SAPA Vol 21(2) 2021

Tried and trusted cold and flu treatment for the whole family:

Indicated for the relief of symptoms associated with colds and flu in children

Analgesic, antipyretic and nasal decongestant properties

Suitable for children from 2 years of age

Fruity vanilla odour

Indicated for the alleviation of cough

Cough suppressant, expectorant and antihistamine properties

Raspberry flavoured

Indicated for the relief of symptoms associated with colds and influenza such as nasal congestion, headache, minor aches and pains

A 6-in-1 combination with analgesic, decongestant and antihistamine properties

2 pain relievers: Paracetamol and Salicylamide

Contains 50 mg of Ascorbic acid (Vitamin C)

This communication is brought to you by Aspen Pharmacare. Should you not wish to receive any further communications, please reply STOP to unsubscribe to the messages.

S2 FLUTEX Cold and Flu capsules with Vitamin C. Ref. No.: G1221 (Act 101/1965). Each capsule contains chlorphenamine maleate 2 mg, phenylephrine hydrochloride 2 mg, paracetamol 100 mg, salicylamide 75 mg, ascorbic acid 50 mg and caffeine anhydrous 30 mg. S2 FLUTEX Co Linctus. Reg. No.: F/10.1/162. Each 5 ml syrup contains codeine phosphate 7,5 mg, diphenhydramine hydrochloride 12,0 mg and ammonium chloride 100,0 mg. S1 FLUTEX Junior Cold and Flu Syrup. Ref. No.: B851 (Act 101/1965). Each 5 ml of syrup contains phenylephrine HCl 3,5 mg and paracetamol 125,0 mg. For full prescribing information refer to the professional information approved by the medicines regulatory authority (FLUTEX Cold and Flu 09/2010; FLUTEX Co Linctus 09/2010; FLUTEX Junior Cold and Flu Syrup 08/1976). Trademarks are owned by or licenced to the Aspen Group of companies. © 2020 Aspen Group of companies or its licensor. All rights reserved. Marketed by Aspen Pharmacare for Pharmacare Limited. Co. Reg. No.: 1898/000252/06. Healthcare Park, Woodlands Drive, 2191. ZAR-ACH-10-20-00001 11/20

OFFICIAL PSSA PUBLICATION FOR PHARMACIST’S ASSISTANTS

PUBLISHER

Medical & Pharmaceutical Publications

(Pty) Ltd trading as Medpharm Publications in collaboration with The Pharmaceutical Society of South Africa.

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Tel: (012) 470 9550, Fax: (012) 470 9556

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Tel: (012) 664-7460, Fax: (012) 664-6276

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Opinions and statements of whatever nature are published under the authority of the submitting author, and the inclusion or exclusion of any medicine or procedure, do not necessarily reflect the views of the editor, the editorial board or Medpharm Publications. While every effort is made to ensure accurate reproduction, the authors, advisors, publishers and their employees or agents shall not be responsible, or in any way liable for errors, omissions or inaccuracies in the publication, whether arising from negligence or otherwise or for any consequences arising therefrom. The publication of advertisements in this journal does not imply an endorsement by the publishers or its editorial board and does not guarantee any claims made for products by their manufacturers.

Why doesn’t my medical aid pay for it?

Lorraine Osman

Medical schemes can be very confusing to consumers. If you’re working in a community pharmacy, they can be just as confusing to you. It’s also quite upsetting when consumers ask you why their medical scheme won’t pay for something. In this article, we’ll examine a few reasons why the medical scheme may not pay for goods and services.

The type of medical scheme plan

At this stage, there’s no such thing as a one-size-fits-all medical scheme. Although we are moving towards Universal Health Coverage, which will be paid for by the National Health Insurance fund, at this stage people wishing to buy goods, such as medicines, and services, such as doctor’s visits, in the private sector must pay for these themselves.

Many people opt to get some kind of financial protection by joining a medical scheme. They pay a monthly contribution, called a premium, in exchange for assistance in paying for healthcare services, such as doctor’s visits and medicines.

There are different plans available which meet your needs at different stages of life. The lowest fee is for a hospital plan, which generally covers only in-hospital expenses. This usually suits young and healthy people. As their family grows, though, and definitely as they get older, many people choose to change the plan to one which covers other benefits, such as doctor visits and medicine.

Savings plan

Some medical schemes have a savings plan. Part of the monthly premium paid goes into a medical savings account (MSA), which is there for the member’s benefit only. It does not go into a pool of money that is used to pay for everyone’s claims. At the beginning of the year, the medical scheme calculates how much the member will pay over the year, and this amount is put into the MSA upfront. So it is received in advance, and not just when the monthly payments are made.

Also at the beginning of the year, the medical scheme calculates an annual threshold for the member. This is the amount that must be paid, whether from the MSA or from the member’s pocket, before the medical scheme will pay for medical expenses. This will differ

from member to member, depending on the number of dependents they have, as well as the ages of the dependents.

Initially during the year, the MSA is used to cover the day-to-day medical expenses. This includes doctor and dentist visits, laboratory tests and X-rays. It is also used to pay for medicines for acute use, including non-prescription medicines. Some, but not all, chronic medicines, for which you have obtained prior authorisation, are paid for from a different risk pool so they won’t use up the money in your MSA.

If you have remained healthy during the year, there may still be money left in the MSA at the end of the year. This will be carried over to the next year. This, however, does not happen very often.

Self-payment gap

In most cases, the MSA runs out of money at some stage. The member then enters the self-payment gap. This means that dayto-day medical expenses must be paid out of the members own pocket, until s/he reaches the amount that was calculated to be the annual threshold. Although the medical scheme will not pay for these expenses, the member must submit the information to the medical scheme, so that it knows when the annual threshold has been reached.

The self-payment gap can occur at different stages for different people. You need to understand what this is and what the implications are for the medical scheme member, so that you can explain it to the member.

Explaining the self-payment gap

Above threshold expenses

The medical scheme will begin to pay for day-to-day expenses after the annual threshold has been reached. The member is then in the above threshold stage. Over-the-counter medicines will not be paid for by the medical scheme from the above threshold benefits. These must be paid directly by the member of the scheme.

Formularies

Medical schemes generally have formularies, i.e. a list of medicines for which they are prepared to pay for treatment of specific conditions. These are often generic medicines, and if a patient insists on buying a branded product, s/he will have to pay the difference in price between the formulary price and the selected product.

Prescribed minimum benefits

To ensure that people receive at least the minimum health services required, medical schemes are obliged to provide certain defined benefits for specific conditions and situations, namely the prescribed minimum benefits (PMB).

Medical schemes must fund these benefits, regardless of which medical scheme plan has been chosen by the member.

These benefits are:

• Medical emergencies

• A limited set of 270 serious medical conditions that may be lifethreatening if not treated appropriately

• 25 chronic conditions, including asthma, diabetes, epilepsy and hypertension

The member of the medical scheme must register the chronic condition with the medical scheme. It must be remembered that the medical scheme may require the conditions to be treated with medicines from the formulary. If the doctor prescribes medication that is not on the list, the patient will be obliged to pay the copayment.

The reason for payment for the PMB services and medicines is in order to keep the member healthy. In this way, emergency situations can often be avoided, as well as expensive and serious complications associated with the condition.

Designated service providers

Most medical schemes have designated service providers. This means the members must go to specific doctors or specific pharmacies. If they choose to go to a doctor or pharmacist who is not a designated service provider, they will usually be obliged to pay a co-payment.

Explaining the benefits and limitations

Although it is unpleasant to have to explain these concepts to patients, it is sometimes necessary to do so because nobody else has done it.

Pholcodine: treatment options for dry cough

Abstract

Pholcodine (3-O-morpholinoethylmorphine) is a centrally acting antitussive derived from morphine, used for the symptomatic relief of colds and flu in children and adults. Pholcodine is a good choice of drug to treat persistent coughs because it has a long half-life, meaning less dosage requirements, and its safety in children has been established as it is registered for use in children from age two. Although pholcodine is derived from morphine, it causes little (or no) analgesia or euphoria. After oral absorption, it crosses the blood–brain barrier to act in the medulla oblongata by inhibiting the peripheric reflexogenic receptors, also known as the “cough centre”, thus increasing the threshold for coughing. Pholcodine interacts with central nervous system (CNS) depressants, monoamine oxidase inhibitors (MAOIs), neuromuscular blocking agents (NMBAs) and drugs that inhibit hepatic enzymes. Suppressants as a class are known to cause gastrointestinal and central effects; however, studies highlight that these rarely occur. Pholcodine is superior to other antitussives such as codeine because of its longer half-life, safer toxicity profile and minimal risk of addiction. The benefits of pholcodine continue to outweigh its risks, and patients can continue taking pholcodine containing medicines.

