td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14483 [post_author] => 3387 [post_date] => 2021-10-13 11:06:39 [post_date_gmt] => 2021-10-13 00:06:39 [post_content] => After more than 100 days in lockdown, New South Wales pharmacists reflect on the challenges of the past few months and what lies ahead. Pharmacists have administered over 1.15 million COVID-19 vaccines (842,400 AstraZeneca and 316,900 Spikevax doses nationally) with NSW and the ACT reaching over 70% double dose vaccination coverage. In a few short months, NSW pharmacists delivered over half a million vaccines (605,900). Canberra-based pharmacists have administered 30,428 vaccine doses to a population of 432,000 since joining the rollout. ‘AstraZeneca, Moderna, they’re being delivered in our pharmacies, and they’re helping to drive these record numbers,’ Federal Minister for Health Greg Hunt said on Saturday. Chelsea Felkai MPS, PSA NSW Branch President, said pharmacists have had a ‘huge’ impact on the state's vaccination rates, particularly due to the accessibility they provide. ‘Once the [vaccination] age dropped, we were seeing people who had just turned 12 wanting to get vaccinated at pharmacies,’ Ms Felkai told Australian Pharmacist. Plenty of pharmacies across the state are still booked out, with some taking on an extra staff member to administer vaccinations after Spikevax rolled out.For others, demand is inconsistent and those with surplus stock are encouraged to find ways to redistribute it to avoid wastage.But while lockdown has lifted, pharmacists still face challenges. ‘We will see an influx of patients coming into the pharmacy, and there's still the anxiety of contracting COVID-19 and spreading it in the community,’ Ms Felkai said.
Mid coast pharmacists have been run off their feet, since the Moderna vaccine arrived in the region.They're bracing for even higher demand, as freedom day approaches.@robdouglas21 pic.twitter.com/4Brllm404M — NBN News (@nbnnews) October 7, 2021
‘Freedom Day’ yet to comeUnder new guidelines endorsed by theAustralian Health Protection Principal Committee, vaccinated healthcare workers may no longer have to isolate after being exposed to COVID-19. This will be progressively rolled out across all states and territories. If you have had COVID-19 in the past 6 months, isolation and testing are not required unless symptomatic. Should a pharmacy staff member test positive, they are still currently required to isolate for 14 days, regardless of vaccination status. Pharmacists must inform NSW Health should more than 3 employees test positive within 7 days. Operating restrictions for pharmacists will largely remain the same at this stage of the roadmap. The density limit is still one person per 4 square meters in indoor venues. ‘Mandatory mask wearing and check-ins [still apply] in all indoor settings, even for the fully vaccinated,’ Ms Felkai said. ‘But you're no longer required to wear masks outdoors.’ While the initial panic around COVID-19 has subsided, pharmacists may experience some difficult patient interactions with patients who think ‘Freedom Day’ means all restrictions are lifted. ‘But in general, the public love what we're doing, they appreciate us, and we just need to keep on educating and supporting them.’
The hotspot pharmacistWith two pharmacies in the south Sydney hotspot area of Riverwood, Ben Galluzzo MPS has had a trying couple of months. In early August, one of his staff members was listed as a casual contact after serving a patient with COVID-19. ‘I was also listed as a close contact after I went to the bank one day,’ Mr Galluzzo told AP. ‘The whole close contact thing has been the hardest thing to manage.’ Over the last few months, he was constantly on call to manage any staffing deficits. ‘I’ve got 40 staff across my two pharmacies, and all the staff react differently,’ Mr Galluzzo said. Using shields, ensuring social distancing and creating an hourly bench-cleaning roster was enough to make some staff members feel safe. ‘Others said, “I can't come into work, I don't feel comfortable,” which was another stress on the business.’ While restrictions have eased, Mr Galluzzo said the risk of transmission remains. ‘But as long as we're all vaccinated, we're all making sure the pharmacy is clean and [maintaining] distance where possible, we're minimising that risk,’ he said. ‘We've almost got on with it to get back to normal as much as we can.’
Vaccinating through the crisisSteering the community through the pandemic is ‘part of the gig’ of being a healthcare professional, Mr Galluzzo said. ‘We studied and trained to help the community, and we carried on doing that during this time.’ While challenging, Mr Galluzzo said it reminded the community how important and accessible pharmacists are. ‘We service aged care facilities, and I know a couple of doctors who retired during this period,’ he said. ‘Some doctors stopped seeing people [in person], but pharmacists kept their doors open the whole time.’ One local doctor who was vaccinating patients against COVID-19 had to close the practice after being listed as a close contact. ‘He referred all his patients to Galluzzo’s Chemist to fulfill their vaccination appointments, which increased our workload,’ Mr Galluzzo said. Over a 2-month period, Mr Galluzzo estimates his pharmacies administered around 1,500 vaccines while faced with the same workload and managing staff shortages. ‘It was pretty stressful,’ he said. ‘I'm happy that there's some light at the end of the tunnel.’
End of lockdown looms for Canberra[caption id="attachment_12018" align="alignright" width="173"] Chelsea Felkai MPS[/caption] From midnight on Friday 15 October, Canberra residents will wake up to fewer restrictions. All businesses must have COVID-19 Safety Plans prepared and must be registered for the Check in CBR app. Face masks must still be worn indoors and outdoors, and a one person per 4 square meter limit must be applied to all usable indoor and outdoor space in essential retail settings. While NSW and Victoria remain ‘COVID-19 Affected Areas’, approved border postcodes to travel to and form NSW will be expanded. [post_title] => How will post-lockdown restrictions impact pharmacists? [post_excerpt] => After more than 100 days in lockdown, New South Wales pharmacists reflect on the challenges of the past few months and what lies ahead. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => nsw-and-act-the-first-to-hit-vaccination-target [to_ping] => [pinged] => [post_modified] => 2021-10-15 01:44:09 [post_modified_gmt] => 2021-10-14 14:44:09 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14483 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => How will post-lockdown restrictions impact pharmacists? [title] => How will post-lockdown restrictions impact pharmacists? [href] => https://www.australianpharmacist.com.au/nsw-and-act-the-first-to-hit-vaccination-target/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14498 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14465 [post_author] => 4574 [post_date] => 2021-10-13 03:43:17 [post_date_gmt] => 2021-10-12 16:43:17 [post_content] => Much has been written about the pressure of the pandemic on pharmacists, but how has COVID-19 affected the profession’s future leaders? Pharmacy student Lina Okati from the University of Sydney spoke with four of her peers. For final year pharmacy student Jodie Jackson, who works as a pharmacy assistant at the Royal Prince Alfred Hospital and in multiple vaccination centres across Sydney, life in lockdown has meant finding new ways to connect. [caption id="attachment_14468" align="alignright" width="200"] Jodie Jackson[/caption] ‘We’ve all had to change the way we learn, from being in an engaging face-to-face environment, to now having to do our course online. Sometimes it’s hard to get adequate guidance and have someone to keep you accountable,’ she said. ‘But over the past year, I’ve learnt to connect with people online, which has made it a lot easier to communicate with my peers and mentors.’ While previously she was reluctant to reach out to people virtually, the pandemic has stripped away any awkwardness and encouraged her to make new connections. ‘Learning to communicate with people online has allowed me to build my network and connect with many individuals who have become valuable mentors throughout my career and studies,’ Ms Jackson added. In her role at the vaccination clinics, Ms Jackson helps train staff members on dispensing, transfers and checking processes and enjoys working in a multidisciplinary team. She hopes a legacy of the pandemic will be an increasing scope of practice for the pharmacy profession. ‘After seeing how great the involvement of pharmacists in the COVID-19 vaccination rollout has been, I would like to see pharmacists gain more responsibilities,’ she said. ‘We’re a very prestigious and reputable source of healthcare and I think we should be utilised to our maximum potential for the benefit of our communities.’
Pharmacy students hopeful for the futureSanam Fath-Abadi and Tyler Crook are both second year pharmacy students who have put their regular community pharmacy jobs on hold to take up roles in vaccination centres. [caption id="attachment_14467" align="alignright" width="267"] Tyler Crook[/caption] Ms Crook said working in a centre with pharmacists from a variety of backgrounds opened her eyes to the breath of roles within the profession. This is something she would like other students to know ‘because they shouldn’t feel limited, especially within such a vast field’. ‘So many students still feel very restricted to hospital or community pharmacy,’ she said. ‘They are not aware of the many great roles available across the profession, which limits the potential for their future careers.’ Although life as a pharmacy student has been difficult during the pandemic, particularly during the latest Sydney lockdown, Ms Fath-Abadi said it has helped to look at the positives. ‘I have more hours to dedicate to my work at the vaccination centre to help my community persevere through these difficult times,’ she said. ‘This work has been such an eye-opening experience and it has allowed me to see a whole other side of pharmacy and the specialisations that exist within it.’ [caption id="attachment_14466" align="alignleft" width="152"] Christian Bejjani[/caption] Vice President of the Sydney University Pharmacy Association, second year student Christian Bejjani is assisting with the vaccine rollout at a community pharmacy. With most of his degree conducted online so far, he said he ‘doesn’t really know much else’. ‘It has definitely had its challenges, as sometimes it’s difficult to sit behind the computer for long periods of time [and ] adjusting to remote labs has been difficult,’ he said. ‘Despite all this, I think my sense of acceptance of the situation and willingness to learn has made this period a lot easier.’ [post_title] => Pharmacy students do their part for vaccine rollout [post_excerpt] => Much has been written about the pressure of the pandemic on pharmacists, but how has COVID-19 affected the profession’s future leaders? Pharmacy student Lina Okati from the University of Sydney spoke with four of her peers. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => pharmacy-students-vaccine-rollout [to_ping] => [pinged] => [post_modified] => 2021-10-15 01:41:56 [post_modified_gmt] => 2021-10-14 14:41:56 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14465 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Pharmacy students do their part for vaccine rollout [title] => Pharmacy students do their part for vaccine rollout [href] => https://www.australianpharmacist.com.au/pharmacy-students-vaccine-rollout/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14469 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14436 [post_author] => 3387 [post_date] => 2021-10-06 15:39:45 [post_date_gmt] => 2021-10-06 04:39:45 [post_content] => As pharmacists approach a huge COVID-19 vaccination milestone this week, curious patients inquire about boosters. After little more than 2 months of administering COVID-19 vaccines, pharmacists have delivered 949,600 doses to patients across Australia. The Moderna vaccine has continued to dominate, with 25,700 doses administered in the last 24 hours compared to 14,600 of AstraZeneca. Victoria is leading the Moderna charge, with 71,400 doses administered since its Spikevax rollout began. The state is fast approaching its vaccination target of 70%, with 53% of residents now fully vaccinated. Due to the vaccination boost, restrictions may be lifted earlier than anticipated on 24 October.
Moderna booster queries on the riseAs Spikevax continues to roll out in pharmacies and more countries introduce boosters, patients are increasingly inquiring about extra COVID-19 vaccine doses, pharmacists report. Since rolling out Spikevax in her Mackay Queensland pharmacy 2 weeks ago, Karalyn Huxhagen FPS has seen an influx of patients wanting to book in for either a Moderna vaccine booster dose, or a second dose of Moderna after receiving a different vaccine. ‘One patient wanted a booster shot because he read in the British media that a [dose] of [an mRNA vaccine] combined with AstraZeneca showed improved efficacy,’ Ms Huxhagen told Australian Pharmacist. Reports on Pfizer’s waning efficacy is also behind some booster inquiries. ‘One elderly gentleman who had two Pfizer [doses] through his doctor rang the other day and wanted a booster of Moderna, based on what he had seen in the media about Pfizer waning quicker,’ Ms Huxhagen said. When explaining that booster doses are not currently recommended in Australia, she makes sure she speaks to patients ‘clearly, calmly, in words they understand’. ‘The majority of the people who are asking these questions are frightened, their health literacy is not amazing and they are a little confused by the different reports,’ she said. Ms Huxhagen explains that COVID-19 is a global problem, and so far local data has not indicated a reduction in immunity after two COVID-19 vaccine doses. ‘I talk in words like “drops away” rather than “decreasing immunity”,’ she said. Ms Huxhagen also discusses local data on hospitalisations, which are primarily in the unvaccinated. ‘I talk about the fact that we don't have evidence that [many] patients are ending up in hospital [after] they have had their two doses, so that tells us that the immunity is not dropping away.’ From an international standpoint, pharmacists could point out that while recent research in the New England Journal of Medicine on the effectiveness of mRNA vaccines in healthcare workers shows that efficacy reduces after some months, this is in relation to symptomatic infection. ‘This effectiveness is against symptomatic infection, not against hospitalisation or death, which is much higher,’ said Associate Professor Nicholas Wood, Associate Director, National Centre for Immunisation Research and Surveillance, in a recent Healthmed lecture. According to new research published this month in The Lancet, the Pfizer vaccine is 90% effective against hospitalisation for up to 6 months.
ATAGI adviceVaccinating the eligible population is the immediate key priority to convey to patients before booster shots come onto the agenda. ‘High primary COVID-19 vaccine coverage is expected to have the largest impact on protection against severe disease both directly (by direct protection) and indirectly (by prevention of transmission),’ the Australian Technical Advisory Group on Immunisation (ATAGI) said last month. It’s also important for patients to understand that the ATAGI is considering the timing of booster doses to ensure protection is provided during future outbreak peaks. For now, a small cohort of patients are expected to require a booster dose, including those who are immunocompromised. Later this month, ATAGI expects to release advice about people – including those who are severely immunocompromised – who may need three doses in their first course of vaccination. As well, it expects release advice about booster doses for the general population.
Remain vigilantPharmacists should ask patients for photo ID and a Medicare card, and check the Australian Immunisation Register before administering the vaccine. ‘Even though they've filled in the form, I still have a set conversation with them to make sure that the answers ticked on a form are actually true,’ Ms Huxhagen said. ‘You just have to be careful.’
Large-scale myocarditis studyNew research in JAMA Internal Medicine has found that acute myocarditis post-mRNA vaccine is exceedingly rare. Out of 2.4 million adults (aged over 18) who received a Pfizer or Moderna vaccine, 15 cases of myocarditis were recorded. These cases were all in men aged 20–32 years old, and each patient recovered. On the other hand, the rate of myocarditis in unvaccinated patients was 5 times higher (75 out of 1.6 million patients), affecting both men and women equally with a median age of 52. ‘Vigilance for rare adverse events, including myocarditis, after COVID-19 vaccination is warranted but should not diminish overall confidence in vaccination during the current pandemic,’ the study authors wrote.
Must know Spikevax advice for pharmacistsWith more patients expecting to visit community pharmacies for COVID-19 vaccines now that Moderna is widely available, an adequate vaccine booking program is crucial. Pharmacists should adopt the national vaccine booking system by connecting to the Vaccine Clinic Finder (VCF). Tonight, PSA is hosting a webinar to equip immunising pharmacists with the necessary skills to successfully roll out the Moderna vaccine and ensure their online booking service and appointment availability is listed on the VCF. The webinar will focus on vaccine specific facts, real-world experience and practical information in order to ensure pharmacists fulfil the requirements of informed consent and patient education, particularly post-vaccination. It will feature health experts and practitioners with experience in the use of the national VCF and booking system. To register for the webinar, which will be held at 7:00 pm AEDST, click here. [post_title] => What’s the deal with booster doses? [post_excerpt] => As pharmacists approach a huge COVID-19 vaccination milestone this week, curious patients inquire about boosters. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => whats-the-deal-with-booster-doses [to_ping] => [pinged] => [post_modified] => 2021-10-07 20:10:03 [post_modified_gmt] => 2021-10-07 09:10:03 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14436 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => What’s the deal with booster doses? [title] => What’s the deal with booster doses? [href] => https://www.australianpharmacist.com.au/whats-the-deal-with-booster-doses/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14454 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14415 [post_author] => 235 [post_date] => 2021-10-06 07:17:24 [post_date_gmt] => 2021-10-05 20:17:24 [post_content] => With a prescription now required to access liquid nicotine for inhalation, PSA has developed new guidelines and education to help pharmacists through the transition. In December last year, the Therapeutic Goods Administration (TGA) announced that from 1 October 2021, patients would need a prescription to legally access nicotine vaping products. Under the changes, general practitioners can prescribe nicotine vaping products by becoming an Authorised Prescriber, through the Special Access Scheme or by providing a prescription for 3 months’ supply via the Personal Importation Scheme. Patients with a valid prescription can access these products either by importing from overseas or having their prescription dispensed at a pharmacy. In its decision, the TGA cited a lack of evidence that nicotine vaping products are a safer alternative to first-line smoking cessation pharmacotherapy, as well as the unknown effects of long-term exposure to heated and inhaled chemicals.
