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Transcript of Pharmacy Today September 2013 MY
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September 2013
PsorCARE program to help manage
psoriasis more effectively
Natural remedies
oen rst choice for
anxiety and insomnia
Seeing AMD through the
eyes of a paent
News Feature
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News | Pharmacy Today | September 20133
By Saras Ramiya
The Psoriasis Coach All-Round Educa-tion (PsorCARE) program aims to en-hance the counseling skills of healthcare
practitioners to optimize treatment outcomes.Psoriasis is a lile-understood skin con-
dition that carries a strong social stigma. Its
emotional impact on patients oen far out-weighs the diseases physical impact. This iswhy good support and guidance from health-care providers is crucial in achieving optimaltreatment adherence, one of the main chal-lenges in psoriasis management.
PsorCARE is a peer-based training plat-form that teaches trainees how to achievea balance between asking, listening and in-forming when communicating with patientsabout living with and overcoming the burdenof psoriasis. The program also enables train-ees to translate theoretical approaches intopractical implementation.
Caring for patients with chronic skin dis-eases such as psoriasis is not only a science butan art which requires continuous support bya dedicated counselor. Nurses best equippedwith the necessary knowledge would ensure
beer outcomes in the management of psoria-sis by improving patient adherence to topicaltreatments which are the mainstay of man-agement of majority of patients, said NajeebAhmad Mohd Safdar, president of the Der-matological Society of Malaysia.
The session, held in June, was led by Bar-bara Page, a dermatology liaison nurse spe-cialist at the Queen Margaret Hospital in Scot-land, UK. Aside from adhering to medicaltreatments, psoriasis patients also face physi-cal and emotional challenges in their daily
lives and it is important for us, as healthcare
providers, to recognize these challenges andprovide them with the much needed support.With the PsorCARE program, I am pleased tohave the opportunity to share my experienceswith other healthcare providers in Malaysiato help enhance our capabilities to further
benet these patients, said Ms. Page.For patients who require long-term thera-
py, treatment adherence whether it be me-
dicinal, behavioral, lifestyle or a combinationof treatments is essential for achieving opti-mal outcomes. Extensive market research hasidentied that adherence is founded on goodcommunication and a positive relationship be-tween patients and healthcare practitioners.This applies in particular to nurses who are inregular contact with patients. (J Eur Acad Der-matol Venereol 2011;25 Suppl 4:9-14)
Psoriasis patients nd it challenging to ad-here to their treatment modality because theapplication of their medicine requires disci-
PsorCARE program to help manage
psoriasis more effectively
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News | Pharmacy Today | September 20134
pline and patience, and this impacts their life-
style. More signicantly, the lack of apparent
results dampens their morale which, in turn,
aects negatively the follow-through with
recommended treatment.LEO Pharma developed the PsorCARE
program in collaboration with PsorAsia (the
Federation of Psoriasis Association in Asia-
Pacic).
Research has shown that there is a signi-
cant need to bridge the gap between admin-
istering medical treatments and providing
patient support. Programs such as PsorCARE
are an essential platform that allows us to
share sustainable approaches with health-
care providers to help them address the high
prevalence in treatment non-adherence and
respond to the patients unmet needs, said
Josef De Guzman, president, PsorAsia.
LEO Pharma is commied to partner with
healthcare professional, doctors, nurses andpharmacists in helping psoriasis patients im-
prove their lives and overcome their burden
of disease and treatment. We are aware of the
challenges that psoriasis patients face and we
want them to know that trained support is
available. Our ultimate aim is to give these pa-
tients hope and empower them with the ability
to control their psoriasis conditions and even-
tually improve their quality of life, said Tan
Keng Aun, country manager of LEO Pharma
Malaysia.
By Rajesh Kumar
Nicotine replacement therapies (NRT)
and other licensed drugs can indeed
help people quit smoking, a system-
atic review has conrmed.
The overview of previous Cochrane re-
views supports the use of smoking cessation
medications that are already widely licensedinternationally, and shows that another drug
licensed in Russia could hold potential as an
eective and aordable treatment. The nd-
ings serve as a reassurance to pharmacists
and other health professionals involved in
smoking cessation programs.
In most countries, including the US and Eu-
rope, the only medications currently licensed
for smoking cessation are NRTs such as nico-
tine patches and gums, the antidepressant
bupropion and the drug varenicline, which
blunts the eects of nicotine on nicotine re-
ceptors in the brain. In Russia and other parts
of Eastern Europe, cytisine, similar to vareni-
cline, is also licensed for smoking cessation.
The researchers combined the ndings of
Quit smoking medications are effective
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existing Cochrane reviews on the subject,
using all the available data from across in-
dividual reviews. In total, they collected
evidence from 267 studies, which together
involved a total of 101,804 people. The stud-ies covered a wide variety of licensed and
unlicensed smoking cessation medications,
comparing the treatments with placebo, and
the three main treatments with each other. If
a person stopped smoking for six months or
longer, this was considered a successful quit
aempt.
The three widely licensed medications
and cytisine all improved smokers chances
of quiing. The odds of quiing were about
80% higher with single NRT or bupropion
than with placebo, and between two and
three times higher with varenicline than with
placebo. However, varenicline was about 50
percent more eective than any single formu-
lation of NRT (patches, gum, sprays, lozenges
and inhalers), but similar in ecacy to com-
bining two types of NRT. Based on two recent
trials, cytisine improved the chances of quit-
ting nearly four-fold compared with placebo.
Among other treatments tested, nortriptyline,
another antidepressant drug, was more eec-
tive than placebo, but did not oer any ad-
ditional improvement when combined with
NRT.
This review provides strong evidence that
the three main treatments, nicotine replace-
ment therapy, bupropion and varenicline, canall help people to stop smoking, said lead
researcher Kate Cahill, of the department of
primary care health sciences at the University
of Oxford in Oxford, UK. Although cytisine
is not currently licensed for smoking cessa-
tion in most of the world, these data suggest
it has potential as an eective and aordable
therapy.
The researchers also assessed the safety of
dierent medications. Bupropion, which is
known to trigger occasional seizures in vul-
nerable people, did not lead to an increase in
the rate of seizures when used for smoking
cessation in its slow-release version. Overall,
NRT, bupropion and varenicline are consid-
ered low-risk treatments, although the re-
searchers say the results are currently less
clear-cut for varenicline.
Further research may be warranted into
the safety of varenicline, said Dr. Cahill.
However, in the trials we looked at we did
not detect evidence of any increase in neuro-
psychiatric, heart or circulatory problems.
READ JPOG ANYTIME, ANYWHERE.Download the digital edition today at www.jpog.com
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News | Pharmacy Today | September 20136
By Leonard Yap
The impact of age-related macular de-generation (AMD) goes far beyond vi-sual impairment as it can also greatly
aect a persons self-esteem and condence,says an AMD patient.
People [with AMD] do become very dis-tressed [with their predicament], people even
become depressed. In some cases people
even consider suicide, said Dennis Lewis, apatient ambassador for AMD Alliance Inter-national.
Patients commonly have low self-esteemand many suer from depression as they feelthey are a burden on their families and friends
because they are no longer able to performmany tasks independently, he said.
This feeling is particularly painful whenthe person is a senior member of the family.
Alternatively, it could happen to somebodywho has had a very successful career and feelsthat these achievements have become history.
[Suddenly] we are facing a future of hav-ing to rely on people for even simple thingslike pouring a drink. I would be worried thatI will spill it. So people start to feel that theyare going to be a burden on the family andyet, as the senior person, they see it as their
responsibility to look aer the family, whichis a challenge, he said.
Some people will think, I am stupid I have accidents all the time, just small acci-dents. It gnaws away at my self-esteem andindependence. Instead of pouring water intoa glass, I might miss the glass. I may walk uptwo steps and miss my step and fall.
Mr Lewis related how he once mistook hiswifes black handbag for the cat. My wifehas a black handbag with a handle and, guesswhat I stroked the other day? It was the hand-
bag and not the cat. It made me feel a bit stu-pid.
AMD is not an eye condition that makespeople completely blind. In the UK, I am le-gally registered as blind, but I can step overhere and touch the microphone. Here is mydaughter, and I can see the audience. I am notcompletely blind. This makes me feel like afraud. People feel I am a bit of a fraud and thisis how it aects the individual. Many peoplekeep these feelings to themselves, he said.
How AMD changes lives
Mr Lewis said although he was looking at theaudience, he was not certain that the audiencewas looking at him. If I go back past two orfour rows, I dont even know if you are there.
This is what people live with every day withfully developed AMD. He also spoke of howhis blindness aects his ability to communi-cate, particularly as he talked to an audience.I have some notes in front of me which Icant read easily, but I wrote them so I think Ishould know what I am saying.
