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Informing pharmacy practice with valuable research

Graem Sims - March 21, 2019

Industry

PSA’s Pharmacists in 2023 vision advocates the implementation of a ‘research culture’ in Australia. Here’s how members can pursue valuable research in their own...

Digital transformation with My Health Record

Thea Cowie and David Barbeler - April 15, 2019

Industry

Pharmacists should be actively contributing to patients' My Health Record (MHR) in order to unlock the full potential of digital transformation, said Dr Kenneth...

Anticonvulsants shown not to provide low back pain benefits

Sharon Smith - September 3, 2018

Clinical

Despite an increase in anticonvulsant use for back and neck pain recently - an increase of 535% in the last 10 years - researchers...

Aged care royal commission welcomed by pharmacist sector

James Chalmers - September 18, 2018

Industry

Following distressing reports of inappropriate medicine use in aged care homes, PSA National President Dr Shane Jackson has welcomed a royal commission into the...

Through crisis comes strength and reform

Dr Chris Freeman FPS - May 25, 2020

Industry

The COVID-19 pandemic continues to challenge us all every day. It challenges us to adjust to new ways of living. Crisis is often a catalyst for change.

Clinical governance: shared responsibility, a common goal

Dr Chris Freeman FPS - June 2, 2019

Industry

New principles will help guide design and delivery of high-quality pharmacy services. We have a high-quality health system in Australia, and a first-class pharmacy...

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SYMPTOM	CAUSE	VALVE LESION
Fatigue Dizziness, blackouts	Inadequate cardiac output	Stenosis
Shortness of breath, cough Swelling of ankles and feet Abdominal swelling	Congestion	Regurgitation Heart failure
Chest pain	Increased workload	Aortic stenosis
Palpitations	Enlargement of heart chambers	Regurgitation (esp. mitral) Mitral stenosis
Stroke	Blood clots	Mitral

Chemical restraint	Environmental restraint	Mechanical restraint	Physical restraint	Seclusion
Antipsychotics Benzodiazepines Z-drugs Sedating antidepressants Anticonvulsants Opioids Androgen blockers	Locked doors Keypad access Restricting access to outside or an activity Meal tray locked for extended time Limited access to walking frame	Lap belts Hand mitts Bed rails Bumpers Low beds Concave mattresses Rockers/recliners Restrictive clothing	Physical force Pinning someone down Pulling someone in a direction they do not want to go ‘Basket’ holds around upper or lower limbs	Locked alone in room Imposing ‘time out’ Limiting access to call bell and/or walker Locking a person in a car/vehicle

ANTIRETROVIRAL	WHEN DOSE REDUCTION IS REQUIRED	KEY SIDE EFFECTS	PRACTICE POINTS
Abacavir	Hepatic impairment8	Nausea Increased cardiovascular events10	Contraindicated in patients with HLA-B*5701 allele; patients are tested for this before prescribing8
Lamivudine	Renal impairment8	Rash8	Activity against hepatitis B virus
Emtricitabine	Renal impairment9	Rash8	Activity against hepatitis B virus8 Only available as a combination product
Tenofovir alafenamide (AF)	Combined with p-glycoprotein inhibitor8 See individual product recommendations for renal impairment 8	Association with weight gain9 Osteopenia8,9	Activity against hepatitis B virus8 Only available as combination product
Rilpivirine	Avoid in severe hepatic impairment8	Insomnia8 Abnormal dreams8	Must be taken with food8 Only start if viral load <100,000 copies/mL8
Dolutegravir	Avoid in severe hepatic impairment8	Association with weight gain9
Bictegravir	Avoid in severe hepatic impairment9	Possible association with weight gain9	Available as a combination product only
Elvitegravir	Alter based on other single tablet regimen components	Possible association with weight gain9	Available as a combination product only Number of drug interactions due to combination with cobicistat
Atazanavir	Avoid in severe hepatic impairment8	Nausea8 Diarrhoea8 Raised lipids8 Raised bilirubin8 Nephrolithiasis8	Take with food8 Available on its own and combined with cobicistat
Darunavir	Avoid in severe hepatic impairment8	Nausea8 Diarrhoea8 Raised lipids8 Rash (sulphonamide moiety)8	Available on its own and combined with cobicistat

BRAND	COMPONENTS
Biktarvy	Bictegravir 50 mg, tenofovir AF 25 mg, emtricitabine 200 mg
Triumeq	Dolutegravir 50 mg, abacavir 600 mg, lamivudine 300 mg
Genvoya	Elvitegravir 150 mg, cobicistat 150 mg, tenofovir AF 10 mg, emtricitabine 200 mg
Odefsey	Rilpivirine 25 mg, tenofovir AF 25 mg, emtricitabine 200 mg
Dovato	Dolutegravir 50 mg, lamivudine 300 mg
Juluca	Dolutegravir 50 mg, rilpivirine 25 mg
Symtuza	Darunavir 800 mg, cobicistat 150 mg, tenofovir AF 10 mg, emtricitabine 200 mg

