ITK August/September 2016 - Issue 49 by Gold Cross Products & Services

ISSUE #49 : AUGUST/SEPTEMBER 2016

P R A C T I C A L I N F O R M AT I O N F O R T O D A Y ’ S CO M M U N I T Y P H A R M A C I S T

IN THE KNOW

• CPD - ANTICOAGULANTS IN ATRIAL FIBRILLATION

• PROBING INTO PROBIOTICS

• CPD - QUANTIFYING THE CUSTOMER EXPERIENCE

• SUCCESSFUL SUCCESSION

• DIABETES COMPLICATIONS

• WOMEN AND ORAL HEALTH

The Art of Innovation

Service. Efficiency. Workflow.

ITK magazine had the opportunity to speak with 3 Australian Pharmacists about the process they followed & benefits gained from implementing an automated system.

Service. Zamil Solanki, owner of Terry White Chemists Mt Gravatt Plaza found that “more openness and improved ability to communicate with the pharmacist” was crucial to customer satisfaction. For this reason, service became the main focus of Zamil’s automation efforts.

Terry White Chemists, Mt Gravatt Plaza, Brisbane READ MORE NEXT PAGE

Efficiency. Already operating an incredibly busy pharmacy, Peter Moschakis, owner of Gaslight Pharmacy felt he needed to improve the efficiency of his practice. He recognized efficiency as the key benefit he gained from the introduction of automation into his pharmacy.

Gaslight Pharmacy, Rose Bay, Sydney. READ MORE PAGE 26

Workflow. We spoke with Noel Fosbery, owner of Friendlies Pharmacy, Falcon. Pharmacy workflow was the main issue that Noel wanted to address by automating his pharmacy. “I wanted things to be done right, and only done once.”

Friendlies Pharmacies, Falcon, Perth. READ MORE PAGE 28

BUSINESS

Innovate or Die? Service. Efficiency. Workflow. JACK MATSON IS OFTEN QUOTED FROM HIS BOOK INNOVATE OR DIE: A PERSONAL PERSPECTIVE ON THE ART OF INNOVATION. WHILE THE MAJORITY WOULD AGREE THAT WE DO NOT DIE FROM A LACK OF INNOVATION, AN INABILITY TO INNOVATE IS CERTAINLY DETRIMENTAL TO BUSINESS GROWTH. ACCORDING TO A REPORT PUBLISHED BY GRAND VIEW RESEARCH IN MAY 2016, THE GLOBAL PHARMACY AUTOMATION DEVISES MARKET SIZE WILL REACH $8.99 BILLION BY 2020. GROWING AT A COMPOUND ANNUAL GROWTH RATE (CAGR) OF 7.3%, PHARMACY AUTOMATION INVOLVES AUTOMATION AND MECHANISATION OF TASKS THAT INCLUDE DISTRIBUTION AND HANDLING MEDICATION PROCESSES IN HOSPITALS AND COMMUNITY PHARMACY.

With reductions in dispensary income continuing to impact Australian community pharmacies, the continued drive to improve efficiencies which have a positive impact on the bottom line and can measurably influence customer care, such as staff skills and realignment of staff resources, workflow processes and procedures are paramount. Better customer care, productivity gains, improved customer satisfaction, reduced costs, waste and enhanced safety are other key elements. When automation is discussed, there is a need to effectively recommit staff time to ensure the benefits gained from saving time and space can be calculated. Dose Innovations is an Australian owned and operated company, providing specialist software, technology and machinery to the pharmaceutical market for the past 10 years. In September 2015, the Pharmacy Guild of Australia endorsed the Rowa dispensary system, a system designed to revolutionise the workflow in a standard pharmacy. We had the opportunity to speak with three Australian pharmacists to identify a little about the process they follow and benefits gained from their implementation of an automated system.

READ THE CASE STUDIES NEXT PAGE & PAGES 26-28

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

BUSINESS

CASE STUDY 1

Service.

Terry White Chemists Mt Gravatt Plaza, Brisbane. We spoke with Zamil Solanki, owner of Terry White Chemists Mt Gravatt Plaza. After extensive discussions with his customers, Zamil found that “more openness and improved ability to communicate with their pharmacist” was a crucial factor contributing to customer satisfaction. For this reason, service became the main focus of Zamil’s automation efforts.

EDITOR: WHAT DID YOU INSTALL? ZAMIL: A Rowa Vmax, as yet unnamed, until our Grand Opening where we’ll announce the winner of the client naming competition. Our robot is built-in on two sides, with the third side the operator’s area, and the final side feeding into our DAA room. We were fortunate that we could construct up through the floating ceiling to install a 3.5 m high robot, allowing for a far smaller footprint. The autoloader was a key feature for me. In my opinion, there’s no point installing a robot without an autoloader. My Rowa is a great size — my stock holding has reduced now that it is better managed, plus I have enough space for my predicted future growth. The shelf cleaning module is a nobrainer and a great time saver.

EDITOR: WHY DID YOU AUTOMATE? ZAMIL: Competition in my area is very fierce — we’re surrounded by other pharmacies, so a high level of service is my main method of maintaining a competitive edge. I wanted to remove the pharmacy technicians as “go-betweens”, and allow my pharmacists to interact directly with my customers. We talk about “innovate or die” but I believe it’s imperative to “interact or die”. The days of hiding behind a high bench are long gone. Customers expect high levels of service and they want to be able to talk face to face with the pharmacist. They don’t want to relay a message about their health concerns via an assistant, as that lowers their perceptions of value. As health professionals, we train for four years, learning skills to help people — automation assists us to use those skills. Being able to talk to my customers, means I can discuss the benefits of complementary medicines, offer Meds Checks, Clinical Interventions and maintain the maximum benefit from other 6CPA/PPI initiatives. I have been able to build my scripts on file by about 300% as well as offer SMS reminders. We use software called Healthnotes to manage this, and usage has increased about 400%.

EDITOR: HOW DID YOU PROCEED? ZAMIL: My business partner, Anita, and I spent 18 months investigating, planning, travelling locally and interstate assessing which system would best fit our pharmacy. One of the alternatives might have been OK, but the footprint was our major concern. In our opinion, the floor space and workflow were not optimised.

health professionals that give free advice every day, so we need our customers to see the value in that, rather than just having an expectation. I’ve also changed my staff screening approach as a direct result. I’ve found I need to recruit people that are confident and comfortable talking to customers, because it will form a large part of their role.

We made sure that our chosen shop fitter had previous experience installing pharmacy robots, and working with other contractors — and this made everything so much easier.

I don’t have a stock controller — I’m just waiting for the final POS software upgrade, which will be the final step in fully automating my stock and inventory management.

I love the redundancy of the Rowa systems — how there are always backups, and fail-safes on everything. The Rowa can basically be out of sight, out of mind. And the functionality is awesome; it’s so easy to use, and the after-sales support is fantastic. Those were my deciding factors.

With my Rowa, I’ve been able to consolidate and condense my stock into a much smaller area. Building up through the ceiling, we have released dispensary space to allow more retail space.

EDITOR: WHAT CHALLENGES DID YOU OVERCOME? ZAMIL: We had the normal delays with centre management, builders, shop fitters, plus we were dependent upon the medical centre relocation, so communication during the process was critical to ensure everyone was on the same page regarding my Rowa installation. At first, my dispensary team was a little worried that the robot was likely to replace them. Before we automated, there was no spare capacity in my team at all. Since we automated, I’ve actually increased my staff to take on an extra pharmacist. So our Rowa has given the team enough capacity to talk to customers, and we’re finding customers respond to that. I think having the live feed TV showing the inside of the Rowa is also very important as it allows the customers to interact and engage rather than keeping the robot hidden.

EDITOR: WHAT’S CHANGED? ZAMIL: I centralised my dispensary in the middle of the back wall, rather than the corner, which is apparently the norm. My workflow is one of the biggest changes, as it’s now streamlined and much more effective. We have a system of arrows on the floor, which is based around the airport check-in system. This generates better flow of foot traffic, and there’s no backtracking or double-up. My team’s time is now optimised — we’ve eliminated staff running back and forth between counters, which wastes so much time. Customers now come to the pharmacist rather than the other way around. We are the only

In a perfect world, my income would be 40% from dispensary, 60% retail. Currently I’m sitting at around 60% dispensary, and 40% retail, but we’re pushing hard for 50/50. This would have been harder to achieve if we didn’t have the floor space for the retail displays we have now. Most of all, my Rowa has enabled my staff to talk to customers. Clients perceive value differently — we’ve all heard stories of people asking why it’s taking so long just to stick a label on a box. Having the Rowa pick the stock, allows my team to stay talking to the customers the entire time, adding value with healthrelated discussion, and increasing perceptions of value. We have great feedback about our service levels. Clients often say things like, “Oh my gosh, my script is done already?”

EDITOR: HOW DOES YOUR FUTURE LOOK? ZAMIL: Our industry is facing significant challenges. We need multi-skilled staff in pharmacy, not specialists. On any given day I can be advising about vaccination, medication interactions, maternity problems, infant care, wound care, age-related issues, recommending vitamins, as well as stock management. The list of demands on pharmacy is increasing. If we can divest some of those responsibilities to a robot, then we enable ourselves to do better at our core competency. This puts us in the spotlight, and allows us to demonstrate the skills we spent four years learning at Uni.

NEXT CASE STUDY - PAGE 26

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

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*MPS 2015 DAA Consumer Research Report

Please review the full product information before recommending, available at www.maxigesic.com.au Maxigesic® film coated tablets (Paracetamol 500mg and Ibuprofen 150mg; 10s, 12s, 16s, 24s and 30s) are for the temporary relief of pain and reduction of fever. Do not use if you have asthma or a stomach ulcer. Do not use in children under 12 years or if you have kidney disease. Do not exceed the daily recommended dose. Do not combine with any other Paracetamol or Ibuprofen containing medicines. Always read the label. Use only as directed. Incorrect use can be harmful. If symptoms persist consult your healthcare professional. Patent No. 2005260243.

Call 1800 003 938

mps-aust.com.au TRANSFORMING MEDICATION MANAGEMENT

CONTENTS

AFTER HOURS 72 EXPLORE AUSTRALIA EXPO

BUSINESS

SEAN TUNNY Editor, Gold Cross Products & Services Pty Ltd

WHAT IS GOOD CUSTOMER SERVICE? A common theme across all business including pharmacy is customer service. In working with our front cover partner in the lead up to this edition, a key pillar of their business was defined as service, justifiably and rightfully so. Good customer service is partly defined by the industry, but a large part of how a company defines it will determine what good customer service means to each of us. There are definitely customer service basics that we should be covering. After some research, I determined that there are common touchpoints to good customer support. Many agree that these four points can help form a structure around defining what good customer service is and it certainly has tangible application to pharmacy, particularly in the growing e-commerce age. These factors may seem simple, but actually implementing them in business may take more strategy, time and effort to achieve a truly satisfying customer experience.

14 DO SHOPPERS TRUST SUPERMARKETS? 26 DOSE INNOVATIONS – INNOVATE OR DIE? 30 PHARMACY ALLIANCE – LEADING THE WAY IN TECHNICAL SUPPORT 32 PROFESSIONAL SERVICES — MORE THAN JUST A SIGN 36 MULTI STORE OWNERSHIP FOR PHARMACISTS 38 LEASE 1 – TOP 10 LEASING TIP 40 BEST OF BOTH WORLD 48 8 TIPS FOR SUCCESSFUL SUCCESSION

HEALTH 4 12 18 20 22 34 52 54 58 60 62

GET THE PLATINUM ADVANTAGE WITH MAXIGESIC PREVENTING TYPE 2 DIABETES PROBING INTO PROBIOTICS HELPING SMOKERS, COPD AND ASTHMA SUFFERERS NASAL AND SINUS IRRIGATION FISH OIL FOR HEALTH AFT PHARMACUTICALS – A PATENTED PARACETAMOL AND IBUPROFEN ANALGESIC DIABETES COMPLICATIONS ASTHMA AUSTRALIA – ASTHMA AND ALLERGY HEALTHY BONES ACTION WEEK AUSTRALIAN DENTAL ASSOCIATION – DENTAL HEALTH WEEK

PRODUCT INSIGHT

Transaction transparency;

50 PCCA — VERSABASE

Help the customer help you;

Build trust and the customer will return.

REGULARS

Best Regards,

Sean Tunny Editor - ITK Publications

BROUGHT TO YOU BY:

POLITICAL SUPPORT FOR COMMUNITY PHARMACY

Don’t make customers wait;

Thank you to all contributors and the large number of partners that allow us to present ITK to you each edition.

NEWS

Perhaps most important of all is to is recognize that good customer service encompasses any interaction, online or off, that a consumer or potential customer may have with your pharmacy, and it includes the entire experience, from initial contact to final sale and beyond. In this edition of ITK, we are pleased to present our regular features relating to business, health and professional education.

66 68 70 73 74

INDUSTRY NEWS AND UPDATES 60 SECONDS WITH PRODUCT SPOTLIGHT HEALTH CALENDAR BUSINESS DIRECTORY

CONTINUING PROFESSIONAL DEVELOPMENT 7

ANTICOAGULANTS: OLD AND NEW APPROACHES IN ATRIAL FIBRILLATION 42 QUANTIFYING THE CUSTOMER EXPERIENCE

PLEASE USE THIS PUBLICATION TO KEEP YOUR PHARMACY IN THE KNOW EDITOR:

Sean Tunny 0457 029 052 Email: sean.tunny@goldx.com.au

DESIGN: BOOST Design 0431 609 683 Email: boostdesign@optusnet.com.au www.boostgraphicdesign.com PRINT & Fergies DISTRIBUTION: 07 3630 6500 | www.fergies.com.au

5,678 In The Know Magazine has been independently audited under the AMAA's CAB Total Distribution Audit. Audit Period: 01/04/2015 – 31/03/2016

PUBLISHED BY: Gold Cross Products & Services: PO Box 505, Spring Hill Qld 4004 Contact: Nicole Star Email: production@goldx.com.au In The Know is produced for the information of Australian Pharmacists. The presence of the logo of the Pharmacy Guild does not constitute endorsement of a product. The Pharmacy Guild of Australia accepts no responsibility for claims made by advertisers. Opinions and views expressed in articles do not necessarily reflect those of Gold Cross.

NEWS

Political Support for

Community Pharmacy GEORGE TAMBASSIS National President of The Pharmacy Guild of Australia

“Our message is clear: community pharmacy is not broken. On the contrary, it is one of the parts of our health system that works very well and the political letters of support attest to this.”

NOW THAT THE FEDERAL ELECTION IS DONE AND DUSTED, IT IS WORTH NOTING THE STRONG LEVEL OF SUPPORT FOR COMMUNITY PHARMACY THAT WAS EXPRESSED BY ALL SIDES OF THE POLITICAL BATTLE.

As pharmacists and pharmacy staff go about their daily work, providing an essential service to health care consumers through the provision of medicines, advice and professional programs, it is comforting to know that there is a genuine level of recognition of that work among political decision makers. During the campaign, the Guild sought letters of support for community pharmacy from all sides of politics — just as we have done in all recent Federal election campaigns. This is an important part of our advocacy on behalf of community pharmacy. These letters are an opportunity for political leaders to recognise the role of community pharmacy, and also to give an indication of their policy intentions into the future, some of which may potentially have an impact on the stability and confidence of the sector. The Guild wanted to ensure that its members, their staff and patients are made fully aware of the various policies that could affect their businesses, jobs and health. In what was a very pleasing result, the Guild received election letters from the Liberal Party, the Nationals, the Australian Labor Party, the Australian Greens and the Nick Xenophon Team. The election letters

are enclosed and can also be accessed on the Guild’s website at www.guild.org.au/ advocacy. Based on the letters, it is clear there is strong cross-party support for community pharmacy and enhancing its role in the broader primary health care system. The task, now that the election is over, is to turn this into tangible outcomes for community pharmacies, pharmacists and patients. All the election letters acknowledged the importance of the commitments to the $50 million Pharmacy Trial Program and the $600 million in new and enhanced funding for pharmacy programs that were secured by the Guild in the Sixth Community Pharmacy Agreement. We now have to make sure these commitments are delivered on time and in full. The letters also confirmed that there continues to be strong, cross-party support for the community pharmacy model. There was broad, if not unanimous support for pharmacies being owned by pharmacists. Some of the letters also contained explicit support for the Location Rules, which have been legislated until mid-2020 with the support of all the major Parties.

In the post-election period we also turn our attention to the Review of Pharmacy Remuneration and Regulation. As we have stressed, the Guild fundamentally sees the Review as an opportunity to build on the outstanding contribution that community pharmacies and their highly professional staff already make to the health system. Our message is clear: community pharmacy is not broken. On the contrary, it is one of the parts of our health system that works very well and the political letters of support attest to this. Community pharmacies are providing an increasingly wide range of medication management and primary health care services, working collaboratively with GPs and other health professionals and helping address gaps and unmet needs in the wider health system. And, just by the way, Australia’s system of subsidised medicines and community pharmacy practice is recognised as world leading. All Guild members and supporters of pharmacy are encouraged to give feedback to the Review Panel, supporting the current pharmacy model, recognising the benefits delivered to patients, and supporting a bigger role for community pharmacy in the health system.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

ADVERTORIAL

Get the

PLATINUM ADVANTAGE

MAXIGESIC

with

PHARMACY HAS BEEN BRACING ITSELF FOR POTENTIAL CHANGES TO THE SCHEDULING OF CODEINECONTAINING ANALGESICS FOR SOME TIME, BUT ANOTHER RECENT SCHEDULING DECISION MAY ALSO PROVE SIGNIFICANT IN HELPING TO SET AN EXCITING FUTURE DIRECTION FOR THE ANALGESICS CATEGORY.

PARACETAMOL/IBUPROFEN COMBINATION RESCHEDULING Since early 2014 when Maxigesic became the first Paracetamol/Ibuprofen combination analgesic introduced to the Australian market, Paracetamol/Ibuprofen combination products have been scheduled as Pharmacist Only Medicines which has limited the ability to promote such products as only through recommendation by healthcare professionals. However, from 1 June 2016 Paracetamol/ Ibuprofen combinations of 12 tablets or less have been rescheduled as Pharmacy Medicines and this decision now means that these smaller Paracetamol/Ibuprofen packs can be promoted and advertised directly to consumers.

NEW PHARMACY MEDICINE PACK In light of this scheduling change, a new Maxigesic 12 tablet pack was made available to pharmacies from early July. This pack provides the focal point of a new Maxigesic consumer campaign that commenced this month, which will assist in driving awareness and purchase of this breakthrough combination analgesic. The new Maxigesic 12 pack can now feature prominently on the Analgesics shelf by providing a premium offering for consumers to consider. Further, it is being introduced in the Paracetamol/Ibuprofen category to consumers as a new and compelling addition amongst current options available for pain relief.

NEW EXCLUSIVE PHARMACY GUILD PACK Also, from early July, a new Maxigesic 24 tablet pack was made available, exclusively for Pharmacy Guild members. This larger pack

is the result of a recent partnership between AFT Pharmaceuticals and the Pharmacy Guild of Australia that includes an exclusive deal for Guild members on the 24 pack, and provides a clear opportunity to trade consumers up to the larger Pharmacist Only (S3) pack sizes to improve profitability.

more Paracetamol and 2 times more Ibuprofen than other registered Paracetamol/Ibuprofen combinations at maximum recommended daily dosage, if required*;

•• Maxigesic is also going global — now licensed in 109 countries around the world.

WHY MAXIGESIC? •• Maxigesic is a patented, world-first specific combination of Paracetamol 500mg and Ibuprofen 150mg with no generic alternatives. This combination is exclusive to pharmacies and cannot be replicated by combining individual OTC products;

•• Maxigesic is the only Paracetamol/ Ibuprofen combination analgesic clinically proven to reduce pain levels by at least 32% more than a full daily OTC dose of either Paracetamol or Ibuprofen alone (32.3% lower vs. Paracetamol 4000mg; 35.8% vs. Ibuprofen 1200mg)1,2;

•• Maxigesic is the only combination analgesic that delivers the maximum recommended daily OTC dose of Paracetamol 4000mg and Ibuprofen 1200mg if required;

•• Maxigesic has a simple, flexible dosage regimen of 1–2 tablets every 6 hours, if required, to help patients manage their daily pain. Other registered Paracetamol/Ibuprofen combinations have a maximum approved daily dose of 3 tablets, compared to the maximum daily dose of 8 tablets for Maxigesic;

•• Due to this difference in approved dosage, Maxigesic delivers 2.7 times

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

SUITABLE FOR A WIDE RANGE OF PAIN Maxigesic provides double-action relief for a wide range of acute pain:

•• •• •• •• •• •• •• •• •• •• •• •• ••

Headache; Migraine headache; Tension headache; Sinus pain; Toothache; Dental procedures; Backache; Sore throat; Arthritis; Tennis elbow; Period pain; M uscular pain; Rheumatic pain.

Maxigesic also reduces fever.

CODEINE-FREE ALTERNATIVE With significant changes looming for codeinecontaining analgesics, now is the time to consider how codeine-free alternatives such as Maxigesic can offer a viable alternative within your Analgesics category. Developed specifically as an effective alternative to codeine without the risks of potential misuse and harmful effects, Maxigesic is helping to challenge the perception that codeine should be the primary option of choice for short-term pain relief — something that will prove vital

ADVERTORIAL

to your customers should codeine become a prescription-only product. Helping consumers make the switch to Maxigesic will not happen overnight for a product that until now has been hidden from consumer view as a Pharmacist Only Medicine. But pharmacists can now openly promote to customers a unique combination product that can help stimulate and grow the analgesic category during a time of significant industry change. Maxigesic – pain relief that’s altogether better 1. Healthcare Professionals should review the full Product Information before recommending Maxigesic as a Pharmacist Only Medicine, available at www.maxigesic.com.au

GET THE

Maxigesic® film coated tablets (Paracetamol 500mg and Ibuprofen 150mg; 10s, 12s, 16s, 24s and 30s) are for the temporary relief of pain and reduction of fever. The usual dosage for Adults and Children over 12 years is 1–2 tablets taken every 6 hours with a full glass of water, as required, up to a maximum of 8 tablets in 24 hours. Patients should not take more than 8 tablets in a 24-hour period. Incorrect use can be harmful. Do not use in children under 12 years or if patients have kidney disease. Do not use if patients have asthma or a stomach ulcer. Do not combine with any other Paracetamol or Ibuprofen containing medicines. Contact: AFT Pharmaceuticals Pty Ltd, Sydney, ABN 29105636413.

REFERENCES: * Based on 2 tablets of MAXIGESIC taken every 6 hours over a 24-hour period (8 tablets total). 1 Merry, A. F., Gibbs, R. D., Edwards, J., Ting, G. S., Frampton, C., Davies, E. and Anderson, B. J. (2010). “Combined acetaminophen and ibuprofen for pain relief after oral surgery in adults: a randomized controlled trial” British Journal of Anaesthesia 104(1): 80–88. Result achieved in a trial of postoperative pain relief after removal of 1–4 wisdom teeth using Maxigesic® compared with Paracetamol 4000mg or Ibuprofen 1200mg alone per day in four divided doses. 2 Mehlisch, D. R., Aspley, S., Daniels, S. E., & Bandy, D. P. (2010). Comparison of the analgesic efficacy of concurrent ibuprofen and paracetamol with ibuprofen or paracetamol alone in the management of moderate to severe acute postoperative dental pain in adolescents and adults: A randomized, double-blind, placebo-controlled, parallel-group, single-dose, two-center, modified factorial study. Clinical Therapeutics, 32(5), 882–895. doi:10.1016/j.clinthera.2010.04.022.

