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AUSTRALIAN PHARMACIST
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    • GLP-1 agonist
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                  [post_date] => 2023-12-11 13:33:42
                  [post_date_gmt] => 2023-12-11 02:33:42
                  [post_content] => Glucagon-like peptide 1 (GLP-1) agonists, traditionally used to manage type 2 diabetes, have been increasingly prescribed off-label for weight loss. 
      
      There are four GLP-1 agonist medicines approved by the Therapeutic Goods Administration (TGA) for use in Australia for the management of Type 2 Diabetes:
      
      • dulaglutide (Trulicity)
      • semaglutide (Ozempic)
      • tirzepatide (Mounjaro)
      • liraglutide (Saxenda). 
      There are only two GLP-1 agonists that are TGA approved for weight loss, semaglutide (Wegovy brand) and liraglutide (Saxenda). With Christmas just around the corner – leaving budgets tight and GP access slim, coupled with substantial, persistent stock shortages – patients may find treatment abruptly interrupted. PSA GP Pharmacist Anouska Feszczur MPS has helped several patients navigate through their reported GLP-1 agonist cessation symptoms. Here are her top tips.

      Prepare for a ravenous appetite and a return of impulsive behaviours

      When patients stop GLP-1 agonists, the most significant cessation symptom is an increased appetite far exceeding pre-treatment levels, said Ms Feszczur. [caption id="attachment_24426" align="aligncenter" width="500"]GLP-1 agonist Anouska Feszczur MPS[/caption] ‘Patients have told me cravings and appetite return with an insatiable force they’ve never experienced before,’ she said. ‘They also experience cravings for foods they had zero interest in while taking a GLP-1 agonist.’  The hunger and cravings tend to be extreme upon cessation, evening out over the space of weeks or months, said Ms Feszczur.  This cessation symptom leads to another common post-treatment effect: weight gain. ‘Evidence shows stopping semaglutide leads to weight gain,’ said Ms Feszczur. ‘In one study, all participants put on two thirds of their weight back on in a year.’  Because patients often gain back the weight they lost post-treatment, other health benefits similarly erode. ‘For example, if a patient's blood pressure or blood sugar levels improve during treatment with a GLP-1 agonist, they can go back to where they were when they stop,’ she said. Mood can also be impacted upon GLP-1 agonist cessation. ‘Patients who felt proud of themselves for losing weight can experience guilt, shame and despair,’ said Ms Feszczur. ’They've spent all this money on treatment, and suddenly the weight has come back on.’ Lastly, some patients have mentioned an impact on impulsive behaviours when the dopamine regulation effects of GLP-1 agonists appear to wear off. ‘Almost all patients have said they drink less alcohol because they just don't get the same buzz, and one patient even stopped chewing their nails,’ she said. ‘Some people have also indicated in forums that online shopping and gambling behaviour changed while they were on Ozempic.’ Those impulsive behaviours can return upon cessation, said Ms Feszczur – rendering the holiday period, where people tend to overeat, drink and spend,  a tricky time to go off these medicines.  ‘It could be quite distressing for patients who feel they have no control over impulsive behaviours.’

      Encourage tapering and identify movement barriers

      When patients cease GLP-1 agonists, optimising medicines for comorbid health conditions could be beneficial, said Ms Feszczur. ‘[Find out] if there’s anything they're taking, or not taking, that might be a barrier to movement. For example, with pain management.’ Other services can help patients work through their movement challenges. ‘I’ve referred a patient with arthritis who ceased semaglutide to painHEALTH, a self-directed learning module on pacing which is all about trying to increase movement while still in pain,’ she said. Ms Feszczur also suggests patients taper from GLP-1 agonists rather than immediate cessation. ‘GLP-1 agonists mimic a hormone. Any other medicine we give patients that mimic hormones, such as steroids, are tapered so the body can start making its own hormones again,’ she said. ‘If I know a patient is running out of Ozempic, and there's no stock anywhere, I’ll advise a plan to reduce it gradually, which also empowers patients to mindfully go into cessation.’

      Eat the right food and seek help for mood changes

      To help reduce an insatiable appetite, pharmacists should recommend patients eat nutrient-rich food with low-calorie density. ‘Suggest eating protein with every meal and water-filled foods that make you feel fuller, such as watermelon, grapes and apples,’ said Ms Feszczur.  Patients should also avoid foods that don't make them feel full. ‘For example if a patient loves chocolate but it doesn’t fill them up, advise them to swap it for low-calorie ice cream.’ Tools such as a food tracker app might also help patients regain a sense of control as they see their intake coming down. Importantly, patients should be advised to be on the lookout for any mood or behavioural changes. ‘You could say to patients, “If you see impulsive behaviours increase, it's important that you try to go to the GP – even though it’s a busy period”,’ said Ms Feszczur. If GP access is difficult over the Christmas period, there are various helplines patients can access, including:
      • National Alcohol and Other Drug Hotline
      • Department of Social Services’ Gambling Support
      • Turning Point.

      Ongoing support is required

      GLP-1 agonist cessation provides a good opportunity for pharmacists to promote a multidisciplinary approach to weight management, said Ms Feszczur.   Nutritional support could come from:
      • a dietician
      • GP
      • formalised online nutrition programs such as Noom or MyFitnessPal.
      ‘A psychologist can also be useful to address some of the behaviours that may have led to overeating,’ she said. ‘Patients could be referred to their GP for a mental health treatment plan.’ Movement support is another area that should be considered. Pharmacists can ask:
      • how are you finding movement? 
      • do you need help from an exercise physiologist to create a plan? 
      • are you happy to pay for a personal trainer? 
      Pharmacists should also encourage patients to make sleep a priority. ‘We know people who have good quality sleep have better luck maintaining their weight,’ said Ms Feszczur.  Sleep hygiene habits, as outlined by the Sleep Health Foundation here, can be discussed with patients. ‘There are also free Cognitive Behavioural Therapy for Insomnia (CBT-I) programs people can do at home to make sleep a priority.’

      Report cessation effects to the TGA

      Given GLP-1 agonist cessation is an emerging area, pharmacists should consider reporting any effects to the TGA, or encourage patients to self-report. ‘As the TGA says, “You don’t have to be certain, just suspicious”,’ said Ms Feszczur. ‘The only way we can build evidence is for people to say something.’ Setting expectations about cessation before patients start a GLP-1 agonist can also help them to prepare. ‘Pharmacists could say, “You might find it easy to lose weight while you're on this medicine. But it’s important to make profound changes to your lifestyle, or most of the weight could come back on,’ she said.

      Watch this space!

      There is an emerging evidence base for using GLP-1 agonists to treat other conditions – including dementia and addiction, said Ms Feszczur.  ‘My advice to pharmacists is to keep an eye out for new and emerging therapeutic areas for GLP-1 agonists, as well as any information you can find on cessation.’ [post_title] => Supporting patients through GLP-1 agonist cessation effects [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => supporting-patients-through-drastic-glp-1-agonist-cessation-effects [to_ping] => [pinged] => [post_modified] => 2023-12-11 14:54:36 [post_modified_gmt] => 2023-12-11 03:54:36 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24423 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Supporting patients through GLP-1 agonist cessation effects [title] => Supporting patients through GLP-1 agonist cessation effects [href] => https://www.australianpharmacist.com.au/supporting-patients-through-drastic-glp-1-agonist-cessation-effects/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 24425 )

      Supporting patients through GLP-1 agonist cessation effects

      belladonna
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                  [post_date] => 2023-12-11 11:18:16
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                  [post_content] => When it comes to belladonna, the eyes have it. Pity it’s highly toxic...
      
      During the Italian Renaissance of the 14–16th centuries, belladonna was a popular cosmetic product. Well-dressed women used juice from the berries of the plant to dilate their pupils, resulting in a fashionably seductive look. Hence the name belladonna, Italian for ‘beautiful woman’.1–6
      
      But millennia before it helped make a fashion statement, belladonna was used as an anaesthetic, pain reliever and remedy for assorted ailments, not to mention as a hallucinogenic component of rituals. It was also used as an oral poison and to tip arrows.1,5,7
      
      Deadly nightshade, murderer’s berries, sorcerer’s berries and even devil’s berries — as belladonna’s alternative names reveal, its not so ‘bella’ side was well known. The plant was associated with broom-riding witches and poison potions.3,4,8
      
      Shakespeare described belladonna’s impact when referring to Juliet’s attempt to feign death to avoid marriage with Paris and escape with Romeo1,4,8:
      
      Her blood is settled, and her joints are stiff: Life and these lips have long been separated; Death lies on her like an untimely frost upon the sweetest flower of all the field.
      

      What is belladonna?

      Atropa belladonna is an ornamental plant of the Solanaceae family. It is native to Europe, North Africa and Western Asia. Growing to a height of 150 centimetres in barren stony soil, belladonna has oval leaves, green-purple flowers and sweet black berries.3-5,9,10,12 The herbaceous perennial is highly poisonous, especially the leaves and fruit. They contain atropine, scopolamine and hyoscyamine alkaloids. Consuming the alkaloids can be deadly. Just touching the leaves may cause a rash.1,6-9,10

      How it works

      Belladonna’s alkaloids affect the body’s nervous system. Specifically, they block the neurotransmitter acetylcholine from binding to the central nervous system and to parasympathetic postganglionic muscarinic receptors.6,7,9-11 Toxic effects can be wide-ranging, as evidenced by the case of an 11-year-old Moroccan girl treated for belladonna toxicity by the intensive care team at the Mother and Child Hospital in Fes.5,7,9 ‘She was given Atropa belladonna by an herbalist in a therapeutic interest,’ they reported. Her symptoms included dry mouth, confusion, incoherent speech, and an inability to recognise family members. She also presented with uncontrollable vomiting, visual disturbances, and hearing and visual hallucinations.7 Belladonna can also cause changes to saliva, sweat, pupil size, urination and digestive functions. It can also cause seizures, headaches and increased heart rate and blood pressure.10,11

      Medical uses

      Today, medicines containing alkaloids found in belladonna, such as atropine, are used in areas such as emergency medicine and anaesthesia.13 Interestingly, atropine is used as an antidote of organophosphate poisoning by reversing its muscarinic effects (such as vomiting, diarrhoea, bradycardia, miosis, sweating and salivation).13 Proving the eyes still have it, atropine is also indicated for use in optometry for conditions like uveitis, myopia progression, amblyopia and sometimes for eye exams.13 Overseas, transdermal scopolamine is sometimes used to help treat nausea and vomiting-related conditions.14

      References

      1. Fletcher J. Uses and risks of belladonna. Medical News Today. 2017. At: https://www.medicalnewstoday.com/articles/318180
      2. Meriney SD, Fanselow EE. Acetylcholine in Synaptic Transmission. Academic Press 2019:345–67. At: https://www.sciencedirect.com/topics/neuroscience/atropa-belladonna
      3. Passos ID, Mironidou-Tzouveleki M. Hallucinogenic Plants in the Mediterranean Countries in Neuropathology of Drug Addictions and Substance Misuse Vol 2. Academic Press. 2016:761–72. At: https://www.sciencedirect.com/science/article/abs/pii/B9780128002124000716
      4. Morris SM. Belladonna: remedy with a dark past. Healthline. 2017. At: https://www.healthline.com/health/belladonna-dark-past
      5. Annisadmin. Atropa belladonna: deadly nightshade. Penny Dreadful Archives. 2016. At: https://pennydreadfularchives.wordpress.com/2016/05/31/atropa-belladonna-deadly-nightshade/
      6. DrugBank. Belladonna. 2017. At: https://go.drugbank.com/drugs/DB13913
      7. Berdai MA, Labib S, Chetouani K, et al. Atropa belladonna intoxication: a case report. Pan Afr Med J 2012;11:72. Epub 2012 Apr 17. At: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361210/
      8. Mann J. Belladonna, broomsticks and brain chemistry. Education in Chemistry. 2008. At: https://edu.rsc.org/feature/belladonna-broomsticks-and-brain-chemistry/2020099.article
      9. Karagoz I, Bilgi M, Boduc E, et al. Atropa belladonna and associated anticholinergic toxic syndrome: a case report. Bali Med J 2017;3(3):S90–S92. At: https://balimedicaljournal.org/index.php/bmj/article/view/673/pdf_330
      10. National Library of Medicine. MedlinePlus. Belladonna. 2022. At: https://medlineplus.gov/druginfo/natural/531.html
      11. Banasik M, Stedeford T. Plants, Poisonous (Humans). Encyclopedia of Toxicology (Third Edition). Academic Press. 2014. p970–78. At: https://www.sciencedirect.com/science/article/abs/pii/B9780123864543000488
      12. Jim’s Mowing. The Essential List of Poisonous Plants in Australia. At: https://www.jimsmowing.com.au/2021/01/the-essential-list-of-poisonous-plants-in-australia/#:~:text=For%20the%20formidable%20deadly%20nightshade,has%20become%20a%20fruitful%20one
      13. Rossi S, ed. Australian medicines handbook. 2023. At: https://amhonline.amh.net.au
      14. Pruthi S, ed. Mayo clinic. 2023. Scopolamine (Transdermal Route). At: www.mayoclinic.org/drugs-supplements/scopolamine-transdermal-route/side-effects/drg-20072848?p=1#:~:text=Scopolamine%20transdermal%20patch%20is%20used,group%20of%20medicines%20called%20anticholinergics
      [post_title] => Belladonna: beautiful but deadly [post_excerpt] => Before it helped make a fashion statement, belladonna was used as an anaesthetic, pain reliever and remedy for assorted ailments. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => belladonna-beautiful-but-deadly [to_ping] => [pinged] => [post_modified] => 2023-12-11 14:54:06 [post_modified_gmt] => 2023-12-11 03:54:06 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24416 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Belladonna: beautiful but deadly [title] => Belladonna: beautiful but deadly [href] => https://www.australianpharmacist.com.au/belladonna-beautiful-but-deadly/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template ) [is_review:protected] => [post_thumb_id:protected] => 24419 )

      Belladonna: beautiful but deadly

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                  [post_date] => 2023-12-06 12:32:37
                  [post_date_gmt] => 2023-12-06 01:32:37
                  [post_content] => The significant rise in Australian asthma deaths is cause for immediate and widespread concern. Here’s what experts say needs to change.
      
      Asthma deaths are again on the rise, revealed new Australian Bureau of Statistics data  recently released by the National Asthma Council Australia.
      
      There were 467 asthma-related deaths in Australia in 2022, up from 355 deaths in 2021. Most (64%) were among women – with 299 female deaths versus 168 male deaths.
      
      Those most at risk of death are women aged 75 and older, accounting for 45% of all deaths followed by men in this age group (18%).
      
      This is the highest number of asthma deaths recorded since 2016-2017. Deaths were down in 2021 as a result of COVID-19 restrictions and lockdowns – leading to fewer respiratory infections and asthma exacerbations. However, asthma exacerbations have now returned to pre-pandemic levels and may even be slightly higher, warned National Asthma Council Australia Director and respiratory physician, Professor Peter Wark.
      
      [caption id="attachment_24414" align="alignright" width="225"] National Asthma Council Australia Director and respiratory physician, Professor Peter Wark[/caption]
      
      This may be the result of the increase in virus infections we saw following the easing of COVID-19 restrictions but the main reasons are a result of the intrinsic problems underlying asthma management in Australia. ‘We're not accurately diagnosing asthma, and we are under-treating it,’ he said.
      

