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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Ienaam Khatib MPS loves being a community pharmacist. But despite only being registered for a year, she’s already questioning how long she can last in the profession.
And Ienaam isn’t alone. Across the country, a lack of fair remuneration and little recognition, on top of the pressures of the pandemic, has many pharmacists asking: ‘Is this what I signed up for?’
In this special episode of Pharmacy & Me, hosts Peter Guthrey and Hannah Knowles get to the heart of the issue, speaking with Ienaam and pharmacy owner Caroline Diamantis MPS about what needs to change when it comes to remuneration.
They also speak to PSA Public Affairs and Communications manager Candice Burch about how PSA is advocating for pharmacists – and how individual pharmacists can help create change.
If you believe pharmacists deserve better remuneration and greater recognition, this is an episode not to be missed.
Listen to the episode below or find it on Spotify, Apple Podcasts and Google Podcasts.
Follow the timestamps to jump to the topics below:
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]With the federal election fast approaching, Australian Pharmacist looks at what pharmacists need to know before stepping into the polling booth.
In the lead up to the weekend election, PSA has called on the major parties to prioritise better consumer access to care through fairer remuneration for pharmacist-delivered services.
This includes:
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Pharmacists across the country are inviting politicians into their pharmacies to discuss the challenges facing the profession – and to help generate change.
Like many pharmacists, Natalie Kopas MPS, the owner of Tucker Road Pharmacy in Bentleigh, south-east of Melbourne, experienced staffing and supply issues during the pandemic.
She also believes there should be consistency between pharmacists and general practitioners when it comes to payments for providing vaccinations, and that remuneration models must change to reflect the evolution of pharmacists’ roles.
Ms Kopas explained all this to Liberal candidate for Hotham Savitri Bevinakoppa when she visited the pharmacy recently.
‘I would encourage anyone interested in the future of their profession – and anyone who has ever had a gripe about any aspect of bureaucracy or remuneration – to take every opportunity to meet with their local political candidates or elected representatives,’ Ms Kopas told Australian Pharmacist.
‘We cannot expect them to understand the myriad services we provide or the gaps in our current systems unless we take the time to build rapport and provide insights into what pharmacists actually do for the community each day.’
This includes easing the burden on other parts of the health system by offering services such as regular blood pressure monitoring as well as hospital intake and discharge medicines reconciliations.
‘These services are provided for free or on a user-pays basis by most pharmacies,’ Ms Kopas said. ‘Pharmacy is no longer a “supply only” model, but a healthcare service provider … remuneration models need to change to recognise this.’
Actions speak louder than words
In Western Australia, 777 Pharmacy Jindalee owner Danielle Walker MPS hosted Liberal candidate for Pearce Linda Aitken.
The pair discussed the valuable role pharmacists play in avoiding medicine misadventure and the pressures faced by community pharmacists during the pandemic.
As a theatre nurse at Hollywood Private Hospital, Ms Aitken was aware of the healthcare challenges facing the community, said PSA WA State Manager Mayli Foong MPS. However, she was still surprised by the level of care pharmacists provide.
‘Linda is passionate about wound care management in the community setting and she was amazed to hear that Lusi Sheehan, Pharmacy 777’s wound care expert, has provided training to pharmacists in Perth,’ Ms Foong said.
‘She asked about pharmacist remuneration for the service, and understands the need for pharmacists to be remunerated on the MBS for the services and consults provided for this patient cohort.’
[caption id="attachment_18531" align="alignnone" width="1000"]
Natalie Kopas MPS (right) with Liberal candidate for Hotham Savitri Bevinakoppa at Tucker Road Pharmacy in Bentleigh, Victoria[/caption]
Ms Foong said regular interactions with local politicians could help to create real change.
‘Bring your local MPs to your workplace, show them what you do and how you help the community – actions speak louder than words,’ she said.
‘Invite them to your pharmacy to take some photos for social media, or invite the MP and their office to come and have their flu shot.
‘This will build the relationship so that when you have concerns and thoughts to improve the future of pharmacy, the office will know you when you call.’
How can you make a difference?
For those who don’t know where to start, Candice Burch, PSA’s Manager – Public Affairs and Communications, and a former member of the ACT Legislative Assembly, said the best way to start is to ‘just reach out’ via email or through social media.
‘It’s really important that your local representatives have the opportunity to hear from you directly about the issues impacting you and your profession,’ she said.
‘Many candidates we’ve spoken to were already aware of a lot of the issues that pharmacists faced through the pandemic, but not necessarily aware of the ongoing workforce challenges and other challenges that pharmacists are facing. It's been particularly important to explain remuneration to them and the ways in which pharmacists are not fairly remunerated.’
Ms Kopas encouraged all pharmacists to get involved in the campaign for fair remuneration.
‘My best tip would be to offer solutions and how you envisage things working better, rather than providing a litany of complaints,’ she said.
‘If you feel hesitant or worried you don’t know “enough”, remember that no one knows your patients, profession, day-to day-schedule or business better than you, so who better to advocate for a better health system for all?’
Ready to get involved? Learn more here.[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
[post_title] => Politicians visit pharmacies ahead of election
[post_excerpt] => Pharmacists across the country are inviting politicians into their pharmacies to discuss the challenges facing the profession – and to help generate change.
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[post_content] => National glory, improved pharmacy services, industry connections and a recruitment boost are just some of the perks of winning PSA's Shark Tank competition.
Anna Barwick MPS is one of the biggest pharmacy stars of 2022. She was announced as the NSW Premier’s Woman of the Year in March for her pharmacist-led telehealth service PharmOnline, and also received the University of Technology Sydney’s (UTS) Innovative Pharmacist of the Year Award last month.
The awards followed Ms Barwick’s win at last year’s Shark Tank competition, held annually at PSA’s national conference to showcase innovative pharmacy ideas that address clinical needs.
Ms Barwick’s innovation, SugarBaby, is a fee-for-service sub-offering of PharmOnline.
Developed as an online clinic for isolated or time-poor women with gestational diabetes (GDM), SugarBaby allows patients to access Credentialled Diabetes Educators and evidence-based information about managing GDM and preventing Type 2 diabetes when it suits them.
‘SugarBaby has provided an additional opportunity for PharmOnline to reach and assist patients,’ Ms Barwick said.
‘Participants told us that they felt more confident about managing their condition and knew what to expect before and after birth by being involved.
‘We are planning on hosting monthly clinics from May onward and the frequency will increase if there is sufficient demand.’
[caption id="attachment_18523" align="alignright" width="343"]
Anna Barwick MPS won the 2021 Shark Tank People's Choice Award[/caption]
Reaping the benefits
As the winner of the People’s Choice award, Ms Barwick received $1,000, along with a further $2,000 for marketing and promotion, which she invested in an updated, user-friendly website.
The Sugarbaby clinics now have a dedicated landing page, meaning patients can easily find them at a time that may be worrisome or even distressing, Ms Barwick said.
‘People can find reliable and convenient information without having to rely on Dr Google,’ she said.
‘It has also allowed us time to get feedback from the Australian Diabetes Educators Association to ensure the materials are current and relevant.’
Winning the Shark Tank competition gave Ms Barwick the confidence to apply for other awards.
‘[It also] provided me and PharmOnline with a great platform to educate the public about the value pharmacists offer, and led to the evolution of my PhD project to include and assess pharmacist telehealth services,’ she said. ‘It allowed us to connect with other pharmacists who were interested in the idea – some have now become part of the PharmOnline team as a result!’
A pharmacy service blueprint
Canberra-based pharmacist Brad Butt MPS, co-owner of Cooleman Court Pharmacy, is an established men’s health advocate, known for offering an extensive range of pharmacy services including the Men's Health Downunder program.
After winning the Shark Tank People’s Choice award in 2019 for his Cardiac Clinic program, Mr Butt won PSA's ACT Pharmacist of the Year Award, the UTS Innovative Pharmacist of the Year Award and the Australian Patients Association’s inaugural ‘Most Outstanding Community Pharmacist’ that same year.
Noticing a lack of compliance among cardiovascular patients, Mr Butt designed Cardiac Clinic with Cooleman Court co-owner Brooke Veasey to support patients following an acute cardiac event.
‘They do cardiac rehab at the hospital for 6 weeks, but when they get home, they don’t understand what they need to do to remain healthy,’ Mr Butt said.
‘The money was a wonderful benefit, but I found that the support from the profession has been the most valuable part of participating.’
Anna Barwick MPS
‘Patients will be started on a cholesterol medication, an ACE inhibitor or similar medication regimen, [but] they'll only take it on discharge for a month because that’s all they’re supplied with.’
Once those initial prescriptions run their course, patients often assume they no longer need the medicines.
‘It seems nobody tells them to continue it and they might not have a regular GP,’ he said.
Mr Butt and Ms Veasey used the accessibility of community pharmacy to provide structured support for these patients through Cardiac Clinic.
‘We facilitate GP appointments and get them back in to get the script so they can continue taking the medication,’ he said.
‘We do MedsChecks, medication reviews, [dose administration aids], home deliveries, and talk to patients about cardiovascular health at any opportunity we get.
‘We also sponsor walking groups that we participate in. You have to walk the walk and talk the talk.’
Three years on from Shark Tank, the team still uses Cardiac Clinic.
‘We still see our cardiovascular patients in the pharmacy and participate in the walking groups,’ Mr Butt said.
Other pharmacies in Cooleman Court’s network have also benefited from the service.
‘Life Pharmacy Group has about 12 stores, and some of the pharmacies use that initiative to help their patients as well,’ he added.
Top tips for aspiring sharks
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Brad Butt MPS[/caption]
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[post_content] => In the lead up to the federal election, Australian Pharmacist asks pharmacists across the country what they would like to see changed when it comes to remuneration.
Pharmacist Judy Williams* is a vital member of her community, providing important health services in a remote Australian town. She hasn’t had a pay rise in over a decade.
Ms Williams has worked as a dose administration aid (DAA) pharmacist in a community pharmacy in her town in northern Australia for the past 11 years. She supplies DAAs to residential aged care facilities, multiple very remote Indigenous health clinics and community members who need them.
‘It’s very busy … We also supply individual dispensed medications for patients in remote locations and bulk shelf-stock supplies for remote health clinics,’ Ms Williams told AP.
The pandemic exacerbated already stressful conditions, especially when stock shortages meant the team had to spend more time locating supplies from elsewhere.
‘Changing brands frequently also created extra work, because the packing identification processes had to be continually revised, patients had to be educated about the change in appearance of their medicines, and we had to put in more frequent requests to doctors for different prescriptions, for example when a particular strength tablet wasn’t available,’ Ms Williams said.
Like many pharmacists, Ms Williams feels under-recognised and said pharmacist remuneration is ‘worse now than it has ever been’. She took part in PSA’s National Advocacy Day of Action in March to help raise awareness about the issue.
‘The remuneration seemed fine, say, 15 years ago, but [for many pharmacists] there have been no pay rises for a decade or more,’ she said.
‘The hourly rate needs to catch up, and we need better recognition of the responsibilities borne by pharmacists in providing accurate dispensing, overseeing complete lists of medications prescribed for individual patients, and giving counselling that many doctors do not have the time to provide.’
Changing fortunes
With a passion for providing healthcare in remote communities, Ms Williams has worked in a number of different roles throughout her 32-year career. This includes as a hospital pharmacist, an accredited pharmacist providing medication management reviews, an on-site dispensing pharmacist with an Indigenous health service and as a researcher.
She has also taken jobs in different fields over the years, including as an artist.
‘This is mostly due to the lack of satisfaction with the repetitive work … Sometimes it is difficult to see how you are making a contribution to society, because there is little recognition,’ she said.
‘I go back to pharmacy because it is what I know and there has always been a job available.’
Ms Williams said remuneration should take into account all the work pharmacists do routinely that is not recognised, such as counselling patients.
The PSA is calling on the incoming federal government to commit to a binding agreement to improve pharmacist wages and working conditions in recognition of their critical responsibilities, advanced training and skills.
It is also asking for a Medicare Benefits Schedule (MBS) rebate for pharmacists to be remunerated for multidisciplinary case conferences, and to introduce an MBS service payment to pharmacists for administering NIP vaccinations.
‘These are both good ideas,’ Ms Williams said. ‘After all, case conferences take time and you need to know the patient's history. With vaccinations, pharmacists must undergo the necessary training, keep up-to-date and spend time counselling and addressing a patient’s concerns or questions.’
While these asks are yet to be addressed, Prime Minister Scott Morrison pledged on Saturday that a re-elected coalition government would cut the price of some medicines listed on the Pharmaceutical Benefits Scheme from 1 January next year. A $10 price cut per prescription would see the maximum cost of PBS medicines drop from $42.50 to $32.50.
Opposition Leader Anthony Albanese also announced his party’s plan to cut costs of medicines on the PBS, with Labor proposing a $12.50 cut – making the maximum price for PBS medicines $30.
Retaining pharmacists
Despite the challenges of working in pharmacy, Ms Williams said she is hopeful about the future of the profession, particularly due to emerging career pathways.
‘There are likely to be more interesting and rewarding opportunities available for pharmacists in aged care facilities,’ she said.
‘I am also hopeful that advocacy will convince more GP clinics to employ pharmacists on-site for patient counselling and education, because I believe this is a more interesting and satisfying work life.’
For more on remuneration, look out for a special episode of PSA’s podcast Pharmacy & Me, coming soon. Catch up on previous episodes here.
* Name has been changed by request
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[post_content] => A new standard of care will help to prevent long-term reliance on opioid analgesics used for acute pain.
The first national Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, developed by the Australian Commission on Safety and Quality in Health Care (ACSQHC), details appropriate opioid use in emergency departments and after surgery.
Released today, the standard suggests considering alternate analgesics and promotes cessation plans where opioids are required.
The aim is to recalibrate the opioid-first habit and provide a guideline to ensure all patients receive the same level of evidence-based safe and effective opioid prescribing.
‘We need to fine-tune our prescribing and use of opioid analgesics for acute pain, to reduce the harms associated with inappropriate prescribing and avoid short-term use becoming a long-term problem,’ said ACSQHC Chief Medical Officer and Conjoint Professor at the University of Newcastle Anne Duggan.
With around 2.5 million operations in Australia per year, PSA General Manager Policy and Engagement Chris Campbell MPS said the standard should help to improve opioid safety in acute care and beyond.
‘Too many Australians use opioids for far longer than intended post-surgery,’ he said. ‘PSA endorses the standard, which should be embedded in practice to improve the management of opioid use in acute care, and prevent harm upon discharge back into the community.’
Pharmacists’ role in opioid management
As medicines experts, pharmacists in all areas of practice play a big role in ensuring opioids are used appropriately, Prof Duggan said.
Hospital pharmacists in charge of stewardship programs should educate junior medical staff, who typically compile discharge summaries.
‘Around 70% of patients in hospitals are discharged on opioids, just in case,’ Prof Duggan said.
‘[Pharmacists] should be reminding clinicians that there is no role for modified-release opioids and clinicians should be prescribing the immediate-release medications,’ she said.
Pharmacists should also educate junior clinicians to not only test for pain, but also function.
‘They should be thinking, “How long does this patient need opioids? How do I calculate, based on the day before discharge, how much they need? How do I calculate what to give them when they get home? And how do I write to the GP?”’
When patients are assessed for opioid prescriptions, pharmacists should ensure clinicians know what other medicines they are taking.
‘[This will prevent] overdose in terms of sedatives, and ensure they're getting the right opioid,’ Prof Duggan added.
With many acute-care patients discharged to residential aged care facilities, on-site pharmacists play a significant role in ensuring opioids are used appropriately.
‘There are few other people with the same expertise to make sure that there’s a good indication for why the patient is on the medication, that the patient is on a sensible dose, that somebody has thought about their other medication and that there is a weaning plan,’ Prof Duggan said.
‘They can certainly raise the alarm with the GP that something's not right.’
Promoting the standard in a community setting
Patients may also be discharged back into the community with opioid scripts, making community pharmacists important gatekeepers in preventing opioid misuse and overdose.
‘When a patient goes to collect their script, pharmacists should educate them on the use of the drug and misuse, and [ensure] that they understand the side effects, risks and benefits of the opioids and what the [discharge] plan is,’ Prof Duggan said.
