td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 13907 [post_author] => 3387 [post_date] => 2021-08-04 13:52:21 [post_date_gmt] => 2021-08-04 03:52:21 [post_content] => As COVID-19 cases continue to grow in New South Wales and Queensland, with 233 locally acquired cases confirmed today, vaccination is under ever-increasing focus. After Prime Minister Scott Morrison announced a 70% vaccination target must be reached before the nation starts to move away from lockdowns, Doherty Industry modelling suggested a refocus in the rollout to target young adult ‘peak spreaders’. The document recommends targeting adults aged 30–39 in early September, followed by the 16–29 age cohort from the beginning of October, estimating that the government's goal could be reached by 1 November. There are currently more than 288 pharmacies across Australia administering the vaccine, which Federal Health Minister for Health Greg Hunt said would swell to 700 in the coming weeks. Mr Hunt also indicated pharmacies could be tapped to conduct rapid antigen tests following the conclusion of a clinical trial. In state vaccination news, the NSW Government has set a target of 6 million by month’s end, around half the state’s population, to address the deepening COVID-19 crisis. Two more deaths were announced today, including an unvaccinated man in his 20s. Following a change in the risk profile due to Queensland’s mounting case numbers, Chief Health Officer Jeannette Young has changed her stance on the AstraZeneca vaccine somewhat. ‘If [people under 60] think they have a particular risk, [they should] immediately go and talk to their own doctor,’ Dr Young said. ‘The ATAGI [Australian Technical Advisory Group on Immunisation] advice said that when we reach a large outbreak, which I think we’re on the verge of … that is the time to discuss [vaccination] with your GP.’ The virus has now popped up in Far North Queensland, with a positive case announced in Cairns yesterday. But residents can now be vaccinated at their local community pharmacy, with over 26 joining the vaccine effort last weekend.
High demand for vaccinesNew data released by Operation COVID Shield has indicated that wealthy Sydney and Melbourne enclaves are the most vaccinated in the nation, while areas such as Sydney’s hard-hit south west are among the lowest. But residents in Sydney’s local government areas of concern are heeding the call to get vaccinated, with some pharmacists who were fast-tracked to administer the vaccine quickly burning through their supply. Pharmacy owner Quinn On MPS, who began administering the vaccine on 26 July in two of his pharmacies, managed to work through 3 weeks’ supply in just 4 days. At Priceline Pharmacy Cabramatta, Mr On administered 600 vaccines in 6 days, borrowing 100 from his other pharmacy and a further 200 from a fellow pharmacist. Luckily, Mr On received a new shipment of 600 vaccines on Monday afternoon to cater to the growing demand, with the Vaccine Operations Centre indicating it would prioritise deliveries for pharmacies in hotspot areas that have run out. ‘People were waiting in line [on Monday] at 8am and we weren’t even open,’ Mr On told Australian Pharmacist. ‘From 10 am until 2 pm, we [administered] 100 vaccines.’
A smooth vaccination processTo ensure they get as many patients through the door as possible, the pharmacy now caters exclusively to walk-ins, with safety procedures in place to minimise the risk of exposure. Fairfield Council has approved Mr On’s use of the footpath outside the pharmacy as a space for patients to line up for their vaccine, complete with appropriately-spaced crosses to ensure social distancing. As they approach the pharmacy doors, patients are screened by staff, including one pharmacist, Mr On’s wife Helen, who will answer any ‘curly’ questions that may arise. Over the past week, the team has encountered patients with an array of concerns, some related to post-vaccine side effects, and others around chronic conditions or contraindications. ‘There’s [been] a lot of queries, such as “I had a brain aneurysm 13 years ago, but I've been fine since then” or “I’m on clopidogrel, or 100 milligram aspirin every day, am I okay?”’ he said. Some patients with preexisting conditions, such as diabetes or high blood pressure, have indicated they are concerned about blood clots. But the team will reassure them that these conditions aren't linked to clotting, and that their screening questionnaire is all clear. If there is any lingering uncertainty around safety, patients will be directed back to their GP. Inside, Mr On’s son, a third-year pharmacy student, is exclusively tasked with drawing up the vaccines. Patients’ time in the vaccination room is short lived, to ensure close contact is kept to a minimum. ‘For the observation [period], we give them a sticker like at the [Sydney mass vaccination] hub,’ he said. ‘So if they were vaccinated at 1 pm, they get a sticker for 1.15 pm, and I will tell them in Vietnamese or Chinese to sit outside in the observation area until [then].’
The road to recoveryMeanwhile, as pharmacies continue to be listed as venues of concern, with more than 100 in greater Sydney subjected to health alerts since early July, many pharmacists and their staff have had to endure periods of isolation. This is a process Chris Pollard knows all too well, after his pharmacy in the south-west Sydney suburb of St Andrews became an exposure site almost a month ago (7 July). ‘It was stressful,’ Mr Pollard told AP. ‘We hold scripts and look after dose administration aids for people, but fortunately we weren't exposed multiple times.’ While half the pharmacy’s staff were required to isolate for 14 days following the exposure, the other half filled the breach to continue to serve the community. ‘We adjusted our operating hours, opening half an hour later and closing an hour earlier,’ he said. ‘While it wasn't a massive reduction in hours, it gave us a bit of time to do after-hours [work] and get on top of things for the next day.’ The groundswell of support from the local community also helped the team persevere. ‘They were checking in that everyone was okay, which was really quite humbling.’ Now that the dust has settled and the staff are out of isolation, the pharmacy has continued to work under a split team arrangement to ensure they can weather another storm. ‘If the same situation [was to arise], we would still have half the staff to manage on,’ Mr Pollard added. If patients with obvious respiratory symptoms enter the pharmacy, and their COVID-19 status is undetermined, they will be asked to wait outside. ‘Our method of handling it is to say “If you’re happy to wait in the car, we'll bring your medicine out to you”,’ he said. As Mr Pollard waits to begin vaccinating patients against COVID-19 later this month, he echoed Mr On’s reports of high demand in the south-west Sydney community. ‘We’re getting multiple requests daily and that should [hopefully] flow through to vaccinations,’ he said. ‘The more places people can go, whether they be GP clinics, pharmacies, or vaccine hubs, [will help] to make it as easy as possible.’ [post_title] => Government shifts focus of COVID-19 battle [post_excerpt] => As COVID-19 cases continue to grow in New South Wales and Queensland, with 233 locally acquired cases confirmed today, vaccination is under ever-increasing focus. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => government-shifts-focus-of-covid-19-battle [to_ping] => [pinged] => [post_modified] => 2021-08-04 15:00:49 [post_modified_gmt] => 2021-08-04 05:00:49 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13907 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Government shifts focus of COVID-19 battle [title] => Government shifts focus of COVID-19 battle [href] => https://www.australianpharmacist.com.au/government-shifts-focus-of-covid-19-battle/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 13911 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 13882 [post_author] => 235 [post_date] => 2021-08-01 16:26:05 [post_date_gmt] => 2021-08-01 06:26:05 [post_content] => With community pharmacists an integral part of the COVID-19 vaccine rollout, it’s time to get serious about allowing pharmacists to administer other injectable medicines. Over the next month, pharmacists in almost 4,000 community pharmacies across the country will begin offering COVID-19 vaccines. This is a far cry from 2014, when pharmacists were unable to administer any medicine – vaccine or otherwise. But while providing influenza and other vaccinations is now commonplace, pharmacists are still not practicing to their full potential. This was the message delivered by PSA’s General Manager, Policy and Program Delivery Chris Campbell during a session at PSA21 Virtual today. ‘Pharmacists in every single jurisdiction have done the training to administer a subcutaneous or intramuscular injection,’ he said. ‘We have the competence and now we’re going to lead the country out of the pandemic.’ Determining whether administering other injectable medicines is within pharmacists’ scope of practice was a ‘simple equation,’ Mr Campbell said. ‘Do we have the competence, the accountability and the authority to do that service?’ For the first two, the answer is yes, he said. Pharmacists have the knowledge to administer other injectables, as they have already completed training on administering subcutaneous and intramuscular injections, and administering medicines has been in the National Competency Standards since 2016. ‘What is now slowing us down is the legislation, Mr Campbell said, ‘the allowance from our state and territories to let pharmacists do this.’ ‘What makes them likely to change legislation? It’s evidence that pharmacists are doing it in another state or territory.’ As legislation in New South Wales, Victoria and the ACT allows pharmacists to administer other injectable medicines, Mr Campbell called on pharmacists in these jurisdictions to ‘lead the way’ for others. To learn more about administering medicines other than vaccines, Mr Campbell advised PSA21 attendees to review PSA’s Guidelines for pharmacists administering medicines by injection. This includes information on professional obligations, practice and training requirements, as well as a checklist to determine whether you are ready to offer the service.
‘Take away the handcuffs’Speaking to Australian Pharmacist ahead of PSA21 Virtual, former PSA National President and CEO Dr Shane Jackson said administering other injectable medicines was about ‘filling a gap’ rather than an expansion of pharmacists’ scope of practice. ‘It’s just about using the workforce and responding to patient need,’ he said. ‘A person can pick up their injection from the local community pharmacist, for example for B12, but in some cases they can’t also receive it. ‘We would appeal to all governments to take away the handcuffs on pharmacists being able to do something which is well within their scope.’ Australia, ‘can’t afford’ to have an under-utilised health workforce, he said. Mr Campbell echoed this in his presentation. ‘There will be a wave coming where all all health professionals will need to practice to their fulfilment scope,’ he said. ‘The country needs us to do that.’ Making it easier for patients to access injectable medicines at their local community pharmacy is also important given PSA’s Pharmacists in 2023: roles and remuneration report, which detailed how Australia’s health system will shift from an illness to a wellbeing focus, or from one-size-fits-all to precision healthcare. ‘It just so happens that a lot of the newer medicines are injectable medicines, and will need to be administered,’ Mr Campbell said. He pointed to Canada, where pharmacists can administer medicines other than vaccines in most jurisdictions, as an example of what’s possible. ‘They started by providing influenza vaccinations, then included other vaccines, and now they can do any drug or vaccine,’ he said. ‘This is the model we use to demonstrate what can happen. Hopefully Australia will do it a little bit faster.’ [post_title] => Community pharmacists need to to move beyond vaccinations [post_excerpt] => With community pharmacists an integral part of the COVID-19 vaccine rollout, it’s time to get serious about allowing pharmacists to administer other injectable medicines. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => community-pharmacists-beyond-vaccinations [to_ping] => [pinged] => [post_modified] => 2021-08-01 17:19:04 [post_modified_gmt] => 2021-08-01 07:19:04 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13882 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Community pharmacists need to to move beyond vaccinations [title] => Community pharmacists need to to move beyond vaccinations [href] => https://www.australianpharmacist.com.au/community-pharmacists-beyond-vaccinations/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 13883 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 13874 [post_author] => 235 [post_date] => 2021-08-01 13:25:46 [post_date_gmt] => 2021-08-01 03:25:46 [post_content] => Theresa Flavin, a 57-year-old mother of five, was diagnosed with dementia at just 46. She says older Australians and those with cognitive dysfunction need a pharmacist ‘on the team’ to promote the quality use of medicines and prevent medicine-related harm. Speaking at the ‘Medicines nightmare in aged care’ session at PSA21 Virtual on Friday, Ms Flavin said her first experience of medicine-related harm was when her mother-in-law, who had Alzheimer’s Disease, kept having falls in her residential aged care facility (RACF). Her mother-in-law was ‘on an absolute boatload of very strong pain medication’, to manage osteoarthritis, but ‘when we looked at the progression of her time in aged care, it almost felt like the pain medication was being used as a sedative,’ Ms Flavin said. While she knew her mother-in-law needed medicine to treat her pain, Ms Flavin said she wished the family had ready access to a pharmacist who could have reviewed her medicines. ‘We need to help people to feel comfortable in their later years, that’s really important, but the risks aren't always communicated well to the [RACF] staff, they're not always communicated well to families,’ she said.‘What I’ve seen from my personal experience is that these medications [antipsychotics] result in falls. This means we give our lives so that somebody can have a quieter day’s work. It’s wrong.’In her own experience as a person with dementia, Ms Flavin said she has seen medicines used to control unsociable behaviours. Reducing the use of chemical restraint in RACFs has been a key focus of the Royal Commission into Aged Care Quality and Safety, with the commissioners calling on the government to introduce stricter requirements for prescribing antipsychotic medicines. ‘When you are diagnosed with dementia, you have a grieving process … We’re angry with ourselves for our loss, we’re angry with the disease, but that can sound like we're angry with you,’ Ms Flavin said. ‘But violence aside, which is a different matter, older people, people with dementia and other cognitive dysfunction, have a right to express ourselves, just like everyone else. ‘What I've seen from my personal experience is that these medications result in falls. This means we give our lives so that somebody can have a quieter day's work. That offends me. It’s wrong. 'Anything that shuts down our cognition is just making life worse for us. It's like giving a drunk person a spiked drink. It's just cruel.'
New approaches needed in RACFsFor pharmacist and Member for Dobell Emma McBride MPS, who lost her father to younger onset Alzheimer’s and her grandmother to dementia, promoting the quality use of medicines in aged care is ‘as much personal as it is professional’. It is estimated 30% of all hospital admissions of older people are medicine-related and approximately half are preventable. And more than 50% of all people living in RACFs are prescribed medicines that are considered potentially inappropriate for older people. ‘These figures are stark, they're quite concerning, but they’re also an opportunity for pharmacists to make a genuine and transformative contribution to aged care and the wellbeing of older Australians,’ Ms McBride told PSA21 Virtual attendees. ‘How do we, individually and professionally, respond to this crisis?’ She pointed to a pilot program in the ACT, where an accredited pharmacist spent 15 hours in an RACF per week. The result was ‘a significant drop in the potentially inappropriate use of medications, particularly around inappropriate use of psychotropics, antipsychotics and benzodiazepine,’ Ms McBride said. Other outcomes included a decrease in emergency department presentations and an increase in immunisation rates. ‘This is a really exciting opportunity to describe the role of a pharmacist embedded and integrated into the multidisciplinary care team to really transform the quality of care for older Australians,’ Ms McBride said. Embedding pharmacists in RACFs should be ‘seen as an investment, rather than a cost’. ‘If we can make that shift in thinking, pharmacists will be able to lift the quality of care,’ she said. ‘We need to see new approaches in aged care in order to provide a safe environment that minimises medication harm and maximises the role of pharmacists as stewards of medication safety.’
