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[post_content] => 'Precautionary and active surveillance' is required to manage the risk of a novel coronavirus outbreak in China, Australia's Chief Medical Officer Professor Brendan Murphy said yesterday.
However, the risk to the Australian public remains 'relatively low', he said.
Chinese health officials have confirmed up to 300 cases1 of a SARS-like infection, first detected in the city of Wuhan four weeks ago.
Six cases have now been discovered outside of Wuhan2, including in other Chinese cities and in Japan, South Korea, Thailand and the United States (US). Three deaths have been confirmed.
The Centers for Disease Control and Prevention1 (CDC) is closely monitoring the outbreak with the first US case1 identified in Seattle this week.
The virus has been linked to a seafood market in Wuhan, but authorities have since established it has spread to people who had not visited the market.
Coronaviruses3 are a large family of viruses that cause illness ranging from the common cold to more severe diseases. They can be transmitted between animals, people and between animals and people. A coronavirus was responsible for the Severe Acute Respiratory Syndrome (SARS), which also began in China and killed nearly 800 people globally during an outbreak in 2002-2003.
The novel coronavirus identified in Wuhan is a strain not previously identified in humans.
Professor Murphy said4 the risk to the Australian public remained 'relatively low' and that the Department of Health was 'alert but not alarmed'.
However, he said it was necessary to implement additional measures to manage the risk.
'There has been a significant increase in case numbers, evidence of some human-to-human transmission and we've heard reports now of six deaths, even though the case numbers are probably over 300,' Professor Murphy told the ABC5 this morning.
'So, we have more concern than we had last week, but we're well prepared in this country to respond.'
With three direct flights a week from Wuhan to Sydney, NSW Health officers and border security staff will begin assessing passengers arriving at Sydney Airport for signs of the virus from tomorrow.
All passengers on direct flights from Wuhan will receive information about the virus on arrival. They will be requested to identify themselves to biosecurity officers if they are unwell. If they have symptoms of an infectious disease they will be assessed by a NSW Health officer.
While there have been no confirmed cases of the virus in Australia to-date, results are pending for a Brisbane man who recently returned from Wuhan and presented to his GP with flu-like symptoms.
NSW Health Director of Health Protection Dr Jeremy McAnulty said advice was also being provided to travellers who may have already returned from Wuhan, as it can take up to two weeks for symptoms to develop.
Common signs of infection3 include respiratory symptoms, fever, cough, shortness of breath and breathing difficulties. In more severe cases, infection can cause pneumonia, severe acute respiratory syndrome and kidney failure.
'There is no need for alarm, but people should be aware of the emerging situation and if they develop symptoms on returning from affected areas overseas, they should call ahead before seeing their GP,' Dr McAnulty said6.
For more information, consumers can visit the Department of Health website4.
Centres for Disease Control and Prevention. 2019 Novel coronavirus, Wuhan, China: Situation Summary. 2020 January 21. At: www.cdc.gov/coronavirus/2019-ncov/index.html
Centres for Disease Control and Prevention. First travel-related case of 2019 novel coronavirus detected in United States. 2020. At: www.cdc.gov/media/releases/2020/p0121-novel-coronavirus-travel-case.html
World Health Organization. Health topics: coronavirus. At: www.who.int/health-topics/coronavirus
Australian Government Department of Health. Canberra. Novel coronavirus update: a statement from the chief medical officer about novel coronavirus. 2020 January 21. At: www.health.gov.au/news/statements/novel-coronavirus-update
Lane S. Australia 'well prepared' for coronavirus: chief medical officer. 2020 January 22. At: www.abc.net.au/radio/programs/am/australia-well-prepared-for-coronavirus:-chief-medical-officer/11888456
NSW Government Health Department. NSW Health advice to travellers returning from Wuhan, China. 2020 January 21. At: www.health.nsw.gov.au/news/Pages/20200121_00.aspx
[post_title] => Coronavirus: Australia 'alert but not alarmed'
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[post_name] => coronavirus-department-of-health-alert-but-not-alarmed
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[title_attribute] => Coronavirus: Australia 'alert but not alarmed'
[title] => Coronavirus: Australia 'alert but not alarmed'
[href] => https://www.australianpharmacist.com.au/coronavirus-department-of-health-alert-but-not-alarmed/
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Coronavirus: Australia 'alert but not alarmed'
[post_content] => Two proactive pharmacists are providing pain management and virtual dental services to a wider reach than previously possible via videoconferencing.
Pharmacist Nicolette Ellis MPS is a member of Beyond Pain, Australia's first interdisciplinary videoconferencing service for complex chronic health conditions such as pain, fatigue and mental health disorders, based in a Melbourne clinic.
And in an Australian first, Krysti-Lee Rigby MPS facilitates a virtual dental service by videoconference from a pharmacy in regional New South Wales (NSW).
Both initiatives came about by chance.
[caption id="attachment_9209" align="alignright" width="319"]  Beyond Pain founder Angelo Ratnachandra and Nicolette Ellis MPS[/caption]
Ms Ellis attended a Beyond Pain workshop with its founder, physiotherapist Anjelo Ratnachandra two years ago. Through his own journey with chronic pain he had experienced a lack of tailored services with specialised healthcare professionals. He wrote the book Beyond Pain, became a counsellor, and started a videoconferencing service some years ago to reach clients in remote areas with poor access to adequate care.
At the workshop, Ms Ellis convinced him of the benefits of including a pharmacist on the team. She joined the team 12 months ago.
Similarly, dentist Christine May was frustrated that people in remote areas needing dental care had difficulty accessing it when and where they needed it. Telehealth was being adopted by other health disciplines (e.g. medicine, psychology and physiotherapy) so she researched its application for teledentistry. She found a number of positive pilot studies, particularly in vulnerable groups, e.g. aged care. From her Sydney base, she established a virtual dental practice known as ViDe.
When Dr May met Ms Rigby, pharmacist-in-charge at Moodie's Pharmacy in Bathurst, and saw its consultation rooms, they discussed the possibility of a teledental service from the pharmacy. After 12 months of planning, the pharmacy-facilitated ViDe service was launched two months ago, in November 2019.
How does the dental service work?
In the pharmacy consultation room a pharmacy assistant, specially trained in the technology, uses an intra-oral camera to take images or a video of the patient's teeth and mouth.
The images are shared with the dentist in their practice, who then conducts a video consultation with the patient via a smart device or computer. The dentist uses Zoom video conferencing, for seamless integration with a healthcare-compliant booking platform and secure online application form.
The cost per consultation is $69, of which $49 is paid to the dentist and $20 to the pharmacy. Referral to local dentists can be made if required.
The patient must agree to ViDe terms and conditions and sign digitally to consent to the service. Professional indemnity insurance applies only to the registered dentist performing the consultation.
Dentists may prescribe for dental treatments only. On their website, ViDe lists medicines that they will not prescribe. Prescriptions are sent to the pharmacy, not the patient, lessening the chance of doctor shopping.
[caption id="attachment_9211" align="alignright" width="357"]  Krysti-Lee Rigby MPS demonstrates the ViDe telehealth technology[/caption]
However, Dr Geraldine Moses, Consultant Pharmacist to the Australian Dental Association, told Australian Pharmacist that the dentist and pharmacist need to have strategies in place to overcome the risk of doctor shoppers feigning pain to take advantage of the service.
Dr Moses also cautions that the role of the dentist is in 'real-life dental treatment, such as draining an abscess or filling a hole in a tooth'.  Teledentistry may provide access to a dentist for people in remote areas, but 'an accurate diagnosis or comprehensive advice and counselling is more achievable in a face-to-face consultation,' she added.
The pilot study for dental telehealth finished in December last year, but the Life Pharmacy Group, which includes Moodies in Bathurst, will now roll out the service to other pharmacies across Central West NSW and the Australian Capital Territory.
Ms Rigby told Australian Pharmacist the concept has the potential to be rolled out to aged care facilities and disability group homes.
'If we can make a positive impact on our patients' health by providing this service it will be successful, even if we help just one person,' she said. There was little expense for the pharmacy as the clinic rooms had been ready for telehealth services for years.
'Pharmacists should not be afraid to reach out to different professions and connect with these potential partnerships,' Ms Rigby added.
How does the pain management service work?
Clients are referred by corporations and health insurers. An initial assessment is undertaken and a quote provided to the referrer with a cost breakdown of services. Plans are individualised and may not require every team member to be involved.
Nicolette Ellis conducts client consultations by videoconference, and provides a report to their relevant pain specialist or psychiatrist by video case conference or in writing.
The team can use tools and videos to explain challenging concepts or when the functional team is developing specific exercises.
'I like to show clients drawings of ways in which medication works or how the body/brain is impacted by persistent pain,' she told Australian Pharmacist.
Improvement in functional capacity is the goal. Patients generally self-report, but measurement tools are also used. In a positive measure, 'we have many clients who return to work or begin volunteering', she said.
Professional indemnity insurance covers her full scope of pharmacy practice.
While diagnosis is outside her scope of practice, Ms Ellis screens for red and yellow flags requiring medical referral. Client consent is requested if needed for clarification of the medical history with a doctor or community pharmacy, or for a joint consultation.
Opioid dependence
Ms Ellis believes many patients living with persistent pain self-escalate their opioid analgesics out of desperation and not knowing what to do about their pain.
'We as pharmacists should be ready to have an honest conversation, understand the reason for dosage escalation, and not jump to the conclusion that they are dependent,' she said.
She also provides guidelines for the client and doctor on how medicines should be managed. As a guide, opioids should be reviewed for improvement in function every 6 weeks. An opioid monitoring tool can be useful.
Ms Ellis urges pharmacists to look for non-traditional opportunities within and outside the profession.
'We should be recognising our skills and not selling ourselves short,' she said of the rewarding work on this new frontier.'
[post_title] => New ways of providing services
[post_name] => new-ways-of-providing-services
[title_attribute] => New ways of providing services
[title] => New ways of providing services
[href] => https://www.australianpharmacist.com.au/new-ways-of-providing-services/
New ways of providing services
[post_author] => 675
[post_content] => More than 40 roles for pharmacists in disasters have been identified in a new study, which also recommends that pharmacy bodies provide specialist training and advocate for supportive disaster pharmacy legislation.
Published last month in PLoS One, the study evaluated the roles pharmacists have in disasters, as accepted by the international disaster health community.1
It concluded pharmacists could undertake 43 roles in the four phases of a disaster – prevention, preparedness, response and recovery – depending on individual jurisdiction.
'Together, pharmacy professional bodies and policymakers can provide better integration of pharmacists' roles in disaster management teams, whether assisting in the community or on deployment,' the authors concluded.1
Consensus among 15 members of an expert panel drawn from international and Australian non-governmental organisations, government, pharmacy, military, public health and disaster management agencies, by pharmacy researchers based in Queensland and Canada, found the overall top priority roles were to:
optimise medication management in chronic disease
administer vaccines
educate the public on reducing the spread of disease/infection
ensure patients are aware of their increased health risks in a disaster
tailor 'point of care' messaging for chronic disease patients.
Pharmacists' roles in disasters were recognised after the events of September 11, 2001 when the World Trade Centre towers in New York collapsed during a terrorist attack. Previously, accepted pharmacist roles had focused on contributions to logistics and supply chain management.
When Hurricane Katrina significantly affected parts of the United States in 2005, the impact pharmacists can have in the response and recovery of a community following a disaster was further highlighted. Pharmacists performed duties and fulfilled additional roles in the absence of other healthcare professionals, including triaging, taking medication histories, assisting with major trauma and performing basic medical checks. Emergency supply rules for pharmacists were used at the time, and are currently in use in Australia until March.
'It has been heartwarming to see pharmacists be supported in their response efforts with the temporary changes made to emergency supply rules and PBS medicines, the study lead author, Dr Kaitlyn Watson told Australian Pharmacist from Canada.
'I hope these changes become integrated into legislation across the states and territories, ready for whatever and wherever the next disaster might be.'
During the thunderstorm asthma event in Melbourne in 2016 a review found 'community pharmacies played a central role in meeting community needs' and 'given their community focus and their geographic coverage, community pharmacies can provide valuable support to the management of health emergencies or emergencies with health impacts'.1
The review of a pharmacist's role in the PLoS One paper used a Delphi study – a process of gathering information through a series of survey rounds until adequate consensus is reached, generally after three rounds. Expert panel members came from New Zealand, the United Kingdom, Pan America, Europe, and Australia.
Final consensus findings
The roles pharmacists are capable of undertaking include:
Prevention phase – reduce health risks posed by hazards, administer vaccines, educate the public on reducing the spread of communicable diseases/infections, tailor 'point of care' messaging to chronic disease patients, and ensure patients are aware of increased risk of adverse health outcomes in a disaster.
Preparatory phase – ensure uninterrupted supply of medicines, know how to access national pharmaceutical stockpiles and who to contact, develop business continuity plans including disaster management plans, develop treatment guidelines in the event of bio-terrorism, be part of a local/state/national disaster preparedness health meetings to give medication management advice.
Response phase – coordinate logistics of medication supply, ration limited supplies, assist in release and allocation of national stockpiles, triage low-acuity patients, wound care, CPR, dispense and provide usual pharmacy items, provide emergency supplies, make therapeutic substitutions, monitor 'at risk' individuals, advocate for the pharmacy, and engage the pharmacy student workforce.
Recovery phase – check on the health of the community, restock supplies, restore order to records, document what worked and what didn't, participate in post-disaster research, and inform reports on pharmacy response improvements.
Dr Watson, formerly of Queensland University of Technology and now based in Edmonton, Canada, said it was 'imperative that primary healthcare (including pharmacists and GPs) are integrated into disaster health teams and form part of the coordinated response before a disaster strikes'.
'It is important that we offer trainings and resources to all pharmacists to be prepared for disasters – including offering trainings for more disaster-specific specialised pharmacist roles and providing avenues for pharmacists and their colleagues for debriefing/ongoing support during the recovery phase which can go on for weeks to years.'
Watson K, Singleton J, Tippett V, et al. Defining pharmacists' roles in disasters: a delphi study. PLoS One 2019;14(12):e0227132.
[post_title] => Roles for pharmacists in disasters
[post_name] => roles-for-pharmacists-disasters
[title_attribute] => Roles for pharmacists in disasters
[title] => Roles for pharmacists in disasters
[href] => https://www.australianpharmacist.com.au/roles-for-pharmacists-disasters/
Roles for pharmacists in disasters
[post_content] => Since Christmas, the NSW south coast, East Gippsland, the Hume region and Portland in Victoria and Kangaroo Island off South Australia have been devastated by bushfires resulting in 28 deaths, more than 6.5 million hectares of land burnt – the size of South Korea – and the destruction or damage of about 3,000 homes.
Challenges to pharmacy services have included loss of power, road closures, reduced staff access to workplaces, provision of medicines to displaced people without prescriptions or money and stock shortages. Smoky conditions have increased the risk of asthma for vulnerable patients.
[caption id="attachment_9178" align="aligncenter" width="450"]  Kangaroo Island fires. Photos courtesy Kerry Tyley[/caption]
Already one-third devastated by fires including major tourism infrastructure, Australia's third largest island benefited from rain on Friday, but residents remain on guard with higher temperatures predicted later this week.
The pharmacist-in-charge at Kildea Pharmacy in Kingscote, Patrick Tiong MPS, told Australian Pharmacist that community members had rallied in support of one another.
Last week, tourists and locals alike, during the busiest period of the year, were evacuated to the mainland. Mr Tiong needed to make emergency deliveries, including supplying asthma inhalers to the local hospital, and dispense after-hours to evacuees. Some medicines were provided without prescriptions.
'We often have to rely on the goodwill of and to trust patients during tough times and hope to be paid later,' Mr Tiong said.
Emergency dispensing rulings should rectify this situation.
After the devastating effect of the fires on wildlife and livestock, pharmacy staff and the community rallied to provide necessities for local fauna including dressings and saline irrigations with donations of expired stock and via a community account paid for by the pharmacy staff and community. Personal care products were given to people in need, and discounts on certain over-the-counter (OTC) medicines offered.
Mr Tiong was thankful that Nick Panayiaris, the Pharmacy Guild's SA Branch President, established a local bushfire relief appeal.
Kildea Pharmacy had procedures in place to respond to bushfires but they didn't need to be activated. Power was not lost and data backups were in 'cloud-storage'.
It's been an emotional time for many in the profession, including Mr Tiong, but, 'as pharmacists, we have an obligation … to act in the patient's best interest and ensure continuity of care and supply'. A good relationship with the local hospital and doctors also helps.
Asthma risk
Bushfires have increased the risk of asthma in vulnerable people due to smoke, ash and poor air quality. Professor Sinthia Bosnic-Anticevich MPS, Research Leader of the Quality Use of Respiratory Medicines Group at the University of Sydney's Woolcock Institute, told Australian Pharmacist that it is more important than ever to speak to patients with asthma in the pharmacy.
Professor Bosnic-Anticevich, who is also a pharmacist, stressed that patients need to be on top of their condition and to monitor how they feel and how much reliever they are using – a very important indicator of asthma control.
'Many patients overestimate how well controlled their asthma actually is,' she said. 'This puts them in a very vulnerable position during times like this, when the air quality is poor and their asthma can flare up very quickly.'
Her advice comes as a recent study from the Woolcock Institute found that more than 70% of people with asthma believe they are managing their condition, when they are not.1
'It is critical that people with asthma have and are using their preventer regularly and correctly.'
Professor Bosnic-Anticevich said it is also important for patients to know they are able to access vital medicines at regular prices without a prescription in an emergency.
P2 masks are being supplied from the National Medical Stockpile to protect people, including Defence Force personnel in bushfire-affected areas. Masks provided or reserved since the bushfires started now total almost 3.5 million, according to the Minister for Health, Greg Hunt, with resupplies underway.2
Supply issues
Hazardous conditions and road closures have affected deliveries in numerous areas, exacerbating stock shortages. A national infrastructure network involving governments and military services was deployed, ensuring cross-border capabilities by air and sea, and logistics networks to support a collaborative emergency response.
Pharmacist Jenny Brichacek from Prumms Pharmacy in Pambula on the south coast of NSW reported that the supply of asthma inhalers ran out in all the town's pharmacies, around New Year at a time of increased need because of smoke following intense fires. Extra stock requests were directed to the local base hospital before supplies were flown in from Victoria. A similar situation evolved at Narooma Pharmacy about 100 kilometres further north.
Patrick Tiong on Kangaroo Island is accustomed to problems with freight deliveries across an expanse of water, so he always ensures sufficient supplies are ordered. Delays during the bushfires were solved by contacting the local airport service coordinator.
[caption id="attachment_9179" align="aligncenter" width="600"]  Photo: Sean McGowan[/caption]
Pharmacist support
Emotionally, the toll on pharmacists in fire-ravaged areas is yet to be reckoned with, but support is available. The Pharmacists' Support Service on 1300 244 910 is available daily between 8 am and 11 pm.
[caption id="attachment_9180" align="aligncenter" width="600"]  Helen Feng, owner of the Alliance Pharmacy in Tallangatta, VIC, with members of the local Country Fire Authority crew. Photo: supplied.[/caption]
With eight affected pharmacies in NSW and Victoria, the Pharmacy Alliance has set up a bushfire appeal which aims to raise $250,000 to provide free medication and personal care items to affected communities. The alliance wants industry partners, member-owners and their customers to donate via the Alliance Pharmacy Bushfire Appeal on GoFundMe.
In addition, 50 Pharmacy Alliance member pharmacies will donate all non-prescription sales to the appeal tomorrow [Thursday] with customer donations also accepted at a number of member pharmacies across Australia.
Queensland pharmacists have also established a GoFundMe page to raise $130,000 for practical assistance to pharmacists in financial stress due to the bushfires and who have lost homes or belongings. Donations can be made to the Bushfire Relief for Community Pharmacists.
PSA President Associate Professor Chris Freeman reminds members who are experiencing challenges in delivering care to their local communities can email bushfires@psa.org.au and your requirements will be passed to the relevant State and or Commonwealth Departments.
Kritikos V, Price D, Papi A, et al. A multinational observational study identifying primary care patients at risk of overestimation of asthma control. Primary Care Respiratory Medicine 2019;29:43.
Number of P2 masks provided for bushfires almost 3.5 million. Media Release. Greg Hunt MP. 2020 Jan 10.
[post_title] => Pharmacy services in bushfire crises
[post_name] => pharmacy-services-in-bushfire-crises
[title_attribute] => Pharmacy services in bushfire crises
[title] => Pharmacy services in bushfire crises
[href] => https://www.australianpharmacist.com.au/pharmacy-services-in-bushfire-crises/
Pharmacy services in bushfire crises
[post_content] => Federal, state and territory governments have worked quickly in the past week to introduce legislation that enables those affected by the bushfire crisis to access full quantities of prescription-only medicines without a prescription and with the usual Pharmaceutical Benefits Scheme (PBS) subsidy.
Yesterday (14 January), in a permanent regulation change welcomed by PSA, the South Australian Government introduced provisions that allow its health minister to declare an emergency area and timeframe in which greater amounts of Schedule 4 medicines can be legally dispensed where it is impractical to obtain a prescription.1
South Australian Health and Wellbeing Minister Stephen Wade said the new regulations under the Controlled Substances Act, 1884 apply only to Kangaroo Island and not other fire-affected areas of the state.
These new regulations will allow pharmacists to fulfil their duty of care to patients in times of emergencies and also better support the health and wellbeing of their local communities,' Mr Wade said.
Yesterday's South Australian announcement follows provisions similar to those established last week in NSW, ACT and Victoria to enable access to full quantities of prescription-only medicines without a prescription.
However, after unprecedented bushfire devastation, particularly on the NSW South Coast, on Tuesday 7 January, NSW Health approved emergency dispensing rules allowing NSW pharmacists to dispense standard PBS quantities and standard pack sizes of non-PBS medicines without a prescription, where there was a need.
The same day, the Therapeutic Goods Administration granted permission for pharmacists – until 30 March – to advertise the availability of over-the-counter salbutamol. While such advertising is normally banned, pharmacies can advertise that people with asthma or COPD can obtain salbutamol puffers or dry powder inhalers from a particular pharmacy – with or without prescription if necessary.
On Thursday 9 January, following catastrophic fires in the East Gippsland area of Victoria, emergency dispensing provisions were established in Victoria until midnight on 1 April.2
On Friday 10 January the ACT Government introduced emergency dispensing provisions which expire on 31 March.
The federal health minister, Greg Hunt, also announced on Friday that Australians affected by bushfires can access medicines through a temporary expansion to continued dispensing that allows pharmacists to dispense the full quantity of their PBS medicines without a prescription.3
On Monday 13 January the expanded PBS Continued Dispensing provision took effect. It expires on Tuesday 31 March. The temporary expansion of PBS Continued Dispensing will cover nearly all PBS medicines except for Controlled Drugs.
