ITK October/November 2016 - Issue 50 by Gold Cross Products & Services

ISSUE #50 : OCTOBER/NOVEMBER 2016

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

IN THE KNOW

• CPD — ALCOHOL MISUSE

• IRON — BEYOND THE BLOOD

• PRACTICE READY — UPDATE FOR PHARMACISTS

• CLINICAL INTERVENTIONS

• CPD — ARE YOU AN EFFECTIVE LEADER?

• HELPING HEART PATIENTS

Service. Service.Efficiency. Efficiency. Workflow. Workflow.

Delivering Delivering Patient-centred Patient-centred Improvements. Improvements.

ITK ITK magazine magazine had had the the opportunity opportunity to to speak Medical speak with with Simon Simon Rudderham Rudderham from from Medical Centre Centre Pharmacy Pharmacy in in Victoria Victoria to to provide provide aa pharmacy’s chose pharmacy’s perspective perspective on on how how they they chose to to improve improve their their DAA DAA services. services.

Following Following the the positive positive response response of of our our previous previous edition, we invited Simon Rudderham edition, we invited Simon Rudderham from from Medical Medical Centre Centre Pharmacy Pharmacy in in Victoria Victoria to to provide provide aa Pharmacy’s Pharmacy’s perspective perspective on on how how they they chose chose to to improve improve their their DAA DAA services. services. Automation Automation is positioned around a primary objective is positioned around a primary objective of of prescription prescription fulfilment fulfilment and and the the investment investment in in automation automation worldwide worldwide is is growing growing at a substantial substantial rate. rate. Automation Automation is is designed such that that community community pharmacy pharmacy may may deliver patientcentred improvements as a centred improvements as a direct direct and indirect result result of of the the art art of of innovation. innovation.

BUSINESS BUSINESS 2 2 BUSINESS BUSINESS 2 BUSINESS

Service. Efficiency. Workflow. Service. Service. Efficiency. Efficiency. Workflow. Workf Service. Efficiency. Workflow.

Delivering Patient-centred Delivering Delivering Patient-centred Patient-c Delivering Patient-centred Improvements. Improvements. Improvements. Improvements.

PHARMACY AUTOMATION IS POSITIONED AROUND A PRIMARY OBJECTIVE OF PRESCRIPTION FULFILMENT PHARMACY PHARMACY AUTOMATION AUTOMATION IS POSITIONED AROUND IS POSITIONED A PRIMARY OBJECTIVE AROUND OF PRESCRIPTION A PRIMARY FULFILMENT OBJECT AND THE INVESTMENT IN AUTOMATION WORLDWIDE IS GROWING AT A SUBSTANTIAL RATE. AUTOMATION PHARMACY AUTOMATION IS POSITIONED AROUND A PRIMARY OBJECTIVE OF PRESCRIPTION FULFILMENT IS AND AND THE INVESTMENT THE INVESTMENT IN AUTOMATION WORLDWIDE IN AUTOMATION IS GROWING ATWORLDWIDE A SUBSTANTIAL RATE.IS AUTOMATION GROWING IS AT A DESIGNED SUCH THAT COMMUNITY PHARMACY MAY IS DELIVER PATIENT-CENTRED IMPROVEMENTS AS A DIRECT AND THE INVESTMENT IN AUTOMATION WORLDWIDE GROWING AT A SUBSTANTIAL RATE. AUTOMATION IS DESIGNED DESIGNED SUCH THAT SUCH COMMUNITY THAT PHARMACY COMMUNIT MAY DELIVER Y PHARMACY PATIENT-CENTRED IMPROVEMENTS MAY DELIVER AS A DIRECT PATIENT AND INDIRECT RESULT THE ART OF INNOVATION. DESIGNED SUCH THAT OF COMMUNITY PHARMACY MAY DELIVER PATIENT-CENTRED IMPROVEMENTS AS A DIRECT AND AND INDIRECT INDIRECT RESULT OF THE RESULT ART OF INNOVATION. OF THE ART OF INNOVATION. AND INDIRECT RESULT OF THE ART OF INNOVATION.

we’ve achieved the goals we set, and my team EDITOR - WHAT MADE YOU INITIALLY EDITOR - WHAT WAS YOUR MAIN GOAL we’ve achieved the goals we set, my team GOAL EDITOR EDITOR - WHAT -MADE WHAT YOU INITIALLY MADE YOU EDITOR INITIALLY WAS MAIN GOAL EDITORisWHAT WAS YOUR MAIN certainly much happier with theand results. INVESTIGATE DAA PACKING AND WHEN YOU- WHAT DECIDED TOYOUR AUTOMATE? we’ve achieved thehappier goalsTO we set, my team EDITOR - WHAT MADE YOU INITIALLY EDITOR - YOU WHAT WAS YOUR MAIN GOAL is certainly much with theand results. INVESTIGATE INVESTIGATE DAA PACKING DAA AND PACKING WHEN AND DECIDED TO AUTOMATE? WHEN YOU DECIDED AUTOMATE? CHECKING AUTOMATION? HAVE YOU ACHIEVED THIS? EDITOR - HOW YOUR TEAM HANDLE is certainly muchDID happier with the results. INVESTIGATE DAA PACKING AND WHEN TOTHIS? AUTOMATE? CHECKING CHECKING AUTOMATION? AUTOMATION? HAVEYOU YOUDECIDED ACHIEVED HAVE YOU ACHIEVED THIS? EDITOR HOW DID YOUR TEAM HANDLE THE CHANGES? Well, in the end we chose a Tosho We wanted an easy to use and SIMON SIMON CHECKING AUTOMATION? HAVE YOU ACHIEVED THIS? -wanted HOW DID YOUR TEAM HANDLE CHANGES? in-the Well, end wein chose the a Tosho end we chose a Tosho wanted an easy to use and We an easy to use and SIMON - Well, SIMON - We SIMON EDITOR -THE XanaSIMON 2400, and a Global Factories MDM2 – accurate system, providing accountability our previous experiences, SIMON - Givenproviding THE CHANGES? Well, 2400, in the end and weFactories chose Tosho wanted an to use and SIMON -2400, SIMON - We Xana and a Global aa Global MDM2 – Factories accurate MDM2 system, providing –easy accountability system, accountability bothXana were installed October 2015. and traceability – particularly given theaccurate larger our previous experiences, SIMON - Given some of the team approached the change Xanaboth 2400, and a Global Factories MDM2 – accurate system, providing accountability both were installed were October installed 2015. October volumes 2015. and traceability – particularly given the and larger traceability – particularly given the larg we pack. Given our previous experiences, SIMON some of- the change We had a different robot packing sachets with great fearteam and approached trepidation. the It was a

both were installed October 2015. and traceability – particularly given thevolumes larger volumes we pack. weofpack. some thefear team approached theIt change WeWe hadatahad different robot sachets robot packing sachets withtechnology great and was so a previously one ofamydifferent otherpacking locations but The software keeps a database of colour new andtrepidation. software to learn, volumes we pack. We had a different robot packing sachets with great fear and trepidation. was of a colour previously previously at one of my at other one locations of my but other locations The software keeps but a database of colour The software keeps a database new technology and software toItlearn, there were so many chipped tablets and other photos of every sachet packed, so we can it’s natural to have some misgivings. Weso previously at one of my chipped other many locations but other The software keepssachet aother database ofso colour new technology andsome software to learn,We so we can there there were so were many tabletsreally chipped and tablets photos of every and packed, weback photos can if of every sachet packed, so it’s natural to have misgivings. packing errors, my team so and I became check on individual sachets, and trace spent some time on training, and everyone is there were so many chipped tablets and other photos of every sachet packed, so we can it’s natural to time haveon some misgivings. We trace packing packing errors, errors, team andmy I became team reallyandrequired, I check became on really sachets, check back if on individual sachets, and back spent some training, and everyone fed up checking all my the sachets manually. to individual the day and time itand wastrace packed, comfortable with the machine and software.is packing errors, mychecking team and I became reallysachets check on individual sachets, and tracepacked, back if spent training, and fedfed up checking up all of the sachets all manually. the required, manually. to the day time it to some the time day and time it wasis packed comfortable withon the machine andeveryone software. We investigated a few the options on the and the technician thatand packed it.was If onerequired, of fed up checking all the sachets the daythe and time it was packed, EDITOR - WHAT CHALLENGES DID YOU with the machine and software. WeWe investigated investigated a few of the manually. options a on of the the required, options and thetotechnician on packed it. If one of the comfortable technician that packed it. If one of market, found the Tosho packing andfew MDM our patients calls withthat a question one ofand my EDITOR - WHAT CHALLENGES DID YOUone of my We investigated fewTosho of thepacking options on the and the technician that packed it. If oneour of my patients OVERCOME THROUGH PROCESS? market, market, founda the the Tosho and MDM packing our patients and calls MDM with question of calls with aTHE question checking solution –found and decided it was best pharmacists just calls upathe image one in the EDITOR - WHAT CHALLENGES DID YOU OVERCOME THE PROCESS? market, found the Tosho packing and ourpharmacists patients calls a up question one in ofpharmacists my checking checking –Deciding and decided – itMDM was and best itand was justwith best calls image the just THROUGH calls up the image in the suited for oursolution needs. solution factors were thedecided software, can help themthe within seconds. We had a few minor teething SIMON OVERCOME THROUGH THE PROCESS? checking solution – and decided it was best justcan callshelp up the image inseconds. the suited suited forXana, our for needs. Deciding needs. were Deciding the pharmacists software, factors and were the them within software,SIMON and -can help them within seconds speed of the the our accuracy offactors the MDM We had a few minor teething and procedural issues which we needed With the Xana’s calibrated cassettes, all the suited for our needs. Deciding factors were the software, and can help them within seconds. speed speed of the Xana, of the the Xana, ofwith the the MDM accuracy MDM hadissues a few which minor we teething SIMON - Webut checking machine, and theaccuracy reliability and procedural needed Withof thethe Xana’s calibrated cassettes, With all the calibrated cassettes, all the address, after that everything went medication is handled properly, so we have far thetoXana’s speed of the Xana, the accuracy of the MDM checking checking machine, and the reliability and with the reliability with and procedural issues which we needed With the Xana’s calibrated cassettes, allmedication the far support available frommachine, Dose Innovations. to address, but after that everything went medication is handled properly, so we have is handled properly, so we have swimmingly. fewer chipped or crushed tablets. We feel that checking machine, and theDose reliability with Dosemedication support support available available from Innovations. from Innovations. toswimmingly. address,or butcrushed after that everything went We feel th is handled properly, so we fewer chipped or crushed tablets. Wehave fewer feel far that chipped tablets. support available from Dose Innovations. swimmingly. fewer chipped or crushed tablets. We feel that GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016 GOLD CROSS PRODUCTS GOLD &CROSS SERVICES PTY PRODUCTS LTD : ITK ISSUE 50 & :SERVICES OCTOBER/NOVEMBER PTY 2016 LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016 GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

BUSINESS

Some of the patients had difficulty with the layout – the Tosho software is quite flexible, so we made a few adjustments with the printing, and the patients are fine now. The biggest challenge was that we installed the machine, plus took on an extra 300 beds on the same day. The packing machine is new to this pharmacy location, so we had to make room out the back to accommodate, and deal with the reduction of space.

CHANGE SUMMARY STATISTICS Average Scripts per day Accuracy/ errors? Packing hours per week # DAA patients packed per week

BEFORE WITH COMPETITORS PACKING MACHINE

NOW WITH TOSHO XANA & MDM SOLUTION

No script change – though average basket size has grown 13% from the extra pharmacist attention Chipped tablets and waste, frequent packing errors

Less errors, and they’re identified quickly and easily

Increased by 8 hours to accommodate extra DAA Increased by 300 patients (and growing)

EDITOR - HAS THE MACHINE EARNT ITS KEEP?

#Staff – Pharmacists

No change – extra volume

SIMON - It’s allowing us to increase our current capabilities, packing more DAAs and taking on more MedChecks and Clinical Interventions, without the cost of additional staffing or infrastructure. We’ve actually recorded 6 times the number of Clinical Interventions, and our average basket size has grown 13% now that my Pharmacists have more time to focus on patients.

#Staff – Assistants

No change – extra volume

EDITOR - WOULD YOU DO ANYTHING DIFFERENTLY NEXT TIME? SIMON - We would probably spend some more time rearranging our aged care packing room to better support workflow.

EDITOR - HOW HAS AUTOMATION CHANGED YOUR FUTURE? SIMON - What would have taken us two solid days of checking sachets manually, can now be completed accurately in about four hours. The Tosho Xana has what’s called a “quad hopper” which allows it to pack very fast, without impacting quality or consistency. This leaves my pharmacists with more time to help to grow my business. Before, it was a chore to obtain growth in my DAA area. Now I’m able to focus on growing that area of revenue, without feeling sick about the work that has to go with it. We’re already considering investment in other automated packing systems following our experience, not to mention the Rowa dispensary robots we’ve already installed at two of our other stores. There’s probably more on the way…

Current Stock on Hand

Less due to the virtual pill count managing medication

Impact upon prof services?

Two whole days spent checking sachets

Clinical interventions have increased 6-fold.

BEFORE WITH COMPETITORS PACKING MACHINE

NOW WITH TOSHO XANA & MDM SOLUTION

Staff Job Satisfaction (1 = poor, 5 = excellent)

3.5

Dispensary Atmosphere (1 = stressed, 5 = calm)

1 (planning to change that soon)

Customer Attitude (1 = reject, 5 = embrace)

Time (1 = less, 5 = more)

Space (1 = less, 5 = more)

Organisation (1 = less, 5 = more)

Workflow (1 = worse, 5 = better)

2.5

5 (doubled)

RATINGS

Packing Accuracy (1 = inaccurate, 5 = accurate)

FIND OUT HOW AUTOMATION CAN HELP YOU! • 1800 00 3673 (1800 00 DOSE) • enquiries@doseinnovations.com • www.doseinnovations.com

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CONTENTS

AFTER HOURS 64 WORLD MASTERS ATHLETICS CHAMPIONSHIP, PERTH 2016

SEAN TUNNY Editor, Gold Cross Products & Services Pty Ltd

Every four years, a readership survey of pharmacy publications is conducted to measure a number of key elements relating to the leading publications value to the profession in print and digital formats. ITK is privileged to be invited and counted as a quality publication. The results of the survey outlined that ITK was a valued and referenced journal. It is the only journal proudly displaying the logo of the Pharmacy Guild of Australia. As a bi-monthly publication, the results for ITK were very encouraging. Some key elements were: 1. 73% of pharmacists indicated that print professional publications were the preferred method of information over other available mediums; 2. Continuing Professional Development (80%), Clinical Information (79%) and Patient Counselling (73%) were identified as being of most value within the publications; 3. The value of ITK to pharmacy assistants in the eyes of pharmacists was acknowledged with 43% of pharmacists passing ITK to a pharmacy assistant; 4. ITK scored the highest rating (71%) when considering the regularity of reading 2 issues (4 months) of the publication; 5. ITK Connect digital reflected the strongest in reading our e-newsletter over a month period (22%); 6. Front of shop/Over the counter products and scheduled medicines rated highest in our image ratings specifically for ITK. As with any research, when comparing against established publications, ITK identified elements that could be enhanced in order to further develop the quality and value pharmacists continue to place in our publication. To this end, we are pleased to introduce the first of our new professional practice ready features “update for pharmacists” in this edition, please refer to Page 4. Dose Innovations continue the third and final in their popular gatefold series on delivering patient-centred improvements. Our two continuing professional development modules, health features, QUT professor editorial, business, interview pieces and many other features are all not to be missed. We look forward to announcing a number of additional improvements in our next edition and thank you for your feedback and support of ITK, in print and digital mediums. Thank you finally to all the contributors, partners and supporters of ITK, wishing you an enjoyable read this edition. Best Regards, Sean Tunny Editor - ITK Publications BROUGHT TO YOU BY:

BUSINESS 12 ENHANCED PHARMACY SERVICES

20 METHSOF GOES MOBILE 26 ARE YOUR LOVED ONES SAFE?

27 LEASE 1 – RISK OUTLOOK REPORT 34 PRIVATE REMUNERATED PROFESSIONAL PHARMACY SERVICES 38 YOU CAN BUILD A BUDGET AND IT CAN BE USEFUL 40 PHARMACY ALLIANCE PARTNERS WITH AKUMYN TO BOOST MEMBER PROFITS

CONTINUING PROFESSIONAL DEVELOPMENT 7

ALCOHOL MISUSE

44 ARE YOU AN EFFECTIVE LEADER?

HEALTH 14 PERFORMING CLINICAL INTERVENTIONS 16 MANAGING TYPE 2 DIABETES 22 SUPPORTING PHARMACISTS THROUGH DOSE ADMINISTRATION AIDS 30 EASING THE BURDEN ON MENTAL HEALTH PATIENTS AND THEIR TREATING PHYSICIANS

32 HELPING HEART PATIENTS GET THE MOST FROM THEIR MEDICATIONS 36

PCCA — WE TAKE YOUR SUCCESS PERSONALLY

48 DRUG ADDICTION AND STIGMA 50 NUTRITION FOR HEALTHY AGEING 52 IRON — BEYOND THE BLOOD 56 ARE YOU READY TO TRY FOR 5?

NEWS 3

MAKING A GREAT SYSTEM EVEN BETTER

PRACTICE READY 4

UPDATES FOR PHARMACISTS

REGULARS 58 INDUSTRY NEWS AND UPDATES 60 60 SECONDS WITH ... 62 PRODUCT SPOTLIGHT 65 HEALTH CALENDAR

66 BUSINESS DIRECTORY

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

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

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

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

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

NEWS

Making a great system even better

GEORGE TAMBASSIS National President of The Pharmacy Guild of Australia

EVERYBODY IN THE COMMUNITY PHARMACY SECTOR WILL BE WELL AWARE THAT THERE IS CURRENTLY A NATIONAL INDEPENDENT REVIEW OF EVERY ASPECT OF THE FUNDING AND REGULATION OF PHARMACIES ACROSS AUSTRALIA. This means that the viability and ongoing operation of local pharmacies is very much in the spotlight. The Pharmacy Remuneration and Regulation Review released a Discussion Paper mid-year, canvassing every aspect of pharmacy — from the cost, distribution and dispensing of medicines, to the provision of professional pharmacy services, the pharmacy location rules, and the expectations and experiences of consumers. The Review Panel conducted a series of forums in towns and cities around Australia. These were attended by pharmacy owners, pharmacy staff, pharmacy interns, pharmacy patients and other interested contributors to the discussion about the future of community pharmacy. I was delighted to see that many outside observers of our industry chipped in with submissions to the review, recognising and praising the role of community pharmacies in our healthcare system. One such submission I’d like to tell you about came from the highly regarded Bravehearts organisation. Bravehearts’ key purpose is to educate, empower and protect Australian kids from sexual assault, and according to founder Hetty Johnston, the network of community pharmacies plays a vital role in this goal.

