ITK JuneJuly Publication by Gold Cross Products & Services

ISSUE #54 : JUNE/JULY 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 • TRANSFORMING YOUR PHARMACY INTO A HEALTH HUB

IN THE KNOW

• MEDICAL CANNABIS: UPDATE FOR PHARMACISTS

• • • •

URINARY TRACT INFECTIONS IN WOMEN CPD — THE BUSINESS OF PHARMACY INCONTINENCE: NO LAUGHING MATTER GESTATIONAL DIABETES

Which products will effectively treat this condition?

Stretch marks can cause significant psychological distress and physical symptoms to sufferers.

60%-70% of pregnant women will get stretch marks.1

Thatâ&#x20AC;&#x2122;s over 180,000 Australian women each year.2

Thousands of women walk into a pharmacy each day searching for a noninvasive product to effectively treat their stretch marks.

Ensure you have the most up-to-date information on this common skin condition and the treatments available.

Reference 1

Osman H, Rubeiz N, Tamim H, Nassar AH. Risk factors for the development of striae gravidarum. Am J Obstet Gynecol. 2007 Jan;196(1):62.e1-5.

Reference 2

http://stat.data.abs.gov.au

The Australian College of Pharmacy is pleased to offer an accredited CPD titled “Stretch marks: Identification and treatment” to all pharmacists to broaden their knowledge and expertise on stretch marks. This will assist to provide your customers with suitable advice on how to best treat this common skin condition more effectively.

Don’t leave stretch marks to cosmetics or chance Accreditation Number: A1706STM1 This activity has been accredited for 1.5 hrs of Group 1 CPD (or 1.5 CPD credits) suitable for inclusion in an individual pharmacist’s CPD plan which can be converted to 1.5 hrs of Group 2 CPD (or 3.0 CPD credits) upon successful completion of relevant assessment activities.

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CONTENTS

AFTER HOURS 60 SPLENDOUR IN THE GRASS BUSINESS 5 PROFESSIONAL SERVICES APPOINTMENTS A BOON FOR PHARMACY REVENUE 20 FACTORS TO CONSIDER WHEN TRANSFORMING YOUR PHARMACY INTO A HEALTH HUB 28 NEGOTIATING YOUR NEXT LEASE

SEAN TUNNY Editor, Gold Cross Products & Services Pty Ltd

TRUST, SERVICE AND ADVICE! Recently, I had the opportunity to attend the parent teacher interview for my daughter, as my wife had done for my son the previous week. “Dad, we will be seeing Mrs Wright, Mrs Brown and Mr Jessop and they teach me in the following subjects” she outlined. Prior to the interviews I was given a tour of the school and an outline of the type of questions that we could possibly talk to the teacher about. As invariably occurs, each teacher advised that Breanna had outlined clearly what she would like to pursue in life. It was interesting that each teacher outlined that the two career paths identified for many school leavers were health and technology. During APP, I spoke to a number of people about our profession. The industry as we know is made up of many parts, the sum of many of my discussions was that although there was movement around and infrequently away from the industry, it is a profession that has an excellent community acceptance and for the most part, a terrific environment. It is the pillars of trust, service and advice that underpins so much of what the profession represents. As June officially signals the start of Winter and Queensland about to go one up in the State of Origin, it is the favourite time of year for many. Ski trips, rugging up, warm soups, open fires and a weekend sleep-in are just some of the highlights. Not everyone complains about the cold it seems. The temperatures are already sliding in many states while our national capital is expecting temperatures close to zero this week. This edition from front cover to back is full of exciting features, reviews and editorial. Our gatefold cover is for stretch marks with a CPD on the topic as part of the feature. In addition, CPD features on UTIs and Health Solution destinations along with our regular features complete the edition. Thank you to all the contributors, partners and supporters of ITK. Best of health. Sean Tunny Editor - ITK Publications

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31 NEXT LEVEL AUTOMATION 38 HOW PHARMACY ALLIANCE IS HELPING MEMBERS COMBAT PBS REFORMS

44 NAPSA PROUDLY SUPPORTING LIVIN FOR CHARITY CUP 2017 48 MANAGING IN A PARTNERSHIP 50 NEW GROWTH AVENUES: NON-CORE CATEGORIES KEY TO DRIVING POSITIVE PHARMACY PERFORMANCE HEALTH 18 IS BAD ORAL HYGIENE MAKING YOU SICK? 26 INCONTINENCE: NO LAUGHING MATTER 40 URINARY TRACT INFECTIONS IN WOMEN 42 GESTATIONAL DIABETES 46 THE BLOOD TYPE YOU DIDN'T KNOW YOU HAD 52 THE MS GONG RIDE IS THE MOST EPIC, SCENIC, ONE-DAY RIDE YOU WILL DO IN 2017!

NEWS 3 THE CHANGING ENVIRONMENT FOR MEDICINES CONTAINING CODEINE PRODUCT INSIGHT 51 EXPEDITE AND IMPROVE YOUR ORAL SUSPENSION COMPOUNDING PROCESS 53 SKINB5 - NATURAL ACNE TREATMENT: TREATING ACNE WITH A NUTRITIONAL APPROACH REGULARS 54 60 SECONDS WITH ...

56 INDUSTRY NEWS AND UPDATES 59 PRODUCT SPOTLIGHT 61 HEALTH CALENDAR 62 BUSINESS DIRECTORY CONTINUING PROFESSIONAL DEVELOPMENT 7 URINARY TRACT INFECTIONS (UTIs) — SYMPTOMS, MANAGEMENT, TREATMENT AND PREVENTION 22 INSULIN NEEDLES AND SUBCUTANEOUS INJECTION TECHNIQUE — THINGS THE PHARMACIST SHOULD KNOW 32 THE BUSINESS OF PHARMACY ... ARE YOU READY?

PLEASE USE THIS PUBLICATION TO KEEP YOUR PHARMACY IN THE KNOW EDITOR: Sean Tunny 0457 029 052 Email: sean.tunny@goldx.com.au DESIGN:

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

NEWS

The Changing Environment for Medicines Containing Codeine "It is the view of the Guild that the scheduling changes are a blunt instrument to address misuse and abuse of these medicines."

GEORGE TAMBASSIS National President of The Pharmacy Guild of Australia

THERE’S BEEN A LOT OF MEDIA LATELY ON PAIN RELIEF MEDICINES CONTAINING CODEINE, THEIR ABUSE AND DANGERS, AND THEIR FUTURE PLACE IN HEALTH CARE IN AUSTRALIA.

I want to take this opportunity to just recap where we have been with this issue and discuss where we are heading. After a full process of submissions and public responses to a committee of the Therapeutic Goods Administration, a final decision was announced in December last year to make all medicines containing codeine Schedule 4 — prescription only — with the implementation date on 1 February 2018. It is the view of the Guild that the scheduling changes are a blunt instrument to address misuse and abuse of these medicines. We fear it will not only be ineffective at addressing concerns of abuse, but could also have unintended consequences: •

For the large majority of people who use these products safely and effectively, rescheduling will make pain relief medicines more expensive and more difficult to obtain.

•

Rescheduling codeine will result in substantial costs to the Medicare Benefits Schedule (MBS) through an increase in medical practitioner visits. There will be an increase in the workload of medical practitioners and increased waiting times for patients, especially as many medical practices have limited capacity to accept new patients. Patients who reside in regional, rural and remote areas would be most impacted, given the time and cost to visit a medical practitioner is substantially greater compared to metropolitan areas.

•

The decision will have cost implications for the Pharmaceutical Benefits Scheme (PBS), particularly if medical practitioners elect to prescribe consumers higher strength

codeine products or other opioids listed on the PBS. •

For patients who do not have ready or affordable access to a medical practitioner, their pain management may go untreated and/or lead to an increase of presentations at hospitals.

The Guild believes there are more costeffective and reliable methods of identifying consumers who are at risk of codeine dependence, without restricting access to the majority of Australians who use these products appropriately. The Guild developed and implemented a national real-time monitoring system called MedsASSIST for the sale of codeine products in community pharmacies in March 2016. As many pharmacy staff will know, MedsASSIST provides a clinical decision support tool to assist pharmacists in identifying patients at risk of codeine dependence, as well as facilitating access to education materials and appropriate referrals when required. The Guild has always argued that the implementation of MedsASSIST in community pharmacy would be more effective, targeted and economical to assist in identifying atrisk consumers and enabling them to access appropriate support. Currently around 70 per cent of community pharmacies are using MedsASSIST (voluntarily) and over 6 million transactions have been recorded to date. We were very pleased recently to see the Federal Minister for Health, Greg Hunt, express strong public support for the continuation of MedsASSIST as a valuable clinical aid in combating codeine abuse. The Guild called for a practical, multipronged approach involving the introduction of a mandatory real-time monitoring for

codeine, complemented with additional measures such as mandatory warning labels advising consumers of the potential for dependence from prolonged use of these products and reduced pack sizes for these products to a maximum of three days’ supply. While the Guild argues that the decision to up-schedule has a number of flaws, it accepts the decision and will instead work with regulatory authorities at the Federal, State and Territory levels to identify solutions that will maintain access to these medicines for acute, short-term pain, with appropriate safeguards and clinical protocols. You may be aware that in countries like New Zealand, scheduling regimes allow for certain prescription medicines to be supplied through the community pharmacy without the need for the patient to first obtain a prescription from their GP. Protocols are put in place governing the direct supply of these medicines through the community pharmacy. These protocols set the circumstances in which the supply can occur without a prescription. In New Zealand, these are commonly described as ‘prescription except when’ medicines. The Guild believes this approach has merit in addressing the codeine issue. A pre-requisite would be to require a pharmacy to use a real-time monitoring system such as MedsASSIST. Direct supply from pharmacies may be restricted to patients who are seeking these medicines for acute, rather than chronic pain. Our approach will maintain access for safe short-term use while making it easier to identify and help people who have problems with these medicines. I look forward to reporting progress on this proposal.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

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BUSINESS

Professional Services Appointments a Boon for Pharmacy Revenue

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KLAUS BARTOSCH Group Co-Founder and Chief Executive Officer 1st Group Ltd

AN INCREASING NUMBER OF PHARMACIES ARE UTILISING PROFESSIONAL SERVICES, SUCH AS INFLUENZA VACCINATION APPOINTMENTS, TO ATTRACT NEW CUSTOMERS AND INCREASE PHARMACY REVENUE.

Many pharmacies are finding that to provide and support this opportunity, an efficient online booking platform is vital. Taking bookings online allows for greater professional services revenue to be achieved, while minimising and even reducing the administrative burden on existing staff as fewer phone calls are required for basic booking and rescheduling functions. Customers are increasingly making decisions about whom they utilise for services, based on their ability to accept online appointments. The easier it is for a customer to engage with your business, at any time of day or night, the more likely you will gain their business. In 2016, over 55% of all appointments were booked online, outside of business hours and without needing to make a phone call. If your pharmacy doesn’t take bookings online, can you expect to make the most out of your professional services offerings?

IS YOUR PHARMACY READY FOR ONLINE BOOKINGS? Community pharmacies play a significant role in primary health care in Australia, while continuing to look for ways to innovate and develop improved, cost-effective health outcomes for their customers. Professional services provided, such as the influenza vaccination service, are one example of this. At 1st Group we provide community pharmacies with an automated appointment booking platform which allows for greater automation, fewer phone calls for your administrative staff, increased booking numbers and happy customers. So, how can we help your pharmacy and why is the capability to take online appointments a critical part of the solution? •

When booking online, customers are able to secure an appointment at their leisure, at any time, from any internet

connected device (phone, tablet, laptop, PC, etc.!). •

24/7 online booking capabilities can increase business to your practice due to additional appointment bookings occurring out of hours.

•

The 1st Group’s online appointment booking system centrally collects data, such as appointment times and booking demographics, which translate into actionable insights to help grow your business.

•

The 1st Group’s online appointment booking system allows you to check your appointments and availability, using any device.

•

Customer cancellations are automatically updated, allowing another customer to take up the appointment slot.

•

Optional add-on modules can turbocharge your customer engagement, including bringing customers back for their regular periodic appointments cost effectively, easily and quickly.

Powered by GObookings, our online pharmacy appointment booking platform gives your pharmacy online booking functionality without the need for expensive servers or infrastructure, while providing an easy-to-use solution, allowing for better management of one-on-one appointments, 24/7. The booking interface is highly customisable and configurable to meet your specific business needs. Our eCommerce platform enables your pharmacy to take preservice payments. We take our customers’ privacy seriously. Data is collected in a secure system which is extensively used by government and corporate organisations. Also, our powerful business intelligence reporting platform provides you with invaluable insights into your data.

We offer the ability to integrate this data with other systems such as existing pharmacy applications, loyalty programs, Medicare and the Australian Immunisation Register. We understand that if a pharmacist or other qualified health practitioner is providing a vaccination service, there is a responsibility to ensure that certain actions are taken to record, share and retain information relating to the vaccination. Our technology makes these processes easier.

HEALTH SERVICES PLATFORM TO CONNECT WITH NEW CUSTOMERS Through 1st Group’s consumer healthcare platform, www.myhealth1st.com.au, we help Australians book their healthcare appointments online with doctors, dentists, physiotherapists, specialists, natural therapists, optometrists and other services. With such a large scale of appointments, we are able to use big data to analyse demographics and predict patient behaviour. Imagine the impact that using this data to direct patients making a healthcare appointment to your store would have on your bottom line. With approximately 62% of all patients across Australia going to a pharmacy after their appointment with a general practitioner*, access to patients at this state of need will give your business the opportunity to acquire new local patients. So the next time a patient in your area is seeking to make a healthcare booking, wouldn’t you like your pharmacy to be the first available? Learn more about how 1st Group can help your pharmacy today at www.1stgrp.com/ pharmacy REFERENCE: * Britt, H. (n.d.). General practice activity in Australia 2014-15. 1st ed.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

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CONTINUING PROFESSIONAL DEVELOPMENT 7 7

Urinary Tract Infections (UTIs) Symptoms, Management, Treatment and Prevention HIDY CHAN Professional Practice Pharmacist — Pharmacy Needle and Syringe Program Pharmacy Guild of Australia (QLD) B.Pharm(Hons), PhD, GCertResComm, AACPA

Learning Objectives: After reading this article, the learner should be able to: 1. Recognise some causes and contributing factors of a urinary tract infection (UTI). 2. Recognise the differences between an uncomplicated, complicated and recurrent UTI. 3. Describe the common symptoms associated with a UTI. 4. Recognise the empirical treatment of an uncomplicated UTI. 5. Describe some measures to help prevent a UTI.

National Competency Standards: 6.1, 6.2, 7.2 Accreditation number: G2016023 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.

URINARY TRACT INFECTION (UTI) REFERS TO A BACTERIAL INFECTION OF THE URINARY SYSTEM. A UTI IS ONE OF THE MOST COMMON REASONS FOR PATIENTS TO SEEK HEALTHCARE, AND FOR THE PRESCRIPTION AND USE OF ANTIBIOTICS1. PHARMACISTS ARE WELL-PLACED TO PROVIDE EDUCATION, APPROPRIATE REFERRAL AND ADVICE REGARDING THIS COMMON CONDITION.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

A urinary tract infection (UTI) is a bacterial infection of the urinary system, which consists of the bladder, urethra, ureters (urine tubes) and kidneys1-3. The urinary system can be separated into two sections: the lower urinary tract (urethra and bladder) and upper urinary tract (ureters and kidneys). Different names are assigned to the infection depending on the part(s) of the urinary system affected4. An infection of the urethra called urethritis. An infection of the lower urinary tract with the involvement of the bladder is called cystitis. An infection of the ureters is known as ureteritis while an infection of the bladder is called pyelonephritis1,5.

UTIs can be broadly classified into three categories: uncomplicated, complicated and recurrent. Treatment and management options differ for the different categories of UTIs1. UTI

Characteristics • No structural or functional abnormality of the genitourinary tract1,3,8

Uncomplicated

• No recent UTI treatment1,8 • Patient is not pregnant or elderly5,8 • Presence of structural or functional abnormality of the genitourinary tract1

Complicated

Recurrent

• Presence of comorbidities (e.g. diabetes, kidney stones, enlarged prostate, neurogenic bladder) that may affect immunological response or success of treatment1 • ≥ two UTIs within six months, or 1 • ≥ three UTIs within one year

CAUSES A range of pathogens commonly cause UTIs – most of these usually reside in the gastrointestinal tract (GIT)6. The unintentional transfer of the bacteria from the GIT to the urinary tract (usually via the urethra) can result in a UTI1,3,7. Escherichia coli (E.coli) accounts for up to 95% of all UTIs1. Other pathogens such as Staphylococcus saprophyticus, Proteus mirabilis, Staphyloccus epidermis and Klebsiella pneumonia are also common causes of UTIs1-4. Numerous factors may increase an individuals’ susceptibility to a UTI infection or re-infection. UTIs occur more commonly in women than men4. This can be attributed to women having a straight and shorter urethra which is closer to the anus, thus allowing the bacteria easier access to the bladder6. Other factors include: •

A compromised immune system (e.g. HIV/AIDS)1,6;

• Diabetes1,3; •

Urinary stone disease3,6;

•

Some connective tissue disease3;

•

Abnormity of the urinary tract (e.g. vesico-ureteral reflux)1,7;

•

Bladder outlet obstruction (e.g. urethral stricture disease, prostatic enlargement)3,7;

•

Hypo-oestrogen states (e.g. atrophic vaginitis, menopause in women)1,3,7;

•

Inflammation of the prostate (e.g. prostatitis, prostatic enlargement in men)1,3,6 ;

•

The use of an indwelling urinary catheter3,6,7;

• Incontinence7; • Constipation; •

Sexual activity (including anal sex);

•

The use of condoms or diaphragms containing spermicide6;

•

The use of anticholinergic medications7.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

CONTINUING PROFESSIONAL DEVELOPMENT

SYMPTOMS The symptoms of a UTI can vary depending on where the infection occurs4. Common symptoms of a lower UTI may include dysuria, urgency, frequency, turbid or malodourous urine, non-specific back pain, suprapubic discomfort and general malaise1,7. Symptoms of an upper UTI are fever, nausea and/or vomiting, diarrhoea, loin pain and confusion1,7. Older people may also present with delirium, confusion, falls, immobility and anorexia7.

DIAGNOSIS The diagnosis of a bacterial UTI is based on the presence of symptoms and results of a urine sample and physical examination1,5. From the urine sample (bacteriuria), microscopy, culture and sensitivity will confirm diagnosis and severity of the UTI and guide antibiotic treatment5. It may also help identify patients with a complicated UTI or those with risk factors who may require prolonged or specific treatment3,4. A midstream urine sample is recommended to ensure that the flora around the urethra, vagina, anus, groin area and hands do not contaminate the sample1,5. A urine sample is highly recommended for the below groups of patients even if the symptoms presented appear characteristic of a uncomplicated UTI1:

A urine test is also warranted for those with recurrent UTIs, previous UTI treatment failures, abnormalities of the urinary tract (e.g. vesico-ureteral reflux), any underlying comorbidities that may negatively affect the condition and treatment, and those who have travelled internationally within the past six months1,5. A physical examination will include checking of vital signs and abdominal and flank examination. External genital and rectal examinations may prove useful to identify atrophic vaginitis in females, phimosis or meatal stenosis and the state of the prostate in men (e.g. prostatitis, enlarged prostate)1.

TREATMENT Most symptomatic UTIs require the empirical treatment of antibiotics1,3. The distinction between complicated and uncomplicated UTI is important in determining appropriate pharmacotherapy. Factors such as antimicrobial resistance and previous treatment failure must be considered to ensure the judicious and effective use of antibiotics1. It is also worthwhile to consider alternative diagnoses such as sexually transmitted diseases and non-infective causes5. The Australian Society for Infectious Disease does not recommend antibiotic therapy for asymptomatic bacteriuria UTIs2,5.

A urine test is advised for

Reason

Male patients

• It is common for males presenting with UTI symptoms to have an abnormality of the urinary tract, or infection of the urethra, prostate or epididymis1. Proper diagnosis and treatment is necessary. • Pregnant women are at risk of developing pyelonephritis even with asymptomatic bacteriuria1. Proper diagnosis and treatment is important to minimise adverse effects on the pregnancy1.

Pregnant women

• Not all antibiotics are safe to be used in pregnancy – a urine test will help guide treatment appropriate for pregnancy1.

Residents in aged care facilities

Young children or babies

• Diagnosis of UTIs in residents of aged care facilities can be difficult. Genitourinary symptoms are often absent and patients may be unable to communicate symptoms5. • Asymptomatic bacteriuria is common in elderly patients5. • Investigation and treatment of turbid or malodourous urine in residents of aged care facilities without UTI symptoms is not recommended5,7. • It is often difficult to distinguish between an upper (e.g. pyelonephritis) or lower (e.g. cystitis) UTI in babies and young children1. Proper diagnosis is vital to assess the nature and severity of the illness1. • Recurrent UTIs in babies and small children may be due to abnormality of the urinary tract1.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

"The diagnosis of a bacterial UTI is based on the presence of symptoms and results of a urine sample and physical examination."

"UTIs are one of the most common reasons for patients to seek healthcare in a community setting, and for the prescription and use of antibiotics."

UNCOMPLICATED UTI The duration of antibiotic treatment differs between female and male patients. A 3-5 day course for women is generally associated with good clinical outcomes while treatment for males is usually longer in duration1. The below lists some commonly used antibiotics and their recommended dose and duration of treatment for an uncomplicated UTI5: Antibiotic & dose

Sex of patient

Duration of treatment

Trimethoprim 300mg orally

Female

Once daily for 3 days

Male

Once daily for 7 days

Female

Twice daily for 5 days

Male

Twice daily for 7 days

Female

Twice daily for 5 days

Male

Twice daily for 7 days

Female

Twice daily for 5 days

Male

Twice daily for 7 days

Cephalexin 500mg orally

Amoxycillin 500mg* + clavulanic acid 125mg orally

Nitrofurantoin 100mg orally

* Amoxycillin (without clavulanic acid) is only recommended if the pathogen has been proven to be susceptible1.

