td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 9351 [post_author] => 235 [post_date] => 2020-02-12 12:59:19 [post_date_gmt] => 2020-02-12 02:59:19 [post_content] => In many rural and remote communities, the pharmacy is often the first stop for any health care question – whether medicine-related or not. This is something Peter Crothers FPS knows firsthand, as the owner of the only pharmacy in Bourke, an outback town of fewer than 2,000 people in north-west New South Wales. ‘There are so few services and clinicians that people can rely on in remote areas that they come into the pharmacy for all sorts of things,’ Mr Crothers told Australian Pharmacist (AP). This could be anything from a woman seeking reassurance about puffy ankles during pregnancy to someone having a mental health crisis or needing help understanding a pathology request form given to them by a GP. ‘One thing you’ll never be able to say is, “I’m sorry, we can’t help you but why don’t you try the pharmacy in the next suburb?”,’ said PSA’s 2019 Pharmacist of the Year. ‘The nearest pharmacy is 100 kilometres away, so you have to do a whole lot of things you wouldn’t usually be expected to do.’
A rural focusThe 7 million Australians living in rural and remote areas tend to have higher rates of chronic conditions and often have poorer health and welfare outcomes compared to those in major cities. [caption id="attachment_9380" align="alignright" width="260"] Peter Crothers FPS[/caption] They also have higher rates of risk factors, such as daily smoking and excessive alcohol consumption, higher rates of preventable hospitalisations due to acute and chronic conditions, higher rates of potentially avoidable death, and die younger. ‘The more remote you go, and the further down the socioeconomic scale you go, the worse it gets,’ Mr Crothers said. ‘There’s a massive health deficit in rural areas.’ While ideally positioned to support their communities and address this disadvantage, ‘community pharmacies in rural and remote Australia are on the brink of extinction’, according to PSA’s 2020-21 Federal Budget submission. ‘Without a specific focus on the rural pharmacist workforce in Australia we will see little improvement in complex and chronic disease management and will fail to deliver on the objectives of Australia’s Long Term National Health Plan and unique National Medicines Policy.’ The organisation is calling on the government to invest $15.5 million to develop a Rural Pharmacy Enhanced Services Program, to assist rural pharmacists in delivering high-quality primary care. This includes providing support for the provision of programs in a ‘health hub’ model, such as structured programs for:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 9352 [post_author] => 235 [post_date] => 2020-02-12 12:32:15 [post_date_gmt] => 2020-02-12 02:32:15 [post_content] => Pharmacists can play a key role in preventing the spread of the 2019 novel coronavirus, which was yesterday formally named COVID-19 by the World Health Organisation (WHO). In a guidance document for pharmacists released last week, the International Pharmaceutical Federation (FIP) said pharmacists need to understand the nature of the virus, how it is transmitted and how to prevent it from spreading further.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 9319 [post_author] => 235 [post_date] => 2020-02-06 10:49:11 [post_date_gmt] => 2020-02-06 00:49:11 [post_content] => Pharmacists have been urged to limit the sales of face masks, with reports of consumers bulk-buying P2 masks from pharmacies, intending to ship them to relatives overseas or resell them online at inflated prices. PSA National President Associate Professor Chris Freeman said yesterday that pharmacists should exercise judgement about how many masks they sell, and to whom. ‘While there is limited stock available from suppliers, we encourage pharmacists to only supply limited quantities of face masks to consumers, consistent with the immediate health needs of an individual person,’ A/Prof Freeman said. His advice comes as an eight-year-old boy was identified as Australia’s 13th case of the 2019 novel coronavirus (2019-nCoV) overnight, amid continuing concern about the spread of the disease globally. The boy, a Chinese citizen from Wuhan, remains in isolation in a stable condition at Gold Coast University Hospital. The World Health Organization last week declared the 2019 n-CoV an international emergency and numerous countries have instituted rigorous travel bans in an attempt to limit its spread from China. Several countries, including Australia, have evacuated citizens from the epicentre in Wuhan. There are now more than 24,000 confirmed cases of 2019-nCoV worldwide at the time of writing, the majority in China. Following Hong Kong reporting its first fatality yesterday the death toll has risen to just under 500 since the outbreak began in December.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 9290 [post_author] => 235 [post_date] => 2020-02-05 13:44:24 [post_date_gmt] => 2020-02-05 03:44:24 [post_content] => Increased funding for pharmacists in aged care and rural and remote communities would save lives and improve health outcomes, PSA has argued in its 2020-21 Federal Budget submission. The organisation is also calling for the creation of a Commonwealth Chief Pharmacist role within the Department of Health; funding for a pilot opioid stewardship program; and an expansion of the Workforce Incentive Program. PSA National President Associate Professor Chris Freeman said the recommendations were about improving Australians’ access to health care by using the full scope of pharmacists’ knowledge and expertise. ‘Accessibility to health care is a major challenge in this country,’ he said. ‘Some members of our community do not get the health care they need and deserve. ‘As our population ages and the number of people with chronic conditions continues to rise, we need to be innovative and use our resources effectively.’
Medicine safety in aged careAs PSA’s 2019 Medicine Safety: Take Care report revealed, 98% of residents in aged care facilities have at least one medicine-related problem and over half are exposed to at least one potentially inappropriate medicine. ‘What we know from the Aged Care Royal Commission interim report is that this is often a sedative or psychotropic medicine that can make them drowsy and more likely to experience harm,’ A/Prof Freeman said. ‘It has been estimated the use of psychotropic medicines in aged care is only clearly justified in about 10% of cases. ‘Older Australians, particularly those in aged care, rely on medicines as part of their treatment but are particularly vulnerable to medicine-related harm.’ To address this issue, PSA recommends the Federal Government invest $8.7 million over four years to establish a Medicine Safety in Aged Care Resources and Support program. This would develop, disseminate, implement and evaluate evidence-based resources for aged care facilities and reduce the current reliance on high-risk medicines.
Rural and remote practicePSA also called on the Federal Government to invest $15.5 million to develop a Rural Pharmacy Enhanced Services Program, to assist rural pharmacists in delivering high-quality primary care. ‘[This] will keep pharmacists in the bush and support delivery of services such as smoking cessation, chronic disease management, health screening, wound care and mental health triage and referral,’ A/Prof Freeman said. Australians in rural and remote areas often suffer from a lack of health care options, with many people having to travel great distances to see a GP or visit hospital. As a result, many turn to their local pharmacist, who may be the only health care provider in the community. ‘It has been very clear during the recent bushfire emergency the role of rural pharmacists and their willingness to step up in times of need,’ A/Prof Freeman said. ‘We want to be able to support our rural pharmacists to do more to be able to help their communities.’
Opioid overuseWith more than three Australians dying each day from opioid overuse, the PSA asked the government to commission a pilot program to support opioid stewardship pharmacists working within general practice. ‘Between 2007 and 2016, the rate of opioid deaths rose by 62%,’ A/Prof Freeman said. ‘In 2016–17, 15.4 million opioid prescriptions were dispensed under the PBS to 3.1 million Australians.’ In its submission, PSA said the 18-month trial should consist of:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 9291 [post_author] => 23 [post_date] => 2020-02-05 13:15:11 [post_date_gmt] => 2020-02-05 03:15:11 [post_content] => Pharmacists considering work in the general practice space now have two enablers – the Workforce Incentive Program (WIP) eligibility, which came into effect on 1 February, and the Pharmaceutical Society’s (PSA’s) GP Pharmacist Foundation Training, launched last year. In a win for patients, allied health professionals and the general practice team, the WIP now applies to an expanded primary care team in which each member can apply their expertise to patient care, which in turn gives patients access to more services. PSA National President, Associate Professor Chris Freeman welcomed the move, where for the first time pharmacists are included as one of the allied health professionals that general practices can engage through the WIP.1 ‘Research shows integrating a pharmacist into the primary care team can improve health outcomes for patients with chronic diseases such as diabetes, osteoporosis and cardiovascular disease; and reduce medicine-related problems, total number of medicines and inappropriately prescribed medicines,’ he said. Two separate WIP payment streams are a Doctor Stream (payments made to medical practitioners), and a Practice Stream (payments made to practices) which supports the engagement of pharmacists, nurses and other allied health professionals.2 The aim of the WIP–Practice Stream is to strengthen team-based and multi-disciplinary models of care, enabling collaborative arrangements to be put in place that will better support community needs.2 See the WIP guidelines. And the Royal Australian College of General Practitioners (RACGP) welcomes this ‘positive development’. RACGP President Dr Harry Nespolon told PSA: ‘The RACGP values team-based models of care in which a range of healthcare professionals can contribute towards patient health outcomes, maximising use of their skills within their scope of practice.’1 While general practices are now supported to employ pharmacists, PSA is concerned the funding cap is insufficient. In its recent Federal Budget submission, PSA called for the value of the WIP per Standardised Whole Patient Equivalent and the upper limit cap on larger general practices to both be increased by 50%. ‘We estimate integrating pharmacists into general practice would yield a net saving of $544.87 million to the health system over four years,’ A/Prof Freeman revealed. In the meantime, PSA encourages general practices and pharmacists to consider how they can work together within the expanded WIP to improve health outcomes in their local community. Pharmacists who want to work in general practice are encouraged to complete the PSA General Practice Pharmacist: Foundation Stage Training Program as a minimum training requirement. In this non-dispensing role, a general practice pharmacist works collaboratively with GPs, nurses and other health professionals to support the quality use of medicines and complement pharmacists’ work in other settings. PSA’s training modules include working with other health professionals and collaborating with community pharmacists. More than 150 pharmacists have completed general practice pharmacist training through PSA. This group of medicine experts is ‘ready and able to be part of the general practice team,’ A/Prof Freeman said. ‘This is a great start and we look forward to growing this workforce in the future.’ Early Career Pharmacist Shefali Parekh MPS initially enrolled in the PSA training course to strengthen her relationships with doctor colleagues at the Royal Hobart Hospital. She also thought ‘it would be a good way to understand how pharmacists and GPs can collaborate better and work more effectively’, she told Australian Pharmacist. While she intends to stay in hospital pharmacy after just completing her internship, Ms Parekh found it interesting to see how GPs fit into the healthcare system and how the general practice team members work together. 'We don’t learn this as pharmacists, and it helps to put yourself in their shoes,’ she said. Ms Parekh completed the 12 online modules in her own time. She fitted the study into a busy intern schedule while still excited to learn at this stage of her career. The training has equipped her with skills she will continue to use in any area of pharmacy practice involving contact with doctors/GPs. It has also given her another option to consider in the future. ‘It means I can dive into something that’s still quite unique in the pharmacy space,’ she reflected. Further information about PSA training and other practice support for pharmacists working in general practice can be found here. References