Providing continuing careAged care, home care and independent living provider IRT Group has 21 locations across New South Wales, Queensland and the ACT. Of these, only three have an embedded pharmacist, with another currently taking part in a pilot program. Speaking at PSA21 Virtual, IRT Group CEO Pat Reid said the main challenge was finding the initial funding to get pharmacists on the floor. ‘But when we do, we see massive improvements in outputs for our residents and our staff,’ he said. ‘We need to make sure pharmacists are actually on the floor, burning shoe rubber, face-to-face with residents, because that's where the bang for buck is, that's where we're going to see really good results for people in aged care, and they deserve it.’ Asked what he thought about the current Residential Medication Management Review (RMMR) program, Mr Reid said reviews should happen when a resident enters an RACF and then regularly afterwards. ‘Once in a blue moon RMMRs is not the method,’ he said. ‘We need to find the proper method, which is continuing service by a pharmacist.’#PSA21virtual pic.twitter.com/qXCxxlL7Wg — Samuel Keitaanpaa (@SKeitaanpaa) July 30, 2021Associate Professor Juanita Breen, an accredited pharmacist who testified at the aged care royal commission, agreed that RMMRs should be more frequent, particularly as the average resident takes about 11 medicines per day. ‘The average length of time a resident spends in an aged care home is about 18 months, so a lot of them won't even get round to having one [review],’ she said. After examining more than 1,200 medicine-related complaints made to the royal commission, A/Prof Breen found many problems weren’t overly complex. ‘We know that people are taking too many psychotropic medicines, that was really highlighted at the aged care royal commission, and many are staying on them for a lot longer than recommended,’ she said. ‘But for the average resident, there are other issues.’ Timing was the problem, particularly for palliative care, pain management and Parkinson’s Disease management, and accounted for more than 25% of all complaints.‘We need to make sure pharmacists are actually on the floor, burning shoe rubber, face-to-face with residents, because that's where the bang for buck is.'Overall medicine management was also an issue, including not having enough trained staff and leaving tablets with residents for them to take by themselves. The third most common complaint related to sedation. ‘As pharmacists we often look for things like drug burden index and a lot of other very complex issues and adverse effects, but sometimes it can be really quite simple,’ A/Prof Breen said. ‘The fact that a lot of people aren’t getting pain management on time is something that's of real importance.’ For Ms Flavin, access to a pharmacist should be sold as a point of difference for consumers when choosing an RACF. ‘I feel like I don’t have any choice. I’m the customer, I’m paying the bills when I enter residential care, and I should be able to choose a residential care facility that has a pharmacist,’ she said. ‘I feel cheated that I can’t.’ [post_title] => Embedding pharmacists in RACFs an investment, not a cost [post_excerpt] => Theresa Flavin, a 57-year-old mother of five, was diagnosed with dementia at just 46. She says older Australians and those with cognitive dysfunction need a pharmacist ‘on the team’ to promote the quality use of medicines and prevent medicine-related harm. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => embedding-pharmacists-in-racfs-investment-not-cost [to_ping] => [pinged] => [post_modified] => 2021-08-01 17:34:23 [post_modified_gmt] => 2021-08-01 07:34:23 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13874 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Embedding pharmacists in RACFs an investment, not a cost [title] => Embedding pharmacists in RACFs an investment, not a cost [href] => https://www.australianpharmacist.com.au/embedding-pharmacists-in-racfs-investment-not-cost/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 8503 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 13854 [post_author] => 175 [post_date] => 2021-07-31 16:07:48 [post_date_gmt] => 2021-07-31 06:07:48 [post_content] => A replacement for cotton wool and tape at injection sites and a new app that tracks expiry dates on medicines to prevent wastage were among six innovative ideas to advance patient care presented to judges at yesterday’s Pharmacy Shank Tank. The PSA21 Virtual session, sponsored by Viatris and hosted by PSA’s Training and Delivery Lead Kevin Ou, also attracted many viewers keen to vote for the popular People’s Choice award. The killer ideas were presented in 5-minute lots to the three sharp-toothed leaders who each had $3,000 to invest in products they felt had the best chance of success. The judges, each of whom felt compelled to split their investments into more than one concept, were PSA Vice President Renae Beardmore, Joey Calandra, Head of Strategy at Vitality and Viatris’s Product Manager, David Lai. They recognised the merit in propositions such as Tien Bui’s idea for free pharmacist metabolic monitoring of patients using second-generation antipsychotics. They also acknowledged that, while there was ’an absolute need’ for Chloe Langfield and Brad Butt’s concept for an app aimed at identifying and bridging gaps in physical, mental and social wellbeing among patients undergoing opioid maintenance therapy, more work may be needed to refine the operating details. But it was University of New England pharmacy lecturer Anna Barwick MPS, founder of PharmOnline, Australia’s first pharmacist-led telehealth service, who took out the $1,000 People’s Choice award with the Sugar Baby telehealth clinic. She was also given investment money from two of the judges. Part of PharmOnline, Sugar Baby is a fee-for-service telehealth clinic for isolated, pregnant women with gestational diabetes mellitus. Walcha, NSW-based Ms Barwick won another $2,000 investment from Mr Lai to put towards marketing and promotion to make it more visible online – without having to type in the actual name of the business. Another $1,000 investment for her concepts came from Mr Calandra. He also used his remaining $2,000 to invest – ‘loved it’ – in Victorian PSA member Angelo Pricolo’s Hy Dot, a thin hydrocolloid post-vaccination covering that is waterproof, easily removed and faster and simpler to apply than the current standard-care cotton wool and tape at injection sites. Cotton wool balls and tape, when removed, can cause more bleeding, as well as skin tears in old and fragile skin, Mr Pricolo convinced the judges, suggesting there had to be something better. Hy Dot is already in production on a small scale and is TGA-approved and registered as a Class 1 medical product. Mr Lai gave his remaining $1,000 to Lindsey Clark MPS and Sunit Ruparelia MPS, (also an IT developer at Esquad Technologies) for their expiration date management software ShrinkMan (managing shrinkage). Specifically targeted at pharmacies, it is currently in production and in Apple’s App Store (available in Australia and New Zealand) and aims for a better way to avoid inconsistent recording of expiry dates and wastage of pharmacy inventory. Pharmacy staff use the app to scan the barcode of a product that will soon be out of date, to plan what will be done with the stock before it expires. The advantage is that all the information is central, with no need to write barcodes or names, quantities and expiry dates when it is easy to lose the paper-based records. All Australian pharmacy barcodes have been pre-loaded into the app. Ms Beardmore ‘split’ her investment ‘50/50’. She gave $1,500 to ShrinkMan ‘to improve their marketing because I do think they need to increase exposure in the industry’. Her other $1,500 went to Steven Krashos to help pharmacists promote telehealth for correct inhaler technique, or other device use. ‘Whilst there’s a little bit of your value proposition that has to be more defined, I do think it’s a self-care product,’ she said. ‘And self-care, I do believe, is complimentary to telehealth. Self-care is a priority of government, and I think your product can help’, she said, while advising Mr Krashos to ‘expand beyond inhalers’. [post_title] => Winners and grinners at Pharmacy Shark Tank [post_excerpt] => A replacement for cotton wool and tape at injection sites and a new app that tracks expiry dates on medicines to prevent wastage were among six innovative ideas to advance patient care presented to judges at yesterday’s session. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => psa21-pharmacy-shark-tank [to_ping] => [pinged] => [post_modified] => 2021-08-01 17:21:40 [post_modified_gmt] => 2021-08-01 07:21:40 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13854 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Winners and grinners at Pharmacy Shark Tank [title] => Winners and grinners at Pharmacy Shark Tank [href] => https://www.australianpharmacist.com.au/psa21-pharmacy-shark-tank/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 13856 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 13849 [post_author] => 235 [post_date] => 2021-07-31 15:11:51 [post_date_gmt] => 2021-07-31 05:11:51 [post_content] => The importance of finding mentors, practicing to your full potential and promoting women into leadership roles were just a few of the topics discussed during a lively Early Career Pharmacist (ECP) forum at PSA21 Virtual yesterday. Seven ECPs, including Dr Sarah Dineen-Griffin, Hannah Knowles, Julian Soriano, Lily Pham, James Buckley, Samantha King and Deanna Mill, who chaired the session, shared what they have learnt during their careers so far. It followed the launch of PSA’s new ECP Communities of Special Interest (CSI) Group, announced by PSA National President Associate Professor Chris Freeman that morning. Despite their varied backgrounds and careers, all panelists agreed that connecting with colleagues was vital for personal and professional development. ‘We only get places by being able to connect with other people,’ Ms Knowles, a Senior Pharmacist at The Royal Brisbane and Women’s Hospital and PSA’s 2020 Queensland ECP of the Year, said. ‘It’s important to know you can have both official and unofficial mentors … You don’t want just one person – the more you can get to bounce ideas off is fantastic.’ Mr Buckley, a community pharmacist in the Noosa Hinterland on Queensland’s Sunshine Coast, said he liked to ‘think outside the box’ when it comes to who you can learn from. ‘If you see someone doing something you like, talk to them,’ he said. ‘We’re great at promoting pharmacy within pharmacy circles … but if you work in a multidisciplinary team, those team members can also help mentor you.’ For example, Mr Buckley has had ‘great mentoring’ from some of the general practitioners and nurses with whom he works. ‘They have different perspectives and views on things, so go and find those people,’ he added.For those working in community pharmacy who don’t know where to start, Ms Mill recommended narrowing your focus. ‘What is it that you want to do? Do you want to improve diabetes management or provide aged care medication reviews? You need to work out what you want and reach out to those people,’ she said. ‘PSA is so well-placed and well-networked to be able to help you with that. If you’re an ECP, reach out to us and we’ll try to connect you with someone in your field of interest. It’s just a matter of asking.’
Truly inspiring discussions made by all panel members at the PSA ECP forum, especially being confident and leading by example for the next generation of pharmacists! #PSA21virtual (1/1) pic.twitter.com/TbClYJHftm— Raymond Truong (@truryAdelaide) July 30, 2021
Promoting pharmacists’ full scope of practiceWhile mentors can help advance your career, the ECPs also discussed the need to continue advancing the profession as a whole, including promoting the recognition of pharmacists and the difference they can make to improving patient outcomes. ‘Until [pharmacists] are integrated and recognised as integral to our health system, and these changes are reflected in policy, our health system will not function at its full capacity,’ said Dr Dineen-Griffin, a lecturer at Charles Sturt University and Vice-President of PSA’s NSW Branch Committee. ‘Now, more than ever, [Australian pharmacists] really need to be working to their full scope of practice.’ ECPs are playing their part in this, Dr Dineen-Griffin said, with 1 in 5 PSA state and territory leadership positions now held by early career pharmacists. ‘The best thing we can do for the next generation is to keep pushing in this generation,’ Ms Mill said. ‘Those new and emerging roles, hopefully by the time the next generation get here, they’re established roles and it's a no-brainer to have a pharmacist in every residential care facility, for example.’
This was 11/10 fun - I am so proud of the #ECP network and it was such a privilege to show case a snippet of our conversations 👏 See ya in the CSI discussion forum @JulianSoriano3 @HMKnowles @sarahdgriffin @lilypham_ Sam + James @PSA_National #psa21virtual https://t.co/nHUFBcJfyR— Deanna Mill (@deanna_mill) July 30, 2021
Women in the workforceBreaking down barriers for women in the profession is also important, particularly for those who are primary caregivers or trying to transition back to work after maternity leave. Although women comprise 63% of the pharmacy workforce in Australia (a figure the International Pharmaceutical Federation predicts will increase globally to 72% by 2030) many still face hurdles relating to career progression. ‘While navigating a career and a family is challenging, having a baby or being a parent should not be a barrier to stepping into leadership positions,’ said Dr Dineen-Griffin, a new mother and member of the National Medicines Policy Review Committee (announced during PSA21 Virtual yesterday morning on behalf of Federal Minister for Health and Aged Care Greg Hunt). ‘It does not mean you cannot do the job, and it certainly does not mean that you cannot do the job well.' For many pharmacists returning from paternity leave, a critical issue is having the current knowledge to operate effectively as a pharmacist, she said. This has been magnified during the pandemic, with practice changes coming thick and fast. While there are options available, such as accessing ‘keeping in touch' days, which allow an employee on parental leave to come into the workplace, these aren’t always promoted. ‘As a profession, I think we really need to gain a greater or deeper understanding of the challenges women in pharmacy face at these critical points in their career,’ Dr Dineen-Griffin said. ‘My main message is let's continue to talk about it. This shouldn't be a taboo topic … There really is no better time for investing in our female pharmacy workforce.’ [post_title] => Early Career Pharmacists on what matters to them [post_excerpt] => The importance of finding mentors, practicing to your full potential and promoting women into leadership roles were just a few of the topics discussed during a lively Early Career Pharmacist forum at PSA21 Virtual yesterday. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => early-career-pharmacists-on-what-matters [to_ping] => [pinged] => https://www.australianpharmacist.com.au/resident-hospital-pharmacist/ https://www.australianpharmacist.com.au/future-of-pharmacy/ [post_modified] => 2021-08-01 17:09:40 [post_modified_gmt] => 2021-08-01 07:09:40 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13849 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Early Career Pharmacists on what matters to them [title] => Early Career Pharmacists on what matters to them [href] => https://www.australianpharmacist.com.au/early-career-pharmacists-on-what-matters/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 13850 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 13904 [post_author] => 4263 [post_date] => 2021-08-04 13:53:34 [post_date_gmt] => 2021-08-04 03:53:34 [post_content] => Each week, pharmacists across the country ring PSA’s Pharmacist to Pharmacist advice line looking for guidance on everything from practice-related queries to ethical dilemmas. In our occasional series, Australian Pharmacist will speak to the experts and answer some of the most frequently asked questions. This month, we’ll again focus on COVID-19 vaccination questions answered by Amanda Fairjones, Professional Support Advisor. Have a question of your own? PSA members can call 1300 369 772 to receive professional advice and support.
1. What do I do when someone under 60 years of age chooses to receive the AstraZeneca vaccine in a community pharmacy?This is dependent on where you practice, as pharmacists must both adhere to relevant state/territory legislation and guidance, and follow the advice of the Australian Technical Advisory Group on Immunisation (ATAGI) and the Therapeutic Goods Administration (TGA). For example, in NSW pharmacist immunisers may administer the COVID-19 AstraZeneca vaccine to individuals aged 18 years and older (regardless of geographical location) providing they do not have a precaution or contraindication to COVID-19 vaccination, and after obtaining fully informed consent. Informed consent requires discussion of the risks and benefits of vaccination using the latest information and advice from ATAGI and the TGA. Pharmacist immunisers must ensure they remain up to date with the advice from ATAGI or the TGA in relation to COVID-19 vaccination. For further information in relation to the state or territory in which you practice please visit www.psa.org.au/coronavirus for more details, or PSA members can contact our professional support line on 1300 369 772.
2. What symptoms should persons be advised to look out for post-vaccination in relation to the AstraZeneca (AZ) vaccine?Persons should be advised to present for medical advice if they develop any severe, persistent symptoms after vaccination. Persons should be provided with advice to immediately seek medical review for any new, severe persistent headache, stomach (abdominal pain), chest pain, vomiting or visual symptoms, bruising or petechial haemorrhages between 4 and 30 days after vaccination with the Covid-19 AZ vaccine. Any patient with concerning signs or symptoms potentially related to thrombosis with thrombocytopenia syndrome (TTS) following receipt of the COVID-19 AZ vaccine should be referred to an emergency department for assessment and investigation.
3. What happens if the second dose of AZ is missed or given late?If the second dose of the AZ vaccine is overdue (i.e. past the recommended 12-week interval for AZ), it should be given as soon as possible. A single dose likely only provides short-term protection. The second dose will be effective regardless of how late it is given. Even if the second dose is late, the current advice is no vaccine doses need to be repeated. The role and evidence for additional booster doses is still emerging. However, it is likely these will be required into the future. It is clear that pharmacists in Australia will play a continued role in COVID immunisation, ensuring adequate booster immunisation rates should they be required.
4. Can pharmacists in suitable community pharmacies administer the second AZ dose if the first is given in a general practice or vaccination clinic?
Yes, this is perfectly okay. In fact, early results are showing, up to 30% of AZ vaccinations given by pharmacists in community pharmacy have been for the second AZ dose, with the first dose being given in a GP or vaccination clinic.
5. When should I upload COVID-19 vaccination information to AIR?COVID-19 vaccine encounters should be uploaded into AIR within 24 hours from vaccine administration (including the patient’s individual Medicare reference number), or as soon as possible, to ensure consumer immunisation information is up to date. It is mandatory under the Australian Immunisation Register Act 2015 to report all COVID-vaccine encounters to the Australian Immunisation Register (AIR). It is recommended pharmacist immunisers also check a patient’s immunisation history in AIR prior to administering the COVID-19 vaccine to ensure the correct vaccine is given within the appropriate timeframe (in some jurisdictions this is mandatory). The ways to report a vaccination to the AIR include:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 13901 [post_author] => 175 [post_date] => 2021-08-04 13:52:55 [post_date_gmt] => 2021-08-04 03:52:55 [post_content] => Senior pharmacists share latest updates on best practice in pain relief for fever in children, osteoarthritis and in older people with comorbidities.
Tailor-made recommendations, specific advice about dose, frequency and duration of analgesics and non-steroidal anti-inflammatories (NSAIDS) and feedback for further advice are the best way pharmacists can help patients seeking pain relief.These were the tips given to PSA21 at the weekend by the University of Sydney’s Head of School and Dean of Pharmacy Professor Andrew McLachlan and Associate Professor Rebekah Moles, together with PSA fellow and leading pharmacist and educator John Bell FPS, a member of the international multidisciplinary Global Pain Faculty, who led the discussion. At PSA21’s session ‘The who, what, why, when and how long of pain relievers in the community setting’ recent reviews of paracetamol efficacy and case studies were used to illustrate the application of changing evidence around the use of many well-known analgesics. Care should be taken with codeine, and with the dose and duration of particular NSAIDs for certain conditions, Mr Bell pointed out. NSAIDs should be avoided in pregnancy. Paracetamol can cause liver damage with excess use, but is safe in pregnancy and breastfeeding, the session was told. According to some systematic reviews of studies presented recently to the International Association for the Study of Pain, Mr Bell said paracetamol for patients with complex cirrhosis was ‘quite reasonable’ at up to 4 gms a day, even if in moderate to heavy drinkers. ‘And it’s quite suitable for patients with chronic kidney disease. However, patients with advanced kidney failure are recommended to use a lower dose,’ he noted.
Pain relievers for older people with comorbidities[caption id="attachment_13920" align="alignleft" width="200"] From top to bottom: Associate Professor Rebekah Moles, John Bell, Professor Andrew McLachlan[/caption] Professor McLachlan presented the case of 55-year-old Wayne, a former surf champion who presented at the pharmacy overweight, with diabetes and a history of cardiovascular disease and reflux after an episode of debilitating lower back pain. Two tablets of paracetamol that morning did not help. His other medicines included irbesartan, atorvastatin, metformin, curcumin supplement and ranitidine (prn for reflux). Key steps, Prof McLachlan advised pharmacists, included taking a medical and pain history and understanding Wayne’s goal: to return to regular surfing. Prof McLachlan recommended starting with an appropriate assessment of any red flags – which should be referred on – including:
‘What we’re using the paracetamol or ibuprofen for is to treat his pain associated with the fever, not actually the number on the thermometer.’Her practical tips for parents included:
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How pharmacists can support patients in the end-of-life period.
The important role that pharmacists play in the entire journey of palliative care is not fully recognised even in international studies.
Yet pharmacists in hospital, community pharmacy or aged-care settings all have stories about a lasting impact they have had on patients, carers and their families.
‘We play a fundamental role from the time of diagnosis right through to bereavement,’ says Paul Tait MPS, a South Australian researcher and pharmacist in a specialist palliative care service.
‘Yet when I conducted a literature review over a year ago (into the community pharmacist’s role with people with palliative care needs), I could only find research on specific aspects of care, not the whole journey.’
Mr Tait has now completed a survey on the role of pharmacists throughout the spectrum via a federally funded End of Life Directions for Aged Care (ELDAC) project. The results were published last month in the international journal, Healthcare.1
‘When you have an older person who is on a number of medicines, there’s always the risk of misadventure,’ he says.
‘Throw in a palliative care illness on top of age and polypharmacy, and you introduce a whole new set of risks. Having pharmacists along that journey can help with foreseeing some of the issues that might cause problems.’
In the hospital
Pharmacist Penny Tuffin FPS has worked in palliative care for 30 years. She divides her time between Royal Perth Hospital, Fiona Stanley Hospital and Bethesda Hospital in Perth and has her own clinic.
‘It can be challenging,’ she says of the work. ‘Communication is the most important skill to have in palliative care.’
Ms Tuffin says often families will blame the medicine for the deterioration of their loved one’s health in the last days of life.
‘People are particularly worried about opioids causing drowsiness and speeding up the dying process, whereas good pain relief may extend a person’s life.’
Ms Tuffin says it’s inappropriate to blandly state that it’s not the medicine, as, of course, medicines may be contributing to drowsiness.
‘You need to have a conversation with the family, and this will take time and may need to happen over a couple of meetings. It is important to understand how they see things changing for the person and what they understand, before you can offer information and choices about medications.’
Ms Tuffin finds the time of discharge the most challenging for caregivers. This is where the pharmacist can play a critical role.
‘People feel overwhelmed by the medicine regimen, as there may have been many changes during hospital admission,’ she says. ‘It’s important to explain the medicine regimen and provide a written medication list and extra information for a backup record of their medicine schedule. Dose administration aids may also be helpful for some people.’
Involving the carer – who could be a family member, neighbour or spouse – is vital. ‘Make the medicine plan simple and explain it clearly,’ she says. ‘It has been repeatedly demonstrated that one of the most stressful issues when caring for a person with palliative care needs is managing medications,’ she says.
Hospital pharmacists also provide a nexus among a host of healthcare professionals. Ms Tuffin recently cared for a woman who had 10 different doctors prescribing medicines which had been dispensed at four different pharmacies.
‘It was important to ensure that all her prescribers were aware of the other medicines prescribed for her, and I contacted several of the prescribers to rationalise the medications – especially duplicate analgesia.’
Mostly, Ms Tuffin works closely with an interdisciplinary team to plan care in hospital and for discharge. ‘All medication changes are discussed as a team, with pharmacist knowledge on pharmacology, pharmacokinetics, interactions, availability and cost important for these decisions.
‘I work towards having a pre-emptive medication regimen that will facilitate the person being comfortable in their place of choice and being able to stay there until they die.’
Other factors that affect this are organ function, other medicines being taken by the patient, the ability to swallow, and the ability to manage the regimen at home, or – if carers or a residential aged care facility are involved – whether they are able to administer and monitor the medications.
With more than 5,000 community pharmacies across the country, many Australians have close contact with a pharmacist, but many pharmacists are unaware of the impact they can have on the delivery of healthcare beyond the dispensing of medicines, Mr Tait says.
One of the problems people encounter is timely access to end-of-life medicines.
Bente Hart is part of a PSA-led project in south-eastern New South Wales, which is funded by the SE NSW Primary Health Network COORDINARE, to help pharmacists better address that issue. It is called ‘Building capacity in the community pharmacy setting to improve access to appropriate end of life medicines for residents of SE NSW’.
Under the leadership of PSA Project Manager, Megan Tremlett, a team has developed a palliative care training package for community pharmacists which it took to the road.
