TREATMENT OF

ACUTE ILLNESSES:
PART 2
Katelyn Alexander, PharmD

3/6/2020
PMPR 3270 Nonprescription Pharmacotherapy, Natural
Medicines, and Self-Care I
Objectives
• Describe the patient assessment process for various
acute illnesses
• Differentiate patients who are not candidates for self-care
• Understand the basic pharmacology, appropriate uses,
adverse effects, and methods of administration of
covered agents
• Develop appropriate regimens based on patient
characteristics and underlying conditions
• Provide appropriate information when counseling patients
• Identify when and how nonpharmacologic therapy can be
utilized to treat patients’ symptoms
Diarrhea
Definitions
• An abnormal increase in stool frequency, liquidity, or
weight

• More than 3 bowel movements/day considered abnormal

• Acute diarrhea – <14 days

• Managed with fluid and electrolyte replacement, dietary
interventions, and nonprescription drug treatment
 Food-borne diarrhea
Causes of Diarrhea can be from viruses,
bacteria, or protozoa
sources!
• Infectious Diarrhea

• Viral
• Norovirus – most common viral cause of acute gastroenteritis
• Transmitted by contaminated water or food, or from person to person
• Outbreaks frequently occur in restaurant patrons, cruise ship
passengers, students on college campuses, in LTC facilities, military
personnel

• Bacterial
• Salmonella, Shigella, E. coli

• Protozoa – self-care not appropriate for these cases

• Giardia, Cryptosporidium
Causes of Diarrhea
• Food-Induced
• Food allergy
• Fatty foods
• Foods that are high in fiber may have a laxative effect

• Food-Intolerance
• Lactose intolerant
• Diverticulitis

• Drug-Induced
• Antibiotics
• Metformin
• Magnesium-containing antacids
• Laxatives
• Chemotherapy
Patient Evaluation
• Symptoms
• Abdominal pain? Any vomiting or fever?
• Characteristics
• Description of stool (color, consistency?) Blood?
• History
• Recent travel? What have you eaten? Happened before?
• What medications are you taking?
• Onset
• When did it start? How long have you had it?
• Location
• Aggravating factors
• What makes it worse?
• Remitting factors
• What makes it better? Nature and amount of fluid intake?
Exclusions for Self-Treatment
• Based on age:
• <6 months of age
• ≥6 month of age with persistent high fever (> 102.2°F)

• Based on symptoms:
• Severe dehydration
• Children showing behavioral changes
• Children who have not urinated in 8 hours
• Children who have no tears when crying
• Blood, mucus, or pus in the stool
• Protracted vomiting
• Severe abdominal pain/distress
Self-care limited
to acute bouts
• Based on duration of symptoms: only (<14 days)
• Persistent diarrhea (14 days to 4 weeks)
• Chronic diarrhea (>4 weeks)
Exclusions for Self-Treatment
• Based on patient characteristics:
• Risk for significant complications
• Diabetes, severe cardiovascular disease (CVD), renal disease
• Multiple chronic conditions
• Immunosuppressed patients
• Frail patients
• Pregnant patients

• Inability of caregiver to administer oral rehydration

solutions (ORS)
• Suboptimal response to ORS already administered
Classifying Dehydration
Minimal Dehydration
Self-treatable
< 3 unformed stools/day
Afebrile or low-grade fever
Normal BP and pulse
Alert
Drinks normally
Normal breathing
Normal eyes
Moist mouth and tongue
Mild-Moderate Dehydration Severe Dehydration
Self-treatable Refer, not self-treatable
3-5 unformed stools/day 6-9 unformed stools/day
Afebrile or may develop a Fever > 102˚F
fever > 102˚F
Mild orthostatic BP and Low BP, dizziness
pulse change Tachycardia
Fatigued or restless, Very lethargic
irritable
Thirsty Drinks poorly, unable to
drink
Breathing normal to fast Deep breathing
Eyes slightly sunken Eyes deeply sunken
Dry mouth and tongue Parched mouth and tongue
**Minimal urine output, severe
abdominal pain
Checking for Dehydration
• Check skin turgor

