Kristene Diggins, FAANP, CNE, NEA-BC, DNP, DCC, MBA

Analgesics—particularly acetaminophen and ibuprofen&mdash;are among the most commonly used medications in primary care. Indeed, they are often the first-line choice for symptom relief for patients visiting retail clinics.

Even though acetaminophen and ibuprofen are OTC medications, it is vital that practitioners understand how to recommend them properly, especially in conjunction with other medications that may be prescribed. It is equally important to consider the risk-benefit ratio when recommending any medication, including both prescription and nonprescription products.

Knowing the patient’s past and current medical history will assist the practitioner in developing a symptom relief strategy with ibuprofen and/or acetaminophen.

Although the efficacy of alternating ibuprofen and acetaminophen has been questioned, the drugs’ individual safety and efficacy are well proven.

To avoid side effects and unintended consequences from potential interactions, analgesics should be taken at the lowest effective dose for the shortest period of time.

For providers in convenient care settings, the main focus must be 2-fold: immediate relief of the patient’s pain and management of the underlying condition. In order to manage the pain and condition effectively, the practitioner must understand the importance of dose efficacy.

provide a reference to potential interactions for both ibuprofen and acetaminophen.

Upon review of the patient’s medication history and any pertinent interactions, it is prudent for the practitioner to review standard OTC dosing for patients. It can be very useful to provide patients with a basic overview of dosing for both acetaminophen and ibuprofen based on the patient’s age and weight. Convenient care practitioners are perfectly situated to provide this level of detailed recommendation for each and every patient to ensure that OTC medication regimens are understood and managed at every clinic visit.

Table 2: Potential Ibuprofen Interactions

Interferes with prothrombin coagulation cascade

Advise against concurrent ibuprofen use with aspirin.

Advise strict adherence to ibuprofen dosing recommendations.

Increases sensitivity of prothrombin/thrombin cascade

Advise patient against concurrent ibuprofen use with DMARDs.

Interacts with apixaban’s therapeutic dosing regimen and increases sensitivity of prothrombin/thrombin cascade

Advise against concurrent ibuprofen use with apixaban.

(elvitegravir, cobicistat, emtricitabine, tenofovir DF)

Interacts with anticoagulant effects and increases sensitivity of prothrombin/thrombin cascade

Advise against concurrent ibuprofen use with Stribild.

DMARDs = disease-modifying antirheumatic drugs; GI = gastrointestinal; NSAIDs = nonsteroidal anti-inflammatory drugs.

is a corporate senior educator at MinuteClinic and faculty member of the University of Phoenix. She has worked as a provider in convenient care for 9 years and enjoys international medical opportunities, as her career goal is to enhance health care access globally.

Moore N, Pollack C, Butkerait P. Adverse drug reactions and drug—drug reactions with over-the-counter NSAIDs.

Bozimowski G. A review of nonsteroidal anti-inflammatory drugs

Murphy R, Swartz R, Watkins PB. Severe acetaminophen toxicity in a patient receiving isoniazid.

1990;113(10):799-800. [Correction: Acetaminophen toxicity.

Articles

Analgesics, particularly acetaminophen and ibuprofen, are among the most commonly used medications in primary care.

Safe and Effective Use of Common OTC Analgesics in Convenient Care

Although her body was aging, Susan walked into the clinic with an air of confidence and her head lifted high.

Before I had the chance to ask her how she was doing, she started to tell me her story. Even though she had only come to the clinic for a cough, her story added a dimension to her visit that I hadn’t seen coming.

In a brief moment, I learned how Susan had recently been through many tragedies. She had lost her husband in the past year, and her grandson had died suddenly in the past month. She shared with me that her grandson had been in his final year at Princeton University with a promising future ahead.

With tears in her eyes, Susan told me how her grandson had been diagnosed with a simple headache at the local emergency room during his last year of college, only to discover a day later that he had bacterial meningitis. Within a few days, his life was claimed by this condition.

As tears flowed down Susan’s cheeks, I nearly forgot why she was at the clinic. I embraced her in that moment and was reminded of my privilege as a nurse practitioner to stand alongside my patients as they share their life stories.

The privilege of being nurse is not quantifiable. It is somewhere in the middle of a patient’s story when the nursing role thrives.

There was evident relief and refocus in Susan’s demeanor as she let her tears flow. I squeezed her hand and prepared to examine her. As I reached over Susan to listen to her lungs, I was struck by the fact that I now had a clear picture of the whole patient.