PLATINUM ADVANTAGE MORE EFFECTIVE PAIN RELIEF than Paracetamol or Ibuprofen alone1

References: 1. Merry, A. F., Gibbs, R. D., Edwards, J., Ting, G. S., Frampton, C., Davies, E. and Anderson, B. J. (2010). “Combined acetaminophen and ibuprofen for pain relief after oral surgery in adults: a randomized controlled trial” British Journal of Anaesthesia 104(1): 80–88. Result achieved in a trial of post-operative pain relief after removal of 1–4 wisdom teeth using Maxigesic® compared with Paracetamol 4000mg or Ibuprofen 1200mg alone per day in four divided doses. Maxigesic® film coated tablets (Paracetamol 500mg and Ibuprofen 150mg; 10s, 12s, 16s, 24s and 30s) are for the temporary relief of pain and reduction of fever. The usual dosage for Adults and Children over 12 years is 1-2 tablets taken every 6 hours with a full glass of water, as required, up to a maximum of 8 tablets in 24 hours. Patients should not take more than 8 tablets in a 24 hour period. Incorrect use can be harmful. Do not use in children under 12 years or if patients have kidney disease. Do not use if patients have asthma or a stomach ulcer. Do not combine with any other Paracetamol or Ibuprofen containing medicines. Patent No. 2005260243. AFT Pharmaceuticals Pty Ltd | Sydney | ABN 29105636413

Cromo-FRESH

The systematic approach to allergy treatment for

Allergic Eyes

The only preservative-free treatment for allergic eyes in a bottle

Precisely delivers at least 300 sterile drops

Phosphate-free

Delivered through the unique COMOD® multi-dose application system

Suitable for both adults & children

Recommend for use before the expected allergy season to help manage symptoms associated with eye allergies

CROMO-FRESH® (sodium cromoglycate 2% w/v eye drops solution, 10mL bottle) is a Pharmacy Medicine for the treatment of allergic conjunctivitis and vernal keratoconjunctivitis. Prophylactic use may help the management of seasonal allergic symptoms. AFT Pharmaceuticals Pty Ltd, Sydney. ABN 29105636413.

Health Headlines Hartley Atkinson M.Pharm, PhD

Founder & CEO, AFT Pharmaceuticals

www.aftpharm.com

1800 2387 4276

CONTINUING PROFESSIONAL DEVELOPMENT 7 77

ANTICOAGULANTS: Old and New Approaches in

ATRIAL FIBRILLATION TIM ROBERTS Manager, National Intern Training Program Pharmacy Guild of Australia (QLD) B.Pharm (Hons), AACPA, DipBusMgt

ATRIAL FIBRILLATION (AF) AFFECTS APPROXIMATELY 2% OF THE POPULATION, IT IS ONE OF THE MOST COMMON CARDIAC RHYTHM DISORDERS SEEN IN PRACTICE WITH A PREVALENCE OF < 1% OF PATIENTS IN PATIENTS UNDER 60 INCREASING TO 10% IN PATIENTS 80 YEARS AND OLDER1,2. AF CAN HAVE A SIGNIFICANT IMPACT ON QUALITY OF LIFE AND IS INDEPENDENTLY ASSOCIATED WITH AN INCREASED RISK OF STROKE, HEART FAILURE AND DEATH3. ORAL ANTICOAGULANTS PROVIDE SUBSTANTIAL BENEFITS IN AF, PARTICULARLY IN REDUCTION OF STROKE RISK. OVER RECENT YEARS TRADITIONAL ANTICOAGULANT APPROACHES FOR PATIENTS WITH AF HAVE EVOLVED WITH THE AVAILABILITY OF NEWER ORAL ANTICOAGULANTS (NOACS). COMMUNITY PHARMACISTS ARE IDEALLY PLACED TO SUPPORT PATIENTS WITH AF IN MANAGING THEIR ANTICOAGULANT THERAPY, PARTICULARLY IN UNDERSTANDING ADHERENCE AND MONITORING REQUIREMENTS FOR BOTH OLD AND NEW APPROACHES TO THERAPY.

LEARNING OBJECTIVES After reading this article, the learner should be able to: •• Identify relevant and validated tools for assessing thromboembolic and bleeding risks for patients with atrial fibrillation;

•• Recognises the pharmacology and mechanisms of action for anticoagulant therapies;

•• I dentify contraindications associated with NOACs; •• Recognises appropriate dosing protocols for switching from warfarin to NOACs.

Competencies Addressed: 6.1, 7.1, 7.2 Accreditation number: G2016005 This activity has been accredited for 1 hours of Group 1 CPD (or 1 CPD credits) suitable for inclusion in an individual pharmacist’s CPD plan which can be converted to 1 hours of Group 2 CPD (or 2 CPD credits) upon successful completion of relevant assessment activities.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

“For many patients, if well controlled on warfarin there may be no clinical benefit in changing to a NOAC. The main reason for choosing a NOAC in many cases is patient preference (when treatment appropriate), due to the burdensome monitoring and dietary requirements imposed with warfarin therapy.”

SOME AFIB SYMPTOMS May include fluttering or “thumping” in the chest, dizziness and shortness of breath.

ASSESSING STROKE AND BLEEDING RISK IN AF AF itself rarely causes death or serious morbidity except through thromboembolic complications. Consequently, an antithrombotic agent (anticoagulant or antiplatelet agent) is considered mandatory as part of the management in almost all patients with AF. The CHADS2 score is a well validated and widely used means of estimating thromboembolic risk in non-valvular atrial fibrillation. Patients are assigned a risk score between 0-6 and treatment recommendations are applied accordingly (see Table 1).

HAS-BLED is a validated predictive tool for assessing the risk of bleeding in patients with AF6;

•• Hypertension (systolic BP > 160 mm HG);

•• Abnormal liver or renal function; •• Stroke history; •• Bleeding history; •• Labile INR; •• Elderly (age >65); •• Drugs (antiplatelet agent, NSAID or alcohol > 8 units/week).

Bleeding risk should be reviewed at least annually or as risk factors change. However it is 4 Table 1: Prophylaxis of stroke in patients with atrial fibrillation important for patients to understand that in CHADS2 score * Risk level Treatment recommendations most cases, the benefits 0 Low No therapy or aspirin of reduction in stroke risk for patients with AF 1 Moderate Oral anticoagulant or aspirin will outweigh the risk of 2 or more High Oral anticoagulant bleeding.

* CHADS2 score derives from adding the following points: 1 point each for age more than 75 years, hypertension, diabetes mellitus, heart failure and 2 points for previous stroke or transient ischaemic attack.

However, a criticism of CHADS2 is that it lumps together many patients with a moderate score who are clearly not all at the same level of risk. This has led to refinements of CHADS2, one of which is the CHA 2DS2 -VASc score4,5. CHA 2DS2 VASc score ranges from 0 to 9 and assigns the following points5:

•• 1 point each for age 65 to 74 years, female sex, hypertension, diabetes mellitus, heart failure, vascular disease (peripheral arterial disease, complex aortic plaque, or myocardial infarction);

•• 2 points each for age 75 years or more, previous stroke or transient ischaemic attack. A patient’s risk of bleeding is the greatest in the first three months after starting therapy,

ANTICOAGULANTS IN ATRIAL FIBRILLATION

Since the 1960’s, warfarin has been the most widely used anticoagulant for thromboembolic conditions – however a number of new oral anticoagulants (NOACs) with properties that overcome the practical limitations of warfarin have become more readily available. These agents have a more stable pharmacokinetic profile, have no significant food–drug interactions and fewer drug–drug interactions, and can be administered in a standard dose without the need for routine monitoring.

WARFARIN Warfarin inhibits the synthesis of Vitamin K– dependent clotting factors (II, VII, IX, X) and the antithrombotic proteins C and S. Warfarin has an established benefit in prevention of stroke in patients with previous myocardial

infarction and increased embolic risk and patients with non-valvular AF at moderate to high risk of stroke or systemic embolism. Anticoagulation with warfarin does not have to be achieved rapidly. A slow loading course is safe and achieves a stable INR of 2–3 in 3–4 weeks in most people.

NEWER ORAL ANTICOAGULANT AGENTS NOAC drugs have been developed as alternatives to warfarin. The three agents proven in clinical trials are the factor Xa inhibitors rivaroxaban and apixaban, and the direct thrombin inhibitor dabigatran. These all have a rapid onset of action, with full anticoagulation 2–3 hours after oral administration; provide predictable anticoagulation so that there is no need for monitoring; and have few food and drug interactions. There are currently no validated tests to measure the anticoagulant intensity of the newer agents and specific antidotes are not available to reverse their effects5,7. It is difficult to manage bleeding associated with NOACs for this reason, as effects cannot be rapidly reversed as they can with warfarin. Routine clinical monitoring is essential for patients using newer agents, particularly monitoring of renal function due to the excretion pathways of NOACs. Dabigatran: Dabigatran is a direct thrombin inhibitor, the oral formulation, dabigatran etexilate, is a prodrug with low bioavailability (approximately 6.5%) and its absorption in the stomach and small intestine is dependent on an acid environment. To promote this microenvironment, dabigatran etexilate is formulated in tartaric acid-containing capsules8. Esterases found in enterocytes, plasma and the liver rapidly convert dabigatran etexilate to dabigatran. The plasma elimination half-life is 7–9 hours, and 12–14 hours in older people. This

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CONTINUING PROFESSIONAL DEVELOPMENT

permits once-or twice-daily dosing. About 20% of dabigatran is conjugated and excreted via the biliary system. The cytochrome P450 system plays no part in the metabolism of dabigatran and there are no active metabolites. The remaining 80% of circulating dabigatran is excreted unchanged via the kidneys, it is contraindicated in significant renal impairment (CrCl < 30 mL/minute)4,8. Rivaroxaban: Rivaroxaban a direct factor Xa inhibitor which is well absorbed orally and can be given once daily (due to a prolonged effect on factor Xa activity). It is cleared hepatically and renally, and dose reduction is required in patients with moderate renal impairment (CrCl 30â&#x20AC;&#x201C;49 mL/min)4,9. Rivaroxaban is partly metabolised by CYP3A4 and is also a substrate for P-glycoprotein (P-GP). Co administration of drugs that are strong inhibitors of both CYP3A4 and P-GP with rivaroxaban is contraindicated. Like dabigatran, it is also contraindicated in significant renal impairment (CrCl < 30 mL/min)9. Apixaban: Apixaban is an orally administered, direct factor Xa inhibitor. It has high oral bioavailability, and is eliminated by renal and faecal routes. Apixaban was demonstrated

in trials (ARISTOTLE and AVERROS) to be superior to warfarin in terms of stroke prevention, and the rate of major bleeding and haemorrhagic stroke were also significantly lower 10. Apixaban is contraindicated in patients with renal impairment with CrCl < 25 ml/min4.

CHOOSING BETWEEN DIFFERENT ANTICOAGULANTS Several meta-analyses have now compared the NOACs with warfarin therapy in patients with AF, showing that NOACs reduced stroke and other embolic events compared to warfarin, mainly because of reduction in rate of haemorrhagic stroke. Factors to consider when deciding between the NOACs include the patientâ&#x20AC;&#x2122;s likelihood to comply with twice daily (dabigatran, apixaban) versus single, daily (rivaroxaban) treatment, and any concomitant chronic medications that may interfere with the metabolism of the drugs. For practical purposes, the most important interactions are with verapamil and amiodarone, which can increase the circulating concentrations of all three NOACs4. For many patients, if well controlled on warfarin there may be no clinical benefit in changing to a NOAC. The main reason for

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choosing a NOAC in many cases is patient preference (when treatment appropriate), due to the burdensome monitoring and dietary requirements imposed with warfarin therapy. Caution should be taken in patients taking warfarin who have difficulty in maintaining correct dosing regimens if considering switching to a novel oral anticoagulant. Because of the shorter half-life of the novel oral anticoagulants, a missed dose is more likely to cause a significant or complete loss of antithrombotic effect14. Pharmacists are well placed to assist patients in understanding the importance of adherence with anticoagulant regimes. Clinical experience with NOACs is limited, compared with warfarin, and the role of NOACs in the broader range of patients than those included in the clinical trials is uncertain. Rare adverse events may yet be encountered and reporting of any events associated with the use of NOACs to the TGA is important.

SWITCHING FROM WARFARIN TO NOACS When switching between anticoagulants it is important to ensure continuous, adequate anticoagulation while minimising bleeding risk. It is also important to ensure that

patients are provided clear instructions to avoid double-dosing / missed doses during the switching process. The following summarizes the key points for switching from warfarin to a NOAC in patients with AF (from www.nps.org.au)4,16. FROM warfarin TO apixaban

•• Stop warfarin, wait until INR <2.0, then start apixaban. FROM warfarin TO dabigatran

•• Stop warfarin, wait until INR <2.0, then start dabigatran. FROM warfarin TO rivaroxaban

•• Stop warfarin, wait until INR <3.0, then start rivaroxaban. Protocols for switching from a NOAC to warfarin differ depending on which oral anticoagulant is being used and is also guided by renal function in the case of dabigatran16. Limited experience/guidance is available when switching between NOACs. Useful guides for practitioners are available to assist in switching doses of oral anticoagulants from www.nps.org.au

SUPPORTING PATIENTS THROUGH COMMUNITY PHARMACY Evidence suggests patients who have a poor understanding of their anticoagulant therapy are at an increased risk of bleeding complications and poor anticoagulant control. Educating patients to ensure

understanding of fundamental aspects of their treatment such as recognising signs and symptoms of bleeding and when to report them, and the importance of adherence to dosing and regular monitoring may reduce bleeding complications15. Some key points that pharmacists can reinforce to patients include15,16;

•• Encourage adherence to medications and provide assistance where possible, particularly with NOACs to ensure that antithrombotic control is not lost;

“Assist patients switching between oral anticoagulants to ensure that protocols are correctly followed to ensure adequate anticoagulation and minimise the risk of bleeding.”

•• Highlight the importance of telling all health professionals about anticoagulant use and ensure the patient understands the need to seek advice about anticoagulation use in the period leading up to elective surgery or procedures, including before dental work;

•• Explain the importance of minimising alcohol consumption;

•• Special considerations – what to do in the event of illnesses such as episodes of diarrhoea or vomiting, or when making travel plans etc;

•• Assist patients switching between oral anticoagulants to ensure that protocols are correctly followed to ensure adequate anticoagulation and minimise the risk of bleeding.

STEPS TO REDUCE YOUR RISK OF AFIB COMPLICATIONS EAT A HEART-HEALTHY DIET FOLLOW AN AFIB-FRIENDLY EXERCISE ROUTINE MAINTAIN A HEALTHY WEIGHT TAKE YOUR PRESCRIBED MEDICATIONS

ECG TRACING

Normal heart rhythm.

In Atrial Fibrillation, the tracing shows tiny, irregular “fibrillation” waves between heartbeats. The rhythm is irregular and erractic.

REFERENCES Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001; 285: 2370-2375. 2 Lloyd-Jones DM, Wang TJ, Leip EP, et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation 2004; 110: 1042-1046. 3 Lip GYH, Tse HF, Lane DA. Atrial fibrillation. Lancet 2012; 379: 648-661. 4 eTG complete [online]. Therapeutic Guidelines: Cardiovascular. Version 6. Melbourne: Therapeutic Guidelines Limited. 2016. 5 Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010;31(19):2369-429. 6 Lip GYH, Andreotti F, Fauchier L, et al. Bleeding risk assessment and management in atrial fibrillation patients. Executive summary of a position document from the European Heart Rhythm Association [EHRA], endorsed by the European Society of Cardiology [ESC] working group on thrombosis. Thromb Haemost 2011;106:997–1011. 7 National Institute for Health and Care Excellence 2014. Anticoagulation – oral – management. 8 Brighton T. New oral anticoagulant drugs - mechanisms of action. Australian prescriber 2011; 33(2): p38-41. 9 Verma AK, Brighton TA. The direct factor Xa inhibitor rivaroxaban. Med J Aust 2009;190:379-83. 10 Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365:981–92. 11 Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365:883–91. 12 Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. [Erratum appears in N Engl J Med 2010;363:1877]. N Engl J Med 2009;361:1139–51. 13 Curnow J. Anticoagulation: a GP primer on the new oral anticoagulants. Australian Family Physician. 2014; 43(5):254-59. 14 Weitz J. & Gross P. New oral anticoagulants: which one should my patient use? Haematology. 2012; 2012(1): 536-540. 15 Kagansky N. et al. Safety of anticoagulation therapy in well-informed older patients. Arch Intern Med. 2004; 164: 2044-2050. 16 National Prescribing Service (NPS). Switching Oral Anticoagulants. NPS Medcinewise 2016 [accessed at www.nps.org.au]. 1

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CONTINUING PROFESSIONAL DEVELOPMENT

ASSESSMENT QUESTIONS The assessment questions below can be found at the Guild Pharmacy Academy myCPD e-learning platform. Login or register at: www.mycpd.org.au

QUESTION 1 Which of the following is NOT a validated tool for assessing anticoagulant use in patients with atrial fibrillation? a. HASBLED b. AUSD risk scale c. CHADS2 d. CHA 2DS2 -VASc

QUESTION 2 Which of the following anticoagulants requires an acid environment for absorption in the stomach and small intestine? a. Warfarin b. Apixaban c. Dabigatran d. Rivaroxaban

QUESTION 3 Which of the following anticoagulants exerts its action by directly inhibiting thrombin? a. Dabigatran b. Apixaban c. Rivaroxaban d. Warfarin

QUESTION 4 Which of the following anticoagulants is contraindicated in patients with CrCl < 30 mL/ minute? a. Apixaban b. Rivaroxaban c. Dabigatran and Rivaroxaban d. Dabigatran, Rivaroxaban and Apixaban

QUESTION 5 Which of the following protocols for changing from warfarin to rivaroxaban is correct? a. Take warfarin and rivaroxaban concurrently until INR is <3.0 b. Stop warfarin, wait until INR is <3.0, commence rivaroxaban c. Stop warfarin, wait until INR is <2.0, commence rivaroxaban d. Stop warfarin, wait 3 days, commence rivaroxaban

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HEALTH

Preventing Type 2 Diabetes DR ALAN BARCLAY Accredited Practising Dietitian BSc; Grad Dip (Dietetics); PhD, APD, AN

Alan is an Accredited Practising Dietitian, having completed a PhD on the association between glycemic carbohydrate and the risk of developing lifestyle-related diseases. He has worked in clinical dietetics, maintaining a private practice in Sydney since 1995 and an official Media Spokesperson for the Accredited Practising Dietitians Association of Australia and has appeared frequently in newspapers, magazines, and radio and television news. He is the author of Reversing Diabetes and a co-author of the Low GI Diet Managing Type 2 Diabetes, and The Ultimate Guide to Sugars and Sweeteners.

DIABETES IS THE WORLD’S FASTEST GROWING CHRONIC DISEASE. THE INTERNATIONAL DIABETES FEDERATION ESTIMATED THAT IN 2015, 415 MILLION PEOPLE HAD DIABETES, AND THAT BY 2040, 642 MILLION PEOPLE WILL HAVE DIABETES1.

Over 1 million Australians have diagnosed type 2 diabetes, and for every four people diagnosed there is another that has the condition but doesn’t know it2. In addition to this, there are a large number of Australians (2–3 million) with impaired glucose tolerance or impaired fasting glycemia3. In the first of a 3-part series on preventing and managing diabetes, Accredited Practising Dietitian, Dr Alan Barclay, reviews the evidence for the prevention of type 2 diabetes.

RISK FACTORS Unchangeable risk factors for pre-diabetes and type 2 diabetes include family history, ethnic background, and advancing age. Risk factors that can be addressed through changes to lifestyle include being overweight or obese, poor diet and physical inactivity. Having central adiposity or carrying excess fat tissue in the abdomen is a particular risk as it is thought that the fat interferes with insulin receptors, resulting in high blood glucose. An online risk assessment tool AUSDRISK (https://www.diabetesaustralia.com.au/ risk-calculator) can be used to screen people at risk.

CLINICAL PREVENTION TRIALS Over the last couple of decades, clinical trials

have been conducted worldwide examining whether people with pre-diabetes can prevent or delay the development of type 2 diabetes4. In similarly designed trials, one group of people with pre-diabetes focused on healthy eating and regular moderate physical activity and another group used common blood glucose lowering medications (e.g. metformin), for 3–5 years. As well as returning fasting blood glucose levels back to the normal range (≤ 5 mmol/L), the studies aimed to reduce body weight modestly — by between 5 and 10% of a person’s weight upon commencing the trial. Weight loss was achieved through moderate kilojoule reduction (around 2,000 kJ less each day), as part of an overall healthy eating plan — consistent with the Australian Dietary Guidelines. People were also advised to do at least 150 minutes of moderate intensity (e.g. brisk walking) physical activity each week, to assist with weight loss, and to decrease insulin resistance. A recent systematic review of all diabetes prevention trials conducted so far4, incorporating over 8,000 people worldwide, found lifestyle interventions could decrease the risk of people with pre-diabetes from developing type 2 diabetes by over 50%, whereas pharmacological interventions (acarbose, flumamine, glipizide, metformin or phenformin) decreased the risk by 70%.

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OBSERVATIONAL STUDIES In addition to clinical trials, there is strong evidence from observational studies, that healthy low glycemic index (GI) and glycemic load diets may decrease the risk of developing diabetes by up to 45%5. Finally, there is also evidence from observational studies that consuming large volumes (1–2, 355 mL cans each day) of regular sweetened soft drink may increase the risk of developing type 2 diabetes by 20%, compared to people who rarely drink them at all6. Foods, meals and diets with a high glycemic load are thought to increase insulin demand, hastening the development of type 2 diabetes in overweight people who are genetically predisposed (e.g. indigenous people, and people from India, South East Asia, the Mediterranean etc.) to the condition.

DIETARY PATTERNS Fortunately, there’s no single diet or way of eating that will reduce the risk of diabetes — a range of healthful patterns can all achieve the same goal7. General advice that can be provided in the pharmacy environment can be based on Australia’s most recent Dietary Guidelines8, which provide a useful framework for helping people to eat healthily and lose a moderate amount of weight. See Guideline table right >>

HEALTH

General advice can also include choosing low GI carbohydrate-containing foods (breads, cereals, starchy vegetables, legumes, fruit, milk and yoghurt).

CONCLUSION There is strong evidence that pre-diabetes and type 2 diabetes can be prevented by adopting a healthy lifestyle. The Australian Dietary Guidelines provide a useful framework for healthy eating. An Accredited Practising Dietitian (APD) provides practical, tailored nutrition advice. To find an APD in your area, visit the DAA website www.daa. asn.au and look under ‘Find an Accredited Practising Dietitian’.

REFERENCES: International Diabetes Federation. IDF Diabetes Atlas Fith edition.1-1-2011.

Australian Bureau of Statistics. Australian Health Survey: First Results, 2011–12. 4364.0.55.001. 29-10-2012.

Cameron AJ, Welborn TA, Zimmet PZ, Dunstan DW, Owen N, Salmon J, et al. Overweight and obesity in Australia: the 1999–2000 Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Med J Aust 2003 May 5;178(9):427-32.

Gillies CL, Abrams KR, Lambert PC, Cooper NJ, Sutton AJ, Hsu RT, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ 2007 Feb 10;334(7588):299.

Livesey G, Taylor R, Livesey H, Liu S. Is there a dose-response relation of dietary glycemic load to risk of type 2 diabetes? Meta-analysis of prospective cohort studies. Am J Clin Nutr 2013 Mar;97(3):584-96.

