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Clinical Pharmacy for OTC Preparation

Definition
Over-the-counter (OTC) drugs are medications that can be purchased at a pharmacy, grocery, or convenience store
without a prescription to treat the symptoms of common colds or pains, such as a headache. The Food and Drug
Administration (FDA) has determined that these medications have medical benefits for common ailments and are safe
for general consumption if taken exactly as prescribed by the packaging.

Antacid
What are antacids, and how do they work?
Antacids are a class of drugs used to treat conditions caused by the acid that is produced by the stomach. The
stomach naturally secretes an acid called hydrochloric acid that helps to break down proteins. This acid causes the
contents of the stomach to be acidic in nature, with a pH level of 2 or 3. (pH levels are a measure of acidity in the
stomach: the lower the number, the greater the acidity.) The stomach, duodenum, and esophagus are protected from acid
by several protective mechanisms. When there is too much acid or protective mechanisms are inadequate, the lining of
the stomach, duodenum or esophagus may become damaged by the acid, giving rise to various gastrointestinal symptoms
such as abdominal pain, heartburn (due to gastroesophageal reflux disease or GERD), and other gastro-esophageal
symptoms.
Antacids reduce acidity by neutralizing (counteracting) acid, reducing the acidity in the stomach, and reducing the
amount of acid that is refluxed into the esophagus or emptied into the duodenum. Antacids also work by inhibiting the
activity of pepsin, a digestive enzyme produced in the stomach that is active only in an acid environment and, like acid,
is believed to be injurious to the lining of the stomach, duodenum, and esophagus.
It is important to note that when antacids are taken on an empty stomach they provide acid reduction for 20 to 40 minutes
only because the antacid is rapidly emptied into the duodenum. When taken after a meal, (approximately 1 hour
afterwards) antacids reduce acid for at least three hours since food from the meal slows emptying of the antacid from the
stomach. It is important to discuss the use of antacids with a physician or pharmacist, especially if used in combination
with other prescribed medications so as to avoid drug interactions.

For what conditions are antacids used?

Antacids are used commonly for symptoms such as heartburn, abdominal pain (sometimes described as sour
stomach) and nausea resulting from a number of conditions such as, acid-peptic ulcers of the esophagus, stomach, and
duodenum or inflammation of the lining of the esophagus (esophagitis), stomach (gastritis), and duodenum (duodenitis).
Aluminum carbonate antacids can be used to treat and manage hyperphosphatemia (abnormally elevated levels of
phosphate in the blood) since they bind phosphate in the intestine and prevent it from being absorbed into the body.
Because of this ability to bind phosphate in the intestine, aluminum carbonate antacids also can be used with a low
phosphate diet to prevent the formation of kidney stones, since kidney stones are made up of various elements including
phosphates.
Calcium carbonate antacids are used in conditions of calcium deficiency such as postmenopausal osteoporosis.
Magnesium oxide antacids are used to treat magnesium deficiencies from either diets or medications that cause
magnesium depletion.
Off label (not FDA-approved) uses for antacids containing aluminum and magnesium or aluminum alone include
preventing stress ulcer bleeding. Other off-label uses for antacids are treatment and maintenance of healing of duodenal
ulcers.

Are there any differences among the different types of antacids?

Some antacid products may neutralize more acid in the stomach than others. The way to express the ability of an
antacid to neutralize acid is by determining the antacid's neutralizing capacity (ANC). The ANC is expressed as
milliequivalents (mEq) of acid that is neutralized, and it measures the ability of the antacid to neutralize acids (ph of 3.5
to 4). Per FDA requirements, an antacid must have a neutralizing capacity of 5 mEq per dose. The most effective
antacids should have a high acid neutralization capacity and rapid gastric acid neutralization qualities. Antacids such as
sodium bicarbonate and calcium carbonate have the greatest neutralizing capacity but are not used for long periods of
time due to adverse events. (Please see the sections on warnings/precautions and side effects.)
An antacid's onset of neutralizing action (how fast the drug dissolves in gastric acid) varies among different antacids.
Sodium bicarbonate and magnesium hydroxide dissolve quickly and provide a rapid buffering effect, while aluminum
hydroxide and calcium carbonate dissolve slowly. Antacid suspensions generally dissolve more easily than tablets or
powders. If a tablet antacid is used, however, it is advisable to chew the tablets thoroughly for maximal effectiveness.
Another difference amongst the antacids is the duration of action (how long it continues to neutralize acid in the
stomach). Sodium bicarbonate and magnesium hydroxide have the shortest duration of neutralizing action, while
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aluminum hydroxide and calcium carbonate have the longest. Combination aluminum-magnesium antacids have an
intermediate duration of action.

What are the warnings and precautions for antacids?

Antacids (for example, calcium carbonate) when consumed in high doses and for long periods of time may cause
acid rebound. Acid rebound is a condition in which the stomach produces even more acid after the consumption
of foods and drinks. Fortunately, the effects of acid rebound are not clinically important.
High-dose calcium carbonate and sodium bicarbonate when taken together can cause a condition called milkalkali syndrome. Its symptoms include headache, nausea, irritability, and weakness, hypercalcemia (high blood
calcium levels), and renal impairment.
Extensive use of aluminum-containing antacids may cause hypophosphatemia (low phosphate levels in the
blood), which in severe cases could lead to muscle weakness, anorexia, and osteomalacia (softening of the
bones due to defective bone mineralization).
Antacids containing aluminum hydroxide should be used with caution in patients who have recently suffered
massive upper GI hemorrhage.
For patients with conditions such as high blood pressure, chronic heart failure, renal failure and those who have
sodium-restricted diets, it is important to pay attention to the sodium level in sodium-based antacid preparations
such as sodium bicarbonate
Antacids should not be given to children under six years of age.

