Chloe Hava
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[post_content] => It’s World Patient Safety Day tomorrow (17 September), with this year’s theme around improving diagnosis for patient safety.
Australian Pharmacist examines three health conditions where diagnosis is commonly delayed, incorrect, or missed – and pharmacists’ important role in ensuring an accurate and timely diagnosis to improve treatment outcomes.
COPD is significantly underdiagnosed
Around 50% of people living with Chronic Obstructive Pulmonary Disorder (COPD) are estimated to be undiagnosed.
While patient symptoms and a physical examination can support diagnosis, full spirometry is required to diagnose the condition correctly, said Advanced Practice Pharmacist Associate Professor Debbie Rigby FPS, head of PSA’s Respiratory Care Community of Specialty Interest.
[caption id="attachment_25619" align="alignright" width="270"]
Associate Professor Debbie Rigby FPS[/caption]
‘There are many other respiratory conditions that can present as symptoms of COPD such as wheeze, shortness of breath, chest tightness, chronic cough and poor exercise intolerance – including asthma,’ she said.
An additional layer of complexity is the stigma associated with COPD, which is commonly perceived as a disease solely caused by cigarette smoking.
‘However, we know that around 30% of people diagnosed with COPD have never smoked a cigarette,’ said A/Prof Rigby. ‘There are many other factors, including genetic [predisposition] and environmental exposures that can lead to COPD.’
Because of the high rate of underdiagnosis of COPD, the condition is often undertreated.
‘It’s important to appropriately treat COPD, because although it can’t be cured, we can slow the progression in decline in lung function with medications as well as non-pharmacological treatments such as pulmonary rehab,’ she said.
The Lung Foundation Australia’s Lung Health Checklist can help pharmacists identify people who are at risk for COPD, looking at factors such as:
Nicolette Ellis MPS[/caption]
‘The National Pain Report 2024 highlights that while it takes an average of 3 years to diagnose a chronic pain condition, endometriosis typically takes 7–9 years to diagnose,’ she said.
‘This delay is largely due to a lack of education, awareness, and the fact that it can only be definitively diagnosed through invasive laparoscopy.’
However, timely diagnosis is crucial for managing pain and preventing its escalation.
‘Early detection improves outcomes, reducing the physical and emotional toll on patients,’ said Ms Ellis. ‘Delayed diagnosis often leads to feelings of dismissal, with many told the pain is "all in their head," further worsening the vicious cycle of chronic pain.’
Pharmacists should be aware that endometriosis can present with a wide range of symptoms, including:
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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"]
Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Melatonin is a naturally occurring hormone responsible for regulating the body’s circadian rhythm. Secretion of melatonin declines during adulthood. Supplemental melatonin can help to reinforce the circadian rhythm, making it useful for treatment of insomnia and jet lag.1
How can pharmacists meet their legal and professional obligations when prescribing melatonin for insomnia?
When prescribing melatonin as a Pharmacist Only medicine, you must establish therapeutic need, determine the medicine is safe for the patient and comply with restrictions of the Schedule 3 listing. This includes that the patient is aged 55 or over and it is for short-term treatment. Routine recording of patient name, address and date of birth supports appropriate provision and is the best way for pharmacists to demonstrate they have met legal and professional obligations.
How long is 'short-term'?
While there is evidence to support the safety and efficacy of melatonin up to 13 weeks,3 patients should be referred to a medical practitioner for review if they require treatment for more than 3 weeks.⁴ Three weeks is consistent with evidence from the pivotal efficacy study noted by the Therapeutic Goods Administration in the final decision to amend melatonin scheduling to Schedule 3.⁵
A patient who has been prescribed melatonin MR 2 mg nightly for 3 months by a medical practitioner presents to the pharmacy seeking a supply as they have run out. What can a pharmacist prescribe?
This pattern of use is not short term, so a pharmacist would not be able to prescribe melatonin within Schedule 3. Other options may apply, such as using emergency supply provisions relating to Schedule 4 medicines. The criteria for emergency supply by a pharmacist, and quantity of medicine able to be supplied, depends on the state or territory in which the pharmacist is practising.
What options are available to pharmacists to treat jet lag?
Despite the inclusion of immediate-release melatonin for jet lag in Schedule 3 of the Poisons Standard, at the time of writing, there is no commercially available immediate-release product in Australia which can be prescribed as a Pharmacist Only medicine. Pharmacists may compound an immediate-release preparation that contains 5 mg or less of melatonin when a particular person requests this medicine. If a commercial product becomes available, compounding would no longer be appropriate. Patients should be advised to avoid purchasing melatonin via the internet because the melatonin content may be unreliable.6
Poisons Standard Schedule 3 entry for melatonin7
MELATONIN in:
(a) modified release tablets containing 2 mg or less of melatonin for monotherapy for the short-term treatment of primary insomnia characterised by poor quality of sleep for adults aged 55 or over, in packs containing not more than 30 tablets; or
(b) immediate release preparations containing 5 mg or less of melatonin for the treatment of jet lag in adults 18 years and over, in a primary pack containing no more than 10 dosage units.