Other antibiotics may be used to treat an uncomplicated UTI. The use of nitrofurantoin may be suitable if the pathogen is resistance to treatment. Caution should be exercised with the longer courses and long-term use due to peripheral neuropathy, particularly in elderly patients, or those with renal impairment1,3,5. Fluroquinoloes (norfloxacin and ciprofloxacin) are generally reserved for use in patients with proven pathogen susceptibility due to concern with resistance. Fluroquinolones are the only orally active drugs against Pseudomonas aeruginosa and other multidrug-resistant bacteria5. There is debate regarding the delayed prescribing of antibiotic and symptomatic management of UTIs as ways to reduce antibiotic use1. Delayed prescribing refers to the prescription of the antibiotic with instructions to use if symptoms worsen or do not resolve (e.g. in approximately 48 hours)1. The risk with delayed prescribing may subject the patient to suffer the symptoms of the UTI for longer 1. The symptomatic management of UTIs involves the use of anti-inflammatory medications (e.g. ibuprofen) instead of antibotics1,9,10. Further research is needed to confirm the clinical effectiveness of this approach1,9,10.

COMPLICATED UTI The management of a complicated UTI aims to manage the genitourinary abnormality and provide supportive care when needed. It is not uncommon for hospitalisation to be required1. The duration of antimicrobial therapy is longer than that of an uncomplicated UTI and may require at least 10-14 days of treatment guided by microbiological results3. It is advisable to perform a urine sample 1-2 weeks post treatment to confirm the eradication of the infection1. Severe complications (urosepsis, renal scarring, end-stage disease) are more likely to occur with complicated UTIs1. Further investigation is warranted for patients with known or suspected kidney stone disease, pyelonephritis, prostatitis or neurogenic bladder to exclude genitourinary tract structural or functional abnormalities or obstruction3. Complicated UTIs associated with urinary tract obstruction (e.g. pyelonephritis, urine stones) are medical emergencies and urgent hospital admission is warranted3.

ANTIBIOTIC RESISTANCE Antibiotic resistance is a major barrier and threat to effective use of antibiotics to treat

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

UTIs. There is worldwide emergence of multidrug resistant E.coli5. Resistance patterns vary for different pathogens and geographical regions1. Local resistance patterns and treatment guidelines should be considered when choosing an antibiotic to treat a UTI1. It is necessary and prudent to regularly review the clinical need to continue, revise or stop the empiric antibiotic treatment based on the patient’s response and available microbiological data1,5. Improper or incorrect use of antibiotics may result in treatment failure, encourage antibiotic resistance, and the need for longer and additional courses of treatment1. Patients should be advised to take the antibiotics only as directed, with a clear understanding of the duration of therapy1. The judicious use of antibiotics will help minimise antibiotic resistance in the community and reduce adverse drug events and incidence of Clostridium difficile infections1,5.

PREVENTION There are ways to prevent UTIs through the use of preventive antibiotics and lifestyle measures. Preventive antibiotics are indicated for individuals with no underlying disease state or abnormalities of the genitourinary tract. These are intended to prevent UTI and are usually taken periodically (when required) or over a longer time period (e.g. three to six month periods)1. Lifestyle measures include6: •

Avoiding deodorants, soap or talcum powder around the genital area: use plain, unperfumed varieties1,6;

•

Have showers instead of baths1,6;

•

Wearing cotton undergarments2,6;

•

Stay hydrated1,6;

•

Avoiding constipation1;

•

Going to the toilet as soon as the need arises and to empty the bladder fully1,6;

•

Empty the bladder immediately after sexual intercourse1,6;

•

Wipe from front to back after urinating1,2;

•

Do not use contraceptive diaphragms or condoms with spermicidal lubricants: use other methods of contraceptive instead2,6.

BUSINESS 11 11 CONTINUING PROFESSIONAL DEVELOPMENT

ASSESSMENT QUESTIONS The assessment questions below can be found at the Guild Pharmacy Academy myCPD e-learning platform. Login or register at: www.mycpd.org.au Evidence is lacking to support the theory that the consumption of cranberry juice is an effective a way to prevent UTIs6,11. The active ingredient, tannin, exhibited only a small potential benefit in reducing the vaginal colonisation of E.coli11. Such benefit was only demonstrated in people taking high doses of cranberry products1. There is evidence to suggest the methenamine hippurate (hexamine hippurate) may be useful to prevent recurrent UTIs1,11,12. In the acidic environment of the bladder, methenamine is converted to ammonia and formaldehyde which alters the chemical composition of urine (makes it “less favourable/attractive” for the bacteria1) and exhibits nonspecific antibacterial activity by denaturing bacterial proteins and nucleic acid11,12. The use of methenamine is not suitable for the prevention of UTIs outside the bladder 12. UTIs can be associated with hypo-

oestrogen states. Oestrogen helps to encourage the proliferation of Lactobacillus in the vaginal epithelium and reduces the pH to minimise the colonisation of uropathogens and bacteriuria11. In some postmenopausal women, the use of intravaginal oestrogen therapies (e.g. pessaries and creams) may help restore vaginal flora and pH, and reduce the incidence and symptoms of UTIs1. It is unclear regarding the type of oestrogens to be used, and the recommended length of therapy, in relation to reducing UTI recurrence1. UTIs are one of the most common reasons for patients to seek healthcare in a community setting, and for the prescription and use of antibiotics1. The management of most UTIs is generally empirical and relatively simple and an array of preventive measures can be adopted to prevent reinfection.

REFERENCES NPS MedicineWise. Conditions: Urinary tract infections [Internet]. Sydney: National Prescribing Service; 2014 [cited 26/04/2017] Available from: http://www.nps.org.au/conditions/urine-bladder-and-kidney-problems/ bladder-disorders/urinary-tract-infections. 2 Health Direct. Urinary tract infection (UTI) [Internet]. Canberra: Department of Health; 2016 [cited 16/12/2016]. Available from: https://www.healthdirect.gov.au/urinary-tract-infection-uti. 3 Jarvis T, Chan L, Gottlieb T. Assessment and management of lower urinary tract infection in adults. Aust Prescr. 2014;37:7-9. 4 What is a urinary tract infection [Internet]. Melbourne: Kidney Health Australia; 2016. Available from: http:// kidney.org.au/your-kidneys/detect/urinary-tract-infections/what-is-a-urinary-tract-infection. 5 eTG Complete: Antibiotic > Urinary tract infections. Melbourne: Therapeutic Guidelines Pty Ltd. ; 2016. 6 National Health Service. Urinary tract infections in adults [Internet]. London: NHS; 2016 [cited 19/12/2016]. Available from: http://www.nhs.uk/conditions/urinary-tract-infection-adults/pages/introduction.aspx. 7 The Royal Australian College of General Practitioners. Medical care of older persons in residential aged care facilities (Silver Book). Common clinical conditions - urinary tract infections. 4th ed. Melbourne: RACGP; 2006. 8 Zalmanovici Trestioreanu A, Green H, Paul M, Yaphe J, Leibovici L. Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database Syst Rev. 2010;6(10):CD007182. 9 Duane S, Beatty P, Murphy A, Vellinga A. Exploring experiences of delayed prescribing and symptomatic treatment for urinary tract infections among General Practitioners and patients in ambulatory care: a qualitiatve study. 5. 2016;3(27). 10 Bleidorn J, Gagyor I, Kochen MW, K, Hummers-Pradier E. Symptomatic treatment (ibuprofen) or antibiotics (ciprofloxacin) for uncomplicated urinary tract infection? - Results of a randomized controlled pilot trial. BMC Med. 2010;8:30. 11 Al-Badr A, Al-Shaikh G. Recurrent urinary tract infections management in women. Sultan Qaboos Uni Med J. 2013;13(3):359-67. 12 Lo T, Hammer K, Zegarra MC, WC. Methenamine: a forgotten drug for preventing recurrent urinary tract infection in a multidrug resistance era. Expert Rev Anti Infect Ther. 2014;12(2):549-54. 1

QUESTION 1 Which of the following is not a common cause or contributing factor to a urinary tract infection (UTI)? a. HIV/AIDS b. Diabetes c. Atrophic vaginitis d. Anal fissures

QUESTION 2 Which of the below patient may have a complicated UTI? a. Paul (75 years old, diabetic) complains of dysuria and difficulty in passing urine b. Jenny (28 years old, not pregnant) has had three UTIs within the last nine months c. Samantha (45 years old, not pregnant) complains of increased urinary frequency and turbid urine d. Linda (82 years old, not pregnant) complains of painless bleeding during bowel movements and irritation around the anal region

QUESTION 3 Which of the following is not a common symptom of a UTI? a. Dysuria b. Vaginal discharge and itching c. Fever d. Increased urinary frequency

QUESTION 4 Which of the following is not commonly used as treatment for an uncomplicated UTI? a. Trimethorpim 300mg daily for three days b. Cephalexin 500mg twice daily for seven days c. Roxithromycin 300mg once daily for five days d. Nitrofurantoin 100mg twice daily for seven days

QUESTION 5 Which of the following is not known to be effective for the prevention of UTIs? a. Cranberry 25,000mg capsule once daily b. Oestriol pessary 500mcg once to twice weekly

myCPD users can submit answers online at www.mycpd.org.au, click on the ‘LOG INTO MYCPD’ button to access your account. Once you have logged in from the ‘myHome’ tab click on the blue ‘Journal Assessments’ button located at the bottom right hand side of the screen.

c. Methenamine hippurate (hexamine hippurate) 1g twice daily d. Urinating immediately after sexual intercourse

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

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PRACTICE READY

Update for Pharmacists AARON D'SOUZA Pharmacist B.Pharm

THIS UPDATE PROVIDES INTRODUCTORY AND PRACTICE INFORMATION FOR PHARMACISTS. FOR IN-DEPTH INFORMATION PLEASE CONSULT THE PRODUCT INFORMATION. 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. 'Practice Ready' aims to consolidate pharmacy information into a valuable, easy to ready article for the busy pharmacist. If there are therapy groups, medications or devices you'd like to see covered, please feel free to contact ITK.

SNAPSHOT

Medical Cannabinoids

Historically, cannabis has played a medical, therapeutic role where pharmacists were involved in supply through compounding. Since the 1960s, however, its place in therapy has been undocumented and alternate — a result of regulation and criminalisation world-wide. Recently, there have been strong movements to re-introduce cannabinoids as a clinical option for conditions including1: •

Chronic and acute pain;

• Glaucoma;

•

Nausea and vomiting associated with cancer;

•

Appetite stimulation in patients with HIV/AIDS;

• Epilepsy;

•

Muscle cramps and nerve pain associated with Multiple Sclerosis and Parkinson’s Disease;

•

Cannabis withdrawal; Inflammatory Bowel Disease.

Medical Cannabinoids represent a very real therapeutic opportunity and further research is helping to establish the benefits and drawbacks. Recent legislation changes, both federally and at state levels, show that community, medical and governmental support is growing. For pharmacists, it is critical to recognise the professional, legislative and counselling requirements. Alongside this, the profession has an obligation to the public in ensuring that the medical use of cannabinoids is clearly distinguished from the illicit use of cannabis.

PHARMACOLOGY Before exploring the pharmacological and endogenous agents, let’s establish the functions of the Endocannabinoid System (ECS). The ECS is a ligand-receptor system. It functions as part of the central nervous system and peripherally in the immune system, amongst others. Whilst the full physiological and pharmacological effects have not yet been established, it is currently believed that the ECS is involved in neuronal, inflammatory and memory pathways.

Watch: Visualisation of the ECS: https://youtu.be/jznQfMj9RWM

The ECS is mediated by the Cannabinoid 1 and 2 (CB1 and CB2) receptors which are part of the super family of G-protein couple receptors2. Table 1 shows the human distribution of the receptors3: Table 1: Distribution of cannabinoid receptors RECEPTOR

CNS

PERIPHERY

CB1

Brainstem, cortex, nucleus accumbens, hypothalamus, cerebellum, hippocampus, amygdala, spinal cord

Immune system, liver, bone marrow, pancreas, longs, vascular system, muscles, gastrointestinal system, reproductive organs

CB2

Brainstem, glial cells

Immune system, liver, bone marrow, pancreas, spleen, bones, skin

Broadly speaking, there are three types of ligands for the cannabinoid receptors1: 1. 2. 3.

Endogenous cannabinoids Phytocannabinoids Synthetic cannabinoids

1. ENDOGENOUS CANNABINOIDS Endogenous cannabinoids (endocannabinoids) such as arachidonoylethanolamide (anandamide (AEA)) and 2-arachidonoylglycerol (2-AG) are naturally produced ligands4.Whilst these are the two most studied endocannabinoids, others include virodhamine, noladin ether, palmitoylethanolamide (PEA), N-arachidonoyl dopamine (NADA), N-arachidonylglycine (NAGly), oleamide and oleoylethanolamine (OEA)1,3.The immediate result of receptor activation is the inhibition of adenylate cyclase via interactions at the G-protein complex. After this common step, there is a complex effect divergence in the downstream effects depending on the receptor’s location. GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

PRACTICE READY 2. PHYTOCANNABINOIDS Plant forms of cannabinoids are generally recognisable and familiar to most people. The three varieties are: 1. 2. 3.

CANNABIS SATIVA CANNABIS INDICA CANNABIS RUDERALIS

The stavia variety is the most commonly grown and has high levels of the ∆-9-tetrahydrocannabinol. Known as THC, the compound has strong psychoactive properties; in fact, it is the main psychotropic constituent of Cannabis stavia5.It is a partial agonist at CB1 and CB2 receptors. Its isomer, ∆-8-tetrahydrocannabinol and their derivative cannabinol (CBN) have a higher ligand-receptor affinity6. Cannabidiol (CBD) is another major constituent of Cannabis stavia which is non-psychoactive. Cannabis indica has been grown for centuries as a building and shipping material and research shows has a higher level of CBD compared with more psychoactive agents6.

3. SYNTHETIC CANNABINOIDS These are pharmaceutical preparations of cannabinoids used for research purposes and now are used clinically. The key molecules include Dronabinol, Nabilone and Nabiximols. See below. It is interesting to note that THC can also act as an antagonist at the CB2 receptor. This strengthens the thought that the roles of the CB1 and CB2 receptors, the complex downstream effects and the actions of the different ligands are yet to be fully established. Alongside this, there is variation in the active yield from plants and extracts. This makes production of therapeutic products such as oils, resins and leaf difficult to prescribe as a unit dose.

THERAPEUTIC CANNABINOIDS The following table summarises the active agents and their therapeutic options1,6–10. ACTIVE

KEY POINTS

PRODUCT

FORM/SOURCE

INDICATIONS

THC: ∆-9tetrahydrocannabinol

— Main psychotropic constituent of Cannabis stavia

—

Cannabis plant (e.g. smoked, resin, oil)

— Various

— Appetite stimulation (AIDS related anorexia)

— Recreational psychotropic

— Partial agonist at CB1 and CB2 Dronabinol [Synthetic THC: ∆-9— tetrahydrocannabinol]

— Unregistered in Australia

Marinol

Oral capsules

2.5mg–10mg

— Synthetic

Mx: Abbvie

Active is dissolved in sesame oil

Schedule 8 Nabilone [Synthetic derivative of THC] Nabiximols [THC (extracted) and CBD]

Oral capsules

— Chemotherapy induced nausea/vomiting

Oral spray

“Symptom improvement in patients with moderate to severe spasticity due to multiple sclerosis (MS) who have not responded adequately to other anti-spasticity medication and who demonstrate clinically significant improvement in spasticity related symptoms during an initial trial of therapy.”

—

Schedule 4 in products containing no more than 2% of other cannabinoids

—

— Unregistered in Australia

Cesamet 1mg

— Synthetic

Schedule 8

— Registered in Australia

Sativex

— Plant extracts

Mx: Emerge Health

Mx: MEDA Pharma

80mg/mL Schedule 8

Cannabidiol (CBD)

— Non-psychoactive

— Chemotherapy induced nausea/vomiting

— Plant extracts Cannabinol (CBN)

— Derivative of THC — Plan extract

AUSTRALIAN REGULATION AND AVAILABILITY Availability of cannabinoids for therapeutic use raises legal and regulatory questions, as well as community concern. Different states in Australia have varying laws on the possession, production (personally and commercially) and use of cannabinoids. Whilst policy is changing, there are still restrictions on who can prescribe, as well as on the product availability. In October 2016, federal legislation was enacted allowing legal cultivation, production and manufacturing of medicinal cannabis. This comes under the administration of the Office of Drug Control. The purpose of the legislation is to make medicinal cannabis available to specific patients11. The TGA has provided a pathway to access including: Step 1: Doctor has consultation with patient Step 2A:

TGA access schemes (i.e. SAS B Form)

Step 2B:

Check State/Territory requirements

Step 3A:

Stock available › Discuss with Pharmacist to supply

Step 3B:

Stock to be imported › Discuss with pharmacist for import from licence holder

https://www.tga.gov.au/sites/default/files/access-medicinal-cannabis-products-steps-using-access-schemes.pdf GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

PRACTICE READY PRESCRIBING AND ACCESS Whilst the legislative framework has been amended to improve access to medical cannabinoids, there are barriers to availability and prescribing. Across the country, each state is reviewing and trialling systems for access12,13. The following table provides a brief state-by-state breakdown; however, it is recommended to visit your state’s health department website. For up-to-date information please follow the links listed here: https://www.odc.gov.au/related-links

STATE

ACCESS

CONSIDERATIONS

QUEENSLAND

1) Specialist doctors prescribing specific products to patients with a particular condition 2) GP/Specialist approved to prescribe to a specific patient Clinical trials 3) Clinical trials https://www.health.qld.gov.au/public-health/ topics/medicinal-cannabis/products

•

TGA SAS – Category B applies

•

Medical practitioner requires approval from Qld Health to prescribe

•

Pharmacist can supply once TGA SAS Cat B form application is approved

Medicinal Cannabis Compassionate Use Scheme for Adults with a terminal illness

•• Scheme only allows patients to

NSW

possess specific amounts of cannabis plant forms

https://www.medicinalcannabis.nsw.gov.au/ regulation/medicinal-cannabis-compassionate-use-scheme ACT

Authority required from ACT Health for doctor to prescribe as Schedule 8 for each patient

•

TGA SAS – Category B applies

•

Pharmacist can supply once TGA SAS Cat B form application is approved

Access to Medicinal Cannabis Act 2016 which is administered by the Office of Medicinal Cannabis (Department of Health and Human Services VIC)

•

Medical practitioners may help patients apply for the scheme

Currently, access is to children with severe intractable epilepsy. A review may see this expanded to other patients in the future.

•

TGA SAS – Category B applies

•

Pharmacist can supply once TGA SAS Cat B form application is approved

Controlled Access Scheme

•

TGA SAS – Category B applies

Aims to help patients access unregistered medicinal cannabis via prescription from their treating medical specialist

•

Pharmacist can supply once TGA SAS Cat B form application is approved

•

Specifications on conditions which can be prescribed for

3) Approval from Commonwealth and SA Health

•

TGA SAS – Category B applies

4) Prescription and procurement/dispensing process at Pharmacy

•

Pharmacist can supply once TGA SAS Cat B form application is approved

•

Specifications on conditions which can be prescribed for

•

TGA SAS – Category B applies

•

Pharmacist can supply once TGA SAS Cat B form application is approved

http://www.health.act.gov.au/public-information/businesses/ pharmaceutical-services/medicinal-cannabis VICTORIA

https://www2.health.vic.gov.au/public- health/drugs-and-poisons/ medicinal-cannabis TASMANIA

https://www.dhhs.tas.gov.au/__data/assets/pdf_file/0012/217110/ Medical_Cannabis_Fact_Sheet.pdf SA

1) Clinical Decision: Medical practitioners can prescribe Schedule 8 2) Select suitable medicine

http://www.sahealth.sa.gov.au/wps/wcm/connect/33c73d8040db6c61a 409a73ee9bece4b/Pathway-overview%281%29.pdf?MOD=AJPERES& CACHEID=33c73d8040db6c61a409a73ee9bece4b WA

Available via prescription from a specialist doctor Restricted medical conditions only http://healthywa.wa.gov.au/~/media/Files/HealthyWA/Original/ Factsheets/medicinal-cannabis-fact-sheet.ashx

No current scheme

ADVERSE EFFECTS Evidence shows that short-term exposure to THC has the following effects14: •

Impaired short-term memory, making it difficult to learn and to retain information;

•

Impaired motor coordination, interfering with driving skills and increasing the risk of injuries;

•

Altered judgement, increasing the risk of sexual behaviours that facilitate the transmission of sexually transmitted diseases;

•

In high doses, paranoia and psychosis.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

PRACTICE READY

In comparison to Sativex (Nabiximols – THC + CBD) which is listed in Australia: •

Mild to moderate dizziness (common);

•

Fainting;

•

Disorientation;

•

“Approximately 10% more patients given Sativex experienced a psychiatric adverse event than those given placebo (17.6% vs 7.8%)15.”

Due to the unknown reactions for many patients, a trial period for the medicine is commonly employed. Refer to specific Product PI’s. Please note that due to the imported nature of the products, PI’s and CMI’s may not be in a familiar format. Pharmacists are advised to prepare counselling appropriately. Adverse effects are dose-dependent, making it difficult when using plant and by-product preparations. Patients should ensure they have a trialled, titrated dose in consultation with their medical prescriber.

SUMMARY Medicinal cannabinoid therapy is a novel field in Australia. Community support is growing and governmental change is cautious, progressive and steady. Understanding the action of THC on CB1 and CB2 receptors in the body is important; however, due to the complex physiology of cannabinoids and their unknown overall effects, therapy is unclear, despite the growing availability of products. Recent legislative change federally and in certain states means pharmacists must be aware of the patient-access-pathways. Prescribers are limited to state laws and pharmacists should be aware of their local laws. The pharmacist’s role in the procurement of products is critical. The TGA has provided a step-by-step guide for prescribers, patients and pharmacists. Medicinal cannabinoids represent a very real therapeutic opportunity for patients who have exhausted current options. The range of conditions which can be improved with medicinal cannabinoids is broad and an appreciation of the therapeutic areas which can be treated and why is important.