What are the side effects of antacids?

Antacids may cause dose-dependent rebound hyperacidity and milk-alkali syndrome.

Antacids that contain aluminum hydroxide may cause constipation, aluminum-intoxication, osteomalacia, and
hypophosphatemia. They also may cause rebound hyperacidity and milk-alkali syndrome.
Antacids that contain magnesium have a laxative effect that may cause diarrhea, and in patients with renal failure
they may cause increased magnesium levels in the blood.

With which drugs do antacids interact?

When antacids are taken with acidic drugs such as [digoxin (Digitek), phenytoin (Dilantin), chlorpromazine
(Thorazine), isoniazid], they cause the absorption of the acidic drugs to be decreased, which causes low blood
concentrations of the drugs, which ultimately results in reduced effects of the drugs.
Antacids taken with drugs such as [pseudoephedrine (Sudafed, Semprex D, Clarinex-D 12hr, Clarinex-D 24hr, ,
Deconsal, Entex PSE, Claritin D, and more), levodopa (Dopar)], increase absorption of the drugs and can cause
toxicity/adverse events due to increased blood levels of the drugs.
Antacids that contain magnesium trisilicate and magnesium hydroxide when taken with some other medications
(such as tetracycline) will bind to the drug, and reduce its absorption and effects.
Sodium bicarbonate has a strong effect on the acidity of the urine, and this can affect the elimination of some drugs.
Thus, sodium bicarbonate inhibits the excretion of basic drugs such as quinidine (Quinidex, Quinidine Gluconate,
Quinidine Sulfate, Quinidine Injection) and amphetamines by the kidneys in the urine, and increases the excretion of
acidic drugs such as aspirin.

Laxatives
What is constipation?
Constipation is a condition that is characterized by infrequent bowel movements that are painful or difficult, or stools
that are hard in consistency. Infrequent bowel movements alone are not a reliable indicator of constipation because bowel
frequency can vary between three times a day to once a week among normal individuals. Therefore, hard stools that are
difficult to pass or infrequent stools accompanied by abdominal pain, back pain, and abdominal bloating define
important constipation.

What are the causes of constipation?

There are many causes of constipation including
Diets low in fiber. Fiber is vegetable material that is resistant to digestion. It promotes soft stools by adding bulk
to the stool and causing water to be retained in stool.
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Side effects of medications such as narcotic pain killers, antidepressants, iron supplements, calcium channel
blockers (a class of medications for high blood pressure), and certain types of antacids.
Narrowing or blockage of the large intestine (colon) due to colon cancer or advanced diverticulosis.
Ineffective contraction or spasm of the colon's muscles due to irritable bowel syndrome or other diseases of the
colon's muscles.
Hormonal (endocrine) disturbances such as an under- active thyroid gland and diabetes mellitus with nerve
damage.
Parkinson's disease, multiple sclerosis, and other neurologic conditions.
Examples of common medications that can cause constipation
Narcotic pain medications: codeine (Tylenol #3), oxycodone (Percocet), and guaifenesin/hydromorphone
(Dilaudid) and others
Antidepressants: amitriptyline (Elavil), fluoxetine (Prozac), and imipramine (Tofranil)
Anticonvulsants: phenytoin (Dilantin) and carbamazepine (Tegretol)
Iron supplements
Calcium channel blockers [for example, diltiazem (Cardizem) and nifedipine (Procardia)]
Antacids [for example, aluminum hydroxide (Amphojel) and aluminum carbonate (Basaljel)]

Before trying laxatives

Before turning to laxatives for relief, try these lifestyle changes to help manage occasional irregularity:
Eat fiber-rich foods, such as wheat bran, fresh fruits and vegetables, and oats.
Drink plenty of fluids daily.
Exercise regularly.
Lifestyle and dietary improvements relieve constipation for many people, but if problems continue despite these changes,
your next choice may be a mild laxative.

How laxatives relieve constipation

Laxatives work in different ways, and the effectiveness of each laxative type varies from person to person. In
general, bulk-forming laxatives, which are also referred to as fiber supplements, are the gentlest on your body and safe to
use long term. Metamucil and Citrucel fall into this category. Stimulant laxatives, such as Ex-Lax and Senokot, are the
harshest and shouldn't be used long term.
Following are some examples of common types of laxatives. Other types also exist. Even though many laxatives are
available over-the-counter, it's best to talk to your doctor about laxative use and which kind may be best for you.
Type of laxative
(brand examples)

How they work

Side effects

Oral osmotics (Phillips' Milk

of Magnesia, Miralax)

Draw water into colon from

surrounding body tissues to allow
easier passage of stool

Bloating, cramping, diarrhea, nausea,

gas, increased thirst

Oral bulk formers (Benefiber,

Citrucel, Fiber Choice,
Metamucil)

Absorb water to form soft, bulky stool,

prompting normal contraction of
intestinal muscles

Bloating, gas, cramping, choking or

increased constipation if not taken with
enough water

Oral stool softeners (Colace,

Kaopectate)

Add moisture to stool to allow strainfree bowel movements

Throat irritation, cramping

Oral stimulants (Ex-lax,

Senokot)

Trigger rhythmic contractions of

intestinal muscles to eliminate stool

Belching, cramping, diarrhea, nausea,

urine discoloration

Rectal stimulants (Bisacodyl,

Pedia-Lax, Dulcolax)

Trigger rhythmic contractions of

intestinal muscles to eliminate stool

Rectal irritation, stomach discomfort,

cramping

Oral laxatives may interfere with your body's absorption of some medications and food nutrients. Rectal laxatives do
not have this effect. Also, some oral and rectal laxatives can lead to an electrolyte imbalance, especially after prolonged
use. Electrolytes, which include calcium, chloride, potassium, magnesium and sodium, regulate muscle contraction, heart
rhythm, nerve function, fluid balance and other body functions. An electrolyte imbalance can cause abnormal heart
rhythms, weakness, confusion and seizures.