Preventing use by non-smokersThe TGA also highlighted the ‘high addiction potential’ of nicotine vaping products. ‘Of particular concern, is the attractiveness of these products to adolescents, and the recent rapid increase in their use by adolescents,’ a TGA delegate wrote. ‘I am satisfied that there is a powerful argument that reducing the ease with which nicotine e-cigarettes can be accessed by adolescents will act to safeguard current and future generations from nicotine addiction.’ Between 2016 and 2019, the number of current e-cigarette users aged 15–24 in Australia increased by 95.7%, to a total of about 147,000 people. An ABC news interview this week highlighted the dangers of e-cigarette use among young people, detailing how a 15-year-old girl ended up in intensive care after developing what doctors believe was EVALI (E-cigarette or Vaping product use-Associated Lung Injury), a new lung illness that has emerged among vape users in the United States. The teenager told the ABC she began vaping in early 2020 as a way to manage her anxiety, and within weeks switched to cartridges that contained nicotine. By the time she was admitted to hospital in September, she was using e-cigarettes up to 3 times a week. But some doctors, who believe vaping can be a useful smoking cessation aid, say the case must be treated with caution. For example, Alex Wodak, a director of the Australian Tobacco Harm Reduction Association, who told the ABC: 'The symptoms [detailed in the report] are those of Acute Respiratory Distress Syndrome, this is a condition that has 20 to 30 possible causes such as infection or allergies.' The case was detailed in the Medical Journal of Australia.
Supporting pharmacistsTo help pharmacists manage the legislative changes, PSA has developed new guidelines and education modules, with support from the Australian Government Department of Health. The Guidelines for pharmacists providing smoking cessation support outline the pharmacist’s role in providing smoking cessation support and detail the key requirements for dispensing nicotine vaping products. They cover information relevant to pharmacists to assist in the safe and appropriate use of these products, which includes:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14410 [post_author] => 3387 [post_date] => 2021-10-06 07:07:30 [post_date_gmt] => 2021-10-05 20:07:30 [post_content] => Outbreaks of COVID-19 in maternity wards and neonatal units show the threat it can pose to newborns and their families. Australian Pharmacist spoke with one pharmacist working to ensure expectant mothers protect themselves and their babies through vaccination. Today, it was announced that a newborn in the neonatal intensive care unit (ICU) of Canberra's Centenary Hospital for Women and Children was infected with COVID-19. Last week, a COVID-19 outbreak spread through the maternity ward and neonatal ICU at Newcastle’s John Hunter Hospital. Of the 6 known infected parents, 3 are unvaccinated, 2 are partially vaccinated, and the vaccine status of the other is unknown. Parents listed as close contacts and the family members of exposed babies were placed in isolation, unable to visit their newborns. Dr Nisha Khot from the Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) told the ABC events like this will become more common due to ongoing community transmission of COVID-19, and should serve as a ‘red flag’ for pregnant women to get vaccinated. ‘Most women want to do the best thing for themselves and their babies and they might think doing nothing is best,’ she said. ‘But in this situation it's not the right thing to do.’ Pregnant women who get COVID-19 are more likely to suffer severe illness and require treatment in intensive care. They also have a higher risk of premature birth and stillbirth. A recent retrospective study by the Journal of the American Medical Association, however, shows that vaccination significantly reduces the chance of pregnant women catching COVID-19. Both the RANZCOG and Australian Technical Advisory Group on Immunisation (ATAGI) recommend that pregnant women are routinely offered mRNA vaccines at any stage of pregnancy. COVID-19 vaccination may also provide indirect protection to babies by transferring antibodies through the placenta (for pregnant women) or through breastmilk (for breastfeeding women), according to RANZCOG.
Pharmacist leading the chargeTo protect pregnant women and their unborn babies from the severe adverse outcomes associated with the virus, Western Australia’s King Edward Memorial Hospital opened a COVID-19 vaccination clinic for pregnant women opened on 20 September. Hospital pharmacist and COVID-19 vaccine coordinator Sarah Woodland explained that the clinic runs via opportunistic referrals. ‘When [patients] attend the antenatal clinic, we have immunisation midwives and obstetricians available to have discussions with them if they have any concerns [about vaccination],’ Ms Woodland told AP. ‘We can talk about the safety of COVID-19 vaccines in pregnancy, breastfeeding and [impacts on] fertility.’ When familiar health professionals provide this information to patients in a safe space, it can reassure them about the process. ‘Then we have the vaccination clinic available, with very minimal wait time,’ Ms Woodland said. While the clinic’s primary focus is antenatal patients and their support people, King Edward’s Breastfeeding Centre also refers women for vaccination. ‘We have lactation consultants involved in the referral process, and there are some pregnant patients who are breastfeeding other children as well,’ she said. ‘Essentially, we've made the clinic available to any outpatient, whether they be pregnant, breastfeeding or a gynaecological patient.’
Clinic set upFor now, there is one vaccinator delivering the service – an immunisation midwife who was already responsible for offering the influenza and pertussis vaccines to pregnant women. Another midwife, set up in the waiting room, offers the COVID-19 vaccine to patients, and discusses vaccine safety and the recommendations in pregnancy. As a pharmacist, Ms Woodland forms the backbone of the clinic. ‘I assist with the preparation of the vaccine, manage the stock control and the reporting, and provide support to the midwives should they have any further questions or referral points,’ she said. This includes inquiries about any potential medicine interactions. Recently a midwife queried whether a patient who needed an Rho(D) immune globulin injection could have her COVID-19 vaccine on the same day. ‘I was able to provide the information that yes, they certainly can,’ Ms Woodland said. ‘The only thing we recommend is that other vaccines, like the flu or whooping cough, are [given] at least 7 days apart from the COVID-19 vaccine.’
Pharmacists best for the jobApproaching a delicate issue like the COVID-19 vaccine in pregnancy is fitting for pharmacists, Ms Woodland said, because they are the ‘champions of evidence-based information’. ‘We're experts in the [quality use of] medicines and medicine safety, so we can provide that information quite readily and easily to patients,’ she said. Ms Woodland uses a COVID-19 database to provide information to midwives and patients, populated with up-to-date information that the pharmacist-run obstetric medicine information service provides. ‘We spent a lot of time curating COVID-19 specific information about the safety [of vaccines] in fertility, pregnancy and breastfeeding,’ Ms Woodland said. ‘So we're able to offer those resources and give additional information on top of what is already available on government, the ATAGI and RANZCOG websites.’
Combatting hesitancyWhile the clinic is just getting started, Ms Woodland said almost 100 patients come through per week for their COVID-19 vaccine. ‘There is still a fair amount of hesitancy in the pregnant population,’ she said, ‘but uptake is slowly improving.’ Ms Woodland cited a recent example of a patient and partner who were worried about receiving the vaccine, and wanted to postpone the process until after birth. ‘So we had a discussion about [why] mRNA vaccines are recommended in pregnancy and that antibodies produced from vaccination cross the placenta and may provide protection to the fetus,’ she said. ‘Having a vaccinated partner also means there's more protection for the family.’ If there is a COVID-19 outbreak in WA, Ms Woodland highlighted this may prevent the partner from visiting mother and baby in the hospital if they are unvaccinated. In the end, both the patient and her partner decided to get vaccinated. Getting the message across can be tricky at times, however, as COVID-19 does not present an immediate threat in WA. ‘But I try to put out the message about being proactive and passing on antibodies to the baby in utero before an outbreak,’ Ms Woodland said. ‘Now is the perfect time to get it done while the clinic is readily available for them without a wait time.’
Tips for community pharmacistsGood resources are the key to reaching vaccine hesitant pregnant women. Ms Woodland recommends MotherToBaby, a free, peer-reviewed source with up-to-date information on the safety of COVID-19 vaccines in pregnant and breastfeeding women. Pharmacists can also get in touch with their jurisdiction’s obstetric medicine information services (state-specific contacts are available here), as well as check the ATAGI and RANZCOG websites for recent updates. ‘It’s certainly not about forcing the vaccine on anyone, but letting them know that being proactive rather than reactive is a really good way to maintain your health,’ she said. ‘And [emphasising] that we have a lot of safety data and the government bodies behind us to support the use of mRNA vaccines in pregnancy and breastfeeding.’ [post_title] => Inside a multidisciplinary antenatal vaccination clinic [post_excerpt] => To protect pregnant women and their unborn babies from the severe adverse outcomes associated with the virus, the first pharmacist-led COVID-19 vaccination clinic for pregnant women opened in Western Australia’s King Edward Memorial Hospital on 20 September. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => pharmacist-run-antenatal-vaccination-clinic [to_ping] => [pinged] => https://www.australianpharmacist.com.au/moderna-bolsters-states-proactive-vaccination-efforts/ [post_modified] => 2021-10-07 20:10:20 [post_modified_gmt] => 2021-10-07 09:10:20 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14410 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Inside a multidisciplinary antenatal vaccination clinic [title] => Inside a multidisciplinary antenatal vaccination clinic [href] => https://www.australianpharmacist.com.au/pharmacist-run-antenatal-vaccination-clinic/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14411 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14458 [post_author] => 3387 [post_date] => 2021-10-12 22:00:01 [post_date_gmt] => 2021-10-12 11:00:01 [post_content] => Pharmacists’ accessibility and expertise make them an essential part of severe allergy management in children. For Phoebe Lynch from Keilor in Melbourne’s northwest, her local pharmacy is crucial to managing her son Owen’s anaphylaxis to egg, dairy and peanuts. When Owen was prescribed a lactose intolerance formula after being diagnosed with a dairy allergy at 3 months old, the pharmacists at Chemist Warehouse Keilor East ensured she had enough supply. And when the formula was low in stock, they advised her what to give Owen. ‘Their care continued, helping us manage his allergies, eczema and EpiPen needs once Owen was diagnosed at risk of anaphylaxis at 3 years of age,’ Ms Lynch told Australian Pharmacist. Owen’s case isn’t unique, with research showing food allergy and anaphylaxis is becoming more common in Australia. Up to 1 in 20 school aged children are now affected, with incidences of anaphylaxis doubling in a decade. Each year, fatalities from food-induced anaphylaxis increase by around 10%. To curb the risk, the National Allergy Strategy (NAS) has released best practice guidelines for the prevention and management of anaphylaxis in schools and children’s education and care. According to Dr Preeti Joshi, paediatric clinical immunology specialist and NAS co-chair, banning food allergens is not enough. ‘A consistent allergy-aware approach with age-appropriate strategies is preferred,’ she said. ‘This includes ensuring staff are adequately trained, especially in the prompt recognition and treatment of an allergic reaction, including anaphylaxis.’ Risk minimisation strategies, supervision and open communication are also important. ‘Things such as timely administration of adrenaline and correct positioning of the person experiencing anaphylaxis are key factors that can potentially save lives,’ she said. ‘Standardised reporting of incidents is also critical so we can learn where the gaps are and then work to increase safety.’
Anaphylaxis management and pharmacistsPharmacists are part of the circle of care for people at risk of anaphylaxis, Maria Said, co-chair of the NAS and CEO of Allergy and Anaphylaxis Australia, told AP. ‘It's important for pharmacists to have an understanding of emergency management and what allergic reactions look like,’ she said. Now that there are two adrenaline autoinjector devices available (Anapen and EpiPen), pharmacists have an even more important part to play in patient education. ‘Because the devices are used differently, there is a risk people might get confused about administration,’ Ms Said said. ‘[Pharmacists should] check that the person knows how to administer the device they're purchasing, and that they have an ASCIA [Australasian Society of Clinical Immunology and Allergy] Action Plan to match that device.’ When dispensing an adrenaline autoinjector, pharmacists should also emphasise the signs and symptoms of anaphylaxis and reinforce the emergency response aspect, Ms Said added.
Parents’ perspectivesJennifer Ayoub, from Carlingford in north-west Sydney, said it’s important for pharmacists to provide medicines advice for her son Oscar, who had an anaphylactic reaction to milk when he was 9 months old. ‘Allergy parents want EpiPens with the longest expiry date possible, especially if we’re buying extras for school or daycare,’ she said. ‘The extras are expensive so the longest expiry date is obviously more cost effective.’ When Ms Ayoub was in need, HealthFirst Pharmacy in Eastwood offered to order an EpiPen by the next morning with the latest expiry date. ‘In the past we just rang around to see what we could get, but this service is amazing for busy parents,’ she said. ‘I just dropped off the script and went in the following morning to pick up the EpiPens.’ Now that Oscar is getting older, Ms Ayoub plans to seek pharmacist advice on transitioning from children’s to adult antihistamines, which need to be carried at all times. Help with excipients is also a must. ‘There have been times Oscar has needed medicine and I have asked the pharmacist to check if it contains milk,’ Ms Ayoub said. ‘They have always looked it up for me and checked to ensure we’re buying something safe.’
A key resourceFor Ms Lynch in Melbourne, her local pharmacy played a particularly important role during the EpiPen Junior shortage last year. Ms Lynch found herself needing new supply every 4 months due to short expiry dates, meaning she had to visit her GP during lockdown. With each new EpiPen, she also had to update the paperwork at childcare. But her local pharmacy was there to help her through this challenging time. ‘They provided me with updates on when the new stock was expected, their expiry dates, and in one instance, organised a courier to deliver an EpiPen Junior from another pharmacy to their branch,’ Ms Lynch said. ‘Each time we get our EpiPen they ask us again if we know how to use it and dispose of it if administered and they are so helpful in labelling it correctly for the childcare requirements.
Anaphylaxis supportThe accessibility of community pharmacies makes them essential destinations for anaphylaxis care, said a pharmacist from Chemist Warehouse Keilor East who did not wish to be named. ‘Sometimes [patients] go to a medical centre and have to [sit] in the waiting room, whereas with pharmacies, they just pop in, and if anyone's having some kind of reaction we see them immediately,’ he said. As Ms Lynch stated, the pharmacy is quick to act in times of short supply. ‘I always make sure to pool my resources,’ the pharmacist said. ‘We’ve got our sister stores around us and even a bit further out, we've got a big network of stores that we can access the stock from.’ With special orders, such as Owen’s prescription formula, there’s always a back-up plan in place. ‘After we dispense the current supply, I make sure to immediately source the next so I've always got it there,’ the pharmacist said. When a patient purchases an adrenaline autoinjector, the pharmacist gives them a consumer medicine information leaflet and explains how to use it. ‘We have demo pens as well, so we actually get them to have a crack at [administering it],’ he said. ‘It doesn’t have a needle in it, but it’s just so they get the hang of the motion, how hard to do it, and the time it should be left against the body, so if they have to use it, they’ve done it before.’ For more information, pharmacists can direct parents to the new ‘Allergy Aware’ online hub, a free evidence-based resource. [post_title] => Pharmacists and anaphylaxis advice [post_excerpt] => Pharmacists’ accessibility and expertise make them an essential part of severe allergy management in children. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => pharmacists-anaphylaxis-advice [to_ping] => [pinged] => [post_modified] => 2021-10-15 02:16:28 [post_modified_gmt] => 2021-10-14 15:16:28 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14458 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Pharmacists and anaphylaxis advice [title] => Pharmacists and anaphylaxis advice [href] => https://www.australianpharmacist.com.au/pharmacists-anaphylaxis-advice/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14459 )
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Residential aged care providers must now ensure chemical restraint is only used as a last resort, implemented for the least amount of time possible; recorded, monitored and reviewed. Many aged care providers are unsure what constitutes chemical restraint and how they can fulfil their obligations when restraint is proposed and used.
Pharmacists working in aged care help providers recognise chemical restraint, recommend alternative strategies before use, and ensure timely monitoring and review.
What is chemical restraint?
Chemical restraint involves the use of medicines for the primary purpose of influencing a care recipient’s behaviour, but does not include the use of medicines prescribed for1,2:
- the treatment of, or to enable treatment of, the care recipient for:
- a diagnosed mental disorder; or
- a physical illness; or
- a physical condition; or
- end of life care.
The medicines are usually psychotropics which affect mood, cognition and behaviour. These include antidepressants, antipsychotics, anxiolytics, hypnotics and anticonvulsants.
When psychotropic medicines are used to manage behavioural and psychological symptoms of dementia is this chemical restraint?
Possibly. Dementia is not one specific medical condition or mental disorder. Dementia is a syndrome characterised by cognitive decline (e.g. memory, judgment) with functional impairment. Causes include Alzheimer’s disease, Vascular or Lewy Body Dementia.
Many people living with dementia develop psychological and behavioural symptoms. These can include anxiety, delusions, hallucinations, depression, insomnia, aggression, agitation, calling out, wandering and disinhibition.
Psychotropics prescribed for the main purpose of managing behaviour (e.g. agitation, calling out, wandering) are chemical restraint. When psychotropics are prescribed to treat a diagnosed mental disorder, such as psychosis or depression, they are not chemical restraint.
Are hypnotics such as temazepam chemical restraint?
Possibly. Insomnia is the inability to fall or stay asleep. Most cases are related to poor sleeping habits, stimulating substances (e.g. caffeine, tobacco) or to a lack of exercise. Addressing these causes through sleep hygiene measures should be tried before medicines.
Prescribing a hypnotic with the main aim of stopping a resident from disturbing other residents or to fit in with the schedule of the home is chemical restraint. Just because a resident is dependent on benzodiazepines does not exclude them being chemical restraint. Prescribing a hypnotic for severe insomnia short-term (up to 2 weeks) after sleep hygiene strategies have been tried is not chemical restraint.
What do providers need to do when a chemical restraint is proposed or used?
When chemical restraint is proposed, providers must assess residents to identify behavioural causes and develop Behaviour Support Plans. They must consider, trial and document non-pharmacological strategies before restraint is used.
Only the prescriber can assess whether chemical restraint is needed, not staff or relatives. The provider must ensure that the prescriber has assessed the resident, that they document the reason for restraint and that they obtain informed consent from the resident or their substitute decision maker.