REFERENCES: The Use of Cannabis for Medical Purposes [Internet]. [cited 2017 Apr 23]. Available from: https://ncpic.org.au/media/1931/the-use-of-cannabis-for-medical-purposes.pdf

Pertwee RG. The diverse CB1 and CB2 receptor pharmacology of three plant cannabinoids: ∆ 9-tetrahydrocannabinol, cannabidiol and ∆ 9-tetrahydrocannabivarin. Br J Pharmacol. 2008 Jan 1;153(2):199–215.

Kruk-Slomka M, Dzik A, Budzynska B, Biala G. Endocannabinoid System: the Direct and Indirect Involvement in the Memory and Learning Processes—a Short Review. Mol Neurobiol. 2016 Dec 6;1–16.

MG GJ and P. The influence of cannabinoids on learning and memory processes of the dorsal striatum. - PubMed - NCBI [Internet]. [cited 2017 Apr 23]. Available from: https:// www.ncbi.nlm.nih.gov/pubmed/26092091?dopt=Abstract.

Pertwee RG. The pharmacology of cannabinoid receptors and their ligands: an overview. Int J Obes. 2006 Apr 1;30:S13–8.

Ondrej Hanuš L, Martin Meyer S, Muñoz E, Taglialatela-Scafati O, Appendino G. Phytocannabinoids: a unified critical inventory. Nat Prod Rep. 2016;33(12):1357–92.

Cannabis and Cannabinoids [Internet]. [cited 2017 Apr 24]. Available from: https://books.google.com/books/about/Cannabis_and_Cannabinoids.html?id=XfW3AAAAQBAJ

Solway Pharmaceuticals. Product information for Sativex (Nabiximols) [Internet]. [cited 2017 Apr 23]. Available from: https://www.fda.gov/ohrms/dockets/ dockets/05n0479/05N-0479-emc0004-04.pdf

Cesamet US insert_12-1352 - Cesamet_PI_50_count.pdf [Internet]. [cited 2017 Apr 24]. Available from: https://www.cesamet.com/pdf/Cesamet_PI_50_count.pdf

ARTG Listing: Sativex [Internet]. [cited 2017 Apr 24]. Available from: https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbid=ebs/PublicHTML/pdfStore.nsf&docid=F85EF3200731 EBC9CA25802D00421DED&agid=(PrintDetailsPublic)&actionid=1.

Administration AGD of HTG. Access to medicinal cannabis products [Internet]. Therapeutic Goods Administration (TGA). 2017 [cited 2017 Apr 24]. Available from: https://www. tga.gov.au/access-medicinal-cannabis-products.

QLD Health. Patient guide to accessing medicinal cannabis | Queensland Health [Internet]. [cited 2017 Apr 24]. Available from: https://www.health.qld.gov.au/public-health/ topics/medicinal-cannabis/patient-guide-to-accessing-medicinal-cannabis.

Medicinal-Cannabis-Compassionate-Use-Scheme_Fact-sheet.pdf [Internet]. [cited 2017 Apr 24]. Available from: https://www.medicinalcannabis.nsw.gov.au/__data/assets/ pdf_file/0025/1987/Medicinal-Cannabis-Compassionate-Use-Scheme_Fact-sheet.pdf

Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse Health Effects of Marijuana Use. N Engl J Med. 2014 Jun 5;370(23):2219–27.

Product information for Sativex (Nabiximols) [Internet]. [cited 2017 Apr 24]. Available from: https://www.tga.gov.au/sites/default/files/auspar-nabiximols-130927-pi.pdf

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GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

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HEALTH

Is Bad Oral Hygiene WHEN WAS THE LAST TIME YOU VISITED THE DENTIST? DO YOU BRUSH YOUR TEETH DAILY? TWICE DAILY? ... AND FLOSS? DANNY AGNOLA B.Pharm James Cook University Member of the Australian College of Pharmacy

CARDIOVASCULAR DISEASE

STROKE / DEMENTIA ALZHEIMER DISEASE

MOUTH CANCER

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

DIABETES

RESPIRATORY PROBLEMS

GUM DISEASE

DENTAL DECAY

BAD BREATH

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

TOOTH LOSS

HEALTH

Making You Sick? EVEN IF WE DO KEEP ON TOP OF OUR ORAL CLEANSING, WE COULD STILL HAVE DANGEROUS BACTERIA GROWING INSIDE OUR MOUTHS. BUT, APART FROM LOCAL EFFECTS SUCH AS PLAQUE BUILD-UP AND PERIODONTITIS (AN ADVANCED FORM OF GUM DISEASE), IS IT POSSIBLE BAD ORAL HYGIENE CAN HAVE MORE SEVERE, SYSTEMIC EFFECTS1? AS IT TURNS OUT, YES …

CARDIOVASCULAR/STROKE RISK Oral infections and cardiovascular diseases share common biological and behavioural risk factors. People with periodontal disease have been found to be two times2 more likely to develop cardiovascular disease. The association between periodontal disease and cardiovascular incidents has several possible pathophysiologic links. Periodontitis represents a systemic burden of bacteria and bacterial products3. This bacterial challenge could induce an abundant production of pro-inflammatory cytokines, cause inflammatory cell proliferation into large arteries, and stimulate hepatic synthesis of clotting factors (e.g. fibrinogen), and thus contribute to atherogenesis and thromboembolic events4. Another study found that intensive periodontal treatment reduced systemic inflammatory markers and systolic blood pressure, and even improved lipid profiles with subsequent beneficial changes in cardiovascular risk when compared with standard therapy5.

INCREASED RISK OF DEMENTIA Tooth loss due to poor dental hygiene is also a risk factor for memory loss and early stage Alzheimer disease6. How is this possible? Established risk factors for Alzheimer’s disease include cerebrovascular disease and its vascular risk factors, many of which share links with evidence of systemic inflammation identified in periodontitis and other poor oral health states7. A recent study found men and women who wore dentures and reported not brushing their teeth daily had a 22–65% greater risk of dementia than those who brushed three times a day6. There are still a lot of unknowns surrounding the aetiology of dementia and Alzheimer’s disease. Considering the treatable and preventable nature of many oral health conditions, correct oral hygiene is necessary to reduce the risks associated with these diseases.

RESPIRATORY PROBLEMS Oral bacteria and especially periodontal pathogens have been implicated as important agents with regard to causing some respiratory diseases.

There are four possible mechanisms to explain this association: 1. O ral pathogens directly aspirated into the lungs. This is particularly relevant for at-risk individuals such as hospitalised patients; 2. S alivary enzymes associated with periodontal disease modify respiratory tract mucosal surfaces, thus facilitating pathogenic colonisation; 3. H ydrolytic enzymes from periodontopathic bacteria may destroy the salivary film that protects against pathogenic bacteria; 4. T he presence of a large variety of cytokines and other biologically active molecules continually released from periodontal tissues and peripheral mononuclear cells8. Many medications we dispense cause dry mouth which actually helps facilitate the growth of oral pathogens and increases the risk of respiratory diseases. If any of your patients have dry mouth and suffer from any of the other disease states listed in this article, referral to the doctor or dentist might be the best option to better treat the condition and reduce the likelihood of more serious conditions from developing.

DIABETES The link between gum disease and diabetes appears to be a two-way street. In addition to having a higher risk of gum disease due to diabetes, periodontal disease may also make it difficult to control blood sugar, putting the patient at risk for even more diabetic complications. The mechanisms that underpin the links between these two conditions are not completely understood, but involve aspects of immune function, neutrophil activity and cytokine biology. Incidences of diabetic nephropathy and end-stage renal disease are increased twofold and three-fold, respectively, in diabetic individuals who also have severe periodontitis compared with diabetic individuals without severe periodontitis. Furthermore, the risk of mortality of ischaemic heart disease and diabetic nephropathy combined is three times higher in diabetic people with severe periodontitis than without 9. These eye-opening links show that oral

and periodontal health should be promoted in our pharmacies as integral components of diabetes management. Maybe an extra question to ask your patient during a Diabetes MedsCheck could be, “When was the last time you visited your dentist?”

PREVENTION AND TREATMENT With 10–15% of the adult population exhibiting signs of periodontal disease2, it should be part of our counselling regime to recommend correct oral hygiene upkeep, especially in patients suffering from the above diseases. To help control or prevent periodontal diseases, it is important to brush (twice daily) and floss (daily) to remove the bacteria that cause gum disease and to see a dentist every six months to one year 10. REFERENCES: Li X, Kolltveit KM, Tronstad L, Olsen I. Systemic Diseases Caused by Oral Infection. Clinical Microbiology Reviews. 2000;13(4):547-558. 2 Society for General Microbiology. "Brush Your Teeth To Reduce The Risk Of Heart Disease." ScienceDaily. www.sciencedaily.com/ releases/2008/09/080908203017.htm (accessed March, 2017). 3 Wu T, Trevisan M, Genco RJ, Dorn JP, Falkner KL, Sempos CT. Periodontal Disease and Risk of Cerebrovascular Disease The First National Health and Nutrition Examination Survey and Its Follow-up Study. Arch Intern Med. 2000;160(18):2749-2755. doi:10.1001/archinte.160.18.2749. 4 Dhadse P, Gattani D, Mishra R. The link between periodontal disease and cardiovascular disease: How far we have come in last two decades? Journal of Indian Society of Periodontology. 2010;14(3):148154. doi:10.4103/0972-124X.75908. 5 D’Aiuto, F et al. Periodontal infections cause changes in traditional and novel cardiovascular risk factors. American Heart Journal. 10.1016/j.ahj.2005.06.018. 6 Atchison, K et al. Dentition, Dental Health Habits and Dementia: The Leisure World Cohort Study. J Am Geriatr Soc 2012. 10.1111/j.15325415.2012.04064.x 7 Noble, J.M., Scarmeas, N. & Papapanou, P.N. Poor Oral Health as a Chronic, Potentially Modifiable Dementia Risk Factor: Review of Literature. Curr Neurol Neurosci Rep (2013) 13: 384. doi:10.1007/s11910013-0384-x 8 Gomes-Filho IS, Passos JS, Seixas da Cruz S. Respiratory disease and the role of oral bacteria. Journal of Oral Microbiology. 2010;2:10.3402/jom. v2i0.5811. doi:10.3402/jom.v2i0.5811. 9 Preshaw PM, Alba AL, Herrera D, et al. Periodontitis and diabetes: a two-way relationship. Diabetologia. 2012;55(1):21-31. doi:10.1007/s00125-011-2342-y. 10 Australian Dental Association. Your Dental Health. http://www.ada.org.au/Your-Dental-Health/Home (accessed March, 2017). 1

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BUSINESS

Factors to Consider when Transforming your Pharmacy into a

HEALTH HUB

ROSS GALLAGHER CEO GuildLink

IN RECENT YEARS BOTH THE DEPARTMENT OF HEALTH AND THE PHARMACY GUILD OF AUSTRALIA HAVE FOCUSED ON THE VALUE OF PATIENT CARE IN PHARMACY AND HAVE BEEN INVESTING IN WAYS TO INCREASE THE CONTRIBUTION OF COMMUNITY PHARMACY TO THE EVERYDAY HEALTH OF AUSTRALIAN PATIENTSi.

The continuing focus on patient care as the future of Community Pharmacy has encouraged a change in the way Community Pharmacy do business, which is evident through the noticeable shift away from dispense-centric towards patient-centric pharmacy. The result of this has been the advent of the concept of a Health Hub, to describe a Community Pharmacy whose business model focuses on patient care over dispense. Practically, a Health Hub or patient-centric business model in Community Pharmacy places high value on the effective implementation of Professional Services and the collaboration of Community Pharmacy with the wider healthcare community, and focuses on the importance of productive community engagement. This in turn has given rise to programs like Health Advice Plus that was designed and delivered by the Guild, providing Community Pharmacy with advice and practical assistance to progress their pharmacy towards a patient-centric business model.

2017 Guild Pharmacy of the Year acceptance speeches and attribute much of their business success to their focus on patient care, in the form of in-pharmacy Professional Services, professional collaboration and engaging with the patient communityii.

ROLE OF PROFESSIONAL SERVICES In 2014, the Pharmacy Guild of Australia released findings from a study that found “Community Pharmacists are the most accessible of all healthcare professionals and provide an array of services … extending beyond the provision of medicinesiii.” The community and industry attitude outlined in this study confirms that Professional Services are fundamental to implementing

HEALTH HUB EXCELLENCE Both Lucy Walker Chemmart, Goondiwindi, 2017 Guild Pharmacy of the Year and 2017 Community Engagement category winner, and Capital Chemist Wanniassa, 2017 Guild Professional Services Innovation category and 2017 GuildCare Pharmacy of the Year, are notable examples of Community Pharmacy successfully implementing a patient-centric business model. Capital Chemist Wanniassa and Lucy Walker Chemmart described themselves as a “health hub” during their

Capital Chemist Wanniassa Staff

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a patient-centric business model. Within a Health Hub, Professional Services work to the benefit of both the patient and the pharmacy business. It is important to ensure that the patient community values the services being offered and the business is able to generate sustainable revenue through conducting Professional Services. During their 2017 Guild Pharmacy of the Year – Professional Services Innovation category acceptance speech, Capital Chemist Wanniassa pharmacy owners, Elise Apolloni and Honor Penprase, explained that in 2014, under financial pressure, the business moved away from a dispense-focused business towards a model that would “maximise patient–pharmacist interaction and grow

BUSINESS

Professional Services, so we [they] could ultimately become a health hub for our [their] community iv.” The business decision to move away from dispense-centric saw them redesign their shop floor and in-pharmacy patient experience to maximise the revenue and engagement potential of Professional Services within their pharmacy.

ROLE OF PROFESSIONAL COLLABORATION Part of being an effective Health Hub and supporting the health of the patient community is collaborating with other healthcare professionals. Effective and professional relationships between Community Pharmacy and other local healthcare providers ensure that patients receive the best possible health outcomes. For example, developing closer professional ties between prescribing doctors and Community Pharmacy can help address issues relating to adherence and compliance, as well as improving the support of patients with chronic illnessv.

ROLE OF PATIENT COMMUNITY ENGAGEMENT To be recognised as a primary healthcare provider or Health Hub pharmacy means that the pharmacy business needs to actively engage with the local patients. Engaging with the local community not only raises the profile of the pharmacy, but it also ensures that the community values the role which Community Pharmacy plays in their health, and builds patient loyalty.

Lucy Walker, Lucy Walker Chemmart

Lucy Walker Chemmart is one of two pharmacies in the Queensland border town of Goondiwindi. During the 2017 Pharmacy of the Year award presentation at APP in March, Guild President, George Tambassis, and judging panel spokesman, Nick Panayiaris, said Lucy Walker Chemmart “was an exceptional example of a pharmacy transforming to a model of care that supports its local community vi.” Aside from instore

services, Lucy Walker and her staff take an active health stance in their region by going out into the community to provide general health education. In a video screened during the 2017 Pharmacy of the Year award presentation, Lucy Walker describes how she travels to a petrol station 100 km north of Goondiwindi to share health knowledge with the regionvii.

HOW TO BECOME A HEALTH HUB Transforming your pharmacy into a Health Hub takes a shift in business practice and mindset, redirecting the focus of the pharmacy business into patient care, as well as identifying the financial benefits and implications of a patient-care-focused business model. The Pharmacy Guild of Australia, the Pharmaceutical Society of Australia (PSA) and the Quality Care Pharmacy Program (QCPP) have a number of programs, resources and guidelines that provide advice and assistance to pharmacies transforming their pharmacy business into a Health Hub. In addition to the programs, there are several business programs and tools that are available to help Community Pharmacy with the implementation of a patientcentric business model. Figure: Sample Health Hub implementation business programs and tools 1. PROFESSIONAL SERVICES VIABILITY TOOL The Pharmacy Guild of Australia provide a specially designed Professional Services Viability Tool to help Community Pharmacy business owners realise the revenue potential and sustainability of Professional Services within their pharmacy. 2. PROFESSIONAL SERVICES RECORDING Invest in a nationally available Professional Services recording platform that is patient-centric. Platforms like GuildCare NG are designed to enable Pharmacists to record and deliver in-pharmacy Professional Services, while keeping the patient’s specific health requirements at the centre of the experience. 3. PATIENT COMMUNICATION CHANNELS As patient expectations increase it is important to stay connected with your patient community outside the pharmacy through a variety of communications channels like sms, email, voice calls or by using a patient app, like myPharmacyLink. Pharmacy services platform GuildCare NG supports Community Pharmacy in managing patient interactions via email, sms, voice calls and myPharmacyLink through the same patient-centric platform used to conduct in-pharmacy Professional Services.

Interested in finding out how you can become a Health Hub with the help of a Professional Services reporting software solution? Visit the GuildCare NG website ng.guildcare.com.au OR contact the GuildLink Pharmacy Services Team for more information. Call 1300 859 328 or email pharmacy@guildlink.com.au REFERENCES: Pharmacy Guild of Australia – Pharmacy Transformation <https://www.guild.org.au/resources/pharmacy-transformation> ii 2017 Pharmacy Guild of Australia – Pharmacy of the Year Awards acceptance speeches. iii 2014 Pharmacy Guild of Australia – Factsheet: Helping Aging Australians to Better Health. iv Elise Apolloni and Honor Penprase, 2017 Pharmacy Guild of Australia – Pharmacy of the Year Professional Services Innovation Awards acceptance speech. v Pharmacy Guild of Australia, Submission to Review of Pharmacy Remuneration and Regulation, Part Five – p. 165. vi https://www.guild.org.au/news-events/news/2017/lucy-walker-chemmart-goondiwindi-guild-pharmacy-of-the-year. vii Lucy Walker, 2017 Pharmacy Guild of Australia – Pharmacy of the Year presentation. viii Pharmacy Guild of Australia – Resource: Professional Services Viability Tool <https://www.guild.org.au/resources/professional-service-viability-tool> xi Quality Care Pharmacy Program <http://www.qcpp.com/qcpp-home> xii Alison Roberts, MPS, A Real Health Destination – Australian Pharmacist, Jan 2014 <https://www.psa.org.au/download/pharmacy-support/health-destination-ap-jan-2014.pdf> i

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Insulin Needles and Subcutaneous THINGS THE PHARMACIST Injection SHOULD KNOW Technique JO COMPER Accredited Pharmacist B. Pharm. Hons. mPharm.

Learning Objectives: After completing this activity, pharmacists should be able to: • Describe the different features of insulin pen needles in line with injection guidelines and clinical research. • Explain why the efficacy and safety of insulin and GLP-1 mimetic therapy depends on correct injection technique, including site rotation, needle selection and injection preparation. • Describe techniques to ensure the injection experience is comfortable and effective.

The 2010 Competency Standards Addressed by this activity include: 2.1, 2.3, 4.2, 4.3, 6.1, 6.3.

The 2016 Competency Standards addressed by this activity include: 1.4, 1.5, 3.2, 3.3.

Accreditation Number: A1706GX1 This activity has been accredited for 1hr 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.

INTRODUCTION A recent study of 346 patients revealed that individuals who were instructed regarding the proper technique for injecting insulin had a reduction in their HbA1c of 0.58%1. This is an appreciable reduction and is the equivalent to the result obtained from the addition of a new oral anti-diabetic medicine2. Clearly it is important that patients be counselled regarding correct injection technique for insulin and other medicines to treat diabetes,

as well as the importance of proper needle selection and injection site rotation. As pharmacists regularly see people living with diabetes when they attend the pharmacy to collect their insulin and other medications, as well as when these patients collect needles and other National Diabetes Services Scheme (NDSS) supplies, they are well placed to have discussions around factors affecting injection. Insulin was first discovered and administered in 1921-22, and was first

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extracted from animal pancreas, but production has since evolved. Synthetic (regular or human) insulin was developed in the 1980s and is less allergenic than the animal insulins that were previously used3. At the end of last century genetic engineering allowed insulin to be produced using recombinant DNA technology, allowing modification of its pharmacokinetic profile to give insulins with various times of onset, peaks and durations of action4.

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DIABETES SUBCUTANEOUS INJECTION TECHNIQUE The Australian Diabetes Education Association (ADEA) has regularly updated clinical guidelines that provide recommendations regarding injectable diabetes medicines, subcutaneous injection technique, needle size and injection site1. The guidelines incorporate new international insulin delivery recommendations that were compiled by 183 diabetes experts at the FITTER workshop which were released in September 20166. Studies found that many individuals using insulin for at least six months were not following evidence-based recommendations for the administration of insulin. Key findings from a survey in 2008-9, involving over 4,300 individuals with type 1 and type 2 diabetes from 171 centres in 16 countries, included7,8: •

7% of participants were unsure of the length of needle they use;

•

21% of participants admitted to injecting into the same site for the entire day, or even over several days;

•

32% of participants reported they did not have a specific injection routine;

•

Half of the syringe users used a syringe only once, while 43% of insulin pen users reported using their pen needles only once;

•

The mean number of needle uses was 3.2 for syringes and 3.6 for pen needles;

•

Approximately 10% of participants admitted to using their needles more than 10 times.

When an individual uses a needle more than once there is a strong tendency (p=<0.0001) for the development of more lipohypertrophic lesions (an adverse reaction associated with repeated incorrectly administered insulin injections) compared to patients who only use a needle once. This is particularly a problem in adolescents and children8.

CORRECT DIABETES SUBCUTANEOUS INJECTION TECHNIQUE The correct diabetes subcutaneous injection technique depends on the following 4 factors1: 1. Correct injection site and rotation of the injection site; 2. Correct needle length and priming the needle; 3. Correct administration method particularly using the skin fold where appropriate; 4. Correct injection angle.

