in air pressure. Decongestants would make this less likely.Glue earSome children who are subject to recurrent otitis media develop glue ear. This occursbecause the fluid which forms in the middle ear does not drain out completely. The fluidbecomes tenacious and sticky. One method of dealing with this common problem is a minor
  • 117. operation in which the fluid is sucked out through the eardrum. After this it is usual to insert asmall grommet into the hole in the drum. The grommet has a small hole in the middle whichallows any further fluid forming to drain from the middle ear. The grommet normally falls outwithin a few months and the small hole in the drum closes over.Ear plugs. Some children are advised not to get water into the ear after the insertion of agrommet. One method is to use ear plugs which can be purchased in the pharmacy.Generally, however, this is not necessary and bathing and swimming can be under takenwithout using plugs. It is sensible to avoid deep diving as water may enter the middle earunder pressure, which will impair hearing and may predispose to infection.
  • 118. Drug Use in Special Populations Drug Use in PaediatricsDrug therapy in paediatric patientsPaediatric drug therapy challenges the pharmacist because children are uniquely differentfrom adults. There is a relatively stable pharmacokinetic profile that characterizes most of theadult years, however, pharmacokinetic parameters in children change as they mature frombirth to adolescence. Complex processes relating to drug absorption, distribution, metabolismand elimination are not fully developed at birth and mature at varying rates throughoutchildhood.Drug selection, doses and dosing intervals change throughout childhood, making drugtherapy monitoring essential.Pharmacokinetic considerations1. Gastrointestinal absorption: Oral drug absorption is a complex and variable processaffected by drug and patient related factors. Patient related factors change with advancingage: a. Gastric pH: Neonates are relatively achlorhydric. Acid production rises steadily but variably from age 7 days to 1 month. Relative achlorhydria may explain the increased bioavailability of basic drugs and the unpredictable, slower absorption of acidic agents. Additionally, drugs normally degraded by gastric acid, such as penicillins, may have an increased bioavailability. b. Gastric emptying: The rate of gastric emptying is important in determining the rate and extent of drug absorption. It is highly variable in neonates and reaches the same rate as adults by 6 to 8 months of age. Most drugs are absorbed from the small intestine, a reduced rate of emptying slows the rate of absorption, which can reduce peak drug concentrations. An increased rate of emptying may reduce the extent of absorption, because contact time with absorptive surfaces in the small intestine is reduced. Breast-fed infants empty their stomachs twice as fast as formula-fed infants. c. Underlying disease state: Disease states that can prolong gastric emptying can affect drug absorption e.g. pyloric stenosis, gastroesophageal reflux, respiratory distress
  • 119. d. Bile salt production: The bile salt pool and rate of bile salt synthesis are reduced approximately 50% in premature and young term infants as compared with adults. e. Pancreatic enzyme function: The absorption of lipid-soluble drugs is also affected by GI concentrations of pancreatic enzymes. Neonates have low levels of lipases, and when combined with reduced bile acid production, lipid soluble drugs may be left insoluble and unabsorbed in the intestine.2. Percutaneous absorption: The skin is made up of 3 layers: the epidermis, dermis andsubcutaneous tissue. The stratum corneum, the outer layer of the skin, provides the mainbarrier function of the skin. Full-term neonates have an intact epidermal layer, unlikepremature neonates who have an immature stratum corneum. Skin hydration is increased in neonates and premature neonates. The skin of a full-term neonate has barrier properties to drug absorption similar to adult skin.3. Intramuscular absorption: Factors affecting drug absorption following intramuscularadministration are the surface area, blood flow and muscle activity. Preterm neonatesdemonstrate erratic drug absorption. IM therapy is well absorbed in infants and older childrenbut is often discouraged secondary to pain.4. Distribution: How a drug distributes in the body is important in both selection and dosageof a drug. a. Protein binding: Acidic drugs bind to albumin and basic substances bind to alpha1- acid glycoprotein. Both of these proteins are reduced in neonates which allows greater amounts of free drug in the serum and tissues. Adult levels of these proteins occur at 10 to 12 months of age. b. Size of body compartments: At birth, extracellular fluid volume constitutes approximately 40% of total body weight, decreasing to 25% by 6 months, and 20% by 12 months. For polar compounds, such as aminoglycosides that distribute into extracellular spaces, loading doses are required in neonates.
  • 120. Changes in the percent of total body fat with age can also alter drug distribution and changes the volume of distribution of fat-soluble drugs. c. Endogenous substances: In neonates, various endogenous substances, like free fatty acids and unconjugated bilirubin can bind to plasma protein, displace drugs from binding sites and can increase unbound:bound drug ratios in plasma. Consider that serum concentrations of these two substances normalize in early infancy. Significant increases in plasma concentrations of the drug occur only when the displaced drug is more than 90% bound and its metabolism is rate-limited.5. Metabolism: Drug metabolism occurs mainly in the liver and involves a series of phase Iand phase II reactions. a. Phase I reactions (nonsynthetic): The major enzymes responsible for phase I oxidation reactions are those in the cytochrome P450 system, which at birth, is at 50% of adult levels. Thus, metabolism of many drugs is reduced and drug serum half-lives are prolonged. The ability to oxidize drugs increases rapidly with age, such that by several weeks of age, metabolic rates are equal to or greater than adult rates. Metabolic rates remain high for 1-5 years and gradually decline to adult levels at puberty. b. Phase II reactions (synthetic): The underlying enzyme systems are unevenly depressed at birth and mature at varying rates. The ability to conjugate most groups is reduced except for sulphate groups (e.g. acetaminophen).6. Elimination: The kidney is the major route of drug elimination for both water-soluble drugsand water-soluble metabolites of lipid-soluble drugs.At birth, glomerular filtration rate in neonates is about 30-50% of the adult value and maturesquickly, approaching 85% of adult values by 3-5 months of age.Tubular secretion is an active process that matures at a slower rate. At birth, neonates havesecretory rates of approximately 20% of adult values and do not achieve adult rates until 6-7
  • 121. months. Tubular reabsorption can be an active or passive process. It is reduced in neonatesand its development is not fully understood.Renal blood flow increases as cardiac output increases and renal vascular resistancedecreases to attain adult values by 6 to 12 months. Protein binding also affects glomerularfiltration because only unbound drug is filtered.Problems in paediatric drug monitoringSeveral problems are inherent to paediatric pharmacotherapy and lack of recognition forthem may lead to greater morbidity or drug related toxicity.1. As previously discussed, children display unique age-dependant changes inpharmacokinetic parameters. Lack of proper clinical monitoring can lead to underdosing,overdosing, therapeutic failure or drug-related toxicity.2. Therapeutic drug monitoring assumes a correlation exists between serum drugconcentrations and therapeutic effects, however many of theses correlations have beendisplayed in adults and not in children and extrapolations to children may not always beappropriate. Besides, the presence of endogenous substances may cross-react withanalytical drug assays.3. Technical problems may interfere with proper drug delivery because paediatric drugdoses are often in small fluid volumes.Adverse Drug ReactionsADRs are not uncommon in children. Antibiotics, anticonvulsants, narcotics, antiemetics andcontrast agents are leading causes of ADRs in children.Dosing considerations in paediatric patients1. Drug doses for adults cannot be extrapolated to children. This is especially true forneonates and infants and for drugs with a narrow therapeutic index. Paediatric doses shouldbe verified using a reference specific to paediatric patients like The Paediatric DrugHandbook or The AphA Paediatric Dosage Handbook. These references provide dosinginformation based most commonly on a patient’s weight or body surface area (BSA). If apediatric dose needs to be calculated based on BSA, use a BSA nomogram or the followingequation:BSA (in m2) = √ height (cm) x weight (kg) / 3600
  • 122. 2. Dosing intervals are often different for children. Because of reduced renal and hepaticfunction, neonates generally require a longer dosing interval compared to children andadults. On the other hand, older infants and children may require shorter dosing intervalsbecause of their enhanced elimination of drugs.3. Underlying disease states may also affect paediatric doses and dosage intervals, e.g.children with cystic fibrosis and cancer often require larger doses and shorter dosing intervalsfor aminoglycosides due to enhanced drug clearance.4. Errors in dosage calculation or drug preparation are more likely to occur in paediatricpatients than adults. Common errors are decimal point errors, dosing on a mg/kg/day versusa mg/kg/dose basis and dosing on a mg/kg versus mg/m2 BSA basis. Arithmetic errors areprone to occur during extemporaneous preparation of paediatric dosage forms or during dosecalculations.
  • 123. Drug Use in Pregnant PatientsPregnant women may require drug therapy for pre-existing medical conditions or forproblems associated with their pregnancy. They may also be exposed to drugs orenvironmental agents that have adverse effects on the unborn. Clinical situations may alsoexist where a fetus may be pharmacologically treated when the mother takes medication.Pharmacotherapy in this patient population requires aknowledge of drug clearance as well aslatent effects which are unique in pregnancy.Foetal developmentThe effects of drug therapy in pregnancy depend largely on the stage of fetal developmentduring which exposure occurs.1. Blastogenesis (the first 15-21 days after fertilization): During this stage, cleavage and germlayer formation occur and embryonic cells are in a relatively undifferentiated state.2. Organogenesis (14-56 days): All major organs start to develop during this period. It is themost critical stage of development and exposure to certain drugs may cause majorcongenital malformations.3. Fetal period (ninth week to birth): Development during this time is primarily maturation andgrowth. Drug exposure during this time is generally not associated with major congenitalmalformations but the developing foetus may be at risk from exposure to a variety of fetotoxicdrugs and microorganisms.Placental transfer of drugsThe placenta is the functional unit between the foetus and the maternal blood. Its functionsinclude nutrition, respiration, metabolism, excretion and endocrine activity. It produces anumber of hormones. The placenta is NOT a protective barrier. The transfer of nutrients,oxygen, waste products, drugs and other substances occurs mainly by passive diffusiondriven by concentration gradient and only a few compounds are actively transported.Factors affecting placental drug transferGeneral principles that apply to drug transfer across any lipid membrane can be applied tothe placenta.The critical factor is whether the rate and extent of transfer are sufficient to cause significantdrug concentrations in the foetus. Factors affecting the rate and extent include:
  • 124. 1. Molecular weight: Low molecular weight drugs (less than 500 daltons) diffuse freely acrossthe placenta. Drugs of molecular weight between 500-1000 daltons cross less easily. Verylarge molecules (e.g. heparin) do not cross the placenta.2. pH: The pH gradient between the maternal and foetal circulation and pH of the drug affectthe rate of placental transfer. Weakly acidic and weakly basic drugs rapidly diffuse across theplacental membranes.3. Lipid solubility: Moderately lipid-soluble drugs easily diffuse across the placenta.4. Drug absorption: During pregnancy, gastric tone and motility are decreased, which mayaffect gastric emptying and oral drug absorption. Nausea and vomiting in pregnancy can alsoaffect oral drug administration and absorption.5. Drug distribution: The volume of distribution increases significantly during pregnancy as aresult of increased plasma volume, increased cardiac output, total body fluid and fat content.6. Plasma protein binding: Only free unbound drugs can cross the placenta. Duringpregnancy, levels of albumin and alpha1-acid glycoprotein decrease, which provides fewerbinding sites and an increase in free drug concentrations may result. However, increasedconcomitant increases in liver metabolism, renal clearance, tissue uptake and alteredreceptor activity may counteract the effect of changes in PPB.7. Physical characteristics of the placenta: The placental membrane becomes progressivelythinner during the course of pregnancy.8. Pharmacological activities of the drug: Drugs with vasoactive properties may affectmaternal and placental blood flow, thus influencing the amount of drug reaching the foetus.9. Co-existing disease states: Maternal diabetes or hypertension may reduce or enhanceplacental permeability and drug transfer.10. Rate of maternal and placental blood flow: Factors that affect maternal blood flow(exercise, meals, etc.) may affect drug absorption and maternal drug concentrationsdeliverable to the foetus.Embryotoxic drugs
  • 125. These are drugs that harm the developing embryo, resulting in termination of pregnancy orshortening of gestational length e.g. hormones, antidepressants, angiotensin convertingenzyme (ACE) inhibitors and certain antibiotics when administered in early pregnancy.Teratogenic drugsThese drugs cause physical defects in a developing fetus. The risk of teratogenesis ishighest during the first trimester. They may cause physical malformations and/or mentalabnormalities and depend mainly on the point of gestation when the drug is ingested.The Food and Drug Administration has developed a classification system for drugs accordingto their potential risk during pregnancy:1. Category A (the safest): Controlled studies performed in women who took these drugsduring pregnancy did not demonstrate a risk to the foetus.2. Category B: Either no well-controlled human studies exist or animal studies with thesedrugs did not demonstrate any risk to the foetus. Or, animal studies demonstrated anadverse effect on animal foetus, but well-controlled human studies did not show similarresults.3. Category C: The human foetal risk is unknown. Either animal studies showed adverseeffects and similar human studies are lacking, or studies in both animals and humans are notavailable.4. Category D: These have demonstrated evidence of human foetal risk. However, pregnantwomen may benefit from treatment of a serious disease or life-threatening situation withthese drugs, which may be acceptable despite the risk to the foetus (benefit outweighs therisk).5. Category X: Drugs in this category caused foetal abnormalities in human or animalstudies, or there is evidence of foetal risk based on human experience, or both. The risk tothe foetus clearly outweighs any benefit to the pregnant woman. These drugs should also notbe used in women who are planning to conceive.Examples of teratogenic and potentially toxic drugs include Vitamin A derivatives, ACEinhibitors, warfarin and warfarin derivatives, Estrogen and androgens, ethanol, antibiotics(tetracycline, metronidazole and quinolone), anticonvulsants, lithuim and antineoplastics.
  • 126. Foetotoxic drug effectsThese result from pharmacological activity of a drug that may physiologically affect thedeveloping foetus during the foetal period.Clinically significant foetotoxic effects include:1. CNS depression may occur with barbiturates, tranquilizers, antidepressants andnarcotics.2. Neonatal bleeding may occur with maternal ingestion of NSAIDs and anticoagulants attherapeutic doses near term.3. Drug withdrawal. Habitual maternal use of barbiturates, narcotics, benzodiazepines,alcohol and other substance abuse may lead to withdrawal symptoms in newborn.4. Reduced birth weight can occur when pregnant women smoke cigarettes, consumelarge amounts of alcohol or abuse drugs.Drug excretion in breast milk90-95% of women receive a medication during the first postpartum week. It is important tounderstand the principles of drug excretion in breast milk and specific information on thevarious medications in order to minimize risks from drug effects in the nursing infant.Transfer of drugs from plasma to breast milk is governed by many of the same principals thatinfluence human membrane drug transfer.Many drugs cross the mammary epithelium via passive diffusion along a concentrationgradient formed by the un-ionized drug content on either side of the membrane. Thismembrane contains small pores that allow for the direct passage of low molecular weightsubstances (less than 200 daltons).Physiochemical properties of drugs that influence the rate and extent of drug passage intobreast milk are:a. Molecular weight of the drug.b. The pH gradient between breast milk and plasma. Human milk tends to be more acidic than plasma, thus weak acids may diffuse across but remain un-ionized so can diffuse back, but weak bases may diffuse and ionize which traps the drug and results in a clinically significant increase in concentration of weak bases in breast milk.c. Degree of ionization: Only the unionized form can diffuse through the lipid membrane.d. Plasma protein binding: Only unbound drug can pass into breast milk.e. Lipid solubility: Necessary for a drug to pass into the breast milk.
  • 127. After a drug is administered to a nursing mother, it may be metabolized to active or inactivemetabolites which will affect the amount of drug in the plasma that is available to pass intobreast milk. The maternal dose, the dosing schedule or frequency and the route ofadministration are other important factors.Drugs affecting the hormone prolactin, which is primarily important for milk production, canaffect the amount of breast milk produced. Drugs such as bromocriptine, ergot alkloids and L-dopa decrease serum prolactin levels. On the other hand, metoclopramide has been shownto enhance milk production.Factors to assess the risk of toxicity to the infant include inherent toxicity of the drug, amountof drug ingested, degree of prematurity and nursing pattern of the infant.One of the goals when using medication in a nursing mother is to maintain a naturaluninterrupted pattern of nursing. We should always choose the drug that is distributed intothe milk the least, has a short t1/2, inactive metabolites and no accumulation in breast milk.It is also desirable to choose a route of administration associated with s lower concentrationin breast milk. In order to minimize drug exposure in case of drugs taken on a scheduledbasis, it is desirable to give a dose immediately before the infant’s feeding.Examples of drugs that readily enter breast milk and should be used with caution in nursingmothers include narcotics, barbiturates, benzodiazepines, antidepressants, antipsychotics,metoclopramide and anticholinergic compounds.
  • 128. Drug Use in Geriatric patients♦ Elderly patients are at increased risk for drug-induced adverse effects. Incidence ofADRs in patients over 65 is two to three times greater compared to younger patients due topolypharmacy, multiple disease states, increasing severity of illness, reduced drugelimination and increased sensitivity to drug effects.♦ Besides, it is also difficult to predict how geriatric patients will respond to any givenmedication due to altered pharmacokinetic and pharmacodynamic profiles.♦ Compliance is another issue that complicates pediatric drug therapy. Factors thathave been shown to increase non-compliance include female gender, lower socioeconomicstatus, living alone, polypharmacy, complicated drug regimens, and multiple diseases.♦ Elderly patients can have diseases that make complying with drug therapy difficult.Conditions that affect vision such as macular degeneration or cataract formation can makereading prescription labels and medication instructions troublesome; hearing loss canprevent patients from understanding and health care professionals from effectivelycommunicating medication information and patient instructions; arthritis can add to difficultyin opening medication bottles.♦ Pharmacists can provide recommendations to eliminate unnecessary drug therapy,monitor medication profiles to avoid potential drug-drug or drug-disease interactions, simplifydrug regimens and employ more cost-effective regimens and enhance compliance.PharmacokineticsPharamcokinetic parameters in elderly patients may be altered in the elderly due to age-related physiologic changes.1. Absorption: Physiologic changes in the elderly include delayed gastric emptying, elevated gastric pH and impaired intestinal motility. Rate of absorption may be altered in some patients, but the extent of absorption is rarely affected.2. Distribution: Drug distribution is altered by age-related physiological changes. a. Elderly patients have a decrease in total body water causing water-soluble drugs to have a smaller volume of distribution. b. Elderly patients have a greater ratio of adipose tissue to lean muscle mass which increases the volume of distribution of lipid-soluble drugs. c. Albumin can be decreased in the elderly, which can increase free drug concentrations of some drugs.
  • 129. d. These age-related changes impacting drug distribution may lead to increases in ADRs in the elderly.3. Renal excretion: The best documented age-related physiologic change is the decline of renal function specially glomerular filtration rate and tubular secretion rate. There is a 50% decline in renal function by age 70 in patients without renal dysfunction. Serum creatinine may not be a good predictor of renal function as creatinine production also declines with age. Drugs primarily eliminated by the kidneys can result in increased concentrations and subsequent adverse effects. Doses of all renally eliminated drugs used in geriatric patients should be adjusted and drugs monitored for potential toxicity.4. Hepatic metabolism: Age-related changes affecting the liver include a reduction in hepatic blood flow and a decline in hepatic metabolism. A reduction in phase I reactions can occur. Drugs depending on phase I reactions for metabolism (e.g., benzodiazepines and certain analgesics) have a prolonged elimination half-lives and may result in drug accumulation and possible adverse effects. Phase II reactions, on the other hand, are relatively unchanged in the elderly.PharmacodynamicsBecause of altered receptor sensitivity, elderly patients can be more or less responsive tocertain drugs compared to younger patients. Studies have shown that elderly patients mayshow a diminished response to beta-blockers. In contrast, elderly patients seem to have anexaggerated response to analgesics, benzodiazepines and warfarin. They should bemonitored carefully when taking these medications.Rule of thumb: When initiating drug therapy in the elderly population, start low and titrateslow.Age-related physiologic changes affecting drug therapyPharmacokinetic factors Change Clinical SignificanceGastrointestinal motility ↓ May affect rate but not extent of drug absorptionGastric pH ↑ No significant change in drug absorptionRenal function ↓ Reduced elimination of renally excreted drugs
  • 130. Serum albumin ↓ Decreased protein binding leading to an increased free fraction of drugPhase I hepatic metabolism ↓ Potential accumulation of drugs metabolized by oxidation, reduction or hydrolysis reactionsBody fat/lean muscle mass ↑ Increased volume of distribution of fat soluble drugsratioTotal body water ↓ Decreased volume of distribution of water soluble drugsPharmacodynamic Factor Change Clinical SignificanceBeta-receptor sensitivity ↓ Potential diminished response to beta-blockersResponse to benzodiazepines ↑ Increased risk of adverse effects with typical dosesand opioid analgesicsDrug therapy considerations♦ Drug therapy in geriatric patients can be very complex because of age-relatedchanges in pharmacokinetics and pharmacodynamics.♦ A lack of clinical trials designed to evaluate the safety and efficacy of drug therapy inthe elderly population increases this problem.♦ Due to alterations in gait, balance and mobility, falls and consequent adverse eventsare frequent occurrences in geriatric patients. It is important to consider medications that canplace the elderly at risk for falls like medications that cause drowsiness, dizziness, blurredvision or confusion. The prevalence of osteoporosis in the elderly results in a higherincidence of fractures which are significant causes of increased morbidity and mortality.♦ Geriatric patients tend to be sensitive to medications that possess anticholinergiceffects. These drugs should be avoided whenever possible.General Principles for appropriate geriatric drug therapy1. Start with a low dose and titrate the medication dose slowly.2. Due to reduced renal and hepatic function, the half-lives of many drugs are prolongedin the elderly.3. Rapid dose escalations prevent attainment of the optimal therapeutic responsebecause a steady state concentration of the drug is not reached and increases the risk fordeveloping an ADR.4. The fewest number of drugs should always be used to treat patients.5. Always evaluate possible drug toxicity. Geriatric patients can have atypicalpresentations of ADRs, which may manifest as central nervous system changes (e.g. alteredmental status).
  • 131. COMMUNICATION SKILLSThe ability to communicate clearly and effectively with patients, families, physicians, nurses,pharmacists and other healthcare professionals is an important skill.Poor communication between pharmacist and patient may result in • Inaccurate patient medication history • Inappropriate therapeutic decisions • Contribute to patient confusion • Disinterest • Non-compliancePoor communication between the pharmacists and the other healthcare professionals mayharm the patients if information is not exchanged in an appropriate manner.I. Verbal communication skills1. Active listening • Use face to face communication • Focus on the patient (to feel like the centre of attention) • Conduct an open, relaxed and unhurried conversation • Set aside all the distractions • Prevent or minimize the interruptions2. Observation and assessment • Use effective two way communication • Use body language and gestures. Certain gestures and postures provide clues regarding the other person’s feelings • Sit or stand at eye level to project a non-threatening, equalizing body position that facilitates open communication • Maintain eye contact • Use focused body posture • Be physically close to provide clear and comprehensive communication • Don’t be too close in order not to be intruder on the other person’s space which may induce discomfort and perceived as physical threatening.3. Barriers to verbal communicationPhysical barriers
  • 132. • Large countertops • Windows with security bars and protective glass • Patients in beds are intimidated by people standing over them (conversation must be face to face at the patient’s eye level).Lack of Privacy • Don’t discuss or debate any patient data or health care issues in public areas (Hallways, walkways, lefts, cafeterias, libraries and parking). • Don’t discuss patient-specific information with family or friends. • Converse with patients and discuss patient-specific information with other health care professionals in private counselling or consultation room. • If no special room available, use a private space as possible. • Close the curtains around the bedThe TelephoneWhen making the call • Identify yourself by name and the purpose of the call • Be prepared to repeat the request several times before being connected to the right person. • Be patient and expect to spend some time waiting • Speak clearly • Listen carefully • Be organized • State facts clearly and calmlyWhen answering the callIdentify yourself and ask for the caller’s identity • Deal with the call as fast as possible • Avoid holding the caller • If too busy to talk arrange to call back at a mutually convenient time • When receiving calls from angry and upset person, stay calm, listen, clarify the issue and handle the problem calmly as possible.II. Written communication skills
  • 133. • Pharmacists must be able to accurately and effectively document patient information in the patient medication records and any other records. • Adhere to legal, ethical and professional standards when documenting information. • Black ink is more recommended than any other colours. • Clear and legible handwriting is important. • Cross out any error with one line and initialling the error. • Document factual information and avoid assessments or judgments.Communication with patientsPatient title • Use the correct title and never assume that all the adults are married or single. • Ask each patient how he or she wants to be addressed to convey a sense of respect for the patient.Respect for the patient • Respond to the patient as a person not a prescription or case or room or bed number. • Avoid exchange personal information and confidences with the patient. • Arrange adequate time for interaction and minimize interruptions. • Introduce yourself and explain the purpose of the interaction. • Explain who will see or use the obtained information. • The environment should be clean, neat and well organized. • Note taking is acceptable but should not control the interaction.Questioning TechniqueThe pharmacist not the patient is the one control the interaction by controlling the types ofquestions asked and the time allowed for response. • Don’t fire off a rapid sequence of YES/NO questions • At the beginning, ask open ended questions to allow patients to talk freely about their medications and concerns (e.g. what medications are you currently taking?). • Use minimal facilitators (e.g. yes, uh, what else?) • Provide non-verbal encouragement by smiling and nodding when appropriate. • Give the patient time to answer. • Use directed and structured questions. • Narrow the focus of the question along the conversation. • Discuss one topic at a time and avoid leading questions.
  • 134. • Take some time to summarize the information provided by the patient. • Close the interaction by providing final summary.Patient instruction • Assess patient needs in the context of the patient’s emotional status, educational background, and intellectual abilities (some want to know everything and others don’t want to know anything). • Ask the patient to summarize or repeat the instruction provided.Medical Jargon • Avoid medical jargon when communicating with patients and translate commonly used pharmacy and medial terms into commonly used terms. • Speak in plain language.Special situationsPharmacists must be able to communicate with patients with special situations or specialneeds. The pharmacist not the patient is responsible for recognizing the special situation andhaving the skills and flexibility to ensure appropriate and effective communication.1. Embarrassing situationsMost patients find it embarrassing to discuss certain topics e.g., • Sex related topics • Obesity • Haemorrhoids • Illiteracy • Birth controls • Constipation or diarrhoea • Enemas • Incontinence • Douches • Noncompliance • Drug or alcohol abuse Clues showing embarrassment • Avoidance of eye contact • Be aware of what may be • Blushing embarrassing and try to bring up the • Stammering subject • Closed body language • Converse in a private environment. • Excessive nervous small talk about • Discuss the issue in a unrelated matters (weather, sports straightforward scientifically appropriate manner. • Avoid humour
  • 135. 2. Mute patients • Use written communication. • Allow sufficient time for adequate communication3. Elderly patientsElderly patients have special needs. They may have hearing impairment which may beassociated with loss of ability to distinguish between different sounds and tones. They maysuffer from visual impairment as well including cataracts, reduced peripheral visionproblems distinguishing some colours. • Take time to engage elderly patients in unhurried conversation. • Speak slowly, distinctly and avoid slang language. • Treat elderly with respect. • Don’t assume that every elderly has impaired hearing. • Speak directly to the patient. • Use large-print written information. • Re-enforce written information with verbal communication.Touching the patient lightly on the arm or shoulder may reassure the patient.4. Paediatric patients • Communicate directly with the paediatric patient as well with the parents. • Information must be age appropriate.5. Physically challenged patients • Don’t assume that physically disable patient is mentally disable. • Engage the patient in unhurried conversation and give the patient time to respond. • Speak directly to the patient and don’t assume that the patient is incompetent. • Don’t stare at the patient or avoid eye contact. • Don’t physically assess the patient without being invited doing this.6. Mentally impaired patients • Don’t assume that the patient is incapable of participation in their health care. • Communicate clearly and directly with the patient. • Communicate clearly and directly with the caregiver.7. Hearing Impaired patients
  • 136. • Don’t assume that all the patients with hearing impairment can read lips or understand the sign language. • Don’t assume that a hearing aid returns the patient’s hearing to normal. • Don’t assume that hearing impairment is accompanied with intellectual impairments. • Communicate clearly, slowly with the most minimum background noise. • Face patients who can read lips. • Use written communication.8. Chronically ill patientsThey may be sophisticated and/or demanding category. Some of them know more aboutthe management of their disease than some healthcare professionals. Some of thechronically ill patients may be completely disillusioned by repeated unsatisfactoryinformation and maybe bitter, cynical and difficult to interact with. • Assess the needs of each patient. • Be flexible to communicate on appropriate level.9. Terminally ill patientsBecause those patients are normally on complicated medication regimens they may bealso sophisticated and/or demanding category. They also may be bitter, cynical and difficultto engage in conversation. • Deal with them with respect • Work with them to achieve optimal therapeutic efficacy within the complexity of their illnesses. • Provide close monitoring and reassurance about the medication regimens.10. Hard to reach patientsThis category includes those of low socioeconomic status, minorities and illiterate persons. • Communicate directly with each patient as an individual. • Provide as much respect, time and information as possible. • Be sensitive to their needs. • Help illiterates organize complex regimens by using different sized containers or colour coding technique. • Be sensitive to the cost of medication.11. Antagonistic patients
  • 137. This category includes those who don’t want to be bothered with medication histories,interviews and interactions. • Try to be as professional and direct as possible. • Limit the length of the interaction to the shortest possible period. • Define the need for the interaction. • Treat them with respect.Communication with health care professionalsPharmacist- physician communication • Be prepared with specific questions, facts or recommendations. • Stay within the pharmacist’s area of expertise. • Never interrupt a physician- patient interaction except for life-threatening cases. • Never interrupt clinical rounds • Don’t involve physicians in lengthy social small talks. • Listen carefully, assess the information or question and ask for clarification.Pharmacist-nurse communicationTreat nurse with respect
  • 138. Patient CounsellingWhen providing pharmaceutical care, pharmacists can learn more about their patients;their medicines; the way they see them and their beliefs about their health and medications.In addition to spending time with the patients, pharmacists need to ensure patientsunderstand how to use their medications as well as making interventions to improve theoutcome of the medication therapy.Patient Counselling • It is well documented that well-informed patients are more likely to use their medication correctly. • Counselling on medication is not an optional extra, but an integral part of the dispensing of medication in the hospital. • Effective counselling is not simply the provision of information. Information is prerequisite to compliance, but the timing and organization of the message and involvement of the patient are critical in determining what the patient understands and remembers. • The counselling should be thought of as an opportunity for information exchange. You are the expert on drug therapy, but patients are experts on their daily routines, how they understand their illness and its treatment, whether they anticipate any problems taking the medicine as prescribed, and so forth. • It is assumed that before the pharmacist counsels the patient, he/she will first assess the appropriateness of the drug therapy.The purpose of counselling is to• Ensure that patients are adequately informed about the medication.• Identify any problem which might cause loss of efficacy of the drug or be detrimental to the health of the patient.• Prevent any problem which might cause loss of efficacy of the drug or be detrimental to the health of the patient.How to go about it? • Counselling should take place in a thoughtful, structured way. • The pharmacist must possess not only a sound knowledge of the drugs and appliances being dispensed, but also excellent communication skills.
  • 139. • Pharmacists should have the ability to explain information clearly and in language the recipient can understand. • Pharmacists must know the right questions, how to ask them and, most importantly, they must know how to listen. • Each situation and patient will have different information needs, but as a general rule, no patient who has been given a medication should leave the hospital without knowing: How and when to take or use the How to recognize side effects and medicine minimize their incidence How much to take or use Lifestyle or dietary changes that How long to continue need to be made What to do if something goes wrongIf approached in a structured manner, good counselling does not always need to take alarge amount of time.a. Recognizing the need: Not every patient will require counselling and advice but the most common error is to assume that the patient is well informed. Use the following criteria to ensure that all people who need advice get it: i. The medication order • Is it for a medicine which the • Are the instructions clear? patient has not had before? • Is the medication order for drugs • Are there several items on the have a complicated or unusual order? regimen ii. Prescribed medicines: • Drugs that have a narrow • Drugs that are likely to cause side therapeutic index effects • Drugs that have a potential for • Information on additional cautionary interaction labels should always be reinforced • Drugs that are presented in a complex dosage form iii. The patient: • In general all elderly patients should be offered counselling • If the medication is for a child, the parent or guardian should be given advice • Patients known to have problems with drug therapy
  • 140. b. Assessing and prioritizing the needs: Depends on a variety of factors: • What counselling has the patient • Does the patient have sight or hearing previously received? problems? • What are the patient’s • Is the patient pregnant or breast- comprehension levels? feeding? • What level of support does the • Does a large amount of information patient need or have? need to be given?c. Check assessment methods: Checking that the patient can read the label, use an inhaler device, or open a container with a child-resistant cap.d. Implementation • Environment • Time • Professional appearance • Patient expectations • Patient
  • 141. e. Assessing the success of the process During the counselling process, the pharmacist should be checking if the information is understood by the patient.Aids to CounsellingPatient information leaflets, warning cards and placebo devices are useful aids when givingadvice to patients.Patient Counselling Checklist• Introduce yourself: It is important for patients to know they are speaking with the pharmacist. They may be reluctant to ask questions or express concerns if they believe they are speaking to a technician or clerk.• Identify to whom you are speaking: If you are talking to the patient directly, information is less likely to be confused or distorted than if you are talking to the patient’s reprresentative, who must pass the information on to the patient. In third party communication, written information becomes even more important than when directly communicating with the patient.• Explain the purpose/importance of the counselling session: People listen and learn more effectively when they are given reasons for what is being asked of them. For example, patients are less likely to take tetracycline with food or dairy products if they are told that decreased absorption and effectiveness of the drug may result. For new patients, it will be necessary to explain why the information being gathered is needed.• Ask the patient what the physician told him/her about the drug and what condition it is treating: Find out what the patient knows or understands about his/her disease. There is no reason for the pharmacist to present information that the patient already has mastered. Generally speaking, in any effective counselling session, the patient should speak more than the healthcare provider. The purpose of the session is to ensure that patients leave the hospital with knowledge about the proper use of the medication. It really does not matter whether the patient gets this information from the pharmacist or physician. Accurate information that the patient supplies should be supported and praised. Inaccurate information should be corrected, and information that is omitted should be added. Use any available patient profile information.• It is important to address these concerns immediately, with as much understanding as possible. Until the concern is addressed, the patient will not register or internalize any other information that is provided. The pharmacist should make all effort to understand the concerns of the patient and treat the concerns with the attention they deserve.
