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[post_content] => Rosa is a 35-year-old professional struggling with persistent sleep disturbances. Despite maintaining a consistent sleep routine, exercising regularly, and avoiding heavy meals before bedtime, she found herself regularly waking during the night.
The consultation
[caption id="attachment_27686" align="alignright" width="300"]
This article is sponsored by Kenvue.[/caption]
Before providing Rosa a sleep aid such as melatonin supplements, you ask a series of questions to identify potential contributing factors for her condition and to determine if a sleep aid is the best treatment option.
Key questions to ask
Medical history:
Duration of symptoms:
Symptom pattern:
Nasal symptoms:
Sensory Irritation:
Environmental factors:
Timing of symptoms:
Current approaches:
Current medical status and medications:
Rosa reveals that when she wakes, she frequently has a blocked nose and itchy eyes, and she sneezes a lot in the evening before bed. She has suffered from very mild hayfever before but never at this time of year.
You suspect allergic rhinitis as the root cause. Rosa was surprised. Like many, she had dismissed her nasal congestion as a minor annoyance rather than a significant factor affecting her rest. She didn’t even think one could get hayfever in winter.
You recommend a treatment plan to tackle the root cause of Rosa’s sleep disturbances. With proper treatment, she can manage her symptoms and improve sleep quality. Alongside managing environmental exposure you can recommend an antihistamine like:
Zyrtec Rapid Acting Allergy Antihistamine and Hayfever Tablets
Dosage: One tablet daily offers 24-hour protection.
You can also recommend Rhinocort nasal spray to be used when symptoms become acute.1
Within days of following the treatment plan, Rosa noticed a remarkable improvement. Her congestion eased, she wasn’t waking up anymore, and she finally felt refreshed and energised throughout the day.
By looking beyond the immediate request for sleep aids, the pharmacist was able to identify the true cause of Rosa’s problem and offer a more effective, long-term solution.
Allergic rhinitis (AR) and sleep disruptionsAllergic rhinitis (AR), commonly known as hayfever, affects around 19% of Australians.2 Chronic nasalcongestion and other symptoms of allergic rhinitis can significantly impact sleep quality.3 This often results in daytime fatigue, decreased productivity, and impaired cognitive function. Patients may not realise that their persistent tiredness or difficulty concentrating stems from untreated allergies. Zyrtec works fast for hayfever relief and stays strong, day after day offering 24-hour relief from multiple symptoms. |
Zyrtec works fast for hay fever relief and stays strong, day after day.4If your patient is struggling with unexplained sleep disturbances, allergies could be the hidden cause.
With the right management you can help them to reclaim restful sleep and feel their best every day.
Urdaneta E, et al. Ann Allergy Asthma Immunol 2010;105(5):A121. (Sponsored by Zyrtec.)
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[post_content] => From 1 May, Spravato (esketamine) will be subsidised under the Pharmaceutical Benefits Scheme (PBS) for adults with treatment-resistant depression, intended for use alongside a newly initiated oral antidepressant.
Up to 30,000 Australians are anticipated to access esketamine via the PBS, paying only $7.70 per dose with a pensioner or concession card, or $31.60 per dose for general patients.
[caption id="attachment_29259" align="alignright" width="233"]
Professor Malcolm Hopwood[/caption]
Australian Pharmacist spoke with Professor Malcolm Hopwood, Ramsay Health Care Professor of Psychiatry at the University of Melbourne, about the treatment process and how pharmacists will be involved.
How effective is esketamine in managing treatment resistant depression?
The largest clinical trials on esketamine efficacy found that about 50% of patients who had not responded to two or three antidepressants did respond to esketamine, Prof Hopwood said.
‘If you compare that to trialing one of the usual medicines, the response rate for the third or fourth [medicine] is probably only about 15%,’ he said. ‘So it’s quite a jump up in terms of response rate.’
Who is eligible to be prescribed esketamine nasal spray?
Those diagnosed with treatment-resistant depression, defined as major depressive disorder that has not responded sufficiently to at least two different antidepressants, each administered at an adequate dose and duration, for the treatment of the current moderate to severe depressive episode.
Who is not a good candidate for this treatment?
Esketamine is currently not indicated for bipolar depression. And caution should be taken for patients with psychotic depression, Prof Hopwood said.
‘[This is] because ketamine, when used in much higher doses, has psychogenic potential,’ Prof Hopwood said.
There is also a precautionary note in the product information around patients with marked hepatic or renal impairment.
‘In terms of drug-drug interactions, it should not be used together with an irreversible monoamine oxidase inhibitor, which these days is only Parnate,’ he said. ‘While not widely used now, it's an important interaction to be aware of.’
What’s the duration of therapy?
Esketamine is initially administered twice weekly for the first 4 weeks, Prof Hopwood said.
‘By the end of that 4-week period, we've usually got a sense whether you're a responder or not.’
Treatment usually stops in non-responders, with responders moving to a once-weekly treatment regimen.
‘Eventually, fortnightly treatment for a 6-month maintenance period is what we recommend,’ Prof Hopwood said.
Is re-treatment recommended?
Given that depression is a highly recurrent condition, it is likely some patients will relapse post treatment. And re-treatment with esketamine could prove beneficial, Prof Hopwood said.
‘There is some data about re-treatment … [with] evidence showing that responders do seem to have a good response rate the second time around,’ he said. ‘That will be permitted under this funding scheme.’
How is esketamine supplied?
Patients cannot be in possession of the spray until they are in the clinic for administration under supervision, Prof Hopwood said.
‘Esketamine needs to be administered in an approved treatment center that involves close supervision for side effects such as dissociation and hypertension,’ he said.
Appropriate pharmacist handling of a Schedule 8 medicine is also required.
‘In our facility, we are fortunate to have an on-site pharmacist who dispenses [the medicine] to a nurse, and then the patient self-administers,’ Prof Hopwood said.
‘But the patient neither brings the medicine to the clinic or takes it away. The intent … is to reduce the risk of diversion.’
Facilities that do not have an on-site pharmacist must establish and demonstrate a connection with a local community pharmacy to qualify as an approved treatment centre.
Is talk therapy involved in the session?
Treatment with esketamine does not involve psychotherapy. However, there is a small body of research currently looking at ketamine-facilitated psychotherapy, Prof Hopwood said.
‘We still don't know whether that offers additional benefit for many patients, [but] if esketamine proves an effective treatment for their depression, they may be able to utilise psychotherapy much more effectively – which they might not be able to do when severely depressed.’
What are the estimated costs of esketamine sessions?
The estimated cost is $300–$350 per treatment session, Prof Hopwood said.
In most clinics, the doctor will see the patient on treatment occasions, but less so as treatment becomes established.
‘If the doctor does visit before the treatment is administered, then they can claim through Medicare as per usual,’ he said. ‘But the nursing and pharmacy [costs] will not be covered.’
Are patients supposed to disassociate when they take esketamine?
Dissociation with treatment is frequent, albeit mild and transient for most patients, Prof Hopwood said.
‘For up to half an hour they [may] feel a little dreamy and not unpleasant,’ he said.
Some evidence suggests that mild dissociative effects may be required for the drug to be effective in the treatment of depression, although this is not definitive, Prof Hopwood said.
‘We monitor patients during that time and keep them safe,’ he said. ‘Most of them simply want to lie there and listen to music or just bliss out for a short period of time.’
While there is no reversal agent for esketamine, any periods of distress are typically short lived.
‘We've had a very small number of patients distressed, consistent with the trials,’ Prof Hopwood said. ‘And they've generally responded to quite simple reassurance.’
Patients’ blood pressure is also monitored ‘It's rarely severe enough that intervention is required, but there can be a transient increase, as we've known from the use of ketamine as an anaesthetic,’ he said.
Where should pharmacists refer interested patients?
GPs are an important resource for knowing where the available treatment centers are, Prof Hopwood said.
‘There is a list of those available, and I predict that number may increase over time now that esketamine is funded.’
There are high levels of patient interest in esketamine and psychedelics, Prof Hopwood said.
‘So it's important they receive accurate, quality information that includes realistic expectations about the likelihood of treatment response and what's involved,’ he said. ‘And pharmacists are very well placed to provide that kind of information.’
What is preferable: esketamine or psychedelics?