[caption id="attachment_9174" align="aligncenter" width="831"]  HMAS Adelaide leaves Eden Harbour this week as fire threat abates. Photo credit: Eden Pharmacy[/caption]
An addendum to PSA's Continued Dispensing Guidelines was published today to provide further guidance to pharmacists supplying bushfire-affected people PBS medicines through this initiative.4
Australians without a prescription will be able to access standard quantities of ongoing PBS medicines for the standard co-payment – $6.60 for concession card holders, and up to a maximum of $41.00 for general patients – where PBS medicines are supplied without a prescription in an emergency situation.
PSA National President Associate Professor Chris Freeman said PSA had been working with state and territory governments around the country to improve access to prescription medicines in emergency situations.
'After the current bushfire crisis subsides, we are keen to work collaboratively with all governments to permanently incorporate these more effective and affordable emergency sup-ply provisions into our health system for future disasters.'
'PSA's guidelines for the continued dispensing of eligible prescribed medicines by pharmacists provide clear information to pharmacists on how to appropriately supply medicines in these situations,' A/Prof Freeman said.
'I am confident pharmacists will adhere to these requirements when supplying PBS medicines under this temporary expansion.'
Prescription pressure lifted in emergencies. Media Re-lease. Steven Marshall, Premier of South Australia. 2020 14 January.
Advice for pharmacists supplying medicines to patients in areas affected by Victorian Bushfires. Victoria State Government. 2020 January 9. At: www2.health.vic.gov.au/public-health/drugs-and-poisons/supplying-patients-affected-by-bushfires
Ensuring continued access to affordable PBS medicines for those impacted by the bushfires. Media release: Greg Hunt, Minister for Health. Canber-ra. 2020 Jan 10. At: www.greghunt.com.au/ensuring-continued-access-to-affordable-pbs-medicines-for-those-impacted-by-the-bushfires/
Guidelines for the continuing dispensing of eligible prescribed medicines by pharmacists. Pharmaceutical Society of Australia. 2018 October. At: https://my.psa.org.au/s/article/Continued-dispensing-guidelines
[post_title] => Bushfire update and emergency dispensing provisions
[post_name] => bushfire-update-and-emergency-dispensing-rulings
[title_attribute] => Bushfire update and emergency dispensing provisions
[title] => Bushfire update and emergency dispensing provisions
[href] => https://www.australianpharmacist.com.au/bushfire-update-and-emergency-dispensing-rulings/
Bushfire update and emergency dispensing provisions
[post_content] => Guidelines for stroke management have been updated.
The time window for thrombolysis has been extended to 9 hours if brain imaging shows it will be of benefit, according to updates to the Stroke Foundation's Clinical Guidelines for Stroke Management.1
And, in a strong recommendation approved by the National Health and Medical Research Council (NHMRC), aspirin and clopidogrel should be prescribed together for the first 3 weeks after a minor stroke or transient ischaemic attack (TIA).
The Clinical Guidelines for Stroke Management are living guidelines, updated as new evidence emerges in accordance with the 2011 NHMRC Standard for clinical practice guidelines. The updated 2019 version — approved in November by the NHMRC — supersedes the Clinical Guidelines for Stroke Management 2017.
Updates to thrombolysis recommendations include an extension of the time window to 9 hours with alteplase (including 9 hours from the mid-point of sleep for patients who wake with stroke symptoms). In a new weak recommendation, tenecteplase may be used as an alternative to alteplase for patients meeting specific eligibility criteria, in a time window of 4.5 hours.1
As the new generation thrombolytic tenecteplase is faster-acting than alteplase, the Director of Neurology at the Royal Melbourne Hospital (RMH), Professor Mark Parsons, told media outlets that, with the use of tenecteplase in an extended window, many patients could avoid the need for surgery.2
An RMH trial will test whether the time window for tenecteplase thrombolysis can be abandoned, and brain imaging (to check for salvageable healthy brain tissue) used to better predict who can still benefit from thrombolysis up to 24 hours after having a stroke.2
With one in five patients currently undergoing clot retrieval surgery, Prof Parsons said he hoped the RMH trial could increase treatment access so more patients achieved positive outcomes following a stroke.2
The recommendation for dual antiplatelet therapy with aspirin and clopidogrel for the first 3 weeks after a minor stroke or high-risk TIA is consistent with research reported in Australian Pharmacist.3 For patients without atrial fibrillation, dual antiplatelet therapy offers a small incremental benefit over monotherapy with aspirin with respect to stroke recurrence.3
Trials of antiplatelet therapy in secondary prevention of stroke have shown the use of monotherapy with aspirin (as soon as imaging has excluded intracerebral haemorrhage) significantly reduces the rate and severity of early recurrent stroke compared to placebo.3
Dual aspirin and clopidogrel therapy was found to reduce subsequent strokes by about 20 per 1,000 population, with an increase in bleeding of 2 per 1,000 population compared to aspirin monotherapy. The authors concluded that discontinuation of therapy within 21 days is likely to maximise benefit and minimise harm.3
However, the combination should not be used in severe stroke where haemorrhagic transformation can occur, and should not be used long-term unless patients have other indications.3
The expert working groups for the clinical guidelines concluded that other recommendations are up-to-date in the Clinical Guidelines for Stroke Management 2017. Recommendations remain unchanged for topics including acute blood pressure-lowering therapy, intracerebral haemorrhage management, anticoagulant therapy and pre-hospital care.
A full list of new and updated recommendations, and unchanged recommendations, is available here.4
Pharmacists are integral to drug selection, dose adjustment and monitoring of drug therapy. Their role in secondary stroke prevention includes ensuring medication adherence, optimising blood pressure management, recommending step-down of dual antiplatelet therapy where appropriate, and consideration of gastroprotection in high-risk patients.3
Clinical guidelines for stroke management. Stroke Foundation. At: https://informme.org.au/Guidelines/Clinical-Guidelines-for-Stroke-Management
O'Connell B. Doctors test clot treatment's extended window. Courier Mail 2019 December 14.
Barras M and Winckel K. Primary and secondary prevention of stroke. Australian Pharmacist. 2019;12:42–51.
Living guidelines updates. Stroke Foundation.
[post_title] => Stroke management in 2020
[post_name] => stroke-management-in-2020
[title_attribute] => Stroke management in 2020
[title] => Stroke management in 2020
[href] => https://www.australianpharmacist.com.au/stroke-management-in-2020/
Stroke management in 2020
[post_content] => Adapted by Ann Winkle MPS.
Regulatory bodies are warning of the potential for diabetic ketoacidosis (DKA) as a serious complication of sodium-glucose co-transporter 2 (SGLT2) inhibitor therapy, particularly in people who undergo surgical or medical procedures.1
Many patients presenting with SGLT2 inhibitor-induced DKA are euglycaemic, making it difficult to identify as blood glucose levels (BGLs) and ketone levels can be near normal.1
A 60-year old man was admitted to hospital for a bilateral hemi-knee replacement.
His regular medicines were:
Empagliflozin/metformin was ceased 3 days prior to surgery and recommenced the day after surgery while still an inpatient. Two days after the operation he became unwell with an increased respiratory rate.
Pathology results
Sodium-glucose co-transporter 2 (SGLT2) inhibitors add to the armament for treating type 2 diabetes, with a mode of action that is independent of beta-cell function in the pancreas. They inhibit SGLT-2 proteins located in the renal tubules responsible for reabsorbing glucose back into the blood. As a result, more glucose is excreted in the urine.
SGLT2 inhibitors carry a low risk of hypoglycaemia and are usually well tolerated. However, diabetic ketoacidosis (DKA), including euglycaemic DKA (euDKA), has emerged as a challenging adverse effect. One possible mechanism is that SGLT2 inhibitors blunt insulin production in the face of stress hormones leading to increased ketotic metabolism.2
DKA is an acute complication of diabetes in which ketone bodies build up in the blood. Early signs and symptoms, typically developed over 24 hours, include abdominal pain, nausea, vomiting, anorexia, excessive thirst, difficulty breathing, unusual fatigue and sleepiness. DKA typically presents with high glucose levels, however, atypical euDKA may occur at lower levels. If DKA is not diagnosed early and treatment initiated more serious signs and symptoms including dehydration, deep gasping breathing, confusion and coma can develop.1
The TGA has received reports of DKA, including euDKA, associated with surgical or medical procedures requiring anaesthesia or light sedation, including cardiovascular, bariatric, orthopaedic or gastrointestinal procedures.1
DKA has also been linked to the pre- and post-surgical use of SGLT2 inhibitors (empagliflozin, dapagliflozin) in major surgery since their introduction into Australia. From March 2018 to August 2019, the TGA received a total of 219 reports of DKA (or metabolic acidosis) where empagliflozin or dapagliflozin were the suspected causative medicine. Reports include cases of SGLT2 inhibitors prescribed outside their licensed indication for type 1 diabetes.1
Other DKA risk factors are infections, gastrointestinal conditions, cardiovascular conditions, dehydration, malnourishment/reduced calorie intake and non-adherence with insulin or reductions in insulin dose.1
The clinical chemistry features of euDKA include2:
Plasma pH < 7.3
Serum bicarbonate < 18 mmol/L
Wide anion gap > 12mmol/L (albumin corrected)
Normal or mildly increased plasma glucose: glucose < 14 mmol/L
Increased plasma ketones.
Case study cont.
Empagliflozin/metformin was ceased, and not recommenced during his hospital stay. BGL levels (taken 3 times daily) were usually between 4–8 mmol/L, except for 3.9 the day after empagliflozin/metformin was given. Although empagliflozin had been ceased before surgery, he may have had other risk factors (e.g. orthopaedic surgery, infection, malnourishment, insufficient post-operative oral intake). His general practitioner was informed of the case by the hospital pharmacist.
Recommendations for practice
Stop a SGLT2 inhibitor 3 days before surgery (2 days prior to, and day of surgery). An increase in other glucose-lowering medicines may be needed during this time. Routinely check blood glucose and ketone levels in the perioperative period if the patient is unwell or has limited oral intake and has been on an SGLT2 inhibitor prior to surgery. Restart when patient is eating and drinking normally.2,3
Stop an SGLT2 inhibitor earlier in bariatric surgery, where the risk of ketoacidosis may remain high for weeks or months after surgery.3
If a pharmacist is alerted to symptoms suggestive of ketoacidosis (e.g. unexplained severe vomiting and abdominal pain) they should refer the patient to their treating doctor, even if glucose appears normal (note that urinary ketone testing may be unreliable).3
Therapeutic Goods Administration. Safety information; Alert – Sodium glucose co-transporter 2 inhibitors: Safety advisory – diabetic ketoacidosis and surgical procedures. TGA 2018.. At: www.tga.gov.au/alert/sodium-glucose-co-transporter-2-inhibitors
Australian and New Zealand College of Anaesthetists. Safety alerts Severe euglycaemic ketoacidosis with SGLT2 inhibitor use in the perioperative period. ANZA; 2018 At: www.anzca.edu.au/fellows/safety-and-quality/safety-alerts/severe-euglycaemic-ketoacidosis-with-sglt2-inhibit
Rossi S, ed. Australian medicines handbook. Adelaide: Australian Medicines Handbook; 2019.
John Wilks MPS is a Clinical Pharmacist at Campbelltown and Norwest Private Hospitals.
[post_title] => Don't discount ketoacidosis in euglycaemia
[post_name] => dont-discount-ketoacidosis-in-euglycaemia
[title_attribute] => Don't discount ketoacidosis in euglycaemia
[title] => Don't discount ketoacidosis in euglycaemia
[href] => https://www.australianpharmacist.com.au/dont-discount-ketoacidosis-in-euglycaemia/
Don't discount ketoacidosis in euglycaemia
[post_content] => The balance between adequate pain relief and safety with opioids is now more achievable with the release of a handy new resource for patients on discharge from hospital.
NPS MedicineWise produced the patient resource as part of a broader opioid education program for health professionals and consumers, 'Opioids, chronic pain and the bigger picture,' using the Choosing Wisely Australia initiative recommendations and principles relevant to opioid use.*
With worldwide opioid misuse and overdose the Managing pain and opioid medicines resource was released on 21 November after testing in hospital surgical wards and emergency departments.
Every day in Australia 3 people die and 150 are hospitalised because of harm from pharmaceutical opioids.1 The risk increases over time. Around 80% of people taking opioids for 3 months or more experience harm which ranges from mild to severe and fatal effects.2
Opioids can be an effective component of the management of acute and cancer-related pain. However, evidence shows that for most patients with chronic non-cancer pain, opioids do not provide clinically important improvement in pain or function compared with placebo.2
An opioid medicine should only be considered for patients with chronic non-cancer pain once non-pharmacological therapies (e.g. patient education, gradually increasing physical activity and cognitive behavioural therapy [CBT]) and non-opioid medicines (e.g. paracetamol and non-steroidal anti-inflammatories) have been optimised.2 Once started, the opioid continues to be one component of a multimodal treatment approach.
Opioid analgesia attenuates with time, while the harm persists or increases with time and increasing doses. For some patients, the primary benefit of opioids becomes the avoidance of withdrawal.1
Recent evidence suggests that tapering opioids improves pain, function and quality of life. However, this is often challenging and can take time.1
Importantly, a personal pain management plan should be created by a patient with their health professional (e.g. pharmacist). That plan needs to include criteria for ceasing the medicine.1
The aim of the Managing pain and opioid medicines resource is to ensure patients use their pain medicine safely and effectively, as well as using other ways of managing pain. It has three key elements: 5 questions to ask a health professional before leaving hospital, tips for taking and storing opioids at home, and a personal pain management plan for development with a health professional. The questions are based on Choosing Wisely Australia's 5 questions to ask your doctor resource to guide better conversation and tests, treatments and procedures.
Hospital staff will be encouraged to provide the two-page patient resource to people prescribed opioids for non-cancer pain as inpatients, or on discharge, and encourage a conversation about using opioids for short-term pain, their adverse effects and other ways of managing pain. Health professionals practising in primary care are encouraged to print copies for their patients and initiate discussions about opioid medicines.
* Do not continue opioid prescription for chronic non-cancer pain without ongoing demonstration of functional benefit, periodic attempts at dose reduction and screening for long-term harms. (Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists).1
Opioids, chronic pain and the bigger picture NPS MedicineWise. At: www.nps.org.au/professionals/opioids-chronic-pain
Opioids out of balance. NPS MedicineWise News. 2 October 2019. At: www.nps.org.au/news/opioids-out-of-balance
[post_title] => New opioid patient resource
[post_name] => new-opioid-patient-resource
[title_attribute] => New opioid patient resource
[title] => New opioid patient resource
[href] => https://www.australianpharmacist.com.au/new-opioid-patient-resource/
New opioid patient resource
[post_content] => Men who have sex with men and use the human immunodeficiency virus (HIV) prevention pill have lower anxiety, new Australian research has revealed.
Those who take the pre-exposure prophylaxis medication (PrEP) against HIV infection have significantly lower levels of HIV-related anxiety, according to a study from the Kirby Institute at UNSW Sydney, published last week in the Journal of Acquired Immune Deficiency Syndromes ahead of World AIDS Day.1
Anxiety about HIV transmission has affected sexual behaviours of men who have sex with men for more than 30 years, but this new research provides the strongest evidence globally that, as well as driving down HIV infection rates, PrEP may be enhancing the mental health and wellbeing of men at risk of HIV.1
PrEP refers to the biomedical prevention of HIV using antiretroviral agents. This includes a fixed-dose combination pill of tenofovir+emtricitabine (e.g. Truvada), which was listed on the Pharmaceutical Benefits Scheme (PBS) in April 2018. Only patients who are at least 18 years old and who are at medium to high risk of infection, as defined by the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) guidelines, are eligible for the treatment.2
The co-lead author on the paper, Phillip Keen [PhD candidate] at the Kirby Institute, said the findings had important implications for understanding the benefits of PrEP.
'We've known for some time that PrEP is very good at protecting people from HIV. This new evidence suggests that another benefit of taking PrEP is improved mental health, through reduced anxiety about HIV,' he said.1
Data was analysed from the 'Following Lives Undergoing Change' study, a national, online survey of the sexual and drug use behaviours of more than 2,500 men at risk of HIV in Australia in 2018.
An earlier 2018 Australian study (pre-PBS listing) showed that less than half of those at high risk for HIV were currently taking PrEP. The authors of the Kirby Institute study concluded that their findings could inform how PrEP is promoted to men and used to support higher PrEP use in Australia.1
This conclusion was endorsed by the Australian Federation of AIDS Organisations (AFAO) CEO Adjunct Associate Professor Darryl O'Donnell, who said the research represents a turning point in our understanding of how fear of HIV has influenced sexual relationships for many men who have sex with men.
'[PrEP] has helped many gay men enjoy sex without being fearful of HIV,' he said.
However David Crawford, Treatments Officer with Positive Life NSW, which has assisted people living with HIV since 1988, said this isn't the case for all people living with HIV.
'Prior to this new Kirby Institute study, the prescribing of PrEP has been recognised as a game changer as it had appeared to alleviate the anxiety of many who were taking it,' he said.
'[But] for people who were assessed as being ineligible for PrEP, this led them to exhibit or express higher levels of anxiety.'
Mr Crawford said pharmacists should keep in mind that for people living with HIV, assurances of privacy are paramount.
'The main concerns people living with HIV have, particularly in smaller communities, are the maintenance of their confidentiality and how they will be responded to and treated when they attend a community pharmacy to collect their medicines,' he said.
World AIDS Day, held every 1 December, raises awareness around the world about the issues surrounding HIV and AIDS. It is a day for people to show support for those living with HIV and to commemorate people who have died.3
The national World Aids Day theme for Australia in 2019 is 'Every Journey Counts'. Australians are encouraged to educate themselves and others about HIV, promote HIV prevention strategies, be aware of and educate others that undetectable = untransmissable (U=U), and ensure that and ensure that people living with HIV can fully participate in the life of the community, free from stigma and discrimination.
In line with Australia's aim to be one of the first countries to eliminate new HIV transmissions – new diagnoses are now at the lowest level in 20 years – the federal Health Minister Greg Hunt announced yesterday an extension of almost $3 million in funding for six national peak organisations.
The funding for 2020–21 will support people living with HIV and other blood-borne viruses and sexually-transmitted infections.
And from next week an estimated 850 Australians living with HIV will save more than $8,500 a year with the Pharmaceutical Benefits Scheme listing of the once-daily combination medicine Dovato (dolutegravir with lamivudine).
A red ribbon is the international symbol of HIV awareness and support.
PSA will host the first of its 'Facing Up To' webinar series in February 2020. The first of which includes an interview with a patient taking PrEP and a clinical update from a pharmacist expert in the area – where questions will be welcomed from the online audience.
Keen P, Hammoud M, Bourne A, et al. Use of HIV pre-exposure prophylaxis (PrEP) associated with lower HIV anxiety among gay and bisexual men in Australia who are at high risk of HIV infection. Results from the Flux Study. Kirby Institute UNSW. JAIDS2019. Epub Nov 20.
Pharmaceutical Benefits Scheme (PBS). Department of Health. Australian Government. 2019. At: www.pbs.gov.au
World Aids Day Australia. 2019. At: www.worldaidsday.org.au/internet/wad/Publishing.nsf/content/home
[post_title] => World AIDS Day – 1 December
[post_name] => world-aids-day-2019
[title_attribute] => World AIDS Day – 1 December
[title] => World AIDS Day – 1 December
[href] => https://www.australianpharmacist.com.au/world-aids-day-2019/
World AIDS Day – 1 December
[post_content] => With increasing overdose deaths from both prescription opioids and heroin, naloxone nasal spray – now listed on the Pharmaceutical Benefits Scheme – is a life-saving and easy-to-use opioid reversal agent to stock in your pharmacy.
And pharmacists this week have been urged to re-think social attitudes to reduce the stigma of drug use, addiction and overdose to ensure easy access to naloxone nasal spray.
Guidance for provision of naloxone is now available in the PSA document Guidance for provision of a Pharmacist Only medicine – Naloxone for the treatment of opioid overdose.1
As John Jackson, Chair of PSA's Harm Minimisation Committee told Australian Pharmacist: 'Naloxone is not a new drug. It has been used extensively in a parenteral form, especially in hospitals where pharmacists have a sound knowledge of its use as a narcotic antagonist.'
But there is growing recognition of its potential benefit for suspected opioid overdose in the community.
Deaths due to illicit drug overdose (e.g. heroin or diverted fentanyl) commonly occur in the presence of another person. There may be a reticence to call an ambulance because of possible police involvement. Broader availability of naloxone among users, their family and friends can save lives.
The potential for overdose also exists with opioids prescribed for chronic pain (e.g. oxycodone), particularly when used with other central nervous system depressants such as alcohol and benzodiazepines. Australian research has found that most chronic pain patients prescribed opioids either expect to be offered naloxone or would appreciate it.2
The director of the Australian Research Centre in Sex, Health and Society at LaTrobe University, Professor Suzanne Frazer, led a recent research project into why naloxone was not accessed more widely. Researchers interviewed 37 health professionals and also 46 people in New South Wales and Victoria who take opioids and found that many were either unaware of how to obtain the reversal agent or were too embarrassed.
Yesterday (Tuesday) the experiences and stories collected through that research were shared on Overdoselifesavers.org, a website launched at the Australasian Professional Society on Alcohol and Other Drugs conference in Hobart.
'Many people we interviewed were keen to know about naloxone, and access it, but were concerned about confidentiality when speaking to pharmacists, or didn't want to bring it up with their GP in case it affected their relationship in the future,' Professor Frazer said.
'We need to rethink our social attitudes to opioid consumption and overdose if naloxone programs are to fully achieve their life-saving potential,' she said yesterday.
Role of the pharmacist
Experience with naloxone may be limited in the community, but pharmacists are uniquely placed to identify people at risk of opioid toxicity and provide them with a reversal agent. Being alert for the signs of opioid overdose, and then facilitating access to naloxone and training for family and friends, presents a good opportunity for pharmacists to undertake early intervention.
And naloxone is safe with no abuse potential. Australian and international studies have demonstrated that supplying naloxone for a layperson to administer is safe, feasible and cost-effective.2
'In the nasal formulation, a simpler, more convenient preparation is able to be readily administered without extensive training,' Mr Jackson said.
Naloxone is a competitive antagonist at opioid receptors with a fast onset of action and a short half-life. When administered in the presence of an opioid, it displaces the opioid at the receptor and reverses its effects – importantly respiratory depression which can be fatal.
