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[post_content] => Case scenario
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A national education program for pharmacists funded by the Australian Government under the Quality Use of Diagnostics, Therapeutics and Pathology program.[/caption]
Amna, 26 years old, is browsing the vitamins and herbal supplements section of the pharmacy, seeking a solution for her sleep problems. Over the past 2 weeks, she has experienced difficulty falling asleep at night and feels exhausted when she wakes up at 7 am to get ready for work. She also wants some information about melatonin, as some of her older colleagues have had success with it. Amna is an otherwise healthy young adult without co-existing medical comorbidities and is not currently taking any other medicines.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Non-prescription sleep aids are frequently purchased by individuals to improve their sleep while delaying seeking medical care.1 Given the product availability and proximity of community pharmacy to the public, the pharmacist has an important role to play in promoting the safe and effective use of non-prescription sleep aids and referring patients to appropriate care.2,3
Non-prescription sleep aids predominantly target insomnia symptoms, utilising their sedative properties to promote faster sleep onset. These are mainly Schedule 3 medicines and include the sedating antihistamines diphenhydramine, promethazine and doxylamine.4 Prolonged-release melatonin may be used as a Schedule 3 medicine in adults ≥55 years of age as a short-term monotherapy for primary insomnia, characterised by poor sleep quality.4
Complementary medicines (CMs; e.g. valerian, passionflower, hops, kava, chamomile) and supplements (e.g. magnesium) are also sometimes used to help aid sleep.5,6 Many of the CMs theoretically act on GABAergic receptors and/or have anxiolytic and relaxant effects.7 The Australian Pharmaceutical Formulary and Handbook contains further information on various CMs and their reported uses in sleep.6
A key practice dilemma that pharmacists face each day is that despite the widespread availability and use of non-prescription sleep aids, several professional sleep societies recommend against their use due to insufficient evidence.8–10 Therapeutic Guidelines also advises not to use sedating antihistamines to treat insomnia.11 Many of the pivotal trials evaluating first-generation sedating antihistamines and CMs have critical study design limitations that fall short of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) standards that are often used to appraise the evidence base.12
While the evidence bases for both CMs and Schedule 3 sleep aids are unlikely to immediately change, a core practice consideration is the risk-benefit profile of the respective non-prescription sleep aids for the individual patient.
Consumers often misperceive non-prescription sleep aids as being safer than prescription medicines due to their ‘naturalness’ or ease of access.13 As such, these sleep aids are often used medically unsupervised to either initially delay seeking medical care,14 or, in combination with prescribed regimens, to offset the perceived harms of prescription sleep aids.15,16 When non-prescription sleep aids are being used unsupervised, consumers may be unaware of the potential contraindications or interactions with existing medicines. For example, melatonin, while seemingly benign, can have undesired effects in high-risk patient groups. Melatonin can potentially interfere with immunosuppressive therapies,17 and may increase risk of bleeding for patients on anticoagulant medicines such as warfarin.18,19 While many of the interactions with CMs are theoretical, pharmacists play a critical role in assessing risk-benefit and providing advice for the safe use of these non-prescription sleep aids. Nonetheless, discerning the risk profiles of the respective CMs is increasingly challenging since many herbal sleep formulations in the pharmacy combine multiple herbal ingredients.
Patients should be advised to avoid the concomitant use of non-prescription sleep aids with alcohol and medicines that have central nervous system depressing effects, and to avoid driving or operating machinery if drowsy.20 The effects of sleep aids, especially sedating antihistamines, can continue the next day.4,20,21 In addition, non-prescription sleep aids should be limited to short-term use. Sedating antihistamines should not be used for longer than 10 consecutive days because tolerance to their sedative effects develops quickly.4,21,22 In older adults, the risks of using non-prescription sleep aids are even higher. This is because they tend to take more medicines, increasing the potential for drug-drug and drug-herb interactions. In addition, the sedative effects of sedating antihistamines may be more pronounced due to age-related pharmacokinetic and pharmacodynamic changes, such as reduced metabolism and clearance.23 Older adults are also more vulnerable to other cognitive and anticholinergic adverse effects of sedating antihistamines, and these medicines can add to the anticholinergic burden.21 Guidelines recommend avoiding the use of sedating antihistamines in older people.⁴ However, older people make up a significant portion of users.23 If it is not possible to avoid use in older people, they should use lower doses than other adults.21
Notwithstanding these acute consequences, one of the main concerns of self-medication is delayed medical help-seeking and initiation of the first-line therapy, cognitive behavioural therapy for insomnia (CBTi).24 Individuals may miss the optimal window to address their sleep complaint and allow perpetuating factors such as poor sleep habits and anxiety about the lack of sleep to develop, resulting in the transition of acute insomnia into chronic insomnia (insomnia lasting ≥3 months).8
Is it really insomnia?From direct product requests to symptom-based requests in the pharmacy, patients will often refer to their sleep complaint as ‘insomnia’ and seek non-prescription sleep aids to improve their sleep. Insomnia symptoms such as difficulty initiating sleep, maintaining sleep, early-morning waking and associated daytime fatigue can appear to overlap with symptoms of other sleep disorders for which non-prescription sleep aids may not be suitable. For example, circadian sleep disorders such as advanced sleep phase disorder and delayed sleep phase disorder share a lot of similarity with insomnia symptoms where the patient experiences difficulty falling asleep at a desired time.25,26 Those with a circadian sleep disorder have an otherwise intact sleep-wake cycle but struggle to fall asleep and wake up at socially acceptable times to meet their daily obligations such as work and school because their internal body clocks have shifted.10 Similarly, for patients with undiagnosed obstructive sleep apnoea (OSA), the daytime fatigue and functional impairments often motivates patients to use non-prescription sleep aids to improve their sleep or alertness, but clinical guidelines recommend against their use.27 Another common sleep disorder, restless legs syndrome (RLS), like insomnia, will result in difficulty falling asleep and/or staying asleep with daytime consequences. The disrupted sleep in RLS is largely attributed to the uncomfortable sensation felt in the legs at night when resting and the urge to move and stretch out the legs to relieve discomfort.28 The symptoms of RLS can be precipitated or exacerbated with use of sedating antihistamines.29
Further clinician and patient information on these conditions can be obtained from Sleep Central (www.sleepcentral.org.au), or consumer-facing resources from the Sleep Health Foundation (www.sleephealthfoundation.org.au).
Patients presenting to the pharmacy for non-prescription sleep aids should be assessed for the presence of other sleep disorders.30,31 Pharmacists can probe further into the nature and history of the sleep complaint by asking patients about potential triggers, sleep-wake schedules, engagement in shift work, the presence of other physical symptoms (e.g. snoring or witnessed breathing pauses during sleep, uncomfortable sensations in the lower legs and ability to fall asleep easily at earlier/later times), and prior treatments and response to treatments.3 In addition, there are evidence-based screening and assessment tools for the different sleep disorders that pharmacists may use in their practice to identify at-risk patients for onward referral and assessment by their medical practitioner.
Further information on assessment tools for insomnia and patient education resources can be found on the Sleep Central website (www.sleepcentral.org.au).
Knowledge to practice Despite insufficient evidence supporting the use of non-prescription sleep aids, it is critical to engage patients in a non-judgemental and open discussion about their non-prescription sleep aid use.32 Through these conversations, pharmacists can gain further information about the nature of the patient’s sleep complaint, their current medical and medicines history and treatment expectations. Pharmacists can then educate patients about the various sleep disorders, potential adverse effects and interactions of pharmacological treatment, and inform them about the benefits of seeing a medical practitioner for assessment and optimal treatment.
Non-prescription sleep aids are widely used by members of the community to improve their sleep, but they may not always be an appropriate choice, and risks can often outweigh perceived benefits. Pharmacists play a key role in ensuring non-prescription sleep aids are used safely and effectively. Pharmacists are well placed to direct consumers to evidence-based resources on sleep health and sleep disorders, which may empower them to be better informed about sleep, improve their sleep health literacy, and understand the need for further assessment from a medical practitioner. They can also facilitate onward referral to a medical practitioner for further assessment, differential diagnosis and management of their sleep disturbance.
Case scenario continuedYou ask Amna about her sleep. She wants to go to sleep by 10:30 pm but typically doesn’t feel sleepy until 1 am. Her sleep complaint is only an issue on weekdays when she needs to follow a strict schedule. Weekends are pleasant as she can sleep and wake when she wants. You suggest that Amna may have symptoms of a delayed circadian rhythm rather than insomnia, and refer her to see her GP for a discussion and referral to a sleep specialist. |
Dr Janet Cheung BPharm, MPhil, PhD, FHEA is a pharmacist and Senior Lecturer in Pharmacy Practice at the Sydney Pharmacy School, University of Sydney. Her research broadly focuses on promoting the quality use of sleep medicines through understanding patient medication-taking patterns and behaviours.
Dr Cheung supervises a PhD candidate on a project exploring treatment experiences and needs of self-identified Chinese patients in Australia. The candidate is employed by ResMed Pty Ltd and the company directly funds the research candidate’s research project costs as part of a professional development fund. The funding and nature of the project is not related to this CPD activity.
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[post_content] => Since 1 December 2024, Queensland-based pharmacists have been able to administer Abrysvo to pregnant patients to protect infants from severe Respiratory Syncytial Virus (RSV), following an expansion to the Queensland Paediatric Respiratory Syncytial Virus Prevention Program.
While Abrysvo will be added to the National Immunisation Program (NIP), as per the federal government’s announcement last month, the vaccine is currently funded by the Queensland government – although the administration fee is not covered at this stage.
But given Abrysvo is a relatively new vaccine, pharmacists will need to factor in pregnancy risk perception into strategies to encourage vaccine uptake.
After vaccinating her first patient against RSV, community pharmacist Anna Chang MPS, based in Brisbane, told Australian Pharmacist what should be considered.
Know how the vaccine needs to be prepared
The mixing instructions for Abrysvo are ‘unique’, said Ms Chang.
The vaccine comes with a lyophilised vaccine powder (vial), vial adapter and pre-filled syringe containing diluent. To prepare the vaccine, the vial adapter must be attached by centering it over the vial stopper and pushing straight down to avoid leaks.
Using a syringe held by the Luer lock adapter, the vial adapter must then be connected – with the entire diluent injected into the vial.
After swirling the vial until the powder is fully dissolved, the vial must be inverted and the complete 0.5 mL dose withdrawn into the syringe. Once the adapter is disconnected and a sterile needle attached, the vaccine is ready for intramuscular injection.
‘I haven’t seen a vaccine that is the same as this,’ she said. ‘We all had to look at the instruction sheet line by line and work it out.’
Take a strategic approach to opportunistic vaccination
Vaccination against RSV is recommended for pregnant patients at 28 to 36 weeks gestation. With the pertussis vaccine recommended at 20–32 weeks gestation, this is an opportune time to discuss protection against RSV.
Noting that a pregnant patient was booked in for a whooping cough vaccine at 31 weeks gestation, the week before her pharmacy received stock of Abrysvo, Ms Chang opted to take this approach.
‘I had her name in my calendar to call her and check if she wanted it when I actually got the stock,’ she said.
After receiving the green light from her obstetrician, the patient came back in 2 weeks after receiving her whooping cough vaccine.
‘The obstetrician wasn’t [promoting] it yet, so she [had to] ask if she should get it or not,’ said Ms Chang. ‘And for the cost saving she thought, “Why not go ahead?’”
At the moment, Ms Chang’s team is letting pregnant patients booked in for other vaccines know that funded Abrysvo vaccines are now available in community pharmacies.
‘We have been doing quite a bit of NIP [funded] whooping cough vaccinations for pregnant patients, so they are [ideal candidates],’ said Ms Chang.
Abrysvo can be co-administered with the whooping cough vaccine, if within the right window (28–32 weeks gestation).
‘We will [also] offer for them to come back the next week, but you still have to make sure not to leave it too late,’ she said.
What to do if the vaccine window is missed
While Abrysvo can be administered beyond 36 weeks gestation, infants are unlikely to be adequately protected unless they are born at least 2 weeks after their mother received the vaccine.
‘If you get the vaccine earlier you're covered if you have a premature baby,’ Ms Chang added.
‘And if you do miss that window and go past 36 weeks or have a premature baby, the baby can still be vaccinated [with nirsevimab] instead.’
