Guidelines for Prescribing for Minor Ailments and Patient Self-Care

Guideline updates (last updated August 24th, 2017)

August 24th, 2017

  • Updated MSK and headache guidelines
    • Ibuprofen, Naproxen and Celecoxib have been found to be the lowest risk NSAID in patients with cardiovascular or cerebrovascular concerns.
      • This is new information from the Precision Study. Prior knowledge suggested Naproxen was the safest NSAID for CV concerns.
    • Dosage information for Ibuprofen updated to show maximum dosage for a migraine (3200mg/day)
    • Naproxen sodium and Diclofenac potassium added as eligible products to prescribe for a headache or migraine.

May 1st, 2017

  • Updated all guidelines with some minor changes to terminology
    • Instead of "refer to MD/physician", the terminology "refer to patient's primary care provider", or simply "refer",  is used instead.  This is to reflect there are different eligible prescribers for a particular patient, and they may not necessarily have a regular physician to refer them to.
    • All PARs / Algorithms / Guideline text updated to reflect this change.

April 11th, 2017

  • Updated Musculoskeletal sprains / strains guideline
    • Updates PAR and algorithm (changed "Refer to MD" to simply "refer", or "refer to primary care provider"
    • Celecoxib removed as an NSAID of concern in CV disorders; recent evidence supports its relative safety in those with CV concerns.

  • Updated Cold sore guideline
    • Made it more clear on PAR / algorithm / guideline text that pharmacist treatment is only for a recurrent episodes of herpes labialis, NOT a primary infection.

  • Updated Insect bites guideline
    • Added icaridin as a recommended insect repellant in kids and adults

  • Updated superficial bacterial skin infection guideline
    • Before we had the statement that polymyxin/bacitracin containing products were ineffective for impetigo.  Updated to say "these products have little evidence for their use, but may be an option."

Feb 14, 2017

  • Updated Allergic Rhinitis guideline
    • Fluticasone deregulated to schedule II (OTC).  This means it is no longer eligible for the prescribing assessment fee.

Nov 30, 2016

  • Updated GERD guideline
    • Esomeprazole deregulated to Schedule II for package sizes ≤ 280 mg; added wherever OTC omeprazole appears
    • Algorithm modified so that a patient in Scenario 1 will only receive one 28-day PPI fill so as not to go longer than 56 days without MD or NP assessment.
    • Minor changes and corrections

Sept 13, 2016

  • Reminder: Hydrocortisone 1% is OTC, UNLESS the patient is under 2 years of age.  If the patient is under 2, you may prescribe hydrocortisone 1% and bill for the minor ailment assessment fee.  This applies to insect bites, diaper dermatitis, and atopic dermatitis.

August 4, 2016

  • Cold Sore guidelines
    • Acyclovir 5% / Hydrocortisone 1% topical cream (Xerese) is now available for pharmacist prescribing.  See the guidelines for where they fit into therapy.

  • Atopic dermatitis guidelines
    • Beclomethasone dipropionate 0.025% cream (Propaderm) can now be prescribed by pharmacists.  It is a medium potency corticosteroid.

March 23, 2016

  • Updated Tinea guidelines
    • Corrected a few errors regarding ketoconazole treatment duration among all 3 tineas
    • Updated algorithm and PAR for all 3 tineas
    • No changes to monitoring, treating, or referral criteria

March 15, 2016

  • Updated superficial bacteria guideline:
    • Added details about rationale for treating impetigo, and risk factors for developing
    • Added pictures
    • Clarified some differential assessments by adding "differentiating factors"
    • Clarified treatment durations to be consistent with new guidelines (5 days for impetigo; 7-10 for folliculitis)
    • Expanded advice/monitoring section
    • Updated PAR and algorithm.  PAR includes new autofill short-form.

