INNOVATION TECHNOLOGY HEALTHCARE PHARMACY Scottish
Review
BIOSIMILAR MEDICINES WHAT YOU NEED TO KNOW
CPD AN UPDATE
WORD ON THE STREET HOMELESSNESS AND PHARMACISTS
DOLLY THE SHEEP A 20-YEAR LEGACY SUMMER SPECIAL 2017 HEALTH HAZARDS IN THE SPOTLIGHT ISSUE 116 - 2017
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SPR WELCOME ISSUE 116 - 2017
MEDCOM www.scothealthcare.com www.pharmacy-life.co.uk Sarah Nelson Editor
EDITOR [email protected] SARAH NELSON [email protected]
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NATIONAL ACCOUNTS MANAGER (SPECIAL FEATURES) HANNA DEVON [email protected] EDITOR'S LETTER ACCOUNTS MANAGER DONNA MARTIN [email protected] Welcome to the latest edition of Scottish EVENTS MANAGER Pharmacy Review! BRIDGET MCCABE [email protected]
STUDIO MANAGER Once upon a time, there was nothing The connection between this season DECLAN NUGENT better than catching the first waft of a and education may evidently resurrect [email protected] flickering barbeque – the universal sign some uneasy feelings for me – but that MANAGING DIRECTOR ADRIAN MAGINNIS that summer was in full swing. Now, doesn’t mean that the time of year isn’t [email protected] however, the aroma fills me, not with a a prime time to broach it. With this in IF YOU WISH TO CONTACT US BY feasting fantasy, but an overwhelming mind, we’re delighted to introduce SPR’s TELEPHONE - 02890 999 441 feeling of dread. Why? Well, it’s all new CPD strand, which is kicked off this Whilst every care has been taken in compiling education’s fault, really. issue with an outline of the personal and this magazine to ensure that it is correct at the time of going to press, the publishers You see, my psychic tendencies may professional benefits of the pursuits – as assume no responsibility for any effects from errors or omissions. The opinions of have not yet reached their full potential well as the systematic changes which you contributors are not necessarily those of the publisher. No part of this publication may be (aka my lottery numbers oddly haven’t need to be aware of (beginning on page reproduced, stored in a retrieval system, or transmitted in any form, or by any means, appeared), but when I was younger, 10). mechanical, electronic, photocopying, recording or otherwise without the prior permission of nobody’s weather-prediction skills Elsewhere, check out this year’s Medical Communications 2015 Ltd. All rights reserved. Data Protection - Please note, your managed to eclipse mine – not even summer special (beginning on page 24) mailing details and copies of any articles supplied will be held on a database and may be Michael Fish’s. – covering inhaler technique findings, shared with associated companies. Sometimes your details may be obtained from, or made Without fail, as I approached my need-to-know allergy updates, and more available to, external companies for marketing purposes. If you do not wish your details to be final years in senior school, and later, – and weigh in on our homeless problem, used for this purpose, please write to: Database Manager, Medical Communications 2015 Ltd, university, the sun soared only on those and how you, the pharmacist, can help 142-148 Albertbridge Road, Belfast, BT5 4GS. Subscription: £120 a year days prior to exams when I was confined (page 16). to the indoors for revision. That’s not all – we once again check in As I tried to soak up knowledge, my with the Scottish Medicines Consortium loved ones sat outside dining and soaking (page 13), and delve into the latest in up the sun; and while I desperately pored nutrition (beginning on page 38). over text books, I could hear the clinking of iced cocktails being poured into Happy reading!
INNOVATION TECHNOLOGY HEALTHCARE PHARMACY glasses. I was miserable with jealousy. Scottish Of course, it was only when I exited the exam hall for the final time, smugly
CREATED FOR PHARMACISTS Review CRAFTED BY YOU thinking of the prospect of pasta salads CHAMPION ROAD RACING CYCLIST ALEX DOWSETT’S and patio furniture that the summer rain INSIDE TRACK ON HAEMOPHILIA showers decided to open up on me. Year after the year, this was the same old story.
IN THIS ISSUE...
CROSSING THE LINE THE LATEST ADVICE ON NEW MEDICINES
MONEY TALKS DO PAST PENSION SCHEMES HAUNT THE INDUSTRY?
GREAT EXPECTATIONS CONFRONT THE FUTURE OF SCOTTISH PHARMACY ISSUE ISSUE
EPILEPSY MANAGEMENT 114 - 2017 HOW THE ROLE OF THE PHARMACIST IS 115 - 2017 @MEDCOMscot Medical Communications Ltd BEING REVAMPED VISIT US AT WWW.SCOTHEALTHCARE.COM
SPR | June 2017 | 1 There’s strength in numbers
That’s why more pharmacies than ever before in Scotland are increasing their profits as members of the Cambrian Alliance Group. Why join them?
We’re independent & impartial meaning we’re truly focused on your needs. With over 1,200 members and an annual spending power of £0.5 billion we save you money on generics, PIs, OTCs & dressings. And we give you with the professional services & technology you need to grow your business including e-CASS - our price comparison, stock ordering tool that makes you money and saves you time.
Contact us today and start making more money. e: [email protected] t: 0845 130 1187 w: cambrianalliance.co.uk 2 | NIHR | April 2017
Medcom Scot mag advert.indd 1 2/22/2017 9:35:31 AM WWW.SCOTHEALTHCARE.COM CONTENTS ISSUE 116 - 2017 4 HEALTH CENTRE RELAUNCHES Cadham Pharmacy has relaunched as the Cadham Pharmacy Health Centre 7 NEW TO THE GAME What challenges and opportunities are biosimilar medicines bringing to the market? 9 HELLO, DOLLY Credit: The Roslin Institute »» p.9 Reflect on Dolly the sheep’s scientific legacy, 20 years on 10 AN EDUCATION Stay sussed on the changing face of CPD in Scotland 14 2017 SCOTTISH PHARMACY CONFERENCE Partake in conversation and debate the motion of, ‘Doctors Diagnose, Pharmacists Prescribe’
»» p.32 »» p.16 16 WORD ON THE STREET There’s strength in numbers How the sector is helping to reshape the health of the homeless That’s why more pharmacies than ever before in Scotland are increasing 18 ADHD: THE PHARMACIST’S their profits as members of the Cambrian Alliance Group. CHALLENGE Why join them? A new perspective is curbing misdiagnoses of the condition We’re independent & impartial meaning we’re truly focused on your needs. 24 UNDER THE SUN
With over 1,200 members and an annual spending power of £0.5 billion »» p.7 The latest on the season’s health hazards – from we save you money on generics, PIs, OTCs & dressings. allergies to inhaler technique findings And we give you with the professional services & technology you need 32 A MIRACLE DRUG FOR ME-CFS? to grow your business including e-CASS - our price comparison, stock The newest need-to-know guidance for the condition ordering tool that makes you money and saves you time. 40 COELIAC DISEASE Contact us today and start making more money. The evolving role of the pharmacist in signposting symptoms e: [email protected] t: 0845 130 1187 w: cambrianalliance.co.uk »» p.24 SPR | June 2017 | 3
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NEWS
to find out more about the Scottish CADHAM Patient Safety Programme, and learn about how patients move PHARMACY from primary care into a hospital environment. HEALTH The visit was part of a fact- finding mission as they look to map out the way services will look CENTRE at the new 1,800-bed Woodlands Integrated Health Campus, which RELAUNCHES is due to open in 2022. The site will bring together an acute hospital, community hospital and nursing With its newly-installed home, all on one site. medicines dispensing robot, NHS Fife was invited to funded by the Scottish host the visit by Healthcare government, Cadham Pharmacy Improvement Scotland in order has relaunched as the Cadham to demonstrate how local primary Pharmacy Health Centre. care services operate, and showcase The benefits of the robot The visit was a huge success its successes around continually have been far-reaching, helping improving safety. in freeing up pharmacists’ time NHS Fife Primary Care to focus on delivering enhanced FIFE STANDARDS COULD PROVIDE Improvement Advisor, Marie patient care, and supporting the Paterson, commented, ‘It was a public and the patients coming BLUEPRINT FOR SINGAPOREAN HEALTH privilege to host the visitors from into the pharmacy health centre. Singapore and showcase our Local MSP, Jenny Gilruth CAMPUS patient safety work. NHS Fife is SNP, officially opened the centre in the unique position of being in which visitors and guests alike Officials from Singapore have built in Singapore’s Northern the only board involved with the flocked to witness the fully- made the long trip to Fife to learn Woodlands region, have visited St design and testing of the Scottish refurbished health centre and the more about the health board’s Andrews’ Community Hospital, Patient Safety programme in both robot in action. comprehensive approach to patient Anstruther’s East Neuk Pharmacy pharmacies and dental practices, as Pharmacist and owner of safety. and the Glenwood Dental Centre well as implementing the national Cadham Pharmacy Health Six senior figures from the in Glenrothes. roll out of the programme to all Centre, Bernadette Brown, upcoming Woodlands Integrated Delegates made the trip in line our GP practices.’ explained, ‘I am absolutely Health Campus, soon to be with the intention of meeting staff delighted to have received this funding from the Scottish RGU REPRESENTATIVE HONOURED AT NATIONAL PHARMACY CONFERENCE government enabling me to install our new robot. This has been my on non-medical prescribers, and dream for years and will maximise the implementation of electronic the time all my pharmacists can systems for medicines in Irish spend offering minor illness hospitals. consultations and chronic Additionally, out of the 40 medication service reviews. talks conducted at the conference, ‘I also have two NHS nurses RGU’s Dr Katie Gibson Smith who assist me with clinics – won the award for best oral one for respiratory conditions presentation for her PhD research, and one for common clinical which involves surveying and conditions. I am so proud of how Dr Katie Gibson Smith interviewing offshore workers and this collaboration is enhancing remote healthcare practitioners what we can offer patients from Academic staff from Robert The HSRPP Conference has in the North East of Scotland on our pharmacy health centre.’ Gordon University recently been held annually for the past promoting self-care in their work returned from successfully 22 years at a different higher environment. partaking in the Health Services education institution in the UK or Speaking on her success, Dr Research and Pharmacy Practice Ireland, in which this year’s event Gibson Smith said, ‘I am delighted (HSRPP) Conference 2017. drew attendees to Nottingham to have received this prestigious Six representatives from the University. award at a key national conference. university’s School of Pharmacy Academics and researchers from I feel that the award highlights and Life Sciences travelled to RGU spoke on a number topics, the importance and impact of the event, in order to deliver including the role of community researching health and wellbeing presentations on the leading health pharmacists in managing in remote populations, such as the research taking place at RGU. dermatitis and acne, influences offshore workforce.’ 4 | SPR | June 2017 WWW.SCOTHEALTHCARE.COM
NEWS EDINBURGH UNIVERSITY SPEARHEADS CHINA’S NEW DIABETES CARE MODEL A cutting-edge diabetes research and treatment centre, based on Scotland’s renowned healthcare model for managing patients with chronic conditions, will be established in a major Chinese city where one-in-10 people has the disease. The International Diabetes Beth Culshaw Centre (IDC) at Shenzhen integration between the NHS People’s Hospital in Southern and council. My first priority is China – supported by the NEW CHIEF OFFICER APPOINTED to work with the team in West University of Edinburgh – aims Dunbartonshire to further to deliver world-leading medical TO WEST DUNBARTONSHIRE HSCP improve outcomes for local education, research, and patient residents.’ A new chief officer has health sector spans over 23 years, care. Meanwhile, West been appointed to lead the in which she has previously worked The IDC, which will occupy Dunbartonshire Council Chief West Dunbartonshire Health and as a manager in primary and three floors of the 2,400-bed Executive, Joyce White, said, ‘The Social Care Partnership (HSCP). secondary care, and community hospital, scheduled to be recruitment panel were really Beth Culshaw will replace services, as well as in social care. operational by November, will be impressed by Beth’s enthusiasm, Keith Redpath, who retires in July, Beth said, ‘I am delighted to based on Scotland’s model for the passion, and desire to continuously at the HSCP, which is responsible have been appointed to this role. care and management of patients improve services. I look forward for delivering all local primary care As one of the first HSCPs in the with chronic conditions. to working closely with her in community health and social care country, the partnership is well- An international team will the coming years as we continue services. established and I am committed develop a new diabetes care and to improve the lives of West Beth’s experience within the to continuing the growth of that management model with a view Dunbartonshire residents.’ to scaling the system across the city’s 16 large public hospitals. It POTENTIAL PRESCRIPTION DRUGS SAVINGS will be underpinned by a strong educational strategy, registry- REPORTED AT EUROPEAN CONFERENCE based care that is supported by a powerful informatics platform NHS Highland is at the forefront The high-level conference the management of polypharmacy and multidisciplinary care teams. of a prescribing revolution that – attended by a pan-European – the use of multiple drugs – to The university will provide could dramatically improve patient audience of health specialists – was deliver better outcomes for training, mentorship, and safety and help make considerable opened by Shona Robison, the patients across Europe and cost- research guidance while its cost savings over the next decade, Scottish Health Minister. With effective use of resources.’ strategic partner Hua-Xia according to a report recently speakers from the World Health As well as outlining the Healthcare provides on-site presented at an international Organisation and European advantages to improving patient management. The IDC receives conference. Commission for Health, building care safety, the polypharmacy financial support from the The report, ‘Polypharmacy blocks were placed to help management report also Shenzhen government. Management by 2030: A Patient stimulate and drive innovative highlighted economic evaluation Professor Andrew Morris, Safety Challenge’, was presented at change in order to improve the care tools developed in Scotland. It’s University of Edinburgh Vice a SIMPATHY Project conference of this growing patient group. estimated that if every practice in Principal and Professor of held at Scotland House, the Shona Robison, said, ‘In Scotland conducted just 10 reviews Medicine, explained, ‘With Scottish government’s EU office in Europe, people are living longer a month of patients taking multiple Shenzhen People’s Hospital, we Brussels. and being treated with multiple medications, then as much as have a major, highly-respected The report was co-authored by medications. This adds pressure £16.8 million would be released in local partner. Our vision is to Dr Martin Wilson, a Consultant to the health and care system and efficiency savings. support the development of at Raigmore Hospital in Inverness, may expose patients to harm. Care a world-class diabetes centre with the intention being to address becomes more complex and cost and quickly grow an electronic issues faced by adult patients who and harms may increase. patient database and bio bank for have to take multiple medications. ‘What we want to do is change international research purposes.’ SPR | June 2017 | 5 LUCOZADE ENERGY IS CHANGING
Lucozade Energy Original now contains approximately 50% less glucose based carbohydrates. All flavours have significantly less glucose based carbohydrates - please check the label.
Some flavours will contain aspartame, which is a source of phenylalanine.
New products will appear on shelf from April 2017, for a time both old and new bottles and cans may be on shelf together so remember to check the label.
This applies to all Lucozade Energy flavours.
FOR PRODUCT INFORMATION PLEASE VISIT: [email protected] OR CONTACT CONSUMER CARE ON 0800 096 3666
Please note that Ribena (Squash and Ready to Drink) and Orangina will also be reducing in sugar during 2017. Please check nutritional label for information. LUCOZADE ENERGY and the Arc Device are a registered trade mark of Lucozade Ribena Suntory Ltd. WWW.SCOTHEALTHCARE.COM
BIOSIMILARS BIOSIMILARS: ACCESS THROUGH EDUCATION Biological medicines are playing a significant role on a global scale in providing effective treatments for patients and contributing to improved survival rates, as well as providing a better quality of life. However, in order to increase access, biosimilar medicines – equivalent products which have no meaningful differences from the original or reference product in terms of quality, safety, or efficacy – also have important roles to play in providing choice for clinicians, driving down cost, and ultimately improving patient outcomes. Warwick Smith, Director General of the British Biosimilars Association (BBA) outlines the challenges and opportunities in the UK. considerable savings to the NHS awareness and knowledge as well compared with originator biologic as supportive guidance from drugs and, while they can’t organisations such as NICE to offer the same percentage price generate confidence in using reductions as traditional generic these products. The BBA – along medicines, this reduction comes off with other industry partners – is a comparatively higher cost base. also taking part in and driving a So greater uptake in biosimilars number of initiatives. can potentially create savings via These initiatives have included competition which will allow working with NHS staff to develop already stretched budgets to be authoritative information about Warwick Smith more efficiently spent and crucially biosimilars as well as organising increase patient access to these educational events. NHS England For biosimilar medicines fully to Biological medicines are vital treatments. These are the has published ‘What is a Biosimilar deliver their potential benefits for dominating global lists of the same principles which have always UK patients, continued education best-selling prescription drugs. Medicine?’ – a document which underpinned the generic medicines and shared experience is a critical Very successful treatments provides key clinical and non- market in the UK which is among element of their introduction. for rheumatoid arthritis and clinical stakeholders with accessible the most successful in the world, It was the driving force behind autoimmune diseases have led the information on how to support and on average saves the NHS why we launched the British way, and as we move forward, other the appropriate use of all biological more than £13 billion every year Biosimilars Association (BBA) disease areas, such as oncology, are medicines, including biosimilar according to figures from the as an authoritative source of increasingly in demand. medicines for the benefit of NHS British Generic Manufacturers information to educate people – be However, with UK healthcare patients. Association (BGMA). they patients, clinicians, regulators, budgets stretched by ageing This collaboration between Because of the lack of or policy-makers – about the populations, technology stakeholders is critical and we have comparable clinical experience opportunity that these important investment, and advances – seen the most effective uptake and thus understanding, some medicines provide. which mean diseases can be in the UK where commissioners clinicians and patients have not There are a number of reasons detected earlier and treated later and medical professionals work yet fully embraced the use of why this needs to take place. From – affordability and value are key together to implement biosimilars biosimilars, although there are a macro perspective, the impact elements of widening patient and share the resulting savings areas of clear progress and success, of biological medicines both now access. The UK, in particular, across their respective institutions. such as G-CSF. Regional variance – and increasingly in the future has been slower than some other One well-documented example across the UK has also been very – cannot be ignored or indeed European countries in fully of this is Southampton, where the mixed. However, if the NHS is to underestimated for patients and adopting the use of biological Trust is able to save £60,000 to cope with its budgetary pressures payors alike. medicines partly because cost and £80,000 per month and invest in while also maintaining access to Biological medicines are value need to be demonstrated via an additional nurse and pharmacist new breakthrough treatments, then protein-based and made or derived the National Institute for Health support. biosimilars must have a crucial role from living organisms. Unlike and Care Excellence (NICE). To maximise the benefits of to play going forward. traditional chemical equivalents, As acknowledged by the biosimilar medicines for both At the start of this year, they can be tailor-made so they NHS England Chief Executive, patients and the NHS, it is there were seven biosimilar bind to specific targets in the Simon Stevens, the NHS is at a important that clear, positive molecules on the market in the body. A biosimilar medicine is ‘crossroads’ and needs to change policy positions are adopted that UK (somatropin, follitropin alfa, manufactured to be highly similar and improve as it moves forward. link the efficiency and financial filgrastim, infliximab, epotein alfa, to an existing licensed ‘reference’ Long-term conditions now benefits to improving patient insulin glargine and etanercept). biological medicine after expiry account for 70 per cent of the access, otherwise the UK could However, this is set to increase due of its patent, with no meaningful health service budget, coupled face falling behind the rest of to a number of factors including differences in terms of quality, with a £30 billion funding Europe. patent expiries, increasing clinical safety, or efficacy. gap. Biosimilar medicines offer SPR | June 2017 | 7
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NEWS INNOVATIVE and widen the range of services available. Since it was introduced PROJECT HELPS in NHS Forth Valley in 2016, several other health boards have, or BREAK DOWN are planning to, introduce similar INTER- services in their local pharmacies. It is anticipated that thousands GENERATIONAL of people across Forth Valley will benefit from the extended range of BARRIERS treatments now available in local pharmacies. Pupils at Fortrose Academy NHS Forth Valley’s Director have been participating in an of Pharmacy, Scott Mitchell, innovative project designed to commented, ‘We are delighted help break down barriers between PHARMACIES EXPAND that so many local people have generations and give them some already taken up the offer to seek realistic insights into the effects of TREATMENTS FOR COMMON the help of a pharmacist for urinary dementia and ageing. infections and impetigo, and The pilot scheme with local HEALTH CONDITIONS community pharmacies are now charity, Black Isle Cares (BIC), looking forward to being able to treat people with other common entailed 12 students attending Pharmacies across Forth for bacterial conjunctivitis, vaginal conditions. weekly sessions to help them Valley are now offering over- thrush, skin conditions – such ‘Offering treatment in address any preconceptions or the-counter treatment for as eczema and contact dermatitis pharmacies not only takes pressure stereotypes they may have about several more common health – and skin infections, including off busy GP services, but also the process of growing old. conditions without the need for a cellulitis, insect bites, and nail makes it easier for people to get As part of the project, students prescription. infections. help without having to make an helped BIC volunteers with its Over the past year, more than The scheme, which is available appointment. Most pharmacies meals on wheels service before 3,500 people have sought the in all 76 Forth Valley pharmacies, are open six days a week, and some planning a soup and dessert lunch advice of a pharmacist for urinary is part of the national Pharmacy located in supermarkets operate in for some of the clients at the tract infections and impetigo. First initiative which aims to the evenings and on Sundays.’ academy. Now treatment is also available make better use of pharmacy skills It’s hoped that realistic portrayals of ageing provided during the sessions will help PHARMACY STUDENT ELECTED TO the pupils have a greater understanding of ageing, including dementia, for example, NATIONAL EXECUTIVE and have a positive impact for Pharmaceutical Society (RPS), it both them and older adults they exists to represent, educate, and meet during the project. entertain its members. The project was assisted by Mara has represented the Ruth Mantle, NHS Highland’s organisation over the past year as Alzheimer Scotland Dementia its Northern Area Co-ordinator, Nurse Consultant, and Dr Leah arranging two conferences, and Macaden from the University of leading a team of representatives Stirling. across four universities – RGU, BIC Chair, Brian Devlin, Durham University, the University spoke of this new, developing of Sunderland, and the University partnership between the charity, of Strathclyde. Fortrose Academy, and NHS She’s set to take up her new role Highland, saying, ‘I think that as part of the national executive this idea of us all working closely in July, following an election that together for one common aim took place at the BPSA Annual – an increased understanding of Mara Gilchrist and BPSA colleagues Conference in Durham last month. the great gift we have in our older A pharmacy student at Robert on the British Pharmaceutical Speaking on her new post, Mara people who are often forgotten Gordon University (RGU) has Students’ Association (BPSA) said, ‘My aim for the next year is about in society – is fantastic.’ spoken of her honour at being Executive. to support our students and help appointed to a key role in a The BPSA is the national body them develop their skills outside national pharmaceutical body. that represents the interests of of the university setting. I look Mara Gilchrist, a third year student pharmacy students and pre- forward to working with a great at the School of Pharmacy and registration trainee pharmacists team of executive members to Life Sciences, has been elected as across the UK, and as the official engage with our members across Education Development Officer student organisation of the Royal the country.’
