1. health and fitness
2. drugs

01_News_PM_0414_rt.qxp:01_PM_0414 14/04/2014 10:59 Page 1
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www.pharmacymag.co.uk
Volume 20 – No 4 April 2014
The Big
Debate
Headache &
migraine
Animal
health
Sport &
fitness
Should pharmacy
be stocking
e-cigarettes?
Page 26
Giving migraine
sufferers the right
therapy and advice
Page 29
What to do when
bunny gets the
bugs...
Page 33
Avoiding,
managing and
treating injuries
Page 36
Promoting physical activity and exercise See page 17
Winner: Best Monthly Title 2013 Avicenna Media Awards
Give us a better system
Good community pharmacy practice is breaking
through despite the system – not because of it,
delegates heard at a recent Westminster Health
Forum event. Ailsa Colquhoun reports
the strategy to enable and
empower community pharmacists to work in this way.
A priority is to change the
commissioning of primary care.
He told policy chiefs that the
NHS has “over-medicalised”
the primary care response.
“If we don’t develop
community pharmacy we will
lose people – and that puts
pressure on the wrong bit of
the system. We will spend
more money than we should
to support people as they use
the NHS,” he said.
GP money better spent in pharmacy?
The elephant in the room...
DISCUSSING the topic of ‘Next
steps for pharmacy services in
England’, Mike Farrar, former
NHS Confederation chief
executive turned independent
consultant, told the conference
that pharmacies could become
a community authority “at the
centre of preventative care”.
Addressing senior officials
from the Department of Health
and NHS England in the
audience, he told them that
community pharmacy needed
enablers to be put in place if
it was to develop at scale and
pace. It was “frustrating”, he
said, that NHS England lacked
Different contracts
“Commissioners of community
pharmacy [services] need to
understand where [the sector]
fits and should empower that
resource,” Farrar continued.
This would mean increasing the
level of resource and integrating
budgets. It should also mean
thinking innovatively – for
example, having different
contracts for different
community pharmacy
contractor types, and entering
into “prime contracts”, where
one organisation subcontracts
services to providers, including
pharmacy.
“We need to have different
ways of working in different
environments. Providers have
different estates, and different
models and they need different
solutions.” However he admitted
that GP funding could be a
major obstacle in achieving
these aims.
“The elephant in the room is
the issue of whether [GP and
pharmacy services] are
competitive,” he said. “We need
to ask questions about value:
is the GMS contract offering the
value that it should? Is there
money trapped in GMS that
might be better directed at
community pharmacy?”
Discussing self-care, Farrar
said: “We need to see it not as
a weak ‘we can’t do anything,
so do it yourself’ response,
but as a way to respond to a
growing consumer appetite for
supported self-care.” This could
include moving traditional
services online, he ventured.
any unplanned admission
amounts to a system failure.
We need to see medicines
not as a cost but as a value
proposition – and if we don’t
see that happening, patients
will end up in hospital.”
New General Pharmaceutical
Council chair Nigel Clarke said
that services such as MURs had
to be evaluated in terms of
outcomes and not just outputs.
“Counting
heads” is not
P
sufficient enough for MURs and
does not equate to good patient
care, he suggested. He also made
clear the regulator’s interest in
achieving pharmacy access to
the summary care record.
“This is crucial. Patients are
at risk if there is no sharing
of information. We need
[pharmacy access to] a single
patient record. Harm is being
done because this doesn’t exist.
We see this as a regulatory issue
and one we can’t run away
from.”
IN THIS ISSUE:
Sleep advice
Value proposition
Ash Soni, vice-chairman of the
RPS English Pharmacy Board,
called for pharmacists to
become NHS England’s “coordinators of medicines” and
said that pharmacists work more
effectively in a multidisciplinary
care environment. Pharmacist
prescribing was crucial to
ensuring patients got the best
out of their medicines.
He urged the NHS in England
to “move to a position where
Omega Pharma is dedicated to
making a difference by equipping
pharmacy teams with the highest
standard of training so that they
can provide expert advice and
service to customers.
www.omegapharma.co.uk
2 Editor’s Comment 4 Insight 6 Opinion 8 Script Sense 14 PM Questions 16 CPPE Focus 25 NPA View 25 Society 28 Practice 39 Business Briefing
02_News_PM_0414_rt.qxp:02_PM_0414 14/04/2014 15:01 Page 2
VIEWPOINT
NEWS
Trusted care providers
twitter: @PharMag_Richard
Richard Thomas, editor
email: [email protected]
COMMUNICATIONS INTERNATIONAL GROUP, Linen Hall, 162-168 Regent Street, London W1B 5TB.
Tel: 020 7434 1530 Fax: 020 7437 0915 Email: [email protected]
EDITOR: Richard Thomas, BSc, FRPharmS. ASSISTANT EDITOR: Charlotte Rixon.
EDITORIAL CONSULTANT: Liz Platts. CLINICAL DIRECTOR: Professor Alison Blenkinsopp
OBE PhD, FRPharmS. FEATURES: Sasa Jankovic, Charlotte Rixon, Francesca
Robinson. DESIGN: Peter Lawrence; Tony Gummer, Truprint Media. COMMERCIAL
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KEY ACCOUNTS: Frances Shortland. EDITORIAL DIRECTOR, CIG HEALTHCARE
PARTNERSHIP: Rosanne Please. PUBLISHING DIRECTOR: 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,
Celesio UK; Ms Sue Sharpe OBE, chief executive PSNC.
Published under licence by Communications International Group Ltd.
© Groupe Eurocom Ltd.
McCaul – first impressions count
independent pharmacies as a
whole suffer from an image
problem, the research found.
The pharmacist was
considered a key element in
an independent pharmacy’s
service offering. Pharmacy
assistants were recognised for
their product knowledge but
less so for their health and
wellbeing expertise.
Three areas were identified
with the potential to grow
independents’ business:
• Introduce/promote services
currently offered by GPs.
Raise awareness of supplementary and emergency
prescription services
• Get closer to customers.
Demonstrate professionalism
combined with friendly
service
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]
PHARMACY MAGAZINE/TRAINING MATTERS COMPETITION RULES
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. 4. Any personal information we collect from
competitions will be used in accordance with the Data Protection Act 1998 and other applicable laws.
A Communications
International Group
publication
2 APRIL 2014 PHARMACY MAGAZINE
RESEARCH BITES
Customer perceptions…
of the multiples:
“Greedy, faceless
organisations”
“Lacking in privacy”
“Greater focus on personal
care”
Customer perceptions…
of independents:
“The first thing I noticed was
the smell”
“Loads of random stuff in the
window – it just looks
messy”
“It’s a shop you have to go to,
rather than want to go to”
16:11 Page 5
Unannounced inspections to stay
The GPhC says its new
inspection model is currently
taking on average around three
to four hours per pharmacy
visit, longer than the two hours
initially envisaged.
However, despite criticism
from pharmacists and other
professional bodies that the
current system of unannounced
visits leaves little time for
pharmacy teams to prepare, the
regulator is “unlikely” to move
away from this approach as it is
considered important for public
credibility, head of inspection
Mark Voce told the IPF spring
conference.
Training had been held for
inspectors on making the visits
more streamlined, he said.
“We are working hard to make
the process as efficient as
possible.” Independents could
help things along by doing as
much preparation in advance as
possible, including thoroughly
briefing their support staff.
“It’s not about catching
people out. We are taking a
Are you...
Undervalued?
Overworked?
Underrepresented?
FOUNDING EDITOR: Anne Anstice
• Improve the retail proposition
with a relevant product range
for the local community and
a clean, uncluttered store.
The research was discussed
at last month’s IPF spring
conference in Hatfield.
Chairman Fin McCaul told
delegates to look at their
pharmacies through the eyes
of their patients. “Get your
friends, husbands and wives to
come into the pharmacy and
look at it from the patient
perspective. Make it the right
environment so that patients
want to come back.”
Do independent pharmacies have an
image problem? According to some new
market research, this could well be the
case (see story opposite).
Pharmacists themselves and, on the
whole, their support staff, came out
well in the research. Lauded for their
expertise, local convenience and
personal service, independents were
considered to be trusted healthcare
providers. But consumers’ overall
experience of independent pharmacy
was less positive.
Words used to describe the
appearance of independents’
premises, for instance, included
‘messy’, ‘old school’, ‘chaotic’,
‘disorganised’ and ‘dark’. Some even
objected to the smell…
Many of our readers won’t
recognise these adjectives as applying
to them. And there has certainly
been some significant investment
by independent owners in recent
years in modernising their
premises. But there are also plenty of pharmacies
that simply aren’t attractive places to visit.
This is not a problem exclusively confined to the
independent sector, either. Pop into any medium-sized
multiple in a typical market town or city centre, and
you’re often greeted by half-empty shelves, with
fixtures and fittings that have seen better days.
Could it be that the hundreds of millions of pounds
sucked out of pharmacy funding since 2005 is
beginning to have an effect? If large parts of the
network are looking tired and down-at-heel, this
does not help pharmacy’s efforts to provide a modern,
inviting healthcare and retail experience.
Independent pharmacies have
more credibility offering advice
and information services than
large chains and supermarket
pharmacies. They are seen as
trusted healthcare providers,
according to new customer
research from Reckitt
Benckiser.
Customer service was the
key driver of pharmacy choice
among users of independents,
who were more likely to place
value on staff, prescription
services and relationships.
Frequent users strongly
associated independents with
medical expertise, locality,
personal service and easy
access to trusted advice.
Multiple pharmacy shoppers,
on the other hand, were
influenced more by the look
and feel of the store, with
convenience and price the
key drivers in supermarket
pharmacies in particular.
However it was felt that
staff lacked knowledge and
experience.
Independents were seen to
offer the least retail expertise
and the quality of the retail
proposition “varied hugely”
from pharmacy to pharmacy.
As a result of those pharmacies
with ‘bad’ retail propositions,
Then help for you could be at hand…
The INDEPENDENT
PHARMACY FEDERATION
is here to support independent
contractors like you.
Membership is only £10 per month – join us at www.theipf.co.uk
human approach,” he said.
No reports of pharmacy visits
will be made available to the
public during the prototype
phase of the scheme, he
reassured delegates.
Comments received so far
from inspected pharmacies had
been positive, according to
Mr Voce. Pharmacists valued
the instant feedback from
inspectors and welcomed the
new ‘show and tell’ approach.
Visits were seen as a learning
and development opportunity
for all the pharmacy team, he
added.
Mr Voce urged pharmacists
to “get on the front foot” with
the inspections. “Don’t wait
to be asked: tell the inspector
the three or four things you
are most proud of and why
patients love your pharmacy
and how you keep them safe.
Don’t be afraid to proactively
identify areas for improvement
and say what you are doing to
make the changes.”
It is up to pharmacies to
provide the evidence and
examples required in whatever
way they choose, he said.
03_News_PM_0414_rt.qxp:03_PM_0414 14/04/2014 15:04 Page 3
NEWS
Both pharmacists and pharmacy
technicians are considerably
less likely to be unemployed
when compared to the
economically active population
as a whole, a survey conducted
by the General Pharmaceutical
Council has revealed (reports
Asha Fowells).
The census provides a good
illustration of the diversity and
adaptability of the profession,
with over a tenth of registrants
having more than one job.
Just 2 per cent of pharmacy
professionals reported being
out of work, a figure that is
considerably lower than the
7.6 per cent for the general
population over the same
period of time.
While some 10 per cent of
pharmacists and 5 per cent of
pharmacy technicians said that
they were not working in a job
relating to pharmacy, the vast
majority said this was because
they were caring for a family.
However the working hours
clocked up by pharmacy
professionals fell short of what
many would consider to be a
full working week, at 35.7 hours
for pharmacists and 32.5 hours
for pharmacy technicians. This
compares to 37.6 hours per
week for the economically
active population as a whole.
Appraisals
Community is the setting
where most pharmacists and
pharmacy technicians work
(72 per cent and 53 per cent
respectively), with hospital the
second largest sector (23 per
cent of pharmacists and 39 per
cent of pharmacy technicians).
Those working in hospital
were considerably more
likely than their community
colleagues to have had a
performance appraisal in the
last year – something that
may be relevant as continuing
fitness to practise draws closer.
The GPhC commissioned the
survey as a way of finding out
where pharmacy professionals
work and the type of responsibilities they have, in order to
develop effective and appropriate regulatory approaches.
All 21,672 pharmacy technicians
and 30,040 of the pharmacists
on the register in autumn 2013
were invited to take part, with
just under 30,000 (55 per cent)
choosing to participate.
PHARMACY PROFESSIONALS IN THE COMMUNITY SETTING
Community settings worked in*
Hours worked**
65%
40%
Large multiple
community pharmacy
Employment status**
27%
73%
Employee
Part time
Full time
21%
24%
Locum/self-employed/
Community pharmacy
with 4 or fewer stores
11%
Another multiple
community pharmacy
35.3
Hours worked per week on average
11% Business owner
Key components
roundup
E-CIGS: ENSURE INFORMED CHOICE
Pharmacies selling e-cigarettes must ensure
that they provide sufficient information and advice
so that customers can make an informed choice as
to whether to use them or not, a legal expert has
advised. Noel Wardle, a partner at Charles Russell,
told delegates at his firm’s spring conference that
procedures and training for pharmacy assistants
must be in place to avoid the prospect of more
undercover media investigations into pharmacy.
PEOPLE MISSING OUT ON HEALTH CHECKS
INSPECTION SUPPORT FROM IPF
Barely half the people who are supposed to get
an NHS Health Check in England are actually getting
one, according to a new report from Diabetes UK.
The report, called NHS Health Checks in Local
Authorities, shows that just over 6 per cent of people
aged 40 to 74 years got one of the checks in the first
nine months since the programme switched from
NHS to local government control – significantly less
than the 11.25 per cent of people in this age range
Diabetes UK says should be getting the check.
The IPF has teamed up with Xact, a company
specialising in human resources, employment law
and regulatory advice, to support members through
the new GPhC inspection regime. Members can
access services at a discounted rate.
learners, as well as for those
who want to deliver learning,
such as employers and local
training organisations
• An assessment framework,
which encourages pharmacy
professionals to work through
a self-assessment process to
identify their learning needs.
There is also an online
assessment, which uses
videoed consultations that
pharmacy professionals can
access to check their learning
and development.
The resources can be accessed
at www.consultationskillsfor
pharmacy.com.
• See also the CPPE Focus
column on p16.
Check out the PM app – news,
views, analysis and CPD
on your tablet or mobile
The answers to the OTC
Treatment Clinic are on p4 of
Pharmacy Magazine
New consultation skills
framework launched
The main components of the
framework are:
• A set of practice standards
for consultation skills in
pharmacy that outline the
competencies that pharmacy
professionals need to achieve
in order to conduct consultations and public health
interventions effectively
• A learning pathway,
which individual pharmacy
professionals can follow to
develop the consultation skills
they need. To coincide with
the launch, a CPPE distance
learning pack will be mailed to
all pharmacists and pharmacy
technicians in England
• A range of training formats
(e.g. face-to-face learning,
e-learning and printed
workbooks). A variety of
resources is available for
email: [email protected]
freelancer/contractor
*All respondents currently working in a paid pharmacy-related job **All respondents with main job in community setting only Source: GPhC
A major new initiative to help
pharmacists and pharmacy
technicians enhance their
communication and
consultation skills has been
launched by the Centre for
Pharmacy Postgraduate
Education (CPPE) and Health
Education England (HEE).
The consultation skills
framework represents the
beginning of a national
programme of change in
pharmacy, says CPPE director,
Professor Christopher Cutts.
“The framework will apply
to more than 60,000 pharmacy
professionals across England.
This includes pharmacists,
pharmacy technicians and preregistration pharmacy trainees.
It also affects those who are
training the next generation
of pharmacists and pharmacy
technicians.”
GPhC census shows pharmacy
still a solid career choice
COMMENTARY: WHY FRAMEWORK IS NEEDED
By CPPE tutor Reena Barai:
I can imagine many of you are rolling
your eyes and thinking – why do I need
to be taught how to do the obvious?
While there are many pharmacy
professionals with great consultation
skills, I am pretty sure every one of us
can remember a consultation with a
patient that hasn’t gone as well as we
would have liked.
It is also fair to say that most of us have never had any formal
training on consultation skills and have relied wholly on our innate
communication skills to get our message across to patients.
Our role and the services we provide are becoming increasingly
patient-facing, be it over the counter or in our consulting rooms.
We have to adopt a patient-centred approach if we are to rise to the
challenge of supporting patients to optimise their medication and
self-care.
Unfortunately time constraints are a potential barrier to adopting
this approach. I would argue that by perfecting our consultation
skills, especially some of the skills needed to close a consultation,
we might actually become more effective and save time.
Historically many pharmacy professionals may have even avoided
conducting consultations due to a fear of needing to be the
perceived ‘expert’. A patient-centred consultation is possibly less
daunting as you actually have to listen more and talk less.
Above all there is the immense sense of job satisfaction you get
from actually delivering patient-centred care and supporting a
patient to achieve a better health outcome.
PHARMACY MAGAZINE APRIL 2014 3
04_Insight_PM_0414_rt.qxp:04_PM_031411/04/201412:07Page4
TEAM TRAINING
VIEWPOINT
subject: ovulation and pregnancy testing
pharmacist
training support
by Alexander Humphries*
I’m tired of people who have never risked anything in
their lives telling me how to run my business. It’s time
we held this civil service bureaucracy to account...
Ivory tower thinking
I’VE SPENT the last few weeks
getting annoyed about the
hypocrisy of unelected and
unaccountable civil servants.
They lecture me about the need
to be efficient and to look for
new models of service. Well,
it’s time we held them to account,
starting with England’s chief
pharmaceutical officer (CPO).
Take the Pharmacy Call to
Action. This began with a wave
of enthusiasm from pharmacy
bodies with an interest in how
the community pharmacy
contract develops, but when
I saw the questions I was less
enthusiastic. Was this an excuse
to wield the axe?
The CPO says there are some
areas where there are too many
pharmacies. In part I share his
view, but I wasn’t the person
in post at the DH in the
aftermath of the disastrous
relaxation of market entry rules,
which let many new pharmacies
in through the back door in
places they weren’t actually
needed or even wanted.
He says that his view “can
be quite disturbing to people
who have invested a lot of time,
energy and money into their
business”. Well, we can certainly
agree on that.
The problem is, the DH and
NHSE seem to want us to move
towards a hub-and-spoke
model, where prescription
‘factories’ ship finished prescriptions out to those pesky
community collection points.
Great news if you happen
to be a wholesaler or a large
chain that can quickly move
towards this new world,
where economies of scale and
efficiencies exist. Not such good
news for small businesses.
The Government should
care about small pharmacy
businesses because they
perform a unique public duty
with respect to their competitive
purchasing of medicines on
behalf of the NHS. You see, it is
in wholesalers’ interests to keep
prices high, because this keeps
their owners happy. It is only
because independents drive
the market price down through
competitive purchasing that
the taxpayer reaps the benefit
through category M clawbacks.
Reduce the number of
independents (and therefore
competition) and you sustain
fewer independent wholesalers,
leading to less competition on
price. The ultimate result is
higher medicine costs.
“
Dr Ridge is
playing with
long-term
economic fire
”
Governments cannot perform
this function efficiently, but the
market can. Dr Ridge is playing
with long-term economic fire if
he thinks otherwise.
It is really easy for civil
servants who are paid
every month, regardless of
performance, with the prospect
of a nice pension at the end,
to lecture us about the need for
efficiencies. And just as easy to
gamble with the sector’s future
when you don’t have a direct
stake in it.
Savings before safety
With regard to technology,
it appears as though the
bureaucrats have made their
mind up that they want wider
use of technology, almost
certainly because they think
it will save them money, not
because it is necessarily safer
or better for patients.
A great example of the hypocrisy of Government is its stance
on the Falsified Medicines
Directive, an EU diktat which
says that the public needs to
be safeguarded from fake
medicines. This could be done
in pharmacies and tied in with
software to remove the danger
of most dispensing errors.
But the Government’s stance is,
we’re reasonably happy for it
to happen – we just don’t want
to pay for it.
A bad deal
A final example of out-of-touch
bureaucrats meddling with no
thought for the long-term
consequences is the
Modernising Pharmacy Careers
programme, which would
present a huge windfall for
universities as it would largely
give them total control of
pharmacist training up to
registration, and the money to
go with it.
The trade-off was supposed
to be a cap on student numbers
to make the profession
sustainable, but that does not
seem to be coming any time
soon. Make no mistake, this is
an historic and irrevocably bad
deal for employers, students
and for pharmacy.
So, returning to the Call to
Action, those bureaucrats who
have already demonstrated a
naive and reckless attitude
towards market entry, technology and training will be able
to cherry pick from the 800
responses... or decide to do
exactly what they wanted to do
in the first place, hiding behind
a thin veneer of legitimacy.
The world must look very
different from those Whitehall
ivory towers, but officials must
be honest – are they trying to
make the pharmacy service
cheaper or better?
* Pen name of a practising community pharmacist. Alexander Humphries’ views are not necessarily those of Pharmacy Magazine.
Does pharmacy policy disadvantage small businesses? Email [email protected]
4 APRIL 2014 PHARMACY MAGAZINE
Activities such as training
your support staff are
important CPD triggers.
This Pharmacist Training
Support column runs in
conjunction with this
month’s OTC Treatment
Clinic in Training
Matters and can be
used as a Team
Tuesday exercise.
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TM APRIL
SUBJECT:
2014
PULL OUT
AND KEEP
OVULATION AND PREGNANCY TESTING
This module provides pharmacists with a useful training
resource for pharmacy assistants. Refer to this month’s
OTC Treatment Clinic on ovulation and pregnancy testing in
Training Matters. The materials are accredited by the NPA.
REFLECTION
• Do we give the best possible advice on the use of ovulation
test kits?
• Do we know how they work and when they should be
used?
• Am I aware of the latest statistics on infertility in this
country?
• Am I aware of the latest NICE guidelines on fertility?
(Clinical guidelines, CG156; February 2013)
• Do we give appropriate, evidence-based lifestyle advice to
couples trying to conceive?
TRAINING CHECKLIST
Ensure support staff understand the following key points:
• Trying to conceive is a sensitive subject
• Conceiving a baby does not necessarily happen quickly
• How the different stages of the female monthly cycle link
in with the way in which ovulation test kits work
• The differences between the newest and older ovulation
test kits
• The importance of healthy eating and lifestyle while trying
to conceive and during pregnancy
• The importance and timing of folic acid supplementation
• How home pregnancy testing kits work.
I WILL ENSURE:
• My knowledge of ovulation test kits is up to date
• My staff know when customers with problems trying to
conceive should see the GP
• My staff understand the importance of sensitivity and
privacy in communication with customers who are trying
to conceive
• My pharmacy assistants can meet the points in the training
checklist.
PRACTICE ACTIVITY
• What support is available to couples having fertility
problems? See: www.nhs.uk/conditions/pregnancy-andbaby/pages/help-infertility.aspx; www.infertility
networkuk.com; and www.fertilityfriends.co.uk
Answers to OTC Treatment Clinic no. 204 on ovulation and
pregnancy testing:
1.c 2.a 3.d 4.d 5.d 6.a
05_PM_0414:05_PM_0414 09/04/2014 13:23 Page 1
Are you up-to-date with emergency
hormonal contraception?
