ITK December/January 2017 - Issue 51 by Gold Cross Products & Services

ISSUE #51 : DECEMBER 2016/JANUARY 2017

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 AY ’ S CO M M U N I T Y P H A R M A C I S T

IN THE KNOW

• PARTNERING TO BETTER HEALTH

• CPD — SUPPORTING GLAUCOMA PATIENTS

• SMOKING CESSATION

• SAXENDA PHARMACY PROGRAM

• CPD — CUSTOMER SERVICE ... BEYOND HELLO

• PHARMACY OF THE YEAR

CHAMPIX

NICOTINE FREEDOM

Help your customers go smoke-free and nicotine-free with CHAMPIX ®1

Nicotine-free quit 1

CHAMPIX PROVIDES YOUR CUSTOMERS WITH A NICOTINE-FREE QUITTING OPTION ®

~2x

SMOKERS ARE NEARLY TWICE AS LIKELY TO QUIT SMOKING WITH CHAMPIX VS. NRT PATCHES AT 12 WEEKS (OR: 1.86; 95% Crl: 1.36–2.54)

SMOKERS ARE UP TO 4X MORE LIKELY TO SUCCEED IN QUITTING WITH THE HELP OF A HEALTHCARE PROFESSIONAL.*

*Compared to quitting unaided; based on data

from UK Stop Smoking Services.

Would your customers benefit from talking to their doctor about a nicotine-free quit?

Nicotine-free quit 1

HELP YOUR CHAMPIX CUSTOMERS MAXIMISE THEIR CHANCES OF QUITTING ®

Remind patients that CHAMPIX® is a full 12‑week course1

Manage nausea by taking CHAMPIX® with a full glass of water and a meal4

Encourage patients to enrol in a support program like My Time To Quit

RESOURCES AVAILABLE TO USE WITH YOUR CUSTOMERS INTERESTED IN QUITTING

Referral pad with nicotine dependence screening tool

Help to Quit website with simple quitting advice

Ask your CHAMPIX® Representative about materials you can use to help your customer quit

~2x

SMOKERS ARE NEARLY TWICE AS LIKELY TO QUIT SMOKING WITH CHAMPIX VS. NRT PATCHES AT 12 WEEKS (OR: 1.86; 95% Crl: 1.36–2.54) ®

Nicotine-free quit 1 Important safety information Serious neuropsychiatric symptoms have occurred in patients being treated with CHAMPIX®. Patients and their families should be advised that the patient should stop taking CHAMPIX® and contact a healthcare professional immediately if changes in behaviour or thinking, agitation or depressed mood that are not typical for the patient are observed, or if the patient develops suicidal ideation or suicidal behaviour.

PBS Information: This product is authority listed on the PBS as an aid for smoking cessation for adults. Refer to PBS schedule for full information.

BEFORE PRESCRIBING, PLEASE REVIEW FULL PRODUCT INFORMATION AVAILABLE AT WWW.PFIZER.COM.AU

CHAMPIX® (varenicline as tartrate) 0.5 mg and 1 mg Tablets. INDICATIONS: Aid to smoking cessation in adults (≥ 18 years). CONTRAINDICATIONS: Hypersensitivity to varenicline or excipients. PRECAUTIONS: Serious neuropsychiatric symptoms including changes in behaviour or thinking, agitation or depressed mood, suicidal ideation or suicidal behaviour which patients and families should be instructed to monitor. Patients are to stop taking CHAMPIX at the first sign of any of these symptoms and contact a health care professional immediately. Alcohol may increase the risk of experiencing neuropsychiatric events. Seizures, hypersensitivity reactions, skin reactions, cardiovascular events, driving or operating machinery, pregnancy, lactation, severe renal impairment. See PI for details. ADVERSE EFFECTS: Smoking cessation/nicotine withdrawal symptoms. Most common: nausea, headache, insomnia, nasopharyngitis, abnormal dreams, abdominal pain, constipation, fatigue, diarrhoea, flatulence, vomiting, dyspepsia, dysgeusia, dry mouth, back pain, change in appetite, somnolence, weight increased, arthralgia, sinusitis, abdominal distension, rash, myalgia, dyspnoea, toothache, chest pain, gastro-oesophageal reflux disease, pruritis. Post-marketing reports of neuropsychiatric symptoms, myocardial infarction, stroke. See PI for details. DOSAGE AND ADMINISTRATION: Patients should set a date to quit smoking and start taking Champix 1 to 2 weeks before this date. Alternatively, patients can begin Champix dosing and then quit smoking between days 8 and 35 of treatment. Days 1 to 3: 0.5 mg once daily. Days 4 to 7: 0.5 mg twice daily. Day 8 to end of treatment: 1 mg twice daily. Patients should be treated for 12 weeks. An additional 12 weeks of treatment can be considered for those who need additional support. Retreatment with varenicline is encouraged in patients who are motivated to quit and did not succeed with prior treatment or who relapsed. Dose tapering is not required at end of treatment. Dose reduction is required for patients with severe renal impairment. See PI for details. V11015 References: 1. CHAMPIX® Approved Product Information. 2. Mills EJ et al. Annals of Medicine. 2012; 44: 588–97 & Supplementary Tables. 3. West R. (2012). Stop smoking services: increased chances of quitting. NCSCT Briefing #8. London; National Centre for Smoking Cessation and Training. 4. Supporting smoking cessation: a guide for health professionals. Melbourne: The Royal Australian College of General Practitioners, 2011 [Updated July 2014]. ©Pfizer 2016. CHAMPIX® is a Registered Trademark. Pfizer Australia Pty Limited. Pfizer Medical Information: 1800 675 229. 38–42 Wharf Road, West Ryde, NSW 2114. PP-CHM-AUS-0196 S&H 10/16 PFECH1282

hildren ddicted to

HEALTH

Are your children

igital devices? d ADDICTED to

Every time I turn around my grandchildren are straining their eyes, playing ames, on smart phones with small screens. So I had my experienced team at ruso’s develop an exclusive nutritional formula called Caruso’s Kids Blue Light Eye Protect to help with eyestrain and support eye health.” FRANK CARUSO - Frank Caruso Founder of Caruso’s Natural Health.

to digital devices?

devices? Executive Chairman and Founder at Caruso's Natural Health

eye strain and minimise effects of blue role in the early development of vision our child use digital devices? “EVERY TIME I TURN AROUND MY GRANDCHILDREN ARE STRAINING THEIR EYES, PLAYING GAMES, ON SMART light in children. during infancy and childhood. In children ays most children last SCREENS. SO I HAD MY EXPERIENCED TEAM AT CARUSO’S PHONEScouldn’t WITH SMALL DEVELOP AN EXCLUSIVE DHA is present in high levels in the Caruso’s Kids WITH Blue Light Eye Protect thout theirNUTRITIONAL digital devices. FORMULA CALLED CARUSO’S KIDS BLUE LIGHT EYE PROTECT TO HELP EYESTRAIN AND membranes of the retina and cerebral comes in a small 1 a day capsule which ng to a study by the Kaiser family SUPPORT EYE HEALTH.” - FRANK CARUSO FOUNDER OF CARUSO’S NATURAL HEALTH. cortex of the brain and has been shown is suitable for children 5 years and over. tion in the US, children and Alternatively the capsule may be cut or rs (ages 8-18) spend more than 7 to be particularly important for optimal development of motor skills and visual the contents squeezed day consuming electronic high levels in the membranes of the retina piercedSoand if you want to help protect the eyes onto of your DOES YOUR CHILDmedia¹ USE acuity in children. and cerebral cortex of the brain and has been most precious ‘little ones’ – try giving them a spoon or mixed with food for younger ’s increasingly technological DIGITAL DEVICES? shown to be particularly important for optimal Caruso’s Light Protect today! children. So if Kids youBlue want toEye help protect Lutemax2020 with Lutein and These days most children couldn’t last a day development of motor skills and visual acuity For more information about this without their digital devices. According to a the eyes of your most precious ‘little ones’ Zeaxanthinin(the natural blue light children. er did youstudy know that these product please call 1300 304 480 or visit by the Kaiser family Foundation in the – try giving them Caruso’s Kids Blue Light filters) www.carusosnaturalhealth.com.au nics may US, emit a “blue light”?(ages 8-18) children and teenagers spend LUTEMAX2020 WITH LUTEIN AND Eye Protect today! more than 7 hours a day consumingCaruso’s electronic Kids Blue Light Eye Protect ht is the highest energy ZEAXANTHIN (THE NATURAL BLUE REFERENCE: media1 in today’s increasingly technological For more information about this product contains Lutein which is a carotenoid LIGHT FILTERS) gth of visible light. 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Lutein and Zeaxanthin deposit deliver oxygen retina and primarily intoto thethe retina and act as antioxidant SO WHAT CAN YOU DO ABOUT BLUE excess ntcortex for children’s eyes that can of the brain and has been shown protectants and also absorb blue light. Lutein is suitable for children 5 years and over. LIGHT cause the generation of free radicals. d in Caruso’s KidsFOR BlueYOUR LightCHILD’S Eye EYES? has the ability to block blue light and may The nutrients which are the most important for Lutein and Zeaxanthin deposit primarily toOmega be children’s particularly forprotect optimal are 3 fatty acids (suchimportant as the retina from blue light. 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nd my grandchildren are straining their eyes, playing with small screens. So I had my experienced team at ive nutritional formula called Caruso’s Kids Blue Light help with eyestrain and support eye health.” Caruso Founder of Caruso’s Natural Health. 1

NEW

that is naturally present in mother’s milk.

please call 1300 304 480 or visit

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

CONTENTS

AFTER HOURS 68 SANTOS TOUR DOWN UNDER BUSINESS 4

ANOTHER FIRST… THE ROWA VMOTION SYSTEM

24 COMPOUND SUCCESS: PARTNER WITH PCCA

SEAN TUNNY Editor, Gold Cross Products & Services Pty Ltd

Is our world population of some 7.4 billion really such a large number? The majority of readers would have heard of the six degrees of separation theory that anyone on the planet can be connected to any other person through a chain of acquaintances that has no more than five intermediaries. The theory was first proposed in 1929 by the Hungarian writer Frigyes Karinthy in a short story called "Chains." In the 1950's, Ithiel de Sola Pool (MIT) and Manfred Kochen (IBM) set out to prove the theory mathematically. In 1967, American sociologist Stanley Milgram devised a new way to test the theory, which he called "the small-world problem." A site called Six Degrees, launched in 1997, was considered to be the first social networking site and the precursor of sites like Facebook and Twitter which have effectively lowered the number of intermediaries in the chain, arguably to almost zero. So, while I am watching Rafael Nadal practice at the Brisbane International in January, I may just invite him to lunch using the above theory! In considering the number of people that assist in the publication of ITK on many levels, while I do not validate or reject the theory above, I am certain that the large circle of support for ITK has been determined by key people who have referred me to others in producing the publication, thank you. In this our final print edition for 2016, we have an array of editorial and professional features which I enthusiastically recommend. These include our smoking cessation and weight loss features, CPD modules and update for pharmacists. Further, our retail sales analysis along with the evolving role of Australian Community Pharmacists rounds out another must read edition. On behalf of the team at ITK, may I take this opportunity to wish you and your families a Merry Christmas and prosperous New Year. Thank you to all the contributors, partners and supporters of ITK. Seasons’ greetings, Sean Tunny Editor - ITK Publications

BROUGHT TO YOU BY:

30 PARTNERING THE WAY TO BETTER HEALTH

32 THE SWEET SMELL OF SEASONAL SALES IN PHARMACY 34 PHARMACY BUSINESS STRUCTURES: IS GENERIC THE PREFERRED OPTION? 36 NEW RULES OF LEASING 38 THE EVOLVING ROLE OF AUSTRALIAN COMMUNITY PHARMACY 48 NEW LEADER GETS ON WITH BUSINESS 56 PHARMACY OF THE YEAR CONTINUING PROFESSIONAL DEVELOPMENT 7

A CLEAR VISION: SUPPORTING PATIENTS WITH GLAUCOMA THROUGH COMMUNITY PHARMACY

40 CUSTOMER SERVICE... BEYOND HELLO HEALTH 14 THE SAXENDA PHARMACY PROGRAM 20 PHARMACY-LED SMOKING CESSATION INITIATIVE 26 HEALTH ADVICE PLUS 29 COMMITTED TO DELIVERING MEANINGFUL HEALTH SOLUTIONS 37 SMOKING CESSATION AND WEIGHT GAIN: A REAL CONCERN? 44 DEHYDRATION: TREATMENT METHODS YOU MAY NEVER HAVE THOUGHT OF

46 COPD AND SMOKING CESSATION IN A PHARMACY SETTING 50 MOTIVATIONAL INTERVIEWING TO ASSIST SMOKING CESSATION IN THE PHARMACY SETTING 52 A NEW CALENDAR YEAR… SAME RESOLUTIONS? 54 PREVENTING THE COMPLICATIONS OF DIABETES NEWS 12 BUILDING A STRONGER PHARMACY NETWORK

PRACTICE READY 16 UPDATES FOR PHARMACISTS - PREZCOBIX REGULARS

QUIT SMOK ING

60 INDUSTRY NEWS & UPDATES 62 60 SECONDS WITH… 64 PRODUCT SPOTLIGHT 69 HEALTH CALENDAR

70 BUSINESS DIRECTORY

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.

BUSINESS David, chronic pain patient

Thereâ&#x20AC;&#x2122;s a reason we reject 250+ chemical lots every year. His name is David. Rigorous quality testing: Because in the business of compounding, the bottom line is always personal. Become a member, for all the right reasons. pccarx.com.au | 02.9316.1500

BUSINESS

Another first… The new Amcal+ Express Chermside is again leading the way, being the first in Australia to install the Rowa Vmotion system – the next generation in OTC display. This follows the 2011 introduction of the Rowa Vmax automated dispensary and inventory management system, also a first in Australia. Rowa Vmotion – the cutting edge of advanced technology. The Vmotion allows your OTC products to be presented on large touch-screens instead of shelves, with products being stored and managed in your Rowa. Located in a specialist medical complex, Amcal+ express Chermside’s customers are mainly patients from the nearby medical consultants.

Pharmacist Shivani Sahai - “Many customers fill a one-off prescription on the way out of their appointment, and we rarely see them again. But we’re starting to see an increase in repeat customers, and scripts on file as more locals hear about our excellent customer service.” Pharmacy Owner George Castrisos – “The Vmotion is an innovative and flexible way of presenting OTC products in my pharmacy. Customer consultation and care has always been the main driver for our innovation, and this is another way we can save time, and redirect our resources to helping our patients.”

What really impresses me is the smiles on my customers faces. “We implemented the Vmotion system a few weeks ago, and we’ve already reduced the amount of capital tied up in physical product displays, and we’ve improved stock GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

BUSINESS

management. But what really impresses me is the smiles on my customers faces – they love the Vmotion, and the interaction that it brings to my pharmacy”

Physical stock presentation is less demanding. Shivani says the new system has already streamlined her work, enabling her to spend more time with customers. “My whole OTC range can be called up on any of the screens, so you’re not tripping over other staff to access products in the corner, and I can consult with impaired mobility patients from one place. Physical stock presentation and behind-the-counter maintenance is less demanding, freeing up time to engage with our customers, which I love.” What does the Pharmacy Team think? • The Vmotion screens show up-to-date information on prices and availability, including package sizes, plus alternative and complementary products. It gives us visual prompts to help customers further. • Contains category management collections (planograms) which can be rearranged in seconds, without even touching stock. So it’s much easier to locate items, and stocking/ re-stocking is no longer a laborious task.

• Flexible displays - special offers, pack arrangement, scalable package sizes (our displays always look perfect!). • Creation of time and weather controlled special offers (all without needing to touch a single pack!). George has noticed the difference too. “The extra space, plus the workflow improvements have allowed us to have a more open pharmacy design. The virtual display presents products in a clear manner and the oversized presentation of the packages on the touch-screens also means that the products are easier to recognize, even from a distance.” “Since we installed Rowa Vmotion, our customers pay greater attention to the displays. We’ve had great feedback on the clear and modern way in which our products are presented. By automating the display and stockroom, we can also work more efficiently. As such, my pharmacy is both competitive and contemporary, and we have far greater interaction with our customers.” Would you like to know more? Please email enquiries@doseinnovations.com to arrange a pharmacy visit, or go to www.doseinnovations. com/chermside to see more photos.

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 51 : DECEMBER 2016/JANUARY 2017

HELPING YOUR PATIENTS KEEP THEIR INDEPENDENCE

OF PATIENTS TURN TO THEIR PHARMACIST AS THEIR TRUSTED ADVISOR ON MEDICATION MANAGEMENT*

Pharmacist Ben & Pharmacy Technician Sarah know their patients well and this is helping to grow their Dose Administration Aid (DAA) business.

portable

Talk to us today about how a DAA strategy can increase your profitability.

at forty, harry had been managing his combination of medication and vitamins for five years â&#x20AC;&#x201C; but he found it hard to manage on his frequent overseas trips. now, harry enjoys the convenience of mps packettes to help him manage his health, wherever he travels.

*MPS 2015 DAA Consumer Research Report

Call 1800 003 938

mps-aust.com.au TRANSFORMING MEDICATION MANAGEMENT

CONTINUING PROFESSIONAL DEVELOPMENT 7 7

A CLEAR VISION:

Supporting Patients with GLAUCOMA through Community Pharmacy

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

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

Learning Objectives: After reading this article, the learner should be able to: • Recognise the clinical features associated with the different presentations of Glaucoma; •

Identify factors which may predispose patients to an increased risk of developing Glaucoma;

•

Recognise the mechanism of action of medications used in the treatment of Glaucoma;

•

Describe techniques which optimise the use of topical Glaucoma medications.

Competencies Addressed: 6.1, 6.2, 7.2 Accreditation Number: G2016019 This activity has been accredited for 1 hour of Group 1 CPD (or 1 CPD credit) suitable for inclusion in an individual pharmacist’s CPD plan which can be converted to 1 hour of Group 2 CPD (or 2 CPD credits) upon successful completion of relevant assessment activities.

GLAUCOMA IS ONE OF THE WORLD’S LEADING CAUSES OF IRREVERSIBLE BLINDNESS, AFFECTING 1 IN 8 AUSTRALIANS OVER THE AGE OF 80 AND WITH AN ESTIMATED 50% OF PATIENTS WHO HAVE GLAUCOMA NOT BEING DIAGNOSED1. GLAUCOMA IS A COLLECTIVE NAME FOR A GROUP OF CONDITIONS IN WHICH THE OPTIC NERVE IN THE BACK OF THE EYE IS DAMAGED, OFTEN THROUGH INCREASED INTRAOCULAR PRESSURE (IOP)1. GLAUCOMA IS OFTEN REFERRED TO AS AN INVISIBLE DISEASE AND ONE THAT AFFECTS PREDOMINATELY OLDER AUSTRALIANS, AND AS SUCH, COMMUNITY PHARMACISTS ARE IDEALLY PLACED TO PROVIDE SUPPORT IN BOTH RAISING AWARENESS AND AIDING IN MEDICATION MANAGEMENT FOR PATIENTS WITH GLAUCOMA.

CLINICAL FEATURES Glaucoma is classified based on the appearance of the iridocorneal angle; there are open-angle, closed-angle and developmental categories, of which there are primary and secondary types2. The two predominate types of glaucoma are chronic (primary open-angle) and acute (angle-closure, closed-angle, or narrow-angle) glaucoma2,3. Acute glaucoma occurs when there is a rapid increase in pressure inside the eye, causing a painful unilateral red-eye and blurred vision and prompting an immediate referral for emergency medical treatment3,4. Primary open-angle glaucoma is the most common form seen in Caucasian patients, accounting for approximately 90–95% of all reported cases of glaucomas5. There are few symptoms presented initially with this form of glaucoma, as the onset of the disease can be slow and painless with visual disturbance only affected later as the disease progresses1,5. It may occur with or without an elevated IOP — in the case that IOP is not elevated, it is referred to as low or normal pressure glaucoma5,6. The main clinical features of primary open-angle glaucoma are an open iridocorneal

angle and cupping of the optic nerve head. The patterns of visual disturbance that occur in this type of glaucoma are related to the location and extent of optic nerve cupping present7.

CONTRIBUTING FACTORS Whilst glaucoma can affect anyone, there are a number of risk factors for the disease which can be taken into consideration, particularly when identifying candidates for early screening. Relevant patient factors for increased glaucoma risk include 2,3,8:

• Family history of glaucoma (1st degree relative);

• Caucasian and Asian patients aged >50 years;

• African descent patients aged >40 years;

• All patients aged >50 with: o

diabetes;

myopia;

long-term steroid use;

migraine;

high blood pressure.

