td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 17505 [post_author] => 3387 [post_date] => 2021-12-08 13:08:26 [post_date_gmt] => 2021-12-08 02:08:26 [post_content] => Gabapentinoids and opioids are commonly co-prescribed, whether to treat acute pain post-surgery or to address chronic pain. Here’s how to mitigate risk when these medicines are combined. Pharmacists from a range of practice settings dispense these combinations, including hospital, community, GP and aged care pharmacists, said hospital pharmacist Hannah Knowles MPS. ‘The original theory of gabapentinoids is that [when co-prescribed] it reduces the opioid dose, and it could potentially give some better pain relief as well,’ Ms Knowles said. But medical bodies such as the Royal Australasian College of Surgeons (RACS), along with Safer Care Victoria and the Medicine and Technology Unit of the Western Australia Department of Health, have recently issued safety warnings about medicine interactions. The RACS highlighted a fatal incident where a patient was prescribed pregabalin combined with opioids after minor foot surgery. The patient, who had existing comorbidities, was found unresponsive and unable to be resuscitated 10 hours later.
Safety risksThe combination of gabapentinoids and opioids can lead to central nervous system depression. ‘In extreme circumstances, the [patient] could experience deep sedation [followed by] respiratory depression,’ Ms Knowles told Australian Pharmacist. There are numerous factors that place some individuals at higher risk of medicine misadventure or drug-induced death, said Nicolette Ellis MPS, Senior Clinical Pharmacist for Beyond Pain. This includes those over the age of 65, patients with renal impairment or other comorbidities such as respiratory and mental health conditions, sleep apnoea, obesity, and a history of substance use disorder. ‘Those who use other substances such as alcohol or illicit drugs, a polydrug mix with other sedative medicines (particularly benzodiazepine and/or z-drugs), or who are prescribed high doses of pregabalin and/or opioids [are also at risk],’ Ms Ellis said. When combining gabapentinoids and opioid therapies, there is no dose that is considered ‘safe’. ‘Patients who are co-prescribed opioids with other sedative medicines are recommended to maintain their total oral morphine equivalent dose below 50 mg daily,’ Ms Ellis said. ‘The combination of these medicines always poses a risk of potential harm, [so] both agents should be prescribed at the lowest possible effective dose, and patients should be closely monitored.’
Patient screening and educationIt is important to screen patients for comorbidities when dispensing these medicines, Ms Knowles said. Pharmacists should also identify any other medicines the patient is on that might put them at higher risk. This includes tricyclic antidepressants, SNRIs like duloxetine or sedating antihistamines. ‘If you practice in a state that has real-time prescription monitoring (RTPM), [you] must check the patient’s record,’ Ms Ellis added. There is also a role for pharmacists in educating patients and their families about the risks of taking these medicines together, Ms Knowles said. Sedation is the first warning sign before people stop breathing, along with shortness of breath and slow, shallow breathing. ‘If someone is difficult to rouse, I would [advise] seeking medical attention,’ Ms Knowles added. In a community setting, pharmacists should warn patients about the risk of using gabapentinoids and opioids when they are unwell, for example if they have a respiratory illness or an infection. ‘The way that your body processes these medicines might change and that's when people are at higher risk,’ Ms Knowles said. ‘When people get sick, they [often] don't eat or drink as much, so they get a bit dehydrated and then the kidneys don't work as well.’ Patients in hospital settings should be closely monitored, and the use of patient-controlled analgesia post-surgery should be considered a risk where gabapentinoids are used. ‘Those pumps often have intravenous opioids in them, so the risk is a lot higher,’ Ms Knowles added.
Medicine consultations and reviewsMedicines like pregabalin and opioids should never be ‘set and forget’, said Ms Ellis. ‘We should be setting expectations with patients that we need to validate efficacy and review regularly,’ she said. Ms Ellis suggests the ‘BRAN’ (Benefits, Risks, Alternatives, Nothing) decision-making model. This means discussing the benefits of the medicine, the risks or adverse effects, identifying any alternatives or deciding whether maintaining the current treatment is the best option. If there is intentional overuse of the medicines, Ms Ellis suggests the three-step model ‘Ask, Advise, Help’. This entails asking about and assessing the behaviour, and providing relevant, non-judgmental advice, along with practical support, follow-up and referral. Patients with chronic pain, many of whom take gabapentinoids combined with opioids, are often open to consultations as they have exhausted all other avenues, said GP Pharmacist Deborah Hawthorne MPS. This gives her the opportunity to discuss their medicine and pain history at length. ‘I look at each of their medicines and find out what they're taking prescription-wise for pain, but also what they’re on over-the-counter, because there is often an NSAID or paracetamol involved,’ she said. ‘I go through why they're taking these medicines, when the pain started, and what sort of pain it is.’ Ms Hawthone also identifies when the medicines were started, the last time they increased or decreased their dose, and if that was effective. ‘I always use that as an opportunity to see whether those agents are appropriate for the type of pain that they have,’ she added. Patients who have chronic pain often take three or more agents, Ms Hawthorne said, so an in-depth medicine review is required. ‘You need to understand how the person feels about each of those medicines,’ she said. Identifying the patient’s relationship to their medicines allows pharmacists to see what can be tweaked or changed. ‘If it's not working, we need to do something,’ Ms Hawthorne added.
Addressing concerns with prescribersAfter establishing the indication of use, benefits of therapy, screening for potential adverse effects or risk of harm, and reviewing RTPM if possible, pharmacists should discuss any concerns they have with prescribers. It’s important to remain positive and emphasise the shared common ground, which is a positive patient outcome, Ms Ellis said. ‘Relay the background information you have established, and [explain] that you would like to discuss some options to minimise medicine-related risks,’ she said. ‘Negotiate with the prescriber what those strategies might be and always try to provide solutions like naloxone therapy, MedsChecks, home medicines reviews or staged supply.’ These conversations are also an opportunity to discuss clinical misconceptions. ‘Pregabalin continues to be prescribed for chronic pain conditions where there is no or limited evidence, such chronic back pain, sciatica, fibromyalgia and complex regional pain syndrome,’ Ms Ellis said.
Tapering advicePatients tapering off long-term opioids used for chronic pain are at a higher risk of overdose and mental health crisis, Ms Ellis said. ‘The limited research we have reviewing the deprescribing of opioids shows that patients are at a higher risk of medicine misadventure or drug-induced death when tapering or reducing opioids, rather than continuing the opioid at the same dose,’ she said. When there is ‘cumulation’ of adverse effects such as sedation or breathing difficulties, many patients are open to deprescribing or reducing their dose of pregabalin, Ms Hawthorne said. ‘Pregabalin is probably an easier agent to [reduce], if they are open to it, especially if they talk about confusion, drowsiness and [difficulty] waking up in the morning,’ she said. When tapering off pregabalin, patients could start by cutting down their dose by 75 mg every couple of weeks, Ms Hawthorne suggested. But pharmacists should check in at each interval before the next reduction. ‘Just find out how they’re going, because it’s hard when you've been on these medicines long term,’ she said. ‘You never know how your body's going to react.’ [post_title] => New safety alert for co-prescribing opioids and gabapentinoids [post_excerpt] => Gabapentinoids and opioids are commonly co-prescribed, whether to treat acute pain post-surgery or to address chronic pain. Here’s how to mitigate risk when these medicines are combined. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => new-safety-alert-for-co-prescribing-opioids-and-gabapentinoids [to_ping] => [pinged] => [post_modified] => 2021-12-08 18:42:52 [post_modified_gmt] => 2021-12-08 07:42:52 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=17505 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => New safety alert for co-prescribing opioids and gabapentinoids [title] => New safety alert for co-prescribing opioids and gabapentinoids [href] => https://www.australianpharmacist.com.au/new-safety-alert-for-co-prescribing-opioids-and-gabapentinoids/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 17506 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 17480 [post_author] => 1092 [post_date] => 2021-12-08 08:14:40 [post_date_gmt] => 2021-12-07 21:14:40 [post_content] => It’s effective, cheap, legal and relatively safe. Caffeine is the most widely consumed psychoactive drug in the world.* At an estimated 2.25 billion daily cups of coffee alone, there is little argument with the claim that people consume more caffeine globally than any other psychoactive drug.1–6,10 Further, caffeine is a component of other popular drinks and foods. Among them, tea and chocolate, not to mention kola nuts, guarana seeds and more than 60 other plants.4,5 Humans have been getting a kick-start from caffeine since our earliest days, and from coffee, specifically, for millennia.4,6 Coffee (Coffea arabica) is a hardy plant originating in Ethiopia. The Persian physician Rhazes (c. 865–925 AD) was the first to spruik its benefits. His assessment: ‘hot and dry and very good for the stomach’.4,6,7 By the 15th century, the use of coffee as a stimulant had spread throughout the Middle East. Coffee houses opened across the Arab world. By the 18th century, Europeans had picked up the habit, and during the 19th century, German chemists isolated then synthesised caffeine. They laid the foundation of today’s thriving caffeine industry by increasing the sources, production, diversity, and availability of products.4,6,8,9
Caffeine todayLike previous generations, most people today consume caffeine to increase alertness, elevate mood, improve physical performance, and reduce drowsiness and fatigue.2,4,6 Little wonder then that consumption continues to rise.2
What are the risks?Some people are more vulnerable than others to caffeine’s negative effects. Among them are pregnant and nursing women, children, adolescents and young adults, as well as those with underlying health conditions. They may experience impaired sleep and cardiovascular function, along with increased harm from smoking and drinking alcohol.2 Thanks primarily to the plethora of affordable caffeine-enhanced products, caffeine abuse and dependence are increasing. The consequence can be ‘caffeine intoxication’, which in turn boosts the risk of premature and unnatural death.4 ‘Caffeine withdrawal syndrome’ is another downside of over-dependence on caffeine. Depending on their daily dose, caffeine fans facing abrupt withdrawal may experience distressing symptoms, from headaches, fatigue, decreased energy and alertness, to depression, irritability and more. The message: reduce consumption gradually.10
What are the benefits?Fortunately, for healthy people the caffeine in food and beverages is ‘relatively safe’.2 It even has significant health benefits,1,3,4,11–14 numerous reports suggest. Decreased mortality tops the list.11 A 2019 meta-analysis of 40 studies found 2–4 cups of coffee daily was associated with ‘inverse associations’ with mortality from all-causes, cardiovascular disease and cancers.11 Other findings indicate caffeine lowers risks associated with liver cancer,12 suicide,3,14 type 2 diabetes and Parkinson’s disease.1,4 Caffeine consumption also reduces neurological disorders and enhances long-term memory.2,4,13 It even contains health-promoting nutrients.1[post_title] => Early elixir: Caffeine, the most widely used psychoactive drug in the world [post_excerpt] => It’s effective, cheap, legal and relatively safe. Caffeine is the most widely consumed psychoactive drug in the world. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => early-elixir-caffeine [to_ping] => [pinged] => [post_modified] => 2021-12-08 08:14:40 [post_modified_gmt] => 2021-12-07 21:14:40 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=17480 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Early elixir: Caffeine, the most widely used psychoactive drug in the world [title] => Early elixir: Caffeine, the most widely used psychoactive drug in the world [href] => https://www.australianpharmacist.com.au/early-elixir-caffeine/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 17497 )
How it worksCaffeine is a central nervous system stimulant. Its primary impact is blocking all four subtypes of adenosine receptors in the brain, especially A2A, which is responsible for wakefulness.2,4,5,7
RegulationIn Australia it’s legal to buy and sell caffeine. Adding it to foods and drinks, however, is regulated by the Australia New Zealand Food Standards Code.6 Conflict of interest * This column was written with the assistance of caffeine References
- Nordqvist J. Health benefits and risks of drinking coffee. Medical News Today. 2019.
- Temple JL, Bernard C, Lipshultz SE, et al. The safety of ingested caffeine: a comprehensive review. Front Psychiatry 2017;8(80).
- Park H, Suh BS, Lee K. Relationship between daily coffee intake and suicidal ideation. J Affect Disord 2019;(256):468–472.
- Cappelletti S, Piacentino D, Sani G, Aromatario M. Caffeine: cognitive and physical performance enhancer or psychoactive drug? Curr Neuropharmacol 2015;13(1):71–88.
- Evans J, Richards JR, Battisti AS. Caffeine. StatPearls [Internet]. StatPearls Publishing 2021.
- Drug Info. State Library New South Wales. Caffeine. 2018.
- Edo Barista. Rhazes and the therapeutic use of coffee in Ancient Persia. 2016.
- Wong S. Friedlieb Ferdinand Runge, the godfather of caffeine. New Scientist. Physics. 2019.
- Nobel Prize Outreach. NobelPrize.org. Emil Fischer – Biographical. 2021.
- Sajadi-Ernazarova KR, Anderson J, Dhakal A, et al. Caffeine withdrawal. StatPearls [Internet]. StatPearls Publishing 2021.
- Kim Y, Je Y, Giovannucci E. Coffee consumption and all-cause and cause-specific mortality: a meta-analysis by potential modifiers. Eur J Epidemiol 2019;34(8):731–752.
- Inoue M, Tsugane S. Coffee drinking and reduced risk of liver cancer: update on epidemiological findings and potential mechanisms. Curr Nutr Rep 2019;8(3):182–186.
- Borota D, Murray E, Keceli G, et al.Post-study caffeine administration enhances memory consolidation in humans. Nat Neurosci 2014;17:201–203.
- Lucas M, O'Reilly EJ, Pan A, et al. Coffee, caffeine, and risk of completed suicide: results from three prospective cohorts of American adults. World J Biol Psychiatry 2014;15(5):377–386.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 17489 [post_author] => 46 [post_date] => 2021-12-08 07:41:57 [post_date_gmt] => 2021-12-07 20:41:57 [post_content] => [vc_row][vc_column width="2/3"][vc_column_text]It’s something every pharmacist experiences – the exciting, slightly terrifying transition from pharmacy student to intern and then again from intern to registered pharmacist. How did you prepare for those transitions? What do you wish you had known before they happened? And what advice would you give to students and interns who are about to face the same thing? In this episode of Pharmacy & Me, PSA’s NSW Intern of the Year Bridgette Mackley and hosts Peter Guthrey and Hannah Knowles answer some of these questions. Plus, Bridgette shares how she handled the pressures of intern year, her best advice for pharmacy students and interns, and how buying a toothbrush holder changed the course of her career. Listen to the episode below or find it on Spotify, Apple Podcasts and Google Podcasts. Pharmacy & Me is proudly produced by the Pharmaceutical Society of Australia.'You're an intern and you're not really responsible for very much other than yourself. And then as soon as you get that registration, it's as fast as the flick of a light.' Bridgette Mackley MPSFollow the timestamps to jump to the topics below:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 17429 [post_author] => 3387 [post_date] => 2021-12-01 13:05:43 [post_date_gmt] => 2021-12-01 02:05:43 [post_content] => Approximately 1.8% of Australians have an Intellectual Disorder (ID), with severe or profound impairment. This equates to almost half a million people, and more than 300,000 of them are aged under 65 years, said Consultant Pharmacist Dr Manya Angley FPS, who addressed the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability last year. The healthcare challenges of this patient cohort are significant. ‘They experience high rates of physical and mental health problems, while access to appropriate healthcare is often poor,’ Dr Angley told Australian Pharmacist ahead of the 2021 International Day of People with Disability (3 December). ‘Life expectancy is lower, and [there is] a relatively high rate of potentially avoidable death.’
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 17421 [post_author] => 3387 [post_date] => 2021-12-01 09:22:20 [post_date_gmt] => 2021-11-30 22:22:20 [post_content] => This World AIDS Day (1 December) comes with a raft of new HIV screening offerings, available in pharmacies nationwide in the coming months. Despite significant progress in HIV prevention and treatment, stigma still impacts the delivery of health services and can prevent people accessing the care they need, said Lisa Dobrin, CEO of the Western Australian AIDS Council. But the availability of HIV self-test kits in pharmacies from December will help to break down these barriers by making HIV testing more accessible. ‘[Pharmacists] are a trusted source of health information, and it is hoped that locating the kits in a mainstream setting will work to normalise HIV testing,’ Ms Dobrin told Australian Pharmacist. ‘This is particularly important to help curb continued increases in HIV cases among emerging priority populations. ‘[Pre-COVID] we were seeing increases in HIV cases among heterosexual men travelling to countries with high prevalences of HIV, many of whom avoid having sexual health tests with their regular physician due to stigma.’
