6.5 Minor Ailment Prescribing and Nonprescription Therapy

Minor Ailment Prescribing Landscape and Clinical Assessment

Across Canadian provinces, the scope of pharmacy practice has expanded to authorize pharmacists to assess and prescribe for designated minor ailments (self-limiting, uncomplicated conditions that do not require laboratory or diagnostic imaging confirmation). Pharmacists perform a differential assessment, identify "red flag" alarm symptoms requiring medical referral, prescribe Schedule I/II/III or unscheduled therapies, and document/communicate interventions to primary care providers.

Systematic Clinical Assessment Frameworks

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|                   SCHOLAR-MAC ASSESSMENT FRAMEWORK                      |
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|  S - Symptoms (What are the primary presenting complaints?)             |
|  C - Characteristics (Quality, intensity, bilateral vs unilateral)      |
|  H - History (Previous episodes, timing, duration)                      |
|  O - Onset (When did symptoms begin; acute vs insidious)                |
|  L - Location (Specific anatomical site of lesion or pain)              |
|  A - Aggravating Factors (What makes the condition worse?)              |
|  R - Relieving Factors (What makes the condition better?)               |
|  ---------------------------------------------------------------------  |
|  M - Medications (Prescriptions, OTC, natural health products, herbs)   |
|  A - Allergies (Drug allergies, excipients, reactions)                 |
|  C - Conditions (Underlying medical comorbidities, pregnancy/lactation) |
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Gastrointestinal Minor Ailments

Dyspepsia and Gastroesophageal Reflux Disease (GERD)

• Alarm Features / Red Flags (Immediate Physician Referral): Dysphagia (difficulty swallowing), odynophagia (painful swallowing), unexplained weight loss, persistent vomiting, hematemesis, melena, anemia, jaundice, palpable abdominal mass, or new-onset dyspepsia in individuals aged $> 50$ years.
• Self-Care & Pharmacological Options:
  1. Antacids: Magnesium hydroxide/aluminum hydroxide (Maalox, Mylanta), calcium carbonate (Tums), sodium bicarbonate. Provide immediate (within 5-15 minutes) but short-duration ($1-2\text{ hours}$) neutralization of gastric acid. Magnesium causes diarrhea; aluminum and calcium cause constipation.
  2. Histamine-2 Receptor Antagonists ($H_2$RAs): Famotidine ($10-20\text{ mg}$ PO once or twice daily). Onset 30-60 minutes, duration 8-12 hours. Subject to tachyphylaxis (tolerance) with continuous daily use.
  3. Proton Pump Inhibitors (PPIs): Omeprazole, Pantoprazole, Esomeprazole, Rabeprazole, Lansoprazole ($20\text{ mg}$ daily). Irreversibly inhibit active $H^+/K^+$ ATPase pumps. Take 30 to 60 minutes before the first meal of the day. Recommended minor ailment duration is 2 to 4 weeks.

Constipation

Constipation Red Flags: Severe localized abdominal pain, fever, vomiting, rectal bleeding / hematochezia, unexplained weight loss, pencil-thin stools, or acute onset in individuals $> 50$ years.

Diarrhea and Hemorrhoids

• Acute Diarrhea: Cornerstone of therapy is Oral Rehydration Therapy (ORT). Loperamide ($4\text{ mg}$ initial dose, then $2\text{ mg}$ after each unformed stool, max $8\text{ mg/day}$ OTC / $16\text{ mg/day}$ Rx) is a peripheral $\mu$-opioid agonist that slows motility. Contraindication: Avoid in bacterial dysentery (high fever, bloody stools) or suspected C. difficile / STEC colitis. Bismuth Subsalicylate (Pepto-Bismol) provides antisecretory/antimicrobial actions; causes harmless black tongue and dark stools (avoid in children due to Reye's syndrome risk, and in salicylate allergy).
• Hemorrhoids: First-line includes high fiber, increased fluids, and warm sitz baths. Pharmacological: Topical astringents/protectants (Zinc oxide), local anesthetics (Pramoxine), and short-term topical corticosteroids (Hydrocortisone $0.5-1%$ limited to $\le 7\text{ days}$ to prevent perianal skin atrophy). Red Flags: Massive rectal bleeding, dark tarry stools, or excruciating sudden perianal pain suggesting thrombosed external hemorrhoids.