Knowing Susan’s story and her present condition allowed me to create a care plan that embraced the totality of who she was in that moment. After sharing this care plan with Susan, I squeezed her hand one more time, and then she walked out of my clinic and my life. I wondered if she knew how much her story had enriched my own journey as a nurse practitioner in that moment.

When Susan left that day, I thought about the immense privilege of the nursing aspect of the nurse practitioner’s role. As a nursing-based health care provider, it is an honor to embrace the totality of each patient’s humanity.

Hearing stories like Susan’s and taking each patient’s individuality into account allows me to craft care plans that encompass the holistic needs of the patient and focus on the particular journey of each person.

Kristene Diggins, FAANP, CNE, NEA-BC, DNP, DCC, MBA, is a Corporate Senior Educator at MinuteClinic and faculty at the University of Phoenix. She has worked as a provider in convenient care for 9 years and she enjoys international medical opportunities, as her career goal is to enhance health care access globally.

It is somewhere in the middle of a patientâ€™s story when the nursing role thrives.

The True Privilege of Nurse Practitioners

Diabetic neuropathy (sometimes referred to as “diabetic nerve pain”) is a medical term for a type of nerve damage that can happen if you have diabetes. All patients with diabetes are at risk of developing diabetic neuropathy, so it is important to understand its causes.

Diabetic neuropathy develops when blood sugars are high for long periods of time and the nerves in the legs and feet become damaged and start to cause pain.

After years of diabetes, it is common to start seeing signs and symptoms of diabetic neuropathy. It is important to note that the condition develops slowly, and you may not notice the symptoms until after many years of high blood sugar. The symptoms of diabetic neuropathy include pain, and numbness in your legs and feet. Sometimes these symptoms can be very painful and dangerous to your health as the circulation or sensation in your legs and arms is decreased.

There are 4 main types of diabetic neuropathy: peripheral neuropathy, autonomic neuropathy, radiculoplexus neuropathy, and mononeuropathy. As a person with diabetes, you can have one type of neuropathy or several different types. Although the symptoms of these different types of neuropathy are slightly different, all types of neuropathy cause cramping, pain, and tingling sensations. The most common type of neuropathy is peripheral neuropathy. Peripheral neuropathy often starts in the feet and then moves up to the hands and arms (your peripheral limbs). Although the main symptoms often include numbness and pain, additional signs of diabetic neuropathy include:

WHAT ARE THE RISK FACTORS ASSOCIATED WITH DIABETIC NEUROPATHY?

Some of the risk factors associated with diabetic neuropathy include:

Being overweight or obese. A person is obese if their body mass index (BMI) is greater than 30, and overweight if it is greater than 25. A BMI over 25 puts a person with diabetes at greater risk for diabetic neuropathy.

Having diabetes for a long period of time. The longer you have diabetes, the greater your risk of developing diabetic neuropathy. It is most common to develop the condition after about 10 years of being diabetic. With each passing year, it becomes even more important to keep your blood sugar under control in order to avoid diabetic neuropathy.

High blood sugar. High blood sugar is the greatest risk factor for complications with diabetes, including nerve damage. One of the ways to avoid complications is to keep your blood sugar in the range set by you and your health care provider.

Smoking. Because of the damage that smoking does to your heart, lungs, and overall health, it is the greatest risk factor for complications with diabetes. This is especially true if you have diabetic neuropathy, since smoking hardens your arteries making blood flow to your feet more difficult.

Like diabetes, diabetic neuropathy has no known cure. Because of this, treatment focuses on:

The most important focus of diabetic neuropathy treatment is pain relief. Not everyone responds well to the same treatments for pain relief, so your health care provider will often try several different approaches to help relieve your pain. Some people do well with acupuncture, massages, or alternative therapies for pain relief. Patients are often looking for pain relief and need to find ways to manage their pain on a daily basis. There are many different types of medications that may help relieve the pain of diabetic neuropathy that you can discuss with your health care provider, such as:

Anti-seizure drugs. The drugs in this class include gabapentin (Neurontin), pregabalin (Lyrica), and carbamazepine (Tegretol, Carbatrol). These drugs are used to treat seizure disorders and can be prescribed to help with your nerve pain.

They work by calming the nerves associated with diabetic neuropathy, reducing the stabbing pain that is caused by the condition.