[post_title] => General practice opportunities for pharmacists [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => general-practice-opportunities-for-pharmacists [to_ping] => [pinged] => [post_modified] => 2020-02-06 10:50:17 [post_modified_gmt] => 2020-02-06 00:50:17 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=9291 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => General practice opportunities for pharmacists [title] => General practice opportunities for pharmacists [href] => https://www.australianpharmacist.com.au/general-practice-opportunities-for-pharmacists/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 9294 )
- Pharmaceutical Society of Australia. Team approach to patient care a win for all. 2020. At: www.psa.org.au/team-approach-to-patient-care-a-win-for-all
- Australian Government Department of Health. Workforce Incentive Program. At: www1.health.gov.au/internet/main/publishing.nsf/Content/work-pr-wip-workforce-incentive-program
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 9347 [post_author] => 23 [post_date] => 2020-02-12 13:20:33 [post_date_gmt] => 2020-02-12 03:20:33 [post_content] => Air pollution is making us sick according to local and global research, including a study linking exposure to air pollution with subsequent acute cardiac events. The health impacts of bushfire smoke are mainly mediated by fine particulate matter, which affects our respiratory, cardiovascular and immune systems when inhaled. Vulnerable people with existing medical conditions such as asthma, diabetes and cardiovascular disease, as well as older people, pregnant women and children are most affected, according to the Centre for Air pollution energy and health Research (CAR).1 And bushfire smoke worsens asthma symptoms to a greater extent than vehicle emissions.1 CAR says weather conditions caused by climate change will likely increase the frequency of extreme bushfires around the world. It advocates that a global approach to tackling climate change is crucial to minimise the health effects of air pollution, including that caused by bushfires.1 Following bushfires in five states, a nationally representative population survey commissioned by the Australia Institute last month found 57% of respondents nationwide were directly affected by bushfires or smoke over the previous three months. Effects included a change in usual routine (e.g. avoiding outside activity including jogging), illness due to smoke haze or an uninhabitable home.2 When the institute combined survey data with Australian Bureau of Statistics (ABS) data, an estimated 5.1 million adult Australians self-assessed health impacts from bushfire smoke. Residents within the five largest Australian capital cities experienced some impact, while those outside cities reported multiple impacts. Common themes resulting from the impact of bushfire smoke were missed work, changed travel plans and closure of a place of business or leisure.2 New South Wales (NSW) residents were impacted most (74%), followed by Victorians (61%). Thirty percent of Western Australian respondents reported impact by fires and smoke. The survey also gauged respondents’ attitudes and concerns about climate change. Those directly impacted by bushfires were much more likely to agree with statements expressing concern about impacts or the need for climate change leadership.2 The Federal Government has announced $5 million in funding for bushfire-related health research. Professor Guy Marks, a respiratory physician and epidemiologist at the University of NSW and a chief investigator with CAR, has gathered experts to take part in world-leading research into the effects of smoke pollution, including the effectiveness of masks.3
PollutantsSuspended fine particulate matter (PM2.5*) in bushfire smoke is the most significant component affecting health. When inhaled, it enters the lungs and bloodstream, affecting respiratory, cardiovascular and immune systems.1 Face masks are useful in limited circumstances, but need to fit correctly to work well.1 Pharmacists can access the CAR bushfire smoke fact sheet which has more information on health impacts and strategies to minimise risk.1 In Australia, air quality is monitored by state-based agencies and reported as an air quality index (AQI). The index is based on a pollutant’s environmental standard and can be compared with other pollutants and regions. As the AQI rises, air quality worsens with noticeable health effects at an AQI ≥150, where air quality is categorised as ‘very poor’.4
Air pollution and cardiac eventsGrowing evidence supports concern about an association between air pollution and cardiovascular disease. A nationwide case-crossover study in Japan published in The Lancet Planetary Health journal last month demonstrated an independent association between ambient air pollution and the risk of cardiac arrest outside hospital – a major medical emergency and public health problem as global survival rates are under 10%.5 The study found an increase in daily exposure to fine particulate matter (PM2.5*) was associated with the risk of out-of-hospital cardiac arrests (OHCA), even at PM2.5 levels lower than existing air quality standards. In the largest study of its kind to date, the data on OHCAs was collected over 2 years in 2014–15. Air quality measurements on the day of an individual’s arrest, or up to 3 days before, were recorded for a possible link. More than 90% of OHCAs occurred at PM2.5 levels lower than the World Health Organization (and Australian) daily standard level of 25 microgram per cubic metre (microgram/ m3), the study showed. Also, 99% of OHCAs occurred at levels lower than the Japanese or American daily standard level of 35 microgram/ m3. Older people were found to be more susceptible. An association between short-term exposure to carbon monoxide, photochemical oxidants, and sulphur dioxide (emissions from coal burning/mining, bushfires and motor vehicles) and increased risk of all-cause OHCAs was also shown. No association was found with nitrogen dioxide. The authors recommended that world leaders, governments and policy makers reassess current air quality standards and improve air quality further by turning to cleaner energy sources.5 References
* Fine particulate matter with a diameter less than 2.5 micrometres [post_title] => The impact of air pollution [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => the-impact-of-air-pollution [to_ping] => [pinged] => [post_modified] => 2020-02-13 09:44:04 [post_modified_gmt] => 2020-02-12 23:44:04 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=9347 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => The impact of air pollution [title] => The impact of air pollution [href] => https://www.australianpharmacist.com.au/the-impact-of-air-pollution/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 9387 )
- Centre for Air pollution energy and health Research. Bushfire smoke: what are the health impacts and what can we do to minimise exposure? 2019. At: www.car-cre.org.au/factsheets
- The Australia Institute. Polling – Bushfire crisis and concern about climate change. January 2020. At: www.tai.org.au/sites/default/files/Polling%20-%20January%202020%20-%20bushfire%20impacts%20and%20climate%20concern%20%5Bweb%5D.pdf
- Greenbank A. Pollution experts team up to propose major new study into health impacts of bushfire smoke. ABC 2020. At: www.abc.net.au/news/2020-01-14/pollution-experts-propose-study-into-fire-smoke-health-impacts/11866756
- Australia State of the Environment: Air Quality Index. 2016. At: soe.environment.gov.au/theme/ambient-air-quality/topic/2016/air-quality-index#ambient-air-quality-box-10
- Zhao B, Johnston F, Salimi F, et al. Short-term exposure to ambient fine particulate matter and out-of-hospital cardiac arrest: a nationwide case-crossover study in Japan. Lancet Planet Health 2020;4:e15–23.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 9236 [post_author] => 235 [post_date] => 2020-01-29 13:25:38 [post_date_gmt] => 2020-01-29 03:25:38 [post_content] => Pharmacists are encouraged to get a travel history for patients presenting with flu-like symptoms, with five cases so far in Australia1 of the novel coronavirus (2019-nCoV) first identified in China last month. In a letter to the PSA on Monday, Australia’s Chief Medical Officer Professor Brendan Murphy asked pharmacists to ‘identify additional cases that may be in Australia or come to Australia in coming weeks’.2 He urged pharmacists to ask patients with flu-like symptoms whether they had been in the Hubei province of China – including the city of Wuhan where the virus may have originated – or had been in contact with people with the coronavirus infection. ‘If the answer is yes, please ask your patient to put on a surgical mask and present to their GP or emergency department (after first phoning ahead to warm them that they are coming),’ Professor Murphy wrote.2 There have been 106 confirmed deaths from the virus in China, with more than 4500 confirmed cases. The majority of cases are in Hubei, with small numbers reported in other Chinese provinces. Cases have also been reported in Hong Kong, Macau and Taiwan.2 Around the world, there have been 56 confirmed cases across 14 countries: Australia, Japan, South Korea, Vietnam, Singapore, Malaysia, Cambodia, Thailand, Nepal, Sri Lanka, the USA, Canada, France and Germany.3 ‘Nearly all of these cases have reported travel to Hubei Province,’ Professor Murphy wrote.2 However, Japan has now reported its first case of human-to-human transmission, with a 60-year-old man who did not travel to Wuhan but drove buses full of tour groups from the city diagnosed with the virus. Speaking to ABC Radio this morning, Professor Murphy said reports of human-to-human transmission outside of China was ‘a concern’.4 ‘The thing that we are determined to avoid internationally and nationally is what we call sustained human-to-human transmission, where you go from one person to another,’ he said.4 ‘These are isolated cases in Japan and Germany, but they are obviously of some concern and we are having that reviewed today by our peak communicable diseases advice panel, to have a look at those cases.’ He said the ‘major goal’ in Australia is to detect early cases in order to isolate them and ensure there is no sustained human-to-human transmission.4 Speaking to the media this afternoon, Professor Murphy confirmed experts believe the virus is contagious before people show symptoms. The update came after a meeting of the Australian Health Protection Principal committee (AHPPC). 'The committee is aware of very recent cases of coronavirus who are at the time of diagnosis asymptomatic or minimally symptomatic,' Professor Murphy said. 'We're also aware of one fairly convincing case of probable transmission from a pre-symptomatic case to other people two days prior to the onset of symptoms.' In a statement,5 the AHPPC said it still believes 'most infections are transmitted by people with symptomatic disease'. However, it said it was important to take a 'highly precautionary approach' and made two recommendations:
'AHPPC recognises that the evidence for pre-symptomatic transmission is currently limited, and this policy is highly precautionary,' the statement said.5 'At this time, the aim of this policy is containment of novel coronavirus and the prevention of person to person transmission within Australia.' Prime Minister Scott Morrison has also announced the Federal Government would try to evacuate about 600 isolated and vulnerable Australians registered as being in Hubei province in China for quarantine on Christmas Island.
- People who have been in contact with any confirmed novel coronavirus cases must be isolated in their home for 14 days following exposure;
- Returned travellers who have been in Hubei Province of China must be isolated in their home for 14 days after leaving Hubei Province, other than for seeking individual medical care.