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Dermatological Minor Ailments

Atopic Dermatitis (Eczema)

Atopic dermatitis involves epidermal barrier dysfunction and immune dysregulation.

• Barrier Maintenance: Daily bathing with lukewarm water, soap-free cleansers, and immediate application of bland, fragrance-free emollients (ointments/creams preferred over lotions) to trap moisture.
• Topical Corticosteroids (TCS): Applied in short bursts (1-2 weeks) during acute flares.
  • Potency Ladder:
    • Low Potency (Class VII): Hydrocortisone acetate $0.5-1%$. Safe for face, neck, axillae, groin, and pediatric infants.
    • Moderate Potency (Class IV-V): Betamethasone valerate $0.05-0.1%$, Clobetasone butyrate $0.05%$, Triamcinolone $0.1%$. Used on trunk and extremities.
    • High Potency (Class II-III): Mometasone furoate $0.1%$, Betamethasone dipropionate $0.05%$. Used on thick, lichenified plaques.
    • Ultra-High Potency (Class I): Clobetasol propionate $0.05%$. Limited to palms, soles, and thick scalp lesions; duration $\le 2-3\text{ weeks}$.
  • Fingertip Unit (FTU): Amount squeezed from a $5\text{ mm}$ nozzle from the distal skin crease to the fingertip of an adult index finger ($0.5\text{ g}$), covering the area of two adult handprints.
  • Steroid-Sparing Alternatives: Topical calcineurin inhibitors (Tacrolimus $0.03-0.1%$, Pimecrolimus $1%$) and PDE4 inhibitor (Crisaborole $2%$). Do not cause skin atrophy, making them ideal for delicate facial and eyelid eczema.

Acne Vulgaris

Acne pathophysiology involves follicular hyperkeratinization, sebum hyperproduction, Cutibacterium acnes proliferation, and inflammation.

• Mild Comedonal / Inflammatory Acne: First-line is Topical Benzoyl Peroxide (BPO $2.5-5%$) (antimicrobial, comedolytic; does not induce bacterial resistance; bleaches fabrics) and/or Topical Retinoids (Adapalene $0.1-0.3%$, Trifarotene, Tretinoin; normalize keratinization; apply at night; cause skin peeling/photosensitivity; contraindicated in pregnancy).
• Moderate Papulopustular Acne: Combination of BPO + Topical Clindamycin $1%$ (fixed-dose combination Biacna, Clindoxyl; always co-prescribe BPO with topical antibiotics to prevent resistance) PLUS Topical Retinoid. If refractory, add oral tetracyclines (Doxycycline $100\text{ mg}$ daily for $\le 3\text{ months}$). Severe nodulocystic acne warrants Oral Isotretinoin (teratogenic; mandatory dual contraception).

Fungal Skin and Nail Infections

• Tinea Pedis (Athlete's Foot) / Tinea Cruris (Jock Itch) / Tinea Corporis (Ringworm): Treat with topical allylamines (Terbinafine $1%$ cream applied daily for 1-2 weeks) or topical azoles (Clotrimazole $1%$, Miconazole $2%$, Ketoconazole $2%$ BID for 2-4 weeks). Continue treatment for 1-2 weeks after clinical resolution.
• Tinea Capitis: Requires oral systemic antifungal therapy (Terbinafine or Griseofulvin); topical antifungals are ineffective for fungal hair shaft invasion.
• Onychomycosis (Fungal Nail): Mild-to-moderate without matrix involvement: Efinaconazole $10%$ (Jublia) solution or Ciclopirox $8%$ nail lacquer applied daily for 48 weeks. Severe or matrix-involved: Oral Terbinafine ($250\text{ mg}$ daily for 6 weeks in fingernails, 12 weeks in toenails; monitor baseline liver enzymes).