When chemical restraint is used, monitoring for effectiveness and side effects and regular documented review is required to ensure that restraint is still needed and the least restrictive form.References
- Australian Government. Federal Register of legislation. Aged Care and Other Legislation Amendment (Royal Commission Response No. 1) Bill 2021. 2021. At: www.legislation.gov.au/Details/C2021B00068
- Aged Care Quality and Safety Commission. Regulatory Bulletin. Regulation of restrictive practices and the role of the Senior Practitioner, Restrictive Practices. RB2021-13. 2021. At: www.agedcarequality.gov.au/sites/default/files/media/rb-2021-13-regulatory-bulletin-regulation-restrictive-practices-role-snr-practitioner.pdf
A/PROF JUANITA BREEN BPharm, MSc(Dist), PhD, GradDipCommPracPharm, AACPA is an accredited pharmacist who currently works as a clinical pharmacist consultant in the Aged Care Quality and Safety Commission Pharmacy Unit.
HELP US HELP YOU
Professionals learn and develop from the experience of their peers. AP welcomes member contributions of practice advice as well as questions to be answered in this column.
Advice contributions may be about ethical dilemmas, pearls of wisdom or integrating new roles or technology into practice.
Responses should be 250–500 words. They may be edited for space, legal, accuracy or privacy purposes.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14120 [post_author] => 235 [post_date] => 2021-09-01 05:34:54 [post_date_gmt] => 2021-08-31 19:34:54 [post_content] => Antimicrobial use has declined in Australia during the pandemic, but the figures show there is no room for complacency. The Fourth Australian report on antimicrobial use and resistance in human health, released last week by the Australian Commission on Safety and Quality in Health Care, found Australia continues to prescribe antimicrobials at much higher rates than most European countries. In 2019, more than 40% of Australians had at least one antimicrobial dispensed in the community, and more than 26.6 million prescriptions were dispensed for antimicrobials. Antimicrobial use in the community, based on defined daily doses per 1,000 people per day, was 22.9. In the Netherlands it is as low as 9.5, while the rate in Canada, which has a similar healthcare system to Australia, is 17.5. The most used antibiotics were cefalexin, amoxicillin and amoxicillin–clavulanic acid. This is of concern, according to the report, as cefalexin and amoxicillin–clavulanic acid are first-line agents for very few conditions. Although antimicrobial dispensing rates have been gradually declining since 2015, the commission’s Senior Medical Advisor Professor John Turnidge AO said this is a trend that must be maintained in order to slow the spread of resistance. ‘We’ve still got a long way to go to get to appropriate prescribing across the country,’ he told Australian Pharmacist. ‘We’re still a lot higher than our benchmark country, which is the Netherlands. We’ve still got high usage, it’s just better than previous years.’
Inappropriate antimicrobial prescribingDespite the existence of therapeutic guidelines that detail when to prescribe antimicrobials, the appropriate dose and the length of time for use, inappropriate prescribing continues to be an issue, Prof Turnidge said. This is particularly true for respiratory infections, which are largely viral. For example, according to the report for a number of general practices, more than 80% of people with acute bronchitis or sinusitis were prescribed antimicrobials when they are not recommended by the prescribing guidelines.‘The most important message for patients and prescribers is that antibiotics are not needed for something like a head cold.'‘When we prescribe antibiotics when they are not needed, we impose unnecessary costs on the patient, and expose them to the risk of side effects,’ Prof Turnidge said. ‘The most important message for patients and prescribers is that antibiotics are not needed for something like a head cold. Many GPs are coming on board, but there’s a huge amount of patient pressure – many patients go to the doctor expecting an antibiotic.’
A positive COVID effectThe COVID-19 pandemic has had a dramatic impact on the dispensing rates of antimicrobials, according to the report, with reductions of between 22% and 49% in dispensing of amoxicillin, cefalexin and doxycycline in 2020. This could be due to a decrease in dispensing for seasonal respiratory infections such as colds and influenza, which saw a drop due to increased hand hygiene, staying at home when unwell, travel restrictions and social distancing. ‘We had very high use [of antimicrobials] in the community, but during COVID there was a significant drop in the use of certain antimicrobials,’ Prof Turnidge said. ‘As there have continued to be outbreaks of COVID, lockdowns and ongoing promotion of hand washing and social distancing in some states and territories, I imagine that the decrease may continue throughout 2021.’ Although the reduction in antimicrobial dispensing is positive, Prof Turnidge said it is important to keep the momentum going. ‘It’s one positive note we can take from COVID, and it’s a message I think we can really develop and get out to prescribers and patients that those things that cause coughs, colds and sore throats, they’re just like COVID. They don’t need antibiotics and they don’t get better with them anyway,’ he said. ‘I hope we’ll be able to keep the gains we’ve got and make even further improvements.’
Cautionary label for antibiotics remains importantTo help address antimicrobial resistance, a new cautionary advisory label (CAL D) for antibiotics was released with the latest edition of the Australian Pharmaceutical Formulary and Handbook this year.‘We had very high use [of antimicrobials] in the community, but during COVID there was a significant drop.'Replacing decades of advice to take the medicines ‘until all used’ or ‘until all taken’, the label is an additional instruction with the words, ‘Take for the number of days advised by your prescriber’. If a patient is not aware of the prescribed duration of treatment and it is not specified on the prescription, the pharmacist should contact the prescriber to confirm the duration. Completion of a recommended course of therapy with an antibiotic can improve therapeutic outcomes and reduce the incidence of relapse. However, taking antibiotics for longer than necessary does not improve outcomes and increases the risk of acquiring resistant bacterial strains.
Practical tips for pharmacistsIn a companion document to its report, the commission set out a number of ways pharmacists can contribute to tackling antimicrobial resistance. For community pharmacists, a good first step is to use dispensing software to understand the antimicrobial use patterns of your community. Other strategies include clarifying the indication and intended duration of any antimicrobial when conducting a MedsCheck and engaging in a discussion with the patient and/or prescriber if the patient has been on an antimicrobial for an extended period. It could also be helpful to display posters with patient care information in the pharmacy, such as how to prevent UTIs, and to highlight vaccinations service during cold and flu season with reminders about why antimicrobials should not be used for viral infections. Hospital pharmacists have an opportunity to assess whether the antimicrobial prescriptions they see follow guidelines and, if not, to engage in discussions with prescribers in instances where patients are treated for conditions such as asymptomatic bacteriuria with antibiotics. Another practical example is to determine the most common antimicrobial prescribed for UTIs and to develop a quality improvement project to address inappropriate use. Find more tips on preventing antimicrobial resistance here. [post_title] => Antimicrobial use decreasing, but resistance still a threat [post_excerpt] => Antimicrobial use has declined dramatically in Australia during the pandemic, but the figures show there is no room for complacency. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => antimicrobial-use-decreasing-resistance-still-a-threat [to_ping] => [pinged] => [post_modified] => 2021-09-01 18:13:50 [post_modified_gmt] => 2021-09-01 08:13:50 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14120 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Antimicrobial use decreasing, but resistance still a threat [title] => Antimicrobial use decreasing, but resistance still a threat [href] => https://www.australianpharmacist.com.au/antimicrobial-use-decreasing-resistance-still-a-threat/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14121 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14012 [post_author] => 235 [post_date] => 2021-08-18 02:35:23 [post_date_gmt] => 2021-08-17 16:35:23 [post_content] => More than 250,000 Australians have faulty heart valves and are at risk of serious complications, including heart failure, stroke and death – yet don’t know it. Australian Pharmacist spoke to an expert about the symptoms pharmacists can help spot in patients. According to a new white paper released this week, Our hidden ageing – time to listen to the heart, more than 500,000 Australians have valvular heart disease, including narrowing (stenosis) and leaking (regurgitation). Developed by experts at Melbourne’s Baker Heart and Diabetes Institute, it also revealed that a quarter of a million people have undiagnosed valvular heart disease. The number of undiagnosed cases is expected to climb over the next 3 decades, reaching 435,000 by 2051. Aortic valve disease is the most frequent cause of severe valvular heart disease. The most common manifestation of this is aortic stenosis, or a narrowing of the aortic valve. Cases of aortic stenosis are expected to climb, the paper stated, to 200,000 by 2031 and 266,000 by 2051. ‘The benefits of living in a first world country means that many of us will survive to a “ripe old age”, so we are living long enough to develop conditions such as aortic stenosis,’ cardiologist and Interim Director of Cardiology at Canberra Hospital Dr Peter French told AP. ‘People with disorders like this may place a significant burden on the healthcare system in that they are constantly in and out of hospital, their quality of life is poor and their contribution to society is limited.’‘The symptoms … may either be quite subtle, or often at times misinterpreted, especially by the older patient, as just a sign of ageing.'
Hidden symptoms of valvular heart diseaseAlthough serious, valvular heart disease is increasingly treatable through procedures including non-surgical valve replacement – provided you know it’s there. But it is not always easy to detect. ‘The symptoms … may either be quite subtle, or often at times misinterpreted, especially by the older patient, as just a sign of ageing,’ Dr French said. ‘With coronary artery disease, the symptoms of angina are often chest pain/discomfort in the chest that restricts the person in normal everyday activities. The symptoms of valvular heart disease may not be as straightforward, especially in the older age groups.’ For example, patients may experience shortness of breath, which limits their normal physical activity. However this may be seen simply as a sign of ageing and accepted as something about which nothing can be done. ‘Therefore, they may not necessarily mention this symptom to their general practitioner when, and if, they see them, for routine medical reviews,’ Dr French said. ‘Other more sinister symptoms, especially in relation to blockage of the aortic valve, [include] dizziness on exertion or, in its most extreme form, actual loss of consciousness on exertion.’ Signs and symptoms of valvular heart disease
|Fatigue Dizziness, blackouts||Inadequate cardiac output||Stenosis|
|Shortness of breath, cough Swelling of ankles and feet Abdominal swelling||Congestion||Regurgitation Heart failure|
|Chest pain||Increased workload||Aortic stenosis|
|Palpitations||Enlargement of heart chambers||Regurgitation (esp. mitral) Mitral stenosis|
‘Emphasising the need for the doctor to listen to the heart with a stethoscope can be exceedingly helpful.'Prior to the pandemic, his job required weekly travel, and he enjoyed spending his free time in the gym. Aside from a health scare in 1997, when he was told to improve his health and fitness, the grandfather and head of insurance at a leading glass supplier had never had any serious heart concerns. ‘I found it hard to complete my fitness workouts and felt a lot more tired than usual,’ he said. ‘My trainer noticed as well. It was very out of character for me … I thought it was just age and fatigue.’ However, a visit to a GP and then a heart specialist confirmed he had heart valve disease. ‘After overhauling my diet and lifestyle in 1997, I honestly never thought I would be at risk,’ Mr Holmes said. ‘I believe all Australians aged 65 and over should be well informed about heart valve disease and the various treatment options available.’ Lead author of the Baker Heart and Diabetes Institute white paper, cardiologist Professor Tom Marwick agreed, and said more needed to be done to raise awareness among the public and health professionals about the disease. ‘It is important to keep in mind that the common symptoms of heart valve disease –especially exercise intolerance – are often misattributed to “old age”,’ he said. ‘We need increased awareness through marketing campaigns; strategies to upskill and support primary care; financial support for the use of emerging technologies; health service design, including improved access to echocardiography; funding to improve access and equity to interventions; and development of national heart valve disease guidelines. ‘We must all keep in mind that valvular heart disease can go unrecognised, undiagnosed, and untreated, and the complications can be devastating.’ Read the Our hidden ageing – time to listen to the heart white paper here. [post_title] => Valvular heart disease: how pharmacists can help [post_excerpt] => More than 250,000 Australians have faulty heart valves and are at risk of serious complications, including heart failure, stroke and death – yet don’t know it. Australian Pharmacist spoke to an expert about the symptoms pharmacists should be aware of. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => valvular-heart-disease-symptoms-for-pharmacists [to_ping] => [pinged] => [post_modified] => 2021-08-18 17:02:05 [post_modified_gmt] => 2021-08-18 07:02:05 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14012 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Valvular heart disease: how pharmacists can help [title] => Valvular heart disease: how pharmacists can help [href] => https://www.australianpharmacist.com.au/valvular-heart-disease-symptoms-for-pharmacists/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14015 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 13949 [post_author] => 175 [post_date] => 2021-08-11 13:29:22 [post_date_gmt] => 2021-08-11 03:29:22 [post_content] => A new Pharmaceutical Benefits Scheme listing last week for dry eye product Cationorm ties into a quirky review of a new area of literature from United States researchers. They found that face mask-associated ocular irritation and dryness is evident, based on a review of studies linking the two. Their findings were published in Ophthalmology Therapy. Dry eye disease is a common condition and the most frequent reason for a visit to an ophthalmologist. It can lead to significant morbidity and affects quality of life for the millions of people living with it worldwide. There are numerous causes, treatment changes frequently and it is mostly incurable. In Australia and New Zealand dry eye affects one adult in 10, according to the Royal Australian and New Zealand College of Ophthalmologists. Ocular researchers from the University of Utah School of Medicines, the Hoopes Vision Research Centre, the Utah Lions Eye Bank and the Department of Ophthalmology and Visual Sciences in Salt Lake City, Utah, found that while the world has taken to mask wearing to prevent the spread of COVID-19, a ‘corresponding increase in ocular irritation and dryness among regular mask users’ has become apparent. ‘This finding has not been previously described in the literature but has important implications on eye health and infection prevention, as mask use is likely to continue for the foreseeable future,’ they wrote. The authors found a marked increase in dry eye symptoms in their community and patient population of elderly, immunocompromised and clinical staff who wear masks ‘almost full-time’. The majority were aware of air blowing upward from the mask into their eyes, which likely accelerated the evaporation of the tear film which could become irritated and inflamed after continuous use for hours or days.While there are studies that discuss the effects on the eye from lagophthalmos (incomplete or defective closure of the eyelids), ectropion or mechanical ventilation, from powered air-purifying respirators, chemical protection hoods and even CPAP masks, which all cause increased air convection, none were described in relation to the use of face masks. In their review of studies published in the first 6 months of the pandemic that discussed face masks and ocular symptoms including dryness, the authors suggest that while some found dry eye symptoms in COVID-19 positive patients and suggest dry eye as a complication of the disease itself, the findings may be partially associated with mandatory, long-term mask use in these patients, ‘rather than the sole sequelae of COVID-19’. For this reason, the authors suggest all mask wearers, patients and healthcare professionals need to be aware that above any mask ‘the unprotected eye remains a vulnerable path of infection’. Irritation from mask use can lead to pathogenic invasion, fomite transmission via rubbing and face touching and a compromised tear film. The researchers suggest mask wearers should:The authors found a marked increase in dry eye symptoms in their community and patient population of elderly, immunocompromised and clinical staff who wear masks ‘almost full-time’.
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Humans have evolved structures and mechanisms to provide protection against harm from exogenous substances.1 In the same way that medicines overcome these to achieve therapeutic effects, poisoning occurs when a substance evades or utilises this protection and reaches a site where it causes adverse effects.1
Paracelsus’s maxim – ‘all substances are poisons, there is none that is not a poison; the right dose differentiates a poison from a remedy’– is helpful to appreciate the potential toxicity of pharmaceuticals.1
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.3, 1.4, 1.5, 2.2, 3.1
Toxicity occurs when the dose of a pharmaceutical passes a point above which it causes adverse effects.1 These adverse effects may occur on a predictable continuum (e.g. respiratory depression increases with opioid dose increase), or occur only once a threshold has been passed (e.g. liver toxicity with paracetamol overdose).1
The major toxicity from a given pharmaceutical is usually seen in only one or two target organs, which may not necessarily be the site of initial exposure or highest concentration.1,2 Some pharmaceuticals are only toxic when they have been transformed to chemically reactive entities as part of normal metabolic activity.1,2
This article focuses on poisoning by pharmaceuticals to provide specific information to pharmacists about substances they are likely to deal with in their usual practice.
