How to reinvigorate self care? -

01_Feb Cover_PM_0212_rt.qxp:01_PM_0112 15/02/2012 10:56 Page 1
Antiplatelets &
Recruiting patients to the NMS
Pregnancy &
Guidance for a healthy pregnancy
Nutrition & weight
Helping customers fight the fat
Wound care
in pharmacy
Tackling hard-to-heal wounds
How to reinvigorate self care?
Reckitt Benckiser’s
controller, Trevor Gore,
said that protocols act
as a “safety blanket” in
a risk-averse environment and suggested
that they might be
more beneficial if
used for a limited
time, until pharmacists and consumers
become familiar with
the product.
It was agreed that
if the self care market
is to move forward,
the focus of care must
shift towards people’s
needs and away from
pharmacists being the
guardians of drugs.
Conference speakers at �Self Care 2020: Achieving the Vision’
Pharmacy Magazine’s Self Care 2020 conference, which took
place in Windsor earlier this month in association with the
PAGB, brought together senior industry figures to discuss how
to reinvigorate self care in community pharmacy
Pharmacists, manufacturers and
regulators all need to reappraise
their approach towards both
OTC medicines and POM-to-P
switches if the self care market is
to be reinvigorated. That was
the consensus among speakers
at Pharmacy Magazine’s Self Care
2020 conference, held earlier this
month, which invited a number
of stakeholders to come up with
a new model for self care.
Research company Hamell
Communications identified that
while some pharmacists fully engage with POM-to-P switches, a
large proportion (around 75 per
cent) only support switches that
they feel are low risk, and a third
group resist them altogether.
“It is not the practical aspects
of time restrictions, price or dose
of the product that inhibits
support, but personal beliefs and
behaviours,” said clinical director
Dr Alison Carr. With appropriately targeted interventions these
could be changed, she said. “If
customers’ perception of pharmacists improved, if pharmacists
received more targeted training
or if they were involved in the
process before the product was
reclassified, it could make a
difference to that product’s
success,” she added.
Regulatory issues were a recurrent theme at the conference,
with manufacturers criticising
the overly complex nature of
the current switching process,
spilling over into pharmacy in
the form of lengthy protocols.
Andrew Clark, trading controller
at GlaxoSmithKline, posed the
questions: “Does the protocol
achieve what it is meant to?
Does it put patients and pharmacists off?”
islation barriers and involving
pharmacists in decisions about
medicines reclassification.
Sheila Kelly, PAGB chief executive, took the opportunity to
highlight that the PAGB has been
Finally, Rob Darracott, chief
executive of Pharmacy Voice,
urged pharmacists to focus on
positive outcomes and not be
disheartened by criticism in the
media. “The Daily Mail can
“The focus of care must shift
towards people’s needs”
working with the MHRA on a
new set of guidelines due out
in the summer that will help
streamline the switching process.
As a part of this, stakeholders will
be involved from the start.
always think of a way to catch us
out but day in, day out, good
things happen in pharmacy. How
we knit our ideas together so that
this good is recognised is the
In the closing session,
delegates drew up a
list of objectives that
need to be met for
community pharmacy
to achieve its self care
vision by 2020.
A key priority was the need to
improve the education process
for both pharmacists and their
teams, to ensure that they were
equipped to respond to change
and communicate pharmacy’s
roles to both the public and GPs.
“To change the mindset we
need to start at undergraduate
level so that pharmacists develop
the leadership and management skills they need,” Liam
Stapleton, managing director,
Metaphor Development, told the
“We must educate pharmacists to be less risk averse and
include GPs in training so that
they are on our side,” added
David Wood, director of clinical
services, Communications International Group.
In addition, delegates agreed
that changes were needed to
facilitate POM-to-P switches,
such as removing European leg-
02_News_PM_0212_rt _to liz.qxp:02_PM_0212 10/02/2012 16:26 Page 2
email: [email protected]
Industry blames parallel exports
for medicines supply problems
Steve Turley, EMG vice-chair
added: “The issue is with a small
number of companies who hold
wholesaler licences. We need to
legally separate the dispenser
and the wholesaler, as there is a
conflict of interest between these
business models.”
The speakers rejected proposals to relax medicines quotas,
insisting that they were necessary to ensure equal access to
Pharmacy bodies were severely critical of the industry’s
stance on medicines shortages,
saying that problems needed to
be addressed across the entire
supply chain.
Other parties have been invited to give their views during
three further evidence sessions
as part of the inquiry.
With various long-term conditions
accounting for 70p in every ВЈ1 spent
on healthcare, things cannot carry on
as they are in the NHS. Furthermore,
everyone agrees that a greater
emphasis on self-care would give
people more control over their health
and improve their quality of life.
But it needs everyone to buy into the self-care
ethos if we are to turn policy and intent into effective
implementation. This will require a change in attitudes
and behaviours by the public and new models of care
for healthcare professionals, including pharmacists.
It is restating the obvious to say that community
pharmacy has a key role in promoting and enabling
self-care. Yet, with the current emphasis firmly on NHSfunded service development (itself a rather precarious
proposition), the sector risks underplaying its hand.
How to reinvigorate the self-medication market and
put self-care back at the centre of pharmacy practice
were the central themes of a conference organised
earlier this month by Pharmacy Magazine and PAGB,
attended by senior figures from the profession, industry
and Government (see front page story).
One of the key messages from the conference
was that there needs to be more joined-up thinking
between manufacturers, regulators, doctors and
pharmacists on matters such as OTC medicines for new
indications, models of POM-to-P switching, information
provision for consumers and training requirements for
pharmacists and their staff.
So let’s have the debate and start to address these
issues. It is in everyone’s interest to fully engage with
the self-care agenda. A more detailed report of the
conference will appear in next month’s issue.
The pharmaceutical industry
has blamed parallel exporters for
the medicines shortages crisis
and called for legislation to separate pharmacies’ wholesaling
and dispensing functions. The
suggestion was made by the Association of the British Pharmaceutical Industry (ABPI) during
an evidence session last month
at the All-Party Pharmacy Group
inquiry into medicines shortages
(reports Charlotte Rigby).
Representatives from the
ABPI, the European Medicines
Group (EMG) and pharmaceutical company Novartis claimed
that the shortages were occurring
because medicines that were
intended for UK patients were
being exported by a small number of sources, despite measures
introduced by manufacturers to
provide emergency stock. They
argued that a legal distinction
between pharmacies’ dispensing
and wholesaling functions would
enable manufacturers to target
drugs in short supply by creating
clearer audit trails.
Heather Masters, director of
commercial operations at Novartis, said: “We have introduced
short-term solutions including
patient priorities and emergency
supplies but we need a longterm, more sustainable solution.
A legal separation between
pharmacy and wholesale would
help us to know with whom we
are dealing.”
Richard Thomas
Reckitts triumphs at this year’s SMaRT Awards
Linen Hall, 162-168 Regent Street,
London W1B 5TB. Tel: 020 7434 1530
Fax: 020 7437 0915
Email: [email protected]
EDITOR: Richard Thomas, BSc, MRPharmS. ASSISTANT EDITOR: Charlotte Rigby. EDITORIAL
CONSULTANT: Liz Platts. CLINICAL DIRECTOR: Professor Alison Blenkinsopp OBE PhD, FRPharmS.
FEATURES: Asha Fowells, Sasa Jankovic, Charlotte Rigby. CO-ORDINATOR: Lesley Anderson.
DESIGN: Tony Gummer, Truprint Media. COMMERCIAL DIRECTOR: Martin Calder-Smith.
Lesley Johnson MRPharmS. PUBLISHINGDIRECTOR: Felim O’Brien. Editorial Panel: Professor Alison
Blenkinsopp OBE PhD, FRPharmS, Professor of the Practice of Pharmacy, University of Bradford;
Dr David Temple PhD, FRPharmS, Welsh School of Pharmacy; Dr Colin Adair MPSNI, director
NICPLD; Dr Gillian Hawksworth, PhD, FRPharmS; Mr Peter Curphey FRPharmS; Mr Alan Nathan
FRPharmS, lecturer King’s College, London; Mr Hemant Patel FRPharmS, past-president RPSGB;
Mr Mark Koziol MRPharmS, chairman PDA; Mr Liam Stapleton MRPharmS, consultant, Metaphor
Development; Mr Steve Howard MRPharmS, pharmacy superintendent, Lloydspharmacy;
Sue Sharpe, chief executive PSNC.
Published under licence by Communications International Group Ltd, В© Groupe Eurocom Ltd.
CIRCULATION/SUBSCRIPTION ENQUIRIES: The National Pharmacy Database, Precision
Marketing Group, Precision House, Bury Road, Beyton, Bury St Edmunds IP30 9PP.
Tel: 01284 718912; email: [email protected]
1. Competitions are only open to pharmacists/pharmacy assistants currently employed at registered UK
premises. 2. Only one entry is allowed per pharmacist/assistant. 3. The names
of competition winners can be obtained by sending a SAE to the address above.
A Communications
International Group
Reckitt Benckiser (RB) has
scooped the coveted Best Overall Company prize at the tenth
annual SMaRT Awards.
Fighting off fierce competition from GlaxoSmithKline, a
previous winner of the accolade,
RB was voted into top spot by
readers of Communications
International Group’s pharmacy
titles – Pharmacy Magazine,
Training Matters, P3, Independent Community Pharmacist and
Beauty Magazine. The company
was clearly a favourite among
readers, as it also walked away
with the Best Sales Force award
and Best Support Package for
Multiple Pharmacy.
McNeil Products also had
cause for celebration as it picked
up a total of five awards: Most Innovative Company; Best Overall
Brand for Nicorette; Best New
Product Launch and Effective
Marketing Award: Large Budget
for Nicorette QuickMist Mouthspray; and Best Educational
Initiative for Pharmacy Support
Staff for Regaine for Men Foam.
Meanwhile Mark James, group
managing director of AAH
Pharmaceuticals and BAPW
chairman, has accused health
ministers of being “in denial”
regarding drug shortages.
His comments were made following a Government response
to written Parliamentary questions from the Conservative MP
Margot James. Ms James asked
what steps the Government is
taking to address delays in the
supply of prescribed medicines.
In reply, health minister Simon Burns stated that “some
shortages and delivery delays
are inevitable” and that the
Department has “well established arrangements for dealing
with these”.
Mr James responded: “If the
Department of Health has �well
established arrangements’ for
dealing with the shortages, what
are these? And if they exist, why
are they not working? This is a
worryingly complacent response
which shows no understanding
of the scale or seriousness of the
Guidance produced by the
Department of Health has had
no impact at all and problems
with the availability of certain
medicines are as bad as ever, he
“Wholesalers have put forward constructive proposals
including amending regulations
to reflect new patient service
obligations, independent third
party monitoring and improved
emergency supply arrangements. But we will not make
progress unless the Department
of Health is willing to play its
The blame game has to stop and
all parties must thrash out a solution to this problem once and for
all. How much longer are patients
going to be made to suffer?
Reckitt Benckiser picking up the prize for Best Overall Company
Herbal medicines brands also
triumphed on the night with A.
Vogel’s Pharmacy Herbal Handbooks programme topping the
Best Educational Initiative for
Pharmacists category and Potter’s Herbal Remedies going
home with the Effective Marketing Award: Small Budget.
Other winners included Procter & Gamble for its Pharmacy
Care Programme (Best Initiative
from a Health and Beauty Brand
or Company), MSD’s Eczema- (Best Patient Support) and Pfizer’s Healthy Partnerships NMS Training (Best
Professional Services Support).
Speaking at the awards, held
earlier this month in Windsor
and attended by nearly 300
people, Pharmacy Magazine
editor Richard Thomas said:
“We believe strongly that a close
relationship between industry
and community pharmacy is
vital, more so than ever in these
challenging times.”
03_News_PM_0212_rt.qxp:03_PM_0212 13/02/2012 13:31 Page 3
news in brief
GSK unveils New approach to
grand plans pharmacy standards
for 2012
GlaxoSmithKline has announced
plans to combine the strengths of
its healthcare, drinks, and sports
and nutrition brands to drive
sales and engage with its customers during 2012. Despite the
economic downturn, the company aims to support its brands
with multi-million pound marketing campaigns and investment in science and innovation,
with the aim of becoming the
world’s first �fast-moving consumer healthcare company’.
Peter Harding, general manager for GSK Consumer Healthcare, Great Britain and Northern
Ireland, said: “GSK is a British
company with a fantastic portfolio of brands that British consumers love and trust. Our
brands are built on unrivalled
scientific expertise and grounded
in consumer and shopper understanding. Far from retreating
from the current global downturn, our world-class team of
people are seizing the opportunities for growth that a disruptive
economic cycle brings.”
The General Pharmaceutical
Council (GPhC) is adopting
a more flexible, less detailed
approach to the regulation of
pharmacy premises in a new set
of draft standards. The pharmacy
regulator is seeking the views
of all stakeholders, including
patients and the public, pharmacy professionals and representative organisations on the
proposed regulatory changes in
a consultation, launched earlier
this month.
The draft standards are
grouped into five main principles covering: governance; staff;
premises; medicines management; and equipment and facilities. At the launch, Bob Nicholls,
GPhC chair, said: “The draft standards set out what patients and
the public should be able to expect from their local pharmacy.”
The standards focus on
achieving outcomes rather than
fulfilling specific criteria, in order
to take account of the rapid
pace of change in pharmacy and
the wide variation in pharmacy
Duncan Rudkin, GPhC chief
executive, explained: “We recog-
Bob Nicholls
nise that our proposed standards
are different from the more
detailed rules-based approach
that pharmacy is used to. The
onus will be on pharmacy owners and superintendent pharmacists to decide how they meet
these standards.”
The consultation, �Modernising pharmacy regulation’,
also outlines the GPhC’s requirements for pharmacy registration
and approach to compliance
and enforcement. To contribute
to the consultation, visit the
website (www.registeredphar11 17213 PBB TAC New PHARM 1/2Pg
macies. org)5/10/11
by May 7.
email: [email protected]
Pharmacy bodies call for ’24-hour
supply’ commitment
Medicines supply issues will not be resolved until
manufacturers and wholesalers commit to implement best practice guidance that calls for supply
within 24 hours, pharmacy representatives told MPs
as part of the All-Party Pharmacy Group’s inquiry
into medicines shortages. During the inquiry’s second
evidence session earlier this month, representatives
from the Royal Pharmaceutical Society, Pharmacy
Voice, Pharmaceutical Services Negotiating Committee and Independent Pharmacy Federation, spoke
of the burden imposed by medicines quotas on
pharmacists and urged all players within the supply
chain to work towards a solution (see also p2).
This month in TM…
To coincide with the 90th anniversary of the first
successful treatment of diabetes with insulin, we
include an in-depth report on the management of
type one diabetes. We also analyse the latest thinking
on quitting smoking in support of No Smoking Day,
while the OTC Treatment
Clinic covers obesity and
weight loss (answers on p4
0 mm
151x 225mm Magazine).
of Pharmacy
AdvagrafВ® Prolonged release hard capsules
containing tacrolimus 0.5 mg, 1 mg,
3mg and 5 mg PrografВ® hard capsules
containing tacrolimus 0.5 mg, 1 mg and
5 mg. Indications: Advagraf: Prophylaxis of
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allograft recipients. Treatment of allograft
rejection resistant to treatment with other
immunosuppressive medicinal products
in adult patients. Prograf: Prophylaxis
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heart allograft recipients. Treatment of
allograft rejection resistant to treatment
with other immunosuppressive medicinal
products. Please consult the relevant
Summary of Product Characteristics before
prescribing particularly in relation to sideeffects, precautions and contra-indications.
Legal Classification: POM. Date of
Revision: February 2011 Marketing
Authorisation Holder: Astellas Pharma
Europe B.V. Elisabethof 19, 2353 EW
Leiderdorp, Netherlands. Further information
available from Astellas Pharma Ltd, 3rd
Floor, Future House, The Glanty, Egham,
TW20В 9AH. For medical information
phone 0800В 783В 5018
The British National Formulary
recommends switching between different oral formulations
of tacrolimus requires careful therapeutic monitoring
Changes to oral tacrolimus therapy should be made only
under the close supervision of a transplant specialist
Unintentional switching between tacrolimus formulations
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It’s up to you
Tacrolimus. Be specific.
Always use the brand name
Adverse events should be
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Date of preparation: October 2011
Different formulations of oral tacrolimus are not bioequivalent or freely
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Find out more
11-17213_PBB TAC NEW Pi_PharmMag_Half Page_AW.indd 2
2012 3
04_Insight_PM_0212_rt.qxp:04_PM_0212 03/02/2012 11:32 Page 4
staff training
by Alexandra Humphries*
I have been watching the
reports on the latest campaign
to decriminalise controlled
substances, such as cannabis,
with growing dismay and alarm....
THE arguments for decriminalising controlled substances are
usually financial (it would save
the police and courts millions
of pounds a year) or social (it
would allow people who use
such drugs to feel less marginalised and, anyway, there is no
evidence that cannabis smokers
progress to �harder’ drugs).
It’s all very well for prominent
figures, such as Sir Richard Branson, to say that cannabis should
be legalised, it does no harm and
people should have free choice
whether to use it or not – but I
think that’s wrong. I see the type
of client that makes Frank Gallagher from �Shameless’ look
posh, swaying about the streets,
not only suffering from their
addictions but also multiple
physical health problems.
They are often manipulated
by others, in abusive relationships, have neglected children
Now, if the estimated savings
to the legal system from decriminalising cannabis were to be put
into intensive programmes of
help, and if there were facilities
to hospitalise people who are
a danger to themselves through
alcohol or drug abuse, then I just
might be persuaded to change
my mind.
I have made my feelings on NMS
clear in the past few months but
I have managed to hit my NMS
target for two months in a row
now. That said, I was still feeling
unsure of the value of most of
the interventions I made.
However, last week a patient
called in to tell me that following
my referral to the GP of a suspected ADR, she had been telephoned by the doctor and following that consultation had had
an appointment resulting in
“I have managed to hit my NMS
target for two months in a row”
living in appalling conditions,
and have got past �choice’ because of the hopelessness of
their situations. Making cannabis
legal will only gloss over the
enormity of their problems.
Public health campaigns
have made smoking socially
unacceptable because of health
problems to smokers and those
around them. Yet cannabis
smoke is just as likely to cause
harm as tobacco smoke.
There are also moves to limit
alcohol use by increasing prices
because of the burden of alcoholrelated liver disease – not just
in the lost and the hopeless but
also the nice middle class folk
who sit at home enjoying a glass
or three of red.
more tests and a change of treatment. Job done!
I just hope that, when the
powers-that-be analyse the
benefits of the NMS, they don’t
expect every intervention to
result in something to report.
When it comes to MURs I tend to
shy away from offering them to
people taking antipsychotics,
which is probably discriminatory. I feel that, as I don’t know
the diagnosis in these cases, I
might make the patient’s situation worse.
On the one occasion when I
decided to make an effort, the
customer was uncomfortable
and worried about records being
kept about him; he didn’t want
the door to the consultation
room closed so confidentiality
must have been compromised.
I did say we needn’t continue,
but we did get to the end of
the review. However I wonder
about the cost to his mental
health as I haven’t seen him since.
In such circumstances I feel
that we need more partnership
with the specialist services and
(here we go again) access to relevant medical records. I know
that if I raise concerns regarding
prescribing for some patients
with mental health issues, the
GP will usually say that he/she
will consult with the mental
health services before resolving
the issue. Maybe the time has
come to say that we can’t be
specialists in everything....
The race to open 100-hour
pharmacy contracts in GP surgeries continues apace. Such
pharmacies are not needed and
contractors are deluding themselves if they think it is a licence
to print money.
I also wonder at the quality of
service provided as those that I
have spied on locally are shoehorned into a corner and seem to
have minimal staff. At one the
single pharmacist apparently
works more than 50 hours a week.
Four such contracts have
opened locally and, while it has
impacted on those pharmacies
closest to the surgeries, the pharmacy I currently work in has
seen an increase in our figures.
If you work in a pharmacy
that is not attached or near a
surgery, you know that you have
to be better on service, availability – in fact absolutely everything in order to attract the
customers. Which is exactly what
we’ve done.
Pharmacist Training
the otc
Supporting Training Initiatives
treatment clinic
Common conditions and their treatment options
This module has been endorsed with the NPA’s Training Seal as suitable for use by medicines counter assistants
as part of their ongoing learning. Complete the questions at the end to include in your self-development portfolio
All pharmacists are
Obesity and weight loss
required to engage
in CPD. Activities
such as training your
professional support
staff are important
CPD triggers. This
Pharmacist Training Support column runs in
conjunction with this month’s OTC Treatment
Clinic in Training Matters
module 178
Welcome to TM’s OTC
Treatment Clinic series. This
handy, four-page section is
specially designed so that
you can detach it from the
magazine and keep it for
future reference.
Each month, TM covers
a different OTC treatment
area to help you keep up-todate with the latest product
developments. In this issue,
we focus on constipation. At
the end of the module there
are multiple choice
questions for you to
complete, so your progress
can be monitored by your
You can find out more in
the Counter Intelligence Plus
training guide.
The last six topics we have
covered are:
l Constipation
l Temporary sleep problems
l Coughs
l Period Pain and the
menstrual cycle
l Haemorrhoids
l Dry skin
You can download previous
modules from
author: Jane Feely, PhD
for this module
OBJECTIVES: After studying this module, assistants will:
• Be aware that, as a nation, we’re getting heavier and that a significant proportion of
people are overweight
• Have an understanding of the health implications of obesity
• Understand how body mass index (BMI) is calculated and what other factors help
determine whether a person is overweight
• Be familiar with the principles of a healthy diet and understand the importance of
regular, physical activity
• Know where OTC products fit into the options available to someone who is wishing to
lose weight.
As a nation our waistlines are expanding and we’re
getting heavier, something that probably isn’t
news to you. Prevalence of obesity has more than
doubled in the last 25 years and more and more
of us are at risk of health problems because of our
weight. You’ve probably seen evidence of this
among your own customers. Maybe you’re one of
the many who feel they struggle with their weight
and always seem to be trying to lose those �few
extra pounds’. This trend towards being
overweight certainly has the medical profession
and even politicians concerned. Being overweight
has implications for our health and that, in turn,
puts an increasing burden on the health service.