‘We are talking to them about the palliative care resources available, giving them tools to engage with their local palliative care team and educating them about the Core Palliative Care Medicines List for NSW Community Pharmacy.
The significant benefit of keeping core stock is that prescribers can be reassured that the pharmacy can supply at short notice, says Mrs Hart. And families prefer sourcing their loved one’s medicines from a known place and familiar face during times of stress.
The NSW Clinical Excellence Commission recommends that community pharmacies in NSW stock five injectable medicines on the Core Palliative Care Medicines List for NSW Community Pharmacy. These are:
‘Pharmacists intending to stock the Palliative Core Medicines list should check with local palliative care teams for any local variations to the list,’ Mrs Hart points out. For instance, in some areas clonazepam is prescribed, but local teams are using midazolam 5 mg/mL.
Ensuring a timely supply of medicines, says Mr Tait, can prevent patients being delayed important symptom control or, worse, sent back to hospital.
Mrs Hart says the project has proved that other healthcare professionals benefit from involving pharmacists more.
‘I see it as very important that community pharmacists are notified of their patients under palliative care so they can inform the palliative care multidisciplinary team of any concerns that may arise,’ she says. ‘Pharmacists can advise on matters such as medicine availability, deprescribing or formulation changes to take into account swallowing problems and discuss what options are available.’
Other solutions for pharmacists to help patients and carers are the use of real-time prescription monitoring and My Health Record, and making any inquiries with compassion and empathy.
Mr Tait recalls having a patient with neck and head cancer who had swallowing problems. ‘The person was in tears when I told her I was a pharmacist getting an up-to-date list of medicines. She said, “I can’t swallow my medicines – I’m really struggling”. So, I rang the community pharmacy and explained the situation. They looked up their profile and realised that particular brand of antidepressants needed to be swallowed whole. By switching to a different brand, they could make it easier to swallow. So, the pharmacist took the lead and contacted the GP about getting a new script in a different formulation.’
Being proactive with prescribers, says Mr Tait, is often a good strategy.
‘I would say something like: “We have a number of people with a life-limiting illness using our services, and we want to be on the front foot. These are the medicines we’re going to hold and wonder how you feel about that?”’
He suggests pharmacists consult the Australian & New Zealand Society of Palliative Medicine’s Consensus-based list of medicines suitable for the management of terminal symptoms in community and residential aged care facilities in Australia, which lists medicines including clonazepam liquid and metoclopramide and morphine injections. (Visit www.palliaged.com.au/Portals/5/Documents/medicine-List-update.pdf)
Palliative care pharmacy, of course, is not just about end-of-life patients, but dealing with those situations can be the most taxing. Ms Tuffin says she is not the one delivering the news when care needs to change direction from cure to symptom management, however she may be present as part of the interdisciplinary team when those conversations occur.
‘I will often be standing there, listening and watching, making sure everybody’s comfortable and that nothing has been missed. When you get out of the room, you’ll often have a conversation with your colleague and may provide feedback and support and say something like, “You did a really good job in there”.‘
Positive feedback from families can be one of the saving graces in such stressful situations. Mr Tait recalls having a young patient on the autism spectrum who was approaching end of life.
‘I was involved in making sure things were set up for the family to care for him at home. I put all the information in writing about how to manage things. Even though a nurse was coming to the home, I wanted them to be empowered. I found that particularly rewarding.’
‘Our care doesn’t end when a person dies,’ Ms Tuffin says. ‘We also provide bereavement follow-up for families.
‘If we are concerned about a family member, one of our team might ring up a few weeks later and ask: “How are you going? How was the funeral? How is everyone in the family?”’
Self-care, says Ms Tuffin, therefore needs to be built into everyday routines.
‘I am lucky that I work in a very supportive, interdisciplinary team. We each have a different way of looking after ourselves: some have formal debriefing with counsellors, whereas others do yoga or meditation, or take time out to walk on the beach. You have to maintain your self-health to have the ability to go back and care for the next person and their family.’
How important is the relationship with GPs?
Good communication ultimately benefits the patient. Early advice of a patient’s palliative status allows support to be tailored. If GPs and nurse practitioners can be encouraged to prescribe anticipatory medicines, it can alleviate suffering and prevent transfer to hospital.
How important is it to stock end-of-life medicines?
Community pharmacists should aim to stock the medicines included on their locally relevant Core Palliative Care Medicines List and ensure nearby prescribers are aware of this. Engage with local GPs and find out who is on the local palliative care team; reach out to them and let them know the pharmacy would like to be involved when one of their patients has been diagnosed with a life-limiting illness.
Explore how best to communicate with the palliative care team.
What can community pharmacists do to help patients in the last days of life?
Undertake further education in palliative care. PSA’s free Essential CPE: Palliative Care activity is available to all pharmacists in Australia. Know your palliative care resources, including the Therapeutic Guidelines: Palliative Care, CareSearch and the palliMEDS smartphone app. The Program of Experience in the Palliative Approach (PEPA) also provides funding to participate in clinical placements or interactive workshops. Its aim is to enhance the capacity of health professionals to deliver a palliative care approach through participation in either clinical placements in specialist palliative care services, or interactive workshops.
Build your skills with PSA Short Courses at psa.org.au/psashortcourses
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By encouraging open communication and breaking down barriers, pharmacists can help empower women when it comes to their sexual and reproductive health.
It’s been nearly two decades since pharmacists in 2004 began providing immediate access to the emergency contraceptive pill (ECP) without a prescription as a Pharmacist Only Medicine.
However, unlike in New Zealand and some parts of the United States and United Kingdom, women cannot access the oral contraceptive pill from specially trained pharmacists. Instead they must see a general practitioner (GP) for a prescription.
Those seeking MS-2 Step for medical abortion also face a barrier in the number of GPs certified to prescribe it – 1,345 out of 35,000 practising GPs – as well as finding a pharmacist who is certified to supply and dispense the medicine.
Any pharmacist can register to be a certified MS-2 Step dispenser through MS Health. The certification is pharmacist-specific rather than pharmacy-specific, so every pharmacist who dispenses MS-2 Step in a particular pharmacy must be certified.
‘Women in Australia currently experience structural (for example, financial and geographical), personal (lack of knowledge) and provider-related (biases or conscientious objection) barriers to accessing comprehensive contraception services,’ says Pip Buckingham, PhD candidate and researcher for the Centre of Research Excellence in Sexual and Reproductive Health for Women in PrimaryCare (SPHERE).
This situation has worsened during the pandemic, says Ms Buckingham, whose research focuses on broadening women’s contraceptive choice in general practice and pharmacy.Indeed, a 2020 report by Marie Stopes Australia into sexual and reproductive health rights in Australia found access to contraception and emergency contraception, and pregnancy and sexually transmitted infection (STI) testing, was reduced due to COVID-19. This inequity has been greater for people who already experience barriers to healthcare, including Aboriginal and Torres Strait Islander people, migrant and refugee communities, young people and those living in regional, rural and remote areas.
Rates of unintended pregnancy are also disproportionately higher among women who are socio-demographically disadvantaged and those living outside metropolitan regions.
Pharmacists can address many of these barriers and present a number of opportunities for accessible contraceptive counselling, products, screening for STIs and medical abortion.
TAREN GILL MPS
Priceline Pharmacy, Maryborough, Vic
We’re in a country town where everyone knows everyone. There are only two pharmacies in Maryborough and only ours is open on a Sunday.
We’ve had teenagers come in to get emergency contraception and they don’t want everyone to know – that is one of the barriers we have to overcome.
One of the ways we try to be more discreet is to have a card (above) in the feminine hygiene section of the pharmacy that says ‘Secret Women’s Business’. It explains that if you want to talk to the pharmacist, you just need to deposit the card at the counter.
We have contraceptive conversations with teenagers who don’t want their parents to know, and I give a talk to Year 10 girls at the local high school about sexual and reproductive health. I like to think that grassroots education helps to increase awareness around these issues and helps empower girls to take control of their reproductive health.
That said, we make sure women who come into the pharmacy looking for contraceptive advice are aware that contraception comes in many forms, including IUDs and implants, and that this is something they can discuss with their doctor. For example, as the contraceptive pill requires a lot of compliance, a 3-month injection may be a better option.
When women come in to access emergency contraception, we try to find out more about their cycle, or what’s going on for them. One of the most common groups looking for this type of help is happily married women with multiple kids who don’t want any more. There is no need for stigma and judgement about the reasons a woman wants to access emergency contraception.
We don’t have a prescriber in town for MS-2 Step. The nearest pharmacy is Ballarat or Bendigo [about 70 kilometres away].
I would feel comfortable about having some forms of contraceptive pill available over the counter if I was able to assess that the person didn’t have risk factors for side effects such as a clot, or wasn’t a smoker or overweight, as they may require closer monitoring. There would be a few things you would need to tick off, and our responsibility as pharmacists is to make sure that the medicines we dispense are safe and efficacious.
It is important that pharmacists feel ready and confident to have discussions about women’s sexual and reproductive health and recognise the actual or perceived barriers women may face, says Stefanie Johnston MPS, PSA’s General Manager – Knowledge Development.
‘PSA has a number of practice support tools, including a Pharmacist Only Medicine guidance document and online education modules to enable pharmacists to upskill in this area,’ she says. ‘Pharmacists are in a great position to provide information to women who have questions about their contraception and what may be the best option for them.’
One barrier is feeling a sense of shame or vulnerability when talking to a pharmacist about emergency contraception, or contraception more generally. A simple solution is to offer patients more privacy, says Ms Johnston. For example, if a woman appears on edge or is constantly looking towards the pharmacy entrance, suggest moving into a consultation room where others can’t see or overhear the conversation.
A lack of knowledge can also make women feel unsure when it comes to their sexual health, so it is important to explain why you need to ask certain questions when providing certain medicines, Ms Johnson says.
‘It’s rare that emergency contraception isn’t appropriate.’ But there are instances, she adds, where it cannot be taken. This could be due to other health conditions, other medicines or the length of time since unprotected sexual intercourse.
As there may be reduced efficacy of ECPs with increasing body weight, pharmacists should also be prepared to ask potentially confronting questions.
‘If it’s a situation where you feel uncomfortable, rehearsing the conversation and considering how you phrase things could be a good idea,’ Ms Johnston says. ‘For example, “I need to ask you a couple of questions to make sure I give you the right medicine and ensure it is as effective as it can be”. ‘
Counselling patients on emergency contraception also provides an opportunity to increase someone’s knowledge about contraception and sexual health more broadly – but only if the patient is open to it.
‘You need to meet people where they are. Some people find it a very personal conversation and are embarrassed, while some are happy to talk about it.’[table id=18 /]
EVA QUEK MPS
Sanctuary Lakes, Victoria
We’ve never refused to issue emergency contraception because there isn’t much of a contraindication.
Sometimes though, we have had to explain that, because the patient has left seeking advice more than 5 days [after sexual intercourse], it is too late, and they will need to go and see their doctor for a discussion about their options.
If this is needed, we might offer to schedule an appointment for them.
If is someone whose first language is not English, we have staff members who speak Vietnamese, Greek, Serbian, Hindi and Mandarin. There is also the Translating and Interpreting Service.
We also find out about any medicines they are on, and we always counsel them on the adverse effects. We might let them know that a more long-term form of contraceptive, like the oral contraceptive, or an implant, may be a useful consideration and suggest they discuss this with their doctor.
As pharmacists, we can provide more information to women who have questions about their contraception.
For example, I have spoken to women in the past who have raised concerns about the risks of deep vein thrombosis with certain oral contraceptive pills and they have decided to consider alternative contraception methods, such as a contraceptive implant instead.
We have two pharmacists in our pharmacy who are registered to provide MS-2 Step.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 12583 [post_author] => 3410 [post_date] => 2021-02-10 11:52:18 [post_date_gmt] => 2021-02-10 00:52:18 [post_content] => New boxed warnings for pregabalin and gabapentin give pharmacists the opportunity to discuss pain management with patients. The Therapeutic Goods Administration (TGA) announced on 1 February that medicines containing pregabalin and gabapentin will now come with boxed warnings in the Product and Consumer Medicine Information (CMI), following an investigation of ongoing misuse of pregabalin, and abuse of and dependence on both pregabalin and gabapentin. In its investigation, the TGA cited data from the National Coronial Information System, which found that pregabalin-related deaths have increased exponentially, rising from 16 in 2013 to 121 in 2016. Most of these deaths were unintentional. The warnings will serve as a guide for health professionals to screen for abuse or misuse, as well as inform patients about the risks associated with use.Gabapentinoids have been increasingly prescribed as the “non-opioid alternative” for all types of chronic pain, including non-neuropathic conditions such as non-specific lower back pain, fibromyalgia and osteoarthritis, despite there being little or no evidence for their use to treat these conditions. But even in the treatment of neuropathic pain, Ms Ellis said, gabapentinoids should be prescribed and dispensed judiciously, as much of the trial evidence is limited to those who live with post-herpetic neuralgia or diabetic peripheral neuropathy. Guidelines also recommend that patients on long-term therapy should attempt to challenge the efficacy and dose of therapy on an annual basis. ‘The benefits and risks of gabapentinoids can be a lot to unpack, and I would encourage pharmacists to use services such as a MedsCheck or Home Medicines Review,’ Ms Ellis, said. ‘Pharmacists should feel confident to discuss medicine risks and how to manage them, particularly when there is concomitant prescribing with other high-risk medicines.’ Evidence indicates that there may be up to a 49% increase in the risk of opioid overdose when combined with gabapentinoids. ‘If a pharmacist believes a patient is at risk of overdose, they should confidently discuss their concerns with the prescriber and ascertain how this risk is being managed,’ Ms Ellis said. ‘If there is no plan, pharmacists need to take a supportive approach and recommend harm minimisation strategies, such as staged supply, dose administration aids, gradual tapering plans and naloxone therapy, if combined with opioids.’
Impact on patientsAccording to Jarrod McMaugh MPS, PSA Senior Pharmacist, Consulting and past President of Chronic Pain Australia, the boxed warnings may have a particular impact on patients who inadvertently overuse pregabalin and gabapentin. [caption id="attachment_10922" align="alignleft" width="216"] Jarrod McMaugh MPS[/caption] ‘Patients who are not achieving adequate pain relief may be less likely to take an extra dose when they are made aware of the black box warning,’ he said. Despite this benefit, Mr McMaugh said some prescribers may be over cautious and see the warnings as a reason to reduce the supply of these medicines. ‘There is a risk that patients might suddenly lose access to these medicines, or they might decide to cease or reduce their use of pregabalin or gabapentin of their own accord,’ Mr McMaugh told Australian Pharmacist. ‘But as long as healthcare professionals review their patients adequately and provide a treatment plan around ceasing use, then it shouldn't be a problem. ‘It would also be useful if gabapentin and pregabalin were included in Real Time Prescription Monitoring (RTPM) programs to ensure that people at increased risk of overuse can be identified and assisted early on,’ he said. Both gabapentin and pregabalin will be incorporated in some jurisdictions’ RTPM systems, including Queensland’s QScript, which should roll out later this year.
Counselling adviceMr McMaugh said the CMI provides pharmacists with an opportunity to discuss patients’ treatment with pregabalin and gabapentin, particularly those who have just commenced use. ‘Pharmacists should inform patients that gabapentinoids are quite potent and they do have some risks associated with them,’ he said. ‘But it’s important to ensure that message is delivered appropriately without alarming the patient, which could lead to cessation.’ If patients do exhibit increased anxiety, pharmacists should reassure them that medicines prescribed for the correct indication are safe, but carry risks. ‘It's very much about allaying a patient's unnecessary fears and putting any concerns they have into perspective,’ Mr McMaugh said. ‘Pharmacists should balance the realistic harms that a patient could be exposed to against the benefits of treatment and the harms of stopping suddenly. ‘It's a matter of taking each person's case individually, and understanding what their risks are and what they are hoping to gain from treatment without lecturing them.’ If a patient is still hesitant, pharmacists should refer them to their prescriber to discuss a treatment plan for tapering to reduce any side effects associated with sudden cessation.
Efficacy of treatmentNicolette Ellis MPS, Senior Clinical Pharmacist for Beyond Pain, said pharmacists should be acutely aware that increased use of pregabalin or gabapentin does not necessarily mean the patient has a substance use disorder. [caption id="attachment_10175" align="alignright" width="220"] Nicolette Ellis MPS (right) with Beyond Pain founder Anjelo Ratnachandra[/caption] Many patients who live with chronic pain may increase their dose with the expectation that the medicine will improve their pain experience, so it’s important to start the conversation with open-ended questions, such as inquiring about how the pain might be impacting their day-to-day life or what they find beneficial about the medicine for their pain. ‘Gabapentinoids have many side effects including weight gain, peripheral edema, low mood, cognitive decline and sedation which can pose a significant barrier to improving an individual’s function, psychosocial abilities and quality of life,’ Ms Ellis told AP. ‘Up to 50% of patients taking gabapentinoids will experience adverse effects and identification of these medicine-related harms tends to be under-recognised. It’s essential that when we are having these conversations we are also screening for these symptoms.’ Ms Ellis also emphasised the importance of talking to patients about the purpose of taking a medicine for chronic pain, which is to improve their function and quality of life. ‘There should be a measurable goal in mind when patients start or continue a medicine for persistent pain, such as being able to walk for 20 minutes daily in the next 1–2 months,’ she said. Ms Ellis suggested pharmacists offer the use of validated tools to measure the benefits of their treatment, which should be selected based on the purpose of use, such as to improve their function, sleep or mood. These tools include:
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Claire, 3 years, has Dravet Syndrome. Her neurologist has recommended she undertake a trial with CBD with the aim of achieving better seizure control. A 100 mg/ml CBD oral liquid product is now listed on the Pharmaceutical Benefits Scheme (PBS) for Dravet Syndrome when used in combination with at least two other anti-epileptic medicines. She is already taking clobazam and sodium valproate.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
The medicinal cannabis article published previously by Australian Pharmacist, focused on the role of the pharmacist in the provision of medicinal cannabinoids. This article will provide a more detailed look at the evidence for specific indications and considerations for the use of medicinal cannabis in epilepsy, pain, multiple sclerosis, nausea and vomiting, and palliation.
In Australia, there are currently two Therapeutic Goods Administration (TGA)-approved medicinal cannabinoid products, with indications for symptom improvement of multiple sclerosis and two rare childhood epilepsies. The TGA provides guidance on other conditions of which the evidence has been assessed where medicinal cannabinoids may have a role in clinical care.1 These guidance documents cover epilepsy, chronic non-cancer pain, multiple sclerosis, nausea and vomiting, and palliation.