What are the symptoms of a coronavirus infection?The most common symptom is a fever.2,6 Other symptoms include a cough, sore throat and shortness of breath. In more severe cases, infection can cause pneumonia with severe acute respiratory distress.2,6,7
Tips for preventionWhile confusion remains about transmission, other human coronavirus strains are spread from person to person through contaminated droplets from a person who is sick with the illness (through coughing or sneezing) or contaminated hands. It is likely this novel coronavirus spreads the same way.8 To minimise the risk of infection, NSW Health advises people8:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 9171 [post_author] => 23 [post_date] => 2020-01-14 15:49:56 [post_date_gmt] => 2020-01-14 05:49:56 [post_content] => Guidelines for stroke management have been updated. The time window for thrombolysis has been extended to 9 hours if brain imaging shows it will be of benefit, according to updates to the Stroke Foundation’s Clinical Guidelines for Stroke Management.1 And, in a strong recommendation approved by the National Health and Medical Research Council (NHMRC), aspirin and clopidogrel should be prescribed together for the first 3 weeks after a minor stroke or transient ischaemic attack (TIA). The Clinical Guidelines for Stroke Management are living guidelines, updated as new evidence emerges in accordance with the 2011 NHMRC Standard for clinical practice guidelines. The updated 2019 version — approved in November by the NHMRC — supersedes the Clinical Guidelines for Stroke Management 2017. Updates to thrombolysis recommendations include an extension of the time window to 9 hours with alteplase (including 9 hours from the mid-point of sleep for patients who wake with stroke symptoms). In a new weak recommendation, tenecteplase may be used as an alternative to alteplase for patients meeting specific eligibility criteria, in a time window of 4.5 hours.1 As the new generation thrombolytic tenecteplase is faster-acting than alteplase, the Director of Neurology at the Royal Melbourne Hospital (RMH), Professor Mark Parsons, told media outlets that, with the use of tenecteplase in an extended window, many patients could avoid the need for surgery.2 An RMH trial will test whether the time window for tenecteplase thrombolysis can be abandoned, and brain imaging (to check for salvageable healthy brain tissue) used to better predict who can still benefit from thrombolysis up to 24 hours after having a stroke.2 With one in five patients currently undergoing clot retrieval surgery, Prof Parsons said he hoped the RMH trial could increase treatment access so more patients achieved positive outcomes following a stroke.2 The recommendation for dual antiplatelet therapy with aspirin and clopidogrel for the first 3 weeks after a minor stroke or high-risk TIA is consistent with research reported in Australian Pharmacist.3 For patients without atrial fibrillation, dual antiplatelet therapy offers a small incremental benefit over monotherapy with aspirin with respect to stroke recurrence.3 Trials of antiplatelet therapy in secondary prevention of stroke have shown the use of monotherapy with aspirin (as soon as imaging has excluded intracerebral haemorrhage) significantly reduces the rate and severity of early recurrent stroke compared to placebo.3 Dual aspirin and clopidogrel therapy was found to reduce subsequent strokes by about 20 per 1,000 population, with an increase in bleeding of 2 per 1,000 population compared to aspirin monotherapy. The authors concluded that discontinuation of therapy within 21 days is likely to maximise benefit and minimise harm.3 However, the combination should not be used in severe stroke where haemorrhagic transformation can occur, and should not be used long-term unless patients have other indications.3 The expert working groups for the clinical guidelines concluded that other recommendations are up-to-date in the Clinical Guidelines for Stroke Management 2017. Recommendations remain unchanged for topics including acute blood pressure-lowering therapy, intracerebral haemorrhage management, anticoagulant therapy and pre-hospital care. A full list of new and updated recommendations, and unchanged recommendations, is available here.4 Pharmacists are integral to drug selection, dose adjustment and monitoring of drug therapy. Their role in secondary stroke prevention includes ensuring medication adherence, optimising blood pressure management, recommending step-down of dual antiplatelet therapy where appropriate, and consideration of gastroprotection in high-risk patients.3 References
[post_title] => Stroke management in 2020 [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => stroke-management-in-2020 [to_ping] => [pinged] => [post_modified] => 2020-01-14 15:49:56 [post_modified_gmt] => 2020-01-14 05:49:56 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=9171 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Stroke management in 2020 [title] => Stroke management in 2020 [href] => https://www.australianpharmacist.com.au/stroke-management-in-2020/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 8937 )
- Clinical guidelines for stroke management. Stroke Foundation. At: https://informme.org.au/Guidelines/Clinical-Guidelines-for-Stroke-Management
- O’Connell B. Doctors test clot treatment’s extended window. Courier Mail 2019 December 14.
- Barras M and Winckel K. Primary and secondary prevention of stroke. Australian Pharmacist. 2019;12:42–51.
- Living guidelines updates. Stroke Foundation.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 9094 [post_author] => 285 [post_date] => 2019-12-16 14:49:07 [post_date_gmt] => 2019-12-16 04:49:07 [post_content] => Adapted by Ann Winkle MPS. Regulatory bodies are warning of the potential for diabetic ketoacidosis (DKA) as a serious complication of sodium-glucose co-transporter 2 (SGLT2) inhibitor therapy, particularly in people who undergo surgical or medical procedures.1 Many patients presenting with SGLT2 inhibitor-induced DKA are euglycaemic, making it difficult to identify as blood glucose levels (BGLs) and ketone levels can be near normal.1
Case studyA 60-year old man was admitted to hospital for a bilateral hemi-knee replacement. His regular medicines were: [table id=6 /] Empagliflozin/metformin was ceased 3 days prior to surgery and recommenced the day after surgery while still an inpatient. Two days after the operation he became unwell with an increased respiratory rate. Pathology results [table id=7 /]
DiscussionSodium-glucose co-transporter 2 (SGLT2) inhibitors add to the armament for treating type 2 diabetes, with a mode of action that is independent of beta-cell function in the pancreas. They inhibit SGLT-2 proteins located in the renal tubules responsible for reabsorbing glucose back into the blood. As a result, more glucose is excreted in the urine. SGLT2 inhibitors carry a low risk of hypoglycaemia and are usually well tolerated. However, diabetic ketoacidosis (DKA), including euglycaemic DKA (euDKA), has emerged as a challenging adverse effect. One possible mechanism is that SGLT2 inhibitors blunt insulin production in the face of stress hormones leading to increased ketotic metabolism.2 DKA is an acute complication of diabetes in which ketone bodies build up in the blood. Early signs and symptoms, typically developed over 24 hours, include abdominal pain, nausea, vomiting, anorexia, excessive thirst, difficulty breathing, unusual fatigue and sleepiness. DKA typically presents with high glucose levels, however, atypical euDKA may occur at lower levels. If DKA is not diagnosed early and treatment initiated more serious signs and symptoms including dehydration, deep gasping breathing, confusion and coma can develop.1 The TGA has received reports of DKA, including euDKA, associated with surgical or medical procedures requiring anaesthesia or light sedation, including cardiovascular, bariatric, orthopaedic or gastrointestinal procedures.1 DKA has also been linked to the pre- and post-surgical use of SGLT2 inhibitors (empagliflozin, dapagliflozin) in major surgery since their introduction into Australia. From March 2018 to August 2019, the TGA received a total of 219 reports of DKA (or metabolic acidosis) where empagliflozin or dapagliflozin were the suspected causative medicine. Reports include cases of SGLT2 inhibitors prescribed outside their licensed indication for type 1 diabetes.1 Other DKA risk factors are infections, gastrointestinal conditions, cardiovascular conditions, dehydration, malnourishment/reduced calorie intake and non-adherence with insulin or reductions in insulin dose.1 The clinical chemistry features of euDKA include2:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 8904 [post_author] => 27 [post_date] => 2019-12-10 10:52:26 [post_date_gmt] => 2019-12-10 00:52:26 [post_content] => The manufactured chemical 2,4-Dinitrophenol has been used in herbicides, dyes, explosives and as a photographic developer. Also, highly effective in weight loss, its toxic effects are easily fatal. The effects of 2,4-Dinitrophenol (2,4-DNP), which can be ingested, inhaled or absorbed through the skin, were first noticed in workers in ammunition and dye factories in France and the United States during World War 1.1 Thirty-six people died in France between 1916 and 1918 and another 27 died in the US over the same period. But after a 1933 research paper by Stanford University doctors,2 2,4-DNP became a popular weight loss drug. Hundreds of thousands of people used or were treated with it between 1933 and 19383 when it was restricted from sale or prescription for weight loss by the forerunner of the current Food & Drug Administration, primarily due to increased likelihood of cataract development.1 Anecdotally, it was reported to have been prescribed during World War II to keep Russian soldiers warm.4,7 Since the late 1990s, when 2,4-DNP was promoted as a ‘fat burner’ there has been renewed interest among body builders and those with eating disorders including bulimia and anorexia.3,5 At least 10 people have died since 2015 in the United Kingdom from 2,4-DNP poisoning amid media reports about prosecutions for distribution and user deaths.7 In Adelaide in 2015, a young woman joined the Australian death toll after taking 50 tablets of an unspecified strength.5
Mechanism of ActionIts exact mechanism of action is still under study8 but in the body it acts as a proton ionophore, crossing over the mitochondrial wall, lowering the ability of cells to generate energy through ATP (adenosine triphosphate) synthase. Energy generated by ATP synthase is lost as heat and, in order to keep up with demand for energy, cells respond by drawing on fat reserves, increasing metabolic rate. 2,4-DNP is acutely toxic with fatal doses as low as 4.3 mg/kg reported.4 Symptoms of overdose include sweating, nausea, headache and hyperthermia. Effects of long-term exposure in addition to cataracts are liver and kidney damage.4
Use in AustraliaIn Australia all dinitrophenols were listed as Schedule 1 dangerous drugs in 1956.5 Since the late 1990s, 2,4-DNP, discussed in internet weight loss and bodybuilding forums, has been sold by internet retailers in drug mixtures known as ‘shredders’ or ‘shudder drugs’.9 In February 2017 the Therapeutic Goods Administration listed it as a Schedule 10 drug – so dangerous to humans it is prohibited from sale, supply or use.5 This year the NSW Department of Health warned against its use, citing several deaths locally and overseas.9 Despite official warnings, fatalities and no known antidote, the drug has other legitimate uses and large quantities can be bought online or from hidden sites on the ‘dark web’.4,7 References:
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- Environmental Protection Agency. Provisional Peer Reviewed Toxicity Values for 2,4-Dinitrophenol. Cincinnati; 2007. At: https://cfpub.epa.gov/ncea/pprtv/documents/Dinitrophenol24.pdf
- Cutting WC, Mehrtens HG, Tainter ML. Actions and uses of dinitrophenol promising metabolic applications. JAMA 1933;101(3):193–195. At: https://jamanetwork.com/journals/jama/fullarticle/244026
- Bleasdale EE, Thrower SN, Petróczi A. Would you use it with a seal of approval? Important attributes of 2,4-Dinitrophenol (2,4-DNP) as a hypothetical pharmaceutical product.’ Front Psychiatry 2018;9(124). At: www.ncbi.nlm.nih.gov/pubmed/29731723
- Grundlingh, J. Dargan,P. El-Zanfaly, M. Wood, D. 2,4-Dinitrophenol (DNP): a weight loss agent with significant acute toxicity and risk of death. J Med Toxicology : Official Journal of the American College of Medical Toxicol 2011;7(3):205–12. At: www.ncbi.nlm.nih.gov/pmc/articles/PMC3550200/
- Therapeutic Goods Administration. Scheduling delegate's interim decisions and invitation for further comment: ACCS/ACMS, July 2016: Schedule 10: New entry –2,4-DINITROPHENOL for human use. At: tga.gov.au/book-page/13-24-dinitrophenol
- Haynes G. The Killer Weight Loss Drug DNP Is Still Claiming Young Lives. Vice, Aug 6, 2018. At vice.com/en_uk/article/bjbyw5/the-killer-weight-loss-drug-dnp-is-still-claiming-young-lives
- DNP: The pills used by slimmers and bodybuilders. June 27, 2018. At: www.bbc.com/news/uk-england-44388389
- Busiello, R. Savarese, S. Lombardi, A. Mitochondrial uncoupling proteins and energy metabolism. Front Physiol 2015. Epub 2015 Feb 10. At: www.ncbi.nlm.nih.gov/pubmed/25713540
- NSW Health. Toxic chemical in some weight loss products. 31 Aug 2019. At: www.health.nsw.gov.au/news/Pages/20180831_00.aspx
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Jack, 17, has been coming to your pharmacy with prescriptions for a topical retinoid for the last 12 months and, in the last few months, prescriptions for doxycycline. Today he has brought in a prescription for oral isotretinoin, to be taken instead of his doxycycline, as his acne is still severe and has not improved. He has heard that this is a very potent drug with some serious adverse effects including depression and is concerned about having to take it.