The ability to read and write is oen verydicult; watching television is a challenge,even if one sits very close to it. If I watch my
favorite sport, which is football, I can see blueand red, but I cant recognize the player. So it
Seeing AMD through the eyes of a patient
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becomes very dicult.
One of the very big symptoms for me is
something that I mentioned earlier, which is
recognizing faces and communicating visu-
ally, because across a crowded room I dontknow who I know. He described how he
has to walk up to a person and stick his nose
right in front of the person to recognize who
he is talking to when he aends a confer-
ence.
I am not sure how you would react if I
came right up to you and stuck my face into
yours and said, I just want to check if I know
you. We dont want to do that, it would be in-
vading somebody elses space. This is a com-
mon problem for those with AMD. He also
related how he would oen be walking down
the street and someone would say, Hey! You
walked straight past me. Why are you ignor-
ing me?
Another serious loss is the ability to drive.
People with AMD cannot drive, thus serious-
ly aecting their independence and mobility,
he said.
He recounted how AMD took over his life
30 years ago. He used to work in the banking
industry, and the onset of the disease ended
his career prematurely. I had to stop work-
ing because I could not do my job to the best
of my ability anymore.Being plundered of good vision did not
stop Mr Lewis from living and giving back to
fellow AMD suerers by becoming involved
in the Macular Society in the UK. He eventu-
ally became a board member of the Macular
Society and a founding member of an orga-
nization which oers emotional support to
people with the condition. This is a growing
organization and we network with each other
throughout the UK to make sure emotional
support is oered wherever necessary.
Having AMD is not a death sentence, but
it is a huge challenge. With the right help and
support, one can overcome it and continue
living a good life. But prevention should be
the priority and eye health must be taken very
seriously, he added.
Mr Lewis was speaking at the recent
Retinal Diseases Awareness Week in Petaling
Jaya.
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By Pank Jit Sin
Urinary incontinence is oen mistak-
enly associated with immaturity
or impaired mental capacity. Thus,
women who suer from urinary leakage of-
ten face embarrassment and a compromised
quality of life.
This was the messaged highlighted by a
new campaign spearheaded by Poise, in
conjunction with World Continence Week
2013. Armed with the tagline Embracing the
Realities of Womanhood and Light Urinary
Leakage, Poise aimed to inspire people suf-
fering from light urinary leakage (LUL) to
arm themselves with the right information
and the right tools to manage the condition
eectively.
The campaign also endeavored to bring
positive, empowering LUL education to all
women via educational articles in the print
media, social media, radio and consumer en-
gagement programs in high-trac locations,
and retail outlets.
Poise also unveiled its new LUL pads and
liners during the event. The new pads are en-
riched with natural extracts of aloe vera andvitamin E, both proven to protect skin from
irritation.
Soo Wan Yee, marketing director of Kim-
berly-Clark Malaysia, manufacturer of Poise
products, said: Many women rely on nor-
mal liners or sanitary pads to cope with uri-
nary leaks, but these arent equipped to han-
dle them as they arent made to absorb uid
quickly or in large volumes, and not made to
prevent odor.
Hence, using wrong products leaves
women susceptible to wetness, leakage and
the strong [urine] odor this unpleasant situ-
ation can lead to discomfort, self-conscious-
ness and anxiety when they are around oth-
ers friends, family or colleagues, said Ms
Soo.
Celebrity Raja Azura, Poises ambassa-
dor and advocate for womanly confidence,
said: We need to accept LUL as a reality
and embrace the fact that it can be man-
aged with a good dose of humor, confi-
dence and the right solution Im living
proof of that!
LUL aects one-in-four women above 35
years of age at least once a week, and is anissue surrounded by embarrassment, misin-
formation and mismanagement.
Dont let incontinence put a damper on life
wrong products leaves women
susceptible to wetness, leakage and
the strong [urine] odor ...
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Relieves &SuppressesChesty Cough
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News | Pharmacy Today | September 201310
By Malvinderjit Kaur Dhillon
Endometriosis occurs when the endome-
trial lining of the uterus aaches and
starts to grow on the surfaces of organs
in the pelvic and abdominal areas, where it
does not normally grow.
Endometrial cells can implant in the ova-
ries, fallopian tubes, outer surface of the uter-
us or intestines, or in the pelvic cavity. Lesscommonly, they can be found in the vagina,
cervix and bladder.
Endometrial tissue outside the womb re-
acts to changing levels of hormones in the
body during the menstrual cycle, causing it
to grow. This can cause inammation and for-
mation of scar tissue, leading to pain.
Endometriosis is a chronic and painful
disease. In some women, there is no perma-nent cure. The pain can be both physically
and mentally exhausting, greatly impact-
ing women in the prime of their lives and
aecting their work life and personal rela-
tionships, said gynecological oncologist Dr.
Suresh Kumarasamy.
This debilitating disease aects almost a
million women during their reproductive
years. Risk factors for developing endome-triosis include women starting their period at
a young age, who have heavy or long-lasting
periods, who have short monthly cycles or
who are related to someone who has endo-
metriosis. The condition is common among
women experiencing infertility; however, it
does not prevent conception.
A recent study that investigated the link
between endometriosis, and body mass index
(BMI), found that the lower a womans BMI,
the higher her risk of having endometriosis.(Hum Reprod 2013;28(7):1783-92)
Some common symptoms of endometriosis
include chronic pelvic pain, period pain and
pain aer sexual activity. Other symptoms are
fatigue, painful bowel movements during pe-
riods and lower back pain.
A survey in Malaysia revealed that women
waited 2 years aer experiencing symptoms of
endometriosis before they sought treatment.Over 60% of these women delayed seeking
treatment as they expected their symptoms to
go away. I urge women with symptoms suspi-
cious of endometriosis not to suer in silence
and to seek medical aention as early as pos-
sible, said Dr. Suresh.
Diagnosis of endometriosis can be chal-
lenging as symptoms may not always be
present. Dierent women experience dier-ent degrees of pain and the amount of pain
experienced is not always related to the size
or number of endometrial lesions. The lack of
awareness surrounding endometriosis causes
women to link their symptoms to dysmenor-
rhea. Endometriosis is diagnosed by physi-
cal and pelvic examinations, ultrasound and
magnetic resonance imaging (MRI) tests and,
most accurately, laparoscopy. Sometimes, a
biopsy is also done to conrm the diagnosis.
Endometriosis the painful truth
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The aim of treatment is to relieve pain,
slow the growth of the endometrium-like tis-
sue, improve or protect fertility, and prevent
the disease from recurring.
There is pressing need for more eectivetreatment options for endometriosis. Cur-
rent treatments oen do not meet the needs
of all women living with endometriosis and
may only be safe and/or eective for a limited
period of time. For example, GnRH analogue
injections are currently the most eective op-
tion for women suering from endometriosis,
but these can only be used for 6 months due
to concerns about side eects, including bone
thinning, said Premitha Damodaran, a con-
sultant obstetrician and gynecologist.
Dr. Suresh and Dr. Premitha were speak-
ing at the launch of Visanne, a new oral treat-ment for endometriosis containing dienogest.
Dienogest has been found to signicantly
reduce pain associated with endometriosis. It
also reduced the severity of endometriosis, with
one-third of diagnosed women no longer hav-
ing evidence of endometriosis aer 24 weeks
of treatment with dienogest. (Int J Gynaecol Ob-
stet 2010;108:21-5)
By Leonard Yap
Alpha lipoic acid (ALA), a compoundinitially classied as a vitamin when
it was rst discovered more than half
a century ago, possesses potent antioxidant
properties that could prevent healthy cells
from geing damaged by free radicals.
The new interest in ALA was aer mount-
ing evidence showed its potential in the treat-
ment of nerve damage and diabetes, said an
expert.Research has shown that ALA is many
times more potent as an antioxidant than vi-
tamins C and E. This may be due to the fact
that ALA dissolves in both fat and water, said
Lenny da Costa, a consultant geriatrician,
preventive cardiologist and specialist in anti-
aging therapy.
This gives it a unique ability to scavenge
more wayward free-radical cells than most
other antioxidants, which either tend to dis-
solve in fat or in water, he said.
ALA exists in many foods. It is also madenaturally in our bodies, but only in tiny
amounts. ALA helps protect the mitochon-
dria, the cells powerhouse, and DNA materi-
al from oxidative stress. ALA also works with
vitamins C and E by recycling them, making
them more eective. Currently, there is no
other antioxidant that can perform this feat,
said Dr. da Costa.
ALA also assists the B vitamins in produc-
ing energy from proteins, carbohydrates and
ALA to the resuce!
