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[post_content] => Pharmacists encounter pregnant and new mums more often than most health professionals, and can have a bird’s-eye view when things go awry.
At 20 weeks pregnant, PSA’s Queensland Pharmacist of the Year Jacqueline Meyer MPS, was diagnosed with intrauterine growth restriction, which severely impacted her fetal growth.
A few weeks later, she stopped working – effective immediately. ‘I was put on immediate bed rest, even though I felt fine,’ she says.
With her amniotic fluid diminished, Ms Meyer’s daughter, Fallon, was born at 28 weeks. Weighing only 520 grams, Fallon was placed in an incubator in the neonatal intensive care unit where she remained for the next 2 months.
Ms Meyer is one of thousands of women who experience pregnancy complications, including gestational diabetes mellitus (GDM), affecting 1 in 6 pregnant Australian women.1
Perinatal depression (PND) is another prevalent complication, affecting up to 1 in 5 expectant or new mothers.2
However, there are significant gaps in pregnancy and early childhood support
in Australia.
With GDM diagnoses doubled within a decade,3 many patients are forced to rely on group education classes, says Anna Barwick MPS, credentialed pharmacist, and founder of remote access telehealth advisory service PharmOnline. Meanwhile, suicide is the third-highest cause of death among new mothers in Australia.4
After her turbulent pregnancy, Ms Meyer thinks pharmacists can help to fill these gaps.
‘We can recognise red flags, direct patients where to seek help, and
provide emotional support about the importance of looking after your own health and nutrition.’
Medicine use in pregnancy
While ‘every woman’ wants to avoid exposing their unborn child to risks associated with taking medicines for chronic conditions such as epilepsy, inflammatory bowel disease and arthritis, those risks can sometimes be overestimated, says Noor Al-Adhami, Women’s and Newborn Pharmacy Team Leader at Brisbane’s Royal Brisbane and Women’s Hospital (RBWH).
‘A gap we often see in RBWH’s Maternity Outpatient Clinic is lack of discussions around safety of medicines prescribed for depression and anxiety in pregnancy and breastfeeding,’ she says.
‘This can lead to women stopping their medicines abruptly without discussing with their GP or midwife, resulting in a deterioration in mental health that can negatively impact maternal and fetal outcomes.’
Pharmacists are in a good position to provide support and information regarding the safety of medicines in pregnancy and to address any concerns in a non-judgemental manner.
‘Advice regarding safety of antidepressant medicines involves discussing the benefit of continuation/initiation on maternal health, including improved function and quality of life, as well as risk to the fetus, which evidence shows is minimal with appropriate antidepressants,’ says Ms Al-Adhami.
Health monitoring
While pregnancy is a short-term phase of life, significant ongoing effects can be experienced, particularly in children from pregnancies that are not well managed, says Ms Barwick.
‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.’
Gestational diabetes
When expectant mums are diagnosed with GDM, community pharmacists can walk them through the process of monitoring blood glucose levels (BGLs).
Where insulin is prescribed, pharmacists can inquire whether the dose is controlling blood glucose levels, and check their injection technique, says Ms Meyer.
The use of insulin, considered a high-risk medication with APINCHs classification,5 Ms Barwick notes, provides justification for a Home Medicines Review (HMR). ‘There’s an advantage to going into the home to observe the patient’s diet, consider potential interactions, and educate patients on the best effects and outcomes,’ she says.
Advice around cleaning blood glucose level (BGL) monitors to ensure accuracy can also be provided. ‘Pharmacists can explain how to put test drops through and clean blood spills on the monitor, common in pregnancy due to higher blood volume,’ says Ms Barwick.
With only 50% of women diagnosed with GDM receiving tests for heart disease and type 2 diabetes post-pregnancy,6 HMRs can be beneficial at this stage of the journey, too.
‘Along with conversations around diet choices, exercise regimes and sleep, I also explain how often testing is required over the next 5–10 years, and how to monitor for signs of the development of diabetes,’ Ms Barwick advises.
Nausea and vomiting in pregnancy
The presence of iron in pregnancy multivitamins may exacerbate symptoms of nausea and vomiting in some pregnancies, according to Ms Barwick.
‘Pharmacists can recommend a trial cessation of the iron component of pregnancy vitamins, often unnecessary in pregnancy,’ she says.
‘A simple change in vitamin to focus on iodine and folate can make a big difference.’ Ms Barwick says community pharmacists may also recommend over-the-counter medicines such as doxylamine for symptoms of nausea and vomiting in pregnancy (NVP), and monitor its effectiveness.
‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.'
ANNA BARWICK MPS
When women have symptoms of NVP, Ms Meyer points out that a family member might come into the pharmacy on their behalf if they are severely unwell.
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency, such as vomiting to the point of severe dehydration, heart palpitations, blurred vision and cramping.’
When ondansetron is prescribed, pharmacists can recommend easy-to-consume forms, such as sublingual wafers, she adds.
Preeclampsia
Pregnant women who present with new hypertension after 20 weeks should be screened for preeclampsia.7
Community and credentialed pharmacists can assist patients with monitoring blood pressure, and look out for signs of preeclampsia, such as sudden oedema and weight gain, says Ms Barwick.
‘Patients can also be taught how to use a home blood pressure monitor appropriately and record the results.
Women at high-risk of developing preeclampsia should consider treatment with low-dose aspirin,8 which can also be used to manage coagulation abnormalities in early pregnancy to prevent miscarriage.
‘A dose of around 75 mg has been shown to be effective for delivering a healthy baby, safely,’ notes Ms Barwick.9 Up to 150 mg can be used to prevent preeclampsia, she adds.10
Pharmacists should also keep a record of pregnant patients using aspirin to monitor for any potential adverse effects, such as bruising or bleeding.
‘While the risk of low-dose, aspirin-associated bleeding is low, reinforce the importance of looking out for any signs, either vaginal or rectal,’ Ms Barwick warns.
Vaccinations
Australia has ‘dismal’ antenatal vaccination rates, with 15% vaccinated against influenza, 27% against pertussis, and only 12% against both among more than 591,000 pregnancies analysed in a population-based linked cohort study of data between 2012–2017.11
COVID-19 vaccine hesitancy has also been detected among pregnant Australian women.12 Overall, there is a lack of understanding of the benefits of antenatal vaccination, including providing immunity to both baby and mother against serious respiratory infections, says Ms Al-Adhami. Reduced access to vaccines is also an issue, particularly among vulnerable populations, such as those with mental health problems, and Aboriginal and Torres Strait Islander peoples.
‘Once we identified some women were having difficulties accessing antenatal vaccinations in the community, we recognised an opportunity to extend our scope of practice and improve our service delivery within the clinic,’ she says.
This included credentialed training and the development of an opportunistic model of care, where ‘at-risk’ women were counselled and offered antenatal vaccinations during clinic visits.
‘Last year 546 vaccines were administered by our specialist antenatal pharmacists, adds Ms Al-Adhami.13
In Ms Meyer’s experience there has also been confusion among women about what vaccines are needed during pregnancy, and where to get them.
‘The states and territories all have different rules and regulations around who can provide National Immunisation Program (NIP) vaccines,’ she says.
With most jurisdictions now increasing the number of vaccines pharmacists can administer, this should be used as an opportunity to initiate conversations with pregnant women about vaccination.
‘Ensure the mother is well educated on what vaccines she, and other family members, should receive according to current guidelines,’ says Ms Meyer.
All about birthing on country[caption id="attachment_25937" align="alignnone" width="500"] In 2020, photographer Bobbi Lockyer created a Birthing on Country project to highlight and create awareness around birthing issues and outcomes in Aboriginal women. For more, see www.bobbilockyer.com[/caption]
Birthing on Country (BOC) is a holistic, integrated and culturally appropriate model of care, aimed at providing the best start in life for Aboriginal and Torres Strait Islander babies and their families.14 Broader than labour and delivery, BOC addresses socio-cultural and spiritual risk not dealt with through mainstream services.
Guiding principles for a BOC program include respect for and incorporation of the knowledge and traditional practice of Aboriginal and Torres Strait Islander peoples, incorporate a holistic definition of health, respect for family involvement, women’s business, connection with Country and continuity of culturally safe care.15 Aboriginal and Torres Strait Islander mothers are 3–5 times more likely to die in childbirth than other mothers. Their babies are almost twice as likely to die in the first year of life – often due to premature birth.16
With research revealing access to community-governed, culturally safe birthing services is linked to a reduced risk of premature birth,17 pharmacists can advocate for and support BOC models of care.
‘BOC is so much broader than where a mother births – it is a social justice movement and system-wide reform. It’s an opportunity to Close the Gap in life outcomes for mums and bubs by recognising the impact of colonisation and the benefits of returning childbirth services to Aboriginal and Torres Strait Island community control,’ says Alice Nugent MPS, Aboriginal Community Controlled Health Organisation Pharmacist. Although not available everywhere, BOC can still involve birthing in a local hospital with the presence of an Aboriginal or Torres Strait Islander midwife or support worker throughout a woman’s pregnancy, birthing and post-natal journey.
Once the baby is born, ongoing support is usually provided to the family, which may include cultural ceremonies for the mother and newborn. |
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency.' Jacqueline Meyer MPSInfant formulas Formula manufacturers commonly use marketing that may feed into parental anxieties in claiming their products can prevent fussiness, help with colic, or improve night-time sleep.22 Pharmacists can emphasise the ‘antibodies, immunoglobulins and health benefits’ that breast milk can provide, along with advice on ensuring milk quality is at optimum levels, says Ms Meyer. ‘The number one thing is to eat before you feed,’ she says. ‘Mothers should also have a wholesome, balanced diet full of fresh nutrients and vegetables, so nutritional intake is at a premium.’ While breastfeeding should be encouraged, pharmacists can also guide mothers around selecting the right formulas when breastfeeding is not possible, says Ms Meyer. ‘We get a lot of questions around milk-free or dairy-free alternatives due to rising concerns of allergies and intolerances,’ she says. Factors to consider include the baby’s age, digestive issues, peptide profiles, short- or long-chain formula requirements, or whether specific formulas need to be prescribed. Pharmacists should also enquire how formulas are tolerated over a trial period – which ones and for how long, any reactions such as refusal, any reflux-type symptoms, changes in stool colour, irritability and any difficulty settling, suggests Ms Meyer. ‘Just trialling the formula for one day is often not enough. A longer period of time is required to identify a true intolerance.’ Medicines and breastfeeding Another reason why mothers opt to stop breastfeeding is medicine use.27 Pharmacists can reassure patients that very small amounts of medicines generally pass through breast milk, says Ms Meyer. ‘Medicine should never be a reason to stop breastfeeding, unless specifically advised to do so.’ Pharmacists can also advise patients when to take their medicines. ‘If the medicine is taken multiple times a day, recommend taking it directly after a breastfeed, so it reaches peak concentration in between feeding cycles,’ she says.
‘If your mum or dad had perinatal mental ill health, you’re more likely to have mental ill-health issues later on.' Lily Pham MPS
What's ailing pregnant and new mums?
Pregnancy and the early stages of motherhood are fraught with discomfort.
In addition to nausea and vomiting, some common ailments in pregnancy include constipation and indigestion, says Ms Al-Adhami.
To overcome constipation, often due to hormone changes that slow down muscles in the bowel, patients should be advised to increase their fibre content by consuming fresh fruit and vegetables, wholemeal breads and breakfast cereals, nuts and legumes.
Supplements such as psyllium husks can also be introduced. As iron tablets can also cause constipation, pharmacists can suggest another product for a trial period.23
Antacids for indigestion are safe to use in pregnancy. Calcium-based formulations are preferable to aluminium-containing antacids.24
When the baby arrives, back pain, incontinence and repetitive strain injuries are common. For mild to moderate pain, paracetamol is considered a safe analgesic during lactation, with the dose transferred through breast milk estimated to be 6% – much smaller than a child’s dose.25 Ibuprofen is also considered to be compatible with breastfeeding.25
Pelvic floor exercises can help to address post-birth incontinence, along with avoidance of persistent heavy lifting, repetitive coughing and straining.26 |
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[post_content] => Nitazenes are becoming more common in the Australian illicit drug market, and are linked to an increasing number of overdoses and deaths.