Evidence supports a screening approach to target individuals at a high risk of glaucoma. Whilst there is currently no optimal test for glaucoma screening, combinations of optic disc assessment, visual field assessment, IOP examination and angle assessment are recommended3,8.

PHARMACOLOGICAL MANAGEMENT STRATEGIES Whilst there is no ‘cure’ for glaucoma, early diagnosis with appropriate management is the best way to either prevent or slow the visual loss associated with the disease (especially with primary open-angle glaucoma). Early treatment preserves the visual field and reduces the rate of glaucoma progression (regardless of whether IOP is raised or not). A target IOP for treatment is determined based upon the patient’s risk factors for glaucoma progression, the amount of initial damage and the rate of deterioration9. Laser or surgical interventions are considered if drug treatment is inadequate or intolerable9. Table 1 (right) summarises the various classes/approaches to glaucoma treatment in Australia.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

CONTINUING PROFESSIONAL DEVELOPMENT

Table 1: Summary of Medications available for the management of Glaucoma2,3,9 CLASS

MEDICATION/STRENGTH

MECHANISM OF ACTION

TREATMENT ORDER

Prostaglandin analogues

• Latanoprost 0.0005% • Bitamoprost 0.03% • Travoprost 0.004%

Reduce IOP by increasing outflow of aqueous humour.

First line

Beta-blockers

Non-selective • Timolol 0.25%, 0.5% ß1 Non-selective • Betaxolol 0.25%, 0.5%

Reduce aqueous humour formation by blockade of beta receptors on the ciliary epithelium.

First line

Alpha 2 agonists

Brimonidine 1% Apraclonidine 0.5%

Effective at lowering IOP quickly by suppressing formation and increasing uveoscleral outflow of aqueous humour.

Second line

Carbonic anhydrase inhibitors

Topical • Brinzolamide 1% • Dorzolamide 2% Systemic • Acetazolamide 250 mg (tablet)

Reduce aqueous humour formation in the ciliary body.

Second line

Cholinergics

• Pilocarpine 1%, 2% • Carbachol 1.5%, 3%

Increase aqueous draining by contracting the iris sphincter and ciliary muscle.

Third line

Fixed dose combinations

• Brimonidine 0.2% / timolol 0.5% (Combigan) • Dorzolamide 2% / timolol 0.5% (Cosopt) • Bitamoprost 0.03% / timolol 0.5% (Ganfort) • Latanoprost 0.0005% / timolol 0.5% (Xalacom) • Travoprost 0.004% / timolol 0.5% (DuoTrav)

As per individual ingredients. May increase adherence through convenience of a simplified dosing schedule.

Second line

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

TREATMENT ISSUES AND MEDICATION ADHERENCE Not surprisingly, due to the asymptomatic nature of chronic glaucoma as a disease, adherence to medications is often reported as poor 9,10. Strategies for maximising patient adherence may be through the simplifying of the dosing regimen (particularly the use of fixed dose combination products if multiple medications are required). Once daily dosing has been shown to improve both patient satisfaction and adherence in glaucoma, prostaglandin analogues are first-line therapy choices2,10,11. Correct instillation of topical medications is also an important pharmacist intervention when dispensing medications for glaucoma. The preferred method for eye drop selfinstillation is to hold the head horizontal with tear duct occlusion and eyelid closure for 2–3 minutes (DOUBLE DOT: Digital Occlusion of Tear Duct and Don’t Open Technique). Systemic absorption can be reduced by up to

70% using this technique9,12. The Glaucoma Australia website features patient support materials and video demonstrations of how to correctly instil topical glaucoma treatments. Beta-blocker eye drops for glaucoma have the greatest propensity for adverse effects stemming from systemic absorption; Betablocker eye drops may cause bradycardia, bronchospasm, hypotension and syncope12. Prostaglandin analogues have minimal systemic side effects9.

SUPPORTING PATIENTS THROUGH COMMUNITY PHARMACY Pharmacists are ideally placed in the community to support patients with glaucoma through a number of mechanisms:

• Raise awareness in store and educate patients to consider their eye health! For patients who may be at an increased risk of developing glaucoma, check if they have spoken to their doctor about having an eye

exam. The ‘silent’ nature of glaucoma progression makes health promotion through community pharmacy highly relevant and may help identify at-risk patients!

• Encourage patient adherence to medications by ensuring that they have a clear understanding about their disease and the importance of regular medication use. Where possible, ensure that patients’ glaucoma regimes are as simplified as possible.

• Educate patients regarding the correct instillation of glaucoma treatments and ensure they are comfortable using their eye drops. Regularly checking in regarding how patients are managing their drops and reinforcing good habits can go a long way! For more information and resources for health professionals to support your patients with glaucoma, visit the Glaucoma Austria website at www.glaucoma.org.au

“The ‘silent’ nature of glaucoma progression makes health promotion through community pharmacy highly relevant and may help identify at-risk patients! Educate patients regarding the correct instillation of glaucoma treatments and ensure they are comfortable using their eye drops.”

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

BUSINESS 11 11 CONTINUING PROFESSIONAL DEVELOPMENT

REFERENCES: Tunnel Vision. The economic impact of Open Angle Glaucoma: a dynamic model. Centre for Eye Research Australia, 2008 [accessed from www.glaucoma.org.au] 2 eTherapeutic Guidelines: Neurology. 2016. Glaucoma. 3 National Health and Medical Research Council. NHMRC guidelines for the screening, prognosis, diagnosis, management and prevention of glaucoma. Canberra: National Health and Medical Research Council; 2010. 4 Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90:262–7. 5 Kwon YH, Fingert JH, Kuehn MH, Alward WL. Primary open-angle glaucoma. N Engl J Med. 2009;360:1113–24. 6 Kroese M, Burton H. Primary open angle glaucoma. The need for a consensus case definition. J Epidemiol Community Health. 2003;57:752–4. 7 Harris A, Rechtman E, Siesky B, et al. The role of optic nerve blood flow in the pathogenesis of glaucoma. Ophthalmol Clin North Am. 2005; 18: 345–353. 8 The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th edn. East Melbourne, Vic: RACGP, 2016. 9 Australian Medicines Handbook Pty Ltd. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook; 2016. 10 Tsai JC. Medication adherence in glaucoma: approaches for optimizing patient compliance. Curr Opin Ophthalmol. 2006;17:190–5. 11 Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487–97. 12 Goldberg I, Moloney G, McCluskey P. Topical ophthalmic medications: what potential for systemic side effects and interactions with other medications? Med J Aust. 2008;189:356–7. 1

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 statements regarding glaucoma is INCORRECT? a. Primary Open-angle glaucoma is the most commonly seen form of the disease; b. Acute glaucoma is a medical emergency, presenting as a rapid increase in IOP, pain and a unilateral red-eye; c. Primary Open-angle glaucoma progresses quickly and affects vision in the early stages of the disease; d. Primary Open-angle glaucoma can occur with or without an elevation in IOP.

QUESTION 2 Which of the following patients would be considered to have the GREATEST increased risk for development of glaucoma? a. Caucasian descent, 30 years old, frequent migraines; b. Asian descent, 45 years old, mild hypertension; c. African descent, 65 years old, Type-2 diabetic; d. Caucasian descent, 50 years old, smoker.

QUESTION 3 How do prostaglandin analogues reduce IOP in patients with glaucoma? a. Decrease outflow of aqueous humour; b. Reduce formation of aqueous humour; c. Increase formation of aqueous humour; d. Increase outflow of aqueous humour.

QUESTION 4 Which of the following medications exerts its effect in glaucoma by reducing the formation of aqueous humour in the ciliary body? a. Timolol; b. Dorzolamide; c. Bitamoprost; d. Brimonidine.

QUESTION 5 Which of the following statements regarding the DOUBLE DOT technique for instillation of glaucoma eye drops is CORRECT? a. Increases the systemic absorption of medication by up to 70%; b. Decreases the systemic absorption by up to 70%; c. Increases the efficacy of treatment by a factor of 2; d. Decreases IOP by 70%.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

NEWS

BUILDING A STRONGER

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

IT’S BEEN A BIG 12 MONTHS IN COMMUNITY PHARMACY, WITH MUCH OF THE INDUSTRY FOCUS ON THE ONGOING REVIEW OF PHARMACY REMUNERATION AND REGULATION. The Guild lodged a major submission in response to the Review Discussion Paper recently to help inform the next stage of the Review process which will commence following the release of an Interim Report. The Review is looking at every aspect of pharmacy — from the cost, distribution and dispensing of medicines, to the provision of professional pharmacy services, the pharmacy location rules, and the expectations and experiences of consumers. At the Guild, we see 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. The Guild strongly supports the tried and tested community pharmacy model, which is underpinned by Location Rules that ensure that Australians have high levels of accessibility to medicines through a well-distributed network of community pharmacies, owned by pharmacists who have a professional obligation to deliver quality health outcomes for their patients.

PBS, the RPBS and related medicine services to the public. •

•

In the interest of PBS universality, the community pharmacy funded optional $1 discount should be abolished.

•

There should be a thorough review of all PBS Patient Co-payments and Safety Net Threshold levels to ensure that PBS medicines are affordable for consumers.

•

Future community pharmacy agreements must reinvest a fair proportion of the savings from PBS reforms into ensuring that the core clinical role of dispensing remains viable and is remunerated at a level that reflects the cost pressures on community pharmacies.

•

The sustainability of the medicines supply chain must be ensured by fully expending the funding for wholesalers committed to in the 6CPA, through a wholesale mark-up floor and retention of the Community Service Obligation (CSO).

•

The Federal Government should fund a fee for service Opiate Dependence Treatment (ODT) program for eligible community-based patients, delivered through community pharmacy to reduce patient barriers to access.

•

For greater efficiency and patient care, the National Diabetes Services

The Guild submission is a very long and comprehensive document, so let me take this opportunity to highlight some of the headline recommendations: •

Retention of the five-year community pharmacy agreements negotiated with the Federal Government which represents the interests of taxpayers and consumers, and the Pharmacy Guild which represents the owners of the community pharmacies who finance the privately capitalised infrastructure required to deliver the

The Federal Government should use the Primary Health Networks (PHNs) to provide incentives for local community pharmacies to coordinate emergency after-hours patient access to PBS medicines and other critical community pharmacy services.

•

We believe there are opportunities for pharmacies to deliver further benefits to patients and the broader health system, provided we have appropriate support. Accordingly, the Guild made a series of recommendations that would deliver improved patient outcomes, and sustain local community pharmacies into the 2020s and beyond.

The Federal Government should fund an ongoing campaign to raise public awareness of the role of community pharmacy as a trusted health destination, and the availability of pharmacy services.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

Scheme (NDSS) supply and remuneration model should parallel the supply arrangements of the PBS. •

The Federal Government should immediately take responsibility for the national implementation of a realtime recording system for Controlled Drugs (e.g. Electronic Recording and Reporting of Controlled Drugs – ERRCD).

•

In order to receive Federal Government funding, all pharmacist-delivered professional services must be uploaded to an e-Health record to ensure coordinated patient care.

•

The Federal Government should fund a fee for service minor ailments program in community pharmacy that uses a recordable pharmacist-only medicine schedule.

•

To provide equity, enhanced patient access, improve uptake and maximise herd immunity, community pharmacies should be funded to administer scheduled vaccines listed on the National Immunisation Program (NIP) Schedule (and should record vaccinations directly to the Australian Immunisation Registers) on a level playing field with other health professionals.

•

The Continued Dispensing arrangements for urgent PBS medicine supply should be expanded to include other medicines used to treat chronic health conditions, with a requirement to inform the prescriber consistent with the current arrangements.

•

Community pharmacies should be funded to become local health hubs where there are health gaps due to demonstrated shortages of GPs and other health professionals.

For those eager to read the full submission, it is available at guild.org.au/pharmacy-review

COMMIT 2 QUIT Help your customers take the smoke-free path

QuitX combination therapy: ®

Patches (nicotine) + Gum (nicotine polacrilex)1,2

Learn more at QuitX.com.au References: 1. QuitX® Patch Product Information. 2. QuitX® Gum Product Information. Before recommending, please review the Product Information available from Mylan. Copyright © 2016 Mylan N.V. All rights reserved. Alphapharm Pty. Limited. ABN 93 002 359 739. Level 1, 30 The Bond, 30-34 Hickson Road, Millers Point NSW 2000. Tel: 1800 274 276 www.mylan.com.au inCeptiv ALP0791 November 2016.

Patches + Gum

HEALTH

The Saxenda

Pharmacy Program Integrating a Prescription-Only Medicine into your Weight Management Category

KOS SCLAVOS PharmaPrograms Systems Architect

PATIENTS SEEK ADVICE FROM THEIR PHARMACIST ABOUT HEALTH SOLUTIONS — THEY ARE NOT CONCERNED ABOUT WHAT SCHEDULE THE MEDICINE IS, OR WHERE IT IS STORED IN THE PHARMACY. IF PHARMACISTS ADOPT THE MINDSET OF HEALTH SOLUTION, THEN INTEGRATING PRESCRIPTION-ONLY MEDICINES INTO TREATMENT OPTIONS FOR PATIENTS WILL LEAD TO BETTER HEALTH OUTCOMES. IN THIS FEATURE I WILL EXPLAIN SOME BEST PRACTICE TECHNIQUES TO INTEGRATE A PRESCRIPTIONONLY MEDICINE INTO YOUR SOLUTION OPTIONS.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

HEALTH

Research conducted by Sinapse indicates that some 85% of patients who seek weight management support in a community pharmacy are existing customers. This means these patients already know your staff, trust them, and are likely to already be filling their prescription medicines at your pharmacy. If that patient is seeking advice on weight management solutions, then the pharmacist should be considering all solutions, from meal replacements through to prescription-only medicines. While the pharmacist will be required to refer the patient back to the doctor if a prescription-only medicine is the most suitable solution in their professional judgement, a systemised approach is required to ensure the patient remains satisfied with your recommendation.

BACKGROUND INFORMATION Saxenda® is the first new prescription medication for obesity available to Australian patients in over a decade and is an injectable treatment that has been shown to be effective in helping patients lose weight and keep the weight off. It is indicated for patients with a BMI 27> with a comorbidity, or BMI 30> with or without comorbidities. It is a private medicine at a cost of $387 for the monthly treatment. There is also a comprehensive Patient Support Program (PSP), and participating pharmacies implement a protocol to support patients. Pharmacies are remunerated $22.36 as a professional service fee at each dispensing for undertaking a Quality Use of Medicines (QUM) role as detailed in the protocol. This professional fee is in addition to the $27.64 dispensing fee. The aim of the support program is to ensure better compliance to medicines, timely access to information and additional value (such as the free NovoFine® 6mm 32G Tip needles).

PHARMACY PREPARATORY WORK For best practice implementation of a professional remunerated program, I suggest the following should form part of a checklist:

1. PROGRAM ADMINISTRATION All requirements to do with program implementation need to be completed, including online registration, and SmartForm templates completed. PharmaPrograms provides a formal Checklist for all of its programs.

2. STAFF PREPARATION Whilst training is obvious, few pharmacies then undertake role-plays and adjust position descriptions for staff members. The role-plays need to include the scenario where a patient in the pharmacy may have tried other solutions that have not worked and would benefit from being referred to the doctor for a prescription medicine, and the pharmacist then initiates a process to facilitate the doctor visit. In some pharmacies the appointment is made by the pharmacist at the local practice. This may not be possible in all scenarios. In relation to adapting position descriptions, team responsibilities need to be reviewed with each program, key performance indicators detailed, and roles within the professional service stipulated. PharmaPrograms provides a formal Staff Meeting Agenda and Q&A Document for all of its programs.

3. DETAIL LOCAL GENERAL PRACTITIONERS It is critically important that the pharmacy has regular discussions with local GPs and practice staff. The pharmacy should be providing the local doctors with information about any specific programs they are participating in. In addition, a key issue is that you need to inform doctors about the price of any private prescription programs because the sad fact is that in 2016, many have simply referred patients to discount pharmacies. PharmaPrograms has some initiatives that involve private prescriptions for which there is a condition of entry to the program where the pharmacy agrees to charge no more than a set price for a specific medicine. This is

then detailed to doctors by pharmaceutical representatives and, in simple terms, it means you should not be losing your patients to discounters if you are participating in these programs. Also, establishing a process with the doctor for prescription-only referrals for weight loss patients is the ideal scenario, especially if the doctor is able to see the patient on the same day — a locked-in appointment is key.

4. STREAMLINE WORKFLOW There are many steps that the pharmacy can undertake to streamline the process. For dispensary-based professional programs, that involve a prescription medicine, it is important to create a pop-up on the dispense software to remind the dispensing pharmacist that a support program for patients exists and it should be executed as described by the protocol. Most vendors allow such a pop-up to be created. In addition, PharmaPrograms generally provide a shelf talker or wobbler to remind staff to instigate a program.

5. CREATE REPORTS A key success factor is to monitor a program and generate a report on a regular basis. For programs such as the Saxenda® Pharmacy Program, it is recommended to create a dispensary report of usage, and to match that against program claims over the same period. This will quickly identify if staff are not instigating the protocol and the relevant program at each dispensing.

6. KNOW HOW TO ENROL A PATIENT TO A PROGRAM Some programs only allow the doctor to enrol a patient, but some allow both doctor and pharmacist to enrol the patient. For Saxenda®, if a prescribed patient has not been enrolled in SaxendaCare™ by their doctor, they will not have a Unique Patient Code. The pharmacy can enrol the patient via the web portal.

"Systems and procedures are key to a successful pharmacy practice." GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

PRACTICE READY

Update for Pharmacists This update provides introductory and practice information for pharmacists. For in-depth information please consult the Product Information.

BY AARON D'SOUZA Pharmacist, B.Pharm

Pharmacy is an exciting profession. We are placed at the front line of health in the unique position of optimising the quality use of medicines for our patients. A great part of that professional excitement is derived from the challenge of new therapies that frequently grace our dispensaries. For the everyday pharmacist on the front line, keeping up with new brands, new mechanisms of actions and new indications can be daunting. I've recently come back to practicing pharmacy. As a returning locum pharmacist, I found that my one year out of the profession made me stumble through a few new brands and therapy objectives. It's why I wanted to partner with In the Know and produce "Practice Ready". This Drug Update for Pharmacists is an ongoing series providing the top line information we all need to successfully engage with customers for new medicines. I look forward to feedback on how we can make this publication move from good to great by being more relevant to you.

SNAPSHOT

Prezcobix [DARUNAVIR + COBICISTAT] Darunavir – HIV-1 Protease inhibitor; Cobicistat – Pharmacokinetic enhancer MF: Janssen-Cilag

Listed: 01 November 2016

INDICATION

Schedule 4: Prescription Only Medicine PATIENT DISCUSSION POINTS3,4

• Human immunodeficiency virus (HIV-1) infection treatment: Initial,

• Note the streamline authority code and tailor

Continuing, Additional therapy1.

counselling based on initial, continuing or optimised;

THERAPY GOAL To reduce HIV associated morbidity and mortality and improved quality of life for HIV patients2.

• Swallow whole with a drink (water, milk etc.)

PBS LISTINGS1

• Must be taken within 30 minutes of having

without breaking or crushing; food – will not work otherwise;

• Item code: 10903W

• Do not stop abruptly or alter dose without

• Streamline Authority Required

discussing with Doctor;

o 6413: Initial Treatment

o 6428: Continuing Treatment

o 6377: Addition to optimised background therapy

• ADRs; • Expectations and clinical follow-up; • This therapy does not cure HIV or prevent

• Category: HSD S100 Community Access (see below for description)

the transmission of HIV. Continue to employ methods of blood and sexual safety to stop the spread of the virus.

DOSING Oral systemic dosing: Oral systemic dosing. Swallow whole ONE (1) tablet every day within 30 minutes of food. Take with water, milk or a nutritional drink. Missed dose: Take within a 12-hour dosing window of the regular time. After 12 hours, take the next dose at the scheduled time. Do not double the dose3.

PREZCOBIX® [DARUNAVIR + COBICISTAT] Traditionally, HIV/AIDS care is an area of community pharmacy practice not frequently experienced. Much of this is due to HIV medicines not being available for dispensing in community pharmacies prior to July 2015 and it is here that we have seen the inception of the HSD100 Community Access scheme. Patients are now able to have their medicines dispensed through community pharmacies — a step forward for patients and pharmacists. As always, pharmacist preparation is the key for quality patient outcomes. The HIV-1 type is the predominant HIV virus seen worldwide. The HIV-2 type is generally concentrated in West Africa5.

STORAGE AND HANDLING Ambient product: Store below 30oC3.

The Kirby Institute reports that in 2014, 1,081 new cases of HIV were diagnosed across Australia. This brings the total number of HIV positive patients to 35,122. The number of new diagnoses are increasing each year6.