      A need for better asthma diagnosis and control

      There was a marked decline in lung function testing during COVID-19. Despite an increase in funding under the Medicare Benefits Schedule for spirometry, there has been a reduction of two thirds in spirometry being billed under the MBS compared to 2018–19, said Prof Wark.  ‘Spirometry remains essential in the diagnosis of asthma and this will lead to under and overdiagnosis,’  said Prof Wark. Up to 20% of people who present to a pharmacy for salbutamol haven't had their asthma confirmed by spirometry, said Advanced Practice Pharmacist and National Asthma Council Australia Clinical Executive Lead Debbie Rigby FPS. ‘Because [pharmacists] can dispense salbutamol over the counter without a prescription, we have a responsibility to ask the right questions to determine patients’ level of control,’ she said.This could include asthma control tests. The Asthma Score is an example of such a test and comprises five questions. As part of this, pharmacists ask patients to rate their symptoms on a scale of one to five to indicate their asthma control over the last 4 weeks, including:
      • How frequently are your symptoms preventing you from participating in work, school or play as well as normal?
      • How often have you had shortness of breath?
      • How often are your symptoms waking you up at night or earlier in the morning than usual? 
      • How often have you been using your reliever?
      • How would you rate your asthma control?
      ‘If  [salbutamol] has been [used] three or more times in the last week, that's indicative of not having good asthma control,’ she said.

      Promoting the right treatments

      Over-the-counter short-acting beta agonists (SABAs) are associated with worse asthma outcomes, including death. But that isn't because the medicine is harmful – it's associated with inadequate asthma control, which has short and long term consequences. Overall there is suboptimal use of inhaled preventers or inhaled corticosteroids, that have been shown to improve asthma control, reduce asthma exacerbations and reduce the risk of death from asthma. This includes suboptimal use of as-needed inhaled low-dose ICS/formoterol for people with mild asthma. This treatment is recommended by Australian and international guidelines as an effective alternative to regular maintenance ICS , in people with mild asthma – and is more effective and safer than using SABAs alone, said Ms Rigby. ‘This more flexible approach to treatment is ideally suited to people with mild asthma, many of whom are now at risk because they are not using an ICS preventer.’ Pharmacists should take the opportunity to provide some much-needed education to patients about the benefits of the budesonide/formoterol combination, said Ms Rigby. ‘Formoterol works just as well and quickly as salbutamol, but they're also getting some inhaled corticosteroid – which helps with the inflammatory process going on in their lungs,’ she said. ‘Whereas with salbutamol, you're just helping with the bronchoconstriction. It's doing nothing about the underlying inflammation.’

      When is a biologic appropriate?

      When patients present with a prescription of prednisone, pharmacists can play an important role in appropriately identifying and informing them that this is a sign of poor asthma control and is a red flag that identifies a risk for severe acute asthma, including the risk of death, said Prof Wark. Aspects to explore should include:
      • Have they been prescribed a preventer? 
      • Are they using the preventer?
      • Are they taking it appropriately? 
      • If they are taking their preventer appropriately but still experiencing acute asthma, they may be eligible for assessment by a specialist for a biologic agent
      Asthma should be adequately controlled on moderate dose ICS together with a LABA. Persistence with high dose ICS or frequent courses of prednisone is certainly not the answer, said Prof Wark. A recent large population-based study conducted in the United Kingdom showed that stepping patients up to the highest doses of ICS adds little benefit to asthma management. ‘If a patient needs more than one or two courses of prednisone, and they're on an ICS/LABA, you need to ask the question, “should they be receiving treatment with a biologic?”’ he said.  Prof Wark advises that patients who might benefit from a biologic include those:
      • who continue to experience exacerbations and are overlying on prednisone
      • with active type two inflammation, identified through blood counts and exhaled nitric oxide.
      ‘The impact prednisone has on health is enormous, it accumulates over a lifetime of exposure and we have very effective treatments for asthma that should reduce our reliance upon its use,’ he said. ‘People in regional and remote Australia, with poor asthma control appear to be at greater risk of needing to use prednisone.’
      ‘Up to 20% of people who present to a pharmacy for salbutamol haven't had their asthma confirmed by spirometry.' Debbie Rigby FPS 
      Once patients exceed a lifetime cumulative dose of 500 mg of prednisone, the health risks increase dramatically  – leaving younger people who use the medicine particularly at risk. ‘Only one or two courses of prednisone in 12 months significantly increases the risk of developing osteoporosis, diabetes and infections such as pneumonia.’ Females over the age of 12 are at greater risk of poor asthma outcomes, said Prof Wark. When female patients have ongoing problems with asthma control and prednisone is needed – a biologic should be considered, he said. ‘If you're not getting good asthma control, these alternative treatments work exceptionally well for everyone, including women.’

      Get moving, and vaccinated

      Vaccination can significantly reduce the impact of respiratory viruses among patients with asthma – particularly those aged 65 and over who may have other comorbidities. Patients with asthma should receive: 
      • an annual influenza vaccination
      • the pneumococcal vaccine
      • a COVID-19 vaccine.
      Pharmacists can also advise patients that influenza vaccines are free of charge for those with asthma, said Prof Wark. ‘RSV vaccines will soon be available, likely targeting patients aged 65 years and over.’ Asthma also interacts with other diseases – particularly diabetes and cardiovascular disease – with around three quarters of people with asthma having another chronic disease, said Prof Wark. ‘When you combine age and a number of comorbidities, there’s a more complex picture. Inactivity and obesity and the relationship to asthma, cardiovascular disease and chronic diseases such as diabetes – are all linked.’ Exercise and activity have been associated with improvements in asthma symptoms, along with overall asthma control. While there should be ‘no limitations’ on the exercise patients with asthma can do, some factors might put them at risk.  ‘For example, exercising in cold or dry air can increase your risk of bronchospasm,’ he said. ‘So warming up before exercise is advised.’ For more information, refer to PSA’s updated treatment guideline in the Australian Pharmaceutical Formulary and Handbook digital site. [post_title] => Over 30% increase in asthma deaths in one year [post_excerpt] => The significant rise in Australian asthma deaths is cause for immediate and widespread concern. Here’s what experts say needs to change. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => over-30-increase-in-asthma-deaths-in-one-year [to_ping] => [pinged] => [post_modified] => 2023-12-06 16:09:30 [post_modified_gmt] => 2023-12-06 05:09:30 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24394 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Over 30% increase in asthma deaths in one year [title] => Over 30% increase in asthma deaths in one year [href] => https://www.australianpharmacist.com.au/over-30-increase-in-asthma-deaths-in-one-year/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 24406 )

      Over 30% increase in asthma deaths in one year

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                  [post_date] => 2023-12-04 14:21:06
                  [post_date_gmt] => 2023-12-04 03:21:06
                  [post_content] => With a plunge in vaccination rates following the COVID-19 pandemic peak, a new report says a concerted push is required, with a focus on national consistency.
      
      The Grattan Institute’s A fair shot: How to close the vaccination gap report recommends action on a National Vaccines Partnership Agreement and harmonisation of the state-based regulations that determine pharmacists’ authority to deliver certain vaccines – which currently differ in each jurisdiction.
      
      These recommendations echo PSA’s ongoing calls ​for a nationally consistent approach to vaccination, and demonstrate just how far we need to go to ensure equitable access to vaccination for all Australians, said PSA National President Dr Fei Sim FPS. 
      
      Australian Pharmacist takes a look at the groups with plummeting vaccination rates, and how empowering primary care professionals such as pharmacists can help to lift them.
      

      Older Australians and Aboriginal and Torres Strait Islander peoples are missing out

      Recommended vaccine uptake rates have continued to fall over the last couple of years, particularly among vulnerable groups. At the beginning of the 2023 winter, 2.5 million Australians over 65 years of age were not up to date with their COVID-19 vaccinations – a five-fold increase from 2022.  Other findings about COVID-19 vaccination include:
      • a crash in up-to-date vaccination from over 90% in December 2021 to less than 10% by the end of February 2023 among those considered high risk
      • vaccination rates only reached 38% among high-risk patients following a 2023 COVID-19 booster push 
      • as of November 2023, less than 4 in 10 aged care residents are considered up-to-date with COVID-19 vaccination.
      Older Australians are also behind with other important vaccinations. Less than half of people aged in their 70s were vaccinated for shingles, with even less (one in five) vaccinated against pneumococcal disease. Influenza vaccination rates are also consistently low across the board, with only 27% of Australians vaccinated against influenza in autumn 2023. High-risk groups that receive no-cost vaccinations under the National Immunisation Program (NIP) are beset by low or inconsistent flu vaccination rates, said the report. For example, only around 16% of Aboriginal and Torres Strait Islander people received an influenza vaccination ahead of winter. The report predicts vaccination rates will fall further due to several factors, including:
      • vaccine fatigue
      • confusion over which vaccines are needed
      • increased vaccine misinformation.
      While Australia has very high childhood vaccination rates by global standards, these factors are likely contributing to a decline in vaccination since 2020. Childhood vaccination rates had climbed up to 95%, but the nation is falling back from this highpoint – which is needed to provide adequate protections against many vaccine preventable diseases.

      Non-English speakers half as likely to get vaccinated against COVID-19

      There are several demographic factors leading to disparities in vaccination rates. Among high-risk adults, vaccination depends on:
      • areas lived
      • language spoken at home
      • level of earnings.
      While vaccination rates among Australians should be higher, the report emphasised that they need to be fairer. For example, patients who speak languages other than English at home are reportedly about half as likely to get recommended COVID-19 vaccinations. Those in rural areas are less likely to get vaccinated, with disparities also existing in major cities. For example, there is a nearly 30% variation in flu vaccination rates in different parts of Brisbane.

      Empowering pharmacists through red tape removal

      The report calls for a policy reset through a National Vaccination Agreement that outlines clearer goals and responsibilities to boost vaccination targets in high-risk groups.  The report also says that Primary Health Networks (PHNs) should be required to make ongoing progress towards reaching national targets, and must be equipped with funding to support general practice, pharmacists, and aged care providers to promote vaccination in mainstream primary care. The recent federal government commitment of 4 years of funding to support pharmacists to deliver free NIP vaccines to eligible people will improve access, increasing vaccination locations by up to 60%. This move will also help to ensure patients can access vaccines from a trusted provider with whom they have an existing relationship. Crucially, the report argues that ‘the federal government should work with state governments to make pharmacy vaccination regulations consistent across Australia’.  ‘State regulations determine whether pharmacists can deliver particular vaccines, who can get particular vaccines from pharmacists, and whether a pharmacist vaccination is free,’ said the report. ‘The federal government’s independent Scope of Practice Review should harmonise these regulations by removing state-specific restrictions, [and] investigate opportunities to remove restrictions on the scope of practice of Aboriginal Health Workers and Aboriginal Health Practitioners.’ A nationally consistent schedule of pharmacist-administered vaccines is key to achieve equitable access to government-funded vaccines by all Australians, agreed Dr Sim. ‘We know that there is no one-size-fits-all approach to improving vaccine uptake, with the report rightly highlighting the need for a tailored approach to ensuring vulnerable cohorts don’t fall through the cracks,’ Dr Sim said.​ ‘The federal government’s move to open up NIP funding for pharmacist-administered vaccines is a welcome first step, but there is more work to be done to allow pharmacists to deliver all vaccines to patients of all ages. ‘Pharmacists can and should be utilised as trusted health care professionals, working hand in glove with the rest of the primary care team to break down the barriers to vaccination, from improving equity and access, to amplifying public health messages.’ [post_title] => We need a nationally consistent vaccination approach, says think tank [post_excerpt] => With a plunge in vaccination rates following the COVID-19 pandemic peak, a new report says a focus on national consistency is required. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => we-need-a-nationally-consistent-vaccination-approach-says-top-think-tank [to_ping] => [pinged] => [post_modified] => 2023-12-04 15:12:35 [post_modified_gmt] => 2023-12-04 04:12:35 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24372 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => We need a nationally consistent vaccination approach, says think tank [title] => We need a nationally consistent vaccination approach, says think tank [href] => https://www.australianpharmacist.com.au/we-need-a-nationally-consistent-vaccination-approach-says-top-think-tank/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14650 )

      We need a nationally consistent vaccination approach, says think tank

      clozapine
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                  [post_date] => 2023-12-04 14:07:21
                  [post_date_gmt] => 2023-12-04 03:07:21
                  [post_content] => Clozapine is indicated for the management of treatment-resistant schizophrenia. Its use is subject to strict regulatory and monitoring requirements due to potential toxicity, most notably agranulocytosis and neutropenia. 
      
      Each brand has its own protocol monitoring service1,2:
      
      • Clozaril (Viatris) – the Clozaril Patient Monitoring System (CPMS), and
      • Clopine (Pfizer) – ClopineCENTRAL.

      Is registration with these services mandatory?

      Yes. Prescribers, pharmacies and pharmacists must be registered with the respective service. Individual pharmacists may be registered to multiple pharmacies. They must be used for every dispense event.

      A patient has run out of medicines but now new blood tests have been provided. Can I dispense an emergency supply?

      No. Dispensing cannot occur beyond the next blood test due date until a doctor and pharmacist have reviewed a new white blood count (WBC) and neutrophil count and deemed them acceptable.

      Is it OK to rely on blood tests I access from MHR or that the prescriber sends to the pharmacy?

      Yes. However, the pharmacist must be satisfied the pathology results have been reviewed and approved by the patient’s medical practitioner. Where the prescriber has not entered these blood results into the relevant monitoring system, the pharmacist must enter these details at the time of dispensing or transmit them to the monitoring system via fax for upload.

      What happens if someone does not collect their prescription within 48 hours of the pathology blood test?

      Interruptions to therapy may require re-titration, so pharmacists should first check to determine if there has been an interruption in therapy of >48 hours. If so, withhold supply and refer for urgent review. If therapy is uninterrupted, the amount supplied would be the original quantity minus the number of days late presenting to the pharmacy. This is known as the ’48-hour rule’. For example, if a patient who had a prescription for 28 days’ therapy presented on Saturday for a blood test taken 5 days earlier on Monday, then up to 25 days’ therapy could be supplied. 

      Is other monitoring required? 

      Yes. In addition to haematological monitoring, people taking clozapine require monitoring for changes in cardiac, metabolic, gastrointestinal and central nervous system functioning.  In April 2022, the Therapeutic Goods Administration (TGA) mandated a boxed warning in the product information for clozapine in relation to the potentially fatal risk of gastrointestinal hypomotility. The TGA alert noted that approximately 10% (n = 103) of clozapine reports with a fatal outcome were due to gastrointestinal disorders.3 All health professionals should enquire routinely about patient’s bowel habits. Nausea and/or vomiting, abdominal distension and/or pain, lack of urge and/or inability to defecate or constipation should prompt further assessment and urgent referral for immediate review.

      References

      1. Chao A. Clopine CENTRAL: Your connection to Clopine (clozapine) patient care, Pfizer Australia, WestRyde. 2017. At: www.clopine.com.au/ClopineCentral
      2. Clozaril Patient Monitoring System Protocol.September 2019, ver. 5. Mylan. At: www.ecpms.com.au/
      3. Therapeutic Goods Administration, Department of Health and Aged Care, Australian Government.Medicines safety update: clozapine and gastrointestinal hypomotility with severe complications. 2022. At: www.tga.gov.au/news/safety-updates/clozapine-and-gastrointestinal-hypomotility-severe-complications
      [post_title] => FAQ: clozapine’s close checks [post_excerpt] => Clozapine, used for the management of treatment-resistant schizophrenia, is subject to strict regulatory and monitoring requirements. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => faq-clozapines-close-checks [to_ping] => [pinged] => [post_modified] => 2023-12-04 15:12:02 [post_modified_gmt] => 2023-12-04 04:12:02 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24360 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => FAQ: clozapine’s close checks [title] => FAQ: clozapine’s close checks [href] => https://www.australianpharmacist.com.au/faq-clozapines-close-checks/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template ) [is_review:protected] => [post_thumb_id:protected] => 24367 )

      FAQ: clozapine’s close checks

  • Clinical
    • GLP-1 agonist
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                  [post_date] => 2023-12-11 13:33:42
                  [post_date_gmt] => 2023-12-11 02:33:42
                  [post_content] => Glucagon-like peptide 1 (GLP-1) agonists, traditionally used to manage type 2 diabetes, have been increasingly prescribed off-label for weight loss. 
      