Last week, nitazines were detected in samples related to a cluster of 20 overdoses in the New South Wales Nepean Blue Mountains local health district.
There have been 16 overdose deaths involving nitazenes in Victoria since 2021, prompting two coroners to recommend the implementation of drug checking services in the state.
[caption id="attachment_10405" align="alignright" width="300"]
Suzanne Nielsen MPS[/caption]
Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne, explains how this little-understood drug entered the market and why pharmacists need to rethink harm minimisation.
What’s the history of this synthetic opioid?
‘Nitazenes’ are a family of drugs. Substances within the class vary in potency, from lower in potency to significantly exceeding fentanyl’s strength.
After nitazenes were synthesised in the late 1950s, development of the opioid as a therapeutic product was abandoned after early testing revealed high rates of adverse effects – including severe respiratory depression.
In recent years, they have emerged as novel psychoactive substances, said Prof Nielsen.
‘Chemists who make illicit drugs [often] go back to drugs that didn't make it through the development pathway,’ she said.
These drugs are therefore not internationally controlled, meaning their manufacture and distribution is ‘not necessarily illegal’.
‘It takes a while for national and international regulations to catch up and make them controlled substances,’ added Prof Nielsen.
Most nitazenes that have been detected in Australia are also similar to, or stronger than fentanyl in potency.
But while the pharmacology and effects of fentanyl are well profiled, the same can’t be said about nitazenes.
‘There are very few studies [that provide] a good sense of exactly how strong they are, how they work and how long they last,’ she said. ‘We do know they're very strong and have other negative effects we haven't fully characterised yet.’
Where are nitazenes found?
Fentanyl and other novel synthetic opioids are commonly packaged and sold as substances such as oxycodone tablets, said Prof Nielsen.
‘Some people go online to find pharmaceuticals because they can be easier to access than through the healthcare system,’ she said. ‘Unless you're familiar with what to look for, these products look quite similar to pharmaceutical products.’
Some people, in the pursuit of a strong opioid, purchase nitazenes intentionally. But the majority of detections are in unintended purchases, when other substances are sought.
‘Sometimes [they are in] opioids such as heroin,’ said Prof Nielsen. ‘But we've seen detections in drugs being sold as ketamine, MDMA or other stimulants.’
These detections are cause for the most concern. ‘People seeking to use MDMA in a festival environment [likely] won't have any opioid tolerance, and will be very susceptible to an opioid overdose.’
Is Australia at risk of a nitazene epidemic?
Nitazenes are causing large ‘clusters of deaths’ in England, Scotland and Ireland – where fentanyl has yet to emerge in the illicit market. There are concerns among addiction experts that Australia could similarly skip over fentanyl and head straight into a nitazene wave, warned Prof Nielsen.
‘There have been reports that the amount of heroin manufactured is dropping off,’ she said. ‘With the Taliban shutting down poppy production, an 80–95% reduction in heroin availability is expected.’
Programs such as real-time prescription monitoring and a tightening of regulations have also contributed to a ‘supply shock’ – which is historically associated with the entrance of potent substances into drug markets, said Prof Nielsen.
With drug checking not widely accessible in Australia, it’s possible there are more nitazenes out there than we know.
‘Given overdose deaths have gone up fairly quickly in other parts of the world where these drugs have emerged, now is the time to raise the alarm.’
What can pharmacists do to help?
With drugs such as MDMA or ketamine containing nitazenes, pharmacists need to broaden their approach to harm reduction, said Prof Nielsen.
This includes anticipating requests for take-home naloxone (THN) from people who use drugs occasionally who have heard about the synthetic opioid – which should always be met with a positive response.
Pharmacists could say, ‘it’s great you're asking for naloxone. I'm happy to provide it for you’, said Prof Nielsen.
Follow-up questions could include:
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[post_content] => Queenslanders are set to have greater access to high-quality, primary healthcare services from today (24 April 2024) under the state government’s Community Pharmacy Scope of Practice Pilot.
Under the Pilot, trained pharmacists will be able to prescribe for a range of common conditions and better support patients with medication management through therapeutic adaptation and substitution, and continued dispensing.
PSA Queensland President Shane MacDonald welcomed Health Minister Shannon Fentiman’s announcement today in Cairns.
‘The 2020 election commitment to work with PSA, the Pharmacy Guild of Australia, and other stakeholders to implement this Pilot is finally being realised,’ he said.
‘It has been a long journey, and we thank the government for the collaborating with the profession to execute this important work.
‘We must also acknowledge the pioneering pharmacists who, amidst their professional workload and family responsibilities, have dedicated themselves to undertake the extensive education program required to participate.’
Queensland is already leading the nation on pharmacist vaccination scope, delivering more vaccines to more patients, and improving vaccine coverage across the state, said Mr MacDonald.
‘This is a vote of confidence from the Queensland Government in the skills and expertise of our pharmacists to continue delivering safe and accessible primary health care to Queenslanders,’ he said.
‘Empowering pharmacists to manage common acute conditions and better support chronic disease management in community pharmacies is a progressive step towards enhancing healthcare accessibility. Piloting this initiative in Queensland will pave the way for nation-wide impact.’
Pharmacists are already getting involved
Queensland PSA Branch Committee member and Pharmacy Partner at LiveLife Pharmacy Macrossan Street (Port Douglas), James Buckley is one of the first pharmacists to complete the training and be authorised to participate.
‘I am really excited to be able to support my local community to have better access to care. Pharmacists are so accessible and our pharmacies are open late and on weekends. It just makes sense to use us to the top of our scope.’
PSA is currently working with the government to become an approved training provider to support the state-wide roll out of the Pilot.
Pilot services
Pharmacists who are approved participate in the Pilot are able to provide additional services that can be grouped into three categories:
1. Medication management services including therapeutic adaptation, therapeutic substitution and continued dispensing.
2. Autonomous prescribing for specified acute common conditions and health and wellbeing services:
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[post_content] => We’ve passed the halfway mark in the CPD year. Top up your credits and develop the most sought-after pharmacy skills by completing these CPD activities.
In a changing social and healthcare landscape – including fears around opioid overdoses, the rise of injectable medicines and new treatments for chronic pain – pharmacists need to keep on top of trends and education to best serve their communities.
AP outlines the most clicked-on CPD articles over the last 12 months and why you should complete them – along with a few other ways to score credits before the CPD year ends.
1. Disposal of Schedule 8 medicines
Did you know that different dose forms of Schedule 8 medicines need to be disposed of in different ways? Or that requirements for authorised witnesses for destruction of Schedule 8 medicines by pharmacists vary per jurisdiction?
All pharmacists must familiarise themselves with local legislation and best practice guidelines for the correct process for disposal of Schedule 8 medicines.
This helpful CPD article summarises environmental and safety considerations, destruction recommendations and considerations for legislative requirements for disposal of Schedule 8 medicines.
2. How to save a life with naloxone
Opioid overdose deaths in Australia have continued to rise. According to Australia’s Annual Overdose Report by the Pennington Institute, unintentional drug overdose deaths have skyrocketed by 71% in 20 years (2001–2021).
Opioids are the drugs most commonly involved in poly-substance deaths (81%).
With experts warning of an impending influx of synthetic opioids into Australia's illicit drug market and the Take-Home Naloxone program now national – all pharmacists should know how to supply and administer this life-saving medicine.
By undertaking PSA’s How to save a life with naloxone CPD article, pharmacists will learn how to effectively counsel patients on using the medicine, learn the key points of the Take Home Naloxone (THN) program and how to provide support and advice to people who use opioids, their peers, and family – all of which can have a significant impact on reducing the number of lives lost.
3. B12 deficiency
The raft of scope of practice changes that continue to occur across Australian states and territories has meant many pharmacists are able to administer medicines by injection (if suitably trained) – such as intramuscular vitamin B12.
Vitamin B12 deficiency can cause serious haematological, neurological, and psychiatric problems – early detection and treatment may reverse and minimise harms. This CPD article will help pharmacists identify and refer patients with possible deficiency, advise on suitable treatments, and know when administration of intramuscular vitamin B12 treatment is appropriate.
4. Cannabis drug interactions
The Australian Institute of Health and Welfare estimates 600,000 Australians use cannabis for medicinal purposes. This is a dramatic uptick from the 2,560 medicinal cannabis prescriptions approved through Therapeutic Goods Administration’s (TGA) Special Access Scheme (SAS) in 2018. In fact, last year there were 132,000 SAS-B applications approved by the TGA from 2,565 medical practitioners.
This CPD article explains the common mechanisms whereby medicinal cannabis may interact with other medicines, and the role of the pharmacist in reviewing and identifying these interactions.
5. Immediate-release melatonin for jet lag
Melatonin is now a schedule 3 medicine for Australians aged 55 years of age or older with primary insomnia with poor sleep quality, and for those aged 18 or older to treat jet lag.
But do you know when melatonin should be taken to stave off jet lag, or its potential adverse effects and drug interactions? There are also several non-pharmacological options to treat jet lag that pharmacists should also be across. Pharmacists can access all this information and more in PSA’s Immediate-release melatonin for jet lag article.
How else can I gain CPD credits?
Prefer to rack up your CPD credits in other ways? If networking with other healthcare professionals while gaining knowledge from the industry's top thought leaders is more your thing, AP has rounded up the top up-coming conferences to attend:
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[post_content] => Influenza is one of the most common vaccine-preventable diseases in Australia. While reported cases are significantly higher than what they were this time last year, vaccination rates are slipping.
There were 30,404 reported cases of influenza from January–March this year, compared to 18,584 during the same time period last year. With 39,230 cases reported to date in 2024, there has been a significant spike in cases over the last few weeks.
As we approach World Immunisation Week (24–30 April 2024), here’s how pharmacists can help to protect the community this season.
Children are undervaccinated and frequently hospitalised. How can this cohort be reached?
In 2023, influenza notifications were highest in children aged 5–9 years old, with hospitalisations peaking in those 15 years of age or younger. Yet the 5–15 age group is the most under-vaccinated cohort, with vaccination rates sitting at only 16% for 2023.
Vaccination rates among children aged 6 months to 5 years of age have been startlingly low post-COVID pandemic (28.3% in 2023), despite the considerable risk to this age group, said Dr Eden Mifsud, Medical Science Liaison, Influenza Vaccines Medical Affairs, at CSL Seqirus in the PSA webinar Influenza 2024 – The Right Vaccine for the Right Patient, held on 17 April 2024.
So how can pharmacists approach this conversation with parents and carers? Firstly, you can remind them that the influenza vaccine is covered under the NIP for children aged 6 months to 5 years because they are susceptible to severe disease associated with influenza, and death.
Making vaccination more accessible for patients aged 5–15 can be achieved by scheduling and promoting after-school vaccination, said webinar co-host Peter Guthrey MPS, PSA Senior Pharmacist, Strategic Policy.
While parents may be hesitant to administer vaccines on a school night due to concern about adverse effects, pharmacists can reassure them that adverse events from influenza vaccines are relatively low compared to other vaccines, said Mr Guthrey.
‘Booking the whole family for the flu vaccine, school holiday or after-school appointments can be a powerful way to help people engage in vaccination,’ he said. ‘Parents are looking to protect the health of their children in a way that doesn't disrupt the routine.’
What are the new ATAGI recommendations in 2024?
There have been a number of updates included in the Australian Technical Advisory Group on Immunisation (ATAGI) advice regarding the administration of 2024 seasonal influenza vaccines.
This year, ATAGI recommends pregnant women who received an influenza vaccine in 2023 receive the 2024 influenza vaccine if available before the end of their pregnancy, said Dr Mifsud.
‘We know antibodies can be passed through the placenta, and these antibodies can also be passed on if the woman chooses to breastfeed,’ she said. ‘That means those maternal antibodies can protect the infant for the first 6 months of its life.’
Another change to the ATAGI recommendations this year is the inclusion of conditions that increase the risk of severe influenza that are not attached to NIP funding eligibility, including:
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[post_content] => Pharmacists encounter pregnant and new mums more often than most health professionals, and can have a bird’s-eye view when things go awry.