The tolerability of emergency
hormonal contraception (EHC)
hasn’t changed..
...
...but the efficacy has.
ellaOne has a tolerability profile
comparable to levonorgestrel1
ellaOne prevents significantly more
unplanned pregnancies than levonorgestrel
Two comparative non-inferiority studies showed ellaOne is at least as
Most frequent adverse events in the intention-to-treat population1
effective in preventing pregnancy as levonorgestrel.1,2 When these data
25
significantly reduced compared with levonorgestrel.1
15
When ellaOne is taken within 24 hours of
UPSI, a woman’s risk of pregnancy drops by
almost two-thirds vs. levonorgestrel1
10
5
Risk of pregnancy with ellaOne vs. levonorgestrel:1 0.9% vs. 2.5%
(odds ratio 0.35; 95% CI 0.11–0.93; p=0.035)
ellaOne (n=1104)
in
pa
k
Ba
c
Which means 16 fewer unplanned
pregnancies per 1000 women1
ab
do
m
al
in
m
do
Ab
levonorgestrel (n=1117)
U
p
in per
al
pa
in
in
pa
es
s
Di
zz
in
ue
tig
Fa
se
a
N
au
a
oe
or
en
Dy
sm
ea
da
rh
ch
e
0
H
Proportion of women (%)
were pooled in a meta-analysis the risk of pregnancy with ellaOne was
20
Adapted from Glasier AF et al., Lancet 2010.1
With ellaOne – 9 unplanned pregnancies per thousand
9
With levonorgestrel – 25 unplanned pregnancies per thousand
25
Adapted from Glasier AF et al., a 2010 Lancet meta-analysis.1
ABBREVIATED PRESCRIBING INFORMATION (UK) ellaOne®(ulipristal acetate). Please refer to
the SmPC before prescribing ellaOne® Presentation: White/off-white, round curved tablet engraved“ella”
on both faces Indications: Emergency contraception within 120 hours (5 days) of unprotected sexual
intercourse or contraceptive failure. Dosage: One 30mg tablet to be taken orally as soon as possible, but
no later than 120 hours after unprotected intercourse or contraceptive failure, with or without food. Another
tablet should be taken if vomiting within 3 hours of intake. Can be taken at any point in menstrual cycle.
Pregnancy should be excluded. Renal or hepatic impairment: no specific dose recommendations.
Severe hepatic impairment: not recommended. Children and adolescents: Limited safety and efficacy data
in women under 18 years. Contraindications: Hypersensitivity to active substance or excipients.
Pregnancy. Special warnings and precautions for use: Concomitant use with an emergency
contraceptive containing levonorgestrel is not recommended. Use in severe asthma insufficiently
controlled by oral glucocorticoid not recommended. Emergency contraception only; women should be
advised to adopt a regular method of contraception. May reduce contraceptive action of regular hormonal
contraception, when continued or initiated immediately after ellaOne use; subsequent acts of intercourse
should be protected by reliable barrier method until next menstrual period. Repeated administration within
the same menstrual cycle is not advisable. No data for unprotected intercourse more than 120 hours before
intake. Does not prevent pregnancy in every case; delay of >7 days in next menstrual period, abnormal
bleeding at menses, or symptoms of pregnancy, exclude pregnancy. If pregnancy occurs, consider possibility
of ectopic pregnancy. Menstrual periods can sometimes occur earlier or later than expected by a few days.
In ~ 7%, menstrual periods occurred > 7 days early. In ~ 18.5% a delay of > 7 days occurred, and in 4% the
delay was > 20 days. Contains lactose monohydrate; patients with galactose intolerance, the Lapp lactase
deficiency or glucose-galactose malabsorption should avoid. CYP3A4 inducers (e.g. rifampicin, phenytoin,
phenobarbital, carbamazepine, efavirenz, fosphenytoine, nevirapine, oxcarbazepine, primidone, rifabutine,
St John’s wort/Hypericum perforatum, long term use of ritonavir) may reduce plasma concentrations of
ulipristal acetate and decrease efficacy, even if stopped enzyme inducer within last 2-3 weeks. Concomitant
use not recommended. Potential for other medicinal products to affect ulipristal acetate:
CYP3A4 inducers - In vivo results using potent inducer show marked decreases of Cmax and AUC (>90%)
and reduced half life (2.2-fold) corresponding to 10-fold decrease in exposure. CYP3A4 Inhibitors - In vivo
results show administration of ulipristal acetate with a potent and a moderate CYP3A4 inhibitor increased
Cmax and AUC of ulipristal acetate 2- and 5.9-fold, (max) respectively; clinical consequences unlikely.
Medicinal products affecting gastric pH - Administration of ulipristal acetate (10 mg) together with
esomeprazole (20 mg daily for 6 days) resulted in approx 65% lower mean Cmax, delayed tmax and 13%
higher mean AUC; clinical relevance unknown. Potential for ulipristal acetate to affect other
medicinal products: P-gp substrates - In vitro data indicate that ulipristal acetate may inhibit P-gp; in
vivo results with fexofenadine inconclusive. Hormonal contraceptives - Ulipristal acetate binds to the
progesterone receptor with high affinity and may interfere with contraceptive action of progestogencontaining products. Fertility, pregnancy and lactation: contra-indicated during existing or suspected
pregnancy. Extremely limited data available on health of the foetus/new-born in pregnancy exposed to
ulipristal acetate. No teratogenic potential was observed; animal data insufficient with regard to reproduction
toxicity. Marketing Authorisation Holder maintains a pregnancy registry to monitor outcomes of pregnancy
in women exposed to ellaOne®. Patients and health care providers are encouraged to report any exposure.
Ulipristal acetate is excreted in human breast milk; breastfeeding is not recommended for one week after
intake. Breast milk should be expressed and discarded. A rapid return of fertility is likely following ellaOne
use; regular contraception should be continued or initiated as soon as possible; subsequent acts of intercourse
should be protected by reliable barrier method until next menstrual period. Undesirable effects: Always
consult the SmPC before prescribing. Most commonly reported adverse reactions: headache, nausea,
abdominal pain and dysmenorrhea. Common (ш1/100 to <1/10): mood disorders, dizziness, abdominal
pain upper, vomiting, abdominal discomfort, myalgia, back pain, dysmenorrhea, pelvic pain, breast
tenderness and faitigue. Uncommon (ш1/1,000 to <1/100): vaginitis, nasopharyngitis, influenza, UTI,
appetite disorders, emotional disorder, anxiety, insomnia, hyperactivity disorder, libido changes, somnolence,
migraine, visual disturbance, hot flush, abdominal pain lower, diarrhoea, dry mouth, dyspepsia, constipation,
flatulence, acne, skin lesion, pruritus, menorrhagia, vaginal discharge, menstrual disorder, metorrhagia,
vaginal haemorrhage, hot flush, premenstrual syndrome, pain, irritability, chills, malaise, pyrexia. Rare
(ш1/10,000 to <1/1,000): conjunctivitis, hordeolum, pelvic inflammatory disease, dehydration,
disorientation, tremor, disturbance in attention, dysguesia, poor quality of sleep, parosmia, syncope,
abnormal sensation in eye, ocular hyperaemia, photophobia, vertigo, haemorrhage, upper respiratory tract
congestion, cough, dry throat, epistaxis, gastro-oesophageal reflux disease, toothache, urticaria, general
pruritus, pain in extremity, arthralgia, urinary tract disorder, chromaturia nephrolithiasis, renal pain,
bladder pain, genital pruritus, dysfunctional uterine bleeding, dyspareunia, ruptured ovarian cyst,
vulvovaginal pain, menstrual discomfort, hypomenorrhea, chest discomfort, inflammation, and thirst.
Package quantities and basic NHS price: ellaOne® 30 mg Tablet Oral use 1 tablet blister pack:
£16.95. Marketing authorisation holder: Laboratoire HRA Pharma, 15, rue Béranger, F-75003 Paris,
France. Marketed in the UK by: HRA Pharma UK & Ireland Limited, Unit 7, RB Building, 557 Harrow Rd Kensal
Green London W10 4RH. Additional information is available on request, contact medical information on
0800 917 9548 or e mail [email protected]. Marketing authorisation number(s)
EU/1/09/522/001 Legal category: POM. Date of last revision of the API text: July 2013.
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to HRA Pharma UK & Ireland Ltd on 0800 917 9548 or email [email protected]
Date of preparation: March 2014
Any case of pregnancy exposed to ellaOne should be reported on www.hra-pregnancy-registry.com
References: 1. Glasier AF et al., Lancet 2010; 375: 555–62. 2. Creinin MD et al., Obstet Gynecol 2006; 108: 1089–97.
Item code: UK/ELLA/0314/0022
06_Opinion_PM_0414_rt.qxp:06_PM_0414 10/04/2014 11:31 Page 6
VIEWPOINT
KEY POINTS: FOOT PROBLEMS IN DIABETES
• 1 million people in the UK with diabetes are at high risk of
developing foot problems
• 15 per cent of people with diabetes still do not receive a foot check
• Delaying a referral can mean the difference between keeping a foot
and losing it
Help us stay one step
ahead of foot disease
Barbara Young, chief executive of Diabetes UK, wants pharmacists to be
on the look-out for diabetic patients at high risk of a ‘foot attack’
IT’S OFTEN THE CASE that
people with diabetes engage
far more regularly with their
pharmacist than they do
with their GP – and this puts
pharmacists in a unique
position to help ensure they
get the care they deserve.
We want pharmacists to
make sure people who are
at high or increased risk of
a foot attack to:
• Know their risk status
• Understand the importance
of good foot care
• Understand the urgent need
to see a doctor if they have
any signs of a foot attack.
When you consider that 1m
people with diabetes are at
high risk of a foot attack, it is
really worrying that many of
these people are being left in
the dark about what to look
for and when they need to
seek urgent medical help.
This means that, all too
often, people are seeing the
signs of foot disease but are
not then acting on it and
potentially losing their foot
as a result.
The NHS needs to shift
its approach to diabetic foot
disease so that people
understand the importance
of addressing foot problems
quickly. Even a matter of hours
in delaying referral can mean
the difference between keeping
a foot and losing it.
Many
hundreds of
amputations a
year could be
prevented
“
”
There is an important role
for pharmacists to play. They
should urgently signpost
people to their GP if they
mention they have any of the
symptoms of a foot attack.
These include:
• A red, warm or swollen foot
• A break in the skin
• Oozing onto socks or
stockings.
This is particularly urgent if
any of these symptoms are
accompanied by feeling unwell.
It is also important to
routinely remind people with
diabetes that having their feet
checked is an important part of
their annual review and that
they, or someone else, need to
be keeping an eye on their feet
for the other 364 days of the
year. National Diabetes Audit
data shows that 15 per cent of
people with diabetes are still
not receiving this check.
Well placed
Pharmacists are well placed to
have a meaningful conversation
with people to ask if they are
aware of their risk status of
having a foot attack and find out
if they know what to do in the
event of having any of the
symptoms. To help with this
conversation we have a new
booklet, ‘How To Spot A Foot
Attack’, which is available
to order free from our online
store.
We would encourage
pharmacists to display the
booklet and give it to anyone
in the ‘at risk’ categories.
It really is a question
of communication and
pharmacists can be invaluable because they have
an opportunity to listen to
what people with diabetes
are saying and respond
accordingly. For example,
many people with diabetes
experience loss of feeling
in their feet, so it is crucial
that they understand the
importance of regularly
checking their own feet for
changes or getting a carer to
do so, as they may be having
a foot attack but not be
experiencing any pain or
discomfort.
By getting better at
providing foot checks and
raising awareness, many
hundreds of amputations
a year could be prevented.
This would mean huge cost
savings for the NHS but also
that those people would avoid
the devastation of having an
amputation that could have
been prevented.
The free booklet can be
ordered from www.shop.
diabetes.org.uk/go/red-cardfoot-booklet.
DEDICATED
Whatever the weather, Kevin’s customers get
their deliveries on-time, every time.
The winter tyres help, but with more than 900 on-time deliveries
every month, it’s his dedication that gets him through.
We can deliver so much more to support your business – giving you
back time to focus on improving patient services.
Find out at www.aah.co.uk/competence or call 0844 561 8899
6 APRIL 2014 PHARMACY MAGAZINE
07_PM_0414:07_PM_0414 09/04/2014 14:39 Page 1
08-13_Script_PM_0414_rt.qxp:08-13_PM_0414 09/04/2014 16:26 Page 8
CLINICAL NEWS
clinical roundup & news reView
scriptsense
edited by Mark Greener
Call to help boost
diabetic foot care
Community pharmacists should do more to
help people with diabetic foot problems avoid
amputation, experts have told Pharmacy
Magazine.
Over a year, researchers from University
Hospitals of Leicester identified 20 patients
with active foot disease who were ‘delayed
new referrals’. In 16 patients, the median time
from first symptom to referral was 25 weeks,
resulting from their reluctance to attend
the clinic or lack of understanding of the
significance of their foot disease.
Three patients presented with gangrene and
the researchers identified one case of Charcot’s
arthropathy. Five patients needed ‘minor’
amputations due to foot sepsis or osteomyelitis. One patient needed an above-knee
amputation for a non-revascularisable limb
that presented with toe gangrene and
rest pain.
“Diabetic foot problems can deteriorate
very quickly. As a result, they require rapid
treatment and assessment,” Nikki Joule,
Diabetes UK policy manager, told PM.
“Community pharmacists can contribute
directly to the prevention of foot problems
by encouraging people with diabetes to get
their annual foot checks, and making sure
they are aware of their risk of developing foot
problems and what they need to look out for.”
“Community pharmacists should signpost
patients with possible diabetes-related foot
ACEIs reduce mortality
in diabetes
Angiotensin-converting enzyme
inhibitors (ACEIs) reduce allcause mortality, cardiovascular
(CV) deaths and major CV
events in patients with diabetes,
a new meta-analysis reports.
The meta-analysis included
23 studies comparing ACEIs
with placebo or active drugs
(32,827 patients) and 13
comparing angiotensin II
receptor blockers (ARBs) with
no therapy (23,867 patients).
Compared with controls,
ACEIs significantly reduced the
risk of all-cause mortality by
13 per cent, CV deaths by 17 per
cent and major CV events by
14 per cent. Specifically, ACEIs
reduced the risk of myocardial
infarction by 21 per cent and
heart failure by 19 per cent.
ARBs did not significantly
influence all-cause mortality,
CV death or major CV events –
except for a 30 per cent
reduction in heart failure.
Neither ACEIs nor ARBs reduced
stroke risk. ACEI benefits on
all-cause and CV mortality did
not depend on baseline blood
pressure and proteinuria or the
type of ACEI.
The authors concluded that
“ACEIs should be considered as
first-line therapy to limit excess
mortality and morbidity” in
people with diabetes. (JAMA
Intern Med doi:10.1001/
jamainternmed.2014.348).
Oseltamivir saves lives
Best foot forward for people with diabetes
problems to appropriate services,” adds Dr
Kath Higgins, diabetes consultant at University
Hospitals of Leicester and one of the study
authors.
“They should be aware of the referral
pathways in the Diabetes UK ‘Putting Feet
First’ literature and their local pathways to
ensure that they are signposting appropriately.
Pharmacists should also understand which foot
problems require urgent attention. It is vital
that patients with diabetes and foot problems
obtain specialist advice at the earliest
opportunity.” (See also Opinion on p6.)
Rapid treatment with a
neuraminidase inhibitor,
such as oseltamivir, reduced
mortality among adults
admitted to hospital with
suspected or proven pandemic
influenza, reports a Rochesponsored meta-analysis in
Lancet Respir Med.
Based on an analysis of
29,234 patients from 78 studies
performed during the 2009-10
H1N1 pandemic, neuraminidase
inhibitors reduced mortality
by 19 per cent compared
to no treatment. Starting
neuraminidase inhibitors
within two days of the onset
of influenza symptoms reduced
mortality by 52 per cent
compared to later treatment
and by 50 per cent compared to
no treatment. Neuraminidase
inhibitors did not significantly
reduce mortality in children.
(doi:10.1016/S2213-2600(14)
70041-4)
AED prevents
head and neck
cancer?
Valproic acid reduces head
and neck cancer risk by 34
per cent with a dose-response
relationship, without affecting
lung, bladder, colon or prostate
cancer (Cancer doi:10.1002/
cncr.28479).
PASSIONATE
Whatever your retail space, Vicki’s there to make it profitable.
The displays and branding help, but its Vicki’s passion for creating the best retail
experiences that drives her to make over 50 pharmacy visits every month.
We can deliver so much more to support your business – giving you back time to focus
on improving patient services.
Find out at www.aah.co.uk/commitment or call 0844 561 8899
8 APRIL 2014 PHARMACY MAGAZINE
09_PM_0414:09_PM_0414 10/04/2014 10:23 Page 1
What do your customers with
eczema use for washing?
• FR
NCE •
R
AG A
FR
EE
NICE and BAD guidelines are clear: eczema sufferers should
avoid using soap and detergent-containing products to avoid
exacerbating their condition.1,2 That means offering your
customers effective emollient wash products, like the Oilatum
wash range.
Less than 15% of GP patients are prescribed both bath and
cream emollients.3 There’s a huge opportunity to help improve
the lives of your customers with eczema – simply recommend
them a wash emollient alongside their cream prescription,
in line with clinical guidelines.1,2
Oilatum wash products protect the skin from drying, and provide
a barrier against allergens and irritants. Recommend a product
from the No.1 prescribed emollient wash range4 as an addition
to your customers’ emollient creams, for soothed skin and
satisfied customers.
Light liquid paraffin
Product Information
Oilatum Junior (light liquid paraffin) Bath Additive.
Oilatum Shower Gel Fragrance-Free (light liquid paraffin).
References:
Indications Contact dermatitis, atopic dermatitis, senile pruritus,
ichthyosis and related dry skin conditions. Dosage and method
of use All ages: Apply to wet skin or add to water. $GXOWEDWK 1-3
capfuls in an 8 inch bath of water, soak for 10-20 minutes, pat
dry. ,QIDQWEDWK ½-2 capfuls in a basin of water, apply gently over
entire body with a sponge, pat dry. Precautions Hypersensitivity
to any ingredient. Stop use if rash or irritation occurs. Side effects
Application site reactions including erythema, rash, pruritus,
dermatitis. GSL . Pack sizes and RSP (excl. VAT): 150 ml £4.21,
250 ml £4.88, 300 ml £7.62, 600 ml £8.83. PL 00079/0708. PL holder
Stiefel, 980 Great West Road, Brentford, Middlesex, TW8 9GS. Date
of revision March 2014.
Indications Contact dermatitis, atopic dermatitis, senile pruritus,
ichthyosis and related dry skin conditions. Dosage and method of
use All ages: Use as often as necessary. Apply to wet skin, normally
as a shower gel. Precautions Hypersensitivity to any ingredient.
Not for use on greasy skin. Side effects Application site reactions
including erythema, rash, pruritus, dermatitis. GSL . Pack size and
RSP (excl. VAT) 150 g £7.73. PL 00079/0704. PL holder Stiefel, 980
Great West Road, Brentford, Middlesex, TW8 9GS. Date of revision
March 2014.
1. NICE Clinical Guideline 57. Atopic eczema in children. Management
of atopic eczema in children from birth up to the age of 12 years.
December 2007. Available at: http://guidance.nice.org.uk/CG57.
Accessed 03/03/14. 2. Primary Care Dermatology Society & British
Association of Dermatologists. Guidelines for the management of
atopic eczema. Available at http://www.eguidelines.co.uk. Accessed
09/04/14. 3. GSK data on file, GP prescription data 2013. 4. IMS unit
performance data, MAT to Jan 2014.
OILATUM and TAKE COMFORT IN OUR SCIENCE are registered trade marks of the GSK group of companies.
08-13_Script_PM_0414_rt.qxp:08-13_PM_0414 09/04/2014 16:27 Page 10
CLINICAL NEWS
Cholesterol rises in the winter
Cholesterol levels rise in the
winter, according to research
presented during the American
College of Cardiology’s annual
meeting. Previous studies
showed that heart attacks and
cardiac mortality peak during
the winter, so researchers at
Johns Hopkins University,
Baltimore, looked at changes
in seasonable lipids in 2.8m
adults.
LDL and non-HDL
cholesterol levels were 3.5 and
1.7 per cent higher in men and
women respectively during the
colder compared to warmer
months. Triglycerides were 2.5
per cent higher in men during
the winter. HDL did not vary
much between seasons.
“In this very large sample,
we found that people tend
to have worse cholesterol
numbers on average during the
Seasonal lipid variation
colder months than in the
warmer months – not by a very
large amount, but the variation
is significant,” said lead
investigator Parag Joshi,
cardiology fellow, Johns
Hopkins Hospital. “It confirms
findings from smaller studies
and raises a lot of interesting
questions” – not least the
cause of the fluctuations.
Behavioural changes seem
to be partly responsible. “In
the summer, we tend to get
outside, we are more active
and have healthier behaviours
overall,” Dr Joshi said. “In the
colder months, we tend to
crawl into our caves, eat
comfort foods and get less
exercise, so what we see is that
LDL and non-HDL are slightly
worse.”
In addition, the limited time
spent outside means less sun
exposure. The resulting lower
concentration of vitamin D
worsens lipid profiles. However, researchers still need to
identify the causes of these
seasonal variations.
Interactions ‘a significant
cause’ of hospitalisations
Drug-drug interactions (DDIs)
are “a significant cause” of
hospital admissions and visits,
according to a meta-analysis
of 13 studies.
Overall, DDIs accounted for
a median of 1.1 per cent of
hospital admissions and 0.1 per
cent of hospital visits (e.g. to
accident and emergency). In
people hospitalised for adverse
drug reactions, DDIs accounted
for a median of 22.2 per cent
of hospital admissions and 8.9
per cent of hospital visits.
Aspirin was the drug most
commonly involved in
interactions with other
medicines, contributing to 23.5
per cent of DDIs that needed
hospital admissions. Other
NSAIDs accounted for 12.9
per cent of DDIs that lead
to hospital admissions.
Gastrointestinal tract
bleeding (40.4 per cent) and
cardiac arrhythmias (29.8 per
cent) were the most frequent
adverse events resulting from
DDIs. (Pharmacoepidemiology
and Drug Safety doi:10.1002/
pds.3592)
Flu usually asymptomatic …
Recent seasonal influenza
outbreaks and the 2009
pandemic were asymptomatic
in about three-quarters of
those infected, a new study
reports.
The analysis, which covered
seasonal and pandemic
influenza in England between
2006 and 2011, accrued 5,448
person-seasons’ of follow-up.
On average, influenza infected
18 per cent of unvaccinated
people each winter. There were
69 respiratory illnesses per
100 person-seasons among
those infected with influenza
compared with 44 per 100 in
those not infected with influ-
enza, the authors say. The
age-adjusted attributable rate
among infected people was
23 illnesses per 100 personseasons, so up to threequarters of influenza infections
were asymptomatic.
The authors hope the
findings will inform seasonal
disease control and pandemic
planning by, for example,
increasing the validity of
models examining the efficacy
and cost-effectiveness of
countermeasures, including
antivirals, vaccines and
behavioural interventions.