It works for all opioids, e.g. heroin, morphine and oxycodone as well as opioid substitution therapies such as methadone. It is also safe in nonusers. When given to healthy volunteers with no recent exposure to opioids, naloxone showed no adverse effects.2
In 2016, naloxone injection 400 microgram/mL became available as a Schedule 3 medicine, available over-the-counter (OTC) and on prescription. It is approved for intramuscular, intravenous and subcutaneous use in Australia, and has been used by ambulance and paramedical staff to treat overdose for over 40 years.2 Naloxone nasal spray, 1.8 mg/actuation, became available OTC and on prescription (PBS subsidised on 1 November), earlier this year.
Mr Jackson said that 'pharmacists need to develop the capability to identify and assess high-risk individuals in a non-stigmatising manner'.
From the PSA guidance document, pharmacists can identify high-risk factors (e.g. high opioid dose (>100 mg morphine equivalents/day)), long-acting form (e.g. methadone) or extended-release preparation). The person may have a respiratory condition, or smoke or take other central nervous system depressants, or may be part of a methadone or detoxification program.
Pharmacists should discuss with patients/carers the risks associated with opioids, and supply naloxone where appropriate. Also, ensure the person has been provided with an emergency opioid overdose protocol.2
'In training people to recognise the symptoms of opioid overdose and how to administer the nasal spray, pharmacists should ensure [they] understand it is not a substitute for professional medical care, and further doses of naloxone may be required,' Mr Jackson warned. Although the nasal spray contains two single dose devices, 'emergency assistance should be sought whenever an opioid overdose is suspected and the spray administered', he added.
'The [nasal] spray can be administered even if the person is not breathing.' Inform users that 'each device contains only one spray and should not be pumped or "primed" before use.'
Be mindful that naloxone has a half-life <1 hour, which is shorter than all the opioids. Observe the patient for 2–3 hours after naloxone administration for relapse. This is particularly important following methadone or controlled-release opioids, where narcosis may persist for >24 hours.3
Refer to the PSA guidance document for the use of naloxone nasal spray in children, pregnancy and while breastfeeding, where the infant needs to be monitored for opioid withdrawal symptoms. Also, refer to the recommendations when supplied to a third party and follow–up advice.1
A training resource is available at: www.penington.org.au/programs-and-campaigns/resources/cope-overdose-first-aid
Although the nasal spray formulation is expensive at present, Mr Jackson said we can expect to see a price reduction, especially as multiple brands are available overseas.
Pharmaceutical Society of Australia. Guidance for provision of a Pharmacist Only medicine: Naloxone. Canberra: PSA; 2019.
Jauncey ME, Nielsen S. Community use of naloxone for opioid overdose. Aust Prescr 2017;40:137–40.
[post_title] => Naloxone nasal spray added to the PBS
[post_name] => naloxone-nasal-spray-added-to-the-pbs
[title_attribute] => Naloxone nasal spray added to the PBS
[title] => Naloxone nasal spray added to the PBS
[href] => https://www.australianpharmacist.com.au/naloxone-nasal-spray-added-to-the-pbs/
Naloxone nasal spray added to the PBS
[post_content] =>
Harold, a 68–year–old man who regularly visits your pharmacy, has come in today to have a new prescription dispensed for isosorbide mononitrate controlled–release 60 mg tablets (one daily) for recent episodes of angina. Harold isn't happy. He tells you his wife and his GP want him to quit smoking because of his heart. However, when he has tried to quit in the past it was too hard, he believes it is because he has been smoking for too long. He has a 40 pack–year history. Harold knows smoking isn't good for his health and would like to stop but finds the habit too hard to break.
When counselling him on his prescription, what advice would you give to encourage him to consider quitting smoking again?
After successful completion of this CPD activity, pharmacists should be able to:
Describe the health risks associated with cigarette smoking
Discuss the difficulties many patients face when trying to cease smoking
Identify the most common therapies in smoking cessation, in particular nicotine-replacement therapy, and counselling points for patients
Describe how pharmacists can support patients attempting to cease smoking.
Competency standards addressed (2016): 1.1, 1.3, 2.1, 2.4, 3.1, 3.2, 3.5, 3.6
This article was produced in partnership with Johnson & Johnson.
Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.
Cigarette smoking remains a leading cause of preventable disease and premature death worldwide. There is extensive evidence to show that tobacco use is a major cause of death from cancer, cardiovascular disease and pulmonary disease.1 A recent Australian study found that current smokers are three times more likely to die from cardiovascular disease, but risks decrease significantly when smokers quit.2
Cigarette smoking is a risk factor for respiratory tract and other infections, osteoporosis, reproductive disorders, postoperative complications and delayed wound healing, duodenal and gastric ulcers, and diabetes. Second-hand smoke also carries risks for non-smokers.1
Smoking-caused disease occurs because of the toxins in tobacco smoke, with nicotine playing only a minor role. However, nicotine addiction is behind the continued use of cigarettes leading to these diseases.1
Australia is a signatory to the WHO Framework Convention on Tobacco Control, which commits governments to a minimum set of policies to curb tobacco use. These include bans on advertising, warning labels, tax on tobacco products, smoke-free policies, and smoking cessation services. Australia is leading the world in the introduction of plain packaging of tobacco products.3
Despite policies ensuring the availability of education programs on the harms of tobacco, quit support services, cigarette packaging warnings and pharmacological treatments, recent Australian data shows that 1 in 8 Australians (12.5%) continue to smoke daily. The prevalence is an improvement from 2007 when 16.6% of people aged 14 years and over smoked tobacco daily. Rates of smoking in Aboriginal and Torres Strait Islander people are much higher, although there has been a progressive decline in daily smokers in this group – 45% in 2007 to 41% in 2012–2013.1
In a positive sign, the number of 'dissonant' smokers (those who want to quit but find it difficult to stop) in Australia has increased to 79%.5 Considering this, smoking cessation is a priority for the Australian government and Australians. The Federal Minister for Health, Greg Hunt, has announced that the Australian government has set a target to reduce smoking rates to under 10% by 2025.6
The cycle and level of addiction
Nicotine sustains tobacco addiction by acting on nicotinic cholinergic receptors in the brain to trigger the release of dopamine and other neurotransmitters such as glutamate and GABA.1 Addiction is complex, with behavioural, cognitive and physiological aspects. Smokers come to depend on smoking to modulate their mood and arousal and to avoid withdrawal symptoms. See Figure 1.
Many smokers attempt to quit by abruptly stopping or cutting down on their own, with mostly poor results.3 One study of self-quitters showed a high rate of early relapse, with up to 76% of smokers who quit unaided relapsing after one week.7 The majority of smokers trying to quit cycle through multiple attempts with relapse and remission over many years before achieving long-term abstinence.3
Figure 1 – Cycle of addiction
Benefits of quitting
Health benefits from quitting are well documented. There are immediate and long-term health benefits of quitting for all smokers. See Figure 2. However, the risk of developing cardiovascular and cerebrovascular disease will never quite reach that of non-smokers.8
Figure 2 – Benefits of quitting
Resting heart rate reduces– which is a key indicator of overall fitness level
The carbon monoxide in the blood reduces dramatically which improves oxygen levels
2–12 WEEKS
The risk of heart attack begins to reduce and blood circulation improves. Lung function improves as well, making it much easier to exercise
1– 9 MONTHS
Coughing, wheezing and breathing problems reduce as lung function continues to improve
The risk of heart attack reduces by half
The risk of stroke reduces to that of a non-smoker 5–15 years after quitting
The risk of heart attack reduces to that of someone who has never smoked before. The risk of lung cancer reduces to about half of that of a smoker
Reference: WHO9
Supporting smokers on their quit journey
Most former smokers average five or six serious attempts to quit.10 Quitting is not easy, but the evidence that it can be done is strong. Smokers trying to quit need to know that additional help is available and increases the likelihood of success. This is particularly important for those who have tried multiple times without long-term success. Many need encouragement, assistance and guidance along their quit journey.3
Assistance includes counselling the individual on the health benefits of quitting, targeted support through the process of quitting such as the 5As approach (below), and a helpline such as Quitline.
Quitline is available in all Australian states and territories. It provides WHO evidence-based counselling, motivational interviewing, psychoeducation, cognitive and behavioural strategies, and assistance with a quitting plan. A free QUIT pack, telephone counselling assistance and links to community programs are also available. Adding Quitline counselling to pharmacotherapy and minimal intervention has been shown to increase abstinence rates. Contact: phone 13 78 48 (13 QUIT) or https://quitlinesa.org.au/
Traditionally the 5As approach has been recommended. It encompasses five components of effective smoking cessation support – ask, assess, advise, assist and arrange follow-up. This structured approach provides an evidence-based framework to give appropriate support according to an individual's level of interest in quitting.3 The approach could be difficult to implement in a busy pharmacy but may be useful as a reference.
Ask about smoking, even if it's just an offer to discuss their readiness to quit.
readiness to quit i.e. their stage of readiness. Re-evaluate at every opportunity. The relationship and communication between the health professional and the smoker can influence the stage of change.
level of nicotine dependence. Ask whether they smoke within 30 minutes of waking, smoke more than 10 cigarettes per day, and their history of withdrawal symptoms in previous quit attempts.
Advise all smokers to quit without being confrontational. Use brief, repeated, consistent, positive reminders to quit. Reinforce efforts by other health professionals. Establish rapport and ask permission to speak about it. Acknowledge that they are aware of the risks and ask if they are ready to discuss options.
Assist. Level of assistance depends on their needs and preferences. It may be provided by the pharmacist or referral to a doctor, or both, plus referral to Quitline. Motivational interviewing could be used but is time-consuming. Consider the barriers to quitting.
Arrange follow-up. Success is more likely with follow-up visits to discuss progress and to provide support. Record interventions.
A discussion with someone about smoking, particularly using the 5As approach, can be difficult in the pharmacy considering a lack of time and space for a prolonged and sensitive conversation. In this instance, a practical 3-step brief advice (Ask, Advise, Help/Assist) approach may be more appropriate.
Pharmacotherapy is currently recommended for moderately to highly nicotine-dependent smokers who are interested in quitting, except where contraindicated. Nicotine Replacement Therapy (NRT), varenicline and bupropion are registered by the Australian Therapeutic Goods Administration (TGA) to aid smoking cessation, with strong supporting evidence. There is also evidence for the effectiveness of nortriptyline, but it is not TGA-approved for smoking cessation. The modified Fagerstrom test for nicotine dependence can be used to give a nicotine dependence score where time to first cigarette and number of cigarettes smoked per day are used.11 The choice of agent is based on clinical suitability and patient preference.3,8,10
Nicotine replacement therapy
NRT temporarily replaces much of the nicotine that was previously absorbed from a cigarette. It also delivers nicotine to the brain at a slower rate than cigarettes, making it less addictive. NRT can help gradually reduce nicotine intake from cigarettes, while helping to minimise nicotine withdrawal symptoms and reduce cigarette cravings.10,11,13
NRT approximately doubles quit rates compared with controls, irrespective of the intensity of other support and interventions. That translates to quit rates increasing from 5% to 10% in primary care, and from 10% to 20% in more intensive settings.8
Using NRT is always safer than continuing to smoke. Adverse effects are usually minor, transient (e.g. sleep disturbance, dizziness, weight gain and headache) and may be related to stopping smoking.10 Gastrointestinal and cardiovascular adverse effects (e.g. palpitations) are possible when using NRT while smoking. Use NRT with caution in people with recent myocardial infarction, unstable angina, severe arrhythmias and recent cerebrovascular events. However, there is growing evidence for the safety of NRT in smokers with acute coronary syndromes and NRT can be used in this situation under medical supervision. NRT is contraindicated in those with nicotine hypersensitivity.3,8,10
In Australia, NRT is available over the counter as gum, inhalation, lozenge, patch and oral spray. Specific brands of patches, gums and lozenges are PBS-subsidised in combination with counselling.
Patches10: 7 mg/24 hr; 14 mg/24 hr; 21 mg/24 hr 5 mg/16 hr; 10 mg/16 hr; 15 mg/16 hr; 25 mg/16 hr
Suitable for those wanting to quit immediately
16-hour preparation mimics the natural pattern of smoking; may be less likely to cause sleep disturbance.10
Gum10: 2 mg; 4 mg
Absorbed quickly; helps craving and withdrawal symptoms.
Inhalation cartridges10: 15 mg
Keeps hands busy
One cartridge lasts approximately 40 minutes of intense use.
Lozenges10: 1.5 mg; 2 mg; 4 mg
Dissolves in the mouth without chewing or swallowing
May take 30 minutes to dissolve.
Spray10: 1 mg/dose
Spray in the mouth, aiming for side of cheek or under the tongue.
Treatment recommendations
Treatment depends on level of nicotine dependence. Levels are described as10:
High – waking at night to smoke or smoking in the first 5 minutes after waking; usually >30 cigarettes daily.
Moderate – smoking within 30 minutes after waking; usually 20–30 cigarettes daily.
Low-to-moderate – no need to smoke within 30 minutes after waking; usually 10–20 cigarettes daily.
Low – no need to smoke in first hour after waking; usually <10 cigarettes daily.
Nicotine patches are not usually recommended for low-dependence groups (i.e. those who smoke fewer than 10 cigarettes per day), although are sometimes used, including in low-weight individuals (<45 kg).8
Aim to taper and stop NRT treatment within 12 weeks, although 6–8 weeks is su cient for most people.8
Combination NRT
Combination NRT has the advantage of high treatment adherence with the patch (for stable nicotine levels) while allowing the patient to self-administer an immediate-release NRT to deal with acute cravings.
The superiority of combination NRT over single-form NRT was shown in an early study,14 and confirmed in a recent Cochrane Systematic Review.15 This review also found that chances of quitting were higher with 4 mg gum compared to the 2 mg formulation for more addicted smokers. There was moderate evidence that higher dose patches were more effective than lower dose patches.15
Considering the diversity of smokers, different formulations suit different smokers. Allowing patient choice increases compliance. Adequate dosage regimens should be stressed in order to avoid underdosing, which is common with NRT3,8. Dosing regimens are also available from eTG, AMH, RACGP and Quit.
NRT in special situations
Can be used by smokers aged 12–17 years.
Can be used by people with stable cardiovascular disease, with caution.
In pregnancy, offer intense support with counselling and Quitline. Use NRT if quitting unsuccessful without it Intermittent, short-acting oral dosage forms are preferred. If patches are chosen, they should be removed at night.10
Nicotine is expressed in breast milk, but unlikely to be harmful. Minimise exposure by taking a dose just after a feed.8
NRT use before quitting
There is evidence that using NRT prior to quitting is safe and more effective than using it from quit day, although more studies are needed.3,14,15 NRT can also be used to reduce tobacco consumption before progression to quitting. The TGA-approved approach is to use NRT to reduce the number of cigarettes smoked before stopping completely within 6 months.3
Varenicline is a partial agonist at nicotine receptors. It can more than double the chances of a smoker quitting, although evidence is based on a limited number of comparative studies. It has similar efficacy to combination NRT. It is available on the PBS as short-term adjunctive therapy for nicotine dependence. It can be prescribed for up to 24 weeks of continuous therapy for smokers enrolled in a support and counselling program and who are abstinent at 12 weeks. Varenicline is started while the person is still smoking.3
Nausea is a common adverse effect, which may be transient and can be reduced by taking with food. Neuropsychiatric adverse effects are a concern, with limited evidence in people with significant psychiatric illness. There is also a small increase in the risk of cardiovascular events.8 Cessation can result in increased withdrawal symptoms.10
The dose is 0.5 mg orally, daily, titrating up to 1 mg twice daily for 12 weeks. Reduce dose in renal impairment.8
VBupropion is a non-nicotine oral therapy with efficacy similar to NRT monotherapy. However, it causes insomnia and has the potential to cause seizures, limiting its use. Bupropion is contraindicated in patients with a history of seizures, eating disorders and those taking monoamine oxidase inhibitors. Caution is needed in combination with medicines that lower the seizure threshold (e.g. antipsychotics, antidepressants). Drug interactions are possible via cytochrome P450 enzymes.8.10
Dose: 150 mg once daily, titrating to 150 mg twice daily for 9 weeks. Bupropion is started while the person is still smoking.8
Summary of pharmacotherapeutic options
Combining two types of NRT is as effective as varenicline and helps more people quit than any single NRT.17
Best results are usually achieved when medicines are used in combination with counselling and support, although the effectiveness of NRT appears to be independent of the intensity of support provided.8
Short-acting NRT 4 mg is more effective than 2 mg in high dependence.15
NRT can be bought without a prescription.
Bupropion and NRT monotherapy are equally effective.3
Varenicline has been shown to be more effective than bupropion.3
Varenicline and bupropion are associated with uncommon but significant adverse effects.8
Neither varenicline nor bupropion have been shown to be effective or safe for smoking cessation treatment in pregnant and breastfeeding smokers. They are not recommended.8
The role of the pharmacist
As the frontline of primary care, pharmacists are in a prime position to provide brief intervention counselling, advice on pharmacotherapy choice and use, and referral to, and collaboration with, Quitline for intensive behavioural support.
The number of people wanting to quit in Australia has grown to almost 80%. The challenge for pharmacists is to help put that desire into practice.
Pharmacists should be proactive. As brief interventions work, ask about an individual's smoking status, advise about the best way for them to quit, and help them in their quitting journey at every stage of readiness to quit. Provide a personalised treatment plan with pharmacological treatments such as NRT, and behavioural strategies. Advise them of the specific benefits to their health by quitting and take into consideration their treatment preference. Refer them to Quitline for ongoing support and resources.
Case scenario continued
Assure Harold that evidence shows that stopping smoking can be done, even with his long-term high dependency. Explain the health benefits of quitting, especially the cardiovascular benefits, and offer him the WHO fact sheet: https://who.int/tobacco/quitting/benefits/en/
Discuss NRT with Harold. Considering his high dependency, suggest a combination of a nicotine patch and a short-acting preparation of his preference. Refer to appropriate references and ensure his dose is adequate. He could see his GP for a nicotine patch, which is available on the PBS. Refer him to Quitline. Offer your support throughout the quitting journey and ask him to return in 2 weeks to see how he is going.
The government has set a target to reduce smoking rates to below 10% by 2025.
The number of people wanting to quit is increasing.
Nicotine replacement therapy (NRT) has proven efficacy and safety as part of a smoking cessation plan.
Pharmacists can support those wanting to quit by asking about smoking, advising on how to quit, and helping individuals through the process by providing a personalised treatment plan with pharmacological treatments such as NRT, and behavioural strategies.
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Benowitz NL. Nicotine addiction. N Engl J Med 2010;362:2295–303. At: https://www.ncbi.nlm.nih.gov/pubmed/20554984
Banks E, Joshy G, Korda RJ, et al. Tobacco smoking and risk of 36 cardiovascular disease subtypes: fatal and non-fatal outcomes in a large prospective Australian study. BMC Med 2019;17(1):128. At: https://www.ncbi.nlm.nih.gov/pubmed/31266500
The Royal Australian College of General Practitioners. Supporting smoking cessation: a guide for health professionals. Melbourne: RACGP, 2011 [Updated July 2014]. At: racgp.org.au
Nicorette Global Omnibus [Australian data]. GSIA. March 2018. At: http://www.pbs.gov.au/info/industry/listing/elements/pbac-meetings/psd/2018-03/Nicotine-psd-march-2018
Australia Quitting Landscape. Consumer Insight debrief. GSIA. 2019. At: https://www.aidr.org.au/media/1760/aidr_handbookcollection_lessonsmanagement_2019.pdf
Ministers: Department of Health. National Press Club address – Long Term National Health Plan. 2019. At: health.gov.au/ministers/the-hon-greg-hunt-mp/media/national-press-club-address-long-term-national-health-plan
Hughes J, Gulliver S, Fenwick J, et al. Smoking cessation among self-quitters. Health Psychol. 1992;11(5):331–4. At: https://psycnet.apa.org/record/1993-11118-001
Smoking cessation [revised June 2019]. In eTG complete. Melbourne: Therapeutic Guidelines; 2013. At: https://tgldcdp.tg.org.au/
World Health Organization. Fact sheet about health benefits of smoking cessation. At: who.int/tobacco/quitting/en_tfi_quitting_fact_sheet.pdf
Rossi S, ed. Australian medicines handbook. Adelaide: Australian Medicines Handbook; 2019. At: https://amhonline.amh.net.au/
NSW Health. Diagnosing and assessing nicotine dependence in mental health facilities. At: http://www.health.nsw.gov.au/tobacco/Publications/tool-02-diagnosing-and-as.pdf
Fant R, Owen L and Henning eld J. Nicotine replacement therapy. Prim Care 1999;26(3):633–52. At: https://www.ncbi.nlm.nih.gov/pubmed/10436291
Hartman–Boyce J, Chepkin SC, Ye W, et al. Nicotine replacement therapy versus control for smoking cessation. Cochrane Database of Systematic Reviews 2018, Issue 5. At: https://www.ncbi.nlm.nih.gov/pubmed/29852054
Fagerström KO, Schneider NG and Lunell E. Effectiveness of nicotine patch and nicotine gum as individual versus combined treatments for tobacco withdrawal symptoms. Psychopharmacology (Berl) 1993;111:271–77. At: https://www.ncbi.nlm.nih.gov/pubmed/7870963
Lindson N, Chepkin SC, Ye W, et al. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2019, Issue 4. At: https://www.ncbi.nlm.nih.gov/pubmed/30997928
Lindson N, Klemperer E, Hong B, et al. Smoking reduction interventions for smoking cessation (Review). Cochrane Database of Systematic Reviews 2019, Issue 9. At: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013183.pub2/abstract
Cahill K, Stevens S, Perera R, et al. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database of Systematic Reviews 2013, Issue 5. At: https://www.ncbi.nlm.nih.gov/pubmed/23728690
ANN WINKLE BPharm, BA, MPS, AACP is a contracting pharmacist with extensive experience in developing and delivering education programs for GPs and pharmacists. She is also accredited to conduct medication reviews. She has previously worked for PSA in the resource development team, NPS MedicineWise as an educational visitor, and hospital clinical pharmacist.
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Smoking cessation: Turning desire to quit into action
You have been asked to perform a home medicines review (HMR) for Jack. Jack is an 82-year-old man who had an ischaemic stroke 3 weeks ago and is having his medicines reviewed by you as part of his HMR. He has a past medical history of hypertension and was prescribed atenolol prior to his stroke. He has no allergies nor other comorbidities. He has had a few dizzy spells recently and his blood pressure is on the low side. He tells you he has otherwise recovered well from his stroke and is currently taking:
Atenolol 50 mg each morning
Ramipril 10 mg each morning
Clopidogrel 75 mg each morning
Atorvastatin 40 mg at night.
Are these medications appropriate for Jack?