  • 142. • Listen carefully and respond with appropriate empathy: These skills are essential to an effective counselling session. The relationship between the patient and practitioner is a key variable in predicting compliance with treatment. Patients need to view healthcare providers as competent, trustworthy professionals who care about what happens to them. Listening and empathic responding are effective tools for communicating caring.• Tell the patient the name, indication, and route of administration of the medication: This and the steps that follow will generally be performed after determining the appropriateness of the medication and filling the prescription. Telling patients the name of the medication helps them get used to identifying it. This is important in case of an emergency (e.g., a child ingesting it, overdose). Stating the indication reinforces the diagnosis and creates confidence in the appropriateness of the therapy. While the route of administration often seems obvious, pharmacists often encounter cases of patients taking a medication by the wrong route. It should not be assumed that printing this information on the label will cover these points. Many patients cannot read, and those who can read do not.• Inform the patient of the dosage regimen: Patients should be told the dosage regimen in order to either reinforce what the doctor instructed or inform them for the first time. While a particular dosage regimen may seem straightforward or obvious, it may be interpreted incorrectly. For example, not everyone eats three meals a day. Patients with diabetes may eat six or seven mini-meals each day. Therefore, directions that state, “Take one tablet after meals and at bedtime,” may prompt some patients to take their medications more than the intended four times per day.• Ask the patient if he/she will have a problem taking the medication as prescribed: This is an important question that is seldom asked by any healthcare provider. Yet, research shows that the complexity of the dosage regimen can greatly affect compliance. In fact, once-a-day dosing generally achieves rates of compliance of greater than 80 %, while four-times-a-day dosing reduces compliance to below 40 %. This has significant implications for the pharmacist. The total cost of care needs to be considered, not just the cost of the drug. Noncompliance as a consequence of complex dosage regimens may result in hospitalization of the patient. Pharmacists should attempt to resolve problems related to the dosage regimen, either through tailoring the regimen or working with the physician to change the medication to a less complicated dosing schedule.• Tailor the medication regimen to the patient’s daily routine: Making a connection between taking a dose of medication and a regular daily task will enhance compliance. This could include identifying when the patient wakes up and goes to bed or which meals
  • 143. he eats. Pharmacists should not assume that patients follow a common routine (e.g., eating three meals a day). They should ask patients about their routines before suggesting a plan.• Tell the patient how long it will take for the drug to show an effect: If patients are not told when to expect onset of action, they may believe the medication is not working. Patients may cease taking a medication, or they may take too much because they believe one dose did not work.• Tell the patient how long he/she might be taking the medication: Patients need to have a reasonable expectation of how long they will need to take the medication. This helps them get into a “mind set” of compliance. It helps to eliminate unrealistic expectations. Moreover, it gives patients a chance to express concerns about the length of the treatment.• Tell the patient when he/she is due for a refill: Patients need to plan in order to be compliant, and this information assists them in doing so. The information may be given in the form of a verbal contract.• Emphasize the benefits of the medication: Pharmacists should make every effort to support the chosen therapy and tell patients about the benefits of the treatment before they discuss potential side effects. This not only helps to put side effects in perspective, but it also promotes patient confidence in the therapy. Lack of confidence in the chosen therapy results in a higher incidence of noncompliance.• Discuss major side effects of the drug: The more specific pharmacists’ advice can be, the better. Will the side effects go away, and if so, within what period of time? Are there steps the patient can take to prevent, alleviate or manage the side effects? What should they do if side effects do not go away or become intolerable? Effective counselling helps patients understand the extent of the risk they are taking by using a medication. It is possible that some patients will not want to know about any side effects, and some will want to know all possible side effects. Pharmacists must develop a flexible approach to the dissemination of information. Leaflets are an excellent way to provide patients with additional information.• Point out that additional, rare side effects are listed in the information sheet: An information sheet summarizing facts about the medication should be given to the patient at the end of the counseling session. Emphasize the rarity of some of the side effects listed, and encourage the patient to call if he/she has any concerns about these.• Use written information to support counselling when appropriate: For literate patients, written information has been shown to reinforce verbal instruction. It gives the
  • 144. patient tangible information to refer to in case he/she forgets what the pharmacist has said. In addition, it can be used to promote more effective counselling. Written information may be given to patients to look over while their prescription is being filled. This can prepare patients to ask better questions and the pharmacist will do less talking.• Discuss precautions (e.g., activities to avoid) and beneficial activities (e.g., exercise, decreased salt intake, diet, self-monitoring): It should not be assumed that the physician has discussed these things with the patient. Ask patients what they have been told, and discuss if necessary.• Discuss drug-drug, drug-food, drug-disease interactions: Patients generally are not aware that other medications, foods, or diseases may interfere with the drug they are taking or affect the condition for which they are being treated. For example, a patient with high blood pressure should be told to ask the pharmacist before taking any medicines for coughs or colds. The patient should also be told why these precautions are necessary.• Discuss storage recommendations, ancillary instructions (e.g., shake well, refrigerate): Many patients still store their medications in medicine cabinets in the bathroom—probably the worst place in the house to keep medicine because of heat and humidity. Give general storage recommendations for all medicines, and specific storage recommendations (e.g., refrigeration) and ancillary instructions to the patient.• Explain to the patient in precise terms what to do if he/she misses a dose: Actual times of day and specific examples should be used to make this clear. The patient should then be asked, for example, “What will you do if it is 3:00 in the afternoon and you realize you have missed your noon dose?” The only way you can assess whether patients understand is by asking them to repeat back the information. If you ask them if they understand, patients may say yes even if they do not.• Check for further understanding by asking the patient to repeat back additional key information: To fully assess whether the patient understands the regimen. The same would be done with side effects, storage conditions, etc. Correct answers should be praised and incorrect information should be corrected. Praising can reinforce compliance.• Check for any additional concerns or questions: The counselling session may have raised additional questions or concerns. The pharmacist should ask if this is so and listen respectfully and carefully to what the patient has to say.• Use appropriate language during the counselling session: On occasion, pharmacists use language that is unnecessarily confusing (e.g., hypertension rather than high blood pressure; GI instead of gastrointestinal or stomach). Many patients will not say they are
  • 145. confused because they do not want to appear stupid. If you detect any confusion, it may be helpful to ask. Language that is simple and understandable promotes compliance.• Maintain control of the counselling session: A great deal of information needs to be covered in order to counsel the patient effectively. Concerns take time to address. Therefore, keep superfluous conversation to a minimum. “Small talk” is helpful to start the counseling session, but it needs to be brief and simply serve to break the ice.• Organize the information in an appropriate manner: The most important information should be provided at the beginning of the counselling session and repeated at the end. In addition, support of the drug should precede side effects. This checklist has been formulated to reflect the recommended organization of the counselling session.
  • 146. THE ROLE OF THE PHARMACIST IN FAMILY PLANNINGFamily Planning is a preventive health system that provides quality, low cost, andeasily accessible reproductive health care to women and men during their reproductiveyears. Family planning helps save womens and childrens lives and preserves their health bypreventing untimely and unwanted pregnancies, reducing womens exposure to the healthrisks of childbirth and abortion and giving women, who are often the sole caregivers, moretime to care for their children and themselves. All couples and individuals have the right todecide freely and responsibly the number and spacing of their children and to have access tothe information, education and means to do so.• Family Planning services are confidential• Everyone has the right to informed consent regarding their reproductive choices and birth control methods. Family planning provides clients with information and counselling needed to do this.• Family planning does not discriminate on the basis of age, sex, race, colour, religion, nationality, income, marital status, number of pregnancies, or contraceptive choice(s).The role of the pharmacist in sexual health is characterized by ignorance, embarrassmentand moral judgment. But over an extended period that role has none the less ranged fromsex education and health information to the supply of contraceptives: from the testing ofpregnancy to the supply of materials that might be used in the procurement of abortion. Ithas included the supply of agents to decrease sexual desire (anaphrodisiacs) as well asthose claimed to increase it (aphrodisiacs), the supply of creams and tablets for thetreatment of impotence and frigidity, and a wide range of substances intended to mitigatethe consequences of unprotected sex, from pregnancy to sexually transmitted diseases.Some FactsMales produce sperms at the prodigious rate of about 1000/second from each testicle,and in the normal ejaculate volume of 3-5 ml, there are up to 300 million sperm. Only oneof these is necessary to fertilize an ovum but in practice, the presence of 3 million highlymotile and active sperm is necessary to ensure a possibility of fertilization. Sperm cannormally survive for up to six hours in the vagina, although this durability is subjected towide variation. Survival times in the fluids of the cervix, uterus, and Fallopian tubes havebeen variously estimated as between 3 - 5 days, but can be as long as nine days.
  • 147. By contrast, women are less prodigious. On average, only one ovum is produced in eachmonthly cycle and under normal circumstances, is only capable of being fertilized forabout 12 hours (maximum 24 hours) after it is released into the Fallopian tube. Ovulationoccurs 1 2 - 1 6 days before the next period. The menstrual cycle is traditionally thought tolast about 28 days, although it may vary from as short as 21 days to as long as 40 days ormore. In practice, many women do not have regular menstrual cycle. Therefore thetime of ovulation may be difficult to predict.The Menstrual and Ovarian cyclesThe changes generally occur on a cyclical basis throughout a womans life, from pubertyuntil the menopause. An ovum is produced within the ovary from a primary oocyte bymeiosis (oogenesis). The ovum is formed within the fluid-filled Graafian follicle and atovulation is released from the follicle into the pelvic cavity. The ovum is guided into thefunnel-shaped in fundibulum of the Fallopian tube by finger-like ciliary projections. Theremaining cells of the Graafian follicle in the ovary multiply rapidly and form the yellow,highly vascularised corpus leteum. The corpus leteum secreted oestrogens andprogestogen, which act on the endometrium to increase its blood supply and thickness inpreparation for the receipt of a fertilized ovum. In normal menstrual cycles, variations occurin the plasma concentrations of gonadotrophins, follicle-stimulating hormone (FSH) andlutenising hormone (LH), and of the female sex hormones, the oestrogens andprogesterone. FSH and LH are secreted by the anterior lobe of the pitutary gland in responseto gonadorelin (gonadotrophin-releasing hormone or GnRI I) produced by the hypothalamus.At the start of a cycle, FSH stimulates the development of 20-25 ovarian follicles that willultimately produce one ovum. FSH also stimulates the secretion of oestrogens from thefollicular cells. Rising oestrogen concentrations inhibit gonadorelin (and consequentlysecretion of FSH), but stimulates further development of the follicles and, together withoestrogens, stimulates the release of the ovum from the ovary, LH also stimulates theformation of the corpus luteum.If fertilization does not occur, the continuous secretion of oestrogens and progestogeninhibits the release of gonadorelin and therefore, the secretion of LH. The corpus luteumremains for about 14 days before it degenerates and consequently concentrations ofoestrogens and progestogen decline, and menstruation occurs. Falling concentrations ofoestrogens and progestogen cause gonadorelin to be secreted; this in turn stimulates therelease of FSH and the start of a new cycle.
  • 148. Fertile and Infertile PhasesCombining knowledge of the survival time of the ovum after ovulation with the survivaltime of sperm in the female genital tract permits the different stages of the monthly cycle tobe considered as infertile or fertile. The first infertile phase of each menstrual cycle beginson the day that menstruation starts. This phase is terminated on the day when sperm canenter reproductive tract and possibly lead to a pregnancy. The length of this period isdetermined by the speed at which the ovum is produced by maturation of the primaryfollicle. The fertile phase includes the one day that the ovum can be fertilized plus thepreceding days that sperm may survive in the reproductive tract.A safety margin of an extra day should be allowed. Fertilization of an ovum can occur ifsexual intercourse takes place at anytime between day 9 and 17 of a 28-day cycle, but thevariability of the time of ovulation produces a much wider range for the possible days onwhich fertilization can occur. The presence of sperm already in the Fallopian tubes as anovum is released from the Graafian follicle produces the greatest likelihood offertilization. The second infertile phase lasts from the day after ovulation until the start ofthe next menses. The likelihood of pregnancy resulting from intercourse has been estimated. If100 couples have frequent intercourse timed to take place during the most fertile period ofthe month, 85 of the women will have a fertilized ovum with one month. Of these, 15 willfail to implant; and of the 70 that do become implanted in the uterus, about 1/2 will be lost.Chorionle gonadotrophin will be detectable in 36 women, of whom only 24 will fail tomenstruate the following month. Of the remaining 24, 3-4 will miscarry; leaving a fertility rateof 20%. The major cause of the high wastage rate is foetal chromosomal abnormalities.ContraceptionThe desire to interrupt the normal physiological events that regulate conception had led tothe development of a wide range of contraceptive methods. The usefulness andappropriateness of each method varies with the circumstance of the woman, her partnerand the age at which contraceptive protection is required; a method that is appropriate atone stage of a womans life may be unacceptable at other stage.The methods of contraception chosen at different age during the fertile lifetime of a womanare also subject to changing trends. Condoms are most commonly used as a form ofcontraception by younger people. This is primarily because condoms are readily available,especially from pharmacies, are easily to use and are not associated with side-effects.Young people may be unaware of the availability of diaphragms or be reluctant to seek an
  • 149. appointment with a doctor or clinic to have it fitted. The intra-uterine device (IUD) is notrecommended for young nulliparous women because of risks of pelvic inflammatorydisease and reduced fertility. There appears to be a greater awareness of the potentialbenefits that condoms provide in protecting against transmission of infections (HIV), and inreducing the risks of cervical cancer. Young people rarely use spermicide with condoms.CONDOMS• A condom is a thin latex or polyurethane sheath. The male condom is placed around the erect penis. The female condom is placed inside the vagina before intercourse. Semen collects inside the condom, which must be carefully removed after intercourse.• Latex condoms help preventing HIV and other STDs. Polyurethane condoms may give some protection against STDs, but they are not as effective as latex ones.• About 14 pregnancies occur over 1 year out of 100 couples using male condoms, and about 21 pregnancies occur over 1 year out of 100 couples using female condoms. They are more effective when spermicide is also used.• Risks include irritation and allergic reactions, particularly to latex.• Condoms are used only once.SPERMICIDES• Spermicides are chemical jellies, foams, creams, or suppositories that kill sperm.• They can be purchased in most drug and grocery stores.• This method used by itself is not very effective. About 26 pregnancies occur over 1 year out of 100 women using this method alone.• Spermicides are generally combined with other methods (condoms or diaphragm) as extra protection.• Warning: The spermicide nonoxynol-9 can help prevent pregnancy, but also may increase the risk of HIV transmission.• Risks include irritation and allergic reactions.DIAPHRAGM AND CERVICAL CAP• A diaphragm is a flexible rubber cup that is filled with spermicidal cream or jelly.• It is placed into the vagina over the cervix, before intercourse, to prevent sperm from reaching the uterus.• It should be left in place for 6 to 8 hours after intercourse.• Diaphragms must be prescribed by a womans health care provider, who determines the correct type and size of diaphragm for the woman.• About 5-20 pregnancies occur over 1 year in 100 women using this method.• A similar, smaller device is called a cervical cap.
  • 150. • Risks include irritation and allergic reactions to the diaphragm or spermicide, and urinary tract infection. In rare cases, toxic shock syndrome may develop in women who leave the diaphragm in too long. A cervical cap may cause an abnormal Pap test.VAGINAL SPONGE• Vaginal contraceptive sponges are soft synthetic sponges saturated with a spermicide. Prior to intercourse, the sponge is moistened, inserted into the vagina, and placed over the cervix. After intercourse, the sponge is left in place for 6 to 8 hours.• It is quite similar to the diaphragm as a barrier mechanism, but it does not need to be fitted by doctor. The sponge can be purchased over the counter.• About 18 to 28 pregnancies occur over one year for every 100 women using this method.• The sponge may be more effective in women who have not previously delivered a baby.• Risks include irritation, allergic reaction, and trouble removing the sponge. In rare cases, toxic shock syndrome may occur.COMBINATION BIRTH CONTROL PILLS• Also called oral contraceptives or just the "pill", this method combines the hormones estrogen and progestin to prevent ovulation.• A health care provider must prescribe birth control pills.• The method is highly effective if the woman remembers to take her pill consistently daily.• Women who experience unpleasant side effects on one type of pill are usually able to adjust to a different type.• About 2 - 3 pregnancies occur over 1 year out of 100 women who never miss a pill.• Birth control pills may cause a number of side effects including: Dizziness, irregular menstrual cycles, nausea, mood changes, and weight gain. In rare cases, they can lead to high blood pressure, blood clots, heart attack, and stroke.THE MINI-PILL• The "mini-pill" is a type of birth control pill that contains only progestin, no estrogen.• It is an alternative for women who cannot take estrogen for any reasons.• The effectiveness of progestin-only oral contraceptives is slightly less than that of the combination type. About 3 pregnancies occur over a 1 year period in 100 women.• Risks include irregular bleeding, weight gain, and breast tenderness.THREE-MONTH PILL (SEASONALE)• It is taken for three straight months, followed by one week of inactive pills.• A woman gets her period about four times a year, during the 13th week of her cycle.• Seasonale is available by prescription.• Fewer than 2 out of 100 women per year get pregnant using this method.
  • 151. • The risks are similar to other birth control pills. Some women may have more spotting between periods.• The pills must be taken daily, preferably at the same time of day.PROGESTIN IMPLANTS• Implants are small rods implanted surgically beneath the skin, usually on the upper arm. The rods release a continuous dose of progestin to prevent ovulation.• Implants work for 5 years. The initial cost is generally higher than some other methods, but the overall cost may be less over the 5-year period.• Less than 1 pregnancy occurs over 1 year out of 100 women using this method.HORMONE INJECTIONS• Progestin injections, such as Depo-Provera, are given into the muscles of the upper arm or buttocks. This injection prevents ovulation.• A single shot works for up to 90 days.• Less than 1 pregnancy occurs over 1 year in 100 women using this method.SKIN PATCH• The skin patch is placed on the shoulder, buttocks, or other convenient location. It continually releases progestin and estrogen. Like other methods, a prescription is required.• The patch provides weekly protection. A new patch is applied each week for three weeks, followed by one week without a patch.• About 1 pregnancy occurs over 1 year out of 100 women using this method.• Risks are similar to combined birth control pills.VAGINAL RING• The vaginal ring is a flexible ring about 2 inches in diameter that is inserted into the vagina. It releases progestin and estrogen.• A prescription is required.• The woman inserts it herself and it stays in the vagina for 3 weeks. Then, she takes it out for one week.• About 1 pregnancy occurs over 1 year out of 100 women using this method.• Risks include vaginal discharge and vaginitis, as well as those similar to the combined birth control pill.IUD• The IUD is a small plastic or copper device placed inside the womans uterus by her health care provider. Some IUDs release small amounts of progestin. IUDs may be left in place for up to ten years, depending on the device used
  • 152. • The method should not be used by women who have a high risk of pelvic infection.• Less than 1 out of 100 women per year will get pregnant using an IUD.• Women who get pregnant with an IUD in place have a higher risk of ectopic pregnancy.• Risks include cramps, bleeding (sometimes severe), pelvic inflammatory disease, infertility, and perforation of uterus.NATURAL FAMILY PLANNING• This method involves observing a variety of body changes in the woman (such as cervical mucus changes, basal body temperature changes) and recording them on a calendar to determine when ovulation occurs. The couple abstains from unprotected sex for several days before and after the assumed day ovulation occurs.• This method requires education and training in recognizing the bodys changes as well as a great deal of continuous and committed effort.• About 15-20 pregnancies occur over 1 year out of 100 women using this method (for those who are properly trained).TUBAL LIGATION• During tubal ligation, a womans fallopian tubes are cut, sealed, or blocked by a special clip, preventing eggs and sperm from entering the tubes. It is usually performed immediately after childbirth, or by laparoscopic surgery.• Tubal ligations are best for women and couples who believe they never wish to have children in the future. While viewed as a permanent method, the operation can sometimes be reversed if a woman later chooses to become pregnant.VASECTOMY• A vasectomy is a simple, permanent procedure for men. The vas deferens (the tubes that carry sperm) are cut and sealed.• A vasectomy is performed safely in a doctor’s office using a local anaesthetic.• Vasectomies are best for men and couples who believe they never wish to have children in the future. While often viewed as a permanent method, they can sometimes be reversed.EMERGENCY ("MORNING AFTER") BIRTH CONTROL• The "morning after" pill consists of two doses of hormone pills taken as soon as possible within 72 hours after unprotected intercourse.• A prescription is required.• The pill may prevent pregnancy by temporarily blocking eggs from being produced, by stopping fertilization, or keeping a fertilized egg from becoming implanted in the uterus.
  • 153. • The morning after pill may be appropriate in cases of rape; having a condom break or slip off during sex; missing two or more birth control pills during a monthly cycle; and having unplanned sex.• Risks include nausea, vomiting, abdominal pain, fatigue, and headache.UNRELIABLE METHODS• Coitus interruptus is the withdrawal of the penis from the vagina prior to ejaculation. Some semen frequently escapes prior to full withdrawal, enough to cause a pregnancy.• Douching shortly after sex is ineffective because sperm can make their way past the cervix within 90 seconds after ejaculation.• Breastfeeding. Despite the myths, women who are breastfeeding can become pregnant.BASAL BODY TEMPERATURE METHODThe body temperature is recorded throughout the menstrual cycle. Temperatures aremeasured with a fertility thermometer, which is calibrated between 35-39°C at 0.1°Cintervals. Readings should be taken every day as soon as waking up, before getting outof bed, and before drinking any hot fluids. Temperatures can be taken via the oral, rectal,or vaginal routes, but whichever method is chosen it should be used consistently and thethermometer should remain in position for 3-5 minutes. Temperatures are recorded onspecially designed charts, and a clear increase in temperature of between 0.2-0.4 C canusually be seen about 12-16 days before the next period. This rise corresponds to theincreased release of progesterone occurring after ovulation. Users of this method shouldclearly understand, however, that the infertile phase does not begin until 3 raisedtemperatures have been recorded above 6 previous lower recordings (excluding days 1-4),and is maintained until the onset of the next menses. Following this peak, unprotectedintercourse can take place until the next menses.The main difficulty in using this method arises because of natural fluctuation in bodytemperature. Increased temperatures can occur as a result of a mild infection (e.g.,common cold) or from drinking alcohol the previous night; reduced temperatures mayfollow administration of aspirin. One further difficulty is that there is no sustainedtemperature rise (i.e., indicating the end if the fertile phase) in an anovulatory cycle, whichis paradoxically an infertile cycle throughout.THE CALENDAR METHODIt is called the rhythm or safe period. The length of the period between ovulation and theend of the menstruation cycle has been shown to be relatively constant at about 14 days(12-16 days), and this forms the basis of the calendar method. A high degree ofmotivation is necessary if this method is to be successful as it requires record of the
  • 154. length of the menstrual cycles to be kept over at least a 6 month period, and ispreferably over 12-months. The period of highest risk of conception for all subsequentcycles falls between 19 days from the end of the shortest cycle and 10 days before theend of the longest cycle.For this method to be effective, intercourse should be avoided between these days. Thecalendar method is not recommended as the sole indicator for predicting the infertile andfertile phases of the menstrual cycle.SYMPTOTHERMAL METHODThis uses a combination of basal body temperature monitoring and assessment of cervicalmucus, plus several other indices which, with practice, women can use to detect ovulation.The most important of these additional indices is the determination of the position andfirmness of the cervix, and the extent to which it is open. During the days immediatelybefore ovulation, the cervix becomes softer to the touch and higher in position, and thecervical opening becomes wider. After ovulation, it descends, becomes firmer to the touch,and the opening becomes smaller.
  • 155. The Role of the Pharmacist in Family Planning ServicesOne of the greatest needs of the hour is to control the tremendously increasing population,especially in the third world countries. Pharmacist is the one who can control this risingpopulation by counselling with people and doing programmes which exhibit the problemsrelated with large families. Counselling should always be an integral part of family planningservices. Appropriate, culturally acceptable materials help individuals and couples make freecontraceptive choices. He can tell the various families planning measures that are available inthe market at affordable prices. He can educate the people and convince them about theadvantages of having small families. So, pharmacist plays a very important role in this case byproviding contraceptive products and giving advice about contraception. Advantages ofpharmacists as suppliers of contraceptive products and a source of advice include:widespread locations allowing ease of accessibility to the majority of population; availabilityfor up to 7 days a week; anonymity of the pharmacist-client relationship; and norequirement for any appointment. Moreover, the pharmacist can act as a source ofinformation about the availability of local family planning services.Factors pharmacist should consider when recommending a contraceptive method:• Effectiveness -- how well does the method prevent pregnancy? If an unplanned pregnancy would be viewed as potentially devastating to the individual or couple, a highly effective method should be chosen. In contrast, if a couple is simply trying to postpone pregnancy, but feels that a pregnancy could be welcomed if it occurred earlier than planned, a less effective method may be a reasonable choice.• Cost -- is the method affordable?• Health risk -- learn any potential health risks. For example, birth control pills are usually not recommended for women over age 35 who also smokers.• Partner involvement -- The willingness of a partner to accept and support a given method may affect your choice of birth control. However, you also may want to re-consider a sexual relationship with a partner unwilling to take an active and supportive role.• Permanence -- do you want a temporary (and generally less effective) method, or a long- term or even permanent (and more effective) method?• Preventing any sexually transmitted diseases (STDs). In general, condoms are the best choice for preventing STDs, especially combined with spermicides.• Availability -- Can the method be used without a prescription?It is the role of the pharmacist to provide up to date information on family planning through:• Leaflets on the different forms of contraception are available in the pharmacy.
  • 156. • The pharmacist can give advice on the advantages and disadvantages of the different forms of contraception.• A list of family planning clinics or centres available.• A range of contraceptive products are available for self selection in the pharmacy.The role of the pharmacist is not only to offer advice or decide on the method to be used butalso will explain their side effects and for whom they are considered most suitable. The userthen makes a decision, based on the information given, about which method she/ he wishes touse. Most women using oral contraceptives obtain them over the counter at a pharmacy andnormally they receive little or no counselling on proper pill use. A number of studies havedemonstrated that many women are using the pill incorrectly, leading to high rates ofdiscontinuation, incorrect use and contraceptive failure. So, it is the role of the pharmacist toprovide all the required information regarding this type of contraceptive specially.Women obtaining oral contraceptives from pharmacies may also be unaware ofcontraindications to pill use; they may smoke cigarettes; they may be suffering fromcontraindications to pill use such as high blood pressure, heart problems, and diabetes orkidney disorders. The pharmacist should appropriately counsel on all the possiblecontraindications before dispensing the pill: He/she should not dispense the pills and explain itto the lady if has any of the following conditions:1. History of heart attack or stroke2. Blood clots in the legs, lung or eyes.3. Chest pain4. Breast cancer, uterus, cervix or vagina.5. Vaginal bleeding with no cause.6. Liver problem during pregnancy or during prior use of the pill.7. Suspected or known pregnancy.Also, it is the role of the pharmacist to warn the woman from the expected side effects and itis very normal that some women may experience irregular vaginal bleeding. This is quitenormal and usually goes away within the first few months. If the bleeding is heavy or if youalso have pain, contact your doctor. Other common side effects includes nausea, vomiting,changes in appetite, fluid retention, spotty darkening of the skin, headache are usuallytemporary and some of them can be minimized by taking the pill at night before resting.
  • 157. Pharmacist should also advice women about the drugs that may interact with their pillsspecially antibiotics, St John’s wort, drugs that prevent seizures and vitamin E which maymake the pill not work as well as it should. This could lead to pregnancy or menstrualirregularities.The pharmacy may also be an ideal place for helping men develops awareness of theirresponsibilities in contraception. The current non-availability of condoms on prescriptionmeans that men will not usually seek advice from their doctors about contraceptivemethods. The display of leaflets and products in the non-threatening environment of thepharmacy may encourage inexperienced or shy men and women to seek advice. Adisplay of family planning leaflets can be ideally complemented by clear statement thatcontraceptive advice can be obtained from the pharmacist, the individuals doctor, or thelocal family planning clinic; the address of the local family planning clinic should also bedisplayed.In addition to the role of the pharmacists in dispensing and counselling on the contraceptives,a comprehensive pregnancy testing service should be offered. Pharmacists now areencouraged to perform pregnancy testing upon woman’s request. There should be certainstandards in performing the test. These standards are:1. Staff has undertaken appropriate training on the use of the test2. Written instructions are available on performing the test.3. The test used is accurate.4. Testing is performed in a separate area.5. A discreet notice advertising the service is displayed.6. Patient privacy is maintained.7. Patients are informed of the accuracy of the test used.8. The results are provided in writing and include: a. Name and address of patient. b. The date. c. The test result.9. If the result is positive the patient is advised to see a doctor.10. Records should be prepared and stored for at least one year.
  • 158. SMOKING CESSATIONDespite more than four decades of evidence demonstrating the adverse health consequences ofsmoking tobacco, the personal and societal consequences of smoking continue to be devastating.Tobacco use remains the single largest preventable cause of mortality. In addition, smoking exertsa substantial morbidity burden, such as lung cancer or chronic obstructive pulmonary disease.Smoking tobacco has been associated with a large and ever-expanding array of health conditions;it is a major risk factor for pulmonary disease, lung (and other) cancers, and coronary arterydisease. Secondary exposure to cigarette smoke also exacts a mortality toll, causing 9% of allsmoking-related deaths. The economic burden of smoking is enormous.Smoking cessation is a complex and difficult undertaking that involves physiologic, behavioural,cultural, and pharmacologic factors, resulting in significant barriers to quitting. Given that smokingis a major cause of death, it would seem imperative that all health care professionals (includingpharmacists) devote substantial time and effort to counsel their patients who smoke and to helpthem quit. Yet, only a small percentage of clinicians are involved with smoking cessationmeasures. Their minimal role in intervention is due to a number of reasons, such as theperception that they are invading patients’ privacy, the cultural acceptance of smoking (relative toother drugs of dependence), their mistaken belief that most smokers are not willing or interested inquitting, and the increasing lack of time they have to spend with patients. In addition, there is ageneral lack of education about smoking cessation in medical and pharmacy schools. Simply put,many clinicians feel they have neither the time nor the training to adequately help their patientsstop smoking. However, basic, effective, and concise methods can be implemented into a busyhealth care provider’s practice that can lead to an increased number of successful quitters.Pathophysiology of SmokingMany non-smokers wonder why it is so difficult to quit smoking. A complex interplay of nicotine’sneurobiology/pharmacology, behavioural cues, psychological adaptive mechanisms, and otherfactors result in the firm grip smoking has on many patients. The numerous effects of nicotine onthe CNS are at the core of tobacco’s addictive properties. Nicotine’s stimulation of severalneurotransmitters, specifically, dopamine in the nucleus accumbens (“pleasure centre” of thebrain), causes many of the rewarding consequences of smoking. These rewards include anincreased perception of pleasure and arousal, as well as alertness. Additionally, an increase innicotine levels leads to the release of adrenal hormones and mild hyperglycemia—the “hit” or“rush” that the first inhalations of a cigarette produce. These and other effects lead to bothphysical tolerance and psychologic dependence. As with other psychoactive drugs that are
  • 159. associated with tolerance, withdrawal symptoms can occur within a few hours of the last cigarettesmoked and can be substantial and debilitating. Smokers’ behaviours are often modelled aroundthe fear or actual development of these symptoms, thus reinforcing smoking further. It is also whythe first cigarette of the day is often the most pleasurable and the most difficult to give up.A number of literatures indicate that cigarettes deliver nicotine rapidly (within 7 seconds) to theCNS and that the tobacco industry was cognizant of this property by referring to cigarettes as“nicotine delivery devices.” The ability of cigarettes to quickly supply nicotine to patients representsanother major barrier to quitting.As a long-term smoker integrates cigarettes with daily his/her activities, the psychological “lift”becomes incorporated with these actions. Thus, when the smoker attempts to quit, he/she iscontinually reminded of the “missing element” involved with the behaviour (e.g., the smoker isreminded that he/she is “missing” the pleasure of an after-meal cigarette). Therefore, quitting iseven more difficult if strategies are not developed to cope with these behavioural cues.Both smokers and non smokers have misperceptions regarding quitting. Smokers often fear theloss of nicotine’s ability to reduce anxiety and improve performance, and many are concerned thatthey will gain excessive weight after quitting. Non smokers can be derisive in their attitudes towardsmokers, feeling incredulous that a person would voluntarily decide to smoke, despite the wealthof information on this behaviour’s negative health effects. These misperceptions add barriers forsmokers who wish to quit. When aiding a smoker to quit, clinicians should approach the patientwith the same compassion and empathy they would display toward any patient. It is also importantto have a frank discussion with the patient, dispelling misconceptions about quitting (e.g., averageweight gain after quitting is 5 pounds, and strategies exist to minimize weight gain). Thus,pharmacists engaged in smoking cessation efforts will find their communication and counsellingskills exercised to a high degree. If pharmacists understand current behavioural models ofsmoking and the coping skills for quitting, they can increase the odds of success.Transtheoretical Model of Smoking CessationThe transtheoretical model (TTM) was initially used to determine a smoker’s readiness toparticipate in smoking cessation interventions. Since then, it has been used to promotebehavioural changes in various health care settings. The essential feature of the TTM is the fivestages of behavioural change smokers undergo before, during, and after the smoking cessationprocess. These stages are precontemplation, contemplation, preparation, action, andmaintenance. The TTM can be applied to various behavioural models and health care
  • 160. interventions; however, addictive behaviours provide an ideal situation in which the TTM can beeffective.Stages in the TTM of Smoking CessationStages of Change Definition of ChangePrecontemplation Patients have no intention for action in the next six months. In this stage, patients are unmotivated and/or under-informed about the consequences of smoking.Contemplation Patients intend to change within the next six months. They are aware of the pros and cons of smoking but are not ready for action-related programs.Preparation Action is planned within the next month. The patient’s plan of action, such as a smoking cessation program, has been identified.Action Modifications in behaviour have occurred in the past six months. Patients abstain from smoking.Maintenance Patients in this stage are preventing relapse. Typically, patients are more confident in their smoking cessation and are at less risk of relapse, compared to patients in the action stage.During the precontemplation stage, smokers are not considering smoking cessation in the next 6months. They overestimate the benefits of smoking, underestimate the risks, and avoidinformation to help them change. In this stage, providing patients with awareness of the adverseeffects of smoking is helpful.Progressing to the contemplation stage, awareness of the problem exists, and some thought hasbeen given to a solution; however, there is no serious action taken to solve the problem. Smokersare considering quitting in the next 6 months but have not set a quit date. They recognize that therisks of smoking outweigh the benefits. In this stage, it is important to emphasize the adverseeffects.In the preparation stage, there is intent to take action within the next month, but no action hasbeen taken at this point. Smokers are planning to quit; a quit date has often been set within two tofour weeks. During this stage, assistance in moving the patient toward smoking cessation isuseful.The action phase requires the most commitment, where patients modify their behaviour to solvethe problem. Smokers move into this stage when they take steps to stop smoking. Interventionsthat address relapse and prevention and reward positive behaviour are most effective in this stageand help reduce the high initial relapse rate.