INJECTION SITE The most commonly recommended site for subcutaneous injections is the abdomen due

concentrations of plasma insulin compared to an unaffected injection site, which highlights the necessity of rotating injection sites for good glycaemic control11.

to its convenience and tendency to produce more rapid and reproducible insulin uptake (Figure 1)5. The buttocks, thighs and arms may also be used, however there is a greater risk of intramuscular injection if the thighs or arms are injected5. In practice it is difficult for patients to successfully inject the upper arms, especially if they have limited dexterity, and differences in absorption between sites needs to be considered for insulins with slower onset of action. A more rapid onset of action would occur when a regular insulin is injected into the abdomen, but slower when injected into the buttocks or thighs6. A slower onset of action is preferred for an isophane insulin. The absorption of analogue insulins is constant across all sites6,9.

Injection sites should be rotated as described in the ADEA guidelines shown in their diagram in Figure 25. Rotating within one area is now recommended over rotating to a different body area with each injection. The ADEA recommendation is to use one quadrant of the abdomen or thigh each week5.

NEEDLE SELECTION There are many subcutaneous pen needles and syringe needles for diabetes injectable medications in Australia, with most being available for free to patients registered with the NDSS. When patients with diabetes enquire about needles, it is important to be able to discuss the different needles that are available, especially if the patient reveals they experience pain or discomfort at the injection site12. The best choice of needle is one that delivers the diabetes medicine into the subcutaneous space without leakage or discomfort13. From clinical research, a shorter needle length (4-6mm) ensures the needle does not enter the muscle when injected at a 90% angle6,14. If longer needles are used (>6mm), the patient may need to inject at a 45% angle or inject into a skin fold (described later) to avoid accidentally injecting into muscle6.

Figure 1: Sites that can be reasonably reached by most patients for the subcutaneous injection of insulin5.

IMPORTANCE OF SITE ROTATION Lipodystrophy is one of the most common complications associated with subcutaneous insulin injections, and presents as either lipoatrophy or lipohypertrophy (LH). Lipoatrophy, which is associated with older forms of insulin that are rarely used anymore e.g. porcine insulin, presents as a scarring lesion with loss (atrophy) of subcutaneous tissue10. Lipohypertrophy is a thickened “rubbery” swelling of tissue that can be either soft or firm to the touch10.

In a 2015 cross study, 4mm pen needles were found to be significantly superior compared to 8mm and 12.7mm pen needles for ease of insertion, ease of use, and incidence of needle anxiety. There was no significant difference in reported leakage (skin back flow) rates among the 3 pen needles tested, all being in the range of 4.1% to 4.3% of injections. The leakage that did occur was generally with higher insulin doses, but was not different for different

A 2013 study of 430 insulin patients revealed that 64% of individuals injecting insulin subcutaneously developed LH. Of the patients who correctly rotated their injection site only 5% had LH, while of the patients who displayed LH, 98% either did not CHOOSE AN AREA SELECT rotate their injection INJECTION ZONE eg Abdomen site, or rotated it incorrectly10. Lipohypertrophy can also affect COMPLETE ZONE SELECT insulin absorption. MOVE ON TO NEXT SIGHT A study of nine male patients with LH who agreed to have their plasma insulin levels monitored following MOVE AROUND USE A ROTATION THE ZONE PATTERN TO HELP subcutaneous SYSTEMATICALLY INJECT AT LEAST injection of insulin 1cm AWAY through their lipohypertrophied and nonlipohypertrophied Figure 2: Site rotations for subcutaneous injection of medicines for diabetes. sites, revealed an (Taken from Australian Diabetes Educators Association (ADEA), Clinical Guiding up to 25% reduction Principles for Subcutaneous Injection Technique). in the maximum

Keep Rotating!

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needle lengths. The leakage volumes (amount leaked) were significantly larger with the 12.7mm pen needles compared to the shorter two15. The current ADEA guidelines state there is no medical reason to recommend needles longer than 6mm for children or longer than 8mm for adults5. It is recommended that initial therapy should commence with shorter (4mm or 6mm) needle lengths5. However, according to NDSS statistics, in 2014-15 almost half (47.9%) of all pen needle users were using needles of 8mm or longer, which suggests a clear disconnect between current clinical guidelines and what patients are actually using on a daily basis5. The number of patients using 12.7mm needles is only 2.8% and the trend is towards lower use. Patients still using insulin syringes over pens only make up a small proportion of total needle use, and are mostly people who have been using insulin for many years, but 30.3% are using needles of 12.7-13mm5. A smaller gauge needle results in significant reduction in pain and bleeding and is associated with better patient acceptance, which could potentially lead to better patient adherence to their insulin regimens16. A study published in the BMJ reported very little or no pain with relatively large needle diameter, but that pain only became significant after the needle became blunt17. There are many causes of needle blunting e.g. when a syringe-needle has been repeatedly used to access insulin through a rubber seal from a vial/cartridge and then injected into the skin, or where a patient uses the same pen needle for multiple injections18. To reduce blunting, insulin pens should be recommended over syringes and each pen needle used only once. Besides reducing blunting, this also reduces the risk of infection and lipohypertrophy7. Figure 3 shows a needle that has blunted from being used too many times. Used needle magnified 370 times

Same used needle magnified 2000 times

Figure 3: Damage that can occur to insulin needles with repeated subcutaneous injection. (Photographs taken from Dieter Look and Kenneth Straus Study “Nadeln Mehrfach Verwinden” Diabetes Journal 1998; 10: S. 31-34).

Extra thin walled pen needles have also been studied18. Extra thin walled pen needles have significantly better performance compared to standard thin walled pen needles in thumb force, flow rate and time to dispense insulin, which were the three performance factors tested18. These needles would be helpful for patients who find it difficult to inject owing to weak thumb force11. A 5-bevel needle tip has been compared to a 3-bevel tip in one study, and the 5-bevel needle was found to require up to 23% less penetration force

compared to a standard BD 3-bevel pen needle. The injection with the 5-bevel needle was perceived to be less painful and was considered preferable by the study subjects19.

PRACTICAL ADMINISTRATION OF DIABETES MEDICINES FROM A PEN DEVICE Insulin pen devices have been available since 1985 and are now the standard choice for the majority of people with diabetes who inject insulin20. Glucagon-like peptide-1 (GLP-1) mimetics, e.g. exanatide and liraglutide, are only formulated in a prefilled pen device. The benefits of using an insulin pen over an insulin syringe include, convenience and ease of use, greater accuracy, greater adherence to treatment protocols, greater perceived social acceptance and reduced fear of needles5. Shorter needles (4 mm) used with pen devices have been shown to be preferred by obese patients injecting large doses of insulin, with less pain and no increase in skin leakage of insulin when compared to 8 mm and 12.7 mm needles15. Pharmacists should advise all patients to always follow the manufacturer’s instructions. Insulin administration steps are as follows5: 1. The pen needle is attached to the pen. It is normally screwed on tightly; 2. If the insulin is cloudy, as in the case with pre-mixed insulins, the pen device should be rocked slowly to ensure both insulins are re-suspended; 3. Remove the pen needle cap prior to priming the needle; 4. The pen should be primed to ensure it is working correctly. This can be accomplished by dialling up two units of insulin, inverting the pen so that the needle faces upwards and pushing the plunger. A few drops of insulin should be seen at the top of the pen needle. If no insulin is seen, a further two units should be dialled and the process repeated. This can be repeated up to four times in total. If no insulin is seen after the fourth occasion, the pen should be deemed faulty and returned to the pharmacy; 5. Do NOT use alcohol swabs on the skin as this can toughen the skin making it harder to inject;

use a 45° angle whilst a normal weight to obese adult can insert the needle at a 90° angle for needle sizes 4-6mm15. 8. Patients are likely to have been told to lift a skin fold as shown in Figure 5. A skin fold is suggested as this reduces the likelihood of a needle entering the muscle. However, using a skin fold is dependent on site of injection e.g. the buttocks have the most subcutaneous fat and therefore there is no requirement to use a skin fold. Whereas the thigh has the highest risk of intramuscular injection and thus a skin fold is required. Pregnant women, very slim adults and individuals who insist on using 8mm or longer needles should also use a skin fold. Skin and subcutaneous tissue thickness measurements estimate that when injecting using a 90° angle, increasing the length of the needle will increase the proportion of injections that reach the muscle. Results indicated that increasing the needle length from 5mm to 6mm and 12.7 mm will increase the proportion of IM injections from 2 to 5 to 45% respectively. Even using a 45° angle theoretically leads to an IM injection 21% of the time with a 12.7 mm needle21. 9. Once the needle has entered the subcutaneous tissue the plunger should be pressed and the needle should be left in situ for a count of 10 or longer before withdrawing.

INJECTION PAIN, FEAR AND ANXIETY Patients using insulin consistently identify multiple factors that contribute to injectionrelated anxiety and non-adherence, with injection related discomfort being a significant factor. One of the most common patient barriers to initiating insulin therapy is the fear that the injections will be painful22. Pharmacists may have conversations with patients living with diabetes about their fear of needles and/or pain, or those who are nervous about the introduction of insulin or GLP-1 mimetics into their therapy because of the necessity of injections. Advances in needle manufacturing technology over the last decade, which have produced shorter and

6. Once the needle is primed, dial up the required units; 7. Insert the needle into the skin. The angle will either be at 45° or 90° depending on two factors. a) Needle length: a 90° angle can be used for a 4mm needle but a 45° angle should be used for needles equal to or longer than 8mm; b) Patient factors: a small child (2-6 years) or a very slim adult should

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90o

Subcutaneous layer

Muscle layer

Figure 5: Skin fold technique.

25 CONTINUING PROFESSIONAL DEVELOPMENT BUSINESS 25

narrower needles, have been associated with progressive improvement of patient self-rating of injection discomfort, with patients now rating discomfort in the bottom third of significant contributors to pain by prevalence22. However, healthcare providers and family member care providers continue to demonstrate a high level of anticipated or perceived pain for the patient, which can affect the patient’s attitude. A number of techniques exist to help allay fears associated with injecting

insulin. Accurate and timely education with reinforcement is important since misinformation plays a role in fear development. Cognitive reframing refers to the examination of one’s specific thoughts to determine whether they are accurate or helpful in a given situation and to then modify those thoughts to make them more accurate or useful. Relaxation techniques can also be employed to help the nervous patient to remain calm prior to injections23.

REFERENCES: 1 Grassi, G., et al. Optimizing insulin injection technique and its effect on blood glucose control. Journal of Clinical & Translational Endocrinology, 2014. 1(4): p. 145-150. 2 Nauck M A et al. Efficacy and safety of dipeptyl peptidase-4 inhibitor sitagliptin, compared with a sulphonylurea, glipizide in patients with type 2 diabetes inadequately controlled on metformin alone: a randomised double blind non-inferiority trial. Diabetes, obesity and metabolism 2007; 9: 194-205. 3 Coast-Senior E et al. Management of Patients with Type 2 Diabetes by Pharmacists in Primary Care Clinics Ann Pharmacother June 1998 vol. 32 no. 6 636-64. 4 Cold Spring Harbour Laboratory, US. https://www.dnalc. org/view/15928-how-insulin-is-made-using-bacteria.html Accessed Apr 2017. 5 Australian Diabetes Educators Association (ADEA). Clinical Guiding Principles for Subcutaneous Injection Technique. Canberra: 2017. https://www.adea.com.au/wp-content/ uploads/2009/10/Injection-Technique-FINAL_170323.docx.pdf 6 Frid AH et al. New insulin delivery recommendations. Mayo Clin Proc. 2016 Sep;91(9):1231-55. 7 Strauss K et al. A pan-European epidemiologic study of insulin injection technique in patients with diabetes. Pract Diabetes Int 2002; 19:71-76. 8 De Coninck C et al. Results and analysis of the 2008-2009 Insulin Injection Technique Questionnaire survey. Journal Diabetes. 2010; 2(3):168-79. 9 Ter Braak E W et al Injection site effects on the pharmacokinetics and glucodynamics of insulin lispro versus regular insulin. Diab Care 1996; 19(12): 1437-1440. 10 Blanco M et al. Prevalence and risk factors of lipohypertrophy in insulin injection patients with diabetes. Diabetes & Metabolism 2013;39: 445-453. 11 Johansson U-B et al. Impaired absorption of insulin aspart from lypohypertrophic injection sites. F=Diab Care 2005; 28(8): 2025-2027. 12 Hirsch L et al Impact of a Modified Needle Tip Geometry on Penetration Force as well as Acceptability, Preference, and Perceived Pain in Subjects with Diabetes. Journal of Diabetes Science and Technology Volume 6, Issue 2, March 2012. 13 Pledger E Et al. Importance of injection technique in diabetes. Journal of diabetes nursing 2012; 16(4). 14 Hofman et al Defining the ideal injection technique when using a 5mm needle in children and adults. Diab Care 2010; 33(9): 1940-1944. 15 Bergenstal R et al. Safety and Efficacy of Insulin Therapy Delivered via a 4mm Pen Needle in Obese Patients With Mayo Clin Proc 2015;90(3):329-338. 16 Harvinder S G et al. Does size matter? J Diabetes Sci Technol. 2007 Sep; 1(5): 725–729. 17 Chanteleux E et al. What makes insulin injections painful? BMJ 1991; 303: 26-7. 18 Aronson R et al. Insulin Pen Needles: Effects of Extra-Thin Wall Needle Technology on Preference, Confidence and Other Patient Ratings. Clinical Therapeutics 2013; 35(7): 923-33. 19 Landau S. Insulin induced lipohypertrophy N Engl J Med 2012; 366: e9. 20 Selam J-L. Evolution of Diabetes Insulin Delivery Devices. Journal of Diabetes Science and Technology. 2010;4(3):505-513. 21 Gibney et al. Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections: implications for needle length recommendations. Curr Med Res Opin. 2010 Jun;26(6):1519-30. 22 Aronson R The role of comfort and discomfort in insulin therapy. Diabetes Technol Ther. 2012; 14(8): 741–747. 23 Choy et al Treatment of specific Phobias in adults. Clin Psych Rev. 2007; 27(3): 266-286.

SUMMARY Ideally, pharmacists should discuss injection technique, injection site rotation and needle length as regularly as possible with diabetes medicine injecting patients, especially for new patients, when reviewing a patient’s insulin regimen, when dispensing an insulin or GLP-1 mimetic prescription, and when undertaking medication management reviews. Any issues identified during these discussions should be referred to a diabetes educator, general practitioner and/or community nurse for further follow up.

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 The ADEA guidelines state there is no medical reason to recommend needles longer than: a. b. c. d. e.

4mm for children and 6mm for adults 6mm for children and 12.7mm for adults 4mm for children and 8mm for adults 6mm for children and 8mm for adults None of the above

QUESTION 2 Which of the following is a factor to consider in correct diabetes subcutaneous injection technique? a. b. c. d. e.

Correct needle length and priming the needle Correct administration method using the skin fold where appropriate Correct injection angle Correct injection site and rotation of the injection site All of the above

QUESTION 3 Which of the following would NOT be beneficial during a discussion with a patient who is anxious and nervous at the prospect of having to self-inject insulin? a. All people living with diabetes who inject insulin experience pain. It is just part of the process. b. Shorter and narrower needles developed over the last decade have resulted in progressively improved patient self-rating of injection discomfort and pain. c. Cognitive reframing may be useful in modifying the anxious thoughts associated with insulin injection. d. Relaxation techniques may help the nervous patient remain calm prior to injection.

QUESTION 4 True or False? Glucagon-like peptide (GLP-1) mimetics available in Australia are only formulated in a prefilled pen device.

QUESTION 5 Which of the following statements about injecting insulin is NOT correct? a. Lipohypertrophy is a complication of insulin injection characterised as thick rubbery swelling of tissue. b. Injection sites should be rotated within defined areas of the body rather than injecting into a different body area each time. c. Longer needles should be injected at a 90 degree angle to reduce the risk of intramuscular injection. d. People injecting larger insulin doses are more likely to have leakage (back flow) from the injection site. e. An injection pen should be primed by dialling up 2 units of insulin, inverting the pen so that the needle faces upwards and pushing the plunger, so that a few drops are seen at the tip of the needle.

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Incontinence:

No Laughing Matter Pharmacists can also download or order posters for World Continence Week 2017 by phoning 1800 33 00 66 or going to continence.org.au/wcw.

MARIA WHITMORE Special Projects Officer Continence Foundation of Australia

INCONTINENCE AFFECTS 4.8 MILLION* AUSTRALIAN ADULTS, MAKING IT MORE PREVALENT THAN ARTHRITIS (3.1 MILLION), ANXIETY DISORDERS (2.3 MILLION) AND ASTHMA (2 MILLION).

Yet it’s rarely discussed and commonly dismissed as an inevitable part of life. A Continence Foundation of Australia survey of 1000 women affected by incontinence revealed that 72 per cent had laughed off the issue in social settings, with the vast majority (84 per cent) believing it was part of having children or ageing. Worryingly, eight in 10 women surveyed said they had not taken any action to treat or manage their incontinence.

The theme for this year’s World Continence Week (19–25 June) is Incontinence: no laughing matter, which aims to tackle this common response to laugh off bladder leakage rather than seek help for a very treatable condition. Continence Foundation of Australia chief executive, Rowan Cockerell said pharmacists’ front-line role in delivering health services was vital in promoting World Continence Week’s key message that continence should never be ignored or laughed off, and should be professionally treated. “We know that incontinence invariably worsens over time if ignored, and can significantly impact a person’s quality of life, with both men and women, at any age, at a higher risk of depression,” she said. Ms Cockerell said pharmacists could help mitigate the burden of incontinence by taking a patientcentred approach. “For example, learning how to take a good history, understanding the importance of pelvic floor exercises, knowing where the local continence services and physios are, and knowing about CAPS (Continence Aids Payment Scheme),” Ms Cockerell said. “I think it’s important for pharmacists to have a good understanding of continence problems and to be able to confidently discuss

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the causes, options and treatments with consumers.” Having up-to-date knowledge of medications that can exacerbate incontinence and any contraindications was also vital, she said. Being aware of associated risks, such as the increased risk of falls with nocturia and the greater risk of prolapse associated with osteoporosis will also inform pharmacists’ choices. The prevalence of incontinence is estimated to increase to 6.5 million by 2030*, and pharmacists will be increasingly called upon to provide support to their customers. In recognition of this, the Continence Foundation of Australia and the Guild Pharmacy Academy have developed two, free online CPD-accredited courses, Continence care for pharmacists and Continence care for pharmacy assistants. (Go to https://www. continence.org.au/pages/online-education. html or phone 03 9810 9930 for more information). Pharmacists are also able to speak with continence nurse advisors on the National Continence Helpline (1800 33 00 66) for clinical advice, information and resources weekdays from 8 am to 8 pm AEST. The service is also available to consumers, and non-English speaking patients can access an interpreter on 131 450. A range of resources, including videos, an online forum and fact sheets in 30 languages is available at continence.org.au. REFERENCE: * Deloitte Access Economics, The economic impact of incontinence in Australia, 2011.

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BUSINESS

Negotiating Your Next Lease (negotiatus [latin] ) : to carry on business)

BY PHILLIP A. CHAPMAN Phillip A. Chapman is the Founder of Lease1 and Director of MiLease Managing Lease Intelligence, both of which are endorsed Gold Cross Member Services.

THE COMMON QUESTION WE RECEIVE FROM RETAILERS WHEN CHALLENGED WITH THE PROCESS OF NEGOTIATING THEIR RETAIL SHOP LEASE IS “WHERE DO I START?” Retail Shop Leases are complex and require a deep understanding of not only our own needs and outcomes but also those of the landlord as well as the legislative boundaries by State & Territory Leases Acts. Each lease, and for that matter each lease negotiation, is different and although most seek to achieve a win-win outcome the end results are closer to win-lose (a zero-sum game). To achieve the holy grail of WIN-WIN (a non-zero sum game) where the wins and losses for both retailer and landlord don’t cancel each other out, there are five basic stages to consider.

FIVE KEY ELEMENTS OF NEGOTIATION PREPARATION

• Should I be negotiating? • What I need to know; • Organise information.

Preparation starts with determining if this is a potential collaborative situation so that you can select the better strategy. Next you spend time researching information, analysing data and leverage, and identifying interests and positions. Finally, you have to consider the relationship you want to build.

RESEARCH COVERS • Players and stakeholders; • The fact base; • Standards and benchmarks.

ANALYSIS INCLUDES • Re-organising data; • Anticipating what will happen; • Assessing strengths and risks.

>> STAGE 1 – PREPARE There is no good short cut to preparation. It is the first stage of any negotiation, though people often don't give it the time it warrants. They often charge into the Information Exchange Stage, or even directly to Bargaining.

INITIAL POINTS TO CONSIDER

>> STAGE 2 – INFORMATION EXCHANGE The Information Exchange Stage occurs when you begin to engage the other side, share information and explore options that address interests – what you each need, as opposed to positions – what you each ask for later in the Bargaining Stage. We will discuss the difference between interests and positions and how critical they are to successful negotiations in depth later, but here is a brief example: It is critical here to focus on building rapport and trust, without which neither party will feel comfortable sharing interests. One way to build the relationship is to do your "social homework" in this stage by finding out and showing interest in the other party's business culture, personality, outside interests and values.

FOUR CRITICAL ASSESSMENTS ARE MADE IN THE EXCHANGE STAGE:

IDENTIFICATION OF YOUR AND THEIR INTERESTS

Trustworthiness – Are they honest and dependable?

• Positions: Goals, Most Desired Outcomes, and Least Acceptable Agreements; • Best Alternatives to a Negotiated Agreement; • Concessions.

Competency – Are they credible and able?

Likeability – Can you work well together?

Alignment of Interests – Are your interests aligned with theirs?

KNOW THE RELATIONSHIP YOU WANT TO BUILD • Plan to build trust; • Prepare for emotional reactions; • Develop Probes to discover "Don't knows" and test Assumptions.

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A GO/NO-GO DECISION TIME IN EXCHANGE If your assessment in this stage of the negotiation process is negative, you make adjustments or implement your Best Alternative to a Negotiated Agreement (BATNA).