• Hydrated = instant recoil

• Mild-moderate dehydration = < 2 sec

• Severe dehydration = > 2 sec

Non-Pharmacologic Treatment:
Fluid and Electrolyte Management
• Options:
• Oral rehydration solutions (ORS)
• Pedialyte

• Clear juices, colas, soups, or sports drinks

• May contain inappropriately high carbohydrates and low
sodium
• Watch sugar content, supplement with sources of sodium
such as crackers or pretzels

• Two Phases:
1. Rehydration Therapy – over 3-4hrs to restore natural body
composition
2. Maintenance Therapy
Non-Pharmacologic Treatment:
Dietary Management
• Oral intake does not worsen diarrhea
• Withhold food no longer than 24 hours
• Restart normal, age-appropriate diet once rehydrated
• BRAT diet
• Not currently recommended exclusively; provides insufficient
calories, protein, and fat
• Complex carbohydrate-rich foods
• Rice, potatoes, breads, yogurt
• Avoid fatty foods, spicy foods, foods rich in simple sugars,
and caffeinated beverages
Preventative Measures
• Isolate individuals with diarrhea
• Hand washing
• Sterile technique
• Strict food handling
• Bismuth subsalicylate used prophylactically to prevent
Traveler’s Diarrhea (?)
• Prophylactic antibiotics (?)
Loperamide
• Stimulates micro-opioid receptors on intestinal
circular muscles to slow intestinal motility

• Adult dosing: 4 mg initially, then 2 mg after

each loose stool (max 8 mg/day)
• Avoid in children under 6

• Do not use longer than 48 hours

• Side effects: dizziness and constipation

• Less common: abdominal pain/distention, dry mouth

• Pregnancy category C
Bismuth Subsalicylate (BSS)
• Antimicrobial effects and anti-secretory effects that
reduce fluid and electrolyte losses
• Onset of action: ~5-10 minutes

• Duration of relief: 30-60 minutes

• Adult dosing: Maximum of 8 doses/day

• Do not use longer than 48 hours
• Avoid in children under 15 years old

• Side effects:
• Harmless black staining of tongue/stool (10%)
• Rarely: salicylate toxicity (tinnitus)
• Interferes with radiographic intestinal studies

• Standard warnings/precautions with salicylates…

• Pregnancy category C
Bismuth Subsalicylate (BSS)
• BSS Formulations
• Kaopectate

• Maalox

• Pepto-Bismol
Probiotics
• Include Lactobacillus, Bifidobacterium, and
Saccharomyces
• Effective in treating and preventing mild
acute, uncomplicated diarrhea, especially
rotavirus in children
• Generally safe in most patients

• Help re-establish gut flora and prevent the

presence of harmful bacteria; may also
stimulate immune system
• Evidence supports prevention of antibiotic-
associated diarrhea and reduction in duration
and severity of all-cause infectious diarrhea

• Side effects: gas, bloating, digestive

gurgling
Special Populations
• Pediatric
• Refer children less than 6 months of age
• For young children (< 6 years), ORS is only option

• Geriatric
• Refer if more severe

• Pregnancy
• Refer

• Lactation
• BSS is contraindicated in breast-feeding
Key Points for Diarrhea
• Most episodes of acute diarrhea stop after 48 hours
• Limit self-care to those patients with mild-moderate
diarrhea and minimal-moderate dehydration
• Dehydration prevention most important component of
treatment
• Counsel on replacement and maintenance rehydration
• Food should be withheld no more than 24 hours
• Because mild-moderate diarrhea is generally self-limiting,
should not use OTC agents beyond 2 days
• If persists beyond 48-72 hours, need to be seen for
evaluation
Intestinal Gas
Process of Digestion
Food, liquid, saliva and atmospheric air are
swallowed

Mix with gastric acid & pepsin in stomach to form

small fragments

Pass to small intestine for digestion/absorption of

vitamins/minerals

Indigestible liquid waste moves to large intestine to

mix with bacteria; Bacterial fermentation occurs and
more absorption

Remainder is eliminated during bowel movement

Process of Digestion
• Gas Formation
• Swallowed air
• Neutralization of stomach acids in small intestine
• Metabolism of dietary substrates
• Bacterial fermentation