Keywords: antitussive, cough, non-productive cough, opioid pholcodine, pholtex

Introduction

Pholcodine (3-O-morpholinoethylmorphine) is an antitussive derived from morphine, used for the symptomatic relief of cough and colds in children and adults.1,2 In South Africa (SA), pholcodine is a Schedule 6 substance; however, it becomes a Schedule 2

substance when combined with one or more active pharmaceutical ingredients in a liquid preparation and/or consisting of 20 mg pholcodine per dosage unit or less (20 mg/5 ml).2 Currently, in SA, pholcodine is available as an over-the-counter (OTC) syrup, namely; Pholtex® Forte (15 mg/5 ml) and Pholtex® Junior (5 mg/5 ml). Other pholcodine containing OTC syrups that are combined with one or more active pharmaceutical ingredients include Pholtex® Plus containing pholcodine 5 mg, phenylephrine hydrochloride (HCl) 3.3 mg/5 ml; Docsed® containing mepyramine maleate 20 mg, codeine phosphate 5 mg, pholcodine 5 mg, ephedrine HCl 8 mg/ 5 ml; as well as Tyxylix® containing promethazine HCl 1.5 mg and pholcodine 1.5 mg/ 5 ml.1 Given all the available cough preparations with different pharmaceutical ingredients, this article will only focus on pholcodine.

Indication

Pholcodine, an antitussive/cough suppressant, is used to treat dry and non-productive persistent coughs.3,4 Coughing provides the benefit of removing pollen, dust, viscous fluids, and inflammatory cells from the upper airways.5 However, a non-productive persistent cough could cause unfavourable effects such as loss of sleep, pneumothorax, rupture of surgical wounds, syncope or even rib fractures.5 Table I gives an overview of the rational use of pholcodine.

An acute cough is a daily cough that lasts for fewer than three weeks, and when this is a dry cough, without any mucous production, pholcodine may be a suitable treatment option.6 It is not recommended to use pholcodine on a chronic basis.

Mechanism of action

When the sensory receptors of the glossopharyngeal and vagus nerves that innervate the mucous membranes of the lower larynx, pharynx, trachea, and smaller airways of the respiratory tract are stimulated, usually, the resulting effect would be a cough.7 Upon stimulation, a signal is transmitted from the receptor to the cough centre in the brain, which stimulates a reflex motor response that leads to the contraction of expiratory muscles, causing a person to cough.7 Centrally acting opioid-like cough suppressants, e.g. codeine, or pholcodine, work on the coughing centre in the central

Elmien Bronkhorst,1 Mankoana Masetla,1 Neelaveni Padayachee2

1 Sefako Magkatho Health Sciences University, School of Pharmacy

2 University of the Witwatersrand, School of Pharmacy

Table I: Indication for pholcodine4-6

Non-productive dry cough Pholcodine indicated

Postnasal drip Short-term; treat the underlying condition

Viral infection (common cold) Short-term with other symptomatic treatment Air pollutants/irritants

Gastro-oesophageal reflux disease (GORD) Not indicated; treat GORD Asthma and allergic conditions

Medication-induced coughing (ACE-I) Not indicated long term; change ACE-I to ARB Aspiration

Heart failure

Not indicated Lung cancer

Psychological causes Short term until the underlying condition is treated Pneumonia and TB

nervous system (CNS) and reduce the discharge of nerve impulses to the muscles that facilitate coughing. Codeine is no more effective than other centrally acting opioids in suppressing cough and is associated with a higher incidence of adverse effects.8

Although pholcodine is a centrally acting opioid antitussive derived from morphine, it causes little (or no) analgesia or euphoria.2 After oral absorption, it crosses the blood–brain barrier to act in the medulla oblongata by inhibiting the peripheric reflexogenic receptors, also known as the “cough centre”, thus increasing the threshold for coughing.7 The effect of pholcodine is selective on the cough centre and does not affect the respiratory centre.9

Pharmacokinetic parameters

Pholcodine is metabolised extensively in the liver with little or no conversion to morphine, unlike codeine.2 It is longer acting than most antitussives.2 It is as effective as codeine; however, pholcodine has a longer elimination half-life of 32–43 hours, thus reducing dosage requirements.2 It is removed from the body at a much slower rate than other opioids, and saliva concentrations become 3–4 times higher than plasma concentrations.10 Pholcodine has a morpholino side chain; this structural modification provides the benefit of not causing any respiratory depression, euphoria, CNS excitation and addiction.10

Cautions and contraindications

Opioids interact with endogenous opioid receptors in the body, including mu, delta and kappa receptors found in the respiratory centre.11 They decrease the stimulation of the respiratory centre by reducing carbon dioxide levels (hypercapnic drive) without producing an effect on the hypoxic drive.5 Opioids also decrease the respiratory rate and tidal volume, thus causing the rate of breathing to decrease to three or four breaths per minute during an opioid overdose.5 Therefore, like other opioids, pholcodine should not be used in patients with respiratory depression, asthma, chronic obstructive pulmonary disease (COPD), bronchiolitis, bronchiectasis, emphysema, and respiratory failure.2 Pholcodine is cleared from the body at a slower rate and should not be used in patients with a liver impairment since the clearance would be slower, leading to an increased risk of unpleasant side effects.2,10,11 It is also contraindicated in pregnancy (especially preparations containing alcohol), lactation, intolerance, or hypersensitivity to pholcodine.12 It is safe for use in children two years and older but should be used with caution.2,3

Drug interactions

When taken concomitantly with alcohol, phenothiazines, benzodiazepines and tricyclic antidepressants at higher doses,

pholcodine may aggravate the CNS depression of these drugs.2 As mentioned before, pholcodine is extensively metabolised in the liver; therefore, drugs that inhibit the cytochrome P450 enzymes will lead to the increment of its levels.2 All antitussives, such as codeine, dextromethorphan and pholcodine, are not recommended with monoamine oxidase inhibitors (MAOIs). Severe reactions, including excitations, hyperpyrexia, hypertension and death, have resulted from the concomitant use; therefore, pholcodine should not be administered while on MAOI therapy or within 14 days of discontinuation.2 There was concern that pholcodine-containing cough syrups increase immunoglobulin E antibodies against neuromuscular blocking agents (NMBAs). However, after a lengthy review process, the European Medicines Agency (EMA) concluded that the evidence of a link between pholcodine and NMBA-related anaphylaxis is circumstantial and not entirely consistent. The EMA further concluded that, based on currently available information, the benefits of pholcodine in the treatment of non-productive cough outweigh the risks.

The EMA’s Committee for Medicinal Products for Human Use concluded on the safety and efficacy of pholcodine:10

• the benefits of pholcodine continue to outweigh its risks;

• there have not been any new risks discovered with pholcodine;

• there is credible information on cross-sensitisation between pholcodine and NMBAs; however, the data available are weak; and

• patients can continue taking pholcodine containing medicines.

Side effects

Although rare, side effects of pholcodine and other antitussives include dizziness and gastrointestinal effects, but with overdose, respiratory depression, confusion and excitation can occur.2 Other side effects include drowsiness, restlessness, nausea and vomiting, ataxia and skin rash.1

Addiction to cough suppressant syrups

In some opioid-containing antitussives, like codeine and dextromethorphan, abuse of and addiction to the preparations have been documented.2 There is an increasing incidence of the abuse of OTC medication, for example, opioid-containing cough preparations, both nationally and internationally, which may warrant their up-scheduling.13,14 However, pholcodine is superior to other antitussives such as codeine because of its longer duration of effect, safer toxicity profile and minimal risk of addiction.15

The toxic dose following pholcodine’s misuse is 4 mg per kg body mass in both adults and children, during which symptoms such as agitation/anxiety, confusion/aggression, euphoria, hallucinations, nightmares/excessive dreaming, bradycardia, hypo-

tension, bronchospasms/wheezing, slow/depressed respiration, constipation, nausea/vomiting, convulsions, depressed level of consciousness/coma, involuntary movements/tremor, hypothermia, enlarged/small pupils, widespread redness or flushing of the skin, can be experienced.16 The drugs of choice in managing opioid dependence include naloxone, buprenorphine, methadone and naltrexone.7

Dosing/Administration

In SA, the adult dose of oral pholcodine is 5–10 mg 3–4 times daily.2 Lower doses such as 5 mg three times daily are recommended in patients with liver disease and the elderly.2 In patients with renal impairment, dose reduction or increased dosing intervals are needed because of pholcodine’s long elimination half-life.2 The dose of oral pholcodine in paediatrics, from 1–5 years, is 2.5 mg three times daily, then older than five years, it is 2.5–5 mg 3–4 times daily.2,6,7

Conclusion

Although pholcodine is derived from morphine, it has not been documented to cause analgesia, euphoria or addiction. This makes it a suitable effective antitussive for the symptomatic relief of nonproductive coughs. In addition, it rarely causes side effects; however, due to it still being an opioid, it is essential to monitor for signs of an overdose such as respiratory depression, confusion, excitation, and sedation.