March 13, 2016

  • Updated oral thrush guideline:
    • Aligned the red-flags for referral to be consistent with current recommendations
    • Added risk factors for thrush to "Description" section
    • Added three types of thrush under "Signs and symptoms" section
    • Added leukoplakia and aphthous ulcer as differential diagnoses
    • No changes to treatment or monitoring recommendations
    • Aligned algorithm and PAR to be consistent with the guidelines
    • PAR now has the new auto-fill short-form
    • Overhauled algorithm and PAR

March 8, 2016

  • Updated oral aphthous ulcer guideline:
    • Added minor, major and herpetiform ulcer symptoms
    • Significant update to "When to Refer" section to better align with current guidelines
    • Added a few non-pharmacologic treatments.  Other treatments remain unchanged.
    • Added directions for using triamcinolone dental paste
    • Added OTC product table to product section
    • Significant content and format changes to algorithm (to better reflect changes to the when to refer section)
    • Significant content and format changes to PAR (including the new auto-fill short-form)

March 5, 2016

  • Updated Hemorrhoids guideline:
    • Added goals of therapy under treatment
    • Added when to choose certain formulations (ointment vs. suppository) under treatment
    • Added OTC product table under "products"
    • Updated algorithm to be consistent with other guidelines
    • Updated PAR: includes new auto-fill short-form, which can be sent to the doctor as the required documentation.

March 3, 2016

  • Updated Musculoskeletal Strains and Sprains
    • Added "grades" of sprains and strains to description section
    • Signs and symptoms section expanded to include how to do an assessment
    • Expanded RICE therapy section under treatment
    • Monitoring, OTC and Rx options remain unchanged
    • Updated algorithm to be consistent with other guidelines
    • Updated PAR: includes new auto-fill short-form, which can be sent to the doctor as the required documentation.

February 25, 2016

  • Updated headache guideline:
    • Added signs and symptoms for cluster headache
    • Added details of questions to ask the patient
    • Updated diagnosis of migraine and medication-overuse headache according to newest IHS guidelines
    • Added drug interaction info for triptans
    • Added section on how to choose the best triptan for a particular patient under treatment
    • Added details to monitoring/follow up
    • Revised PAR and algorithm to standard format.  PAR includes new auto-fill short-form, which can be sent to the doctor as the required documentation.

February 11, 2016

  • Updated dysmenorrhea guideline:
    • Expanded differential assessment section by including several other conditions
    • Clarified some of the red flags
    • Added non-pharm and more OTC treatment options
    • Expanded monitoring section by adding goals of therapy
    • Major revisions to algorithm to be more clear and reflect current guidelines
    • Updated PAR to include above changes and the new auto-fill short form, which can be sent to the doctor as the required documentation.

February 8, 2016

  • Updated diaper dermatitis guideline:
    • Added risk factors and epidemiology to description
    • Added more red flags for referral to be consistent with current guidelines
    • Minor updates and corrections to other sections
    • Clarified treatment duration (7days + 7 at follow up if some improvement)
    • Revised algorithm to be more clear and consistent with standard format, and newest guidelines
    • Updated PAR to include revision and the new autofill short-form.

February 4, 2016

  • Updated Cold Sore guideline:
    • Added risk factors and triggers to description section
    • Added transmission info under signs and symptoms
    • Clarified details with some differential assessment conditions
    • Aligned red-flags for referral with other guideline recommendations:
      • Removed age limit of <12 years.  Can prescribe acycvloir if between 2 and 12
      • Removed renal dysfunction as a red flag
      • Added frequent recurrences (>6 per year), as prophylaxis is more appropriate
    • Added renal and pediatric dosing to treatment section
    • Clarified when oral antiviral prescriptions are appropriate.
    • Updated algorithm to modern format and some content changes to be more clear.
    • Updated PAR form, including a short-form that is automatically filled in.  This short-form is all you need to send to the patient's doctor to comply with the requirements of the program.

February 1, 2016

  • Updated Atopic Dermatitis guideline:
    • Updated signs and symptoms to include primary and secondary atopic dermatitis, as well as acute and chronic differentiation
    • Added some details to description section, including risk factors
    • Added more conditions (tinea corporis, cutaneous T-cell lymphoma, drug-induced) to the differential assessment section
    • Added goals of treatment to treatment section
    • Added more details about non-pharmacologic methods of optimal skin care
    • Added more patient counselling tips and monitoring parameters
    • Updated algorithm to standardized format
    • Updated PAR form, including a short-form that is automatically filled in.  This short-form is all you need to send to the patient's doctor to comply with the requirements of the program.