Greenwood DC, Threapleton DE, Evans CE, Cleghorn CL, Nykjaer C, Woodhead C, et al. Association between sugarsweetened and artificially sweetened soft drinks and type 2 diabetes: systematic review and dose-response metaanalysis of prospective studies. Br J Nutr 2014 Sep 14;112(5):725-34.

Evert AB, Boucher JL, Cypress M, Dunbar SA, Franz MJ, Mayer-Davis EJ, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 2014 Jan;37 Suppl 1:S120-43. doi: 10.2337/dc14S120.:S120-S143.

National Health and Medical Research Council. Australian Dietary Guidelines. 18-2-2013. Canberra, Australia, Health and Medical Research Council.

GUIDELINE 1:

GUIDELINE 3: 3:

Maintain a healthy weight by being physically active and choose amounts of nutritious food and drinks to meet your energy needs.

Limit intake of foods containing saturated fat, added salt, added sugars and alcohol.

•• Children and adolescents should eat sufficient nutritious foods to grow and develop normally. They should be physically active every day and their growth should be checked regularly;

•• Older people should eat nutritious foods and keep physically active to help maintain muscle strength and a healthy weight.

GUIDELINE 2: Enjoy a variety of nutritious foods from these 5 food groups every day: •• Plenty of vegetables: different types/colours and legumes/ beans; •• Fruit; •• Grain (cereal) foods: mostly wholegrain and/or high cereal fibre varieties, such as breads, cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley; •• Lean meats and poultry: fish, eggs, tofu, nuts and seeds, and legumes/beans; •• Milk, yoghurt, cheese and/or their alternatives: mostly reduced fat (reduced fat milks are not suitable for children under 2 years). And drink plenty of water.

a. Limit intake of foods high in saturated fat such as many biscuits, cakes, pastries, pies, processed meats, commercial burgers, pizza, fried foods, potato chips, crisps and other savoury snacks.

•• Replace high fat foods which contain predominantly saturated fats such as butter, cream, cooking margarine, coconut and palm oil with foods which contain predominantly polyunsaturated and monounsaturated fats such as oils, spreads, nut butters/pastes and avocado;

•• low fat diets are not suitable for children under the age of 2 years. b. Limit intake of foods and drinks containing added salt.

•• Read labels to choose lower sodium options among similar foods;

•• Do not add salt to foods in cooking or at the table. c. Limit intake of foods and drinks containing added sugars such as confectionary, sugar-sweetened soft drinks and cordials, fruit drinks, vitamin waters, energy and sports drinks. d. If you choose to drink alcohol, limit intake. For women who are pregnant, planning a pregnancy or breastfeeding, not drinking alcohol is the safest option.

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BUSINESS

Do Shoppers Trust Supermarkets to Provide Healthcare Products?

DR GARY MORTIMER Senior Lecturer QUT Business School

A CHALLENGE FACING COMMUNITY PHARMACY Health care has become an important category for supermarkets worldwide with a market size of USD$980 billion in 2013, projected to grow to USD$1.226 trillion by 2018. While supermarkets globally have moved quickly to take advantage of in-store pharmacies, Australia represents an interesting marketplace in which supermarkets are prevented from either owning or embedding in-house pharmacies into their stores. Constrained by legislation, Australian supermarkets have moved to increase their product ranges of unscheduled and complementary medicines within their healthcare category. These products, commercially known as ‘open sellers’, include pain and fever, coughs and colds, indigestion medicines, and other complementary medicines, like vitamins. It has been suggested that the growth in this sector is the result of consumers’ desire to self-treat their illnesses, perceptions that such medication is a safe and effective self-care option, spiralling healthcare costs and an aging population. Such socio-economic drivers suggest this growth will not abate, and therefore represents an important and growing market for supermarkets and a potential threat for community pharmacy.

The descheduling of medicines has increased the availability through channels beyond community pharmacies. Despite a number of advantages offered by nonpharmacy retailers, such as lower prices, convenience and improved access to health products, it has been argued that such retailers do not have the best interests of healthcare consumers in mind. The price of unscheduled medications appears no longer a salient factor influencing consumers’ choice, as the growth of warehouse-style discount pharmacies now provides the same low price offered by supermarkets. Product brands remain consistent across both channels, suggesting this attribute is not a determining factor influencing consumer choice between channels. Accordingly, this article seeks to examine other salient factors, specifically the roles of trust and perceived risk. This article provides pharmacy operators insight into healthcare consumer behaviours in this context.

UNKNOWN FACTORS No studies have established a direct link between trust and risk variables and how they work to influence a consumer’s decision to patronise a particular retailer for the purchase of unscheduled medicines. Existing research

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on trust in the medical–pharmaceutical context has only focused on buyer–seller relationships (i.e. patients and physicians, or medical institutions), and consumers’ trust in the sources of information (i.e. sources of physician-quality information and online prescription drug information), whereas studies of perceived risk have only investigated the effect of risk perceptions on consumers’ resistance toward generic drugs and risk perceptions of non-prescription medicines. Consequently, there remains a substantial gap in our knowledge as to how trust and perceived risk may influence consumers’ choices between visiting a supermarket and community pharmacy for their healthcare needs. Previous research that has focused on trust identified four main components: firstly, willingness to provide transparent and relevant information is a key component in building and maintaining trust; secondly, competence, which is defined as the retailers’ perceived skills and expertise; thirdly, ability is defined as a consumer’s confidence in a retailer to fulfil their required task; and, finally, benevolence reflects a customer’s belief that a retailer has good intentions. Perceived risk is also considered a multidimensional construct. Firstly, psychological risk refers to a consumer’s negative self-

BUSINESS FIG. 1 PROPOSED MODEL OF PURCHASE INTENTION Provision of Information Competence Ability INTENTIONS TO PURCHASE UNSCHEDULED MEDICINES AT A SUPERMARKET

Benevolence

Psychological Risk Time Risk Physical Risk Social Risk

FIG. 2 FINAL MODEL OF PURCHASE INTENTION Provision of Information

.243 (Sig .000)

Competence

.159 (Sig .008)

Psychological Risk

-.152 (Sig .046) -.247 (Sig .000)

INTENTIONS TO PURCHASE UNSCHEDULED MEDICINES AT A SUPERMARKET

Time Risk

perception caused by their own lack of knowledge and experience. Secondly, time risk has been defined as the perceived time wasted in relation to the time spent looking for it. Thirdly, physical risk is defined as the possibility that a product can potentially cause harm. Finally, social risk often prevails when consumers purchase a product, or patronise a certain store which is deemed by their peers, family or friends as a poor or inferior choice. Based on the above discussion of these factors, the proposed purchase intention model is presented in Fig. 1.

RESEARCH APPROACH AND PRELIMINARY FINDINGS In order to identify the drivers and barriers of purchasing ‘open sellers’ in a supermarket, an online survey was sent to 300 primary grocery shoppers which captured demographics, perceptions of the retailer’s trustworthiness and risks associated with purchasing. Preliminary results indicated that the provision of information and benevolence did not have a significant impact on purchase intention for supermarket shoppers. Simply, shoppers did not expect supermarkets to provide information, possibly as they did not have staff allocated to their health products aisles, nor did they reasonably believe supermarkets acted with genuine concern. However,

customers felt supermarkets were competent and had the ability to supply unscheduled and complementary medicines. Regarding the perceived risk dimensions, psychological risk was considered a barrier to purchase intention for the supermarket shopper, as was social risk. Thus, customers’ inability to foresee the consequences of their purchase decisions increased their psychological risks and motivated them to purchase from a pharmacy. This may have been exasperated due to a lack of information available in supermarkets. Further, respondents were concerned about what friends and family (social risk) may think of them purchasing healthcare products in a supermarket. In contrast, both time risk and physical risk were not significant, as supermarkets were considered just as convenient as pharmacy and branded products thought of as safe. The final model of purchase intentions of unscheduled and complementary medicines in a supermarket is presented in Fig. 2. This current study found that shoppers who purchase unscheduled and

complementary medicines in a supermarket did so because they perceived supermarkets were competent to, and had the ability to provide safe products and effectively process transactions. Respondents indicated that the provision of information and benevolence were not drivers of purchase intention in a supermarket. This study identified two barriers that negatively impacted on shoppers’ intentions to purchase health products in a supermarket, psychological risk and social risk. Herein, shoppers indicated that purchasing unscheduled medicines in a supermarket did create mild anxiety and concerns about social acceptance. Community pharmacy should leverage against these barriers. Respondents indicated a lack of knowledge, even when selecting ‘open-sellers’, and this caused anxiety and psychological stress. Accordingly, pharmacy should promote well trained pharmacy assistants and provide information to reduce stress and anxiety during purchase. Pharmacy should also tap into their customers’ social norms, using a social media campaign.

“Supermarkets globally have moved quickly to take advantage of in-store pharmacies.” GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

Monitor respiratory conditions

Pre/post-exercise

Pre/post-operative conditions

For further information and deals call your local JA Davey representative or call 1800 807 464

Your healthcare professional will advise you whether this product is suitable for you/your condition. Always read the label and instructions. Use only as directed.If symptoms persist see your healthcare professional.

The best products start with the best ingredients.

VersaBaseÂŽ Special Micronised Progesterone Ask our pharmacists about hormone replacement therapy.

HEALTH

Probing into

PROBIOTICS: An evidence-based approach

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HEALTH

OLIVER CANFELL Nutritionist, Student Dietitian The University of Queensland BENS

“Probiotics, in themselves, are a supplement that poses a considerable challenge to understand. The wide and confusing variation in probiotic species and strains creates an exorbitant scientific maze necessary for consumer decryption.”

A RELATIVELY NEW AND EXCITING TREND, THE USE OF SUPPLEMENTARY PROBIOTICS HAS NOT ALWAYS BEEN AT THE FOREFRONT OF HEALTH POP CULTURE. UNBELIEVABLY, IT ALL BEGAN WITH THE INCEPTION OF THE INFAMOUS “YAKULT” IN 1935, GIVING BIRTH TO THE CONCEPT OF PROBIOTICS IN MANY, AND FLEXING THE INTEREST OF A POPULATION. IT TOOK ALMOST SEVENTY YEARS FOR THE INDUSTRY TO CATCH UP AND, IN 2006, THE USE OF PROBIOTICS EXPLODED2.

Probiotics, in themselves, are a supplement that poses a considerable challenge to understand. The wide and confusing variation in probiotic species and strains creates an exorbitant scientific maze necessary for consumer decryption. Their natural complexity and variation also generates a multitude of challenges in studying their efficacy within clinical trials. As our understanding of their role in the treatment of antibiotic-associated diarrhoea (AAD) and irritable bowel syndrome (IBS), as well as the prevention of gastrointestinal (GI) issues in the healthy has evolved, as has our confusion surrounding their place as a viable and worthwhile form of supplementation, with very recent and emerging evidence perhaps paving a different future than once predicted in 2006. Probiotics are live microorganisms that, when administered in an adequate amount, provide a health benefit to the host in the form of maintaining an appropriate balance between beneficial and harmful bacteria within the digestive tract3. Dissected into genus, species and strain, the most clinically popular of these have been Lactobacillus, Bifidobacterium and Saccharomyces1. The diversified and impactful role of the gut has spawned a desire among healthy individuals to optimise its functionality, with probiotics a seemingly easy and efficient way to achieve this. Recent literature has begun to suggest otherwise, with a systematic review citing a lack of evidence for probiotics to have any impact on the gut microbiota in healthy adults3. For the majority of consumers, probiotic supplementation is the pharmacological

beacon of hope for relieving symptoms of IBS, whether they may be sub-typed as IBS-C (constipation), IBS-D (diarrhoea), IBS-M (mixed) or IBS-U (unclassified). The British Dietetic Association very recently (June, 2016)4 performed a systematic review of all systematic reviews pertaining to the use of probiotics in managing IBS in adults and consequently updated their recommendations based on these findings, concluding that probiotics are unlikely to provide substantial change in the presence and severity of IBS symptoms4. Despite this, marginal improvements in not all, but some of the associated symptoms of IBS were demonstrated in only certain probiotic strains in a limited number of trials. For individuals who are desperate for symptomatic relief, it appears a minimum 4-week trial of a chosen probiotic is necessary to truly ascertain if a benefit can be achieved4. Arguably, purchase and consumption of probiotic supplementation is most common within and publicised for healthy individuals and individuals with AAD and/or IBS. In lieu of the above conclusions and their applicability to the general population, perhaps their most efficacious, evidence-based application has been one that most consumers are unaware of, with a recent systematic review concluding supplementary probiotic consumption reduces the risk of AAD1. Their role extends not only to AAD, but also in the management of inflammatory bowel disease (IBD) and associated pathologies such as pouchitis, as well as in chronic constipation within children, other much less publicised and prevalent issues2.

Secondary to the absolute depth and complexity of probiotics as a field, progress in truly understanding their mechanism and applicability has been slow, sometimes conflicting and is ever-evolving. Certainly the specific composition, concentrated dose and ease of consumption associated with probiotic capsules make them a more efficient medium than probiotic-rich foods. Perhaps the challenge lies in targeting and promoting the less publicised and well-supported uses of probiotics, while evidence evolves and solidifies concerning their more publicised, but currently less efficacious uses. Community pharmacists can help close the gap between evidence and practice, delivering the freedom of a personal decision with the added cushion of professional support if necessary. REFERENCES: Hempel, S., Newberry, S. J., Maher, A. R., Wang, Z., Miles, J. N., Shanman, R., . . . Shekelle, P. G. (2012). Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. Jama, 307(18), 1959-1969. 2 Jain, D., & Chaudhary, H. S. (2014). Clinical significance of probiotics in human. International Journal of Nutrition, Pharmacology, Neurological Diseases, 4(1), 11. 3 Kristensen, N. B., Bryrup, T., Allin, K. H., Nielsen, T., Hansen, T. H., & Pedersen, O. (2016). Alterations in fecal microbiota composition by probiotic supplementation in healthy adults: a systematic review of randomized controlled trials. Genome medicine, 8(1), 1. 4 McKenzie, Y., Thompson, J., Gulia, P., & Lomer, M. (2016). British Dietetic Association systematic review of systematic reviews and evidence‐based practice guidelines for the use of probiotics in the management of irritable bowel syndrome in adults (2016 update). Journal of Human Nutrition and Dietetics. 1

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HEALTH

Professional Services

Helping Smokers, COPD and Asthma Sufferers BY ROMA CECERE General Manager, Strategic Business Performance, GuildCare

1 IN 7 AUSTRALIANS OVER 40 HAVE SOME FORM OF COPD Despite declining death rates, COPD is still a main cause of death and disease after heart disease, stroke and cancer 1. Nevertheless, the World Health Organisation predicts that COPD will become the third leading cause of death worldwide by 20302. An Australian study shows 1 in 7 Australians have some form of COPD3. The prevalence of COPD among Indigenous Australians4 is 2.5 times higher than the prevalence for other Australians. COPD is the second leading cause of avoidable hospital admissions5. Assisting smokers to quit is the only intervention that has been shown to slow the long-term deterioration in lung function associated with COPD6. Although Australia has one of the lowest smoking rates in the world, over 10% of Australians still die from smoking related diseases7. Addressing behavioural risk factors can prevent many smoking related deaths, and pharmacists are ideally placed to do this. Through intervention, pharmacists can also thwart a broad range of other associated health issues from taking hold.

SUCCESSFUL ACT SMOKING CESSATION PROGRAM A smoking cessation pilot conducted in 80% of ACT pharmacies ended in June 2016. 290 ACT pharmacists and staff were trained in smoking cessation counselling where they learned how to converse with smokers, helping them to identify the state of readiness of patients to quit. Discussions with patients about

INTERESTED IN SUBSCRIBING TO GUILDCARE? One of our Pharmacy Relationship Consultants can answer any questions you have in becoming a GuildCare subscriber. Simply email hub@guildcare.com.au or call 1300 859 328 (8.30 am – 6 pm weekdays AEST) and visit www.guildcare.com.au

chronic diseases proved to be a successful conversation starter which flowed naturally towards smoking, without any inference of judgement or harassment. Margaret Beerworth, the ACT Guild Branch Director says, “The most successful pharmacies had a Quit Smoking champion on the team who set goals for the pharmacy, organised relevant health promotions (COPD, Asthma, Quit smoking) and motivated others in the team.” One of the more successful pharmacies achieved 11% cessation rate (defined as not smoking after 6 months). Beerworth says pharmacists have access to patients’ dispense history and can shape patient behaviour to improve their quality of life. 98% of participating pharmacies used GuildCare to manage the program. GuildCare enabled many to easily identify other relevant professional services for their patients. Beerworth further adds that analysis also indicated a correlation between the overall successful implementation of the program in their pharmacy and an increase in NRT sales. Customers with prescriptions for Champix also proved to be receptive to interventions on quitting.

10% OF AUSTRALIANS HAVE ASTHMA Around 2.3 million Australians, 10.2% of the total population, have asthma8. The rate of asthma is almost twice as high among Indigenous Australians than in nonIndigenous Australians, a rate ratio of 1.99. Reviewing how patients use their inhalers

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opens up more opportunities to provide primary health care in pharmacy and may count as a clinical intervention if the patient is doing it incorrectly. GuildCare identifies more clinical interventions than any dispense or other software system.

GUILDCARE – COMMITTED BUSINESS PARTNERSHIP WITH 3,000 PHARMACIES GuildCare enables pharmacies to develop a patient-centric model of care. With one, easy-to-use, seamless software, pharmacies can navigate professional service delivery effectively and efficiently. It has Australia’s biggest number of professional services programs, including Inhaler Technique and COPD. Through its constant commitment to innovation, GuildCare continues to add more and more modules. Recent additions include:

•• MPS Healthstream – generates more opportunities for pharmacies to improve medication compliance, deliver more accurate DAAs and drive workflow efficiency.

•• myDNA Life – makes genetic testing services available in community pharmacy. GuildCare also has patient and GP messaging services. Notably and unlike other messaging services, patients’ details are always controlled and retained by the pharmacy, critical to maintaining the long-term relationship with patients, as well as the value of the pharmacy business.

“Assisting smokers to quit is the only intervention that has been shown to slow the long-term deterioration in lung function associated with COPD.”

HEALTH

REFERENCES 1 AIHW 2012. Australia’s health 2012. Australia’s health no. 13. Cat. no. AUS 156. Canberra: AIHW. 2 http://www.who.int/respiratory/copd/en/ 3 Toelle B, Xuan W, Bird T, Abramson M, Burton D, Hunter M, Johns D, Maguire G, Wood-Baker R, Marks G. COPD in the Australian burden of lung disease (BOLD) study. Respirology 2011;16 (Suppl 1):12. 4 ABS 2013 (across all age groups). 5 Page A, Abrose S, Glover J et al. Atlas of Avoidable Hospitalisations in Australia: ambulatory caresensitive conditions. Adelaide PHIDU. University of Adelaide. 2007. 6 Anthonisen et al. 2005; Anthonisen et al. 1994. 7 http://www.tobaccoinaustralia.org.au/chapter-3-health-effects/3-30-deaths-attributable-to-tobaccoby-disease-cat. 8 http://www.aihw.gov.au/asthma/prevalence/ 9 ABS 2013 (after adjusting for differences in age structure between Indigenous and non-Indigenous Australians).

1 IN 7

AUSTRALIANS OVER 40 HAVE SOME FORM OF

COPD

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HEALTH

Nasal and Sinus Irrigations SEAN TUNNY

PROFESSOR PETE SMITH

Editor, Gold Cross Products & Services Pty Ltd

BMedSci, MBBS, FRACP, PhD Medical Director, Allergy Medical

Professor Pete Smith is one of Australia's most accomplished and respected allergists and immunologists. He has a PhD in molecular immunology and is the Medical Director of Allergy Medical. Pete is also a Professor of Clinical Medicine at Griffith University, where he is conducting research into molecular aspects of pain in allergic conditions. He is also involved in medical education and frequently speaks at national and international meetings and conferences.

SINCE 2003, ENT TECHNOLOGIES PTY LTD HAS LED THE WAY BY PROVIDING THE MOST INNOVATIVE NASAL AND SINUS IRRIGATIONS IN THE AUSTRALIAN MARKETPLACE. ENT TECHNOLOGIES IS COMMITTED TO THE LATEST ADVANCEMENTS AND TECHNOLOGIES IN DEVELOPING EFFECTIVE FORMULATIONS AND EASY DELIVERY SYSTEMS FOR MANAGING A WIDE RANGE OF COMMON NASAL AND SINUS PROBLEMS.

EDITOR: Professor Smith, we all have patients with both seasonal and perennial rhinitis and most of them use nasal steroid sprays, not infrequently, with suboptimal results. Could you suggest additional treatment options for these customers? PROF. SMITH: First off, the World Health Organisation sponsored Allergic Rhinitis and its Impact on Asthma (ARIA) report of 2001 suggested we call rhinitis as intermittent and persistent (rather than seasonal or perennial) and we also think about severity when classifying. In some regions a seasonal allergen may be a mould or a grass, which in other areas this allergen is present all year round (e.g. grass in a tropical or subtropical area). A good percentage (34–50%) of patients with allergic rhinitis have non-allergic triggers as well (e.g. smoke, cold air, solvents) so working out irritants is helpful. Up to one third of patients attending US rhinitis clinics were found to be purely non-allergic. If you use a nasal spray, use it correctly. Aim to the outer canthus or the ear side of the nostril you are treating. Aim to the lateral wall of the nose. You do not need to sniff hard. There is little evidence that an oral antihistamine ADDs to a nasal steroid in symptom control but intranasal nasal corticosteroids (INCS) are better than oral antihistamines in treating rhinitis. Topical antihistamines and combination intranasal antihistamine/INCS are more effective. 20% of patients do not fill their steroid script — they are worried about the word steroid. That results in non-compliance use of oral antihistamines (which are not as effective as nasal steroids and are not as cost effective). I find explaining that allergies are an “over-response” to a perceived threat — their body is over-working to that threat and they have symptoms of allergy — which are all fairly protective. If the body is stressed, it makes steroids to control inflammation. Treating a 50 cent area in each nostril is smarter and easier to do than the whole body being “stressed” and making endogenous steroids. The ARIA report of 2008 said that there is no role for sedating

antihistamine in the treatment of rhinitis. Note that 70% of patients take more than the recommended dose of antihistamines and about 60% of patients with rhinitis do not feel they have good control with their medication. Make sure that they are not taking an alpha-agonist agent as this can cause rhinitis medicamentosa and refractory rhinitis. Nasal steroids are safe for long-term use as well. Immunotherapy is another add that is very effective in well selected patients. EDITOR: There have been publications suggesting that washing the nose prior to instillation of the medicated spray improves results. Could you comment on this please? PROF. SMITH: Yes, there is pioneering work on this that aligns the concepts I have outlined above. If there is an allergen or irritant, there are receptors that detect the threat and respond to it with neural activation (sneezing, itch and discomfort/sinus pain); mucous and destructive enzyme production; increased cilia beating and also turbinate swelling. Turbinate swelling increases the surface area that will come in contact with the real or perceived threat (allergen/irritant). Whilst this can be useful acutely, it is dysfunctional chronically and causes a heavy and often under-recognised burden on airway function, productivity and quality of life. The nose has very important roles in warming, humidifying and filtering the greater than 10,000 litres we breathe every day. If the nose is blocked, the work of breathing increases. This impacts the lower airway from a physiological point of view (there is also immune activation) and also there is increased risk of ENT infections and upper airway obstruction which contributes to poor learning and workplace productivity. Nasal lavages both remove the threat and also help to remove components (enzymes and mucous) of the dysfunctional response — as stated by an independent Cochrane summary. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010728/full “Nasal saline has been used as a homeopathic remedy for centuries and has recently gained attention as an adjunctive treatment

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HEALTH

Look Down - Spray a "V" • INHALE THE MIST NICE AND GENTLY • HEAD TILTED FORWARD • SPRAYER ANGLED OUTWARDS • KEEP MIST INSIDE NOSE

for a number of sinonasal diseases. Nasal saline is able to clear allergens, mucus and other irritants from the nasal passages and to increase nasal patency with few associated side effects. Additionally, several studies have shown that the use of nasal saline may decrease medication requirements (Garavello 2003; Garavello 2005; Harvey 2007; Li 2009).” Nasal saline works for both allergic and non-allergic rhinitis. EDITOR: Is there a role for the use of nasal saline solutions being used intermittently throughout the day as well? PROF. SMITH: It is very safe to use these nasal salines as required, as long as they are at the correct osmolality and do not contain irritants. Symptom relief is very quick and patients can self dose. Use these before medications as there is evidence of augmented response in terms of reduced nasal symptom scores. EDITOR: There are many options of nasal saline irrigation solutions, some with preservatives, namely Benzalkonium Chloride (BKC), and others without. Some publications suggest that prolonged use of saline with this preservative shows adverse effects on normal physiology after use for only 3 weeks. For patients with allergic rhinitis, from whichever cause, is there any downside to using nasal saline solutions containing this preservative? PROF. SMITH: There are several levels to this answer. BKC is an antimicrobial and is a compound that can cause mucosal irritation. Many medications used in the nose have this preservative as well. BKC also appears to impair nasal mucocillary clearance. Countering this, there may be benefits of not having topical steroid medications cleared. The mucosa in the inflamed nose is also more vulnerable to irritation. Many pharma companies have taken BKC out of their INCS sprays in the last 10 years, but then many have not. Studies in healthy individuals show nasal stuffiness with BKC compared to controls — but this is in health controls. The nasal microbiome is also important

“If you use a nasal spray, use it correctly. Aim to the outer canthus or the ear side of the nostril you are treating. Aim to the lateral wall of the nose. You do not need to sniff hard.”

in rhinitis and destruction of this with a preservative may result in a dysbiosis and aberrant inflammation. EDITOR: Many of the steroid nasal sprays also contain the preservative Benzalkonium Chloride, is there any reason to suggest that we should recommend formulations which have an alternate preservative system? PROF. SMITH: For many patients BKC does not cause symptoms. It is a big step to: 1. Use an INCS; 2. Use it correctly; 3. Use it regularly. Currently, there is not enough research looking at the microbiome and airway inflammation with BKC in patients with allergic rhinitis. Potassium sorbate is being used as a preservative in products and appears to cause less irritation than BKC. EDITOR: Many patients with Allergic Rhinitis have significant nasal obstruction when they first see a healthcare practitioner. Could you let us know how you feel about the use of medicated decongestant sprays in these patients? PROF. SMITH: There is a recent study of 4 weeks of concomitant use of nasal steroids when used with oxymetazoline. Whist we talk about rebound after 3–5 days, the study did not find that was the case with patients treated with oxymetazoline alone for 4 weeks. www.ncbi.nlm.nih.gov/pubmed/21377716 Do not use oxymetazoline alone. It is best to be cautious. I personally suggest using this combination up to 4 times a day with acute rhinosinusitis and frequent nasal lavage. In my clinical experience, this makes a difference on the first day, but I have not run a randomised controlled trial of this. For more information, please go to www.enttech.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

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BUSINESS

Innovate or Die? Service. Efficiency. Workflow.