References
1. Goldstein, CA. Overview of circadian rhythm sleep-wake disorders. UpToDate [updated Dec 2023]. At: https://sso.uptodate.com/contents/overview-of-circadian-rhythm-sleep-wake-disorders?search=melatonin&source=search_result&selectedTitle=3%7E113&usage_type=default&display_rank=3
2. Insomnia in adults. Therapeutic guidelines [updated Mar 2021]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Psychotropic&topicfile=insomnia-adults
3. Treatment guidelines for pharmacists: insomnia. In: Sansom LN, ed. Australian pharmaceutical formulary and handbook. 26th edn. Canberra: Pharmaceutical Society of Australia; 2024.
4. Therapeutic Goods Administration. Notice of final decision to amend the current Poisons Standard in relation to melatonin. 2020. At: www.tga.gov.au/resources/publication/scheduling-decisions-final/notice-final-decision-amend-current-poisons-standard-relation-melatonin
5. Pharmacy Board of Australia. FAQ – For pharmacists on the compounding of medicines. At: www.pharmacyboard.gov.au/documents/default.aspx?record=WD15%2f16635&dbid=AP&chksum=rE0qmZcEafURzzXc3NBiuA%3d%3d
6. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard. 2023. At: www.tga.gov.au/sites/default/files/2023-10/notice-interim-decisions-amend-not-amend-the-current-poisons-standard.pdf
7. Therapeutic Goods (Poisons Standard – June 2024) Instrument 2024. At: www.legislation.gov.au/F2024L00589/latest/text (edited)
[post_title] => Pharmacist prescribing of melatonin
[post_excerpt] => Melatonin is a naturally occurring hormone responsible for regulating the body’s circadian rhythm. Here's when pharmacists can prescribe it.
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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[post_content] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve patient health and safety.
As the 2024 FIP World Congress continues, Australian Pharmacist reports from Cape Town on some innovative services presented which are improving health across the globe.
South Africa: Improving access to HIV treatment and prevention
There are 7.9 million people in South Africa between the ages of 15 and 49 years living with HIV. Despite strides in treatments and preventative therapies, the rate of new infections remains high.
One project driven by pharmacists is aiming to change this, allowing community pharmacists to initiate high-risk young women and men onto HIV Pre-Exposure Prophylaxis (PrEP). In this implementation study, 10 pharmacies in Gauteng and the Western Cape (Cape Town) initiated high-risk individuals on combination tenofovir and lamivudine/emtricitabine for a period of 13 months. Patients were recruited inside and outside of the pharmacy.
Of the 838 potential participants, 88% (n = 737) were initiated on PrEP between June 2023 and January 2024. Risk assessment found most were sexually active, and more than three quarters (n = 595) engaged in sexual activity without a condom. Initial results from the study were positive, with further analysis to explore patient perceptions of PrEP initiation in community pharmacy.
Spain: Pharmacy reporting of stock shortages helps detect shortages sooner
The General Council of Pharmacists of Spain has developed two systems to prevent and mitigate medicine shortages.
The first is CisMED, a system that generates real-time information on supply incidents at a pharmacy level.
Over 10,000 pharmacies participated in this initiative in 2023 – over half of all pharmacies. CisMED reported a 30% increase in medicines that could not be supplied, with over half the alerts generated being for medicines not listed by their regulator, the Spanish Medicines Agency.
The second initiative, FarmaHelp, is a communication system which allows pharmacists to communicate with nearby pharmacies when a request for a medicine cannot be fulfilled. From the 10,000 pharmacies connected to the system, the number of medicines ‘found’ increased from 106,925 to 389,364. This meant 73.5% of the time, the pharmacist was able to offer a solution to the patient due to the FamraHelp system.
In combination, these digital systems have helped pharmacists both contribute to a more accurate and complete medicine shortage database, and allowed pharmacists to find more options to support access to scarce medicines to their patients more often.
The Netherlands: Palliative care kit improves access to care at end-of-life
The decision to initiate palliative care is often a time where medicines need to be prescribed and initiated at short notice, with a new and often complex regimen of medicines.
A project in The Netherlands led by the Royal Dutch Pharmacists Association, is trying to make this a smoother process for patients and their families through the introduction of a ‘palliative care kit’.
Based on the concept of a first-aid kit, the ‘palliative care kit’ contains everything patients will need to facilitate administration of medicines at end-of-life. This includes morphine and midazolam ampoules, syringes, needles, bandages and a urinary catheter with insertion set.
The kit is supplied by a pharmacy, which receives reimbursement for the medicines, and a professional fee for facilitating the supply of the kit.
The kit contains a permission document from the GP to use the supplies when necessary. The kit is delivered to the home of palliative patients when they enter the terminal phase at a time that can be planned. This allows a nurse to immediately use that kit when necessary.
The kit has reduced unnecessary time spent by community nurses, GPs and pharmacists in facilitating palliative care, particularly during evenings, nights and on weekends. Families report the presence of the kit reassuring because they know their loved one will be able to access the medicines they need instantly, should they experience acute deterioration.