In Australia, Poisons Information Centres (PICs) receive calls from the public and health professionals seeking advice about exposure to poisons. They are physically located in New South Wales, Queensland, Victoria and Western Australia, and use a referral system to provide a national 24-hour service (see Figure 1).3[caption id="attachment_14518" align="alignright" width="250"] Figure 1 – National poisons information hotline. Reference: NSW Poisons Information Centre4[/caption]
In 2015 Australian PICs received calls related to nearly 165,000 poisoning exposure events involving more than 1,800 different substances.3 Although not all poisonings result in a call to a PIC, these calls include both actual and suspected poisoning, and broadly indicate the pharmaceuticals that are commonly involved in poisoning.3,5
Six of the 10 most frequent classes of substances reported to PICs in 2015 across all age groups were pharmaceuticals. These, along with the most common substance reported in each class, are listed in Table 1.3 A similar list is seen in more recent annual reports from the individual state PICs.6–9
In 2015, 64.4% of reported exposures to PICs were unintentional, 18.1% were related to medication errors, and 10.7% involved deliberate self-poisoning. The circumstances of exposure varied across age groups (see Table 2).Table 1 – Frequently reported pharmaceuticals to Poisons Information Centres in 2015
Pharmaceutical classes involved in calls to PICs (% of total exposures)
Most common substance(s) in this class (% of exposures within each class)
Paracetamol-containing analgesics (10.2)
Cardiovascular agents (3.4)
Beta-blockers (22.1), including metoprolol (7.4)
Benzodiazepines (83.2), including diazepam (45.5)
PICs = Poisons Information Centres References: Huynh, et al3
The number of deaths (1,391 in the 12 months to 30 June 2017) associated with poisoning by pharmaceuticals in Australia is small compared to the number of calls received by PICs (more than 16,000).10–12 The majority of these involved narcotics and hallucinogens (see Table 3).11,13
Many of these deaths involved more than one of these substances. Most people (about 73%) who died from unintentional poisoning by pharmaceuticals were 30–54 years old.11
In the same time period there were 3,039 deaths by suicide in Australia, of which 401 (around 13%) involved poisoning with ‘drugs, medicaments or biological substances’ (see Table 3).11 The most common pharmaceuticals involved include benzodiazepines and antidepressants. Non-opioid analgesics, including paracetamol and NSAIDs, were also implicated (see Table 3).11
Consideration of the different circumstances and substances involved in pharmaceutical poisoning in different populations can help pharmacists provide tailored advice regarding safe use of medicines for individuals.14 Further information about individual pharmaceuticals commonly associated with poisoning is described below. The treatments mentioned are intended as summaries of key points which may be of interest to pharmacists. The referenced source material should be consulted for details.Table 2 – Circumstances of exposures across age groups
Age groups (years)
Circumstance of exposure
Mostly deliberate self-poisoning
Medication errors, unintentional and deliberate self-poisoning
Older adults (>74)
References: Huynh, et al,3 Huynh, et al5
Paracetamol is one of the most common drugs involved in poisoning worldwide, in part due to its perceived safety, widespread use and accessibility.15–17 It is commonly involved in both unintentional and intentional poisonings for all age groups and is the most common cause of acute liver failure in Australia.3,5,11,15–17 Hospitalisations for paracetamol overdose have risen over the past two decades.15–17
At therapeutic doses, paracetamol is metabolised in the liver and generally eliminated without causing toxicity. In overdose however, the relative contribution of a usually minor CYP1A2 pathway increases, where paracetamol is oxidised to the electrophilic N-acetyl-p-benzoquinone imine (NAPQI) intermediate, which is then conjugated with glutathione and eliminated.1 If glutathione becomes depleted, NAPQI accumulates and binds to cellular proteins causing centrilobular necrosis and liver damage.1
Signs and symptoms of paracetamol poisoning include abdominal pain, nausea and vomiting from acute liver injury, kidney impairment and mild coagulopathy. In more severe cases, hypoglycaemia, severe coagulopathy, metabolic acidosis and hepatic encephalopathy from liver failure and death can occur.17–20
In acute poisoning, the toxic dose is 10 g (or 200 mg/kg if under 50 kg) as a single dose of either immediate or modified-release formulations.17–20
In repeated dose poisoning (supratherapeutic dosing), the toxic dose is 10 g (or 200 mg/kg if under 50 kg) over 24 hours, or 12 g (or 300 mg/kg if under 40 kg) or more over 48 hours.17–20
Therapeutic doses of 60 mg/kg (up to 4 g) daily over several days can be toxic in some circumstances, especially in people with reduced glutathione stores.17,18 Contributing factors include dehydration, advanced age, comorbidities affecting liver function, alcohol use, poor nutritional status, concurrent medications (especially CYP1A2 inducers) and genetic predisposition.17,18
All people with suspected acute intentional paracetamol poisoning or suspected ingestion of a toxic dose of paracetamol should be referred to hospital for assessment.18
The antidote acetylcysteine (or N-acetylcysteine, NAC) is effective when given promptly, preventing hepatotoxicity in most cases if given within 8 hours of an acute ingestion.18 There are well-established hospital treatment protocols for intravenous NAC administration, which vary depending on time since ingestion, acute versus repeated supratherapeutic ingestion, and immediate versus modified-release preparations. Serum paracetamol and serum ALT are measured to determine the need for and duration of treatment.17–20
Activated charcoal is sometimes given to remove unabsorbed solid-dose paracetamol after recent (2–4 hours) ingestion of immediate-release formulations, or within 4 hours of ingestion of modified-release preparations.18
Table 3 – Deaths and associated pharmaceuticals
Reason for exposure
Number of deaths
Narcotics and hallucinogens
Drugs, medicaments or biological substances
Non-opioid analgesics (e.g. paracetamol, NSAIDs)
*Heroin is classified as a pharmaceutical in the International Statistical Classification of Diseases and Related Health Problems, Revision10 References: AIHW,11 WHO13
NSAIDs, particularly ibuprofen, are commonly associated with poisoning in children and adolescents.3,5,11 NSAID poisoning rarely causes hospitalisation or death; most poisonings are asymptomatic and resolve spontaneously without requiring supportive treatment.21,22 Aspirin poisoning is treated separately as salicylate poisoning.21,23
Toxicity is a consequence of excessive inhibition of the COX-1 enzyme.21 Most exposures result in mild gastrointestinal symptoms, such as nausea, vomiting and epigastric discomfort.21,22 Large exposures can result in severe toxicity, including acute renal impairment and subsequent metabolic acidosis, seizures (associated with mefenamic acid), neurological symptoms (e.g. drowsiness, confusion, nystagmus, blurred vision, diplopia, headache and tinnitus), and coma.21,22 Acute renal impairment can be exacerbated by existing renal and cardiovascular disease, or hypovolemia from vomiting or concurrent alcohol ingestion.22
Acute doses of ibuprofen less than 100 mg/kg are likely to be asymptomatic.21 Severe toxicity is generally seen at doses more than 400 mg/kg.22,24,25
There is no antidote for NSAID poisoning. Treatment is primarily observation and support for specific symptoms if they occur.22,24,25 Activated charcoal is sometimes given after recent (2 hours) massive overdoses.22
Quetiapine is commonly involved in poisoning in adolescents and adults.3,5,11 It is approved in Australia for treating schizophrenia and bipolar disorder. Quetiapine is also prescribed off-label for other psychiatric conditions, such as treatment-resistant depression and generalised anxiety disorder, which are associated with an increased risk of intentional poisoning.26
Quetiapine is an atypical antipsychotic, antagonising serotonin receptors and to a lesser extent dopaminergic, histaminic, muscarinic and peripheral alpha1-adrenoreceptors.27,28 The features of poisoning include anticholinergic activity (tachycardia, delirium, urinary retention), peripheral vasodilation and hypotension, increased QT interval, CNS and respiratory depression with loss of airway protection and rarely seizures.27–29
In children, 25 mg may be toxic and doses greater than 100 mg may be associated with severe toxicity.27,28
In adults, acute doses of 10 mg/kg are significant, and more than 2 g of immediate-release quetiapine increases risk of toxicity, especially coma.27-29 Doses of more than 3 g are associated with significant CNS depression and hypotension.27-29
The toxic dose for modified-release quetiapine is not known. Symptoms have delayed onset (up to 12 hours, compared to up to 6 hours for immediate-release preparations) and are prolonged (up to 72 hours).27-29
There is no specific antidote and treatment is supportive, as required, depending on the symptoms. Supportive care includes intubation, ventilation and intravenous fluid resuscitation.27–29
Activated charcoal is sometimes given to remove unabsorbed quetiapine after recent (2 hours) ingestion of immediate-release formulations, or within 4 hours of ingestion of modified-release preparations.27
Diazepam and temazepam are commonly associated with both intentional and unintentional self-poisoning in adolescents and adults, and are commonly involved in accidental and suicide poisoning deaths.3,5,11,30 Intentional poisoning often involves other pharmaceuticals and/or alcohol.3,5,11,30
When taken alone in overdose, usually only mild to moderate CNS and respiratory depression occurs, with a ceiling on the CNS effect despite increased exposure.30–32 Features of toxicity include drowsiness, ataxia and slurred speech. Large overdoses may cause hypotension, bradycardia and hypothermia.30–32 When taken with other CNS depressants, deep coma, significant respiratory depression and death may occur.30–32
The toxic dose varies widely due to tolerance. Acute doses of 1–4 times the maximum daily dose may cause significant CNS depression in benzodiazepine-naive patients, whereas dependent patients may have few adverse effects with 10–50 times the daily dose.30 Co-ingestion with other CNS depressants significantly amplifies toxicity and is a common scenario leading to death.30–32
Treatment is usually supportive, including airway protection, intubation and ventilation if required. Decontamination with activated charcoal is not indicated because of the rapid onset of sedation in poisoning.30–32
The antidote flumazenil is not commonly used as it can precipitate withdrawal in dependent people, cause seizures and unmask arrhythmias.30–32
Treatment of toxicity from co-ingested substances is also important.31,32
Antidepressants are commonly associated with intentional and unintentional poisoning.3,5,11 The most common antidepressants reported in poisoning exposures to PICs are SSRIs, specifically fluoxetine in children and adolescents, and sertraline in adults.3,5
SSRI poisoning is usually benign, sometimes with nausea, vomiting and drowsiness.34,35 A more serious acute serotonergic toxidrome (i.e. serotonin syndrome) may occasionally occur in massive overdoses, or if taken in combination with other serotonergic substances, with symptoms of neuromuscular excitation, hyperthermia and altered conscious state.33–35
Acute doses greater than 300 mg of escitalopram or 600 mg of citalopram are associated with QT interval prolongation.33,34 Doses of 50 times the daily dose of other SSRIs have been reported to cause no severe adverse effects.33–35
Treatment is supportive, with specific treatment for hypotension, serotonergic toxidrome and arrhythmias if they occur.33–35 Activated charcoal may be used for toxic doses of citalopram and escitalopram within 4 hours of ingestion, and for massive overdoses of other SSRIs if ingestion is recent (2 hours).33
Cardiovascular agents are a large group of medicines with a wide range of mechanisms of action and toxicity. Poisoning is mainly reported in adults (20–74 years) and older adults (>74 years).3,5
The most commonly reported cardiovascular agents involved in poisoning are beta-blockers; the most common among these is metoprolol.3,5
Different beta-blockers have different toxicities, and metoprolol is considered relatively less toxic than propranolol and sotalol.36,37
The effects of beta-blocker poisoning are related to their action on beta-receptors, including bradycardia, hypotension, heart block, bronchospasm and hypo- or hyperglycaemia.36,37 Toxicity is increased if an individual has reduced cardiovascular reserve.36 Ingestion with other cardiovascular agents can increase the risk of cardiac toxicity.36,37 Further, propranolol can cause QRS widening, and sotalol can cause QT-interval prolongation, both of which can cause life-threatening cardiovascular toxicity.36,37
Ingestion of more than 2 g of propranolol is associated with seizures, delirium and coma due to its lipophilicity.36,37 Modified-release metoprolol may cause delayed toxicity.36,37
Treatment of beta-blocker poisoning may require intubation and ventilation, especially if cardiac function is unstable or consciousness is reduced.36,37 Activated charcoal is sometimes given after recent (2 hours) ingestion of immediate-release formulations, or within 4 hours of ingestion of modified-release metoprolol.36,37 Intravenous fluid resuscitation, atropine, adrenaline or isoprenaline, and high-dose insulin euglycaemia therapy, may be used to restore circulation.36,37 Intravenous glucose can be used for seizure control, which is presumed to be caused by intracellular glucose depletion.36,37
Opioids, mainly heroin and methadone, are the most common cause of unintentional drug-related death in Australia, often in combination with other substances.11,38 Oxycodone is the most common opioid reported in calls to PICs, mostly in adults and older adults.3,5,11 Opioids are also commonly associated with poisoning-related suicide deaths.11
Poisoning causes respiratory and CNS depression by agonising mu2-receptors.38–40 Methadone, oxycodone and loperamide poisoning can also cause QT-interval prolongation and torsades de pointes.38,39 Nausea, vomiting and constipation can also occur.38–40
Toxic effects are dose-dependent but vary widely due to tolerance.38,39 Opioid-naive people may experience toxic effects with small doses, especially if co-ingested with other sedating substances. Long-acting opioids can cause delayed and prolonged toxicity.38,39 Methadone can be fatal to children in small amounts.38,39
Treatment includes airway and breathing support and use of the antidote naloxone. Activated charcoal may be used within 2 hours if immediate-release formulations have been ingested or 6 hours where modified-release formulations are involved.38–40
Naloxone is a competitive opioid receptor antagonist used to reverse hypoventilation and increase a person’s ability to protect their airway.38–41 Protocols exist for intramuscular or intranasal administration by non-medically trained people in the community (e.g. friends and family) and for intravenous administration in hospital.38–42 Pilot programs are currently underway in some Australian states to assess the benefits of supplying free naloxone to people at high risk of opioid overdose, and to people likely to witness an overdose.41,43
Pharmacists in many practice settings can respond to reports and questions about poisoning, especially by using and promoting the services of PICs.
Pharmacists should promote the safe use of pharmaceuticals as a core part of their practice. Consideration should be given to populations, circumstances and specific medicines associated with increased risk of accidental and deliberate poisoning.
Pharmacists may use key aspects of pharmacy practice to reduce the risk of poisoning by pharmaceuticals, including5:
Pharmacists are the custodians of medicines and have an important role in ensuring their safe and appropriate use. Knowledge of the substances and populations most likely to be associated with poisoning, either intentional or unintentional, can help to provide individualised information and support to minimise the risk of harms.
BEN GILBERT BPharm, GradCertHigherEd, GradDipTox, MPS is a community pharmacist with experience in pharmacy business ownership, university teaching and research, and working with developing countries to strengthen their medical supply chains.[post_title] => Poisoning with common pharmaceuticals [post_excerpt] => Knowledge of the substances and populations most likely to be associated with poisoning, either intentional or unintentional, can help to provide individualised information and support to minimise the risk of harms. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => poisoning-with-common-pharmaceuticals-cpd [to_ping] => [pinged] => [post_modified] => 2021-10-19 05:27:06 [post_modified_gmt] => 2021-10-18 18:27:06 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14517 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Poisoning with common pharmaceuticals [title] => Poisoning with common pharmaceuticals [href] => https://www.australianpharmacist.com.au/poisoning-with-common-pharmaceuticals-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 14521 )
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One of your regular patients, Angela, 43, comes to see you. She has just seen her doctor about some redness and cracking at the corners of her mouth, which has been present for 3–4 days. Her doctor has told her that it is called ‘angular cheilitis’ and that she should buy some antifungal cream to treat it.
You are aware that Angela is taking iron supplements and also has coeliac disease. She is not taking any other medicines, has no other medical conditions, and is not pregnant or breastfeeding.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.3, 1.5, 2.3, 3.2, 3.5
Angular cheilitis is a common condition that presents as redness or maceration at the corners of the mouth.1,2 It is an inflammatory condition, and often has a fungal and/or bacterial cause.1–3 Angular cheilitis may also be known as angular stomatitis, angulus infectiosus, cheilosis or perleche (perlèche).2,4 As primary healthcare professionals, pharmacists are often asked about different dermatological conditions.5 Pharmacists need to be able to diagnose angular cheilitis, advise patients on causes and treat and/or refer as appropriate.
Angular cheilitis often has an infectious cause. Infective organisms include Candida albicans, Staphylococcus aureus and Streptococcus.3,6 It is also often associated with intra-oral candidiasis.3
A number of factors may contribute to angular cheilitis, although it may also occur spontaneously (see Box 1).4 It is more common in elderly patients due to an overhanging upper lip. This causes skin folds, which allows saliva to accumulate, leading to a constant moist environment and skin irritation from the saliva.7 A receding jawline and poorly fitting dentures may also cause angular cheilitis and promote secondary bacterial or candida infections.7
Angular cheilitis is common and affects both children and adults (although it is more common in the elderly).2,7 While it may develop spontaneously, it is more common in those who wear dentures or other oral appliances.6 Small children who dribble excessively, suck their thumbs, lick their lips, bite the corners of their mouth or use dummies can also develop the condition.6,10 People with other medical conditions and who have poor health in general are at higher risk of angular cheilitis.2 See Box 2 for risk factors for angular cheilitis.