How would you counsel Jack?
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Acne vulgaris is an inflammatory disease of the pilosebaceous follicles of the skin with clinical features of comedones (blackheads are open comedones, whiteheads are closed comedones), papules, pustules, and in severe cases, nodules and cysts1 (see Figures 1–4). Acne is a common disease affecting about 85% of teenagers with onset at puberty and resolution in most people in their early 20s,3 but it can persist into adulthood, more commonly in women. Acne can have profound effects on self-esteem, self-image and wellbeing, patients with acne have been shown to have an increased risk of depression and suicide attempts.4
Treatment of mild acne with topical products such as benzoyl peroxide, topical retinoids, topical antibiotics and combinations of these, has been discussed previously (Topical management of acne, Australian Pharmacist, December 2019).5 In this article the management of moderate and severe acne with systemic treatments will be explored.
Acne may be mild, moderate or severe6:
Acne lesions may be non-inflammatory (open and closed comedones), inflammatory (pustules, red papules, nodules and cysts) or resolving (macules or scars).6
Four main factors contribute to the condition7:
Certain drugs, including androgens, corticosteroids, hormonal contraceptives containing androgenic progestogens (e.g. higher doses of levonorgestrel), isoniazid and lithium may produce an acneiform rash as may substances such as tars, oils and oily cosmetics.8
There is no evidence that fatty foods and chocolate affect acne, although there is emerging data that suggests that a diet consisting mainly of high glycaemic index foods may aggravate acne.9 A balanced, healthy diet should be encouraged. Acne is not caused by a hormone imbalance in the majority of people. Most people with acne have normal hormone levels, but their skin is more sensitive to the hormones. Acne is only related to a hormone imbalance in a minority of individuals.6
There is no evidence that poor hygiene causes acne and washing the face more frequently does not improve the condition.6 Washing the face twice a day with a gentle, soap-free, pH-balanced cleansing agent is all that is required. It should be stressed that harsh soaps and vigorous scrubbing and exfoliating should be avoided as this is more likely to cause dryness and irritation to the skin.
Oily skin products and heavy, greasy cosmetics should be avoided as they can make acne worse. Water-based non-comedogenic cosmetics and sunscreens should be used to minimise the drying effects of treatments.
There is no evidence that poor hygiene causes acne and washing the face more frequently does not improve the condition.6 Washing the face twice a day with a gentle, soap-free, pH-balanced cleansing agent is all that is required. It should be stressed that harsh soaps and vigorous scrubbing and exfoliating should be avoided as this is more likely to cause dryness and irritation to the skin.
Oily skin products and heavy, greasy cosmetics should be avoided as they can make acne worse. Water-based non-comedogenic cosmetics and sunscreens should be used to minimise the drying effects of treatments.
Systemic treatments consist of oral antibiotics, the oral contraceptive pill, spironolactone and oral isotretinoin. They are used when topical agents are ineffective and when the lesions are more widespread and become more papular, nodular, pustular and cystic. (See Figure 5, next page.)
Initial treatment for moderate to severe acne recommended by Australian guidelines is an oral antibiotic which is used for its anti-inflammatory action.6
Oral therapy should be started in combination with a topical retinoid or a topical combination of retinoid plus benzoyl peroxide.
Doxycycline at a dose of 50–100 mg daily in the morning is the first choice and minocycline 50–100 mg is used if doxycycline is not tolerated.
If tetracyclines are not tolerated or are contraindicated (e.g. in pregnancy), erythromycin 250–500 mg orally, twice daily or erythromycin ethyl succinate 400–800 mg twice daily for 6 weeks is used.6
Treatment is started with the lower dose of antibiotic in smaller patients or to check tolerability. With increasing concerns of antibiotic resistance there is a trend to use shorter courses, usually 3 to 6 months of treatment. Using antibiotics with benzoyl peroxide can reduce bacterial resistance.
If the acne has not responded after 6 weeks:
The COCP is an alternative to antibiotics in teenage girls and women with moderate to severe acne.6
COCPs most likely to improve acne contain cyproterone. If a cyproterone containing COCP is not tolerated (e.g. weight gain, adverse effect on mood), switch to a COCP containing drospirenone, desogestrel or gestodene.6
A 6-month trial is recommended as the benefit may not be apparent for 3 months. If the response to a COCP is insufficient after 6 months, an oral antibiotic can be added or spironolactone can be added or substituted. Alternatively, the patient can be referred to a specialist for oral isotretinoin.6
Spironolactone has antiandrogenic and diuretic properties. It is used to treat acne in female patients when a COCP is contraindicated, not desired or not tolerated or when it is not sufficient as monotherapy.
Spironolactone is contraindicated in pregnancy because of the risk of defective virilisation of the male foetus. Pregnancy must be excluded and effective contraception in place prior to commencing treatment. When a COCP alone has not been sufficiently effective, adding spironolactone at a dose of 25–50 mg daily and increasing gradually to 50–100 mg daily as tolerated can enhance the benefit. Any well-tolerated COCP can be chosen as the choice of progestin does not matter in this situation. The COCP also provides reliable contraception and minimises adverse effects of spironolactone.6
Adverse effects of spironolactone include irregular menstrual bleeding and spotting and breast tenderness. Blood pressure, kidney function and liver biochemistry should be checked before starting spironolactone, and every 6 months thereafter during treatment.6 Spironolactone is well tolerated in younger women but should be used with care in older women who have kidney impairment or are taking angiotensin converting enzyme inhibitors or angiotensin II blockers.
Oral isotretinoin is the treatment of choice for acne that6:
Isotretinoin inhibits sebaceous gland function and keratinisation. The decrease in sebum secretion is reversible and the extent is related to the dose and duration of treatment.11
Because oral isotretinoin is a potent teratogen, prescribing is restricted to dermatologists and other authorised medical practitioners (contact relevant state/territory health departments).
Initial dose is 0.5 mg/kg/day as a single dose or in two divided doses with food. Dosage may be increased to 1 mg/kg after 4 weeks according to response and tolerance. To reduce the risk of relapse, treatment should be continued until the total cumulative dose is 120–150 mg/kg.10
A single course of 4–9 months usually brings prolonged remission in most patients. Some people may need more than one course which should be initiated after an 8 week drug free period as patients may continue to improve while off drug.
Most adverse effects resemble excess vitamin A intake and are generally dose-related.
Common adverse effects: dry skin, lips, mucous membranes and eyes, lethargy, myalgia and joint stiffness.11
Rare adverse effects: dyslipidaemia, pancreatitis, hepatitis, rectal bleeding, tinnitus, severe skin reactions and benign intracranial hypertension.11
Evidence for an association between oral isotretinoin and psychiatric disorders of depression and suicide is conflicting.10 Mood often improves as acne improves; patients can be treated for depression and acne at the same time. However, it is wise to counsel patients and monitor for psychological symptoms.10
The following advice should be given to patients who are dispensed oral retinoids:
Laser and light-based therapies have been increasingly used over the past few years. Light therapy, in the form of blue light and blue and red light is thought to target Cutibacterium acnes. However, treatment with this technique has produced inconsistent results.1 Any long-term adverse effects of these therapies have still not been determined.
Chemical peels using salicylic acid and glycolic acid are available as an adjuvant treatment for acne affecting the face. Chemical peels improve acne by minimising the abnormal pattern of keratinisation. It causes desquamation which reduces keratinocyte blockage, allowing the promotion of normal epidermal differentiation. However, this requires multiple treatments to be efficacious which is costly and can have adverse effects of redness and irritation.6
Resurfacing with fractional laser therapy is one method used to treat residual acne scarring which occurs in the more severe forms of acne.1
Acne is a common complaint in the community and pharmacists play a crucial role in the management of this condition. Identification of mild, moderate and severe acne and knowing when to refer is important. Ensuring that patients understand how to use or take their medicines, avoiding interactions and managing adverse reactions is all part of patient care and will contribute to compliance and a successful treatment outcome.
Case scenario continued
You reassure Jack that serious adverse effects of oral isotretinoin are rare and that evidence for isotretinoin causing depression is conflicting. You advise Jack that if he does notice a low mood, he should see his doctor without delay. You also let Jack know that his acne could possibly get worse in the first few weeks before he notices any significant improvement.
You discuss the other adverse effects of isotretinoin with Jack and advise him to take his capsules with food. You review a copy of the CMI with him, pointing out important information such as avoiding the tetracycline antibiotics and topical anti-acne preparations that he has been using. You advise him to continue to use lip balm and moisturiser for any dryness that may occur as well as sun protection if going outdoors. You tell him that, in the unlikely event that he gets any headaches, nausea, visual changes or loss of night vision, to see his doctor promptly. You also advise him not to donate blood whilst being treated with isotretinoin as it may be given to a pregnant woman and subsequently cause a birth defect.12
You reiterate to Jack that before starting his new isotretinoin capsules, he needs to stop his current antibiotics and cream.