      There are four GLP-1 agonist medicines approved by the Therapeutic Goods Administration (TGA) for use in Australia for the management of Type 2 Diabetes:
      
      • dulaglutide (Trulicity)
      • semaglutide (Ozempic)
      • tirzepatide (Mounjaro)
      • liraglutide (Saxenda). 
      There are only two GLP-1 agonists that are TGA approved for weight loss, semaglutide (Wegovy brand) and liraglutide (Saxenda). With Christmas just around the corner – leaving budgets tight and GP access slim, coupled with substantial, persistent stock shortages – patients may find treatment abruptly interrupted. PSA GP Pharmacist Anouska Feszczur MPS has helped several patients navigate through their reported GLP-1 agonist cessation symptoms. Here are her top tips.

      Prepare for a ravenous appetite and a return of impulsive behaviours

      When patients stop GLP-1 agonists, the most significant cessation symptom is an increased appetite far exceeding pre-treatment levels, said Ms Feszczur. [caption id="attachment_24426" align="aligncenter" width="500"]GLP-1 agonist Anouska Feszczur MPS[/caption] ‘Patients have told me cravings and appetite return with an insatiable force they’ve never experienced before,’ she said. ‘They also experience cravings for foods they had zero interest in while taking a GLP-1 agonist.’  The hunger and cravings tend to be extreme upon cessation, evening out over the space of weeks or months, said Ms Feszczur.  This cessation symptom leads to another common post-treatment effect: weight gain. ‘Evidence shows stopping semaglutide leads to weight gain,’ said Ms Feszczur. ‘In one study, all participants put on two thirds of their weight back on in a year.’  Because patients often gain back the weight they lost post-treatment, other health benefits similarly erode. ‘For example, if a patient's blood pressure or blood sugar levels improve during treatment with a GLP-1 agonist, they can go back to where they were when they stop,’ she said. Mood can also be impacted upon GLP-1 agonist cessation. ‘Patients who felt proud of themselves for losing weight can experience guilt, shame and despair,’ said Ms Feszczur. ’They've spent all this money on treatment, and suddenly the weight has come back on.’ Lastly, some patients have mentioned an impact on impulsive behaviours when the dopamine regulation effects of GLP-1 agonists appear to wear off. ‘Almost all patients have said they drink less alcohol because they just don't get the same buzz, and one patient even stopped chewing their nails,’ she said. ‘Some people have also indicated in forums that online shopping and gambling behaviour changed while they were on Ozempic.’ Those impulsive behaviours can return upon cessation, said Ms Feszczur – rendering the holiday period, where people tend to overeat, drink and spend,  a tricky time to go off these medicines.  ‘It could be quite distressing for patients who feel they have no control over impulsive behaviours.’

      Encourage tapering and identify movement barriers

      When patients cease GLP-1 agonists, optimising medicines for comorbid health conditions could be beneficial, said Ms Feszczur. ‘[Find out] if there’s anything they're taking, or not taking, that might be a barrier to movement. For example, with pain management.’ Other services can help patients work through their movement challenges. ‘I’ve referred a patient with arthritis who ceased semaglutide to painHEALTH, a self-directed learning module on pacing which is all about trying to increase movement while still in pain,’ she said. Ms Feszczur also suggests patients taper from GLP-1 agonists rather than immediate cessation. ‘GLP-1 agonists mimic a hormone. Any other medicine we give patients that mimic hormones, such as steroids, are tapered so the body can start making its own hormones again,’ she said. ‘If I know a patient is running out of Ozempic, and there's no stock anywhere, I’ll advise a plan to reduce it gradually, which also empowers patients to mindfully go into cessation.’

      Eat the right food and seek help for mood changes

      To help reduce an insatiable appetite, pharmacists should recommend patients eat nutrient-rich food with low-calorie density. ‘Suggest eating protein with every meal and water-filled foods that make you feel fuller, such as watermelon, grapes and apples,’ said Ms Feszczur.  Patients should also avoid foods that don't make them feel full. ‘For example if a patient loves chocolate but it doesn’t fill them up, advise them to swap it for low-calorie ice cream.’ Tools such as a food tracker app might also help patients regain a sense of control as they see their intake coming down. Importantly, patients should be advised to be on the lookout for any mood or behavioural changes. ‘You could say to patients, “If you see impulsive behaviours increase, it's important that you try to go to the GP – even though it’s a busy period”,’ said Ms Feszczur. If GP access is difficult over the Christmas period, there are various helplines patients can access, including:
      • National Alcohol and Other Drug Hotline
      • Department of Social Services’ Gambling Support
      • Turning Point.

      Ongoing support is required

      GLP-1 agonist cessation provides a good opportunity for pharmacists to promote a multidisciplinary approach to weight management, said Ms Feszczur.   Nutritional support could come from:
      • a dietician
      • GP
      • formalised online nutrition programs such as Noom or MyFitnessPal.
      ‘A psychologist can also be useful to address some of the behaviours that may have led to overeating,’ she said. ‘Patients could be referred to their GP for a mental health treatment plan.’ Movement support is another area that should be considered. Pharmacists can ask:
      • how are you finding movement? 
      • do you need help from an exercise physiologist to create a plan? 
      • are you happy to pay for a personal trainer? 
      Pharmacists should also encourage patients to make sleep a priority. ‘We know people who have good quality sleep have better luck maintaining their weight,’ said Ms Feszczur.  Sleep hygiene habits, as outlined by the Sleep Health Foundation here, can be discussed with patients. ‘There are also free Cognitive Behavioural Therapy for Insomnia (CBT-I) programs people can do at home to make sleep a priority.’

      Report cessation effects to the TGA

      Given GLP-1 agonist cessation is an emerging area, pharmacists should consider reporting any effects to the TGA, or encourage patients to self-report. ‘As the TGA says, “You don’t have to be certain, just suspicious”,’ said Ms Feszczur. ‘The only way we can build evidence is for people to say something.’ Setting expectations about cessation before patients start a GLP-1 agonist can also help them to prepare. ‘Pharmacists could say, “You might find it easy to lose weight while you're on this medicine. But it’s important to make profound changes to your lifestyle, or most of the weight could come back on,’ she said.

      Watch this space!

      There is an emerging evidence base for using GLP-1 agonists to treat other conditions – including dementia and addiction, said Ms Feszczur.  ‘My advice to pharmacists is to keep an eye out for new and emerging therapeutic areas for GLP-1 agonists, as well as any information you can find on cessation.’ [post_title] => Supporting patients through GLP-1 agonist cessation effects [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => supporting-patients-through-drastic-glp-1-agonist-cessation-effects [to_ping] => [pinged] => [post_modified] => 2023-12-11 14:54:36 [post_modified_gmt] => 2023-12-11 03:54:36 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24423 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Supporting patients through GLP-1 agonist cessation effects [title] => Supporting patients through GLP-1 agonist cessation effects [href] => https://www.australianpharmacist.com.au/supporting-patients-through-drastic-glp-1-agonist-cessation-effects/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 24425 )

      Supporting patients through GLP-1 agonist cessation effects

      belladonna
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                  [post_date] => 2023-12-11 11:18:16
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                  [post_content] => When it comes to belladonna, the eyes have it. Pity it’s highly toxic...
      
      During the Italian Renaissance of the 14–16th centuries, belladonna was a popular cosmetic product. Well-dressed women used juice from the berries of the plant to dilate their pupils, resulting in a fashionably seductive look. Hence the name belladonna, Italian for ‘beautiful woman’.1–6
      
      But millennia before it helped make a fashion statement, belladonna was used as an anaesthetic, pain reliever and remedy for assorted ailments, not to mention as a hallucinogenic component of rituals. It was also used as an oral poison and to tip arrows.1,5,7
      
      Deadly nightshade, murderer’s berries, sorcerer’s berries and even devil’s berries — as belladonna’s alternative names reveal, its not so ‘bella’ side was well known. The plant was associated with broom-riding witches and poison potions.3,4,8
      
      Shakespeare described belladonna’s impact when referring to Juliet’s attempt to feign death to avoid marriage with Paris and escape with Romeo1,4,8:
      
      Her blood is settled, and her joints are stiff: Life and these lips have long been separated; Death lies on her like an untimely frost upon the sweetest flower of all the field.
      

      What is belladonna?

      Atropa belladonna is an ornamental plant of the Solanaceae family. It is native to Europe, North Africa and Western Asia. Growing to a height of 150 centimetres in barren stony soil, belladonna has oval leaves, green-purple flowers and sweet black berries.3-5,9,10,12 The herbaceous perennial is highly poisonous, especially the leaves and fruit. They contain atropine, scopolamine and hyoscyamine alkaloids. Consuming the alkaloids can be deadly. Just touching the leaves may cause a rash.1,6-9,10

      How it works

      Belladonna’s alkaloids affect the body’s nervous system. Specifically, they block the neurotransmitter acetylcholine from binding to the central nervous system and to parasympathetic postganglionic muscarinic receptors.6,7,9-11 Toxic effects can be wide-ranging, as evidenced by the case of an 11-year-old Moroccan girl treated for belladonna toxicity by the intensive care team at the Mother and Child Hospital in Fes.5,7,9 ‘She was given Atropa belladonna by an herbalist in a therapeutic interest,’ they reported. Her symptoms included dry mouth, confusion, incoherent speech, and an inability to recognise family members. She also presented with uncontrollable vomiting, visual disturbances, and hearing and visual hallucinations.7 Belladonna can also cause changes to saliva, sweat, pupil size, urination and digestive functions. It can also cause seizures, headaches and increased heart rate and blood pressure.10,11

      Medical uses

      Today, medicines containing alkaloids found in belladonna, such as atropine, are used in areas such as emergency medicine and anaesthesia.13 Interestingly, atropine is used as an antidote of organophosphate poisoning by reversing its muscarinic effects (such as vomiting, diarrhoea, bradycardia, miosis, sweating and salivation).13 Proving the eyes still have it, atropine is also indicated for use in optometry for conditions like uveitis, myopia progression, amblyopia and sometimes for eye exams.13 Overseas, transdermal scopolamine is sometimes used to help treat nausea and vomiting-related conditions.14

      References

      1. Fletcher J. Uses and risks of belladonna. Medical News Today. 2017. At: https://www.medicalnewstoday.com/articles/318180
      2. Meriney SD, Fanselow EE. Acetylcholine in Synaptic Transmission. Academic Press 2019:345–67. At: https://www.sciencedirect.com/topics/neuroscience/atropa-belladonna
      3. Passos ID, Mironidou-Tzouveleki M. Hallucinogenic Plants in the Mediterranean Countries in Neuropathology of Drug Addictions and Substance Misuse Vol 2. Academic Press. 2016:761–72. At: https://www.sciencedirect.com/science/article/abs/pii/B9780128002124000716
      4. Morris SM. Belladonna: remedy with a dark past. Healthline. 2017. At: https://www.healthline.com/health/belladonna-dark-past
      5. Annisadmin. Atropa belladonna: deadly nightshade. Penny Dreadful Archives. 2016. At: https://pennydreadfularchives.wordpress.com/2016/05/31/atropa-belladonna-deadly-nightshade/
      6. DrugBank. Belladonna. 2017. At: https://go.drugbank.com/drugs/DB13913
      7. Berdai MA, Labib S, Chetouani K, et al. Atropa belladonna intoxication: a case report. Pan Afr Med J 2012;11:72. Epub 2012 Apr 17. At: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361210/
      8. Mann J. Belladonna, broomsticks and brain chemistry. Education in Chemistry. 2008. At: https://edu.rsc.org/feature/belladonna-broomsticks-and-brain-chemistry/2020099.article
      9. Karagoz I, Bilgi M, Boduc E, et al. Atropa belladonna and associated anticholinergic toxic syndrome: a case report. Bali Med J 2017;3(3):S90–S92. At: https://balimedicaljournal.org/index.php/bmj/article/view/673/pdf_330
      10. National Library of Medicine. MedlinePlus. Belladonna. 2022. At: https://medlineplus.gov/druginfo/natural/531.html
      11. Banasik M, Stedeford T. Plants, Poisonous (Humans). Encyclopedia of Toxicology (Third Edition). Academic Press. 2014. p970–78. At: https://www.sciencedirect.com/science/article/abs/pii/B9780123864543000488
      12. Jim’s Mowing. The Essential List of Poisonous Plants in Australia. At: https://www.jimsmowing.com.au/2021/01/the-essential-list-of-poisonous-plants-in-australia/#:~:text=For%20the%20formidable%20deadly%20nightshade,has%20become%20a%20fruitful%20one
      13. Rossi S, ed. Australian medicines handbook. 2023. At: https://amhonline.amh.net.au
      14. Pruthi S, ed. Mayo clinic. 2023. Scopolamine (Transdermal Route). At: www.mayoclinic.org/drugs-supplements/scopolamine-transdermal-route/side-effects/drg-20072848?p=1#:~:text=Scopolamine%20transdermal%20patch%20is%20used,group%20of%20medicines%20called%20anticholinergics
      [post_title] => Belladonna: beautiful but deadly [post_excerpt] => Before it helped make a fashion statement, belladonna was used as an anaesthetic, pain reliever and remedy for assorted ailments. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => belladonna-beautiful-but-deadly [to_ping] => [pinged] => [post_modified] => 2023-12-11 14:54:06 [post_modified_gmt] => 2023-12-11 03:54:06 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24416 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Belladonna: beautiful but deadly [title] => Belladonna: beautiful but deadly [href] => https://www.australianpharmacist.com.au/belladonna-beautiful-but-deadly/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template ) [is_review:protected] => [post_thumb_id:protected] => 24419 )

      Belladonna: beautiful but deadly

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                  [post_date] => 2023-12-06 12:32:37
                  [post_date_gmt] => 2023-12-06 01:32:37
                  [post_content] => The significant rise in Australian asthma deaths is cause for immediate and widespread concern. Here’s what experts say needs to change.
      
      Asthma deaths are again on the rise, revealed new Australian Bureau of Statistics data  recently released by the National Asthma Council Australia.
      
      There were 467 asthma-related deaths in Australia in 2022, up from 355 deaths in 2021. Most (64%) were among women – with 299 female deaths versus 168 male deaths.
      
      Those most at risk of death are women aged 75 and older, accounting for 45% of all deaths followed by men in this age group (18%).
      
      This is the highest number of asthma deaths recorded since 2016-2017. Deaths were down in 2021 as a result of COVID-19 restrictions and lockdowns – leading to fewer respiratory infections and asthma exacerbations. However, asthma exacerbations have now returned to pre-pandemic levels and may even be slightly higher, warned National Asthma Council Australia Director and respiratory physician, Professor Peter Wark.
      
      [caption id="attachment_24414" align="alignright" width="225"] National Asthma Council Australia Director and respiratory physician, Professor Peter Wark[/caption]
      
      This may be the result of the increase in virus infections we saw following the easing of COVID-19 restrictions but the main reasons are a result of the intrinsic problems underlying asthma management in Australia. ‘We're not accurately diagnosing asthma, and we are under-treating it,’ he said.
      