References

1. Snyman RJ. PHOLTEX, Inova. Monthly Index of Medical Specialties. Cipla Medpro; 2019.

2. Rossiter D. South African Medicines Formulary. 12th ed. Health and Medical Publishing Group; 2016.

3. Strauss J. Complications from flu – an unnecessary evil! S Afr Pharm J. 2018;85(3)1218.

4. Ismail H, Schellack N. Colds and flu–an overview of the management. South African Family Practice. 2017;59(3):5-12. https://doi.org/10.4102/safp.v59i3.4704.

5. Brenner GM, Stevens CW. Brenner and Stevens’ Pharmacology. Elsevier Health Sciences; 2017.

6. Kandiwa KT, Thom L, Schellack N. A modern approach to cough management. S Afr Pharm J. 2021;88(1):15-20

7. Bardal SK, Waechter JE, Martin DS. Applied pharmacology. Elsevier Health Sciences; 2011.

8. Van Schoor J. An approach to recommending cough mixtures in the pharmacy. S Afr Pharm J. 2018;85(4):40-44

9. Wishart DS, Knox C, Guo AC, et al. 2008. DrugBank: a knowledge base for drugs, drug actions and drug targets. Nucleic Acids Research. 2008;36(Suppl 1):D901-6.

10. Florvaag E, Johansson SGO. The pholcodine case. Cough medicines, IgEsensitization, and anaphylaxis: a devious connection. World Allergy Organization Journal. 2012;5(7):73-78. https://doi.org/10.1097/WOX.0b013e318261eccc.

11. Yamanaka T, Sadikot RT. Opioid effect on lungs. Respirology. 2013;18(2):255-62. https://doi.org/10.1111/j.1440-1843.2012.02307.x.

12. Soleimanpour H, Safari S, Nia KS, Sanaie S, Alavian SM. Opioid drugs in patients with liver disease: a systematic review. Hepat Mon. 2016;16(4):e32636. https://doi. org/10.1111/j.1440-1843.2012.02307.x.

13. Chua SS, Sabki NH.Use of non-prescription medications by the general public in the Klang Valley. Journal of Applied Pharmaceutical Science. 2011;1(9):93.

14. Myers B, Siegfried N, Parry CD. Over-the-counter and prescription medicine misuse in Cape Town-findings from specialist treatment centres. South African Medical Journal. 2003;93(5):367-70.

15. Blanchard E, Tunon de Lara M. New insights into the role of pholcodine in the treatment of cough in 2013? Therapies. 2013;68(2):85-91. https://doi.org/10.2515/ therapie/2013019.

16. EMGuidance. 2016. Pholcodine poisons information. Available from: https:// emguidance.com/discover. Accessed 1 May 2021.

Fever in infants

Wilna Rabbets Amayeza Information Services

Introduction

A fever is a temporary increase in body temperature and is a common symptom of illness. When a fever occurs, the immune system is launching an attack to remove the cause of the illness by raising the body’s temperature (heat inactivates many pathogens). As adults, we have a tightly controlled thermostat to help regulate our body temperature. Because a newborn’s temperature regulation system is immature, an unexplained fever is a cause for concern.

Causes of fevers in infants

• Viral infections – colds and flu are the most common causes, as is gastroenteritis.

• Bacterial infections such as urinary tract and ear infections.

• Fevers sometimes occur after some vaccinations – usually, the parents will be forewarned.

• Teething does not cause fevers. However, when babies are teething, they often chew on anything in reach, causing them to pick up infections that way.

How to measure an infant’s temperature

Digital thermometers are widely available and the most accurate. Glass thermometers containing mercury are not recommended. Other types of thermometers, like plastic strip and pacifier thermometers are not as accurate as digital thermometers.

The temperature can be measured in the armpit for infants who cannot hold a thermometer under their tongue. For infants up to three months of age, it may be necessary to take the temperature rectally. Temperatures measured in the ear or on the forehead are less accurate than oral and rectally measured temperatures. Just feeling a child’s forehead does not give an accurate indication of fever at all.

When to seek medical attention

The average child will get several viral or bacterial infections during childhood, which means several fevers. Most fevers are mild and pass in a day or two. There are, however, some circumstances when parents should seek medical attention.

• If the child is less than 3 months old – with a rectal temperature of 38 oC or greater. Babies older than 3 months with a temperature of 39 oC or higher or whose fever lasts 24 hours or longer.

• Change in behaviour – if the baby is unusually sleepy or floppy or even extremely irritable. If the baby shows signs of having difficulty moving any part of the body (like the neck).

• If a rash accompanies the fever – some viruses like measles and chickenpox and some bacterial infections like strep throat and cellulitis can cause rashes. These infections require medical attention. A dark rash that looks like a bruise and does not get paler when you press on it is a sign of a serious infection.

• If the baby is dehydrated – they are drinking much less than usual and urinating less than usual.

• If the fever lasts longer than 2–3 days

Treating a fever at home

In most cases, a child with a fever can be treated at home.

• Medications – Paracetamol and ibuprofen are the most effective way to treat fevers. Paracetamol 120 mg/5 ml syrup (2.5–5 ml) can be given 4-hourly to infants from 3 months – no more than four doses per 24-hour period should be given.

• Ibuprofen 100 mg/5 ml syrup can be given 6–8-hourly to infants from 6 months – no more than three doses per 24-hour period should be given. The dose is calculated using the infant’s weight (5 mg/kg/dose).

• For infants younger than 3 months, consult a doctor first.

• Aspirin is not recommended in children under 18 years of age.

• Adjust their clothing – when the infant is overdressed, excess clothing traps body heat.

• Increase fluids – it is essential that an infant does not become dehydrated.

• Sponging and lukewarm baths – do not use ice or rubbing alcohol.

• Rest – it is unnecessary to wake a sleeping infant for a dose of medicine if the infant is sleeping comfortably.

Bibliography

◦ Crook J. Paracetamol use in infants and young children. The Pharmaceutical Journal. 2021;306(7946). Available from: https://pharmaceutical-journal.com/article/ ld/paracetamol-use-in-infants-and-young-children#intravenous-paracetamol. Accessed 5 Apr 2021.

◦ Farinde A. Pediatric ibuprofen oral dosing: pediatric ibuprofen oral dosing [Internet]. Emedicine.medscape.com. c2020. Available from: https://emedicine. medscape.com/article/2172401-overview. Accessed 25 Mar 2021.

◦ Fever (0-12 Months) [Internet]. Seattle Children’s Hospital. c2021. Available from: https://www.seattlechildrens.org/conditions/a-z/fever-0-12-months/. Accessed 25 Mar 2021.

◦ Kaneshiro N. When your baby or infant has a fever: MedlinePlus Medical Encyclopedia [Internet]. Medlineplus.gov. c2019. Available from: https://medlineplus.gov/ ency/patientinstructions/000319.htm#:~:text=Acetaminophen%20(Tylenol)%20 and%20ibuprofen%20(,first%20before%20giving%20them%20medicines.

Accessed 25 Mar 2021.

◦ Mayo Clinic. Fever - Symptoms and causes [Internet]. Mayo Clinic. c2020. Available from: https://www.mayoclinic.org/diseases-conditions/fever/symptoms-causes/ syc-20352759. Accessed 25 Mar 2021.

◦ McCarthy C. When to worry about your child’s fever [Internet]. Harvard Health Blog. c2020. Available from: https://www.health.harvard.edu/blog/worry-childsfever-2017072512157. Accessed 25 Mar 2021.

◦ Sick baby? When to seek medical attention [Internet]. Mayo Clinic. c2019. Available from: https://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/ in-depth/healthy-baby/art-20047793#:~:text=If%20your%20baby%20is%20 younger,C)%2C%20contact%20the%20doctor. Accessed 25 Mar 2021.

◦ Silver N. How to safely bring down a fever in a baby [Internet]. Healthline. c2020. Available from: https://www.healthline.com/health/parenting/how-to-bringdown-baby-fever#treatment. Accessed 25 Mar 2021.

◦ Timmons J. Baby fever 101: caring for a sick baby [Internet]. Healthline. c2018. Available from: https://www.healthline.com/health/parenting/baby-fever-101. Accessed 25 Mar 2021.

◦ Ward M. Fever in children [Internet]. Uptodate.com. c2021. Available from: https://www.uptodate.com/contents/fever-in-children-beyond-thebasics?search=fever%20infant%20beyond%20the%20basics&source=search_ result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed 25 Mar 2021.