All patients discharged on opioids should eventually come off them, she warned.
With pharmacists often on the receiving end of prescribing, there are several checks they can conduct to ensure the guidelines have been followed.
Along with screening for modified-release opioids, pharmacists can pick up issues on prescriptions that don’t make sense.
‘[For example], the patient is X weeks postoperative and they are still on the same dose,’ Prof Duggan said.
‘Pharmacists can identify patients who haven't got a weaning plan, check the patient knows when to take it and why they're taking it, and identify and address [adverse] effects.’
Pharmacists can also assess patients in terms of the risk benefit.
‘If the patient is in trouble, pharmacists have a great role to play by ringing the GP and saying, “This patient's on this. I don't know why they're on it and they're having problems”.’
Real Time Prescription Monitoring (RTPM) can also be used to screen patients at risk of opioid misuse.
‘RTPM is another string to the bow with all the things we’re currently trying to do to reduce the harm from opioids,’ Prof Duggan said. ‘It's a great complementary initiative.’
Carefully dispensing opioids
To educate patients about the risks of opioids, pharmacists should take additional measures including labelling the medicines correctly, and providing take-home information and naloxone.
A fact sheet in the Australian Pharmaceutical Formulary Handbook (APF) digital issue, approved by the Therapeutic Goods Administration, outlines use of the Cautionary and Advisory Label 24 for opioid medicines.
Label 24, which states, ‘Use of this medicine has the risks of overdose and dependence’, is recommended for opioid medicines including buprenorphine, codeine, dihydrocodeine, fentanyl, hydromorphone, methadone, morphine, oxycodone, tapentadol and tramadol.
The risk of harm from opioids increases when patients use opioids in high doses, for longer than 90 days, or with medicines or substances with sedative or central nervous system depressant effects (including alcohol and illegal drugs). The risk of harm also increases when patients have complex comorbidities.
Harm from opioids includes overdose, physical dependence and opioid use disorder such as addiction and psychological dependence.
Pharmacists should provide the Opioid medicines patient information handout to patients receiving opioid medicines marked with Label 24. However, the label and handout may not be appropriate in some circumstances, such as when patients are using opioids for cancer or palliative care needs.
Pharmacists should also consider supplying take-home naloxone nasal spray or injection to patients receiving opioid medicines. For more information, see Naloxone for opioid overdose in the APF.
Opioid safety is everyone’s responsibility
Like most aspects of healthcare, the solution to opioid safety doesn’t lie with one root source, Prof Duggan said.
‘From the pharmacist point of view, they are the medication experts and they are in a fantastic position to influence prescribing practices,’ she said.
‘The doctor holds the pen, and the consumer is the one who is getting the medication and should be asking questions. They also know all the side effects [they are experiencing].’
Lastly, hospital pharmacists can ensure the standard is met by developing stewardship programs.
‘Everyone has a bit of expertise, so if everyone works together, you get a much better outcome,’ Prof Duggan added.
Read the full Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard here.
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[post_content] => Experts share vaccination advice for ensuring the community is protected against COVID-19 and influenza.
1. Perfect your co-administration technique
Co-administering the influenza and COVID-19 vaccines provides both convenience for the patient and protection against both types of viruses, said Dr Mary Bushell MPS, Clinical Assistant Professor at the University of Canberra and a contributor to the 2022 Immunisation Update.
‘Research also shows that being vaccinated against influenza provides some cross-protection to COVID-19, reducing hospitalisation and death,’ she added.
[caption id="attachment_18371" align="alignright" width="208"]
Dr Mary Bushell MPS[/caption]
GP Pharmacist Zachary Sum, who has just started co-administering the vaccines, said it is best to administer the COVID-19 vaccine in one arm and the influenza vaccine in another.
‘If the patient wants to receive both in one arm, they should be spaced horizontally 2.5 cm apart in the central and thickest part of the deltoid muscle,’ he said.
Pharmacists should ensure they use landmarking techniques so that both vaccines are administered into the deltoid mass, Dr Bushell said.
‘A vaccine given too high, too low or too far to the side may cause shoulder injury related to vaccination,’ she added.
It is crucial to check the patient's eligibility for the COVID-19 ‘winter dose’ in terms of timing, however.
‘Co-administering the vaccines is a good idea but it is equally important to ensure that eligible patients receive the COVID-19 winter booster dose at least 4 months after their third dose,’ Mr Sum said.
2. Patient care improves when barriers are removed
Queensland-based GP Pharmacist Catherine Laird MPS recently demonstrated why location-specific regulations should be removed to allow pharmacists to vaccinate patients in different settings.
‘Yesterday, one of our practice nurses had to go home sick unexpectedly, but we had patients waiting for flu and COVID-19 shots,’ she said.
‘I said, “I can help out”.’
While Ms Laird was able to see each patient who was booked in for a vaccination, she also provided extended protection to some patients through co-administration.
‘A couple of the people I spoke to were only there for a COVID-19 shot and they didn't realise the influenza shots were available,’ she said. ‘So I was able to [vaccinate them against influenza] as well.’
[caption id="attachment_18356" align="alignright" width="300"]
GP pharmacist Catherine Laird MPS vaccinating a patient[/caption]
This shows just how important pharmacists are in helping to keep the community safe.
‘Pharmacists are the medicines experts, so [we] have the knowledge to answer people's questions, for example around co-administration,’ Ms Laird said.
Removing barriers for pharmacists to provide other vaccines along with the locations for administration is in the best interests of the community, she believes.
‘There were patients booked in for other vaccines yesterday, and I got asked if I could help with those patients as well,’ she said.
‘I had to explain that pharmacists can't administer tetanus/whooping cough vaccines outside of a pharmacy, which was met with some bemusement.
‘The more access points to vaccination, [such as] in a GP practice like I did yesterday or expanding into aged care facilities, the more people are going to be able to get vaccinated.’
3. Remind overseas travellers to get vaccinated against flu at least 2 weeks before flying
The most common vaccine-preventable disease acquired by international travellers is Influenza. With overseas travel now permitted, it is essential prospective travellers arm themselves against the virus.
‘Individuals who are planning international travel should be vaccinated against influenza at least 2 weeks before their trip,’ said Dr Bushell.
4. Protecting children under 3 is a priority
Children are ‘superspreaders’ of influenza. According to research by the Infectious Diseases Society of America, Children aged 1−5 years have a higher total viral burden with prolonged virus shedding.
‘There is concern that they are at a higher risk of influenza and its complications this year,’ Dr Bushell said.
Dr Bushell said that more children under the age of 5 years old are hospitalised with influenza in Australia each year than any other vaccine-preventable disease – including COVID-19.
‘Vaccination provides children with protection against influenza and its complications,’ she said.
‘In an influenza season where there are more unknowns than usual, it’s the best way to keep your child protected.’
Children under 9 years of age who are receiving the influenza vaccine for the first time will need two doses, spaced 1 month apart.
5. Queensland-based pharmacists can vaccinate children 5 years and older
In an Australian first, it was announced last month that pharmacists in Queensland can vaccinate children aged 5 years and older against influenza.
Under emergency health orders, Queensland pharmacists are permitted to administer influenza vaccines to children in this age group in any Australian Government and Queensland Government controlled COVID-19 vaccination service.
This includes community pharmacies, medical centres, hospitals, Aboriginal Community Controlled Health Organisations, aged care facilities and disability centres.
‘Children can be influenza super-spreaders and vaccination is the best line of defence for themselves and those around them,’ said PSA’s Queensland Branch President Shane MacDonald.
‘The school holidays are a great opportunity for kids to come in for their COVID-19 and influenza vaccines on the same day.’
Looking to refresh your immunisation knowledge? Check out PSA's Immunisation Online Refresher Course.
[post_title] => Top tips for protecting patients against ‘flurona’
[post_excerpt] => New regulations and building back immunity to influenza are key to protecting the community this season and avoiding 'flurona'.
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[title_attribute] => Top tips for protecting patients against ‘flurona’
[title] => Top tips for protecting patients against ‘flurona’
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[post_content] => After 2 years of low influenza rates due to COVID-19, the 2022 flu season is unpredictable, and could be a whopper. Here are six things you need to know.
1. ATAGI recommends influenza vaccines for everyone over 6 months of age
The Australian Technical Advisory Group on Immunisation (ATAGI) recommends all Australians aged 6 months and over receive an influenza vaccination annually, unless medically contraindicated.
Australia experienced ‘historically low’ levels of influenza in 2021, with just 598 laboratory-confirmed cases and no deaths. This is compared to 313,033 notifications and 953 deaths pre-pandemic in 2019. ATAGI has warned that ‘with borders reopening, a resurgence of influenza is expected in 2022’, however the severity and timing of outbreaks is impossible to predict.
Not just for the most at risk, influenza vaccination is recommended for all. If a patient had an influenza vaccine in late 2021 or early 2022, ATAGI advice states they should still receive the 2022 formulation.
2. NIP vaccines won’t arrive until early April. Eligible patients should wait
For patients 65 years and older, the adjuvanted influenza vaccine (Fluad Quad) is preferred over the standard influenza vaccine. It is the only National Immunisation Program (NIP) vaccine funded for people over 65 years of age.
Immunisers should not administer non-NIP vaccines to those over 65 years unless there is a compelling reason, for example imminent travel before the NIP vaccine is available.
Influenza vaccines funded through the NIP will be available through pharmacies in all states and territories except Queensland in 2022. This includes New South Wales, Tasmania and South Australia, which all came on board for NIP-funded influenza vaccines for the first time this year.
There have been no changes this year to the medical conditions that make some individuals (5–65 years of age) eligible for NIP influenza vaccines. Only some states provide NIP vaccines to community pharmacies for this cohort.
3. You need to check AIR before every jab (and upload it, too)
It is essential to check the Australian Immunisation Register (AIR) before each vaccination to ensure vaccination is appropriate, the correct patient is identified and the record of administration is uploaded to the correct profile.
Rather than seeing this as a burden, it is a chance to identify missing vaccinations, said PSA’s General Manager Policy and Engagement Chris Campbell MPS.
‘You really should use the influenza vaccination as an opportunity to promote COVID-19 vaccination, and vice versa,’ he said.
‘If you have a patient’s AIR history on the screen in the consult room, it’s a great conversation starter about making sure other vaccines are up-to-date or booked in.
‘It’s a great environment for serendipitous vaccination. ATAGI has advised influenza vaccines can safely be co-administered with any COVID-19 vaccine, which means there is no reason to delay either vaccination’.
4. Despite administering COVID-19 vaccines, pharmacists still can’t vaccinate against influenza in kids <10 years
Make sure you don’t inadvertently give a vaccine you’re not authorised to.
There is a double-standard when it comes to pharmacist immunisers vaccinating children, Mr Campbell said.
‘We can give COVID-19 vaccines to children aged 5–11 years, but we can’t give flu shots to any child under 10 years of age,’ he said. ‘This is something that needs to change – parents shouldn’t be penalised by red tape.’
5. Children <3 years have never been exposed to influenza and are now a priority
The historically low levels of influenza due to the pandemic mean most children under 3 years of age have never been exposed to the virus, making them a priority group for vaccination.
All children under 3 years of age are eligible for an NIP-funded influenza vaccines.
6. Influenza vaccination should be offered throughout the flu season, not just at the start
While most pharmacies and medical practices administer the majority of influenza vaccines in March–May each year, ATAGI recognises there is still benefit to vaccination when administered later in the flu season.
Vaccination should continue to be offered as long as influenza viruses are circulating and a valid vaccine (before expiration date) is available. Some vaccine brands have an expiry date of February 2023.
PSA continues to fight to remove barriers to vaccination
Making NIP vaccines available through community pharmacies, and other places pharmacists practice, makes it easier for the most vulnerable members of the community to protect their health.
Mr Campbell said this needs to be expanded to include all NIP-funded vaccines and remuneration for vaccine administration.
In its 2022–23 pre-Budget submission, PSA called on the federal government to introduce an immunisation service payment of $39.10 per NIP vaccination administered by pharmacists.
It advised the payment should be implemented through the Medicare Benefits Schedule (MBS) and modelled on the Level B payment available to GPs. This is defined as professional attendance by a general practitioner lasting less than 20 minutes, which includes providing appropriate preventive health care.
‘Improving remuneration ensures pharmacists are recognised in accordance with other vaccinators, both financially and professionally,’ Mr Campbell said.
‘Funding for pharmacists will ensure there are no out-of-pocket costs for the most vulnerable Australians who access the National Immunisation Program, aligning with the policy intent of the program.’
Pay parity would also help ensure vaccination services remain viable for pharmacies, which is particularly important in rural and remote areas where access to a GP may be limited.
| 2022 influenza vaccination resources: |
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[post_content] => Suspected of drug-seeking behaviour. Told their excruciating pain is ‘normal’. Waiting years for a diagnosis. These experiences are all too common for women with endometriosis, but pharmacists can be important allies for the hundreds of thousands of ‘endo warriors’ across the country.
When 24-year-old Jane* came into the pharmacy where Sepehr Shafizadeh MPS was working in Mackay, Queensland complaining of intense period pain and bad irritable bowel syndrome (IBS) symptoms, he suspected there was more to the story.
‘She was asking for Ponstan for period pain,’ Mr Shafizadeh told Australian Pharmacist.
‘I asked about the timing of the pain, and she mentioned that previously it occurred just before menstrual bleeding but now it was happening a few days before as well.’
Mr Shafizadeh ascertained Jane had suffered from IBS ‘for a long time’ and that the symptoms, including painful bloating, were often worse during her period. She was taking 10 mg of Lexapro per day and using Iberogast.
‘She was very distressed and said her IBS wasn’t really under control,’ Mr Shafizadeh said. ‘She said it was really affecting her quality of life and that the antidepressant wasn’t providing any relief.’
Endometriosis quick facts
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[post_content] => Note: For more DAA top tips, see the February-March 2022 issue of Australian Pharmacist.
Two pharmacists share safety risks averted by using every DAA packing check as a mini-medicine review.
Checking dose administration aids (DAAs) is a fundamental part of the role of nearly all
community pharmacists.
Most pharmacists are very familiar with accuracy checks – whether it be for a single patient or a large cohort of checking.
However, less active consideration is probably given to an equally important part of the checking process – and it is probably something you do without realising it; a mini-medicine use review.
Some red flags pop up during the dispensing process where a medicine is initiated (e.g. methotrexate erroneously prescribed as a daily medicine), whereas others might jump out when glancing through a medicine profile during accuracy checks – such as a triple-whammy risking acute renal injury.
But what are pharmacists’ obligations? And how do you make sure you don’t miss significant medicine safety problems?
PSA community pharmacist members Kevin Ou, in Sydney, and George Salib, outside Perth, share their tips for a top DAA service.
Professional obligation to oversee medicine profile
Standard 15 of the Professional Practice Standards for Pharmacists describes the professional obligations of pharmacists in DAA services as overseeing: ‘holistic services that encompass medication assessment and reconciliation, packing of DAAs, and the professional support provided to ensure the optimal use of DAAs, to support the safe and effective administration of the patient’s medication and improve adherence’.
This includes an obligation to: ‘regularly review the appropriateness of the patient’s medication administration solution(s) or DAA device and adjusts arrangements
in response’.
This also means identifying any problems and resolving them when they come up through opportunistic or routine medication review services.
Review of the medicine profile should occur:
‘You must have your brain in gear when working with DAAs and patients who use them, says Kevin Ou MPS. ‘They are often patients at greatest risk of safety problems with their medicines.
‘Something as simple as documenting OTC purchases as non-packed medicines can identify potential drug-drug interactions,’ he advises.
‘Checking a DAA for accuracy is an ideal time to run your eye down the medicine list for anything unusual. Are sedating medicines being packed for a morning dose? Do the doses of some medicines suggest renal impairment when others seem to be at the full dose?’
Mr Ou suggests to pharmacists to ‘ask yourself “is this a safe pack?” when looking through the medicines, which can efficiently go a long way to finding and resolving problems which might otherwise go unnoticed until a fall, or hospitalisation, or worse’.