CASE STUDY 2

Efficiency.

Gaslight Pharmacy, Rose Bay, Sydney. We spoke with Peter Moschakis, owner of Gaslight Pharmacy who recognised efficiency as the key benefit he gained from the introduction of automation into his pharmacy.

feed directly from inside the robot.

EDITOR: WHAT DID YOU INSTALL? PETER: A Rowa Vmax. We called our system

EDITOR: HOW DID YOU PROCEED? PETER: We investigated the alternative

Amy. We chose not to tuck the entire Rowa right up against the rear wall, instead moving it out a little to allow for an extra output, feeding directly to our DAA packing area.

EDITOR: WHY DID YOU AUTOMATE? PETER: Already operating an incredibly busy pharmacy, we felt we needed to improve the efficiency of our practices. Our end-to-end inventory management process was slow and laborious. We wanted to increasingly empower our Technicians to handle the scripts, and allow the Pharmacists to consult with our customers. The traditional stocktaking process was painful, but following the introduction of Amy, we can now look up specific quantities in seconds, or export a full stock report within a few minutes. We also sought to add a flash of originality, so we included the CCTV screen showing a live

The future benefits were a key influencing factor, knowing that the machine will well outlive its repayment period.

automation options and while the prices were comparable, we chose the Rowa Vmax. My Pharmacy Manager, Tiffany, has previously used a different type of robot, but has employed the Rowa system with relative ease — it’s easy to locate stock, dispensing errors are practically non-existent, and new team members adapt very easily to the Rowa.

EDITOR: WHAT CHALLENGES WERE OVERCOME? PETER: While I think we’ve achieved most of our original objectives, we’re still tweaking some of our workflows. I was very proud of my team and the way they embraced the changes that came with our automation. They genuinely radiated excitement about the new robot and this transferred to our regular customers.

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BUSINESS

As with any new technology, we’ve had a few teething problems which we’ve addressed through education and training. We experienced some challenges with software integration at the start, so now they’re resolved, I’m looking forward to the extra reporting functionality. Part of our plan was always to complete a full store refit, so it was the perfect time to consider dispensary automation. The robot allowed us to maximise our floor space, optimise our dispensary workflows, and we’ve been able to accommodate three counselling and treatment rooms to support our professional services. But my team tells me one of the best parts is the stock management. We used to have trouble with newly arrived stock sitting in the store room, waiting to be checked off and shelved; however, in the meantime, someone else would order more thinking we’d run out. Now, the team no longer wastes time shuffling packs of medication

around. As soon as orders arrive, they go straight into the autoloader, for the robot to process.

EDITOR: WHAT’S CHANGED? PETER: Amy has definitely changed our pharmacy — she has removed much of the drudgery from the team, and she saves time, and saves frustration. While my staffing has changed during this process, it has never been about reducing staff — someone will still be needed to feed the packs into the autoloader, and most importantly, people will still be needed to consult with customers. Tiffany has noticed that there’s a lot less time spent dispensing, “I can do a script for antibiotics in under 60 seconds, without having to leave the customer’s side. There are fewer errors too, because you’re focused and the workflow is streamlined. There are no picking errors from the robot — it’s only if the details on

the script are incorrect. We can also maximise opportunities now, in that we never have to turn someone away because we can’t find a particular item, or think we’ve sold out. Our inventory is up to date and Amy doesn’t forget where she’s put things.”

EDITOR: HOW DOES YOUR FUTURE LOOK? PETER: One of my team described my pharmacy before as “busy and chaotic”. Now she says it’s just as busy, but “organised and orderly”. Our future now is one with less waste, and better efficiency. We have fast and accurate stocktakes, with less out-of-date or wasted stock. Processing and dispensing prescriptions is more efficient, with ever-improving workflows. And our customer service and satisfaction are improving as our customers continue to access quality health consultation with our pharmacists.

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BUSINESS

Innovate or Die? Service. Efficiency. Workflow.

CASE STUDY 3

Workflow.

Friendlies Pharmacy, Falcon, Perth.

We spoke with Noel Fosbery, owner of Friendlies Pharmacy, Falcon. Pharmacy workflow was the main issue that Noel wanted to address by automating his pharmacy, “I wanted things to be done right, and only done once.”

EDITOR: WHAT DID YOU INSTALL? NOEL: A Rowa Vmax, white. The staff have named him Arnie (Schwarzenegger). He’s a decent size, holding roughly 12,000–13,000 packs, depending on a few variables. My other Pharmacy in High Wycombe was a Top 5 finalist for the Guild Pharmacy of the Year — we have a smaller Vmax there, and since the script volumes are smaller, we didn’t install an autoloader. Falcon is processing higher volumes, so I needed a larger machine, and I wanted the autoloader so I stayed with the Vmax. The Vmax allowed me to customise dimensions to a great extent, so I could tailor it around the pharmacy workflow, and maximise our available space.

EDITOR: WHY DID YOU AUTOMATE? NOEL: My mantra has always been, “Do it right, do it once” and dispensary automation has been key to success in this area.

I wanted to make sure the staff had everything they needed to get their job done properly. Computers are cheap but staff are expensive. Small problems compound, which creates bottlenecks and a congested pharmacy. Staff try to catch up, so details get missed, paperwork gets lost, things don’t get done properly and you end up needing to redo and fix them.

retrace your steps, track down an error, redo/ re-dispense.

The Friendlies Group is now focusing on professional services. As part of our refit and automation, we built a consulting room to take advantage of the 6CPA/ PPI, as well as new things like flu vaccinations. While we’ve always offered private consultations, having the robot takes the pressure off my staff, so it’s now easier for them to make sure their paperwork is processed properly.

EDITOR: HOW DID YOU PROCEED?

Dispensing accuracy contributes directly to effective workflow, and Rowa accuracy is awesome — not only with the type of medication, but with quantities. If the script says three, the robot dispenses three, leaving no room for you to forget, and just dispense one. The barcode system does not dispense an incorrect medication, so your errors are practically zero, and you hardly ever need to

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The simplest improvement is that your stock is only touched once as you’re putting away, and once when you’re dispensing it for sale. There’s no constant reshuffling, rotating or checking, and that alone produces a vast improvement.

NOEL: Way back in 2005, I thoroughly investigated channel machines but decided they weren’t for me. I’ve kept informed since then, and my mind hasn’t changed. I believe my Rowa Vmax gives me true automation. We love our autoloader. In some of the other types of robots, you’re only loading in one pack at a time, and there’s no guarantee that it’s been loaded correctly (due to human error), so this can cause dispensing errors. My Rowa stock is optimised on the shelves automatically to take full advantage of the space available. The machine itself can be fully enclosed on three sides if you wish, so there’s no wasted floor space. At Falcon I‘ve chosen to install a series of gravity-fed

BUSINESS

conveyors in order to fully realise all the efficiency available, given my store layout and location.

EDITOR: WHAT CHALLENGES DID YOU OVERCOME? NOEL: We haven’t reduced staff numbers during the process, so one of the challenges is to make sure my pharmacists know how to use their extra time in the proper fashion, talking to people. Some of my staff and clients are quite technophobic, and were worried. I tried to keep the installation low key, and specifically didn’t put a camera into the robot with TV in the dispensary. I didn’t want to scare staff or customers, but the option is there for the future if things change. I’m happy to say that the technophobes have made friends with the robot, and have no problems using it at all.

disclosing their health issues, and our professional services income has increased. It’s also made it easier for us to offer flu vax through HBF, so we’ve been able to further improve our customer relationships. I have one staff member controlling stock now — we can receive 20 Symbion tubs in one day, and she can process it all into the robot in 60 minutes by herself. She tells me the hardest part of receiving the order is tearing off the outer wrapper … previously, incoming stock would have taken 2 or 3 staff, around 3 hours each. In the meantime, the front of shop would not have been centre of attention. I did worry at first that we wouldn’t be able

to put everything in the robot, but at Falcon we basically have one cupboard for the larger glass bottles. Everything else fits.

EDITOR: HOW DOES YOUR FUTURE LOOK? NOEL: While our income from scheduled medicine has decreased due to an increase in local competition, our overall prescriptions are up. In addition to our community DAA patients, we’ve been able to take on DAA packing for a 110-bed nursing home since we installed the robot. So even though I’m facing stronger competition, I feel like my pharmacy team and I are better prepared to handle whatever the future might bring.

My big problem now is that my Pharmacists prefer to work in my robotic stores, rather than my non-automated ones. There are fewer hassles, less walking, it’s more peaceful, everything just works better, and there’s much less pressure.

EDITOR: WHAT’S CHANGED? NOEL: It can feel like it’s difficult to quantify exactly what’s changed, but when you look at the overall picture, the benefits are clear. The dispensary just feels calmer. I was talking to some of my Falcon team recently, and although last December’s script numbers were higher, the staff said it felt like we had fewer customers. Previously we used to order stock in bulk, and stash it in various places all over the store — some on the shelves, some under the counter, the rest in the storeroom. So we’d be handling one pack many times as we moved it from place to place. But now we only order a maximum of two weeks at any one time. We place the pack into the autoloader, the robot shelves it, and then we only touch that pack again when we’re dispensing it for sale. Interaction between pharmacists and patients has seen a marked increase. Our Rowa has condensed the dispensary, so during our shop refit we were able to double our consultation bench space, plus add a private consultation room. While we used to offer services before, space was cramped, and customers found it difficult to have a private discussion with their pharmacist. The new layout promotes confidential discussion, so patients feel more comfortable

Contact Dose Innovations today to find out how automation can help you. • 1800 00 3673 (1800 00 DOSE) • enquiries@doseinnovations.com • www.doseinnovations.com GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

BUSINESS

PHARMACY ALLIANCE

Leading the Way in

TECHNICAL SUPPORT to MEMBERS

SEAN TUNNY

JAYSON ATKINS

Editor, Gold Cross Products & Services Pty Ltd

Member - Pharmacy Alliance Owner of Jayson Atkins Pharmacy

In July 2015, Pharmacy Alliance announced a partnership with BOS/ POS software provider, Z Software.

EDITOR: In terms of your pharmacy staff, what is their most favourite feature of Z POS/Dispense?

The Pharmacy Alliance and Z Software partnership means that Pharmacy Alliance members receive best-in class, simple dispensing solution, with advanced patient management that is fully integrated into a POS system. This integrated BOS and POS solution also incorporates advanced reporting and analytics, providing a more cost effective and more responsive solution not only for now, but into the future.

JAYSON: My staff are very impressed by the internal support given by Pharmacy Alliance. It is hard to choose just one favourite feature of the system. The automation of things like scheduled reporting and the Alliance Connect support makes it easy to dispense. All this began with seamless conversion and the training provided.

Now, almost one year on, Pharmacy Alliance is providing Alliance Connect for Z Software to take away the burden of many administrative tasks associated with managing Z Software POS, Dispense and Office allowing their members to focus on managing their pharmacy and, more importantly, servicing their customers.

HOW DOES ALLIANCE CONNECT WORK? Alliance Connect allows Pharmacy Alliance to manage and maintain products, supplier/manufacturer information, pricing and promotions for the pharmacy. Any changes or modifications made to this information is reflected in the pharmacy in real time. There is no more waiting until the next day. We recently spoke with Pharmacy Alliance member Jayson Atkins, Pharmacist and owner of Jayson Atkins Pharmacy. Jayson has implemented Z Software POS, Dispense and Office and is piloting Alliance Connect in his pharmacy. EDITOR: Why is Z Software different to other POS/Dispense systems? JAYSON: Z Software is a stable and well designed platform. Itâ&#x20AC;&#x2122;s great to have support from an accessible in-house team representing Pharmacy Alliance members who are dedicated to resolution of issues and ongoing improvement of the technical support.

EDITOR: With the Head Office solution, how will Pharmacy Alliance be able to support members? JAYSON: Alliance Connect for Z Software will seamlessly maintain our catalogue promotions, buying information, departmental structures, and planograms and pricing information. As such, this service allows us to focus on executing member initiative like the catalogue program and planograms. EDITOR: How will this make pharmacy staff more efficient? JAYSON: This now facilitates freeing up my staff from time consuming tasks and allows my staff more time to engage with customers. EDITOR: What is the feedback so far from the pharmacies that are on the pilot? JAYSON: After speaking with other members who are also on the pilot, the feedback so far is that there are still items in the development pipeline but this implementation has been a clear improvement on previous software solutions. All in all, we agree that this is a huge step in the right direction to making our life easier, so that we can focus on the more important things in our pharmacies â&#x20AC;&#x201D; something that will no doubt be to the benefit of all members. To learn more about Pharmacy Alliance and Z Software visit: http://www.pharmacyalliance.com.au/z-software

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

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BUSINESS

PROFESSIONAL SERVICES

More than just a sign?

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

BUSINESS

"Why put up a sign if you’re not going to actively promote it? The more reasons you give a customer to come into your store, the fewer reasons you are giving them to go elsewhere."

WARREN PARKES B.Pharm, Dip. Mgt, Cert IV TAE Professional Practice Pharmacist

WHEN YOU WALK INTO MOST PHARMACIES IN AUSTRALIA YOU WILL NO DOUBT SEE A SIGN CLAIMING THEY OFFER PROFESSIONAL SERVICES. DOES PUTTING A SIGN UP, LISTING AVAILABLE SERVICES MEAN ANYTHING TO YOUR CUSTOMERS?

The pharmacy industry is still in a flux of change with the PBS reforms placing a large number of pharmacies under financial pressure. There are a number of funding opportunities under the 6CPA, which is great, but it’s important to have a look at other opportunities to secure the long-term future of your business.

In most pharmacies the majority of customer contact is with pharmacy assistants, so if you’ve trained them in the details of the services you offer, they will be more likely to know what to look out for and be able to inform the customer of what you can offer them.

It may sound ridiculous, but do all your staff actually know all the services that your pharmacy offers? If your staff don’t know, what chance do your customers have? Pharmacies are happy to put the signs up and list many services, but this doesn’t mean the customers will see the signs or even know what they mean. It’s important that you actually offer services that are relevant to your customers. The ultimate goal of any professional service is to provide and add value to the customers’ experience in the pharmacy, as this will ultimately increase the profitability of your business.

FOR EXAMPLE:

It’s important to ensure your customers see the ‘value add’ your pharmacy offers compared to your competitors. More time spent engaging with your customers will enable you to gain a rapport with them. We all ensure we train our staff on how to take a prescription in and how to sell pharmacy-only and pharmacist-only medicines. However, Professional Services seems to be another story, as it seems to be only on a need-to-know basis. Is it because you think some staff don’t actually perform the service so they don’t need to know the details? How many missed opportunities for paid professional services are being lost because of insufficient training of all your staff?

Jenny comes into the pharmacy all excited as her daughter is due to give birth to her first grandchild. Amanda, one of your pharmacy assistants, is helping her with a number of things for her daughter and the baby. Your pharmacy is approved to provide vaccinations, so if Amanda is trained appropriately, what could she do next? Amanda could ask how long ago Jenny had a Whooping Cough Vaccination as it is recommended to have a booster every 10 years and at least two weeks before they come in contact with the baby. If Jenny tells Amanda she hasn’t had a booster for a very long time, Amanda could inform Jenny that the pharmacy offers a vaccination service where the pharmacist can administer a booster for her now if she would like. Amanda could explain the details of the service and if required, refer Jenny to the pharmacist for the service to be carried out. Business owner, motivational speaker and customer service expert, Tom O’Toole, sums up training perfectly when he says, “What if I train them and they leave? But what if you don’t train them and they stay?” Training your staff properly will not only lead to better productivity and better outcomes for the business, but also happier staff as they will feel better self-worth.

Why put up a sign if you’re not going to actively promote it? The more reasons you give a customer to come into your store, the fewer reasons you are giving them to go elsewhere. Pharmacies pay a lot of money to have beautifully printed repeat folders, which often list the services they offer, but do you have your staff pointing these out and explaining to customers what they actually entail, and how the customer can access them or benefit from them? The staff can only perform this task if they themselves know what it all means. It is important that when you decide to offer professional services, to ensure that what you offer is what your customers actually require. Their health needs should be taken into account and the services promoted and recommended accordingly. Talk to your customers, do market research, and offer customer surveys to ensure the services you offer fit the demographics of your pharmacy. Most people in life often ask the question “What’s in it for me?” (WIIFM) before they commit, so it’s important, as part of your staff training, to ensure the staff are able to communicate the benefits of each service to the customers. I’m sure you think your staff and customers all know what services you offer and what they actually are. Now, I challenge you to open up a conversation and see if they actually do!! Results may be surprising, but will provide you with direction to improve. If your staff are unaware of the available services, start the training process today and watch your professional services grow.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

HEALTH

Fish Oils F O R H E A LT H TALIA FELLER Naturopath Health World Limited

ARE WE SWIMMING UPSTREAM? Cardiovascular disease (CVD) is Australia’s leading cause of death and disease burden1 with 1 in 5 adults affected2. Poor dietary choices and sedentary lifestyles have led Australians to this unhealthy situation, so this, of course, needs to be addressed; however, an impactful option exists with omega-3 long-chain unsaturated fatty acids, comprised of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The international guidelines for omega-3 intake suggest a minimum of 500mg of EPA+DHA combined daily for cardiovascular health3, with the Heart Foundation supporting this recommendation4; however, Australians are just not getting enough. According to a recent food survey, 80% of the Australian population are not consuming sufficient omega-3, and 90% of women of childbearing age fail to get enough DHA5.

SO WHAT MAKES FISH OILS BETTER THAN OTHER SOURCES OF OMEGA-3? Omega-3s are termed ‘essential’ as they need to be obtained from dietary sources; however, plant-based omega-3s, such as alpha-linoleic acid, need to be converted in the body to EPA and DHA. This conversion process is inefficient, and may even be inadequate in some people, for example, those with an elevated dietary intake of saturated fats, high cholesterol, a glucose-

rich diet, excess alcohol consumption, elevated adrenaline and/or glucocorticoids (e.g. stressed individuals), advancing age, and/or diabetes. These factors may all inhibit the desaturase enzymes required for the endogenous formation of EPA and DHA6. The solution is fish oil derived from the fatty layers of cold water fish, which provides a source of EPA/DHA without the need for conversion.

HEALTH BENEFITS OF FISH OIL EPA and DHA are important structural and functional components in cell membranes. In addition, they play a significant role as anti-inflammatory agents, modulating the production of downstream eicosanoids and cytokines. It has also become apparent that both EPA and DHA are the substrates for a newly identified class of chemical mediators known as specialised proresolving mediators (SPMs)7, which are required for the healthy resolution of inflammatory processes. It is this combination of actions that make EPA and DHA beneficial not only for joint health, but also for healthy brain and nervous system development and function. In addition, they are of great benefit to the cardiovascular

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system, with evidence supporting the use of fish oils in the following cardiovascular conditions: • • • • • •

Dyslipidaemia8; Atherosclerosis9; Hypertension10; Arrhythmia11; Atrial fibrillation12; CVD events post infarction13.

PROVIDING SUPPORT FOR CUSTOMERS Consumers are becoming increasingly aware of their health and where their food originates from. With many fish species now imported, contamination with pollutants is a growing concern. In situations of insufficient oily fish intake, or cases of increased EFA need, supplementation may be required. Fortunately, convenient daily maintenance dosing or higher therapeutic dosing is possible with fish oil supplements. Within Australia you can easily recommend high-strength, reliable options that are sustainably-sourced, pure, and free from contaminants, therefore helping to allay consumer concerns, equipping them with a beneficial strategy to support their health.

HEALTH

“According to a recent food survey, 80% of the Australian population are not consuming sufficient omega-3, and 90% of women of childbearing age fail to get enough DHA.”