"According to the 2014 National Surveillance Report, between 13,200 and 19,500 diagnosed individuals were receiving antiretroviral treatment and had undetectable levels of HIV 6."

HIV Human Immunodeficiency Virus (HIV) is a retrovirus. There are seven stages to the HIV life cycle7:

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

It is recommended to scan the QR code with your phone or visit the link here for a visualisation of the process. Video on HIV Lifecycle and the Immune system: https://youtu.be/odRyv7V8LAE Essential viewing.

CLINICAL USE1,3 Prezcobix® [Darunavir + Cobicstat] is an antiviral combination medicine for oral systemic use in Human Immunodeficiency Virus (HIV-1) positive patients. Darunavir is an inhibitor of HIV-1 protease. This means it works at Step 7: “Budding” in

PRACTICE READY STEP

DESCRIPTION

PHARMACOLOGICAL INTERVENTION

1. Binding

Virus binds to CD4 receptor.

CCR5 Antagonist

2. Fusion

Virus envelope and host cell membrane fuse.

Fusion Inhibitors

3. Reverse transcription

HIV enzyme Reverse Transcriptase converts the HIV RNA to HIV DNA.

Non-nucleoside reverse transcriptase inhibitors (NNRTIs) Nucleoside reverse transcriptase inhibitors (NRTIs)

4. Integration

HIV enzyme ‘Integrase’ inserts the HIV DNA into the host genome. (Hence life-long infection)

Integrase Inhibitors

5. Replication

The host cell’s replication machinery then replicates the HIV DNA, producing mRNA which transports outside the nucleus. HIV proteins are expressed ready for assembly.

6. Assembly

The HIV proteins and HIV RNA then move to the host cell’s surface where they assemble to create the non-infectious immature virus.

7. Budding

The immature virus buds off from the host cell. Inside the virus Protease aces to clip long protein chains and these combine to form the infectious, mature virus.

the HIV life cycle by inhibiting the cleaving of proteins required to create a mature infectious virus. Cobicstat is an inhibitor of the CYP-450 enzyme family CYP3A. It has no known anti-viral effect. Its purpose is to increase Darunavir concentrations. Under the PBS, Prezcobix is subsidised for use as initial, continuing or optimising therapy. It must be prescribed in combination with other antiretroviral agents and must not be used in combination with Ritonavir.

PRECAUTIONS AND CONTRAINDICATIONS Contraindications:3

• Allergic to Darunavir, Cobicistat or other ingredients in product.

• Administration with medicines highly dependent on CYP3A for clearance and/or have plasma concentrations associated with life-threatening events/a narrow therapeutic index. o

Including: Apixaban (Eliquis®), Cisapride (Prepulsid®), Colchicine (in patients with renal and/ or hepatic impairment), Ergotamine (Cafergot®), Sildenafil (when used for treatment of pulmonary arterial hypertension), Simvastatin, Antiarrhythmic drugs (Amiodarone, Flecanide, Quinidine).

Precautions and warnings:

• Patients should be advised that treatment with Prezcobix does not cure HIV, nor does it prevent the transmission of HIV to other people. Continue to employ methods of blood and sexual safety to stop the spread of the virus.

• Patients with increased risk of liver function abnormalities should continue to seek laboratory testing

Protease Inhibitors

before and whilst on Prezcobix. Evidence of new or worsening liver dysfunction prompts referral to the prescriber for therapy review.

• Signs of severe skin reactions – refer to prescriber for immediate discontinuation of therapy. Rash has occurred in trials without discontinuation of therapy.

• Caution and monitoring should be used if the patient has a sulphonamide allergy.

• Ensure patients with Diabetes Mellitus monitor their blood sugar levels — hyperglycaemia can occur.

• rash (including Stevens–Johnson syndrome)2;

• changes in blood sugar levels; • changes in body fat o

Combination ART therapies may cause “Lipodystrophy” in HIV patients. This includes a redistribution of body fat from peripheral/facial subcutaneous fat to the abdomen, viscera, breasts and dorso-cervical area.

DRUG INTERACTIONS3,8

Pregnancy – Category B2 Lactation – do not use.

Administration with medicines highly dependent on CYP3A for clearance and/or have plasma concentrations associated with life-threatening events/a narrow therapeutic index. This includes a significant number of drugs across many drug classes. It is recommended to use the Product PI which has a thorough list by drug class of the interaction, severity and outcome.

WHAT’S IN THE PACK?4

PHARMACOKINETICS3,9

• Caution is exercised with patients over 65.

• Safety and efficacy is not established in children.

PREGNANCY AND LACTATION3

• Plastic bottle with child-resistant cap; • 30 film-coated tablets; • Pink oval-shaped tablet, debossed with “800” on one side and “TG” on the opposite side.

DOSING INFORMATION3 Oral systemic dosing: Swallow whole ONE (1) tablet every day within 30 minutes of food. Take with water, milk or a nutritional drink. Missed dose: Take within a 12-hour dosing window of the regular time. After 12 hours, take the next dose at the scheduled time. Do not double the dose 3.

ADVERSE EFFECTS

3,4

• nausea, vomiting; • headache; • abdominal pain, diarrhoea,

Darunavir exhibits the following characteristics: Tmax: 3 - 4.5 hours Distribution: Darunavir is approximately 95% bound to plasma proteins. Vd = 88.1L (Darunavir alone) Bioavailability: 37% (absolute oral bioavailability – darunavir alone). Note: in the presence of CYP3A inhibitor Ritonavir, Darunavir bioavailability is 82%. Terminal Half-life: ~11 hours (Darunavir, in presence of Cobicistat)

THERAPY OPTIMISING PRODUCTS Ensure the patient has a nutritional plan. Offer powdered nutritional formulas. Ensure the patient has Oral Rehydration Salts in case of vomiting or diarrhoea. Outline options for mild rash treatment.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

PRACTICE READY

Image taken from7 https://www.aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/hiv-in-yourbody/hiv-lifecycle/ This process causes the eventual death of the T-helper cell leaving the patient’s immune system depleted and susceptible to life-threatening infections.

Did you know? COMMUNITY ACCESS The HSD community access arrangements introduced 1 July 2015 better aligned existing HSD program arrangements with current clinical practice. These arrangements allow authorised community-based practitioners to prescribe Clozapine for the treatment of schizophrenia (maintenance therapy only), HIV antiretroviral and hepatitis B medicines without the need to be affiliated with a hospital. Patients also have greater choice about where they access their medicines, through either a community pharmacy, or a private or public hospital pharmacy. Community pharmacists are able to dispense these medicines regardless of where the medicine is prescribed. The remuneration rates for HSDs through community pharmacies are as follows:

•• 10% for drugs with a price ex-manufacturer of less than $40;

•• $4 for drugs with a price ex-manufacturer of between $40 and $100;

•• 4% for drugs with a price ex-manufacturer of between $100.01 and $1000;

•• $40 for drugs with a price ex-manufacturer of greater than $1000. https://www.pbs.gov.au/info/ browse/section-100/s100highly-specialised-drugs

REFERENCES: Health AGD of. Pharmaceutical Benefits Scheme (PBS) | [Internet]. Australian Government Department of Health; [cited 2016 Oct 28]. Available from: http://www.pbs.gov.au/ medicine/item/10903W. 2 Topic | Therapeutic Guidelines [Internet]. [cited 2016 Oct 31]. Available from: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Antibiotic&topicfile=hum an-immunodeficiency-virus-infection&guidelineName=Antibiotic&sectionId=toc_d1e97#toc_d1e97. 3 Prezcobix PI [Internet]. [cited 2016 Oct 28]. Available from: https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2015-PI-024951&d=2016102816114622483. 4 Prezcobix CMI [Internet]. [cited 2016 Oct 28]. Available from: https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2015-CMI-02497-1. 5 HIV strains and types | AVERT [Internet]. [cited 2016 Oct 28]. Available from: http://www.avert.org/professionals/hiv-science/types-strains. 6 HIV; viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2015 - ASR2015.pdf [Internet]. [cited 2016 Oct 28]. Available from: https:// kirby.unsw.edu.au/sites/default/files/hiv/resources/ASR2015.pdf 7 About HIV | ASHM [Internet]. [cited 2016 Oct 28]. Available from: http://www.ashm.org.au/hiv/about-hiv. 8 Prezcobix (darunavir/cobicistat) dosing, indications, interactions, adverse effects, and more [Internet]. [cited 2016 Oct 28]. Available from: http://reference.medscape.com/ drug/prezcobix-darunavir-cobicistat-999948#3. 9 Back D, Sekar V, Hoetelmans R. Review Darunavir: pharmacokinetics and drug interactions. Int Med Press. 2008;13:1–13. 1

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

SCALES

Digital Body Weight Scale HN283

Digital Personal Scale-Black HN289-BK

Digital Slimline Body Weight Scale HN286

Body Composition Scale HBF214AU

Step into summer with

PEDOMETERS

‘Steps’ Pedometer HJ005-BL

‘Walking Style’ Pedometer HJ320

Premium ‘Walking Style’ Pedometer HJ325W

For further information and deals call your local JA Davey representative or call 1800 807 464 or visit the website: omronhealthcare.com.au

HEALTH

MARGARET BEERWORTH BA GradCert Mktg M.Mgmt Branch Director ACT, Pharmacy Guild of Australia

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

HEALTH

BACKGROUND On 30 June 2016, the ACT Branch of the Pharmacy Guild of Australia successfully completed a two-year program: Community Pharmacy Smoking Cessation Program, made possible through a $138,000 grant received from the Healthy Canberra Grants Program. The Community Pharmacy Smoking Cessation Program focused on developing and implementing a pharmacy-led smoking cessation program in ACT community pharmacies. The implementation of the program led to an increase in quit attempts and successful long-term quitting, with results being documented in the GuildCare smoking cessation module throughout the program. The objectives were to communicate to the public the value of smoking cessation services by community pharmacists, together with the promotion of available services. Further, the program sought to improve access to and available choice of quit smoking services, extending to advice on smoking cessation therapy and options, support tools, resources and follow-up.

ACHIEVEMENTS Of the 74 community pharmacies in Canberra, 61 implemented the program. Over 290 pharmacists and staff attended smoking cessation counselling training by qualified trainers designed to equip them with the knowledge and skills to confidently offer the service to smokers. Training was conducted by Tobacco Treatment Specialist, Dr Colin Mendelsohn, the Cancer Council ACT and GSK. Following the smoking cessation training, pharmacists and staff reported an increase in skills, knowledge and confidence in assisting smokers by using best practice, evidencebased strategies. The results indicated that their advice and support had certainly helped many smokers to achieve their goal. During the program, 15 pharmacies purchased Smokerlyzers® to monitor carbon monoxide levels of smokers and these provided valuable encouragement for smokers who were attempting to quit. There were 593 carbon monoxide level measurements recorded in these pharmacies. Further, there were 627 profiles of smokers attempting to quit created in GuildCare Smoking Cessation modules which were piloted in ACT pharmacies specifically

for the program. The majority of these profiles were recorded in the second year of the program as the pharmacies developed strategies for implementing the service in their pharmacy. The average length of interventions recorded in GuildCare was 11 minutes and the program reported that more women than men participated in the sit-down recorded interventions. A small pharmacy, recording with hard copy templates, reported 58 quit attempts with 22 of these progressing to be successful quitters. This program resulted in an increase in the number of interventions in pharmacies, including recorded interventions — electronic and hard copy — combined with an increase in successful quit attempts and long-term quitters. Brief interventions of 2–5 minutes were not recorded as pharmacies found it challenging to record these in the busy pharmacy setting. In addition, many pharmacies reported an increase in nicotine replacement therapy (NRT) product sales, with some reporting increases of over 80% in a month. One pharmacy reported that changing the NRT display to product focused rather than brand, proved to be most beneficial to customers and staff. There were peaks and troughs in the program adoption by smokers, with particularly January, May and June recording the highest program engagement. The program identified through qualitative and quantitative data, essential elements necessary for the successful implementation of the service within a pharmacy environment. A number of pharmacies indicated strong engagement particularly when adopting a number of elements as part of the program. These included:

• Pharmacists and staff comprehensively trained in smoking cessation counselling and NRT therapy;

• Finding a ‘champion’ in the team passionate about quit smoking to lead the implementation of the service and encourage staff participation;

• ‘Whole of team’ involvement in establishing an active engagement plan which extended to training and communication within the team;

• Accountability and goal setting for the team such as NRT sales and recording in GuildCare, which are monitored and reported back to staff;

• Taking the opportunity for quit smoking interventions while assisting customers to manage health conditions exacerbated or caused by smoking — these reportedly occurred more easily at this time;

• Conducting health promotions on disease states that are exacerbated by smoking such as asthma, COPD, diabetes and cardiovascular disease and incorporated positive messages on the benefits of quit smoking. Pharmacies indicated they would continue to offer the service.

RECOMMENDATIONS While the Community Pharmacy Smoking Cessation Program demonstrates a strong rationale for conducting activities to reduce harm from smoking within a pharmacy setting, it is pivotal that pharmacists and staff are provided with the appropriate training and support to increase their skills and afforded opportunities to help smokers achieve their goals to quit.

THE FUTURE: QUIT FOR 2 IN COMMUNITY PHARMACY The ACT Branch will continue to assist pharmacies to build on the success of the smoking cessation program through an additional two-year grant from the Healthy Canberra Grants Program, focusing on smoking and pregnancy: Quit for 2 in Community Pharmacy. This next phase will extend to promote the service to the community — a particular emphasis will be on pregnant women, and their support networks. It will involve working in partnership with a number of organisations in Canberra, such as the PHN, YWCA and other women’s health organisations in order to promote the smoking cessation service available within the pharmacy environment. During the program, a number of focus groups will be conducted with pregnant women and pharmacists to develop specific strategies to assist women quit smoking. Finally, a closed peer support page will be designed and launched to provide women trying to quit with a private online support group.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

NEW The only GLP-1 analogue that is TGA approved for weight management as an adjunct to diet and exercise1

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LOSING WEIGHT

Introducing Saxenda®

Significant and sustained weight loss with simultaneous improvements in cardiometabolic risk factors.1,2 In a 1-year study: • 9 out of 10 patients achieved some weight loss, with 1 in 3 losing >10%2 • Patients lost weight and kept it off1,2

PBS Information: This product is not listed on the PBS.

Saxenda® increases heart rate. The clinical significance of the increase in heart rate with Saxenda® is unclear. The effects of Saxenda® on cardiovascular morbidity and mortality have not been established. [See PRECAUTIONS]

Please review Product Information before prescribing. The Product Information can be accessed at www.novonordisk.com.au Indication: Saxenda® (liraglutide (rys)) is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial Body Mass Index of ≥30 kg/m2 (obese) or ≥27 kg/m2 to <30 kg/m2 (overweight) in the presence of at least one weight related comorbidity, such as dysglycaemia (pre-diabetes and type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea. Treatment with Saxenda® should be discontinued after 12 weeks on the 3.0 mg/day dose if a patient has not lost at least 5% of their initial body weight. Long-term use should be informed by the following: long-term safety data are limited. Adverse reactions that are uncommon (frequency <1/100) and/or are associated with prolonged use (>12 months) might not have been identified in the clinical development program; long-term efficacy data are limited. The treatment effect has only been documented for 1 year. Dosage and administration: Saxenda® is administered once daily at any time, independent of meals, subcutaneously injected in the abdomen, thigh or upper arm, preferably around the same time every day. The starting dose is 0.6 mg daily. The dose should be increased to 3.0 mg daily in increments of 0.6 mg per week to improve gastro-intestinal tolerability. If escalation to the next dose step is not tolerated for two consecutive weeks, consider discontinuing treatment. Daily doses higher than 3.0 mg are not recommended. Contraindications: Not to be used in patients with hypersensitivity to liraglutide or any of its excipients, or with a past history of Glucagon-like Peptide-1 (GLP-1)analogue associated pancreatitis. Precautions: Saxenda® is not indicated for patients with obesity secondary to endocrinological or eating disorders or to treatment with medicinal products that may cause weight gain, or <18 years; must not be administered intravenously or intramuscularly, or used as a substitute for insulin; should not be used with insulin; is not recommended in patients with a history of pancreatitis, heart failure, cardiac conduction disorders, severe renal impairment including end-stage renal disease, hepatic impairment or insufficiency, inflammatory bowel disease or diabetic gastroparesis, ≥75 years, or in combination with other prescription, over-the-counter or complementary medicines intended for weight loss; must be used with caution in patients 65-74 years, with mild/moderate renal impairment, with thyroid disease or on other drugs that increase heart rate. Dehydration: patients should be advised of the potential risk of dehydration in relation to gastrointestinal side effects and take precautions to avoid fluid depletion. Pancreatitis: If pancreatitis is suspected, treatment should be discontinued promptly. If acute pancreatitis is confirmed, Saxenda® should not be restarted. Cholelithiasis and cholecystitis: In clinical trials, a higher rate was observed in patients treated with Saxenda® than in patients on placebo. Cholelithiasis and cholecystitis may lead to hospitalisation and cholecystectomy. Patients should be informed of the characteristic symptoms. Heart rate: Saxenda® should be discontinued for patients who experience a sustained increase in resting heart rate. Overweight or obese patients with type 2 diabetes: For patients on Saxenda® consider reducing the dose of concomitantly administered insulin secretagogues to reduce the risk of hypoglycaemia. Pregnancy and lactation: Category B3. Saxenda® should not be used during pregnancy or breastfeeding. If a patient wishes to become pregnant treatment with Saxenda® should be discontinued. Interactions: No clinically significant drug interactions have been demonstrated with Saxenda®. Very low potential for drug-drug interactions related to cytochrome P450 (CYP) and plasma protein binding. The delay of gastric emptying caused by liraglutide may impact absorption of concomitantly administered oral medicinal products. Clinically relevant interactions with compounds with narrow therapeutic index, or medications associated with local gastrointestinal irritation (e.g. bisphosphonates, potassium chloride) cannot be excluded. Upon initiation of Saxenda® in patients on warfarin or other coumarin derivatives, more frequent monitoring of International Normalised Ratio is recommended. Adverse effects: Overall, gastrointestinal reactions, nausea, vomiting, diarrhoea and constipation, were the most frequently reported side effects. Other commonly reported side effects include dyspepsia, abdominal pain upper, abdominal distension, eructation, flatulence, gastroesophageal reflux disease, dry mouth, gastritis, hypoglycaemia, injection site reactions, fatigue, asthenia, dizziness, dysgeusia, cholelithiasis and insomnia. Refer to the Product Information for details of potential uncommon or rare adverse reactions observed in clinical trials. Date of preparation: December 2015 Reference: 1. Saxenda® Approved Product Information, December 2015. 2. Pi-Sunyer X, Astrup A, Fujioka K, et al. N Engl J Med 2015;373:11–22.

Novo Nordisk Pharmaceuticals Pty Ltd, ABN 40 002 879 996, Level 3, 21 Solent Circuit, Baulkham Hills NSW 2153. NovoCare® Customer Care Centre 1800 668 626. www.novonordisk.com.au ® Registered trademark of Novo Nordisk A/S. AU/LO/0916/0320a. SAX0119/ANZOS. September 2016.

BUSINESS

Compound for SUCCESS:

Partner with PCCA

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BUSINESS

“Fortunately, with a shift in public awareness, you now see compounding in hospitals, home healthcare pharmacies and many independent pharmacies.” COMPOUNDING: GET BACK TO THE ROOTS OF PHARMACY It was estimated that in 1940, 50% of all written prescriptions were compounds. With the advent of mass drug manufacturing in the 1950s and ‘60s, compounding rapidly declined. The pharmacist’s role quickly changed to an order filler, and most pharmacists were no longer trained to compound medications. However, the “one-size-fits-all” nature of mass-produced medications doesn’t always account for the differences between individuals. And with conditions like autism and allergies on the rise, compounded medications are a necessity for many. Fortunately, with a shift in public awareness, you now see compounding in hospitals, home healthcare pharmacies and many independent pharmacies. But compounding is still not everywhere, and patients still need more pharmacists to provide these solutions. Compounding pharmacies make a difference for patients. And as the industry’s most comprehensive resource, PCCA makes a difference for compounding pharmacists. We offer our member pharmacies a lot, but it really comes down to three things: support, education and exclusive quality products.

PCCA members also have access to more than 115 live and online educational opportunities and events each year. In addition to C3 and International Seminar, we offer specialty symposiums focusing on trending topics like Hormone Replacement Therapy and Veterinary Compounding. Our events draw more than 3,900 compounding pharmacists and physicians annually, allowing for the greatest networking opportunities. But, if traveling is not an option for you, our Video on Demand service and scheduled webinars provide members with the convenience to learn from home or the office.