• 99% of gas passed is odorless At any given

• 1% contains volatile gases time, ~200mL of
• Sulfur-based gases gas resides in
the GI tract
Causes of Intestinal Gas
• Disruptions in normal physiologic processes

• Diet

• Underlying medical conditions

• Lactose intolerance (most common)
• Irritable bowel syndrome
• Celiac disease

• Excessive swallowing of air

• Alterations in intestinal flora

• Drugs
Diet
• Dietary sugars
• Incomplete absorption of simple carbohydrates
• Malabsorption of complex carbohydrates
• Indigestible oligosaccharides

• Fats
• May be malabsorbed

• Dietary fiber
• May lead to bloating and flatulence

• Sulfate-containing foods cause worse odors

Gas-Producing Foods
MAJOR Gas-Producers Moderate Gas-Producers
Legumes Dairy Potatoes Citrus fruit
Brussel sprouts Fatty Foods Turnips Apples
Cabbage Beer Cauliflower Non-wheat
bread
Celery Red wine Cucumber
Carrots Carbonated Peppers
beverages
Prunes, raisins Sugar-free Radishes
products
Bananas Eggplant
Apricots
Wheat
Lactose Intolerance
• Deficiency in lactase enzyme
• Inability to digest lactose

Lactase
Lactose Glucose +
Galactose

• Intolerance to cow’s milk and milk products

• Causes gas symptoms + diarrhea

Signs and Symptoms
• Excessive belching
• Abdominal discomfort
• Cramping
• Bloating
• Flatulence

• Refer if symptoms are:

• Severe
• Persistent for longer than several months or occur more often than
occasionally
• Abdominal pain worsens or suddenly changes in location
• Accompanied by other significant GI symptoms
Non-Pharmacologic Treatment
• Eat and drink slowly
• Avoid washing solids down with a beverage
• Do not use straws to sip beverages
• Dietary changes
• Reduce/avoid gas-producing foods (see previous slides)
• Reduce/avoid dairy if lactose intolerant
• Reduce/avoid foods with air whipped into them
• Reduce/avoid carbonated beverages

• Stop smoking
• Avoid chewing gum and sucking on hard candies
Pharmacologic Therapy
• Anti-flatulent medications
• Simethicone
• Activated charcoal

• Digestive enzymes
• Alpha-galactosidase
• Lactase replacement

• Probiotics
Simethicone
• Defoaming agent that reduces surface
tension of gas bubbles

• Safe in infants and children, as well as

pregnant and breastfeeding mothers

• Not absorbed from the GI tract

• No known systemic side effects

• Combination products with antacids available

• Simethicone + loperamide works well in diarrhea to
relieve gas-related discomfort

• Discontinue if adequate relief not obtained

after 24hrs of use
Activated Charcoal
• Supposedly beneficial for elimination of
malodorous, sulfur-based gases

• Not approved for this use or shown to be

very effective

• Poor palatability
Alpha-galactosidase
• Degrades oligosaccharides to component parts
to be metabolized
• Prevents symptoms
• Take with first bite of meal or problem foods
• Inactivated by high temperatures- add to food once
cooled
•

• Precaution: may cause allergic rxn in those with

mold allergies

• Special populations
• Caution use in diabetic patients
• Safety/efficacy not established in pediatrics
• Pregnant/nursing patients should consult provider
Lactase Supplementation
• Contain the enzyme lactase
• Breaks down lactose into glucose and galactose

• Prevents symptoms
• Take at first bite of dairy-containing food
• Dosing may vary by amount of lactase in product and
level of lactose intolerance

• No side effects noted

• Patients with lactose intolerance may require

supplementation of Calcium and Vitamin D to
obtain recommended daily allowance
• Counsel on other avoidance strategies
• Low-lactose milk
• Fortified soy milk
Natural Therapies:
Carminatives
• Proposed MOA:
• Reduce tone of lower esophageal sphincter to facilitate expulsion of gas
• May also prevent the formation of gas

• Agents include:
• Anise, Basil, Cardamom, Cinnamon, Coriander, Cumin, Dill, Fennel, Garlic,
Marjoram, Mustard, Nutmeg, Oregano, Pepper, Peppermint, Rosemary, Saffron,
Sage, Thyme…