At 20 weeks pregnant, PSA’s Queensland Pharmacist of the Year Jacqueline Meyer MPS, was diagnosed with intrauterine growth restriction, which severely impacted her fetal growth.
A few weeks later, she stopped working – effective immediately. ‘I was put on immediate bed rest, even though I felt fine,’ she says.
With her amniotic fluid diminished, Ms Meyer’s daughter, Fallon, was born at 28 weeks. Weighing only 520 grams, Fallon was placed in an incubator in the neonatal intensive care unit where she remained for the next 2 months.
Ms Meyer is one of thousands of women who experience pregnancy complications, including gestational diabetes mellitus (GDM), affecting 1 in 6 pregnant Australian women.1
Perinatal depression (PND) is another prevalent complication, affecting up to 1 in 5 expectant or new mothers.2
However, there are significant gaps in pregnancy and early childhood support
in Australia.
With GDM diagnoses doubled within a decade,3 many patients are forced to rely on group education classes, says Anna Barwick MPS, credentialed pharmacist, and founder of remote access telehealth advisory service PharmOnline. Meanwhile, suicide is the third-highest cause of death among new mothers in Australia.4
After her turbulent pregnancy, Ms Meyer thinks pharmacists can help to fill these gaps.
‘We can recognise red flags, direct patients where to seek help, and
provide emotional support about the importance of looking after your own health and nutrition.’
Medicine use in pregnancy
While ‘every woman’ wants to avoid exposing their unborn child to risks associated with taking medicines for chronic conditions such as epilepsy, inflammatory bowel disease and arthritis, those risks can sometimes be overestimated, says Noor Al-Adhami, Women’s and Newborn Pharmacy Team Leader at Brisbane’s Royal Brisbane and Women’s Hospital (RBWH).
‘A gap we often see in RBWH’s Maternity Outpatient Clinic is lack of discussions around safety of medicines prescribed for depression and anxiety in pregnancy and breastfeeding,’ she says.
‘This can lead to women stopping their medicines abruptly without discussing with their GP or midwife, resulting in a deterioration in mental health that can negatively impact maternal and fetal outcomes.’
Pharmacists are in a good position to provide support and information regarding the safety of medicines in pregnancy and to address any concerns in a non-judgemental manner.
‘Advice regarding safety of antidepressant medicines involves discussing the benefit of continuation/initiation on maternal health, including improved function and quality of life, as well as risk to the fetus, which evidence shows is minimal with appropriate antidepressants,’ says Ms Al-Adhami.
Health monitoring
While pregnancy is a short-term phase of life, significant ongoing effects can be experienced, particularly in children from pregnancies that are not well managed, says Ms Barwick.
‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.’
Gestational diabetes
When expectant mums are diagnosed with GDM, community pharmacists can walk them through the process of monitoring blood glucose levels (BGLs).
Where insulin is prescribed, pharmacists can inquire whether the dose is controlling blood glucose levels, and check their injection technique, says Ms Meyer.
The use of insulin, considered a high-risk medication with APINCHs classification,5 Ms Barwick notes, provides justification for a Home Medicines Review (HMR). ‘There’s an advantage to going into the home to observe the patient’s diet, consider potential interactions, and educate patients on the best effects and outcomes,’ she says.
Advice around cleaning blood glucose level (BGL) monitors to ensure accuracy can also be provided. ‘Pharmacists can explain how to put test drops through and clean blood spills on the monitor, common in pregnancy due to higher blood volume,’ says Ms Barwick.
With only 50% of women diagnosed with GDM receiving tests for heart disease and type 2 diabetes post-pregnancy,6 HMRs can be beneficial at this stage of the journey, too.
‘Along with conversations around diet choices, exercise regimes and sleep, I also explain how often testing is required over the next 5–10 years, and how to monitor for signs of the development of diabetes,’ Ms Barwick advises.
Nausea and vomiting in pregnancy
The presence of iron in pregnancy multivitamins may exacerbate symptoms of nausea and vomiting in some pregnancies, according to Ms Barwick.
‘Pharmacists can recommend a trial cessation of the iron component of pregnancy vitamins, often unnecessary in pregnancy,’ she says.
‘A simple change in vitamin to focus on iodine and folate can make a big difference.’ Ms Barwick says community pharmacists may also recommend over-the-counter medicines such as doxylamine for symptoms of nausea and vomiting in pregnancy (NVP), and monitor its effectiveness.
‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.'
ANNA BARWICK MPS
When women have symptoms of NVP, Ms Meyer points out that a family member might come into the pharmacy on their behalf if they are severely unwell.
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency, such as vomiting to the point of severe dehydration, heart palpitations, blurred vision and cramping.’
When ondansetron is prescribed, pharmacists can recommend easy-to-consume forms, such as sublingual wafers, she adds.
Preeclampsia
Pregnant women who present with new hypertension after 20 weeks should be screened for preeclampsia.7
Community and credentialed pharmacists can assist patients with monitoring blood pressure, and look out for signs of preeclampsia, such as sudden oedema and weight gain, says Ms Barwick.
‘Patients can also be taught how to use a home blood pressure monitor appropriately and record the results.
Women at high-risk of developing preeclampsia should consider treatment with low-dose aspirin,8 which can also be used to manage coagulation abnormalities in early pregnancy to prevent miscarriage.
‘A dose of around 75 mg has been shown to be effective for delivering a healthy baby, safely,’ notes Ms Barwick.9 Up to 150 mg can be used to prevent preeclampsia, she adds.10
Pharmacists should also keep a record of pregnant patients using aspirin to monitor for any potential adverse effects, such as bruising or bleeding.
‘While the risk of low-dose, aspirin-associated bleeding is low, reinforce the importance of looking out for any signs, either vaginal or rectal,’ Ms Barwick warns.
Vaccinations
Australia has ‘dismal’ antenatal vaccination rates, with 15% vaccinated against influenza, 27% against pertussis, and only 12% against both among more than 591,000 pregnancies analysed in a population-based linked cohort study of data between 2012–2017.11
COVID-19 vaccine hesitancy has also been detected among pregnant Australian women.12 Overall, there is a lack of understanding of the benefits of antenatal vaccination, including providing immunity to both baby and mother against serious respiratory infections, says Ms Al-Adhami. Reduced access to vaccines is also an issue, particularly among vulnerable populations, such as those with mental health problems, and Aboriginal and Torres Strait Islander peoples.
‘Once we identified some women were having difficulties accessing antenatal vaccinations in the community, we recognised an opportunity to extend our scope of practice and improve our service delivery within the clinic,’ she says.
This included credentialed training and the development of an opportunistic model of care, where ‘at-risk’ women were counselled and offered antenatal vaccinations during clinic visits.
‘Last year 546 vaccines were administered by our specialist antenatal pharmacists, adds Ms Al-Adhami.13
In Ms Meyer’s experience there has also been confusion among women about what vaccines are needed during pregnancy, and where to get them.
‘The states and territories all have different rules and regulations around who can provide National Immunisation Program (NIP) vaccines,’ she says.
With most jurisdictions now increasing the number of vaccines pharmacists can administer, this should be used as an opportunity to initiate conversations with pregnant women about vaccination.
‘Ensure the mother is well educated on what vaccines she, and other family members, should receive according to current guidelines,’ says Ms Meyer.
All about birthing on country[caption id="attachment_25937" align="alignnone" width="500"] In 2020, photographer Bobbi Lockyer created a Birthing on Country project to highlight and create awareness around birthing issues and outcomes in Aboriginal women. For more, see www.bobbilockyer.com[/caption]
Birthing on Country (BOC) is a holistic, integrated and culturally appropriate model of care, aimed at providing the best start in life for Aboriginal and Torres Strait Islander babies and their families.14 Broader than labour and delivery, BOC addresses socio-cultural and spiritual risk not dealt with through mainstream services.
Guiding principles for a BOC program include respect for and incorporation of the knowledge and traditional practice of Aboriginal and Torres Strait Islander peoples, incorporate a holistic definition of health, respect for family involvement, women’s business, connection with Country and continuity of culturally safe care.15 Aboriginal and Torres Strait Islander mothers are 3–5 times more likely to die in childbirth than other mothers. Their babies are almost twice as likely to die in the first year of life – often due to premature birth.16
With research revealing access to community-governed, culturally safe birthing services is linked to a reduced risk of premature birth,17 pharmacists can advocate for and support BOC models of care.
‘BOC is so much broader than where a mother births – it is a social justice movement and system-wide reform. It’s an opportunity to Close the Gap in life outcomes for mums and bubs by recognising the impact of colonisation and the benefits of returning childbirth services to Aboriginal and Torres Strait Island community control,’ says Alice Nugent MPS, Aboriginal Community Controlled Health Organisation Pharmacist. Although not available everywhere, BOC can still involve birthing in a local hospital with the presence of an Aboriginal or Torres Strait Islander midwife or support worker throughout a woman’s pregnancy, birthing and post-natal journey.
Once the baby is born, ongoing support is usually provided to the family, which may include cultural ceremonies for the mother and newborn. |
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency.' Jacqueline Meyer MPSInfant formulas Formula manufacturers commonly use marketing that may feed into parental anxieties in claiming their products can prevent fussiness, help with colic, or improve night-time sleep.22 Pharmacists can emphasise the ‘antibodies, immunoglobulins and health benefits’ that breast milk can provide, along with advice on ensuring milk quality is at optimum levels, says Ms Meyer. ‘The number one thing is to eat before you feed,’ she says. ‘Mothers should also have a wholesome, balanced diet full of fresh nutrients and vegetables, so nutritional intake is at a premium.’ While breastfeeding should be encouraged, pharmacists can also guide mothers around selecting the right formulas when breastfeeding is not possible, says Ms Meyer. ‘We get a lot of questions around milk-free or dairy-free alternatives due to rising concerns of allergies and intolerances,’ she says. Factors to consider include the baby’s age, digestive issues, peptide profiles, short- or long-chain formula requirements, or whether specific formulas need to be prescribed. Pharmacists should also enquire how formulas are tolerated over a trial period – which ones and for how long, any reactions such as refusal, any reflux-type symptoms, changes in stool colour, irritability and any difficulty settling, suggests Ms Meyer. ‘Just trialling the formula for one day is often not enough. A longer period of time is required to identify a true intolerance.’ Medicines and breastfeeding Another reason why mothers opt to stop breastfeeding is medicine use.27 Pharmacists can reassure patients that very small amounts of medicines generally pass through breast milk, says Ms Meyer. ‘Medicine should never be a reason to stop breastfeeding, unless specifically advised to do so.’ Pharmacists can also advise patients when to take their medicines. ‘If the medicine is taken multiple times a day, recommend taking it directly after a breastfeed, so it reaches peak concentration in between feeding cycles,’ she says.
‘If your mum or dad had perinatal mental ill health, you’re more likely to have mental ill-health issues later on.' Lily Pham MPS
What's ailing pregnant and new mums?
Pregnancy and the early stages of motherhood are fraught with discomfort.
In addition to nausea and vomiting, some common ailments in pregnancy include constipation and indigestion, says Ms Al-Adhami.
To overcome constipation, often due to hormone changes that slow down muscles in the bowel, patients should be advised to increase their fibre content by consuming fresh fruit and vegetables, wholemeal breads and breakfast cereals, nuts and legumes.
Supplements such as psyllium husks can also be introduced. As iron tablets can also cause constipation, pharmacists can suggest another product for a trial period.23
Antacids for indigestion are safe to use in pregnancy. Calcium-based formulations are preferable to aluminium-containing antacids.24
When the baby arrives, back pain, incontinence and repetitive strain injuries are common. For mild to moderate pain, paracetamol is considered a safe analgesic during lactation, with the dose transferred through breast milk estimated to be 6% – much smaller than a child’s dose.25 Ibuprofen is also considered to be compatible with breastfeeding.25
Pelvic floor exercises can help to address post-birth incontinence, along with avoidance of persistent heavy lifting, repetitive coughing and straining.26 |
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[post_content] => Nitazenes are becoming more common in the Australian illicit drug market, and are linked to an increasing number of overdoses and deaths.