S2 MYBULEN (tablets). Reg. No.: 30/2.8/0138. Each tablet contains ibuprofen 200 mg, paracetamol 350 mg and codeine phosphate 10 mg.

S2 MYBULEN Capsules. Reg. No.: A38/2.8/0527. Each capsule contains ibuprofen 200 mg, paracetamol 250 mg and codeine phosphate 10 mg.

S2 MYBULEN Suspension. Reg. No.: A39/2.8/0237. Each 10 ml contains ibuprofen 200 mg, paracetamol 250 mg and codeine phosphate 10 mg.

S2 IBUMOL Banana. Reg No.: A39/2.8/0228. Each 10 ml suspension contains ibuprofen 200 mg and paracetamol 250 mg.

S2 IBUMOL Grape. Reg. No.: A39/2.8/0229. Each 10 ml suspension contains ibuprofen 200 mg and paracetamol 250 mg.

For full prescribing information, refer to the professional information approved by the medicines regulatory authority (MYBULEN 05/2009, MYBULEN Capsules 07/2005, MYBULEN Suspension 09/2005. IBUMOL Banana 11/2005, IBUMOL Grape 09/2012).Trademarks are owned by or licensed to the Aspen Group of companies. © 2020 Aspen Group of companies or its licensor. All rights reserved. Pharmacare Limited. Co. Reg. No.: 1898/000252/06. Healthcare Park, Woodlands Drive, Woodmead, 2191.

Soothe the swallow: relief of pharyngitis and tonsillitis

Lynda Steyn Amayeza Information Services

Introduction

Patients will most often visit a pharmacy as the first port of call to seek symptomatic relief of a sore throat. Pharyngitis, the medical term for a sore throat, is inflammation of the pharynx (the back of the throat). When the tonsils become inflamed, it is known as tonsillitis. In some cases, both the pharynx and the tonsils become inflamed, this is known as pharyngotonsillitis.

Causes

Pharyngitis or tonsillitis occur as a result of an infection that leads to inflammation. There are many different causes of throat infections. However, the majority (approximately 90%) of the infections are due to viruses. Only a small percentage of throat infections occur as a result of a bacterial infection. Viruses that can cause pharyngitis or tonsillitis include:

• Common cold viruses (e.g. coronavirus, rhinovirus)

• Influenza (flu) virus

• Epstein–Barr virus

A bacterial cause of pharyngitis or tonsillitis is most commonly due to Group A Streptococcus (GAS). Other less common causes may be fungal or parasitic infections.

Symptoms

Symptoms of pharyngitis or tonsillitis may include:

• Cold symptoms (congestion, cough)

• Sore throat

• Headache

• Stomach ache

• Fever

• Painful swallowing

• Hoarseness

• Nausea and/or vomiting

Management

Management of pharyngitis or tonsillitis will depend on the cause. Often, a viral throat infection will resolve on its own within a week or so. However, it is important to know when to refer the patient to a doctor for further investigation, as a bacterial throat infection caused by GAS requires management with antibiotics.

Refer the patient to the doctor if the patient has:

• Difficulty in swallowing, or if the pain in the throat is severe

• A fever persisting more than 5 days

• A sore throat lasting more than 10 days

• A rash

• Difficulty breathing

Viral throat infections do not respond to antibiotics and symptoms may be relieved with over-the-counter (OTC) medications.

Treatment

OTC medications for pharyngitis or tonsillitis are aimed at providing relief of the symptoms.

• Paracetamol or ibuprofen can be used for relief of pain or fever.

• Gargles, lozenges and throat sprays may provide symptomatic relief of a sore throat.

Lozenges, gargles, or throat sprays available OTC may contain:

• An antiseptic (e.g. chlorhexidine gluconate, cetylpyridium chloride)

• An anaesthetic (e.g. benzocaine, lidocaine)

• An anti-inflammatory (e.g. benzydamine, flurbiprofen)

• A combination of these ingredients

Table I lists some of the OTC products available for symptomatic relief of a sore throat.

Table I: Some OTC products available for symptomatic relief of a sore throat

Table adapted from: Van Schoor J. Colds, flu and coughing: over-the-counter products for pharyngitis and tonsillitis. South African Family Practice. 2013;55(4):330-3.

*Always refer to the package inserts for manufacturer’s instructions for use.

Other supportive measures include:

• Encouraging rest

• Encouraging increased fluid intake

• Gargling with salt water

• Sucking on ice chips or ice lollies for children

• Sipping warm beverages, such as tea or soup

The choice of OTC medications for the management of pharyngitis or tonsillitis depends on:

• The patient’s age – children under six years of age can usually not gargle properly, and lozenges may provide a choking hazard in children under five years of age.

• The patient’s symptoms

• The patient’s preference

Conclusion

Viral throat infections typically last for four to five days. Antibiotics are not an effective treatment for viral throat infections and are managed symptomatically. A bacterial throat infection may last longer and often requires the use of an antibiotic. Most cases of pharyngitis and tonsillitis are viral and resolve on their own. However, it is crucial to know when to refer the patient to a doctor for treatment, as untreated bacterial pharyngitis or tonsillitis may lead to complications.

Bibliography

◦ Aung K. Viral pharyngitis follow-up. Medscape. [updated 16 Jul 2019]. Available from: https://emedicine.medscape.com/article/225362-followup#e5.

◦ Aung K. Viral pharyngitis. Medscape. [Updated 16 Jul 2019]. Available from: https:// emedicine.medscape.com/article/225362-print. Accessed 7 Apr 2021.

◦ Eske J. What is pharyngitis? MedicalNewsToday. [Updated 10 Jan 2019]. Available from: https://www.medicalnewstoday.com/articles/324144. Accessed 8 Apr 2021.

◦ John Hopkins Medicine. Pharyngitis and Tonsillitis. c2021. Available from: https:// www.hopkinsmedicine.org/health/conditions-and-diseases/pharyngitis-andtonsillitis. Accessed 8 Apr 2021.

◦ Martel J. Pharyngitis. Healthline. [Updated 7 March 2019]. Available from: https:// www.healthline.com/health/pharyngitis. Accessed 4 Apr 2021.

◦ MIMS. Vol 61 Number 1. February 2021.

◦ Rossiter D. South African Medicines Formulary. 13th ed. South African Medical Association; 2020.

◦ Stead W. Patient education: Sore throat in adults (Beyond the Basics). In: UpToDate. Available from: https://www.uptodate.com/contents/sore-throat-in-adults-beyond -the-basics. Accessed 4 Apr 2021.

◦ University of Rochester Medical Center. Pharyngitis and Tonsillitis. c2021. Available from: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid =85&contentid=P01320. Accessed 8 Apr 2021.

◦ Van Schoor J. Colds, flu and coughing: over-the-counter products for pharyngitis and tonsillitis. South African Family Practice. 2013;55(4):330-3.

◦ Wald E. Patient education: Sore throat in children (Beyond the Basics). In: UpToDate. [Updated 24 Sept 2019]. Available from: https://www.uptodate.com/contents/ sore-throat-in-children-beyond-the-basics. Accessed 30 Mar 2021.

◦ Watson S. Sore throat 101: symptoms, causes, and treatment. Healthline. [Updated 23 Jun 2020]. Available from: https://www.healthline.com/health/sore-throat. Accessed 4 Apr 2021.

Constipation

Lynn Lambert Amayeza Information Services

Introduction

The general definition of constipation is having fewer than three bowel movements a week and stools are difficult to pass. When constipation becomes a chronic condition, the infrequent bowel movements or difficulty to pass stools persists for several weeks or longer. Although constipation is a common complaint, it may interfere with the ability to go about daily tasks. Chronic constipation may also cause people to strain excessively to have a bowel movement. Constipation most commonly occurs when the stool moves too slowly through the digestive tract or cannot be eliminated from the rectum, causing the stool to become hard and dry.

Constipation can affect people of all ages. However, the following people are more likely to suffer from constipation or develop chronic constipation. These include (but are not limited to):

• People of older age. Older people generally have a slower metabolism and less muscle contraction strength along their digestive tract than when they were younger.

• Being female, especially during and after pregnancy. Changes in hormones make women more prone to constipation.

• Being dehydrated (not drinking enough water).

• Not eating enough high-fibre foods. High-fibre foods keep food moving through the digestive system.

• Living a sedentary lifestyle.

• Taking certain medication which may cause constipation as a side effect, including opioid analgesics such as codeine.

• Having an eating disorder.