EXCLUSIVE QUALITY PRODUCTS With the most extensive product line in the industry, we have everything you need to shine. The PCCA Research and Development team keeps our members at the cutting edge of compounding pharmacy and innovation. Our dedication to quality assurance, product development and scientific research translates into rich rewards for your practice and your patients. As a member, you’ll have access to a database of more than 8,000 formulas and more than 50 high-quality exclusive bases. You will also have access to technical reports and case studies so you can show proof of patient success to practitioners. Infant facial burn after using PCCA PracaSilTM-Plus a proprietary anhydrous silicone base.

A PLATFORM FOR SUCCESS As a PCCA member, you’ve got a powerhouse of support right at your fingertips. When you join PCCA, our family becomes an extension of your staff. You will be assigned a territory manager to help you understand your local market, and an account representative to help you meet the unique healthcare needs of your patients. Your team instantly grows with three different PCCA departments, accessible by every member. If you have questions along the way, our Pharmacy Consulting Department (PCD) — comprised of over 30 pharmacists, chemists and PhDs — is available 24/7 to take your call. Our Public Affairs team works behind the scenes to grow compounding by advocating on behalf of our members. Finally, our Customer Service team is your personal assistance to ordering, registration and questions. We also offer the industry’s best services to help you manage your practice, diversify your business and ensure compound quality.

TRAINING AND EDUCATION PCCA offers Continued Pharmacy Development (CPD) educational opportunities. Every PCCA membership includes free education, so new members can immediately begin to grow their practice. Upon joining, you will receive two free one-week Comprehensive Compounding Course (C3) registrations. Members have a full year to take advantage of this benefit.

PCCA members can rest easy knowing that we set our quality standards higher than USP, rejecting on average three lots per week. All of our products go through an eight-step quality assurance process — the most comprehensive in the industry — giving you quality compounds and peace of mind.

NEXT STEPS Partner with us today by becoming a PCCA member. One patient. One doctor. One pharmacist. A triad relationship with a common goal: achieving a positive therapeutic outcome for the patients. And in the midst of this relationship and common goal is PCCA, the leader in pharmacy compounding since 1981.

Visit pccarx.com.au/join-pcca or call (02) 9316 1500 to discover all the benefits of membership.

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HEALTH

Health ADVICE Plus PETER WATERMAN Communications Specialist Pharmacy Guild of Australia

A COMMITMENT TO DELIVERING MORE PROFESSIONAL SERVICES TO ITS PATIENTS HAS BEEN THE DRIVER BEHIND A WEST BRUNSWICK PHARMACY BECOMING PART OF A UNIQUE PROGRAM WHICH UNDERSCORES THE INCREASING HEALTHCARE ROLES OF COMMUNITY PHARMACIES.

Priceline Pharmacy West Brunswick’s proprietor, Alvin Narsey, said he signed onto the Pharmacy Guild’s Health Advice Plus program to support his decision to move further and more strategically into the delivery of professional services. The Health Advice Plus program provides a suite of resources and processes which are tailored to the unique demands and needs of each individual pharmacy to enable them to transition to a new business model. Health Advice Plus provides a way forward for pharmacies seeking to transform their model in such a way as to be beneficial for their business and for their patients. Mr Narsey said he examined what was available in the market and saw that Health Advice Plus suited his needs perfectly. “I realised that we needed to do something more at the pharmacy in the way of professional services,” he said. “I had to do a little bit more than I was already. I needed to be able to quickly work out the nuts-and-bolts issues of what I needed to do and how to do it, and that’s what got me on board the program.” Mr Narsey said his focus on professional services was the result of talking to patients and seeing that the needs of the community were changing. “Clearly patients and the community wanted more of the pharmacy, especially in areas where we already have expertise,” he said.

“They also wanted to be able to make the most of our accessibility — to be able to walk in and access professional services without adding to the workload of their GPs.”

go ahead with it. I saw it as providing an opportunity to formalise the structures for existing services that we already provided in our pharmacies.”

“The community benefits from our new approach and there is satisfaction for the pharmacy staff as our skills and knowledge are being better utilised.”

Mr Barone said he also was influenced by the fact that the implementation partner in the program, Instigo, had experience in this area.

Mr Narsey said that changing his pharmacy model required planning and expert advice and assistance. “I explored Health Advice Plus and the other program that is on the market at the moment, Health Destination, and decided to go with Health Advice Plus as it meets my needs and I believe is better value for money,” he said. Barone Pharmacy Woodcroft is one of the leaders in this field, and proprietor, Mario Barone, has reinforced the work he has already done by signing onto the unique Heath Advice Plus program, which seeks to provide better health options for his patients. Mr Barone said he decided to become part of the Pharmacy Guild of Australia’s program because he recognised that it fitted in with his philosophical approach to the profession and the way the profession was developing. “I recognise the need to be proactive as we move forward,” Mr Barone said. “I looked at Health Advice Plus and the concept sounded good, so I decided to

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“That was a big positive as far as I was concerned,” he said. “The Instigo people were able to tell me what they had already done and what had been successful in other pharmacies. It all added up and looked good to me — it looked as if it would ideally suit my needs and the needs of my pharmacies”. Mr Barone said the program not only strengthened existing programs, but opened the door for new programs. “It’s early days for us yet, but the hope is that once you have the framework or formal structure in place, then new services can fall within that framework,” he said. “The Opportunity Analysis, which is the first step in the process, was a good exercise to undergo because it quantified the opportunities that were there. It made them real and it gave me an idea of what was possible if we achieved those numbers.” “And it was clear the returns would be sooner rather than later. The Opportunity Analysis showed us the way to build on what was already there.”

Start your pharmacy’s transformation by understanding your professional service opportunity

Transformation is about making fundamental changes in how you conduct your business to meet shifts in the market Pharmacy environment. Health Solutions The Guild is focussed on

delivering the best to Guidesupport on initial steps towards optimising our members in the interests health outcomes from of enhancing the value of front of pharmacy community pharmacy.

Opportunity Analysis Tool The Opportunity Analysis tool is a key component of the Guild member Opportunity Health Adviceand only Health Advice Plus Program Analysis Plus is designed to provide a customised Tool Program report using a pharmacy’s data to Helps identify Program income focussed on highlight lost opportunity opportunities available change management linked to key service areas. Once you for professional and operational have completed your opportunity services under workflows to support 6CPA implementation analysis, a Health Advice Plus of

Health Advice Plus Program focussed on change management and operational workflows to support implementation of professional health services

professional health services.

Professional Service Viability Tool Helps to understand potential profit available from provision of services and associated support sales

representative will contact you to conduct a 45 minute one-on-one Professional feedback session. Your Health Advice Service Viability Plus representative will discuss and Tool analyse the results with you, providing Helps to understand advice and recommendations for tools potential profit and services to assist in developing your available from pharmacy’s professional services offer. provision of services and associated support sales

Pharmacy Health Solutions Guide on initial steps towards optimising health outcomes from front of pharmacy

For more information on the Guild’s newest suite of services and tools – available only to Guild members visit guild.org.au/transformation

PATIENT

MANUFACTURERS

DOCTOR

PHARMACIST

HEALTH

PHARMACY ALLIANCE

Committed to Delivering Meaningful Health Solutions NIMFA MARTINEZ General Manager, Marketing and Member Services Pharmacy Alliance

IN A PERIOD OF REGULATORY REFORM, PHARMACY ALLIANCE IS PROVIDING INDEPENDENT PHARMACY WITH ACCESS TO MARKETING, MERCHANDISE AND PROFESSIONAL SERVICE PROGRAMS WITH THEIR CO-BRAND INITIATIVE, ‘ALLIANCE PHARMACY’, WITHOUT THE PRESSURE OF FRANCHISE FEES.

Pharmacy Alliance 500+ members were introduced to the ‘Alliance Pharmacy’ co-brand in 2014 as a way to connect the Pharmacy Alliance member network to consumers across Australia, whilst retaining their own independent pharmacy name or brand. With more than 60 pharmacies now displaying the Alliance Pharmacy signage, Pharmacy Alliance recently announced the next stage of their co-brand initiative with ‘Alliance Pharmacy’ that centres on a pharmacist-led and smarter-retailing proposition, with the primary aspiration to help customers have the best quality of life, at every stage of life. Along with this, Pharmacy Alliance is planning an integrated marketing strategy that shows how independent pharmacy provides meaningful health solutions, and how they play a pivotal role in the prosperity of their communities. “With ‘Alliance Pharmacy’ the vision is to make life better every day for everybody,” said Nimfa Martinez, General Manager Marketing and Member Services. “Our aim was to encapsulate simply what our members stand for and build an experience for all Australians that would provide solutions for their health goals or conditions. Rather than purely starting with price, products and the current buzz of professional services, the true value of what our pharmacies provide is in the conversations they have with their customers. We also want the experience in the pharmacy

to showcase the real value that the pharmacist profession adds to a customer or patient’s visit by emphasising the dispensary, professional services and other pharmacy-only product ranges through signage, and differentiate the other product ranges or services that may not need high involvement interactions. The smarter-retailing component of our strategy recognises the Australian consumers’ demand for value and convenience, which we will address through a localised pricing strategy, tailoring product ranges to demographic needs and a loyalty program that provides consumers another reason to stay loyal to their ‘Alliance Pharmacy’ co-branded pharmacy, as well as giving us all important data to provide tailored health,” Nimfa continued. Despite the fact that Australian consumers are growing more concerned with their health, which can be seen in what’s happening in the grocery sector with the decline in sugar sales# and preference for low carbohydrate food products*, it is projected that up to 3 million Australians over 25 will have diabetes by 2025^, which means that demand for support with diabetes and other related health conditions will increase. “Although there is a lot of activity around delivering professional services in the industry, much of it is not hitting the mark with consumers — as highlighted at APP2016, how we communicate in general to consumers is in industry ‘speak’ and not in normal everyday language that Australians use. With Alliance

Pharmacy, we are using consumer insights to create meaningful messages that will help them understand the benefits their local pharmacy can provide,” said Nimfa. Further, Pharmacy Alliance recognises that this means a significant change in the mindset of member pharmacies today, as well as operational changes. “Alliance Pharmacy was designed to help our members transform — this means our pharmacy owners need to think about how they apply this in their pharmacies and how this may change staff capabilities and their pharmacy capabilities. We will be designing training programs to equip staff to deliver on the pharmacist-led, smarter-retailing objectives and continue working with our pharmacies to create better efficiencies in dispensary and overall pharmacy store design, and leverage our work with Z Software for BOS/ POS technology to facilitate efficiencies as well,” Nimfa added. REFERENCES: # http://www.nielsen.com/au/en/insights/ news/2016/not-so-sweet-sugar-consumption-indecline-due-to-growing-consumer-health-concerns. html * http://www.heraldsun.com.au/news/ victoria/nutrition-australia-fears-lowcarb-diets-with-no-potatoes-has-turnedpeople-off-eating-vegetables/news-story/ c50bdc10e726d4f764836b61eb3aadc0. ^ https://static.diabetesaustralia.com.au/s/ fileassets/diabetes-australia/e7282521-472b4313-b18e-be84c3d5d907.pdf

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BUSINESS

TAMMY SHERWOOD Marketing, MPS Australia

NOWHERE ARE PARTNERSHIPS MORE IMPORTANT THAN IN HEALTHCARE. WHETHER IT IS THE RELATIONSHIP BETWEEN DOCTOR AND PATIENT OR BETWEEN PHARMACIST AND CUSTOMER, THE OUTCOME IS INEVITABLY STRONGER WHEN EACH PARTY WORKS TOGETHER.

We’re used to hearing that trust and understanding are the key to positive personal relationships, but this is very much the case in healthcare as well. The GP whose patient trusts them with personal information can improve their patients’ standard of care. And the pharmacist that understands the needs of residential aged care facilities can build a positive partnership with aged care staff. At MPS, we’re grateful that the trust we have established with our pharmacy network has led to deeper understanding of the challenges they face. It means we can work together towards our common aim: safe, cost-effective medication management for all Australians. The part that pharmacies play in health outcomes should never be underestimated. We see firsthand the hard work and dedication that goes into growing a pharmacy business and serving the community. Little wonder that pharmacists are the number one source of trusted information for Australians about

their medication. A pharmacist plays an important part in the health and wellbeing of all Australians, and this is a driving force in our work and in our profession. Pharmacists are also among the strongest healthcare advocates for Australians. There is a deep awareness of the potential impact of changes to the Pharmaceutical Benefits Scheme (PBS). Our partnerships will help pharmacies to combat the effects of PBS reform, while still delivering the high service standards that customers depend on. Few people outside the pharmacy industry see the amount of administration time that goes into serving each customer. This can put limitations on the time available to interact with customers, and restrict opportunity for business growth. Add to that the technologydriven consumer trends that lead to everincreasing expectations of immediate response; pharmacists face working longer hours for hard-earned returns. How much time exactly? Well, checking

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fifty blister packs manually can take more than three hours; in comparison, checking fifty MPS rolls can be done in under an hour. When your staff spend that time with customers instead, they get to know their needs better, which means more cross-selling and happier outcomes. That time for discussions with customers is inevitably well spent. Aside from the revenue increase, it paves the way for tackling important conversations. One topic that many pharmacy staff told us they found hard to broach was the benefits of Dose Administration Aids. More than 1.5 million Australians regularly take five or more medications, and that number is set to double by 2025. Our research shows that only half a million of these are currently using a Dose Administration Aid, meaning many more are yet to realise the advantages. It is worth finding a way to break the ice. Our market research showed us that pharmacy customers are very open

"We are also working with dispensing software providers, so that more customers can benefit from our Software, which can reduce DAA script administration by 75%."

BUSINESS

“A pharmacist plays an important part in the health and wellbeing of all Australians, and this is a driving force in our work and in our profession.”

to solutions that make medication safer and more convenient, as long as the subject is raised the right way. We delved deeper, and used the insights from our research to develop tools that support our pharmacy partners to start the Dose Administration Aid (DAA) conversation. The results have been fascinating. The tools — including staff training information, counter mats and videos — target four distinct customer profiles. Each profile type requires a specific approach that guides the conversation. Our pharmacy staff are reporting that their Dose Administration Aid sales are rising significantly — customers have responded more positively than we could have expected. It appears that when their trusted pharmacist suggests something that makes their life easier, customers are delighted. Partnership makes our Dose Administration Aid easily available to more pharmacies. It represents an easy way to

increase efficiency and offer enhanced services. We are also working with dispensing software providers, so that more customers can benefit from our Software, which can reduce DAA script administration by 75%. MPS have invested heavily in software, dovetailing into the combined benefits of substantial investment in cutting-edge machinery and packing technology, as well as sophisticated, patented soft solutions. Delegated packing also allows the ability to automate and eliminate errors from process, and dispense accurately and efficiently for the increasing volume of users. Like with any good partnership though, we have learned that it is about far more than finances. Just as our pharmacy partners have been generous in sharing their frontline experiences with us, it is only fair that we share our own expertise in return. While our partners have access to our team of specialists, we learn a lot from them about the challenges they face. Feedback

about our products and services is fed into development — updates and new products are targeted towards making medication as safe and efficient as possible. The aim is to create tools and services the way that pharmacists would design them — if only they had the time. The collaboration with our pharmacy partners and community customers, as well as aged care facilities, really is key to what we do. If it is a relationship that brings benefits to our partners, and to the customers they care so strongly about, we are happy. After all, that is what a good partnership is about. MPS delivers medication management solutions to enable pharmacists to better serve both community patients and residential aged care facility residents. This is facilitated by smart solutions which help make provisioning and taking medicines simple, safe and secure.

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"Closer to summer, sales for sun care products pick up, with the eight weeks between the middle of November and the middle of January accounting for almost a quarter of annual sales in pharmacy."

BUSINESS

THE SWEET SMELL OF

Seasonal Sales in Pharmacy MARK BLITENTHALL Associate Director The Nielsen Company

CATEGORY SEASONALITY HAS ALWAYS BEEN AN IMPORTANT CONSIDERATION IN RETAIL. IN RECENT YEARS, HOWEVER, WE HAVE SEEN RETAILERS INCREASE THEIR EFFORTS IN MAXIMISING THE OPPORTUNITIES PARTICULAR EVENTS AND HOLIDAYS CAN BRING. BIG SEASONAL IN-STORE DISPLAYS AND MERCHANDISING ARE NO LONGER LIMITED TO JUST VALENTINE’S DAY, EASTER AND CHRISTMAS; THEY HAVE EXTENDED TO OTHER EVENTS, INCLUDING HALLOWEEN, FOOTBALL GRAND FINALS AND AUSTRALIA DAY, AMONG OTHERS.

Understanding the peaks and troughs in demand that seasonality creates, is key to leveraging the growth opportunities certain occasions can bring to specific categories. Having the right offer and sufficient stock on hand to service customers during these special occasions, is critical to seasonal sales success.

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FRAGRANCES OFFER PHARMACY’S FRAGRANCES OFFER PHARMACY’S MOST CONCENTRATED SEASONAL MOST CONCENTRATED SEASONAL OPPORTUNITY OPPORTUNITY

COUGH, COLD, COUGH, COLD, SINUS, THROAT SINUS, THROAT

ANTI-ALLERGY ANTI-ALLERGY

FRAGRANCES FRAGRANCES CARE SUNSUN CARE

CONTRIBUTION CONTRIBUTION OF OF SEASON TO CATEGORY SEASON TO CATEGORY ANNUAL SALES ANNUAL SALES

43% 43%

36%23% 23% 12%12%36%

December January January

Even for pharmacies that aren’t in a position to heavily discount their fragrance products, the festive season still presents an opportunity to maximise category and store sales by delivering an attractive range at the best price possible. It is also important to ensure staff are well trained to provide a superior level of customer service to compete against department stores.

"The eight weeks leading up to Christmas account for around 35% of annual fragrance sales."

July August August September September October October November November December

Although seasonality within the pharmacy channel might at first glance appear to be mainly weather dependent, there are still sizeable event-related opportunities to be explored. The fragrances category is one where the impact of event driven seasonality is particularly noticeable due to the high volume of sales generated over a relatively short time period. The eight weeks leading up to Christmas account for around 35% of annual fragrance sales. Other key, event-related periods such as Valentine’s Day and Mother’s Day, pale in significance when compared to Christmas, making it a key period to focus on, to drive additional growth in this channel.

That being said, the fragrance category in pharmacy is extremely competitive, with many stores discounting well below the recommended retail price in order to drive foot traffic. Overall, pricing is now between 33–50% of the recommended retail price for many of the top-selling women’s fragrance SKUs, making the pharmacy channel an increasingly attractive destination for fragrance shoppers. Despite department stores having a strong association with fragrance products, everyday pricing in this channel has remained for the most part, closer to the recommended retail price.

March April April May May June June July

In pharmacy, however, much of the channel seasonality appears to be driven by factors such as weather. Over 40% of the sales for categories such as cough, cold, sinus and flu medication and throat preparations are achieved between June and September. Likewise, as we move into spring, categories such as allergy and hay fever start to see an upswing in sales. In 2015, 12% of the overall sales for this category were achieved between the middle of September and the middle of October. Closer to summer, sales for sun care products pick up, with the eight weeks between the middle of November and the middle of January accounting for almost a quarter of annual sales in pharmacy.

February February March

Implementing Pharmacy Automation is

Easier than you think!

Pharmacy Automation can: • • • •

Maximise your Pharmacist’s time with your customers; Optimise your dispensary workflow; Reduce your costs, increase your income; and Build customer loyalty.

Contact Dose Innovations today to find out how automation can help you. • 1800 00 3673 (1800 00 DOSE) • enquiries@doseinnovations.com • www.doseinnovations.com

BUSINESS

Pharmacy Business Structures

is GENERIC

the Preferred

PETER SACCASAN FACP FCA National Director, Pharmacy Services RSM Australia

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Option?

BUSINESS

CHOOSING THE RIGHT STRUCTURE FOR YOUR PHARMACY BUSINESS CAN BE A DAUNTING PROCESS. AS BUSINESSES CONTINUE TO EVOLVE AND CHANGE, SO DOES THE LEGISLATIVE FRAMEWORK IN WHICH THEY OPERATE. GET THE STRUCTURE RIGHT AND YOU WILL REAP THE REWARDS OF BUSINESS EFFICIENCY, SECURITY AND PREFERABLE TAX OUTCOMES. GET THE STRUCTURE WRONG AND YOU MAY FIND YOURSELF IN A WORLD OF PAIN.

When it comes to choosing the right structure, there are many variables to consider. Importantly, one size does not fit all and “generic” may not always be the preferred option. For those with an existing structure that does not suit their needs, the prognosis is not all bad — change is possible!

• Sole traders are taxed at their

BACK TO BASICS

• Companies are usually taxed at 30%

The basic business structures include sole traders, partnerships, companies and trusts.