BUSINESS

"There is no good short cut to preparation. It is the first stage of any negotiation, though people often don't give it the time it warrants."

If your assessment in this stage of the negotiation process is positive, you move forward. With trust developed, you explore for creative solutions that address interests and see the potential to create real value.

DIVE INTO BARGAINING NOW? You will be eager at this point to dive into the Bargaining Stage. Pause to create one critical tool that will guide and protect you for the stages that follow. That is the development of a joint agenda.

>> STAGE 3 – BARGAIN Bargaining is where the "give-and-take" happens. If you think success means all take and no give, you won't capture real value. You make and manage your concessions in bargaining. When you give and take that which satisfies both parties' interests, you will build a lasting relationship and a fruitful outcome. During the Bargaining Stage, you continue to create value, and with trades, finally capture value.

TO BE TRUSTED, YOU MUST BE GENUINE! There are two tools you will need from your negotiator's toolbox in the Bargaining Stage; the Probe and Creativity. Bargaining is your "face-time" with the other person, even when you are not face-toface. Like all interpersonal relations, emotions can help or hinder progress. Specific negotiator's tools and behavioral skills matter greatly here. Finely tuned communication skills are critical at this juncture as you explore options to create value and execute trades to capture value. You will be most successful when solutions satisfy everyone's needs.

>> STAGE 4 – CONCLUDE Stage 4 is the point in the process when you reach agreement. It is important to find out if the other side has the capacity to follow through with the things they said they

would do. This is the time to put down in writing the common interests and produce a comprehensive summary of the agreement. Sometimes you have to consider strategies here to lock-in a commitment. Be sure to agree on next steps as well. And never forget to thank the other party for their willingness to negotiate – even when no agreement is reached.

>> STAGE 5 – EXECUTE Stage 5 is the implementation of the agreement. This stage may also be viewed as preparation for the next negotiation opportunity. You must ensure that you follow through on promises made in order to strengthen the relationship and to build trust. You will learn more in this stage about the other side. This will lead to easier negotiations next time around. And remember that during execution you are likely to apply the total negotiation process and BNPs to unexpected events, failures in performance and the inevitable changes.

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BUSINESS

Next Level Automation ROBERT ALLEN CEO Dose Innovations

NOT ALL TECHNOLOGY IS EQUAL. MORE AND MORE PHARMACISTS ARE INVESTING INTO THEIR PHARMACIES WITH TECHNOLOGY, EITHER IN DISPENSARY AUTOMATION OR DAA AUTOMATION. PREVIOUSLY, PHARMACISTS HAD ONLY ONE OR TWO CHOICES, BUT THE INCREASE IN UPTAKE HAS BROUGHT A LARGER NUMBER OF SUPPLIERS TO THE MARKET. MORE CHOICE CAN SOMETIMES MAKE IT MORE DIFFICULT TO SELECT THE RIGHT SOLUTION, BUT THERE ARE WAYS TO DIFFERENTIATE YOUR OPTIONS.

Australia is in the infancy of automation, and as such, it would be wise for an individual to assess which providers are present globally, and what their market share is. Today, for any machinery, the software plays an equally important role as the hardware, and to keep the device up to date, software development is the key. A company with a large global market share will make the investment required to further develop your product and support it for many years to come. Many companies will provide cheap versions of automated machines — do not forget, the price difference is there for a reason. Given that funding cost is at an alltime low, if you purchase a cheaper product that doesn’t do the job, it may cost you more in the long run. The fact is that interest rates will rise so there has never been a better time to lease equipment.

•

When making this investment for your pharmacy it is imperative to research the market thoroughly, prioritise your wants and needs for automation, and be sure to make an informed buying choice. Thankfully, I hear fewer and fewer pharmacists compare dispensary automation investment to buying a car. When we make a purchase in Australia we are all protected by the ACCC consumer rights. The difference with a car is that the Department of Infrastructure has national standards that regulate aspects of a vehicle able to be sold in Australia. No such standards exist for Dispensary Automation which makes it easier for the wrong partners to exist in the market. ISO 9001 certification is a company standard to look for and peak body endorsement is another.

•

YOU DON’T KNOW WHAT YOU DON’T KNOW – Pharmacists are generally happy if their current situation is even slightly better than before. Given that you aren’t able to try multiple machines before you buy, and unless you have worked with each different technology, it is hard to tell the difference that it could make to your store. DUE DILIGENCE – Using the car assumption, quite often the distinctive abilities of the technologies can be overlooked. Not all machines are the same. It’s imperative that you are given a choice of at least six sites to visit, rather than the old “staged presentation”. Talking to people that have worked with different technologies is invaluable. DECISION MAKERS – Quite often the decision maker for the investment is not the person that is working in the store and won’t be the person working with the machine. So again, it is hard to tell the difference between the machines — and they are very different. DIGITAL STRATEGY – The world has embarked on digitalisation, and software is delivering possibilities that five years ago were imaginary. Pharmacy in Australia was behind the eight ball but you can see that there is significant excitement in the possibilities that software is starting to deliver. If you have a dispensary robot that is “smart” then it can be enhanced by software development and it will be relevant for many years

"If you have a dispensary robot that is “smart” then it can be enhanced by software development and it will be relevant for many years to come, rather than soon becoming outdated." to come, rather than soon becoming outdated. Some really exciting new developments have emerged recently. •

Paperless reconciled dispensary orders have recently become available with the Rowa Machine. Peace of mind with huge time savings is now possible by checking off and stock receipting all of your dispensary orders at the touch of a button — with no paper.

•

Rowa V-Motion are touch screens that can standardise category management whilst assisting pharmacists to counsel and recommend products at the touch of the screen. The added benefit is that these products can be stored in your Rowa, negating the need to stocktake, merchandise and clean shelves, simplifying stock ordering, receipt and put away.

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CONTINUING PROFESSIONAL DEVELOPMENT

The Business of Pharmacy

Learning Objectives: After reading this article, the learner should be able to: 1. Recognise the benefits of analysing your pharmacy’s business performance. 2. Identify the steps required in developing an action plan to support business and management development.

Competencies Standards Addressed: 3.1, 3.4 Accreditation Number: G2017013 This activity has been accredited for 1 hour of Group 1 CPD (or 1.0 CPD credits) suitable for inclusion in an individual pharmacist’s CPD plan which can be converted to 1 hour of Group 2 CPD (or 2.0 CPD credits) upon successful completion of relevant assessment activities.

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CONTINUING PROFESSIONAL DEVELOPMENT

... ARE YOU READY? KELLY DANVERS Cert. III Community Pharmacy Cert. IV Frontline Management Business Support Officer The Pharmacy Guild of Australia Queensland Branch

CONTRIBUTORS: JACQUELINE HENRICKS B.Pharm, AACPA Cert IV TAE, Pharmacy Business Support State Manager, Pharmacy Guild of Australia, QLD Branch WARREN PARKES B.Pharm, Dip. Mgt, Cert IV TAE, Professional Practice Pharmacist, Pharmacy Guild of Australia, QLD Branch

OUR PHARMACY INDUSTRY IS IN A STATE OF CHANGE. WE ARE TRANSFORMING OUR WAYS OF THINKING AND OUR BUSINESS PRACTICES TO KEEP OUR INDUSTRY VIABLE AND AT THE FOREFRONT OF CONSUMER HEALTHCARE AND THEIR NEEDS. WE HEAR THE WORD TRANSFORMATION MENTIONED EVERYWHERE BUT IT IS IMPORTANT THAT WE UNDERSTAND WHAT TRANSFORMATION MEANS AND HOW WE CAN ACHIEVE IT SUCCESSFULLY.

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CONTINUING PROFESSIONAL DEVELOPMENT

It is time to become a solution based pharmacy. To create a point of difference from other retailers, to return our focus to service and not just price, as being price competitive may not be a single sustainable strategy for the future of pharmacy. For transformation to succeed, all members of our community should have a shared purpose. Pharmacy is not just about completing the dispensing of prescriptions. It is about promoting health awareness and contributing to the betterment of the community. Whilst many pharmacists would agree that this has always been our purpose, it has never been more relevant than in today’s society. Pharmacies across Australia witnessed a steady incline in prescription numbers up until the last decade, and now negative growth is a projection that is realistic for many community pharmacies. The Guild Digest’s data shows prescription revenue as a percentage of sales dropped by 6.1% with a decrease of 4.6% in per pharmacy script volume (Comparative study 2013/14 – 2014/15). In addition, Cost of Goods sold increased marginally by 1.1%. This in turn with the decrease in Sales produced a marginally lower Gross Margin as a percentage of Sales, at 45.13% compared with 46.47% in 2013-14¹. In the past, another reliable strategy for increasing profit for pharmacy was generic conversion of prescription medication. In 2014 KordaMentha published a report about the 6CPA that stated “The generics windfall profit window is closing, and relying on generics as

“For transformation to succeed, all members of our community should have a shared purpose."

a single profit maintenance strategy will not be sustainable. Pharmacies need to invest and restructure, moving away from transacting and reacting to a ‘customer-centric’ model that focuses on customer experience and skilled and specialist staff as differentiators to the volume driven approach of discounters2." The 6CPA “Community Needs Project” conducted by PricewaterhouseCoopers in 2014, also offered the idea that in order to inform the further development of consumerfocused policy in relation to community pharmacy services, consumer needs, expectations and experiences must be better understood. The project identified that the key areas of focus for community pharmacy in the future, to better address consumer need, include: Greater services in the pharmacy to meet consumer needs and improved communication about what the pharmacy can offer; greater differentiation from supermarkets; greater privacy in community pharmacy; and improved integration with other health service providers3.

THE FIRST STEP FOR PHARMACY TRANSFORMATION IS: >> GOAL SETTING Without very clear goals and objectives, the transformation will be difficult, unstructured and may not even succeed. Everyone knows what a goal is, however, a goal that's not written down is a wish. Similar to your vision, you have to be able to identify specifically what it is and have it written down so you can measure your progress against it.

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Having goals will: • • • •

Achieve your objectives; Improve teamwork and collaboration; Help everyone understand the direction your business is heading in; And most importantly HELP YOUR BUSINESS GROW!

Peter Saccasan is quoted as saying “A strategy that is 90% right but 100% executed is better than one which is 100% right and never executed.” A common acronym for goal setting used by Peter Sacassan and many others is SMART. Your SMART goal is a goal that is Specific, Measurable, Achievable, Realistic, and Time bound. S — Specific: Great goals are well-defined and focused. The moment you focus on a goal, your goal becomes a magnet, pulling you and your resources toward it. M — Measurable: A goal without a measurable outcome is like a sports competition without a scoreboard or scorekeeper. Numbers are an essential part of business. Put concrete numbers in your goals to know if you’re on track. A goal white board posted in your office can help as a daily reminder to keep yourself and your employees focused on the targeted results you want to attain. A — Achievable: Check pharmacy industry benchmarks to get a handle on realistic performance outcomes to set smart goals. R — Realistic: Achievable business goals are based on the current conditions and realities of the broader sector, as well as the available resources and expertise within the business.

CONTINUING PROFESSIONAL DEVELOPMENT

T — Time bound: Business goals and objectives just don’t get done when there’s no time frame tied to the goal-setting process. Whether your business goal is to increase revenue by 20% or find 15 new customers, choose a time-frame in which you will seek to accomplish your goal4. As we move towards the Health Solutions model, some attainable common goals for pharmacy could be: 1. Increase Script Reminder Service to 14% of total script numbers; 2. Within three months; 3. Implement Pharmacy vaccination service by flu season 2017; 4. Increase DAA service to 3% of total script number within 6 months; 5. Engage diabetes educator in pharmacy two days per week.

THE SECOND STEP: >> ALIGNING YOUR GOALS Transformational change must involve as many people as possible as early as possible. The role of a leader in pharmacy needs to be to build a strong team environment, create a new culture within their pharmacy and align their people and their customers to change5. Pharmacy owners and managers need to promote communication and identify their goals in consultation with their key team members to ensure they are on-board with the proposed plans and share the company vision. Goal alignment is critical for business success. It ensures that each person within your organisation can see the direction for the business and know how their job fits in with the “Big Picture”. To achieve goal alignment in your organisation, you must then communicate your strategic business objectives across the entire company. Then there are the customers. We need to ensure our goals are aligned with our customer needs. Often mistakes are made because we assume we know what our customers want without asking the actual question or we assume they are satisfied with our pharmacy simply because they keep returning. What if they want more but don’t know what more is on offer? Or they just haven’t been given the opportunity to say… An effective way to gather this important information is to complete an impartial customer survey of your pharmacy. Whilst many retailers are nervous about having customer surveys, especially when done by an independent auditing company, they are an opportunity to set your goals based on your customer feedback. A professional survey may focus on such

areas as customer service and pharmacy appearance as well as identify the customer’s awareness of the services you provide. Pharmacy customer survey statistics reveal that 64% of customers were not aware of any of the professional services provided by their pharmacy6. The reports generated following a customer audit will benchmark your results against other pharmacies giving you an awareness of what is happening in the industry. Data currently being collated indicates that observationally pharmacies have a lack of appropriate place for confidential conversation in more than 15% of pharmacies. That would then lead your pharmacy to set a goal to enhance private consultation screens, or discrete locations in the pharmacy where customers feel more comfortable and discuss their health needs appropriately.

THE THIRD STEP: >> GATHER YOUR TOOLS We are building a new business structure in our pharmacy and nothing can be achieved without the appropriate tools. Today, pharmacy owners are able to find assistance from different industry representatives and business development companies to take their first step into this new environment. There are programs that can be chosen to not only align with the transformation of pharmacy but also to align with the specific goals of the pharmacy and the experience of the team. Within these programs there are often different levels of support specific to the pharmacy needs and the experience of the team. Many pharmacies find significant benefits with being part of a Banner Group as they provide experience and knowledge as well as help develop plans for the pharmacy to achieve. They may help with advertising of the new services of the pharmacy to consumers and even use your data to help identify the results of any implementations after a length of time. There are also professionally developed tools to ensure that pharmacies have experienced teams. Training modules may be part of the program you choose for your pharmacy. Pharmacy owners have access to up-to-date standards and guidelines for delivering services within your pharmacy. It is important to make the time (set the goal) to educate yourself and understand and adhere to standards and guidelines to remain professional at all times. If in doubt pharmacists should refer to professional codes, guidelines and policies available from APHRA which include such documents

as a social media policy, compounding, staged supply, dose administration aids and advertising regulated health services, such as vaccinations7.

THE FOURTH STEP: >> IMPLEMENTING YOUR PLANS What actions are needed to implement these strategies? Implementation of your goals will need to happen on many different levels and therefore this step may be the most demanding on your time and resources. But pharmacy teams need to be dedicated to this wholeheartedly if they hope to achieve success. Prioritising before implementing is vital. Pharmacy teams need to create a business plan. If we are working towards improving our current productivity, having a good business plan is an important step to implementing our plans and achieving your goals. Creating a business plan can increase efficiency, quality and accountability. There are many business plan templates available for the owner and pharmacist to utilise. One example is from the Plan for the Future of your Business which describes how resilience involves purposeful action to work out your plan, commit to change and incrementally adjust. The template used in this example is one which poses questions to the user such as why, what, how, who and when and review4. If one of our pharmacy goals was to increase our script reminder service numbers, then to make this happen we would have to designate time and money to purchasing a software program, train ourselves and our team on the system, revise our workflow to ensure we have appropriate availability to explain the process and benefits of this new program to our customers. Whilst this example doesn’t involve all of the steps necessary, it shows why a structured approach and robust analytics is required prior to investing time and resources. If another goal was to introduce Personal Health Checks, such as a 30 minute Women’s Health Check, into our pharmacy we would again need to train appropriate staff on how to deliver this professional service and then provide them with suitable recording procedures and guidelines. Looking within the pharmacy industry, there are many inspiring examples of pharmacies that have successfully achieved their transformation goals. Capital Chemist Wanniassa are the Guildcare Pharmacy of the Year for Excellence in Professional Innovation 2017. They are passionate about engaging with their community and so they implemented a plan to extend their trading hours and are now available to their patients for 99 hours

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CONTINUING PROFESSIONAL DEVELOPMENT

per week. They are quoted as saying “Our mission is to be the pharmacy experts at the forefront of extended-hours healthcare. Our vision is to make a positive impact and support the health of our community. Our team strives to be the most educated and passionate pharmacist health experts in Canberra,” and as Elise Apollini says, “We want all our customers to leave the pharmacy feeling like they have received a ‘health hug”.

FINAL STEP: >> ANALYSING YOUR ACHIEVEMENTS How will you measure whether you have achieved your goal? Now is not the time to assume we have been successful, or give up on our goals because we haven’t seen instant success either. It is critical that pharmacy managers and pharmacists are aware of the results of any new programs or services they have developed and if they have they received return on their investment. The process of evaluating data using analytical and logical reasoning to examine each component of the data provided is necessary for a complete analysis8. This is not just the investment of money for the pharmacy. For example, a pharmacy installs a new consultation room which costs approximately $10,000 and delivering services in the first year may have only generated $2000 for your pharmacy. However, other measures along the way to track and review your success could be measuring pharmacist floor time, calculating the number of referrals over defined time period, number of consults that were executed seamlessly. Observe your staff and ensure they are a continued reflection of your new pharmacy model. Have open discussions with your team and management regularly and encourage opinions.

REFERENCES: ¹ Guild Digest 2016, A Survey of Independent Pharmacy Operations in Australia. Pharmacy Guild of Australia. 2 Pharmacy, A challenging and changing outlook. KordaMentha. February 2014 Publication No. 14-01. 3 6CPA Consumer Needs Project. 6th Community Pharmacy Agreement. PriceWaterhouseCoopers RFT2010/11-01. 4 Plan for the future of your business. Peter Saccasan — Director of Pharmacy Services, RSM PLAN https://www. guild.org.au/__data/assets/pdf_file/0018/5652/plan-for-the-future-of-your-business.pdf 5 How to Get Health Care Employees Onboard with Change. Jeffrey Brickman. Harvard Business Review. November 23, 2016. 6 Customer Experience Index, Customer Awareness – Pharmacy Services, The Pharmacy Guild of Australia. 7 AHPRA Pharmacy Board of Australia Codes, Guidelines and Policies 2016 http://www.pharmacyboard.gov.au/ Codes-Guidelines.aspx 8 BD Business Directory 2017 http://www.businessdictionary.com/definition/data-analysis.html 9 Benchmarking your pharmacy and extracting value from your professional services offer. Kos Scalvos. March 2017; APP2017.

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 The Guild Digest Comparative Study 2014/15 and 2013/14 saw what percentage per pharmacy decrease in script volume? a. 2.6% b. 4.6% c. 7.1% d. 6.4%

QUESTION 2 According to the PricewaterhouseCoopers 6CPA Consumer Needs Project which one of the following was NOT identified as a key area of focus for community pharmacy in the future? a. Greater privacy in community pharmacy b. Improved communication about what the pharmacy can offer c. Decreased differentiation from supermarkets d. Improved integration with other health service providers

QUESTION 3 Thinking about the Goal Setting acronym SMART, which one of the following would be helpful in measuring a new professional service in your pharmacy? a. Time taken (minutes) for the pharmacist to perform the professional service in comparison to pharmacy assistant. Therefore allowing to find efficiencies in service delivery and staff behaviour. b. Utilising a demographic tool when developing the professional service to ensure it meets your consumer’s needs and disease state concerns. c. Investment and training in a real time tracking and recording platform for the professional service and utilisation by all pharmacy staff. d. Monthly reports information provided to pharmacy management staff.

QUESTION 4

Pharmacies cannot underestimate the net benefit achieved from professional services and clinics. Elements such as patient fees, prescriptions dispensed, stickiness, 6CPA remuneration and over-thecounter purchases equal gross profit for the pharmacy. By putting this against the clinic costs, labour and resources, pharmacies complete business planning and can have a clearer understanding 9.

Which one of the following would not benefit the pharmacy in aligning your goals? a. Investment in a third party provider to facilitate goals for the business and therefore conduct robust reporting and analysis performance of the team. b. Conduct a consumer survey to ensure the pharmacy’s goals align with the consumer’s needs. c. When selecting staff members to be ‘champions’ of professional services it is recommended to delegate to avoid confrontation and ensure all services have been accounted for. d. Describing the vision of the business to other allied health professionals in the area and ensure same message is delivered in all facets of the business.

Becoming a health solution for the consumers is not a phrase that should be thrown around lightly. It is a transformational approach for the community pharmacy industry to move into the future. The key steps described here should place you in the starting blocks to enhance consumer engagement, provide optimal health outcomes and remain viable in the future.

QUESTION 5 Which one following is not a step in pharmacy transformation? a. Reducing pharmacies reliance on revenue received from the dispensary. b. Reducing labor costs and enhance incentives for staff to perform professional services on an ad-hoc basis. c. Re-evaluating goals for the business and discussion projections into the future to ensure viability in a changing market. d. Utilisation of business intelligence tools and awareness of competitors.

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BUSINESS

How Pharmacy Alliance is Helping Members Combat PBS Reforms NIMFA MARTINEZ General Manager, Marketing and Member Services Pharmacy Alliance

WITH AN INCREASINGLY CHALLENGING PHARMACY ENVIRONMENT CONTRIBUTING TO BUSINESS TURNOVER, AND PROFITABILITY DECLINING OVER THE LAST FEW YEARS, PHARMACY OWNERS ARE REQUIRED TO LOOK BEYOND WHOLESALE TRADING TERMS, GENERIC MARGINS AND PBS REVENUES THAT WERE ONCE THE DRIVING FORCE OF BUSINESS PROFITABILITY.

disclosure and highlight these within Z Software Dispense. Accessing information early from the PBS has been vital. Once we have this information, we analyse it and make prudent decisions on how we should manage the line impacted by price disclosure; then flag these lines within our ordering systems. By doing this, we have been able to lessen the upfront impact of the decrease via stock management and reduce our ordering leading up to the change.