      A need for better asthma diagnosis and control

      There was a marked decline in lung function testing during COVID-19. Despite an increase in funding under the Medicare Benefits Schedule for spirometry, there has been a reduction of two thirds in spirometry being billed under the MBS compared to 2018–19, said Prof Wark.  ‘Spirometry remains essential in the diagnosis of asthma and this will lead to under and overdiagnosis,’  said Prof Wark. Up to 20% of people who present to a pharmacy for salbutamol haven't had their asthma confirmed by spirometry, said Advanced Practice Pharmacist and National Asthma Council Australia Clinical Executive Lead Debbie Rigby FPS. ‘Because [pharmacists] can dispense salbutamol over the counter without a prescription, we have a responsibility to ask the right questions to determine patients’ level of control,’ she said.This could include asthma control tests. The Asthma Score is an example of such a test and comprises five questions. As part of this, pharmacists ask patients to rate their symptoms on a scale of one to five to indicate their asthma control over the last 4 weeks, including:
      • How frequently are your symptoms preventing you from participating in work, school or play as well as normal?
      • How often have you had shortness of breath?
      • How often are your symptoms waking you up at night or earlier in the morning than usual? 
      • How often have you been using your reliever?
      • How would you rate your asthma control?
      ‘If  [salbutamol] has been [used] three or more times in the last week, that's indicative of not having good asthma control,’ she said.

      Promoting the right treatments

      Over-the-counter short-acting beta agonists (SABAs) are associated with worse asthma outcomes, including death. But that isn't because the medicine is harmful – it's associated with inadequate asthma control, which has short and long term consequences. Overall there is suboptimal use of inhaled preventers or inhaled corticosteroids, that have been shown to improve asthma control, reduce asthma exacerbations and reduce the risk of death from asthma. This includes suboptimal use of as-needed inhaled low-dose ICS/formoterol for people with mild asthma. This treatment is recommended by Australian and international guidelines as an effective alternative to regular maintenance ICS , in people with mild asthma – and is more effective and safer than using SABAs alone, said Ms Rigby. ‘This more flexible approach to treatment is ideally suited to people with mild asthma, many of whom are now at risk because they are not using an ICS preventer.’ Pharmacists should take the opportunity to provide some much-needed education to patients about the benefits of the budesonide/formoterol combination, said Ms Rigby. ‘Formoterol works just as well and quickly as salbutamol, but they're also getting some inhaled corticosteroid – which helps with the inflammatory process going on in their lungs,’ she said. ‘Whereas with salbutamol, you're just helping with the bronchoconstriction. It's doing nothing about the underlying inflammation.’

      When is a biologic appropriate?

      When patients present with a prescription of prednisone, pharmacists can play an important role in appropriately identifying and informing them that this is a sign of poor asthma control and is a red flag that identifies a risk for severe acute asthma, including the risk of death, said Prof Wark. Aspects to explore should include:
      • Have they been prescribed a preventer? 
      • Are they using the preventer?
      • Are they taking it appropriately? 
      • If they are taking their preventer appropriately but still experiencing acute asthma, they may be eligible for assessment by a specialist for a biologic agent
      Asthma should be adequately controlled on moderate dose ICS together with a LABA. Persistence with high dose ICS or frequent courses of prednisone is certainly not the answer, said Prof Wark. A recent large population-based study conducted in the United Kingdom showed that stepping patients up to the highest doses of ICS adds little benefit to asthma management. ‘If a patient needs more than one or two courses of prednisone, and they're on an ICS/LABA, you need to ask the question, “should they be receiving treatment with a biologic?”’ he said.  Prof Wark advises that patients who might benefit from a biologic include those:
      • who continue to experience exacerbations and are overlying on prednisone
      • with active type two inflammation, identified through blood counts and exhaled nitric oxide.
      ‘The impact prednisone has on health is enormous, it accumulates over a lifetime of exposure and we have very effective treatments for asthma that should reduce our reliance upon its use,’ he said. ‘People in regional and remote Australia, with poor asthma control appear to be at greater risk of needing to use prednisone.’
      ‘Up to 20% of people who present to a pharmacy for salbutamol haven't had their asthma confirmed by spirometry.' Debbie Rigby FPS 
      Once patients exceed a lifetime cumulative dose of 500 mg of prednisone, the health risks increase dramatically  – leaving younger people who use the medicine particularly at risk. ‘Only one or two courses of prednisone in 12 months significantly increases the risk of developing osteoporosis, diabetes and infections such as pneumonia.’ Females over the age of 12 are at greater risk of poor asthma outcomes, said Prof Wark. When female patients have ongoing problems with asthma control and prednisone is needed – a biologic should be considered, he said. ‘If you're not getting good asthma control, these alternative treatments work exceptionally well for everyone, including women.’

      Get moving, and vaccinated

      Vaccination can significantly reduce the impact of respiratory viruses among patients with asthma – particularly those aged 65 and over who may have other comorbidities. Patients with asthma should receive: 
      • an annual influenza vaccination
      • the pneumococcal vaccine
      • a COVID-19 vaccine.
      Pharmacists can also advise patients that influenza vaccines are free of charge for those with asthma, said Prof Wark. ‘RSV vaccines will soon be available, likely targeting patients aged 65 years and over.’ Asthma also interacts with other diseases – particularly diabetes and cardiovascular disease – with around three quarters of people with asthma having another chronic disease, said Prof Wark. ‘When you combine age and a number of comorbidities, there’s a more complex picture. Inactivity and obesity and the relationship to asthma, cardiovascular disease and chronic diseases such as diabetes – are all linked.’ Exercise and activity have been associated with improvements in asthma symptoms, along with overall asthma control. While there should be ‘no limitations’ on the exercise patients with asthma can do, some factors might put them at risk.  ‘For example, exercising in cold or dry air can increase your risk of bronchospasm,’ he said. ‘So warming up before exercise is advised.’ For more information, refer to PSA’s updated treatment guideline in the Australian Pharmaceutical Formulary and Handbook digital site. [post_title] => Over 30% increase in asthma deaths in one year [post_excerpt] => The significant rise in Australian asthma deaths is cause for immediate and widespread concern. Here’s what experts say needs to change. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => over-30-increase-in-asthma-deaths-in-one-year [to_ping] => [pinged] => [post_modified] => 2023-12-06 16:09:30 [post_modified_gmt] => 2023-12-06 05:09:30 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24394 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Over 30% increase in asthma deaths in one year [title] => Over 30% increase in asthma deaths in one year [href] => https://www.australianpharmacist.com.au/over-30-increase-in-asthma-deaths-in-one-year/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 24406 )

      Over 30% increase in asthma deaths in one year

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                  [post_date] => 2023-12-04 14:21:06
                  [post_date_gmt] => 2023-12-04 03:21:06
                  [post_content] => With a plunge in vaccination rates following the COVID-19 pandemic peak, a new report says a concerted push is required, with a focus on national consistency.
      
      The Grattan Institute’s A fair shot: How to close the vaccination gap report recommends action on a National Vaccines Partnership Agreement and harmonisation of the state-based regulations that determine pharmacists’ authority to deliver certain vaccines – which currently differ in each jurisdiction.
      
      These recommendations echo PSA’s ongoing calls ​for a nationally consistent approach to vaccination, and demonstrate just how far we need to go to ensure equitable access to vaccination for all Australians, said PSA National President Dr Fei Sim FPS. 
      
      Australian Pharmacist takes a look at the groups with plummeting vaccination rates, and how empowering primary care professionals such as pharmacists can help to lift them.
      

      Older Australians and Aboriginal and Torres Strait Islander peoples are missing out

      Recommended vaccine uptake rates have continued to fall over the last couple of years, particularly among vulnerable groups. At the beginning of the 2023 winter, 2.5 million Australians over 65 years of age were not up to date with their COVID-19 vaccinations – a five-fold increase from 2022.  Other findings about COVID-19 vaccination include:
      • a crash in up-to-date vaccination from over 90% in December 2021 to less than 10% by the end of February 2023 among those considered high risk
      • vaccination rates only reached 38% among high-risk patients following a 2023 COVID-19 booster push 
      • as of November 2023, less than 4 in 10 aged care residents are considered up-to-date with COVID-19 vaccination.
      Older Australians are also behind with other important vaccinations. Less than half of people aged in their 70s were vaccinated for shingles, with even less (one in five) vaccinated against pneumococcal disease. Influenza vaccination rates are also consistently low across the board, with only 27% of Australians vaccinated against influenza in autumn 2023. High-risk groups that receive no-cost vaccinations under the National Immunisation Program (NIP) are beset by low or inconsistent flu vaccination rates, said the report. For example, only around 16% of Aboriginal and Torres Strait Islander people received an influenza vaccination ahead of winter. The report predicts vaccination rates will fall further due to several factors, including:
      • vaccine fatigue
      • confusion over which vaccines are needed
      • increased vaccine misinformation.
      While Australia has very high childhood vaccination rates by global standards, these factors are likely contributing to a decline in vaccination since 2020. Childhood vaccination rates had climbed up to 95%, but the nation is falling back from this highpoint – which is needed to provide adequate protections against many vaccine preventable diseases.

      Non-English speakers half as likely to get vaccinated against COVID-19

      There are several demographic factors leading to disparities in vaccination rates. Among high-risk adults, vaccination depends on:
      • areas lived
      • language spoken at home
      • level of earnings.
      While vaccination rates among Australians should be higher, the report emphasised that they need to be fairer. For example, patients who speak languages other than English at home are reportedly about half as likely to get recommended COVID-19 vaccinations. Those in rural areas are less likely to get vaccinated, with disparities also existing in major cities. For example, there is a nearly 30% variation in flu vaccination rates in different parts of Brisbane.

      Empowering pharmacists through red tape removal

      The report calls for a policy reset through a National Vaccination Agreement that outlines clearer goals and responsibilities to boost vaccination targets in high-risk groups.  The report also says that Primary Health Networks (PHNs) should be required to make ongoing progress towards reaching national targets, and must be equipped with funding to support general practice, pharmacists, and aged care providers to promote vaccination in mainstream primary care. The recent federal government commitment of 4 years of funding to support pharmacists to deliver free NIP vaccines to eligible people will improve access, increasing vaccination locations by up to 60%. This move will also help to ensure patients can access vaccines from a trusted provider with whom they have an existing relationship. Crucially, the report argues that ‘the federal government should work with state governments to make pharmacy vaccination regulations consistent across Australia’.  ‘State regulations determine whether pharmacists can deliver particular vaccines, who can get particular vaccines from pharmacists, and whether a pharmacist vaccination is free,’ said the report. ‘The federal government’s independent Scope of Practice Review should harmonise these regulations by removing state-specific restrictions, [and] investigate opportunities to remove restrictions on the scope of practice of Aboriginal Health Workers and Aboriginal Health Practitioners.’ A nationally consistent schedule of pharmacist-administered vaccines is key to achieve equitable access to government-funded vaccines by all Australians, agreed Dr Sim. ‘We know that there is no one-size-fits-all approach to improving vaccine uptake, with the report rightly highlighting the need for a tailored approach to ensuring vulnerable cohorts don’t fall through the cracks,’ Dr Sim said.​ ‘The federal government’s move to open up NIP funding for pharmacist-administered vaccines is a welcome first step, but there is more work to be done to allow pharmacists to deliver all vaccines to patients of all ages. ‘Pharmacists can and should be utilised as trusted health care professionals, working hand in glove with the rest of the primary care team to break down the barriers to vaccination, from improving equity and access, to amplifying public health messages.’ [post_title] => We need a nationally consistent vaccination approach, says think tank [post_excerpt] => With a plunge in vaccination rates following the COVID-19 pandemic peak, a new report says a focus on national consistency is required. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => we-need-a-nationally-consistent-vaccination-approach-says-top-think-tank [to_ping] => [pinged] => [post_modified] => 2023-12-04 15:12:35 [post_modified_gmt] => 2023-12-04 04:12:35 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24372 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => We need a nationally consistent vaccination approach, says think tank [title] => We need a nationally consistent vaccination approach, says think tank [href] => https://www.australianpharmacist.com.au/we-need-a-nationally-consistent-vaccination-approach-says-top-think-tank/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14650 )

      We need a nationally consistent vaccination approach, says think tank

      clozapine
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                  [post_date] => 2023-12-04 14:07:21
                  [post_date_gmt] => 2023-12-04 03:07:21
                  [post_content] => Clozapine is indicated for the management of treatment-resistant schizophrenia. Its use is subject to strict regulatory and monitoring requirements due to potential toxicity, most notably agranulocytosis and neutropenia. 
      
      Each brand has its own protocol monitoring service1,2:
      
      • Clozaril (Viatris) – the Clozaril Patient Monitoring System (CPMS), and
      • Clopine (Pfizer) – ClopineCENTRAL.

      Is registration with these services mandatory?

      Yes. Prescribers, pharmacies and pharmacists must be registered with the respective service. Individual pharmacists may be registered to multiple pharmacies. They must be used for every dispense event.

      A patient has run out of medicines but now new blood tests have been provided. Can I dispense an emergency supply?

      No. Dispensing cannot occur beyond the next blood test due date until a doctor and pharmacist have reviewed a new white blood count (WBC) and neutrophil count and deemed them acceptable.

      Is it OK to rely on blood tests I access from MHR or that the prescriber sends to the pharmacy?

      Yes. However, the pharmacist must be satisfied the pathology results have been reviewed and approved by the patient’s medical practitioner. Where the prescriber has not entered these blood results into the relevant monitoring system, the pharmacist must enter these details at the time of dispensing or transmit them to the monitoring system via fax for upload.

      What happens if someone does not collect their prescription within 48 hours of the pathology blood test?

      Interruptions to therapy may require re-titration, so pharmacists should first check to determine if there has been an interruption in therapy of >48 hours. If so, withhold supply and refer for urgent review. If therapy is uninterrupted, the amount supplied would be the original quantity minus the number of days late presenting to the pharmacy. This is known as the ’48-hour rule’. For example, if a patient who had a prescription for 28 days’ therapy presented on Saturday for a blood test taken 5 days earlier on Monday, then up to 25 days’ therapy could be supplied. 

      Is other monitoring required? 

      Yes. In addition to haematological monitoring, people taking clozapine require monitoring for changes in cardiac, metabolic, gastrointestinal and central nervous system functioning.  In April 2022, the Therapeutic Goods Administration (TGA) mandated a boxed warning in the product information for clozapine in relation to the potentially fatal risk of gastrointestinal hypomotility. The TGA alert noted that approximately 10% (n = 103) of clozapine reports with a fatal outcome were due to gastrointestinal disorders.3 All health professionals should enquire routinely about patient’s bowel habits. Nausea and/or vomiting, abdominal distension and/or pain, lack of urge and/or inability to defecate or constipation should prompt further assessment and urgent referral for immediate review.

      References

      1. Chao A. Clopine CENTRAL: Your connection to Clopine (clozapine) patient care, Pfizer Australia, WestRyde. 2017. At: www.clopine.com.au/ClopineCentral
      2. Clozaril Patient Monitoring System Protocol.September 2019, ver. 5. Mylan. At: www.ecpms.com.au/
      3. Therapeutic Goods Administration, Department of Health and Aged Care, Australian Government.Medicines safety update: clozapine and gastrointestinal hypomotility with severe complications. 2022. At: www.tga.gov.au/news/safety-updates/clozapine-and-gastrointestinal-hypomotility-severe-complications
      [post_title] => FAQ: clozapine’s close checks [post_excerpt] => Clozapine, used for the management of treatment-resistant schizophrenia, is subject to strict regulatory and monitoring requirements. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => faq-clozapines-close-checks [to_ping] => [pinged] => [post_modified] => 2023-12-04 15:12:02 [post_modified_gmt] => 2023-12-04 04:12:02 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24360 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => FAQ: clozapine’s close checks [title] => FAQ: clozapine’s close checks [href] => https://www.australianpharmacist.com.au/faq-clozapines-close-checks/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template ) [is_review:protected] => [post_thumb_id:protected] => 24367 )

      FAQ: clozapine’s close checks

  • CPD
    • GLP-1 agonist
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                  [post_date] => 2023-12-11 13:33:42
                  [post_date_gmt] => 2023-12-11 02:33:42
                  [post_content] => Glucagon-like peptide 1 (GLP-1) agonists, traditionally used to manage type 2 diabetes, have been increasingly prescribed off-label for weight loss. 
      