Hetty Johnston wrote: “For many Australians — especially in rural and regional areas — they are the first point of contact for health issues and advice. Pharmacists and their staff play an important role in recognising signs of abuse and providing support and referrals to those in need.” “Importantly, pharmacies are the most accessible health service. The current rules and regulations that govern the location of where community pharmacies are located have worked well and provide a broad access for people in genuine need of these services,” Ms Johnston wrote. “The current network and structure of community pharmacy is well placed to support some of the most vulnerable people in our community.” “Supermarket pharmacies would simply not be able to provide the level of privacy, comfort and customer care that is seen at a community pharmacy. It is the welcoming, yet confidential feel of a community pharmacy and pharmacists that works to not only recognise, but importantly, assist people in times of crisis.” “In addition, many people who have been subjected to sexual assault are now on medications; some of them are on numerous medications. Community pharmacists go

above and beyond in not only dispensing the medication, but providing advice and intervention where required to ensure the health outcomes of all patients are recognised, particularly those on multiple medications,” Ms Johnston wrote. That’s the kind of heartfelt support for the role of community pharmacies that should make all pharmacy owners and staff extremely proud. At the Guild, we see the Review as an opportunity to build on the outstanding contribution that community pharmacies and their highly professional staff already make to the health system. Pharmacies enjoy very high levels of public support, and often pharmacies are the first port of call for patients who are unwell. Community pharmacies also provide an increasingly wide range of medication management and primary healthcare services, working collaboratively with GPs and other health professionals and helping address gaps and unmet needs in the wider health system. We believe there are opportunities for pharmacies to deliver further benefits to patients and the broader health system, provided we have appropriate support.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

PRACTICE READY

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

BY AARON D'SOUZA Pharmacist, B.Pharm

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

SNAPSHOT

BEMFOLA [FOLLITROPIN ALPHA]

MF: Finox Biotech Australia

INDICATION •• Anovulatory infertility; •• Assisted Reproductive Technologies; •• Infertility (hypogonadotrophic hypogonadism in men).

PATIENT DISCUSSION POINTS:

•• Are you taking your first injection under •• •• •• ••

PBS LISTINGS •• •• •• •• •• •• •• ••

5 units (5.5 microgram)/0.125 mL injection, 5 x 0.125 mL injection devices; 7 150 units (11 microgram)/0.25 mL injection, 5 x 0.25 mL injection devices; 225 units (16.5 microgram)/0.375 mL injection, 5 x 0.375 mL injection devices; 300 units (21.84 microgram)/0.5 mL injection, 0.5 mL cartridge; 300 units (22 microgram)/0.5 mL injection, 5 x 0.5 mL injection devices; 450 units (32.76 microgram)/0.75 mL injection, 0.75 mL cartridge; 450 units (33 microgram)/0.75 mL injection, 5 x 0.75 mL injection devices; 900 units (65.52 microgram)/1.5 mL injection, 1.5 mL cartridge.

DOSING The prescribed dose will be dictated by the indication. The starting dose may be increased depending on the patient’s response.

BEMFOLA [FOLLITROPIN ALPHA] Bemfola® [Follitropin Alfa] mimics the action of follicle stimulating hormone (FSH) and is classed as a gonadotrophin. It was PBS listed on 01 August 20161. It is a bio-similar of Gonal-f ®. CLINICAL USE In adult women, Follitropin Alfa is indicated for1:

•• Anovulatory infertility in women who have been unresponsive to clomiphene citrate or where clomiphene citrate is contraindicated. “This medicine can help develop and release the egg from the ovary”;

•• Controlled hyper-stimulation of the ovaries in women undergoing assisted reproductive technologies (ART). “This medicine can help several egg sacs or ‘follicles’ develop”;

•• Use in conjunction with luteinising hormone (LH). The preparation is recommended for the stimulation of follicular development in women with severe LH and FSH deficiency.

Pharmacy storage: Refrigerate between 2°C to 8°C. Do not freeze. Protect from light. Patient storage: Before opening and within its shelf-life, the medicine may be removed from the refrigerator, without being refrigerated again, for up to 3 months, kept at or below 25°C. The product, if stored at or below 25°C, must be discarded if it has not been used after 3 months. Discard used pen and needle in sharps container.

Interesting fact: In developed countries it is reported that infertility can affect up to 16.7% of women aged between 20 and 443, while 34% of men aged over 40 reports having one or more reproductive health problems5.

Video Link: FSH in females: https://youtube/pNe43KGZTl8 In men FSH stimulates primary permatocytes to form secondary spermatocytes. Video link: FSH in males: https://youtube/XK5DaKKDcoE PRECAUTIONS AND CONTRAINDICATIONS Contraindications2: •• Allergic to FSH or other ingredients in product;

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

your Dr’s supervision?; Injection techniques; Storage and disposal; ADRs; Expectations.

STORAGE AND HANDLING

In adult men: •• Used to stimulate the production of sperm in combination with human chorionic gonadotrophin (hCG)2.

MECHANISM OF ACTION Follitropin Alfa mimics the action of FSH. In females FSH works in the ovary to stimulate the growth of non-developed follicles2.

Listed: 01 August 2016

•• Present tumour in hypothalamus or pituitary gland.

•• In women: o o o o

Large ovaries or ovarian cysts of unknown origin; Unexplained vaginal bleeding; Ovarian, uterine or breast cancer; Malformed reproductive organs or ovarian failure.

•• In men: o

Damaged testicles that cannot be healed.

Precautions and warnings2: •• Porphyria; •• Ovarian hyper-stimulation syndrome – lower abdominal pain is the most common symptom; •• Higher risk of multiple pregnancy; •• Higher risk of miscarriage; •• Family or personal history of blood clots in the legs or lungs or a heart attack or stroke; •• Males with high FSH levels – may indicate testicular failure4.

PRACTICE READY BREASTFEEDING AND LACTATION Breastfeeding – do not use2. Lactation – do not use2. WHAT’S IN THE PACK? The Bemfola cartridge or pen injector is available across 6 strengths1: UNITS

DEVICE

PACK

75 IU 150 IU 225 IU 300 IU 300 IU 450 IU 450 IU 900 IU

Pen injector Pen injector Pen injector Pen injector Cartridge Pen injector Cartridge Pen injector

5 x 0.125ml 5 x 0.25ml 5 x 0.375ml 5 x 0.5ml 1 x 0.5ml 5 x 0.75ml 1 x 0.75ml 1 x 1.5ml

Bemfola is a clear, colourless solution containing recombinant human follicle stimulating hormone (follitropin alfa [rch]). Other ingredients include: Sucrose, Disodium hydrogen, phosphate dehydrate, Sodium dihydrogen, phosphate dehydrate, phosphoric acid, polaxamer, methionine, water for injection. Included in each pen injector pack are sufficient needles and alcohol swabs for correct administration4. There are a number of studies showing that patients prefer the pre-filled pen. It provides patients with faster preparation and greater confidence when administering the correct dose6. DOSING INFORMATION Bemfola is administered via subcutaneous injection usually in the lower abdomen (near the navel or waistline, or the front thigh) at the same time each day. Rotation of the injection site is recommended. It comes as a pre-filled, one-useonly pen. The first dose should be given under Dr’s supervision4. (Refer to table 1) Video link – How to inject Bemfola: https://youtube/vzTElO_Syv0 DRUG INTERACTIONS2:

•• Other medicines involved in fertility treatments;

•• Gonadotropin-releasing hormone (GnRH).

TABLE 1 SITUATION

STARTING DOSE

DOSE RANGE

LENGTH OF THERAPY

Anovulatory infertility

75 IU daily

As per response to maximal daily dose of 225 IU

Response dependant. May require more than one treatment cycle

ART

150IU daily, commencing on day 2 or 3 of the cycle

As per response to maximal daily dose of 450 IU

Anovulation with very low FSH and LH hormones

Between 75IU and 150IU of Follitropin alfa daily plus 75IU or lutropin alfa daily

As per response

Hypogonadotrophic hypogonadism

150IU three times per week plus hCG therapy

May continue for at least 4 months up to 18–24 months

Missed dose — contact prescriber, do not double dose.

ADVERSE EFFECTS2 As Bemfola acts to mimic natural systems in the body, it is generally well tolerated. WOMEN: FREQUENCY (#/PEOPLE)

SIDE EFFECT

LEVEL

Lower abdominal pain with nausea or vomiting

Serious

Common (1/100)

Seek medical attention. May be Ovairan Hyper-Stimulation Syndrome (OHSS) – where large ovarian cysts have developed

Thromboembolic events

Serious

Very rare (1/10000)

Seek immediate medical attention

Headache Injection site reactions

Non-serious

Very common (1/10)

Seek medical attention

Allergic reactions: rash, red skin, hives, swelling of face, difficulty breathing

Serious

Very rare (1/10000)

Seek immediate medical attention

Worsening asthma

Assess

Very rare (1/10000)

Assess patient’s asthma and refer accordingly

FREQUENCY (#/PEOPLE)

ADVICE

MEN: SIDE EFFECT

LEVEL

Allergic reactions: rash, red skin, hives, swelling of face, difficulty breathing

Serious

Very rare (1/10000)

Seek medical attention

Injection site reactions

Non-serious

Very common (1/10)

Seek medical attention

Swelling of the veins above and behind the testicles

Serious

Very rare (1/10000)

Seek immediate medical attention

Worsening asthma

Assess

Very rare (1/10000)

Assess patient’s asthma and refer accordingly

Acne, some breast development, weight gain

Assess

Common (1/100)

Assess and refer accordingly

PHARMACOKINETICS7

THERAPY OPTIMISING PRODUCTS

Follitropin alfa exhibits the following characteristics: Onset: 2.7–18 months (spermatogenesis); within cycle (females); Volume of distribution: 10 L; Bioavailability: 66–76% (healthy female volunteers); Half-life: 50 hr (IM in healthy female volunteers); 24 hr (SC in healthy female volunteers); Peak plasma time: 8–16 hr (SC in females); 25 hr (IM in females); 11–20 hr (IM in males).

The product comes with swabs and needles for sufficient use. Ensure the patient has a sharps container and knows where to dispose of that container once full. Ensure a discussion about common side effects occurs with a focus on compliance to their asthma medicines and appropriate access to analgesics for headaches.

REFERENCES Commonwealth of Australia Department of Health PBS Website. Bemfola. Canberra. Department of Health; Aug 2016. Available from: http://www.pbs.gov.au [Search Bemfola]. Bemfola Product Information [Internet]. Finox Biotech. 2014. Available from: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/ human/002615/WC500166818.pdf 3 McChesney P. Demographics of infertility. O&G Magazine. Vol 12 No 3 Spring 2010. Available from: https://www.ranzcog.edu.au/doc/doc.../313-14-demographics-ofinfertility.html 4 Bemfola Consumer Medicines Information [Internet]. TGA website; 2016. Bemfola: 18/11/2015; 11 pages. Available from: https://www.ebs.tga.gov.au/ebs/picmi/ picmirepository.nsf/pdf?OpenAgent&id=CP-2016-CMI-01751-1&d=2016082516114622483. 5 Andrology Australia. Homepage. Melbourne, Australia: 2016. Available from: https://www.andrologyaustralia.org/mens-health-statistics/. 6 Bühler K. Managing infertility with the follitropin alfa prefilled pen injector – patient considerations. Ther Clin Risk Manag. 2015; 11: 995–1001. Published online 2015 Jun 29. 7 Medscape. Follitropin alfa Pharmacokinetics. August 2016. Available from: http://reference.medscape.com/drug/gonal-f-rff-follitropin-alfa-342804#10. 1 2

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

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Please review the full product information before recommending, available at www.maxigesic.com.au References: 1. Merry, A. F., Gibbs, R. D., Edwards, J., Ting, G. S., Frampton, C., Davies, E. and Anderson, B. J. (2010). “Combined acetaminophen and ibuprofen for pain relief after oral surgery in adults: a randomized controlled trial” British Journal of Anaesthesia 104(1): 80–88. Result achieved in a trial of post-operative pain relief after removal of 1–4 wisdom teeth using Maxigesic® compared with Paracetamol 4000mg or Ibuprofen 1200mg alone per day in four divided doses. 2. Mehlisch, D. R., Aspley, S., Daniels, S. E., & Bandy, D. P. (2010). Comparison of the analgesic efficacy of concurrent ibuprofen and paracetamol with ibuprofen or paracetamol alone in the management of moderate to severe acute postoperative dental pain in adolescents and adults: A randomized, double-blind, placebo-controlled, parallel-group, single-dose, two-center, modified factorial study. Clinical Therapeutics, 32(5), 882–895. doi:10.1016/j.clinthera.2010.04.022 *2 tablets of Maxigesic taken every 6 hours over a 24 hour period (8 tablets maximum). Maxigesic® film coated tablets (Paracetamol 500mg and Ibuprofen 150mg; 10s, 12s, 16s, 24s and 30s) are for the temporary relief of pain and reduction of fever. Do not use if you have asthma or a stomach ulcer. Do not use in children under 12 years or if you have kidney disease. Do not exceed the daily recommended dose. Do not combine with any other Paracetamol or Ibuprofen containing medicines. Always read the label. Use only as directed. Incorrect use can be harmful. If symptoms persist consult your healthcare professional. Patent No. 2005260243.

CONTINUING PROFESSIONAL DEVELOPMENT 7 77

ALCOHOL MISUSE: Supporting Patients through Community Pharmacy

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

LEARNING OBJECTIVES After reading this article, the learner should be able to: • Recognize the guidelines for reducing harms from alcohol consumption in Australia; •

Identify how to calculate a standard drink according to Australian guidelines;

•

Identify appropriate treatment strategies for dealing with acute harms from alcohol use;

•

Recognize the mechanism of action for medications used in the treatment of long-term alcohol dependence in Australia;

•

Identify the cumulative health-related risks associated with long-term harmful alcohol consumption.

Competencies Addressed: 6.1, 6.2, 7.2 Accreditation number: G2016012 This activity has been accredited for 1 hour of Group 1 CPD (or 1 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 CPD credits) upon successful completion of relevant assessment activities.

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ALCOHOL PLAYS A COMPLEX ROLE IN AUSTRALIAN SOCIETY AND CULTURE, WITH MOST AUSTRALIAN’S DRINKING ALCOHOL FOR ENJOYMENT, RELAXATION AND SOCIABILITY1. WHILE THE MAJORITY OF DRINKERS DO SO AT LEVELS WHICH ARE UNLIKELY TO CAUSE SIGNIFICANT ADVERSE EFFECTS, THERE ARE HOWEVER A SUBSTANTIAL PROPORTION OF PEOPLE WHO DRINK AT LEVELS WHICH MAY INCREASE THEIR RISK OF ALCOHOL RELATED HARM. EXCESSIVE ALCOHOL CONSUMPTION IS LINKED AS A CAUSE OF A WIDE RANGE OF HEALTH AND OTHER HARMS INCLUDING BEING A MAJOR CAUSE OF ROAD AND OTHER ACCIDENTS1. IN ADDITION, EXCESSIVE ALCOHOL CONSUMPTION IN COMBINATION WITH CHRONIC DISEASE, MEDICATION AND IN ELDERLY PATIENTS CAN ALSO BE PRE-DISPOSING FACTORS TO ALCOHOL RELATED HARM. PHARMACISTS ARE IDEALLY PLACED IN THE COMMUNITY AS FRONTLINE HEALTHCARE PROFESSIONALS TO PROVIDE SUPPORT, GUIDANCE AND REFERRAL TO PATIENTS WHO MAY BE STRUGGLING WITH ALCOHOL MISUSE OR EXCESSIVE DRINKING AS WELL AS PROVIDE EDUCATION TO REDUCE THE RISK OF ALCOHOL RELATED HARMS.

Most Australians who drink alcohol do so at levels that have few adverse effects. However, any level of drinking increases the risk of ill-health and injury. The 2013 National Drug Strategy Household Survey indicated the following trends in alcohol use from 20102:

•• A lower proportion of Australians

•• About half (49%) of drinkers took

•• Almost 1 in 5 (18.2%) people aged

action to reduce their alcohol intake in 2013 and the main reason for doing this was due to concern for their health.

14 or older consumed more than 2 standard drinks per day on average, exceeding the lifetime risk guidelines;

•• More than 1 in 3 (38%) people aged 14 or older reported they had, on at least 1 occasion in the previous 12 months, consumed alcohol at a level placing them at risk of injury and 1 in 4 had done so as often as monthly (26%);

•• In 2013, about four-fifths of Australians aged 14 or older reported they had consumed alcohol in the past year and 6.5% drank on a daily basis;

on a single drinking occasion in the past 12 months, a lower proportion than 2010 (16.8%);

in risky quantities in 2013 compared to 2010 — the proportion of lifetime risky drinkers and single occasion risky drinkers declined;

STANDARD DRINKS AND STATISTICS ON ALCOHOL CONSUMPTION IN AUSTRALIA

•• In 2013, around 1 in 6 (15.6%)

aged 14 or older consumed alcohol

people aged 12 or older had consumed 11 or more standard drinks

The National Health and Medical Research Council developed a set of four guidelines in 2009 to help Australians reduce their health risks from drinking alcohol (see table 1 below), these guidelines move away from previous ‘risk based’ threshold approaches and recognize that the lifetime risk of harm from consuming alcohol increases progressively with the amount consumed1. In Australia, a standard drink refers to

TABLE 1: NHMRC GUIDELINES TO REDUCE HEALTH RISKS FROM DRINKING ALCOHOL1 GUIDELINE 1 — REDUCING THE RISK OF ALCOHOL-RELATED HARM OVER A LIFETIME

•• T he lifetime risk of harm from drinking alcohol increases with the amount consumed. •• For healthy men and women, drinking no more than two standard drinks on any day reduces the lifetime risk of harm from alcohol-related disease or injury. GUIDELINE 2 — REDUCING THE RISK OF INJURY ON A SINGLE OCCASION OF DRINKING

49%

of people action to took red their alco uce ho intake in l 2013.