The need for newborn vaccination is determined by if and when the pregnant woman received the RSV vaccine, said Ms Chang.
‘They should be asked to advise their obstetrician, midwife or the hospital of receiving the vaccine,’ she added.
Spread the word among other healthcare professionals
While Ms Chang thinks there has been more media coverage of RSV vaccination in 2024, there is unlikely to be widespread awareness of its availability, and benefits.
‘People talk a lot about the flu vaccine and COVID-19 vaccines, but RSV vaccination is [somewhat] new,’ she said.
Pharmacists can discuss the importance of RSV vaccination in pregnancy by letting patients know that it protects infants against severe RSV disease when they are most susceptible, with a clinical trial finding vaccine efficacy of 57% against hospitalisation for RSV for up to 6 months.
But pregnant patients may need assurance from multiple trusted healthcare sources that it’s safe to get vaccinated against RSV, advised Ms Chang.
‘I’ve sent letters to the nearby obstetricians to let them know that we’re [offering this vaccine],’ she said. ‘And in the new year we will let the GPs know.’
Be prepared to answer patients’ questions
Along with queries about vaccine efficacy and timeframe, pregnant patients may want to know about the potential adverse effects.
According to clinical trials, ‘very common’ adverse events include headache, myalgia and injection site pain.
Vaccination might provide protection for pregnant women against RSV disease. However, RSV is typically mild in adults, and clinical trials have not specifically assessed the vaccine's efficacy in protecting the mother.
‘[While] there is no data available on the duration of antibodies for the women, [pharmacists could] advise [patients] that it has shown to give protection for 12–16 months for older adults in the clinical studies.’
[post_title] => A pharmacist’s guide to RSV vaccination for pregnant patients
[post_excerpt] => One of the first pharmacists to administer an RSV vaccine to a pregnant patient explains how to promote, prepare and administer Abrysvo.
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[post_content] => With the festive season in full swing and the summer heat rising, pharmacists are at the forefront of helping patients navigate holiday health challenges.
Dive into Australian Pharmacist’s essential guide to keep your community safe this festive season.
Protect your patients against summer risks
With another festive season upon us, and the Bureau of Meteorology predicting extreme summer heat, pharmacists have an important role in keeping patients and families safe and healthy.
This includes advice around alcohol consumption with medicines, protection against mosquito-borne diseases and preventing dehydration.
And while the festive season is merry for some, it can be a difficult time of year for many. This means pharmacists should be on high alert to patients who could be taking higher-than-prescribed medication – potentially for doses for stronger sedation or self-harm.
Refer to this handy pharmacist advice piece by PSA’s resident clinical expert Shani Pickering as a go-to summer guide.
Raise awareness of new sun safety guidelines
The one-size-fits-all approach to sun safety is now out, with a tailored approach based on skin type, now the way to go.
The new sun protection guidelines, released earlier this year, are designed around skin cancer risk. While those with pale skin need to rely on a full suite of sun protection measures when the UV index is ≥3, those with deeply pigmented skin must ensure they get enough vitamin D to avoid a deficiency.
Before your patients start presenting in droves for their summer sun block, give AP’s sun safety guide a squizz.
And while you’re at it, make sure you’re abreast of the sunscreen myths floating around on social media – and how to dispel them.
Be alert to new illicit drug threats this festival season
Every year, the summer season ushers in a wave of music festivals, attended by thousands of revellers nationwide. But this season threatens to be different, with the deadly synthetic opioids, nitazenes, having infiltrated the illicit market.
While seasoned opioid users will have some tolerance to nitazenes, known to be more potent than fentanyl, it has been detected in other illicit drugs such as MDMA and cocaine – which can lead to rapid overdose in casual drug users. In fact, the potent opioids are thought to be linked to mass overdose deaths in Victoria this year.
While there are pill testing services available in Victoria, the ACT and Queensland, Australia’s most populous state, New South Wales, has yet to implement drug checking.
Expert Professor Suzi Nielsen MPS broke down the risks for AP earlier this year, outlining a revised approach to harm reduction.
Navigate summertime nicks, scrapes and scalds
The warmer months often mean more time spent outdoors, leading to increased risks of cuts and scrapes on the beach to nasty insect bites and burns from summer grilling.
With the most common wounds encountered in pharmacy being abrasions, cuts and burns, it's important for pharmacists to know the ABC’s of wound care. This includes providing therapeutic products, guidance on the right dressing selection and when to refer on.
AP’s Management of acute wounds commonly seen in community pharmacy CPD can help to bring you up to speed. And with infections such as cellulitis also more common during the summer months, this wound infection CPD can help pharmacists keep patients safe from harm.
Help patients take the (blood) pressure down this Christmas
The holiday period can come with an excess of stress, salty foods and alcohol consumption – all of which can play havoc with blood pressure. But with recent research finding that most patients aren’t monitoring their blood pressure correctly, it’s important for patients to know what’s artificially, and actually, inflating their blood pressure this holiday season.
This recent AP article analyses where patients get it wrong and how pharmacists can help them take an accurate blood pressure reading. And with low-density lipoprotein cholesterol also more likely to spike after a bit of holiday indulgence, pharmacists can help patients calculate their cardiovascular risk with the new Australian Cardiovascular risk calculator.
Prevent the festive season becoming a headache
Migraine triggers are plentiful during the holiday period, from extreme heat and bright lights, to poor diet and lack of sleep. Migraine and tension headaches can be managed through non-pharmacological strategies, such as stress reduction, obtaining adequate sleep and regular exercise. But pharmacists can also prescribe a number of triptans, where appropriate, and Schedule 3 medicines.
To help patients make it through the holiday season migraine free, read PSA’s Migraine and tension-type headache CPD.
Happy holidays from AP!
[post_title] => A prescription for a safer festive season
[post_excerpt] => With the festive season in full swing, pharmacists are at the forefront of helping patients navigate holiday health challenges.
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[post_content] => 2024 National Credentialed Diabetes Educator of the Year Julie Kha MPS loves collaborating to deliver better outcomes for her patients.
What led you to pharmacy?
Pharmacy was an exciting choice, enabling an understanding of how medicines can affect us, which can then be communicated to patients to ensure they are informed how to best achieve their shared health goals.
As a profession, pharmacy also offers incredible flexibility with an increasingly specialised workforce.
For example, pharmacists or credentialed pharmacists have now extended into various practice settings such as general practice and aged care – with a continual expansion of scope of practice for those who undertake additional training.
Why did you decide to become a credentialed diabetes educator?
During my formative years, I was fortunate to work alongside the first Australian pharmacist credentialed diabetes educator (CDE) Kirrily Chambers.
I noticed the impact she had on the lives of people with diabetes and their families as they exited the consult room where she worked in private practice and I wanted to generate that same impact from each patient interaction I had.
I was also fortunate to have come across another pharmacist CDE, Cindy Tolba, who was working in a diverse community where English is not the primary language.
Here, she utilised family members and even generated her own resources in the patient’s own language to better convey the workings and impact of diabetes.
Not too surprisingly, my Asian heritage played a role with our increased risk of diabetes. Dr Chris Verrall, an advocate for individualised patient goals, encouraged me to complete my accredited pharmacist requirement and then become a CDE.
How do you support patients who have been newly diagnosed?
Collaboration with the patient’s GP is where we work best. During the early stages, the patient may require time to navigate their new diagnosis and have many questions, or none at all. This takes time that GPs, who are underfunded and in short supply, don’t always have.
Establishing a person-centred approach is also of utmost importance. From this, an individualised plan can be generated to provide personalised education and support with resources and tools to empower the person with diabetes to be in a position where they are able to self-manage this chronic condition.
I had one patient whose glycated haemoglobin (HbA1c) remained elevated despite the addition of insulin.
Following a discussion about injection technique, and more importantly injection site rotation, it was discovered that the abdomen had developed areas of lipohypertrophy as ‘these areas didn’t hurt as much’.
After collaboration with the GP, the person with diabetes was just as excited to hear their insulin dose would be decreasing with a follow-up review scheduled soon thereafter.
How will pharmacists’ roles evolve in chronic disease management?
I was delighted to hear about the partnered prescribing models in our South Australian public hospitals.
With the right education and collaboration, I believe we can develop a similar model to our Canadian pharmacist colleagues, who provide structured chronic disease management programs in collaboration with GPs, practice nurses and other allied health to improve patient outcomes.
I believe one of the first steps would be to incorporate pharmacist CDEs into the hospital system, both public and private, to encourage greater interprofessional collaboration.
I’m proud to be part of pharmacy in this era of change and excited for our pharmacists of the future.
Advice for pharmacists looking to specialise in diabetes care?
Pursue your passion with a group of like-minded colleagues and mentors.
This way, your continuous learning will ensure the outcomes of each person with diabetes, and their families, are improved via an individualised approach and collaboration with the
best evidence-based practice.
A day in the life of Julie Kha MPS, Credentialed Diabetes Pharmacist, Adelaide, SA.
| 8.00 am | Before hitting the road Organise paperwork and plan (travel routes) for the day. |
| 9.00 am | Client education Meet diabetes education clients to understand their health goals to ensure personalised care. Transfer a concession card number into the National Diabetes Services Scheme (NDSS) for a person with type 1 diabetes; she was pleased to learn her costs would be further reduced! Review Libre 2 sensor data for a patient with type 2 diabetes who is on insulin. He was surprised about the impact of his banh mi (sandwich) lunch on his interstitial glucose levels. |
| 1–2.00 pm | Lunch break Replying to emails and returning GP and patient calls. |
| 2–6.00 pm | Clinical afternoon Finalise reports for GPs and specialists. Follow up with any high-risk patients e.g. persons with chronic kidney disease (CKD) or persons with diabetes and still titrating insulin. Remind a patient with type 2 diabetes on a sodium-glucose cotransporter-2 (SGLT2) inhibitor to stop her tablet 3 days prior to her colonoscopy next week. |
| 6.00 pm | Home Medicines Review Meet the last patient of the day for a Home Medicines Review after hours because they work full time. Discover they are taking a NSAID for arthritis pain on top of their ACE inhibitor and diuretic; looks like a call to the GP is in order tomorrow morning to discuss the triple whammy and the risk of acute kidney injury! |
| 8-9.30 pm | Remains of the day Continue writing reports and, if time permits, peruse the Australian Stock Exchange (ASX) movements! |
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[post_content] => When an injection doesn’t go as planned, it can be stressful for both patients and pharmacists. Here’s how to calmly handle these situations while maintaining safety and trust.
Yesterday morning, a mother of two came into a Queensland-based pharmacy requesting emergency contraception.
During the consultation, pharmacist Grace Quach MPS, PSA MIMS Intern Pharmacist of the Year 2023, asked the patient when she had her last period.
‘She had just had a baby 2 months ago, so she hadn't had her period for 9 months, or a normal period since,’ said Ms Quach. ‘However, she did have a Depo Provera injection last week.’
[caption id="attachment_23324" align="aligncenter" width="600"]
Grace Quach MPS[/caption]
The patient then revealed that a nurse, supervised by a doctor, administered the injectable contraceptive but pulled out the needle too quickly – leaving the medicine to dribble down her arm.
The GP brushed it off, saying ‘I'm not sure if you’ll get the full amount of protection. See how you go’, leaving the patient stunned.
While mistakes are bound to happen during vaccinations or when administering medicines by injection, there are certain do’s and dont’s that should be followed.
What if a vaccine is partially administered?
If the process of administering a vaccine is interrupted (for example by syringe-needle disconnection), pharmacists should ask themselves:
For example, this could entail letting a patient know that more than 50% of the vaccine was administered, if this was the case, which is deemed enough to form an immune response according to ATAGI.
‘The patient [should not be put in a position] where they are unsure of whether or not they've received correct treatment once they leave the vaccination [or medicine by injection] room,’ said Ms Jadeja ‘That also reduces trust in that healthcare professional, which is not a good scenario at the end of the day.’ PSA’s Pharmacist-to-Pharmacist Advice Line offers expert advice to members in real time. The Pharmacist Advice Line is an exclusive member service offering professional advice from a senior pharmacist on technical, ethical and practice questions. This includes:td_module_mega_menu Object
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[caption id="attachment_28475" align="alignright" width="244"] A national education program for pharmacists funded by the Australian Government under the Quality Use of Diagnostics, Therapeutics and Pathology program.[/caption]
Amna, 26 years old, is browsing the vitamins and herbal supplements section of the pharmacy, seeking a solution for her sleep problems. Over the past 2 weeks, she has experienced difficulty falling asleep at night and feels exhausted when she wakes up at 7 am to get ready for work. She also wants some information about melatonin, as some of her older colleagues have had success with it. Amna is an otherwise healthy young adult without co-existing medical comorbidities and is not currently taking any other medicines.