Since 1 July 2023, patients with treatment-resistant depression have legally been allowed to receive treatment with psilocybin and MDMA, under specific conditions.
There is a degree of overlap between the patient populations considered suitable for ketamine and psychedelic therapy, Prof Hopwood said.
‘Most of the current guidance, including from The Royal Australian and New Zealand College of Psychiatrists, would say that psychedelic therapy is still more at a research level,’ he said.
‘Whereas, esketamine, reflected in the funding, has reached a higher level of evidence at this point.
‘So I would certainly see it as coming before psychedelic therapy in any hierarchy.’
To find out more about the use of psilocybin for treatment-resistant depression, read Australian Pharmacist's CPD article on the therapeutic potential of psychedelics.
[post_title] => PBS-backed esketamine rolls out for depression with S8 controls
[post_excerpt] => Esketamine will soon be funded for treatment-resistant depression, requiring pharmacists to adhere to strict supply and handling conditions.
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[post_content] => Aside from administering medicines by injection, Queensland-based community pharmacist Fiona Watson MPS loves tearing up a Latin dance floor.
Tell us about your pharmacy career.
I had a varied early career, moving to North Queensland for a year shortly after I graduated as well as locuming around Australia for a while.
This gave me a great introduction to community pharmacy and a lot of different experiences – both good and bad. When locuming, you develop a clear idea of the factors that contribute to a well-run pharmacy.
I then moved to the United Kingdom where I completed a Certificate in Clinical Pharmacy. You can tell how old I am because I was one of the last pharmacists able to register in the UK with only a month under supervision.
I was a ‘rotational resident pharmacist’, living on-site at the hospital. I covered renal, gastro, cardiology, oncology, aged care, palliative care and surgery wards.
We worked on call overnight, and could get called upon to help with all sorts of different situations – one of the most interesting being calculating the correct dose for the antidote to antifreeze.
More recently, I was very fortunate to be given the opportunity to go into partnership with my mum and sister, both pharmacists, as the managing partner at Redland Bay Wholelife Pharmacy and Healthfoods.
What medicines do you administer by injection?
About 10 years ago, I became a trained vaccinator administering thousands of vaccines during the COVID-19 pandemic.
When Queensland allowed pharmacists to expand the range of medicines they could administer, I completed the Medication Administration course, as I believe this is an essential skill for pharmacists to have.
So many new medications are injectable, and for some patients self-administration just isn’t an option. We were one of the first pharmacies in our area to offer long-acting injectable buprenorphine services, which can be a life-changing option for patients.
Tell us about your administering injections beyond vaccines.
The majority of pharmacists I work with at Redland Bay are trained vaccinators and have completed medicines administration courses. When we come across a new medication that requires administration by injection we collate the available information from the manufacturer and ensure everyone has read it. Many companies, such as Novartis with inclisiran (Leqvio), have reps who are happy to provide additional training.
Once you are comfortable with subcutaneous injections, it’s a matter of familiarising yourself with the different types of devices available. It seemed a logical step for us to provide this service. We have great consult room facilities and it brings variety to our role.
What role do you see pharmacists playing in cardiovascular care in future?
The sky is the limit. We’re on the cusp of a fundamental change in the way Australians receive health care and I hope to see pharmacists embrace the opportunities this will bring.
There’s a workforce crisis and an ageing population, so we need to become more efficient and accessible. If you think about how much the role of a nurse practitioner has changed in the last 10–15 years, you can see where pharmacists have even greater potential. A patient with a diagnosis of heart failure should be able to be titrated to optimum therapy by a pharmacist in a community pharmacy. A patient should have their HbA1c or lipids checked in the pharmacy, with appropriate therapy initiated or adjusted. We should also be actively involved in screening and chronic disease management.
Pharmacy is an incredibly rewarding and enjoyable career, and now is an especially exciting time to be a pharmacist. There is just so much opportunity.
Day in the life of Fiona Watson MPS, Community pharmacist at Redland Bay Wholelife Pharmacy, QLD.
| 5.00am |
Hit the gym I get up and do a HIIT or Muay Thai class most mornings for positive effects on my mental health. Passionate about preventative health care, I see the long-term effects of patients’ lifestyle choices every day. |
| 8.00am |
Open the pharmacy Every day is different. At least two pharmacists are rostered on, ensuring we give each patient the time they need while providing a wide range of different services. |
| 9.00am |
Vaccination service Embarking on a cruise in 2 months, a couple in their 60s asks about COVID-19 vaccines. More than 12 months since their last vaccine they are happy to be vaccinated on the spot. Not wanting more than one vaccine at a time, we book them in for a follow-up appointment in a month for the shingles vaccination. |
| 10.00am |
Collaborative care A local GP phones about a recently discharged mutual patient who’s not coping well on his new medicines. We spend some time with the patient doing a medicine review and setting up his profile for a dose administration aid. |
| 1.00pm |
Lunchtime It’s important that all staff, especially pharmacists, prioritise their breaks. We all need a little downtime to reset and refresh. |
| 1.30pm |
Medicines injection A regular patient comes in for her second dose of inclisiran (Leqvio) after I administered her first 3 months ago. She is happy with the more convenient option than visiting her GP. |
| 3.00pm |
Infection control In a call from our pharmacy car park, we learn a patient has tested positive for COVID-19 and has an e-script. We dispense and counsel over the phone and then deliver out to their car (with appropriate precautions). |
| 6.30pm |
OCP continuance A stressed young woman, with a 2-week wait for a GP appointment, has run out of her pill. She is relieved when seen by a colleague who prescribes Estelle under the Queensland Hormonal Contraceptive Pilot. I dispense it. |
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[post_content] => Vaccination coverage in older Australians remains alarmingly low. Off-site services provided by pharmacists are key to closing the gap in aged care.
Older Australians are highly susceptible to serious complications from influenza and COVID-19. But the vaccination rates in patients aged 75 and over are nowhere where they need to be to protect this vulnerable patient cohort from harm, including hospitalisations and death.
The national influenza vaccination rate of patients aged 65 and over currently sits at 7.2%. And in the last 12 months, only 37.7% of Australians aged 75 and over received a COVID-19 vaccination.
But boosting immunisation rates in older Australians is more important than ever. The influenza season started earlier and stronger than usual, with 60,594 cases of influenza reported this year.
As of 10 April, there were also 70 active outbreaks of COVID-19 in residential aged care facilities (RACFs). Last year, case numbers were highest among those most at risk, with notifications peaking in the 75–79, 80–84 and 85+ (12,607).
With GPs not always available to address vaccination gaps in aged care, pharmacists are well positioned to step in and provide this essential service.
In the video above, community pharmacist Lachlan Rose MPS outlines the benefits of providing offsite vaccinations in aged care settings, including financial incentives, workplace variety and the protection of one of the most vulnerable populations.
[post_title] => All pharmacists should consider off-site vaccinations in aged care
[post_excerpt] => Vaccination rates in older Australians are alarmingly low. Off-site services provided by pharmacists are key to closing the gap in aged care.
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[post_content] => The Fair Work Commission’s Expert Panel for pay equity in the care and community sector has today issued its initial decision on the Gender-based undervaluation – priority awards review – making determinations on the Pharmacy Industry Award 2020, which most community pharmacists are employed under.
What did the Expert Panel find?
The Expert Panel found that pharmacists covered by the Pharmacy Industry Award 2020 (and several other awards) have been the subject of gender-based undervaluation.
As a result, the Expert Panel has determined that findings constitute work value reasons, justifying variation of the modern award minimum wage rates across all categories of pharmacists.
What is ‘gender-based undervaluation’?
Gender-based undervaluation considers a range of factors to determine whether minimum award pay rates are undervalued because of assumptions based on gender.
The range of factors considered extends to historical undervaluing, exercise of ‘invisible skills’, exercise of caring work and workforce qualifications, among others.
How does the Expert Panel intend to address the undervaluation?
For pharmacists employed by the Pharmacy Industry Award 2020, the Expert Panel has issued a determination that there will be a total increase in the minimum wage rates of 14.1% over three years.
This increase will be implemented in three equal phases on:
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[post_content] => Rosa is a 35-year-old professional struggling with persistent sleep disturbances. Despite maintaining a consistent sleep routine, exercising regularly, and avoiding heavy meals before bedtime, she found herself regularly waking during the night.