•• O n a single occasion of drinking, the risk of alcohol-related injury increases with the amount consumed. •• For healthy men and women, drinking no more than four standard drinks on a single occasion reduces the risk of alcohol-related injury arising from that occasion. GUIDELINE 3 — CHILDREN AND YOUNG PEOPLE UNDER 18 YEARS OF AGE

•• For children and young people under 18 years of age, not drinking alcohol is the safest option. o

Parents and carers should be advised that children under 15 years of age are at the greatest risk of harm from drinking and that for this age group, not drinking alcohol is especially important.

For young people aged 15−17 years, the safest option is to delay the initiation of drinking for as long as possible.

GUIDELINE 4 — PREGNANCY AND BREASTFEEDING

•• Maternal alcohol consumption can harm the developing foetus or breastfeeding baby. o

For women who are pregnant or planning a pregnancy, not drinking is the safest option.

For women who are breastfeeding, not drinking is the safest option.

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CONTINUING PROFESSIONAL DEVELOPMENT

10 grams of alcohol (equivalent to 12.5ml of pure alcohol). On average, this is how much the human body can process in one hour. A standard drink is a unit of measurement. In the same way one meter measures a particular distance travelled, one standard drink measures a particular amount of alcohol consumed3. The formula for calculating standard drinks is3:

•• Volume of Container in Litres multiplied by the percentage of alcohol volume multiplied by 0.789 (specific gravity of ethyl alcohol), equals the number of standard drinks;

•• For example – One 375ml stubbie of beer (5% alcohol by volume) 0.375 x 5 x 0.789 = 1.47 (~1.5) standard drinks.

ALCOHOL MISUSE: ACUTE HARMS AND TREATMENT STRATEGIES There are a number of both short and long term harms associated with alcohol misuse and in some instances medical intervention may be required to help manage alcohol misuse syndromes. The following are the major harms associated with alcohol misuse and their associated treatments4-6; Acute alcohol intoxication and overdose: Alcohol overdose is potentially fatal; death is usually due to inhalation of vomitus or to respiratory depression. The average lethal blood alcohol concentration (BAC) is around 0.45% to 0.5% (450 to 500 mg/100 mL). However, people who have developed high tolerance to alcohol will be able to cope with higher BACs4,5. Treatment of intoxication and overdose is supportive and symptomatic, with careful monitoring of the BAC, airway, level of consciousness and responsiveness, and oxygen saturation. Acute alcohol withdrawal: Acute withdrawal syndrome is characterized by anxiety, tremor, sweating, nausea and vomiting, agitation, headache and perceptual disturbances. Seizures are occasionally observed (50% of patients who experience a seizure only suffer a single fit)4,5. Most people undergo alcohol with supportive care measures in place, however if medication is required patients may be prescribed diazepam at a dose of 20mg every 2 hours until symptoms abate. Additionally, as alcohol dependent patients are usually thiamine deficient, thiamine (initially IM/IV followed by oral) may need to be administered. Alcohol Withdrawal Delirium: This is the most severe manifestation of alcohol withdrawal. It usually commences 3-5 days after cessation of drinking and is characterized by gross tremors and

fluctuating levels of agitation, hallucinations (usually tactile), disorientation and impaired attention. It is a medical emergency which requires immediate hospitalization, the mortality rate is high if inadequately treated (from multiple potential complications, including heart failure)4,5. The principles of treatment (including appropriate supportive care and the use of thiamine and diazepam) are the same as those for milder withdrawal syndromes, however in a hospital/care setting to manage complications. In some cases, antipsychotic use may be required – haloperidol (oral or IM) or droperidol (for severe psychotic symptoms) can be used. Chlorpromazine is avoided due to its potential to lower the seizure threshold4-6.

“There are numerous health-related risks from long-term harmful drinking, including memory loss, permanent brain damage, nerve damage, headache, gastrointestinal bleeding/ulcers and anxiety/mood disorders.”

LONG TERM MANAGEMENT OF ALCOHOL DEPENDENCE Alcohol use disorders fit chronic disease models, as frequently relapsing illness. After withdrawal (detoxification), ongoing treatment may be required. Severity ranges from mild, where publicly available resources (ie. online or telephone interventions) may be useful, to more severe dysfunction, where dedicated/specialist alcohol and drug service involvement may be sought4,5. There are three drugs with different modes of action which may be used in treatment: disulfiram, acamprosate and naltrexone. Choice of drug needs to be individualized, depending on the person's circumstances. Combining psychosocial interventions with drugs has a much greater chance of maintaining abstinence than drug treatment alone5,6.

DISULFIRAM Disulfiram can give good results for highly motivated, physically fit individuals who are capable of compliance with an abstinencebased program4. Disulfiram primarily works by inhibiting the action of aldehyde dehydrogenase, an enzyme involved in the second step in the metabolism of alcohol, namely the conversion of acetaldehyde to acetate. This results in unpleasant symptoms from accumulation of acetaldehyde including flushing, dizziness, nausea and vomiting, irregular heartbeat, breathlessness and headache which act as a deterrent to alcohol use4,6. The evidence for disulfiram is weaker than its counterparts, however in the right patient it can still form an effective part of a comprehensive treatment approach5.

NALTREXONE Naltrexone is an orally active opioid receptor antagonist. By blocking μ opioid receptors, naltrexone reduces levels of dopamine (the major reward neurotransmitter in the brain)

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in response to alcohol use, reducing the rewarding effects of alcohol and reducing craving for alcohol5,6. Because naltrexone reduces rate of relapse to heavy drinking and increases the number of abstinence days it may be most effective in patients with a history of binge drinking and those who have been drinking heavily4,5. Patients currently using opioids or who require opiate-based pain relief are not suitable candidates for naltrexone use6.

ACAMPROSATE Acamprosate is thought to reduce drinking by modulating the brain GABA and glutamate function and reduces the neuronal hyperexcitability characteristic of alcohol withdrawal. While not an effective treatment for the acute phase, acamprosate reduces the symptoms of protracted alcohol withdrawal (eg anxiety, irritability, insomnia, craving)5,6. The drug only reaches desired levels in the brain after 1 to 2 weeks4,5. In conjunction with a counselling program, acamprosate should be started following cessation of the acute phase of alcohol withdrawal (approximately 1 week after cessation of drinking)6.

ALCOHOL USE AND PATIENT CONSIDERATIONS There are numerous health-related risks from long-term harmful drinking, including memory loss, permanent brain damage, nerve damage, headache, gastrointestinal bleeding/ulcers and anxiety/mood disorders5,6. Additionally, there are a number of other considerations to take into account for patients with chronic disease who may also be misusing or have a long term dependence on alcohol. Pharmacists are

ideally placed to support patients with the following conditions which may be impacted by excessive alcohol use: Cardiovascular disease: Long-term use of alcohol can raise blood pressure and increase the risk of arrhythmias, shortness of breath, congestive cardiac failure, haemorrhagic stroke and other circulatory problems. Alcoholic cardiomyopathy and cardiac conduction disturbances are also associated with heavy alcohol intake. Low levels of alcohol raise high-density lipoprotein cholesterol and reduce plaque accumulations in arteries. Alcohol can also have a mild anticoagulating effect5. Cancers: Alcohol has been associated with a raised risk of cancer: There is some evidence that alcohol is carcinogenic to humans, being causally related to cancers of the oral cavity, pharynx, larynx, oesophagus, liver, colorectal and female breast5. Diabetes: Moderate-heavy intake of alcohol can mask a patient’s perception

of hypoglycaemia symptoms in their early stages. Through inhibiting hepatic gluconeogenic capacity, alcohol can impair the body’s ability to provide glucose and restore low glucose levels toward normal, posing a risk for severe hypoglycaemia with excessive consumption5. Alcohol is best taken with meals to reduce peak alcohol levels in the blood. Infectious diseases: Heavy alcohol consumption may impair immune function, leading to an increased risk of infections including skin and respiratory infections5. This is of particular concern for patients with already impaired immunity such as those with hepatitis, HIV or are using immunosuppressant drugs4. Liver diseases: Alcohol intake can increase the severity of hepatitis C, nonalcoholic fatty liver and other drug-induced liver injury1,5. Mental Health: There is growing evidence that alcohol increases the risk of highly

prevalent mental health conditions such as depression and anxiety in some people, and may affect the efficacy of antidepressant medication1,5. The co-occurrence of major depression and alcohol-use disorders increases the risks of both violence and suicidal behaviour5. Nutrition Related Conditions: Alcohol consumption (particularly excessive, chronic use) is linked to malnutrition, WernickeKorsakoff syndrome due to thiamine (vitamin B1) deficiency, folate deficiency and vitamin A depletion1,5. Sleep Disorders: Alcohol can cause or interruptions to normal sleep patterns, particularly in the later stages of REM-cycle sleep5. Sexual Dysfunction: Whilst at low levels, alcohol intake can reduce inhibition and increase sexual desire it is seen to cause or exacerbate a range of sexual dysfunctions in both men and women with heavy and longterm use5.

SUPPORTING PATIENTS THROUGH COMMUNITY PHARMACY Pharmacists have a significant opportunity to support patients and the wider community in both raising awareness and providing education in regards to excessive alcohol consumption. Some targeted interventions that pharmacists may consider include:

Consider running health promotion initiatives which encourage patients to consider their alcohol use, the long-term impacts on their health and to assist in identifying patients who may require additional support or referral – encourage patients to seek help and have honest discussions with their GP about their consumption of alcohol;

Become familiar with local support organizations and interventions for people who may identify as having problems with excessive use of alcohol. Support programs (such as the '12-step', programs associated with alcoholics anonymous groups) and other social interventions are often effective alone or in conjunction with therapeutic intervention;

When undertaking patient medication reviews or clinical interventions, consider the role that alcohol consumption (particularly excessive use) may play in a patients overall wellbeing including impacts/cumulative effects with other conditions. Also consider the importance of alcohol-drug interactions in patients who identify that they are regularly/excessively consuming alcohol.

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CONTINUING PROFESSIONAL DEVELOPMENT

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

QUESTION 1 Which of the following statements regarding the 2009 NHMRC Guidelines to Reduce Health Risks from Drinking Alcohol is correct? a. For healthy men and women, drinking no more than four standard drinks on any day reduces the lifetime risk of harm from alcohol-related disease or injury; b. For healthy men and women, drinking no more than two standard drinks on a single occasion reduces the risk of alcohol-related injury arising from that occasion; c. For women who are pregnant, planning a pregnancy or breastfeeding; not drinking is the safest option; d. All of the above.

QUESTION 2 How many standard drinks (approx) would be consumed for a patient who describes the following alcohol intake: Four 275ml pots of full strength (4.7% alcohol by volume) beer per night? a. 6 b. 4 c. 2.5 d. 1

QUESTION 3 Which of the following medications should be avoided when treating alcohol withdrawal delirium? a. Diazepam b. Haloperidol c. Chlorpromazine d. Thiamine

QUESTION 4 Which of following medications for treatment of long-term management of alcohol dependence exhibits its effect by inhibiting an enzyme involved in the metabolism of alcohol? a. Disulfiram b. Naltrexone c. Acamprosate

REFERENCES National Health and Medical Research Council 2009. Australian guidelines to reduce the risks from drinking alcohol. Commonwealth of Australia. 2 Australian Institute of Health and Welfare 2014. National Drug Strategy Household Survey detailed report 2013. Drug statistics series 28(183). Canberra: AIHW. 3 Department of Health. The Australian Standard Drink [Internet]. 2012 [accessed Aug 2016]. Available from: http://www.alcohol.gov.au/internet/alcohol/ publishing.nsf/Content/standard. 4 eTG complete [online]. Therapeutic Guidelines: Cardiovascular. Version 6. Melbourne: Therapeutic Guidelines Limited. 2016. 5 Haber, P, Lintzeris N, Proude, E and Lopatko O. Guidelines for the treatment of alcohol problems. University of Sydney. 2009. 6 AMH [Internet]. Adelaide: Australian Medicines Handbook Pty Ltd.; 2016 Jan. <www.amh.net.au>. 1

d. Clonidine

QUESTION 5 Which of the following is associated with increased alcohol consumption? a. Thiamine deficiency b. Sexual dysfunction c. Sleep disorders d. All of the above

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BUSINESS

ENHANCED PHARMACY SERVICES:

Healthcare Consumers’ Viewpoints THE DEBATE SURROUNDING THE ROLE PHARMACY CAN PLAY IN COMMUNITY HEALTH IS A CONTENTIOUS ONE. SUPPORTERS CLAIM ENHANCED PHARMACY SERVICES WILL CREATE EFFICIENCIES IN AN ALREADY OVERBURDENED HEALTHCARE SYSTEM BY PROVIDING GREATER ACCESS TO PRESCRIPTION REPEATS, TREATMENT OF MINOR AILMENTS AND VACCINATIONS. IT HAS BEEN FURTHER SUGGESTED THAT SUCH SERVICES MAY EXTEND TO POST HOSPITAL AND TRANSITIONAL CARE SUPPORT, HEALTH CHECKS, SCREENING AND PREVENTATIVE HEALTH SERVICES.

"Results indicated 60% of respondents would trust a suitably qualified pharmacist to administer a flu jab, 21% disagreed."

DR GARY MORTIMER Associate Professor QUT Business School

Already, Australia’s 5,500 community pharmacies play an important role in diabetes maintenance, asthma management and blood pressure monitoring. Opponents, on the other hand, argue that such services have been, and continue to be, successfully delivered in general practice. Warning — any change to existing protocols may create undue risk and fragmentation of care. Rather than critique these positions, the purpose of this article is to provide a voice for the consumer and simply to measure consu mers’ desire for such enhanced services and draw inferences from preliminary data in relation to emerging trust and risk issues. During 2015, I conducted a preliminary study into consumer demand for enhanced pharmacy services. An online survey of 403 shoppers (Male = 175, Female = 227) gathered data from across Australia. The study sought to quantify the following items: 1. It would save me time if I could get my flu vaccination at my pharmacy. 2. I would trust my pharmacist to give me a flu vaccination.

those with children, lower income groups and the elderly. It is suggested that some of these barriers to consumer adoption of enhanced pharmacy services could be reduced, or removed through educational programs and societal marketing strategies. Ultimately, more empirical research is needed to develop a deeper understanding of consumer intentions to utilise enhanced services.

TIME Consumers engage with Australia’s community pharmacy network on a regular basis; often to collect prescription medicines, or purchase health and beauty, vitamins or skincare products. Location and accessibility are key strategic strengths behind the push for enhanced services. Simply being able to walk into a local community pharmacy for a flu

jab is more time efficient for consumers than having to book appointments and sit around in waiting rooms. In total, 56% of respondents agreed (Somewhat Agreed, Agreed, Strongly Agreed) that they would save time if they were able to acquire a flu vaccination at their local community pharmacy. A little over 20% disagreed (Somewhat Disagreed, Disagreed, Strongly Disagreed). Differences were detected between genders, with 64% of males agreeing such an enhanced service would save time, while only 50% of female respondents agreed. Respondents in higher income brackets were more likely to see the benefits of this service, with 61% of respondents earning over $110,000 in support, higher than the 52% of respondents earning between $50,000 and $70,000. In relation to age, younger consumers were more

ENHANCED SERVICES Strongly Disagree

Disagree

Somewhat Disagree

Somewhat Agree

Agree

Strongly Agree

Neither Agree/Disagree

3. If I was travelling overseas, I would be happy for my pharmacist to give me my travel vaccination/s. 4. If my child needed their scheduled vaccinations, I would trust my pharmacist to administer them. 5. It would be convenient to get my vaccinations done at the pharmacy. While the outcomes of this study generally exhibit an affinity for enhanced pharmacy services, results also identified cautionary consumers, particularly female consumers,

SAVE TIME

FLU JABS

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TRAVEL VACINATIONS

CHILDHOOD VACINATIONS

CONVENIENCE

BUSINESS

likely to agree this service would save time, with 70% of those aged 25–35 in agreeance, while only 52% of respondents aged over 56 years agreed.

TRUST When dealing with healthcare matters, even with the most minor ailments, trust within the relationship vital. Results indicated 60% of respondents would trust a suitably qualified pharmacist to administer a flu jab, 21% disagreed. Again, gender delivered differing outcomes, with 64% of men and 57% of women agreeing with the statement. Those on higher incomes, over $110,000, were more likely to place trust in their pharmacist, whereas lower income groups were less inclined to trust: under $20,000 – 55% agreed, $20,001–$50,000 – 60% agreed. Younger cohorts of consumers were less risk adverse, with 61% of 25–35 year olds trusting pharmacists to administer flu jabs, in contrast to only 54% aged over 65 years.

TRAVEL Today, consumers have greater access to international travel than ever before, with adventure travel to third-world countries like Cambodia, Brazil and Morocco, amongst others, increasing each year. As such, it was proposed to test whether consumers would consider having a suitably trained pharmacist administer travel vaccinations. Results indicated 54% of respondents would. In relation to gender, 60% of men and 49% of women agreed with this statement. 64% of consumers on incomes over $110,000 were more likely to have a pharmacist

administer a travel vaccination, whereas only 46% of consumers in lower income groups were less inclined. This variance in income may be correlated with the ability to travel internationally. Younger consumers, 18–24 years would be more likely to attain a travel vaccination from a pharmacy (68%), in contrast to older consumers: 56–65 years – 53% and over 65 years at 44%. Again, it is suggested other medical issues may be presented in older cohorts and accordingly they may be less inclined to seek out alternative arrangements.

CHILDREN The health and wellbeing of children is of vital importance. Issues surrounding mental health, obesity, healthy eating and childhood vaccinations permeate popular media and academic journals. This study sought to measure consumers’ intentions to have a pharmacist administer scheduled childhood vaccinations. Herein, the results indicated only 46% of respondents would be comfortable having a pharmacist administer their children’s vaccinations, with 33% disagreeing with the proposition. Female consumers were more risk adverse, with over 38% advising they wouldn’t support pharmacists administering childhood vaccinations. Interrogating the income data found that only those consumers earning over $110,000 would be willing to support this service, but only just at 51%. Low to middle income earners were less likely to support this service. Younger consumers, 18–24 years were more likely to have their children vaccinated by a pharmacist (67%); however, all other age groups were more or less opposed. It

is suggested lack of knowledge or ‘no-vax’ campaigns have created a sense of insecurity and mistrust in this area.