HIV screening and counselling adviceThe rollout of self-testing is an ‘important step’ in recognising community pharmacists' role in HIV prevention and early testing, said pharmacist Kristian Ray, Health Services Manager at WA’s Pharmacy 777, one of the first banner groups to stock the kit. ‘We anticipate the rollout will create greater public awareness of their availability and hope it will help generate a conversation around screening and prevention of HIV,’ he told AP. When self-test kits are purchased, Mr Ray said pharmacists should inform the person about the accuracy of the test. The window period is up to 3 months. If a patient suspects they have been exposed within this period they should be referred to their GP or sexual health clinic for further discussion. If potential exposure occurred within the last 72 hours, the person is eligible for Post-Exposure Prophylaxis. ‘If [patients] are on PrEP, GPs complete 3-monthly HIV and STI testing,’ he said. ‘[These patients] should talk to their GP to see if the self-test is right for [them].’ Pharmacists should explain how to use the device to ensure correct and accurate use, Mr Ray said. ‘You [have to] lance the finger using the integrated lancing device, fill the collection tube with a small amount of blood, add four drops of test fluid and wait 15 minutes,’ he said. While the Self-Test is very accurate, it is a screening test and is not diagnostic. Because it is a screening test, getting a positive result does not mean you have HIV. Should the patient receive a positive result, a follow-up test at a sexual health clinic or GP is required. Knowing when to re-test is also key. People who should consider routine, regular HIV testing include:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14533 [post_author] => 4584 [post_date] => 2021-10-20 12:49:52 [post_date_gmt] => 2021-10-20 01:49:52 [post_content] => Each week, pharmacists across the country ring PSA’s Pharmacist to Pharmacist advice line looking for guidance on everything from practice-related queries to ethical dilemmas. In this series, Australian Pharmacist speaks to the experts and answers some of the most frequently asked questions. This month Amanda Fairjones MPS, PSA Professional Support Advisor, and Peter Guthrey MPS, Senior Pharmacist – Strategic Policy, answer your questions about COVID-19 vaccine requirements and the new nicotine vaping guidelines. Have a question of your own? PSA members can call 1300 369 772 to receive professional advice and support.
1. What are the correct dosing intervals for the AstraZeneca and Moderna COVID-19 vaccines?The AstraZeneca vaccine has an approved interval of 4–12 weeks, with the preferred interval 12 weeks. In an outbreak situation, an interval of 4–8 weeks is preferred (currently Victoria, NSW and ACT). The Moderna COVID-19 vaccine has an approved interval of 4–6 weeks, with the preferred interval 28 days (4 weeks). An interval of 28 days should be considered the minimum interval. All pharmacists should check the Australian Immunisation Register (AIR) prior to administering a COVID-19 vaccine. This is a legal requirement in some jurisdictions and an essential safety requirement nationally. Checking AIR prior to vaccination supports correct patient identification, and confirms correct vaccine and dosing interval. It is additionally strongly recommended to verbally confirm this information, including the name of the patient, date of birth and vaccine to be administered as read off the label on the syringe/vial.
2. Is it mandatory for pharmacists and pharmacy staff to be vaccinated with a COVID-19 vaccine?This is dependent on the state or territory in which you practice and the nature of the work you do. AHPPC has recommended mandatory vaccinations for all workers in healthcare settings as a condition of work. Further, AHPPC has also recommended the first dose of a TGA approved COVID-19 vaccine by 30 October 2021 and a second dose by 15 December 2021. State and territory governments have announced a range of COVID-19 vaccine requirements which affect workplaces where pharmacists work, implementing this agreed AHPPC recommendation. Currently:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14458 [post_author] => 3387 [post_date] => 2021-10-12 22:00:01 [post_date_gmt] => 2021-10-12 11:00:01 [post_content] => Pharmacists’ accessibility and expertise make them an essential part of severe allergy management in children. For Phoebe Lynch from Keilor in Melbourne’s northwest, her local pharmacy is crucial to managing her son Owen’s anaphylaxis to egg, dairy and peanuts. When Owen was prescribed a lactose intolerance formula after being diagnosed with a dairy allergy at 3 months old, the pharmacists at Chemist Warehouse Keilor East ensured she had enough supply. And when the formula was low in stock, they advised her what to give Owen. ‘Their care continued, helping us manage his allergies, eczema and EpiPen needs once Owen was diagnosed at risk of anaphylaxis at 3 years of age,’ Ms Lynch told Australian Pharmacist. Owen’s case isn’t unique, with research showing food allergy and anaphylaxis is becoming more common in Australia. Up to 1 in 20 school aged children are now affected, with incidences of anaphylaxis doubling in a decade. Each year, fatalities from food-induced anaphylaxis increase by around 10%. To curb the risk, the National Allergy Strategy (NAS) has released best practice guidelines for the prevention and management of anaphylaxis in schools and children’s education and care. According to Dr Preeti Joshi, paediatric clinical immunology specialist and NAS co-chair, banning food allergens is not enough. ‘A consistent allergy-aware approach with age-appropriate strategies is preferred,’ she said. ‘This includes ensuring staff are adequately trained, especially in the prompt recognition and treatment of an allergic reaction, including anaphylaxis.’ Risk minimisation strategies, supervision and open communication are also important. ‘Things such as timely administration of adrenaline and correct positioning of the person experiencing anaphylaxis are key factors that can potentially save lives,’ she said. ‘Standardised reporting of incidents is also critical so we can learn where the gaps are and then work to increase safety.’
Anaphylaxis management and pharmacistsPharmacists are part of the circle of care for people at risk of anaphylaxis, Maria Said, co-chair of the NAS and CEO of Allergy and Anaphylaxis Australia, told AP. ‘It's important for pharmacists to have an understanding of emergency management and what allergic reactions look like,’ she said. Now that there are two adrenaline autoinjector devices available (Anapen and EpiPen), pharmacists have an even more important part to play in patient education. ‘Because the devices are used differently, there is a risk people might get confused about administration,’ Ms Said said. ‘[Pharmacists should] check that the person knows how to administer the device they're purchasing, and that they have an ASCIA [Australasian Society of Clinical Immunology and Allergy] Action Plan to match that device.’ When dispensing an adrenaline autoinjector, pharmacists should also emphasise the signs and symptoms of anaphylaxis and reinforce the emergency response aspect, Ms Said added.
Parents’ perspectivesJennifer Ayoub, from Carlingford in north-west Sydney, said it’s important for pharmacists to provide medicines advice for her son Oscar, who had an anaphylactic reaction to milk when he was 9 months old. ‘Allergy parents want EpiPens with the longest expiry date possible, especially if we’re buying extras for school or daycare,’ she said. ‘The extras are expensive so the longest expiry date is obviously more cost effective.’ When Ms Ayoub was in need, HealthFirst Pharmacy in Eastwood offered to order an EpiPen by the next morning with the latest expiry date. ‘In the past we just rang around to see what we could get, but this service is amazing for busy parents,’ she said. ‘I just dropped off the script and went in the following morning to pick up the EpiPens.’ Now that Oscar is getting older, Ms Ayoub plans to seek pharmacist advice on transitioning from children’s to adult antihistamines, which need to be carried at all times. Help with excipients is also a must. ‘There have been times Oscar has needed medicine and I have asked the pharmacist to check if it contains milk,’ Ms Ayoub said. ‘They have always looked it up for me and checked to ensure we’re buying something safe.’
A key resourceFor Ms Lynch in Melbourne, her local pharmacy played a particularly important role during the EpiPen Junior shortage last year. Ms Lynch found herself needing new supply every 4 months due to short expiry dates, meaning she had to visit her GP during lockdown. With each new EpiPen, she also had to update the paperwork at childcare. But her local pharmacy was there to help her through this challenging time. ‘They provided me with updates on when the new stock was expected, their expiry dates, and in one instance, organised a courier to deliver an EpiPen Junior from another pharmacy to their branch,’ Ms Lynch said. ‘Each time we get our EpiPen they ask us again if we know how to use it and dispose of it if administered and they are so helpful in labelling it correctly for the childcare requirements.
Anaphylaxis supportThe accessibility of community pharmacies makes them essential destinations for anaphylaxis care, said a pharmacist from Chemist Warehouse Keilor East who did not wish to be named. ‘Sometimes [patients] go to a medical centre and have to [sit] in the waiting room, whereas with pharmacies, they just pop in, and if anyone's having some kind of reaction we see them immediately,’ he said. As Ms Lynch stated, the pharmacy is quick to act in times of short supply. ‘I always make sure to pool my resources,’ the pharmacist said. ‘We’ve got our sister stores around us and even a bit further out, we've got a big network of stores that we can access the stock from.’ With special orders, such as Owen’s prescription formula, there’s always a back-up plan in place. ‘After we dispense the current supply, I make sure to immediately source the next so I've always got it there,’ the pharmacist said. When a patient purchases an adrenaline autoinjector, the pharmacist gives them a consumer medicine information leaflet and explains how to use it. ‘We have demo pens as well, so we actually get them to have a crack at [administering it],’ he said. ‘It doesn’t have a needle in it, but it’s just so they get the hang of the motion, how hard to do it, and the time it should be left against the body, so if they have to use it, they’ve done it before.’ For more information, pharmacists can direct parents to the new ‘Allergy Aware’ online hub, a free evidence-based resource. [post_title] => Pharmacists and anaphylaxis advice [post_excerpt] => Pharmacists’ accessibility and expertise make them an essential part of severe allergy management in children. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => pharmacists-anaphylaxis-advice [to_ping] => [pinged] => [post_modified] => 2021-10-15 02:16:28 [post_modified_gmt] => 2021-10-14 15:16:28 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14458 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Pharmacists and anaphylaxis advice [title] => Pharmacists and anaphylaxis advice [href] => https://www.australianpharmacist.com.au/pharmacists-anaphylaxis-advice/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14459 )
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Residential aged care providers must now ensure chemical restraint is only used as a last resort, implemented for the least amount of time possible; recorded, monitored and reviewed. Many aged care providers are unsure what constitutes chemical restraint and how they can fulfil their obligations when restraint is proposed and used.
Pharmacists working in aged care help providers recognise chemical restraint, recommend alternative strategies before use, and ensure timely monitoring and review.
What is chemical restraint?
Chemical restraint involves the use of medicines for the primary purpose of influencing a care recipient’s behaviour, but does not include the use of medicines prescribed for1,2:
- the treatment of, or to enable treatment of, the care recipient for:
- a diagnosed mental disorder; or
- a physical illness; or
- a physical condition; or
- end of life care.
The medicines are usually psychotropics which affect mood, cognition and behaviour. These include antidepressants, antipsychotics, anxiolytics, hypnotics and anticonvulsants.
When psychotropic medicines are used to manage behavioural and psychological symptoms of dementia is this chemical restraint?
Possibly. Dementia is not one specific medical condition or mental disorder. Dementia is a syndrome characterised by cognitive decline (e.g. memory, judgment) with functional impairment. Causes include Alzheimer’s disease, Vascular or Lewy Body Dementia.
Many people living with dementia develop psychological and behavioural symptoms. These can include anxiety, delusions, hallucinations, depression, insomnia, aggression, agitation, calling out, wandering and disinhibition.
Psychotropics prescribed for the main purpose of managing behaviour (e.g. agitation, calling out, wandering) are chemical restraint. When psychotropics are prescribed to treat a diagnosed mental disorder, such as psychosis or depression, they are not chemical restraint.
Are hypnotics such as temazepam chemical restraint?
Possibly. Insomnia is the inability to fall or stay asleep. Most cases are related to poor sleeping habits, stimulating substances (e.g. caffeine, tobacco) or to a lack of exercise. Addressing these causes through sleep hygiene measures should be tried before medicines.
Prescribing a hypnotic with the main aim of stopping a resident from disturbing other residents or to fit in with the schedule of the home is chemical restraint. Just because a resident is dependent on benzodiazepines does not exclude them being chemical restraint. Prescribing a hypnotic for severe insomnia short-term (up to 2 weeks) after sleep hygiene strategies have been tried is not chemical restraint.
What do providers need to do when a chemical restraint is proposed or used?
When chemical restraint is proposed, providers must assess residents to identify behavioural causes and develop Behaviour Support Plans. They must consider, trial and document non-pharmacological strategies before restraint is used.
Only the prescriber can assess whether chemical restraint is needed, not staff or relatives. The provider must ensure that the prescriber has assessed the resident, that they document the reason for restraint and that they obtain informed consent from the resident or their substitute decision maker.
When chemical restraint is used, monitoring for effectiveness and side effects and regular documented review is required to ensure that restraint is still needed and the least restrictive form.References
- Australian Government. Federal Register of legislation. Aged Care and Other Legislation Amendment (Royal Commission Response No. 1) Bill 2021. 2021. At: www.legislation.gov.au/Details/C2021B00068
- Aged Care Quality and Safety Commission. Regulatory Bulletin. Regulation of restrictive practices and the role of the Senior Practitioner, Restrictive Practices. RB2021-13. 2021. At: www.agedcarequality.gov.au/sites/default/files/media/rb-2021-13-regulatory-bulletin-regulation-restrictive-practices-role-snr-practitioner.pdf
A/PROF JUANITA BREEN BPharm, MSc(Dist), PhD, GradDipCommPracPharm, AACPA is an accredited pharmacist who currently works as a clinical pharmacist consultant in the Aged Care Quality and Safety Commission Pharmacy Unit.
HELP US HELP YOU
Professionals learn and develop from the experience of their peers. AP welcomes member contributions of practice advice as well as questions to be answered in this column.
Advice contributions may be about ethical dilemmas, pearls of wisdom or integrating new roles or technology into practice.
Responses should be 250–500 words. They may be edited for space, legal, accuracy or privacy purposes.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14120 [post_author] => 235 [post_date] => 2021-09-01 05:34:54 [post_date_gmt] => 2021-08-31 19:34:54 [post_content] => Antimicrobial use has declined in Australia during the pandemic, but the figures show there is no room for complacency. The Fourth Australian report on antimicrobial use and resistance in human health, released last week by the Australian Commission on Safety and Quality in Health Care, found Australia continues to prescribe antimicrobials at much higher rates than most European countries. In 2019, more than 40% of Australians had at least one antimicrobial dispensed in the community, and more than 26.6 million prescriptions were dispensed for antimicrobials. Antimicrobial use in the community, based on defined daily doses per 1,000 people per day, was 22.9. In the Netherlands it is as low as 9.5, while the rate in Canada, which has a similar healthcare system to Australia, is 17.5. The most used antibiotics were cefalexin, amoxicillin and amoxicillin–clavulanic acid. This is of concern, according to the report, as cefalexin and amoxicillin–clavulanic acid are first-line agents for very few conditions. Although antimicrobial dispensing rates have been gradually declining since 2015, the commission’s Senior Medical Advisor Professor John Turnidge AO said this is a trend that must be maintained in order to slow the spread of resistance. ‘We’ve still got a long way to go to get to appropriate prescribing across the country,’ he told Australian Pharmacist. ‘We’re still a lot higher than our benchmark country, which is the Netherlands. We’ve still got high usage, it’s just better than previous years.’
Inappropriate antimicrobial prescribingDespite the existence of therapeutic guidelines that detail when to prescribe antimicrobials, the appropriate dose and the length of time for use, inappropriate prescribing continues to be an issue, Prof Turnidge said. This is particularly true for respiratory infections, which are largely viral. For example, according to the report for a number of general practices, more than 80% of people with acute bronchitis or sinusitis were prescribed antimicrobials when they are not recommended by the prescribing guidelines.‘The most important message for patients and prescribers is that antibiotics are not needed for something like a head cold.'‘When we prescribe antibiotics when they are not needed, we impose unnecessary costs on the patient, and expose them to the risk of side effects,’ Prof Turnidge said. ‘The most important message for patients and prescribers is that antibiotics are not needed for something like a head cold. Many GPs are coming on board, but there’s a huge amount of patient pressure – many patients go to the doctor expecting an antibiotic.’
A positive COVID effectThe COVID-19 pandemic has had a dramatic impact on the dispensing rates of antimicrobials, according to the report, with reductions of between 22% and 49% in dispensing of amoxicillin, cefalexin and doxycycline in 2020. This could be due to a decrease in dispensing for seasonal respiratory infections such as colds and influenza, which saw a drop due to increased hand hygiene, staying at home when unwell, travel restrictions and social distancing. ‘We had very high use [of antimicrobials] in the community, but during COVID there was a significant drop in the use of certain antimicrobials,’ Prof Turnidge said. ‘As there have continued to be outbreaks of COVID, lockdowns and ongoing promotion of hand washing and social distancing in some states and territories, I imagine that the decrease may continue throughout 2021.’ Although the reduction in antimicrobial dispensing is positive, Prof Turnidge said it is important to keep the momentum going. ‘It’s one positive note we can take from COVID, and it’s a message I think we can really develop and get out to prescribers and patients that those things that cause coughs, colds and sore throats, they’re just like COVID. They don’t need antibiotics and they don’t get better with them anyway,’ he said. ‘I hope we’ll be able to keep the gains we’ve got and make even further improvements.’
Cautionary label for antibiotics remains importantTo help address antimicrobial resistance, a new cautionary advisory label (CAL D) for antibiotics was released with the latest edition of the Australian Pharmaceutical Formulary and Handbook this year.‘We had very high use [of antimicrobials] in the community, but during COVID there was a significant drop.'Replacing decades of advice to take the medicines ‘until all used’ or ‘until all taken’, the label is an additional instruction with the words, ‘Take for the number of days advised by your prescriber’. If a patient is not aware of the prescribed duration of treatment and it is not specified on the prescription, the pharmacist should contact the prescriber to confirm the duration. Completion of a recommended course of therapy with an antibiotic can improve therapeutic outcomes and reduce the incidence of relapse. However, taking antibiotics for longer than necessary does not improve outcomes and increases the risk of acquiring resistant bacterial strains.
