Ruth Cooper
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[post_content] => For patients undergoing opioid dependence treatment (ODT), long-acting injectable buprenorphine (LAIB) can be a life-changing therapeutic option.
Since 2020, the demand for LAIB has steadily increased, replacing older ODT therapies such as methadone, said John Jones MPS, who administers LAIB in his Shortland, NSW pharmacy.
‘The National Opioid Pharmacotherapy Statistics Annual Data collection shows there is a significant growth trend in that space,’ he said.
But with changes to the ODT program kicking off on 1 July 2023 – including new Pharmaceutical Benefits Scheme (PBS) arrangements only allowing LAIB to be funded through hospital or community pharmacies – pharmacists are likely administering the lion’s share.
To help pharmacists meet this demand, Australian Pharmacist investigates the pros and cons of administering LAIB for both patients and pharmacists, as well as the intricacies of running an efficient LAIB clinic.
What are the key benefits of LAIB?
To access most ODT therapies, such as methadone or buprenorphine and naloxone sublingual films, patients must visit their community pharmacist up to 30 times per month.
But LAIB’s longer dosing intervals means patients need to present much less often – allowing them to fulfil work or childcare responsibilities, or even go on holiday.
LAIB is a stable and predictable medicine, with withdrawal from the medicine reported to be associated with less severe symptoms than cessation of other ODT medicines such as sublingual buprenorphine or methadone.
‘The risk of diversion is also a lot lower and it allows our patients to lead a more normal life,’ said Mr Jones.
[caption id="attachment_13111" align="aligncenter" width="500"]
John Jones MPS, pharmacist immuniser and owner of My Community Pharmacy Shortland in Newcastle, NSW[/caption]
The way LAIB is administered also places it squarely in line with other therapies administered in a community pharmacy setting.
‘Patients let the pharmacy assistants know that they are there for their injection, and then they just sit and wait,’ he said. ‘It’s dosed in a private space so patients could be receiving any injection, which helps to remove some of the stigma associated with other forms of opioid replacement.’
Administering LAIB can also mean less paperwork for pharmacists. ‘You don’t have the daily signing out doses that you do with oral forms,’ he said.
However, patient consultations for LAIB can take longer. ‘Because of the longer period between doses, more information needs to be gathered than in a daily appointment, including establishing patient stability,’ said Mr Jones.
Circumstances can also change within monthly intervals, including a decline in mental health. ‘Pharmacists then need to reach out to their wider healthcare team to let them know what has occurred.’
What LAIB options are available?
There are three LAIB products currently available on the PBS under an s100 opioid-dependence listing:
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[post_content] => The theme of this year’s National Pain Week (22–28 July 2024) is ‘Pain colours your world’ – designed to highlight that for the 3.6 million Australians living with chronic pain, the impacts extend far beyond feeling pain itself.
The effects are also not limited to the person experiencing pain, with the reverberations extending throughout the economy and society.
Almost half of the respondents to the 2024 National Pain Survey have stopped working because of their pain condition, with around 30% needing to limit their hours.
Most (two thirds) feel that their condition strains their family relationships – whether through a lack of intimacy or inability to pick up their child.
With chronic pain taking an average of 3 years to diagnose, these findings illuminate the prevalence of underservicing and lack of support in the chronic pain space, said Nicolette Ellis MPS, Chair of Chronic Pain Australia.
‘Chronic pain is taking far too long to diagnose, and multidisciplinary pain management, which offers the best hope for controlling this complex condition, remains largely inaccessible,’ she said.
As the most accessed health professional by patients with chronic pain – with 35% of respondents visiting a pharmacy once a month and 43% even more frequently – Australian Pharmacist delves into how pharmacists can help to improve the pain experience for these patients.
Medicine management missing in chronic pain care
When respondents were asked if they had been offered a medicine management plan, such as a Home Medicines Review (HMR) or MedsCheck, the findings revealed a surprising lack of oversight, including:
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[post_content] => Most Australians don’t use their asthma inhalers correctly. By distinguishing between the two different types of inspiratory flow rates, this new inhaler label could help to improve a dismal status quo.
Asthma and chronic obstructive pulmonary disease (COPD) are common respiratory conditions with a significant burden of disease.
Around 2.7 million Australians report having asthma, while COPD affects an estimated one in 13 adults over 40 years of age (7.7%) – rising to 29% among people aged 75 years and older.
The mainstay of pharmacological treatment for asthma and COPD is inhaled therapy with bronchodilators and corticosteroids, delivered via:
Debbie Rigby FPS explaining how to correctly use different inhaler devices[/caption]
To promote better inhaler technique, the National Asthma Council Australia (NAC) and PSA have developed supplementary labels to be affixed to inhalers in addition to the dispensing label.
Pharmacists can point out: ‘There’s a new sticker that focuses on how you breathe in and your inspiratory flow rate. Because if you don't have the correct inhalation technique, you're not getting the most out of your medicines, and therefore not controlling your asthma or COPD as best as you can.’
When patients are using multiple inhalers with different inspiratory flow rates, for example a DPI and pMDI, a supplementary label can be applied to each, acting as a prompt and reminder about which way they should be breathing in.
Pharmacists could then follow up by saying, say, ‘Did you know the best way to use DPI inhalers is quick and deep inhalation?’ – either demonstrating the process on placebo devices, or showing patients the NAC’s videos on inhaler technique.
When patients understand the importance of something, behavioural change is more likely.
When dispensing DPIs, for example, pharmacists could explain that they don’t contain a propellant like some other inhalers, meaning a quick and deep inhalation is needed to separate the drug from the lactose powder – helping to ensure the active ingredient gets down into the small airways of the lungs.
Pharmacists can then ask patients if they would feel comfortable to demonstrate their inhaler technique on the dispensed devices.
An In-Check Dial – a hand-held device with an adjustable dial to mimic the internal resistance of different inhalers – can be used to identify suboptimal PIFR and help with inhaler device selection and technique training.
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[post_content] => An important aspect of chronic disease management is patients taking ownership of their own health – whether checking their weight or tracking physical activity, heart rate, or blood sugar levels.
Smartwatches, owned by around one in three Australians, can provide a handy, continuous, and integrable monitoring platform that greatly facilitates this process. But they are not without drawbacks.
Australian Pharmacist explores the pros, cons and potential uses of smartwatches in healthcare, and how pharmacists can best support patients to use them in chronic disease management.
There’s an app for that
There are numerous smartwatch apps on the market, which can track a variety of health metrics such as:
Professor Sepehr Shakib[/caption]
‘They're then able to monitor that information and look at trends or changes over time,’ he said. ‘By having this data readily accessible, patients can then communicate it much more easily with healthcare professionals such as pharmacists.’
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[post_content] => With the coming requirement for pathology providers to upload all test results to My Health Record, pharmacists will be able to ‘see’ patients more clearly.
Until this year, many pathology test results were not visible to pharmacists, patients or indeed anyone other than the referring doctor. They were generally not uploaded to My Health Record (MHR) by pathology providers, who instead sent them directly only to prescribers.
