Home - Australian Pharmacist

COVID-19: Continued Dispensing extended to ensure supply of essential medicines

Ruth Cooper - April 1, 2020

Industry

Emergency measures to allow continued access to essential medicines through the Pharmaceutical Benefits Scheme (PBS) have been extended to at least 30 June this year.

PBS changes for prescription opioids

Ann Winkle MPS - June 3, 2020

Clinical

Changes to regulations on opioid supply in Australia came into effect this week, with new Pharmaceutical Benefits Scheme listings resulting in smaller quantities and restrictions around opioid prescribing for pain treatment.

A cup of tea, a Bex and a good lie down

Scott Casey - June 12, 2018

Clinical

Immortalised in Australian slang, the analgesic phenacetin (used in Bex powder) is wrapped up in the development of the modern pharmaceutical industry and has...

COVID-19 and influenza vaccinations: tips for community pharmacists

Ruth Cooper - April 8, 2020

Pharmacy vaccinations offer almost 1.8 billion people around the world the possibility of being vaccinated.

Industry

The COVID-19 pandemic makes it more important than ever for Australians to access influenza vaccinations and pharmacist immunisers are ready to help protect the community.

New Label 24 to help pharmacists reduce opioid risks

Jennifer Cooke - June 24, 2020

Industry

In line with TGA regulatory changes to enhance medicine safety, PSA has developed a cautionary advisory label that warns consumers about the risk of opioid overdose and dependence.

New migraine treatment approved

Sharon Smith - September 4, 2018

Clinical

The TGA has approved a new preventative treatment for migraine, with a new medicine that targets the calcitonin gene-related peptide receptor. Patients experiencing migraine will...

12 3...145 Page 1 of 145

MODIFIABLE CARDIOVASCULAR DISEASE RISK FACTORS	NON-MODIFIABLE CARDIOVASCULAR DISEASE RISK FACTORS
Diabetes High blood pressure High blood cholesterol levels Poor nutrition Obesity Sedentary lifestyle Smoking Excessive alcohol intake Depression	Older age Family history of cardiovascular disease Gender – at younger ages men are at higher risk compared to women, but women’s risk increases after menopause Ethnicity – Aboriginal and Torres Strait Islander peoples, South Pacific Islander peoples, Maori and people from South Asian countries are at higher risk than other ethnicities

COMMON SYMPTOMS OF ACS	LESS COMMON SYMPTOMS OF ACS
Chest pain/discomfort Shortness of breath Nausea and vomiting Sweating Dizziness, feeling light-headed or faint Feelings similar to indigestion Acute anxiety	Burning pain Pain on breathing in Upper abdominal pain

TREATMENT OF ANGINA EPISODES
DRUG	DOSE
Glyceryl trinitrate sublingual spray	400–800 microgram (1–2 sprays) sublingually, as needed to treat acute angina
	OR 400 microgram (1 spray) 5–10 minutes prior to activity likely to precipitate angina
Glyceryl trinitrate sublingual tablet	300–600 microgram (0.5–1 tablet) sublingually, as needed to treat acute angina
	OR 5–10 minutes prior to activity likely to precipitate angina
Isosorbide dinitrate sublingual tablet	5–10 mg (1–2 tablets) sublingually, as needed to treat acute angina
	OR 10 minutes prior to activity likely to precipitate angina
PREVENTION OF ANGINA EPISODES
DRUG	ROLE IN THERAPY
Beta blockers	First-line therapy for prevention of stable angina unless contraindicated or not tolerated
	Bisoprolol, carvedilol, nebivolol or long-acting metoprolol are useful in comorbid heart failure
Diltiazem	First-line therapy for the prevention of stable angina. Alternative agent to beta blockers
	Avoid in heart failure
	Avoid in combination with beta blockers due to risk of heart block
Verapamil	First-line therapy for the prevention of stable angina. Alternative agent to beta blockers
	Avoid in heart failure
	Avoid in combination with beta blockers due to risk of heart block
Dihydropyridine calcium channel blockers	First-line therapy for prevention of stable angina. Alternative agent to beta blockers, but may worsen angina and cause reflex tachycardia when first started
	Can be added to beta blocker therapy if beta blocker therapy alone is inadequate
Isosorbide mononitrate (slow release oral tablet)	Second-line therapy for prevention of stable angina where beta blockers and or calcium channel blockers are contraindicated, not tolerated or provide inadequate symptom control
	Dose once daily to avoid tachyphylaxis
Glyceryl trinitrate (transdermal patch)	Second-line therapy for prevention of stable angina where beta blockers and or calcium channel blockers are contraindicated, not tolerated or provide inadequate symptom control
	Requires a patch-free interval to avoid tachyphylaxis
Nicorandil	Third-line therapy for the prevention of stable angina. Can be added to beta blockers, calcium channel blockers or long acting nitrates (or combinations of these agents), where symptom control is inadequate
Ivabradine	Third-line therapy for the prevention of stable angina. Can be added to beta blockers, dihydropyridine calcium channel blockers or long acting nitrates (or combinations of these agents) with caution, where symptom control is inadequate
	Indicated for refractory angina in patients with heart rate over 70 beats per minute
Perhexiline	Specialist use for the prevention of angina refractory to other medical or surgical treatment
	Requires therapeutic drug monitoring