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Presenting case Male in early 70s with atrial fibrillation brought DAA to hospital for a cardiac-related admission. Discharged with new script for apixaban 5 mg for addition to DAA twice daily with no other changes. At the pharmacy patient requested apixaban dispensed as non-packed until next DAA due. |
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Regular medicines
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Relevant medical history atrial fibrillation, atherosclerotic cardiovascular disease, GORD |
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Medicine safety risk life-threatening bleed due to excessive anticoagulation therapy |
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Assessment Medication reconciliation undertaken with new prescription following pharmacy protocols when changes made to a DAA. This revealed patient also on aspirin and warfarin (non-packed). Patient unaware apixaban was to replace the warfarin. |
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Action With safety concerns, apixaban not immediately dispensed. Cardiologist contacted. Due to patient’s INR, confirmed patient should cease warfarin and start apixaban immediately. Pharmacist organised new DAA, delivered to patient’s home and warfarin collected to reduce risk of duplication. Patient education was provided. |
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Resolution The risk of a life-threatening bleed was removed. |
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Presenting case Female patient, aged 84, regularly bought paracetamol at the supermarket for arthritic pain in addition to medicines packed in her DAA. She did not recall paracetamol was already in her DAA. |
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Regular medicines
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Relevant medical history suspected dementia, elevated LFTs |
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Medicine safety risk paracetamol toxicity |
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Assessment After recommending a Mini-Mental State Examination to her GP, GP requested a HMR. HMR identified nightly alcohol consumption. |
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Action HMR outcomes reported to GP. GP ceased all paracetamol and advised stopping alcohol to eliminate as many causes of elevated LFTs as possible. Husband now oversees wife taking DAA medicines to ensure she does not take anything not prescribed by either a pharmacist or GP. |
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Resolution LFTs now within normal range. |
To learn more, visit the What’s in the DAA? session at the NSW ATU at psa.org.au/events
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[post_content] => Case scenario
Craig, a 26-year-old male, enters your pharmacy and asks to speak to the pharmacist. He enquires about the use of ecstasy and explains that he will be attending a music festival on the weekend with friends. It is the middle of summer, and you know it’s going to be very hot on the weekend. Craig asks you for advice on the risks associated with ecstasy use and methods for reducing these risks.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.2, 1.4, 1.5, 1.6, 2.2, 2.3 |
Drug checking, also known as pill testing, is a process involving the chemical analysis of an illicit substance such as a pill or powder, followed by tailored feedback and counselling. The main aim of the service is to reduce drug-related harms, hospital admissions and deaths. Drug checking services have become well established overseas, with services set up in a number of countries including the Netherlands, Spain, the United States, Canada, the United Kingdom and New Zealand.1,2 These provide a mix of postal, fixed-site and on-site services, allowing people to anonymously post drugs for analysis, attend a permanent site, or visit a mobile facility such as those provided at festivals. In Australia, the first government-sanctioned on-site drug checking trial was conducted in 2018 at the Groovin the Moo festival in the ACT, followed by a second trial in 2019. In October 2021, the ACT Government approved and provided funding for Pill Testing Australia (PTA) and Harm Reduction Australia (HRA) to pilot a fixed-site pill testing service in the ACT. 3,4
The Pharmaceutical Society of Australia (PSA), Australian Medical Association (AMA) and Royal Australian College of Physicians (RACP) support further trials to inform the role of drug checking in Australia’s harm minimisation strategy.5–7 The 2019 National Drug Strategy Household Survey (NDSHS) found that 57% of Australians supported drug checking at designated sites, while 27% were opposed and the other 15% were unsure.8
Illicit drug use among Australians is common. The 2019 NDSHS found that 9 million people (43%) aged 14 years and over had illicitly used a drug (including pharmaceuticals for non-medical purposes) at some point during their lifetime.8
With respect to drug checking, the hallucinogenic amphetamine3,4 methylenedioxymethamphetamine (MDMA, or ecstasy) is of particular interest, as it is commonly used and tested for at music festivals and events. The 2019 NDSHS found that 2.6 million people (12.5%) aged 14 and over had used this drug during their lifetime, with 3% of people aged 14 and over (600,000 people) reporting use in the last 12 months.8
Between July 2016 and January 2017, several young Australians tragically lost their lives following the consumption of substances they believed to be MDMA or psilocybin (magic mushrooms).9 In April 2021, the Victorian Coroner released findings related to the examination of five of these deaths. Postmortem analysis revealed that what they had taken was not pure MDMA or psilocybin, but rather the novel psychoactive substances 4-fluoroamphetamine and 25C-NBOMe.9 As a result of these findings, the Victorian Coroner recommended that drug checking services be implemented in Victoria as a matter of urgency.9
Prior to the Victorian Coroner’s report, the New South Wales Coroner released findings into the deaths of six young people between December 2017 and January 2019.10 In these cases, deaths occurred as a result of MDMA toxicity, with each individual found to have had dangerously high plasma MDMA concentrations.10 The NSW Coroner also noted 29 pre-hospital intubations, 25 intensive care admissions and 23 drug-related hospital admissions during the festival season between 2018 and 2019, which encompassed 25 music festivals.10 They considered the difficulty in discussing issues such as drug checking due to the illegality of drug use, and raised the inadequate nature of the ‘just say no’ message that is currently promoted. In addition, the NSW Coroner determined that the individuals involved lacked understanding of the risks associated with high-dose MDMA and were unable to identify signs of MDMA toxicity.10
Drug use occurs in a wide variety of settings, including music festivals, nightclubs and at home. While the NSW Coroner’s report focused on music festivals, several of the Victorian cases involved taking the drugs at home with friends.9
Novel psychoactive substances (NPS), also known as ‘designer drugs’, have been designed to mimic the effects of popular recreational substances including amphetamines (such as MDMA), hallucinogens (such as lysergic acid diethylamide [LSD]), and cannabis. The NPS implicated in the Victorian Coroner’s report were 25C-NBOMe and 4-fluoroamphetamine.
25C-NBOMe is a stimulant and hallucinogenic substituted phenethylamine, part of a group of drugs commonly referred to as an ‘N bomb’. It is highly potent and can be taken orally, sublingually or insufflated (nasally inhaled). Mild toxicity manifests as hallucinations, tachycardia, hypertension, sweating, agitation and confusion.
In severe cases, seizures, rhabdomyolysis, hyperthermia and death can occur.9 4-fluoroamphetamine is a central nervous system (CNS) stimulant with dopaminergic and serotonergic effects. De Sousa et al noted elevations in blood pressure following administration of 4-fluoroamphetamine in volunteers.11 Several case reports exist of haemorrhagic stroke and other cardiovascular complications following recreational use.12 Both substances have since been the subject of public warning campaigns.13
Despite being considered a novel psychoactive substance, 4-fluoroamphetamine was first synthesised in the 1940s.14 NBOMes (including 25C-NBOMe) are newer, being first synthesised between 2008, when 25I-NBOMe was synthesised by a German chemist, and 2010, when they began to appear on the internet.15
The NPS seen on the market are highly variable, with substances disappearing and reappearing on the market.9,13
MDMA is a hallucinogenic amphetamine that produces effects such as euphoria, feelings of closeness and decreased fear, making it a popular party drug.16,17 It is also currently being investigated as a potential adjunct to psychotherapy for the treatment of post-traumatic stress disorder (PTSD).18 A standard recreational dose of MDMA is generally 75–125 mg, though higher strength pills are not uncommon.16,19,20
Toxicity manifests as hyponatraemia leading to cerebral oedema and seizures.21 Hyperthermia may lead to complications, including rhabdomyolysis and disseminated intravascular coagulation.22
Given the lack of professional drug checking services in Australia, at-home reagent testing is the primary method of drug checking currently available. This is a rudimentary method of checking drugs that can be done using a small set of reagents at home. These reagents are legally available for sale in Australia, and in some cases have been distributed to users by harm reduction organisations such as Students for Sensible Drug Policy (SSDP).23 Upon contact with the substance, a colour change will occur which can then be compared to a chart. This can provide an indication of the presence of a substance (expected or not), but gives no assurance as to its purity or dose.
In combination with the development of an early warning network, to alert the public to dangerous substances in circulation, drug checking has the potential to reduce harm and deaths associated with the use of drugs obtained from an unregulated market.9 Quality control in the illegal drug market is non-existent, leaving individuals at risk of unknowingly consuming a drug that is not what they expected, adulterated or a higher dose than intended. Worldwide there has been a trend towards the manufacture of high-strength MDMA pills. For example, in 2019 UK-based drug checking organisation, The Loop, discovered 300 mg MDMA pills (three times the usual dose).19 Of particular note is the prevalence of NPS, which are often mis-sold as other drugs such as MDMA.
The drug checking process usually consists of two components: chemical analysis of the substance to give an indication of content and purity, and a healthcare consultation to provide tailored harm reduction information and support to the service users. A number of different models are used to provide this service.2
Chemical analysis
Chemical analysis is a critical component of the drug checking process. It should be undertaken by professional chemists using specialised laboratory equipment and followed by a discussion with a harm reduction or healthcare worker, who interprets the result for the end user.
The most sophisticated method of analysis uses gas chromatography in combination with mass spectrometry (GCMS).24 This is a method that can be used to determine the concentration of the detected substance as well as any known adulterants or dangerous excipients.24 There are downsides to this method – it is expensive, requires a trained chemist, the equipment is difficult to transport, and the results can take time.24 Fourier-transform infrared spectroscopy (FTIR) is a somewhat more accessible method that is commonly used. It is cheaper and more portable, and can be used to identify known substances using a database.24 It only requires a small sample to be submitted, such as a scraping from a pill or a small amount of powder. This method also has its downsides: it is not able to detect substances that are not in its database, and it doesn’t provide information on dose.24 FTIR is used by The Loop and was used during the 2018 and 2019 Australian drug checking trials at Groovin the Moo in Canberra.
Research conducted by Barratt et al in 2018 revealed that only one-third of service users would be willing to give up an entire pill, which is required for a comprehensive quantitative result where the amounts of individual ingredients are determined.25 This type of analysis is particularly important where there is a trend towards pills of high potency, such as what has been seen with MDMA in both the UK and Australia.19,20 However, the study also found that service users were only slightly more interested in quantitative results than qualitative results.25 The limitations of the method of analysis used should be highlighted during the healthcare consultation phase.
Healthcare consultation
The healthcare consultation component of the drug checking process, also referred to as a brief intervention, is fundamental for the promotion of harm reduction.
Qualified and appropriately trained healthcare workers, including doctors and pharmacists, deliver individualised counselling to assist the service user in understanding the implications of the chemical analysis result. There is usually no charge for the consultation, and advice is provided in a non-judgemental manner.
The healthcare worker takes into consideration individual factors such as weight, gender, tolerance, mental state and presence of other drugs (including alcohol or prescription medicines), as well as the environment (for example, hot days can increase risk). Service users may be counselled individually or in groups. They are given the opportunity to ask questions, and harm reduction resources including fact sheets and contact details for drug and alcohol services are made available.
In the case of on-site facilities at festivals, attendees can be referred directly to medical services if deemed necessary. A survey of Australian festival and nightlife attendees who use drugs found that only 36% of respondents would use a service with no individualised feedback, highlighting the importance of this intervention and the willingness of users to engage with a health professional.25
An argument often highlighted by those opposed to drug checking is that the presence of these services equates to condoning drug use.26 It is important to note that regardless of the result, drug use is never stated as being safe, but rather the focus is on minimising harms associated with use. It is made clear to the service user that the only way to guarantee safety is to avoid use. The focus is on pragmatic strategies to reduce harm, such as taking a lower dose, taking it over a longer period of time, or in the case of known dangerous adulterants, encouraging disposal.
Research shows that when seeking information about the contents of a substance, friends are the most common source of information followed by the dealer.25 Drug check reporting websites that test substances and publish results are also frequently accessed by service users.25 Only a minority of people who use drugs in Australia have their drugs tested, either with at-home reagent kits or through a professional service (where these have been available).25
Despite critics of drug checking services citing a lack of evidence for harm reduction, a recently published systematic review suggests that the presence of drug checking services, in combination with healthcare consultations and an early warning system, is effective in reducing harms.27 A study conducted by The Loop found a 95% decrease in drug-related hospital admissions at a festival in 2016 compared with the previous year, where no drug checking was conducted, with the change attributed to increased awareness of mis-selling (for example, selling NPS as MDMA) and the presence of contaminants, as well as alerts made via social media and word of mouth.28
The results of chemical analysis, combined with a brief healthcare consultation, have been found to change consumption behaviours.28 For example, a survey conducted following on-site drug checking at three music festivals in the UK found that 20.8% of people whose drugs were found to be ‘not as expected’ discarded the drug on-site at the drug checking facility.29 A further 29.6% self-reported disposing of the drug after leaving the testing area.29 Another 20.1% took a smaller dose than originally intended, and 9.4% returned the drug to their supplier, potentially reducing demand for these particular substances and subsequently supply.29
Related to this is evidence to suggest that drug checking services can alter drug markets, so people can make more informed decisions about what they choose to purchase. For example, over the 30 years that the Netherlands’ DIMS service has been running, the contents of MDMA pills have been found to be increasingly more consistent with expectations, and there has been a decrease in poor quality, adulterated or dangerous substances.30
Pharmacists have played a role in drug-checking services overseas. Pharmacists possess a unique set of skills that make them particularly suited to delivery of healthcare consultations following drug checking. For example, a risk assessment is undertaken with consideration to the service user’s physical and mental health, environment, gender, weight and other consumed substances (prescription or recreational, including alcohol) to identify any ‘red flags’ that might require prompt referral or in-depth counselling.
A 2016 Australian survey found that 85% of respondents would be willing to use a fixed-site service, external to events, and 61% of respondents would wait one week for results if the results were reliable.25 As such, a model where fixed sites (such as pharmacies) are used as nominated drop-off points for off-site analysis could be considered.
Pharmacists in Australia and internationally have been involved in harm minimisation strategies.31 Currently, pharmacists in Australia are involved in the needle and syringe exchange and supply of pharmacotherapy for the management of opioid and nicotine addiction.32 The facilitation of drug checking services is in line with the harm minimisation work that pharmacists already do, and like other harm minimisation strategies, it is not intended to spread the message that illicit drug use is safe or without risk. Rather, it can be a way to provide support to hard-to-reach members of the population, including young people who use drugs. It is an opportunity for these people to engage with a health professional who is able to provide accurate and evidence-based advice and support without judgement. In some cases, referral to an external support service may be appropriate. Support services include:
While many on-site drug checking models utilise the skills of analytical chemists to operate laboratory equipment, pharmacists are able to interpret the results of testing and provide tailored advice to help the service user understand the result and its relevance.
Case scenario continuedYou ask Craig if he would like to join you in the private counselling room to discuss his queries, and ensure that advice is provided in a non-judgemental manner. You explain that there is no safe level of illicit stimulant use. You also explain that drugs sold as ecstasy do not always contain MDMA, instead they can be a mix of other substances; and if they do contain MDMA, the amount can vary. You outline a number of possible adverse effects, including seizures, cerebral oedema, arrhythmia, haemorrhage and death. Finally, you explain that the risk is also increased if other drugs (including alcohol) are taken at the same time, and that hot weather can contribute. You provide Craig with the details of the Alcohol and Drug Foundation website (and explain this has useful information on reducing the risks of drugs) as well as the Alcohol and Drug Foundation Drug information and advice line for further information. |
Drug checking is a harm-minimisation strategy that aims to provide service users with information on the chemical makeup of their drugs, and the risks associated with their consumption, to reduce drug-related harms, hospital admissions and deaths. Drug checking can also contribute data to early warning systems that can alert health professionals and law enforcement agencies to the current nature of illicit drug markets and enable them to tailor their response. Drug checking services are well established overseas with many utilising the expertise of health professionals, including pharmacists, to provide tailored and non-judgemental advice to service users based on the results of chemical analysis. With increasing local and international evidence supporting its use as a harm minimisation intervention, drug checking is expected to play an increasing role within Australia’s health system in coming years.