8 | SPR | June 2017 WWW.SCOTHEALTHCARE.COM
FEATURE HELLO, DOLLY Can you believe that it was back in 1997 when the world’s most famous sheep first began to lay the groundwork for her long-lasting legacy? As the first confirmed mammal to be cloned from an adult animal cell, Dolly commanded scores of media coverage – but, more significantly, massive changes to science and research have also ensued. SPR reflects, 20 years on. from Dolly in his research. COUNTING SHEEP Professor Whitelaw has remarked that one of the main Further indicative that the drivers in the mid-1990s for scientists’ mode of action continues developing cloning was to to be relevant in modern society provide a cell system for genetic is the fact that Dolly’s scope of engineering. influence has spanned worldwide. He recalled, ‘Cloning enabled In fact, recent research published gene-targeting strategies to be used. by the University of Nottingham, We have now moved on from using in the academic journal Nature cloning technology and instead use Communications, has shown very efficient genetic engineering Professor Sir Ian Wilmut with Dolly at the that four clones derived from the methods that can be directly same cell line – genomic copies of launch of the Towards Dolly exhibition applied to the fertilised egg. Dolly – have reached their eighth Credit: Dave Cheskin ‘These are based on DNA- birthdays in good health. editing technology which enable Nottingham’s Dollies – Debbie, 20 years after Dolly the sheep’s the late Professor Sir Keith extremely precise changes of the Denise, Dianna and Daisy – dramatic entrance to the world, Campbell – has been fundamental genome of animals. We apply this have just celebrated their ninth researchers have been reminiscing to the development of a range of exciting method in farm livestock birthdays and along with nine about her scientific legacy, and the treatments, including stem cell and poultry, aiming to produce other clones they are part of a lessons which her presence in the technology. animals that are less susceptible to unique flock of cloned sheep under world paved the way for. As the first animal ever to be disease.’ the care of Professor Kevin Sinclair, In particular, scientists based cloned from an adult animal cell, In producing Dolly, scientists an expert in developmental at the Roslin Institute – which news of Dolly’s creation, which took a fully-formed adult sheep biology, in the School of hosted Dolly’s unveiling in was subsequently published in the cell and effectively turned the clock Biosciences. February 1997 after her birth the journal, Nature, understandably back to make it behave like a cell The research, ‘Healthy Ageing previous summer, and is now part prompted intense public debate from a newly-fertilised embryo. of Cloned Sheep’ is the first of the University of Edinburgh around the ethics of cloning. Dr Tilo Kunath, Chancellor’s detailed and comprehensive site – have spoken about how she However, her introduction to Fellow at the University of assessment of age-related non- continues to influence their work. the world not only sparked a media Edinburgh’s MRC Centre for communicable disease in cloned The staff have especially storm, but also inspired a new Regenerative Medicine, was a PhD offspring. highlighted how the breakthrough generation of scientists. student in Toronto at the time. opened up previously Professor Bruce Whitelaw, He remembered, ‘Dolly really unimaginable possibilities in who is now interim Director of changed our view of biology, biology and medicine. Dolly the Roslin Institute, was working showing us that we could take – unveiled by a team led by at Roslin when Dolly was formed adult cells and reverse them in Professor Sir Ian Wilmut, and – and he still uses lessons reaped time. ‘Reprogramming cells in this way is something that I use to search for treatments for degenerative conditions like Parkinson’s disease. Dolly’s influence on scientists around the world will continue to impact on cell and tissue repair research for many years to come.’ Dolly – who was put down in 2003 after a short illness at six- and-a-half years old – is now on display at the National Museum of The original Nature Scotland. Professor Sir Ian Wilmut with Dolly paper cover, featuring Credit: The Roslin Institute Dolly
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CPD CONTINUING PROFESSIONAL DEVELOPMENT – AN UPDATE With the roles of pharmacy professionals shifting in nature, taking charge of your CPD has never been more crucial. Jenny Macdonald, Lead Pharmacist Education & Training, and Lesley Dunbar, Senior
Pharmacist Education & Training, NHS reflective case-based discussion THE CPD CYCLE Greater Glasgow & Clyde, outline the report on practice and this is now CPD is a continual process of life- forming the basis of the recently- long learning. It is recorded using personal and professional benefits of launched GPhC Consultation a cycle of four stages; reflection, the pursuits – as well as the systematic on revalidation for pharmacy planning, action and evaluation. professionals (2). How can As you can see from figure 2, it changes which you need to be aware of. we make best use of CPD for is a cyclical process – there is not our own effective professional one specific place to start or finish. development? In practice, most CPD cycles start at either reflection or action and Continuing Professional robust and respected by the THE GENERAL finish at evaluation. However, you Development (CPD) has been multidisciplinary team? PHARMACEUTICAL COUNCIL can also start at planning or at with us for many years, however (GPHC) STANDARDS evaluation. CONTINUING FITNESS TO it may not attract the attention it The current GPhC requirements If in your evaluation you PRACTICE – REVALIDATION deserves and may still be viewed for CPD (3) , listed in figure 1, identify further learning needs, or as something else on the ever- Undertaking, recording, and apply equally to all pharmacy some original learning needs have increasing list of things to do evaluating CPD has been a professionals – regardless of not been met, then this leads you during our busy professional lives. mandatory requirement for all whether you work part-time or to start another cycle at reflection. Perhaps we can take a fresh registered pharmacy professionals full-time, in a busy community So let’s look at some examples. look at our CPD and think about since 2010. Unless you have pharmacy or in an intensive care it differently. CPD should be joined the General Pharmaceutical ward, GP practice or managing EXAMPLE CPD CYCLE 1, worthwhile and bring value and Council (GPhC) register very a service – if you are a registered STARTING AT REFLECTION improvement to us as individual recently, you will already have had pharmacy professional then you • Reflection – A new computer pharmacy professionals and your CPD called for review at least have to do it. system is being introduced and I ultimately to our professional once, so you know what’s required. However, your CPD should have identified that I need to learn practice. The GPhC are now working be targeted at what your practice how to use it How can we take advantage on the plan to introduce new involves. It’s not dictated to you, • Planning – What am I going to of the learning opportunities requirements to assess registrants’ it’s not decided by your employer do to help me learn how to use the that arise during the course of continuing fitness to practice or your manager. It’s not about system? I could: the working day and use these to and these will come into force going on courses, being lectured - Attend a training session run benefit our future practice? How in 20181. A pilot study in 2016 to or spending your time at home by the manufacturer can we make sure that we are up- with 1,300 volunteers required studying. It is something that - Read the SOPs / manual to-date with key areas of pharmacy participants to submit CPD is already part of your everyday and try using the system for a few practice so that our contribution entries, undertake a peer review working life. dummy runs as pharmacy professionals is discussion, and complete a - Ask my manager to show me
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CPD
am not confident about doing pharmacy specific this and don’t know how to use - I have a friend who is a PowerPoint® to enhance my teacher – I could ask her advice presentations. I would like to about speaking to large groups of know what points to focus on to unruly people develop my confidence in making • Action – Choose some or all of presentations and also how to use the above plans and do them PowerPoint®. (By reflecting on • Evaluation – Did I learn what you need, you’ve actually everything I set out to learn? If identified two separate learning not, what do I still need to do? needs – one for improving oral How have I put that learning into presentation skills, one for learning practice? By presenting confidently how to use PowerPoint®. So make to a department meeting and these two different CPD entries. receiving positive feedback from This example will now focus on staff, I am now feeling much more oral presentation skills) confident about a presentation I • Planning – What could I do to have to do next week to a much help me improve my confidence in bigger group presenting to groups? - Arrange to do a short talk on Ideally, most of your CPD a topic I feel comfortable about to entries should begin at reflection Figure 2 a group of two or three friends and – as a Reflective Practitioner (4) ask them to comment on positive / , you should be identifying your how to use it that I need to address? How have negative aspects of my presentation learning needs through a number - Talk to my colleagues in other I put that learning into practice? skills to help me know exactly what of different processes, including sites about problems they have By starting to use the new system to try to improve formal employers’ appraisals or had with the system and how they successfully and improving our - Speak to colleagues who do resulting from one of your own resolved them workflow as a result this regularly to see if they can CPD entries. However, don’t • Action – Choose some or all of offer me any advice ignore the unplanned episodes the above plans and commit to do EXAMPLE CPD CYCLE 2, - Find information on the which result in valuable learning them STARTING AT REFLECTION internet or a book from the library too. • Evaluation – Did I learn • Reflection – I have started a about the topic and read up on it everything I set out to learn? If new job and am going to have - Find out if employer or NES EXAMPLE CPD CYCLE 3, not, what do I still need to do? to make oral presentations to run any courses on presentation STARTING AT PLANNING Do I have new learning needs different groups of people. I skills – it doesn’t need to be • Planning – I am going to attend
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CPD a conference that looks very detail in reality, however they FIGURE 1: THE GPHC the GPhC CPD framework. interesting and relevant to my should illustrate that the normal STANDARDS FOR CPD 5. Submit your CPD record to the practice but I don’t know exactly things you are doing in your day- GPhC when requested. what I will learn to-day role can be used as CPD. You must do the following: • Action – Attend the conference The important aspect is that your • Evaluation – What did I CPD should be targeted at what REFERENCES 1. Keep a legible record of your learn that I intend to apply in your practice involves. This means CPD – either online at uptodate. 1. https://www. my practice? This may as easily that even if you learn new things, if org.uk, on a desktop computer, pharmacyregulation.org/ have been through an informal they are not relevant to your job or or on paper. It needs to be in a registration/continuing–fitness– conversation as through a formal help to improve your practice, then format published or approved presentation or poster. In fact, it’s not CPD. practise accessed 7/4/17 by the GPhC, carrying the often this is the more common For instance, if you work 2. https://www. CPD–approved logo. Update: mode of learning through this type only in a paediatric hospital and The paper submission facility has pharmacyregulation.org/ of event you attend an NES course on been withdrawn from the regular revalidationconsultation accessed supporting patients with dementia methods for submission of CPD 28/04/2017 EXAMPLE CPD CYCLE 4, – it might be very interesting but entries, with effect from January STARTING AT ACTION it is not relevant to your job so 3. https://www. 2016 • Action – I received a doesn’t count as CPD. However, pharmacyregulation.org/ 2. Make a minimum of nine CPD prescription for a new drug if you are intending to apply for entries per year for each full year of education/continuing– that I have not seen before. I a new job in primary care, this registration, or the date you joined professional–development/cpd– wanted to know what it is used might very well be appropriate to the register (whichever is later), standards for. I needed to know if there consider as CPD. These examples or the date you last submitted were any interactions with other also illustrate the range of different 4. Schön, D. The Reflective CPD records as part of a call and medications and what counselling roles of a pharmacy professional Practitioner: How Professionals review request, that reflect the points I needed to think about to and the fact that, for individuals, context and scope of your practice Think in Action. Basic Books, tell the patient. Therefore, I looked these change over time. If you take as a pharmacist or pharmacy 1984. it up in the BNF and spoke to on management responsibilities technician. the pharmacist about the patient then you have a lot of new learning 3. Keep a CPD record that counselling required to do, most of which you will complies with the good practice • Evaluation– What did I learn? be using on a daily basis. If you criteria for CPD recording How have I put that learning become an independent prescriber published in the GPhC’s into practice? By speaking to the then the same applies. requirements for undertaking and patient. How will that learning Working within a recording CPD: Plan and record help my future practice? I will multidisciplinary team requires 4. Record how your CPD has know what I need to consider new ways of thinking. Taking on contributed to the quality or when I see that drug prescribed the role of a pre-registration tutor development of your practice using in the future and I will have or workplace based assessor opens confidence in providing the patient up new opportunities too. All of with the required information. your different professional roles Do I need to learn anything should be reflected in the range of further? (If the answer is no then your CPD entries. you can stop here and this entry is Taking CPD seriously complete.) I would like to know provides personal benefits as which other drugs are in the same well as increasing professional class so I can recognise similar satisfaction. The roles of pharmacy issues in the future – I will start professionals are changing and by another CPD cycle at reflection to taking charge of your CPD you do this could improve your chances of expanding your role or moving in a EXAMPLE CPD CYCLE 5, completely new direction. STARTING AT EVALUATION • Evaluation – I previously learned FURTHER SOURCES OF about learning styles as I had been INFORMATION asked to take on the role of pre- • www.pharmacyregulation.org – registration tutor. I have since been GPhC website involved in teaching large groups • www.nes.scot.nhs.uk/education– of pharmacy undergraduates and and–training/by–discipline/ • have had to revisit this learning and pharmacy.aspx – NHS Education apply it in a different situation. for Scotland website. Information on courses, distance learning, and These are just basic illustrations other resources available that can be developed in more
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SCOTTISH MEDICINES CONSORTIUM
CROSSING THE LINE SPR checks in on the Scottish Medicines Consortium’s latest advice about the newly-accepted medicines in NHS Scotland.
APRIL 2017 MEDICINE FOR THE TREATMENT OF… Trastuzumab Emtansine (Kadcyla) An aggressive, advanced type of breast cancer known as HER2 positive metastatic breast cancer
Ibrutinib (Imbruvica) Chronic lymphocytic leukaemia in patients with disease that have relapsed after previous therapy
Daclizumab (Zinbryta) Severe or relapsing forms of multiple sclerosis Helping prevent sexually transmitted HIV-1 infection in adults Emtricitabine / Tenofovir Disoproxil (Truvada) who are at high risk of being infected (‘pre-exposure prophylaxis’ [PrEP])
Plaque psoriasis, an inflammatory skin condition which causes red Ixekizumab (Taltz) scaly patches (known as plaques) on the skin
MAY 2017 MEDICINE FOR THE TREATMENT OF… Idebenone (Raxone) Leber’s hereditary optic neuropathy (LHON), a severely disabling and extremely rare genetic disease of the eye which can cause sudden blindness
Belimumab (Benlysta) Systemic lupus erythematosus, an autoimmune disease where the immune system attacks a person’s body, causing inflammation and organ damage which can result in life-threatening complications for some patients
Micronised Progesterone (Utrogestan) Can be used to support embryo implantation and pregnancy as part of fertility treatment
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HOMELESS WORD ON THE STREET: HOMELESSNESS AND PHARMACISTS
Imagine a world where you have people are more likely to have TAKE TIME TO problems and advises checking nowhere to rest, wash, or eat. asthma, heart disease, hepatitis C, whether patients can open bottles, Where you have lost touch with or tuberculosis. EXPLAIN or dispense from blister packs. the people you love, and have A St Mungo’s report found that Dosetting is seen as an no idea where you’ll sleep that PRESCRIBING over 50 per cent of homeless expensive last resort, but it can night. It’s a frightening, lonely, people have literacy problems, so increase concordance in patients unhealthy existence – but for many HELP it’s vital that verbal information is who are struggling, potentially people, it’s a reality. An increasing Healthcare and prescribing may given as well as leaflets. avoiding a costly inpatient stay. number of people are becoming seem a world away from the person Take time to explain things Alternatively, slow release, once- homeless because of rising rents, sleeping under a blanket in the and work with the patient. Not a-day versions of medications may redundancies, or benefit changes. doorway, or a family crammed everyone can predict when they help. into a bed and breakfast room; but will have access to food, so ‘take Sam also talks passionately Government statistics show that you can play a key role in helping it before breakfast’ might not be about the need for patients last year: homeless people recover. helpful. Ask what is routine for being prescribed injectables to • 59,250 people or households In England, patients (including that person – would arriving at a be assessed, urging professionals were accepted as homeless in some on benefits) are charged day centre be a better reminder? not to assume that patients who England for medication. A three-month Kate Robinson, a Drug and have injected street drugs, can • 18,628 people presented prescription may reduce costs, Alcohol Nurse at a central London safely inject insulin or Clexane themselves as homeless in but patients may struggle to store teaching hospital, believes that for example. Pharmacies offering Northern Ireland medication or keep it dry. Some educating patients improves on-site dispensing may wish to hostels restrict medications for concordance, saying, ‘Patients who consider linking with needle • 34,662 people made legal reasons or because they fear are withdrawing from heroin often exchange services. homelessness applications in it may be stolen to sell (and this don’t understand the reasons for Even ‘safe’ methods of delivery Scotland is not always the most obvious Methadone dose titration. I explain might not be so safe. One • 7,128 households were assessed drugs). the long half-life of Methadone, hospital pharmacy was asked not as ‘threatened with homelessness’ Free prescriptions in Scotland, and that an effective dose will be to dispense certain brands of a in Wales Northern Ireland and Wales have achieved over time. painkilling patch after finding radically changed the prescribing ‘Unless the patient knows that out the active ingredient could Some will be sleeping on the landscape. they are being heard, there is a risk be removed and injected. Drug streets, and many more will be Dr Richard Lowrie, Pharmacist that they’ll self-discharge to seek dealers were targeting patients, ‘hidden homeless’: sleeping on at the homeless health service in heroin, abandoning vital medical leaving them without medication. a friend’s sofa, on buses, moving Glasgow, explained, ‘Depending treatment. It’s much harder for Local knowledge is invaluable, between night shelters, or on the medicine, I write a month- us to get back in touch with a so talk to patients and local teams. exchanging sex for somewhere to long prescription to be dispensed homeless patient.’ sleep. weekly. It reduces the amount that A few words of explanation BUILD Most have physical or mental is lost or wasted, and it means that from a pharmacist could literally health problems or a dependency I can monitor patients as they be the difference between life and RELATIONSHIPS on drugs or alcohol, often those adapt to new medicines. It helps death. Homeless people on the street are who do not will develop problems the patient to build trust through often ignored. One man described when faced with life on the streets. regular engagement with the THINK METHOD feeling ‘invisible, less than human’. Our home is important to our community pharmacist. Then, suddenly, patients beginning The method of medication delivery sense of safety. People without a ‘Conversely, some patients to engage with services are is also important. home are nine times more likely engage better if given the whole bombarded with an overwhelming Specialist Nurse, Sam Dorney- to take their own life, and have month supply – it shows that we number of staff as they move Smith, describes great results high rates of depression and trust them to manage.’ between night shelters, hostels, through breath-activated inhalers anxiety. Homelessness is also bad temporary accommodation, and for those with co-ordination for physical health, and homeless flats.