      There are four GLP-1 agonist medicines approved by the Therapeutic Goods Administration (TGA) for use in Australia for the management of Type 2 Diabetes:
      
      • dulaglutide (Trulicity)
      • semaglutide (Ozempic)
      • tirzepatide (Mounjaro)
      • liraglutide (Saxenda). 
      There are only two GLP-1 agonists that are TGA approved for weight loss, semaglutide (Wegovy brand) and liraglutide (Saxenda). With Christmas just around the corner – leaving budgets tight and GP access slim, coupled with substantial, persistent stock shortages – patients may find treatment abruptly interrupted. PSA GP Pharmacist Anouska Feszczur MPS has helped several patients navigate through their reported GLP-1 agonist cessation symptoms. Here are her top tips.

      Prepare for a ravenous appetite and a return of impulsive behaviours

      When patients stop GLP-1 agonists, the most significant cessation symptom is an increased appetite far exceeding pre-treatment levels, said Ms Feszczur. [caption id="attachment_24426" align="aligncenter" width="500"]GLP-1 agonist Anouska Feszczur MPS[/caption] ‘Patients have told me cravings and appetite return with an insatiable force they’ve never experienced before,’ she said. ‘They also experience cravings for foods they had zero interest in while taking a GLP-1 agonist.’  The hunger and cravings tend to be extreme upon cessation, evening out over the space of weeks or months, said Ms Feszczur.  This cessation symptom leads to another common post-treatment effect: weight gain. ‘Evidence shows stopping semaglutide leads to weight gain,’ said Ms Feszczur. ‘In one study, all participants put on two thirds of their weight back on in a year.’  Because patients often gain back the weight they lost post-treatment, other health benefits similarly erode. ‘For example, if a patient's blood pressure or blood sugar levels improve during treatment with a GLP-1 agonist, they can go back to where they were when they stop,’ she said. Mood can also be impacted upon GLP-1 agonist cessation. ‘Patients who felt proud of themselves for losing weight can experience guilt, shame and despair,’ said Ms Feszczur. ’They've spent all this money on treatment, and suddenly the weight has come back on.’ Lastly, some patients have mentioned an impact on impulsive behaviours when the dopamine regulation effects of GLP-1 agonists appear to wear off. ‘Almost all patients have said they drink less alcohol because they just don't get the same buzz, and one patient even stopped chewing their nails,’ she said. ‘Some people have also indicated in forums that online shopping and gambling behaviour changed while they were on Ozempic.’ Those impulsive behaviours can return upon cessation, said Ms Feszczur – rendering the holiday period, where people tend to overeat, drink and spend,  a tricky time to go off these medicines.  ‘It could be quite distressing for patients who feel they have no control over impulsive behaviours.’

      Encourage tapering and identify movement barriers

      When patients cease GLP-1 agonists, optimising medicines for comorbid health conditions could be beneficial, said Ms Feszczur. ‘[Find out] if there’s anything they're taking, or not taking, that might be a barrier to movement. For example, with pain management.’ Other services can help patients work through their movement challenges. ‘I’ve referred a patient with arthritis who ceased semaglutide to painHEALTH, a self-directed learning module on pacing which is all about trying to increase movement while still in pain,’ she said. Ms Feszczur also suggests patients taper from GLP-1 agonists rather than immediate cessation. ‘GLP-1 agonists mimic a hormone. Any other medicine we give patients that mimic hormones, such as steroids, are tapered so the body can start making its own hormones again,’ she said. ‘If I know a patient is running out of Ozempic, and there's no stock anywhere, I’ll advise a plan to reduce it gradually, which also empowers patients to mindfully go into cessation.’

      Eat the right food and seek help for mood changes

      To help reduce an insatiable appetite, pharmacists should recommend patients eat nutrient-rich food with low-calorie density. ‘Suggest eating protein with every meal and water-filled foods that make you feel fuller, such as watermelon, grapes and apples,’ said Ms Feszczur.  Patients should also avoid foods that don't make them feel full. ‘For example if a patient loves chocolate but it doesn’t fill them up, advise them to swap it for low-calorie ice cream.’ Tools such as a food tracker app might also help patients regain a sense of control as they see their intake coming down. Importantly, patients should be advised to be on the lookout for any mood or behavioural changes. ‘You could say to patients, “If you see impulsive behaviours increase, it's important that you try to go to the GP – even though it’s a busy period”,’ said Ms Feszczur. If GP access is difficult over the Christmas period, there are various helplines patients can access, including:
      • National Alcohol and Other Drug Hotline
      • Department of Social Services’ Gambling Support
      • Turning Point.

      Ongoing support is required

      GLP-1 agonist cessation provides a good opportunity for pharmacists to promote a multidisciplinary approach to weight management, said Ms Feszczur.   Nutritional support could come from:
      • a dietician
      • GP
      • formalised online nutrition programs such as Noom or MyFitnessPal.
      ‘A psychologist can also be useful to address some of the behaviours that may have led to overeating,’ she said. ‘Patients could be referred to their GP for a mental health treatment plan.’ Movement support is another area that should be considered. Pharmacists can ask:
      • how are you finding movement? 
      • do you need help from an exercise physiologist to create a plan? 
      • are you happy to pay for a personal trainer? 
      Pharmacists should also encourage patients to make sleep a priority. ‘We know people who have good quality sleep have better luck maintaining their weight,’ said Ms Feszczur.  Sleep hygiene habits, as outlined by the Sleep Health Foundation here, can be discussed with patients. ‘There are also free Cognitive Behavioural Therapy for Insomnia (CBT-I) programs people can do at home to make sleep a priority.’

      Report cessation effects to the TGA

      Given GLP-1 agonist cessation is an emerging area, pharmacists should consider reporting any effects to the TGA, or encourage patients to self-report. ‘As the TGA says, “You don’t have to be certain, just suspicious”,’ said Ms Feszczur. ‘The only way we can build evidence is for people to say something.’ Setting expectations about cessation before patients start a GLP-1 agonist can also help them to prepare. ‘Pharmacists could say, “You might find it easy to lose weight while you're on this medicine. But it’s important to make profound changes to your lifestyle, or most of the weight could come back on,’ she said.

      Watch this space!

      There is an emerging evidence base for using GLP-1 agonists to treat other conditions – including dementia and addiction, said Ms Feszczur.  ‘My advice to pharmacists is to keep an eye out for new and emerging therapeutic areas for GLP-1 agonists, as well as any information you can find on cessation.’ [post_title] => Supporting patients through GLP-1 agonist cessation effects [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => supporting-patients-through-drastic-glp-1-agonist-cessation-effects [to_ping] => [pinged] => [post_modified] => 2023-12-11 14:54:36 [post_modified_gmt] => 2023-12-11 03:54:36 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24423 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Supporting patients through GLP-1 agonist cessation effects [title] => Supporting patients through GLP-1 agonist cessation effects [href] => https://www.australianpharmacist.com.au/supporting-patients-through-drastic-glp-1-agonist-cessation-effects/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 24425 )

      Supporting patients through GLP-1 agonist cessation effects

      belladonna
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                  [post_date] => 2023-12-11 11:18:16
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                  [post_content] => When it comes to belladonna, the eyes have it. Pity it’s highly toxic...
      
      During the Italian Renaissance of the 14–16th centuries, belladonna was a popular cosmetic product. Well-dressed women used juice from the berries of the plant to dilate their pupils, resulting in a fashionably seductive look. Hence the name belladonna, Italian for ‘beautiful woman’.1–6
      
      But millennia before it helped make a fashion statement, belladonna was used as an anaesthetic, pain reliever and remedy for assorted ailments, not to mention as a hallucinogenic component of rituals. It was also used as an oral poison and to tip arrows.1,5,7
      
      Deadly nightshade, murderer’s berries, sorcerer’s berries and even devil’s berries — as belladonna’s alternative names reveal, its not so ‘bella’ side was well known. The plant was associated with broom-riding witches and poison potions.3,4,8
      
      Shakespeare described belladonna’s impact when referring to Juliet’s attempt to feign death to avoid marriage with Paris and escape with Romeo1,4,8:
      
      Her blood is settled, and her joints are stiff: Life and these lips have long been separated; Death lies on her like an untimely frost upon the sweetest flower of all the field.
      

      What is belladonna?

      Atropa belladonna is an ornamental plant of the Solanaceae family. It is native to Europe, North Africa and Western Asia. Growing to a height of 150 centimetres in barren stony soil, belladonna has oval leaves, green-purple flowers and sweet black berries.3-5,9,10,12 The herbaceous perennial is highly poisonous, especially the leaves and fruit. They contain atropine, scopolamine and hyoscyamine alkaloids. Consuming the alkaloids can be deadly. Just touching the leaves may cause a rash.1,6-9,10

      How it works

      Belladonna’s alkaloids affect the body’s nervous system. Specifically, they block the neurotransmitter acetylcholine from binding to the central nervous system and to parasympathetic postganglionic muscarinic receptors.6,7,9-11 Toxic effects can be wide-ranging, as evidenced by the case of an 11-year-old Moroccan girl treated for belladonna toxicity by the intensive care team at the Mother and Child Hospital in Fes.5,7,9 ‘She was given Atropa belladonna by an herbalist in a therapeutic interest,’ they reported. Her symptoms included dry mouth, confusion, incoherent speech, and an inability to recognise family members. She also presented with uncontrollable vomiting, visual disturbances, and hearing and visual hallucinations.7 Belladonna can also cause changes to saliva, sweat, pupil size, urination and digestive functions. It can also cause seizures, headaches and increased heart rate and blood pressure.10,11

      Medical uses

      Today, medicines containing alkaloids found in belladonna, such as atropine, are used in areas such as emergency medicine and anaesthesia.13 Interestingly, atropine is used as an antidote of organophosphate poisoning by reversing its muscarinic effects (such as vomiting, diarrhoea, bradycardia, miosis, sweating and salivation).13 Proving the eyes still have it, atropine is also indicated for use in optometry for conditions like uveitis, myopia progression, amblyopia and sometimes for eye exams.13 Overseas, transdermal scopolamine is sometimes used to help treat nausea and vomiting-related conditions.14

      References

      1. Fletcher J. Uses and risks of belladonna. Medical News Today. 2017. At: https://www.medicalnewstoday.com/articles/318180
      2. Meriney SD, Fanselow EE. Acetylcholine in Synaptic Transmission. Academic Press 2019:345–67. At: https://www.sciencedirect.com/topics/neuroscience/atropa-belladonna
      3. Passos ID, Mironidou-Tzouveleki M. Hallucinogenic Plants in the Mediterranean Countries in Neuropathology of Drug Addictions and Substance Misuse Vol 2. Academic Press. 2016:761–72. At: https://www.sciencedirect.com/science/article/abs/pii/B9780128002124000716
      4. Morris SM. Belladonna: remedy with a dark past. Healthline. 2017. At: https://www.healthline.com/health/belladonna-dark-past
      5. Annisadmin. Atropa belladonna: deadly nightshade. Penny Dreadful Archives. 2016. At: https://pennydreadfularchives.wordpress.com/2016/05/31/atropa-belladonna-deadly-nightshade/
      6. DrugBank. Belladonna. 2017. At: https://go.drugbank.com/drugs/DB13913
      7. Berdai MA, Labib S, Chetouani K, et al. Atropa belladonna intoxication: a case report. Pan Afr Med J 2012;11:72. Epub 2012 Apr 17. At: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361210/
      8. Mann J. Belladonna, broomsticks and brain chemistry. Education in Chemistry. 2008. At: https://edu.rsc.org/feature/belladonna-broomsticks-and-brain-chemistry/2020099.article
      9. Karagoz I, Bilgi M, Boduc E, et al. Atropa belladonna and associated anticholinergic toxic syndrome: a case report. Bali Med J 2017;3(3):S90–S92. At: https://balimedicaljournal.org/index.php/bmj/article/view/673/pdf_330
      10. National Library of Medicine. MedlinePlus. Belladonna. 2022. At: https://medlineplus.gov/druginfo/natural/531.html
      11. Banasik M, Stedeford T. Plants, Poisonous (Humans). Encyclopedia of Toxicology (Third Edition). Academic Press. 2014. p970–78. At: https://www.sciencedirect.com/science/article/abs/pii/B9780123864543000488
      12. Jim’s Mowing. The Essential List of Poisonous Plants in Australia. At: https://www.jimsmowing.com.au/2021/01/the-essential-list-of-poisonous-plants-in-australia/#:~:text=For%20the%20formidable%20deadly%20nightshade,has%20become%20a%20fruitful%20one
      13. Rossi S, ed. Australian medicines handbook. 2023. At: https://amhonline.amh.net.au
      14. Pruthi S, ed. Mayo clinic. 2023. Scopolamine (Transdermal Route). At: www.mayoclinic.org/drugs-supplements/scopolamine-transdermal-route/side-effects/drg-20072848?p=1#:~:text=Scopolamine%20transdermal%20patch%20is%20used,group%20of%20medicines%20called%20anticholinergics
      [post_title] => Belladonna: beautiful but deadly [post_excerpt] => Before it helped make a fashion statement, belladonna was used as an anaesthetic, pain reliever and remedy for assorted ailments. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => belladonna-beautiful-but-deadly [to_ping] => [pinged] => [post_modified] => 2023-12-11 14:54:06 [post_modified_gmt] => 2023-12-11 03:54:06 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24416 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Belladonna: beautiful but deadly [title] => Belladonna: beautiful but deadly [href] => https://www.australianpharmacist.com.au/belladonna-beautiful-but-deadly/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template ) [is_review:protected] => [post_thumb_id:protected] => 24419 )

      Belladonna: beautiful but deadly

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                  [post_date] => 2023-12-06 12:32:37
                  [post_date_gmt] => 2023-12-06 01:32:37
                  [post_content] => The significant rise in Australian asthma deaths is cause for immediate and widespread concern. Here’s what experts say needs to change.
      
      Asthma deaths are again on the rise, revealed new Australian Bureau of Statistics data  recently released by the National Asthma Council Australia.
      
      There were 467 asthma-related deaths in Australia in 2022, up from 355 deaths in 2021. Most (64%) were among women – with 299 female deaths versus 168 male deaths.
      
      Those most at risk of death are women aged 75 and older, accounting for 45% of all deaths followed by men in this age group (18%).
      
      This is the highest number of asthma deaths recorded since 2016-2017. Deaths were down in 2021 as a result of COVID-19 restrictions and lockdowns – leading to fewer respiratory infections and asthma exacerbations. However, asthma exacerbations have now returned to pre-pandemic levels and may even be slightly higher, warned National Asthma Council Australia Director and respiratory physician, Professor Peter Wark.
      
      [caption id="attachment_24414" align="alignright" width="225"] National Asthma Council Australia Director and respiratory physician, Professor Peter Wark[/caption]
      
      This may be the result of the increase in virus infections we saw following the easing of COVID-19 restrictions but the main reasons are a result of the intrinsic problems underlying asthma management in Australia. ‘We're not accurately diagnosing asthma, and we are under-treating it,’ he said.
      