Practical tips for pharmacistsIn a companion document to its report, the commission set out a number of ways pharmacists can contribute to tackling antimicrobial resistance. For community pharmacists, a good first step is to use dispensing software to understand the antimicrobial use patterns of your community. Other strategies include clarifying the indication and intended duration of any antimicrobial when conducting a MedsCheck and engaging in a discussion with the patient and/or prescriber if the patient has been on an antimicrobial for an extended period. It could also be helpful to display posters with patient care information in the pharmacy, such as how to prevent UTIs, and to highlight vaccinations service during cold and flu season with reminders about why antimicrobials should not be used for viral infections. Hospital pharmacists have an opportunity to assess whether the antimicrobial prescriptions they see follow guidelines and, if not, to engage in discussions with prescribers in instances where patients are treated for conditions such as asymptomatic bacteriuria with antibiotics. Another practical example is to determine the most common antimicrobial prescribed for UTIs and to develop a quality improvement project to address inappropriate use. Find more tips on preventing antimicrobial resistance here. [post_title] => Antimicrobial use decreasing, but resistance still a threat [post_excerpt] => Antimicrobial use has declined dramatically in Australia during the pandemic, but the figures show there is no room for complacency. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => antimicrobial-use-decreasing-resistance-still-a-threat [to_ping] => [pinged] => [post_modified] => 2021-09-01 18:13:50 [post_modified_gmt] => 2021-09-01 08:13:50 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14120 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Antimicrobial use decreasing, but resistance still a threat [title] => Antimicrobial use decreasing, but resistance still a threat [href] => https://www.australianpharmacist.com.au/antimicrobial-use-decreasing-resistance-still-a-threat/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14121 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14012 [post_author] => 235 [post_date] => 2021-08-18 02:35:23 [post_date_gmt] => 2021-08-17 16:35:23 [post_content] => More than 250,000 Australians have faulty heart valves and are at risk of serious complications, including heart failure, stroke and death – yet don’t know it. Australian Pharmacist spoke to an expert about the symptoms pharmacists can help spot in patients. According to a new white paper released this week, Our hidden ageing – time to listen to the heart, more than 500,000 Australians have valvular heart disease, including narrowing (stenosis) and leaking (regurgitation). Developed by experts at Melbourne’s Baker Heart and Diabetes Institute, it also revealed that a quarter of a million people have undiagnosed valvular heart disease. The number of undiagnosed cases is expected to climb over the next 3 decades, reaching 435,000 by 2051. Aortic valve disease is the most frequent cause of severe valvular heart disease. The most common manifestation of this is aortic stenosis, or a narrowing of the aortic valve. Cases of aortic stenosis are expected to climb, the paper stated, to 200,000 by 2031 and 266,000 by 2051. ‘The benefits of living in a first world country means that many of us will survive to a “ripe old age”, so we are living long enough to develop conditions such as aortic stenosis,’ cardiologist and Interim Director of Cardiology at Canberra Hospital Dr Peter French told AP. ‘People with disorders like this may place a significant burden on the healthcare system in that they are constantly in and out of hospital, their quality of life is poor and their contribution to society is limited.’‘The symptoms … may either be quite subtle, or often at times misinterpreted, especially by the older patient, as just a sign of ageing.'
Hidden symptoms of valvular heart diseaseAlthough serious, valvular heart disease is increasingly treatable through procedures including non-surgical valve replacement – provided you know it’s there. But it is not always easy to detect. ‘The symptoms … may either be quite subtle, or often at times misinterpreted, especially by the older patient, as just a sign of ageing,’ Dr French said. ‘With coronary artery disease, the symptoms of angina are often chest pain/discomfort in the chest that restricts the person in normal everyday activities. The symptoms of valvular heart disease may not be as straightforward, especially in the older age groups.’ For example, patients may experience shortness of breath, which limits their normal physical activity. However this may be seen simply as a sign of ageing and accepted as something about which nothing can be done. ‘Therefore, they may not necessarily mention this symptom to their general practitioner when, and if, they see them, for routine medical reviews,’ Dr French said. ‘Other more sinister symptoms, especially in relation to blockage of the aortic valve, [include] dizziness on exertion or, in its most extreme form, actual loss of consciousness on exertion.’ Signs and symptoms of valvular heart disease
|Fatigue Dizziness, blackouts||Inadequate cardiac output||Stenosis|
|Shortness of breath, cough Swelling of ankles and feet Abdominal swelling||Congestion||Regurgitation Heart failure|
|Chest pain||Increased workload||Aortic stenosis|
|Palpitations||Enlargement of heart chambers||Regurgitation (esp. mitral) Mitral stenosis|
‘Emphasising the need for the doctor to listen to the heart with a stethoscope can be exceedingly helpful.'Prior to the pandemic, his job required weekly travel, and he enjoyed spending his free time in the gym. Aside from a health scare in 1997, when he was told to improve his health and fitness, the grandfather and head of insurance at a leading glass supplier had never had any serious heart concerns. ‘I found it hard to complete my fitness workouts and felt a lot more tired than usual,’ he said. ‘My trainer noticed as well. It was very out of character for me … I thought it was just age and fatigue.’ However, a visit to a GP and then a heart specialist confirmed he had heart valve disease. ‘After overhauling my diet and lifestyle in 1997, I honestly never thought I would be at risk,’ Mr Holmes said. ‘I believe all Australians aged 65 and over should be well informed about heart valve disease and the various treatment options available.’ Lead author of the Baker Heart and Diabetes Institute white paper, cardiologist Professor Tom Marwick agreed, and said more needed to be done to raise awareness among the public and health professionals about the disease. ‘It is important to keep in mind that the common symptoms of heart valve disease –especially exercise intolerance – are often misattributed to “old age”,’ he said. ‘We need increased awareness through marketing campaigns; strategies to upskill and support primary care; financial support for the use of emerging technologies; health service design, including improved access to echocardiography; funding to improve access and equity to interventions; and development of national heart valve disease guidelines. ‘We must all keep in mind that valvular heart disease can go unrecognised, undiagnosed, and untreated, and the complications can be devastating.’ Read the Our hidden ageing – time to listen to the heart white paper here. [post_title] => Valvular heart disease: how pharmacists can help [post_excerpt] => More than 250,000 Australians have faulty heart valves and are at risk of serious complications, including heart failure, stroke and death – yet don’t know it. Australian Pharmacist spoke to an expert about the symptoms pharmacists should be aware of. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => valvular-heart-disease-symptoms-for-pharmacists [to_ping] => [pinged] => [post_modified] => 2021-08-18 17:02:05 [post_modified_gmt] => 2021-08-18 07:02:05 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14012 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Valvular heart disease: how pharmacists can help [title] => Valvular heart disease: how pharmacists can help [href] => https://www.australianpharmacist.com.au/valvular-heart-disease-symptoms-for-pharmacists/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14015 )
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Arteen comes into your pharmacy requesting fish oil for his rheumatoid arthritis (RA) pain. Arteen takes methotrexate 10 mg once weekly and folic acid 5 mg every other day of the week; his RA is usually well controlled. Arteen has been experiencing mild residual joint pain and has been taking regular, therapeutic doses of ibuprofen but finds the ibuprofen occasionally upsets his stomach.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Omega-3 fatty acids are essential fatty acids that are needed for biological processes in the body.1 They are one of two major classes of polyunsaturated fatty acids and are composed of carbon chains with a methyl group on one end and a carboxyl group at the other.2 The ‘3’ component of omega-3 fatty acids is derived from the presence of a double bond at the third carbon from the methyl end of the chain.2 These fatty acids are unable to be synthesised in the body, and as such, need to be ingested.1
While there are several different omega-3 fatty acids, research has focused on alpha-linolenic acid (ALA), docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA).2
ALA is an intermediate-chain omega-3 fatty acid that contains 18 carbon atoms and is only found in some plants and their oils (e.g. flaxseed, walnuts and canola).3 It is a precursor to EPA and DHA.4 DHA and EPA are considered long-chain omega-3 fatty acids, containing 20 and 22 carbons respectively.2 They are found primarily in fish and shellfish, and are the main active constituents in fish oil.2,5
The purported benefits of fish oil are widely discussed, and evidence for benefit from trials and studies varies. This is most notable with respect to cardiovascular disease (CVD) risk reduction, as meta-analyses of clinical trials involving marine omega-3 fatty acids have shown them to have multiple cardiovascular and metabolic effects.6 There is widespread public belief that omega-3 fatty acids are beneficial for cardiovascular health, although public health advice about fish oil consumption and supplementation varies around the world.7
The following are some of the conditions fish oil is commonly purported to be of benefit for, according to current evidence8:
There is insufficient reliable evidence for the benefit of fish oil in psychosis, age-related cognitive decline, Alzheimer’s disease and asthma.8
Claims that omega-3 fatty acid supplementation can decrease the risk of heart disease, stroke and death have not been proven, and to date trials have shown minimal protective effects.7
The protective effect of omega-3 fatty acids in CVD has been proposed to include: decreasing blood pressure, changing lipid profile (in particular, decreasing triglyceride levels), modulating arterial lipoprotein lipase levels, decreasing thrombotic tendency, anti-inflammatory and anti-arrhythmic effects, improving vascular endothelial function and improving insulin sensitivity.7,10–14
Marine omega-3 fatty acids have been shown to decrease triglyceride levels when taken at a daily dose of 2–4 g.15 This effect is due to DHA and EPA reducing very low-density lipoprotein (VLDL) cholesterol production in the liver and increasing the conversion of VLDL-apolipoprotein B to intermediate density and low-density lipoprotein B.5
DHA and EPA have shown, with high certainty evidence, to decrease triglycerides by around 15% in a dose-dependent manner, with no effect on other lipids or adiposity.7 Some studies have shown a reduction in triglyceride levels by 25–30%.16–20
Studies have not shown marine omega-3 fatty acids to decrease low-density lipoprotein (LDL).15
What does the evidence say?
Findings from a Cochrane review showed that ALA, DHA and EPA may have slight protective effects in some heart and circulatory diseases.7 There was high certainty evidence that DHA and EPA do not have significant effects on all-cause mortality, and moderate certainty evidence that they have no or little effect on cardiovascular disease mortality, arrhythmia or stroke in primary or secondary prevention. There was low certainty evidence that omega-3 fatty acids may slightly decrease coronary heart disease mortality and coronary heart disease events.7
Increased consumption of ALA was found to probably make little or no difference to cardiovascular or coronary deaths or events, but might slightly decrease cardiovascular events and arrhythmia (moderate or low certainty evidence).7
The VITAL trial consisted of 25,871 adults without known CVD. In this trial, after a median time of 5.3 years, low-dose omega-3 fatty acid supplementation (1 g/day) did not reduce the primary endpoint of major cardiovascular events. However, a review of secondary outcomes showed a reduction in total myocardial infarction, percutaneous intervention, total coronary heart disease and death from myocardial infarction.21,22
The REDUCE-IT trial potentially provides the best evidence for fish oil to be used in secondary prevention of cardiovascular events.23 This trial was a large scale, randomised trial of patients with hypertriglyceridaemia and established CVD or diabetes with at least one additional risk factor.24 Patients treated with 4 g per day of an omega-3 fatty acid preparation, containing icosapent ethyl, an ethyl ester of EPA, in conjunction with a statin were shown to have reduced CVD events.23,24
What are the implications to practice?
Aside from triglyceride reduction, the beneficial effects on cardiovascular health have been found to be very small. This is in line with advice that supplementation is probably not useful in both the prevention and treatment of CVD, but that the long chain omega-3 fatty acids can reduce serum triglycerides.7
Fish oil may be used for hypertriglyceridaemia, or in conjunction with medicines that decrease LDL in mixed hyperlipidaemia.15 Omega-3 fatty acids may be recommended to some patients with hypertriglyceridaemia to lower triglyceride levels and decrease CVD risk.26 The reduction of triglycerides has been shown to be dose-dependent.27 However, the independent benefit they have on CVD is not as clear, especially in patients that are already receiving treatment with statins.28
Reducing LDL cholesterol is a primary aim of both primary and secondary prevention; statins are used first line, adjunctive to therapeutic lifestyle changes.29,15
The National Heart Foundation of Australia does not recommend routine supplementation with fish oil for heart health, but advises that supplements will provide a level of marine-sourced omega-3 fatty acids for people who do not consume fish.25 They also note that omega-3 fatty acid supplements may be considered in patients with high triglycerides.25 In patients with heart failure, omega-3 fatty acid supplements may be recommended along with standard medicines.25 For ALA, the foundation recommends all Australians consume 1 g of plant-sourced omega-3 fatty acids as part of a heart healthy diet.25
As DHA and EPA are precursors to some eicosanoids and inflammatory mediators, fish oil is thought to have anti-inflammatory effects.30 Experimental evidence also suggests that metabolites of DHA and EPA may have a role in helping resolve inflammation. As DHA and EPA can decrease arachidonic acid metabolites and cytokines, they may improve symptoms that patients experience in RA.31–35
What does the evidence say?
A randomised controlled trial examined the effects of high-dose fish oil supplementation on treatment outcomes in patients with recent onset RA. Eighty-six participants received high-dose fish oil and 53 patients received low-dose fish oil (control group) added to triple therapy with disease-modifying anti-rheumatic drugs: methotrexate, sulfasalazine and hydroxychloroquine.
The results showed a significant reduction in the percentage of patients failing to achieve remission on the high-dose fish oil treatment regimen when compared to treatment with the addition of low-dose fish oil.36
Meta-analyses of randomised trials have shown a decrease in inflammatory markers such as C-reactive protein, interleukin 6 and tumour necrosis factor-alpha when fish oil is taken.5,37,38,39
A systematic review and meta-analysis of randomised trials using fish oil supplements to alleviate arthritis pain had shown moderate quality evidence in patients with RA but low quality evidence in osteoarthritis patients.40 Another trial compared an anti-inflammatory dose of fish oil with a low dose of fish oil in patients with knee osteoarthritis and found a reduction in pain and improvement in physical function in both groups; the anti-inflammatory dose of fish oil offered no extra benefit over low-dose fish oil.41,42
What are the implications to practice?
Consumption of at least 2.7 g of omega-3 fatty acids daily can decrease the severity of symptoms in patients with RA when compared to placebo, although this is not routinely recommended in current treatment algorithms and guidelines.13,38 However, fish oil may be a treatment option for patients with well controlled RA experiencing mild residual joint pain.42
Due to their anti-inflammatory effects, DHA and EPA can be used to decrease the need for non-steroidal anti-inflammatory drugs (NSAIDs) and therefore the risk of side effects associated with NSAIDs. It can take up to 3 months for the maximum benefit of fish oil to be observed, and as such, alternate pain relief may also be required initially.32,42
The majority of clinical research has not shown fish oil supplementation to improve cognitive function in most people. However, it may help elderly people, with self-reported cognitive decline, to carry out daily activities.8
Multiple longitudinal cohort studies have shown a relationship between higher fish oil consumption and decreased dementia risk and cognitive decline.44–49 However, there have been some exceptions to these findings50,51 and other studies have also suggested that the benefits of fish oil may vary depending on genotype.52–54
What does the evidence say?
Randomised trials have not had sufficient power or duration to ascertain if fish oil consumption decreases incident dementia.43 A meta-analysis of three trials reviewed the impact of fish oil supplementation on cognitive performance in people ≥60 years old. The analysis found there was no beneficial effect after 6–40 months of administration.55 Other trials have also reported findings consistent with this.55–57
Fish oil supplementation is not standard care for cognitive decline and current evidence supports this.43
What are the implications to practice?
Consumers requesting fish oil supplements for cognitive decline should be provided with information about the current evidence so they can make an informed decision.
Knowledge to practice
Fish oil has been purported to be of benefit for cardiovascular conditions, joint health and cognitive decline. While the potential benefits from fish oils are widely discussed, the studies and trials to support these are variable, and evidence is lacking.5,8
With the exception of triglyceride reduction, the beneficial effects of fish oil on cardiovascular health appear to be very limited.7 Similarly, current evidence does not support fish oil supplementation for dementia, consistent with current standards.43 Pharmacists should provide patients with accurate information on the current evidence and recommendations for fish oil supplementation. This will assist patients to make informed decisions and help to manage patient expectations.
Where evidence supports use or if patients decide to take supplements, pharmacists can monitor and advise on appropriate dose, product formulation and potential side effects (e.g. gastrointestinal side effects, fishy aftertaste, diarrhoea and heartburn).58
As there is a wide range of fish oil products available, a lower strength product would require more capsules to be taken for an effective dose; this may not be tolerated by all patients. The size of capsule also varies between products, and patients may prefer a smaller capsule size. Liquid fish oil is an option, especially for patients with swallowing difficulties. While this formulation is not the most palatable option, pharmacists can advise on recommendations to improve palatability (e.g. keeping liquid in the fridge, taking juice immediately after).9,58
Doses of omega-3 fatty acids ≥3 g daily can inhibit platelet aggregation.58 Risk of harm in clinical trials has been shown to be low, but there is a theoretical bleeding risk.9 Evidence of increased bleeding incidence when used alone, or in combination with warfarin or antiplatelet medicines is conflicting.58 Other precautions include: patients with seafood hypersensitivity, familial adenomatous polyposis, concomitant immunosuppressant medicines, orlistat and implantable defibrillators.58
Case scenario continued
You advise Arteen that fish oil has been shown to have a mild anti-inflammatory effect in RA and can be trialled as a way to facilitate decreasing the use of ibuprofen. It can take up to 3 months for maximal benefits to be observed, and as such, other pain relief options may be required in the interim. Current evidence tells us that a daily dose of at least 2.7 g of omega-3 fatty acids is needed. Based on Arteen’s preference to take a capsule instead of liquid, and to take as few capsules as possible, you identify a concentrated capsule for him. You provide advice on alternative pain relief options, such as paracetamol and topical products that could be used to reduce the use of ibuprofen. You provide Arteen with lifestyle advice, such as regular exercise (low-impact aerobic activities and strength training) and resting when joints are swollen. You also counsel Arteen about using the lowest effective dose of ibuprofen for the shortest time to help with the gastrointestinal side effects, and advise him to see his GP if stomach upset or joint pain persists.