January 28, 2016

  • Updated Allergic rhinitis guideline:
    • Definition of intermittent and persistent updated to match new guidelines from American Academy of Otolaryngology
      • Intermittent: symptoms <4 days per week and <4 weeks consecutive
      • Persistent: symptoms  >4 days per week and >4 weeks consectuvie 
      • Algorithm and PAR also updated to reflect this change

    • Updated PAR form, including a short-form that is automatically filled in.  This short-form is all you need to send to the patient's doctor to comply with the requirements of the program.

January 26, 2016

  • Updated Acne guideline:
    • Most notable content change:  non-pharmacologic therapy for 8 weeks no longer required before proceeding to prescription treatment
    • Updated algorithm
    • Updated PAR form, including a short-form that is automatically filled in.  This short-form is all you need to send to the patient's doctor to comply with the requirements of the program.

August 19, 2015

  • Superficial bacterial infections (Impetigo, folliculitis):
    • New impetigo guidelines from IDSA recommend treatment duration of 5 days with mupirocin (down from 7 days)
    • New data provides conflicting evidence whether removal of impetigo crusts is necessary for antibiotic absorption.
    • Updated the guidelines, algorithm and PAR to reflect this new information.

May 12, 2015

  • Cold sores
    • Clarified the assessment section of the PAR, eg. when you can prescribe or not
    • Added option to prescribe acyclovir suppressive therapy if anticipated exposure to a trigger coming (eg. prolonged sun exposure) -- updated on PAR, algorithm and main guideline.

April 6, 2015

  • GERD: OTC omeprazole (20 mg) added to algorithm and guidelines information
    • Included in OTC options
    • Information in guidelines about using  OTC as on-demand or intermittent therapy in subsequent episodes
  • GERD:  More clearly defined timelines for discrete recurrences and potential rebound symptoms; incorporated into algorithm and PAR
  • Allergic Rhinitis: removed triamcinolone acetonide from prescription options

March 9th, 2015 (clarified Sep 13, 2016)

  • Removed hydrocortisone 1% as prescription options for insect bites, diaper dermatitis and atopic dermatitis for patients over 2 years of age.
    • PARs and algorithms updated
    • If the patient is under 2 years of age, hydrocortisone 1% is still a prescription product, thus you can bill a minor ailment assessment fee for that product.

December 18th, 2014

  • Dysmenorrhea, Headache and Musculoskeletal pain guidelines:
    • Added more detailed description of cardiovascular / cerebrovascular concerns when prescribing NSAIDs or triptans under "Treatment" section for all three guidelines
    • Updated PAR to included cardiovascular / cerebrovascular disease recommendations

October 7, 2014

  • Added new safety information about NSAIDs, particularly diclofenac, in the headache, dysmenorrhea and musculo-skeletal pain guidelines.
  • New dosing maximum for diclofenac in headache, dysmenorrhea, and musculo-skeletal pain guidelines. 

Sept 30, 2014

  • Clarified "review of symptoms" section on atopic dermatitis in the PAR

July 29, 2014

  • Guideline updates will now be tracked and posted here
  • Added a "billing details" section to all guidelines, which includes:
    • The pseudoDIN to bill the assessment fee to the drug plan (pseudoDIN also now appears in the PAR)
    • Quantity and refill limits (also now appears in the PAR)
    • Any other prescribing details specific to a condition will be listed in this section
  • Removed brand-specific DINs from "products" section.  Only active ingredients approved for the minor ailment will be listed.
Introduction to Minor Ailment and Self-Care Prescribing

I Background

The Pharmacy Act, 1996 was originally amended effective September 1, 2003 giving pharmacists authority to prescribe drugs which at that time was limited to emergency contraception. On March 3, 2010 the Saskatchewan Minister of Health announced his intention to approve regulations and bylaws expanding this authority to other drugs. In the meantime, stakeholders from various groups involved in drug management (e.g. physicians, nurses, dentists, pharmacists, etc.) were involved in the Advisory Working Group which developed the policies for pharmacist prescribing. The Saskatchewan College of Pharmacists Council approved these policies and drafted the regulations and bylaws awaiting ministerial approval.