ALICE NORVILL BSc, BPharm is a pharmacist and specialist in poisons information working at the Victorian Poisons Information Centre, assisting in the management of unintentional and intentional exposures to various substances, including illicit drugs. In 2019 she volunteered with Pill Testing Australia to deliver brief interventions at the Groovin the Moo trial in the ACT.
The author would like to acknowledge: Rohan Elliott, BPharm, BPharmSc(Hons) MClinPharm, PhD, FSHP, and Dr Monica Barratt, BSc(Psych)(Hons), PhD, for their contribution to this paper.
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[post_content] => Case scenario
Mrs Ma, aged 60, presents with a prescription for osimertinib 80 mg once daily. It is a new medicine for her. She has a history of metastatic adenocarcinoma NSCLC with right-lung primary and bone metastasis. Mrs Ma returns to the pharmacy 2 weeks later complaining of a rash and tenderness to her arms. On examination, the rash looks pustular and erythematous and only extends to her right forearm. Mrs Ma denies any other rashes on her body or recent changes to her medicines or creams/body washes.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency addressed: 1.1, 1.4, 2.1. 2.2, 3.1, 3.2. 3.3 3.5 |
Lung cancer is the most common cause of cancer-related death both worldwide and in Australia.1,2 Lung cancer is the fifth most diagnosed cancer in Australia, with the highest mortality rate and a 5-year survival rate of around 18%.1,2 There are two major subdivisions of lung cancer: small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC).3–5
NSCLC accounts for approximately 85% of all lung cancers, with the remaining being SCLC.3–5 NSCLC arises from the epithelial cells of the lung situated within the central bronchi to terminal alveoli. The most common histologies are squamous cell carcinoma (30%), adenocarcinoma (30–40%) and large cell carcinoma (10–15%).3–5 Squamous cell carcinoma starts near a central bronchus, while adenocarcinoma and bronchioalveolar carcinoma usually originate from peripheral lung tissue.3–5 SCLC arises in peribronchial locations and tends to infiltrate the bronchial submucosa.3–5
Risk factors for lung cancer include3–5:
Although NSCLCs are associated with cigarette smoking, adenocarcinomas can be found in patients who have never smoked.3–5 Smokers have on average a 10-fold higher risk of developing lung cancer than lifetime non-smokers.3–5
The most common symptoms at presentation include3–5:
In SCLC, infrequently patients may present with signs and symptoms of one of the following paraneoplastic syndromes due to various peptide hormone productions3–5:
At initial presentation, a thorough history is required, taking note of3–5:
Investigations to aid diagnosis and staging3–5:
SCLC is defined by the spread of the cancer. Cancer that has spread beyond the supraclavicular areas is classified as extensive stage disease (ED), while cancer that has not spread is called limited stage disease (LD).6
The staging of NSCLC uses the American Joint Committee on Cancer (AJCC) TNM system, which stages cancer using these three key criteria7:
In July 2021 the Australian Government announced a $6.9 million budget to commence early scoping of a potential national lung cancer screening program to increase early diagnosis and survivorship of lung cancer.8 The screening program will target high-risk individuals by conducting 2-yearly low-dose computed tomography (LDCT) scans in these individuals.8
Primary prevention is still one of the most important strategies for reducing the burden of lung cancer in Australia. As primary healthcare professionals, pharmacists are integral in providing education and support for smoking cessation, preventing smoking uptake and providing counselling on minimising our patients’ exposure to second-hand tobacco smoke.
The pharmacist can play a major role in guiding patients through smoking cessation. Guidelines for smoking cessation are widely accessible and include the PSA’s counselling guideline for common aliments – smoking cessation.9 When assessing a patient, it is important to gather patient information, including medical history, current medications, readiness to quit, nicotine dependence and previous attempts to quit.
The PSA guideline outlines how to assess nicotine dependence and situations where patients may require referral, such as history of cardiovascular disease.9 When developing a quit strategy for patients, a combination of behavioural and medicinal interventions should be used. Patients should be provided with verbal and written information on the use of smoking cessation products and referred to Quitline for additional support packs and telephone counselling.9 It is important to consider the impact that smoking cessation may have on other medicines, as tobacco smoking induces CYP1A2 metabolising enzymes. As a result, smoking cessation can increase the levels of drugs metabolised by this enzyme.9
Management of lung cancer is multimodal and includes surgery, radiation therapy, chemotherapy and targeted therapy. These therapies can be used either alone or in combination, depending on the type of lung cancer, stage of lung cancer, molecular mutations, and the patient’s performance status.
These decisions are often made by multidisciplinary teams to help assess all aspects of the patient’s condition.3,11
Surgery
Patients with early-stage NSCLC disease have the best chance of cure if surgery is undertaken to remove the primary tumour.3 Surgery also allows for further testing to define the stage of cancer, and therefore guides the ongoing treatment decisions. The common surgical procedures include segmentectomy (removal of part of a lobe), lobectomy (removal of one of the lobes) or pneumonectomy (removal of part or all of lung).12 The type of surgery is determined by the extent of disease and the cardiopulmonary reserve of the patient.11
Radiation therapy
While not always a first-line option, radiation therapy has a potential role in all stages of NSCLC, as either definitive (intention of cure) or palliative therapy (end-of-life comforting therapy).
Radiation therapy is generally used in early-stage NSCLC in combination with chemotherapy as definitive therapy and in advanced stage NSCLC as palliative therapy.11,12
Pharmacotherapy
Recent advances in pharmaceutics have increased the availability of medicines to treat NSCLC. As a result, a range of targeted therapies and chemotherapy are used in the management of NSCLC. New therapies such as targeted mutation therapy have shown increased median survivals of around 25 months.3
Targeted therapies – tyrosine kinase inhibitors (TKIs)
NSCLC consists of molecular subtypes identified by genetic aberrations, which allows for use of targeted therapy. Targeted therapies produce higher response rates than immunotherapy in metastatic NSCLC, and patients should receive these agents first-line where indicated.13
TKIs are small molecule inhibitors which inhibit specific tyrosine kinases that are abnormally activated in some types of cancer.14 Activation of tyrosine kinases can increase survival and proliferation of malignant cells and increase angiogenesis, invasiveness, and metastatic potential of tumours.14 TKIs can target tumours harbouring targetable driver mutations.
Epidermal growth factor receptor (EGFR) tyrosine kinase Inhibitors
EGFR mutations cause uncontrolled cancer cell proliferation. EGFR has been shown to be over-expressed in more than 60% of NSCLC cases and is associated with a poor prognosis.15
EGFR TKIs inhibit EGFR-dependent tumour cell proliferation and can be further classified as3:
EGFR TKIs are indicated as first-line treatment for advanced stage NSCLC in patients with evidence in tumour of an activating EGFR gene mutation.16 The EURTAC study demonstrated that erlotinib had better progression-free survival (PFS) of 9.4 months versus 5.2 months with conventional first-line chemotherapy.16 Afatinib and osimertinib are indicated and PBS-listed for first-line treatment of Stage IIIB (locally advanced) or Stage IV (metastatic) NSCLC. The use of first-generation eGFR TKIs, erlotinib and gefitinib, is less favoured due to the availability of superior alternatives.23 Osimertinib is also available on the PBS as second-line EGFR TKI therapy for patients who have progressed on prior EGFR TKI therapy and have evidence of EGFR T790M mutation in tumour material.
Adverse effects of EGFR TKIs
As this is an emerging therapy, pharmacists should be aware of potential adverse effects of these agents.
Outlined below are some of the common adverse effects for osimertinib (EGFR TKI) and incidences of each adverse effect26:
Further information on side effects and management can be found in eviQ under individual agent treatment protocols.23
Pharmacists play a key role in management of EGFR inhibitor skin reactions. EGFR TKIs commonly cause skin reactions which present as a papulopustular rash, usually on the face and upper body, within the first 2–4 weeks of treatment.14 This could also present as itch, dry skin, paronychia, nail disorders and abnormal hair growth. It is important to note that this adverse effect occurs because of direct EGFR inhibition, and not as an allergic reaction to the therapy.23
These reactions are treated with topical corticosteroids (hydrocortisone 1% cream) and patients may be started on a tetracycline such as doxycycline. Pre-emptive prophylactic doxycycline may be used with initiation of EGFR TKI at the discretion of the prescriber.23 It is important to provide advice to patients on general measures to reduce skin reactions, including twice daily application of moisturiser and the use of sunscreen before going outdoors, as rash may be more severe in areas of skin exposed to sunlight.14,23 Patients should be advised to report within 24 hours any skin changes such as rash and itch to their oncologist.
Drug interactions – osimertinib
Osimertinib is metabolised by CYP3A4 and strong inducers of this metabolising enzyme such as carbamazepine, phenytoin, rifampicin and St John’s wort may decrease exposure of osimertinib. These drugs should be avoided, but if that is not possible the dose of osimertinib should be doubled.
Osimertinib is an inhibitor of P-gp, and drugs metabolised by P-gp with a narrow therapeutic index (e.g. digoxin and dabigatran) should be monitored for signs of increased exposure.
Anaplastic lymphoma kinase (ALK) fusion inhibitors
ALK gene mutation occurs in 2–7% of NSCLC resulting in constitutive activity and oncogenesis.3,5 Crizotinib is a first-generation ALK TKI which has activity against ALK mutations.15 It is also important to note that crizotinib has other molecular targets that are significant in NSCLC, such as the c-ROS oncogene 1 (ROS-1) and has recently also been approved for treatment of patients with evidence of ROS1 gene rearrangement in tumour material in Stage IIIB (locally advanced) or Stage IV (metastatic) NSCLC.23
Second-generation ALK inhibitors target ALK mutations with higher affinity and include ceritinib, alectinib and brigatinib. These are preferred agents for treatment of ALK positive Stage IIIB (locally advanced) or Stage IV (metastatic) NSCLC.23 Lorlatinib is a third-generation ALK TKI that was approved in November 2018 for patients who have progressed on crizotinib and another ALK inhibitor or after progression using alectinib or ceritinib as a first-line ALK inhibitor.3 This was based on the study by Solomon et al showing overall response rate (ORR) of 48% and median response rate of 12.5 months with lorlatinib in patients who previously received one or more ALK inhibitors.3
Emerging molecular targets
ROS, BRAF, RET, MET, NTRK and KRAS G12C mutations are other mutations that may initiate and maintain the growth of cancer cells. These gene mutations may be tested for in NSCLC due to emerging new TKIs being developed and approved for use in Australia that target these mutations.
Vascular endothelial growth factor (VEGF) receptor inhibitors
Bevacizumab is a monoclonal antibody (MAB) that targets the VEGF, inhibiting the formation of new blood vessels and reducing vascularisation and growth of tumours.14 Study E4599 (bevacizumab + carboplatin + paclitaxel vs carboplatin + paclitaxel) showed that the addition of bevacizumab resulted in a statistically significant improvement in overall survival and PFS.17 Consequently, bevacizumab is indicated for advanced or metastatic NSCLC in combination with carboplatin and paclitaxel and for continuing treatment, as monotherapy in a patient who does not have progressive disease.11
Immunotherapy PD1 and PDL1 inhibitors
The immune system is capable of anticancer activity; however, immune checkpoints or ‘brakes’ generated from the tumour can suppress the immune system’s activity.3 Immune checkpoint inhibitors release the ‘brakes’ of the immune system, allowing for full activity against the tumour.3 Pharmaceutical agents execute this through inhibition of T-cell antigen 4 (CTLA-4), program death ligand 1 (PDL-1) and its receptor (PD-1).14 Pembrolizumab, nivolumab (PD1 inhibitors), atezolizumab, and durvalumab (PDL-1 inhibitors) are immune checkpoint inhibitors approved for use in NSCLC. These agents may be used according to PBS restrictions for advanced stage disease in combination with chemotherapy, for patients with no targetable mutations, advanced stage disease following progression of first-line maintenance therapy for patients with locally advanced, un-resectable disease.11,12
The use of these agents in these settings is supported by several clinical trials. The IMpower150 trial, compared combination atezolizumab, bevacizumab, carboplatin and paclitaxel (ABCP) versus bevacizumab plus chemotherapy as first-line therapy.19 This study showed improved median overall survival in the ABCP arm compared to the bevacizumab plus chemotherapy arm (19.2 months versus 14.7 months).19
Adverse effects of PD1 and PDL1 Inhibitors
As immunotherapy boosts the immune response, an adverse effect of this may be over-stimulation of the immune system resulting in immune-related adverse events (irAE). These present as a range of autoimmune toxicities affecting any body system. Reactions may affect any organ system, including the liver, kidneys, skin (rash), endocrine (hypo- or hyperthyroidism), lungs (pneumonitis) and gastrointestinal tract (diarrhoea and colitis). Early identification and swift management are key in avoiding life-threatening severity.
Management of irAE requires referral to the patient’s medical oncologist without delay and will generally include treatment with corticosteroids and holding or permanently stopping the product depending on the grade of reaction.14 Further information on signs and symptoms of irAE can be found in eviQ.23
Chemotherapy in NSCLC generally includes the use of a platinum-based drug (carboplatin or cisplatin) in combination with another agent such as etoposide, pemetrexed, paclitaxel, gemcitabine or docetaxel.12 The role of chemotherapy in NSCLC varies significantly according to the stage of cancer and the ability to resect the cancer. To summarise, chemotherapy is generally used post- surgery in early-stage disease in combination with radiation for curative intent or in advanced-stage disease for patients without targetable mutations to increase survival and improve quality of life. Concurrent radiation and chemotherapy is more efficacious than sequential chemoradiation but increases the risk of adverse effects, particularly esophagitis.11
Patients diagnosed with SCLC often have extensive disease at the time of diagnosis.
As a result, the goal of treatment is the prolongation of survival and palliation of symptoms.12 In extensive disease, where patients are appropriate for chemotherapy, the standard regime is a platinum drug plus etoposide for 4–6 cycles in combination with radiation. These patients may also receive prophylactic cranial irradiation if disease responds well to chemotherapy.20 Patients who present with limited stage SCLC may be managed with concurrent chemotherapy and thoracic irradiation.12
The aim of palliative care is to improve the quality of life by reducing symptoms of cancer and slowing the spread of the cancer without the goal of curing the disease. These symptoms, which directly impact quality of life, include dyspnoea, cough, anorexia and fatigue.3 The involvement of a palliative care team can assist patients with advanced lung cancer in managing the symptoms as well as pain, nausea and end-of-life decisions.21
Each mode of therapy has significant adverse effects which are amplified by the use of these modalities in combination. Supportive care medications aim to prevent and manage these adverse effects. Pharmacists can play a role in the recognition of adverse effects of chemotherapy and immunotherapy and in ensuring appropriate referral and management. Patients experiencing adverse effects should be referred to their oncologist for further assessment.14
Patients undergoing treatment at a medical oncology centre are often supported by a team of doctors, nurses and allied health professionals who are willing to help. If patients have concerns regarding their treatment or adverse effects, they should be referred urgently to their treatment centre for direction.
Useful resources include:
The safe delivery of cancer treatment requires a multidisciplinary approach, and often care is shared between hospital specialists, hospital cancer care pharmacists, general practitioners and pharmacists.22 Communication between this team is key in ensuring best outcomes for the patient.
The accessibility of pharmacists allows them to play a key role in the care of patients with lung cancer. One of the most significant roles is that of encouraging smoking cessation. However, the emergence of oral therapies has resulted in the accessibility of cancer care medications in the community pharmacy. These medications require close clinical review for appropriateness, including screening for potential drug interactions and interactions with current medications, as well as complementary and alternative medicines. Patients commenced on these oral anti-cancer therapies in the community should be provided with detailed counselling and written information of treatment regime and adverse-effect management (accessible via eviQ).23 Patients receiving treatment from a cancer care centre may also present to community pharmacy, and therefore pharmacists can play a key role in early identification and management of adverse effects.
Case scenario continuedYou explain to Mrs Ma that the rash she has is common in people who take osimertinib and reassure her that prompt treatment with OTC hydrocortisone 1% cream and doxycycline will bring it under control. You emphasise that she should contact her oncologist without delay for assessment and prescription of the antibiotic so that the rash does not become worse. |
Lung cancer is the most common cause of cancer-related death both worldwide and in Australia.1,2 The identification of key mutations in NSCLC has allowed for emerging oral targeted therapy to be an integral part of NSCLC cancer management. Pharmacists have a key role in the education of patients on new targeted therapy and in the identification and management of adverse effects of treatment.