One of the only two approved cannabinoids products in Australia, Epidyolex, contains cannabidiol (CBD), with an indication for use in two rare and severe childhood epilepsies, Lennox-Gastaut Syndrome and Dravet Syndrome. This product is the only cannabinoids with a PBS listing limited to use for Dravet Syndrome, taking effect on May 1, 2021.2
The mechanism of action of CBDs anticonvulsant effects is unknown, though this is the one of the most well-researched indications for CBD. A systematic review of six randomised controlled trials and 30 observational studies identified that the evidence is largely limited to the use of CBD in rare and severe childhood forms of epilepsy, with little evidence for the use of other cannabinoids or other forms of epilepsy.3 CBD has only been trialled as an adjunctive medicine (i.e. in addition to existing first-line treatments for epilepsy). It is not recommended as a sole treatment, and most clinical trials have tested the use of CBD in combination with at least two other medicines.4 Most evidence for the use of CBD in epilepsy is limited to two rare and severe childhood disorders, Lennox-Gastaut Syndrome and Dravet Syndrome.5 The recommended starting dose is 2.5 mg/kg CBD taken twice a day for a week, titrated in response to both clinical effect and tolerance to a maintenance dose of 5 mg/kg with a maximum recommended dose of 10 mg/kg taken twice a day.4
There is insufficient evidence to demonstrate any role of THC in the treatment of epilepsy.6
Common adverse effects reported in trials of CBD include drowsiness, dizziness and diarrhoea.3 There is also clinically meaningful interactions between CBD and other commonly used anticonvulsants, such as clobazam and topiramate, which can lead to changes in serum levels and increased sedation, in addition to potential interactions with sodium valproate.6 Furthermore, concerns have been identified with abnormal liver function results (elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST)), highlighting the importance of routine monitoring.6,7 This risk appears to be greatest when CBD is used with sodium valproate and clobazam.8
Chronic pain is one of the most common reasons for which people report seeking medicinal cannabis, with one in three people in a recent cross-sectional survey reporting that they use it for pain.9 The endocannabinoid system is involved in a range of pain pathways. CB1 and CB2 receptors are differentially expressed on the central nervous system and play important roles in pain processes.10,11 Both cannabinoid receptors and endocannabinoids are present in the primary afferent pain circuits to the brain.12,13 Cannabinoid-induced analgesic effects involve a range of mechanisms including the release of neurotransmitters and neuropeptides from presynaptic nerve endings, modulation of neuronal excitability, activation of descending inhibitory pain pathways, and reduction of neural inflammation.14
Despite its common use for pain and proposed mechanisms for its analgesic effects, evidence suggests that meaningful pain relief is experienced by a minority of people who use it, with 24 people needed to be treated with medicinal cannabis for one to report a clinically meaningful effect (a 30% reduction in self-reported pain).15 Most evidence explores effects of cannabinoids for chronic pain. Significant reductions in pain intensity have been seen in neuropathic pain (MS and non-MS related), and a single study found a positive effect in rheumatoid arthritis.15 Results from 18 randomised controlled trials found no significant effect of cannabinoids on physical functioning.15
Very few studies have examined the role of CBD alone for pain. A recent double-blind clinical trial tested a single dose of 400 mg of CBD as an adjunct for acute lower back pain and found that CBD did not lower pain scores, reduce need for other analgesics and was not superior to placebo.16
The Australian and New Zealand Faculty of Pain Medicine have recently released a statement indicating that there is a critical lack of evidence that cannabinoids provide a consistent benefit for any type of chronic non-cancer pain, despite 90% of Special Access Scheme approvals being for chronic pain. They recommend limiting the use of cannabinoids to within well-controlled clinical trials until more evidence is available.17 Similarly, the International Association for the Study of Pain has stated it ‘does not currently endorse general use of cannabis and cannabinoids for pain relief’ due to the lack of sufficient evidence.18
Cannabinoids have been proposed as a strategy to reduce opioid doses, or to provide an ‘opioid-sparing’ effect, though clinical evidence to support this approach is still lacking.19
There is limited evidence to guide the most effective ratios of CBD:THC for pain, though most studies have used either Cannabis Sativa, nabiximols (with a 1:1 ration of CBD to THC), dronabinol or nabilone.15 Wide dose ranges have been used in clinical trials, for example, for MS-related pain, patients received a total daily dose ranging from 0.81 mg THC / 0.75 mg CBD, up to 129.6 mg THC / 120 mg CBD per day (0.3 to 48 sprays per day). Lower doses (up to 12 sprays per day) are now recommended for MS. Studies of dronabinol (THC) have tested doses of 5–25 mg, and doses of nabilone have ranged from 0.25 mg–8 mg.15
It is common for people who use medicinal cannabis for pain to experience adverse effects (during clinical trials, one in six report adverse effects – withdrawal was common). Common adverse effects in clinical trials include dizziness, cognitive impairment, drowsiness and intoxication.15 Slower initial dose titration may reduce the impact of adverse effects. As medicinal cannabinoids are commonly used as an adjunctive medicine with other analgesics, interactions should be considered, including the potential for combined sedative effects with other CNS depressants.20,21 CBD also inhibits CYP3A4 and CYP2C19 with reports of toxicity from the co-administration of medicines such as opioids and benzodiazepines.22,23
In Australia, nabiximols are an approved medicine for patients with moderate to severe spasticity due to multiple sclerosis (MS) who have not responded adequately to other anti-spasticity medicine. They must also show meaningful improvement in spasticity related symptoms during an initial trial of therapy.24 There are several common symptoms that nabiximols, and potentially other cannabinoid medicines may be used for. One of the most common symptoms that cannabinoids may be considered for is neuropathic pain and pain in association with muscle spasms.25
Preclinical studies demonstrate that the endocannabinoid system has a role in the tonic control of spasticity via the endocannabinoid system, and medicinal cannabinoids have modest efficacy for treating spasticity in clinical trials in adult populations. 26–28
MS can present in a heterogeneous way, with different patients experiencing different symptoms as more problematic. Based on a systematic review of reviews, there is evidence to support the use of nabiximols for symptoms of pain and spasticity in MS.29 There is emerging evidence to suggest that there may also be benefits for symptoms related to bladder function and sleep, although evidence is insufficient to make conclusive recommendations for these.29
Most evidence for the use of cannabinoids in MS is based on data from trials with nabiximols, the only approved cannabinoid medicine for MS. Nabiximols, is an approximate 1:1 ratio, containing 2.7 mg THC and 2.5 mg CBD in a single oromucosal spray. In trials, the average dose was eight sprays of nabiximols per day.24 The product information recommends commencing with a single spray in the evening for 2 days, then increasing to two sprays in the evening for a further 2 days before adding in a morning dose. The number of sprays per day can be increased every 1–2 days to a maximum of 12 sprays in 24 hours (32.4 mg THC and 30 mg CBD). The dose should be slowly titrated up to an optimal and tolerable dose. 24 Due to a lack of research, recommendations cannot be made on other ratios of THC:CBD.
One common side effect of cannabinoids is cognitive impairment, which can also be a clinical manifestation of MS. Whether cannabinoids may worsen existing cognitive impairment is an important consideration for its use in MS.29 Approximately 75% of people with MS are women,30 and onset is typically during the reproductive period. Nabiximols may induce enzymes that metabolise the hormonal contraceptive pill, so additional methods of contraception may be required in women of reproductive age.24 Interactions due to enzyme inhibition with other drugs, and combined sedative effects with other CNS depressants, should also be considered.
Some of the earliest licenced cannabinoid products were the synthetic cannabinoids dronabinol (THC) and nabilone, licensed in the 1980s as antiemetics prior to the development and widespread use of 5-HT3 antagonists.31 THC is thought to primarily act at the CB1 receptor to suppress vomiting through central actions in the brain, in addition to peripherally reducing gastrointestinal motility; there may be multiple mechanisms of action.31
A number of clinical trials for nausea and vomiting with chemotherapy have found benefits compared to placebo,32 though the majority of the studies were conducted more than two decades ago. Since that time, the range of effective medicines for nausea and vomiting has expanded quite rapidly. Cannabinoids have not been compared directly to these newer, more effective medicines. For this reason, there is very little contemporary evidence to demonstrate a role of medicinal cannabinoids for nausea and vomiting, other than where existing first-line treatments are ineffective. Typical starting doses of dronabinol are 2.5–5 mg, with dosing 1–3 hours before chemotherapy, repeating every 2–4 hours. A reduced dose of 2.5 mg is recommended in older adults to reduce CNS adverse effects.33
Cannabis use is contraindicated during pregnancy, though some pregnant women perceive it to be safer than other medicines and are unaware of the adverse effects that cannabis has on the foetus.34,35 Pregnant women with nausea and vomiting should be referred for medical assessment for prescription medicines that are established to be safe in pregnancy.
In palliation, the use of cannabinoids has been explored for their potential role in improving quality of life through addressing a range of symptoms including nausea and vomiting, cachexia (wasting and loss of muscle mass), sleep and analgesia.
A systematic review explored the role of cannabinoids for palliative care, synthesising a limited body of literature on the use of cannabinoids for cancer and human immunodeficiency virus (HIV) infection. The review found cannabinoids were no different to placebo in improving cancer-related weight loss, caloric intake, appetite, nausea and vomiting, sleep, quality of life or pain; however on the outcome of pain, there was a trend towards a positive effect. The two studies that examined the effect of cannabinoids on cancer pain were considered low quality, and the number of patients that would need to receive cannabinoids in order for one to report a meaningful reduction in pain was 13, suggesting that most patients would not see a benefit.36
For palliative care in HIV there were fewer studies overall but they did find low quality evidence that cannabinoids use could increase weight gain and improve appetite, though no difference was observed between cannabinoids and placebo for outcomes of nausea, or quality of life. Only two studies had an active comparator, directly comparing megestrol to dronabinol (THC). Both studies found that megestrol was superior to dronabinol on outcomes of weight gain (in people with cancer and HIV-related illness) and increasing appetite (in people with cancer). The review also found that patients were at increased risk of developing mental health symptoms with dronabinol.
Overall, the quality of studies to understand the role of cannabinoids in palliation was low to very low, though of note there are a number of larger high-quality studies ongoing, including in Australia to look at the use of cannabinoids in palliative care.37,38 These studies will be important in informing clinical practice in this area.
Due to the limited evidence, and the fact that many studies to date have not demonstrated benefits of cannabinoids for different aspects of palliation, the current recommendation in the TGA guidance is that medicinal cannabis treatment should be used only after standard treatments have failed. Medicinal cannabis may interact with chemotherapy and other medications used in palliative care, highlighting the importance of pharmacist involvement.
There is limited evidence to guide starting doses and dose titration though, in general, slower dose titration over 1–2 weeks is better tolerated. Most studies have used dronabinol, making it difficult to provide recommendations on dosing with other formulations.
Through a series of guidance documents, the TGA has summarised the state of evidence across some of the more commonly proposed indications for medicinal cannabis. There is generally limited evidence to inform clinical practice outside the already approved indications. The recent PBS listing of cannabidiol for Dravet syndrome will make products more affordable for this indication.2 Having a knowledge of what research has shown can help to set reasonable expectations about the likelihood a patient will find cannabinoids beneficial. Although pain is one of the most common reasons people request medicinal cannabis, a growing number of studies show that the amount of pain relief provided is usually relatively small. This must be balanced for patients against the cost of unsubsidised products, where patients report spending an average of over AUD$80 a week on medicinal cannabis.39
The TGA website, NPS and published systematic reviews provide the latest summaries of evidence on the use of medicinal cannabinoids. There are a large number of clinical trials underway which may further inform where cannabinoids have a clinical role and where they are ineffective. Given the rapidly changing evidence base, pharmacists will need to stay up to date with emerging evidence to be able to address patient queries and provide evidence-based advice.
NPS MedicineWise has produced resources for pharmacists, including a process for dispensing. Available at: www.nps.org.au/professionals/medicinal-cannabis-what-you-need-to-know
The evidence on the medical use of cannabinoids is still emerging for most conditions, with limited evidence of efficacy for many of the reasons that patients may request it. Pharmacists have an important role in helping patients navigate information and weigh up whether a trial of cannabinoids may be appropriate for them, and where cannabinoids have been prescribed, manage expectations, monitor for clinical effectiveness, adverse effects and consider the impact of potential drug interactions.
Case scenario continued
Claire has been prescribed a starting dose of 30 mg twice a day (she is 12 kg, and the usual starting dose is 2.5 mg/kg twice a day). You advise her parents that she will need to use the 1 ml syringe provided with the product to give a dose of 0.3 ml. If she responds and tolerates the dose, it may be increased after 1 week. You advise her parents that Claire may become drowsy, as this is a common side effect and there is an interaction between the cannabidiol and her existing medicines, which can also increase drowsiness. You advise them to monitor for this and other side effects as dose adjustments of clobazam and sodium valproate may be needed if Claire becomes excessively drowsy. Her parents confirm they have a follow-up appointment and that the doctor is also monitoring her liver function.
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Mr Ho, 67 years, asks you for treatment for an itchy rash on his back. He reports that it started yesterday, has a burning sensation and is very painful, despite his use of paracetamol. You elicit that the area was also painful before the rash appeared. After looking at the rash, you note the presence of fluid-filled vesicles in a roughly linear distribution on the right side of his back. You refer Mr Ho to his GP as you suspect he may have shingles.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5
Shingles is the common name for herpes zoster: a re-activation of latent varicella zoster virus (VZV) in someone who has already had primary VZV infection (i.e. chickenpox).1,2 The symptoms and complications of shingles can be severe and debilitating, requiring both pharmacological and non-pharmacological measures.
Pharmacists have an important role in ensuring effective shingles treatment and supporting patients to implement management plans.
In Australia, most adults will likely have had chickenpox at some point in their lives and therefore have some risk of developing shingles.3 Approximately 120,000 cases of shingles occur annually in Australia,4 and it is thought that one in three Australians will develop shingles in their lifetime.5
The incidence of shingles appears to be increasing, both in Australia and globally.4,6 The reasons for this trend are uncertain, but may be due to ageing populations and the increased use of immunosuppressant medicines.4,7 In Australia, the incidence of shingles in people aged over 80 years is three times higher than the incidence across all age groups.4
Pathophysiology and aetiology
Shingles results from re-activation of VZV in people who have previously had chickenpox and, very rarely, in people who receive the chickenpox vaccine.1,8 When the body’s immunity to VZV fails, latent VZV in the dorsal root ganglia can re-activate.9 The lifetime risk of VZV re-activation is approximately 50%.10 It is uncertain exactly what triggers this re-activation, however potential causes include malignancies, acute infections, stress and trauma.9
External re-exposure to VZV may also trigger re-activation.9 However, frequent re-exposure to VZV is also thought to help maintain a person’s immunity to VZV in people who have already experienced chickenpox.8 Risk factors for developing shingles (see Box 1) are largely related to reduced immunity to VZV, as a result from either immunosuppression or decline in immunity.8,9
When VZV is re-activated, an inflammatory response occurs along the neurons involved, and the virus travels along the neuron to the surface of the skin.8,9 This causes a characteristic, painful skin rash with fluid-filled vesicles.8,9 The virus can also spread to other organ systems, like the eyes (herpes zoster ophthalmicus [OZV]), or the central nervous system, which can result in serious complications.8,9
BOX 1 – Risk factors for developing shingles
HIV: human immunodeficiency virus; AIDS: acquired immunodeficiency syndrome References: Centres for Disease Control and Prevention8; Janniger9
Shingles typically presents with a characteristic rash along an affected dermatome, most commonly on the torso, which does not usually cross the body’s midline (see Box 2).8,9 The rash is usually painful, tingly or itchy, and develops clusters of fluid-filled vesicles.8,9 These vesicles continue to form over 3–5 days before crusting over, and usually heal within 2–4 weeks.8,9 People may experience a prodromal phase, with symptoms including painful or tingly skin of the affected dermatome and other non-specific symptoms (see Box 2).8,9
Immunocompromised people are more likely to experience involvement of multiple dermatomes or disseminated shingles.8,9 Disseminated shingles is characterised by the formation of additional, extradermatomal vesicles 7–14 days after the initial rash and can be difficult to differentiate from chickenpox.8,9 Disseminated shingles increases the risk of severe and life-threatening complications, including pneumonia, encephalitis and death.9
The diagnosis of shingles is largely based on clinical history and physical findings, namely the characteristic rash.8,9 Laboratory studies can confirm the diagnosis, such as polymerase chain reaction testing of vesicular fluid.9 However, due to the time for test results to return, laboratory confirmation is generally not required unless the presentation is atypical (e.g. in immunocompromised people).8,11
Differential diagnoses of the shingles rash consist mainly of other skin conditions, including cellulitis, chickenpox, atopic dermatitis, coxsackievirus, insect bites and erysipelas.9 Conjunctivitis and corneal ulceration are differential diagnoses for OZV.9 Other important conditions to consider with respect to shingles complications include Bell’s palsy, cholecystitis, and trigeminal neuralgia.9
Many people present to community pharmacies for treatment of a skin rash; shingles is an important consideration for pharmacists in the evaluation of such presentations. As shingles is a notifiable disease in Australia and treatment is time sensitive, pharmacists must refer anyone with suspected shingles to a general practitioner for review as soon as possible.8,9,12
BOX 2 – Signs and symptoms of shingles
References: Centres for Disease Control and Prevention8; Janniger9
Oral guanine analogues reduce acute pain, duration of the rash, viral shedding and ocular complications.1,13 The most benefit is seen when given within 72 hours of rash onset.1,13 Oral aciclovir, famciclovir and valaciclovir (a prodrug of aciclovir) are all recommended for treatment of shingles in immunocompetent adults and adolescents within 72 hours of rash onset (see Table 1a).1,14,15 For immunocompromised patients, it is recommended that treatment is commenced regardless of the timing of rash onset.1 There is no evidence to support the use of topical antiviral agents for the treatment of shingles.13
Valaciclovir and famciclovir both have less frequent dose intervals (see Table 1a)1,14 and may be more effective at reducing acute pain compared to aciclovir.1,13 Aciclovir is the preferred agent in pregnancy due to limited safety data for other agents, however some clinicians prefer valaciclovir because of the simpler dose frequency.1,13
Guanine analogues are generally well tolerated, with adverse effects mainly consisting of neurological symptoms such as vertigo and confusion.14 Aciclovir crystals can precipitate in renal tubules of dehydrated patients and cause renal impairment.14 Dose reductions are recommended in severe renal impairment (see Table 1a) to reduce the risk of adverse effects.16–19 Pharmacists should counsel patients to promptly commence therapy, complete the full treatment course, and avoid driving or operating heavy machinery if they experience confusion.14 For aciclovir and valaciclovir, patients should be counselled to ensure adequate hydration to reduce the risk of renal impairment.14TABLE 1a – Selected pharmacotherapy for the management of shingles
Acute pain associated with shingles can occur during the prodromal phase, with the rash and after resolution of the rash.20 The pain intensity can range from mild to severe and usually has both nociceptive and neuropathic features.20 In most cases, the pain will resolve over approximately 3 weeks, however elderly patients are at increased risk of longer and more severe pain.20 It is important to manage pain promptly,20 as higher pain intensity is a risk factor for developing chronic shingles pain.8
Simple analgesia (i.e. oral paracetamol and non-steroidal anti-inflammatory drugs [NSAIDs]), is recommended for mild nociceptive shingles pain unless otherwise contraindicated (see Table 1b).20 Oral prednisolone hastens resolution of shingles pain and is recommended for moderate to severe shingles pain (see Table 1b).20 Opioid analgesics can be added if oral paracetamol, NSAIDs and prednisolone are not effective or are not clinically appropriate.20 Analgesia for nociceptive pain should be continued until lesions are healed.20
Topical lidocaine patches are recommended as an adjunct option for neuropathic shingles pain if the skin is not broken, as there is lower risk of systemic adverse effects and drug interactions (see Table 1b).20 While this may be useful for elderly patients or those taking multiple medicines, the need to wait until lesions are healed and the lack of PBS-subsidy15 may limit utility in practice. Topical anaesthetic creams, gels and low-concentration capsaicin creams are not recommended, as there is no evidence of benefit in treatment of neuropathic pain.13,20–22
Gabapentin and pregabalin are recommended in conjunction with or as systemic alternatives to lidocaine patches (see Table 1b).20 These agents should be slowly titrated to effect to reduce adverse effects, such as sedation.14,20 Neuropathic pain may persist after lesions are healed, so regular re-assessment of pain and a plan for tapering of therapy is required.20
Non-pharmacological management options are important for preventing bacterial superinfection of shingles lesions and for preventing spread of infection.8 Patients should be counselled to keep the rash clean and dry, and to avoid scratching.2 A non-stick dressing to cover the rash can help avoid spreading of the virus, and may help protect the rash from painful stimuli and facilitate abstinence from scratching.1,2 Other options that may provide symptom relief include cold compresses and ice packs.20
TABLE 1b – Pharmacotherapy of acute pain associated with shinglesPBS: Pharmaceutical Benefits Scheme a Ibuprofen is listed here as an example of an NSAID rather than a preferred agent. b Pregabalin and gabapentin doses can be titrated to effect in intervals of 3–7 days. c Lower doses are recommended in renal impairment, and should also be considered for elderly and frail patients.14 Consult the Australian Medicines Handbook for more information.14 References: Rossi,14 PBS,15 eTG20
Complications of shingles
Complications of shingles are common, occurring in 13–26% of cases, and can be severe and debilitating.9 Complications are more common in elderly patients, disseminated disease and in immunocompromised patients.1,8,9 Severe complications include vision loss (in HZO), cranial nerve palsies, pneumonia, encephalitis and death.8,9
The most common complication of shingles is postherpetic neuralgia (PHN): pain that persists for at least 3 months after healing of lesions.10,20 PHN is usually severe and neuropathic.20 PHN significantly impacts quality of life, with pain sometimes lasting years.23 The risk of PHN increases with age, occurring in 20% of cases in patients older than 80 years compared to 10% in patients aged 50–59 years.10 Other risk factors for PHN include higher severity of acute pain associated with shingles, involvement of upper-body dermatomes and HZO.8,9,20
PHN has typical neuropathic pain features, such as burning and stabbing sensations and allodynia.20 Management involves adjunct pharmacotherapy (see Table 1) and elements of chronic pain management including social, psychological and physical techniques.20 While antiviral treatment of shingles reduces acute pain, it has not been shown to prevent the incidence of PHN.20,24
Bacterial superinfection of lesions is another complication of shingles and is usually due to group A Streptococcus species or Staphylococcus aureus.1 Superinfection of shingles lesions requires antibiotic treatment; recommended empirical options include topical mupirocin ointment, oral flucloxacillin or dicloxacillin.25,26
The live attenuated vaccine for herpes zoster (the zoster vaccine or Zostavax) is recommended for all immunocompetent Australians over 60 years, unless contraindicated, to prevent the incidence of shingles and shingles complications.10 The zoster vaccine boosts VZV immunity by producing an immune response to an attenuated VZV, thus protecting against re-activation of latent, wild-type VZV.27 Vaccination against shingles has been shown to significantly reduce the incidence of shingles and PHN, and reduces the burden of shingles illness.10
People with shingles vesicles that have not yet crusted can transmit VZV to other people, mainly via direct contact with vesicular fluid, although respiratory transmission is also possible.8,9 This can cause chickenpox in people who have not previously had chickenpox or the chickenpox vaccine.8,9 To prevent this, people with shingles should be counselled on self-care measures to prevent transmission until vesicles are crusted. These include: limiting contact with high-risk people (non-immune pregnant women, children <1 month, immunocompromised people); covering the rash; avoiding sharing bedding and towelling; practising vigilant hand hygiene; and avoiding touching or scratching the vesicles.1,2,8,9
Timely and effective treatment of shingles is critical given the risk of complications and disease transmission, and pharmacists have an important role to play. In addition to referring a suspicious rash for GP review, pharmacists can use their knowledge to ensure optimal management of shingles and help implement management plans. For example, pharmacists can advise doctors about the feasibility of treatment options in addition to clinical appropriateness, given the variability in dose regimens, cost and PBS subsidy. Pharmacists can also support patients to take non-pharmacological measures to manage and prevent shingles, such as assisting with dressing selection and explaining the need to limit contact with certain groups of people.