CONVENIENCE While 56% of consumers advised the implementation of enhanced pharmacy services would save them time, 59% considered it would also be a convenient option, with 61% of men and 58% of women agreeing with the statement. Of those on incomes over $110,000, 67% were more likely to consider the convenience of enhanced services than those consumers on lower incomes: under $20,000 – 52%, $20,001–$50,000 – 57%. Younger cohorts of consumers sought convenience, with 75% reporting enhanced pharmacy services would be a convenient option, whereas those aged over 65 years (45%), and possibly retired, did not consider the service convenient.

FENCE SITTERS Predominant across this study were those who reported to, ‘neither agree nor disagree’ with the statements. In many cases, somewhere between 18% and up to almost 24% of respondents, fell into this group. Such a result suggests not apathy, but rather uncertainty. As presented above, those respondents with children, lower income groups and those over the age of 65 years were less inclined to support enhanced services. For these groups, any change to the status quo comes with heightened degrees of perceived risk. As such, before any rigorous conclusions can be drawn, further qualitative, quantitative and scenariobased consumer research is required.

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HEALTH

Performing Clinical Interventions

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HEALTH

NATE HENTSCHEL Pharmacist, B. Pharm.

CLINICAL INTERVENTIONS ARE A FUNDED SERVICE WHEREBY A PHARMACY CAN BE REMUNERATED FOR DETECTING AND RESOLVING, OR PREVENTING, ANY PROBLEM RELATING TO A MEDICATION. PHARMACISTS CAN PERFORM CLINICAL INTERVENTIONS TO HELP IMPROVE HEALTH OUTCOMES FOR THEIR PATIENTS, OR TO AVOID POTENTIAL ADVERSE REACTIONS OR INTERACTIONS THAT COULD OCCUR IN THE FUTURE. INTERVENTIONS ARE A SHORT AND SIMPLE SERVICE WHICH CAN HELP TO INCREASE PHARMACIST INVOLVEMENT WITH PATIENTS.

“Training staff on what to look out for, and ensuring they are asking all of the appropriate questions when dealing with scheduled medicines, will enable a pharmacist to be aware of potential interventions.”

Most pharmacists are performing tasks which constitute a clinical intervention without even realising it, and the key is to ensure that it is adequately recorded at some point to allow the pharmacy to receive remuneration for their time and services. While the payment per intervention may seem fairly small, it is a step in the right direction for pharmacy as a business model to be more professional services focused. While the intervention itself should be handled and documented by the pharmacist involved, staff throughout the dispensary are a great asset when trying to detect clinical interventions. Training staff on what to look out for, and ensuring they are asking all of the appropriate questions when dealing with scheduled medicines, will enable a pharmacist to be aware of potential interventions. This then aids the pharmacist in taking a more proactive role in interacting with patients, thus leading to more clinical interventions, MedsChecks, HMR referrals or other professional services. Teaching dispensary staff and other staff to be vigilant with medications can help ensure interventions are recognised and dealt with accordingly. A simple and useful area for pharmacists to look at is in the supply of schedule 2 and 3 medicines. As these products are typically requested by the patient, things such as drug interactions, safety or appropriateness are rarely taken into account in advance, so it is often the ideal situation for a pharmacist to detect and perform clinical interventions. Clinical interventions can be performed in a situation where there is an adverse drug reaction, an untreated or under-treated condition, or the potential for compliance issues or interactions. Prescribing errors and other situations where another health professional needs to be contacted, may also constitute a clinical intervention. Generally, where a particular intervention or activity is within the scope of practice of a pharmacist and involves medications, it may be able to be recorded as a clinical intervention. The essential aspects of a clinical intervention include:

•• Date of the intervention; •• A patient name or unique identifier and their gender;

•• An age range; •• The relevant medications; •• The intervention type; •• The outcome and recommendation(s);

•• Pharmacist name or initials. Blank templates exist for recording clinical interventions on paper, and programs such as GuildCare enable online recording which can also help detect possible interventions when dispensing. The interventions are classified under the D.O.C.U.M.E.N.T. system, which relates to issues regarding drug selection, over- or under-dose, compliance, under-treated, monitoring, education/information, not classifiable, and toxicity/adverse reactions. Each intervention can only be recorded under a single classification, and it is important to note that those recorded under monitoring, education/ information or not classifiable are not currently remunerated. Interventions which involve drug toxicity or adverse reactions should also be reported to the Therapeutic Goods Administration. In addition to classifying the intervention, the outcome of the intervention can be summarised through a choice of recommendations, numbered from R1 to R19. Unlike the classification, an intervention can have multiple recommendations or outcomes. A suitable storage and recording system should be maintained, whether electronic as through GuildCare, or paper based. Pharmacies should be aiming to record all their clinical interventions in order to maximise their revenue from the services that many pharmacists are already doing. The service provides an excellent opportunity to expand upon pharmacist interactions with patients, and although clinical interventions have now been around for a few years, there are still pharmacies which are not recording these interventions, and are thus missing out on this opportunity. As the profession and industry continues to experience price cuts and reform, moving towards a more service-based remuneration system already in place will make adapting to future changes much easier.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

HEALTH

MANAGING

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

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

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

HEALTH

OVER 1 MILLION AUSTRALIANS HAVE BEEN DIAGNOSED WITH TYPE 2 DIABETES (T2D), AND FOR EVERY FOUR PEOPLE DIAGNOSED THERE IS ANOTHER PERSON THAT HAS THE CONDITION BUT DOESN’T KNOW IT 1. ALONG WITH HIGH BLOOD GLUCOSE, MOST PEOPLE WITH T2D CARRY WEIGHT CENTRALLY, HAVE ABNORMAL BLOOD LIPIDS AND/OR HIGH BLOOD PRESSURE, A CONSTELLATION OF SYMPTOMS KNOWN COLLECTIVELY AS METABOLIC SYNDROME2. ALL THESE SYMPTOMS CAN BE EFFECTIVELY MANAGED THROUGH APPROPRIATE MEDICAL NUTRITION THERAPY3.

WEIGHT MANAGEMENT Approximately 80% of people with T2D are overweight or obese (Body Mass Index > 25 kg/m2), and typically excess body fat is stored intra-abdominally3. Losing 5–10% of current body weight will significantly improve all facets of metabolic syndrome. There are many ways of eating healthily that can help with long-term weight loss, including (but not limited to) Mediterranean style, low fat, vegetarian/vegan, and low carbohydrate patterns3. An individual’s personal preferences (e.g. tradition, culture, religion, health beliefs and goals, finances) and metabolic goals should be considered when recommending an eating pattern3. Moderate sustainable weight loss (0.5 kg per week) can be achieved by decreasing energy intake by approximately 2000 kJ daily, regardless of the eating pattern. For a typical Australian adult consuming around 8,700 kJ per day this is approximately a 25% reduction in total energy consumption. Very low energy diets (VLEDs) use a special kind of meal replacement, suitable under certain circumstances, to help people with type 2 diabetes lose weight rapidly as they provide less than 3,300 kJ daily4,5. For more information on VLEDs see ITK Issue #45: December 2015/January 2016. Doing at least 150 minutes of moderate intensity (e.g. brisk walking) physical activity each week will also assist with fat loss, decrease insulin resistance6 and improve glucose uptake.

BLOOD GLUCOSE MANAGEMENT Carbohydrate in foods affects blood glucose and insulin levels and consequently the amount and type consumed is typically the focus of medical nutrition therapy3. To ensure people with diabetes consume a balanced diet, providing adequate vitamins, minerals and dietary fibre, a total carbohydrate intake of 45–60% of energy (depending on cultural background, personal food preferences, clinical goals etc.) is generally recommended7. which for an adult consuming 8,700 kJ daily

equates to 230–310 g of carbohydrate daily. For people using insulin or oral hypoglycaemic agents that can cause hypoglycaemia, it is recommended that total carbohydrate intake is spread out throughout the day. It should also be noted that excessive alcohol intake can adversely affect blood glucose control.

BLOOD LIPID MANAGEMENT People with diabetes typically have elevated LDL cholesterol and triglycerides and relatively low HDL cholesterol levels. Fats in food affect blood lipids. Saturated and trans fats elevate LDL cholesterol levels and unsaturated fats (mono and polyunsaturated fats) lower them, while also raising HDL cholesterol8. Trans fats lower HDL cholesterol. For optimal blood lipids, people should avoid trans fats and consume twice as much unsaturated fat as saturated fat. For example, if a person consumes 10% of energy from saturated fat they should consume 20% of energy from unsaturated fats. Soluble dietary fibres like ß-glucans (primarily found in oats and barley) can also help lower cholesterol levels, as can phytosterols found in certain margarines3,7. Excessive alcohol and refined carbohydrate consumption raises triglyceride levels3,7.

“People with diabetes typically have elevated LDL cholesterol and triglycerides and relatively low HDL cholesterol levels.”

BLOOD PRESSURE MANAGEMENT Losing weight and regular moderate physical activity are two of the most effective ways of lowering blood pressure3. Reducing sodium consumption and increasing potassium consumption will also help improve blood pressure3,7. To reduce sodium intake, reduce salt used in cooking and at the table, reduce processed meats, takeaway foods and processed foods — buy salt reduced or no added salt varieties. To increase potassium, consume at least 5 serves of fresh or frozen vegetables and 2 serves of fruit daily.

CONCLUSION

80%

People with type 2 diabetes can OF PEOPL successfully E WITH manage their T 2 D AR condition with OVERWE E medical nutrition IGH OR OBES T therapy. An E Accredited Practising Dietitian (APD) provides practical, tailored nutrition advice. To find an APD in your area, visit the DAA website www.daa.asn.au and look under ‘Find an Accredited Practising Dietitian’.

TYPES OF FATS: Saturated and trans fats are solid at room temperature. Saturated fats are found in butter, cream, meat fat, chicken skin, coconut oil, palm oil, many fried takeaway foods and many commercially made cakes, biscuits, pies and pastries. Trans fat intake in Australia is relatively low due to manufacturing processes. Trans fats are found in many of the same foods as saturated fat, so minimising these foods is the way to go. Unsaturated fats are liquid at room temperature. They can be found in oily fish such as salmon and sardines, nuts, avocado, olive oil, canola oil, sunflower oil and spreads made from these.

REFERENCES: Australian Bureau of Statistics. Australian Health Survey: First Results, 2011–12. 4364.0.55.001. 29-10-2012. 2 Royall D, et al. Can J Diet Pract Res 2014 Sep;75(3):132-9. 3 Evert AB, et al. Diabetes Care 2014 Jan;37 Suppl 1:S120-43. doi: 10.2337/dc14-S120.:S120-S143. 4 Tsai AG, Wadden TA. Obesity (Silver Spring) 2006 Aug;14(8):1283-93. 5 Rehackova L, et al. Diabet Med 2016 May;33(5): 580-91. 6 Gillies CL, et al. BMJ 2007 Feb 10;334(7588):299. 7 Dworatzek PD, et al. Can J Diabetes 2013 Apr;37 Suppl 1:S45-55. doi: 10.1016/j.jcjd.2013.01.019. Epub;%2013 Mar 26.:S45-S55. 8 Mensink RP, et al. Am J Clin Nutr 2003 May;77(5):1146-55. 1

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

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BUSINESS

goes MOBILE CARL ZUFI CEO, Methsof

THE PHARMACY INDUSTRY IS BECOMING MORE AND MORE COMPETITIVE, AND THIS PRESENTS NUMEROUS CHALLENGES; HOWEVER, IT ALSO PRESENTS MANY OPPORTUNITIES, PARTICULARLY TO THOSE WHO CAN ADAPT AND EMBRACE NEW WAYS OF THINKING, SUCH AS LEVERAGING TECHNOLOGY TO BRING AGILITY AND CAPABILITY LIKE NEVER BEFORE.

How can pharmacies differentiate themselves? How can they 'stand out from the crowd' so to speak? How can pharmacies grow their customer numbers?

How can pharmacies create “stickiness” with their customers, in essence, creating loyalty and, therefore, repeat business? How can pharmacies increase revenue opportunities? How can a physical store remain relevant in an online world?

These are just some of the challenges facing pharmacy today that got us thinking at Methsof. In many ways our survival is very much tied to the success of our customers.

Over the past 3 years, Methsof has been developing a new solution specifically designed to help pharmacies meet these and other challenges — indeed to help shape the future of pharmacy. Our platform was recently launched with one of Australia’s largest and well known pharmacy banner groups, with other large banner groups soon to follow.

The core of our new solution revolves around a mobile application platform like no other. We live in a multi-channel, internetconnected and increasingly mobile world. The mobile phone is unlike any other device, primarily because it is always with us and it is very personal. This brings incredible opportunities to pharmacies that want to embrace the future.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

The mobile application supports a complete branding opportunity. Each pharmacy (and banner group) has their own unique position in the marketplace, targeting certain demographics or regions, focusing on particular products or services. It therefore stands to reason that any mobile solution needs to be able to adapt to the brand or image of the pharmacy which helps that pharmacy “differentiate” themselves from their competitors. A mobile solution that encompasses all aspects of the pharmacy experience provides a level of convenience that consumers will naturally gravitate towards, which in turn fosters loyalty. Medication management is a critical component for any pharmacy mobile application; however, Methsof recognises that medication dispensing and management makes up only one component of today’s modern pharmacy. Other important components include over-the-counter sales (OTC), as well as professional service and advice. The platform includes functionality for all of these components in the one solution, thus providing a full pharmacy experience from within the app.

BUSINESS

"We truly believe this mobile application platform will be the future of how pharmacies will interact with their customers."

Aside from the medication management component (including prescription management and dose reminders), we also include advanced OTC shopping functionality for those that wish to search for, or purchase, over-the-counter products through the app, as well as a myriad of other functions, such as ‘pharmacy chat’ for a one-on-one chat with the pharmacists, a ‘news’ component for broadcasting customised messaging to your customer base, a ‘loyalty’ component, a ‘coupon’ component, and other great features. Functionality can be added to the app, or existing functions removed, depending on the pharmacy requirements. Essentially, the app is a blank canvas for the pharmacy to create their own customised experience for their unique customer base. In fact, this is why there is no official name for the platform — our customers are free to call it whatever they want! This platform is not simply an ‘off-the-shelf’ product — Methsof licenses the technology to our customers and they add their level of customisation, branding and ‘splash of colour’ relevant to their needs. Our platform provides an unparalleled level

of integration capability and flexibility to pharmacies that allows them to execute the vision and strategy that is uniquely important to them. Modern business is acutely aware of the value and importance of data. Methsof does not seek to profit from your customers or sell your data. Instead, your data is yours to leverage how you see fit, whether you seek to monetise the data, analyse the data to gain insights into your customers’ behaviour, or for any other purpose. Methsof are extremely proud to be releasing this product to market. We truly believe this mobile application platform will be the future of how pharmacies will interact with their customers. We believe this platform will provide pharmacies with a powerful capability to meet today’s challenges, enabling our customers to succeed in these competitive times.

ABOUT METHSOF Established in 2003, Methsof is well known in the pharmacy industry as Australia’s leading supplier of electronic controlled drug register software (DD-Book), opioid substitution management software (Meth.D.A), as well as other pharmacyrelated products. With over 60% of all Australian pharmacies using at least one of our products on a daily basis, Methsof has well established relationships with both large pharmacy banner groups and individual community pharmacies. As a result of these relationships, Methsof has built up a strong level of trust with our customers through delivering progressive, cutting-edge software that is genuinely appreciated by our large client base. Phone: (03) 9867 2785 Email: sales@methsof.com.au www.methsof.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

“We continually review how to improve the services we provide. The Guild’s endorsement pushes us to look beyond the DAA to consider how we can add greater value to our community pharmacy partners.”

HEALTH

Supporting Pharmacists through

Dose Administration Aids SEAN TUNNY

LUKE FITZGERALD

Editor, Gold Cross Products & Services Pty Ltd

Chief Executive Officer, Australia

TECHNOLOGY HAS BROUGHT MANY CHANGES TO PHARMACIES, BUT IT IS REASSURING TO KNOW THAT ONE THING REMAINS CONSTANT — THE HIGH REGARD THAT PATIENTS HAVE FOR PHARMACY PROFESSIONALS. IN FACT, 75% TURN TO THEIR PHARMACIST AS A TRUSTED ADVISOR WHEN THEY NEED ADVICE.

To learn more about what makes patients tick, dose administration aid (DAA) experts, MPS, worked with RAW Marketing on some detailed consumer research into Pharmacy audiences. This research is being used by MPS to provide medication solutions that help Pharmacies to better serve their community customer and their Residential Aged Care Residents. Here are some of their findings. EDITOR: Who are DAA customers? The research revealed that those between 35 and 75 are most receptive to using DAAs. It identified four personas that were familiar to most pharmacy staff. We assessed:

•• •• •• ••

The most popular age cohorts that visited the Pharmacy; Common medication management challenges they experience; Those on both prescribed and non-prescribed medications; Family members, spouses and carers helping patients managing 5 or more medications.