• Sole traders are individuals that carry on business in their own name and have unlimited liability to creditors.

• Partnerships consist of two or more entities (usually individuals) that carry on business jointly, with profits being shared accordingly. Each partner is usually jointly and severally liable to the liabilities of the partnership.

• Companies are separate legal entities that carry on business in their own right. They are distinct from the shareholders and directors that control them and their liability to creditors is often limited to the assets of the company. However, this liability may be expanded when personal guarantees are signed, as is often required by landlords.

• Trusts are essentially a relationship between the trustee and the beneficiaries. The trustee carries on the business with the trust profits distributed to the beneficiaries. Limited liability to creditors can often be achieved by appointing a company to act as trustee. Once again, the requirement to sign personal guarantees can increase your exposure.

TAX CONSIDERATIONS The tax treatment will vary depending on the business structure, together with the type of income it receives. Business profits — being the ordinary income of the business, less deductions — are taxed as follows:

marginal tax rates 0% to 49%, with the rate of tax increasing as profits increase.

• Partnerships are not taxed in their own right. Each partner is subject to tax at their respective tax rate on their share of the partnership income. although some companies that qualify as small business entities are taxed at 28.5%. However, if the shareholders want to use the money outside the company, there is more tax payable.

• Trusts that distribute their net income to beneficiaries are not subject to tax; however, the beneficiaries receiving the distribution are subject to tax at their respective tax rates. Capital gains — being gains made on the disposal of capital assets — are taxed as follows:

• Sole traders can usually discount the capital gain by 50% (known as the general discount) and then, if the gain is on an active asset, e.g. a pharmacy business, if other criteria are met another 50% discount is applied and then the balance is taxed at the sole trader’s marginal tax rate.

• Partners in a partnership will each be assessed on their share of the capital gain. If the partners are individuals, they will have the same tax position as sole traders noted above.

• Companies are not entitled to the general 50% discount but may be eligible for the active asset discount and are taxed on the gain at 30% or 28.5% if they are considered a small business entity.

• Trusts can distribute their capital gains to beneficiaries. If the beneficiary is an individual, the general 50% discount and the active asset discount are usually available. Other capital gains concessions are available for small businesses which may further reduce the tax payable on capital gains (often to nil), providing certain eligibility criteria are met.

GETTING TECHNICAL In addition to the above, the type of business structure may also elicit other tax implications that should be considered. One such example is Division 7A which effectively deems loans from private companies to shareholders or their associates as dividends, with the recipient then being subject to tax on the amount of the loan received. Beyond tax, consideration must also be given to the requirements imposed under the relevant State Pharmacy Act which, amongst other things, details the ownership requirements for pharmacy businesses.

BEYOND “GENERIC” Using a “generic” business structure may not always be preferable. Often a mix-and-match approach of various entities within a single business structure will yield the best result. Using operating companies with separate service and finance entities, together with asset holding trusts may allow for operational efficiency and asset protection, and help to reduce the overall tax payable.

CHANGE IS POSSIBLE! For those with existing business structures that may not be optimal, there is good news. You are not stuck with your structure — change is possible! From 1 July 2016 eligible small businesses operating as solder traders, partnerships, companies or trusts can change their business structures without incurring significant tax liabilities under the Small Business Restructure Roll-over provisions. There are a number of requirements that must be met; however, broadly, these provisions allow small business entities to transfer capital gains assets, depreciating assets, trading stock and other revenue assets to one or more entities without realising a tax liability for the gain made on transfer. These provisions present a great opportunity for business owners to reconsider their current business structures into the best possible solution without incurring significant income tax liabilities. As with all complex matters, such as taxation, make sure you seek advice from a professional adviser.

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BUSINESS

NEW RULES OF LEASING

Time to change your thinking! R

m O/ T/

BY PHILLIP A. CHAPMAN Director MiLease - New Rules of Leasing (Endorsed Lease and Management providers to the Australian Retailers Association & Pharmacy Guild of Australia, Members of Franchise Council of Australia)

Time - Critical Path

AS I ENTER MY 20TH YEAR IN BUSINESS, SUPPORTING RETAILERS IN ALL FACETS OF RETAIL LEASING AND THE CHALLENGES INHERENT IN THE LESSEE/LESSOR RELATIONSHIP, IT IS TIME TO REFLECT WHERE THE INDUSTRY STANDS AND HOW IT HAS EVOLVED. Ironically, our very first client was in fact a small chain of pharmacies (4 sites) and I remember after completing a very successful lease renewal, I was given a bonus on top of our fee, a carton of Ipana toothpaste — which lasted past its Use By Date. Although the internet was up and running and retailers may have had an email address, we were still ordering stock via fax, deals were done face to face or over the phone, and documents were exchanged by facsimile or express post — document couriers were still in existence. Smart phones weren’t heard of and social media consisted of the society pages in the Saturday newspaper, but Australia’s first shopping centre was about to turn 40 and the shopping centre management industry was hitting its prime. Centre managers were more highly regarded than leasing executives (certainly by salary) and relationships between retailers and landlords was far more personal. Today, we constantly hear from clients who have barely met their centre manager but know the mobile number of the leasing agent. What hasn’t changed in 20 years is the information gap regarding data surrounding retail leases, and real estate performance between retailers and landlords. In fact, this void has significantly widened as technology has expediently exploded and landlords have applied their superior resources to leverage their position manifestly. Although retailers have certainly lifted their game when it comes to collating lease data and intelligence, the practices of how they apply this information and their strategic planning has not. When I leapt over from the dark side 20 years ago, there was at best a handful of retailer lease advocates, and I wanted to

ensure we remained relevant and transparent through aligning ourselves with retailer/ industry associations. Now, there are probably upwards of a hundred, most of whom have evolved into the role within their group or brand without any real depth of experience, which has invariably lead to the old way of doing business (negotiating a retail lease) being passed down the line and reflects the outcomes we see across the market currently. Every day my team comes to me with yet another lease benchmark review which is the result of a poor lease deal done 5–10 years ago, and the compounding effects have over time fractured the sensitive retail equation. The world is full of Monday morning halfbacks, who tell everyone who will listen how they would have made the play to get the winning result. When it comes to retail leases, these half-backs usually dust themselves off as experts every 5 or so years and believe their last deal was always the best available (time usually brings them unstuck, but they are too proud to admit it) or they are employed to maintain (and grow) a group or brand’s number of sites, at someone else’s expense — yours! How else has retail property continued to remain the investment poster child for funds managers? Although we have made significant changes to Retail (shop) Lease legislation in every state and territory to improve the rights of lessees, we still have retailers making the same fundamental and hugely costly mistakes. The profession of managing and strategically leveraging the numerous commercial terms to deliver the right outcome to a retail investment that adds value (to the retailer — you know, the person who pays the bills) must change from just delivering a deal to taking the responsibility of future proofing

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the retailer/lessee (the client) to the next lease event/renewal — and even the one after that. It is not hard to scan the news headlines for the past 12 months and see the number of retail failures to realise we don’t have another 20 years to deliver this transformation. For pharmacy, this is even more critical as the 6CPA core objective is to unshackle community pharmacies from the trading terms associated with the supply of PBS medicines, yet when it comes to the most important contract, the lease, attitudes are stuck in the past. And all the while, change is happening right before our eyes. This is why the New Rules of Leasing is long overdue. The time has come to invest in not only delivering the right outcomes, but to change the mindset of retailers/lessees and industry stakeholders to level the playing field, and not just for the deal done today, but for the future. MiLease-New Rules of Leasing is a program that delivers outcomes and also provides the tools and mentoring to bring about a mindset change in how leases are treated as assets, how relationships can be developed, and how to successfully negotiate for the future. If you have a lease expiring within the next 2 years, are responsible for brand/ franchisee development, want to grow your portfolio, and are thinking of buying a pharmacy or want to be part of this transformation, there is a New Rules of Leasing program to empower you for the future. As Albert Einstein is quoted, “Insanity is doing the same thing over and over again while expecting a different result.” Let’s stop the insanity. (www.milease.com.au)

HEALTH

Smoking Cessation and Weight Gain: A REAL CONCERN? OLIVER CANFELL Accredited Practising Dietitian MDietSt, BENS APD, AN

Tobacco smoking, now indisputably one of the most convincing risk factors for chronic disease and early mortality, is still one of the most monumental public health issues we face. It remains the largest preventable cause of cancer, contributing an estimated 20% to Australia’s cancer burden each year 1. Despite this, it is undeniable that significant progress has been made in reducing the number of adult smokers. In 2001, the adult daily smoking rate was at 22.3% of adults, whereas in 2011–12 the rate had dropped to 16.3% — a reduction of over one-quarter2. Improvements are still very much necessary and achievable; however, a common fear surrounding quitting smoking is post-cessation weight gain (PCWG), a phenomena acting as a possible deterrent for those considering the benefits and downfalls of smoking cessation. Despite the high prevalence of PCWG, its underlying mechanisms are still largely unknown. The most common and plausible theory is nicotine’s role as an appetite suppressant, therefore inducing a higher overall energy intake upon smoking cessation, resulting in weight gain. Nicotine uptake promotes elevation of neurotransmitters with a role in appetite suppression, namely dopamine and serotonin3. In consequence, individuals utilising nicotine replacement therapy during the period of smoking cessation only delay the onset of appetite and metabolism normalisation, a process that inevitably begins on cessation of nicotine intake. Additionally, tobacco use induces adrenergic activity, a response that increases thermogenesis. This increases energy expenditure and results in body weight loss, a process reversed on smoking cessation3. Perhaps more psychological than metabolic, quitters may act to fill the void of smoking with indulgence in food. It is highly discouraging for potential quitters to be faced with the possibility of PCWG, with

heavier, more calorie-dense options like muffins, cakes, biscuits or soft drinks;

weight gain being a high risk factor itself for long-term health consequences, namely the development of overweight and obesity and associated comorbidities. It is important, however, to acknowledge the variability in the severity of PCWG between individuals (if any PCWG is present at all), dependant on factors such as physical activity levels, socioeconomic status and the level of smoking prior to cessation. The presence of PCWG is well established, with a recent systematic review and metaanalysis finding smoking cessation was associated with a mean weight gain of approximately 4.1kg over an average of 5 years post-cessation4. While perhaps a relatively modest number, it is crucial to remember that the risk posed to overall health by continuing smoking is overwhelmingly greater than a modest weight gain over a number of years. Body image concerns can be a powerful motivator, or deterrent in this situation; yet in terms of long-term health and risk of chronic disease development, smoking cessation is highly advantageous and preferable to post-cessation weight gain, which most often manifests at a high intensity initially, but exponentially decreases over time as lifestyle and eating habits stabilise. It is therefore absolutely crucial to encourage a healthy, sustainable approach to diet and exercise post-cessation, rather than an emphasis on dieting, which can largely comprise of unrealistic and unsustainable eating behaviours. The following are a selection of strategies best employed for sustainable weight loss and subsequent weight management: o

Eat small, frequent meals (3–5 a day);

Have light snacks for morning tea and afternoon tea, such as veggie sticks with dip, wholegrain crackers with tuna, or yoghurt and fruit rather than

Understand the difference between actual hunger and smoking cravings. Try having a large glass of water and wait 15 minutes before deciding to eat;

When plating, try to allocate half of your plate to vegetables, a third to wholegrain carbohydrates and a third to your choice of lean meat;

Eat a variety of fresh fruit, vegetables and wholegrains, moderate amounts of low-fat dairy and lean meats, and small amounts of discretionary or “sometimes” foods;

Foods that are high in protein, fibre and/or low GI help to manage hunger by prolonging satiety;

Engage in regular physical activity. Current guidelines recommend being active on most — preferably all — days every week, combining moderate and vigorous physical activities.

An Accredited Practising Dietitian provides evidence-based, tailored nutrition advice. To find an APD in your area, visit the DAA website www.daa.asn.au and locate the link ‘Find an Accredited Practising Dietitian’. REFERENCES: Cancer Council Australia (2016). Smoking and Tobacco. Retrieved from 1. http://www.cancer. org.au/preventing-cancer/smoking-and-tobacco/ smoking.html 2 Department of Health (2016). Tobacco Control key facts and figures. Retrieved from http://www. health.gov.au/internet/main/publishing.nsf/ Content/tobacco-kff 3 Tian, J., Venn, A., Otahal, P., & Gall, S. (2015). The association between quitting smoking and weight gain: a systemic review and meta‐analysis of prospective cohort studies. Obesity Reviews, 16(10), 883-901. 1

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"There is always a place for students in a community pharmacy."

BUSINESS

The evolving role of

Australian Community Pharmacists SEAN TUNNY Editor, Gold Cross Products and Services Pty Ltd

AMANDA SEETO Professional Practice Pharmacist and Branch Committee Representative, The Pharmacy Guild of Australia (Qld Branch) B.Pharm, DipMgmt

COMMUNITY PHARMACISTS DISPENSE PRESCRIPTIONS, PROVIDE ADVICE ON MEDICINE SELECTION AND USAGE TO DOCTORS AND OTHER HEALTH PROFESSIONALS, OFFER PRIMARY HEALTHCARE ADVICE AND SUPPORT, AND PROVIDE EDUCATION TO PATIENTS ON HEALTH PROMOTION, DISEASE PREVENTION AND THE PROPER USE OF MEDICINES. THE ROLE OF A PHARMACIST IN AUSTRALIA HAS CERTAINLY ALTERED OVER TIME.

Community pharmacy is at the forefront of Health Services in Australia, assisting patients with a range of health-related conditions. We had the opportunity to speak with pharmacist, Amanda Seeto, and invited her to outline a little of the role of Community Pharmacy and the evolving role of an Australian Community Pharmacist. EDITOR: Can you outline a little of your background? AMANDA: I graduated from the University of Queensland in 1998, and was working at Bishops Pharmacy, Wynnum, where I had worked since my second year of university. I have also worked at Terry White Chemists and Discount Drug Store. In 2005, I joined Good Price Pharmacy and later purchased a share of the pharmacy. In 2014, I was asked if I would like to nominate to be a Branch Committee representative for the Pharmacy Guild of Australia, Queensland Branch. In 2016, I started working part-time at the Pharmacy Guild as a Professional Practice Pharmacist, while still also working part-time at the pharmacy. EDITOR: It is almost 20 years since you graduated, how has the profession evolved over this time?

the prospect of leaving your business in the hands of others for an extended period of time and delegating duties. Fortunately, you have several months to prepare for your departure! This allows time to train and skill your staff to handle all aspects of the business; it is also beneficial for your staff. By leaving them to run your business, you are empowering them to make decisions on your behalf and handle situations that they may have normally passed on to you. This in turn made it easier for me to return to work part-time, as I knew my staff could work effectively in my absence. Effective delegating of duties was a key outcome. EDITOR: Can you explain more about your branch committee role? AMANDA: I took on the role at the encouragement of my business partner who held the position before me. She told me that the committee meets for one day, five times per year. Our input is sought on many issues, giving insight from a pharmacist and owner perspective. In addition, there is important advocacy work which accelerates around election time. There is great discipline that is needed in delivering a succinct message in a 10 to 15 minute meeting. The Guild Branch provides briefing papers and guidance.

AMANDA: Community Pharmacy certainly has changed in the last 20 years, in particular the role of the pharmacist — from being up on an elevated dispensary, pushing the scripts through as fast as you can, barely having time to do anything else; to handing over much of the technical/processing duties to trained technicians. Further, we have embraced a more patient-centred role of greeting and conversing with customers to fully utilise our clinical expertise in delivering health solutions to them.

At Branch Committee election time I was about to return to work from my second maternity leave, and although I didn’t realise it, I was looking for a change of scenery. I was still wanting to stay in the pharmacy sector, and I still wanted to retain my partnership and role in the pharmacy — I guess I wanted it all!

EDITOR: During this time, you have enjoyed a number of professional and personal milestones, including family and buying into your pharmacy. Can you share some more about this?

EDITOR: 75% of the workforce in pharmacy are women. Has the landscape changed or is it evolving in this area?

AMANDA: The purchase of a pharmacy had been a goal of mine since graduating. This happened before children, and it honestly never occurred to me that being a pharmacy owner would be a barrier to having a family. One of the biggest challenges that having a family incurs is facing

I have always been someone to take on a challenge when it’s offered, the time commitment didn’t seem too much, and I had the support of my family to pursue it.

AMANDA: Community Pharmacy has always been a female-dominated workforce, but this has not necessarily been reflected in leadership positions at the Pharmacy Guild, partly because women were less likely to be pharmacy owners. As the number of female members of the Guild increases, so does their opportunity to take more active roles, such as being on the Branch Committee.

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BUSINESS

EDITOR: There would undoubtedly be a number of highlights working on the Branch Committee. Could you outline a couple of these?

because sometimes when you hear yourself say something out loud, you realise that it’s not such a great idea!

AMANDA: This is my first tenure as a committee member, and during this time I have had the opportunity to meet the State and Federal Health Ministers at a number of functions. Recently, I was able to thank the Queensland Health Minister, Hon Cameron Dick MP, for his role in legislating pharmacist vaccinations in Queensland just in time for the influenza season this year, and give him feedback on the positive outcomes in my pharmacy. My first meeting with the Federal Health Minister, Hon Sussan Ley MP, subsequently lead to her visiting my pharmacy a few weeks later while she was visiting the Gold Coast. It provided some valuable one-on-one time without media attention, when I could show her around my store, demonstrate the services that we provide, and inform her what I, as a pharmacy owner, would like from the government. Politicians need to hear from pharmacists, at a grassroots level, what our issues are and what we want from them.

There is always a place for students in a community pharmacy as it is important for them to be familiar with all aspects of the business. So if it is a student’s first time on placement, they can become familiar with stock by helping with marking off orders or putting stock on the shelves, both in the retail and dispensary areas. Customer service and knowing how to have a conversation with customers, while looking after them, is also a skill to develop. So, put a placement student at the cash and wrap counter with your assistant; the pharmacist does not have to be the mentor every minute of the day. The usual skills also need to be developed, such as dispensing, stock management, and use of the GuildCare software. For students in the final years of their degree, once I am confident in their ability, I will ask them to counsel patients and then I give the students feedback on that.

I have also had the opportunity to represent the Pharmacy Guild at forums and conventions, such as the annual conferences of the major political parties. These may sound like daunting tasks, but most of the time you only have the chance to shake some hands, introduce yourself and mention that you are present on behalf of the Pharmacy Guild. In addition, I have attended functions on the invitation of important stakeholders and supporters of community pharmacy, such as the Bravehearts annual dinner. It is wonderful to be able to meet inspiring people, such as Hetty Johnston, which would not be possible without the connections that this role affords. Further, I am a member of a newly formed national Primary Health Care Subcommittee which will allow me to make a contribution to exploring future opportunities for community pharmacy in the delivery of primary health care services. EDITOR: Interns are a vital link in the Community Pharmacy chain. Can you outline your role and involvement with interns in your pharmacy? AMANDA: I strongly support the idea of employing an intern pharmacist and giving pharmacy students placement positions. Interns are a wealth of drug knowledge that I have repeatedly drawn on. In return, coaching an intern to be a great pharmacist based on your own life experiences is rewarding. It is also a type of self-improvement,

An example of what mentoring can achieve from my own business experience: we regularly take on university students for placement positions, and most years have also employed an intern. Of my current two full-time pharmacists, one is a former intern and the other is a student who made a big impression on me during her final year of placement while at university. Not only does mentoring allow you to mould young pharmacists for the future of the profession, it also contributes to the development of staff to take on larger roles in your pharmacy. EDITOR: Finally, what are the support initiatives in place for all community pharmacists? AMANDA: Pharmacists working in community pharmacies that are members of the Pharmacy Guild are welcome to contact their local branch or branch committee for support and advice. There are many resources and support available. At the Queensland branch, the number of pharmacists employed has increased, ranging from younger pharmacists to ex-owners, and these staff are available for advice on a range of topics. Also available to every pharmacist, intern and pharmacy student in Australia is the Pharmacists’ Support Service on 1300 244 910 for a listening ear during times of stress.

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CONTINUING PROFESSIONAL DEVELOPMENT

Customer Service KATE ELLIS B.Pharm.

Learning Objectives: After reading this article, the learner should be able to: 1. To recognise the complexities of customer service in the healthcare (pharmacy) industry; 2. To recognise the meaning of and application of the Net Promoter Score; 3. To identify positive and negative non-verbal cues; 4. To recognise the importance of customer complaints as a tool for continual improvement in the pharmacy.

National Competency Standards: 1.2, 1.3, 1.4, 2.1, 2.2, 2.4, 2.5, 3.4

Accreditation number: G2016015 This activity has been accredited for 1 hour of Group 1 CPD (or 1 CPD credit) suitable for inclusion in an individual pharmacistâ&#x20AC;&#x2122;s CPD plan which can be converted to 1 hour of Group 2 CPD (or 2 CPD credits) upon successful completion of relevant assessment activities.