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FAQs on ED answered
fats from food, he added. It is used in the body
to induce the breakdown of carbohydrates
and to make energy for organs in the body.
Several studies have found that ALA can
improve insulin resistance. They have alsodiscovered that ALA supplements can help
with neuropathy, nerve damage caused by
diabetes or cancer treatment. ALA appears
to reduce symptoms like pain, tingling, and
prickling in the feet and legs. It may also help
protect the retina from some of the damage
that can occur due to diabetes.
There is some early evidence that long-
term use of ALA may help with the symp-
toms of dementia. Other studies suggest that
ALA creams could repair skin damage related
to aging. ALA has also been researched as a
treatment for many other conditions. These
include Amanita mushroom poisoning, glau-
coma, kidney disease, migraine and periph-
eral arterial disease. The evidence for these
indications remain unclear.
Though the eects of ALA on diabetes and
cancer are promising, patients should seek
proper medical treatment rst.
Dr. da Costa was speaking at the 10th Ma-
laysian Conference and Exhibition on Anti-
Aging, Aesthetic and Regenerative Medicinein Kuala Lumpur.
Natural sources of ALA
Many foods contain ALA in very low amounts.
These include spinach, broccoli, yams, pota-
toes, yeast, tomatoes, brussels sprouts, car-
rots, beets and rice bran.
Red meat, particularly organs like liver, is
also a good source.
How much to take?
ALA is an unproven treatment and there is no
established dose. Some studies used between
600-1,200 mg daily for diabetes and neuropa-
thy. One review concluded that the evidence
is convincing for the use of 600 mg daily for
three weeks to treat symptoms of diabetic
neuropathy.
By Malvinderjit Kaur Dhillon
Afree booklet entitled Your Question
on ED is now available to the public.
It aims to provide answers to ques-
tions frequently asked by Malaysians about
erectile dysfunction (ED).
Malaysian men and their spouses still nd
it dicult to talk about their sexual health and
address their ED condition with their doctor
or healthcare professional. Understanding
their sentiments, we collaborated with phar-
macies to make available a private platform
for members of the public to ask any ques-tions about ED which they deemed too em-
barrassing to ask their doctor, said Vicknesh
Welluppillai, medical director of Pzer.
We were overwhelmed by the response
and hope the answers stated via the booklet
will motivate them to seek further treatment
of their ED condition via the proper chan-
nels as stated in the booklet. The booklet also
serves to increase their understanding of ED
as a medical condition, which could also be a
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pre-cursor to other medical conditions, said
Dr Vicknesh.
Among the questions asked by men and
women aged 21 to 65 were Whom should I
consult if I suspect that I have ED, Can ED betreated? and Is ED caused by low testoster-
one level or low libido?. The most repeatedly
asked questions were picked and answered
by Ong Teng Aik, a consultant urologist at
University Malaya Medical Centre (UMMC).
People may not be aware that, amongst
others, hardness level is the rst indication if
someone has ED. There are four hardness lev-
els for men to gauge if they have ED and theErection Hardness Score (EHS) Grade, which
ranges from 1 until 4, is clearly explained in the
booklet. Grade 1 means severe ED, where your
erectile hardness is akin to the soness of a
tofu, Grade 2 is akin to a peeled banana, Grade
3 an unpeeled banana and Grade 4, a cucum-
ber, which is the best erectile hardness you will
want. It is important for men and women to
be satised with erection hardness as penilehardness is associated with satisfaction with
sex and with life overall, said Prof. Ong.
According to the 2009 Ideal Sex Survey,
both men and women in Asia agreed that
erection hardness or the ability to maintain
an erection ranks as the most important ele-
ment for ideal sex. Eighty percent of men and
women valued the quality of sex over quan-
tity of sex.Late last year, Pzer Malaysia launched
this initiative under its We Love, Sustaining
Passions Campaign to encourage couples to
ask questions and arm themselves with the
power of knowledge on ED. This eort led
to couples enjoying greater intimacy and
strengthened bonds.
Query boxes were made available at se-
lected pharmacies, providing an outlet for
the public to drop o any ED-related ques-
tions and have them answered by a qualiedhealthcare professional.
The booklet also includes facts from the
2009 Ideal Sex Survey and The Asia Pacif-ic Sexual Health and Overall Wellness (AP
SHOW) survey. The objectives of these sur-
veys were to examine the perception of men
and women on ideal sex, and the importance
of erectile hardness in their relationship and
satisfaction with life overall.
The booklet is available at more than 80
participating pharmacies in three dierent
languages; English, Bahasa Malaysia and
Chinese.
Eighty percent of men and
women valued the quality
of sex over quantity of sex
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News | Pharmacy Today | September 201315
Tracking of polypharmacy across Dis-trict Health Boards (DHBs) in New
Zealand has highlighted a trend of old-
er people taking multiple medications, which
may be doing more harm than good.
While rates varied from DHB to DHB,
the Health Quality and Safety Commissions
(HQSC) new Atlas of Healthcare Variation
shows a high rate of polypharmacy in elderly
people across the board, which increases aspeople age.
Around one-in-four people aged 65 to 74
received ve or more long-term medicines in
2011, according to national data.
This gure doubled once people reached
85, and those aged 85 and over were 2.5 times
more likely to receive 11 or more medicines
than those aged 65 to 74.
The frequency of adverse drug events in-creases with the number of medicines taken:
13% with two medicines, 58% with ve medi-
cines and 82% when seven or more medicines
were taken, the HQSC website said.
While these increased rates do not neces-
sarily indicate overprescribing, older people,
especially if frail or suering from multiple
conditions, are more vulnerable to medicine-
related illness and death.Possible negative outcomes of polyphar-
macy are reduced adherence, high costs for
both patients and health services, and in-
creased adverse eects and interactions.
Also of concern to the HQSC is an increase
in prescriptions of benzodiazepines and anti-
psychotics as people get older.
People on these drugs have a substantially
higher risk of adverse eects, including im-
paired functional ability, agitation, confusion,
blurred vision, urinary retention, constipa-tion, postural hypotension and falls. Combin-
ing the two drugs further increases the chance
of adverse eects.
According to the HQSC Atlas, up to one-in-
ve people aged 85 years and over were given
benzodiazepines or antipsychotics in 2011.
While the rate of concurrent use of the two
is reassuringly low, the variation between
DHBs indicates a lack of standardized prac-tice, the atlas accompanying commentary
said.
Auckland DHB had the highest rate of con-
current use with 13 elderly people per 1000 on
both types of drugs, followed by Canterbury
at 12.1, and Nelson-Marlborough at 11.1.
The regions with the lowest concurrent use
were Tairawhiti (3.7), West Coast (5.9) and
Counties Manukau (6.8).
Challenging information
As a geriatrician in Canterbury and chair of
the HQSC Polypharmacy Expert Advisory
Group, Nigel Millar said he found some of
the information revealed in the atlas, such
as the high rate of polypharmacy for elderly
Cantabrians compared with other areas very
challenging.The prime purpose of the atlas is to make
variations in services visible because whenev-
er variations exist, there is usually an oppor-
tunity to improve equity in health services, Dr
Millar said.
Variation in the supply of medications is
generally due to the health system rather than
dierences in populations, he said.
Benzodiazepines are an example of wide
variation in medication. Some areas gave
New data shed light on polypharmacy
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them to one-in-20 elderly people, while one-
in-10 received them in the highest areas.
In the 85-plus age group, one-in-ve people
were receiving benzodiazepines in some areas.
Local communities need to decide whetherthese drugs are absolutely essential treatment
for elderly patients.
We have work to do to look at prescrip-
tion paerns and make sure we are doing the
right thing, Dr Millar said.
There is slim to no evidence of the ecacy
of many drugs in the frail elderly with mul-
tiple comorbidities because clinical trials tend
to pick younger test subjects with only one
condition, he said.
At the same time, doctors are dealing with
the pressures of feeling the need to prescribe
drugs to reduce the risk of diseases like heart
aacks and strokes.
More research is needed into the benetsand harms of giving multiple medicines to
elderly patients with multiple comorbidities,
and health professionals need beer informa-
tion presented to them, with a focus on how
likely the drugs will work on an individual,
Dr Millar said.
He hopes every pharmacist will look into
the information presented in the atlas, ask
what it means for them and have a debate
about it in the wider community.
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Feature
Insomnia aects people in various ways,from having trouble going to sleep, to hav-ing a disturbed sleep and waking up sev-
eral times throughout the night.Anxiety causes feelings of being tense, ner-
vous and worried, and it can trigger sleepingproblems. Both health issues can cause dis-ruptions to peoples everyday lives.