Learning objectivesAfter reading this article, pharmacists should be able to:
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Non-prescription sleep aids are frequently purchased by individuals to improve their sleep while delaying seeking medical care.1 Given the product availability and proximity of community pharmacy to the public, the pharmacist has an important role to play in promoting the safe and effective use of non-prescription sleep aids and referring patients to appropriate care.2,3
Non-prescription sleep aids predominantly target insomnia symptoms, utilising their sedative properties to promote faster sleep onset. These are mainly Schedule 3 medicines and include the sedating antihistamines diphenhydramine, promethazine and doxylamine.4 Prolonged-release melatonin may be used as a Schedule 3 medicine in adults ≥55 years of age as a short-term monotherapy for primary insomnia, characterised by poor sleep quality.4
Complementary medicines (CMs; e.g. valerian, passionflower, hops, kava, chamomile) and supplements (e.g. magnesium) are also sometimes used to help aid sleep.5,6 Many of the CMs theoretically act on GABAergic receptors and/or have anxiolytic and relaxant effects.7 The Australian Pharmaceutical Formulary and Handbook contains further information on various CMs and their reported uses in sleep.6
A key practice dilemma that pharmacists face each day is that despite the widespread availability and use of non-prescription sleep aids, several professional sleep societies recommend against their use due to insufficient evidence.8–10 Therapeutic Guidelines also advises not to use sedating antihistamines to treat insomnia.11 Many of the pivotal trials evaluating first-generation sedating antihistamines and CMs have critical study design limitations that fall short of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) standards that are often used to appraise the evidence base.12
While the evidence bases for both CMs and Schedule 3 sleep aids are unlikely to immediately change, a core practice consideration is the risk-benefit profile of the respective non-prescription sleep aids for the individual patient.
Consumers often misperceive non-prescription sleep aids as being safer than prescription medicines due to their ‘naturalness’ or ease of access.13 As such, these sleep aids are often used medically unsupervised to either initially delay seeking medical care,14 or, in combination with prescribed regimens, to offset the perceived harms of prescription sleep aids.15,16 When non-prescription sleep aids are being used unsupervised, consumers may be unaware of the potential contraindications or interactions with existing medicines. For example, melatonin, while seemingly benign, can have undesired effects in high-risk patient groups. Melatonin can potentially interfere with immunosuppressive therapies,17 and may increase risk of bleeding for patients on anticoagulant medicines such as warfarin.18,19 While many of the interactions with CMs are theoretical, pharmacists play a critical role in assessing risk-benefit and providing advice for the safe use of these non-prescription sleep aids. Nonetheless, discerning the risk profiles of the respective CMs is increasingly challenging since many herbal sleep formulations in the pharmacy combine multiple herbal ingredients.
Patients should be advised to avoid the concomitant use of non-prescription sleep aids with alcohol and medicines that have central nervous system depressing effects, and to avoid driving or operating machinery if drowsy.20 The effects of sleep aids, especially sedating antihistamines, can continue the next day.4,20,21 In addition, non-prescription sleep aids should be limited to short-term use. Sedating antihistamines should not be used for longer than 10 consecutive days because tolerance to their sedative effects develops quickly.4,21,22 In older adults, the risks of using non-prescription sleep aids are even higher. This is because they tend to take more medicines, increasing the potential for drug-drug and drug-herb interactions. In addition, the sedative effects of sedating antihistamines may be more pronounced due to age-related pharmacokinetic and pharmacodynamic changes, such as reduced metabolism and clearance.23 Older adults are also more vulnerable to other cognitive and anticholinergic adverse effects of sedating antihistamines, and these medicines can add to the anticholinergic burden.21 Guidelines recommend avoiding the use of sedating antihistamines in older people.⁴ However, older people make up a significant portion of users.23 If it is not possible to avoid use in older people, they should use lower doses than other adults.21
Notwithstanding these acute consequences, one of the main concerns of self-medication is delayed medical help-seeking and initiation of the first-line therapy, cognitive behavioural therapy for insomnia (CBTi).24 Individuals may miss the optimal window to address their sleep complaint and allow perpetuating factors such as poor sleep habits and anxiety about the lack of sleep to develop, resulting in the transition of acute insomnia into chronic insomnia (insomnia lasting ≥3 months).8
Is it really insomnia?From direct product requests to symptom-based requests in the pharmacy, patients will often refer to their sleep complaint as ‘insomnia’ and seek non-prescription sleep aids to improve their sleep. Insomnia symptoms such as difficulty initiating sleep, maintaining sleep, early-morning waking and associated daytime fatigue can appear to overlap with symptoms of other sleep disorders for which non-prescription sleep aids may not be suitable. For example, circadian sleep disorders such as advanced sleep phase disorder and delayed sleep phase disorder share a lot of similarity with insomnia symptoms where the patient experiences difficulty falling asleep at a desired time.25,26 Those with a circadian sleep disorder have an otherwise intact sleep-wake cycle but struggle to fall asleep and wake up at socially acceptable times to meet their daily obligations such as work and school because their internal body clocks have shifted.10 Similarly, for patients with undiagnosed obstructive sleep apnoea (OSA), the daytime fatigue and functional impairments often motivates patients to use non-prescription sleep aids to improve their sleep or alertness, but clinical guidelines recommend against their use.27 Another common sleep disorder, restless legs syndrome (RLS), like insomnia, will result in difficulty falling asleep and/or staying asleep with daytime consequences. The disrupted sleep in RLS is largely attributed to the uncomfortable sensation felt in the legs at night when resting and the urge to move and stretch out the legs to relieve discomfort.28 The symptoms of RLS can be precipitated or exacerbated with use of sedating antihistamines.29
Further clinician and patient information on these conditions can be obtained from Sleep Central (www.sleepcentral.org.au), or consumer-facing resources from the Sleep Health Foundation (www.sleephealthfoundation.org.au).
Patients presenting to the pharmacy for non-prescription sleep aids should be assessed for the presence of other sleep disorders.30,31 Pharmacists can probe further into the nature and history of the sleep complaint by asking patients about potential triggers, sleep-wake schedules, engagement in shift work, the presence of other physical symptoms (e.g. snoring or witnessed breathing pauses during sleep, uncomfortable sensations in the lower legs and ability to fall asleep easily at earlier/later times), and prior treatments and response to treatments.3 In addition, there are evidence-based screening and assessment tools for the different sleep disorders that pharmacists may use in their practice to identify at-risk patients for onward referral and assessment by their medical practitioner.
Further information on assessment tools for insomnia and patient education resources can be found on the Sleep Central website (www.sleepcentral.org.au).
Knowledge to practice Despite insufficient evidence supporting the use of non-prescription sleep aids, it is critical to engage patients in a non-judgemental and open discussion about their non-prescription sleep aid use.32 Through these conversations, pharmacists can gain further information about the nature of the patient’s sleep complaint, their current medical and medicines history and treatment expectations. Pharmacists can then educate patients about the various sleep disorders, potential adverse effects and interactions of pharmacological treatment, and inform them about the benefits of seeing a medical practitioner for assessment and optimal treatment.
Non-prescription sleep aids are widely used by members of the community to improve their sleep, but they may not always be an appropriate choice, and risks can often outweigh perceived benefits. Pharmacists play a key role in ensuring non-prescription sleep aids are used safely and effectively. Pharmacists are well placed to direct consumers to evidence-based resources on sleep health and sleep disorders, which may empower them to be better informed about sleep, improve their sleep health literacy, and understand the need for further assessment from a medical practitioner. They can also facilitate onward referral to a medical practitioner for further assessment, differential diagnosis and management of their sleep disturbance.
Case scenario continuedYou ask Amna about her sleep. She wants to go to sleep by 10:30 pm but typically doesn’t feel sleepy until 1 am. Her sleep complaint is only an issue on weekdays when she needs to follow a strict schedule. Weekends are pleasant as she can sleep and wake when she wants. You suggest that Amna may have symptoms of a delayed circadian rhythm rather than insomnia, and refer her to see her GP for a discussion and referral to a sleep specialist. |
Dr Janet Cheung BPharm, MPhil, PhD, FHEA is a pharmacist and Senior Lecturer in Pharmacy Practice at the Sydney Pharmacy School, University of Sydney. Her research broadly focuses on promoting the quality use of sleep medicines through understanding patient medication-taking patterns and behaviours.
Dr Cheung supervises a PhD candidate on a project exploring treatment experiences and needs of self-identified Chinese patients in Australia. The candidate is employed by ResMed Pty Ltd and the company directly funds the research candidate’s research project costs as part of a professional development fund. The funding and nature of the project is not related to this CPD activity.
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[post_content] => Since 1 December 2024, Queensland-based pharmacists have been able to administer Abrysvo to pregnant patients to protect infants from severe Respiratory Syncytial Virus (RSV), following an expansion to the Queensland Paediatric Respiratory Syncytial Virus Prevention Program.
While Abrysvo will be added to the National Immunisation Program (NIP), as per the federal government’s announcement last month, the vaccine is currently funded by the Queensland government – although the administration fee is not covered at this stage.
But given Abrysvo is a relatively new vaccine, pharmacists will need to factor in pregnancy risk perception into strategies to encourage vaccine uptake.
After vaccinating her first patient against RSV, community pharmacist Anna Chang MPS, based in Brisbane, told Australian Pharmacist what should be considered.
Know how the vaccine needs to be prepared
The mixing instructions for Abrysvo are ‘unique’, said Ms Chang.
The vaccine comes with a lyophilised vaccine powder (vial), vial adapter and pre-filled syringe containing diluent. To prepare the vaccine, the vial adapter must be attached by centering it over the vial stopper and pushing straight down to avoid leaks.
Using a syringe held by the Luer lock adapter, the vial adapter must then be connected – with the entire diluent injected into the vial.
After swirling the vial until the powder is fully dissolved, the vial must be inverted and the complete 0.5 mL dose withdrawn into the syringe. Once the adapter is disconnected and a sterile needle attached, the vaccine is ready for intramuscular injection.
‘I haven’t seen a vaccine that is the same as this,’ she said. ‘We all had to look at the instruction sheet line by line and work it out.’
Take a strategic approach to opportunistic vaccination
Vaccination against RSV is recommended for pregnant patients at 28 to 36 weeks gestation. With the pertussis vaccine recommended at 20–32 weeks gestation, this is an opportune time to discuss protection against RSV.
Noting that a pregnant patient was booked in for a whooping cough vaccine at 31 weeks gestation, the week before her pharmacy received stock of Abrysvo, Ms Chang opted to take this approach.
‘I had her name in my calendar to call her and check if she wanted it when I actually got the stock,’ she said.
After receiving the green light from her obstetrician, the patient came back in 2 weeks after receiving her whooping cough vaccine.
‘The obstetrician wasn’t [promoting] it yet, so she [had to] ask if she should get it or not,’ said Ms Chang. ‘And for the cost saving she thought, “Why not go ahead?’”
At the moment, Ms Chang’s team is letting pregnant patients booked in for other vaccines know that funded Abrysvo vaccines are now available in community pharmacies.
‘We have been doing quite a bit of NIP [funded] whooping cough vaccinations for pregnant patients, so they are [ideal candidates],’ said Ms Chang.
Abrysvo can be co-administered with the whooping cough vaccine, if within the right window (28–32 weeks gestation).
‘We will [also] offer for them to come back the next week, but you still have to make sure not to leave it too late,’ she said.
What to do if the vaccine window is missed
While Abrysvo can be administered beyond 36 weeks gestation, infants are unlikely to be adequately protected unless they are born at least 2 weeks after their mother received the vaccine.
‘If you get the vaccine earlier you're covered if you have a premature baby,’ Ms Chang added.
‘And if you do miss that window and go past 36 weeks or have a premature baby, the baby can still be vaccinated [with nirsevimab] instead.’
