Minor Ailment Pharmacy Enhanced Service

Pharmacy Protocol

Updated March 2015 (CJL)

Cough Protocol

Definition
A reflex action to clear the airways of mucus and irritants, such as dust or smoke. Cough may be classified as:
Productive cough:
  • Described as “chesty or loose”
  • Brings up mucus (also called sputum or phlegm)
  • This cough is helpful, as it clears the phlegm from lung passages.
Unproductive cough:
  • Described as “dry, tight or tickly”
  • No mucus is produced
  • Happens when throat and upper airways become inflamed (swollen)
  • The common cold or flu causes a dry cough because the brain thinks the inflammation in the throat and upper airways is a foreign object and tries to remove it.

Description of symptoms
  • Type of cough
  • Colour and consistency of any sputum
  • Presence of other symptoms.

Investigative questions
  • Cough worse at any particular time of day?
  • How long have you had the cough?
  • Previous remedies tried?
  • Any regular prescribed or OTC medicine?
  • Do you smoke?
  • How does the cough sound?

Criteria for inclusion

Troublesome cough requiring soothing.

Criteria for exclusion

NOTE - Patients under 6 years should not be provided with medication

  • Thick yellow, green, brown or foul smelling sputum
  • Blood stained sputum
  • Pink, frothy sputum
  • Cough of sudden onset
  • Chest pain
  • Shortness of breath, chest tightness, wheeze
  • Painful calf
  • Unexplained weight loss
  • Cough exceeding 2 weeks without improvement
  • Recurrent coughs
  • Asthmatics presenting with wheeze / reduced PEFR
  • Failure of OTC remedy to improve symptoms
  • Gastro-oesophageal reflux disease is suspected cause of cough.

Precipitating factors

  • Adverse drug reactions
  • Air pollution
  • Allergy
  • Asthma
  • Dry atmosphere
/

Infection

  • Serious conditions (e.g. lung cancer)
  • Temperature changes
  • Smoking (active or passive)

Advice to be given

  • Reassure patient that coughs are usually self-limiting. If symptoms persist beyond 3 weeks with no improvement or if cough gets progressively worse see GP
  • Treatment isn't usually necessary, but a home remedy containing honey and lemon may help ease a short-term cough
  • There’s little evidence to suggest that cough medicines will be any more effective but cough medicine may be supplied

OTC medication

Non-productive cough
  • Simple linctusSF 200ml
  • Paediatric simple linctus SF 200ml
  • Pholcodine linctus 5mg/5ml SF 200ml
Productive cough
  • Ammonia & ipecacuanha mixture 200ml
  • Guaifenesin linctus 200ml

Non pharmaceutical treatment

  • A home remedy containing honey and lemon may help ease a short-term cough.

Referral criteria

Consider supply, but patient should be advised to make a routine appointment to see GP
  • A cough lasting 3 weeks or more or a cough that gets gradually worse
  • Unsuccessful treatment with OTC medicines of more than 3 weeks
  • A persistent dry, night time cough in children / elderly
  • A dry cough in a patient prescribed an ACE inhibitor
  • Discoloured or bloodstained sputum (green sputum is common in viral infections and may not warrant referral) with no other symptoms.

Rapid referral

  • Very high temperature or shortness of breath accompanied by a cough, particularly in patients aged over 65 or under two years
  • Chest pain other than solely with coughing
  • Difficulty breathing/wheezing
  • If chest pain related to exertion
  • ‘Pink and frothy’ or blood stained sputum (especially if accompanied by breathlessness and swollen ankles)
  • Blood stained sputum associated with chronic fever and night sweats
  • Suspected whooping cough or croup.

References

  • CPPE: Responding to Minor Ailments, 2008.
(
  • NHS Choices: Cough
(

Conjunctivitis Protocol

Definition
Redness and inflammation of the thin layer of tissue that covers the front of the eye (the conjunctiva).
Conjunctivitis can be caused by an irritant, such as chlorine or dust, an allergy (for example, to pollen), or an infection.
Description of symptoms
Allergic conjunctivitis - usually affect both eyes and is intensely itchy
Viral conjunctivitis - tends to affect one eye first (which becomes watery), with redness developing in the second eye a few days later. Most cases of viral conjunctivitis occur along with a common cold
Bacterial conjunctivitis - usually causes a sticky discharge from the eye and crusting around the eyelids.

General Symptoms:

  • Itchiness and watering of the eyes
  • Red eye
  • Burning sensation in the eyes
  • Feeling of grit in the eyes.

Investigative questions

Duration of symptoms?

  • Previous remedies tried?
  • Concurrent medication?