Last week, nitazines were detected in samples related to a cluster of 20 overdoses in the New South Wales Nepean Blue Mountains local health district.
There have been 16 overdose deaths involving nitazenes in Victoria since 2021, prompting two coroners to recommend the implementation of drug checking services in the state.
[caption id="attachment_10405" align="alignright" width="300"] Suzanne Nielsen MPS[/caption]
Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne, explains how this little-understood drug entered the market and why pharmacists need to rethink harm minimisation.
What’s the history of this synthetic opioid?
‘Nitazenes’ are a family of drugs. Substances within the class vary in potency, from lower in potency to significantly exceeding fentanyl’s strength.
After nitazenes were synthesised in the late 1950s, development of the opioid as a therapeutic product was abandoned after early testing revealed high rates of adverse effects – including severe respiratory depression.
In recent years, they have emerged as novel psychoactive substances, said Prof Nielsen.
‘Chemists who make illicit drugs [often] go back to drugs that didn't make it through the development pathway,’ she said.
These drugs are therefore not internationally controlled, meaning their manufacture and distribution is ‘not necessarily illegal’.
‘It takes a while for national and international regulations to catch up and make them controlled substances,’ added Prof Nielsen.
Most nitazenes that have been detected in Australia are also similar to, or stronger than fentanyl in potency.
But while the pharmacology and effects of fentanyl are well profiled, the same can’t be said about nitazenes.
‘There are very few studies [that provide] a good sense of exactly how strong they are, how they work and how long they last,’ she said. ‘We do know they're very strong and have other negative effects we haven't fully characterised yet.’
Where are nitazenes found?
Fentanyl and other novel synthetic opioids are commonly packaged and sold as substances such as oxycodone tablets, said Prof Nielsen.
‘Some people go online to find pharmaceuticals because they can be easier to access than through the healthcare system,’ she said. ‘Unless you're familiar with what to look for, these products look quite similar to pharmaceutical products.’
Some people, in the pursuit of a strong opioid, purchase nitazenes intentionally. But the majority of detections are in unintended purchases, when other substances are sought.
‘Sometimes [they are in] opioids such as heroin,’ said Prof Nielsen. ‘But we've seen detections in drugs being sold as ketamine, MDMA or other stimulants.’
These detections are cause for the most concern. ‘People seeking to use MDMA in a festival environment [likely] won't have any opioid tolerance, and will be very susceptible to an opioid overdose.’
Is Australia at risk of a nitazene epidemic?
Nitazenes are causing large ‘clusters of deaths’ in England, Scotland and Ireland – where fentanyl has yet to emerge in the illicit market. There are concerns among addiction experts that Australia could similarly skip over fentanyl and head straight into a nitazene wave, warned Prof Nielsen.
‘There have been reports that the amount of heroin manufactured is dropping off,’ she said. ‘With the Taliban shutting down poppy production, an 80–95% reduction in heroin availability is expected.’
Programs such as real-time prescription monitoring and a tightening of regulations have also contributed to a ‘supply shock’ – which is historically associated with the entrance of potent substances into drug markets, said Prof Nielsen.
With drug checking not widely accessible in Australia, it’s possible there are more nitazenes out there than we know.
‘Given overdose deaths have gone up fairly quickly in other parts of the world where these drugs have emerged, now is the time to raise the alarm.’
What can pharmacists do to help?
With drugs such as MDMA or ketamine containing nitazenes, pharmacists need to broaden their approach to harm reduction, said Prof Nielsen.
This includes anticipating requests for take-home naloxone (THN) from people who use drugs occasionally who have heard about the synthetic opioid – which should always be met with a positive response.
Pharmacists could say, ‘it’s great you're asking for naloxone. I'm happy to provide it for you’, said Prof Nielsen.
Follow-up questions could include:
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[post_content] => Queenslanders are set to have greater access to high-quality, primary healthcare services from today (24 April 2024) under the state government’s Community Pharmacy Scope of Practice Pilot.
Under the Pilot, trained pharmacists will be able to prescribe for a range of common conditions and better support patients with medication management through therapeutic adaptation and substitution, and continued dispensing.
PSA Queensland President Shane MacDonald welcomed Health Minister Shannon Fentiman’s announcement today in Cairns.
‘The 2020 election commitment to work with PSA, the Pharmacy Guild of Australia, and other stakeholders to implement this Pilot is finally being realised,’ he said.
‘It has been a long journey, and we thank the government for the collaborating with the profession to execute this important work.
‘We must also acknowledge the pioneering pharmacists who, amidst their professional workload and family responsibilities, have dedicated themselves to undertake the extensive education program required to participate.’
Queensland is already leading the nation on pharmacist vaccination scope, delivering more vaccines to more patients, and improving vaccine coverage across the state, said Mr MacDonald.
‘This is a vote of confidence from the Queensland Government in the skills and expertise of our pharmacists to continue delivering safe and accessible primary health care to Queenslanders,’ he said.
‘Empowering pharmacists to manage common acute conditions and better support chronic disease management in community pharmacies is a progressive step towards enhancing healthcare accessibility. Piloting this initiative in Queensland will pave the way for nation-wide impact.’
Pharmacists are already getting involved
Queensland PSA Branch Committee member and Pharmacy Partner at LiveLife Pharmacy Macrossan Street (Port Douglas), James Buckley is one of the first pharmacists to complete the training and be authorised to participate.
‘I am really excited to be able to support my local community to have better access to care. Pharmacists are so accessible and our pharmacies are open late and on weekends. It just makes sense to use us to the top of our scope.’
PSA is currently working with the government to become an approved training provider to support the state-wide roll out of the Pilot.
Pilot services
Pharmacists who are approved participate in the Pilot are able to provide additional services that can be grouped into three categories:
1. Medication management services including therapeutic adaptation, therapeutic substitution and continued dispensing.
2. Autonomous prescribing for specified acute common conditions and health and wellbeing services:
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[post_content] => We’ve passed the halfway mark in the CPD year. Top up your credits and develop the most sought-after pharmacy skills by completing these CPD activities.
In a changing social and healthcare landscape – including fears around opioid overdoses, the rise of injectable medicines and new treatments for chronic pain – pharmacists need to keep on top of trends and education to best serve their communities.
AP outlines the most clicked-on CPD articles over the last 12 months and why you should complete them – along with a few other ways to score credits before the CPD year ends.
1. Disposal of Schedule 8 medicines
Did you know that different dose forms of Schedule 8 medicines need to be disposed of in different ways? Or that requirements for authorised witnesses for destruction of Schedule 8 medicines by pharmacists vary per jurisdiction?
All pharmacists must familiarise themselves with local legislation and best practice guidelines for the correct process for disposal of Schedule 8 medicines.
This helpful CPD article summarises environmental and safety considerations, destruction recommendations and considerations for legislative requirements for disposal of Schedule 8 medicines.
2. How to save a life with naloxone
Opioid overdose deaths in Australia have continued to rise. According to Australia’s Annual Overdose Report by the Pennington Institute, unintentional drug overdose deaths have skyrocketed by 71% in 20 years (2001–2021).
Opioids are the drugs most commonly involved in poly-substance deaths (81%).
With experts warning of an impending influx of synthetic opioids into Australia's illicit drug market and the Take-Home Naloxone program now national – all pharmacists should know how to supply and administer this life-saving medicine.
By undertaking PSA’s How to save a life with naloxone CPD article, pharmacists will learn how to effectively counsel patients on using the medicine, learn the key points of the Take Home Naloxone (THN) program and how to provide support and advice to people who use opioids, their peers, and family – all of which can have a significant impact on reducing the number of lives lost.
3. B12 deficiency
The raft of scope of practice changes that continue to occur across Australian states and territories has meant many pharmacists are able to administer medicines by injection (if suitably trained) – such as intramuscular vitamin B12.
Vitamin B12 deficiency can cause serious haematological, neurological, and psychiatric problems – early detection and treatment may reverse and minimise harms. This CPD article will help pharmacists identify and refer patients with possible deficiency, advise on suitable treatments, and know when administration of intramuscular vitamin B12 treatment is appropriate.
4. Cannabis drug interactions
The Australian Institute of Health and Welfare estimates 600,000 Australians use cannabis for medicinal purposes. This is a dramatic uptick from the 2,560 medicinal cannabis prescriptions approved through Therapeutic Goods Administration’s (TGA) Special Access Scheme (SAS) in 2018. In fact, last year there were 132,000 SAS-B applications approved by the TGA from 2,565 medical practitioners.
This CPD article explains the common mechanisms whereby medicinal cannabis may interact with other medicines, and the role of the pharmacist in reviewing and identifying these interactions.
5. Immediate-release melatonin for jet lag
Melatonin is now a schedule 3 medicine for Australians aged 55 years of age or older with primary insomnia with poor sleep quality, and for those aged 18 or older to treat jet lag.
But do you know when melatonin should be taken to stave off jet lag, or its potential adverse effects and drug interactions? There are also several non-pharmacological options to treat jet lag that pharmacists should also be across. Pharmacists can access all this information and more in PSA’s Immediate-release melatonin for jet lag article.
How else can I gain CPD credits?
Prefer to rack up your CPD credits in other ways? If networking with other healthcare professionals while gaining knowledge from the industry's top thought leaders is more your thing, AP has rounded up the top up-coming conferences to attend:
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[post_content] => Influenza is one of the most common vaccine-preventable diseases in Australia. While reported cases are significantly higher than what they were this time last year, vaccination rates are slipping.
There were 30,404 reported cases of influenza from January–March this year, compared to 18,584 during the same time period last year. With 39,230 cases reported to date in 2024, there has been a significant spike in cases over the last few weeks.
As we approach World Immunisation Week (24–30 April 2024), here’s how pharmacists can help to protect the community this season.
Children are undervaccinated and frequently hospitalised. How can this cohort be reached?
In 2023, influenza notifications were highest in children aged 5–9 years old, with hospitalisations peaking in those 15 years of age or younger. Yet the 5–15 age group is the most under-vaccinated cohort, with vaccination rates sitting at only 16% for 2023.
Vaccination rates among children aged 6 months to 5 years of age have been startlingly low post-COVID pandemic (28.3% in 2023), despite the considerable risk to this age group, said Dr Eden Mifsud, Medical Science Liaison, Influenza Vaccines Medical Affairs, at CSL Seqirus in the PSA webinar Influenza 2024 – The Right Vaccine for the Right Patient, held on 17 April 2024.
So how can pharmacists approach this conversation with parents and carers? Firstly, you can remind them that the influenza vaccine is covered under the NIP for children aged 6 months to 5 years because they are susceptible to severe disease associated with influenza, and death.
Making vaccination more accessible for patients aged 5–15 can be achieved by scheduling and promoting after-school vaccination, said webinar co-host Peter Guthrey MPS, PSA Senior Pharmacist, Strategic Policy.
While parents may be hesitant to administer vaccines on a school night due to concern about adverse effects, pharmacists can reassure them that adverse events from influenza vaccines are relatively low compared to other vaccines, said Mr Guthrey.
‘Booking the whole family for the flu vaccine, school holiday or after-school appointments can be a powerful way to help people engage in vaccination,’ he said. ‘Parents are looking to protect the health of their children in a way that doesn't disrupt the routine.’
What are the new ATAGI recommendations in 2024?
There have been a number of updates included in the Australian Technical Advisory Group on Immunisation (ATAGI) advice regarding the administration of 2024 seasonal influenza vaccines.
This year, ATAGI recommends pregnant women who received an influenza vaccine in 2023 receive the 2024 influenza vaccine if available before the end of their pregnancy, said Dr Mifsud.
‘We know antibodies can be passed through the placenta, and these antibodies can also be passed on if the woman chooses to breastfeed,’ she said. ‘That means those maternal antibodies can protect the infant for the first 6 months of its life.’
Another change to the ATAGI recommendations this year is the inclusion of conditions that increase the risk of severe influenza that are not attached to NIP funding eligibility, including:
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[post_content] => Pharmacists encounter pregnant and new mums more often than most health professionals, and can have a bird’s-eye view when things go awry.