Obesity is a priority for the Government. The
White Paper – Healthy lives, healthy people: Our
strategy for public health in England – set out
how the Government plans to improve public
health, including how to tackle obesity. One
element of this is the Change4Life campaign
which continues to help individuals and families to
�eat well and move more.’
So, should we be concerned if we are
overweight? The short answer is �yes’. Many
people put their health at risk by eating unhealthy
food and shunning physical activity. In some cases,
they may not realise the damage they’re doing or
may not have the necessary knowledge to correct
their unhealthy choices. However, there is
evidence that people become more motivated to
lose weight if advised to do so by a healthcare
professional. From formal weight loss clinics to
This module provides pharmacists with a useful training resource
for pharmacy assistants.
Refer to: This month’s OTC Treatment Clinic on obesity and
weight loss in Training Matters. The materials are accredited
by the NPA.
в– Do I feel confident about asking obese customers whether
they have considered trying to lose weight?
в– Can I communicate the risks of obesity and the benefits of
weight loss?
в– Can I help obese people think about what they eat, when
and why, and help them identify and address their personal
barriers to weight loss?
в– Can I provide accurate information on appropriate dietary
patterns for weight loss?
в– Am I up-to-date regarding recommendations for physical
в– Am I clear about the licensed indications for both
prescription and OTC weight loss medications?
в– Do I have the knowledge and skills to provide appropriate
support for someone wanting to lose weight with the help
of medication?
в– Do I know when to refer obese people for further help?
Ensure support staff understand the following key points:
в– The risks of obesity
в– How to prevent obesity
в– The benefits of weight loss, healthy eating (including
appropriate portion control) and physical activity
в– Indications for weight loss medication
в– When to refer to the pharmacist.
I will:
■Reassess my and my staff’s interventions with obese
в– Consider developing a healthy eating guide to give to
patients who want to lose weight
■Assess the pharmacy team’s knowledge and skills in
delivering information on healthy eating, physical activity
and the role of weight loss medications
в– Train my pharmacy assistants to ensure that they can meet
the points in the training checklist and consider this as a
potential entry in my CPD record.
Answers to OTC Treatment Clinic no. 178 on
obesity and weight loss:
1.b 2.d 3.a 4.d 5.a 6.b
05_PM_0212:05_PM_0212 09/02/2012 09:45 Page 1
e ski
n all
wrapped up
Aveeno is clinically proven to
soothe and relieve from day one1
Formulated with active colloidal oatmeal,
proven to restore the epidermal barrier2
Easily absorbed, non-greasy emollient
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Available with or without prescription
References: 1. Double-blind, randomised, comparative clinical study
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AVEENO® Dry skin study – February 2008, n=133 participants at week 2.
06_Celtic_PM_1211_rt.qxp:06_PM_1211 02/02/2012 15:19 Page 6
npa view
The Department of Health’s new Public Health Outcomes
Framework for England contains a number of indicators
that fit well with the community pharmacy skills set
Public health indicators
Pharmacy and the EU highlight pharmacy’s potential
Decisions made in Brussels can seen
remote and irrelevant to pharmacy but
the impact on business and practice in
the UK can be very close to home, says
Gareth Jones, NPA public affairs manager
You’d be forgiven for thinking
that the only issue that matters
in the European Union right
now is the debt crisis. It’s not.
2011 saw the passing of the Falsified Medicines Directive by
the European Parliament – one
of the most significant European Directives for community
pharmacy that we have ever
The aim of the directive is to
reduce the risk of counterfeit
medicines reaching patients by
introducing authentication systems and new safety features
on packaging. The directive will
take a number of years to implement, but it is likely that by
around 2016 pharmacists in the
UK will be expected to scan
many medicines at the point of
dispensing to verify that they
are not counterfeit.
It is paramount that implementation is risk-based and proportionate – protecting patients but
not introducing unnecessary
bureaucracy. We also want to
ensure that pharmacy owns any
data that is generated. To this
end, the NPA has been working
with manufacturers, pharmacy
representatives and other stakeholders as part of a long-term
implementation programme.
Further progress was made
in implementing the Pharmacovigilance Directive, which will
strengthen the monitoring of
the safety of medicines after
they reach the market. The European Parliament also took an
interest in adherence to medicines.
NPA board member Raj Patel, who leads the UK delegation
to the Pharmaceutical Group of
the European Union (PGEU),
was one of the keynote speakers
Gareth Jones
at a special meeting of the European Parliament to discuss
the issue. He highlighted the
contribution pharmacists in the
UK make to better medicines
management through Medicines Use Review (MURs) and
the New Medicine Service
2011 also saw the Department of Health decide to remove the so-called “three year
rule.” The restriction, which
emanated from European law,
prevented pharmacists from
overseas from working in a
pharmacy that had been open
for less than three years.
With the squeeze on national
budgets around Europe, many
Governments were looking at
how they could cut spending
on medicines and pharmacy.
Liberalisation of ownership
rules, something that is very familiar in the UK, is now firmly
on the agenda in other European countries.
Working out further details
of the anti-counterfeiting system and dealing with a proposed new directive to increase
the information patients receive
on their medicines will be high
on the NPA’s agenda in 2012.
“2011 saw the passing of the
Falsified Medicines Directive”
Improvements against the 66
public health indicators laid out
in the DH’s new Public Health
Outcomes Framework for England are expected to increase
healthy life expectancy and reduce differences in life expectancy and healthy life expectancy between communities.
The indicators are divided
into four groups:
• Improving the wider determinants of health
• Health improvement
• Health protection
• Healthcare public health and
preventing premature mortality.
Indicators include excess
weight in adults, smoking prevalence, successful completion of
drug treatment, and falls and injuries in the over 65s. The framework also considers tackling the
causes of ill-health, with indicators such as school attendance,
domestic abuse, homelessness
and air pollution.
The framework is designed to
underpin a more effective, integrated and professional public
health system that will give clear
accountability for the improvement and protection of the public’s health. It embodies localism,
with new responsibilities and resources for local government. It
also gives central government
the key responsibility of protecting the health of the population.
Public Health England will be
the new national delivery organisation for the public health system, working with partners
across the system and in wider
society to deliver support and
enable improvements in the areas set out in the framework. It
will also design and maintain
systems to protect the population against existing and future
threats to health.
From April next year, councils
will be given a ring fenced budget (a share of around ВЈ5.2bn)
and will be able to choose how
they spend it according to the
needs of their population. Those
who make the most improvements will be rewarded with a
cash incentive.
Community pharmacy has a key
role in improving the public’s
health, says Mike Holden, chief
executive of the National Phar-
macy Association, and member
of the Pharmacy and Public
Health Forum. “If you look at the
progress indicators that local authorities will be measured
against – such as fewer falls and
smokers – you can immediately
see where community pharmacy
fits in. The Healthy Living Pharmacy initiative demonstrates
what can be achieved if the energy of pharmacists and pharmacy teams is backed by commissioners.”
The emerging structures of
the NHS and public health mean
that pharmacists need to be
reaching out to GPs and local authorities to make sure that pharmacy is not overlooked when it
public health and wellbeing role.
Community pharmacies need
certainty and consistency in service commissioning, and will be
looking to the national contractual framework to support an expanded role in public health service, says Sue Sharpe, chief executive of PSNC. “This is possible
within the new commissioning
structure. We will play our part in
working with the Department of
Health to ensure that the pharmacy contract facilitates and
recognises a growing role for
community pharmacy in public
Overall success will be determined by how well policy and intent can be transferred into effective
implementation, says
Professor Richard
Parish, chief executive of the Royal
Society for Public
Health and chair
of the new Pharmacy and Public
Health Forum.
“We all have our
part to play in delivering these outcomes. We need
to use all the tools in the toolbox
if we are to make a real impact on
health in the future.”
The King’s Fund warns that
publishing data alone will not be
enough. “The key tests of
whether ministerial rhetoric on
public health is matched by reality will follow in the next few
weeks, with the announcement
of how shadow budgets will be
allocated to local authorities and
the publication of the alcohol
strategy,” says David Buck, the
King’s Fund’s senior fellow on
public health.
“Public Health
England will be the
new national delivery
comes to commissioning services, says Mr Holden. “Around
the country, pharmacists are doing excellent work in public
health – we need to get better at
making commissioners and
other healthcare professionals
aware of this contribution.”
At the launch of the framework, health secretary Andrew
Lansley stated that community
pharmacy needs to work closely
with local authorities, Health and
Wellbeing Boards and GPs, and
the current pharmacy contract
needs revisiting because it does
not lend itself to an extended
• Recorded diabetes
• Chlamydia diagnoses (15-24 year olds)
• Population vaccination coverage
• Emergency readmissions within 30 days of discharge from hospital
• Mortality from all cardiovascular diseases, cancer, liver and respiratory disease
• Under 18 conceptions
• Smoking status at time of delivery
• Smoking prevalence in adults
• Take up of the NHS Health Check programme
• Diet
• Excess weight in adults
• Falls and injuries in the over 65s
• Successful completion of drug treatment
• Proportion of physically active and inactive adults
07_PM_0212:07_PM_0212 14/02/2012 15:20 Page 1
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08_Society_PM_0212_rt.qxp:08_PM_0212 13/02/2012 13:39 Page 8
news & comment
email: [email protected]
Warning about online statins
Get the new Counter
Intelligence Dispensing
Assistants’ Course from
leading healthcare training
provider CIG Healthcare
020 7534 7220
or go to
for more information.
Researchers at the University of
Portsmouth have warned that
unregulated websites selling
statins pose a risk to the public.
Writing in Pharmacoepidemiology
and Drug Safety, Professor David
Brown said that most of the
websites studied presented
“a chaotic and incomplete list of
known side-effects and failed to
apprise consumers of the potential
problems or dangers associated
with the medication”. The
researchers looked at information
on over 180 websites from at least
17 different countries.
Deadline extended
The submission deadline for the
APTUK /AAH Technician of the
Year Awards 2012 has been
extended to April 30. With the
Diamond Jubilee conference now
being held at a later date in
September, AAH Pharmaceuticals
and APTUK are urging technicians
to use this extra time to send in
submissions for both the primary
and secondary awards and
nominations for the professional
award. Further details at
New trustees
Four new trustees have been
appointed at Pharmacist Support –
the charity for pharmacists and
their families, former pharmacists
and pharmacy students. The new
recruits, Professor Peter Noyce,
Steve Churton, Professor Denis
Anthony and Richard Fass, will all
serve a three-year term. They join
existing board members David
Thomson, Arthur Williams, Doreen
Laity, Leonard Brookes and
Professor David Johns. “Our new
members bring a wealth of
expertise to the board and are
worthy successors to our departing
colleagues,” says chairman David
Thomson. “I am very much
encouraged and optimistic for the
charity as we progress into 2012
and beyond.”
Numark calls for moratorium
Communications International Group
Linen Hall,
162–168 Regent Street,
London W1B 5TB
Numark has called for a moratorium on 100-hour applications
while the Department of Health
considers its recommendations
on market entry. In its response to
the Department’s consultation,
Numark also questions the
robustness of PNAs, challenges
the proposals regarding market exit
and the proposed exception from
the market entry test for distance
selling pharmacies. Says Mimi Lau,
Numark’s director of pharmacy
services: “We welcome the
Department of Health’s proposals
to update the market entry
regulations and have highlighted
four main areas that we believe
need addressing.”
This year looks set to be another busy one
with National Board elections and issues such
as medicines safety and the Society’s work
on decriminalisation a high priority, says Mair
Davies, chair of the Welsh Pharmacy Board
This year sees the first National
Board elections held since the
Royal Pharmaceutical Society
split from its regulatory functions
almost 18 months ago. The Board
election process begins this
month with nominations open
to RPS members wishing to
stand for election.
Being part of one of the National Boards really is a chance
to have an input, not only into
the direction of the Society over
the coming years, but the profession and its future.
For the Welsh Pharmacy
Board, our plans for this year
have member needs at the very
heart, ensuring the issues important to the profession are
addressed. Last year, we worked
very closely with local practice
forums so that we could listen to
our members and respond to
the membership’s needs and
aspirations, while providing the
support, encouragement and
recognition to help fulfil professional potential across Wales.
We know that more is achieved
by working together, so we constantly look to ensure the RPS in
Wales is fully engaged with other
organisations, the Welsh Government and the media. We have
already secured diary commitments to meet the minister for
health and social services, the
chief executive for NHS Wales,
and the Royal College of General
We will look for opportunities
to promote the importance of
pharmaceutical care in the rollout of plans for �Together for
Health’, Wales’ vision for health-
Mair Davies
“Medicines safety
will be a key
focus for all
of us this year”
care over the next five years,
and we will be keeping a close
eye on the inquiry into the contribution of community pharmacy to health in Wales, to
which we made a submission
last year.
Medicines safety will be a key
focus for all of us this year with
the Society hosting a medicines
safety symposium, �Making Great
Britain a safer place to take medicines’, in the summer. This will
build on the work of the Welsh
Pharmacy Board following the
successful medicines safety symposium held in Cardiff at the end
of 2010 in partnership with 1000
Lives Plus (Wales’ national improvement programme for the
09_PM_0212:41_PM_1111 03/02/2012 12:01 Page 1
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withdrawal symptoms during abrupt/gradual/temporary smoking cessation and to aid reduction in smoking. Dosage: Adults (18 and over): Once daily. ≥ 10 cigarettes a day start with step 1, otherwise step 2. Cessation
to be encouraged, professional advice if no quit attempt after 6 months/difficulty discontinuing use after quitting. Abrupt cessation: ≥ 10 cigarettes/day; Step 1 for 6 weeks, then Step 2 for 2 weeks, then Step 3
for 2 weeks. <10 cigarettes/day; Step 2 for 6 weeks then Step 3 for 2 weeks. Gradual Cessation (21 mg only): Prior to schedule above use 21 mg patch for 2 – 4 weeks to reduce cigarette consumption. Reduction
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10-12_Script_PM_0212_rt.qxp:10-12_PM_0212 03/02/2012 09:54 Page 10
clinical news
national strategy for COPD and asthma
Hasanin Khachi, a member of the UKCPA’s
respiratory committee, says the national
strategy for COPD and asthma represents
an opportunity for community pharmacists
to play a big role in its success
COPD is the fifth biggest killer
in the UK, accounting for over
30,000 deaths each year, and the
second commonest cause of
emergency hospital admissions.
Over 835,000 people are diagnosed with COPD, but it is estimated that over 2.2 million remain undiagnosed.
The prevalence of asthma is
among the highest in the world,
with 5.9 per cent of the population in England affected. Asthma
accounts for over a 1,000 deaths
a year, with 90 per cent thought
to be preventable.
Six key objectives of the
national strategy for COPD and
asthma are to:
1. Improve respiratory health
and decrease inequalities
2. Reduce the number of people
who develop COPD
3. Reduce the number of people
who die from COPD prematurely
4. Enhance the
quality of life
for people with
5. Ensure people
with COPD receive safe and
effective care
6. Ensure people with asthma
are free of symptoms and are
supported to self-manage
their own condition.
conditions, such as COPD and
The average community
pharmacist will look after 450
asthma patients but current
research indicates that a large
proportion of these patients are
inadequately controlled.
Given that the cornerstone of
both COPD and asthma treatment is inhaled therapy, it is particularly concerning that up to
50 per cent of patients may use
their inhalers incorrectly, which
may lead to the clinical condition
worsening and increase the
likelihood of an exacerbation
leading to hospitalisation.
Furthermore, up to 70 per
cent of patients do not adhere
to some aspect of their recommended inhaler treatment. Good
adherence with inhaled therapy
is strongly correlated with reduced frequency of hospital
“The average community
pharmacist will look after
450 asthma patients”
A section has been included
within the national strategy highlighting the importance of community pharmacists and how
they can support the strategy.
While existing services, such
as stop smoking services, have
been in place for a while, newer
initiatives such as the new
medicine service and targeted
medicines use reviews represent
an opportunity to further improve adherence to medicines
for patients with long-term
admissions and lower mortality.
Targeted MURs in specific
patient groups, such as those
with COPD and asthma, have
already shown that pharmacists
increase patients’ knowledge of
their medicines and condition,
help to identify non-adherence
and address their causes. They
result in an average of 1.8 interventions per MUR carried out.
Patients newly initiated on
medicines for chronic conditions
such as COPD and asthma
may be reluctant to discuss
queries and concerns with their
doctor. Community pharmacists
are suitably placed to support
these patients following their
initiation or when collecting
repeat prescriptions.
For more information about the
UKCPA, access
or tel: 0116 2776999
Pharmacist-led adherence
services are cost-effective
Reduced emergency admissions
and savings in medications offset
the cost of pharmacist-led medication review services, according to an analysis of 117 patients
referred to the Norfolk Medicines
Support Service (NMSS). Patients
(>65 years of age) referred to the
service have difficulties managing their medication at home.
During domiciliary visits, a
pharmacist determines the problems causing poor adherence,
undertakes a medication review,
makes clinical recommendations to the patient’s GP and suggests interventions, such as compliance aids or the carer administering medicines. Four weeks
later, the pharmacist checks
whether the recommendations
have been implemented and
whether the problem is resolved.
The mean cost per patient of
prescribing and hospital admissions in the six months before
NMSS and in the six months
after intervention was ВЈ2,190 and
£1,883 – an average saving of
ВЈ307. The number of emergency
hospital admissions fell from
52 to 31.
The number of patients admitted to hospital declined from
42 to 25. Before NMSS, 19 patients were adherent according
to the Medication Adherence
Report Scale – this rose to 29
after intervention. (Int J Pharmacy Prac 2012; 20:41-49)
Drug errors in care homes
Half of UK care home residents
are at risk from serious prescribing errors, according to a study of
345 older people living in nine
residential and four nursing
Researchers used a barcode
medication administration system (BCMA) to analyse 188,249
medication attempts over three
months. On average, each resident received nine drugs.
Ninety per cent of residents
were exposed to at least one
error. In 45 per cent of cases this
was being given medication at
the wrong time. On average, each
resident experienced 6.6 potential errors.
Over three months, 52 per
cent of residents were exposed to
a serious error, such as an attempt to give them the wrong
“Older people in long-term
residential care are clearly at
increased risk of medication
errors,” said study author Ala
Szczepura, professor of health
services research, Warwick Medical School. “Since 37 per cent
of people with dementia now live
in a care home, many residents
are unable to comment on their
The BCMA system can “reliably … improve quality of care
and patient safety,” she said.
Non-compliance with system
alerts occurred in just 0.075 per
cent of administrations. (BMC
Geriatrics 2011;11:82)
Shire recently submitted its once-daily ADHD treatment lisdexamfetamine dimesylate
(Venvanse) for European approval.
This column is produced in association with the UKCPA. The views expressed are those of the author and
are not necessarily those of either Pharmacy Magazine or the UKCPA
Sycrest (asenapine) is now available as a fast-dissolving sublingual tablet for moderate to
severe manic episodes associated with bipolar I disorder in adults.
COC and dysmenorrhoea
Pill prevents
painful periods
The combined oral contraceptive (COC) pill alleviates dysmenorrhoea, a recent study in
Human Reproduction confirms.
Swedish researchers questioned three groups of 19-yearold women in 1981, 1991 and
2001. Each group, which included approximately 400-520
women, was re-evaluated five
years later using a visual analogue scale (VAS) and the verbal
multidimensional scoring system (VMS), which grades pain
and takes into account the
effect on daily activity and
analgesic use.
“We found that combined
oral contraceptive use reduced
dysmenorrhoea by 0.3 units,
which means that every third
woman went one step down on
the VMS scale; for instance from
severe pain to moderate pain.
The reduction meant that they
suffered less pain, improved
their working ability and there
was a decrease in the need for
analgesics,” reports lead author
Ingela Lindh of the Sahlgrenska
Academy, Gothenburg University. “On the VAS scale there
was a reduction in pain of nine
Independently of COC use, increasing age reduced dysmenorrhoea severity, shifting women
down 0.1 units on the VMS scale
and five millimetres on the VAS
scale. Childbirth also seemed to
reduce symptom severity, although few women gave birth
between the ages of 19 and 24
More of the women in the
youngest group (born in 1982)
reported painful periods more
frequently and worse symptom
severity. “We are unsure why this
is,” said Dr Lindh. “It may be
due to changes in the type of
oral contraceptive used – for
example, differences in oestrogen content and progestogen
type – or a different appreciation
of pain in the women born in
later years, in that they may be
more pain sensitive or are more
prepared to complain about
pain than women of the same
age but born earlier.” (Human
Reproduction doi:10.1093/humrep/der417)
10-12_Script_PM_0212_rt.qxp:10-12_PM_0212 09/02/2012 09:30 Page 11
Gout patients
The UK Gout Society recently
launched a new factsheet warning sufferers about the link between gout and other serious
medical conditions. About 1.5 per
cent of the UK population suffers
currently from gout. Apart from
excruciating pain, gout is linked
to diabetes, high blood pressure,
stroke, heart attack, angina, kidney disease, peripheral vascular
disease and psoriasis. Patients
can download the factsheet from
Pain patients and analgesics
Osteoarthritis (OA) or chronic
lower back pain patients commonly switch or discontinue
analgesics, Pain Practice reports.
Researchers analysed the prescribing of non-selective NSAIDs,
COX-2 inhibitors, paracetamol
and tramadol, as well as weak
and strong opioids, using a UK
database. Discontinuation rates
varied from 86.9 per cent with
COX-2 inhibitors to 93.2 per cent
with weak opioids in OA, and
from 86.8 per cent with strong
opioids to 97.2 per cent with
NSAIDs in chronic low back pain.
Between 30.0 per cent
(NSAIDs) and 59.6 per cent
(strong opioids) of OA patients
switched analgesic, while between 7.5 per cent (COX-2 inhibitors) and 20.2 per cent (strong
opioids) augmented therapy in
chronic low back pain. Two-
Reassuring findings about vaccines
Anaphylaxis is extremely rare
following childhood immunisation in the UK and Ireland, say
researchers who investigated
the seven reports of anaphylaxis
following immunisation among
children under 16 years between
September 2008 and October
2009. Four children reacted more
than 30 minutes after receiving
the vaccine. All recovered fully.