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HOMELESS
Last year, 34,662 people made homelessness applications in Scotland. But with the role of the pharmacist extending to much more than just raising awareness about this segment of the population, they can help reset the reality of sufferers – through methods such as regular engagement, medication delivery, and more. Cat Whitehouse, of the leading homeless healthcare charity, Pathway, sheds light.
A constant relationship with patients, and an opportunity to using street drugs because they managed a specialist community a healthcare worker, within build a relationship. This provides cannot cope with the impact of nursing team, providing outreach professional boundaries, can help a chance for ongoing monitoring hospital release, opiate withdrawal to homeless hostels and day to counter those changes, take time of mood and health conditions, and housing relocation all in one centres in London. She is the to chat if you can. and a potential avenue into health day. founder of the UK’s largest and Your work will be most screenings. busiest homeless health team, successful if you ask your patient’s Successful trials of pharmacy- OUT THERE AND Pathway King’s Health Partners, permission to work with everyone based hepatitis / HIV screening and a member of the Faculty of involved in their care. That might have identified that many ‘at-risk’ DOING IT Homeless and Inclusion Health mean letting support workers patients prefer walk-in services • Alison Hair and Richard Lowrie working group, examining safe know about potential side-effects and feel more comfortable being began working in homelessness medication dispensing in homeless or notifying prescribers if a person screened and receiving anti- after realising there were gaps in hostels. stops collecting medication retrovirals at a pharmacy. mainstream NHS pharmaceutical (especially if this is a warning sign Specialist Homelessness Nurse, services. Today, they are based ABOUT PATHWAY that a mental health problem or Sam Dorney-Smith, says that at Hunter Street Homeless Pathway is a charity dedicated substance misuse issue may have pharmacists can really help with Service, Parkhead Health Centre to homelessness and health. It recurred). Support workers can smoking cessation, commenting, and hostels across Glasgow, works in the NHS to create teams also work alongside pharmacists to ‘This aspect of care is often providing weekly sessions in a of doctors, nurses and housing help patients move from dosetting wrongly ignored for homeless multidisciplinary team. Half- specialists in hospitals to help to self-administration. patients, but with incredibly high day clinics usually involve five patients access accommodation levels of COPD among the target or six patients, focussing on the and support. THE WIDER HOMELESS population, it’s vital that support management of chronic diseases. The charity is home to the COMMUNITY is offered.’ Independent prescribing has Faculty of Homeless and Inclusion Medication storage and improved the efficiency of the Health – a free network of 900 management is a huge problem HOSPITAL PHARMACIST clinics, and the pharmacists work professionals working with patients for many homeless hostels, Timely TTAs can make the closely with other specialists in the facing barriers to healthcare, such and many patients haven’t had difference between a person getting team. as: medication reviews. Getting to housing, or sleeping on the street • Kate Robinson is a Drug and know local hostel workers can reap after leaving hospital. How? • Homeless people Alcohol Nurse at a central London considerable rewards. Approaching a local council for • Vulnerable migrants teaching hospital. She provides Pharmacies can help by carrying housing often means queuing early assessment and treatment planning • People from gypsy and traveller leaflets for local housing support in the morning, as many use a ‘first for patients with drug and alcohol communities services to help patients. These come, first served’ system. issues, patient advocacy, liaison • People involved in the sex also signal that you will not act Having TTAs ready first thing with existing treatment providers, industry pejoratively towards homeless in the morning helps workers and referral to follow-up care. patients. ensure a patient will be seen. Most Many of her patients are homeless, The network brings together homeless patients don’t have the or at risk of losing their homes. In researchers, commissioners, money to come back to hospital WHAT YOU CAN addition to her patient work she consultants, doctors, nurses, later, so it’s vital that they’re ready. gives guidance to clinicians on housing workers and pharmacists DO AS A… If patients with opiate prescribing and management for and others through regional and dependency are being released patients using drugs or alcohol, national updates and events. The COMMUNITY PHARMACIST on a Friday consider whether you through formal training and point- Scottish Faculty is particularly can offer a weekend methadone Community pharmacists of-care advice. active, often running training in dispensing medicines to aid in prescription. Your short-term the region. support could be the difference • Samantha Dorney-Smith is a the treatment of opiate addiction For more information, visit between a person engaging with Pathway Nursing Fellow. She is a have a unique opportunity to www.pathway.org.uk. have daily contact with these support services or reverting to Nurse Prescriber and previously
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ADHD ADHD: THE GP AND PHARMACIST CHALLENGE The plethora of brain research conducted throughout the past 20 years has resulted in a completely new perspective of ADHD. How can the sector move forward with this insight and apply it to prevent misdiagnosis? Dr Tony Lloyd, Chief Executive of the ADHD Foundation, offers his view.
Once viewed as a childhood an NHS disease impact report. services. lottery. Diagnostic protocols (20) behavioural disorder, ADHD The mental health outcomes are NHS estimates that ADHD have improved since the wider is now recognised as a lifetime alarming – with an estimated 40 affects five per cent of the school use of QB testing – an objective genetic condition (1) (2) with per cent suffering from anxiety age population of 550,000 computer-based cognitive distinct differences in the frontal and depression, and one-in-five children, and various researchers functioning test that measures lobe, parietal lobe, cerebellum, attempting suicide. (9) Substance estimate that between 30 per ADHD core characteristics cingulate gyrus, corpus striatum misuse, addiction and eating cent to 60 per cent are still at 80 per cent accuracy. (21) (3), as well as dopaminergic disorders are also more prevalent ‘symptomatic’ in adulthood. (15) Symptomology scales, however, regulation resulting in differences in the ADHD population (10) (16) (17) still have a part to play when in brain functioning. (4) (11) (12) – something not fully discerning how the condition Like other neurodevelopmental understood by GPs. LOW DIAGNOSTIC impacts on daily functioning conditions, it is frequently ADHD is 70 per cent heritable, PREVALENCE for the patient. However, how comorbid with autism (5), sensory (12) (13) (14) and like ASD, Contrary to popular belief – ADHD impacts on the individual processing difficulties, dyslexia, is a chronic spectrum disorder. ADHD is underdiagnosed in can vary widely as a result of dyspraxia, tics and poor executive Symptoms include hyperactivity, the UK, with only three per cent environmental factors, such as functioning skills. Comorbidity is inattention and impulsivity, of children diagnosed, and less early diagnosis, healthy lifestyle, the rule, not the exception, with resulting in frustration, anxiety, than one per cent medicated. and in the case of children, schools over 70 per cent of those diagnosed intolerance and sometimes (18) (19) In Scotland, diagnostic that have well-trained staff able with ADHD having at least one aggressive ‘fight or flight’ prevalence is estimated at only to identify children with learning comorbidity. (6) (7) (8) DSM 5 behaviours which are the result one per cent. Where are the and developmental delay (rather made it possible for clinicians to of an inability to self-regulate remaining 250,000 UK children than poor behaviour, which sadly diagnose comorbidities, whereas emotion. It is, however, the impact who have the condition but have is still the main reason why most until five years ago, the patient’s on mental health as a direct result not been diagnosed? I would like children are referred to the NHS needs were seen through a singular of the low emotional resilience to think that they are functioning by schools). diagnosis rather than recognising associated with ADHD that sufficiently well to not require ADHD is a heritable condition the frequent comorbidity. should be a cause of concern for treatment. The truth, however, is in 70 per cent of cases, but genetic GPs. The impact of ADHD on that many are misdiagnosed with potential can be triggered and WHY THE LACK OF life chance trajectories can result other mental health problems in acquired; for example, we know UNDERSTANDING? in school failure, loss of status, and the adult psychiatric system. Only that deficiency in vitamin D The impact on the lives of rejection by peers, sustained levels when patients see an expert is the (22), iron (23) and zinc (24) in those living with the condition of anxiety, depression, psychosis, underlying ADHD identified and pregnancy can increase the risk in the UK has never been self-harm, increased risk of treated. factors of ADHD. Traumatic truly understood by mental addiction through self-medication Referral pathways vary birth and epilepsy (25) are also health practitioners and NHS and long-term unemployment – all significantly throughout the UK, risk factors. Research has proven commissioners, due to the lack of of which come at cost to statutory so it is something of a postcode there is a correlation between older 18 | SPR | June 2017 WWW.SCOTHEALTHCARE.COM
ADHD
parents and increased prevalence symptomology. clinicians to use generic medicines November. of ADHD which may explain is understandable; however red- For more information, visit why one-in-three children born MAKING THE TREATMENT rated controlled psychotropic www.adhdfoundation.org.uk. through IVF have ADHD. (26) CHOICE drugs affect different patients in (27) GPs could play a key role in Prescribing of ADHD medications different ways and tolerance to MEDICATIONS the early identification of children has doubled in the UK in the side-effects means that pharmacists with ADHD if they were aware of past five years. Pharmaceutical should be advised to dispense WIDELY USED TO the aetiology of the condition. companies state quite clearly that exactly what is prescribed. TREAT ADHD We receive lots of complaints medication should not be used in There have been several recent • Methylphenidate acts on from patients where their GP has isolation, yet many NHS trusts announcements by ministers dopaminergic function and is dismissed a request for an ADHD are still failing to implement calling for parity of esteem for prescribed in various fast release assessment stating reasons, such NICE guidelines of multi-modal mental health services. In the case and slow release mechanisms as, ‘You have a degree so you can’t support that includes CBT, psycho of ADHD, the government needs under the brand names: Equasym, possibly have ADHD’, or the fact educative, and psycho social to fund research in psycho social Medikinet, Concerta and Xenidate they have reached adulthood, and training. interventions, such as CBT for • Atomoxetine branded as many GPs still believe that this is Medication is the first – and ADHD and empower families Strattera and Guanfacine branded purely a childhood condition. often the only – line of treatment. with the knowledge and skills to as Intuniv act on noredranegic The ADHD Foundation is Although medication is the only take responsibility for their health function and can take up to six introducing training programmes intervention proven to significantly outcomes. weeks to become effective for GPs, newly-qualified improve brain functioning, it The one-off cost of one year • psychiatrists, and paediatricians to is not a cure and does not teach of multi-modal interventions at Lisdexamphetamine branded address this, but lack of resources those who suffer with ADHD the ADHD Foundation is the as Elvanse is a precursor that makes it difficult for clinicians to about how to self-regulate and equivalent to that of one year of becomes effective only after the access this much-needed training. become emotionally resilient, with medication – £700. While there digestive system converts it into GPs need to understand the a strength-based approach to their will always be some for whom dexamphetamine impact of ADHD on the lives of mental health so they can learn medication is necessary, there is a families and recognise the distress how to live successfully with this good case for a more far sighted caused by the condition and how condition in the same way we treat view and an ‘invest to save’ unsupported ADHD can impact other chronic conditions, such as approach in meeting the needs of on the long-term mental health of diabetes. those with ADHD, while making those affected and the cost of their cost savings. unnecessary life-long dependence WIDER SOCIETY The largest ADHD conference on health services through missed Pharmacists also need to know for GPs, psychiatrists and diagnosis and misdiagnosis more about the medications used paediatricians in the UK is taking arising out of complexity of to treat ADHD. The imperative on place in Liverpool on 9th and 10th SPR | June 2017 | 19 WWW.SCOTHEALTHCARE.COM
ADHD
disorder/Pages/Introduction.aspx 17. Preuss U, Ralston SJ, Baldursson G et al. Study design, baseline patient characteristics and intervention in a cross-cultural framework: REFERENCES results from the ADORE study. European Journal of Adolescent Psychiatry 2006;15(1):4–14. doi:10.1007/s00787-006-1002-0 18. McCarthy, Suzanne; Asherson, Philip; Coghill, David; Hollis, Chris; Murray, Macey; Potts, Laura; Sayal, Kapil; de Soysa, Ruwan; Taylor, 1. Faraone SV, Perlis RH, Doyle AE et al. Molecular genetics of Eric; Williams, Tim; Wong, Ian C. K. In: Attention-deficit hyperactivity attentiondeficit/ disorder : treatment discontinuation in adolescents and young adults. hyperactivity disorder. Biological Psychiatry 2005;57:1313–1323. British Journal of Psychiatry, Vol. 194, No. 3, 03.2009, p. 273-277. doi:0.1016/j.biopsych.2004.11.024 Research output: Contribution to journal › Article 10.1192/bjp. 2. Biederman J, Spencer T, Lomedico A et al. Deficient emotional bp.107.045245 regulation 19. http://www.thesundaytimes.co.uk/sto/news/uk_news/Health/ and paediatric attention deficit hyperactivity disorder: a family risk article1615092.ece analysis. Psychological Medicine 2012;42:639–646. doi:10.1017/ 20. Vogt C & Shameli A. Assessments for attention-deficit hyperactivity S0033291711001644 disorder: 3. Lugo-Candelas L, Posner J.Collective analytics: advancing the use of objective measurements. The Psychiatrist 2011;35:380–383. neuroscience of ADHD. The Lancet. Psychiatry.Vol4,No. 4 p266-268 doi:10.1192/pb.bp.110.032144 April 2017. Doi:http://dx.doi/10.1016/s2215-0366(17)30056-1 21. Hall, C, Valentine A, Groom, M.,Walker,G, Sayal,K. Daley, D.Hollis 4. Martine Hoogman et al: Subcortical brain volume differences in C,2015.The clinical utility of the continuous performance test and participants with attention deficit hyperactivity disorder in children and objective measures of activity for diagnosing and monitoring ADHD adults: a cross-sectional mega-analysis. The Lancet Psychiatry, 2017; in children: a systematic review EUROPEAN CHILD & ADOLESCENT DOI: 10.1016/S2215-0366(17)30049-4 PSYCHIATRY.1-23. 5. Antshel, K. M., Zhang-James, Y., Wagner, K. E., Ledesma, A., & 22. Morales E1, Julvez J, Torrent M, Ballester F, Rodríguez-Bernal CL, Faraone, S. V. (2016). An update on the comorbidity of ADHD and ASD: Andiarena A, Vegas O, Castilla AM, Rodriguez-Dehli C, Tardón A, Sunyer A focus on clinical management. Expert Review of Neurotherapeutics, J. Vitamin D in Pregnancy and Attention Deficit Hyperactivity Disorder- 16(3), 279-293. DOI: 10.1586/14737175.2016.1146591 like Symptoms in Childhood. 6. Reiersen A., Constantino J., Volk H., and Todd R. 2007 Autistic traits Epidemiology. 2015 Jul;26(4):458-65. doi: 10.1097/ in a population-based ADHD twin sample. Journal of Child Psychology EDE.0000000000000292. and Psychiatry 48(5) 464-472 23. http://health.usnews.com/health-news/mews/articles/2013/12/02/ 7. Pauc, R. Comorbidity of dyslexia, dyspraxia, attention deficit disorder low-iron-in-brain-a-sign-of-adhd (ADD), attention deficit hyperactive disorder (ADHD), obsessive 24. Shahin Akhondzadeh, Mohammad-Reza Mohammadi, Mojgan compulsive disorder (OCD) and Tourette's syndrome in children: a KhademiBMC . Zinc sulphate as an adjunct to methylphenidate for prospective epidemiological study. URL http://dx.doi.org/10.1016/j. the treatment of attention deficit hyperactivity disorder in children: A clch.2005.09.007 Journal Clin Chiropr. 2005 Dec;8(4):189-198 double blind and randomized trial [ISRCTN64132371] Psychiatry 2004, 8. GermanòDivision of Child Neurology and Psychiatry Pediatric 4:8 - Upon publication this article will be freely available according to Department of Policlinico G. Martino , University of Messina , Gazzi- BMC Psychiatry's Open Access policy at http://www.biomedcentral. Messina, Italy , E; Antonella Gagliano, A. Division of Child Neurology com/1471-244X/4/8/ and Psychiatry Pediatric Department of Policlinico G. Martino , 25. Ettinger AB, Ottman R, Lipton RB, et al. Attention-deficit/ University of Messina , Gazzi-Messina, Italy &Curatolo, P Pediatric hyperactivity disorder symptoms in adults with self-reported epilepsy: Neurology Unit, Tor Vergata, University of Rome, Department of Results from a national epidemiologic survey of epilepsy. Epilepsia. Neuroscience , Roma, Italy Comorbidity of ADHD and Dyslexia. 2015;56:218-224. Abstract Pages 475-493 | Received 09 Nov 2008, Accepted 11 Aug 2009, 26. Lyall K, Pauls DL, Santangelo S et al. Fertility therapies, infertility, Published online: 16 Aug 2010. Download citation http://dx.doi. and autism spectrum disorders in the Nurses’ Health Study II. org/10.1080/87565641.2010.494748Pages 475-493Received 09 Nov 2008 Paediatric and Perinatal Epidemiology 2012;26:361–372. doi:10.1111/ 9. Accepted 11 Aug 2009 j.1365-3016.2012.01294.x Published online: 16 Aug 2010 27. Mikkelsen, S. Olson, J.Bech, B. Obel, C. 2016 Parental age and Milberger S, Biederman J, Faraone SV, Murphy J, Tsuang MT. Attention attention-deficit/hyperactivity disorder (ADHD) Jørn Olsen2Department deficit hyperactivity disorder and comorbid disorders: issues of of Clinical Medicine, Clinical Epidemiolgy, Aarhus University, Aarhus, overlapping symptoms. Am J Psychiatry. 1995;152:1793-1799. Denmark, 3Department of Epidemiology, Fielding School of Public 10. Lahey, B. "Children with ADHD at increased risk for Health, University of California, Los Angeles, CA, USA, depression and suicidal thoughts as adolescents." ScienceDaily. Search for other works by this author on: ScienceDaily, 4 October 2010.
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CLINICAL NEGLIGENCE
SAFETY FIRST Dr John R Payne, Consultant Cardiologist, Scottish Patient Safety Programme Fellow and Physician Executive, Scotland, InterSystems, talks about the importance of tackling clinical safety head-on.
