Over-the-Counter Medicines: Triage, Referral Criteria and When to Refer

OTC Medicines and the Pharmacist's Role

Over-the-counter (OTC) medicines are those available without a prescription — either as Restricted Medicines (Part II, requiring pharmacist supervision), Pharmacy-Only Medicines (Part III), or General Sale Medicines (Part IV) under the Medicines Act 1981. The pharmacist's role in OTC consultations is to act as a gatekeeper: providing appropriate self-care advice and OTC products when suitable, while identifying presentations that require medical referral.

OTC consultations are among the most common interactions in community pharmacy. A structured approach is essential to differentiate minor self-limiting conditions from those requiring medical assessment.

Structured Consultation Frameworks

WWHAM (Who, What, How long, Action taken, Medicines) is the most widely used framework in NZ community pharmacy. It guides systematic information gathering before recommending a product or referring.

SIT DOWN SIR is an alternative mnemonic for patient history: Site/Severity, Intensity, Type of symptom, Duration, On/Off (pattern), When did it start, Nurse/Doctor consulted, Self-treatment, Investigations, Referral decision.

Both frameworks direct the pharmacist to collect information before recommending any product.

Triage Categories

Green (self-care): Minor, self-limiting condition amenable to OTC treatment. Examples: mild tension headache, common cold, mild hay fever, athlete's foot, uncomplicated cold sore, simple dyspepsia.

Amber (pharmacist intervention/advice without referral): Conditions requiring pharmacist guidance but not urgent medical review. Examples: moderate allergic rhinitis requiring antihistamine counselling, vaginal thrush (first episode in women >16 years), mild UTI symptoms in otherwise healthy non-pregnant women aged 16–65 (depending on local protocol).

Red (urgent/emergency referral): Symptoms suggesting serious pathology requiring same-day medical assessment or emergency services. Red flags include: chest pain or tightness; sudden severe headache ("thunderclap headache" — possible subarachnoid haemorrhage); symptoms of stroke (FAST: Face drooping, Arm weakness, Speech difficulty, Time to call 111); significant dyspnoea; blood in urine, stool, or vomit; unexplained weight loss; jaundice; high fever with rash; severe abdominal pain; vision changes.

Common OTC Presentations and Referral Criteria

Pain (headache): Refer if: worst headache of life, associated fever and neck stiffness (meningitis), associated neurological symptoms, headache in pregnancy, headache in child <2 years, headache following head injury.

Gastrointestinal symptoms: Refer dyspepsia if: age >55 with new onset, dysphagia, persistent vomiting, unexplained weight loss, signs of upper GI bleed (haematemesis, melaena). Simple heartburn without alarm features can be managed with antacids or alginate preparations.

Skin conditions: Refer if: rapidly spreading cellulitis, skin lesion with suspicious features (asymmetry, irregular border, multiple colours, diameter >6 mm, evolving — ABCDE criteria for melanoma), infected wound not resolving with topical antiseptics.

Eye conditions: Refer if: vision changes, photophobia with red eye (possible anterior uveitis or keratitis), eye pain (not just irritation), recent eye trauma, contact lens wearers with red eye (risk of Pseudomonas keratitis — urgent referral).

Child presentations: Lower threshold for referral in children. Refer any febrile infant <3 months immediately. Refer children with persistent symptoms, high fever, poor feeding, or parental concern.

Special Populations

Pregnancy: Paracetamol is the preferred analgesic throughout pregnancy. Avoid ibuprofen in the first and third trimesters. Most antihistamines lack adequate safety data in pregnancy — refer to the prescriber or use loratadine (limited data). Folic acid 800 mcg daily is recommended for all women planning pregnancy and in the first trimester.

Elderly: Risk of anticholinergic effects (urinary retention, constipation, confusion), drug interactions with polypharmacy, falls risk with sedating antihistamines or codeine products, and impaired renal clearance requiring dose adjustment.

Paediatric dosing: Always check age and weight-based dosing. Aspirin is contraindicated in children <16 (Reye's syndrome risk). Codeine is contraindicated in children <12 and in any child following tonsillectomy/adenoidectomy (CYP2D6 ultra-rapid metabolisers at risk of respiratory depression).