• Avoid in patients with gastroesphageal reflux disease (GERD)

• May also help with indigestion

Key Points for Treating Gas
• No major exclusions for self-treatment

• For symptoms NOT associated with food/beverage…

• Simethicone

• For symptoms associated with dairy…

• Reduce/avoid dairy or use lactase replacement

• For symptoms associated with oligosaccharides…

• Reduce/avoid or use alpha-galactosidase prior to food

• For symptoms associated with other food/beverage…

• Reduce/avoid intake
Poisoning
Signs and Symptoms
• Vary depending on the drug

• For any life-threatening symptoms, call 9-1-1!

• Call poison control center for assistance with assessment and

treatment
For General Poison Exposures…
• Inhalation exposures
• Remove patient to fresh air
• Irrigation beneficial to decrease contact time with skin or mucosal
surface

• Eye exposures
• Immediately irrigate with water for 10-15 minutes

• Topical exposures
• Wash skin with soap and water twice to decrease contact time
• Focus on nail beds and hair when appropriate

• Ingestion
• Administer a small amount of fluids if poison is a liquid
• Do NOT administer fluids after ingestion of a drug
• Do NOT try to manually stimulate the gag reflex
Syrup of Ipecac
• Acts as an emetic to induce vomiting

• No longer commercially available- but patients may

have an old supply at home!

• No longer routinely recommended

• No evidence that ipecac improves outcomes
• American Academy of Pediatrics does not support use

• Do not administer without consulting a poison

control center first

• Do not use in ingestions of substances likely to

produce CNS depression or seizures, as well as
ingestions of corrosive substances
Activated Charcoal
• Tasteless, gritty, fine black insoluble powder

• Highly adsorbent
• A solid that adsorbs another substance, preventing their absorption
• Does not bind well to all products, including alcohols and cyanide

• Usual dose = 1g/kg

• Available as a powder for reconstitution into an oral suspension
and as a “slurry” – SHAKE both!

• Most effective if given within 1 hour of ingestion

• Repeat doses may enhance elimination

• Most common side effects = vomiting and black stools

• Do not administer without consulting a poison control center

Food Poisoning
• Occurs when food is contaminated with bacteria or other
toxins

• Symptoms start ~4 to 36 hours after ingestion and

include:
• Diarrhea
• Nausea and vomiting
• Stomach cramps
• Headaches
• Low-grade fever
Causative Microbes
• Clostridium botulinum
• Clostridium jejuni
• Clostridium perfringens
• E. coli
• Listeria monocytogenes
• Salmonella
• Shigella
• Staphylococcus aureus
• V. cholerae
Prevention of Food Poisoning
• Wash your hands and clean any dishes or utensils when you
are making or serving food
• Keep juices from meat, poultry, and seafood away from ready-
to-eat foods
• Cook foods to proper temperatures

• Refrigerate any food you will not be eating right away

• If you make canned food at home, make sure to follow proper

canning techniques to prevent botulism
• Don't feed honey to children under 1 year of age

• When traveling where contamination is more likely, eat only

hot, freshly cooked food. Boil water before drinking. Don't eat
raw vegetables or unpeeled fruit.
Treatment Plan
• Oral rehydration and
dehydration prevention

• Agents selected for symptom-

based relief

• May require antibiotics or

antitoxins

• Prevention strategies for the

future
QUESTIONS AND
DISCUSSION
References
• Handbook of Nonprescription Drugs: An Interactive
Approach to Self-Care, 19th edition. 2018. American
Pharmacists Association. Chapters 14, 16, & 20.
• Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG,
Yee GC, eds. Pharmacotherapy: A Pathophysiologic
Approach. 8th ed. New York: McGraw-Hill; 2011.
http://www.accesspharmacy.com.
• University of Maryland Medical Center. Complementary
and Alternative Medicine Guide. Available at:
http://umm.edu/health/medical/altmed.
 TREATMENT OF
ACUTE ILLNESSES:
PART 2
Katelyn Alexander, PharmD

3/6/2020
PMPR 3270 Nonprescription Pharmacotherapy, Natural
Medicines, and Self-Care I