HOW DO YOU DEFINE measured and quantified. Data in supported prescription system To improve hospital and patient SAFETY IN A HOSPITAL? a digital format can be sliced and within an EPR where no safety, it is important to have an I believe safety in a hospital refers diced easily and, therefore, there handwriting is required. open culture, not a culture of to preventing harm to patients, are many ways in which EPRs can blame. An open culture allows staff with harm including adverse events help to measure processes and APART FROM THE OBVIOUS to report errors without the worry such as death or complications. harm reliably. BENEFITS TO THE that they will be blamed. A blame If we can say in hindsight that PATIENT, ARE THERE ANY culture results in errors not being we could have done better, it is CAN YOU GIVE ME OTHER BENEFITS TO THE reported and effectively being a case of preventable harm. We EXAMPLES OF COMMON IMPROVEMENTS IN SAFETY? ‘buried’. continuously need to challenge MISTAKES OCCURRING IN Improving safety in healthcare In my view, the safest hospitals the level of preventable harm by HOSPITALS? has the potential to reduce the are those that publish the level of implementing effective systems and Errors in prescribing medication overall financial cost. For example, harm patients have experienced. processes to reduce it. are a common source of harm. improvements in safety can reduce Salford Royal NHS Foundation A US study conducted several the risk of complications in a Trust and several other healthcare HOW DO ELECTRONIC years ago found that 50,000 to hospital, reducing the need for organisations have made their PATIENT RECORDS (EPRS) 100,000 deaths annually are due to further treatment (e.g., antibiotics hospitals safer by publishing the MAKE HOSPITALS SAFER preventable medical errors. These for a post-operative wound amount of harm that their patients PLACES? include errors in the prescription infection) and the length of stay. are experiencing. Recognising any Kaiser Permanente’s former CEO, process, such as giving the wrong harm that is occurring in a hospital George C Halvorson, describes one drug or not taking into account HOW DO YOU MEASURE is the first step in reducing it. of the crucial benefits of an EPR by possible drug interactions. CHANGES IN A HOSPITAL’S Better safety is about learning saying that introducing an EPR is A simple example is a SAFETY LEVEL? from errors and embracing these as the single most important step in hospitalised patient who receives The standardised mortality rate an opportunity to improve. improving safety. You cannot make Insulin; it is still common corrected for age and comorbidity For more information, visit something better if you cannot practice to hand write on paper can be used as a measure of harm www.intersystems.com. measure it; measuring the amount the prescription of drugs, such as and patient safety. In addition, of harm in a hospital is the first Insulin. Omitting or adding a zero measuring the compliance to step in improving safety. for the dosage of Insulin can be standardised safety practices such For example, if you need to lethal (e.g., 10 units instead of 100 as handwashing, safety briefs etc. Acknowledgement lose weight, the first step you must units). can also be used to assess the level This article first appeared take is to regularly weigh yourself. Handwritten prescriptions are of safety of a hospital. in HealthTech Wire. Halvorson argues that paper prone to errors and increase the records bury mistakes and errors likelihood of harm occurring. A HOW ARE ERRORS USUALLY whereas an EPR allows these to be safer alternative is an electronically DEALT WITH IN HOSPITALS?
SPR | June 2017 | 21 WWW.SCOTHEALTHCARE.COM
CLINICAL NEGLIGENCE
Dr Edward Farnan, Medico-Legal Adviser at the Medical Defence Union, explores a few of BETTER SAFE the confidentiality risks which can scupper healthcare professionals, and shares how the THAN SORRY obstacles can be minimised.
email. Although convenient, others being able to view the screen THE MDU it’s risky because it is easy to from the side. accidentally send information to Also, make staff aware that their ADVISES HEALTH the wrong person, or to share it conversations may be overheard by PROFESSIONALS DO with more people than intended. patients in the waiting area. and For example, the Information staff should always be mindful of THE FOLLOWING TO Commissioner fined an NHS being discrete and not discussing PROTECT PATIENTS’ organisation £70,000 after a confidential or identifying consultant’s letter was emailed information within earshot of CONFIDENTIALITY: Dr Edward Farman to the wrong patient who had a others. similar name to the patient who should have received the email. Additionally, you should be • Fully acquaint yourself and your advice Confidentiality is an essential part careful not to send an email to colleagues with up-to-date legal • Prevent unauthorised access to of a trusting relationship between a group of patients using the requirements and GMC and NHS practice computers, for example, a doctor and patient. However, ‘to’ or ‘CC’ function instead of guidance on confidentiality, as well by using password protection there are a number of risks to the ‘BCC’ function. To do this as any local policies and providing members of staff, be aware of when protecting breaches patient confidentiality • Nominate a person to including locums, with unique patients’ confidentiality which because the recipients can see each be responsible for practices passwords. Always log out when have only increased as information other’s email addresses, it reveals and procedures for handling away from the computer, even for moves from paper to being stored who is on the mailing list, and short periods depending on the content of the confidential data digitally. • Ensure that paper records are email, it can also reveal the service • Report any loss of data So, what steps can you in locked cabinets when not in being offered to that patient. straightaway to the nominated implement to reduce these risks use. Both paper and computer It’s important to take extra person in your practice, so that and protect patients? records should only be accessible care when sending emails to action can be taken to prevent to members of the practice who are TECHNOLOGY prevent these easy mistakes from further breaches and the authorised to do so happening. Take your time, avoid information commissioner can be Under the 1998 Data Protection • Act, it’s your responsibility to using ‘auto select’ functions where informed, if appropriate Ensure that paper records and ensure that patient information it could be easy to click the wrong • Train all staff to keep computer screens cannot be seen is held securely and protected address, and always review the information confidential and by other patients from unauthorised or unlawful email before pressing send. reinforce the message regularly • Do not store patient data on processing. It might be a good • Write a confidentiality clause your own home computer, laptop, idea to seek the advice from an IT THE PRACTICE / CLINIC into contracts of employment and tablet, or other mobile device specialist on the best way to ensure There are many changes that can ensure the team are aware of the • Do not send information by the security of patients’ digital be made to your practice or clinic need not to discuss patients or email unless you can be sure of the records. which can help reduce the risk of their care on social media sites recipient’s identity and that their confidential patient information In reality, no system will ever • Keep discussion about the system is secure being inadvertently shared in the be 100 per cent secure, but if there clinical management of patients • Check the identity of telephone reception and waiting area. does happen to be an unauthorised private and out of earshot of the callers asking for information All computers at reception disclosure of information, you public about a patient, if necessary by will need to be able to justify the should be facing away from the • Have an information security calling them back via directory steps you have taken to prevent the counter so patients and other policy in place and ensure that all enquiries confidentiality breach. Your Trust visitors attending the practice are staff are aware of it • Ensure that patients’ details or CCG Information Governance not able to see any information on are up-to-date before sending lead may be able to assist in this. the screen. You could also consider • Take professional advice before information to their home address Some of the most significant purchasing privacy filters for the connecting your computer to a confidentiality breaches involve computer screens, which prevent network and keep a record of the
22 | SPR | June 2017 WWW.SCOTHEALTHCARE.COM
SPR | May 2017 | 23 WWW.SCOTHEALTHCARE.COM
SUMMER SPECIAL INHALER TECHNIQUE: MAKE NO MISTAKE With it being the prime season for foreign adventures, for many asthmatic sufferers, confusion as to how to best manage their condition is a major cause for concern. It’s easy to see why – given that a recent International CRITIKAL Study shed a startling light on the reality of poor inhaler technique. SPR talks to Professor David Price, Chair of Primary Care Respiratory Medicine at the University of Aberdeen, Director of the Observational and Pragmatic Research Institute, and ex- Chairman of the Respiratory Effectiveness Group, about the findings, and how these critical errors can be addressed.
they are. You can potentially make need to do something about this. up to 20 errors with each inhaler, One is the effects on people and it’s very hard for clinicians to with asthma – their lifestyle is focus on all 20. limited, and they’re also more So, the aim of this was to look likely to have asthma attacks. It also at these and to understand which leads to a bigger problem in that areas are the most important. if patients aren’t seeing the benefit What we found with the of their treatment, they may stop classical ‘press and breathe’ inhaler taking it. was patients failing to empty the The other thing is that one lungs – they breathed out before of the biggest healthcare spends they breathed in – and then in any setting today is asthma pressing their inhaler before they and COPD and inhalers, and if started breathing in. patients inhale badly, they might With dry-powder inhalers, the end up taking twice as much drug simplest error was failure again to to get the same effect which can empty the lungs first, and then not lead to waste. breathing in hard and fast. Effective use of inhalers This tells us that doctors, is probably one of the most Professor David Price pharmacists, and patients need to important interventions we can focus on these particular problems, make in healthcare. CAN YOU TELL US ABOUT Immunology: In Practice examined as well as their general education THE LATEST FINDINGS for the first time which errors of inhalers. WHY ARE PATIENTS NOT RELATING TO INHALER people make with their inhalers, BEING SUFFICIENTLY ERRORS AND POORER and most importantly, the impact WHAT ARE THE WIDER EDUCATED? ASTHMA OUTCOMES IN of this on their asthma control. SYSTEMATIC IMPLICATIONS There’s obviously a challenge PATIENTS? Previous work has shown that OF FAILURE TO UTILISE in finding time for education – The new study published in the errors are impossible to know – no INHALER DEVICES certainly in some countries it’s very Journal of Allergy and Clinical one has really worked out what CORRECTLY? hard to set up routine care services There are several reasons why we in a way that supports that. It is,
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SUMMER SPECIAL
however, important that patients patients will have a device which – such as a light which tells them if direction. have proper time to be trained – at has a particular series of issues, they’re using it incorrectly. We need to ensure that patients least once a year. and then another device which The other big thing is that we know exactly how to use them. Beyond that, the problem has another set of issues. It’s very must educate and try and find the is that healthcare professionals important that we encourage device that’s easiest for that patient. WHAT ISSUES COME themselves don’t necessarily know consistent use, rather than employ What I always say to healthcare INTO PLAY WHEN enough about how to use the two or three different inhalers. professionals is, ‘Stop trying to fit ASTHMATIC PATIENTS ARE inhalers, so we need to ensure that The second thing is that we the patient to the device or the TRAVELLING? they’re educated. This study was need to make sure that we give drug – fit the device and drug to The most important thing is to about saying that there are many them the device which is easiest the patient and their instinctive remind patients not to forget their things that we need to address for them to use – and certainly way of using it.’ inhalers! The patient should try about inhalers, but let’s focus on one of the things that is happening to have an action plan from their the most important areas, rather today is that we’re doing quite well DO YOU THINK THAT doctor and remember to bring it than every single thing. Yes, it’s with innovation. But saying that, PACKAGING / LABELS with them, and make sure that they important to take the cap off the we should still be making sure that REPRESENT A MAJOR ROLE? know and understand what the inhaler, but actually only two they can use that one adequately. Unfortunately, because of instructions are. If they don’t have people in 5,000 in the study forgot What we have seen is that regulations, we end up with an action plan, and they’ve had to. metered dose inhalers have packages which, although full of previous attacks from their asthma, become more advanced; they come information, are actually of little it’s really important for them WHAT ADVICE SHOULD BE out slower and gentler, and are use to the patient. I think it’s to talk to their asthma nurse or TAKEN ON-BOARD WHEN more tolerant of people inhaling important for the regulator to be doctor about what they should do HELPING THE VULNERABLE incorrectly. thinking about how we can make and bring if they get into trouble. PORTION OF PATIENTS Also, we have inhalers with information that’s genuinely useful They sometimes need to think IMPROVE THEIR ASTHMA smaller spaces for people who for the patient. about where they’re going and MANAGEMENT? can’t co-ordinate their pressing Very, very simple packaging consider their circumstances, There are several measures we can and breathing, and we have and instructions are important. and to make sure that their travel carry out to make it easier. One of new inhalers coming out that Sometimes things on the inhalers insurance is up-to-date. the things that we’ve found from will actually overcome that co- themselves can help – such as an our research is that we should try ordination problem. There are also arrow showing that an inhaler to keep devices consistent. Many some inhalers which give feedback needs to be pointed in a certain
SPR | June 2017 | 25 Designed to deliver.
• Ready in one flip of the cover • For severe asthma and COPD*1 • Provides cost-savings vs. Seretide® (salmeterol/fluticasone) Accuhaler® 50/500 mcg2
*Aerivio Spiromax® is licensed for use in adults aged 18 years and over and is available in one strength of 50/500 mcg.1
Please refer to the Summary of Product should be reviewed and the dose of inhaled corticosteroid predisposed to low levels of serum potassium. Paradoxical diuretics. Use with other adrenergic-containing medicinal Characteristics (SmPC) for full details of titrated downwards as appropriate to maintain disease bronchospasm may occur. In such patients treatment should products can have a potentially additive effect. Avoid use with Prescribing Information. control. COPD Adults: One inhalation twice daily. Elderly: No be discontinued and a rapid-acting bronchodilator treatment ritonavir due to expected marked increase in fl uticasone dose adjustment required. Renal impairment: No dose initiated immediately. Systemic effects may occur, particularly propionate plasma levels. Concomitant treatment with Aerivio® Spiromax® (salmeterol/fluticasone) adjustment required. Hepatic impairment: No data. at high doses prescribed for long periods. It is important that ketoconazole or other potent CYP3A inhibitors such as 50mcg/500mcg inhalation powder Abbreviated Prescribing Contraindications: Hypersensitivity to the active the patient is reviewed regularly and dose of inhaled itraconazole, and telithromycin should also be avoided. Information substances or to any of the excipients. Precautions and corticosteroid is reduced to lowest effective dose. Prolonged Caution is recommended with moderate CYP3A inhibitors Presentation: Each delivered dose contains 45 micrograms warnings: Not to be used to treat acute asthma symptoms treatment with high doses of inhaled corticosteroids may such as erythromycin and long term treatment should be of salmeterol (as salmeterol xinafoate) and 465 micrograms for which a fast and short-acting bronchodilator is required. result in adrenal suppression and acute adrenal crisis. avoided. Pregnancy and lactation: Not recommended. of fl uticasone propionate. Each metered dose contains 50 Patients should not be initiated on Aerivio Spiromax during an Additional systemic corticosteroid cover should be considered Effects on ability to drive and use machines: No or micrograms of salmeterol (as salmeterol xinafoate) and 500 exacerbation, or if they have signifi cantly worsening or during periods of stress or elective surgery. Patients negligible infl uence on the ability to drive and use machines. micrograms of fluticasone propionate. Indications: acutely deteriorating asthma. Serious asthma-related adverse transferring from oral steroids may remain at risk of impaired Adverse reactions: Paradoxical bronchospasm, Treatment of patients with severe asthma where use of a events and exacerbations may occur. Patients should continue adrenal reserve. Adrenocortical function should be regularly anaphylactic reactions including anaphylactic shock. combination product (inhaled corticosteroid and long-acting treatment but seek medical advice if asthma symptoms monitored in such patients. COPD patients should be Pneumonia (in COPD patients) Very Common: Headache,
β2 agonist) is appropriate such as: patients not adequately remain uncontrolled or worsen after initiation of treatment. monitored for possible development of pneumonia as clinical nasopharyngitis. Common: Candidiasis of mouth and throat, controlled on a lower strength corticosteroid combination Patients who have an increased requirement for use of features of such infections overlap with symptoms of COPD bronchitis, hypokalaemia, throat irritation, hoarseness, product or patients already controlled on a high dose inhaled reliever medication, or decreased response to reliever exacerbations. In COPD patients experiencing exacerbations, dysphonia, sinusitis, contusions, muscle cramps, traumatic
corticosteroid and long-acting β2 agonist. Aerivio Spiromax is medication should be reviewed. Patients who experience treatment with systemic corticosteroids is typically indicated. fractures, arthralgia, myalgia. Consult the Summary of indicated for the symptomatic treatment of patients with sudden and progressive deterioration in control of their Patients should seek medical attention if symptoms Product Characteristics in relation to other side effects.
COPD, with a FEV1 <60% predicted normal (pre- asthma should undergo urgent medical assessment and deteriorate with Aerivio Spiromax treatment. Discontinuation Overdose: An overdose of salmeterol may lead to: bronchodilator) and a history of repeated exacerbations, who increase in corticosteroid therapy should be considered. Once of therapy in COPD patients may be associated with dizziness, increases in systolic blood pressure, tremor, have signifi cant symptoms despite regular bronchodilator asthma symptoms are controlled consideration may be given symptomatic decompensation and such patients should be headache and tachycardia. Hypokalaemia can occur and therapy. Dosage and administration: Not for use in to gradually reduce the dose of the inhaled corticosteroid. monitored. To minimise risk of oropharyngeal candida therefore serum potassium levels should be monitored. children < 18 years of age. For inhalation use. Use daily. Patients should be reviewed regularly as treatment is stepped infections patients should rinse mouth with water. As with Potassium replacement should be considered. An overdose of Reassess patients regularly. Dose should be titrated to the down. Lowest dose of inhaled corticosteroid should be used. other lactose containing products, the small amounts of milk fl uticasone propionate may lead to temporary suppression of lowest dose at which effective control of symptoms is Treatment should not be stopped abruptly in patients with proteins present may cause allergic reactions. Interactions: adrenal function. In cases of chronic overdose adrenal reserve maintained. Asthma Adults: One inhalation twice daily. For asthma due to risk of exacerbation. Use with caution in Beta adrenergic blockers may weaken or antagonise the should be monitored until stabilised. Price: £29.97. Legal use in treatment of patients with severe asthma only. Not patients with active or quiescent pulmonary tuberculosis and effect of salmeterol. Both non-selective and selective blockers category: POM. Marketing Authorisation Number: intended for the initial management. If an individual patient fungal, viral or other infections of the airway. Use with caution should be avoided. Potentially serious hypokalaemia may EU/1/16/1122/001-2. Marketing Authorisation
requires dosage outside the recommended regimen, in patients with severe cardiovascular disorders or heart result from β2 agonist therapy. Particular caution is advised Holder: Teva Pharma B.V. Swensweg 5, 2031GA Haarlem, appropriate doses of β2 agonist and/or corticosteroid should rhythm abnormalities and in patients with diabetes mellitus, in acute severe asthma as this effect may be potentiated by The Netherlands. Job Code: UK/MED/16/0153. Date be prescribed. Once control of asthma is attained treatment thyrotoxicosis, uncorrected hypokalaemia or patients concomitant treatment with xanthine derivatives, steroids and of Preparation: November 2016.
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Teva UK Limited on 0207 540 7117 or [email protected]
References: 1. Aerivio Spiromax Summary of Product Characteristics. 2. MIMS. Available at: http://www.mims.co.uk/drugs/respiratory-system/asthma-copd/seretide-accuhaler. Last accessed: January 2017. Approval code: UK/ARO/16/0002c Teva UK Limited, Ridings Point, Whistler Drive, Castleford, West Yorkshire WF10 5HX Date of preparation: March 2017
16101VW_Aerivio_297X210_Bottle.indd 1 30/03/2017 12:22 WWW.WWW.NIHEALTHCARESCOTHEALTHCARE.COM.COM
SUMMER SPECIAL Designed to deliver. THE (NOT SO?) GREAT OUTDOORS Revelling in the sun rays at barbeques, and setting off for scenic strolls across the countryside, summer’s arrival brings with it plans galore. But there’s nothing that dashes the illusion quite like the impact of seasonal allergies, particularly hay fever. AllergyUK's Nurse Advisor, Holly Shaw, overviews the main culprits – and how the pharmacist’s role in the symptoms management process has evolved.