This is about to change. In the coming months, following federal government intervention, pathology providers will be required to upload pathology to MHR by default. This will be visible to all health professionals in MHR – including pharmacists.
It is hoped this will mean pharmacists will no longer have to dispense ‘in the dark’, blind to critical information required to determine whether a medicine is ‘safe and therapeutically appropriate’.
Professional expectation when pharmacists dispense medicinesStandard 7 (Dispensing) Action 2: The pharmacist assesses the information gathered and reviews the prescription or order to determine if dispensing the therapeutic good for the patient is:
|
AP asked three pharmacists how using pathology results has already made a difference to the clinical decisions they make in supporting their patients to use medicines safely and effectively.
Lee McLennan MPS Owner LiveLife Pharmacy, Cannonvale, Queensland
Mrs B, aged 58, was referred to me for a HMR due to instability with blood pressure control. She had been commenced on atenolol 50 mg daily about 6 months ago, and had recently been increased to 50 mg twice daily to reduce blood pressure to < 130/80 mmHg.
[caption id="attachment_26802" align="alignright" width="200"]
Lee McLennan MPS[/caption]
Her medicines:
Mrs B is a retired schoolteacher and lives with her husband. They’d recently moved from Victoria to the warmer Whitsundays.
Using dispense history, records provided by her prescriber and also physical reconciliation, I determined she adhered to her medicine regimen. I wanted to double-check this, as she presented several brands of her atenolol medication. However, this turned out to be a result of recent travel, and she was confident with taking them as prescribed.
Her blood pressure at the HMR was 153/97 mmHg.
I considered adding an ACEI or ARB. An ACEI would have reno-protective effects, slowing the progression of diabetic kidney disease in the future. In the HMR report, I recommended commencing perindopril 5 mg daily, titrating up to 10 mg if required. The prescriber then initiated Mrs B on 5 mg and conducted bloods to confirm renal function and electrolytes prior to ACEI commencement, with a review to be conducted in 2 weeks’ time.
The review showed an increase in serum creatinine of 35% over baseline and a reduction in eGFR (estimated glomerular filtration rate) of 29%. On further discussion with the prescriber, we agreed to withhold meloxicam (NSAID). Meloxicam had been continued after a knee replacement 2 years prior, without review since. Mrs B confirmed her pain levels had significantly decreased and she was willing to trial ceasing meloxicam, particularly with the potential impact on her serum creatinine levels.
In terms of full-scope practice, having access to blood level results is crucial, particularly with patient participation in the CVD risk-reduction program.
For a prescribing pharmacist to fully assess a patient and provide optimal outcomes, it will be important to have these details so we can determine appropriateness of therapy.
Dr Natalie Soulsby FPS, Adv Prac Pharm Head of Clinical Excellence, Embedded Health Solutions Senior Consultant Pharmacist, Clinical Pharmacology, Royal Adelaide Hospital
[caption id="attachment_26803" align="alignright" width="200"]
Dr Natalie Soulsby FPS, Adv Prac Pharm[/caption]
A 54-year-old gentleman attended his regular clinic appointment in the hospital.
He was very excited having recently started a new job, which was going well.
He was HIV-positive and had been on antiretroviral therapy since his mid-20s. With a reaction to abacavir in the past, his current treatment was with bictegravir/emtricitabine/tenofovir, and he had been stable on this for the last 2 years.
He also had hyperlipidaemia, hypertension, was hypothyroid and took rosuvastatin, candesartan and levothyroxine. With difficulty controlling pain, he had started on medicinal cannabis (both CBD and THC) and felt this was helping with his pain.
During my conversation with him, he complained of increasing fatigue and the need for daily naps and was worried that this might affect his new job, which involved shift work. He wondered if it was connected with his diagnosis or his medicines or something else. When I asked him about sun exposure, he admitted he didn’t spend as much time outdoors as he used to and he always wore sunscreen.
I asked about recent blood tests, as his last available results on our hospital system did not show anything abnormal, nor did they include vitamin D. He said he had some done a few weeks ago by a different pathology group, which did not automatically upload onto our system.
I asked his permission to access My Health Record to see if his recent pathology results had been uploaded into the system and they had.
On checking his results, I saw that he had a recent vitamin D level of 18 nmol/L (reference range 50–200 nmol/L). I thought that would explain his symptoms.
We started him on vitamin D supplements at a dose of 5,000 IU per day for 3 months and then to reduce to 1,000 IU per day after that. I booked him in for a follow-up appointment in 3 months’ time. On his return, he was happy to report that his energy levels had improved, and he no longer needed daytime naps.
Joanne Gross MPS MMR-Credentialed and Senior Specialist Pharmacist – Quality Use of Medicines, Department of Health, Tasmania
[caption id="attachment_26801" align="alignright" width="200"]
Joanne Gross MPS[/caption]
Mr S, an 80-year-old male reported that he only took the night-time dose of his twice daily dabigatran about half the time. His GP wanted advice regarding how to safely swap to a different DOAC – maybe rivaroxaban due to its once-daily dosing.
The GP specifically wondered if a washout was needed during the transition. His history included atrial fibrilliation, CABG (1997), hypertension, dyslipidaemia, type 2 diabetes, CKD (Stage 2), fatty liver, BPH, diverticulosis and gout.
Medicines
Pathology
The referral included pathology results from 3 months’ prior showing estimated glomerular filtration rate (eGFR) of 61 mL/min/1.73 m2. However, Mr S had undergone a trans-urethral resection of a bladder tumour (TURBT) 1 week prior and My Health Record revealed pre-operative pathology results including an eGFR of 48 mL/min/1.73 m2. Mr S reported ongoing frank haematuria, (bright red urine and passing of large clots) 7 days post-TURBT.
I called the clinic to flag the ongoing frank haematuria with the clinic nurse so the GP could promptly review the patient.
Recommendations
1. Switch dabigatran twice daily to rivaroxaban once daily to improve adherence. No overlap or ‘washout’ required. Commence rivaroxaban when next (morning) dose of dabigatran is due.2 Monitor adherence. Poor adherence increases stroke risk. eGFR 1 week ago was 48 mL/min/1.73 m2. Repeat electrolytes, urea and creatinine (EUC) prior to commencing rivaroxaban to inform dosing:
2. Cease aspirin if bleeding continues. Evidence increasingly supports DOAC monotherapy in patients with AF and stable coronary artery disease (cardiologist advice might assist).3
3. To reduce lipids further, a swap to ezetimibe-rosuvastatin 10 mg-20 mg is recommended – the longer half-life of rosuvastatin enables efficacy with morning dosing.
4. Consider Shingrix vaccination. Mr S’s AIR history via MHR did not report varicella vaccinations.
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[post_content] => For patients undergoing opioid dependence treatment (ODT), long-acting injectable buprenorphine (LAIB) can be a life-changing therapeutic option.