Symptoms

Although bowel movement patterns vary from person to person, the longer the time between bowel movements, the more difficult it becomes to pass a stool. The following are signs and symptoms of chronic constipation:

• Passing less than three stools a week

• Stools are hard and dry

• Straining to have bowel movements

• Painful bowel movements as stools are difficult to pass

• Feeling as though bowels have not completely emptied

What happens in the body to cause constipation?

Constipation occurs when the colon absorbs too much water from the stool, which dries it out, making it hard in consistency and difficult to expel from the body.

• During normal digestion: as food moves through the digestive tract, nutrients are absorbed. The partially digested food (waste) that remains moves from the small intestine to the large intestine, also called the colon. The colon absorbs water from this waste, which creates a solid matter called stool.

• If constipated: food may move too slowly through the digestive tract. This gives the colon more time to absorb water from the waste, resulting in the stool becoming dry, hard, and difficult to pass.

Complications of constipation

Complications usually associated with chronic constipation include:

• Haemorrhoids/piles: straining to have a bowel movement may cause swelling in the veins in and around the anus.

• Torn skin in the anus (anal fissure). A large or hard stool can cause tiny tears in the anus.

• Stool that cannot be expelled (faecal impaction). Chronic constipation may cause an accumulation of hardened stool that gets stuck in the intestines.

• Intestine that protrudes from the anus (rectal prolapse). Straining to have a bowel movement can cause a small amount of the rectum to stretch and protrude from the anus.

You are what you eat

Lifestyle intervention is considered the first form of intervention when it comes to a patient with constipation. Patients should be advised to increase their fluid intake and levels of physical activity. It is also recommended that patients add high-fibre foods to their diet, including beans, vegetables, fruits, whole grain cereals and bran. The consumption of processed foods that have low amounts of fibre should be reduced.

Achieving the recommended amount of fibre through diet alone may be difficult for some people. Therefore, if necessary, fibre supplements (bulking agents) should be added to the diet. The natural sugars in fruit have an osmotic effect that may be of benefit. In particular, a study found that prunes can significantly improve spontaneous bowel actions compared to psyllium.

Patients should be advised to attempt defaecation within two hours of waking up, half an hour after breakfast, when colonic motility is strongest. They should also be encouraged to establish a routine –same time, same place – and to ‘heed nature’s call’ immediately.

Treating constipation with laxatives

Many patients turn to laxatives when they do not have a regular bowel movement each day. This often leads to excessive use of laxatives or ‘laxative abuse’. Laxative abuse may lead to complications such as low potassium levels in the body (hypokalaemia) and damage to the colon.

Bulking agents

Ispaghula (psyllium), sterculia and methylcellulose are examples of bulking agents (fibre replacement products) which are considered the first-line of treatment of constipation. These agents are soluble fibre supplements that retain water to increase stool mass, which stimulates the movement of stool in the colon. It takes about two to three days for patients to notice a difference. Side effects from these agents include gas, bloating and cramps, particularly in patients with irritable bowel syndrome. To reduce the risk of gas and cramping, it is recommended to slowly increase the dose of a bulking agent and to always take it with plenty of water. Bulking agents are non-habitforming and may be used as supplements to dietary fibre.

Bulking agents containing sodium should be used with caution in patients with hypertension or other conditions that may be aggravated by fluid and water retention. These agents may interfere with the absorption of certain medications, e.g. digoxin, lithium, carbamazepine and anti-diabetic agents.

Osmotic laxatives

Osmotic laxatives may also be used as first-line therapy and may be used concurrently with bulking agents. Polyethylene glycol (PEG) is the most commonly used osmotic laxative and may be preferred in some patients since it does not cause gas or bloating. It is indicated for relief of occasional constipation and generally produces a bowel movement in one to three days. Other commonly used examples of osmotic laxatives include sorbitol and lactulose. These laxatives are poorly soluble sugars that draw water into the colon, aiding the movement of the stool through the colon, facilitating its passage.

Stimulant laxatives

Bisacodyl and senna are examples of stimulant laxatives because they stimulate peristalsis in the colon, speeding the movement of stool in the colon, i.e. ‘forces’ the stool out. These agents are only recommended for short-term use since they can cause chronic changes in the colon and may also lead to dependency. Repeated misuse of stimulant laxatives may result in excessive water and electrolyte loss, resulting in medical complications.

Senna or bisacodyl should be used only if patients do not respond to bulking agents, and should be restricted to short-term use.

Stool softeners

Glycerine suppositories and liquid paraffin are stool softeners. Glycerine suppositories are useful as an adjunct to other laxative agents. Liquid paraffin, widely used by patients, should be avoided as it may cause anal seepage, anal irritation and possible fat-soluble vitamin malabsorption.

When to see a doctor?

Patients should be advised to see their doctor if:

• Constipation is a new problem.

• There is blood in their stool.

• They experience abdominal pain, nausea and/or vomiting.

• They are losing weight unintentionally.

• Suffering from severe pain with bowel movements.

• Constipation has lasted more than three weeks.

Conclusion

Patients often consult at their pharmacy for assistance with gastric and digestive complaints. One of the most common complaints is constipation. Certain medical conditions preclude the use of certain types of laxatives. Therefore, a general overview of the patient’s medical history is essential before recommending a laxative. Equally important is to recognise the warning signs warranting a referral to the doctor.

Bibliography

◦ Constipation. Available from: https://www.mayoclinic.org/diseases-conditions/ constipation/symptoms-causes/syc-20354253. Accessed 10 Apr 2021.

◦ Constipation. July 2019. Available from: https://my.clevelandclinic.org/health/ diseases/4059-constipation. Accessed 10 Apr 2021.

◦ Constipation. July 2019. Available from: https://my.clevelandclinic.org/health/ diseases/4059-constipation#:~:text=Constipation%20occurs%20when%20 bowel%20movements,to%20inadequate%20intake%20of%20fiber. Accessed 10 Apr 2021.

◦ Pray WS, Pray GE. Counselling patients about constipation. US Pharm. 2013;38(12):811.

◦ Rossiter D, editor. South African medicines formulary (SAMF) 12th ed. Cape Town: Health and Medical Publishing Group; 2016. p. 32-36.

◦ Wald A. Patient education: Constipation in adults (beyond the basics). July 2020. Available from: https://www.uptodate.com/contents/constipation-in-adults-beyo nd-the-basics#H4. Accessed 10 Apr 2021.

◦ Watermeyer G. An approach to the patient with chronic constipation. deNovo Medica. 2019. Available from: https://www.denovomedica.com/cpd-online/wpcontent/uploads/An-approach-to-the-patient-with-chronic-constipation.pdf. Accessed 10 Apr 2021.

Heartburn and gastro-oesophageal reflux disease

Introduction

Gastro-oesophageal reflux disease (GORD) is a common condition that occurs when acid from the stomach leaks up into the oesophagus and/or mouth. Almost everyone has heartburn caused by acid reflux from time to time. Occasional reflux is normal and may occur in healthy infants, children, and adults, most often after eating a meal. Most episodes are brief and do not cause bothersome symptoms or complications. In contrast, people with GORD experience annoying symptoms or damage to the oesophagus as a result of acid reflux. GORD is a chronic condition and once it begins, it usually is life-long.

What causes GORD?

At the lower end of the oesophagus (food pipe), where it connects to the stomach, there is a circular ring of muscle called the lower oesophageal sphincter (LOS). When swallowing, it relaxes to allow food and liquid to flow into the stomach. It then closes again, which helps to keep the contents of the stomach from rising back up the oesophagus. However, if the LOS becomes weakened or relaxes abnormally, it may not close properly, allowing stomach acid to flow back up into the oesophagus, causing symptoms such as heartburn. This constant backwash of acid irritates the lining of the oesophagus, often causing it to become inflamed. In some people, acid reflux causes bothersome symptoms or injury to the oesophagus over time. When this occurs, the condition is considered GORD.

Symptoms

Heartburn and regurgitation are common symptoms of GORD. Heartburn is experienced as a burning sensation or feeling of discomfort in the chest, usually after eating. This may be worse at

night. Regurgitation occurs when the stomach contents (acid mixed with bits of undigested food) flow back into the mouth or throat. Other symptoms of GORD may include nausea, stomach pain, a sensation of a lump in the throat, difficulty or pain when swallowing, chest pain, a persistent sore throat, bloating and belching.