COMING INTO SUMMER, and some are sodium cromoglicate. As I mentioned, it’s really really comes into play. WHAT ARE THE CORE HAY For more moderate signs of important that patients’ severity FEVER TRIGGERS? hay fever, the next step is the is matched to the appropriate FOR MANY, ALLERGIES It will be very individual as to inclusion of a steroid nasal spray treatment. For example, if they TEND TO MASQUERADE which pollen or aeroallergen hay – an intranasal corticosteroid have moderate-to-severe hay fever, AS OTHER ILLNESSES. DO fever patients are allergic to, but – and the key message here for they’re not going to get the results YOU HAVE ANY ADVICE • Ready in one flip of the cover the majority of hay fever patients healthcare professionals is that they or the symptom-management if FOR HEALTHCARE • For severe asthma and COPD*1 – about 80 per cent – are affected need to be showing patients how they choose the treatment options PROFESSIONALS TO AID by grass pollen. We have crops to use that spray. We know that that we’ve talked about. THEM WITH THE DIAGNOSIS ® • Provides cost-savings vs. Seretide which come into play during medications are only effective if If something isn’t working PROCESS? (salmeterol/fluticasone) Accuhaler® 50/500 mcg2 their particular cycle too. Hay patients take them correctly. The – if they’re using a nasal spray Whatever condition a patient fever can be year-round or specific nasal sprays can be antihistamine and don’t feel like it’s effective has, there’s always an alternative depending on which pollen etc. the or steroid-based, or a combination – there could be a reason, such diagnosis, and certainly *Aerivio Spiromax® is licensed for use in adults aged 18 years person is allergic to. of the two. as it not being properly utilised. with allergies, and hay fever and over and is available in one strength of 50/500 mcg.1 As well as that, there are some Just because one antihistamine in particular, the signs and WHAT ARE THE other add-ons, like saline nasal doesn’t work, doesn’t mean to say symptoms can often be seen in RECOMMENDED PATHS OF douching – irrigating the nasal that another one might not be of other conditions, such as chronic TREATMENT? passages with a saline solution benefit. rhinitis, and the common cold. The goal is to achieve symptom may provide some benefit to those It’s important that leading control, and everyone’s symptoms with inflamed airways – and HOW IMPORTANT IS THE questions are asked to get the Please refer to the Summary of Product should be reviewed and the dose of inhaled corticosteroid predisposed to low levels of serum potassium. Paradoxical diuretics. Use with other adrenergic-containing medicinal PHARMACIST’S ROLE IN Characteristics (SmPC) for full details of titrated downwards as appropriate to maintain disease bronchospasm may occur. In such patients treatment should products can have a potentially additive effect. Avoid use with are a little bit different, with decongestants can help too. right information. Take a detailed Prescribing Information. control. COPD Adults: One inhalation twice daily. Elderly: No be discontinued and a rapid-acting bronchodilator treatment ritonavir due to expected marked increase in fl uticasone treatment being based on their TREATING ALLERGIES, allergy-focused history from the dose adjustment required. Renal impairment: No dose initiated immediately. Systemic effects may occur, particularly propionate plasma levels. Concomitant treatment with HOW CAN THIS MINIMISED AND HOW HAS THEIR Aerivio® Spiromax® (salmeterol/fluticasone) severity. patient. adjustment required. Hepatic impairment: No data. at high doses prescribed for long periods. It is important that ketoconazole or other potent CYP3A inhibitors such as 50mcg/500mcg inhalation powder Abbreviated Prescribing Mild hay fever symptoms will POLLEN EXPOSURE BE SENSE OF RESPONSIBILITY It’s also important to Contraindications: Hypersensitivity to the active the patient is reviewed regularly and dose of inhaled itraconazole, and telithromycin should also be avoided. Information ACHIEVED? ENHANCED? substances or to any of the excipients. Precautions and corticosteroid is reduced to lowest effective dose. Prolonged Caution is recommended with moderate CYP3A inhibitors be treated with a daily, non- acknowledge if it’s out of your Presentation: Each delivered dose contains 45 micrograms warnings: Not to be used to treat acute asthma symptoms treatment with high doses of inhaled corticosteroids may such as erythromycin and long term treatment should be sedating antihistamine – the key • Wear wrap-around sunglasses The pharmacist has a key role to remit and you need help. of salmeterol (as salmeterol xinafoate) and 465 micrograms for which a fast and short-acting bronchodilator is required. result in adrenal suppression and acute adrenal crisis. avoided. Pregnancy and lactation: Not recommended. message there is ‘non-sedating’. that cover the corners of the eyes to play in educating patients with of fl uticasone propionate. Each metered dose contains 50 Additional systemic corticosteroid cover should be considered Patients should not be initiated on Aerivio Spiromax during an Effects on ability to drive and use machines: No or We recommend a first- prevent the pollen from irritating regards to hay fever. What we’re HOW DO YOU FORESEE THE micrograms of salmeterol (as salmeterol xinafoate) and 500 exacerbation, or if they have signifi cantly worsening or during periods of stress or elective surgery. Patients negligible infl uence on the ability to drive and use machines. FUTURE RELATIONSHIP micrograms of fluticasone propionate. Indications: acutely deteriorating asthma. Serious asthma-related adverse transferring from oral steroids may remain at risk of impaired Adverse reactions: Paradoxical bronchospasm, generation antihistamine; there them finding is that patients who come BETWEEN ALLERGIES AND Treatment of patients with severe asthma where use of a events and exacerbations may occur. Patients should continue adrenal reserve. Adrenocortical function should be regularly anaphylactic reactions including anaphylactic shock. are many different types and the • The application of a nasal through to the AllergyUK hotline combination product (inhaled corticosteroid and long-acting treatment but seek medical advice if asthma symptoms monitored in such patients. COPD patients should be Pneumonia (in COPD patients) Very Common: Headache, pharmacist is well placed to make often don’t want to burden their THE HEALTHCARE SECTOR? β agonist) is appropriate such as: patients not adequately remain uncontrolled or worsen after initiation of treatment. monitored for possible development of pneumonia as clinical nasopharyngitis. Common: Candidiasis of mouth and throat, allergen balm is encouraged for 2 those recommendations. What GP or health professional, and Increasing public awareness of controlled on a lower strength corticosteroid combination Patients who have an increased requirement for use of features of such infections overlap with symptoms of COPD bronchitis, hypokalaemia, throat irritation, hoarseness, adults – it acts as a pollen trap we do know about the slightly pharmacists are well placed to see allergies in a responsible way product or patients already controlled on a high dose inhaled reliever medication, or decreased response to reliever exacerbations. In COPD patients experiencing exacerbations, dysphonia, sinusitis, contusions, muscle cramps, traumatic • Wash your hair and hands when corticosteroid and long-acting β agonist. Aerivio Spiromax is medication should be reviewed. Patients who experience treatment with systemic corticosteroids is typically indicated. fractures, arthralgia, myalgia. Consult the Summary of older and the second-generation patients. Patients don’t need an is important; getting out key 2 you come in from the outside – indicated for the symptomatic treatment of patients with sudden and progressive deterioration in control of their Patients should seek medical attention if symptoms Product Characteristics in relation to other side effects. of antihistamines is that they appointment – they can walk in messages for the safe management COPD, with a FEV <60% predicted normal (pre- asthma should undergo urgent medical assessment and deteriorate with Aerivio Spiromax treatment. Discontinuation Overdose: An overdose of salmeterol may lead to: rinse the pollen off because it can 1 can make people feel sleepy and and access that expert knowledge. of the symptoms. bronchodilator) and a history of repeated exacerbations, who increase in corticosteroid therapy should be considered. Once of therapy in COPD patients may be associated with dizziness, increases in systolic blood pressure, tremor, be quite sticky drowsy, so we advocate the newer They’re a really great source for There’s lots of information out have signifi cant symptoms despite regular bronchodilator asthma symptoms are controlled consideration may be given symptomatic decompensation and such patients should be headache and tachycardia. Hypokalaemia can occur and • therapy. Dosage and administration: Not for use in to gradually reduce the dose of the inhaled corticosteroid. monitored. To minimise risk of oropharyngeal candida therefore serum potassium levels should be monitored. varieties, and that means that Don’t sleep with the windows people in the community. there and we know that patients children < 18 years of age. For inhalation use. Use daily. Patients should be reviewed regularly as treatment is stepped infections patients should rinse mouth with water. As with Potassium replacement should be considered. An overdose of people can carry on with their daily open; this allows the pollen Of course, we have to be are drawn to information online Reassess patients regularly. Dose should be titrated to the down. Lowest dose of inhaled corticosteroid should be used. other lactose containing products, the small amounts of milk fl uticasone propionate may lead to temporary suppression of lives. to enter the room which is mindful that even if a patient and doing their own research, so lowest dose at which effective control of symptoms is Treatment should not be stopped abruptly in patients with proteins present may cause allergic reactions. Interactions: adrenal function. In cases of chronic overdose adrenal reserve After that hay fever mainstay, problematic if you’re breathing that does go to see their GP, the GP it’s key that they go to reliable maintained. Asthma Adults: One inhalation twice daily. For asthma due to risk of exacerbation. Use with caution in Beta adrenergic blockers may weaken or antagonise the should be monitored until stabilised. Price: £29.97. Legal in all night use in treatment of patients with severe asthma only. Not patients with active or quiescent pulmonary tuberculosis and effect of salmeterol. Both non-selective and selective blockers category: POM. Marketing Authorisation Number: we recommend that you add on has a very short timeframe with sources in order to get the correct intended for the initial management. If an individual patient fungal, viral or other infections of the airway. Use with caution should be avoided. Potentially serious hypokalaemia may EU/1/16/1122/001-2. Marketing Authorisation things for management according that patient. They may write a information and care, such as requires dosage outside the recommended regimen, in patients with severe cardiovascular disorders or heart result from β agonist therapy. Particular caution is advised Holder: Teva Pharma B.V. Swensweg 5, 2031GA Haarlem, WHAT ABOUT THE COMMON 2 to individual symptoms. For prescription for a nasal spray, but AllergyUK – we have a hotline and appropriate doses of β agonist and/or corticosteroid should rhythm abnormalities and in patients with diabetes mellitus, in acute severe asthma as this effect may be potentiated by The Netherlands. Job Code: UK/MED/16/0153. Date 2 PATIENT PERSPECTIVE THAT they may not have the time to a website with detailed factsheets be prescribed. Once control of asthma is attained treatment thyrotoxicosis, uncorrected hypokalaemia or patients concomitant treatment with xanthine derivatives, steroids and of Preparation: November 2016. example, some patients will have issues with their eyes. They may THEY SHOULD CHANGE UP show the patient how it works. which can be accessed. wish to use eye drops – some of THEIR TREATMENT OPTION That’s where the pharmacist’s role For more information, www. Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. those have antihistamines in them, TO PREVENT IT FROM in education and product choice allergyuk.org. Adverse events should also be reported to Teva UK Limited on 0207 540 7117 or [email protected] BECOMING INEFFECTIVE? SPR | June 2017 | 27 References: 1. Aerivio Spiromax Summary of Product Characteristics. 2. MIMS. Available at: http://www.mims.co.uk/drugs/respiratory-system/asthma-copd/seretide-accuhaler. Last accessed: January 2017. Approval code: UK/ARO/16/0002c Teva UK Limited, Ridings Point, Whistler Drive, Castleford, West Yorkshire WF10 5HX Date of preparation: March 2017
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SUMMER SPECIAL ON THE LOOK OUT The arrival of this time of year often elicits patient concern regarding eye-related health issues and the best course of pharmacist- recommended action. Dr Susan Blakeney, the College of Optometrists’ Clinical Adviser, offers an insight, and delves particularly into dry eye syndrome.
layer structure. might help keep tears in the eyes a chance to blink. What we know is The bottom layer that’s closest little bit longer. that if you’re staring at a screen, it to the eye is very thin and sticks You can also get some sprays can reduce the blink rate. the tears to the eye, then you’ve that are sprayed on the closed Also, if you have a portable got the watery layer which is the eye lids and help to replenish the device, then we recommend thickest layer by some margin, that oily layer on the front surface of looking down at it, rather than makes up the bulk of the tears and the tears, and that reduces the straight ahead, as when you look increases when you cry. There’s also evaporation. It could be that the down, your eyelids naturally close an oily layer and that reduces the tears aren’t of a good enough a little bit and that lubricates the evaporation of the tears, and so quality because of a condition eyes. Using a lower brightness is Dr Susan Blakeney if the tears evaporate too quickly, called blepharitis which involves suggested too, and try to avoid then they don’t do the job of inflammation of the eyelid, and it using a screen in a dark room. WHAT ARE THE MOST staying in the eyes long enough to can block the glands that produce COMMON SYMPTOMS OF DRY lubricate them. the oily layer of the tears. DO YOU HAVE ANY ADVICE EYE SYNDROME? What’s really important is FOR PROFESSIONALS It tends to cause signs of redness that if patients think that they IS THERE ANY RECENT WHEN THEY DISCUSS and soreness in and around the might have dry eye, a diagnosis is RESEARCH OR INNOVATION WITH PATIENTS HOW THEY eye, and sometimes there’s a bit necessary to find out what caused THAT WILL BE COMING INTO CAN MAINTAIN THEIR EYE of grittiness too. It can affect the it so the treatment is decided PLACE? HEALTH WHEN ON HOLIDAY? vision as if it’s very severe, then accordingly. Drop technology is constantly It’s about wearing decent quality your cornea no longer becomes evolving. The problem with drops sunglasses from a reputable smooth, and so you find that your HOW PREVALENT IS DRY can be that as soon as they’re put manufacturer with a CE mark – vision might fluctuate a little bit EYE SYNDROME? in the eye, they start washing out, they don’t have to be expensive. when you blink or might be a little It’s pretty common. It’s estimated and you really want them to stay in Also, advise them to wear a hat bit smudgy. Most of the time, it that about one in every three the eye as long as possible without with a brim. doesn’t impact the vision though – people over the age of 65 smudging the vision. They should never wear it just causes discomfort. experience some problems with dry contact lenses when they’re going eyes, and it’s also more common HOW HAVE EYE HEALTH swimming as there’s a little bug WHAT FACTORS in women. It’s less prevalent in RISKS EVOLVED OVER THE that lives in tap water and it’s CONTRIBUTE TO THE younger people. YEARS, SUCH AS EXPOSURE terrible if you get it in your eye. DEVELOPMENT OF THE TO MODERN DEVICES? Never be tempted to rinse contact SYNDROME? WHAT ARE THE When using a screen, we encourage lenses with any type of tap water. There are two main reasons for RECOMMENDED ‘visual hygiene’ which is a matter All year-round, regular eye dry eye. It can either be caused by TREATMENTS FOR THE of using your eyes effectively. We examinations are encouraged – the patient not producing enough CONDITION? suggest the ’20-20-20’ rule which at least every two years – as the tears, or they can produce enough The treatment is usually some sort means that every 20 minutes, you people who get glaucoma are often tears, but they aren’t of a good of lubricant like dry eye drops. look about 20ft away for about 20 those who haven’t got their eyes enough quality to stay in the eye Patients may also have punctal seconds. That not only relaxes the tested in ages due to quite a complicated three- plugs put in the drainage holes that eye muscles, but it also gives you a
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SUMMER SPECIAL
HITTING THE BOTTLE Appearance pressures, coupled with the social side of summer, may be encouraging the rise of a new type of eating disorder. Dr Sarah Jarvis, Medical Advisor to Drinkaware, shares why we need to especially be on the lookout for signs of ‘drunkorexia’ among female patients – in which they’re skipping meals in order to save calories to drink alcohol.
We should all be encouraging our vitamins and minerals in amounts red flags for possible alcohol patients to pay attention to the that make any significant misuse, to suggest a possible case of REFERENCES number of calories in alcoholic contribution to diets. The human ‘drunkorexia’. Women who drink drinks – in addition to helping body cannot store alcohol, and on an empty stomach may be more 1. Burke, Sloane C.; Cremeens, combat our obesity epidemic, it removing it from the system takes prone to short-term alcohol-related Jennifer; Vail-Smith, Karen; may enable many to make better priority over all other metabolic harm because of faster alcohol Woolsey, Conrad; Drunkorexia: and healthier decisions about processes (4), including nutrient absorption and higher peak blood Calorie Restriction Prior to alcohol. But there are worrying absorption and fat burning. alcohol levels, but this is not Alcohol Consumption among reports that an increasing Further clinical investigation is inevitable. There is no research College Freshman; Journal of awareness of alcohol and its needed, but dieticians are reporting evidence to suggest women with Alcohol and Drug Education, calorific content is leading to a new a link between binge drinking this combination of problems are v54 n2 p17-34 Aug 2010 phenomenon whereby people are behaviours and eating disorders, likely to be underweight, although 2. Knight and Simpson 2013, skipping meals so that they can like anorexia and bulimia: what the they may be at higher risk of Drunkorexia: an empirical binge drink without putting on media has termed ‘drunkorexia’. vitamin and mineral deficiency investigation of disordered weight. (1) No one is suggesting that than other women. eating in direct response to Reports (2) are suggesting that everyone who skips a meal now This is, of course, a particular saving calories for alcohol use some people have been known to and again so they can drink will go issue for post-menopausal women. amongst Australian female go an evening, or in some cases, on to develop an eating disorder. Passing the menopause and excess university students. Journal of a full day, without a meal so that However, a repeated pattern alcohol are both well-recognised Eating Disorders 2013 1(Suppl they can drink instead. There should be considered as a high risk factors for osteoporosis. A 1):P6 have also been reports of people risk behaviour, especially in those diet deficient in calcium because 3. Osborne, Sher, Winograd calculating how many calories are who are already vulnerable. Eating a woman has been restricting her 2011, Disordered eating in their drinks and offsetting their disorder experts also believe that calorie intake to ‘make space’ for patterns and alcohol misuse in eating accordingly. problems can arise when someone’s alcohol is a further compounding college students: evidence for Some reports from America pattern of skipping meals in order factor. “drunkorexia”?. Comprehensive (3) suggest that the phenomenon to drink leads to obsessing over As healthcare professionals, Psychiatry, 52;6;e12 Nov 2011 appears to be more prevalent food and this obsession starts to we need to maintain a high index 4. Raben et al 2003, Meals with among young, weight conscious control them. of suspicion for this problem, similar energy densities but rich women and seems to have evolved Many heavy drinkers are and be prepared to tackle the in protein, fat, carbohydrate, from a need for girls and young notoriously secretive about issue promptly but sensitively. or alcohol have different effects women in particular to meet two their alcohol intake, and women Alcohol-related harm wreaks on energy expenditure and of society’s expected norms – being in particular may feel a social enough damage without the added substrate metabolism but not on thin and being a drinker. stigma associated with alcohol complications of nutritional appetite and energy intake, Am Alcohol’s calories have no intake, particularly if they are also deficiency and possibly additional J Clin Nutr January 2003 vol. 77 nutritional value and most mothers. There may be no clear psychological disturbance. no. 1 91-100 alcoholic drinks do not have indicators, other than the standard
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SUMMER SPECIAL WEIGHING ON THE MIND
We often see with summer that the surge in temperature prompts a renewed focus on fitness and health. To tie in with this – and the revelation that less than half of obese patients are advised by their healthcare professional to lose weight – Rachel Clark, Health Promotion Manager at World Cancer Research Fund, overviews how raising the issue can yield discomfort, and shares her top tips for you how can approach this tricky territory.