What over-the-counter preparations can be used for constipation?

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Laxatives are medicines that increase the frequency and ease of passing bowel movements. Many types of laxatives
are available over-the-counter (OTC) for the relief of mild, occasional constipation. If the constipation becomes moderate
to severe or does not respond to OTC products, a doctor should be consulted.
Most OTC laxatives are safe, effective, and well tolerated. There are distinct classes of laxatives, which function
differently and have varying degrees of effectiveness and potential side effects.

Bulk-Forming Laxatives
Bulk-forming laxatives are the most commonly recommended initial treatments for constipation. Bulk-forming
laxatives may work as quickly as 12 hours or take as long as three days to be effective. Some bulk-forming laxatives are
derived from natural sources such as agar, psyllium, kelp (alginates), and plant gum. Others are synthetic cellulose
compounds such as methylcellulose and carboxymethylcellulose. Natural and synthetic bulk-forming laxatives act
similarly. They dissolve or swell in the intestines, lubricate and soften the stool, and make the passage of bowel
movements easier and more frequent.
Examples of bulk-forming laxatives are methylcellulose (Citrucel) psyllium hydrophilic mucilloid (Metamucil),
polycarbophil (FiberCon), guar gum (Benefiber) and malt soup extract (Maltsupex). Many of these agents are available
as powders and are mixed with fluids. Fruit drinks, fruit juice, and soft drinks mask the gritty taste of these laxatives
better than water. Some are available as wafers, which are designed to be eaten with a separate beverage.

The benefits of bulk-forming laxatives are

Bulk-forming laxatives are not absorbed from the intestines into the body and are safe for long-term use. They
are also safe for elderly patients with constipation.
They are helpful in patients with irritable bowel syndrome, diverticulosis, and colostomies.
Some bulk-forming laxatives (such as guar gum) are used as fiber supplements in patients whose diets contain
insufficient fiber. High fiber consumption can help control weight gain and sometimes modestly lower the level
of cholesterol in the blood.

Precautions for using bulk-forming laxatives

Each dose of a bulk-forming laxative should be taken with at least a full glass (8 ounces) of fluid to be safe and
effective. Therefore, bulk-forming laxatives may not be appropriate for patients who must restrict oral fluid
intake (such as patients with kidney failure).
Patients with narrowing of the digestive tract (including esophageal stricture, intestinal stricture, or severe
adhesions) should not use bulk-forming agents without their doctors' approval due to the risk of blockage of the
intestine or the esophagus.
Some patients may be allergic to the laxative or other substances contained in the product, such as coloring or
artificial sweeteners.
Abdominal bloating, discomfort, and flatulence (gas) can be bothersome to some patients using bulk-forming
laxatives.
Some of these products contain sugar. Diabetes mellitus patients may need to select sugar-free bulk-forming
laxatives. By trying different types of bulk-forming laxatives, it usually is possible to find one that does not
cause discomfort.
They can decrease the absorption of certain medications (aspirin, warfarin (Coumadin), and carbamazepine
(Tegretol) and can also reduce blood sugar levels.

Stool Softeners (emollient laxatives)

Stool softeners, called emollient laxatives, prevent hardening of the feces by adding moisture to the stool. The active
ingredient in most stool softeners is a medicine called docusate. Agents containing docusate do not by themselves
stimulate or increase the number of bowel movements. They are used more to prevent constipation than to treat it.
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Stool softeners are commonly recommended for patients who should avoid straining while defecating, including:
Patients recovering from abdominal, pelvic, or rectal surgery, childbirth, or a heart attack; persons with severe
high blood pressure or abdominal hernias; and
Patients with painful hemorrhoids and/or anal fissures. Softening the stool in these patients can help reduce pain
during defecation.
Stool softeners available OTC includes Colace, Surfak, and pharmacy or store-branded products containing
docusate. Some preparations (for example, Peri-Colace) combine a stool softener with a stimulant laxative to activate
bowel movements.

Precautions for using stool softeners

Stool softeners are generally safe and well tolerated. They should not be combined with mineral oil, a lubricant
laxative, because stool softeners may increase the absorption and toxicity of mineral oil. Mineral oil droplets absorbed
into the body can deposit and cause inflammation in the lymph glands, liver, and spleen.

Lubricant Laxatives
Mineral oil (liquid petrolatum) coats and softens stool. Like stool softeners, mineral oil is used by patients who need
to avoid straining (for example, after hernia repair, hemorrhoid surgery, heart attacks, and childbirth).

Precautions for using lubricant laxatives

Mineral oil should be avoided in patients taking blood thinners, such as warfarin (Coumadin). Mineral oil
decreases the absorption of vitamin K (important in forming clotting factors in the blood) from the intestines.
The decreased assimilation of vitamin K in patients taking Coumadin can potentially lead to "over-thinning" of
the blood and increasing the risk of excessive bleeding.
Mineral oil should not be taken during pregnancy since it may inhibit vitamin absorption and decrease the
availability of vitamin K to the fetus.
Mineral oil can cause pneumonia if it leaks into the lungs. Leakage of secretions and other contents from the
mouth and the esophagus into the lungs is called aspiration. Certain individuals (for example, the very young,
the elderly, stroke victims, and those with swallowing difficulties) are prone to aspirate, especially while lying
down. Therefore, mineral oil should not be given at bedtime or to individuals who are prone to aspirate.
Mineral oil should only be used for short periods of time. A significant absorption of mineral oil into the body
can occur if used repeatedly over prolonged periods.