EDITOR: What was learned about patient non-adherence and medication errors? Pharmacy advice is clearly influential; it was observed patients place exceptional trust in their Pharmacist and/or Pharmacy Assistant when it comes to recommendations and advice about DAAs. “100,000 hospital admissions per year in Australia are associated with preventable medication incidentsi that are associated with medication incidences that could be prevented. Probably one of the

things for the consumer to be aware of is that 1 in 4 patients go into an aged care facilityii because the carer says, ‘It’s actually becoming too difficult to manage your medications.’” For elderly patients, a DAA represents an opportunity to stay home longer and retain greater independence. When the pharmacist explains it to the patient in that way, they appear to adapt to the changes more readily. EDITOR: What defines a patient’s suitability for a dose administration aid? Government incentives are an important consideration, and these are invoked when a patient takes five or more packable medications. The government identifies the importance of a DAA and increasing the PPI, which is a positive for the collaboration between patients and pharmacies. The Market research uncovered four key customer cohorts: 1. Carers who worry that their family member takes medications incorrectly, and like the confidence and peace of mind the DAA brings. 2. People who want a safe, personalised and convenient medication strategy that helps them stay at home longer. 3. Active patients who want more time to enjoy life, with the convenience of portable individual doses that could simply be torn off and taken to Bowls or other social events.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

HEALTH

4. Finally, the fourth persona uncovered something unexpected — the busy forty-something needing a compact and convenient solution to manage a combination of medications and supplements. EDITOR: When dose administration aids are packed by a third party, such as a community pharmacy, interdisciplinary communication and teamwork, patient education, monitoring and regular medicines reconciliation and review are vital to minimise the risk of problems. A lot of Pharmacies want to develop a DAA strategy and determine the role the DAA will play in their Pharmacy. The most frequent questions were how to involve staff, how to communicate with customers about DAAs, and whether to outsource or pack in-house. EDITOR: How does MPS partner with community pharmacies? Community pharmacy partnerships are a core part of how MPS works. In fact, a lot of importance is placed on the partnership with the Pharmacy Guild of Australia, and also on our understanding of community pharmacies and their patients as we aim to make medication management safer. We continually review how to improve the services we provide. The Guild’s endorsement pushes us to look beyond the DAA to consider how we can add greater value to our community pharmacy partners. We also have a host of partnerships with community banner groups. These partnerships or alliances enable us to identify what’s good for the consumer, while being supportive of the Guild’s work.

Further, we are uniquely positioned to support community pharmacists with their own businesses, and the individual goals and plans they have in place. For example, Guildlink was our first choice IT partner due to the innovative e-health solutions they demonstrated. They have a close connection with Australian community pharmacies that helps to create DAA solutions that work in a real-world environment. We are collaborating to ensure both companies’ existing software works seamlessly together, so that pharmacy staff can spend less time on administration and more time caring for patients. In September 2015, The Pharmacy Board of Australia developed a schedule of guidelines on dose administration aids and staged supply of dispensed medicines. In our next edition of ITK, we will explore the impacts and implications this has had on, and, for community pharmacy. To get a copy of the research report or to find out how you can utilise the MPS personas to help grow your Dose Administration Aid business, contact the friendly MPS team 1800 003 938 or visit www.mps-aust.com.au.

REFERENCES: http://www.ncbi.nlm.nih.gov/pubmed/19671158. https://search.informit.com.au/browsePublication;subject=Pharmacology%20 %26%20therapeutics;py=2010;vol=91;res=IELHEA;issn=0311-8002;iss=1081.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

BUSINESS

Are Your Loved Ones SAFE? RICHARD O'GRADY General Manager Australian Vehicle Buying Services

WE ARE ALL IN THE BUSINESS OF LOOKING AFTER PEOPLE AND THEIR HEALTH. OVER THE PAST FEW MONTHS, AVBS HAS HAD AN INCREASED LEVEL OF REQUESTS FOR VEHICLES THAT OFFER HIGH LEVELS OF SAFETY. THE WELL-KNOWN VICTORIAN CAMPAIGN TOWARDS ZERO, FAMOUS FOR CREATING THE INVINCIBLE ‘GRAHAM’, REINFORCES THE SIGNIFICANCE THAT INVESTING IN A SAFER CAR WILL HAVE ON REDUCING THE NATIONAL ROAD TOLL. SO IT’S WORTH ASKING YOURSELF — ARE YOU AND YOUR LOVED ONES THE SAFEST YOU CAN POSSIBLY BE?

The advantage of dealing with a buying service like AVBS, is that we are not loyal to any brand. Be assured, if you walk into a dealership, their vehicles will be the safest on the road, no matter what brand it is. They all can’t be right.

There are many features that are now available that can decrease your chances of having an accident, while increasing your chances of being safe if contact does happen. These features are often spread across various add-on packs, like Tech Packs, Comfort Packs, Driver Assist Packs, etc. AVBS can help to clear up the confusion.

spot. If you try and change lanes, the system signals that there is a vehicle there. If you put your indicator on to change lanes, the system gets a bit more vocal, warning of the hazard. Adaptive Cruise Control – Here again we have a few options: one that beeps and flashes when you get too close to the car in front, and the next adjusts the speed of your vehicle to maintain the distance between you and the car in front. This system (in many cases) has collision mitigation, meaning the vehicle brakes and attempts to avoid and reduce the impact speed, which reduces injuries. Some vehicle systems use steering, braking and power control to avoid collisions. One thing to be careful of is that for some vehicles if cruise control is not engaged, collision mitigation is also inactive.

Blind Spot Monitor – If you have ever driven in traffic, there are times when you just don’t notice the car or motorbike that is just behind — and in your blind spot. Most systems have a red light in the rear-view mirror that illuminates when a vehicle is in your blind

The Simple Things – Often we don't think of the simple things that help increase road safety — heated mirrors, auto dipping head lights, tyre pressure monitors, run flat tyres, seatbelt pre-tensioners, improved braking, better steering systems, traction control, ESP systems, and the list goes on. A car has two primary functions: to get you (and equipment) from A to B, and to protect you and your loved ones (from injury and the elements). Some might be drawn into a debate about looks, status, sport etc., but for the most part these are the two primary functions that matter most. Otherwise, we may as well ride a motor bike.

Some of the features to consider are: Lane Departure – There two programs in play here: lane departure warning which beeps and, in some cases, shakes the steering wheel if you stray over to the white line; then there is lane departure assist which actively steers you back inside the lane when you stray.

many years; however, side curtain, seatbelt and pedestrian airbags, are all now featured to reduce injury and deaths.

Fatigue Alert – This excellent little system monitors the driver and makes noises to keep the driver alert and also instructs them to take a break. Airbags – These seem to be a forgotten feature, yet when the worst happens, they play such a critical role in reducing deaths. Driver and passenger airbags have been around for

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

Time to Trade Up to the safest car you can afford? Call AVBS today and we can take the hassle out of the process and get you more safety for your dollar. Call 1300 76 49 49 Or visit www.avbs.com.au/enquiry-form

BUSINESS

MAJOR RETAILERS FACE FINANCIAL RUIN WITHIN THE YEAR. (Inside Retailing)

MORE TROUBLE ON THE WAY FOR RETAIL SECTOR. (Courier Mail)

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

HEADLINES LIKE THESE HAVE BEEN SPARKED BY THE RELEASE OF SV PARTNERS’ AUGUST 2016 COMMERCIAL RISK OUTLOOK REPORT, WHICH STATED THAT “OVER 1000 AUSSIE RETAILERS FACE FINANCIAL FAILURE WITHIN 12 MONTHS.”

What is even more alarming is what was not commented on in this report. SV Partners only made reference to the major and large retail sector. It is costly running retail stores, and even more so if you don’t have the scale and capital of the large Retailers. How many small to medium Retailers are facing financial ruin this year? Based on this report, it is safe to assume this number will be in the 1000s. The cost of goods, wages growth and spiralling occupancy costs are strangling Retailing across the board. Retailing is one of the nation’s top industry contributors to GDP; hence, it has never been more vital than now to transform how we do business and refocus on the basics to profitability. The industry drastically needs an exponential shift in thinking when it comes to operating a profitable retail business. The New Rules of Leasing is a program to educate, advise, guide and coach Retailers in the transformation and new thinking required to manage and reduce occupancy costs, whilst continually striving to add value to the retail business. There needs to be a reboot to the attitude and action within the relationship of Lessee and Landlord if occupancy cost ratios are to be reined in whilst leveraging security of tenure. Retailers are bogged down in outdated views of their lease and fail to identify and measure the performance of the real estate and, hence, are not in a position to manage these costs. Old negotiating practices concentric on

the rent per square metre and space only serve to benefit the outcomes of the Landlord. Adopting the new thinking of performance and time are the metrics that form the basics of managing your real estate costs. Failure to be effective or by keeping your head in the sand over strategies to address occupancy cost management only leaves Retailers 2 levers to improve their bottom line — Cost of Goods and Wages. Unfortunately, an overwhelming number of Retailers don’t have processes or strategies to address reducing their cost of goods and efficiencies in wages. On top of this, when it comes to occupancy cost/leasing, this is just treated as all too hard and nothing is done — more for the Landlord! Good Retailers are constantly reviewing and negotiating with their supply chain to reduce costs, reduce replenishment times and improve stock turn. They also are adopting the new approach on wages, measuring sales per shift KPIs to find efficiencies in rostering to drive sales. But, GREAT Retailers (and the most profitable) address these 2 key areas, as well as the measurement and management of their real estate performance. And, it is these Retailers who prove the most resilient and secure during any adverse trading conditions.

Whether you are a CEO, Portfolio Manager, Franchisor, Broker, Financier, Franchisee/Licensee, Owner of a group of shops or a single outlet Retailer, there is a Membership level that will add value to your business, whilst being part of the transition to more profitable relationships throughout your Retail business. From your own Lease Coach through to educational webinars and workshops, including regular reports and reviews of your business performance (and numerous other tools), there is opportunity to gain the insights into unlocking the hidden value in your lease/portfolio to meet not only current, but future challenges of running a profitable retail business. Supported by associated industry professionals, MiLease – New Rules of Leasing will have exclusive access to The New Rules of Retailing and importantly The New Rules of Negotiation programs being rolled out within the membership program (depending on Membership level). With so much packaged into the Platinum and Gold memberships, numbers have to be limited to 200 and 300 respectively and are filling up quickly.

If you don’t want to be another headline like the ones above, you need to understand The New Rules of Leasing to secure your business’s most important asset — the Lease.

One of the key benefits of the Platinum membership is the dedicated Lease Coach/ Executive who will not only be constantly reviewing performance and managing your occupancy costs, but will also deliver on your specific lease event, such as lease renewal or option included in the subscription.

MiLease – New Rules of Leasing is a Membership only program delivered by the TEAM at LEASE1 – to provide the tools, support and education for all Industry stakeholders.

When you consider that the MiLease/ Lease1 Team have been delivering Millions in rental savings annually since 1997, your membership represents extraordinary value to any retail business.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

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HEALTH

Easing the Burden on MENTAL HEALTH PATIENTS and their Treating Physicians DR LIOR RAUCHBERGER Co-Founder and Director of myDNA

A trained medical doctor and a successful technology entrepreneur, Lior is passionate about the potential for medical technology to build a better future.

AS MORE AND MORE AUSTRALIANS ARE USING ANTI-DEPRESSANTS, OR MEDICATIONS ASSOCIATED WITH MENTAL ILLNESS, THE TIME IS RIGHT FOR A RE-THINK ON THE APPROACH TO TREATMENT OF THESE CONDITIONS.

Eighty-nine Australians in every 1,000 are now prescribed some form of daily antidepressant, but 10 years ago the rate was closer to 45 – near enough to a 100 percent increase, and more than enough cause for concern. While the causes of this increase are numerous, and the centre of many debates that don’t provide concrete resolutions about how to tackle the problem, one problem we can address is the lack of precision in depression treatment. On average, statistics show that only 50 per cent of patients respond to their first anti-depressant treatment, making an already sensitive process difficult and time consuming. There is also a degree of subjectivity that goes into mental health treatment, unlike many other medical areas that generally provide an accepted guideline for diagnosis and treatment that varies little from patient to patient. Add to that the fact that adjusting to new medication can take 3-4 weeks, patient’s wellbeing can be seriously compromised. In essence, these factors mean that by its very nature, depression treatment can be “trial and error”. That is not to say for a moment that doctors are at fault here – let me be abundantly clear that this is not the case, nor is it inferred – it is simply the status quo. Indeed, doctors do the very best they can with the information they have. But given the complexities associated with mental illness, and the variations in patients, prescribing is at best hit and miss. In light of this, myDNA has recently

launched the “Peace of Mind” campaign – a program run in conjunction with our pharmacy partners, designed to raise awareness of the possibilities for pharmacogenomic testing in treating depression. myDNA is a multigene pharmacogenomic test that identifies variations in a number of genes affecting the metabolism of many commonly prescribed anti-depressants. According to Kos Sclavos, the immediate Past National President of the Pharmacy Guild of Australia, pharmacogenomics is the gateway to “personalised medicine”. He says that “this kind of paradigm shift represents the next generation of healthcare, and technology has enabled pharmacies to be at the forefront of the new frontier”. In that sense, myDNA places the pharmacy as a key player in the improvement of the lives of people suffering from mental illness, and given the prevalence of it in the general population , such a role has never been so important. Analysis of 4750 patients who took a myDNA test showed that 6 in 10 people had a finding relevant to their ability to process anti-depressants. That figure alone is enough to demonstrate the potential for pharmacogenomic testing to dramatically change the treatment landscape for mental illness. Getting medication and dosage right at the initial prescription unquestionably helps the well-being of the patient, but will also save time and cost – for the physician, the patient, and potentially even the health care system.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

Around 80 per cent of common antidepressants are metabolised by specific CYP450 enzymes that are covered by myDNA’s capability for multigene testing, along with a number of common antipsychotic medications. To this point, around 12,000 myDNA testing kits have been ordered by Australian physicians, however I’m confident that broader adoption of proactive pharmacogenomic testing is only a matter of time. It’s not if, but when. I appreciate that pharmacogenomic testing moving into medical practice represents a big shift to accepted practice, and a challenge to conservative treatment. But the opportunity is there for pharmacies to lead off the next generation of healthcare - by delivering a new level of personal information, and thus redefining the patient-doctor relationship. It’s a chance set new guidelines and break new ground here in Australia. Certainly, in the United States, authorities are embracing the concept, and it is gradually becoming mainstream – the Department of Veterans Affairs for one already cover the test for patients who fail their first treatment. The Clinical Pharmacogenetics Implementation Consortium (CPIC) and other international bodies have published guidelines for 67 different drugs including many anti-depressants, while the US Food and Drug Administration provide a list of over 150 labels that carry warnings based on pharmacogenomics biomarkers. The change is coming and it begins with Peace of Mind.

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

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mps-aust.com.au TRANSFORMING MEDICATION MANAGEMENT GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

HEALTH

Helping Heart Patients get the most from their SASHA BENNETT PhD BPharm Dip Hosp Pharm FSHPA AACPA Executive Officer, NSW Therapeutic Advisory Group Pharmacist, Cardiac Rehabilitation Program, St Vincent’s Hospital, Sydney

AS WE LIVE LONGER, THE GREATER THE LIKELIHOOD THAT WE WILL TAKE MORE THAN FIVE MEDICINES A DAY. INCREASINGLY, HEART PATIENTS TAKE FOUR TO FIVE MEDICINES FOR THEIR HEART CONDITIONS, AS WELL AS OTHER MEDICINES FOR OTHER CHRONIC DISEASES. MEDICINES TO PREVENT AND TREAT HEART DISEASE ARE RESPONSIBLE FOR THE 50 PERCENT REDUCTION1 IN CARDIOVASCULAR MORTALITY THAT HAS BEEN SEEN OVER THE LAST FEW DECADES; HOWEVER, TAKING MEDICINES IS NOT NECESSARILY EASY. A KEY FOCUS FOR ALL PHARMACISTS IS MAKING SURE AUSTRALIANS WHO HAVE HEART DISEASE GET THE MOST BENEFIT FROM THEIR MEDICINES, WHILE REDUCING THE POSSIBILITY OF ANY SIDE EFFECTS.

Pharmacists can be found in a variety of settings. Not only are they found in the community and in many hospital wards, but they can also be a member of the cardiac rehabilitation team, working in a hospital clinic or visiting patients in their home for a home medicines review. There are also an increasing number of general practices employing non-dispensing pharmacists. Wherever they may be, they are key to helping patients understand the purpose of their medications, how to take them and what side effects to look out for, and whether there are any interactions between the medicines that the patient is taking, or between their medicines and food. In our hectic world, patients do not always understand the information given to them or they search answers to their questions on the internet, which may not always be appropriate. The pharmacist has an important role in individualising information for each patient’s circumstances and helping to show them how their medicines work together to improve their health. If a patient is having problems remembering to take their medicines, the pharmacist can help with strategies to improve this.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

HEALTH

Medications

Useful strategies for remembering to take medication, include a dosette box or blister pack, or an alarm on one’s phone. Using a dosette box can also help a patient know when they are about to run out of medicines and when they should next visit the pharmacy. Linking medicine taking with mealtimes can also be very useful (as long as the medicine is not one of the few that needs to be taken on an empty stomach). If the patient is concerned about possible side effects of their medication, the pharmacist can suggest strategies to reduce the risk, such as taking the medicine with food, changing the timing of the dose and advising on how and when to undertake precautionary monitoring. There are strategies that can also be used to reduce the ongoing cost of medicines. For example, the use of combination products or higher strengths of tablets which can be cut in half with a pill cutter can reduce the costs of medicines. All heart patients should have a medication list and have the list regularly reviewed by their doctor and pharmacist. Patients can carry a paper medication list, or increasingly, many store their list on a smart phone. These smart phone lists are also able to store information about healthcare appointments, and alarms for medicine taking. Useful information about medicine lists can be found on the NPS website. The patient’s medication list is also very important information when entering and leaving hospital, or visiting new healthcare providers. The list should include information about the strength of the medications, the dose the patient is taking, when to take it and any other special instructions. Pharmacists can help make sure that a patient’s medication lists match when different doctors and healthcare professionals are caring for the patient. This is especially important when care has been transferred, for example between hospital and general practice or vice versa. Going to the same GP and community pharmacy also helps ensure consistency of information and care. Community pharmacists have an advantage in that they usually see their heart patients on a regular basis, often more frequently than patients see their GP. They are a very useful first port of call for advice about any medication issues and they can help patients know when they should seek further advice. This is especially important when getting to see a doctor may be difficult such as in rural or remote areas. Community pharmacists can also provide lifestyle advice that supplements and complements the benefits of medicines. There are also some very important services that pharmacists provide that can be especially useful for people taking lots of medications or taking medicines that require special care and monitoring. Home medicines review (HMR) is a pharmacist service that is funded by the Australian government2, with specialist training available for the pharmacist. For this service, and with the consent of the patient, the GP provides a referral to a pharmacist or community pharmacy (of the patient’s choice) to undertake a review of the patient’s medicines. This usually involves a visit to the patient’s home to discuss the medicines and any health issues the patient may have for about an hour. The pharmacist writes up a report for the GP and the report’s recommendations are then discussed with the patient. Community pharmacists can also provide a MedsCheck3 or Diabetes MedsCheck (for those with Type 2 diabetes). A review of a patient’s medicines is provided when visiting a community pharmacy and focuses on education and optimising a patient’s self-management of their medications. The MedsCheck service must take place in a private consultation area of a community pharmacy and should take approximately 30 to 45 minutes to complete. These services are also funded by the Australian Government. In summary, pharmacists have a wealth of knowledge and skills to ensure heart patients get the most out of their medications. REFERENCES: Ford ES, Asjani UA, Croft JB et al. Explaining the decrease in US deaths from coronary disease, 1980–2000. NEJM 2007 Jun; 356 (23):2388-98. 2 http://www.nps.org.au/topics/how-to-be-medicinewise/managing-your-medicines/ home-medicine-review. 3 http://www.health.gov.au/internet/main/publishing.nsf/Content/consumerpharmacy#MedsCheck. 1

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

BUSINESS

Private Remunerated Professional Pharmacy Services KOS SCLAVOS PharmaPrograms Systems Architect

ALMOST EVERY PHARMACY INDUSTRY COMMENTATOR STRESSES THE IMPORTANCE OF MOVING INTO PROFESSIONAL PHARMACY SERVICES. WHILE THE FOCUS OF THE MESSAGE IS PRIMARILY ON 6CPA PROGRAMS, THERE ARE NUMEROUS PRIVATE PROGRAMS THAT SHOULD BE THE FOCUS OF EVERY PHARMACY. THERE ARE PRIVATE REMUNERATED PROFESSIONAL PHARMACY PROGRAMS DEVELOPED BY THIRD PARTIES, AND THAT IS WHERE PHARMAPROGRAMS COMES INTO PLAY.