While many people want to make receiving health professional advice comfortable introducing the topic they make. Health professionals changes to improve their health to lose weight. during a routine consultation if are worried that this could damage and are aware of the benefits There are many reasons why patients had come to see them the patient relationship and cause of losing weight, they may lack health professionals find it hard about something else. more harm than good. the motivation, knowledge, and to raise the issue of weight with One study participant For others, they were worried resources needed to sustain long- their patients. The fact that commented, ‘Just bringing it up, about damaging their professional term changes. society tends to view overweight how do you bring it up, when reputation and didn’t want to be Obesity is associated with a and obesity in a negative way they’ve come in about a cold? It’s seen as the ‘nagging doctor’. range of health problems and is is just one of the barriers (5), really difficult, isn’t, it because Health professionals also linked to an increased risk of 11 leaving health professionals you know we’ve all got to be very expressed concern about patients common cancers, including breast feeling uncomfortable raising politically correct (PC) and people with mental health issues and the and prostate. The NHS costs and discussing the issue of weight get very hurt even with medical fear of compromising their duty attributable to overweight and because of this stigma. terms like obesity or overweight, it of care. obesity are projected to reach £9.7 A British Medical Journal can be really challenging.’ billion by 2050, with wider costs paper explored GPs’ and nurses’ There was also uncertainty LIMITED TIME AND to society estimated to reach £49.9 perceived barriers to raising the around what language and RESOURCES TO BRING UP A billion per year. (2) topic of weight with patients (6), terminology to use, as overweight SENSITIVE TOPIC With around 62 per cent of the main barriers identified are and obese are generally seen as Lack of time was cited as a barrier, adults in the UK now overweight listed and discussed in this piece. negative terms. particularly for GPs. Both GPs or obese (3), health professionals However, those who had and nurses reported not having are being called on more and more LIMITED UNDERSTANDING received training in obesity sufficient resources or services to to ‘Make Every Contact Count’ ABOUT OBESITY CARE management did feel equipped to signpost patients to, such as referral (MECC) and use opportunistic Some health professionals felt that raise the issue and support patients options and weight management moments to raise the issue of body they lacked the knowledge and to lose weight. information. If the resources were weight with patients. Despite skills needed to support patients to not available to support patients, strong calls to action, patient lose weight. They expressed beliefs CONCERN ABOUT NEGATIVE then raising the issue seemed surveys suggest that less than half that there was no standardised CONSEQUENCES pointless. of obese patients are advised by approach to raising the issue with As mentioned, there is a stigma their physician to lose weight. (4) patients and reported that they surrounding overweight and OWN WEIGHT STATUS AS A In fact, a survey of 810 rely on various resources including obesity. Some health professionals BARRIER overweight and obese patients personal stories and media sources. worry that raising the issue could The majority of health found that only 17 per cent of They also expressed concerns be interpreted as a comment professionals in this study reported overweight and 43 per cent of about the appropriateness of about someone’s appearance or a that their own weight, and obese respondents recalled ever raising the issue. They didn't feel judgment about the life choices personal beliefs about weight loss,
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SUMMER SPECIAL could act as barriers. There are several ways that professionals. It is therefore important that brief Some overweight practitioners health professionals can overcome interventions are patient-centred. felt that they could empathise these barriers, such as increasing HOW TO RAISE THE ISSUE (8) more with overweight patients, their knowledge of obesity care It’s important to acknowledge whereas others felt that it would be and local pathways. The National the complexity of the condition PATIENT-CENTRED a hindrance. Institute for Health and Care – overweight and obese APPROACH A study participant explained, Excellence (NICE) provides patients often have a fear of, and These are some of the skills needed ‘Being a rather large person myself, guidance on obesity prevention unfortunately experience of, being for a client-centred approach: I find it sometimes a little bit and management, which can be labeled as ‘greedy’ or ‘lazy’. • Active listening sensitive to say, ‘You really ought to found on their website. Acknowledging the extent of • Good non-verbal lose some weight’, when, actually, Health professionals can also the problem and emphasising the communication, such as eye the same person could be saying it talk to their local authorities about many and varied factors which contact and body language back to me.’ the weight management services contribute to obesity can help • Health professionals with a available in their area and how covey that this is not a condition Reflection – the ability to reflect weight in the healthy range also they can signpost to them. Having which should be blamed solely on words and feelings and to clarify thought that their weight could act a list of local resources, as well as ‘weak-willed’ individuals. that you have understood them as a barrier because patients might evidence-based printed and online One of the things health correctly perceive a lack of empathy. tools to refer patients to is also professionals can do is link a • The ability to build rapport This issue is also complex useful. patient’s weight to an existing from a patient perspective. Some World Cancer Research Fund medical concern. This will help Find out more about the people may prefer to talk about has lots of free information provide a context for why the issue patient-entered approach by their weight with an overweight available to health professionals is being raised. Listening carefully listening to World Cancer professional to feel better to help them break down barriers to patient responses can provide Research Fund’s webinar at www. understood. Others might feel with their patients. some insight into their self- wcrf-uk.org/uk/here-help/health- awkward bringing up the subject Training on how to raise the recognition, and motivation for professionals/webinar-obesity- with someone who is overweight issue in a non-judgmental way any treatment suggestions. and-cancer. because of the negative stigma will help address fears about the If patients are interested in attached to it. potential negative consequences. losing weight, health professionals TOOLS TO SUPPORT YOUR There are a variety of training should offer them practical advice WORK ADDRESSING THE BARRIERS courses available. Health and support. Having a list of World Cancer Research Fund The positive thing is that there is Education England lists some available options in the area is provides health professionals with evidence that health professional good options on their new MECC helpful. free training and resources to help advice to lose weight increases platform. What we do know is that them talk to patients about how people’s motivation to lose weight Motivational interviewing, a patients actually do want to be lifestyle choices affect cancer risk. and change their behavior. (7) It is method that works on facilitating heard and understood, so that they For more information about therefore important to address the and engaging motivation within a can have the opportunity to tell the free cancer prevention package, barriers that health professionals client in order to change behavior, their story. They also want to gain visit www.wcrf-uk.org/uk/here- face. may be of interest to some health information and feel able to cope. help/health-professionals.
REFERENCES DID YOU KNOW?
1. www.yougov.co.uk/news/2014/01/03/new-years-resolutions- According to a study published in the Obesity journal late last year, britain-looks-health-2014/ children are at greater risk of gaining unhealthy amounts of weight 2. www.noo.org.uk/NOO_about_obesity during summer vacation than during the school year. 3. www.noo.org.uk/NOO_about_obesity/adult_obesity/UK_ Researchers in America studied more than 18,000 kindergartners prevalence_and_trends over two years and found that obesity increased only during the two 4. www.bmjopen.bmj.com/content/3/11/e003693.full summer vacations, and not at all during the school years. 5. www.britishjournalofobesity.co.uk/journal/2015-1-1-14 6. www.bmjopen.bmj.com/content/5/8/e008546.full 7. www.ncbi.nlm.nih.gov/pmc/articles/PMC4264677/ 8. Moira Stewart. Patient-centered Medicine: Transforming the Clinical Method. Second Edition. 2003
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ME-CFS A Miracle Drug for ME-CFS? For years, confusion and disagreement have permeated the nature and treatment of ME-CFS. Now, Jan Russell, Chair of WAMES, shares the latest research and need-to-know guidance on effective treatments for the condition.
In 2009 the news of a drug potential responders. Norwegian researchers and She experienced significant relief which could cure people with As a number of people research charity Invest in ME [5] from ME-CFS symptoms as well. ME spread like wildfire through didn’t respond to rituximab, should result in a trial taking place Imdur reduces blood pressure the international ME-CFS the Norwegian researchers set based in Norwich [6] with support by dilating the blood vessels, thus community. Oncology researchers up a trial of the chemotherapy from the ME Association. [7] letting the blood flow more freely. in Norway had stumbled across a and immune depressant drug Fluge and Mella began to surprisingly positive response in Cyclophosphamide with 29 of the COULD THERE explore the dilation of blood three people with ME-CFS, who non-responders. [4] The results vessels, and in 2014 applied were being treated for cancers of should be published during this BE OTHER for a patent for a Nitros Oxide the white blood system with the year. Another immune suppressant, donor (relatively high doses of monoclonal antibody rituximab etanercept, was not found to be ROUTES TO L-Arginine 5 g twice daily and against the protein CD20, a drug helpful and the pilot study was RECOVERY? L-Citrulline 200 mg twice daily) also used to treat the autoimmune abandoned. The researchers believe in combination with a B-cell disorders MS, SLE and RA [1]. their findings point to ME-CFS Research showing immune depleting agent such as rituximab The researchers Fluge and Mella being an autoimmune disorder. dysfunction, central nervous to treat ME-CFS and ran a trial were intrigued and followed up in Some patients were anxious to system dysfunction, autonomic alongside the rituximab study. [8] 2011 with an RCT pilot trial of 30 try the drug and dismissed the system dysfunction and hormonal patients [2], two thirds of whom warnings from doctors about abnormalities have all led to small- METABOLOMICS showed significant improvements serious side-effects and the need scale trials of drugs. A growing area of research hailed across almost all symptoms. for it to be administered by an Most recently, attention has as a likely source of treatment A larger study began in 2015 expert. Anecdotal reports suggest been focussed on the following is that of metabolomics, with 152 patients, hoping for that people who travelled to areas: where sophisticated answers to questions about the America to take the drug outside analytical technologies and percentage of people who respond clinical trials have not experienced VASODILATION statistical methods of data to rituximab, and whether the good results. Unfortunately, too Another serendipitous event interpretation are being used to response is always delayed and many people with ME have such a occurred when one of Fluge identify and quantify cellular temporary. [3] The results are due poor quality of life they feel they and Mella’s original lymphoma metabolites – the small molecules out in 2018 and the researchers have little to lose, and are prepared patients with ME-CFS, whose within cells, biofluids, tissues, or report that so far a subset of to take the chance. symptoms returned after the course organisms. participants are responding. Other patients are more of Rituximab ended, received The work over the last few years North American researchers wary and have been working isosorbide mononitrate (Imdur®) by Bob Naviaux of UCSD [9], and clinicians have joined the towards UK trials for rituximab. for transient ischemic heart pain. Ron Davis of the Open Medicine search for a biomarker to detect A collaboration between the 32 | SPR | June 2017 WWW.SCOTHEALTHCARE.COM
Foundation [10], Neil McGregor and metformin can do the same.) from around the world, and there to improve the evidence base, and Chris Armstrong et. al. in However, they acknowledge were many failed Freedom of but recognised that the lack of Australia [11, 12], Maureen that some patients do improve Information requests made to the evidence did not stop patients Hanson at Cornell University [13], while on drugs that are considered authors for data to be released, so using a large number and variety and Fluge and Mella in Norway to be inhibitors of mitochondrial that it could be checked by other of medications, obtaining [14], all suggest that cellular energy function. This could be because researchers. Eventually in 2015 them online or from overseas if metabolism is abnormal and is most drugs have metabolic effects articles by an American public necessary. likely to be at the heart of the key beyond their primary action. health professor, David Tuller, ME-CFS symptoms of post- challenged the validity of the MEDICATIONS exertional malaise and physical and UK EVIDENCE- research on many fronts and that PRESCRIBED BY ME- mental fatigue. kicked off a renewed campaign, CFS CLINICIANS The discoveries have been BASED [21] leading to the Information described as a ‘hypometabolic Commissioner ordering the release It would be easy to conclude that state’ ‘low-level chronic starvation TREATMENTS of data. [22] without a strong research evidence of mitochondria’ and something FOR ME-CFS? The data was re-analysed and a base for ME-CFS treatments, it making the body switch from paper published in early 2017 [23], is not possible for the medical profession to safely advise patients burning sugar to a far less efficient NICE revealed that – when recovery was way of making energy. Similar to defined according to the original with ME-CFS about treatments. In 2007, the NICE guideline for what’s found in another severely trial protocol – recovery rates in However, research is CFS/ME CG53 found that there fatiguing disease called biliary the CBT and GET groups were continually revealing clues to the was no known pharmacological cirrhosis, Fluge and Mella believe low and not significantly higher nature of ME, which is helping treatment or cure, but that that autoantibodies are attacking than in the control group (four clinicians to select drugs for a symptoms of CFS/ME should the metabolic pathways that per cent, seven per cent, and three particular patient, and use them be managed as in usual clinical regulate energy production in the per cent respectively). The authors off-label, to relieve symptoms or practice, ‘except where it was body. concluded, ‘The claim that patients groups of symptoms. inappropriate for people with McGregor and Armstrong can recover as a result of CBT An American study published CFS/ME’ e.g. if they were ‘more suggest that the treatment and GET is not justified by the in January 2016 gave the results of intolerant of drug treatment protocols similar to those used data, and is highly misleading to a survey which asked a group of 11 and have more severe adverse / to safely bring people out of clinicians and patients considering international expert clinicians in side-effects’. Then the dose may be starvation might be able to help these treatments.’ The PACE trial ME/CFS to rate medications for increased gradually, in agreement in ME/CFS. Those protocols authors continue to support their 18 symptoms and list symptom with the patient. It also specifies involve providing combinations of findings and some continue to groups that they considered as that specific drug treatment for metabolites, vitamins, and minerals carry out research into the use interrelated and representative of children and young people with and then monitoring their of CBT and GET for CFS/ME, different ME/CFS phenotypes. CFS/ME should be started by a metabolomics over time to see the this time with children i.e. the Citalopram was reported to be paediatrician. effect they’ve had. [15] FITNET trial [24]. more than moderately effective for The treatments that were Naviaux is testing a possible The implications of this for depression / anxiety and similarly considered to have a stronger biomarker and hopes to start small doctors is that many patients will fentanyl for muscle aches and evidence base for improving clinical trials in 2017 of nutritional refuse to be referred to a service arthralgias. Low-dose stimulants symptoms were Cognitive interventions. offering CBT and GET, and and low-dose bupriopion were Behavioural Therapy (CBT) and will be looking for medical and viewed as effective for fatigue by Graded Exercise Therapy (GET), management advice from primary five respondents. RINTATOLIMOD with the proviso that no single After years of struggles to get care. strategy will be successful for all Regarding ME/CFS phenotypes, rintatolimod (Ampligen) approved patients, or during all stages of the respondents suggested that: for ME-CFS in America, it was condition (1.6.2.2). [18] so they GUIDANCE FOR (a) Sleep improvement can Argentina that became the first recommended that ‘it should be ameliorate post-exertional malaise, country to approve the drug in DOCTORS? offered to people with mild or pain and headache, August 2016, for use with the moderate CFS/ME and provided (b) Treatment of orthostatic severely affected. Ampligen is an to those who choose these SYSTEMATIC REVIEW intolerance can improve fatigue, immunomodulator that targets approaches’. OF DRUG STUDIES light headedness, mental fog, a portion of the immune system NICE have now commenced A 2016 systematic review of headache and pain, while that fights viruses. Extensive trials a ‘formal check of the need to studies of drug therapies for ME- (c) Epigastric pain, reflux, and early showed significant increases in update the clinical guideline CFS [25] found that evidence was satiety may suggest nutritional function, quality of life, exercise CG53’ based on three American limited and conflicting and that no hypersensitivity tolerance and a reduction in reports published in 2016 and the universal pharmaceutical treatment [26] use of drugs for symptom relief. new information about the 2011 could be recommended. 10 Like other drugs for people with PACE trial. [19] medications were shown to be only ME-CFS, Ampligen doesn’t slightly to moderately effective: MORE work for everyone, but markers PACE TRIAL Hydrocortisone; rituximab; NAD; INFORMATION to determine who will benefit are In 2011, the PACE trial results Nefazodone; Moclobemide; IVIG; thought to be under development. began to be published [20] ALCAR; Dextroamphetamine; The most up-to-date overview [16] supporting the effectiveness of Rintatolimod; and of the nature of and treatments Naviaux and Davis have CBT and GET for CFS/ME. lisdexamfetamine. for ME-CFS and from a UK cautioned that antivirals and These results were challenged by They identified a need for antibiotics can pound the clinicians, researchers and patients trials with clearly defined cohorts mitochondria. (Statins, valproate, Continued onto next page
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2016 edition of: ME/CFS/PVFS NICE DEFINITION CFS/ INTERNATIONAL an exploration of the key clinical ME CONSENSUS PRIMER issues [27] The most recent guide to DEFINITION strictly defined ME is: Myalgic MYALGIC encephalomyelitis – adult and ENCEPHALOMYELITIS paediatric: International consensus (ME) primer for medical practitioners Fatigue with all of the following (2012) [28] features: The cardinal feature of Post- The results of the 2010 ME • Exertional Neuroimmune Association survey gives the New or had a specific onset (that is, it is not lifelong) Exhaustion – PEN’-Ẹ is a patients’ point of view: Managing pathological inability to produce my ME what people with ME/ • Persistent and/or recurrent • sufficient energy on demand with CFS and their carers want from Unexplained by other prominent symptoms primarily in the UK’s health and social services. conditions the neuroimmune regions. Jan Russell [29] • Has resulted in a substantial The 2015 British Association reduction in activity level Characteristics are: ABOUT THE AUTHOR for CFS/ME’s 2015 guide • Characterised by post-exertional 1. Marked, rapid physical and / or Jan Russell is chair of WAMES gives information to support malaise and/or fatigue (typically cognitive fatigability in response (Welsh Association of ME & CFS the biopsychosocial view delayed, for example by at least to exertion, which may be minimal Support). of management, and also 24 hours, with slow recovery over such as activities of daily living She was a librarian in a Welsh includes some pharmaceutical several days) plus one or more or simple mental tasks, can be university until she developed ME recommendations: British symptoms debilitating and cause a relapse 30 years ago. Since then, she has Association for CFS/ME: therapy 2. Post-exertional symptom experienced symptoms which have and symptom management in exacerbation: e.g. acute flu-like led to a fluctuation between severe CFS/ME [30] symptoms, pain and worsening of and moderate severity. Websites which regularly post other symptoms overviews of research are ME For more information about 3. Post-exertional exhaustion may WAMES, call 029 2051 5061, Research UK [31] and Health occur immediately after activity or rising [32]. Me-pedia aims to be a visit www.wames.org.uk, or email be delayed by hours or days [email protected]. detailed online encyclopedia of all 4. Recovery period is prolonged, things ME and CFS usually taking 24 hours or longer. A relapse can last days, weeks or longer 5. Low threshold of physical and mental fatigability (lack of stamina) results in a substantial reduction in preillness activity level Plus Three neurological impairments Three immune / gastro-intestinal / genitourinary impairments One energy metabolism / ion transport impairment REFERENCES / LINKS 1. https://www.ncbi.nlm.nih.gov/pubmed/19566965 19. https://www.nice.org.uk/Guidance/cg53 2. https://www.ncbi.nlm.nih.gov/pubmed/22039471 20. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60096- 3. https://clinicaltrials.gov/ct2/show/record/ 2/abstract NCT02229942?term=fluge+rituximab&rank=1 21. http://me-pedia.org/wiki/PACE_trial 4.https://clinicaltrials.gov/ct2/show/ 22. http://informationrights.decisions.tribunals.gov.uk//DBFiles/Decision/i1854/ NCT02444091?term=cyclophosphamide+chronic+fatigue+syndrome&rank=1 Queen%20Mary%20University%20of%20London%20EA-2015-0269%20(12-8- 5. http://www.investinme.org 16).PDF 6. http://www.ukrituximabtrial.org/home.htm 23. http://www.tandfonline.com/doi 7. http://www.meassociation.org.uk abs/10.1080/21641846.2017.1259724?journalCode=rftg20 8. https://data.epo.org/publication-server/pdf-document/EP13168487NWA1. 24. http://wames.org.uk/cms-english/2016/11/crawley-study-to-compare-online- pdf?PN=EP2805730%20EP%202805730&iDocId=7868378&iepatch=.pdf cbt-activity-management-for-children/ 9. http://www.pnas.org/content/113/37/E5472.full 25. http://www.sciencedirect.com/science/article/pii/S014929181630306X 10. http://www.openmedicinefoundation.org/expanded-mecfs-metabolomics- 26. http://www.tandfonline.com/doi/ study/ abs/10.1080/21641846.2015.1126025?journalCode=rftg20 11. http://link.springer.com/article/10.1007/s11306-015-0816-5 27. Free paper copy available to NHS staff http://www.meassociation.org. 12. http://link.springer.com/article/10.1007/s11306-016-1145-z uk/2016/06/the-eight-edition-of-our-clinical-and-research-masterwork-is- 13. http://pubs.rsc.org/en/Content/ArticleLanding/2016/MB/ published-today-1-june-2016/ C6MB00600K?utm_source=feedburner&utm_medium=feed&utm_ 28. http://www.name-us.org/defintionspages/DefinitionsArticles/2012_ICC%20 campaign=Feed%3A+rss%2FMB+(RSC+-+Mol.+BioSyst.+latest+articles)#!div primer.pdf Abstract 29. http://www.meassociation.org.uk/managing-my-me-me-association-publish- 14. https://www.ncbi.nlm.nih.gov/pubmed/28018972 results-of-huge-survey-report/ 15. http://www.huffingtonpost.com.au/2017/02/02/how-gut-bacteria-is-helping- 30. https://www.bacme.info/sites/bacme.info/files/file-attachments/BACME%20 to-unpack-chronic-fatigue-syndrome/ Therapy%20%26%20Symptom%20Management%20Guide.pdf 16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4917909/ 31. http://www.meresearch.org.uk/ 17. https://www.healthrising.org/forums/resources/robert-naviauxs-q-a-for-the- 32. https://www.healthrising.org 2016-me-cfs-metabolomics-paper.382/ 33. http://me-pedia.org/wiki 18. https://www.nice.org.uk/guidance/cg53/evidence/full-guideline-196524109 WWW.SCOTHEALTHCARE.COM
SEPSIS
SEPSIS: A MATTER OF INFECT
Claiming 50,000 lives annually in the UK, and costing the NHS an estimated £2.5 billion, the risk of sepsis is fraught with danger, and warrants immediate action. So, why is it often underplayed? Dr Ron Daniels, an NHS Consultant in Intensive Care and Anaesthesia – as well as Chief Executive of the UK Sepsis Trust and the Global Sepsis Alliance – explains.