Differentiate between primary and secondary stroke prevention
Summarise the pharmacological management of ischaemic strokes
Recognise when dual antiplatelet therapy is appropriate
Discuss the role of the pharmacist in ischaemic stroke prevention and management
Competencies (2016) addressed: 1.5, 2.1, 2.2, 3.3, 3.5
A stroke occurs every 15 minutes in Australia, equating to over 36,000 cases per year.1 It is the third leading cause of death. Mortality has declined over the past 10 years as a result of strategies to mitigate risks: specialist stroke recovery units and advances in reperfusion strategies.1 The subsequent burden of stroke to patients and carers is demanding. Potentially modifiable risk factors are estimated to cause more than 90% of strokes, these could be reduced by controlling metabolic and behavioural risk factors.2 Pharmacological intervention is important; pharmacists must be actively involved in stroke management.
The primary prevention of stroke has become topical following three recent aspirin studies.3,4,5 The focus of primary prevention of stroke in patients without atrial fibrillation (AF) should be on the modification of risk factors. The use of medicines in acute stroke and secondary prevention is standard practice with guidelines recommending clear pathways. Pharmacists are integral to drug selection, dose adjustment and monitoring of drug therapy.
The aim of this article is to discuss the pharmacological management of stroke, in particular primary and secondary prevention. The role of the pharmacist will be highlighted. There will be a description of modifiable risk factors and the associated goals of therapy.
A stroke, often referred to as a cerebrovascular accident (CVA), is defined as an acute episode of focal dysfunction of the brain, retina or spinal cord lasting longer than 24 hours, or if confirmed earlier by imaging.6 A transient ischaemic attack (TIA) is diagnosed if the dysfunction is less than 24 hours and there is no radiological evidence of a stroke.6 A TIA occurs when the blood supply to the brain is blocked temporarily. Patients with TIAs are at high risk for early ischaemic stroke.
Approximately 85% of strokes are ischaemic, caused by vascular occlusion, with the remainder haemorrhagic.6 An ischaemic stroke (IS) can be either an embolic event, typically in patients with AF, or a thrombotic event due to plaque rupture in carotid/cerebral arteries. A third classification is cryptogenic stroke, which is of an undetermined source. A haemorrhagic stroke is described by location. For example, an intracerebral haemorrhage (ICH) is a result of an artery rupture or leak, and is often associated with hypertension. A subarachnoid haemorrhage (SAH) is bleeding within the meninges of the brain.
Signs of stroke
The typical signs and symptoms of stroke include: sudden unilateral weakness, numbness, visual loss, altered speech, vertigo, headache and confusion. The time elapsed before medical intervention is critical to survival and recovery. The acronym for suspicion of stroke is FAST:
Facial drooping
Arm weakness
Speech difficulties
Time to call emergency services.
FAST has been widely adopted. Pharmacists should educate consumers about FAST, particularly in at-risk patients. Radiological imaging is used for further categorisation and subsequent treatment.6
Risk factors can be classified as either modifiable or non-modifiable, where the overall aim for clinicians is to reduce modifiable factors (Table 1). Non-modifiable risk factors for stroke include age, sex and race/ethnicity.2,6
The 'ten' modifiable risk factors account for approximately 90% of attributable risk of stroke.2 Obesity, smoking, alcohol use, chronic inflammation and hormonal therapy are modifiable risk factors that have less direct evidence of causing stroke, however, their link to cardiovascular disease (CVD) is well known.
TABLE 1 – Ten modifiable risk factors for stroke
MODIFIABLE RISK FACTOR
STROKE DEATHS (%)
TYPE OF STROKE MOST LIKELY CAUSED
FIRST-LINE TREATMENTS
I or H
ACEI, CCBs
Antiplatelets, Statins
Hypercholesteroleamia
NRT, buproprion, varenicline
Metformin, SGLT2 Inhibitors
Poor diet
Non-drug treatments preferred
Increase in waist to hip ratio
I = ischaemic, H = haemorrhagic, ACEI = ACE inhibitors, CCB = calcium channel blockers,
NRT = nicotine replacement therapy, SGLT2 = sodium glucose co-transporter2
References: Feigin VL et al,2 Hankey G et al6
Primary and secondary prevention of stroke
Primary prevention refers to the treatment of individuals with risk factors for stroke but have no prior history of stroke/TIA. Therapy focuses on the modification of risk factors. Secondary prevention refers to the treatment of patients who have had a stroke/TIA. The initiation of effective secondary prevention after stroke/TIA can reduce the risk of early recurrent stroke by 80%.6 Aspirin started as soon as intracerebral haemorrhage has been excluded reduces the rate and severity of stroke by 50% within the first 6–12 weeks.1,2 There is augmented benefit when clopidogrel is added in the short term for minor stroke or high-risk TIA (refer to section on dual antiplatelet therapy). The benefits of antiplatelets in secondary prevention for patients with a TIA or stroke are similar as the pathophysiology of TIA and stroke is the same.
Stroke prevention in patients with atrial fibrillation
AF is a leading cause of IS and is a condition where pharmacists can play a significant role in the appropriate use of medicines. Adherence and persistence strategies are particularly important in this population group. Targeted treatment of all patients with AF at increased risk of IS is imperative, and oral anticoagulants are highly effective at reducing stroke risk. Anticoagulation should be routinely offered to all patients with AF except those defined as having a very low stroke risk.7 Aspirin is not routinely recommended. Stroke risk can be estimated using scores such as the CHA2DS2-VA.7,8 Bleeding risk, using the HAS-BLED score should help focus on modifying reversible risk factors of bleeding rather than precluding the use of anticoagulants.7,8
Meta-analyses demonstrate a 60% reduction in the incidence of stroke and a 26% reduction in mortality when compared to placebo, if warfarin is used.9 Direct oral anticoagulants (DOACs) may offer additional reductions in stroke, mortality and bleeding when compared to warfarin, and have a simpler dosing regimen without the requirement for INR monitoring.8,10 Therefore, most guidelines now recommend DOACs in preference to warfarin for patients with non-valvular AF and adequate renal function.8,11 Warfarin is an appropriate alternative to DOACS in patients with moderate to severe renal impairment or valvular AF (mitral valve stenosis or mitral valve replacement). Important characteristics of anticoagulants available in Australia are summarised in Table 2.
Treatment algorithms for AF are presented in a number of publications and websites.8,11 Bleeding risk is always of concern, however, the risk of stroke invariably outweighs the risk of bleeding in the majority of patients.7,8,10 Strategies to reduce bleeding should be implemented where possible (see Box 1).7,8,11
Pharmacists should be aware of the common drug-drug interactions with both warfarin and the DOACs. Patient education is essential.
In AF patients who have undergone a percutaneous coronary intervention (PCI), careful consideration is required and antithrombotic therapy individualised to each patient. These patients can require a combination of one, or two anti-platelets with anticoagulant therapy. Current international guidelines have differing advice on this issue.12 In Australia, the National Heart Foundation has recently provided guidance.8 Factors such as the type, size and location of deployment of the stent, and presence of risk factors for bleeding are important in determining optimal treatment in this cohort.
BOX 1 – STRATEGIES TO REDUCE BLEEDING
↓ BP in hypertensive patients
↓ NSAID use
↓ Tobacco use
↓ Alcohol consumption
Initiate PPI
Monitor INR regularly if on warfarin
BP = blood pressure, NSAID = non-steroidal anti-inflammatory drug,
PPI = proton pump inhibitor, INR = international normalised ratio
References: NPS,7 National Heart Foundation,8 European Society of Cardiology11
TABLE 2 – Characteristics of oral anticoagulants used in atrial fibrillation for stroke prevention
Vitamin K antagonist
Factor Xa inhibitor
Direct thrombin inhibitor
Dosing frequency
Twice daily
Oral bioavailability (%)
% excreted unchanged in urine
Half-life in healthy volunteers (hours)
Highly variable 20-60
5-15 (mean=7)
Potential for drug interactions
CYP2C9, CYP1A2, CYP3A4 plus many others
PGP, CYP3A4
PGP, PPIs
Vitamin K (phytomenadione)
Idarucizumab
*Bioavailability reduced with increasing gastric pH
PPI = proton pump inhibitor, PGP = P-glycoprotein, CYP = cytochrome P450
References: MIMS,13 Chin P et al,14 Weidmann L et al,15 Bereznicki L16
Antiplatelets
Aspirin is not recommended in primary prevention. Its early justification had been extrapolated from its efficacy in secondary prevention of stroke.15 Three landmark studies demonstrate that there was no significant reduction in stroke in primary prevention, however, there was a higher risk of bleeding (Table 3).3-5 Two excellent reviews for pharmacists have been published recently by Rigby and Connell.17,18
Overall these trials informed us that aspirin for primary prevention is not routinely warranted. Notably, in all of these trials, almost half of the bleeding was gastrointestinal (GI),3-5 mainly upper GI, which can be reduced by the use of PPIs.
P2Y12 inhibitors – clopidogrel and ticagrelor
Evidence for clopidogrel originates from the CAPRIE study, a randomised controlled trial (RCT) designed to assess its efficacy versus aspirin in reducing cardiovascular (CV) events and death.20 In this study 5.3% of patients treated with clopidogrel had an IS compared with 5.7% of patients taking aspirin (RRR 8.7% p=0.043).20 The THEMIS is a large double-blind study (>20 000 patients) that is currently evaluating the effi cacy and safety of ticagrelor plus aspirin compared to aspirin monotherapy in primary prevention. Results are expected later this year.21 There have been no head-to-head trials investigating ticagrelor and clopidogrel monotherapy in primary prevention.
TABLE 3 – Important aspirin trials for primary prevention of stroke3-5
DURATION (YEARS)
HR FOR ALL-CAUSE MORTALITY (95% CI)
HR FOR STROKE (95% CI)
HR FOR BLEEDING (95% CI)
ASPREE
Double blind placebo controlled RCT
n = 19,114
Australia/US
Median follow up 4.7
1.14* (1.01–1.29), NS
0.89 (0.71–1.11), NS
1.38* (1.18–1.62), P<0.001
Mainly Germany/UK
Median follow up 5
0.99 (0.80– 1.24), NS
2.11* (1.36–3.28), p=0·0007
Mean follow up 7.4
1.29* (1.09–1.52), p=0.003
* Indicates aspirin worse than placebo, HR = hazard ratio, CI = confidence interval, n = number, RCT = randomised controlled trial,
US = United States, UK = United Kingdom, NS = not statistically significant
References: Gaziano JM et al,3 The ASCEND Study Collaborative Group,4 McNeil JJ et al5
Secondary prevention
Monotherapy
In patients without AF, antiplatelet therapy is a cornerstone for secondary prevention and is summarised in Table 4. These trials indicate that monotherapy with aspirin offers significant reductions in stroke compared to placebo, and adding dipyridamole or changing to clopidogrel or ticagrelor offers a small incremental benefit in terms of stroke recurrence.
Dual antiplatelet therapy (DAPT)
A meta-analysis on the MATCH, CHANCE and POINT studies showed that DAPT with clopidogrel and aspirin after TIA or IS reduces subsequent stroke by about 20 per 1,000 population, with an increase in bleeding of 2 per 1,000 population when compared with aspirin monotherapy.31 The authors concluded that the discontinuation of DAPT within 21 days, and possibly as early as 10 days, is likely to maximise benefit and minimise harm. In the first few days after TIA or IS, the underlying atherosclerotic plaque is most unstable and the risk of recurrent stroke is highest. Evidence for ticagrelor and aspirin as DAPT is currently unclear.
These studies indicate that either clopidogrel monotherapy or the combination of aspirin with dipyridamole should be used as first line long-term antiplatelet therapies. Aspirin should be commenced as soon as possible post imaging (to exclude an active bleed or confirm resolution of haemorrhage) and definitely within the first 48 hours.32 After this, aspirin plus clopidogrel may be used in the short term (3 weeks) to prevent early stroke recurrence in patients with low risk of haemorrhagic transformation of their IS (those with non-major strokes).31,33 This combination should not be used in severe stroke where there is an increase in the risk of haemorrhagic transformation of IS and should not be used long-term unless patients have other indications, for example recent PCI.31,33 If a patient re-presents with an IS while taking DAPT, they will require a full assessment of potential causes including adherence, evidence of undiagnosed AF and genetic resistance to clopidogrel. Further medication management would need to be discussed with a stroke team (and the patient) as evidence is lacking in this space.
Figure 1 represents the authors' local (Princess Alexandra Hospital) prescribing guidelines for antiplatelet agents post-acute stroke. Please note that other treatment guidelines/algorithms exist based on stroke definitions and severity. National Institutes of Health Stroke Scales (NIHSS) are often used to distinguish the severity of stroke.34
The COMPASS trial35 showed reduced stroke in a high risk primary prevention cohort without AF with low dose rivaroxaban 2.5 mg twice daily plus aspirin vs aspirin alone (HR 0.58, CI 0.44 to 0.76 P<0.0001), although the relevance of this is unclear to the Australian environment due to the unavailability of rivaroxaban 2.5 mg tablets and the uncertainty about the benefit of aspirin in this cohort. No clear difference was seen between the third arm of rivaroxaban 5 mg twice daily monotherapy when compared to aspirin monotherapy.35
TABLE 4 – Trials of antiplatelet agents in secondary prevention of stroke
MONOTHERPY
n = 40,821 with acute IS
Any antiplatelet
11% RRR composite of IS/MI/death in patients with acute stroke
P= 0.00002
n = 23,020 with prior IS/TIA
22% RRR composite of IS/MI/death for long term secondary prevention
P=0.0003
ESPS-2
n = 6,602 with prior IS/TIA
Aspirin with dipyridamole (A+D)
Either drug alone or placebo
18% RRR IS, aspirin vs placebo
37% RRR IS, (A+D) v placebo
P=0.013
P<0.001
n = 12,033 with prior IS
7% RRR in composite outcome of any stroke /MI/ death from any cause
8.7% RRR in IS, MI or vascular death
P=0.26
n = 13,199 with IS/TIA
11% RRR in composite outcome of IS/MI/death
14% RRR stroke
P = 0.07
P = 0.046
DUAL ANTIPLATELET THERAPY
20% RRR in a composite of CV death non-fatal stroke, non-fatal MI, bleeding complication
16% RRR in IS
p-value not stated
95% CI 0.66–0.98
95% CI (0.64-1.10)
Aspirin with dipyridamole
18% RRR IS Aspirin vs placebo
37% RRR IS (A+D) v placebo
n = 20,332 with IS
No difference in recurrent IS (HR = 1.01)
P value not stated
n = 7,599 with IS/TIA
Aspirin with clopidogrel
No difference in IS (HR = 1.00)
6.4% RRR in composite end point of IS, MI, vascular death or rehospitalisation for ischemic events
95% CI (-4.6% to 16.3%)
32% RRR in IS (8.2% vs 11.7%) after 90 days
n = 4,881 with stroke or TIA
25% RRR in IS (5% vs 6.5%) after 90 days
TRIPLE ANTIPLATELET THERAPY
n = 3,096 with IS/ TIA
Aspirin + Dipyridamole + clopidogrel
Clopidogrel OR Aspirin + Dipyridamole
RRR=10% but stopped early due to significantly increased risk of bleeding (RRI 154%)
P = 0.0001
RRR = relative risk reduction, RRI = relative risk increase, CV = cardiovascular, MI = myocardial infarction, IS = ischaemic stroke, TIA = transient ischaemic attack,
A+D = aspirin with dipyridamole, OR = odds ratio, CI = confidence interval, n = number, p = probability
References: Caprie Steering Committee,20 Antithrombotic Trialists Collaborative,22 Diener HC et al,23 Von Maxen A et al,24 Sacco R et al,25 Johnston SC et al,26 Diener HC et al,27 Wang Y et al,28 Johnston SC et al,29 Bath PM et al30
FIGURE 1 – Antiplatelet therapy following an acute stroke – example pathway
Modification of modifiable risk factors
The following is a summary of drug interventions for two key modifiable risk factors. All patients with a stroke or TIA should be assessed and strategies to modify risk factors should be introduced as soon as possible.
High blood pressure is a risk factor for CVD in general, but particularly for ICH and IS. It is the single most important modifiable risk factor. Most patients should take antihypertensives to achieve a BP <140/90 mmHg.36 Recent evidence for BP targets <140/80 mmHg comes from the SPRINT trial, which demonstrated that a systolic BP target of 120 mmHg reduced the incidence of stroke when compared to 140 mmHg.37 However, it is important to note that patients who had previously suffered a stroke had been excluded from the SPRINT trial, and the trial has been criticised for allowing automated unobserved BP monitoring, which is likely to lead to lower than clinic-based BP readings (treatment guidelines are based on clinic BP readings).32,38
ACE Inhibitors (ACEIs) are often advocated as first line agents.36 However, calcium channel blockers, and thiazide diuretics can also be used first-line.36 Choice of agent is dependent on comorbidities. In the absence of comorbidities, ACEIs are a good choice. Beta blockers are not recommended as first-line agents for hypertension: compared to other agents, there is a lack of benefit in stroke prevention.36
The use of statins in primary prevention is hotly debated but is generally based on an assessment of absolute CV risk. A US Task Force (which often informs Australian guidelines) has thoroughly reviewed this question recently and concluded that adults aged 40–75 years who do not have a history of CVD and a 10%–10-year risk of a CV event should be offered a low- to moderate-dose statin in primary prevention.39
For secondary prevention of stroke, cholesterol lowering reduces the risk of IS, and atorvastatin 80 mg daily showed significant benefits (absolute risk reduction for stroke was 2.2% over 5 years) compared to placebo.40 Guidelines recommend the use of high-dose statins and all patients with a reasonable life expectancy should be prescribed a high-potency statin, regardless of lipid levels.36 Many clinicians have concerns over whether elderly patients benefit from statins. This is a controversial area, however strong arguments exist not to withhold statins in the elderly, purely because of their age.41,42 All patients on high-dose statins should be monitored for adverse drug effects, such as muscle pain, and the dose reassessed accordingly, in particular in the setting of poor renal function.
The role of proprotein convertase subtilsin-kexin type 9 (PCSK9) inhibitors is evolving and may benefit patients with stroke, particularly those intolerant of statins.43
There are a number of other strategies that can help reduce the risk of stroke. Pharmacists play an important role in promoting and monitoring these strategies including: a diet high in fruits and grains and low in sodium and sugar; reduction in tobacco and alcohol consumption; good diabetes control; reduction in weight for obese patients; and regular exercise. Fish oil is unlikely to be of benefit.44,45
What's new in prevention and treatment of stroke?
Thrombolysis (alteplase, and more recently tenecteplase) is now established as an effective treatment if used within the appropriate timeframe, approximately 20% of patients are eligible.32,36 A recent study has suggested that the window of time that a thrombolytic agent can be administered may be extended in patients with ischaemic but not yet infarcted brain tissue, although reductions in neurological deficits were accompanied by increased risk of cerebral haemorrhage.46 There is currently a draft consultation open for discussion in the Australian guidelines to consider this.36 This treatment, in addition to endovascular thrombectomy, has led to the introduction of systems that maximise the benefits in a larger population of patients. Ambulance pre-assessment and pre-hospital triage are increasingly used in combination with mobile stroke teams. Public awareness is increasing, in particular with the advertising of the FAST acronym.32,36 Hospitals are now starting to employ pharmacists in their acute stroke teams and stroke units.47,48 In these settings, their duties include assessment for thrombolytic use, medication reconciliation, identification and resolution of drug therapy problems, risk-factor reduction, and patient education.47-49 There is evidence that pharmacists in these roles reduce the incidence of recurrent strokes.43
Key roles for pharmacists in the primary prevention of stroke revolve around rationalising the inappropriate use of antiplatelets and increasing the use of and adherence to anticoagulants. In addition, optimising modifiable risk factors is a vital role and can be done in both community, clinic and hospital settings.
The roles for pharmacists in secondary prevention include ensuring medication adherence, optimising blood pressure management, assisting patients with smoking cessation, recommending step down of DAPT where appropriate and considering gastroprotection in high-risk patients.
As the most accessible healthcare practitioners in Australia, pharmacists also play an important role in educating consumers on early identification of stroke.
As part of your HMR, you confirm that Jack does not suffer from AF. He tells you that he often forgets to take his tablets, which hasn't been an issue in the past. You are concerned that Jack's dizzy spells and low blood pressure may result in syncopal episodes. In your recommendation to his doctor, you suggest that Jack down titrates and ceases his atenolol. You recommend that he continues taking clopidogrel 75 mg daily and atorvastatin 40 mg daily, with a potential consideration to increase atorvastatin to 80 mg daily if tolerated. BP, lipid levels, U+Es and LFTs should be monitored routinely. Jack should be provided with both verbal and written education.
Jack may have some cognitive deficit as a result of his stroke. He may benefit from a dose administration aid. You advise him that, should he wish, this can be organised for him. Jack feels that this may help him remember to take his tablets and thanks you for your time.
Stroke is increasingly common and often fatal or disabling to survivors. It is a leading cause of mortality and morbidity in Australia. As such, stroke care is undergoing a revolution that includes new therapies for its primary and secondary prevention. Pharmacists are integral to the selection of appropriate regimens, individualised to each patient. Risk factor modification is essential to reduce the incidence of first and recurrent stroke, and proactive intervention by pharmacists will help reduce stroke burden.
Direct-acting anticoagulants (DOACs) largely replaced warfarin in AF due to comparable or greater efficacy and greater ease of use.
Pharmacists can play a vital role in stroke risk-factor modification and monitoring.
Aspirin should no longer be routinely recommended in primary prevention.
Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor may be appropriate post ischaemic stroke but only in the first few weeks.