There have been a number of case reports of angular cheilitis occurring in patients with COVID-19.12 Angular cheilitis has also been seen in healthcare workers during the COVID-19 pandemic due to increased use of personal protective equipment.12
Box 1 – Causes of angular cheilitis
References: Rossi,1 Oakley,2 Lugović-Mihić,4 Devani,6 Bear,7 Stoopler,8 Mowad9
Angular cheilitis is an inflammatory condition. It often presents as irritation, redness and skin maceration at the corners of the mouth, usually bilaterally.1,6–9,13 Dry lips are often present.6 There may be cracks, skin fissures, ulcers or blisters, which can be painful.2,6 Patients may describe a burning sensation in the area where the lesions are.6 Bleeding, oozing or crusting of the sores may also occur.2,8 Crusting may suggest a bacterial infection with Staphylococcus aureus.1
Angular cheilitis may last for several days or be an ongoing condition depending on the cause.2 It may be recurrent, particularly in older patients.7 Fungal or bacterial infection may potentially progress to cause more widespread infection on nearby skin or elsewhere in the body.2 Licking the lips worsens symptoms.2
The severity of pain with angular cheilitis can range from no pain to severe discomfort.8 Pruritis may also be present.8
In the majority of cases, diagnosis is based on clinical examination and taking a patient history.6,8 Patient history should include4,6:
Patients with angular cheilitis caused by Candida should also be assessed for oral candidiasis, as these two conditions may co-present. Symptoms of oral candidiasis include white patches in the mouth, redness, soreness, burning in the mouth and loss of taste.8,14
Patients using dentures or other oral appliances are more likely to be colonised with Candida, while patients who regularly use face masks are more likely to have Staphylococcus aureus colonisation.6 Swabs taken from angular cheilitis may identify any infectious causes (e.g. Candida albicans, Staphylococcus aureus, herpes simplex).2 Skin biopsies are not usually required.2
Box 2 – Risk factors for angular cheilitis
HIV = human immunodeficiency virus References: Oakley,2 eTG,3 Lugović-Mihić,4 Devani,6 Bear,7 College of Dental Hygienists of Ontario11
Most cases of angular cheilitis can be easily identified, however some cases may present similarly to other conditions.6 Other conditions to exclude include herpes labialis, secondary syphilis, erosive lichen planus, contact dermatitis and actinic cheilitis.4,6,8 Taking a detailed history of the condition, including symptom duration, any previous treatment used, and whether symptoms are recurring, will assist in differentiating angular cheilitis from other conditions.6
Patients should be referred when a definitive diagnosis cannot be made by the pharmacist, when the patient is unresponsive to treatment, or where a prescription medicine is indicated.3,8 Patients with underlying medical conditions that may contribute to angular cheilitis should also be referred. 3,6,8
If a dental cause is suspected (e.g. poorly fitting dentures), patients should be referred for a dental review.3
Treatment of angular cheilitis will depend on the cause. In many cases, it is a self-limiting condition and will resolve on its own; however, in other cases, prolonged treatment may be required.2,7 Treatments used may include2:
lip balm or other emollient ointment
Topical azole antifungals are the recommended initial treatment for angular cheilitis with a fungal cause. Recommended treatments are3:
Topical clotrimazole and miconazole are generally well tolerated.1 They may infrequently cause burning, stinging, itching or redness, and rarely allergic contact dermatitis.1 Patients should be counselled that for the treatment to be successful, it needs to be applied regularly.1 Topical azoles will generally not cause drug interactions; however, occasionally topical miconazole may be absorbed in a sufficient amount to interact with other drugs.1 Azoles inhibit CYP3A4, and miconazole also inhibits CYP2C9.1 Azoles may reduce the metabolism of warfarin and increase its anticoagulant effect and bleeding risk. If this combination is used, INR should be monitored and warfarin dose reduced where needed.1 The Australian Medicines Handbook advises that this interaction can occur with the use of topical products such as miconazole or econazole.1 The product information for miconazole oral gel contraindicates its use in combination with warfarin.15
To relieve any inflammation, hydrocortisone 1% cream may be applied, in addition to topical azole antifungals, twice daily to the corners of the mouth until the inflammation clears.3 If a combination product containing both an antifungal and corticosteroid is used, this should only be used until the inflammation clears. Treatment should then continue with a topical antifungal alone for 14 days after symptoms clear.3
Adverse effects associated with topical corticosteroids include folliculitis, skin atrophy, striae, depigmentation, acneiform eruptions, and infrequently allergic contact dermatitis.1
If oral candidiasis is also present, this should be treated with appropriate antifungal treatment (see ‘Oral candidiasis’, Australian Pharmacist, September 2021).
If Staphylococcus aureus infection is present, topical treatment with mupirocin applied to the corners of the mouth may be used.6 Hydrocortisone cream 1% may also be used in addition to mupirocin to treat the inflammation.6
Mupirocin cream is indicated for infected small skin lesions.1 It is generally applied three times a day for a maximum of 10 days.1 Mupirocin may cause localised skin reactions, such as itch, burning, erythema, stinging, pain or swelling.1 Avoid contact with eyes and mouth.1
The Australian Medicines Handbook recommends avoiding the use of topical sodium fusidate as its oral form is effective against methicillin-resistant Staphylococcus aureus (MRSA). Using sodium fusidate topically can promote antimicrobial resistance.1 It may however be prescribed for staphylococcal skin infections if other options are unsuitable.1 It is applied 2–3 times a day for 7 days. Infrequently, a rash, contact dermatitis, itch, burning or irritation may occur with its use.1 Contact with eyes should be avoided.1
Other management strategies
Strategies to limit saliva coming into contact with the skin should be recommended. Using lip balms during the day and petroleum jelly or another barrier cream at night can protect the skin.7,9 A hydrocortisone ointment in conjunction with an antifungal cream may reduce recurrence.7 If dentures are worn, they should be kept clean and removed at night.7
Patients should use a new toothbrush once treatment has commenced for an infectious cause to avoid re-infection.8 If patients do not respond to treatment, further investigations should be undertaken to identify any underlying causes.6 This includes haematological screening to measure haemoglobin, mean corpuscular volume, folate, vitamin B12, iron, ferritin, transferase, and fasting blood glucose levels.6 A dental review is important if dental or denture-related causes are contributing to angular cheilitis.3 Any predisposing factors (e.g. other medical conditions, nutritional deficiencies) should also be identified and managed.3
The prognosis of angular cheilitis is usually positive. In most cases, the condition will respond to appropriate treatment. However, recurrence is common if the underlying cause(s) are not identified and appropriately managed.7
Preventing further recurrences of angular cheilitis should focus on addressing and managing underlying or contributing factors (e.g. malnutrition, diabetes).7 Patients using inhaled corticosteroids should ensure they rinse their mouth out with water afterwards to remove any residual medicine.6 Other strategies to reduce recurrence include ensuring properly fitting dentures, avoiding irritants, ensuring proper salivation and addressing any structural abnormalities.6 Good oral hygiene should also be encouraged.6
Pharmacists can support patients with suspected or confirmed angular cheilitis by taking a thorough patient history. Based on these responses, pharmacists can advise patients on appropriate management and treatment, strategies to prevent recurrence, or refer for further medical review as required. Supporting patients with potential underlying causes by ensuring adherence to medicines and supplements, and by providing lifestyle advice for chronic conditions, is also important.
Angular cheilitis is a common condition that can occur in people of all ages, although it is most commonly seen in older people. It usually presents as redness and skin maceration at the corners of the mouth, and cracks, fissures, ulcers or blisters can develop. A number of factors can increase the risk of developing angular cheilitis, including poor oral hygiene, poorly fitting dentures, nutritional deficiencies, other medical conditions and skin sensitivity. Management focuses on treating any infectious cause (fungal or bacterial) and addressing any underlying causes. Pharmacists should advise patients on available treatments and refer where required.
Case scenario continued
You recommend clotrimazole 1% cream to be applied twice a day to the corners of her mouth. You advise that it must be used regularly to be effective, and continued for 2 weeks after the symptoms clear. She can also use a lip balm for her lips and corners of her mouth to protect from excess moisture.
Angela mentions that the doctor has referred her for a blood test to check her iron and other blood levels. You advise her that nutritional deficiencies can increase the risk of developing angular cheilitis, and reinforce the importance of having the blood tests and seeing her doctor for the results afterwards.
Therapeutic Guidelines: Oral and Dental has information on the management of angular cheilitis: www.tg.org.au
DermNet NZ: Angular cheilitis provides an overview of angular cheilitis, including causes and potential treatment options, and also has photos of how angular cheilitis may present: https://dermnetnz.org/topics/angular-cheilitis/References
NAOMI WEIER BPharm(Hons), GradCertPharmPract, GradDipClinEd, MClinPharm, CertIV TAE, AACPA, MPS is a pharmacist and PhD candidate. She has experience working in community pharmacy, private hospitals, undertaking Home Medicines Reviews, and has previously worked as a pharmacist in PSA’s Knowledge Development team. Naomi currently works in Aboriginal health and as a tutor for the University of Tasmania’s School of Pharmacy and Pharmacology.[post_title] => Angular cheilitis [post_excerpt] => Pharmacists need to be able to diagnose angular cheilitis, advise patients on causes and treat and/or refer as appropriate. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => angular-cheilitis-cpd [to_ping] => [pinged] => [post_modified] => 2021-10-13 08:12:58 [post_modified_gmt] => 2021-10-12 21:12:58 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14474 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Angular cheilitis [title] => Angular cheilitis [href] => https://www.australianpharmacist.com.au/angular-cheilitis-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 14478 )
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Frederick, 64, has type 2 diabetes and hypertension. He requests treatment for worsening reflux and mentions he has been drinking more lately. You agree that alcohol can cause and worsen reflux symptoms, and you obtain his consent to ask a few questions about his alcohol use.
Frederick tells you he drinks 2–4 cans of beer on most days and more on Friday nights. He doesn’t describe any withdrawal effects when he doesn’t drink, nor are there any red flags associated with his reflux symptoms. When you ask him how he feels about his alcohol use, he tells you it has increased more than he would like, especially during lockdown.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.4. 1.5, 2.2, 3.1, 3.5
Alcohol is the drug most commonly used by Australians, with 1 in 4 Australians aged 14 or older drinking at harmful levels at least monthly.1 More than 2%, or 1 in 50 Australians are estimated to be alcohol dependent, making alcohol dependence the most common drug problem in Australia.2
So what is alcohol dependence? There are various classification systems and terms used to define alcohol dependence. According to the World Health Organization’s International Classification of Diseases, now in its 11th revision (the ICD-11), alcohol dependence is ‘a disorder of regulation of alcohol use arising from repeated or continuous use of alcohol’, with the characteristic feature being a strong drive to use alcohol.3
The US Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), uses similar concepts but defines a spectrum of alcohol use disorder from mild to severe depending on the number of symptoms, defined as ‘a problematic pattern of alcohol use leading to clinically significant impairment or distress’.
Tolerance is defined as needing to drink a larger amount for the same effect, or the same amount having a lesser effect.4 Alcohol tolerance is associated with an upregulation of the enzymes that break down alcohol, the alcohol dehydrogenases.5
Like all substance use disorders, alcohol dependence is frequently a chronic remitting and relapsing health condition, though often those with less severe disorders will resolve their alcohol dependence without formal help.6 There are genetic, psychological, social and environmental contributors to developing alcohol dependence, and chronic alcohol use can also lead to changes in the brain that make cessation challenging.7 Risk factors for developing alcohol dependence include drinking larger amounts over a long period of time, alcohol consumption from an early age, family history, mental health problems, a history of trauma and other social factors that may promote alcohol consumption.4,8
Alcohol withdrawal severity can range from mild (headache, anxiety, agitation, tremor, disturbed sleep, palpitations and sweating), to severe and potentially life threatening (seizures, persistent vomiting, extreme agitation, autonomic instability, confusion, paranoia and delirium), making careful assessment and planning for withdrawal critical.9 Patients should be advised not to cease alcohol suddenly without medical support if they have been drinking larger quantities for a long period of time, especially if they describe tolerance and withdrawal symptoms.4
The onset of withdrawal symptoms can begin within 6–24 hours from the last drink, peaking after 2–3 days and subsiding after around 1 week.10,11
Box 1 – Audit-C questionnaire
1 How often do you have a drink containing alcohol?
A Never (0)
B Monthly or less (1)
C 2–4 times a month (2)
D 2–3 times a week (3)
E 4 or more times a week (4)
2 How many standard drinks containing alcohol do you have on a typical day?
A 1 or 2 (0)
B 3 or 4 (1)
C 5 or 6 (2)
D 7 to 9 (3)
E 10 or more (4)
3 How often do you have six or more drinks on a single occasion?
A Never (0)
B Less than monthly (1)
C Monthly (2)
D Weekly (3)
E Daily or almost daily (4)
A score of 4 or more for men and 3 or more for women indicates risky drinking, with a higher score considered to indicate higher-risk drinking.
To meet the criteria for ICD-11 alcohol dependence, there are three broad features, which are usually evident over a period of at least 12 months; however, if alcohol use is continuous over at least 3 months, a diagnosis may be made.3,12 The three broad features are (1) impaired control over use, (2) alcohol becoming an increasing priority in life (over other responsibilities or personal care, or despite harm), and (3) physiological features of tolerance, withdrawal, and continued use despite harm.3,12
The DSM-5 criterion for alcohol use disorder is the presence of at least two of the following symptoms occurring within a 12-month period: craving; persistent desire to cut down; use in larger amounts than intended; use leading to a failure to fulfil role obligations; considerable time spent obtaining, using or recovering from alcohol; continued use despite persistent physical or psychological problems; or continued use despite alcohol exacerbating social or interpersonal problems.
The DSM-5 alcohol use disorder diagnosis has sub-classifications of mild, moderate and severe, depending on the symptoms score: 2–3 is mild, 4–5 is moderate, ≥6 is severe.
In practice, these concepts are often simplified to conceptualise dependence or ‘addiction’ to the ‘Four Cs’: Compulsive use, Craving, Continued use despite harm, and loss of Control over use.
To identify likely alcohol dependence in the pharmacy setting, there are a number of brief screening tools that have been validated against these diagnostic criteria. One of the most widely used tools is the Alcohol Use Disorders Identification Test (AUDIT), which can identify hazardous and harmful alcohol use as well as possible dependence.13 This brief 10-item tool provides a score out of a possible 40, with a score of 8–15 indicating hazardous use, warranting simple advice focusing on reducing hazardous drinking; a score of 16–19 suggests the need for brief counselling combined with ongoing monitoring of alcohol use and harms; and a score of 20 or higher indicates the need for referral for further diagnostic assessment of dependence. The AUDIT test can be accessed at www.drugabuse.gov/sites/default/files/audit.pdf.
A briefer, 3-question, yet reliable tool is the AUDIT-C (See Box 1).14,15 Answers are allocated a score according to response, and these are added up to give a result out of 12. Scores of 4 or more in men and 3 or more in women are considered a positive screen for risky or hazardous use. This should trigger a review of recent alcohol use patterns to evaluate the likelihood of more severe dependence requiring medical assessment and management. Where the three questions indicate hazardous use, using the full AUDIT may help determine the need for referral.
Another common screening approach is to use the CAGE tool,9 which comprises four yes/no questions (see Box 2). Two or more ‘yes’ answers are likely to indicate alcohol dependence, and a need for referral for assessment and possible treatment.
The AUDIT, AUDIT-C and the CAGE are well validated screening tools used in primary care settings.17–19
There are good reasons for pharmacists to ask about alcohol use. We now know that alcohol use contributes to cancer, with greater consumption associated with greater risk.20,21 This is in addition to increased risks of injury and falls, effects on mental health, and the development of other medical conditions. For these reasons, the National Health and Medical Research Council guidelines now recommend drinking no more than 10 standard drinks a week, and no more than 4 standard drinks on any one occasion.20 There is no safe level of alcohol consumption during pregnancy, nor in those under 18 years of age.20 Additionally, alcohol use can contribute to poor sleep, anxiety and gastritis, all of which may lead to presentations in the pharmacy and requests for non-prescription medicines.
These risks are in addition to pharmacodynamic and pharmacokinetic interactions that influence the absorption, distribution, metabolism and excretion of medicines and/or alcohol.22 These interactions can increase the likelihood of adverse effects with commonly used medicines such as nonsteroidal anti-inflammatories, increase the risk of liver toxicity with paracetamol, increase the risk of sedation with opioids and increase the risk of falls. Acute alcohol use can also increase availability of warfarin, risking haemorrhage, and enhance the effects of insulin, risking hypoglycaemia. These are just a few examples of how alcohol can complicate management of a range of chronic conditions that make discussions on alcohol use in the pharmacy a key part of pharmacy practice.
Long-term alcohol dependence can result in severe and persistent effects on cognition through direct effects on the brain (e.g. negative effects on the brain and memory) and indirect effects (e.g. thiamine deficiency). Severe cases of thiamine deficiency can cause Wernicke–Korsakoff syndrome, which affects coordination, memory, and can cause psychoses.23
Liver dysfunction, including cirrhosis, is another common long-term effect of alcohol dependence.24 In people with regular alcohol use and dependence, type-2 diabetes, cardiovascular disease and neurological problems are also common.20 Compared with the general population, people with alcohol use disorders have substantially increased risk of death. A systematic review showed a more than 10-fold risk for death from liver cirrhosis and mental disorders, a 7-fold risk for a fatal injury, and double the risk for cardiovascular and cancer deaths.25
Box 2 – CAGE questionnaire
1 Have you ever felt you should Cut down on your drinking?
2 Have people Annoyed you by criticising your drinking?
3 Have you ever felt bad or Guilty about your drinking?
4 Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
Treatment for alcohol dependence often involves management of acute withdrawal symptoms in the short term and pharmacotherapies to support abstinence or reduced drinking in the longer term.
Often the first step in treating alcohol dependence is medically managed alcohol withdrawal. Alcohol withdrawal can be managed in a range of settings, with a careful clinical assessment required to determine the optimal setting.
Many patients with mild to moderate alcohol withdrawal symptoms can be managed in an outpatient setting. However, some patients will require inpatient management. This includes patients with a history of withdrawal seizures, severe symptoms of withdrawal delirium, and other substance-dependent or medical comorbidities that may complicate withdrawal management.4 Additionally, patients without a safe and supportive home environment should be managed in an inpatient setting.4
Benzodiazepines are the first-line treatment for alcohol withdrawal, and when commenced early can prevent severe complications, such as seizures and withdrawal delirium.26 When benzodiazepines for alcohol withdrawal are required in an outpatient setting, patient safety concerns need to be considered. For this reason, staged supply (e.g. daily dispensing) is often used to help prevent overuse and over-sedation if taken in combination with alcohol. Staged supply is often used in combination with daily assessment of alcohol intoxication and withdrawal symptoms to mitigate risks.