Omega-3 fatty acids are essential fatty acids required for biological processes in the body.1 The main omega-3 fatty acids are ALA, DHA and EPA. ALA is found in some plants and their oils (e.g. flaxseed, canola and walnuts).5 EPA and DHA are found primarily in fish and shellfish, and are the main active constituents in fish oil.2,5 Purported potential benefits from fish oils for cardiovascular conditions, joint health and to prevent cognitive decline are widely discussed, and variable evidence exists to support these claims.8 Pharmacists should advise patients on the evidence for omega-3 fatty acids for the management of different conditions, counsel patients on the side effects that may be experienced, and identify potential drug interactions.
EVONNE FONG BPharm(Hons)is the Head of the Pharmacy Department at Rockingham General Hospital, WA. She has a particular interest in critical care, having worked primarily as a clinical pharmacist in intensive care and emergency medicine. She has also worked as a medication safety and antimicrobial stewardship pharmacist.[post_title] => Omega–3 fatty acids: What's the evidence? [post_excerpt] => Pharmacists should advise patients on the evidence for omega-3 fatty acids for the management of different conditions, counsel patients on the side effects that may be experienced, and identify potential drug interactions. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => omega-3-fatty-acids-whats-the-evidence-cpd [to_ping] => [pinged] => [post_modified] => 2021-11-30 03:31:53 [post_modified_gmt] => 2021-11-29 16:31:53 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=17405 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Omega–3 fatty acids: What’s the evidence? [title] => Omega–3 fatty acids: What’s the evidence? [href] => https://www.australianpharmacist.com.au/omega-3-fatty-acids-whats-the-evidence-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 17407 )
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Sally, 36, was recently diagnosed with breast cancer. She presents to her local pharmacy and requests advice about non-prescription treatments for constipation. Sally mentions that she commenced her first cycle of chemotherapy 5 days ago, and she shows you patient information about her chemotherapy regimen that she received from her hospital. She is receiving a combination of doxorubicin and cyclophosphamide, and this chemotherapy regimen is classified as highly emetogenic. You suspect Sally has received a combination of antiemetics, including an NK1 receptor antagonist, 5-HT3 receptor antagonist and dexamethasone. Sally confirms this.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Nausea and vomiting (or emesis) are common and often troubling side effects for many patients receiving cancer treatment (chemotherapy, radiotherapy and/or surgery). Chemotherapy-induced nausea and vomiting (CINV) can occur as a result of different anticancer treatments, including chemotherapy, immunotherapy, and biological and molecular targeted therapies.1 Poorly controlled CINV can have a negative impact on patients, potentially affecting adherence, resulting in dose reductions or discontinuation of anticancer therapy.2
CINV occurs due to the release of neurotransmitters (primarily serotonin and substance P) which induces the emetic reflex.2 Antiemetics, used for prevention, act to inhibit the effect of these neurotransmitters. Antiemetics are prescribed based on several factors, including the emetogenic potential of the chemotherapy protocol, patient-specific risk factors and the type of emesis experienced. There are five classifications of CINV: acute, delayed, anticipatory, breakthrough or refractory.3
Pharmacological therapies are the mainstay for prevention and treatment of CINV. Pharmacists can educate patients about the optimal use of antiemetics to effectively prevent and treat CINV and ensure patients have adequate antiemetic cover when being treated with chemotherapy.
CINV results from the release of neurotransmitters and is thought to be triggered by both peripheral and central pathways.3
The peripheral pathway results from chemotherapeutic medicines causing irritation and damage to the gastrointestinal mucosa, releasing serotonin (5-HT) and activating 5-HT3 receptors.4,5 This stimulates the chemoreceptor trigger zone (CTZ) and vomiting centre in the brain stem, inducing an emetic response.3 This pathway is usually associated with acute emesis occurring within 24 hours of chemotherapy.2
The central pathway involves chemotherapeutic medicines in the blood or cerebrospinal fluid that stimulate the CTZ, causing release of substance P, which activates neurokinin-1 (NK1) receptors.4,5 This stimulates the vomiting centre and is usually associated with a delayed emetic response (more than 24 hours following chemotherapy).2
Aside from the 5-HT3 and NK1 receptor pathways, other receptors thought to be involved with CINV include dopamine, muscarinic, corticosteroid, histamine, cannabinoid, opioid and gamma-aminobutyric acid (GABA), although their functions are less clear.3,4 Antiemetic regimens may contain a combination of medicines that target different pathways to ensure effective control.
There are five classifications of CINV3:
Table 1 – Anticancer therapies classified by emetic risk group (Note: Classifications of emetic risk varies across references)
References: Cancer Institute NSW,1 Ettinger DS,3 Hesketh PJ,10 Roila F11
The incidence of acute nausea and vomiting reported in observational studies is up to 44% and 14%, respectively, following highly emetogenic chemotherapy despite antiemetic prophylaxis.6,7 Adherence to evidence-based antiemetic guidelines3,10,11 is shown to reduce the risk of CINV and thus improve the patient experience and outcomes.8,9
Patient-specific risk factors
Patient-specific risk factors that contribute to the incidence of CINV3,12,13:
Emetic risk of chemotherapy
Parenteral chemotherapeutic medicines are classified into four categories of emetic risk, based on the likelihood of acute emesis without prophylaxis:
The aim of treatment is to prevent nausea and vomiting. Antiemetic choice is determined by the emetic risk of the medicine, patient-specific risk factors and previous response.3
5-HT3 receptor antagonists
Ondansetron, granisetron and |palonosetron are the preferred 5-HT3 antagonists used in practice; tropisetron is licensed for the prevention of CINV,14 however is not currently recommended by Australian guidelines.1
5-HT3 antagonists block 5-HT3 receptors peripherally (gastrointestinal tract) and centrally (CTZ), inhibiting the emetic response.4,5 The acute emetic response, initiated by 5-HT, has led to the widespread use of 5-HT3 antagonists for high and moderate emetic risk chemotherapy.2 Oral and parenteral routes have equivalent efficacy when prescribed at appropriate doses and frequency.3
Ondansetron and granisetron are first-generation 5-HT3 antagonists. Ondansetron is available as a tablet, orally disintegrating tablet (ODT), wafer and injection. The ODT and wafer are particularly useful for patients with swallowing difficulties or enteral feeding tubes. Ondansetron has the shortest half-life and can be administered up to three times a day for breakthrough emesis.15 Granisetron is available as a tablet and injection, has a duration of action up to 24 hours and is usually administered once daily.15
Palonosetron, a second-generation 5-HT3 antagonist, has a long half-life (approximately 40 hours) and has shown benefit over ondansetron and granisetron in preventing delayed emesis, in addition to acute emesis.5,16 Palonosetron is available as an injection and a capsule in combination with netupitant (NK1 receptor antagonist).
Common adverse effects of 5-HT3 antagonists include constipation, headache and dizziness.15 Patients should be educated about constipation risk and the appropriate use of laxatives; if left untreated, this may contribute to nausea and vomiting. Some chemotherapy medicines (e.g. vincristine) can also cause constipation, compounding the issue. If patients experience constipation with cycle 1 of chemotherapy, regular prophylactic laxatives should be considered for subsequent cycles. First-generation 5-HT3 antagonists are associated with cardiac side effects, including electrocardiogram (ECG) abnormalities and QT prolongation.3 Caution should be taken if patients are taking other QT prolonging medicines and ECG monitoring performed, if required. Palonosetron does not appear to be associated with the same cardiac adverse effects, but should be used with caution in patients at increased risk of QT prolongation.17
NK1 receptor antagonists
Aprepitant, fosaprepitant (a prodrug of aprepitant) and netupitant are the available NK1 receptor antagonists in Australia.14 They are all administered once per chemotherapy cycle on day 1.3,14 NK1 receptor antagonists prevent the emetic response by inhibiting substance P activation of NK1 receptors in the vomiting centre.4,5 The introduction of NK1 receptor antagonists and their use in combination with dexamethasone and 5-HT3 antagonists has significantly improved both acute and delayed CINV in high and moderate emetic risk chemotherapy.18,19 NK1 receptor antagonists are generally well tolerated, with common side effects including diarrhoea, fatigue, headache and hiccups.5,15
Potential drug interactions should be considered as aprepitant and fosaprepitant inhibit, induce and are metabolised by CYP3A4 and induce CYP2C9.3 Netupitant also inhibits CYP3A.4 Some medicines that require particular attention are warfarin, which may require additional INR monitoring; oral contraceptives, which may require a different contraceptive; and strong inducers (e.g. rifampicin, carbamazepine) or inhibitors (e.g. ketoconazole, erythromycin) of CYP3A4.3 However, short-term intermittent use of NK1 receptor antagonists may not result in significant clinical outcomes. NK1 receptor antagonists may increase the serum concentration of dexamethasone, therefore the dose of dexamethasone for antiemetic prophylaxis in suggested regimens is adjusted to account for this interaction.1,3,19
Dopamine receptor antagonists
Metoclopramide is one of the most commonly used dopamine antagonists in CINV. Metoclopramide inhibits dopamine receptors and, at certain doses, 5-HT3 receptors in the CTZ, therefore inhibiting the emetic response.15 It also exerts a prokinetic effect via stimulation of the cholinergic receptors on gastric smooth muscle cells; useful if gastroparesis is also present.3 Historically, dopamine receptor antagonists were the primary medicines used to prevent CINV; however, they have been superseded by the introduction of newer medicines (5-HT3 or NK1 receptor antagonists) with more favourable safety and efficacy profiles.2 Common adverse effects of metoclopramide include drowsiness, dizziness and extrapyramidal side effects (e.g. akathisia, parkinsonism).15 Metoclopramide should only be used if absolutely necessary in patients under 20 years due to the increased risk of serious extrapyramidal side effects (dystonia).14 Metoclopramide is now primarily used for breakthrough emesis or for low or minimal emetic risk chemotherapy.1 Other dopamine antagonists used in CINV include prochlorperazine and haloperidol.
Dexamethasone is the primary glucocorticoid used in the prevention of CINV. The mechanism of action by which glucocorticoids exert their antiemetic effect has not been fully elucidated.5 A meta-analysis was conducted in 2,000 reviewed studies over the previous 30 years and found clear benefit for dexamethasone over placebo in minimising CINV for both the acute and delayed phases of CINV.20 Oral and intravenous dexamethasone can be used both before and after chemotherapy to target acute and delayed emesis. The doses and duration of dexamethasone varies between regimens and is largely dependent on what was used in the original clinical trial. Dexamethasone may not be well tolerated by patients due to potential adverse effects, including insomnia, mood disturbance, increased appetite, and increased blood sugar levels (BSLs).3,5 Diabetic or prediabetic patients should be advised to monitor their BSLs closely when dexamethasone is administered and report abnormal readings to their doctor.3 Severe intolerance can occur for some patients, and dose reductions can be considered to balance quality of life and emesis control. Olanzapine can be considered as an alternative antiemetic if dexamethasone is deemed inappropriate.3
Olanzapine, an atypical antipsychotic, inhibits multiple receptors implicated in CINV: serotonin, dopamine, histamine, alpha-adrenergic, muscarinic and weakly binds to GABA receptors.3,15,21,22 Its antiemetic activity is likely due to inhibition of dopamine and 5-HT3 receptors. Addition of oral olanzapine to standard antiemetic regimens has demonstrated benefit in preventing both acute and delayed CINV in patients receiving high or moderate emetic risk chemotherapy.21,22 Olanzapine 5–10 mg orally is administered at night; a lower starting dose may be preferred in elderly patients or patients at increased risk of adverse effects. Common adverse effects include drowsiness, hypotension, and anticholinergic and extrapyramidal side effects.3,15 As olanzapine is often administered with 5-HT3 antagonists, there may be an increased risk of QT prolongation. It is recommended that patients are monitored and an ECG performed, particularly in those patients with other cardiac risk factors.3,15
Treatment guidelines may vary between local institutions based on cost, preference and previous experience. It is recommended that all oral and intravenous antiemetics are administered 60 minutes and 30 minutes, respectively, before treatment.1
High emetic risk
Moderate emetic risk
Low emetic risk
Minimal emetic risk
Treatments and prophylaxes for CINV are well established but continually evolving. Prevention of CINV is the primary goal of management, and available guidelines recommend antiemetic prophylaxis based on the emetic risk of the chemotherapy administered. The antiemetic regimen should also consider cover for both acute, delayed and breakthrough emesis. Cancer therapies are primarily delivered in the hospital setting; however, patients may present to community pharmacies with antiemetic prescriptions or advice following chemotherapy treatment. Pharmacist awareness of doses and duration of prophylactic antiemetics prescribed with chemotherapy (e.g. dexamethasone for 3 days post-chemotherapy) will allow appropriate patient education and improve adherence. Pharmacists can monitor potential side effects experienced from antiemetics or identify potential drug interactions and refer to the prescriber, if appropriate. Particular issues to consider include management of constipation and appropriate laxative use when dispensing 5-HT3 antagonists, and BSL monitoring with dexamethasone. If patients are experiencing ongoing nausea and vomiting despite optimal therapy, pharmacists may consider alternative antiemetics to trial or suggest investigation for other causes (e.g. bowel obstruction, progressive disease). Non-pharmacological interventions that may help to manage CINV include dietary adjustments, such as frequent small meals and avoiding rich food.
Case scenario continued
On questioning, Sally explains her last bowel movement was 3 days ago; she usually goes each day, and she has made no changes to her diet recently. She is experiencing no nausea and vomiting but describes some discomfort in her stomach. You explain to Sally the constipation may be an adverse effect from one of the medicines she was given to prevent nausea and vomiting, and that this is common. You discuss options for constipation treatment and advise that an osmotic laxative may be most appropriate; you also discuss dietary and lifestyle changes she can make, such as increasing the fluid and fibre intake in her diet. You advise Sally that if this is ineffective, other options are available, but suppositories or enemas should be avoided due to the risk of infection. You advise Sally to discuss this with her oncologist at her next appointment.
CINV can be a severe and disabling adverse effect for patients receiving cancer treatment. Multiple factors can contribute to the incidence and severity. This includes the combination of chemotherapy medicines used, the dose and regimen, and patient-specific risk factors. The antiemetics used are targeted to prevent both acute and delayed nausea and vomiting. Depending on the emetogenicity of chemotherapy, a combination of antiemetics may be used. Pharmacists can ensure the prescribed antiemetics are appropriate and monitor for potential adverse effects or drug interactions.
Further informationEviQ (eviq.org.au) – Nausea and vomiting during cancer treatment patient information. Cancer Council Australia (www.cancer.org.au) A list of cancer-specific support groups are also available:
AISLING YEO BSc, MPharm, MPH is a senior pharmacist at Peter MacCallum Cancer Centre, where she works as a clinical pharmacy trainer and lung clinic pharmacist. She has worked at Peter Mac since 2014, where she has gained clinical experience with anticancer therapies across the inpatient, day therapy and outpatient clinic settings.[post_title] => Antiemetics in cancer care for adults [post_excerpt] => Pharmacists can educate patients about the optimal use of antiemetics to effectively prevent and treat chemotherapy-induced nausea and vomiting. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => antiemetics-in-cancer-care-for-adults-cpd [to_ping] => [pinged] => [post_modified] => 2021-11-24 08:31:42 [post_modified_gmt] => 2021-11-23 21:31:42 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14840 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Antiemetics in cancer care for adults [title] => Antiemetics in cancer care for adults [href] => https://www.australianpharmacist.com.au/antiemetics-in-cancer-care-for-adults-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 14845 )
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Case scenarioMark, a smoker, has recently been diagnosed and treated for a stage I head and neck cancer. He received curative radiation therapy and has come into your pharmacy complaining of dry eyes. What advice do you offer?
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Head and neck cancer (HNC) is estimated to be the seventh most commonly diagnosed cancer in Australia, with 5,212 new cases in 2019.1 HNC disproportionately affects people from socioeconomically disadvantaged backgrounds and is more common in men than women.1,2 The typical risk factors for HNC include tobacco and alcohol consumption, and the use of areca nut or betel quid. Although a banned substance in Australia, areca nut is still available in many different preparations, and use is more prevalent among immigrants from South-East Asian and Pacific countries, including, Fiji, Papua New Guinea, Bangladesh, Myanmar, India and Pakistan.
More recently, there has been an increase in the incidence of oropharyngeal carcinoma associated with prior infection with human papillomavirus (HPV), independent of the typical risk factors for oral cancer.3–8 Treatment for HNC can involve surgery, chemotherapy, immunotherapy or radiotherapy, or a combination of these modalities, dependent on factors such as cancer diagnosis, tumour staging at time of diagnosis and patient factors.