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CONTINUING PROFESSIONAL DEVELOPMENT

... Beyond Hello BUSINESSES WITH GREAT CUSTOMER SERVICE OUTPERFORM THEIR COMPETITORS BY 26% IN GROSS MARGIN AND 85% IN SALES GROWTH, ACCORDING TO INTERNATIONAL RESEARCH CONDUCTED BY THE GALLUP ORGANISATION1. FURTHERMORE, A RECENT STUDY BY CLICKFOX FOUND THAT QUALITY AND CUSTOMER SERVICE ARE THE TWO BIGGEST DRIVERS FOR RETAINING CUSTOMER LOYALTY, EVEN MORE SO THAN PRICE2. AS EVERY ONE OF US IS A CONSUMER OURSELVES, THESE RESULTS MAY NOT SURPRISE YOU. BUT AS STAFF IN A RETAIL PHARMACY, HOW WE PROVIDE CUSTOMER SERVICE ON A DAILY BASIS APPEARS TO HAVE A MASSIVE IMPACT ON OUR BUSINESS. SO WHAT CAN BE DONE TO MAXIMISE THE EXPERIENCE FOR YOUR CUSTOMERS?

“THE CUSTOMER IS ALWAYS RIGHT” Yep, we have all heard this one before! The phrase was originally coined back in 1909 by Harry Gordon Selfridge, founder of Selfridge’s department store in London, and is still used today as a way for businesses to ensure that employees give high priority to customer satisfaction. The question remains though, is the customer really always right? Community pharmacy is in a unique position in that it is both a professional health services destination and often a retail shop front as well. Pharmacies and Pharmacists have legal, professional and ethical obligations which must be adhered to and sometimes compromising with a customer’s demands is simply not an option. Furthermore, with the hustle and bustle, and demands of everyday life, people of the 21st century complain more than ever of being ‘time poor’. They want something done, and they want it done now. So how do we navigate saying, “No” or “Wait” to a customer when it is clear that is not the answer they are willing to accept? Consider this ... it’s 3.30 pm on a Thursday afternoon. There is late night shopping in the centre where you work and it’s ‘after school rush’ time, with a myriad of customers appearing in your store at once. Your dispense technician has called in sick, your junior staff member is out on a delivery and the pharmacy assistant is busy putting through sales at the till. You have a backlog of five baskets full of scripts and you have four more people waiting at the back counter to be served. Naturally, the first customer you speak to is rather a complex case and is taking longer than you expected. You can feel the eyeballs of the other three customers burning into the side of your head as they stand there, stagnantly waiting. Founder of Retail Minded, Nicole Leinbach-Reyhale, notes that you need to make your customers feel heard and

appreciated, and avoid making it all about you3. Yes, I am sure that they can see that you’re understaffed. Yes, they can see that you are stressed and running around like a headless chook. BUT, yes, they would still like to be acknowledged as a valuable customer and not an inconvenience to your day. It may only take an extra 30 seconds of your time, but by just stopping what you’re doing, making eye contact with the waiting customers, apologising and letting them know that someone will be with them as soon as possible, can go a long way. Perhaps one of those customers just wants to hand in a script and continue shopping elsewhere, or perhaps one of them just wants to buy some tissues but are waiting at the wrong counter? Leinbach-Reyhale reinforces the importance of simply adopting a friendly smile, an interest in the goals of your customer and a genuine appreciation for them doing business with you3. The basics of good customer service are pivotal to the success of any business. Worthy of discussion is the Net Promoter Score (NPS) which was first introduced in 2003 as part of a Harvard Business Review article, One Number You Need to Grow 4. The NPS is understood on a scale whereby -100 is the worst possible score (everybody is a detractor to the business) or as high as +100 (everybody is a promoter of the business). To put this into perspective, a NPS that is more than zero (positive) is seen to be good, and a NPS of +50 or more is seen to be excellent. To determine a NPS for a business, customers of the store are asked one simple question, “On a scale of 0 to 10, how likely are you to recommend this business to a friend or colleague?” From this, based on the rating they give, customers are classified into three categories: promoters (answered 9 or 10), passive (gave a score of 7 or 8) or detractors (responded with a score

of less than or equal to 6). The NPS is then calculated by subtracting the percentage of customers who are detractors from the percentage of customers who are promoters. This will therefore generate a score between -100 to 100. Of particular interest are the results of a recent Australian Customer Experience Index survey, currently being trialled by the Pharmacy Guild of Australia. This survey revealed that Australian community pharmacies have an average Net Promoter Score of 78.45.In comparison to other industries across the globe, such as telecommunications which is ranked at 22.6 and consumer brands at 43.3, community pharmacy in Australia is in a great position6.

“IT’S NOT WHAT YOU SAY, BUT HOW YOU SAY IT” In 1971, Albert Mehrabian famously published the book, Silent Messages, where he concluded that just 7% of the salesperson’s creditability was based on their actual words, whilst 55% was attributed to the speaker’s body language and 38% to the tone of their voice7.Thus, it has been established time and time again that good customer service involves more than just verbal communication. In the pharmacy, interpreting your customers’ non-verbal signals and behaviours allows you, as the staff member assisting them, to read their attitude and better understand their needs. In a similar way, by projecting positive non-verbal cues yourself, you can help make your customer feel at ease. Whilst having good non-verbal cues seems like common sense, it can be easy to adopt bad habits subconsciously, particularly if stressed. On the next page is a summary of good nonverbal practices that should be adopted in the pharmacy and bad practices to be avoided8.

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CONTINUING PROFESSIONAL DEVELOPMENT

The table below provides simplified examples of codes for different organisations9. TYPE OF ORGANISATION

EXAMPLE OF CODE COMPONENT

PIZZA DELIVERY COMPANY

MEDICAL CLINIC

RETAILER ASSOCIATION

HOTEL

TRAIN

Promise

"If the pizza is not delivered hot and within 30 minutes, the pizza is free."

"Patients will be told promptly of any delayed appointments, and given the option of another time."

"If scanned price of an item is higher than displayed price, the individual or business customer is entitled to receive the item free."

"If the guest is not satisfied with the service, the hotel will make every effort to make it right or the guest will receive a discount."

"If the train is late, the washroom is dirty or the service is discourteous, the customer will be reimbursed the price of the ticket."

Limitations on the promise communicated to the customer

Geographic, weather or traffic condition limits.

Emergencies disrupting regularly scheduled appointments.

Does not apply to behind-the-counter cosmetics and individually priced items.

Circumstances beyond the control of the hotel.

Severe weather conditions.

Other code provisions

Statement that cost of late pizza is not deducted from wages of pizza deliverer.

Statement of availability of doctors outside of normal hours.

Statement of code objective: "to maintain accurate scanner pricing."

Statement of code objective: "complete guest satisfaction."

Statement of code objective: "clean, punctual trains and courteous service."

Supportive information

How to make a complaint.

How to make an enquiry.

How to make an enquiry or complaint.

How to get a discount.

Where refund can be obtained.

Code planning, design, development and implementation activity

Pilot test programme.

Customer service training.

Consult with members of the association.

Use focus groups to determine most appropriate remedy.

Educate personnel in dealing with public.

Maintenance and improvement activity

Conduct survey and make changes to code wording as a result.

Evaluate complaint data.

Involve consumer organisations in review of data.

Revise marketing campaign.

Change procedures for cleaning wash rooms.

Performance indicators

Percentage of on-time deliveries.

Percentage of patients informed.

Percentage of mis-priced items.

Percentage of dissatisfied guests.

Percentage of passenger complaints.

CUSTOMER COMPLAINTS Customer complaints are always a tricky issue to deal with — just the phrase, “I’d like to speak to your manager” may send shivers down your spine. These misconceptions we might have about customer complaints as being ‘frustrations’ or ‘inconveniences’ must be flipped around and showcased as opportunities for your store. Furthermore, the pharmacy should act to remove the underlying causes of existing and possible problems which may lead to complaints, in order to prevent their existence and recurrence9. This is why adopting a continual improvement model within the pharmacy is so important. According to the Australian and New Zealand guidelines for customer satisfaction and quality management, the organisation should use preventative and corrective actions to employ innovative improvements in order to continually improve the code framework for increasing customer satisfaction9. According to these guidelines, the store should9:

• Explore, identify and apply best practices in the structure, content and use of a code;

• Foster a customer-focused approach within the organisation;

• Encourage code innovation; • Recognise examples of outstanding performance and practices related to the code.

For example, in relation to pharmacy and promoting a high level of customer service and satisfaction, there may be a promise in place that ‘a pharmacist will hand out and counsel on every single prescription for patients’. Whilst certainly good practice in theory, this code or promise has limitations in that some patient counselling will take longer than others, potentially slowing the process for those customers who would prefer more of an ‘in and out’ type of service arrangement. In these types of situations it is important that customers who are unsatisfied with their level of customer service know how to make an enquiry and who best to direct this to. Additionally, when there are escalating customer queries or complaints in the pharmacy, it is also important to be mindful of ensuring that all relevant information is passed onto the relevant person as soon as possible to avoid any inconveniences for the customer. ClickFox’s second annual benchmarking survey revealed that 42% (almost half) of customers said that when receiving customer service over the phone the most frustrating part of an experience was having to speak to multiple agents and starting over every time with their question10. Finally, it’s vital that this feedback loop is closed. Ideally, it is beneficial to record all customer complaints that you receive because chances are that, for the one or two people

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who may make an off-handed comment or complaint, there could be several more people that are thinking it but not telling you. It would be useful to log these issues somewhere tangible within your pharmacy such as on an incident register or continual improvement register. This way, patterns and trends within your pharmacy’s customer service model can be more easily identified and viewed as part of the bigger picture. In contrast, one isolated complaint which you originally thought may have been significant enough to markedly make changes within your pharmacy could be viewed as an outlier. The consumer decision-making process for service-based products, particularly those that are health related, is a complex system that integrates direct and/or indirect effects on behavioural intentions11. This is why customer service in the pharmacy space needs to be considered from all angles. Non-verbal cues should be acknowledged as significant from both the customer and staff member perspective. Ensuring that every customer feels heard in your store and that constructive feedback is fed back through the relevant channels is critical. With these points in mind, it is hopeful that every customer that walks out of your store is happy, on their way to positive health outcomes, and is a promoter of your business.

CONTINUING PROFESSIONAL DEVELOPMENT

Expression

Good

Bad

FACIAL

• Smiling • Raised eyebrows • Relaxed mouth

• Wrinkling the nose • Furrowing the brow • Rolling the eyes

EYE CONTACT

• Looking back to customer's face and at your products

• Avoiding your customer • Looking outside your sales space

SMILE

• Smiling • Relaxed mouth

• Closed, firm or expressionless mouth

HANDS

• Hands moving freely • Relaxed and touching product

• Hands folded to the chest • Hands near the face

GESTURES

• Open Arms • Nodding the head

• Closed arms • Dismissive hand gestures

POSTURE

• Standing upright • Inclining the body forward

• Slouching • Shoulders turned away

POSITION

• Observing personal space • Accommodating cultural differences

• Moving too close • Facing away

REFERENCES: Australian Customer Service Awards. Are You Listening To Your Customers? [Internet]. Sydney NSW: Australian Customer Service Awards; 2016. Available from: http://www.serviceexcellence.com.au/

Businesses Are Made Of Relationships. [Internet]. San Fransisco CA: Zendesk; 2016. Building Customer Loyalty; 2016 [cited 2016 Sep 26]; [1 screen]. Available from: https://www.zendesk.com/ resources/building-customer-loyalty/

Leinbach-Reyhle N. 3 Tips to Delivering Good, Old Fashioned Customer Service. Forbes [Internet]. 2015 Mar 24 [cited 2016 Sep 26]. Available from: http://www.forbes.com/sites/nicoleleinbachreyh le/2015/03/24/3-tips-to-delivering-good-old-fashioned-customer-service/#45c1b2852f6e.

Reichheld FF. The One Number You Need to Grow. Harvard Business Review. 2003 Dec; 12.

The Pharmacy Guild of Australia. Customer Experience Index. Canberra: The Pharmacy Guild of Australia; 2016.

Customer Gauge. NPS Benchmarks [Internet]. 2016 [cited 2016 Sep 27]. Available from: https:// npsbenchmarks.com/#

Mehrabian A. Silent messages. Belmont, CA: Wadsworth; 1971 Jan.

Queensland Government. Non-verbal Communication Skills for Selling [Internet]. 2016 [updated 2016 Jun 24; cited 2016 Sep 26]. Available from: https://www.business.qld.gov.au/business/ running/sales-customer-service/sales-skills/non-verbal-communication-skills.

Joint Technical Committee QR-008, Quality Management System. Australian/New Zealand Standard™: Quality Management guidelines 2012 - Quality management - Customer satisfaction - Guidelines for codes of conduct for organizations. Sydney NSW: SAI Global Limited & Wellington NZ: Standards New Zealand; 2012. 29.

Businesses Are Made Of Relationships. [Internet]. San Fransisco CA: Zendesk; 2016. What is Bad Customer Service?; 2016 [cited 2016 Sep 26]; [1 screen]. Available from: - https://www.zendesk. com/resources/what-is-bad-customer-service/

Bastos J, de Muñoz Gallego P. Pharmacies Customer Satisfaction and Loyalty: A Framework Analysis. New Trends in Business Management. 2008; 1-30.

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 As a customer satisfaction management tool, what does NPS stand for? a. National Prescribing Service; b. National Prescription Satisfaction; c. Net Prescription Score; d. Net Promoter Score; e. Net Promoter Satisfaction.

QUESTION 2 According to the Customer Experience Index, Australian community pharmacies score on average what NPS? a. 78.4; b. 41.3; c. -41.3; d. 67.7; e. 50.

QUESTION 3 According to research by Albert Mehrabian in his 1971 book, Silent Messages, a salesperson’s creditability is based on: a. Their actual words (55%), their body language (38%), their tone of voice (7%); b. Their actual words (7%), their body language (38%), their tone of voice (55%); c. Their actual words (7%), their body language (55%), their tone of voice (38%); d. Their actual words (55%), their body language (35%), their tone of voice (10%); e. None of the above.

QUESTION 4 Which of the following are examples of good non-verbal cues? a. Smiling, wrinkling the nose, shoulders turned away; b. Hands moving freely, standing upright, facing away; c. Hands near the face, standing upright, relaxed mouth; d. Looking outside your sales space, nodding the head, open arms; e. Raised eyebrows, relaxed mouth, inclining the body forward.

QUESTION 5 According to the Australian and New Zealand guidelines for customer satisfaction and quality management, the organisation should: a. Explore, identify and apply best practices in the structure, content and use of a code; b. Foster a customer-focused approach within the organisation; c. Encourage code innovation; d. Recognise examples of outstanding performance and practices related to the code; e. All of the above.

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Treatment methods you may never WARREN PARKES B.Pharm, Dip. Mgt, Cert IV TAE Professional Practice Pharmacist Pharmacy Guild of Australia (QLD)

THERE ARE NOT MANY PEOPLE ON THE PLANET WHO JUST DRINK WATER AND NOTHING ELSE. WITH SO MANY FLAVOURSOME DRINKS OUT THERE, WHY WOULD YOU ONLY DRINK WATER?

Can some drinks cause your body to become slightly dehydrated? There are many myths about which drinks dehydrate you, and even if you investigate the scientific research, you will get different answers. Think about all of the different types of drinks you would have and how they might affect your hydration state. You could have the same drink as one of your friends and get a totally different result. Think about a night out and having a few beers or wines ... Everyone will require a different amount of fluid to maintain a state of normal hydration. Many things affect these requirements: weight, exercise levels, kidney function and medication, to name a few. Even how your body processes a type of drink will differ from others. Therefore, the thought that you need to drink two litres of water a day is merely a guide. Common sense must prevail in deciding

how much you need to drink in one day. Recently, a study was undertaken and published in The American Journal of Clinical Nutrition to assess the potential of different beverages to affect hydration status: development of a beverage hydration index1.

on a daily basis, we can sleep at night knowing it is better than water! Also surprising, coffee and beer were not much different to water; however, that may have to do with the low amount consumed.

The results were quite interesting in that some were obvious and others were to me, quite surprising. They used plain water as reference 1 (BHI Beverage Hydration Index) and then tested how much of the drink was retained in the two to four hours immediately after consumption. So, if the beverage ended up with a BHI score of 1.4, it would mean that 40 percent more of the beverage was retained in the body more than water.

I was quite intrigued by the result of the milk in this study, so I did a bit of research and found that milk for recovery after exercise may be the next big thing. There have been some studies undertaken on low fat chocolate milk, highlighting the benefit to an athlete’s recovery after strenuous exercise. You did read that correctly — chocolate milk. I immediately thought, “Yes! I could go and do some exercise, and justify to myself the choccy milk treat!”

It was pleasing to see that an Oral Rehydration Solution did perform the best, followed by milk (yes milk) and orange juice. Considering pharmacies do recommend ORS

When you think about it, milk does contain many minerals like calcium, potassium, sodium and magnesium. These are all essential electrolytes which are lost in sweat

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have thought of

"I was quite intrigued by the result of the milk in this study, so I did a bit of research and found that milk for recovery after exercise may be the next big thing."

during exercise. Not only can they help with rehydration, but also muscle recovery — this sounds like a new, blockbuster treatment! A number of elite athletes have jumped on the chocolate-milk-post-exercise bandwagon, including USA Olympic swimmer, Jessica Hardy, and Australian Tri-athlete, Craig Alexander. I think this is definitely a ‘watch this space’ theory. Most instances of dehydration we see in pharmacy are generally related to gastroenteritis, so recommending chocolate milk wouldn’t be appropriate advice. However, the choccy milk theory made me think, are there any other means we can utilise to ensure we do not get dehydrated, besides water, ORS or milk?

Watermelon is made up of over 90% water and also contains salt, calcium and magnesium which are all beneficial for rehydration. Probably not the easiest product to lug around especially for athletes. I don’t think we will see any bike helmets soon with two straws going into a watermelon. Celery is another option with high water content and high levels of potassium, slightly easier to transport than watermelon. Cucumber, strawberries and lettuce have high water content but not as many electrolytes as watermelon or celery. So these can be beneficial for general wellbeing to maintain the status quo in your body’s normal hydration. The new-age latest fad, coconut water, has also been shown to be effective for

rehydration after light exercise2. It contains a high level of potassium which is beneficial for cramps, but is low in sodium; hence, why it is not that effective for vigorous exercise where you sweat a lot. So next time you are feeling a little dehydrated, you may be able to spice up your life with an occasional venture and try something other than water!

REFERENCES: http://ajcn.nutrition.org/content/ early/2015/12/23/ajcn.115.114769 2 https://www.sciencedaily.com/ releases/2012/08/120820143902.htm 1

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COPD and Smoking Cessation in a Pharmacy Setting DIANE BARTON COPD National Program Marketing and Communications Coordinator Lung Foundation Australia

JUDY POWELL COPD Project Manager Education and Training Lung Foundation Australia

PHARMACISTS PLAY A PIVOTAL ROLE IN ASSISTING PEOPLE TO QUIT SMOKING. WHILST QUITTING IS BENEFICIAL FOR EVERYONE, FOR PEOPLE WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), SMOKING CESSATION HELPS TO PRESERVE REMAINING LUNG FUNCTION AND INCREASE SURVIVAL.

COPD is an umbrella term for a group of obstructive airway disorders, including chronic bronchitis, emphysema, and chronic asthma which is not fully reversible with treatment1. It is a disease which is preventable and treatable, where airflow limitation is usually progressive with an abnormal inflammatory response of the lungs to noxious particles2. In Australia, smoking is the major cause of COPD and around 1 in 4 smoking-related deaths are due to COPD3. The research confirms unequivocally that smoking cessation is the single most important intervention to prevent or slow the progression of COPD. Evidence shows that quitting reduces the rate of decline of lung function4,5,6 by preserving residual lung function at any stage of the disease, thus delaying the onset of disability and death7. COPD is the second leading cause of avoidable hospital admissions8 and smoking cessation has been shown to reduce the risk of an exacerbation.