The consultation
[caption id="attachment_27686" align="alignright" width="300"] This article is sponsored by Kenvue.[/caption]
Before providing Rosa a sleep aid such as melatonin supplements, you ask a series of questions to identify potential contributing factors for her condition and to determine if a sleep aid is the best treatment option.
Key questions to ask
Medical history:
Duration of symptoms:
Symptom pattern:
Nasal symptoms:
Sensory Irritation:
Environmental factors:
Timing of symptoms:
Current approaches:
Current medical status and medications:
Rosa reveals that when she wakes, she frequently has a blocked nose and itchy eyes, and she sneezes a lot in the evening before bed. She has suffered from very mild hayfever before but never at this time of year.
You suspect allergic rhinitis as the root cause. Rosa was surprised. Like many, she had dismissed her nasal congestion as a minor annoyance rather than a significant factor affecting her rest. She didn’t even think one could get hayfever in winter.
You recommend a treatment plan to tackle the root cause of Rosa’s sleep disturbances. With proper treatment, she can manage her symptoms and improve sleep quality. Alongside managing environmental exposure you can recommend an antihistamine like:
Zyrtec Rapid Acting Allergy Antihistamine and Hayfever Tablets
Dosage: One tablet daily offers 24-hour protection.
You can also recommend Rhinocort nasal spray to be used when symptoms become acute.1
Within days of following the treatment plan, Rosa noticed a remarkable improvement. Her congestion eased, she wasn’t waking up anymore, and she finally felt refreshed and energised throughout the day.
By looking beyond the immediate request for sleep aids, the pharmacist was able to identify the true cause of Rosa’s problem and offer a more effective, long-term solution.
Allergic rhinitis (AR) and sleep disruptionsAllergic rhinitis (AR), commonly known as hayfever, affects around 19% of Australians.2 Chronic nasalcongestion and other symptoms of allergic rhinitis can significantly impact sleep quality.3 This often results in daytime fatigue, decreased productivity, and impaired cognitive function. Patients may not realise that their persistent tiredness or difficulty concentrating stems from untreated allergies. Zyrtec works fast for hayfever relief and stays strong, day after day offering 24-hour relief from multiple symptoms. |
Zyrtec works fast for hay fever relief and stays strong, day after day.4If your patient is struggling with unexplained sleep disturbances, allergies could be the hidden cause.
With the right management you can help them to reclaim restful sleep and feel their best every day.
Urdaneta E, et al. Ann Allergy Asthma Immunol 2010;105(5):A121. (Sponsored by Zyrtec.)
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[post_content] => From 1 May, Spravato (esketamine) will be subsidised under the Pharmaceutical Benefits Scheme (PBS) for adults with treatment-resistant depression, intended for use alongside a newly initiated oral antidepressant.
Up to 30,000 Australians are anticipated to access esketamine via the PBS, paying only $7.70 per dose with a pensioner or concession card, or $31.60 per dose for general patients.
[caption id="attachment_29259" align="alignright" width="233"] Professor Malcolm Hopwood[/caption]
Australian Pharmacist spoke with Professor Malcolm Hopwood, Ramsay Health Care Professor of Psychiatry at the University of Melbourne, about the treatment process and how pharmacists will be involved.
How effective is esketamine in managing treatment resistant depression?
The largest clinical trials on esketamine efficacy found that about 50% of patients who had not responded to two or three antidepressants did respond to esketamine, Prof Hopwood said.
‘If you compare that to trialing one of the usual medicines, the response rate for the third or fourth [medicine] is probably only about 15%,’ he said. ‘So it’s quite a jump up in terms of response rate.’
Who is eligible to be prescribed esketamine nasal spray?
Those diagnosed with treatment-resistant depression, defined as major depressive disorder that has not responded sufficiently to at least two different antidepressants, each administered at an adequate dose and duration, for the treatment of the current moderate to severe depressive episode.
Who is not a good candidate for this treatment?
Esketamine is currently not indicated for bipolar depression. And caution should be taken for patients with psychotic depression, Prof Hopwood said.
‘[This is] because ketamine, when used in much higher doses, has psychogenic potential,’ Prof Hopwood said.
There is also a precautionary note in the product information around patients with marked hepatic or renal impairment.
‘In terms of drug-drug interactions, it should not be used together with an irreversible monoamine oxidase inhibitor, which these days is only Parnate,’ he said. ‘While not widely used now, it's an important interaction to be aware of.’
What’s the duration of therapy?
Esketamine is initially administered twice weekly for the first 4 weeks, Prof Hopwood said.
‘By the end of that 4-week period, we've usually got a sense whether you're a responder or not.’
Treatment usually stops in non-responders, with responders moving to a once-weekly treatment regimen.
‘Eventually, fortnightly treatment for a 6-month maintenance period is what we recommend,’ Prof Hopwood said.
Is re-treatment recommended?
Given that depression is a highly recurrent condition, it is likely some patients will relapse post treatment. And re-treatment with esketamine could prove beneficial, Prof Hopwood said.
‘There is some data about re-treatment … [with] evidence showing that responders do seem to have a good response rate the second time around,’ he said. ‘That will be permitted under this funding scheme.’
How is esketamine supplied?
Patients cannot be in possession of the spray until they are in the clinic for administration under supervision, Prof Hopwood said.
‘Esketamine needs to be administered in an approved treatment center that involves close supervision for side effects such as dissociation and hypertension,’ he said.
Appropriate pharmacist handling of a Schedule 8 medicine is also required.
‘In our facility, we are fortunate to have an on-site pharmacist who dispenses [the medicine] to a nurse, and then the patient self-administers,’ Prof Hopwood said.
‘But the patient neither brings the medicine to the clinic or takes it away. The intent … is to reduce the risk of diversion.’
Facilities that do not have an on-site pharmacist must establish and demonstrate a connection with a local community pharmacy to qualify as an approved treatment centre.
Is talk therapy involved in the session?
Treatment with esketamine does not involve psychotherapy. However, there is a small body of research currently looking at ketamine-facilitated psychotherapy, Prof Hopwood said.
‘We still don't know whether that offers additional benefit for many patients, [but] if esketamine proves an effective treatment for their depression, they may be able to utilise psychotherapy much more effectively – which they might not be able to do when severely depressed.’
What are the estimated costs of esketamine sessions?
The estimated cost is $300–$350 per treatment session, Prof Hopwood said.
In most clinics, the doctor will see the patient on treatment occasions, but less so as treatment becomes established.
‘If the doctor does visit before the treatment is administered, then they can claim through Medicare as per usual,’ he said. ‘But the nursing and pharmacy [costs] will not be covered.’
Are patients supposed to disassociate when they take esketamine?
Dissociation with treatment is frequent, albeit mild and transient for most patients, Prof Hopwood said.
‘For up to half an hour they [may] feel a little dreamy and not unpleasant,’ he said.
Some evidence suggests that mild dissociative effects may be required for the drug to be effective in the treatment of depression, although this is not definitive, Prof Hopwood said.
‘We monitor patients during that time and keep them safe,’ he said. ‘Most of them simply want to lie there and listen to music or just bliss out for a short period of time.’
While there is no reversal agent for esketamine, any periods of distress are typically short lived.
‘We've had a very small number of patients distressed, consistent with the trials,’ Prof Hopwood said. ‘And they've generally responded to quite simple reassurance.’
Patients’ blood pressure is also monitored ‘It's rarely severe enough that intervention is required, but there can be a transient increase, as we've known from the use of ketamine as an anaesthetic,’ he said.
Where should pharmacists refer interested patients?
GPs are an important resource for knowing where the available treatment centers are, Prof Hopwood said.
‘There is a list of those available, and I predict that number may increase over time now that esketamine is funded.’
There are high levels of patient interest in esketamine and psychedelics, Prof Hopwood said.
‘So it's important they receive accurate, quality information that includes realistic expectations about the likelihood of treatment response and what's involved,’ he said. ‘And pharmacists are very well placed to provide that kind of information.’
What is preferable: esketamine or psychedelics?
Since 1 July 2023, patients with treatment-resistant depression have legally been allowed to receive treatment with psilocybin and MDMA, under specific conditions.