Stimulant Laxatives
Stimulant laxatives induce bowel movements by increasing the contraction of muscles in the intestines, and are
effective when used on a short term basis. Examples of stimulant laxatives include aloe, cascara, senna compounds,
bisacodyl, and castor oil. Bisacodyl (Dulcolax, Correctol) is available OTC in oral pill form and as a suppository or
enema. The oral form takes 6 to 10 hours to work. Bisacodyl is commonly used in cleansing the colon for colonoscopies,
barium enemas, and intestinal surgeries. While effective for occasional constipation, bisacodyl should not be taken for
more than a week, and a doctor should supervise repeated use.
Other stimulant laxatives include senna (Ex-Lax, Senokot), cascara sagrada (Nature's Remedy), and casanthranol.
These laxatives are converted by the bacteria in the colon into active compounds which then stimulate the contraction of
colon muscles. After taking these products orally, bowel movements occur after 8 to 24 hours. Prolonged, chronic use of
these laxatives can cause the lining of the colon to become darker than normal (melanosis coli) due to the accumulation
of a pigment (melanin).
Castor oil (an ingredient of Purge Concentrate) is a liquid stimulant laxative that works in the small intestine. It
causes the accumulation of fluid in the small intestine and promotes evacuation of the bowels. Castor oil should not be
taken with food, although juice or other flavored liquids can help hide its unpleasant taste. This laxative works rather
quickly, usually within 2 to 6 hours. Castor oil is usually used to cleanse the colon for surgery, barium enema, or
colonoscopy. The absorption of nutrients and minerals by the small intestine can be impaired by the frequent use of
castor oil. Therefore, this medicine is not recommended for the repeated treatment for constipation.

Precautions
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The intensity of the action of stimulant laxatives is dose related. A large dose of any stimulant laxative can
produce serious adverse effects.
Side effects include severe cramps, excess fluid loss and dehydration, blood electrolyte disturbances such as low
levels of blood potassium, and malnutrition with chronic use.
Chronic, long-term use of stimulant laxatives can lead to loss of colon function (cathartic colon). After years to
decades of frequent use of stimulant laxatives, the nerves of the colon slowly disappear, the colon muscles
wither, and the colon becomes dilated. Consequently, constipation becomes increasingly worse and unresponsive
to laxatives

Saline Laxatives
The active ingredients in saline laxatives are mostly magnesium, sulfate, citrate, and phosphate ions. These ions draw
water into the intestines. The additional water softens the stool, increases pressure within the intestines, and increases
intestinal contractions resulting in the discharge of softer stool. Fleet Phospho-Soda, milk of magnesia, and magnesium
citrate are examples of saline laxatives.
Oral doses of saline laxatives should be taken with one to two glasses of water. The onset of bowel response is
usually 1/2 to 3 hours after consuming the laxative. Small doses are sometimes recommended for the treatment of
occasional constipation, while larger doses can produce complete evacuation of the intestine. Complete cleansing of the
bowel is useful in preparing for colonoscopy, sigmoidoscopy, and barium enema.

Precautions
Since there may be some absorption of the active ingredients from the intestines into the blood circulation, saline
laxatives should not be used in certain patients. Patients with impaired kidney function should not use laxatives
containing magnesium or phosphate salts. Excess accumulation of magnesium and phosphate in the blood of these
patients can lead to toxicity. Patients who need to limit their sodium intake, such as those with congestive heart failure,
kidney disease, and high blood pressure, should not use laxatives that contain sodium.

Enemas and Suppositories

Rectally administered enemas and suppositories are commonly used to cleanse the rectum and the sigmoid colon (the
part of the colon closest to the rectum) prior to surgery, child delivery, and flexible sigmoidoscopy. Enemas and
suppositories are also used to relieve constipation and rectal fecal impaction (blockage of the rectum by hard, compacted
stool). They can also be used in conjunction with oral laxatives in cleansing the colon in preparation for barium enema
studies.
Enemas and suppositories include docusate (Microenema), bisacodyl (Dulcolax Suppository), and sodium
phosphate (Fleet Enema). These products are intended for occasional use and are not recommended as a chronic laxative
regimen unless directed by a physician.
Patients should carefully follow instructions in using enemas. The patient should lie on the left side with the knees bent.
The enema solution should be inserted slowly into the rectum. The person should retain the solution in the rectum until
definite rectal pressure and the urge to have a bowel movement are felt. Evacuation usually occurs within minutes to an
hour.

Precautions

Soapsuds enemas can cause rectal irritation and sometimes rectal gangrene. Therefore, soapsuds enemas are not
recommended.
Enema solutions can cause fluid and electrolyte disturbances in the blood if used on a chronic basis.

Antidiarrhoeal
Antidiarrhoeal
In general, acute diarrhea can be managed effectively with the use of nonprescription antidiarrheal products in
conjunction with adequate fluid-electrolyte replacement and dietary interventions. Existing nonprescription antidiarrheal
products contain loperamide or bismuth subsalicylate (Table).

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Loperamide
Loperamide is indicated for traveler's diarrhea, nonspecific acute diarrhea, or chronic diarrhea associated with
inflammatory bowel disease.1 The therapeutic effects include reduction of daily fecal volume, increased viscosity and
bulk volume, and reduced fluid and electrolyte loss.
Loperamide should not be used by individuals with fecal leukocytes, high fever, or blood or mucus in the stool.
Adverse effects associated with loperamide include dizziness and constipation. 1 Typically, loperamide is not
recommended for children under 6 years of age unless under the direct supervision of a physician.