UNDERSTANDING WHAT WORKS Motivation is the key to smoking cessation and it is only those people who remain motivated that will be successful in quitting. Around 60 per cent of smokers are thinking about or preparing to make a quit attempt 9 and therefore would be open to a conversation about this. It is useful to keep in mind that people with COPD often have more barriers to quitting than others, due to lower self-belief and confidence, which often impairs their ability to quit. Comorbidities are common in this group with 44 per cent of those hospitalised with COPD having depression10. Brief counselling is effective and every smoker should be offered this intervention at every visit11. Whilst evidence indicates that spending more time (longer than ten minutes) yields higher abstinence rates than minimal advice, offering even three minutes of advice has been shown to provide clear benefits. Best practice in counselling and supporting behaviour change is

summarised in the 5-A strategy12:

• Ask and identify smokers; • Assess the degree of nicotine dependence and motivation or readiness to quit;

• Advise smokers about the risks of smoking and benefits of quitting, and discuss options;

• Assist cessation which may include specific advice about pharmacological interventions or referral to a formal cessation program;

• Arrange follow-up to reinforce messages and help prevent relapse. For a comprehensive approach to assisting smokers to quit, both pharmacotherapy and behavioural support interventions are suggested12. The success of quit attempts are doubled when pharmacotherapies are used13 and when combined with behavioural techniques, quit rates are increased further 14,15,16,17,18,19,20,21. Smoking cessation interventions have varying degrees of success and quit rates at 12 months are shown in the table below 22: Smoking Cessation Interventions Health professionals short advice Intensive behavioural support Self-help material Proactive telephone counselling Nicotine products (NRT) Bupropion SR Intensive support & NRT/bupropion Intensive support & varenicline

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Quit Rate (%) 2 7 1 2 5–15 9 13–19 22–23

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"Around 60 per cent of smokers are thinking about or preparing to make a quit attempt 9 and therefore would be open to a conversation about this." PRIMARY CARE RESPIRATORY TOOLKIT Tips for pharmacists to support smoking cessation:

1. COPD should be considered in all smokers and ex-smokers aged over 35 years. 2. Check smoking status, encourage and support smoking cessation initiatives. 3. Educate smokers on pharmacotherapy to support smoking cessation. 4. Use the Lung Age Estimator to personalise smoking cessation counselling.

BUILDING PHARMACY CAPACITY TO SUPPORT PEOPLE WITH COPD Lung Foundation Australia has a suite of resources and online training modules to help pharmacists increase their knowledge, confidence and skills working with patients with COPD. Topics covered in the online training modules include health promotion, risk assessment and screening, disease management and planning a COPD service. For more information visit http://lungfoundation.com.au/health-professionals/pharmacy/

Age in years

SEEING IS BELIEVING There is evidence to show that personalising smoking cessation advice based on lung function results and telling people their lung age, encourages them to quit smoking23. The Lung Age Estimator can be used at the Advise stage as a visually effective tool to help motivate smokers to quit. Lung Age is the age of the average healthy person who would perform similarly on spirometry to the smoker being assessed. Lung Foundation Australia has developed an open access online Lung Age Estimator. Simply enter the patient’s age, height and spirometry results online and the tool provides a personalised graph showing the rate of decline for that particular patient and what that would look like if they continue to smoke compared to a non-smoker. It also provides a revised rate of decline in lung function if the patient quits. The FEV1 results from a test with a COPD screening, such as the PiKo-6 or COPD-6, and can be used in the Lung Age Estimator only if the results are abnormal (yellow or red zone) and the patient is a current smoker. REFERENCES: Abramson, Michael, et al. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease V2.44. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. [Online] December 2015. [Cited: 19 May 2016.] http://www.copdx.org.au/home. 2 GOLD. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease. [Online] December 2011. [Cited: 3 August 2012.] http://www.goldcopd. org/guidelines-global-strategy-for-diagnosis-management.html. 3 Scollo, M M and Winstanley, M H. Tobacco in Australia: Facts and Issues. 3rd Edition. Melbourne : Cancer Council Victoria, 2008. Available from: http://www. tobaccoinaustralia.org.au. 4 Anthonisen, N R, Connett, J E and Murray, R P. Smoking and lung function of lung health study participants after 11 years. Am J Respir Crit Care Med. 2002, Vol. 166, pp. 675–679. 1

Fletcher, C and Peto, R. The natural history of chronic airflow obstruction. BMJ. 1977, Vol. 1, pp. 1645–1648. 6 Tashkin, D P, et al. Methacholine reactivity predicts changes in lung function over time in smokers with early chronic obstructive pulmonary disease. The Lung Health Study Research Group. Am J Respir Crit Care Med. 153, 1996, pp. 1802–11. 7 Tonnesen, P, et al. Smoking cessation in patients with respiratory disease: a high priority, integral component of therapy. Eur Respir J. Feb, 2007, Vol. 29, 2, pp. 390–417. 8 Page, A, Abrose, S and Glover, J. Atlas of Avoidable Hospitalisations in Australia: ambulatory care-sensitive conditions. University of Adelaide. Adelaide : Adelaide PHIDU, 2007. 9 Prochaska, J O, et al. Size, consistency, and stability of stage effects for smoking cessation. Addict Beh ort, NHLBI/WHO Workshop. Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD): Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. Bethesda : National Institutes of Health – National Heart, Lung and Blood Institute, 2001. 10 Zwar, N A, Mendelsohn, C P and Richmond, R L. Supporting smoking cessation. BMJ. 348, 2014, Vol. f7535. 11 Cahill, K, et al. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 5, 2013. 12 Eisenberg, M J, et al. Pharmacotherapies for smoking cessation: a meta-analysis for randomised controlled trials. CMAJ. 179, 2008, pp. 135–44. 13 Hartmann-Boyce, J, Lancaster, T and Stead, L F. Print-based self-help interventions for smoking cessation. Cochrane Database Syst Rev. 6, 2014. 14 Stead, L F, et al. Telephone counselling for smoking cessation. Cochrane Database Syst Rev. 8, 2013. 15 Civljak, M, et al. Internet-based interventions for smoking cessation. Cochrane Database Syst Rev. 7, 2013. 16 Stead, L F, et al. Physician advice for smoking cessation. Cochrane Database Syst Rev. 5, 2013. 17 Whittaker, R, et al. Mobile phone-based interventions for smoking cessation. cochrane Database Syst Rev. 11, 2012. 18 Cahill, K, Lancaster, T and Green, N. Stage-based interventions for smoking cessation. Cochrane Database Syst Rev. 2010. 19 Stead, L F and Lancaster, T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev. 2005. 20 Tonnesen, P. Smoking cessation: How compelling is the evidence? A review. Health Policy. 2009, Vol. 91, Suppl 1:S15–25. 21 Parkes, G, et al. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ. 2008, Vol. 336, pp. 598–600. 5

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BUSINESS

AUSTRALIAN COLLEGE OF PHARMACY

New Leader gets on with Business JENNY BERGIN General Manager Australian College of Pharmacy B.Pharm. MBA, FACP, GAICD

IT’S BEEN SAID THAT, UNTIL RECENTLY, THE AUSTRALIAN COLLEGE OF PHARMACY (ACP) WAS ONE OF PHARMACY’S BEST KEPT SECRETS. I GUESS THAT’S WHAT HAPPENS WHEN YOU TAKE TWO REASONABLY WELLKNOWN PHARMACY ORGANISATIONS (AIPM AND ACPP) AND A NEW PHARMACY ENTITY IS FORMED.

The melded organisation has been in existence since 2004 and this week marked a watershed moment for the College. The first female President in the history of the organisation, Georgina Twomey, was elected. Georgina has been a member of the Board and Vice President since 2014. She is the epitome of: If you want something done, ask a busy woman! Since she graduated her Bachelor of Pharmacy with Honours from the University of Tasmania, Georgina has become a partner/ manager in eight community pharmacies across northern Queensland. In addition to her role at the College, she studies (Advanced Diploma of Leadership and Management), has two young children and is actively involved in the Cairns community (Regional Gallery Foundation, Chamber of Commerce and Advance Cairns). In another important milestone, the College is pleased to announce that 50% of the Board of the College is female. The Board comprises Dr Treasure MacGuire, Sue Holzberger, Carolyn Clemenston, Matthew Harris, Paul Jaffar, Mark Douglass and Joseph O’Malley. The College Board made a decision to focus on getting the right Board member skill mix, so the demographic is a reflection that there are brilliant men and women pharmacists who aspire to leadership positions. A balanced Board is important in terms of gender and mix of skills.

Georgina has paid tribute to outgoing College Board members: former President and Fellow, Patrick Reid, and Director of Finance and Fellow HC, Peter Saccasan, for their outstanding contributions. Both Patrick and Peter now have even more demanding day jobs than when they were first elected and have been part of the team which included the Chair of the Academic Board, Professor Mike Roberts. They steered the College through its ambitious move to develop an integrated learning management system with the capability to: •

Meet all the requirements for CPD as outlined by the Pharmacy Board;

•

Deliver high quality learning and assessment for accredited CPD and the Advanced Diploma of Leadership and Management.

The new approach to gaining a formal qualification, outlined in Figure 1, is also gaining traction. Members can now use CPD activities to build towards an Advanced Diploma. Put another way, the College Advanced Diploma eLearning modules have been broken into CPD activities that are ‘chunk size’ and take around an hour to complete, including assessment. This allows pharmacists to: •

Complete the CPD activities as part of their annual CPD plan;

•

Get a taste of the Advanced Diploma content;

•

Build to an Advanced Diploma qualification in manageable steps.

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Motivational Interviewing to Assist Smoking Cessation in the Pharmacy Setting MANDY FRAME Quitline Team Leader (SA/WA/NT) Cancer Council SA

Although smoking rates in Australia have been declining, tobacco smoking is still one of the leading causes of preventable illness and death in Australia. It is estimated that two in three long-term smokers will die from a smoking-related illness, and that on average, those who smoke die around 10 years earlier than those who have never smoked. As soon as people stop smoking, their bodies have a remarkable capacity to repair themselves. There are immediate and longterm benefits for quitting smoking for men and women of all ages. Our Quitline, operated by Cancer Council SA, covers South Australia, Northern Territory and Western Australia, and is staffed by highly trained counsellors who specialise in motivational interviewing to assist people every step of the way through quitting smoking. Pharmacists have a unique opportunity to engage with people who smoke and provide the assistance they may need to quit smoking. Although time is limited, a brief discussion about smoking and a referral to Quitline can double the chances of quitting successfully. So how can we make the most of our opportunity when talking with those who smoke? Motivational Interviewing (MI) is a style of talking with people about behaviour change which harnesses that person’s own motivation for change and honours autonomy and the knowledge people have about themselves. This collaborative conversation about change is underpinned by empathy and respect. When we are engaged in a conversation about behaviour change, MI principles help us to step back from the expert role and take on a more guiding or collaborative approach. When we are speaking with people about quitting smoking, our aim is to grow their intrinsic motivation by allowing them to voice their reasons for change — giving an opportunity for them to hear themselves arguing for change rather than us!

TALKING ABOUT SMOKING USING A MOTIVATIONAL INTERVIEWING APPROACH STEP 1 – ASK PERMISSION Asking permission to talk about smoking is a good first step, particularly if your patient

has presented for other reasons. Your patient has then opted in to a conversation about smoking, making the exchange feel less confrontational and more collaborative. ‘I wonder if it would be ok if we could have a chat about smoking?’ If your patient declines the offer, it is an opportunity to demonstrate understanding and empathy, but also to offer support should your patient want to speak about smoking with you in the future. ‘I understand that it may not be the right time at the moment. If in the future you would like to talk about smoking, we have many ways to support you to quit, so please come back for a chat if you think it might be helpful.’ This respects your patient’s choice and also leaves the door open should they change their mind down the track.

STEP 2 – ASK ‘HOW DO YOU FEEL ABOUT SMOKING?’ To enable us to provide the support that is appropriate to the patient’s needs, we want to understand how they feel about smoking at the moment and how open they may be to making changes. A good way to assess this is to simply ask! ‘I’m wondering how you’re feeling about smoking at the moment?’ Most people will respond to this question with a mixture of change talk and sustain talk. Change talk is defined as the person’s own statements that favour change. Patients might say things such as, ‘Well, I’m not happy that I’m smoking. It costs a lot these days and I do sometimes worry about my health.’ We might also hear some sustain talk in response to this question. Sustain talk is defined as the person’s own arguments for not changing. A response such as, ‘I have a lot of stress at the moment and I get really cranky when I’ve tried to quit before’ is an example of sustain talk. We expect to hear both change talk and sustain talk as this demonstrates the ambivalence people often feel when they are thinking about behaviour change. In motivational interviewing the aim is to increase the amount of change talk your patient engages in. This has been shown to increase the chances that your patient will actually make the behaviour change. To do this, we ask people to tell us more about the reasons they want to make the change and we can use reflections to allow them to hear themselves arguing for the change.

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Anyone wanting support to quit smoking can call Quitline on 13 7848.

STEP 3 – ASK ABOUT PREVIOUS QUITTING EXPERIENCE We know most people who smoke have tried to quit before, often many times. Asking about previous quitting attempts allows us to bring forth that person’s own knowledge about themselves, and strategies that may have been helpful in the past. ‘Have you ever quit smoking before? How did you do it?’ Most people feel very negatively about previous quit attempts. They focus on the return to smoking and not the achievement of having abstained from smoking for a period of time. Our role here can be to build confidence for a future quit attempt. To do this, we can congratulate any previous quitting success, even if it’s only 24 hours!

STEP 4 – LEAVE THE NEXT STEP TO THE PATIENT This important step acknowledges that it is your patient who decides whether they will quit smoking or not. When people recognise that the choice is theirs and they hear themselves voicing their own reasons for change, the change becomes more possible. ‘I really appreciate you having this chat with me and I think I understand a bit more about how you feel about smoking at the moment. I wonder what your next step might be with smoking?’ Depending on your patient’s response, we are then able to offer support accordingly. This might be information, nicotine replacement therapy, referral to Quitline, or just going away and having a think about it. Remember Quitline support can double the chances of your patient quitting successfully. If your patient would like some support to quit smoking, or just to talk about the options, you can complete a Quitline referral form. For a SA/WA/NT Quitline referral save the link below. https://www.cancersa.org.au/quitline/im-ahealth-professional/quitline-referral To download other smoking cessation resources for Health Professionals, visit: https://www.cancersa.org.au/quitline/im-ahealth-professional For more information about motivational interviewing, visit http://www.motivationalinterviewing.org/

Pharmacists can refer their patients to Quitline Completing a referral will ensure that a Quitline counsellor will contact your patient. Our Quitline counsellors have extensive up to date knowledge of smoking cessation and are trained in the use of motivational interviewing for behaviour change. Aboriginal counsellors are also available to support Indigenous patients to quit smoking successfully.

quitlinesa.org.au

HEALTH

A new Calendar Year ... same Resolutions? NATE HENTSCHEL Pharmacist, B. Pharm.

TRADITIONALLY, A TREMENDOUS NUMBER OF PEOPLE MAKE A RESOLUTION TO QUIT SMOKING AT THE START OF A NEW YEAR. REGRETTABLY, AS PHARMACISTS, WE ONLY WITNESS A SMALL NUMBER STICK WITH IT AND ACHIEVE THIS GOAL. THE CHEMICAL AND PSYCHOLOGICAL ADDICTION OF SMOKING IS A TOUGH ADDICTION TO BREAK.

Pharmacists are the most accessible health professionals when it comes to educating the public about smoking cessation, and thus have the responsibility to promote and support quitting for patients. Counselling and support from pharmacists has been shown to have a pivotal role in the success of smoking cessation. Pharmacists can discuss treatment options such as nicotine replacement therapy, as well as provide counselling to guide the patient through the quitting process. The aim is to empower the patient with the knowledge and confidence to use the products effectively.

THE CONSEQUENCES OF SMOKING It is important to stress and reinforce the

positive reasons to quit. Due to successful education campaigns by the government and health professionals, most people are fully aware that smoking is harmful and addictive, but many still carry the belief that such things won’t happen to them. Smoking can cause numerous negative effects to the body: increasing the risk of several types of cancer, heart disease, stroke, and it can reduce the sensations of taste and smell, among many other health concerns.

NICOTINE REPLACEMENT THERAPY (NRT) Without doubt, the most popular quitting aid is NRT. It comes in a variety of forms which

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can cater towards the individual needs of the patient, and will typically advise a very gradual approach to reducing cigarette consumption. This slower approach helps the patient adjust better to the lack of nicotine in their body. NRT patches, gums, fast-acting sprays and lozenges all exist. Some are designed to provide baseline relief through the day, such as patches, while others are designed for quick craving relief, such as lozenges. Depending on the patients’ medical history, level of addiction and what they have tried in the past, many will find the best option is to combine a long-acting option with intermittent use of a fast-acting option for immediate cravings. The majority of smokers will start on

HEALTH

“Pharmacists can discuss treatment options such as nicotine replacement therapy, as well as provide counselling to guide the patient through the quitting process.”

QUIT SMOK ING

the higher dose NRT products and may use a fast-acting option through the day, but should gradually taper down over the course of two to three months.

PRESCRIPTION OPTIONS

The exact mechanism of Buproprion in reducing the cravings and withdrawal symptoms of nicotine are unknown, however, it appears to be relatively effective over short courses and there has been some evidence of additional success in combination with NRT. Much like Varenicline, it does have limitations via contraindications and adverse effects, both of which should be discussed with a prescriber before commencing.

While NRT as outlined is popular, a number of patients may find themselves unable, or unwilling, to use NRT. In this case, they should see a doctor to investigate other options, which could include prescription items such as Bubroprion or Varenicline.

WHICH OPTION IS BEST?

Varenicline has been shown to be effective in reducing cravings for smokers, usually over a two month course. It does, however, have a fairly extensive adverse effect profile, including cardiovascular and psychiatric effects, and there will be patients for whom it is not suitable or who do not tolerate it. Their medical history and current medications should be carefully assessed before commencing with Varenicline. Due to its mechanism of action, it is generally not necessary to combine Varenicline with NRT.

The best way to determine an appropriate treatment is to use a questionnaire, such as the Fagerstrom Test, which is a simple way to assess the level of nicotine dependence, from low to high. Those with higher levels of dependence are more likely to need combination replacement therapy and more support compared to those with a low dependence, who may be able to quit using only short-acting replacement therapies.

SUPPORTING THE PROCESS Regardless of the choice of quitting, whether that be NRT or through prescription medication, the biggest factor in quitting is psychological. The patient must want to quit. To help them, counselling and support should be provided, and it may be useful to set out a plan of how they will cut back their cigarette consumption, while also decreasing the use of their NRT. Pharmacists should remain vigilant to a patient’s medical history, as both smoking and NRT can cause some significant drug interactions. If their medical history suggests potential drug interaction, it is often worthwhile to consult with their prescriber before initiating NRT. Ultimately, community pharmacists have a key role in guiding patients through the quitting process, and this is one way in which pharmacists can contribute to preventative health. Actively engaging consumers who are looking to quit can help them move in the right direction towards a better, healthier future.

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HEALTH

Preventing the Complications of

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 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.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

HEALTH

IT’S GREAT NEWS — THE AVERAGE LIFE EXPECTANCY OF PEOPLE LIVING WITH DIABETES IN AUSTRALIA HAS IMPROVED DRAMATICALLY OVER THE PAST FEW DECADES1. THIS IS DUE TO RAPID DEVELOPMENTS IN BLOOD GLUCOSE LOWERING MEDICATIONS/INSULINS, BLOOD GLUCOSE MONITORING TECHNOLOGY, AND OUR UNDERSTANDING OF HEALTHY LIFESTYLE MANAGEMENT.

Despite this, there are a number of potential complications of diabetes affecting blood vessels and nerves in particular, which can develop if the condition is not managed effectively. The most common complications that occur in people with diabetes include:

• Cardiovascular disease This is the most common cause of death in people with diabetes, primarily due to heart attack or stroke. It can also affect peripheral blood vessels — in particular, those in the lower legs and feet. High blood glucose, blood pressure, and cholesterol are the primary risk factors that contribute to the development of cardiovascular complications.

• Neuropathy Persistently high blood glucose can damage the nerves throughout the body. This can lead to problems with digestion (e.g. gastroparesis), reproduction (e.g. erectile dysfunction), and many other vital organs. Among the most commonly affected areas are the extremities — in particular, the hands and feet. Nerve damage in these areas is called peripheral neuropathy and can lead to pain, tingling and loss of feeling. Loss of feeling is particularly important in the feet because it can allow injuries to go unnoticed, leading to serious infections and potential amputations. Consequently, people with diabetes should regularly examine their feet — ideally daily. •

Retinopathy Diabetic retinopathy occurs when the tiny blood vessels inside the retina at the back of the eye are damaged. It can seriously affect vision and in some cases cause blindness. Consistently high blood glucose and high blood pressure are the main causes of retinopathy. It can be managed through regular eye checks and keeping blood glucose and blood pressure levels at or close to normal.

•

Nephropathy Nephropathy is caused by damage to the small blood vessels in the

•

kidneys leading to the kidneys becoming less efficient, or making them fail altogether. Maintaining near normal levels of blood glucose and blood pressure reduces the risk of developing nephropathy.

activity are two of the most effective ways of lowering blood pressure2. Reducing sodium consumption and increasing potassium consumption will also help improve blood pressure2,3.