There is a degree of overlap between the patient populations considered suitable for ketamine and psychedelic therapy, Prof Hopwood said.
‘Most of the current guidance, including from The Royal Australian and New Zealand College of Psychiatrists, would say that psychedelic therapy is still more at a research level,’ he said.
‘Whereas, esketamine, reflected in the funding, has reached a higher level of evidence at this point.
‘So I would certainly see it as coming before psychedelic therapy in any hierarchy.’
To find out more about the use of psilocybin for treatment-resistant depression, read Australian Pharmacist's CPD article on the therapeutic potential of psychedelics.
[post_title] => PBS-backed esketamine rolls out for depression with S8 controls
[post_excerpt] => Esketamine will soon be funded for treatment-resistant depression, requiring pharmacists to adhere to strict supply and handling conditions.
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[title_attribute] => PBS-backed esketamine rolls out for depression with S8 controls
[title] => PBS-backed esketamine rolls out for depression with S8 controls
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[post_content] => Aside from administering medicines by injection, Queensland-based community pharmacist Fiona Watson MPS loves tearing up a Latin dance floor.
Tell us about your pharmacy career.
I had a varied early career, moving to North Queensland for a year shortly after I graduated as well as locuming around Australia for a while.
This gave me a great introduction to community pharmacy and a lot of different experiences – both good and bad. When locuming, you develop a clear idea of the factors that contribute to a well-run pharmacy.
I then moved to the United Kingdom where I completed a Certificate in Clinical Pharmacy. You can tell how old I am because I was one of the last pharmacists able to register in the UK with only a month under supervision.
I was a ‘rotational resident pharmacist’, living on-site at the hospital. I covered renal, gastro, cardiology, oncology, aged care, palliative care and surgery wards.
We worked on call overnight, and could get called upon to help with all sorts of different situations – one of the most interesting being calculating the correct dose for the antidote to antifreeze.
More recently, I was very fortunate to be given the opportunity to go into partnership with my mum and sister, both pharmacists, as the managing partner at Redland Bay Wholelife Pharmacy and Healthfoods.
What medicines do you administer by injection?
About 10 years ago, I became a trained vaccinator administering thousands of vaccines during the COVID-19 pandemic.
When Queensland allowed pharmacists to expand the range of medicines they could administer, I completed the Medication Administration course, as I believe this is an essential skill for pharmacists to have.
So many new medications are injectable, and for some patients self-administration just isn’t an option. We were one of the first pharmacies in our area to offer long-acting injectable buprenorphine services, which can be a life-changing option for patients.
Tell us about your administering injections beyond vaccines.
The majority of pharmacists I work with at Redland Bay are trained vaccinators and have completed medicines administration courses. When we come across a new medication that requires administration by injection we collate the available information from the manufacturer and ensure everyone has read it. Many companies, such as Novartis with inclisiran (Leqvio), have reps who are happy to provide additional training.
Once you are comfortable with subcutaneous injections, it’s a matter of familiarising yourself with the different types of devices available. It seemed a logical step for us to provide this service. We have great consult room facilities and it brings variety to our role.
What role do you see pharmacists playing in cardiovascular care in future?
The sky is the limit. We’re on the cusp of a fundamental change in the way Australians receive health care and I hope to see pharmacists embrace the opportunities this will bring.
There’s a workforce crisis and an ageing population, so we need to become more efficient and accessible. If you think about how much the role of a nurse practitioner has changed in the last 10–15 years, you can see where pharmacists have even greater potential. A patient with a diagnosis of heart failure should be able to be titrated to optimum therapy by a pharmacist in a community pharmacy. A patient should have their HbA1c or lipids checked in the pharmacy, with appropriate therapy initiated or adjusted. We should also be actively involved in screening and chronic disease management.
Pharmacy is an incredibly rewarding and enjoyable career, and now is an especially exciting time to be a pharmacist. There is just so much opportunity.
Day in the life of Fiona Watson MPS, Community pharmacist at Redland Bay Wholelife Pharmacy, QLD.
| 5.00am |
Hit the gym I get up and do a HIIT or Muay Thai class most mornings for positive effects on my mental health. Passionate about preventative health care, I see the long-term effects of patients’ lifestyle choices every day. |
| 8.00am |
Open the pharmacy Every day is different. At least two pharmacists are rostered on, ensuring we give each patient the time they need while providing a wide range of different services. |
| 9.00am |
Vaccination service Embarking on a cruise in 2 months, a couple in their 60s asks about COVID-19 vaccines. More than 12 months since their last vaccine they are happy to be vaccinated on the spot. Not wanting more than one vaccine at a time, we book them in for a follow-up appointment in a month for the shingles vaccination. |
| 10.00am |
Collaborative care A local GP phones about a recently discharged mutual patient who’s not coping well on his new medicines. We spend some time with the patient doing a medicine review and setting up his profile for a dose administration aid. |
| 1.00pm |
Lunchtime It’s important that all staff, especially pharmacists, prioritise their breaks. We all need a little downtime to reset and refresh. |
| 1.30pm |
Medicines injection A regular patient comes in for her second dose of inclisiran (Leqvio) after I administered her first 3 months ago. She is happy with the more convenient option than visiting her GP. |
| 3.00pm |
Infection control In a call from our pharmacy car park, we learn a patient has tested positive for COVID-19 and has an e-script. We dispense and counsel over the phone and then deliver out to their car (with appropriate precautions). |
| 6.30pm |
OCP continuance A stressed young woman, with a 2-week wait for a GP appointment, has run out of her pill. She is relieved when seen by a colleague who prescribes Estelle under the Queensland Hormonal Contraceptive Pilot. I dispense it. |
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[post_content] => Vaccination coverage in older Australians remains alarmingly low. Off-site services provided by pharmacists are key to closing the gap in aged care.
Older Australians are highly susceptible to serious complications from influenza and COVID-19. But the vaccination rates in patients aged 75 and over are nowhere where they need to be to protect this vulnerable patient cohort from harm, including hospitalisations and death.
The national influenza vaccination rate of patients aged 65 and over currently sits at 7.2%. And in the last 12 months, only 37.7% of Australians aged 75 and over received a COVID-19 vaccination.
But boosting immunisation rates in older Australians is more important than ever. The influenza season started earlier and stronger than usual, with 60,594 cases of influenza reported this year.
As of 10 April, there were also 70 active outbreaks of COVID-19 in residential aged care facilities (RACFs). Last year, case numbers were highest among those most at risk, with notifications peaking in the 75–79, 80–84 and 85+ (12,607).
With GPs not always available to address vaccination gaps in aged care, pharmacists are well positioned to step in and provide this essential service.
In the video above, community pharmacist Lachlan Rose MPS outlines the benefits of providing offsite vaccinations in aged care settings, including financial incentives, workplace variety and the protection of one of the most vulnerable populations.
[post_title] => All pharmacists should consider off-site vaccinations in aged care
[post_excerpt] => Vaccination rates in older Australians are alarmingly low. Off-site services provided by pharmacists are key to closing the gap in aged care.
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[post_content] => The Fair Work Commission’s Expert Panel for pay equity in the care and community sector has today issued its initial decision on the Gender-based undervaluation – priority awards review – making determinations on the Pharmacy Industry Award 2020, which most community pharmacists are employed under.
What did the Expert Panel find?
The Expert Panel found that pharmacists covered by the Pharmacy Industry Award 2020 (and several other awards) have been the subject of gender-based undervaluation.
As a result, the Expert Panel has determined that findings constitute work value reasons, justifying variation of the modern award minimum wage rates across all categories of pharmacists.
What is ‘gender-based undervaluation’?
Gender-based undervaluation considers a range of factors to determine whether minimum award pay rates are undervalued because of assumptions based on gender.
The range of factors considered extends to historical undervaluing, exercise of ‘invisible skills’, exercise of caring work and workforce qualifications, among others.
How does the Expert Panel intend to address the undervaluation?
For pharmacists employed by the Pharmacy Industry Award 2020, the Expert Panel has issued a determination that there will be a total increase in the minimum wage rates of 14.1% over three years.