Shingles is common in Australia and can have severe and debilitating complications. Management of shingles involves antiviral therapy, analgesia and non-pharmacological measures to help with symptom relief, prevent complications and prevent transmission. Pharmacists play an important role in optimising treatment of shingles and supporting the implementation of management plans.
Case scenario continued
Mr Ho returns later in the afternoon with a prescription for valaciclovir 500 mg tablets and pregabalin 75 mg capsules, advising that his GP had diagnosed shingles. Mr Ho is hesitant about taking the pregabalin because people can become addicted to ‘pain killers’.
You counsel Mr Ho that pregabalin is used to treat nerve pain and that he is unlikely to form an addiction. You also counsel him to start the valaciclovir that evening and to ensure he keeps hydrated to avoid adverse effects.
Lastly, you explain that both medicines can cause confusion, and advise him to avoid driving or operating heavy machinery if this occurs.
SARA LINTON Bsc MPHARM MPS is a clinical pharmacist at the Royal Melbourne Hospital. Sara has provided clinical pharmacy services to general and acute medical units at several tertiary hospitals in Australia. Sara has also worked as a policy adviser on the Heart Foundation’s clinical guideline team.[post_title] => Management of shingles (herpes zoster) [post_excerpt] => Pharmacists can help ensure effective shingles treatment and support patients to implement management plans. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => management-of-shingles-herpes-zoster-cpd [to_ping] => [pinged] => [post_modified] => 2021-07-19 21:29:55 [post_modified_gmt] => 2021-07-19 11:29:55 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13700 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Management of shingles (herpes zoster) [title] => Management of shingles (herpes zoster) [href] => https://www.australianpharmacist.com.au/management-of-shingles-herpes-zoster-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 13703 )
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Ben, 28 years, takes olsalazine 500 mg twice daily maintenance dose for management of his ulcerative colitis. Recently Ben has been experiencing some acute flare-ups and personal issues, as he lost his job, which has forced him to start shift work. Ben discusses this with you and says he is finding it hard to maintain a routine. He also mentions that he has been forgetting to take his night dose. You think this may be contributing to his acute flare-ups and decide to contact his doctor.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.3, 1.4, 2.1, 2.3, 2.4, 3.2
Ulcerative colitis (UC) is a chronic, idiopathic inflammatory disease affecting the gastrointestinal tract (GIT) that results in continuous mucosal inflammation of the colon. The intestinal inflammation is confined to the colonic mucosa extending from the rectum towards the caecum. The natural history of UC is characterised by episodes of relapse and remission.1-3 UC is commonly grouped with Crohn’s disease (CD), another inflammatory disorder affecting the GIT, which fall under the umbrella term of inflammatory bowel disease (IBD).
The relapsing nature of UC typically results in a significant part of management consisting of reactive treatment of an acute flare. This invariably results in increased economic burden due to higher utilisation of health resources, such as surgery, and indirect costs, such as time off work or carer’s leave.4 Incidence of UC peaks in the second and third decade of life, which can heavily impact an individual’s ability to work, study and form relationships.2,3 Currently there is no known cure, and as a result of the disease’s relapsing nature, patients are repeat users of healthcare services in order to control exacerbations. Lifelong management of the disease involves a multimodal approach including: pharmacotherapy, nutritional supplementation, dietary modifications and surgical resection of diseased tissue.
The Australian Government’s publication of a strategic national IBD action plan, in March 2019, identifies and seeks to address the current shortfalls in the management of IBD as well as establishing a framework to enact impactful change.5 One of the identified priorities is the implementation of a multidisciplinary team of healthcare professionals to provide specialised patient-centred care and therapy. Pharmacists are one of the three allied health professionals, along with psychologists and dietitians, identified as integral to management of IBD patients.5 This highlights the importance of pharmacists in the management of patients with IBD, and as more therapies become available, complexity of regimens may increase and pharmacists will be further relied upon to provide evidence-based health advice to other healthcare professionals and patients.6
IBD was previously seen as a disease of Western developed countries, however recent data indicates increasing emergence in Asia and South America.7 Australia has one of the highest rates of prevalence and incidence of IBD globally, representing a significant cost burden to the healthcare system.8,9
Population studies indicate that UC exhibits a bimodal age distribution, initially peaking between the ages of 20 and 30, and a smaller second peak occurring between the ages of 50 and 80.3 Currently there are no consistently identified significances predisposing UC in either sex.2 A familial history has been identified in 8–14% of patients with UC, with first-degree relatives at four times the increased risk of developing the disease.10,11
Overlap exists between the risk factors for UC and CD, and include age, gender, genetics, environmental factors (such as diet and smoking), intestinal microbiota disequilibrium and previous appendectomy.2,12
Despite sharing risk factors, the effects of smoking and appendectomy prior to diagnosis have diverging effects between the two conditions. Counter to the established healthcare benefits of smoking cessation, smoking tobacco demonstrates a protective effect in UC, reducing the severity of disease as well as decreasing the risk of developing disease.3 Whereas seemingly counterintuitive to current public health advice, smokers who are at increased risk of developing UC and quit are nearly at a 70% higher risk of developing UC and will often develop more widespread and treatment-resistant disease in comparison to individuals who have never smoked.3,12 Prior appendectomy, or mesenteric lymphadenitis during childhood/adolescence, appears to reduce the risk of developing UC later in life.3 The removal of the appendix after a diagnosis of UC as a therapeutic option for disease management is less understood, with further research required.2,3
The precise aetiology or pathogenesis of UC is currently not known, thereby impeding the possible development of curative medical therapy. Surgical colectomy is considered curative in UC; however, it is associated with significant morbidity, such as pouchitis, faecal incontinence, and female infertility.2,3,13,14TABLE 1– Montreal classification of extent of ulcerative colitis Reference: Silverberg MS19
The classical UC presentation of bloody diarrhoea with or without mucus is due to inflammation in the colon resulting in gastric contents rapidly passing through. Other symptoms include: rectal urgency, tenesmus (crampy abdominal pain that is often relieved by defecation), and systemic symptoms (e.g. fatigue, fever and weight loss).2,3,12 The symptoms are dependent upon the extent and severity of disease and present episodically, sometimes escalating in frequency and severity, which can result in hospitalisation for acute management, possibly requiring surgery.3
Patients with IBD are at 3–4 times higher risk of venous thromboembolism (VTE), which is further increased when patients are admitted to hospital with an acute flare.15 Unless there are contraindications, VTE prophylaxis should be prescribed during an inpatient stay.16
Extraintestinal manifestations (EIM) are also seen in patients with UC, however they are less common than with CD.2 The most common EIM seen in UC patients are those affecting the musculoskeletal system (e.g. peripheral arthritis, spondylitis) followed by dermatological (e.g. erythema nodosum, pyoderma gangrenosum), renal (e.g. nephrolithiasis), and ocular (e.g. conjunctivitis, uveitis). Approximately a third of UC patients will develop EIM during their lifetime, with up to a quarter of patients having an EIM prior to their UC diagnosis.2,8,17
Timing from onset of symptoms to diagnosis is usually shorter in UC than CD, often occurring over weeks to months as opposed to years.3 Diagnosis is based on the combination of a detailed clinical history of the patient’s presenting symptoms, physical examination, laboratory tests (e.g. biochemical and stool sample), endoscopic findings and biopsy histology. These investigations are necessary to exclude similar gastrointestinal disorders, such as irritable bowel syndrome, infectious gastroenteritis (viral or bacterial [e.g. Clostridium difficile]), traveller’s diarrhoea, appendicitis, neoplasm, coeliac disease or CD.2,3,12,14,18
Once diagnosis is confirmed, determining the distribution, severity and the site(s) affected are integral to guide selection of pharmacotherapy, appropriate route of administration and prognosis.1,2,12 The Montreal classification system is commonly used and is based on extent and severity of disease (see Table 1 and Table 2).19
TABLE 2 – Montreal classification of severity of ulcerative colitis*ESR: erythrocyte sedimentation rate Reference: Silverberg MS19
The goals of management are to induce and maintain remission without the need for surgery, heal mucosa, prevent disease progression, and limit the adverse effects of the chosen pharmacotherapy.14
Pharmacological management is determined by3,14,20,21:
First-line therapy for mild to moderate disease is the aminosalicylates (5-ASA), which are available in a variety of formulations, including tablets, suppositories, foam applicators and enemas. 5-ASAs exert a local anti-inflammatory effect to the mucosa, with limited effect on deeper inflammation.17,21–23
Foam applicators and enemas have greater colon penetration than suppositories and should be used if inflammation extends beyond 20 cm from the anal verge. Although foam applicators are better tolerated than enemas, they only reach the sigmoid colon, whereas enemas reach the splenic junction.1,17
Combination therapy with oral and topical formulations should always be used to induce remission of left-sided UC.17,21,23
For isolated proctitis, targeted topical therapy with suppositories has shown greater therapeutic outcomes, compared to oral formulations.1,10,23 When proctitis treatment is refractory to 5-ASA, a topical corticosteroid should be introduced.1,17 Topical corticosteroids offer an alternative for patients intolerant of 5-ASA.1,17 Rectal corticosteroids are also used as second-line add-on therapy to induce remission in left-sided UC if patients have an inadequate response to 5-ASA therapy.1
Introduction of an oral corticosteroid is dependent on: response and tolerance of 5-ASA, extent of disease, as well as the patient’s preference. The typical time frame to achieve a sustained clinical remission with 5-ASA therapy is 37–45 days; 24 cessation of rectal bleeding is expected at around 10–14 days after treatment is commenced.21 Initiation of oral corticosteroids as an adjunctive to 5-ASA treatment is recommended when symptoms worsen, rectal bleeding continues past 10–14 days, or overall symptom relief has not been achieved after 40 days.17,21,23,24 If required, prednisolone or prednisone are started at 40–50 mg once daily, until response, then tapered down over a 6–8 week period.1,21 Patients should be counselled about possible short-term adverse effects, such as sleep and mood disturbance, glucose intolerance and dyspepsia.21
5-ASAs have proven efficacy at maintaining remission, and patients who achieve remission with 5-ASA should continue on the same medicine.1 Patient surveys indicate 5-ASA non-adherence is a significant problem that can contribute to the development of flares and disease progression. Simplifying regimens and consulting with patients about their preferences regarding the formulation (i.e. granules or tablets), regimen and the size and total number of tablets taken have shown to improve adherence.25 Once-daily dosing of 5-ASA in both induction and maintenance has demonstrated comparable efficacy to divided doses and can be considered to improve adherence.1,23
If there is no response to 5-ASA treatment, or the patient has poor prognostic factors, escalation in therapy with immunomodulators (thiopurines or methotrexate) and/or biological treatment (anti-TNF-α or anti-integrin therapy) may be required.1 Factors associated with poor prognosis include: young age at disease onset, extensive colitis, deep ulcerations, two or more courses of corticosteroids in a year or corticosteroid dependence.14,17,21
Patients who start treatment with an immunomodulator require full blood count monitoring during the first 3 months of treatment.1 Those started on thiopurines require thiopurine S-methyltransferase (TPMT) testing prior to commencement to establish their enzymatic activity.14 Immunomodulators have a slow onset of action (2–3 months) and are therefore intended for maintenance treatment.14
Moderate to severe disease
Induction and maintenance
Initiation of biological therapy with an anti-TNF-α (e.g. infliximab or adalimumab) or an anti-integrin (vedolizumab), with or without an immunomodulator, requires specialist care. Commencement of biological therapy requires a thorough assessment of the patient, including factors beyond usual patient characteristics such as age, comorbidities and previously trialled therapies. Patient preference (e.g. subcutaneous injection versus intravenous infusion), risk of adverse effects, likely adherence and ability to attend appointments for regular infusions need to be considered when determining therapy, which should be individualised with a shared decision-making process in place.26
For biological therapy to be Pharmaceutical Benefits Scheme (PBS)subsidised, patients must have either failed to reach adequate response to, or developed an intolerance necessitating withdrawal of, an immunomodulator. Commencement of biological therapy does not necessitate removal of an immunomodulator, despite inadequate response being the reason for biological therapy initiation.1,27 The UC-SUCCESS trial demonstrated that combined infliximab and azathioprine treatment is more effective in achieving clinical remission and mucosal healing than with monotherapy of each.28
Combination therapy also has established evidence in reducing immunogenicity associated with biological treatment, a contributing factor to infusion reactions and loss of response.23,29 This is significant as UC is a lifelong chronic disease, and if response can be maintained to biological therapy, this will help prevent further relapses.
Once remission is induced, treatment should continue to become maintenance therapy.1 Specialist involvement is necessary to monitor the patient’s progress and to re-evaluate ongoing combination therapy. Combination therapy is usually continued for 12–18 months to preserve efficacy by preventing development of antibodies, before possible de-escalation to monotherapy.30 Therapeutic decisions to change therapy should be made on a case-by-case basis directed by a specialist, in consultation with the patient.14
Acute severe ulcerative colitis
Acute severe ulcerative colitis (ASUC) is a life-threatening medical emergency requiring admission to hospital and specialist management.1 Patients are commenced on intravenous corticosteroids to reduce inflammation and are monitored closely over the next several days to see whether escalation of medical therapy or surgery is required.12 Failure to respond to intravenous corticosteroids within 3–5 days requires escalation to either intravenous ciclosporin or infliximab.1,12,17 Surgery is required if these medicines fail.12,17
Psychological impact and disease burden
Despite greater awareness and recognition of the psychological impact IBD has on a patient’s quality of life, the importance and management of this is often overlooked.5,6 In an Australian survey, results showed 51% of IBD patients had possible anxiety or depression, with 16% on psychotropic medicines.6 Surveys directed to elucidate patients’ concerns with IBD revealed the majority of answers ‘were not simply disease symptom-related, but included fatigue/loss of energy, fear of uncertainty/loss of control, body image and fear of producing unpleasant odours’.31
Pharmacists should not only recognise the significant impact that living with a chronic disease can have on a person’s life, but also their responsibility to discuss these matters with patients and normalise any associated stigma. Pharmacists should encourage patients to discuss these matters with their doctor in order to organise referral to a psychologist, if required.