Pharmacists provide a wide range of patient-centred care in Australia.9 Managing the care of patients with chronic health problems over a period of time is increasingly important, given the complexity and frequency of chronic healthcare problems and polypharmacy. Collaboration and communication with medical practitioners are essential for the safe provision of medicines and includes monitoring patients and medicine adherence. Pharmacists may find themselves in a position where patients confide in them or mention signs and symptoms possibly related to a head and neck cancer that they might not discuss with their medical practitioner or dentist. Suspicious signs/symptoms may warrant further investigation. Pharmacists could be instrumental in making this connection and encouraging patients to seek a more formal examination and investigation.
This article discusses ways in which pharmacists may play a role in HNC, from identifying a cancer early, to providing information about screening and referral pathways, and providing supportive care for patients during and after treatment of a head and neck cancer.
HNC may present with many varied signs and symptoms. Some of the more common complaints are listed in Box 1. If patients are complaining of these symptoms, and there is not another reason to explain them, further investigation may be warranted.11Box 1 – Signs and symptoms
Suspicious lesions should be referred for a clinical examination. There will always be some delay between the onset of disease and commencement of treatment. Prompt diagnosis is likely to have benefits in earlier-stage disease with improved treatment, survival and quality of life.12
A recent systematic review and meta-analysis found that every 4-week delay in commencing cancer treatment is associated with increased mortality in seven different tumour types, including head and neck.13 This review concluded that for head and neck cancers, a 9% increase in mortality occurred with every 4-week delay in the commencement of definitive HNC radiotherapy.13 Pharmacists can refer patients to their general practitioner, dentist or medical specialist and potentially improve cancer outcomes.
The treatment for HNC depends on the anatomical site, tumour stage and functional outcome. Early-stage cancers (Stages I and II) are usually treated with either surgery or radiotherapy alone.14 Approximately 80–90% of patients with early-stage disease will be cured, highlighting the importance of an early diagnosis. Locally advanced cancers (Stages III and IV) typically require multimodality treatment, including a combination of surgery, radiotherapy and/or cytotoxic chemotherapy.14
Immunotherapy is being explored as an option for recurrent or metastatic disease.15 The involvement of an experienced multidisciplinary team is recommended, and patients should have appropriate access to optimal care pathways and supportive services.16
Surgical resection of the lesion is desirable, provided access is possible, and resection of the tumour, leaving clear margins, will not cause significant functional disturbances or morbidity. Frequently, neck dissection will be indicated depending on staging of disease.16
Radiation therapy (RT) is delivered by intensity-modulated radiation treatment (IMRT) to the tumour and lymph nodes, depending on staging of disease.
RT dose is measured in grays (Gy). Typically, this is delivered as 2 Gy per treatment (fraction): 1 week of radiotherapy is 10 Gy in 5 fractions. A curative course is 70 Gy and a post-operative course is between 60 Gy and 66 Gy. These doses can vary between treating institutions and clinical scenarios. The total dose will not exceed 70 Gy delivered in 35 fractions to the tumour site and the target nodes, with high-risk nodes and elective nodes receiving a lower dose.16
The mechanism of action of RT is to cause lethal damage to tumour cell DNA. Tumour cells often replicate rapidly and have impaired DNA repair mechanisms. They have a reduced capacity to repair damaged DNA compared to surrounding normal tissue cells. Irreparable DNA damage leads to cell death at the time of cell replication, which may occur hours or days after the RT delivery.
RT has the advantage of being more likely to preserve normal tissue structures than surgery in anatomically complex sites of the head and neck region, potentially yielding improved functional outcomes and reducing morbidity.17 Over the past 20 years, the standard of care for radiotherapy for head and neck squamous cell carcinoma has evolved, with improved organ-sparing techniques. Despite this, a degree of normal tissue DNA damage still occurs, resulting in acute and late toxicities, including those affecting the oral cavity.
Chemotherapy will typically involve either cisplatin, cetuximab, carboplatin or 5-fluorouracil, depending on tolerance to cisplatin and performance status. Induction chemotherapy followed by concurrent chemoradiotherapy may be considered for patients with bulky primary disease with upper airway obstruction.16 For patients who are unable to tolerate cisplatin, radiotherapy plus cetuximab alone, or radiotherapy and carboplatin-fluorouracil/docetaxel, are the preferred treatment regimens.16
Immune checkpoint inhibitors are emerging as a promising therapeutic strategy for recurrent or metastatic head and neck squamous cell carcinomas, including those of the oropharynx. Standard first-line treatment for recurrence that cannot be managed with local therapy is cetuximab plus a platinum-based agent and 5-fluorouracil; this leads to overall survival of 10 months.15 Recent trials with immune checkpoint inhibitors (pembrolizumab or nivolumab) improved overall survival and have been demonstrated to be appropriate first-line therapy in PD-L1-positive metastatic or recurrent head and neck cancers.15
Surgery can have both physical and psychological adverse effects. Functional disturbance is common; for example, speech and chewing difficulties, dysphagia, and restricted mouth opening (trismus). The psychological impact from surgery of the head and neck cannot be underestimated. Facial disfigurement is not uncommon, and slurred or unintelligible speech can severely impact quality of life.18
Adverse effects from chemotherapy for HNC will depend on the type and dosing regimen and may include taste disturbances, mucositis, dry mouth (xerostomia), hearing impairment, immunosuppression and neuropathy. Although the oral adverse effects will usually resolve following treatment completion, some may be long-term.
Radiotherapy for HNC results in both acute and long-term adverse effects (see below). Supportive care from pharmacists is critical in helping patients manage some of these adverse effects and improve quality of life.
Mucositis (erythema and ulceration of the mucosal surfaces) can be severe during treatment, causing significant pain, difficulty with eating and swallowing (leading to subsequent nutritional deficits), and localised or systemic infection, particularly in those with immunosuppression from chemotherapy (see Figure 1).
The Multinational Association of Supportive Care in Cancer (MASCC) has published evidence-based guidelines on best practice for mucositis management.19,20 Management of mucositis typically involves pain relief – either oral medicines or topical mouthwashes. Pharmacists should refer patients to their radiation oncologist for the most appropriate pain management regime. It is essential that good oral health is maintained to prevent secondary infection. Usually, a saltwater mouthwash with bicarbonate soda is recommended (500 mL water, 1 teaspoon table salt, 2 teaspoons bicarb soda). Mucositis typically resolves within 2–3 months following the completion of RT; however, fibrosis and scarring of the mucosa are common long-term adverse effects.
Figure 1 – radiation adverse effects
Trismus, or fibrosis of the musculature, is a common late effect following radiotherapy to the head and neck, and may present as reduced mouth opening, temporomandibular disorder, pain with mouth opening, limited function, and difficulty with swallowing.21 Trismus can lead to difficulties with speech, mastication, swallowing and compromised oral health.22 When trismus is compounded with xerostomia, the risk of rapid deterioration of the dentition is extremely high.
Infection such as candidiasis is commonly seen in the oral cavity and oropharyngeal region, resulting in pain and dysphagia, affecting oral intake with consequent impact on the nutritional status. Candidiasis presents a significant challenge when regional or systemic dissemination occurs.21,22
Taste and olfactory dysfunction
Taste and olfactory dysfunction are common acute and chronic toxicities related to RT, often related to inflammation, ulceration and mucosal atrophy, and can be further exacerbated by dry mouth and infection.21,22 Recovery following treatment is highly variable. Alteration to taste may be further affected by hyposalivation. The taste for sweet foods is often the last to go and first to return; patients sometimes have a predilection for overly sweetened beverages (or flavoured water) and foods, which will pose an increased risk for dental caries. Asking patients about the type of beverages consumed can be important. In addition, many patients remain dependent on nutritional support products which are often very sugary. Counselling about optimal oral health and the use of bicarbonate mouthwashes after eating or consuming sugar-sweetened substances can help to minimise the caries risk, as can lifelong use of a high-fluoride toothpaste.
Attaining the right balance is important and nutritional support must be a priority; however, if the only oral intake consists of highly calorific dietary supplements, then oral health is going to be jeopardised. Educating your patient about ways to minimise the harm to the dentition is imperative to prevent deleterious outcomes.
Xerostomia/hyposalivation is often a profoundly debilitating toxicity of head and neck RT (see Figure 1.) Both the volume and consistency of saliva is altered, leading to a shift in the oral microbiome in favour of the cariogenic Streptococcus mutans, Lactobacillus and Candida species.23–25
Saliva is critical for maintaining equilibrium of the oral environment and dental integrity via its pH buffering ability, oral clearance and remineralisation properties. Xerostomia can lead to difficulty eating, loss of appetite and nutritional deficiency, which is sometimes difficult to reverse.23 Return of salivary function depends on many factors, including the volume and dose of RT received. For many patients, it is a lifelong toxicity and salivary function never fully recovers. The impact of a dry mouth on quality of life cannot be underestimated.
Radiation caries is the term used to describe the rapid onset of rampant caries following RT. It is frequently seen on incisal edges or along the cementoenamel junction of the root surfaces causing a ‘ringbarking’ effect. Prompt referral to a dentist is encouraged. Teeth extraction may be indicated, posing the added threat of osteoradionecrosis (ORN), see Figure 3. ORN is the presence of exposed bone for greater than 3 months in a previously irradiated site that is not related to tumour recurrence or metastatic disease.26 ORN can occur spontaneously or in response to trauma such as friction from an ill-fitting denture, periodontal debridement, or surgical procedure such as dental extraction.26 Referral to a dental specialist is encouraged if ORN is suspected.
Optimising oral health is an essential step in limiting serious late toxicities, such as radiation caries and ORN. Commencing a high-fluoride toothpaste is recommended, and meticulous oral hygiene including the use of floss or interdental brushes is imperative.
Treatment for HNC often results in a devastating impact on the person’s quality of life, psychosocial wellbeing, and many aspects of daily functioning. Patients frequently experience impaired speech, swallowing, mastication and breathing, in conjunction with facial and oral disfigurement.27 These adverse effects cannot be underestimated. Downstream effects include loss of self-esteem, mental health issues and, frequently, financial stress. Pharmacists, like all healthcare professionals, may be able to recognise particular issues and refer for support where indicated.
Understanding the risk factors and discussing these with patients could be instrumental in reducing harm.
Smoking is one of the most common risk factors for HNC. Pharmacists can provide advice about smoking cessation and the various associated treatment modalities, such as nicotine replacement therapy and other pharmacological and non-pharmacological management strategies.
Brief repeated conversations with healthcare professionals can be instrumental in motivating people to quit smoking.28 Furthermore, formal training in smoking cessation interventions has been shown to have a measurable effect on smoking prevalence and continued abstinence,29 highlighting the potentially beneficial impact that pharmacists may have in reducing one of the known risks for HNC. Pharmacists can influence and help patients quit smoking. There are good resources available to support pharmacists in this role.30 See PSA Guidelines for pharmacists providing smoking cessation support, at https://my.psa.org.au/s/article/Guidelines-for-pharmacists-providing-smoking-cessation-support
Discussion about alcohol consumption and referral to the GP may also be appropriate in some situations.
Counselling patients about the risk of areca nut and the strong association with HNC is important when required.
RT, chemotherapy and opioids are all associated with causing dry mouth. Pharmacists can provide advice and recommend saliva substitutes and mouth rinses for xerostomia, as well as high-fluoride toothpaste and tooth mousse to protect teeth from decay. RT can cause dryness of the nose and reduced nasal mucociliary clearance; pharmacists can recommend saline nasal sprays and hypertonic saline respectively for these conditions. Eye lubricants (without preservatives) can also be recommended if patients experience dry eyes due to RT.
Nutritional supplements and liquid medicines (e.g. nystatin oral drops) can contain sugar. Pharmacists should counsel on appropriate oral hygiene measures, as frequent use, necessitated by the increased risk of oral candidiasis, compounded with the patient’s reduced salivary function, predisposes the patient to increased tooth decay.31 Counselling the patient on the importance of maintaining their oral hygiene is paramount, as is advising them on the importance of HPV immunisation in relation to HNC.
Pharmacists should develop a network of local general practitioners and other medical or dental specialists to enable collaborative care and support for patients. Early identification and referral of suspicious lesions will result in earlier initiation of treatment and better outcomes for patients. In addition, encouraging patients to seek long-term care and surveillance is important for identification of recurrent or|metastatic disease.
Finally, pharmacists are essential in providing supportive care for HNC patients in the long term.
Case scenario continued
You advise Mark on the different preservative-free eye drops available to help manage his dry eyes. You also take the opportunity to discuss his current smoking status. Mark tells you he is aware that smoking is a risk factor for head and neck cancers. And although this was discussed during his diagnosis, he was not in a position to consider quitting at the time. He is interested in what options may be available to him now, as he is concerned that smoking may cause his cancer to relapse.
You discuss the nicotine replacement therapies, associated tools and counselling available. Mark tells you he will consider what has been discussed, but for now he is only wanting to purchase some eye drops.
You supply Mark with the preservative-free eye drops and ensure he knows how to correctly administer them. You make a note to gently revisit smoking cessation with him when he is next in the pharmacy.
Managing patients with HNC requires a multidisciplinary approach. Working in collaboration with oncology and dental specialists to identify oral and dental products that are most beneficial for patients is essential to improve patient outcomes and quality of life.
SOPHIE BEAUMONT BDS, BSciDent (Hons), MPH, MCncrSc is the Head of Dental Oncology at the Peter MacCallum Cancer Centre. She is also a Dental Practitioner with teaching experience at the University of Melbourne.
Dr LEANNE TEOH BPharm(Hons), BDSc(Hons), PhD is a research fellow at the Melbourne Dental School, University of Melbourne, and is a practising pharmacist and dentist.
Professor MICHAEL MCCULLOUGH BDSc, MDSc, FRACDS (Oral Med), PhD FOMAA, FPFA, FICDis the Professor in Oral Medicine at the Melbourne Dental School, the University of Melbourne and an Oral Medicine Clinical Consultant to the Royal Dental Hospital of Melbourne and the Royal Melbourne Hospital.[post_title] => Role for pharmacists in head and neck cancers [post_excerpt] => There are numerous ways in which pharmacists may play a role in head and neck cancers, from identifying a cancer early, to providing information about screening and referral pathways, and providing supportive care for patients. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => role-for-pharmacists-head-neck-cancers-cpd [to_ping] => [pinged] => [post_modified] => 2021-11-17 09:16:01 [post_modified_gmt] => 2021-11-16 22:16:01 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14764 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Role for pharmacists in head and neck cancers [title] => Role for pharmacists in head and neck cancers [href] => https://www.australianpharmacist.com.au/role-for-pharmacists-head-neck-cancers-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 14765 )
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Lily, 29, is in the pharmacy to purchase paracetamol for a tension-type headache. She mentions that she has recently noticed a new mole on her leg which appears to be growing. She explains that she spends a lot of time training in outdoor swimming pools as she is a competitive swimmer. Despite trying to be sun-safe, she has been sunburnt a number of times over the years. You note she has a fair complexion. You examine the mole and also notice it is not a consistent colour and the edges are uneven. You think this mole is suspicious for cutaneous melanoma and refer Lily to her GP for further investigation.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.2, 3.5
Melanoma is a type of malignant tumour resulting from the uncontrolled proliferation of pigment-producing cells, known as melanocytes. Melanoma can arise in the skin (known as cutaneous melanoma), mucosal surfaces, leptomeninges and the uveal tract.1–4
Depending on the stage and location of the melanoma, the symptoms and individual patient factors, one or more treatments may be recommended. These treatments include surgery, radiotherapy and systemic anti-cancer medicines, including oral targeted therapies and checkpoint inhibitor immunotherapies.2 This article will focus on cutaneous melanoma and its management with oral targeted therapies.
Pharmacists can help in both prevention and management of melanoma, and are involved in several steps, from clinical verification of the medicines, to counselling on their safe and effective use.5
In 2020, it was estimated that 16,221 new cases of cutaneous melanoma were diagnosed in Australia (9,480 males and 6,741 females).2 This represented 11% of all new cancer diagnoses, making it the third most commonly diagnosed cancer behind breast and prostate cancer.2 During the same year, it is estimated there were 1,375 deaths from cutaneous melanoma (891 males and 484 females).2 Based on 2013–2017 data, the 5-year survival rate following a cutaneous melanoma diagnosis is 92%.6
Between 1982 (when data collection started) and 2005, the risk of being diagnosed with cutaneous melanoma by the age of 60 followed an upward trend.6 Subsequent to this, there was a downward trend until 2012, after which it has remained fairly stable.6 In 2005, the occurrence of melanoma was 1 in 56 people; in 2020, it was estimated to be 1 in 65 people.6
Melanoma is considered a multifactorial disease; an individual’s risk is dependent on genetic and environmental factors and their level of interplay. Overexposure to ultraviolet (UV) radiation is the main cause of DNA damage giving rise to melanoma.1
Melanocytes reside in the basal layer of the epidermis of the skin (see Figure 1). Abnormal cell growth can be triggered when melanocytes are subject to unrepairable DNA damage, and a mass of cancerous cells can eventually form.4
Figure 1 – The layers of the skin
In most cases of cutaneous melanoma, an initial radial (horizontal) growth phase is followed by a vertical growth phase. The radial growth phase occurs within the epidermis and occasionally within the papillary dermis.7 The vertical growth phase extends deeper, and can reach blood vessels or the lymphatic system and therefore metastasise.7
About 90% of melanomas are due to sporadic (non-inherited) gene mutations, while the remaining 10% are due to inherited gene mutations, such as the CDKN2A gene.7 About 40–60% of individuals with melanoma have a non-inherited mutation in the BRAF gene.7,8
Melanoma risk is increased in individuals who have:
There is currently no population-based screening program in place for melanoma or other skin cancers, as there has been no evidence of decreased mortality.9 Skin self-examinations should be conducted regularly by individuals. For difficult-to-see areas, such as the scalp and back, a mirror can be used, or otherwise a friend/family member can assist.4
The main sign or symptom of cutaneous melanoma is usually a spot or mole that is new or has changed.3,4 The appearance of any spot or mole can be inspected for melanoma risk using the ABCDE guideline (see Figure 2). If the particular spot or mole meets any of the criteria described in the categories (asymmetry, border, colour, diameter and evolving),5 the person should arrange for a skin assessment by their doctor.