(Lancet Respir Med dx.doi.org/
10.1016/S2213-2600(14)70034-7)
… but flu jabs save lives
Influenza vaccination
significantly reduces
hospitalisations for major
cardiovascular and respiratory
conditions as well as lowering
all-cause mortality in type 2
diabetes, according to research
from Imperial College, London,
presented at the Diabetes UK
Professional Conference.
The retrospective study
collected data from the Clinical
Practice Research Database for
124,503 patients with type 2
diabetes between 2003/4 and
2009/10. After adjustment,
vaccination reduced
hospitalisations for:
• Stroke by 30 per cent
• Acute myocardial infarction
by 21 per cent
• Heart failure by 20 per cent
• Pneumonia or influenza by
15 per cent.
All-cause mortality was 28
per cent lower in vaccinated
compared with non-immunised
people. The authors conclude
that “efforts should be focused
on improvements in vaccine
uptake in this important target
group”.
New natural eczema treatment
Drug interactions warning
Reczema is a new natural
treatment that the manufacturer Secuvie says is
“clinically proven to
significantly improve the
symptoms of eczema and
irritated skin”. According to
Secuvie, Reczema calms and
moisturises dry and irritated
skin, forms a barrier layer and
encourages “intense cellular
repair” due to CHD-FA, a
“pure and concentrated form
of fulvic acid” that “helps cells
… absorb the vital nutrients
they need to heal”.
PROMISE
When you make one to a patient, we’ll help you keep it.
That’s why every one of our 180,000 monthly telephone orders is processed in
lightning-quick time. And why every one of our 500,000 deliveries is guaranteed
to arrive at the same time each day. Twice if you need us.
To make sure patients get their prescriptions on time, every time. We promise.
We can deliver so much more to support your business – giving you back time
to focus on improving patient services.
Brian Deal
Pharmacist, Ashwell Pharmacy
10 APRIL 2014 PHARMACY MAGAZINE
Find out at www.aah.co.uk/promise or call 0844 561 8899
11_PM_0414:11_PM_0414 08/04/2014 10:17 Page 1
PROMOTION
THE TERMS heartburn and
indigestion are often used
interchangeably. They both
occur soon after eating or
drinking, yet these are two
different digestive symptoms.
Nearly three-quarters of
people in the UK suffer from
both heartburn and indigestion,
and nearly one in five cases
suffer from both symptoms
at the same time.1
Many people get confused
about which symptoms they
are suffering from, leading them
to misdiagnose themselves.
This can make it difficult
for pharmacy teams to give
appropriate advice and make
product recommendations.
Identifying the cause of the
symptoms is important, as
indigestion and heartburn
treatments have different
modes of action.
indigestion can ease their
symptoms by adapting their
lifestyle and taking suitable OTC
remedies such as antacids and
alginates.5
Antacids provide immediate
relief from indigestion.8 They
work by neutralising excess
stomach acid so that it no
longer causes irritation.8
Alginates relieve heartburn and
acid reflux.8 They form a
protective barrier that floats
on the surface of the stomach
contents, keeping acid in the
stomach and away from the
oesophagus.8
Some medicines, such
as Gaviscon Double Action,
contain an alginate and
antacids to tackle the symptoms
of heartburn and indigestion at
the same time.
Heartburn versus
indigestion
Gaviscon Double Action is ideal
for customers suffering from
both heartburn and indigestion.
Its powerful formula has two
modes of action, offering dual
relief in one product.
1. Sodium alginate forms a
strong raft over the stomach
contents to soothe the burning
pain of heartburn.8
2. The two antacids, sodium
bicarbonate and calcium
carbonate, neutralise excess
stomach acid to relieve the
pain and discomfort of
indigestion.8
In most people, heartburn and
indigestion are mild and occur
only occasionally.2 Sometimes
they are associated with gastrooesophageal reflux disease
(GORD).2,3
Heartburn is a burning pain
or a feeling of discomfort
behind the breastbone and at
the back of the throat.4 It may
be accompanied by an acid
taste in the mouth.4 Symptoms
occur when acid, pepsin and
bile, which normally sit within
the protective lining of the
stomach, escape back up into
the oesophagus (called reflux).
The acid damages the lining
of the oesophagus.5
Indigestion, also
known as dyspepsia,
is often used to
describe a range
of different
symptoms.6 It
tends to cause an
uncomfortable or
painful feeling in
the upper chest or
stomach, usually
associated with
sickness, bloating and
nausea.7 Indigestion is
caused by stomach acid
coming into contact with the
sensitive lining of the digestive
system, causing irritation and
inflammation.2
product
champion
For customers suffering from heartburn
and indigestion, Gaviscon
Double Action offers effective
dual-action relief13,14
Gaviscon Double
Action
about the management of
heartburn and indigestion.11
As well as making appropriate
product recommendations,
they can suggest lifestyle
measures to relieve the
symptoms, such as
losing weight,
stopping smoking
and avoiding any
trigger foods.11
Pharmacists are also
ideally placed to refer
customers to their GP
if the symptoms are
frequent or severe or
don’t respond to OTC
medicines.
Customers can learn more
about heartburn and
indigestion by visiting
www.gaviscon.co.uk.
A definite
Product
Champion!
Management options
Heartburn and indigestion are
more common in people who
smoke or are overweight, and
in pregnant women.5 They
tend to have similar triggers,
including eating rich or fatty
foods, wearing tight clothes and
stooping or bending forwards.5
Most people with mild to
moderate heartburn and
Research shows that 50 per cent
more consumers enjoy fast relief
with Gaviscon Liquid versus
an antacid gel9 containing
magnesium and aluminium
hydroxide. Around 90 per cent
say they would use Gaviscon
Double Action Liquid again.10*
Pharmacy
recommendation
Pharmacists play an important
role in advising customers
Gaviscon Double Action
Key benefits to customers:
• Provides dual relief from
heartburn and indigestion
• Liquids soothe in three
minutes10
• Lasts for up to four hours, up
to twice as long as antacids12
• Contains double the
concentration of calcium
carbonate (antacid) compared
to Gaviscon Original products.
• Suitable for use in
pregnancy13,14
• Suitable for adults and
children 12 years and over
• Available in mint liquid,
tablets and liquid sachets
formats.
Sodium alginate,
Sodium bicarbonate,
Calcium carbonate
REFERENCES
1. Winkle, global segmentation research, 2010
2. Indigestion: Introduction. NHS Choices. 2012.
www.nhs.uk/conditions/Indigestion/Pages/Introduction.aspx [accessed February 2014]
3. Heartburn and gastro-oesophageal reflux disease – causes. NHS Choices. 2012.
www.nhs.uk/Conditions/Gastroesophageal-reflux-disease/Pages/Causes.aspx
[accessed February 2014]
4. Heartburn and gastro-oesophageal reflux disease – symptoms. NHS Choices. 2012.
www.nhs.uk/Conditions/Gastroesophageal-reflux-disease/Pages/Symptoms.aspx
[accessed February 2014]
5. Information about heartburn and gastro-oesophageal reflux. Core charity. February 2011.
www.corecharity.org.uk/files/files/A1213_Heartburn%20A5_AW.pdf [accessed February 2014]
6. Indigestion. British Society of Gastroenterologists.
www.bsg.org.uk/patients/general/indigestion.html [accessed February 2014]
7. Indigestion: Symptoms. NHS Choices. 2012.
www.nhs.uk/Conditions/Indigestion/Pages/Symptoms.aspx [accessed February 2014]
8. Indigestion – treatments. NHS Choices 2012.
www.nhs.uk/Conditions/Indigestion/Pages/Treatment.aspx [accessed February 2014]
9. Chevrel B. J Int Med Res 1980; 8(4):300-2
10. Strugala V, et al. J Int Med Res 2010; 38:449-57
11. Indigestion (dyspepsia) in adults. Information for the Public. NICE 2004.
www.nice.org.uk/nicemedia/live/10950/29462/29462.pdf [accessed February 2014]
12. Dector DL, Malcolm R, Maton PN, Lanza FL and Gottlieb S. Effects of aluminium/
magnesium hydroxide and calcium carbonate on esophageal and gastric pH in subjects
with heartburn. American Journal of Therapeutics 2, 546-552 (1995)
13. Gaviscon Double Action Mint Tablets Summary of Product Characteristics. Date of last
revision 27/1/11. Available at: www.medicines.org.uk. [Last accessed 15/11/12]
14. Gaviscon Double Action Mint Summary of Product Characteristics. Date of last revision
28/1/11. www.medicines.org.uk [last accessed 15/11/12]
* based on 45 sufferers
UK/G-OTC/0214/0019
Prescribing information can be found on the page overleaf
This article is supported by an educational grant from Reckitt Benckiser Healthcare (UK) Limited and has been developed in partnership with Pharmacy Magazine
PHARMACY MAGAZINE APRIL 2014 11
08-13_Script_PM_0414_rt.qxp:08-13_PM_0414 09/04/2014 16:27 Page 12
CLINICAL NEWS
Essential information:
Essential Information for Gaviscon Double Action
Mint and Gaviscon Double Action Tablets
Active Ingredients: Gaviscon Double Action
Mint: Each 10ml dose contains sodium alginate
500mg, sodium bicarbonate 213mg and calcium
carbonate 325mg. Also contains methyl and
propyl hydroxybenzoates and sodium saccharin.
Gaviscon Double Action Tablets: Each tablet
contains sodium alginate 250 mg, sodium bicarbonate 106.5mg and calcium carbonate 187.5mg.
Also contains mannitol, aspartame and xylitol.
Indications: Treatment of symptoms of
gastro-oesophageal reflux such as acid regurgitation, heartburn and indigestion, for example,
following meals or during pregnancy, and for
symptoms of excess stomach acid (hyperacidity). Dosage Instructions: Gaviscon Double
Action Mint For oral administration. Adults and
children 12 years and over: 10-20ml after meals
and at bedtime, up to four times per day. Gaviscon Double Action Tablets: For oral administration, after being thoroughly chewed. Adults and
children 12 years and over: Two to four tablets
after meals and at bedtime, up to four times per
day. Contraindications: Hypersensitivity to
any of the ingredients, including the esters of
hydroxybenzoates (parabens). Precautions and
Warnings: Care needs to be taken in treating
patients with hypercalcaemia, ephrocalcinosis
and recurrent calcium containing renal calculi.
Treatment of children younger than 12 years of
age is not generally recommended, except on
medical advice. If symptoms do not improve
after seven days, the clinical situation should be
reviewed. Due to the presence of calcium carbonate which acts as an antacid, a time-interval
of 2 hours should be considered between Gaviscon intake and the administration of other medicinal products, especially H2-antihistaminics
tetracyclines, digoxin, fluoroquinolone, iron salt,
ketoconazole, neuroleptics, thyroxine, penicill
amine, beta-blockers (atenolol, metoprolol,
propranolol), glucocorticoid, chloroquine, and
diphosphonates. Gaviscon Double Action Mint:
Each 10ml dose has a sodium content of
127.25mg (5.53mmol). This should be taken into
account when a highly restricted salt diet is recommended, e.g. in some cases of congestive
cardiac failure and renal impairment. Each 10ml
dose contains 130mg (3.25mmol) of calcium.
Care needs to be taken in treating patients with
hypercalcaemia, nephrocalcinosis and recurrent
calcium containing renal calculi. Gaviscon Double
Action Tablets: The sodium content of a twotablet dose is 110.75 mg (4.82 mmol). This should
be taken into account when a highly restricted
salt diet is recommended, e.g. in some cases of
congestive cardiac failure and renal impairment.
Each two-tablet dose contains 150 mg (3.75
mmol) of calcium. Due to its aspartame content
this product should not be given to patients with
phenylketonuria. Pregnancy and Lactation: Open controlled studies in 281 pregnant
women did not demonstrate any significant adverse effects of Gaviscon on the course of pregnancy or on the health of the foetus/new-born
child. Based on this and previous experience the
medicinal product may be used during pregnancy and lactation. Care should be taken when
recommending medicines for use in pregnancy
as medicines can cross the placenta and may
affect the fetus. Side-effects: Very rarely
(<1/10,000) patients sensitive to the ingredients
may develop allergic manifestations such as
urticaria or bronchospasm, anaphylactic or
anaphylactoid reactions. Ingestion of large quantities of calcium carbonate may cause alkalosis,
hypercalcaemia, acid rebound, milk alkali
syndrome or constipation. These usually occur
following larger than recommended dosages.
Retail Price: Gaviscon Double Action Mint
150ml £4.79, 300ml £7.89, 600ml £11.99, Liquid
Sachets £4.99, Gaviscon Double Action Tablets:
8s £2.17; 16s £3.39, 32s £5.49. Marketing
Authorisation: Gaviscon Double Action Mint PL00063/0552 Gaviscon Double Action Tablets PL 00063/0157. Supply Classification: GSL
Holder of Marketing Authorisation: Reckitt
Benckiser Healthcare (UK) Limited, Dansom
Lane, Hull HU8 7DS. Date of Preparation Liquids:
February, 2011. Date of Preparation Tablets:
March, 2014.
12 APRIL 2014 PHARMACY MAGAZINE
VIEWPOINT
FROM UKCPA
Pharmacists can help improve the suboptimal management of patients with
CHD, says Rani Khatib, senior cardiology
pharmacist and lecturer at Leeds Teaching
Hospitals NHS Trust
Supporting GTN use
Coronary heart disease (CHD)
is the UK’s biggest killer with
an estimated 2.6m people living
with the condition. NICE
emphasises the importance
of prescribing the appropriate
secondary prevention medicines in patients with CHD and
the up-titration of beta-blockers
and ACE inhibitors to evidencebased target doses or maximum
tolerated doses.
Despite an improvement
in prescribing secondary
prevention medicines,
up-titration of doses
post-discharge is still poor.
Of 37 post-myocardial
infarction patients in a recent
study who were followed up
to six months post-discharge,
85 per cent did not have any
up-titration of their beta-
The team
has developed
a GTN advice
card
“
”
blocker doses, nor 47 per cent
of their ACE inhibitor doses.
The symptom most commonly experienced by patients
with CHD is chest pain. Sublingual glyceryl trinitrate (GTN)
is often prescribed to alleviate
anginal chest pain but various
studies have shown that not all
angina patients are prescribed
it – and many do not seem to
know how to use it.
Failure to use
An evaluation of 35 patients
with established CHD who
were admitted to our cardiology
wards revealed that 12 did not
use their GTN when they had
experienced chest pain, with
five citing fear of side-effects
as a reason. When knowledge
of how to use GTN was
assessed, only six patients
showed full knowledge, despite
being providing with various
booklets and educational
sessions about their CHD
medicines. Advice on how to
use GTN was not retained
(possibly due to its infrequent
use) and patients reported a
lack of satisfaction with the
GTN written information, which
was not readily accessible, nor
simple and practical.
The pharmacy teams should
include assessment of GTN
use as part of their medicines
optimisation strategy to ensure
that patients who have angina
are prescribed GTN, provided
with correct advice on how to
use it and offered a refresher
on its use, possibly once a year
or whenever a new GTN supply
is dispensed. Verbal advice
should be supported with
appropriate written material.
GTN advice card.
To further reinforce this
message the cardiac team,
in collaboration with CHD
patients, has developed a
GTN advice card. NICE has
quality assured the development of the card and made
the full project available
as “shared-learning” at
www.nice.org.uk/shared
learning.
The UKCPA has also endorsed
the card, which is now available
for use by all healthcare
professionals in primary and
secondary care. Orders can be
placed with the Leeds Teaching
Hospitals NHS Trust Print Unit
([email protected]).
For more information about the
UKCPA, access www.ukcpa.org
or tel: 0116 2776999
COPD linked to mild
cognitive impairment
COPD increases the risk of
non-amnesic mild cognitive
impairment (MCI), JAMA
Neurology reports.
Researchers followed 1,425
people aged 70-89 years with
normal cognition at baseline
for a median of 5.1 years.
Of these, 171 had COPD at
baseline, while 370 developed
MCI during follow-up. COPD
significantly increased the risk
of non-amnesic-MCI by 83 per
cent but did not significantly
increase the risk of MCI
or amnesic-MCI. People
diagnosed with COPD for
longer than five years at
baseline were 58 and 158 per
cent more likely to develop
MCI and non-amnesic-MCI
respectively.
The authors suggest that
inflammation, vascular disease
and hypoxia could explain the
link between COPD and MCI.
The findings may suggest
targets for “early intervention
to prevent or delay the onset
and progression of MCI,”
especially non-amnesic
impairment, they say.
(doi:10.1001/jamaneurol.
2014.94)
Women with AF have a
high stroke risk
Atrial fibrillation (AF) increases
stroke risk by about five-fold.
However numerous factors
influence each AF patient’s risk
of stroke, including a history
of congestive heart failure,
hypertension, diabetes,
previous stroke or transient
ischaemic attack; being at least
75 years of age; and, according
to a new study, being female.
A meta-analysis of 17 studies
revealed that women with AF
were 31 per cent more likely to
have a stroke than men with
arrhythmia. Women aged 75
years and over accounted for
most of the increased risk –
they were 28 per cent more
likely to have a stroke than men
of the same age with AF. The
increased risk of stroke in
women emerged in those
receiving (29 per cent) and not
taking (49 per cent) oral
anticoagulation.
The results underscore the
importance of identifying and
treating AF patients at the
highest stroke risk, say the
authors. (QJM doi:10.1093/
qjmed/hcu054)
Research: pre-hypertension and stroke
WHAT IS THE BACKGROUND?
Previous studies assessing whether pre-hypertension – blood
pressure that is just above normal – increases stroke risk have
produced inconsistent results.
WHAT WAS THE METHOD?
A meta-analysis involving 762,393 people from 19 studies.
Researchers defined low- and high-range pre-hypertension as
120-129/80-84 and 130-139/85-89mmHg respectively.
WHAT WERE THE RESULTS?
Pre-hypertension increased stroke risk by 66 per cent compared
with blood pressure below 120/80mmHg. After controlling for
other cardiovascular risk factors, low- and high-range prehypertension increased stroke risk by 44 and 95 per cent
respectively. The population attributable risk – essentially the
number of strokes caused by pre-hypertension – was 19.6 per cent.
Results were consistent across stroke type, stroke endpoint, age,
study characteristics, follow-up duration and ethnicity.
WHAT ARE THE CONCLUSIONS?
Even low-range pre-hypertension increases stroke risk compared
with optimal blood pressure.
REFERENCE
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
Huang Y, Cai X, Li Y et al. (2014) Pre-hypertension and the risk of
stroke: A meta-analysis. Neurology
08-13_Script_PM_0414_rt.qxp:08-13_PM_0414 09/04/2014 16:28 Page 13
CLINICAL NEWS
Saving a minute saves almost two days
“Realistically achievable small
reductions” in the time between the start of symptoms
and tissue-type plasminogen
activator (tPA) therapy can produce “significant and robust”
improvements in outcomes,
says a report in Stroke.
For example, a 15-minute
decrease in onset-to-treatment
time translated into, on
average, an additional month
of disability-free life.
Researchers applied
evidence from major tPA trials
to 2,258 consecutive stroke
patients from Australia and
Finland. Each minute of onsetto-treatment time saved
translated into, on average,
1.8 days of “extra healthy life”.
The benefit of reducing onsetto-treatment time emerged in
all groups assessed.
For example, each minute
reduction provided:
• 0.6 days in old people (80
years) with severe strokes
• 0.9 days in old people with
mild strokes
• 2.7 days in young people (50
years) with mild stokes
• 3.5 days in young people
with severe strokes.
“‘Save a minute, save a day’
is the message from our study,”
says lead author Atte Meretoja
associate professor of
neurology, University of
Melbourne, Australia. Each
reduction of a minute between
symptom onset and treatment
may save around two million
neurones.
Dr Meretoja hopes that the
“concrete easy-to-relate-to
figures will inspire medical
services to measure and
improve their game for the
benefit of our stroke patients.
Patients should never wait a
single minute for stroke signs,
such as face droop, arm
weakness or speech
disturbance, to go away.
They should call for help
immediately.”
Intravenous thrombolysis
with tissue-type plasminogen
activator (tPA) is described as
“the only medical therapy
shown to improve patient
outcomes in acute ischaemic
stroke”. (10.1161/STROKEAHA.
113.002910)
No wonder patients with
chronic anal fissure
avoid the toilet…
Heart of the matter...
How old is
your heart?
A new website helps patients
prevent cardiovascular disease
(CVD) by estimating their
heart’s age.
The recently published Joint
British Societies’ consensus
recommendations for the
prevention of cardiovascular
disease (JBS3) extends the
focus from targeting people at
high risk of a heart attack or
stroke within the next 10 years
to also include those whose
familial and lifestyle factors
indicate a low short-term risk,
but a high lifetime risk.
The JBS based the recommendations on growing evidence
that a long pre-clinical phase
precedes CVD and that most
heart attacks and strokes occur
in people at ‘intermediate’ risk.
So the recommendations
include a risk calculator
(www.jbs3risk.com) to help
healthcare professionals and
patients understand and tackle
cumulative lifetime CVD risk.
For example, the calculator
estimates the heart’s age based
on current familial and lifestyle
risk factors, and predicts how
many more years the person
can expect to live before a
heart attack or stroke if they
don’t take action.
CHMP approval
The CHMP recently approved
combining insulin degludec
(Tresiba), a once-daily basal
insulin, and the GLP-1 receptor
agonist liraglutide (Victoza).
Further information is available on request from: ProStrakan Limited, Galabank
Business Park, Galashiels TD1 1QH, UK. Legal Category: POM. Please consult
Summary of Product Characteristics before prescribing, particularly in relation to side
effects, precautions and contraindications. Information about this product, including
adverse reactions, precautions, contraindications and method of use can be found at
http://www.medicines.org.uk/emc/. Rectogesic® 4mg/g Rectal Ointment is indicated
for relief of pain associated with chronic anal fissure. Marketing Authorization
Holder: ProStrakan Ltd, Galabank Business Park, Galashiels, Scotland TD1 1QH.
Date of preparation: March 2014. M011/1207.
glyceryl trinitrate 4mg/g
Rectal Ointment
Adverse events should be reported. Reporting forms and information
can be found at www.mhra.gov.uk/yellowcard. Adverse events should
also be reported to ProStrakan Ltd. on 01896 664000
PHARMACY MAGAZINE APRIL 2014 13
14_pm0414_PM Questions_rt.qxp:14_PM_0413 11/04/2014 11:58 Page 18
INTERVIEW
THIS MONTH:
CLARE HOWARD
pmquestions
Talking to the personalities on pharmacy’s front line
PEOPLE PROFILE
Clare Howard has been involved in pharmacy since the
age of 16 and studied for her degree at Aston University.
She became deputy chief pharmaceutical officer for
NHS England in 2013 and is married with two children.
NHS England’s deputy chief pharmacist Clare Howard is leading on the medicines
optimisation agenda but has strong views on a variety of issues currently affecting
community pharmacy. Interview by Asha Fowells
Not another buzzword
There has been criticism from
some quarters that medicines
optimisation is simply the latest
in a long line of DH catchphrases. Ms Howard is adamant
that this isn’t the case.
“Is it another buzzword?
Absolutely not. The project
recognises that we have over
the last few years focused on
the cost of medicines at the
expense of fundamental areas
that we now recognise have led
to the use of medicines in this
country being sub-optimal.”
Medicines optimisation aims
14 APRIL 2014 PHARMACY MAGAZINE
to shift the emphasis away
from drug costs and towards
achieving better value by
supporting patients to get more
out of their medicines, she
explains.