Complications of GORD may include:

• ulcers

• laryngeal and throat inflammation

• inflammation and infection of the lungs

• asthma and cough

• Barrett’s oesophagus

• a collection of fluid in the sinuses and middle ear

Risk factors

The following factors may aggravate acid reflux:

• consuming certain foods (triggers) such as spicy, fried or fatty foods

• stress

• smoking

• eating large meals or eating late at night

• drinking certain beverages, such as coffee or alcohol

• certain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs)

Conditions that may increase the risk of developing GORD include:

• being overweight or obese

• pregnancy, due to changes in hormone levels which may relax the LOS, as well as the increased pressure on the stomach during pregnancy

• slow or prolonged emptying of the stomach

• bulging of the top of the stomach up into the diaphragm (hiatus hernia)

• abnormal oesophageal contractions

Haley Smith

Table I: Management of heartburn and GORD

Lifestyle changes

Certain lifestyle and dietary changes may often help relieve symptoms of GORD. They include maintaining a healthy weight, avoiding foods that trigger symptoms, quitting smoking and cutting back on alcohol. It is also recommended to raise the head of the bed if symptoms are worse at night and to avoid lying down after eating. Eating smaller portions more frequently, instead of 3 large meals each day and eating the evening meal 2 to 3 hours before going to bed may help prevent symptoms. Wearing loose, comfortable clothing may also be helpful.

Medication

Lifestyle changes alone may not be effective in controlling symptoms in certain patients. OTC medications are available to help alleviate symptoms. In addition to lifestyle changes, the initial treatment of mild GORD includes the use of non-prescription antacids, antacid combinations or histamine receptor antagonists. Patients with more severe or frequent symptoms, complications related to GORD, or mild symptoms that have not responded to the above medications usually require treatment with a medication called a proton pump inhibitor (PPI).

Antacid combinations

Antacids help to neutralise the acid in the stomach. They are commonly used for the short-term relief of symptoms such as heartburn, flatulence and indigestion. Antacids may be calcium-, aluminium- or magnesium-based.4 Alginates are extracts from algae. When used in combination with antacids, they may help to prevent reflux oesophagitis. Antacids may provide quick relief as they have a rapid onset of action. However, the neutralising effect only lasts for a short period of time (approximately 30 to 60 minutes after each dose). They are emptied from the empty stomach quickly, in less than an hour, and the acid then re-accumulates.

Histamine (H2) receptor antagonists

The H2 receptor antagonists reduce gastric acid production/secretion by blocking the action of histamine at the H2 receptors in the parietal cells of the stomach. H2 receptor antagonists do not act as quickly as antacids, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours. Stronger versions are available with a prescription.

Proton pump inhibitors

As a class, the PPIs are potent suppressors/blockers of gastric acid secretion. PPIs also protect the oesophagus from acid secretion, allowing time for damaged oesophageal tissue to heal.2-5 Certain PPIs are available OTC, including lansoprazole, pantoprazole and omeprazole. They are indicated for the short-term relief of heartburn and hyperacidity. It is recommended to take the lowest possible dose for the shortest possible time.

Management

GORD is treated according to the frequency and severity of symptoms, as well as whether or not there are complications. Most people may manage the discomfort of GORD with lifestyle changes and over-the-counter (OTC) medications. However, some patients with GORD may need to be referred to the doctor for prescribed medications or to have surgery to ease symptoms.

When to refer?

The patient should be referred to the doctor if they experience severe and frequent symptoms. They should also see the doctor if the symptoms are not fully relieved by OTC medications or a change in lifestyle. Other indications for referral include pain or difficulty when swallowing, chest pain, loss of weight and exacerbation of symptoms when exercising. Having signs of bleeding in the gastrointestinal tract, such as black stools, blood in the vomit or dark-coloured vomit that looks like coffee grounds may indicate a more serious problem and requires prompt referral to the doctor.

Conclusion

Heartburn experienced once or twice a month may be managed with lifestyle changes and OTC medication. The patient should be referred to the doctor if they have frequent and severe symptoms and are using OTC medications on a daily or weekly basis.

Bibliography

◦ GORD (Reflux) Health Direct. Last reviewed: September 2020. Australian Government. Department of Health. Available from: https://www.healthdirect.gov. au/gord-reflux.

◦ Kahrilas PJ, MD. Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics). UpToDate. Last updated: 6 Apr 2020. c2021. Available from: https://www.uptodate.com/contents/gastroesophageal-reflux-disease-in-adultsbeyond-the-basics.

◦ Mayo clinic. Gastroesophageal reflux disease. c2021. Available from: https://www. mayoclinic.org/diseases-conditions/gerd/drc-20361959. Accessed 11 Apr 2021.

◦ Marks JW. GORD (Acid reflux/heartburn). Medically reviewed 9 Jan 2020. c2021. Medicinenet. Available from: /www.medicinenet.com/gastroesophageal_reflux_ disease_gerd/article.htm.

◦ South African Medicines Formulary (SAMF). 13th ed. Drugs for acid-related disorders. Drugs for peptic ulcer and Gastro-oesophageal reflux disease (GORD). Health and Medical Publishing Group; 2020. p. 40-45.

Coping with general and exam stress

Jacky van Schoor Amayeza Information Services

Stress affects everybody. Some people may notice symptoms of stress building up during demanding times at work or school, when managing their finances or when dealing with challenging relationships.

The origin of stress lies in a primitive response that was necessary for man’s survival – the ‘fight or flight’ response. In prehistoric days, the enemy was a visible, external and dangerous adversary. Today, humans face different adversaries, such as unemployment, bureaucracy, rising costs of living, crime and poverty. Nonetheless, the stress response is the same – setting off a whole chemical and biological cascade that floods the body to anticipate and prepare for action.

What is stress?

Stress is a feeling of emotional or physical tension and the body’s reaction to a challenge or demand. In short bursts, stress can be positive such as when preparing for an exam or facing a dangerous situation. However, persistent or ‘chronic’ stress that lasts for a longer time, can have damaging effects on a person’s health and well-being. When a person has chronic stress, the body stays alert, even though there is no danger. Over time, chronic stress can lead to health problems such as high blood pressure, heart disease, depression or anxiety.

Managing stress

When stress does occur, it is important for the individual to recognise and deal with it. People who say they are feeling ‘stressed’ need to make a conscious choice about doing something to relieve their stress.

Much has been written about stress management, but some simple stress management techniques include the following:

Regular exercise

Exercise is often considered the single most important aspect in dealing with stress. This is because stress is a result of the fight or flight response that essentially prepares the body for action. So, in order to counteract the effects of the fight or flight response, one needs activity so that the stress is ‘released’. There is an added benefit to exercise and that is a moderate release of endorphins, which gives the person a natural lift in mood and a feeling of being better able to cope with the ‘stress’. Exercise also benefits the heart and muscles so that there is an all-round increase in physical and mental well-being.

Nutrition

Stress and diet have always been linked. Invariably, excessive stress goes hand in hand with poor eating habits, and by focusing on better eating habits, this will in itself relieve some of the stress. Eating a diet rich in fresh fruit and vegetables may help ensure an adequate intake of the required nutrients, including vitamins and minerals. Focus on foods containing vitamins B, C and magnesium. B vitamins found in bananas, leafy greens, nuts, seeds, meat, fish and dairy products may help provide the body with energy after a period of stress. Eat plenty of vitamin C-rich foods such as oranges, tomatoes, peppers, leafy greens and broccoli. Magnesium can help to relax muscles and reduce anxiety. Nuts, particularly brazil nuts, are high in magnesium, as are beans and lentils, whole grains and leafy greens.

Substances that may have negative effects on the body when under stress include caffeine and alcohol. Caffeine reduces the ability to deal with stress because it acts as a stimulant. High levels of caffeine may also contribute to nervousness and insomnia, which are intrinsically linked with stress. Substituting coffees and teas for herbal varieties can help reduce caffeine consumption. While drinking alcohol may have an instant calming effect on the body, in the long-term, relying on alcohol increases the amount of stress. Drinking heavily can also lead to complications such as sleep problems, nervousness and alcohol dependence.

Time management

There are a finite number of hours in the day in which we can do productive work. By accepting this and planning accordingly may make the management of time a little easier. It may help to make a list of tasks that need to be done and then to do them one at a time, giving priority to the most important ones. Schedule time for recreation, rest and relaxation. Reading and activities such as meditation are ways of introducing the very necessary time of ‘notdoing’.

Share the stress

It helps to talk to someone, perhaps a friend, family member or a teacher. However, if stress is having a negative effect on an individual’s thinking ability, emotions, behaviour or physical health, professional help should be recommended.

Bibliography

◦ MedlinePlus. Stress and your health. c2018. [Accessed 08 August 2020]. Available from: https://medlineplus.gov/ency/article/003211.htm#:~:text= Stress%20is%20a%20feeling%20of,danger%20or%20meet%20a%20deadline.

◦ WebMD. Stress symptoms. c2019. [Accessed 08 August 2020]. Available from: https://www.webmd.com/balance/stress-management/stress-symptomseffects_of-stress-on-the-body#1

◦ Webber C. Stress. Professional Nursing Today. 2001;5(3):6-9.