REFERENCES: Australian Institute of Health and Welfare. Leading causes of death. 2016. Available from: http://aihw.gov.au/deaths/leading-causes-ofdeath/ [Cited 23/05/16]. 2 Australian Institute of Health and Welfare. Cardiovascular disease. 2015. Available from: http://www.aihw.gov.au/cardiovasculardisease/ [Cited 23/05/16]. 3 Omega-3 Centre. International Omega-3 Guidelines. Available from: http://omega3centre.com/health-professionals/internationalomega-3-guidelines/ [Cited 23/05/16]. 4 Heart Foundation. Omega-3 fatty acid: The importance of fat in a healthy diet. 2015. Available from: http://heartfoundation.org.au/ news/omega-3-fatty-acid-the-importance-of-fatin-a-healthy-diet [Cited 23/05/16]. 5 Meyer BJ. Australians are not meeting the recommended intakes for omega-3 long chain polyunsaturated fatty acids: results of 1

an analysis from the 2011–2012 National Nutrition and Physical Activity Survey. Nutrients. 2016;8(3):111. doi:10.3390/nu8030111. Das UN. Essential fatty acids: biochemistry, physiology and pathology. Biotechnol J. 2006;1(4):420-39. Buckley CD, Gilroy DW, Serhan CN. Proresolving lipid mediators and mechanisms in the resolution of acute inflammation. Immunity. 2014.40(3):315-27. Howe P, Mori T, Buckley J. Long chain Omega-3 fatty acids and cardiovascular disease - FSANZ consideration of a commissioned review. FSANZ. 2013. Available from: www.foodstandards. gov.au/consumer/labelling/nutrition/ documents/FSANZ%20consideration%20of%20 omega-3%20review1.pdf [Cited 23/05/16]. von Schacky C, Baumann K, Angerer P. The effect of n-3 fatty acids on coronary atherosclerosis: results from SCIMO, an angiographic study, background and Implications. Lipids.

2001;36(Suppl):S99-102. Geleijnse JM, Giltay EJ, Grobbe DE, et al. Blood pressure response to fish oil supplementation: meta-regression analysis of randomised trials. J Hypertension. 2002;20:1493-1499. 11 Leaf A, Albert CM, Josephson M, et al. Prevention of fatal arrhythmias in high-risk subjects by fish oil n-3 fatty acid intake. Circulation. 2005;112(18):2762-8. 12 Calò L, Bianconi L, Colivicchi F, et al. N-3 Fatty acids for the prevention of atrial fibrillation after coronary artery bypass surgery: a randomised, controlled trial. J Am Coll Cardiol. 2005;45(10):1723-8. 13 Marchioli R, Barzi F, Bomba E, et al. Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI)Prevenzione. Circulation. 2002;105:1897-1903. 10

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BUSINESS

Multi-store ownership takes a change of Mindset

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

BUSINESS

PETER SACCASAN FACP FCA National Director, Pharmacy Services RSM Australia

IN 1986, A BOOK THAT WAS TO BECOME A BESTSELLER IN THE BUSINESS WORLD WAS PUBLISHED. IT WAS CALLED THE E MYTH BY MICHAEL E. GERBER. THE ‘E’ STOOD FOR ‘ENTREPRENEUR’ AND THE BOOK WAS PROBABLY RESPONSIBLE FOR THE POPULARITY OF THE PHRASE ‘WORKING ON YOUR BUSINESS AND NOT IN IT’.

Mr Gerber essentially identified that small businesses were generally operated by technicians who mistakenly thought they could run a business which specialised in the skill of the technicians, and that they could be entrepreneurs. “This”, he said, “was a fatal assumption”. To make an analogy, pharmacy owners do very little management training in their university course and yet often very quickly find themselves running a sometimeslarge retail operation. To quote Gerber, “It is a fatal assumption to think that if you understand the technical work of a business, you understand a business that does technical work.”

THE FIRST STORE Young pharmacy owners move into the ownership of their first store and to some it is a brave new world. Dispensing prescriptions, anticipated keenly as the crowning moment of why they endured university, turns out to be the last thing they get to do because of the myriad of management tasks that need to be attended to. It doesn’t matter what profession you undertake, generally your education won’t prepare you for ownership. Even accountants are not trained in how to run an accounting practice. Having transitioned to business ownership at 28, I can vividly recall some of the ‘eye-openers’ that I met early on which I simply did not expect or anticipate. So the pharmacist takes on a store and throws themselves into it — struggling with rosters, suppliers, staff, customers, stock, space, landlords, banks and solicitors … and accountants! After a while they get the hang of it and, despite themselves, some semblance of order descends upon the pharmacy. A routine develops and the business becomes a nice place to be. The next interesting moment comes when a second pharmacy is purchased. The same techniques are applied with a little bit of stretch and everything is managed to be held together. And then perhaps a third pharmacy is acquired and life starts to get interesting.

THE IMPACT OF MORE STORES With one store to concentrate on, the whole pharmacy is the focus. As the number of stores increases, it is challenging to ensure that the whole of EACH pharmacy remains the focus. In addition, the cash flows become quite large for the group and the dynamics are more intricate. The mindset change required is important. In the words of Gerber, “The technician needs to become an entrepreneur”. It is important to note too that Gerber’s use of the word ‘entrepreneur’ is a reference to a business manager, not to a wheeler and dealer. When the new businesses are bought, the ‘back-ofthe-envelope’ assessment is usually based on current cash flow of the existing business, the new business and some ‘blue sky’. After all, we are all naturally optimists. What we often fail to do is adjust the thinking when some of the assumptions drop out. For example, let’s say that in the original store, which may have been the cash cow that underpins the building of this empire, you decide to go to a major brand and undertake a refit. What does this do for cash flow? Firstly, the cash flow of the current business will either stop altogether or be drastically slowed. Secondly, there will be additional costs of the fit-out to pay for every month. Thirdly, once it is open, the new store might take some time to get back up to and exceed its previous performance. Does our ‘back-of-the-envelope’ thinking allow for the impact of these things? The impact of this type of normal business activity can be extended. What if you have

just geared up to buy the 4th pharmacy, the first pharmacy is doing the rebrand mentioned above and the plan for the new pharmacy is to refit the space as well? Suddenly, you have 2 remaining stores trying to meet the impact on cash flow of 2 stores which are running below par. And add to that, for example, the timing of the change of your bank loan from interest only to principal and interest repayments. Perhaps your bank loan is by now quite large and the principal reductions will be a big number. I think you get the picture.

MANAGING THE BALANCE SHEET As ‘the empire’ grows, the focus should expand. We still need to ensure that each pharmacy performs to the best of its ability. There is no replacement for the fact that the group survives in part from the bottom up — the cash comes from the better performance of each store. However, in addition to this, there needs to be a strong understanding of the impact on the need for cash and the use of cash, and of the decisions made at the top. Multistore owners need to stop and consider the impact on what they currently have and of what they are about to do. History is littered with failures of people who were apparently successful but they went hard on one acquisition too many or took too many wrong turns and pushed a successful group under water. Although it’s 30 years old, the original book by Michael Gerber and its successor The E-Myth Revisited are a worthwhile read.

“To make an analogy, pharmacy owners do very little management training in their university course and yet often very quickly find themselves running a sometimes-large retail operation.” GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

BUSINESS

TOP 10 Leasing Tips BY PHILLIP A. CHAPMAN Phillip A. Chapman is the Founder and Director of MiLease and Lease1, celebrating their 20th year specialising in Pharmacy retail leases and 7 years as a Gold Cross service provider.

Over the past 12 months this series of articles relating specifically to your retail lease has covered a lot of specific areas from research and relationships, through to selling your retail business.

4. KNOW YOUR LESSOR

Although we provide a lot of detail and recommendations to get the best from your lease negotiations and the Landlord/Lessee relationship, we still have Members calling daily who find themselves in situations due mainly to missing the basics.

Remember always that the nice Leasing Executive who buys you a coffee is employed by the Lessor to increase their business returns.

As this time of year (August through November) is when the majority of leases experience events and anniversaries, we thought it timely to revisit these basics. The following Tips are not new and should be understood by every Lessee/Manager and/ or advisor to your business:

1. RESEARCH IS MANDATORY Regardless of any negotiations you enter into, research is required to establish the outcomes you need to achieve. In retail, tenancy leasing research is needed on your industry, your business, the shopping centre, the Landlord and the current market.

2. LEVERAGE TIME Every lease has two common elements, a commencement date and, more importantly, an expiry date. Time can be your enemy or your friend. Make a conscious decision to leverage your negotiations. In most cases this means starting the process early. Don't be the one waiting for the Landlord to contact you, by then it's too late.

3. BENCHMARK REAL ESTATE PERFORMANCE Make it your business to know how the real estate you lease performs for your business, not how you perform for the real estate (landlord). Know your occupancy cost percentage and sales per square meter ratios and how these compare to industry benchmarks.

Before any negotiation, know who you are dealing with, their structure, their capacity to make decisions, and the process/reporting they need to make to have a deal approved.

5. KNOW THE SHOPPING CENTRE Just like having your own product knowledge, details about the Lessor's product — the shopping centre — are vital. Know what the majors turnover, the sales of the centre, and the number of customers. Find out how these compare to other similar shopping centres, because the Landlord is comparing your business against a wide range of others.

6. KNOW YOUR CAPITAL COSTS Before you look at any new lease, renewal, or option, have a clear and concise knowledge of your fitout/refurbishment costs. How long you need to amortise these comfortably and make these known within the negotiations, your lease needs to reflect achieving these Key Performance Indicators as well.

7. LEASE TERM TO EXCEED AMORTISATION Following on from tip number 6, the lease term should always exceed the amortisation of capital period. For example, if your capital is a facility over say 5 years, then your lease needs to be over 6–7 years.

8. MAKE MEETING FILE NOTES At each lease negotiation’s meeting, each phone call, and each e-mail, make notes. Keep a file in date order that is easy to reference. After each meeting, confirm your understanding of the points back to those you meet or call. Continue to maintain this file by adding notes after the lease has been entered into.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

You never know when you will need to rely on these to protect your position.

9. CREATE RELATIONSHIPS Establish positive and regular communication and professional relationships with Landlords, Agents, Centre Mangers, and even the Cleaners. You don't have to like them but you are in business with them. It’s much easier to raise a problem from within a positive relationship. Remember, Landlords keep file notes too and they have long memories.

10. GET ADVICE Don't go into lease negotiation without getting advice — not from friends or family, but from people who know. Source your advice from Industry Associations, Retailer Groups, Other Retailers, Franchisors, Government, Industry Experts, and Retailer Advocates. Don't be afraid to ask even what may seem like the simplest of questions. Get it wrong and it can cost you for a long time. A final issue that needs to be taken seriously is the shift in power to Landlords under the Location Rules. An alarming number of Pharmacists have contacted our office this year because they are under threat of losing their business due to aggressive and predatory competitive activity when it comes to their exposure when a lease approaches expiry. We cannot emphasis more the importance of getting the above basics right, and in particular Research and Leveraging Time (Tips 1 & 2). Ignore these and you could quite easily be handing your business over to someone else. Remember, for every Pharmacy that said, “I’m ok I’ve got a great relationship with my Landlord” there are a large portion that regret assuming the status quo. There is too much at stake to leave security of your business (tenure) to chance. See our advert in this edition for value added solutions.

ITK Advertisement - Gold Cross.pdf 1 4/28/2016 8:16:07 AM

BUSINESS

BEST OF BOTH WORLDS

PHARMACY GROWTH

continues, while Online Opportunities Abound

MARK BLITENTHALL Associate Director The Nielsen Company

GROWTH IN AUSTRALIAN PHARMACY CONTINUES TO OUTPACE THE GROCERY AND CONVENIENCE CHANNELS, AND THIS TREND COULD PERSIST WITH FURTHER DEVELOPMENT OF ONLINE RETAILING FOR HEALTH AND BEAUTY PRODUCTS.

Australians have increased their dollar spend at the pharmacy counter more than any other retail channel. Over-the-counter (OTC) pharmacy sales increased by 11% annually (52 weeks to 3 April 2016), compared to sales in grocery and convenience — both up by just over 3% in the same period.

seen strong traction for beauty-related categories online. The 2016 Nielsen Australian Connected Consumers Report showed that in 2015, 21% of online Australians aged over 16 purchased cosmetics, perfume and skincare online over a six-monthly period — up from 16% the prior year.

Channel innovation and competitive pricing has made pharmacies an increasingly attractive shopping destination. Research from Nielsen’s Homescan Shopper Panel revealed that in 2015, an additional 258,000 households shopped in a pharmacy outlet, compared to the previous year. The vitamins category, due to its size and attractiveness to other markets (Asia in particular), is another key driver behind the solid performance in the pharmacy trade.

Looking outside of Australia, we know that online is already a strong channel for health and beauty categories in neighbouring countries. Nielsen data to June 2015, showed that in China, online accounted for one-third of total category sales for baby-related products — an increase of 40% on the previous year. Similarly, 25% of personal care products moved through the online channel in China — up by 35% on the previous year.

And, while sales in pharmacies continue to flourish, it is imperative that retailers focus on and leverage the online trade to sustain this upward growth trend. We have already

With intense competition for health and beauty products online, the key to success for Australian pharmacies lies in understanding consumers’ motivation to purchase. Factors including convenience, product assortment,

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

product information and reviews, value for money, and useful online features should all come together to provide a winning online shopping space for consumers. That being said, retailers also need to look for ways to optimise the entire purchase process. Nielsen’s Category Shopping Fundamentals study shows that beauty and personal care categories demonstrate high levels of planning. This represents an opportunity to reach consumers of these categories pre-store with lots of product information and reviews online. Digital should be viewed as an opportunity for traditional pharmacy outlets. Instead of thinking in terms of online and off, retailers should be taking an integrated approach to drive sales in both, while providing an engaging experience for consumers regardless of whether they buy in-store or online.

BUSINESS

KEY DRIVERS OF PHARMACY KEY DRIVERS OF PHARMACY GROWTH IN AUSTRALIA

GROWTH IN AUSTRALIA

+ +

INCREASED PATRONAGE +258,000 HOUSEHOLDS

GROWTH +10.8%

CHANNEL INNOVATION

OF PHARMACY AUSTRALIA

Source: Aggregated Nielsen services/ studies

INCREASED PATRONAGE +258,000 HOUSEHOLDS

ONLINE

"Australians have increased their dollar spend at the pharmacy counter more than any other retail channel."

GROWTH +10.8%

RODUCT D SERVICE NOVATION

dies

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

CONTINUING PROFESSIONAL DEVELOPMENT

Quantifying the

Customer Experience DANNY AGNOLA B.Pharm, James Cook University Member of the Australian College of Pharmacy

LEARNING OBJECTIVES After reading this article, the learner should be able to: 1. List the steps in dealing with a customer complaint. 2. Recognise the different ways a customer can review your pharmacy. 3. Identify the different priorities consumers use to assess a pharmacy. 4. Describe the process involved in measuring the Service Quality Index Rating and Customer Experience Index.

Competencies Addressed: 1.4, 2.1, 3.4 Accreditation number: A1608GX1 This activity has been accredited for 0.75hrs of Group 1 CPD (or 0.75 CPD credits) suitable for inclusion in an individual pharmacistâ&#x20AC;&#x2122;s CPD plan which can be converted to 0.75hrs of Group 2 CPD (or 1.5 CPD credits) upon successful completion of relevant assessment activities.

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CONTINUING PROFESSIONAL DEVELOPMENT

WITH THE ADVENT OF WEBSITES AND PHONE APPS SUCH AS TRIPADVISOR, TRUELOCAL AND EVEN GOOGLE REVIEWS, IT HAS BECOME EXTREMELY SIMPLE FOR CONSUMERS TO SEARCH FOR REVIEWS AND CRITICALLY REVIEW MANY DIFFERENT TYPES OF BUSINESSES, INCLUDING PHARMACIES. WHAT DO YOU DO IF YOUR PHARMACY IS THE SUBJECT OF A NEGATIVE REVIEW? WILL IT AFFECT YOUR BUSINESS? AND MORE IMPORTANTLY, HOW CAN WE BE SURE TO KEEP THE CUSTOMER SATISFIED BEFORE LEAVING THE STORE?

CONSIDER THE FOLLOWING:

The male pharmacist who served me was rude and condescending and deliberately embarrassed me. He thinks he has the right to raise his voice and talk over customers when what he really needs to learn is manners and basic listening skills. Shame on him1!

I was able to find the above reviews about local pharmacies in a matter of minutes. Both of these pharmacies also had received many positive reviews, but unfortunately it is the unhappy consumers who are the ones most likely to post online. Due to human nature and issues which are out of our control, we can never satisfy everyone 100% of the time, especially in pharmacy. But it is how we approach a complaint or a dissatisfied customer that is paramount. Employing the following six steps will go a long way in not only dealing with an unhappy consumer, but making sure they return to your business: 1.

Don’t interrupt. Listen carefully to what the customer has to say, and let them finish;

Ask questions in a caring and concerned manner;

Put yourself in their shoes;

Apologise without blaming;

Ask the customer, “What would be an acceptable solution for you?”;

Solve the problem, or find someone to solve the problem – quickly3!

Now that we have learnt how to deal with a consumer complaint, how do we prevent complaints from happening? If we were to gauge a customer’s satisfaction before leaving the store, would that enable us to improve our performance and prevent unnecessary reviews from happening both online and by word-ofmouth? If so, what are some of the ways we can measure customer satisfaction before a customer leaves the store?

Tonight at 10.30pm, rocked up. Left my script. Then waited for the next 15-20 minutes watching everyone else get served (over 10 people after me in the line). This isn’t the first time their priorities haven’t been fixed on customer service. Prices are average (except for their home brand). Never have I felt so ignored 2.

WHAT IS QUALITY? Many consumers have a different definition of what ‘quality’ means to them. The ISO 8402-1986 standard defines quality as “the totality of features and characteristics of a… service that bears its ability to satisfy stated or implied needs4.” Service quality has been linked to many and varied pharmacy business performance metrics, including customer satisfaction, loyalty, word-of-mouth referral, price insensitivity, sales growth and market share5. How is this relatable to health care delivery? Consider the following formula:

SQ = f ( FQ, TQ ) SQ = SERVICE QUALITY Overall consumer perceptions of quality provided by pharmaceutical services.

FQ = FUNCTIONAL QUALITY Perceptions by the consumer about how the services were delivered (e.g. Were services fast and friendly?)

TQ = TECHNICAL QUALITY Perceptions by the consumer about what was received from those services (e.g. Did the consumer get the drug? Did they get counseled?) Figure 1: Model of pharmaceutical service quality 6

“What do you do if your pharmacy is the subject of negative reviews? And more importantly, how can we be sure to keep the customer satisfied before leaving the store?”

We can see consumer evaluations of service quality are a function of how the service is perceived to be delivered (i.e. functional quality) and perceptions of what is received for that service (i.e. technical service). They are interrelated, and both are critical in assessing service quality. In other words, how a service is delivered can affect a customer’s perceptions of outcome, and the outcome of service can influence perceptions of how the service is delivered 6.

SERVICE QUALITY INDEX RATING (SQI RATING): Generally speaking, a quality index rating is a ‘measure of quality.’ The index rating can be measured in one of two ways: the metric based approach or the Question-Answer (QA) based approach. Both these methods enable the tabulation of consumers responses via a point score directly (eg, 1-10) or by objectively gauging responses via a questionnaire. How are these ratings done in pharmacy? An independent research group conducts over 1500 online interviews with pharmacy consumers in Australia every year. These interviews provide a base line result for quantitative comparison and involve every demographic group. Pharmacies are then given a Service Quality Index rating based on customer feedback on the following criteria:

•• Personalisation – providing a tailored customer experience;

•• Understanding – demonstrating empathy for the customer’s needs;

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

“Data from the mystery shopping program associated with QCPP showed a number of pharmacies scoring an ‘unsatisfactory’ result.”

CONTINUING PROFESSIONAL DEVELOPMENT

•• Simplicity – making the process quick and easy for the customer;

•• Reliability – consistently delivering high quality customer service;

•• Satisfaction – delivering, and exceeding, customer expectations7.

SURVEYS: A customer survey can be carried out in store (on paper, iPads) or with the customer’s consent via email or online through service providers such as Survey Monkey or People Pulse. These simple questionnaires can be developed to help identify consumers' likes and dislikes, and even areas for improvement that might exist in your business. So what are some tips for creating a customer survey to improve aspects of your business? According to www.surveymonkey. com, it depends on if you want to concentrate on customer loyalty, improving the customer experience or establishing performance goals. Fundamentally, your questions will need to be clear, specific and always ask lots of questions. When we ask lots of specific questions rather than just one general question, it will not only make your questions easier to answer for your respondents, but it will also make your data easier to analyse and act upon8.

CLIENT FOCUSED EVALUATION PROGRAM (CFEP): The Client Focused Evaluation Program (CFEP) in partnership with the Quality Care Pharmacy Program (QCPP) has been gathering and measuring outcomes of customer feedback. This partnership ties in with the QCPP’s Requirements Manual Element 6 Action 1, “ensuring the business model/mix is responsive to consumer requirements and market pressures as well as internal business circumstances9”. Once a QCPP-accredited pharmacy is enrolled in CFEP, survey forms, envelopes as well as a collection box are delivered to the pharmacy. All customer identification

information is filtered out by CFEP when they collate and evaluate the answers. Having done so, CFEP reports back to the pharmacy with a comprehensive report showing a summary of the answers to each of the specific questions, a comparison with other pharmacies participating in CFEP and customers' comments. These surveys provide pharmacy owners and their staff with knowledge on how patients choose to experience their pharmacy care. The honest feedback from customers, has led pharmacies to make sometimes small, but nevertheless, significant changes to how they are run. Consider the following quotes from pharmacy staff after the program was completed10: “Made staff aware of protocols relating to privacy whilst speaking with customers.” “We are now separating our prescriptions counter to have a script-in and scriptout side and putting up barriers so all customers get served in order.” “Addressed greeting of customers with our staff.”

MYSTERY SHOPPING PROGRAM: I am sure many of us in our careers have been the ‘victim’ of a mystery shopper. Mystery shopping or a ‘secret shopper’ as it is also referred to, is a tool used externally by market research companies or internally by businesses or organisations themselves, to measure the quality of service and specific information about products and services. This program is conducted in many different ways in pharmacy, but generally mystery shoppers assess:

•• S taff member’s initial greeting; •• Staff friendliness, professionalism and knowledge;

•• S tore cleanliness and presentation; •• Range of products and services; •• Promotions or loyalty programs11. Data from the mystery shopping program

associated with QCPP showed a number of pharmacies scoring an ‘unsatisfactory’ result12. This ‘disappointing number’ was only 6% according to previous Pharmacy Guild President Kos Sclavos, and was due to the strict marking system associated with the program13. Even though this particular program related specifically to Supplying Pharmacy Only Medicines and Pharmacist Only Medicines, it provided pharmacy owners and managers with an insight into ways the pharmacy could improve the customer experience. This was achieved through the store’s general appearance, or the knowledge of the pharmacists or pharmacy assistants and their ability to build customer relationships.

CONSUMER EXPERIENCE INDEX (CEI): “Seeing your business through your customer’s eyes.” The above is the call sign of an initiative by The Pharmacy Guild of Australia. Customer experience measurement programs are gaining widespread acceptance as a valuable management tool for improving the service delivery performance of an organisation. It enables a business to evaluate customer service, identify patterns and trends, continually build the brand the business is hoping to build, develop sales strategies, improve performance, reinforce training and motivate staff. The Customer Experience Index (CEI) itself is seen as a business tool which provides business insights from a customers' perspective, discusses improvement opportunities and delivers industry benchmarked data to pharmacies14. What are some of the design measures that allow the overall customer experience to be tabulated? These include:

•• •• •• •• •• •• ••

Operational performance; On-site branding and merchandising; Product availability and placement; Up-selling products and services; Wait and service time; Sales force effectiveness; leanliness and general appearance C of premises both interior and exterior;

•• C leanliness and functionality; •• Staff appearance, friendliness and engagement;

•• Overall on-site customers' experience. GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

CONTINUING PROFESSIONAL DEVELOPMENT

How are the above indicators measured? The measurement of a CEI is a high level process as detailed in the following steps. Firstly, the CEI employee will greet the pharmacy, will undertake a pharmacy appearance and service evaluation using a checklist template, speak with customers and collect customers' experiences in a survey form, collate the data and provide feedback to the pharmacist owner or manager. This process tends to take around 2 hours in total, however, only 20-30 minutes of the pharmacist owner/manager’s time is required which makes it generally a non-invasive process. Following the visit, the pharmacy will receive a formal report which includes detailed feedback on the pharmacy premises and accessibility, staff interactions and services and the overall pharmacy appearance.