Figure 2 – The ABCDE signs of melanoma[caption id="attachment_14691" align="alignnone" width="1212"] Source: Cancer Council Australia4[/caption]
While the ABCDE guideline is useful, some individuals are diagnosed with cutaneous melanoma despite not having a mole that fits the criteria in the guideline. This reiterates the importance of having a skin check by a doctor for any spot or mole that has changed or is different from others – growing, firm or new – in addition to scheduled skin checks which are conducted at a time interval determined according to risk. There are other possible signs and symptoms of melanoma (particularly for more advanced stages of the disease) that are non-specific, such as swollen lymph nodes, headache, fatigue and pain.4
Physical examination and biopsy
The ABCDE signs of melanoma are considered by the doctor as part of the examination with a dermatoscope and forms part of the initial diagnosis. If a spot or mole is suspicious for melanoma, a biopsy of the lesion including a margin will be carried out by a GP, dermatologist or surgeon.4 A pathologist then examines the tissue and reports on features, including thickness and ulceration.10 This pathology report, along with other information, provides an indication of the stage of the melanoma.4
Staging incorporates information about the risk profile and extent of melanoma spread. Staging usually includes at least two of the following three methods: examination of the tissue for specific features, examination of lymph node groups for evidence of spread, and imaging such as CT, MRI and PET scans. The stages of melanoma are4:
Stage 0: confined to the cells in the epidermis and has not invaded the dermis, also known as melanoma in situ
Stage I: up to 2 mm thickness without ulceration, or up to 1 mm thick with ulceration
Stage II: thicker than 2 mm with or without ulceration OR between 1 mm and 2 mm with ulceration
Stage III: any thickness and involvement of nearby lymph nodes or tissues
Stage IV: any thickness and has metastasised to distant lymph nodes or to distant sites, such as the lung, liver or brain.
Gene mutation testing
Gene mutation testing (for example, on BRAF, NRAS and C-KIT ) may also be performed to assist the prescriber in the choice of pharmacotherapy. The majority of melanomas have mutations involved with the signal transduction pathway, known as the mitogen-activated protein kinase (MAPK) pathway.8,10,11 This pathway is important for cell growth, proliferation and survival and is also referred to as the Ras-Raf-MEK-ERK pathway.8,10,11
Multiple mechanisms are possible for the oncogenic activation of this pathway. The most common (accounting for about half of all somatic mutations in cutaneous melanoma) is the activating mutation of the serine-threonine kinase BRAF gene which causes constitutive activation of BRAF protein.8 This causes increased proliferation and survival of melanoma cells. The most common BRAF mutations observed are substitutions of valine at codon 600: V600E (substituted with glutamate), V600K (substituted with lysine) and V600R (substituted with arginine). In a small percentage of patients, non-V600 BRAF mutations have been known to occur (note that oral targeted therapies are currently only listed on the PBS for patients with V600 mutations).8,11
A number of conditions, including pigmented basal cell carcinoma and lentigo, present with similar signs and symptoms to melanoma and need to be considered.10
Management of melanoma may involve surgery, radiotherapy and pharmacological therapy.4 Oral targeted therapies and checkpoint inhibitor immunotherapies are the mainstay of pharmacological treatment.12 For individuals with a BRAF mutant, oral targeted therapies or checkpoint inhibitor immunotherapies can be used.13 For those with wild type (non-mutated), checkpoint inhibitor immunotherapies can be used.13 These will be discussed in detail in next month’s article, ‘Cutaneous melanoma: the role of immune checkpoint inhibitors’.
Many factors influence the decision to initiate pharmacological treatment, including BRAF mutant status, PBS eligibility, history of autoimmune disease, and patient comorbidities and preferences.
Three pairs of BRAF inhibitor and MEK inhibitor are used for the treatment of BRAF mutant melanoma (see Table 1). Each combination is thought to have comparable efficacy and are not interchangeable.13 Pairs of targeted therapies are prescribed because in the MAPK pathway (see Figure 3), the binding of BRAF and MEK occurs at two different points and causes cell cycle arrest by inhibiting downstream signalling. The inclusion of MEK inhibition with BRAF inhibition decreases the speed at which the tumour becomes resistant to the BRAF inhibitor, therefore delaying disease progression.8
Figure 3 – The MAPK pathway and the role of the BRAF and MEK inhibitors
Reference: Hepner A11
RTKS: receptor tyrosine kinases; GF: growth factor; GTP: guanosine triphosphate; NRAS: neuroblastoma RAS viral oncogene homolog; BRAF: V-Raf murine sarcoma viral oncogene homolog B; MEK: mitogen-activated protein kinases enzyme; ERK: extracellular signal-regulated kinase.
Patients who take dabrafenib and trametinib for the adjuvant indication should cease treatment prior to the 12-month mark upon disease recurrence or unacceptable toxicity. For unresectable stage III or IV, the treatment must be ceased upon disease progression or unacceptable toxicity. An individual may switch from one pair to another pair of BRAF-MEK inhibitors (for unresectable stage III or IV melanoma indication only), if not tolerating one particular pair.21
Pharmacists, in both the hospital and community setting, should access and review blood test results in order to carry out the required clinical verification of a BRAF and MEK inhibitor prescription.5
Dabrafenib, vemurafenib, encorafenib and cobimetinib are implicated in many interactions, and these should be considered by the pharmacist when checking the appropriateness of the prescription. Trametinib and binimetinib are implicated in fewer interactions due to their mechanism of metabolism; however, interactions should still be considered.13 A useful resource for checking interactions with cancer treatments is eviQ (a free Australian Government resource available at www.eviq.org.au).13
Each BRAF and MEK inhibitor combination has its own adverse effect profile.22 Common adverse effects include a non-infectious fever (most common with dabrafenib and trametinib), fatigue and skin toxicity.13 Skin toxicity may present in several ways, including squamous cell carcinomas, basal cell carcinomas, plantar-palmar hyperkeratosis and photosensitivity.1
Non-infectious fever has a median onset of 1 month, and symptoms include dehydration, rigors, temperature of 38 °C or above, dizziness, weakness and fatigue.13 For a patient who has an uncomplicated fever without localising infective symptoms, a septic work up may not be required, but referral to the treating team is still necessary. If an uncomplicated fever is confirmed, the treating team could manage this situation by13:
Fatigue can be managed by dose reduction or an intermittent regimen. The resource eviQ is useful for clinical information, including guidance on dose modifications.14
Table 1 – BRAF and MEK inhibitor pairs indicated in the treatment of BRAF V600 mutant melanoma
References: Cancer Institute NSW,13 Novartis,14,15 Pierre Fabre,16,17 Roche,18,19 Australian Government Department of Health20
To ensure the safe and effective use of oral targeted therapies, the pharmacist must have access to any relevant test results, including blood tests, when clinically verifying the prescription. If the patient does not bring a copy of these results with their prescription, then the pharmacist must obtain these prior to dispensing.
At every supply, pharmacists can ask individuals about possible adverse effects and their management, and whether there have been recent changes to medicines, including non-prescription medicines, in case of potential drug interactions. There have been known occasions of patients mixing up the directions of the BRAF and MEK inhibitors. It is imperative that pharmacists counsel patients and/or their carers on these medicines and check for understanding of the directions.
Some of the common adverse effects of the BRAF and MEK inhibitor pairs were highlighted, including non-infectious fever and skin toxicity.
Pharmacists can recommend that patients contact Cancer Council Australia, Melanoma Patients Australia, and the Melanoma Institute of Australia. These organisations can provide information, education and emotional support, and can facilitate peer-to-peer connections.4,23
Case scenario continued
Lily returns to the pharmacy 2 months later with a prescription for dabrafenib and trametinib (for her resected melanoma) and a copy of her blood test results. Her GP agreed that the mole was suspicious and referred her to a melanoma service. She then underwent surgery (which showed presence of a BRAF V600E mutant) including a sentinel lymph node biopsy which showed 2 micrometastases measuring 1.2 mm in diameter. A PET scan revealed no evidence of distant spread.
Pharmacists can provide advice on skin protection and detection of melanoma, refer patients to their GP for acute and regular skin checks, and provide clinical services to optimise use of treatments for cutaneous melanoma. These roles are vital in contributing to decreased melanoma incidence and improved quality of life and survival outcomes.
MARISSA RYAN BPharm, Grad Dip Clin Pharm, MHlthMgt is Team Leader of Cancer Services at the Princess Alexandra Hospital in Brisbane. She is an experienced cancer pharmacist and is actively involved in research, education and training.
Dr CHRISTINE CARRINGTON BPharm (Hons), Dip Clin Pharm, Masters MedSci Oncology, Doctor of Clinical Pharmacy is Senior Consultant Pharmacist of Cancer Services at the Princess Alexandra Hospital in Brisbane. She is an experienced cancer pharmacist and is actively involved in research, education and training.[post_title] => Cutaneous melanoma – The role of oral targeted therapies [post_excerpt] => Part 1 of this 2-part series explores the role of oral targeted therapies in cutaneous melanoma. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => cutaneous-melanoma-part-1-cpd [to_ping] => [pinged] => [post_modified] => 2021-11-10 12:07:40 [post_modified_gmt] => 2021-11-10 01:07:40 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14678 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Cutaneous melanoma – The role of oral targeted therapies [title] => Cutaneous melanoma – The role of oral targeted therapies [href] => https://www.australianpharmacist.com.au/cutaneous-melanoma-part-1-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 14689 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14569 [post_author] => 23 [post_date] => 2021-10-26 07:31:19 [post_date_gmt] => 2021-10-25 20:31:19 [post_content] =>
Matt is a healthy 30-year-old builder who spends his working week outdoors on construction sites and most Sundays board-riding at the beach. He has come to the pharmacy to ask for advice on a sunscreen to buy. He admits he hasn’t been good at protecting his skin from the sun, but his uncle recently died of melanoma, so he wants to be more vigilant.
What recommendations would you make to Matt about sunscreens and other sun protection measures?
He also says his girlfriend is concerned about titanium products causing cancer. How would you allay his fears?
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.3, 1.5, 2.3, 3.2, 3.5
Australia is the skin cancer capital of the world.1 Two in three Australians will be diagnosed with skin cancer by the age of 70.2,3
It is estimated that each year more than 11,500 Australians are diagnosed with melanoma and about 434,000 are treated for a non-melanoma skin cancer.1 In Australia, more than 80% of new cancer diagnoses each year are skin cancers1; many are due to occupational exposure.2
The incidence of melanoma is increasing.1,4 From 1982 to 2016, the age-standardised incidence rose from 27 to 49 cases per 100,000, and deaths due to melanoma rose from 4.7 to an estimated 6.2 per 100,000. In a positive sign, incidence decreased in people aged under 40 years over this period.4
However, skin cancer is almost entirely preventable. Regular sunscreen use reduces the risk of skin cancer, including melanoma. The best protection also includes protective clothing, a hat, shade and sunglasses.1
Australian public awareness campaigns (e.g. Slip, Slop, Slap) have been in place for decades, but there are many misconceptions about skin cancer and sun protection.1 Pharmacists can provide accurate information on sunscreen and other sun protection measures, in line with expert health recommendations from organisations such as Cancer Council Australia and the Australasian College of Dermatologists.1
Sunlight reaching the Earth consists of ultraviolet (290–400 nanometres), visible light (400–760 nanometres) and infrared (>760 nanometres) wavelengths. Ultraviolet (UV) wavebands are subdivided into UVB (290–320 nanometres) and UVA (320–400 nanometres).5
On Earth we are exposed to UV radiation consisting of 5% UVB, which is mostly absorbed by the epidermis, and 95% UVA, which can penetrate below the dermis.5,6
Ultraviolet radiation, particularly higher energy UVB, causes sunburn and direct damage to DNA.5,6 UV radiation also causes photo-ageing, cataracts, immuno-suppression and skin cancer, and can trigger photosensitivity-related dermatoses and activate latent viruses. Higher wavelength infrared radiation and visible light also contribute to photo damage and skin cancer.7 See Figure 1 for the effects of different UV wavelengths.
The damage resulting from UV radiation exposure is cumulative. Skin cancers may take 25 years or more to appear, highlighting the importance of sun protection in childhood to prevent skin cancers in adulthood.5
Sunburn describes acute skin inflammation caused by excessive exposure to UV radiation, particularly UVB. Risk is highest in the middle of the day. After exposure, painful erythema presents within 2–6 hours, with the maximum effect at 24 hours. Blistering can occur, sometimes accompanied by malaise, fever, nausea and vomiting in severe cases. Sunburn takes 4–7 days to resolve with skin peeling.7
Underlying damage can be long-lasting. Sunburn is a significant determinant of all major skin cancers.8
A Queensland study using population-based surveys in 2009 and 2010 found that sunburn remains a key public health problem for Queensland residents, particularly people under 45 years of age. Compared to people aged 65 and over, those aged 18–24 years were seven times more likely to report sunburn on the previous weekend (adjusted odds ratio (OR) 7.35; 95% confidence interval (CI) – 5.09–10.62), while those aged 35–44 years were five times more likely to report sunburn (adjusted OR 5.22; 95% CI – 3.78–7.22).8
The World Health Organization uses a Global Solar UV index to measure UV levels on a scale from 0 (low) to 11+ (extreme). Levels are affected by time of day, time of year, cloud cover, altitude, proximity to the equator, scattering and reflection.9
Sun protection is recommended at a UV Index of 3 or above. Damage can also occur if there are extended periods of sun exposure where the UV index is below 3. Safe Work Australia recommends sun protection for outdoor workers regardless of the UV Index.9 Individuals can check the UV level for their location by downloading the SunSmart app9,10 or visiting myuv.com.au or bom.gov.au.
Figure 1 – Effects of different UV radiation wavelengths
Sunscreens are safe and effective in protecting the skin from excessive exposure to UV radiation.5 When applied properly they protect against sunburn, tanning, sunspots and premature ageing.9
Products should be stored below 30 °C as heat affects their efficacy.9
By blocking UV radiation from the skin, sunscreen can prevent DNA damage leading to skin cancer.9,11
Sunscreen types and how they work
Early sunscreens were designed to block UVB radiation with little effect on UVA bands.5 However, UVA can damage cells under the dermis, leading to premature skin ageing and some skin cancers. Ideally, sunscreens block both UVB and UVA radiation, and are often included in anti-ageing beauty products.5
In Australia, active ingredients approved by the Therapeutic Goods Administration (TGA) as sunscreens either absorb or reflect UV radiation.7
Absorbent (also known as organic or chemical) sunscreens absorb a particular range of UV wavelengths, mostly UVB.7,10 Only the benzophenones absorb both UVA and UVB radiation.15
Absorbent sunscreen types are: benzophenones (e.g. oxybenzone), cinnamates (e.g. octyl methoxycinnamate), para-aminobenzoic acid (PABA) (e.g. octyl dimethyl PABA), salicylates (e.g. octyl salicylate), camphor-based (e.g. benzylidene camphor sulfonic acid) and miscellaneous (e.g. octyl triazone).5,12
Reflectant (also known as inorganic or physical blockers/barrier agents) sunscreens (e.g. titanium dioxide, zinc oxide) have a broader range of effect. They protect against UVB and UVA radiation, with titanium dioxide providing better UVB protection.5 Reflectant agents also act across higher wavelengths, including visible light.7
Early reflectant sunscreens were micro-sized (200–500 nanometres) and needed to be applied thickly to provide a barrier, appearing as an opaque white layer on the skin. Since the early 1990s they have been formulated as nanoparticles (<100 nanometres) to be more cosmetically acceptable as they are transparent on the skin.5,9
Current broad-spectrum sunscreens usually contain both types of sunscreen – a reflectant and a UVB- and UVA- absorbing agent.7
Sun protection ratings
A sunscreen’s ability to block UVB radiation (but not UVA) is represented as its sun protection factor (SPF).5,7 Derived by laboratory testing, SPF measures the time taken for minimal erythema to appear when sunscreen is applied compared to the minimal erythema time (MED) without sunscreen. The testing protocol specified an application layer of 2 mg/cm.2,5,9
If it takes 10 minutes for the skin to start to burn without sunscreen, an SPF30 sunscreen will take 300 minutes to start to burn.5 This translates to an SPF30 sunscreen filtering 96.7% of UV radiation and an SPF50 sunscreen filtering 98% when applied correctly. That is, the extra benefit of SPF50 is small.7,13
Choosing a sunscreen
Cancer Council Australia recommends a product that is:
Aerosol sunscreens are not recommended by the Cancer Council because of the difficulty in applying it correctly. Cosmetic products with sunscreen provide protection for a limited time and are generally not protective in water. A sunscreen that meets the criteria above is preferred over a cosmetic with SPF when outdoors for a long time, swimming or sweating.9
Sunscreen should be applied in a thick layer to all exposed areas at least 20 minutes before sun exposure, and reapplied regularly – at least every 2 hours.