This increase will be implemented in three equal phases on:
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[post_content] => Rosa is a 35-year-old professional struggling with persistent sleep disturbances. Despite maintaining a consistent sleep routine, exercising regularly, and avoiding heavy meals before bedtime, she found herself regularly waking during the night.
The consultation
[caption id="attachment_27686" align="alignright" width="300"] This article is sponsored by Kenvue.[/caption]
Before providing Rosa a sleep aid such as melatonin supplements, you ask a series of questions to identify potential contributing factors for her condition and to determine if a sleep aid is the best treatment option.
Key questions to ask
Medical history:
Duration of symptoms:
Symptom pattern:
Nasal symptoms:
Sensory Irritation:
Environmental factors:
Timing of symptoms:
Current approaches:
Current medical status and medications:
Rosa reveals that when she wakes, she frequently has a blocked nose and itchy eyes, and she sneezes a lot in the evening before bed. She has suffered from very mild hayfever before but never at this time of year.
You suspect allergic rhinitis as the root cause. Rosa was surprised. Like many, she had dismissed her nasal congestion as a minor annoyance rather than a significant factor affecting her rest. She didn’t even think one could get hayfever in winter.
You recommend a treatment plan to tackle the root cause of Rosa’s sleep disturbances. With proper treatment, she can manage her symptoms and improve sleep quality. Alongside managing environmental exposure you can recommend an antihistamine like:
Zyrtec Rapid Acting Allergy Antihistamine and Hayfever Tablets
Dosage: One tablet daily offers 24-hour protection.
You can also recommend Rhinocort nasal spray to be used when symptoms become acute.1
Within days of following the treatment plan, Rosa noticed a remarkable improvement. Her congestion eased, she wasn’t waking up anymore, and she finally felt refreshed and energised throughout the day.
By looking beyond the immediate request for sleep aids, the pharmacist was able to identify the true cause of Rosa’s problem and offer a more effective, long-term solution.
Allergic rhinitis (AR) and sleep disruptionsAllergic rhinitis (AR), commonly known as hayfever, affects around 19% of Australians.2 Chronic nasalcongestion and other symptoms of allergic rhinitis can significantly impact sleep quality.3 This often results in daytime fatigue, decreased productivity, and impaired cognitive function. Patients may not realise that their persistent tiredness or difficulty concentrating stems from untreated allergies. Zyrtec works fast for hayfever relief and stays strong, day after day offering 24-hour relief from multiple symptoms. |
Zyrtec works fast for hay fever relief and stays strong, day after day.4If your patient is struggling with unexplained sleep disturbances, allergies could be the hidden cause.
With the right management you can help them to reclaim restful sleep and feel their best every day.
Urdaneta E, et al. Ann Allergy Asthma Immunol 2010;105(5):A121. (Sponsored by Zyrtec.)
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[post_content] => From 1 May, Spravato (esketamine) will be subsidised under the Pharmaceutical Benefits Scheme (PBS) for adults with treatment-resistant depression, intended for use alongside a newly initiated oral antidepressant.
Up to 30,000 Australians are anticipated to access esketamine via the PBS, paying only $7.70 per dose with a pensioner or concession card, or $31.60 per dose for general patients.
[caption id="attachment_29259" align="alignright" width="233"] Professor Malcolm Hopwood[/caption]
Australian Pharmacist spoke with Professor Malcolm Hopwood, Ramsay Health Care Professor of Psychiatry at the University of Melbourne, about the treatment process and how pharmacists will be involved.
How effective is esketamine in managing treatment resistant depression?
The largest clinical trials on esketamine efficacy found that about 50% of patients who had not responded to two or three antidepressants did respond to esketamine, Prof Hopwood said.
‘If you compare that to trialing one of the usual medicines, the response rate for the third or fourth [medicine] is probably only about 15%,’ he said. ‘So it’s quite a jump up in terms of response rate.’
Who is eligible to be prescribed esketamine nasal spray?
Those diagnosed with treatment-resistant depression, defined as major depressive disorder that has not responded sufficiently to at least two different antidepressants, each administered at an adequate dose and duration, for the treatment of the current moderate to severe depressive episode.
Who is not a good candidate for this treatment?
Esketamine is currently not indicated for bipolar depression. And caution should be taken for patients with psychotic depression, Prof Hopwood said.
‘[This is] because ketamine, when used in much higher doses, has psychogenic potential,’ Prof Hopwood said.
There is also a precautionary note in the product information around patients with marked hepatic or renal impairment.
‘In terms of drug-drug interactions, it should not be used together with an irreversible monoamine oxidase inhibitor, which these days is only Parnate,’ he said. ‘While not widely used now, it's an important interaction to be aware of.’
What’s the duration of therapy?
Esketamine is initially administered twice weekly for the first 4 weeks, Prof Hopwood said.
‘By the end of that 4-week period, we've usually got a sense whether you're a responder or not.’
Treatment usually stops in non-responders, with responders moving to a once-weekly treatment regimen.
‘Eventually, fortnightly treatment for a 6-month maintenance period is what we recommend,’ Prof Hopwood said.
Is re-treatment recommended?
Given that depression is a highly recurrent condition, it is likely some patients will relapse post treatment. And re-treatment with esketamine could prove beneficial, Prof Hopwood said.
‘There is some data about re-treatment … [with] evidence showing that responders do seem to have a good response rate the second time around,’ he said. ‘That will be permitted under this funding scheme.’
How is esketamine supplied?
Patients cannot be in possession of the spray until they are in the clinic for administration under supervision, Prof Hopwood said.
‘Esketamine needs to be administered in an approved treatment center that involves close supervision for side effects such as dissociation and hypertension,’ he said.
Appropriate pharmacist handling of a Schedule 8 medicine is also required.
‘In our facility, we are fortunate to have an on-site pharmacist who dispenses [the medicine] to a nurse, and then the patient self-administers,’ Prof Hopwood said.
‘But the patient neither brings the medicine to the clinic or takes it away. The intent … is to reduce the risk of diversion.’
Facilities that do not have an on-site pharmacist must establish and demonstrate a connection with a local community pharmacy to qualify as an approved treatment centre.
Is talk therapy involved in the session?
Treatment with esketamine does not involve psychotherapy. However, there is a small body of research currently looking at ketamine-facilitated psychotherapy, Prof Hopwood said.
‘We still don't know whether that offers additional benefit for many patients, [but] if esketamine proves an effective treatment for their depression, they may be able to utilise psychotherapy much more effectively – which they might not be able to do when severely depressed.’
What are the estimated costs of esketamine sessions?
The estimated cost is $300–$350 per treatment session, Prof Hopwood said.
In most clinics, the doctor will see the patient on treatment occasions, but less so as treatment becomes established.
‘If the doctor does visit before the treatment is administered, then they can claim through Medicare as per usual,’ he said. ‘But the nursing and pharmacy [costs] will not be covered.’
Are patients supposed to disassociate when they take esketamine?
Dissociation with treatment is frequent, albeit mild and transient for most patients, Prof Hopwood said.
‘For up to half an hour they [may] feel a little dreamy and not unpleasant,’ he said.
Some evidence suggests that mild dissociative effects may be required for the drug to be effective in the treatment of depression, although this is not definitive, Prof Hopwood said.
‘We monitor patients during that time and keep them safe,’ he said. ‘Most of them simply want to lie there and listen to music or just bliss out for a short period of time.’
While there is no reversal agent for esketamine, any periods of distress are typically short lived.
‘We've had a very small number of patients distressed, consistent with the trials,’ Prof Hopwood said. ‘And they've generally responded to quite simple reassurance.’
Patients’ blood pressure is also monitored ‘It's rarely severe enough that intervention is required, but there can be a transient increase, as we've known from the use of ketamine as an anaesthetic,’ he said.
Where should pharmacists refer interested patients?
GPs are an important resource for knowing where the available treatment centers are, Prof Hopwood said.
‘There is a list of those available, and I predict that number may increase over time now that esketamine is funded.’
There are high levels of patient interest in esketamine and psychedelics, Prof Hopwood said.
‘So it's important they receive accurate, quality information that includes realistic expectations about the likelihood of treatment response and what's involved,’ he said. ‘And pharmacists are very well placed to provide that kind of information.’
What is preferable: esketamine or psychedelics?
Since 1 July 2023, patients with treatment-resistant depression have legally been allowed to receive treatment with psilocybin and MDMA, under specific conditions.