Calcium 1000 mg daily and vitamin D (800–1000 IU daily) should be commenced in patients with IBD being treated with corticosteroid therapy, if dietary intake is inadequate.1 Although this treatment should result in increased bone density, it is unknown whether it prevents fractures in IBD patients.14
Infection prevention and vaccination
Infection risk is increased with the medicines used to treat UC. Inactivated vaccines, such as the influenza vaccine and pneumococcal vaccine, are generally safe and appropriate in patients on immunosuppressive treatment.32 Whereas attenuated vaccines are typically contraindicated in patients receiving immunosuppressive therapy.32 If patients need to catch up on immunisation or require a live vaccine for travel purposes (e.g. yellow fever vaccines) they should liaise with their specialist.32
Iron deficiency anaemia (IDA) is a common complication of IBD, attributed to poor nutritional intake or malabsorption, chronic blood loss and the effect inflammation has on bone marrow and iron transport.1 It is imperative pharmacists check and confirm whether a patient’s doctor has investigated the possibility of IDA. Oral iron supplements have the ability to worsen symptoms and should therefore be avoided in IBD patients; intravenous iron therapy is a suitable alternative if IDA is confirmed.1
Women should be referred to their doctor to discuss management in relation to pregnancy and breastfeeding, and any changes to therapy that may be needed. Men should also seek input, as sperm quality can be affected by 5-ASA and methotrexate.1
Either sex with inactive IBD has comparable ability to the general population to conceive. Despite this, women with IBD demonstrate a lower birth rate, unrelated to fertility, suggesting ‘voluntary childlessness’.6 An Australian IBD cohort study reported five areas of IBD-related fear regarding reproductive decision-making: adverse fetal effects of IBD medicines and surgery (84%), adverse effect of disease activity on pregnancy outcome (19%), adverse effect of pregnancy on disease activity (18%), congenital abnormalities (18%) and IBD inheritance (15%).33
Ulcerative colitis is a chronic, potentially debilitating gastrointestinal disorder that can significantly impact a patient’s quality of life, affecting both their future health and economic prospects. At present there is no cure. Patients are commonly treated with a combination of prescription medicines, which cause suppression of the inflammation via immunosuppressive mechanism of action. Surgical resection is also routine for management of UC; however, these cases are predominantly severe, treatment-refractory cases. With an increasing global incidence of IBD, no current cure and the introduction of increasingly complicated regimens, it is imperative pharmacists stay abreast of the challenges associated with the disease and work collaboratively with other healthcare providers to support patients.
Case scenario continued
You discuss with Ben’s doctor that his acute flare-ups may be related to lack of adherence. Ben is now working night shifts and is sometimes forgetting to take his night dose. You recommend a trial of taking both tablets in the morning as a single dose. This has been shown to be as effective as divided doses and may help with adherence. Ben’s doctor agrees with you and sends you a new prescription with these details.
You advise Ben that you have spoken to his doctor and you both agreed that he should trial taking both tablets in the morning as a single dose. You inform him this will be just as effective and possibly reduce the number of flare-ups he may experience in the future.
CHARLES PALMER BPharm (Hons)is a Senior Pharmacist at Fiona Stanley Hospital, Western Australia. He has been involved in the management of patients with IBD receiving regular maintenance biological therapy. His interests include Indigenous health, infectious diseases, immunology, biological medicines and general medicine. He is currently completing a Master of Infectious Diseases.[post_title] => Ulcerative colitis: The colon is just the tip of the iceberg [post_excerpt] => With the introduction of increasingly complicated regimes, it is imperative pharmacists stay abreast of the challenges associated with the disease. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => ulcerative-colitis-cpd [to_ping] => [pinged] => [post_modified] => 2021-07-29 21:46:41 [post_modified_gmt] => 2021-07-29 11:46:41 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13649 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Ulcerative colitis: The colon is just the tip of the iceberg [title] => Ulcerative colitis: The colon is just the tip of the iceberg [href] => https://www.australianpharmacist.com.au/ulcerative-colitis-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 13653 )
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Felix, 75 years, tells you he sleeps poorly these days. For the last 6 months he has been waking 2–3 times during the night, and it takes him a long time to get back to sleep. He worries about his wife, who is getting frail and may need to go into care. They don’t go out much and rely on delivered evening meals.
He asks if he can take valerian with his other medicines, as it’s a natural product. His medicines are irbesartan, atorvastatin, and ibuprofen when needed for osteoarthritis. How do you respond?
After successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.3, 1.5, 2.3, 3.2, 3.5
Insomnia is an inability to fall asleep or remain asleep, despite adequate opportunity, that can lead to daytime impairment.1,2 It has historically been referred to as a primary condition or secondary to another disorder (e.g. depression or pain), and can be acute (short term) or chronic.3 Insomnia is one of the most common complaints presenting to primary care,1 and community pharmacists are in the right place to offer advice on initial management.
The Therapeutic Guidelines state that 30% of the population3 complain of sleep disruption, while a prevalence closer to 40% has been estimated in international studies.4 Estimates of insomnia prevalence vary depending on the definitions used.4
A recent Australian report found almost 60% of adult Australians across all age groups regularly experience at least one chronic sleep symptom (e.g. trouble falling asleep, staying asleep, waking too early) that affects their quality of life.1 Almost 15% of respondents met the clinical criteria for chronic insomnia defined by the International Classification of Sleep Disorders. Few had consulted a doctor for a diagnosis.1
When a patient presents to a pharmacy with a sleep problem, non-pharmacological strategies are the treatment of choice for both short-term and chronic insomnia and should be recommended.2,5,6
If pharmacological treatment is necessary, when symptoms are severe or causing distress, or if there is no response to behavioural strategies, non-prescription medicines may be used. Melatonin modified-release tablets containing 2 mg or less are now included as a Schedule 3 Pharmacist Only medicine for packs containing fewer than 30 tablets.6 This listing is indicated for short-term treatment (≤3 weeks) of primary insomnia in people aged 55 years and over.7
Insomnia is a common condition for which consumers seek pharmacist advice. In light of the recent melatonin down-schedule, it’s even more important for pharmacists to understand the condition and its management.
NPS MedicineWise sleep hygiene fact sheet. At: www.nps.org.au/consumers/how-to-sleep-right
Sleep Health Foundation fact sheets about sleep. At: www.sleephealthfoundation.org.au/fact-sheets.html
Sleep Australia. Insomnia Severity Index. At: https://sleepaustralia.com.au/docs/Insomnia-Severity-Index-Sleep-Australia.pdf
Best Practice Advocacy Centre New Zealand sleep hygiene information. At: https://bpac.org.nz/2017/docs/insomnia-patient.pdf
Insomnia is defined as a perceived inability to initiate or maintain sleep, or a lack of refreshing sleep (i.e. quality sleep), despite adequate opportunity to sleep.1,3 Daytime consequences can be wide-ranging, including distress or functional impairment in social, occupational, educational, academic and behavioural areas.1
Acute insomnia usually occurs in response to a short-term stressor (e.g. stress, physical illness)3 or environmental factors such as light exposure, high or low temperature or an uncomfortable bed. If not addressed and poor sleeping habits develop, the condition can become chronic.4
When insomnia occurs at least three times a week for at least 3 months, it meets the criteria for classification as chronic insomnia disorder.1
These definitions align with classifications in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and the International Classification of Sleep Disorders (ICSD-3).1 Although these international classifications define ‘chronic’ as 3 months or more, the Therapeutic Guidelines refer to chronic insomnia as lasting more than 30 days.3
Insomnia has historically been classified as primary or secondary. Primary insomnia describes sleeplessness that cannot be attributed to an existing medical, psychiatric or environmental cause, including drug abuse or medicine, and is not associated with another sleep disorder.4
Secondary insomnia occurs as a secondary effect of another medical condition (e.g. cancer, Parkinson’s disease), psychiatric illness (e.g. anxiety), another sleep disorder (e.g. sleep apnoea) or a movement disorder (e.g. restless legs). It can also arise from drug or alcohol use or withdrawal.4,8 Anxiety and depression are the most common comorbidities with chronic insomnia.4
This article will now refer to insomnia that is the primary type.
Insomnia is thought to be a condition of hyperarousal.4 Worry about life events (e.g. a death) and stresses (e.g. work pressures) can affect sleep onset and problems getting back to sleep after waking. Once experienced, sleep disruption can persist because of anxiety and poor adaptation to the situation.4
Physiological observations (e.g. oxygen levels, heart rate) also suggest a hypermetabolic state. Metabolic rates are higher, and heart rates are higher and less variable, during all stages of sleep compared to normal sleepers. Heart rate variability provides a measure of sympathetic and parasympathetic nervous system activity, but more evidence is needed to link this to insomnia.4
Hyperarousal is considered much less common in older people, as daytime sleepiness is usually the only sign of daytime impairment in this age group.1
An Australian report found older respondents (65 years and over) woke more during the night or early in the morning than those aged 18–24 years, while younger respondents had more trouble falling asleep.1 Women worried more about getting a good night’s sleep and being overwhelmed by disruptive thoughts, while daytime impairment was more common in women and younger people.1
Age-related findings can be partly explained by changing sleep patterns with aging. Older people (without dementia) spend less time in restorative stages of sleep and more time in lighter stages when periods of wakefulness can occur.2 Those with dementia can experience more disruptive, shallow sleep that exacerbates dementia symptoms.2
This report also concluded that insomnia is affected by activities in the hour before bed, including use of technology, working, eating, drinking alcohol and use of social media, regardless of age.1
Medicines can contribute to sleep disturbances by causing nocturia, nightmares, stimulation or changed sleep patterns.2 Causative agents include alcohol, amiodarone, antihistamines, beta-blockers, caffeine, corticosteroids, diuretics, donepezil, hypnotics, levodopa, methyldopa, statins, nicotine, pseudoephedrine, SSRIs, levothyroxine and venlafaxine.2 Acetylcholinesterase inhibitors, dopamine agonists and SSRIs are most likely to be associated with sleep disturbance.4
Other risk factors with a strong correlation to insomnia include traumatic brain injury, poor sleep hygiene and pain.4
Few Australians speak to their doctor about sleep issues.1 Considering the potential consequences of a lack of quality sleep on a person’s health, the diagnosis and identification of a possible cause are important so appropriate treatment can be accessed.4
When a secondary cause is excluded, diagnosis is made by taking a medical and sleep history.4 The patient should be asked about their sleep habits, level of distress, daytime naps, use of stimulants and their worries. A sleep diary (e.g. http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf) or an actigraphy wrist monitor can help, particularly when the patient’s history is incomplete or unreliable.4
Questionnaires can be used to help with diagnosis and quantify the extent of the problem. These include the Pittsburgh Sleep Quality Index, Insomnia Severity Index and Epworth Sleepiness Scale.9,10,11
In a laboratory, a sleep study using polysomnography (PSG) to monitor physiological variables is the best test for evaluating sleep, but it is rarely required for diagnosis.4 PSG is used when obstructive sleep apnoea or movement disorders are suspected, or when treatments (e.g. cognitive behavioural therapy, medicines) are unsuccessful.4
A patient with sleep disturbance should be considered for an underlying cause, including medicines, pain and other suspected sleep disorders (e.g. obstructive sleep apnoea). If a secondary cause or chronic insomnia is suspected, the patient should be referred for specific management.4,6 Patients should also be referred if there is no response to non-pharmacological treatment or any contraindications to non-prescription treatment options.6
Patients may be referred to a sleep specialist if the diagnosis is unclear. Further investigation (e.g. sleep study) may be needed, if the patient has a long history of sleep problems, is nonresponsive to treatment, or has a suspected intrinsic sleep disorder.3
The aim of treatment is to improve sleep quality and quantity, and relieve subsequent daytime impairment.3
Non-pharmacological therapy is considered first-line.2 Pharmacological treatment may be considered if symptoms are severe, causing distress, or if there is no response to behavioural strategies.6
Behavioural and psychological interventions have demonstrated effectiveness, including in older people, and the effects are longer lasting than pharmacological therapy.2 These include4,6:
In addition, all patients should be educated about healthy sleep behaviours (previously known as sleep hygiene) that are conducive to sleep, including2,6:
If pharmacological treatment is required, it should be used in combination with non-pharmacological therapies for the shortest duration possible and preferably on an ‘as required’ basis.3 Hypnotics should be used at the lowest effective dose for no more than 2 weeks.5
Melatonin is an endogenous hormone associated with circadian rhythms and sleep regulation.3 It is used for managing sleep disorders and jet lag, and to resynchronise circadian rhythm in shift work and blindness.12
Melatonin may be used to reduce sleep onset latency and improve sleep quality in some people aged over 55 years, although only 30–50% of people respond.5,6 To date, there is limited long-term efficacy and safety data to support melatonin treatment beyond 3 weeks.2,3
A prolonged-release 2 mg tablet is available in Australia with a new S3 listing: ‘monotherapy for the short-term treatment of primary insomnia characterised by poor quality of sleep in patients who are aged 55 years or over.’7 The dose should be administered 1–2 hours before bedtime.2,5
Melatonin may be preferred when there are concerns about adverse effects with other agents, e.g. benzodiazepines.12 It does not appear to cause dependence, withdrawal symptoms or rebound insomnia.5 Unlike hypnotics, it does not appear to impair daytime function or risk abuse.3
There is limited evidence for the effectiveness of sedating antihistamines to treat insomnia (e.g. diphenhydramine, promethazine, doxylamine).3,4,6 They can cause significant adverse effects and their long-term use has not been evaluated.4
Prescription medicines used in the treatment of insomnia include benzodiazepines (e.g. diazepam, oxazepam, temazepam), zolpidem, zopiclone and suvorexant.6
Hypnotics lose their efficacy after consecutive use for 2 weeks, impair daytime function and increase the risk of tolerance and dependence with long-term use.2,3 This is more likely with long-acting benzodiazepines (e.g. diazepam, nitrazepam), which should be avoided.2
Zolpidem and zopiclone have similar sedative properties to benzodiazepines.3 They are not ‘safer’ (e.g. risk of falls) than shorter-acting benzodiazepines,2 but may offer less morning sedation and disruption on normal sleep patterns.3
The newer medicine suvorexant (non-PBS) may be useful for sleep maintenance, but it has not shown benefit in falling asleep. Further evidence is needed to demonstrate its place compared to other treatment options.5
Antipsychotics and antidepressants are not recommended because of limited evidence of efficacy and the risk of adverse effects (e.g. anticholinergic effects), particularly in older people.2–5
Many complementary or herbal sleep products are available to help improve sleep. These include valerian, passion flower, hops, chamomile tea, catnip and magnesium. They all claim to have hypnotic properties, but current evidence does not support their use and they are not included in guidelines.2,5
Complementary medicines in Australia are regulated as unscheduled medicines and are self-selected.13
Acupuncture and homeopathy may also be considered to treat insomnia but evidence is lacking. Further studies to assess the efficacy of alternative therapies are needed.2,4
Melatonin adverse effects were reported at a similar rate to placebo.5,6 Some potential interactions include ciprofloxacin, fluvoxamine, antineoplastics and alcohol (can result in dose dumping of the modified release formulation).6 Melatonin is contraindicated in people with hepatic impairment and autoimmune disorders.6
Adverse effects to sedating antihistamines include drowsiness (may include daytime sedation), dizziness, dry mouth, blurred vision and tolerance.6 Alcohol increases the sedative effects of these medicines, other interactions include dalteparin, ketamine, and monoamine oxidase inhibitors.6 Sedating antihistamines are contraindicated in people with closed-angle glaucoma, jaundice, bladder neck obstruction and in children younger than two years.6
Hypnotics can cause daytime sleepiness and sedation, dizziness, ataxia, falls, confusion, incontinence, dependence, short-term memory loss and respiratory depression.2,4 Older people are more vulnerable to these effects.2
Benzodiazepines can affect the quality of sleep (shallow and less restorative), with daytime consequences.2
Risky, sleep-related behaviours have been associated with benzodiazepine-related hypnotics, such as sleepwalking. Impaired alertness has been reported the morning after zolpidem, particularly in women and older people.2 Considering their adverse effects and potential for dependence, withdrawal and rebound insomnia if taken for longer than 2 weeks, benzodiazepines and related drugs should be used intermittently for short periods only, at the lowest dose possible.2,3
They should be avoided in people with sleep apnoea or chronic obstructive pulmonary disease.2
As a cytochrome P450 (CYP3A4) inhibitor, valerian has the potential to interact with medicines metabolised by CYP3A4. Alprazolam levels have been shown to increase significantly in combination with valerian. Pharmacodynamically, the adverse effects of CNS depressants can be increased in combination with valerian. Patients should be discouraged from using valerian with alprazolam or CNS depressants.13
The Therapeutic Goods Administration is currently investigating the safety of valerian following reports of liver injury. Based on international evidence to date the effect is rare, however the investigation findings could result in regulatory and labelling changes in the future.14
Knowledge of insomnia and its management allows pharmacists to implement theory into everyday practice for this common complaint.
Consider if an underlying condition has caused a person’s sleep problems, and refer if necessary. If the condition is likely to be primary insomnia, suggest they use a sleep questionnaire resource and/or sleep diary to assess sleep quality. Counsel them about sleep hygiene and recommend avoidance of triggers, if possible.
For chronic insomnia, a pharmacist could suggest relaxation techniques, sleep hygiene practices, and cognitive behavioural therapy (CBT). Follow-up to assess the benefits of lifestyle and behavioural measures is important, as persistent problems may need referral for further investigation (e.g. sleep study).
A non-prescription medicine could be considered if behavioural therapies are ineffective or unsuitable. Historically complementary medicines have been suggested, but their use is not recommended because of limited evidence. The patient may meet the criteria for melatonin supply as an S3.
This recent down-schedule provides direction for appropriate use in the over 55-year-old cohort.
Pharmacists should provide advice on the safe, short-term use of hypnotics, including duration of therapy, consideration of other medicines that compound adverse effects, and follow-up as needed.
The resources listed below may help patients with behavioural strategies.
The digital version of the Australian Pharmaceutical Formulary (APF) contains a recently updated non-prescription medicine guideline on insomnia. This includes information about a pharmacist’s professional and legal obligations, factors that may contribute to the development of insomnia, management options, including a summary table of non-prescription medicine options, and patient counselling advice.
Accompanying case studies, accredited for Group 2 CPD points, have been developed to support pharmacists with the recent down-schedule of modified-release melatonin and can be accessed here: https://my.psa.org.au/s/training-plan/a110o00000C0uF7AAJ/insomnia-treatment-guideline-case-studies
Sleep problems are common, but few people consult a doctor for help. After ruling out an underlying cause, management should start with non-pharmacological strategies, which have demonstrated effectiveness. Pharmacists are able to refer, when appropriate, and advise on the safe use of prescribed and non-prescription medicines.