The estimated incidence was
12.0 anaphylaxis cases per
100,000 doses of the single component measles vaccine and 1.4
cases per million doses of the
thirds of those patients who
switched, augmented or discontinued therapy did so within two
months of starting treatment.
(Pain Practice doi 10.1111/j.15332500.2011.00524.x)
bivalent human papillomavirus
vaccine. No cases of anaphylaxis
followed �routine’ infant and preschool immunisation (including
measles, MMR and influenza)
despite approximately 5.5 million infants receiving the vaccines. “This is extremely reassuring data,” the authors concluded.
(Arch Dis Child doi:10.1136/arch
…as new
treatment is
Rilonacept – an experimental
protein that traps the proinflammatory cytokines interleukin-1
alpha and beta – might reduce
the frequency of gout flares,
according to a study funded by
In addition to allopurinol, 83
patients with gout received onceweekly subcutaneous rilonacept
or placebo. The mean number
of gout flares per patient over 12
weeks was 0.15 with rilonacept
and 0.79 with placebo. The
number of flares differed from
placebo by four weeks after the
start of treatment. Rilonacept
also reduced the proportion of
patients who experienced a
flare (14.6 per cent) compared to
placebo (45.2 per cent).
Flare rate did not rebound in
the six weeks after rilonacept’s
or placebo’s discontinuation
and adverse events were similar
between the two arms. (Arthritis
& Rheumatism doi:10.1002/
Diabetes pen for
kids from Novo
Novo Nordisk has launched a
new insulin pen – NovoPen Echo.
The company says the device is
“specifically designed to meet
the needs of children with diabetes”. NovoPen Echo includes
a memory, which records dose
and approximate time since
last injection, and a half-unit
dosing option, allowing finetuned insulin dosing.
Avastin approved
The EMA recently approved
Avastin (bevacizumab) for advanced ovarian cancer, in
combination with standard
chemotherapy (carboplatin and
Benzydamine Hydrochloride
Essential Information:
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10-12_Script_PM_0212_rt.qxp:10-12_PM_0212 03/02/2012 09:55 Page 12
clinical news
Drug-related falls in dementia patients...
Even low-dose SSRIs increase the
risk of falls and injuries among
nursing home residents with
dementia, according to the
British Journal of Clinical Pharmacology.
Researchers recorded drug
use and falls in 248 nursing home
residents over two years, amassing a dataset of 85,074 persondays. The risk of an injurious fall
increased with age (hazard ratio
[HR] 1.05) and the use of antipsychotics (HR 1.76) and antidepressants (HR 2.58).
When researchers analysed
classes of antidepressants, only
the relationship with SSRIs (HR
2.50) remained significant. Doseresponse relationships emerged
for hypnotics or sedatives (HR
2.55) and antidepressants (HR
2.97). After analysing antidepressant sub-groups, only the doseresponse relationship for SSRIs
(HR 2.98) remained significant.
The authors illustrate the risk
by considering female residents
aged 85 years. Those not on a
SSRI, hypnotic or sedative had
an absolute risk of an injurious
fall of 0.12 per cent per day. Taking 0.25 defined daily dose (DDD
– the average dose taken by adults
for the main indication) of a SSRI
increased the risk of an injurious
fall by 31 per cent.
SSRIs at a DDD of 0.5 and 1.0
increased the risk by 73 and 198
per cent respectively. The combination of 1.00 DDD of a SSRI and
0.50 DDD of a hypnotic or sedative increased the absolute risk of
an injurious fall by 373 per cent.
“Staff in residential homes are
always concerned about reducing the chance of people falling
and I think we should consider
developing new treatment protocols that take into account
the increased risk of falling that
occurs when you give people
SSRIs,” said lead author Carolyn
Shanty Sterke, Erasmus University Medical Centre, Rotterdam,
The Netherlands. “Physicians
… and younger people
Younger adults taking multiple
prescription medications are at
increased risk of falls, reports
Injury Prevention. Researchers
compared 335 people (25-60
years of age) who died or were
admitted to hospital following
falls at home, and 352 controls.
After controlling for confounders, taking two or more
medication-overuse headache
Although relatively common, previous studies have not determined either the
incidence of, or risk factors for, medication-overuse headache (MOH).
Researchers evaluated 25,596 Norwegians who did not suffer chronic daily
headache (CDH) at baseline.
Falls risk increased with SSRIs
should be cautious in prescribing
SSRIs to older people with
dementia, even at low doses.”
(British Journal of Clinical Pharmacology DOI:10.1111/j.13652125.2012.04124.x)
prescription medications more
than doubled the risk of injury
after a fall (OR 2.5). Antihypertensives (OR 3.1) and lipid lowering drugs (OR 2.5) were the medicines most commonly linked to
falls. The authors suggest considering the role of multiple prescription medications in younger
adults in programmes to prevent
falls. (Injury Prevention (doi:10.
1136/injury prev-2011-040202)
Sleep disturbances are often bedfellows with
other common diseases
Sleep quality is a real issue for
many people. Half of elderly
people report insomnia and dissatisfaction with sleep quality
(Sleep Res 2007; 16:372-80). But
insomnia doesn’t occur in isolation. About half of people who
report insomnia endure daytime
problems, such as poor concentration, reduced energy and
impaired memory (Nat Rev Drug
Discov 2008; 7:530-40), while
sleep disturbances are often
intimate bedfellows with other
common diseases.
Sleep and diabetes are closely
intertwined, for example, with
insulin secretion and blood
glucose levels showing marked
circadian fluctuations. Furthermore, several sleep disorders
seem to promote the development of metabolic syndrome
and type 2 diabetes, while poorly
controlled diabetes may trigger
symptoms such as night-time
thirst, nocturia and hypoglycaemia that disturb sleep. And,
according to some studies, up
to 90 per cent of type 2 diabetes
patients have obstructive sleep
apnoea (Chest doi:10.1378/
Mark Greener
onset’ and the �number of awakenings’ respectively. Thirty-two
per cent showed little or no
improvement in any sleep parameter.
In 36 patients, mean HbA1c
declined significantly from 9.13
per cent at baseline to 8.47 per
cent after five months’ treatment. The authors speculate
that melatonin may “reinforce
“Improving sleep seems to
enhance blood glucose control”
Improving sleep seems to
enhance blood glucose control.
In a recent study, prolongedrelease melatonin produced a
net improvement of more than
three per cent in sleep efficiency
in 55 per cent of 22 type 2 diabetes patients with insomnia
compared with placebo. Sixtyeight and 55 per cent showed
net improvements of at least 25
per cent in �wake time after sleep
Over the 11-year follow-up, 0.8 per cent of subjects developed MOH (0.72
cases per 1,000 patient years) and 1.0 per cent reported CDH without
medication overuse. Several baseline factors increased MOH risk including:
daily smoking (OR 1.8); physical inactivity (OR 2.7); a combination of
musculoskeletal conditions, gastrointestinal complaints and anxiety/
depression (OR 4.7); regularly using tranquillisers (OR 5.2); migraine
(OR 8.1); and experiencing headaches on seven to 14 days a month (OR 19.4).
Smoking, the combination of ailments, inactivity and tranquillisers did not
significantly increase the risk of CDH without medication overuse, while the
association with migraine (OR 2.3) and regular headaches (OR 6.4) was less
marked than with MOH.
The different pattern of factors suggests MOH is distinct from CDH without
medication overuse. If further studies identify these as causal associations,
improving management of co-morbid conditions, increasing physical activity,
and reducing use of tobacco and tranquilisers “may limit transformation to
Hagen K, Linde M, Steiner TJ et al. Risk factors for medication-overuse
headache: An 11-year follow-up study. The Nord-TrГёndelag Health Studies.
Pain 2012;153:56-61
Pharmacy Magazine online learning:
the mark greener column
In a nutshell....
circadian control of glucose
metabolism”, thereby improving
glycaemic control (Diab Meta
Synd Obes 2011; 4:307-13). However further studies need to
confirm these findings.
monotherapy were 47 per cent
more likely to receive antidepressants than non-diabetic
controls. The likelihood of requiring antidepressants was
highest in patients aged 30-39
years who were receiving both
oral antidiabetic medicines
and insulin (Diabet Med
doi:10.1111/ j.1464-5491.2011.
03530.x). In other words, diabetes forges another link between sleep disturbances and
psychiatric conditions.
Recent studies are starting to
unravel the biological basis of
the intimate relationship between sleep and psychiatric
disease. For example, the products of at least eight key genes
interact to drive the circadian
clock, several of which also link
to psychiatric conditions.
Variants in one circadian
gene – aptly called CLOCK –
seem to increase the risk of early,
middle and late insomnia, as
well as influencing changes in
sleep patterns during antidepressant treatment. Polymorphisms in another circadian
gene (PER3) are associated
with worse mood in the evening
(Curr Neuropharmacol 2011;9:
Another strand of the web linking diabetes and sleep problems
points to depression. In a recent
study, patients using insulin
A recent study from Korea has reported a significant association
between single nucleotide polymorphisms (SNP) in ROR1 and
PLCB1 and insomnia. Each SNP
represents a difference in a single
nucleotide: cytosine replacing
thymine, for example. SNPs do
not usually alter the amino acid
code or the change affects noncoding DNA, so most SNPs are
clinically silent but some are
clinically important.
Genetic studies link ROR1 to
bipolar disorder and PLCB1 to
schizophrenia. Circadian disturbances and the metabolic syndrome (forging another link to
diabetes) are common in both
disorders. In other words, certain
SNPs link sleep, diabetes and
psychiatric diseases (PLoS ONE
Yet sleep isn’t about to give up
all its secrets. In the early 1980s,
doctors investigated a spate of
deaths among Laotian Hmong
refugee men aged between 25
and 50 years in the US who died
in their sleep. Yet all seemed
healthy and the autopsies found
nothing amiss. Clinical detective
work linked this �Sudden Unexpected Nocturnal Death Syndrome (SUNDS)’ with sleep
Despite these important insights, treatment has in fact
advanced little since a doctor
in 1834 recommended avoiding
“heavy suppers” and “late hours”
and keeping “as cheerful … as
13_PM_0212:13_PM_0212 13/02/2012 13:33 Page 1
“ I used to be stuck on smoking.
I’m sticking with quitting”
Effectively helps manage cravings and other withdrawal symptoms
that can threaten a successful quit attempt in week 11,2
Well tolerated with a good safety profile1
Help your customers quit. Recommend NICORETTEВ® INVISIPATCHв„ў
Designed to help your
smokers quit for good
Nicorette Invisi Patch Product Information:
Presentation: Transdermal delivery system available in 3 sizes (22.5, 13.5 and 9cm2)
releasing 25mg, 15mg and 10mg of nicotine respectively over 16 hours. Uses: Nicorette Invisi
Patch relieves and/or prevents craving and nicotine withdrawal symptoms associated with
tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to quitting,
to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking
for smokers and those around them. Nicorette Invisi Patch is indicated in pregnant and
lactating women making a quit attempt. If possible, Nicorette Invisi Patch should be used in
conjunction with a behavioural support programme. Dosage: It is intended that the patch is
worn through the waking hours (approximately 16 hours) being applied on waking and
removed at bedtime. Smoking Cessation: Adults (over 18 years of age): For best results,
most smokers are recommended to start on 25 mg / 16 hours patch (Step 1) and use one
patch daily for 8 weeks. Gradual weaning from the patch should then be initiated. One
15 mg/16 hours patch (Step 2) should be used daily for 2 weeks followed by one 10 mg/
16 hours patch (Step 3) daily for 2 weeks. Lighter smokers (i.e. those who smoke less than
10 cigarettes per day) are recommended to start at Step 2 (15 mg) for 8 weeks and decrease
the dose to 10 mg for the final 4 weeks. Those who experience excessive side effects with the
25 mg patch (Step 1), which do not resolve within a few days, should change to a 15 mg patch
(Step 2). This should be continued for the remainder of the 8 week course, before stepping
down to the 10 mg patch (Step 3) for 4 weeks. If symptoms persist the advice of a healthcare
professional should be sought. Adolescents (12 to 18 years): Dose and method of use are
as for adults however, recommended treatment duration is 12 weeks. If longer treatment
is required, advice from a healthcare professional should be sought. Smoking Reduction/
Pre-Quit: Smokers are recommended to use the patch to prolong smoke-free intervals and
with the intention to reduce smoking as much as possible. Starting dose should follow the
smoking cessation instructions above i.e. 25mg (Step 1) is suitable for those who smoke
10 or more cigarettes per day and for lighter smokers are recommended to start at Step 2
(15 mg). Smokers starting on 25mg patch should transfer to 15mg patch as soon as cigarette
consumption reduces to less than 10 cigarettes per day. A quit attempt should be made as
soon as the smoker feels ready. When making a quit attempt smokers who have reduced to
less than 10 cigarettes per day are recommended to continue at Step 2 (15 mg) for 8 weeks
and decrease the dose to 10 mg (Step 3) for the final 4 weeks. Temporary Abstinence: Use
a Nicorette Invisi Patch in those situations when you can’t or do not want to smoke for
prolonged periods (greater than 16 hours). For shorter periods then an alternative intermittent
dose form would be more suitable (e.g. Nicorette inhalator or gum). Smokers of 10 or
more cigarettes per day are recommended to use 25mg patch and lighter smokers are
recommended to use 15mg patch. Contraindications: Hypersensitivity. Precautions: Unstable
cardiovascular disease, diabetes mellitus, renal or hepatic impairment, phaeochromocytoma
or uncontrolled hyperthyroidism, generalised dermatological disorders. Angioedema and
urticaria have been reported. Erythema may occur. If severe or persistent, discontinue
treatment. Stopping smoking may alter the metabolism of certain drugs. Transferred
dependence is rare and less harmful and easier to break than smoking dependence. May
enhance the haemodynamic effects of, and pain response, to adenosine. Keep out of reach
and sight of children and dispose of with care. Pregnancy and lactation: Only after consulting
a healthcare professional. Side effects: Very common: itching. Common: headache, dizziness,
nausea, vomiting, GI discomfort; Erythema. Uncommon: palpitations, urticaria. Very rare:
reversible atrial fibrillation. See SPC for further details. RRP (ex-VAT): 25mg packs of 7:
(ВЈ14.83); 15mg packs of 7: (ВЈ14.83); 10mg packs of 7: (ВЈ14.83). Legal category: GSL.
PL holder: McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG.
PL numbers: 15513/0161; 15513/0160; 15513/0159. Date of preparation: October 2010
References: 1. Tønnesen P et al. Eur Resp J 1999; 13: 238–246. 2. Data on File – CEASE 1.
Date of preparation: November 2011
14_NICE_PM_0212_rt.qxp:14_PM_0212 03/02/2012 10:04 Page 14
clinical practice
management of epilepsy
Last month NICE issued a new
guideline on the use of antiepileptic
drugs in adults and children.
Jo Lumb reports
EPILEPSY is the commonest
serious neurological disorder. It is
estimated to affect up to 415,000
people in England, with a prevalence of five to 10 cases per 1,000
people. Two-thirds of people
with active epilepsy have their
condition satisfactorily controlled by drugs but it can take a
while to find the best treatment
for an individual patient.
A new guideline was needed
because a number of drugs
have been introduced since the
original epilepsy NICE clinical
guideline was published in 2004.
The revised guideline updates
recommendations on pharmacological treatment.
In general terms, NICE emphasises that patients should be
treated with a single drug where
possible. If the first treatment is
unsuccessful, monotherapy with
another drug can be tried, building up to an adequate dose before the first drug is tapered off.
Combination therapy (also called
adjunctive therapy) is only recommended if monotherapy has
not led to freedom from seizures.
The key is to balance effectiveness in reducing seizure frequency with tolerability of sideeffects. So it might be appropriate to revert to monotherapy
if the combination does not
produce worthwhile benefits.
NICE emphasises the need to
maintain consistent supply of a
particular manufacturer’s drug,
unless this is not seen as a concern in individual cases.
The newer drugs considered
include gabapentin, lamotrigine,
levetiracetam, oxcarbazepine,
tiagabine, topiramate and vigabatrin. The guideline presents
summary tables dividing drugs
into first-line, adjunctive, and
suitable for consideration in tertiary care. There are also lists of
drugs that should not be used in
specific seizure types because
of risk of worsening seizures.
For newly diagnosed focal
seizures, recommended first-line
antiepileptic drugs are carbamazepine or lamotrigine. If these
are not suitable or not tolerated,
NICE suggests levetiracetam
(but only if the drug’s cost is lowered), oxcarbazepine or sodium
The first-line drug for generalised tonic-clonic seizures is
sodium valproate. Lamotrigine
is second choice, with carbamazepine and oxcarbazepine
as alternatives. When carbamazepine is used, NICE recommends use of controlled release
Sodium valproate – one of the
older drugs – remains a recommended first choice for several
seizure types. However, NICE
emphasises the specific issues
with this drug in women of
childbearing age and the need
to be aware of teratogenic risks,
particularly when the drug is
NICE advises that monotherapy is preferable in epilepsy where possible
“The key is to balance effectiveness in reducing
seizure frequency with tolerability of side-effects”
taken in higher doses (more than
800mg/day) or in combination
therapy. There are, it says, limited
data on teratogenic risks of the
newer drugs.
Contraception is also covered,
with NICE highlighting the possibility of interaction between
antiepileptic drugs and oral contraceptives. A new warning is that
use of oestrogen-based contraceptives can reduce lamotrigine
levels. When these contraceptives are started or stopped, the
Also new from NICE....
Roflumilast and COPD
NICE has rejected routine use of roflumilast (Daxas tablets). This drug was
launched in 2010 for maintenance therapy in severe COPD. It is a phosphodiesterase-4 inhibitor anti-inflammatory drug, licensed as an add-on to
bronchodilator treatment in patients with frequent exacerbations. NICE’s view
is that, for now, roflumilast should only be used as part of a clinical trial as
there is still uncertainty about clinical and cost-effectiveness. Patients already
taking the drug should have the option to continue treatment.
Severe asthma intervention
An interesting piece of guidance relates to a new intervention called bronchial
thermoplasty for severe asthma. This treatment, described as the first
non-drug treatment for severe asthma, involves application of radiofrequency
(heat) energy to the airway wall. The aim is to reduce the excessive
airway smooth muscle mass seen in severe asthma, so reducing
NICE says that there is some evidence that thermoplasty can improve
symptoms and quality of life in patients with difficult asthma, reducing
exacerbations and hospital admissions. However, there are still uncertainties
about long-term safety. “Bronchial thermoplasty has the potential to offer
improvements in quality of life for many patients, if further evidence supports
its efficacy,” it says.
dose of lamotrigine may therefore need to be adjusted.
The guideline notes the need
for vigilance over serious adverse
effects, mentioning possible
reduced bone density with some
drugs and a small risk of suicidal
thoughts which may apply to
all drugs.
Another of the new recommendations concerns emergency treatment of patients with
prolonged (lasting five minutes
or more) or repeated (three or
more in an hour) convulsive
seizures in the community.
First-line treatment is buccal
midazolam. Rectal diazepam is
an alternative. These treatments
should only be prescribed for
patients who have had a previous episode of prolonged or
serial convulsive seizures.
Regular blood monitoring
of antiepileptic drug levels is
not recommended but the
guideline says that monitoring
might be useful, for example, for
detection of non-compliance,
suspected toxicity, and management of pharmacokinetic interactions.
Recommendations on withdrawal of drug therapy are
unchanged. Essentially, NICE
says that the risks and benefits
of continuing or withdrawing
therapy should be discussed
when patients have been seizure
free for at least two years. When
treatment is being discontinued,
it should be done slowly (over at
least two to three months) and
one drug should be withdrawn
at a time.
As well as updated drug recommendations, the new guideline mentions use of a ketogenic
diet (high fat and low carbohydrate/protein diet). NICE says
that anecdotal data and limited
trial data in paediatric epilepsy
show reduction in seizure
frequency and that the number
of antiepileptic drugs may be
reduced with this dietary approach. It recommends that children and young people whose
seizures have not responded to
appropriate drug therapy are
referred to a tertiary specialist
for consideration of this diet.
There are no data on use of
the ketogenic diet in adults but
NICE recommends a clinical trial
in adults with drug-resistant
Available at
• The epilepsies: the diagnosis and
management of the epilepsies in
adults and children in primary and
secondary care. Clinical guideline
137; January 2012
• Roflumilast for the management
of severe chronic obstructive
pulmonary disease. Technology
appraisal 244; January 2012
• Bronchial thermoplasty for severe
asthma. Interventional procedure
guidance 419; January 2012
15_PM_0212:15_PM_0212 13/02/2012 13:51 Page 1
1 in 4
off yourr adult patients
could develop
d lo
lop shingles
shi es inn their
lifetime if they are among
the 90% that have
had chickenpox1,2
Prevention of shingles and post-herpetic
neuralgia – 1 dose* for adults aged 50+
ZOSTAVAXВ®Wpowder and solvent for suspension for injection [shingles (herpes zoster)
vaccine (live)] Refer to Summary of Product Characteristics for full product information.
Presentation: Vial containing a lyophilised preparation of live attenuated varicella-zoster
virus (Oka/Merck strain) and a pre-filled syringe containing water for injections. After
reconstitution, one dose contains no less than 19400 PFU (Plaque-forming units) varicellazoster virus (Oka/Merck strain). Indications: Active immunisation for the prevention of
herpes zoster (“zoster” or shingles) and herpes zoster-related post-herpetic neuralgia (PHN) in
individuals 50 years of age and older. Dosage and administration: A single dose should be
administered by subcutaneous injection, preferably in the deltoid region. Contraindications:
Hypersensitivity to the vaccine or any of its components (including neomycin). Individuals
receiving immunosuppressive therapy (including high-dose corticosteroids) or who have
a primary or acquired immunodeficiency. Individuals with active untreated tuberculosis.