Morna Falkland BPharm, MSHP was formerly the Medicines Information Pharmacist at The Canberra Hospital and contributes to Australian pharmacy journals.[post_title] => Systemic treatment options for acne [post_excerpt] => Acne is a common disease affecting about 85% of teenagers with onset at puberty and resolution in most people in their early 20s, but it can persist into adulthood, more commonly in women. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => systemic-treatment-options-for-acne [to_ping] => [pinged] => [post_modified] => 2020-02-12 16:23:50 [post_modified_gmt] => 2020-02-12 06:23:50 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=9331 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Systemic treatment options for acne [title] => Systemic treatment options for acne [href] => https://www.australianpharmacist.com.au/systemic-treatment-options-for-acne/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 9332 )
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One of the worst influenza seasons on record was in 2019, with over 308,000 confirmed cases of influenza in Australia.1 It was atypical, with the season hitting early and maintaining through the warmer months.1Immunisation rates increased from an estimated 11 million2 in 2018 to 13 million in 2019.3 Pharmacists played a significant role in this increase, doubling immunisations delivered in community pharmacy from an estimated 1 million in 20182 to 2 million in 2019.3 Pharmacists can increase the provision of immunisation in adults and expand the service to children 10 years and older.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
In Australia, influenza is a considerable burden, particularly in 2019 (see Table 1, opposite and Table 2 and Figure 1); over 800 Australians died as a result of influenza.4
Preparation is key in ensuring you are ready for the 2020 flu season.
Access to stock at the right time can be critical. In 2019 a manufacturer took drastic action by sourcing overseas-approved influenza vaccines and fast tracking it through the Therapeutic Goods Administration (TGA) due to stock shortages in Australia.5
Manufacturing of the influenza vaccines can take at least 6 months from identification of required influenza strains to production.6 Determination of strains to be included can change from year to year and is dependent on the World Health Organization (WHO) advice for the southern hemisphere and the Australian Influenza Vaccine Committee (AIVC).7 Planning and predicting volumes are further complicated due to the nature of the vaccine manufacturing process with manufacturers needing to look at least 2 years into the future in terms of predicting market volumes.
The best way to secure stock is early communication and commitment to manufacturers for your pharmacy supply. Ensuring adequate stock supply will help enable widespread vaccination, leading to herd immunity within the community.
One strategy is to analyse figures from the previous years and then add on a growth percentage. Have a plan to increase immunisation numbers and commit to it. Community pharmacy doubled its reach from 2018 to 2019. With this in mind, it’s not unreasonable to look at what resources would be required to at least double your year-on-year numbers for 2020. If coverage rates of the most at-risk adults is at less than 63%,8 pharmacists have a tremendous opportunity and obligation to address this.
Australia has one of the best wholesaling systems in the world that is supported by a generously funded Community Service Obligation (offers financial support to wholesalers to ensure supply of a full range of PBS medicines).9 Relying on ad hoc orders for your supply is a risk, with volume taken up by those who have made prior commitments to manufacturers.
Although complex and multifaceted factors are involved, availability of ample stock during peak season, as well as access to stock during shoulder peak, will enable a successful pharmacy immunisation program. Failure to plan can result in a missed opportunity and lower immunisation rates, potentially putting the community at risk.
Fridge space, maintaining cold chain and ‘strive for 5’ principles10 also need to be considered; staggered delivery of vaccines may solve some storage issues but is not always feasible. Many pharmacies will need to rationalise space during peak immunisation season and consider extra storage solutions.
You want to be able to maximise the opportunistic immunisations and make a walk-in patient and booked patient feel as though they are cared for, are always moving in the right direction, and your pharmacy is a destination for health services. Great systems can help to ensure consistent experience.
Clinically, your entire team needs to know the benefits of immunisation and the appropriate approach for patients, families and carers who may be vaccine-hesitant.
Discussion around vaccine hesitancy needs to be handled respectfully and empathetically to ensure patients leave more informed, unthreatened and comfortable to return. It’s important to listen to and acknowledge the concerns of patients and carers. This not only fosters a higher level of trust, it has been shown to be an effective approach, particularly for patients unsure of immunisation benefits.12
Ensure all pharmacists are immunisation trained, this includes interns for states where they can immunise under supervision such as QLD, NSW, ACT and WA. The future of the profession will see all pharmacists graduating with medication administration accreditation as pharmacy schools embed this into their degrees via Australian Pharmacy Council (APC) standards.13 In the meantime, ‘retrofitting’ of the profession with immunisation courses will need to continue.
Almost all state jurisdictions require relevant yearly immunisation CPD to be undertaken as well as holding a current first aid/CPR certification.14-21 It’s also suggested to ensure that you routinely revise the Australasian Society of Clinical Immunology and Allergy (ASCIA) guidelines22 that now form part of the immunisation training.
Case reports of shoulder injury related to vaccine administration (SIRVA) each year (see Box 1) provide a timely reminder to review your technique regularly. Diagrams in the immunisation handbook (https://immunisationhandbook.health.gov.au/resources/publications/avoiding-shoulder-injury-related-to-vaccine-administration) are quite helpful for immunisers across all levels of experience.23
If you do notice a patient with SIRVA, as with all adverse events following immunisation (AEFI), it’s important to report it to your state health departments.
AFEI reporting numbers:
Shoulder injury related to vaccine administration (SIRVA) is a rare complication of incorrect vaccine administration, when the vaccine is given too high into the shoulder joint. This can cause shoulder pain and restricted range of movement.
SIRVA can result from bursitis, tendinitis and rotator cuﬀ tears. Bursitis is the most commonly reported diagnosis on ultrasound. Symptoms often begin at the time of injection and can last from weeks to years.
Both the legislative space and vaccine- preventable disease space are rapidly changing and evolving. As immunisers it’s important to be cognisant of the changes in recommendations for immunisations.
The following resources are strongly recommended:
Despite ever-improving access to immunisation, and growing immunisation rates, influenza remains a common cause of hospitalisation and death in Australia.28
The main complications leading to hospitalisation and death include pneumonia, myocarditis and neurological complications.28
Influenza immunisation is regarded as one of best tolerated immunisations, with the only absolute contraindications to influenza vaccines being anaphylaxis after a previous dose of any influenza vaccine or anaphylaxis due to any component of the influenza vaccine (see Box 2).28
The majority of confirmed influenza cases in Australia in 2019 were influenza A (76.9%).29
With quadrivalent vaccines containing two A strains (H1N1 and H3N2) and two B strains (Yamagata and Victoria linages), it’s important to know how well matched the vaccine was to the circulating strains. While as immunisers we can’t influence the choice, it’s helpful to know some of the detail around why some people may still contract influenza when they have been vaccinated.
One explanation is not only does it take, on average, 2 weeks for influenza immunisation to become effective, the vaccine match and effectiveness typically ranges from 40–60% each year.28 This means even when we get the match correct, it doesn’t completely remove the risk of contracting influenza. This is particularly important in the over 65 population. Immunosenescence30 reduces the immunogenic response even further in these populations and is the key reason for the introduction of adjuvanted and high dose influenza vaccinations for over 65s in the 2019 season.
Thankfully even for low matching years, the vaccine does decrease secondary complications and hence there are still reductions in morbidity and mortality for immunised individuals.28
As with every year, the Australian Influenza Vaccine Committee (AIVC)8 takes local antigenic and epidemiological data as well as WHO recommendations for the southern hemisphere.31 In 2020, three of the four strains have been changed to match the predicted circulating strains.
The recommended influenza viruses for influenza vaccines for the Australian 2020 season are32:
In 2020 there are also some important changes in the ARTG approvals for the 5 different brands that are relevant to all immunisers (see Table 3).
With the continuous extension of the age pharmacists can immunise across the country (see Table 4), its important to keep abreast of any changes as they occur.
While NIP is only available in Western Australian, Australian Capital Territory and Victorian pharmacies, the private market is the ‘community pharmacy market’; 12–20% of patients still chose pharmacy although they were eligible for free vaccination from the NIP.39-41
Annual vaccination is recommended before the onset of each influenza season. Optimal protection against influenza occurs after two weeks and continues for the first 3 to 4 months following vaccination. Protection is generally expected to last for the whole season, particularly for the younger, 10–64-year-old population, and the over 65s who have received an enhanced quadrivalent influenza vaccination.28
With the period of peak influenza circulation for the majority of Australia occurring from June to September, April is an opportune month for immunisation to commence. In saying that, it is never too late to vaccinate since influenza can circulate all year round.
In some subsets of the population, such as pregnancy, it’s also never too early in the season to vaccinate.28 The recommendations are to immunise with the prior year’s vaccine up until February or as soon as the new year’s vaccine has arrived, usually mid-March.
Vaccination should continue to be offered as long as influenza viruses are circulating and a valid vaccine (before expiration date) is available.28
It’s also important to note that receiving a second vaccination in a season is not contraindicated, indeed Australians travelling during the Northern Hemisphere influenza season are strongly recommended to receive the current Australian influenza vaccine two weeks prior to leaving.28
Those who have already received a current Southern Hemisphere influenza vaccine and are travelling later in the year to the Northern Hemisphere are recommended to receive a second dose of influenza vaccine within the same year.28
The best way to manage consumer expectation is a clear flow of communication. Consumers need to know that no vaccine is 100% effective and it may take about 2 weeks to develop immunity following vaccination. The virus’ ability to change and mutate means that while it’s the most effective form of prevention, other measures such as hand hygiene and avoiding crowded areas when unwell, can all reduce transmission.
Antivirals such as oseltamivir can be used for institutional outbreak control as an adjunct to other measures. Ideally, it should be started within 24 hours after the onset of symptoms.42
Counselling on adverse effects such as sore arm and flu-like symptoms is important, as well as ensuring consumers notify the pharmacist of any adverse effects following immunisation.
Immunisation services have now become a staple in the community pharmacy landscape in Australia.
It’s important not only to continue to grow your current influenza patient base, but to ensure opportunistic immunisations continue to occur across all vaccine-preventable diseases, particularly those that can be provided by pharmacist outlined in Table 3.
Focusing on continuous improvement of your systems, your marketing reach, your booking process and patient recall will not only provide a lift in terms of profitability from the service, more importantly your role in running an efficient, growing immunisation service will continue to have considerable public health benefits for years to come.