Since 2020, the demand for LAIB has steadily increased, replacing older ODT therapies such as methadone, said John Jones MPS, who administers LAIB in his Shortland, NSW pharmacy.
‘The National Opioid Pharmacotherapy Statistics Annual Data collection shows there is a significant growth trend in that space,’ he said.
But with changes to the ODT program kicking off on 1 July 2023 – including new Pharmaceutical Benefits Scheme (PBS) arrangements only allowing LAIB to be funded through hospital or community pharmacies – pharmacists are likely administering the lion’s share.
To help pharmacists meet this demand, Australian Pharmacist investigates the pros and cons of administering LAIB for both patients and pharmacists, as well as the intricacies of running an efficient LAIB clinic.
What are the key benefits of LAIB?
To access most ODT therapies, such as methadone or buprenorphine and naloxone sublingual films, patients must visit their community pharmacist up to 30 times per month.
But LAIB’s longer dosing intervals means patients need to present much less often – allowing them to fulfil work or childcare responsibilities, or even go on holiday.
LAIB is a stable and predictable medicine, with withdrawal from the medicine reported to be associated with less severe symptoms than cessation of other ODT medicines such as sublingual buprenorphine or methadone.
‘The risk of diversion is also a lot lower and it allows our patients to lead a more normal life,’ said Mr Jones.
[caption id="attachment_13111" align="aligncenter" width="500"] John Jones MPS, pharmacist immuniser and owner of My Community Pharmacy Shortland in Newcastle, NSW[/caption]
The way LAIB is administered also places it squarely in line with other therapies administered in a community pharmacy setting.
‘Patients let the pharmacy assistants know that they are there for their injection, and then they just sit and wait,’ he said. ‘It’s dosed in a private space so patients could be receiving any injection, which helps to remove some of the stigma associated with other forms of opioid replacement.’
Administering LAIB can also mean less paperwork for pharmacists. ‘You don’t have the daily signing out doses that you do with oral forms,’ he said.
However, patient consultations for LAIB can take longer. ‘Because of the longer period between doses, more information needs to be gathered than in a daily appointment, including establishing patient stability,’ said Mr Jones.
Circumstances can also change within monthly intervals, including a decline in mental health. ‘Pharmacists then need to reach out to their wider healthcare team to let them know what has occurred.’
What LAIB options are available?
There are three LAIB products currently available on the PBS under an s100 opioid-dependence listing:
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[post_content] => The theme of this year’s National Pain Week (22–28 July 2024) is ‘Pain colours your world’ – designed to highlight that for the 3.6 million Australians living with chronic pain, the impacts extend far beyond feeling pain itself.
The effects are also not limited to the person experiencing pain, with the reverberations extending throughout the economy and society.
Almost half of the respondents to the 2024 National Pain Survey have stopped working because of their pain condition, with around 30% needing to limit their hours.
Most (two thirds) feel that their condition strains their family relationships – whether through a lack of intimacy or inability to pick up their child.
With chronic pain taking an average of 3 years to diagnose, these findings illuminate the prevalence of underservicing and lack of support in the chronic pain space, said Nicolette Ellis MPS, Chair of Chronic Pain Australia.
‘Chronic pain is taking far too long to diagnose, and multidisciplinary pain management, which offers the best hope for controlling this complex condition, remains largely inaccessible,’ she said.
As the most accessed health professional by patients with chronic pain – with 35% of respondents visiting a pharmacy once a month and 43% even more frequently – Australian Pharmacist delves into how pharmacists can help to improve the pain experience for these patients.
Medicine management missing in chronic pain care
When respondents were asked if they had been offered a medicine management plan, such as a Home Medicines Review (HMR) or MedsCheck, the findings revealed a surprising lack of oversight, including:
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[post_content] => Most Australians don’t use their asthma inhalers correctly. By distinguishing between the two different types of inspiratory flow rates, this new inhaler label could help to improve a dismal status quo.
Asthma and chronic obstructive pulmonary disease (COPD) are common respiratory conditions with a significant burden of disease.
Around 2.7 million Australians report having asthma, while COPD affects an estimated one in 13 adults over 40 years of age (7.7%) – rising to 29% among people aged 75 years and older.
The mainstay of pharmacological treatment for asthma and COPD is inhaled therapy with bronchodilators and corticosteroids, delivered via:
Debbie Rigby FPS explaining how to correctly use different inhaler devices[/caption]
To promote better inhaler technique, the National Asthma Council Australia (NAC) and PSA have developed supplementary labels to be affixed to inhalers in addition to the dispensing label.
Pharmacists can point out: ‘There’s a new sticker that focuses on how you breathe in and your inspiratory flow rate. Because if you don't have the correct inhalation technique, you're not getting the most out of your medicines, and therefore not controlling your asthma or COPD as best as you can.’
When patients are using multiple inhalers with different inspiratory flow rates, for example a DPI and pMDI, a supplementary label can be applied to each, acting as a prompt and reminder about which way they should be breathing in.
Pharmacists could then follow up by saying, say, ‘Did you know the best way to use DPI inhalers is quick and deep inhalation?’ – either demonstrating the process on placebo devices, or showing patients the NAC’s videos on inhaler technique.
When patients understand the importance of something, behavioural change is more likely.
When dispensing DPIs, for example, pharmacists could explain that they don’t contain a propellant like some other inhalers, meaning a quick and deep inhalation is needed to separate the drug from the lactose powder – helping to ensure the active ingredient gets down into the small airways of the lungs.
Pharmacists can then ask patients if they would feel comfortable to demonstrate their inhaler technique on the dispensed devices.
An In-Check Dial – a hand-held device with an adjustable dial to mimic the internal resistance of different inhalers – can be used to identify suboptimal PIFR and help with inhaler device selection and technique training.
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[post_content] => An important aspect of chronic disease management is patients taking ownership of their own health – whether checking their weight or tracking physical activity, heart rate, or blood sugar levels.
Smartwatches, owned by around one in three Australians, can provide a handy, continuous, and integrable monitoring platform that greatly facilitates this process. But they are not without drawbacks.
Australian Pharmacist explores the pros, cons and potential uses of smartwatches in healthcare, and how pharmacists can best support patients to use them in chronic disease management.
There’s an app for that
There are numerous smartwatch apps on the market, which can track a variety of health metrics such as:
Professor Sepehr Shakib[/caption]
‘They're then able to monitor that information and look at trends or changes over time,’ he said. ‘By having this data readily accessible, patients can then communicate it much more easily with healthcare professionals such as pharmacists.’
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[post_content] => With the coming requirement for pathology providers to upload all test results to My Health Record, pharmacists will be able to ‘see’ patients more clearly.
Until this year, many pathology test results were not visible to pharmacists, patients or indeed anyone other than the referring doctor. They were generally not uploaded to My Health Record (MHR) by pathology providers, who instead sent them directly only to prescribers.
This is about to change. In the coming months, following federal government intervention, pathology providers will be required to upload pathology to MHR by default. This will be visible to all health professionals in MHR – including pharmacists.