◦ Nutritionist Resource [Internet]. Stress and diet. c2020. [Accessed 10 August 2020]. Available from: https://www.nutritionist-resource.org.uk/articles/stress. html#stressanddiet.

◦ SADAG. Self-help tips for stress.

Dry skin

Introduction

The skin is the largest organ in the body, and when it does not retain a sufficient amount of moisture, it becomes dry.

Dry skin, unless it is an inherited disorder or is caused by another condition, is called xeroderma.

Dry skin is an uncomfortable condition causing the skin to become irritated and itchy. The skin may at times slough off in small flakes and scales. Scaling most often affects the lower legs. Rubbing or scratching dry skin can lead to infection and scarring.

What causes skin to become dry?

Normal skin is soft and pliable in texture due to its water content. To help protect against water loss, the epidermis or outer layer of skin contains oil, which slows water evaporation and holds moisture in the deeper layers of skin. If this oil is depleted, the skin becomes dry. Certain factors can increase the risk of developing dry skin, including (but not limited to):

• Ageing causes pores to produce less oil; therefore, older people are more likely to develop dry skin.

• Cold, dry weather.

• Using very hot water when bathing or showering.

• Bathing too frequently, particularly if using harsh soaps. Some people, however, may naturally have dry skin.

Tips for relieving dry skin

• Seal in the moisture

It is advised to moisturise the skin to rehydrate the top layer of skin cells and seal in moisture. Skin moisturisers usually contain:

▫ Humectants, which help attract moisture. These include ingredients such as ceramides, glycerin, sorbitol, hyaluronic acid, and lecithin.

▫ Petroleum jelly, silicone, lanolin, and mineral oil which help seal moisture within the skin.

▫ Emollients, such as linoleic and lauric acids, smoothen skin by filling in the spaces between skin cells.

In general, the thicker and greasier a moisturiser, the more effective it is said to be. Petroleum jelly and moisturising oils such as mineral oil, although inexpensive, are often found to be most effective in relieving dry skin. This is because they contain no water and work best to seal in moisture if used while the skin is still damp after a bath or washing hands. Other moisturisers containing water and oil are often more cosmetically appealing than petroleum jelly or oils because they are less greasy.

• Use gentle, fragrance-free skin care products

Some skin care products, such as deodorant soaps, are too harsh for dry, sensitive skins. Look for products that are labelled “fragrance-free”. Be cautious of “unscented” products as these may contain chemicals that can irritate dry, sensitive skin. Products containing alcohol, alpha-hydroxy acid, fragrance and retinoids can exacerbate dry skin by removing natural oils from the skin.

• Add moisture to the air

A humidifier can be used to increase the moisture levels in the air, especially in cold, dry weather.

• Avoid bathing or washing with very hot water

Dry hands, a side effect from preventing COVID-19

Since the dawn of the COVID-19 pandemic, it has been ingrained in our minds to wash and/or sanitise our hands frequently. While this is one of the most important measures in preventing the spread of COVID-19 and other viruses and bacteria, frequent washing and sanitising of hands has left many, if not, most people suffering from dry, cracked skin.

Moisturising the skin, particularly after washing or sanitising will help keep skin hydrated. Dermatologists have recommended using a hand cream or ointment that:

• contains mineral oil or petroleum jelly,

• comes in a tube, rather than a pump bottle, and

• is fragrance-free.

When using sanitiser, allow it to dry before applying hand cream or ointment.

Lynn Lambert Amayeza Information Services

Conclusion

Dry skin is common and can affect people of all ages, especially older people. Since itching is a common symptom of having dry skin, patients must be advised against scratching and instead opt to moisturise to alleviate the itch. Choosing the right type of moisturiser is an important intervention in relieving the discomfort of dry skin. Frequent washing or sanitising of hands is still recommended to remove harmful bacteria and viruses. However, to alleviate dry skin, always moisturise after washing your hands to keep the skin hydrated.

Bibliography

◦ American Academy of Dermatology Association (AAD). Dermatologists’ top tips for relieving dry skin. Available from: https://www.aad.org/public/everyday-care/skin-

care-basics/dry/dermatologists-tips-relieve-dry-skin. Accessed 9 Apr 2021.

◦ American Academy of Dermatology Association (AAD). Dry skin relief from COVID-19 handwashing. Available from: https://www.aad.org/public/everydaycare/skin-care-basics/dry/coronavirus-handwashing. Accessed 9 Apr 2021.

◦ Benedetti J. Structure and function of the skin. c2019. Available from: https:// www.msdmanuals.com/home/skin-disorders/biology-of-the-skin/structure-andfunction-of-the-skin.

◦ Dinulos JGH. Dry skin (xeroderma). c2020. Available from: https://www. msdmanuals.com/home/skin-disorders/cornification-disorders/dry-skinxeroderma. Accessed 9 Apr 2021.

◦ Dinulos JGH. Xeroderma. January 2020. Available from: https://www.msdmanuals. com/professional/dermatologic-disorders/cornification-disorders/xeroderma.

◦ Harvard Health Publishing. 9 ways to banish dry skin. c2021. Available from: https:// www.health.harvard.edu/staying-healthy/9-ways-to-banish-dry-skin. Accessed 9 Apr 2021.

◦ Moore K, Cobb C. What causes dry skin and how to treat it. c2019. Available from https://www.healthline.com/health/dry-skin. Accessed 9 Apr 2021.

Frequently asked questions about COVID-19 vaccines

Vaccines are considered the most promising approach for curbing the coronavirus disease 2019 (COVID-19) pandemic, preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

What types of COVID-19 vaccines are being developed?

There are many COVID-19 vaccines being developed. They work in slightly different ways. However, all authorised COVID-19 vaccines have been found to be effective in preventing serious illness and death from COVID-19. They include:

Vector vaccines

Vector vaccines contain a weakened version of a different virus, called an adenovirus. This virus does not cause illness, but acts as a “vector,” or a way to deliver instructions to cells in the body. These instructions tell the body to make the protein generally found on the virus that causes COVID-19. The immune system then makes antibodies that recognise and attack the virus in the future. Vector vaccines for COVID-19 have been made by Johnson & Johnson and AstraZeneca/Oxford University.

Administration of the Johnson & Johnson vaccine was temporarily stopped in several countries, including South Africa. This happened because a very small number of people developed blood clots after receiving the vaccine. However, this possible side effect appears to be extremely rare, and the vaccine is now available again. The risk of getting ill with COVID-19 is greater than the risk of severe side effects from the vaccine.

mRNA vaccines

mRNA refers to genetic material from the virus that causes COVID-19. This genetic material is used in the vaccine. It gives the body instructions to make a specific piece of protein that is normally found on the virus. In response, the immune system then makes antibodies that can recognise and attack the virus in the future. The mRNA vaccines for COVID-19 are made by the Pfizer and Moderna companies. They both require two doses given a few weeks apart. Both doses for the vaccine are needed for vaccination to be most effective.

Other vaccines under investigation include inactivated virus vaccines and recombinant protein vaccines.

COVID-19 vaccines do  not contain the infectious SARS-CoV-2 virus. So, they cannot cause COVID-19. They also do not affect a person’s DNA.

What are the benefits of COVID-19 vaccination?

Vaccination protects people from getting seriously ill and dying from COVID-19. The COVID-19 vaccines provide protection against the disease, as a result of developing an immune response to the SARS-CoV-2 virus.  Developing immunity through vaccination means there is a reduced risk of developing the illness and its consequences. Having the vaccine may also protect other people, as vaccinated people are less likely to infect someone else. It is particularly important to protect people at increased risk for severe illness from COVID-19, such as healthcare workers, the elderly and people with other medical conditions.

Do the vaccines protect against SARS-CoV-2 variants?

The COVID-19 vaccines are expected to provide at least some protection against new virus variants and are effective at preventing serious illness and death. This is because COVID-19 vaccines create a broad immune response, and any virus changes or mutations should not make the vaccines completely ineffective.

Jacky van Schoor Amayeza Information Services

Are COVID-19 vaccines safe?

COVID-19 vaccines go through a comprehensive, multi-stage testing process, including large clinical trials designed to identify any common side effects or other safety concerns.

Once a clinical trial shows that the vaccine is effective and welltolerated, a series of independent reviews of the safety and efficacy evidence is required, including regulatory review and approval by local health authorities.

An external panel of experts from the World Health Organization (WHO) also analyses the results from clinical trials and other information. The panel then recommends whether and how the vaccine should be used.

Does the COVID-19 vaccine cause side effects?

Minor side effects following vaccination are common. They can include:

• Pain, redness or swelling at the injection site

• Fever

• Fatigue

• Headache

• Chills

• Nausea

These side effects should not last longer than a day or two. Having these minor side effects does not mean that the person is sick, just that the immune system is responding to the vaccine.