PharmaPrograms’ initiatives are IT-enabled programs where the pharmaceutical industry partners develop powerful patient health solutions — through PharmaPrograms. Patient support programs assist patients to achieve better medication compliance and persistence. These programs are not new and indeed have been in existence for decades. What is new is ensuring pharmacists play a key remunerated role in this process. PharmaPrograms set protocols for each program, and the IT system enables the pharmacist to deliver a streamlined service. Our goal is to create value for patients in a variety of ways:

•• Access to prescription medications prior to PBS listing;

•• Establish a viable and affordable private prescription market;

•• Facilitate additional treatment options to support their medication regime;

•• Establish simplified professional programs to enhance the patient treatment experience;

•• Facilitate Quality Use of Medicines (QUM) initiatives to improve medication adherence and persistence. These national programs are tailored solutions. Some involve doctors recommending services to patients, and the local pharmacy facilitates a specific program. Doctors are happy to recommend the service because they know exactly what the protocol contains and they know it is within the scope of practice of pharmacists. Patient support programs and patient familiarisation programs are not new, but the valuable role that a pharmacist can play has been ignored in the past — indeed, community pharmacy was bypassed in most programs. At PharmaPrograms we believe the pharmacist has a key role. With many chronic therapy medicines, perhaps with five repeats, the pharmacist sees the patient six times for the one time that they consult with their local doctor. There is no possible way that medication compliance and medication persistence can be maximised without the pharmacist playing an important clinical role.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

Many pharmaceutical manufacturers required bespoke solutions and with therapy becoming more complex with the next biosimilars entering the market, this area of practice will grow significantly. We build an IT-enabled process to deliver a specific protocol. We respect that pharmacists are busy health professionals and need to integrate systems into their existing workload. PharmaPrograms was born out of this process where now 4400 pharmacies have enrolled in at least one program, 86 pharmacy groups have adopted the programs and 4300 doctors are participating. As program architect I can assure pharmacist colleagues we have designed programs with their issues front of mind. The $1 million that has been paid to pharmacies to date is a bonus.

HOW DOES PHARMAPROGRAMS WORK? The aim of each medication-specific program is to establish a national network of pharmacies to support patients to ensure better compliance with their medication,

BUSINESS

“4400 pharmacies have enrolled in at least one program, 86 pharmacy groups have adopted the programs, 4,300 doctors are participating.”

timely access to information and services. This national network is promoted to doctors and patients as the Network Pharmacies. A pharmacy must first register for a specific medication-based Pharmacy Program and then they must agree with the Terms and Conditions of the program. Network Pharmacies are informed of new programs as they come on board, and in the 18 months since launch, 5 programs have been brought to the market. Registration will occur online at www.pharmaprograms.com.au.

Protocol for the program is triggered. As part of the service, the pharmacist completes some online eForms and the patient is provided some information through a tailored onepage leaflet. Pharmacies are remunerated for these professional services with the amount depending on the rigor of the program. Doctors and patients are then informed about your pharmacy’s participation in the program via a pharmacy locator where prescribers can assist patients to locate a Network Pharmacy.

Pharmacies are provided resources (hard copy Kits and online resources) for tailored Pharmacy Programs. There is a web portal, which is not for public viewing, and which requires a general Username and Password to access. Pharmacies complete all necessary details on the Program Registration eForm and the Pharmacy ID will be emailed to you. The resources page on the site has been set up to assist pharmacists, and as updated versions of documents are created, they will be located here. Once set up, as patients present prescriptions for that medicine the

ARE PHARMACIES PAID FOR THE SERVICE? Pharmacies are paid a professional fee for delivering a program according to the protocol and this is above and beyond their normal remuneration for dispensing the medicine. While each program is different, there is generally a key quality use of medicines (QUM) component that the pharmacist needs to deliver. Those messages differ depending on which repeat is being dispensed. The IT systems assist the pharmacist to know which service to provide and the printed

material received by the patient is labelled with the pharmacy’s details, ensuring that the patient knows it is the pharmacist who was providing the service. Unlike other programs that refer patients to particular websites or printed resources, we utilise the skills of the pharmacist to deliver the key messages. This is critical for better outcomes because it overcomes any language or communications difficulties that the patient may be experiencing. It is the pharmacist who can pitch the key QUM message and tailor that message to the patient to maximise concordance. We have a dedicated website and indeed through this portal, pharmacists make their claims for payment in an automated fashion. The site also houses all program collateral which supports pharmacists in implementing the programs. www.pharmaprograms.com.au contact@pharmaprograms.com.au

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

HEALTH

"Member pharmacies have access to the industryâ&#x20AC;&#x2122;s best support with more than 30 pharmacists and pharmaceutical chemists on-hand to answer the toughest compounding and clinical questions."

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

HEALTH

We take your

SUCCESS Personally

WHILE OUR MEMBERS HAVE ACCESS TO OVER 4,560 ACTIVE AND NON-ACTIVE CHEMICALS — MORE THAN ANY OTHER COMPOUNDING PHARMACY SUPPLIER — THE COMPETITIVE ADVANTAGE WE BRING OUR MEMBERS IS THE INDUSTRY’S MOST COMPREHENSIVE QUALITY CONTROL AND ASSURANCE PROGRAM.

will have more options to treat patients, from VersaBase® topicals, specifically designed for compounded HRT delivery, to Lipoderm®, the industry’s only transdermal proven to deliver four drugs simultaneously, to PracaSil™Plus, our newest base for scar therapy, backed by a number of studies showing its effectiveness.

Here is the quality difference that PCCA brings to Member Pharmacies every day:

•• Every lot — not just the initial lot — is tested o

We do not solely rely upon the USP or manufacturer’s label to ensure the quality of the chemicals received.

Every lot received is tested using Fourier Transform Infrared Spectroscopy, ultraviolet-visible analysis, melting point, specific gravity, solubility and chemical identifications.

Continuing education is the key to quality compounding solutions. Pharmacists must meet the minimum requirements for continuing professional development (CPD) in line with the Pharmacy Board of Australia guidelines.

PCCA offers training for both Pharmacists and technicians several times each year in Australia.

The PCCA C3 Comprehensive Compounding Course which covers all aspects of complex compounding, including Regulatory, Quality, Hands on Lab work and specific areas of compounding practice, attracts 50 group 2 points and is available to all PCCA members and their staff.

PCCA members are able to stay up to date with the latest developments, innovations and technology through a vast and varied curriculum of courses, both locally and internationally (self-accredited) that will continue to grow and develop their knowledge base.

Additional testing of APIs is done using actual formulations.

•• 14 checks and analyses are performed on each chemical lot o

•• Comprehensive education is the key to compounding

Nine qualitative and quantitative analyses are performed on every incoming chemical lot before it is released for repacking or sale.

Each lot is tested against the certificate of analysis (C of A), including: USP, EP, NF, FCC, ACS and PCCA standards.

After initial testing, all results are reviewed for accuracy by a second QC analyst.

Chemicals are tested only by degreed Chemical Analysts.

•• PCCA rejects almost 200 chemical lots per year o

PCCA is fully registered by the FDA, DEA and State of Texas as a manufacturer, and follows current Good Manufacturing Practices (cGMP).

Only FDA-registered and GMP-certified manufacturers are used for the purchase of active pharmaceutical ingredients (APIs).

Exclusive, proven bases and formulas.

•• Proven bases for more patient options o

•• Complete support o

Member pharmacies have access to the industry’s best support with more than 30 pharmacists and pharmaceutical chemists on-hand to answer the toughest compounding and clinical questions.

Would you like more information about PCCA Membership?

With access to more than 60 proprietary bases — unavailable to other compounders — your PCCA pharmacy

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

BUSINESS

You CAN Build a BUDGET PETER SACCASAN FACP FCA National Director, Pharmacy Services RSM Australia

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

BUSINESS

and it CAN be USEFUL SETTING THE RIGHT BUDGET WILL ENSURE YOU INCREASE PROFITABILITY AND ACHIEVE STRONG CASH FLOW — ALMOST GUARANTEED!! THIS IS NO LIGHT CLAIM, AND IT STEMS FROM AN OLD SAYING: IF YOU HAVE NOTHING TO AIM AT, YOU CAN’T HIT THE TARGET.

HOW CAN MY BUDGET INCREASE PROFITABILITY? Setting your budget for next year means you can see if it is going to give you the result you want. If it isn’t, you can do something about it today. When we work through the budget setting process with owners in the right way, we are able to set stronger revenue targets, highlight possible inefficiencies and aim for an improved bottom line.

LET’S BUILD THE BUDGET In the dispensary, owners should examine:

•• Script types and changing patterns for impact of pricing, particularly expensive scripts;

•• The source of scripts to see if doctor relationships should be freshened up;

•• Dispensed medicines to see if there is any revenue leverage to be had from additional solutions or products. In retail, owners should examine:

•• Department performance to see which ones are below the store benchmark;

•• Reviewing product pricing continually; •• Stock levels and buying prices for continual improvement;

•• Missing merchandise that would complement popular prescriptions;

•• What health solutions are not complete due to missing lines. In almost each instance, where owners budget by department, and set marketing budgets to support those sales budgets, revenue increases more substantially. Professional services are now a growing source of revenue. Owners should:

•• Seek to maximise 6CPA programs suited to their pharmacy;

•• Identify their own private services based on their customer data;

•• Review store layout and merchandise to ensure success in delivery of these services. Overall, owners should seek to build a complete healthcare hub, whereby the services and retail offering address customer

needs and present a complete solution. If each of these revenue areas is budgeted properly, you should also end up with your marketing plan and be able to budget what you will spend on these costs.

CONSTANT COST CONTROL The overheads in pharmacy are not complicated. The major costs are staff, marketing and occupancy costs.

•• Staff costs are known and can easily be budgeted;

•• Marketing costs come from the intended marketing plan;

•• Occupancy costs are also known; •• The rest — you should be able to assess these based on the past.

PROFIT DOES NOT EQUAL CASH The budget will focus on the profits of the business. The cash flow forecast, which falls out of the budget, deals with the financial commitments arising from the business’s financial position. There are a number of questions where the answer will impact on cash flow: a. How much debt was borrowed to buy the pharmacy and what are the repayment terms? b. What finance was used to do the new fit-out? c. Is more money needed to be spent to enable services to be provided? d. By how much should we increase stock to help drive sales? e. How much money does the owner need to take out of the business? f. When is the tax on last year’s profit due to be paid? The cash to support these activities comes from four places: from profits of the business, from selling an unneeded asset like a building, from loans from banks and creditors, or from cash put in by the owner. The aim is to be in a position where you have the cash you need when you need it.

HOW CAN MY BUDGET AND CASH FLOW FORECAST BE USEFUL? 1. Firstly, by simply preparing these documents, you have taken the big step towards understanding in advance what is happening in your pharmacy. 2. The next step is to monitor how it is performing against expectations. If the actual results begin to make the budget look like a fairytale, then it’s time to recast the budget so that you can start dealing with reality. There is no point in relying on a budget of turnover of $4m, if monthly sales in reality are saying you will be lucky to hit $3.5m. 3. In having set the budget, this should be driving your store activities and focusing your staff on what you want to each achieve each month. 4. The budget should produce target KPIs, and hitting these each day or week or month will give you the right indicators. If you are consistently falling short, it should also ring the alarm bells early enough to take corrective action. Your budget should be measured against your actual results as you progress throughout the year. Where there are variations between the two, steps should be taken to understand what those differences are. And it is this last step which really determines the usefulness of the budget — taking action!

SIMPLE BUT EFFECTIVE We work with many businesses — both pharmacies and non-pharmacies — and the budget and cash flow forecasts are probably the simplest, yet least utilised management tool. With financial pressures building on pharmacy through many industry changes, it helps to keep your financial position and future under control. The first time is always the hardest. Get some help and make your budget a useful document. Then, be committed to implementing and monitoring the business against it. What works best is if you delegate this so that it can happen without you.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

BUSINESS

Pharmacy Alliance Partners with Merchandising Experts RETAIL AKUMYN to BOOST Member Profits ANDY JACKSON Principal Strategy and Implementation

PHARMACY ALLIANCE, AUSTRALIA’S LEADING INDEPENDENT PHARMACY GROUP, HAVE PARTNERED WITH RETAIL AKUMYN, THE EXECUTION ARM OF THE AKUMYN GROUP OF COMPANIES, EXPERIENCED IN RETAIL ANALYTICS AND CUSTOMER EXPERIENCE MANAGEMENT. THE PURPOSE OF THIS PARTNERSHIP IS TO PROVIDE MEMBERS WITH AN ALL-ROUND SOLUTION TO GROW RETAIL IN THEIR PHARMACY.

Retail Akumyn have significant experience and understanding of the pharmacy channel. Pharmacy Alliance has been able to implement a full store merchandising and maintenance program which is already proving to deliver significant benefits to both pharmacies and suppliers. Pharmacy Alliance identified that the current environment in pharmacy is creating significant challenges for pharmacy owners. in particular, members are faced with these issues which needed to be addressed:

•• How to generate profitable growth; •• Cost, time and skills required to implement innovative retail programs to improve retail competitiveness;

•• Need and desire to increase customer engagement. In addition, suppliers to the pharmacy are faced with similar challenges which mean:

•• •• •• ••

Poor compliance in pharmacy, reducing revenue potential; Inconsistent planograms and ranging; Erratic promotion execution; Visibility into the impact of retail programs.

In order to better align the objectives of both member pharmacys and pharmacy suppliers, Pharmacy Alliance identified these key objectives: For members:

•• Increased time to focus on customers; •• Pharmacy profitable growth; •• Increased competitiveness of pharmacy through innovative retail programs.

For suppliers:

•• •• •• •• ••

00+ stores merchandised to approved planogram; 5 Full ongoing compliance; Pharmacy turnover growth; Fast promotion execution; Reduction in cost to service pharmacies.

Central to the partnership is the creation of a retail pharmacy team, trained and experienced in the delivery of retail principles, visual merchandising standards and stock management. For Pharmacy Alliance and its suppliers, this maximises the ability to ensure, across the national group of pharmacies, category compliance, unified retail standards, price integrity and the minimisation of out of stocks. The speed and quality controlled execution maximises the return on investment. Also significant to this partnership is the Retail Akumyn technology platform, together with their expertise in data driven insights. The impact of retail programs, such as merchandising, promotions etc. can be measured both by the pharmacy and the suppliers through detailed analytics driven from the pharmacies’ own retail transaction data. James Lambert, General Manager of Merchandise Pharmacy Alliance, has said, regarding the partnership, “The early results of the pharmacy merchandising trials have seen double-digit growth in retail sales and new benchmarks set for retail standards in each location. Retail Akumyn delivers a fast, quality field marketing solution for our complex pharmacy retail merchandising needs”.

Pharmacy Alliance Merchandising Program

PHA R M AC Y A L L I A NCE M E R C HA N DISIN G P R OGR A M

Audit & Compliance

AUDIT AND COMPLIANCE » » » » »

Store layout » Store Layout » Retail compliance Retail compliance » Inventory Inventory » Pricing Pricing » Share of Shelf Share of shelf

Activation

ACTIVATION

» Category plan plan » Category » Planogram » Planogram implementation Implementation » “A” line share of shelf » “A” line share of shelf » »Stock Stock adjacencies adjacencies »» Retail & & standards Retailprinciples principles »standards Seasonal & promotional activities » Seasonal & promotional activities

Reporting &

Analytics REPORTING » POS transaction data AND ANALYTICS

» Intransaction house developed » POS data platform & reporting tools » In» house Before developed & after visualization platform & reporting tools » Before & after visualization

Maintenance

MAINTENANCE » National coverage National Coverage » Minimum » Pen & ink monthly store visits » Speed to market » Ad hoc merchandising » Minimum monthly store visits requests » merchandising Pen & Ink » Ad hoc requests » Speed to market

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

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

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

Solutions The Guild is focussed on delivering the best to Guidesupport on initial steps optimising our members intowards the interests health outcomes from of enhancing the value of front of pharmacy community pharmacy.

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

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

professional health services.

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

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

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

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

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

Business School CRICOS No.00213J ÂŠ QUT 2016 22134

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CONTINUING PROFESSIONAL DEVELOPMENT

Are you an effective Do you want to know WHAT IT TAKES AMANDA SEETO Professional Practice Pharmacist and Branch Committee Representative, The Pharmacy Guild of Australia (Queensland Branch) B. Pharm, DipMgmt

LEARNING OBJECTIVES After reading this article, the learner should be able to: 1. I dentify the skills that contribute to effective leadership; 2. R ecognise ways to develop the necessary leadership skills in a pharmacy.