Bismuth Subsalicylate
Bismuth subsalicylate is indicated for the treatment of mild nonspecific diarrhea. Patients should be advised that the
use of this agent may cause discoloration of the tongue and stool. The use of this agent should be avoided in the
following patient populations
Patients with a history of salicylate allergies or those currently taking salicylate products
Patients with a history of ulcers or coagulation abnormalities
Patients with medical conditions such as arthritis, diabetes, or gout
Children or teenagers with or recovering from the flu or chickenpox

What types of OTC drugs treat diarrhea?

Over-the-counter (OTC) drugs are medicines you can buy without a prescription from your doctor. Some OTC drugs
can help you feel better if you have diarrhea. These are called antidiarrheal medicines.
Antidiarrheal medicines include loperamide (one brand name: Imodium) and bismuth subsalicylate (some brand
names: Kaopectate, Pepto-Bismol). Bismuth subsalicylate can also be used for upset stomach and as an antiemetic (a
medicine that treats nausea and vomiting).
Depending on the cause of your diarrhea, you may also need to take antibiotics prescribed by your doctor.
Antibiotics are medicines that kill bacteria. If your doctor prescribes an antibiotic for you, its important to talk to your
doctor before taking any OTC medicine to relieve your symptoms.

When not to use antidiarrheal medicines

When diarrhea is a symptom of an infection caused by bacteria or parasites, antidiarrheal medicines can actually
make the condition worse. This is because the medicine keeps your body from getting rid of the bacteria or parasite that
is causing the diarrhea.
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Talk to your family doctor if you think your diarrhea is caused by a bacterial or parasitic infection.

How do antidiarrheal medicines work?

Loperamide works by slowing down the speed of fluids moving through your intestines (bowels).
Bismuth subsalicylate works by balancing the way fluid moves through your intestines. It also reduces
inflammation and keeps certain bacteria and viruses that cause diarrhea from growing in the stomach and
intestines.

Should I treat diarrhea?

Most of the time, diarrhea doesnt require treatment. It most often lasts only a couple of days whether you treat it or
not. However, medicine can help you feel better, especially if you also have cramping.

What are some common side effects of antidiarrheal drugs?

Healthy adults usually dont experience side effects from antidiarrheal medicines. However, they may be a concern
for older adults or people who have health problems. Call your doctor if you notice any side effects.
Loperamide side effects:
Abdominal pain
Constipation
Dizziness
Nausea
Bismuth subsalicylate side effects:
Constipation
Blackened stools and/or tongue
Ringing sound in the ear (called tinnitus)

Who shouldnt take these drugs?

Dont give loperamide to children 6 years of age or younger unless your doctor says its okay. You shouldnt take
loperamide if you have a fever, or if youve ever had a rash or an allergic reaction when taking it. Dont take loperamide
if you have bloody or black stools. These may be signs of a more serious problem, so talk to your family doctor.
People who are allergic to aspirin or other salicylate medicines should not take bismuth subsalicylate. Dont give
bismuth subsalicylate to children 12 years of age or younger. Dont give bismuth subsalicylate to children or teenagers
12 to 18 years of age who may have the flu or chickenpox. This increases their risk for Reyes syndrome, which is a
serious illness that can lead to death.

Can OTC antidiarrheal drugs cause problems with any other medicines I take?
Before taking loperamide if you also take
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Antiviral medicines for human immunodeficiency virus (HIV)

Antibiotics
Prescription pain medicines
Using any of these medicines with loperamide can increase your risk for side effects, so your doctor may need to
adjust your dosages.
Bismuth subsalicylate may cause side effects if combined with other drugs. Ask your doctor before taking bismuth
subsalicylate if you also take:
Blood-thinning medicines
Medicines for gout
Medicines for arthritis
Medicines for diabetes

Antiemetics
Antiemetics
Antiemetics are drugs used to control nausea and vomiting. These drugs are taken before surgical operations, during
bouts of sickness, or after feeling queasy and unwell. You can purchase over-the-counter (OTC) antiemetics from your
local pharmacy or have them prescribed by your physician.
Bismuth Subsalicylate
It is used to treat nausea, vomiting and upset stomach. It can also be useful in treating diarrhea.

Antihistamines
These work by preventing motion sickness. They can be purchases OTC under the names dimenhydrinate
(Dramamine) and meclizine hydrochloride (Dramamine Less Drowsy). These work better if taken before you get sick.

Promoethazine
This is a form of antihistamine used to treat motion sickness, allergy symptoms and effects of sedation. It is given by
your doctor as an intramuscular injection, or prescribed as a suppository or syrup.

Serotonin Receptor Antagonists

These drugs are used after an operation to control nausea and vomiting caused by anesthesia or pain medication.
They are also used for patients undergoing chemotherapy.

Dronabinol
It is used to stop anorexia in AIDS patients. Marinol is also used in cancer patients who have not responded to other
forms of antiemetics

What types of OTC drugs treat nausea and vomiting?

Over-the-counter (OTC) drugs are medicines you can buy without a doctor as prescription. Medicines for nausea are
called antiemetic drugs. They can help relieve nausea and vomiting. Several OTC medicines are used as antiemetics.
Bismuth subsalicylate (some brand names: Kaopectate, Pepto-Bismol) may help treat some types of nausea and
vomiting, such as from gastroenteritis (also called as stomach flack). It is also used for upset stomach and as an
antidiarrheal (medicine to treat diarrhea).
Certain antihistamines may help prevent nausea and vomiting caused by motion sickness. These include
dimenhydrinate (brand name: Dramamine) and meclizine hydrochloride (brand name: Dramamine Less Drowsy).

How do antiemetic drugs work?

Bismuth subsalicylate works by protecting the stomach lining. Antihistamines appear to dull the inner ears ability to
sense motion. They block messages to the part of the brain that controls nausea and vomiting. This is why they work best
if you take them before you think you might have a problem with motion sickness.

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What are some common side effects of antiemetic drugs?