The need for newborn vaccination is determined by if and when the pregnant woman received the RSV vaccine, said Ms Chang.
‘They should be asked to advise their obstetrician, midwife or the hospital of receiving the vaccine,’ she added.
Spread the word among other healthcare professionals
While Ms Chang thinks there has been more media coverage of RSV vaccination in 2024, there is unlikely to be widespread awareness of its availability, and benefits.
‘People talk a lot about the flu vaccine and COVID-19 vaccines, but RSV vaccination is [somewhat] new,’ she said.
Pharmacists can discuss the importance of RSV vaccination in pregnancy by letting patients know that it protects infants against severe RSV disease when they are most susceptible, with a clinical trial finding vaccine efficacy of 57% against hospitalisation for RSV for up to 6 months.
But pregnant patients may need assurance from multiple trusted healthcare sources that it’s safe to get vaccinated against RSV, advised Ms Chang.
‘I’ve sent letters to the nearby obstetricians to let them know that we’re [offering this vaccine],’ she said. ‘And in the new year we will let the GPs know.’
Be prepared to answer patients’ questions
Along with queries about vaccine efficacy and timeframe, pregnant patients may want to know about the potential adverse effects.
According to clinical trials, ‘very common’ adverse events include headache, myalgia and injection site pain.
Vaccination might provide protection for pregnant women against RSV disease. However, RSV is typically mild in adults, and clinical trials have not specifically assessed the vaccine's efficacy in protecting the mother.
‘[While] there is no data available on the duration of antibodies for the women, [pharmacists could] advise [patients] that it has shown to give protection for 12–16 months for older adults in the clinical studies.’
[post_title] => A pharmacist’s guide to RSV vaccination for pregnant patients
[post_excerpt] => One of the first pharmacists to administer an RSV vaccine to a pregnant patient explains how to promote, prepare and administer Abrysvo.
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[title_attribute] => A pharmacist’s guide to RSV vaccination for pregnant patients
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[post_content] => With the festive season in full swing and the summer heat rising, pharmacists are at the forefront of helping patients navigate holiday health challenges.
Dive into Australian Pharmacist’s essential guide to keep your community safe this festive season.
Protect your patients against summer risks
With another festive season upon us, and the Bureau of Meteorology predicting extreme summer heat, pharmacists have an important role in keeping patients and families safe and healthy.
This includes advice around alcohol consumption with medicines, protection against mosquito-borne diseases and preventing dehydration.
And while the festive season is merry for some, it can be a difficult time of year for many. This means pharmacists should be on high alert to patients who could be taking higher-than-prescribed medication – potentially for doses for stronger sedation or self-harm.
Refer to this handy pharmacist advice piece by PSA’s resident clinical expert Shani Pickering as a go-to summer guide.
Raise awareness of new sun safety guidelines
The one-size-fits-all approach to sun safety is now out, with a tailored approach based on skin type, now the way to go.
The new sun protection guidelines, released earlier this year, are designed around skin cancer risk. While those with pale skin need to rely on a full suite of sun protection measures when the UV index is ≥3, those with deeply pigmented skin must ensure they get enough vitamin D to avoid a deficiency.
Before your patients start presenting in droves for their summer sun block, give AP’s sun safety guide a squizz.
And while you’re at it, make sure you’re abreast of the sunscreen myths floating around on social media – and how to dispel them.
Be alert to new illicit drug threats this festival season
Every year, the summer season ushers in a wave of music festivals, attended by thousands of revellers nationwide. But this season threatens to be different, with the deadly synthetic opioids, nitazenes, having infiltrated the illicit market.
While seasoned opioid users will have some tolerance to nitazenes, known to be more potent than fentanyl, it has been detected in other illicit drugs such as MDMA and cocaine – which can lead to rapid overdose in casual drug users. In fact, the potent opioids are thought to be linked to mass overdose deaths in Victoria this year.
While there are pill testing services available in Victoria, the ACT and Queensland, Australia’s most populous state, New South Wales, has yet to implement drug checking.
Expert Professor Suzi Nielsen MPS broke down the risks for AP earlier this year, outlining a revised approach to harm reduction.
Navigate summertime nicks, scrapes and scalds
The warmer months often mean more time spent outdoors, leading to increased risks of cuts and scrapes on the beach to nasty insect bites and burns from summer grilling.
With the most common wounds encountered in pharmacy being abrasions, cuts and burns, it's important for pharmacists to know the ABC’s of wound care. This includes providing therapeutic products, guidance on the right dressing selection and when to refer on.
AP’s Management of acute wounds commonly seen in community pharmacy CPD can help to bring you up to speed. And with infections such as cellulitis also more common during the summer months, this wound infection CPD can help pharmacists keep patients safe from harm.
Help patients take the (blood) pressure down this Christmas
The holiday period can come with an excess of stress, salty foods and alcohol consumption – all of which can play havoc with blood pressure. But with recent research finding that most patients aren’t monitoring their blood pressure correctly, it’s important for patients to know what’s artificially, and actually, inflating their blood pressure this holiday season.
This recent AP article analyses where patients get it wrong and how pharmacists can help them take an accurate blood pressure reading. And with low-density lipoprotein cholesterol also more likely to spike after a bit of holiday indulgence, pharmacists can help patients calculate their cardiovascular risk with the new Australian Cardiovascular risk calculator.
Prevent the festive season becoming a headache
Migraine triggers are plentiful during the holiday period, from extreme heat and bright lights, to poor diet and lack of sleep. Migraine and tension headaches can be managed through non-pharmacological strategies, such as stress reduction, obtaining adequate sleep and regular exercise. But pharmacists can also prescribe a number of triptans, where appropriate, and Schedule 3 medicines.
To help patients make it through the holiday season migraine free, read PSA’s Migraine and tension-type headache CPD.
Happy holidays from AP!
[post_title] => A prescription for a safer festive season
[post_excerpt] => With the festive season in full swing, pharmacists are at the forefront of helping patients navigate holiday health challenges.
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[post_content] => 2024 National Credentialed Diabetes Educator of the Year Julie Kha MPS loves collaborating to deliver better outcomes for her patients.
What led you to pharmacy?
Pharmacy was an exciting choice, enabling an understanding of how medicines can affect us, which can then be communicated to patients to ensure they are informed how to best achieve their shared health goals.
As a profession, pharmacy also offers incredible flexibility with an increasingly specialised workforce.
For example, pharmacists or credentialed pharmacists have now extended into various practice settings such as general practice and aged care – with a continual expansion of scope of practice for those who undertake additional training.
Why did you decide to become a credentialed diabetes educator?
During my formative years, I was fortunate to work alongside the first Australian pharmacist credentialed diabetes educator (CDE) Kirrily Chambers.
I noticed the impact she had on the lives of people with diabetes and their families as they exited the consult room where she worked in private practice and I wanted to generate that same impact from each patient interaction I had.
I was also fortunate to have come across another pharmacist CDE, Cindy Tolba, who was working in a diverse community where English is not the primary language.
Here, she utilised family members and even generated her own resources in the patient’s own language to better convey the workings and impact of diabetes.
Not too surprisingly, my Asian heritage played a role with our increased risk of diabetes. Dr Chris Verrall, an advocate for individualised patient goals, encouraged me to complete my accredited pharmacist requirement and then become a CDE.
How do you support patients who have been newly diagnosed?
Collaboration with the patient’s GP is where we work best. During the early stages, the patient may require time to navigate their new diagnosis and have many questions, or none at all. This takes time that GPs, who are underfunded and in short supply, don’t always have.
Establishing a person-centred approach is also of utmost importance. From this, an individualised plan can be generated to provide personalised education and support with resources and tools to empower the person with diabetes to be in a position where they are able to self-manage this chronic condition.
I had one patient whose glycated haemoglobin (HbA1c) remained elevated despite the addition of insulin.
Following a discussion about injection technique, and more importantly injection site rotation, it was discovered that the abdomen had developed areas of lipohypertrophy as ‘these areas didn’t hurt as much’.
After collaboration with the GP, the person with diabetes was just as excited to hear their insulin dose would be decreasing with a follow-up review scheduled soon thereafter.
How will pharmacists’ roles evolve in chronic disease management?
I was delighted to hear about the partnered prescribing models in our South Australian public hospitals.
With the right education and collaboration, I believe we can develop a similar model to our Canadian pharmacist colleagues, who provide structured chronic disease management programs in collaboration with GPs, practice nurses and other allied health to improve patient outcomes.
I believe one of the first steps would be to incorporate pharmacist CDEs into the hospital system, both public and private, to encourage greater interprofessional collaboration.
I’m proud to be part of pharmacy in this era of change and excited for our pharmacists of the future.
Advice for pharmacists looking to specialise in diabetes care?
Pursue your passion with a group of like-minded colleagues and mentors.
This way, your continuous learning will ensure the outcomes of each person with diabetes, and their families, are improved via an individualised approach and collaboration with the
best evidence-based practice.
A day in the life of Julie Kha MPS, Credentialed Diabetes Pharmacist, Adelaide, SA.
| 8.00 am | Before hitting the road Organise paperwork and plan (travel routes) for the day. |
| 9.00 am | Client education Meet diabetes education clients to understand their health goals to ensure personalised care. Transfer a concession card number into the National Diabetes Services Scheme (NDSS) for a person with type 1 diabetes; she was pleased to learn her costs would be further reduced! Review Libre 2 sensor data for a patient with type 2 diabetes who is on insulin. He was surprised about the impact of his banh mi (sandwich) lunch on his interstitial glucose levels. |
| 1–2.00 pm | Lunch break Replying to emails and returning GP and patient calls. |
| 2–6.00 pm | Clinical afternoon Finalise reports for GPs and specialists. Follow up with any high-risk patients e.g. persons with chronic kidney disease (CKD) or persons with diabetes and still titrating insulin. Remind a patient with type 2 diabetes on a sodium-glucose cotransporter-2 (SGLT2) inhibitor to stop her tablet 3 days prior to her colonoscopy next week. |
| 6.00 pm | Home Medicines Review Meet the last patient of the day for a Home Medicines Review after hours because they work full time. Discover they are taking a NSAID for arthritis pain on top of their ACE inhibitor and diuretic; looks like a call to the GP is in order tomorrow morning to discuss the triple whammy and the risk of acute kidney injury! |
| 8-9.30 pm | Remains of the day Continue writing reports and, if time permits, peruse the Australian Stock Exchange (ASX) movements! |
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[post_content] => When an injection doesn’t go as planned, it can be stressful for both patients and pharmacists. Here’s how to calmly handle these situations while maintaining safety and trust.
Yesterday morning, a mother of two came into a Queensland-based pharmacy requesting emergency contraception.
During the consultation, pharmacist Grace Quach MPS, PSA MIMS Intern Pharmacist of the Year 2023, asked the patient when she had her last period.
‘She had just had a baby 2 months ago, so she hadn't had her period for 9 months, or a normal period since,’ said Ms Quach. ‘However, she did have a Depo Provera injection last week.’
[caption id="attachment_23324" align="aligncenter" width="600"] Grace Quach MPS[/caption]
The patient then revealed that a nurse, supervised by a doctor, administered the injectable contraceptive but pulled out the needle too quickly – leaving the medicine to dribble down her arm.
The GP brushed it off, saying ‘I'm not sure if you’ll get the full amount of protection. See how you go’, leaving the patient stunned.
While mistakes are bound to happen during vaccinations or when administering medicines by injection, there are certain do’s and dont’s that should be followed.
What if a vaccine is partially administered?
If the process of administering a vaccine is interrupted (for example by syringe-needle disconnection), pharmacists should ask themselves:
For example, this could entail letting a patient know that more than 50% of the vaccine was administered, if this was the case, which is deemed enough to form an immune response according to ATAGI.