Competencies Addressed: 2.1, 2.2, 2.7, 3.1 Accreditation number: A1610ITK This activity has been accredited for 0.5 hour of Group 1 CPD (or 0.5 CPD credit) suitable for inclusion in an individual pharmacistâ&#x20AC;&#x2122;s CPD plan which can be converted to 1 Group 2 CPD credits upon successful completion of relevant assessment activities.

GOLD CROSS PRODUCTS & SERVICES PTY LTD : ITK ISSUE 50 : OCTOBER/NOVEMBER 2016

CONTINUING PROFESSIONAL DEVELOPMENT

leader?

to be a leader in your pharmacy? THIS ARTICLE AIMS TO TRANSLATE CERTAIN QUALITIES INTO PRACTICAL TIPS ON HOW TO BE AN EFFECTIVE LEADER IN YOUR PHARMACY. WHILST THIS ARTICLE FOCUSES ON PHARMACISTS, ANYONE CAN APPLY THESE SKILLS REGARDLESS OF THEIR ROLE IN THE PHARMACY, WHETHER YOU ARE A PHARMACY OWNER, A RETAIL MANAGER, A PHARMACIST WHO HAS ‘FALLEN’ INTO THE ROLE OF BEING IN CHARGE, AN EARLY CAREER PHARMACIST MANAGER LOOKING TO REFINE YOUR LEADERSHIP SKILLS, OR A PHARMACY ASSISTANT WITH ASPIRATIONS OF ONE DAY LEADING A TEAM WITHIN A PHARMACY.

PERSONAL CHARACTERISTICS OF LEADERS There are various defining characteristics of an effective leader, with honesty, intelligence and decisiveness being considered ‘absolutely essential’ by at least eight in ten adults1. Being organised, compassionate, innovative and ambitious are also deemed necessary by over half of the adult population (based on a survey in the United States)1. Goleman2 has defined four characteristics of leadership, collectively known as emotional intelligence — being intelligent about emotions — and these are considered to be the ‘soft’ skills of leaders.

•• Self-awareness – you are seen by others as having a sense of certainty in your own abilities and understanding your own strengths and limitations;

•• Self-management – staying calm under pressure, being adaptable and having initiative;

•• Empathy – there are two kinds: cognitive and emotional. Possessing cognitive empathy means you understand how others think about the world. This understanding allows you to phrase what you want to convey to your team in terms that will make sense to them. Leaders with emotional empathy are able to sense immediately how another person feels, giving the opportunity to fine tune what they say to have a positive impact;

•• Relationships – being competent in this skill enables teamwork and collaboration, influence and helping others build their leadership skills. When reading this article, it will become evident that emotional intelligence plays an integral role in leading your pharmacy team. In pharmacy, the transition to leadership often happens serendipitously3. A pharmacist may unexpectedly find themself in a leadership role for reasons such as the sudden departure of a staff member or as recognition for consistent work. If someone is ‘thrust’ into leadership, the learning curve to effective leadership can be a steep one, so possessing the right skills prior to the change will make that change smoother. Zilz et al. say that a leader is visible, and direct contact is necessary for building relationships with their team. Being present enables leaders to get to know their staff better 4. It is no wonder then that pharmacists are the natural choice for a sudden leadership role, simply because of their physical location within the store. A pharmacist who also displays integrity, who is consistent in their approach, who treats others with respect and who serves as a role model, is one who will swiftly find themselves in a leadership role. Effective leadership always ties in with a leader’s ability to interact with people. Leadership involves others, the members of your team and, therefore, how you are perceived by them is critical. They naturally will follow you when your integrity is perceived to be strong and allowing you to take the lead is attractive to them5.

So, strive to build and maintain authentic relationships with your staff, as it’s much easier to work towards your goals with people who enjoy working with you. People are happier and more satisfied in their work when they have supportive leaders who empathise at a personal level6. As John C. Maxwell wrote, ‘Man does not live on bread alone: sometimes he needs a little buttering up’. Genuine interactions with others in your workplace, such as catching up on the previous weekend’s events, also help you to maintain your own healthy work–life balance. The following sections provide more detail regarding a leader’s people skills.

LEADERSHIP REQUIRES EFFECTIVE COMMUNICATION An effective leader will possess the ability to communicate well with both their staff and customers7. When it comes to your staff, let them know what’s going on and your expectations of them. Be sure that they know what their role is. This can be in the form of written position descriptions, proactive performance management and/or scheduled performance reviews. Pharmacists often possess the exceptional skill of communicating information to their patients; however, they sometimes do not take the time to express instructions clearly to their staff. If you are a pharmacy leader in this category, then utilise your counselling ability to develop this skill: stick to three main points, back them up with written instructions and check for their understanding8. It may seem like a lengthy

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organisation10. While this article will focus on what comprises good leadership, good management skills within an organisation are still important as they are what will transform a leader’s vision into action and successful implementation11. Table 1 distinguishes the differing skill sets of leaders and managers.

process, but it is less time consuming than if they misunderstood you and corrections need to be made. Similarly, be proactive in your communication with your customers and don’t act like you are hiding something. For example, if a medication that they are expecting will be delayed due to short supply (as if that never happens), then ensure the customer has been informed of the delay, what alternative arrangements have been made and the new expected time of arrival. Being upfront with your customers demonstrates to your team that regardless of the situation, you will address any issue that you confront and proactively manage it until a resolution is achieved.

LEADERSHIP USES INFLUENCE TO INNOVATE

A key to effective communication is active listening, again to both your staff and customers. Be an active listener to ideas and issues from your staff, and be prepared to receive feedback as well as giving it. If a customer has a complaint, allow them to voice their concern without interruption, paraphrase the complaint to confirm your understanding of it, and then discuss what can be done to resolve the situation. It may be that all that the customer desired was to be heard and acknowledged.

LEADING AND MANAGING ARE NOT THE SAME Keep in mind that although management and leadership skills do overlap and someone may effectively do both, a good leader may not necessarily possess the right skills to be a manager, and vice versa. A manager’s role is to focus on the operational aspects of the business, or ‘doing things right’, whereas a leader is seen to be ‘doing the right things’9. Kotter (1990) will argue that leadership and management are two distinct, yet complementary systems within an

Leadership is a process of influence in which someone is able to enlist the aid and support of others in accomplishing a common goal3. The goal of increasing the average basket size may have arisen from an idea of a staff member who wanted everyone to know about their favourite cold and flu companion products and how to sell them. If you are able to create an atmosphere of mutual trust and respect within your team, you then encourage others to share their ideas towards developing a goal. A leader’s passion for achieving goals will reach the staff and give them energy to persist towards it, even when faced with setbacks. A pharmacy leader should examine what has worked and what needs to be changed or abandoned, then own and champion that change13. For example, if you are looking to boost sales through selling products to promote a total health solution, you may experiment with product placement near the counselling area for ease of access, then regularly monitor and assess this via sales reports. Another example is the range of technology platforms available to pharmacy that can facilitate more advanced methods of communication with customers, increase adherence to medication and record clinical interventions to name a few. As previously mentioned, pharmacists are ideally placed within the pharmacy to be visible to the staff in their active promotion of change and innovation.

TABLE 1: LEADERS VERSUS MANAGERS10,11,12 LEADERS

MANAGERS

Emotional involvement

Minimal emotional involvement

Change people’s attitudes

Change people’s behaviour

Advocate change and new approaches

Advocate stability and the status quo

Understand people’s beliefs

Carry out responsibilities

Developing a vision

Planning and budgeting

Aligning people with the vision through communication

Organising and staffing

Gain commitment

Exercise authority

Motivating people to action

Controlling and problem solving

Choices will affect their organisation

Decisions are determined by the organisation

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“If someone is ‘thrust’ into leadership, the learning curve to effective leadership can be a steep one, so possessing the right skills prior to the change will make that change smoother.”

It is difficult to be successful without risks, but how do you do that when as a pharmacist you are trained to minimise all clinical risk to your patients? The Pharmacy Board of Australia Guidelines and Pharmaceutical Society of Australia Professional Practice Standards provide the benchmark that pharmacists must adhere to when dispensing and making clinical judgements and these are rules that cannot be bent. Stepping out of that role into one of leading staff down the path of innovation is where pharmacy leaders can challenge accepted practices8. The Quality Care Pharmacy Program exists to provide community pharmacy with support and guidance on delivering professional health services and pharmacy business operations, and is a useful tool to ensure that you are meeting all of your regulatory requirements when pioneering your changes. So challenge the old adage ‘if it ain’t broke, don’t fix it’, and look for innovation in areas that don’t appear to need fixing — is there a more effective way to place orders for stock, direct traffic flow at the schedules counter, or even run your lunch breaks? When looking to develop your leadership skills, it is worth taking the time to ask yourself, ‘Do I enjoy being in charge?’ Without a presence of obvious authority, leadership skills are difficult to develop8.

LEADERSHIP IS GROOMING/ DEVELOPING OTHERS TO LEAD Established leaders should also recognise the need for continual development of new leaders, and this can be a rewarding process. Routinely invest the time to provide opportunities for students, staff and professional colleagues to learn from you13, perhaps in the form of accepting university students on placement or employing an intern pharmacist. Having potential leaders in the pipeline can contribute to a smooth transition when it’s time for a new leader to be at the helm of the business. The industry is experiencing an unprecedented period of financial uncertainty where community pharmacy owners are decreasing the number of pharmacists and pharmacy assistants in their employment14. This lack of confidence in the profitability of the business is leading

CONTINUING PROFESSIONAL DEVELOPMENT

to outgoing staff not necessarily being replaced, making it even more important to develop, coach and mentor existing staff for leadership.

DELEGATION Displaying a level of trust in your team to carry out their daily tasks and working towards your shared goals is a sign of strength in a leader 15. Otherwise, the more you stretch yourself, the lower the quality of your own work output. To delegate, identify the strengths of

individuals in your team. Chances are that your daydreamer creative assistant will find setting up a new display more enjoyable, and put more thought and effort into it, than your fast-walking bull-at-a-gate assistant. Similarly, give your staff the opportunity to solve their own problems. Imagine the pride of ownership your up-and-coming assistant will have if they are given the opportunity to place the top up order for their favourite skincare range that they keep selling out of!

IN SUMMARY: A great pharmacy leader will possess the ability to communicate with staff and customers, have a positive influence on the staff to promote innovation, and build a trusting relationship with the staff to confidently delegate tasks towards achieving a common goal. All of this, while remaining energetic and passionate in the workplace and maintaining that essential workâ&#x20AC;&#x201C;life balance. If you have figured out how to do this, please call me.

REFERENCES:

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

QUESTION 1 Which of the following attributes is not considered absolutely essential for an effective leader? a. Intelligence; b. Punctuality; c. Honesty; d. Decisiveness.

QUESTION 2 Possessing the skills of a good manager automatically translates into also being a good leader. a. True; b. False.

QUESTION 3 Pharmacists are often seen as a natural choice for a leadership role because: a. They possess good clinical knowledge; b. Their physical location within a pharmacy enables them to be visible to staff for direct contact; c. They interact with customers; d. They are usually the manager.

QUESTION 4 Emotional intelligence is comprised of the following characteristics: a. Self-awareness, self-management, empathy, relationships; b. Self-awareness, self-management, a good listener, relationships; c. Self-awareness, planning and budgeting, empathy, relationships; d. Problem solving, advocate stability, empathy, relationships.

QUESTION 5 Which of the following are not skills of an effective leader? a. Investing time in the development of new leaders; b. Identifying strengths of individuals in your team and delegating tasks suited to them; c. Talking over your staff when they are giving you feedback; d. Creating an atmosphere of mutual trust to encourage the sharing of ideas.

Parker K, Mensasce Horowitz J, Wang W, Brown A, Patten E. Women and Leadership: Public Says Women are Equally Qualified, but Barriers Persist. Washington, D.C.: Pew Research Centre; 2015 2 Goleman D. What Makes a Leader? [Internet]. 2014 [cited 2016 Aug 3]. Available from: http://www. danielgoleman.info/daniel-goleman-what-makes-aleader-2/ 3 Mark S, Saenz R, Clark JS, Stevenson JG. Leadership Essentials for Pharmacists [Internet]. Massachusetts: Jones & Bartlett Publishers; 2012 [cited 2016 June 29]. Available from: http://samples.jbpub.com/9781449660284/57253_ CH02_SECURE.pdf 4 Zilz D, Woodward B, Thielke T, Shane R, Scott B. Leadership skills for a high-performance pharmacy practice. Am J Health-Syst Pharm. 2004; 61:2562-74. 5 Professionals Australia (AU). Five steps to effective leadership [Internet]. Melbourne, VIC (Australia): Professionals Australia (AU); 2013 [cited 2016 June 29]. Available from: http://www. professionalsaustralia.org.au/blog/five-steps-toeffective-leadership/. 6 Al-Sawai A. Leadership of Healthcare Professionals: Where Do We Stand? OMJ. 2013; 28(4):285-287. 7 Babcock K. 4 Leadership Skills Every Pharmacy Owner Should Master [Internet]. Palm Springs, FL: Pharmacy Development Services (US); 2015 [cited 2016 June 29]. Available from: http://www. professionalsaustralia.org.au/blog/five-steps-toeffective-leadership/. 8 Coaching for leadership. Community Pharmacy [Internet]. 2002 [cited 2016 May 16]. Available from: http://gateway.library.qut.edu.au/login?url=http:// search.proquest.com/docview/225262683?account id=13380 9 Bennis W, Goldsmith J. Learning to Lean: A Workbook on Becoming a Leader. New York: Basic Books; 2003. 10 Kotter J. What leaders really do. Harvard Business Review, 1990; 68:103-111. 11 Lununberg F. Leadership versus Management: A Key Distinction-At Least in Theory. International Journal of Management, Business and Administration. 2011; 14(1). 12 Rowe WG. Creating wealth in organisations: The role of strategic leadership. Academy of Management Executive. 2001; 15(1):81-94. 13 Bush P. Leadership at all levels. Am J Health. 2012; 69:1326-30. 14 Employment Expectations Report [Internet]. Canberra: The Pharmacy Guild of Australia; 2014 April [cited 2016 June 29]. Available from: http://www.guild. org.au/docs/default-source/public-documents/ news-and-events/Community-Pharmacy-UnderThreat/employment-expectations-survey-report_ april2014_546786_3.pdf?sfvrsn=0. 15 Prive T. Top 10 Qualities That Make a Great Leader [Internet]. Forbes; 2012 Dec [cited 2016 June 29]. Available from: http://www.forbes.com/sites/ tanyaprive/2012/12/19/top-10-qualities-that-makea-great-leader/#5b7debf03564. 1

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Drug Addiction and Stigma DR HIDY CHAN B.Pharm(Hons), PhD, GCertResComm, CertIVTAE, AACPA Professional Practice Pharmacist

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“The key to reducing discrimination and removing stigmas associated with substance abuse is education and awareness.”

HEALTH

“TO BE STIGMATISED IS TO BE HELD IN CONTEMPT, SHUNNED OR RENDERED SOCIALLY INVISIBLE BECAUSE OF SOCIALLY DISAPPROVED STATUS1.”

Stigma against people with substance abuse and addiction is deeply rooted in society and is associated with negative perceptions and discriminations2. Stigma is rarely based on facts and differs from disapproval of certain behaviours as it is not necessarily linked to an individual’s action, but rather, on assumptions, generalisations and preconceptions3,4. When the terms “addiction” and “drugs” are mentioned, many people often conjure up stereotyped images of someone who is dirty, dangerous, unemployed, criminal, skirting the edges of society, victim of bad upbringing, prostitute, high school dropout etc3,5. Elements of fear and blame are commonly associated with such imageries and labels are applied for life3. In addition, the language used to refer to people who use drugs often carry stigma. Individuals are often labelled with disdainful terms, such as “addict”, “junkie”, “druggo”, “crackhead” and “pillhead”, with dehumanising and demeaning implications and inferences that substance abuse is a lifestyle choice. In reality, the majority of substance abusers are just like everyone else and do not fit the abovementioned descriptions.

THE IMPACTS OF STIGMA Social stigma and disapproval are strongly associated with substance dependence6 and can be imposed by all members of society4. Stigma impacts on nearly all aspects of life and occurs in a wide range of settings3: drug treatment services, doctors’ surgeries, pharmacies, hospitals (A&E), employment and housing services, social services and the criminal justice system (police, probation, prisons and courts)3. In a pharmacy setting, individuals with substance addiction report discrimination most commonly in the form of the pharmacy staff’s judgemental expressions and attitudes, and hesitancy or refusal to touch their hands (e.g. when handling money). Stigma results in prejudice, avoidance, rejection and discrimination, leading to economic, social and medical consequences4. Stigma can prevent individuals with substance addiction recognising their emerging problem, completing addiction treatments and using harm reduction services, and seeking help7. Asking for help may mean admitting to themselves and others that they embody the abovementioned imageries and acquire all the negative labels that go with it3. Stigma can also be internalised and its effects can be cumulative and long-lasting3. People who are victims of stigma internalise the hate it carries, transforming it to shame and hiding

from its effects. Shame and worthlessness engendered through stigmatisation prevent people accessing help and treatment because they feel “they are not worth bothering with”3. The chronic stress of discrimination can affect the mental and social health of individuals who use drugs, causing profound loneliness and isolation3,4.

— Fear and ignorance are two of the biggest reasons why people stigmatise drug use and addiction. Drug addiction is a disease, just like any other, such as cancer and asthma. Addiction is a disease of the brain that manifests itself in compulsive behaviours8.

Deemed as incompetent family members, families (and friends) often report shame and blame for the onset of an individual’s drug addiction and/or relapse1,3. Stigma amongst people who use drugs is also common2. People who use substances that are legal, or deemed more “socially acceptable” (e.g. alcohol) may house prejudices against those that use illegal drugs (e.g. marijuana). Furthermore, those that use “soft” drugs (e.g. marijuana) may have negative connotations against those that use “hard” drugs (e.g. cocaine)2. The way a drug is used can also be associated with stigma — those that may snort or inhale their drug of choice may discriminate against people who inject2.

•

Avoid use of discriminatory labels and language (e.g. “addict”, “junkies”).

•

Devise ways to help those with addiction through participation in a Harm Minimisation Program such as the Opioid Replacement Treatment or the Pharmacy Needle & Syringe Program.