  • 161. After 6 months in the action stage, patients move into the maintenance phase. Patients work onmethods to prevent the recurring and develop ways to prevent future obstacles. Successfulpatients avoid relapse and are well adjusted to handle situations when temptation is greatest. Mostpatients in this stage have seen positive results from their cessation and are self-motivated toremain smoke-free. However, these patients are not invincible to relapse, and continuedmotivation is required.The TTM permits tailoring to meet a smoker’s need. Monitoring motivational levels and providingpsychological and behavioural strategies for smokers is essential to achieving behaviour change.Psychological and Cognitive Behavioural StrategiesBehavioural therapy focuses on building skills to resist relapse, such as developing incompatiblebehaviours, coping thoughts, and refusal skills. This type of therapy increases quitting rates.Patients can recognize situations in which they are most likely to use tobacco, avoid thesesituations, and cope more effectively with situations that trigger cravings or relapse.Common elements of behavioural and cognitive techniques for smoking cessation involve socialsupport, didactic information about nicotine dependence, withdrawal symptoms, high-risksituations for relapse (e.g., alcohol use, negative moods, the presence of other smokers). Manysmoking cessation programs use standardized protocols and focus on only some of thesetechniques, whereas others try to include a variety, if not all, of the techniques.Patient Individuality and Buy-In Strategies: The key to using cognitive and behaviouralstrategies is to ensure that the strategy is tailored to the individual patient and that patients learnnew coping skills and develop new habits. Every patient trying to quit smoking will have differentreasons and motivations. Therefore, discussing issues that do not affect the patient and offeringtechniques to resolve these issues will not be helpful. In fact, since the mental attitude of thequitting patient can be fragile, discussing irrelevant information could lead to relapse or causepatients to drop out of smoking cessation programs. Getting patients to “buy in” to the smokingcessation program and see that it will be individualized to their specific difficulties can be thegreatest barrier.Reduction of Nicotine Intake: Another cognitive behavioural strategy is non-scheduled reductionof nicotine intake, or tapering. This technique involves gradually reducing the number of cigarettesthat the patient smokes in 24 hours. Initially, patients are asked to count every cigarette theysmoke within a one-hour period for 24 hours. Then, the number of cigarettes that they smokeduring certain hours of the day is reduced over a period of time. The ultimate goal is for the patient
  • 162. to smoke no more than 10-12 cigarettes/day. Achieving this goal aids the transition to the nicotinepatch and helps reinforce that smokers have control over nicotine and the amount that theysmoke.Similar scheduled smoking reduction programs have demonstrated efficacy; however, in theseprograms, smoking reduction was more prescriptive. Participants were instructed to smoke only atspecific times of the day, with the intercigarette interval being progressively increased by smokingcessation clinic personnel. Patients using the scheduled smoking reduction program hadabstinence rates of 44% at one year, compared to 18% of patients using a non-scheduledprogram.Validated Cessation Practices: The Treating Tobacco Use and Dependence guideline panel hasidentified effective and experimentally validated cognitive behavioural cessation practices that canbe implemented in a variety of clinic settings. One behavioural technique is using dieting andphysical activity interventions to increase abstinence rates. Possible interventions range frommoderate exercise (e.g., walking) to more vigorous exercise (e.g., running, cycling) as a way forpatients to fight cravings and deal with the psychological aspects of wanting to smoke.Problem-solving and coping skills, another validated technique that has been shown to be helpful,involves counselling patients on recognizing “danger situations” (e.g., being around othersmokers, time pressure, experiencing urges). The patient can be advised on how to implementtechniques to cope (e.g., anticipate and avoid temptations, incorporate lifestyle changes thatreduce stress, distract attention to deal with urges). Through education and counselling, patientscan successfully use the learned techniques when situations arise that may result in returning tosmoking.Some techniques, such as hypnosis, acupuncture, and aversion therapy, have been studied.While not an exhaustive or exclusive list, other techniques that may or may not have data tosupport their use include taste aversion, oral fixation replacement, smoke-free zones, andsmoking substitutions. These behavioural techniques provide unique but integrated ways to help apatient quit. Although each technique can be used alone, these techniques often need to becombined to provide adequate relief during smoking cessation to ensure that a patient’s chancesof relapse are minimal.Taste Aversion and Oral Fixation Replacement: Both involve patients using a taste and oralstimulus that makes cigarettes taste unpleasant. There are many options for taste stimuli, such asusing peppermints, brushing teeth with strongly flavoured toothpaste, and using flavoured
  • 163. toothpicks. If these stimuli are used when patients have the urge to smoke, either the taste stimulireplace the urge or patients find they cannot tolerate the taste of cigarettes. All taste aversionoptions provide an oral fixation that satisfies many smokers in the manner that cigarettes formerlydid. Other oral fixation techniques involve drinking water or chewing sugar-free gum. Regardlessof the taste aversion stimulus or oral replacement used, the goal is to provide patients with analternative to cigarettes.Smoke-Free Zones: Another cognitive behavioural technique is to have patients identify areas intheir home or working environment where they can go to escape the pressures of smoking. Thesesmoke-free zones help patients have an area where they know they cannot smoke. With thistechnique, patients identify a place they enjoy that they know is smoke-free. When patients havethe urge to smoke or are confronted with others who are smoking, they can go to the smoke-freearea to escape this pressure.Smoking Substitutions: Many smoking cessation patients will create smoking substitutions touse when they have the urge to smoke. These substitutions are frequently combined with tasteaversions and oral fixations; however, other substitutions, such as a hobby or activity, can beused. There is no limit to the types of substitutions that can be implemented. Smokingsubstitutions are effective for many patients and can be used in a variety of settings. Substitutionshelp the patient to feel in control of his/her therapy.Pharmacotherapy for Smoking CessationPharmacotherapy significantly increases the odds of quitting, although the effect may be modest.Interestingly, new data are emerging about the pharmacogenetics of patients and the likelihood ofa successful response to smoking cessation pharmacotherapy.Before reviewing the pharmacotherapeutic options, it is important to understand the goal of suchtreatment is complete smoking cessation. Although a reduction in the daily number of cigarettessmoked may increase the odds of quitting, the preponderance of published data suggests that itdoes not improve mortality. It is also important to realize that pharmacotherapy for smokingcessation is primarily an aid to be used in conjunction with psychological and behaviouralcounselling.
  • 164. NRT: NRTs were the first pharmacotherapeutic agents approved in to aid in smoking cessation. Several dosage forms are available, and sold over the counter (OTC). NRT supports quitting efforts primarily by reducing withdrawal symptoms and providing some of the “reward” produced by nicotine in the CNS. Unfortunately, because NRT does not interfere with everyday sensory stimuli that produce tobacco cravings, they are often considered ineffective by patients attempting to quit. Of the five forms of NRT available—transdermal patches, nicotine gum, lozenges, nasal inhalers, and oral inhalers— transdermal patches are the only system that delivers a continuous amount of nicotine to the patient, while the other forms allow the patient to titrate the dosage as needed. The selection of an agent depends on such factors as the number of cigarettes smoked, possible adverse reactions, cost, and preference. Efficacy of the NRT formulations has been largely equivalent.Pharmacotherapy for SmokingMedication Duration Adverse Effects Comments
  • 165. NRT _ ADRs include headache, Combination therapy with the patch & nausea, vertigo, vivid dreams, more immediate- release treatments can and tachycardia be usedNicotine gum 2-4 mg (1-2 pieces) hourly. Titrate Product-specific: Jaw _ off over 12 weeks soreness, sore throatNicotine patch Start at 15 or 10 mg, depending Product specific: Local site Designed for 16-hour use on amount smoked. Monitor after reactions (minimized by 12 weeks. rotating application sites)Nicotine patch Start at 14 or 21 mg, depending Product specific: Local site Designed for 24-hour use on amount smoked reactions (minimized by rotating application sites)Nicotine patch Start at 14 or 21 mg, depending Product specific: Local site Designed for 24-hour use on amount smoked reactions (minimized by rotating application sites)Nicotine patch Start at 11 or 22 mg, depending Product specific: Local site Designed for 24-hour use on amount smoked. Taper off reactions (minimized by after 12 weeks rotating application sites)Nicotine lozenge 2-4 mg hourly. Similar to gum except for jaw _ Taper off after 12 weeks sorenessNicotine nasal inhaler 1 spray in each nostril every 30 Product-specific: nasal Initially use at least eight doses daily. Do min. to 1 hr initially. burning, rhinitis, throat not exceed 40 doses daily Taper off over 14 weeks. irritation, and sneezingNicotine oral (vapor) Taper over 3-6 months Product specific: coughing Avoid use in patients with chronic lunginhaler and throat irritation diseaseBuproion 150 mg daily for three days, then Dry mouth, insomnia and The most effective aid in SC available.(sustained-release) twice daily for a total of 12 weeks nervousness common. Seizure risk is negligible if patients are Increased risk of seizures properly selectedNortriptyline Titrate to 75 mg orally at bedtime Dry eyes and mouth, Effective for SC but still considered for 12 weeks sedation, constipation, & second-line therapy. May be an effective orthostatic hypotension additive agentClonidine 0.1 mg orally three times daily for Dry eyes & mouth, sedation, Least robust data to support use for SC. eight to 12 weeks constipation, depression, Adverse-effect profile limits use hypotension, and bradycardiaADR: adverse drug reaction; OTC: over-the-counter; SC: smoking cessation. Source: References 21 and 32 • Transdermal patches: Four patch formulations are available. Length of therapy, duration of wear, and dosage strength all vary between brands of patches, requiring the clinician to become familiar with each type. Patch application causes an initial increase in serum nicotine levels, followed by steady levels throughout the rest of the dosing period. Patches are available in both 16- and 24-hour applications. The 24-hour patches have the advantage of possibly decreasing
  • 166. severe nicotine craving upon awakening but can cause insomnia or vivid dreams. In patients whosmoke less than 10 cigarettes daily, a lower initial dose (e.g.,14 mg) should be selected, whilepatients who smoke more should be started at a higher dose (e.g., 21 mg).Adverse effects associated with the patch include localized skin reactions, headache, nausea, andvertigo. Patches may come off when a patient sweats, which can be an obstacle in using this formof NRT. Local reactions are usually self-limiting and can be minimized by rotating application sitesor applying hydrocortisone 1% cream. Although the patches deliver a steady amount of nicotine, atleast one study has shown that patients who use patches may be as susceptible to externaltriggers for smoking as those who do not use this form of NRT. Thus, in patients with heavycravings, or in patients who do not achieve success with the patch, combination NRT may berequired with the patch in a form that attains rapid serum levels of nicotine.• Nicotine gum: Available since the early 1980s. It is available in several flavours, including mintand orange, and offered in two dosage strengths: 2 - 4 mg, both of which deliver about 50% ofthat amount to the body. To use appropriately, the patient should chew the gum until it tingles(sometimes described as a “peppery” taste), then “park” the gum buccally to aid in nicotineabsorption. Once the tingling sensation abates, the gum can be rechewed.Product information suggests that 1-2 pieces an hour may be chewed, depending on dose.Patients who smoke more than one pack daily should consider starting with the higher 4-mgdosage. An error some smokers make is to chew gum only when cravings occur. In fact, regularusage (initially one to two pieces an hour) during the day is essential for full effect. Since acidicsubstances can decrease the buccal absorption of nicotine, patients should be counseled to avoiddrinking beverages such as coffee or soft drinks for 15 minutes prior to chewing the gum. Oneadvantage of nicotine gum is its ability to reduce cravings in response to a smoking stimulus, likelydue to the delivery of nicotine and the behavioural effects of gum chewing. Although themanufacturing information recommends a 12-week course of therapy, patients can use this formof NRT longer if necessary. Adverse effects are mild and include jaw soreness, dyspepsia,nausea, hiccups, and flatulence.• Nicotine lozenges: Nicotine lozenges (2 and 4 mg) have been available since 2002. Dosagedepends on the time until the first cigarette is smoked; most patients require the 4 mg dose. Aswith gum, nicotine is absorbed buccally via the lozenge. This dose has been shown to be about aseffective as other forms of NRT, including the patch.31 Nicotine lozenges may be an alternative forpatients who have developed excessive jaw soreness with nicotine gum, patients who do not
  • 167. enjoy chewing gum, or patients who feel that it is socially unacceptable. Adverse effects aresimilar to the side effects from nicotine gum.• Nasal inhalers: Available since 1996, nicotine nasal sprays deliver the drug to the CNS fasterthan all other commercially available NRT. In fact, this NRT pharmacokinetically mimics cigarettesthe closest, with a peak plasma level of nicotine occurring within 10 minutes.Patients spray one squirt of the inhaler (0.5 mg) in each nostril one to two times per hour.(Patients should not exceed five doses an hour or 40 doses daily.) Use should be titrated basedon cigarette cravings, but most patients require about 15 doses daily. About one to two canistersshould be used per week. Nasal inhalers should be used for up to 12 weeks, during which timethe patient should taper usage. Like nicotine gum, the nasal spray allows the smoker to control thedosage and to treat cravings as they occur. One study suggests that the nasal spray may relievecraving symptoms quicker than the gum. Adverse effects, e.g., nasal burning and rhinitis,headache, throat irritation, and sneezing, tend to occur in the first few days of therapy anddiminish with continued use.• Oral inhalers: Oral inhalers do not actually deliver nicotine to the lungs; rather, nicotine isabsorbed primarily through the oral or gastrointestinal mucosa. This dosage form may beparticularly useful in a subgroup of smokers for whom the hand-to-mouth ritual of smoking isimportant. About 80 “puffs” on the inhaler are necessary for the patient to receive approximately 2mg of nicotine. Yet, studies have shown that with lower ambient temperatures, the amountdelivered may decrease. Most patients will require between six and 16 cartridges daily. Theinhaler is recommended for up to 12 weeks before being tapered over an additional 6-12 weeks.Adverse effects include coughing, headache, and throat irritation. Studies with the inhalerexcluded patients with reactive airway disease; thus, its safety in this population is unknown.Bupropion: The discovery of benefit associated with the antidepressant bupropion in smokingcessation was a major advancement in pharmacotherapy for this condition. Although its exactmechanism is unknown, it is believed that through its action as a weak dopaminergic antagonist, itdecreases the activation of the nucleus accumbens in response to nicotine. This lowers thepleasure reinforcement that smokers derive from nicotine. Additional benefits to bupropion use aredecreased withdrawal symptoms and possible increased alertness and concentration. The drugmay blunt the weight gain associated with quitting.Patients can be counseled to start bupropion extended-release 150 mg daily for three days, thentwice daily. The patient’s quit date should be one week (or more, depending on how much they
  • 168. smoke) after the initiation of bupropion and continued for 12 weeks. If a patient relapses after thisperiod, bupropion can be reinitiated as above.Minor adverse effects include dry mouth, insomnia, and nervousness. The most feared adverseeffect of bupropion is seizures. However, it is important to remember this risk is small if patientsare selected carefully. Specifically, the drug is contraindicated in those with epilepsy, patients witha history of head trauma, stroke, or brain surgery, and patients with eating disorders (anorexia orbulimia). The pharmacist should be aware of the importance of avoiding concomitant use of otherdrugs that lower the seizure threshold (e.g., ciprofloxacin, tramadol, neuroleptics).Bupropion or NRT is considered first-line pharmacotherapy to aid in smoking cessation.Clonidine and Nortriptyline: Clonidine is used to ease withdrawal symptoms in opioid addiction.Thus, it may have some benefit in smoking cessation. Adverse effects with clonidine aresubstantial and include anticholinergic effects, hypotension, bradycardia, and depression.Nortriptyline, a secondary amine tricyclic antidepressant, has also been examined in smokingcessation with generally favourable results. Therefore, nortriptyline could be considered when apatient does not have success with or tolerate other, more commonly accepted smoking cessationaids. In a patient who has relapsed several times, combination therapy may be an option. Adverseevents with nortriptyline are anticholinergic effects, such as dry mouth and eyes, constipation, andorthostatic hypotension. Notably, nortriptyline is less expensive than brand-name bupropion.Upcoming Treatment OptionsAlthough pharmacotherapy options for smoking cessation are more numerous than ever before, itis important to realize that the overall efficacy of these modalities is much less than optimal. Asour understanding of the factors associated with nicotine addiction increases, new therapies maygive smokers an even greater chance of quitting.Rimonabant is a cannabinoid-1 receptor antagonist undergoing review by the FDA for both weightloss and smoking cessation. The cannabinoid receptor system is involved with the reward andsatiety system in the nucleus accumbens. Thus, blockade of this system would decrease both thepsychological rewards of smoking and the need to smoke again. Nausea has been the mostcommon adverse effect reported.Varenicline is a partial nicotinic agonist that selectively binds to the alpha-4, beta-2 receptor. Thisreceptor is thought to have a large role in the addictive properties of nicotine. Adverse effects thusfar include nausea and abnormal dreams.
  • 169. As unlikely as it seems, several companies are developing vaccines that induce antibodiesagainst the nicotine molecule. Thus, nicotine would not be able to reach the central nervoussystem, and cigarettes would have a reduced or negligible effect.
  • 170. PHYSICAL ASSESSMENT SKILLSLaboratory data, data obtained during a patient history interview and information obtained fromthe physical examination are used to assess patient response to drug and non-drug therapy.THE PROCESSThe examination, usually conducted from the patient’s right side, follows a generally acceptedsequence that minimizes the number of changes in position by the patient and clinician. It isimportant to respect the patient’s privacy and minimize patient discomfort during examination.The physical examination consists of detailed patient evaluation using four fundamentaltechniques:• Inspection: visual surveillance (inspect the colour of the skin, the presence of lesions, trauma)• Percussion: determines the density of a specific area or part of the body either by tapping the body directly with the distal end of a finger (direct percussion) or by tapping a finger placed on the body (indirect percussion). The resultant sound is described using one of four notes: resonant (percussion over normal lung tissues), dull (percussion over solid organs such as liver), tympanic (percussion over the stomach) or flat (percussion over large muscles).• Palpation: using the hands to feel areas that cannot be seen. It is performed with the fingertips (to feel the lower edge of the liver), palms, or back of the hand (to assess temperature).• Auscultation: listening directly with the ear or indirectly with the aid of a device (stethoscope) to sounds that arise spontaneously from the body (breath sounds, heart sounds, bowel sounds).EQUIPMENTEquipment PurposeFlashlight Assess papillary reflexes; aid in the inspection of the oropharynx and skinOphthalmoscope Perform funduscopic examinationOtoscope Assess external ear canal and tympanic membraneTongue depressor Inspect oropharynxWatch (digital or sweep second hand) Assess heart and respiratory rateThermometer Obtain body temperatureStethoscope Assess cardiovascular, pulmonary and abdominal systemsSphygmomanometer Obtain blood pressureReflex hammer Assess neurologic functionTuning fork Assess neurologic functionSigns and symptoms
  • 171. When interpreting a history and physical examination, clinical signs and symptoms are oftendescribed. A sign refers to objective information gathered by the examiner during the physicalexamination (heart murmur, ankle oedema). A symptom refers to subjective information gatheredfrom the patient while obtaining the history (nausea, pain). The patient’s descriptions of symptomsmay be scrutinized further, clarified, and quantified by additional questioning.Organization of the physical examinationRecorded physical examinations are typically arranged in the following order: • General appearance • Vital signs • Skin, hair and nails • Lymph nodes • HEENT (head, eyes, ears, nose and throat) • Neck • Back • Chest (general, lungs, and breast examination) • Cardiovascular system • Abdomen • Genitourinary and rectal system • Peripheral vascular system • Musculoskeletal system • Neurological system
  • 172. General appearanceThis portion of the physical examination provides brief description of the patient’s overallappearance. In geriatric patient, it is an important assessment and may reflect the individual’sgeneral health, nutritional status, and general cognitive function. The patient’s posture, facialexpression, hygiene, level of distress, and mental status may be noted there as well.Vital signsJust as name implies, a patient’s vital signs are critical in assessing the clinical status of thepatient and the acuity of a given problem. Vital signs include body temperature, pulse, bloodpressure, and respiration. In addition, height and weight are typically recorded in this section.Body temperature (T)Body temperature is measured in the mouth, rectum, or axilla. Identification of the route isessential for interpretation of the results. Normal adult body temperatures are as follows: • Mouth: 35.8º – 37.3º C • Axillary: 35.3º – 36.8º C • Rectal: 36.3º – 37.8º CFever is associated with infection, inflammation, or cancer. The elderly and immunosuppressedpatient may not mount a normal febrile response. Fever may also be an adverse drug reaction(e.g., neuroleptic malignant syndrome or drug fever from Amphotericin B).The normal temperature in children ranges by age, with neonates’ temperatures beingapproximately 1ºF higher than adolescents in total. There is also a diurnal variation of 1-3º,highest in early evening and lowest close to midnight.Pulse (P)Clinicians typically assess the rate, rhythm, and strength of the pulse. The normal heart rate (HR)is 60-100 beats/min (BPM). Deviation from normal, particularly tachycardia (>100 BPM), is asensitive indicator of disease. Bradycardia (< 60 BPM) can be normal in a well-conditioned athleteand can be abnormal in a patient with hypothyroidism. A HR less than 60 BPM can also indicateincreased vagal tone, cardiac conduction defects, or the effect of drugs with a negativechronotropic effect (e.g., β-blockers, digoxin). Tachycardia has a broad differential diagnosisencompassing a myriad of conditions including pain, anxiety, volume depletion, tachyarrhythmias,and pulmonary embolism. Tachycardia can also be a side effect of drugs (e.g., sympathomimeticand anticholinergic medications).Rhythm is difficult to assess accurately without the aid of electrocardiographic monitoring;however pulse’s regularity or irregularity can be assessed. A pulse characterized as “irregularly
  • 173. irregular” may indicate atrial fibrillation, whereas occasional “regularly irregular” beats mayindicate premature atrial or ventricular contraction.Blood Pressure (BP)Blood pressure can vary according to age, race, and gender. It can even vary from minute tominute in any given patient. Adult blood pressure greater than 140/90 mm Hg on more than oneoccasion is considered abnormal. Hypertension is associated with stroke and renal failure.Systolic hypertension, particularly in elderly, is also a predictor of vascular risk. A systolic BP dropof greater than 10 mm Hg or a pulse rise of greater than 10-20 BPM can reflect intravascularvolume depletion, autonomic dysfunction, antihypertensive drug therapy, or a side effect ofmedications (e.g., anticholinergics and antidepressants).The peripheral blood pressure is measured with stethoscope, blood pressure cuff, and mercury oraneroid sphygmomanometer. Both types of sphygmomanometers are accurate and easy to use;however, the mercury column must be kept vertical and the meniscus read at eye level. Aneroidsphygmomanometer must be recalibrated periodically.Use an appropriately sized cuff. Cuffs that are too short or too narrow falsely elevate the bloodpressure. Place the arterial portion of the cuff directly over the brachial artery with the bottom ofthe edge approximately 2.5 cm above the antecubital crease; palpate for the brachial artery beforepositioning the cuff on the arm. Support the patient’s arm at the level of the heart; tensed musclesfalsely elevate the blood pressure. Place the stethoscope over the brachial artery and inflate thecuff to about 20-30 mm Hg over the predicted systolic blood pressure. Deflate the cuff slowly.There are no audible sounds (Korotkoff sounds) until the cuff pressure approximated the systolicblood pressure; the systolic blood pressure is the pressure at which at least two Korotkoff soundsare audible. As the pressure falls, the sounds become louder and then slowly diminish beforedisappearing altogether. The diastolic pressure is the pressure at which the beats are no longeraudible. Depending on the clinical situation, it may be necessary to obtain the blood pressure inboth arms or in more than one body position (i.e., sitting and standing, sitting and supine). Do notreinflate the cuff after partial deflation; cuff reinflation causes venous congestion and inaccurateblood pressure assessment.Respiratory rate (RR)The rate and pattern of breathing are assessed and can reflect cardiopulmonary or neurologicdisease. A normal adult breathes at a rate of 12-18 respirations/min. Tachypnoea (RR>20respirations/min) can be caused by anxiety, pain, cardiopulmonary disease, acidosis, or salicylate
  • 174. toxicity. Bradypnoea (RR< 10 respirations/min) can be a sign of drug-induced respiratorydepression such as that associated with opiates.Cheyne-Stokes breathing is a periodic breathing characterized by periods of apnoea alternatingwith a series of respiratory cycles in which the rate and amplitude increase to a maximum (i.e.,hyperpnoea or deep rapid breathing). Cheyne-Stokes breathing occurs in patients with braindamage, patients with congestive heart failure (CHF), and in normal persons at high altitude.Kussmaul’s respirations are deep irregular respirations that occur independent of the rate. Itoccurs in diabetic ketoacidosis and hyperventilatory respiratory compensation for the metabolicacidosis.Height and weightHeight and weight can be used together to calculate the body surface area (BSA) and lean bodyweight (LBW). Day-to-day variation in body weight reflects changes in total body weight (TBW),which is important in assessing the hydration and fluid status of the patient or for assessingresponse to diuretic therapy. Long-term weight loss (>10% body weight) may indicate nutritionaldeficiency in the elderly or an eating disorder.SKINThe skin is evaluated using inspection and palpation.Inspection. Inspect the skin for colour (pallor, cyanosis, redness, and yellowness), lesions,trauma, or other abnormalities. Inspect the nails and nail beds for clubbing, cyanosis, or trauma.Note the distribution, amount and texture of the body hair.Palpation. Palpate the skin for turgor (hydration status), moistness, temperature (warm, cool),texture (rough, smooth), thickness, mobility and oedema.HairHair is considered a skin appendage. It is described according to texture (e.g., dry and coarse asin hypothyroidism) and distribution. Hirsutism (the growth of hair in women in male pattern) can bedue to androgen excess syndromes, corticosteroids and Cushing’s syndrome, oral contraceptives,and androgenic medications. Hypertrichosis (increased hair growth, particularly on the face) is anadverse effect of medications such as minoxidil and cyclosporine. Alopecia, or hair loss, can occurduring or after can chemotherapy.Inspection. Inspect the hair for quantity, texture and distribution.
  • 175. Palpation. Palpate the hair for the texture (coarse, fine, dry, oily).NailsNails are considered a skin appendage. Clubbing is the selective bullous enlargement of the distalsegment of the digit due to an increase in soft tissue and is associated with flattening of the anglebetween the nail and the nail base. It can be hereditary or idiopathic and is associated with avariety of conditions, including cyanotic heart disease and pulmonary disorders (e.g., COPD,cystic fibrosis and lung cancer). Pitting and ridging of the nails is another common finding and ischaracteristic of psoriasis. Beau’s lines (horizontal ridge of the nails) can occur duringchemotherapy.Lymph nodesLymph nodes are not usually palpable, unless enlarged.Enlargement can be due to variety ofdisorders including infections, neoplasia, immunologic disorders and other illnesses.Rarely, phenytoin produces a pseudolymphomatous enlargement.Lymph nodes are described according to their size, location, firmness, mobility and tenderness.Tender nodes suggest infection, whereas firm, nontender, immobile nodes suggest malignancy.Shotty nodes are small nodes that feel “like buckshot” underneath the skin and are not necessarilypathologic.HEAD AND NECKThe structures of the head and neck (skull, scalp, face, neck, nose, ears, mouth, pharynx andeyes) are evaluated through inspection and palpation; percussion and auscultation are rarelyindicated. Visual acuity, hearing and facial and ophthalmic reflexes are tested when clinicallyindicated.SkullInspection. Inspect the skull for size, contour, shape and evidence of trauma.Palpation. Palpate the skull for lumps, bumps, and evidence of trauma.ScalpInspection. Inspect the scalp for lesions and scales.FaceInspection. Inspect the face for expression, symmetry, movement, lesions, and oedema.
  • 176. NeckInspection. Inspect the neck for symmetry, masses, and enlargement of the parotid andsubmaxillary glands and lymph nodes. Note the position and size of the sternomastoid musclesand the carotid arteries and the position of the trachea.Palpation. Palpate the thyroid gland for size, shape, symmetry, tenderness, and nodules. Palpatethe lymph nodes for size, shape, mobility, and tenderness.NoseInspection. Inspect the external nose and nasal cavity for symmetry, inflammation, and lesions.Palpation. Palpate the frontal, ethmoid, and maxillary sinuses for tenderness.EarThe inner ear contains specialized structures to transmit sound via the auditory branch of 8thcranial nerve and balance via the vestibular branch of the 8th cranial nerve.Damage to this apparatus (from Aminoglycosides, Frusemide, or cisplatin) can manifest ashearing loss or vestibular dysfunction.Inspection. Inspect external ear for lesions, trauma, size, and contour. Inspect the ear canal andtympanic membranes (TM) with otoscope. Inspect the canal for foreign bodies (insects),discharge, colour, and oedema. Inspect the tympanic membrane for colour, bulging, perforation,and air-fluid levels.Palpation. Palpate the external ear for nodules.HearingA general but relatively inaccurate assessment of hearing is obtained by testing, one ear at a time,the ability of the patient to hear a sequence of equally accented syllables (e.g., 3- 5- 2- 4)whispered from a distance of a couple of feet. The Rinne test compares bone and air conduction.Place the tip of a tuning fork on the mastoid process behind the ear; this tests bone conduction.Instruct the patient to signal when he/she no longer hears the vibrating fork. Remove the fork fromthe mastoid process and hold the prongs in front of but not touching the ear canal; this tests airconduction. Normally, air conduction is better than bone conduction; that is, the patient can hearthe vibrating tuning fork when the tuning fork is moved from the mastoid process to in front of theear canal.Mouth and Pharynx
  • 177. Inspection. Inspect the lips and mucosa for colour, ulcerations, hydration and lesions. Inspect theteeth and gums for colour, bleeding, inflammation, caries, missing teeth, ulceration and lesions.Inspect the hard palate for colour, architecture, symmetry, ulceration and lesions. Note themovement of soft palate when patient says “ah”. Inspect the tonsils and posterior palate for colour,oedema, ulcerations, exudates, and lesions. Inspect the top, sides, and bottom of the tongue forcolour, symmetry, ulcerations, and lesions. Note the odour of the breath.EyesInspection. Inspect the external and the internal structures of the eyes, and if indicated, assessvisual acuity (VA), visual fields (VF), the external eye, the extraocular muscles (EOM) andpapillary responses. Obtain a general assessment of the visual acuity by asking the patient toread a sentence or two from any printed material. The snellen eye chart provides a more accurateassessment of the visual acuity.Decreases visual acuity with aging is a common geriatric problem and may compromise activitiesof daily living. Visual fields can only be grossly tested at the bedside. The conjunctiva of theexternal eye is inspected for inflammation, mattering, and exudates. The presence of conjunctivalpallor may indicate anaemia.Test the peripheral visual fields with the confrontation technique. Bring a small object from thepatient’s visual periphery into the patient’s field of vision from several different directions.Inspect the iris and the pupil for the size, shape, and equality. Assess the iris for abnormalpigments or deposits. Test the pupillary reaction to light by briefly flicking a light on the pupil andnoting the direct and consensual (opposite eye) response.Inspect the fundi with the ophthalmoscope. Select the appropriate aperture.Inspect the retinal blood vessels, optic disc, physiologic cup, macula, and retina through theophthalmoscope for lesions.Chest and lungsAssessment of the chest and the lungs requires a clear understanding of pulmonary anatomy,landmarks, and reference points. The ribs, clavicle, scapula, and vertebrae serve as usefullandmarks. Count ribs on the anterior chest by placing a finger in the substernal notch and slidingthe finger from the substernal notch left or right to the space between the first and the second ribs;count the intercostals spaces or ribs from that point.
  • 178. Inspection. Inspect the chest throughout at least one complete inspiratory-expiratory cycle. Notechest wall abnormalities, accessory muscle use, the anteroposterior diameter, and skeletalabnormalities.Percussion. Percuss over intercostals spaces to assess lung density. Percussion over normallung tissue creates a loud, low-pitched, resonant note. Percussion over areas of lung withincreased air volume (e.g., emphysema) creates a very loud, low-pitched, hyperresonant note.Areas of consolidation (fluid) produce a dull or flat percussion note; shifting dullness is associatedwith freely moving fluid within the pleural cavity. Assess all lobs, comparing the right and the leftlobes.Percuss to determine the diaphragmatic location and excursion. Determine the location of eachdiaphragm with the lungs fully expanded and emptied; the difference between the two positions isdiaphragmatic excursion. Percuss down the posterior chest between the vertebral column and thescapula from about the 6th rib downward with the lung fully expanded, repeat with the lungsempties. Normal diaphragmatic excursion is about 3 cm for females and 5-6 cm for males; theright diaphragm is slightly higher than the left.Palpation. Palpate the chest masses, pulsations, crepitation, and tactile fremitus. To assess fortactile fremitus, place the palm of the hand on the chest and have the patient say “99” or “1-2-3”Auscultation. Auscultate the lung with a stethoscope. On the posterior chest, auscultate betweenthe scapulae and vertebral column. Place diaphragm of the stethoscope flat against the chest walland instruct the patient to breathe deeply and slowly through the mouth each time the stethoscopetouches the skin.Breath sounds are described as tracheal, bronchial, bronchovesicular, or vesicular. Breath soundsare distinguishable through auscultation over areas of the lungs that normally produce the sounds(trachea, large central bronchi, and small airways). These sounds are considered abnormal ifheard over other areas of the lung. Other abnormal breath sounds include wheezes, rhonchi,stridor, and crackles. A pleural friction rub, created when the visceral and parietal pleurae rubtogether, sounds like creaking leather and is heard best at the base of the lung.Cardiovascular System (CVS)Inspection. Inspect the chest for visible cardiac motion. Estimate the jugular venous pressure(JVP) and assess the jugular venous waveforms by observing pulsations in the jugular vein withthe patient supine and the head of the bed elevated.
  • 179. Palpation. Palpate for the point of maximal impulse (PMI), local and general cardiac motion, andcardiac thrills. The PMI normally has a diameter of 2 cm and is located within about 10 cm of themidsternal line; use the fingertips to locate PMI. Palpate for local and general cardiac motion withthe fingertips with the patient in a supine position. Palpate for the radial, carotid, brachial, femoral,popliteal, posterior tibial, and dorsalis pedis peripheral pulses. Rate the strength of the pulse asnormal, diminished, or absent.Auscultation. Auscultate the heart with a stethoscope. Use the diaphragm to assess higher-pitched sounds; apply the diaphragm tightly to the skin. Use the bell loosely to the skin. Heartsounds are very soft; it may help to listen in a quiet area or close the eyes to reduce conflictingstimuli.The first heart sound (S1), created by mitral and tricuspid valve closure, is loudest at the cardiacapex. The second sound (S2), created by the aortic and pulmonic valve closure is loudest at thebase of the heart. It can be “split” into distict aortic and pulmonic components by deep inspiration(physiologic splitting) or disease (e.g., pulmonary hypertension). The third sound (S3), anabnormal sound associated with volume overload, is a soft sound heard just after S2. The fourthsound (S4), an abnormal heart sound associated with pressure overload, is a soft sound heard justbefore S1.Other abnormal heart sounds include opening snaps (associated with mitral stenosis), ejectionclicks (associated with sudden dilation of the aorta and the pulmonary artery), and midsystolicclicks (associated with floppy mitral valves). Gallops are exaggerated normal diastolic sounds;friction rubs are associated with pericarditis.Murmurs (abnormal heart sounds created by turbulent flow across a valve or the septum and bydiseases such as anaemia and hyperthyroidism) are described according to their timing in thecardiac cycle (systolic murmurs occur between S1 and S2; diastolic murmurs occur between S2and S1), loudest location, radiation, shape, intensity and pitch or quality of sound.Auscultation is also used to detect vascular murmurs, known as bruits. Bruits (sounds made byturbulent blood flow) are heard over vessels with constricted lumens. The carotid and femoralarteries are routinely assessed for bruits.AbdomenInspection. Inspect the abdomen for the appearance of the skin, umbilicus, and abdominalcontour; note visible aortic and hepatic pulsations, peristaltic waves, and fluid shifts. Free fluid in
  • 180. the peritoneal cavity may shift with position, causing bulging at the flanks when the patient issupine.Auscultation. Auscultate the abdomen for bowel sounds and abdominal bruits. Bowel sounds,produced by the movement of fluid and air in the bowel, vary from low rumbles in loosely stretchedintestines to high-pitched tinkling sounds in tightly stretched intestines. Bowel sounds audiblewithout a stethoscope are called borborygmi. Normal peristaltic movement creates normal bowelsounds; bowel sounds are absent if there is no peristalsis. Listen on one quarter to screen forbowel sounds. Depending on the clinical situation, it may be necessary to listen for bowel soundsin all four quadrants. Listen for bruits over the aorta, right and left renal arteries, right and left iliacarteries, and right and left femoral arteries; friction rubs may be heard over the liver and spleen.Percussion. Percuss to determine the liver span and to differentiate between abdominal fluid andair. Percussion over the liver produces a dull note; percussion over air-filled loops of bowelproduces a hallow tympanic note. The normal live span along the right midclavicular line is about10 cm. Determine the liver span by percussing down the right midclavicular starting at midchest.Palpation. Palpate tender or rigid areas with light palpation; use the pads of the fingertips withlight pressure. Use deep palpation to determine the outlines of the abdominal organs and toassess the size, shape, mobility and tenderness of the lymph nodes.Palpate for the liver edge using deep palpation below the right costal margin during full inspiration.Place the left hand under the back on the posterior 12th rib along the iliac crest. Place the righthand in the right upper quadrant parallel and lateral to the rectus muscle and a couple of inchesbelow the lower margin of dullness as identified on percussion. The liver edge, normally smooth,firm, and regular, slides over the fingertips as the liver is pushed downward by the expandinglungs.The kidneys may be palpable on deep palpation, but the normal-sized spleen, duodenum, andpancreas cannot be palpated. The tip of an enlarged spleen may be palpated near the left 10th ribjust posterior to the midaxillary line. Intraabdominal structures may not be palpable if the abdomenis obese or distended by fluids. Abdominal rigidity may be present if the abdomen is tender.Musculoskeletal SystemInspection. Inspect the musculoskeletal system for symmetry, proportion, and musculardevelopment; note the curvature of the spine. Observe the gait; stance; and ability to stand, sit,rise from a sitting position, and grasp objects. Inspect the muscles for symmetry.
  • 181. Palpation. Palpate the large and the small joints. Assess joint range of motion. Decreased rangeof motion is associated with arthritis, fibrosis in or around the joint, tissue inflammation around thejoint, and fixed joints. Increased range of motion indicates increased joint mobility and may be asign of joint instability. Assess joint tenderness by gently palpate in and around the joints forabnormalities such as warmth, tenderness, crepitation, and deformities.Neurological systemExamination of the nervous system includes evaluation of the mental status, cranial nerves, motorand sensory function, coordination, deep tendon reflexes (DTRs), and gait.