Chris Campbell BPharm, MPS is PSA’s Queensland Branch President, the Professional Practice manager at TerryWhite Chemmart, a Visiting Fellow at Queensland University of Technology and an Adjunct Senior Lecturer at the University of Queensland.References
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Case scenarioHarold, a 68–year–old man who regularly visits your pharmacy, has come in today to have a new prescription dispensed for isosorbide mononitrate controlled–release 60 mg tablets (one daily) for recent episodes of angina. Harold isn’t happy. He tells you his wife and his GP want him to quit smoking because of his heart. However, when he has tried to quit in the past it was too hard, he believes it is because he has been smoking for too long. He has a 40 pack–year history. Harold knows smoking isn’t good for his health and would like to stop but finds the habit too hard to break. When counselling him on his prescription, what advice would you give to encourage him to consider quitting smoking again?
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Figure 2 – Benefits of quitting20 MINUTES Resting heart rate reduces– which is a key indicator of overall fitness level 12 HOURS The carbon monoxide in the blood reduces dramatically which improves oxygen levels 2–12 WEEKS The risk of heart attack begins to reduce and blood circulation improves. Lung function improves as well, making it much easier to exercise 1– 9 MONTHS Coughing, wheezing and breathing problems reduce as lung function continues to improve 1 YEAR The risk of heart attack reduces by half 5 YEARS The risk of stroke reduces to that of a non-smoker 5–15 years after quitting 10-15 YEARS The risk of heart attack reduces to that of someone who has never smoked before. The risk of lung cancer reduces to about half of that of a smoker Reference: WHO9
Case scenario continuedAssure Harold that evidence shows that stopping smoking can be done, even with his long-term high dependency. Explain the health benefits of quitting, especially the cardiovascular benefits, and offer him the WHO fact sheet: https://who.int/tobacco/quitting/benefits/en/ Discuss NRT with Harold. Considering his high dependency, suggest a combination of a nicotine patch and a short-acting preparation of his preference. Refer to appropriate references and ensure his dose is adequate. He could see his GP for a nicotine patch, which is available on the PBS. Refer him to Quitline. Offer your support throughout the quitting journey and ask him to return in 2 weeks to see how he is going.
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Case scenarioYou have been asked to perform a home medicines review (HMR) for Jack. Jack is an 82-year-old man who had an ischaemic stroke 3 weeks ago and is having his medicines reviewed by you as part of his HMR. He has a past medical history of hypertension and was prescribed atenolol prior to his stroke. He has no allergies nor other comorbidities. He has had a few dizzy spells recently and his blood pressure is on the low side. He tells you he has otherwise recovered well from his stroke and is currently taking:
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
|MODIFIABLE RISK FACTOR||STROKE DEATHS (%)||TYPE OF STROKE MOST LIKELY CAUSED||FIRST-LINE TREATMENTS|
|Hypertension||28||I or H||ACEI, CCBs|
|Carotid artery stenosis||Unclear||I||Antiplatelets, Statins|
|Current tobacco use||Unclear||I or H||NRT, buproprion, varenicline|
|Diabetes||Unclear||I||Metformin, SGLT2 Inhibitors|
|Poor diet||Unclear||I or H||Non-drug treatments preferred|
|Physical inactivity||Unclear||I||Non-drug treatments preferred|
|Increase in waist to hip ratio||Unclear||I or H||Non-drug treatments preferred|
|Excessive alcohol||Unclear||I or H||Non-drug treatments preferred|
BOX 1 – STRATEGIES TO REDUCE BLEEDING
|Mechanism||Vitamin K antagonist||Factor Xa inhibitor||Factor Xa inhibitor||Direct thrombin inhibitor|
|Dosing frequency||Daily||Twice daily||Daily||Twice daily|
|Oral bioavailability (%)||100||50||>80||6.5*|
|% excreted unchanged in urine||0||34||36||85|
|Half-life in healthy volunteers (hours)||Highly variable 20-60||12||5-15 (mean=7)||13.4|
|Potential for drug interactions||CYP2C9, CYP1A2, CYP3A4 plus many others||PGP, CYP3A4||PGP, CYP3A4||PGP, PPIs|
|Antidote||Vitamin K (phytomenadione)||Andexanet alfa||Andexanet alfa||Idarucizumab|
|TRIAL||TRIAL TYPE||PATIENTS||STUDY LOCATION||DURATION (YEARS)||HR FOR ALL-CAUSE MORTALITY (95% CI)||HR FOR STROKE (95% CI)||HR FOR BLEEDING (95% CI)|
|ASPREE||Double blind placebo controlled RCT||n = 19,114||Australia/US||Median follow up 4.7||1.14* (1.01–1.29), NS||0.89 (0.71–1.11), NS||1.38* (1.18–1.62), P<0.001|
|ARRIVE||Double blind placebo controlled RCT||n = 12,546||Mainly Germany/UK||Median follow up 5||0.99 (0.80– 1.24), NS||1.12* (0.80–1.55), NS||2.11* (1.36–3.28), p=0·0007|
|ASCEND||Double blind placebo controlled RCT||n = 15,480||UK||Mean follow up 7.4||0.94 (0.85– 1.04), NS||1.12* (0.70–1.77), NS||1.29* (1.09–1.52), p=0.003|
|ATT||n = 40,821 with acute IS||Any antiplatelet||Placebo||11% RRR composite of IS/MI/death in patients with acute stroke||P= 0.00002|
|ATT||n = 23,020 with prior IS/TIA||Any antiplatelet||Placebo||22% RRR composite of IS/MI/death for long term secondary prevention||P=0.0003|
|ESPS-2||n = 6,602 with prior IS/TIA||Aspirin with dipyridamole (A+D)||Either drug alone or placebo||18% RRR IS, aspirin vs placebo 37% RRR IS, (A+D) v placebo||P=0.013 P<0.001|
|CAPRIE||n = 12,033 with prior IS||Clopidogrel||Aspirin||7% RRR in composite outcome of any stroke /MI/ death from any cause 8.7% RRR in IS, MI or vascular death||P=0.26 P=0.043|
|SOCRATES||n = 13,199 with IS/TIA||Ticagrelor||Aspirin||11% RRR in composite outcome of IS/MI/death 14% RRR stroke||P = 0.07 P = 0.046|
|DUAL ANTIPLATELET THERAPY|
|ESPIRIT||n = 2,739 with prior IS/TIA||Aspirin with dipyridamole (A+D)||Aspirin||20% RRR in a composite of CV death non-fatal stroke, non-fatal MI, bleeding complication 16% RRR in IS||p-value not stated 95% CI 0.66–0.98 p-value not stated 95% CI (0.64-1.10)|
|ESPS-2||n = 6,602 with prior IS/TIA||Aspirin with dipyridamole||Either drug alone or placebo||18% RRR IS Aspirin vs placebo 37% RRR IS (A+D) v placebo||P = 0.013 P<0.001|
|PROFESS||n = 20,332 with IS||Aspirin with dipyridamole||Clopidogrel||No difference in recurrent IS (HR = 1.01)||P value not stated 95% CI (0.92-1.11)|
|MATCH||n = 7,599 with IS/TIA||Aspirin with clopidogrel||Clopidogrel||No difference in IS (HR = 1.00) 6.4% RRR in composite end point of IS, MI, vascular death or rehospitalisation for ischemic events||P value not stated 95% CI (-4.6% to 16.3%)|
|CHANCE||n = 5,170 with IS/TIA||Aspirin with clopidogrel||Aspirin||32% RRR in IS (8.2% vs 11.7%) after 90 days||P<0.001|
|POINT||n = 4,881 with stroke or TIA||Aspirin with clopidogrel||Aspirin||25% RRR in IS (5% vs 6.5%) after 90 days||P = 0.02|
|TRIPLE ANTIPLATELET THERAPY|
|TARDIS||n = 3,096 with IS/ TIA||Aspirin + Dipyridamole + clopidogrel||Clopidogrel OR Aspirin + Dipyridamole||RRR=10% but stopped early due to significantly increased risk of bleeding (RRI 154%)||P = 0.47 P = 0.0001|
Case scenario continuedAs part of your HMR, you confirm that Jack does not suffer from AF. He tells you that he often forgets to take his tablets, which hasn’t been an issue in the past. You are concerned that Jack’s dizzy spells and low blood pressure may result in syncopal episodes. In your recommendation to his doctor, you suggest that Jack down titrates and ceases his atenolol. You recommend that he continues taking clopidogrel 75 mg daily and atorvastatin 40 mg daily, with a potential consideration to increase atorvastatin to 80 mg daily if tolerated. BP, lipid levels, U+Es and LFTs should be monitored routinely. Jack should be provided with both verbal and written education. Jack may have some cognitive deficit as a result of his stroke. He may benefit from a dose administration aid. You advise him that, should he wish, this can be organised for him. Jack feels that this may help him remember to take his tablets and thanks you for your time.