DANIELLE WOOLLEY BPharm (Hons) is pharmacist team leader at Royal Brisbane and Women’s Hospital and has practised in cancer care for the past 4 years.
VIVIAN DAY BPharm (Hons), GradDip (Clin Pharm) is a senior cancer care pharmacist at the Royal Brisbane and Women’s Hospital. She has been a pharmacist for 10 years, four of them in oncology, and is pursuing a postgraduate master’s degree in oncology.
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Case scenario
Natasha, a 23-year-old woman, presents to the pharmacy to speak to the pharmacist following a recent cold. She has nasal congestion, sinus tenderness, dental pain, fever (38.5 °C) and general malaise. Natasha has been using a non-prescription saline sinus flush with no apparent effect. Her friend Molly had similar symptoms months ago and told Natasha a full course of antibiotics solved her problems straight away. A full-time lawyer, Natasha says she must return to work as soon as possible and would like the quickest solution. She asks if antibiotics would be appropriate to alleviate her symptoms.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.5, 2.3, 3.5 ,5.3 |
As health professionals, pharmacists are inundated with new information from the thousands of articles published every year, creating an ever-expanding knowledge bank. Before we can effectively communicate research evidence to our patients, we must first be familiar with the ways that study results are presented. The number needed to treat (NNT) is a simple representation that compares the efficacy of different therapeutic interventions. The effects of new drugs described in randomised controlled trials (RCTs) and systematic reviews are usually based on dichotomous outcomes such as survival vs death, or cure vs no cure. The probabilities generated from these studies can be used to calculate a number of statistical values (i.e. NNT, relative risks, odds ratios, hazard ratios and absolute risk reductions) that can assist pharmacists to make informed decisions when evaluating treatment benefits or harms. But how exactly do we interpret the NNT? And what do we mean by risks and odds?
Risks and odds
The terms ‘risks’ and ‘odds’ are often used interchangeably to define the likelihood or chance of an event happening.1 In statistics, the two terms have specific meanings and are calculated in different ways. As such, they are not synonymous and should not be used interchangeably.
Risk is a concept that appears more familiar to patients and health professionals.1 It is the probability of an event occurring as a proportion of all possible outcomes.2 If we were to apply risk to rolling a six-sided die, there is a 1 in 6 (16.7%) chance of rolling any particular number. Building on risks, RCTs or cohort studies tend to report relative risks or risk ratios (RR). The RR of an event is the likelihood of its occurrence after being exposed to a risk variable (e.g. drug substances, surgery, other interventions), as compared with the likelihood of its occurrence in a control group (e.g. placebo, gold-standard therapy).3
Odds is a concept more commonly used to describe gambling stakes.1 It is the probability of an event occurring, divisible by the probability of the event not occurring.2 Hence, the odds of rolling any number from a six-sided die is 1 in 5 (20%). Case–control studies will typically report study results as an odds ratio (OR). The OR is the ratio of the odds of an event occurring in the exposed group, compared to the odds of occurrence in the unexposed group.4
Number needed to treat
The NNT is defined as the number of patients who need to be treated by an intervention (e.g. drug, therapy, surgery) over a defined time period to achieve one extra beneficial outcome, as compared to an alternative intervention or control. For example, a Cochrane review found aldosterone antagonists (i.e. eplerenone or spironolactone) reduced death in patients with chronic kidney disease requiring dialysis, reporting an NNT of 14 (95% Confidence Interval (CI) 10–21).5 This means that for every 14 patients using aldosterone antagonists in dialysis-dependent chronic kidney disease for approximately 1.2 years, one patient avoids death, compared to placebo.5 The number needed to benefit (NNTB) is used interchangeably with the NNT in some medical texts.
Alongside the NNT, a few other absolute risk figures have been derived from the clinical literature. These include the number needed to harm (NNH), the number needed to screen (NNS), and the number unnecessarily treated (NUT).
These measures are likewise bound to a specified time period and are compared to a control intervention (placebo or gold-standard therapy).
Number needed to harm
The NNH defines the number of patients who need to be treated by an intervention (e.g. pharmacotherapy or medical procedure) for one patient to be harmed. It reflects the adverse effects or undesirable outcomes associated with treatment options. In context, the NNH associated with using aldosterone antagonists for dialysis-dependent chronic kidney disease was 38 (95% CI 26–68), meaning for every 38 patients taking either spironolactone or eplerenone for approximately 1.2 years, one person will develop gynaecomastia as a harmful outcome.5
Number needed to screen
The NNS refers to the number of patients needed to screen in order to prevent a death or harmful outcome.
Its applications pertain to areas of epidemiological research; for example, to estimate the number of women needed to screen to prevent one breast cancer death. A study found that 84 women aged 40–84 need to be screened annually (mammography) to save one life from breast cancer.6
Number unnecessarily treated
The NUT quantifies the number of patients who do not receive the beneficial outcome of treatment.7 This measure is inversely related to the NNT.
As an example, let us consider patients who are treated with high-dose statins after hospitalisation to prevent secondary myocardial infarction. Assuming that the absolute difference between the treatment and control arms in developing a second heart attack is 20% implies an NNT of 5. This means if five patients need to be treated to prevent one extra myocardial infarction episode, the remaining four will undergo high-dose statin without benefit; such is the concept of the NUT.7
Absolute measures of risk
Absolute risk is simply defined as the chance or probability of any event occurring in a group.8
The absolute risk reduction (ARR) is the difference between the basic probability of an event occurring in the intervention group (EER) versus its occurrence in the control group (CER) of a RCT.8
ARR = CER – EER
(EER = experimental event group event rate, CER = control group event rate)
It differs from relative risk reduction (RRR), which express the risk difference between the intervention and control groups, as a proportion of the risk in the control group.8
RRR = CER – EER
CER
Most RCTs preferentially report RRRs over ARRs or NNTs because communication of relative terms tends to overstate the effectiveness of a treatment.9 The CURE study10 highlighted that patients taking a combination of clopidogrel and aspirin had a 20% RRR for heart attack, cardiovascular death or stroke compared to an ARR of only 2.1%. Drug company representatives promoting the clopidogrel/aspirin combination may prefer to quote the 20% risk reduction, obscuring the perceived benefit of the medication(s). Figures like the ARR or NNT present more concrete information about an intervention by incorporating both the baseline risk without treatment and the magnitude of the risk reduction.9 Treatment effectiveness is often perceived to be lower when quoting ARRs or NNTs, which may explain why these values are typically under-reported even among top-cited journals.9,11
Box 1 – Key resources
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Many statistical terms are used to measure and showcase the results of therapy trials. An understanding of figures such as event rates, absolute risk, odds ratio, relative risk and risk reductions is crucial to the calculation and interpretation of the NNT (Box 1). These values can help health practitioners at a basic level to determine whether novel treatments are superior to other treatments or placebo.
The NNT is calculated by taking the reciprocal of the ARR 1/ARR and is rounded up to the nearest whole number (see Table 1). Note that the NNH is likewise calculated in this way but is rounded down to the nearest whole number.
The NNT appears in the medical literature, and so pharmacists should be confident to interpret it. The NNT is typically quoted as a whole number (NNT = n), but can also be expressed as a simple frequency (1 in n), a comparative measure (n more patients will benefit) or as a pictograph (Cates Plot13).14 When communicating risk to patients, using pictures to visually demonstrate potential treatment outcomes can have more impact than simply quoting an NNT.15
Time should also be considered in the context of NNTs, RRs and ORs. Risk is spread across time, and a treatment that doubles the 'risk' of 10-year post-myocardial infarction survival may be more desirable than a treatment which doubles the same 'risk' at 10 months.2
Pharmacists can develop and use NNTs generated from multiple research papers to compare the effectiveness of different treatments. The quality of evidence should be similar in both cases, accounting for study participants, timeframe and internal validity (blinding, events outside of the study). For instance, high-dose pregabalin for post-herpetic neuralgia (PHN) has an NNT of 3.9 (95% CI 3.1–5.5) for 50% pain reduction and an NNH of 7.1 (95% CI 5.3–11) for adverse effects causing study withdrawal (somnolence, dizziness).16,17
High-dose gabapentin for the same indication has an NNT of 6.7 (95% CI 5.4–8.7) for 50% pain reduction and an NNH of 30 (20.0–66.0) for adverse effects causing study withdrawal (somnolence, peripheral oedema, gait disturbance, dizziness).16,18
A low NNT means that more people will receive the potential ‘benefits’ of the treatment. A high NNH means that fewer persons will receive the potential ‘harms’ of the treatment. Pregabalin has a lower NNT compared to gabapentin, suggesting it may be better for PHN pain control. Gabapentin has a greater NNH compared to pregabalin, which may indicate an increased frequency of adverse effects.
Is the NNT statistically significant?
If there is a statistically significant difference in the outcomes of the treatment and control groups of therapy trials, the observed difference is unlikely to have occurred by chance. The difference is then meaningful to patient care. If NNT is to be incorporated into medical decision-making, it must be a statistically significant outcome.
There are two main ways in which studies represent statistical significance: p-values and confidence intervals. Either should always accompany the NNT in the clinical literature.
P-values
Standard convention deems a p-value (probability value) of less than 0.05 as statistically significant.19 This means there is a less than 5% probability that the study results occurred by chance alone, and the difference between the two groups is likely caused by the intervention.19
Confidence intervals
How confident can a researcher be that the results for the sample population represent those for the entire population? In research, this is expressed as a confidence interval (CI), which refers to the interval or range in which the true value for the entire population (known as the target population) lies. A confidence level of 95% is usually selected for medical research. A 95% CI means that if we were to replicate any study 100 times exactly, then 95 of the generated confidence intervals would contain the true effect size (mean, relative risk, odds ratio, hazards ratio).19 Hence, a 95% CI of any single study has a 95% probability of the true effect size sitting between the upper and lower ranges given.19 For dichotomous outcomes (i.e. survival vs death, disease vs disease-free), 1 is the null value of the effect size. This contrasts with continuous outcomes (i.e. blood pressure, total cholesterol, height, weight) where the null value is set at 0. If a 95% CI includes the null value, then there is no statistically meaningful difference between the groups. A smaller 95% CI range also indicates greater precision in the point estimate of effect.
Table 1 – How to calculate the ARR, RRR and NNT
CER = control event rate, EER = experimental event rate
We can use the NNT to present research evidence to patients, with a few considerations. The ‘external validity’ or degree to which the results of studies can be generalised to populations outside of the study is a key parameter.20 It is important to know that if a healthcare intervention works under ideal conditions (i.e. efficacy), it is also effective in populations and settings outside of the clinical study (i.e. effectiveness).20
Pharmacists should contemplate whether data gathered from study participants is applicable to everyday patients. This involves considering the baseline characteristics (i.e. age, sex, comorbidities), confounding factors, inclusion and exclusion criteria, or type of analysis (i.e. intention to treat, per protocol).20
Studies should also specify a timeframe from which the benefits or risks of treatments are derived. For instance, in the earlier study, women were randomly assigned to receive either oral tamoxifen 20 mg daily or placebo for 5 years. When communicating the evidence of tamoxifen therapy, pharmacists should recognise that treatment outcomes may rely on continual medication compliance over a longer timeframe. The benefits may not be immediately apparent in the short term, and this should be emphasised in discussions of the treatment plan.
Box 2 – Risk pictographs
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Using NNT pictographs
Pictographs can be used to communicate the incremental benefits of risk-reducing treatments to patients in ways that are easy to interpret (see Figure 1).21 Icon arrays are derivations of NNTs, where one shape (e.g. smiley faces, human figures) is repeated a number of times and some shapes are altered (change of colour or shape) such that they represent a clear proportion. For example, in Figure 1, the 5-year NNT for rosuvastatin for myocardial infarction, stroke, revascularisation or death was 20 (95% CI 14–34).22 This means that 20 patients need to take rosuvastatin for 5 years in order for one patient to avoid a cardiovascular outcome. One in 20 (5%) of the icons are coloured blue, representing those who are protected at 5 years from a cardiovascular event. The other 95% (19/20) remain grey, representing those who do not receive this benefit after 5 years. Multiple colours or patterns can also be used to describe the risk of developing adverse effects from medications. Pictographs have the potential to improve patients’ understanding of health information, including treatment options and medication adverse effects.21 Studies have also indicated the promising effects of such aids on health-related outcomes (i.e. quality of life and medical decision-making).21 Going forth in their practice, health practitioners may find a number of resources useful to generate their own or utilise ready-made medical infographics (see Box 2).
Case scenario continued
You extrapolate the significant data into a 100-icon pictograph and discuss the findings with Natasha. You explain that if 100 people were to take antibiotics for rhinosinusitis, only five would achieve cure faster than those who did not take antibiotics. This means 95 persons would take antibiotics with no apparent benefit. You explain further that the risk of taking antibiotics for rhinosinusitis is that 13 more people will experience adverse effects with antibiotics compared to those people without antibiotics. In this case, the risk outweighs the benefit. You counsel Natasha to get rest (stay at home and limit travelling to public spaces), drink lots of water, take paracetamol to reduce fever and manage pain, and use an oxymetazoline nasal spray for congestion over the next 3 days. Symptoms of infective rhinosinusitis generally resolve or reduce in severity within 7–14 days. You also advise Natasha to see her general practitioner if her symptoms do not improve or worsen (i.e. nasal obstruction, purulent discharge, fever) in 5 days, as antibiotics may be more beneficial. |
With the upsurge of new study trials and research, pharmacists and health professionals are continuously exposed to the mathematical language used to describe treatment effects. Such terminology is often synonymous with other terms and may perpetuate a general feeling of confusion or bafflement towards approaching research statistics. An understanding of absolute risk, relative risk, odds ratio, risks ratio, NNT, NNH and statistical significance is crucial in evaluating whether a new treatment has any advantage over standard therapy or placebo. With many universities adopting statistical analysis or evidence-based medicine in their pharmacy schools, pharmacists are well-equipped with the necessary research appraisal skills to acquire, assess and convey information to patients. As the most accessible primary health providers, there is also opportunity for knowledge translation to occur outside of a single patient encounter, as pharmacists are more likely to see patients on a regular basis. Pharmacists should be prepared to answer questions from prescribers and health consumers about the effectiveness or appropriateness of medications using evidence-based practices and manipulate the data into easier to understand pictographs.
| Rosuvastatin | Ridker Paul M, MacFadyen Jean G, Fonseca Francisco AH, et al. Number needed to treat with rosuvastatin to prevent first cardiovascular events and death among men and women with low low-density lipoprotein cholesterol and elevated high-sensitivity c-reactive protein. Circ Cardiovasc Qual Outcomes 2009;2(6):616–23. |
| Atorvastatin | Sever PS, Dahlöf B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ascot-lla): a multicentre randomised controlled trial. Lancet 2003;361(9364):1149–58. |
| Pantoprazole | Pilotto A, Leandro G, Franceschi M. Short- and long-term therapy for reflux oesophagitis in the elderly: a multi-centre, placebo-controlled study with pantoprazole. Aliment Pharmacol Ther 2003;17(11):1399–406. |
| Esomeprazole | Gralnek IM, Dulai GS, Fennerty MB, et al. Esomeprazole versus other proton pump inhibitors in erosive esophagitis: a meta-analysis of randomized clinical trials. Clin Gastroenterol Hepatol 2006;4(12):1452–8. |
| Perindopril | Campbell DJ. A review of perindopril in the reduction of cardiovascular events. Vasc Health Risk Manag 2006;2(2):117–24. |
| Cefalexin | Rosengren H, Heal CF, Buttner PG. Effect of a single prophylactic preoperative oral antibiotic dose on surgical site infection following complex dermatological procedures on the nose and ear: a prospective, randomised, controlled, double-blinded trial. BMJ Open 2018;8(4):e020213. |
| Metformin | O'Connor PJ, Spann SJ, Woolf SH. Care of adults with type 2 diabetes mellitus. A review of the evidence. J Fam Pract 1998;47(5 Suppl):S13–22. |
| Escitalopram | Montgomery S, Hansen T, Kasper S. Efficacy of escitalopram compared to citalopram: a meta-analysis. Int J Neuropsychopharmacol 2011;14(2):261–8. |
| Amoxicillin | Little P, Stuart B, Moore M, et al. Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis 2013;13(2):123–9. |
| Sertraline | Cipriani A, Furukawa TA, Geddes JR, et al. Does randomized evidence support sertraline as first-line antidepressant for adults with acute major depression? A systematic review and meta-analysis. J Clin Psychiatry 2008;69(11):1732–42. |
| Top 10 drugs | Top 10 drugs 2019–20. Aust Prescr 2020;43:209. |
CASSANDRA NGUYEN BPharm, Dr MARY BUSHELL BPharm (Hons), AACPA, GCTLHE, AFACP, MPS, PhD, LYN TODD BPharm, Dr JACKSON THOMAS BPharm, MPharmSc, PhD, Professor MARK NAUNTON BPharm (Hons), PhD, Head, School of Health Sciences, University of Canberra.