Australian Institute of Health and Welfare 2018. Canberra: AIHW. At: aihw.gov.au/getmedia/fe037cf1-0cd0-4663-a8c0-67cd09b1f30c/aihw-aus-222.pdf.aspx?inline=true
Feigin VL, Roth GA, Naghavi M, et al. Global burden of stroke and risk factors in 188 countries, during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet Neurol 2016;15:913–24. At: https://www.ncbi.nlm.nih.gov/pubmed/27291521
Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 2018;392(10152):1036–46. At: https://www.ncbi.nlm.nih.gov/pubmed/30158069
The ASCEND Study Collaborative Group, Bowman L, et al. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med 2018;379(16):1529–39. At: https://www.nejm.org/doi/full/10.1056/NEJMoa1804988
McNeil JJ, Nelson MR, Woods RL, et al. Effect of aspirin on all-cause mortality in the healthy elderly. N Engl J Med 2018;379(16):1519–28. At: https://www.nejm.org/doi/full/10.1056/NEJMoa1803955
Hankey G, Blacker D. Is it a stroke? BMJ 2015;350:h56. At: https://www.ncbi.nlm.nih.gov/pubmed/25591946
National Prescribing Service (NPS) MedicineWise. Predicting risk with oral anticoagulants. 2017. At: nps.org.au/news/predicting-risk-with-oral-anticoagulants
National Heart Foundation of Australia. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018. At: heartfoundation.org.au/for-professionals/clinical-information/atrial-fibrillation
Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have non-valvular atrial fibrillation. Ann Intern Med 2007;146:857–67. At: https://www.ncbi.nlm.nih.gov/pubmed/17577005
Bereznicki L. Chronic Disease Management: An update on atrial fibrillation. Australian Pharmacist 2018;37(10):30–6. At: https://www.australianpharmacist.com.au/atrial-fibrillation-update/
European Society of Cardiology (ESC). Atrial Fibrillation (Management of) Guidelines. ESC Clinical Practice Guidelines 2016. At: escardio.org/Guidelines/Clinical-Practice-Guidelines/Atrial-Fibrillation-Management
Lip G et al. Management of antithrombotic therapy in AF patients presenting with ACS and/or undergoing PCI. Eur Heart J 2018;39 (31):2847–50. At: https://www.ncbi.nlm.nih.gov/pubmed/30137444
Sydney: MIMS Australia; 2019. At: http://www.mims.com.au/
Chin P, Doogue M. Long term prescribing of new oral anticoagulants. Aust Prescr 2016;39(6):200–4. At: https://www.nps.org.au/australian-prescriber/articles/long-term-prescribing-of-new-oral-anticoagulants
Weidmann L, Obeid S, Mach F, et al. Pre-existing treatment with aspirin or statins influences clinical presentation, infarct size and inflammation in patients with de novo acute coronary syndrome. Int J Cardiol 2019;275:171–8. At: https://www.ncbi.nlm.nih.gov/pubmed/30344063
Bereznicki L. Stroke prevention in atrial fibrillation. Novel anticoagulants. Australian Pharmacist 2013;32(4):64–9. At: https://www.australianpharmacist.com.au/
Rigby D. Aspirin Who needs it? AJP 2019;100(1182):66–70. At: https://ajp.com.au/cpd/medication-in-review/
Connell C. CPD: Medicines update: aspirin use in healthy elderly people. Australian Pharmacist 2019;38(2):44–50. At : https://www.australianpharmacist.com.au/aspirin-use-healthy-elderly-people/
Szabo IL, Matics R, Hegyi P, et al. PPIs prevent aspirin-induced gastrointestinal bleeding better than H2RAs. A systematic review and meta-analysis. J Gastrointestin Liver Dis 2017;26(4):395–402. At: https://www.ncbi.nlm.nih.gov/pubmed/29253055
CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996;348 (9038):1329–39. At: https://www.ncbi.nlm.nih.gov/pubmed/8918275
Bhatt DL, Fox K, Harrington RA, et al. Rationale, design and baseline characteristics of the effect of ticagrelor on health outcomes in diabetes mellitus patients Intervention study. Clin Cardiol 2019;42(5):498–505. At: https://www.ncbi.nlm.nih.gov/pubmed/30788847
Antithrombotic Trialists Collaborative (ATT). Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002;324(7329):71–86. At: https://www.ncbi.nlm.nih.gov/pubmed/11786451
Diener HC, Cunha L, Forbes C, et al. European stroke prevention study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J. Neurol. Sci 1996;143(1–2):1–13. At: https://www.ncbi.nlm.nih.gov/pubmed/8981292
VonMaxen A, Wille H, Schoenhoefer P. Aspirin plus dipyridmole versus aspirin alone after cerebral ischaemia of arterial origin (ESPIRIT Trial). Lancet 2006;367:1665–73. At: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69147-2/fulltext
Sacco R, Diener HC, Yusuf S, et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke. N Engl J Med 2008;359(12):1238–51. At: https://www.ncbi.nlm.nih.gov/pubmed/18753638
Johnston SC, Amarenco P. Ticagrelor versus aspirin in acute stroke or transient ischemic attack. N Engl J Med 2016;375(14):1395. At: https://www.ncbi.nlm.nih.gov/pubmed/27160892
Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (match): randomised, double-blind, placebo-controlled trial. Lancet 2004;364(9431):331–337. At: https://www.ncbi.nlm.nih.gov/pubmed/15276392
Wang Y, Wang Y, Zhao X, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med 2013;369(1): 11–9. At: https://www.ncbi.nlm.nih.gov/pubmed/23803136
Johnston SC, Easton JD, Farrant M, et al. Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA.N Engl J Med 2018;379(3):215–25. At: https://www.nejm.org/doi/full/10.1056/NEJMoa1800410
Bath PM, Woodhouse LJ, Appleton JP, et al. Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial. Lancet 2018;391(10123):850–9. At: https://www.ncbi.nlm.nih.gov/pubmed/29274727
Hao Q, Tampi M, O'Donnell M, et al. Clopidogrel plus aspirin versus aspirin alone for acute minor ischaemic stroke or high risk transient ischaemic attack: systematic review and meta-analysis. BMJ 2018;363:k5108. At: https://www.bmj.com/content/363/bmj.k5108
Campbell CV. Advances in stroke medicine. Med J Aust 2019;210(8):367–74. At: https://www.mja.com.au/journal/2019/210/8/advances-stroke-medicine
Prasad K, Siemieniuk R, Hao Q, et al. Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline. BMJ 2018;363:k5130. At: https://www.ncbi.nlm.nih.gov/pubmed/30563885
NIH Stroke Scale. 2003. At: stroke.nih.gov/documents/NIHStrokeScale.pdf
Sharma M, Hart RG, Connolly SJ, et al. Stroke outcomes in the COMPASS trial. Circulation 2019;139(9):1134–45. At: https://www.ncbi.nlm.nih.gov/pubmed/30667279
Stroke foundation. Clinical Guidelines for Stroke Management. 2017. At: https://informme.org.au/Guidelines/Clinical-Guidelines-for-Stroke-Management
SPRINT research group, Wright JT Jr, Williamson JD, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373(22): 2103–16. At: https://www.nejm.org/doi/full/10.1056/NEJMoa1511939
Drawz P, Ix J. BP measurement in clinical practice: time to SPRINT to guideline-recommended protocols. J Am Soc Nephrol 2018; 29(2):383–8. At: https://www.ncbi.nlm.nih.gov/pubmed/29051347
US Preventive Services Task Force. Statin use for the primary prevention of cardiovascular disease in adults: preventive medication draft recommendation statement. 2015. At: uspreventiveservicestaskforce.org/Page/Document/draft-recommendationstatement175
Amarenco P, Bogousslavsky J, Callahan A 3rd, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006;355(6):549–59. At: https://www.ncbi.nlm.nih.gov/pubmed/16899775
Cholesterol Treatment Trialists' Collaboration. Efficacy and safety of statin therapy in older people: a meta-analysis of individual participant data from 28 randomised controlled trials. Lancet 2019;393(10170):407–15. At: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31942-1/fulltext
Winckel K. An argument to continue statins for secondary prevention in the elderly. Australian Pharmacist 2016;35(6):66–7. At: https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-016-0505-0
Castilla-Guerra L, Fernandez-Moreno MC, Rico-Corral MA. Cholesterol and stroke: role of PCSK9 inhibitors. Neurologia 2019;34 (3):198–203. At: https://www.ncbi.nlm.nih.gov/pubmed/28549755
Rizos EC, Ntzani EE, Bika E, et al. Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events. A systematic review and meta-analysis. JAMA 2012;308 (10):1024–33. At: https://www.ncbi.nlm.nih.gov/pubmed/22968891
Abdelhamid AS, Martin N, Bridges C, et al. Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2018, Issue 11. At: https://www.ncbi.nlm.nih.gov/pubmed/30019767
Ma H, Campbell BCV, Parsons MW, et al. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med 2019;380(19):1795– 1803. At: https://www.nejm.org/doi/full/10.1056/NEJMoa1813046
Rech MA, Bennett S, Donahey S. Pharmacist participation in acute ischemic stroke decreases door-to-needle time to recombinant tissue plasminogen activator. Ann Pharmacother 2017;51(12):1084–89. At: https://www.ncbi.nlm.nih.gov/pubmed/28759998
Andres J, Stanton-Ameisen O, Walton S, et al. Pharmacists' impact on secondary stroke prevention. J of Pharm Pract 2019;32(5):503–508. At: https://www.ncbi.nlm.nih.gov/pubmed/29591369
Basaraba JE, Picard M, George-Phillips K, et al. Pharmacists as care providers for stroke patients: a systematic review. Can J Neurol Sci 2018;45(1):49–55. At: https://www.ncbi.nlm.nih.gov/pubmed/28929979
A/PROF MICHAEL BARRAS BPharm, GradDipclinpharm, PhD, AdvAccredPharm, FSHP is the Deputy Director of Pharmacy (Clinical) at the Princess Alexandra Hospital and a Research Conjoint at the School of Pharmacy, The University of Queensland.
KARL WINCKEL BPHARM, GradCertClinPharm, GradDipPharmPrac, GradCertTherap, GradCertHighEd is a Senior Pharmacist at the Princess Alexandra Hospital and Conjoint Lecturer at The University of Queensland.
Conflicts of interest: Karl has delivered educational sessions for PSA in partnership with Boehringer Ingelheim.
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Hypertension is a significant burden on the Australian healthcare system. In 2017 to 2018, close to 6.3 million adult Australians reported having measured high blood pressure (BP), hypertension as a medical condition or the use of antihypertensive medicines.1
Discuss current guidelines for the management of hypertension
Explain the importance of absolute cardiovascular risk assessment in guiding hypertension treatment decisions
Describe the role of the pharmacist in supporting patients with hypertension, including monitoring and referral when indicated
Competencies standards addressed (2016): 1.1, 1.3, 1.6, 2.3, 2.4, 3.1, 3.5, 3.6
Management of hypertension is a key component of risk factor modification in both primary and secondary prevention of cardiovascular disease (CVD) and end organ damage.2,3 The high prevalence of hypertension means that it is often managed in the setting of additional co-morbid conditions, requiring judicious use of the wide range of available hypertension treatment options.
This article will discuss the management of hypertension in the context of absolute cardiovascular risk and primary prevention. Recommendations for non-pharmacological and pharmacological antihypertensive management from key Australian cardiology guidelines will be explored, with consideration of treatment strategies and options in the setting of co-morbid conditions. Finally, this article will explore the role of the pharmacist in the treatment of hypertension with regards to medication safety, monitoring and patient education.
Hypertension and Absolute Cardiovascular Risk
'Prevention is better than cure' is a claim made with respect to many facets of life, including healthcare. Primary prevention – any work that is done to prevent the first instance of a disease or condition – requires careful consideration of predicted risk compared to predicted benefits. Increasingly, sophisticated methods are being developed to enable prediction, or calculate the likelihood of CVD incidence for an individual based on a set of confirmed risk factors. This approach, known as absolute risk, has been adopted as best practice in Australian2 and international guidelines4,5 for the prevention of CVD. Moderated reductions in several risk factors may be more effective than a large reduction in an isolated risk factor.⁶
In Australia, the National Vascular Disease Prevention Alliance (NVDPA) has developed an absolute cardiovascular risk algorithm,⁷ which is recommended for use in adults over 45 years and Aboriginal and Torres Strait Islander (ATSI) adults over 35 years, without known CVD. This tool calculates an individual's probability of a CVD event in the next five years. The parameters used in this calculation are listed in Box 1. Consideration of additional risk factors including family history, social history and alcohol intake aid the final assessment of risk. The NVDPA 2012 Guidelines for Management of Absolute Cardiovascular Risk then stratify management strategies for risk factor modification, including management of hypertension, based on an individual's level of absolute cardiovascular risk.2 A comprehensive list of risk factor considerations can be accessed via the website for the NVDPA absolute cardiovascular risk assessment.⁷
BOX 1 – PARAMETERS FOR ABSOLUTE CARDIOVASCULAR RISK CALCULATION
Smoking status
Presence of diabetes
Cholesterol (HDL ratio)
Systolic BP
Reference: NVDPA7
In the NVDPA 2012 guidelines, the intensity of risk factor management increases with increasing absolute risk.2 The management strategies for hypertension may vary for individuals that present with similar BP readings, but with different absolute cardiovascular risk profiles. The goal of the absolute risk approach is to reduce the level of absolute CVD risk by managing multiple risk factors concurrently, rather than any one factor in isolation.
Blood pressure monitoring and targets
Diagnostic categories of hypertension according to the National Heart Foundation of Australia (NHFA) are given in Table 1.
TABLE 1 – Classification of clinic blood pressure levels in adults
DIAGNOSTIC CATEGORY*
SYSTOLIC (mmHg)
DIASTOLIC (mmHg)
High-normal
Grade 1 (mild) hypertension
Grade 2 (moderate) hypertension
Grade 3 (severe) hypertension
Isolated systolic hypertension
* When a patient's systolic and diastolic blood pressure levels fall into different categories, the higher diagnostic category and recommended actions apply. Reproduced with permission from Guideline for diagnosis and management of hypertension in adults 2016.
©2016 National Heart Foundation of Australia
Reference: National Heart Foundation3
Improvements in BP measurement technology have resulted in a variety of available BP-monitoring techniques including: traditional clinic BP monitoring, home monitoring and ambulatory, 24-hour BP monitoring. Clinic BP measurement can be subject to error and variation, and may not be sufficient in the accurate diagnosis and ongoing management of hypertension.3 Home and ambulatory BP monitors might assist, but measurements out of clinic are not recommended for use in assessing CVD risk as they might underestimate risk.3 The use of finger or wrist BP monitors are not currently recommended.3 The availability and expertise of pharmacists is important in providing regular BP measurement and appropriate training on BP measurement techniques with home or ambulatory devices.
BP targets may be individualised depending on cardiovascular risk and adverse effects from pharmacotherapy. The target in patients with uncomplicated hypertension (i.e. hypertension that is uncomplicated by other comorbidities such as heart failure and chronic renal failure) is 140/90 mmHg or lower, if tolerated (Figure 1).3 In patients with high cardiovascular risk, a more intensive target of less than 120 mmHg systolic BP can be considered by the treating physician; close monitoring for symptomatic hypotension and medication adverse effects is required.3
FIGURE 1 – Treatment strategy for patients with newly diagnosed hypertension.
Lifestyle modifications and non-pharmacological techniques are important components for the management of hypertension and absolute cardiovascular risk. Smoking cessation, dietary changes, reduction in alcohol intake and habitual physical activity have all been demonstrated to have measurable effects on BP readings. Additionally, medical conditions responsible for secondary hypertension, such as obesity or obstructive sleep apnoea, may be managed with lifestyle modifications rather than medicines. Pharmacological management of hypertension is often initiated while the causative medical condition is being addressed through other means. Highlighting the potential impact of non-pharmacological management on BP readings during medication counselling may assist the patient in making meaningful change.
Smoking cessation reduces BP, heart rate and an individual's probability of a CVD event.⁸ A study of 39 normotensive men compared heart rate and BP measurements made after one week of smoking compared to one week of smoking abstinence.⁹ During the week of abstinence, plasma noradrenaline and adrenaline were reduced, day time BP was reduced by 3.5±1.1 mmHg systolic (P<0.01) and by 1.9±0.7 mmHg diastolic (P<0.05) and heart rate was reduced by 7.3±1.0 beats/min (P<0.0001).
Dietary sodium restriction reduces both systolic and diastolic BP, however there is insufficient evidence that this translates to any improvement in cardiovascular outcomes.10 A recent systematic review found that in Caucasian and Asian populations with hypertension, low sodium intake reduced systolic BP by 5.5 mmHg and 7.75 mmHg respectively.11 This review also found that in both normotensive and hypertensive individuals with a sodium restricted diet; renin, aldosterone, noradrenaline, adrenaline, cholesterol and triglycerides were increased.11
The influence of sodium on BP is blunted by potassium. One study of the effects of dietary potassium reported that an increase in dietary potassium in patients with hypertension reduced systolic BP by 4–8 mmHg, however there is no evidence that this translates to any improvement in cardiovascular outcomes.12 The recommended daily dietary intake of potassium varies depending on life stage and gender. A healthy, adult male requires 3800 mg/day (100 mmol) and a healthy, adult female (not pregnant or breastfeeding) requires 2800 mg/day (72 mmol).13
To put this into context: half a cup of sweet potatoes contains about 475 mg of potassium and a medium banana contains about 420 mg of potassium. Too much potassium is dangerous in patients with chronic kidney disease as well as those taking angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), mineralocorticoid receptor antagonists (e.g. spironolactone, eplerenone) and other medicines that increase serum potassium.14 Many patients with hypertension are prescribed agents that can increase serum potassium, dietary potassium changes should be discussed and monitored by a general practitioner before being implemented.
The Dietary Approaches to Stop Hypertension (DASH) eating plan involves increasing fruits and vegetables and reducing saturated and total fat consumption. This eating plan has been found to reduce BP in normotensive and hypertensive subjects by 3.5–2.1 mmHg and 11.4–5.5 mmHg.15
Alcohol consumption increases BP by several mechanisms, including activation of the renin-angiotensinaldosterone system and release of a potent vasoconstrictor–endothelin. BP can be raised by up to 10 mmHg depending on the amount of alcohol consumed.16
In healthy people consuming less than or equal to two standard drinks a day, any transient increase in BP from alcohol intake does not translate to an increase in cardiovascular risk.16
Australian guidelines suggest that physical activity can reduce BP and cardiovascular risk.2,3 Habitual physical activity, in the form of aerobic exercise, on average, reduces systolic BP by 7 mmHg and diastolic BP by 6 mmHg.17 Patients taking antihypertensive medicines, or with uncontrolled hypertension at rest, should speak with their doctor or exercise physiologist before increasing their daily activity.
A healthy body mass index (BMI) and waist circumference should be the aim of all patients with hypertension. Weight loss in adults with a BMI greater than 35 kg/ m2 reduces BP.18 A weight loss of 1 kg can reduce both systolic and diastolic BP by 1 mmHg. A 5 kg loss was found to reduce systolic and diastolic BP by 7 mmHg and 3 mmHg respectively; and a 10 kg loss was found to reduce systolic and diastolic BP by 13 mmHg and 7 mmHg respectively.18
Emerging evidence suggest that meditation, in the form of mindfulness, transcendental meditation and Zen meditation, can reduce BP. The clinical relevance of these studies is difficult to assess, as uniformity and standardisation of this intervention is difficult to establish. One review/study reported that meditation can reduce systolic and diastolic blood pressure by up to 12.7 mmHg and 8.1 mmHg respectively.19
Pharmacotherapy in hypertension
Treatment strategies
Effective pharmacotherapy of hypertension requires judicious selection of agents, dose, and treatment target. This is followed by monitoring for efficacy (and adverse effects), adjustment of doses and where indicated, prescription of additional agents. A strategy recommended by the 2016 NHFA Guidelines for the Diagnosis and Management of Hypertension in Adults is summarised in Figure 2. In some cases, it may be appropriate to consider initiation of treatment with combination therapy.3 Additionally, other co-morbid conditions may guide the intensity or aggressiveness of the strategy chosen to reach BP targets. Examples include aggressive control of BP in aortic dissection, compared to cautious titration of antihypertensive agents in frail and elderly patients.
FIGURE 2 – Drug treatment strategy to reach blood pressure target
Pharmacotherapeutic agents
The focus of antihypertensive treatment is the reduction of CVD risk and end organ damage in both primary and secondary prevention settings. The consensus of various hypertension guidelines on the comparative benefits of different classes of antihypertensive agents has evolved over the past decade.3,20 The clinical benefits of antihypertensive treatment are now largely considered to be due to the blood pressure lowering effect, independent of medication class or action, as found in several meta-analyses.21-23
ACE inhibitors, ARBs, calcium channel blockers and thiazide diuretics can be considered in the first-line management of uncomplicated hypertension.3 Beta blockers are less effective and are no longer recommended as first-line therapy.3 Differences in more specific outcomes have been demonstrated between classes. Delaying or preventing the onset of diabetes, renal nephropathy, ischaemic heart disease and heart failure make some agents more suitable than others when treating hypertension in the presence of certain comorbidities (Table 2).22-24
Adherence to pharmacotherapy differs between the classes of antihypertensive agents.24,25 Precautions, contraindications, tolerability and cost are important considerations prior to and during pharmacotherapy. Certain drug combinations should be avoided due to an unfavorable balance between efficacy and safety.26,27
TABLE 2 – Classes of antihypertensive treatment agents and their place in clinical practice according to key guidelines
PHARMACODYNAMICS
PLACE IN CLINICAL PRACTICE
Captopril
Quinapril
Trandolapril
Reduce blood pressure by reducing vasoconstriction, sodium reabsorption and aldosterone release through inhibition of conversion of angiotensin-1 to angiotensin-2, and subsequent reduction of angiotensin-2-induced effects.14
ACE inhibitors also inhibit the breakdown of bradykinin, commonly resulting in a persistent dry cough.14
ACE inhibitors are considered a suitable first-line option for the treatment of hypertension that is uncomplicated by other co-morbidities.3
ACE inhibitors (or ARBs) are recommended as first-line hypertension therapy in patients with chronic kidney disease (CKD) with micro or macro albuminuria.3
ACE inhibitors are recommended for secondary prevention of ischaemic heart disease (IHD) in patients with certain concurrent indications, including hypertension.32
ACE inhibitors are recommended in patients with heart failure (HF) with reduced left ventricular ejection fraction (LVEF), in order to reduce mortality and hospitalisation.33
ARBs
Candesartan
Eprosartan
Olmesartan
Reduce blood pressure by reducing vasoconstriction, sodium reabsorption and aldosterone release through competitive antagonism of type 1 angiotensin-2 receptors, and subsequent reduction of angiotensin-2-induced effects.14
ARBs do not inhibit bradykinin breakdown and are therefore often used as an alternative to ACE inhibitors if a patient experiences a persistent, dry cough with ACE inhibitor therapy.14
ARBs are considered a suitable first-line option for the treatment of hypertension that is uncomplicated by other co-morbidities.3
ARBs (or ACE inhibitors) are recommended as first-line hypertension therapy in patients with CKD with micro or macro albuminuria.3
ARBs are inferior to ACE inhibitors in the prevention of IHD,22 and in reduction of mortality in patients with HF.34 However, it is reasonable to use ARBs instead of ACE inhibitors in this population if there is an intolerance to ACE inhibitors (caution in angioedema).3,14
Thiazide diuretics
Thiazide-related diuretics
Chlortalidone Indapamide
Induce diuresis via inhibition of sodium and chloride reabsorption in the distal convoluted tubule of the nephron, with additional increased potassium excretion.14
Antihypertensive effects at low doses are hypothesised to be the result of various direct and indirect vasodilatory actions, with no clear consensus for the mechanism thiazide-induced vasodilation.35
Thiazide (and thiazide-related) diuretics are considered a suitable first-line option for treatment of hypertension that is uncomplicated by other comorbidities.3 However, thiazide diuretics are associated with an increased risk of diabetes onset, requiring careful consideration of this risk against the benefit gained from managing hypertension in the context of patient age.3,36
In practice, thiazide diuretics do not often end up being first-line agents in treating hypertension in co-morbid conditions such as CKD, IHD, HF and atrial fibrillation. This is due to the preference of other agents (such as ACE inhibitors, ARBs and beta blockers) for the treatment and secondary prevention of the co-morbid condition.3,32,33,37
Dihydropyridines:
Clevidipine
Nifodepine
Nimodepine
Non-dihydropyridines:
Reduce blood pressure by reduction of peripheral vascular resistance through reduction of calcium influx into smooth muscle.14 This effect is seen in arteriolar smooth muscle with dihydropyridine calcium channel blockers, and, to a lesser extent, diltiazem.14
Non-dihydropyridine calcium channel blockers (diltiazem and verapamil) also have this effect on cardiac smooth muscle, resulting in; reduction of heart rate, cardiac contractility, myocardial oxygen requirements and angina symptoms.14
Calcium channel blockers are considered a suitable first-line option for the treatment of hypertension that is uncomplicated by other co-morbidities.3 The combination of calcium channel blockers with ACE inhibitors is superior to either ACE inhibitors with diuretics or beta-blockers with diuretics for the reduction of cardiovascular events and mortality in the treatment of uncomplicated hypertension.38,39
In practice, calcium channel blockers do not often end up being first-line agents for monotherapy in treating hypertension in co-morbid conditions such as CKD, IHD and HF. This is due to the preference of other agents (such as ACE inhibitors, ARBs and beta blockers) for the treatment and secondary prevention of the co-morbid condition.3,32,33
Conversely, non-dihydropyridine calcium channel blockers are a first-line option for rate control in the treatment of atrial fibrillation (in patients without heart failure).37 Thus, treatment of hypertension in this population should be balanced with and account for the antihypertensive effects of rate control agents already employed.