LEVEL OF MOLECULAR RESPONSE (MR)	EQUIVALENT BCR-ABL1 %	SIGNIFICANCE AND ALTERNATIVE TERMS
	100%	Median at diagnosis
MR1	≤10%	Also known as early molecular response (EMR) Ideally should be reached by 3 months
MR2	≤1%	Equivalent to complete cytogenetic remission (CyR) Ideally should be reached by 6 months
MR3	≤0.1%	Also known as major molecular response (MMR) Ideally should be reached by 12 months A level of remission associated with optimal overall survival
MR4	≤0.01%	Below this level is termed deep molecular response (DMR) The minimum level of response required for consideration of treatment free remission (TFR)
MR4.5	≤0.0032%	May be associated with higher chance of successful TFR
MR5	≤0.001%	Current limit of detection

PATIENTS WITH RECENTLY DIAGNOSED CML	PATIENTS WITH ESTABLISHED THERAPY FOR CML
Explain the mechanism of action of TKIs Explain how to take the medicine Explain the key adverse effects Review for drug-drug and drug disease state interactions Emphasise the importance of adherence to control disease progression and treatment resistance	Ensure medications are taken correctly Monitor for adverse effects and refer as required Monitor for clinically significant drug-drug interactions and refer as required Review drug adherence and assist in improving compliance

	DOSING	KEY ADVERSE EVENTS	CYP3A4 SUBSTRATE	PPI/H2 INTERACTION	QT INTERVAL PROLONGATION
Imatinib	Daily with food	Fluid retention Myalgias Arthralgias Gastrointestinal (nausea, vomiting, diarrhoea)	Y	N	N
Dasatinib	Daily	Pleural effusion Pulmonary arterial hypertension (rare) Some increase in cardiovascular events May increase risk of bleeding	Y	Y	Y
Nilotinib	Twice daily on empty stomach	Increase in cardiovascular events (MI, stroke, peripheral cardiovascular disease) Pancreatitis Dyslipidaemia Hyperglycaemia	Y	Y	Y
Ponatinib	Daily	Significant increase in cardiovascular events	Y	N	Y

DRUG	MECHANISM OF ACTION	PRECAUTIONS/ADVERSE EFFECTS	MONITORING	COMPARATIVE AND OTHER INFORMATION
Silodosin	Alpha_1A receptor antagonist Significantly less systemic side effects such as hypotension.	Highest propensity to cause ejaculatory dysfunction. Start with a reduced dose if CrCl <60 mL/min. Not recommended for CrCl <30mL/ min. No data for use in severe hepatic impairment Can cause first dose hypotension Drug specific adverse effects include thirst, loose stools	Monitor for hypotension particularly when used with other antihypertensives	More selective than but similar efficacy to tamsulosin Significant improvements in symptom scores at 12 weeks Currently not covered under Pharmaceutical Benefit Scheme (PBS) May be a drug of choice in men where ejaculatory side effects are not a concern
Tamsulosin	Alpha_1A receptor antagonist Significantly less systemic side effects such as hypotension	Can cause retrograde ejaculation First dose hypotension particularly in renal impairment. Caution in hepatic impairment	Monitor for hypotension particularly when used with other antihypertensives and in older patients	Reimbursement is only covered under Repatriation PBS
Alfuzosin	Alpha₁ receptor antagonist	Use with caution in renal impairment Contraindicated in hepatic impairment	Monitor for hypotension particularly when used with other antihypertensives Alfuzosin contraindicated with strong Cytochrome P450 subtype 3A4 inhibitors	Reimbursement is only covered under Repatriation PBS
Prazosin	Alpha₁ receptor antagonist Highest systemic effect particularly on blood pressure Higher propensity to cause dizziness and discontinuation of therapy. No longer recommended as first line	Use with caution in renal impairment	Close monitoring required for hypotensive adverse effects – particularly after the first dose Use with caution in older adults	Available under general schedule of PBS