[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row] [post_title] => Interpreting clinical trials and the number needed to treat (NNT) [post_excerpt] => Pharmacists should be prepared to answer questions from prescribers and health consumers about the effectiveness or appropriateness of medications using evidence-based practices. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => interpreting-clinical-trials-and-number-needed-to-treat-cpd [to_ping] => [pinged] => [post_modified] => 2022-05-13 06:59:02 [post_modified_gmt] => 2022-05-12 20:59:02 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=18373 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Interpreting clinical trials and the number needed to treat (NNT) [title] => Interpreting clinical trials and the number needed to treat (NNT) [href] => https://www.australianpharmacist.com.au/interpreting-clinical-trials-and-number-needed-to-treat-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 18511 )
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A 53-year-old female presents to the pharmacy with diagnosed hand osteoarthritis. She currently uses a splint and has used a topical non-steroidal anti-inflammatory drug in the past but finds it inconvenient to apply at work. Her pain is flaring up again and she is seeking pain relief.
Introduction
Osteoarthritis (OA) is the most common form of arthritis in Australia, with an increasing prevalence among the ageing population.1 OA most commonly affects the hands, knee, hip and spine, and is the predominant condition leading to knee and hip replacement surgery in Australia.1
Guidelines for the management of OA have mainly focused on large joint OA (i.e. knee and hip). However, these recommendations cannot be readily extrapolated to other types of OA, such as hand OA, due to the differing functionality, risk factors and pathophysiological mechanisms of OA at different joint sites.2
Despite being one of the most common phenotypes with a high clinical burden, hand OA was long regarded as a ‘forgotten disease’, with limited clinical evidence to guide treatment recommendations.2,3 In recent years, hand OA has attracted more attention, as emerging evidence has given fresh insights into treatment options.2
This CPD module will focus on the latest best practice management for hand OA, based on the 2018 update to recommendations from the European Alliance of Associations of Rheumatology (formerly known as EULAR).
Understanding the nuances in management of differing OA subtypes can help pharmacists to personalise care for their patients with OA.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.5, 2.1, 2.3, 3.1, 3.2, 3.5 |
This article is produced in partnership with Reckitt Benckiser.[/caption]
OA is an inflammatory disease characterised by progressive onset of joint damage, commonly associated with pain.4 Upregulation of inflammatory pathways results in the presence of cytokines and growth factors in the extracellular matrix of cartilage surrounding the affected joint.4 This can result in changes to the production of aggrecan, a highly negatively charged protein that helps give cartilage its compressive stiffness.4 Over time, the cartilage disintegrates, and bone marrow lesions can form which narrow the joint space and cause symptoms such as pain and stiffness.2,4
Several factors play a role in the aetiology of hand OA. Environmental factors, such as stress from mechanical loading, especially to vulnerable joints, predispose individuals to developing OA. Other risk factors for hand OA include age, gender, obesity, smoking, genetics, diet and occupation (Table 1).4
Table 1 – Risk factors for hand OA
|
Age: Risk is highest in ages 50–60 and then decreases with age. |
|
Gender: Females are 2.6 times more likely to develop hand OA compared to males. Risk is greatest at postmenopausal age, potentially due to changes in hormone activity. |
|
Obesity: It is well recognised that obesity is a cause of “meta-inflammation”, which induces low-grade inflammation throughout the body and has been associated in the pathophysiology of chronic pain and OA.5 Currently, there are conflicting studies which associate a link between obesity and hand OA. |
|
Smoking: Recent studies have indicated smoking as having a neutral effect on hand OA. |
|
Ethnicity/environment: Various cultures and ethnic groups have varying prevalence of OA. This may be due to anatomical differences and different activity between cultures. |
|
Genetics: Genetic links have been found with many joints that are affected by hand OA. This includes association on chromosome 11 on q arm, sections 11–12. Link to presence of polymorphism ASPN (SNP rs13301537) to presence of osteophytes and JSN.* |
|
Occupation: Lines of work involving repetitive movement of the hands have a higher prevalence of hand OA, e.g. people in the clothing manufacturing industry. |
* JSN: joint space narrowing. SNP: single nucleotide polymorphism. Adapted from Table 2, Leung et al 2013.4
Patients with hand OA may present with pain in the hand joints, functional limitation and decreased grip strength. These symptoms can hinder the patient’s quality of life, as everyday tasks, such as writing or lifting objects, become challenging.4 Clinical hallmarks of the disease include bony enlargement and deformities of the hand joints, sometimes accompanied by soft tissue swelling.2 Typically, both hands are affected, most commonly in the distal interphalangeal (DIP) joints, thumb bases, proximal interphalangeal (PIP) joints, and second and third metacarpophalangeal (MCP) joints.6
The clinical presentation differs between each subtype of hand OA6:
Progression of hand OA can be a slow, ongoing process, but the disease course is highly variable.3 Erosive OA is associated with a higher clinical burden, whereas thumb-base OA may have more pain and disability than finger OA.3 A high level of baseline functional impairment and a greater number of painful joints increase the risk of adverse clinical outcomes.3,6
Diagram 1 – Joints of the hand
Overarching principles of managementThe management of hand OA primarily aims to manage symptoms and optimise hand function to achieve the best possible activity, performance, participation and quality of life (Table 2).2 A core management strategy is the ongoing provision of patient education on the nature and course of disease, particularly in patients with chronic symptoms, as the information is reinforced and expanded upon over time. Focus group interviews have shown that hand OA patients often struggle to understand the impact of disease and perceive a lack of support and/or contradictory advice from healthcare professionals.3 Providing education to patients is an important role that trained health professionals like pharmacists can play.2
Since hand OA is a heterogenous disease, optimal management usually requires a multidisciplinary approach that combines both non-pharmacological and pharmacological intervention.2 Management strategies should be individualised to the patient as OA localisation (e.g. finger versus thumb-base OA), severity of symptoms and presence of comorbidities can influence treatment decisions. Severity may include a high number of hand joints with OA, one or two severely affected joints, or acute joint inflammation due to OA.2
Additionally, a shared decision-making approach should be taken to ensure both the healthcare professional and patient mutually share and consent to the preferred management strategy.2 This can be achieved by building and maintaining a therapeutic relationship with the patient and sharing the best evidence to make an informed decision.2
Table 2 – The overarching principles for the management of hand OA
|
A. The primary goal of managing hand OA is to manage or reduce symptoms, such as pain and stiffness, and to optimise hand function, in order to maximise activity, participation and quality of life. |
|
B. All patients should be offered information on the nature and course of the disease, as well as education on self-management principles and treatment options. |
|
C. Management of hand OA should be individualised, taking into account its localisation and severity, as well as comorbidities. |
|
D. Management of hand OA should be based on a shared decision between the patient and the health professional. |
|
E. Optimal management of hand OA usually requires a multidisciplinary approach. In addition to non-pharmacological modalities, pharmacological options and surgery should be considered. |
Adapted from Table 1, Kloppenburg et al 2019.2
Non-pharmacological interventions
Education on ergonomic principles, pacing of activity and use of assistive devices are important aspects of management that should be offered to every patient.2 An assistive device is a piece of equipment that can increase, maintain or improve the functional capabilities of the patient, including orthoses such as a splint or ergonomic equipment.3 They are commonly used in hand OA and have been shown to improve a patient’s self-management of the disease.2 Long-term use of orthoses may be required to relieve symptoms in patients with thumb-base OA.2 Choosing a splint should be a shared decision with the patient, since there are no recommendations to use a particular type of splint.3 It is important to ensure the chosen orthoses is properly fitted to improve patient compliance and increase long-term use.2
Exercise has been shown to benefit pain and function, joint stiffness and grip strength while resulting in few and non-severe adverse effects.2 Exercises should aim to improve joint mobility, muscle strength and thumb-base stability in a regimen that is specific to the disease location. For example, the first carpometacarpal (CMC–1) joints require different exercises to the interphalangeal joints.2 In line with a multidisciplinary approach, patients can be referred to their physician/rheumatologist or a physiotherapist for guidance on appropriate exercises for them.
Pharmacological interventions
Treatment choice may depend on the number of joints affected.2 For single joints, topical non-steroidal anti-inflammatory drugs (NSAIDs) may be an appropriate option to deal with flare-up pain and may be used in combination with assistive devices when pain is localised to the hand (Table 3).2 Most NSAIDs work by reversibly inhibiting the enzyme cyclo-oxygenase (prostaglandin endoperoxide synthase or COX), which mediates the production of prostaglandins, thereby regulating the role of prostaglandins in inflammatory and pain processes.7
If several joints are affected, oral NSAIDs can be considered.2 They were shown to improve pain and function after 2–4 weeks in three high-quality studies.2 Paracetamol use, however, has been a topic of debate in hand OA due to its risk-benefit profile.2 Evidence from two large meta-analyses showed that paracetamol was associated with an increased risk of liver test abnormalities, although the clinical relevance of this finding is undetermined and there was no increased risk in other safety parameters.2 The efficacy of paracetamol in the treatment of hand OA is unknown and likely to be small, but there is no need to refrain from prescribing it for short durations in selected patients; for example, when oral NSAIDS are contraindicated.2
Other interventions with limited efficacy or uncertain benefit in hand OA include2:
Surgical interventions
Surgery should only be considered for patients with structural abnormalities when other treatment modalities have been insufficient to effectively relieve pain.2 For example, trapeziectomy may be considered in patients with thumb base OA and arthrodesis or arthroplasty in patients with interphalangeal OA.2
Table 3 – Recommendations for the management of hand OA
|
Grade of recommendation* |
Level of agreement (0–10)† |
|
|
1. Education and training in ergonomic principles, pacing of activity and use of assistive devices should be offered to every patient |
A |
9.3 (1.1) |
|
2. Exercises to improve function and muscle strength, as well as to reduce pain, should be considered for every patient |
A |
9.1 (1.6) |
|
3. Orthoses should be considered for symptom relief in patients with thumb-base OA. Long-term use is advocated |
A |
9.3 (1.0) |
|
4. Topical treatments are preferred over systemic treatments because of safety reasons. Topical NSAIDs are the first pharmacological topical treatment of choice |
A |
8.6 (1.8) |
|
5. Oral analgesics, particularly NSAIDs, should be considered for a limited duration for relief of symptoms |
A |
9.4 (0.9) |
|
6. Chondroitin sulfate may be used in patients with hand OA for pain relief and improvement in functioning |
A |
7.3 (2.7) |
|
7. Intra-articular injections of glucocorticoids should not generally be used in patients with hand OA but may be considered in patients with painful interphalangeal joints |
A |
7.9 (2.4) |
|
8. Patients with hand OA should not be treated with conventional or biological disease-modifying antirheumatic drugs |
A |
8.8 (1.8) |
|
9. Surgery should be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain. Trapeziectomy should be considered in patients with thumb-base OA and arthrodesis or arthroplasty in patients with interphalangeal OA |
D |
9.4 (1.4) |
|
10. Long-term follow-up of patients with hand OA should be adapted to the patient’s individual needs |
D |
9.5 (1.7) |
Adapted from Table 1, Kloppenburg et al 2019.2 *A: based on consistent level 1 evidence; D: based on level 5 evidence or on troublingly inconsistent or inconclusive studies of any level. †From an international taskforce of 19 physicians, healthcare professionals and patients from 10 European countries.
When oral NSAIDs are appropriate to relieve symptoms during a flare-up, they should be used at the lowest effective dose for the shortest duration, as adverse effects are dose dependent.8 This approach is vital to balancing efficacy and safety.8 Oral NSAIDs should only be initiated if the benefit outweighs the risk of treatment, especially in patients with a risk of gastrointestinal, cardiovascular or renal adverse effects.2
Consider initiating oral NSAIDs in a stepwise approach that corresponds to the severity of pain and the individual needs of the patient. For mild to moderate hand OA, ibuprofen can provide effective pain relief that may last up to 8 hours,9–11 while also having a similar gastrointestinal tolerability profile to paracetamol at over-the-counter doses, in patients without contraindications or precautions.12,13 Modified-release ibuprofen formulations that provide 12-hour duration of effect are also available for patients that may benefit from a reduced dosing frequency or extended pain relief; for example, those who are not used to or struggle to take oral medication frequently.
If the pain is not sufficiently managed with ibuprofen alone, or if the patient is reporting stronger pain from the outset, a combined formulation of ibuprofen with paracetamol may provide effective relief for moderate to severe pain, while also minimising the risk of adverse effects that would otherwise be associated with a dose increase.7,11 This is supported by a multicentre, 2-stage, randomised, double-blind, parallel-group, placebo-controlled, factorial study in patients with moderate to severe postoperative dental pain, which showed that a fixed-dose combination of ibuprofen 200 mg/paracetamol 500 mg had significantly lower rates of treatment-related adverse events compared with ibuprofen 200 mg and paracetamol 500 mg alone (6.3% vs 16.0%; p<0.05 and 22.4%; p<0.001 respectively).11
For moderate to severe pain, it may be more appropriate to initiate pharmacotherapy with a combination NSAID plus paracetamol formulation from the start. This strategy is supported by a 2015 Cochrane review analysing 21 over-the-counter analgesics for acute pain, which determined that more patients achieved pain relief success (defined as at least 50% maximum pain relief over 6 hours) with ibuprofen 200 mg/paracetamol 500 mg than those taking NSAID monotherapy with ibuprofen 400 mg (Figure 1).7
Figure 1 – Success rates for at least 50% maximum pain relief
Adapted from Appendix 4, Moore et al 20157
Finally, long-term follow-up of patients with hand OA is recommended, and pharmacists can play an important role here. Adequate follow-up provides an opportunity for re-evaluation and adjustment of pharmacological treatments, while also helping to increase patient adherence to non-pharmacological therapies and ensure they are on the best route to recovery.2 The spectrum of patients seen with hand OA is diverse, and the need for long-term follow-up should be adapted to their individual needs, taking into account severity of symptoms, presence of erosive disease, and the patient’s wishes and expectations.2
Case scenario continuedThis video is part of the article. To complete your CPD points, watch the video and learn from John Bell how pharmacists can manage the case scenario introduced at the start of this article. Video references
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[post_content] => Case scenario
Lawrence, 66, was diagnosed with chronic lymphocytic leukaemia (CLL) following a routine cholesterol test in 2018. His malignant cell-line count was 5.8 x 109/L, and genetic testing revealed he did not have a p53 gene deletion. He underwent the standard FCR protocol in 2018 and had repeated treatments in 2020.
Lawrence says he feels good and is otherwise well. For their upcoming wedding anniversary, Lawrence and his wife would like to travel interstate to visit their son and new grandchild. The destination requires that visitors are fully vaccinated against COVID-19.