Case scenario continued
You advise Felix that his sleep can be improved with some simple strategies. You provide education about sleep hygiene and suggest he try some relaxation exercises and go for a walk during the day. Felix tells you he doesn’t want to leave his wife at home alone and his waking is causing him distress. You decide that pharmacological treatment may be appropriate, and recommend he take non-prescription melatonin modified-release tablets 2 mg 1–2 hours before bed. You explain there is better evidence for the use of melatonin compared to valerian. You explain melatonin should not be taken for longer than 3 weeks at a time and ask him to return within 3 weeks for review, or sooner if he has any concerns.
ANN WINKLE BPharm, BA, AACP, MPS is a contracting and accredited pharmacist with extensive experience in developing and delivering education programs to GPs and pharmacists. Ann has previously worked for PSA on the National Resource Development team, NPS MedicineWise as a facilitator and as a clinical hospital pharmacist.[post_title] => Insomnia [post_excerpt] => Insomnia is one of the most common complaints presenting to primary care, and community pharmacists are in the right place to offer advice on initial management. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => insomnia-cpd [to_ping] => [pinged] => [post_modified] => 2021-07-12 21:36:05 [post_modified_gmt] => 2021-07-12 11:36:05 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13628 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Insomnia [title] => Insomnia [href] => https://www.australianpharmacist.com.au/insomnia-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 13631 )
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John has been experiencing chronic pain for 5 years related to an occupational injury. His friend said THC oil would take all his pain away. John has just started a new job as a delivery driver and has reasonable pain control with his current analgesics, but he wonders if his life would be better if he could get THC. He asks you for your advice.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.3, 1.4, 1.5, 3.5
Over the past decade there has been a growing interest in medicinal cannabis in many countries, including Australia. There is a limited range of approved cannabinoid medicines in Australia, though unregistered products are accessible for therapeutic use. There is no agreed definition for the term ‘medicinal cannabis’, but the term is broadly used to refer to products containing delta-9-tetrahydrocannabinol (delta-9-THC or ‘THC’), cannabidiol (CBD), or synthetically derived cannabinoid compounds similar to those derived from the Cannabis sativa plant that are used for a therapeutic indication.1 In contrast with unregulated forms of cannabis, cannabinoids accessed through current Special Access Schemes (SAS) have known quantities of THC and/or CBD and have been cultivated according to approved safety standards.
With the introduction of the SAS for cannabinoids as unregistered medicines, pharmacists have an increasingly important role in providing information to patients on the therapeutic effectiveness, the adverse effects and the possible role of medicinal cannabis products in treating various conditions. Pharmacists can assist consumers in understanding the plethora of conflicting information available in the mainstream media and online fora, identifying where there may be evidence to support a trial of cannabinoids for a specific indication, monitoring outcomes, and identifying potential interactions and adverse effects.
The most widely studied cannabinoids are THC and CBD. In addition, there is a range of synthetic therapeutic cannabinoids such as dronabinol and nabilone. Dronabinol has the same chemical structure as THC; nabilone has a similar chemical structure to THC but is considered more potent.2
Cannabinoids are highly lipophilic, crossing the blood-brain barrier easily. Bioavailability depends on the route of administration, with higher bioavailability when inhaled and taken by oral mucosal spray compared with when taken orally, due to high first-pass metabolism. Absorption of THC and CBD is also influenced by dietary fats, with a 2–3 fold increase in absorption when co-administered with lipids, having the potential to contribute to toxicity.3
THC binds to two different G-protein coupled receptors (GPCR), referred to as the cannabinoid type-1 receptor (CB1) and type-2 receptor (CB2). CB1 receptors are found predominantly, but not exclusively, in the central nervous system, while CB2 receptors are commonly found on immune receptors. THC effects are primarily through activation of CB1 receptors, where it acts as a partial agonist. Nabilone binds to the same receptors but is more potent, 1 mg of nabilone equivalent to approximately 7 mg of THC.2 CB1 receptor agonists, such as THC and nabilone, have analgesic, antiemetic and antispasmodic effects, and psychoactive effects including sedation, euphoria and cognitive impairment. THC appears to act at both spinal and supraspinal (central and peripheral) levels to produce analgesia.4
CBD is often referred to as being ‘non-psychoactive’, as it does not directly cause effects such as sedation and hallucinations, although there are various studies that explore its effects on conditions like anxiety.5 Unlike THC, CBD is not considered to contribute to other psychoactive effects such as euphoria (often referred to as producing a ‘high’). The mechanism of the therapeutic effects of CBD are not well understood; the most understood are anticonvulsant effects.5
How cannabidiol exerts its anticonvulsant effects in humans is currently unknown, though it is not via cannabinoid receptors. Pre-clinical data support several plausible mechanisms by which cannabidiol reduces neuronal excitability, such as through functional antagonism of GPR55 receptors, desensitisation of TRPV1 receptors and inhibition of adenosine transport.6
There is also some interplay between THC and CBD, although the evidence is unclear. CBD is proposed to reduce some of the unwanted psychoactive effects of THC; conversely some studies suggest it may worsen symptoms.7,8 Evidence in pain is also conflicting and inconclusive. For example, in one study CBD administered with THC led to increased THC plasma concentrations but reduced THC-induced analgesic effects.9 This result was thought to suggest synergistic pharmacokinetic but antagonistic pharmacodynamic interactions of THC and CBD.9
In addition to their effects via CB1 and CB2 receptors, cannabinoids act on multiple other receptors, including deorphanised GPCRs, serotonin, NMDA, GABA and adenosine receptors in the central nervous system.10 There is also interplay between the opioid and cannabinoid system, with synergistic mechanisms between cannabinoid and opioid analgesic pathways, which may explain the opioid-sparing effects of cannabinoids seen in some pre-clinical studies.10,11
There is evidence suggesting some cannabinoids may be efficacious for a range of conditions, although it is important for pharmacists to note that cannabinoids are not first-line treatments for any conditions, and their place in therapy is where existing treatments have not been effective.12
Two cannabinoid products are approved medicines in Australia. The first is a nabiximols product (Sativex oromucosal spray), a THC:CBD combination product with a specific indication for symptom improvement in patients with moderate to severe spasticity due to multiple sclerosis (MS) who have not responded adequately to other anti-spasticity medicines and demonstrate clinically significant improvement in spasticity-related symptoms during an initial trial of therapy.13 The second approved product is Epidyolex oral solution, a CBD product that was registered on the Australian Register of Therapeutic Goods (ARTG) in September 2020 for use as adjunctive therapy of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome for patients 2 years and older.14
Other cannabinoids can be accessed via the SAS in Australia as unregistered medicines. Although these products do not have approved indications, the Australian Therapeutic Goods Administration (TGA) has produced guidance around their use in epilepsy, pain, multiple sclerosis, nausea, vomiting and palliation, and this will be covered in more detail in Part 2 of this article series in the next edition of Australian Pharmacist.15
There is some evidence to suggest modest effects of THC for some pain conditions,16 but there is little evidence to support benefits when used in advanced cancer.17 For nausea and vomiting, the evidence base is largely older studies with placebo comparison groups that were conducted before newer and more effective products for nausea and vomiting became available.18 Therefore, for nausea and vomiting, cannabinoids should only be considered where newer, standard approved medicines have been ineffective.18
Much of the information on adverse effects of cannabinoids is derived from studies of non-medical use. In populations who use cannabinoids non-medically, short-term use of THC can lead to dose-related impaired memory, cognitive impairment, paranoia and psychosis.19 Cardiovascular adverse effects have also been documented with THC, including increased heart rate, increased blood pressure and orthostatic hypotension.20 Common adverse effects from THC during trials include dizziness, drowsiness, dysphoria and confusion, with those receiving cannabinoids being significantly more likely to withdraw from treatment due to adverse effects compared to placebo arms in trials.21 A systematic review and meta-analysis showed that, in double-blind studies, acute administration of THC induces positive, negative and other symptoms associated with schizophrenia and other mental disorders in healthy adults with a large effect size.8
It is expected that a proportion of those who use THC or other cannabinoid agonists may develop dependence or ‘addiction’, and therefore monitoring for signs of emerging problems with cannabinoids is warranted.21 Long-term effects of THC also include changes to cognition and memory, though how common these effects are with therapeutic use is not well understood.19
Importantly, as with all medicines, consideration needs to be given to the relative balance between benefits and harms. A systematic review on 104 studies examining cannabinoids for chronic pain found that though statistically significant, the magnitude of effects that cannabinoids had on pain was small, while adverse effects were common.16 In this review, 24 patients needed to be treated with cannabinoids in order for one patient to report a 30% reduction in pain, yet 1 in 6 patients reported adverse events. This highlights the importance of discussions with patients to balance expectations of benefit versus harm.16
THC can contribute to pharmacokinetic drug interactions through effects on membrane transporters and metabolising enzymes, in addition to pharmacodynamic interactions with potentiation of sedation with other sedative medicines.22,23 CBD also inhibits CYP3A4 and CYP2C19, both of which are involved in the metabolism of many medicines, with reports of potentially fatal intoxication from medicines like methadone due to drug interactions with CBD.24,25 Another important example includes the CBD inhibition of clobazam metabolism (CYP2C19), increasing its sedative effects.23
Currently, most medicinal cannabinoids are accessed through two main mechanisms for unregistered drugs in Australia. The first mechanism is through the SAS, where an application must be submitted for the individual. The second mechanism is access via an Authorised Prescriber Scheme, where a prescriber can be approved to prescribe a specific cannabinoid to a group of patients. There are also some state-based variations in who can prescribe cannabinoids, and what documents are required, so it is important that pharmacists are familiar with the requirements for prescribing medicinal cannabinoids in their jurisdiction (See Table 1).
TABLE 1 – Links to state and territory requirements
New South Wales
www.sahealth.sa.gov.au/wps/wcm/connect/69a4190040db6d6aa44ba73ee9bece4b/Fact+Sheet+-+Approvals+to+ prescribe+medicinal+cannabis+in+SA+%28Oct+2018%29.pdf?MOD=AJPERES& amp;CACHEID=ROOTWORKSPACE-69a4190040db6d6aa44ba73ee9bece4b-niQIESV
Australian Capital Territory
A listing of cannabidiol (Epidyolex) for the treatment of Dravet syndrome was recently added to the Pharmaceutical Benefits Scheme (www.pbs.gov.au) after a positive recommendation from the Pharmaceutical Benefits Advisory Committee (PBAC) in November 2020. The listing is for use as a third-line treatment in combination with at least two other anti-epileptic medicines.26
An application for subsidy of nabiximols (Sativex) was submitted to the PBAC, but the application was rejected due to insufficient evidence demonstrating comparative effectiveness and safety for the use as anti-spasticity treatment in patients with multiple sclerosis.27
Cannabis products (including seeds, extracts, resins and the plant, and any part of the plant) when prepared or packed for human therapeutic use are Schedule 8 (S8) medicines in Australia,28 so pharmacists must meet all storage requirements and ensure that prescriptions for cannabis products adhere to jurisdictional requirements. Many medicinal cannabinoid products also require refrigeration; the requirements for refrigerated storage of an S8 medicine also vary by jurisdiction. In some jurisdictions, refrigerated storage conditions must be approved by the jurisdictional state health department. Nabiximols have a separate Schedule 8 entry, and also require refrigeration.
CBD in preparations for therapeutic use, where CBD comprises 98% or more of the total cannabinoid content of the preparation, is a Schedule 4 medicine in Australia.28 In December 2020, a decision was announced to down-schedule lower-dose (up to 150 mg/day) CBD to Schedule 3 for use in adults. The decision limits non-prescription supply to products that are approved by the TGA and included on the ARTG.28 Until an approved and registered product is available, it will not be possible for pharmacists to supply cannabidiol without a prescription.
Most unregistered products are not included in standard dispensing software, so when pharmacists add individual products to software, they must ensure that the correct schedule is assigned to the product. With a wide range of unregistered products, the extent to which cannabinoids may be included in prescription monitoring programs is also unclear.
Depending on the jurisdictional requirements for unregistered products, pharmacists may need to provide the wholesaler with a copy of the TGA approval before the wholesaler can release the product; pharmacies may not be able to hold stock without the approval in place (see Table 1 for links to find state and territory-based requirements).
Patients may have heard about medicinal cannabinoids from a range of sources. It is important to help patients access reliable information on whether these products may be appropriate for them. Simple guides have been developed to help patients understand what medicinal cannabinoids are and how to navigate the current system to access medicinal cannabinoids (see Further information p27). Non-subsidised cannabinoids can be expensive for patients, which will be a consideration when weighing up the likely benefits.
Medicinal cannabinoids are generally recommended for a trial period where first- and second-line treatments have been ineffective. Cannabinoids should only be continued where there is clear evidence of benefit.
We are yet to understand the prevalence of the development of problems like addiction with cannabinoids when used therapeutically. We know that 10–15% of those who use cannabinoids non-medically develop dependence,29 but there is limited evidence to date on how common it is to develop problems with cannabinoids when they are used therapeutically. This risk was underestimated for opioids, leading to significant problems. Pharmacists should discuss this potential risk with patients, so they can make an informed decision before commencing cannabinoids. Dronabinol and nabilone have demonstrated lower abuse liability compared with smoked cannabis.30-32
Driving with THC in your system is not legal in Australia. Patients must consider if taking a product containing THC will impact their independence. Consideration also needs to be given to the long half-life. In the future, the rules on driving with THC may vary by state or territory. For example, a bill has been introduced in Victoria to treat prescribed cannabinoid products in a similar way to other prescription medicines.33 As THC is highly lipophilic, it can be detected in toxicology for weeks (or longer) after regular use, and factors such as recent exercise can increase THC levels in the body.34 THC use may also have implications for those who must undertake workplace drug testing as part of their professional role.
Nabilone is not converted into THC, therefore it does not produce a positive urine toxicology result for THC.2
Pharmacists need to be aware that products are available in a variety of formulations with different onset of effect.
There is a lot of interest in medicinal cannabinoids. Many clinical trials are underway, yet for many conditions, the evidence is limited. This is likely to change over time with further research.
Being able to provide accurate information on the evidence and likely effect of cannabinoids for different conditions is important, alongside discussing potential adverse effects and interactions. Patients may also require support to explain and navigate the pathways for accessing unregistered medicines, and understanding the difference between medicinal cannabinoids accessed through the TGA system and cannabis bought outside the medical system. Any medicinal cannabinoids should be commenced as a trial, with clear clinical endpoints that are assessed to determine if the patient is receiving benefit.
Medicinal cannabinoids are relatively new on the Australian therapeutic landscape. Pharmacists are a trusted source of information and can assist with informing where a trial of cannabinoids may be warranted, likely adverse effects and possible interactions.
Case scenario continued
You explain to John that no THC products are currently approved for use in Australia for chronic pain, and the current evidence is that most people with chronic pain won’t experience meaningful pain relief from THC. Only around 1 in 24 people find it effective for pain relief, while around 1 in 6 people report adverse effects. You also discuss that THC may affect his ability to drive, which could affect his employment.
Information for consumers is available on the following NPS and TGA websites:
Associate Professor SUZANNE NIELSEN BPharm, BPharmSc(Hons), PhD, MPS is the Deputy Director of the Monash Addiction Research Centre in Melbourne, and is a current NHMRC Career Development Fellow. She has co-authored a series of systematic reviews on the therapeutic use of cannabinoids and conducted research on drug-related problems. She has over 20 years’ experience as a pharmacist, with clinical experience in the treatment of substance use disorders.
The author would like to acknowledge Associate Professor Bridin Murnion MBChB, FRACP, FFPMANZCA, FAChAM, for her contribution to this article.[post_title] => Medicinal Cannabis: Part 1 of a two-part series [post_excerpt] => Pharmacists have an increasingly important role in providing information to patients on the therapeutic effectiveness, the adverse effects and the possible role of medicinal cannabis in treating various conditions. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => medicinal-cannabis-part-1-cpd [to_ping] => [pinged] => [post_modified] => 2021-07-04 17:49:03 [post_modified_gmt] => 2021-07-04 07:49:03 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13571 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Medicinal Cannabis: Part 1 of a two-part series [title] => Medicinal Cannabis: Part 1 of a two-part series [href] => https://www.australianpharmacist.com.au/medicinal-cannabis-part-1-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 13575 )
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How and where did you get your start in pharmacy?
I got in relatively late, starting my degree at the University of Sunderland, United Kingdom, in 2008 at 23. After time as a pharmacy assistant and then a dispensary technician I really loved the work, so decided to study pharmacy.
In what settings have you practised?
I’ve worked in both community and hospital pharmacy and honestly love the variation of both. In the UK, I worked as a hospital pharmacist and appreciated the insight I gained into the clinical side of pharmacy. At weekends I locummed in community pharmacy, a much different pace. Since moving to Australia 7 years ago, I chose to continue in community pharmacy. Living and working in rural Mission Beach for 6 years now, it definitely stands out as providing the greatest variety. Shortages in local doctors and servicing a range of customers, from young families to tourists and older locals and grey nomads, means I never know what will happen.
What are some unusual critter experiences you’ve had in ‘paradise’?
Living in tropical far North Queensland I’ve seen some of the most extreme bite reactions presenting in swelling and welts. I’ve also personally had wasp stings with my ear swelling in one instance. A local snake catcher presented after a snake compressed around her head causing the blood vessels in her eyes to burst. We often see coral rash and jellyfish stings – not something I thought I’d be dealing with while studying pharmacy in the UK!
As one of the initial 56 pharmacies in Australia to start COVID-19 vaccination, what has been your experience so far?
It was a bit stressful for the team initially getting workflow right, reviewing pre-screening and not overbooking during busy times, but we reached the sweet spot in a few days. I have vaccinated more than 200 people [to press time], with a 50:50 mix of tourists and locals.‘I’ve had lots of comments about how [COVID-19 vaccination at a pharmacy] is more relaxing for patients.’
My first vaccination appointments begin at 9 am so I organise my vaccination vials and get ready to spend time with my patients. Our team is amazing at handling customer queries and facilitating the vaccination process and appointments.
I had one appointment amongst dispensing scripts, which probably took up around 45 minutes of my time, with an elderly gentleman who wanted to be fully confident in identifying any adverse effects following his vaccination. Overall, the response is very positive. Locals know I’ve been vaccinating for years, and tourists are pleasantly surprised to have an accessible location without travelling an hour to a state-run facility.
Since being a listed pharmacy we’ve received many calls from grey nomads booking ahead for a second vaccination, so from mid-July my calendar was booked through to September. I’ve had lots of comments about how it’s more relaxing for patients. They also experience my casual humour and out-of-key singing while waiting for the 15-minute post-vaccination observations.
Is this where you’d like to end up, or is it just a staging post in your career?
I’m 100% committed to Mission Beach. After a one-night holiday [then extended] stopover in 2009, we saw our ideal version of Australia – the rainforest, the reef, the laid-back lifestyle and the cassowaries. We emigrated in 2014, and after working 9 months in the big city saw a position for a pharmacist manger at the LifeLive Pharmacy Mission Beach. I couldn’t believe it when I got an interview with the founding partner of the LiveLive group.