Healthy adults usually do not experience side effects from antiemetic medicines. Side effects can be a concern for
older adults or people who have health problems.
The most common side effects of bismuth subsalicylate are darkened stools or tongue, constipation and a ringing
sound in the ears (tinnitus). These are short-term side effects.
Antihistamines may make you feel sleepy. This can affect your ability to drive or operate machines. It can make it
hard for you to think clearly. They may also cause your mouth and eyes to feel dry. Remember, alcohol can increase the
drowsiness caused by antihistamines.

Who should not take antiemetic drugs?

Do not take bismuth subsalicylate if you have ever had an allergy to aspirin or any other product that contains
salicylates. Also, do not give bismuth subsalicylate to children 12 years of age or younger, or to children and teenagers
12 years to 18 years of age who may have the flu or chickenpox, because of an increased risk of Reyes syndrome.

Can OTC antiemetic drugs cause problems with any other medicines I take?
Bismuth subsalicylate may affect some drugs so that they do not work as well. It also may cause side effects if
combined with other drugs. If you take any of the following drugs, talk to your doctor before taking bismuth
subsalicylate
Blood-thinning drugs
Drugs to treat gout
Drugs to treat arthritis
Drugs for diabetes
Also, be careful not to double upon salicylate. Some pain relievers, cold medicines and prescription drugs contain
aspirin, which is a salicylate, or some other type of salicylate. Because bismuth subsalicylate also contains salicylate, you
may take more salicylate than you intend if you take more than one of these products.
Talk to your doctor before taking an antihistamine if you take sleeping pills, sedatives or muscle relaxants. Many
OTC cold and allergy products contain antihistamines. If you take more than one of these products, you may take more
antihistamine than you intend. Some prescription drugs have side effects similar to the side effects of antihistamines
(including dry mouth and drowsiness), so you should also talk with your doctor before taking these medicines at the
same time

Analgesic
Introduction to OTC pain medication and fever reducers
Pain is the most common reason for people to seek medical advice; pain medicine is the most frequently purchased
over-the-counter (OTC) medication. Fever is one of the most common reasons that children visit the doctor. Moreover,
one in five emergency room visits for children is due to fever. Since OTC medicines that are effective in treating pain
also are effective at reducing fever, they will be considered together in this article.

What are the classifications of pain?

Pain can be classified as acute, chronic non-malignant, chronic malignant. Headaches are the most common cause of
pain and can be considered a separate class of pain.
Acute pain
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Acute pain is experienced by everyone; it is usually short in duration with an identifiable pathology, a predictable
prognosis, and treatment that usually includes analgesics. Acute pain is most often due to injuries. Examples of injuries
include:
Muscle soreness due to overuse, sprains or strains, or viral infections,
Tears of the ligaments,
Broken bones,
Bruises, and
Cuts.
Acute pain from such injuries can respond well to OTC pain medication. Muscle soreness also may respond well to
heat and massage.

Chronic non-malignant pain

Chronic non-malignant pain often begins as acute pain, but it continues beyond the typical time expected for
resolution of the problem or persists or recurs for other reasons. It is a type of pain associated with progressive,
debilitating diseases such as arthritis. Treatment for chronic non-malignant pain can include OTC medications .
However, because of the chronic nature of the pain, regular use of OTC medications can lead to side effects.

Chronic malignant pain

Chronic malignant pain is pain associated with advanced, progressive diseases (often fatal) such as cancer, multiple
sclerosis, AIDS, and terminal kidney disease. OTC medications for pain may be useful for the management of chronic
malignant pain. However, stronger prescription medications are usually necessary.

What are the types of headaches?

Headaches are the most common reason that pain medications (analgesics) are taken. Headaches can be classified
into three types:
1. Muscle contraction,
2. Migraine or vascular, and
3. Sinus.

Muscle contraction headache

A muscle contraction headache, the most common type, results from the continuous tightening of the muscles in the
upper back, neck, or scalp. This type of headache often is described as a tight, pressing, or throbbing sensation of the
head. It can be brought on by emotional stress and anxiety ("tension headaches"). Acute muscle contraction headaches
generally respond well to OTC analgesics, but chronic muscle contraction headaches can require physical therapy or
relaxation techniques.

Migraine or vascular headaches

Migraine or vascular headaches are due to dilation (widening) of blood vessels in the head. An estimated 28 million
people in the United States (about 12% of the population) will experience migraine headaches. Migraine headaches
affect children as well as adults. Before puberty, boys are affected more than girls by migraine headaches. However, as a
child nears adolescence, girls are affected more than boys. An estimated 6% of men and up to 18% of women will
experience a migraine headache. Although many patients use the expression "migraine" to describe any particularly
painful headache, many of these are actually muscle contraction headaches. OTC medications for pain may be quite
effective for treating migraine headaches. However, prescription medications that are specifically formulated for treating
or preventing migraines are often necessary.

Sinus headache
A sinus headache is caused by inflammation or an infection or blockage of one or more sinuses. The pain often is
limited to the area around the eyes or the forehead. The pain may occur upon awakening, and may decrease in intensity
after the person stands or sits up for a period of time. In addition to analgesics, OTC decongestants can be effective to
help drain the sinuses.

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What causes fever?

Most fevers last only a few hours or days and are not dangerous; however, they may cause a great deal of discomfort.
A rectal temperature of greater than 101.8 F (38.8 C), an oral temperature of more than 100 F (37.8 C), or an armpit
temperature of greater than 99 F (37.2 C) is considered significantly abnormal. Fevers are usually due to viral or bacterial
infections; however, they also can be due to cancers, injury to tissue (for example, heart attacks), hyperthyroidism, other
illnesses in which there is inflammation, and dehydration. Additionally, many different drugs have been reported to cause
"drug fever."
Harmful effects of fever (for example, dehydration, changes in consciousness, seizures, or coma) are likely to occur
at temperatures above 106 F. Lower fevers can be dangerous in persons with heart disease, since fever increases the
effort required by the heart to pump blood.
Two percent to four percent of children between the ages of 6 months and 5 years (usually before age 3) with high fevers
will experience febrile seizures; though these seizures generally last no more than 15 minutes. Moreover, children who
experience febrile seizures have a higher risk of developing epilepsy later in life.