  • 182. ‫التشريعات الصيدلية‬ ‫"الئحة تقاليد المھنة"‬ ‫"الباب األول"‬ ‫شعار الصيادلة والعالقة بينھم‬ ‫مادة 1 : شعار الصيادلة االخالص والتضحية فى سبيل خدمة المريض‬‫مادة 2: يجب أن تكون العالقات بين الصيادلة على أساس من التعاون على أداء الواجب ويعملوا فيما بينھم عل ى تنمي ة روح‬ ‫ھذا التعاون.‬ ‫مادة 3: على الصيدلى أال يسئ إلى زمالئه وذلك باالنتقاص من مكانتھم العلمية أو األدبية أو المادية أو بأية وسيلة أخرى .‬‫م ادة 4: على الصيدلى الذى يعمل بالمؤسسات الصيدلية المختلفة أيا كان نوعھا أن ال يزاحم زمالءه مزاحمة غير مشروعة‬ ‫سواء كان ذلك بطريقة مباشرة أو غير مباشرة وعليه أن يراعى األحكام اآلتية:‬‫- أن يتب ع مواعي د العم ل بالمؤسس ات الص يدلية والقواع د التنظيمي ة المنص وص عليھ ا ف ى ق رار وزي ر الص حة‬ ‫العمومية الخاص بمواعيد اإلجازات السنوية والراحة األسبوعية والخدمة الليلية .‬ ‫- أن يمتنع عن إعداد المؤسسة أو استعمالھا فى غير األغراض المرخصة لھا.‬‫- أن يمتنع عن استخدام الوس ائل غي ر المش روعة لجل ب العم الء وع ن الدعاي ة لھ ا بطريق ة تتن افى وكرام ة المھن ة‬ ‫وعن التحايل بأية طريقة للتخلف عن تنفيذ األحكام.‬ ‫- أن يمتنع عن السعى بأى وسيلة الجتذاب موظفى المؤسسات األخرى فى مؤسسته.‬ ‫- أال ينتحل ميداليات أو دبلومات أو جوائز على غير الحقيقة.‬ ‫- أال يغتصب االسم التجارى لصيدلى آخر ويقلد العالمة التجارية أو الرسم.‬ ‫" الباب الثانى"‬ ‫العالقة بين الصيادلة وأعضاء المھن الطبية األخرى‬ ‫مادة 5: يجب على الصيدلى أن يتعاون فى نطاق مھنته مع األطباء وأن يقدم لھم المعونة الفنية كلما طلب منه.‬‫م ادة 6: يجب على الصيدلى أن يحرص على كرامة األطباء وأال يحرج أحدھم باالنتقاص من مكانته العلمية أو ب ث الدعاي ة‬ ‫بين عمالئه ضد اى طبيب.‬‫مادة 7: ال يج وز للص يدلى أن يعق د اتفاق ا م ن أى ن وع ك ان م ع أى طبي ب لص رف األدوي ة لمرض اه لش روط خاص ة أو أن‬ ‫يتعاون مع أدعياء الطب بأى صورة كانت.‬‫مادة 8: ال يجوز للصيدلى أن يستبدل بالدواء المبين بالتذكرة الطبية دواء أخر ولو كان بديال له إال بعد موافقة الطبي ب ال ذى‬ ‫حررھا .‬‫م ادة 9: عل ى الص يدلى إذا كش ف خط ا ف ى الت ذكرة الطبي ة – أن يمتن ع ع ن ص رف ال دواء ويج وز إص الح الخط أ إذا ك ان‬ ‫االتصال بالطبيب الذى حرر التذكرة ممكنا على ان يثبت ذلك فيھا .‬ ‫" الباب الثالث "‬ ‫العالقة بين الصيادلة والجمھور‬‫مادة 01: يجب على الصيدلى أن يحرص على كرامة المظھ ر وأن يراع ى كرام ة المھن ة وأن يص ون كرام ة مؤسس ته أم ام‬ ‫الجمھور بوجه عام وعمالئه بوجه خاص وأن يحسن معاملة المترددين على مؤسسته.‬‫مادة 11: يجب أال تكون أسعار األدوية موضع نقاش ب ين الص يدلى وعمالئ ه ,. كم ا يج ب أال تك ون الت ذكرة الطبي ة موض ع‬ ‫بحث فى صالحية الدواء بين الصيدلى والطبيب أو من يحمل تلك التذكرة.‬ ‫" الباب الرابع "‬ ‫العالقة بين الصيادلة والنقابة‬ ‫مادة 21: يجب أن يتعاون الصيدلى مع نقابته فى تنفيذ أحكام القوانين واللوائح ذات االرتباط بتقاليد المھنة وآدابھا.‬
  • 183. ‫مادة 31: على الصيدلى أن ينفذ القرارات التى تصدرھا النقاب ة أو ھيئتھ ا التأديبي ة وال يج وز للص يدلى مقاض اة أح د زمالئ ه‬‫بسبب يتصل بالمھنة قبل الحصول على أذن كتابى من مجلس النقاب ة ويج وز ف ى أح وال االس تعجال أن يص در األذن م ن‬ ‫النقيب .‬ ‫مادة 41: على الصيدلى أن يبلغ النقابة عن المؤسسات التى يزاول المھنة بھا وأن يخطرھا عن كل تغييريطرأ.‬ ‫مادة 51: يجب على الصيدلى ان يخطر النقابة بكل ما يقع من الغير ويعتبر ماسا بكرامة المھنة .‬‫مادة 61: ال يجوز للصيدلى أن يعلن فى الجرائد عن حاجته إلى عمل بل يتصل بمجلس النقابة إلرشاده إلى المحال الخالي ة .‬ ‫وعلى السادة مديرى الصيدليات والمؤسسات الصيدلية االتصال بالنقابة عند حاجتھم إلى صيادلة.‬ ‫"الباب الخامس"‬ ‫فى الئحة تقاليد المھنة‬ ‫أحكام عامة‬ ‫مادة 71: على الصيدلى أن يراعى المھنة وآدابھا وأن يعمل على رفع مستواھا.‬ ‫مادة 81: ال يجوز للصيدلى إفشاء األسرار التى أؤتمن عليھا بحكم مھنته إال فى الحدود المبينة قانونا .‬ ‫مادة 91: على الصيدلى أن يشترى المواد الدوائية من المؤسسات الصيدلية المرخص لھا فى ذلك.‬ ‫مادة 02: ال يجوز للصيدلى أن يعرض األدوية للبيع بواسطة الباعة المتجولين ولو كانت األدوية خالية من المواد السامة.‬ ‫مادة 12: الصيدلى ھو المسئول عن تنفيذ أحكام القوانين واللوائح المتعلقة بمزاولة المھنة وأحكام ھذه الالئحة فى صيدليته.‬ ‫مادة 22: لمجلس النقابة فى جميع األحوال أن يكلف الصيدلى اإلمتناع عن أى مخالفة لھذه الالئحة فورا وإزالة المخالفة.‬ ‫"الباب السادس"‬ ‫التأديب‬ ‫المحكمة التأديبية:‬ ‫)أ( يح ال للھيئ ات التأديبي ة بالنقاب ة ك ل عض و م ن غي ر م وظفى الحكوم ة أت ى أم را مخ ال بش رفه أو ماس ا‬ ‫باستقامته أو أس اء أو أھم ل ف ى أداء مھنت ه ول و ل م يص در حك م ض ده أو يك ون ق د خ الف حكم ا م ن األحك ام‬ ‫الخاصة بالدمغة الطبية أو خالف حكما من أحكام الئحة تقاليد المھنة .‬ ‫)ب( أما األعضاء من موظفى الحكومة فيحاكمون أمام مجالسھم التأديبية الخاص ة ف ى جمي ع م ا ينس ب إل يھم‬ ‫فى دائرة عملھم الحكومى من مخالفات لھا عالقة بأعمالھم الحكومية وأمام مجلس النقابة فيما يقع منھم بسبب‬ ‫مزاولة مھنتھم فيما عدا ذلك.‬‫)ج( كذلك يحاكم أمام الھيئات التأديبية للنقابة كل عضو صدر ضده حكم نھائى بعقوبة أو بتعويض من محكمة جنائية‬‫أو مدنية أو تأديبية مختصة ألمور استقامته أو ألية مخالفة فى مزاولة مھنته, واعماال لھذا النص تقوم وزارة الص حة‬‫بإبالغ نقابة الصيادلة عن جميع المحاضر التى تحرر للصيادلة من مخالفات القوانين الصيدلية لمح اكمتھم تأديبي ا إل ى‬ ‫جانب محاكمتھم جنائيا أمام المحاكم المختصة .‬ ‫العقوبات التأديبية:‬ ‫العقوبات التاديبية ھى :‬ ‫- اإلنذار والتوبيخ والغرامة لغاية عشرين جنيھا تدفع لخزينة النقابة‬ ‫– اإليقاف لمدة ال تتجاوز سنة‬ ‫- شطب االسم من سجل وزارة الصحة ومن جدول النقابة .‬‫وللھيئات التاديبية أن تحكم بأى عقوبة إلى جانب المحاكمات الجنائية األخرى التى تأخذ طريقتھا المرسوم وللھيئ ة أن‬ ‫تحكم باى حكم من العقوبات سالفة الذكر دون التقيد بتسلسلھا.‬ ‫ھيئات التأديب:‬ ‫تشكل ھيئات التأديب من الدرجة األولى من:‬‫وكيل النقابة أو من ين وب عن ه م ن مجل س النقاب ة وعض وين يعينھم ا مجل س النقاب ة م ن أعض ائه وموظ ف كبي ر م ن‬ ‫صيادلة وزارة الصحة وأستاذ أو أستاذ مساعد من كلية الصيدلة .‬
  • 184. ‫وتشكل الھيئات التاديبية من الدرجة الثانية من:‬‫النقي ب أو م ن ين وب عن ه م ن مجل س النقاب ة وعض وين يعينھم ا مجل س النقاب ة م ن أعض ائه ومستش ار م ن محكم ة‬ ‫االستئناف ومديرا ألحد أقسام الصيدلة بوزراة الصحة‬ ‫وتشكل الھيئة التأديبية من الدرجة الثالثة من احدى دوائر محكمة النقض .‬ ‫لجنة التحقيق:‬‫تج رى التحقيق ات بمعرف ة لجن ة تؤل ف م ن عض وين م ن أعض اء مجل س النقاب ة ينتخبھم ا المجل س ومن دوب م ن قس م‬ ‫الرأى بمجلس الدولة يمثل الرأى القانونى.‬ ‫إجراءات التأديب :‬‫يجرى التأديب أمام لجنة التحقيق ويحول على مجلس النقابة برأى اللجنة وترفع الدعوى أمام ھيئ ة التأدي ب بن اء عل ى‬‫قرار المجلس ويتولى أحد أعضاء لجنة التحقيق االتھام أمام ھيئة التأديب ويعل ن الم تھم بالحض ور أم ام ھيئ ة التأدي ب‬‫بكت اب موص ى علي ه بعل م الوص ول قب ل موع د الجلس ة بخمس ة عش ر يوم ا عل ى األق ل موض حا ب ه الموع د وال تھم‬‫المنسوبة إليه ويجوز للمتھم أن يحضر بنفسه أو يقدم دفاعه كتابة أو يوكل من يشاء للدفاع عن ه وتعل ن الق رارات إل ى‬‫المحكوم عليه على ي د محض ر ف ى م دى عش رة أي ام م ن ت اريخ ص دورھا أو بتس ليمھا للمحك وم علي ه بإيص ال كت ابى‬ ‫ويجوز المعارضة فى الحكم الغيابى فى ظرف 03 يوم من تاريخ إعالن القرار بتحرير يودع بسكرتارية النقابة.‬‫ويجوز للمتھم أو ھيئات التحقيق أو التأديب تكليف حضور الشھود ويبل غ مجل س النقاب ة النياب ة العمومي ة ع ن الش ھود‬ ‫فى حالة االمتناع عن الحضور أو أداء شھادة زور لتطبيق أحكام القوانين الجنائية.‬ ‫قرارات ھيئة التأديب )تبليغھا واستئنافھا(:‬‫تنعقد ھيئة التأديب فى جلسة غير معلنة ويص در الق رار بع د س ماع طلب ات االتھ ام وال دفاع بأغلبي ة األص وات إال ف ى‬‫قرار محو االسم فيجب أن يكون بأغلبية أربع أصوات ويكون القرار مسببا وتقرر الھيئة أسبابه قبل النطق به ويجوز‬‫لمن صدر ضده حكم أن يتظلم أمام ھيئ ة الدرج ة الثاني ة ولم ن ص در ق رار بمح و اس مه م ن الس جل وم ن الج دول أن‬‫يتظلم أمام ھيئة الدرجة الثالثة فى موعد أقصاه ثمانية وثالثين يوما م ن ت اريخ ص دور الحك م إن ك ان حض وريا وم ن‬‫تاريخ انتھاء المعارضة إن كان غيابيا وحكم الدرجة الثانية نھائى إال إذا كان محو االسم فيجوز استئنافه أم ام الدرج ة‬‫الثالثة وكذلك لمجلس النقابة أن يستأنف فى المواعيد المقررة. وتبلغ الق رارات إل ى وزارة الص حة ف ى ظ رف أس بوع‬ ‫من تاريخ صدورھا.‬‫وينشر منطوق الحكم دون األسباب فى الجريدة الرسمية فى حال ة الحك م ب الوقف أو بمح و االس م. ولم ن ص در الحك م‬‫بمحو اسمه من الجدول حكما نھائيا أن يلتمس من ھيئة الدرجة الثالثة التأديبية إلعادة النظ ر ف ى أم ره إذا توص ل إل ى‬‫أدلة جديدة على برائته ويجوز تجديد الطلب بأدلة جديدة بعد مضى سنة على األقل وال يتج اوز التجدي د م رتين, وبع د‬‫مضى 5 سنوات يجوز له أن يتقدم لمجلس النقاب ة ب أن الم تھم ق د ص لح م ن ش أنه ليع ود إل ى العم ل كعض و أم ين ف ى‬ ‫مھنته.‬ ‫تحقيق النيابة العمومية مع أعضاء المھن الطبية:‬‫إذا اتھم عض و م ن أعض اء المھ ن الطبي ة بجناي ة أو جنح ة يج ب عل ى النياب ة العمومي ة إخط ار النقي ب قب ل الب دء ف ى‬‫التحقيق وعلى النقيب أن يحضر بنفسه أو من ينوب عنه من أحد أعضاء مجلس النقاب ة لمعاون ة الم تھم واب داء ال رأى‬ ‫الفنى فى التھمة الموجھة للعضو.‬‫وإذا رأت النيابة أن التھمة ال تستدعى المعاقب ة الجنائي ة وج ب عليھ ا إب الغ نتيج ة تحقيقھ ا لمجل س النقاب ة ھ ذا ع الوة‬ ‫على أن المحاكم الجنائية ال تعفى من المحاكمة التأديبية لنفس التھمة .‬ ‫القانون رقم 721 لسنة 5591 فى شأن مزاولة مھنة الصيدلة المعدل بالقوانين اآلتية:‬
  • 185. ‫2- القانون رقم 7 لسنة 6591‬ ‫1- القانون رقم 352 لسنة 5591‬ ‫4- القانون رقم 16 لسنة 9591‬ ‫3- القانون رقم 063 لسنة 6591‬
  • 186. ‫الفصل األول‬ ‫مزاولة مھنة الصيدلة‬‫م ادة 1: ال يج وز ألح د أن ي زاول مھن ة الص يدلة بأي ة ص فة كان ت إال إذا ك ان مص ريا أو م ن بل د تجي ز قوانين ه للمص رين‬ ‫مزاولة مھنة الصيدلة به وكان اسمه مقيد بسجل الصيادلة بوزارة الصحة العمومية وفى جدول نقابة الصيادلة.‬‫وتعتبر مزاولة مھنة الصيدلة ف ى حك م ھ ذا الق انون تجھي ز أو تركي ب أو تجزئ ة أى دواء أو عق ار أو نب ات طب ى أو م ادة‬‫ص يدلية تس تعمل م ن الب اطن أو الظ اھر أو بطري ق الحق ن لوقاي ة اإلنس ان أو الحي وان م ن األم راض أو عالج ه منھ ا أو‬ ‫توصف بأن لھا ھذه المزايا.‬‫مادة 2: يقيد بس جل وزارة الص حة العمومي ة م ن ك ان حاص ال عل ى درج ة البك الوريوس ف ى الص يدلة م ن إح دى الجامع ات‬ ‫المصرية أو من كان حاصال على درجة أو دبلوم أجنبى يعتبر معادال وجاز بنجاح االمتحان المنصوص عليه فى المادة.‬‫وتعتبر الدرجات أو الدبلومات األجنبي ة معادل ة لدرج ة البك الوريوس المص رية بق رار يص در م ن لجن ة مكون ة م ن أربع ة‬‫أعضاء يعينھم وزير الصحة العمومية على أن يكون اثنان منھم على األقل من الصيادلة األس اتذة بإح دى كلي ات الص يدلة‬ ‫ومن مندوب صيدلى يمثل وزارة الصحة العمومية .‬‫مادة 3: يكون امتحان الحاص لين عل ى ال درجات أو ال دبلومات األجنبي ة وفق ا لم نھج االمتح ان النھ ائى لدرج ة البك الوريوس.‬‫وعلى من يرغب فى دخول االمتحان أن يقدم إلى وزارة الصحة العمومية طلبا على النموذج المعد لذلك ويرف ق ب ه أص ل‬‫الدرجة أو الدبلوم الحاص ل علي ه أو ص ورة رس مية من ه والش ھادة المثبت ة لتلق ى مق رر الدراس ة أو أي ة وثيق ة أخ رى تق وم‬‫مقامھا وعليه أن يؤدى رسما لالمتحان قدره عشرة جنيھات ويرد ھذا الرسم فى حالة عدوله ع ن االمتح ان أو ع دم األذن‬ ‫له بدخوله.‬‫ويؤدى االمتحان باللغة العربية ويجوز تأديته بلغة أجنبية ويوافق عليھ ا وزي ر الص حة العمومي ة بش رط أن يك ون الطال ب‬‫ملما باللغة العربية قراءة وكتابة وإذا رسب الطالب فى االمتحان ال يجوز ل ه أن يتق دم إلي ه أكث ر م ن ث الث م رات أخ رى‬ ‫خالل سنتين وتعطى وزارة الصحة العمومية من جاز االمتحان بنجاح شھادة بذلك.‬‫م ادة 4: يج وز ل وزير الص حة العمومي ة أن يعف ى م ن أداء االمتح ان المنص وص علي ه ف ى الم ادة )3( المص ريين إذا ك انوا‬‫حاصلين على شھادة الدراسة الثانوية القسم الخاص أو ما يعادلھا وكانوا مدة دراستھم حسنى الس ير وم واظبين عل ى تلق ى‬ ‫دروسھم العلمية طبقا لبرنامج المعاھد التى تخرجوا منھا.‬‫م ادة 5: يقدم طالب القيد بالسجل إلى وزارة الصحة العمومية طلبا ملصقا عليه صورته الفوتوغرافية وموقعا عليه من ه يب ين‬‫أسمه ولقبه وجنسيته ومحل إقامته ويرفق به أصل شھادة الدرجة أو الدبلوم أو ص ورة رس مية من ه أو ش ھادة االمتح ان أو‬‫اإلعفاء منه حسب األحوال وإيصال تسديده رس م القي د بج دول نقاب ة الص يادلة وعلي ه أن ي ؤدى رس ما للقي د بس جل وزارة‬‫الصحة قدره)جنيه واحد( ويقيد فى السجل اسم الصيدلى ولقبه وجنسيته ومح ل أقامت ه بت اريخ الدرج ة أو ال دبلوم الحاص ل‬‫عليه والجھة الصادر عنھا وتاريخ شھادة االمتحان أو اإلعفاء منه حس ب األح وال وتبل غ ال وزارة نقاب ة الص يادلة إلج راء‬‫القيد فى سجل النقابة ويعطى المرخص إليه ترخيصا بمزاولة المھنة ملصقا عليه صورته وعليه حفظ ھذا المس تخرج ف ى‬ ‫المؤسسة التى يزاول المھنة فيھا عند أى طلب من مفتشى وزارة الصحة العمومية.‬‫م ادة 6: على الصيدلى إخطار وزارة الصحة العمومية بخطاب موصى عليه بك ل تغيي ر ف ى مح ل إقامت ه خ الل أس بوع م ن‬ ‫تاريخ حصول التغيير .‬‫مادة 7: كل قيد فى سجل الصيادلة بالوزارة يتم بطريق التزوير أو بطريق احتيالية أو بوس ائل أخ رى غي ر مش روعة يلغ ى‬‫بقرار من وزير الصحة العمومية ويشطب المقيد نھائيا منه. وتخطر نقاب ة الص يادلة والنياب ة العام ة ب ذلك. ويج ب إخط ار‬ ‫وزارة الصحة العمومية بكل قرار يصدره مجلسھا أو ھيئتھا التأديبية بوقف صيدلى عن مزاولة المھنة أو يشطب اسمه.‬‫م ادة 8: تتولى وزارة الصحة العمومية نشر الجدول الرسمى ألسماء الصيادلة المرخص لھم فى مزاولة المھنة وتق وم س نويا‬ ‫بنشر ما يطرأ عليه من تعديالت.‬‫م ادة 9: يجوز لوزير الصحة العمومية بعد أخذ رأى نقابة الصيادلة أن يرخص لصيدلى ال تت وافر في ه الش روط المنص وص‬‫عليھا فى المادة )2( فى مزاولة مھنة الصيدلة فى مصر للمدة الالزمة لتأدية ما تكلفه به الحكومة أو المؤسسات الص يدلية‬
  • 187. ‫الفصل الثانى‬ ‫المؤسسات الصيدلية‬ ‫1- تعريف‬‫م ادة 01: المؤسسات الصيدلية فى تطبيق أحكام القانون ھى الص يدليات العام ة والخاص ة ومص انع المستحض رات الص يدلية‬ ‫ومخازن األدوية ومستودعات الوسطاء فى األدوية ومحال االتجار فى النباتات الطبية ومتحصالتھا.‬ ‫2- أحكام عامة لكل المؤسسات الصيدلية‬‫مادة 11: ال يجوز إنشاء مؤسسة صيدلية إال بترخيص من وزارة الصحة العمومية ويجب آال يقل سن طال ب الت رخيص ع ن‬ ‫12 سنة.‬‫ويعتبر الترخيص شخصيا لصاحب المؤسسة فإذا تغير وجب على م ن يح ل محل ه أن يق دم طلب ا ل وزارة الص حة العتم اد‬ ‫نقل الترخيص إليه بشرط أن تتوافر فى الطالب الشروط المقررة فى ھذا القانون.‬‫مادة 21: يحرر طلب الترخيص إلى وزارة الصحة عل ى النم وذج ال ذى تع ده وزارة الص حة العمومي ة ويرس ل إل ى ال وزارة‬ ‫بخطاب مسجل بعلم الوصول مرفقا به ما يأتى :‬ ‫1- شھادة تحقيق الشخصية وصحيفة عدم وجود سوابق.‬ ‫2- شھادة الميالد أو أى مستند أخر يقوم مقامھا.‬ ‫3- رسم ھندسى من ثالث صور للمؤسسة المراد الترخيص بھا.‬ ‫4- اإليصال الدال على سداد النظر وقدره)خمسة جنيھات(.‬‫فإذا قدم الطلب مستوفيا أدرج فى السجل الذى يخصص لذلك ويعطى للطالب إيصال ويوض ح ب ه رق م ت اريخ قي د الطال ب‬ ‫فى السجل .‬‫م ادة 31: يرس ل الرس م الھندس ى إل ى الس لطة الص حية المختص ة للمعاين ة وتعل ن ال وزارة طال ب الت رخيص رأيھ ا ف ى موق ع‬‫المؤسسة فى موعد ال يجاوز ثالثين يوما من تاريخ قيد الطلب بالسجل المشار إليه ويعتبر فى حكم الموافق ة عل ى المواق ع‬‫ف وات الميع اد الم ذكور دون إب الغ الطال ب ب الرأى بش رط ع دم اإلخ الل بأحك ام الفق رة الثاني ة م ن الم ادة )03( م ن ھ ذا‬‫الق انون ف إذا أثبت ت المعاين ة أن االش تراطات الص حية المق ررة مس توفاة ص رفت الرخص ة خ الل ثالث ين يوم ا م ن ت اريخ‬‫المعاينة وإال وجب إعطاء الطالب المھلة الكافية إلتمامھا ثم تعاد المعاينة ف ى نھايتھ ا ويج وز منح ه مھل ة ثاني ة ال تتج اوز‬ ‫نصف المھلة األولى فإذا ثبت بعد ذلك أن االشتراطات لم تم رفض طلب الترخيص نھائيا.‬ ‫مادة 41: تلغى تراخيص المؤسسات الصيدلية فى األحوال اآلتية :‬ ‫1- إذا أغلقت المؤسسة بصفة متصلة مدة تجاوز سنة ميالدية .‬‫2- إذا نقلت المؤسسة من مكانھا إلى مكان أخر ما لم يكن النقل قد تم بسبب الھ دم أو الحري ق فيج وز االنتق ال ب نفس‬ ‫الرخصة إلى مكان آخر متى توفرت فيه الشروط الصحية المقررة.‬‫م ادة 51: يج ب عل ى ص احب الت رخيص الحص ول عل ى موافق ة وزارة الص حة العمومي ة عل ى ك ل تغيي ر ي ود إج راؤه ف ى‬‫المؤسسة الصيدلية وعليه أن يقدم طلبا مصحوبا بوصف دقيق للتعديالت المطلوب إجراؤھا ورسم ھندسى وعلي ه أن ينف ذ‬‫كافة االشتراطات المطلوبة ومتى تمت االشتراطات المطلوبة تؤش ر وزارة الص حة عل ى إج راء التع ديل عل ى الت رخيص‬ ‫السابق صرفه عن المؤسسة .‬‫م ادة 61: تخض ع المؤسس ات الص يدلية للتفت يش الس نوى ال ذى تق وم ب ه الس لطة الص حية المختص ة للتثب ت م ن دوام ت وافر‬‫االش تراطات المنص وص عليھ ا ف ى الم ادة )11( ف إذا أظھ ر التفت يش أنھ ا غي ر مت وافرة وج ب عل ى ص احب الت رخيص‬‫إتمامھا خالل المدة التى تحدد له بحيث ال تجاوز ستين يوما فإذا لم يتم خالل ھذه المھلة جاز لوزارة الصحة تنفي ذھا عل ى‬ ‫نفقته, وعلى صاحب الترخيص أداء رسم التفتيش السنوى.‬
  • 188. ‫م ادة 71: يجب أن يكتب اس م المؤسس ة الص يدلية واس م ص احبھا وم ديرھا المس ئول عل ى واجھ ة المؤسس ة بح روف ظ اھرة‬ ‫باللغة العربية.‬‫مادة 81: ال يجوز استعمال المؤسسة الصيدلية لغير الغرض المخصص لھا بموجب الترخيص المعطى لھ ا كم ا ال يج وز أن‬ ‫يكون لھا اتصال مباشر مع مسكن خاص أو محل مدار لصناعة أخرى أو منافذ تتصل بأى شئ.‬‫م ادة 91: يدير كل مؤسسة صيدلى مضى على تخرجه سنة على األقل أمضاھا ف ى مزاول ة المھن ة ف ى مؤسس ة ص يدلية ف إذا‬‫كان األمر يتعلق بص يدلية خاص ة أو مس تودع وس يط ج از إس ناد اإلدارة لمس اعد ص يدلى يك ون اس مه مقي دا بھ ذه الص فة‬ ‫بوزارة الصحة وليس لمدير المؤسسة الصيدلية أن يدير أكثر من مؤسسة واحدة.‬‫مادة 02: يجوز لمدير المؤسسة الصيدلية أن يستعين فى عمله وتحت مسئوليته بمساعد صيدلى ويك ون لمس اعد الص يدلى أن‬‫ي دير الص يدلية نياب ة ع ن م ديرھا إذا ل م يك ن بھ ا ص يدلى آخ ر وذل ك ف ى حال ة غي اب الم دير عنھ ا أثن اء راحت ه اليومي ة‬‫والعطلة األسبوعية واألعياد الرسمية أو مرضه أو غيابه بس بب قھ رى عل ى أال تزي د م دة الغي اب ف ى الح التين اآلخ رتين‬‫على أسبوعين فى العام الواحد الذى يبدأ من أول ين اير وعل ى أن يخط ر الم دير ال وزارة بتل ك النياب ة وبإنھائھ ا وف ى ھ ذه‬ ‫األحوال يخضع مساعد الصيدلى لجميع األحكام التى يخضع لھا مدير الصيدلية.‬‫م ادة 12: يص در وزي ر الص حة العمومي ة ق رارا بت أليف ھيئ ة تأديبي ة ابتدائي ة واس تئنافية لمس اعدى الص يادلة ويع ين الق رار‬ ‫أعضاء الھيئة والعقوبات التأديبية التى تحكم بھا واإلجراءات التى تتبع أمامھا.‬‫مادة 22: مدير المؤسسة الصيدلية مسئول عن مستخدمى المؤسسة من غير الصيادلة فيم ا يخ تص بتنفي ذ أحك ام ھ ذا الق انون‬‫وإذا ترك المدير اإلدارة وج ب إخط ار ال وزارة ف ورا بخط اب موص ى علي ه وعل ى ص احب المؤسس ة أن يع ين لھ ا ف ورا‬‫مديرا جديدا وإخطار وزارة الصحة العمومية باسمه مع إقرار منه بقبول إدارتھا وإال وجب على صاحبھا إغالقھا ف إذا ل م‬ ‫يغلقھا قامت السلطات الصحية بإغالقھا إداريا.‬‫وعلى مدير المؤسسة عند ترك إدارتھا أن يسلم م ا ف ى عھدت ه م ن الم واد المخ درة إل ى م ن يخلف ه ف ورا وعلي ه أن يح رر‬‫بذلك محضرا من ثالث ص ور موق ع علي ه م ن كليھم ا وترس ل ص ورة من ه إل ى وزارة الص حة وتحف ظ الثاني ة بالمؤسس ة‬‫للرجوع إليھا عند االقتضاء وتحفظ الصورة الثالثة لدى مدير المؤسسة الذى ترك العمل وإذا لم يعين مدير جديد للمؤسسة‬‫فعلى المدير الذى سيترك العمل أن يس لم م ا ف ى عھدت ه م ن واق ع ال دفتر الخ اص بقي د المخ درات إل ى من دوب م ن وزارة‬‫الصحة العمومية بالقاھرة أو إلى طبيب الصحة الواقعة فى دائرة المؤسسة ويجب على مندوب ال وزارة أو طبي ب الص حة‬‫ختم الدواليب المحتوية على ھذه المواد بخاتمه وخاتم المدير ال ذى ت رك العم ل ويج ب عل ى م ديرى المؤسس ات الص يدلية‬ ‫أال يتغيبوا عن مؤسساتھم أثناء ساعات العمل الرسمية ما لم يكن من بين موظفيھا من يجوز قانونا أن يكون مديرا.‬‫مادة 32: يجوز لكل طالب صيدلة مقيد اسمه بھذه الصفة بإحدى الجامعات المصرية وكل طالب صيدلة مقيد اسمه بالطريق ة‬‫القانوني ة ف ى كلي ة أجنبي ة للص يدلة معت رف بھ ا أن يمض ى م دة تمرين ه المق ررة ب اللوائح الجامعي ة بإح دى المؤسس ات‬ ‫الصيدلية وذلك بعد موافقة الكلية التى ينتمى إليھا الطالب بوزارة الصحة العمومية .‬‫م ادة 42: يجوز لك ل ص يدلى حاص ل عل ى درج ة أو دبل وم ف ى الخ ارج ويرغ ب ف ى التق دم لالمتح ان المنص وص علي ه ف ى‬‫المادة )3( أن يمض ى م دة تمرين ه ف ى إح دى الص يدليات العام ة بع د موافق ة وزارة الص حة العمومي ة بحي ث ال تزي د م دة‬ ‫التمرين على سنتين تحت أشراف المدير ومسئوليته.‬‫م ادة 52: على العمال والعامالت الذين يشتغلون بالمؤسسات الصيدلية أو بتوص يل األدوي ة أن يحص لوا عل ى ت رخيص ب ذلك‬‫من وزارة الصحة العمومية بعد تقديم شھادة تحقيق شخصية وصحيفة عدم وجود س وابق عل ى أن يكون وا ملم ين ب القراءة‬ ‫والكتابة كما يخضعون للقيود الصحية التى يقررھا وزير الصحة .‬‫م ادة 62: يجب عل ى أص حاب المؤسس ات الص يدلية والص يادلة ومس اعدى الص يادلة وطلب ة الص يدلة تح ت التم رين إخط ار‬‫وزارة الصحة العمومية بخطاب موصى عليه بتاريخ بدئھم العمل بھذه المؤسسات وكذلك إخطارھم بمجرد تركھم العمل.‬
  • 189. ‫مادة 72: إذا أراد صاحب المؤسسة الصيدلية أو مديرھا خزن أدوي ة لحاج ة مؤسس ته ف ى مح ل أخ ر وج ب علي ه أن يحص ل‬ ‫مقدما على ترخيص بذلك مقابل رسم قدره ثالثة جنيھات مصرية وبالشروط التى يصدر بھا قرار من وزير الصحة .‬‫م ادة 82: يجب ان يكون كل ما يوجد بالمؤسسة الم رخص بھ ا بموج ب ھ ذا الق انون م ن أدوي ة أو متحص الت أقرباذيني ة أو‬‫مستحضرات صيدلية أو نباتات طبية أو مواد كيماوية مطابقا لمواصفاتھا المذكورة بدس اتير األدوي ة ولتركيباتھ ا المس جلة‬‫وتحفظ حسب األصول الفنية ويجب أن تزود ھذه المؤسسات باألدوية واألدوات واألجھزة الالزمة للعم ل ولحف ظ األدوي ة‬ ‫بھا مع المراجع العليمة والقوانين الخاصة بالمھنة ويكون صاحب المؤسسة ومديرھا مسئولين عن تنفيذ ذلك.‬‫مادة 92: يجب على المؤسسات الصيدلية أخطار وزارة الصحة عن تصفيتھا وذل ك بأس بوعين عل ى األق ل قب ل الب دء ويرف ق‬‫باإلخطار كش ف بي ان الم واد المخ درة الموج ودة بالمح ل ويش ترط أن يك ون المش ترى م ن األش خاص الم رخص لھ م ف ى‬‫االتجار فى األصناف التى سيشتريھا فى حدود الترخيص الممنوح له ويعتبر الترخيص الخ اص بھ ذه المؤسس ة الص يدلية‬‫ملغيا بع د إنھ اء التص فية الم ذكورة. كم ا يج ب عليھ ا إخط ار ال وزارة عن د حص ول س رقة أو تل ف ف ى األدوي ة الموج ودة‬ ‫بالمؤسسة ألى سبب وذلك بمجرد حصول ذلك.‬ ‫3- أحكام خاصة لكل نوع من أنواع المؤسسات الصيدلية‬ ‫أوال: الصيدليات العامة:‬‫مادة 03: ال يمنح الترخيص بإنشاء صيدلية إال لصيدلى مرخص له ف ى مزاول ة مھنت ه يك ون مض ى عل ى تخرج ه س نة عل ى‬‫األقل قضاھا فى مزاولة المھنة فى مؤسسة حكومية أو أھلية ويعفى من شرط قضاء ھذه الم دة الص يدلى ال ذى ت ؤول الي ه‬‫الملكي ة بطري ق المي راث أو الوص ية وال يج وز للص يدلى أن يك ون مالك ا أو ش ريكا ف ى أكث ر م ن ص يدليتين اال اذا ك ان‬‫موظفا حكوميا فال يجوز له أن يكون مالكا أو شريكا فى أكثر من صيدلية واحدة. ويراعى إال تق ل المس افة ب ين الص يدلية‬ ‫المطلوب الترخيص بھا وأقرب صيدلية مرخص لھا على مائة متر .‬‫مادة 13: إذا توفى صاحب صيدلية جاز بقاء الرخصة لصالح الورثة لمدة أقصاھا عشر سنوات على أن يعين الورث ة وك يال‬ ‫عنھم يخطر عنه وزارة الصحة وتغلق الصيدلية اداريا بعد انتھاء ھذه المدة ما لم تبع الصيدلية.‬‫م ادة 23 : ال يج وز للص يدلى أن يص رف للجمھ ور أى دواء محض ر بالص يدلية إال بموج ب ت ذكرة طبي ة ع دا التراكي ب‬‫الدستورية التى تستعمل من الظاھر وكذلك التراكيب الدستورية التى تستعمل من الباطن بشرط أال يدخل فى تركيبھا مادة‬‫من المواد المذكورة فى الجدول رقم )1( الملحق بھذا القانون كم ا ال يج وز ل ه أن يص رف أى مستحض ر ص يدلى خ اص‬‫يحت وى عل ى م ادة م ن الم واد المدرج ة بالج دول رق م )2( الملح ق بھ ذا الق انون إال بت ذكرة طبي ة وال يتك رر الص رف إال‬ ‫بتأشيرة كتابية من الطبيب.‬‫وال يجوز للصيدليات أن تبيع بالجملة أدوية أو مستحضرات طبية للصيدليات األخرى أو مخ ازن األدوي ة أو الوس طاء أو‬ ‫المستشفيات أو العيادات ما عدا المستحضرات الصيدلية المسجلة باسم الصيدلى صاحب الصيدلية.‬‫مادة 33: ال تصرف ت ذكرة م ن الص يدليات م ا ل م تك ن مح ررة بمعرف ة طبي ب بش رى أو بيط رى أو طبي ب أس نان أو مول دة‬ ‫مرخص لھا مزاولة المھنة فى مصر .‬‫م ادة 43: ك ل دواء يحض ر بالص يدليات بموج ب ت ذكرة طبي ب يج ب أن يط ابق المواص فات الم ذكورة ف ى دس تور األدوي ة‬‫المصرى ما لم ينص فى التذكرة على دستور أدوية معين ففى ھذه الحال ة يحض ر حس ب موص فاتھا وال يج وز إج راء أى‬‫تغيير فى المواد المذكورة بھا كما أو نوعا بغير موافقة محررھا قب ل تحض يرھا ك ذلك ال يج وز تحض ير أى ت ذكرة طبي ة‬ ‫بعبارات أو عالمات مصطلح عليھا, والصيدلى مسئول عن جميع األدوية المحضرة.‬‫مادة 53: كل دواء يحضر بالصيدلية يجب أن يوضع فى وعاء مناسب ويوض ع عل ى بطاقت ه اس م الص يدلية وعنوانھ ا واس م‬‫ص احبھا ورق م القي د ب دفتر الت ذاكر الطبي ة واس م ال دواء وت اريخ التحض ير وكيفي ة اس تعمال ال دواء طبق ا لم ا ھ و م ذكور‬ ‫بالتذكرة الطبية واسم الدواء إذا صرف بغير تذكر طبية.‬