Criteria for inclusion

Treatment with eye drops is only required in bacterial (infective) conjunctivitis and ONLY after self-care methods have been used for at least 48 hours with no improvement in symptoms.
Self-care for conjunctivitis involves following the below advice:
  • Avoid touching the eye and spreadingany infection to the other eye
  • Bathe eye(s) with cool boiled water for 48hrs, to soothe and cleanse
  • Do not wear make-up or contact lenses until the conjunctivitis has cleared
  • Do not share towels, flannelsandpillow cases with others in the home
  • Call back to pharmacy after 48 hours (2 days) if no improvement in symptoms to be supplied with eye drops /ointment.

Criteria for exclusion

Children less than two years of age

History of hypersensitivity to chloramphenicol or to any other ingredient within the preparation

Pregnant or breastfeeding

Unresponsive / insufficient response to active episode of treatment

  • Eye surgery or laser treatment in the past six months
  • Recently returned from abroad
  • Family history of a severe blood disorder

Precipitating factors

  • Old or young: more common in children and the elderly, possibly because children come into contact with more infections at school and elderly people may have a weaker immune system,
  • Recent upper respiratory tract infection, such as a cold,
  • Diabetes or another condition that weakens the immune system,
  • Concomitant medication, such as corticosteroids
  • Blepharitis (inflammation of the rims of the eyelids)

Advice to be given

Self-care for conjunctivitis involves following the below advice:
  • Avoid touching the eye and spreadingany infection to the other eye
  • Bathe eye(s) with cool boiled water for 48hrs, to soothe and cleanse
  • Do not wear make-up or contact lenses until the conjunctivitis has cleared
  • Do not share towels, flannelsandpillow cases with others in the home while you have conjunctivitis
  • Call back to pharmacy after 48 hours (2 days) if no improvement in symptoms to be supplied with eye drops /ointment.

IF eye drops /ointment are supplied (after 48hous of self-care):

Eye drops should be stored in a refrigerator (2-8oC)

  • Eye ointment should be stored in a cool, dry place, away from direct heat and light

May experience transient burning or stinging sensation in the eye when applying eye drops

Gently clean away sticky discharge using cotton wool soaked in water

Do not wear contact lenses until the symptoms have cleared up (where applicable)

  • Wash hands regularly.

OTC medication

  • Chloramphenicol 0.5% eye drops, 10mL
  • Chloramphenicol 1% eye ointment, 4g
Maximum treatment is 5 days.

Non pharmaceutical treatment

  • Self-care for 48 hours before medication (see above advice)

Referral criteria

  • If symptoms do not improve after 48 hours of self-care then advise return for medication
  • If symptoms do not improve after 48 hours of treatment with medication
  • Where conjunctivitis may be related to wearing contact lenses
  • Already using other eye drops or eye ointment
  • Intense redness in one or both eyes.

Rapid referral

  • Newborn baby with conjunctivitis
  • Severe pain in the eye(s)
  • Blurred vision
  • Sensitivity to light.

References

  • NHS Choices: Conjunctivitis
(
  • Practice guidance: OTC chloramphenicol eye drops, Royal Pharmaceutical Society of Great Britain (

Fever Protocol

Definition
A body temperature over 37.5oC

Description of symptoms

  • Feeling hot (often with sweating) or cold (often with shivering)
  • Often accompanied by headache and aching muscles.

Investigative questions

Has the temperature been measured?

Normal body temperature (when taken in the mouth) 36.5-37.5oC.

Criteria for inclusion

Body temperature over 37.5oC

Criteria for exclusion

Children less than 3 months old

  • Temperature above 40oC.

Precipitating factors

Infection – upper respiratory tract / ear / urinary

  • Teething in infants
  • Common childhood illnesses, such as chicken pox
  • Tonsilitis
  • Post-vaccinations
  • Overheating due to excessive bedding or clothing.

Advice to be given

  • Treatment should provide relief of symptoms and avoid febrile convulsions (fits) in infants
  • Enquire about concurrent analgesic usage.

OTC medication

Paracetamol 500mg tablets,32 pack

  • Paracetamol suspension, 120mg/5mLSF 100ml
  • Paracetamol suspension 250mg/5mL SF 200ml
  • Ibuprofen 200mgtablets,24 pack
  • Ibuprofen 400mg tablets, 24 pack
  • Ibuprofen suspension, 100mg/5mL SF, 100ml
Do NOT supply ibuprofen if patient has asthma or GI problems.
  • Advise patient to take with/after food to limit GI side effects
  • Avoid in patients sensitive to aspirin
  • Avoid in patients taking lithium
  • Contra-indicated in patients with congestive heart failure or renal impairment.