Pregnancy. Warnings and precautions: Appropriate facilities and medication should be
available in the rare event of anaphylaxis. Deferral of vaccination should be considered in
the presence of fever. In clinical trials with Zostavax, transmission of the vaccine virus has
not been reported. However, post-marketing experience with varicella vaccines suggest that
transmission of vaccine virus may occur rarely between vacinees who develop a varicella-like rash
and susceptible contacts (for example, VZV-susceptible infant grandchildren). Transmission of
vaccine virus from varicella vaccine recipients without a varicella-zoster virus (VZV)-like rash has
been reported but has not been confirmed. This is a theoretical risk for vaccination with Zostavax.
The risk of transmitting the attenuated vaccine virus from a vaccinee to a susceptible contact
should be weighed against the risk of developing natural zoster and potentially transmitting
wild-type VZV to a susceptible contact. As with any vaccine, vaccination with Zostavax may
not result in protection in all vaccine recipients. Pregnancy and lactation: Zostavax is not
intended to be administered to pregnant women. Pregnancy should be avoided for three months
following vaccination. Caution should be exercised if Zostavax is administered to a breastfeeding woman. Undesirable effects: Very common side effects include: pain/tenderness,
erythema and swelling at the injection site. Common side effects include pruritus, warmth and
haematoma at the injection site and headache. Post marketing use has shown hypersensitivity
reactions including anaphylactic reactions, joint and muscle pain, fever, swollen glands, rash,
also hives and rash at the injection site. For a complete list of undesirable effects please refer to
the Summary of Product Characteristics. Package quantities and basic NHS cost: Vial
and pre-filled syringe with two separate needles. This vaccine is currently not available through
the NHS. Marketing authorisation holder: Sanofi Pasteur MSD SNC, 8 Rue Jonas Salk,
F-69007 Lyon, France Marketing authorisation number: EU/1/06/341/011
Legal category: POM В® Registered trademark Date of last review: August 2011
Adverse events should be reported. Reporting forms and
information can be found at
Adverse events should also be reported to Sanofi Pasteur MSD,
telephone number 01628 785291.
References: 1. Miller E, Marshall R, Vudien J. Epidemiology, outcome and control of varicella-zoster infection. Rev Med Microbiol 1993; 4: 222-30. 2. Bowsher D.
The lifetime occurrence of Herpes zoster and prevalence of post-herpetic neuralgia: A retrospective survey in an elderly population. Eur J Pain 1999; 3: 335-42.
3. ZOSTAVAXВ® SmPC, 2011.
* The need for a second dose is currently unknown
ZostavaxВ® cannot currently be prescribed on an NHS prescription (FP10)
but can still be made available to your patients using a private prescription.
Scan the QR code above
with your smartphone to
UK15206 d 01/12
16_CPPE_PM_0212_rt.qxp:16_PM_0212 31/01/2012 16:34 Page 16
cppe focus
The use of drugs in sport
The history of using drugs in sport can be traced back to the time of the Ancient Olympics. This month’s CPPE Focus looks
at a new series of e-learning programmes that will form an integral part of the training for pharmacists, pharmacy
technicians and other healthcare professionals associated with the London 2012 Olympic and Paralympic Games
�THE use of drugs in sport: a
healthcare professional’s perspective’ is a series of three
e-learning programmes that
have been developed by the
CPPE with members of the
Pharmacy Clinical Services
Group of the London Organising
Committee for the 2012 Olympic
and Paralympic Games (David
Mottram, Trudy Thomas and
Mark Stuart), with input from
Joe Marshall, workforce manager, London 2012.
Healthcare professionals have
always had a role in supporting
the wellbeing of athletes and
competitors in sporting events,
however large or small. It is
important that they are able to
provide advice on medicines in
sport and fitness by being aware
of doping and anti-doping and
the use of supplements.
Within this role they need to
be familiar with the common
sport-related injuries and minor
ailments and what options are
available for treatment. They
will also need to consider if
any supplements taken may or
may not have the potential to
enhance performance.
Each e-learning programme
in the series will:
Support the learning of
healthcare professionals with
an interest in drug use in sport
and fitness
Be one of the key learning
components for pharmacist
volunteers of London 2012
Provide learning for an online
assessment – successful com-
Example activity
From this list of OTC medicines
used for treating the symptoms of
coughs and colds, which contain a
stimulant that appears in the World
Anti-Doping Agency (WADA)
Prohibited List?
• Beechams All-in-One Tablets
• Benylin Day & Night Tablets
• Do-Do Chesteze Tablets
• Lemsip Max Cold & Flu Capsules
• Sudafed Decongestant Tablets
• Nurofen Cold & Flu Tablets
• Otrivine Adult Nasal Spray
• Vicks Sinex Decongestant
pletion of the assessment will be
a requirement for all pharmacy
volunteers at London 2012.
The three programmes in this
series are:
Doping and anti-doping
Pharmacy services and support in sport and fitness
Medical services at international sporting events.
The first programme covers
a range of topics from the roles
and responsibilities of anti-doping agencies to practical information on the classes of drugs
and methods that are banned
in sport. There is information
on how athletes and healthcare
professionals can establish
whether a particular medicine
contains a prohibited substance,
the processes for drug testing
in sport, and an outline of the
sanctions that may apply.
In the second programme,
users will consider how pharmacy teams can support athletes and other members of the
general public who participate
in sport and fitness regimens.
There is information relating
to common injuries and minor
ailments suffered by people
undertaking physical activity,
Activity answer
The medicines that contain a
stimulant are:
• Benylin Day & Night Tablets
• Do-Do Chesteze tablets
• Sudafed Decongestant
• Nurofen Cold & Flu Tablets
• Otrivine Adult Nasal Spray
along with best practice advice
for treatment and/or referral.
Specific advice is also given
on the potential benefits and
dangers associated with the use
of supplements.
The final programme details
the support and scope of medical services at major international sporting events, such as
the Olympic, Paralympic and
Commonwealth Games. The use
of medicines at such events and
the important role for pharmacy
in ensuring the safe use of drugs,
particularly by athletes, is considered.
In 2012 the UK will host two of
the greatest sporting events in
the world: the Olympic and
Paralympic Games. While
healthcare teams have already
been established for these
events, there are many sporting
events that happen locally on a
small to medium scale – making
this e-learning series a timely
opportunity for pharmacists to
update knowledge and skills in
these areas.
Next month...
Next month’s article will focus on
adverse drug reactions and the
role of pharmacists
Contact CPPE
Email: [email protected]
General enquiries:
0161 778 4000
17-24_CPD Module_PM_0212_rt.qxp:00-00_PM_0212 31/01/2012 16:16 Page 17
cpd module
This module is suitable for use by pharmacists as part of their continuing professional development. After reading this module,
complete the learning scenarios and post-test at and include in your CPD portfolio. Previous modules
in the Pharmacy Magazine CPD Programme are also available to download from the website
Welcome to the one hundred and ninety sixth module
in the Pharmacy Magazine Continuing Professional
Development Programme, which looks at antiplatelet
and anticoagulant therapy and the NMS. It is valid until
January 2015.
Continuing professional development (CPD) is a
statutory requirement for pharmacists. Journal-based
educational programmes are an important means
of keeping up-to-date with clinical and professional
developments and form a significant element of your
CPD. Completion of this module will contribute to the
nine pieces of CPD that must be recorded a year.
Before reading this module, test your existing
understanding of the topic by completing the pre-test
at Then after studying the
module in the magazine, work through the six learning
scenarios and post-test on the website. Record your
learning and how you applied it in practice using the
CPD report form, available online and on pviii.
Self-assess your learning needs:
• What are the main indications and side-effects
of anticoagulation therapy?
• When should concomitant use of warfarin be
• How will you identify patients newly prescribed anticoagulants for entry into the NMS?
Warning: The content of this module is the copyright of
Pharmacy Magazine and cannot be reproduced without
permission in the form of a valid written licence granted
after July 1, 2011
Contributing author: Samixa Shah PgDip ClinPharm, MRPharmS,
AxiMas Consulting; pharmaceutical consultant and clinical writer
Over 25,000 people die each year from blood
clots due to venous or arterial thromboembolism1. Arterial thromboembolism is the
main cause of cardiovascular disease (CVD).
Risk factors are:
A high fat diet
Lack of exercise
Alcohol misuse.
Occlusive vascular events include ischaemic
stroke, transient ischaemic attack and myocardial infarction. They occur when blood flow is
impeded because an artery is blocked or restrict-
ed due to atherosclerosis and atherothrombosis.
Damage to the vascular endothelium leads to
atherosclerotic plaques forming in artery walls.
If an atherosclerotic plaque is suddenly disrupted, platelet activation and thrombus (clot) formation follows, leading to atherothrombosis.
The thrombus can block an artery, either at the
original site of the plaque formation or further
down. People who have had an occlusive vascular event are at increased risk of another.
Peripheral arterial disease is a condition in
which the arteries that carry blood to the arms
or legs become narrowed or clogged, slowing or
stopping the flow of blood. It occurs most often
because of atherosclerosis. People who have
peripheral arterial disease are at high risk of
having an occlusive vascular event.
G O A L : To provide an overview of the management of patients prescribed
antiplatelet or anticoagulant therapy and the role of the NMS.
OBJECTIVES: After completing this module, you should be able to:
• Explain the current management of patients on antiplatelet therapy as
recommended by NICE
• Understand the current management of patients on anticoagulant therapy
as recommended by the National Patient Safety Agency.
17-24_CPD Module_PM_0212_rt.qxp:00-00_PM_0212 31/01/2012 16:16 Page 18
Reflection exercise 1
Do you know what the indications are for prescribing
anticoagulants or antiplatelets to prevent venous or
arterial thromboembolism?
Patients on antiplatelet and anticoagulant therapy can be recruited onto the NMS
Multivascular disease is when people with
cardiovascular disease have the condition in
more than one vascular site. Such people are at
increased risk of death, myocardial infarction
or stroke compared to those with disease in a
single vascular bed.
Each year in the UK an estimated 98,000 people have a first ischaemic stroke, between 46,000
and 65,000 people have a transient ischaemic
attack and 146,000 have a myocardial infarction.
Approximately two per cent of the population of
England and Wales have had a stroke and about
70 per cent of all strokes are ischaemic. In the
UK, in total, around 510,000 people have had a
transient ischaemic attack and over 1.4 million
have had a myocardial infarction. About 20 per
cent of the UK population aged 55-75 years have
evidence of lower extremity peripheral arterial
disease, equating to a prevalence of 850,000
people, of whom five per cent have symptoms.
An estimated 16 per cent of people with cardiovascular disease have multivascular disease2.
Antiplatelet agents are prescribed to prevent
arterial thromboembolism after a stroke, heart
attack, acute coronary syndrome or the insertion
of a coronary stent, and for secondary prevention of cardiovascular disease. Antiplatelet drugs
decrease platelet aggregation and inhibit thrombus formation in the arterial circulation because,
in faster-flowing vessels, thrombi are composed
mainly of platelets with little fibrin.
Venous thromboembolism causes deep vein
thrombosis (DVT) and pulmonary embolism.
Risk factors are:
Family history
Previous clots
Being overweight / immobile
Anticoagulants are prescribed if someone has
already had, or is at risk of having, a blood clot.
Examples of people who are at risk include
anyone who has:
Atrial fibrillation
A mechanical heart valve
Mitral stenosis
Inherited thrombophilia; antiphospholipid
Had surgery to replace a hip or knee.
The main use of anticoagulants is to prevent
thrombus formation or extension of an existing
thrombus in the slower-moving venous side of
the circulation, where the thrombus comprises a
fibrin web enmeshed with platelets and red cells.
A number of anticoagulants are available.
They include warfarin, acenocoumarol and
phenindione, which are older types of anticoagulants that have been used for many years
in the UK, and dabigatran and rivaroxaban,
which are newer.
The older anticoagulants block the effects of
vitamin K, which is needed to help make clots.
Blocking vitamin K prevents blood clots forming
so easily by increasing the time it takes to make
fibrin. Fibrin binds platelets together to form a
blood clot. It usually takes two or three days for
the full anticoagulant effect to be seen.
Dabigatran and rivaroxaban both prevent a
blood chemical (thrombin) from working, which
in turn prevents fibrin from being formed.
Dabigatran binds to thrombin and rivaroxaban
stops thrombin from being produced. Both work
quickly – within two to four hours3. Rivaroxaban
is a direct inhibitor of activated factor X, while
dabigatran is a direct inhibitor of thrombin.
Thrombin is a key enzyme in blood clot
(thrombus) formation because it enables the
conversion of fibrinogen to fibrin during the
coagulation cascade. Inhibition of thrombin
prevents the further development of clot formation.
This clot formation may be associated with
inactivity and some surgical procedures.
Dabigatran etexilate holds a marketing authorisation for the primary prevention of venous
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thromboembolic events in adult patients who
have undergone elective total hip or knee
replacement surgery4. It is also now licensed for
stroke and systemic embolism prevention in
people with non-valvular atrial fibrillation.
Both rivaroxaban and dabigatran do not
require therapeutic monitoring and the commonest side-effect is haemorrhage. Patients
should be monitored for signs of bleeding and
anaemia, and treatment should be stopped if
severe bleeding occurs5.
There are around 500,000 patients in the UK
who are currently given oral anticoagulant drugs,
with warfarin the most frequently prescribed.
Warfarin requires monitoring and frequent dose
adjustment to maintain the desired therapeutic
action and minimise adverse bleeding events.
Under-anticoagulation can result in thrombosis;
over-anticoagulation can result in haemorrhage
– both of which can be fatal6.
Anticoagulation is not indicated for:
Ischaemic stroke without atrial fibrillation
Retinal vessel occlusion
Peripheral arterial thrombosis
Coronary artery graft or coronary angioplasty
and stents.
Reflection exercise 2
• Have you seen the NPSA anticoagulant information
pack for patients?
• Do you check whether patients who are on warfarin
therapy have got this yellow booklet?
Monitoring anticoagulation
Pharmacists must ensure that patients prescribed anticoagulants receive appropriate verbal and written information throughout the
course of their treatment. The British Society
of Haematology (BSH) and the National Patient
Safety Agency (NPSA) have updated the patientheld information (�yellow’) booklet. The new
information pack contains:
1. An anticoagulant alert card
2. General information about the safe use of oral
3. Blood test results and dosage information.
Electronic copies of the yellow book in English
and a range of languages are available at www.
Patients taking oral anticoagulant drugs must
have regular measurement of their International
Normalized Ratio (INR) with appropriate anticoagulant dose adjustment. Normally, blood
Table 1: Indications, target INR and duration of anticoagulation6,8
Target INR
Duration of anticoagulation
Pulmonary embolus
6 months
Proximal deep vein thrombosis
6 months*
Calf vein thrombosis
3 months
Recurrence of venous thromboembolism when no
longer on warfarin therapy
Consider long-term
Recurrence of venous thromboembolism while on
warfarin therapy
Consider long-term
Antiphospholipid syndrome
Consider long-term
Atrial fibrillation
Three weeks before and four weeks
after procedure
Mural thrombus
Three months
Mechanical prosthetic heart valve
that is not anticoagulated has an INR of approximately 1.0.
The NPSA states that, in order to promote safe
practice, prescribers and pharmacists should
check that the INR is being monitored regularly
and that the level is safe before issuing or dispensing repeat prescriptions for oral anticoagulants7.
In many cases, the GP who issues repeat
prescriptions for anticoagulants is not the same
practitioner who monitors and adjusts the
dosage of the therapy. Repeat prescriptions of
anticoagulants should only be issued if the
prescriber has checked that:
The patient is regularly attending the anticoagulation clinic or is having regular INR tests
The INR test result is within safe limits
The patient understands what dose to take.
It should not be assumed that the prescriber
has undertaken the safety checks, so pharmacists
should review the patient-held record every
time a prescription for warfarin is requested or
dispensed and confirm this with the patient. The
record can be the yellow booklet or a printed
dosage sheet, which should include the date of
the last clinic appointment, the latest INR test
result and current dose.
If the patient is unable to request or collect
his or her warfarin prescription and sends a representative, this person should provide the
patient-held information instead. The patient or
carer should be contacted if any of the information is unavailable.
The NPSA recommends that prescribing and
dispensing software should include a function to
record the date of the last clinic appointment,
the latest INR test result and current dose when
this information is being checked prior to issuing
or dispensing a repeat prescription for an oral
The maintenance period and the target INR
can vary. The commonest indications are shown
in Table 1 (left).
Many prescribed and over-the-counter drugs,
herbal or alternative remedies can interact with
warfarin. These can be found in the BNF. A noninteracting medicine should be chosen when
*Shortening treatment to three months will be recommended if circumstances indicate that the risk-benefit ratio favours this; for example if a reversible
precipitating factor was present and there are risk factors for bleeding (age >65 years)
**Depending on valve type and/or location. See BCSH guidelines6,8
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Table 2: Drug interactions5
AVOID concomitant use of warfarin
Except where combination specifically indicated (e.g.
mechanical valve prosthesis, recurrent thrombosis)
Co-proxamol, ketorolac (post-operative)
Non-steroidal anti-inflammatory drugs
Azapropazone, phenylbutazone
Enteral feeds containing vitamin K
ADJUST dose of warfarin-enhanced anticoagulant effect
(metabolism of warfarin inhibited)
Ulcer healing
Cimetidine, omeprazole
Amiodarone, propafenone
Lipid lowering
Carbamazepine, phenobarbitone, phenytoin, primidone
Alcohol dependency
Aztreonam, cefamandol, chloramphenicol, ciprofloxacin,
co-trimoxazole, erythromycin, griseofulvin, metronidazole,
ofloxacin, rifampicin, sulphonamides
Non-steroidal anti-inflammatory drugs
Allopurinol, sulphinpyrazone
Aminoglutethimide, barbiturates, ciclosporin,
mercaptopurine, oral contraceptive steroids
Inc. thyroid
(carbimazole, thiouracils, thyroxine)
MONITOR INR more frequently with the following drugs:
Anticoagulant effect of warfarin may be enhanced or reduced
GI motility
Quinidine, amiodarone
Lipid lowering
Colestyramine, statins
Serotonin re-uptake inhibitors
Consult BNF if not listed under �adjust dose’
Non-steroidal anti-inflammatory drugs
If not listed under �avoid’ or �adjust dose’
Anabolic steroids, corticosteroids, hormone antagonists,
ifosfamide, influenza vaccine, Rowachol, sucralfate
* This list is not exhaustive: if in doubt consult the BNF 8
Table 3: Warfarin therapy maximum recall periods during maintenance therapy*
One INR high
Recall in 7-14 days (stop treatment for 1-3 days;
maximum 1 week in prosthetic valve patients)
One INR low
Recall in 7-14 days
One INR therapeutic
Recall in 4 weeks
Two INRs therapeutic
Recall in 6 weeks (maximum for prosthetic valve patients)
Three INRs therapeutic
Recall in 8 weeks apart from prosthetic valve patients
Four INRs therapeutic
Recall in 10 weeks apart from prosthetic valve patients
Five INRs therapeutic
Recall in 12 weeks apart from prosthetic valve patients
possible. For short courses of a new medicine,
warfarin dose adjustment is not essential. For a
medicine change lasting more than seven days,
an INR test should be performed three to seven
days after starting the new medication so that
the warfarin dose can be adjusted on the basis
of the INR result8.
Patients are often prescribed mixed strengths
of warfarin (e.g. 1mg, 3mg and 5mg) to enable
the dose to be adjusted, but 0.5mg tablets rather
than half-tablets should be prescribed to
enable more accurate dose adjustment. The dose
should be prescribed in milligrams (mg) and not
number of tablets. Successful, safe anticoagulation depends on patient education, good compliance, and communication with the patient
and between the individuals responsible for
his/her clinical care.
Warfarin is metabolised by cytochrome p450
2C9 (CYP2C9). Patients with liver disease or
those taking drugs that inhibit the activity of
CYP2C9 will require less warfarin, while those
taking drugs that accelerate the metabolism of
warfarin will require more. Changes in a patient’s
clinical condition, particularly associated with
liver disease, concurrent illness or drug administration, necessitates more frequent testing.
Table 2 shows possible drug interactions with
warfarin and the action to be taken.
Foods rich in vitamin K may affect the INR
result. Such foods include green leafy vegetables,
chick peas, liver, egg yolks, cereals containing
wheat bran and oats, mature cheese, blue
cheese, avocado and olive oil. These foods are
important in the diet but eating them in large
amounts may lower the INR result. Patients
should be advised to take the same amount of
these foods on a regular basis.
Drinking cranberry juice can also affect the
INR result, so this should be avoided altogether
if possible. If a patient’s diet changes greatly over
a seven-day period, they should be advised to
have their INR monitored.
Reflection exercise 3
• Do you know what medicines and foods will
affect the INR?
• Do you record this in the patient’s medication
record when a change in INR has occurred?
Note: Patients seen after discharge from hospital with prosthetic valves may need more frequent INR monitoring in the first few weeks (based on data
from Ryan et al. British Medical Journal. 1989; 299: 1207-1209)
* Taken from the BMA outline for the national enhanced service – anticoagulation monitoring
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Serious side-effects
The most serious side-effect of anticoagulants
is bleeding. If a patient experiences any of the
symptoms listed below, he/she should seek
medical attention and have an urgent INR test:
Prolonged nosebleeds (more than 10 minutes)
Blood in vomit / sputum
Passing blood in urine or faeces
Passing black faeces
Severe or spontaneous bruising
Unusual headaches
For women, heavy or increased bleeding
during a period or any other vaginal bleeding.
Immediate medical attention should be
advised if a patient on an anticoagulant:
Is involved in major trauma
Suffers a significant blow to the head
Is unable to stop bleeding.
In the majority of cases dental treatment can
go ahead as normal without the anticoagulant
dose being stopped or adjusted. However, the
dentist will need to see a recent INR test result
to ensure that it is safe to provide treatment.
Patients should be advised to contact their
dentist before an appointment in case they are
required to have an extra blood test.
Ongoing monitoring
Once a patient has a stable INR, the recall interval can be progressively lengthened – something
that is built into many computerised dosing
support systems.
Indications for antiplatelet therapy
Ischaemic stroke and myocardial infarction
are associated with a high mortality rate.