Oxprenolol
Pindolol
Reduce blood pressure mainly by reduction of cardiac output via antagonism of beta-1 adrenoreceptors on cardiac tissue. Antagonism of beta-1 adrenoreceptors causes reductions in heart rate, cardiac contractility, cardiac conduction and relaxation rate.14
Additionally, beta-blockers can antagonize peripherally located beta-2 adrenoreceptors accounting for a myriad of additional, non-cardiac physiological effects.14 Finally, carvedilol and labetalol also antagonize peripheral alpha-1 receptors, causing additional antihypertensive effects from vasodilation.14
Differences in the selectivity of individual beta-blockers for the different types of adrenoreceptors account, for the most part, for the preference of certain betablockers in certain clinical conditions, and the variation in side-effect profiles.
Beta-blockers are not recommended as a first-line option for the treatment of hypertension that is uncomplicated by other co-morbidities, due to the unfavourable balance between safety and efficacy.3
However, selected beta-blockers are recommended for:
secondary prevention of ischaemic heart disease in patients with reduced LVEF.32
management of heart failure in patients with moderately or severely reduced LVEF (may be considered in patients with mildly reduced LVEF).33
a first-line option for rate control in the treatment of atrial fibrillation with co-morbid heart failure (alternative beta-blockers are considered suitable in the absence of heart failure).37
Thus, the treatment of hypertension in the co-morbid populations listed above should be balanced with and account for the antihypertensive effects of agents used for management and secondary prevention of the relevant co-morbid condition.
Selected beta-blockers: carvedilol, bisoprolol, slow-release metoprolol and nebivolol.3
Combination pharmacotherapy
When BP targets are not met after three months of monotherapy (at a low to moderate dose), a second agent should be commenced (Figure 2, p36).3 If blood pressure targets continue to be evasive on the maximum dose of two antihypertensive medicines, a third agent should be introduced.3 Co-formulations of antihypertensive medicines may improve medication adherence and have the potential to reduce cost to the patient. Pharmacists are well placed to advise both patients and doctors on the availability of co-formulations (see Table 3).
Some antihypertensive combinations have the potential to reduce adverse effects and counter any negative physiological response by the body to otherwise increase BP.28,29 Both ACE inhibitors and ARBs block the release of aldosterone and counteract the release of renin that results from diuretics.28 Peripheral oedema caused by calcium channel blockers can be prevented in some patients with ACE inhibitors or ARBs.28 Diuretics can prevent or reduce fluid retention caused by many vasodilators.28
Some combinations of antihypertensives should be avoided due to an unfavourable balance between efficacy and safety. Combinations of ACE inhibitors and ARBs are not recommended due to the increased risk of renal failure, hyperkalaemia and symptomatic hypotension.26-28 Combinations of non-dihydropyridine calcium channel blockers (e.g. diltiazem, verapamil) with beta-blockers significantly increase the risk of bradycardia and atrio-ventricular block.28
Combinations of calcium channel blockers with ACE inhibitors or ARBs are superior in reducing cardiovascular morbidity and mortality, whilst producing similar BP reductions, compared to alternative combinations in patients with hypertension.30 A 2016 meta-analysis found that the combination of calcium channel blockers and ACE inhibitors or ARBs were superior to alternative combinations for the reduction of BP and mortality in patients with hypertension and type 2 diabetes mellitus.31 Co-formulations of these combinations are available in Australia (see Table 3) as a result of growing evidence to support their use.
TABLE 3 – Co-formulation of antihypertensive medicines available in Australia
Angiotensin Receptor Blocker Combinations
Angiotensin Converting Enzyme Inhibitor Combinations
+amlodipine
Sevikar
+hydrocholorthiazide
Enalapril/HCT, Sandoz, Renitec Plus
Hydrene
Olmetec Plus
+lercanidipine
Zan-Extra
Kaluril
+hydrochlorothiazide
Sevikar HCT
Monopril
Fosipril
Fosetic
Exforge
Co-Diovan
Coveram
Exforge HCT
+Indapamide
Atacand Plus
Accuretic
Teveten
Tritace
Teveten Plus
+felodipine
Triasyn
Avapro, Karvea
Gopten
Avapro HCT, Karvezide
+verapamil
Pritor/Amlodipine, Twynsta
Micardis Plus
Reference: AMH14
Pharmacists can provide valuable advice to prescribers on the safety and efficacy of antihypertensive medicines, especially in the context of prescribing for patients with comorbidities.
Patient counselling on the safe use of antihypertensive medicines remains a core aspect of patient care. Pharmacists can encourage compliance, help manage adverse effects and interactions, and communicate treatment strategies and the latest recommendations for absolute cardiovascular risk. Helping patients to understand the approach of absolute cardiovascular risk, as opposed to treating isolated risk factors, could have an important impact on the success of treatment strategies. Helping a patient understand the importance of BP control, lifestyle modifications and pharmacotherapy may empower patients to adhere to prescribed treatment plans.
The management of hypertension is based on the assessment of a combination of risk factors, including absolute cardiovascular risk and existing comorbidities. Treatment options vary between individuals and often requires a multi-modal approach.
Angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers and thiazide diuretics can be considered in the first-line management of uncomplicated hypertension.
Beta blockers are no longer recommended as first-line therapy in the treatment of uncomplicated hypertension.
Absolute cardiovascular risk is important but not the only factor required to inform treatment options in hypertension.
Australian Bureau of Statistics. Hypertension and measured high blood pressure. 2018. At: abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.001~2017-18~Main%20Features~Hypertension%20and%20measured%20high%20blood%20pressure~60
National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. Melbourne: National Stroke Foundation; 2012. At: http://cvdcheck.org.au/pdf/AbsoluteCVDRiskFullGuidelines.pdf
National Heart Foundation. Guideline for the diagnosis and management of hypertension in adults – 2016. Melbourne: National Heart Foundation of Australia; 2016. At: heartfoundation.org.au/images/uploads/publications/PRO-167Hypertension-guideline-2016WEB.pdf
Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts): Developed with the special contribution of the European Association for Cardiovascular Prevention and Rehabilitation. Europ J Prev Cardiol 2016;23(11):NP1–NP96. At: https://www.ncbi.nlm.nih.gov/pubmed/27222591
Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129(25 Suppl 2):S49–73. At: https://www.ncbi.nlm.nih.gov/pubmed/24222018
Jackson R, Lawes CM, Bennett DA, et al. Treatment with drugs to lower blood pressure and blood cholesterol based on an individual's absolute cardiovascular risk. Lancet 2005;365(9457):434–41. At: https://www.ncbi.nlm.nih.gov/pubmed/15680460
National Vascular Disease Prevention Alliance. Australian absolute cardiovascular risk calculator 2012. At: cvdcheck.org.au/
Gratziou C. Respiratory, cardiovascular and other physiological consequences of smoking cessation. Curr Med Res Opin 2009;25(2):535–45. At: https://www.ncbi.nlm.nih.gov/pubmed/19193001
Minami J, Ishimitsu T, Matsuoka H. Effects of smoking cessation on blood pressure and heart rate variability in habitual smokers. Hypertension 1999;33(1 Pt 2):586–90. At: https://www.ncbi.nlm.nih.gov/pubmed/9931170
Adler AJ, Taylor F, Martin N, et al. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane database of systematic reviews 2014, Issue 12. At: https://www.ncbi.nlm.nih.gov/pubmed/25519688
Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride. Cochrane database of systematic reviews 2017, issue. At: https://www.ncbi.nlm.nih.gov/pubmed/22071811
Lawton WJ, Fitz AE, Anderson EA, et al. Effect of dietary potassium on blood pressure, renal function, muscle sympathetic nerve activity, and forearm vascular resistance and flow in normotensive and borderline hypertensive humans. Circulation 1990;81(1):173–84. At: https://www.ncbi.nlm.nih.gov/pubmed/2297825
National Health and Medical Research Council. Potassium. Canberra: NHMRC; 2006. At: nrv.gov.au/sites/default/files/content/n35-potassium0.pdf
Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997;336(16):1117–24. At: https://www.ncbi.nlm.nih.gov/pubmed/9099655
Husain K, Ansari RA, Ferder L. Alcohol-induced hypertension: mechanism and prevention. World J Cardiol 2014;6(5):245–52. At: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4038773/
Sharman JE, Stowasser M. Australian Association for Exercise and Sports Science Position Statement on Exercise and Hypertension. J Sci Med Sport 2009;12(2):252–7. At: https://www.ncbi.nlm.nih.gov/pubmed/19147407
Neter JE, Stam BE, Kok FJ, et al. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2003;42(5):878–84. At: https://www.ncbi.nlm.nih.gov/pubmed/12975389
Goldstein CM, Josephson R, Xie S, et al. Current perspectives on the use of meditation to reduce blood pressure. Int J Hypertens 2012;2012:578397. At: https://www.hindawi.com/journals/ijhy/2012/578397/
Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018;39(33):3021–104. At: https://academic.oup.com/eurheartj/article/39/33/3021/5079119
Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 4. Effects of various classes of antihypertensive drugs – Overview and meta-analyses. J Hypertens 2015;33(2):195–211. At: https://www.ncbi.nlm.nih.gov/pubmed/25485720
Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure-lowering on outcome incidence in hypertension: 5. Head-to-head comparisons of various classes of antihypertensive drugs – overview and meta-analyses. J Hypertens 2015;33(7):1321–41. At: https://www.ncbi.nlm.nih.gov/pubmed/26039526
Thomopoulos C, Parati G, Zanchetti A. Effects of blood-pressure-lowering treatment on outcome incidence. 12. Effects in individuals with high-normal and normal blood pressure: overview and meta-analyses of randomized trials. J Hypertens 2017;35(11):2150–60. At : https://www.ncbi.nlm.nih.gov/pubmed/28858984
Corrao G, Zambon A, Parodi A, et al. Discontinuation of and changes in drug therapy for hypertension among newly-treated patients: a population-based study in Italy. J Hypertens 2008;26(4):819–24. At: https://www.ncbi.nlm.nih.gov/pubmed/18327094
Thomopoulos C, Parati G, Zanchetti A. Effects of blood-pressure- lowering treatment in hypertension: 9. Discontinuations for adverse events attributed to different classes of antihypertensive drugs meta-analyses of randomized trials. J Hypertens 2016;34(10):1921–32. At: https://www.ncbi.nlm.nih.gov/pubmed/27454050
Fried LF, Emanuele N, Zhang JH, et al. Combined Angiotensin Inhibition for the Treatment of Diabetic Nephropathy. N Engl J Med 2013;369(20):1892–903. At: https://www.ncbi.nlm.nih.gov/pubmed/24206457
The ONTARGET Investigators, Yusuf S, Teo KK, et al. Telmisartan, Ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008;358(15):1547–59. At: https://www.ncbi.nlm.nih.gov/pubmed/18378520
Guerrero-Garcia C, Rubio-Guerra AF. Combination therapy in the treatment of hypertension. Drugs context 2018;7:212531. At: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5992964/
Gradman AH, Basile JN, Carter BL, et al. Combination therapy in hypertension. J Am Soc of Hypertens: 2010;4(1):42–50. At: https://www.ncbi.nlm.nih.gov/pubmed/20374950
Chi C, Tai C, Bai B, et al. Angiotensin system blockade combined with calcium channel blockers is superior to other combinations in cardiovascular protection with similar blood pressure reduction: A meta-analysis in 20,451 hypertensive patients. J Clin Hypertens (Greenwich) 2016;18(8):801–8. At: https://www.ncbi.nlm.nih.gov/pubmed/26778747
Remonti LR, Dias S, Leitao CB, et al. Classes of antihypertensive agents and mortality in hypertensive patients with type 2 diabetes-Network meta-analysis of randomized trials. J Diabetes Complications 2016;30(6):1192–200. At : https://www.ncbi.nlm.nih.gov/pubmed/27217022
Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. Heart Lung Circ 2016;25(9):895–951. At: https://www.heartfoundation.org.au/images/uploads/publications/Clinical_Guidelines_for_the_Management_of_Acute_Coronary_Syndromes_2016.pdf
Atherton JJ, Sindone A, De Pasquale CG, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018;27(10):1123–208. At: https://www.ncbi.nlm.nih.gov/pubmed/30077227
Heran BS, Musini VM, Bassett K, et al. Angiotensin receptor blockers for heart failure. Cochrane Database of Systematic Reviews 2012, Issue 4. At: https://www.ncbi.nlm.nih.gov/pubmed/22513909
Duarte JD, Cooper-DeHoff RM. Mechanisms for blood pressure lowering and metabolic effects of thiazide and thiazide-like diuretics. Expert Rev Cardiovasc Ther 2010;8(6):793–802. At: https://www.ncbi.nlm.nih.gov/pubmed/20528637
Zillich AJ, Garg J, Basu S, et al. Thiazide diuretics, potassium, and the development of diabetes: a quantitative review. Hypertension 2006;48(2):219–24. At: https://www.ncbi.nlm.nih.gov/pubmed/16801488
Brieger D, Amerena J, Attia J, et al. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018. Heart Lung Circ 2018;27(10):1209–66. At: https://www.ncbi.nlm.nih.gov/pubmed/30077228
Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med 2008;359(23):2417–28. At: https://www.ncbi.nlm.nih.gov/pubmed/19052124
Dahlof B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo- Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 2005;366(9489):895–906. At: https://www.ncbi.nlm.nih.gov/pubmed/16154016
ADAM HORT BPharm, GradDipClinPharm MSHP is the Lead Pharmacist for Cardiovascular and Respiratory Medicine at the Fiona Stanley Hospital. Adam is also a member of the Australian Council of Smoking and Health, and the Western Australian Drug Evaluation Panel.
SARA LINTON BSc, MPharm is the Senior Clinical Policy Advisor at the National Heart Foundation of Australia. She has previously worked as a clinical cardiology pharmacist at the Fiona Stanley Hospital.
The views expressed in this article are Sara's own, and are not indicative of the views of the National Heart Foundation of Australia.
[post_title] => Management of hypertension – a contemporary approach
[post_name] => management-hypertension-contemporary-approach-cpd
[title_attribute] => Management of hypertension – a contemporary approach
[title] => Management of hypertension – a contemporary approach
[href] => https://www.australianpharmacist.com.au/management-hypertension-contemporary-approach-cpd/
Management of hypertension – a contemporary approach
Imogen is a 15-year-old girl who comes into the pharmacy with her mother. She states that she started to develop acne about 1 year ago. Recently her acne has become worse and she is now embarrassed about the appearance of her skin. You notice that she has some comedones and a few pustules on her nose and chin. She wants to know what she can apply to clear up her pimples. Imogen has not previously used any products on her acne and is not on any other medicines.
Identify and classify mild, moderate and severe acne
Summarise topical treatment options and non-pharmacological measures in the management of acne
Describe the topical treatment algorithm and when referral is appropriate.
Competency standards addressed (2016): 1.1, 1.4, 2.3, 2.4, 3.1
Acne vulgaris is defined as a chronic inflammatory disease of the pilosebaceous follicles of the skin, with comedones, papules, pustules, nodules and cysts.1 Comedones are keratin-filled plugs that can be described as open or closed. Closed comedones are commonly referred to as whiteheads while open comedones, also known as blackheads, appear as an open pore with a black plug; the black appearance is due to oxidisation of keratin plugs. Papules are comedones that have become inflamed forming small red lesions that may be tender to touch; pustules are also inflamed lesions and resemble whiteheads except they have a red ring around the bump and a white, yellowish tip caused by puss. If the acne becomes more inflamed, larger, redder, deeper nodules and cysts may develop. These very inflamed lesions can lead to scarring.2
Acne is a common disease affecting about 85% of teenagers.3 Onset peaks in puberty and usually resolves in most people during their early twenties but can persist into adulthood, particularly in women.
Acne may be mild, moderate or severe⁴:
Mild acne consists of some comedones with a few papules and pustules mainly confined to the forehead, nose and chin, without scarring.
Moderate acne consists of numerous papulopustules and comedones which affect extensive areas of the face and trunk but there is no scarring.
Severe acne consists of nodules, cysts and scarring which may be confined to the face or may also affect the trunk.
In this article the management of mild acne with topical treatments will be discussed. Acne lesions may be non-inflammatory (open and closed comedones), inflammatory (pustules, red papules, nodules and cysts) or resolving (macules or scars).⁴
Impact on well-being
Acne can have a profound impact on self-esteem, mood and well-being in all age groups. Patients with acne have been shown to have an increased risk of depression and suicide attempts.⁵ Adolescence is a stage of life during which body image, socialisation and vocational choices become important and is a time when young people are psychologically vulnerable due to hormonal changes and the effect of media which portrays clear skin as the ideal. Patients who develop acne early begin to experience lower self-esteem and impairment with relationships at an early age. In older age groups the presence of acne may influence employment and social functioning. The more severe the acne, the greater the impact on quality of life and self-esteem.⁵
Four main factors contribute to the condition⁶:
Increased sebum production: increased androgen production which occurs in puberty stimulates sebaceous glands to enlarge and produce more sebum.
Abnormal follicular keratinisation: keratinocytes are retained and accumulate due to increased cohesiveness and keratin plugs are formed. These block the follicle openings in the epidermis and cause them to dilate beneath the skin surface.
Overgrowth of Cutibacterium acnes (formerly Propionibacterium acnes): these gram positive rods are found deep in follicles and stimulate the production of pro-inflammatory mediators and lipases.
Inflammation and immune response: inflammatory cells and mediators efflux into the disrupted follicle, leading to the development of papules, pustules, nodules and cysts.
The management of acne is aimed at counteracting these causes and is individualised according to the severity and extent of the disease.
Genetics is also a contributing factor. The likelihood of acne is increased in those whose parents or siblings have also had acne.⁷
Certain drugs, including androgens, corticosteroids, hormonal contraceptives containing androgenic progestogens such as higher doses of levonorgestrel, isoniazid and lithium may produce an acne-form rash as may substances such as tars, oils and oily cosmetics.⁸
Myths about acne and what patients can do to help
Acne is caused by a hormone imbalance
Most people with acne have normal hormone levels, but their skin is more sensitive to the hormones. Acne is only related to a hormone imbalance in a minority of people.⁴
Acne is caused by a poor diet
False. There is no evidence that fatty foods and chocolate affects acne, although there is emerging data that suggests that a diet consisting mainly of high glycaemic index foods may aggravate acne.⁹ A balanced, healthy diet should be encouraged.
Acne is caused by poor hygiene
False. There is no evidence that poor hygiene causes acne, and washing the face more frequently does not improve the condition. Washing the face twice a day with a gentle, soap-free, pH balanced cleansing agent is all that is required. It should be stressed that harsh soaps and vigorous scrubbing and exfoliating should be avoided as this is more likely to cause dryness and irritation to the skin and blockage of sebaceous glands by causing damage and inflammation in the epidermal barrier. It will also make the use of prescription therapies such as topical retinoids problematic.
Oily products and heavy, greasy cosmetics should be avoided as they can make acne worse. Water-based non-comedogenic cosmetics and sunscreens should be used.⁶
Avoid squeezing and picking lesions as this leads to follicular rupture and more inflammatory acne, and exacerbates scarring.
Topical treatment options
Mild acne is treated with topical products available both over-the-counter (benzoyl peroxide) and by prescription (retinoids and antibiotics), which are applied to the whole area, not just to single lesions. Topical therapies may be used as monotherapy or in combination with other topical therapies (see Figure 1).
FIGURE 1– Acne treatment progression
Benzoyl peroxide is thought to be keratolytic through an irritant effect leading to increased turnover of the follicular epithelial cells and increased sloughing, and is bactericidal against C. acnes.10 Benzoyl peroxide is available over the counter and is available in strengths of 2.5–10% as a cream or gel. Strengths greater than 5% cause greater irritation and dryness. Treatment should be started with benzoyl peroxide 5% unless there is a history of atopic dermatitis or dry, sensitive skin, in which case, start with benzoyl peroxide 2.5%.⁴ After washing with a soap substitute and patting dry, a thin layer should be applied to the affected areas once daily for a week then increased to twice a day. For mild acne on the chest and back, a wash of benzoyl peroxide 5% can be used.
The main side effect of benzoyl peroxide is dryness and irritation of the skin which can be minimised by application to dry skin rather than wet skin. Patients should be warned that irritation and redness may occur in the first few days of use. If this occurs, then a lower strength product and less frequent application can be suggested. If it persists or is severe, treatment should be ceased.11 Avoid contact with eyes, lips and other sensitive areas.12 Warn patients that benzoyl peroxide bleaches clothes, towels and sheets. Benzoyl peroxide is safe to use in pregnancy.12 Continue treatment for 6 weeks before assessing efficacy.12
Azelaic acid is available over the counter and is not commonly used. It is a naturally occurring dicarboxylic acid with antimicrobial, comedolytic and mild anti-inflammatory properties.13 It may be useful for acne and post-inflammatory hyperpigmentation in darker skinned individuals.14 It is used twice daily and is safe in pregnancy.