A New Zealand pharmacist, Ban Quillin-
ichi, said his Auckland city sta regularlytreat people with sleep problems who want to
try a complementary health solution so as toavoid taking prescription medications.
People always have a concern that theywill come to rely on it [prescription medica-tion], she said.
In such instances, Ms Quillinchi most of-ten recommends magnesium supplements,which help relax the muscles, aiding peopleto get to sleep. Magnesium is also particular-
ly benecial for those who are have troublesleeping due to stress.
Natural remedies often first choice for
anxiety and insomniaMany insomnia and anxiety sufferers go to the pharmacy for natural health supplements as first-line
treatment before seeing a GP, say pharmacy staff, as Pharmacy Today New Zealand reports
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Feature | Pharmacy Today | September 2013 Sleep & Insomnia19
Products with passionower can help peo-ple sleep as it has a drowsiness eect.
Increasingly, people come into her phar-macy aer searching information on the In-
ternet, but oen what they have read is incor-rect, such as dosage information, she said.
Pharmacists should be aware of this andadvise customers on options and correct dos-ages, Ms Quillinchi said.
A retail manager at another pharmacy, Del-wyn Galbraith, also regularly gives comple-mentary healthcare advice to people sueringfrom insomnia and anxiety.
Ms Galbraith agreed there is a stigma ofaddiction to prescription medicines, so peo-ple oen seek a natural alternative.
She also recommends passionower andmagnesium products for insomnia and anxi-ety, as well as chamomile tea for sleep support.
She frequently recommends vitamin Bsupplements to aid anxiety as it helps to sup-port the nerves.
As a retail manager, she is clear about
where her limitations lie in recommendingthese products, and will always call a phar-macist into the conversation if the person istaking other prescription medications, or hasother health issues, to check for contraindica-tions.
Tart cherry, valerian root are great aidsMedical researcher Shaun Holt said there are
a number of natural health products whichare eective in treating both insomnia andanxiety issues.
While tart cherry is quite new to the mar-ket as a sleep aid, Mr Holt says there is somemerit to its use.
Tart cherry contains naturally occurringmelatonin, which helps to promote sleep. Anumber of studies also back its use.
However, both Ms Quillinchi and Ms Gal-
braith are reluctant to recommend tart cherrysupplements, as they say they have more ex-
perience with other supplements.Interestingly, melatonin supplements are
only available on prescription in New Zealand.In America you can buy it [melatonin]
from the corner store, but here its classed as ahypnotic, Mr Holt said.
He believes a move to reclassify melatoninas a pharmacy-only medicine would make itmore accessible to New Zealanders sueringfrom sleep deprivation.
Valerian root is a safe and natural sedative,and can be used to help treat insomnia andanxiety, he said.
However, due to its strength, pharmacistsshould make the same recommendationsthey do for alcohol, Mr Holt said.
Do not operate heavy machinery, be carefulwith, and avoid where possible, using othersedatives, and monitor alcohol consumptionif taking valerian root, he added.
People with insomnia and anxiety issuescould also consider kava. Widely used in thePacic islands, the roots are used to create a
drink which has sedative properties.Other products for helping with anxiety
and sleep include tryptophan and 5-hydroxy-tryptrophan, which are both amino acids.
Researchers have found high levels oftryptophan in turkeys, which is said to be thecause of the drowsy feeling aer consuming aturkey dinner, he says.
Aromatherapy can also help relax people,
which may work as a sleep aid. While Mr Holtrecommends all of these products for treatingboth sleep and anxiety, he specically sug-gests vitamin B supplements, in a tablet form,for anxiety.
There is also weak evidence to supportthe use of chamomile tea as a sleep aid, but herecommends the other options rst.
Manage peoples expectations
It is important that pharmacy sta managepeoples expectations when recommending
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Feature | Pharmacy Today | September 2013 Sleep & Insomnia20
natural health supplements for anxiety and
insomnia.
It is sometimes trial and error and [eec-
tiveness] does depend on the individual, Ms
Galbraith said.Products can take two to three weeks to be
eective and people should be aware of this.
The pharmacy sta should also follow up
with people, particularly elderly patients,
about a week aer they have started taking
natural supplements for insomnia, to see
if they have been eective or whether they
should try something else.
Go beyond selling products
The experts all stress the importance of help-
ing people get to the root cause of their in-
somnia or anxiety issues, with a particular
focus on individual lifestyles.
For example, people should take into ac-
count how much caeine they have through-
out the day specically coee and energydrinks.
As both are stimulants, they hype people
up and it may take them a while to fall asleep
at night, Ms Galbraith said.
One customer came into the pharmacy
complaining of trouble going to sleep, but
when asked about her coee drinking habits,
she admied she drank around ve cups a
day.
Sleep disruption is also oen linked to
drinking excessive alcohol or a lack of regular
exercise, Mr Holt said.
Treat anxiety with compassion
New Zealanders are some of the most
anxious people in the world, second
only to Americans, according to Te
Rau Hinengaro the New Zealand Mental
Health Survey (2006; Wellington: the Ministry
of Health).
In a 2004 survey of 13,000 New Zealand-
ers, 14.7% of respondents said they sueredfrom anxiety. The corresponding US gure is
18.2%.
While most people experience a certain
amount of anxiety in their day-to-day lives,
according to the New Zealand Phobic Trust
website, suering from generalized anxiety
disorder can be debilitating. (www.phobic.
org.nz/)
People with generalized anxiety disorder
have chronic and exaggerated worry and ten-
sion, usually without any tangible cause.
Having this disorder means always an-
ticipating disaster.
Sometimes, simply the thought of geing
through the day provokes anxiety.
Suerers realize their reactions are dispro-
portionate, but are unable to control them.
They oen also have trouble sleeping.Physical symptoms can include trembling,
twitching, muscle tension, headaches, irrita-
bility, sweating and hot ushes.
Suerers may feel lightheaded or out of
breath. They may feel nauseated or have to go
to the bathroom frequently, or they might feel
as though they have a lump in the throat.
They tend to feel tired, have trouble con-
centrating and oen also suer from other
mental and/or physical disorders. General-
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ized anxiety disorder is a gradual disease,
most oen developing in childhood or ado-
lescence.
It is diagnosed when someone spends at
least six months worrying excessively about anumber of everyday problems.
However, the Best Practice Journal warns
that conditions which cause symptoms simi-
lar to anxiety should be considered when
making a diagnosis.
This includes hyper- and hypothyroidism,
angina, asthma, depression and substance
misuse, e.g. caeine, amphetamines, canna-
bis, cocaine.
Some medications also cause symptoms of
anxiety, such as anticholinergics and toxicity
from digoxin (Best Practice Journal 2009;25:20-8).
Show compassion and encourage seeking
help
Mental Health Foundation of New Zealand
chief executive Judi Clements said while there
is more awareness of depression due to ad-vertising campaigns, anxiety is also a com-
mon occurrence and the two disorders oen
go hand-in-hand.
Many people suer from anxiety and still
cope well. It is when it tips over into the per-
son not being able to function fully that peo-
ple need to seek help, Ms Clements said.
Some suerers become so anxious that
they cannot cope with life, she said.
The advice for people suering from anxi-
ety is to seek help, to look at their lifestyle,
especially whether they are geing enough
sleep.
Looking aer your mental health is not
something anyone else can do for you, Ms
Clements said.
A pharmacist may be the rst point of callfor those suering from anxiety because they
do not have to make an appointment and it is
free, she said.
People may also come in looking for over-
the-counter supplements to help with anxiety
aer having done their own Internet research.
A good question to ask is whether they
have already talked to someone, such as their
GP, about their anxiety.
If they have suered from anxiety before, it
is helpful to ask who they talked to about it in
the past and what worked for them last time.
Taking the time to listen and asking if they
are alright really helps.
Showing compassion is one of the most im-
portant things you can do for a person with
mental health issues as they are oen already
in a state of hypersensitivity and can easily
feel like they are being ignored or not taken
seriously.
Pharmacists should talk patients through
potential side eects from anxiety medica-
tions and refer them back to their GP if the
drugs are not working for them.
Treatments
Cognitive and anxiety management therapiesare both eective treatments, Otago School of
Medicine lecturer Christopher Gale said in a
clinical review of generalized anxiety disor-
der published in the British Medical Journal
(2007;334:579-81).
Anxiety management therapy is a struc-
tured therapy involving education, relax-
ation training, and gradually increasing
exposure to something which triggers anxi-
ety, oen through visualizations or images.