Level 1 of enhanced prescribing authority for pharmacists includes the provision for pharmacists to prescribe Schedule 1 drugs for the treatment of minor, self-limiting and self-diagnosed ailments such as rashes, cold sores and hay fever. Similar minor ailment models have been piloted and implemented in Great Britain within the past decade. Preliminary data from Britain suggests that these programs have increased access for the public to healthcare for minor ailments, increased access to physicians for patients with more serious conditions and reduced costs to the national healthcare system. In Nova Scotia, legislation approving expanded prescribing authority for pharmacists including prescribing for minor ailments has just been passed. Similar programs are being considered in many other Canadian provinces.

In a minor ailment program, the pharmacist is the first point of contact for the patient. The patient approaches the pharmacist for advice about treatment of a self-diagnosed condition. If the self-diagnosis is reasonable based on the pharmacist’s assessment and the best treatment option in the pharmacist’s judgement is a Schedule 1 drug, the pharmacist can initiate a prescription. If the pharmacist is unable to confirm the patient’s diagnosis and / or the patient’s symptoms are severe, the pharmacist will refer the patient to a physician or other appropriate healthcare provider. The prescribed drug must be (1) listed in minor ailment guidelines and (2) have an approved indication for the patient’s self-diagnosed condition. The pharmacist is required to record the prescription with the Pharmaceutical Information Program and to notify the patient’s physician of the prescription. Physician or other practitioner authorization is required for repeat or maintenance therapy.

II Developing the Minor Ailment Guidelines

The Saskatchewan Drug Information Service was contracted by the Saskatchewan College of Pharmacists to prepare the Minor Ailment guidelines. The first step was to review the literature and consult with other Canadian pharmacy organizations. From this information, a list of conditions that could potentially qualify as minor ailments and a list of prescription drugs that might be suitable for patient self-care of these conditions were compiled. The next step was consultation with Saskatchewan community pharmacists through nominal group meetings; the first in Saskatoon, Jan. 5th, 2010 and the second in Regina. Jan. 12th, 2010. The groups were asked to (1) select criteria to define minor ailments and prescription drugs appropriate for pharmacists to prescribe for these conditions and (2) to apply these criteria to select specific conditions and drugs to be included in Saskatchewan minor ailment program. The results from the group meetings are summarized below.

Suggested criteria for Minor Ailment conditions

  • Can be reliably self-diagnosed by patient
  • Self-limiting condition
  • Laboratory tests are not required for diagnosis
  • Treatment will not mask underlying conditions
  • Medical and medication histories can reliably differentiate more serious conditions
  • Only minimal or short-term follow-up needed

Suggested criteria for prescription drugs suitable for pharmacist prescribing for patient minor ailments

  • Has an official indication for the self-care condition
  • Has valid evidence of efficacy for the self-care condition
  • Has wide safety margin
  • Not subject to abuse
  • Dosage regimen for treatment of self-care conditions is not complicated

 Using these criteria, the conditions and Schedule I drugs listed in Table 1 were considered appropriate for the Minor Ailment program.

TABLE 1: Schedule I drugs appropriate for prescription by pharmacists for specified minor ailment or self-care conditions

System

Condition

Drug Class

Specific Rx Drug

CNS

Headache and Migraine

NSAIDs

ibuprofen all strengths
naproxen all strengths
diclofenac

Triptans

(Appropriate for self-diagnosis of recurrences but initial diagnosis should be made by physician)

almotriptan
naratriptan
rizatriptan
sumatriptan
zolmitriptan
eletriptan (non-formulary)
frovatriptan (non-formulary)

Eyes, Ears, Oral

 

 

 

Cold sore

Antivirals (topical, oral)

acyclovir cr/oint/oral
famciclovir 
valacyclovir

Mouth ulceration
(mild)

Corticosteroids (dental)

triamcinolone dental paste

Oral thrush

Antifungals (oral)

nystatin drops

Dermatology

Acne (mild – mod.)