For almost 15 years, Pharmacy Alliance has helped pharmacy owners create sustainable pharmacies to not only meet their customers' health needs, but ensure their pharmacy is maximising their profitability. As another round of cuts came into effect in April — with reductions of up to 30% on higher value items such as Rosuvastaton — it has become crucial to unlock new sources of long-term revenue streams to aid offsetting the ongoing impact of PBS reforms and to also maintain future profitability in the years to come. Increasing business operational efficiency over the past 12–18 months has also been a focus in reducing overall business expenses, and freeing up and redeploying existing labour resources to new business services and offerings in order to unlock new income streams, without increasing overall labour costs. Our Partner Alliance membership service creates high performing pharmacies that meet community needs and deliver the agreed business plan for each pharmacy for pharmacy owners. In light of the challenging trading environment, with our 70+ Partner Alliance pharmacies, we have implemented a strong program to increase operational efficiency.

•

We ensure our pharmacy teams focus on generic lines where an originator line incurs a brand price premium and we emphasise the importance of using the generic drug to capture the extra $1.74 that is offered from the 6CPA. We also reward our members for this behaviour via our generic rewards program, Pharmacy Alliance Generic Module (PAGM) that pays a rebate for generic substitution within the dispensary. We have implemented our pharmacistled program: o

We have trained and developed our pharmacy team to forward dispense to drive companion selling and to engage the customer to improve customer loyalty.

We have re-merchandised selected pharmacies into zones where customers receive undivided attention with

THE PROGRAM FOR PARTNER ALLIANCE PHARMACIES •

Through our partnership with pharmacy management software company Z Software, we have developed a way to measure lines which have been impacted by price

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their pharmacist and other professionally trained staff to provide health solutions rather than just products or services. •

To compliment the PAGM program, our pharmacy teams have been trained and coached to focus on front-of-shop and middle-of-shop lines where more margins can be generated to recoup some of the loss from the dispensary via our latest rewards program, Alliance Rewards. In addition to this, our category management team works closely with our operations team to ensure that each pharmacy has the right categories and product ranges to meet the unique needs of each pharmacy.

•

We have worked with our preferred wholesaler to minimise the impact of trading terms through new ordering initiatives.

•

We have had a strong focus on sleep apnoea partnering with a service provider to implement a Sleep Apnoea program where it adds value to the pharmacy. Where we have done so, the pharmacy has been able to unlock over $40k in revenue in the first 7 months with a healthy GP margin of 40%. The program has also resulted in letters of gratitude from local GPs and numerous testimonials from customers using the service, helping the pharmacy to extend their services to the community as well as strengthen the collaboration with other local health professionals.

As part of the Queensland Government’s Community Work Skills project, The Pharmacy Guild of Australia, Queensland Branch is currently facilitating Certificate II in Community Pharmacy (SIR20116) training. The fully subsidised, 6 week program includes two weeks of unpaid vocational placement, and provides graduates with the skills necessary to succeed in an entry level role in community pharmacy.

“While in previous years there has been some gaps in terms of entry methods for Pharmacy Assistants into the industry, this program provides a good first step.”

Michael Garret, Pharmacist and Manager at Arana Plaza Day and Night Chemmart employed Community Work Skills graduate, Glenn Frost after meeting him during the two week vocational placement component of the course.

“I would definitely recommend the program to other Pharmacies considering hiring a graduate from the program.”

“It quickly became apparent that Glenn had a great foundational skill set from his training with the Guild, which has continued to develop over time in his role.” He said.

Mr Garrett shared that it had been a rewarding process, getting to teach someone from the beginning of their pharmacy career.

With three intakes of the program now complete and another three set to commence before the end of July, there are certainly opportunities to employ program graduates. REGISTERED TRAINING ORGANISATION (0452)

To view our current course graduates, visit www.guild.org.au/graduates or to learn more about the program, visit www.guild.org.au/cws

HEALTH

Urinary Tract Infections in Women PROFESSOR BERNARD HAYLEN MB BS (SYD) MD (L’POOL) FRCOG FRANZCOG CU Consultant Urogynaecologist St Vincent’s and Mater Clinics Prince of Wales Private Hospitals Conjoint Professor, University of NSW, Sydney, NSW

A: INTRODUCTION – TYPES OF URINARY TRACT INFECTIONS (UTI) Around 50% of women will have a urinary tract infection (UTI) sometime in their life1. Most of these will be uncomplicated, i.e. there is no structural or functional abnormality of the genitourinary tract, particularly those abnormalities interfering with normal voiding and flushing of any bacteria from the urine. Examples of a complicated UTI include a wide range of causes of urinary tract obstruction or impaired voiding, urogenital surgery/ instrumentation, renal impairment or immunecompromise. Recurrent urinary tract infections in women involve the determination of the occurrence of at least three symptomatic and medically diagnosed UTI over the preceding 12 months2. Recurrent UTI is of the six “most common2” diagnoses in female pelvic floor dysfunction (PFD).

B: EPIDEMIOLOGY The majority of recurrent UTI are believed to be re-infection from extraurinary sources such as the rectum or vagina. However, uropathogenic E. coli, which cause the vast majority (around 80%) of UTI, are known to invade urothelial cells and form quiescent intracellular bacterial reservoirs (QIRS). It is thought QIRS may provide a source for bacterial persistence and recurrence3,4.

Other causative pathogens are Klebsiella, Enterobacter, Proteus, Pseudomonas, Staphylococcus and Enterococcus.

C: CLINICAL PRESENTATIONS Acute or recurrent presentations will note the typical symptoms of dysuria, pain, suprapubic cramping, frequency, nocturia, cloudy urine or haematuria and urgency. Pyrexia, flank and/or back pain, in addition to lower urinary tract symptoms may indicate involvement of the upper urinary tract (pyelonephritis). Older patients may present with delirium, confusion, falls or immobility. The presence of nitrites, with or without leucocyte esterase, in dipstick analysis, indicates a likely UTI. Midstream urine with bacteriuria greater than 105 colony forming units (CFU)/mL is sufficient for diagnosis of a UTI. Acute antimicrobial treatments may be based on practitioner preference and prior experience, culture sensitivities and case complexity. A history of 3 symptomatic and medically proven UTI is needed to absolutely confirm the diagnosis of recurrent UTI. Appropriate microbiological evidence should be sought, if available.

D: INVESTIGATION OF RECURRENT UTI A renal tract ultrasound is an eminently reasonable investigation, looking for (i) high post-void residual (PVR); (ii) calculi; (iii)

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other urinary tract abnormality or pathology. Specialist or subspecialist assessment, including cystoscopy will depend on the complexity of the UTI history and/or treatment difficulty. Pain or haematuria with infections would definitely lower the threshold for this assessment. A “functional study of the lower urinary tract” urodynamics may be required if other symptoms of pelvic floor dysfunction, including symptoms and/or signs of pelvic organ prolapse, (POP), which can create voiding dysfunction, are present.

E: MANAGEMENT OF RECURRENT UTI Medical management of recurrent UTI (and voiding dysfunction if present), in most cases, involves effective UTI prophylaxis, not only to prevent infections, but to improve inflammatory contributions to abnormal voiding parameters, in particular, a raised PVR. Surgical management may be at times necessary for both if the recurrent UTI are deemed to be due to a high PVR — in turn, the result of a surgically relievable cause (more in older women), such as urethral stenosis (urethral dilatation) or POP repair. Outcomes of management for the majority of cases of both diagnoses are effective with symptomatic and objective control. Different medical and surgical factors, however, can certainly increase the complexity of their diagnosis and the efficacy of treatment.

HEALTH

“Acute or recurrent presentations will note the typical symptoms of dysuria, pain, suprapubic cramping, frequency, nocturia, cloudy urine or haematuria and urgency. Pyrexia, flank and/or back pain, in addition to lower urinary tract symptoms may indicate involvement of the upper urinary tract.”

F: UTI PROPHYLAXIS In terms of non-antibiotic UTI prophylaxis, there is Cochrane evidence supporting the use of methenamine (hexamine) hippurate5, which requires acidic urine (pH<5.5) and there is limited evidence for the role of Vitamin C6 in acidifying urine; and vaginal (though not oral) oestrogen in postmenopausal women7. As a Category A medication, the use of methenamine hippurate (Hiprex™) can be used in pregnancy and breastfeeding though it is contraindicated in cases of renal or hepatic impairment, gout or dehydration. Long-term use has demonstrated a favourable safety profile. The use of cranberry products (tablets or juices) to prevent UTI has not been supported by updated Cochrane reviews8. Insufficient evidence is available to make a recommendation on D-Mannose or Probiotics. In terms of antibiotic UTI prophylaxis, there is evidence for the efficacy in sexually active women, of a single postcoital dose of antibiotic to prevent recurrent UTI, if it was established the UTI were definitely postcoital. Studies have involved trimethoprimsulfamethazole9 or ciprofloxacin10; the latter study showing no difference in efficacy between postcoital and daily use. Other postcoital antibiotics used are nitrofurantoin, cephalexin and norfloxacin; however, the latter is generally reserved for treatmentresistant organisms. There is Cochrane evidence11 for the efficacy of continuous low-dose antibiotics. The same range and dose of antibiotics has been used as for the above postcoital antibiotics. The severe sideeffect profile was low with less severe side effects, including vaginal and oral candidiasis and gastrointestinal symptoms. Caution needs to be taken when using nitrofurantoin where there are the risks of hepatotoxicity, pneumonitis and some neurological symptoms11,12. References available on request

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HEALTH

Gestational Diabetes ELLIE GRESHAM Accredited Practising Dietitian B. Nutrition and Dietetics PhD

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HEALTH

GESTATIONAL DIABETES IS A FORM OF DIABETES THAT OCCURS IN WOMEN DURING PREGNANCY, USUALLY AROUND THE 24TH TO 28TH WEEK OF GESTATION. IN AUSTRALIA, 12–14% OF WOMEN WILL DEVELOP GESTATIONAL DIABETES. WHILE MOST WOMEN WILL NO LONGER HAVE DIABETES AFTER THE BABY IS BORN, SOME WILL CONTINUE TO HAVE HIGH BLOOD GLUCOSE LEVELS, WITH APPROXIMATELY 50% OF WOMEN DEVELOPING TYPE 2 DIABETES. THE BABY IS ALSO AT INCREASED RISK OF DEVELOPING TYPE 2 DIABETES LATER IN LIFE.

Diabetes is a condition where there is too much glucose (sugar) in the bloodstream. Glucose is an important source of energy, originating from carbohydrate-containing foods such as breads, cereals, potato, pasta, rice, fruit and certain dairy products. Blood glucose levels are regulated by insulin, a hormone produced by the pancreas. Insulin moves glucose from the blood into the body’s cells where it can be used as energy. Diabetes develops when the body does not make enough insulin or the insulin is not working properly. During pregnancy, the placenta produces hormones that support the baby’s growth and development. Some of these hormones reduce the action of insulin, known as insulin resistance. As a result, the need for insulin in pregnancy can be 2 or 3 times higher than normal. If the pancreas cannot produce enough insulin, blood glucose levels rise and gestational diabetes develops. After the baby is born, the mothers’ insulin requirements return to normal and the diabetes usually resolves.

WHO IS AT RISK? Risk factors for developing gestational diabetes are: •

Increasing maternal age (≥40 years);

•

Family history of type 2 diabetes or a first degree relative (mother or sister) who had gestational diabetes;

•

BMI > 30 kg/m2 (pre-pregnancy or on entry to care);

•

Ethnicity (Aboriginal or Torres Strait Islander, Asian, Indian subcontinent, Maori, Middle Eastern, non-white African);

•

Previous gestational diabetes;

•

Previous elevated blood glucose level;

•

Polycystic ovary syndrome;

•

Multiple pregnancy;

•

Previous large for gestational age (LGA) (birth weight > 4500g or 90th percentile);

•

Previous perinatal loss;

•

Medications (corticosteroids, antipsychotics).

• Frequent thirst; • Excessive urination; • Tiredness; • Thrush (yeast infections); • Bladder infections; • Nausea and vomiting; • Sugar in urine; • Blurred vision; • Mood changes.

INDICATIONS FOR BEING TESTED Women who have one or more risk factors should be tested initially when their pregnancy is confirmed and then again at 24 weeks if diabetes was not detected earlier. All women should be tested around 24–28 weeks gestation (except those already diagnosed with diabetes or known to have gestational diabetes). Gestational diabetes is diagnosed using an oral glucose tolerance test (OGTT). Diagnosis occurs when the woman’s blood glucose level is above normal range at either the fasting (≥ 5.1 mmol/L), one (≥ 10 mmol/L) and/or two (≥8.5 mmol/L) hour blood tests.

MANAGEMENT OF GESTATIONAL DIABETES Management of gestational diabetes is a multidisciplinary team effort, involving the woman with gestational diabetes, doctor, specialist doctors (if necessary), Accredited Practising Dietitian (APD), Credentialed Diabetes Educator, pharmacist and midwife. Gestational diabetes is often initially managed with healthy eating, regular physical activity and monitoring blood glucose levels.

Dietary advice Managing gestational diabetes can help keep blood glucose levels in the target range for a healthy pregnancy. Women with gestational diabetes are encouraged to: •

Eat regular meals and small amounts often;

•

Include controlled amounts of carbohydrate foods at every meal and snack, choosing high fibre and lower glycaemic index (GI) options such as rolled oats, grainy breads, milk, yoghurt, brown rice and natural museli;

•

Avoid food and drinks that are high in added sugars and have little nutritional value;

Some women who develop gestational diabetes have no known risk factors.

WHAT ARE THE SYMPTOMS? Gestational diabetes usually has no symptoms. If symptoms do occur, they can include:

•

Limit foods high in saturated fat by choosing lean meats, skinless chicken and low-fat dairy;

•

Include small amounts of healthy fats such as olive oil, avocado, seeds and unsalted nuts;

•

Eat a wide variety of nutritious foods including vegetables, fruits, lean meats, low-fat dairy and wholegrain breads and cereals;

•

See an APD who can provide expert advice on the proper nutrients for a healthy pregnancy.

Physical activity Physical activity helps reduce insulin resistance and is an effective way to lower blood glucose levels. Engaging in 30 minutes of moderate physical activity daily is advisable. Women should talk to their doctor before starting or continuing any physical activity.

Monitoring blood glucose levels Blood glucose monitoring is an essential part of managing gestational diabetes, and is helpful for understanding the effects of food and physical activity on blood glucose levels. Suggested blood glucose levels are: fasting/before meals ≤5.0 mmol/L, 1 hour after commencing meal ≤7.4 mmol/L and 2 hours after commencing meal ≤6.7 mmol/L. If blood glucose levels are elevated, medication may be needed.

Common medications used Blood glucose lowering medications are generally not used during pregnancy, with the exception of metformin. Therefore, insulin injections may be necessary. Approximately 27% of women require insulin to help keep their blood glucose levels in the target range. Women requiring insulin s work closely with their doctor and diabetes educator to monitor and review medications and blood glucose levels. Patients seeking individualised dietary advice should be referred to an APD. APDs are University-trained to provide evidencebased dietary advice tailored to the specific needs of each client. Pharmacists are a key referral agent to APDs and are well positioned to ensure that both, medications and dietary advice are followed. To locate your local APD, search ‘Find an Accredited Practising Dietitian’ at www.daa.asn.au or freecall 1800 812 942.

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BUSINESS

NAPSA Proudly Supporting

LIVIN for Charity Cup 2017 VASILIOS SOTIROPOULOS NAPSA Pharmacy Awareness Chair

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BUSINESS

For full access to media releases and position statements, please visit our website: www.napsa.org.au | E: pharmacy.awareness@napsa.org.au | P: 0451 096 007 *For more information on LIVIN, please visit www.livin.org.au

CHARITY CUP IS A PHARMACY AWARENESS INITIATIVE OF THE NATIONAL AUSTRALIAN PHARMACY STUDENTS’ ASSOCIATION (NAPSA), WHICH BEGAN 8 YEARS AGO, AND WHERE EACH BRANCH COMPETES TO RAISE THE MOST MONEY FOR A CHOSEN CHARITY. NAPSA HAS CONCLUDED ANOTHER SUCCESSFUL CHARITY CUP IN EFFORTS TO RAISE MONEY AND AWARENESS FOR LIVIN. THE ANNUAL, NATIONWIDE COMPETITION BEGAN ON 3 APRIL, CONCLUDING ON 26 MAY.

The 2016 National Pharmacy Student Survey (NPSS) highlighted the areas of education pharmacy students would like to see a heavier focus on from NAPSA. 56% of respondents indicated mental health (see Figure 1) and following this, 73% of respondents indicated that Mental Health First Aid training should be a requirement of the Pharmacy Board of Australia (PBA) to become a Registered Pharmacist (see Figure 2)1. It is this widespread consensus that led NAPSA to choose LIVIN as our chosen charity for Charity Cup 2017.

Figure 2

Do you think MHFA training should be a requirement of the Pharmacy Board of Australia to become registered as a Pharmacist?

16.8%

Figure 1

Which areas of education would you like to see a heavier focus from NAPSA?

9.9%

NO 73.3%

Mental Health Pharmacy placements

TYPE OF EDUCATION

YES

UNSURE

Pharmacy practice GuildCare training Business-related education Smoking cessation Vitamin training Asthma Cardiovascular disease

One common event, across all NAPSA branches, was a session to have LIVIN representatives come to each state to present an educational event to students. Whilst raising much needed funds for LIVIN was a goal for Charity Cup, it was important to not lose sight of the impact NAPSA can have by raising awareness about what LIVIN do to help those with mental illness.

First Aid Diabetes Other

NUMBER OF RESPONSES

Branch members proudly supported LIVIN, a not-for-profit, mental health charity founded with a mission to eradicate the stigma associated with mental illness in today’s modern society, and raise awareness for suicide prevention. Their mantra #itaintweaktospeak, has resonated with many students, who themselves are advocates for mental health. NAPSA has observed many members show solidarity and strength together with those afflicted with illnesses commonly found in the younger generation, such as depression and anxiety. Unlike other charities in the mental health space, past and present, LIVIN use apparel, mainstream media and profiles to get people talking about mental health. This strategy is perfectly aligned in the core target demographic and by implementing the mission, vision and values, LIVIN and NAPSA believe together, we can change the way people understand and interpret mental illness.

By turning the spotlight on causes previously considered taboo or controversial, NAPSA intends for this campaign to help remove the stigma surrounding mental illness. In doing so, this will empower, embrace and effectively give hope to those that need it most. NAPSA aims to encourage students to own their mental illness and lived experiences, and not be embarrassed to talk about their issues. The more people that talk and accept mental illness for what it is, the more comfortable and confident people will feel about seeking help and getting back on track. As long as you are speaking, you are never alone. Charity Cup is about more than just raising money for a worthy organisation; it’s also about showcasing student support of those often marginalised by society.

NAPSA organised an Everyday Hero website to track how branches place against each other in receiving online donations, but the involvement doesn’t stop there: branches also had barbeques, organised chocolate drives, quiz nights and cocktail events. Education is key to the success of reducing suicide rates in society. Therefore, the funds raised are going to be funnelled towards stigma reduction and motivational awareness campaigns, and programs throughout schools and universities.

The winners of Charity Cup 2017 will be announced at NAPSA’s Annual Dinner on 15 July in Melbourne. NAPSA encourages and welcomes the pharmaceutical industry to support LIVIN* and future NAPSA Charity Cup campaigns. REFERENCES: National Pharmacy Students' Association 2016, National Pharmacy Students' Survey 2016, viewed 24 April, <https://surveys.utas.edu.au/index.php/578874>.

"Charity Cup is about more than just raising money for a worthy organisation; it’s also about showcasing student support of those often marginalised by society." GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

HEALTH

The

Blood Type

You Didn’t Know You Had ALISON GOULD Clinical Services and Research at the Australian Red Cross Blood Service

SOMETIMES IT TAKES A RARE OCCURRENCE TO UNDERSTAND THE COMMONPLACE. IN A WORLD-LEADING STUDY, BLOOD SERVICE SCIENTISTS HAVE WORKED WITH COLLEAGUES IN THAILAND TO UNCOVER A BLOOD GROUP THAT, UNTIL NOW, HAS HIDDEN IN PLAIN SIGHT.

Apart from the commonly known ABO and Rhesus blood groups, there are hundreds of possible variations in blood type encoded in our genes and reflected in small changes on the surface of red blood cells. Accurate matching of these blood groups is particularly important for people who require frequent blood transfusions, such as those with diseases like thalassemia or sickle cell anaemia. Frequent transfusions with blood that is not a perfect match may lead to the development of harmful antibodies. This is what happened to one patient in Thailand who received a blood transfusion to help rectify his anaemia. He suffered from thalassemia — an inherited blood disease in which the body doesn’t make enough of the oxygen carrier, haemoglobin. After the transfusion, his body reacted by developing antibodies that could destroy red cells. This meant any future transfusions for the patient needed to be from blood that would not be destroyed by those antibodies. The Thai Red Cross National Blood Centre took samples of the patient’s blood and scoured their collections for blood that would evade the antibodies developed by the patient. They found just two compatible units of blood in their collection of thousands of samples. The Thai Red Cross National Blood Centre now had

three blood samples: one from the patient and two from donors, and knew that these samples had something rare in common, but did not know what that was. It was then that an Australian Red Cross Blood Service red cell serologist, scientist Dr Yew-Wah Liew, who was in Thailand for an international symposium, visited the Thai laboratory and noticed a poster describing the unsolved problem of the patient’s unusual antibody. This visit sparked an international collaboration as researchers in Australia and Thailand set out to solve the problem. The task was to discover what was special about the red cells from the patient and the two donors. The researchers turned to cutting-edge red cell serology and genetic analysis, called massively parallel sequencing, a specialty of our Research team at the Blood Service. Back in Australia, Blood Service scientists tested the three samples with very rare and specific reagents and analysed the blood group genetics for all three. They found that all samples had one molecular change in common. “The total testing strategy is very innovative and uses a combination of techniques that look at genes and at proteins,” explains Professor Robert Flower, group

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leader. “We gathered lots of data and it all fitted together, showing that this patient had a new variation in one of his red cell surface molecules. Patients who have this variation are at risk if they receive blood from anyone other than another person with the same variation.” In September this year, scientists from Professor Flower’s team, along with the Red Cell Reference laboratory manager, travelled to Dubai, presenting their results to the International Society for Blood Transfusion Reference Group, where their work was accepted as proof of the existence of a new blood group that is shared by more than 90 per cent of people — to be known as JENU (and officially designated MNS49). This story is just one example of how modern genetic techniques allow blood types to be characterised with pinpoint accuracy. “What’s great about this work is that it shows our researchers are part of a global community of research scientists who work together to improve the practice of blood transfusion worldwide,” concludes Professor Flower.