At 20 weeks pregnant, PSA’s Queensland Pharmacist of the Year Jacqueline Meyer MPS, was diagnosed with intrauterine growth restriction, which severely impacted her fetal growth.
A few weeks later, she stopped working – effective immediately. ‘I was put on immediate bed rest, even though I felt fine,’ she says.
With her amniotic fluid diminished, Ms Meyer’s daughter, Fallon, was born at 28 weeks. Weighing only 520 grams, Fallon was placed in an incubator in the neonatal intensive care unit where she remained for the next 2 months.
Ms Meyer is one of thousands of women who experience pregnancy complications, including gestational diabetes mellitus (GDM), affecting 1 in 6 pregnant Australian women.1
Perinatal depression (PND) is another prevalent complication, affecting up to 1 in 5 expectant or new mothers.2
However, there are significant gaps in pregnancy and early childhood support
in Australia.
With GDM diagnoses doubled within a decade,3 many patients are forced to rely on group education classes, says Anna Barwick MPS, credentialed pharmacist, and founder of remote access telehealth advisory service PharmOnline. Meanwhile, suicide is the third-highest cause of death among new mothers in Australia.4
After her turbulent pregnancy, Ms Meyer thinks pharmacists can help to fill these gaps.
‘We can recognise red flags, direct patients where to seek help, and
provide emotional support about the importance of looking after your own health and nutrition.’
Medicine use in pregnancy
While ‘every woman’ wants to avoid exposing their unborn child to risks associated with taking medicines for chronic conditions such as epilepsy, inflammatory bowel disease and arthritis, those risks can sometimes be overestimated, says Noor Al-Adhami, Women’s and Newborn Pharmacy Team Leader at Brisbane’s Royal Brisbane and Women’s Hospital (RBWH).
‘A gap we often see in RBWH’s Maternity Outpatient Clinic is lack of discussions around safety of medicines prescribed for depression and anxiety in pregnancy and breastfeeding,’ she says.
‘This can lead to women stopping their medicines abruptly without discussing with their GP or midwife, resulting in a deterioration in mental health that can negatively impact maternal and fetal outcomes.’
Pharmacists are in a good position to provide support and information regarding the safety of medicines in pregnancy and to address any concerns in a non-judgemental manner.
‘Advice regarding safety of antidepressant medicines involves discussing the benefit of continuation/initiation on maternal health, including improved function and quality of life, as well as risk to the fetus, which evidence shows is minimal with appropriate antidepressants,’ says Ms Al-Adhami.
Health monitoring
While pregnancy is a short-term phase of life, significant ongoing effects can be experienced, particularly in children from pregnancies that are not well managed, says Ms Barwick.
‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.’
Gestational diabetes
When expectant mums are diagnosed with GDM, community pharmacists can walk them through the process of monitoring blood glucose levels (BGLs).
Where insulin is prescribed, pharmacists can inquire whether the dose is controlling blood glucose levels, and check their injection technique, says Ms Meyer.
The use of insulin, considered a high-risk medication with APINCHs classification,5 Ms Barwick notes, provides justification for a Home Medicines Review (HMR). ‘There’s an advantage to going into the home to observe the patient’s diet, consider potential interactions, and educate patients on the best effects and outcomes,’ she says.
Advice around cleaning blood glucose level (BGL) monitors to ensure accuracy can also be provided. ‘Pharmacists can explain how to put test drops through and clean blood spills on the monitor, common in pregnancy due to higher blood volume,’ says Ms Barwick.
With only 50% of women diagnosed with GDM receiving tests for heart disease and type 2 diabetes post-pregnancy,6 HMRs can be beneficial at this stage of the journey, too.
‘Along with conversations around diet choices, exercise regimes and sleep, I also explain how often testing is required over the next 5–10 years, and how to monitor for signs of the development of diabetes,’ Ms Barwick advises.
Nausea and vomiting in pregnancy
The presence of iron in pregnancy multivitamins may exacerbate symptoms of nausea and vomiting in some pregnancies, according to Ms Barwick.
‘Pharmacists can recommend a trial cessation of the iron component of pregnancy vitamins, often unnecessary in pregnancy,’ she says.
‘A simple change in vitamin to focus on iodine and folate can make a big difference.’ Ms Barwick says community pharmacists may also recommend over-the-counter medicines such as doxylamine for symptoms of nausea and vomiting in pregnancy (NVP), and monitor its effectiveness.
‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.'
ANNA BARWICK MPS
When women have symptoms of NVP, Ms Meyer points out that a family member might come into the pharmacy on their behalf if they are severely unwell.
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency, such as vomiting to the point of severe dehydration, heart palpitations, blurred vision and cramping.’
When ondansetron is prescribed, pharmacists can recommend easy-to-consume forms, such as sublingual wafers, she adds.
Preeclampsia
Pregnant women who present with new hypertension after 20 weeks should be screened for preeclampsia.7
Community and credentialed pharmacists can assist patients with monitoring blood pressure, and look out for signs of preeclampsia, such as sudden oedema and weight gain, says Ms Barwick.
‘Patients can also be taught how to use a home blood pressure monitor appropriately and record the results.
Women at high-risk of developing preeclampsia should consider treatment with low-dose aspirin,8 which can also be used to manage coagulation abnormalities in early pregnancy to prevent miscarriage.
‘A dose of around 75 mg has been shown to be effective for delivering a healthy baby, safely,’ notes Ms Barwick.9 Up to 150 mg can be used to prevent preeclampsia, she adds.10
Pharmacists should also keep a record of pregnant patients using aspirin to monitor for any potential adverse effects, such as bruising or bleeding.
‘While the risk of low-dose, aspirin-associated bleeding is low, reinforce the importance of looking out for any signs, either vaginal or rectal,’ Ms Barwick warns.
Vaccinations
Australia has ‘dismal’ antenatal vaccination rates, with 15% vaccinated against influenza, 27% against pertussis, and only 12% against both among more than 591,000 pregnancies analysed in a population-based linked cohort study of data between 2012–2017.11
COVID-19 vaccine hesitancy has also been detected among pregnant Australian women.12 Overall, there is a lack of understanding of the benefits of antenatal vaccination, including providing immunity to both baby and mother against serious respiratory infections, says Ms Al-Adhami. Reduced access to vaccines is also an issue, particularly among vulnerable populations, such as those with mental health problems, and Aboriginal and Torres Strait Islander peoples.
‘Once we identified some women were having difficulties accessing antenatal vaccinations in the community, we recognised an opportunity to extend our scope of practice and improve our service delivery within the clinic,’ she says.
This included credentialed training and the development of an opportunistic model of care, where ‘at-risk’ women were counselled and offered antenatal vaccinations during clinic visits.
‘Last year 546 vaccines were administered by our specialist antenatal pharmacists, adds Ms Al-Adhami.13
In Ms Meyer’s experience there has also been confusion among women about what vaccines are needed during pregnancy, and where to get them.
‘The states and territories all have different rules and regulations around who can provide National Immunisation Program (NIP) vaccines,’ she says.
With most jurisdictions now increasing the number of vaccines pharmacists can administer, this should be used as an opportunity to initiate conversations with pregnant women about vaccination.
‘Ensure the mother is well educated on what vaccines she, and other family members, should receive according to current guidelines,’ says Ms Meyer.
All about birthing on country[caption id="attachment_25937" align="alignnone" width="500"] In 2020, photographer Bobbi Lockyer created a Birthing on Country project to highlight and create awareness around birthing issues and outcomes in Aboriginal women. For more, see www.bobbilockyer.com[/caption]
Birthing on Country (BOC) is a holistic, integrated and culturally appropriate model of care, aimed at providing the best start in life for Aboriginal and Torres Strait Islander babies and their families.14 Broader than labour and delivery, BOC addresses socio-cultural and spiritual risk not dealt with through mainstream services.
Guiding principles for a BOC program include respect for and incorporation of the knowledge and traditional practice of Aboriginal and Torres Strait Islander peoples, incorporate a holistic definition of health, respect for family involvement, women’s business, connection with Country and continuity of culturally safe care.15 Aboriginal and Torres Strait Islander mothers are 3–5 times more likely to die in childbirth than other mothers. Their babies are almost twice as likely to die in the first year of life – often due to premature birth.16
With research revealing access to community-governed, culturally safe birthing services is linked to a reduced risk of premature birth,17 pharmacists can advocate for and support BOC models of care.
‘BOC is so much broader than where a mother births – it is a social justice movement and system-wide reform. It’s an opportunity to Close the Gap in life outcomes for mums and bubs by recognising the impact of colonisation and the benefits of returning childbirth services to Aboriginal and Torres Strait Island community control,’ says Alice Nugent MPS, Aboriginal Community Controlled Health Organisation Pharmacist. Although not available everywhere, BOC can still involve birthing in a local hospital with the presence of an Aboriginal or Torres Strait Islander midwife or support worker throughout a woman’s pregnancy, birthing and post-natal journey.
Once the baby is born, ongoing support is usually provided to the family, which may include cultural ceremonies for the mother and newborn. |
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency.' Jacqueline Meyer MPSInfant formulas Formula manufacturers commonly use marketing that may feed into parental anxieties in claiming their products can prevent fussiness, help with colic, or improve night-time sleep.22 Pharmacists can emphasise the ‘antibodies, immunoglobulins and health benefits’ that breast milk can provide, along with advice on ensuring milk quality is at optimum levels, says Ms Meyer. ‘The number one thing is to eat before you feed,’ she says. ‘Mothers should also have a wholesome, balanced diet full of fresh nutrients and vegetables, so nutritional intake is at a premium.’ While breastfeeding should be encouraged, pharmacists can also guide mothers around selecting the right formulas when breastfeeding is not possible, says Ms Meyer. ‘We get a lot of questions around milk-free or dairy-free alternatives due to rising concerns of allergies and intolerances,’ she says. Factors to consider include the baby’s age, digestive issues, peptide profiles, short- or long-chain formula requirements, or whether specific formulas need to be prescribed. Pharmacists should also enquire how formulas are tolerated over a trial period – which ones and for how long, any reactions such as refusal, any reflux-type symptoms, changes in stool colour, irritability and any difficulty settling, suggests Ms Meyer. ‘Just trialling the formula for one day is often not enough. A longer period of time is required to identify a true intolerance.’ Medicines and breastfeeding Another reason why mothers opt to stop breastfeeding is medicine use.27 Pharmacists can reassure patients that very small amounts of medicines generally pass through breast milk, says Ms Meyer. ‘Medicine should never be a reason to stop breastfeeding, unless specifically advised to do so.’ Pharmacists can also advise patients when to take their medicines. ‘If the medicine is taken multiple times a day, recommend taking it directly after a breastfeed, so it reaches peak concentration in between feeding cycles,’ she says.
‘If your mum or dad had perinatal mental ill health, you’re more likely to have mental ill-health issues later on.' Lily Pham MPS
What's ailing pregnant and new mums?
Pregnancy and the early stages of motherhood are fraught with discomfort.
In addition to nausea and vomiting, some common ailments in pregnancy include constipation and indigestion, says Ms Al-Adhami.
To overcome constipation, often due to hormone changes that slow down muscles in the bowel, patients should be advised to increase their fibre content by consuming fresh fruit and vegetables, wholemeal breads and breakfast cereals, nuts and legumes.
Supplements such as psyllium husks can also be introduced. As iron tablets can also cause constipation, pharmacists can suggest another product for a trial period.23
Antacids for indigestion are safe to use in pregnancy. Calcium-based formulations are preferable to aluminium-containing antacids.24
When the baby arrives, back pain, incontinence and repetitive strain injuries are common. For mild to moderate pain, paracetamol is considered a safe analgesic during lactation, with the dose transferred through breast milk estimated to be 6% – much smaller than a child’s dose.25 Ibuprofen is also considered to be compatible with breastfeeding.25
Pelvic floor exercises can help to address post-birth incontinence, along with avoidance of persistent heavy lifting, repetitive coughing and straining.26 |
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[post_content] => Nitazenes are becoming more common in the Australian illicit drug market, and are linked to an increasing number of overdoses and deaths.