Many services have their own policies and procedures for the management and treatment of alcohol withdrawal, including the use of the Alcohol Withdrawal Scale (AWS) and the Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar)27 to assess withdrawal symptoms, and a protocol for either fixed-dose benzodiazepines or symptom-triggered dosing.
Other features of complex alcohol withdrawal include psychotic symptoms, agitation, delirium and dehydration.28
As long-term alcohol use often results in thiamine depletion, intravenous thiamine is often initiated at the same time (200–900 mg intravenously or intramuscularly daily for 3–5 days; the required dose is dependent on risk factors and symptoms; these will also determine the duration), with longer-term oral thiamine (100–300 mg daily) also recommended.28,29
Acamprosate and naltrexone can be used following acute withdrawal to support abstinence. Acamprosate and naltrexone reduce alcohol craving and disrupt the reward pathways.28 Naltrexone, an opioid antagonist, should not be used in people who are opioid dependent or use opioids for pain relief.28
Disulfiram, an aversive medicine, causes flushing, nausea and vomiting when alcohol is consumed, by blocking aldehyde dehydrogenase. Disulfiram is used second-line in relapse prevention.28 There are various safety considerations with disulfiram, including ensuring alcohol withdrawal is complete before commencing, and consideration of liver toxicity. Disulfiram is commonly used with supervised administration, as the evidence for effectiveness outside supervised dosing is limited.28
Where there is suspected nutritional deficiency, supplementation with multivitamins, zinc and magnesium may be considered.28 Magnesium supplementation may assist with muscle rigidity and cramping if there is magnesium deficiency.
In addition to pharmacological management, there are various important psychosocial aspects to consider. Individual psychological approaches such as CBT to address behavioural and thinking patterns that might contribute to ongoing alcohol use are effective, in addition to developing strategies to manage triggers and cravings.30 Group approaches such as smart recovery and peer support groups can also provide crucial support to people in the long term, and assist patients after any acute management of alcohol withdrawal is complete.31
When talking to patients, one way to raise alcohol use is to discuss its relevance to the management of other chronic diseases. For example, alcohol use can complicate the clinical outcomes for common conditions such as diabetes and cardiovascular disease.32,33 When responding to requests for non-prescription medicines such as proton pump inhibitors or medicines for insomnia or anxiety, it may also be useful to consider if alcohol use is contributing to the symptoms. Use of techniques like motivational interviewing to explore the patient’s potential reasons for change and support them in making these changes is recommended.
Brief interventions are appropriate for people with risky alcohol use, but are not effective or appropriate on their own for alcohol dependence. Motivational interviewing techniques can still play a role in supporting patients to make changes and follow up on referrals. Where you suspect a patient has developed tolerance and alcohol dependence, a referral for assessment and appropriate follow-up care is required.
When asking about alcohol use, use the 5 As approach of Ask, Assess, Advise, Assist and Arrange34:
Further information and a diagrammatic representation of this approach can be accessed at www.monash.edu/medicine/sphpm/general-practice/research-projects/reach.
If patients want to seek resources themselves, www.counsellingonline.org.au provides free 24-hour support (either online or via state-based telephone services though the site). This can enable patients to confidentially and anonymously seek advice, self-assessment, support and referral options, and to access online or telephone counselling.
Substance use, including alcohol dependence, carries an enormous stigma. Patients experience problematic alcohol use for an average of 18 years before seeking help.35 Often multiple supportive conversations are needed over time to develop readiness to access care. An individual interaction may not result in immediate change, yet the long-term and population-level effects of brief interventions are important. Pharmacists can play a crucial role by having regular conversations about alcohol use in a non-judgemental way and encouraging patients to access help sooner, reducing the potential severity of their dependence and health consequences.
Pharmacists can identify risky alcohol use and alcohol dependence, and facilitate patients to seek treatment. Discussing alcohol can be made relevant for patients in the context of common drug interactions, management of chronic conditions, broader health benefits of reducing alcohol, or in association with requests for non-prescription medicines. Uncomplicated alcohol withdrawal can be managed in outpatient settings, and a range of pharmacotherapy options are available to support patients in maintaining abstinence following withdrawal treatment.
Case scenario continued
Frederick’s AUDIT-C score indicates he is drinking at risky levels, but he is not likely to be dependent. You discuss the current NHMRC guideline recommendations and ask him what might help him cut down. Frederick feels that ‘grabbing a beer’ has become habitual, and he suggests going for a walk, substituting tea in the evenings, or stopping at one beer as possible strategies to break the habit. You discuss that alcohol is probably contributing to his reflux and may also be complicating his diabetes management. Frederick recognises the potential benefits of decreased alcohol use and agrees to check in with you next week.
A/Prof SUZANNE NIELSEN BPharm, BPharmSc(Hons), PhD, MPS is the Deputy Director of the Monash Addiction Research Centre, and a registered pharmacist with extensive experience in addiction treatment and research, including working in community and specialist drug treatment services.[post_title] => Alcohol dependence [post_excerpt] => Pharmacists can identify risky alcohol use and alcohol dependence, and facilitate patients to seek treatment. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => alcohol-dependence-cpd [to_ping] => [pinged] => [post_modified] => 2021-10-06 16:34:36 [post_modified_gmt] => 2021-10-06 05:34:36 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14403 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Alcohol dependence [title] => Alcohol dependence [href] => https://www.australianpharmacist.com.au/alcohol-dependence-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 14442 )
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Urea cycle disorders (UCD) are rare inherited metabolic disorders with an incidence estimated to be 1:35,000 births.1 UCDs are caused by the dysfunction of any of the six enzymes (namely, carbamoyl phosphate synthetase I, N-acetylglutamate synthetase, ornithine transcarbamylase, argininosuccinic acid synthetase, argininosuccinate lyase, and arginase) or the two transport proteins (ornithine translocase and aspartate/glutamate carrier) involved in urea biosynthesis.2,3 The urea cycle converts the highly toxic ammonia produced from amino acid catabolism into urea, for excretion via the kidneys. A defect in urea synthesis results in hyperammonemia.2
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.3, 1.4, 1.5, 3.4, 3.5
UCDs are usually diagnosed in early childhood, however partial enzyme deficiencies can remain silent, until rare episodes of protein overload or increased catabolism can result in hyperammonemia.1 Hyperammonemia risk is also increased in cases of prolonged fasting, surgery, trauma, pregnancy, or episodes of increased catabolism in infections such as gastroenteritis.1 UCDs account for approximately 23% of acute hyperammonemia in critically ill children.4 For hyperammonemia caused by UCDs or increased ammonia plasma levels due to acute liver failure, the nitrogen (ammonia) scavengers, such as sodium phenylacetate and sodium benzoate, are key medicines for bypassing the urea cycle.3, 4 Phenylacetate (or its precursor, phenylbutyrate) binds with glutamine to generate phenylacetylglutamine, and sodium benzoate binds with glycine to form hippurate (Figure 1).3 These conjugates are then excreted in urine, thereby reducing ammonia plasma levels.3-5
Active pharmaceutical ingredient (API)
Sodium benzoate (C6H5.CO2Na, molecular weight (MW) = 144.1 g/mol) (Figure 2), is a white or almost white, slightly hygroscopic, crystalline or granular powder. It is soluble in the following solvents: 1 in 2 of water, 1 in 75 of alcohol, and 1 in 50 of alcohol (90%).5
Soluble 1 in 50 means 1 g of solute (drug) will dissolve in 50 mL of solvent.
Sodium benzoate is well known as a preservative in pharmaceutical formulations, including oral preparations, due to its antibacterial and antifungal properties.5 The benzoates are also used as preservatives in foods, and are present naturally in some foods, and in cosmetics.5 The antimicrobial activity of sodium benzoate is due to the un-dissociated sodium benzoate and is pH-dependent, where it is relatively inactive above a pH of 5, due to the presence of the benzoate anion, which is unable to penetrate the bacterial cell wall (Figure 2).5
Sodium benzoate, for the treatment of UCDs, is not marketed in Australia but may be available through the Special Access Scheme.6 This active pharmaceutical ingredient (API) can therefore be sourced as pure powder and is suitable for preparation as an oral liquid, since it is absorbed from the gastrointestinal tract and rapidly excreted in the urine.5
Stability and palatability of sodium benzoate oral liquid
A 250 mg/mL sodium benzoate (API) oral liquid prepared with ORA-Sweet was shown to be stable (API above 96%) for 90 days, when stored in amber plastic prescription bottles at room temperature (23–25 °C).7 There were no detectable physical changes in the oral liquid throughout the 90-day study period.7 Similar stability results (94.5%, 93.0% and 93.7% of the initial API concentration remaining after 96 days) were achieved when sodium benzoate was dissolved in 40 mL of water, with and without the addition of 1 mL of flavour (no flavour, cherry, mint) and made up to volume with syrup (to 100 mL), to achieve a concentration of 200 mg/mL.8
Patient adherence often presents a challenge due to the odour and taste of sodium benzoate. Maines et al 8 prepared five differently flavoured oral solutions: cherry, cacao, vanilla, berries and mint. Mint was preferred by both adults and paediatric patients. This study also included a long-term follow-up of two paediatric patients with UCDs treated with the mint-flavoured formulation; both patients demonstrated good metabolic control and tolerability during the follow-up period.8
ORA-Sweet was one of the original commercial vehicles available to pharmacists for preparing oral liquids. The formula for ORA-Sweet is available in the United States Pharmacopeia–National Formulary (USP–NF) as Vehicle for Oral Solution NF, and the ingredients are described in the latest edition of the Australian Pharmaceutical Formulary (APF 25), which states the pH of this vehicle is between 4–5.9
ORA-Sweet contains sucrose, glycerol, sorbitol, dibasic sodium phosphate, citric acid, potassium sorbate, methyl paraben and purified water.9 Due to the solubility of sodium benzoate in water,5 a suspending agent was not required. A number of commercial vehicles are available for pharmacists, such as Suspendit from the Professional Compounding Pharmacists of Australia (PCCA),10 Oral Mix from Medisca,11 and the SyrSpend range from Fagron.12 Contact your local supplier for appropriate vehicle options.
Formula, method and stability
The formula and method of preparation for sodium benzoate oral liquid (250 mg/mL) shown in Figure 3 is adapted from Atkins et al,7 which is prepared with pure API in ORA-Sweet and reported to be stable for 90 days, when stored in low-light conditions in amber, plastic prescription bottles at room temperature (23–25° C).
Figure 3 – Formula and method of preparation
SODIUM BENZOATE (250 mg/mL)
ORAL LIQUID (100 mL)
Sterile water (solvent) 50 mL
Sodium benzoate powder USP 25 g
ORA-Sweet (vehicle) to 100 mL
Packaging, storage and labelling
Compounded products must be prepared and dispensed in a manner that complies with legislative standards and ensures their quality, safety and efficacy.9 The APF provides a brief overview of compounded preparations, including references for important standards and guidelines.9 Pharmacists must use professional judgment to assess the potential risks to staff and the patient associated with preparing and dispensing a compounded product. The Professional Practice Standards has a compounding decision support and risk assessment tool for assessing risk that is available online (Appendix 7).13 Compounded products must be labelled in accordance with the relevant state or territory legislation, and should include the approved pharmacopoeial or APF name (where applicable), the name and quantity/concentration of all APIs and any preservatives used, the expiry date, storage details, directions for use and cautionary advisory labels.9 Pharmacists should use a systematic approach for quality assurance of compounding activities, using principles of good compounding practice. Processes and procedures should be reviewed regularly to identify areas for improvement and the resulting actions should be documented.9
Since the formula should be protected from light, amber prescription bottles with child-resistant caps are recommended. Contact your local supplier for packaging options. Oral syringes may be more suitable for infants and young children, whereas measuring cups are appropriate for older children.6 It is important that patients and carers are counselled on correct use, storage and appropriate disposal.9 The preparation should be stored out of reach of children and pets.
Box 2 – Cautionary advisory labels used for this preparation
In the preparation of compounded products, the pharmacist is guided by the professional standards and guidelines,9 the prescriber and the needs of the carer and patient. Patient counselling and education may be adapted from CMIs available for commercial products,14 or patient support groups such as Medicines for Children15 or the National Urea Cycle Disorders Foundation.16
Essential information should include:
Practice points, patient advice and counselling
Directions for use
A variety of medicines are commonly compounded by pharmacists in Australia. Compounding of a medicine is appropriate when there is no suitable and available commercial product or therapeutic alternative. In addition in the case of sodium benzoate oral liquid, because of the extremely poor taste of sodium benzoate, pharmacists have been integral in compounding this oral liquid to improve its palatability, to improve adherence in paediatric patients.8
Pharmacists involved in the compounding of medicines must ensure they comply with all relevant and applicable legislative requirements and ensure professional obligations are met.
Dr ALISON HAYWOOD MPS is a Senior Lecturer at Griffith University’s School of Pharmacy and Medical Sciences.
Professor BEVERLEY GLASS FPS is a Professor of Pharmacy at James Cook University’s College of Medicine and Dentistry.[post_title] => Compounding sodium benzoate oral liquid for urea cycle disorders [post_excerpt] => Because of the extremely poor taste of sodium benzoate, pharmacists have been integral in compounding this oral liquid to improve its palatability, to improve adherence in paediatric patients. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => compounding-sodium-benzoate-oral-liquid-cpd [to_ping] => [pinged] => [post_modified] => 2021-09-28 02:44:10 [post_modified_gmt] => 2021-09-27 16:44:10 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14343 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Compounding sodium benzoate oral liquid for urea cycle disorders [title] => Compounding sodium benzoate oral liquid for urea cycle disorders [href] => https://www.australianpharmacist.com.au/compounding-sodium-benzoate-oral-liquid-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 14344 )
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Oral candidiasis, also known as oral candidosis or oral thrush, is an opportunistic infection of the oral cavity caused by the Candida species.1 It is a common fungal infection of the oral cavity.2 There are a variety of clinical presentations. It is often regarded as the ‘disease of the diseased’,3–5 highlighting the opportunistic nature of the infection. Management is with antifungal medicines, however addressing any underlying or contributing factors is key to best care.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.3, 1.5, 2.3, 3.2, 3.5
The Candida spp. are the most common fungal pathogens isolated from the oral cavity and can be found in a large percentage of the population.6 C. albicans is isolated most frequently.6 Oral carriage of Candida spp. is generally asymptomatic and occurs in 35–80% of healthy individuals.7 Those with active carious lesions involving their dentition and people who smoke have been found to have higher carriage of oral Candida.10 The presence of Candida alone is not indicative of pathology.10
Opportunistic infections can result in the presence of an underlying condition.10 This transition from harmless colonisation to pathogenic microorganisms is the result of the upset between the balance of host immune defences and fungal virulence factors.11 While strain-specific phenotypic characteristics may give specific Candida strains advantages, it is the host’s immune competence that determines the outcome (i.e. clearance, colonisation or infection).8,11 The prevalence of oral candidiasis is impacted by age and is more commonly seen in the very young or old.13 There is no gender predilection.9 Superficial C. albicans infections are non-lethal (compared to systemic infections, which can be fatal).13
Oral candidiasis should be managed with antifungal therapy.16 Topical preparations are available as Pharmacist Only medicines. In moderate to severe cases, or if unresponsive to topical treatment, systemic antifungals may be necessary.16 It is important that there is treatment and proper management of any predisposing cause; recalcitrant cases should be referred to an oral medicine specialist (i.e. specialist dentist) or the patient’s general practitioner (GP) in a timely manner. Pharmacists need to provide advice on the appropriate use of antifungal medicines, identify potential drug interactions, and support patients in optimising their health.