Approximately 23 per cent of people die within
30 days of having a stroke and, of the people
who survive, 60 to 70 per cent die within three
years. Thirty per cent of people die from their
first myocardial infarction.
In terms of morbidity, an occlusive vascular
event can lead to a stay in hospital, reduced
health-related quality of life and long-term disability, with a resulting impact on care providers.
Stroke is the leading cause of disability in the UK
Patients on anticoagulants with nosebleeds lasting longer than 10 minutes require urgent referral
and it is thought that more than 900,000 people
in England are living with the effects of stroke,
with about half dependent on others for support
with everyday activities.
The aim of treatment is to prevent occlusive
vascular events and their recurrence. Treatment
can include pharmacological therapy with
one or more antiplatelet agents (e.g. aspirin,
clopidogrel and modified-release dipyridamole).
Treatment options are:
For people:
Who have had an ischaemic stroke –
Who have a contraindication or intolerance
to clopidogrel – modified release dipyridamole
plus aspirin
Who have a contraindication or intolerance to
both clopidogrel and aspirin – modified-release
dipyridamole alone
Who have had a transient ischaemic attack –
modified-release dipyridamole plus aspirin
Who have a contraindication or intolerance to
aspirin – modified-release dipyridamole alone
Who have had a myocardial infarction – offer
aspirin and continue indefinitely
With peripheral arterial disease – clopidogrel
With multivascular disease – clopidogrel.
Clopidogrel is recommended only when
treatment with aspirin is contraindicated or not
tolerated. Treatment with clopidogrel to prevent
occlusive vascular events should be started with
the least costly licensed preparation.
Prasugrel in combination with aspirin is recommended as an option for preventing atherothrombotic events in people with acute coronary
syndromes having percutaneous coronary
intervention, only when:
Immediate primary percutaneous coronary
intervention for ST-segment-elevation myocardial infarction is necessary
Stent thrombosis has occurred during clopidogrel treatment
The patient has diabetes mellitus9.
People currently receiving prasugrel for
treatment of acute coronary syndromes whose
circumstances do not meet the criteria above
17-24_CPD Module_PM_0212_rt.qxp:00-00_PM_0212 31/01/2012 16:17 Page 22
Reflection exercise 4
Table 4: NMS intervention stage
Prompts and notes
Have you had the chance to start taking your new medicine
Check whether the patient has started taking the
antiplatelet/anticoagulant medication
How are you getting on with it?
Assess whether the patient is experiencing any side-effects,
has any concerns about taking the medication or is just not
sure why he/she needs to take it
Are you having any problems with your new medicine,
or concerns about taking it?
Any extra information in addition to that obtained above
Do you think it is working?
(Prompt: is this different from what you were expecting?)
Does the patient feel that the medication is having an effect
on his/her circulation? Check the patient-held INR record
Do you think you are getting any side-effects or unexpected
Check with the patient whether he/she has experienced
anything different since starting the medication or noticed
anything different, particularly signs of bruising with warfarin
People often miss taking doses of their medicines, for a wide
range of reasons. Have you missed any doses of your new
medicine, or changed when you take it? (Prompt: when did
you last miss a dose?)
This may have already been covered in the earlier questions
Is there anything else you would like to know about your new
medicine or is there anything you would like me to go over
Give the patient a chance to discuss any other concerns or
issues he/she may have about the new medicine
should have the option to continue therapy until
it is considered appropriate to stop.
The NMS and antiplatelet/anticoagulant therapy
It is hoped that the successful implementation
of the NMS will:
Improve patient adherence
Increase patient engagement with their
condition and medicines
Reduce medicines wastage
Reduce hospital admissions due to adverse
events from medicines
Lead to increased Yellow Card reporting of
adverse reactions by pharmacists and patients,
supporting improved pharmacovigilance
Receive positive assessment from patients
Improve the evidence base on the effectiveness of the service
Support the development of outcome and/or
quality measures for community pharmacy.
Patients can be recruited in two ways:
Opportunistically when they first present a
prescription for a medicine that is eligible for the
Table 5: NMS follow-up stage
Prompts and notes
How have you been getting on with your new medicine since
we last spoke? (Prompt: are you still taking it?)
This is a general question to open up a natural dialogue and
to see whether the patient is still taking the new medicine
Last time we spoke, you mentioned a few issues you’d been
having with your new medicine. Shall we go through each of
these and see how you’re getting on?
Use the pharmacy records to refer to each of the issues
that arose from the initial contact with the patient at the
intervention stage
A) The first issue you mentioned was [refer to specific issue] –
is that correct?
B) Did you try [the advice/solution recommended at the
previous contact] to help with this issue?
Use the pharmacy records to refer back to the advice or
solution recommended to the patient. This question should
be phrased according to the specific advice, information or
solution offered to the patient at the intervention stage
Did you try anything else?
This allows you to check whether the patient received help
or advice from elsewhere
Did this help? (Prompt: how did it help?)
Document the outcome from the issue
Is this still a problem or concern?
The question above may give you the answer to this already
but if not, it allows you to clearly establish whether or not
the problem/concern is still an issue. If the problem/concern
is still there, then the patient will need to be referred
appropriately before exiting the service
People often miss taking doses of their medicines, for a wide
range of reasons. Since we last spoke, have you missed any
doses of your new medicine, or changed when you take it?
(Prompt: when did you last miss a dose?)
You need to obtain a reason as to why a dose was missed.
Evaluate whether there is a need to provide the patient
with any extra aids or verbal or written advice
Have there been any other problems/concerns with your new
medicine since we last spoke?
If new problems exist, then the patient will need to be referred
appropriately, as mentioned above
Have you read the NICE technology review on
the prescribing of clopidogrel and modified release
dipyridamole for the prevention of occlusive vascular
When they are prescribed an eligible medicine
while at hospital (whether as an inpatient or
outpatient). In this situation the patient must
continue to take the medicine as part of a course
of treatment when they are no longer at the
hospital, and they must be referred to the service
by a healthcare professional at the hospital who
is wholly or partly responsible for a course of
In many cases it is hospital pharmacists
who will be the key personnel referring patients
for the NMS. Where IT systems and resources
permit, it may be possible for community pharmacists to receive copies of relevant discharge
summaries. [In January a national referral form
was produced by PSNC and NHS Employers,
designed to formalise how hospital and community pharmacists share information about
changes to patients’ prescriptions while in
It is recommended that community and
hospital pharmacists meet to:
Raise awareness of the new service
Discuss how eligible patients are made aware
of the service
Discuss what support can be provided for
community pharmacists to identify the reason
for initiation of the treatment where this is
Patients who are prescribed the following
medicines from Chapter 2 of the BNF can be
enrolled onto the NMS11:
2.8.2 Oral anticoagulants – warfarin, acenocoumarol, phenindione, dabigatran, rivaroxaban
2.9 Antiplatelet drugs – aspirin, clopidogrel,
dipyridamole, prasugrel.
When an approved medicine for antiplatelet/anticoagulation therapy is dispensed for
the first time, the pharmacist must offer the
Reflection exercise 5
How can you ensure that a patient who has been
prescribed a new medicine for antiplatelet/anticoagulant therapy will be referred to you for the NMS?
17-24_CPD Module_PM_0212_rt.qxp:00-00_PM_0212 31/01/2012 16:18 Page 23
cpd module
patient opportunistic advice on healthy living/
public health topics in line with the promotion
of healthy lifestyles essential service and explain
to the patient the advantage of enrolling onto the
Once the patient has consented to take part
in the NMS and signed the consent form, an
appointment should be made to come and see
the pharmacist for an intervention in one to two
weeks’ time and a follow-up two to four weeks
after that10. Tables 4 and 5 show the questions to
be asked at each stage.
The intervention and follow-up stages of the
service will also be appropriate times to offer the
patient continued healthy lifestyle advice and
this should be recorded on the relevant forms.
A record should be made of the intervention and
follow-up interviews, and these will need to be
kept for two years.
Healthy lifestyle advice
Healthy lifestyle advice should focus on areas
such as diet and nutrition, alcohol consumption,
smoking status, sexual health, physical activity
and weight management. This can be achieved
by (for example):
Discussing the patient’s diet and exercise patterns because a healthy diet and regular exercise
can prevent the recurrence of vascular events.
Offer appropriate guidance and written or
audiovisual materials to promote lifestyle
changes. Signpost to appropriate healthcare
professionals if necessary
Ascertaining alcohol consumption and encouraging a reduced intake if the patient drinks
excessively can reduce the risk of recurring
vascular events and has broader health benefits
Offering advice and help to smokers to stop
smoking – signpost to the NHS Stop Smoking
Service ( if you do not
offer a smoking cessation service yourself.
CPD competences
This module supports the following community pharmacy competences:
GlaxoSmithKline: 0845 762 6637
Where this module supports competence development
G1a: Using expert knowledge and skills to
benefit patients
This module helps pharmacists to have a greater understanding of
antiplatelet and anticoagulant therapy to enable them to support patients
who have been prescribed a new medicine in this area and to ensure
regular therapy monitoring is undertaken where required
G1f: Using clinical and pharmaceutical
knowledge to optimise the balance among
effectiveness, safety and cost of medicines
Reflection exercise 4 encourages pharmacists to read the current NICE
guideline and understand the rationale for cost-effective prescribing
G1w: Taking on new roles or
The importance of effective consultation skills in undertaking the NMS
is highlighted
C1c: Reviewing medication with patients
to identify difficulties and potential risk
(e.g. concordance issues, adverse effects,
changing medication needs)
The module explains how pharmacists can ensure patients on warfarin
have regular monitoring and also how they can advise patients on any
change in INR levels that may occur due to a change in other medicines
and diet
C1d: Monitoring indicators of disease
progress, drug efficacy or toxicity
The module explains how, by asking the appropriate questions as part
of the NMS, pharmacists will be able to see signs of over- or undercoagulation with warfarin
C2c: Creating and making use of
opportunities to encourage healthy
How healthy lifestyle advice can be incorporated into the consultation
process is explained in the module
C5c: Developing and implementing new
services under local or national contracts
The place of the NMS in the patient journey is explained. Pharmacists are
encouraged to work closely with patients so that the NMS will have the
best possible impact on patients, as well as on professional relationships
Future developments
By becoming actively involved in providing
the NMS for newly prescribed drugs for
antiplatelet/anticoagulant therapy, community
pharmacists will help the NHS by facilitating a
reduction in hospital admissions due to warfarin-related adverse reactions and occlusive
vascular events, and by promoting cost-effective
prescribing and ensuring adherence to the prescribed medicines.
1. National Pharmacy Association (NPA). NMS mini guides to conditions:
2. Clopidogrel and modified release dipyridamole for the prevention of occlusive vascular events.
Review of NICE technology appraisal guidance 90:
3. Patient UK. Anticoagulants:
4. Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery
in adults:
5. BNF 62:
6. British Committee for Standards in Haematology (BCSH) guidelines. Safety indicators for inpatient and
outpatient oral anticoagulant care. Available at
7. NPSA. Actions that can make anticoagulant therapy safer – alert and other information:
8. BCSH guidelines on oral anticoagulation with warfarin; 4th edition. Available at:
9. Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention:
10. NMS Service Specification (Pharmaceutical Services Negotiating Committee, 2011):
11. NMS – list of medicines: uk/data/files/
Pharmacy Magazine’s CPD modules are now available on
Cegedim Rx’s PMR systems, Pharmacy Manager and Nexphase.
Just click on the �Professional Information & Articles’ button
within Pharmacy KnowledgeBase and search by therapy area.
Please call the Cegedim Rx helpdesk on 0844 630 2002 for
further information.
17-24_CPD Module_PM_0212_rt.qxp:00-00_PM_0212 31/01/2012 16:18 Page 24
Activity completed. (Describe what you did to increase your learning. Be specific)
A N T I P L AT E L E T S / A N T I C O A G U L A N T S & T H E N M S
1. Food rich in which vitamin
may affect the INR result?
b. Dabigatran
c. Rivaroxaban
d. Warfarin
a. Vitamin B
b. Vitamin C
c. Vitamin D
d. Vitamin K
6. What is the recommended
treatment option for patients
who have had a myocardial
2. Is it a mandatory
requirement to check the
yellow record booklet when
dispensing warfarin?
a. Modified-release
dipyridamole plus
b. Aspirin to be taken
c. Clopidogrel to be taken
d. Clopidogrel to be taken
for one year
a. Yes
b. No; it is a safe practice
recommendation by the
c. Yes; but only if the
patient is recruited onto
the NMS
d. Yes; and the pharmacist
can only dispense the
prescription if the
booklet is seen
7. What lifestyle advice is NOT
going to benefit a patient
prescribed an antiplatelet
or anticoagulant?
a. Smoking cessation
b. Reducing alcohol
c. Changing to a healthy
diet and increasing
d. Taking iron supplements
3. When initiating warfarin
treatment the full anticoagulant effect can be seen
a. 12-36 hours
b. 24-36 hours
c. 48-72 hours
d. 72-96 hours
8. When a patient is prescribed
an anticoagulant, what is the
most important advice you can
give them as part of the NMS?
4. The recommended duration
of treatment and target INR for
atrial fibrillation is:
Time taken to complete activity:
What did I learn that was new in terms of developing my skills, knowledge and behaviours? Have my learning
objectives been met?*
How have I put this into practice? (Give an example of how you applied your learning. Why did it benefit your practice?
How did your learning affect outcomes?)
Do I need to learn anything else in this area? (List your learning action points. How do you intend to
meet these action points?)
a. To keep their yellow alert
card with them all the
b. To monitor their INR
c. Lifestyle advice on
foods and alcohol
consumption to avoid
major changes in blood
clotting factors
* If as a result of completing your evaluation you have identified another new learning objective, start a new cycle –
d. To continue taking the
this will enable you to start at Reflect and then go on to Plan, Act and Evaluate. This form can be photocopied to
avoid having to cut this page out of the module. Complete the learning scenarios at
a. Lifelong treatment and a
target INR of 2.5
b. Three months’ treatment
and a target INR of 3.0
c. Six months’ treatment
and a target INR of 2.5
d. Lifelong treatment and a
target INR of 3.0
5. Which anticoagulant is a
direct inhibitor of thrombin?
a. Acenocoumarol
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25_Public Health_PM_0212_rt.qxp:00_PM_0212 01/02/2012 09:38 Page 2
public health
HIV awareness
More people in the UK are living
with HIV than ever before, yet public
knowledge about the disease is waning.
So how can pharmacists help to raise
awareness of the condition and tackle
the stigma still sometimes attached to it?
Charlotte Rigby reports
THERE are currently 90,000
people in the UK with HIV and
between 6,000 and 7,000 cases
are diagnosed every year. HIV
disproportionately affects certain groups, including gay and
bisexual men and people of
African origin, but increasing
numbers of people outside these
groups are being diagnosed. In
fact, less than half of new diagnoses now occur in gay or bisexual people.
Despite this growing prevalence, research by the National
AIDS Trust (NAT) has highlighted
widespread ignorance about the
routes of transmission and the
reality of living with HIV today.
“As the number of people
with HIV in the UK approaches
100,000, it is crucial for everyone
to understand how HIV is passed
on so they can protect themselves and others,” says Deborah
Jack, NAT chief executive.
A public attitude survey, published by NAT last year, revealed
that only 30 per cent of UK adults
can identify correctly every way
in which HIV can and cannot
be transmitted from a list of
possible routes. Just 80 per cent
of respondents were aware that
HIV could be transmitted during
unprotected heterosexual sex,
compared with 91 per cent in
2000, and less than half knew
that infection could occur after
sharing needles or syringes.
The survey also revealed that
a significant proportion of
people believe that HIV can be
caught through blood transfusion, biting or treading on a used
needle, when in fact, for all these
instances, there is only a very
remote or theoretical chance of
transmission. More worryingly,
around a fifth identified at least
one impossible route of transmission, such as kissing, spitting,
sneezing or sharing a glass. One
in six respondents admitted that
they did not know enough about
how to protect themselves from
HIV during sex.
According to Charli Scouler,
NAT communications manager,
this decline in knowledge is due
to the lack of high profile public
health campaigns in recent years.
“HIV has become largely invisible in today’s society,” she
says. “People born since the
1980s are not aware of the risks
or they may have in their minds
that it is only associated with, for
example, African or gay people.
HIV is also barely talked about in
schools so people grow up without the information they need to
protect themselves and others.”
Thankfully, prejudice against
people with HIV has declined
over the past 10 years, while
support and understanding
have increased. Nevertheless,
NAT figures highlight inconsistent attitudes towards HIV suf-
ferers among the public. For instance, 69 per cent of people are
glad that there are anti-discrimination laws to protect people
with HIV, yet 38 per cent would
want to know if they had a
HIV-positive colleague.
It’s also clear many people
hold outdated views about the
reality of living with HIV today.
For example, nearly half of
people believe it is impossible
to prevent transmission during
pregnancy, while a third believe
that people with HIV take more
time off work due to illness. In
fact, it is now possible to reduce
the risk of mother-to-baby transmission of HIV to less than one
per cent and there is no evidence
that HIV-positive people take
more sick leave than anyone
else. Raising awareness of these
facts is essential, as there is a
strong link between good general
knowledge of HIV and supportive attitudes towards sufferers.
“It is certainly positive to see
the majority of the public have
supportive attitudes towards
people with HIV, but there are
still huge gaps in awareness of
what it means to live with HIV in
the UK today,” says Jack. “While
HIV treatment has advanced
rapidly in the past 10 years,
knowledge and attitudes have
sadly not kept pace, resulting in
stigma and discrimination.”
в—Џ Around 90,000 people in the UK are HIV-positive but over a
quarter are unaware that they have the condition
в—Џ Awareness of the routes of transmission of HIV has
declined over the past 20 years
в—Џ Public health strategies are needed to raise awareness of
the condition, reduce stigma and improve diagnosis rates
Encouragingly, 85 per cent of
the public agree that all young
people should be taught about
HIV at secondary school and
over two-fifths would like to
receive more information about
how the disease affects people
HIV testing and the widely held
belief that HIV is not a relevant
issue for most people.
“An early diagnosis means
treatment can start at the correct
time and a person will avoid
having their immune system severely compromised by the virus.
“Less than half of new diagnoses
now occur in gay or bisexual people”
NAT estimates that over a quarter of HIV-positive people in the
UK are unaware that they have
the condition. Another common
misconception is that HIV test
results take at least three months
after exposure when, in fact, they
are possible within four weeks.
This wrongly held belief could
deter many people from getting
tested at precisely the time they
are most infectious – as could
the strong stigma associated with
“It also means they can take
the necessary steps to avoid
passing it on,” says Scouler. “In
order to improve diagnosis rates
we need to increase the uptake of
HIV testing and effectively communicate the health benefits of
knowing your HIV status. We
also need to remove the stigma
around testing in order to encourage more people to come
NAT agrees that community
pharmacy has an important role
to play in improving diagnosis
rates by signposting patients who
may have been exposed to the
virus to local screening centres,
as well as raising awareness of
the transmission routes during
sexual health consultations and
services for drug users. Pharmacists should be familiar with
British HIV Association (BHIVA)
and NICE guidelines on HIV testing and can use the online resource from NAT and Durex
to improve their knowledge and
The National AIDS Trust has
made several recommendations
to the Government for raising
awareness of HIV. These include:
Compulsory sex and relationships education that includes
HIV at secondary school
An accurate portrayal of the
condition in the media
Sexual health campaigns with
HIV as a key component.
“In addition to improving
knowledge of HIV, intensive work
also needs to go into tackling
the often deep-seated judgments
and beliefs held about HIV and
the people affected,” says Jack.
“The Government made a
concerted and effective effort to
tackle the stigma surrounding
mental health – it is time HIV was
addressed in the same way,” she
believes. в—Џ
26_NHS reforms_pm_0212_(rt).qxp:00_PM_0011 02/02/2012 09:56 Page 2
nhs reforms
THE Government’s Health and
Social Care Bill promises to be
the biggest shake-up of the
NHS since its foundation. The
central theme of the reforms is
the transfer of power from the
centre – the Secretary of State
and the Department of Health
(DH) – to local organisations
(clinicians and local authorities)
and independent regulators. As
the Coalition’s �Equity and Excellence’ white paper puts it, the
aim is to “liberate the NHS” from
central control1.
In line with this objective,
strategic health authorities are
being abolished, along with most
centrally determined targets and
national service plans – which
begs the question: what will drive
the system forward? The Coalition’s answer is patient choice.
But patient choice can only operate if there is a range of possible providers to choose from – in
other words, competition.
The Health Bill –
what does it really mean for
community pharmacy?
The In’s and Out’s of NHS reform....
The Government is abolishing PCTs and replacing them
with clinical commissioning groups (CCGs), consisting
mainly of GPs but also involving hospital doctors, nurses
and lay people. These will be responsible for the allocation
of about 60 per cent of the NHS budget.
Most of the remainder of the budget will be allocated by
a new body – the NHS Commissioning Board (NHSCB).
This body will be responsible for the specialised services
currently commissioned at national or regional level.
In addition it will hold the contracts for local community
practitioner services, including pharmacy.
In practice these contracts will be overseen and
managed by new regional and local outposts of the NHSCB
– four regional commissioning sectors covering the whole
of England and 15-20 local fieldforce teams.
Both national and local commissioners will be supported
by local professional networks and clinical networks of
experts, and by clinical senates, whose advice clinical
commissioners are expected to follow. They will also
need to have effective means in place for engaging with
patients, carers, local authorities and other stakeholders.
Monitor, the current regulator of foundation trusts,
will become the economic regulator of all providers of
services to the NHS. It will take over some key functions
from the DH including setting the tariff for hospital services,
and in due course for community-based services, and for
ensuring continuity of service if providers get into financial
In addition, it will oversee the development of a market
in healthcare services. However, instead of having a
positive duty to promote competition – the Government’s
original intention – it will only be required to exercise
its functions with a view to preventing anti-competitive
behaviour that is not in the interests of patients. In addition
it will be tasked, along with the NHSCB, with supporting
the delivery of integrated services where this would
improve quality of care for patients or reduce inequalities
in access and outcomes.