What are the different classes OTC pain relievers and fever reducers?
The three classes of OTC analgesic/antipyretic medications are:
Salicylates: aspirin (also called acetylsalicylic acid or ASA), choline salicylate, magnesium salicylate, and
sodium salicylate;
Acetaminophen
Nonsteroidal antiinflammatory drugs (NSAIDs): ibuprofen, naproxen sodium, and ketoprofen. (Aspirin is
also an NSAID, but it is considered separately from the other NSAIDs because it has some unique properties.)
Each of these drugs is discussed in detail below.
In most circumstances, these medications all have very similar abilities to relieve pain and fever. Their onsets of
action (the interval from the time of ingestion to the start of pain relief) also are similar. Naproxen sodium may have a
somewhat longer duration of pain relief (analgesia) than the other NSAIDs or aspirin. At high doses, salicylates and
NSAIDs suppress inflammation and are, therefore, particularly useful in treating inflammatory diseases, such as arthritis.
Acetaminophen does not have anti-inflammatory actions.
Many OTC analgesics are available in combination with other drugs. There is some evidence that caffeine and
antihistamines enhance the effects of analgesics. Thus, caffeine increases the pain-relieving effects of aspirin and
ibuprofen, and the antihistamines orphenadrine and phenyltoloxamine enhance the pain-relieving effects of
acetaminophen. Combinations of decongestants with analgesics are logical only when nasal or sinus congestion are
present, such as with sinus headaches.

Aspirin
Aspirin can damage the lining of the stomach and duodenum, thereby causing abdominal pain, bleeding, and/or
ulcers. As a result, 1 in 5 persons who take aspirin in a dose of 2.5 grams per day or more develops ulcers and about 1 in
6 will lose enough blood from gastrointestinal bleeding to develop anemia. In an attempt to reduce the potential for these
complications, some aspirin-containing tablets have been coated with a special coating that prevents the tablet from
dissolving until it is past the stomach and duodenum. These "enteric-coated" aspirin products may reduce the frequency
of abdominal pain, but not the bleeding or ulcers. Moreover, the onset of pain relief is delayed with enteric-coated aspirin
because it takes more time for the tablets to dissolve.
Aspirin, when taken together with an anti-coagulant such as warfarin (Coumadin) or enoxaparin (Lovenox), can
greatly impair the body's ability to form blood clots, resulting in excessive bleeding spontaneously, from ulcers, or
related to a procedure. Therefore, patients on such combinations must be closely monitored by a doctor.
Low dose aspirin can raise levels of uric acid in the blood and may need to be avoided in patients with increased uric
acid levels or gout.
Certain NSAIDs, particularly ibuprofen (Motrin, Advil), if taken just before aspirin or in multiples doses each day,
can reduce the anti-platelet effects of aspirin treatment and theoretically render aspirin less effective in preventing heart
attacks and ischemic strokes.

Salicylates other than aspirin

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Choline salicylate (Arthropan) is available as a liquid. It is absorbed more quickly, but its onset of action is no
different than that of aspirin. Some people find choline salicylate fishy tasting. Fortunately, it can be mixed with juice or
soda prior to ingestion. It is less effective at reducing fevers in children than either aspirin or acetaminophen.
Magnesium salicylate (Arthriten; Backache) is as effective as aspirin at reducing pain. Patients with chronic kidney
disease should avoid magnesium salicylate, since the magnesium may accumulate in the body.
Sodium salicylate (Scot-Tussin Original) and aspirin are equally effective in the long-term treatment of rheumatoid
arthritis, but sodium salicylate is less effective at reducing pain or fever.

Acetaminophen
Acetaminophen comes in various oral formulations, including different types (elixirs or syrups) and flavors of
liquids, capsules, tablets, caplets, and suppositories. The capsules contain tasteless granules that can be emptied onto a
teaspoon containing a small amount of drink or soft food, and can then be swallowed. However, the granules should not
be mixed in a glass of liquid since the granules will stick to glass itself. The amount of acetaminophen that is absorbed
from rectal suppositories is about half that of the oral formulations.

Side effects of acetaminophen

Acetaminophen generally is safe to use, and few people develop side effects. In high doses, however, it can cause
liver damage and doses of 4000 mg (4 grams) per day should not be exceeded.

Pregnancy/breastfeeding and acetaminophen

Acetaminophen has no known harmful effects on the mother, fetus, or infant and, therefore, can be used safely
during pregnancy and breastfeeding.

Drug interactions and acetaminophen

It has been reported that patients with HIV-related diseases (such as AIDS) who take AZT (zidovudine; Retrovir) and
acetaminophen are at an increased risk of developing suppression of their bone marrow. Such patients develop lower
white and red blood cell and platelet counts and, therefore, are more susceptible to infection, anemia, and bleeding.

Nonsteroidal Anti-inflammatory Drugs (NSAIDS)

There are three OTC NSAIDs; ibuprofen, naproxen sodium, and ketoprofen. All have pain relieving (analgesic),
fever reducing (antipyretic), and anti-inflammatory properties. Additionally, NSAIDs are more effective than aspirin or
acetaminophen for menstrual cramps.

Preparations of NSAIDs
Ibuprofen is available in tablets as well as in a pediatric suspension. Naproxen sodium is available in tablets.
Ketoprofen is available as tablets and capelets.