Find out more about Blood Service research at donateblood.com.au

HEALTH

“Apart from the commonly known ABO and Rhesus blood groups, there are hundreds of possible variations in blood type encoded in our genes and reflected in small changes on the surface of red blood cells.”

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BUSINESS

Managing in a Partnership FRANK SIRIANNI Management Consultant MEDICI CAPITAL www.medici.com.au

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

PARTNERSHIPS ARE, AND ALWAYS HAVE BEEN, AN IMPORTANT PART OF THE PHARMACY OWNERSHIP LANDSCAPE. RECENTLY THEY HAVE BECOME A MORE LIKELY METHOD OF PHARMACY OWNERSHIP AS THE CAPITAL AND MANAGEMENT REQUIREMENTS OF OWNERSHIP HAVE INCREASED BEYOND THE SCOPE OF MOST INDIVIDUALS.

•

an ability to share the joys & challenges;

The success of the partnership and related business is founded on how well the partners work and drive the pharmacy together.

•

a sensible financial approach;

3. Take some ‘me’ time

•

a permanent working arrangement;

Make sure you take some time off.

•

a possible step to future independence.

Turn off the mobile phone and build a weekly calendar which includes:

On the positive side, partnership offers partners:

However, managing a partnership requires different skills and approaches. Here is a checklist of 10 suggestions to a healthy and sustainable partnership based on successful pharmacy partnerships.

10 SUGGESTIONS TO WORKING IN A PARTNERSHIP 1. You are not the boss As a sole owner you are in charge. But as a partner, you need to consider the wishes and impact on your partner(s). It is a democratic process driven by equity or the Management and/or Partnership Agreement.

•

a decision-making framework.

focus on you and your family;

•

healthy exercise;

•

business idea generation.

Certain business decisions are critical to both the business and all partners (e.g. refit, refinance, introduction of a new partner, etc.).

discussion and debate;

• compromise;

time away from the pharmacy;

•

4. When a big decision needs to be made, include all partners

Recognise that you need: •

•

Consult all partners;

•

Agree to a process;

•

Comply with the Management and/or Partnership Agreement.

If you feel strongly about a decision, work through it to a consensus. Don’t be a dictator on decisions.

You need to establish and implement a decision-making process which meets each partner’s personal and business objectives. Even if you have effective majority control from a legal perspective for decisions, consider the long-term effect on your partnership. You don’t want the rot to set in or spoil the sustainability of the partnership relationship.

5. Walk in your partner’s shoes from time to time

2. Take regular time out together

Being in business is busy … time consuming. Your partner knows and understands this more than most.

Take regular time out away from the business to work on the business and not just in it.

Talk to your partner(s) about their views and how they feel about the business. Give some thought to their perspective. 6. Make communication with your partner(s) a priority

Make sure you:

This may be as simple as a weekly cup of coffee or breakfast, social/sporting pursuit, or as complex as a formal partnership meeting with an agenda.

•

understand that when your partner seeks to communicate with you, he or she knows that you are busy and must feel that the issue is important enough to bother you;

Use it to celebrate the successes, and work on the constantly required business improvements.

•

make time to communicate with your partners in both formal and informal ways.

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BUSINESS

"The success of the partnership and related business is founded on how well the partners work and drive the pharmacy together."

7. Make managing the partnership (as well as the business) a priority

BUILD YOUR PARTNERSHIP MANAGEMENT SKILLS There is a competent and willing generation of young pharmacists ready to take the challenge of pharmacy ownership. These individuals will form the cornerstone of independent community pharmacy and engaging with them in the form of partnership creates a solution to the continuity of the profession. We also note that there appears to be an increasing number of disenfranchised pharmacists struggling to raise the capital required for first-time ownership.

Don’t squeeze the partnership issues into the 5 or 10 minutes at handover. Management of the partnership requires a specific approach which is in addition to the business management. 8. Treat your partner as if he or she is the most important client or customer to you You’ll win clients, customers and patients through marketing, service and delivering results (outcomes or solutions). Your customers trust you because you care and offer genuine attention.

I see partnerships (whether corporatised or by agreement) as an important feature of independent community pharmacy. What do you think about this issue? Email your comments to me: fsirianni@medici. com.au.

Recognise the skills you use in customer management and professional service delivery, and apply the same principles to your partner(s). 9. Set and acknowledge each partner’s role •

Set clear roles for each partner. This will provide an understanding of their specialty skills and contribution to the business;

•

Acknowledge this role to staff as well as other partners.

WHAT ARE YOUR IDEAS? Tell us your story. What are your ideas? How are you building your new road map for your pharmacy in the light of recent challenges? Tell us some success stories. Let’s discuss — email me or call.

Staff should be aware of what each partner’s role and authority is in the business. Celebrate the contributions and successes. Let all concerned know when a partner has achieved a milestone or success and celebrate! 10. Review, contemplate and revise Make a point of having a regular review (i.e. quarterly or annual review). Spend some time to: •

review how the business (and the partnership) is tracking;

•

contemplate how to improve or work smarter;

•

revise, improve and regenerate.

These 10 suggestions are based on my research and experience.

As explained above, I am of the opinion that partnerships are a win–win solution not only for the individual partners (both incoming and exiting too), but also for the profession.

Please call Medici Capital on (03) 9853 7933 for further information. The following provides a summary of the websites where more information can be obtained: MEDICI CAPITAL – CORPORATE WEBSITE www.medici.com.au PRACTICE4SALE – LISTING SERVICE FOR PHARMACY SALES www.practice4sale.com.au JOBS4CAREERS – LISTING SERVICE FOR PHARMACY JOBS www.jobs4careers.com.au ATTAIN – BUSINESS BROKERS AND PROPERTY SALES www.iattain.com.au

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BUSINESS

NEW GROWTH AVENUES: Non-Core Categories Key to Driving Positive Pharmacy Performance MARK BLITENTHALL Associate Director Nielsen

A year later, channel growth has moderated substantially, to just below 1%. Despite this new low growth environment, strong performance in other, smaller pockets of the store — including infant formula and cosmetics — signals positive future growth prospects in pharmacy. Using the combined advantage of QuintilesIMS and Nielsen data, we can better understand the key dynamics driving the stabilisation of pharmacy sales over the past year, particularly in the three biggest segments: health, beauty and personal care. Nielsen data shows that solid growth in both the beauty (+5.9%) and personal care (+10.9%) segments has offset declines in health segment sales. Health, covering categories such as vitamins, analgesics and allergy remedies, is the pharmacy channel’s primary raison d’etre, accounting for around 60% of sales. Previously the channel’s heartland and growth engine, it has become its Achilles heel, with sales down by -3.2% driven by two main developments. Firstly, overseas demand for Australian vitamin products fuelled a windfall growth for the category starting from the second half of 2014, with a commensurate flow-on for the entire pharmacy channel. However, changes to Chinese import regulations in April last year dramatically reversed these gains. The second development relates to significant declines in the analgesics category. With a share of around 14% of all healthcare sales, analgesics has fallen by more than -13% over the last year, accounting for 63% of total healthcare declines. Nielsen ScanTrack Pharmacy data shows that the delisting of Panadol Osteo from the Pharmaceutical Benefits Scheme in January 2016 contracted the brand’s sales by almost -36%. On top of this, the imminent rescheduling of codeine-containing products in early 2018 has already impacted the market. The introduction of the Pharmacy Guild’s MedsASSIST program in response to this announcement has reduced sales of products containing codeine by around 20%. The effect of this new legislation will continue to be felt by the pharmacy channel for some time. In spite of these key changes, there are still stories of success coming from other pockets of the store. QuintilesIMS data shows that infant formula, for example, has grown by 82% over the last year, driven largely by Nutricia (+97% one year ago). And in beauty, cosmetic skincare products are starting

THIS TIME LAST YEAR, PHARMACY WAS THE STAND-OUT CHANNEL FOR FMCG SALES, WITH ANNUALISED VALUE GROWTH FOR OVER-THECOUNTER (OTC) PRODUCTS IN THE ORDER OF 14.2%.

FROM SOARING TO STABLE: KEY DRIVERS IN PHARMACY CHANNEL PERFORMANCE

to drive strong growth. Products such as Blackmore’s Vit E cream, a relatively new entrant to the category, is growing at 103%, while other new brands like Eaoron are also driving customer interest in the category. Interestingly, sales of these fast-growing categories have become more concentrated over time, giving more scope to players who want a share of this growth prize. QuintilesIMS data shows that in infant formula, 17.2% of pharmacies accounted for 80% of total category value in February 2013; this has now shrunk to just 3.8% of pharmacies accounting for 80% of sales in February 2017. The situation for multivitamins and supplements is similar, with 27.1% of pharmacies accounting for 80% of category value in 2013, to 14.1% accounting for 80% in 2017. The outlook continues to be moderate for the pharmacy channel for the rest of this year and into next. However, as the cases illustrated by cosmetic skincare and infant formula demonstrate, there are still areas where pharmacy can differentiate, versus other channels, to continue to drive growth. The trends also highlight that factors such as changes to government legislation, which pharmacists have a limited ability to influence, can have a profound and lasting effect on the channel.

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ABOUT QUINTILESIMS QuintilesIMS (NYSE:Q) delivers integrated information and technology solutions to drive health care forward. Around the world, healthcare stakeholders are working to improve real-world patient outcomes through treatment innovations, care provision and access to health care. For the information, technology and service solutions they need to drive new insights and approaches, they count on QuintilesIMS. With a global team of 50,000, at QuintilesIMS we harness insights, commercial and scientific depth, and executional expertise to empower clients to achieve some of their most important goals: improving clinical, scientific and commercial results, realising the full potential of innovations and ultimately, driving health care forward. For more information, visit www.quintilesims.com.

ABOUT NIELSEN Nielsen N.V. (NYSE: NLSN) is a global performance management company that provides a comprehensive understanding of what consumers Watch and Buy. Nielsen’s Watch segment provides media and advertising clients with Total Audience measurement services across all devices where content — video, audio and text — is consumed. The Buy segment offers consumer packaged goods manufacturers and retailers the industry’s only global view of retail performance measurement. By integrating information from its Watch and Buy segments and other data sources, Nielsen provides its clients with world-class measurement, as well as analytics that help improve performance. Nielsen, an S&P 500 company, has operations in over 100 countries that cover more than 90 percent of the world’s population. For more information, visit www.nielsen.com.

PRODUCT INSIGHT

Expedite and Improve your Oral Suspension Compounding Process MARINA HOLT BPharm MPS MACP PCCA Education and Training Manager

COMPOUNDING ALLOWS FOR THE CREATION OF CUSTOMISED MEDICATIONS THAT CAN BE ADAPTED TO FIT EACH INDIVIDUAL’S SPECIFIC NEEDS. HOWEVER, IT CAN BE A TIME-CONSUMING PROCESS. AT PCCA, MANY OF OUR INNOVATIONS ARE FOCUSED AROUND CREATING CUSTOMISED SOLUTIONS … FASTER.

Let’s say a patient is in need of an oral suspension that includes a bitter active pharmaceutical ingredient. The classic way to compound a suspension for bitter drugs takes some time to make. Even shortcuts — like mixing equal parts oral suspending agent and syrup vehicle with flavours — though effective, are still relatively time-consuming. Compounders want to make medication available to patients as soon as possible, so the prospect of a lengthy compounding process can prompt a search for a faster alternative.

It’s made with monk fruit. A natural, flavour-neutral, sugarfree sweetener, monk fruit has a pleasant sweet taste, which helps to neutralise the bad taste of the active ingredient.

It’s allergy-friendly. For the patient with multiple allergies, SuspendIt may be the answer. It is formulated without dye, gluten, casein, dairy, soy, egg, nuts, ethanol, parabens, propylene glycol, carrageenan, flavours, modified food starch or carbomer. The absence of these common allergens means that SuspendIt can be used for a wide variety of patients, including patients requiring a gastrostomy tube or jejunostomy tube.

INTRODUCING A MORE EFFICIENT WAY TO WORK PCCA SuspendIt™ is an all-in-one suspension base with a unique, patent-pending natural suspending agent. With SuspendIt, compounding pharmacists and technicians have the ease of using one versatile base. SuspendIt also works well with PCCA flavours and additional sweeteners, if desired.

COMPOUNDING SUGGESTIONS When compounding with SuspendIt, no additional wetting agent is needed. Compounding pharmacists can simply use a small portion of SuspendIt to wet the active ingredients included in their preparation. Although it is formulated without sugar, SuspendIt has a pleasant taste, so some APIs require no additional flavour or sweeteners. However, when working with extremely bitter actives, sweeteners such as Steviol Glycosides 95% and Acesulfame Potassium FCC can be added.

THREE MORE REASONS TO LOVE SUSPENDIT

SuspendIt uses a unique group of polymers that provides exceptional thixotropic flow. For the patient, this means their medication will more easily redisperse when shaken. For the pharmacist, this means that active ingredients are much less likely to cake at the bottom of the bottle. And for the practitioner, this means knowing that their patient is getting a more accurate and consistent dose.

Here’s how it works: When you suspend an active ingredient in a suspension base, the active ingredient isn’t dissolving — it’s just being suspended in the base. When a patient stores their medication on a shelf for daily use, the active ingredient starts to settle to the bottom. But, when a suspension has thixotropic flow, agitation causes the suspension to become thinner, allowing the active ingredients to redisperse quicker and easier.

WHAT’S THE BOTTOM LINE? For practitioners, SuspendIt means peace of mind knowing that their patients are getting more consistent and accurate dosing. Don’t hesitate to talk to PCCA about this product — it’s a great solution for many patients.

Do you have questions about PCCA Membership? Contact us today at PCCA Australia on (02) 9316 1500 or visit pccarx.com.au/join-pcca

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

HEALTH

The MS Gong Ride is the most Epic, Scenic, One-Day Ride you will do in 2017! DUSSY KUTTNER Marketing and Communications Specialist

FOR 36 YEARS, TENS OF THOUSANDS OF CYCLISTS HAVE HIT THE ROAD IN THIS LEGENDARY RIDE FROM SYDNEY TO WOLLONGONG TO RAISE FUNDS FOR PEOPLE LIVING WITH MULTIPLE SCLEROSIS.

Both the 90 km and 58 km courses take you through spectacular scenery as you make your way through the Royal National Park, enjoy incredible views from Stanwell Tops, pedal over the breathtaking Sea Cliff Bridge and cross the finish line in Wollongong amongst a backdrop of sun, sand and surf. This event WILL sell out, so gear up, get going, GONG and take on this awesome challenge to fight MS on Sunday 5 November 2017!

DIFFERENCE YOU MAKE The funds that you raise ensure that people living with Multiple Sclerosis get the support they need to live well, and ensure that no one has to face this disease alone.

“For the first time since being diagnosed, I was honest about what I was feeling, and I was able to do that with someone who I could have an intelligent and well-informed conversation with.” •

990 people were assisted with specialised advice from nurses, occupational therapists and social workers, helping people to maintain their quality of life, employment and delay of disease progression.

Here are some examples of what we have been able to do in the last year* thanks to you and the thousands of other supporters and participants who donated and fundraised.

•• 7,055 people living with Multiple Sclerosis were provided vital information and support via our MS Connect call centre.

•

“The MS Education program is critical in ensuring that people are making informed choices and have the right tools, information and techniques when they’re talking about Multiple Sclerosis with caregivers, care providers, employers, friends, family, and importantly, kids.” •

“Our experience in the NDIS trial sites suggests that only 30 percent of people living with Multiple Sclerosis will, at any one time, receive an individualised support package. We are looking forward to the positive impact MS Advisor will have on the remaining 70 percent who will still rely on MS services to maintain their quality of life.”

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2,367 people participated in 117 MS Education programs, providing them with critical information so that they can make informed choices about their health.

626 healthcare workers received education about Multiple Sclerosis to enhance the quality of care and outcomes for people with MS.

“The MS Education program is critical to making sure people are making informed choices.”

To register visit:

msgongride.org.au

PRODUCT INSIGHT

SkinB5 - Natural Acne Treatment Treating Acne with a Nutritional Approach JUDY CHEUNG Founder and Owner SkinB5

ACNE IS THE NO.1 SKIN DISEASE WORLDWIDE — 80% OF THE POPULATION EXPERIENCES IT. ACNE OCCURS ON THE FACE AND BODY, AND SEVERE ACNE CAN LEAD TO PERMANENT SCARRING. ACNE STARTS FROM WITHIN THE BODY, WHERE WE PRODUCE SKIN OILS, RELEASE HORMONES AND HARBOUR STRESS.

reduce acne by supporting fatty acids metabolism (via coenzyme A synthesis).

The first stop in an acne patient’s journey is their local pharmacy to seek professional advice. The difficulty with most OTC treatments is that they’re purely ‘topical’ and customers are only treating the surface with limited or short-term results. This is why SkinB5 is revolutionary — internally addressing the root causes, namely overactive sebum production, hormonal imbalance, immunity and stress, which are the main causes of acne. SkinB5 uses powerful nutritional formulas to effectively clear the skin from within, and also externally by applying healing skincare products. SkinB5 is also suitable for hormonal acne and acne with dry skin. SkinB5 addresses a gap in the market as a credible natural acne treatment combining both supplements and skincare to effectively achieve long-term results. Developed and made in Australia, SkinB5 is an innovative (patented) 4-step treatment to stop acne, from INSIDE and OUT.

WHY A NUTRITIONAL APPROACH TO TREATING ACNE IS EFFECTIVE SkinB5’s powerful nutritional supplements include a potent dose of vitamin B5, treating the root causes of acne by controlling skin oil production, strengthening immunity, relieving stress, supporting hormone balance and cell renewal (to help reduce scarring).

VITAMIN B5 FOR ACNE ••

Vitamin B5 is destroyed by modern food processing and is water soluble, so therefore, it needs to be replenished.

••

Scientific evidence shows higher doses can decrease pore size and

••

Excessive sebum production creates bacterial overgrowth, leading to congestion, blocked pores and acne.

••

By increasing the levels of B5 in the body, coenzyme - A production is increased which helps reduce sebum production, so skin will become less congested.

OTHER ESSENTIAL NUTRIENTS TO TREAT ACNE •

Vitamin B3 (Nicotinamide): Clinical studies show oral administration of Vitamin B3 is an effective treatment for acne.

•

Folic Acid (Vit B9): Studies found the combination of Copper, Zinc, Nicotinamide and Folic Acid as highly effective treatment of acne, skin healing and cell renewal.

•

Biotin (Vit H): Essential for skin, hair and nail health! It also helps the absorption of other B vitamins.

•

Zinc: Medical research suggests that people with acne might have low zinc levels. Zinc also helps heal blemishes and balance hormones.

•

Vitex (herb): Research has shown that Vitex Agnus Castus is ideal for treating hormonal acne with its amazing hormone balancing power. The Caplets contain Vitex.

•

SkinB5 Extra Strength Tablets are for moderate to severe acne. The Caplets are for mild, dry skin and hormonal acne, as well as for prevention and maintenance. The supplements are supported by gentle skincare products, all containing vitamin B5. They are designed to help the skin heal and rebuild, and restore its natural protective abilities against outside conditions, including bacteria. An awardwinning, 5-minute Skin Purifying Mask complements the range to purify skin and reduce inflammation.

SkinB5's effectiveness is proven and safe for users 12 years and above. SkinB5 is designed to tailor a solution to suit the individual and is suitable for all acne types. SkinB5 is available through Sigma, API and Symbion. RRP from $29.95 to $56.95 Stockist enquiry: 1300 088 655 or email pharmacy@skinb5.com For more information, visit www.skinb5.com

Silica: Scientific research supports the use of Silica to promote collagen formation, skin healing and cell renewal.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

60 SECONDS

WITH...

ROWAN LOWE

My best getaway ever was …

Donnybrook Pharmacy

I decided to become a pharmacist because … I wanted to work in a retail environment and also had an interest in health sciences. I admired the fact that pharmacy is such a well respected profession and I didn’t just want to become a salesman, but instead be able to have a positive influence on customers’ product choices.

I have been working as a pharmacist for …

A trip I took to Turkey with my wife. The country had more to offer than I realised, and we saw some amazing historical sites and tasted some delicious and different food.

How I keep myself updated on the market news … By flicking through industry publications, reading online content and discussions with my peers and colleagues.

Nine years.

Over the next three years in pharmacy, I predict …

What I like best about my job is … Getting to know our customers and their families. I like the fact that I have been able to develop relationships with my customers that carry over to when I see them out and about in the street. I enjoy working in a rural setting, not only for the close community feel but also as it gives me the opportunity to provide a large amount of wound care advice and primary care for skin conditions.

My favourite hobbies are ... Cycling. I enjoy both mountain biking and road riding, depending on the weather.

My favourite book is … The Darren Lockyer Autobiography … I am a big Rugby League fan.

It will continue on the path of becoming more service orientated, with the door being opened for Pharmacists to provide even more health care related services to the public.

If I could give any advice to someone starting a career in pharmacy, it would be… Keep yourself open to every avenue that the Pharmaceutical industry has to offer. There are many possibilities and opportunities that could come your way so be careful not to pigeon hole yourself. 10 years ago when I was completing my internship I would never have expected to be the owner of a community pharmacy in country Western Australia, but it has been amazing experience thus far and I am grateful for the learning experiences that it has provided me.