“Patients are clearly telling us
they want more information,
better consultation and to
understand what services are
available, particularly from
community pharmacy, to help
them [with their medicines],”
says Ms Howard. The work will
also filter through to local level,
she adds.
“We are in the process of
developing a sort of prototype
‘dashboard’ with measures that
aim to help CCGs think about
what they need to be looking
at locally, to make sure that
patients in their area get the
most out of their medicines.”
This is clearly a huge
programme of work with a
broad remit. Ms Howard
describes a couple of examples,
such as how the programme is
looking to improve services
for patients with long-term
conditions and support those
recently discharged from
IN SOME WAYS it feels like
NHS England has always been
around. Every month the body
is in the news because of a
new initiative, campaign, event
or policy, and a quick glance
at NHSE’s website confirms
a constant stream of news
stories and announcements.
Certainly there has been a lot
going on – yet NHS England is
only one year old.
A former community
pharmacist and pharmaceutical
adviser, Ms Howard was
seconded to the Department
of Health in 2012 to lead the
national medicines use and
procurement QIPP work stream.
She was announced as chief
pharmaceutical officer Keith
Ridge’s deputy just ahead of the
NHS reforms coming into force
in April 2013.
While some deputies prefer
to work in the background and
leave someone else to be the
public face of an organisation,
this has certainly not been the
case for the NHS England
pharmacy team. Ms Howard has
been vocal on a whole range of
topics affecting the profession
and is also leading the work
on the medicines optimisation
agenda.
Clare Howard on:
The possibility of a new pharmacy contract
One of the benefits of Call to Action was the spotlight that it shone
on collaborative working. “There are some incredible examples of
community pharmacy and general practice working well together
for the good of their patients,” Ms Howard says.
The success of repeat dispensing in the North East is a prime
illustration. “It has worked really well because pharmacists and GPs
have sat down together at training events to work out how this could
work for their patients… The benefits are there and you see it in
action in their figures.”
In some instances, the differences between community pharmacy
and general practice are worth exploiting, she suggests. “Look at
the vaccination programmes that have been run where community
pharmacy has been able to demonstrate that it can get access to
patients who don’t necessarily see their GP.”
Another example is the South Central respiratory project,
which demonstrated a reduction in admissions and also an
improvement in quality of life for patients. However the flip side is
that sometimes the gap between general practice and community
pharmacy feels more like a chasm, with concerns voiced in some
quarters about how well the two professions can work together when
their contracts are so disparate. But there may be light at the end of
the tunnel. “We are exploring how the [pharmacy] contract could be
better organised to support patients in primary care,” she says.
With NHS England now responsible for the national contracts
for both pharmacy and general practice, might we finally see some
formal alignment between the two? It would be long overdue.
Something no doubt for Ms Howard’s overflowing in-tray...
that medication use is as safe as
possible,” she says.
Call to Action
A national
contract is
often quite
a blunt
instrument to
resolve all the
issues
“
”
hospital, and is clear that it sits
comfortably with other NHSE
priorities. “Things like the better
use of EPS and electronic
patient records will make sure
Talk to anyone prominent in
pharmacy – or even primary
care – and the NHS Call to
Action consultation soon crops
up. It’s the major topic of the
moment. And quite right too.
As Ms Howard puts it: “It is the
opportunity for pharmacy to
help the NHS and shape the way
that primary care services are
organised in the future.”
NHS England has been
delighted with how the
profession has risen to the
challenge, she adds, explaining,
“I am really encouraged by the
sorts of things that pharmacists
have put forward and have been
thinking about”.
What is also reassuring is the
fact that the views of healthcare
professionals seem aligned with
what patients want, she says. “I
think that some of what we are
hearing chimes with what we
have already heard through the
medicines optimisation work,
which is that patients want
more support around their
medicines taking.”
However what is increasingly
evident is the lack of public
awareness of what community
pharmacy can offer in addition
to dispensing. Campaigns such
as NHS England’s ‘The earlier,
the better’ and Pharmacy Voice’s
‘Dispensing health’ clearly have
an important role
to play here, she says.
The “conversation” phase of
the community pharmacy Call
to Action ended on March 18
but Ms Howard is keen to
emphasise that this wasn’t a
paper-pushing exercise with an
already decided outcome. “We
don’t want to pre-empt things…
we’ll need a period of time to
reflect on what’s come in.”
The responses will also be
considered with the Calls to
Action for other areas of
primary care, such as general
practice and dentistry, and the
review of emergency care
services, she points out.
Although NHS England will
take its time to sift through the
ideas and suggestions that have
stemmed from events and
online replies, Ms Howard
stresses that the process is
about more than just deciding
overall NHS strategy.
“Call to Action isn’t just about
what happens nationally. It is
there for [NHSE’s] area teams,
who over the next few months
will be developing their five-year
plans around community
pharmacy, primary care and
out-of-hospital care in general.
My sense is that area teams will
be using what they have heard
at their events to shape their
strategies.”
The trick will always be about
achieving a balance between the
national need for consistency
while at the same time making
sure that local areas have the
ability to innovate and develop
services, she says. “A national
contract is often quite a blunt
instrument to resolve all the
issues.”
“If we hadn’t had that local
flexibility, then some of the
amazing services and great
innovative work that has come
out of community pharmacy
in recent times wouldn’t have
happened. At a local level,
things can happen quite
quickly.”
THIS INTERVIEW FIRST APPEARED IN THE APP VERSION OF THE MARCH ISSUE
15_PM_0414:15_PM_0414 11/04/2014 12:17 Page 1
17:29
16_CPPE_PM_0414_rt.qxp:16_PM_0314 10/04/2014 12:07 Page 16
LEARNING ZONE
Consultation skills for
pharmacy practice
Effective consultations lie at
the heart of delivering patientcentred care. To help you
assess and develop your
consultation skills, a new
website (www.consultationskills
forpharmacy.com) has been
developed to provide easy
access to a range of resources,
including guidance, practice
standards, learning options
and assessment tools. The
website, which also offers
advice to employers and
trainers, supports users
through a six-step learning
pathway:
1. Why are consultation
skills important for all
pharmacy professionals?
Using effective consultation
skills will enable you to
enhance patient care, and
promote the respect and
recognition of pharmacy
professionals among patients
and other healthcare
professionals.
2. How do I know what
standard is expected of me?
A new set of national practice
standards has been prepared to
define the competencies that
all pharmacy professionals
should aspire to.
3. How do I know how
effective my consultation
skills are now?
There is a range of options
available for you to establish
how effective your current
practice is when conducting
medicines and public health
consultations.
Health Education
England (HEE) and
CPPE have launched
new national practice
standards and a
Consultation Skills
for Pharmacy
Practice learning
and development
programme
4. How do I improve my
performance?
People learn in different ways,
so a set of learning steps are
recommended to enable you to
achieve your development goal.
5. How can I check my
learning and development?
Once you have worked through
your chosen learning pathway,
you will be able to complete an
online assessment to evaluate
your knowledge and ability
to identify good practice
in delivering effective
consultations.
6. How do I continue to
develop my performance?
At this stage of your learning
pathway, you can access the
options available for you to
regularly reassess your
performance and identify
opportunities for further
improvement.
Core learning
• The new distance learning
programme, Consultation
Skills for Pharmacy Practice:
Taking a Patient-Centred
Approach, has been developed
to support you to assess and
develop your skills.
• A face-to-face workshop,
Consultation Skills: Meeting
the New Practice Standards
for Pharmacy, is also being
run by the CPPE to help you
apply your knowledge and
skills to practice.
More information at
www.consultationskillsfor
pharmacy.com
Contact CPPE
Website: www.cppe.ac.uk
Email: [email protected]
General enquiries:
0161 778 4000
You can follow us on:
Facebook: www.facebook.com/cppeengland
Twitter: www.twitter.com/cppeengland
LinkedIn: www.linkedin.com/company/centre-for-pharmacypostgraduate-education
YouTube: www.cppe.ac.uk/youtube
16 APRIL 2014 PHARMACY MAGAZINE
PRACTICE
SCENARIO
intermittent fasting
Technician Lucy
returns to the
pharmacy after
her lunch break
with a magazine
in her hand and
a puzzled look on
her face...
“Can you help me get
my head round this
please?” Lucy asks
pharmacist Parveen.
“I’ve been reading in
this magazine about
something called 16:8
eating. Is it the same as
the 5:2 diet? But that
would mean that you eat
for 16 days then fast for
eight. It’s so confusing!”
ANSWER
The 16:8 diet involves
restricting eating to an eighthour window each day and rose
to fame when a book entitled
‘The 8 Hour Diet’ was published
last year. The author makes
many claims about this way
of eating, but there is little
evidence supporting such an
approach to weight loss.
One study in mice suggested
that feeding times influenced
metabolism, and while another
paper pointed towards a
combination of calorie
restriction, exercise and
intermittent fasting as a way of
reversing some of the changes
caused by ageing, the research
team agreed that more work
needed to be done to explore
exactly what regimen of eating
and fasting works best.
The truth of the matter is
that restricting the time during
which someone can eat to just
eight hours a day tends to limit
the amount of calories that
they consume. By only eating
between the hours of, say 210pm each day, the individual
will miss breakfast, and have
a late lunch meaning they are
more likely to eat a smaller
dinner. Ultimately, if the number
of calories being taken in is
exceeded by the calories being
used up, weight loss will result.
email:[email protected]
NPA HITS THE ROAD
The NPA is running another
event in Wales to help members prepare for the new GPhC
inspection and ratings model.
It takes place on Wednesday
May 14, 7.20-9.30pm, at the
Kinmel Manor Hotel in Conwy
and includes a presentation
from the GPhC on understanding the premises standards and
inspection process and what
pharmacists can expect from
a visit by the inspector.
PHARMA CHALLENGES
The bigger picture
Intermittent fasting hit the
headlines when the BBC
screened a Horizon
documentary on the topic
in 2012. The 5:2 diet quickly
became popular because it is
much more straightforward
than many weight loss plans:
eat normally for five days a
week, and fast for the other two
days, which must not run
consecutively. The fasting days
involve restricting calorie intake
to just 500 per day for women
and 600 for men.
There is evidence supporting
the health benefits of the 5:2
model. A 2010 study found that
this way of eating achieved
similar levels of weight loss as a
more general calorie controlled
diet, and there was a decrease
in a number of biomarkers,
which point towards a possible reduction in the risk of
developing conditions such
as type 2 diabetes.
A 2012 study found that
there may also be a reduction
in the risk of developing breast
cancer. However, much of the
success of the 5:2 diet has been
attributed to the simple fact that
fasting helps people relearn
what it feels like to both be
hungry and full. This, in turn,
makes people more aware of
what they are eating on nonfasting days. Most people who
follow the 5:2 diet experience
a net decrease in calorie intake
over the week.
Extend your learning
• Find out more about intermittent fasting at www.nhs.uk/
news/2013/01January/Pages/
Does-the-5-2-intermittentfasting-diet-work.aspx and
www.bbc.co.uk/news/health19112549.
Over half of the active products
in the global industry research
pipeline are personalised medicines – but the UK healthcare
system is at risk of failing to
adapt to this new challenge, a
new report from the ABPI has
revealed. The discussion paper,
‘Securing a Future for Innovative
Medicines’, highlights further
challenges including rising drug
development costs and difficulty
with patient recruitment for
clinical trials. The UK needs to
improve trial performance by
enabling faster patient enrolment, encouraging the use of
electronic health records and
streamlining the research governance process, the ABPI says.
TURBO-CHARGED NHS
The NHS must achieve “turbocharged” change in the way
health is delivered in England
if it is to significantly improve
care for patients, says Monitor.
Setting out its corporate
strategy for 2014-17, the regulator adds there is a growing
consensus about the fundamental changes required to
achieve “nothing short of a
complete redesign of how
care is delivered in England.”
This includes integrating access
to care around the needs of
patients, breaking down
traditional barriers between
providers, doing less in
hospitals and more in the
community, and inventing
new models of hospital care.
CPD MODULE
This month’s CPD module
in Pharmacy Magazine is on
promoting physical activity
and exercise. It can be found
on the centre pages of this
issue. Remember to complete
the pre-test, learning scenarios
and post-test at www.pharmacy
mag.co.uk.
17-24_CPD Module_PM_0414_rt.qxp:00-00_PM_0414 07/04/2014 11:48 Page 17
CPD MODULE
the
continuing
professional
development
module 222
programme
www.pharmacymag.co.uk
THIS IS the two hundred and twenty second module
in the Pharmacy Magazine Continuing Professional
Development Programme. This module looks at
promoting physical activity and exercise.
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 can 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,
as stipulated by the GPhC.
Before reading this module, test your existing
understanding of the topic by completing the pre-test
at www.pharmacymag.co.uk. Then, after studying
the module in the magazine, work through the six
learning scenarios and post-test.
Record your learning and how you applied it in
your practice using the CPD report form available
online and on pviii of this module.
Self-assess your learning needs:
• What are the recommended amounts of
physical activity for adults and young people?
• What is meant by ‘active living’?
• Are you familiar with the ‘Let’s Get Moving’
screening questions?
forthismodule
GOAL
To update pharmacists on the latest
thinking regarding physical activity
and exercise.
OBJECTIVES:
After completing this module you should be able to:
• Provide brief interventions to help people to
exercise
• Explain the amount and type of physical activity
needed to produce health benefit
• Advise individual patients on an appropriate
physical activity programme.
pharmacy
First in professional development
Promoting physical
activity and exercise
Contributing authors:
Professor Claire Anderson,
University of Nottingham,
and Professor Alison
Blenkinsopp, University
of Bradford
Background
There is strong evidence that a sedentary
lifestyle is detrimental to health and that
undertaking regular physical activity can
improve health and prolong life. Regular
activity is related to reduced incidence of
many chronic conditions such as diabetes,
CHD, cancer, joint disease and mental
health. Regular physical activity can
improve health outcomes irrespective of
whether individuals achieve weight loss.
Physical activity encompasses, but is
not restricted to, exercise (see Table 1).
The chief medical officer for England
recommends that adults should achieve
at least 30 minutes of moderate activity
on five or more days of the week. NICE has
issued guidance on four common methods
used to increase the population’s physical
activity levels:
• Brief interventions in primary care
• Exercise referral schemes
• Pedometers and community-based
walking
• Cycling programmes.
Guidance has also been issued on promoting physical activity in children and
young people.
magazine
PULL OUT AND KEEP
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 www.pharmacymag.co.uk
and include in your CPD portfolio. Previous modules in the Pharmacy
Magazine CPD Programme are available to download from the website.
LEARNING SCENARIOS FOR THIS MODULE AT WWW.PHARMACYMAG.CO.UK
PHARMACY MAGAZINE APRIL 2014 CPD i
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www.pharmacymag.co.uk
Physical activity: any bodily movement produced by
skeletal muscles resulting in energy expenditure
Exercise: anything that is planned, structured,
involves repetitive bodily movements and is usually
undertaken during leisure time for the purpose of
maintaining physical fitness
Physical fitness: a set of attributes that people have or
can acquire that relates to their ability to perform
physical activity. These are:
• Aerobic fitness: the ability of the heart and lungs to
supply fuel during sustained physical activity and
to eliminate waste products
• Strength: the amount of external force that
a muscle can exert
• Flexibility: the range of motion at a joint.
Intensity: the intensity of physical activity is
important:
• Light activities require little exertion, not causing
a noticeable change in breathing
• Moderate activities require sustained, rhythmic,
muscular movements and leave someone warm and
slightly out of breath
• Vigorous activity requires sustained, rhythmic,
large muscle movements at a minimum of 60-70
per cent of maximum heart rate and leaves
someone sweating and out of breath.
In a 2008 national survey only 39 per cent of
adult men and 29 per cent of adult women met
the chief medical officer’s recommendations for
physical activity (encouragingly, up slightly from
35 per cent of men and 24 per cent of women in
the previous survey conducted in 2004).
The proportion meeting the guideline
recommendations decreased steadily with age.
Research has also shown that people in higher
income quintiles are more likely to have
participated in at least one occasion of physical
activity of at least moderate intensity in the
previous four weeks. Physical activity levels are
strongly related to body mass index (BMI) and
activity levels fall from 30 per cent among those
who have a desirable BMI, to 18 per cent among
those who are obese or morbidly obese (BMI
over 40).
Men and women with low activity levels are
more likely to have a raised waist circumference
compared to those with high activity levels.
Within minority ethnic groups, Irish and Black
Caribbean men have the highest percentage
Why get involved?
Table 1: Definitions
Table 2: Health benefits of regular
physical activity
• Lower mortality from all causes
• Reduced risk of developing coronary heart disease
• Reduced mortality after a heart attack
• Reduced risk of a heart attack in obese patients
• Possible reduced risk of stroke
• Prevention or delay in development of high blood
pressure
• Reduction of high blood pressure in people with
hypertension
• Greater weight loss than by dieting alone, and
a better conservation of fat-free body tissue
during dieting
• Decreased risk of cancer of the colon
• Lower risk of developing non-insulin dependent
diabetes
• Higher bone mass density and fewer osteoporotic
fractures
• Reduction in mild anxiety and depression
• Sleep patterns improve
meeting the current physical activity recommendations (39 and 37 per cent respectively)
but were also more likely to be obese.
Bangladeshis were the least active and almost
twice as likely as the general population to be
classified as sedentary. Only 11 per cent of
Bangladeshi and 14 per cent of Pakistani women
reported achieving the recommended amounts
of physical activity in the previous four weeks.
Among women, Bangladeshi females reported
low levels of physical activity but they were also
among the groups least likely to be obese.
With community pharmacies increasingly
involved in supporting healthy lifestyles,
pharmacy teams are well placed to advise on
physical activity in association with services such
as cardiovascular risk assessment and weight
management, as well as through signposting
to support self-care and public health.
Physical activity and improved health:
the evidence
Recent years have seen a large increase in
research on physical activity and health. Table 2
contains a summary of health benefits. Physical
activity has been definitively shown to play a
Regular physical activity will reduce the incidence of many long-term health conditions
ii CPD APRIL 2014 PHARMACY MAGAZINE
Reflection exercise 1
Think about the profile of the customers and patients
who use your pharmacy. How might you make use of
the data on physical activity to inform your practice?
new medicine
service extended – again
The NMS has been extended until
2014-15 pending the results of an
evaluation study
LEARNING SCENARIOS FOR THIS MODULE AT WWW.PHARMACYMAG.CO.UK
PULL OUT AND KEEP
17-24_CPD Module_PM_0414_rt.qxp:00-00_PM_0414 07/04/2014 11:50 Page 19
CPD MODULE
Starting a conversation about
physical activity
Most members of the public do not know how
much and what sort of physical activity they
should be aiming for. A third of people surveyed
had not heard about the recommended levels
of physical activity. The majority of adults
perceived themselves as fairly active, with only
one in 20 considering themselves to be not at all
physically active. Encouragingly, more than twothirds of adults said they would like to do more
physical activity. Work commitments and lack
of leisure time were the most commonly
reported barriers.
Improvements in health and fitness depend
on the intensity (see Table 1), duration and
frequency of the activity. The key questions are:
• How much is good for you?
• How often and how hard?
• How long should each session last?
The ‘Let’s Get Moving’ primary care screening
questions can be useful (see Table 4 below).
People are asked which statement most applies
to them. Using these simple statements gives
both you and the customer a starting point for
any discussion.
part in the prevention and treatment of
hypertension, non-insulin dependent diabetes,
osteoporosis, stroke, some cancers and
depression. It can help to keep older people
independent and active and reduce the
incidence of falls.
The key messages to convey are:
• Becoming even moderately active on a regular
basis can improve the health of people who
are usually inactive
• Physical activity does not need to be
strenuous to improve health
• There is no need to join a gym – ‘active living’
and home-based activities are just as
beneficial for health.
Table 3: Specific benefits of physical
activity for older people
• Improved muscle strength and flexibility leading
to reduced risk of falls (muscle strengthening
exercises)
• Reduction in bone fractures (muscle strengthening
exercises)
• Improved memory
• Improved self-esteem and confidence in performing
daily tasks
• Enhanced ability to live independently
For people who are in the preparation or
contemplation stage, find out more and make
some suggestions that will fit that person’s
lifestyle and preferences. Where someone is at
the pre-contemplation stage, encourage further
discussion in the future. Make a note on your
PMR to remind you that you have had the
conversation and record a suggested date for
a future one.
The NHS recommendations for adults aged
19-64 years and for people aged 65 years and
over who are generally fit and have no health
conditions that limit their mobility are the same
(see Table 5). No one is too old to benefit from
regular physical activity and most people can
start a gentle programme without any problems.
To make sure that all local health professionals
are giving the same messages, it would be
helpful to discuss advice on physical activity
with local GP practices to agree who might need
medical advice.
Guidelines in the US suggest that men over 40
years and women over 50 who are planning to
start a programme of vigorous activity should
check with their doctor first. Exercise sessions
should be postponed during illness, such as
colds and flu, and care should be taken when
the weather is very hot or humid.
Moderate activity slightly raises the heart
rate (see Table 6 for examples). Musclestrengthening activities include lifting weights,
Table 4: The ‘Let’s Get Moving’ screening questions
You do some physical activity but not enough to meet the description of regular
physical activity
Preparation
You are not regularly physically active but are thinking about becoming more active
in the next six months
Contemplation
You are not regularly physically active and do not intend to be in the next six months
Pre-contemplation
PULL OUT AND KEEP
working with resistance bands, doing exercises
that use body weight for resistance (e.g. pushups and sit-ups), heavy gardening (e.g. digging
and shovelling) and yoga.
It was thought in the past that vigorous
aerobic exercise was the only sort that could
have health benefits. Research has shown that
this is not the case and the emphasis is now
on ‘active living’ – the integration of moderate
physical activity into daily living. Younger people
are likely to need activity of higher intensity (e.g.
cycling) than older people to raise the heart rate
in order to gain benefit.
In older age groups, brisk walking will provide
sufficient intensity, likely to raise the heart rate
to ‘training level’ in the over 50s. A further
benefit of regular walking for older people is
that it helps other daily activities – for example,
a regular daily 30-minute walk is associated
with maintaining the ability to climb stairs.
Some activities can be performed at different
intensities – table 6 offers a guide to using daily
living activities in a programme of physical
activity. The aim should be a feeling of mild
fatigue after moderate activity, not exhaustion.
Older people who are doing walking as their
main form of activity can take the ‘talk test’ –
if they cannot carry on a conversation while
walking, they should slow down.
Physical activity for children and
young people
When thinking about encouraging physical
activity among children it is important to bear
in mind that parental physical activity levels are
associated with children’s activity levels. In
households where both parents report high
levels of physical activity, children in all age
and gender groups are also more likely to report
higher levels than in those households where
only one parent has high activity levels.
The NHS recommends that children and
young people between five and 18 years of age
should do at least 60 minutes (one hour) of
physical activity every day, which should range
between moderate-intensity activity (e.g. cycling
and playground activities) and vigorousintensity activity (e.g. fast running and tennis).