In line with the policy of delegation, local authorities
are to have a greater say in how the NHS operates. Each
authority will establish a health & wellbeing board (HWB)
charged with developing strategies to promote the health
of their local population, which CCGs will have to take into
In addition, they will be allocated funds specifically for
public health projects. HWBs will take over responsibility
for local pharmaceutical needs assessments from PCTs.
Taken overall, these changes are so far reaching that it is
hard to make a firm forecast of how they will work out in
National guidance to facilitate
relationships with the new commissioners has been produced2.
Pharmacy Voice has released
an excellent guide to the new
NHS landscape3 and the CPPE
has published materials to
help pharmacists engage with
clinical commissioning groups4.
The newly formed Pharmacy and
Public Health Forum – which
leads development, implementation and evaluation of public
health practice for pharmacy –
brings together national leaders
within pharmacy and outside it.
According to its chair, Richard
Parish, chief executive of the
Royal Society of Public Health:
“Pharmacy has acquired some
extremely influential advocates”.
The Forum’s initial priorities are
about rolling out healthy living
pharmacies, developing standards in public health for pharmacists and their staff, building
the evidence base for pharmacy,
and looking at how the role of
pharmacy integrates with the
rest of the health system.
Pharmacy’s longer-term survival, however, will depend on
how well it understands and
negotiates the new NHS landscape. It has considerable resources and capabilities in relationship building, marketing and
selling, which it must now use to
demonstrate to new commissioners how it can deliver high quality,
cost-effective and accessible services to meet their objectives.
в– Eileen Neilson is director
of Willow Consulting
([email protected]).
Anthony Harrison is an
independent consultant
and research associate at the
King’s Fund
1. Department of Health (2010).
Equity and excellence: Liberating the
2. Eg. BDA, BMA, Optical Confederation, Pharmacy Voice & RPS (2011).
Engaging with primary healthcare
professionals to improve the health
of the local population.
images/press/engaging_ primary_
health_ of_local_ population_
3. Pharmacy Voice (2011). The
changing NHS and public health
landscape. What does it mean for
local representation?
4. Cutts C (2011). Selling the new
medicine service to GPs. Pharmacy
Magazine, October 2011, p22.
The changing NHS represents the most challenging environment
pharmacy has ever faced. In the first of two articles in this month’s
issue on the health reforms, Eileen Neilson and Anthony Harrison urge
community pharmacists to build strong, positive relationships with the
new commissioners or risk being sidelined
The Government hopes that giving GPs greater control over how
NHS resources are used will lead
to more innovation in the way
that services are provided.
GPs as commissioners therefore occupy a central and considerably more powerful role
in the reformed NHS: seeing
them as customers rather than
competitors will require a different mind-set. It is expected that
the Government’s focus on integration of services will lead to
contracts being let for �years of
care’ and to care pathways for
chronic conditions. Pharmacists
must ensure their contribution to
these – in particular improved
health outcomes resulting from
the new medicine service (NMS)
and targeted MURs (tMURs) – is
fully recognised.
Local authority health and
wellbeing boards (HWBs), the
other new commissioning bloc,
may well want to commission
smoking cessation and other
services pharmacists have a
strong track record in providing.
Although pharmacists meet paid
carers collecting clients’ medication, they have previously had
little contact with social care
decision-makers (e.g. local councillors, social services officers and
care managers commissioning
individual care packages).
HWBs will also reflect other
local authority services that impact on health and wellbeing,
such as children’s services, education, environment, housing,
leisure and transport, whose
perspectives and professional
cultures are different from pharmacy’s. Pharmacists will be in
complex and unfamiliar territory.
will be in
complex and
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Date of preparation: December 2011
28_Long Opinion_PM_0212_rt.qxp:28_PM_0212 01/02/2012 13:14 Page 2
nhs reforms
It’s good
to talk
It is time to end our slavish
reliance on guidance, best
practice and engagement, and
move towards a system where
healthcare professionals are
contracted to talk to each other,
argues Andrew McCoig
IRECENTLY took Cider, my Golden
Retriever, to the vet for his annual
check-up and vaccination. The
service was faultless, as it had
been on all previous occasions.
Cider receives far better attention
and healthcare than we do on
the NHS.
Veterinary services are not
cheap but we do get what we pay
for and the lines of communication are very short, with the patient offering no opinion whatsoever on his treatment. Having
suffered a deep cut to his paw in
the summer, his treatment was
swift and exemplary, resulting in
a fast return to normal status,
towards their fellow citizens. NHS
systems are full of “guidance”,
“best practice” and “engagement”
– all words that ensure its continuing failure and dysfunctionality.
We often hear that the aviation
industry is the benchmark when
it comes to safety and the effective handling and transfer of
millions of people worldwide.
There is no such thing as guidance, best practice or engagement in this industry, as this
would rely on somebody doing
something because they think
they should – as in the NHS. It
comply and you face prosecution. The industry is built on a
solid reputation of safety and is
heavily regulated. Broad compliance with all aspects of aviation
regulations is mandatory for all
employees at every level.
So why is it we are still developing proper, fit for purpose,
discharge procedures from
hospital to primary care settings
63 years after the NHS was first
The other week I met some
people who are responsible for
“engaging” all who work in these
two sectors to produce patientcentred pathways that would
“The NHS is where the aviation
industry was in the 1930s”
with the owner (or rather his
insurer) being out of pocket by
£570. Cider’s care and aftercare
was, by any measure, excellent.
The NHS is not cheap either–
and we certainly don’t get what
we, the taxpayers, pay for.
Healthcare standards are rather
hit and miss, particularly if you’re
elderly and a poor communicator, and have nobody to help you
carve an effective, rapid path
through to successful treatment.
The service is wholly dysfunctional.
Most of the system works on
the basis of goodwill and common sense – commodities that
can be scarce at times. Care pathways rely on effective communication and a reliance on people’s
altruism and good behaviour
is safer to board an aircraft in
London bound for any destination in the world than it is to
enter a major London teaching
The good news is that we like
aviation that way and willingly
and routinely put our lives in the
hands of the industry and its
services. That’s why there are
approximately half a million
people in the air at any one time.
In this environment, all
employed people follow orders,
instructions, adhere to standards
of practice that have been developed over many decades and,
above all, communicate with
each other.
There is no “wriggle” room in
an Air Navigation Order or in
Civil Aviation regulations. Fail to
lead to a seamless transfer of care
between hospital and social and
primary care. It’s not hard to
guess what the outcome will be:
failure at worst or some temporary partial success with some
In some ways, the NHS is
where the aviation industry was
in the 1930s – i.e. people are
dying needlessly through preventable accidents and human
We still rely on the goodwill of
healthcare professionals to talk
to each other and communicate
effectively to ensure a reasonable patient outcome. My view is
that while this culture of reliance
on decent human behaviour
continues, the NHS will continue
to be dysfunctional.
GPs do not have to talk to
pharmacists and vice versa. They
can somehow continue to muddle through. A supply request for
medicines can be transferred to
a pharmacist from the prescribing doctor without any formal
communication on how to ensure that the patient uses those
medicines as they should.
We have known for decades
that the amount of waste generated by the inappropriate use
of medicines is substantial – yet
there is still no proper dialogue
between the two professions.
Imagine a scenario where a
pilot with 400 passengers in his
aircraft ignores air traffic control,
or air traffic control ignores the
pilot. It’s unthinkable but this is
precisely what is happening in
the NHS today. Mass communication failure is endemic.
Even if the pilot doesn’t like
the idea of talking to an air
traffic controller from another
country, he has a statutory duty
to do so and will comply with
that duty. His safety and the
safety of his passengers depend
upon this compliance.
One of the substantial reasons communication failure in
the NHS is the continuing policy
of developing all healthcare
professional contracts or job
descriptions in isolation from
each other.
One healthcare professional
will talk to another if he or she
thinks it is appropriate or good
sense to do so – not because they
have a contractual duty to do so.
Therein lies the problem.
We continually learn of examples of good practice, where
people of good intention have
applied themselves to a particular scenario for better patient
care and come up with a model
way of working. The flaw is that
it is always based on a few personalities forming an effective
network of like-minded people.
Revisiting sites of “best practice”
years later it is often the case that
the originators have moved on
and the system has fallen apart.
We need a root and branch
review not of the NHS itself,
which is happening at the moment, but of the culture and
hierarchies that exist in today’s
health service. People should be
compelled to meet and talk to
other people when patient safety,
treatments and outcomes are the
issues, no matter what levels they
work at within the system. And,
if it makes good common sense
to do so, then let’s regulate it into
every contractual arrangement.
The fear of prosecution
should not just be reserved for
personal professional failure but
also for breach of contractual
communication. There should
be no place for failure to reply or
respond to another colleague
elsewhere in the NHS where
patient care is in question – but
this is precisely what is happening at the moment.
Malcolm Grant, the newly
appointed chair of the NHS Commissioning Board, recently described the proposed healthcare
reforms as “completely unintelligible”. He may be right, but he
would be on safer ground if
he described inter-professional
communication within the NHS
in the same terms. в—Џ
29-32_Pregnancy_PM_0212_rt.qxp:29-32_PM_0212 09/02/2012 10:48 Page 29
pregnancy and baby care
The best possible start
в—Џ At least 40 per cent of pregnancies in the UK are unplanned
в—Џ Being overweight or obese increases the risk of almost all
pregnancy complications
в—Џ Smoking during pregnancy can cause miscarriage, stillbirth
and low birth weight as well as future health problems
в—Џ Current NICE guidelines advise women to avoid alcohol
during pregnancy
Unhealthy lifestyles before and during pregnancy are
associated with serious complications and long-term
health consequences. So what can you do to help
ensure babies have the best possible start in life?
In 2004, 40 per cent of pregnancies in the UK were unplanned,
according to a OnePoll survey
of 3,000 mothers. Experts believe
today’s figure is even higher.
This means that many
women become pregnant before
making necessary changes to
their lifestyles, such as losing
weight, giving up smoking or
cutting down on alcohol. It is
therefore essential that these
women are offered the support
and guidance they need to give
their babies the best possible
start in life.
Nearly half the women of childbearing age in this country are
overweight or obese. Furthermore around one in five pregnant women have a BMI of 30
or above at the beginning of their
pregnancy, according to figures
from the NHS Information
While the majority of overweight women will have a
straightforward pregnancy and
birth, the higher a woman’s
BMI is over 25, the higher her
chance of having a miscarriage
or developing complications,
such as thrombosis, gestational
diabetes and pre-eclampsia.
active. It’s also a myth that pregnant women need to eat for two,”
says Annette Briley, consultant
midwife for Tommy’s, the baby
Managing weight after birth is
also important, as keeping the
weight on or gaining additional
weight will increase the risk of
complications during subsequent pregnancies. Besides offering numerous health benefits to
the baby, breastfeeding can aid
weight loss. However, according
to RCOG, obese mothers are less
likely to breastfeed, and therefore
may require extra support.
The NICE guideline recognises a role for pharmacists in
weight management before and
after pregnancy and advises the
use of any opportunity to provide
overweight and obese women
with relevant information.
In the UK, smoking in pregnancy
causes up to 5,000 miscarriages,
300 peri-natal deaths and around
2,200 premature births each year,
according to a 2010 report by the
Royal College of Physicians. Furthermore, children of parents
who smoke have an increased
risk of respiratory infections,
asthma, learning difficulties and
behaviourial problems, as well
as diabetes and heart disease
in later life. Children whose
mothers smoked during pregnancy are also three times more
likely to develop a smoking habit
Toxins from cigarette smoke
pass from the mother’s bloodstream to her baby through
the placenta, while the carbon
monoxide in cigarette smoke
binds with haemoglobin 200
times faster than oxygen, disrupting the transport of oxygen
to the placenta and impairing
foetal growth and development.
“Many women become pregnant before making
necessary changes to their lifestyles”
After reading this feature you
should be able to:
в– Support women to reduce
their risks of pregnancy
в– Raise awareness of the
importance of being a healthy
weight, reducing alcohol or
giving up smoking before
в– Advise on managing common
minor health problems during
pregnancy and treating
common infant ailments.
“Being overweight or obese is
associated with almost all complications. It can impair the
development of the baby and
lead to heart or spine defects. It
is also associated with a higher
incidence of early labour, induction, caesarian sections and
shoulder dystocia and, postdelivery, there is an increased
risk of bleeding and infection,”
says Dr Daghni Rajasingam,
consultant obstetrician at Guy’s
and St Thomas’ Foundation Trust
and spokesperson for the Royal
College of Obstetricians and
Gynaecologists (RCOG).
While following a weight loss
diet during pregnancy is not
recommended, it is possible for
overweight expectant mothers
to reduce these risks. NICE
guidance advises following a balanced diet and only increasing
calorie intake by 200 calories per
day during the final trimester.
Moderate physical activity
should also be encouraged, unless there is a complication, such
as a low-lying placenta.
All women are advised to take
400mcg folic acid before conception and until the twelfth week
of pregnancy to prevent neural
tube defects, but overweight or
obese women may need to be
prescribed a higher dose.
A recent double-blind controlled trial funded by the Australian Government revealed
that omega-3 supplementation
during pregnancy could reduce
the risk of pre-term delivery and
low birth weight.
“Weight loss in pregnancy is
not associated with good outcomes for mother and baby but
we advise that women watch
what they eat and try not to pile
on the pounds. There is a general
perception that it is okay to sit
around when pregnant, when
actually it’s important to keep
29-32_Pregnancy_PM_0212_rt.qxp:29-32_PM_0212 09/02/2012 09:31 Page 30
pregnancy and baby care
“If a woman smokes, the
advice is to stop completely, as
giving up can reduce these risks.
This is hard if she has a heavy
habit but it is never too late to
stop. For example, the Scope
study from New Zealand found
that even giving up in the second
trimester causes babies to be a
better size and in better health,”
says Briley.
There is mixed evidence that
NRT is effective in helping pregnant women to give up smoking
and insufficient evidence that
it poses a risk to infant health.
However, NRT can be recommended to women who are
struggling to quit without it.
Research suggests that passive
smoking can be almost as harmful as maternal smoking, so
partners should also be offered
support to quit.
Heavy drinking (more than six
units a day) during pregnancy
can lead to miscarriage and
is associated with a range of
developmental problems known
collectively as foetal alcohol
spectrum disorder (FASD).
Children with FASD may have
a low birth weight and suffer
from facial abnormalities, heart
defects, poor growth and severe
mental and developmental
Current NICE guidance recommends that women abstain
from alcohol entirely during
pregnancy and while trying to
conceive. However, if women do
choose to drink, it advises them
to stick to one to two units no
more than once or twice a week
during the second and third
trimesters and not at all during
the first. These guidelines were
updated in 2008 following a
survey that revealed that one in
10 expectant mothers exceed the
recommended limits.
“The trouble is that lots of
women don’t realise they are
pregnant straightaway and may
continue to drink during the
first month; however one bout
of binge drinking early on is
unlikely to cause any harm,”
reassures Rajasingam.
“Reducing alcohol at any
stage of pregnancy will help to
reduce the risk of complications
and also help women to live
healthier lives in the long run.”
Briley recommends that
women make sure they are aware
of the number of units in different drinks to ensure that they
don’t exceed the limits. Heavy
drinkers will require expert
help to reduce their alcohol intake and manage withdrawal
Both Briley and Rajasingam
agree that community pharmacists have an important role in
providing women with accurate
health information, particularly
before conception and during
the initial stages of pregnancy.
“Pharmacists provide an ideal
initial interface before a woman
has seen a midwife. For example,
if a woman is buying folic
acid supplements, this is a good
opportunity to ask if she has
thought about changing her diet
or reducing alcohol,” says Briley.
“Women are also less likely to be
embarrassed about asking their
pharmacist certain questions
than their GP or midwife.”
“The biggest barrier to behavioural change is lack of knowledge and we are particularly bad
in the UK at raising awareness
of the importance of a healthy
lifestyle before getting pregnant,”
adds Rajasingam. “Pharmacists
have a huge opportunity here,
as they are in regular contact
with young women and provide
a trusted source of advice.”
Back pain
As her baby grows, the hollow in
a mother’s back can become
more pronounced, leading to
backache. In addition, the body’s
ligaments become looser during
pregnancy, putting a strain on
the joints of the lower back.
Women can help prevent backache by avoiding lifting heavy objects, wearing flat shoes, ensuring
they have a good posture and
getting enough rest in the later
stages. Sleeping on a firm mattress, massage and soothing heat
patches may provide relief too.
Constipation is a common complaint during pregnancy because
hormonal changes slow down
the digestive tract. If unmanaged,
this can lead to haemorrhoids.
One in five pregnant women
have gone for more than four
days without a bowel movement,
according to a recent survey by
Dulcobalance, but many expectant mothers are unaware of
lifestyle factors that can exacerbate the problem. The survey
also revealed that one in three
pregnant women become increasingly sedentary and that
over a quarter take prenatal
supplements containing iron,
which can lead to constipation.
Self-care measures include
drinking adequate amounts of
fluid, eating foods high in fibre
and taking regular, moderate
exercise. If these are insufficient,
bulk-forming laxatives or a
remedy containing macrogol or
lactulose can be recommended.
Some women find that they
suffer from headaches during
Women should try to avoid excessive weight gain during pregnancy
Young mothers look to pharmacists and their staff for guidance on managing
common infant ailments and advice on when to seek medical help
Excessive crying is often a sign of colic, which is common during the first
three months of a baby’s life. Colic is generally thought to be digestive pains,
due to the immaturity of the gut, or bubbles of trapped wind. Massage,
burping or using an anti-colic teat if bottle-feeding may help ease discomfort.
In some cases, colic may be linked with transient lactase deficiency, a
temporary condition in which the baby’s gut does not produce sufficient
levels of the enzyme lactase to digest lactose. Removing dairy from the
mother’s diet if breastfeeding or administering lactase drops to the baby can
manage the problem.
Milk allergy is less common than transient lactase deficiency but is
thought to affect two to seven per cent of babies under one year of age,
according to NHS Choices. It is characterised by vomiting and diarrhoea after
feeding, as well as skin rashes, wheezing and swelling. A dairy elimination
diet (if breastfeeding) or milk substitute formula (if bottle-feeding) is
Nappy rash
This is common during the first 18 months and is usually due to prolonged
skin contact with waste. Infrequent nappy changing, diarrhoea and using
soap, detergent or bubble bath can exacerbate the problem. Symptoms are
usually mild and include redness and pimples but severe symptoms, including
cracked skin, ulceration and blisters can be distressing for the baby. Changing
nappies regularly, cleansing the baby’s bottom with cotton wool or baby
wipes and then applying a barrier cream will all help prevent and relieve
nappy rash. If thrush is present, an antifungal cream can be recommended.
Milk teeth erupt during the first six to 12 months of a baby’s life. Contrary to
common belief, the teeth do not actually cut through the gums but instead,
chemical messages tell certain gum cells to die, allowing the teeth to
emerge. Nevertheless, teething can be painful, making a baby irritable, grizzly
and clingy. Dribbling and flushed cheeks are also signs that a baby is teething.
Gels containing local anaesthetic and liquid analgesic can help reduce
Fever occurs when the baby’s core body temperature exceeds 37.50C. Digital
and ear thermometers are the most effective types of thermometer to use
on a baby. The best way to lower temperature is with an antipyretic medicine,
such as liquid ibuprofen or paracetamol, as well as keeping the baby hydrated
and removing layers. Cold sponging is no longer recommended as it can lead
to vasoconstriction in the surface of the skin, trapping heat inside the body
and making the child feel worse. Red flags include a high pitched, weak or
continuous cry; a lack of responsiveness; a bulging fontanelle; not drinking
for more than eight hours; neck stiffness; repeated vomiting; turning blue;
breathing difficulties; convulsions; and a purple-red rash.
“Smoking in pregnancy causes
up to 5,000 miscarriages”
31_PM_0212:31_PM_0212 14/02/2012 10:52 Page 1
When pain and fever of a child leaves mum
feeling a little anxious, give herВ® a word of
Trusted by healthcare professionals and parents for over 40 years,
Calpol Infant Suspension (paracetamol) and CalpolВ® SixPlus Suspension (paracetamol)
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Your trusted advice with our trusted name
Calpol Infant and Sugar-free Infant Suspension Product Information: Presentation:
Suspension containing 120mg Paracetamol per 5ml Uses: Treatment of mild to moderate pain
and as an antipyretic. Can be used in many conditions including headache, toothache, earache,
teething, sore throat, colds and influenza, aches and pains and post immunisation fever. Dosage
for Children over 3 months: Do not give more than 4 doses in 24 hours and leave at least 4 hours
between doses. Children 4 to 6 years: 10ml. Children 2 years to 4 years: 7.5 ml. Children 6 to 24
months: 5 ml. Children 3 to 6 months: 2.5 ml. Dosage for Infants 2-3 months: Post–vaccination
fever at 2 months: 2.5ml, and a second dose, if necessary, after 4-6 hours. The same two doses
can be given for the treatment of mild to moderate pain and as an antipyretic in infants weighing
over 4kg and not born before 37 weeks. Contraindications: Hypersensitivity to paracetamol or
other ingredients. Precautions: Caution in severe hepatic or renal impairment. Interactions with
domperidone, metoclopramide, colestyramine, anticoagulants, alcohol, anticonvulsants and oral
contraceptives. Patients with rare hereditary problems of fructose intolerance should not take
this medicine. Due to the presence of sucrose and sorbital in the Infant Suspension, patients
with glucose-galactose malabsorption or sucrose-isomaltase insufficiency should not take this
medicine. Maltitol may have a mild laxative effect (Sugar-Free only). Parahydroxybenzoates and
carmoisine may cause allergic reactions. Pregnancy and lactation: Consult doctor before use.
Side effects: Very rarely hypersensitivity and anaphylactic reactions including skin rash. Blood
dyscrasias, chronic hepatic necrosis and papillary necrosis have been reported. RRP (ex-VAT):
100ml bottle: ВЈ2.54; 200ml bottle: ВЈ4.25; 12 x 5ml sachets: ВЈ2.80; 20 x 5ml sachets (sugar
free only): ВЈ4.50. Legal category: 200ml bottle: P; 100ml bottle: GSL; Sachets: GSL. PL holder:
McNeil Products Ltd, Maidenhead, Berkshire, SL6 3UG. PL numbers: Calpol Infant suspension:
100ml bottle: 15513/0122; 200ml bottle: 15513/0004; Sachets: 15513/0154. Calpol Sugar-free
Infant Suspension: 100ml bottle: 15513/0123; 200ml bottle: 15513/0006; Sachets: 15513/0155.