Contact with eyes should be avoided.9
Users should check the expiry date before applying to ensure it is in date.9
A product may state ‘4 hours water resistant’, but that refers to testing under laboratory conditions and doesn’t reflect real life. Generous amounts should be reapplied every two hours after swimming, exercise, heavy perspiration or after towel drying the skin where the sunscreen can rub off.9
SPF laboratory measurements were achieved with an application rate of 2 mg/cm2, equating to two finger lengths of product applied to each exposed part of the body.13 The Cancer Council describes the amount needed as: at least one teaspoonful of sunscreen for each arm and leg, for the front and the back of the torso, and for the face, including the neck and ears, totalling at least seven teaspoons (35 mL) for the full body.9
However, it has been recognised for some time that sunscreens are not being applied in adequate quantities. Actual quantities applied are said to be one-third of that used under testing conditions, possibly for cosmetic and financial reasons. It is proposed that more realistic SPF levels should be stated on the label, suggesting that both ‘tested SPF’ (e.g. SPF30) and ‘expected SPF’ (e.g. SPF10) are included. Public campaign messages should be modified so people are better informed about the actual level of protection they are achieving with sunscreen.13
Widespread sunscreen use in babies under six months is generally not recommended because of their skin sensitivity. When the UV Index is 3 and above, primary sun protection is recommended for babies under 12 months, including avoidance of direct sunlight, minimising time outside in the middle of the day, protective clothing and shade. A small amount of sunscreen may be used occasionally on some parts of the skin, using suitable products for babies (e.g. zinc oxide).9
Adverse effects with sunscreens are rare (<0.1%),12 but allergic reactions or sensitivities to ingredients are possible, as for cosmetics and other skin treatments. If reactions occur, they may present after single or repeated use. Sometimes fragrance and alcohol cause minor stinging or irritation, but this is less likely with creams and milks formulated for sensitive skin. Patch testing could be trialled before more widespread use.9
Potential oestrogenic effects of some products (e.g. benzophenones with high bioavailability or cinnamates with weak oestrogenic effects in vitro) have not been demonstrated. Current sunscreens would need to be 100,000 times more potent to exert any hormonal effect. Also, newer ingredients have been formulated with a high molecular weight for decreased skin penetration.5
Sunscreens are regulated by the TGA to ensure safety and efficacy.9 Consumers should report any adverse effects to the TGA at: www.tga.gov.au/reporting-problems.14
Nanoparticles are not safe
Some public health groups have questioned the safety of nanoparticulate-based sunscreens. A 2017 national survey found only 55% of Australians believed it was safe to use sunscreen every day, down from 61% in 2014. There is a concern that it is absorbed systemically and causes cancer.15
Research into the safety of zinc oxide and titanium dioxide products found that, in the presence of UV light, in vitro nanoparticles (NPs) can damage cellular components, but there is no evidence that they penetrate skin, even compromised skin. They remain on the skin surface and the outer layer of the stratum corneum, and do not reach significant concentrations in the systemic circulation.16
Australian research confirmed no evidence of skin penetration or toxicity with repeated application of zinc oxide-NP broad-spectrum sunscreen.15
On current evidence, the known benefits of NP-containing sunscreens clearly outweigh potential minor risks.16
Fake tans protect against UV damage
Artificial tans are safer than sunbathing and solarium use, but some individuals assume they protect against sunburn and UV damage.1
Fake tanning procedures, (e.g. tanning tablets, bronzers, skin dyes, spray tans) stain the skin a darker colour, but this colour does not protect the skin against UV radiation. There is also no evidence that ‘tanning accelerators’ stimulate melanin production.17
People using fake tanning products should use sun protection measures such as seeking shade, wearing protective clothing (hat and sunglasses), and applying SPF30+ sunscreen.17
Sunscreen affects vitamin D levels
Some sun exposure is necessary for production of vitamin D, but all sun exposure is associated with skin and eye damage and risk of skin cancer.21 Extended sun exposure without sun protection when the UV Index is 3 or more is not recommended, even for those with vitamin D deficiency.9,18
Population studies have shown regular sunscreen use has little effect on vitamin D levels.1,9
A few minutes of sun exposure rather than long periods may be more efficient at producing vitamin D, and daily exercise also helps. Supplementation may be considered for people at risk of vitamin D deficiency.9
Pharmacists can provide accurate information on the appropriate use of sunscreens, and allay fears about suspected harms. The benefits of daily sunscreen use are clear in reducing UV damage, photo-ageing and skin cancers, including melanomas.12
Recommendations start with appropriate sunscreen choice – one that has a high SPF of 30 or more, is broad spectrum and water resistant. Ensure the user stores the product below 30 °C and checks the expiry date before use. Sunscreen should be applied 20 minutes before going outside.9
Advice on the amount of sunscreen to apply is particularly important, as underuse is common. Inform patients that the benefits of a high SPF are only valid when sufficient quantities are applied and reapplied frequently. Other sun protection measures should be implemented per public campaigns – protective clothing, shade, hat and sunglasses.
Sun protection is important for patients taking photosensitising drugs or immunosuppressants and in those with photodermatoses or hyperpigmentation disorders.12
If both a sunscreen and insect repellent are needed, a combination product is preferable to application of separate products that may reduce the efficacy of both.12
Reassure consumers that nanoparticles in sunscreens do not penetrate the skin to cause systemic harm, that fake tans are not protective, and that sunscreen has minimal effect on vitamin D absorption.
Skin cancer information:
Sunscreen fact sheet:
Case scenario continued
You advise Matt to apply a broad-spectrum, water-resistant sunscreen that is SPF30 or above in addition to other sun protection measures, regardless of the UV index, explaining cumulative UV radiation exposure to him. You acknowledge his girlfriend’s concern about titanium products causing cancer and explain that current evidence of the known benefits of titanium NP-containing sunscreens clearly outweigh any potential minor risks.
Sunscreens are safe and effective in protecting the skin from UV damage. For best coverage, a broad-spectrum high SPF sunscreen applied according to directions will protect against sunburn, photo-ageing and skin cancer, including melanomas. Sunscreen users need to be aware of the actual benefit when the product is underused.
ANN WINKLE BPharm, BA, AACP, MPS is a contracting and accredited pharmacist with extensive experience in developing and delivering education programs to GPs and pharmacists. Ann has previously worked for PSA on the National Resource Development team, NPS MedicineWise as a facilitator and as a clinical hospital pharmacist.[post_title] => CPD: Sunscreens [post_excerpt] => Pharmacists can provide accurate information on the appropriate use of sunscreens, and allay fears about suspected harms. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => sunscreens-cpd [to_ping] => [pinged] => [post_modified] => 2021-11-26 09:22:46 [post_modified_gmt] => 2021-11-25 22:22:46 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14569 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => CPD: Sunscreens [title] => CPD: Sunscreens [href] => https://www.australianpharmacist.com.au/sunscreens-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 14570 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14835 [post_author] => 1925 [post_date] => 2021-11-24 07:38:34 [post_date_gmt] => 2021-11-23 20:38:34 [post_content] => Margaret Sneddon Bickle AO, FPS, PhC, MPharm(Hon.Univ.Syd) has been a role model for women in pharmacy since she joined PSA 70 years ago. Now 90, she remains a registered, non-practising pharmacist, because ‘it’s still important’.
What drew you to pharmacy?There weren’t a lot of opportunities for women in 1947. I contemplated going to university and becoming a teacher. But I was influenced by a friend who was a pharmacist. She told me how good a career it was. She proved to be correct.
Pharmacy was very different then. We made many of our own products, such as mixtures, eyedrops, powders, creams and ointments. You were trained to be exact and meticulous, and while there was always oversight, you learned quickly that your judgement was important. Much of that remains true for pharmacists today.
Were you one of the first women to own her own pharmacy?
In 1950 when I graduated, there was a massive influx of men returning from the war. There were 300 of us in the class and just 30 were women! A woman owning any sort of business in those days was also rare. But I’d served my apprenticeship and learned a lot from the pharmacist about how to run a business. I saw an opportunity at Engadine. I had the support of friends and family, which was important. Starting the business in 1951 was tough, and I learned along the way. They say a successful pharmacy owner is always a successful businessperson, which is true.
How did you fit family in?
Very well. My late husband, Kenneth Bickle AM, FPS, a former President of the Pharmacy Board of New South Wales, was a strong supporter of me through my life. We met in about 1948 while studying pharmacy at the University of Sydney. Pharmacy was ideal for bringing up a family because, after I bought and later sold the first of my pharmacies, I ended up with three when I retired, in Merrylands, Epping and Putney. I could employ people so I could spend time at home with my children when they were growing up. Pharmacy did give me that opportunity, even though it was long hours and very demanding.
Our children did not become pharmacists, although they worked in our pharmacies in their school holidays. Our daughter is a designer and our son is an engineer, and I have three grandchildren. My husband and I travelled a lot, going to Federation Internationale Pharmaceutique (FIP) conferences. He was a traveller, wine buff and a gourmet.‘Take every opportunity that comes your way. I have loved pharmacy. It has been my life.’
Why was being a strong advocate for women important to you?
I have always believed women should have the opportunity to fulfil roles in whichever area of pharmacy they pursue.
When I started, only a few women had the opportunity to own a business. Now changes in laws about ownership have helped more women achieve these goals.
A group of us would hold meetings at the university to encourage women to get involved in pharmacy leadership. You can’t always do it on your own. You need people to encourage and believe in you.
How did you been keep busy during the Sydney lockdown?
Like most people, I have been exercising and trying to keep fit. I am a member of a book club. I read Australian Pharmacist, an excellent publication, and the trade press. I like to keep up to date with politics, history, art and music. I’m always busy and enjoying my retirement.
What is your advice to ECPs, especially females in the profession?
Take every opportunity that comes your way. I have loved pharmacy. It has been my life. It has opened many doors and led to many international friendships.
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By day, Mustafa Dhahir is a newly minted ECP at a community pharmacy in South Western Sydney. But to his 250,000 TikTok followers, he is ‘@pharmustafa’, a myth-busting influencer combating medical misinformation in style.
Why did you choose pharmacy?
My passion for pharmacy was ignited by my family, primarily my father, who is a doctor, and my eldest brother, who is a pharmacist. I pursued pharmacy because I wanted to make a difference – like my role models do.
What aspects of pharmacy are you passionate about?
My favourite thing is having a positive impact. Nothing feels better than providing recommendations that help a patient. I also enjoy compounding. Being able to provide this service can really help in managing a patient’s condition, and I love being a part of that. Compounding is also hands-on and requires skill, which is why I really enjoy it and take so much pride in my work.
Your TikTok videos have racked up more than 8 million ‘likes’. How did you get started?
It was during lockdown in mid-2020. Like most people, I was stuck at home and wanted some entertainment. I made my first video as a joke, but I noticed it was gaining attention and people genuinely enjoyed the content. I wanted to bring some positivity to the TikTok world and build a pharmacy-themed page that highlighted the crucial roles of pharmacists in healthcare.
What kind of videos do you create?
I create videos that demonstrate the role of the pharmacist, where I explain concepts like compounding, MedsChecks, medicine packs and other valuable services that show pharmacists do more than just ‘count pills’ or ‘stick a label on a box’.
I also produce COVID-related videos that aim to provide up-to-date information regarding guidelines and vaccine availability in pharmacies, as well as busting misinformation and answering questions.
Some people falsely believe I get paid by the government to promote COVID-related content or to inform people about the safety and efficacy of vaccines. I use satire or metaphors in conjunction with studies green-screened in the background to simultaneously highlight how ridiculous the conspiracies are and how reliable my COVID-19 information is.
My approach to creating informative videos is very similar to the way I counsel patients in the pharmacy. I deliver information in simple terms so everyone can understand, including those with low health literacy. I also aim to avoid jargon, or explain the jargon when I do use it. This isn’t just to allow for easy comprehension of my content, but also so my audience can use my explanation and pass this knowledge on to others.
I also do skits, jokes and other light-hearted content. This is to show that we aren’t all robots; we have a sense of humour and like to have fun.
You are also pursuing a medical degree – why did you decide on further study?
My goal is to ‘be the change you want to see’. On several occasions I have seen prescriptions and thought that a pharmacist could have made better prescribing choices.
Sometimes it’s a simple error, such as not putting a safety net on a patient’s prescriptions on PBS despite them being eligible. In other cases, it’s a major error that could have been avoided with more attention to detail, like prescribing a patient diuretics for peripheral oedema from their calcium channel blockers that would lead to volume depletion and dehydration.
People ask me why I’m leaving pharmacy for medicine, but my answer is that I’m not. I will continue to work in pharmacy while I’m completing my medical training, and I plan on maintaining a dual registration of pharmacy and medicine. I believe that the best doctors are pharmacists first.
What advice do you have for other early career pharmacists?
You can learn from anyone and everyone, so make sure to treat everyone with respect, have an open mind and a good attitude. You never know what you might learn.
DAY IN THE LIFE of Mustafa Dhahir, TikTok star and intern pharmacist at TerryWhite Chemmart, Narellan Town Centre, New South Wales.
8.30 am – Morning fuel
Order usual breakfast (latte and banana bread) from the cafe next to the pharmacy. Pick up coffees for the manager, pharmacist in charge and dispense technician.
9.00 am – Shift starts
Check for any notes left behind from the previous shift and for app orders made overnight. The notes inform me there should be Xolair on the order for a patient that should arrive today, so I keep an eye out for that.
11.30 am – Quality use of medicines
While packing a dose administration aid, I notice the pill burden can be reduced with some minor changes. The patient is taking paracetamol 2 tablets qid long term, which could be swapped to paracetamol MR 2 tablets TDS. This would have the same therapeutic effect, be more cost effective and reduce the pill burden. I also notice he is taking Avodart and Flomaxtra in separate tablets instead of taking Duodart, which contains the same medicines in the same capsule. I contact the doctor and organise a change of medicine regimen, new prescriptions and a medication chart.
2.00 pm – Vaccination stationI take over COVID-19 vaccinations while the pharmacist in charge has a break, and vaccinate 15–20 people. We currently offer Moderna and AstraZeneca vaccines.
4.30 pm – Delivery duty
I prepare to hand over to the evening staff. I collect medicine deliveries, log them in our register and deliver medicines to patients who can’t afford to leave their homes due to COVID-19 infections.
7.30 pm – Study session
I study for a few hours, eat, make a TikTok video or two and prepare for the next day. Tomorrow, I have my weekly clinical day where I shadow doctors in the hospital and learn clinical skills and procedures.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 14679 [post_author] => 3387 [post_date] => 2021-11-10 11:24:01 [post_date_gmt] => 2021-11-10 00:24:01 [post_content] => Four of PSA’s Intern Training Program (ITP) leads share the highlights of their diverse careers, and what you can expect to encounter during this challenging and exciting year.