Cold Sores (Herpes Simplex Labialis)

• Self-limiting HSV-1 vesicular lesions on lips. Treatment is most effective when initiated during the prodromal stage (tingling, burning before vesicles appear).
• Pharmacotherapy: Topical Docosanol $10%$ (Abreva, viral entry inhibitor) applied 5 times daily; or prescription Oral Valacyclovir ($2\text{ g}$ PO BID for 1 day, separated by 12 hours).

Impetigo

• Superficial bacterial skin infection (S. aureus, S. pyogenes) with classic "honey-colored" crusted erosions.
• Localized non-bullous: Topical Mupirocin $2%$ or Fusidic Acid $2%$ ointment/cream TID for 5-7 days. Extensive/bullous: Oral Cephalexin.

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Respiratory and ENT Minor Ailments

Allergic Rhinitis

Characterized by sneezing, rhinorrhea, nasal congestion, and itchy/watery eyes triggered by allergens (pollen, dust mites, animal dander).

1. Intranasal Corticosteroids (INCS): Fluticasone furoate/propionate, Mometasone furoate, Budesonide, Ciclesonide. First-line, most effective monotherapy for all nasal symptoms (including congestion) and ocular symptoms. Direct spray away from nasal septum to avoid epistaxis and septal perforation. Regular daily use is required for optimal efficacy.
2. Oral Antihistamines (Second-Generation): Cetirizine, Loratadine, Fexofenadine, Desloratadine, Bilastine, Rupatadine. Preferred over first-generation agents (diphenhydramine, chlorpheniramine) due to selective peripheral $H_1$ blockade without anticholinergic sedation, cognitive impairment, or urinary retention.
3. Decongestants:
   • Oral Pseudoephedrine: Alpha-1 adrenergic vasoconstrictor. Use with caution in hypertension, ischemic heart disease, glaucoma, and benign prostatic hyperplasia.
   • Topical Decongestants (Oxymetazoline, Xylometazoline): Provide rapid nasal airflow improvement. Must be restricted to a maximum of 3 to 5 consecutive days to prevent Rhinitis Medicamentosa (rebound severe nasal congestion and mucosal dependency).

Eye and Ear Minor Ailments

• Allergic Conjunctivitis: Bilateral itchy, watery eyes. Treat with Topical Dual Antihistamine/Mast Cell Stabilizers (Olopatadine $0.1-0.2%$, Ketotifen $0.025%$).
• Bacterial Conjunctivitis: Unilateral or bilateral purulent discharge ("glued shut" eyelids in morning). Self-limiting; treat with topical Polymyxin B/Gramicidin (Polysporin) drops or Erythromycin ointment. Contact lens wearers require topical fluoroquinolone coverage (Ciprofloxacin $0.3%$) to prevent Pseudomonas aeruginosa keratitis. Red flags: Eye pain, visual acuity loss, photophobia, ciliary flush, or corneal ulceration $\implies$ urgent ophthalmology referral.
• Otitis Externa (Swimmer's Ear): External canal inflammation/pain upon manipulation of tragus/pinna. Treat with topical Ciprofloxacin/Dexamethasone (Ciprodex) or Polymyxin B/Neomycin/Hydrocortisone drops. Aminoglycoside-containing drops (neomycin, tobramycin, gentamicin) are contraindicated if tympanic membrane perforation cannot be excluded due to risk of irreversible ototoxicity.