Over the last 12 years, we’ve and we’re currently trying to get moved from intensive care-focused into Northern Ireland as well. therapies to delivery of very basic therapies – and what we deliver in IS THE WIDER PUBLIC general hospitals is a package of ARENA TAKING SUFFICIENT care called the ‘sepsis six’. ACTION? That strategy is in place across It’s absolutely vital that the public the UK, as well as 22 other is made more aware. We had a countries, and the beauty of it is study across England, Wales, and that it’s really simple. Northern Ireland, where they The therapies are: looked at case reports of people 1. To give oxygen where it’s who had a hospital-based diagnosis Dr Ron Daniels appropriate. If someone’s oxygen of sepsis, and they found that in 60 saturation levels are low, we correct per cent of cases where the expert them group thought that the patient OVERALL, HAS THE THREAT impact – the risk of sepsis increases 2. To take blood culture samples to should have arrived at hospital OF SEPSIS DIMINISHED OR as we get older and we perform send it off for analysis sooner, it was because they hadn’t ESCALATED WITHIN THE UK interventions on these patients. 3. To give antibiotics which are asked for help. OVER THE PAST 10 TO 15 generally intravenous, and that’s It wasn’t because a GP or YEARS? WHY IS THIS? HOW DEADLY ARE THE something that can be achieved in paramedic had missed it; it was the We know that the incidence of CONSEQUENCES? the community person not asking for healthcare sepsis is on the rise, and that’s We know that between one-in- 4. To give intravenous fluids support. So we know that they something we’re seeing globally. four and one-in-two people with 5. To measure something in the need to be more aware, and we Over the last decade, every year it’s sepsis will die, so it’s a hugely fatal blood called lactate because that need to target at-risk groups. For been rising between eight and 13 condition, and the earlier we catch helps us to predict how serious example, children under five years per cent. it, the better chances we have of the problem is, as well as guide of age are at a much greater risk Across the UK, it affects improving the outcomes. ongoing therapy than children over five. People 260,000 every year, with at least If someone does develop sepsis, 6. To measure the urine output who have family members who 50,000 of those people dying. It’s then every hour we wait in giving By carrying out those six tasks, are older, and particularly in more common than a heart attack intravenous antibiotics, the risk of we half the risk of somebody dying. residential care homes, need to be or stroke. It’s a bigger killer than death goes up by eight per cent. focused on too. any cancer – and takes more lives DO YOU THINK THERE’S than bowel, breast, and prostate HOW HAS TREATMENT ENOUGH AWARENESS OF cancer put together. EVOLVED OVER THE YEARS? SEPSIS? Why is that? Well, it’s partly The evolution of treatment is that I think it’s gradually changing. because there is more noise about it has simplified over time. We We’ve had small pots of cash for sepsis and we’re recognising it more have a system of international a public awareness campaign frequently, therefore recording and guidelines, that have been largely in England. Obviously, with coding it more frequently. Also, drawn up by the intensive care devolution, we have to do this an ageing population has had an community. separately with each government, SPR | June 2017 | 35 WWW.SCOTHEALTHCARE.COM
CLINICAL NEGLIGENCE THE SKY’S THE LIMIT Prior to his post as an airline pilot, Captain Niall Downey qualified as a doctor from Trinity College, Dublin, in 1993, and trained as a surgeon in Belfast. Now, he explains to SPR why taking on-board the lessons garnered from aviation can reduce the number of patients being inadvertently harmed by simple human error in our health services.
1. Firstly, and crucially, aviation accepts that error is inevitable, no matter what is involved in the operation how good we are, and no matter how hard we work. We operate a ‘just – those that have accepted the culture’ system in which we can put our hands up and admit an error invitation usually leave armed in the knowledge that we will not be disciplined (unless it was grossly with ideas they translate to their negligent or deliberate – it’s not a ‘get out of jail free’ card). own workplace to the benefit of This open reporting system is the foundation on which the rest of the both staff and patients alike. In Safety Management System is built on. short, they leave thinking like a pilot – anticipating where plans 2. Secondly, we adapt and refine our systems in light of what we find from may go awry and preparing Plan B analysing the information we gather by our reporting procedures. (and Plan C and maybe Plan D) Put simply, we look at how each error arose and try to find the for when it does! Communication ‘tripwire’ the crew member fell over and replace it with a ‘safety net’, and situational awareness are two reducing the chance of a repeat and adding a failsafe in case it does happen of our most valuable tools and are Niall Downey again. very transferable to healthcare. An example would be keeping vials of concentrated Potassium Aviation has faced similar Have you ever made a mistake? Chloride in a different cupboard to vials of saline, and also adding a red problems to healthcare. By letting Yeah, me too… all the time! The label to the KCl, to avoid inadvertent boluses of potassium causing cardiac us share what we have learned, we problem is that when you work in arrest. It’s very simple, very cheap, but very effective. can hopefully enable healthcare a safety critical industry, such as to transform much faster than we healthcare or aviation, mistakes 3. Lastly, we need to train staff to think like pilots! We use an error did. Our error management system are very expensive, in terms of lives management framework called Crew Resource Management (CRM) is transferable to the healthcare lost, harm to both patients and which gives staff a structured approach to issues, such as situational environment if tailored to the staff, and ultimately, financially. awareness and decision-making. unique needs of that industry. A UK study published in the This system is often misunderstood in healthcare as team training. BMJ in 2001 (and borne out Although this is a component of CRM, it greatly undersells its usefulness. Preliminary research in America in subsequent studies in many We use it in conjunction with our culture and systems thinking to suggests adverse event reduction countries before and since) complete a comprehensive error management training package. in the range of 40 to 70 per shows unintended harm rates at cent. When did you last see a approximately 10 per cent of all medication achieve that sort of hospital admissions. Mortality The crux of CRM involves a broad view of who the ‘crew’ are and being improvement in mortality rate? rates are disputed, but can be aware of the ‘resources’ available. For more information, visit estimated to be over 1,000 per In a healthcare environment, the crew includes the patient and their www.frameworkhealth.net. week in the UK alone. So, what family who have probably spent more time reading about their particular to do? ailment than you, so can provide useful information and specifically Do we perhaps turn to other on how it affects them given that it’ll probably exist with other co- industries to see how they deal morbidities. with error? Aviation is one of the Secondly, resources extend well beyond your own knowledge, however leaders in this field after 40 years extensive that might be. In aviation, we are not expected to know of development and improvement everything. but we are expected to know where to look for it. We are following several high-profile encouraged to go into the manuals while trying to resolve an issue and to accidents in the 70s, culminating contact staff on the ground for input if necessary. Our long-haul fleet even with the Tenerife disaster in 1977. has a satellite telephone on the flight-deck to facilitate this.
Critics of the approach often cite patients as being more complex than aeroplanes. This is of course true – patients are infinitely more AVIATION HAS A complex, but it misses the fundamental point. As an airline captain, flying the aeroplane is one component of my role, but my main function is to THREE-STAGE manage a rapidly-changing, complex, high-stakes environment, and to APPROACH TO use all the staff (and passengers if necessary) at my disposal to ensure the safety of the flight. THIS PROBLEM: Very few critics of our error management framework’s relevance to healthcare have actually sat in the flight-deck during a flight to witness 32 | SPR | June 2017 NICE RECOMMENDED1, 2 AND SMC ACCEPTED3,4 IN NVAF AND VTE
® ONCE-DAILY LIXIANA (edoxaban).
Only LIXIANA® combines: Proven effi cacy comparable to well-controlled warfarin5,6 Superior reduction in clinically relevant bleeding vs. well-controlled warfarin5,6 Once-daily dosing across both NVAF and VTE indications7*
* Following a 5 day heparin lead in for VTE
Indicated for:7 Prevention of stroke and systemic embolism in adult patients with nonvalvular atrial fibrillation (NVAF) with one or more risk factors, such as congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischaemic attack (TIA) Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and prevention of recurrent DVT and PE in adults
LIXIANA (edoxaban) 60 mg/30 mg/15 mg film coated tablets ophthalmic surgery, recent intracranial haemorrhage, known or pulmonary embolectomy: Not recommended. Patients with active See summary of product characteristics prior to prescribing for full suspected oesophageal varices, arteriovenous malformations, cancer : Not recommended. Drug interactions: The P-gp inhibitors list of adverse events vascular aneurysms or major intraspinal or intracerebral vascular ciclosporin, dronedarone, erythromycin, or ketoconazole result in abnormalities. Uncontrolled severe hypertension. Concomitant increased concentration of edoxaban and a dose reduction of 30 mg Presentation: 60 mg (yellow)/30 mg (pink)/15 mg (orange) treatment with any other anticoagulants e.g. UFH, low molecular is required. Edoxaban should be used with caution with concomitant edoxaban film coated tablets (as tosilate). Indications: Prevention weight heparins, heparin derivatives (fondaparinux, etc.), VKA P-gp inducers (e.g. phenytoin, carbamazepine, phenobarbitol or of stroke and systemic embolism in adult patients with nonvalvular or NOACs except under specific circumstances of switching oral St John’s Wort). Concomitant high dose ASA (325 mg) or chronic atrial fibrillation (NVAF) with one or more risk factors, such as anticoagulant therapy or when UFH is given at doses necessary to NSAIDs is not recommended. There is very limited experience congestive heart failure, hypertension, age ≥75 years, diabetes maintain an open central venous or arterial catheter. Pregnancy with dual antiplatelet therapy or fibrinolytic agents. Undesirable mellitus, prior stroke or transient ischaemic attack (TIA) and and breastfeeding. Special warnings and precautions for use: effects: Common: anaemia, epistaxis, lower GI haemorrhage, upper treatment of deep vein thrombosis (DVT) and pulmonary embolism Haemorrhagic risk: Use with caution in patients with increased risk GI haemorrhage, oral/pharyngeal haemorrhage, nausea, blood (PE), and prevention of recurrent DVT and PE in adults. Posology of bleeding such as elderly on ASA and should be discontinued if bilirubin increased, gamma GT increased, cutaneous soft tissue and method of administration: NVAF – The recommended dose severe haemorrhage occurs. The anticoagulant effect of edoxaban haemorrhage, rash, pruritus, macroscopic haematuria/urethral is 60 mg edoxaban once daily with or without food. Therapy with cannot be reliably monitored with standard laboratory testing. haemorrhage, vaginal haemorrhage, puncture site haemorrhage, edoxaban in NVAF patients should be continued long term. VTE – The A specific anticoagulant reversal agent for edoxaban is not liver function test abnormal. Uncommon: hypersensitivity, intracranial recommended dose is 60 mg edoxaban once daily following initial use available. Haemodialysis does not significantly clear edoxaban. haemorrhage (ICH), intraocular haemorrhage, other haemorrhage, of parenteral anticoagulant for at least 5 days with or without food. Renal impairment: Renal function should be assessed prior to haemoptysis, surgical site haemorrhage. Rare: anaphylactic Duration of therapy (at least 3 months) should be based on risk profile initiation of edoxaban and afterwards when clinically indicated. reaction, allergic oedema, subarachnoid haemorrhage, pericardial of the patient. For NVAF and VTE the recommended dose is 30 mg Not recommended in patients with end-stage renal disease or on haemorrhage, retroperitoneal haemorrhage, intramuscular edoxaban once daily in patients with one or more of the following dialysis. Renal function and NVAF: A trend towards decreasing haemorrhage (no compartment syndrome), intra-articular clinical factors: moderate or severe renal impairment (creatinine efficacy with increasing creatinine clearance was observed for haemorrhage, subdural haemorrhage, procedural haemorrhage. clearance (CrCL) 15–50 ml/min), low body weight ≤60 kg and/or edoxaban compared to well-managed warfarin. Edoxaban should Legal category: POM. Package quantities and basic NHS costs: concomitant use of the following P-glycoprotein (P-gp) inhibitors: only be used in patients with NVAF and high creatinine clearance 60 mg/30 mg – 28 tablets £51.80; 15 mg – 10 tablets £18.50. ciclosporin, dronedarone, erythromycin, or ketoconazole. The after a careful benefit risk evaluation. Hepatic impairment: Not Marketing Authorisation (MA) number: EU/1/15/993/001–16. 15 mg dose of edoxaban is not indicated as monotherapy, and should recommended in patients with severe hepatic impairment and MA holder: Daiichi Sankyo Europe GmbH, Zielstattstrasse 48, 81379 only be used during a switch from edoxaban to VKA (see SmPC for should be used with caution in patients with mild or moderate hepatic Munich, Germany. Date of prep of PI: May 2016. EDX/15/0150(2). full details). If a dose of edoxaban is missed, the dose should be impairment. Edoxaban should be used with caution in patients with taken immediately and then continued once daily on the following elevated liver enzymes (ALT/AST >2 x ULN) or total bilirubin ≥1.5 x Adverse events should be reported. day. Contraindications: Hypersensitivity to the active substance or ULN. Surgery or other interventions: discontinue edoxaban at least Reporting forms and information can be found at to any of the excipients; clinically significant active bleeding. Hepatic 24 hours before the procedure. If the procedure cannot be delayed, disease associated with coagulopathy and clinically relevant bleeding the increased risk of bleeding should be weighed against the www.mhra.gov.uk/yellowcard. Adverse events risk. Lesion or condition, if considered to be a significant risk for urgency of the procedure. Edoxaban should be restarted as soon should also be reported to Daiichi Sankyo major bleeding. This may include current or recent gastrointestinal as haemostasis is achieved. Prosthetic heart valves and moderate UK Medical Information on 0800 028 5122, (GI) ulceration, presence of malignant neoplasms at high risk to severe mitral stenosis: Not recommended. Haemodynamically [email protected] of bleeding, recent brain or spinal injury, recent brain, spinal or unstable PE patients or patients who require thrombolysis or
References: 1. NICE Technology Appraisal 355. Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation. September 2015. Available at: www.nice.org.uk/guidance/ta355 Accessed September 2015. 2. NICE Technology Appraisal 354. Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism. August 2015. Available at: www.nice.org.uk/guidance/ ta354 Accessed September 2015. 3. Scottish Medicines Consortium. SMC No. (1095/15). edoxaban (Lixiana) for NVAF. Available at: http://www.scottishmedicines.org.uk/files/advice/edoxaban__Lixiana__NVAF_ FINAL_October_2015_Amended_03.11.15.pdf Accessed: May 2016. 4. Scottish Medicines Consortium. SMC No. (1095/15). edoxaban (Lixiana) for NVAF. Available at: http://www.scottishmedicines.org.uk/files/ advice/edoxaban__Lixiana__VTE_FINAL_October_2015_Amended_26.10.15___03.11.15_for_website.pdf Accessed: May 2016. 5. Giugliano RP et al. NEJM 2013;369(22):2093–2104. 6. The Hokusai-VTE Investigators. NEJM 2013;369(15):1406–1415. 7. LIXIANA®, Summary of Product Characteristics. © (2016) Daiichi Sankyo UK Limited. All rights reserved. Date of preparation: December 2016. EDX/15/0075k(1) www.lixiana.co.uk WWW.SCOTHEALTHCARE.COM
NUTRITION PAEDIATRIC NUTRITION: A WINDOW OF OPPORTUNITY Having the power to determine and dismantle the long-term health of children, the nutritional choices made during the first 1,000 days of life are of vital importance. Nicole Rothband, Specialist Paediatric Dietitian, and British Dietatic Association spokesperson, weighs in on the growing need for healthcare professionals to recognise and combat cases of malnutrition.
generations who have better health that health visitor knowledge and wellbeing through their lives.’ A QUESTION OF SERVICE of child malnutrition should be (1) Malnutrition is not just a problem good, but this was considered to for developing countries. The not always be the case and it was A QUESTION OF GUIDANCE Patients Association began a reported that their advice was not In 2013, the World Health project in February 2014 to always consistent with government Organisation (WHO) published examine whether malnutrition advice. It was also found that ‘Essential Nutrition Actions, among children is increasing, doctors required further support Improving Maternal, Newborn, and to find out whether and training to develop their Infant and Young Child Health existing methods used to detect skills as providers of nutritional and Nutrition’, summarising malnutrition in children are information. WHO guidance on nutrition adequate. The project focused Dentists and pharmacists were interventions targeting the first specifically on the ability of the also seen as having a key role in Nicole Rothband 1,000 days of life. primary, acute, and public health nutrition and that all health care The first 1,000 days encompass sectors to identify and then professionals, as well as education In 1990 the British epidemiologist, the time just before conception combat malnutrition wherever it and social care professionals, David J Barker, proposed a to two years of age. Many of exists. should be involved in public health hypothesis that intrauterine the recommendations in this One area examined by this education. (3) growth retardation, low birth document have become part project was the awareness of The consequences of child weight, and premature birth of our canon of public health malnutrition among health malnutrition are well-documented. have a causal relationship to the nutrition interventions intended and social care professionals. The causes can be multi-factorial, origins of hypertension, coronary to safeguard maternal and infant They found more education of and include inadequate dietary heart disease, and non-insulin- health. professionals on child malnutrition intake, disease, household income, dependent diabetes in middle age. The WHO guidance was was required; a lack of awareness and food security, maternal and Since then, he has developed a new published against the backdrop among GPs about nutrition issues, childcare, health services and the developmental model to explain of some alarming data regarding and that GPs were considered environment. (1) Malnourished the origins of chronic disease. malnutrition. Malnutrition is to be slow at picking up cases children suffer from deficits in He concluded, ‘Many babies defined as a state of nutrition in of malnutrition, with 80 per growth and cognitive function. in the womb in the Western which a deficiency or excess (or cent of cases being missed in the They are more likely to contract world today are receiving imbalance) of energy, protein, and community. infections due to poor nutrition, unbalanced and inadequate diets. other nutrients causes measurable As a result, they recommended which additionally affects their Many babies in the developing adverse effects on tissue / body that GP practices should have nutritional status due to anorexia world are malnourished because form (body shape, size and a GP with special interest in and or malabsorption. In the long- their mothers are chronically composition) and function and children, and identified shortages term, addressing malnutrition can malnourished. Protecting the clinical outcome. (2) Globally, in in the numbers of health visitors reduce infant and child mortality, nutrition and health of girls and 2011, approximately 101 million and school nurses as potentially improve physical and cognitive young women should be the children under five years old were contributing factors. Health growth and development, and cornerstone of public health. Not underweight, 165 million stunted, visitors’ core role is to screen ultimately improve productivity. only will this prevent chronic and 43 million overweight or children through the First 1,000 (1) disease, but it will produce new obese. Days initiative. It was thought
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NUTRITION
The following Essential So how do all healthcare professionals, not just Nutrition Actions, dietitians, ensure that they’re helping to optimise recommended by the maternal and child nutrition? WHO, are embodied in the First 1,000 Days initiative, A good starting point is NICE Guideline PH11 Maternal and Child Health. To and most are enshrined in summarise the priority recommendations, you need to know about the following (4):
Department of Health and • The Healthy Start scheme and how eligible parents can access the benefits NICE guidelines. • Women who are planning a pregnancy or in the first 12 weeks of pregnancy require supplementation of folic acid 400 micrograms (μg) daily, before pregnancy and throughout the first 12 weeks, even if they are already eating foods fortified with • Nutrition for adolescents and women folic acid or a diet rich in folate. (5mg folic acid daily is required for women who have during pregnancy and lactation diabetes or where there is a family history of neural tube defects) • Exclusive breastfeeding during the first • Vitamin D 10 micrograms / day (400 IU) should be taken throughout pregnancy. six months of life (New guidelines now recommend that all adults and children over one-year-old take • Complementary feeding starting at six this level of vitamin D supplementation) (5) months, with continued breastfeeding to • How to encourage pregnant women and mothers to initiate and maintain two years of age and beyond breastfeeding and direct them to a structured breastfeeding programme using the • Nutritional care of sick or Breast Feeding Initiative (BFI) as the minimum standard malnourished children • How to advise parents on the introduction of complementary foods, in addition to • Prevention of vitamin A deficiency in milk when infants are six months of age women and children • All children aged from six months to four years should be given supplementation of • Prevention and control of anaemia in children’s vitamins A, C and D. Healthy Start vitamin supplements should be offered women and children to parents receiving the Healthy Start benefit • Consumption of iodised table salt • Health professionals and support workers who care for children under five years and women who may become – or who are – pregnant should train, as part of their continuing professional development, to deliver education on all the above-mentioned recommendations
References
(1) publichealthjrnl.com/article/S0033-3506(11)00366- 0/fulltext (2) bapen.org.uk/malnutrition-undernutrition/ introduction-to-malnutrition (3) patients-association.org.uk/wp-content/ uploads/2015/01/Child-Malnutrition-in-the-UK.pdf (4) nice.org.uk/guidance/ph11 (5) gov.uk/government/uploads/system/uploads/ attachment_data/file/537616/SACN_ Vitamin_D_and_Health_report.pdf
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COELIAC DISEASE STEPPING UP TO THE PLATE While the recognition of coeliac disease is improving, with a fourfold increase in the last two decades, diagnosis remains worryingly low. Norma McGough, Coeliac UK Director of Policy, Research and Campaigns, provides a glimpse into how community pharmacists are now being tasked with curbing these dangers and signposting the symptoms in patients earlier.