WHAT IT MEANS TO YOUR BOTTOM LINE: Highlighting customer service positives and negatives to your staff is obviously worth money to your pharmacy. But how will you notice this rise in profit in my store?

High levels of customer satisfaction can achieve this in one of four ways15: 1. Y ou’ll save money by retaining customers – keeping a customer happy means your store is less likely to lose them to a competitor. Once you lose a customer, acquiring a new one can cost anywhere from four to ten times more money15; 2. Y our revenue will grow a lot – businesses that ensure high levels of customer satisfaction by acting on feedback have an economic advantage16; 3. You’ll avoid negative online reviews – as mentioned earlier, preventing a disgruntled customer from posting online will benefit your business financially; 4. Your employees’ performance will improve – a great feedback tool for your pharmacy will also help improve your employees’ performance as it motivates them to strive to provide the best service.

And so we can see the vital importance insight into our customers’ methods of thinking and how ‘happy’ they are with the custom and knowledge of our staff, and the services the pharmacy business provides. By adopting one of the above programs, they will also appreciate being able to genuinely provide feedback to a pharmacy looking to improve. So when was the last time you adopted a feedback mechanism in your store, or Googled your pharmacy and read the customer reviews?

REFERENCES: True Local Reviews. Cited April 2016. Available from: www.truelocal.com.au Google Reviews. Cited April 2016. Available from: www.google.com.au/reviews. 3 Ridler B. Six steps to dealing with customer complaints. Cited April 2016. Available from: https://www.eonetwork. org/octane-magazine/special-features/sixstepstodealingwithcustomercomplaints. 4 Business Dictionary. Cited April 2016. Available from: http://www.businessdictionary.com/definition/quality. html. 5 Bell S, et al. Customer Relationship Dynamics: service quality and customer loyalty in the context of varying levels of customer expertise and switching costs. Journal of the Academy of Marketing Science. 2005:Vol33:No2:169-183. 6 Holdford D, Schulz R. Effect of technical and functional quality on patient perceptions of pharmaceutical service quality. Pharm Res. 1999;16(Sep):1344-51. 7 Haggan M. Amcal chalks up two years as best service winner. Cited May 2016. Available from: https://ajp.com. au/news/amcal-chalks-two-years-best-service-winner/. 8 Survey Monkey. Cited April 2016. Available from: https://www.surveymonkey.com/mp/customer-satisfactionsurveys/. 9 Quality Care Pharmacy Program: Requirements Manual, The Pharmacy Guild of Australia, Updated August 2014. 10 Matthews A. QCPP pharmacy patient questionnaire. Excellence: Supporting Excellence in Pharmacy. July-August 2014:25-27. 11 Mystery Customer: Services for pharmacies and chemists. Cited April 2016. Available from: http:// mysterycustomer.com.au/services-pharmacies-and-chemists. 12 Reeves P. New scope and latest results for mystery shopper program. Excellence: Supporting Excellence in Pharmacy. July-August 2012:12-14. 13 O’Donoghue N. Pharmacy News: Mystery Shopper data not for public consumption: Guild. Cited May 2016. Available from: http://www.pharmacynews.com.au/News/Latest-news/Mystery-Shopper-data-not-for-publicconsumption-Gu. 14 Pharmacy Guild of Australia: Victoria Branch. Cited April 2016. Available from: https://www.guild.org.au/ vic_branch/membership/customer-experience-index. 15 Dindar S. 4 ways customer feedback can increase profits. Cited April 2016. Available from: http://customerthink. com/4-ways-customer-feedback-can-increase-profits/. 16 Bradley K, Hatherall R. The powerful economics of customer loyalty in Australia. Cited May 2016. Available from: http://www.bain.com/offices/australia/en_us/Images/BAIN_BRIEF_The_powerful_economics_of_customer_ loyalty_in_Australia.pdf 2

The assessment questions below can be found at the Guild Pharmacy Academy myCPD e-learning platform. Login or register at: www.mycpd.org.au

QUESTION 1 What should you NOT do if a customer has a complaint about the service in your pharmacy? a. Listen carefully to what the customer has to say, but don’t hesitate to interrupt them if necessary b. Apologise without blaming c. Put yourself in their shoes d. Find someone to solve the problem quickly

QUESTION 2 Which of the following is NOT a tip when writing a survey for your store? a. Ask lots of questions

CONCLUSION:

ASSESSMENT QUESTIONS

b. Be clear c. Be specific d. Quantify questions

QUESTION 3 Which of the following is NOT a measure used when tabulating a customer experience index? a. b. c. d.

Staff appearance and friendliness Amount of external parking Cleanliness and functionality Sales force effectiveness

QUESTION 4 Which of the following customer feedback mechanisms is best described as the measure of quality via a quality ratings score? a. b. c. d.

Mystery shopping program Service quality index Online survey Client focused evaluation program

QUESTION 5 How much of the pharmacist’s/ manager’s time is generally taken up during a customer experience index store visit? a. b. c. d.

2 hours 10 minutes 1 hour 30 minutes

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

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Eight Tips for Successful Succession FRANK SIRIANNI Pharmacy Valuer and Management Consultant, MEDICI CAPITAL Twitter - @ medicicapital

Frank Sirianni can be contacted at Medici Capital, Level 10, 52 Collins Street, Melbourne VIC 3000 or by email at office@medici.com.au. Medici Capital, industry leaders in pharmacy valuation, finance and management consulting. Helping pharmacists achieve their goals. www.medici.com.au

THERE IS NO ONE WAY OR BEST WAY TO PLAN YOUR RETIREMENT. IT REQUIRES CAREFUL PLANNING AND NEEDS TO BE TAILORED TO EACH INDIVIDUAL. SOME PHARMACY OWNERS SAY THEY REGRETTED SELLING THEIR PHARMACY WHILE OTHERS HAVE ENJOYED THE NEW HORIZON. THERE ARE WAYS TO IMPROVE YOUR CHANCES TO EXIT YOUR PHARMACY SUCCESSFULLY AND ENJOY A REWARDING RETIREMENT — “NEXT PHASE OF YOUR CAREER”. HERE ARE SOME COMMON SUCCESSION (EXIT) PLANNING MISTAKES FOR YOU TO AVOID.

Many vendors can end up unhappy because they are unable to adapt to retirement and tend to look at retirement as being the “final stage”. However, if you take the view that life is really a series of cycles in which you reinvent yourself every 5–10 years, you’ll be much better prepared for the next cycle: post-pharmacy ownership. A retirement of 20 or 30 years gives you a lot of time to test out new roles for yourself, and if you do, you've boosted the odds that you'll succeed at retirement. As you begin to think about exiting your business and redefining yourself (for many pharmacy owners their business is what defines them), there are a number of lessons for you.

1. EXIT WHEN THE TIME IS RIGHT FOR YOU — BE READY Exiting from your pharmacy early may seem like a status symbol, signalling your financial success. But that doesn't mean it's the right thing to do. Make sure you have considered all of the business, personal, financial, estate and tax issues. Use a consultant who is trained and experienced to help you wrestle with these issues. Plan early and consider all the issues: financial, emotional, and lifestyle. I recommend that you allow at least 5 years to enable all the required processes to be

completed properly, including preparing your pharmacy for sale. Preparing yourself to let go can include: 1. Building a future pathway for you. This may include activities and new horizons for your time after pharmacy ownership. There is only so much golf that one can play. We have often seen vendors come back looking to buy another pharmacy. 2. Building a satisfying and rewarding life beyond ownership. 3. Considering a financial plan which addresses: a. what you will do with the proceeds of the sale; b. the timing and key milestones you wish to achieve; c. your protection. 4. Considering “counselling” to let go. If it is still too difficult, surround yourself with a support team which will help you through the process. Maybe you need to consider professional help, but at the very least, give some thought to having mentors who have been through the process — owners who have completed a succession plan.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

There are many mentors and other pharmacy owners you could discuss this with, but be careful of the bravado that you may hear on the golf course!

2. CONSIDER A STAGED SUCCESSION PLAN For all of us, retirement is inevitable. While we can choose how and when we might go, ultimately we cannot continue forever. A good solution for many pharmacy owners is to use partnership as a staged succession plan. This provides you with a method to ease yourself into the next phase (or retirement), while creating opportunity for ownership for young pharmacists. It also provides a valuable transition of knowledge and management skills from you to the next generation. Many owners find this method both financially rewarding, as well as providing the structured framework for making themselves ready to let go. However, to be successful, it needs to be a relatively structured plan. Succession to a junior partner enables independent community pharmacy to survive and grow.

"Exiting from your pharmacy early may seem like a status symbol, signalling your financial success."

3. UNDERSTAND YOUR PHARMACY’S VALUE

5. COMMUNICATE WITH YOUR FAMILY AND SUPPORT NETWORK

You've built up a nest egg, but for many, a significant percentage of their wealth is the value of their pharmacy. Make sure you understand the value of your pharmacy before you plan your financial future.

Spending decades of your working life with a spouse or significant other(s) doesn't necessarily mean you've shared all your thoughts and dreams about retirement.

Our data indicates that more than half of the pharmacy owners we deal with overestimate the value of their pharmacy. Do you know what your pharmacy is worth? A great financial retirement plan based on an incorrect assumption can do a great deal of harm. Have your pharmacy valued by an experienced pharmacy valuer, but be cautious relying on business brokers — they may have a vested interest. Then discount the results in planning and funding your retirement plan. It’s important to be conservative when you’re planning the financial security of your future.

4. BE OPEN AND FLEXIBLE For many boomers, retirement is the first time in their adult lives to be their own boss — no longer servants to the government or customers. That is, if you choose to sell. While planning what you want to accomplish in retirement can be exciting, it can also be overwhelming. You should have some sort of a “retirement-life plan”, but it shouldn’t be carved in stone. Consider breaking up your retirement plans into small periods. Think of your retirement in two-year blocks and plan two years out while having an overarching series of objectives and, perhaps, key frameworks. Be open and flexible, and seize the opportunities as they arise.

Consider sitting down with your spouse to write down a list of retirement goals — separately. Then compare them. You might find that the two lists look very different. The challenge is then to find middle ground that leaves both feeling they will have a retirement they can look forward to. Also, communicate with your broader support network, or friends and family. They know you well and may provide some sound advice on your plans.

BUSINESS

7. CONSULTING OR LOCUM WORK MAY BE AN OPPORTUNITY FOR SOME When it comes to pondering a post-retirement activity, the field of consulting or locum work is a perennial favourite. But how many locums does the pharmacy really need? If you're expecting locum work to help pay the bills in retirement, test the waters before you dive in.

8. EASY DOES IT Many boomers may want to avoid the unfulfilling years of leisure lived by their parents in retirement, but it's possible to veer too far in the other direction as well. Make sure your life is balanced and addresses all of your physical, spiritual, and mental needs at the same time.

6. RESEARCH, TEST, AND REVIEW Retirement dreams and reality often clash. What you enjoy during a 10-day vacation isn't necessarily what you'll want from 20 years of retirement. The same rules apply to retirement careers. Whether you plan to start another business or move to Italy, it’s a good idea to test-drive your plans before you begin. Work in a similar business for a few months before making the leap, or spend a few months in Rome before you buy that villa. Also, consider contribution to the profession. Many pharmacists use the early part of their retirement from ownership to mentor others, contribute to the various professional associations, support their local community, and provide contribution to the pharmacy profession and the community. Don’t let your experience be lost. It is often very valuable.

WHAT ARE YOUR IDEAS? Tell us your story. What are your ideas? How are you working on your retirement? Tell us some success stories. Let’s discuss — email us at office@medici.com.au or call Medici Capital on (03) 9853 7933 for further information or to discuss the results. The following provides a summary of the websites where more information can be obtained: Medici Capital – Corporate Website www.medici.com.au Practice4Sale – Listing Service for Pharmacy Sale www.practice4sale.com.au Jobs4Careers – Listing Service for Pharmacy Jobs www.jobs4careers.com.au Attain – Business Brokers and Property Sales www.iattain.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

PRODUCT INSIGHT

The best

HRT Outcomes start with the best Ingredients

1. Sharquie, K.E., Al-Hamamy, H.R., Noaimi, A.A. and Tahir, vulgaris with 5-alpha avocuta cream 2% in comparison w blind comparative study)’, Journal of Cosmetics, Dermato 2, 179-183, http://dx.doi.org/10.4236/jcdsa.2012.23034

2. Evaluation of Different Formulations applied to Psoriasi

AS AWARENESS OF HORMONE-RELATED PROBLEMS HAS GROWN, SO HAS THE MASS PRODUCTION OF MEDICATIONS TO TREAT THEM. BUT EACH PERSON’S BODY IS DIFFERENT, AND COMMERCIALLY MANUFACTURED PRODUCTS, WHICH TEND TO BE “ONE-SIZE-FITS-ALL”, DON’T ALWAYS ACCOUNT FOR THAT.

A C c L

P 8 p

C M

"The cream form is gentle, yet stable and durable, simulating the natural moisturising barrier of the skin through its emulsion system to deliver the ideal release profile for Active Pharmaceutical Ingredients (API) like progesterone."

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

PRODUCT INSIGHT

Not only was PCCA the first supplier to provide hormone replacement therapy products for compounding, we also back them up with studies and continue to innovate new solutions to help your patients feel like themselves again.

VersaBase is the most used base for vaginal and topical hormone preparations.

NO TWO WOMEN ARE ALIKE, OF COURSE, AND COMPOUNDING PHARMACISTS UNDERSTAND THIS FACT

The cream form is gentle, yet stable and durable, simulating the natural moisturising barrier of the skin through its emulsion system to deliver the ideal release profile for Active Pharmaceutical Ingredients (API) like progesterone. Formulated without oil, parabens, propylene glycol, petrochemicals or petrolatum, VersaBase is odour-free and spreads easily and absorbs quickly.

Pharmacy compounding is the art and science of preparing customised medications for patients. The advantage of compounded HRT is that it can be adapted specifically to fit each individual’s body and hormone levels. HRT can utilise hormones that have the exact chemical structure as the hormones in the human body. The body recognises them and allows them to mimic the function of the hormones the body produces on its own.

VersaBase’s gel form is transparent, smooth and light to touch, with a silky feel that spreads and absorbs easily. It is extremely stable, is formulated without surfactant emulsifiers, and can be used topically, vaginally and on mucous membranes. It can be used as a thickener or stabiliser for oil-in-water emulsions, to easily create hydroalcoholic gels for hormone replacement therapy in men, or to make surfactant-free “gel-creams”.

A compounding pharmacist can provide a hormone evaluation for the patient to fill out. A pharmacist experienced in HRT may assist the healthcare provider in helping interpret the results of serum of saliva tests which measure a patient’s hormone levels. The healthcare provider, compounding pharmacist, and the patient can use the results of these diagnostic tools to help determine a course of treatment which will give the patient the exact amount of hormones her body needs.

Both VersaBase Cream and Gel are:

Working closely with a woman and her healthcare provider, a compounding pharmacist can help a woman start and maintain a hormone replacement regimen that brings her hormones back into balance and closely mimics what her body has been doing naturally for years. With a healthcare provider’s prescription, the pharmacist can prepare hormones in a variety of strengths and dosage forms.

PCCA #30-3530

Once the therapy has begun, the pharmacist will continue to work with the woman and her prescriber to make sure the HRT is working correctly, adjusting the dosage if necessary to ensure that the medication is just right for her body. The advantage of compounded HRT is that the dose can be adjusted to fit a person’s specific needs and hormone levels. Topical administration is often a good choice for HRT, but it’s important to use a base that is proven to deliver the hormones through the skin effectively.

VERSABASE® Cream: PCCA #30-3641 | Gel: PCCA #30-3656 Exclusively available to PCCA members,

•• Stable – Can be formulated with a variety of Active Pharmaceutical Ingredients (API) at a wide pH range;

meet the specialised needs of compounding pharmacists. Every batch of the dilution is meticulously tested to ensure accurate potency and content uniformity. Each 1 Gm of PCCA Estriol Dilution contains 0.01 Gm (10 mg) of estriol, and each 1 Gm of PCCA Estradiol Dilution contains 0.01 Gm (10 mg) of estradiol in a 100% naturally derived, patent-pending solvent system. The loss on drying and potency assay have already been accounted for in the dilution to save time and help ensure accurate dosing. These dilutions can be used in making a wide variety of topical and vaginal hormone preparations. Benefits:

•• Safety – No free-flowing powders minimises exposure to highly potent hormones;

•• Convenience – Eliminates the need to weigh static-prone powders and prepare various powder triturations for each formulation;

•• Ease of use – Easily mixes into cream or gel base since the Active Pharmaceutical Ingredients (API) are already solubilised, providing improved content uniformity.

•• Versatile – Can be used topically or vaginally; the gel can also be used on mucous membranes.

SPECIAL MICRONISED PROGESTERONE PCCA’s Special Micronised Progesterone not only meets USP standards, it exceeds them when it comes to particle size, with independent testing results showing 99% less than 5 microns. Regardless of the delivery method, reduced particle size can result in increased therapeutic response — and a better product for your patients. Features:

•• Particle size – 100% <10 microns and 95–99% <5 microns;

•• Quality – Above and beyond USP standards;

•• Verified – Tested in PCCA formulations;

•• Consistent source – FDA-registered and GMP-compliant facilities.

ESTRIOL AND ESTRADIOL DILUTIONS Estriol: PCCA #55-4893 Estradiol: PCCA #55-4892 PCCA is the only company in the compounding industry that offers 10 mg/Gm dilutions of both micronised estriol (E3) and micronised estradiol (E2) in solution to

HORMONE THERAPY IS DESIGNED SPECIFICALLY TO YOUR PATIENT’S BODY HRT is most often prescribed to ease the symptoms of menopause, but it also can be used to treat a variety of conditions that women of all ages may experience, including:

•• •• •• •• •• •• •• •• •• •• •• •• •• ••

Pre-menstrual syndrome (PMS); Irregular menstrual cycle; Moodiness; Infertility; Post-partum depression; Weight gain; Endometriosis; Fibrocystic breasts; Sleep disturbances; Hot flushes; Night sweats; Decreased libido; Painful sexual intercourse; Vaginal dryness.

Would you like more information about PCCA Membership? Contact us today: (02) 9316 1500 or visit www.pccarx.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

HEALTH

A Patented Paracetamol and Ibuprofen Analgesic DR HARTLEY ATKINSON M.Pharm (Dist), Ph.D. Managing Director, CEO AFT Pharmaceuticals

Paracetamol and ibuprofen are combined in Maxigesic for simple, broad-spectrum pain relief that is greater than its individual parts. Maxigesic merges standard OTC doses of paracetamol 500mg and ibuprofen 150mg — first line mainstays of pain relief around the world — in the one-dose form for effects that go beyond what either ingredient can provide alone. Invented and developed by Perth-born pharmacist, Dr Hartley Atkinson, Maxigesic has attracted interest around the world and is currently licensed for use in over 109 countries. Maxigesic utilises these two widely used active pain ingredients, paracetamol 500mg and ibuprofen 150mg, and combines them in a specific formulation. The dose is given as one to two tablets every six hours, up to eight tablets a day. The maximum dose corresponds with the maximal daily dose of paracetamol (4000mg) or ibuprofen (1200mg) when given without a prescription. Although Maxigesic uses a lower single dose amount of ibuprofen, ibuprofen displays a shallow dose response curve between 50 and 400mg doses and Maxigesic has been shown to be more effective than a daily full dose OTC ibuprofen (1200mg/day). This is in contrast to the other registered paracetamol/ibuprofen combination products (Paracetamol 500mg/ Ibuprofen 200mg) in Australia which are not more effective than 1200mg/day ibuprofen at their recommended maximum doses. TOTPAR response as a proportion of Placebo

IBUPROFEN DOSE RESPONSE

SYNERGISTIC BENEFITS OF TWO MECHANISMS OF ACTION Pain is a multifactorial clinical entity and to manage it most effectively, treatment also

should be multimodal. Maxigesic fulfils this need in the one tablet by reducing pain through two complementary metabolic pathways. Maxigesic’s paracetamol component is thought to act on the endogenous cannabinoid receptor system, while ibuprofen inhibits COX-1 and COX-2 pro-inflammatory enzymes. Although not always directly relevant to use in humans, interestingly this double-headed pharmacological approach has been shown to be synergistic in animal acute pain studies.5 Prescribing both paracetamol and ibuprofen together is not new nor uncommon — it occurs routinely in hospitals, outpatient clinics and dental and day surgeries to treat post-operative pain6–9. However, whereas paracetamol is typically given in a dose regimen of six-hourly, ibuprofen is given in an eight-hourly dosing interval10. Because asynchronous dosing can affect adherence and persistence11, the single-dose formulation and simplified dosing that Maxigesic provides should improve compliance and hence outcomes. In addition, there is the benefit of full patient instructions — warnings and precautions being brought together rather than risk patient confusion as key information is spread across different packaging.

CLINICAL DATA In 135 patients recovering from oral surgery for wisdom teeth extraction, pain relief provided pre- and postoperatively by Maxigesic was found to be superior to that of the maximum OTC daily doses of paracetamol (4000mg) and ibuprofen (1200mg) alone in a double-blind randomised controlled trial (RCT). Combination therapy resulted in significantly less pain recorded on a Visual Analogue Scale (VAS) at rest and on activity — one third lower than for paracetamol and 35.8% lower than for ibuprofen — in the first 48 hours. Moreover, there was no evidence of pharmacokinetic interaction between the two actives administered together 12.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

FURTHER RESEARCH EVIDENCE In a further double-blind, parallel-group doseranging RCT of 159 patients who had two to four wisdom teeth removed, a two-tablet, one-tablet and half-tablet dose of Maxigesic or placebo was given four times a day for 24 hours. The mean-adjusted Sum of Pain Intensity Difference (SPID) in all the Maxigesic doses was significantly higher than placebo, consistent with superior pain relief for all Maxigesic doses.

DOSAGE, INDICATIONS, CONTRAINDICATIONS AND CAUTIONS The usual dosage is one to two tablets taken every six hours as required, up to a maximum daily dose of eight tablets. Maxigesic should not be used in children

HEALTH

under 12 years of age, nor combined with other medications containing paracetamol or ibuprofen. It is also recommended that patients only take it a few days at a time or for 48 hours unless they’re medically directed otherwise. Caution is advised in patients:

•• Taking other medicines, especially •• •• •• ••

painkillers; With asthma; Aged 65 years or older; With bleeding or vision problems; Taking anticoagulants, antihypertensives, diuretics, lithium, methotrexate or other pain relief.

INDICATIONS Maxigesic is indicated for a wide range of pain including: •• Headache; •• Migraine headache; •• Tension headache; •• Sinus pain; •• Sore throat; •• Toothache; •• Dental procedures; •• Period pain; •• Backache; •• M uscular pain; •• Rheumatic pain; •• Arthritis; •• Tennis elbow; •• Aches and pains associated with colds and flu. Maxigesic also reduces fever.