Guild Intern Training Program Preparing interns for their pharmacy future since 2011 “I chose the Guild Intern Training Program because it was the best choice for my community pharmacy career as it seamlessly combined clinical and practical knowledge to a high level. The assessments were relevant not only in preparing for the oral and written exam but also in daily practice.”

INTERN TRAINING PROGRAM

MORGAN KENNEDY, 2016 MIMS PHARMACY GUILD INTERN OF THE YEAR AWARD WINNER

WE KNOW PHARMACY

PRACTICAL LEARNING & FLEXIBLE STRUCTURE

MAXIMUM EXAM SUPPORT

MARKET LEADER IN PRICE

ACCESS TO INDUSTRY EVENTS

1300 110 161 info@internpharmacist.com.au www.internpharmacist.com.au

pharmacy

connect

Clinical updates

1 - 3 SEPTEMBER 2017 / HILTON SYDNEY

Fantastic speaker line up including 11 international speakers

Business growth, profitability & management topics

Access to business mentoring

Networking opportunities

MAJOR SPONSORS

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INDUSTRY NEWS & UPDATES ``HAVE YOU ASKED THE QUESTION: “ARE YOU AT RISK OF COELIAC DISEASE?” Coeliac Australia has launched an online self assessment tool for coeliac disease to help identify the many thousands of Australians unaware they are living with the autoimmune condition. Around 1.5% of Australians are affected by coeliac disease, but 80% remain undiagnosed. Untreated coeliac disease can cause chronic ill health and lead to liver disease, osteoporosis, other autoimmune illnesses and cancer. The self assessment tool www.coeliac.org.au/assess has been created for people to check symptoms of ill health or other risk factors for coeliac disease. If risk factors for coeliac disease are identified, the participant can download a letter to take to their GP with details of their results and links to Coeliac Australia’s resources. Once thought of as a childhood illness characterised by failure to

thrive and diarrhoea, coeliac disease is more commonly seen in adults, who may be apparently asymptomatic or suffer a variety of extra-intestinal manifestations caused by systemic inflammation. Pharmacists may be familiar with the commonly reported symptoms in coeliac disease including gastrointestinal upset, iron deficiency and lethargy. But presentations can be related, sometimes solely, to issues such as headaches, polyarthralgias, infertility, obstetric complications, hepatitis, dermatitis herpetiformis, osteoporosis, autoimmunity such as thyroid disease and type 1 diabetes, peripheral neuropathies, and neutropaenia. By being familiar with symptoms and associated conditions, pharmacists can play an important role in helping those with untreated coeliac disease. For details of the resources available to health professionals go to www.coeliac.org.au/resources.

``ALERE IN FOCUS Because Knowing now mattersTM , Alere delivers simple, fast and reliable health information through point-of-care (POC) testing solutions. Our product portfolio includes the Alere AfinionTM AS100 Analyzer which provides laboratory-quality HbA1c results in just over 3 minutes making this product ideal for use in pharmacies to support early diagnosis and management of diabetes.

“Alere also offers a large range of infectious disease tests, including the first molecular POC influenza test and the first POC HIV test available in Australia.”

Alere also offers a large range of infectious disease tests, including the first molecular POC influenza test and the first POC HIV test available in Australia. By making critical clinical diagnostic information available in a cost effective and actionable timeframe, Alere products help streamline healthcare delivery and improve patient outcomes. Visit www.alere.com.au

``OVER 55% OF PROFESSIONAL SERVICES APPOINTMENTS ARE MADE OUTSIDE OF BUSINESS HOURS! While you may already be providing professional services at your pharmacy, such as influenza vaccinations, are you able to take online bookings? 1st Group has taken over five million appointments via it’s online booking platforms, and in the past three years, over 55% of those appointments are made by customers outside of standard operating hours. Imagine a highly customisable solution that allows your pharmacy to take appointments for vaccinations online through your website at any time of day or night, take pre-service payments – and all of this integrated into your existing pharmacy

applications, loyalty programs, Medicare and the Australian Immunisation Register. Powered by GObookings, our online pharmacy vaccination portal gives your pharmacy an online presence without the need for expensive servers or infrastructure, while providing an easy to use solution allowing for better management of one-on-one appointments, 24/7. Want to learn more about how GObookings can help your pharmacy allow customers to make bookings online? Visit 1stgrp.com/pharmacy/ or head to page 56.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

INDUSTRY NEWS & UPDATES

``STRATPHARMA Stratpharma is a Swiss based dermatology company. With over 10 years in operation, Stratpharma products are in over 50 countries worldwide.

“Stratpharma products are also available through leading Australian pharmacies.”

The Stratpharma product range in Australia is used by leading dermatologists, plastic surgeons, cosmetic surgeons and physicians. Now Stratpharma products are also available through leading Australian pharmacies so pharmacists can also provide their customers with the most professional products to treat wounds, scars and stretch marks.

redness and discolouration, and relieves the itching and discomfort associated with scars. Strataderm is easy to apply once daily.

Stratamed is a gel dressing that can be used on open wounds such as surgical incisions, minor burns, cuts and grazes. It is a flexible film-forming wound dressing that provides faster wound healing and helps prevent abnormal scar formation.

Stratamark, unlike cosmetic and moisturising products, is a topical medical device that is clinically proven for the prevention and treatment of stretch marks. Stratamark is easy to apply once daily.

Strataderm is a professional scar treatment for scars both old and new. Strataderm helps to soften and flatten raised scars, reduce

For more information on Stratpharma and their product range please visit www.stratpharma.com or call 1800 567 128.

``PHARMACY ALLIANCE SUPPORTS FULLIFE FOUNDATION TO SAVE LIVES OF WOMEN AND CHILDREN IN AFRICA On Monday 8th May, the team at Pharmacy Alliance in conjunction with preferred charity partner, The Fullife Foundation, rallied together at the Member Support Office in Melbourne to pack 200 safe birthing kits to send to Africa. The Fullife Foundation was founded by Pharmacy Alliance Member and Pharmacist, Ian Shanks. Having visited Africa on numerous occasions, Ian witnessed the devastation of people trapped in a cycle of poverty with little hope for the future. In particular, Ian found a passion and set out on a mission to improve the health of women and children specifically in Ethiopia, Africa after discovering the number of senseless and preventable deaths amongst expectant mothers and their babies. The safe birthing kits provide a clean and safe birthing environment for women in developing countries to reduce the incidence of infant and maternal morbidity and mortality.

In addition, selected Alliance Pharmacies actively support the Fullife Foundation by running a special promotion in the lead up to Mother’s Day selling the safe birthing kits to be made to send to Africa. The stores also collect money through donations for certification requests.

“Ian witnessed the devastation of people trapped in a cycle of poverty with little hope for the future.”

Stratamark is specifically designed for the prevention and treatment of Striae • • • •

StripAd S2-AU 04-17.indd 1

Softens and flattens raised and depressed Striae Reduces redness and discolouration of Striae Relieves itching and discomfort of Striae Suitable for pregnant women, breastfeeding mothers, children and people with sensitive skin

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

26/04/2017 4:32 p

Join us on Facebook ‘Australian Pharmacy Assistants’

PH ARMACY ASSISTAN T N ATION AL CON FE RE N CE

Send two pharmacy assistants & receive a FREE APP2018 registration (valued at $890)* *Limited to one (1) registration per pharmacy, oﬀer is for a full registration excluding APP Street Party

26 - 28 OCTOBER 2017

QT GOLD COAST

MAJOR SPONSORS

EDUCATION SPONSORS

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

PRODUCT SPOTLIGHT ``ORBIS — BABY FACIAL SERUM Babies are not little adults. In fact, a baby’s skin is up to 20-30% thinner than adult skin and has a higher surface pH. This makes their skin ultra-sensitive to environmental influences and more prone to drying and irritation. Made especially for the sensitive and tender skin of newborns, infants and toddlers, DUIT Baby Facial Serum, is scientifically formulated to help soothe and heal any discomfort caused by milk rash, dribble rash, chafing and windburn for happier babies. Containing pure, high quality certified organic oils and real natural plant extracts, we are committed to promising a Nasty FREE Guarantee:

• Allergen or irritant FREE; • Paraben, phenoxyethanol or phthalates FREE; • Petrolatum, mineral oil, soap, artificial fragrance and sulphate FREE.

>> orbis.net.au

``SKINB5 - NATURAL ACNE TREATMENT SkinB5 is an innovative patented way to stop all types of acne. SkinB5’s powerful nutritional supplements include a potent dose of vitamin B5, treating the overproduction of skin oils. Extra strength tablets are suitable for moderate+ acne. When used as directed, the SkinB5 supplements address underlying causes of breakouts through sebum control, hormonal balance, strengthening immunity, stress relief and cell renewal.

RRP from $29.95 to $56.95 FREE Pharmacy Support Program & Stockist enquiry: 1300 088 655 or email pharmacy@skinb5.com >> skinb5.com

The supplements are supported by healing skincare containing vitamin B5; acne control cleansing mousse, and moisturiser to maximise the efficacy of treatment inside and out. The 5 minute skin purifying mask complements the range to soothe skin and reduce inflammation. Developed and made in Australia, SkinB5 is the world’s first long term acne solution that treats the cause of acne and clears skin from within. SkinB5 offers a FREE Pharmacy Support Program to help increase companion sales with training and patient information, enabling pharmacies to facilitate patient suitability for acne treatment with SkinB5’s Complete Acne Control System. Under the 6CPA, a clinical Intervention may be able to be claimed for this program!

``STRATAMARK — FOR THE PREVENTION

>> stratamark.net

AND TREATMENT OF STRETCH MARKS

Stretch marks can be more than just a cosmetic concern. They are a common skin condition that can cause physical symptoms, such as itching, tenderness and pain, and can significantly affect one’s self esteem. Unlike cosmetic and moisturising products, Stratamark is a medical product which is clinically proven for the prevention and treatment of stretch marks. Stratamark is a unique gel formulation that: • Prevents stretch marks from forming; • Reduces redness and discolouration associated with stretch marks; • Relieves itching and discomfort of stretch marks;

• Softens and flattens stretch marks; • Is easy to apply once daily; • Hydrates and protects the skin.

``VERSABASE® CREAM PCCA VersaBase Cream is soothing and gentle, even for the most sensitive areas. This elegant, yet durable, topical cream simulates the natural moisturising barrier of the skin through its emulsion system and rubs in quickly, leaving a soft and silky feel. VersaBase Cream be used for a variety of pharmaceutical and cosmetic applications, and it’s an ideal compounding base for topical and vaginal hormone replacement therapy. Because it is noncomedogenic, hypoallergenic, non-irritating and odour-free, it suits the needs of a variety of patients.

>> pccarx.com

•

Elegant and durable: Simulates the natural moisturising barrier of the skin plus its thick and smooth, not sticky.

•

Gentle application: Non-irritating, paraben-free, and propylene glycol-free, with a pH of approximately 6.

•

Proven results: Study confirms that VersaBase Cream with PCCA’s Special Micronised Progesterone delivers up to four times more progesterone to the dermis than commercial base Vanicream®. GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

AFTER HOURS

SPLENDOUR IN THE GRASS T he 17th A nnual Music & A r t s Fe stiv al

Nor th B y ron P ar kl ands

Friday 21 July, Saturday 22 July, Sunday 23 July

ITS NAME ALONE, SPLENDOUR IN THE GRASS, EVOKES LAZY, LANGUID AFTERNOONS AND EVENINGS HANGING AROUND, RELAXING, SOAKING UP SUMMER’S RAYS AND LIFE’S BEST UNPLANNED MOMENTS.

Or maybe it makes you think of that old classic movie. The temps are mild enough for enjoyment — Byron Bay is a surfer’s paradise and home to lots of creative types. When you add a lineup of super popular artists, along with food trucks, teepees, crafts, a kids’ area, yoga, spa activities, workshops, speakers and the requisite circus performers — you get more things than you could possibly do in three days. You get Splendour in the Grass. Taking its name not from any of those aforementioned things but instead, the English poet William Wordsworth’s “Ode: Imitations of Immortality,” Splendour in the Grass was founded by music producers Jessica Ducrou and Paul Piticco (former manager of Powderfinger) and began as a one-day affair on July 21, 2001 at Belongil Fields. Artists who performed at the debut included Powderfinger, Michael Franti & Spearhead, Steve Malkmus and the Jicks, Squarepusher, and more.

FOOD GLORIOUS FOOD — AND THEN SOME You could easily spend the entire fest doing nothing but hanging around the markets and craft venues, interacting with the various art

installations, snacking from the many food trucks, or relaxing with a massage. If shopping is your thing, the pop-up experience Very Small Mall offers a wide range of clothing options, from trendy to laid-back to vintage. There’s even something for the smallest of festers at Little Splendour, geared toward kids.

SPLENDOUR IN THE GRASS — GREEN LIVING AND GIVING The festival has long had a tradition of giving back to their host community, and their new home, as of 2013, North Byron Parklands, is no exception. That year’s fest donated money to schools. The festival also received a Highly Commended Award for its 2012 event which was held at Belongil Fields—its home before the Parklands. The international organization Greener Festival Awards granted the honour for the festival’s various sustainability initiatives, including employing a huge machine to sort through garbage and separate various commingled recyclables and garbage; a carbon offset program for its tickets, ride share initiatives, onsite environmental ambassadors, shuttle buses, and more. Original editorial sourced from www.everfest.com.

The medical device specifically designed for the prevention and treatment of stretch marks 1

StripAd S1-AU 04-17.indd 2

Malkova S. New EU Magazine of Medicine, July 2014, 1–4/2014

Manufactured by: Stratpharma AG Aeschenvorstadt 57 CH-4051 Basel Switzerland

Sponsor in Australia: A L Kerr Medical Pty Ltd 174 Willoughby Road Crows Nest NSW 2065 Tel: 1800 567 007

26/04/2017 5:00 pm

HEALTH CALENDAR

J U N E /J U LY 2 0 17 WORLD BLOOD DONOR DAY 14th June >> www.who.int

BOWEL CANCER AWARENESS MONTH 1st – 30th June >> www.bowelcancerawarenessmonth.org

What can you do? Give blood. Give now. Give often

Bowel Cancer Awareness Month is an annual initiative of Bowel Cancer Australia running throughout the month of June (1 - 30 June each year), to raise public awareness of a disease that claims the lives of 80 Australians every week. Bowel cancer is the third most common type of newly diagnosed cancer in Australia affecting both men and women almost equally and is Australia’s second biggest cancer killer after lung cancer. Bowel Cancer Awareness Month has a positive message – saving lives through early detection – as bowel cancer is one of the most treatable types of cancer if found early.

Every year, on 14 June, countries around the world celebrate World Blood Donor Day (WBDD). The event serves to raise awareness of the need for safe blood and blood products and to thank blood donors for their life-saving gifts of blood. Blood is an important resource, both for planned treatments and urgent interventions. It can help patients suffering from life-threatening conditions live longer and with a higher quality of life, and supports complex medical and surgical procedures. Blood is also vital for treating the wounded during emergencies of all kinds (natural disasters, accidents, armed conflicts, etc.) and has an essential, life-saving role in maternal and perinatal care. A blood service that gives patients access to safe blood and blood products in sufficient quantity is a key component of an effective health system. Ensuring safe and sufficient blood supplies requires the development of a nationally coordinated blood transfusion service based on voluntary non-remunerated blood donations. However, in many countries, blood services face the challenge of making sufficient blood available, while also ensuring its quality and safety. ........................................................................................................................

From the city to the country, from the home to the workplace, individuals, loved ones, health professionals, schools and businesses help to spread the word. Bowel Cancer Awareness Champions donate their time, services and creativity. Many also kindly make monetary donations to help Bowel Cancer Australia with our work.

MEN'S HEALTH WEEK 12th - 18th June >> www.menshealthweek.com.au

Without the support of all the wonderful individuals and organisations raising funds and awareness, Bowel Cancer Awareness Month and the work of Bowel Cancer Australia would not be possible. To everyone who has in any way got involved with Bowel Cancer Awareness Month over the past years, please know that your support means a lot to us at Bowel Cancer Australia. We’re a relatively small team and proudly 100% community funded, so the more people getting behind Bowel Cancer Awareness Month with us the better! ........................................................................................................................

For Men’s Health Week 2017 communities across Australia come together to create fun and engaging events, promotions and activities tailored to the needs of men and boys. These events focus on improving and maintaining the health of our men, boys and their families, and having those meaningful conversations about the factors that keep us healthy in body and mind. This year’s theme “HEALTHY BODY – HEALTHY MIND: KEEPING THE BALANCE” explores the different ways men and boys are managing to keep healthy, physically and emotionally, in a busy and sometimes challenging world. Balancing these challenges means doing things that are nourishing and good. Reach out to men and boys this Men’s Health Week and create events that respond to the issues impacting on the health of men, boys and their families in your local area.

NATIONAL BURNS AWARENESS MONTH 1st – 30th June >> www.mundicare.com.au

Men’s Health Week is your opportunity to make a positive difference in the lives of our men and boys. ........................................................................................................................

88% of minor burns occur at home and with an increased risk in winter. Although the overwhelming majority of Australian burn sufferers (88%) know it is important to treat a burn immediately, alarmingly 90% don’t know the correct treatment for a burn. There is a significant need for greater awareness of the correct first aid treatment. During National Burns Awareness Month, a series of educational initiatives will be hosted Australia wide, highlighting the importance of prevention of burns and helping Australians know how to best treat minor burns. Joern Packross, Director of Consumer Health at Mundipharma, said: “Mundipharma has been supporting the Julian Burton Burns Trust for years and we are delighted to partner with them for the first National Burns Awareness Month. This initiative provides a fantastic opportunity to break down some of the many misconceptions when it comes to the best way to treat everyday burns, and will have a significant impact on improving health outcomes in the community.” Julian Burton OAM, Founder of the Julian Burton Burns Trust who also suffered life-threatening burn injuries in the 2002 Bali Bombings, commented: “Correct burns first aid of ‘Remove – Cool – Cover’ is important to stop the burning process. REMOVE yourself from danger and remove any clothing or jewellery around the affected burn area; COOL the burn under cool running water for 20 minutes and then COVER with a hydrogel, such as Burnaid® gel, to help relieve the pain and then cover with a clean dressing.” Professor Fiona Wood, President, Australian & New Zealand Burn Association (ANZBA), added: “Cool running water for 20-minutes is key to minimising the impact of burns and it is critical to raise awareness of this simple step as the first action to take when suffering from a minor burn. The inaugural National Burns Awareness Month is a great initiative to drive this much needed education on the treatment of minor burns, at a community level.”

WORLD VITILIGO DAY 25th June >> www.25june.org World Vitiligo Day takes place on June 25, 2017. The World Vitiligo Day is an initiative aimed to build global awareness about vitiligo, a frequent and often disfiguring disease that can have significant negative psychosocial impact on patients, also because of numerous misconceptions still present in large parts of the world. Vitiligo is an acquired disease characterised by skin depigmentation, due to destruction or malfunction of melanocytes (cells that produce melanin). It is present worldwide, and its prevalence in different countries ranges from less than 0.1% to more than 8% of general population (~1% in the United States and in Europe); thus, it can be estimated that approximately 100 million people in the world are affected. ........................................................................................................................

WORLD HEPATITIS DAY 28th July >> www.worldhepatitisday.org On 28 July World Hepatitis Day (WHD) brings the world together to raise awareness of the global burden of viral hepatitis and to influence real change in disease prevention and access to testing, treatment and care. One of just four disease-specific global awareness days officially endorsed by the World Health Organisation (WHO), WHD unites patient organisations, governments and the general public to boost the global profile of viral hepatitis. The sixth official WHD took place on 28 July 2016 and was a huge success, with over 1000 events in 174 countries across the globe.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

BUSINESS DIRECTORY

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

Business Directory group 2C, 2-12 Foveaux St Surry Hills NSW 2010 Tel: 1300 266 517 >> myhealth1st.com.au

12 Mowbray Tce East Brisbane QLD 4169 Tel: +61 7 3363 7100 >> alere.com

Level 2, 9/65 Tennant St, Fyshwick ACT 2609 Tel: 02 6188 4320 >> acp.edu.au

417 St Kilda Rd Melbourne VIC 3004 Tel: 03 9863 1600 >> donateblood.com.au

Suite 1, 41-45 Pacific Highway WAITARA NSW 2077 Tel: 1300 458 836 >> coeliac.org.au

Level 1, 30-32 Sydney Rd Brunswick VIC 3056 Tel: 1800 330 066 >> continence.org.au

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

20B Lathe St Virginia QLD 4014 Tel: 1800 003 673 >> doseinnovations.com

1/13 Network Dve Carrum Downs VIC 3201 Tel: 03 9708 2276 >> flowsell.com.au

Level 3, Suite 301, 151 Castlereagh St Sydney NSW 2000 Tel: 1300 647 492 >> guildlink.com.au

4 Irving St Phillip ACT 2606 Tel: 02 6232 4257 >> hepatitisaustralia.com

12 Help St Chatswood NSW 2067 Tel: 02 8918 6322 >> inovapharma.com

Level 10, 52 Collins St Melbourne VIC 3000 Tel: 03 9853 7933 >> medici.com.au

Private Bag 900, Blackburn VIC 3130 Tel: 1300 733 690 >> mswalk.org.au

NAPSA 40a Birmingham Rd Alexandria NSW 2015 Tel: 03 9855 2655 >> napsa.org.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 54 : JUNE/JULY 2017

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

520 8th Avenue, 12th Floor New York USA 10018 Tel: 1-800-ORBIS-US (1-800-672-4787) >> orbis.org

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

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

Guild House, 40 Burwood Rd Hawthorn VIC 3122 Tel: 03 9810 9999 >> guild.org.au

Suite 5-6, 307 Maroondah Highway Ringwood VIC 3134 Tel: 1300 088 655 >> skinb5.com

4 Bridge St Rydalmere NSW 2116 Tel: 02 9684 6555 >> southernature.com.au

Level 1, 174 Willoughby Rd Crows Nest NSW 2065 Tel: 1800 567 007 >> stratpharma.com

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