On three days a week, these activities should
involve muscle-strengthening activities (e.g.
push-ups) and bone-strengthening activities
‘More than two-thirds of adults
said they would like to do more
physical activity’
LEARNING SCENARIOS FOR THIS MODULE AT WWW.PHARMACYMAG.CO.UK
PHARMACY MAGAZINE APRIL 2014 CPD iii
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www.pharmacymag.co.uk
Table 5: NHS recommendations for
adults aged 19 years and over
• At least 150 minutes (two hours and 30 minutes)
of moderate-intensity aerobic activity, such as
cycling or fast walking, every week, and musclestrengthening activities on two or more days a week
that work all major muscle groups (legs, hips, back,
abdomen, chest, shoulders and arms)
OR
• 75 minutes (one hour and 15 minutes) of vigorousintensity aerobic activity, such as running or a game
of singles tennis every week, and musclestrengthening activities on two or more days a week
that work all major muscle groups (legs, hips, back,
abdomen, chest, shoulders and arms)
OR
• An equivalent mix of moderate- and vigorousintensity aerobic activity every week (e.g. two 30minute runs plus 30 minutes of fast walking), and
muscle-strengthening activities on two or more days
a week that work all major muscle groups (legs,
hips, back, abdomen, chest, shoulders and arms).
(e.g. running). Many vigorous-intensity activities
can help meet weekly muscle- and bonestrengthening requirements (e.g. running,
skipping, gymnastics, martial arts and football).
Coronary heart disease
People who undertake regular physical activity
are less likely to die from heart disease and
more likely to live longer. While the mechanism
of protection is not completely understood,
physical activity is likely to modify other risk
factors such as body weight, decreasing blood
clotting, lowering blood pressure, improving
lipid profile and increasing insulin sensitivity.
Obese people who take regular exercise can
reduce their risk of heart disease to the same as
that of exercisers of normal weight. After a heart
attack the risk of death is reduced by about
20 per cent by regular physical activity.
Diabetes
Physical activity/exercise is now widely
considered to be an integral element of diabetes
management and evidence demonstrates that it
can produce a clinically important improvement
in glucose control in people with type 2 diabetes
(in the absence of weight loss), producing an
average improvement in HbA1c of between -0.4
and -0.6 per cent.
Type 2 diabetes
NICE gives general advice about physical activity
in type 2 diabetes saying that people with
diabetes should be assessed regarding:
• Activity at work, and in getting to and from the
workplace
• Activity in domestic activities and hobbies
• The possibility of formal physical exercise on a
regular basis; for example:
• Brisk walking for 30 minutes a day
• Active swimming for one hour, three times
a week.
People with diabetes should be advised that
physical exercise can benefit insulin sensitivity,
blood pressure and blood lipid control, and
should be taken at least every two to three days
for optimum effect. They also need to be aware
that exercise may increase the risk of acute and
delayed hypoglycaemia.
Pharmacists should check what the patient
has been told already about appropriate
blood glucose self-monitoring, additional
carbohydrate and dose adjustment of glucoselowering therapy for those using insulin.
Alcohol may exacerbate the risk of hypoglycaemia after exercise. There are also risks
from foot damage for people with diabetes, so
low impact exercise is best if this is a problem.
Cancer
Increased physical activity may protect against
various cancers and much research has focused
on colon cancer. A significant, inverse association between physical activity level and risk of
colon cancer has been reported. Studies show
that exercise could reduce colon cancer risk by
about a quarter. By maintaining a healthy weight
as well, the studies estimate that colon cancer
risk could be as much as halved, compared to
people who are overweight and don’t exercise.
Physical activity doesn’t appear to have an effect
on rectal cancer risk.
Studies in breast cancer have shown a
protective effect ranging from 20 to 40 per cent,
so being active may lower women’s risk of
developing breast cancer by between a fifth
and just over a third. Womb cancer risk is also
lowered by exercise, by between one-fifth to a
third. There is also some evidence that exercise
helps to lower the risk of prostate cancer.
Moderate exercise enhances the immune
system and this may be linked to a reduced
cancer risk. Exercise fitness may also reduce
reactivity to stress (psychosocial) and mitigate
Specific health conditions and
physical activity
Type 1 diabetes
In type 1 diabetes, NICE offers the following
guidance to healthcare professionals:
• Advise that physical activity can reduce
enhanced arterial risk in the medium and
longer term
• If the person chooses to increase physical
activity he/she should be advised on:
• Appropriate intensity and frequency of
physical activity
• Self-monitoring of changed insulin and/or
nutritional needs
• Effect of exercise on blood glucose levels
when insulin levels are adequate (risk of
hypoglycaemia) or when hypoinsulinaemic
(risk of exacerbation of hyperglycaemia)
• Appropriate adjustments of insulin dosage
and/or nutritional intake for exercise and for
24 hours afterwards
• Alcohol may exacerbate the risk of hypoglycaemia after exercise.
Table 6: Examples of moderate
amounts of ‘daily living’ physical
activity*
Less vigorous (more time)
• Cleaning windows or floors for 45-60 minutes
• Decorating (painting, wallpapering) for 45-60 minutes
• Gardening for 45-60 minutes
• Walking a mile-and-three-quarters in 35 minutes (20
minutes per mile) – walking up a 5 per cent gradient
increases energy expenditure by 50 per cent
“Mall walking”, a popular group activity in the US, is
becoming common in the UK with groups running at
shopping centres such as the Bullring in Birmingham,
The Trafford Centre in Manchester and the White Rose
in Leeds
• Cycling five miles in 30 minutes (10 miles per hour)
• Pushing a pushchair one-and-a-half miles in 30
minutes (20 minutes per mile)
More vigorous (less time)
• Walking two miles in 30 minutes (15 minutes per mile)
• Aqua aerobics for 30 minutes
• Cycling four miles in 15 minutes (16 miles per hour)
• Skipping for 15 minutes
• Running one-and-a-half miles in 15 minutes
(10 minutes per mile)
• Stair walking for 15 minutes
• “Green gyms”, where experienced leaders guide
volunteers through a range of practical projects, giving
them the opportunity to tackle physical jobs in the
outdoors.
* Roughly equivalent to 150 calories per activity
iv CPD APRIL 2014 PHARMACY MAGAZINE
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Pharmacists should seek every opportunity to promote exercise and physical activity to customers
exercise programme and can be prevented by
gradually increasing the level of activity to the
desired level over a period of weeks.
Injuries also occur when people undertake
excessive amounts of physical activity, sometimes when they know they are becoming tired
but want to make a last effort.
Pharmacists are well placed to offer both
preventive advice and treatment when minor
musculoskeletal problems occur. The use of ice
or heat packs (depending on the time since the
injury occurred) and support aids (e.g. for knees
and wrists) can help.
Concerns have been expressed about the
adverse cardiovascular effects of vigorous
exertion and there have been well publicised
cases of joggers dying from heart attacks while
out exercising. However these cases of sudden
death are extremely rare and they are more
likely in someone who was previously sedentary
and has quickly moved to vigorous exercise.
The net effect of physical activity is a lower risk
of mortality from cardiovascular disease.
How community pharmacy can help
amount recommended for ‘active living’ do not
cause arthritis or make existing disease worse.
Reflection exercise 2
How might you target those people at risk from
osteoporosis with health promotion messages about
physical activity? What would your message for them be?
against the effects of biochemical changes
associated with the stress response. This may
also be linked to a reduced cancer risk but the
evidence is not yet definitive.
Osteoporosis
Weight-bearing exercise helps to maintain bone
mass. Active men and women have a higher
bone density and fewer osteoporotic fractures
than those who are sedentary. The mechanism
is not yet fully clear because exercise, in
addition to its effects on bone density, also
improves muscle strength, co-ordination and
balance. Physical activity thus has an important
role in preventing falls as well as reducing the
harm caused when they occur.
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Adverse effects of physical activity
Musculoskeletal injuries related to physical
activity often occur in the early stages of an
Arthritis
Regular physical activity can help to control
joint swelling and pain. Activities of the type and
Mental health
Evidence is emerging indicating the benefits
of exercise on psychological wellbeing as well
as on physical health. Studies show that exercise increases self-esteem and self-efficacy (the
belief that one can influence one’s own life in a
positive way). Physical activity has been shown
to improve mood and to enhance cognitive
functioning and quality of life. Patients suffering
from anxiety, stress and depression are less
likely to be exercising regularly and can benefit
from doing so. In depression aerobic exercise
e.g. jogging and cycling, and weight training,
are most likely to be beneficial but needs to
be sustained over several months.
Reflection exercise 3
Think about what your pharmacy is already doing to
promote physical activity. How could you extend this?
Which people might you target and how?
If everyone adopted the recommended levels
of physical activity the overall gain in health
would be:
• Nearly one-third of all CHD incidence avoided
• One-quarter of stroke avoided
• Nearly one-quarter of non-insulin dependent
diabetes in over 45s avoided
• Just over half the hip fractures in over 45s
avoided.
The informal atmosphere of a community
pharmacy, together with the regular contact
with the public and provision of services
like vascular and diabetes screening, make
it an excellent setting for this sort of health
promotion advice.
NICE guidance states that commissioners
need to pay attention to the needs of hardto-reach and disadvantaged communities,
including minority ethnic groups, when
developing service infrastructures to promote
physical activity. Pharmacists come into contact
with many people who could benefit from
increased physical activity and can also target
specific groups of patients from their PMRs.
Local campaigns encouraging the public to
get advice on physical activity from community
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Table 7: Department of Health’s general practice physical activity questionnaire
General Practice Physical Activity Questionnaire
Brief interventions
Brief interventions involve opportunistic advice,
discussion, negotiation or encouragement.
They are commonly used by pharmacists in
many areas of health promotion. Interventions
vary from basic advice to more extended,
individually-focused attempts to identify and
change factors that influence activity levels.
There is sufficient evidence to recommend the
use of brief interventions in primary care.
Physical activity –
NICE recommendations
1. Primary care practitioners should take the
opportunity, whenever possible, to identify
inactive adults and advise them to aim for 30
minutes of moderate activity on five days of
the week (or more). They should use their
judgement to determine when this would
be inappropriate (e.g. because of medical
conditions or personal circumstances).
They should use a validated tool, such as the
Department of Health’s general practice physical
activity questionnaire (see Table 7), to identify
inactive individuals.
2. When providing physical activity advice,
primary care practitioners should take into
account the individual’s needs, preferences
and circumstances. They should agree goals
with them. They should also provide written
information about the benefits of activity and
local opportunities to be active. They should
follow them up at appropriate intervals over a
three- to six-month period.
Date………………………
Name……………………..
1.
Most people who currently are sedentary say
that lack of time, lack of facilities and costs are
Reflection exercise 4
Check the signposting list in your pharmacy. What does
it contain regarding physical activity opportunities?
Look up local authority and primary care organisation
websites to find out what is available (e.g. free
swimming, green gyms, walking groups, chair-based
exercise).
Please tell us the type and amount of physical activity involved in your work.
Please
mark one
box only
a
I am not in employment (e.g. retired, retired for health reasons, unemployed, fulltime carer etc.)
b
I spend most of my time at work sitting (such as in an office)
c
I spend most of my time at work standing or walking. However, my work does
not require much intense physical effort (e.g. shop assistant, hairdresser,
security guard, childminder, etc.)
d
My work involves definite physical effort including handling of heavy objects and
use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse,
gardener, postal delivery workers etc.)
e
My work involves vigorous physical activity including handling of very heavy
objects (e.g. scaffolder, construction worker, refuse collector, etc.)
2.
During the last week , how many hours did you spend on each of the following activities?
Please answer whether you are in employment or not
Please mark one box only on each row
None
Some but 1 hour but 3 hours or
less than less than
more
1 hour
3 hours
d
Physical exercise such as swimming,
jogging, aerobics, football, tennis, gym
workout etc.
Cycling, including cycling to work and
during leisure time
Walking, including walking to work,
shopping, for pleasure etc.
Housework/Childcare
e
Gardening/DIY
3.
How would you describe your usual walking pace? Please mark one box only.
a
b
c
Advice on getting started
vi CPD APRIL 2014 PHARMACY MAGAZINE
pharmacies raise awareness of pharmacists’ role
and increase customer loyalty. Pharmacies can
also make sure their lists of local facilities and
services for signposting include those involving
physical activity.
Slow pace
(i.e. less than 3 mph)
Steady average pace
Brisk pace
Fast pace
(i.e. over 4mph)
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CPD MODULE
the main barriers. Community pharmacists
are well-placed to advise on types of physical
activity to fit with the person’s lifestyle and
existing commitments. It should be borne in
mind that while some people prefer exercise
as a solitary activity, others may welcome a
social component. Find out what activities are
available locally. Examples might be walking
schemes, cycling programmes, outdoor gyms
or gentle exercise classes for older people.
Should pharmacists wait to be asked
for advice on physical activity?
Helping people to keep going with
physical activity
Many people drop out of physical activity
programmes, even when they started with
enthusiasm and the best of intentions. As with
medicines, non-compliance or non-adherence
to physical activity routines is widely recognised
to be a problem.
People need physical and/or psychological
goals to motivate them to continue with a
physical activity programme. Getting someone
Planning pharmacy-based support
for physical activity
Rather than seeing physical activity as a
‘campaign’, it should be thought of as a longterm input. Targeting patients from PMRs (e.g.
those with angina, hypertension, osteoporosis)
can be done gradually over a long period of
time to control the rate and numbers of people
offered advice.
To help ensure that the same messages are
given throughout the healthcare team:
• Find out what your local primary care
organisation’s policy is concerning physical
activity
• Use leaflets (e.g. patients targeted from PMRs)
• Respond to requests for advice about exercise
• Suggest that the person keeps an exercise
diary to monitor his/her progress
• Encourage follow-up by visits to the pharmacy
so progress can be monitored.
Pharmacy teams can use the “4 A’s” to
individualise advice:
Assess – what is the current level and type of
physical activity? Does the patient need to do
more?
Advise – might they prefer an ‘active living’
approach or organised exercise sessions?
Assist – have leaflets available with simple
guidelines on increasing physical activity;
also have details on-hand of local facilities
Arrange follow-up – invite the person to come
back to tell you how they are doing.
Pharmacists are sometimes concerned that
a customer might object if they are offered
advice without having asked for it. However
research has shown that the vast majority of
people offered health advice in community
pharmacies welcomed it and many would never
have thought to ask for it.
This lack of awareness that pharmacists have
a lot to offer in terms of general health advice
can only be changed if pharmacists and their
staff become more proactive. The way in
which advice is offered is also important,
and introducing the subject by saying that
your pharmacy is taking part in local initiatives
to improve health can break the ice.
who was previously sedentary to take up and
maintain simple lifestyle activities is more likely
to produce a sustained change than starting
a vigorous exercise programme that requires
attendance at exercise classes. The costs of an
‘active living’ approach are also considerably
less. People who take up a home-based physical
activity programme are more likely to stick to
it than those required to attend a health club
or leisure centre.
To avoid possible injuries and muscle
soreness, activity should be increased gradually.
For older people, for example, increasing
walking distance by an additional two minutes
every other week has been suggested. Careful
stretching of key muscles before and after
unaccustomed activity, such as gardening or
decorating, can help. Wearing well-fitting and
comfortable shoes with good arch support is
important for walking.
Keeping a diary to record the activity
undertaken and progress towards goals
(e.g. weight loss) has been shown to increase
adherence. Pharmacists can help by asking
about progress and encouraging continued
participation. Flagging the PMRs of patients
to whom you give advice about physical activity
will provide a reminder to ask them how they
are doing when they next come into the
pharmacy for a prescription.
Norfolk folk get fit...
In Norfolk community pharmacies have been working
with national and local sports organisations to develop
a series of community walking groups and activities to
encourage physical activity for people aged 50 years
and over.
The programme is promoted through community
pharmacies in conjunction with lifestyle advice and
health services such as cholesterol testing, health checks
and MURs.
Over 2,700 people have registered with the programme
and more than 1,100 events have taken place.
In September 2013 a referral scheme was launched in the
Broadlands area of Norfolk. Pharmacists in this area are
able to refer patients directly to an ‘Active Broadlands’
co-ordinator for assessment and a fully funded and
supervised exercise programme.
Pharmacy Magazine’s CPD modules are 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.
Note: the content of this module remains the copyright of Pharmacy Magazine and cannot be reproduced without permission in
the form of a valid licence granted after July 1, 2011.
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Pharmacy Magazine
CPD record
PROMOTING PHYSICAL ACTIVITY & EXERCISE
April
2014
Use this form to record your learning and action points from this module on
Promoting physical activity & exercise and include it in your CPD portfolio and
record online at www.uptodate.org.uk
1. There is good evidence that
physical activity can prevent
death or prolong survival in
which of the following?
a. Osteoporosis
b. Stroke
c. People who have had a
myocardial infarction
d. Breast cancer
2. Which is NOT one of the 4A’s
of health promotion advice?
a. Address the agenda
b. Assess the person’s level
c. Advise on an approach
d. Arrange follow-up
3. Which is the FALSE
statement regarding
regular physical activity?
a. The risk of death from stroke
is reduced
b. The relative risk of death from
heart disease is reduced
c. Blood pressure is reduced in
hypertensive individuals
d. Half of all CHD incidence
would be avoided if people
adopted recommended levels
of exercise
4. Which is TRUE? Current
NHS guideline-based
recommendations on
physical activity for adults
recommend:
a. The same amount and type
of physical activity for adults
aged over 19 years
b. 150 minutes each week of
moderate or vigorous intensity
activity dependent on age
c. 90 minutes of vigorous
activity
d. Muscle-strengthening
activities that work all major
muscle groups once a week
Activity completed. (Describe what you did to increase your learning. Be specific)
(ACT)
5. Identify the TRUE statement:
a. Physical activity should not be
advised for people over 80
b. Older people undertaking
regular physical activity
are less likely to have a fall
c. Aerobic exercise is more
beneficial than other types
of exercise in preventing falls
in older people
d. Most hip fractures would be
avoided if people adopted
recommended levels of
physical activity
Date:
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?*
(EVALUATE)
6. Which statement about brief
interventions is FALSE?
a. There is sufficient evidence
to recommend the use of brief
interventions in primary care
b. Pharmacists should use a
validated tool to identify
inactive individuals
c. Pharmacists should provide
written information about
the benefits of activity and the
local opportunities to be active
d. Pharmacists should follow up
people annually
How have I put this into practice? (Give an example of how you applied your learning)
Why did it benefit my practice? (How did your learning affect outcomes?)
(EVALUATE)
7. Which is an example of
moderate physical activity?
a. Cleaning windows or floors for
two hours
b. Painting/wallpapering for a day
c. Gardening for an afternoon
d. Walking a mile-and-threequarters in 35 minutes
Do I need to learn anything else in this area? (List your learning action points. How do you intend
to meet these action points?)
(REFLECT & PLAN)
8. Which cancer risk does
physical activity NOT appear
to have an effect on?
a. Colon cancer
b. Breast cancer
c. Rectal cancer
d. None of the above
* If as a result of completing your evaluation you have identified another new learning objective,
start a new cycle. 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 www.pharmacymag.co.uk
ENTER YOUR ANSWERS HERE Please mark your answers on the sheet below by placing a cross in the box next to the correct answer. Only mark one box
for each question. Once you have completed the answer sheet in ink, return it to the address below together with your payment of £3.75. Clear photocopies are
acceptable. You may need to consult other information sources to answer the questions.
1.
a.
b.
c.
d.
2.
a.
b.
c.
d.
3.
a.
b.
c.
d.
4.
a.
b.
c.
d.
5.
a.
b.
c.
d.
6.
a.
b.
c.
d.
7.
a.
b.
c.
d.
Name (Mr, Mrs, Ms)
Business/home address
Town
Postcode
Tel
GPhC/PSNI Reg no.
I confirm the form submitted
is my own work (signature)
Please charge my card the sum of £3.75
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Date
viii CPD APRIL 2014 PHARMACY MAGAZINE
Visa
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Completed answer sheets should be
sent to Precision Marketing Group,
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OPINION
SOCIETY SPOTLIGHT
OTCPRODUCTNEWS
NPA VIEW
NPA launches
consultation on
wholesalers
regional
matters
What do you think
of your wholesalers’
service standards, asks
Gareth Jones, NPA
public affairs manager
THE NPA HAS LAUNCHED a member consultation on
pharmaceutical wholesaler service standards. The purpose
is to:
• Gather data about wholesaler service standards generally,
against the backdrop of limited distribution and direct-topharmacy supply arrangements
• Create tools with which NPA members can measure and
benchmark the performance of their wholesaler/s. NPA
members will then be in a better position to challenge poor
service or acknowledge good service – and to make informed
choices, where choice exists
• Inform wholesalers about how their service is viewed by NPA
members.
Our starting point is to ask members to endorse or modify the
performance framework laid out in our consultation document.
We suggest the following as service principles against which to
assess performance:
• Fairness (e.g. any surcharges should be proportionate and
linked to the value of service provided)
• Responsiveness (e.g. responding promptly to queries or
complaints)
• Timely communication (e.g. proactively notifying a pharmacy
at the point of ordering if the wholesaler is unable to supply
a product)
• Efficiency (e.g. reliable, regular and frequent supply)
• Transparency (e.g. describing in detail why a quota has been
set at a certain level).
NPA members can answer consultation questions online at:
npa.co.uk/independents-voice/consultations/wholesalers.
Positive developments
Members can also access a medicines supply chain toolkit
(see last month’s column), which includes a branded product
availability chart (showing which wholesalers supply the
product of those manufacturers that use direct-to-pharmacy
or restricted wholesaler schemes), a list of the medicines
currently subject to supply problems and a patient leaflet
explaining the background to medicines shortages, in the event
of difficulties supplying
to a patient in a timely
fashion.
The wholesaler
consultation and the
toolkit both result from
recommendations of the
Manifesto for Independent
Community Pharmacy
task groups.
A manifesto progress
report will be presented at the NPA conference in London
on Sunday June 8. NPA members can register at
npa.co.uk/conference2014.
The NPA is
now consulting
on wholesaler
service
standards
“
”
FEVER’S RISING
BIG DEBATE: SHOULD YOU STOCK E-CIGARETTES? SEE P26
Including a community pharmacy
pilot in the Scottish Patient Safety
Programme (SPSP) is great news,
says Professor John Cromarty,
Scottish Pharmacy Board chair
PHARMACY IS OFTEN described as a risk averse
profession, contrasted, for example, with the medical
profession’s approach to dealing with uncertainty. However
there are strengths in pharmacists’ ability to detect errors
in their scrutiny of prescriptions and in their advice on drug
interactions that provide important protection for patients.
With the Public Bodies (Joint Working) (Scotland) Bill now
approved by the Scottish Parliament, it will become even
more crucial that pharmacists’ contribution to medicines
safety is integrated within the wider health and social care
system. Access and input into a shared patient record is
clearly important in enabling effective collaboration and
partnership working between health and social care
professionals in order to improve patient care.
Positive impact
Within community-based care, there is a particular
opportunity for pharmacists to become more fully
involved in the relevant parts of the Scottish Patient Safety
Programme (SPSP). This was launched in 2008 to reduce
adult mortality and adverse events in acute hospitals by
the end of 2012. In that time mortality was reduced by
12.4 per cent across Scotland.
However, while that was the
programme’s key aim, it also
demonstrated a real positive
impact for patients, such as
reduced infection rates and
reliability in the completion
of surgical checklists that
are a key part of the care of
patients receiving any surgical procedure. The programme
was recently awarded funding from the Health Foundation
to test the expansion further into community pharmacy.