It is hoped this will mean pharmacists will no longer have to dispense ‘in the dark’, blind to critical information required to determine whether a medicine is ‘safe and therapeutically appropriate’.
Professional expectation when pharmacists dispense medicinesStandard 7 (Dispensing) Action 2: The pharmacist assesses the information gathered and reviews the prescription or order to determine if dispensing the therapeutic good for the patient is:
|
AP asked three pharmacists how using pathology results has already made a difference to the clinical decisions they make in supporting their patients to use medicines safely and effectively.
Lee McLennan MPS Owner LiveLife Pharmacy, Cannonvale, Queensland
Mrs B, aged 58, was referred to me for a HMR due to instability with blood pressure control. She had been commenced on atenolol 50 mg daily about 6 months ago, and had recently been increased to 50 mg twice daily to reduce blood pressure to < 130/80 mmHg.
[caption id="attachment_26802" align="alignright" width="200"] Lee McLennan MPS[/caption]
Her medicines:
Mrs B is a retired schoolteacher and lives with her husband. They’d recently moved from Victoria to the warmer Whitsundays.
Using dispense history, records provided by her prescriber and also physical reconciliation, I determined she adhered to her medicine regimen. I wanted to double-check this, as she presented several brands of her atenolol medication. However, this turned out to be a result of recent travel, and she was confident with taking them as prescribed.
Her blood pressure at the HMR was 153/97 mmHg.
I considered adding an ACEI or ARB. An ACEI would have reno-protective effects, slowing the progression of diabetic kidney disease in the future. In the HMR report, I recommended commencing perindopril 5 mg daily, titrating up to 10 mg if required. The prescriber then initiated Mrs B on 5 mg and conducted bloods to confirm renal function and electrolytes prior to ACEI commencement, with a review to be conducted in 2 weeks’ time.
The review showed an increase in serum creatinine of 35% over baseline and a reduction in eGFR (estimated glomerular filtration rate) of 29%. On further discussion with the prescriber, we agreed to withhold meloxicam (NSAID). Meloxicam had been continued after a knee replacement 2 years prior, without review since. Mrs B confirmed her pain levels had significantly decreased and she was willing to trial ceasing meloxicam, particularly with the potential impact on her serum creatinine levels.
In terms of full-scope practice, having access to blood level results is crucial, particularly with patient participation in the CVD risk-reduction program.
For a prescribing pharmacist to fully assess a patient and provide optimal outcomes, it will be important to have these details so we can determine appropriateness of therapy.
Dr Natalie Soulsby FPS, Adv Prac Pharm Head of Clinical Excellence, Embedded Health Solutions Senior Consultant Pharmacist, Clinical Pharmacology, Royal Adelaide Hospital
[caption id="attachment_26803" align="alignright" width="200"] Dr Natalie Soulsby FPS, Adv Prac Pharm[/caption]
A 54-year-old gentleman attended his regular clinic appointment in the hospital.
He was very excited having recently started a new job, which was going well.
He was HIV-positive and had been on antiretroviral therapy since his mid-20s. With a reaction to abacavir in the past, his current treatment was with bictegravir/emtricitabine/tenofovir, and he had been stable on this for the last 2 years.
He also had hyperlipidaemia, hypertension, was hypothyroid and took rosuvastatin, candesartan and levothyroxine. With difficulty controlling pain, he had started on medicinal cannabis (both CBD and THC) and felt this was helping with his pain.
During my conversation with him, he complained of increasing fatigue and the need for daily naps and was worried that this might affect his new job, which involved shift work. He wondered if it was connected with his diagnosis or his medicines or something else. When I asked him about sun exposure, he admitted he didn’t spend as much time outdoors as he used to and he always wore sunscreen.
I asked about recent blood tests, as his last available results on our hospital system did not show anything abnormal, nor did they include vitamin D. He said he had some done a few weeks ago by a different pathology group, which did not automatically upload onto our system.
I asked his permission to access My Health Record to see if his recent pathology results had been uploaded into the system and they had.
On checking his results, I saw that he had a recent vitamin D level of 18 nmol/L (reference range 50–200 nmol/L). I thought that would explain his symptoms.
We started him on vitamin D supplements at a dose of 5,000 IU per day for 3 months and then to reduce to 1,000 IU per day after that. I booked him in for a follow-up appointment in 3 months’ time. On his return, he was happy to report that his energy levels had improved, and he no longer needed daytime naps.
Joanne Gross MPS MMR-Credentialed and Senior Specialist Pharmacist – Quality Use of Medicines, Department of Health, Tasmania
[caption id="attachment_26801" align="alignright" width="200"] Joanne Gross MPS[/caption]
Mr S, an 80-year-old male reported that he only took the night-time dose of his twice daily dabigatran about half the time. His GP wanted advice regarding how to safely swap to a different DOAC – maybe rivaroxaban due to its once-daily dosing.
The GP specifically wondered if a washout was needed during the transition. His history included atrial fibrilliation, CABG (1997), hypertension, dyslipidaemia, type 2 diabetes, CKD (Stage 2), fatty liver, BPH, diverticulosis and gout.
Medicines
Pathology
The referral included pathology results from 3 months’ prior showing estimated glomerular filtration rate (eGFR) of 61 mL/min/1.73 m2. However, Mr S had undergone a trans-urethral resection of a bladder tumour (TURBT) 1 week prior and My Health Record revealed pre-operative pathology results including an eGFR of 48 mL/min/1.73 m2. Mr S reported ongoing frank haematuria, (bright red urine and passing of large clots) 7 days post-TURBT.
I called the clinic to flag the ongoing frank haematuria with the clinic nurse so the GP could promptly review the patient.
Recommendations
1. Switch dabigatran twice daily to rivaroxaban once daily to improve adherence. No overlap or ‘washout’ required. Commence rivaroxaban when next (morning) dose of dabigatran is due.2 Monitor adherence. Poor adherence increases stroke risk. eGFR 1 week ago was 48 mL/min/1.73 m2. Repeat electrolytes, urea and creatinine (EUC) prior to commencing rivaroxaban to inform dosing:
2. Cease aspirin if bleeding continues. Evidence increasingly supports DOAC monotherapy in patients with AF and stable coronary artery disease (cardiologist advice might assist).3
3. To reduce lipids further, a swap to ezetimibe-rosuvastatin 10 mg-20 mg is recommended – the longer half-life of rosuvastatin enables efficacy with morning dosing.
4. Consider Shingrix vaccination. Mr S’s AIR history via MHR did not report varicella vaccinations.
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[post_date_gmt] => 2024-07-24 03:05:39
[post_content] => For patients undergoing opioid dependence treatment (ODT), long-acting injectable buprenorphine (LAIB) can be a life-changing therapeutic option.
Since 2020, the demand for LAIB has steadily increased, replacing older ODT therapies such as methadone, said John Jones MPS, who administers LAIB in his Shortland, NSW pharmacy.