Lawrence is concerned about receiving a COVID-19 vaccination. He is ‘immunocompromised’ and worried about the effect a vaccine will have on his CLL and medications. He asks about vaccine exemptions that may allow him to travel.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.5, 2.2, 2.3, 2.4, 3.1, 3.2, 3.5 |
Chronic lymphocytic leukaemia (CLL) is the most common form of leukaemia in Australia.1 It affects developing B lymphocytes – specialised white blood cells that produce antibodies in response to infection or disease. The median age of diagnosis is approximately 70 years and incidence is higher in males.2
The exact cause of CLL is unknown; however, exposure to some chemicals, such as Agent Orange, has been implicated.3 There is a familial association; for those with a first-degree relative with CLL, there is approximately an eightfold increase in developing the disease.4
CLL is thought to be preceded by a premalignant proliferative disorder known as monoclonal B-cell lymphocytosis (MBL), which has been observed in 5–10% of the population older than 60 years.5 MBL can progress to CLL at approximately 1–2% per year. MBL may initially arise from antigenic stimulation, gene mutations, epigenetic mutations and cytogenetic abnormalities which may occur at the haematopoietic stem cell stage. Further genetic changes/mutations can result in progression to CLL.6
CLL is frequently diagnosed incidentally (i.e. persistent elevated white cell count on blood tests performed for other reasons). Occasionally, patients may present with active disease where B symptoms (e.g. unintentional weight loss, persistent fevers and/or drenching night sweats) will be evident.
CLL may be associated with immune dysfunction manifesting as immunodeficiency (with recurrent infections) and/or autoimmune complications. Autoimmune symptoms can include haemolytic anaemia and thrombocytopenia, caused by the production of autoimmune antibodies against red cells or platelets respectively.
When CLL manifests in the lymph nodes instead of the blood and bone marrow, it is referred to as small lymphocytic lymphoma (SLL). CLL and SLL are considered the same disease with the same in key genetic abnormalities, prognosis and treatment.
CLL may be suspected based on an abnormal full blood count and blood film: an elevated lymphocyte count (normal range 1.5–4.0 x 109/L) may indicate CLL. Elevated lymphocyte counts can also be caused by infections or reactions to a medicine. Malignant lymphocytes observed in the blood film will usually be small in size, have a mature nucleus, and will be frequently smudged due to fragility.2
Diagnosis is confirmed using flow cytometry, which identifies abnormal proteins expressed on the cell surface. CLL cell lines display the usual B-cell antigens CD19, CD20 and CD23, but also CD5, which is aberrantly expressed and characteristic of the disease.7 Flow cytometry can also quantify the population of cells that exhibits this abnormal pattern of protein expression. A population of greater than 5 x 109/L is required for the diagnosis of CLL; below this threshold is considered MBL.2
Without treatment, the prognosis of CLL is extremely variable; survival ranges from a few years to decades, with a median survival time of approximately 10 years. The Rai and Binet classifications are two clinical staging systems used to differentiate prognostic groups in patients with CLL.8,9 Both systems use an algorithm that considers clinical features (e.g. enlarged lymph nodes and spleen) and blood count measures (low platelets or anaemia) to determine patient prognosis. The Rai classification separates patients into Stage I to III, with varied median survival from 19 to 150 months. The Binet classification ranges from Stage A, where the median survival is comparable to age-matched general population, to Stage C, where there is a median survival of 24 months.
More recently, the addition of genetic (e.g. TP53 mutation) and biochemical (beta-2 microglobulin) assays allow for improved patient prognostication to further guide management.10
There are many classes of medicines for CLL, and the choice of treatment will depend on the stage of the disease, the results of genetic tests, and patient age, health and personal preferences.
Numerous studies have shown that starting active treatment in patients with early asymptomatic disease does not confer an increased survival benefit; a ‘watch and wait’ approach is recommended. Patients are usually monitored 3–6 monthly. Guidelines provide the criteria for treatment initiation: for example, the presence of B symptoms, cytopenias (decreased platelet count or anaemia), and/or accelerated progression (e.g. lymphocyte doubling time, size of lymph nodes).11
A current standard of care for patients who are otherwise well and without significant comorbidities is the combination therapy of fludarabine, cyclophosphamide (two cytotoxic medicines), and the anti-CD20 antibody, rituximab (Rituxan). This treatment regimen, known as FCR, has been shown to induce a clinical response in 90% of patients and improve survival (87% at 3 years) compared to prior standards of therapy.12
In patients who are older than 65 years or have significant comorbidities, obinutuzumab (Gazvya), another anti-CD20 antibody, is used in combination with chlorambucil and has been shown to achieve an overall survival of 91% at 3 years.13
In cases where CLL relapses and has not responded to first-line treatments, other treatments may be considered.
Cytotoxic therapies have lower efficacy in patients with unfavourable genetic mutations (e.g. TP53 mutation) and in relapsed disease. Novel immune-targeted therapies are used to manage these patients and are increasingly being used in all patient cohorts.
In Australia, the immune-targeted therapies available include ibrutinib, acalabrutinib, venetoclax and idelalisib. Ibrutinib and acalabrutinib are Bruton’s tyrosine kinase (BTK) inhibitors, venetoclax inhibits B-cell lymphoma protein (Bcl-2) and idelalisib inhibits the delta-isoform of phosphatidylinositol 3-kinase (PI3Kδ). Both BTK and PI3K are associated with signalling from the B-cell receptor, ultimately leading to B-cell survival and proliferation. Disruption of these pathways leads to apoptosis of CLL cells. Conversely, Bcl-2 is a protein significantly upregulated in CLL cells, allowing them to evade apoptosis and proliferate. Inhibition of Bcl-2 with venetoclax has been shown to induce rapid CLL cell death.2
Targeted immune-therapies have become standard care in the treatment of relapsed/resistant CLL, especially in those with high-risk mutations. They are increasingly used in the frontline setting, particularly in patients with high risk disease.2
Patients need to be monitored for treatment response and adverse effects. For those in remission, ongoing surveillance for disease relapse is required. Patients receiving chemoimmunotherapy are closely monitored in a specialist setting at the local cancer centre.
Community pharmacists are likely to have a direct encounter with patients’ prescribed targeted therapy as they can be dispensed in community pharmacies.
Ibrutinib (Imbruvica)
Ibrutinib acts by irreversibly binding to BTK proteins. Along with acalabrutinib, it belongs to the class of medicines called BTK inhibitors.
The standard initiation dose is 420 mg orally daily, taken at the same time every day.14 Dose reduction may be required to manage toxicities.
Ibrutinib is a substrate of cytochrome P450 (CYP) enzyme 3A4. Strong inhibitors or inducers should be avoided where possible. If a prolonged course of moderate CYP3A4 inhibitor cannot be avoided, dose reduction may be required.15
Common adverse effects include skin rash, diarrhoea and fatigue. Major haemorrhage occurs in up to 9% of patients, and up to half of patients experience increased bruising.16 Patients should be advised to seek medical attention if there is unusual bruising or bleeding. Co-administration of antiplatelet and anticoagulant medicines further increases bleeding risk and should be avoided where possible. Patients should inform their haematologist when concomitant antiplatelet or anticoagulant therapy has been started.
Cardiac rhythm disorders, in particular atrial fibrillation and flutter, are frequently reported in patients taking ibrutinib. More severe arrhythmias such as ventricular tachycardias have also been described. Other cardiac effects include new or worsening hypertension; regular blood pressure monitoring should be advised.16,17
Acalabrutinib (Calquence)
Acalabrutinib is a second-generation BTK inhibitor with higher specificity to BTK than ibrutinib. Comparative trials have shown that it may be better tolerated than ibrutinib with a lower effective dose and potentially fewer bleeding complications.18 Trials are ongoing, and as such ibrutinib is currently preferred due to weight of evidence.
The standard dose of acalabrutinib is 100 mg orally twice daily. Drugs that increase gastric pH such as proton pump inhibitors should be avoided, and antacids should be separated by 2 hours. Like ibrutinib, it is a substrate of CYP3A4.
Venetoclax (Venclexta)
Venetoclax inhibits Bcl-2, an over-expressed homeostatic protein that helps CLL cells survive longer than they should. It is started at 20 mg daily, increasing to a target dose of 400 mg daily.14 Tablets are taken orally once daily, and should be taken with food at the same time every day. Bioavailability is reduced when taken on an empty stomach.
Gradual dose titration is required to reduce the risk of tumour lysis syndrome, a life-threatening complication where rapid tumour cell death leads to the release of intracellular ions, nucleic acids, protein and metabolites into the systemic circulation. This results in significant electrolyte disturbances and hyperuricaemia, which can lead to renal failure, cardiac arrhythmias, seizures, neurological complications and death.19
Venetoclax is a substrate of the CYP3A4 enzyme. Concurrent administration of inhibitors or inducers of CYP3A4 should be avoided where possible. Strong inhibitors are contraindicated during the dose titration phase. If a moderate or strong CYP3A4 inhibitor must be used, a dose reduction of 50–75% may be required.20
Idelalisib (Zydelig)
Idelalisib inhibits the delta isoform of the phosphoinositide 3-kinase enzyme, also known as P110δ, which is important in regulation of the cell cycle in leukocytes. It is used with rituximab in relapsing CLL where other treatments have not been successful.21 The standard dose of idelalisib is 150 mg orally twice daily.14
It is both a substrate and inhibitor of CYP3A4, therefore coadministration of idelalisib with other CYP3A4 substrates or medicines with narrow therapeutic index should be avoided, where possible.22
Common adverse effects include fever, fatigue, nausea and diarrhoea. Potentially life-threatening adverse effects include hepatic dysfunction, severe diarrhoea/colitis and pneumonitis.23
Regular liver function monitoring is required. Patients with worsening diarrhoea, abdominal pain and nausea should be referred to discuss this with their treating physician. Diarrhoeal illness in some cases may require dose modification. Drug cessation may be required in severe cases of colitis and bowel perforations. Cough, fevers and/or shortness of breath may be symptoms of pneumonia or non-infectious pneumonitis. Patients should be referred for medical attention if these symptoms develop.23
Patients with CLL may be at an increased risk of infection, even prior to the initiation of treatment. Treatment with both cytotoxic and immune-targeted therapies will further increase infection risk, and symptomatic patients (e.g. fever) should be referred to hospital immediately.11
Patients with CLL should have annual influenza as well as pneumococcal vaccinations.24 Vaccine efficacy is decreased after treatment, particularly with B-cell depleting therapies such as rituximab and ibrutinib. Live attenuated vaccines are contraindicated in patients with CLL as death has occurred.25
Counselling patients with CLL who are using oral immune-targeted therapies may follow the approach described previously for chronic myeloid leukaemia (see ‘Chronic myeloid leukaemia’, Australian Pharmacist, October 2020). Pharmacists should explain the mechanism of action, key adverse effects and dosing directions. Drug interactions should also be reviewed, and drug adherence should be encouraged and enabled. Poor drug adherence can potentially impact clinical outcome and increase the risk of disease progression.26
Ongoing clinical trials are focused on the optimal sequencing or combination of these therapies. Preliminary results have shown that combinations of cytotoxic and immune-targeted medicines are effective in the eradication of ‘minimal residual disease’ that may lead to durable remission and a prospect of cure.27,28 Future treatments under investigation include whole-cell, antibody, and cytotoxic-free therapies.29
Case scenario continuedLawrence is naturally cautious about his illness and treatment; he is worried that a vaccine will overload his immune system. You reassure him that this is unlikely, and that it is best practice for CLL patients to ensure they are fully vaccinated. On balance, CLL patients are less sick and live longer if they are fully vaccinated. The vaccination will reduce his risk of becoming very ill, and with a dose interval of 4–6 weeks, the sooner he receives his first dose the sooner he will be able to travel. After three rounds of FCR to date, Lawrence asks if you know what the next steps are. You discuss the role of immune-targeted therapies and explain that they treat cancer by a different mechanism and are often useful when the original treatment hasn’t worked. You encourage Lawrence to discuss them with his treating team, which would be best placed to advise for his situation. Lawrence appreciates the advice and seems relieved. |
The management of CLL has changed dramatically in the last decade with the introduction of novel oral immune-targeted therapies. There are increasing opportunities for pharmacists to contribute to the multidisciplinary care of patients with CLL to ensure medicine safety and best patient outcomes.
DR ERIC WENLONG LI BPharm(Hons), MBBSis an Advanced Trainee in Haematology at Concord Repatriation General Hospital. He also lectures at the School of Pharmacy at the University of Sydney on topics relating to haematology.
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The former Director of Pharmacy at Adelaide’s Women’s and Children’s Hospital, Kingsley Coulthard FPS, is South Australia’s PSA Lifetime Achievement Award winner for 2022.
Why did you choose pharmacy?
Because my best mate from high school did. One of my best decisions! University life was a wonderful experience, especially learning and interacting with lecturers and other students . . . and it was face to face – regrettably ceased in many universities, a casualty of COVID-19.
What are you most proud of in your career?
Contributions to paediatric therapeutics, especially cystic fibrosis (CF), and the opportunity to mentor to some wonderful young pharmacists over many years. Many factors have contributed to the dramatic increase in survival for patients with CF, in particular the development of new therapies and the establishment of specialised CF clinics. The incorporation of pharmacists into these clinics is essential, and the opportunities for patient care and research are endless.
What about ‘the little people’?
Paediatric therapeutics have traditionally been neglected in favour of adults, especially in access to appropriate medicines/formulations and clinical trials. Although this has improved in recent years due to international pressure on the pharmaceutical industry and regulatory organisations, there is still a lot to do.
After your retirement in 2010, what links have you retained in pharmacy?
I have an active role in the profession as Adjunct Associate Professor at the University of South Australia and involvement with Asthma Australia as a member of the Professional Advisory Committee. And I was part of the National Asthma Council paediatric writing group for the latest edition of the Australian Asthma Handbook.
I have a close alliance to rural pharmacy and now locum, mainly on Yorke Peninsula. It is rewarding to see how country people in small towns value their local pharmacy. I am a strong believer in face-to-face education and organise such events on Yorke which are open to all health professionals.
What big changes have you have seen during your career?
The expansion of hospital pharmacy services – in particular ward-based, community services such as Home Medicines Reviews and integration into GP clinics/aged care and the impact of IT.
Pharmacy has established itself and been accepted as part of the health team.
What is the one thing you wish pharmacists could do better in respiratory care?
Pharmacists need more time to talk to and counsel patients with respiratory diseases, but the demands of inappropriate dispensing workloads are prohibitive. In areas such as CF, there needs to be specialised pharmacists who remain in those areas for extended periods of time to allow for the development of clinical and patient relationship skills.
What advice would you give to ECPs?
Seek out a mentor. If you’re frustrated with your current role, look at other areas of practice before abandoning the profession.
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Two slipped discs on a construction site led to Sean Richardson’s unusual career segue into the pharmacy profession.
Was pharmacy always your first choice as a career?
Not completing Year 10 led indolently into the laborious side of the construction industry. Years on, I injured my back and had 3 months of rehabilitation – a blessing in disguise. I was encouraged to attend a university open day, which led to a Foundation Studies course (UniSA College), uncovering an appetite for learning, which led to a Bachelor of Pharmacy (Honours).
How did you find your ‘mature age’ student experience?
Approaching tertiary study felt heavy – the age difference and sensation of being ‘behind’ helped shape how I managed my time. Networking with the university student group (South Australian Pharmacy Students’ Association), attending conferences by the National Australian Pharmacy Students’ Association and PSA, and becoming involved in the industry early was a priority. They were the building blocks to later career steps.
Employment early in my degree was key for the student-to-pharmacist transition while enjoying guidance from some of the best clinical, managerial and owner pharmacists in the profession.
Hear more from Sean in the podcast episode below:
What attracted you to locum work?
Two factors contributed: career progression options and remuneration. Looking at the role of a pharmacist in a logical sequence, experience is defined by environment, time and opportunity. So if I pursued constant new areas of learning, challenges and scope expansion, I would find myself upskilling quicker than working within the confines of one place.
Initially, it was confronting; the buck stops with you. In most locum roles, you are the sole pharmacist thrown in the deep end, expected to provide an accurate and professional service in a completely new setting. While challenging, your level of adaptability increases 10-fold, with new dispensing programs, medication familiarity and use patterns, servicing structures, team operation styles and pharmacy cultures.
Self-development as a pharmacist becomes constantly progressive, allowing positive change implementation. Locum positions are usually structured to allow convenience and a ‘slot in’ nature for the pharmacist. In most cases, travel costs, accommodation and car use are provided additional to fair remuneration ($45–$80 per hour plus superannuation, depending on urgency/location/duration/skill set and other factors).