Showing compassion is
one of the most important things
you can do for a person with
mental health issues
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Feature | Pharmacy Today | September 2013 Sleep & Insomnia22
ResourcesThere are several online resources which pharmacists can direct their patients to:
l The Malaysian Psychiatric Assocation (MPA) oers a range of mental disorders resources
which can be accessed atwww.psychiatry-malaysia.org/listcat.php?cid=6
l The MPA website also provides a list of support groups and a list of private psychia-
trists registered with it.
l The Malaysian Mental Health Association (MMHA) also provides information on
understanding mental health at www.mentalhealth.org.my
lMMHA organizes various programs and activities including two rehabilitation pro-
grams to help people with mental disorders to reintegrate into their community.
l Patients can also turn to Befrienders (www.befrienders.org.my), a safe platform estab-
lished to provide emotional support for people who need a listening ear or a shoulder
to cry on.
Cognitive behavioral therapy involves rec-
ognizing and challenging false underlying
thought paerns which help create anxiety
and depression.
Antidepressants, benzodiazepines, buspi-
rone and kava all reduce anxiety, but they oen
have clinically signicant side eects which
can aect adherence, Dr. Gale said.
Working against the clock makes you fat
Shi work is becoming increasingly common
in our modern, 24/7 society. Gone are the
days when everyone worked 9-to-5 or, as
in earlier eras, rose at dawn and slept at nightfall.
Health website everybody.co.nz denesshi work as work which starts before 8am or
nishes aer 6pm or any work hours which
cause a change in normal sleep paerns.
Many industries literally operate around
the clock, and sta who do shi work need to
learn how to cope with not just a lack of sleep,
but also a range of possible health eects.
It is one of the leading causes of fatigue.If youre working as a truck driver, a nurse or
police ocer, for example, you will at some
stage be required to work when your body is
naturally at rest this disrupts your natural
body clock and can lead to fatigue, physical
and mental ill health and accidents, which are
more common between midnight and dawn,
the website said.
Working at night has a greater impact than
working the same number of hours during the
Staying awake late into the night
and being woken by alarm clocks
means our natural circadian rhythms
are out of synch with modern life
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Feature | Pharmacy Today | September 2013 Sleep & Insomnia23
day. Shi workers lose an average of between
one and one-and-a-half hours sleep each 24-
hour period. Aer four nights, workers will
have lost six hours of sleep. To compensate, they
need at least two consecutive full nights sleep.
The only way to recover from fatigue is
to get adequate sleep. The average amount
of sleep needed to be healthy and alert is be-
tween seven and nine hours a night.
According to the New Zealands Ministry
of Business, Innovation and Employment,
there are three steps to managing workplace
fatigue consultation, evaluation, and train-
ing and education.
Employers should make sure sta take
regular rest breaks, be aware of times people
are most likely to be aected by fatigue, and
manage shi work and overtime so employ-
ees have opportunities to recover.
Creating the right environment to recover
from night shi is vital. Leing family, neigh-
bors and friends know and understand shi
schedules will make them more cooperative.
Keeping the bedroom dark, cool and quiet isimportant, as is having a routine to wake up.
Everybody.co.nz recommends shi work-
ers sleep only long enough aer their last shi
in the cycle to feel refreshed, and still be able
to sleep later that night.
Sleeping longer or napping can delay the
adjustment to a regular, daytime work/sleep-
ing paern.
Exercise and avoiding sleeping pills and al-
cohol are also benecial to normal sleep.
There is a recognized condition suered
by some shi workers known as shi work
sleep disorder, with symptoms including in-
somnia, excessive sleepiness, headaches, ir-
ritability, reduced concentration and a lack
of energy.
Some researchers have also identied a syn-
drome known as social jetlag, which may be
causing not only sleep deprivation, but obesity.
Staying awake late into the night and being
woken by alarm clocks means our natural circa-
dian rhythms are out of synch with modern life.
A team from the University of Munich
has been collecting data from thousands of
participants to learn about social jetlag (doi
10.1016/j.cub, 2012.03.038).Social jetlag quanties the discrepancy
that oen arises between circadian and social
clocks, which results in chronic sleep loss, re-
searcher Till Roennberg said. The circardian
clock also regulates energy homeostasis and
its disruption as with social jet lag may
contribute to weight-related pathologies.
Our results demonstrate that living
against the clock may be a factor contribut-ing to the epidemic of obesity.
Possiblehealtheectsoflostsleepinclude:l mental ill healthl obesityl type 2 diabetesl heart diseasel accidents.
Employees should know about:l
What to eat and when.l The impact of caeine and alcohol
on sleep.
l How to make the most of breaks.
l How to use recovery and rest time
appropriately.
l How to adjust sleeping areas to pro-
mote good sleep.
l How to recognize fatigue.
lGeing to and from work safely.
l The impact of exercise on fatigue.
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Feature | Pharmacy Today | September 2013 Sleep & Insomnia24
Insomnia closely linked to depression
Anyone who has suered from insom-
nia will know what a frustrating andstressful condition it can be. Insomnia
literally means without sleep. Sleep is essen-tial to health, and being deprived of it can causemany physical and psychological problems.
Whether it is caused by an overactive mind,a health issue or simply extraneous noise, los-ing even small amounts of sleep can have acumulative eect.
A sleep researcher at Auckland Universitysschool of population health, Karen Falloon,said depression and anxiety are the biggest
causes of insomnia. They are dierent fromother causes such as temporary life stresses andso-called sleep hygiene issues, including caf-feine or alcohol intake, discomfort and noise.
The rst thing when treating it is to de-termine which sleep disorder you are dealingwith, Dr. Falloon said.
There are simple things which can help,such as reducing or entirely cuing the intakeof caeine. People should also try to get intoa routine and not overcompensate for poorsleep by going to bed too early. Make sure
you are sleepy when you go to bed.Curiously, some insomnia suerers report
being tired or exhausted but not sleepy.Many people will suer from transient
insomnia during their lives and get over it,but others will suer from chronic insomniawhich can last for months or years, Dr. Fal-loon said.
Psychological problems and insomnia canbe closely linked, she added. There is anincrease in the risk of developing depressionand anxiety. However, there is a chicken andegg element, and depression and sleep issuesalso need to be treated separately, and othercauses of insomnia considered.
Insomnia is also being linked to otherhealth issues. There is building evidence that
there are some cardiovascular complicationswhich can occur, Dr. Falloon said. There iseven some evidence about an increased riskof myocardial infarction. And there are thequality of life things such as irritability andrelationship stress, which are not to be takenlightly.
But can a lack of sleep actually cause death?In a nutshell, yes, Dr. Falloon said. However,she explained, this is more likely to be as a re-sult of accidents, particularly car crashes, rath-er than a physiological cause.
Many factors can contribute toinsomnia. These include:l stress
l alcohol, nicotine and caeine con-
sumption
l depression or anxiety
l other medical conditions and medi-
cines
l snoring and breathing diculties
l tooth grinding
l ongoing pain
l restless legs.
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Spotlight| Pharmacy Today | September 201325
Sniffing out the difference between a cold
and the flu
Spotlight
Inuenza and the common cold share
many symptoms, and people oen be-
lieve one is merely a stronger version of
the other.
When someone is suering from a nasty
head cold, blocked nose, streaming eyes, sore
throat and perhaps a cough, its easy to be-
lieve it is u.
However, u is a much more serious ill-
ness, strains of which have been responsible
for countless deaths over the course of history.
Medical experts are quick to point out that
the two ailments are quite dierent.
A community health website, www.my-
health.gov.my, provides information on cold
and u. These are commonly confused with
one another, especially when it comes to treat-
ment.
A fever is oen an indication a person has the u rather than a cold
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However, there are many dierences. The
cold and u are two dierent illnesses caused
by dierent types of viruses. They aect dier-
ent areas of the body, the speed with which the
symptoms emerge dier and they vary in sever-
ity. The u is preventable, while the cold is not.
Cold symptoms typically last from one to
ve days. Usually, irritation in the nose or a
scratchy feeling in the throat is the rst sign,followed within hours by sneezing and a wa-
tery nasal discharge. Colds tend to last about
a week, with perhaps a few lingering symp-
toms, such as a cough, for an additional week
or so.
The u can have much more serious ef-
fects, making suerers feel sick all over. It is
caused by a single family of viruses and con-
tracted by a similar means as the cold, whichis coming into contact with the virus through
touching an infected area door handles, ta-
bles, etc or being around a person infected
who coughs or sneezes.
The u is highly contagious, but short-
lived. Usually, both the cold and u will sub-
side on their own within a week.
However, it is recommended to use medi-
cation to treat the symptoms. If symptomspersist or become more severe aer a week,
medical advice should be sought, advised
www.myhealth.gov.my.
Some New Zealand experts are predicting
a bad u season if the paern seen in the US is
repeated there. The US has had its worst out-
breaks since the inuenza pandemic which
began in 2009.