‘The National Opioid Pharmacotherapy Statistics Annual Data collection shows there is a significant growth trend in that space,’ he said.
But with changes to the ODT program kicking off on 1 July 2023 – including new Pharmaceutical Benefits Scheme (PBS) arrangements only allowing LAIB to be funded through hospital or community pharmacies – pharmacists are likely administering the lion’s share.
To help pharmacists meet this demand, Australian Pharmacist investigates the pros and cons of administering LAIB for both patients and pharmacists, as well as the intricacies of running an efficient LAIB clinic.
What are the key benefits of LAIB?
To access most ODT therapies, such as methadone or buprenorphine and naloxone sublingual films, patients must visit their community pharmacist up to 30 times per month.
But LAIB’s longer dosing intervals means patients need to present much less often – allowing them to fulfil work or childcare responsibilities, or even go on holiday.
LAIB is a stable and predictable medicine, with withdrawal from the medicine reported to be associated with less severe symptoms than cessation of other ODT medicines such as sublingual buprenorphine or methadone.
‘The risk of diversion is also a lot lower and it allows our patients to lead a more normal life,’ said Mr Jones.
[caption id="attachment_13111" align="aligncenter" width="500"] John Jones MPS, pharmacist immuniser and owner of My Community Pharmacy Shortland in Newcastle, NSW[/caption]
The way LAIB is administered also places it squarely in line with other therapies administered in a community pharmacy setting.
‘Patients let the pharmacy assistants know that they are there for their injection, and then they just sit and wait,’ he said. ‘It’s dosed in a private space so patients could be receiving any injection, which helps to remove some of the stigma associated with other forms of opioid replacement.’
Administering LAIB can also mean less paperwork for pharmacists. ‘You don’t have the daily signing out doses that you do with oral forms,’ he said.
However, patient consultations for LAIB can take longer. ‘Because of the longer period between doses, more information needs to be gathered than in a daily appointment, including establishing patient stability,’ said Mr Jones.
Circumstances can also change within monthly intervals, including a decline in mental health. ‘Pharmacists then need to reach out to their wider healthcare team to let them know what has occurred.’
What LAIB options are available?
There are three LAIB products currently available on the PBS under an s100 opioid-dependence listing:
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[post_date] => 2024-07-22 13:28:40
[post_date_gmt] => 2024-07-22 03:28:40
[post_content] => The theme of this year’s National Pain Week (22–28 July 2024) is ‘Pain colours your world’ – designed to highlight that for the 3.6 million Australians living with chronic pain, the impacts extend far beyond feeling pain itself.
The effects are also not limited to the person experiencing pain, with the reverberations extending throughout the economy and society.
Almost half of the respondents to the 2024 National Pain Survey have stopped working because of their pain condition, with around 30% needing to limit their hours.
Most (two thirds) feel that their condition strains their family relationships – whether through a lack of intimacy or inability to pick up their child.
With chronic pain taking an average of 3 years to diagnose, these findings illuminate the prevalence of underservicing and lack of support in the chronic pain space, said Nicolette Ellis MPS, Chair of Chronic Pain Australia.
‘Chronic pain is taking far too long to diagnose, and multidisciplinary pain management, which offers the best hope for controlling this complex condition, remains largely inaccessible,’ she said.
As the most accessed health professional by patients with chronic pain – with 35% of respondents visiting a pharmacy once a month and 43% even more frequently – Australian Pharmacist delves into how pharmacists can help to improve the pain experience for these patients.
Medicine management missing in chronic pain care
When respondents were asked if they had been offered a medicine management plan, such as a Home Medicines Review (HMR) or MedsCheck, the findings revealed a surprising lack of oversight, including:
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[post_date] => 2024-07-17 12:18:22
[post_date_gmt] => 2024-07-17 02:18:22
[post_content] => Most Australians don’t use their asthma inhalers correctly. By distinguishing between the two different types of inspiratory flow rates, this new inhaler label could help to improve a dismal status quo.
Asthma and chronic obstructive pulmonary disease (COPD) are common respiratory conditions with a significant burden of disease.
Around 2.7 million Australians report having asthma, while COPD affects an estimated one in 13 adults over 40 years of age (7.7%) – rising to 29% among people aged 75 years and older.
The mainstay of pharmacological treatment for asthma and COPD is inhaled therapy with bronchodilators and corticosteroids, delivered via:
Debbie Rigby FPS explaining how to correctly use different inhaler devices[/caption]
To promote better inhaler technique, the National Asthma Council Australia (NAC) and PSA have developed supplementary labels to be affixed to inhalers in addition to the dispensing label.
Pharmacists can point out: ‘There’s a new sticker that focuses on how you breathe in and your inspiratory flow rate. Because if you don't have the correct inhalation technique, you're not getting the most out of your medicines, and therefore not controlling your asthma or COPD as best as you can.’
When patients are using multiple inhalers with different inspiratory flow rates, for example a DPI and pMDI, a supplementary label can be applied to each, acting as a prompt and reminder about which way they should be breathing in.
Pharmacists could then follow up by saying, say, ‘Did you know the best way to use DPI inhalers is quick and deep inhalation?’ – either demonstrating the process on placebo devices, or showing patients the NAC’s videos on inhaler technique.
When patients understand the importance of something, behavioural change is more likely.
When dispensing DPIs, for example, pharmacists could explain that they don’t contain a propellant like some other inhalers, meaning a quick and deep inhalation is needed to separate the drug from the lactose powder – helping to ensure the active ingredient gets down into the small airways of the lungs.
Pharmacists can then ask patients if they would feel comfortable to demonstrate their inhaler technique on the dispensed devices.
An In-Check Dial – a hand-held device with an adjustable dial to mimic the internal resistance of different inhalers – can be used to identify suboptimal PIFR and help with inhaler device selection and technique training.
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[post_date] => 2024-07-15 09:48:23
[post_date_gmt] => 2024-07-14 23:48:23
[post_content] => An important aspect of chronic disease management is patients taking ownership of their own health – whether checking their weight or tracking physical activity, heart rate, or blood sugar levels.
Smartwatches, owned by around one in three Australians, can provide a handy, continuous, and integrable monitoring platform that greatly facilitates this process. But they are not without drawbacks.
Australian Pharmacist explores the pros, cons and potential uses of smartwatches in healthcare, and how pharmacists can best support patients to use them in chronic disease management.
There’s an app for that
There are numerous smartwatch apps on the market, which can track a variety of health metrics such as:
Professor Sepehr Shakib[/caption]
‘They're then able to monitor that information and look at trends or changes over time,’ he said. ‘By having this data readily accessible, patients can then communicate it much more easily with healthcare professionals such as pharmacists.’
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[post_date] => 2024-07-12 15:58:48
[post_date_gmt] => 2024-07-12 05:58:48
[post_content] => With the coming requirement for pathology providers to upload all test results to My Health Record, pharmacists will be able to ‘see’ patients more clearly.