Which is the best vaccine?

All the approved vaccines have shown to be effective in clinical trials. Since the amount of vaccine available is limited, it is best to have whatever vaccine is offered.

Do people who have had COVID-19 need a vaccine?

Experts recommend having the vaccine even if the person has had COVID-19 in the past. People who had COVID-19 do develop antibodies that provide some protection against re-infection. However, it is not known exactly how long antibodies last after a person recovers. Local experts recommend waiting 90 days after being infected with COVID-19 before being vaccinated.

How long does it take for the vaccine to take effect?

Even though vaccines work very well to prevent COVID-19, it is still possible to get the infection. It will also take some time to learn exactly how long immunity lasts after a person is vaccinated.

For the first 14 days after having the vaccine, the person does not have significant levels of protection, then it increases gradually. For a single-dose vaccine, immunity will generally occur two weeks after vaccination. For two-dose vaccines, both doses are needed to achieve the highest level of immunity possible.

Even after having the vaccine, it is important to continue social distancing, wearing a face mask, and washing the hands often.

Can the COVID-19 vaccine be administered with other vaccines such as the influenza vaccine?

Other vaccines, such as the influenza vaccine, should not be administered within at least 14 days of the COVID-19 vaccine. There are no data regarding safety and efficacy when COVID-19 vaccines are administered with other vaccines.

What about post-vaccination testing to check immunity?

There is no role for post-vaccination testing for COVID-19 antibodies. Most of the currently available antibody tests do not measure vaccine antibody response.

When will the pandemic end?

The pandemic will be controlled when countries have “herd immunity.” This is when enough people are immune to the disease and it can no longer spread easily. To get to herd immunity, many people need to get vaccinated. It has been estimated that South Africa needs to vaccinate 67% of the population to achieve herd immunity.

Even after people have been vaccinated and to help keep others safe, it is recommended to continue infection protection measures, such as social distancing, wearing a mask in the community, covering coughs and sneezes and cleaning the hands frequently.

Bibliography

◦ World Health Organization. Coronavirus disease (COVID-19) vaccines [Internet]. c28/10/2020. Available from: https://www.who.int/news-room/q-a-detail/ coronavirus-disease-(covid-19)-vaccines?adgroupsurvey={adgroupsurvey}&gc lid=CjwKCAjw2ZaGBhBoEiwA8pfP_khYuh5hDL2uPNCKagPy9Erd5JiiSdeiIj1qzxviG6MPgCLwh6kWBoCIUUQAvD_BwE. Accessed 27 Apr 2021.

◦ SOuth African Government. COVID-19 Coronavirus-19 vaccine [Internet]. c2021. Available from: https://www.gov.za/covid-19/vaccine/vaccine?gclid=CjwKCAjw2 ZaGBhBoEiwA8pfP_nNE9RoKmU5QPgjbio_aTbYWzxqVj3IW3XrBYXUW GEO7RMkr5klObxoC5QAQAvD_BwE. Accessed 27/4/2021.

◦ Edwards KM, Orenstein WA. COVID-19: Vaccines to prevent SARS-CoV-2 infection [Internet]. c17/3/2021. Available from: https://www.uptodate.com/contents/covid19-vaccines-to-prevent-sars-cov-2-infection. Accessed 20 Apr 2021

◦ UpToDate. Patient education: COVID-19 vaccines (The Basics) [Internet]. c26/4/ 2021. Available from: https://www.uptodate.com/contents/covid-19-vaccines-thebasics. Accessed 26 Apr 2021

Showing appreciation with Sponsors of Brave: The Gratitude Season

Season 3 of Sponsors of Brave is now open for nominations! Calling all South African residents to the frontline! It’s time to rally together to celebrate our Pharmacy heroes who have made our safety their priority during this global pandemic and beyond.

Since the advent of the coronavirus, we’ve witnessed the unwavering bravery and strength displayed by our Pharmacists and other healthcare workers. News24 and Adcock Ingram OTC are joining forces once more to express the nation’s gratitude toward our frontline healthcare workers who have helped us through the pandemic shift into 2021. And this time the focus is on thanking our Pharmacy frontline heroes, by nominating your Pharmacist, Pharmacy assistant, or Pharmacy who always goes the extra mile for their customers and community.

Nicole Austin, Spokesperson of Adcock Ingram OTC Sponsors of Brave said, “As a Pharmacist I hold immense value for this campaign, which is an authentic and meaningful expression of gratitude towards the Pharmacy profession. I, myself, am grateful, and more excited than ever to be the Adcock Ingram OTC Sponsors of Brave Spokesperson. In the past two seasons, a growing appreciation for our healthcare workers has been encouraged, and I am certain that this season will cement their immense value in our hearts and minds. I honestly believe that gratitude is our greatest tool to cultivate hope and cast vision for the future. The pharmacy profession is filled with everyday heroes from all corners of the country, and they certainly deserve some of this gratitude.”

Off the heels of success

Following the successful debut and sophomore seasons of Sponsors of Brave that celebrated our healthcare workers and upcoming future Pharmacists, this season wants to cast a spotlight on the existing Pharmacy heroes making an impact in their community.

Andrea Firth, Editor of BrandStudio.24 said, “We’re really honoured to be working on a third season of Sponsors of Brave with Adcock Ingram OTC - through this campaign we’ve been able to impact the lives of healthcare professionals and students across South Africa and say thank-you in such a meaningful way.”

Readers and Pharmacists are urged to cast their votes to nominate a Pharmacy or Pharmacist or Pharmacy Assistant they believe are

truly enacting change so that these healthcare professionals could win some exciting prizes that are up for grabs. Even nominations stand to win one of eight R5,000 cash prizes!

From the nominations, eight lucky finalists will be selected to be celebrated by their community. Two of these featured nominees will be selected as overall winners: one by a nationwide public vote on the News24 platform, and another chosen by the Adcock Ingram OTC Sponsors of Brave panel of judges. These Pharmacy related professionals will go on to win an exciting opportunity to pay it forward and pursue a passion project of their choice.

The passion project is an opportunity to give back to the community to the value of R25,000; whether this is painting a school, planting a community garden, supporting a soup kitchen, or any other community service orientated activity.

So, South Africa, it’s time to celebrate your Pharmacist and its staff and let the nation know where their heroes are making waves. Visit https://partners.24.com/SponsorsofBrave/index.html website for more entry criteria, and to cast your nomination.

#SponsorsOfBrave

BACK IN STOCK!

throat. minutes mouth

Antihistamine - Relieves histamine induced tight chests2

- Gets to work to stop a cough

References: 1. Pubchem. Dextromethorphan [online] [cited 22 May 2020]; Available from URL: https://pubchem.ncbi.nlm.nih.gov/compound/dextromethorphan 2. CEPACOL® cough linctus (linctus) approved professional information, March 1979. 3. Artime CA, Sanchez CA. Preparation of the Patient for Awake Intubation. In: Benumof and Hagberg’s Airway Management, 2013 [online] [cited 22 May 2020]; Available from URL: https://www.sciencedirect.com/topics/neuroscience/benzocaine. 4. CEPACOL® sore throat and cough relief discs (lozenges) approved professional information, October 1969. 5. CEPACOL® throat lozenges (lozenges) approved professional information,October 2014. 6. CEPACOL® antibacterial throat gargle (solution) approved professional information, August 2005.

S0 CEPACOL® Throat Lozenges Menthol. Each lozenge contains: Cetylpyridinium chloride 1,47 mg and Benzyl alcohol 6,5 mg. Reg. No.: A4016.4/0297. S0 CEPACOL® Throat Lozenges Regular. Each lozenge contains: Cetylpyridinium chloride 1,47 mg and Benzyl alcohol 6,5 mg. Ref No: H1388 (Act 101 of 1965). S0 CEPACOL® Throat Lozenges Blackcurrant Flavour. Each lozenge contains: Cetylpyridinium chloride 1,47 mg and Benzyl alcohol 6,5 mg. Reg. No.: 33/16.4/0492. S0 CEPACOL® Throat Lozenges Honey and Lemon Flavour. Each lozenge contains: Cetylpyridinium chloride 1,47 mg and Benzyl alcohol 6,5 mg. Reg. No.: 33/16.4/0505. S0 CEPACOL® Antibacterial Throat Gargle. Each 100 ml solution contains: Cetylpyridinium chloride 50 mg, alcohol 15,8 % v/v and disodium edetate (antioxidant) 1,0 mg. Ref. No.: H 1387 (Act 101 of 1965). S2 CEPACOL® Cough Linctus. Each 10 ml contains: Dextromethorphan hydrobromide 30 mg, doxylamine succinate 6 mg, sodium citrate 500 mg, cetylpyridinium chloride