CONTRAINDICATIONS Maxigesic is contraindicated for use:

•• In patients with known hypersensitivity reaction to paracetamol, ibuprofen, aspirin, other NSAIDs or any other ingredients in the product;

•• In patients with active alcoholism as chronic excessive alcohol ingestion may predispose patients to paracetamol hepatoxicity (due to the paracetamol component);

•• In patients who have experienced asthma, urticaria, or allergic-type reactions after taking aspirin, ibuprofen or other NSAIDs;

•• In patients with active GI bleeding,

GET THE

peptic ulceration or other stomach disorders; •• During pregnancy or in patients planning to become pregnant; •• During breastfeeding; •• In patients with impaired kidney function, impaired liver function or heart problems.

thirds of all analgesics sold1, and pharmacists are critical to safely encouraging and assisting pain sufferers to make the switch from codeinebased medication. Notes: Maxigesic® is a registered trademark of AFT Pharmaceuticals Pty Ltd. REFERENCES IMS Health 2012, Australian Pharmaceutical Index, MAT market data to Dec 2012. 2 National Drugs and Poisons Schedule Committee. Record of Reasons 55th Meeting 17–18 Feb 2009. Canberra: Therapeutic Goods Administration, 2009. URL www.tga.gov.au/pdf/archive/ndpsc-record-55. pdf, accessed 5 May 2014. 3 Roxburgh A, Burns L. Accidental drug-induced deaths due to opioids in Australia, 2008. Sydney: National Drug and Alcohol Research Centre, 2012. Online: http://ndarc.med.unsw.edu.au/sites/ default/files/ndarc/resources/NIDIP%20Bulletin%20 -%20opioid%20induced%20deaths%20in%20 Australia%202008.pdf 4 2012–2014 International Overdose Awareness Day. Over-dose: Worse than the road toll. Fact Sheet, 15 Aug 2013. 5 Miranda HF, et al. Synergism between paracetamol and non-steroid and anti-inflammatory drugs in experimental acute pain. PAIN 2006; 121:22–8. 6 Mitchell A, et al. A randomized controlled trial comparing acetaminophen plus ibuprofen versus acetaminophen plus codeine plus caffeine after outpatient general surgery. J Am Coll Surg 2008; 206:472–9. 7 Menhinick KA, et al. The efficacy of pain control following nonsurgical root canal treatment using ibuprofen or a combination of ibuprofen and acetaminophen in a randomized, double-blind, placebo-controlled study. Int Endod J 2004; 37:531– 41. 8 Viitanen H, et al. Analgesic efficacy of rectal acetaminophen and ibuprofen alone or in combination for paediatric day-case adenoidectomy. Br J Anaesth 2003; 91:363–7. 9 Hyllested M, et al. Comparative effect of paracetamol, NSAIDs or their combination in postoperative pain management: a qualitative review. Br J Anaesth 2002; 88:199–214. 10 MARTINDALE: The Extra Pharmacopoeia. London: The Royal Pharmaceutical Society of Great Britain, 1996. 11 TGA Medicines Evaluation Committee, 2003. Review of non-prescription analgesics: Multiple Strength of Oral Liquids. Australia: Therapeutic Goods Administration, 2003. 12 Merry AF, Gibbs RD, Edwards J. Combined acetaminophen and ibuprofen for pain relief after oral surgery in adults: a randomized controlled trial. Brit J Anaesth 2010; 104(1):80–8. 13 Schou S, Nielsen H, Nattestad A, Hillerup S, Ritzau M, Branebjerg PE, et al. Analgesic dose-response relationship of ibuprofen 50, 100, 200, and 400 mg after surgical removal of third molars: A singledose, randomized, placebo-controlled, and doubleblind study of 304 patients. Journal of Clinical Pharmacology. 1998;38(5):447-54. 1

CODEINE ALTERNATIVE Combination analgesics such as Maxigesic offer an alternative in many cases to existing codeine-based combinations. Codeine is widely available but increasingly misused in combination products with paracetamol or ibuprofen which dominate the Australian OTC analgesia category: annual IMS market data show that about half of market value and units sold involved codeine combination painkillers1. Codeine is added to paracetamol or ibuprofen products to amplify their effects, but codeine is an opiate and there is growing concern in Australia over its potential for misuse, and additional measures such as ‘Realtime Monitoring’ or rescheduling have been proposed in order to address these concerns. While codeine’s gastrointestinal side effects such as constipation and diarrhoea are well known to pharmacists, its risks of substance abuse and dependence constitute a growing concern for community pharmacy, which the National Drugs and Poisons Scheduling Committee established a Codeine Working Party to address2. Opioid drug overdoses are estimated to have increased 95.8 per cent between 2007 and 20103, while prescriptions for opioid painkillers trebled between 1992 and 2007 to seven million a year.4 Deaths from pharmaceutical opioid medications are surpassing those from illicit drugs such as heroin, and often involve people who started taking the drugs following an injury or illness and are less likely to have a background of illicit drug use4. Paracetamol–Ibuprofen combinations such as Maxigesic, without the dependence-forming opioid codeine and a tolerability profile similar to that of paracetamol and NSAIDs, have therefore emerged at a crucial time when opioid-free pain relief is becoming a public health priority. It is important that Maxigesic is only available from pharmacies because retail pharmacy remains the purchase point for two

PLATINUM ADVANTAGE MORE EFFECTIVE PAIN RELIEF than Paracetamol or Ibuprofen alone1

HEALTH

STAYING IN TARGET RANGE TO TACKLE

Diabetes Complications EILEEN COLLINS Diabetes Educator Diabetes Victoria

1.7

DIABETES IS AUSTRALIA’S FASTEST GROWING CHRONIC CONDITION, CURRENTLY AFFECTING AN ESTIMATED 1.7 MILLION AUSTRALIANS. 280 AUSTRALIANS DEVELOP DIABETES EVERY DAY — THAT’S ONE PERSON EVERY FIVE MINUTES.

WHAT IS THE DIABETES EPIDEMIC? More than 100,000 Australians have developed diabetes in the past year. There are three main types of diabetes — type 1 diabetes, type 2 diabetes and gestational diabetes — and they are all increasing in prevalence. For every person diagnosed with diabetes there is usually a family member or carer who also ‘lives with diabetes’ every day in a support role. This means that an estimated 2.4 million Australians are affected by diabetes. Diabetes is a major global threat to human health and productivity. Type 2 diabetes is the epidemic of the 21st century and the biggest challenge confronting Australia’s health system. The total annual cost impact of type 2 diabetes in Australia is estimated at $14.6bn. Recent figures published by the International Diabetes Federation (IDF) suggest that most countries spend 5–20% of their healthcare budget on diabetes.

WHAT ARE COMMON COMPLICATIONS OF DIABETES? Diabetes is a serious, progressive and complex condition. There is no such thing as ‘mild’ diabetes. All types of diabetes are serious and can lead to complications if not managed. Diabetes can have a significant

impact on quality of life and can reduce life expectancy.

DIABETES: •• Is the leading cause of blindness in working age adults;

•• Is a leading cause of kidney failure and dialysis;

•• Increases the risk of heart attacks and stroke by up to 4 times;

•• Is a major cause of limb amputations. Some people already have complications at diagnosis because diabetes can be asymptomatic until blood glucose levels are 15mmol/l or more.

WHAT ARE NORMAL BLOOD GLUCOSE LEVELS? Normal blood glucose levels (BGLs) range between 4.0–7.8mmol/L. The glycosylated haemoglobin (HbA1c) test shows an average of blood glucose levels over the past 10–12 weeks. The normal HbA1c level is <42 mmol/mol (6%).

WHY IS GLYCAEMIC CONTROL IMPORTANT? To reduce the risk of developing long-term

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

MILLION

AUSTRALIANS AFFECTED BY

DIABETES

complications, it is important to keep blood glucose levels as close to target as possible. Regular checking and recording of blood glucose can assist in identifying patterns and the need to modify treatment, and providing feedback about lifestyle choices. The target levels recommended by the National Health and Medical Research Council (NHMRC) are:

•• Type 1 diabetes:

a Target levels 4–8mmol/L fasting and before meals

a 5–10mmol/L two hours after starting a meal

•• Type 2 diabetes:

a Target levels 6–8mmol/L fasting and before a meal

a 6–10mmol/L two hours after starting a meal.

Two large-scale studies — the UK Prospective Diabetes Study (UKPDS) and the Diabetes Control and Complications Trial (DCCT) — demonstrated that improving HbA1c by 1% (or 11 mmol/mol) for people with type 1 diabetes or type 2 diabetes cuts the risk of microvascular complications by 25%. The HbA1c goal for most people with diabetes is between 6.5–7 percent (48–53mmol/mol).

HEALTH

While it is important to keep BGLs and HbA1c as close to normal as possible, it is equally important that people with diabetes discuss with their diabetes team and decide on a target that is both appropriate and realistic for every individual’s circumstances.

WHY CAN GLYCAEMIC CONTROL BE A CHALLENGE? It can be difficult to achieve target BGLs or HbA1c because blood glucose levels may be affected by the amount and type of food eaten, exercise, medication and illness or stress. Hyperglycaemia (high blood glucose levels) may occur due to illness. Ketones are a by-product of fat breakdown which occurs in people with type 1 diabetes if they develop persistently high blood glucose levels (hyperglycaemia). Diabetic Ketoacidosis (DKA) may develop if these acidic ketones accumulate in the blood. DKA is a very serious condition, so urgent medical attention in hospital and treatment with insulin and fluids is required. DKA rarely occurs in people with type 2 diabetes but has been reported when SLG2 medication is used.

HYPOGLYCAEMIA Early signs of hypoglycaemia may be sweating, shaking, dizziness, hunger and/ or pallor. Treatment with 15 grams of a quick-acting carbohydrate should be taken immediately. After fifteen minutes recheck and if the blood glucose has not risen above 4 mmol/L the quick-acting carbohydrate should be repeated. It is important to treat hypoglycaemia quickly to stop the blood glucose level from

falling even lower, potentially causing severe hypoglycaemia. Severe hypoglycaemia is defined as having low blood glucose levels that requires assistance from another person to treat. Signs may include:

•• •• •• •• ••

Confusion; Disorientation; Convulsions; Seizures; Loss of consciousness.

Severe hypoglycaemia can be a challenge for a number of people, especially if they have impaired hypoglycaemia awareness (IHA). Research has shown that people who are unable to sense their hypoglycaemia have less activation of brain regions involved in the stress response and emotional salience. Consequently, people who have an impaired awareness of hypoglycaemia are more likely to experience severe hypoglycaemia, and will require assistance with treatment. About a quarter of all adults with type 1 diabetes are affected by this problem, as are around one in ten adults with insulin treated type 2 diabetes. Impaired awareness of hypoglycaemia increases the risk for experiencing severe hypoglycaemia. There is a recognised pathway to restore impaired awareness of hypoglycaemia: the first step is through structured education programs like DAFNE (Dose Adjustment For Normal Eating) and flexible insulin therapy; modern diabetes technology is another option. Insulin pump therapy can reduce hypoglycaemia issues four-fold and the same applies to continuous glucose monitoring devices. As a last resort, there is the possibility of a pancreas or islet transplant.

HEART AND BLOOD VESSEL DISEASES

STROKE

HEART ATTACK

PERIPHERAL ARTERY DISEASE

EYE DISEASES AND BLINDNESS

DIABETIC RETINOPATHY

CATARACTS

GLAUCOMA

KIDNEY FAILURE AND DIALYSIS

A MAJOR CAUSE OF LIMB AMPUTATIONS

"Diabetes is a major global threat to human health and productivity. Type 2 diabetes is the epidemic of the 21st century and the biggest challenge confronting Australia’s health system."

TYPE 1 DIABETES

TYPE 2 DIABETES

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

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Health Headlines Hartley Atkinson M.Pharm, PhD

Founder & CEO, AFT Pharmaceuticals

www.aftpharm.com

1800 2387 4276

SPONSORED HEALTH MESSAGE

Asthma

and

Allergy 2.4

MILLION AUSTRALIA NS HAVE

ASTHMA

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

NATIONAL ASTHMA WEEK 1st-7th September

SPONSORED HEALTH MESSAGE

Resources are available by emailing info@asthmaaustralia.org.au or phoning 1800 ASTHMA (1800 278 462)

ASTHMA IS A CHRONIC HEALTH CONDITION WHERE PEOPLE EXPERIENCE A NARROWING OF THE AIRWAYS IN THE LUNGS, OBSTRUCTING THE FLOW OF AIR INTO AND OUT OF THE LUNGS.

This narrowing can normally be reversed using medications, and people with asthma can therefore lead normal, active lives if they follow a medication regime as prescribed and use their device correctly. Asthma is most easily recognised by the following symptoms: o

Wheezing when breathing out;

A persistent irritable cough, especially at night;

Difficulty in breathing and shortness of breath;

Tightness and heaviness in the chest;

Wheezing or coughing with exercise (exercise induced asthma).

Triggers for asthma include colds and flu, infections, exercise, cold air, changes in temperature and cigarette smoke, but the most common form of asthma is allergic asthma, meaning that the asthma symptoms are triggered by an allergic reaction. Allergy occurs when the immune system in a person reacts to allergens (things that they are sensitive to) which are substances in the environment that do not cause problems for most people. This reaction leads to inflammation (redness and swelling) that causes allergic conditions, which can affect different parts of the body, such as:

•• Allergic rhinitis (hay fever) which affects the nose and eyes;

•• Eczema or urticaria (hives) which affect the skin;

•• Anaphylaxis (the most severe allergic reaction) which can affect the whole body;

•• Asthma which affects the lungs. Allergens can be found in house dust mites, pollens, pets, moulds, some antibiotic medicines, insect stings or bites, latex (natural rubber) and foods. Community pharmacies are the most accessible and visited primary healthcare network in Australia, providing a touch point for people with both asthma and allergies, many of whom don’t regularly consult with a GP. As 2.4 million Australians have asthma,

and 80% also suffer from allergic rhinitis, which can trigger asthma symptoms, it is particularly important to help patients manage their allergic rhinitis in order to help manage their asthma. So, remember to discuss asthma with allergy patients, and allergy with asthma patients. Australia’s National Guidelines for Asthma Management recommend to prescribe or recommend intranasal corticosteroids for adults and children with persistent allergic rhinitis or moderate-to-severe intermittent allergic rhinitis, even if the person is already taking regular inhaled corticosteroids for asthma. The handbook can be accessed at www.asthmahandbook.org.au. In addition, community pharmacists have a role to play in encouraging people with asthma to:

•• Regularly take medications as prescribed;

•• C heck their device technique; •• Use a spacer with MDI inhalers; •• Manage any allergies appropriately in association with their asthma. Therefore, it is very important that pharmacists and pharmacy assistants are aware of the Guidelines for Asthma Management and discuss allergic rhinitis in the context of asthma management with their patients for the best outcomes. Asthma Australia is the nation’s leading lung health charity whose purpose is to seek a cure for asthma and strive to improve the quality of life for people with asthma by providing accessible, affordable and evidence-based services. They have a range of very useful resources on asthma and allergy available on their website at: www.asthmaaustralia.org.au to assist people with asthma and their families including: -

Asthma score calculator (to check the level of asthma control);

A 1800 ASTHMA helpline to gain personalised information, resources and support to help people manage their asthma better;

Videos that help demonstrate correct technique with a range of medication devices. Asthma Australia has also just released its

new “Asthma Patient Education Tool” which is free to download from the app store. It is absolutely vital that pharmacists encourage their patients who suffer from asthma to ensure they have an asthma action plan that has been formulated with their GP. It is critical for patients to know and recognise the signs of worsening asthma and the immediate actions that they must take to help prevent it worsening, or where it’s necessary, to seek additional medical attention. An Asthma Action Plan is a set of instructions written with a patient’s doctor or nurse that helps them to stay in control of their asthma. It’s usually on a piece of paper, but there are also apps or electronic versions that might be more useful for patients. It has been estimated that up to 90% of patients may not use their inhaler device correctly, which will compromise how much of the medication will be absorbed and take effect. Pharmacists are perfectly placed to help advise on correct inhaler technique and the use of other aids, such as spacers, for use with metered-dose inhalers. It may seem that some patients are not interested in this information as you hear them say, “I know all about it. I’ve lived with asthma all my life.” When an over-the-counter reliever medicine is requested, a conversation about the person’s asthma is useful: Is your asthma affected by exercise? How has it been controlled lately? Do you suffer from allergies? Through these conversations and interactions, pharmacists can help patients understand why it is important to manage allergies appropriately to gain control of their asthma, and that means:

•• They don’t have symptoms on more than two days a week;

•• They only need their reliever medicine no more than two days a week, or not at all;

•• Their activities aren’t limited by asthma;

•• They don’t get any symptoms at night or upon waking. For more information about asthma, how to best control it or to contribute to raising funds to finding a cure, please visit Asthma Australia at: www.asthmaaustralia.org.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

SPONSORED HEALTH MESSAGE

TAKE ACTION for

Healthy Bones LOOK AFTER YOUR BONES TO LIVE THE LIFE YOU WANT IS THE KEY MESSAGE OF THIS YEARâ&#x20AC;&#x2122;S HEALTHY BONES ACTION WEEK TO BE HELD NATIONALLY FROM 1 TO 7 AUGUST 2016.

"Osteoporosis is a health risk which can cause chronic pain, disability, loss of independence and even premature death."

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

SPONSORED HEALTH MESSAGE

Despite looking and feeling great, the majority of women over 50 do not consume enough calcium-rich dairy foods to keep bones strong, particularly as they approach and go through menopause.

•

If you’re a risotto fan, replace 1/3 of the stock with milk for a really creamy result;

•

Use light cream cheese mixed with milk as a creamy base for pasta sauce;

It is estimated that the average woman loses up to 10 per cent of her bone mass in the first five years after menopause, causing bones to become thinner, more fragile and more likely to fracture easily.

•

Enjoy a tasty cheese and fruit platter at the end of a meal;

•

Snuggle up with a warm glass of milk or hot chocolate before bed.

That’s why it is so important to take action to maintain bone health so that you can live well - whether that be working, exercising, socialising, travelling or looking after family – in your 50s, 60s and beyond. Healthy Bones Action Week is an ideal time to remember that osteoporosis can be preventable by taking three simple steps to protect your bones and overall health. These include increasing calcium intake through dairy foods; doing weight-bearing exercise; and, getting enough safe sunshine for vitamin D. Dairy Australia’s Kelly Ward said that today’s women in their 50s are busier than ever and want strategies for staying well and feeling good as they age. "Osteoporosis is a health risk which can cause chronic pain, disability, loss of independence and even premature death. "There is no better feeling in the world than getting up in the morning knowing you can live life to the fullest, no matter what your age is," Kelly said. Visit www.healthybones.com.au for more information, resources and calcium-rich recipe ideas.

3 TIPS FOR STRONG BONES 1.

Consume plenty of calcium-rich foods each day. Milk, cheese and yoghurt are the richest sources of calcium in the Australian diet and the calcium contained in these foods is well absorbed. A serve is 250ml milk, 200ml yoghurt, 40g cheese or 120g ricotta cheese.

Secondly, ensure you do weight-bearing exercise daily. Just like muscles, bones grow stronger and harder when they are exercised. Known as ‘weight bearing exercise’, this includes any exercise where your feet and legs carry your weight.

Vitamin D from safe sun exposure is the final important factor for building and maintaining strong bones. Vitamin D helps the calcium to absorb while also helping to control the levels of calcium in the bloodstream.

ROASTED HONEY PEARS WITH YOGHURT

Serves 2

INGREDIENTS /4 cup honey /2 cup water 2 pears, cut into eighths 1 /4 cup raisins 1 cinnamon stick 400g vanilla yoghurt (or natural if you prefer) 2 tablespoons natural flaked almo nds, toasted 1

METHOD 1. Combine honey and water in a small roasting pan. Add pears, raisins and cinnamon. Cover pan tightly with foil and roast at 200oC for 20 minutes. Remove foil and turn the pears. Roast uncovered for a further 10 minu tes or until pears are caramelised and tender, basting with syrup during cooking. 2. S poon yoghurt into serving bowls, top with warm pears and sprinkle almo nds.

IDEAS FOR GETTING MORE CALCIUM EACH DAY •

Throw a handful of cheddar cheese into scrambled eggs for a calcium boost at breakfast;

•

Try making Café Latte Porridge with milk instead of water and flavour it with some freshly brewed coffee;

•

For an energising fruit smoothie, throw together some fruit, yoghurt and milk;

•

Make the ultimate toasted cheese sandwich by using mozzarella or colby, they are fantastic melting cheeses and taste delicious;

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

HEALTH

Dental Health Week | 1ST - 7 TH August

Women and Oral Health DR PETER ALLDRITT Chairman of the Australian Dental Association's Oral Health Committee

For more information about women and oral health please go to the ADA’s DHW website: www.dentalhealthweek.com.au.

DENTAL HEALTH WEEK (DHW) IS THE AUSTRALIAN DENTAL ASSOCIATION’S (ADA) MAJOR ANNUAL ORAL HEALTH PROMOTION EVENT (1ST–7TH AUGUST). ITS AIM IS TO EDUCATE AUSTRALIANS ABOUT THE IMPORTANCE OF MAINTAINING GOOD ORAL HEALTH IN EVERY ASPECT OF THEIR LIVES.

Throughout the course of DHW 2016, the ADA encourages Australians to take a more preventive, hands-on approach to their dental health as they learn more about the ways their teeth, gums and mouth are affected during each of the pivotal phases of their life. DHW focuses on the significant way that hormones can play havoc with a woman’s oral health, an especially important topic in light of a recent study commissioned by the ADA that revealed that many women are unaware of the significant impact that various life stages have on the health of their teeth and gums. The reality is that major life events like puberty, menstruation, pregnancy, and menopause, dramatically affect women’s dental health.

PREGNANCY IS A TIME WHEN ORAL HEALTH REALLY NEEDS ATTENTION Just like the rest of your body, your teeth, gums and mouth are affected by hormonal changes during pregnancy. Increased levels of certain hormones can make your gums more susceptible to inflammation and infection, so regular checkups and professional cleanings are a must, as is brushing twice daily with fluoridated toothpaste and flossing once a day. Your dentist should be on the list of health professionals whom you consult regularly, alongside your GP and obstetrician. You may find that your gums are more swollen and sensitive during pregnancy;

they might bleed and can be quite painful to brush and floss. This is known as ‘pregnancy gingivitis’ and is a result of changes in hormones that make gums more sensitive to the bacteria found in plaque. Bleeding while brushing and flossing due to increased sensitivity of the gums should not stop you from taking care of your oral health. You might also develop what are called ‘pregnancy tumours’ (pyogenic granulomas), which are red, lumpy lesions that appear along the gum line and between the teeth. They're quite harmless, resembling red, raw mulberries, and usually go away once you've had your baby. Morning sickness is beyond your control but it’s important to understand that vomit is extremely acidic and can cause irreversible damage to your teeth. This is known as dental erosion and can make your teeth more susceptible to sensitivity and can accelerate decay. No matter how much you might want to, don’t brush your teeth for at least one hour after vomiting. Otherwise, the tooth brush can abrade the softened tooth enamel. Instead, try rinsing your mouth a couple of times with a solution of ¼ teaspoon of baking soda mixed into 1 cup of warm water, chew sugar-free gum or eat an acid-neutralising food such as milk, cheese or yoghurt. You can even smear a small amount of fluoridated toothpaste on your teeth which gives you

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

additional protection and improves the taste in your mouth. If you’re having difficulty, consult your dentist who can suggest alternate preventive care or treatment options. There are many myths surrounding dental X-rays, but the truth is you are exposed to far more radiation on a single domestic plane flight than from a dental X-ray. Health professionals take every precaution to minimise radiation. During pregnancy, if an X-ray is a part of your routine check-up, your dentist may recommend waiting until after the birth of your child. However, if an X-ray is required to assist in diagnosing a serious dental condition such as an infection or trauma, your dentist may recommended an X-ray and will use a lead apron to cover your abdomen, minimising your baby’s exposure. It might seem like a good idea to delay dental treatment while you are pregnant because of a perceived risk to your baby. However, routine and urgent dental procedures can be undertaken throughout your pregnancy and you should be seeing your dentist on a regular basis. Having a healthy mouth before you plan to become pregnant is the best way to continue easy dental visits through your pregnancy. Having a healthy mouth is also linked to your child having good oral health.