What are some memorable experiences?
My first locum trip was to Coober Pedy via Greyhound bus (11 hours). I arrived late evening to no visible locals, no Vodaphone reception and a disappearing bus. I took the plane back on my return journey!
In Mt Isa one day, a very country-proud, Akubra-wearing customer wanted to know why I wasn’t wearing R.M. Williams boots, as he compared my brown generics with his polished black pair. I got some on my next trip back to Adelaide! No hat though.
What are the key challenges for pharmacy in regional Australia?
Access and consistency. Communication channels between community groups, hospitals, pharmacies and medical centres are crucial, with healthcare workers required to forward-think most decisions, especially for the Indigenous community, where patient location and movement timeframe plays a large role in medicines access.
Healthcare worker turnover is generally high, and adjusting to the setting can be difficult for new professionals.
Rather than position/employment satisfaction, recruiters need to dive deeper to a personal level.
Understand interests, lifestyle, social factors, family commitment/intentions and sense of community for an individual. Greater consideration needs to be taken to employ rurally, equal to that of those contemplating to venture.
What advice would you give to other early career pharmacists (ECPs)?
ECPs are commonly influenced by their immediate first experiences, but should note that their initial pharmacy may not be the staple representation of the industry – the diversity is extensive.
Challenges and constant developments await in the journey ahead. Don’t have any goals? That is step 1. Be resourceful. Seek opportunities, responsibility and be accountable. Aim to add your value.
Day in the life of Sean Richardson MPS, locum pharmacist in Bundaberg, QLD.Heading into a new position – 6.00 am Queensland sunrises (after moving from Adelaide) make exiting the pillow light work, even after trekking 620 kilometres the day before to accommodation. Bundaberg has a population of 93,000, but there’s minimal traffic, no line-ups and friendly service! Head start – 8.15 am Arrive 15 minutes early at the pharmacy to get acquainted with the new team; introductions and quick adaptions to follow. Navigate around the store, dispensing systems/POS, dispensary procedurals, staff roles, individual pharmacist expectations; become familiar with surroundings. Familiarisation process – 8.30 am Burrum Street Pharmacy (Bundaberg West) runs a tight boat with a Schedule 8 Maintenance and Opioid Replacement Therapy program providing suboxone services. Start the day with a stock check on the Schedule 8 safe and prepare for pick-ups. Staff guidance is crucial to getting up to speed to maintain expected level of service and accuracy. Ask lots of questions of the experienced team, which knows the community and customers and guides operations. Taste test – 9.30 am Discussions on antibiotic dosing for an extremely picky 2-year-old patient uneasy about the taste of medicines. ‘We’ve tried all of the flavours!’ Non-pharmacological advice is as important as medicinal; by placing the plastic syringe down the side of the tongue when administering to avoid tasting, junior had no time to think otherwise. Multitasking – 11.00 am It can be challenging to safely juggle the competing priorities of scanning over DAAs as well as script checking between two dispense technicians. Usually I dispense high script volume in other roles, but in this store technicians dominate. Lunch, as such – 12.00-2.00 pm Sole pharmacist lunches are as social as it gets – in the dispensary! Somewhere in between, I wolf down a quick microwave meal via fork or straw, whatever is at hand. Migraine medicine options – 3.00 pm Patient requested paracetamol/ibuprofen (Nuromol) for migraine, while taking eletriptan (Relpax). Discovered patient was directed to take additional Relpax even if first tablet failed (secondary dose unlikely to be effective if initial has failed). Further talks highlighted gastric stasis symptom of migraine and reduced tablet absorption. Recommended dissolvable aspirin and paracetamol as alternatives. Local culinary delights – 5.30 pm Time to close up with attempts to put the right code in the alarm. Head for the gym and dinner at a local restaurant. |
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It’s a fair way from the sheep farm in South Australia to working at five pharmacies in outback Broken Hill, New South Wales. Meet Blake McCallum, PSA’s 2022 NSW Intern of the Year.
Why did you choose pharmacy?
I was an all-rounder in high school and always enjoyed the sciences, but also needed a social environment. One day just before I started year 12 my nan told me I should be a ‘chemist’. It struck me as interesting and here I am!
You did your internship in outback New South Wales. What attracted you to working in a regional area?
I grew up in the Southern Flinders Ranges in South Australia, in a town of about 250 people. After university in Adelaide, I wanted to return to a slower pace of life and find a community to be involved in. With a population of approximately 17,000 people, I considered Broken Hill plenty big enough.
There definitely have been some shock factors to living here, including the constant dust storms and dehydrated scenery. But the wonderful community, my incredible co-workers and the great work-life-culture balance has surprised me. I feel like I could be here for quite some time yet.
'Seriously consider doing some rural work, whether it’s a locum gig or a longer-term position.'
Blake McCallum
Tell us about your intern year?
I found the PSA intern training very flexible which was great for working during these times of the pandemic (outback internet issues notwithstanding!); allowing me to work at my own pace and not feel too much stress as most sessions were online.
My internship was a joint role between community pharmacy group Outback Pharmacies, Broken Hill Base Hospital and Maari Ma Aboriginal Health Corporation.
The sheer variety of working between community pharmacy, the hospital and with the Indigenous Health Service in Wilcannia [about 200 km from Broken Hill] was phenomenal for my worldview, experience and building confidence as a pharmacist. One of my bosses also organised additional education sessions via Zoom with other rural interns in Mt Isa in Queensland and Karratha in Western Australia.
How did you feel winning the NSW Intern Pharmacist of the Year award?
It’s overwhelming to think that ‘little old me’ in Broken Hill was picked out of so many other interns. I tend to live by my family’s motto of ‘getando’ and try my hardest to help people the best I can.
You now work across five pharmacies in Broken Hill. What excites you most about the role?
I get to see a lot of variety, as all the pharmacies run on different models to cater for the community. Depending on the day, I do everything from organising medicines for Royal Flying Doctor Service clinics out of town to supporting local aged care facilities and giving COVID-19 vaccinations.
Is there anything you wish you had known before becoming a pharmacist?
Probably that I’d forget what a chair feels like, or the pure exhaustion of being asked hundreds of questions a day. But the satisfaction of those heart-melting positive interactions and helping people fully make up for it.
What advice would you give to other early career pharmacists?
It might be cliché for me to say, but seriously consider doing some rural work, whether it’s a locum gig or a longer-term position. You’ll get to experience the trust that rural communities have in their local pharmacist. Plus, the experience you’ll get from working in a smaller town, where you’ll likely know most of the other health professionals, will make all the difference to your career. And don’t forget to look after yourself. With the ongoing pandemic and recent flooding on the east coast, it’s more important than ever to remember that, while as pharmacists we’re there to help other people, we also need to take care of ourselves.
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[post_excerpt] => It’s a fair way from the sheep farm in South Australia to working at five pharmacies in outback Broken Hill, New South Wales. Meet Blake McCallum, PSA’s 2022 NSW Intern of the Year.
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[post_content] => Deanna Mill MPS, a PhD candidate and PSA’s Early Career Pharmacist Board Appointed Director, is passionate about promoting professionalism in pharmacy practice.
Why pharmacy?
When I was young, I had a lot of trouble with repeated respiratory infections and was prescribed prednisolone several times. I was intrigued by how that drug made me feel – hungry, bloated, irritable. It affected my sleep but also helped me clear the infections. I remember the pharmacist telling Mum about it, and I wanted to know more. Then in high school I did work experience at the local pharmacy. In a country town where it took weeks to see a GP, the pharmacist was a hero helping people daily with their health, and I wanted to be like her.
What happened after you left university?
I landed a hospital pharmacy internship with the Southern Adelaide Local Health Network in 2017, working in different areas, including Port Pirie in country South Australia. In early 2019, I left to complete my PhD.
I have since worked as a tutor, a workshop facilitator and practical demonstrator in pharmacy programs at the University of Western Australia (UWA) and University of South Australia (UniSA) – and casually in a community pharmacy that services a private hospital, and as a research assistant.
Hear more from Deanna Mill in the podcast episode below:
What has been your most fulfilling role?
This is like asking me to choose a favourite child (or cat in my case). I’ve learnt so much from every workplace, and I encourage early career pharmacists (ECPs) to experiment early on in their careers. Once you know what you like, build a job that has all of those things!
My hospital and community pharmacy experiences make me a better teacher and researcher because I can contextualise content for my students and ensure my research will benefit all practising pharmacists. I love educating people. It’s so rewarding to help our next generation grow.
I also love research. Practice improvement is close to my heart, and research helps us understand why things are the way they are and how we can change them to ensure we provide the best possible care for patients. I can’t describe how rewarding it is to see someone pick up your research and use it to change their practice.
What inspired you to start a PhD?
I was frustrated by the barriers pharmacists face that prevent us from being able to practise to our full scope. I wanted to understand the systems that we work in, how to change them, and contribute to the evidence to do so.
'I wanted to understand the systems that we work in, how to change them, and contribute to the evidence to do so.'
Deanna Mill MPS
How can the issue of pharmacist remuneration be overcome?
The main issue is that our current system only remunerates us for providing a product. We need to be recognised for the value that we add providing services, medicines and health information and support in prescribing decisions and reviewing therapy. These are the things that we should be remunerated for. Attaching funding to pharmacists and their time and expertise – instead of a product – will promote quality use of medicines for all. Pharmacists promote quality care when given the time and resources to do so, and every Australian deserves the best care, not the bare minimum.
You’re also Chair of PSA’s ECP Community of Speciality Interest. Why did you take on this role?
I wanted to make sure our extraordinary ECPs are seen and heard and can continue to support PSA’s advocacy efforts with constructive discussions about the challenges we face as a profession.
I hope to help ECPs connect and share their thoughts, concerns and innovations.
By empowering each other, we can elevate the ECP voice to create the profession that we and all Australians deserve. The ECPs I have met and worked with so far have quickly become fast friends and my biggest supporters. I wanted to get involved to give everyone the opportunity to find their ‘pharmily’ and have the experience that I have had.
What do you see as the future of pharmacy in Australia?
I’d like to see a pharmacist in every residential care facility, general practice, hospital ward, ambulance service – wherever medicines are prescribed and used, we should be there. Australians deserve access to our expertise no matter where they access healthcare. Imagine how many problems we could fix and prevent if we worked in these settings as decisions were being made!
A day in the life of Deanna Mill MPS, PSA ECP Board Appointed Director and PhD candidate at UWA.
7.00 am – Gym time
Rising early isn’t really my thing, but starting the day with a complete task gets me motivated for the day ahead. CrossFit-style training is my go-to.
9.00 am – At the desk
Writing, my least favourite task, is scheduled first. This week’s tasks include adding new literature to my paper on the results of a study on pharmacists’ use of guidelines, and providing feedback to a colleague on our manuscript about pharmacists’ use of the Australian Pharmaceutical Formulary.
11.30 am – Research meetings
Supervising several pharmacy students at UniSA and UWA, the research team meets today to discuss recruitment strategies for our survey looking at personality traits and career outlook of pharmacists, interns and pharmacy students. The students have had trouble recruiting other students for the survey, so we chat about strategies to encourage more completion.
12.00 pm – In the classroom
I facilitate a workshop for second-year pharmacy students on supplying emergency contraception. Role- playing different scenarios, we discuss the pharmacist’s responsibilities, including how to balance getting a thorough history to supply while ensuring the patient is comfortable and gets all the necessary information.
2.00 pm – Lunchtime
Always at least half an hour away from screens for lunch. Listening to a podcast in the garden while eating helps to switch off and reset for a bit.
2.40 pm – ECP duties
A quick review of the ECP CSI discussion forum shows an interesting thread on the differences in pharmacy practice between countries. Consider how we could expand on this to learn from pharmacists around the world. Meet with the chairs of the other CSIs and PSA staff to discuss successes so far, including the launch of Pharmacy & Me, PSA’s podcast featuring ECPs.
4.30 pm – Emails and admin
Time to review my to-do list and emails, plan what is needed for the next day and who I am meeting.
6.00 pm – Winding down
With many evening meetings, I make sure to take similar time off soon after, with a later start next day or a longer lunch break. Balance is crucial to managing my workload. If there are no scheduled meetings, it’s time to cook a delicious meal, water my many plants, watch some trashy Netflix, do some stretching and rest.
Explore new paths at www.psa.org.au/careerpathway
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University lecturer, community pharmacist and PSA NSW Branch Vice-President Dr Sarah Dineen-Griffin MPS has packed a lot into her 16 years in pharmacy – and she shows no sign of slowing down.
Was pharmacy always your goal?
Short answer: yes! I started working in community pharmacy at age 15 and met some brilliant people. I saw pharmacy as exciting and constantly evolving. Pharmacists directly impact patient health outcomes and I wanted to help people.
Where has pharmacy taken you?
I’ve worked in many professional settings, including as a professional services pharmacist and managing different pharmacies. I also gained accreditation as a consultant pharmacist and started undertaking Home Medicines Reviews. Completing my PhD in 2020 opened doors to international research groups and to present at international conferences. Over 9 months I explored health systems, community pharmacy services and international pharmacy models in the United Kingdom and Europe for my PhD and have been a university lecturer and researcher for the past 2 years.
What are your hopes for your research?
My vision is to achieve evidence-based change in pharmacy practice. Community pharmacy must increasingly be part of primary care, including closer collaboration with medical practitioners, state and federal governments and PHNs – that’s where the future lies. My research focuses on three important, interconnected areas. Pharmacists constantly manage minor ailments, but we see patients seek care from emergency departments or general practice, which is more costly to the health system.
We should work with all stakeholders to reduce this burden.Then there’s self-care, which is becoming increasingly important. We should educate pharmacists on how to teach people the skills to look after themselves and their families. Finally, health and digital literacy are vital – where individuals have the skills and knowledge to access, understand and use information to make important decisions about medicines and health.
‘[On the National Medicines Policy Review Expert Advisory Committee] my role is to ensure the views of younger healthcare professionals (the future voice) are heard.’
You recently had your first child – what have you learnt about navigating a career and family?
I’ve gained a greater understanding of the barriers for women with family and child-rearing responsibilities to progress into and maintain pharmacy leadership positions. Women are 63% of the Australian pharmacist workforce. We need a deeper understanding of the challenges women in pharmacy might face at critical points in their career and life, and find solutions. And we need a strategic plan to support women (and men) to re-enter the profession – in work and leadership positions – after a birth. We should promote a workplace culture where it is more comfortable for conversations with employers about starting a family or taking breastfeeding breaks.
Tell us about your role on the National Medicines Policy (NMP) Review Expert Advisory Committee.
There have been substantial changes in the health landscape since the NMP was published in 2000. My role is to ensure the views of younger healthcare professionals (the future voice) are considered following extensive consultation with key stakeholders including PSA, the AMA, the pharmaceutical industry, consumer organisations, and others. A draft policy is being prepared so the refreshed NMP, as a high-level policy framework, will ensure health system changes are addressed.
It’s important the future needs of the health system are covered. This includes digital technology and interoperability, health providers working to full scope of practice and expansion in treatment options and access avenues, like advances in medical technologies and the potential for repurposing medicines and accessing clinical trials – with a sound implementation process and measurable outcomes.
What advice would you give to early career pharmacists?
Be dynamic, continually upskill and don’t settle. Experience pharmacy in many different roles when you’re starting out, find an area of interest and pursue it. Listen to those around you and model yourself on a mentor. They can introduce you to people, provide support, help you grow and advise you throughout your career. Remember, it’s important to enjoy what you do.
[post_title] => Insight is leading change
[post_excerpt] => University lecturer, community pharmacist and PSA NSW Branch Vice-President Dr Sarah Dineen-Griffin MPS has packed a lot into her 16 years in pharmacy – and she shows no sign of slowing down.
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CPD credits
Accreditation Number : CAP1810A
Group 1 : 0.75 CPD credits
Group 2 : 1.5 CPD credits
This activity has been accredited for 0.75 hours of Group 1 CPD (or 0.75 CPD credits) suitable for inclusion in an individual pharmacist's CPD plan, which can be converted to 0.75 hours of Group 1 CPD (or 1.50 CPD credits) upon successful completion of relevant assessment activities.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