Until this year, many pathology test results were not visible to pharmacists, patients or indeed anyone other than the referring doctor. They were generally not uploaded to My Health Record (MHR) by pathology providers, who instead sent them directly only to prescribers.
This is about to change. In the coming months, following federal government intervention, pathology providers will be required to upload pathology to MHR by default. This will be visible to all health professionals in MHR – including pharmacists.
It is hoped this will mean pharmacists will no longer have to dispense ‘in the dark’, blind to critical information required to determine whether a medicine is ‘safe and therapeutically appropriate’.
Professional expectation when pharmacists dispense medicinesStandard 7 (Dispensing) Action 2: The pharmacist assesses the information gathered and reviews the prescription or order to determine if dispensing the therapeutic good for the patient is:
|
AP asked three pharmacists how using pathology results has already made a difference to the clinical decisions they make in supporting their patients to use medicines safely and effectively.
Lee McLennan MPS Owner LiveLife Pharmacy, Cannonvale, Queensland
Mrs B, aged 58, was referred to me for a HMR due to instability with blood pressure control. She had been commenced on atenolol 50 mg daily about 6 months ago, and had recently been increased to 50 mg twice daily to reduce blood pressure to < 130/80 mmHg.
[caption id="attachment_26802" align="alignright" width="200"] Lee McLennan MPS[/caption]
Her medicines:
Mrs B is a retired schoolteacher and lives with her husband. They’d recently moved from Victoria to the warmer Whitsundays.
Using dispense history, records provided by her prescriber and also physical reconciliation, I determined she adhered to her medicine regimen. I wanted to double-check this, as she presented several brands of her atenolol medication. However, this turned out to be a result of recent travel, and she was confident with taking them as prescribed.
Her blood pressure at the HMR was 153/97 mmHg.
I considered adding an ACEI or ARB. An ACEI would have reno-protective effects, slowing the progression of diabetic kidney disease in the future. In the HMR report, I recommended commencing perindopril 5 mg daily, titrating up to 10 mg if required. The prescriber then initiated Mrs B on 5 mg and conducted bloods to confirm renal function and electrolytes prior to ACEI commencement, with a review to be conducted in 2 weeks’ time.
The review showed an increase in serum creatinine of 35% over baseline and a reduction in eGFR (estimated glomerular filtration rate) of 29%. On further discussion with the prescriber, we agreed to withhold meloxicam (NSAID). Meloxicam had been continued after a knee replacement 2 years prior, without review since. Mrs B confirmed her pain levels had significantly decreased and she was willing to trial ceasing meloxicam, particularly with the potential impact on her serum creatinine levels.
In terms of full-scope practice, having access to blood level results is crucial, particularly with patient participation in the CVD risk-reduction program.
For a prescribing pharmacist to fully assess a patient and provide optimal outcomes, it will be important to have these details so we can determine appropriateness of therapy.
Dr Natalie Soulsby FPS, Adv Prac Pharm Head of Clinical Excellence, Embedded Health Solutions Senior Consultant Pharmacist, Clinical Pharmacology, Royal Adelaide Hospital
[caption id="attachment_26803" align="alignright" width="200"] Dr Natalie Soulsby FPS, Adv Prac Pharm[/caption]
A 54-year-old gentleman attended his regular clinic appointment in the hospital.
He was very excited having recently started a new job, which was going well.
He was HIV-positive and had been on antiretroviral therapy since his mid-20s. With a reaction to abacavir in the past, his current treatment was with bictegravir/emtricitabine/tenofovir, and he had been stable on this for the last 2 years.
He also had hyperlipidaemia, hypertension, was hypothyroid and took rosuvastatin, candesartan and levothyroxine. With difficulty controlling pain, he had started on medicinal cannabis (both CBD and THC) and felt this was helping with his pain.
During my conversation with him, he complained of increasing fatigue and the need for daily naps and was worried that this might affect his new job, which involved shift work. He wondered if it was connected with his diagnosis or his medicines or something else. When I asked him about sun exposure, he admitted he didn’t spend as much time outdoors as he used to and he always wore sunscreen.
I asked about recent blood tests, as his last available results on our hospital system did not show anything abnormal, nor did they include vitamin D. He said he had some done a few weeks ago by a different pathology group, which did not automatically upload onto our system.
I asked his permission to access My Health Record to see if his recent pathology results had been uploaded into the system and they had.
On checking his results, I saw that he had a recent vitamin D level of 18 nmol/L (reference range 50–200 nmol/L). I thought that would explain his symptoms.
We started him on vitamin D supplements at a dose of 5,000 IU per day for 3 months and then to reduce to 1,000 IU per day after that. I booked him in for a follow-up appointment in 3 months’ time. On his return, he was happy to report that his energy levels had improved, and he no longer needed daytime naps.
Joanne Gross MPS MMR-Credentialed and Senior Specialist Pharmacist – Quality Use of Medicines, Department of Health, Tasmania
[caption id="attachment_26801" align="alignright" width="200"] Joanne Gross MPS[/caption]
Mr S, an 80-year-old male reported that he only took the night-time dose of his twice daily dabigatran about half the time. His GP wanted advice regarding how to safely swap to a different DOAC – maybe rivaroxaban due to its once-daily dosing.
The GP specifically wondered if a washout was needed during the transition. His history included atrial fibrilliation, CABG (1997), hypertension, dyslipidaemia, type 2 diabetes, CKD (Stage 2), fatty liver, BPH, diverticulosis and gout.
Medicines
Pathology
The referral included pathology results from 3 months’ prior showing estimated glomerular filtration rate (eGFR) of 61 mL/min/1.73 m2. However, Mr S had undergone a trans-urethral resection of a bladder tumour (TURBT) 1 week prior and My Health Record revealed pre-operative pathology results including an eGFR of 48 mL/min/1.73 m2. Mr S reported ongoing frank haematuria, (bright red urine and passing of large clots) 7 days post-TURBT.
I called the clinic to flag the ongoing frank haematuria with the clinic nurse so the GP could promptly review the patient.
Recommendations
1. Switch dabigatran twice daily to rivaroxaban once daily to improve adherence. No overlap or ‘washout’ required. Commence rivaroxaban when next (morning) dose of dabigatran is due.2 Monitor adherence. Poor adherence increases stroke risk. eGFR 1 week ago was 48 mL/min/1.73 m2. Repeat electrolytes, urea and creatinine (EUC) prior to commencing rivaroxaban to inform dosing:
2. Cease aspirin if bleeding continues. Evidence increasingly supports DOAC monotherapy in patients with AF and stable coronary artery disease (cardiologist advice might assist).3
3. To reduce lipids further, a swap to ezetimibe-rosuvastatin 10 mg-20 mg is recommended – the longer half-life of rosuvastatin enables efficacy with morning dosing.
4. Consider Shingrix vaccination. Mr S’s AIR history via MHR did not report varicella vaccinations.
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[post_content] => For patients undergoing opioid dependence treatment (ODT), long-acting injectable buprenorphine (LAIB) can be a life-changing therapeutic option.