Mortality
was reduced
by 12.4 per
cent
“
”
Great news
The inclusion of the community pharmacy pilot in the SPSP
is great news. Full inclusion of community pharmacy in
medicines reconciliation, particularly when patients enter
and return from other care settings (e.g. hospital or
care home), will provide more clear information for all
professionals involved. This will improve safety and overall
patient care.
The Scottish Government’s increased focus and
acknowledgement of the clinical and patient-facing role of
pharmacists can only be welcomed, but it will be crucial that
we get patients’ buy-in and understanding of the expert
input on medicines that pharmacists can provide.
The number of hay fever
sufferers is set to more than
double to 31.8 million by
2030, leading pollen expert
Dr Jean Emberlin has warned
in a new report sponsored by
Opticrom Hayfever Eye Drops.
The report claims that as a
result of pollution and climate
change, up to 45 per cent
of people in big cities like
London are expected to suffer
from hay fever in the next two
decades. In a survey of 2,000
UK adults by Opticrom, nearly
a third reported worsening
symptoms over the past few
years.
GOT THE ITCH?
New emollient range XeraCalm A.D from Eau Thermale
Avene by Pierre Fabre has
been found to reduce itching
by up to 97 per cent in a study
of 32 children with eczema.
A survey of eczema sufferers
and parents of children with
eczema commissioned by the
company revealed that itching
was the most troublesome
symptom (81 per cent),
followed by dryness (60 per
cent) and redness (43 per
cent). One in ten adult
sufferers had never found an
effective treatment and 61 per
cent of parents had applied
aqueous cream to their
child’s eczema. XeraCalm A.D
contains I-modulia, which has
been shown through in-pharmacological testing to reduce
inflammation and increase
the skin’s innate immunity,
says Pierre Fabre.
BE HAIR AWARE
Hair loss supplement
Nourkrin is sponsoring
the National Hair Aware
Campaign throughout 2014.
The brand will be reaching
over 35 million people
through a £1 million investment, including TV, radio and
print advertising. POS material and educational materials
will be mailed to community
pharmacies. In a consumer
trial of 3,000 Nourkrin users,
90 per cent noticed a visible
improvement in their hair
after six months. Approved
by EFSA, Nourkrin contains a
drug-free formulation called
Marilex, which contains substances similar to those found
naturally in the scalp.
. More product news on p39
PHARMACY MAGAZINE APRIL 2014 25
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FORUM
THE BIG
DEBATE
YOUR COMMENTS
Where do you stand on
pharmacies selling
e-cigarettes?
Email [email protected]
Should we
be stocking
e-cigarettes?
E-cigarettes are one of the most controversial products
ever to hit pharmacy shelves – but do they belong
there? Chris Chapman investigates
BACKGROUNDER
Regardless of where you stand
on the e-cigarette issue –
and it’s certainly a hugely
controversial issue that has
divided pharmacy – there’s
little doubt that they’ve taken
the UK by storm. E-cigarettes
have hit the shelves in Boots,
LloydsPharmacy, Tesco,
Superdrug and Asda and,
increasingly, independent
pharmacies are getting in
on the act too.
According to market research
company IRI, the e-cig market
in the UK is worth a staggering
£100m in just traditional
pharmacy and grocery outlets
alone. And, with pop-up shops,
market stalls and other, less
traditional operators grabbing a
slice of the action, it’s likely the
market value is far higher.
“They are a godsend for
independent grocers,” remarks
IRI’s retail head of strategic
insight Martin Wood, “but e-
cigarettes are still a pin-prick
in the tobacco market.”
The market
Context is key. The £100m seen
in community pharmacy and
grocery outlets is almost a
match for traditional stopsmoking products (worth
around £125m in the UK) but
only about 5 per cent of the
total e-cigarette market.
However, that is nothing
compared with the tobacco
market, worth anywhere
between £15bn and £25bn
a year.
This growth area is attracting
major players who may be
unwelcome bedfellows on
pharmacy shelves; for example,
Phillips,
pharmacist and contractor, Hertfordshire
YES Graham
I believe community
pharmacy has a bright
future based upon our core
safe-supply role, combined
with medicines optimisation
and public health.
Key to the last of these
is smoking cessation – a
passion of mine since NRT
first went OTC in the 1980s,
at a time when the NHS
abdicated any responsibility
for cessation. My local
primary care group (PCG)
established smokingcessation services more than
10 years ago, and I was the
smoking lead, training local
GPs. So it may surprise you
that I believe pharmacies
should stock e-cigarettes.
I want pharmacy to be the
‘go to’ place for quitting. And
while I’m entirely in favour of
licensing e-cigarettes, if we
26 APRIL 2014 PHARMACY MAGAZINE
wait for licences to be
granted we will have missed
the boat. Consumers – they
don’t see themselves as
patients because they are not
ill – will simply go elsewhere
for the products and we will
lose out, just as we have in
the vitamins and health food
markets.
Let’s have a nationallycommissioned pharmacy
smoking cessation service.
That said, we must remember
not to take a paternalistic
attitude to the public’s health,
or we render ourselves
irrelevant as healthcare
providers. We don’t just
lose the sales; we lose the
opportunity to help people
make healthy choices.
Pharmacy has a wider
tendency to be over-cautious.
We sometimes seem so
worried about not doing
If we wait for licences to be
granted we will have missed
the boat
“
”
Why do we need 100
variations of what is
essentially the same service?
And let’s have a national
NHS PGD for varenicline.
harm that we risk not doing
good. This is the same riskaverse psychology that
allowed nurses to be NHS
prescribers years before
Vype is owned by British
American Tobacco.
“You have to set the
e-cigarette market’s [growth
and] size against the lack of
growth in the OTC market,
and the contracting but
enormous tobacco market,”
Wood explains. “Now the big
boys are muscling in.”
With such heavy hitters –
with heavy advertising budgets
– ready to enter the market,
pharmacists will need to ask
themselves whether they are
comfortable about where their
money goes when they stock
e-cigarettes.
Effectiveness
pharmacists; we lacked
confidence.
Many of us will remember
when NRT could not be
supplied to pregnant women
due to the concern about risk
to the unborn child. This was
looking through the wrong
end of the telescope. The
question we should have
asked then was: “Which
is safer in pregnancy: continuing to smoke or using NRT?”
Today’s question should be:
“Which is safer – smoking or
e-cigarettes?” It’s a nobrainer.
Another thorny issue is that
of effectiveness. Currently
e-cigarettes are not health
products regulated by the
MHRA and make no claims
about helping smokers to quit.
Yet advocates are clear that
they consider e-cigarettes a
reduced-harm option that can
help people quit smoking for
good. This is a situation only
likely to be compounded by
the EU’s Tobacco Products
Directive, which will see
e-cigarettes not sold and
regulated as medicines classed
as tobacco products.
The problem is that, as yet,
the evidence doesn’t support
26-27_Debate_PM_0414_liz_rt.qxp:26-27_PM_0414 10/04/2014 16:26 Page 27
FORUM
“
This
growth area
is attracting
major players
who may be
unwelcome
bedfellows
on pharmacy
shelves
Johnson,
senior medicines information pharmacist, Newcastle-upon-Tyne
NO Hayley
Selling cigarettes for
the treatment of asthma
was not, with hindsight,
pharmacy’s greatest
moment. But sell them
we did, and they were,
staggeringly, a pharmacy
staple until 1985.
Of course, we know now
that smoking cigarettes is
more likely to significantly
worsen asthma than treat it,
thanks to the emergence of
robust, scientific research
and consensus. Asthma
cigarettes are now
an interesting – if
embarrassing – part
of pharmacy history.
Could e-cigarettes be
leading the profession
down a similarly dangerous
path? At the moment, we
just don’t have enough
research to know for
certain. We can reasonably
theorise that they are
probably safer than
cigarettes, but without
good, robust safety and
efficacy data, we simply
don’t know.
”
this concept. Last month a
longitudinal analysis of 949
smokers, of whom 88 were
using e-cigarettes, was
published in JAMA Internal
Medicine. It found that although
85 per cent of smokers using ecigarettes reported using them
to quit, they were no more
successful in their quit attempts
than non-users a year later.
The dilemma
The question facing the
profession is whether they
have any place in community
glycol and other excipients
known to be harmful
through inhalation are
present in many e-cigarette
products, and their longterm safety is unknown.
Under what circumstances can we sell these
products in a pharmacy?
They aren’t regulated as
medicines, so we can’t
make any claims that they
act as nicotine replacement
therapies. We are therefore
selling them for recreational
use. Is this a suitable
precedent to set for
pharmacy? It leaves us
The more we know about
e-cigarettes, the less rosy the
picture is looking
“
medical literature. Poisons
centres worldwide are
dealing with cases of
accidental nicotine
poisoning due to ingestion
of nicotine refills. Propylene
pharmacies today – or whether
we wait to see what the MHRA,
and the evidence, says.
”
in an awkward ethical
situation.
While e-cigarettes are
undoubtedly a useful
product for many – there is
a vociferous, passionate
Effectiveness and concerns
about their safety aside, there
is a clear consumer demand
for the products that shows
absolutely no signs of lessening.
And while major tobacco
companies are taking over the
market, this is ultimately a
side issue: there is little doubt
e-cigarettes are less harmful
than traditional tobacco
cigarettes themselves.
Are all the cries of
“probably safer” and “maybe
more effective” enough for
us as a profession to hang
our hats on?
The more we know about
e-cigarettes, the less rosy
the picture is looking.
Several studies have
suggested that they often
contain different levels of
nicotine to that claimed.
A small German study
suggests they may cause
indoor air pollution.
Cases of fatal ingestion
of e-cigarette refill liquid
have been emerging in the
community supporting their
use – their unregulated
nature is limiting their
promise. As healthcare
professionals, we should
be vocally supporting the
need for research before
encouraging their wider
adoption by the public.
At the moment, the
e-cigarette situation leaves
us with more questions
than answers. We should be
demanding the evidence
before we throw ourselves
headlong into another
potential asthma cigarette
situation.
COMMENTARY
The ultimate NRT?
By Darush
Attar-Zadeh,
smoking cessation
trainer and clinical
leader for the
respiratory pathway
redesign project
at Barnet CCG
TABLE 1. E-CIGARETTES – THE CURRENT STATE OF PLAY
Company/organisation
Policy
When?
Asda
Boots
British Medical Association
Co-operative Pharmacy
LloydsPharmacy
NPA
NICE
Stocks
Stocks
Regulate
Stocks
Stocks
Regulate
Against
MHRA
Morrisons
Rowlands
RPS
Sainsbury’s
Superdrug
Tesco
Regulate
Stocks
Stocks
Regulate
Stocks
Stocks
Stocks
Introduced April 2013, now in 90 per cent of stores
Introduced February 2014 – Puritane only
Supports regulation and ban in public spaces
Introducing products April 2014
Introduced December 2013, initially in 20 per cent of stores
Supports regulation
Recommends NRT due to lack of evidence on safety and
effectiveness as a stop-smoking aid
Supports regulation; will licence from 2016
Introduced April 2012, now in 99 per cent of stores
Vype only
Supports regulation; seeking a consensus
Introduced July 2012, now in 99 per cent of stores
Introduced, first as trial, 2012, now in 98 per cent of stores
Introduced end of 2012, now in 99 per cent of stores
Data: IRI UK
Are e-cigarettes the ultimate NRT? They certainly could tick a
lot of boxes that help smokers to stop or reduce their cigarette
usage since they have the capacity to raise the blood level of
nicotine quickly (by at least 10ng/ml in 10 minutes), they
come in a formulation that avoids local side-effects and they
incorporate sensory properties and behavioural rituals of the
kind that help to make cigarette smoking so attractive.
Sales of e-cigarettes are growing at an exceptional rate. If,
ultimately, this leads to more people quitting smoking or reducing
harm, then it has to be a positive outcome. But there
are a few things that concern me about e-cigarettes:
• They could be seen as undermining the smoke-free policy by
confusing the issue of what is and isn’t allowed indoors
• They could normalise vaping (especially among the young)
and may be a precursor to smoking
• Selling e-cigarettes in pharmacies may give the public the
impression that they are safe and tested.
If we are selling these items, then it’s very important we are
able to discuss the technique, dose, side-effects, cautions,
contra-indications and duration of course. We can do this with
licensed treatments because they have gone through rigorous
clinical trials. So I look forward to a day when we can start
recommending licensed e-cigarettes that don’t undermine
our smoke-free legislation.
PHARMACY MAGAZINE APRIL 2014 27
28_Therapeutic Update_PM_0414_rt.qxp:28_PM_0414 07/04/2014 15:07 Page 28
CLINICAL PRACTICE
THERAPEUTIC
UPDATE
LEARNING OBJECTIVE
After reading this article you should be able to:
• Appreciate the important role pharmacy teams
can play in ensuring patients are able to use their
asthma and COPD inhalers correctly
Is your technique
letting you down?
What chance do patients have to manage their asthma
and COPD properly when most healthcare professionals
are unable to demonstrate how to use inhalers correctly?
Mark Greener reports
EFFECTIVE MANAGEMENT of
asthma and chronic obstructive
pulmonary disease (COPD)
depends on good inhaler
technique. Yet despite a
proliferation of devices – most
recently the dry powder inhaler
(DPI) Relvar Ellipta – patients
often experience problems that
undermine the effectiveness of
these potentially lifesaving
therapies. To add to their woes,
most healthcare professionals
don’t get the technique right
either. Now a new initiative aims
to tackle this pervasive problem.
Numerous studies highlight
the scale of the problem posed
by poor inhaler technique.
One review reported that only
between 23 and 43 per cent of
patients got all the steps right
when using a metered dose
inhaler (MDI). Just 55-57 per
cent of those using a spacer
with a MDI and 53-59 per cent
of those using a DPI performed
all the steps correctly1.
Moreover, 10-15 per cent
of people aged 20 to 40 years
made a mistake using their DPI
that affected the amount of drug
they inhaled. This proportion
increased to 40 and 60 per cent
among people aged more than
60 and 80 years respectively2.
They are not alone. According
to Rita Bali, a pharmacist and
executive development officer
for Cambridgeshire and
Peterborough LPC, 90 per cent
of healthcare professionals
(HCPs) cannot demonstrate
inhaler technique correctly to
their asthma and COPD patients.
A recent study revealed that
just 7 per cent of 150 HCPs in
primary and secondary care –
including doctors, nurses and
community pharmacy staff –
got all seven steps needed for
correct MDI technique right and
showed appropriate, objectively
28 APRIL 2014 PHARMACY MAGAZINE
Rita Bali
measured, inspiratory flow. Only
9 per cent of the 113 HCPs who
said they taught inhaler technique could demonstrate all
seven steps3.
“Time and time again, poor
inhaler technique emerges as an
GPs, respiratory nurses and
community matrons – on the
Isle of Wight received training in
inhaler technique. Community
pharmacists who received MUR
payments trained patients.
After training, emergency
admissions for asthma fell by
50 per cent (41 to 20 over three
months) and deaths by 75 per
cent, from eight to two over
the same time.
(To put these figures into
context, the Isle of Wight’s
population is around 142,000.)
Initial results also suggested
that prescriptions for selective
beta-agonist and corticosteroids
declined by 25 and 5 per cent
respectively – trends that seem
to be continuing4.
90 per cent of HCPs cannot
demonstrate correct inhaler
technique to their patients
“
issue in the sub-optimal care of
people with asthma or COPD,”
says Monica Fletcher, chief
executive of the charity
Education for Health. “Inhaler
technique often gets forgotten,
particularly when time is
limited. Indeed, with so many
people typically involved with
the care of patients, many
HCPs think that someone else
has trained the patient. So
community pharmacists and
their staff have a vital role in
improving inhaler technique.”
”
Against this background, a
new programme developed
by Napp Pharmaceuticals and
Education for Health aims
to both train HCPs in correct
inhaler use and work with
CCGs to audit outcomes.
During the training programme, Education for Health
“concentrates on what’s
happening at a local level” and
Training to make
a difference
Effectively and efficiently
training patients and
professionals is essential to
enhance inhaler technique
and improve outcomes.
Recently, for example, multidisciplinary teams – including
Monica Fletcher
INTEGRATED APPROACH IN PETERBOROUGH
An ongoing project in Peterborough is developing an integrated approach to asthma management between hospital and
community. After patients are discharged from hospital following
a severe asthma attack, community pharmacists perform regular
MURs to check inhaler technique. Initial results should be
available later this year. “I really hope we’ll see that we prevent
readmissions due to poor inhaler technique,” says Rita Bali. “I also
hope the project will help hospital and community teams to work
more closely together to help people with asthma and COPD.”
prioritises teaching on inhalers
that are in local formularies,
says Monica Fletcher. Teaching
sessions cover all the devices
on the market, not just those
sold by Napp. The meetings
also look at ways to optimise
the effectiveness of local
primary healthcare teams,
such as the interaction between
practice nurses and pharmacists. That said, there’s a lot
of ground to cover.
There are currently around
15 inhaler devices available and
still more to come to market,
says Monica Fletcher. “I believe
we need innovation,” she says,
“but with so many available,
it will get more and more
confusing for HCPs and patients
alike. The hope is, one day,
a company will develop the
perfect device but it seems we’re
not there yet. So pharmacists
and other HCPs need to understand and be able to teach how
to use a range of inhalers.”
Rita Bali agrees that
community pharmacists need
to keep up to date about the
various inhaler devices.
“Pharmacists should be the
experts on new medicines.
They should understand the
subtle nuances of the different
devices.” Community
pharmacists should use this
expertise to aid the development
of local formularies, she adds.
Piloting a new course
in inhaler training
Pilot programmes with community pharmacists started last
December in Gateshead,
and Cambridgeshire and
Peterborough CCG (see panel).
“Community pharmacists
generally have more contacts
with patients than any other
HCP,” Rita Bali told Pharmacy
Magazine, “so they are ideally
placed to demonstrate inhaler
technique to their patients.
We received very good feedback
from the participants.
“The meeting was oversubscribed and we plan to run
further training sessions. There
is definitely an interest in
improving knowledge about
inhaler technique and a recognition that intervention by
community pharmacists can
make a difference.”
Monica Fletcher adds that
a pharmacist or other HCP
should sign off on the patient’s
management plan that he
or she has received inhaler
technique training – something
pharmacists could do during
MURs or when counselling
patients when they receive a
new device.
“Checking inhaler technique
improves the quality of the
intervention without adding
a burden to community
pharmacists,” says Rita Bali.
Patients’ ability to use an inhaler
correctly gradually declines, so
community pharmacists should
check patients’ technique “as
often as possible, and certainly
at least annually”, she says.
Monica Fletcher believes
companies should offer more
placebo inhalers and says HCPs
also need anatomical teaching
aids (e.g. images of lung
deposition) to show the
importance of the correct
inhaler technique. She also
believes there is a growing role
for technology, such as an
iPhone app that ensures people
use the inhaler correctly by
recording the breathing sound.
“Patients often don’t realise why
good inhaler technique is so
important,” she comments.
“It is essential to ensure that
asthma and COPD patients get
the most benefit from drugs. A
HCP wouldn’t start a patient on
insulin without explaining how
to use a pen device. GPs, nurses
and pharmacists need to take
inhaler use much more seriously.”
REFERENCES
1. Health Technology Assessment
2001; 5:26
2. Lancet 2010; 376:803-13
3. Thorax 2010; 65:A117
4. Pharmacy management 2009;
25(3):15-19
29-32_Headache_PM_0414_rt.qxp:29-32_PM_0414 08/04/2014 13:29 Page 29
HEADACHE & MIGRAINE
Key facts
• Migraine affects 8m people
in the UK
• Some pharmacy staff
lack confidence when it
comes to recommending
sumatriptan
• People who take painkillers
on a regular basis are
at risk of developing
medication overuse
headache
“
Migraine is
under-diagnosed
and under-treated
in at least half of
patients
By Francesca Robinson
Head hunter
Which? showed that pharmacy
staff are not offering migraine
sufferers adequate advice.
So how can they get ahead?
MOST HEADACHES, including migraine, although debilitating
for the sufferer, aren’t serious and can be treated with OTC
remedies and self-care.
However the recent Which? report found that nearly a quarter
of pharmacy staff, in particular medicine counter assistants, were
unsure about the sales procedure for OTC sumatriptan (Imigran
Recovery) and the advice they should be offering migraine
sufferers. In some cases the mystery shoppers, posing as ideal
candidates for the medication, were unnecessarily referred to
their GP.
Other research shows that migraine is under-diagnosed and
under-treated in at least half of patients and that one-third of
sufferers will experience significant disability as a result of their
migraines at some stage of their lives. Such research demonstrates
how crucial it is that pharmacy staff understand the type of
headache a customer has and the best treatment to recommend.
“The pharmacy team needs to be able to feel confident about
recommending migraine treatments based on what is best for the
patient,” says community pharmacist Sultan Dajani. “If they are
unsure, then this is something they should do as a CPD point.
Having Imigran Recovery as an OTC medication and not using it
is a waste for patients in terms of their quality of life – and it is
also a waste of a POM to P switch.”
LEARNING
OBJECTIVES
After reading this feature
you should be able to:
• Recognise the different
types of common
headache
• Accurately identify
migraine
• Recommend the most
appropriate treatments
and offer self-care
advice for migraine
and headache
While there are around 200 distinct types of headache,
95 per cent are due to four types of treatable disorders:
• Tension-type headache
• Migraine
• Cluster headache
• Medication overuse headache.
These types of headaches are known as primary headaches
(i.e. they are based on symptoms and are not due to an underlying
health problem).
Another category is secondary headaches (i.e. those headaches
that have a distinct cause). This category includes headaches
associated with a head injury, stroke, substance misuse and/or its
withdrawal (including alcohol), infection and disorders of the neck,
eyes, nose, sinuses or teeth.
Dr Mark Weatherall, consultant neurologist at Charing Cross and
Ealing Hospitals and a trustee of the Migraine Trust, says: “Primary
headache disorders are by far the commonest type of headache.
If you start from the basis that patients are sufficiently troubled to
actually seek advice about their headache rather than just take
tablets at home, then the most likely reason that they are seeking
advice in the pharmacy is that they have a migraine.”
Migraine affects 8 million people in the UK, mostly adults aged
35-45 years, but it can affect all ages including children. Migraine
is commoner in women – affecting 18 per cent of women
compared to just 8 per cent of men.
How to identify migraine
Migraines are experienced as a headache of at least moderate
severity, usually on one side of the head, accompanied by other
symptoms such as nausea, vomiting, and sensitivity to light and
noise. The headache is usually made worse by physical activity.
Migraines usually last from four to 72 hours and in most cases
there is complete freedom from symptoms between attacks.
PHARMACY MAGAZINE APRIL 2014 29
29-32_Headache_PM_0414_rt.qxp:29-32_PM_0414 08/04/2014 13:30 Page 30
THE PRINCESS MARGARET MIGRAINE CLINIC CHARING CROSS HOSPITAL/SPL
HEADACHE & MIGRAINE
Certain factors are involved in triggering an attack in those predisposed to migraine. These can include lifestyle and hormonal
changes.
There are several types of migraine:
• Migraine with aura is when there is a warning sign before the
migraine begins. About a third of people with migraine have this.
Warning signs may include visual problems (such as flashing
lights) and stiffness in the neck, shoulders or limbs
• Migraine without aura
• Migraine without headache, also known as silent migraine. This
is when an aura or other migraine symptoms are experienced,
but a headache does not develop.