‘The patient [should not be put in a position] where they are unsure of whether or not they've received correct treatment once they leave the vaccination [or medicine by injection] room,’ said Ms Jadeja ‘That also reduces trust in that healthcare professional, which is not a good scenario at the end of the day.’ PSA’s Pharmacist-to-Pharmacist Advice Line offers expert advice to members in real time. The Pharmacist Advice Line is an exclusive member service offering professional advice from a senior pharmacist on technical, ethical and practice questions. This includes:td_module_mega_menu Object
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[post_content] => Case scenario
[caption id="attachment_28475" align="alignright" width="244"] A national education program for pharmacists funded by the Australian Government under the Quality Use of Diagnostics, Therapeutics and Pathology program.[/caption]
Amna, 26 years old, is browsing the vitamins and herbal supplements section of the pharmacy, seeking a solution for her sleep problems. Over the past 2 weeks, she has experienced difficulty falling asleep at night and feels exhausted when she wakes up at 7 am to get ready for work. She also wants some information about melatonin, as some of her older colleagues have had success with it. Amna is an otherwise healthy young adult without co-existing medical comorbidities and is not currently taking any other medicines.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Non-prescription sleep aids are frequently purchased by individuals to improve their sleep while delaying seeking medical care.1 Given the product availability and proximity of community pharmacy to the public, the pharmacist has an important role to play in promoting the safe and effective use of non-prescription sleep aids and referring patients to appropriate care.2,3
Non-prescription sleep aids predominantly target insomnia symptoms, utilising their sedative properties to promote faster sleep onset. These are mainly Schedule 3 medicines and include the sedating antihistamines diphenhydramine, promethazine and doxylamine.4 Prolonged-release melatonin may be used as a Schedule 3 medicine in adults ≥55 years of age as a short-term monotherapy for primary insomnia, characterised by poor sleep quality.4
Complementary medicines (CMs; e.g. valerian, passionflower, hops, kava, chamomile) and supplements (e.g. magnesium) are also sometimes used to help aid sleep.5,6 Many of the CMs theoretically act on GABAergic receptors and/or have anxiolytic and relaxant effects.7 The Australian Pharmaceutical Formulary and Handbook contains further information on various CMs and their reported uses in sleep.6
A key practice dilemma that pharmacists face each day is that despite the widespread availability and use of non-prescription sleep aids, several professional sleep societies recommend against their use due to insufficient evidence.8–10 Therapeutic Guidelines also advises not to use sedating antihistamines to treat insomnia.11 Many of the pivotal trials evaluating first-generation sedating antihistamines and CMs have critical study design limitations that fall short of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) standards that are often used to appraise the evidence base.12
While the evidence bases for both CMs and Schedule 3 sleep aids are unlikely to immediately change, a core practice consideration is the risk-benefit profile of the respective non-prescription sleep aids for the individual patient.
Consumers often misperceive non-prescription sleep aids as being safer than prescription medicines due to their ‘naturalness’ or ease of access.13 As such, these sleep aids are often used medically unsupervised to either initially delay seeking medical care,14 or, in combination with prescribed regimens, to offset the perceived harms of prescription sleep aids.15,16 When non-prescription sleep aids are being used unsupervised, consumers may be unaware of the potential contraindications or interactions with existing medicines. For example, melatonin, while seemingly benign, can have undesired effects in high-risk patient groups. Melatonin can potentially interfere with immunosuppressive therapies,17 and may increase risk of bleeding for patients on anticoagulant medicines such as warfarin.18,19 While many of the interactions with CMs are theoretical, pharmacists play a critical role in assessing risk-benefit and providing advice for the safe use of these non-prescription sleep aids. Nonetheless, discerning the risk profiles of the respective CMs is increasingly challenging since many herbal sleep formulations in the pharmacy combine multiple herbal ingredients.
Patients should be advised to avoid the concomitant use of non-prescription sleep aids with alcohol and medicines that have central nervous system depressing effects, and to avoid driving or operating machinery if drowsy.20 The effects of sleep aids, especially sedating antihistamines, can continue the next day.4,20,21 In addition, non-prescription sleep aids should be limited to short-term use. Sedating antihistamines should not be used for longer than 10 consecutive days because tolerance to their sedative effects develops quickly.4,21,22 In older adults, the risks of using non-prescription sleep aids are even higher. This is because they tend to take more medicines, increasing the potential for drug-drug and drug-herb interactions. In addition, the sedative effects of sedating antihistamines may be more pronounced due to age-related pharmacokinetic and pharmacodynamic changes, such as reduced metabolism and clearance.23 Older adults are also more vulnerable to other cognitive and anticholinergic adverse effects of sedating antihistamines, and these medicines can add to the anticholinergic burden.21 Guidelines recommend avoiding the use of sedating antihistamines in older people.⁴ However, older people make up a significant portion of users.23 If it is not possible to avoid use in older people, they should use lower doses than other adults.21
Notwithstanding these acute consequences, one of the main concerns of self-medication is delayed medical help-seeking and initiation of the first-line therapy, cognitive behavioural therapy for insomnia (CBTi).24 Individuals may miss the optimal window to address their sleep complaint and allow perpetuating factors such as poor sleep habits and anxiety about the lack of sleep to develop, resulting in the transition of acute insomnia into chronic insomnia (insomnia lasting ≥3 months).8
Is it really insomnia?From direct product requests to symptom-based requests in the pharmacy, patients will often refer to their sleep complaint as ‘insomnia’ and seek non-prescription sleep aids to improve their sleep. Insomnia symptoms such as difficulty initiating sleep, maintaining sleep, early-morning waking and associated daytime fatigue can appear to overlap with symptoms of other sleep disorders for which non-prescription sleep aids may not be suitable. For example, circadian sleep disorders such as advanced sleep phase disorder and delayed sleep phase disorder share a lot of similarity with insomnia symptoms where the patient experiences difficulty falling asleep at a desired time.25,26 Those with a circadian sleep disorder have an otherwise intact sleep-wake cycle but struggle to fall asleep and wake up at socially acceptable times to meet their daily obligations such as work and school because their internal body clocks have shifted.10 Similarly, for patients with undiagnosed obstructive sleep apnoea (OSA), the daytime fatigue and functional impairments often motivates patients to use non-prescription sleep aids to improve their sleep or alertness, but clinical guidelines recommend against their use.27 Another common sleep disorder, restless legs syndrome (RLS), like insomnia, will result in difficulty falling asleep and/or staying asleep with daytime consequences. The disrupted sleep in RLS is largely attributed to the uncomfortable sensation felt in the legs at night when resting and the urge to move and stretch out the legs to relieve discomfort.28 The symptoms of RLS can be precipitated or exacerbated with use of sedating antihistamines.29
Further clinician and patient information on these conditions can be obtained from Sleep Central (www.sleepcentral.org.au), or consumer-facing resources from the Sleep Health Foundation (www.sleephealthfoundation.org.au).
Patients presenting to the pharmacy for non-prescription sleep aids should be assessed for the presence of other sleep disorders.30,31 Pharmacists can probe further into the nature and history of the sleep complaint by asking patients about potential triggers, sleep-wake schedules, engagement in shift work, the presence of other physical symptoms (e.g. snoring or witnessed breathing pauses during sleep, uncomfortable sensations in the lower legs and ability to fall asleep easily at earlier/later times), and prior treatments and response to treatments.3 In addition, there are evidence-based screening and assessment tools for the different sleep disorders that pharmacists may use in their practice to identify at-risk patients for onward referral and assessment by their medical practitioner.
Further information on assessment tools for insomnia and patient education resources can be found on the Sleep Central website (www.sleepcentral.org.au).
Knowledge to practice Despite insufficient evidence supporting the use of non-prescription sleep aids, it is critical to engage patients in a non-judgemental and open discussion about their non-prescription sleep aid use.32 Through these conversations, pharmacists can gain further information about the nature of the patient’s sleep complaint, their current medical and medicines history and treatment expectations. Pharmacists can then educate patients about the various sleep disorders, potential adverse effects and interactions of pharmacological treatment, and inform them about the benefits of seeing a medical practitioner for assessment and optimal treatment.
Non-prescription sleep aids are widely used by members of the community to improve their sleep, but they may not always be an appropriate choice, and risks can often outweigh perceived benefits. Pharmacists play a key role in ensuring non-prescription sleep aids are used safely and effectively. Pharmacists are well placed to direct consumers to evidence-based resources on sleep health and sleep disorders, which may empower them to be better informed about sleep, improve their sleep health literacy, and understand the need for further assessment from a medical practitioner. They can also facilitate onward referral to a medical practitioner for further assessment, differential diagnosis and management of their sleep disturbance.
Case scenario continuedYou ask Amna about her sleep. She wants to go to sleep by 10:30 pm but typically doesn’t feel sleepy until 1 am. Her sleep complaint is only an issue on weekdays when she needs to follow a strict schedule. Weekends are pleasant as she can sleep and wake when she wants. You suggest that Amna may have symptoms of a delayed circadian rhythm rather than insomnia, and refer her to see her GP for a discussion and referral to a sleep specialist. |
Dr Janet Cheung BPharm, MPhil, PhD, FHEA is a pharmacist and Senior Lecturer in Pharmacy Practice at the Sydney Pharmacy School, University of Sydney. Her research broadly focuses on promoting the quality use of sleep medicines through understanding patient medication-taking patterns and behaviours.
Dr Cheung supervises a PhD candidate on a project exploring treatment experiences and needs of self-identified Chinese patients in Australia. The candidate is employed by ResMed Pty Ltd and the company directly funds the research candidate’s research project costs as part of a professional development fund. The funding and nature of the project is not related to this CPD activity.
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[post_content] => Since 1 December 2024, Queensland-based pharmacists have been able to administer Abrysvo to pregnant patients to protect infants from severe Respiratory Syncytial Virus (RSV), following an expansion to the Queensland Paediatric Respiratory Syncytial Virus Prevention Program.
While Abrysvo will be added to the National Immunisation Program (NIP), as per the federal government’s announcement last month, the vaccine is currently funded by the Queensland government – although the administration fee is not covered at this stage.
But given Abrysvo is a relatively new vaccine, pharmacists will need to factor in pregnancy risk perception into strategies to encourage vaccine uptake.
After vaccinating her first patient against RSV, community pharmacist Anna Chang MPS, based in Brisbane, told Australian Pharmacist what should be considered.
Know how the vaccine needs to be prepared
The mixing instructions for Abrysvo are ‘unique’, said Ms Chang.
The vaccine comes with a lyophilised vaccine powder (vial), vial adapter and pre-filled syringe containing diluent. To prepare the vaccine, the vial adapter must be attached by centering it over the vial stopper and pushing straight down to avoid leaks.
Using a syringe held by the Luer lock adapter, the vial adapter must then be connected – with the entire diluent injected into the vial.
After swirling the vial until the powder is fully dissolved, the vial must be inverted and the complete 0.5 mL dose withdrawn into the syringe. Once the adapter is disconnected and a sterile needle attached, the vaccine is ready for intramuscular injection.
‘I haven’t seen a vaccine that is the same as this,’ she said. ‘We all had to look at the instruction sheet line by line and work it out.’
Take a strategic approach to opportunistic vaccination
Vaccination against RSV is recommended for pregnant patients at 28 to 36 weeks gestation. With the pertussis vaccine recommended at 20–32 weeks gestation, this is an opportune time to discuss protection against RSV.
Noting that a pregnant patient was booked in for a whooping cough vaccine at 31 weeks gestation, the week before her pharmacy received stock of Abrysvo, Ms Chang opted to take this approach.
‘I had her name in my calendar to call her and check if she wanted it when I actually got the stock,’ she said.
After receiving the green light from her obstetrician, the patient came back in 2 weeks after receiving her whooping cough vaccine.
‘The obstetrician wasn’t [promoting] it yet, so she [had to] ask if she should get it or not,’ said Ms Chang. ‘And for the cost saving she thought, “Why not go ahead?’”
At the moment, Ms Chang’s team is letting pregnant patients booked in for other vaccines know that funded Abrysvo vaccines are now available in community pharmacies.
‘We have been doing quite a bit of NIP [funded] whooping cough vaccinations for pregnant patients, so they are [ideal candidates],’ said Ms Chang.
Abrysvo can be co-administered with the whooping cough vaccine, if within the right window (28–32 weeks gestation).
‘We will [also] offer for them to come back the next week, but you still have to make sure not to leave it too late,’ she said.
What to do if the vaccine window is missed
While Abrysvo can be administered beyond 36 weeks gestation, infants are unlikely to be adequately protected unless they are born at least 2 weeks after their mother received the vaccine.
‘If you get the vaccine earlier you're covered if you have a premature baby,’ Ms Chang added.