      A need for better asthma diagnosis and control

      There was a marked decline in lung function testing during COVID-19. Despite an increase in funding under the Medicare Benefits Schedule for spirometry, there has been a reduction of two thirds in spirometry being billed under the MBS compared to 2018–19, said Prof Wark.  ‘Spirometry remains essential in the diagnosis of asthma and this will lead to under and overdiagnosis,’  said Prof Wark. Up to 20% of people who present to a pharmacy for salbutamol haven't had their asthma confirmed by spirometry, said Advanced Practice Pharmacist and National Asthma Council Australia Clinical Executive Lead Debbie Rigby FPS. ‘Because [pharmacists] can dispense salbutamol over the counter without a prescription, we have a responsibility to ask the right questions to determine patients’ level of control,’ she said.This could include asthma control tests. The Asthma Score is an example of such a test and comprises five questions. As part of this, pharmacists ask patients to rate their symptoms on a scale of one to five to indicate their asthma control over the last 4 weeks, including:
      • How frequently are your symptoms preventing you from participating in work, school or play as well as normal?
      • How often have you had shortness of breath?
      • How often are your symptoms waking you up at night or earlier in the morning than usual? 
      • How often have you been using your reliever?
      • How would you rate your asthma control?
      ‘If  [salbutamol] has been [used] three or more times in the last week, that's indicative of not having good asthma control,’ she said.

      Promoting the right treatments

      Over-the-counter short-acting beta agonists (SABAs) are associated with worse asthma outcomes, including death. But that isn't because the medicine is harmful – it's associated with inadequate asthma control, which has short and long term consequences. Overall there is suboptimal use of inhaled preventers or inhaled corticosteroids, that have been shown to improve asthma control, reduce asthma exacerbations and reduce the risk of death from asthma. This includes suboptimal use of as-needed inhaled low-dose ICS/formoterol for people with mild asthma. This treatment is recommended by Australian and international guidelines as an effective alternative to regular maintenance ICS , in people with mild asthma – and is more effective and safer than using SABAs alone, said Ms Rigby. ‘This more flexible approach to treatment is ideally suited to people with mild asthma, many of whom are now at risk because they are not using an ICS preventer.’ Pharmacists should take the opportunity to provide some much-needed education to patients about the benefits of the budesonide/formoterol combination, said Ms Rigby. ‘Formoterol works just as well and quickly as salbutamol, but they're also getting some inhaled corticosteroid – which helps with the inflammatory process going on in their lungs,’ she said. ‘Whereas with salbutamol, you're just helping with the bronchoconstriction. It's doing nothing about the underlying inflammation.’

      When is a biologic appropriate?

      When patients present with a prescription of prednisone, pharmacists can play an important role in appropriately identifying and informing them that this is a sign of poor asthma control and is a red flag that identifies a risk for severe acute asthma, including the risk of death, said Prof Wark. Aspects to explore should include:
      • Have they been prescribed a preventer? 
      • Are they using the preventer?
      • Are they taking it appropriately? 
      • If they are taking their preventer appropriately but still experiencing acute asthma, they may be eligible for assessment by a specialist for a biologic agent
      Asthma should be adequately controlled on moderate dose ICS together with a LABA. Persistence with high dose ICS or frequent courses of prednisone is certainly not the answer, said Prof Wark. A recent large population-based study conducted in the United Kingdom showed that stepping patients up to the highest doses of ICS adds little benefit to asthma management. ‘If a patient needs more than one or two courses of prednisone, and they're on an ICS/LABA, you need to ask the question, “should they be receiving treatment with a biologic?”’ he said.  Prof Wark advises that patients who might benefit from a biologic include those:
      • who continue to experience exacerbations and are overlying on prednisone
      • with active type two inflammation, identified through blood counts and exhaled nitric oxide.
      ‘The impact prednisone has on health is enormous, it accumulates over a lifetime of exposure and we have very effective treatments for asthma that should reduce our reliance upon its use,’ he said. ‘People in regional and remote Australia, with poor asthma control appear to be at greater risk of needing to use prednisone.’
      ‘Up to 20% of people who present to a pharmacy for salbutamol haven't had their asthma confirmed by spirometry.' Debbie Rigby FPS 
      Once patients exceed a lifetime cumulative dose of 500 mg of prednisone, the health risks increase dramatically  – leaving younger people who use the medicine particularly at risk. ‘Only one or two courses of prednisone in 12 months significantly increases the risk of developing osteoporosis, diabetes and infections such as pneumonia.’ Females over the age of 12 are at greater risk of poor asthma outcomes, said Prof Wark. When female patients have ongoing problems with asthma control and prednisone is needed – a biologic should be considered, he said. ‘If you're not getting good asthma control, these alternative treatments work exceptionally well for everyone, including women.’

      Get moving, and vaccinated

      Vaccination can significantly reduce the impact of respiratory viruses among patients with asthma – particularly those aged 65 and over who may have other comorbidities. Patients with asthma should receive: 
      • an annual influenza vaccination
      • the pneumococcal vaccine
      • a COVID-19 vaccine.
      Pharmacists can also advise patients that influenza vaccines are free of charge for those with asthma, said Prof Wark. ‘RSV vaccines will soon be available, likely targeting patients aged 65 years and over.’ Asthma also interacts with other diseases – particularly diabetes and cardiovascular disease – with around three quarters of people with asthma having another chronic disease, said Prof Wark. ‘When you combine age and a number of comorbidities, there’s a more complex picture. Inactivity and obesity and the relationship to asthma, cardiovascular disease and chronic diseases such as diabetes – are all linked.’ Exercise and activity have been associated with improvements in asthma symptoms, along with overall asthma control. While there should be ‘no limitations’ on the exercise patients with asthma can do, some factors might put them at risk.  ‘For example, exercising in cold or dry air can increase your risk of bronchospasm,’ he said. ‘So warming up before exercise is advised.’ For more information, refer to PSA’s updated treatment guideline in the Australian Pharmaceutical Formulary and Handbook digital site. [post_title] => Over 30% increase in asthma deaths in one year [post_excerpt] => The significant rise in Australian asthma deaths is cause for immediate and widespread concern. Here’s what experts say needs to change. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => over-30-increase-in-asthma-deaths-in-one-year [to_ping] => [pinged] => [post_modified] => 2023-12-06 16:09:30 [post_modified_gmt] => 2023-12-06 05:09:30 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24394 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Over 30% increase in asthma deaths in one year [title] => Over 30% increase in asthma deaths in one year [href] => https://www.australianpharmacist.com.au/over-30-increase-in-asthma-deaths-in-one-year/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 24406 )

      Over 30% increase in asthma deaths in one year

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                  [post_date] => 2023-12-04 14:21:06
                  [post_date_gmt] => 2023-12-04 03:21:06
                  [post_content] => With a plunge in vaccination rates following the COVID-19 pandemic peak, a new report says a concerted push is required, with a focus on national consistency.
      
      The Grattan Institute’s A fair shot: How to close the vaccination gap report recommends action on a National Vaccines Partnership Agreement and harmonisation of the state-based regulations that determine pharmacists’ authority to deliver certain vaccines – which currently differ in each jurisdiction.
      
      These recommendations echo PSA’s ongoing calls ​for a nationally consistent approach to vaccination, and demonstrate just how far we need to go to ensure equitable access to vaccination for all Australians, said PSA National President Dr Fei Sim FPS. 
      
      Australian Pharmacist takes a look at the groups with plummeting vaccination rates, and how empowering primary care professionals such as pharmacists can help to lift them.
      

      Older Australians and Aboriginal and Torres Strait Islander peoples are missing out

      Recommended vaccine uptake rates have continued to fall over the last couple of years, particularly among vulnerable groups. At the beginning of the 2023 winter, 2.5 million Australians over 65 years of age were not up to date with their COVID-19 vaccinations – a five-fold increase from 2022.  Other findings about COVID-19 vaccination include:
      • a crash in up-to-date vaccination from over 90% in December 2021 to less than 10% by the end of February 2023 among those considered high risk
      • vaccination rates only reached 38% among high-risk patients following a 2023 COVID-19 booster push 
      • as of November 2023, less than 4 in 10 aged care residents are considered up-to-date with COVID-19 vaccination.
      Older Australians are also behind with other important vaccinations. Less than half of people aged in their 70s were vaccinated for shingles, with even less (one in five) vaccinated against pneumococcal disease. Influenza vaccination rates are also consistently low across the board, with only 27% of Australians vaccinated against influenza in autumn 2023. High-risk groups that receive no-cost vaccinations under the National Immunisation Program (NIP) are beset by low or inconsistent flu vaccination rates, said the report. For example, only around 16% of Aboriginal and Torres Strait Islander people received an influenza vaccination ahead of winter. The report predicts vaccination rates will fall further due to several factors, including:
      • vaccine fatigue
      • confusion over which vaccines are needed
      • increased vaccine misinformation.
      While Australia has very high childhood vaccination rates by global standards, these factors are likely contributing to a decline in vaccination since 2020. Childhood vaccination rates had climbed up to 95%, but the nation is falling back from this highpoint – which is needed to provide adequate protections against many vaccine preventable diseases.

      Non-English speakers half as likely to get vaccinated against COVID-19

      There are several demographic factors leading to disparities in vaccination rates. Among high-risk adults, vaccination depends on:
      • areas lived
      • language spoken at home
      • level of earnings.
      While vaccination rates among Australians should be higher, the report emphasised that they need to be fairer. For example, patients who speak languages other than English at home are reportedly about half as likely to get recommended COVID-19 vaccinations. Those in rural areas are less likely to get vaccinated, with disparities also existing in major cities. For example, there is a nearly 30% variation in flu vaccination rates in different parts of Brisbane.

      Empowering pharmacists through red tape removal

      The report calls for a policy reset through a National Vaccination Agreement that outlines clearer goals and responsibilities to boost vaccination targets in high-risk groups.  The report also says that Primary Health Networks (PHNs) should be required to make ongoing progress towards reaching national targets, and must be equipped with funding to support general practice, pharmacists, and aged care providers to promote vaccination in mainstream primary care. The recent federal government commitment of 4 years of funding to support pharmacists to deliver free NIP vaccines to eligible people will improve access, increasing vaccination locations by up to 60%. This move will also help to ensure patients can access vaccines from a trusted provider with whom they have an existing relationship. Crucially, the report argues that ‘the federal government should work with state governments to make pharmacy vaccination regulations consistent across Australia’.  ‘State regulations determine whether pharmacists can deliver particular vaccines, who can get particular vaccines from pharmacists, and whether a pharmacist vaccination is free,’ said the report. ‘The federal government’s independent Scope of Practice Review should harmonise these regulations by removing state-specific restrictions, [and] investigate opportunities to remove restrictions on the scope of practice of Aboriginal Health Workers and Aboriginal Health Practitioners.’ A nationally consistent schedule of pharmacist-administered vaccines is key to achieve equitable access to government-funded vaccines by all Australians, agreed Dr Sim. ‘We know that there is no one-size-fits-all approach to improving vaccine uptake, with the report rightly highlighting the need for a tailored approach to ensuring vulnerable cohorts don’t fall through the cracks,’ Dr Sim said.​ ‘The federal government’s move to open up NIP funding for pharmacist-administered vaccines is a welcome first step, but there is more work to be done to allow pharmacists to deliver all vaccines to patients of all ages. ‘Pharmacists can and should be utilised as trusted health care professionals, working hand in glove with the rest of the primary care team to break down the barriers to vaccination, from improving equity and access, to amplifying public health messages.’ [post_title] => We need a nationally consistent vaccination approach, says think tank [post_excerpt] => With a plunge in vaccination rates following the COVID-19 pandemic peak, a new report says a focus on national consistency is required. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => we-need-a-nationally-consistent-vaccination-approach-says-top-think-tank [to_ping] => [pinged] => [post_modified] => 2023-12-04 15:12:35 [post_modified_gmt] => 2023-12-04 04:12:35 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24372 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => We need a nationally consistent vaccination approach, says think tank [title] => We need a nationally consistent vaccination approach, says think tank [href] => https://www.australianpharmacist.com.au/we-need-a-nationally-consistent-vaccination-approach-says-top-think-tank/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14650 )

      We need a nationally consistent vaccination approach, says think tank

      clozapine
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                  [post_date] => 2023-12-04 14:07:21
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                  [post_content] => Clozapine is indicated for the management of treatment-resistant schizophrenia. Its use is subject to strict regulatory and monitoring requirements due to potential toxicity, most notably agranulocytosis and neutropenia. 
      
      Each brand has its own protocol monitoring service1,2:
      
      • Clozaril (Viatris) – the Clozaril Patient Monitoring System (CPMS), and
      • Clopine (Pfizer) – ClopineCENTRAL.

      Is registration with these services mandatory?

      Yes. Prescribers, pharmacies and pharmacists must be registered with the respective service. Individual pharmacists may be registered to multiple pharmacies. They must be used for every dispense event.

      A patient has run out of medicines but now new blood tests have been provided. Can I dispense an emergency supply?

      No. Dispensing cannot occur beyond the next blood test due date until a doctor and pharmacist have reviewed a new white blood count (WBC) and neutrophil count and deemed them acceptable.

      Is it OK to rely on blood tests I access from MHR or that the prescriber sends to the pharmacy?

      Yes. However, the pharmacist must be satisfied the pathology results have been reviewed and approved by the patient’s medical practitioner. Where the prescriber has not entered these blood results into the relevant monitoring system, the pharmacist must enter these details at the time of dispensing or transmit them to the monitoring system via fax for upload.

      What happens if someone does not collect their prescription within 48 hours of the pathology blood test?

      Interruptions to therapy may require re-titration, so pharmacists should first check to determine if there has been an interruption in therapy of >48 hours. If so, withhold supply and refer for urgent review. If therapy is uninterrupted, the amount supplied would be the original quantity minus the number of days late presenting to the pharmacy. This is known as the ’48-hour rule’. For example, if a patient who had a prescription for 28 days’ therapy presented on Saturday for a blood test taken 5 days earlier on Monday, then up to 25 days’ therapy could be supplied. 

      Is other monitoring required? 

      Yes. In addition to haematological monitoring, people taking clozapine require monitoring for changes in cardiac, metabolic, gastrointestinal and central nervous system functioning.  In April 2022, the Therapeutic Goods Administration (TGA) mandated a boxed warning in the product information for clozapine in relation to the potentially fatal risk of gastrointestinal hypomotility. The TGA alert noted that approximately 10% (n = 103) of clozapine reports with a fatal outcome were due to gastrointestinal disorders.3 All health professionals should enquire routinely about patient’s bowel habits. Nausea and/or vomiting, abdominal distension and/or pain, lack of urge and/or inability to defecate or constipation should prompt further assessment and urgent referral for immediate review.

      References

      1. Chao A. Clopine CENTRAL: Your connection to Clopine (clozapine) patient care, Pfizer Australia, WestRyde. 2017. At: www.clopine.com.au/ClopineCentral
      2. Clozaril Patient Monitoring System Protocol.September 2019, ver. 5. Mylan. At: www.ecpms.com.au/
      3. Therapeutic Goods Administration, Department of Health and Aged Care, Australian Government.Medicines safety update: clozapine and gastrointestinal hypomotility with severe complications. 2022. At: www.tga.gov.au/news/safety-updates/clozapine-and-gastrointestinal-hypomotility-severe-complications
      [post_title] => FAQ: clozapine’s close checks [post_excerpt] => Clozapine, used for the management of treatment-resistant schizophrenia, is subject to strict regulatory and monitoring requirements. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => faq-clozapines-close-checks [to_ping] => [pinged] => [post_modified] => 2023-12-04 15:12:02 [post_modified_gmt] => 2023-12-04 04:12:02 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24360 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => FAQ: clozapine’s close checks [title] => FAQ: clozapine’s close checks [href] => https://www.australianpharmacist.com.au/faq-clozapines-close-checks/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template ) [is_review:protected] => [post_thumb_id:protected] => 24367 )

      FAQ: clozapine’s close checks

  • People
    • GLP-1 agonist
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                  [post_date] => 2023-12-11 13:33:42
                  [post_date_gmt] => 2023-12-11 02:33:42
                  [post_content] => Glucagon-like peptide 1 (GLP-1) agonists, traditionally used to manage type 2 diabetes, have been increasingly prescribed off-label for weight loss. 
      