Periodontal disease

BLOOD CHOLESTEROL AND TRIGLYCERIDES

Periodontal diseases are infections of the gum and bone that hold teeth in place. It may lead to painful chewing problems and even tooth loss. High blood glucose, blood pressure, and cholesterol are the primary risk factors and these should be maintained at or close to normal. Good oral hygiene will also help reduce the risk. The good news is that it is possible to prevent, or at the very least delay, the development of these common complications if people with diabetes are able to achieve and maintain2: •

Blood glucose levels in the recommended range (6–8 mmol/L fasting and 8–10 mmol/L after meals) or as close to recommended as is safely possible;

•

Blood pressure levels in the recommended range (≤ 140/90 mmHg) or as close to recommended as is safely possible;

•

An optimal blood cholesterol (HDL ≥ 1.0 mmol/L and LDL < 2.0 mmol/L) and triglyceride (< 2.0 mmol/L) profile.

Medical Nutrition Therapy for these primary risk factors was covered in detail in part 2 of this series (ITK Oct/Nov 2016), but in summary:

BLOOD GLUCOSE A total carbohydrate intake of 45–60% of energy (depending on cultural background, personal food preferences, clinical goals, etc.) is generally recommended3, which for an adult consuming 8,700 kJ daily equates to 230– 310g of carbohydrate daily. For people using insulin or oral hypoglycaemic agents that can cause hypoglycaemia, it is recommended that total carbohydrate intake is spread out relatively evenly throughout the day.

BLOOD PRESSURE Losing weight and regular moderate physical

Avoiding trans fats and consuming twice as much unsaturated fat as saturated fat has the most beneficial effect. Soluble dietary fibres like β glucans (primarily found in oats and barley) can also help lower cholesterol levels, as can phytosterols found in certain margarines and milks2,3. Excessive alcohol4 (e.g. more than 4 standard drinks per drinking occasion5) and refined carbohydrate (e.g. confectionery, sugar sweetened soft drinks and highly processed breads, breakfast cereals, white rice, potato crisps, French fries, etc.) consumption raise triglyceride levels, and therefore should ideally be saved for special occasions, if consumed at all2,3.

CONCLUSION People with type 2 diabetes can prevent the development of the common complications of diabetes with medical nutrition therapy. 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: Harding JL, Shaw JE, Peeters A, Guiver T, Davidson S, Magliano DJ. Mortality trends among people with type 1 and type 2 diabetes in Australia: 1997– 2010. Diabetes Care 2014 Sep;37(9):2579-86. 2 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/dc14-S120.:S120-S143. 3 Dworatzek PD, Arcudi K, Gougeon R, Husein N, Sievenpiper JL, Williams SL. Nutrition therapy. Can J Diabetes 2013 Apr;37 Suppl 1:S45-55. doi: 10.1016/j.jcjd.2013.01.019. Epub;%2013 Mar 26.:S45-S55. 4 Van de Wiel A. The effect of alcohol on postprandial and fasting triglycerides. Int J Vasc Med 2012;2012:862504. doi: 10.1155/2012/862504. Epub;%2011 Sep 22.:862504. 5 National Health and Medical Research Council. Australian Dietary Guidelines. 18-2-2013. Canberra, Australia, Health and Medical Research Council. 1

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

BUSINESS

Pharmacy of the Year PETER WATERMAN Communications Specialist Pharmacy Guild of Australia

THE ANNUAL GUILD PHARMACY OF THE YEAR AWARDS IS A HIGHLIGHT OF THE PHARMACY CALENDAR, WHERE PHARMACIES THAT ARE LEADING THE WAY IN PROVIDING INNOVATIVE AND OPTIMAL HEALTHCARE FOR MEMBERS OF THEIR COMMUNITY ARE RECOGNISED AND HIGHLIGHTED.

The awards recognise excellence in pharmacy across three categories:

• Business Management • Community Engagement • Professional Services Innovation The finalists come from a broad field of nominated pharmacies and each is a leader in their field. A different community pharmacy will be selected as the winner in each category, with the Guild Pharmacy of the Year for 2017 being selected from these three individual category winners and announced at APP 2017 on the Gold Coast in March. Being named Pharmacy of the Year is an honour which has lasting and ongoing effects as the 2016 winner — Pharmacy 777 at Nollamara in Western Australia — can attest to. Proprietor, Swarup Afsar (Sam), said the award helped to cement the culture of excellence at Pharmacy 777 and also underscored the close relationship the pharmacy has with its patients and the local community. Mr Afsar said that nearly a year after winning the award, the pharmacy is on a mission of continuing improvement. This mission has been underpinned by winning the award, an event which also marked “the start of a process, rather than the end of one”.

Another outcome of winning the award was that the pharmacy was looking at employing another mental health counsellor. “The award has given us a lot of recognition over the provision of the mental health services we provide and now we are looking to expand the number of hours of counselling we can offer in response to increased demand,” he said. “Other pharmacies in the Pharmacy 777 group are also now looking to share a counsellor so they can offer expanded mental health services after seeing our model. Our group is very close-knit and we share ideas and concepts across pharmacies.” The pharmacy’s patients love being able to go to a pharmacy that was recognised as the best in Australia, and some have been travelling up to 40km just to visit the pharmacy. “Their response has been great, but we also recognise that our patients are what make us so we have been thanking them. We rolled out a red carpet for more than three months so that every patient recognised that we regard them as very special people.” The pharmacy also organised a street party celebration in conjunction with other businesses and local clubs, and Mr Afsar said it attracted more than 400 people. “Basically the whole of Nollamara came.”

“Excellence is no longer an option; it’s a given,” Mr Afsar said. “Being named Pharmacy of the Year was a real eye-opener for us. It has been a launching pad for us to achieve even better results for our patients, and also for the pharmacy business.” “It has also been great recognition for the staff — all the staff and pharmacists are now committed to taking our pharmacy to the next level.” GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

Federal Member for Stirling, the Hon Michael Keenan MP, and Amber-Jade Sanderson, MLC member for East Metropolitan Region, Ian Britza, MLA member for Morley, and Janine Freeman, MLA member for Mirrabooka, were among the dignitaries to attend the street party. Mr Afsar said the party was a thank you for the patients without whom the pharmacy would not have been able to reach the heights of success it has. “Our patients have been great. We support each other and we treat each other like a big happy family,” Mr Afsar said. This approach was commented on by one of the judges of the award, pharmacist, Bill Scott. “Everybody is greeted by a pharmacist — usually by their name. The pharmacy has a rule that everybody is a patient, not a customer, but for me everybody seems like a friend. Professionalism counts,” he said. Mr Afsar said treating everyone as a patient was a strict rule in the pharmacy. “We actually have a swear jar — everyone has to put in a dollar for uttering the word 'customer'. Such a culture helps us emphasise our professional services,” he said. “We have only pharmacists attending to every patient. Our pharmacists hand out every prescription which allows the best advice to be given out every time. We want to dispense our knowledge and not just prescriptions.” For any pharmacy thinking of entering The Guild Pharmacy of the Year competition, Mr Afsar’s advice is: “Go for it.” “It is a very rewarding process and builds confidence in you and your staff, and is a great incentive for continuing to improve and introduce new services,” he added.

Partner with real-world research experts. We partner with organisations to provide solutions to business problems using our expertise in creative problem-solving and tailored research design. Find out more www.qut.edu.au/business

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INDUSTRY NEWS & UPDATES ``EXERCISING 20 MINUTES A DAY REDUCES THE RISK OF CHRONIC DISEASE! About half of all Australians have a chronic disease, and around 20% of these people have at least two (multiple conditions) according to the Australian Institute of Health and Welfare (AIHW)*. Older people are more vulnerable to developing many diseases, and Australians' increasing life expectancy means a greater chance for multiple conditions to arise. Nearly 40% of Australians aged 45 and over have two or more of the eight chronic diseases examined. For this age group, the two most common chronic diseases to occur in combination with any other chronic disease were arthritis and cardiovascular disease.* It doesn’t have to be this way. Health Care Professional’s have long known about the health benefits of regular exercise in the

prevention of heart disease, obesity and other related health conditions. However with all the evidence supporting the benefits of exercising and the major role it plays in preventing chronic disease, over 70% of adults (almost 12 million Australians) don’t do enough physical activity to maintain good health. The good news is recent studies have shown that by exercising for as little as 20 minutes a day you can reduce your chances of developing chronic diseases dramatically but also help you manage the symptoms. See Frank Caruso’s 20-Minute Functional Bodyweight Workout for all ages at www.carusoshealth.com.au >> www.aihw.gov.au/chronic-diseases

``LEASE1 - NEW RULES OF LEASING It is not hard to scan the News headlines for the past 12 months and see the number of Retail failures. For Pharmacy, this is even more critical as the 6CPA core objective is to unshackle community pharmacies from the trading terms associated with the supply of PBS medicines yet when it comes to the most important contract – The Lease, attitudes are stuck in the past. That is why the New Rules of Leasing is long overdue, the time has come to invest in not only delivering the right outcomes but to change the mind set of Retailers/Lessees and industry stakeholders to level the playing field not just for the deal done today but for the future.

MiLease-New Rules of Leasing is a program delivers outcomes, provides the tools and mentoring to bring about a mindset change in how Leases are treated as assets, how relationships can be developed and how to successfully negotiate for the future. If you have a Lease expiring in 2 years, are responsible for brand/ franchisee development, want to grow your portfolio, are thinking of buying a Pharmacy or want to be part of this transformation, there is a New Rules of Leasing program to empower you for the future. >> www.milease.com.au

``DOSE ADMINISTRATION AID CHOICE THE ANSWER FOR AN OVERDOSE CRISIS HITTING MIDDLE-AGED AUSTRALIANS Increasingly complex medication regimes are raising risk of overdose among those aged between 30 and 59. Almost 80 per cent of Australians dying from accidental overdose fall in this age group, according to a recent Penington Institute report. Luke Fitzgerald, CEO of medication management experts MPS, said increased understanding of people taking multiple medications is vital if the trend is to be addressed. “The perception is that they are elderly, but this is often not the case,” said Mr Fitzgerald. “Taking multiple medications while pursuing a busy lifestyle can be challenging, and accidents can happen all too easily.”

Fitzgerald’s Australian-based company partners with pharmacies and residential aged care facilities to reduce risk of medication incidents. “When pharmacists have the full picture, they can identify concerns more readily,” said Mr Fitzgerald. MPS delivers medication management solutions to enable pharmacists to better serve both community patients and Residential Aged Care Facility residents. This is facilitated by smart solutions which help make provisioning and taking medicines simple, safe and secure. >> www.mps-aust.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

INDUSTRY NEWS & UPDATES

``COMPOUNDING: GET BACK TO THE ROOTS OF PHARMACY Compounding is the art and science of creating personalised medication. For the 30 to 40 million people who aren’t served by commercially available products, compounding pharmacists offer life-changing, even life-saving, solutions.

“For people like the child who can’t swallow pills or the cancer patient who needs a drug that’s in short supply, compounding provides more than medicine – it instills hope.”

Here are just a few reasons you should consider incorporating compounding in your pharmacy:

BETTER YOUR BUSINESS Compounding pharmacists distinguish their practices by providing a unique and much needed service. It leads not just to improved patient compliance, but also to increased sales and higher profit margins.

MAKE A DIFFERENCE For people like the child who can’t swallow pills or the cancer patient who needs a drug that’s in short supply, compounding provides more than medicine – it instills hope.

CAREER SATISFACTION As a compounding pharmacist, you’re not an order filler. You get to use your hard-earned skills and education working with a variety of medical specialties, all while experiencing a level of independence and work-life balance the big chains can’t offer. Ready to get started? Visit pccarx.com.au/join-pcca or call (02) 9316 1500 to discover all the benefits of membership. >> www.pccarx.com.au/join-pcca

``PHARMACY ALLIANCE COMMITTED TO DELIVERING MEANINGFUL HEALTH SOLUTIONS In a period of regulatory reform Pharmacy Alliance is providing independent pharmacy with access to marketing, merchandise and professional service programs with their co-brand initiative ‘Alliance Pharmacy’ without the pressure of franchise fees. Pharmacy Alliance 500+ members were introduced to the ‘Alliance Pharmacy’ co-brand in 2014 as a way to connect

"Pharmacy Alliance is planning an integrated marketing strategy that shows how independent pharmacy provides meaningful health solutions and how they play a pivotal role in the prosperity of their communities."

the Pharmacy Alliance member network to consumers across Australia, whilst retaining their own independent pharmacy name or brand. With more than 60 pharmacies now displaying the Alliance Pharmacy signage, Pharmacy Alliance recently announced the next stage of their co-brand initiative with ‘Alliance Pharmacy’ that centres on a pharmacist-led and smarter-retailing proposition with the primary aspiration to help customers have the best quality of life, at every stage of life. Along with this Pharmacy Alliance is planning an integrated marketing strategy that shows how independent pharmacy provides meaningful health solutions and how they play a pivotal role in the prosperity of their communities. ‘Alliance Pharmacy was designed to help our members transform – this means our pharmacy owners need to think about how they apply this in their pharmacies and how this may change staff capabilities and their pharmacy capabilities. With ‘Alliance Pharmacy’ the vision is to make life better every day for everybody’ said Nimfa Martinez, General Manager Marketing and Member Services. >> www.pharmacyalliance.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

60 SECONDS

WITH...

JESS NIERLE Centre Pharmacy Unanderra I decided to become a pharmacist because ... I enjoyed science in high school and thought it would be a career that I’d thoroughly enjoy. I’ve always loved engaging with customers which is why I thought pharmacy would be a rewarding job. I have been working as a pharmacist for ... 4 years. What I like best about my job is ... Playing an essential role in improving the health of others. including magazines, online articles, emails and newsletters.

My favourite hobby is ... Going on coastal walks.

Over the next 3 years in pharmacy, I predict ... That pharmacist’s role in the community will expand by providing more services within the pharmacy.

My favourite book is ... Gone Girl. My best getaway ever was ... Travelling around Europe for 3 months. How I keep myself updated to the market news ... By reading various pharmacy publications

If I could give any advice to someone starting a career in pharmacy, it would be ... Go into this career with an open mind and the motivation to continually learn.

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GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

Health Destination Hub

It was Albert Einstein who said, ‘Try not to become a man of success, but rather a man of value’. Having spent the last few months working in a number of different and busy pharmacies, I have found myself facing a new...

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AFTER HOURS

SANTOS TOUR DOWN UNDER Australia's premier cycling race with rich history

THE SANTOS TOUR DOWN UNDER IS AN ACTION-PACKED NINE DAYS OF WORLD-CLASS CYCLING WITH GALA DINNERS, STREET PARTIES AND AN AMAZING ATMOSPHERE FOR RIDERS AND SPECTATORS, VISITORS AND LOCALS ALIKE.

The event was first staged in 1999 with local rider Stuart O’Grady taking the win. Since then, numerous internationally renowned cyclists have joined the Honour Roll. The event has grown year on year to become the biggest cycling race in the southern hemisphere. In 2008 the Santos Tour Down Under joined the prestigious UCI WorldTour, the first event outside cycling's traditional home of Europe to do so. The event is held in January every year, making it the first event on the international cycling calendar.

The Santos Tour Down Under visits some of South Australia’s spectacular beaches, world-famous wine regions and historic country towns before the finale on the streets of Adelaide. The elite of world cycling such as Cadel Evans, Marcel Kittel, Andy Schleck and Andre Greipel have all come to South Australia to conquer the roads of the Santos Tour Down Under. In 2017, the world's top cyclists will once again be back to stamp their authority on the new season.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

In 2016 the Santos Tour Down Under saw 795,0000 spectators line the roads of South Australia to watch Australian hero Simon Gerrans of Orica-GreenEDGE take victory for the third time in his career, with more than 39,000 visitors from interstate and overseas. The event generated $49.6m in revenue for the state’s economy and contributed to many communities across the state. The 2017 Santos Tour Down Under is looking to be just as exciting with new race stages and a wide range of associated events from 14-22 January 2017.

HEALTH CALENDAR

DECEMBER 2016/JANUARY 2017

DECEMBEARD The Month of December 2016 >> www.decembeard.org.au Decembeard® Australia: Grow a beard, raise funds and help us beat bowel cancer. Beards aren't just for hipsters, those with tattoos, men that ride motorbikes or people that are too lazy to shave. Anyone can help make real change happen. All you need to do is grow a beard (some chin stubble or bum fluff), and promote your facial hair to raise awareness and funds for Australia’s second biggest cancer killer - bowel cancer. Now in its fourth year down under, December is Decembeard® for Bowel Cancer Australia. A hair-raising fundraiser held during the month of December (1st-31st December), Decembeard® encourages men to grow a beard in the final month of the year to raise awareness and much needed funds for bowel cancer. Register now and start making a difference at Decembeard® Australia: Grow a Beard. Women and children are also encouraged to take part in Decembeard® Australia by helping raising awareness of bowel cancer and encouraging your fathers, brothers, husbands, boyfriends, partners and male friends to find out about bowel cancer and grow a beard for Decembeard®! Register now and start making a difference at Decembeard® Australia: Grow a Beard.

AUSTRALIA DAY 26th January 2017 >> www.australiaday.org.au Australia Day is the most popular national day on the calendar, so why not start your celebrations early by hosting an Australia Day at Work morning tea, barbecue or special event in your workplace? Australia Day at Work is a chance to celebrate what’s great about Australia and being Australian with your work colleagues. It's a great opportunity to get together as a team for a morning tea or lunch and remember how lucky we are to live in Australia. Register your workplace for an Australia Day at Work and you'll receive a free Australia Day event pack with printable decorations, props, and games ideas to make your Australia Day at Work celebration great. To ensure your Australia Day at Work event is part of the official Australia Day celebrations, remember to take a photo and post it on Twitter using #australiaday so everyone can see how you mark the occasion.

WORLD AIDS DAY 1st December 2016 >> www.worldaidsday.org.au World AIDS Day is held on 1 December each year. It raises awareness across the world and in the community about the issues surrounding HIV and AIDS. It is a day for people to show their support for people living with HIV and to commemorate people who have died. The aim of World AIDS Day is to encourage all Australians to be aware of HIV; to take action to reduce the transmission of HIV by promoting safe sex practices; and to ensure that people living with HIV can participate fully in the life of the community, free from stigma and discrimination. As a community and as individuals, there is a lot we can do in relation to HIV. Working in partnership with people living with HIV, we can encourage others to understand how the virus is transmitted. We can support people to access testing and treatment, as we know that getting treatment at the early stages of infection results in better health outcomes. We can raise awareness that HIV positive people have the right to participate in a community free from stigma and discrimination.

BIG RED BBQ 26th January 2017 >> www.kidney.org.au/connect/ events/big-red-bbq-external Looking to make a difference this year? Consider hosting your very own Big Red BBQ in support of Kidney Health Australia! You can hold your Big Red BBQ anywhere. Have one with your family and friends at home, host one at work and invite your colleagues, go to a park with your neighbours, arrange one at a community function centre or your local church, school or uni. The possibilities are endless. All we ask is that you turn it RED and have fun along the way! Proceeds raised from your Big Red BBQ will go towards our programs to promote good kidney health through education, advocacy, research and support.

Show your support for people living with HIV on World AIDS Day by wearing a red ribbon, the international symbol of HIV awareness and support.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

BUSINESS DIRECTORY

Business Directory m

AUSTRALIAN COLLEGE OF PHARMACY Level 2, 9/65 Tennant Street Fyshwick ACT 2609 Tel: 02 6188 4320 >> www.acp.edu.au

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

NOVO NORDISK AUSTRALIA PO Box 7586 Baulkham Hills Business Centre NSW 2153 Tel: 1800 224 321 >> www.novonordisk.com.au

PCCA

CARBINE MEDIA Unit 4 Level 3, 399 Leighton Place Hornsby NSW 2077 Tel: 02 9476 5933 >> www.carbinemedia.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

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

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

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

PFIZER AUSTRALIA 38-42 Wharf Road West Ryde NSW 2114 Tel: 02 9850 3333 >> www.pfizer.com.au

FLOWSELL

NIELSEN

PHARMACY ALLIANCE

1/13 Network Drive Carrum Downs VIC 3201 Tel: +61 3 9708 2276 >> www.flowsell.com.au

Level 2, Building B, 11 Talavera Road Macquarie Park NSW 2113 Tel: 02 8873 7000 >> www.nielsen.com

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

Would you like to advertise in our Business Directory? Contact Nicole Star on Ph: 07 3040 4415 or Email: production@goldx.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 51 : DECEMBER 2016/JANUARY 2017

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