In that year, more than 1,400 people with
inuenza were treated in New Zealand hos-
pitals.
Pharmacists acknowledge grey areaNew Zealand pharmacist David Postlewaight
has already seen quite a few customers with
winter ailments over the past few weeks.
He described the dierence between a cold
and u as a bit of a grey area.
Its hard to make a distinction between
a cold and the u. I suppose the severity of
symptoms dictates whether or not we refer to
the doctor.
If they are managing to struggle along
with daily tasks and just need symptom re-
lief, we oer OTC products. If its more severe
and the patient is struggling to do normal
daily tasks or seems to have secondary infec-
tion, such as green or brown phlegm, then we
refer to the doctor. Also, if it seems to be a pro-
longed bout, we oen refer.
Graeme Brash, from Ascot Amcal Pharma-
cy in Invercargill, New Zealand, agreed there
is confusion among customers about what
constitutes a cold, as opposed to u.
Customers generally lump everything to-
gether as u, Mr Brash said.
Our job is to dierentiate it for them, and
the classic symptom which dierentiates it is
fever.Products which oer symptomatic relief
for both ailments are the pharmacys biggest
sellers during winter, but its also important
to give the right advice, Mr Brash added.
Its really important with u and fever
that patients get uids and electrolytes.
Mr Brash also refers patients to their GP if
symptoms are severe or long-lasting.
... there is confusion among
customers about what constitutes
acold,asopposedtou
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Decongestant spray for relief of nasal
congestion
We all know how frustrating it feelsto not be able to breathe properlyand to have the blocked nose sen-
sation return no maer how many times youblow your nose. It is also inconvenient to haveour hearing and sense of smell impaired
It is a common misconception that nasal
congestion is caused by accumulation of ex-cess mucus, leading to the blocked nose sen-sation.
Nasal congestion is typically caused by theswelling of the mucosal lining. Several biolog-ically active agents such as histamine, tumornecrosis factor-, interleukins and cell adhe-sion molecules contribute to inammation,which can manifest as venous engorgement,increased nasal secretions and tissue swell-
ing/edema. This leads to impaired airowand the sensation of nasal congestion.
Nasal congestion aects various age groupsand can cause discomfort. In older childrenand adolescents, nasal congestion is oen justan annoyance. However, it may cause otherproblems as it can interfere with hearing andspeech development. Nasal congestion canlead to sequelae such as sinusitis and otitis
media. It can accelerate the onset or worsen-ing of mild-to-severe sleep disturbances, in-cluding sleep apnea. These sleep disturbancescan detrimentally aect a persons daytimeenergy levels, mood and daytime functions.This, in turn, can aect performance in schoolor at work.
A study published in Treatments in Respi-ratory Medicine looked at the impact of nasalcongestion on quality of life and work pro-
ductivity in allergic rhinitis. Of the 2,355 par-ticipants, 85% had nasal congestion and this
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was the one symptom that most adults andchildren wished to prevent. It was found thatnasal congestion aected most participants atwork or school, had a notable emotional im-
pact and hampered their ability to performdaily activities. [2005;4(6):439-46]
A congested nose may occur when a per-son has the common cold, u or a sinus in-fection. It can also be caused by hay fever orother allergies, nasal polyps, pregnancy andvasomotor rhinitis.
Home remedies can help provide a tempo-rary relief from a blocked nose. It is impor-
tant for the nasal passages to be kept moist asbreathing in dry air dries up the membraneand further irritates it. Patients can use a hu-midier or a vaporizer to prevent the nasalpassages from drying up. Taking a hot show-er and breathing in the steam can also providerelief. An alternative to this is to carefully
breathe in steam from a bowl of boiling water.Increasing uid intake is also recommend-
ed to help thin out the mucus. Patients can
also use a warm compress on the face. Placinga towel soaked in warm water on the face mayhelp open up nasal passages. When sleep-ing, keeping the head elevated by proppingthe head with several pillows can help make
breathing more comfortable.Otrivin, a decongestant nasal spray, helps
provide long-lasting relief from congestion.The spray is applied directly to nasal tissue
and it works right away, with its decongestanteect lasting up to 10 hours.Otrivin is available in exible dosage in
a convenient and easy-to-use packaging. Itcontains the active ingredient xylometazolinehydrochloride, which constricts nasal bloodvessels and increases nasal airow, making itmuch easier for patients with a blocked noseto breathe.
A double-blind placebo-controlled parallel
group study investigated groups of patientswith a common cold who were treated with
Otrivin nasal spray or placebo (saline solu-tion). The study primarily aimed to determinethe decongestion eect. Secondary objectivesof the study were to determine the peak sub-
jective eect, duration of relief of nasal con-gestion, cold symptoms and general well
being of patients and adverse events. [Am JRhinol & Allergy 2008;22:1-6]
The decongestant eect of Otrivin wasfound to be signicantly greater than placeboas demonstrated by nasal conductance at onehour aer spraying with the nasal spray. Na-sal airow remained above the threshold for
nasal obstruction for up to 10 hours.Otrivin was also found to improve commoncold symptoms such as runny nose, blockednose, sore throat and ear ache, leading togreater patient satisfaction with treatment.
Otrivin provides double-acting relief, com-bining a vasoconstrictor eect with a mois-turizing formula. It contains two moistur-izing ingredients which are no strangers tothe pharmaceutical and cosmetics industry
sorbitol and hydroxypropyl methylcellulose(HPMC).
Sorbitol, oen used as a moisturizer, helpsnormalize the level of liquid in mucosa, ensur-ing that dryness and irritation do not occur. Itprovides a soothing eect. HPMC strength-ens the moisturizing eect and prevents nasalmucosa from drying out.
Otrivin is indicated for patients with colds
of various types, to aid drainage in sinus con-ditions, as an adjuvant to decongest the na-sopharyngeal mucosa in otitis media and tofacilitate rhinoscopy.
Contraindications for Otrivin include dryrhinitis, acute angle glaucoma or known hy-persensitivity to ingredients of the product.Caution should be used in patients with hy-pertension, cardiovascular diseases and hy-perthyroidism. Due to its vasoconstrictive
properties, Otrivin should be avoided duringpregnancy as a precaution.
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The right needle matters in insulin therapy
Insulin therapy is primarily injection ther-
apy, and the needle provides the means ofpenetrating the skin barrier.
In addition to penetrating the skin, the
needle provides the means of transporting
insulin through the underlying tissue to the
deposition area near the bloodstream in the
subcutaneous tissue.
Considering these key roles, the design and
structure of the needle plays a pivotal role in
inuencing the successful outcome of insulintherapy. The functional design of the needle in-
uences the usage of the needle, its ease of use,
the application of the correct injection tech-
nique and the ease of choosing an individually
correct needle. All these factors greatly inu-
ence user preference and satisfaction.
Importantly, the structure of the needle
inuences the correct deposition and absorp-
tion of insulin and, thereby, metabolic con-
trol. The needle length determines the correct
depth of the deposition. The diameter deter-
mines the potential post-injection leakage and
the sharpness inuences the severity of both
acute and chronic tissue damage.The injection process will always cause
some tissue damage accompanied with pain
or discomfort, and will usually cause a certain
level of anxiety, especially among new users.
Most people are uncomfortable with the
thought of having injections, especially the
idea of injecting themselves. While this anxi-
ety generally disappears once the person has
tried a few injections, as many as 10% of peo-
ple with diabetes suer from a fear of needles
to the point where needle anxiety is an obsta-
cle to overcome. (J Fam Pract 1995;41(2):169-
75) People with type 2 diabetes might bypass
injections or avoid taking injections for a more
extended time.
It is important to distinguish between the
actual or real pain and perceived pain experi-
enced when using a needle. Real pain causedby the actual stimulation of pain receptors is
mostly inuenced by the needle diameter a
needle with a larger diameter touches more
nerve endings, causing more pain. A longer
needle, on the other hand, causes painful per-
foration of the muscle fascia.
Other factors inuencing the level of real
pain are the sharpness of the needle tip and
the smoothness of the surface.
Perceived pain is psychological in nature,
Most people are uncomfortable
with the thought of having injections ...
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Spotlight| Pharmacy Today | September 201330
but of signicant clinical importance. It is the
type of pain most oen involved in needle
anxiety and, therefore, a very serious barrier
to the initiation of injection therapy. A key fac-
tor is the appearance of the needle.People with type 2 diabetes are mostly old
or elderly, while people with type 1 diabetes
are oen children when diagnosed. All require
ease of use, good ergonomics, easy handling in
mounting and a low force for injection.
For optimal ease of use, it is important that
a minimum number of steps are involved in
the overall process. In addition, the needle it-
self needs to be easily disposable.