There is a degree of overlap between the patient populations considered suitable for ketamine and psychedelic therapy, Prof Hopwood said.
‘Most of the current guidance, including from The Royal Australian and New Zealand College of Psychiatrists, would say that psychedelic therapy is still more at a research level,’ he said.
‘Whereas, esketamine, reflected in the funding, has reached a higher level of evidence at this point.
‘So I would certainly see it as coming before psychedelic therapy in any hierarchy.’
To find out more about the use of psilocybin for treatment-resistant depression, read Australian Pharmacist's CPD article on the therapeutic potential of psychedelics.
[post_title] => PBS-backed esketamine rolls out for depression with S8 controls
[post_excerpt] => Esketamine will soon be funded for treatment-resistant depression, requiring pharmacists to adhere to strict supply and handling conditions.
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[post_content] => Aside from administering medicines by injection, Queensland-based community pharmacist Fiona Watson MPS loves tearing up a Latin dance floor.
Tell us about your pharmacy career.
I had a varied early career, moving to North Queensland for a year shortly after I graduated as well as locuming around Australia for a while.
This gave me a great introduction to community pharmacy and a lot of different experiences – both good and bad. When locuming, you develop a clear idea of the factors that contribute to a well-run pharmacy.
I then moved to the United Kingdom where I completed a Certificate in Clinical Pharmacy. You can tell how old I am because I was one of the last pharmacists able to register in the UK with only a month under supervision.
I was a ‘rotational resident pharmacist’, living on-site at the hospital. I covered renal, gastro, cardiology, oncology, aged care, palliative care and surgery wards.
We worked on call overnight, and could get called upon to help with all sorts of different situations – one of the most interesting being calculating the correct dose for the antidote to antifreeze.
More recently, I was very fortunate to be given the opportunity to go into partnership with my mum and sister, both pharmacists, as the managing partner at Redland Bay Wholelife Pharmacy and Healthfoods.
What medicines do you administer by injection?
About 10 years ago, I became a trained vaccinator administering thousands of vaccines during the COVID-19 pandemic.
When Queensland allowed pharmacists to expand the range of medicines they could administer, I completed the Medication Administration course, as I believe this is an essential skill for pharmacists to have.
So many new medications are injectable, and for some patients self-administration just isn’t an option. We were one of the first pharmacies in our area to offer long-acting injectable buprenorphine services, which can be a life-changing option for patients.
Tell us about your administering injections beyond vaccines.
The majority of pharmacists I work with at Redland Bay are trained vaccinators and have completed medicines administration courses. When we come across a new medication that requires administration by injection we collate the available information from the manufacturer and ensure everyone has read it. Many companies, such as Novartis with inclisiran (Leqvio), have reps who are happy to provide additional training.
Once you are comfortable with subcutaneous injections, it’s a matter of familiarising yourself with the different types of devices available. It seemed a logical step for us to provide this service. We have great consult room facilities and it brings variety to our role.
What role do you see pharmacists playing in cardiovascular care in future?
The sky is the limit. We’re on the cusp of a fundamental change in the way Australians receive health care and I hope to see pharmacists embrace the opportunities this will bring.
There’s a workforce crisis and an ageing population, so we need to become more efficient and accessible. If you think about how much the role of a nurse practitioner has changed in the last 10–15 years, you can see where pharmacists have even greater potential. A patient with a diagnosis of heart failure should be able to be titrated to optimum therapy by a pharmacist in a community pharmacy. A patient should have their HbA1c or lipids checked in the pharmacy, with appropriate therapy initiated or adjusted. We should also be actively involved in screening and chronic disease management.
Pharmacy is an incredibly rewarding and enjoyable career, and now is an especially exciting time to be a pharmacist. There is just so much opportunity.
Day in the life of Fiona Watson MPS, Community pharmacist at Redland Bay Wholelife Pharmacy, QLD.
| 5.00am |
Hit the gym I get up and do a HIIT or Muay Thai class most mornings for positive effects on my mental health. Passionate about preventative health care, I see the long-term effects of patients’ lifestyle choices every day. |
| 8.00am |
Open the pharmacy Every day is different. At least two pharmacists are rostered on, ensuring we give each patient the time they need while providing a wide range of different services. |
| 9.00am |
Vaccination service Embarking on a cruise in 2 months, a couple in their 60s asks about COVID-19 vaccines. More than 12 months since their last vaccine they are happy to be vaccinated on the spot. Not wanting more than one vaccine at a time, we book them in for a follow-up appointment in a month for the shingles vaccination. |
| 10.00am |
Collaborative care A local GP phones about a recently discharged mutual patient who’s not coping well on his new medicines. We spend some time with the patient doing a medicine review and setting up his profile for a dose administration aid. |
| 1.00pm |
Lunchtime It’s important that all staff, especially pharmacists, prioritise their breaks. We all need a little downtime to reset and refresh. |
| 1.30pm |
Medicines injection A regular patient comes in for her second dose of inclisiran (Leqvio) after I administered her first 3 months ago. She is happy with the more convenient option than visiting her GP. |
| 3.00pm |
Infection control In a call from our pharmacy car park, we learn a patient has tested positive for COVID-19 and has an e-script. We dispense and counsel over the phone and then deliver out to their car (with appropriate precautions). |
| 6.30pm |
OCP continuance A stressed young woman, with a 2-week wait for a GP appointment, has run out of her pill. She is relieved when seen by a colleague who prescribes Estelle under the Queensland Hormonal Contraceptive Pilot. I dispense it. |
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[post_content] => Vaccination coverage in older Australians remains alarmingly low. Off-site services provided by pharmacists are key to closing the gap in aged care.
Older Australians are highly susceptible to serious complications from influenza and COVID-19. But the vaccination rates in patients aged 75 and over are nowhere where they need to be to protect this vulnerable patient cohort from harm, including hospitalisations and death.
The national influenza vaccination rate of patients aged 65 and over currently sits at 7.2%. And in the last 12 months, only 37.7% of Australians aged 75 and over received a COVID-19 vaccination.
But boosting immunisation rates in older Australians is more important than ever. The influenza season started earlier and stronger than usual, with 60,594 cases of influenza reported this year.
As of 10 April, there were also 70 active outbreaks of COVID-19 in residential aged care facilities (RACFs). Last year, case numbers were highest among those most at risk, with notifications peaking in the 75–79, 80–84 and 85+ (12,607).
With GPs not always available to address vaccination gaps in aged care, pharmacists are well positioned to step in and provide this essential service.
In the video above, community pharmacist Lachlan Rose MPS outlines the benefits of providing offsite vaccinations in aged care settings, including financial incentives, workplace variety and the protection of one of the most vulnerable populations.
[post_title] => All pharmacists should consider off-site vaccinations in aged care
[post_excerpt] => Vaccination rates in older Australians are alarmingly low. Off-site services provided by pharmacists are key to closing the gap in aged care.
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[post_content] => The Fair Work Commission’s Expert Panel for pay equity in the care and community sector has today issued its initial decision on the Gender-based undervaluation – priority awards review – making determinations on the Pharmacy Industry Award 2020, which most community pharmacists are employed under.
What did the Expert Panel find?
The Expert Panel found that pharmacists covered by the Pharmacy Industry Award 2020 (and several other awards) have been the subject of gender-based undervaluation.
As a result, the Expert Panel has determined that findings constitute work value reasons, justifying variation of the modern award minimum wage rates across all categories of pharmacists.
What is ‘gender-based undervaluation’?
Gender-based undervaluation considers a range of factors to determine whether minimum award pay rates are undervalued because of assumptions based on gender.
The range of factors considered extends to historical undervaluing, exercise of ‘invisible skills’, exercise of caring work and workforce qualifications, among others.
How does the Expert Panel intend to address the undervaluation?
For pharmacists employed by the Pharmacy Industry Award 2020, the Expert Panel has issued a determination that there will be a total increase in the minimum wage rates of 14.1% over three years.
This increase will be implemented in three equal phases on:
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[post_content] => Rosa is a 35-year-old professional struggling with persistent sleep disturbances. Despite maintaining a consistent sleep routine, exercising regularly, and avoiding heavy meals before bedtime, she found herself regularly waking during the night.