‘And if you do miss that window and go past 36 weeks or have a premature baby, the baby can still be vaccinated [with nirsevimab] instead.’
The need for newborn vaccination is determined by if and when the pregnant woman received the RSV vaccine, said Ms Chang.
‘They should be asked to advise their obstetrician, midwife or the hospital of receiving the vaccine,’ she added.
Spread the word among other healthcare professionals
While Ms Chang thinks there has been more media coverage of RSV vaccination in 2024, there is unlikely to be widespread awareness of its availability, and benefits.
‘People talk a lot about the flu vaccine and COVID-19 vaccines, but RSV vaccination is [somewhat] new,’ she said.
Pharmacists can discuss the importance of RSV vaccination in pregnancy by letting patients know that it protects infants against severe RSV disease when they are most susceptible, with a clinical trial finding vaccine efficacy of 57% against hospitalisation for RSV for up to 6 months.
But pregnant patients may need assurance from multiple trusted healthcare sources that it’s safe to get vaccinated against RSV, advised Ms Chang.
‘I’ve sent letters to the nearby obstetricians to let them know that we’re [offering this vaccine],’ she said. ‘And in the new year we will let the GPs know.’
Be prepared to answer patients’ questions
Along with queries about vaccine efficacy and timeframe, pregnant patients may want to know about the potential adverse effects.
According to clinical trials, ‘very common’ adverse events include headache, myalgia and injection site pain.
Vaccination might provide protection for pregnant women against RSV disease. However, RSV is typically mild in adults, and clinical trials have not specifically assessed the vaccine's efficacy in protecting the mother.
‘[While] there is no data available on the duration of antibodies for the women, [pharmacists could] advise [patients] that it has shown to give protection for 12–16 months for older adults in the clinical studies.’
[post_title] => A pharmacist’s guide to RSV vaccination for pregnant patients
[post_excerpt] => One of the first pharmacists to administer an RSV vaccine to a pregnant patient explains how to promote, prepare and administer Abrysvo.
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[post_content] => With the festive season in full swing and the summer heat rising, pharmacists are at the forefront of helping patients navigate holiday health challenges.
Dive into Australian Pharmacist’s essential guide to keep your community safe this festive season.
Protect your patients against summer risks
With another festive season upon us, and the Bureau of Meteorology predicting extreme summer heat, pharmacists have an important role in keeping patients and families safe and healthy.
This includes advice around alcohol consumption with medicines, protection against mosquito-borne diseases and preventing dehydration.
And while the festive season is merry for some, it can be a difficult time of year for many. This means pharmacists should be on high alert to patients who could be taking higher-than-prescribed medication – potentially for doses for stronger sedation or self-harm.
Refer to this handy pharmacist advice piece by PSA’s resident clinical expert Shani Pickering as a go-to summer guide.
Raise awareness of new sun safety guidelines
The one-size-fits-all approach to sun safety is now out, with a tailored approach based on skin type, now the way to go.
The new sun protection guidelines, released earlier this year, are designed around skin cancer risk. While those with pale skin need to rely on a full suite of sun protection measures when the UV index is ≥3, those with deeply pigmented skin must ensure they get enough vitamin D to avoid a deficiency.
Before your patients start presenting in droves for their summer sun block, give AP’s sun safety guide a squizz.
And while you’re at it, make sure you’re abreast of the sunscreen myths floating around on social media – and how to dispel them.
Be alert to new illicit drug threats this festival season
Every year, the summer season ushers in a wave of music festivals, attended by thousands of revellers nationwide. But this season threatens to be different, with the deadly synthetic opioids, nitazenes, having infiltrated the illicit market.
While seasoned opioid users will have some tolerance to nitazenes, known to be more potent than fentanyl, it has been detected in other illicit drugs such as MDMA and cocaine – which can lead to rapid overdose in casual drug users. In fact, the potent opioids are thought to be linked to mass overdose deaths in Victoria this year.
While there are pill testing services available in Victoria, the ACT and Queensland, Australia’s most populous state, New South Wales, has yet to implement drug checking.
Expert Professor Suzi Nielsen MPS broke down the risks for AP earlier this year, outlining a revised approach to harm reduction.
Navigate summertime nicks, scrapes and scalds
The warmer months often mean more time spent outdoors, leading to increased risks of cuts and scrapes on the beach to nasty insect bites and burns from summer grilling.
With the most common wounds encountered in pharmacy being abrasions, cuts and burns, it's important for pharmacists to know the ABC’s of wound care. This includes providing therapeutic products, guidance on the right dressing selection and when to refer on.
AP’s Management of acute wounds commonly seen in community pharmacy CPD can help to bring you up to speed. And with infections such as cellulitis also more common during the summer months, this wound infection CPD can help pharmacists keep patients safe from harm.
Help patients take the (blood) pressure down this Christmas
The holiday period can come with an excess of stress, salty foods and alcohol consumption – all of which can play havoc with blood pressure. But with recent research finding that most patients aren’t monitoring their blood pressure correctly, it’s important for patients to know what’s artificially, and actually, inflating their blood pressure this holiday season.
This recent AP article analyses where patients get it wrong and how pharmacists can help them take an accurate blood pressure reading. And with low-density lipoprotein cholesterol also more likely to spike after a bit of holiday indulgence, pharmacists can help patients calculate their cardiovascular risk with the new Australian Cardiovascular risk calculator.
Prevent the festive season becoming a headache
Migraine triggers are plentiful during the holiday period, from extreme heat and bright lights, to poor diet and lack of sleep. Migraine and tension headaches can be managed through non-pharmacological strategies, such as stress reduction, obtaining adequate sleep and regular exercise. But pharmacists can also prescribe a number of triptans, where appropriate, and Schedule 3 medicines.
To help patients make it through the holiday season migraine free, read PSA’s Migraine and tension-type headache CPD.
Happy holidays from AP!
[post_title] => A prescription for a safer festive season
[post_excerpt] => With the festive season in full swing, pharmacists are at the forefront of helping patients navigate holiday health challenges.
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[post_content] => 2024 National Credentialed Diabetes Educator of the Year Julie Kha MPS loves collaborating to deliver better outcomes for her patients.
What led you to pharmacy?
Pharmacy was an exciting choice, enabling an understanding of how medicines can affect us, which can then be communicated to patients to ensure they are informed how to best achieve their shared health goals.
As a profession, pharmacy also offers incredible flexibility with an increasingly specialised workforce.
For example, pharmacists or credentialed pharmacists have now extended into various practice settings such as general practice and aged care – with a continual expansion of scope of practice for those who undertake additional training.
Why did you decide to become a credentialed diabetes educator?
During my formative years, I was fortunate to work alongside the first Australian pharmacist credentialed diabetes educator (CDE) Kirrily Chambers.
I noticed the impact she had on the lives of people with diabetes and their families as they exited the consult room where she worked in private practice and I wanted to generate that same impact from each patient interaction I had.
I was also fortunate to have come across another pharmacist CDE, Cindy Tolba, who was working in a diverse community where English is not the primary language.
Here, she utilised family members and even generated her own resources in the patient’s own language to better convey the workings and impact of diabetes.
Not too surprisingly, my Asian heritage played a role with our increased risk of diabetes. Dr Chris Verrall, an advocate for individualised patient goals, encouraged me to complete my accredited pharmacist requirement and then become a CDE.
How do you support patients who have been newly diagnosed?
Collaboration with the patient’s GP is where we work best. During the early stages, the patient may require time to navigate their new diagnosis and have many questions, or none at all. This takes time that GPs, who are underfunded and in short supply, don’t always have.
Establishing a person-centred approach is also of utmost importance. From this, an individualised plan can be generated to provide personalised education and support with resources and tools to empower the person with diabetes to be in a position where they are able to self-manage this chronic condition.
I had one patient whose glycated haemoglobin (HbA1c) remained elevated despite the addition of insulin.
Following a discussion about injection technique, and more importantly injection site rotation, it was discovered that the abdomen had developed areas of lipohypertrophy as ‘these areas didn’t hurt as much’.
After collaboration with the GP, the person with diabetes was just as excited to hear their insulin dose would be decreasing with a follow-up review scheduled soon thereafter.
How will pharmacists’ roles evolve in chronic disease management?
I was delighted to hear about the partnered prescribing models in our South Australian public hospitals.
With the right education and collaboration, I believe we can develop a similar model to our Canadian pharmacist colleagues, who provide structured chronic disease management programs in collaboration with GPs, practice nurses and other allied health to improve patient outcomes.
I believe one of the first steps would be to incorporate pharmacist CDEs into the hospital system, both public and private, to encourage greater interprofessional collaboration.
I’m proud to be part of pharmacy in this era of change and excited for our pharmacists of the future.
Advice for pharmacists looking to specialise in diabetes care?
Pursue your passion with a group of like-minded colleagues and mentors.
This way, your continuous learning will ensure the outcomes of each person with diabetes, and their families, are improved via an individualised approach and collaboration with the
best evidence-based practice.
A day in the life of Julie Kha MPS, Credentialed Diabetes Pharmacist, Adelaide, SA.
| 8.00 am | Before hitting the road Organise paperwork and plan (travel routes) for the day. |
| 9.00 am | Client education Meet diabetes education clients to understand their health goals to ensure personalised care. Transfer a concession card number into the National Diabetes Services Scheme (NDSS) for a person with type 1 diabetes; she was pleased to learn her costs would be further reduced! Review Libre 2 sensor data for a patient with type 2 diabetes who is on insulin. He was surprised about the impact of his banh mi (sandwich) lunch on his interstitial glucose levels. |
| 1–2.00 pm | Lunch break Replying to emails and returning GP and patient calls. |
| 2–6.00 pm | Clinical afternoon Finalise reports for GPs and specialists. Follow up with any high-risk patients e.g. persons with chronic kidney disease (CKD) or persons with diabetes and still titrating insulin. Remind a patient with type 2 diabetes on a sodium-glucose cotransporter-2 (SGLT2) inhibitor to stop her tablet 3 days prior to her colonoscopy next week. |
| 6.00 pm | Home Medicines Review Meet the last patient of the day for a Home Medicines Review after hours because they work full time. Discover they are taking a NSAID for arthritis pain on top of their ACE inhibitor and diuretic; looks like a call to the GP is in order tomorrow morning to discuss the triple whammy and the risk of acute kidney injury! |
| 8-9.30 pm | Remains of the day Continue writing reports and, if time permits, peruse the Australian Stock Exchange (ASX) movements! |
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[post_content] => When an injection doesn’t go as planned, it can be stressful for both patients and pharmacists. Here’s how to calmly handle these situations while maintaining safety and trust.
Yesterday morning, a mother of two came into a Queensland-based pharmacy requesting emergency contraception.
During the consultation, pharmacist Grace Quach MPS, PSA MIMS Intern Pharmacist of the Year 2023, asked the patient when she had her last period.
‘She had just had a baby 2 months ago, so she hadn't had her period for 9 months, or a normal period since,’ said Ms Quach. ‘However, she did have a Depo Provera injection last week.’
[caption id="attachment_23324" align="aligncenter" width="600"] Grace Quach MPS[/caption]
The patient then revealed that a nurse, supervised by a doctor, administered the injectable contraceptive but pulled out the needle too quickly – leaving the medicine to dribble down her arm.
The GP brushed it off, saying ‘I'm not sure if you’ll get the full amount of protection. See how you go’, leaving the patient stunned.
While mistakes are bound to happen during vaccinations or when administering medicines by injection, there are certain do’s and dont’s that should be followed.
What if a vaccine is partially administered?
If the process of administering a vaccine is interrupted (for example by syringe-needle disconnection), pharmacists should ask themselves:
For example, this could entail letting a patient know that more than 50% of the vaccine was administered, if this was the case, which is deemed enough to form an immune response according to ATAGI.