Of the Candida spp., the dimorphic yeast C. albicans is the most common and is generally regarded as the most virulent.6 Other members of the Candida genus (C. tropicalis, C. glabrata, C. parapsilosis, C stellatoidea, C. krusei and C. kyfer) are more frequently seen in people who are immunosuppressed, such as patients living with HIV/AIDS.6
Morphological changes (such as changing from budding yeast to filamentous forms) under different environmental conditions, and the ability for Candida to adhere to epithelial cells of human tissues, impact the organism’s virulence.4 Other pathogenic mechanisms that increase virulence include the expression of adhesins and invasins on the cell surface, thigmotropism, the formation of biofilms, phenotypic switching and the secretion of hydrolytic enzymes.13 The virulence factors of C. albicans underscore its ability to infect diverse host niches.4,13
Risk factors for the development of oral candidiasis are numerous. Examples of local predisposing factors include poor oral hygiene, use of a prosthesis such as dentures, endogenous epithelial changes (e.g. from smoking), changes in the normal oral flora, and qualitative and quantitative salivary changes (e.g. hyposalivation).1 Systemic risk factors include extremes of age, primary and secondary immunodeficiencies, nutritional deficiencies (e.g. iron, vitamin B6, magnesium), endocrine conditions (e.g. diabetes) and chemotherapy and radiotherapy.3 Other risk factors for candidiasis may include use of inhaled corticosteroids and oral medicines such as antibiotics.14,16 Optimal management of predisposing factors is imperative for the management of candidiasis.1
Figure 1 – Group I: primary oral candidiasis conditions[caption id="attachment_14274" align="alignnone" width="1000"] Images courtesy of Dr Amanda Phoon Nguyen[/caption]
Oral candidiasis can present in a number of ways. A proposed classification for oral candidiasis lesions divides the condition into two main groups5,17:
Primary oral candidiasis
This broadly, includes pseudomembranous (acute and chronic), erythematous (acute and chronic) and chronic hyperplastic candidiasis (see Figure 1).19
Candida-associated lesions under this classification include angular cheilitis, median rhomboid glossitis, denture-associated erythematous stomatitis (DAES) and linear gingival erythema.19
Secondary oral candidiasis
This includes chronic mucocutaneous candidiasis, a heterogenous group of syndromes. White plaques may be seen intraorally which become widespread, thick and adherent.20
Acute pseudomembranous candidiasis presents as white flecks, plaques or nodules, which will usually wipe off with gauze. These are typically semi-adherent, leaving a red erythematous base when removed. Lesions are usually asymptomatic, though patients may sometimes complain of burning and dysphagia. It can occur anywhere on the oral mucosa.15
Chronic hyperplastic candidiasis may present as an adherent white plaque of variable thickness, usually asymptomatic, with an irregular surface texture. The most common sites include the buccal mucosa and tongue. Hyperplastic candidiasis may be associated with endocrinopathies and hairy leukoplakia. Chronic hyperplastic candidiasis may be potentially malignant and associated with a higher degree of dysplasia and malignancy, and a biopsy is usually mandatory.21
Erythematous candidiasis presents as raw-appearing lesions of the oral mucosa. Erythematous candidiasis, especially in the acute form, may occasionally be painful.3
Some conditions, such as denture stomatitis and median rhomboid glossitis,3 are known as Candida-associated conditions rather than an oral candidiasis, and Candida is not the only causative agent.5 These conditions are linked to the Candida species as well as other causes. Candida-associated conditions include3:
Angular cheilitis is a common condition. This is a multifactorial, inflammatory condition, commonly with an infectious origin, affecting the oral commissures for variable durations. It is estimated to affect up to 1% of the population. It affects both adults and children, with no gender predilection. The condition may be prevalent in groups where anaemia is a factor.5 Infectious organisms involved include Candida albicans, Staphylococcus aureus and Beta-haemolytic streptococci.22
Figure 2 – An oral mucosal biopsy with Periodic acid-Schiff (PAS) stain showing the presence of candidal hyphae.
Broadly, the diagnosis of oral candidiasis is generally based on clinical signs and symptoms, in conjunction with a thorough medical history and examination.3 Currently, there is no convincing evidence of a single test or method able to identify the transition from candidal colonisation to pathogenicity.22 A number of techniques can be used to isolate Candida within the oral cavity. These include the use of a smear, a plain swab, an imprint culture, collection of saliva, the concentrated oral rinse, and mucosal biopsy (see Figure 2).23
The morphological changes of Candida under different environmental conditions may help explain some of the confusion surrounding the clinical utility of methods used to detect and confirm candidal infection in the oral cavity. The use of swabs for culture and microscopy is not necessarily able to discriminate the transition between candidal carriage and invasiveness in the oral cavity.22 The most correct methods of sampling and detection will therefore depend on the nature of the lesion being investigated.
There are numerous other conditions that may be associated with oral symptoms similar to those of oral candidiasis. These should be considered as differential diagnoses and include:
Pharmacists should refer patients with suspected chronic mucocutaneous candidiasis, if there is uncertainty of the diagnosis or if unable to exclude other differential diagnoses such as oral mucosal disease. They should also refer patients whose presentation persists beyond initial therapy, or if there is recalcitrant/recurrent disease.
Should there be failure of initial therapy, additional laboratory testing should be undertaken by the specialist, with careful consideration of any underlying systemic risk factors and potential for drug-resistant Candida strains.25
Pharmacists should also refer patients who have underlying medical conditions contributing to oral candidiasis that are not being optimally managed.
TABLE 1 – Antifungal medicines for primary oral candidiasis
|First line Miconazole 2% oral gel||Adults and children ≥2 years: 2.5 mL is topically applied, then swallowed, 4 times a day, after food, for 7–14 days Neonates and children <2 years: 1.25 mL is topically applied, then swallowed, 4 times a day, after feeding, for 7–14 days. Apply at the front of the mouth in small amounts to avoid choking Treatment should continue for 7 days after resolution of symptoms||Patients should be advised to place gel on the tongue and hold in the mouth for as long as possible before swallowing As the primary reservoir for oral Candida carriage, the tongue dorsum is often the initiating point of infection9|
|Second-line Amphotericin B lozenges||Adults and children ≥2 years: 10 mg lozenge is sucked, then swallowed, after food, for 7–14 days. Treatment should continue for 2–3 days after resolution of symptoms||Use with caution in patients with salivary gland hypofunction, as it is difficult to dissolve and the sucking action may further irritate the oral mucosa|
|Third-line Nystatin oral liquid 100,000 units/mL||Adults and children ≥2 years: 1 mL is topically applied, then swallowed, 4 times a day, after food, for 7–14 days. Treatment should continue for 2–3 days after resolution of symptoms Neonates and children <2 years: 1 mL is topically applied, then swallowed, 4 times a day, after feeding, for 7–14 days. Treatment should continue for 2–3 days after resolution of symptoms||Nystatin liquid contains sucrose. There may be a risk of dental caries The patient must not eat or drink directly after application as successful treatment requires an adequate contact time between the drug and oral mucosa|
References: Vila,4 eTG16
Management of an oral candidal infection is based on the differentiation of candidal lesions from other similar clinical presentations. The choice of antifungal treatment depends on the patient’s immunological status, presenting symptoms and anticipated adherence with the selected treatment.25
Antifungal agents such as nystatin, amphotericin B or azoles are commonly used in the pharmacological management of oral candidiasis. They work by targeting ergosterol biosynthesis which interferes with cell wall permeability, leading to cell death.18 Azoles are fungistatic drugs, and this has led to the emergence of resistance.4 See Table 1 for treatment options.
Oral candidiasis should be managed with antifungal therapy16; there is a scarcity of robust evidence for complementary treatment options. Anti-Candida diets have been proposed. While high Candida abundance has been associated with the recent consumption of carbohydrates, there is a lack of supporting evidence for patients to be encouraged to adopt these diets.24
Patients must be reminded to remove any prosthesis such as dentures when using topical antifungal therapy. Miconazole or nystatin are the treatments of choice for people with dentures.16 Miconazole oral gel may be applied directly to the fitting surface of dentures and should be used at least twice a day.16 Denture hygiene, such as removing nightly and appropriate cleaning, must also be reinforced.16 Patients should be instructed to store dentures in a dry area overnight to reduce the risk of fungal colonisation.16 Nystatin contains sucrose, and should be used with caution in dentate patients with oral candidiasis, particularly for those with a history of radiation therapy, salivary gland hypofunction and/or a high caries risk.
For angular cheilitis, a Candida-associated condition, management includes assessment and management of any causative factors.16 A topical antifungal cream should be applied to the corners of the mouth; treatment should continue for 14 days after symptoms resolve.16 Recommended treatments include16:
Topical application of 1% hydrocortisone cream can be used in addition to the antifungal cream until inflammation subsides.16 The patient may need to see their dentist for review of potential dental-related causes of angular cheilitis.16
Adverse effects associated with nystatin include nausea, vomiting and diarrhoea, although these are generally more severe with higher doses.12 Amphotericin B lozenges may infrequently cause mild nausea, vomiting or diarrhoea, while miconazole oral gel can cause mild gastrointestinal disturbances.12
Nystatin oral drops and miconazole oral gel are pregnancy category A and are considered safe to use in breastfeeding.12 Amphotericin B is pregnancy category B3, and its risks and benefits should be considered. There is likely to be minimal infant exposure if amphotericin B lozenges are used in breastfeeding.12
Both nystatin and amphotericin B are poorly absorbed through the oral mucosa, so drug interactions are rare.
Oral miconazole can be absorbed systemically through the oral mucosa and may cause clinically relevant drug interactions.12 Miconazole inhibits CYP3A4 and CYP2C.9 The manufacturer of miconazole oral gel contraindicates its use with many drugs, including warfarin, medicines that prolong the QT interval (e.g. cisapride, quinidine, terfenadine), ergot alkaloids, HMG-CoA reductase inhibitors (e.g. simvastatin, lovastatin), triazolam and oral midazolam.12 Pharmacists should check the product information to identify potential interactions and recommended management strategies accordingly.
Preventive measures include encouraging the patient to have a healthy diet (including limiting sugar intake), reinforcing proper oral and denture hygiene, ensuring adequate hydration and rinsing the mouth out with water after using corticosteroid inhalers.16 It is also important that patients ensure they are using antifungal medicines correctly to properly treat any infection.
Pharmacists can support patients with oral candidiasis by identifying cases and providing treatment where appropriate, or referring to another health professional for further review. Pharmacists also have an important role in educating patients, including counselling on the appropriate use of antifungal medicines, providing advice on preventing future episodes, and supporting patients in managing underlying medical conditions.
Oral candidiasis is a common fungal infection of the oral cavity. Diagnosis is typically through clinical examination and patient history. There are a variety of clinical presentations; diagnosis may be confusing. Oral candidiasis is often regarded as the ‘disease of the diseased’, highlighting the opportunistic nature of the infection. Careful consideration of any underlying or systemic contributors is imperative. Antifungals, with consideration to adverse effects and drug interactions, in addition to appropriate counselling from the pharmacist, are used to manage the condition. Pharmacists must also recognise when referral is required.
Dr AMANDA PHOON NGUYEN BDSc, MRACDS (GDP), DClinDent (OralMed), MRACDS (OralMed), Cert ADL, FOMAA, FPFA, FICD is an Oral Medicine Specialist in Perth, Western Australia. She is also a PhD candidate, Adjunct Senior Lecturer at University of Western Australia, and Consultant at Perth Children’s Hospital. Her expertise includes oral mucosal disease, orofacial pain, temporomandibular disorders, dental sleep medicine and paediatric oral medicine.[post_title] => Oral candidiasis [post_excerpt] => Oral candidiasis is often regarded as the ‘disease of the diseased’, highlighting the opportunistic nature of the infection. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => oral-candidiasis-cpd [to_ping] => [pinged] => [post_modified] => 2021-09-21 23:05:46 [post_modified_gmt] => 2021-09-21 13:05:46 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14272 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Oral candidiasis [title] => Oral candidiasis [href] => https://www.australianpharmacist.com.au/oral-candidiasis-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 14277 )
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Over a combined 103 years, the joint recipients of this year’s Lifetime Achievement Award, Valerie Constable and the late John Ware, helped progress the pharmacy profession for the next generation.
The Pharmacists Support Service (PSS) recorded an 80% jump in calls last year, its team of volunteers speaking to pharmacists, interns and students seeking a listening ear during a particularly challenging time.
But if a distressed pharmacist rang the helpline 26 years ago, it would have been Valerie Constable’s voice on the end of the line.
It was 1995 when PSA’s Victorian branch received a letter from the Doctors’ Health Advisory Service (DHAS) saying it had been contacted by pharmacists asking for help, including one who ultimately died by suicide. While substance abuse was a big issue for doctors, pharmacists in Victoria were experiencing frequent robberies, and DHAS suggested PSA establish its own targeted support service.
Ms Constable, PSA’s first female President in Victoria, immediately saw the need for a helpline run by pharmacists, for pharmacists.
‘I felt quite strongly about it,’ she says of the initiative, the highlight of her career. ‘My family had experienced suicide and I knew what it did to people. So I put my hand up and said if anybody should do it, it should be PSA, because they represent all pharmacists. I took the calls for the first 2 years. It was seat-of-the-pants stuff, as there wasn’t another organisation in Australia to follow. Similar outfits in the UK and US were just getting started.'
Ms Constable proved there was demand for the service, and PSA Victoria provided ongoing funding. Over time, PSS expanded nationally, taking on more volunteers, developing a formal training program with Lifeline and bringing on Kay Dunkley FPS as CEO (its first paid employee). From 20 calls a year initially, PSS now handles about 10 calls a week and provides valuable, non-judgmental support to those in need.
In addition to leadership roles with PSA and establishing PSS, Ms Constable’s career was dedicated to community pharmacy. She met her husband Bob at the Victorian College of Pharmacy in the early 1950s, and spent 36 years living above their pharmacy in a former drapery store in Pascoe Vale South, about 10 kilometres north of Melbourne’s CBD.
Times are changing
Ms Constable says she would find pharmacy ‘very hard’ now. ‘I love being a pharmacist and have never wished to be anything else ... [But] it has become very stressful with lots of pressure, even more so in this pandemic,’ she says.
‘The main thing I always practiced and tried to teach our trainees was that every patient who leaves your pharmacy must feel you have done your very best to help them.’‘I hope I have given something back to the profession I love.’
While PSS issues have changed over the years – bullying has become more prevalent, but there are fewer holdups – the service is just as relevant.
‘A big aim of the PSS is to alleviate stress and find a way around it. And having a pharmacist answer the phone each time is important, because they understand the situation – they’ve been there, done that,’ Ms Constable says.
‘I am confident that PSS will achieve even more in the future and I am proud of what has already been achieved. I hope I have given back something to the profession I love.’
What change in pharmacy in the past 2 years were you most excited about?
The change which most excited me was that Commonwealth and State governments publicly recognised the value of pharmacists’ expertise, experience and accessibility.
This is witnessed by the use of community pharmacists as vaccinators during the present COVID-19 pandemic.
What action in PSA’s Pharmacists in 2023 is the most important?
Action 4: Facilitate pharmacist prescribing within a collaborative care model. This will benefit pharmacists as well as the public and the government.
Lifetime Achievement Award joint recipient John Ware OAM
A community pharmacist for 40 years, John Ware FPS OAM posthumously received a Lifetime Achievement Award. He died in December 2020 aged 92.[caption id="attachment_14340" align="alignright" width="254"] John Ware OAM[/caption]
After graduating from the Victorian College of Pharmacy in 1950, Mr Ware operated pharmacies in Melbourne and rural Australia and served as PSA’s National President and President of the Victorian Branch, as well as President of the Western Pacific Pharmaceutical Forum and the International Pharmaceutical Federation (FIP) Foundation.
After his OAM in 2002, in 2006, Mr Ware became one of a small number of Australians to receive a Fellowship of the FIP and in 2014 received the FIP Distinguished Service Award.
He was remembered fondly by Professor Arthur Christopoulos, Dean of Monash University’s Faculty of Pharmacy and Pharmaceutical Sciences, and Victorian PSA President John Jackson.
‘He epitomised the professional pharmacist, improving care especially through education, collaboration and commitment to pharmacy organisations such as PSA and FIP,’ said Prof Christopoulos.The PSA Lifetime Achievement Award is proudly sponsored by Symbion. [post_title] => How PSA's 2021 joint Lifetime Achievement Award recipients led the way [post_excerpt] => Over a combined 103 years, the joint recipients of this year’s Lifetime Achievement Award, Valerie Constable and the late John Ware, helped progress the pharmacy profession for the next generation. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => 2021-lifetime-achievement-award [to_ping] => [pinged] => [post_modified] => 2021-09-24 19:05:42 [post_modified_gmt] => 2021-09-24 09:05:42 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14336 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => How PSA’s 2021 joint Lifetime Achievement Award recipients led the way [title] => How PSA’s 2021 joint Lifetime Achievement Award recipients led the way [href] => https://www.australianpharmacist.com.au/2021-lifetime-achievement-award/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14332 )
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From producing the world’s first comprehensive guide to drugs in sport to supporting her community through bushfires, and now the pandemic, Linda Badewitz-Dodd MPS is always willing to step up to the challenge.
A coal-face pharmacist who practices what she preaches. A pioneer. A community leader. These are just a few of the ways Ms Badewitz-Dodd’s peers describe her, and it’s easy to see why.
Her pharmacy in Merimbula on the New South Wales south coast, which she co-owns with business partner Tania Dwyer, provides a wide range of professional services with a focus on personalised support and care. During the 2019–20 bushfires, the pharmacy remained open, supplying face masks, essential medicines and emergency support to the community, while Ms Badewitz-Dodd dealt with the threat of fire to her own home in nearby Tathra.
‘When you live in a small town, your friends become your family,’ she says. ‘Ensuring the pharmacy stayed open and getting things for the community when it needed them was very rewarding. Helping people and accepting help (when you are accustomed to giving it) – that’s what defines community to me.’
A clinical start
Ms Badewitz-Dodd didn’t always aspire to life as a community pharmacist. After graduating from the University of Sydney in 1985, she did a post graduate diploma in hospital pharmacy as it ‘offered an avenue for specialties and to see closer at hand your knowledge being applied’.
She went on to work as a clinical pharmacist at Sydney’s Royal Prince Alfred Hospital, doing ward rounds with doctors and spending time in the intensive care, neurosurgery and neurosurgical intensive care units.
‘That was an amazing experience. It’s when I realised that we’re all here together for one purpose, and that’s looking after the patient … It shaped my belief in pharmacists being part of a team and able to contribute meaningfully.’
Drugs in sport
Before the 1990 Commonwealth Games in Auckland, Ms Badewitz-Dodd, by then Managing Editor of MIMS, wanted to include a`Permitted in Sport’ or `Not Permitted in Sport’ symbol in MIMS Bi-Monthly that clearly identified products that could be taken by athletes.‘If you have an opinion, voice it. don’t be afraid to be wrong or to have the discussion – and know when not to accept a simple “no”.’