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IntroductionHypertension is a significant burden on the Australian healthcare system. In 2017 to 2018, close to 6.3 million adult Australians reported having measured high blood pressure (BP), hypertension as a medical condition or the use of antihypertensive medicines.1
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
BOX 1 – PARAMETERS FOR ABSOLUTE CARDIOVASCULAR RISK CALCULATION
|DIAGNOSTIC CATEGORY*||SYSTOLIC (mmHg)||DIASTOLIC (mmHg)|
|Grade 1 (mild) hypertension||140–159||and/or||90–99|
|Grade 2 (moderate) hypertension||160–179||and/or||100–109|
|Grade 3 (severe) hypertension||≥180||and/or||≥110|
|Isolated systolic hypertension||>140||and||<90|
|CLASS||PHARMACODYNAMICS||PLACE IN CLINICAL PRACTICE|
||Reduce blood pressure by reducing vasoconstriction, sodium reabsorption and aldosterone release through inhibition of conversion of angiotensin-1 to angiotensin-2, and subsequent reduction of angiotensin-2-induced effects.14 ACE inhibitors also inhibit the breakdown of bradykinin, commonly resulting in a persistent dry cough.14||ACE inhibitors are considered a suitable first-line option for the treatment of hypertension that is uncomplicated by other co-morbidities.3 ACE inhibitors (or ARBs) are recommended as first-line hypertension therapy in patients with chronic kidney disease (CKD) with micro or macro albuminuria.3 ACE inhibitors are recommended for secondary prevention of ischaemic heart disease (IHD) in patients with certain concurrent indications, including hypertension.32 ACE inhibitors are recommended in patients with heart failure (HF) with reduced left ventricular ejection fraction (LVEF), in order to reduce mortality and hospitalisation.33|
||Reduce blood pressure by reducing vasoconstriction, sodium reabsorption and aldosterone release through competitive antagonism of type 1 angiotensin-2 receptors, and subsequent reduction of angiotensin-2-induced effects.14 ARBs do not inhibit bradykinin breakdown and are therefore often used as an alternative to ACE inhibitors if a patient experiences a persistent, dry cough with ACE inhibitor therapy.14||ARBs are considered a suitable first-line option for the treatment of hypertension that is uncomplicated by other co-morbidities.3 ARBs (or ACE inhibitors) are recommended as first-line hypertension therapy in patients with CKD with micro or macro albuminuria.3 ARBs are inferior to ACE inhibitors in the prevention of IHD,22 and in reduction of mortality in patients with HF.34 However, it is reasonable to use ARBs instead of ACE inhibitors in this population if there is an intolerance to ACE inhibitors (caution in angioedema).3,14|
||Induce diuresis via inhibition of sodium and chloride reabsorption in the distal convoluted tubule of the nephron, with additional increased potassium excretion.14 Antihypertensive effects at low doses are hypothesised to be the result of various direct and indirect vasodilatory actions, with no clear consensus for the mechanism thiazide-induced vasodilation.35||Thiazide (and thiazide-related) diuretics are considered a suitable first-line option for treatment of hypertension that is uncomplicated by other comorbidities.3 However, thiazide diuretics are associated with an increased risk of diabetes onset, requiring careful consideration of this risk against the benefit gained from managing hypertension in the context of patient age.3,36 In practice, thiazide diuretics do not often end up being first-line agents in treating hypertension in co-morbid conditions such as CKD, IHD, HF and atrial fibrillation. This is due to the preference of other agents (such as ACE inhibitors, ARBs and beta blockers) for the treatment and secondary prevention of the co-morbid condition.3,32,33,37|
|Calcium channel blockers
||Reduce blood pressure by reduction of peripheral vascular resistance through reduction of calcium influx into smooth muscle.14 This effect is seen in arteriolar smooth muscle with dihydropyridine calcium channel blockers, and, to a lesser extent, diltiazem.14 Non-dihydropyridine calcium channel blockers (diltiazem and verapamil) also have this effect on cardiac smooth muscle, resulting in; reduction of heart rate, cardiac contractility, myocardial oxygen requirements and angina symptoms.14||Calcium channel blockers are considered a suitable first-line option for the treatment of hypertension that is uncomplicated by other co-morbidities.3 The combination of calcium channel blockers with ACE inhibitors is superior to either ACE inhibitors with diuretics or beta-blockers with diuretics for the reduction of cardiovascular events and mortality in the treatment of uncomplicated hypertension.38,39 In practice, calcium channel blockers do not often end up being first-line agents for monotherapy in treating hypertension in co-morbid conditions such as CKD, IHD and HF. This is due to the preference of other agents (such as ACE inhibitors, ARBs and beta blockers) for the treatment and secondary prevention of the co-morbid condition.3,32,33 Conversely, non-dihydropyridine calcium channel blockers are a first-line option for rate control in the treatment of atrial fibrillation (in patients without heart failure).37 Thus, treatment of hypertension in this population should be balanced with and account for the antihypertensive effects of rate control agents already employed.|
||Reduce blood pressure mainly by reduction of cardiac output via antagonism of beta-1 adrenoreceptors on cardiac tissue. Antagonism of beta-1 adrenoreceptors causes reductions in heart rate, cardiac contractility, cardiac conduction and relaxation rate.14 Additionally, beta-blockers can antagonize peripherally located beta-2 adrenoreceptors accounting for a myriad of additional, non-cardiac physiological effects.14 Finally, carvedilol and labetalol also antagonize peripheral alpha-1 receptors, causing additional antihypertensive effects from vasodilation.14 Differences in the selectivity of individual beta-blockers for the different types of adrenoreceptors account, for the most part, for the preference of certain betablockers in certain clinical conditions, and the variation in side-effect profiles.||Beta-blockers are not recommended as a first-line option for the treatment of hypertension that is uncomplicated by other co-morbidities, due to the unfavourable balance between safety and efficacy.3 However, selected beta-blockers are recommended for: secondary prevention of ischaemic heart disease in patients with reduced LVEF.32 management of heart failure in patients with moderately or severely reduced LVEF (may be considered in patients with mildly reduced LVEF).33 a first-line option for rate control in the treatment of atrial fibrillation with co-morbid heart failure (alternative beta-blockers are considered suitable in the absence of heart failure).37 Thus, the treatment of hypertension in the co-morbid populations listed above should be balanced with and account for the antihypertensive effects of agents used for management and secondary prevention of the relevant co-morbid condition. Selected beta-blockers: carvedilol, bisoprolol, slow-release metoprolol and nebivolol.3|
|MEDICATION||BRAND NAME||MEDICATION||BRAND NAME||MEDICATION||BRAND NAME|
|Angiotensin Receptor Blocker Combinations||Angiotensin Converting Enzyme Inhibitor Combinations||Other Combinations|
|Olmesartan||Olmetec||Enalapril||Multiple brands||Triamterene||Not available|
|+amlodipine||Sevikar||+hydrocholorthiazide||Enalapril/HCT, Sandoz, Renitec Plus||+Hydrocholorthiazide||Hydrene|
|+amlodipine +hydrochlorothiazide||Sevikar HCT||Fosinopril||Monopril Fosipril||+Hydrocholorthiazide||Moduretic|
|+amlodipine +hydrochlorothiazide||Exforge HCT||+Indapamide||Coversyl Plus|
|+Hydrochlorothiazide||Avapro HCT, Karvezide||+verapamil||Tarka|
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 9326 [post_author] => 12 [post_date] => 2020-02-11 08:48:20 [post_date_gmt] => 2020-02-10 22:48:20 [post_content] =>
After moving from Sweden 20 years ago, Tasmanian Pharmacist of the Year Fred Hellqvist MPS, owner of Dover Pharmacy, has become a leading voice for rural pharmacies across Australia.
What brought you to Dover, Tasmania, from Sweden?
As part of any degree in Sweden, you have to do a thesis, and Professor Ron Quinn from Griffith University was visiting Gothenberg. We discussed a possible thesis and he was happy for me to come out and do it. I did my six-month thesis in Brisbane in 2000, that’s where I met my wife Katie Stott, and I just stayed in Australia from there.
So, where does your passion for rural pharmacy stem from?
I started working in Australia in a regional centre for a couple of years and realised that seeing patients over and over again meant you found out more things about them, they trusted you more, and you could more easily solve their problems. I would encourage pharmacists who haven’t given rural practice a proper go to actually do so because it’s professionally rewarding.
How did you become co-chair of the new Rural Pharmacy Network Australia (RPNA) group?
RNPA has grown out of another group Terry Burnett, my wife and I started a couple of years back called the Small Pharmacies Group. The intention of that group was to connect smaller pharmacies because we all felt isolated. It quickly turned into advocacy and from there we realised there were a lot of issues rural in nature that needed their own forum, the RPNA.
What’s on your RPNA wish list?
Outside the metropolitan areas, the more rural you go, the more the chronic disease burden goes up. But the way the remuneration system works is volume-based. We need to put in mechanisms where clinical work is actually acknowledged and we are rewarded for the work we’re doing.
How do you attract and retain staff in remote locations?
A comprehensive package of workforce incentives is needed that brings pharmacy in line with the incentives available to other professions practicing in rural areas. Community pharmacy employers need to be able to offer better remuneration as well.
What do you believe is the biggest opportunity for rural pharmacy?
It’s a buzzword at the moment with health, but we’re a health hub. We triage a lot, we refer people who are at heightened healthcare risk, and we treat the people we can treat as best as we can to fill holes in the health care system. But we need support to continue to do so.
What are your main goals over the coming years?
Basically, to keep advocating for rural pharmacy and to gain more resources so we can adequately help our patients and our regions. Personally, I’d like to hire more pharmacists so I can do more of the things we are doing. Because there is quite a big unmet need out there.
What do you need out of the 7CPA?
RPNA is calling for a Rural Viability Package as part of 7CPA – a package that compensates rural pharmacies for the higher costs associated with delivering care to disadvantaged patients, the costs associated with attracting and retaining staff in rural and remote locations, and appropriate and flexible funding for clinical healthcare services.
It is vitally important that such a package is delivered to ensure that rural pharmacies are sustainable into the future and able to provide the care their communities need and deserve. Community pharmacy employers need to be able to offer better remuneration as well as other incentives such as extended paid leave, formal career development and recognition opportunities, housing, transport and family support.[post_title] => Rural pharmacy resource advocate [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => rural-pharmacy-resource-advocate [to_ping] => [pinged] => [post_modified] => 2020-02-12 16:23:57 [post_modified_gmt] => 2020-02-12 06:23:57 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=9326 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Rural pharmacy resource advocate [title] => Rural pharmacy resource advocate [href] => https://www.australianpharmacist.com.au/rural-pharmacy-resource-advocate/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 9327 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 8924 [post_author] => 11 [post_date] => 2020-01-12 11:31:15 [post_date_gmt] => 2020-01-12 01:31:15 [post_content] => [vc_row][vc_column width="2/3"][vc_column_text]PSA life member Steve Cohen is not slowing down on a mission to improve medicines safety. He tells of the many changes he’s seen in a career spanning half a century.
What started you on your road to advocacy around consumer information, safety and health literacy?I was born with very bad vision – myopic astigmatism – so I have always been aware of what it’s like not to have good vision. Later I owned a pharmacy in Marrickville, a very multicultural part of Sydney, and I was always concerned that customers might take their medications incorrectly if they couldn’t read their medicine labels.
Before translation software was readily available, how did you improve medicine safety?I always had multilingual staff. I would have someone who spoke Greek, someone who spoke Arabic and someone who spoke Vietnamese. I had also learned German and French at school and could understand a little bit of Italian, Spanish and Portuguese from my days of learning Latin so we had quite a broad knowledge base to be able to help them. Interestingly enough though, in the mid-1980s, I was involved in selling the first computers into pharmacy. I helped train pharmacists to use them and the software that translated labels into different languages.
After 50-odd years in the industry, what are your words of wisdom for pharmacists today?Don’t be confined to traditional ideas of pharmacy – it’s such a broad area. You can work in retail, the pharmaceutical industry, manufacturing but you can also diversify and have your own website for pharmacy-related business. Business has become really, really competitive in the last 50 years so pharmacists today need to start having special business models.