The new NovoFine 32G Tip ETW (Extra
Thin Wall) is now the new standard in gentle
injections. Its Tapered tip technologyTM is a
unique needle geometry where the needle ta-
pers to a 32G tip, making it the thinnest insulin
needle, hence, less pain and bleeding and gen-
tle to insert. (Somatosens Mot Res 2006;23:37-43)
It is chemically polished and silicone coated toremove surface imperfections for a smooth in-
jection, and causes less pain on insertion. Its
thin wall technology results in less force need-
ed when injecting. It is of ideal needle length
(6 mm) and provides safe and eective insulin
injections for most people, with less discom-
fort and psychological fear.
Furthermore, the NovoFine needle is for
single use only. Reused needles may cause in-
creased pain, increased risk of infections, lipo-
hypertrophy, altered insulin ow and change
in insulin concentration.
Pharmacy Update brings you updates on disease management and advances in
pharmacotherapy based on reports from symposia, conferences and interviews,
as well as latest clinical data. This months updates are made possible through
unrestricted educational grants from MSD.
Early combination therapy treats diabetes to target, delays insulin initiation P31
Pharmacy UPDATE
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31 Pharmacy Update
Early combination therapy treats diabe-
tes to target, delays insulin initiation
The use of multiple treatment modali-ties early in the diagnosis of diabetesallows a longer time frame before
insulin initiation, says a prominent endo-crinologist.
Richard OBrien, clinical dean of medi-cine and chair, Academic Center, Univer-
sity of Melbourne, Australia, said currentdata point to the use of multiple treatmentmodalities earlier in the course of diabetesto bring patients to target and to keep themon target for a longer period of time.
In his presentation at a symposiumsponsored by Merck Sharp & Dohme(MSD), Prof OBrien also discussed theAmerican Association of Clinical En-docrinologists (AACE)s recommenda-tion for initial combination therapy inpatients with HbA
1c>7.5 percent on di-
agnosis. This recommendation is meantto tackle the short span of time betweenprescription and failure of treatment,and subsequent addition of other antidi-abetic drugs. (J Clin Pract 2005;59:1345-55) By combining lifestyle modificationswith oral antidiabetic combination ther-
apy, the patient can be brought to tar-get and stay in target for a much longerduration before the eventuality of treat-ment failure and insulin initiation. (JClin Pract 2005;59:1345-55)
The importance of good glycemic con-trol early in the course of diabetes has beendemonstrated by the UK Prospective Dia-
betic Study (UKPDS) post-study follow-
up. Prof OBrien said: Good control earlyin the course of the disease can prevent
complications many years later and myinterpretation [of the legacy eect] is thatwe should probably be more aggressive intreating our patients early in the course ofdiabetes.
In what is commonly known as the lega-cy eect, patients in the intensive glycemic
control arm of the UKPDS were observedto have less diabetes-related deaths, deathsfrom any cause, myocardial infarction,stroke, peripheral and microvascular dis-ease. The benets were observed 10 yearsaer the original study ended. (N Engl J
Med 2008;359:1577-89)Conversely, Prof OBrien said it is proba-
bly beer to less aggressively treat patientswho have more severe diabetes as there isa need to balance glycemic benets withthe risk of hypoglycaemia, especially in el-derly patients; those with long duration ofdiabetes; and those with pre-existing car-diovascular disease.
Comparing dierent oral antidiabeticcombinations, Prof OBrien said the com-
bination of DPP-4 inhibitor sitagliptin plusmetformin (Janumet, MSD) caused less
hypoglycemia compared to a sulfonyl-urea plus metformin combination. (Diabe-tes Obes Metab 2007;9:194-205) Even withmonotherapy, sitagliptin caused less gas-trointestinal symptoms compared withmetformin monotherapy. (Diab Obes Metab2010;12(3):252-61)
The AACE also lists the possibility of us-ing DPP-4 inhibitors as potential rst-line
monotherapy as it is comparable to bothmetformin and sulfonylurea in terms of
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32 Pharmacy Update
HbA1c
reduction, but with fewer side ef-
fects such as weight gain and hypoglyce-
mia. [Diab Obes Metab 2010;12(3):252-61,
2007;9:194-205] Prof OBrien noted that al-though incretin-based therapies have been
suspected of causing pancreatitis, meta-
analysis of randomized trials have shown
no such association.
In countries with a large population of
Muslim diabetics, fasting in the month of
Ramadan can be a challenge as incidents
of hypoglycemia increase during the fast-
ing month. A study carried out in India
and Malaysia on diabetics during Rama-dan showed that by utilizing DPP-4 in-
hibitors such as sitagliptin, the incidence
of hypoglycemia could be halved (1.9%
in sitagliptin versus 3.8 percent in the
sulfonylurea group). (Curr Med Res Opin
2012;28(8):1289-96)
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Pharmacy Practice | Pharmacy Today | September 201333
Managing chronic pain
Pharmacy Practice
Recognised by
Academy of Pharmacy
Earn1CPDpointeverymonth
Dr. Eugene WongConsultant Orthopedic and Spine SurgeonAdjunct Assistant Professor
Perdana University Graduate School of MedicineSerdang, Selangor
Chronic pain is a state in which pain
persists beyond the usual course of an
acute disease or healing of an injury.
It is a persistent or intermient condition usu-
ally dened as lasting for at least six months.
It may or may not be associated with an acute
or chronic pathologic process that causes con-
tinuous or intermient pain over months or
years.
The cause is oen unknown, develops in-
sidiously and is associated with a sense of
hopelessness and helplessness. There are sev-
eral risk factors which predispose one to the
development of chronic pain. (Table 1) This
multifaceted disorder has biopsychosocial
components. It is a debilitating clinical condi-
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Genetics
Severe initial pain
Sleep dysunction
Fatigue
Level o education
Female gender
Anxiety/depression
HPA (stress) axis dysunction
Time o work
Job satisaction
Younger age
Low sel-help skills
Table 1: Risk factors leading to chronic pain
Anti-inammatories
Steroids, NSAIDs, COX-2 antagonists
Neuropathic pain agents
Tricyclic antidepressants, anticonvulsants, antiarrhythmics
Muscle relaxants
Narcotics
Alternative medicine
Acupuncture, massage therapy, herbal remedies
Pain coaching
Lie counselingCognitive behavioral therapy
Pain psychologist
Sleep evaluation
Rehabilitation
Interventional
blocks, spinal cord stimulator, intrathecal pump
Neurolytic procedures
Table 2: Medical management of chronic pain
tion associated with a variety of disease en-
tities including diabetic neuropathy, low back
pathology, bromyalgia and neurological dis-
orders. Chronic pain produces signicant be-
havioral and psychological changes such asdepression, sleeping disorders, preoccupation
with the pain and a tendency to deny pain.
Persistent pain causes maladaptive changes
that aect pain perception and pain sensations
out of proportion. Hyperalgesia is due to sen-
sitization of peripheral nociceptors, whereas
allodynia is due to activation of low-threshold
mechanoreceptors. Central sensitization is due
to loss of inhibitory eects of myelinated pri-
mary aerents, which causes prolonged exci-
tation or sensitization of spinal pain transmis-
sion neurons.
Chronic pain can be categorized as malig-
nant, nonmalignant or neuropathic (either ma-
lignant or nonmalignant). Drug treatment is
largely dependent on the type of chronic pain
syndrome. Some of the ways to measure pain
include asking and observing the patient, and
evaluating function and mood. The principles
of treatment include the reduction of pain, re-
habilitation and coping. Rehabilitation consists
of reconditioning and pain prevention.
Treatment strategies targeted at underlying
pain mechanisms are most likely to provide
long-term relief of pain. Regimens involve a
multidisciplinary approach utilizing educa-tion, medication, and physical, occupational
and behavioral therapy. The focus of diagnosis
and evaluation of chronic pain should be on
reversible causes of the pain. Initiation of pain
treatment should not be delayed while a diag-
nostic work-up is completed as uncontrolled
pain has signicant adverse eects on quality
of life, functioning and mood. (Table 2)
The combination of medications serves todecrease pain by altering pain pathways in a
multimodal fashion. Start low and go slow ondrugs. The WHO has a simple and validated
three-step approach to pain management.
(Table 3) The basic principles behind the three
steps of the ladder include selecting the appro-
priate analgesic for the pain intensity and indi-
vidualizing the dose by titration of analgesics.
A score of 1-3 on the pain intensity scale
equals to mild pain. Mild pain can be ade-
quately treated with aspirin, acetaminophenand nonsteroidal anti-inammatory drugs
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(NSAIDs). Acetaminophen is the analgesic of
rst choice in patients (who do not have liver
disease and do not consume excessive amounts
of alcohol) with mild-to-moderate pain. This is
a rst-line agent for osteoarthritis. It is a safealternative to NSAIDs for non-inammatory
pain when given up to a maximum of 4 g/day.