From then producing a handbook for athletes, coaches and sport management staff was a logical progression and resulted in the first edition of Drugs in Sport in 1990, she recalls.
‘A similar publication was produced for MIMS UK. Then the world was becoming digital and internationally there were “Live Drug Databases” which were the precursors to the Current Global DRO – a collaboration between numerous countries including the United States, Canada, the United Kingdom, Australia, Switzerland, New Zealand, Japan and others.’
Ms Badewitz-Dodd and the other pharmacists in the group manage the ingredients and she additionally manages the brands for Australia, Canada and New Zealand.
Having her first child meant, sadly, stepping away from MIMS as, ‘nothing compared to being a mum’.
Ms Badewitz-Dodd continued her drugs in sport consultancy work, joined PSA’s NSW Branch Committee and presented Insight, a PSA education program (‘on cassettes!’).
Meanwhile, her husband David Dodd was working hard in his pharmacy at Eastwood, in Sydney’s north-west.
The long hours took its toll on the young family (the couple had children aged 2 and 4 at this point). They spent a few months travelling before moving to Tathra where they began working for local pharmacist Warren Seeto, who had been Ms Badewitz-Dodd’s first (and last) boss.
And while she continued to raise their children, Mr Seeto and Mr Dodd went into partnership – until his tragic death in 2013 when he was hit by a car.
‘When my husband was killed I inherited his half of the business, so I had to set up and become a community pharmacist,’ Ms Badewitz-Dodd says.
‘I was doing a bit of relieving around the place, but it was never my passion. It is now though,’ she says. ‘I think whatever you choose to do, if you don’t do it with passion, people can tell.’
Her advice for others is to be brave. ‘If you have an opinion, voice it. Don’t be afraid to be wrong or to have the discussion – and know when not to accept a simple “no”.'
What change in pharmacy in the past 2 years were you most excited about?
The drive to empower pharmacists to practice to their scope of practice is a game changer for me professionally. Recognition that pharmacists can and do provide services to our community, such as vaccinations and administration of IM and SC medicines, is well overdue. I am excited to see where this will take us.
What action in PSA’s Pharmacists in 2023 is the most important?
That is a difficult question as so many of the actions go hand in hand. But Action 4: Facilitate pharmacist prescribing within a collaborative care model has the most scope for our profession. For example with flu vaccinations, we already prescribe – we make the clinical judgment as to whether it is beneficial for a particular patient and then act accordingly. There are so many other things we can do – let’s just do it.The PSA Intern of the Year Award is proudly sponsored by Symbion. [post_title] => Linda Badewitz-Dodd MPS is PSA's 2021 Pharmacist of the Year [post_excerpt] => From producing the world’s first comprehensive guide to drugs in sport to supporting her community through bushfires, and now the pandemic, Linda Badewitz-Dodd MPS is always willing to step up to the challenge. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => 2021-pharmacist-of-the-year [to_ping] => [pinged] => [post_modified] => 2021-09-24 18:18:29 [post_modified_gmt] => 2021-09-24 08:18:29 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14331 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Linda Badewitz-Dodd MPS is PSA’s 2021 Pharmacist of the Year [title] => Linda Badewitz-Dodd MPS is PSA’s 2021 Pharmacist of the Year [href] => https://www.australianpharmacist.com.au/2021-pharmacist-of-the-year/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14333 )
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Just 3 years out of university, Maria Berbecaru MPS made history by implementing an Australian-first aged care pharmacy service. She hopes her experience will inspire others and help make embedding pharmacists in aged care the norm.
A 2016 graduate of the University of Tasmania, Maria Berbecaru credits two experiences during her intern year at Swansea Pharmacy, on Tasmania’s east coast, with igniting her interest in aged care.
The first was assisting nursing staff during medicine administration rounds at a local residential aged care facility (RACF), where she answered questions about the crushability of medicines and the correct administration techniques of eye preparations and inhalers.
A few months later, Ms Berbecaru shadowed the visiting consultant pharmacist who conducted medication reviews at the RACF, helping with patient interviews and sitting in on discussions about drug-related problems with the pharmacist and local GP.
‘I was intrigued by how well-received the medicine suggestions were by the GP and the beneficial impact the pharmacist had on residents’ overall health,’ she says.
‘Witnessing first-hand the significant impact pharmacists could have on the well-being of individuals is what sparked an interest for me to pursue a pathway into aged care.’
Finishing her internship, Ms Berbecaru began working at Lindisfarne Amcal Pharmacy in Hobart and gained her accreditation. Since then, she has not only pursued aged care but has been a pioneer – implementing Australia’s first integrated community pharmacy delivered medicine supply and on-site clinical service model at an RACF. The service began in a single RACF in January 2019 and expanded to a second location this year, providing care to approximately 250 residents.
Although there have been similar models trialled in Australia, most have relied on dedicated grants. Ms Berbecaru’s model, on the other hand, was established in collaboration with the RACFs, which help fund her employment at the Lindisfarne pharmacy.
From daily ward visits, helping nurses with patient admissions, assisting visiting GPs with rounds, to performing residential medication management reviews (RMMRs), Ms Berbecaru’s duties at the RACFs vary depending on the day.‘My goal is to promote and elevate the embedded pharmacists in aged care model.’
It’s this variety that she enjoys most. ‘Every day is different and presents different challenges that keep me on my toes,’ she says. ‘I also enjoy the interprofessional collaboration, where everyone works towards improving delivery of care for the residents.
‘For example, [if I identified] a resident was experiencing pain despite using pain medicines [I would] discuss the pain in further detail with the resident and communicate this to the GP via phone or email. The GP either reviews the resident’s pain during their next visit to the facility or accepts the medicine recommendation [I have] put forward.’
She also does 3-monthly psychotropic reviews, which have had a measurable impact.
The use of antipsychotics at the first RACF to adopt the resident aged care pharmacist is now less than 6% of residents, down from almost 20% when Ms Berbecaru started.
Ms Berbecaru says being recognised so early in her career is an honour and a reminder that the work she does matters, but that it is a ‘collective win’.
‘I wouldn’t have achieved what I have without the individuals who supported me, taught me and tolerated me … Together we are treading on new territory and illustrating the importance of pharmacists within aged care.’
When she isn’t exploring new hiking tracks with friends or increasing her heart rate by skydiving or aquatic parasailing, she hopes to inspire other pharmacists to become involved in aged care.
‘My goal is to promote and elevate the embedded pharmacists in aged care model … Additionally, [I’d like] to assist with solidifying a sustainable funding model, so that this unique role becomes widely adopted across other residential aged care facilities in Australia.
‘I believe with the right opportunities, guidance and a sustainable funding model in place, embedded residential clinical pharmacists will become the norm.
'They will be pivotal members of the care team, promoting safe prescribing, appropriate use and administration of medicines and optimising resident care,’ she believes.
What change in pharmacy in the past 2 years were you most excited about?
The expanding scope of pharmacists’ practice and recognised need for them within healthcare teams. For example, pharmacists practicing within GP clinics, immunising pharmacists (and their increased vaccination scope) and embedded residential clinical pharmacists has increased public awareness and understanding of pharmacists’ significant impact within care teams and the health system overall.’
What action in PSA’s Pharmacists in 2023 is the most important?
I believe all 11 actions are equally important, but if we draw attention to Action 3, embedding pharmacists within healthcare teams, it will be both a short-term and long-term solution to reduce the burden on Australia’s strained healthcare system. Pharmacists are the 'cogs' of the healthcare machine.The PSA Early Career Pharmacist of the Year Award is proudly sponsored by Symbion. [post_title] => Aged care innovator is PSA's 2021 ECP of the Year [post_excerpt] => Just 3 years out of university, Maria Berbecaru MPS made history by implementing an Australian-first aged care pharmacy service. She hopes her experience will inspire others and help make embedding pharmacists in aged care the norm. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => 2021-early-career-pharmacist-of-the-year [to_ping] => [pinged] => [post_modified] => 2021-10-13 12:44:04 [post_modified_gmt] => 2021-10-13 01:44:04 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14326 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Aged care innovator is PSA’s 2021 ECP of the Year [title] => Aged care innovator is PSA’s 2021 ECP of the Year [href] => https://www.australianpharmacist.com.au/2021-early-career-pharmacist-of-the-year/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14327 )
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While most interns were focused on simply surviving their first year of practice during a pandemic, Erin Cooper MPS found time to give back to her peers.
The start of Ms Cooper’s professional career was quite literally a baptism by fire, as she arrived in Canberra to begin her internship at Capital Chemist Wanniassa just days before the Black Summer bushfires reached the ACT.
She had come from Orange, about 270 kilometres away in New South Wales, where she worked in a local community pharmacy, attended Charles Sturt University and was President of the National Australian Pharmacy Students’ Association (NAPSA).
‘I remember being at my friend’s house on New Year’s Eve. I was starting work the next day and we were sitting outside on the deck, when suddenly we got engulfed in smoke,’ Ms Cooper says of her arrival in Canberra.
‘I had to hit the ground running from the minute I started. People were coming [into the pharmacy] wanting masks and Ventolin, and we could only have one of the doors open because there was so much smoke coming in.’
And then came the pandemic. The Wanniassa pharmacy team was split into two groups to reduce the risk of infection, and Ms Cooper ended up on the opposite side to her preceptor.
‘That was difficult, but I formed such great connections with everyone else that I felt like I had a whole team of mentors, not just one … I feel quite confident in my role having come out of that.’
A graduate’s guide
While finding her feet during the first half of her internship, Ms Cooper was also responsible for leading her peers through a time of great uncertainty as NAPSA President.
University campuses were closed and students were worried they wouldn’t be able to do their placement hours and finish their courses. On top of this, they needed to start thinking about life after university.‘I don’t think you’ll get anywhere if you don’t get involved.’
Before getting her internship in Wanniassa, Ms Cooper tried to gather as much information as possible, but found it hard to keep track of all the different requirements. In a bid to help others, and inspired by a previous NAPSA publication, she decided to create a guide to internships for the graduating class of 2020.
‘When you’re applying for internships, you have an enormous list of things to do and you need to make sure you do them all by the right date. I found it really difficult. My lecturers were super helpful, but even then there were still things that were quite ambiguous,’ she says.
After contacting ‘everyone I could think of who is involved in the intern process’, and many hours of edits, NAPSA’s Intern Guide for 2020 Pharmacy Graduates was born – helping pharmacy students across the country prepare for one of the most important years of their career.
With the pressure of her intern year now behind her, Ms Cooper is currently enjoying life as a community pharmacist and the relationships she has developed with patients. It also leaves her with enough time to indulge in another passion – teaching ballet.
She says her biggest piece of advice for others is to get involved, whether through PSA’s Communities of Specialty Interest, Early Career Pharmacists groups or with NAPSA.
‘If I hadn’t gotten involved I wouldn’t know all the people I do now, my best friends who I met through NAPSA and now live all across Australia, who I still talk to almost daily. I don’t think you’ll get anywhere if you don’t get involved.’
What change in pharmacy in the past 2 years were you most excited about?
The expansion in pharmacists’ scope of practice, particularly in vaccinations. I know this varies state by state, but at the beginning of my intern year pharmacists in the ACT could only administer vaccines for whooping cough and the flu to those over 16 years. Now I can vaccinate anyone over 10 with the flu shot and provide Boostrix, MMR and COVID vaccines in the pharmacy.
What action in PSA’s Pharmacists in 2023 is the most important?
Action 7: Equip the pharmacist workforce through practitioner development to address Australia’s existing and emerging health challenges is important to further the profession. As seen through the COVID-19 pandemic, pharmacists can play a huge role. This is reflected through our ever-expanding scope of practice allowing us to provide services not previously available in the pharmacy.The PSA Intern of the Year Award is proudly sponsored by MIMS. [post_title] => Erin Cooper MPS is PSA's 2021 Intern of the Year [post_excerpt] => While most interns were focused on simply surviving their first year of practice during a pandemic, Erin Cooper MPS found time to give back to her peers. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => 2021-intern-of-the-year [to_ping] => [pinged] => [post_modified] => 2021-09-24 18:14:35 [post_modified_gmt] => 2021-09-24 08:14:35 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14321 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Erin Cooper MPS is PSA’s 2021 Intern of the Year [title] => Erin Cooper MPS is PSA’s 2021 Intern of the Year [href] => https://www.australianpharmacist.com.au/2021-intern-of-the-year/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14322 )
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Why did you study pharmacy in Tasmania?I am Apple Isle born and bred and proud of it! I was accepted into both the University of Tasmania and the University of South Australia but chose Tasmania to be closer to my family. My aunt completed her Bachelor of Pharmacy there and I knew studying at a smaller university would give me more personalised learning. Having lecturers who knew me, and were accessible, was important. UTas has excellent placement programs and hospital case study visits.
How did you wind up in Maddingley, half-way between Melbourne and Ballarat?My partner and I moved to Victoria in 2016 because the likelihood of achieving career goals was much higher on the mainland. I completed my internship with Advantage Pharmacy Group in Warragul, in regional Victoria, before full-time locum work for the group. As a newly registered pharmacist, the opportunity to work in diverse types of community pharmacies in metropolitan and rural locations all over Victoria was invaluable.
What about the next step?I sent a message to the owner of the pharmacy closest to where I was living in Ballarat, offering my services as a weekend locum. After 18 months, the owners asked me to take charge of a new pharmacy in Bacchus Marsh. The opportunity to open and build up a new pharmacy, and move into management, was one I could not pass up – especially because it came with a future ownership opportunity. In January 2020, we opened Terry White Chemmart Maddingley, co-located with a medical centre, literally on the edge of a paddock. There are no other shops around it (yet) but it’s a big growth area. It has been a great first 18 months, but I would never recommend anyone open a new pharmacy 2 months before a global pandemic hit.
How has the pandemic changed the way you interact with consumers?I certainly hadn’t provided healthcare from behind a Perspex barrier before last year. Our pharmacy is unique in this respect as we don’t know anything pre-COVID. We opened 2 days after the very first case was recorded in Australia. We were also on the lucky side of the ring of steel. We were also in the first major town outside Melbourne’s COVID border. A number of consumers lived on the other side, so I wrote many letters for people, confirming they were customers and allowed to travel through the patrolled border. Another unexpected adjustment was finding the balance between yelling at customers, so they hear me through masks and shields, while ensuring privacy during medicines discussions.
Have there been any good changes from the pandemic?Absolutely! We have become so much more resilient and accessible in the way we deliver healthcare. We now offer a drive-through pick up service. Families regularly use it, so they stay with kids in the car; also those with cold and flu symptoms, and to mitigate risk from anyone who may have been tested for COVID at the clinic next door. Our home delivery service has had a massive uptake. Some days, 10–20% of our script volume is delivered directly to homes. One day recently we served more customers via delivery than in-store.
What precautions were taken to stay ahead of possibly infectious consumers?During the July lockdown, our largest local school and several local businesses became hotspots, and more than 1,000 families were forced to isolate. Our delivery service was useful with staff trained to be vigilant when delivering. They knocked, stood well away from the door, and asked, before approaching, if the person who answered was in isolation. We worked particularly with COVID-positive consumers to deliver medicines safely and securely. At the same time, people wanted to get vaccinated. We were inundated, but had not been given the go-ahead at that time. Thankfully, we have now started.
And the dream?I turned 30 in June. We started the buying- in process in July/August so I will be about 30 and a half when I officially sign on.
DAY IN THE LIFE of Lauren Haworth, Pharmacist in Charge at TerryWhite Chemmart, Maddingley, VIC.8.00 am – Open up Prepare for early morning before-school rush and complete any overnight orders via our app. Choose the store playlist. Pop or rock today? Hmm.... 9.30 am – Patient consulting
Speak with woman aged 30, with heavy, extended period bleeding. Prescribed Mefenamic Acid for 3–5 days per cycle, she is worried about impact on attempted conception. Discuss blood test results, indicating low iron levels and how to increase them via alternative dietary options. Doctor advised her to eat red meat, but she is a vegetarian. 11.30 am – Double checking
Deal with script, handed in by wife of man, 48, a week post-surgery who was discharged on oxycodone 5 mg 1 q4h prn and tapentadol IR 50 mg 1 up to QID prn. GP added a follow-on script for tapentadol SR 50 mg 2 TDS. I call doctor and confirm with her that script should have read 1 BD, because she wanted slow-release coverage with IR prn. I advise the patient.
Collaborate with GPs next door regarding new palliative care patient. Organise required medicines to go with afternoon delivery. We facilitate a lot of this on behalf of families of those patients to ensure to maximise family time and minimise stress. 4.30 pm – A first for me
Set up and dispense my first-ever script from the My Active Script List. Now patients will be less stressed about accidentally deleting repeat tokens and it will help make distanced healthcare (delivery or drive-through), particularly in a COVID-19 world, much easier. A momentous day! 6.00 pm – Cross your fingers
A patient on CPAP has called about the possibility of postponement of upcoming bariatric surgery. Her surgeon is concerned about her oxygen level drop during a pre-surgery sleep test. Recommend, with concurrence of surgeon, adding a pulse oximeter to her CPAP for a few days to test it. Set up oximeter and cross fingers and toes the surgery can proceed. She has waited long enough. 8.00 pm – Home and the dog
Time to shut up shop and head home. I love to take Murray, my beautiful Airedale Terrier, for a leisurely evening walk to round out my day.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.