Non pharmaceutical treatment

Avoid dehydration by increasing intake of cool water

  • Try to keep room at a comfortable temperature, about 18oC
  • Keep child cool if the environment is warm, for example, cover with a lightweight sheet, but ensure they are still appropriately dressed for their surroundings.

Referral criteria

Temperature above 40oC

  • Cyclicalfever – questions should be asked to ascertain whether patient has recently returned from foreign travel or works in a medical laboratory
  • Young babies and elderly patients that appear to be very unwell - these patients easily become hyper – or – hypothermic respectively.

Rapid referral

  • Under three months old and temperature of 38oC or above
  • Aged between three and six months old with a temperature of 39oC or above
  • Over six months old and has other signs of being unwell, such as floppiness and drowsiness.
Suspected meningitis – telephone surgery
References
  • NHS Choices: Fever in children (

Hay Fever Protocol

Definition
Seasonal allergic reaction by exposure to pollens, grass, flowers or trees
Description of symptoms

Typically early spring to late autumn when the pollen count is over 50

Frequent sneezing

  • Runny or blocked nose
  • Itchy, red or watery eyes (also known as allergic conjunctivitis)
  • Itchy throat, mouth, nose and ears
  • Cough, usually caused by postnatal drip.

Investigative questions

Family history of hay fever / other allergies?

Previous diagnosis?

  • Which symptoms are the most troublesome?
  • Previous remedies tried?
  • Concurrent medication? (Antihistamines contra-indicated in patients with Glaucoma, patients taking anti-arrhythmic drugs).

Criteria for inclusion

Typical symptoms of hayfever where other possible causes have been excluded (see referral criteria)

Criteria for exclusion

Patients under age of 6

  • Pregnancy.

Precipitating factors

Exposure to allergens

  • Pollution.

Advice to be given
  • If possible, stay indoors when the pollen count is over 50
  • Keep windows and doors shut. If it gets too warm, draw the curtains to keep the sun out and temperature down
  • Avoid fresh flowers in the house
  • Regularly damp dust the house
  • Where possible, avoid drying clothes outside as this will help prevent bringing pollen inside the house
  • Change your clothes when you have been outside
  • Wear wraparound sunglasses to prevent pollen getting in the eyes (also dark glasses may help if photophobia a problem
  • Have pollen filters fitted to car air inlet system and also on vacuum cleaner
  • Check pollen count daily on weather forecast
  • With respect to antihistamines – beware of drowsiness, do not exceed maximum doses
  • If no improvement is noted after 5 days*, refer to GP.

OTC medication

Chlorpheniramine 4mg tablets, 28 pack

Chlorpheniramine 2mg/5mL liquid, 150ml

**see BNF for interactions - avoid in patients with prostatic hypertrophy, glaucoma and epilepsy

  • Cetirizine 10mg tablets, 30 pack
  • Loratadine 10mg tablets, 30 pack
  • Otrivine-Antistin (antazoline sulphate 0.5%, xylometazoline 0.05%) eye drops, 10ml
  • Sodium cromoglicate 2% eye drops, 10ml
  • Beclomethasone 50 micrograms/metered dose nasal spray, 100 doses

Non pharmaceutical treatment

Cold compress applied to eyes may offer symptomatic relief.

Referral criteria

If symptomatic treatment is unsuccessful / persists beyond September

  • Pregnancy
  • Patients who are breathless / wheezing heavily / chest tightness
  • Asthma suffers who still have difficulty breathing despite using their prescribed medicines
  • Patients who may have a secondary infection, such as otitis media or sinusitis
  • Purulent, rather than clear, discharge from the eyes, which may indicate infection.

Rapid referral

  • Asthmatics (as mentioned above)

Seasonal asthmatics.

References
  • NHS Choices: Hayfever
(
  • Symptoms in the Pharmacy: A guide to the management of common illness. Alison Blenkinsopp & Paul Paxton, 3rd ed.*
  • The Pharmaceutical Journal, Vol 270, no. 7242, 29 March 2003

Headache Protocol

Definition
Pain anywhere in the region of the head or neck
Headaches have many different causes but can generally be split into two types:
  • Primary – not due to another underlying health problem
  • Secondary – have a separate cause, such as illness.

Description of symptoms
Tension-type headache
  • due to stress or tension
  • commonly episodic (occur less than 15 times per month)
  • usually bilateral, pressing/tightening (non-pulsating)
  • can last 30minutes or more.

Investigative questions
  • Nature of pain?
  • Site of pain?
  • Previous history of headaches?
  • Current medication? It is important to identify possible ADR e.g. nitrates. Identify potential interactions with OTC medication.

Criteria for inclusion

Patients requiring pain relief for tension headache.