Last week, nitazines were detected in samples related to a cluster of 20 overdoses in the New South Wales Nepean Blue Mountains local health district.
There have been 16 overdose deaths involving nitazenes in Victoria since 2021, prompting two coroners to recommend the implementation of drug checking services in the state.
[caption id="attachment_10405" align="alignright" width="300"] Suzanne Nielsen MPS[/caption]
Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne, explains how this little-understood drug entered the market and why pharmacists need to rethink harm minimisation.
What’s the history of this synthetic opioid?
‘Nitazenes’ are a family of drugs. Substances within the class vary in potency, from lower in potency to significantly exceeding fentanyl’s strength.
After nitazenes were synthesised in the late 1950s, development of the opioid as a therapeutic product was abandoned after early testing revealed high rates of adverse effects – including severe respiratory depression.
In recent years, they have emerged as novel psychoactive substances, said Prof Nielsen.
‘Chemists who make illicit drugs [often] go back to drugs that didn't make it through the development pathway,’ she said.
These drugs are therefore not internationally controlled, meaning their manufacture and distribution is ‘not necessarily illegal’.
‘It takes a while for national and international regulations to catch up and make them controlled substances,’ added Prof Nielsen.
Most nitazenes that have been detected in Australia are also similar to, or stronger than fentanyl in potency.
But while the pharmacology and effects of fentanyl are well profiled, the same can’t be said about nitazenes.
‘There are very few studies [that provide] a good sense of exactly how strong they are, how they work and how long they last,’ she said. ‘We do know they're very strong and have other negative effects we haven't fully characterised yet.’
Where are nitazenes found?
Fentanyl and other novel synthetic opioids are commonly packaged and sold as substances such as oxycodone tablets, said Prof Nielsen.
‘Some people go online to find pharmaceuticals because they can be easier to access than through the healthcare system,’ she said. ‘Unless you're familiar with what to look for, these products look quite similar to pharmaceutical products.’
Some people, in the pursuit of a strong opioid, purchase nitazenes intentionally. But the majority of detections are in unintended purchases, when other substances are sought.
‘Sometimes [they are in] opioids such as heroin,’ said Prof Nielsen. ‘But we've seen detections in drugs being sold as ketamine, MDMA or other stimulants.’
These detections are cause for the most concern. ‘People seeking to use MDMA in a festival environment [likely] won't have any opioid tolerance, and will be very susceptible to an opioid overdose.’
Is Australia at risk of a nitazene epidemic?
Nitazenes are causing large ‘clusters of deaths’ in England, Scotland and Ireland – where fentanyl has yet to emerge in the illicit market. There are concerns among addiction experts that Australia could similarly skip over fentanyl and head straight into a nitazene wave, warned Prof Nielsen.
‘There have been reports that the amount of heroin manufactured is dropping off,’ she said. ‘With the Taliban shutting down poppy production, an 80–95% reduction in heroin availability is expected.’
Programs such as real-time prescription monitoring and a tightening of regulations have also contributed to a ‘supply shock’ – which is historically associated with the entrance of potent substances into drug markets, said Prof Nielsen.
With drug checking not widely accessible in Australia, it’s possible there are more nitazenes out there than we know.
‘Given overdose deaths have gone up fairly quickly in other parts of the world where these drugs have emerged, now is the time to raise the alarm.’
What can pharmacists do to help?
With drugs such as MDMA or ketamine containing nitazenes, pharmacists need to broaden their approach to harm reduction, said Prof Nielsen.
This includes anticipating requests for take-home naloxone (THN) from people who use drugs occasionally who have heard about the synthetic opioid – which should always be met with a positive response.
Pharmacists could say, ‘it’s great you're asking for naloxone. I'm happy to provide it for you’, said Prof Nielsen.
Follow-up questions could include:
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[post_content] => Queenslanders are set to have greater access to high-quality, primary healthcare services from today (24 April 2024) under the state government’s Community Pharmacy Scope of Practice Pilot.
Under the Pilot, trained pharmacists will be able to prescribe for a range of common conditions and better support patients with medication management through therapeutic adaptation and substitution, and continued dispensing.
PSA Queensland President Shane MacDonald welcomed Health Minister Shannon Fentiman’s announcement today in Cairns.
‘The 2020 election commitment to work with PSA, the Pharmacy Guild of Australia, and other stakeholders to implement this Pilot is finally being realised,’ he said.
‘It has been a long journey, and we thank the government for the collaborating with the profession to execute this important work.
‘We must also acknowledge the pioneering pharmacists who, amidst their professional workload and family responsibilities, have dedicated themselves to undertake the extensive education program required to participate.’
Queensland is already leading the nation on pharmacist vaccination scope, delivering more vaccines to more patients, and improving vaccine coverage across the state, said Mr MacDonald.
‘This is a vote of confidence from the Queensland Government in the skills and expertise of our pharmacists to continue delivering safe and accessible primary health care to Queenslanders,’ he said.
‘Empowering pharmacists to manage common acute conditions and better support chronic disease management in community pharmacies is a progressive step towards enhancing healthcare accessibility. Piloting this initiative in Queensland will pave the way for nation-wide impact.’
Pharmacists are already getting involved
Queensland PSA Branch Committee member and Pharmacy Partner at LiveLife Pharmacy Macrossan Street (Port Douglas), James Buckley is one of the first pharmacists to complete the training and be authorised to participate.
‘I am really excited to be able to support my local community to have better access to care. Pharmacists are so accessible and our pharmacies are open late and on weekends. It just makes sense to use us to the top of our scope.’
PSA is currently working with the government to become an approved training provider to support the state-wide roll out of the Pilot.
Pilot services
Pharmacists who are approved participate in the Pilot are able to provide additional services that can be grouped into three categories:
1. Medication management services including therapeutic adaptation, therapeutic substitution and continued dispensing.
2. Autonomous prescribing for specified acute common conditions and health and wellbeing services:
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[post_content] => We’ve passed the halfway mark in the CPD year. Top up your credits and develop the most sought-after pharmacy skills by completing these CPD activities.
In a changing social and healthcare landscape – including fears around opioid overdoses, the rise of injectable medicines and new treatments for chronic pain – pharmacists need to keep on top of trends and education to best serve their communities.
AP outlines the most clicked-on CPD articles over the last 12 months and why you should complete them – along with a few other ways to score credits before the CPD year ends.
1. Disposal of Schedule 8 medicines
Did you know that different dose forms of Schedule 8 medicines need to be disposed of in different ways? Or that requirements for authorised witnesses for destruction of Schedule 8 medicines by pharmacists vary per jurisdiction?
All pharmacists must familiarise themselves with local legislation and best practice guidelines for the correct process for disposal of Schedule 8 medicines.
This helpful CPD article summarises environmental and safety considerations, destruction recommendations and considerations for legislative requirements for disposal of Schedule 8 medicines.
2. How to save a life with naloxone
Opioid overdose deaths in Australia have continued to rise. According to Australia’s Annual Overdose Report by the Pennington Institute, unintentional drug overdose deaths have skyrocketed by 71% in 20 years (2001–2021).
Opioids are the drugs most commonly involved in poly-substance deaths (81%).
With experts warning of an impending influx of synthetic opioids into Australia's illicit drug market and the Take-Home Naloxone program now national – all pharmacists should know how to supply and administer this life-saving medicine.
By undertaking PSA’s How to save a life with naloxone CPD article, pharmacists will learn how to effectively counsel patients on using the medicine, learn the key points of the Take Home Naloxone (THN) program and how to provide support and advice to people who use opioids, their peers, and family – all of which can have a significant impact on reducing the number of lives lost.
3. B12 deficiency
The raft of scope of practice changes that continue to occur across Australian states and territories has meant many pharmacists are able to administer medicines by injection (if suitably trained) – such as intramuscular vitamin B12.
Vitamin B12 deficiency can cause serious haematological, neurological, and psychiatric problems – early detection and treatment may reverse and minimise harms. This CPD article will help pharmacists identify and refer patients with possible deficiency, advise on suitable treatments, and know when administration of intramuscular vitamin B12 treatment is appropriate.
4. Cannabis drug interactions
The Australian Institute of Health and Welfare estimates 600,000 Australians use cannabis for medicinal purposes. This is a dramatic uptick from the 2,560 medicinal cannabis prescriptions approved through Therapeutic Goods Administration’s (TGA) Special Access Scheme (SAS) in 2018. In fact, last year there were 132,000 SAS-B applications approved by the TGA from 2,565 medical practitioners.
This CPD article explains the common mechanisms whereby medicinal cannabis may interact with other medicines, and the role of the pharmacist in reviewing and identifying these interactions.
5. Immediate-release melatonin for jet lag
Melatonin is now a schedule 3 medicine for Australians aged 55 years of age or older with primary insomnia with poor sleep quality, and for those aged 18 or older to treat jet lag.
But do you know when melatonin should be taken to stave off jet lag, or its potential adverse effects and drug interactions? There are also several non-pharmacological options to treat jet lag that pharmacists should also be across. Pharmacists can access all this information and more in PSA’s Immediate-release melatonin for jet lag article.
How else can I gain CPD credits?
Prefer to rack up your CPD credits in other ways? If networking with other healthcare professionals while gaining knowledge from the industry's top thought leaders is more your thing, AP has rounded up the top up-coming conferences to attend:
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[post_content] => Influenza is one of the most common vaccine-preventable diseases in Australia. While reported cases are significantly higher than what they were this time last year, vaccination rates are slipping.
There were 30,404 reported cases of influenza from January–March this year, compared to 18,584 during the same time period last year. With 39,230 cases reported to date in 2024, there has been a significant spike in cases over the last few weeks.
As we approach World Immunisation Week (24–30 April 2024), here’s how pharmacists can help to protect the community this season.
Children are undervaccinated and frequently hospitalised. How can this cohort be reached?
In 2023, influenza notifications were highest in children aged 5–9 years old, with hospitalisations peaking in those 15 years of age or younger. Yet the 5–15 age group is the most under-vaccinated cohort, with vaccination rates sitting at only 16% for 2023.
Vaccination rates among children aged 6 months to 5 years of age have been startlingly low post-COVID pandemic (28.3% in 2023), despite the considerable risk to this age group, said Dr Eden Mifsud, Medical Science Liaison, Influenza Vaccines Medical Affairs, at CSL Seqirus in the PSA webinar Influenza 2024 – The Right Vaccine for the Right Patient, held on 17 April 2024.
So how can pharmacists approach this conversation with parents and carers? Firstly, you can remind them that the influenza vaccine is covered under the NIP for children aged 6 months to 5 years because they are susceptible to severe disease associated with influenza, and death.
Making vaccination more accessible for patients aged 5–15 can be achieved by scheduling and promoting after-school vaccination, said webinar co-host Peter Guthrey MPS, PSA Senior Pharmacist, Strategic Policy.
While parents may be hesitant to administer vaccines on a school night due to concern about adverse effects, pharmacists can reassure them that adverse events from influenza vaccines are relatively low compared to other vaccines, said Mr Guthrey.
‘Booking the whole family for the flu vaccine, school holiday or after-school appointments can be a powerful way to help people engage in vaccination,’ he said. ‘Parents are looking to protect the health of their children in a way that doesn't disrupt the routine.’
What are the new ATAGI recommendations in 2024?
There have been a number of updates included in the Australian Technical Advisory Group on Immunisation (ATAGI) advice regarding the administration of 2024 seasonal influenza vaccines.
This year, ATAGI recommends pregnant women who received an influenza vaccine in 2023 receive the 2024 influenza vaccine if available before the end of their pregnancy, said Dr Mifsud.
‘We know antibodies can be passed through the placenta, and these antibodies can also be passed on if the woman chooses to breastfeed,’ she said. ‘That means those maternal antibodies can protect the infant for the first 6 months of its life.’
Another change to the ATAGI recommendations this year is the inclusion of conditions that increase the risk of severe influenza that are not attached to NIP funding eligibility, including:
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[post_content] => Pharmacists encounter pregnant and new mums more often than most health professionals, and can have a bird’s-eye view when things go awry.