•

Be familiar with the contact details of local support organisations such as Alcohol, Tobacco and Other Drugs Services (ATODS) so individuals in need can be referred to such venues for support and help.

•

Actively participate in health promotions and campaigns, such as “International Overdose Awareness Day”, “National Drug & Alcohol Facts Week” and “Alcohol Awareness Week”.

WHAT CAN BE DONE TO FIGHT STIGMA? Combating the stigma associated with drug addiction and its treatment is not an easy feat. The key to reducing discrimination and removing stigmas associated with substance abuse is education and awareness. Leadership is required in all sectors of the community — government, schools and community groups — to provide education, change attitudes and behaviour, and promote greater integration and recovery3. Being highly accessible, pharmacies can play a big role in reducing stigma in the community. The list below highlights some ways to reduce stigma3,4: •

Treat all customers (whether they are in the pharmacy to buy toothpaste or a sharps kit!) with the same friendly professionalism. — Pharmacy staff are generally the first point of contact for most customers. Having friendly, nonjudgemental staff will help bring in, and keep, customers.

•

Improve knowledge and understanding among the general public and staff about drug dependency and recovery to reduce the levels of fear and blame (i.e. replacing negative attitudes with evidence-based facts).

REFERENCES: Corrigan P, Watson AM, FE. Blame, shame and contamination: The impact of mental illness and drug dependence stigma on family members. J Fam Psychol. 2004;20(2):239-46. 2 Stigma and the people who use drugs [Internet]. New York: Drug Policy Alliance; [cited 22/08/2016]. Available from: http://www.drugpolicy.org/sites/ default/files/DPA_Fact_Sheet_Stigma_and_People_ Who_Use_Drugs.pdf. 3 UK Drug Policy Commission. Getting seroius about stigma: the problem with stigmatising drug users. An overview. London: UKDPC, 2010. 4 Villa L. Shaming the sick: addiction and stigma [Internet]. San Diego, USA: Drug Abuse.com; [cited 22/08/2016]. Available from: http://drugabuse. com/library/addiction-stigma/. 5 McLaughlin D, Long A. An extended literature review of health professionals perceptions of illicit drugs and their clients who use them. J Psychiatr Ment Health Nurs. 1996;3(5):283-8. 6 Goffman E. Stimga: notes on the management of a spoiled identify. New Jersey, USA: Prentice-Hall 1963. 7 Luoma J, Twohig M, Waltz T, Hayes S, Roget N, Padilla M, et al. An investigation of stigma in individuals receiving treatment for substance abuse. Addict Behav. 2007;32(7):1331-46. 8 Drugs & Health Blog. Fear of stigma: does it hold you back? [Internet]. London: National Institute on Drug Abuse for Teens; 2016 [cited 22/08/2016]. Available from: https://teens.drugabuse.gov/blog/ post/fear-stigma-does-it-hold-you-back. 1

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Nutrition for Healthy Ageing Protein and Energy Balance JO ANDREWS Naturopath and Nutritionist BSc(ChemEng), BHSc(CompMed), MHSc(HumNutri)

AN IMPORTANT COMPONENT OF SUCCESSFUL AGEING IS ADEQUATE NUTRITION THROUGH THE LATER YEARS. WHILE IT IS FAIR TO SAY THAT THE EARLIER HEALTHY EATING AND LIFESTYLES ARE IMPLEMENTED, THE GREATER THE BENEFITS IN THE LONG RUN, HEALTH AND VIGOUR ARE DEFINITELY PROMOTED WHEN GOOD NUTRITION IS INITIATED AT A LATER AGE. MAINTAINING ENERGY BALANCE AND CONSUMING SUFFICIENT GOOD QUALITY PROTEIN ARE OF SPECIFIC IMPORTANCE IN THIS LIFE STAGE TO AMELIORATE AND EVEN REVERSE THE DELETERIOUS EFFECTS OF AGEING.

By 2051 it is estimated that 25% of Australians will be over 65, a good indication that the overall health experience is better now than ever before. Those in middle age have a prolonged life expectancy; however, ageingassociated problems have not yet been solved. With ageing, the number of people affected by ill health increases, and if the predictions are correct, Australia faces a number of challenges in supporting the increasing numbers of people with age-related disabilities and activity limitations. Good nutrition is central to both the prevention and the treatment of disease. Older people are a very diverse group and each personâ&#x20AC;&#x2122;s health status and disease risk is unique; therefore, individual assessment is fundamental to ensuring adequate nutrition. Health promotion recommendations are ideally personalised, focusing on healthy ageing and ways to improve age-related declines in function.

THE AGEING PROCESS AND MAINTAINING A HEALTHY BODY WEIGHT Ageing is a normal phenomenon and changes in body composition occur naturally with time. We tend to lose lean body mass which is primarily bone and muscle, becoming relatively fatter and commonly absolutely fatter. While for men this typically occurs gradually, for women, menopause marks the time of greatest change. The effects on our health are profound. Bone loss leads to height

loss, postural deterioration and fractures, and changes in the chest cage reduce lung capacity and function. Muscle loss (or sarcopenia) leads to reduced muscle strength, increasing fall and fracture risk. Impaired mobility limits normal daily movement and decreases opportunities to increase energy expenditure1. Weight or energy balance is maintained when food intake is equivalent to energy expenditure and in the elderly, this can be particularly challenging. Ageing is associated with progressive declines in energy expenditure2, and although thyroid function also decreases with age, this is probably too small a change to significantly affect the balance. More important is the effect of reduced skeletal muscle mass. Because the metabolic rate of fat is lower than that of muscle, caloric requirements are decreased. Unless the older individual reduces their food intake and increases their energy expenditure, they will gain weight with age, which is typically the case. After 65 years in males and 75 years in females, the picture is somewhat different. The proportion of overweight and obese adults declines which is attributed to the long-term loss of skeletal muscle. Including regular exercise into their lifestyles can slow down the deleterious effects of ageing on the muscle tissue.

MEETING DIETARY RECOMMENDATIONS To meet the Australian dietary recommendations for protein, a male over 51

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years must eat at least two and a half serves of protein-rich foods per day. This could include 2 eggs for breakfast, a portion of lean meat or poultry for lunch and a small handful of nuts for a snack. For women, only two serves are required. In the most recent Australian survey (carried out in 2011â&#x20AC;&#x201C;2012), the average reported intakes of protein for adults of all ages exceeded recommendations6. Not withstanding these positive results, inadequate protein intakes are seen in elderly people living in the community, although this is more common in residential care establishments3. Meeting dietary requirements becomes more difficult later in life. Chronic illness is common, and most older people take medications or combinations thereof daily. Chronic disease can reduce appetite and, along with drug-nutrient reactions, can affect the absorption, use and ultimate excretion of these nutrients. For many older people, appetite, taste and smell diminish and as a result, their interest in food lessens, reducing the capability of meeting the recommendations and increasing the risk of malnutrition.

INDIVIDUAL NUTRITIONAL SCREENING The elderly should be routinely screened for nutritional risk. Measuring BMI and weight loss is suitable for detecting pre-existing under-nutrition. If more information is

HEALTH

Maintaining a healthy body weight for as long as possible is fundamental to successful ageing. It is well understood that either major weight loss or weight gain reduces life expectancy for the elderly. Frailty (of which underweight is one component), is commonly associated with poor appetite and physical inactivity. It is typically experienced alongside a number of coexisting diseases and has an increased risk of hip fractures, reduced mobility and increased mortality. Obesity, on the other hand, is associated with poor physical performance and disability. An even greater effect on physical disability, morbidity and mortality is the combination of increased fat mass and reduced muscle mass, a condition referred to as sarcopenic obesity. From a nutritional perspective, much can be done to ameliorate (and possibly reverse) the deleterious effects of ageing. Paramount is fastidious food selection with tightly regulated calories and a balanced nutrient content.

Nutritional Risk Because of their low energy intakes, underweight older people are at an increased risk of inadequate consumption of required nutrients. On the other hand, the regular consumption of high-energy, low-nutrient foods places obese individuals at nutritional risk as well.

THE IMPORTANCE OF PROTEIN Proteins are required by every living cell for function and structure and we are unable to survive without complete proteins in our diet. Protein-energy malnutrition is associated with decreased immunity, impaired muscle function, reduced cognitive function and decreased bone mass, eventually leading to increased morbidity and mortality3. In studies of elderly subjects, high protein intakes were associated with greater bone densities and reduced rates of hip fracture, and when combined with high intensity, resistance exercise, muscle hypertrophy was enhanced3. While total energy requirements decrease for older adults, their protein requirements increase with age, as they appear to have a 25% higher protein requirement for body maintenance when compared to younger adults. Table 1 presents the protein requirements for Australian adults4,5.

required, healthcare professionals will carry out a Mini Nutritional Assessment which includes anthropometric, dietary, general and subjective questions. If malnutrition is indicated by this screening tool, further investigations will include detailed nutritional assessments and biochemical markers.

SUPPLEMENTING INADEQUATE DIETS Older people with insufficient energy or protein intakes can supplement their diets by including milk and milk-based drinks, such as Milo, and by adding skim-milk powder to

Complete Protein This term is used to describe proteins that contain all the essential amino acids in adequate proportions to support normal tissue growth and maintenance. Animal proteins (eggs, milk, meat, poultry, fish), soya beans and quinoa are examples of foods that are complete proteins.

their meals when suitable. High-energy highprotein drinks, such as Ensure or Sustagen, are fortified with a range of micronutrients, which are of additional benefit. For lactoseintolerant individuals, lactose-free milk is commercially available and for vegans, soy or almond milks fortified with calcium are ideal.

TABLE 1: RECOMMENDED DIETARY INTAKES OF PROTEIN FOR AUSTRALIAN ADULTS4,5 Males Age

For a 76 kg male

g/kg/day

Females Serves of protein-rich* foods per day

For a 61 kg female

g/kg/day

Serves of protein-rich* foods per day

31–50 years

64g/day

0.84

46g/day

0.75

2½

51–70 years

64g/day

0.84

2½

46g/day

0.75

>70 years

81g/day

1.07

2½

57g/day

0.94

Protein-rich foods* – Lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans. A standard serve is approximately: 100g raw lean meat or poultry; 115g raw fish; 2 large eggs; 1 cup of cooked legumes; 170g tofu; 30g nuts and seeds. REFERENCES Rivlin RS. Keeping the young-elderly healthy: is it too late to improve our health through nutrition? The American Journal of Clinical Nutrition. 2007;86(5):1572s-6s. Roberts SB, Dallal GE. Energy requirements and aging. Public Health Nutrition. 2005;8(7a):1028-36. 3 Nowson C. Nutritional challenges in the elderly. Australian Doctor: The independent weekly newspaper from Reed Business Publishing. 2009(27 March):25-6, 8-30,2. 4 Department of Health and Ageing NHaMRC. Nutrient Reference Values for Australia and New Zealand. Executive Summary. Canberra 2006. 5. Australian Government Department of Health and Ageing NHaMRC. Australian Dietary Guidelines: Summary. Canberra: Commonwealth of Australia 2013. 6. Australian Bureau of Statistics. Australian Health Survey: First Results, Food and Nutrients. 2011–12 Canberra; 2015. 1 2

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Iron BEYOND THE BLOOD TALIA FELLER Naturopath Health World Limited

IRON DEFICIENCY IS THE MOST COMMON NUTRITIONAL DISORDER IN THE WORLD, WITH ANAEMIA — PREDOMINANTLY FROM IRON DEFICIENCY — AFFECTING TWO BILLION PEOPLE WORLDWIDE; OR >30% OF THE HUMAN POPULATION1. INADEQUATE IRON INTAKE IS ASSOCIATED WITH FATIGUE AND POOR WORK PERFORMANCE2, BUT ALSO DECREASED IMMUNITY, INCREASED SUSCEPTIBILITY TO INFECTION3, AND CARDIOVASCULAR DISEASE4.

HOW TO RECOMMEND ORAL SUPPLEMENTATION OF IRON High dose iron is often recommended to treat deficiency; however, this can cause undesirable effects such as nausea and constipation. Whether this effect is experienced or not largely depends upon the structure of the molecule, or the compound to which iron is bound. For example, iron bound to cations such as sulphur (i.e. ferrous sulphate), can disassociate in the gut, releasing free iron. This is difficult to absorb and, therefore, can lead to gastrointestinal upsets in sensitive customers. In contrast, iron covalently bound to an amino acid, such as glycine, is rapidly and efficiently absorbed via amino acid transporters into enterocytes, and then released into the bloodstream12. That said, iron diglycinate offers a practical choice for customers looking for a highly bioavailable iron that is less likely to create adverse gastrointestinal effects when offered at therapeutic doses.

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There are multiple factors to consider when helping customers maintain a healthy iron status and Pharmacists play an important role in identifying customers with low iron who may need education regarding how best to attain an adequate intake. Groups at risk include vegans, vegetarians, menstruating and pregnant women, infants from 6 months to 4 years, adolescents and the elderly5,6.

THE IMPORTANCE OF IRON STUDIES Symptoms of iron deficiency may include fatigue, lethargy, pallor and poor immunity; all suggesting iron levels may need addressing. However, it’s important to note that these symptoms may not always relate to low iron. Symptoms of iron excess (seen in conditions

including haemochromatosis or thalassemia) may mimic some common deficiency signs7. Unnecessary supplementation may have adverse effects, and iron toxicity can lead to organ damage or even death. For this reason, recommend customers get an ‘Iron Studies’ test to assess iron status before supplementing with iron. This also provides a valuable baseline to monitor customers’ iron levels, ensuring safe prescribing.

IRON’S ACTIONS Iron is central to haemoglobin, the molecule that distributes oxygen around the body and removes carbon dioxide. It is also found in muscular myoglobin, facilitating oxygen release during muscle contraction.

Furthermore, iron is critical for energy production, plays an important role in amino acid and carbohydrate metabolism, and in the synthesis of hormones and neurotransmitters8. Iron is also essential for healthy immunity. Studies show links between iron levels and T-lymphocyte proliferation, with low iron associated with both humoral and cellular immune defects8, as well as reduced antibacterial defences9. Correcting iron status in your customers may provide an effective treatment when supporting healthy immune system function, increasing energy levels, or improving general health and wellbeing. Table One outlines some common interactions between iron and certain medications, noting tips for management.

TABLE ONE: COMMON INTERACTIONS* DRUG CLASS / SUPPLEMENT

SIGNIFICANCE

MANAGEMENT

Angiotensin-converting enzyme (ACE) inhibitors.

Co-administration of iron can abolish cough induced by ACE inhibitors. Iron and ACE medications may bind, reducing absorption of both agents.

If cough is present, recommend iron; however, separate intake by at least 2 hours10.

Antacids/H2 receptor antagonists, proton pump inhibitors.

May reduce the absorption and bioavailability of iron10.

Iron supplementation may be needed. Separate dose by at least 2 hours and monitor iron levels10.

Antibiotics including cephalosporin, fluoroquinolone, neomycin, penicillamine, tetracycline.10

Chelation can impair absorption of both agents if used concurrently11.

Avoid iron during short-term antibiotic therapy; however, iron supplementation may be needed with extended therapy. Monitor iron levels and separate intake by several hours10.

Aspirin/Acetylsalicylic acid.

Long-term use of aspirin may lead to iron depletion. Iron may reduce haematologic adverse effects of medication10.

Separate dose and monitor iron levels10.

Levothyroxine/Thyroid hormones.

Iron supplementation may decrease absorption of thyroid medication10.

Separate intake by 2–4 hours. Monitor thyroid function10.

Calcium and Zinc.

Compete for absorption; however, this is dependent on the form used; chelates are absorbed much more efficiently than inorganic salts10.

Separate supplements by 2 or more hours10. Alternatively, recommend amino acid chelated iron (iron diglycinate), which will not compete for absorption.

Vitamin C.

Vitamin C enhances iron absorption10.

Recommend concurrent use.

Long-term use of antibiotics may lead to iron depletion10.

*Not all interactions are listed. Refer to Natural Standards Database for more information.

REFERENCES: World Health Organisation. Nutrition: Micronutrient deficiencies. 2016. Available from URL: http://www.who.int/nutrition/topics/ida/en/ [Cited 15/8/2016]. Patterson AJ, Brown WJ, Roberts CK. Dietary and supplement treatment of iron deficiency results in improvements in general health and fatigue in Australian women of child bearing age. JACN. 2001;20(4):337-342. 3 Brock JH. Benefits and dangers of iron during infection. Curr Opin Clin Nutr Metab Care. 1999 Nov;2(6):507-10. 4 von Haehling S, Jankowska EA, van Veldhuisen DJ, et al. Iron deficiency and cardiovascular disease. Nat Rev Cardiol. 2015 Nov 1;12(11):659-69. 5 National Institutes of Health. Who is at risk of anaemia? 2012. Available from URL: https://www.nhlbi.nih.gov/health/health-topics/topics/anemia/atrisk [Cited 16/8/2016]. 6 National Institutes of Health. Who is at risk for iron-deficiency anaemia? 2014. Available from URL: https://www.nhlbi.nih.gov/health/health-topics/topics/ida/atrisk [Cited 16/8/2016]. 7 Kaplan M. Iron: too much or too little can cause all-too-familiar problems. 2014. Available from URL: http://www.anapsid.org/cnd/diffdx/irondisease.html. [Cited 16/8/2016]. 1 Braun L, Cohen M. Herbs and Natural Supplements, an Evidence Based Guide, 4th edn. Elsevier/Churchill Livingstone. Sydney. 2015:584-97. 9 Bowlus CL. The role of iron in T cell development and autoimmunity. Autoimmun Rev. 2003 Mar;2(2):73-8. 10 Stargrove MB, Treasure J, McKee DL. Herb, Nutrient and Drug Interactions: Clinical Implications and Therapeutic Strategies. St. Louis, MO: Mosby Elsevier. 2008:531-5, 537-8, 542-3, 545-9, 553-4, 580. 11 Natural Medicines Professional Database. Iron. 2015. Available from URL: https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/ professional.aspx?productid=912#interactionsWithHerbsSupplements [Cited 18/8/2016]. 12 Ashmead SD. The chemistry of ferrous bis-glycinate chelate. Arch Latinoam Nutr. 2001 Mar;51(1Suppl1):7-12. 1 2

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