Salicyclic acid is a beta hydroxy acid.13 It is has antibacterial, comedolytic and mild anti-inflammatory properties.13,15,16 It is usually applied once daily but can be used up to three times a day.13 Salicylic acid and benzoyl peroxide can be used in combination.13 Higher concentrations of salicylic acid have been used to perform chemical peels.13,15 Safety data for use in pregnancy is lacking; short term topical use over a small area is considered safe in pregnancy.16,17 In small quantities, it is considered safe to use during breastfeeding.16,17
Tea tree oil has antimicrobial and anti-inflammatory properties. Two trials in 60 and124 patients found that a gel containing 5% tea tree oil had effects similar to benzoyl peroxide. However the effect is slower and can take months rather than weeks to show a comparable result.7,13 Patients should be warned that it can cause a severe allergic reaction in 1 in 40 individuals and that the product should first be tested on a small area of skin away from the face for 2–3 days.7
Topical retinoids
Topical retinoids available in Australia are adapalene, tazarotene and tretinoin. They are vitamin A derivatives that target follicular hyperproliferation and have some anti-inflammatory activity.12 They are beneficial for both comedonal and inflammatory acne. They act by normalizing follicular hyperkeratosis and preventing formation of new comedones.
Topical retinoids cannot be used in pregnancy or women planning to become pregnant due to the risk of teratogenicity. Women who have become pregnant while using a topical retinoid should be advised to ring a pregnancy information service. However, they can be reassured that the risk of teratogenicity is very low due to reduced systemic absorption through the skin, and that inadvertent exposure to a topical retinoid during pregnancy is unlikely to cause harm to the developing foetus.17 Therapy should be ceased and an alternative treatment considered.
Topical retinoids can be irritating to the skin and are applied (after washing) every second night at bedtime for the first two weeks, then applied every night thereafter.⁴ They also have the potential for photosensitivity; night time application that is washed off in the morning is recommended. Apply to the whole area affected, not just individual lesions. A cream should be used for patients with dry or sensitive skin, and a gel for those with oily skin.⁴
Retinoids may cause redness, peeling and irritation, particularly in the first few weeks of treatment. If irritation is severe, patients should be referred to their doctor. Steps to minimise irritation include12:
waiting until skin is completely dry after washing (15–20 minutes) before applying
applying only a thin layer (a pea sized amount)
avoiding use of other drying medications on skin unless advised by a doctor
using a water-based non-comedogenic moisturiser in the morning
avoiding waxing treated areas l always using a SPF50+ sunscreen and protective clothing if going out in the sun.
Australian guidelines recommend either adapalene 0.1% cream/gel or tretinoin 0.025% cream to be applied for 6 weeks, then review. Improvement should be evident by 6 weeks and continue to improve for up to 6 months.⁴
If the response to either drug is inadequate at 6 weeks, then a change to a topical combination is advised. Alternatively, patients using topical tretinoin can try a higher strength (0.05%, then 0.1%) before changing to a topical combination.4
If both topical tretinoin and topical benzoyl peroxide are being used, tretinoin should be applied at night and benzoyl peroxide in the morning because of the oxidising effect of benzoyl peroxide on tretinoin (adapalene and tazarotene are stable in the presence of benzoyl peroxide).13
Topical Antimicrobials
Topical antibiotics such as clindamycin are used in patients with inflammatory acne. They suppress inflammation by reducing the numbers of C. acnes in the sebaceous follicles.
Development of antibiotic resistance is an increasing problem with the use of antibiotics, both topical and systemic, particularly when used as monotherapy.2,3,6 By combining clindamycin with benzoyl peroxide the risk of antibiotic resistance is greatly reduced and together they have a synergistic effect. Nevertheless, clindamycin can be used alone in patients with atopic skin conditions.⁴
A combined preparation containing clindamycin should be stopped when papular inflammation has resolved and the patient switched to a single ingredient preparation containing a retinoid or benzoyl peroxide.⁴
Topical clindamycin is safe to use in pregnancy and breastfeeding.12
Topical Combinations
Topical combinations of clindamycin, benzoyl peroxide or a retinoid have a number of advantages including convenience of use, increased potency and reduced risk of antibiotic resistance. Some proprietary fixed combination products are available.
For mild acne that is mainly comedonal and inflammatory, a topical combination of benzoyl peroxide 5% and clindamycin 1% can be used once daily for 6 weeks.⁸
For mild acne that is mainly comedonal, a topical combination of benzoyl peroxide 2.5% and adapalene 1% can be used daily for 6 weeks, then reviewed.⁸
A combined topical preparation containing a retinoid can be continued indefinitely. A combined preparation containing a topical antibiotic should be stopped when inflammation has resolved and a single ingredient preparation containing a retinoid or benzoyl peroxide should be used for maintenance.⁴
Treatment progression in topical treatment of acne is shown in Figure 1.
The role of the pharmacist in the management of acne is to:
Describe how topical treatments should be used, applying to cleansed, dry skin of the whole area affected.
Explain that acne won't disappear overnight and the full effects of treatment may take several months; some improvement, however, can be seen in mild cases within a couple of weeks. Advise that patience and adherence to treatment is required even if early improvement is not seen. Discussion of adherence to treatment recommended or prescribed at each visit to the pharmacy will lead to more consistent treatment and a better therapeutic response.
Describe what adverse effects to expect, such as dry skin and chapped lips, and how to minimise these with non-oily lip and skin moisturisers. Both benzoyl peroxide and the retinoids may cause reddening and soreness early on in treatment and patients should be warned of this (see further advice in Topical retinoids section above).
Recognise when a patient should be referred to their doctor.
Patients should be referred to their doctor in the following circumstances10:
Acne is moderate with widespread pustules and papules or severe with nodules, cysts and scarring on presentation.
Treatment of mild acne with benzoyl peroxide has not been effective.
Patients have significant psychological distress and depression.
Acne beginning or persisting outside the normal age range (teenage years and early twenties).
Suspected drug-induced acne.
Acne can have a profound impact on self-esteem, mood and well-being in all age groups. The treatment and management of acne is dependent on severity, patient preference and response to therapy. It is imperative that pharmacists are able to diagnose, treat and counsel patients on the best course of action, and recognise when to refer.
As Imogen's acne is confined to the nose and chin and she does not have a large number of comedones, only a few pustules and no nodules, cysts or scarring you suggest she use benzoyl peroxide 5% cream as initial treatment. You advise her to cleanse first with a soap substitute, pat dry her skin and then apply a thin layer of the cream at night to the whole affected area, not just the pimples. You explain that this is because benzoyl peroxide also acts by preventing new pimples. She should wash her hands after application and avoid contact with her eyes and lips and with her hair and clothes and towels. You advise her that she may feel some dryness, redness and irritation for the first few weeks and if it is troublesome she should use it every second day until it settles down. She can also use a non-comedogenic moisturiser in the morning. You should make clear that her acne won't get better overnight, but that with regular use she should notice some improvement after a few weeks and that she should persist with treatment for 4–6 weeks. If there is no improvement by then she should see her doctor for further treatment options.
Acne is a common skin condition that can have a marked psychological impact, causing low self-esteem and depression.
Treatment is based on level of severity, with topical treatments used in mild cases. Topical benzoyl peroxide and topical retinoids are first-line treatments in mild to moderate acne. When inflammation is present topical clindamycin may be added.
Consumers who present with a moderate number of comedones and only a few pustules and papules can initially be treated by the pharmacist with benzoyl peroxide in addition to appropriate advice on how to deal with the drying effects of this product.
Consumers with more numerous comedones, pustules and papules, more extensive disease or more severe acne with nodules and cysts, those who have failed treatment with benzoyl peroxide and those with severe psychological effects should be referred to their doctor.
Consumers should be given full information on adverse effects of treatments and how to manage them. The importance of long-term adherence to obtain the full benefit of treatment should be emphasised.
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Graber E. Treatment of acne vulgaris. UpToDate 2018. At: uptodate.com/contents/treatment-of-acne-vulgaris
See J-A. Drug treatment of acne. Aust Prescr 2012;35(6):180– 182. 15. Mayo Clinic. Acne. At: mayoclinic.org/diseasesconditions/acne/diagnosis-treatment/drc-20368048
Rossi S, ed. Australian medicines handbook. Adelaide: Australian Medicines Handbook; 2019. At: https://amhonline.amh.net.au/chapters/dermatological-drugs/drugs-psoriasis/other-drugs-psoriasis/salicylic-acid
The Women's Pregnancy and Breastfeeding Guide 2018. At: https://thewomenspbmg.org.au
MORNA FALKLAND BPharm, MSHP was formerly the Medicines Information Pharmacist at The Canberra Hospital and is published in Australian pharmacy journals.
[post_title] => Topical management of acne
[post_name] => topical-management-acne-cpd
[title_attribute] => Topical management of acne
[title] => Topical management of acne
[href] => https://www.australianpharmacist.com.au/topical-management-acne-cpd/
Topical management of acne
[post_content] => The most fundamental change in asthma management in 30 years is currently happening. The Global Initiative for Asthma (GINA) no longer recommends treating asthma in adults and adolescents with short-acting bronchodilators alone. Instead, they should receive a symptom-driven (in mild asthma) or daily corticosteroid-containing inhaler, to reduce the risk of severe exacerbations.1
Understand the extent and consequences of over-reliance on relievers alone
Compare patient outcomes between as-needed inhaled corticosteroid (ICS)/ formoterol, as-needed short acting beta2 agonist (SABA) and ICS maintenance therapy in patients with mild asthma.
Discuss benefits of anti-inflammatory reliever therapy in patients with mild asthma.
Competency standards addressed (2016): 1.1, 1.5, 2.2, 3.5
Accreditation number: CAP1911MUDR
For patients with mild asthma, GINA recommends as-needed low-dose inhaled corticosteroid (ICS)/formoterol as the preferred option to prevent exacerbations and control symptoms. Australian guidelines are currently under review.
Evidence from recently published large 52-week studies, shows as-needed ICS/ formoterol controls mild asthma symptoms better than as-needed short acting beta2 agonist (SABAs), substantially reduces exposure to ICS compared to low-dose maintenance ICS, and reduces the risk of severe exacerbations.2,3,4
In Australia, the registered indication for budesonide/formoterol (Symbicort) was updated in July 2019 for the treatment of asthma to achieve overall asthma control, including the relief of symptoms and the reduction of the risk of exacerbations in mild asthma. Prior to this it had a registered indication for use as a reliever only when in combination with maintenance therapy (i.e. Symbicort anti-inflammatory reliever plus maintenance therapy).
Mild asthma
An estimated 1 in 9 Australians have asthma, which is approximately 2.5 million people. Most of our population (about 70%) have mild asthma. However, mild asthma can lead to severe complications and the need for emergency treatment. Between 30% and 40% of exacerbations requiring emergency care are in patients with mild asthma.6 15% to 20% of adults dying from asthma were largely asymptomatic in the preceding 3 months (i.e. had asthma symptoms less than weekly).1
There are three goals of therapy for patients with asthma:
relieve and control symptoms
prevent exacerbations
reduce loss of lung function, with minimal adverse effects.
SABAs relieve symptoms rapidly but have no effect on the underlying inflammation associated with asthma. Formoterol, a long-acting beta2 agonist (LABA), has a rapid onset of action, comparable to SABAs. Inhaled corticosteroids reduce the incidence and severity of symptoms, reduce severe exacerbation risk, and reduce airway remodelling due to their anti-inflammatory actions.6
There are currently no studies that address patients presenting with symptoms less than twice a month with no exacerbation risk factors. For these patients the Australian Asthma Handbook recommends SABA as needed.7 In adult and adolescent patients with symptoms twice a month or more, the Australian Asthma Handbook recommends regular ICS starting at a low dose plus a SABA as needed.7 However adherence to regular therapy is poor in real life, with most patients relying on SABA-only treatment when symptoms present. SABAs are available over-the-counter in Australia, allowing easy access, often without actual diagnosis or regular asthma review by general practitioners.
Too much reliever
It is well recognised that excessive use of SABA alone to manage asthma increases adverse events from asthma.
Trust and reliance on SABAs for symptom control is often established as a child.
Regular exposure to relatively large doses of SABA medications in the absence of adequate preventer therapy paradoxically increases airway hyper-responsiveness and worsening of symptoms.8 This increase in airway hyper-responsiveness can eventually result in life-threatening exacerbations.9 Regular SABA monotherapy has also been associated with a near-doubling of sputum eosinophil counts10 (an indication of airway inflammation and disease) and an increase in allergen-induced airway hyper-responsiveness.11 Overuse of SABAs may also mask the true asthma severity and result in under-treatment.
Results from many studies show that ICS benefit patients with chronic persistent asthma by decreasing airway inflammation, improving lung function, lessening symptoms and airway hyper-responsiveness, reducing the frequency and severity of asthma flare-ups, and reducing mortality.7 Australian asthma guidelines recommend low-dose regular preventers plus SABA as needed for most adults and adolescents.7 Low-dose ICS reduce severe exacerbations by about 50% in patients with mild asthma, as well as controlling symptoms and improving quality of life.12
A recent Australian survey of 412 participants aged 16 years and older showed 70.1% overused SABAs obtained in community pharmacy.13 Overuse is defined as use for symptom relief more than twice a week in the previous 4 weeks.7 Overall, 31% of participants used 5–12 puffs per day and a staggering 6% used more than 12 puffs per day.
Nearly three-quarters (73.6%) of participants reported not using a preventer daily and about one in four patients (25.9%) used their preventer on an as-needed basis.13
Overusers were also more likely to use oral corticosteroids to manage worsening asthma symptoms and visit the doctor for their asthma in the past 12 months.13 SABA overusers were more likely to have moderate-severe rhinitis symptoms.
TABLE 1 – Definitions of asthma symptom control in adults and adolescents
GOOD CONTROL
PARTIAL CONTROL
POOR CONTROL
All of:
Daytime symptoms ≤2 days per week
Need for reliever ≤2 days per week
No limitation of activities
No symptoms during night or on waking
One or two of:
Daytime symptoms >2 days per week
Need for reliever >2 days per week
Any limitation of activities
Any symptoms during night or on waking
Three or more of:
Reference: Australian Asthma Handbook7
FIGURE 1 – Asthma symptom control of participants in community pharmacy survey
For safety, GINA no longer recommends starting with SABA-only treatment.14 This decision was based on evidence that SABA-only treatment increases the risk of severe exacerbations, and that adding any ICS significantly reduces the risk. GINA recommends that all adults and adolescents with asthma should receive ICS-containing treatment, to reduce their risk of serious exacerbations and to control symptoms. This is a population-level risk reduction strategy. Evidence from the double-blind SYGMA trials and the open-label Novel START trial supports this recommendation.
SYGMA trials
The two Symbicort Given as needed in Mild Asthma (SYGMA) trials were large 52-week, double-blind studies involving patients 12 years of age or older with mild asthma.2,3 Participants had a demonstrated need for ICS, determined by use of a SABA on three or more days in the previous week, but were not severely uncontrolled.
In the SYGMA 1 trial,2 asthma symptom control was assessed with patients randomly assigned to one of three regimens:
Twice daily placebo plus terbutaline 500 microgram used as needed
Twice daily placebo plus budesonide/ formoterol 200/6 microgram used as needed
Twice daily budesonide 200 microgram plus terbutaline 500 microgram used as needed.
As-needed budesonide/formoterol controlled asthma symptoms better than as-needed terbutaline. The mean percentage of weeks with well-controlled asthma with budesonide/formoterol as-needed was 34.4% compared to 31.1% with as-needed terbutaline (odds ratio (OR) 1.14, 95% confidence interval (CI) 1.00–1.20, p=0.046). However, as-needed budesonide/formoterol was inferior to budesonide maintenance therapy (34.4% vs 44.5%, OR 0.64, 95% CI 0.57 to 0.73).
Whilst the actual number of severe exacerbations in this cohort was small, as-needed budesonide/formoterol resulted in a 64% lower rate of severe exacerbations compared to as-needed terbutaline. Severe exacerbation was defined as worsening asthma leading to the use of oral corticosteroids (prednisone, prednisolone) for three or more days, hospitalisation or an emergency department visit leading to the use of oral corticosteroids.
The SYGMA 2 trial compared the annualised rate of severe exacerbations between budesonide/formoterol used as needed and budesonide maintenance therapy3:
In both trials, there was no difference in the rate of severe exacerbations between as-needed budesonide/formoterol and budesonide maintenance therapy. Budesonide maintenance therapy was better in controlling asthma symptoms than as-needed budesonide/formoterol in both SYGMA trials. However, there was a substantial reduction in the median daily ICS dose, with an 83% reduction in SYGMA 1 and 75% reduction in SYGMA 2 (Table 3).
Adherence was measured electronically with the use of an inhaler monitor. In SYGMA 1 trial, adherence to the twice-daily, blinded regimen was around 80% and did not differ across the three groups.2 Similarly, adherence did not differ substantially between the two groups in SYGMA 2; the mean percentage of daily doses was 64.0 ±} 30.0% of placebo doses in the budesonide/formoterol group and 62.8 ±} 29.4% of budesonide maintenance doses.3 In real-life, adherence is likely to be much lower.
In summary, the SYGMA 1 and 2 trials show as-needed budesonide/formoterol leads to a reduction of inflammation and relieves symptoms at the same time. As needed budesonide/formoterol reduces the risk of severe exacerbations to the same extent as budesonide maintenance therapy, at a considerably lower dose of steroids. However, regular ICS twice daily has best long-term efficacy and safety data and will remain best strategy for the patient with good adherence.
FIGURE 2 – Median daily dose of inhaled corticosteroids
Novel START
An open-label trial called Novel Symbicort Turbuhaler Asthma reliever Therapy (Novel START) was designed to better reflect clinical practice.4 It involved 668 patients with a diagnosis of mild asthma from a doctor. In the 52-week study, adults aged 18 to 75 years were randomly assigned one of three treatments:
Salbutamol 100 microgram 2 inhalations used as needed
Twice daily budesonide 200 microgram plus salbutamol used as needed.
Budesonide/formoterol 200/6 microgram used as needed
The primary outcome was annualised rate of exacerbations, with asthma control, lung function, fraction of exhaled nitric oxide (FENO), an indication of airway inflammation, and number of severe exacerbations as secondary outcome measures. Education was provided around inhaler technique and use. Similar to the SYGMA trials, electronic inhaler usage monitors were used to assess adherence. Overall mean adherence to twice-daily doses of budesonide maintenance therapy was 56%.
Novel START participants at enrolment were only taking SABA and had less severe asthma, with about 50% using SABA on 2 or less occasions per week in the four weeks before enrolment (Table 2). Participants' asthma was not well-controlled as determined by the Asthma Control Questionnaire-5 (ACQ-5) score.
There was a 51% reduction in rate of exacerbations per patient per year with budesonide/formoterol as needed compared to salbutamol as needed; with no difference when compared to budesonide maintenance therapy (Figure 3).
The median daily dose of budesonide in the Novel START trial was 73 microgram per day in the budesonide/formoterol group and 247 microgram per day in the budesonide maintenance group. This significant reduction in steroid load reflects similar results in the SYGMA trials (Table 3).
In contrast to the SYGMA trials, the number of severe exacerbations was lower in the budesonide/formoterol as-needed group than in the other two arms of the trial. This could be explained by reduced adherence to regular maintenance therapy in those with mild asthma in the real-world setting. Overall mean adherence to twice-daily dose of budesonide maintenance was 56%.
Results of the Novel START trial confirm that ICS/formoterol is an alternative to regular ICS in mild asthma and clearly superior to SABA as needed.
TABLE 2 – Baseline patient characteristics
BUD MAINTENANCE
BUD-FOR
Mean age (years)
Current smoker (%)
SABA use ≤2 occasions per week (%)
Median puffs per week
Any severe exacerbations in previous year (%)
ACQ-5 score
BUD = budesonide, BUD-FOR = budesonide/formoterol
References: O'Byrne PM et al,2 Bateman ED et al3
TABLE 3 – Median daily inhaled budesonide dose (micrograms)
BUDESONIDE MAINTENANCE GROUP
BUDESONIDE/FORMOTEROL AS-NEEDED GROUP
SYGMA 1
Reference: O'Byrne PM et al,2 Bateman ED et al,3 Beasley R et al4
FIGURE 3 – Annualised exacerbation rate
Anti-inflammatory reliever
Product Information for budesonide/ formoterol (Symbicort Rapihaler and Turbuhaler) now describes 3 different treatment approaches:
Symbicort anti-inflammatory reliever therapy (patients with mild disease)
Symbicort anti-inflammatory reliever plus maintenance therapy
Symbicort maintenance therapy (fixed dose).
Symbicort Rapihaler 100/3 is registered for use in adults and adolescents as anti-inflammatory reliever therapy in a dose of 2 inhalations as needed in response to symptoms. If symptoms persist after a few minutes, an additional 2 inhalations should be taken. No more than 12 inhalations should be taken on any single occasion. A total daily dose of more than 16 inhalations is normally not needed, however a total daily dose of up to 24 inhalations can be used temporarily.
Symbicort Turbuhaler 200/6 is registered for use in adults and adolescents as anti-inflammatory reliever therapy in a dose of one inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. No more than 6 inhalations should be taken on any single occasion. A total daily dose of more than 8 inhalations is normally not needed, however a total daily dose of up to 12 inhalations can be used temporarily.
The National Asthma Council Australia has suggested down-scheduling preventers as a strategy to address overuse of SABAs and poor adherence to maintenance therapy.15 Symbicort is not currently PBS listed as an anti-inflammatory reliever for the first-line treatment of mild asthma (See Box 1).
BOX 1 – PBAC JULY 2019 RECOMMENDATION
In July 2019, PBAC did not recommend listing for budesonide with formoterol fixed dose combination (Symbicort) as first-line treatment for asthma to include use as an anti-inflammatory reliever therapy administered as needed for adolescent and adult patients with mild asthma.
The PBAC considered that ICS maintenance plus SABA as needed was the appropriate main comparator. However, the PBAC considered the results reported for severe asthma exacerbations and well-controlled asthma weeks meant the claim of non-inferior comparative effectiveness versus ICS plus SABA was uncertain.
Reference: PBS16
Patient discussion
The anti-inflammatory reliever approach leverages patients' inherent relief-seeking behaviour to also deliver inhaled corticosteroids as soon as symptoms appear; and thus reduces the likelihood of the progression of an exacerbation. This approach may address patients' concerns about the risks of treatment, which causes over-reliance on SABAs and poor adherence to ICS maintenance treatment. Budesonide-formoterol used as needed is at least as effective as budesonide maintenance therapy in reducing exacerbation risk, without the need for regular twice-daily treatment and therefore reduces ICS load. Cost is likely to be a significant barrier to as-needed budesonide/formoterol use.