Episodic migraine (defined as fewer than 15 headache days a month)
is the commonest migrainous condition and can occur at any time.
Frequency can vary between one attack a year to one a week.
Chronic migraine is defined as more than 15 headache days a
month over a three-month period, of which more than eight are
migrainous. Those afflicted are classified as chronic sufferers.
This type of migraine affects less than 1 per cent of the population.
The most basic way to diagnose migraine is to identify a
recurrent headache with certain features. Migraine should
comprise:
• At least two of the following symptoms: unilateral pain,
throbbing pain, aggravation by movement, moderate or severe
intensity
• At least one of the following symptoms: nausea/vomiting or
photophobia and phonophobia.
A pharmacist can make a migraine diagnosis if the patient has an
established pattern of migraine.
Migraine treatments
The main non-prescription migraine treatment options are
analgesics and sumatriptan.
Analgesics
Analgesics, such as paracetamol, NSAIDs (aspirin, ibuprofen and
diclofenac) and combined analgesics containing paracetamol or an
NSAID with codeine, can be used as first-line treatment to relieve
the pain of the migraine headache. There are also treatments that
can be combined with paracetamol, such as buclizine and
prochlorperazine to treat the nausea as well as the headache.
If the patient is nauseous a soluble painkiller may be
recommended as these are absorbed quicker from the stomach.
When to recommend analgesics
Analgesics can be recommended:
• For the first three attacks of migraine unless the initial attacks
are very severe and disabling
• If the customer has previously used analgesics and is happy with
the relief they provide
• For customers who have not been diagnosed with migraine.
When not to recommend analgesics
Analgesics should not be recommended:
• If the treatment has failed on three occasions
• If a woman is pregnant (refer to doctor)
30 APRIL 2014 PHARMACY MAGAZINE
About a
third of people
who suffer
with migraine
have aura
“
• Refer to doctor and do not give NSAIDs to a customer who has
ulcers or a history of bleeding in the stomach or intestines,
anaemia, high blood pressure, or kidney, liver or heart disease
• Be cautious when recommending NSAIDs to asthmatics
• Be alert to a patient who might be chronically overusing
analgesics or addicted to their properties and consequently
suffering from medication overuse headache.
“The first general principle for migraine is to recommend that
patients take an [appropriate] dose of whatever painkiller they are
going to take as early as possible when they feel an attack coming
on,” says Mark Weatherall. “People sometimes have a tendency to
take, say, 500mg of paracetamol two hours into an attack and will
then get only a mild or partial response.
“With simple analgesics, that means taking paracetamol 1g or
[the maximum dose of] ibuprofen. People should not take more
than 1,200mg ibuprofen in a day or 900-1,200mg of aspirin a day.
As well as advising on an adequate dosage of analgesics, the
pharmacist should also ask questions about nausea and, if needed,
recommend an anti-emetic.
“Although medication containing codeine is widely advertised
and available for treating migraine I would always advise
pharmacists to be cautious about recommending opiates because
there is quite a high chance of people becoming dependent on
them or developing medication overuse headache. I spend a lot
of my working life getting people off codeine.”
Triptans
Triptans (e.g. sumatriptan) are generally recommended to sufferers
if ordinary painkillers are not helping to relieve their migraine.
They relieve pain by narrowing blood vessels in the head and
blocking the transmission of pain in the sensory nerves that supply
the skin and structures of the face. As well as relieving the pain
associated with migraine, sumatriptan also relieves nausea and
sensitivity to light.
The OTC triptan Imigran Recovery (sumatriptan) has replaced
its pre-sale two-page questionnaire with a simpler sales protocol
that can be used as a reference for pharmacy staff.
When to recommend sumatriptan
Sumatriptan can be recommended:
• For customers with an established and stable pattern of migraine
• For customers who have failed to obtain relief from OTC
analgesics on three occasions
• If the initial attacks are very severe and disabling.
When not to recommend sumatriptan
Sumatriptan should not be recommended to:
• Those under 18 or over 65 years of age
• Pregnant or breastfeeding women (refer to doctor)
• Customers with heart problems or with a family history of heart
problems
• Customers who have had a stroke
• Customers with high blood pressure
• Customers with kidney, peripheral vascular or liver disease
• Customers with epilepsy or who are prone to fits
• Women taking combined oral contraceptives (refer to GP).
When to refer...
Red flag symptoms associated with headache include:
• Frequent or severe headaches that come on suddenly
• Anyone complaining of the following symptoms: unilateral muscle weakness,
double vision, tinnitus, clumsy and uncoordinated movement and reduced level of
consciousness, weakness of muscles controlling eye movement, along with a headache
lasting a week or more
• A headache following an accident, in particular a head or neck injury
• Anyone experiencing blackouts
• Headaches brought on with every cough, sneeze, bend or by standing up
• Weakness, numbness or slurred speech
• Anyone with a headache lasting longer than 24 hours
• Additional features such as seizure-like movements, a rash or a headache confined
to the back of the head
• Headaches that frequently wake someone from sleep
• Anyone whose migraine attack occurs for the first time after 50 years of age
• Anyone diagnosed with high blood pressure
• Recent marked deterioration in migraine (duration, severity or frequency)
• Women with migraine using the combined oral contraceptive pill.
31_PM_0414:31_PM_0414 14/04/2014 10:25 Page 1
A
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29-32_Headache_PM_0414_rt.qxp:29-32_PM_0414 08/04/2014 13:31 Page 32
HEADACHE & MIGRAINE
“If a customer has been previously diagnosed with migraine
and in the absence of any other neuro symptoms or injury I would
have no qualms about recommending sumatriptan as a first-line
treatment because taking other painkillers might just be delaying
the inevitable,” says Sultan Dajani. “It is a perfectly safe
medication, the side-effects are very rare and the worst case
scenario is that it won’t work. If that is the case, then it’s a sign
the patient needs to see their GP.”
With cluster headaches the pain is always unilateral and,
although for some people the side can vary from time to time,
it is usually centred over one eye, one temple or the forehead.
It can spread to a larger area making diagnosis harder. Cluster
headaches occur in clusters for four to 12 weeks around the same
time of year. The pain is often experienced at a similar time each
day. Such patients should be referred to the GP.
Migraine and self-care
Medication-induced headache, the third commonest cause of
headache, is the result of taking painkillers too often. Up to one
in 50 people experience headaches caused by medication overuse
and women are five times more likely to get them than men.
NICE guidance advises pharmacists to be alert to the possibility
of medication overuse headaches in people whose headache
developed or worsened while they were taking the following drugs
for three months or more:
• Triptans, opioids, ergots or combination analgesic medications
on 10 days a month or more
• Paracetamol, aspirin and a NSAID, either alone or any
combination, on 15 days a month or more.
Such patients should be referred to the GP.
Martin Underwood, a GP and professor of primary care research
at Warwick Medical School, who chaired the NICE guideline on
the diagnosis and management of headache, says: “Treatment
involves stopping medication abruptly with the headache getting
much worse for several weeks before it will improve. When talking
to people about a headache it is important to warn them to
prevent medication overuse.”
Medication overuse headache
Pharmacists have a key role to play in educating migraine sufferers
on how to bring their condition under control and take preventive
action between attacks to help avoid migraine altogether.
Triggers for migraine attacks can vary from one person to
another and sufferers should be advised to keep a migraine diary
to try to identify the causes. It is likely a combination of triggers
will cause a migraine attack.
Triggers can include:
• Certain foods (e.g. cheese and chocolate) and drinks containing
caffeine and alcohol
• Emotional stress
• Menstrual periods
• Changes in normal sleep pattern
• Extreme fatigue
• Skipping meals and fasting
• Sudden changing weather conditions
• Exercise
• Smoking
• Bright and flickering lights
• Odours
• Medicines such as the combined oral contraceptive pill,
hormone replacement therapies and sleeping tablets.
The misery of migraine...
• Image on p30 shows a single photon emission tomography image
of the brain in a patient during an attack of classical migraine.
Migraine diary
headache & migraine
4HEAD
Described as a completely different way to treat headaches, 4head
is applied directly to the forehead targeting the pain relief just
where it is needed, says DDD. Containing levomenthol as its active
ingredient, 4head works to block headache pain signals and relax
the muscles in the head associated with tension headaches, says
the company. (Tel: 01923 205704)
Commonest types of recurring
headache
Tension headache
Tension-type headaches are the most commonly occurring. The
pain is often described as feeling like a tight band around the head
or a weight on top of it. The neck or shoulder muscles may also
hurt and the pain can last from 30 minutes to several days, or may
be continuous.
Stress is one cause, but others may include drinking too much
alcohol, not getting enough sleep, depression, skipping meals and
becoming dehydrated.
Whereas migraine can be identified as a headache with associated features, such as nausea and sensitivity to light, people
experiencing headaches without features are likely to be suffering
from the tension variety.
These headaches can be treated with OTC painkillers such as
ibuprofen and paracetamol. Self-care advice could include learning
relaxation techniques, avoiding stressful situations where possible,
using hot and cold packs to relax the muscles in the head and
neck, or massaging the affected areas.
cpd resources
• NICE guidance on diagnosis and management of headache in young
people and adults (http://publications.nice.org.uk/headaches-cg150)
• Imigran Recovery support package for pharmacy staff:
www.imigranrecovery.co.uk
A migraine diary should record:
• When the migraine started and ended
• The symptoms
• Whether it’s a throbbing or piercing pain
• Where the pain is
• Any other medication taken prior to the attack
• Amount of sleep prior to the attack
• Food eaten recently
• Any recent exercise.
“Migraine is a complex disorder with very individual symptoms
and triggers,” says Dr Nicholas Silver, consultant neurologist at the
Walton Centre, Liverpool. “That’s why it is important for sufferers
to understand their condition and what triggers attacks so they
can get the best out of their healthcare professional. The most
successful migraine management plans rely on a foundation of
good lifestyle and effective treatment.”
KOOL‘N’SOOTHE
SOLPADEINE
Many migraine sufferers find
cooling relief to be of benefit
during a migraine attack.
Kool‘n’Soothe Migraine are
soft gel sheets that need no
refrigeration and are ready to
use straight from the pack. Each
gel sheet will stay in place on
the forehead delivering eight
continuous hours of cooling
relief. (Tel: 0208 987 9976)
The Solpadeine
line-up includes a
wide range of pain
solutions to address
different customer
needs. Pharmacy training for the brand includes
on and off-line training tools aimed at refreshing
pharmacy knowledge on the pain management
category. The Omega Pharma online training portal
can be found at www.omegapharmatraining.co.uk.
Face-to-face training and in-store POS materials
to support customer selection are also available.
([email protected])
Cluster headache
IMIGRAN
Cluster headaches are one of the most painful conditions an
individual can experience and are even more debilitating than
migraine. They are excruciatingly painful headaches, which cause
an intense pain around one eye.
A relatively rare condition affecting one or two people in every
1,000, cluster headaches are often misdiagnosed as migraine or
sinus headache and subsequently mistreated.
Imigran Recovery has replaced its pre-sale two-page
questionnaire with a simpler sales protocol reminder
as part of a new and improved support package for
pharmacy staff. The support pack also features an
A5 flowchart which can be used as a reference tool, a
treatment pathway tool, a pharmacy training module and
a consumer information booklet. (Tel: 0844 243 6661)
32 APRIL 2014 PHARMACY MAGAZINE
33-35_Animal Health_PM_0414_CR_rt.qxp:33-35_PM_0414 08/04/2014 16:05 Page 33
ANIMAL HEALTH
Pet
peeves
Key facts
• The number of pets in the
UK increased by 4 million
from 2012 to 2013
• Lyme disease and
lungworm infections
are on the rise
• Vets are treating more pets
for accidental poisoning
By Charlotte Rixon
Britain may be a nation of animal lovers,
but pet health awareness could be
higher. This ought to give pharmacists
pause for thought...
Animal welfare
According to the latest PDSA Animal Wellbeing (PAW) report, there
are 7.8 million pet dogs, 9.5 million pet cats and 1 million pet
rabbits in the UK, with nearly half of households having a pet.
Figures from the Pet Food Manufacturers’ Association (PFMA)
show that the total pet population (excluding fish) increased by
4 million in just one year, from 67 million in 2012 to almost 71
million in 2013.
Under the Animal Welfare Act 2006, pet owners have a ‘duty of
care’ to ensure that they meet their pets’ five welfare needs:
• A suitable environment
• A suitable diet
• The need to express normal behaviour
• The need to live with or apart from other animals
• Protection from pain, suffering, injury and disease.
However the PAW report found that just 38 per cent of people
who keep a pet are aware of this legislation, while over a quarter
undertook no research into the costs and obligations of pet
ownership before acquiring a pet. “People should do their
research before getting a pet,” advises PDSA senior vet, Elaine
Pendlebury. “Find out how much exercise a dog needs and make
sure you are not allergic to pet dander. It is not fair on the animal
if you take it on and discover you can’t provide for its needs.”
Preventative healthcare
Practising preventative healthcare, including regularly checking
for and treating parasitic infestations, is an essential part of
animal welfare, yet only 63 per cent of owners surveyed in the
PAW report thought that preventative healthcare could extend an
animal’s life – and 6 per cent had reduced spending on it since
the start of the recession, potentially affecting nearly 1 million
animals.
So what is the current advice for preventing and managing
parasitic infestations in pets?
LEARNING
OBJECTIVES
After reading this feature
you should be able to:
• Help pet owners
minimise the risks
of zoonosis
• Remind owners to
correctly treat pets
for infestations
• Raise awareness of
the risks of poisoning
in pets
PET OWNERSHIP in the UK continues to rise despite the recent
recession, with most pet owners agreeing that ours is a nation
of animal lovers. Yet due to misinformed choices and lack of
awareness of preventative healthcare, vets and animal charities
are concerned that the welfare needs of many pets are being
compromised.
For example, preventative treatments, such as regular defleaing
and worming, are not only essential for animal welfare but also
reduce the risk of potentially serious zoonoses – infections that
are transmitted between vertebrate animals and people.
With an estimated 500,000 pet owners visiting community
pharmacies every day, pharmacists have a responsibility to raise
awareness of the importance of preventative healthcare in pets,
as well as providing sensible, but not alarmist, advice on reducing
the risk of zoonotic diseases.
UNHAPPY BUNNIES ...
The PDSA (People’s Dispensary for Sick Animals) is concerned that
many rabbits are at risk of serious conditions like myxomatosis
and flystrike, because they are often bought for young children,
on a whim or as a result of ‘pester power’, without considering the
responsibility involved.
Myxomatosis
The myxoma virus is transmitted to rabbits via fleas and other
biting insects, including mites and mosquitoes, and can also pass
directly between rabbits. The first sign of myxomatosis in unvaccinated rabbits is runny eyes and swollen genitals. The disease
rapidly progresses, causing severe conjunctivitis, blindness, lumpy
swellings on the head and body, and death after around two weeks.
Treatment is usually futile and serves only to prolong the
animal’s suffering, so euthanasia is usually recommended.
Vaccinated rabbits usually develop a milder, treatable form of
the disease but the PDSA is concerned that less than half of all
pet rabbits may be vaccinated against myxomatosis and viral
haemorrhagic disease – another preventable, deadly disease.
Rabbits in households where there is also a cat or a dog, or in
rural areas with wild rabbit populations, are most at risk. Besides
ensuring that their pets are vaccinated, rabbit owners are advised
to fit insect screens to outdoor hutches and runs and eliminate
standing water from gardens.
Flystrike
During the summer months rabbits are vulnerable to flystrike.
This is caused by flies laying eggs on the rabbit’s fur, which hatch
into maggots that eat the animal’s flesh. The problem is associated
with dirty living conditions, so regularly cleaning hutches and
runs is essential. It’s also important to check under the tail for
signs of flystrike at least twice a day in summer.
PHARMACY MAGAZINE APRIL 2014 33
33-35_Animal Health_PM_0414_CR_rt.qxp:33-35_PM_0414 08/04/2014 16:07 Page 34
ANIMAL HEALTH
Fleas
According to Stephen Goddard, Frontline veterinary surgeon, one
in five cats and one in 10 dogs have fleas at any given time – yet
around half of owners are unaware that their pet has an infestation.
“Unprotected pets can pick up fleas from the garden, park or an
infested home – wherever wild animals, stray cats or unprotected
pets have been,” he says.
Flea infestations can result in intense itching and scratching,
leading to inflammation, fur loss and secondary bacterial infections.
Animals with flea allergy dermatitis (FAD), due to an allergic reaction
to antigens in flea saliva, can develop severe irritation and inflammation from a single bite, while heavy infestations can lead to lifethreatening anaemia in puppies and kittens. Furthermore, fleas carry
the risk of tapeworm infestations because tapeworms spend part of
their lifecycle inside fleas.
Symptoms and treatment
Signs of a flea infestation include scratching, biting and grooming
more than usual, and inflamed skin. Fleas or flea dirt may also be
visible on the coat, while owners may notice insect bites on their
own skin. However cats and dogs should be treated for fleas
throughout the year, even if they have no signs of infestation.
“Any gap in treatment can allow fleas and ticks to survive and breed
on your pet, which may also allow a home infestation to develop,”
says Goddard.
NFA-VPS licensed flea treatments include ‘spot-on’ products
containing fipronil, which spreads around the body, killing fleas
within 24 hours and ticks within 48 hours, and is suitable for use on
cats and dogs, but not rabbits. Imidacloprid offers an alternative to
fipronil that is suitable for rabbits, but does not kill ticks.
Animals should be defleaed at least once every three months,
at the same time as worming although, for optimum flea control,
Goddard advises using fipronil every four to five weeks on cats,
and every one to two months on dogs.
It is vital to administer the correct product and dosage according
to the animal’s species, age, weight and health status. All pets in the
same household should be treated together, while animals with FAD
require specialist veterinary treatment.
Frequent vacuuming, washing pet bedding above 60 degrees and
using a household spray containing an insect growth regulator will
help reduce the problem.
TOXIC HAZARDS
The PDSA has reported an increase in accidental pet poisoning cases in recent years, with vet referrals
to the Veterinary Poisons Information Service (VPIS) rising by 73 per cent between 2002 and 2009.
The charity lists the top five commonest causes of accidental poisoning in pets as:
• Incorrect use of flea treatments in cats (using too much or using treatments intended for dogs)
• Rat and mouse poisons
• Human medication such as paracetamol
• Slug and snail killer
• Antifreeze.
On a daily basis vets see cases where owners have inadvertently poisoned their cats with permethrinbased flea treatments intended for dogs. “The margin of toxicity with permethrin in cats is very small,”
says PDSA senior vet, Elaine Pendlebury. “Even coming into contact with a dog that has been treated
with permethrin can be dangerous.”
The wrong medicine
Most human medicine poisoning cases occur when owners give paracetamol or ibuprofen to their pets in
a misguided attempt to relieve their pain, or when pets consume human medicines that have not been
safely put out of reach. In particular, paracetamol is highly toxic to cats because they lack the enzymes
to break it down. While vets do prescribe human medicines to pets when there is no specific animal
equivalent, it is important to stress to pet owners that all medicines they use on their pets should either
be licensed for use in that specific animal or given in accordance with their vet’s instructions.
Poisonous perils
Ticks
Ticks are small parasitic mites that commonly live in damp shaded
areas like woodland and rough grassland, but can also be found
in urban parks and gardens. A recent study in the journal Medical
and Veterinary Entomology found that at any one time nearly
15 per cent of dogs are infested with ticks. A single tick may go
unnoticed, but a heavy infestation can cause pain and anaemia.
Elaine Pendlebury advises dog owners to check their dog’s fur
carefully all over with rubber gloves after walking in wooded areas,
as well as checking their own skin and clothing. Ticks can be
difficult to remove, as their mouthparts can remain embedded
in the skin, which may lead to irritation and infection. The PDSA
recommends seeking a vet’s advice initially regarding the correct
removal technique. Special devices for removing ticks are available.
Lyme disease
Ticks carry the threat of infectious diseases, including Lyme disease,
the commonest vector-borne disease in Europe. The Health
Protection Agency (HPA) says there has been a 300 per cent increase
in the number of reported human cases in the UK since 2001.
The first symptom is usually a circular rash (erythema migrans),
which expands over several days or weeks. Infected individuals may
also experience flu-like symptoms, such as headaches, tiredness and
Rat and mouse poisons and slug and snail killer pose obvious hazards, while antifreeze contains
ethylene glycol, which tastes pleasant to dogs and cats but causes kidney damage. In addition, chocolate
can poison dogs due to the toxic effects of theobromine, with vets seeing an increase in cases around
Easter, while all parts of the lily plant can cause kidney failure in cats. Pet owners should contact their
vet immediately if they suspect their pet has been poisoned and should never ‘watch and wait’.
“
The welfare
of many pets
is being
compromised
joint pain and, without treatment, may develop neurological
symptoms and heart problems. According to Elaine Pendlebury,
the reasons behind the rise are unclear. “It could be due to climate
change, increasing deer populations or the rise in popularity of
outdoor activity holidays, or it could be simply that diagnosis has
improved,” she says.
Being ‘tick aware’ by sticking to footpaths and covering up with
long clothing in wooded areas, as well as regularly treating pets for
external parasites, can reduce the risk of infectious diseases.
Worms
Two types of parasitic worm (helminth) affect cats and dogs –
roundworm (nematodes) and tapeworm (cestodes). Animals pick up
the former by consuming dead animals or sniffing faeces containing
their larvae, while they become infested with the latter through
swallowing infected fleas during grooming.
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34 APRIL 2014 PHARMACY MAGAZINE
Available to
download via Apple
App Store and Google
Play for all devices.
33-35_Animal Health_PM_0414_CR_rt.qxp:33-35_PM_0414 09/04/2014 16:00 Page 35
ANIMAL HEALTH
Worm infestations can cause diarrhoea and vomiting, poor
condition and weight loss. Infested puppies and kittens can become
malnourished, and in some cases, worms may be present in vomit
or faeces, but there are often no obvious signs in adult animals.
The commonst roundworm, Toxocara canis, presents a zoonotic risk
(toxocariasis), which in rare cases can cause blindness.
“Worm eggs can survive in the soil for up to three years; they are
very resilient and can endure cold temperatures, so it’s important
to be sensible, always pick up after your dog, and don’t let your
dog lick your face,” urges Elaine Pendlebury. “Children should be
encouraged to wash their hands thoroughly before eating and after
playing outdoors.”
Lungworm
Another type of nematode that is becoming increasingly common
in the UK, and which can cause life-threatening health problems in
dogs, is the lungworm
Angiostrongylus vasorum.
Dogs become infected by
ingesting slugs, snails or frogs
(intermediate hosts to the
lungworm larvae) or from
contact with soil contaminated
with fox faeces.
Infestation signs include
coughing, tiring easily, excessive
bleeding from even minor
wounds, anaemia, appetite loss,
vomiting and diarrhoea. If dog
owners suspect that their dog
has been infected with
lungworms, they should seek
urgent help from their vet.
Regularly washing food and
water bowls and bringing in
dog toys from the garden may
help to reduce the risk.
Pet care in pharmacy:
opportunity knocks
Pet healthcare continues to provide a significant opportunity to community pharmacy.
The total UK animal medicines market is estimated to be worth £530m, with companion
animals making up 56 per cent of the share.