  • 190. ‫م ادة 63: كل دواء يحضر بالصيدلية يجب أن يقيد بدفتر التذاكر الطبي ة أوال ب أول ف ى نف س الي وم ال ذى يص رف في ه وتك ون‬‫صفحات ھذا ال دفتر مرقم ة ب رقم مسلس ل ومختوم ة بخ اتم وزارة الص حة ويج ب أن يثب ت ت اريخ ھ ذا القي د ب رقم مسلس ل‬‫وبخط واضح دون أن يتخلله بياض ودون أن يقع فيه كشط وكل قيد بذلك الدفتر يجب أن توضح به أسماء وكميات المواد‬‫التى تدخل ف ى تركي ب ال دواء ويج ب عل ى محض ر ال دواء أن يوق ع بال دفتر وأن يكت ب ثم ن ال دواء واس م الطبي ب مح رر‬‫التذكرة وال تعاد التذكرة الطبية إلى حاملھا إال بعد ختمھا بخاتم الص يدلية ووض ع ت اريخ القي د ورقم ه عليھ ا وثم ن ال دواء‬‫وفى حالة االحتفاظ بالتذكرة الطبية فى الصيدلية التقاء المسئولية يجب أن يعطى حاملھا ص ورة طب ق األص ل منھ ا وھ ذه‬‫الصورة يجب ختمھا بختم الصيدلية ووضع التاريخ الذى صرفت في ه ورق م القي د عليھ ا م ع ال ثمن وك ذلك تعط ى للطبي ب‬‫المعالج أو المريض صورة من التذكرة الطبية عند طلبھا وذلك دون مقابل وإذا تكرر التذاكر الطبي ة المحتوي ة عل ى م واد‬‫مدرجة فى الجدول رقم )2( الملحق بھذا القانون يكتف ى أن ي ذكر ف ى دفت ر قي د الت ذاكر الطبي ة ت اريخ التك رار ب رقم جدي د‬ ‫مسلسل مع اإلشارة إلى الرقم الذى قيدت به التذكرة فى المرة األولى.‬‫م ادة 73: ال يجوز لغير الصيادلة أو مساعدى الصيادلة المسجلين بھذه الص فة بج دول المس اعدين ب وزارة الص حة أو طلب ة‬‫الصيدلة الذين يقضون مدة تمرينھم فى الصيدلية التدخل فى تحضير التذكرة الطبية أو ص رفھا أو ف ى بي ع المستحض رات‬‫الصيدلية للجمھور, وبھذا النص القانونى الحاسم تحدد األشخاص الذين لھم حق تحضير وصرف األدوية للجمھ ور, وفي ه‬‫خير ضمان لسالمة العمل الصيدلى والحفاظ على صحة المواطنين, وتحديد المسئولية القانونية كلما استدعى األم ر, وم ع‬‫وجود ھذا النص فال محل لتدخل من جانب بائع أدوية أو صاحب الصيدلية غير الصيدلى فى ھذه الن واحى. وق د ج اء ف ى‬‫موضوع آخ ر م ن الق انون ن ص يح رم عل ى المؤسس ات الص يدلية األخ رى ـ غي ر الص يدليات ـ بي ع األدوي ة للجمھ ور أو‬ ‫صرفھا له أو حتى إعطائھا له بالمجان أو التوسط فى تحضير التذاكر الطبية .‬ ‫مادة 83: مواعيد العمل فى الصيدليات العامة :‬‫أص در وزي ر الص حة تنفي ذا لھ ذا الق انون الق رار ال وزارى الت الى خاص ا بمواعي د العم ل ف ى الص يدليات وم ا يتب ع ف ى‬ ‫اإلجازات السنوية والراحة األسبوعية واألعياد الرسمية :‬‫- يب دأ العم ل ف ى الص يدليات العام ة بعواص م المحافظ ات ف ى تم ام الس اعة التاس عة ص باحا وينتھ ى ف ى تم ام الس اعة‬‫التاسعة مساءا من كل يوم ما عدا أي ام الراح ة األس بوعية والعط الت الس نوية. عل ى أن تتخلل ه فت رة ث الث س اعات‬‫للراحة اليومية تغلق فيھ ا الص يدلية. أم ا ف ى بقي ة ب الد الجمھوري ة فتك ون المواعي د م ن الثامن ة ص باحا إل ى الثامن ة‬ ‫مساءا.‬‫- تعل ن الص يدلية ف ى مك ان ظ اھر عل ى بابھ ا الخ ارجى بالفت ة مكتوب ة باللغ ة العربي ة وبإح دى اللغ ات األجنبي ة ع ن‬ ‫مواعيد العمل والراحة اليومية واألسبوعية.‬ ‫- يخطر مدير الصيدلية وزارة الصحة بھذه المواعيد.‬‫- تتولى نقابة الصيادلة ترتي ب مواعي د الراح ة اليومي ة ب ين الص يدليات الت ى تق ع ف ى قس م إدارى واح د بحي ث يت وفر‬ ‫وجود عدد منھا مفتوحا فى جميع األوقات حسب النظام الموضوع .‬ ‫- يسمح بتجاوز 51 دقيقة قبل وبعد المواعيد المحددة.‬‫وقد وضع ھذا التنظيم ليكفل ت وافر الخدم ة الص يدلية للجمھ ور ف ى جمي ع األوق ات وتن اوب الص يدليات ف ى ھ ذا الترتي ب,‬‫واإلعالن عن ھذه المواعيد مع االلتزام بھا يسھل مھم ة الجمھ ور بتوجيھ ه إل ى الص يدلية القائم ة بالخدم ة مباش رة وبغي ر‬ ‫مشقة. كما يھئ ظروف العمل بالنسبة للصيدليات المنوط بھا مھمة الخدمة الليلية.‬ ‫شروط الترخيص بالخدمة الليلية للصيدليات العامة :‬‫1- الصيدليات التى تقوم بالخدمة الليلة يجب أن يصرح لھا بذلك من وزارة الصحة. وتبدأ العمل بعد انتھ اء مواعي د‬‫العمل المحددة للخدمة النھارية بالصيدليات أى من التاسعة مساءا فى عواصم المحافظات ومن الثامنة مساءا ف ى‬ ‫البالد األخرى وذلك إلى الساعة السابعة صباحا.‬ ‫2- يتولى العمل خالل ھذه الفترة صيدلى أو مساعد صيدلى تخطر الوزارة باسمه من المالك ومن القائم باإلدارة.‬ ‫3- يجب أن يخصص دفتر خاص لقيد التذاكر الطبية التى تصرف ليال.‬‫4- ت زود الص يدلية بتليف ون ص الح لالس تعمال وف انوس مض اء مكت وب علي ه خدم ة ليلي ة وج رس كھرب ائى ص الح‬‫لالستعمال يوضع على الباب الخارجى وعليه ضوء أحم ر يرش د إل ى موقع ه م ع ت وفير خ ادم ودراج ة لتوص يل‬ ‫األدوية.‬
  • 191. ‫5- تزود الصيدلية بأدوات طبية وأدوية اإلسعاف طبقا للكشف الذى تعده اإلدارة.‬‫6- على مالك الصيدلية أن يترك بابھا الخارجى مفتوحا أثناء فترة الخدمة الليلية وبأن يترك ضوءا كافيا فيھ ا بحي ث‬ ‫يظھر من الخارج.‬ ‫7- تدفع المحافظة لمالك الصيدلية مكافأة شھرية تدفع بعد نھاية كل شھر مقابل قيامه بتنفيذ ھذه الشروط.‬‫8- لمحافظة القاھرة الحق فى أن توقع على مالك الصيدلية غرامة عن كل مخالفة ألى شرط م ن ھ ذه الش روط دون‬‫حاجة إلى تنبيه وال يكون لمالك الصيدلية الحق فى االعتراض على رأى المحافظة فى تقري ر وق وع المخالف ة أو‬ ‫فرض الغرامة.‬‫9- يكون لمحافظة القاھرة الحق فى أن تخصم من المكافأة الش ھرية الغرام ة المش ار إليھ ا بالن د الس ابق أو أى مب الغ‬ ‫مستحقة لمالك الصيدلية قبل المحافظة أو أى جھة حكومية أخرى.‬‫01- لمحافظة القاھرة الحق فى إنھاء ھذا الترخيص فى أى وقت دون حاجة إلى اتخاذ أى إجراء سوى إخط ار مال ك‬‫الصيدلية بذلك قبل قيامھا بإلغاء الترخيص بشھر عل ى األق ل وال يك ون لمال ك الص يدلية الح ق ف ى المطالب ة ب أى‬ ‫تعويض فى حالة إنھاء الترخيص.‬ ‫ثانيا : الصيدليات الخاصة:‬ ‫مادة 93: الصيدليات الخاصة نوعان:‬‫1- ص يدليات المستش فيات والمستوص فات والعي ادات الش املة وعي ادات األطب اء المص رح لھ م ف ى ص رف األدوي ة‬ ‫لمرضاھم.‬ ‫2- الصيدليات التابعة لجمعيات تعاونية مشھرة.‬‫م ادة 04: يجوز للطبيب البشرى أو البيطرى المرخص له مزاولة المھن ة أن يص رف ويجھ ز أدوي ة خاص ة بعيادت ه ويعط ى‬‫ھذا الترخيص للطبيب البشرى أو البيطرى متى ثبت أن المسافة ب ين عيادت ه وأق رب ص يدلية موج ودة بالجھ ة تزي د عل ى‬ ‫خمسة كيلومترات.‬‫ويلغ ى ھ ذا الت رخيص عن د ف تح ص يدلية عام ة أو خاص ة بالجھ ة الموج ودة بھ ا العي ادة الطبي ة الحاص لة عل ى ھ ذا‬‫الترخيص ويعطى الطبيب مھلة قدرھا تسعون يوما من تاريخ فتح الص يدلية لتص فية األدوي ة الت ى بالعي ادة الم رخص‬ ‫بھا وإال وجب إغالق الصيدلية الخاصة والعيادة إداريا مع ضبط األدوية الموجودة بھا .‬ ‫ثالثا: وسطاء األدوية:‬‫م ادة 14: يجب على كل م ن يري د االش تغال كوس يط أدوي ة أو كوكي ل مص نع أو جمل ة مص انع ف ى األدوي ة والمستحض رات‬‫الطبية أو األقرباذينية أن يحصل على ترخيص بذلك من وزارة الصحة العمومي ة ويج ب أن يك ون طل ب الت رخيص عل ى‬ ‫النموذج الذى تعده الوزارة لذلك ومصحوبا بما يأتى :‬ ‫1- شھادة تحقيق شخصية وصحيفة عدم وجود سوابق.‬‫2- شھادة من المصنع مصدقا عليھا م ن الجھ ات المختص ة الرس مية تثب ت وكال ة الطال ب ع ن المص نع أو المص انع‬‫وتلحق بھا قائمة بأسماء األدوية والمستحضرات الصيدلية التى ھو وكيل عن مصانعھا مع إيضاح تركيبھ ا نوع ا‬ ‫وكما.‬‫مادة 24: الترخيص للوسيط شخصى وعلى الوسطاء إخطار الوزارة أوال ب أول بك ل مص نع جدي د يمثلون ه او يتن ازلون ع ن‬ ‫تمثيله وأن يرسلوا فى شھر ديسمبر من كل سنة باسم المصنع أو المصانع التى يمثلونھا.‬‫م ادة 34: يجب على الوسطاء الذين يرغبون فى أن يكون لھم مستودعات لحفظ األدوية أو المستحضرات الص يدلية الت ى ھ م‬ ‫وكالء عنھا أن يحصلوا على ترخيص فى ذلك وفقا لألحكام العامة بالمؤسسات الصيدلية.‬ ‫مادة 44: يكون تخزين وبيع األدوية من مستودعات الوسطاء بالشروط اآلتية:‬ ‫1- يجب أن تباع مغلفة فى مغلفاتھا األصلية .‬‫2- يج ب أن يك ون البي ع مقص ورا عل ى الص يدليات العام ة والخاص ة وعل ى مخ ازن األدوي ة والمعاھ د التعليمي ة‬ ‫واليكون للجمھور.‬‫م ادة 54: يجب على مدير المستودع أن يمسك دفترا لقيد الوارد من األدوية إلى المستودع والمنصرف من ه وتك ون ص فحات‬ ‫ھذا الدفتر مرقومة برقم مسلسل ومختومة بخاتم وزارة الصحة.‬
  • 192. ‫رابعا : مخازن األدوية:‬ ‫مادة 64: ال يسمح بالترخيص لمخزن أدوية إال فى المحافظات أو عواصم المديريات والمراكز التى بھا صيدليات.‬ ‫مادة 74: يجب أن يكون محل حفظ األدوية والمستحضرات الصيدلية فى المخزن مستقال عن باقى أقسامه.‬ ‫مادة 84: تفتح مخازن األدوية فى نفس ساعات ومواعيد العمل المحددة للصيدليات.‬ ‫مادة 94: يجب أن تباع األدوية من المخزن فى عبواتھا األصلية.‬‫مادة 05: على مدير المخزن أن يمسك دفترا يقيد فيه الوارد والمنصرف وتك ون ص فحات ھ ذا ال دفتر مرقوم ة ب رقم مسلس ل‬ ‫ومختومة بخاتم وزارة الصحة.‬ ‫خامسا: محال االتجار فى النباتات الطبية ومتحصالتھا:‬‫مادة 15: يجب على كل من يريد فتح محل لالتجار فى النباتات الطبية الواردة فى دس اتير األدوي ة أو ف ى أج زاء مختلف ة م ن‬‫ھذه النباتات أو فى المتحصالت الناتجة بطبيعتھا من النباتات الحصول على ترخيص بذلك وفقا لألحكام العام ة والخاص ة‬ ‫للمؤسسات الصيدلية وال يسرى ھذا الحكم على محال بيع النباتات الطبية الواردة بالجدول السابع الملحق بھذا القانون.‬‫م ادة 25: يجب أن تباع النباتات الطبية فى عبوات مغلقة مبينا عليھا اسم دستور األدوية الذى يطابق مواص فاتھا وك ذا ت اريخ‬‫الجمع وتاريخ انتھ اء ص الحيتھا لالس تعمال إن وج د ويك ون البي ع مقص ورا عل ى الص يدليات ومخ ازن األدوي ة ومص انع‬ ‫المستحضرات الصيدلية والھيئات العلمية ويجوز البيع لألفراد الذين ترخص لھم فى ذلك وزارة الصحة.‬‫مادة 35: كل ما يرد إلى محل االتجار فى النباتات الطبية وكل ما يصرف منھا يجب قي ده أوال ب أول ف ى دفت ر خ اص تك ون‬‫صفحاته مرقومة برقم مسلسل ومختومة بخاتم وزارة الصحة وأن يك ون القي د بخ ط واض ح دون أن يتخلل ه بي اض أو يق ع‬ ‫فيه كشط.‬ ‫سادسا: مصانع المستحضرات الصيدلية:‬‫م ادة 45: يج ب أن يك ون بك ل م ن مص انع المستحض رات الص يدلية معم ل تحالي ل م زود باألدوي ة واألجھ زة الالزم ة‬‫ويشرف على ھذا المعمل ص يدلى أو أكث ر م ن غي ر الص يادلة المكلف ين بتجھي ز المستحض رات أو المتحص الت بالمص نع‬ ‫ويكون الصيدلى المحلل مسئوال مع الصيدلى مدير المصنع عن جودة األصناف المنتجة وصالحيتھا لالستعمال.‬‫مادة 55: يجوز للصيدلى بع د موافق ة وزارة الص حة العمومي ة أن يص نع ف ى ص يدليته مستحض رات ص يدلية خاص ة ب ه‬‫ويشترط أن تكون الصيدلية مجھزة بجميع األدوات واآلالت الالزمة لصنع وتحليل تلك المستحضرات ومستوفاة للش روط‬ ‫التى تضعھا الوزارة.‬‫م ادة 65: عل ى ك ل م ن الص يدلى ال ذى يق وم بتجھي ز مستحض رات خاص ة ف ى ص يدليته وم دير مص نع المستحض رات‬‫الصيدلية أن يمسك دفترين أحدھما للتحضير يدون فيه أوال بأول مق دار الكمي ة المجھ زة ف ى ك ل م رة ع ن ك ل مستحض ر‬‫وتاريخ التجھيز ويعطى رقم مسلس ل لك ل عملي ة تجھي ز موقع ا علي ه م ن الص يدلى المحض ر والص يدلى المحل ل. وال دفتر‬‫األخر لقيد الكميات المنصرفة وتاريخ صرفھا والجھات المنصرف إليھا ويوقع عل ى ھ ذا ال دفتر الص يدلى الم دير. ويج ب‬ ‫أن تكون صفحات كل دفتر مرقومة برقم مسلسل ومختومة بخاتم وزارة الصحة.‬‫مادة 75: يجب أن يوضع عل ى األوعي ة الت ى تعب أ فيھ ا الم واد الدوائي ة أو المستحض رات الص يدلية ومغلفاتھ ا الخارجي ة‬ ‫بطاقات تذكر فيھا البيانات اآلتية:‬ ‫1- اسم المستحضر وأسماء المواد الفعالة فى التركيب ومقاديرھا.‬ ‫2- اسم المصنع أو الصيدلية التى قامت بعملية التعبئة أو التجھيز أو التركيب وعنوانھا واسم البلد الذى جھزت فيه.‬ ‫3- كيفية استعماله ومقدار الجرعة الواحدة.‬ ‫4- كمية الدواء داخل العبوة.‬
  • 193. ‫5- األثر الطبى.‬ ‫6- الرقم المسلسل لعملية التعبئة أو التجھيز أو التركيب )رقم التشغيلة(.‬‫7- وأن ك ان م ن األدوي ة الت ى يتغي ر مفعولھ ا بمض ى بع ض الوق ت في ذكر ت اريخ التحض ير وكيفي ة احتفاظ ه بقوت ه‬ ‫وتاريخ صالحيته لالستعمال وكذلك كيفية حفظه.‬ ‫8- بيان بالمواد الملونة والحافظة والمذيبة ونسبة كل منھا إن وجدت.‬ ‫9- رقم التسجيل بدفاتر وزارة الصحة العمومية.‬ ‫01- الثمن المحدد الذى تباع به للجمھور.‬ ‫الفصل الثالث‬ ‫المستحضرات الصيدلية الخاصة والدستورية‬‫مادة 85: تعتبر مستحضرات صيدلية خاصة فى تطبيق أحكام ھذا القانون- المتحص الت والتراكي ب الت ى تحت وى او‬‫توصف بأنھا تحتوى على مادة أو أكث ر ذات خ واص طبي ة ف ى ش فاء اإلنس ان م ن األم راض أو للوقاي ة منھ ا وكان ت‬ ‫غير واردة فى إحدى طبعات دساتير األدوية وملحقاتھا الرسمية.‬‫مادة 95: يحظر تداول المستحضرات الصيدلية الخاصة سواء أكانت محضرة محليا أم مستوردة من الخارج إال بع د‬‫تسجيلھا بوزارة الصحة العمومية وال تسجل تلك المستحضرات إال إذا كان طلب التسجيل مقدما من أح د الص يادلة أو‬‫األطب اء البش ريين أو البيط ريين أو أطب اء األس نان م ن المص رح لھ م ف ى مزاول ة المھن ة ف ى مص ر أو م ن أص حاب‬‫مصانع األدوية المحلية أو من أصحاب المصانع األجنبية فى الخارج أو وكالئھم ويصاحب طلب تسجيل المستحض ر‬‫برسم قدره )خمسة جنيھات( عن كل مستحض ر نظي ر فح ص الطل ب وث الث عين ات م ن المستحض رات ف ى عبواتھ ا‬‫األصلية كل منھا مختومة بخاتم الصيدلى الذى قام بتجھيزھا أو بخاتم المصنع ال ذى جھ زت في ه وص ورتين لك ل م ن‬‫البطاقة والمطبوعات التى سيغلف بھا المستحضرات موقعا عليھا من الصيدلى أو م ن وكي ل أو م دير المص نع وعل ى‬ ‫صاحب الشأن أن يقدم كافة البيانات األخرى التى تطلب منه.‬‫مادة 06: ال يتم تسجيل أى مستحضر صيدلى خاص إال إذا أقرته اللجنة الفنية لمراقبة األدوية والتى يصدر بتشكيلھا‬ ‫قرار من وزارة الصحة العمومية وتؤلف من رئيس وتسعة أعضاء كاآلتى :‬ ‫وكيل وزارة الصحة أو من ينوب عنه )رئيسا(.‬ ‫1- أستاذ صيدلى من إحدى كليات الصيدلة .‬ ‫2- أستاذ طبيب من إحدى كليات الطب .‬ ‫3- مندوب صيدلى من وزارة الصحة .‬ ‫4- مدير معھد األبحاث وطب المناطق الحارة بوزارة الصحة أو من ينوب عنه .‬ ‫5- صيدلى من غير الموظفين ترشحه نقابة الصيادلة.‬ ‫6- طبيب من غير الموظفين ترشحه نقابة أطباء البشريين .‬ ‫7- مندوب من اللجنة الدائمة لدستور األدوية .‬ ‫8- صيدلى حكومى مختص بتحليل األدوية .‬ ‫9- طبيب حكومى مختص بالتحاليل البيولوجية.‬‫وتمثل اللجنة بتشكيلھا على ھذا الوجه جميع األط راف المعني ة بش ئون ال دواء, كم ا تض م جمي ع الخب رات ال الزم توافرھ ا‬ ‫ألداء المھمة الموكولة إليھا من جانب وزارة الصحة وھى تسجيل ومراقبة األدوية.‬ ‫مادة 16: اختصاصات اللجنة الفنية لمراقبة األدوية:‬ ‫تسجيل األدوية‬ ‫1-‬ ‫حظر تداول األدوية‬ ‫2-‬ ‫السماح بتداول األدوية‬ ‫3-‬ ‫الموافقة على إعالنات األدوية‬ ‫4-‬
  • 194. ‫مادة 26: تعتبر مستحضرات ص يدلية دس تورية ف ى أحك ام ھ ذا الق انون – المتحص الت والتراكي ب الم ذكورة ف ى أح دث‬‫طبعات دساتير األدوية الت ى يص در بھ ا ق رار م ن وزارة الص حة ك ذلك الس وائل والمجھ زات الدس تورية المع دة للتطھي ر‬ ‫ويجوز صنع ھذه المستحضرات فى مصانع األدوية أو الصيدليات دون حاجة إلى تسجيلھا.‬‫وال يجوز البدء فى تجھيز المستحضرات الدستورية إال بعد إخطار وزارة الصحة بذلك وموافقتھا ببيان الدستور الم ذكور‬ ‫فيه المستحضر وعينة من العبوة والبطاقة التى ستلصق عليھا وموافقة وزارة الصحة.‬‫مادة 36 : يجب أن تباع المستحضرات الصيدلية مغلفة داخل غال فاتھا األصلية ويستثنى م ن ذل ك األمب ول إذا ك ان اس م‬‫الدواء ومقداره واسم المصنع المجھز مطبوعا عليه بم ادة ثابت ة تص عب إزالتھ ا ويج ب أن تك ون البيان ات الم ذكورة عل ى‬‫بطاقات المستحضرات الصيدلية وعلى ما يوزع من النشرات واإلعالن ات متفق ة م ع م ا تحتوي ه فع ال تل ك المستحض رات‬‫م ن م واد م ع خواص ھا العالجي ة كم ا يج ب أال تتض من عب ارات تتن افى م ع اآلداب العام ة أو يك ون م ن ش أنھا تض ليل‬‫الجمھ ور. ويج ب الحص ول عل ى موافق ة اللجن ة الفني ة لمراقب ة األدوي ة ب وزارة الص حة عل ى نص وص تل ك البيان ات أو‬ ‫النشرات أو اإلعالنات ووسائلھا وذلك قبل نشرھا.‬‫مادة 46: لوزير الصحة بناء على توصية اللجنة الفنية لمراقب ة األدوي ة أن يص در ق رارات بحظ ر الت داول ألى م ادة أو‬‫مستحضرات صيدلية يرى ف ى ت داولھا م ا يض ر بالص حة العام ة وف ى ھ ذه الحال ة يش طب تس جيل المستحض ر م ن دف اتر‬‫الوزارة أن كان مسجال وتصادر الكميات الموجودة منه اداري ا أينم ا وج دت دون أن يك ون ألص حابھا الح ق ف ى الرج وع‬ ‫على الوزارة بأى تعويض .‬ ‫الفصل الرابع‬ ‫استيراد األدوية والمستحضرات الصيدلية والمتحصالت األقربازينية والنباتات الطبية‬ ‫ومتحصالتھا الطبيعية‬‫مادة 56: ال يسمح بدخول المستحضرات الصيدلية الخاصة فى مصر ولو كانت عينات طبي ة مجاني ة وال ب اإلفراج عنھ ا‬ ‫إال إذا توافرت فيھا الشروط اآلتية وبعد موافقة اللجنة الفنية لمراقبة األدوية:‬ ‫1- أن تكون مسجلة بدفاتر وزارة الصحة.‬ ‫2- أن تكون بنفس االسم المعروفة به فى بالدھا األصلية.‬ ‫3- أن تجلب داخل غالفات محكمة الغلق وال يجوز أن تجلب فرطا أو بدون حزم.‬ ‫4- أن تذكر على بطاقاتھا البيانات المنصوص عليھا فى المادة )75(.‬‫مادة 66: ال يجوز السماح بدخول المستحضرات الصيدلية الدستورية او النباتات الطبية أو المواد الدوائي ة ف ى مص ر إال‬‫إذا ك ان مبين ا عليھ ا اس م دس تور األدوي ة المجھ زة بموجب ه وت اريخ تجھيزھ ا أو جمعھ ا وأن تك ون مطابق ة تمام ا لجمي ع‬ ‫اشتراطات ھذا الدستور وأن تجلب داخل غالفات محكمة الغلق.‬‫مادة 76: يجوز لوزير الصحة أن يصدر قرار بعدم السماح بإدخال أية مواد مم ا ھ و منص وص علي ه ف ى الم ادة الس ابقة‬ ‫فى مصر إال إذا توافرت فيھا صفات خاصة وبعد اختبارھا والتأكيد من صالحيتھا الطبية.‬‫مادة 86: ال يجوز اإلفراج عن المواد الدوائية أو المتحصالت األقرباذينية أو المستحضرات الصيدلية أو النباتات الطبي ة‬‫ومتحصالتھا الطبيعية المستوردة التى تتوافر فيھا الشروط المنصوص عليھا فى ھذا القانون إال لألشخاص المرخص لھم‬‫باالتجار فى تل ك الم واد ك ل م نھم ف ى ح دود الرخص ة الممنوح ة إلي ه بش رط أن تك ون تل ك األص ناف واردة م ن الخ ارج‬‫خصيصا لھم كما ال يجوز لغير ھؤالء األشخاص تصدير تلك األصناف إلى الخارج ومع ذلك يجوز لألفراد اس تيراد تل ك‬‫األصناف أو تصديرھا على أن تكون بكميات محدودة لالستعمال الخاص بشرط الحص ول مق دما عل ى تص ريح ب ذلك م ن‬ ‫وزارة الصحة.‬‫م ادة 96: يج ب ان توض ع الم واد المدرج ة بالج دولين األول والثال ث والملحق ين بھ ذا الق انون وك ذلك المستحض رات‬‫الصيدلية المحتوية على مادة أو اكثر من ھذه المواد عند وصولھا إلى الجمرك منعزلة عن البضائع األخ رى وال تس لم إال‬
  • 195. ‫الفصل الخامس‬ ‫أحكام عامة‬‫مادة 07: ال يجوز للصيدلى أن يجمع بين مزاولة مھنته ومزاولة مھنة الطب البشرى أو الطب البيطرى أو طب األسنان‬ ‫حتى ولو كان حاصال عى مؤھالتھا.‬‫م ادة 17: ال يج وز حف ظ الم واد الدوائي ة أو المتحص الت األقرباذيني ة أو المستحض رات الص يدلية أو النبات ات الطبي ة‬‫ومتحصالتھا أو بيعھا أو طرحھا أو عرضھا للبيع إال فى المحال الم رخص لھ ا بموج ب ھ ذا الق انون ك ل منھ ا ف ى ح دود‬‫الرخص ة الممنوح ة لھ ا وال يج وز االتج ار فيھ ا لغي ر األش خاص الم رخص لھ م ب ذلك كم ا اليج وز ش راؤھا إال م ن تل ك‬ ‫المحال ومن ھؤالء األشخاص .‬‫م ادة 27: ال يج وز االتج ار ف ى عين ات األدوي ة والمستحض رات الص يدلية المع دة للدعاي ة أو عرض ھا للبي ع وال يج وز‬‫حيازتھا لغير المؤسسات الصيدلية المرخص لھا ف ى اس تيرادھا او ص نعھا. وال يج وز للوس يط أن يح تفظ بعين ات األدوي ة‬‫ف ى أى مك ان أخ ر غي ر المس تودع الم رخص ل ه ب ه كم ا يج ب أن يك ون مطبوع ا عل ى بطاق ات ھ ذه العين ات الداخلي ة‬ ‫والخارجية بشكل واضح عبارة )عينة طبية مجانية(.‬‫مادة 37: ال يجب تداول المواد المدرجة فى الجدول األول الملحق بھذا القانون ومستحضراتھا بين المؤسس ات الص يدلية‬ ‫إال بموجب طلب كتابى موقع عليه من مدير المؤسسة الصيدلية وعليه خاتم )سموم(.‬‫مادة 47: يجب حفظ الدفاتر المنصوص عليھا فى ھذا القانون وجميع المس تندات الخاص ة بھ ا كالت ذاكر الطبي ة والف واتير‬‫والطلب ات م دة خم س س نوات ابت داء م ن اخ ر قي د ف ى ال دفاتر وعل ى أص حاب المؤسس ات الص يدلية وم ديرھا تق ديم تل ك‬ ‫الفواتير والمستندات لمفتشى وزارة الصحة كلما طلبوا منھم ذلك.‬‫مادة 57: يجوز ل وزير الص حة أن يم نح ت راخيص وقتي ة لف تح ص يدلية أو أكث ر ف ى المص ايف أو المش اتى المؤقت ة وفق ا‬ ‫للحاجة وباالشتراطات التى تراھا وزارة الصحة العمومية .‬‫مادة 67: ال يجوز اإلفراج الجمرك ى ع ن رس ائل األدوي ة المس توردة إال بع د موافق ة وزارة الص حة كم ا يل زم الحص ول‬‫على تلك الموافقة قبل تداول األدوية المحضرة محليا – ويضع وزير الصحة القواعد الت ى تتب ع ف ى ھ ذا الش أن بن اء عل ى‬‫ما تقترحه اللجنة الفنية لمراقب ة األدوي ة وعل ى أص حاب المستحض رات الص يدلية المحلي ة دف ع الرس م ال ذى تح دده وزارة‬ ‫الصحة العمومية على كل عينة من ھذه الرسائل ثمنا للتحليل.‬‫مادة 77: يجوز لوزير الصحة العمومية بعد اخذ رأى مجلس نقاب ة الص يدلة أن ي رخص للص يادلة الفلس طينيين الالجئ ين‬‫الذين أجبرتھم الظروف القھرية الدولية على مغادرة بالدھم وااللتجاء إل ى مص ر لإلقام ة إل ى أن تس تقر حال ة بالدھ م ف ى‬‫مزاولة مھنتھم بجمھورية مصر العربية لمدة أقصاھا سنة قابلة للتجديد م ع إعف ائھم م ن تأدي ة االمتح ان المنص وص علي ه‬ ‫فى المادة )3( بشرط حصولھم على الدبلوم المنصوص عليه فى المادة )2(.‬‫مادة 87: تعتمد الجداول الملحقة بھذا القانون وتعتبر مكملة له, ويجوز لوزير الصحة أن يص در ق رارا بإض افة أي ة م ادة‬ ‫أخرى. كما له أن يحذف منھا أية مادة, وتنشر تعديالت الجداول فى الجريدة الرسمية.‬
  • 196. ‫الجداول الملحقة بھذا القانون‬ ‫الجدول األول‬ ‫الجدول األول‬ ‫)المــواد الســـامـــــة(‬‫ويحتوى على المواد الواجب حفظھا فى أماكن منعزلة و مغلقة و مكتوب عليھا )مــواد ســـامـــــة( ويرسم عليھا جمجمة و عظمتان‬ ‫ويحتوى على‬ ‫وھى:‬ ‫01.. الـھــيوســـــــين..‬ ‫01 الـھــيوســـــــين‬ ‫1.. الزرنـــــيخ..‬ ‫1 الزرنـــــيخ‬ ‫11.. الـھــيوسيامــين..‬ ‫11 الـھــيوسيامــين‬ ‫2.. أنـتـيـــمون..‬ ‫2 أنـتـيـــمون‬ ‫21.. الــنـــيــكوتـــين..‬ ‫21 الــنـــيــكوتـــين‬ ‫3.. الزئـــــــبق..‬ ‫3 الزئـــــــبق‬ ‫31.. الـبـابـافــريـــــن..‬ ‫31 الـبـابـافــريـــــن‬ ‫4.. الـديـجـيـتال..‬ ‫4 الـديـجـيـتال‬ ‫41.. االســتـركـــنــين..‬ ‫41 االســتـركـــنــين‬ ‫5.. الديونـين..‬ ‫5 الديونـين‬ ‫51.. أمـالح الــفـــضة..‬ ‫51 أمـالح الــفـــضة‬ ‫6.. الكودايـين..‬ ‫6 الكودايـين‬ ‫61.. أمـالح الرصاص..‬ ‫61 أمـالح الرصاص‬ ‫7.. األدرينالين..‬ ‫7 األدرينالين‬ ‫71.. الـــداتـــــــــــورة..‬ ‫71 الـــداتـــــــــــورة‬ ‫الـــداتـــــــــــورة‬ ‫8.. الســـكـاران..‬ ‫8 الســـكـاران‬ ‫81.. الفــــيـــــــــــنول..‬ ‫81 الفــــيـــــــــــنول‬ ‫9.. الـــــــبــروم..‬ ‫9 الـــــــبــروم‬ ‫الجدول الثاني‬ ‫الجدول الثاني‬ ‫ويحتوى على المواد التى يجب أال تصرف من الصيدليات إال بتذكرة طبية و ال يتكرر الصرف إال بتأشيرة كتابية من الطبيب,, وھى::‬ ‫ويحتوى على المواد التى يجب أال تصرف من الصيدليات إال بتذكرة طبية و ال يتكرر الصرف إال بتأشيرة كتابية من الطبيب وھى‬ ‫االدرينالين للحقن..‬ ‫االدرينالين للحقن‬ ‫1.‬ ‫مواد التخدير العامة و الموضعية فيما عدا مستحضراتھا التى تستعمل من الظاھر..‬ ‫مواد التخدير العامة و الموضعية فيما عدا مستحضراتھا التى تستعمل من الظاھر‬ ‫2.‬ ‫أشباة قلويات االفيون و مشتقاتھا فيما عدا البابافرين و الديونين و الكودايين..‬ ‫أشباة قلويات االفيون و مشتقاتھا فيما عدا البابافرين و الديونين و الكودايين‬ ‫3.‬ ‫زيت حب الملوك..‬ ‫زيت حب الملوك‬ ‫4.‬ ‫خالصة الغدة الدرقية و الثيروكسين..‬ ‫خالصة الغدة الدرقية و الثيروكسين‬ ‫5.‬ ‫أمالح األنتيمون..‬ ‫أمالح األنتيمون‬ ‫6.‬ ‫الكوكا..‬ ‫الكوكا‬ ‫7.‬ ‫االرجوت..‬ ‫االرجوت‬ ‫8.‬ ‫الكورتيزون..‬ ‫الكورتيزون‬ ‫9.‬ ‫أمالح الزرنيخ..‬ ‫أمالح الزرنيخ‬ ‫01.‬ ‫الھيبارين..‬ ‫الھيبارين‬ ‫11.‬ ‫االستركنين و أمالحه..‬ ‫االستركنين و أمالحه‬ ‫21.‬ ‫الھرمونات للحقن ما عدا اآلنسولين..‬ ‫الھرمونات للحقن ما عدا اآلنسولين‬ ‫31.‬ ‫مركبات جوزه الطيب..‬ ‫مركبات جوزه الطيب‬ ‫41.‬ ‫الحقن المستعملة عن طريق النخاع..‬ ‫الحقن المستعملة عن طريق النخاع‬ ‫51.‬ ‫مستحضرات المضادات الحيوية فيما عدا الـبـنسـلـــــين..‬ ‫مستحضرات المضادات الحيوية فيما عدا الـبـنسـلـــــين‬ ‫61.‬ ‫الجدول الثالث‬ ‫الجدول الثالث‬ ‫)المخدرات(‬ ‫ويحتوى على المواد و المستحضرات المعتبرة مخدرة و التى يجب أن تعزل و تحفظ فى دوالب خاص يكتب عليه كلمة )مخدرات(.‬ ‫ويحتوى على‬ ‫الجدول الرابع‬ ‫الجدول الرابع‬ ‫)األدوية التى يجوز صرفھا بمعرفة المولدّة(‬ ‫)األدوية التى يجوز صرفھا بمعرفة المولدّة(‬ ‫ويحتوى على األدوية التى يجوز للصيدلى صرفھا بموجب تذكرة محررة بمعرفة المولدّةّة,, وھى::‬ ‫ويحتوى على األدوية التى يجوز للصيدلى صرفھا بموجب تذكرة محررة بمعرفة المول د وھى‬ ‫8.. قطرة أرجيرول وبروتاجول..‬ ‫8 قطرة أرجيرول وبروتاجول‬ ‫1.. المطھرات الموضعية مثل الليزول و الديتول..‬ ‫1 المطھرات الموضعية مثل الليزول و الديتول‬ ‫9.. قطرة السلفا..‬ ‫9 قطرة السلفا‬ ‫2.. محلول حمض البكريك..‬ ‫2 محلول حمض البكريك‬
  • 197. ‫01.. محلول ميركروكروم..‬ ‫01 محلول ميركروكروم‬ ‫3.. محلول برمنجنات البوتاسا..‬ ‫3 محلول برمنجنات البوتاسا‬ ‫11.. درماتول مسحوق..‬ ‫11 درماتول مسحوق‬ ‫4.. محلول نترات الفضة..‬ ‫4 محلول نترات الفضة‬ ‫21.. بودرة السلفا..‬ ‫21 بودرة السلفا‬ ‫5.. محلول اليود..‬ ‫5 محلول اليود‬ ‫31.. البنسلين..‬ ‫31 البنسلين‬ ‫6.. حبوب و شراب الكاسكارا..‬ ‫6 حبوب و شراب الكاسكارا‬ ‫41.. أمبول ارجوتين..‬ ‫41 أمبول ارجوتين‬ ‫7.. جلسرين أكتيول..‬ ‫7 جلسرين أكتيول‬ ‫51.. تركيبات دوش مھبلى من دستور األدوية للمستشفيات المصرية..‬ ‫51 تركيبات دوش مھبلى من دستور األدوية للمستشفيات المصرية‬ ‫الجدول الخامس‬ ‫الجدول الخامس‬ ‫)المواد البسيطة(‬ ‫)المواد البسيطة(‬‫ويحتوى على المواد البسيطة التى يصرح باالتجار فيھا فى مخازن األدوية ويشترط أن تكون ھذه األصناف داخل عبوات محكم ة الغل ق‬‫ويحتوى على المواد البسيطة التى يصرح باالتجار فيھا فى مخازن األدوية ويشترط أن تكون ھذه األصناف داخل عبوات محكم ة الغل ق‬‫ومبينا ًا ً عليھا اسم الصنف وكميت ه وال ثمن واسمم المؤسس ة الص يدلية ال واردة منھاا وعنوانھاا واسمم الص يدلى محض ر أو مج زئ الص نف و‬‫ومبين عليھا اسم الصنف وكميت ه وال ثمن واس المؤسس ة الص يدلية ال واردة منھ وعنوانھ واس الص يدلى محض ر أو مج زئ الص نف و‬ ‫يشترط ان تباع فى عبواتھا االصلية,, وھى::‬ ‫يشترط ان تباع فى عبواتھا االصلية وھى‬ ‫72.. كبريت مسحوق..‬ ‫72 كبريت مسحوق‬ ‫41.. لبخة الكاولين..‬ ‫41 لبخة الكاولين‬ ‫1.. بيكربونات الصودا..‬ ‫1 بيكربونات الصودا‬ ‫82.. الصابون الطبى..‬ ‫82 الصابون الطبى‬ ‫51.. بارافين سائل..‬ ‫51 بارافين سائل‬ ‫2.. ماء أكسجين..‬ ‫2 ماء أكسجين‬ ‫92.. فانيليا..‬ ‫92 فانيليا‬ ‫61.. ملح أنجليزى..‬ ‫61 ملح أنجليزى‬ ‫3.. ورق بوكو..‬ ‫3 ورق بوكو‬ ‫03.. محلول اليود..‬ ‫03 محلول اليود‬ ‫71.. زيت خروع..‬ ‫71 زيت خروع‬ ‫4.. سائل قاتل للحشرات..‬ ‫4 سائل قاتل للحشرات‬ ‫13.. قرفة..‬ ‫13 قرفة‬ ‫81.. ينسون..‬ ‫81 ينسون‬ ‫5.. مسحوق العرقسوس المركب..‬ ‫5 مسحوق العرقسوس المركب‬ ‫23.. كحول نقى..‬ ‫23 كحول نقى‬ ‫91.. نفتالين..‬ ‫91 نفتالين‬ ‫6.. مسحوق ففحم نباتى..‬ ‫6 مسحوق حم نباتى‬ ‫33.. أقراص األسبرين..‬ ‫33 أقراص األسبرين‬ ‫02.. قطن طبى..‬ ‫02 قطن طبى‬ ‫7.. خشب المر..‬ ‫7 خشب المر‬ ‫43.. زيت كافور..‬ ‫43 زيت كافور‬ ‫12.. زبدة كاكاو..‬ ‫12 زبدة كاكاو‬ ‫كاكاو‬ ‫8.. درماتول..‬ ‫8 درماتول‬ ‫53.. اللزقات فيما عدا المحتوية على‬ ‫53 اللزقات فيما عدا المحتوية على‬ ‫22.. سترات الصودا الفوارة الجاھزة..‬ ‫22 سترات الصودا الفوارة الجاھزة‬ ‫9.. سلفات الصودا..‬ ‫9 سلفات الصودا‬ ‫مواد سامه أو مخدرة..‬ ‫مواد سامه أو مخدرة‬ ‫63.. فازلين..‬ ‫63 فازلين‬ ‫32.. قطرات العين الجاھزة..‬ ‫32 قطرات العين الجاھزة‬ ‫01.. سائل مطھر..‬ ‫01 سائل مطھر‬ ‫73.. مقياس حرارة..‬ ‫73 مقياس حرارة‬ ‫42.. حقنة شرجية..‬ ‫42 حقنة شرجية‬ ‫11.. جاسرين..‬ ‫11 جاسرين‬ ‫83.. ثدى صناعى..‬ ‫83 ثدى صناعى‬ ‫52.. روح النعناع..‬ ‫52 روح النعناع‬ ‫21.. مرھم زنك..‬ ‫21 مرھم زنك‬ ‫93.. حلمة الثدى..‬ ‫93 حلمة الثدى‬ ‫62.. ورق السينامكا..‬ ‫62 ورق السينامكا‬ ‫31.. كراوية..‬ ‫31 كراوية‬ ‫04.. أربطة شاش..‬ ‫04 أربطة شاش‬ ‫الجدول السادس‬ ‫الجدول السادس‬ ‫)المواد الملتھبة والمفرقعة والخطرة(‬ ‫)المواد الملتھبة والمفرقعة والخطرة(‬‫ويحتوى على المواد القابلة لاللتھاب و المواد المفرقعة و المواد الخطرة التى يجوز خزنھا فف ى المؤسس ات الص يدليه و المح ال الم رخص‬‫ويحتوى على المواد القابلة لاللتھاب و المواد المفرقعة و المواد الخطرة التى يجوز خزنھا ى المؤسس ات الص يدليه و المح ال الم رخص‬ ‫لھا باالتجار فى المواد الصناعية,, وھى::‬ ‫لھا باالتجار فى المواد الصناعية وھى‬ ‫أأ-- المواد القابلة لاللتھاب‬ ‫المواد القابلة لاللتھاب‬ ‫عدد‬ ‫عدد‬ ‫عدد‬ ‫عدد‬ ‫02 لتر بنزين..‬ ‫02 لتر بنزين‬ ‫01 لتر إثير..‬ ‫01 لتر إثير‬ ‫5 لتر تربنتينا..‬ ‫5 لتر تربنتينا‬ ‫01 لتر كلوديون..‬ ‫01 لتر كلوديون‬ ‫ب-- المواد المفرقعة‬ ‫المفرقع‬ ‫ب المواد المفرقعة‬ ‫5 كيلو كلورات البوتاسا..‬ ‫5 كيلو كلورات البوتاسا‬ ‫½ كيلو كلورات الصودا..‬ ‫½ كيلو كلورات الصودا‬ ‫5 كيلو نترات البوتاسا.‬ ‫جـ-- المواد الخطرةة‬ ‫جـ المواد الخطر‬ ‫5 كيلو حامض الخليك..‬ ‫5 كيلو حامض الخليك‬ ‫01 لتر كحول بدرجة 001..‬ ‫01 لتر كحول بدرجة 001‬ ‫2 كيلو حامض الكبريت..‬ ‫2 كيلو حامض الكبريت‬ ‫05 لتر كحول بدرجة 59..‬ ‫05 لتر كحول بدرجة 59‬ ‫02 كيلو حامض النتريك..‬ ‫02 كيلو حامض النتريك‬ ‫05 لتر كحول بدرجة عادى..‬ ‫05 لتر كحول بدرجة عادى‬ ‫052 جرام حامض البكريك..‬ ‫052 جرام حامض البكريك‬ ‫5 كيلو نترات الصودا..‬ ‫5 كيلو نترات الصودا‬