      There are four GLP-1 agonist medicines approved by the Therapeutic Goods Administration (TGA) for use in Australia for the management of Type 2 Diabetes:
      
      • dulaglutide (Trulicity)
      • semaglutide (Ozempic)
      • tirzepatide (Mounjaro)
      • liraglutide (Saxenda). 
      There are only two GLP-1 agonists that are TGA approved for weight loss, semaglutide (Wegovy brand) and liraglutide (Saxenda). With Christmas just around the corner – leaving budgets tight and GP access slim, coupled with substantial, persistent stock shortages – patients may find treatment abruptly interrupted. PSA GP Pharmacist Anouska Feszczur MPS has helped several patients navigate through their reported GLP-1 agonist cessation symptoms. Here are her top tips.

      Prepare for a ravenous appetite and a return of impulsive behaviours

      When patients stop GLP-1 agonists, the most significant cessation symptom is an increased appetite far exceeding pre-treatment levels, said Ms Feszczur. [caption id="attachment_24426" align="aligncenter" width="500"]GLP-1 agonist Anouska Feszczur MPS[/caption] ‘Patients have told me cravings and appetite return with an insatiable force they’ve never experienced before,’ she said. ‘They also experience cravings for foods they had zero interest in while taking a GLP-1 agonist.’  The hunger and cravings tend to be extreme upon cessation, evening out over the space of weeks or months, said Ms Feszczur.  This cessation symptom leads to another common post-treatment effect: weight gain. ‘Evidence shows stopping semaglutide leads to weight gain,’ said Ms Feszczur. ‘In one study, all participants put on two thirds of their weight back on in a year.’  Because patients often gain back the weight they lost post-treatment, other health benefits similarly erode. ‘For example, if a patient's blood pressure or blood sugar levels improve during treatment with a GLP-1 agonist, they can go back to where they were when they stop,’ she said. Mood can also be impacted upon GLP-1 agonist cessation. ‘Patients who felt proud of themselves for losing weight can experience guilt, shame and despair,’ said Ms Feszczur. ’They've spent all this money on treatment, and suddenly the weight has come back on.’ Lastly, some patients have mentioned an impact on impulsive behaviours when the dopamine regulation effects of GLP-1 agonists appear to wear off. ‘Almost all patients have said they drink less alcohol because they just don't get the same buzz, and one patient even stopped chewing their nails,’ she said. ‘Some people have also indicated in forums that online shopping and gambling behaviour changed while they were on Ozempic.’ Those impulsive behaviours can return upon cessation, said Ms Feszczur – rendering the holiday period, where people tend to overeat, drink and spend,  a tricky time to go off these medicines.  ‘It could be quite distressing for patients who feel they have no control over impulsive behaviours.’

      Encourage tapering and identify movement barriers

      When patients cease GLP-1 agonists, optimising medicines for comorbid health conditions could be beneficial, said Ms Feszczur. ‘[Find out] if there’s anything they're taking, or not taking, that might be a barrier to movement. For example, with pain management.’ Other services can help patients work through their movement challenges. ‘I’ve referred a patient with arthritis who ceased semaglutide to painHEALTH, a self-directed learning module on pacing which is all about trying to increase movement while still in pain,’ she said. Ms Feszczur also suggests patients taper from GLP-1 agonists rather than immediate cessation. ‘GLP-1 agonists mimic a hormone. Any other medicine we give patients that mimic hormones, such as steroids, are tapered so the body can start making its own hormones again,’ she said. ‘If I know a patient is running out of Ozempic, and there's no stock anywhere, I’ll advise a plan to reduce it gradually, which also empowers patients to mindfully go into cessation.’

      Eat the right food and seek help for mood changes

      To help reduce an insatiable appetite, pharmacists should recommend patients eat nutrient-rich food with low-calorie density. ‘Suggest eating protein with every meal and water-filled foods that make you feel fuller, such as watermelon, grapes and apples,’ said Ms Feszczur.  Patients should also avoid foods that don't make them feel full. ‘For example if a patient loves chocolate but it doesn’t fill them up, advise them to swap it for low-calorie ice cream.’ Tools such as a food tracker app might also help patients regain a sense of control as they see their intake coming down. Importantly, patients should be advised to be on the lookout for any mood or behavioural changes. ‘You could say to patients, “If you see impulsive behaviours increase, it's important that you try to go to the GP – even though it’s a busy period”,’ said Ms Feszczur. If GP access is difficult over the Christmas period, there are various helplines patients can access, including:
      • National Alcohol and Other Drug Hotline
      • Department of Social Services’ Gambling Support
      • Turning Point.

      Ongoing support is required

      GLP-1 agonist cessation provides a good opportunity for pharmacists to promote a multidisciplinary approach to weight management, said Ms Feszczur.   Nutritional support could come from:
      • a dietician
      • GP
      • formalised online nutrition programs such as Noom or MyFitnessPal.
      ‘A psychologist can also be useful to address some of the behaviours that may have led to overeating,’ she said. ‘Patients could be referred to their GP for a mental health treatment plan.’ Movement support is another area that should be considered. Pharmacists can ask:
      • how are you finding movement? 
      • do you need help from an exercise physiologist to create a plan? 
      • are you happy to pay for a personal trainer? 
      Pharmacists should also encourage patients to make sleep a priority. ‘We know people who have good quality sleep have better luck maintaining their weight,’ said Ms Feszczur.  Sleep hygiene habits, as outlined by the Sleep Health Foundation here, can be discussed with patients. ‘There are also free Cognitive Behavioural Therapy for Insomnia (CBT-I) programs people can do at home to make sleep a priority.’

      Report cessation effects to the TGA

      Given GLP-1 agonist cessation is an emerging area, pharmacists should consider reporting any effects to the TGA, or encourage patients to self-report. ‘As the TGA says, “You don’t have to be certain, just suspicious”,’ said Ms Feszczur. ‘The only way we can build evidence is for people to say something.’ Setting expectations about cessation before patients start a GLP-1 agonist can also help them to prepare. ‘Pharmacists could say, “You might find it easy to lose weight while you're on this medicine. But it’s important to make profound changes to your lifestyle, or most of the weight could come back on,’ she said.

      Watch this space!

      There is an emerging evidence base for using GLP-1 agonists to treat other conditions – including dementia and addiction, said Ms Feszczur.  ‘My advice to pharmacists is to keep an eye out for new and emerging therapeutic areas for GLP-1 agonists, as well as any information you can find on cessation.’ [post_title] => Supporting patients through GLP-1 agonist cessation effects [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => supporting-patients-through-drastic-glp-1-agonist-cessation-effects [to_ping] => [pinged] => [post_modified] => 2023-12-11 14:54:36 [post_modified_gmt] => 2023-12-11 03:54:36 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24423 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Supporting patients through GLP-1 agonist cessation effects [title] => Supporting patients through GLP-1 agonist cessation effects [href] => https://www.australianpharmacist.com.au/supporting-patients-through-drastic-glp-1-agonist-cessation-effects/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 24425 )

      Supporting patients through GLP-1 agonist cessation effects

      belladonna
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                  [post_date] => 2023-12-11 11:18:16
                  [post_date_gmt] => 2023-12-11 00:18:16
                  [post_content] => When it comes to belladonna, the eyes have it. Pity it’s highly toxic...
      
      During the Italian Renaissance of the 14–16th centuries, belladonna was a popular cosmetic product. Well-dressed women used juice from the berries of the plant to dilate their pupils, resulting in a fashionably seductive look. Hence the name belladonna, Italian for ‘beautiful woman’.1–6
      
      But millennia before it helped make a fashion statement, belladonna was used as an anaesthetic, pain reliever and remedy for assorted ailments, not to mention as a hallucinogenic component of rituals. It was also used as an oral poison and to tip arrows.1,5,7
      
      Deadly nightshade, murderer’s berries, sorcerer’s berries and even devil’s berries — as belladonna’s alternative names reveal, its not so ‘bella’ side was well known. The plant was associated with broom-riding witches and poison potions.3,4,8
      
      Shakespeare described belladonna’s impact when referring to Juliet’s attempt to feign death to avoid marriage with Paris and escape with Romeo1,4,8:
      
      Her blood is settled, and her joints are stiff: Life and these lips have long been separated; Death lies on her like an untimely frost upon the sweetest flower of all the field.
      

      What is belladonna?

      Atropa belladonna is an ornamental plant of the Solanaceae family. It is native to Europe, North Africa and Western Asia. Growing to a height of 150 centimetres in barren stony soil, belladonna has oval leaves, green-purple flowers and sweet black berries.3-5,9,10,12 The herbaceous perennial is highly poisonous, especially the leaves and fruit. They contain atropine, scopolamine and hyoscyamine alkaloids. Consuming the alkaloids can be deadly. Just touching the leaves may cause a rash.1,6-9,10

      How it works

      Belladonna’s alkaloids affect the body’s nervous system. Specifically, they block the neurotransmitter acetylcholine from binding to the central nervous system and to parasympathetic postganglionic muscarinic receptors.6,7,9-11 Toxic effects can be wide-ranging, as evidenced by the case of an 11-year-old Moroccan girl treated for belladonna toxicity by the intensive care team at the Mother and Child Hospital in Fes.5,7,9 ‘She was given Atropa belladonna by an herbalist in a therapeutic interest,’ they reported. Her symptoms included dry mouth, confusion, incoherent speech, and an inability to recognise family members. She also presented with uncontrollable vomiting, visual disturbances, and hearing and visual hallucinations.7 Belladonna can also cause changes to saliva, sweat, pupil size, urination and digestive functions. It can also cause seizures, headaches and increased heart rate and blood pressure.10,11

      Medical uses

      Today, medicines containing alkaloids found in belladonna, such as atropine, are used in areas such as emergency medicine and anaesthesia.13 Interestingly, atropine is used as an antidote of organophosphate poisoning by reversing its muscarinic effects (such as vomiting, diarrhoea, bradycardia, miosis, sweating and salivation).13 Proving the eyes still have it, atropine is also indicated for use in optometry for conditions like uveitis, myopia progression, amblyopia and sometimes for eye exams.13 Overseas, transdermal scopolamine is sometimes used to help treat nausea and vomiting-related conditions.14

      References

      1. Fletcher J. Uses and risks of belladonna. Medical News Today. 2017. At: https://www.medicalnewstoday.com/articles/318180
      2. Meriney SD, Fanselow EE. Acetylcholine in Synaptic Transmission. Academic Press 2019:345–67. At: https://www.sciencedirect.com/topics/neuroscience/atropa-belladonna
      3. Passos ID, Mironidou-Tzouveleki M. Hallucinogenic Plants in the Mediterranean Countries in Neuropathology of Drug Addictions and Substance Misuse Vol 2. Academic Press. 2016:761–72. At: https://www.sciencedirect.com/science/article/abs/pii/B9780128002124000716
      4. Morris SM. Belladonna: remedy with a dark past. Healthline. 2017. At: https://www.healthline.com/health/belladonna-dark-past
      5. Annisadmin. Atropa belladonna: deadly nightshade. Penny Dreadful Archives. 2016. At: https://pennydreadfularchives.wordpress.com/2016/05/31/atropa-belladonna-deadly-nightshade/
      6. DrugBank. Belladonna. 2017. At: https://go.drugbank.com/drugs/DB13913
      7. Berdai MA, Labib S, Chetouani K, et al. Atropa belladonna intoxication: a case report. Pan Afr Med J 2012;11:72. Epub 2012 Apr 17. At: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361210/
      8. Mann J. Belladonna, broomsticks and brain chemistry. Education in Chemistry. 2008. At: https://edu.rsc.org/feature/belladonna-broomsticks-and-brain-chemistry/2020099.article
      9. Karagoz I, Bilgi M, Boduc E, et al. Atropa belladonna and associated anticholinergic toxic syndrome: a case report. Bali Med J 2017;3(3):S90–S92. At: https://balimedicaljournal.org/index.php/bmj/article/view/673/pdf_330
      10. National Library of Medicine. MedlinePlus. Belladonna. 2022. At: https://medlineplus.gov/druginfo/natural/531.html
      11. Banasik M, Stedeford T. Plants, Poisonous (Humans). Encyclopedia of Toxicology (Third Edition). Academic Press. 2014. p970–78. At: https://www.sciencedirect.com/science/article/abs/pii/B9780123864543000488
      12. Jim’s Mowing. The Essential List of Poisonous Plants in Australia. At: https://www.jimsmowing.com.au/2021/01/the-essential-list-of-poisonous-plants-in-australia/#:~:text=For%20the%20formidable%20deadly%20nightshade,has%20become%20a%20fruitful%20one
      13. Rossi S, ed. Australian medicines handbook. 2023. At: https://amhonline.amh.net.au
      14. Pruthi S, ed. Mayo clinic. 2023. Scopolamine (Transdermal Route). At: www.mayoclinic.org/drugs-supplements/scopolamine-transdermal-route/side-effects/drg-20072848?p=1#:~:text=Scopolamine%20transdermal%20patch%20is%20used,group%20of%20medicines%20called%20anticholinergics
      [post_title] => Belladonna: beautiful but deadly [post_excerpt] => Before it helped make a fashion statement, belladonna was used as an anaesthetic, pain reliever and remedy for assorted ailments. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => belladonna-beautiful-but-deadly [to_ping] => [pinged] => [post_modified] => 2023-12-11 14:54:06 [post_modified_gmt] => 2023-12-11 03:54:06 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24416 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Belladonna: beautiful but deadly [title] => Belladonna: beautiful but deadly [href] => https://www.australianpharmacist.com.au/belladonna-beautiful-but-deadly/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template ) [is_review:protected] => [post_thumb_id:protected] => 24419 )

      Belladonna: beautiful but deadly

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                  [post_date] => 2023-12-06 12:32:37
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                  [post_content] => The significant rise in Australian asthma deaths is cause for immediate and widespread concern. Here’s what experts say needs to change.
      
      Asthma deaths are again on the rise, revealed new Australian Bureau of Statistics data  recently released by the National Asthma Council Australia.
      
      There were 467 asthma-related deaths in Australia in 2022, up from 355 deaths in 2021. Most (64%) were among women – with 299 female deaths versus 168 male deaths.
      
      Those most at risk of death are women aged 75 and older, accounting for 45% of all deaths followed by men in this age group (18%).
      
      This is the highest number of asthma deaths recorded since 2016-2017. Deaths were down in 2021 as a result of COVID-19 restrictions and lockdowns – leading to fewer respiratory infections and asthma exacerbations. However, asthma exacerbations have now returned to pre-pandemic levels and may even be slightly higher, warned National Asthma Council Australia Director and respiratory physician, Professor Peter Wark.
      
      [caption id="attachment_24414" align="alignright" width="225"] National Asthma Council Australia Director and respiratory physician, Professor Peter Wark[/caption]
      
      This may be the result of the increase in virus infections we saw following the easing of COVID-19 restrictions but the main reasons are a result of the intrinsic problems underlying asthma management in Australia. ‘We're not accurately diagnosing asthma, and we are under-treating it,’ he said.
      