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Musculoskeletal Minor Ailments: Sprains and Strains

• Acute Soft-Tissue Injury Management: Follow the PEACE & LOVE protocol (Protect, Elevate, Avoid anti-inflammatory modalities in immediate 24-48h if severe tissue repair needed, Compress, Educate; followed by Load, Optimism, Vascularization, Exercise).
• Topical vs. Oral NSAIDs: Topical Diclofenac Gel ($1.16%$ or $2.32%$) is first-line for acute localized strains/sprains and knee/hand osteoarthritis. It provides equivalent analgesia to oral NSAIDs while resulting in $> 90%$ lower systemic plasma concentrations, significantly reducing risks of GI bleeding, acute kidney injury, and cardiovascular events.
• Red Flags (Ottawa Ankle Rules - Referral for Radiography): Bone tenderness along distal $6\text{ cm}$ of posterior edge of fibula/lateral malleolus or tibia/medial malleolus, bone tenderness at base of 5th metatarsal or navicular, or inability to bear weight both immediately and for 4 steps in clinic.

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Reproductive and Women's Health Minor Ailments

Vulvovaginal Candidiasis (VVC)

• Clinical Presentation: Vulvar pruritus, burning, dyspareunia, and thick, white "cottage cheese-like" non-malodorous discharge.
• Pharmacological Treatment:
  • Topical Azoles: Clotrimazole ($1-2%$ cream or $100-200\text{ mg}$ vaginal ovules for 1-7 days) or Miconazole vaginal suppositories.
  • Oral Azole: Fluconazole ($150\text{ mg}$ PO single dose).
• Pregnancy Warning: Oral fluconazole is contraindicated in pregnancy (associated with spontaneous abortion and congenital anomalies). Pregnant patients must be treated only with a 7-day topical azole regimen (e.g., clotrimazole $1%$ vaginal cream for 7 consecutive days).
• Red Flags: Recurrent VVC ($\ge 4$ episodes/year), severe intractable symptoms, premenarchal girls, abnormal vaginal bleeding, or fever/pelvic pain.

Dysmenorrhea

• Primary Dysmenorrhea: Painful menstrual cramping occurring with ovulatory cycles in the absence of pelvic pathology. First-line therapy is NSAIDs (Naproxen $500\text{ mg}$ initially then $250\text{ mg}$ q6-8h, Ibuprofen $400\text{ mg}$ q6h, or Mefenamic acid $500\text{ mg}$ then $250\text{ mg}$ q6h), initiated at onset of menses or 1-2 days prior. Second-line: Combined hormonal contraceptives.

Emergency Contraception (EC)

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|                   EMERGENCY CONTRACEPTION COMPARISON                    |
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|                                                                         |
|  1. LEVONORGESTREL 1.5 mg (*Plan B*, Unscheduled / Schedule III):       |
|     - Mechanism: Delays/inhibits LH surge and ovulation                |
|     - Window: Within 72 hours (up to 120h, but efficacy drops)          |
|     - Weight/BMI Rule: Efficacy decreases at BMI >= 25 kg/m2 or weight  |
|       > 70-80 kg. Preferred response is ulipristal or a copper IUD,     |
|       NOT a doubled levonorgestrel dose (a randomized trial found       |
|       3.0 mg did not improve ovulation delay in obesity)                |
|     - Enzyme inducers: a 3.0 mg dose IS advised with CYP3A4 inducers    |
|       (e.g., carbamazepine, rifampin, St. John's wort); a copper IUD    |
|       remains the more reliable option                                  |
|                                                                         |
|  2. ULIPRISTAL ACETATE 30 mg (*Ella*, Schedule I / Prescribed):         |
|     - Mechanism: Selective Progesterone Receptor Modulator (SPRM);     |
|       inhibits ovulation even AFTER the LH surge has started            |
|     - Window: Up to 120 hours (5 days) with consistent high efficacy    |
|     - Superior to levonorgestrel in individuals with BMI >= 25-30 kg/m2 |
|     - Critical Rule: Must wait 5 DAYS after ulipristal before resuming   |
|       or starting regular progestin-containing hormonal contraception   |
|                                                                         |
|  3. COPPER INTRAUTERINE DEVICE (Cu-IUD):                                |
|     - Mechanism: Spermicidal copper ions prevent fertilization/implants |
|     - Window: Inserted within 7 days post-unprotected intercourse      |
|     - Gold standard: > 99% efficacy regardless of body weight/BMI       |
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