Antidepressants. Antidepressants are another type of drug that may be used to treat diabetic neuropathy. Examples of these drugs include amitriptyline (Elavil), desipramine (Norpramin), imipramine (Tofranil), and duloxetine (Cymbalta). Antidepressants work in diabetic neuropathy by blocking pain messages on their way to your brain.

Pain relievers. Pain relievers such as, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and aspirin are often helpful to treat the discomfort associated with diabetic neuropathy. NSAIDs work by reducing inflammation.

Anesthetic creams. Anesthetic creams such as lidocaine, capsaicin, and others

are a great option for patients with diabetic neuropathy, as they numb the specific area of your skin where the pain is located. Your health care provider will prescribe what works best for you.

IS THERE A WAY TO AVOID DIABETIC NEUROPATHY?

Diabetic neuropathy is a common complication of diabetes. It is important to be aware of the risk of this condition and the symptoms so that treatment and foot care are started as early as possible. The American Diabetes Association recommends a detailed foot exam for all patients with diabetes every year.

During this exam, the provider will check for sores, blisters, and circulation in your feet. In addition, the patient should ensure the following:

Keep blood pressure under control. Since patients with diabetes are more likely to have high blood pressure, it is very important to try to keep it under control to reduce the risk of diabetic neuropathy. High blood pressure damages your blood vessels, and when present with diabetes, puts you at a great risk for diabetic neuropathy.

Eat healthy every day. Remember, it is very important to include fruits and vegetables in your daily food choices and to avoid fats to keep your nerves and arteries healthy and prevent hardening in your arteries.

Stay active. The American Heart Association and the American Diabetes Association generally recommend about 30 minutes of moderate exercise a day at least 5 times a week.

Staying active will keep your heart in shape and your arteries from hardening, helping the circulation to the nerves in your hands and feet.

Keep feet clean and dry. Wash your feet every day with lukewarm water and mild soap. Avoid soaking your feet. Dry your feet carefully, including the area between your toes, by blotting or patting with a soft towel. Keep your feet moisturized, but be sure not to put lotion between your toes since this can cause fungal infections. Although the moisture will help keep your feet from drying out, too much moisture can make it easier for fungus to grow around your feet.

Cut your toenails with caution. Make sure you always cut in a straight line to keep your nails from growing into your skin and causing infection. Keeping your nails evenly trimmed will prevent ingrown nails and other problems that can lead to infection.

Wear good shoes. It is very important to wear shoes that protect your feet.

Make sure your shoes fi t well, especially around your toes. Make sure your socks are always clean to avoid infection and fungus. Good orthopedic shoes will help support your feet and protect them from injuries.

Although diabetic neuropathy is a problem that causes pain for diabetics in their hands and feet, there are many ways to help decrease the pain and help protect your feet from infection. Following these basic tips can help ensure that diabetic neuropathy does not worsen or cause problems for your feet, as you strive to achieve your active, healthy living goals!

Kristene Diggins, FAANP, CNE, NEA-BC, DNP, DCC, MBA is a doctorally prepared nurse practitioner (NP) who has recently completed her MBA. Dr. Diggins works as the manager of professional practice for MinuteClinic, striving to enhance the practice of convenient care for patients and providers. She has worked as a provider in convenient care for 8 years and also teaches as NP adjunct faculty for Kaplan University and the University of Phoenix online. Kris enjoys international medical opportunities, as her career goal is to enhance health care access, globally.

Neuropathy (nerve damage). American Diabetes Association website. www.diabetes.org/living-with-diabetes/complications/neuropathy.

Feldman EL, McCulloch DK. Treatment of diabetic neuropathy. UpToDate website. www.uptodate.com/contents/treatment-of-diabetic-neuropathy.

Griebeler ML, Morey-Vargas OL, Brito JP, et.al. Pharmacologic interventions for painful diabetic neuropathy: An umbrella systematic review and comparative effectiveness network meta-analysis.

2014;161(9): 639-649. doi: 10.7326/M14-0511.

Kiani J, Sajedi F, Nasrollahi SA, Esna-Ashari F. Topical clonidine and capsaicin in the treatment of diabetic neuropathy.

Foot care. American Diabetes Association website.

http://www.diabetes.org/living-with-diabetes/complications/foot-complications/foot-care.html

. Updated October 10, 2014. Accessed August 26, 2015.