‘The patient [should not be put in a position] where they are unsure of whether or not they've received correct treatment once they leave the vaccination [or medicine by injection] room,’ said Ms Jadeja ‘That also reduces trust in that healthcare professional, which is not a good scenario at the end of the day.’ PSA’s Pharmacist-to-Pharmacist Advice Line offers expert advice to members in real time. The Pharmacist Advice Line is an exclusive member service offering professional advice from a senior pharmacist on technical, ethical and practice questions. This includes:td_module_mega_menu Object
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[post_content] => Case scenario
[caption id="attachment_28475" align="alignright" width="244"] A national education program for pharmacists funded by the Australian Government under the Quality Use of Diagnostics, Therapeutics and Pathology program.[/caption]
Amna, 26 years old, is browsing the vitamins and herbal supplements section of the pharmacy, seeking a solution for her sleep problems. Over the past 2 weeks, she has experienced difficulty falling asleep at night and feels exhausted when she wakes up at 7 am to get ready for work. She also wants some information about melatonin, as some of her older colleagues have had success with it. Amna is an otherwise healthy young adult without co-existing medical comorbidities and is not currently taking any other medicines.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Non-prescription sleep aids are frequently purchased by individuals to improve their sleep while delaying seeking medical care.1 Given the product availability and proximity of community pharmacy to the public, the pharmacist has an important role to play in promoting the safe and effective use of non-prescription sleep aids and referring patients to appropriate care.2,3
Non-prescription sleep aids predominantly target insomnia symptoms, utilising their sedative properties to promote faster sleep onset. These are mainly Schedule 3 medicines and include the sedating antihistamines diphenhydramine, promethazine and doxylamine.4 Prolonged-release melatonin may be used as a Schedule 3 medicine in adults ≥55 years of age as a short-term monotherapy for primary insomnia, characterised by poor sleep quality.4
Complementary medicines (CMs; e.g. valerian, passionflower, hops, kava, chamomile) and supplements (e.g. magnesium) are also sometimes used to help aid sleep.5,6 Many of the CMs theoretically act on GABAergic receptors and/or have anxiolytic and relaxant effects.7 The Australian Pharmaceutical Formulary and Handbook contains further information on various CMs and their reported uses in sleep.6
A key practice dilemma that pharmacists face each day is that despite the widespread availability and use of non-prescription sleep aids, several professional sleep societies recommend against their use due to insufficient evidence.8–10 Therapeutic Guidelines also advises not to use sedating antihistamines to treat insomnia.11 Many of the pivotal trials evaluating first-generation sedating antihistamines and CMs have critical study design limitations that fall short of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) standards that are often used to appraise the evidence base.12
While the evidence bases for both CMs and Schedule 3 sleep aids are unlikely to immediately change, a core practice consideration is the risk-benefit profile of the respective non-prescription sleep aids for the individual patient.
Consumers often misperceive non-prescription sleep aids as being safer than prescription medicines due to their ‘naturalness’ or ease of access.13 As such, these sleep aids are often used medically unsupervised to either initially delay seeking medical care,14 or, in combination with prescribed regimens, to offset the perceived harms of prescription sleep aids.15,16 When non-prescription sleep aids are being used unsupervised, consumers may be unaware of the potential contraindications or interactions with existing medicines. For example, melatonin, while seemingly benign, can have undesired effects in high-risk patient groups. Melatonin can potentially interfere with immunosuppressive therapies,17 and may increase risk of bleeding for patients on anticoagulant medicines such as warfarin.18,19 While many of the interactions with CMs are theoretical, pharmacists play a critical role in assessing risk-benefit and providing advice for the safe use of these non-prescription sleep aids. Nonetheless, discerning the risk profiles of the respective CMs is increasingly challenging since many herbal sleep formulations in the pharmacy combine multiple herbal ingredients.
Patients should be advised to avoid the concomitant use of non-prescription sleep aids with alcohol and medicines that have central nervous system depressing effects, and to avoid driving or operating machinery if drowsy.20 The effects of sleep aids, especially sedating antihistamines, can continue the next day.4,20,21 In addition, non-prescription sleep aids should be limited to short-term use. Sedating antihistamines should not be used for longer than 10 consecutive days because tolerance to their sedative effects develops quickly.4,21,22 In older adults, the risks of using non-prescription sleep aids are even higher. This is because they tend to take more medicines, increasing the potential for drug-drug and drug-herb interactions. In addition, the sedative effects of sedating antihistamines may be more pronounced due to age-related pharmacokinetic and pharmacodynamic changes, such as reduced metabolism and clearance.23 Older adults are also more vulnerable to other cognitive and anticholinergic adverse effects of sedating antihistamines, and these medicines can add to the anticholinergic burden.21 Guidelines recommend avoiding the use of sedating antihistamines in older people.⁴ However, older people make up a significant portion of users.23 If it is not possible to avoid use in older people, they should use lower doses than other adults.21
Notwithstanding these acute consequences, one of the main concerns of self-medication is delayed medical help-seeking and initiation of the first-line therapy, cognitive behavioural therapy for insomnia (CBTi).24 Individuals may miss the optimal window to address their sleep complaint and allow perpetuating factors such as poor sleep habits and anxiety about the lack of sleep to develop, resulting in the transition of acute insomnia into chronic insomnia (insomnia lasting ≥3 months).8
Is it really insomnia?From direct product requests to symptom-based requests in the pharmacy, patients will often refer to their sleep complaint as ‘insomnia’ and seek non-prescription sleep aids to improve their sleep. Insomnia symptoms such as difficulty initiating sleep, maintaining sleep, early-morning waking and associated daytime fatigue can appear to overlap with symptoms of other sleep disorders for which non-prescription sleep aids may not be suitable. For example, circadian sleep disorders such as advanced sleep phase disorder and delayed sleep phase disorder share a lot of similarity with insomnia symptoms where the patient experiences difficulty falling asleep at a desired time.25,26 Those with a circadian sleep disorder have an otherwise intact sleep-wake cycle but struggle to fall asleep and wake up at socially acceptable times to meet their daily obligations such as work and school because their internal body clocks have shifted.10 Similarly, for patients with undiagnosed obstructive sleep apnoea (OSA), the daytime fatigue and functional impairments often motivates patients to use non-prescription sleep aids to improve their sleep or alertness, but clinical guidelines recommend against their use.27 Another common sleep disorder, restless legs syndrome (RLS), like insomnia, will result in difficulty falling asleep and/or staying asleep with daytime consequences. The disrupted sleep in RLS is largely attributed to the uncomfortable sensation felt in the legs at night when resting and the urge to move and stretch out the legs to relieve discomfort.28 The symptoms of RLS can be precipitated or exacerbated with use of sedating antihistamines.29
Further clinician and patient information on these conditions can be obtained from Sleep Central (www.sleepcentral.org.au), or consumer-facing resources from the Sleep Health Foundation (www.sleephealthfoundation.org.au).
Patients presenting to the pharmacy for non-prescription sleep aids should be assessed for the presence of other sleep disorders.30,31 Pharmacists can probe further into the nature and history of the sleep complaint by asking patients about potential triggers, sleep-wake schedules, engagement in shift work, the presence of other physical symptoms (e.g. snoring or witnessed breathing pauses during sleep, uncomfortable sensations in the lower legs and ability to fall asleep easily at earlier/later times), and prior treatments and response to treatments.3 In addition, there are evidence-based screening and assessment tools for the different sleep disorders that pharmacists may use in their practice to identify at-risk patients for onward referral and assessment by their medical practitioner.
Further information on assessment tools for insomnia and patient education resources can be found on the Sleep Central website (www.sleepcentral.org.au).
Knowledge to practice Despite insufficient evidence supporting the use of non-prescription sleep aids, it is critical to engage patients in a non-judgemental and open discussion about their non-prescription sleep aid use.32 Through these conversations, pharmacists can gain further information about the nature of the patient’s sleep complaint, their current medical and medicines history and treatment expectations. Pharmacists can then educate patients about the various sleep disorders, potential adverse effects and interactions of pharmacological treatment, and inform them about the benefits of seeing a medical practitioner for assessment and optimal treatment.
Non-prescription sleep aids are widely used by members of the community to improve their sleep, but they may not always be an appropriate choice, and risks can often outweigh perceived benefits. Pharmacists play a key role in ensuring non-prescription sleep aids are used safely and effectively. Pharmacists are well placed to direct consumers to evidence-based resources on sleep health and sleep disorders, which may empower them to be better informed about sleep, improve their sleep health literacy, and understand the need for further assessment from a medical practitioner. They can also facilitate onward referral to a medical practitioner for further assessment, differential diagnosis and management of their sleep disturbance.
Case scenario continuedYou ask Amna about her sleep. She wants to go to sleep by 10:30 pm but typically doesn’t feel sleepy until 1 am. Her sleep complaint is only an issue on weekdays when she needs to follow a strict schedule. Weekends are pleasant as she can sleep and wake when she wants. You suggest that Amna may have symptoms of a delayed circadian rhythm rather than insomnia, and refer her to see her GP for a discussion and referral to a sleep specialist. |
Dr Janet Cheung BPharm, MPhil, PhD, FHEA is a pharmacist and Senior Lecturer in Pharmacy Practice at the Sydney Pharmacy School, University of Sydney. Her research broadly focuses on promoting the quality use of sleep medicines through understanding patient medication-taking patterns and behaviours.
Dr Cheung supervises a PhD candidate on a project exploring treatment experiences and needs of self-identified Chinese patients in Australia. The candidate is employed by ResMed Pty Ltd and the company directly funds the research candidate’s research project costs as part of a professional development fund. The funding and nature of the project is not related to this CPD activity.
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[post_content] => Since 1 December 2024, Queensland-based pharmacists have been able to administer Abrysvo to pregnant patients to protect infants from severe Respiratory Syncytial Virus (RSV), following an expansion to the Queensland Paediatric Respiratory Syncytial Virus Prevention Program.
While Abrysvo will be added to the National Immunisation Program (NIP), as per the federal government’s announcement last month, the vaccine is currently funded by the Queensland government – although the administration fee is not covered at this stage.
But given Abrysvo is a relatively new vaccine, pharmacists will need to factor in pregnancy risk perception into strategies to encourage vaccine uptake.
After vaccinating her first patient against RSV, community pharmacist Anna Chang MPS, based in Brisbane, told Australian Pharmacist what should be considered.
Know how the vaccine needs to be prepared
The mixing instructions for Abrysvo are ‘unique’, said Ms Chang.
The vaccine comes with a lyophilised vaccine powder (vial), vial adapter and pre-filled syringe containing diluent. To prepare the vaccine, the vial adapter must be attached by centering it over the vial stopper and pushing straight down to avoid leaks.
Using a syringe held by the Luer lock adapter, the vial adapter must then be connected – with the entire diluent injected into the vial.
After swirling the vial until the powder is fully dissolved, the vial must be inverted and the complete 0.5 mL dose withdrawn into the syringe. Once the adapter is disconnected and a sterile needle attached, the vaccine is ready for intramuscular injection.
‘I haven’t seen a vaccine that is the same as this,’ she said. ‘We all had to look at the instruction sheet line by line and work it out.’
Take a strategic approach to opportunistic vaccination
Vaccination against RSV is recommended for pregnant patients at 28 to 36 weeks gestation. With the pertussis vaccine recommended at 20–32 weeks gestation, this is an opportune time to discuss protection against RSV.
Noting that a pregnant patient was booked in for a whooping cough vaccine at 31 weeks gestation, the week before her pharmacy received stock of Abrysvo, Ms Chang opted to take this approach.
‘I had her name in my calendar to call her and check if she wanted it when I actually got the stock,’ she said.
After receiving the green light from her obstetrician, the patient came back in 2 weeks after receiving her whooping cough vaccine.
‘The obstetrician wasn’t [promoting] it yet, so she [had to] ask if she should get it or not,’ said Ms Chang. ‘And for the cost saving she thought, “Why not go ahead?’”
At the moment, Ms Chang’s team is letting pregnant patients booked in for other vaccines know that funded Abrysvo vaccines are now available in community pharmacies.
‘We have been doing quite a bit of NIP [funded] whooping cough vaccinations for pregnant patients, so they are [ideal candidates],’ said Ms Chang.
Abrysvo can be co-administered with the whooping cough vaccine, if within the right window (28–32 weeks gestation).
‘We will [also] offer for them to come back the next week, but you still have to make sure not to leave it too late,’ she said.
What to do if the vaccine window is missed
While Abrysvo can be administered beyond 36 weeks gestation, infants are unlikely to be adequately protected unless they are born at least 2 weeks after their mother received the vaccine.
‘If you get the vaccine earlier you're covered if you have a premature baby,’ Ms Chang added.