HEALTH

"You may find that your gums are more swollen and sensitive during pregnancy; they might bleed and can be quite painful to brush and floss. This is known as ‘pregnancy gingivitis’ and is a result of changes in hormones that make gums more sensitive to the bacteria found in plaque."

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

is turning 75, and to celebrate, we’re letting customers leave of their own by creating Glucoriffic artworks elebrate, we’re letting customers leave using virtual jelly our Create with Glucojel site –virtual glucojel.com.au. ng Glucoriffic artworks using jelly ojel site 2016 – glucojel.com.au. August you can win up to $2500 by creating a

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n up to $2500 by creating a Until 31st August 2016 you can win up to $2500 by creating a harmacy. our 75 Birthday, we’re giving you the chance to unleash delicious GlucojelFor display in your pharmacy. th

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phone number in your email. GLUCOJEL .COM.AU/CREATE Visit website for terms and conditions.

75 years of fun. We like to think that when Glucojel hit pharmacy shelves around Australia in 1941, it launched a whole new era in fun. Here’s our take on the Glucojel effect:

At the height of Beatlemania, The Beatles tour Australia.

Australia wins our very first Oscar

1941

1943

1956

1964

TV comes to Australia hits pharmacy shelves

$2500

t Glucojel

y Display

1969

The Sydney Opera House is officially opened

1973

Advance Australia Fair becomes our official anthem

The Wiggles are formed

1991

Neil Armstrong is the first man on the moon

1988

1984

1976 Apple releases its first computer

Australia celebrates our bicentenary Glucojel black gets its own pack! Aniseed lovers rejoice.

Blueberry flavour is introduced and the ‘green bean’ changes from lime to apple.

Our Glucojel teddy bear comes to life

2000 Sydney hosts the Olympics

2007

Black 150gm is launched

2012 The Colour run comes to Australia

2015

INDUSTRY NEWS & UPDATES ``BNS - UBIQUINOL MAY IMPROVE MITOCHONDRIAL DYSFUNCTION Ubiquinol may improve function in people with mitochondrial dysfunction, according to a new Dutch study i.

increase energy production and help reduce toxic by-products that may be associated with these disorders.

The breakthrough study found that mitochondrial dysfunction can be partially reversed using Ubiquinol – the active and the major form of CoQ10 that naturally occurs in the body.

Always read the label. If symptoms persist consult your healthcare practitioner.

Up to one in 200 Australians are at risk of developing Mitochondrial Diseases, a group of chronic illness that robs sufferers of energy, and damages the muscles and major organs like the brain and stomachii. Mitochondria are known as the ‘powerhouse’ of cells and act like a digestive system that takes in nutrients, breaks them down, and creates energy for the cell. CoQ10 is often used as a therapy for mitochondrial disorders to

>> www.bioceuticals.com.au REFERENCES: Novel In Vivo Human Model For Transient Mitochondrial Dysfunction: Simvastatin-Induced Mitochondrial Dysfunction In Healthy Subjects And Its Reversibility By The Reduced Form Of Co-Enzyme Q10. Journal of World Mitochondria Society 2015 (2015) http://journal.medsys-site.com/WMS/ article/view/322. ii Mitochondrial Disease Fact Sheet - http://www.amdf.org.au/wp-content/ uploads/2014/05/Mitochondrial-Disease-Fact-Sheet.pdf i

``COMVITA - MEDIHONEY® ECZEMA CARE RANGE Comvita’s Medihoney® Eczema Care Range is the first to be certified by the Natural Products Association and fits well with conventional eczema management approach. The Medihoney® Natural Eczema Care Range holistically helps sufferers manage the different stages of eczema. This range includes tailored products for specific eczema care needs.

This unique skincare range can be used as a system: Step 1: Protect and nourish with Medihoney® Natural Skintensive Cream; Step 2: Relieve from itching, irritations and flare ups with Medihoney® Natural Eczema Cream; Step 3: Treat eczema wounds or cracked skin with Medihoney® Antibacterial Wound Gel™.

All Medihoney® Natural Eczema Care products contain medical grade antibacterial Manuka honey. This key ingredient has been scientifically researched and clinically proven to support wound healing and reduce the risk of infection.

Products start from $16.95

Medihoney Natural Skintensive Cream is a great daily essential to help hydrate even the most sensitive and eczema prone skin. It also helps to soothe and relieve itchy, irritated skin.

For stockist inquiries or orders, free call 1800 466 392.

Always read the label. Use only as directed. If symptoms persist consult your healthcare practitioner. >> www.comvita.com.au

``LEASE 1 - SALES REPORTING CODE OF CONDUCT As this edition of ITK is being read by pharmacists, the NSW Cabinet as part of the review of the Retail Leases Act 1994 are considering a new Code of Conduct (COC) titled the “Sales Reporting Code of Conduct”. Assuming the CoCs’ adopts this code, it introduces a higher level of transparency for Retailers/Lessees who are contractually obligated to report sales data to Lessors. In essence the CoCs’ main thrust is to ensure that if a Retailer/Lessee reports sales then the Lessor must firstly acknowledge how they treat this data in respect of GST (or over uplift factors). Secondly, they are obliged to reciprocate by providing sales data (and other available research information (i.e. traffic trends) back to Retailers. Naturally this data will be sensitised by category so as to maintain privacy of information. These changes may sound quite subtle however the improved transparency available when Lessees are performing research,

particularly in the case of a Lease negotiation is a large step towards levelling the playing field regarding the inequities of information between Lessee and Landlord. Phillip Chapman of Lease1 has been striving to achieve such a code since outcomes of the Productivity Commission Report were released, The Market for Retail Leases in Australia 2009, when he drafted the first Industry Code to Retailer Stakeholders. Further, he has been instrumental in facilitating the leading Retailer Associations, The Pharmacy Guild of Australia, Australian Retailers Association and Franchise Council of Australia as the key signatories to the new Code. The impact of the code once adopted by NSW Parliament it is anticipated will quickly be endorsed Nationally as an Industry regulated Code to benefit all Retailers. >> www.lease1.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

INDUSTRY NEWS

``MPS - HELP YOUR PATIENTS KEEP THEIR INDEPENDENCE MPS have had an action packed few months, exhibiting at leading pharmacy tradeshow events including APP 2016, Discount Drug Stores Conference and Priceline Pharmacy Franchise Conference. The highlight has been chatting to new and existing partners on driving innovation and refocusing on the business opportunities that come with providing Dose Administration Aids to customers. Do you know who your ideal customers are? As a result of our consumer research project with local pharmacies, we have developed the MPS consumer personas to assist pharmacies speaking with their customers about medication management. Watch our video to see how your customers, like our personas Mary, Jenny, Bob and Harry, can benefit from MPS Packettes https://vimeo.com/171039680

“75% of customers are looking to their pharmacist as their trusted advisor.”

The MPS Consumer Market Research Report 2015 shows that 75% of customers are looking to their pharmacist as their trusted advisor on medication management and Dose Administration Aid options. With MPS advanced solutions, you can help your patients keep their independence. To get a copy of the research report or to find out how you can utilise the MPS personas to help grow your Dose Administration Aid business, contact the friendly MPS team on 1800 003 938. >> www.mps-aust.com.au

``PCCA - ESTRIOL AND ESTRADIOL DILUTIONS PCCA is the only company in the compounding industry that offers 10 mg/Gm dilutions of both micronised estriol (E3) and micronised estradiol (E2) in solution to meet the specialised needs of compounding pharmacists. Every batch of the dilution is meticulously tested to ensure accurate potency and content uniformity. Each 1 Gm of PCCA Estriol Dilution contains 0.01 Gm (10 mg) of estriol, and each 1 Gm of PCCA Estradiol Dilution contains 0.01 Gm (10 mg) of estradiol in a 100% naturally derived, patent-pending solvent system. The loss on drying and potency assay have already been accounted for in the dilution to save time and help ensure accurate dosing. These dilutions can be used in making a wide variety of topical and vaginal hormone preparations.

Benefits: •

Safety – No free-flowing powders minimizes exposure to highly potent hormones;

•

Convenience – Eliminates the need to weigh static-prone powders and prepare various powder triturations for each formulation;

•

Ease of use – Easily mixes into cream or gel base since the APIs are already solubilized, providing improved content uniformity.

Dilutions are exclusively available from PCCA Member compounding pharmacies only. >> www.pccarx.com

``PHARMACY ALLIANCE - 2016 MEMBERS' FORUM BEAT THE COMPETITION! With the impact of regulatory change now a reality, the industry is more focused on the customer than ever. This means that competition in Australian pharmacy will become more intense. With Pharmacy Alliance membership now at 536 members, we have the largest independent pharmacy network in Australia, and as such, we are in a fantastic position to use our size to capture attention and engage consumers nationally. At this year’s Forum, my aim will be to get real outcomes to Beat the competition by outsmarting our competitors through having a deeper understanding of the evolving needs of the consumer, outselling by translating the insights into tangible benefits for customers in our pharmacies, and be outstanding by delivering an exceptional customer experience. Plus, you will take home a focused 12-month business plan which we will help you build throughout the Forum.

“With Pharmacy Alliance membership now at 536 members, we have the largest independent pharmacy network in Australia.” We have developed an exciting Forum program where you will hear from great industry speakers, as well as speakers from other industries, that will provide a different perspective to help challenge our thinking and our ‘big assumptions’. >> www.pharmacyalliance.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

60 SECONDS WITH ... DANNY AGNOLA Pharmacy Guild of Australia (QLD Branch)

What I like best about my job is ... Customer interactions and hearing some amazing stories from some of the older folk. So many people that you wouldn’t expect have lived extraordinary lives. My favourite hobby is ... Hiking, kayaking and travelling. Ideally heaping them all together. I decided to become a pharmacist because ... I enjoyed the combined aspects of science, business and providing better health outcomes. I have been working as a pharmacist for ... 9 years.

My favourite book is ... Too many to list. I read anything and everything. My best getaway ever was ... Trekking the Himalayas in Nepal. But travelling somewhere new is always an experience.

How I keep myself updated to the market news ... Through industry newsletters, journals and other publications. Over the next 3 years in pharmacy, I predict ... A strong focus on extra professional services. If I could give any advice to someone starting a career in pharmacy, it would be ... Listen to and respect your customer. Pharmacy can be an extremely busy place sometimes, so it’s always important to have the fundamentals done correctly.

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PRODUCT SPOTLIGHT ``DEMAZIN KIDS Demazin has a strong heritage in Cold & Flu Liquids and the #1 selling Cold & Flu Liquid in the category. Brought to you by Bayer, the Life Sciences company, Demazin is launching a new kids range for children 2 years and over. Demazin Kids Cold & Flu Relief Liquid contains Black Elderberry, Zinc and Vitamin C, to help boost immunity and to help reduce the duration and severity of cold and flu symptoms. Berry flavoured, it is available in 200mL (RRP $18.95) and 100mL (RRP $12.95) sizes. Demazin Kids Cough Relief Liquid contains Ivy Leaf extract, which helps to thin and loosen mucus, to soothe and relieve a chesty cough and clear chest congestion. It is sugar-free with a natural strawberry flavour and is available in 200mL. (RRP $13.95) The new range will be supported with strong marketing both in store and on TV. Customer Service Enquiries: 1800 008 757 >> www.demazin.com.au

``IBEROGAST - YOUR IBS ESSENTIAL Iberogast is a combination of 9 medicinal herbs that act together to provide clinically proven, multi-targeted relief for a range of upper and lower abdominal symptoms associated with conditions such as medically diagnosed Irritable Bowel Syndrome and Functional Dyspepsia. Always read the label. Use only as directed. If symptoms persist see your healthcare professional. (RRP: $26.95) Customer Service Enquiries: 1800 023 884 >> www.iberogast.com.au

``ISOWHEY REFUEL AND REBUILD IsoWhey Sports Refuel & Rebuild is a specially designed formula to supply working muscles with the essential nutrients needed for recovery post-exercise. Refuel and Rebuild combines pure whey protein, BCAAs and tart cherry and magnesium. Isowhey Refuel & Rebuild is used for assistance in muscle recovery, and supplying essential nutrients to rebuild and repair tissue to maintain muscle mass. Isowhey Refuel & Rebuild has been tested and certified to be free from substances that have been banned by the World AntiDoping Authority (WADA), and are ensured to be safe for athletes to use. Always speak to your healthcare practitioner when considering supplementation. When taking supplements, make sure to always read the label and use only as directed. If symptoms persist, see your healthcare practitioner. Supplements should not replace a balanced diet. (RRP: $54.95) Customer Service Enquiries: 1300 476 943 >> www.isowheysports.com.au

``PEACE OF MIND - PERSONALISED -

MORE TIME - CONVENIENT AND COMPACT A better way for customers to manage medications and keep their independence. MPS Packettes are convenient, personalised pouches that ensure patients take exactly the right medications and dosage at the right time, every time. Customer Service Enquiries: 1800 003 938 >> www.mps-aust.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

Smart dispensary solutions

MORE STORAGE, LESS SPACE, BETTER MANAGEMENT

PROUDLY AUSTRALIAN OWNED

Flowsell offers a wide range of high quality pharmacy shelving solutions, purpose built to match your requirements. As an Australian owned company, Flowsell are able to offer a world-class product without an international price tag. FIND YOUR PERFECT FIT ON OUR BRAND NEW WEBSITE AT WWW.FLOWSELL.COM.AU T: (03) 9708 2276

E: sales@flowsell.com.au

AFTER HOURS

EXPLORE

AUSTRALIA EXPO

EXPLORE AUSTRALIA EXPO IS ONE OF AUSTRALIA’S BEST OUTDOOR LEISURE EXHIBITIONS, BRINGING TOGETHER THE ELITE OF THE OUTDOOR INDUSTRIES AND A DIVERSITY OF OVERLAPPING COMMUNITIES – ALL WITH A THIRST FOR ADVENTURE! Outdoor adventure means so many things to so many different people. But the heart of it all is a deep seated passion to explore the experience, the opportunities and the environment. You may be a seasoned traveller or a novice adrenalin junkie, a well-travelled 4×4 and outdoor adventure lover, or a mad-keen fisho… then rest assured the team behind Explore Australia Expo don’t just understand you, we are you! We live and breathe the lifestyle ourselves and the show is just one forum for us to express and live our own adventures. Explore Australia Expo will not only entertain and inspire you, but will engage

you in manner like no other show has done before. We have unprecedented educational platforms, workshops, seminars, activities and challenges for you to participate in. Personalities and identities will be on hand, but not how you have seen them before. Industry leaders and experts will offer advice, solutions and inside tips. And best of all, you will see a united presence as the best facets of every aspect of your adventure are brought together for a total experience. Our March 2015 event was a huge success, with over 17,500 outdoor enthusiasts flocking to Manly Boat Harbour Brisbane to experience a unique,

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 48 : AUGUST/SEPTEMBER 2016

professionally run, premium 4wd, Camping, Fishing & Outdoor Adventure Exhibition. The overwhelming success of our debut event saw us outgrow the Manly Harbour location in our first year! Therefore, the new location for Explore Australia Expo in 2016 and beyond, is the iconic and exciting Doomben Racecourse. To say that we are excited about this event is an understatement. We have so much planned, we just can’t wait. We look forward to inspiring, educating and entertaining you all, September 2-4, Doomben Racecourse, Brisbane.

HEALTH CALENDAR

AUGUST/SEPTEMBER 2016

DONATELIFE WEEK 31st July – 7th August >> www.donatelife.gov.au

DonateLife Week is the national awareness week to promote organ and tissue donation in Australia. In 2016, DonateLife Week will be held from Sunday 31 July to Sunday 7 August. DonateLife Week provides a timely reminder to all Australians of the need to discuss their donation decision with loved ones, and to ask and know their donation decisions. It’s a week dedicated to having the chat that saves lives. We invite you to get involved and promote DonateLife Week in your workplace, your school, your community. Family discussion and knowledge of donation decisions is vital. The majority of families say that having discussed and knowing the donation decision of their loved one made it much easier to support donation proceeding. Rarely, does a family decline donation if they knew the deceased’s wishes. The DonateLife Week campaign is part of the Organ and Tissue Authority’s broader community education efforts supporting the National Reform Programme to increase organ and tissue donation rates in Australia.

JEANS FOR GENES DAY 5th August >> www.jeansforgenes.org.au

NPS MedicineWise clinical adviser Dr Andrew Boyden says that being medicinewise means knowing how and when to use medicines safely and effectively across all life stage. ‘Given the changes to our bodies and physiological processes that we experience over a lifespan it is not surprising that one size doesn’t fit all when it comes to your medicines. People at different ages and stages in life may need to use medicines quite differently,’ says Dr Boyden. To help people make wiser decisions about their medicines during any stage of life, NPS MedicineWise has developed a suite of free Be Medicinewise Week resources to support individuals, community groups and health professionals getting involved in the week.

DEMENTIA AWARENESS MONTH Month of September >> www.fightdementia.org.au Alzheimer’s Australia represents the more than 353,800 Australians living with dementia and the estimated 1.2 million Australians involved in their care. Dementia is a collection of symptoms that affect a person’s thinking, behaviour and ability to perform everyday tasks. It comes in many forms, greatly impacting individuals and their loved ones. Dementia Awareness Month is to encourage Australians to become dementia-aware, have a better understanding of what it is like for a person to live with dementia, and ultimately be encouraged to create communities where people with dementia are supported to live a high quality of life with meaning, purpose and value.

Each year, Australians unite by wearing their favourite jeans and outdoing each other with crazy denim outfits, and donating money or purchasing merchandise, to support genetic research. Most babies are born healthy, but sadly 1 in 20 children is born with a birth defect or genetic disease. On average, that’s one in every classroom. Children’s Medical Research Institute is dedicated to finding ways to treat or prevent childhood cancer, epilepsy, birth defects and genetic diseases in order to create brighter futures for all children including those who are with us today & those yet to come in to this world. Many major advances in children’s health have resulted from medical research including the demise of previously fatal illness like polio, smallpox & diphtheria so, together, we really can make a difference & give kids around the world the opportunity for a healthy start to life. Every dollar raised on the day helps scientists at Children’s Medical Research Institute discover treatments and cures, to give every child the opportunity to live a long and healthy life.

RU OK DAY 8th September >> www.ruok.org.au R U OK?’s role in tackling this heart-breaking issue is to help all Aussies play a role in stopping feelings of loneliness and isolation among family members, friends and workmates by having regular, meaningful conversations. It’s also our aim to help reduce the stigma around mental illness and suicide, as well as increase the likelihood that people will access professional support as soon as it’s needed. Here are some stats to help you understand how important suicide prevention is:

•• About seven people take their own lives every day in Australia •• 65,000 people attempt suicide each year

BE MEDICINEWISE WEEK 22-28th August >> www.nps.org.au

•• Suicide is the biggest killer of Australians under 44 years •• Men account for around 75 per cent of all suicide deaths

You may need to think differently about medicines at different times in your life. Being medicinewise means knowing how to use medicines safely at these different life stages The fifth annual Be Medicinewise Week will be held 12-18 October 2015 to promote the safe and wise use of medicines by all Australians.

This is why R U OK? places such a big emphasis on the power of connection. By inspiring people to take the time to ask “Are you ok?” and listen, we can help people struggling with life feel connected long before they even think about suicide. It all comes down to regular, face-to-face, meaningful conversations about life.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

Would you like to advertise in our Business Directory?

BUSINESS DIRECTORY

Contact Nicole Star on Ph: 07 3040 4415 or Email: production@goldx.com.au

Business Directory AFT PHARMAACEUTICALS Level 1, 296 Burns Bay Road Lane Cove NSW 2066 >> www.aftpharm.com

MPS FLOWSELL 1/13 Network Drive, Carrum Downs VIC 3201 Tel: +61 3 9708 2276 >> flowsellpharmacysolutions.com.au

8 Clunies Ross Court Eight Mile Plains QLD 4113 Tel: 1800 003 938 >> www.mps-aust.com.au

DOSE INNOVATIONS 20B Lathe St Virginia Brisbane QLD 4014 PO Box 696 Virginia Tel: 1800 003 673 >> www.doseinnovations.com

PCCA HEALTH WORLD 741 Nudgee Road Northgate QLD 4013 Tel: 07 3117 3300 >> www.healthworld.com.au

1/73 Beauchamp Road Matraville NSW 2036 Tel: 1300 722 269 >> www.pccarx.com.au

DOWARD INTERNATIONAL 50 Malcolm Road Braeside VIC 3195 Tel: 1800 369 273 >> www.doward.com.au

PHARMACY ALLIANCE

JA DAVEY

DIETICIANS ASSOCIATION OF AUST.

Head Office 626 Lorimer Street Fishermans Bend VIC 3207 Tel: 03 9646 5488 >> www.jadavey.com.au

1/8 Phipps Close, Deakon ACT 2600 Tel: 02 6163 5200 >> www.daa.asn.au

ENT TECHNOLOGIES Tel: +61 3 9832 3700 Suite 304, 12 Cato Street Hawthorn East VIC 3123 >> www.enttech.com.au

Level 4, 111 Coventry Street, South Melbourne VIC 3205 Tel: 03 9860 3300 >> www.pharmacyalliance.com.au

PHARMACY.COM.AU 70 Jellicoe Street Lidcombe NSW 2141 Tel: 1300 286 880 >> www.pharmacy.com.au

LEASE1 Retailer House â&#x20AC;&#x201C; Level 1, Unit 3 321 Kelvin Grove Road Kelvin Grove QLD 4059 Tel: 1300 766 369 >> www.lease1.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 49 : AUGUST/SEPTEMBER 2016

QUT Tel: 07 3138 2000 >> www.qut.edu.au

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Please review the full product information before recommending, available at www.maxigesic.com.au MaxigesicÂŽ film coated tablets (Paracetamol 500mg and Ibuprofen 150mg; 10s, 12s, 16s, 24s and 30s) are for the temporary relief of pain and reduction of fever. Do not use if you have asthma or a stomach ulcer. Do not use in children under 12 years or if you have kidney disease. Do not exceed the daily recommended dose. Do not combine with any other Paracetamol or Ibuprofen containing medicines. Always read the label. Use only as directed. Incorrect use can be harmful. If symptoms persist consult your healthcare professional. Patent No. 2005260243.

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References: 1. Merry, A. F., Gibbs, R. D., Edwards, J., Ting, G. S., Frampton, C., Davies, E. and Anderson, B. J. (2010). “Combined acetaminophen and ibuprofen for pain relief after oral surgery in adults: a randomized controlled trial” British Journal of Anaesthesia 104(1): 80–88. Result achieved in a trial of post-operative pain relief after removal of 1–4 wisdom teeth using Maxigesic® compared with Paracetamol 4000mg or Ibuprofen 1200mg alone per day in four divided doses. 2. Mehlisch, D. R., Aspley, S., Daniels, S. E., & Bandy, D. P. (2010). Comparison of the analgesic efficacy of concurrent ibuprofen and paracetamol with ibuprofen or paracetamol alone in the management of moderate to severe acute postoperative dental pain in adolescents and adults: A randomized, double-blind, placebocontrolled, parallel-group, single-dose, two-center, modified factorial study. Clinical Therapeutics, 32(5), 882–895. doi:10.1016/j.clinthera.2010.04.022 *2 tablets of Maxigesic taken every 6 hours over a 24 hour period (8 tablets maximum)

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