American Heart Association recommendations for physical activity in adults. American Heart Association website.

www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/FitnessBasics/American-Heart-Association-Recommendations-for-Physical-Activity-in-Adults_UCM_307976_Article.jsp

Steps to prevent or delay nerve damage. American Diabetes Association website.

www.diabetes.org/living-with-diabetes/complications/neuropathy/steps-to-prevent-or-delay.html

All patients with diabetes are at risk of developing diabetic neuropathy, and thus it is important to understand its causes.

Taking Steps to Prevent Diabetic Neuropathy

Advanced practice clinicians are often faced with difficult decisions in the management of medications for patients with diabetes who present to the convenient care clinic. As children prepare to go back to school, advanced practice clinicians in local convenient care clinics can collaborate with pharmacists to determine the individual risk factors for each patient.

In diabetes management, individualized treatment regimens start with behavior modification. In addition, medications are often required to achieve glycated hemoglobin (A1C) goals. Patients and their families may be unaware of the importance of medication adherence in the management of diabetes, however.

Children with diabetes often struggle with understanding medication administration and injectable routes

and frequently lack the motivation to maintain medication adherence. They tend to do best when families are involved to help manage prescriptions. Because of this, adherence counseling efforts for this population are often targeted at the caregivers.

Advanced practice clinicians are perfectly suited to collaborate with other professionals, such as pharmacists, on the medication counseling needed for children and adolescents with diabetes. This type of interprofessional care of medication regimens promotes the Institute of Medicine’s 6 goals in evidence based medicine: patient centeredness, effectiveness, efficiency, safety, timeliness, and equitability.

The emphasis on initiating and addressing medication counseling is particularly important because only 20% to 30% of chronic disease medications are refilled by patients with diabetes and other chronic diseases.

Pharmaceutical counseling should be considered for patients with diabetes who present to the convenient care setting with any complaint. Medication counseling in this model of care delivery will allow for collaboration between the patient, family, and other health care professionals. This team approach has been shown to be an effective method of improving medication regimen efficacy and adherence.

The convenient care setting is a pivotal framework for implementation of such care, as children present with a myriad of complaints that are often unrelated to their diabetes and medication regimen.

In a recent study, 100 patients who were on a regimen of 4 or more medications and who had a diagnosis of uncontrolled diabetes (A1C >7.5) were selected for collaborative diabetes medication counseling and management. The A1C levels of the patients were measured at the beginning and end of the intervention period. At the onset of project implementation, patients on the polypharmaceutical regimen were seen by a nurse practitioner (NP) who reviewed the patient’s medication regimen in depth. The patients were then referred to a pharmacist to answer any patient questions. Each medication was reviewed and determinations were made regarding the best time of day to take medications and whether combination drugs might be available to replace multiple prescriptions. Cost was also reviewed, and the best options were considered. Patients at high risk for medication errors and nonadherence were counseled, along with their caregiver, on the importance of medication adherence.

Following the meeting with the pharmacist, the NPs worked with patients and their families to identify areas of medication nonadherence, answering questions on existing prescriptions and emphasizing the importance of the maintenance regimen for diabetes. Six months after implementation of the care plans, follow-up A1Cs were reviewed. The results demonstrated a statistically significant improvement in the A1C levels, which shows that there may be value in advanced practice clinicians, such as NPs, initiating pharmaceutical counseling with patients and their families in the community setting.

With the advent of the school year and flu season soon after, advanced practice clinicians will have ample opportunities to implement drug therapy counseling in conjunction with a multidisciplinary team. Advanced practice clinicians can provide an important foundation in the convenient care setting for medication management for children with diabetes and their families, as collaboration among professionals is pivotal for medication adherence.

Kristene Diggins is a doctorally prepared nurse practitioner (NP), who has recently completed her MBA. Dr. Diggins works as the manager of professional practice for MinuteClinic, striving to enhance the practice of convenient care for patients and providers. She has worked as a provider in convenient care for 8 years and also teaches as NP adjunct faculty for Kaplan University. Kris enjoys international medical opportunities, as her career goal is to enhance health care access, globally.

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Kristene Diggins, FAANP, CNE, NEA-BC, DNP, DCC, MBA

Articles

Safe and Effective Use of Common OTC Analgesics in Convenient Care

The True Privilege of Nurse Practitioners

Taking Steps to Prevent Diabetic Neuropathy

Collaborative Diabetes Medication Management: Advanced Practice Clinicians Working with Pharmacists