  • 198. ‫01 كيلو حامض الفوسفوريك..‬ ‫01 كيلو حامض الفوسفوريك‬ ‫ولتخزين ھذه المواد يجب إتباع الشروط اآلتية::‬ ‫ولتخزين ھذه المواد يجب إتباع الشروط اآلتية‬‫1. توضع كل مجموعة من ھذه المجاميع الثالثة على حدة داخل ص ناديق م ن الخش ب بھاا طبق ة س ميكة م ن الرم ل األص فر‬‫توضع كل مجموعة من ھذه المجاميع الثالثة على حدة داخل ص ناديق م ن الخش ب بھ طبق ة س ميكة م ن الرم ل األص فر‬ ‫الناعم..‬ ‫الناعم‬‫2. توضع صناديق المجاميع الثالثة داخل دوالب مستقل مقسم إل ى أقس ام رأس ية بك ل قسمم مجموعت ه و بھ ذا ال دوالب ثق وب‬‫توضع صناديق المجاميع الثالثة داخل دوالب مستقل مقسم إل ى أقس ام رأس ية بك ل قس مجموعت ه و بھ ذا ال دوالب ثق وب‬ ‫للتھوية تغطى من الداخل بشبك من السلك الضيق النـسيج و يوضع عليھا الفتة مكتوب عليھا ))مواد خطرة(.‬ ‫للتھوية تغطى من الداخل بشبك من السلك الضيق النـسيج و يوضع عليھا الفتة مكتوب عليھا مواد خطرة(.‬ ‫3. توضع جميع السوائل داخل زجاجات سميكة مغلقة إغالقا ًا ً محكما ًا ً و باقى المواد داخل عبوات مناسبة..‬ ‫توضع جميع السوائل داخل زجاجات سميكة مغلقة إغالق محكم و باقى المواد داخل عبوات مناسبة‬ ‫4. تمأل جميع الزجاجات و العبوات خارج مكان تخزينھا..‬ ‫تمأل جميع الزجاجات و العبوات خارج مكان تخزينھا‬ ‫5. توضع ھذه المواد فى جھة واحدة من المحال المرخص بھا و بطريقة تجعل الوصول إليھا سھالً من الش ارع و بعيدداًاً‬‫توضع ھذه المواد فى جھة واحدة من المحال المرخص بھا و بطريقة تجعل الوصول إليھا سھالً من الش ارع و بعي ع ن‬‫عن‬ ‫مكان إشعال النار..‬ ‫مكان إشعال النار‬ ‫6. ضرورة وجود جھاز إطفاء رغوى سعة 2 جالون مع وضعه فى مكان قريب..‬ ‫ضرورة وجود جھاز إطفاء رغوى سعة 2 جالون مع وضعه فى مكان قريب‬ ‫الجدول السابع‬ ‫الجدول السابع‬ ‫)العـطارة النباتية(‬ ‫ويحتوى على عبارة عن أصناف العـطارة النباتية التى يمكن للعطارين االتجار فيھا, وھى:‬ ‫ويحتوى على‬ ‫91.. حنة بغدادى..‬ ‫91 حنة بغدادى‬ ‫01.. حبھان..‬ ‫01 حبھان‬ ‫1.. تمر ھندى..‬ ‫1 تمر ھندى‬ ‫02.. زھرة بنفسج..‬ ‫02 زھرة بنفسج‬ ‫11.. حلبة..‬ ‫11 حلبة‬ ‫2.. حبة البركة..‬ ‫2 حبة البركة‬ ‫12.. فلفل أسود..‬ ‫12 فلفل أسود‬ ‫21.. زنجبيل..‬ ‫21 زنجبيل‬ ‫3.. زعفران..‬ ‫3 زعفران‬ ‫22.. سنامكى..‬ ‫22 سنامكى‬ ‫31.. صبر..‬ ‫31 صبر‬ ‫4.. عرقسوس..‬ ‫4 عرقسوس‬ ‫32.. صمغ..‬ ‫32 صمغ‬ ‫41.. قرنفل..‬ ‫41 قرنفل‬ ‫5.. قرفة..‬ ‫5 قرفة‬ ‫42.. كثبره..‬ ‫42 كثبره‬ ‫51.. كبريت..‬ ‫51 كبريت‬ ‫6.. كراوية..‬ ‫6 كراوية‬ ‫52.. لبان..‬ ‫52 لبان‬ ‫61.. كركديه..‬ ‫61 كركديه‬ ‫7.. كركم..‬ ‫7 كركم‬ ‫62.. محلب..‬ ‫62 محلب‬ ‫71.. كمون..‬ ‫71 كمون‬ ‫8.. مغات..‬ ‫8 مغات‬ ‫72.. ينسون..‬ ‫72 ينسون‬ ‫81.. نعناع..‬ ‫81 نعناع‬ ‫9.. بذر كتان..‬ ‫9 بذر كتان‬ ‫الفصل السادس‬ ‫العقوبات‬ ‫مادة 97: يعاقب بالحبس مدة ال تجاوز سنتين وبغرامة ال تزيد على مائتين جنيه أو بإحدى ھاتين العقوبتين كل من:‬ ‫أ- زاول مھنة الصيدلة بدون ترخيص‬ ‫ب- حصل على ترخيص بفتح مؤسسة صيدلية بطريق التحاليل أو باستعارة اسم صيدلى‬ ‫ج-الصيدلى الذى أعار اسمه لھذا الغرض‬‫د-كل شخص غير مرخص له فى مزاولة المھنة يعلن عن نفسه بأى وسيلة تحمل الجمھور على االعتقاد بأنه له الح ق‬ ‫فى مزاولة مھنة الصيدلة.‬‫مادة 08: يعاقب بغرامة ال تقل عن 05 جنيھ ا وال تزي د عل ى 002 جني ه ك ل م ن ف تح أو أنش أ أو أدار مؤسس ة ص يدلية‬‫ب دون ت رخيص وف ى ھ ذه الحال ة تغل ق المؤسس ة إداري ا وف ى حال ة الع ودة تك ون العقوب ة الح بس م دة ال تزي د عل ى س نة‬ ‫والغرامة فى الحدود المتقدمة معا.‬‫مادة 18: يعاقب بغرامة ال تقل عن 02 جنيھا وال تزيد على 001 جنيه كل من أدار صناعة اخرى بالمؤسسة الص يدلية‬‫المرخص لھا وإذا تكررت المخالفة خالل ثالثة أعوام من تاريخ الحكم فى المحاكم ة األول ى يحك م ب إغالق المؤسس ة م دة‬ ‫ال تقل عن ستة اشھر وال تزيد على سنة.‬‫مادة 28: كل مخالفة ألحكام المادة 57 يعاقب مرتكبيھا بغرامة ال تق ل ع ن خمس ة جنيھ ات وال تزي د ع ن عش رين جني ه‬‫وتوقع العقوبة على كل من البائع وصاحب المؤسسة ومديرھا وإذا تكررت المخالفة خ الل ثالث ة أع وام م ن ت اريخ وق وع‬
  • 199. ‫مادة 38: كل مخالفة ألحكام القانون او القرارات الصادرة تنفيذا له يعاقب مرتكبيھا بغرامة ال تقل ع ن جنيھ ين وال تزي د‬ ‫على عشرة جنيھات وذلك مع عدم اإلخالل بأية عقوبة أشد يقضى بھا أى قانون آخر .‬‫م ادة 48: ف ى جمي ع األح وال يحك م فض ال ع ن العقوب ات المتقدم ة بمص ادرة األدوي ة موض وع المخالف ة واألدوات الت ى‬ ‫ارتكبت بھا.‬‫مادة 58: يعتبر من مأورى الضبط القض ائى ف ى تطبي ق أحك ام ھ ذا الق انون الص يادلة الرؤس اء ومس اعدوھم م ن مفتش ى‬ ‫الصيدليات بوزارة الصحة وكذلك كل من ينتدبه وزير الصحة لھذا الغرض .‬ ‫طلب فتح صيدلية‬ ‫يرسل ھذا الطلب لوزارة الصحة – قسم الصيدليات – بخطاب مسجل مصحوب بالبيانات التالية:‬ ‫1- اسم ولقب طالب الترخيص وعنوانه.‬ ‫2- جنسيته‬ ‫3- سن طالب الترخيص وقت تقديم الطلب بالحساب الميالدى.‬ ‫4- اسم وعنوان الصيدليات التى يملكھا الطالب أو يشارك فيھا.‬ ‫5- نوع الترخيص المطلوب .‬ ‫6- االسم الذى سيطلق على المؤسسة .‬ ‫7- عنوان المؤسسة المطلوب الترخيص بھا.‬ ‫8- اسم مالك العقار .‬ ‫9- اسم وعنوان آخر مؤسسة كان يشتغل بھا طالب الترخيص .‬ ‫01- رقم قيد الطالب فى النقابة والوزارة.‬ ‫11- رقم اإليصال الدال على سداد رسم النظر.‬ ‫21- تاريخ تقديم الطلب‬ ‫31-شھادة تحقيق الشخصية وصحيفة خلو من السوابق.‬ ‫41- شھادة الميالد أو مستخرج رسمى منھا .‬ ‫51-إيصال يدل على سداد رسم قدره خمسة جنيھات رسم النظر المقرر.‬ ‫61-رسم ھندسى للمؤسسة المراد الترخيص بھا من ثالث صور بمعرفة مھندس نق ابى ملص قا علي ه طواب ع‬ ‫ھندسية ومبينا أطوال المحل من الداخل ومساحته.‬ ‫71-شھادة من الوزارة بأنه مضى على تخرجه أكثر من عام.‬ ‫81-شھادة من الوزارة بعدد الصيدليات التى يمتلكھا صاحب األوراق أويشارك فيھا.‬ ‫91-شھادة من النقابة العامة للصيادلة بالقاھرة بأن طالب الترخيص ما زال مقيدا بسجالتھا.‬ ‫02- شھادة من النقابة الفرعية للصيادلة بالموافقة على االسم التجارى للصيدلية‬ ‫12-صورة عقد اإليجار الموثق الخاص بالصيدلية .‬ ‫22-عمل الفتة مبين عليھا اسم الصيدلية تحت الترخيص فى مكان ظاھر‬ ‫االشتراطات الصحية الواجب توافرھا فى المؤسسات الصيدلية:‬ ‫االشتراطات الصحية المستديمة الواجب توافرھا فى جميع المؤسسات الصيدلية:‬‫ينشأ البناء بالدبش أو الطوب األحمر أو الخرسانة ويجب أن يكون السقف من الخرسانة المسلحة, أو م ن أي ة م ادة أخ رى‬‫توافق عليھا اإلدارة الص حية المختص ة وتك ون غي ر قابل ة لالحت راق وبارتف اع 07.2 مت را عل ى األق ل وأن تك ون جمي ع‬ ‫المبانى واألرضيات واألحواض والمراحيض وأدوات الصرف وغيرھا بحالة جيدة ونظيفة.‬
  • 200. ‫يج ب أن تك ون أرض ية المح ل منخفض ة ع ن مس توى الطري ق الع ام أو األرض المج اورة للمح ل كم ا يج ب أن ت دك‬‫بالخرسانة دكا متينا وتغطى بالبالط فى المكان المعد للبيع أو الخ زن أو المس تعملة مكات ب وبش رط أن يك ون الخش ب م ن‬ ‫النوع الجيد وأن تكون فواصله ملحومة جيدا.‬‫يجب أن يبطن أسفل الحوائط من ال داخل باألس منت األمل س الس ميك بارتف اع مت ر ونص ف عل ى األق ل م ن األرض ية وأن‬‫يبطن ما ف وق ذل ك بمون ة الجي ر والرم ل كم ا يج ب رش الح وائط والس قف ب الجير م ع دھ ن الج زء األس فل م ن الج دران‬ ‫بالبوية الزيتية ويعاد البياض بالزيت كلما لزم ذلك.‬‫تفتح فى المحل النوافذ الكافي ة للتھوي ة وتغط ى بنس يج م ن الس لك لمن ع ال ذباب ويج ب إال تق ل مس احة م ا يف تح منھ ا عل ى‬‫الفض اء مباش رة ع ن س دس مس احة األرض, وف ى حال ة وج ود فتح ات باألس قف لإلض اءة أو التھوي ة فإن ه يج ب تغطيتھ ا‬ ‫بطريقة ال يتسبب عنھا نقص فى الضوء والتھوية. تدھن جميع األخشاب بالبوية الزيتية.‬‫ويجب إيج اد ف رع خ اص م ن الم ورد العم ومى للمي اه المرش حة ويؤخ ذ من ه المي اه راس يا بواس طة حنفي ات داخ ل المح ل‬‫ويجب أن تكون األحواض من الصينى أو الفخار المزجج وبأسفل كل منھا ماسورة حرف ‪ S‬ويجب تغطي ة الح ائط أعل ى‬‫كل حوض وكذلك أعلى الرخامة المائلة بجوار حوض غسيل األوان ى ب البالط القش انى األب يض الم زجج غي ر المش طوف‬ ‫الحواف بارتفاع 06 سم على األقل.‬‫يجب صرف متخلفات المحل فى المجارى العمومية حسب الرسم المعتمد بشرط موافقة الجھ ة المختص ة باألش راف عل ى‬‫المجارى فإذا لم توجد مجارى صرف عام على بعد 03 مترا أو أق ل فيك ون الص رف ف ى خ زان مس تقل يبن ى ف ى فض اء‬‫تابع وخارج المبانى طبقا للرسم المعتمد أو فى خ زان تحلي ل وبي ارة ص رف أو خن دق حس ب طبيع ة الترب ة ويل زم تغطي ة‬‫فتحات المجارى أو الخزان بأغطية حديدية محكمة وتغذيتھا بماسورة أربعة بوصة ترتفع مترين على األق ل ع ن األس طح‬‫المج اورة والمقابل ة وتغط ى فتحتھ ا العلي ا بس لك ض يق النس يج لمن ع البع وض, عل ى أن ه مت ى اقترب ت المج ارى العام ة‬‫وأصبحت على بعد ثالثين مترا أو اقل عن المحل وجب توصيل مياه المح ل إليھ ا وردم الخزان ات الموج ودة بع د كس حھا‬‫بحي ث ال بترت ب عل ى كس حھا أي ة أض رار أو الم رور ف ى أي ة غرف ة م ن غ رف التش غيل كم ا يج ب أن تك ون بعي دة ع ن‬‫الحوائط بمقدار مترين على األقل ما لم يكن الخزان أصم فيجوز فى ھذه الحالة التجاوز عن شرط البعد عن الحوائط وإذا‬‫عمل الخزان فى شارع عمومى فيج ب أن يبن ى تح ت منس وب الش ارع وتعم ل حوائط ه وقاع ه ب الطوب األحم ر والمون ة‬‫األسمنتية ويخفف جيدا باألسمنت وتعمل له فتحة 6.6 سم ويغطى باحكام وبشرط موافقة الجھة المختصة بالمجارى عل ى‬‫إقامة الخزان بالشارع ويجب تغطية جميع الغ رف عل ى أنواعھ ا بأغطي ة م ن الزھ ر محكم ة ال تنف ذ منھ ا الغ ازات ويل زم‬‫غرفة التفتيش عامود تھوية وفى حالة تعذر رفع ماسورة التھوية بالقدر المطل وب يج وز تركي ب رأس ف ى نھايتھ ا بداخل ه‬ ‫لوح يسمح بدخول الھواء الخارجى وال يسمح بمرور الھواء الداخلى.‬‫إذا وافقت وزارة الصحة على وجود صندرة بالمحل فيجب أن يراعى توافر الض وء والتھوي ة اس فلھا وأعالھ ا وأن تك ون‬ ‫متينة البنيان وأن تحاط حوافھا بحاجز بارتفاع 07 سم على األقل وأن يخصص سلم متين ليوصل إليھا.‬ ‫- ال يجوز تأجير أى من المحل للغير وال استعماله لغير الغرض المرخص له.‬ ‫- ال يجوز إيجاد مواد أو أدوات خالف الالزمة للعمل المرخص له.‬ ‫- ال يجوز وجود حيوانات أو طير بالمحل .‬‫- يج ب العناي ة بنظاف ة المح ل عل ى ال دوام ويج ب إيج اد وع اء للمتخلف ات يكت ب علي ه اس م ص احب المح ل بالبوي ة‬ ‫الزيتية.‬‫يجب أن يكون المحل مطابقا آلخر رسم ھندسى معتمد من السلطات المختصة وشامال لجميع البيانات المدونة على الرس م‬‫وال يج وز إج راء أى تع ديل بأوض اع المح ل قب ل الحص ول مق دما عل ى موافق ة كتابي ة م ن وزارة الص حة ويج ب حف ظ‬ ‫الرخصة ونسخة من ھذه االشتراطات وصورة الرسم المعتمد ودفتر للعمال بالمحل على الدوام لتقديمھا عند الطلب‬ ‫يجب آال تقل مساحة الصيدلية عن 52 مترا مربعا.‬ ‫الجواھر المخدرة فى القانون رقم 281 لسنة 0691 والمعدل بالقانون لسنة 891 بشأن مكافحة‬ ‫المخدرات وتنظيم استعمالھا أو االتجار فيھا‬ ‫الفصل األول‬
  • 201. ‫المواد المعتبرة مخدرة‬ ‫تعريف الجواھر المخدرة:‬ ‫1-‬‫الج واھر المخ درة ھ ى م واد ومستحض رات ص يدلية لھ ا ت أثير فارم اكولوجى عل ى اإلنس ان يختل ف ب اختالف األدوي ة‬ ‫وجرعاتھا عند استعمال أحدھا كمسكن لأللم أو كمنوم أو كمخدر.‬ ‫2- األدمان:‬‫من المعلوم أن ھذه الجواھر المتقدمة ال غنى عنھا فى العالج الطبى , بل قد يلزم اس تخدامھا إلنق اذ حي اة م ريض – غي ر‬‫أن إدمانھا تنجم عنه أضرار بليغة للفرد والمجتمع, فھى بالنسبة للمدمن تقضى على بدن ه وعقل ه قض اء مب رم. وال مبالغ ة‬‫إذا قلن ا أنھ ا تھ دم كي ان البش ر كمخل وق آدم ى بجان ب إض اعة مثل ه العلي ا وإھ دار كاف ة قيم ه الروحي ة والمعنوي ة – أم ا‬‫المجتمع الذى يض م ب ين جنبات ه ھ ؤالء الم دمنين فھ و مجتم ع متخل ف حض اريا غي ر أھ ل للس ير ف ى رك ب التق دم العلم ى‬‫واألدبى على حد سواء من أجل ھذا لم يكن غريبا أن تعلن الدول المختلفة حربا ال ھوادة فيھا على إدم ان المخ درات ب ين‬‫أبنائھا وأن تنظم التشريعات المختلفة استعمال ھذه المخدرات واالتجار فيھا ومن أج ل ھ ذا أيض ا ك ان الق انون رق م 281‬‫لس نة 0691 المع دل بالق انون 221 لس نة 9891 ال ذى نح ن بص دد دراس ته وق د أدرج ت في ه الج دول األول الملح ق ب ه‬ ‫المواد المعتبرة مخدرة والمسببة لإلدمان والتى تسرى عليھا احكام ھذا القانون.‬ ‫3- النباتات التى تستخرج منھا المواد المخدرة:‬ ‫‪PAPAVER SOMNIFERUM‬‬ ‫أوال: الخشخاش‬ ‫‪ERYTHROXYLUM-COCA‬‬ ‫ثانيا: الكوكا‬ ‫‪CANNABID‬‬ ‫ثالثا: الحشيش‬ ‫‪CATHA EDULIS‬‬ ‫رابعا القات‬ ‫ويتم استخالص األفيون من الخشخاش بتجريح ثماره وأھم اشباه قلوياته ھو "المورفين" ومركباته وامالحه ومشتقاته.‬ ‫4- الجواھر المخدرة المخلقة:‬‫تضمن الجدول األول المشار إليه والملح ق بالق انون مركب ات كثي رة مخلق ة معملي ا لھ ا نف س المفع ول المس كن أو المخ در‬‫ألشباه القلوي ات المس تخرجة م ن النبات ات الس ابق ذكرھ ا وأن كان ت ق د أعطي ت لھ ا اس ماء تجاري ة وتس رى عليھ ا تنظ يم‬ ‫استعمال المخدرات وتخضع ألحكام اإلدمان.‬ ‫5- المنومات والمنبھات:‬‫شاع استعمال بعض مركب ات حم ض "الباربيتيوري ك" المس تخدمة كمنوم ات ب ين الطبق ة المدمن ة عل ى تع اطى األفي ون إذ‬‫أنھا تھيئ للمدمنين نفس األثر الناتج من تعاطيھم األفيون وإزاء ذل ك ك ان الب د م ن مكافح ة ھ ذا الن وع م ن األدم ان ايض ا‬‫إلدراج تلك المركبات فى الجدول السابق منعا إلدمانه, ومع كونه أثره الفارماكولوجى ھ و التنبي ه عل ى نق يض المخ درات‬ ‫إال إنھما يتفقان فى أنھما يسببان اإلدمان وھو ما شرع القانون لمكافحته.‬ ‫جداول قانون المخدرات‬ ‫"الجدول رقم 1"‬ ‫المواد المعتبرة مخدرة‬ ‫ومن أمثلتھا:‬ ‫1- كوكايين:‪ :Cocaine‬وكافة أمالحه ومستحضراته التى تحتوى على أكثر من 1% من الكوكايين.‬ ‫2- ھيروين ‪ Heroin‬ثنائى أستيل مورفين‬ ‫3- مورفين ‪ :Morphine‬وكافة أمالحه ومستحضراته.‬ ‫4- أوكسيمورفين ‪Oxymorphine‬‬ ‫5- اسيتورفين ‪Acetorphine‬‬ ‫6- داى ھيدرومورفينون ‪Dihydromorhinone‬‬ ‫7- مثيل داى ھيدرومورفين ‪Methyldihydromorphine‬‬ ‫ويشمل األفيون الخام وكافة مستحضرات األفيون.‬ ‫8- بنزويل مورفين ‪Benzolymorphine‬‬
  • 202. ‫9- ديزومورفين ‪Desomorphine‬‬ ‫01-أموباربيتال ‪Amobarbital‬‬ ‫11- استيل ميثادول ‪Acetylmethadol‬‬ ‫21- ألفاستيل ميثادول ‪Alphacetylmethadol‬‬ ‫31- ھيدروكودون ‪Hydrocodone‬‬ ‫41- بثيدين ‪Pethidine‬‬ ‫51- ثيبايين ‪Thebaine‬‬ ‫61- ثيباكون ‪Thebacone‬‬ ‫71- الحشيش بجميع أنواعه ومسمياته مثل الكمنجة أو البانجو أو المارجوانا.‬ ‫81- أمفيتامين ‪Amphetamine‬‬ ‫91- ديكسامفيتامين ‪ :Dexamphetamine‬بجميع أمالحه ومستحضراته مثل ماكستون.‬ ‫02- مستخلصات قش الخشخاش ‪Concentrate of poppy straw‬‬ ‫12- مثيل فينيدات ‪ Methylphenidate‬بجميع أمالحه ومستحضراته مثل ‪Ritalin‬‬ ‫22- اكوجونين ‪Ecogonine‬‬ ‫"الجدول رقم 2"‬ ‫وھو يحوى المستحضرات المستثناة من النظام المطبق على المواد المخدرة.‬ ‫"الجدول رقم 3"‬ ‫يحوى المواد التى تخضع لبعض قيود الجواھر المخدرة, وأھم ھذه القيود أنھا تعتبر من المخدرات فى حالة االستيراد والتصدير, ومن أمثلتھا:‬ ‫وھو‬ ‫ايثيل المورفين وامالحه‬ ‫1-‬ ‫ميثيل المورفين وامالحه‬ ‫2-‬ ‫داى ھيدروكودايين وامالحه‬ ‫3-‬ ‫أستيل داى ھيدروكودايين وامالحه‬ ‫4-‬ ‫"الجدول رقم 4"‬‫وھوالذى ورد به بيان الحد األقصى لكميات الجواھر المخدرة ال ذى ال يج وز لألطب اء البش ريين وأطب اء األس نان تج اوزه‬ ‫فى وصفة طبية واحدة.‬ ‫60.0 جرام‬ ‫االفيون‬ ‫)1(‬ ‫06.0جرام‬ ‫المورفين وكافة امالحه‬ ‫)2(‬ ‫60.0جرام‬ ‫بنزويل المورفين وامالحه‬ ‫)3(‬ ‫02.0 جرام‬ ‫اوكسى مورفين‬ ‫)4(‬ ‫60.0 جرام‬ ‫ديزومورفين‬ ‫)5(‬ ‫60.0جرام‬ ‫داى ھيدروموفينون وامالحه‬ ‫)6(‬ ‫3.0 جرام‬ ‫ميثيل داى ھيدرومورفين وامالحه‬ ‫)7(‬ ‫1.0جرام‬ ‫االكوجونين وكافة امالحه‬ ‫)8(‬ ‫51.0 جرام‬ ‫الثيبايين وامالحه‬ ‫)9(‬
  • 203. ‫الكوكايين وكافة امالحه:‬ ‫)01(‬ ‫1.0جرام‬ ‫لالستعمال الباطنى‬ ‫04.0جرام‬ ‫لالستعمال الظاھرى‬ ‫06.0جرام‬ ‫القنب الھندى "كانابيس ساتيفا "‬ ‫)11(‬ ‫02.0جرام‬ ‫راتنج القنب الھندى‬ ‫02.0جرام‬ ‫خالصة القنب الھندى‬ ‫06.0ملليلتر‬ ‫خالصة القنب الھندى السائلة‬ ‫00.4ملليلتر‬ ‫صبغة القنب الھندى‬ ‫"الجدول رقم 5"‬ ‫النباتات الممنوع زراعتھا فى مصر‬ ‫النباتات الممنوع زراعتھا فى مصر‬ ‫1.. القنب الھندي ))كانابيس ساتيفا(( بجميع أنواعه ومسمياته مثل الحشيش أو الكمنجة أو البانجو أو المارجوانا..‬ ‫1 القنب الھندي كانابيس ساتيفا‬ ‫2.. الخشخاش ))بابافر سومنيفرم(.‬ ‫2 الخشخاش بابافر سومنيفرم(.‬ ‫3.. جميع أنواع جنس البابافر..‬ ‫3 جميع أنواع جنس البابافر‬ ‫4.. الكوكا ))ارثيروكسيلوم كوكا(.‬ ‫4 الكوكا ارثيروكسيلوم كوكا(.‬ ‫5.. القات بجميع أصنافه و مسمياته..‬ ‫5 القات بجميع أصنافه و مسمياته‬ ‫"الجدول رقم 6"‬ ‫أجزاء النباتات المستثناة من أحكام القانون و التى يمكن تداولھا‬ ‫1.. بذور الخشخاش المحموسة حمسا ًا ً يكفل عدم إنباتھا..‬ ‫1 بذور الخشخاش المحموسة حمس يكفل عدم إنباتھا‬ ‫2.. رؤوس الخشخاش المجرحة الخالية من البذور..‬ ‫2 رؤوس الخشخاش المجرحة الخالية من البذور‬ ‫3.. بذور القنب الھندي المحموسة حمسا ًا ً يكفل عدم إنباتھا..‬ ‫3 بذور القنب الھندي المحموسة حمس يكفل عدم إنباتھا‬ ‫4.. ألياف سيقان نبات القنب الھندى..‬ ‫4 ألياف سيقان نبات القنب الھندى‬ ‫التعامل مع المحظور فى الجواھر المخدرة‬ ‫النص القانونى :‬‫نصت المادة الثانية من القانون على انه "يحظر على أى شخص أن يجلب أو يصدر أو ينتج أو يملك أو يحرز أو يشترى‬‫أو يبيع جواھر مخدرة بأى صفة كانت أو أن يتدخل بصفته وسيطا فى شئ من ذلك إال فى األحوال المنصوص عليھا فى‬ ‫ھذا القانون وبالشروط المبينة به ".‬ ‫الجلب والتصدير والنقل )القيود القانونية(‬ ‫الجلب والتصدير :‬‫ال يج وز جل ب الج واھر المخ درة إل ى جمھوري ة مص ر العربي ة أو تص ديرھا إال بمقتض ى ت رخيص كت ابى م ن الجھ ة‬ ‫اإلدارية المختصة وتمثل وزارة الصحة ھذه الجھة وبالشروط التى حددھا ھذا القانون .‬ ‫أذن جلب:‬ ‫ال يمنح أذن جلب الجواھر المخدرة إال لألشخاص اآلتية :‬ ‫1- مديرى المحال المرخص لھا فى االتجار فى الجواھر المخدرة )المؤسسة المصرية العامة لألدوية وشركاتھا(.‬ ‫2- مديرى الصيدليات أو مصانع المستحضرات األقرباذينية.‬ ‫3- مديرى معامل التحاليل الكيميائية أو الصناعية أو األبحاث العلمية .‬ ‫4- مصالح الحكومة والمعاھد العلمية المعترف بھا.‬‫وتعداد ھؤالء األاشخاص وارد فى القانون على سبيل الحصر وھم يمثلون المجال المختلفة التى قد تحتاج فى أعمالھا إلى‬ ‫الجواھر المخدرة.‬ ‫أذن تصدير :‬‫ال يم نح أذن تص دير الج واھر المخ درة إال لم ديرى المح ال الم رخص لھ ا ف ى االتج ار ف ى الج واھر المخ درة وتمثلھ ا‬ ‫المؤسسة المصرية العامة لألدوية.‬ ‫طلب الحصول على أذن الجلب أو التصدير :‬‫للحصول على أذن جلب أو تصدير الجواھر المخدرة يتقدم الطالب إلى الجھة اإلدارية المختصة بطلب يبين فيه ما يلى :‬
  • 204. ‫1- اسم الطالب‬ ‫2- عنوان عمله‬ ‫3- اسم الجوھر المخدر بالكامل وطبيعته من حيث الشكل الصيدلى وقوته‬ ‫4- الكمية التى يراد جلبھا أو تصديرھا‬ ‫5- بيان األسباب المبررة للجلب أو التصدير‬‫وھذه البيانات تدون فى الطلب إلى جان ب البيان ات األخ رى الت ى تطلبھ ا الجھ ة اإلداري ة المختص ة وعل ى النم وذج المع د‬ ‫لذلك والذى يحصل عليه الطالب من وزارة الصحة.‬ ‫وللجنة اإلدارية رفض طلب الحصول على األذن أو خفض الكمية المطلوبة.‬ ‫قيد الجواھر المخدرة:‬ ‫على الصيدلى مدير المخزن أو المستودع ان يمسك دفترا خاصا لقيد الجواھر المخدرة به على الوجه التالى :‬ ‫1- ترقم صحائف الدفتر وتختم بخاتم الجھة اإلدارية المختصة )وزارة الصحة(.‬ ‫2- يقيد فى الدفتر تاريخ ورود الجواھر المخدرة للمحل واسم البائع وعنوانه وتاريخ الصرف واسم المشترى وعنوانه.‬ ‫3- يذكر فى الوارد والمنصرف اسم الجوھر المخدر بالكامل وطبيعته)الشكل الصيدلى( وكميته ونسبته.‬ ‫اإلخطار الشھرى بالعھدة :‬‫على الصيدلى مدير المخزن أو المستودع أن يرسل بكتاب موص ى علي ه إل ى الجھ ة اإلداري ة المختص ة )وزارة الص حة(‬‫فى األسبوع األول من كل شھر كشفا موقع ا علي ه من ه ومبين ا ب ه ال وارد م ن الج واھر المخ درة والمص روف منھ ا خ الل‬ ‫الشھر السابق, والباقى منه وذلك على النماذج التى تعدھا الوزارة لھذا الغرض.‬‫وبذلك تتجمع لدى الوزارة البيانات الكاملة عن الحركة الشھرية للجواھر المخدرة فى المخازن والمستودعات التى تت اجر‬‫فيھ ا وت تمكن ال وزارة م ن مراقب ة عملي ات االتج ار )البي ع والش راء ومتوس طاتھا المعت ادة( وتكش ف ب ذلك العلمي ات غي ر‬‫العادي ة ف ور وقوعھ ا لتقص ى أس بابھا وذل ك بجان ب التفت يش ال دورى والمف اجئ ال ذى تجري ه ال وزارة عل ى ھ ذه المح ال‬ ‫بواسطة مفتشيھا.‬ ‫األحكام الخاصة بورود الجواھر المخدرة إلى الصيدليات وصرفھا منھا‬ ‫حصول الصيدلية على الجواھر المخدرة :‬‫تحصل الصيدلية على الجواھر المخدرة طبقا ألحكام ھذا القانون إما باستيرادھا من الخارج بموجب أذن جلب يعطى م ن‬‫الجھة اإلدارية المختصة )وزارة الصحة( إلى الصيدلى مدير الصيدلية وعند وصولھا إلى الجمارك يعط ى ل ه أذن س حب‬‫كتابى لتسلمھا منھ ا وام ا ان تش تريھا الص يدلية م ن المح ال الم رخص لھ ا باالتج ار ف ى الج واھر المخ درة وھ ى مخ ازن‬ ‫ومستودعات شركات المؤسسة المصرية العامة لألدوية وشركاتھا.‬ ‫قيد الجواھر المخدرة بالصيدلية :‬‫يج ب عل ى م دير الص يدلية أن يع د دفت را خاص ا لقي د ال وارد والمنص رف م ن الج واھر المخ درة ف ى ص يدليته مرقوم ة‬‫صحائفه, ومختومة بخ اتم وزارة الص حة, ويس جل في ه ك ل م ا ي رد إل ى ص يدليته أو يص رف منھ ا أوال ب أول, ويب ين ف ى‬ ‫الدفاتر تاريخ الورود واسم الجھة التى اشتريت منھا ھذه الجواھر وعنوانھا ونوع المخدر وشكله الصيدلى وكميته.‬ ‫صرف الجواھر المخدرة فى الحاالت المرضية العادية :‬ ‫مستند الصرف )التذكرة الطبية المعدة للمخدر (:‬‫فى األمراض العادية أو المفاجأة التى تحتاج إلى استعمال الجواھر المخدرة لتخفيف األلم أو للتخدير لفترة مح دودة يك ون‬‫الص رف بت ذكرة طبي ة م ن طبي ب بش رى أو أس نان ح ائز عل ى دبل وم أو بك الوريوس . وللت ذاكر الطبي ة المع دة لوص ف‬ ‫الجواھر المخدرة مواصفات خاصة وبيانات وشروط.‬ ‫مواصفات التذاكر الطبية المعدة للمخدرات:‬‫تق وم الجھ ة اإلداري ة المختص ة)وزارة الص حة( بطب ع الت ذاكر الطبي ة المع دة لوص ف وص رف الج واھر المخ درة م ن‬‫الصيدليات وبيعھا لألطباء , وتكون ھذه التذاكر مجموعة فى دفتر واحد يتس لمه الطبي ب وك ل ت ذكرة من ه مختوم ة بخ اتم‬ ‫وزارة الصحة كما تحمل ھذه التذاكر أرقاما مسلسلة .‬ ‫المدة المحددة لصرف التذكرة الطبية :‬
  • 205. ‫نصت المادة )6( من القانون على انه "ال يجوز للصيادلة صرف ت ذكرة تحت وى عل ى مخ در بع د مض ى خمس ة أي ام م ن‬ ‫تاريخ تحريرھا .‬‫وقد حددت ھذه المدة على اعتبار أن الحالة المرضية العادية التى تحتاج إلى دواء مخدر لتخفي ف األل م ع ن الم ريض ف ى‬‫المغص الكلوي أو المراري مثال آو لتخ دير موض عي ف ى جراح ات عاجل ة أو لمس اعدة الم ريض للحص ول عل ى الراح ة‬‫بالنوم فى الحاالت العصبية أو األزمات القلبية أو فى الجروح أو الحروق الكبيرة, كل ھ ذه الح االت تحت اج ال ى اس تعمال‬‫المخدر على الفور ، وقد رأى المشرع أن عدم صرف التذكرة الطبية فى غضون خمسة أيام م ن تحريرھ ا –مھم ا كان ت‬‫اسباب ذلك – فأن المخدر المطلوب يصبح ال لزوم له وبالتالي ال داعي لصرفه، وتصبح التذكرة الطبية الص ادرة ب ه ف ى‬ ‫حكم الملغاة بنص القانون ، ويتعين على الصيدلى عدم صرفھا بفوات ھذه المدة واال استحق عقاب القانون .‬ ‫االحتفاظ بالتذكرة الطبية :‬‫يجب حفظ التذكرة الطبية التى تحتوى على الجواھر الطبية فى الصيدلية بعد صرفھا وال ترد لحاملھا ألنھا المس تند ال دال‬‫على ھذا الصرف ، ويكون االحتفاظ بھا لمدة عشر سنوات حيث يح ق لمف تش وزارة الص حة االط الع عليھ ا ط وال ھ ذه‬‫الفت رة – وم ع ھ ذا فحام ل الت ذكرة ل ه الح ق ف ى أن يطل ب م ن الص يدلية الص ارفة تس ليمه ص ورة منھ ا مختوم ة بخ اتم‬‫الصيدلية – وقد نص القانون على حظر استخدام ھذه الصورة فى الحص ول عل ى ج واھر مخ درة أو أدوي ة تحت وى عل ى‬ ‫تلك الجواھر مرة أخرى .‬ ‫قيد تذاكر الجواھر المخدرة :‬ ‫يجب أن تقيد التذكرة فى دفتر الجواھر المخدرة وأن يشمل القيد ما يلى من البيانات :-‬ ‫اسم وعنوان محرر التذكرة‬ ‫اسم المريض بالكامل ولقبه وسنه وعنوانه‬ ‫التاريخ الذى صرف فيه الدواء‬ ‫رقم القيد فى دفتر التذاكر الطبية‬ ‫كمية الجواھر المخدرة المصروفة‬ ‫ويجب أن يكون القيد فى ذات يوم الصرف أوال بأول‬ ‫ويجب االحتفاظ بھذا الدفتر لمدة عشر سنوات أيضا من تاريخ أخر قيد فيه .‬ ‫صرف الجواھر المخدرة فى الحاالت المرضية المزمنة :‬ ‫الصرف بموجب بطاقة الرخصة :‬‫قد يحتاج األمر إلى استعمال الجواھر المخدرة ومثل ذلك مرض‬ ‫فى أحوال األمراض المزمنة التى تقتضى عالجا ً طويالً‬‫السرطان الذى يلزم المصاب به حقن ا ً مس تمراً بھ ا تخفيف ا ً ل الالم القاس ية . وق د يمت د اآلج ل ب المريض أيام ا ط واال فھن اك‬ ‫يكون الصرف لھذه الجواھر من الصيدلية بموجب بطاقة رخصة يحصل عليھا الطبيب المعالج من وزارة الصحة .‬ ‫إجراءات صرف بطاقة الرخصة من الصيدلية :‬‫1- يقدم الطبيب المعالج بطاقة الرخصة الى الصيدلية مصحوبة بتذكرة طبية من التذاكر العادية ويكتب فى ھ ذه الت ذكرة‬‫العادية اسم الجوھر المخدر وشكله الص يدلى ونس بته وكميت ه باألرق ام وب الحروف وطبق ا ً للكمي ات المص رح بھ ا ف ى‬‫بطاقة الرخصة مع كتابة رقم البطاقة وتاريخھا ويكون تدوين ھذه البيانات جميعھا بالم دار أو ب القلم األنيل ين حت ى ال‬ ‫يكون ھناك مجال للكشط أو العبث ويدون فى النھاية تاريخ ھذه التذكرة مع أمضائه.‬‫2- يقوم الصيدلى بصرف الجواھر المخدرة طبقا للكمية المحددة ف ى الت ذكرة العادي ة المقدم ة ل ه ويقي د ھ ذه الت ذكرة ف ى‬‫دفتر التذاكر الطبية ثم فى دفتر الجواھر المخدرة ويحتفظ بالتذكرة لمدة عشر سنوات اسوة بتذاكر الجواھر المخ درة‬‫السابق اإلشارة إليھا وھى المستعملة فى الحاالت المرضية العاجلة نظرا ألن ھذه التذاكر جميعھا كما سبق لنا الق ول‬ ‫ھى سند الصيدلى الصارف الثبات صحة عمله ومشروعيته.‬‫3- يدون الصيدلى فى بطاقة الرخصة الكمية التى قام بصرفھا بموجب التذكرة العادية وتاريخ ھذا الصرف ويوقع عل ى‬ ‫ھذا البيان مع ختمه بخاتم الصيدلية ثم يرد بطاقة الرخصة فى النھاية إلى الطبيب .‬‫4- يج ب عل ى الطبي ب المع الج بع د ذل ك أن ي رد بطاق ة الرخص ة إل ى وزارة الص حة خ الل أس بوع م ن ت اريخ انتھ اء‬ ‫مفعولھا.‬