      A need for better asthma diagnosis and control

      There was a marked decline in lung function testing during COVID-19. Despite an increase in funding under the Medicare Benefits Schedule for spirometry, there has been a reduction of two thirds in spirometry being billed under the MBS compared to 2018–19, said Prof Wark.  ‘Spirometry remains essential in the diagnosis of asthma and this will lead to under and overdiagnosis,’  said Prof Wark. Up to 20% of people who present to a pharmacy for salbutamol haven't had their asthma confirmed by spirometry, said Advanced Practice Pharmacist and National Asthma Council Australia Clinical Executive Lead Debbie Rigby FPS. ‘Because [pharmacists] can dispense salbutamol over the counter without a prescription, we have a responsibility to ask the right questions to determine patients’ level of control,’ she said.This could include asthma control tests. The Asthma Score is an example of such a test and comprises five questions. As part of this, pharmacists ask patients to rate their symptoms on a scale of one to five to indicate their asthma control over the last 4 weeks, including:
      • How frequently are your symptoms preventing you from participating in work, school or play as well as normal?
      • How often have you had shortness of breath?
      • How often are your symptoms waking you up at night or earlier in the morning than usual? 
      • How often have you been using your reliever?
      • How would you rate your asthma control?
      ‘If  [salbutamol] has been [used] three or more times in the last week, that's indicative of not having good asthma control,’ she said.

      Promoting the right treatments

      Over-the-counter short-acting beta agonists (SABAs) are associated with worse asthma outcomes, including death. But that isn't because the medicine is harmful – it's associated with inadequate asthma control, which has short and long term consequences. Overall there is suboptimal use of inhaled preventers or inhaled corticosteroids, that have been shown to improve asthma control, reduce asthma exacerbations and reduce the risk of death from asthma. This includes suboptimal use of as-needed inhaled low-dose ICS/formoterol for people with mild asthma. This treatment is recommended by Australian and international guidelines as an effective alternative to regular maintenance ICS , in people with mild asthma – and is more effective and safer than using SABAs alone, said Ms Rigby. ‘This more flexible approach to treatment is ideally suited to people with mild asthma, many of whom are now at risk because they are not using an ICS preventer.’ Pharmacists should take the opportunity to provide some much-needed education to patients about the benefits of the budesonide/formoterol combination, said Ms Rigby. ‘Formoterol works just as well and quickly as salbutamol, but they're also getting some inhaled corticosteroid – which helps with the inflammatory process going on in their lungs,’ she said. ‘Whereas with salbutamol, you're just helping with the bronchoconstriction. It's doing nothing about the underlying inflammation.’

      When is a biologic appropriate?

      When patients present with a prescription of prednisone, pharmacists can play an important role in appropriately identifying and informing them that this is a sign of poor asthma control and is a red flag that identifies a risk for severe acute asthma, including the risk of death, said Prof Wark. Aspects to explore should include:
      • Have they been prescribed a preventer? 
      • Are they using the preventer?
      • Are they taking it appropriately? 
      • If they are taking their preventer appropriately but still experiencing acute asthma, they may be eligible for assessment by a specialist for a biologic agent
      Asthma should be adequately controlled on moderate dose ICS together with a LABA. Persistence with high dose ICS or frequent courses of prednisone is certainly not the answer, said Prof Wark. A recent large population-based study conducted in the United Kingdom showed that stepping patients up to the highest doses of ICS adds little benefit to asthma management. ‘If a patient needs more than one or two courses of prednisone, and they're on an ICS/LABA, you need to ask the question, “should they be receiving treatment with a biologic?”’ he said.  Prof Wark advises that patients who might benefit from a biologic include those:
      • who continue to experience exacerbations and are overlying on prednisone
      • with active type two inflammation, identified through blood counts and exhaled nitric oxide.
      ‘The impact prednisone has on health is enormous, it accumulates over a lifetime of exposure and we have very effective treatments for asthma that should reduce our reliance upon its use,’ he said. ‘People in regional and remote Australia, with poor asthma control appear to be at greater risk of needing to use prednisone.’
      ‘Up to 20% of people who present to a pharmacy for salbutamol haven't had their asthma confirmed by spirometry.' Debbie Rigby FPS 
      Once patients exceed a lifetime cumulative dose of 500 mg of prednisone, the health risks increase dramatically  – leaving younger people who use the medicine particularly at risk. ‘Only one or two courses of prednisone in 12 months significantly increases the risk of developing osteoporosis, diabetes and infections such as pneumonia.’ Females over the age of 12 are at greater risk of poor asthma outcomes, said Prof Wark. When female patients have ongoing problems with asthma control and prednisone is needed – a biologic should be considered, he said. ‘If you're not getting good asthma control, these alternative treatments work exceptionally well for everyone, including women.’

      Get moving, and vaccinated

      Vaccination can significantly reduce the impact of respiratory viruses among patients with asthma – particularly those aged 65 and over who may have other comorbidities. Patients with asthma should receive: 
      • an annual influenza vaccination
      • the pneumococcal vaccine
      • a COVID-19 vaccine.
      Pharmacists can also advise patients that influenza vaccines are free of charge for those with asthma, said Prof Wark. ‘RSV vaccines will soon be available, likely targeting patients aged 65 years and over.’ Asthma also interacts with other diseases – particularly diabetes and cardiovascular disease – with around three quarters of people with asthma having another chronic disease, said Prof Wark. ‘When you combine age and a number of comorbidities, there’s a more complex picture. Inactivity and obesity and the relationship to asthma, cardiovascular disease and chronic diseases such as diabetes – are all linked.’ Exercise and activity have been associated with improvements in asthma symptoms, along with overall asthma control. While there should be ‘no limitations’ on the exercise patients with asthma can do, some factors might put them at risk.  ‘For example, exercising in cold or dry air can increase your risk of bronchospasm,’ he said. ‘So warming up before exercise is advised.’ For more information, refer to PSA’s updated treatment guideline in the Australian Pharmaceutical Formulary and Handbook digital site. [post_title] => Over 30% increase in asthma deaths in one year [post_excerpt] => The significant rise in Australian asthma deaths is cause for immediate and widespread concern. Here’s what experts say needs to change. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => over-30-increase-in-asthma-deaths-in-one-year [to_ping] => [pinged] => [post_modified] => 2023-12-06 16:09:30 [post_modified_gmt] => 2023-12-06 05:09:30 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24394 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Over 30% increase in asthma deaths in one year [title] => Over 30% increase in asthma deaths in one year [href] => https://www.australianpharmacist.com.au/over-30-increase-in-asthma-deaths-in-one-year/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 24406 )

      Over 30% increase in asthma deaths in one year

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                  [post_date] => 2023-12-04 14:21:06
                  [post_date_gmt] => 2023-12-04 03:21:06
                  [post_content] => With a plunge in vaccination rates following the COVID-19 pandemic peak, a new report says a concerted push is required, with a focus on national consistency.
      
      The Grattan Institute’s A fair shot: How to close the vaccination gap report recommends action on a National Vaccines Partnership Agreement and harmonisation of the state-based regulations that determine pharmacists’ authority to deliver certain vaccines – which currently differ in each jurisdiction.
      
      These recommendations echo PSA’s ongoing calls ​for a nationally consistent approach to vaccination, and demonstrate just how far we need to go to ensure equitable access to vaccination for all Australians, said PSA National President Dr Fei Sim FPS. 
      
      Australian Pharmacist takes a look at the groups with plummeting vaccination rates, and how empowering primary care professionals such as pharmacists can help to lift them.
      

      Older Australians and Aboriginal and Torres Strait Islander peoples are missing out

      Recommended vaccine uptake rates have continued to fall over the last couple of years, particularly among vulnerable groups. At the beginning of the 2023 winter, 2.5 million Australians over 65 years of age were not up to date with their COVID-19 vaccinations – a five-fold increase from 2022.  Other findings about COVID-19 vaccination include:
      • a crash in up-to-date vaccination from over 90% in December 2021 to less than 10% by the end of February 2023 among those considered high risk
      • vaccination rates only reached 38% among high-risk patients following a 2023 COVID-19 booster push 
      • as of November 2023, less than 4 in 10 aged care residents are considered up-to-date with COVID-19 vaccination.
      Older Australians are also behind with other important vaccinations. Less than half of people aged in their 70s were vaccinated for shingles, with even less (one in five) vaccinated against pneumococcal disease. Influenza vaccination rates are also consistently low across the board, with only 27% of Australians vaccinated against influenza in autumn 2023. High-risk groups that receive no-cost vaccinations under the National Immunisation Program (NIP) are beset by low or inconsistent flu vaccination rates, said the report. For example, only around 16% of Aboriginal and Torres Strait Islander people received an influenza vaccination ahead of winter. The report predicts vaccination rates will fall further due to several factors, including:
      • vaccine fatigue
      • confusion over which vaccines are needed
      • increased vaccine misinformation.
      While Australia has very high childhood vaccination rates by global standards, these factors are likely contributing to a decline in vaccination since 2020. Childhood vaccination rates had climbed up to 95%, but the nation is falling back from this highpoint – which is needed to provide adequate protections against many vaccine preventable diseases.

      Non-English speakers half as likely to get vaccinated against COVID-19

      There are several demographic factors leading to disparities in vaccination rates. Among high-risk adults, vaccination depends on:
      • areas lived
      • language spoken at home
      • level of earnings.
      While vaccination rates among Australians should be higher, the report emphasised that they need to be fairer. For example, patients who speak languages other than English at home are reportedly about half as likely to get recommended COVID-19 vaccinations. Those in rural areas are less likely to get vaccinated, with disparities also existing in major cities. For example, there is a nearly 30% variation in flu vaccination rates in different parts of Brisbane.

      Empowering pharmacists through red tape removal

      The report calls for a policy reset through a National Vaccination Agreement that outlines clearer goals and responsibilities to boost vaccination targets in high-risk groups.  The report also says that Primary Health Networks (PHNs) should be required to make ongoing progress towards reaching national targets, and must be equipped with funding to support general practice, pharmacists, and aged care providers to promote vaccination in mainstream primary care. The recent federal government commitment of 4 years of funding to support pharmacists to deliver free NIP vaccines to eligible people will improve access, increasing vaccination locations by up to 60%. This move will also help to ensure patients can access vaccines from a trusted provider with whom they have an existing relationship. Crucially, the report argues that ‘the federal government should work with state governments to make pharmacy vaccination regulations consistent across Australia’.  ‘State regulations determine whether pharmacists can deliver particular vaccines, who can get particular vaccines from pharmacists, and whether a pharmacist vaccination is free,’ said the report. ‘The federal government’s independent Scope of Practice Review should harmonise these regulations by removing state-specific restrictions, [and] investigate opportunities to remove restrictions on the scope of practice of Aboriginal Health Workers and Aboriginal Health Practitioners.’ A nationally consistent schedule of pharmacist-administered vaccines is key to achieve equitable access to government-funded vaccines by all Australians, agreed Dr Sim. ‘We know that there is no one-size-fits-all approach to improving vaccine uptake, with the report rightly highlighting the need for a tailored approach to ensuring vulnerable cohorts don’t fall through the cracks,’ Dr Sim said.​ ‘The federal government’s move to open up NIP funding for pharmacist-administered vaccines is a welcome first step, but there is more work to be done to allow pharmacists to deliver all vaccines to patients of all ages. ‘Pharmacists can and should be utilised as trusted health care professionals, working hand in glove with the rest of the primary care team to break down the barriers to vaccination, from improving equity and access, to amplifying public health messages.’ [post_title] => We need a nationally consistent vaccination approach, says think tank [post_excerpt] => With a plunge in vaccination rates following the COVID-19 pandemic peak, a new report says a focus on national consistency is required. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => we-need-a-nationally-consistent-vaccination-approach-says-top-think-tank [to_ping] => [pinged] => [post_modified] => 2023-12-04 15:12:35 [post_modified_gmt] => 2023-12-04 04:12:35 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24372 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => We need a nationally consistent vaccination approach, says think tank [title] => We need a nationally consistent vaccination approach, says think tank [href] => https://www.australianpharmacist.com.au/we-need-a-nationally-consistent-vaccination-approach-says-top-think-tank/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 14650 )

      We need a nationally consistent vaccination approach, says think tank

      clozapine
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                  [post_content] => Clozapine is indicated for the management of treatment-resistant schizophrenia. Its use is subject to strict regulatory and monitoring requirements due to potential toxicity, most notably agranulocytosis and neutropenia. 
      
      Each brand has its own protocol monitoring service1,2:
      
      • Clozaril (Viatris) – the Clozaril Patient Monitoring System (CPMS), and
      • Clopine (Pfizer) – ClopineCENTRAL.

      Is registration with these services mandatory?

      Yes. Prescribers, pharmacies and pharmacists must be registered with the respective service. Individual pharmacists may be registered to multiple pharmacies. They must be used for every dispense event.

      A patient has run out of medicines but now new blood tests have been provided. Can I dispense an emergency supply?

      No. Dispensing cannot occur beyond the next blood test due date until a doctor and pharmacist have reviewed a new white blood count (WBC) and neutrophil count and deemed them acceptable.

      Is it OK to rely on blood tests I access from MHR or that the prescriber sends to the pharmacy?

      Yes. However, the pharmacist must be satisfied the pathology results have been reviewed and approved by the patient’s medical practitioner. Where the prescriber has not entered these blood results into the relevant monitoring system, the pharmacist must enter these details at the time of dispensing or transmit them to the monitoring system via fax for upload.

      What happens if someone does not collect their prescription within 48 hours of the pathology blood test?

      Interruptions to therapy may require re-titration, so pharmacists should first check to determine if there has been an interruption in therapy of >48 hours. If so, withhold supply and refer for urgent review. If therapy is uninterrupted, the amount supplied would be the original quantity minus the number of days late presenting to the pharmacy. This is known as the ’48-hour rule’. For example, if a patient who had a prescription for 28 days’ therapy presented on Saturday for a blood test taken 5 days earlier on Monday, then up to 25 days’ therapy could be supplied. 

      Is other monitoring required? 

      Yes. In addition to haematological monitoring, people taking clozapine require monitoring for changes in cardiac, metabolic, gastrointestinal and central nervous system functioning.  In April 2022, the Therapeutic Goods Administration (TGA) mandated a boxed warning in the product information for clozapine in relation to the potentially fatal risk of gastrointestinal hypomotility. The TGA alert noted that approximately 10% (n = 103) of clozapine reports with a fatal outcome were due to gastrointestinal disorders.3 All health professionals should enquire routinely about patient’s bowel habits. Nausea and/or vomiting, abdominal distension and/or pain, lack of urge and/or inability to defecate or constipation should prompt further assessment and urgent referral for immediate review.

      References

      1. Chao A. Clopine CENTRAL: Your connection to Clopine (clozapine) patient care, Pfizer Australia, WestRyde. 2017. At: www.clopine.com.au/ClopineCentral
      2. Clozaril Patient Monitoring System Protocol.September 2019, ver. 5. Mylan. At: www.ecpms.com.au/
      3. Therapeutic Goods Administration, Department of Health and Aged Care, Australian Government.Medicines safety update: clozapine and gastrointestinal hypomotility with severe complications. 2022. At: www.tga.gov.au/news/safety-updates/clozapine-and-gastrointestinal-hypomotility-severe-complications
      [post_title] => FAQ: clozapine’s close checks [post_excerpt] => Clozapine, used for the management of treatment-resistant schizophrenia, is subject to strict regulatory and monitoring requirements. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => faq-clozapines-close-checks [to_ping] => [pinged] => [post_modified] => 2023-12-04 15:12:02 [post_modified_gmt] => 2023-12-04 04:12:02 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=24360 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => FAQ: clozapine’s close checks [title] => FAQ: clozapine’s close checks [href] => https://www.australianpharmacist.com.au/faq-clozapines-close-checks/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template ) [is_review:protected] => [post_thumb_id:protected] => 24367 )

      FAQ: clozapine’s close checks

AUSTRALIAN PHARMACIST Australian Pharmacist
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Supporting patients through GLP-1 agonist cessation effects

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Over 30% increase in asthma deaths in one year

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