Date of preparation: June 2011. Calpol Six Plus Suspension, Calpol Six Plus Sugar
Free Suspension and Calpol Six Plus Suspension Sugar Free Product Information:
Presentation: Suspension containing 250mg paracetamol per 5ml. Uses: Treatment of mild
to moderate pain and as an antipyretic. It can be used in many conditions including headache,
toothache, earache, sore throat, colds and influenza, aches and pains and post-immunisation
fever. Dosage: Adults and Children over 16 years: 10 ml to 20 ml; Children 12-16 years: 10 ml
to 15 ml; Children 10 to 12 years: 10 ml. Children 8 to 10 years 7.5 ml. Children 6 to 8 years:
5 ml. Children under 6 years: not recommended. Do not give more than 4 doses in 24 hours.
Leave at least 4 hours between doses. Contraindications: Hypersensitivity to paracetamol or
other ingredients. Precautions: Caution in severe hepatic or renal impairment. Interaction with
domperidone, metoclopramide, colestryamine, anticoagulants, alcohol, anticonvulsants and oral
contraceptives. Sorbitol may have a mild laxative effect (Six Plus Suspension), sorbital and maltitol
may have a mild laxative effect (sugar free). Pregnancy and lactation: Consult doctor before use.
Side effects: Very rarely hypersensitivity and anaphylactic reactions including skin rash. Blood
dyscrasias, chronic hepatic necrosis and papillary necrosis have been reported. RRP (ex-VAT):
Six Plus Suspension 200ml bottle, ВЈ4.93; Six Plus Sugar Free Suspension, 100ml bottle, ВЈ3.06,
200ml bottle, ВЈ4.93, 12 x 5ml sachets, ВЈ3.40; Six Plus Suspension Sugar Free, 80ml bottle ВЈ2.54.
Legal category: Six Plus Suspension 200ml bottle: P; Six Plus Sugar Free Suspension 100ml
and 200ml bottle: P; Sachets: GSL and Six Plus Suspension Sugar Free 80 ml bottle: GSL. PL
holder: McNeil Products Ltd, Maidenhead, Berkshire, SL6 3UG. PL numbers: Six Plus Suspension:
15513/0002; Six Plus Sugar Free Suspension 100 ml and 200 ml
bottles & sachets: 15513/0003, Six Plus Suspension Sugar
Free 80 ml bottle 15513/0164. Date of preparation: June 2011.
ID: UK/CA/11-0014
29-32_Pregnancy_PM_0212_rt.qxp:29-32_PM_0212 09/02/2012 09:31 Page 32
foods. Sleeping propped up
with a pillow can help manage
nocturnal gastro-oesophageal
reflux. Antacids or alginates can
be recommended for mild symptoms that are not adequately
controlled through lifestyle interventions. If the symptoms are
persistent or severe, then women
will need to be referred to their
GP, who may prescribe the proton pump inhibitor omeprazole.
Indigestion and heartburn
Many women suffer from dyspepsia (indigestion) during the
later stages of pregnancy, due
to the growing uterus pressing
on a full stomach. Heartburn is
another common complaint, because hormones cause the lower
oesophageal sphincter to relax,
allowing gastric acid to creep up
the oesophagus.
Self-care tips include eating
smaller meals, sitting up straight
to eat and avoiding troublesome
Stress urinary incontinence (SUI)
can be a problem during the later
stages of pregnancy due to the
loosening of the pelvic floor muscles in preparation for delivery
and pressure from the baby
pressing against the bladder.
Women may experience leakage
of urine when they cough, laugh,
sneeze or exercise. SUI can usually be prevented or managed
with pelvic floor exercises, which
can also help during labour and
aid recovery of the muscles after
When a woman buys an ovulation or pregnancy testing kit, it provides an ideal
opportunity to start a conversation about lifestyle habits before and during
pregnancy. Research by P&G, the manufacturer of Clearblue pregnancy and
ovulation tests, shows that women make special trips to buy pregnancy tests
from familiar stores and are not influenced by price. It also found that 41 per
cent of shoppers feel that these products are located on shelves too low down.
“The purchase of pregnancy or ovulation tests is very significant for the
consumer, whether she is facing the prospect of a planned or unplanned
pregnancy,” says Amine Boukhris, P&G healthcare business leader. “Many
consumers are looking for advice and reassurance, and this is where the
pharmacist is uniquely placed to be able to provide a valuable service.”
Boukhris advises pharmacies to boost category sales by stocking more digital
pregnancy tests and educating women about the benefits of ovulation monitors.
“There is still a significant opportunity for growth in the sale of fertility and
ovulation tests, as many consumers still do not understand how the products
work or how they can help them,” she says.
Nausea and vomiting during the
first 12 weeks of pregnancy is
often referred to as morning
sickness, although it can occur at
any time of day. Eating little and
often rather than large meals,
getting adequate rest, wearing
comfortable clothing and drinking plenty of fluids can all help
relieve nausea. If the symptoms
are severe and do not improve
with lifestyle measures, then a
GP may prescribe a short course
of anti-emetics. There is also
some evidence that antihista-
mines or ginger supplements are
effective against nausea.
Stretch marks
These are purplish pink marks
that may appear on the abdomen, thighs or breasts during
pregnancy but usually fade and
become less noticeable after
birth. Stretch marks are commoner in women who gain more
weight than average. Most
women gain between 10kg and
12.5kg in pregnancy, according
to NHS Choices, although weight
gain varies greatly between
women and depends on their
pre-pregnancy weight.
Some women find that applying special creams and oils helps
to reduce the appearance of
stretch marks. в—Џ
pregnancy & baby care
Customers suffering from morning
sickness could try Lillipops Iced
Soothies – ice pops formulated to help
alleviate their symptoms of nausea,
dry mouth, heartburn and indigestion.
Available in five natural flavours –
grapefruit & tangerine, lemon & mint,
camomile & orange, lime & vanilla and
ginger – the ice pops contain no artificial
colours or sweeteners. A multipack of
20 retails for ВЈ9.95. (Tel: 01923 804182)
With many women experiencing
light bladder weakness during
pregnancy, SCA Hygiene says Lights by
TENA are superior to sanitary products
in terms of level and rate of absorbency
and odour control. They not only offer
ultimate security and protection, says
the company, but also feel dry and
gentle against the skin – offering
comfort, confidence and discretion.
(Tel: 0870 333 0874)
Spatone Apple, which combines
the natural liquid iron supplement
(Spatone) with an apple taste, plus added
vitamin C to aid absorption of the iron,
is suitable for pregnant women, says
Nelsons. By containing Spatone spa
water sourced from the Welsh mountains
of Snowdonia National Park it can help
top up iron levels while causing fewer
of the unpleasant side-effects often
experienced with conventional iron
supplements, says the company.
(Tel: 0208 780 4257)
pregnancy. Paracetamol at the
recommended dose is considered safe for use during pregnancy, but other oral analgesics
should be avoided. Cooling gel
strips are also beneficial, along
with rest and adequate fluid
intake. Women with severe or
frequent headaches should be referred to their doctor or midwife
because this can be a sign of high
blood pressure or pre-eclampsia.
pregnancy and baby care
Vitabiotics Pregnacare Plus
combines the original Pregnacare
tablet with an omega-3 DHA capsule.
The tablets and capsules can be taken
from pre-conception, during pregnancy
through to the end of breast-feeding, says
Vitabiotics. Pregnacare Plus includes a
range of vitamins and minerals, including
400mcg folic acid and 10mcg vitamin D3,
while each omega-3 capsule provides
300mg of DHA. A month’s supply retails
for ВЈ13.25. (Tel: 0208 955 2600)
One daily dose of Dalivit
Multivitamin Drops (25ml ВЈ4.95,
50ml ВЈ7.95) supplies the recommended
amounts of seven essential vitamins
for normal health and growth in early
childhood, says Boston Healthcare.
The drops, which come with an
integral dropper system, do not
contain peanut oil, are suitable for
and have
no added
colours or
adds the
(Tel: 0845
A one-week trial of Colief Infant
Drops (ВЈ11.99) may help parents
determine if sensitivity to milk could be
the cause of their baby’s colic, says Forum
Health Products. When added to breast
or formula milk the drops can help break
down the lactose a baby is struggling to
digest, making the feed more easily
digestible. If the baby shows no sign of
improvement after a week, this can be
ruled out as the cause, says the company.
(Tel: 01737 857793)
Infacol relieves infant colic and griping pain
and assists in bringing up babies’ wind, says
Forest Laboratories. Suitable for use from birth
onwards, Infacol comes with an integral dropper and
should be administered before each feed, says the
company. Each pack contains up to 100 doses and
retails for ВЈ4.20. (Tel: 01322 421 800)
Pharmacy Magazine online learning
33_PM_0212:33_PM_0212 14/02/2012 11:44 Page 1
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34-35_Nutrition_PM_0212.qxp:34-35_PM_0212 07/02/2012 10:47 Page 34
nutrition and weight management
Pharmacists are ideally placed to offer
customers advice on lifestyle and dietary
changes that will improve their nutrition
and help them manage their weight
в—Џ The UK population is becoming fatter, with almost a quarter
of England’s population obese
After reading this feature you
should be able to:
в– Appreciate the sensitivity
needed when discussing
weight issues with your
в– Tailor different measures to
different people
в– Decide if your pharmacy could
run a weight loss service.
The Government has disbanded
its expert advisory group on
obesity – despite current figures
showing that Britain has the
highest proportion of obese
women and young people in
Europe and the second largest
number of obese men. Almost
a quarter of the population of
England is now classified as
obese, as defined by the World
Health Organization (a body
mass index of 30 or above).
New research also shows that
death rates for cardiovascular
disease and cancer are higher in
Scotland, Wales and Northern
Ireland than they are in England.
As it is well known that these
diseases are associated with a
poor diet that is high in saturated fats and salt, and low in
fibre, fruits and vegetables, the
research claims that around
4,000 deaths could be prevented
every year if the UK population
adopted the average diet eaten
in England.
So why have public health
messages and medical treatments failed to stem the obesity
epidemic? Christina Wright,
Numark’s services development
manager, says there are often
psychological issues behind
overeating. “If it was as simple as
just eating a bit less and exercising more, there would not be a
problem,” she says. So what can
be done to reverse this trend?
в—Џ Getting slimmer is not just about looking better,
it contributes to a healthier life
в—Џ Many overweight people are in denial, which can lead to
Professor David Haslam, chair
of the National Obesity Forum,
believes that better food labelling
is the way to go. “People have
a right to know what they’re
eating,” he says, “but they need
to understand what the label is
telling them. It’s no use labelling
the calorie content if the food
is still full of salt. I’d rather see
an improvement in the overall
quality of food.”
Christina Wright agrees that
labelling is only useful if people
can decipher the meaning of
the labels, adding: “Labelling
is still deceptive, with many
manufacturers making it look
as though products are low in
calories and fat by giving the
values for a small portion size.
This is where pharmacy can play
a role in the general education
of the public.”
When it comes to �fat taxes’ –
higher prices to discourage the
purchase of fattier foods – Professor Haslam is not convinced.
“I’m not sure this is the right
thing to do, as it’s difficult to
action,” he says. “I’d rather see a
carb tax on foods, such as chips,
bread and potatoes, which some
people think are actually more
to blame for obesity than fat.
The common argument with a
�fat tax’ is that you’re taxing those
who can least afford it, plus I’d
like to know what the Government would do with the money
raised. Would it really be used
to fight obesity?”
What he suggests instead is a
subsidy on fruit and vegetables.
“There should be more promotions in supermarkets on fruit
and veg,” he says, “and you
shouldn’t be presented with
displays of reduced-price beer
and biscuits as soon as you
walk in the door.” Christina
Wright agrees such a subsidy
might encourage the five-a-day
habit, adding that, “as fruit and
veg can be expensive, this would
support low income families to
eat more healthily”.
This already happens in some
schools but the problem is that
parents can opt their child out.
“It’s always the bigger kids who
are opted out because their
parents don’t want them to be
named and shamed,” says Professor Haslam. “The National
Obesity Forum is pro this measure but the approach is flawed.
It should be a mandatory requirement in schools, as long as
it is done sensitively.”
Mary Lloyd, technical director
of Bio-Life International, thinks
educating children about nutrition at a young age could be
more valuable. “Nutrition should
be taught in schools and colleges,” she says, “and every
student should have designed a
nutritional programme as a
project by the time they are 16
years of age.”
For some people, exercise can
be prescribed but Christina
Wright is doubtful about its
success. “Exercise prescriptions
may work for some people but
they would have to be motivated
“Hopefully the Olympic Games will encourage people to
take up different activities”
34-35_Nutrition_PM_0212.qxp:34-35_PM_0212 07/02/2012 10:48 Page 35
to make the change for themselves so this could not be used
alone. Pharmacists know from
their delivery of smoking cessation services, for instance, that
behavioural change is not easy.”
Mary Lloyd agrees. “The word
prescription is anathema to
many. Sport, sport and more
sport is a more rewarding activity and needs more encouragement. Hopefully the Olympic
Games will encourage people to
take up different activities.”
Stomach stapling, bypass or
gastric bands all force patients to
eat less by limiting the capacity
of their stomachs. NHS guidelines restrict such procedures
to patients with BMIs of 40+
(or 35+ if there are co-morbidities
like diabetes or heart disease).
The NOF is all for bariatric
surgery. We think the NHS selection process is spot on and the
NICE guidelines are good, says
Professor Haslam. “However, it
seems that some PCTs add in
their own guidelines which
narrow the eligibility criteria,
wrongly in my opinion. It’s a
dramatic solution but if chosen
for the right people for the right
reasons then it can save lives and
save the NHS money in the long
run. It costs around ВЈ6,000ВЈ8,000 but it pays for itself in 18
months in terms of other healthcare costs.”
As well as advising customers on
small, realistic changes they can
make to their diet and exercise
routines, Fiona Caplan-Dean,
clinical services manager at
The Co-operative Pharmacy, says
there are some weight loss products that can also help. “Our
pharmacists will talk to individuals to try and find the most
appropriate weight loss option to
meet their needs. It is important
that people who are learning to
manage their weight feel supported along the way so regular
consultations and discussions
incorporating a set plan and
weigh-ins can help motivation.”
With adult obesity in the UK
showing no signs of decreasing,
pharmacists are ideally placed
to run a weight management
service. However, Christina
Wright warns that common
mistakes made by pharmacies
when setting up such a service
include “not adequately publicising it, and stocking an insufficient product range”.
Ajit Malhi, head of marketing
services for AAH Pharmaceuticals, says pharmacy weight management services can make a big
difference. “A successful weight
management programme relies
on the partnership between the
patient and the pharmacist.
Together they will set achievable
goals and an agreed action plan.
Every patient wishing to lose
weight has different needs. These
can best be addressed with the
ongoing help and support of a
healthcare professional, and, in
pharmacists, we have healthcare
professionals who are discreet
and easily accessible.”
“People have a right to know what
they’re eating”
Pharmacies see two important
groups of people thanks to their
frontline role in healthcare. One
group is people with repeat prescriptions, and the other is those
who never go to their GP and are
therefore lost to primary care.
Professor Haslam believes
pharmacy can really make a difference by raising general awareness of the problems associated
with obesity. “Pharmacy can
signpost customers to screening
for blood pressure or diabetes,
either in the pharmacy or with
their GP or nurse. Obesity leads
to heart disease, cancer, diabetes
and liver problems, so losing
weight is not just about looking
better, but about being healthier
as well.”
Graham Jones, pharmacist at
Lambourn Pharmacy and chair
of the West Berkshire Health &
Wellbeing Board, is well aware
that tackling the topic of weight
with customers is a very sensitive
issue, but says it is one that needs
to be addressed – for the benefit
of customers and of the pharmacy itself.
“Lots of overweight people
are in denial, particularly as
society has begun to see larger
sized bodies as more normal.
However, I think we have good
authority in pharmacy to get
people to accept our opinions
on losing weight, because they
see us as healthcare professionals. Pharmacy has challenges to
face over the next decade and
I think it has to reinvent itself as
a �wellness centre’ and develop
the Healthy Living Pharmacy
concept in order to succeed –
which is definitely a niche that
pharmacy can fill.” ●
1. Differences in coronary heart
disease, stroke, and cancer mortality rates between England, Wales,
Scotland and Northern Ireland:
role of diet and nutrition 2011;
doi 10.1136/bmjopen-2011-000
2. BMJ 2011;343:d6500 doi: 10.11
A recent study published on revealed that commercial weight loss
programmes are more effective than NHS-based services .
The researchers compared six weight loss programmes with a minimal
intervention comparator group provided with 12 vouchers for free entrance
to a local leisure centre. Three of the weight loss programmes were
provided by commercial operators (Weight Watchers, Slimming World, and
Rosemary Conley) and three were provided by the NHS (Size Down – a
group weight loss programme) and two primary care programmes (nurseled one-to-one support in general practice, and one-to-one support by a
Participants in the commercial programmes lost a mean 2.3kg more than
those in the primary care programmes, leading the study authors to
conclude: “Our findings suggest that a 12-week group-based dedicated
programme of weight management can result in clinically useful amounts
of weight loss that are sustained at one year in an unselected primary care
population with obesity. Interventions provided by primary care showed no
evidence of effectiveness.”
Professor David Haslam, chair of the National Obesity Forum, says there is
a reason for the study findings: “Patients who undertake commercial groups
are self-referrals and, therefore by definition, motivated, whereas primary
care has a duty to attempt to induce weight loss in all our patients,
especially those with co-morbidities, whether they like it or not – a much
more arduous task.
“Having said that, I am supportive of commercial programmes but would
like it to be recognised that it is a whole different cohort of patients. People
turn up to Weight Watchers because they realise they are fat, and want to
get help. Patients turn up to their GP because they have angina or symptoms
of diabetes; their weight may be the last thing on their mind.”
weight management
Teva UK was the first company to
launch generic Orlistat in the UK.
A generic version of Xenical, Orlistat is
indicated in conjunction with a mildly
hypocaloric diet for the treatment of
obese patients with a body mass index
(BMI) greater or equal to 30kg/m2, or
overweight patients (BMI ≥ 28kg/m2)
with associated risk factors.
(Tel: 0800 085 8621)
Leominster pharmacy helps slimmers stay motivated
Westfield Walk Pharmacy in Leominster runs a 12-week weight management programme to help slimmers reach their goals. The programme
involves an initial consultation where slimmers fill out a diet diary and
questionnaire. A programme is then drawn up with advice on healthy eating,
portion control and exercise, and weekly weigh-ins to monitor results.
Pharmacist Ross Dooland says: “Losing weight is easier said than done
and it can take a lot of determination and hard work to conquer bad habits.
Logging results and seeing improvements will help slimmers stay motivated
and resist temptation. We encourage people to record health data in a vital
statistics profile on the website where they can
keep track of their weight loss and get advice from top experts including
leading fitness trainers.”
The Alphega Pharmacy Weight Loss
Support Service is available free to
full members of the Alphega Pharmacy UK
network and as a �top up’ option for other
membership levels. The service involves
giving customers one-to-one personal
support through a 12-step programme.
Marketing materials in the form of a
counter card, customer leaflets, bespoke
posters and screen grabs are provided
to Alphega members as are scales,
a comprehensive service guide and
distance learning training material for the
pharmacy team. (Tel: 020 3044 8969)
Adios and Adios MAX are natural
herbal tablets, which help speed
up weight loss by acting on the body’s
metabolism, says Dendron. When taken
as part of a calorie-controlled diet with
exercise, this can lead to a loss of calories
and weight, with consumer home trials
showing users lost up to half a stone in
just under four weeks, adds the company.
TV advertising, women’s press advertising
and online support are all planned for this
year. (Tel: 01923 229251)
Co-operating for weight loss success
Alison Cooper, manager of The Co-operative Pharmacy in Radcliffe, provides
weight management advice and has offered a Lipotrim service for two years.
The pharmacy has seen a 20 per cent increase in new customers in its
second year of running the weight management programme, with a number
of word-of-mouth referrals from individuals who have been successful at
losing weight.
Alison says: “Although the programme can be difficult for some as it
requires a lot of determination, with support from the pharmacy team
individuals can monitor their progress. Even once they have lost their target
weight, they can continue to come to the pharmacy as part of our
maintenance programme.”
While Alison holds the initial consultation with the customer, once the
programme is underway she has support from her pharmacy team who can
help with the weigh-ins.
The team has helped one customer – a carer and mother of two – to lose
five and half stones via the service. “After trying a number of times to lose
weight over a period of years via slimming clubs and medication after visiting
her GP, she wanted to try our service but was very sceptical as nothing had
worked for her previously,” says Alison. In the first week she lost seven
pounds and it took her a year to reach her target weight, but when she saw
the initial results, this spurred her on to stay with the programme. She now
visits us as part of the maintenance programme for additional support.
“As a pharmacist I try and understand how difficult it is for the customer to
lose weight. I also try to have empathy with them and not suggest making
drastic changes to their lifestyle. By offering them flexible solutions they are
more likely to continue with the programme and achieve success.”
B-Slenda from Pharma Nord
contains FibrePrecise, a natural
indigestible fibre that is said to reduce
calorie intake by clinging to dietary fat
and removing it before it can accumulate
in the body. Pharma Nord says the special
fibres in B-Slenda are extracted from
freshly caught coldwater shrimp from
Icelandic waters. Registered as a
medical device, B-Slenda retails at
ВЈ19.95 for 40 tablets. (Tel: 0800 591 756)
Pharmacy Magazine online learning
36-38_Wound Care_PM_0212_rt.qxp:36-38_PM_0212 09/02/2012 10:51 Page 36
first aid and wound management
Helping healing....
Hard-to-heal wounds are not only distressing for patients
and carers but place a considerable burden on the NHS
After reading this feature you
should be able to:
в– Explain the three stages of the
wound healing process
в– Appreciate the factors that can
affect wound healing
в– Discuss some of the challenges
that wound care clinicians face
in their everyday practice.