  • 206. ‫أحكام عامة‬ ‫حفظ دفاتر الجواھر المخدرة‬‫يجب حفظ دفاتر الجواھر المخدرة لمدة عشر سنوات من تاريخ آخر قيد ت م فيھ ا, كم ا تحف ظ الت ذاكر الطبي ة واإليص االت‬ ‫المنصوص عليھا فى ھذا القانون للمدة من التاريخ المبينم عليھا.‬ ‫نسبة التسامح فى العھدة :‬‫يح دد الق انون نس بة معين ة للتس امح ف ى العھ دة ل دى األش خاص ال ذين لھ م الح ق ف ى أن يح وزوا الج واھر المخ درة أو‬‫يحرزوھا وھذه العھدة قد تزيد أو تقل عن القدر المفروض نتيجة تعدد عمليات الوزن والكيل التى ترد عليھا عند التعام ل‬ ‫وھذه النسبة محددة على الوجه اآلتى:‬ ‫01% فى الكميات التى التزيد على جرام واحد فى المساحيق .‬ ‫أ-‬‫5% فى الكميات التى تزيد على جرام وحت ى 52 ج رام ويش ترط أال يزي د مق دار التس امح ع ن 05 س نتجرام ف ى‬ ‫ب-‬ ‫المساحيق .‬ ‫ج- 2% فى الكميات التى تزيد عن 52 جرام فى المساحيق .‬ ‫د- 5% فى الجواھر السائلة أيا كان مقدارھا.‬ ‫رجال الضبط القضائى‬ ‫وھؤالء ينقسمون إلى ثالث فئات حددھم القانون على الوجه اآلتى:‬ ‫أ- مدير ادارة مكافحة المخدرات.‬ ‫ب- مفتشى اإلدارة العامة للصيدلة بوزارة الصحة.‬ ‫ج- مفتشى وزارة الزراعة ووكالئھم والمھندسين الزراعيين المساعدين والمعاونين الزراعيين.‬ ‫إنشاء نقابة الصيادلة وأھدافھا‬‫تنشا نقابة للصيادلة تكون لھا الشخصية االعتبارية, وتباشر نشاطھا فى إطار السياسة العامة للدولة ويكون مقرھا الق اھرة‬ ‫ولھا فروع على مستوى المحافظات.‬ ‫مادة 2: تعمل النقابة على تحقيق األھداف التالية:‬ ‫1- االرتقاء بالمھنة والمحافظة على كرامتھا ورفع المستوى العلمى والمھنى للصيادلة‬ ‫2- المساھمة فى توفير الدواء لجميع أفراد الشعب .‬ ‫3- تعبئة قوى أعضاء النقابة وتنظيم جھودھم لتحقيق األھداف القومية.‬ ‫4- التفاعل الديمقراطى داخل إطار قوى الشعب العاملة بما يدفع إمكانيات التقدم.‬ ‫5- المشاركة فى دراسة خطة التنمية والمشروعات الصيدلية والدوائية المختلفة.‬ ‫6- البحث العلمى والعمل على ربط البحوث العلمية والصيدلية بواقع اإلنتاج.‬ ‫7- دراسة ونشر وسائل تحسين وزيادة اإلنتاج الدوائى وخفض تكاليفه.‬ ‫8- دراسة ونشر وسائل تحسين الخدمة الدوائية بالمستشفيات والصيدليات على جميع أنواعھا .‬‫9- حصر الكفاءات العلمية والخبرات للصيادلة وفق ا لتخصص اتھم ومس توى خب راتھم لالس تفادة ب ذلك ف ى ش ئون التعبئ ة‬ ‫العلمية والقومية.‬ ‫01- االسھام فى تخطيط وتطوير وتنفيذ برامج التعليم والتدريب المھنى والفنى للصيادلة‬‫11- االش تراك ف ى دراس ة الموض وعات والمش روعات ذات الط ابع المش ترك ب ين ال بالد العربي ة واألفريقي ة واألس يوية‬ ‫وتبادل المعلومات والخبرات الصيدلية فيما بينھا.‬ ‫21- العمل على دعم اتحاد الصيادلة العرب وتحقيق أھدافه .‬ ‫31- التعاون مع المنظمات المحلية والدولية فى كل ما يخدم أھداف النقابة .‬ ‫41- تيسير الخدمات العالجية واالجتماعية للصيادلة.‬
  • 207. ‫وفى شروط العضوية والقيد بجدول النقابة:‬ ‫تنشأ بالنقابة الجداول اآلتية:‬ ‫أ- الجدول العام: يقيد فيه كل من استوفى الشروط اآلتية بعد سداد رسم القيد وقدره خمسة جنيھات.‬‫أن يكون حاصال على درج ة البك الوريوس ف ى الص يدلة والكيمي اء الص يدلية أو م ا يعادلھ ا م ن اح دى الجامع ات‬ ‫1-‬ ‫المعترف بھا.‬‫أن يك ون متمتع ا بالجنس ية المص رية أو بجنس ية إح دى ال دول العربي ة بش رط المعامل ة بالمث ل وبموافق ة الجھ ات‬ ‫2-‬ ‫المختصة.‬ ‫أن يكون محمود السيرة حسن السمعة, وأال تكون قد صدرت ضده أحكام جنائية تمس الشرف .‬ ‫3-‬ ‫أن يكون مقيدا بسجالت وزارة الصحة .‬ ‫4-‬‫ب- جدول األخصائيين: بعد تطبيق نظام اتحاد المھن الطبية والذى يضم األطباء البشريين- أطب اء األس نان – الص يادلة -‬‫األطباء البيطريين تقرر أنشاء جدول األخصائيين ويقيد فيه كل م ن أس توفى الش روط المنص وص عليھ ا ف ى ھ ذا الق انون‬ ‫وفى الالئحة الداخلية لالتحاد بعد سداد رسم القيد وقدره عشرة جنيھات.‬ ‫ج- جدول غير المشتغلين‬ ‫واجبات أعضاء النقابة :‬‫1- على العضو أن تتوفر فيه األمانة فى أداء واجباته وتقاليد مھنت ه, ومقتض يات ش رفھا وأن يحل ف ام ام ھيئ ة مش كلة م ن‬ ‫أعضاء يختارھم مجلس النقابة اليمين اآلتية:‬‫أقسم با العظيم أن أكون مخلصا لوطنى , وأن أؤدى أعمالى باألمانة والش رف, وأن أح افظ عل ى س ر المھن ة , وأنف ذ‬ ‫قوانينھا واحترام تقاليدھا وآدابھا.‬‫2- ال يجوز لعضو النقابة أن يروج لھمنته بأى طريق من طرق اإلعالن والنشر ويستثنى م ن ذل ك اإلع الن ع ن مواعي د‬ ‫العمل.‬ ‫3- يجب على أعضاء النقابة االمتناع عن كل مزاحمة أو مضاربة أو تجريح, وكل ما من شانه أن يمس المھنة وآدابھا.‬‫4- ال يجوز ألعضاء النقابة اتخ اذ إج راءات قض ائية ض د اى عض و أخ ر بس بب عم ل م ن أعم ال المھن ة إال بع د ع رض‬ ‫األمر على مجلس النقابة.‬ ‫5-على كل عضو مقيد بالجدول العام أن يؤدى لصندوق النقابة فى ميع اد أقص اه أخ ر ديس مبر م ن ك ل ع ام اش تراكا‬ ‫عضويا على الوجه المبين فى قانون اتحاد نقابات المھن الطبية.‬ ‫6-على العضو سداد االشتراك المقرر لنادى الصيادلة وإال حصل إجباريا مع اشتراك النقابة السنوى.‬ ‫توزع حصيلة اشتراكات األعضاء ورسوم القيد فى الجدول العام على النحو اآلتى:‬ ‫51% لصندوق النقابة والنشاط العلمى .‬ ‫01% لصندوق النقابة الفرعية.‬ ‫07% لصندوق اإلعانات والمعاشات التحاد نقابات المھن الطبية .‬ ‫5% للمصروفات اإلدارية التحاد نقابة المھن الطبية.‬ ‫تكوين النقابة‬ ‫تتكون النقابة من:‬ ‫أ- الجمعية العمومية ومجلس النقابة على مستوى الجمھورية .‬ ‫ب- الجمعيات العمومية ومجالس النقابات الفرعية على مستوى المحافظات.‬ ‫الجمعية العمومية ومجلس النقابة:‬ ‫أوال : الجمعية العمومية :‬‫1- تت ألف الجمعي ة العمومي ة م ن كاف ة األعض اء المقي دة أس ماؤھم ف ى الج دول الع ام ال ذين أدوا االش تراكات الس نوية‬ ‫المستحقة حتى أخر السنة المنتھية.‬
  • 208. ‫ويرأس النقيب الجمعية العمومية, وإذا غاب يرأسھا الوكيل فإذا غاب كالھما تكون الرئاس ة ألكب ر أعض اء مجل س النقاب ة‬ ‫الحاضرين سنا.‬‫2- تعقد الجمعية العمومية للنقابة اجتماعھا العادى بالقاھرة ف ى ش ھر م ارس م ن ك ل ع ام كم ا تعق د اجتماع ا غي ر ع ادى‬‫كلما رأى مجل س النقاب ة ض رورة لعق دھا أو إذا ق دم ب ذلك طل ب موق ع علي ه م ن م ائتى عض و عل ى األق ل مم ن لھ م ح ق‬‫حضورھا مع توضيح الغرض من ذل ك ويج ب أن ي تم انعقادھ ا ف ى ھ ذه الحال ة خ الل ش ھر م ن ت اريخ تق ديم الطل ب وإال‬ ‫انعقدت الجمعية العمومية الغير عادية دون الرجوع إلى مجلس النقابة وفى الميعاد الذى يحدده طالبوا انعقاد الجمعية.‬‫3- ال يكون اجتماع الجمعية العمومية صحيحا إال إذا حضره على األقل خمسمائة عضو مم ن لھ م ح ق حض ور االجتم اع‬‫فإذا لم يتوافر ھذا الع دد بع د مض ى س اعة دعي ت الجمعي ة العمومي ة ال ى االجتم اع ثاني ة ف ى ظ رف 12 يوم ا م ن ت اريخ‬ ‫االجتماع األول ويكون انعقادھا فى ھذه الحالة صحيحا إذا حضره مائتان عضو على األقل.‬ ‫وتصدر الجمعية العمومية قراراتھا باألغلبية فإذا تساوت اآلراء ترجح رأى الجانب الذى فيه الرئيس .‬‫4- يدعى األعضاء لحضور الجمعية العمومية بدعوة شخصية قبل يوم االنعقاد بخمسة عشر يوما يب ين فيھ ا مك ان وزم ان‬‫وج دول الجمعي ة العمومي ة ويعل ن ع ن ذل ك ف ى الجرائ د الت ى يختارھ ا مجل س النقاب ة وال يج وز للجمعي ة أن تن اقش غي ر‬‫المسائل المقي دة بالج دول, وألى عض و م ن أعض اء النقاب ة أن يق دم إل ى المجل س اى اقت راح ي رى عرض ه عل ى الجمعي ة‬ ‫العمومية العادية وذلك قبل موعد عقدھا بأسبوع على األقل.‬‫5- للجمعي ة العمومي ة غي ر العادي ة الح ق ف ى س حب الثق ة م ن مجل س النقاب ة عل ى أن يحض ر ھ ذه الجمعي ة نص ف ع دد‬‫األعض اء عل ى األق ل المقي دين بالج دول الع ام مم ن لھ م الح ق ف ى االنتخ اب ويك ون الق رار بأغلبي ة أص وات األعض اء‬ ‫الحاضرين.‬ ‫اختصاصات الجمعية العمومية‬ ‫تختص الجمعية العمومية بما ياتى :‬ ‫1- انتخاب النقيب وأعضاء مجلس النقابة .‬ ‫2- مناقشة السياسة العامة للنقابة.‬ ‫3- إقرار الالئحة الداخلية والئحة تقاليد المھنة اللتين يضعھما مجلس النقابة وتصدران بقرار من وزير الصحة .‬ ‫4- مناقشة مشروع الميزانية السنوية التى يعرضھا مجلس النقابة واعتمادھا.‬ ‫5- اعتماد الحساب الختامى للسنة المنتھية بعد اإلطالع على تقرير مراقب الحسابات .‬ ‫6- النظر فيما يھم النقابة من المسائل التى يعرضھا مجلس النقابة العتمادھا.‬ ‫7- تعيين مراقب للحسابات.‬ ‫ثانيا : مجلس النقابة :‬‫يشكل مجل س النقاب ة م ن النقي ب و42 عض و م ن األعض اء المقي دين بس جالت النقاب ة والمس ددين لالش تراك ويش ترط أن‬ ‫يكون األعضاء من العاملين ويكون تشكيل المجلس على الوجه اآلتى:‬ ‫1- ينتخب النقيب و21 عضو باالنتخاب المباشر على مستوى الجمھورية يتم انتخابھم من جميع الص يادلة األعض اء‬ ‫المقيدين بالنقابة ويشترط أن يكون نصف عدد األعضاء من المقيدين ألقل من 51 عاما والنصف األخر من المقيدين‬ ‫ألكثر من 51 عاما.‬ ‫2- األثنا عشر عضوا يمثلون المناطق الست اآلتية:‬ ‫1- منطقة القاھرة وتشمل منطقتى القاھرة والجيزة.‬ ‫2- منطقة وسط الدلتا وتشمل محافظات المنوفية والغربية وكفر الشيخ والقليوبية.‬ ‫3- منطقة غرب الدلتا وتشمل محافظات اإلسكندرية والبحيرة ومرسى مطروح.‬‫4- منطقة شرق الدلتا وتشمل محافظات الدقھلية والشرقية ودمياط وب ور س عيد واإلس ماعيلية والس ويس وس يناء‬ ‫والبحر األحمر .‬ ‫5- منطقة شمال الوجه القبلى وتشمل محافظات الفيوم وبنى سويف والمنيا.‬ ‫6- منطقة جنوب الوجه القبلى وتشمل محافظات أسيوط وسوھاج وقنا وأسوان والوادى الجديد.‬‫ويمثل كل منطقة عضوان إحداھما مضى على قيده فى الجدول العام 51سنة والث انى مض ى عل ى قي ده أق ل م ن 51 س نة‬‫بحيث ال يزي د ممثل وا محافظ ة ع ن عض و واح د, وال يج وز للعض و الواح د الجم ع ب ين الترش يح لمجل س النقاب ة ومجل س‬‫النقابة الفرعية فى وقت واحد وإذا انتقل عض و م ن مجل س النقاب ة إل ى خ ارج المنطق ة الت ى يمثلھ ا ح ل محل ه لب اقى مدت ه‬
  • 209. ‫وفى جميع الحاالت يفوز الحاصلون على أكثر األصوات وعند التساوى يجرى االختيار بطريق القرعة .‬‫3- يجرى انتخاب النقيب ومجل س النقاب ة تح ت أش راف لجن ة عام ة عل ى مس توى الجمھوري ة ولجن ة فرعي ة ف ى ك ل نقاب ة‬ ‫فرعية على الوجه المبين فى الالئحة الداخلية للنقابة.‬‫4- يكون انتخاب النقيب وأعضاء المجل س إجباري ا وال يج وز ألى عض و م ن أعض اء النقاب ة أن يتخل ف بغي ر ع ذر يقبل ه‬‫مجلس النقابة أو مجالس النقابات الفرعية كل فى دائرة اختصاصه ع ن تأدي ة الواج ب االنتخ ابى وإال وقع ت علي ه غرام ة‬‫قدرھا جنيه واحد تحصل إجباريا لحساب صندوق النقابة, ويعتبر الصوت باطال ويلغى االنتخاب إذا انتخب العض و ع ددا‬ ‫أكثر أو أقل من العدد المطلوب انتخابه سواء لمجلس النقابة أو مجالس النقابات الفرعية .‬‫5- يشترط فى من يرشح نفسه لمركز النقيب أن يكون من األعضاء الذين مضى عل ى قي دھم بالج دول الع ام للنقاب ة خمس ة‬ ‫عشر سنة على األقل.‬ ‫6- يكون انتخاب النقيب لمدة أربع سنوات وال يجوز انتخابه أكثر من مرتين متتاليتين.‬‫7- تكون العضوية لمجل س النقاب ة أرب ع س نوات ويتج دد ك ل س نتين انتخ اب نص ف ع دد األعض اء عل ى أن ه بع د انقض اء‬‫السنتين األولين تنتھ ى م دة نص ف ع دد األعض اء م ن المجل س بطريق ة القرع ة م ع مراع اة النس ب المق ررة لك ل فئ ة ف ى‬‫تشكيل المجلس على أن تحتسب السنتان األوليان من أول ميعاد الجمعية العمومية التى تنعقد بع د أول انتخاب ات ث م يص بح‬ ‫التجديد بالدور والتسلسل كل سنتين وال يدخل النقيب فى القرعة كما ال يجوز انتخاب العضو اكثر من مرنين متتاليتين.‬‫8- ينتخ ب مجل س النقاب ة م ن ب ين أعض ائه وك يال وس كرتيرا وأمين ا للص ندوق وس كرتيرا مس اعدا للص ندوق ويكون وا م ع‬‫النقيب ھيئة المكتب على أن تكون إق امتھم بالق اھرة أو الجي زة وعل ى مجل س النقاب ة أن يخط ر وزي رى الص حة والداخلي ة‬‫بنتيجة االنتخابات كما يجب عليه أن يخطر وزير الصحة بجميع قرارات الجمعيات العمومية وذلك فى مدى خمس ة عش ر‬ ‫يوما من تاريخ انعقاد الجمعية العمومية .‬‫9- يصدر مجلس النقابة قرار بإسقاط عضوية مجلس النقابة عن العضو إذا فق د ش رطا م ن ش روط العض وية وللمجل س أن‬ ‫يقرر سقوط عضوية من غاب عن جلساته ثالث مرات متتالية بغير عذر يقبله المجلس وذلك بعد استدعائه لسماع أقواله.‬‫01- إذا خال مركز النقي ب ألى س بب م ن األس باب ح ل محل ه الوكي ل إل ى أن تنتخ ب الجمعي ة العمومي ة ف ى أول اجتم اع‬‫الحق خلف ا ل ه وإذا خ ال مرك ز أح د أعض اء المجل س ح ل محل ه م ن ح از أكث ر األص وات بع د اخ ر م ن أنتخ ب لعض وية‬ ‫المجلس فى االنتخابات السابقة من نفس تمثيله النقابى وفى حالة االنتخاب بالتزكية يفتح باب الترشيح لمن يحل محله.‬ ‫اختصاصات مجلس النقابة‬ ‫يختص مجلس النقابة بما يأتى :‬ ‫العمل على تحقيق أھداف النقابة ووضع وسائل تنفيذھا ومتابعتھا.‬ ‫1-‬ ‫اقتراح الالئحة الداخلية والئحة تقاليد المھنة وما يرى إدخاله عليھما ومراقبة تنفيذھا.‬ ‫2-‬ ‫تشكيل لجان فنية للمعاونة فى حل مشاكل التطبيق على مستوى المحافظات والمراكز.‬ ‫3-‬ ‫تنفيذ قرارات الجمعية العمومية .‬ ‫4-‬‫تنظيم العالقة بين مجلس النقابة والنقابات الفرعية وله حق االعتراض على قرارات مجلس النقاب ات الفرعي ة‬ ‫5-‬‫التى قد تتعارض مع السياسة العامة للنقابة وذلك خالل ثالثين يوما من تاريخ إخطار مجل س النقاب ة بمحض ر‬ ‫مجلس النقابة الفرعية .‬ ‫حفظ سجالت المھنة .‬ ‫6-‬ ‫تحصيل رسوم القيد واالشتراكات والنظر والبت فى طلبات األعضاء .‬ ‫7-‬‫إدارة أم وال النقاب ة وقب ول الھب ات والتبرع ات واإلعان ات وس ائر الم واد األخ رى واألش راف عل ى حس ابات‬ ‫8-‬ ‫النقابة .‬ ‫إعداد الميزانية السنوية والحساب الختامى .‬ ‫9-‬‫01- تمثي ل النقاب ة ف ى اتح اد نقاب ات المھ ن الطبي ة واالتص ال بالجھ ات الحكومي ة واألھلي ة وب األفراد فيم ا يتعل ق‬ ‫بشئون النقابة والدفاع عن حقوقھا وحقوق أعضائھا.‬ ‫11- تنفيذ قرارات مجلس اتحاد نقابات المھن الطبية .‬ ‫21- الوساطة بين األعضاء لحسم النزاع بينھم بسبب عمل من أعمال المھنة أو بينھم وبين الغير لذات السبب .‬ ‫31- النظر فى الشكاوى المتعلقة بتصرفات األعضاء.‬
  • 210. ‫السعى لدى الحكومة والقطاع العام وغيره لتھيئة فرص العمل لكل صيدلى .‬ ‫41-‬‫اختيار ممثلى النقابة فى المج الس واللج ان والھيئ ات والم ؤتمرات عل ى مس توى الجمھوري ة وعل ى المس توى‬ ‫51-‬ ‫الدولى .‬‫دع وة مج الس النقاب ات الفرعي ة م رتين عل ى األق ل ك ل س نة لالجتم اع م ع مجل س النقاب ة لدراس ة مش كالت‬ ‫61-‬ ‫التطبيق االشتراكى.‬ ‫مباشرة السلطة التأديبية على األعضاء طبقا ألحكام ھذا القانون.‬ ‫71-‬‫االشتراك مع الجھ ات الحكومي ة وأجھ زة القط اع الع ام ف ى وض ع دراس ة وتنق يح الق وانين والل وائح وتخط يط‬ ‫81-‬ ‫المشروعات والخطة الدوائية .‬ ‫تنظيم مزاولة المھنة حسب ما تحدده الالئحة الداخلية والئحة آداب المھنة .‬ ‫91-‬ ‫التعبير عن رأى الصيادلة فى المشاكل االجتماعية والوطنية.‬ ‫02-‬‫العم ل عل ى االرتق اء بالمس توى العلم ى للص يادلة بتش كيل اللج ان العلمي ة وإص دار النش رات الدوري ة وعق د‬ ‫12-‬ ‫الندوات وتشجيع األبحاث والمشتغلين بھا مھنيا وماديا.‬ ‫تحديد رسوم الشھادات التى تصدرھا النقابة لألغراض المختلفة.‬ ‫22-‬ ‫ثالثا: الطعن فى القرار‬‫1- لخمس ين عض و عل ى األق ل مم ن حض روا الجمعي ة العمومي ة الطع ن ف ى ص حة انعقادھ ا أو ف ى تش كيل مجل س النقاب ة‬‫بتقري ر موق ع علي ه م نھم يق دم إل ى قل م كت اب محكم ة ال نقض خ الل 51 يوم ا م ن ت اريخ انعقادھ ا بش رط التص ديق عل ى‬ ‫التوقيعات من الجھة المختصة ويجب أن يكون الطعن مسببا وإال كان غير مقبول شكال.‬‫2- تفصل محكمة النقض فى الطعن على وجه االستعجال فى جلسة سرية وذل ك بع د س ماع أق وال مستش ار الدول ة ل وزارة‬ ‫الصحة وأقوال النقيب أو من ينوب عنه ووكيل عن األعضاء مقدمى الطعن.‬‫3- إذا قبل الطعن فى صحة انعقاد الجمعية العمومي ة تبط ل قراراتھ ا وت دعى لالنعق اد خ الل ثالث ين يوم ا م ن ت اريخ قب ول‬ ‫الطعن .‬ ‫النقابات الفرعية بالمحافظات:‬ ‫يختص مجلس النقابة الفرعية بما يأتى :‬ ‫1- مباشرة نشاط النقابة فى دائرة اختصاصه وتنفيذ قرارات الجمعية العمومية للنقابة الفرعية .‬ ‫2- االشتراك فى دراسة المشروعات الخاصة بالصيدلة فى دائرة اختصاصه والعمل على حل المشاكل الموجودة .‬ ‫3- العمل على رفع المستوى الثقافى واالقتصادى واالجتماعى ألعضاء النقابة الفرعية.‬ ‫4- اعداد الميزانية والحساب الختامى.‬ ‫5- رفع محاضر اجتماعاته وتقرير شھرى عن نشاطه إلى مجلس النقابة .‬ ‫6- النظر فى الشكاوى من تصرفات األعضاء .‬ ‫اللجان‬‫يش كل مجل س النقاب ة الفرعي ة لجان ا لمتابع ة النش اط العلم ى والمھن ى ولجان ا للنظ ر ف ى الش كاوى واالقتراح ات ويج وز‬ ‫للمجلس تشكيل لجان أخرى كلما استدعى األمر ذلك وتبين الالئحة الداخلية طريقة تشكيل اللجان واختصاصاتھا.‬ ‫صندوق اإلعانات والمعاشات‬‫ينشئ مجلس االتحاد صندوقا يسمى "صندوق اإلعان ات والمعاش ات" تك ون ل ه الشخص ية االعتباري ة ويك ون مق ره مدين ة‬‫الق اھرة ويق وم بترتي ب مع اش لجمي ع أعض اء النقاب ات الطبي ة أو إعان ات وقتي ة أو ودي ة طبق ا لنص وص الق انون ويت ولى‬ ‫مجلس االتحاد إدارة ھذا الصندوق ويمثله قانونا رئيس مجلس االتحاد.‬ ‫يتكون رأس مال الصندوق من :‬ ‫أوال: إعانات الحكومة السنوية .‬ ‫ثانيا: الرصيد الموجود لدى اتحاد نقابات المھن الطبية عند العمل بھذا القانون.‬
  • 211. ‫ثالثا: 7% من رسوم القيد فى الجدول العام تدفعھا كل نقابة.‬ ‫رابعا 7% من االشتراكات تدفعھا كل من النقابات الطبية األربع.‬ ‫خامسا : حصيلة الدمغة الطبية ويكون تحصيلھا إلزاميا على الخدمات التى تقدم بأجر س واء ف ى القط اع الخ اص‬ ‫أو القطاع العام, ويوضح مجلس اتحاد نقابات المھن الطبية القواعد واألنظمة لتحصيل الدمغات المقرره .‬ ‫سادسا: التبرعات والوصايا لھذا الصندوق.‬‫تودع أموال الص ندوق ف ى حس اب خ اص ف ى أح د المص ارف بالق اھرة يخت اره مجل س االتح اد ويك ون الص رف بش يكات‬‫موقع عليھا من الرئيس ومن أحد الوكالء ويكون مفوضا فى ذلك بقرار من مجلس االتحاد م ع أم ين الص ندوق أو األم ين‬ ‫المساعد.‬‫يضع مجلس االتحاد ميزانية الصندوق يصدق عليھا م ن الجمعي ة العمومي ة وال يج ب أن يج اوز بن د المص روفات 08%‬‫م ن إي رادات الص ندوق الس نوية أم ا العش رون ف ى المائ ة الباقي ة فيك ون منھ ا احتي اطى للص ندوق يخص ص لس د العج ز‬ ‫الطارئ فى ميزانية المعاشات واإلعانات.‬‫ويتم انفاق المصروفات العادية للصندوق فى الحدود الواردة فى الميزانية ويحدد مجلس االتحاد مرتب ات ومكاف أة م وظقى‬ ‫صندوق اإلعانات والمعاشات ومن يندب للتفتيش على الدمغة الطبية.‬‫ولمجلس االتحاد أن يقترح مشروعات تعود على أعضائه بالنفع العام على ان يكون تخصيص المب الغ الالزم ة ل ذلك بن اء‬ ‫على قرار من الجمعية العمومية .‬‫يضع مجلس االتحاد فى حدود الموارد المالية لصندوق المعاشات الالئحة الت ى تح دد قيم ة المع اش ال ذى يص رف للعض و‬ ‫أو األسرة.‬‫المعاش حق لك ل عض و وف ى حال ة وفات ه يك ون المع اش حق ا ألس رته دون النظ ر إل ى دخل ه الخ اص أو معاش ه م ن جھ ة‬‫أخرى أو دخل أسرته من أى مصدر كان بشرط أن يكون مسددا اللتزاماته قبل النقابة التى يتبعھ ا. ويش ترط لم ن يحص ل‬‫على المعاش أن يكون متمتعا بجنسية جمھورية مص ر العربي ة وأن يك ون مقيم ا ھ و وأس رته ف ى حال ة وفات ه إقام ة دائم ة‬ ‫بجمھورية مصر العربية .‬‫فى جميع األحوال يجب على العضو الذى يتقاضى معاشا أن يتوقف تماما عن مزاولة نشاطه المھنى على أية صورة م ن‬‫الصور وفى حالة المخالفة يحصل منه ما حصل عليه بدون وجه حق مع سقوط حقه ھو فى المع اش ويع ود ح ق المع اش‬ ‫على أسرته بعد وفاته.‬‫تقدم طلبات المعاش واإلعانة كتابة لرئيس مجلس اتحاد وعلى مجلس االتحاد الفصل فيھا خالل ثالثين يومي ا عل ى األكث ر‬ ‫من تاريخ تسليم المستندات التى تحددھا الالئحة وتعتمدھا النقابة التى يتبعھا العضو.‬‫إذا طرأ عل ى العض و أو أس رته م ا يقتض ى إعانت ه ج از لمجل س االتح اد أن يق رر إعان ة وقتي ة لمواجھ ة حالت ه ف ى ح دود‬ ‫الالئحة .‬‫يضع مجلس االتحاد فى موعد نھاية ش ھر فبراي ر م ن ك ل ع ام ميزاني ة الص ندوق للس نة التالي ة والحس اب الخت امى للس نة‬‫المنتھية فى 13 ديسمبر من العام السابق له. ويعتمد مجلس االتح اد خ الل ش ھر م ارس م ن ك ل س نة الميزاني ة والحس اب‬‫الختامى المذكورين تمھيد لعرضھا على الجمعية العمومية العادية لفحصھا والتص ديق عليھ ا بش رط مراجعتھ ا واعتمادھ ا‬ ‫من المراقب المالى الذى تعينه الجمعية العمومية لالتحاد.‬‫تعفى أموال الصندوق الثابتة والمنقولة وجميع العمليات االستشارية أيا كان نوعھا من جميع الض رائب والرس وم والدمغ ة‬ ‫والقواعد التى تفرضھا الحكومة أو اية سلطة عامة .‬‫تح دد المزاي ا الت ى يمنحھ ا الص ندوق بع د فح ص المرك ز الم الى للص ندوق بواس طة خبي ر أكت وارى يعين ه مجل س اتح اد‬ ‫وبموافقة الجمعية العمومية االتحاد .‬
  • 212. ‫يجب على كل عضو من أعضاء المھن الطبية أن يدفع لنقابته خمس جنيھات عند قي ده بالج دول الع ام وأن ي ؤدى اش تراكا‬ ‫سنويا فى موعد غايته آخر ديسمبر من كل عام على الوجه اآلتى :‬ ‫6 جنيھات عن كل سنة من السنوات الثالثة األولى من تاريخ التخرج .‬ ‫9 جنيھات عن كل سنة من السنوات الثالثة التالية.‬ ‫21 جنيھا عن كل سنة بعد السنوات الست األولى من التخرج.‬‫ويكون تحصيل االشتراكات بطرق ميسرة إما مباشرة أو مخصومة من المرتب على أقساط شھرية وإذا ل م ي دفع العض و‬‫لنقابته االشتراكات فى الموعد المحدد نبه إلى ذلك بخطاب موصى عليه مع علم الوصول فإذا ل م ي دفع خ الل ثالث ة أش ھر‬‫استبعد أسمه من جدول النقابة وتخطر وزارة الصحة لمنعه من مزاولة المھنة ولكل من استبعد اسمه من الج دول ويطل ب‬ ‫إعادة قيده مقابل رسم قدره عشرة جنيھات مع القيام بتنفيذ اإلجراءات التى ترتب على عدم تنفيذھا استبعاد اسمه.‬‫يعفى العضو المستحق للمعاش م ن تس ديد االش تراكات الس نوية لنقابت ه م ن ت اريخ تقري ر المع اش ل ه ولمجل س االتح اد أن‬ ‫يقرر إعفاء أحد األعضاء من تسديد االشتراك لمدة محددة بسبب من مجلس النقابة التى ينتمى إليھا العضو .‬
  • 213. COMMUNITY PHARMACY ANDPHARMACY PRACTICE (Practical notes)
  • 214. COLD AND FLU Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................Case1A woman in her mid fifties asks what you can recommend for her husband. He has avery bad cold; the worst symptoms are his blocked nose and sore throat. Although his
  • 215. throat feels sore, she tells you there is only a slight reddening (she looked thismorning). He has had the symptoms since last night and is not feverish. He does nothave earache but has complained of a headache. When you ask her if he is taking anymedicines she says yes, he’s been taking some tablets for his high blood pressure.They are pink, but she cannot remember what they are called.……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
  • 216. COUGH Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................Case 1A woman aged about 30 asks what you can recommend for a cough. On questioningyou find that her son, aged 6 years, has had a cough for 2 weeks. He gets it at night and
  • 217. it is disturbing his sleep although he does not seem to be troubled during the day. Thecough is not productive and she has given her son some Buttercup syrup (expectorant)before he goes to bed but the cough is no better. The boy is not taking any othermedication. He has no pain on breathing nor shortness of breath. He has not had a coldrecently, but has had this kind of cough before.……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Case 2A man aged 25 asks if you can recommend something for his cough. He sounds as if hehas a bad cold and looks a bit pale. You find out that he has the cough for a few days,with a blocked nose and sore throat. He has no pain on breathing nor shortness of breath.The cough was chesty to begin with but he tells you it is now ‘tickly’ and ‘irritating’. He hasnot tried any medicines and is not taking and medicines from the doctor.………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • 218. SORE THROAT Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................Case 1A woman comes to ask your advice about her son’s very sore throat. He is 15years old and is at home in bed. She says he has a temperature and that she can
  • 219. see creamy white matter at the back of his throat. He seems lethargic and has notbeen eating very well because his throat has been so painful. The sore throat startedabout 5 days ago and he has been in bed since yesterday. The glands on his neckare swollen and he has been complaining of pain in his abdomen.…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Case 2A middle-aged lady comes to ask your advice about her husband’s bad throat. Hehas had a hoarse gruff voice for about a month and has tried all sorts of lozengesand pastilles without success. He has been a heavy smoker for over 20 years andworks as a bus driver.………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • 220. ALLERGIC RHINITIS Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................Case 1A woman in her early thirties wants some advice about the best medicine for her to take.She tells you that she has hay fever and a blocked nose, and is finding it difficult to
  • 221. breathe. When you question her you find out that she has had the symptoms for a fewdays; they have gradually got worse. She gets hay fever every summer, and it is usuallycontrolled by chlorpheniramine tablets, which she buys every year and which she istaking at the moment. As a child, she suffered quite badly from eczema, and is stilltroubled by it occasionally. She tells you that she has been a little wheezy for the past dayor so, but she does not have a cough, and has not coughed up any sputum. She is nottaking any other medicine.………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Case 2A young man in his early twenties presents in late May. He asks what you canrecommend for his runny nose, which he has had since the day before yesterday. Onquestioning, he tells you that his eyes have been itching a little and are slightly watery,that he has been sneezing, and that his throat is dry. He has not had hay fever in thepast. He will not be driving, but is a student at the local college and has exams up nextweek. He is not taking any medicine.………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • 222. MOUTH ULCERS Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................………………………………………………………………………………………
  • 223. Case 1Ahmed, a man aged in his early fifties, asks you to recommend something for painfulmouth ulcers. On questioning, he tells you that he has two ulcers at the moment and hasoccasionally suffered from the problem over many years. Usually he gets one or twoulcers inside the cheek or lips and they last for about a week. Mr. Ahmed is not taking anymedicines and has no other symptoms. You ask to see the lesions and note that there aretwo small white patches, each with an angry-looking red border. One ulcer is located onthe edge of the tongue, the other inside the cheek. Mr. Ahmed cannot remember anytrauma or injury to the mouth and has had the ulcers for a couple of days. He tells youthat he used pain-killing gels in the past, and they have provided some relief.……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Case 2One of your counter assistants asks you to recommend a strong treatment for mouthulcers for a lady who has already tried several treatments. The woman tells you that shehas a troublesome which has persisted for few weeks. She has used some pastillescontaining a local anaesthetic and an antiseptic mouthwash but with no improvement.………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • 224. HEART BURN Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................Case 1