Since 2020, the demand for LAIB has steadily increased, replacing older ODT therapies such as methadone, said John Jones MPS, who administers LAIB in his Shortland, NSW pharmacy.
‘The National Opioid Pharmacotherapy Statistics Annual Data collection shows there is a significant growth trend in that space,’ he said.
But with changes to the ODT program kicking off on 1 July 2023 – including new Pharmaceutical Benefits Scheme (PBS) arrangements only allowing LAIB to be funded through hospital or community pharmacies – pharmacists are likely administering the lion’s share.
To help pharmacists meet this demand, Australian Pharmacist investigates the pros and cons of administering LAIB for both patients and pharmacists, as well as the intricacies of running an efficient LAIB clinic.
What are the key benefits of LAIB?
To access most ODT therapies, such as methadone or buprenorphine and naloxone sublingual films, patients must visit their community pharmacist up to 30 times per month.
But LAIB’s longer dosing intervals means patients need to present much less often – allowing them to fulfil work or childcare responsibilities, or even go on holiday.
LAIB is a stable and predictable medicine, with withdrawal from the medicine reported to be associated with less severe symptoms than cessation of other ODT medicines such as sublingual buprenorphine or methadone.
‘The risk of diversion is also a lot lower and it allows our patients to lead a more normal life,’ said Mr Jones.
[caption id="attachment_13111" align="aligncenter" width="500"] John Jones MPS, pharmacist immuniser and owner of My Community Pharmacy Shortland in Newcastle, NSW[/caption]
The way LAIB is administered also places it squarely in line with other therapies administered in a community pharmacy setting.
‘Patients let the pharmacy assistants know that they are there for their injection, and then they just sit and wait,’ he said. ‘It’s dosed in a private space so patients could be receiving any injection, which helps to remove some of the stigma associated with other forms of opioid replacement.’
Administering LAIB can also mean less paperwork for pharmacists. ‘You don’t have the daily signing out doses that you do with oral forms,’ he said.
However, patient consultations for LAIB can take longer. ‘Because of the longer period between doses, more information needs to be gathered than in a daily appointment, including establishing patient stability,’ said Mr Jones.
Circumstances can also change within monthly intervals, including a decline in mental health. ‘Pharmacists then need to reach out to their wider healthcare team to let them know what has occurred.’
What LAIB options are available?
There are three LAIB products currently available on the PBS under an s100 opioid-dependence listing:
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[post_date] => 2024-07-22 13:28:40
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[post_content] => The theme of this year’s National Pain Week (22–28 July 2024) is ‘Pain colours your world’ – designed to highlight that for the 3.6 million Australians living with chronic pain, the impacts extend far beyond feeling pain itself.
The effects are also not limited to the person experiencing pain, with the reverberations extending throughout the economy and society.
Almost half of the respondents to the 2024 National Pain Survey have stopped working because of their pain condition, with around 30% needing to limit their hours.
Most (two thirds) feel that their condition strains their family relationships – whether through a lack of intimacy or inability to pick up their child.
With chronic pain taking an average of 3 years to diagnose, these findings illuminate the prevalence of underservicing and lack of support in the chronic pain space, said Nicolette Ellis MPS, Chair of Chronic Pain Australia.
‘Chronic pain is taking far too long to diagnose, and multidisciplinary pain management, which offers the best hope for controlling this complex condition, remains largely inaccessible,’ she said.
As the most accessed health professional by patients with chronic pain – with 35% of respondents visiting a pharmacy once a month and 43% even more frequently – Australian Pharmacist delves into how pharmacists can help to improve the pain experience for these patients.
Medicine management missing in chronic pain care
When respondents were asked if they had been offered a medicine management plan, such as a Home Medicines Review (HMR) or MedsCheck, the findings revealed a surprising lack of oversight, including:
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[post_date] => 2024-07-17 12:18:22
[post_date_gmt] => 2024-07-17 02:18:22
[post_content] => Most Australians don’t use their asthma inhalers correctly. By distinguishing between the two different types of inspiratory flow rates, this new inhaler label could help to improve a dismal status quo.
Asthma and chronic obstructive pulmonary disease (COPD) are common respiratory conditions with a significant burden of disease.
Around 2.7 million Australians report having asthma, while COPD affects an estimated one in 13 adults over 40 years of age (7.7%) – rising to 29% among people aged 75 years and older.
The mainstay of pharmacological treatment for asthma and COPD is inhaled therapy with bronchodilators and corticosteroids, delivered via:
Debbie Rigby FPS explaining how to correctly use different inhaler devices[/caption]
To promote better inhaler technique, the National Asthma Council Australia (NAC) and PSA have developed supplementary labels to be affixed to inhalers in addition to the dispensing label.
Pharmacists can point out: ‘There’s a new sticker that focuses on how you breathe in and your inspiratory flow rate. Because if you don't have the correct inhalation technique, you're not getting the most out of your medicines, and therefore not controlling your asthma or COPD as best as you can.’
When patients are using multiple inhalers with different inspiratory flow rates, for example a DPI and pMDI, a supplementary label can be applied to each, acting as a prompt and reminder about which way they should be breathing in.
Pharmacists could then follow up by saying, say, ‘Did you know the best way to use DPI inhalers is quick and deep inhalation?’ – either demonstrating the process on placebo devices, or showing patients the NAC’s videos on inhaler technique.
When patients understand the importance of something, behavioural change is more likely.
When dispensing DPIs, for example, pharmacists could explain that they don’t contain a propellant like some other inhalers, meaning a quick and deep inhalation is needed to separate the drug from the lactose powder – helping to ensure the active ingredient gets down into the small airways of the lungs.
Pharmacists can then ask patients if they would feel comfortable to demonstrate their inhaler technique on the dispensed devices.
An In-Check Dial – a hand-held device with an adjustable dial to mimic the internal resistance of different inhalers – can be used to identify suboptimal PIFR and help with inhaler device selection and technique training.
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[post_date] => 2024-07-15 09:48:23
[post_date_gmt] => 2024-07-14 23:48:23
[post_content] => An important aspect of chronic disease management is patients taking ownership of their own health – whether checking their weight or tracking physical activity, heart rate, or blood sugar levels.
Smartwatches, owned by around one in three Australians, can provide a handy, continuous, and integrable monitoring platform that greatly facilitates this process. But they are not without drawbacks.
Australian Pharmacist explores the pros, cons and potential uses of smartwatches in healthcare, and how pharmacists can best support patients to use them in chronic disease management.
There’s an app for that
There are numerous smartwatch apps on the market, which can track a variety of health metrics such as:
Professor Sepehr Shakib[/caption]
‘They're then able to monitor that information and look at trends or changes over time,’ he said. ‘By having this data readily accessible, patients can then communicate it much more easily with healthcare professionals such as pharmacists.’
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[post_author] => 175
[post_date] => 2024-07-12 15:58:48
[post_date_gmt] => 2024-07-12 05:58:48
[post_content] => With the coming requirement for pathology providers to upload all test results to My Health Record, pharmacists will be able to ‘see’ patients more clearly.