The values and work ethic of the group were exactly what I was looking for. There is nowhere else I’d rather be. It’s an amazing location for our young family. Growing up in the UK is a stark contrast to the opportunities and lifestyle our boys have here and, lets face it, who doesn’t want to live in paradise?[post_title] => The COVID-19 vaccinator [post_excerpt] => Jamie Dalton MPS was among the first group of Australian community pharmacists to join the national COVID-19 rollout in June in his own slice of ‘paradise’ – Mission Beach, Queensland. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => the-covid-19-vaccinator [to_ping] => [pinged] => [post_modified] => 2021-07-29 21:39:19 [post_modified_gmt] => 2021-07-29 11:39:19 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13794 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => The COVID-19 vaccinator [title] => The COVID-19 vaccinator [href] => https://www.australianpharmacist.com.au/the-covid-19-vaccinator/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 13796 )
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PSA’s 2020 Queensland Pharmacist of the Year Bridget Totterman is the Chief Operating Officer of the White Retail Group. She leads and manages seven pharmacies and eight medical practices. And she owns another four pharmacies herself.
What made you decide to become a pharmacist?
My mum was a nurse and had a grounding in healthcare. She suggested pharmacy in my final years at school. With a wide range of interests and comfortable engaging in conversation with pretty much anyone, my mum pointed out that pharmacy seemed like an industry which would give me the opportunity to work in these areas. She was right.
What specialisation appealed to you?
I love every aspect of human connection to which pharmacy introduced me. From chatting to a mum about a body wash for her baby with eczema, and being able to help her understand the condition better; to bringing health information to the public; assisting carers who need help managing the medicines for their loved ones; working with team members, helping them develop in their chosen career – seeing them bloom; and working with the most amazing pharmacists and learning from them.
What is the most satisfying part of your role?
Seeing improvement. I love that we started the Queensland Pharmacist Immunisation Pilot (QPIP) for pharmacist-administered flu vaccines and now we can do it Australia-wide. I love seeing an intern who was nervous counselling on a particular medicine regime, absolutely nail it after a focused training session. I love seeing a pharmacy manager give a speech at a staff meeting that rallies the whole team to front up to work every day to assist the community during the pandemic. I also love that every day the government understands a little better, the vital role pharmacists have in the healthcare system and how they need to be recognised and remunerated for the amazing work they do.
By what route did you wind up at the White Retail Group?
White Retail Group is owned by Terry and Rhonda White. They asked me to come on board and manage their pharmacies, after I had been a managing partner at TWC Brookside for 9 years. This led me to the White Retail Group where I began overseeing the management of the pharmacies and medical centres and then took over the support office as well, which offers many centres payroll, IT and finance services. Rhonda White told me: ‘You build a reputation by what you do every day and if you do your best ... someone is always watching and will give you an opportunity, so say “yes’”. I wound up here by saying ‘yes’.
What is the greatest satisfaction you’ve had with a patient interaction?
Helping a young mum of six on her journey to overcoming addiction to an S3 medicine. It took months. She was abrupt and defensive about her regular use, but I was determined to win her over. I engaged her in conversation, showed empathy and concern (not judgement) at her story, which involved domestic violence and one child in juvenile detention. I welcomed her by name each time she came in. Eventually she divulged that the medicine helped manage her pain and get housework done but also made her tired, moody and snappy with the kids. After 3 months I called her GP about care plans and subsidised psychology support and physiotherapy. A walking group and weight loss in time led to her ceasing the medicine after about a year.
Any advice for ECPs?
Keep up the amazing passion you have for our industry. Don’t be too rushed – there are lessons to be learned along the way. And don’t compare your beginning to someone else’s middle. Make your own path.
And finally, what is your dream?
I have three beautiful sons and an amazing husband – their interests and hobbies keep me busy enough. My dream? I am living it. A loving, happy family and a challenging and rewarding career.
DAY IN THE LIFE of Bridget Totterman MPS, COO White Retail Group and 2020 Queensland Pharmacist of the Year.
5.30 am – Rise and shine
Exercise, make lunches for the kids and always a healthy breakfast.
7.30 am – Off to school
Take the kids to school. They grow up so fast.
8.30 am – In the office in Hamilton
Start the day meeting our shop fitter about a refresh planned for one of our pharmacies. We discuss design and potential workflow. Afterwards I conduct a team meeting in the support office (accountants, IT, payroll staff) and deliver an update on COVID, discussing the need to stay diligent with hand washing and cleaning.
10.30 am – Managerial meetingsDrive to a local medical centre. Interview a GP interested in working in one of our medical centres. Then on to one of my pharmacies to assist a manager preparing for a QCPP assessment. On to another pharmacy to help another manager with roster and wage management.
1.30 pm – Reviewing procedures
Observe and review procedures in the pharmacies for the flu clinics and check clinic rooms are at a high standard. Check in with staff on various issues. For example, I am currently asking QLD pharmacies how they are going with UTI Pharmacy Pilot (UTIPP) – getting their feedback for the UTIPP Steering Committee.
3.30 pm – Planning and preparing
Use a quiet moment to prepare notes for a lecture I am due to give soon on professional services at QLD University of Technology. I often use this time of the afternoon to respond to calls for help from any pharmacy or practice manager. I also take the opportunity to begin planning for a regular managers’ meeting, where we upskill and train the managers on various topics in pharmacy.
5.30 pm – Heading home
But my phone is on 24/7 if the people on the frontline need me.
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Professor Sinthia Bosnic-Anticevich MPS is a respiratory pharmacist who has helped change the clinical care of chronic respiratory conditions as Research Leader at the Woolcock Institute of Medical Research and the University of Sydney.
What sparked your interest in pharmacy?
Initially I was enrolled in a Bachelor of Information Technology at the University of Technology Sydney but, coming from a family of healthcare professionals, I guess I got cold feet and switched to a Bachelor of Pharmacy. I am not the type of person to ever look back.
Can you describe your career path?
Traditional for an academic, though it didn’t start out that way. I thought I was going to be a hospital pharmacist, but got drawn into the research and didn’t think twice about doing a PhD.
My first full-time job was in the pharmaceutical industry, and I saw a successful future there. But 5 years later, a new academic position came up at the University of Sydney’s then Faculty of Pharmacy. In those days  there were very few people with PhDs in pharmacy practice, but that is what they were looking for and that is what I had.
How did you develop an interest in respiratory medicines?
It was circumstantial. The academic who was my role model was a respiratory researcher, and I wanted to be just like her. One can never underestimate the importance of role models in shaping careers. I am so grateful to mine.
What is different after your research?
My research has established the ‘gold standard’ for inhaler technique assessment and training, influenced inhaler prescribing policy and the development of asthma, COPD and allergic rhinitis management guidelines.
'Being a research leader is like being a businessperson, where your product is new knowledge generation, dissemination and impact.'
It has led to the development of tools to support both patients and healthcare professionals in delivering optimal care around inhaler use. Through partnerships, collaborations and consultation with industry, my research has influenced the development of digital inhalers, which are set to be the next big advance in inhaler use and self-management.
What would other pharmacists find surprising about your role?
Firstly, the extent of the impact you can have as a researcher. The extent to which you can influence the health of individuals, society and health policy both nationally and globally is just amazing. Secondly, the high level of control you have in developing your area of research and expertise. And finally, the particular skill set you need to run a successful program of research. It requires a broad range of transferrable skills.
I often say that being a research leader is like being a businessperson, where your product is new knowledge generation, dissemination and impact. You are responsible for innovation, productivity and the financial sustainability of your team. You need to enjoy leading, mentoring and problem solving. You need to know how to get maximum return on investment.
It is such an exciting role. I love it.
What topic will you be addressing at PSA21?
I will be discussing the latest trends around the use of medicines in asthma, COPD and allergic rhinitis and the unique, effective and efficient solutions that only pharmacists can provide. Knowledge gaps are around patient behaviours, hidden disease burden, shifting approaches and new guidelines. It is an exciting time in respiratory medicine. I would like attendees to be better prepared to identify the hidden problems and deliver unique, targeted solutions, efficiently and seamlessly.
What do you see as the future of pharmacy?
As always it depends on our ability to evolve and drive change, and there will be challenges. I see it involving a digital, data-driven approach, the delivery of efficient, pharmacy-specific, sophisticated care and financial models that are sustainable and reward pharmacists for the unique, fundamental contribution they make to the health and wellbeing of our nation.
Don't miss Professor Sinthia Bosnic-Anticevich speaking at PSA21 on Saturday 31 July.[post_title] => The respiratory researcher [post_excerpt] => Professor Sinthia Bosnic-Anticevich MPS is a respiratory pharmacist who has helped change the clinical care of chronic respiratory conditions. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => the-respiratory-researcher [to_ping] => [pinged] => [post_modified] => 2021-07-04 17:12:54 [post_modified_gmt] => 2021-07-04 07:12:54 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13565 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => The respiratory researcher [title] => The respiratory researcher [href] => https://www.australianpharmacist.com.au/the-respiratory-researcher/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 13567 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 13537 [post_author] => 3410 [post_date] => 2021-06-30 16:38:35 [post_date_gmt] => 2021-06-30 06:38:35 [post_content] => Kerry Schiemer MPS has been a proud pharmacist for more than 60 years. Set to retire next month, he reflects on the best parts of pharmacy practice and why patient-centred care is so important. Pharmacy wasn’t the first career choice for the New South Wales-based pharmacist. Instead, he wanted to be a pilot, but finding out he was red-green colour blind in Year 10 put paid to that dream. After graduating from Sydney’s St Joseph's College in the mid-1950s, Mr Schiemer planned to work on the family farm in the north-western NSW town of Coolah. But the headmaster at St Joseph's advised him to consider another option. ‘He said, “Kerry, you’d be a good chemist ... I'll put your name down for an apprenticeship”,’ Mr Schiemer told Australian Pharmacist. Unconvinced and disappointed that his flying career was not to be, Mr Schiemer worked on the farm for a year until 1957, when he received a call about an apprenticeship on offer at a pharmacy in the Newcastle suburb of Wallsend. ‘I didn’t know what I was doing or where I was going, I just went and had the interview,’ Mr Schiemer said. ‘But 3 days after I started, I knew I was to be a pharmacist. Wasn’t I lucky?’
The importance of mentorsIn the early stages of his career, Mr Schiemer was fortunate enough to work for some very influential pharmacists. ‘I was apprenticed to Jim Matthews, who became the National President of the Pharmacy Guild of Australia, while I was studying part-time at Sydney University,’ he said. ‘And as an intern in Harbord [in Sydney’s northern beaches] my apprenticeship was transferred to John McDonagh. Alan Fraser, who was PSA’s state secretary, was a locum there at the time.’ It was from these mentors that Mr Schiemer learnt the importance of personalised care. ‘I never wanted to work in a big pharmacy. I wanted to run a small, one-man business where I could personally assist people,’ he said. ‘I learned a lot about that from these men, and I wanted to be like them.’‘I never wanted to work in a big pharmacy. I wanted to run a small, one-man business where I could personally assist people.'In 1965, at the age of 27, Mr Schiemer had his first foray into pharmacy ownership in Whitebridge, Newcastle. ‘With my dad’s help, I bought a cottage and built a little pharmacy at the front with a doctor's surgery on the side. We also lived on the premises,’ he said. About 8 years later, Mr Schiemer sold the Whitebridge establishment and bought a pharmacy 10 kilometres away in the beachside suburb of Redhead, where he firmly established himself as an integral part of the community. ‘I think I was probably practicing forward pharmacy because as soon as a patient had any illness that needed attention, the staff came and got me and I went out and helped them,’ he said.
Establishing servicesAfter purchasing Shoal Bay Pharmacy in 1992, Mr Schiemer introduced medicine reviews to the entire Tomaree Peninsula (221 kilometres north of Sydney). ‘In 1997, I was the first pharmacist in the area to gain the qualifications, and I very gently introduced GPs to the benefits of medicine reviews,’ he said. ‘Now it’s just routine.’ Mr Schiemer conducted medicine reviews at a local nursing home and a low-care facility, and the service had a significant impact on the community's health. ‘When patients were on anti-inflammatories, for example, we’d try reducing the dose or trial Panadol Osteo when that came out,’ he said. ‘In the end, we managed to get a lot of people off anti-inflammatories.'
Benefits of ‘old-fashioned’ pharmacyWhen compounding medicines was the norm, the formulations Mr Schiemer concocted were targeted to address the community's health issues. ‘When I was an apprentice in Newcastle, for example, it was a coal mining area, and a large percentage of the miners had dreadful chests because of the vapours and carbon floating around,’ he said.‘Experience is still the greatest of all teachers, I'm quite sure of that.’‘We used to make a medicine called Fagan's Compound, which had creosote in it. It was a wonderful expectorant cough medicine.’ After consulting desks became a part of pharmacy practice more than 25 years ago, Mr Schiemer’s Shoal Bay pharmacy was one of the first in the region to install one. ‘I had a computer screen with a beautiful set of [anatomy] pictures, so I could pull up a visual of what we were treating and explain to the patient how their medicine was going to work,’ he said. ‘Afterwards, they would say, “Kerry, how much is it for the consultation?” But we never charged for our services as pharmacists.’ Back then, Mr Schiemer said, pharmacists promoted themselves as ‘family chemists’ – an integral first port of call for any healthcare needs. ‘When my patients would get sick, the first thing they'd think was “I’m crook, I'll go see Kerry”. That’s why I didn't need to advertise,’ he said. ‘Depending on what it was, I’d either send them off to the doctor, or see if I could treat them myself, and I'd tell them to call in a couple of days later to let me know how they were going.’ One of the aspects of pharmacy practice Mr Schiemer enjoyed most was early childhood care, which used to be commonplace. ‘Mums would bring their babies in when they were a few weeks old, and from then on until they were toddlers, I would weigh them, check their ears with an otoscope, and inspect the rest of the body if there was anything wrong,’ he said. ‘If they had a rash, I'd take a look at it and dispense medicines to try and fix it, and if that didn’t work I’d refer them to the doctor.’ He recalls first offering these services as an apprentice pharmacist, which he learnt how to do on the job. ‘We had absolutely no medical training and our academic education was very basic, but our experience was marvellous,’ he said. ‘Experience is still the greatest of all teachers, I'm quite sure of that.’ When it comes to offering advice to the next generation of pharmacists, Mr Schiemer’s message is simple. ‘Your patient comes first. We help sick people get well and healthy people stay healthy,’ he said. ‘That's our challenge in life and it is very satisfying.’ [post_title] => An ode to pharmacy practice [post_excerpt] => Kerry Schiemer MPS has been a proud pharmacist for more than 60 years. Set to retire next month, he reflects on the best parts of pharmacy practice and why patient-centred care is so important. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => kerry-schiemer [to_ping] => [pinged] => [post_modified] => 2021-07-01 09:52:12 [post_modified_gmt] => 2021-06-30 23:52:12 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13537 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => An ode to pharmacy practice [title] => An ode to pharmacy practice [href] => https://www.australianpharmacist.com.au/kerry-schiemer/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 13554 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 13454 [post_author] => 3387 [post_date] => 2021-06-16 12:13:08 [post_date_gmt] => 2021-06-16 02:13:08 [post_content] => Three pharmacists from across the country were recognised in the 2021 Queen’s Birthday Honours list for their significant contributions to the profession. The recipients included NSW-based pharmacist Associate Professor Faye McMillan, South Australian Donald Burge and Brenley McMillan Milsom from Queensland. PSA National President Associate Professor Chris Freeman said it was great to see pharmacists recognised for their service to the community. ‘I congratulate all of the Queen’s Birthday Honours recipients and thank them for their ongoing service to the pharmacy profession and their local communities,’ he said. A/Prof McMillan was appointed a Member of the Order of Australia (AM) for her work in Aboriginal and Torres Strait Islander mental health care and tertiary education. Mr Burge, who received a Medal of the Order of Australia (OAM), has long been a fixture in SA’s inner south-western suburb of Edwardstown, where he both owned a community pharmacy for many years and contributed extensively to the local Lions Club. Mr Milsom, who also received an OAM, has had a diverse career, including serving as a registered pharmacist for almost 30 years. He was also a visiting lecturer at Griffith University School of Pharmacy and Secretary of the Australian Drug Evaluation Committee for the Therapeutic Goods Administration.
Making a difference in rural and remote healthA/Prof McMillan, from the University of New South Wales’ School of Population Health, told Australian Pharmacist it was an honour to receive the title. ‘It’s a recognition of the work you do and it’s so lovely to be honoured,’ she said. ‘But I’d also like to say thank you to all of the unsung pharmacists who go about doing the work they do. It certainly hasn’t gone unnoticed.’ A proud Wiradjuri yinaa (woman), A/Prof McMillan has extensive experience in Aboriginal and Torres Strait Islander and rural and remote healthcare, including being a founding member of Indigenous Allied Health Australia, which works to secure recognition of the significant contributions and roles of Indigenous health professionals in Australia. She was also part of PSA’s National Aboriginal Community Controlled Health Organisation Leadership Group and recently took on the newly minted role of Deputy National Rural Health Commissioner in the Federal Government. Through this, A/Prof McMillan hopes to increase the standing of rural and remote healthcare practitioners to the level they deserve. ‘I'd like other health professionals to see the opportunities being regional, rural and remote health practitioners provides, and would like us to be considered equal,’ she said. ‘I also want to make a difference to how people perceive the disparity between regional, rural and remote and urban centres. ‘I think the quality of care is outstanding [in regional, rural and remote areas] and I want to improve the recognition of this.’ Importantly, A/Prof McMillan would like to see more diversity and inclusion across health service delivery – where pharmacy plays a significant role. ‘Pharmacy is part of the machinery that comes together to make sure services to regional, rural and remote areas are fluid and seamless, and [pharmacists] should feel part of a bigger system that works,’ A/Prof McMillan told AP. This is especially so in particularly remote areas, where pharmacists might be the only consistent health professional the community can call on. Of A/Prof McMillan’s award, A/Prof Freeman said: ‘As Australia’s first registered pharmacist who identifies as Aboriginal, Faye has been an exemplar for the pharmacy profession for many years. ‘I congratulate her on her AM and look forward to working with her in her role as the Deputy National Rural Health Commissioner to better utilise the network of pharmacists in rural and remote Australia.’ View the full 2021 Queen's Birthday Honours list. [post_title] => Pharmacists receive Queen’s Birthday Honours [post_excerpt] => Three pharmacists from across the country were recognised in the 2021 Queen’s Birthday Honours list for their significant contributions to the profession. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => pharmacists-receive-queens-birthday-honours [to_ping] => [pinged] => [post_modified] => 2021-06-16 12:13:08 [post_modified_gmt] => 2021-06-16 02:13:08 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=13454 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Pharmacists receive Queen’s Birthday Honours [title] => Pharmacists receive Queen’s Birthday Honours [href] => https://www.australianpharmacist.com.au/pharmacists-receive-queens-birthday-honours/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 13455 )
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.