Tell us about your online business – Our Pills Talk – and why you started it.I developed a medicine safety app – Our Pills Talk – where people can scan QR barcode labels and the app will read out their doctor’s prescription information and instructions. It will also translate the labels into their preferred language. All the pharmacist needs to do is print out a QR barcode label that they place alongside their traditional pharmacy label for the patient to scan. What led me down this pathway is that it’s costing our government up to $1.4 billion annually with 250,000 people admitted to public hospitals due to adverse drug events.
What are your thoughts on retirement?I’m allergic to it.[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row] [post_title] => Diversity is the word [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => diversity-is-the-word [to_ping] => [pinged] => [post_modified] => 2020-01-14 10:53:23 [post_modified_gmt] => 2020-01-14 00:53:23 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=8924 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Diversity is the word [title] => Diversity is the word [href] => https://www.australianpharmacist.com.au/diversity-is-the-word/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 8925 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 9141 [post_author] => 23 [post_date] => 2020-01-08 09:09:48 [post_date_gmt] => 2020-01-07 23:09:48 [post_content] => Images of holidaymakers being evacuated by Navy ship as bushfires closed in on Mallacoota have made the Victorian coastal town a global symbol of the unprecedented nature of the bushfire crisis. In the lead-up to New Year’s Eve, up to 5,000 people became trapped after fires closed the only road into the remote coastal town, located just a few kilometres south of the NSW-Victoria border. Like other pharmacists across fire-ravaged parts of the nation, Mallacoota Pharmacy Pharmacist-in-Charge Emmanuel Pasura MPS has been serving a vital role in helping local communities meet their healthcare needs. Running on generator power, the Mallacoota Pharmacy dispensed more than double its usual amount of scripts, facing severe stock shortages, missed deliveries and panicked evacuees. At the peak of the crisis, Mr Pasura was working almost around the clock and spent two nights sleeping in his car beside his pharmacy as he and his three front-of-shop staff dealt with a deluge of people whose medicineshad run out or who had lost theirs while being evacuated. ‘Just a few weeks before the fire I started ordering increased quantities of medicines like Ventolin (salbutamol) and antibiotics just in case,’ he said. ‘We always get a lot of visitors during this time of the year so, naturally, our orders are bigger than normal. Despite having ordered increased quantities when the fire finally roared into town it became apparent that we were very much understocked.’ Mr Pasura said he had run out of salbutamol within an hour of opening on December 30, well before the fire even reached Mallacoota. After reaching out to a local GP and connecting with various government agencies, an intervention from the Pharmacy Guild’s Victorian Branch Director Allan Crosthwaite helped secure a shipment of salbutamol, antibiotics and P2 masks from Sigma, brought in by police barge on the next day. ‘Managing my stock was very difficult,’ he said. ‘At one point, I was dispensing only enough medications for a week if I felt that item was running low.’ As of Tuesday this week, Mr Pasura was still awaiting a new shipment, due in from Sale via helicopter, that had already been delayed for three days due to visibility concerns. ‘I hope I will get it today as I am now very desperate,’ he said. There was a heavy sadness in the town, he said, with many of his patients losing their homes. ‘Nothing prepares you for such a disaster,’ Mr Pasura said. [post_title] => On the ground in Mallacoota: community pharmacy at the front line [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => on-the-ground-in-mallacoota-community-pharmacy-at-the-front-line [to_ping] => [pinged] => [post_modified] => 2020-01-08 13:51:36 [post_modified_gmt] => 2020-01-08 03:51:36 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=9141 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => On the ground in Mallacoota: community pharmacy at the front line [title] => On the ground in Mallacoota: community pharmacy at the front line [href] => https://www.australianpharmacist.com.au/on-the-ground-in-mallacoota-community-pharmacy-at-the-front-line/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 9142 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 8769 [post_author] => 235 [post_date] => 2019-11-27 09:13:11 [post_date_gmt] => 2019-11-26 23:13:11 [post_content] => Three outstanding pharmacists recognised at the 2019 Victorian Pharmacists Dinner in Melbourne last week represent the difference dedicated members of the profession make every day to healthcare in the community. The executive officer of the Pharmacists’ Support Service (PSS), Kay Dunkley MPS, was awarded the PSA Victorian Excellence Award for her commitment to improving the wellbeing of health professionals, particularly through peer support. [caption id="attachment_8788" align="alignright" width="219"] Kay Dunkley MPS[/caption] This includes her involvement with the PSS and her help in establishing the AMA Victoria Peer Support Service in 2008. She has also travelled extensively in Australia and the United Kingdom promoting the welfare of pharmacists and pharmacy students. Ms Dunkley said a highlight of her work was ‘being able to make a difference to the lives of those we care for as pharmacists’. ‘PSS is about caring for each other within the pharmacy profession to ensure that as a profession we can care for the Australian community,’ she said. ‘I really value the generosity of the PSS volunteers in giving their time and energy to be there for their colleagues in times of stress.’ The inaugural Victorian Early Career Pharmacist (ECP) of the Year title was won by Amanda Cross MPS. A postdoctoral research fellow at the Monash Department of Clinical Epidemiology, Cabrini Institute, Dr Cross has already gained a high level of expertise in research and clinical practice and is an exemplary role model for other ECPs. She is also an Australian Pharmacist columnist. [caption id="attachment_8791" align="alignright" width="219"] Amanda Cross MPS[/caption] Her PhD, awarded this year just months before giving birth to her second child, focused on the prevalence and impact of potentially inappropriate medication use in older people with cognitive impairment, which has implications for medicine safety in Australia. Dr Cross said she chose to do a PhD to try and make a difference on a larger scale. ‘I would frequently see patients struggling with medicine adherence and commonly using inappropriate medicines,’ she said. ‘Medicine safety is important to me because as a pharmacist it is my responsibility to ensure people are taking the right medicines, at the right dose, for the right duration to ensure the medicine is creating more benefit than harm.’ [caption id="attachment_8782" align="alignright" width="219"] Roslyn Stewart MPS[/caption] The Victorian Pharmacist Medal was awarded to Roslyn Stewart MPS, in recognition of her wide-ranging, 40-year career which included time at the Fairfield Infectious Diseases Hospital during the AIDS epidemic and as a senior pharmacist at the Royal Melbourne Hospital before 20 years in community pharmacy. She has also conducted medicines reviews in aged care facilities and the community, and does volunteer work as a Mental Health First Aid Instructor. Reflecting on her career, Ms Stewart said being a pharmacist offered a wealth of options. ‘I have taken advantage of this, working in research, hospital and community pharmacy,’ she said. ‘I have enjoyed each new challenge. Few careers provide this type of flexibility.’ [post_title] => Leading Victorian pharmacists honoured [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => leading-victorian-pharmacists-honoured [to_ping] => [pinged] => [post_modified] => 2019-11-27 13:43:06 [post_modified_gmt] => 2019-11-27 03:43:06 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=8769 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Leading Victorian pharmacists honoured [title] => Leading Victorian pharmacists honoured [href] => https://www.australianpharmacist.com.au/leading-victorian-pharmacists-honoured/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 8785 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 8664 [post_author] => 11 [post_date] => 2019-11-12 13:31:18 [post_date_gmt] => 2019-11-12 03:31:18 [post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Claire O’Reilly was an intern pharmacist when a patient experience got her thinking about a pharmacist’s role in improving mental health care. Now she’s Dr Claire O’Reilly FPS – academic, mental health researcher and trainer.
How did you find this role?There was a situation when I was an intern pharmacist and a regular patient was having an acute psychotic episode. I learned so much watching the senior pharmacist that day – she was wonderful at keeping the patient calm and in the pharmacy until we could get help. It led me to reflect that we don’t really teach pharmacists how to handle those situations.
What did you learn early, during a University of Sydney project evaluating the role of pharmacists within community mental health teams?I was doing medication reviews and participating in team handover meetings and saw pharmacists could really help address polypharmacy and the many physical health issues that arise, particularly in complex mental health cases.
Now you’re a senior lecturer, what are your research focusses?One focus is on how we can better prepare and upskill pharmacists to feel confident supporting people with a mental illness. The other is growing the evidence base for how pharmacists can contribute to better outcomes for people with mental illness. We’re doing projects around how pharmacists can screen people who might be at risk of depression, and how they can intervene and support in a mental health crisis.
Day-to-day, what are the biggest challenges you face?In a university academic role there is always the challenge of juggling teaching and research commitments and there’s often pressures around publishing your work and sourcing grants to support it. Before I embarked on this career pathway it would have been helpful to have more insight into challenges around getting grant funding but, having said that, I don’t think it would have changed my decision.
What is the most satisfying part of your job?The most tangible rewards are related to pharmacists who have come along to a training course I’ve run and contacted me afterwards to say, ‘thank you so much for the skills that I learned. This person came into the pharmacy in a crisis and I felt so much more confident to be able to help them due to the training’.
Where will this career path take you?I hope to continue to develop the evidence base for pharmacists in mental health care so that we can design some more specific career pathways. Ideally, I’d like to see the creation of a primary health care mental health pharmacist role. I’d also like to see more opportunities in the community pharmacy setting, for embedding pharmacists within community mental health teams, and for pharmacists playing roles in mental health triage, early intervention, crisis support and suicide prevention.
POINTERSPharmacists interested in mental health can consider PSA CPD point offerings at https://my.psa.org.au/s/education-catalogue:
A DAY IN THE LIFE OF
Dr Claire O’Reilly FPS University of Sydney senior lecturer in pharmacy practice8:00 am: Prepare response to research paper review Arrive at work, check and respond to colleague and student emails, prepare response to reviewer comments on a research paper investigating peoples’ experiences of stigma and discrimination in mental illness. Get a coffee! 9:00 am: Honours student supervision Meet with pharmacy honours student to discuss progress with honours research project investigating pharmacists’ experiences of people who have died by suicide and resulting personal and professional impacts. 10:00 am: Video conference on research project Join a video conference with interstate research colleagues to discuss details of an upcoming research project developing a pharmacist-led support service for people living with severe and persistent mental illness, focussing on improving adherence and physical health care needs of consumers. 11:00 am: Curriculum planning Meeting with pharmacy academic colleagues to discuss development of our new pharmacy undergraduate curriculum. 12 pm: Working lunch Lunch and prepare materials for afternoon of teaching pharmacy students. 1-5 pm: Mental health training for students Deliver a session of Mental Health First Aid (MHFA) training to fourth year pharmacy students. This is provided to all our final pharmacy students as an embedded part of our BPharm and MPharm curricula. In the weeks following MHFA training our students undergo simulated patient assessment to test their newly acquired MHFA skills. 5:00 pm: Academic day ends Head home to spend the evening with my family.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.