Patient-related factors include:
Insufficient blood supply:
This reduces the amount of
oxygen and nutrients available,
so impairs the rate of healing.
This is why dressings should not
be applied too tightly
Age: The wound healing
process takes place at a slower
rate in older people as they are
likely to have poorer circulation
and nutrition, and concurrent
medical conditions or medication than younger patients
Nutrition: Good nutrition is
essential for effective healing,
and it is worth reminding
Regardless of whether the skin has been cut, scratched, bitten or become
ulcerated, all wounds follow the same healing process, which comprises three
в– The inflammatory phase: This involves blood clotting and inflammation
at the wound site, with the aim of cleaning the area of harmful dead tissue
and any debris. The wound becomes red, swollen and painful. Hard-to-heal
wounds often do not move beyond this stage of the healing process
в– The proliferative phase: This includes granulation of the dermis to
rebuild the tissue including a new network of blood vessels, and epithelialisation of the epidermis, which involves epithelial cells forming a new surface
on the wound before contracting so the wound edges move closer together
(although not usually symmetrically). It is also known as the healing phase,
and can begin as soon as 48 hours after the injury has occurred
в– The maturation phase: This takes place once the wound has closed.
Scar tissue forms and matures over a period of up to two years, during which
time the number of blood vessels decreases while the tissue strength increases.
The optimum environment for wound repair involves adequate levels of
water and oxygen, a constant temperature of 37В°C and an absence of trauma,
infectious organisms and other particles.
patients that the process increases the body’s usual metabolic requirements
Smoking: Wound healing is
impaired due to carbon monoxide reducing oxygen levels in
the blood, and the vasoconstrictor nicotine reducing the blood
supply itself. Nicotine also in-
“The optimum environment for wound repair
involves adequate levels of water and oxygen”
creases platelet aggregation, thus
increasing the risk of thrombosis
in the blood vessels surrounding
the wound
Medical conditions: Conditions such as diabetes, anaemia
and vascular disorders adversely
affect wound healing, so should
be addressed and managed
Medicines: Medication that
affects the immune system (e.g.
corticosteroids, cytotoxics and
immunosuppressants) can adversely affect wound healing,
as can NSAIDs.
A woman walks into the pharmacy and asks to speak to the
pharmacist. As you approach
her, you notice she appears extremely anxious.
“It’s my mum,” she bursts out,
before you have even had a
chance to introduce yourself.
“She fell over and gashed her
leg, and it just isn’t healing. She
keeps telling me not to worry,
but it’s been a couple of months
now and she’s obviously in pain
with it. She can’t move about as
she used to, so isn’t able to wash
herself and cook. I’m worried
she’s just going to fade away.
She’s in her eighties, you know.”
This scenario isn’t unusual
as wound healing is a complex
process (see panel) and it could
easily apply to many other
types of individual, such as a
bedridden patient with bedsores,
or a patient with diabetes who
has an ulcer on the foot. The rate
of wound healing is influenced
by many factors, and these may
be related to the patient or the
37_PM_0212:37_PM_0212 13/02/2012 13:34 Page 1
We know that you’re one of the people patients and their families turn to with their questions.
To complement your expert support, we produce a wide range of information on subjects that might help
people affected by cancer. This includes benefits and financial support, as well as information on cancer
types and treatments, the emotional effects of cancer, and practical issues such as how to talk about cancer.
Order our free information and support booklets at
If you think that someone you know will benefit from talking to a cancer support specialist, benefits adviser
or cancer information nurse, please refer them to the Macmillan Support Line on 0808 808 00 00.
Macmillan Cancer Support, registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604).
36-38_Wound Care_PM_0212_rt.qxp:36-38_PM_0212 07/02/2012 10:52 Page 38
first aid and wound management
Wound-related factors include:
Too much moisture, which
can lead to the wound becoming
macerated, impairing healing
and increasing the risk of infection. Macerated skin appears
waterlogged and the wound
will have white edges
Temperature outside the optimum 37В°C will reduce healing
Reduced oxygen availability
(e.g. due to smoking) also adversely affect the process
Infection or foreign particles
prolong the inflammatory phase,
so should be addressed.
A wound is described as �hard
to heal’ if it does not respond as
expected to appropriate treatment, and is not only painful and
distressing for the patient but
also costly to the NHS – both in
terms of the dressings and number of consultations required.
A recent survey of wound care
clinicians published in Wound
UK found that nearly all those
responding agreed that hard-toheal wounds usually warranted
a departure from the usual treatment options (see panel). For
example, skin ulcers are usually
managed by first treating any
infection and debriding any dead
tissue before applying a simple,
“One way to start building
evidence could be to set
up a database”
Selecting the correct dressing is vital for wound healing to be successful
and there are many different types including:
в– Vapour permeable film dressings (e.g. Opsite Flexigrid) provide a moist
healing environment but are non-absorbent
в– Low adherent dressings (e.g. Melolin, NA) are suitable for dry or lightly
exuding wounds
в– Hydrocolloid dressings (e.g. Granuflex) are waterproof dressings that are
suitable for dry or exuding wounds
в– Alginate dressings (e.g. Sorbsan) absorb exudates and are available as
sheets or packing materials. They are not suitable for non-exuding wounds
в– Foam dressings (e.g. Lyofoam) maintain a moist and warm wound
environment to promote healing. They are suitable for wounds with all
levels of exudate
в– Hydrogel dressings (e.g. Granugel) are available as sheets or in tubes or
sachets and maintain a moist wound environment. They are not suitable
for heavily exuding wounds
в– Silicon dressings (e.g. Mepitel) are suitable when it is important to
prevent trauma to the wound and can be used on scar tissue
в– Capillary dressings (e.g. Advadraw) draw exudate away from the wound
by capillary action, and again, are not suitable for non-exuding wounds
в– Honey dressings (e.g. Mesitran) are antibacterial and absorb odours,
so are suitable for dry wounds that are sloughy or necrotic
в– Iodine dressings (e.g. Inadine) have antiseptic properties
в– Odour controlling dressings (e.g. Lyofoam C) contain charcoal to absorb
any offensive odour
в– Silver dressings (e.g. Aquacel Ag) are antibacterial
в– Negative pressure dressings (e.g. Vacuum Assisted Closure [VAC])
reduce oedema and microbes at the wound site, and increase blood
supply, but evidence supporting their use is limited.
Two methods that were considered archaic but have now come back into
use are:
в– Maggots: These degrade dead tissue and reduce odour, and have a place
in the management of ulcers and burns
в– Leeches: Sometimes used for reconstructive surgery to remove any
blood that has accumulated in the veins.
Hard-to-heal wounds typically don’t get beyond the inflammatory stage
non-adhesive dressing (e.g. a
foam dressing) and then compressing using either graduated
hosiery or specialised bandages.
Hard-to-heal ulcers are more
likely to need antimicrobial
therapy, either in the form of a
dressing or systemic treatment,
analgesics, more advanced
dressings (e.g. negative pressure
products) or even surgery.
The major problems for clinicians working to resolve hardto-heal wounds have traditionally been a lack of clinical guidelines for this patient group, and
restrictions on the management
options available, courtesy of
local prescribing and dressings’
Omar Ali, formulary development pharmacist for Surrey and
Sussex NHS Trust, says that a
new problem is rearing its head:
cost. “Evidence-based medicine
and cost-effectiveness pervade
the NHS, and cardiovascular
disease and diabetes are good
examples of this,” he says.
“Yet certain areas such as
dressings and sip feeds have
been left out, because – even
though we understand the science behind these products –
there just isn’t the body of evidence in the same way as for
other therapeutic areas. But
dressings and sip feeds cost a lot
of money, so these areas are now
coming under the spotlight because of the current economic
While keeping up to date with all the latest developments and challenges in
wound care, it’s all too easy to lose sight of the basics such as emergency
life support (ELS) – the actions required to keep someone alive until
professional help arrives. Although this may sound like cardiopulmonary
resuscitation (CPR), the term ELS actually includes other lifesaving actions,
such as dealing with choking, serious bleeding and helping an individual who
may be having a heart attack.
The Resuscitation Council (UK) is working with a number of organisations
including the British Heart Foundation (BHF) to lobby for ELS to be included
in the national curriculum. The aim of the campaign is for all children to
learn basic lifesaving skills when they start secondary school and then
undergo refresher training every year to ensure they stay up-to-date. More
information at
The BHF has recently added more weight to the campaign – as well as
raising awareness of the need for people to have lifesaving skills – by
launching an advertisement featuring actor and ex-footballer Vinnie Jones
performing CPR to the strains of “Staying Alive” by the Bee Gees.
Another public health campaign that is currently underway is the
Department of Health’s stroke awareness campaign. Known as “FAST”,
this encourages people to look for the main symptoms of stroke (facial
weakness, arm weakness, speech problems) and to call 999 to increase
the proportion of sufferers diagnosed in the early stages. More information
This lack of evidence means
that wound care guidelines tend
to settle for signposting best
practice and urging clinicians to
use the cheapest option. In the
real world, this tends not to be
the case, says Ali, who has first
hand experience of the tension
that can occur when NHS medicines management teams ask
tissue viability nurses (TVNs) –
who are the most experienced
clinicians in terms of hard-toheal wounds – to justify why they
are using certain dressings. Much
like community pharmacists,
TVNs tend to work in isolation,
Under health and safety regulations, all pharmacies are required to undertake
a first aid needs assessment. As a minimum, there must be someone
appointed to take care of first aid arrangements, a suitably stocked first aid
box, and information provided to all staff so they know what the first aid
arrangements are. More information at
If your employer has decided that your workplace needs first aiders, they
must have been trained by an approved organisation and hold an appropriate
qualification, such as a First Aid at Work certificate. Both the British Red
Cross (
and St John Ambulance ( run
suitable courses, either at their centres or in the workplace if a large number
of people require training.
so there are few opportunities
for sharing experiences with
colleagues and hence adopting
a consistent approach.
One way to start building evidence of the different dressing
types could be to set up a database into which all TVNs could
enter information, such as the
type of wound, treatment options tried, length of time requiring treatment and outcome,
proposes Ali. Dressings’ manufacturers could assist with the
financial side of setting this up,
he suggests, although in order
to make the project work, both
NHS medicines management
teams and TVNs would first
need to better understand each
other’s roles and the pressure
they experience.
Such joint working would pay
dividends for all concerned, not
only in providing a resource
that would allow fuller wound
care guidelines to be developed
and hopefully save the NHS a
considerable amount of money,
but also in improving outcomes
for patients. в—Џ
39_Stock_PM_0212_rt.qxp:39_PM_0112 07/02/2012 10:43 Page 39
business roundup
How would you cope in a crisis?
Nearly one in five businesses suffer some form of major disruption every year according
to the Business Continuity Institute. So how would you cope if the worse happened?
Adam Bernstein suggests some coping strategies
WHILE we don’t suffer from major
earthquakes and tsunamis, we
are not immune from other
threats. Cast your mind back to
the Buncefield oil depot explosion, the terrorist attacks in
London, the floods in Cumbria
and the heavy snow falls over
the past couple of years.
The first step in any business
continuity plan is to understand
the potential threats to its normal
operation. Involve your staff
and look at every aspect of the
business – from people you employ and the stock you need to
operate to how you provide your
Natural disasters: Flooding
caused by burst water pipes or
heavy rain, or wind damage
following storms
Theft or vandalism: Theft of
computer equipment could
prove devastating. Similarly, vandalism of machinery or vehicles
could be costly and pose health
and safety risks
Fire: Few other situations
have such potential to physically
destroy a business
Power cut: Would you be able
to operate without IT or telecoms systems, key machinery
or equipment?
Fuel shortages: Shortages in
fuel could prevent staff getting to
work and affect your ability to
make and receive deliveries
IT or telecoms system failure:
What would happen if your
telephones or broadband failed
due to viruses, hackers or system
Restricted access to premises:
How would your business function if you couldn’t access your
Loss or illness of key staff:
How would you cope if a key
member of staff were to leave or
be incapacitated?
Crises affecting suppliers:
Could you source alternative
Terrorist attack: Consider the
risks to your employees and business from a terrorist strike.
Once you’ve analysed the business you’ll find that there are
some risks you accept and others
you choose to ignore. But however you approach it, ensure that
the plan you devise is written
in plain English so that all can
understand it.
Guidance on how to write a
plan can be found at https://
where there is a free piece of software that has been designed by
several insurance companies.
Equipment, especially IT, can fail.
The hard drive in your computer,
for example, has a �mean time
before failure’ rating – how long
it’s expected to operate before it
fails – but that doesn’t mean that
it won’t fail much sooner. You
need to back up your data regularly, at least once a day, and keep
the backup offsite and accessible.
Telephones and broadband
are now so critical to the running
of a business. This is especially
acute if your telephone system is
based on VOIP (internet) rather
than the traditional hardwired
BT phoneline. Is there someone
with a wireless connection that
you can agree a reciprocal piggyback arrangement?
Can documents be scanned
and filed electronically? There are
plenty of fast, double sided automatic scanners that will not only
turn paper into PDF files that
can be backed up, but which
will give you a searchable archive
on your computer. Even better,
you’ll be able to store the originals
elsewhere to further spread the
risk of loss.
Never skip on your insurance
payments. Note down all policy
details and keep them offsite.
Apart from the obvious insurances (e.g. premises, stock, vehicles, public and employers
liability) look at:
Directors and officers insurance that covers negligence
when running a firm
Business interruption insurance that pays to keep a business
alive following a catastrophe
Keyman insurance that provides a sum of money following
the death of a key person – coowner or shareholder – to the
surviving business partner(s) to
keep the business afloat or to buy
out the estate of the deceased
Critical illness cover that pays
out following the diagnosis of defined serious illness that invariably is terminal or life threatening
Permanent health insurance
that pays an income where the
insured can no longer work.
Having good polices and risk assessing threats will mean that,
not only will you be able to forestall any obvious threats such as
simple fire risks, but they may
help you lower your insurance
premiums on the basis that you
present a lower risk to the insurer. Also, everyone will know
what to do. For example, by writing a bad weather policy both
you and your staff know the effort level that is expected when
trying to get into work and the
pay/leave arrangements for when
they fail to make it.
Draw up a list of emergency contacts that includes key staff, the
utilities (water, gas, electricity,
telephone and broadband),
employment agencies and key
Work out how you can divert
your calls if you cannot access
the building to do so. Include in
your list of contacts details of
your accountant, solicitor and
the tax/VAT office (with your
references) and neighbouring
businesses in case they need to
be informed. Also ensure that
you are still able to contact your
customers – they need to know
that you are still in business,
especially if you have moved.
Finally, having spent time, effort
and money in creating a disaster
recovery plan, carry out a test
without telling anyone so you
can see if and where the plan
falls over.
Pharmacies should have business continuity plans and/or a standard operating
procedure (SOP) in place in case they are affected by adverse weather, says
Leyla Hannbeck, NPA head of information services
Pharmacies that open late due to the responsible pharmacist being unable
to reach the pharmacy because of bad weather must notify the primary care
organisation (PCO). A sign should be placed in the window advising customers
of the nearest alternative pharmacy premises and, if possible, an expected
time of opening. As a matter of good practice local GP practices should also
be notified, as well as patients who may be due to collect instalments of their
Similarly, if staff are unable to reach the pharmacy, a decision will need to
be made as to whether the pharmacy can operate safely. If the pharmacy has
to close early the PCO must be notified.
Delivery of medicines to the pharmacy can be delayed or missed in bad
weather. Pharmacies may wish to check if their local delivery depots have
contingency plans in place for bad weather, and arrange their stock orders
accordingly. Pharmacies should be aware of patients who are due medicines
and ensure stock is ordered in anticipation. Where stock is delayed,
pharmacies can consider contacting other local pharmacies and requisitioning
stock from them.
ActiBan to be
From March the ActiBan short
stretch bandage will no longer
be available but Activa Healthcare
points out that its alternative
short stretch compression bandage, Rosidal K, will remain
available. Supplied in a variety of
widths, the 100 per cent cotton,
Licensed liquid Ramipril launched
machine washable bandage is
useful in the management of
oedema, lymphoedema and
venous insufficiency, says the
Activa Healthcare: 08450 606 707
Wartner wins!
The Wartner Verruca & Wart
Removal Pen has been named
Product of the Year 2012 in the
medicated skin category of a
survey conducted by TNS Research
International. Voted for by over
9,000 consumers in the UK,
marketing manager Louise White
says the award gives pharmacy
staff “that added assurance that
they are recommending an
effective treatment that is fast
acting and precise”.
A licensed liquid Ramipril has
been launched by Rosemont
Pharmaceuticals. Ramipril Oral
Solution 2.5mg/5ml is available in
150ml. Says Jan Flynn, marketing
manager at Rosemont Pharmaceuticals: “Our newly licensed
liquid Ramipril is the only
licensed liquid ACE inhibitor.
With a pleasant menthol taste
Ramipril Oral Solution is a
welcome answer for patients who
find tablets or capsules hard to
Rosemont Pharmaceuticals:
0113 244 1999
Actavis extends day-one patent expiry portfolio
Actavis has extended its portfolio of products
launched on day one of patent expiry with
the addition of Latanoprost (2.5ml, ВЈ3.99)
and Latanoprost/Timolol Eye Drops Solution
(2.5ml, ВЈ11.99) to its range of medicines
for the treatment of glaucoma and ocular
Actavis: 0800 373 573
Actavis: 0800 373 573
No part of this publication may be reproduced without the written permission of the publishers. Published under license by Communications International Group Ltd. Some of the editorial photographs in this issue are courtesy of the companies whose products
they feature. Unbranded pictures copyright Photodisc/Digital Stock/iStockphoto. Certain articles in this issue are supported by educational grants from manufacturers. The publisher accepts no responsibility for any statements made in signed contributions or in
those reproduced from any other source, nor for claims made in advertisements, or information on products or ranges featured in editorial stories. В© Groupe Eurocom Ltd. Colour Repro by Truprint Media, Margate. Printed by Grange Press, Brighton.
Pharmacy Magazine is published monthly, copies are available on subscription to individuals who do not qualify within the terms of the controlled circulation. UK £90, $140, €107 Overseas £163, $253, €194. ABC figure for January to December 2010 is 17,364.
40_PM_0212:40_PM_0212 09/02/2012 09:45 Page 1
Whatever the reason,
whatever the season
fluticasone furoate
Allergic rhinitis relief
Relief from nasal and ocular symptoms in Perennial Allergic Rhinitis1
Prescribing Information
(Please refer to the full Summary of Product Characteristics
before prescribing)
AvamysВ® Nasal Spray Suspension (fluticasone furoate 27.5
micrograms/metered spray)
Uses: Treatment of symptoms of allergic rhinitis in adults and
children aged 6 years and over. Dosage and Administration:
For intranasal use only. Adults: Two sprays per nostril once daily
(total daily dose, 110 micrograms). Once symptoms controlled,
use maintenance dose of one spray per nostril once daily (total
daily dose, 55 micrograms). Reduce to lowest dose at which
effective control of symptoms is maintained. Children aged
6 to 11 years: One spray per nostril once daily (total daily dose,
55 micrograms). If patient is not adequately responding,
increase daily dose to 110 micrograms (two sprays per nostril,
once daily) and reduce back down to 55 microgram daily dose
once control is achieved. Contraindication: Hypersensitivity
to active substance or excipients. Side Effects: Systemic
effects of nasal corticosteroids may occur, particularly when
prescribed at high doses for prolonged periods. These effects
are much less likely to occur than with oral corticosteroids and
may vary in individual patients and between different
corticosteroid preparations. Potential systemic effects may
include Cushing’s syndrome, Cushingoid features, adrenal
suppression, growth retardation in children and adolescents,
cataract, glaucoma, and, more rarely, a range of psychological
or behavioural effects including psychomotor hyperactivity,
sleep disorders, anxiety, depression or aggression (particularly
in children). Very common: epistaxis. Epistaxis was generally
mild to moderate, with incidences in adults and adolescents
higher in longer-term use (more than 6 weeks). Common: nasal
ulceration. Uncommon: rhinalgia, nasal discomfort (including
nasal burning, nasal irritation and nasal soreness), nasal
dryness. Rare: hypersensitivity reactions including anaphylaxis,
angioedema, rash and urticaria. Precautions: Treatment with
higher than recommended doses of nasal corticosteroids may
result in clinically significant adrenal suppression. Consider
additional systemic corticosteroid cover during periods
of stress or elective surgery. Caution when prescribing
concurrently with other corticosteroids. Growth retardation has
been reported in children receiving some nasal corticosteroids
at licensed doses. Monitor height of children. Consider referring
to a paediatric specialist. May cause irritation of the nasal
mucosa. Caution when treating patients with severe liver
disease, systemic exposure is likely to be increased. Nasal and
inhaled corticosteroids may result in the development
of glaucoma and/or cataracts. Close monitoring is warranted
in patients with a change in vision or with a history of increased
intraocular pressure, glaucoma and/or cataracts. Pregnancy
and Lactation: No adequate data available. Recommended
nasal doses result in minimal systemic exposure. It is unknown
if fluticasone furoate nasal spray is excreted in breast milk. Only
use if the expected benefits to the mother outweigh the
possible risks to the foetus or child. Drug Interactions: Caution
is recommended when co-administering with inhibitors of the
cytochrome P450 3A4 system, e.g. ketoconazole and ritonavir.
Presentation and Basic NHS Cost: Avamys Nasal Spray
AvamysВ® is a registered trademark of
the GlaxoSmithKline group of companies.
Suspension: 120 sprays: ВЈ6.44. Marketing Authorisation
Number: EU/1/07/434/003. Legal Category: POM. PL
Holder: Glaxo Group Ltd, Greenford, Middlesex, UB6 0NN,
United Kingdom. Last date of revision: November 2011.
Adverse events should be
reported. Reporting forms and
information can be found at
Adverse events should also
be reported to GlaxoSmithKline
on 0800 221 441.
Reference: 1. Avamys Summary
of Product Characteristics Nov 2011.
Date of preparation: January 2012