NSAIDs can be used if acetaminophen fails
to provide relief, or if the patient has an acute
inammatory condition. There is considerable
risk of gastrointestinal bleeding, sodium reten-
tion and renal impairment in the elderly. COX-
2 inhibitors are recommended for long-term
treatment of individuals who have chronic
pain caused by inammatory or other under-
lying conditions such as osteoarthritis. These
agents reduce, but do not eliminate, risk of
gastrointestinal bleeding. The risk of renal im-
pairment is the same as for NSAIDs.
Tramadol is a centrally acting analgesic and
may be added to acetaminophen or NSAIDS,
either alone or in combination, to manage
moderate-to-severe pain. These drugs dier
from opioids in two important ways in that
there is a ceiling eect to the analgesia where
using more drugs is not associated with greater
pain control, and they do not produce physical
dependence. Acetaminophen is preferable in
patients at risk for side eects of NSAIDs such
as renal failure, bleeding, hepatic dysfunc-
tion and gastric ulceration. NSAIDs or aspirinmay be appropriate if there is an inammatory
component of the pain.
A score of 4-6 equates with moderate pain.
In the initial treatment of moderate pain,
low-dose opioid drugs are added to aspi-
rin, acetaminophen or NSAIDs. For patient
convenience, many opioids are marketed as
combination products containing one of these
agents.When the score exceeds 7, the patient has
severe pain. The treatment of severe pain re-
quires stronger opioid agonist drugs and the
continuation of aspirin, acetaminophen or
NSAIDs, if possible. Codeine, oxycodone, hy-
drocodone, hydromorphone and fentanyl are
commonly used opioids. Codeine, oxycodone
and hydrocodone are available as immediate-
release (short-acting) preparations or in com-
bination with aspirin or acetaminophen. Many
of these are now available both in immediate
and extended-release forms.
Opioid analgesics are appropriate for mod-
erate-to-severe acute pain that is not relievedby other categories of analgesics. Long-term
use of opioids for pain relief does not appear
to cause organ damage and does not cause loss
of control, tolerance or addictive behavior in
most individuals. Patients should be placed
on bowel regimes to avoid constipation. The
tapering of the drug dose is required to avoid
signicant withdrawal symptoms.
The fentanyl transdermal patch is anotheroption for patients who require around-the-
First Tier
NSAIDs
TENS
Psychological
Nerve Blocks
Second Tier
Opioids
Neurolysis
Thermal
Procedures
Third Tier
Neurostimulation
Implantable
Drug Pumps
Surgical Intervention
Neuromodulation
Intrathecal Inusion
Table 3: Chronic pain treatment continuum
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clock pain control. It is inadvisable to use it as
the initial approach without establishing that
the patient requires continuous opioid use of
10 mg every 4-6 hours. Transdermal opioids
require 24-72 hours to reach a steady stateand may be administered every 48-72 hours. It
may, therefore, be necessary to ensure that the
patient is also being treated with immediate-
release opioids on a scheduled or PRN basis
for the rst 24-72 hours when the transdermal
opioid is started.
Opioids are associated with adverse ef-
fects, especially during the commencement
or change in dosing and administration. The
various medication issues are listed in Table
4. When opioids are used for prolonged peri-
ods, drug tolerance, chemical dependency and
addiction may occur. Ongoing monitoring for
safety and eectiveness is essential, including
regular review of functional progress or main-
tenance, urine drug testing and surveillance
of data from the state prescription monitor-
ing program. (Table 5) Ineective, unsafe or
diverted opioid therapy should be promptly
tapered or stopped.1
Opioids are commonly prescribed for
chronic non-cancer pain and may be eective
for short-term pain relief. Long-term eective-
ness is variable, with evidence ranging from
moderate for the use of transdermal fentanyl
and sustained-release morphine, to limited foroxycodone, and indeterminate for hydrocodo-
ne and methadone.2
Addiction should be distinguished from
physical dependence. Any person who takes
sucient doses of certain types of drugs for a
signicant length of time can have withdrawal
symptoms if the drug is suddenly stopped or
reversed by another medicine. This shows the
presence of physical dependence, but does notconstitute addiction. The risk of addiction is
not well dened in chronic use. When it occurs,the drug is a liability rather than an asset to the
Maximize non-opioid analgesic strategies frst
Inorm subjects o risks beore initiating opioid therapy
Facilitate the use o opioid agreements or patients initi-
ating or increasing opioids
Schedule ollow-up visits at intervals o 2-3 months and
perorm periodic urine tests to confrm adherence
Monitor pain severity and pain-related unctional
impairment at ollow-up visits since analgesic response
may wane in some patients over time
Avoid opioid dose escalations without frst assessing
pain severity and intererence
Consider discontinuing opioids i not benefcial
Consider opioid rotation i tolerance to one opioid is
suspected
Table 5: Opioid management strategy
Addiction
loss of control, harm, focus
Pseudoaddiction
looks like addiction but resolves with adequate pain control
Substance abuse
using medications for alternative reasons
Chemical copers
treating underlying depression, anxiety, insomnia
Table 4: Opioid medication issues
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Clinical Pharmacy | Pharmacy Today | September 201337
person. There are four core elements in true ad-
diction compulsive use and preoccupation
with the drug and its supply, inability to con-
sistently control the quantity used, craving the
psychological eects of the drug, and contin-ued use despite adverse eects from the drug.
Some drugs are not to be taken long term.
Certain drugs are not recommended in chron-
ic pain management. These include pethidine,
which has a short half-life and the risk of cen-
tral nervous system toxicity at high doses. Can-
nabis and cocaine have dysphoric side eects.
Indomethacin, piroxicam and meclofenamate
cause serious side eects such as peptic ulcer-
ation, gastrointestinal hemorrhage, confusion,
agitation and hallucinations. Meperidine is
associated with increased confusion. Pentazo-
cine, butorphanol and other agonist-antago-
nist combinations have lile analgesic ceiling
eects and are associated with dysphoria and
hallucinations, and may precipitate withdraw-
al in opioid-dependent patients.
Neuropathic pain is initiated or caused by a
primary lesion or dysfunction in the nervous
system. There is a wide range of medications
used to treat neuropathic pain. (Table 6) Topi-
cal creams with capsaicin are used to treat pain
from a wide range of chronic conditions includ-
ing neuropathic pain. Following application to
the skin, capsaicin causes enhanced sensitivity
to noxious stimuli, followed by a period withreduced sensitivity and, aer repeated appli-
cations, persistent desensitization.3
Coanalgesics or adjuvants used to treat
chronic pain include antidepressants, anticon-
vulsants, topical agents, skeletal muscle relax-
ants and antispasmodic agents. (Table 7)
Interventional techniques can be used to
treat chronic pain. These target the source of
pain. An injection of steroids can be done attrigger points, joints, peripheral nerve and epi-
dural space. This localizes the delivery of the
medication. Nucleoplasty or percutaneous dis-
cectomy is a procedure where a needle aspi-
ration of a portion of the nucleus pulposus is
carried out. Intradiscal thermocoagulation can
be done to stop leakage of the nucleus.
Physical or restorative therapy may be used
as part of a multimodal strategy for patientswith chronic low back pain. Psychological
Antidepressant
amitriptyline, doxepin
Anticonvulsants
carbamazepine, gabapentin
Anti-emetic
scopolamine
Anxiolytics
benzodiazepines
Glucocorticoids
Topical agents
Mixture o ketamine, clonidine, gabapentin and lido-
caine
Table 7: Adjuvant therapy for chronic pain
Tricyclic antidepressants
Nortriptyline
Anticonvulsants
Gabapentin, carbamazepine, pregabalin
Local anesthetics
Parenteral, oral, topicalTopical capsaicin
Opioids
Antiarrhythmics
Bacloen
Carbamazepine
Trigeminal neuralgia
Duloxetine
Peripheral diabetic neuropathy
Gabapentin
Postherpetic neuralgiaLidocaine patch
Postherpetic neuralgia
Pregabalin
Peripheral diabetic neuropathyPostherpetic neuralgia
Table 6: Treatments for neuropathic pain
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treatments include the use of cognitive behav-
ioral therapy, biofeedback or relaxation train-
ing. These interventions may be used as part
of a multimodal strategy for patients with low
back pain, as well as for other chronic painconditions. Supportive psychotherapy, group
therapy and counseling can be used in the
treatment of chronic pain. The elderly are more
likely to have signicant pain issues and are at
particularly high risk of having their pain in-
adequately managed.4
Chronic pain is a multifactorial phenome-
non