Until this year, many pathology test results were not visible to pharmacists, patients or indeed anyone other than the referring doctor. They were generally not uploaded to My Health Record (MHR) by pathology providers, who instead sent them directly only to prescribers.
This is about to change. In the coming months, following federal government intervention, pathology providers will be required to upload pathology to MHR by default. This will be visible to all health professionals in MHR – including pharmacists.
It is hoped this will mean pharmacists will no longer have to dispense ‘in the dark’, blind to critical information required to determine whether a medicine is ‘safe and therapeutically appropriate’.
Professional expectation when pharmacists dispense medicinesStandard 7 (Dispensing) Action 2: The pharmacist assesses the information gathered and reviews the prescription or order to determine if dispensing the therapeutic good for the patient is:
|
AP asked three pharmacists how using pathology results has already made a difference to the clinical decisions they make in supporting their patients to use medicines safely and effectively.
Lee McLennan MPS Owner LiveLife Pharmacy, Cannonvale, Queensland
Mrs B, aged 58, was referred to me for a HMR due to instability with blood pressure control. She had been commenced on atenolol 50 mg daily about 6 months ago, and had recently been increased to 50 mg twice daily to reduce blood pressure to < 130/80 mmHg.
[caption id="attachment_26802" align="alignright" width="200"] Lee McLennan MPS[/caption]
Her medicines:
Mrs B is a retired schoolteacher and lives with her husband. They’d recently moved from Victoria to the warmer Whitsundays.
Using dispense history, records provided by her prescriber and also physical reconciliation, I determined she adhered to her medicine regimen. I wanted to double-check this, as she presented several brands of her atenolol medication. However, this turned out to be a result of recent travel, and she was confident with taking them as prescribed.
Her blood pressure at the HMR was 153/97 mmHg.
I considered adding an ACEI or ARB. An ACEI would have reno-protective effects, slowing the progression of diabetic kidney disease in the future. In the HMR report, I recommended commencing perindopril 5 mg daily, titrating up to 10 mg if required. The prescriber then initiated Mrs B on 5 mg and conducted bloods to confirm renal function and electrolytes prior to ACEI commencement, with a review to be conducted in 2 weeks’ time.
The review showed an increase in serum creatinine of 35% over baseline and a reduction in eGFR (estimated glomerular filtration rate) of 29%. On further discussion with the prescriber, we agreed to withhold meloxicam (NSAID). Meloxicam had been continued after a knee replacement 2 years prior, without review since. Mrs B confirmed her pain levels had significantly decreased and she was willing to trial ceasing meloxicam, particularly with the potential impact on her serum creatinine levels.
In terms of full-scope practice, having access to blood level results is crucial, particularly with patient participation in the CVD risk-reduction program.
For a prescribing pharmacist to fully assess a patient and provide optimal outcomes, it will be important to have these details so we can determine appropriateness of therapy.
Dr Natalie Soulsby FPS, Adv Prac Pharm Head of Clinical Excellence, Embedded Health Solutions Senior Consultant Pharmacist, Clinical Pharmacology, Royal Adelaide Hospital
[caption id="attachment_26803" align="alignright" width="200"] Dr Natalie Soulsby FPS, Adv Prac Pharm[/caption]
A 54-year-old gentleman attended his regular clinic appointment in the hospital.
He was very excited having recently started a new job, which was going well.
He was HIV-positive and had been on antiretroviral therapy since his mid-20s. With a reaction to abacavir in the past, his current treatment was with bictegravir/emtricitabine/tenofovir, and he had been stable on this for the last 2 years.
He also had hyperlipidaemia, hypertension, was hypothyroid and took rosuvastatin, candesartan and levothyroxine. With difficulty controlling pain, he had started on medicinal cannabis (both CBD and THC) and felt this was helping with his pain.
During my conversation with him, he complained of increasing fatigue and the need for daily naps and was worried that this might affect his new job, which involved shift work. He wondered if it was connected with his diagnosis or his medicines or something else. When I asked him about sun exposure, he admitted he didn’t spend as much time outdoors as he used to and he always wore sunscreen.
I asked about recent blood tests, as his last available results on our hospital system did not show anything abnormal, nor did they include vitamin D. He said he had some done a few weeks ago by a different pathology group, which did not automatically upload onto our system.
I asked his permission to access My Health Record to see if his recent pathology results had been uploaded into the system and they had.
On checking his results, I saw that he had a recent vitamin D level of 18 nmol/L (reference range 50–200 nmol/L). I thought that would explain his symptoms.
We started him on vitamin D supplements at a dose of 5,000 IU per day for 3 months and then to reduce to 1,000 IU per day after that. I booked him in for a follow-up appointment in 3 months’ time. On his return, he was happy to report that his energy levels had improved, and he no longer needed daytime naps.
Joanne Gross MPS MMR-Credentialed and Senior Specialist Pharmacist – Quality Use of Medicines, Department of Health, Tasmania
[caption id="attachment_26801" align="alignright" width="200"] Joanne Gross MPS[/caption]
Mr S, an 80-year-old male reported that he only took the night-time dose of his twice daily dabigatran about half the time. His GP wanted advice regarding how to safely swap to a different DOAC – maybe rivaroxaban due to its once-daily dosing.
The GP specifically wondered if a washout was needed during the transition. His history included atrial fibrilliation, CABG (1997), hypertension, dyslipidaemia, type 2 diabetes, CKD (Stage 2), fatty liver, BPH, diverticulosis and gout.
Medicines
Pathology
The referral included pathology results from 3 months’ prior showing estimated glomerular filtration rate (eGFR) of 61 mL/min/1.73 m2. However, Mr S had undergone a trans-urethral resection of a bladder tumour (TURBT) 1 week prior and My Health Record revealed pre-operative pathology results including an eGFR of 48 mL/min/1.73 m2. Mr S reported ongoing frank haematuria, (bright red urine and passing of large clots) 7 days post-TURBT.
I called the clinic to flag the ongoing frank haematuria with the clinic nurse so the GP could promptly review the patient.
Recommendations
1. Switch dabigatran twice daily to rivaroxaban once daily to improve adherence. No overlap or ‘washout’ required. Commence rivaroxaban when next (morning) dose of dabigatran is due.2 Monitor adherence. Poor adherence increases stroke risk. eGFR 1 week ago was 48 mL/min/1.73 m2. Repeat electrolytes, urea and creatinine (EUC) prior to commencing rivaroxaban to inform dosing:
2. Cease aspirin if bleeding continues. Evidence increasingly supports DOAC monotherapy in patients with AF and stable coronary artery disease (cardiologist advice might assist).3
3. To reduce lipids further, a swap to ezetimibe-rosuvastatin 10 mg-20 mg is recommended – the longer half-life of rosuvastatin enables efficacy with morning dosing.
4. Consider Shingrix vaccination. Mr S’s AIR history via MHR did not report varicella vaccinations.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