The key message for most people with mild asthma is that budesonide/formoterol used as needed is better than as-needed SABA for asthma symptom control and for reducing the risk of asthma exacerbations, at a substantially low total corticosteroid load and without the need for adherence to twice-daily maintenance schedule.
Poor adherence to regular inhaled corticosteroids in patients with intermittent asthma symptoms has led to research into alternate approaches to treatment. It is clear that a good number of patients with mild asthma actually practice intermittent medication when symptoms occur. Recent trials have explored the use of ICS taken only in response to symptoms. Budesonide/ formoterol on an as-needed basis reduces the risk of exacerbations and loss of lung function, the most serious outcomes of poorly controlled asthma. As-needed budesonide/formoterol is less effective at mitigating symptoms but lowers exposure for corticosteroids substantially compared to budesonide maintenance therapy. Anti-inflammatory reliever therapy in patients with mild asthma should be considered a population-level risk reduction strategy.
As-needed short acting beta2 agonists (SABA) should not be considered primary treatment for mild asthma in adults and adolescents.
As-needed budesonide/formoterol is superior to as-needed SABA, but inferior to budesonide maintenance therapy for symptom control.
As-needed budesonide/formoterol reduces severe exacerbations at least as effectively as regular maintenance therapy with inhaled corticosteroids.
As-needed budesonide/formoterol substantially lowers exposure for inhaled corticosteroids compared to budesonide maintenance therapy.
Reddel HK, FitzGerald JM, Bateman ED, et al. GINA 2019: a fundamental change in asthma management. Eur Respir J 2019;53:1902046. At: https://www.ncbi.nlm.nih.gov/pubmed/31249014
O'Byrne PM, FitzGerald JM, Bateman ED, et al. Inhaled combined budesonide-formoterol versus maintenance budesonide in mild asthma. New Engl J Med 2018;378:1865– At: https://www.nejm.org/doi/full/10.1056/NEJMoa1715274
Bateman ED, Reddel HK, O'Byrne PM, et al. As-needed budesonide-formoterol versus maintenance budesonide in mild asthma. New Engl J Med 2018;378:1877– At: https://www.nejm.org/doi/full/10.1056/NEJMoa1715275
Beasley R, Holliday M, Reddel HK, et al. Controlled trial of budesonide-formoterol as needed for mild asthma. New Engl J Med 2019;380:2020– At: https://www.ncbi.nlm.nih.gov/pubmed/31112386
Australian Centre for Asthma Monitoring. Asthma in Australia 2008. AIHW Asthma Series no. 3. Cat. no. ACM 14. Canberra: AIHW; 2008. At: https://www.aihw.gov.au/getmedia/4e5eca8a-bd59-4dd5-af58-36357b12a008/aia08.pdf.aspx?inline=true
Dusser D, Montani D, Chanez P, et al. Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations. Allergy 2007;62(6):591– At: https://www.ncbi.nlm.nih.gov/pubmed/17508962
National Asthma Council Australia. Australian Asthma Handbook, Version 2.0. 2019. At: asthmahandbook.org.au
Page CP, Spina D. s2-agonists and bronchial hyperresponsiveness. Clin Rev Allergy Immunol 2006;31(2-3):143– At: https://www.ncbi.nlm.nih.gov/pubmed/17085790
Suissa S, Ernst P, Boivin JF, et al. A cohort analysis of excess mortality in asthma and the use of inhaled beta-agonists. Am J Resp Crit Care Med 1994;149:604– At: https://www.ncbi.nlm.nih.gov/pubmed/8118625
Aldridge RE, Hancox RJ, Robin TD, et al. Effects of terbutaline and budesonide on sputum cells and bronchial hyperresponsiveness in asthma. Am J Respir Crit Care Med 2000;161:1459– At: https://www.ncbi.nlm.nih.gov/pubmed/10806139
Cockcroft DW, O'Byrne PM, Swystun VA, et al. Regular use of inhaled albuterol and the allergen-induced late asthmatic response. J Allergy Clin Immunol 1995;96:44– At: https://www.jacionline.org/article/S0091-6749(95)70031-5/fulltext
Pauwels RA, Pedersen S, Busse WW, et al. Early intervention with budesonide in mild persistent asthma: a randomised, double-blind trial. Lancet 2003;361:1071– At: https://www.ncbi.nlm.nih.gov/pubmed/12672309
Azzi EA, Kritikos V, Peters MJ, et al. Understanding reliever overuse in patients purchasing over-the-counter short-acting beta2 agonists: an Australian community pharmacy-based survey. BMJ Open 2019;9:e028995. At: https://www.ncbi.nlm.nih.gov/pubmed/31412998
Global Initiative for Asthma. Global strategy for asthma management and prevention. 2019. At: https://ginasthma.org/
National Asthma Council Australia. Current practice and new approaches in asthma: Perspectives of asthma practitioners and patients. Melbourne: National Asthma Council Australia; 2019. At: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/reports-and-statistics/current-practice-and-new-approaches-in-asthma
Pharmaceutical Benefits Scheme. Recommendations made by the PBAC – July 2019. At: pbs.gov.au/info/industry/listing/elements/pbac-meetings/pbac-outcomes/recommendations-pbac-july-2019
DEBBIE RIGBY BPharm, GradDipClinPharm, AdvPracPharm, AACPA, FPS is an Advanced Practice Pharmacist with postgraduate qualifi cations in clinical pharmacy, geriatrics and respiratory medicine. She is Director, NPS MedicineWise; past Vice-President of PSA; past Chair of AACP. She currently works in general practice, conducts Home Medicines Reviews, and provides medicines education to pharmacists and other health professionals through her company Pharmeducation.
Conflicts of interest: Debbie has accepted honorariums for presentations, advisory groups and travel with AstraZeneca.
[post_title] => Anti-inflammatory reliever for mild asthma
[post_name] => anti-inflammatory-reliever-mild-asthma-cpd
[title_attribute] => Anti-inflammatory reliever for mild asthma
[title] => Anti-inflammatory reliever for mild asthma
[href] => https://www.australianpharmacist.com.au/anti-inflammatory-reliever-mild-asthma-cpd/
Anti-inflammatory reliever for mild asthma
[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]PSA life member Steve Cohen is not slowing down on a mission to improve medicines safety. He tells of the many changes he's seen in a career spanning half a century.
What started you on your road to advocacy around consumer information, safety and health literacy?
I was born with very bad vision – myopic astigmatism – so I have always been aware of what it's like not to have good vision.
Later I owned a pharmacy in Marrickville, a very multicultural part of Sydney, and I was always concerned that customers might take their medications incorrectly if they couldn't read their medicine labels.
Before translation software was readily available, how did you improve medicine safety?
I always had multilingual staff. I would have someone who spoke Greek, someone who spoke Arabic and someone who spoke Vietnamese.
I had also learned German and French at school and could understand a little bit of Italian, Spanish and Portuguese from my days of learning Latin so we had quite a broad knowledge base to be able to help them.
Interestingly enough though, in the mid-1980s, I was involved in selling the first computers into pharmacy. I helped train pharmacists to use them and the software that translated labels into different languages.
After 50-odd years in the industry, what are your words of wisdom for pharmacists today?
Don't be confined to traditional ideas of pharmacy – it's such a broad area. You can work in retail, the pharmaceutical industry, manufacturing but you can also diversify and have your own website for pharmacy-related business.
Business has become really, really competitive in the last 50 years so pharmacists today need to start having special business models.
Tell us about your online business – Our Pills Talk – and why you started it.
I developed a medicine safety app – Our Pills Talk – where people can scan QR barcode labels and the app will read out their doctor's prescription information and instructions. It will also translate the labels into their preferred language.
All the pharmacist needs to do is print out a QR barcode label that they place alongside their traditional pharmacy label for the patient to scan.
What led me down this pathway is that it's costing our government up to $1.4 billion annually with 250,000 people admitted to public hospitals due to adverse drug events.
What are your thoughts on retirement?
I'm allergic to it.[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
[post_title] => Diversity is the word
[post_name] => diversity-is-the-word
[title_attribute] => Diversity is the word
[title] => Diversity is the word
[href] => https://www.australianpharmacist.com.au/diversity-is-the-word/
[post_content] => Images of holidaymakers being evacuated by Navy ship as bushfires closed in on Mallacoota have made the Victorian coastal town a global symbol of the unprecedented nature of the bushfire crisis.
In the lead-up to New Year's Eve, up to 5,000 people became trapped after fires closed the only road into the remote coastal town, located just a few kilometres south of the NSW-Victoria border.
Like other pharmacists across fire-ravaged parts of the nation, Mallacoota Pharmacy Pharmacist-in-Charge Emmanuel Pasura MPS has been serving a vital role in helping local communities meet their healthcare needs.
Running on generator power, the Mallacoota Pharmacy dispensed more than double its usual amount of scripts, facing severe stock shortages, missed deliveries and panicked evacuees.
At the peak of the crisis, Mr Pasura was working almost around the clock and spent two nights sleeping in his car beside his pharmacy as he and his three front-of-shop staff dealt with a deluge of people whose medicineshad run out or who had lost theirs while being evacuated.
'Just a few weeks before the fire I started ordering increased quantities of medicines like Ventolin (salbutamol) and antibiotics just in case,' he said.
'We always get a lot of visitors during this time of the year so, naturally, our orders are bigger than normal. Despite having ordered increased quantities when the fire finally roared into town it became apparent that we were very much understocked.'
Mr Pasura said he had run out of salbutamol within an hour of opening on December 30, well before the fire even reached Mallacoota.
After reaching out to a local GP and connecting with various government agencies, an intervention from the Pharmacy Guild's Victorian Branch Director Allan Crosthwaite helped secure a shipment of salbutamol, antibiotics and P2 masks from Sigma, brought in by police barge on the next day.
'Managing my stock was very difficult,' he said. 'At one point, I was dispensing only enough medications for a week if I felt that item was running low.'
As of Tuesday this week, Mr Pasura was still awaiting a new shipment, due in from Sale via helicopter, that had already been delayed for three days due to visibility concerns.
'I hope I will get it today as I am now very desperate,' he said.
There was a heavy sadness in the town, he said, with many of his patients losing their homes.
'Nothing prepares you for such a disaster,' Mr Pasura said.
[post_title] => On the ground in Mallacoota: community pharmacy at the front line
[post_name] => on-the-ground-in-mallacoota-community-pharmacy-at-the-front-line
[title_attribute] => On the ground in Mallacoota: community pharmacy at the front line
[title] => On the ground in Mallacoota: community pharmacy at the front line
[href] => https://www.australianpharmacist.com.au/on-the-ground-in-mallacoota-community-pharmacy-at-the-front-line/
On the ground in Mallacoota: community pharmacy at the front line
[post_content] => Three outstanding pharmacists recognised at the 2019 Victorian Pharmacists Dinner in Melbourne last week represent the difference dedicated members of the profession make every day to healthcare in the community.
The executive officer of the Pharmacists' Support Service (PSS), Kay Dunkley MPS, was awarded the PSA Victorian Excellence Award for her commitment to improving the wellbeing of health professionals, particularly through peer support.
[caption id="attachment_8788" align="alignright" width="219"]  Kay Dunkley MPS[/caption]
This includes her involvement with the PSS and her help in establishing the AMA Victoria Peer Support Service in 2008. She has also travelled extensively in Australia and the United Kingdom promoting the welfare of pharmacists and pharmacy students.
Ms Dunkley said a highlight of her work was 'being able to make a difference to the lives of those we care for as pharmacists'.
'PSS is about caring for each other within the pharmacy profession to ensure that as a profession we can care for the Australian community,' she said.
'I really value the generosity of the PSS volunteers in giving their time and energy to be there for their colleagues in times of stress.'
The inaugural Victorian Early Career Pharmacist (ECP) of the Year title was won by Amanda Cross MPS. A postdoctoral research fellow at the Monash Department of Clinical Epidemiology, Cabrini Institute, Dr Cross has already gained a high level of expertise in research and clinical practice and is an exemplary role model for other ECPs. She is also an Australian Pharmacist columnist.
[caption id="attachment_8791" align="alignright" width="219"]  Amanda Cross MPS[/caption]
Her PhD, awarded this year just months before giving birth to her second child, focused on the prevalence and impact of potentially inappropriate medication use in older people with cognitive impairment, which has implications for medicine safety in Australia.
Dr Cross said she chose to do a PhD to try and make a difference on a larger scale.
'I would frequently see patients struggling with medicine adherence and commonly using inappropriate medicines,' she said.
'Medicine safety is important to me because as a pharmacist it is my responsibility to ensure people are taking the right medicines, at the right dose, for the right duration to ensure the medicine is creating more benefit than harm.'
[caption id="attachment_8782" align="alignright" width="219"]  Roslyn Stewart MPS[/caption]
The Victorian Pharmacist Medal was awarded to Roslyn Stewart MPS, in recognition of her wide-ranging, 40-year career which included time at the Fairfield Infectious Diseases Hospital during the AIDS epidemic and as a senior pharmacist at the Royal Melbourne Hospital before 20 years in community pharmacy.
She has also conducted medicines reviews in aged care facilities and the community, and does volunteer work as a Mental Health First Aid Instructor.
Reflecting on her career, Ms Stewart said being a pharmacist offered a wealth of options.
'I have taken advantage of this, working in research, hospital and community pharmacy,' she said.
'I have enjoyed each new challenge. Few careers provide this type of flexibility.'
[post_title] => Leading Victorian pharmacists honoured
[post_name] => leading-victorian-pharmacists-honoured
[title_attribute] => Leading Victorian pharmacists honoured
[title] => Leading Victorian pharmacists honoured
[href] => https://www.australianpharmacist.com.au/leading-victorian-pharmacists-honoured/
Leading Victorian pharmacists honoured
[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Claire O'Reilly was an intern pharmacist when a patient experience got her thinking about a pharmacist's role in improving mental health care. Now she's Dr Claire O'Reilly FPS – academic, mental health researcher and trainer.
How did you find this role?
There was a situation when I was an intern pharmacist and a regular patient was having an acute psychotic episode. I learned so much watching the senior pharmacist that day – she was wonderful at keeping the patient calm and in the pharmacy until we could get help. It led me to reflect that we don't really teach pharmacists how to handle those situations.
What did you learn early, during a University of Sydney project evaluating the role of pharmacists within community mental health teams?
I was doing medication reviews and participating in team handover meetings and saw pharmacists could really help address polypharmacy and the many physical health issues that arise, particularly in complex mental health cases.
Now you're a senior lecturer, what are your research focusses?
One focus is on how we can better prepare and upskill pharmacists to feel confident supporting people with a mental illness. The other is growing the evidence base for how pharmacists can contribute to better outcomes for people with mental illness. We're doing projects around how pharmacists can screen people who might be at risk of depression, and how they can intervene and support in a mental health crisis.
Day-to-day, what are the biggest challenges you face?
In a university academic role there is always the challenge of juggling teaching and research commitments and there's often pressures around publishing your work and sourcing grants to support it.
Before I embarked on this career pathway it would have been helpful to have more insight into challenges around getting grant funding but, having said that, I don't think it would have changed my decision.
What is the most satisfying part of your job?
The most tangible rewards are related to pharmacists who have come along to a training course I've run and contacted me afterwards to say, 'thank you so much for the skills that I learned. This person came into the pharmacy in a crisis and I felt so much more confident to be able to help them due to the training'.
Where will this career path take you?
I hope to continue to develop the evidence base for pharmacists in mental health care so that we can design some more specific career pathways. Ideally, I'd like to see the creation of a primary health care mental health pharmacist role. I'd also like to see more opportunities in the community pharmacy setting, for embedding pharmacists within community mental health teams, and for pharmacists playing roles in mental health triage, early intervention, crisis support and suicide prevention.
Pharmacists interested in mental health can consider PSA CPD point offerings at https://my.psa.org.au/s/education-catalogue:
Standard Mental Health First Aid (up to 24 CPD credits)
Blended Mental Health First Aid in the Pharmacy (up to 24 CPD credits)
Mindfulness Workshop (up to 4 CPD credits)
Mums & Bubs & Dads too – Postnatal Depression & Developmental Milestones (up to 2 CPD credits)
Anxiety: Rethinking the options (up to 3 CPD credits).
Dr Claire O'Reilly FPS University of Sydney senior lecturer in pharmacy practice
8:00 am: Prepare response to research paper review
Arrive at work, check and respond to colleague and student emails, prepare response to reviewer comments on a research paper investigating peoples' experiences of stigma and discrimination in mental illness. Get a coffee!
9:00 am: Honours student supervision
Meet with pharmacy honours student to discuss progress with honours research project investigating pharmacists' experiences of people who have died by suicide and resulting personal and professional impacts.
10:00 am: Video conference on research project
Join a video conference with interstate research colleagues to discuss details of an upcoming research project developing a pharmacist-led support service for people living with severe and persistent mental illness, focussing on improving adherence and physical health care needs of consumers.
11:00 am: Curriculum planning
Meeting with pharmacy academic colleagues to discuss development of our new pharmacy undergraduate curriculum.
12 pm: Working lunch
Lunch and prepare materials for afternoon of teaching pharmacy students.
1-5 pm: Mental health training for students
Deliver a session of Mental Health First Aid (MHFA) training to fourth year pharmacy students. This is provided to all our final pharmacy students as an embedded part of our BPharm and MPharm curricula. In the weeks following MHFA training our students undergo simulated patient assessment to test their newly acquired MHFA skills.
5:00 pm: Academic day ends
Head home to spend the evening with my family.
Want to find out more about different career pathways for pharmacists? Visit www.psa.org.au/careerpathways [/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
[post_title] => The mental health researcher
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The mental health researcher
[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Dimitra Tsucalas FPS, co-owner of Ascot Vale Supercare Pharmacy, has seen it all. From late-night triage, shift workers, opioid seekers and everything in between, she says the best thing about 24-hour trade is the ability for patients to access a healthcare professional at any time.
What are the patient benefits of Supercare 24-hour pharmacies?
The benefits are essentially that they can approach a health professional to ascertain whether they need to get something that can resolve their problem reasonably quickly or [whether] they need to get to the next level to an Emergency Department or see a doctor; whether it's something they need to worry about or not.
Essentially, they are seeing a health professional to triage – to either treat at a primary care level or move into the next stage – and they're accessible at all hours.
So, at 2am when the itch becomes absolutely intolerable they can come and see someone. Or if symptoms are so problematic that it's causing them anxiety they can come and see someone and decide whether they need to go to the Emergency Department.
What are challenges you might face after hours?
One of the biggest challenges was managing patients seeking over-the-counter codeine products. Now that has shifted to codeine containing and/or other medicines that are dependence inducing or potentially dangerous.
This issue is addressed to a great extent by SafeScript. But the challenge with SafeScript is that the pharmacist then becomes a police officer.
Certainly at night, people will try to obtain medicines when they shouldn't. A refusal to fill a script can create the potential for confrontation – both physical and verbal. For young graduates or new employees working overnight, it can be quite confronting.
How long has your practice been using SafeScript?
Since the beginning. We use FRED pharmacy software, so any SafeScript warnings pop up as an alert, urging us to look into the person's supply history.
What are you most proud of from your involvement in a Supercare pharmacy?
It is a big job transitioning from eight staff to 28 staff. It introduces a lot of new learning opportunities and challenges and you've got to keep making it work. You are professionally stimulated. I think all after-hours work can be, especially if you are working on your own.
So, pharmacists working on their own of an evening and overnight have to make calls that they don't make necessarily on their own through the day. They can't call a doctor and they can't call a colleague so they will have to make the call. I think it's empowering. The best thing about 24-hour trade is professional accessibility.
Dimitra Tsucalas on a typical overnight shift
Unsure about whether to go to hospital for stitches, a mum brings in her two-year-old boy with a minor gash over his eyebrow. It is a small, clean cut. The bleeding has stopped and there are no red flags in his behaviour or appearance. I suggest some Solosite® gel to keep it moist and promote healing, and tell her to monitor for redness, inflammation or easily visible pus. I tell her to come back in or see a GP for review in 1–2 days if the wound is not healing.
A mother brings in her daughter, 17, who has an exam the next day. Unwell and unable to focus or study, she has urinary frequency indicating a possible urinary tract infection. Her options: call overnight doctor services for assessment and possibly an antibiotic script if indicated; purchase hexamine as a stop-gap until her GP can be seen next morning or after her exam; or try the Instant-Script® service which assesses and allows for a trimethoprim script so she can begin treatment before review by her GP.
A pregnant lady is brought in by her partner with dizziness, weakness and fainting. She is unable to keep anything down so dehydration is possible.
We provide a private consult room for her to lie down while taking her blood pressure and blood sugar, and then decide to call an ambulance.
She is taken to the Emergency Department for assessment.
A regular customer arrives with a script she forgot to fill earlier. She asks about an itchy eye corner for which she had already tried allergy drops numerous times in recent months.
A slightly elevated area near her nose bridge is visible, which is still itchy. I don't supply her a product. Instead, I suggest a referral to an ophthalmologist or at least an optometrist for triage.
She calls a month later: it was a malignant growth which has been removed. She gives her thanks.
The phone rings. It is a dad with an 18-month-old baby calling about a dose of paracetamol, but he only has a bottle of Panadol® 5–12 Years at home.
He asks if this is ok, and about the size of the dose.
I tell him that it's fine and ask how much the baby weighs so I can calculate the dose.
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[post_title] => Night moves
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Australian Pharmacist
Home Industry Pharmacy services in bushfire crises
Ann Winkle MPS
Photo: Sean McGowan
Since Christmas, the NSW south coast, East Gippsland, the Hume region and Portland in Victoria and Kangaroo Island off South Australia have been devastated by bushfires resulting in 28 deaths, more than 6.5 million hectares of land burnt – the size of South Korea – and the destruction or damage of about 3,000 homes.
Kangaroo Island fires. Photos courtesy Kerry Tyley
It's been an emotional time for many in the profession, including Mr Tiong, but, 'as pharmacists, we have an obligation … to act in the patient's best interest and ensure continuity of care and supply'. A good relationship with the local hospital and doctors also helps.
Pharmacist Jenny Brichacek from Prumms Pharmacy in Pambula on the south coast of NSW reported that the supply of asthma inhalers ran out in all the town's pharmacies, around New Year at a time of increased need because of smoke following intense fires. Extra stock requests were directed to the local base hospital before supplies were flown in from Victoria. A similar situation evolved at Narooma Pharmacy about 100 kilometres further north.
Helen Feng, owner of the Alliance Pharmacy in Tallangatta, VIC, with members of the local Country Fire Authority crew. Photo: supplied.
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Industry AP Staff - January 22, 2020
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