Criteria for exclusion

  • Children under the age of 12

Patients with headache following injury or trauma to the head

  • Patients with suspected ADR
  • Migraine.

Precipitating factors

Psychological, social and emotional factors

Advice to be given

  • Treatment with analgesics (particularly those containing codeine) can give rise to rebound headaches. For this reason treatment should be restricted to 7 days or less
  • Enquire about other concurrent analgesic usage
  • If the headache does not respond to OTC analgesics within a day, referral is advisable.

OTC medication

Paracetamol 500mg tablets, 32 pack

  • Paracetamol 250mg/5mL suspension SF, 200ml
  • Ibuprofen 200mg tablets, 24 pack
  • Ibuprofen 400mg tablets, 24 pack
  • Ibuprofen 100mg/5mL suspension SF,100ml
**Do NOT supply ibuprofen if patient has asthma or GI problems.
  • Advise patient to take with/after food to limit GI side effects,
  • Avoid in patients sensitive to aspirin,
  • Avoid in patients taking lithium,
  • Contra-indicated in patients with congestive heart failure or renal impairment.

Non pharmaceutical treatment

As the most frequently reported trigger factors for headache are stress (mental or physical), irregular or inappropriate meals, high intake of coffee and other caffeine-containing drinks, dehydration, sleep disorders, too much or too little sleep, reduced or inappropriate exercise and psychological problems, identity which factor affects your patient and advise on appropriate action.

Rest, try to relax and avoid stress

  • Improve posture
  • Consider hot or cold packs
  • Headaches associated with reading or other close work may be due to deteriorating sight. An eye test to see if spectacles are needed would be advisable.

Referral criteria

  • Worsening headache with fever
  • Sudden-onset headache reaching maximum intensity within 5 minutes
  • New-onset neurological deficit
  • New-onset cognitive dysfunction
  • Change in personality
  • Impaired level of consciousness
  • Recent (typically within the past 3 months) head trauma
  • Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze
  • Headache triggered by exercise
  • Orthostatic headache (headache that changes with posture)
  • Symptoms and signs of acute narrow-angle glaucoma
  • Substantial change in the characteristics of their headache
  • Cluster headache.

Referral criteria continued

Refer a person who present with new-onset headache and any of the following:
  • Compromised immunity, caused, for example, by HIV or immunosuppressive drugs
  • Aged under 20 years and a history of malignancy
  • History of malignancy known to metastasise to the brain
  • Vomiting without other obvious cause.
Refer a person over 60 who present with sudden development of:
  • A severe headache
  • Jaw pain when eating
  • Blurred or double vision
  • A sore scalp.

Rapid referral

  • Paralysis or weakness in one or both arms and/or one side of the face
  • Slurred or garbled speech
  • Sudden agonising headache resulting in a blinding pain unlike anything experienced before
  • Headache along with a high temperature, stiff neck, mental confusion, seizures, double vision and a rash
  • Headache accompanied by other focal or non-focal neurological symptom, such as blackout, change in personality or memory.

References
  • Wikipedia: Definition of headache.
(
  • NICE guidance: Headache, CG150, September 2012.
(
  • NHS Choices: Headache
(
  • NHS Choices: Migraine
  • (
  • GP Notebook: Headache (adult, criteria for urgent referral)
(
  • GP Notebook: Headache (features when it is suggested that investigation or referral is required)
(
  • Bendtsen, L. ‘Drug and nondrug treatment tension-type headache’. Ther Adv Neurol Disord, May 2009; 2(3): 155-161.
(

Head Lice Protocol

Definition
Head lice are tiny insects that feed on blood from the human scalp. To confirm an active head lice infestation, a louse must be found through a reliable, accurate method, such as detection combing.
Description of symptoms
  • Head lice are whitish to grey-brown in colour, and smaller than the size of a pinhead when first hatched.
  • When fully grown they are the size of a sesame seed.
  • The female head louse lays eggs by cementing them to hairs (often close to the root), where they’re kept warm by the scalp.
  • After 7 to 10 days, the eggs hatch and the empty eggshells remain glued in place (known as nits).
  • Nits are white and become more noticeable as the hair grows and carries them away from the scalp.
  • Head lice take 9 to 10 days to become fully grown and the female may start to lay eggs from 9 days after she’s hatched.
  • To break the cycle and stop the spread, they need to be removed within 9 days of hatching.
  • Itching is caused by an allergy to the lice and not from the lice biting the scalp.
  • As not everyone is allergic to head lice, a head lice infestation may be hard to notice.
  • Even if someone is allergic to head lice, itching can take up to three months to develop.
  • In some cases, a rash may appear on the back of the neck. This is caused by a reaction to lice droppings.

Investigative questions

Have live lice been detected?