The consultation
[caption id="attachment_27686" align="alignright" width="300"] This article is sponsored by Kenvue.[/caption]
Before providing Rosa a sleep aid such as melatonin supplements, you ask a series of questions to identify potential contributing factors for her condition and to determine if a sleep aid is the best treatment option.
Key questions to ask
Medical history:
Duration of symptoms:
Symptom pattern:
Nasal symptoms:
Sensory Irritation:
Environmental factors:
Timing of symptoms:
Current approaches:
Current medical status and medications:
Rosa reveals that when she wakes, she frequently has a blocked nose and itchy eyes, and she sneezes a lot in the evening before bed. She has suffered from very mild hayfever before but never at this time of year.
You suspect allergic rhinitis as the root cause. Rosa was surprised. Like many, she had dismissed her nasal congestion as a minor annoyance rather than a significant factor affecting her rest. She didn’t even think one could get hayfever in winter.
You recommend a treatment plan to tackle the root cause of Rosa’s sleep disturbances. With proper treatment, she can manage her symptoms and improve sleep quality. Alongside managing environmental exposure you can recommend an antihistamine like:
Zyrtec Rapid Acting Allergy Antihistamine and Hayfever Tablets
Dosage: One tablet daily offers 24-hour protection.
You can also recommend Rhinocort nasal spray to be used when symptoms become acute.1
Within days of following the treatment plan, Rosa noticed a remarkable improvement. Her congestion eased, she wasn’t waking up anymore, and she finally felt refreshed and energised throughout the day.
By looking beyond the immediate request for sleep aids, the pharmacist was able to identify the true cause of Rosa’s problem and offer a more effective, long-term solution.
Allergic rhinitis (AR) and sleep disruptionsAllergic rhinitis (AR), commonly known as hayfever, affects around 19% of Australians.2 Chronic nasalcongestion and other symptoms of allergic rhinitis can significantly impact sleep quality.3 This often results in daytime fatigue, decreased productivity, and impaired cognitive function. Patients may not realise that their persistent tiredness or difficulty concentrating stems from untreated allergies. Zyrtec works fast for hayfever relief and stays strong, day after day offering 24-hour relief from multiple symptoms. |
Zyrtec works fast for hay fever relief and stays strong, day after day.4If your patient is struggling with unexplained sleep disturbances, allergies could be the hidden cause.
With the right management you can help them to reclaim restful sleep and feel their best every day.
Urdaneta E, et al. Ann Allergy Asthma Immunol 2010;105(5):A121. (Sponsored by Zyrtec.)
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[post_content] => From 1 May, Spravato (esketamine) will be subsidised under the Pharmaceutical Benefits Scheme (PBS) for adults with treatment-resistant depression, intended for use alongside a newly initiated oral antidepressant.
Up to 30,000 Australians are anticipated to access esketamine via the PBS, paying only $7.70 per dose with a pensioner or concession card, or $31.60 per dose for general patients.
[caption id="attachment_29259" align="alignright" width="233"] Professor Malcolm Hopwood[/caption]
Australian Pharmacist spoke with Professor Malcolm Hopwood, Ramsay Health Care Professor of Psychiatry at the University of Melbourne, about the treatment process and how pharmacists will be involved.
How effective is esketamine in managing treatment resistant depression?
The largest clinical trials on esketamine efficacy found that about 50% of patients who had not responded to two or three antidepressants did respond to esketamine, Prof Hopwood said.
‘If you compare that to trialing one of the usual medicines, the response rate for the third or fourth [medicine] is probably only about 15%,’ he said. ‘So it’s quite a jump up in terms of response rate.’
Who is eligible to be prescribed esketamine nasal spray?
Those diagnosed with treatment-resistant depression, defined as major depressive disorder that has not responded sufficiently to at least two different antidepressants, each administered at an adequate dose and duration, for the treatment of the current moderate to severe depressive episode.
Who is not a good candidate for this treatment?
Esketamine is currently not indicated for bipolar depression. And caution should be taken for patients with psychotic depression, Prof Hopwood said.
‘[This is] because ketamine, when used in much higher doses, has psychogenic potential,’ Prof Hopwood said.
There is also a precautionary note in the product information around patients with marked hepatic or renal impairment.
‘In terms of drug-drug interactions, it should not be used together with an irreversible monoamine oxidase inhibitor, which these days is only Parnate,’ he said. ‘While not widely used now, it's an important interaction to be aware of.’
What’s the duration of therapy?
Esketamine is initially administered twice weekly for the first 4 weeks, Prof Hopwood said.
‘By the end of that 4-week period, we've usually got a sense whether you're a responder or not.’
Treatment usually stops in non-responders, with responders moving to a once-weekly treatment regimen.
‘Eventually, fortnightly treatment for a 6-month maintenance period is what we recommend,’ Prof Hopwood said.
Is re-treatment recommended?
Given that depression is a highly recurrent condition, it is likely some patients will relapse post treatment. And re-treatment with esketamine could prove beneficial, Prof Hopwood said.
‘There is some data about re-treatment … [with] evidence showing that responders do seem to have a good response rate the second time around,’ he said. ‘That will be permitted under this funding scheme.’
How is esketamine supplied?
Patients cannot be in possession of the spray until they are in the clinic for administration under supervision, Prof Hopwood said.
‘Esketamine needs to be administered in an approved treatment center that involves close supervision for side effects such as dissociation and hypertension,’ he said.
Appropriate pharmacist handling of a Schedule 8 medicine is also required.
‘In our facility, we are fortunate to have an on-site pharmacist who dispenses [the medicine] to a nurse, and then the patient self-administers,’ Prof Hopwood said.
‘But the patient neither brings the medicine to the clinic or takes it away. The intent … is to reduce the risk of diversion.’
Facilities that do not have an on-site pharmacist must establish and demonstrate a connection with a local community pharmacy to qualify as an approved treatment centre.
Is talk therapy involved in the session?
Treatment with esketamine does not involve psychotherapy. However, there is a small body of research currently looking at ketamine-facilitated psychotherapy, Prof Hopwood said.
‘We still don't know whether that offers additional benefit for many patients, [but] if esketamine proves an effective treatment for their depression, they may be able to utilise psychotherapy much more effectively – which they might not be able to do when severely depressed.’
What are the estimated costs of esketamine sessions?
The estimated cost is $300–$350 per treatment session, Prof Hopwood said.
In most clinics, the doctor will see the patient on treatment occasions, but less so as treatment becomes established.
‘If the doctor does visit before the treatment is administered, then they can claim through Medicare as per usual,’ he said. ‘But the nursing and pharmacy [costs] will not be covered.’
Are patients supposed to disassociate when they take esketamine?
Dissociation with treatment is frequent, albeit mild and transient for most patients, Prof Hopwood said.
‘For up to half an hour they [may] feel a little dreamy and not unpleasant,’ he said.
Some evidence suggests that mild dissociative effects may be required for the drug to be effective in the treatment of depression, although this is not definitive, Prof Hopwood said.
‘We monitor patients during that time and keep them safe,’ he said. ‘Most of them simply want to lie there and listen to music or just bliss out for a short period of time.’
While there is no reversal agent for esketamine, any periods of distress are typically short lived.
‘We've had a very small number of patients distressed, consistent with the trials,’ Prof Hopwood said. ‘And they've generally responded to quite simple reassurance.’
Patients’ blood pressure is also monitored ‘It's rarely severe enough that intervention is required, but there can be a transient increase, as we've known from the use of ketamine as an anaesthetic,’ he said.
Where should pharmacists refer interested patients?
GPs are an important resource for knowing where the available treatment centers are, Prof Hopwood said.
‘There is a list of those available, and I predict that number may increase over time now that esketamine is funded.’
There are high levels of patient interest in esketamine and psychedelics, Prof Hopwood said.
‘So it's important they receive accurate, quality information that includes realistic expectations about the likelihood of treatment response and what's involved,’ he said. ‘And pharmacists are very well placed to provide that kind of information.’
What is preferable: esketamine or psychedelics?
Since 1 July 2023, patients with treatment-resistant depression have legally been allowed to receive treatment with psilocybin and MDMA, under specific conditions.
There is a degree of overlap between the patient populations considered suitable for ketamine and psychedelic therapy, Prof Hopwood said.