Oya Gulal MPS
Pharmacist Immuniser at the Royal Flying Doctor Service (RFDS) and PSA Pharmacist – Training Officer, New South WalesDescribe your role as a pharmacist immuniser with RFDS. I travel to remote towns with a team of immunisers to administer the Pfizer COVID-19 vaccine to patients. We meet at the RFDS airport base where we fly to the nearest airport of our destination. We are then greeted by locals or other RFDS members who drive our team to the rural town. When we arrive, we quickly set up our stations – including an area to draw up and prepare the vaccines, laptops for checking in patients and data collection, and tables where patients sit to get vaccinated – so we can power through the line of people waiting to get immunised. What’s the most interesting part of your role? Flying to work in a small plane! Every trip is unique in destination and experience. It is great to interact with people from different locations, and making a health service like vaccination so accessible gives you immense career fulfilment. [caption id="attachment_14684" align="alignleft" width="322"] Ms Gulal's first trip with the RFDS was to Mullaley, about 474 km from Sydney[/caption] A highlight was my first RFDS trip to Mullaley in NSW, where I met the team of nurses I would be working with. I was nervous and not sure what to expect, but all the locals were lovely and so grateful for the service we were providing. I was really proud of the team and what we were achieving. How did your intern year prepare you for your role? Working under supervision is one of the best aspects of being an intern pharmacist. It’s a great year to learn from mistakes and bounce information and decisions off your colleagues. At first it feels overwhelming as you try to recall what you learnt during university, but you soon find that information is best retained during application. For example, as I linked medicines to certain patients and situations, I was able to better recall information about that drug for future reference. The intern year also prepared me for interacting with patients from all walks of life, which is something you can’t learn at university. I fine-tuned my emotional intelligence skills and expanded my abilities in conflict resolution, and those experiences helped to mould the type of pharmacist I am today. Advice for new interns? Make the most of your PSA membership. The available tools and CPD activities are great! During my internship, I was so overwhelmed with work and submitting requirements that I didn’t explore these resources until after the program was over. I would also recommend keeping your membership with PSA as an early career pharmacist. It’s the best way to stay on top of pharmacy updates, particularly the changes to legislation and advice for vaccinating pharmacists during the COVID-19 pandemic. It was also through PSA that I came across the RFDS immunising role, which has been the most memorable time in my career to date. [caption id="attachment_14681" align="alignright" width="231"] Emily Thorp MPS[/caption]
Emily Thorp MPS
Community pharmacist and PSA Pharmacist – Trainer and Assessor, TasmaniaWhat is it like working as a community pharmacist in a rural area? I have managed pharmacies in both urban and rural areas, but it’s in the rural towns where you get to know your patients and really make a difference. At the moment I work in a small pharmacy servicing a mental health centre, which allows me to showcase my mental health first aid skills and suicide prevention training. Those interactions make it all worthwhile, and allow me to reflect on the full scope of pharmacy practice when facilitating intern workshops. Why did you choose this pathway? Being the most accessible health professional is such an important role. The area I work in has low health literacy levels, which means explaining to patients how to treat something over the counter, why a blood test is important for certain medicines, or why seeing a counsellor might be a great first step before starting a medicine. Being the person people come to when their mental health deteriorates and they don’t know who else to turn to creates lifelong bonds. It’s an amazing feeling to reflect on the lives you’ve changed just by instigating a conversation and really listening. What’s the best thing about working as an ITP trainer? Seeing the interns grow! We held an icebreaker event in August where each intern had to discuss a ‘high five’ moment in their ITP. We realised how far everyone had progressed and what a difference they had made already. One intern attended our suicide prevention training only weeks before a patient came in and let her know his mental health was declining. She had the confidence to ask him the vital questions about suicide and got him the help he needed. Another started a conversation about a newly initiated moclobemide script, only to discover the patient thought it was an anti-inflammatory and the prescriber thought they had chosen Mobic. These interns prevented medicine-related harm, immunised patients and decreased vaccine hesitancy, and had mental health conversations that could have been lifesaving. The future of pharmacy and our community is in fantastic hands. What do you wish you had known before starting your intern year? What shoes to wear. It’s taken years of trial and error, but Skechers are my top pick for comfort. What’s the best memory of your intern year? Reuniting with friends at ITP workshops and hearing how everyone else is going. You can feel quite isolated in a new workplace while finding your way, and knowing your mates are having the same experiences is fantastic. What advice would you give to new interns? Make sure you have all the support you can get. In the ITP, your trainer and assessor is a pharmacist who remembers their intern year. They will welcome you to the program, provide regular support and give feedback throughout the year. It’s also important to be open with your preceptor about what you are finding challenging and what you feel you are good at. But remember to reward yourself for all your achievements – you’re almost there! [caption id="attachment_14680" align="alignright" width="231"] Penny Macklin MPS[/caption]
Penny Macklin MPS
PSA Senior Pharmacist – Trainer and Assessor, QueenslandHow did you get your start in pharmacy? Packing dose administration aids at an aged care-focused pharmacy while completing my degree in 2005. I did my internship at the same pharmacy, then bought into a partnership there in 2013. After selling the pharmacy in 2017, I worked as a professional services pharmacist at an innovative Brisbane pharmacy that focused on forward dispensing. I started working for PSA in 2019, which was a great opportunity to branch out in my career and to give back to the profession. This year, I was given the opportunity to work at a Queensland Health community vaccination clinic as a clinical lead. What was it like vaccinating patients at a major hub? Fast-paced and rewarding. The centre averaged 1,200 vaccinations a day at its peak and no two days were the same. As a clinical lead I oversaw the vaccinators, and ensured the centre delivered safe and efficient care. This meant addressing the clinical concerns of patients and assessing their readiness for vaccination, monitoring vaccine preparation and administration, and watching over patients’ recovery post-vaccine on a daily basis. Most of the other clinical leads in the program were registered nurses, but having a pharmacist on the team brought a different perspective. A lot of questions revolved around the co-administration of medicines, so I had the knowledge and expertise to confidently assess and reassure patients. What did you find challenging in your intern year? Stepping up to take responsibility for decisions. When you’re a student, you are always checking in with senior staff. But once you become an intern, you need to make that shift to solving problems independently, rather than just taking them to your supervisor. What do you wish you had known as an intern? To seek out every opportunity, and use the year to consolidate your clinical skills. Your knowledge will only get you so far, so use your internship to translate it into exceptional patient care while you have a great support network around you. It’s a huge year and it is what you make it. Be open to new opportunities and find your passion. Immunisation and pharmacy education is mine! [caption id="attachment_14683" align="alignright" width="231"] Kerri Barwick MPS[/caption]
Kerri Barwick MPS
PSA Manager – Trainer and Assessor, QueenslandHow did you get your start in pharmacy? As a 15-year-old high school casual in a community pharmacy, before working my way up to shop manager. After that, I moved to working in buying, marketing and other areas behind the scenes while doing a business degree, which led to a role at the Quality Care Pharmacy Program (QCPP). How did you end up as a trainer and assessor with PSA? From my role at QCPP, I started training pharmacy assistants before I took some time off to have my three kids. I returned to working at a community pharmacy on a casual basis when the kids were small, which helped me realise I always wanted to stay in the industry, so I went back to university and got my pharmacy degree. After working as a pharmacist for a while, I wanted to give back and decided training was the best avenue. I love helping my community and providing valuable advice, but I wanted more pharmacists to be able to do the same. What better way to do that than become involved with interns and help to shape the future of our profession. What surprised you about your intern year? Going from being a pharmacy assistant to a pharmacist, I was really shocked at how differently the patients treat you. I got first-hand experience of what it feels like to be one of the most trusted professionals. What was challenging? A couple of patients I was close to passed away. Talking to their families after this can be really difficult. What’s your best memory of your intern year? The connections you form with patients. We’re often the first to know if people are sick, pregnant or having health worries, so I felt very privileged to be let into people’s lives. To participate in next year’s Intern Training Program, click here to enrol now. [post_title] => The pharmacy role models shaping the profession’s next generation [post_excerpt] => Four of PSA’s Intern Training Program leads share the highlights of their diverse careers, and what you can expect to encounter during this challenging and exciting year. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => meet-psa-intern-training-program-leads [to_ping] => [pinged] => [post_modified] => 2021-11-10 14:18:09 [post_modified_gmt] => 2021-11-10 03:18:09 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14679 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => The pharmacy role models shaping the profession’s next generation [title] => The pharmacy role models shaping the profession’s next generation [href] => https://www.australianpharmacist.com.au/meet-psa-intern-training-program-leads/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14682 )
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Over a combined 103 years, the joint recipients of this year’s Lifetime Achievement Award, Valerie Constable and the late John Ware, helped progress the pharmacy profession for the next generation.
The Pharmacists Support Service (PSS) recorded an 80% jump in calls last year, its team of volunteers speaking to pharmacists, interns and students seeking a listening ear during a particularly challenging time.
But if a distressed pharmacist rang the helpline 26 years ago, it would have been Valerie Constable’s voice on the end of the line.
It was 1995 when PSA’s Victorian branch received a letter from the Doctors’ Health Advisory Service (DHAS) saying it had been contacted by pharmacists asking for help, including one who ultimately died by suicide. While substance abuse was a big issue for doctors, pharmacists in Victoria were experiencing frequent robberies, and DHAS suggested PSA establish its own targeted support service.
Ms Constable, PSA’s first female President in Victoria, immediately saw the need for a helpline run by pharmacists, for pharmacists.
‘I felt quite strongly about it,’ she says of the initiative, the highlight of her career. ‘My family had experienced suicide and I knew what it did to people. So I put my hand up and said if anybody should do it, it should be PSA, because they represent all pharmacists. I took the calls for the first 2 years. It was seat-of-the-pants stuff, as there wasn’t another organisation in Australia to follow. Similar outfits in the UK and US were just getting started.'
Ms Constable proved there was demand for the service, and PSA Victoria provided ongoing funding. Over time, PSS expanded nationally, taking on more volunteers, developing a formal training program with Lifeline and bringing on Kay Dunkley FPS as CEO (its first paid employee). From 20 calls a year initially, PSS now handles about 10 calls a week and provides valuable, non-judgmental support to those in need.
In addition to leadership roles with PSA and establishing PSS, Ms Constable’s career was dedicated to community pharmacy. She met her husband Bob at the Victorian College of Pharmacy in the early 1950s, and spent 36 years living above their pharmacy in a former drapery store in Pascoe Vale South, about 10 kilometres north of Melbourne’s CBD.
Times are changing
Ms Constable says she would find pharmacy ‘very hard’ now. ‘I love being a pharmacist and have never wished to be anything else ... [But] it has become very stressful with lots of pressure, even more so in this pandemic,’ she says.
‘The main thing I always practiced and tried to teach our trainees was that every patient who leaves your pharmacy must feel you have done your very best to help them.’‘I hope I have given something back to the profession I love.’
While PSS issues have changed over the years – bullying has become more prevalent, but there are fewer holdups – the service is just as relevant.
‘A big aim of the PSS is to alleviate stress and find a way around it. And having a pharmacist answer the phone each time is important, because they understand the situation – they’ve been there, done that,’ Ms Constable says.
‘I am confident that PSS will achieve even more in the future and I am proud of what has already been achieved. I hope I have given back something to the profession I love.’
What change in pharmacy in the past 2 years were you most excited about?
The change which most excited me was that Commonwealth and State governments publicly recognised the value of pharmacists’ expertise, experience and accessibility.
This is witnessed by the use of community pharmacists as vaccinators during the present COVID-19 pandemic.
What action in PSA’s Pharmacists in 2023 is the most important?
Action 4: Facilitate pharmacist prescribing within a collaborative care model. This will benefit pharmacists as well as the public and the government.
Lifetime Achievement Award joint recipient John Ware OAM
A community pharmacist for 40 years, John Ware FPS OAM posthumously received a Lifetime Achievement Award. He died in December 2020 aged 92.[caption id="attachment_14340" align="alignright" width="254"] John Ware OAM[/caption]
After graduating from the Victorian College of Pharmacy in 1950, Mr Ware operated pharmacies in Melbourne and rural Australia and served as PSA’s National President and President of the Victorian Branch, as well as President of the Western Pacific Pharmaceutical Forum and the International Pharmaceutical Federation (FIP) Foundation.
After his OAM in 2002, in 2006, Mr Ware became one of a small number of Australians to receive a Fellowship of the FIP and in 2014 received the FIP Distinguished Service Award.
He was remembered fondly by Professor Arthur Christopoulos, Dean of Monash University’s Faculty of Pharmacy and Pharmaceutical Sciences, and Victorian PSA President John Jackson.
‘He epitomised the professional pharmacist, improving care especially through education, collaboration and commitment to pharmacy organisations such as PSA and FIP,’ said Prof Christopoulos.The PSA Lifetime Achievement Award is proudly sponsored by Symbion. [post_title] => How PSA's 2021 joint Lifetime Achievement Award recipients led the way [post_excerpt] => Over a combined 103 years, the joint recipients of this year’s Lifetime Achievement Award, Valerie Constable and the late John Ware, helped progress the pharmacy profession for the next generation. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => 2021-lifetime-achievement-award [to_ping] => [pinged] => [post_modified] => 2021-09-24 19:05:42 [post_modified_gmt] => 2021-09-24 09:05:42 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14336 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => How PSA’s 2021 joint Lifetime Achievement Award recipients led the way [title] => How PSA’s 2021 joint Lifetime Achievement Award recipients led the way [href] => https://www.australianpharmacist.com.au/2021-lifetime-achievement-award/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14332 )
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From producing the world’s first comprehensive guide to drugs in sport to supporting her community through bushfires, and now the pandemic, Linda Badewitz-Dodd MPS is always willing to step up to the challenge.
A coal-face pharmacist who practices what she preaches. A pioneer. A community leader. These are just a few of the ways Ms Badewitz-Dodd’s peers describe her, and it’s easy to see why.
Her pharmacy in Merimbula on the New South Wales south coast, which she co-owns with business partner Tania Dwyer, provides a wide range of professional services with a focus on personalised support and care. During the 2019–20 bushfires, the pharmacy remained open, supplying face masks, essential medicines and emergency support to the community, while Ms Badewitz-Dodd dealt with the threat of fire to her own home in nearby Tathra.
‘When you live in a small town, your friends become your family,’ she says. ‘Ensuring the pharmacy stayed open and getting things for the community when it needed them was very rewarding. Helping people and accepting help (when you are accustomed to giving it) – that’s what defines community to me.’Ms Badewitz-Dodd will share her incredible career story in an an episode of PSA's new podcast, Pharmacy & Me, coming soon.
A clinical start
Ms Badewitz-Dodd didn’t always aspire to life as a community pharmacist. After graduating from the University of Sydney in 1985, she did a post graduate diploma in hospital pharmacy as it ‘offered an avenue for specialties and to see closer at hand your knowledge being applied’.
She went on to work as a clinical pharmacist at Sydney’s Royal Prince Alfred Hospital, doing ward rounds with doctors and spending time in the intensive care, neurosurgery and neurosurgical intensive care units.
‘That was an amazing experience. It’s when I realised that we’re all here together for one purpose, and that’s looking after the patient … It shaped my belief in pharmacists being part of a team and able to contribute meaningfully.’
Drugs in sport
Before the 1990 Commonwealth Games in Auckland, Ms Badewitz-Dodd, by then Managing Editor of MIMS, wanted to include a`Permitted in Sport’ or `Not Permitted in Sport’ symbol in MIMS Bi-Monthly that clearly identified products that could be taken by athletes.‘If you have an opinion, voice it. don’t be afraid to be wrong or to have the discussion – and know when not to accept a simple “no”.’
From then producing a handbook for athletes, coaches and sport management staff was a logical progression and resulted in the first edition of Drugs in Sport in 1990, she recalls.
‘A similar publication was produced for MIMS UK. Then the world was becoming digital and internationally there were “Live Drug Databases” which were the precursors to the Current Global DRO – a collaboration between numerous countries including the United States, Canada, the United Kingdom, Australia, Switzerland, New Zealand, Japan and others.’
Ms Badewitz-Dodd and the other pharmacists in the group manage the ingredients and she additionally manages the brands for Australia, Canada and New Zealand.
Having her first child meant, sadly, stepping away from MIMS as, ‘nothing compared to being a mum’.
Ms Badewitz-Dodd continued her drugs in sport consultancy work, joined PSA’s NSW Branch Committee and presented Insight, a PSA education program (‘on cassettes!’).
Meanwhile, her husband David Dodd was working hard in his pharmacy at Eastwood, in Sydney’s north-west.
The long hours took its toll on the young family (the couple had children aged 2 and 4 at this point). They spent a few months travelling before moving to Tathra where they began working for local pharmacist Warren Seeto, who had been Ms Badewitz-Dodd’s first (and last) boss.
And while she continued to raise their children, Mr Seeto and Mr Dodd went into partnership – until his tragic death in 2013 when he was hit by a car.
‘When my husband was killed I inherited his half of the business, so I had to set up and become a community pharmacist,’ Ms Badewitz-Dodd says.
‘I was doing a bit of relieving around the place, but it was never my passion. It is now though,’ she says. ‘I think whatever you choose to do, if you don’t do it with passion, people can tell.’
Her advice for others is to be brave. ‘If you have an opinion, voice it. Don’t be afraid to be wrong or to have the discussion – and know when not to accept a simple “no”.'
What change in pharmacy in the past 2 years were you most excited about?
The drive to empower pharmacists to practice to their scope of practice is a game changer for me professionally. Recognition that pharmacists can and do provide services to our community, such as vaccinations and administration of IM and SC medicines, is well overdue. I am excited to see where this will take us.
What action in PSA’s Pharmacists in 2023 is the most important?
That is a difficult question as so many of the actions go hand in hand. But Action 4: Facilitate pharmacist prescribing within a collaborative care model has the most scope for our profession. For example with flu vaccinations, we already prescribe – we make the clinical judgment as to whether it is beneficial for a particular patient and then act accordingly. There are so many other things we can do – let’s just do it.The PSA Intern of the Year Award is proudly sponsored by Symbion. [post_title] => Linda Badewitz-Dodd MPS is PSA's 2021 Pharmacist of the Year [post_excerpt] => From producing the world’s first comprehensive guide to drugs in sport to supporting her community through bushfires, and now the pandemic, Linda Badewitz-Dodd MPS is always willing to step up to the challenge. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => 2021-pharmacist-of-the-year [to_ping] => [pinged] => [post_modified] => 2021-10-20 17:54:34 [post_modified_gmt] => 2021-10-20 06:54:34 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=14331 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Linda Badewitz-Dodd MPS is PSA’s 2021 Pharmacist of the Year [title] => Linda Badewitz-Dodd MPS is PSA’s 2021 Pharmacist of the Year [href] => https://www.australianpharmacist.com.au/2021-pharmacist-of-the-year/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14333 )
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.