DRUG	% REDUCTION IN DHT CONCENTRATION	DOSING, ONSET OF ACTION	SOME ADVERSE EFFECTS AND COMPARATIVE INFORMATION	AVAILABILITY
Dutasteride – inhibits both the type 1 and type 2 isoenzymes of 5-alpha-reductase.	90–95%	Longer half-life (3–5 weeks) than finasteride. Clinical improvement can take up to 3 to 6 months. Patients and their female partners should be counselled on handling precautions; risk of feminisation of male foetus.	Reduced libido, erectile dysfunction, ejaculation disorder (including decreased ejaculate volume, breast tenderness and enlargement. Finasteride and dutasteride appear to be similarly effective in reducing prostate size, improving symptoms and urinary flow rate. Both have similar side effect profile.	Available as mono drug or in combination with tamsulosin. Available under both general and repatriation schedule of PBS.
Finasteride only inhibits the type 2 isoenzyme.	75%	Half-life – 6 hours Clinical improvement can take up to 3 to 6 months.	Long-term use of 5ARIs reduces the risk of acute urinary retention and the need for surgery.	Finasteride is only available as mono-drug. Available under both general and repatriation schedule of PBS.

PLANT EXTRACT	PROPOSED MECHANISM OF ACTION	QUALITY OF EVIDENCE
Saw palmetto – fruit (Serenoa repens)	Antiandrogenic, Anti-inflammatory	Saw Palmetto (Serenoa repens) remains the most widely used herbal medication for the treatment of BPH Despite its popularity, clinical evidence is conflicting. A Cochrane review published in 2012 concluded that Serenoa repens was no more effective than placebo for treatment of urinary symptoms consistent with BPH
African plum bark (Pygeum africanum)	Antiandrogenic, potential growth factor manipulation, anti-inflammation actions Decrease in nocturia, residual urine volume	Likely effective, however lacks strong clinical evidence; requires further robust clinical trials
Pumpkin– seed (Cucurbita pepo)	Phytosterols are thought to be amongst the active compounds	Possibly effective, however requires further robust clinical trials
Cernilton pollen (Secale cereale, Rye)	Inhibition of alpha adrenergic receptors	Results from a systematic review observed a modest improvement in symptoms and did not significantly improve peak and mean urine flow rates
South African star grass root (Hypoxis rooperi)	Antiandrogenic, alteration in detrusor function	Nil robust evidence
Stinging nettle root	Steroid hormone manipulation reducing prostate growth	Nil robust evidence

Follow-up visits

PALLIATIVE CARE

Jo McMahon Pharmacist, Moruya, NSW

Palliative care

HMR

Zhiyong Zachary Sum MPS Consultant pharmacist, Melbourne, VIC

Impact of the pandemic

HMR

Dr Natalie Soulsby MPS Advanced practice pharmacist Head of Clinical Development, WardMM, based in Adelaide, SA

Pharmacists shouldn’t be forgotten

Other commitments

A mental health pharmacist's approach

Community pharmacist perspective

Training for pharmacists

Seeing solutions

Looking to the future

Ethical considerations

Community pharmacist experiences

Does the supply of salbutamol need to be recorded?

Expert opinion

Stakeholder response

Challenges for pharmacists

What can pharmacists do?

Reducing over-reliance on SABAs

Other treatment changes

Case scenario

Learning objectives

Introduction

What are the types of otitis media?

What causes otitis media?

What are the symptoms of otitis media?

What are the risk factors?

How is otitis media diagnosed?

Differential diagnosis

What are the pharmacological treatment options?

Adverse effects of antibiotic treatment

When is referral required?

How can otitis media be prevented?

What is the role of the pharmacist?

Conclusion

Case scenario continued

Key points

Introduction

Learning objectives

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Angina in Australia

TABLE 1 – Examples of risk factors for cardiovascular disease

Symptoms of Angina

TABLE 2 – Symptoms of ACS

Diagnostic work-up of angina

Treatment of angina episodes

BOX 1 – KEY STEPS FOR SELF-MANAGEMENT OF AN ANGINA EPISODE

TABLE 3 – Key medications used in the treatment and prevention of angina

Long-term management of angina

Role of the pharmacist

Conclusion

Key points

Introduction

Learning objectives

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Prevalence of Chronic Myeloid Leukaemia (CML)

Pathophysiology

Clinical presentation

Diagnosis

Treatment

Monitoring

TABLE 1 – Molecular response

Treatment-free remission

Medicine management and role of the pharmacist

TABLE 2 – Counselling points for TKIs

TABLE 3 – Tyrosine kinase inhibitor facts

Future Directions

Conclusion

Key points

References

Introduction

Learning objectives

Pathophysiology

Risk factors

Symptoms