At 20 weeks pregnant, PSA’s Queensland Pharmacist of the Year Jacqueline Meyer MPS, was diagnosed with intrauterine growth restriction, which severely impacted her fetal growth.
A few weeks later, she stopped working – effective immediately. ‘I was put on immediate bed rest, even though I felt fine,’ she says.
With her amniotic fluid diminished, Ms Meyer’s daughter, Fallon, was born at 28 weeks. Weighing only 520 grams, Fallon was placed in an incubator in the neonatal intensive care unit where she remained for the next 2 months.
Ms Meyer is one of thousands of women who experience pregnancy complications, including gestational diabetes mellitus (GDM), affecting 1 in 6 pregnant Australian women.1
Perinatal depression (PND) is another prevalent complication, affecting up to 1 in 5 expectant or new mothers.2
However, there are significant gaps in pregnancy and early childhood support
in Australia.
With GDM diagnoses doubled within a decade,3 many patients are forced to rely on group education classes, says Anna Barwick MPS, credentialed pharmacist, and founder of remote access telehealth advisory service PharmOnline. Meanwhile, suicide is the third-highest cause of death among new mothers in Australia.4
After her turbulent pregnancy, Ms Meyer thinks pharmacists can help to fill these gaps.
‘We can recognise red flags, direct patients where to seek help, and
provide emotional support about the importance of looking after your own health and nutrition.’
Medicine use in pregnancy
While ‘every woman’ wants to avoid exposing their unborn child to risks associated with taking medicines for chronic conditions such as epilepsy, inflammatory bowel disease and arthritis, those risks can sometimes be overestimated, says Noor Al-Adhami, Women’s and Newborn Pharmacy Team Leader at Brisbane’s Royal Brisbane and Women’s Hospital (RBWH).
‘A gap we often see in RBWH’s Maternity Outpatient Clinic is lack of discussions around safety of medicines prescribed for depression and anxiety in pregnancy and breastfeeding,’ she says.
‘This can lead to women stopping their medicines abruptly without discussing with their GP or midwife, resulting in a deterioration in mental health that can negatively impact maternal and fetal outcomes.’
Pharmacists are in a good position to provide support and information regarding the safety of medicines in pregnancy and to address any concerns in a non-judgemental manner.
‘Advice regarding safety of antidepressant medicines involves discussing the benefit of continuation/initiation on maternal health, including improved function and quality of life, as well as risk to the fetus, which evidence shows is minimal with appropriate antidepressants,’ says Ms Al-Adhami.
Health monitoring
While pregnancy is a short-term phase of life, significant ongoing effects can be experienced, particularly in children from pregnancies that are not well managed, says Ms Barwick.
‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.’
Gestational diabetes
When expectant mums are diagnosed with GDM, community pharmacists can walk them through the process of monitoring blood glucose levels (BGLs).
Where insulin is prescribed, pharmacists can inquire whether the dose is controlling blood glucose levels, and check their injection technique, says Ms Meyer.
The use of insulin, considered a high-risk medication with APINCHs classification,5 Ms Barwick notes, provides justification for a Home Medicines Review (HMR). ‘There’s an advantage to going into the home to observe the patient’s diet, consider potential interactions, and educate patients on the best effects and outcomes,’ she says.
Advice around cleaning blood glucose level (BGL) monitors to ensure accuracy can also be provided. ‘Pharmacists can explain how to put test drops through and clean blood spills on the monitor, common in pregnancy due to higher blood volume,’ says Ms Barwick.
With only 50% of women diagnosed with GDM receiving tests for heart disease and type 2 diabetes post-pregnancy,6 HMRs can be beneficial at this stage of the journey, too.
‘Along with conversations around diet choices, exercise regimes and sleep, I also explain how often testing is required over the next 5–10 years, and how to monitor for signs of the development of diabetes,’ Ms Barwick advises.
Nausea and vomiting in pregnancy
The presence of iron in pregnancy multivitamins may exacerbate symptoms of nausea and vomiting in some pregnancies, according to Ms Barwick.
‘Pharmacists can recommend a trial cessation of the iron component of pregnancy vitamins, often unnecessary in pregnancy,’ she says.
‘A simple change in vitamin to focus on iodine and folate can make a big difference.’ Ms Barwick says community pharmacists may also recommend over-the-counter medicines such as doxylamine for symptoms of nausea and vomiting in pregnancy (NVP), and monitor its effectiveness.
‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.'
ANNA BARWICK MPS
When women have symptoms of NVP, Ms Meyer points out that a family member might come into the pharmacy on their behalf if they are severely unwell.
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency, such as vomiting to the point of severe dehydration, heart palpitations, blurred vision and cramping.’
When ondansetron is prescribed, pharmacists can recommend easy-to-consume forms, such as sublingual wafers, she adds.
Preeclampsia
Pregnant women who present with new hypertension after 20 weeks should be screened for preeclampsia.7
Community and credentialed pharmacists can assist patients with monitoring blood pressure, and look out for signs of preeclampsia, such as sudden oedema and weight gain, says Ms Barwick.
‘Patients can also be taught how to use a home blood pressure monitor appropriately and record the results.
Women at high-risk of developing preeclampsia should consider treatment with low-dose aspirin,8 which can also be used to manage coagulation abnormalities in early pregnancy to prevent miscarriage.
‘A dose of around 75 mg has been shown to be effective for delivering a healthy baby, safely,’ notes Ms Barwick.9 Up to 150 mg can be used to prevent preeclampsia, she adds.10
Pharmacists should also keep a record of pregnant patients using aspirin to monitor for any potential adverse effects, such as bruising or bleeding.
‘While the risk of low-dose, aspirin-associated bleeding is low, reinforce the importance of looking out for any signs, either vaginal or rectal,’ Ms Barwick warns.
Vaccinations
Australia has ‘dismal’ antenatal vaccination rates, with 15% vaccinated against influenza, 27% against pertussis, and only 12% against both among more than 591,000 pregnancies analysed in a population-based linked cohort study of data between 2012–2017.11
COVID-19 vaccine hesitancy has also been detected among pregnant Australian women.12 Overall, there is a lack of understanding of the benefits of antenatal vaccination, including providing immunity to both baby and mother against serious respiratory infections, says Ms Al-Adhami. Reduced access to vaccines is also an issue, particularly among vulnerable populations, such as those with mental health problems, and Aboriginal and Torres Strait Islander peoples.
‘Once we identified some women were having difficulties accessing antenatal vaccinations in the community, we recognised an opportunity to extend our scope of practice and improve our service delivery within the clinic,’ she says.
This included credentialed training and the development of an opportunistic model of care, where ‘at-risk’ women were counselled and offered antenatal vaccinations during clinic visits.
‘Last year 546 vaccines were administered by our specialist antenatal pharmacists, adds Ms Al-Adhami.13
In Ms Meyer’s experience there has also been confusion among women about what vaccines are needed during pregnancy, and where to get them.
‘The states and territories all have different rules and regulations around who can provide National Immunisation Program (NIP) vaccines,’ she says.
With most jurisdictions now increasing the number of vaccines pharmacists can administer, this should be used as an opportunity to initiate conversations with pregnant women about vaccination.
‘Ensure the mother is well educated on what vaccines she, and other family members, should receive according to current guidelines,’ says Ms Meyer.
All about birthing on country[caption id="attachment_25937" align="alignnone" width="500"] In 2020, photographer Bobbi Lockyer created a Birthing on Country project to highlight and create awareness around birthing issues and outcomes in Aboriginal women. For more, see www.bobbilockyer.com[/caption]
Birthing on Country (BOC) is a holistic, integrated and culturally appropriate model of care, aimed at providing the best start in life for Aboriginal and Torres Strait Islander babies and their families.14 Broader than labour and delivery, BOC addresses socio-cultural and spiritual risk not dealt with through mainstream services.
Guiding principles for a BOC program include respect for and incorporation of the knowledge and traditional practice of Aboriginal and Torres Strait Islander peoples, incorporate a holistic definition of health, respect for family involvement, women’s business, connection with Country and continuity of culturally safe care.15 Aboriginal and Torres Strait Islander mothers are 3–5 times more likely to die in childbirth than other mothers. Their babies are almost twice as likely to die in the first year of life – often due to premature birth.16
With research revealing access to community-governed, culturally safe birthing services is linked to a reduced risk of premature birth,17 pharmacists can advocate for and support BOC models of care.
‘BOC is so much broader than where a mother births – it is a social justice movement and system-wide reform. It’s an opportunity to Close the Gap in life outcomes for mums and bubs by recognising the impact of colonisation and the benefits of returning childbirth services to Aboriginal and Torres Strait Island community control,’ says Alice Nugent MPS, Aboriginal Community Controlled Health Organisation Pharmacist. Although not available everywhere, BOC can still involve birthing in a local hospital with the presence of an Aboriginal or Torres Strait Islander midwife or support worker throughout a woman’s pregnancy, birthing and post-natal journey.
Once the baby is born, ongoing support is usually provided to the family, which may include cultural ceremonies for the mother and newborn. |
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency.' Jacqueline Meyer MPSInfant formulas Formula manufacturers commonly use marketing that may feed into parental anxieties in claiming their products can prevent fussiness, help with colic, or improve night-time sleep.22 Pharmacists can emphasise the ‘antibodies, immunoglobulins and health benefits’ that breast milk can provide, along with advice on ensuring milk quality is at optimum levels, says Ms Meyer. ‘The number one thing is to eat before you feed,’ she says. ‘Mothers should also have a wholesome, balanced diet full of fresh nutrients and vegetables, so nutritional intake is at a premium.’ While breastfeeding should be encouraged, pharmacists can also guide mothers around selecting the right formulas when breastfeeding is not possible, says Ms Meyer. ‘We get a lot of questions around milk-free or dairy-free alternatives due to rising concerns of allergies and intolerances,’ she says. Factors to consider include the baby’s age, digestive issues, peptide profiles, short- or long-chain formula requirements, or whether specific formulas need to be prescribed. Pharmacists should also enquire how formulas are tolerated over a trial period – which ones and for how long, any reactions such as refusal, any reflux-type symptoms, changes in stool colour, irritability and any difficulty settling, suggests Ms Meyer. ‘Just trialling the formula for one day is often not enough. A longer period of time is required to identify a true intolerance.’ Medicines and breastfeeding Another reason why mothers opt to stop breastfeeding is medicine use.27 Pharmacists can reassure patients that very small amounts of medicines generally pass through breast milk, says Ms Meyer. ‘Medicine should never be a reason to stop breastfeeding, unless specifically advised to do so.’ Pharmacists can also advise patients when to take their medicines. ‘If the medicine is taken multiple times a day, recommend taking it directly after a breastfeed, so it reaches peak concentration in between feeding cycles,’ she says.
‘If your mum or dad had perinatal mental ill health, you’re more likely to have mental ill-health issues later on.' Lily Pham MPS
What's ailing pregnant and new mums?
Pregnancy and the early stages of motherhood are fraught with discomfort.
In addition to nausea and vomiting, some common ailments in pregnancy include constipation and indigestion, says Ms Al-Adhami.
To overcome constipation, often due to hormone changes that slow down muscles in the bowel, patients should be advised to increase their fibre content by consuming fresh fruit and vegetables, wholemeal breads and breakfast cereals, nuts and legumes.
Supplements such as psyllium husks can also be introduced. As iron tablets can also cause constipation, pharmacists can suggest another product for a trial period.23
Antacids for indigestion are safe to use in pregnancy. Calcium-based formulations are preferable to aluminium-containing antacids.24
When the baby arrives, back pain, incontinence and repetitive strain injuries are common. For mild to moderate pain, paracetamol is considered a safe analgesic during lactation, with the dose transferred through breast milk estimated to be 6% – much smaller than a child’s dose.25 Ibuprofen is also considered to be compatible with breastfeeding.25
Pelvic floor exercises can help to address post-birth incontinence, along with avoidance of persistent heavy lifting, repetitive coughing and straining.26 |
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[post_content] => Nitazenes are becoming more common in the Australian illicit drug market, and are linked to an increasing number of overdoses and deaths.
Last week, nitazines were detected in samples related to a cluster of 20 overdoses in the New South Wales Nepean Blue Mountains local health district.