‘Most of the current guidance, including from The Royal Australian and New Zealand College of Psychiatrists, would say that psychedelic therapy is still more at a research level,’ he said.
‘Whereas, esketamine, reflected in the funding, has reached a higher level of evidence at this point.
‘So I would certainly see it as coming before psychedelic therapy in any hierarchy.’
To find out more about the use of psilocybin for treatment-resistant depression, read Australian Pharmacist's CPD article on the therapeutic potential of psychedelics.
[post_title] => PBS-backed esketamine rolls out for depression with S8 controls
[post_excerpt] => Esketamine will soon be funded for treatment-resistant depression, requiring pharmacists to adhere to strict supply and handling conditions.
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[post_content] => Aside from administering medicines by injection, Queensland-based community pharmacist Fiona Watson MPS loves tearing up a Latin dance floor.
Tell us about your pharmacy career.
I had a varied early career, moving to North Queensland for a year shortly after I graduated as well as locuming around Australia for a while.
This gave me a great introduction to community pharmacy and a lot of different experiences – both good and bad. When locuming, you develop a clear idea of the factors that contribute to a well-run pharmacy.
I then moved to the United Kingdom where I completed a Certificate in Clinical Pharmacy. You can tell how old I am because I was one of the last pharmacists able to register in the UK with only a month under supervision.
I was a ‘rotational resident pharmacist’, living on-site at the hospital. I covered renal, gastro, cardiology, oncology, aged care, palliative care and surgery wards.
We worked on call overnight, and could get called upon to help with all sorts of different situations – one of the most interesting being calculating the correct dose for the antidote to antifreeze.
More recently, I was very fortunate to be given the opportunity to go into partnership with my mum and sister, both pharmacists, as the managing partner at Redland Bay Wholelife Pharmacy and Healthfoods.
What medicines do you administer by injection?
About 10 years ago, I became a trained vaccinator administering thousands of vaccines during the COVID-19 pandemic.
When Queensland allowed pharmacists to expand the range of medicines they could administer, I completed the Medication Administration course, as I believe this is an essential skill for pharmacists to have.
So many new medications are injectable, and for some patients self-administration just isn’t an option. We were one of the first pharmacies in our area to offer long-acting injectable buprenorphine services, which can be a life-changing option for patients.
Tell us about your administering injections beyond vaccines.
The majority of pharmacists I work with at Redland Bay are trained vaccinators and have completed medicines administration courses. When we come across a new medication that requires administration by injection we collate the available information from the manufacturer and ensure everyone has read it. Many companies, such as Novartis with inclisiran (Leqvio), have reps who are happy to provide additional training.
Once you are comfortable with subcutaneous injections, it’s a matter of familiarising yourself with the different types of devices available. It seemed a logical step for us to provide this service. We have great consult room facilities and it brings variety to our role.
What role do you see pharmacists playing in cardiovascular care in future?
The sky is the limit. We’re on the cusp of a fundamental change in the way Australians receive health care and I hope to see pharmacists embrace the opportunities this will bring.
There’s a workforce crisis and an ageing population, so we need to become more efficient and accessible. If you think about how much the role of a nurse practitioner has changed in the last 10–15 years, you can see where pharmacists have even greater potential. A patient with a diagnosis of heart failure should be able to be titrated to optimum therapy by a pharmacist in a community pharmacy. A patient should have their HbA1c or lipids checked in the pharmacy, with appropriate therapy initiated or adjusted. We should also be actively involved in screening and chronic disease management.
Pharmacy is an incredibly rewarding and enjoyable career, and now is an especially exciting time to be a pharmacist. There is just so much opportunity.
Day in the life of Fiona Watson MPS, Community pharmacist at Redland Bay Wholelife Pharmacy, QLD.
| 5.00am |
Hit the gym I get up and do a HIIT or Muay Thai class most mornings for positive effects on my mental health. Passionate about preventative health care, I see the long-term effects of patients’ lifestyle choices every day. |
| 8.00am |
Open the pharmacy Every day is different. At least two pharmacists are rostered on, ensuring we give each patient the time they need while providing a wide range of different services. |
| 9.00am |
Vaccination service Embarking on a cruise in 2 months, a couple in their 60s asks about COVID-19 vaccines. More than 12 months since their last vaccine they are happy to be vaccinated on the spot. Not wanting more than one vaccine at a time, we book them in for a follow-up appointment in a month for the shingles vaccination. |
| 10.00am |
Collaborative care A local GP phones about a recently discharged mutual patient who’s not coping well on his new medicines. We spend some time with the patient doing a medicine review and setting up his profile for a dose administration aid. |
| 1.00pm |
Lunchtime It’s important that all staff, especially pharmacists, prioritise their breaks. We all need a little downtime to reset and refresh. |
| 1.30pm |
Medicines injection A regular patient comes in for her second dose of inclisiran (Leqvio) after I administered her first 3 months ago. She is happy with the more convenient option than visiting her GP. |
| 3.00pm |
Infection control In a call from our pharmacy car park, we learn a patient has tested positive for COVID-19 and has an e-script. We dispense and counsel over the phone and then deliver out to their car (with appropriate precautions). |
| 6.30pm |
OCP continuance A stressed young woman, with a 2-week wait for a GP appointment, has run out of her pill. She is relieved when seen by a colleague who prescribes Estelle under the Queensland Hormonal Contraceptive Pilot. I dispense it. |
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[post_content] => Vaccination coverage in older Australians remains alarmingly low. Off-site services provided by pharmacists are key to closing the gap in aged care.
Older Australians are highly susceptible to serious complications from influenza and COVID-19. But the vaccination rates in patients aged 75 and over are nowhere where they need to be to protect this vulnerable patient cohort from harm, including hospitalisations and death.
The national influenza vaccination rate of patients aged 65 and over currently sits at 7.2%. And in the last 12 months, only 37.7% of Australians aged 75 and over received a COVID-19 vaccination.
But boosting immunisation rates in older Australians is more important than ever. The influenza season started earlier and stronger than usual, with 60,594 cases of influenza reported this year.
As of 10 April, there were also 70 active outbreaks of COVID-19 in residential aged care facilities (RACFs). Last year, case numbers were highest among those most at risk, with notifications peaking in the 75–79, 80–84 and 85+ (12,607).
With GPs not always available to address vaccination gaps in aged care, pharmacists are well positioned to step in and provide this essential service.
In the video above, community pharmacist Lachlan Rose MPS outlines the benefits of providing offsite vaccinations in aged care settings, including financial incentives, workplace variety and the protection of one of the most vulnerable populations.
[post_title] => All pharmacists should consider off-site vaccinations in aged care
[post_excerpt] => Vaccination rates in older Australians are alarmingly low. Off-site services provided by pharmacists are key to closing the gap in aged care.
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[post_content] => The Fair Work Commission’s Expert Panel for pay equity in the care and community sector has today issued its initial decision on the Gender-based undervaluation – priority awards review – making determinations on the Pharmacy Industry Award 2020, which most community pharmacists are employed under.
What did the Expert Panel find?
The Expert Panel found that pharmacists covered by the Pharmacy Industry Award 2020 (and several other awards) have been the subject of gender-based undervaluation.
As a result, the Expert Panel has determined that findings constitute work value reasons, justifying variation of the modern award minimum wage rates across all categories of pharmacists.
What is ‘gender-based undervaluation’?
Gender-based undervaluation considers a range of factors to determine whether minimum award pay rates are undervalued because of assumptions based on gender.
The range of factors considered extends to historical undervaluing, exercise of ‘invisible skills’, exercise of caring work and workforce qualifications, among others.
How does the Expert Panel intend to address the undervaluation?
For pharmacists employed by the Pharmacy Industry Award 2020, the Expert Panel has issued a determination that there will be a total increase in the minimum wage rates of 14.1% over three years.
This increase will be implemented in three equal phases on:
CPD credits
Accreditation Code :
Group 1 : CPD credits
Group 2 : CPD credits
This activity has been accredited for hours of Group 1 CPD (or CPD credits) suitable for inclusion in an individual pharmacist's CPD plan, which can be converted to hours of Group 2 CPD (or CPD credits) upon successful completion of relevant assessment activities.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