of coeliac disease from under with both significant cost diagnosis to living with the implications for the NHS and the condition. risk of individuals diagnosed later Our diagnosis campaign in life developing more serious isitcoeliacdisease? first launched complications. (1) With screening during the charity’s Awareness tools and a National Institute Week in May 2015 and focuses of Health & Clinical Excellence on raising awareness of the (NICE) clinical standard for symptoms of coeliac disease and coeliac disease now in place, steering people towards a pathway Coeliac UK is campaigning to help to diagnosis. The campaign has tackle these issues. (3) included a range of activities, targeting both people at risk of CAMPAIGNING IN coeliac disease and also healthcare COMMUNITY PHARMACIES professionals in primary care. Diagnosing coeliac disease can Recently-published research, be a challenge; this is largely Norma McGough based on primary care data and attributed to the wide range of spanning over two decades since symptoms, including ongoing 1990 has been used to underpin gastrointestinal problems, chronic the campaign activities. fatigue and anaemias due to iron, Coeliac disease is a common and investigations at a cost to the With one per cent of the UK B12 and folate deficiency. (4) In autoimmune disease associated patient and the NHS. (1) population having coeliac disease, addition, a significant number with chronic inflammation of The treatment for coeliac but only 24 per cent of these of people (one-in-four) will have the small intestine, resulting in disease is adherence to a strict having a diagnosis, around half a been misdiagnosed previously malabsorption which leads to gluten-free diet which requires million people are suffering with with IBS. (5) NICE clearly states nutritional deficiencies. The long- eliminating foods containing undiagnosed coeliac disease across that it is necessary to screen for term complications of untreated wheat, barley and rye. Gluten is the UK. (2) In addition, it is taking coeliac disease before confirming a or undiagnosed coeliac disease found in cereal and flour based around 13 years, from the first diagnosis of IBS. (6) include osteoporosis, and intestinal staple foods like bread, as well as appearance of symptoms, to secure It is imperative that individuals lymphoma so the benefits of early a wide range of other processed a diagnosis of coeliac disease. have not removed gluten from diagnosis are well recognised. foods. Coeliac UK’s campaigning Late diagnosis is associated their diets before or during testing Late diagnosis is associated agenda is far-reaching to address with repeated appointments to the for coeliac disease. Since the with repeated GP appointments the wide range of challenges GP and additional investigations, gluten-free diet is the treatment
40 | SPR | June 2017 GLUTEN FREE SUPPORT FOR YOU AND YOUR COELIAC PATIENTS
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COELIAC DISEASE for coeliac disease, once the diet Association of Primary Care of these results were attributed • Are accessing prescription is established, the markers for the (NAPC), the Pharmaceutical to customers on prescription or over the counter treatments disease disappear. While screening Services Negotiating Committee, medications, so people who had for irritable bowel syndrome or using serological antibody tests Pharmacy Voice, the Royal already seen a GP, were referred to anaemias (iron, B12 or folate (IgA tissue transglutaminase Pharmaceutical Society and the their GP for further testing. deficiency) (tTGA) or endomysial (EMA) is University of East Anglia to trial The pharmacy-led project was • Include gluten in their diet generally initiated in primary care, a pharmacy-led approach that published in the International (wheat, barley and rye) (and if they community pharmacies are ideally identified individuals at risk of Journal of Clinical Pharmacy have previously removed gluten, placed to recognise individuals coeliac disease. in 2016. (17). A further article, they should include at least one who may be at risk of coeliac The approach targeted has been published in the March meal containing gluten per day for disease and refer them to their GP. customers who were purchasing 2017 issue of the Pharmaceutical six weeks); and The symptoms of coeliac disease medicines in community Journal. (8) • may be put down to everyday pharmacies to treat IBS or iron, Following on from our project Have not been tested for coeliac lifestyle issues or may not be B12 or folate deficiency, either in 2015, we would like community disease before checked out because they’ve been over the counter or on prescription pharmacies to take an active For more information, email experiencing symptoms off and and who had not been tested for role in identifying those people [email protected], on for a long time. These people coeliac disease and were not on a who should be tested for coeliac and to find out more about the may be managing their symptoms gluten-free diet. Customers were disease. We’re asking pharmacists isitcoeliacdisease? campaign, or to with over the counter (OTC) asked if they wanted to have a free to identify people who may be at view the online assessment, visit treatments from community Point of Care Test (POCT) for risk of coeliac disease, to signpost www.isitcoeliacdisease.org.uk. pharmacies rather than going to coeliac disease. Nearly 10 per cent people to their GP surgery for the GP for an investigation. of the 550 patients that were tested screening. During 2015, Coeliac UK during the six-month trial had We’d like pharmacists to target teamed up with the National positive test results and 50 per cent people who: THE COELIAC REFERENCES one or two selections of biscuits, 1.Violato, M., et al., Resource use and costs associated with no cakes or buns, and limited coeliac disease before and SUFFERER’S STORY choices for dinners. Food you after diagnosis in 3,646 cases: 27-year-old Leanne Seeley, from Co. Armagh, wouldn’t even imagine contained results of a UK primary care gluten was cut from my diet, and database analysis. PLoS One, Northern Ireland, first began to showcase and as well as the selection being so 2012. 7(7): p. e41308 suspect signs of the autoimmune disease over limited, it was extremely expensive. 2.West, J., et al., Incidence and 10 years ago. She shares with SPR her journey A loaf of bread with approximately prevalence of celiac disease 10 slices was over £2! and dermatitis herpetiformis in the UK over two decades: of diagnosis and condition control – and how Over the first few years, I did population-based study. Am J the question of choice often comes into play. slip and cheat on normal food, Gastroenterol, 2014. 109(5): p. possibly because of the lack of 757-68 She was a coeliac sufferer for many selection and taste. However, the 3.NICE, Coeliac disease quality years and although my symptoms more often you cheat, the more standard ; QS134. 2016 weren’t identical to what hers had sensitive you become and soon 4.NICE, NG20 Coeliac disease; recognition, assessment and been, there were some similarities. even cheating on a small treat once every few months became management. 2015 Just three days after following 5.Card, T.R., et al., An excess a ‘no-no’ for me. The pain and a strict coeliac diet my symptoms of prior irritable bowel improved. My vision wasn’t as sickness wasn’t worth it anymore, syndrome diagnoses or blurry, my energy levels had and so I would say that it’s been a treatments in Celiac disease: increased, my appetite was coming good six years from I intentionally evidence of diagnostic delay. back, and the pains in my tummy ate anything containing wheat or Scand J Gastroenterol, 2013. had eased considerably! I decided gluten. 48(7): p. 801-7 6.NICE, Irritable bowel to stick this out and over the Luckily though, the selection of foods has improved greatly. The syndrome in adults: diagnosis coming weeks and months my and management 2008. variety of breads, biscuits, cereals, Leanne Seeley symptoms had either eased hugely, 7.Urwin, H., et al., Early or completely disappeared. and even cakes, in supermarkets is recognition of coeliac I started really noticing my It isn’t an easy diet, however, a million miles away from what it disease through community symptoms at the age of 16; blurry and after a few months my cravings was 10 years ago. Restaurants have pharmacies: a proof of concept vision, fatigue, hair loss, bloating, for ‘normal food’ increased. The a good bit of catching up to do, study. Int J Clin Pharm, 2016. lack of appetite, weight gain – the food was bland, tasteless, and however more and more are adding 38(5): p. 1294-300 8. Wright, D., H. list went on. Unable to pinpoint very limited. There was only one at least one gluten-free option to their menu which is great to see. Urwin, and N. McGough, what was going on, my mum type of bread available which had How to identify symptoms of Here’s hoping the improvements suggested to me one day that I cut to be toasted to taste somewhat coeliac disease in community gluten and wheat from my diet. enjoyable. There were no cereals, continue! pharmacy and primary care. The Pharmaceutical Journal, 42 | SPR | June 2017 2017. 298; 7899 Health & wellbeing toolkit to support your coeliac customers
• Juvela Product Guide • Customer Food Diary • Customer Information & Recipe Resources
All toolkit resources can be downloaded for free from www.juvela.co.uk/downloads
The Juvela essential gluten-free foods have been produced to support your coeliac customers in following a healthy, balanced gluten-free diet. All Juvela gluten-free products are available from the pharmacy
For your FREE pharmacy toolkit call: 0800 783 1992
email [email protected] visit www.juvela.co.uk/hcp
Scotland’s favourite essential gluten-free foods
Juvela Scottish Pharmacy vers ad.indd 1 07/04/2017 08:49 WWW.SCOTHEALTHCARE.COM
NEWS diabetes online platform created BRAIN CANCER by University of Dundee for NHS Scotland – was honoured with the DISCOVERY eHealth Adoption Award at the eHealth Week 2017 conference REVEALS CLUES which recently took place in Malta. ‘This is a major honour for the FOR NEW university and Scotland’s health THERAPIES system,’ commented Dr Deborah Wake, Clinical Senior Lecturer in the University of Dundee School Researchers have pinpointed of Medicine, and Clinical Lead for two key molecules that drive the My Diabetes My Way. growth of an aggressive type of ‘The My Diabetes My Way adult brain cancer. service is genuinely unique The findings shed light on the worldwide, providing electronic mechanisms that underpin brain health records access to an entire cancer progression and could national population. Every day we eventually reveal targets for the hear from users that our website development of much-needed is a useful tool that not only aids therapies. self-management, but improves The team identified two a patient’s knowledge of their (L to R) Dr Scott Cunningham and molecules that are produced at condition.’ high levels by the cells – called Dr Deborah Wake The platform allows patients FOXG1 and SOX2. Similar levels to have online access to test of these molecules are found in results, clinic letters, and data- brain stem cells and are a defining INTERNATIONAL EHEALTH driven tailored treatment plans. feature of these cells, and the It also contains multimedia researchers found that SOX2 PRIZE FOR DIABETES INITIATIVE resources aimed at improving self- drives glioblastoma cells to keep management, including traditional dividing, a hallmark of cancer. information leaflets, interactive Both FOXG1 and SOX2 A major international prize for access their medical records online, educational tools, videos describing work by controlling when key eHealth has been awarded to a support their self-management, diabetes-related complications, target genes are switched on project developed at the University and improve their knowledge of and testimonials from people and off by the cell, with the of Dundee which allows people their condition. with diabetes talking about their researchers analysing which genes with diabetes across Scotland to My Diabetes My Way – the experiences. were affected, and identifying several factors that are involved in controlling cell division. NEW CAMPAIGN TARGETS HEPATITIS AND Lead researcher, Dr Steve Pollard, CRUK Senior Cancer Research Fellow at the University HIV AWARENESS of Edinburgh, explained, ‘Brain of a major campaign to raise the hepatitis C now only have to take cancer cells seem to be hijacking profile of these illnesses which will a course of pills for around 12 important cell machinery that is include local radio advertising, and weeks of pills, compared with the used by normal brain stem cells. posters in shopping centres and GP traditional weekly injections for 48 The tactic they appear to use is to surgeries. weeks which had many side-effects produce high levels of these key Around 3,000 people in the – and the cure rate is now in excess regulators. This locks the tumour health board area are believed to of 90 per cent. cells into perpetual cycles of be infected with hepatitis C – ‘Hepatitis B when diagnosed growth and stops them listening known as the silent disease – but can be treated and monitored to the signals that normally so far only around 1,500 have been to prevent further liver damage control cell specialisation.’ diagnosed. and there is also a highly effective The study was led by scientists Carol Crawford, from NHS treatment for HIV. This can at the Medical Research Council Forth Valley’s Blood Borne Virus hugely reduce the viral load of Centre for Regenerative Medicine Managed Care Network, explained the infection making it much less at the University of Edinburgh, Health experts in NHS Forth that advances in medication are infectious to other people. HIV is while the research is published in Valley are urging people who may producing huge dividends with now considered to be a long-term Genes and Development, and was have been at risk of contracting blood-borne viruses. condition and many people are funded by Cancer Research UK a blood-borne virus to have a She said, ‘Treatment for now dying with HIV and not from and the Wellcome Trust. confidential single finger-prick hepatitis and HIV has greatly HIV.’ test which can detect hepatitis improved in recent years. For C, hepatitis B, and HIV. It’s part example, most people with 44 | SPR | June 2017
ButecNEW 15 STRENGTH
Now Available μg/h Patch Buprenorphine 7 Day Matrix Patch 5µg/h, 10µg/h, 15µg/h, 20µg/h
Moving from BuTrans 5,10,15 or 20µg/h to Butec.. A like for like switch.. Butec sits in Category C of the drug tariff. Prescribing Butec by brand is the only way to ensure patients receive a like for like switch while delivering drug cost savings to the NHS.
For further information and latest pricing please contact Qdem enquiries on: 01223 426929
Or contact your local account manager at: www.qdem.co.uk/hcp/team.php
Butec patches contain an opioid analgesic. Butec® 5 and a withdrawal syndrome may occur. May affect diverticulitis, biliary colic, urticaria, dermatitis μg/h, 10 μg/h, 15 μg/h and 20 μg/h Transdermal Patch ability to drive and use machinery. INTERACTIONS contact, face oedema, urinary retention, erectile PRESCRIBING INFORMATION United KingdomPLEASE MAOIs, CNS depressants (e.g. benzodiazepines, dysfunction, sexual dysfunction, oedema, drug READ THE SUMMARY OF PRODUCT CHARACTERISTICS opioid derivatives, antidepressants, sedatives, withdrawal syndrome (including neonatal), BEFORE PRESCRIBING.PRESENTATION Butec 5 µg/h, 10 alcohol, anxiolytics, neuroleptics, clonidine). CYP chest pain, alanine aminotransferase increased, µg/h, 15 µg/h, 20 µg/h. Transdermal beige patches 3A4 inhibitors and inducers, products reducing accidental injury, fall. Please consult the SPC for containing buprenorphine. INDICATIONS Treatment hepatic blood flow (e.g. halothane). PREGNANCY details of other side-effects. LEGAL CATEGORY CD of non-malignant pain of moderate intensity when AND LACTATION Butec should not be used during (Sch3) POM PACKAGE QUANTITIES AND PRICE 4 an opioid is necessary for obtaining adequate pregnancy or in women of childbearing potential individually sealed patches: 5 µg/h transdermal analgesia. Butec is not suitable for the treatment of who are not using effective contraception. patch £7.92, 10 µg/h transdermal patch £14.20, 15 acute pain. DOSAGE AND ADMINISTRATION Butec The use of Butec during lactation should be µg/h transdermal patch £22.12, 20 µg/h transdermal should be administered every 7th day. Elderly and avoided. SIDE-EFFECTS Very common (≥1/10) and patch £25.86. Marketing Authorisation numbers adults over 18 years only: Use the 5 µg/h patch common (≥1/100, <1/10) side-effects are anorexia, PL 40431/0024 – 0027. MARKETING AUTHORISATION for at least the first 3 days of treatment, before confusion, depression, insomnia, nervousness, HOLDER Qdem Pharmaceuticals Limited, increasing the dose if necessary. Short-acting anxiety, headache, dizziness, somnolence, Cambridge Science Park, Milton Road, Cambridge, supplemental analgesics may be required during tremor, dyspnoea, constipation, nausea, vomiting, CB4 0AB, United Kingdom. Tel: 01223 426929. For titration until analgesic efficacy is attained. Do abdominal pain, diarrhoea, dyspepsia, dry mouth, medical information enquiries, please contact not use more than two patches at a time, up to a pruritus, erythema, rash, sweating, exanthema, [email protected]. maximum dose of 40 µg/h. CONTRA-INDICATIONS muscular weakness, application site reaction, DATE EFFECTIVE: February 2017. ® Butec and Known buprenorphine or excipient hypersensitivity, tiredness, asthenic conditions, peripheral oedema. QDEM are registered trade marks. © 2013 Qdem opioid-dependent patients, narcotic withdrawal Uncommon (< 1/100) but potentially serious Pharmaceuticals Limited. treatment, respiratory depression, use of monoamine side-effects are hypersensitivity, anaphylactic/ oxidase inhibitors (MAOIs) within the past 2 weeks, anaphylactoid reaction, affect lability, restlessness, myasthenia gravis, delirium tremens. PRECAUTIONS agitation, euphoric mood, hallucinations, libido Adverse events should be reported. Reporting forms AND WARNINGS Acute alcohol intoxication, head decreased, aggression, psychotic disorder, drug and information can be found at www.mhra.gov.uk/ injury, shock, reduced consciousness of uncertain dependence, mood swings, depersonalisation, yellowcard. Adverse events should also be reported origin, intracranial lesions or increased intracranial sedation, dysarthria, migraine, syncope, to Qdem Pharmaceuticals Limited on 01223 426929. pressure, severe hepatic impairment, history of paraesthesia, balance disorder, speech disorder, drug abuse, alcohol abuse, serious mental illness or convulsions, blurred vision, visual disturbance, seizure disorder. Not recommended immediately eyelid oedema, vertigo, palpitations, tachycardia, PI CODE: UK/QDEM-16010(6) postoperatively or for situations characterised angina pectoris, hypotension, circulatory collapse, PI APPROVED: January 2017 by a narrow therapeutic index or for rapidly hypertension, orthostatic hypotension, wheezing, varying analgesic requirements. Chronic use of respiratory depression, respiratory failure, asthma buprenorphine may lead to physical dependence aggravated, hyperventilation, dysphagia, ileus,
www.qdem.co.uk
® Butec and QDEM are registered trade marks. © 2013 Qdem Pharmaceuticals Limited. Date of preperation: March 2017 UK/QDEM-16023a(1)
ButecWelshPharmA4_16023a(1).indd 1 03/03/2017 13:14