‘And if you do miss that window and go past 36 weeks or have a premature baby, the baby can still be vaccinated [with nirsevimab] instead.’
The need for newborn vaccination is determined by if and when the pregnant woman received the RSV vaccine, said Ms Chang.
‘They should be asked to advise their obstetrician, midwife or the hospital of receiving the vaccine,’ she added.
Spread the word among other healthcare professionals
While Ms Chang thinks there has been more media coverage of RSV vaccination in 2024, there is unlikely to be widespread awareness of its availability, and benefits.
‘People talk a lot about the flu vaccine and COVID-19 vaccines, but RSV vaccination is [somewhat] new,’ she said.
Pharmacists can discuss the importance of RSV vaccination in pregnancy by letting patients know that it protects infants against severe RSV disease when they are most susceptible, with a clinical trial finding vaccine efficacy of 57% against hospitalisation for RSV for up to 6 months.
But pregnant patients may need assurance from multiple trusted healthcare sources that it’s safe to get vaccinated against RSV, advised Ms Chang.
‘I’ve sent letters to the nearby obstetricians to let them know that we’re [offering this vaccine],’ she said. ‘And in the new year we will let the GPs know.’
Be prepared to answer patients’ questions
Along with queries about vaccine efficacy and timeframe, pregnant patients may want to know about the potential adverse effects.
According to clinical trials, ‘very common’ adverse events include headache, myalgia and injection site pain.
Vaccination might provide protection for pregnant women against RSV disease. However, RSV is typically mild in adults, and clinical trials have not specifically assessed the vaccine's efficacy in protecting the mother.
‘[While] there is no data available on the duration of antibodies for the women, [pharmacists could] advise [patients] that it has shown to give protection for 12–16 months for older adults in the clinical studies.’
[post_title] => A pharmacist’s guide to RSV vaccination for pregnant patients
[post_excerpt] => One of the first pharmacists to administer an RSV vaccine to a pregnant patient explains how to promote, prepare and administer Abrysvo.
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[post_content] => With the festive season in full swing and the summer heat rising, pharmacists are at the forefront of helping patients navigate holiday health challenges.
Dive into Australian Pharmacist’s essential guide to keep your community safe this festive season.
Protect your patients against summer risks
With another festive season upon us, and the Bureau of Meteorology predicting extreme summer heat, pharmacists have an important role in keeping patients and families safe and healthy.
This includes advice around alcohol consumption with medicines, protection against mosquito-borne diseases and preventing dehydration.
And while the festive season is merry for some, it can be a difficult time of year for many. This means pharmacists should be on high alert to patients who could be taking higher-than-prescribed medication – potentially for doses for stronger sedation or self-harm.
Refer to this handy pharmacist advice piece by PSA’s resident clinical expert Shani Pickering as a go-to summer guide.
Raise awareness of new sun safety guidelines
The one-size-fits-all approach to sun safety is now out, with a tailored approach based on skin type, now the way to go.
The new sun protection guidelines, released earlier this year, are designed around skin cancer risk. While those with pale skin need to rely on a full suite of sun protection measures when the UV index is ≥3, those with deeply pigmented skin must ensure they get enough vitamin D to avoid a deficiency.
Before your patients start presenting in droves for their summer sun block, give AP’s sun safety guide a squizz.
And while you’re at it, make sure you’re abreast of the sunscreen myths floating around on social media – and how to dispel them.
Be alert to new illicit drug threats this festival season
Every year, the summer season ushers in a wave of music festivals, attended by thousands of revellers nationwide. But this season threatens to be different, with the deadly synthetic opioids, nitazenes, having infiltrated the illicit market.
While seasoned opioid users will have some tolerance to nitazenes, known to be more potent than fentanyl, it has been detected in other illicit drugs such as MDMA and cocaine – which can lead to rapid overdose in casual drug users. In fact, the potent opioids are thought to be linked to mass overdose deaths in Victoria this year.
While there are pill testing services available in Victoria, the ACT and Queensland, Australia’s most populous state, New South Wales, has yet to implement drug checking.
Expert Professor Suzi Nielsen MPS broke down the risks for AP earlier this year, outlining a revised approach to harm reduction.
Navigate summertime nicks, scrapes and scalds
The warmer months often mean more time spent outdoors, leading to increased risks of cuts and scrapes on the beach to nasty insect bites and burns from summer grilling.
With the most common wounds encountered in pharmacy being abrasions, cuts and burns, it's important for pharmacists to know the ABC’s of wound care. This includes providing therapeutic products, guidance on the right dressing selection and when to refer on.
AP’s Management of acute wounds commonly seen in community pharmacy CPD can help to bring you up to speed. And with infections such as cellulitis also more common during the summer months, this wound infection CPD can help pharmacists keep patients safe from harm.
Help patients take the (blood) pressure down this Christmas
The holiday period can come with an excess of stress, salty foods and alcohol consumption – all of which can play havoc with blood pressure. But with recent research finding that most patients aren’t monitoring their blood pressure correctly, it’s important for patients to know what’s artificially, and actually, inflating their blood pressure this holiday season.
This recent AP article analyses where patients get it wrong and how pharmacists can help them take an accurate blood pressure reading. And with low-density lipoprotein cholesterol also more likely to spike after a bit of holiday indulgence, pharmacists can help patients calculate their cardiovascular risk with the new Australian Cardiovascular risk calculator.
Prevent the festive season becoming a headache
Migraine triggers are plentiful during the holiday period, from extreme heat and bright lights, to poor diet and lack of sleep. Migraine and tension headaches can be managed through non-pharmacological strategies, such as stress reduction, obtaining adequate sleep and regular exercise. But pharmacists can also prescribe a number of triptans, where appropriate, and Schedule 3 medicines.
To help patients make it through the holiday season migraine free, read PSA’s Migraine and tension-type headache CPD.
Happy holidays from AP!
[post_title] => A prescription for a safer festive season
[post_excerpt] => With the festive season in full swing, pharmacists are at the forefront of helping patients navigate holiday health challenges.
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[post_content] => 2024 National Credentialed Diabetes Educator of the Year Julie Kha MPS loves collaborating to deliver better outcomes for her patients.
What led you to pharmacy?
Pharmacy was an exciting choice, enabling an understanding of how medicines can affect us, which can then be communicated to patients to ensure they are informed how to best achieve their shared health goals.
As a profession, pharmacy also offers incredible flexibility with an increasingly specialised workforce.
For example, pharmacists or credentialed pharmacists have now extended into various practice settings such as general practice and aged care – with a continual expansion of scope of practice for those who undertake additional training.
Why did you decide to become a credentialed diabetes educator?
During my formative years, I was fortunate to work alongside the first Australian pharmacist credentialed diabetes educator (CDE) Kirrily Chambers.
I noticed the impact she had on the lives of people with diabetes and their families as they exited the consult room where she worked in private practice and I wanted to generate that same impact from each patient interaction I had.
I was also fortunate to have come across another pharmacist CDE, Cindy Tolba, who was working in a diverse community where English is not the primary language.
Here, she utilised family members and even generated her own resources in the patient’s own language to better convey the workings and impact of diabetes.
Not too surprisingly, my Asian heritage played a role with our increased risk of diabetes. Dr Chris Verrall, an advocate for individualised patient goals, encouraged me to complete my accredited pharmacist requirement and then become a CDE.
How do you support patients who have been newly diagnosed?
Collaboration with the patient’s GP is where we work best. During the early stages, the patient may require time to navigate their new diagnosis and have many questions, or none at all. This takes time that GPs, who are underfunded and in short supply, don’t always have.
Establishing a person-centred approach is also of utmost importance. From this, an individualised plan can be generated to provide personalised education and support with resources and tools to empower the person with diabetes to be in a position where they are able to self-manage this chronic condition.
I had one patient whose glycated haemoglobin (HbA1c) remained elevated despite the addition of insulin.
Following a discussion about injection technique, and more importantly injection site rotation, it was discovered that the abdomen had developed areas of lipohypertrophy as ‘these areas didn’t hurt as much’.
After collaboration with the GP, the person with diabetes was just as excited to hear their insulin dose would be decreasing with a follow-up review scheduled soon thereafter.
How will pharmacists’ roles evolve in chronic disease management?
I was delighted to hear about the partnered prescribing models in our South Australian public hospitals.
With the right education and collaboration, I believe we can develop a similar model to our Canadian pharmacist colleagues, who provide structured chronic disease management programs in collaboration with GPs, practice nurses and other allied health to improve patient outcomes.
I believe one of the first steps would be to incorporate pharmacist CDEs into the hospital system, both public and private, to encourage greater interprofessional collaboration.
I’m proud to be part of pharmacy in this era of change and excited for our pharmacists of the future.
Advice for pharmacists looking to specialise in diabetes care?
Pursue your passion with a group of like-minded colleagues and mentors.
This way, your continuous learning will ensure the outcomes of each person with diabetes, and their families, are improved via an individualised approach and collaboration with the
best evidence-based practice.
A day in the life of Julie Kha MPS, Credentialed Diabetes Pharmacist, Adelaide, SA.
| 8.00 am | Before hitting the road Organise paperwork and plan (travel routes) for the day. |
| 9.00 am | Client education Meet diabetes education clients to understand their health goals to ensure personalised care. Transfer a concession card number into the National Diabetes Services Scheme (NDSS) for a person with type 1 diabetes; she was pleased to learn her costs would be further reduced! Review Libre 2 sensor data for a patient with type 2 diabetes who is on insulin. He was surprised about the impact of his banh mi (sandwich) lunch on his interstitial glucose levels. |
| 1–2.00 pm | Lunch break Replying to emails and returning GP and patient calls. |
| 2–6.00 pm | Clinical afternoon Finalise reports for GPs and specialists. Follow up with any high-risk patients e.g. persons with chronic kidney disease (CKD) or persons with diabetes and still titrating insulin. Remind a patient with type 2 diabetes on a sodium-glucose cotransporter-2 (SGLT2) inhibitor to stop her tablet 3 days prior to her colonoscopy next week. |
| 6.00 pm | Home Medicines Review Meet the last patient of the day for a Home Medicines Review after hours because they work full time. Discover they are taking a NSAID for arthritis pain on top of their ACE inhibitor and diuretic; looks like a call to the GP is in order tomorrow morning to discuss the triple whammy and the risk of acute kidney injury! |
| 8-9.30 pm | Remains of the day Continue writing reports and, if time permits, peruse the Australian Stock Exchange (ASX) movements! |
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[post_content] => When an injection doesn’t go as planned, it can be stressful for both patients and pharmacists. Here’s how to calmly handle these situations while maintaining safety and trust.
Yesterday morning, a mother of two came into a Queensland-based pharmacy requesting emergency contraception.
During the consultation, pharmacist Grace Quach MPS, PSA MIMS Intern Pharmacist of the Year 2023, asked the patient when she had her last period.
‘She had just had a baby 2 months ago, so she hadn't had her period for 9 months, or a normal period since,’ said Ms Quach. ‘However, she did have a Depo Provera injection last week.’
[caption id="attachment_23324" align="aligncenter" width="600"] Grace Quach MPS[/caption]
The patient then revealed that a nurse, supervised by a doctor, administered the injectable contraceptive but pulled out the needle too quickly – leaving the medicine to dribble down her arm.
The GP brushed it off, saying ‘I'm not sure if you’ll get the full amount of protection. See how you go’, leaving the patient stunned.
While mistakes are bound to happen during vaccinations or when administering medicines by injection, there are certain do’s and dont’s that should be followed.
What if a vaccine is partially administered?
If the process of administering a vaccine is interrupted (for example by syringe-needle disconnection), pharmacists should ask themselves:
For example, this could entail letting a patient know that more than 50% of the vaccine was administered, if this was the case, which is deemed enough to form an immune response according to ATAGI.
‘The patient [should not be put in a position] where they are unsure of whether or not they've received correct treatment once they leave the vaccination [or medicine by injection] room,’ said Ms Jadeja ‘That also reduces trust in that healthcare professional, which is not a good scenario at the end of the day.’ PSA’s Pharmacist-to-Pharmacist Advice Line offers expert advice to members in real time. The Pharmacist Advice Line is an exclusive member service offering professional advice from a senior pharmacist on technical, ethical and practice questions. This includes:Get your weekly dose of the news and research you need to help advance your practice.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