There have been 16 overdose deaths involving nitazenes in Victoria since 2021, prompting two coroners to recommend the implementation of drug checking services in the state.
[caption id="attachment_10405" align="alignright" width="300"] Suzanne Nielsen MPS[/caption]
Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne, explains how this little-understood drug entered the market and why pharmacists need to rethink harm minimisation.
What’s the history of this synthetic opioid?
‘Nitazenes’ are a family of drugs. Substances within the class vary in potency, from lower in potency to significantly exceeding fentanyl’s strength.
After nitazenes were synthesised in the late 1950s, development of the opioid as a therapeutic product was abandoned after early testing revealed high rates of adverse effects – including severe respiratory depression.
In recent years, they have emerged as novel psychoactive substances, said Prof Nielsen.
‘Chemists who make illicit drugs [often] go back to drugs that didn't make it through the development pathway,’ she said.
These drugs are therefore not internationally controlled, meaning their manufacture and distribution is ‘not necessarily illegal’.
‘It takes a while for national and international regulations to catch up and make them controlled substances,’ added Prof Nielsen.
Most nitazenes that have been detected in Australia are also similar to, or stronger than fentanyl in potency.
But while the pharmacology and effects of fentanyl are well profiled, the same can’t be said about nitazenes.
‘There are very few studies [that provide] a good sense of exactly how strong they are, how they work and how long they last,’ she said. ‘We do know they're very strong and have other negative effects we haven't fully characterised yet.’
Where are nitazenes found?
Fentanyl and other novel synthetic opioids are commonly packaged and sold as substances such as oxycodone tablets, said Prof Nielsen.
‘Some people go online to find pharmaceuticals because they can be easier to access than through the healthcare system,’ she said. ‘Unless you're familiar with what to look for, these products look quite similar to pharmaceutical products.’
Some people, in the pursuit of a strong opioid, purchase nitazenes intentionally. But the majority of detections are in unintended purchases, when other substances are sought.
‘Sometimes [they are in] opioids such as heroin,’ said Prof Nielsen. ‘But we've seen detections in drugs being sold as ketamine, MDMA or other stimulants.’
These detections are cause for the most concern. ‘People seeking to use MDMA in a festival environment [likely] won't have any opioid tolerance, and will be very susceptible to an opioid overdose.’
Is Australia at risk of a nitazene epidemic?
Nitazenes are causing large ‘clusters of deaths’ in England, Scotland and Ireland – where fentanyl has yet to emerge in the illicit market. There are concerns among addiction experts that Australia could similarly skip over fentanyl and head straight into a nitazene wave, warned Prof Nielsen.
‘There have been reports that the amount of heroin manufactured is dropping off,’ she said. ‘With the Taliban shutting down poppy production, an 80–95% reduction in heroin availability is expected.’
Programs such as real-time prescription monitoring and a tightening of regulations have also contributed to a ‘supply shock’ – which is historically associated with the entrance of potent substances into drug markets, said Prof Nielsen.
With drug checking not widely accessible in Australia, it’s possible there are more nitazenes out there than we know.
‘Given overdose deaths have gone up fairly quickly in other parts of the world where these drugs have emerged, now is the time to raise the alarm.’
What can pharmacists do to help?
With drugs such as MDMA or ketamine containing nitazenes, pharmacists need to broaden their approach to harm reduction, said Prof Nielsen.
This includes anticipating requests for take-home naloxone (THN) from people who use drugs occasionally who have heard about the synthetic opioid – which should always be met with a positive response.
Pharmacists could say, ‘it’s great you're asking for naloxone. I'm happy to provide it for you’, said Prof Nielsen.
Follow-up questions could include:
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[post_date_gmt] => 2024-04-24 04:29:47
[post_content] => Queenslanders are set to have greater access to high-quality, primary healthcare services from today (24 April 2024) under the state government’s Community Pharmacy Scope of Practice Pilot.
Under the Pilot, trained pharmacists will be able to prescribe for a range of common conditions and better support patients with medication management through therapeutic adaptation and substitution, and continued dispensing.
PSA Queensland President Shane MacDonald welcomed Health Minister Shannon Fentiman’s announcement today in Cairns.
‘The 2020 election commitment to work with PSA, the Pharmacy Guild of Australia, and other stakeholders to implement this Pilot is finally being realised,’ he said.
‘It has been a long journey, and we thank the government for the collaborating with the profession to execute this important work.
‘We must also acknowledge the pioneering pharmacists who, amidst their professional workload and family responsibilities, have dedicated themselves to undertake the extensive education program required to participate.’
Queensland is already leading the nation on pharmacist vaccination scope, delivering more vaccines to more patients, and improving vaccine coverage across the state, said Mr MacDonald.
‘This is a vote of confidence from the Queensland Government in the skills and expertise of our pharmacists to continue delivering safe and accessible primary health care to Queenslanders,’ he said.
‘Empowering pharmacists to manage common acute conditions and better support chronic disease management in community pharmacies is a progressive step towards enhancing healthcare accessibility. Piloting this initiative in Queensland will pave the way for nation-wide impact.’
Pharmacists are already getting involved
Queensland PSA Branch Committee member and Pharmacy Partner at LiveLife Pharmacy Macrossan Street (Port Douglas), James Buckley is one of the first pharmacists to complete the training and be authorised to participate.
‘I am really excited to be able to support my local community to have better access to care. Pharmacists are so accessible and our pharmacies are open late and on weekends. It just makes sense to use us to the top of our scope.’
PSA is currently working with the government to become an approved training provider to support the state-wide roll out of the Pilot.
Pilot services
Pharmacists who are approved participate in the Pilot are able to provide additional services that can be grouped into three categories:
1. Medication management services including therapeutic adaptation, therapeutic substitution and continued dispensing.
2. Autonomous prescribing for specified acute common conditions and health and wellbeing services:
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[post_date] => 2024-04-24 12:52:50
[post_date_gmt] => 2024-04-24 02:52:50
[post_content] => We’ve passed the halfway mark in the CPD year. Top up your credits and develop the most sought-after pharmacy skills by completing these CPD activities.
In a changing social and healthcare landscape – including fears around opioid overdoses, the rise of injectable medicines and new treatments for chronic pain – pharmacists need to keep on top of trends and education to best serve their communities.
AP outlines the most clicked-on CPD articles over the last 12 months and why you should complete them – along with a few other ways to score credits before the CPD year ends.
1. Disposal of Schedule 8 medicines
Did you know that different dose forms of Schedule 8 medicines need to be disposed of in different ways? Or that requirements for authorised witnesses for destruction of Schedule 8 medicines by pharmacists vary per jurisdiction?
All pharmacists must familiarise themselves with local legislation and best practice guidelines for the correct process for disposal of Schedule 8 medicines.
This helpful CPD article summarises environmental and safety considerations, destruction recommendations and considerations for legislative requirements for disposal of Schedule 8 medicines.
2. How to save a life with naloxone
Opioid overdose deaths in Australia have continued to rise. According to Australia’s Annual Overdose Report by the Pennington Institute, unintentional drug overdose deaths have skyrocketed by 71% in 20 years (2001–2021).
Opioids are the drugs most commonly involved in poly-substance deaths (81%).
With experts warning of an impending influx of synthetic opioids into Australia's illicit drug market and the Take-Home Naloxone program now national – all pharmacists should know how to supply and administer this life-saving medicine.
By undertaking PSA’s How to save a life with naloxone CPD article, pharmacists will learn how to effectively counsel patients on using the medicine, learn the key points of the Take Home Naloxone (THN) program and how to provide support and advice to people who use opioids, their peers, and family – all of which can have a significant impact on reducing the number of lives lost.
3. B12 deficiency
The raft of scope of practice changes that continue to occur across Australian states and territories has meant many pharmacists are able to administer medicines by injection (if suitably trained) – such as intramuscular vitamin B12.
Vitamin B12 deficiency can cause serious haematological, neurological, and psychiatric problems – early detection and treatment may reverse and minimise harms. This CPD article will help pharmacists identify and refer patients with possible deficiency, advise on suitable treatments, and know when administration of intramuscular vitamin B12 treatment is appropriate.
4. Cannabis drug interactions
The Australian Institute of Health and Welfare estimates 600,000 Australians use cannabis for medicinal purposes. This is a dramatic uptick from the 2,560 medicinal cannabis prescriptions approved through Therapeutic Goods Administration’s (TGA) Special Access Scheme (SAS) in 2018. In fact, last year there were 132,000 SAS-B applications approved by the TGA from 2,565 medical practitioners.
This CPD article explains the common mechanisms whereby medicinal cannabis may interact with other medicines, and the role of the pharmacist in reviewing and identifying these interactions.
5. Immediate-release melatonin for jet lag
Melatonin is now a schedule 3 medicine for Australians aged 55 years of age or older with primary insomnia with poor sleep quality, and for those aged 18 or older to treat jet lag.
But do you know when melatonin should be taken to stave off jet lag, or its potential adverse effects and drug interactions? There are also several non-pharmacological options to treat jet lag that pharmacists should also be across. Pharmacists can access all this information and more in PSA’s Immediate-release melatonin for jet lag article.
How else can I gain CPD credits?
Prefer to rack up your CPD credits in other ways? If networking with other healthcare professionals while gaining knowledge from the industry's top thought leaders is more your thing, AP has rounded up the top up-coming conferences to attend:
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[post_date] => 2024-04-22 12:59:04
[post_date_gmt] => 2024-04-22 02:59:04
[post_content] => Influenza is one of the most common vaccine-preventable diseases in Australia. While reported cases are significantly higher than what they were this time last year, vaccination rates are slipping.
There were 30,404 reported cases of influenza from January–March this year, compared to 18,584 during the same time period last year. With 39,230 cases reported to date in 2024, there has been a significant spike in cases over the last few weeks.
As we approach World Immunisation Week (24–30 April 2024), here’s how pharmacists can help to protect the community this season.
Children are undervaccinated and frequently hospitalised. How can this cohort be reached?
In 2023, influenza notifications were highest in children aged 5–9 years old, with hospitalisations peaking in those 15 years of age or younger. Yet the 5–15 age group is the most under-vaccinated cohort, with vaccination rates sitting at only 16% for 2023.
Vaccination rates among children aged 6 months to 5 years of age have been startlingly low post-COVID pandemic (28.3% in 2023), despite the considerable risk to this age group, said Dr Eden Mifsud, Medical Science Liaison, Influenza Vaccines Medical Affairs, at CSL Seqirus in the PSA webinar Influenza 2024 – The Right Vaccine for the Right Patient, held on 17 April 2024.
So how can pharmacists approach this conversation with parents and carers? Firstly, you can remind them that the influenza vaccine is covered under the NIP for children aged 6 months to 5 years because they are susceptible to severe disease associated with influenza, and death.
Making vaccination more accessible for patients aged 5–15 can be achieved by scheduling and promoting after-school vaccination, said webinar co-host Peter Guthrey MPS, PSA Senior Pharmacist, Strategic Policy.
While parents may be hesitant to administer vaccines on a school night due to concern about adverse effects, pharmacists can reassure them that adverse events from influenza vaccines are relatively low compared to other vaccines, said Mr Guthrey.
‘Booking the whole family for the flu vaccine, school holiday or after-school appointments can be a powerful way to help people engage in vaccination,’ he said. ‘Parents are looking to protect the health of their children in a way that doesn't disrupt the routine.’
What are the new ATAGI recommendations in 2024?
There have been a number of updates included in the Australian Technical Advisory Group on Immunisation (ATAGI) advice regarding the administration of 2024 seasonal influenza vaccines.
This year, ATAGI recommends pregnant women who received an influenza vaccine in 2023 receive the 2024 influenza vaccine if available before the end of their pregnancy, said Dr Mifsud.
‘We know antibodies can be passed through the placenta, and these antibodies can also be passed on if the woman chooses to breastfeed,’ she said. ‘That means those maternal antibodies can protect the infant for the first 6 months of its life.’
Another change to the ATAGI recommendations this year is the inclusion of conditions that increase the risk of severe influenza that are not attached to NIP funding eligibility, including:
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