Side effects and NSAIDs

The most frequent side effect of NSAIDs is damage to the lining of the stomach and duodenum that can lead to
abdominal pain, nausea, and loss of appetite. NSAIDs also can cause ulcers and bleeding from the stomach and
duodenum, but less frequently and less severely than occurs with aspirin use. NSAIDs, like aspirin, affect platelets and
can inhibit the formation of blood clots, and, therefore, they should be discontinued at least 3 days before surgery or
dental procedures.
Because alcohol intensifies the effect of NSAIDs on bleeding, alcohol should not be taken with NSAIDs. NSAIDs
also can cause kidney damage, particularly in the elderly or patients with high blood pressure, diabetes, atherosclerosis,
or who take diuretic medications ("water pills").
Patients who are allergic to aspirin should not take NSAIDs since they are likely to be allergic to NSAIDs as well.
NSAIDs may cause fluid retention in persons with congestive heart failure.
The most serious side effects are kidney failure, liver failure, ulcers, and prolonged bleeding after an injury or surgery.

Pregnancy/breastfeeding and NSAIDs

NSAIDs are safe for use during the first or second trimesters of pregnancy, but should not be taken during the third
trimester because they can:
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Prolong labor and delay birth,

Increase bleeding in the mother following birth, and
Can cause cardiac (heart) and vascular (blood vessels) complications in the newborn.
Nevertheless, use of NSAIDs during any portion of pregnancy should be approved by the treating doctor. Ibuprofen
and naproxen sodium also are safe for use by nursing mothers. Due to insufficient data, ketoprofen is not recommended
for use by nursing mothers.

Drug interactions and NSAIDs

NSAIDs reduce the blood pressure-lowering effects of certain high blood pressure (antihypertensive) medications,
including:
Thiazide diuretics such as hydrochlorothiazide (Dyazide, Maxzide);
Beta-blockers such as propranolol (Inderal, Inderal LA), atenolol (Inderal, Tenormin), and metoprolol
(Lopressor);
Angiotensin receptor antagonists such as enalapril (Vasotec), lisinopril (Zestril; Prinivil), benazepril (Lotensin),
quinapril (Accupril), ramipril (Altace), and captopril (Capoten); and
Some medications that act on the brain, such as clonidine (Catapres).
NSAIDs reduce blood flow to the kidneys and reduce the action of diuretics and decrease the elimination of lithium
(Eskalith) and methotrexate (Rheumatrex).
NSAIDs also decrease the ability of the blood to clot and can increase the risk of bleeding. When used with other
drugs that also increase bleeding risk (for example, warfarin [Coumadin]), there is an increased likelihood of serious
bleeding or complications of bleeding. Therefore, individuals who are taking drugs that reduce the ability of blood to clot
should avoid the prolonged use of NSAIDs.

What about overdoses of pain relievers and fever reducers?

The American Association of Poison Control Centers reported that of all overdoses of OTC products, 66% involved
acetaminophen, 19% involved ibuprofen, and 15% involved aspirin.
Aspirin overdose can occur with as little as 150 mg/kg (10,000 mg or 10 grams in the average sized male) as a single
dose, or 90 mg/kg per day for at least two consecutive days. Symptoms of toxicity due to aspirin include:
Tiredness,
Ringing in the ears,
Rapid breathing,
Seizures, vomiting,
Bleeding, and
Coma.
Large doses of acetaminophen rarely cause serious problems in children. In adults, as little as 10 grams can damage
the liver and the kidneys.
Overdoses of ibuprofen rarely produce important problems. Nausea, vomiting, stomach pain, tiredness, and dizziness
are the most common symptoms of large doses of ibuprofen. Rarely, coma may occur.

Contraceptives
Contraceptives
Over-the-counter birth control methods are not as effective against pregnancy as some prescription methods.
However, they are more effective against STIs than any other method except not having intercourse (abstinence). They
enable people to protect themselves against pregnancies and STIs.

Condoms

A male condom is a thin sheath placed on the penis. In the case of the female condom, the condom is placed
inside the vagina before intercourse. Semen is collected inside the condom, which must be carefully held in
place and then removed after intercourse.
About 14 pregnancies occur out of 100 couples using male condoms over 1 year. About 21 pregnancies occur
out of 100 couples using female condoms. Condoms are more effective when spermicide is also used.
Condoms are available in most drug and grocery stores. Some family planning clinics may offer free condoms.
Latex condoms help prevent HIV and other STIs.
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Spermicides

Spermicides are chemical gels, foams, creams, or suppositories that kill sperm. They are inserted into the vagina
before intercourse.
They can be purchased in most drug and grocery stores.
This method used by itself is not very effective. About 26 pregnancies occur out of 100 women using this
method alone over 1 year. Therefore, spermicides are often combined with other methods (such as condoms or
diaphragm) for extra protection.
Spermicides are generally combined with other methods (such as 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.

Vaginal Sponge

Vaginal contraceptive sponges are soft artificial sponges covered with a spermicide. Before intercourse, the
sponge is moistened, inserted into the vagina, and placed over the cervix. After intercourse, the sponge is left in
place for 6 - 8 hours.
The sponge is similar to the diaphragm (which you must get from a doctor) as a barrier protection method.
About 18 - 28 pregnancies occur out of every 100 women using this method over 1 year. The sponge may be
more effective in women who have not already given birth to a baby.
Risks include irritation, allergic reaction, and trouble removing the sponge. In rare cases, toxic shock syndrome
may occur.

Emergency ("Morning After") Birth Control

The "morning after" pill consists of two doses of hormone pills taken within 72 hours after unprotected
intercourse.
The emergency contraceptive pill is available as either single pill (Plan B One-Step) or as two pills (Plan B, Next
Choice).

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