“Appropriate training for registered SQPs (suitably qualified persons) can reduce any
apprehension regarding selling animal medicines over the counter, and pharmacists can
then provide a knowledgeable pet advice service that will gain new and repeat business,”
says Frontline veterinary surgeon Stephen Goddard.
Most of the leading animal health manufacturers provide training materials for
pharmacy staff, such as the ‘Pharmacy Pet Healthcare’ training series from Merial Animal
Health, as well as posters and leaflets for pet owners.
Treatment
The British Small Animal
Veterinary Association (BSAVA)
recommends that dogs and cats
be wormed at least every three
months, while young puppies
and kittens require more
frequent treatment under
the supervision of a vet.
As with flea treatments,
owners should ensure they
follow the manufacturer’s
instructions carefully to ensure
they administer the correct
dose for the animal’s species,
age, size and weight.
Toxoplasmosis
Another parasitic infection,
which is common in cats and
presents a zoonotic risk, is
toxoplasmosis. The infection
is caused by the protozoa
Toxoplasma gondii, which can
be picked up from food or soil
contaminated with cat faeces,
undercooked meat and
unpasteurised goat’s milk.
There is also a small risk of
infection during the lambing
season.
The infection rarely causes
any symptoms in cats or people;
however it can have serious
complications in immunocompromised individuals and
pregnant women who have
not previously been infected.
Nevertheless the risks are
low and can be minimised by
good hand hygiene and avoiding
cat litter.
PHARMACY MAGAZINE APRIL 2014 35
36-38_Sport_PM_0414_rt.qxp:36-38_PM_0414 09/04/2014 11:29 Page 36
SPORT & FITNESS
Pull the other o
Knowing how to advise customers to avoid, treat and manage a range of sports injuries
correctly can help them steer clear of long-term muscular pain and joint damage
A WORRYINGLY HIGH percentage of people simply ignore
niggling sports injuries or treat them incorrectly, according to
a new survey carried out by Lanes Health. The survey found that
men are three times more likely to injure themselves playing sport
than women (27 per cent versus 9 per cent), and that a fifth of
UK adults injure themselves playing sport and leave the injury
untreated.
According to the survey, the commonest injuries that put people
out of action for a fortnight or more are:
• Backache (15 per cent)
• Muscle strains (9 per cent)
• Muscle inflammation (7 per cent)
• Neck ache (6 per cent).
So how are these injuries caused in the first place? “Sprains and
strains happen when muscles or ligaments are overstretched,
when competing for the ball, making a sudden stop or changing
direction sharply,” says Matthew Jamieson, senior product
manager at Mentholatum, “while injuries such as tennis elbow,
shin splints, stress fractures or runners’ knee problems are typical
of injuries that occur when too much is done too soon. They may
happen when someone starts exercising or playing sport after
doing little or nothing for some time.”
Most sprains and strains can usually be treated with self-care
such as the PRICE technique (protection, rest, ice, compression
and elevation), and should improve within six to eight weeks –
although severe muscle strains may take longer. However leaving
an injury untreated can lead to “a once fixable problem having
long-term, serious implications,” warns GP and medical
broadcaster Dr Sarah Jarvis.
While painkillers can be used to help ease any discomfort, advise
customers to see their GP if they are in severe pain or if their injury
is either not improving or getting worse.
LEARNING
OBJECTIVES
After reading this feature
you should be able to:
• Explain the causes of
the commonest sports
injuries
• Advise customers on
how to prevent them
in the first place
• Identify which
therapies and OTC
remedies might help
relieve symptoms
Jogger’s nipple
Another common condition – not just experienced by runners –
is the obviously named jogger’s nipple. This is caused when the
nipples are irritated by chafing against clothing during physical
activity. Again, taking a break from running will give the nipple
time to heal and an antiseptic cream can help treat the irritation
and prevent infection.
Shin splints
Anyone taking part in strenuous exercise that involves impact
or a lot of stopping and starting (e.g. long-distance running,
tennis and basketball) can suffer from shin splints – the general
term for exercise-induced pain at the front of the shins.
The commonest cause is medial tibial stress syndrome (MTSS),
which is the result of frequent and intense periods of exercise
when the body is not used to it. According to NHS advice, it is
important that sufferers don’t continue to exercise in case the
pain is a sign of an injury to the bone and surrounding tissues.
Customers should be advised to take a break from load-bearing
exercise for at least a fortnight and to speak to their GP if the
problem persists.
Tennis elbow
Tennis elbow (lateral epicondylitis) is a self-limiting condition
usually caused by overuse of the muscles attached to the elbow
that straighten the wrist, leading to pain around the outside of the
elbow when bending, extending or lifting the arm. If these muscles
and tendons are strained, tiny tears and inflammation can
develop near the bony lump (the lateral epicondyle) on the
outside of the elbow.
Despite its name, tennis elbow is caused by
any activity that places repetitive stress
on the elbow, such as playing
the violin or decorating,
as well as racquet sport.
Avoiding the activity
should help the
symptoms to
improve, as will
applying a
cold or gel
compress
to the area.
Running obstacles
With April the start of marathon season, it’s important that runners
look after their joints as well as their muscles. Acute knee injuries
include runner’s knee (patellofemoral pain syndrome), which
is caused by the impact of running irritating the site where the
patella rests against the femur, resulting in sharp or dull pain
and swelling.
“Knee injury can increase the chances of developing and
aggravating osteoarthritis in many people,” warns fitness expert
and personal trainer Kristoph Thompson, so anyone experiencing
knee pain should “allow enough time for full recovery and seek
advice [from their GP] if symptoms persist.”
“
A fifth of UK adults injure themselves
playing sport and leave the injury untreated
”
36-38_Sport_PM_0414_rt.qxp:36-38_PM_0414 09/04/2014 11:30 Page 37
SPORT & FITNESS
r one
Warming up and cooling down
By Sasa Jankovic
Paracetamol can help with the pain and ibuprofen will reduce any
swelling, but customers should consult their GP if the condition
persists.
Feet first
All kinds of activities can lead to blisters, which are the skin’s way
of protecting itself from excessive heat, moisture and friction.
Although painful, most blisters will heal on their own unless
they become infected, but they can be easily prevented in the first
place by covering tender spots with a friction-resistant dressing
or plaster. If they do occur, then specialist blister plasters, which
claim to aid rapid healing by absorbing the fluid, protecting skin
from bacteria and helping relieve the pain of friction and pressure,
can be used.
Remind customers who have diabetes to be particularly vigilant
when checking for blisters, as their foot injuries take longer to heal
due to poorer blood circulation.
Key facts
• Many UK adults do not
know how to deal with
sports injuries
• Leaving an injury
untreated can lead to
long-term problems
• Prevention and self-care
are important in maintaining sports health and
fitness
Swimmer’s ear
Another painful condition afflicting swimmers is swimmer’s ear, or
otitis externa, which causes inflammation of the external ear canal
between the outer ear and eardrum.
Most cases are caused by a bacterial infection, although
swimmer’s ear can also be caused by irritation, fungal infections
and allergies. Repeated exposure to water can make the ear canal
more vulnerable to inflammation. Symptoms include ear pain,
itchiness in the ear canal, discharge of liquid or pus from the ear,
and some degree of temporary hearing loss.
Customers should see their GP, who will prescribe ear drops
or even antibiotics. Remind them to avoid inserting cotton wool
buds and other objects into their ears as this can damage the
sensitive skin in the ear canal. They should also avoid getting
water, soap or shampoo into their ears during bathing while
the infection clears up.
Regular swimmers should take a break from the pool until the
symptoms pass and then consider using ear plugs or wearing a
swimming cap to cover their ears when swimming to avoid further
infections.
Verruca assault
Staying on the subject of feet, don’t forget verrucas – often caught
from the wet floors in changing rooms and swimming pools –
which manifest as warts growing up into the soles of the feet with
a black dot in the centre surrounded by a harder, white area.
It is common to have more than one verruca at a time, and they
can become more painful the longer they are left. Up to 80 per cent
resolve themselves within about two years, but OTC treatments
can treat verrucas much faster.
Advise customers to use such treatments with care as they are
generally tissue destructive. Many contain salicylic acid, which
breaks down the verruca, so they should not be applied to healthy
skin, which can be shielded with petroleum jelly or surgical tape.
Cryotherapy treatments that freeze the verruca are also available
over the counter, but again all surrounding healthy tissue must be
protected.
If your customers would rather not tackle verrucas themselves,
recommend they see a podiatrist.
Joint action
Joints can also benefit from a bit of ongoing care and attention,
as Kristoph Thompson explains. “Injury can occur when a joint
is taken outside of its comfortable range of motion, so stronger
stabiliser muscles and increased flexibility lessen the likelihood
or severity of an injury.
“Maintaining a healthy weight can also be beneficial on joints.
One study claimed that losing about a pound of weight delivers
almost a four-pound reduction in knee joint load for each step.”
Managing pain
Athlete’s foot
Regular exercisers and gym-goers also increase their risk of
another common foot condition – athlete’s foot (tinea pedis).
Athlete’s foot is caused by the Trichophyton fungus, which thrives
in warm, moist environments (e.g. sweaty trainers) and can be
picked up from changing room floors.
Symptoms include itching or burning and flaking skin,
particularly between the toes, although the whole foot can be
affected. The condition can be treated with products containing
fungicidal or fungistatic ingredients. Making sure the feet are
completely dry after washing; regularly changing footwear and
wearing cotton socks can help ensure feet are less fungus-friendly.
Just as a Formula One driver warms up his tyres before he begins
racing, so sports players at every level should not expect their body
to perform as well as it can when ‘starting from cold’, says Matthew
Jamieson. “It is essential to make time to get the blood circulating
in your muscles and to stretch those ligaments that you will soon
be putting under stress.”
Ideally, you should spend 15 or 20 minutes warming up and
stretching before the game or training session starts, he says.
“It is also important to be sensible and, especially if you have
not taken much exercise for a while, to build up slowly to more
strenuous activity.”
DID YOU KNOW?
Ankle sprains account for
an estimated 1.5 million
visits to UK hospital accident
and emergency departments
each year, according to
nhs.uk.
“Topical analgesics are a popular and effective treatment for the
sprains, strains and knocks that are part and parcel of playing
sport – but it is crucial that the appropriate product is chosen for
the needs of each individual,” says Matthew Jamieson.
“For example, when someone has suffered a sprain or strain,
it should be treated with a cold or freeze product for the first 72
hours to help reduce swelling and inflammation and only when
this period is over should heat be used to help increase blood flow
to the affected area bringing oxygen, proteins and other nutrients
to help promote healing.”
Cold and heat therapies can be as simple as using a pack of
frozen peas in a damp cloth or a hot water bottle on the affected
area but these are not always practical, adds Matthew, “which is
why many turn to topical analgesics as a convenient option, with
a choice of rubs, sprays and patches that combine ease of use with
effectiveness.
“Topical NSAID products that offer an anti-inflammatory action
together with pain relief are another option to help with muscle
and joint aches and pains arising from sports injuries.”
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PHARMACY MAGAZINE APRIL 2014 37
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SPORT & FITNESS
Gyms and health clubs are not everyone’s cup of tea, but there are
many other exercise alternatives that people can do by themselves,
or with friends, that don’t need expensive equipment or lots of
training to take part in.
The key to getting active – and sticking at it – is finding
something that a person enjoys and can easily build into their
lifestyle. Joining up with a ‘fitness buddy’ to keep them company
can also help maintain motivation.
Diet and movement specialist Joanna Hall, one of the UK’s
leading fitness and walking experts and co-founder of the
Walkactive initiative that encourages people to incorporate more
walking into their day, is an advocate of simply putting one foot in
front of the other.
“Walking is simple, easy, and just about anyone can do it,” she
says. “Some people are sceptical about many of its benefits, but
there is no disputing the research. Walking at the right pace and
with the right technique can reduce the risk of many diseases and
painful conditions. Whether someone is completely new to fitness,
wants to firm up, lose excess pounds, or just get fitter and
healthier, walking is perfect, has few side-effects and can be done
by almost anyone, anywhere.”
Cycling is another effective way to burn calories and increase
cardiovascular fitness, as well as being an environmentally-friendly
mode of travel that can save time and money.
“Cycling has many more health benefits than you think,” says
Claire Beaumont, Evans Cycles’ fitness expert. “We all think of it
as an alternative mode of transport but the workout you get from
cycling helps keep you fit without realising it and is so much better
for your wellbeing.”
THROW AWAY THE GYM MEMBERSHIP...
SPORT & FITNESS
DEEP FREEZE
GOPO
Results of a study published in
the British Journal of Sports
Science show that the natural
anti-inflammatory, painkilling
effects of GOPO could benefit
active people, says Lanes Health.
Researchers found that just 12
weeks’ supplementation with
GOPO decreased joint pain,
improved the quality of joint
movement, and could prevent
the degeneration of joint tissue
and cartilage. (Tel: 01452
507458)
Mentholatum is running a
10-week campaign of adverts,
promotions and sponsorship
on XFM, The Rock, indie and
alternative music radio stations. Research shows
listeners are more likely to participate in sport. Sports bulletins on the
weekday breakfast and drive shows will be sponsored by Deep Freeze
and there will be core messages delivered at the weekend when
listeners, who are likely to be playing or getting ready to play sport,
have the chance to win sport-related prizes. (Tel: 01202 780558)
ARNICARE
Many injuries can be avoided by warming
up and doing stretches immediately before
and after physical activity. Nelsons
Arnicare arnica cooling gel combines the
benefits of arnica with the refreshing
sensation of natural grapefruit oil and
menthol. The gel is perfect to massage into
muscles following physical exertion or to
revive tired, heavy legs, says Nelsons.
(Tel: 0208 780 1290)
Sports supplements
While it remains important to follow a varied and balanced diet
and healthy lifestyle, some people believe that sports supplements
have a role to play in boosting their performance and recovery, and
helping them avoid injury.
“Exercise puts added strain on the body, such as the immune
system, muscles and heart,” says Dr Carrie Ruxton from the
Health Supplements Information Service. “While a balanced, high
carbohydrate diet with plenty of fluid should be the cornerstone
of any advice, dietary supplements can also help those taking part
in regular exercise.”
According to Dr Ruxton, examples include:
• Multinutrient supplements, which deliver recommended
amounts of vitamins and minerals. These are useful as research
shows that intakes of vitamin D, iron, calcium, selenium and
magnesium are low in the general population, especially women
• Omega-3 fatty acids and antioxidant nutrients (e.g. vitamins C
and E, selenium) help to reduce inflammation and may help
muscle soreness
• Vitamin C, vitamin D and zinc are proven to support immune
function and may reduce the duration of respiratory illnesses
• Products high in nitrates, such as beetroot and spinach, have
been shown to boost endurance performance
• Products containing caffeine which, if taken before endurance
sports such as marathons or long cycle races, can reduce fatigue
and improve alertness
• Creatine supplements can help build muscle and improve high
intensity exercise (e.g. weight lifting, sprinting).
“The Self Care Forum factsheets suggest that patients should
visit their pharmacy for help in treating minor problems,” adds
Matthew Jamieson, “and pharmacists and counter staff should
be ready with advice to help them make the appropriate choices
[and] have a selection of lines from trusted manufacturers to give
customers a good choice of market-leading products.”
With self-care being strongly promoted to the general public
at the moment, now is the ideal time to not only encourage your
customers to find a form of exercise that they enjoy, but also to
remind them there is much they can do to look after themselves
while they do it. (See also this month’s CPD module on promoting
physical activity and exercise, starting on p17.)
FURTHER INFORMATION
• Self Care Forum factsheets: www.selfcareforum.org/fact-sheets
• Health Supplements Information Service: www.hsis.org
• Walkactive: www.joannahall.com/index.php
38 APRIL 2014 PHARMACY MAGAZINE
BAZUKA
Bazuka offers a range of treatments for verrucas
and warts including Bazuka Gel (P) and Bazuka
Treatment Gel (GSL) – both with the original
formulation. Also available are Bazuka Extra
Strength (P) and Bazuka Extra Strength Treatment
Gel (GSL), which contain twice the amount of
salicylic acid as the original formulation. For
those looking for a freeze treatment, there’s
Bazuka Sub-Zero. (Tel: 01923 205704)
MENTHOLATUM
As many as 22m sporting injuries are suffered in the
UK each year, most commonly sprains and pulled
muscles, says senior product manager Matthew
Jamieson. “Mentholatum is the expert in muscle and
joint care and the Deep Freeze and Deep Heat ranges
allow sports injury sufferers to treat their minor
injuries effectively with products that can take them
from the moments after a sprain or strain through the
healing and recovery period and right back onto the
pitch or track.” (Tel: 01202 780558)
TENA
One in four women experience light bladder weakness while
exercising and playing sport, according to a recent survey for
lights by TENA. The range of liners is specifically
designed to ensure women experiencing light
bladder weakness feel fresh and confident, even
when exercising, says the company. At 3.5mm
thick, each liner offers discreet protection,
locking moisture away from the body for
all-day comfort. (Tel: 0870 333 0874)
MAXINUTRITION
#FeedYourMuscles is a new £5m advertising
campaign from GlaxoSmithKline to promote
the benefits of its protein-based sports
nutrition range, Maxinutrition. The TV advert
uses real people training across a range of
sports to demonstrate how Maxinutrition
products improve performance and
recovery and includes the tagline:
‘You, Stronger’. It is supported by
experiential, print and online advertising.
The Maxinutrition range includes
products suitable for every level of
exercise. Tel: 0870 240 8602
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TEAM TRAINING
pharmacist
support column
Team Tuesday is a chance for your pharmacy team
to learn together. On the first Tuesday of the month
after Pharmacy Magazine and Training Matters
arrive in-store, get together for a training session
based on selected content in the magazines. This
support column is designed to help pharmacists
structure and lead a Team Tuesday training session.
SUBJECT: HAY FEVER
This column provides pharmacists with a training resource for
support staff.
REFLECTION
• Can the pharmacy team explain the advantages and disadvantages of the different types of hay fever product for a
customer’s specific symptoms (e.g. blocked nose, itchy eyes)?
• Do I know which hay fever remedies are suitable for pregnant
women?
• Is the pharmacy team confident to advise on how to use
hay fever remedies effectively (e.g. timing, dose, frequency)?
• Is the team confident in its ability to pass on tips on hay fever
symptom reduction/prevention?
• Are we confident in our advice on how to use nasal sprays
and eye drops?
• Do we stress the importance of compliance?
TRAINING CHECKLIST
Ensure your support staff understand the following key points:
• The incidence of hay fever and other allergies is increasing
• Which oral antihistamines are most or less likely to cause
drowsiness
• The importance of the pollen count
• Which products suitable for hay fever are licensed for
customers under the age of 18 years
• Specific lifestyle tips for customers with hay fever
• Hay fever can develop in people with asthma
• Hay fever can result in complications such as sinusitis
• When to refer customers with hay fever to the pharmacist.
ACTION. I WILL:
• Consider how we can raise awareness of starting hay fever
prevention before symptoms start
• Ensure that the pharmacy team is up to date on the role of
drug-free treatments for hay fever
• Train my pharmacy assistants to ensure that they can meet
the points in the training checklist.
PRACTICE POINTS
• Do a Google search for phone and tablet apps for pollen
forecasts and allergy. Discuss their quality and usability with
the pharmacist. Which one(s) might you recommend?
• What is non-allergic rhinitis, what causes it and what can be
recommended to treat it?
TEAM TUESDAY: LEARNING TOGETHER
STOCKCHECK
Juvela improves its
cookies
Dioralyte back
on TV screens
Juvela has reformulated
and improved its
range of low
protein cookies.
While the
cookies are still
available in choc-chip, cinnamon and orange
flavours, the flower-design has been replaced with
a more traditional shape. The new-look cookies are
chunkier, have a lighter crisper texture and an
improved flavour, says Juvela. ACBS approved,
the low protein cookies come in boxes of 12 (125g),
containing two individual trays of six. A box retails
for £7.62.
Dioralyte is back on TV during
April and May with 10- and 20second ads appearing on a range
of mainstream TV channels,
such as ITV1 and Channel 4.
“We are excited to be relaunching our TV ad campaign
this spring,” says consumer brand manager Eleonore
Baco, “and we hope this support will continue to
generate increased sales…by communicating the
brand’s key messages and increasing awareness among
non-users.” The ad campaign follows a couple through
common life stages and highlights product usage in
different scenarios.
Juvela 0800 783 1992
Refer to this month’s Team Tuesday focus feature in Training
Matters on hay fever and work through the training exercises
and quiz questions together with your team.
The answers to the MCQs are: 1.d 2.a 3.d 4.b 5.c 6.a
PRODUCTS
Ceuta Healthcare:
01202 780558
BUSINESS BRIEFING
Avoiding pension pitfalls
The pension landscape is changing and employers
can be fined if they fail to comply, warns Heather Chandler
The Government has for some time been concerned that people are not saving enough for their
retirement and has moved from the concept of
employees being able to choose to join a pension
scheme to one of automatic enrolment.
Since October 2012, larger businesses have been
required to automatically enrol eligible employees
into a pension scheme and pay a minimum level
of pension contributions for each employee. By
February 2018, every employer, no matter how
small the company, will be subject to the same
obligations.
Generally speaking, employers with between 50
and 249 employees will have staging dates (to join
auto-enrolment) between April 2014 and April
2015. Employers with fewer than 50 employees
will be subject to the requirements between April
2015 and April 2017. New businesses have staging
dates at the end of the timetable.
The pensions regulator will notify every
business of its staging dates. Following their
staging date, they must register with the regulator.
There are penalties for non-compliance.
Who is covered?
Those covered by the auto-enrolment rules include
permanent, fixed-term and temporary employees,
as well as agency workers. The self-employed will
not be subject to the requirements. Employees
already enrolled into a qualifying scheme through
their workplace will remain in that scheme and
the duty of auto-enrolment will not apply in
respect of them. A sole trader who does not
employ anybody else is not affected.
Workers fall into different categories depending
on age and earnings, and the obligations on
employers differ accordingly. Employees between
the age of 22 and state pension age, who earn over
the income tax threshold, are ‘eligible jobholders’
who must be automatically enrolled into a scheme
at the staging date (or on later joining the
business). The employer is required to pay
contributions into the pension scheme in respect
of these employees.
Those earning below the income tax threshold
but above the lower earnings limit, and those
earning above the lower earnings limit but who do
not meet the age criteria, will be able to opt into
the scheme should they wish. If they do opt in, the
employer must also pay contributions for them.
What if employees do not want
to be enrolled?
For those employees who do not want to be
enrolled, the process demands that they must first
be automatically enrolled into the scheme before
being allowed to opt out. They must then be
automatically re-enrolled every three years.
Finding a scheme to join
To implement the new system, a firm can use an
existing occupational or personal pension scheme
if it meets certain statutory requirements; set up
a new scheme; or enrol employees in the National
Employment Savings Trust (NEST), a new central
scheme set up by the Government.
The pensions regulator suggests businesses
allow 12-18 months to prepare for auto-enrolment.
There is a fixed penalty of £400 for noncompliance and there are other financial
penalties, including escalating penalty notices of
£50 to £10,000 a day, depending on employee
numbers.
Information
www.nestpensions.org.uk
www.thepensionsregulator.gov.uk
Heather Chandler is a partner in the pensions
team at Shoosmiths LLP
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. © Groupe Eurocom Ltd. Colour Repro by Truprint Media, Margate. Printed by Grange Press, Brighton.
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