Benzoyl peroxide

benzoyl peroxide (BP) up to 10 %

Antibiotics (topical)

clindamycin phosphate
clindamycin / BP
clindamycin / tretinoin
erythromycin / BP
erythromycin / ethyl alcohol /avobenzone/octinoxate  
erythromycin / tretinoin

Retinoids

adapalene cr 0.1%, 0.3%; gel 0.1%
adapalene 0.1%/BP 2.5%
tazarotene 0.05%,0.1% cr or gel
tretinoin cr or gel all strengths 
tretinoin/avobenzone/octinoxate cr all strengths

Atopic dermatitis (mild – moderate)

Corticosteroids, low  - moderate potency (topical)

hydrocortisone cream 1 %, 2.5 %
desonide 0.05 %
betamethasone valerate
clobetasal butyrate
diflucortolone valerate
hydrocortisone valerate
mometasone furoate
triamcinolone acetate

Diaper rash

Antifungal / corticosteroids (topical)

clotrimazole hydrocortisone 1 % cr / oint

Insect bites

Mild corticosteroids

hydrocortisone 1 % cr/oint

Skin infections
(bacterial)

Antibiotics (topical)

fucidic acid cr/oint
mupirocin cr/oint

Tinea infections (athlete’s foot, jock itch, ringworm)

Antifungal (topical

terbinafine 1 % cr
ketaconazole 2 % cr

Gastrointestinal

Dyspepsia / GERD

H2 Receptor antagonists

cimetidine 300, 400, 600 mg
famotidine 40 mg
nizatadine 150, 300 mg
ranitidine 150, 300 mg

PPIs

esomeprazole 20, 40 mg
lansoprazole 15, 30 mg
omeprazole 10, 20 mg
pantoprazole 40 mg
rabeprazole 10, 20 mg

Hemorrhoids

Corticosteroid combinations (rectal)

HC / zinc sulphate
HC /  zinc sulfate, pramoxine

Genitourinary

Dysmenorrhea

NSAIDs

celecoxib
diclofenac
ketoprofen
mefenamic acid
naproxen sodium

Musculoskeletal

Pain

NSAIDS

diclofenac
diclofenac/misoprostol
naproxen

Cox-2 Inhibitors

celecoxib
meloxicam

Respiratory

Allergic rhinitis

Intranasal antihistamine

levocabastine

Intranasal corticosteroids

beclomethasone
mometasone furoate
fluticasone proprionate

TABLE 2: Schedule I drugs appropriate for pharmacists to prescribe under the circumstances described below:
NOTE: SASKATCHEWAN PHARMACISTS ARE NOT CURRENTLY AUTHORIZED TO PRESCRIBE FOR THESE 
CONDITIONS ALTHOUGH THEY HAVE BEEN APPROVED IN PRINICPLE BY THE SASKATCHEWAN COLLEGE OF PHARMACY PROFESSIONALS COUNCIL.

a) Self-diagnosed recurrences of specified conditions after initial diagnosis or assesment for underlying conditions by physician or nurse practitioner

  • Conditions
    • Uncomplicated lower urinary tract infection (UTI)
    • Erectile dysfunction (ED)
    • Onychomycosis
  • Patient history of previous medical diagnosis of condition and assessment of risk factors is a requirement before pharmacists can prescribe for these conditions, otherwise the patient must be referred to a medical doctor or nurse practitioner (or podiatrist in case of onychomycosis) for initial evaluation and diagnosis.
  • There is limited information on the length of time a prior diagnosis or assessment would be valid, so this will be left up to the judgement of the pharmacist. (For example, anecdotal reports suggest women who have had a previously confirmed episode of UTI would be able to recognize symptoms of a recurrence many years after the initial occurrence.)
  • Check PIP and/or pharmacy records) for medication used to treat previous episodes.
  • Check eHR Viewer if lab tests, culture results are relevant to prescribing.

b)  Pharmacists have access to additional training on assessment and prescribing criteria for these conditions

  • Conditions
    • Pharyngitis
    • Influenza
    • Conjunctivitis
    • Shingles
  • Training on throat swab technique and analysis, relevant physical assessment and antimicrobial stewardship prescribing guidelines for these conditions will be provided for pharmacists.
  • Pharmacist prescribing of oral antiviral agents will be authorized ONLY during an epidemic or pandemic declared by the Chief Medical Health officer for Saskatchewan

 c) Health promotion / wellness services

  • Conditions
    • Contraception, ongoing: hormonal contraceptives (HC)
    • Emergency contraception (EC)
    • Obesity
    • Smoking cessation
  • Comprehensive training on assessment, prescribing and monitoring of HCs, providing EC and family planning counselling (including long acting reversible and permanent contraceptive options) will be provided for pharmacists. When non-hormonal contraception is the most appropriate or preferred option, the patient will be referred to a medical doctor or nurse practitioner.
  • Prescribing for smoking cessation or obesity should be part of an overall lifestyle change program for smoking cessation (e.g., PACT) or weight loss whenever possible to increase the likelihood of successful therapy.