MEDICINE / CLASS OF MEDICINE	MECHANISM	EXAMPLES	MANAGEMENT
Integrase inhibitors	Cationic chelation reduces absorption	Iron Calcium Zinc Magnesium aluminium	Dosing of integrase inhibitors and cations usually need to be separated. Timing depends on the specific medicines involved
Dolutegravir	Blocks organic cation transporter 2 (OCT2) in kidney	Metformin level increased	Consider monitoring glycaemic control and adjusting metformin dose when starting or stopping co-administration with dolutegravir. Some sources suggest a maximum dose of 1 gram metformin daily
Elvitegravir/cobicistat	P450 3A4 inhibition (cobicistat)	Increased levels of 3A4 substrates	Modify dose or avoid use of 3A4 substrate
Bictegravir	P450 3A4 substrate: levels lowered by inducers	Rifampicin Carbamazepine Phenytoin	Avoid strong inducers of 3A4
Tenofovir AF	P-glycoprotein substrate: absorption decreased by inducers	Rifampicin Carbamazepine St John’s wort	Avoid strong inducers of p-glycoprotein
Rilpivirine	Increased stomach pH reduces absorption	Antacids H2 antagonists Proton pump inhibitors	Take with a main meal Give antacids either 2 hours before or 4 hours after rilpivirine Give H2 antagonist at least 12 hours before or 4 hours after rilpivirine Avoid proton pump inhibitors
Older NNRTIs (efavirenz, nevirapine)	P450 3A4 inducers, reduce levels of other medicines	Methadone Statins Anticoagulants Antiplatelets	Recommendation differs for each individual medicine
Atazanavir	Increased stomach pH reduces absorption	Antacids H2 antagonists Proton pump inhibitors	Take with food Separate doses of antacids and atazanavir by at least 2 hours Refer to reference for H2 antagonist and proton pump inhibitor recommendations
Pharmacokinetic enhancers (cobicistat, ritonavir)	P450 3A4 inhibition	Warfarin Statins Anticoagulants Antiplatelets Corticosteroids Colchicine	Check every co-administered medicine when starting or stopping pharmacokinetic enhancer containing ART
Ritonavir	Inducer of: UGT1A1, CYP1A2, 2B6, 2C8, 2C9, 2C19 Inhibitor of: CYP3A4, 2D6, 2C9, 2C19, 2A6, 1A2, 2E1, p-glycoprotein	Levothyroxine Digoxin Lamotrigine Voriconazole Olanzapine Amphetamines	Check every co-administered medicine when starting or stopping ritonavir containing ART

New vaccine coming soon

Oral antiviral treatments approved

1. Explain the safety steps in your processes

2. Acknowledge patients immediately

3. Talk directly to patients, not through others

4. Offer solutions, not problems

5. Don’t make decisions for patients; offer options with recommendation

Close contact changes

RAT payment

Preserving mental health

Close encounters of the unpleasant kind

Counselling advice

Advice for pharmacists

1. What are the correct dosing intervals for the AstraZeneca and Moderna COVID-19 vaccines?

2. Is it mandatory for pharmacists and pharmacy staff to be vaccinated with a COVID-19 vaccine?

3. What is the eligibility criteria to administer the Moderna vaccine?

4. I have been presented with a script for a nicotine vaping product, where can I find further information?

5. Can a pharmacist issue a medical certificate for vaccination exemption?

Anaphylaxis management and pharmacists

Parents’ perspectives

A key resource

Anaphylaxis support

What is chemical restraint?

When psychotropic medicines are used to manage behavioural and psychological symptoms of dementia is this chemical restraint?

Are hypnotics such as temazepam chemical restraint?

What do providers need to do when a chemical restraint is proposed or used?

Inappropriate antimicrobial prescribing

A positive COVID effect

Cautionary label for antibiotics remains important

Practical tips for pharmacists

Hidden symptoms of valvular heart disease

Greater awareness of valvular heart disease needed

Case scenario

Learning objectives

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Background

Legislation

Restrictive practice

What is chemical restraint?

Mental health disorders and chemical restraint

Dementia and chemical restraint

Case scenario

Case scenario

Chemical restraint must not be used unless8:

Reference: Australian Government8

Case scenario

Case scenario

Requirements of aged care homes when restrictive practice is proposed and used

Conclusion

Key points:

Case scenario

Learning objectives

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Introduction

Australian epidemiology

Management with antiretroviral therapies

Drug interactions

HIV prevention

Knowledge to practice

Case scenario continued

Conclusion

Key points:

Case scenario

Learning objectives

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Introduction

How does SIRVA occur?

Background

Prevention

Intervention strategies

Knowledge to practice

Case scenario continued

Conclusion

Key points:

Case scenario

Learning objectives

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Introduction

What are the benefits?

Cardiovascular disease

Chemical restraint must not be used unless⁸:

Reference: Australian Government⁸