  • 225. Mrs. A is a lady aged about 50 who wants some advice about a stomach problem. Onquestioning, you find out that sometimes she gets a burning sensation just above thebreastbone and that she feels the burning in her throat, sometimes with a bitter taste as ifsome food has been brought back up. She has been having the problem for a week ortwo and hasn’t tried to treat it yet. Mrs. A. is not taking any medicines from the doctor. Toyour experienced eye, this lady is at least a stone overweight. You ask Mrs. A if thesymptoms are worse at any particular time, and she says they are worst shortly aftergoing to bed at night.……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Case 2You have been asked to recommend a ‘strong’ mixture of heartburn for Mr. H., a localman in his late fifties who works in a nearby foundry. Mr. H., tells you that he has beengetting terrible heartburn for which his doctor prescribed some mixture about a week ago.You remember dispensing a prescription for a liquid alginate preparation. The bottle isnow empty, and the problem is no better. When asked if he can point to where the pain is,Mr. H., gestures across his chest and clenches his fist when describing the pain which hesays feels ‘heavy’. You ask whether the pain ever moves, and Mr. H., tells you thatsometimes it goes to his neck and jaw. Mr. H., is a smoker and is not taking any othermedications. When asked if the pain is worse when bending or lying down, Mr. H., saysno, but he tells you he usually gets the pain when he’s at work, especially on busy days.………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • 226. CONSTIPATION Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................Case 1Your medicines counter assistant asks if you will have a word with a youngwoman who is in the shop. She was recognized by your assistant as a regular
  • 227. purchaser of stimulant laxatives. You explain to the woman that you will need toask a few questions because regular use of laxatives may mean an underlyingproblem which is not improving. In answer to your questions she tells you thatshe diets almost constantly and always suffers from constipation. Her weightappears to be within the range of her height. You show her your pharmacy’sbody mass index chart and work out with her where she is on the chart, whichconfirms your initial feeling. However, she is reluctant to accept your advice,saying that she is definitely needs to lose some more weight. You ask about herdiet and she tells you that she has tried all sorts of approaches, most of whichinvolve eating very little.………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Case 2Mr. A is a middle-aged man who occasionally visits your pharmacy. Today hecomplains of constipation, which he has had for several weeks. He has beenhaving a bowel movement every few days; normally they are every day or everyother day. His motions are hard, and painful to pass. He has not tried anymedicines as he thought the problem would go of its own accord. He has neverhad problems with constipation in the past. He has been taking atenolol tablet 50mg, one daily for over a year. He does not have any other symptoms, except aslight feeling of abdominal discomfort. You ask him about his diet; he tells youthat since he was made redundant from his job 3 months ago he has tended toeat less than usual; his dietary intake sounds as if it is low in fibre. He tells youthat he has been applying for jobs, with no success so far. He says he feelsreally ‘down’ and is starting to think that he may never get another job.………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • 228. …………………………………………………………………………………………………………………………………………
  • 229. INDIGESTION Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................………………………………………………………………………………………
  • 230. Case 1Mrs J, an elderly lady, complains of indigestion and an upset stomach. Onquestioning, you find out she has had the problem for a few days; the pain isepigastric and does not seem to be related to food. She has been feeling slightlynauseated. You ask about her diet - she has not changed her diet recently, andhas not been overdoing it. She tells you that she is taking four lots of tablets, forher heart, her waterworks and some new ones for her bad hip (indomethacin 25mg three times a day). She has been taking them after meals, as advised, andhas not tried any medicines yet to treat her symptoms. Before the indomethacin,she was taking paracetamol for the pain.…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Case 2Mr. K is a local milkman in his early fifties, and he comes in to ask your adviceabout his stomach trouble. He tells you that he has been having the problem fora couple of months, but it seems to have got worse. The pain is in the middle ofhis chest, quite high up; he had similar pain a few months ago, but it got betterand has now come back again. The pain seems to get better after a meal;sometimes it wakes him during the night. He has been taking Rennies to treat hissymptoms; they did the trick, but dont seem to be working now, even though hetakes a lot of them, and he has also been taking some Maalox liquid. He is nottaking any other medicines.……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • 231. DIARRHEA Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................………………………………………………………………………………………
  • 232. Case 1Mrs R. asks what you can recommend for diarrhea. Her son, D, aged 11, hasdiarrhea and she is worried that her other two children, Natalie, aged 4 and Tom,aged just over a year, may also get it. Ds diarrhea started yesterday; he went tothe toilet about 5 times, and was sick once, but has not been sick since. He hasgriping pains, but is generally well, and is quite lively. For lunch yesterday he hadpie and chips from the local takeaway during his break at school. No one else inthe family ate the same food. Mrs. R has not given him any medicine, but hassome kaolin and morphine mixture at home and wants to know if D could takesome of that; also the other children if necessary…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Case 2Mrs. Jean Berry wants to stock up on some medicines before her family sets offon their first holiday abroad - they will be going to Spain next week. Mrs. Berrytells you she has heard of people whose holidays have been ruined by holidaydiarrhea, and she wants you to recommend a good treatment. On questioning,you find out that Mr. and Mrs. Berry and their two boys, aged 10 and 14 years willbe going on the holiday.…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Cae 3Mr Radcliffe is an elderly man who lives alone. Today, his home help asks whatyou could recommend for diarrhea; Mr Radcliffe has been suffering for 3 days.He has been passing watery stools quite frequently, and feels rather tired andweak. He has sent the home help because he dare not leave the house and goout of reach of the toilet. He takes several different medicines: digoxin,
  • 233. frusemide, paracetamol, and last week he started to take mefenamic acidcapsules for his rheumatoid arthritis, which has been getting worse. The homehelp tells you that he has been eating his usual diet, and there does not seem tobe a link between food and his symptoms…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • 234. Haemorrhoids Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................………………………………………………………………………………………………………………………………………………………………………………Case 1Mr. T a customer whom you know quite well, asks if you can recommend something forhis ‘usual problem’. You ask him to tell you more about it – Mr. T suffers from piles
  • 235. occasionally, and you have dispensed prescriptions for Anusol HC and similar productsin the past, and have previously advised him about dietary fibre and fluid intake.He hasbeen away on holiday for 2 weeks and says he hasn’t been eating the same foods as hedoes when at home. His symptoms are itching and irritation of th perianal area but nopain, and he has a small swelling, which hangs down from the anus after he has passeda motion but which he is able to push back again. He is a little constipated, but is nottaking any medication.……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………
  • 236. ECZEMA AND DERMATITIS Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................………………………………………………………………………………………
  • 237. Case 1L is a young mother who had her first baby a few weeks ago. She asks youradvice about her hands which are dry and sore. The skin is flaky but not brokenand there is no sign of secondary infection such as weeping or pus. Only the skinof the hands is affected. Mrs. L has occasionally had the problem before but notso severe. On further questioning you discover that she is soaking terry nappiesin a proprietary solution before putting them in a washing machine. She does notwear gloves. She has not changed her detergent or washing powder, and shehas no history of hay fever or asthma.…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Case 2R is a local man in his mid-thirties and a regular customer of yours. Today hewants to buy some hydrocortisone cream for his eczema which has flared up. Hehas had eczema for many years and usually obtains his hydrocortisone cream ona repeat prescription from his GP. As a child Mr. R was asthmatic and bothasthma and hay fever are present in some members of his family. He has justseen an advert for a proprietary over-the-counter hydrocortisone cream and sayshe would prefer to buy his supplies from you in future to save both himself andthe GP some time. The eczema affects his ankles, shins and hands.…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • 238. ATHLETES FOOT Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................………………………………………………………………………………………
  • 239. Case 1M is a young man aged in his early twenties who is a local milkman; he captainsthe local football team on Sunday mornings. Today he wants to buy somethingfor his athletes foot, which he tells you he just cant get rid of. His girlfriendbought him some cream a few days ago but it doesnt seem to be having anyeffect. The skin between the third and fourth toes and between the second andthird toes is affected. M tells you the skin is itchy, and that it looks flaky. He tellsyou that he has had athletes foot before, and that it keeps coming back again.He wears training shoes most of the time (he has them on now) and has usedthe cream his girlfriend bought most days…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Case 2L, a local woman asks if you can recommend anything for athletes foot. She tellsyou that it affects her toes and the soles and top of her feet and is extremelyitchy. When asked about the skin between her toes, she tells you she does notthink the rash is between the toes. The skin is dry and red, says Ms Green, andhas been like this for several days. She has not tried any medication to treat it.…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • 240. HEADACHES Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................………………………………………………………………………………………………………………………………………………………………………………Case 1
  • 241. Z is a regular visitor to your shop. She is a young mum, aged 25 years and todayshe seeks your advice about headaches which have been troubling her recently.The headaches are of a migraine type, quite severe and affecting one side of thehead. Z had her second child a few months ago and when you ask if she istaking any medicines she tells you that she recently started to take the combinedoral contraceptive pill. In the past, she had suffered from migraine headaches,but occasionally and never as severe as the ones she has been experiencingduring the past weeks. The headaches have been occurring once or twice aweek for about 2 weeks. Paracetamol has given some relief, but Z likes to trysomething stronger.…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Case 2A woman aged 30 years has asked to speak to you. She tells you that she wouldlike you to recommend something for the headaches which she has been gettingrecently. You ask her to describe the headache and she explains that the pain isacross her forehead and around the back of the head. The headaches usuallyoccur during the daytime and have been happening for several weeks, severaltimes a week. There are no associated gastrointestinal symptoms, and there isno nasal congestion. No medicines are being taken, apart from a compoundover-the-counter product containing aspirin, which she has been taking for herheadaches.On questioning about recent changes in lifestyle, this lady tells you that she hasrecently moved to the area and started a new job last month. In the past she hassuffered from the occasional headache, but not regularly. This lady does notwear glasses and says she has not had trouble with her eyesight in the past. Sheconfides that she has been worried that the headaches might be due tosomething serious.…………………………………………………………………………………………………………………………………………………………………………..…
  • 242. MUSCULOSKELETAL PROBLEMS Drug ReportTrade Name …………………………………………………………………...........Manufacturer ………………………………………………………………….........Physical Appearance…………………………………………………………..........Active Ingredients……………………………………………………………..........Additive Ingredients…………………………………………………………...........………………………………………………………………………………............Role of each Ingredient………………………………………………………......………………………………………………………………………………............Uses…………………………………………………………………………………………………………………………………………………………........................Dose………………………………………………………………………………………………………………………………………………………….......................Dose Regimen………………………………………………………………............………………………………………………………………………………………………………………………………………………………………………………OTC or Rx……………………………………………………………….................Patient Instructions………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………Drug Interaction…………………………………………………………….............………………………………………………………………………………………………………………………………………………………………………………Side Effects………………………………………………………………...............………………………………………………………………………………………………………………………………………………………………………………Comments………………………………………………………………..................………………………………………………………………………………………………………………………………………………………………………………Case 1A middle-aged man comes into your shop. He is wearing a tracksuit and trainingshoes and asks what you can recommend for an aching back. On questioning,
  • 243. you find out that the product is in fact required for his wife, who was doing somegardening yesterday because the weather was fine, and who now feels stiff andaching. The pain is in the lower back and is worse on movement. The lady is nottaking any medicines on a regular basis, but took two paracetamol last night,which helped to reduce the pain.…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Case 2An elderly female customer asks what would be the best thing for rheumaticswhich are worse now that the weather is getting colder. The pain is in the joints,particularly of the fingers and knees. On further questioning, you find out that thelady has suffered from this problem for some years, and sees her doctor quiteregularly about this and a variety of other complaints. She is taking five differentmedicines a day, and is unable to identify two of them. Her regular medicationincludes a combination diuretic preparation, sleeping tablets and tablets for thearthritis. The joint pains seem to have become worse during the recent spell ofbad weather.…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • 244. DRUG-DRUG INTERACTIONMany people neglect to mention their use of OTC drugs to their doctor or pharmacist. Drugs takenintermittently, such as those for colds, constipation, or an occasional headache, are mentioned evenless often. Health care practitioners may not think of asking about use of OTC drugs or medicinalherbs when they are prescribing or dispensing a prescription. Yet many OTC drugs and medicinalherbs can interact adversely with a wide range of drugs.Cytochrom P-450 (CYP 450) Interaction Cytochrom P450 enzyme system is the liver enzyme system that is responsible for drug metabolism and biotransformation. There are different isoenzymes in the CYP 450 family. For each isoenzyme there are drugs that called enzyme substrate on which the enzyme act and break it down. There are also drugs that is called inhibitors that inhibit the enzyme activity, The enzyme inducers are drugs that induce the enzyme activity.Drug-drug interactions can be defined as the modulation of the pharmacological activity of one drug(i.e., the object drug) by the prior or concomitant administration of another drug (i.e., the precipitantdrug). In these reactions, the pharmacological properties of the object drug and/or the precipitant drugcan be either severely enhanced or diminished.The interaction is called synergism when the combined effect of the two drugs is greater than the totaleffects of the drugs used separately. The interaction can be expressed as antagonism when theresulting effect is less than the combined effects of the two drugs when used separately or when theeffect partially or completely nullifies the effect(s) of each drug.In some instances, predictable drug-drug interactions in patients are beneficial, and clinicians allowthem to occur because they result in lower doses of the drug(s) being administered while stillachieving therapeutic serum drug levels. For example, administering penicillins (renally excreted) withthe drug probenecid significantly elevates serum levels of penicillin and prolongs its half-life.New and important drug interactions are being identified on a daily basis. Many involve theCytochrom P-450 isoenzymes, which are located in the intestines, liver, lung, kidney and brain.Drug interactions are frequently characterized as pharmacokinetic or pharmacodynamic in nature.Pharmacokinetic interactions influence the disposition of a drug in the body and involve the effects ofone drug on the absorption, distribution, metabolism and/or excretion of another drug. Theseinteractions frequently cause marked shifts in serum drug levels and alter clinical response.Pharmacodynamic interactions are related to the pharmacological activity of the interacting drugs.These interactions are frequently associated with synergism, antagonism, or altered cellular transport,and they affect organ systems and/or receptor sites.
  • 245. Drug metabolism occurs in two phases - Phase I involves oxidation, reduction, and hydrolysis. PhaseII involves synthesis and conjugation. The CYP 450 isoenzymes are involved in Phase I oxidativereactions.CYP 450 interactions generally result from one of two processes - inhibition and induction. Inductionmeans that a substance stimulates the synthesis of the enzyme and metabolic capacity is increased.Inhibition means competitive binding at an enzymes binding site(s). A drug with a high affinity for anenzyme will slow the metabolism of any low affinity drug.To Check CYP 450 System Interaction: Look at the CYP 450 interaction table, which contain 2 pages. Page 1 (substrate table): check in it if one or more of your prescription have being a substrate for any of the listed isoenzymes. Page 2: see the effect of anther drug on the enzyme you determined from the first page either inhibitor or inducers. For example if verapamil is substrate for 1A2 enzyme, in the second page look at 1A2 column only and check the presence of the other drugs as omeprazole as inhibitor or inducer. Construct a table.
  • 246. P450 DRUG-INTERACTIONS TABLE Substrates 1A2 2B6 2C19 2C9 2D6 2E1 3A4,5,7 amitriptyline bupropion Proton Pump Inhibitors: NSAIDs: Beta Blockers: Anesthetics: Macrolide antibiotics: HMG CoA Reductase Inhibitors: caffeine cyclophosphamide lansoprazole diclofenac carvedilol enflurane clarithromycin atorvastatin clomipramine efavirenz omeprazole ibuprofen S-metoprolol halothane erythromycin (not 3A5) cerivastatin clozapine ifosfamide pantoprazole meloxicam propafenone isoflurane NOT azithromycin lovastatin cyclobenzaprine methadone E-3810 S-naproxen=>Nor timolol methoxyflurane NOT pravastatin estradiol piroxicam sevoflurane Anti-arrhythmics: simvastatin fluvoxamine Anti- suprofen Antidepressants: quinidine=>3-OH (not 3A5) haloperidol epileptics: diazepam=>Nor amitriptyline acetaminophen Steroid 6beta-OH: imipramine N-DeMe phenytoin(O) Oral Hypoglycemic clomipramine =>NAPQI Benzodiazepines: estradiol mexiletine S-mephenytoin Agents: desipramine aniline alprazolam hydrocortisone naproxen phenobarbitone tolbutamide imipramine benzene diazepam=>3OH progesterone ondansetron glipizide paroxetine chlorzoxazone midazolam testosterone phenacetin=> amitriptyline ethanol triazolam acetaminophen=>NAPQI carisoprodol Angiotensin II Antipsychotics: N,N-dimethyl formamide Miscellaneous: propranolol citalopram Blockers: haloperidol theophylline Immune Modulators: alfentanyl riluzole clomipramine losartan perphenazine =>8-OH cyclosporine buspirone ropivacaine cyclophosphamide irbesartan risperidone=>9OH tacrolimus (FK506) cafergot tacrine hexobarbital thioridazine caffeine=>TMU theophylline imipramine N-DeME amitriptyline alprenolol HIV Antivirals: cocaine verapamil indomethacin celecoxib amphetamine indinavir dapsone (R)warfarin R-mephobarbital fluoxetine bufuralol nelfinavir codeine- N-demethylation zileuton moclobemide fluvastatin glyburide chlorpheniramine ritonavir dextromethorphan zolmitriptan nelfinavir phenytoin=>4-OH chlorpromazine saquinavir eplerenone nilutamide rosiglitazone codeine (=>O-desMe) fentanyl finasteride primidone tamoxifen debrisoquine Prokinetic: gleevec progesterone torsemide dexfenfluramine cisapride haloperidol proguanil S-warfarin dextromethorphan irinotecan propranolol encainide Antihistamines: LAAM teniposide flecainide astemizole lidocaine R-warfarin=>8-OH fluoxetine chlorpheniramine methadone fluvoxamine terfenidine odanestron lidocaine pimozide metoclopramide Calcium Channel Blockers: propranolol methoxyamphetamine amlodipine quinine mexiletine diltiazem salmeterol nortriptyline felodipine sildenafil minaprine lercanidipine sirolimus ondansetron nifedipine tamoxifen perhexiline nisoldipine taxol phenacetin nitrendipine terfenadine phenformin verapamil trazodone propranolol vincristine quanoxan zaleplon sparteine zolpidem tamoxifen tramadol venlafaxineInhibitors1A2 2B6 2C19 2C9 2D6 2E1 3A4,5,7amiodarone thiotepa cimetidine amiodarone amiodarone dithiocarbamate HIV Antivirals:cimetidine ticlopidine felbamate fluconazole buproprion disulfiram delaviridinefluoroquinolones fluoxetine fluvastatin celecoxib indinavirfluvoxamine fluvoxamine fluvoxamine chlorpromazine nelfinavirfurafylline indomethacin isoniazid chlorpheniramine ritonavirinterferon? ketoconazole lovastatin cimetidine saquinavir
  • 247. methoxsalen lansoprazole paroxetine clomipramine amiodaronemibefradil modafinil omeprazole phenylbutazone cocaine NOT azithromycinticlopidine paroxetine probenicid doxorubicin cimetidine probenicid sertraline fluoxetine ciprofloxacin ticlopidine sulfamethoxazole halofantrine clarithromycin topiramate sulfaphenazole red-haloperidol diethyl- dithiocarbamate teniposide levomepromazine diltiazem trimethoprim metoclopramide erythromycin zafirlukast methadone fluconazole mibefradil fluvoxamine moclobemide gestodene paroxetine grapefruit juice quinidine itraconazole ranitidine ketoconazole ritonavir mifepristone sertraline nefazodone terbinafine