Condition

Drug Class

Specific Rx Drug

Comments

Conjunctivitis, allergic

Antihistamines, mast cell stabilizers (Ophth)

 

ketotifen drops
olapatadine drops
lodoxamide drops
nedocromil drops

Concern about patient ability to differentiate between bacterial and allergic conjunctivitis

Conjunctivitis, bacterial

Antibiotics (Ophth)

erythromycin oint.
trimethoprim-polymixin drops
tobramycin oint., drops

As above. Anecdotal reports of resistance to gentamicin ophthalmic drops.

Contraception, emergency

levonorgestrel
ulipristal acetate

Contraception, ongoing

Hormonal contraceptives

combined estrogen/progestin: oral, dermal patch, vaginal
Progestin-only oral

Erectile dysfunction

PDE inhibitors

sildenafil
tadenafil
vardenafil

Concerns about recreational use, abuse.

Herpes zoster (Shingles)

Antivirals (oral)

acyclovir
famciclovir 
valacyclovir

Suggested as possibly appropriate. No precedent found in the literature

Influenza treatment / prophylaxis

Antivirals

oseltamavir
zanamavir

Concerns about inappropriate use, resistance

Obesity

Lipase inhibitor

orlistat

Obesity not considered a self-limiting condition

Onychomycosis

Antifungal, topical

efinaconazole

Medical guidelines recommend microscopy of nail scrapings to diagnosis and culture if uncertainty

Pharyngitis (Sore throat)

Local analgesics
Antibiotics

benzydamine
penicillin V
amoxicillin
cephalexin
clindamycin
clarithromycin
azithromycin

Concern regarding masking strep throat

Urinary tract infections in women

Antibiotics

co-trimoxazole
fosfomycin tromethamine
nitrofurantoin
trimethoprim

Appropriate for self-diagnosis of recurrences but initial diagnosis should be made by physician.

 Participants in the group meetings suggested that the following information should be included in the guidelines:

  • Information used by physicians for diagnosis
  • Time frame for follow-up with patients
  • When to refer patients to family physician
  • Comparisons of drug efficacy, side effects, etc. to help in choice of drug to prescribe.
  • Age restrictions
  • Drug dosage protocols
  • Limitations on quantity of drug prescribed / duration of treatment.

III Guideline Format/Content

The purpose of the guidelines is to provide community pharmacists with tools to facilitate the decision-making and documentation processes of prescribing for minor ailments self-diagnosed by patients. Each guideline consists of three documents; (1) an overview of pathophysiology, patient assessment and treatment for each condition (2) a treatment algorithm and (3) an assessment and treatment checklist.

1. Overview

  • Brief description of pathophysiology and epidemiology of condition
  • Common symptoms - To assess patient self-diagnosis.
  • Differential diagnosis / when to refer – alternative diagnoses, patient characteristics (e.g. age, concurrent medical conditions), red flag symptoms that could indicate more serious conditions 
  • Non-pharmacological treatment
  • Over-the-counter drug options
  • Schedule 1 drug options appropriate for pharmacist prescribing – points to consider in choosing which agent to prescribe
  • Advice/Monitoring parameters  - special directions for use, onset of effect, when to follow-up with patient, when to refer to physician, advice on prevention, etc.

2. Algorithm

  • Visual treatment decision tree for quick reference

3.  Pharmacist Assessment / Treatment Checklist

  • Checkbox list of criteria for diagnosis confirmation, physician referral and choice of treatment (recommendations and / or prescription)
  • Can be copied to fax to physician
  • Can serve as documentation of patient intervention

Document prepared by Karen Jensen MSc, BSP
Manager, Saskatchewan Drug Information Service
April 28, 2010