Thailand: Medicine reviews for high-risk CKD patients
In Thailand, 30% of people with chronic kidney disease (CKD) use NSAIDs or other herbal medicines which may accelerate the progression of CKD. A pilot project has shown pharmacists can help reduce this.
In this pilot, a nurse at the CKD clinic referred patients (n = 23) with medicine problems to a pharmacy for medicine reconciliation, adherence checks and to review for potential causes of acute kidney injury. Importantly, the pharmacist also managed any problems identified and monitored kidney function for at least 3 months.
Half (52%) of patients stopped using NSAIDs, and kidney function improved from Stage 3 to Stage 2 in five patients within 3 months. While not statistically significant, the small pilot concluded the model of care appeared to reduce costs associated with medicines and CKD management.
Australian pharmacist on SA TV!
Meanwhile, Australian pharmacist and FIP President Paul Sinclair AM MPS has appeared on South African breakfast television to talk about the important role of pharmacists. Paul told SABC’s Expresso Show he was excited about the opportunities around the world for pharmacists.
[caption id="attachment_27480" align="aligncenter" width="507"]
FIP President Paul Sinclair AM MPS (left)[/caption]
‘Health care across the world is changing very quickly. It’s being driven by innovation, and pharmacists historically have embraced innovation and technology,' he said.
‘What excites me most about our profession at the moment is that we have the chance to do more. Our scope of practice is expanding rapidly, and with that comes opportunities to help more people deliver more outcomes and improve the health system.'
[post_title] => What are pharmacists doing in other countries?
[post_excerpt] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve health and safety.
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[post_content] => It’s World Patient Safety Day tomorrow (17 September), with this year’s theme around improving diagnosis for patient safety.
Australian Pharmacist examines three health conditions where diagnosis is commonly delayed, incorrect, or missed – and pharmacists’ important role in ensuring an accurate and timely diagnosis to improve treatment outcomes.
COPD is significantly underdiagnosed
Around 50% of people living with Chronic Obstructive Pulmonary Disorder (COPD) are estimated to be undiagnosed.
While patient symptoms and a physical examination can support diagnosis, full spirometry is required to diagnose the condition correctly, said Advanced Practice Pharmacist Associate Professor Debbie Rigby FPS, head of PSA’s Respiratory Care Community of Specialty Interest.
[caption id="attachment_25619" align="alignright" width="270"] Associate Professor Debbie Rigby FPS[/caption]
‘There are many other respiratory conditions that can present as symptoms of COPD such as wheeze, shortness of breath, chest tightness, chronic cough and poor exercise intolerance – including asthma,’ she said.
An additional layer of complexity is the stigma associated with COPD, which is commonly perceived as a disease solely caused by cigarette smoking.
‘However, we know that around 30% of people diagnosed with COPD have never smoked a cigarette,’ said A/Prof Rigby. ‘There are many other factors, including genetic [predisposition] and environmental exposures that can lead to COPD.’
Because of the high rate of underdiagnosis of COPD, the condition is often undertreated.
‘It’s important to appropriately treat COPD, because although it can’t be cured, we can slow the progression in decline in lung function with medications as well as non-pharmacological treatments such as pulmonary rehab,’ she said.
The Lung Foundation Australia’s Lung Health Checklist can help pharmacists identify people who are at risk for COPD, looking at factors such as:
Nicolette Ellis MPS[/caption]
‘The National Pain Report 2024 highlights that while it takes an average of 3 years to diagnose a chronic pain condition, endometriosis typically takes 7–9 years to diagnose,’ she said.
‘This delay is largely due to a lack of education, awareness, and the fact that it can only be definitively diagnosed through invasive laparoscopy.’
However, timely diagnosis is crucial for managing pain and preventing its escalation.
‘Early detection improves outcomes, reducing the physical and emotional toll on patients,’ said Ms Ellis. ‘Delayed diagnosis often leads to feelings of dismissal, with many told the pain is "all in their head," further worsening the vicious cycle of chronic pain.’
Pharmacists should be aware that endometriosis can present with a wide range of symptoms, including:
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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"] Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Melatonin is a naturally occurring hormone responsible for regulating the body’s circadian rhythm. Secretion of melatonin declines during adulthood. Supplemental melatonin can help to reinforce the circadian rhythm, making it useful for treatment of insomnia and jet lag.1
How can pharmacists meet their legal and professional obligations when prescribing melatonin for insomnia?
When prescribing melatonin as a Pharmacist Only medicine, you must establish therapeutic need, determine the medicine is safe for the patient and comply with restrictions of the Schedule 3 listing. This includes that the patient is aged 55 or over and it is for short-term treatment. Routine recording of patient name, address and date of birth supports appropriate provision and is the best way for pharmacists to demonstrate they have met legal and professional obligations.
How long is 'short-term'?
While there is evidence to support the safety and efficacy of melatonin up to 13 weeks,3 patients should be referred to a medical practitioner for review if they require treatment for more than 3 weeks.⁴ Three weeks is consistent with evidence from the pivotal efficacy study noted by the Therapeutic Goods Administration in the final decision to amend melatonin scheduling to Schedule 3.⁵
A patient who has been prescribed melatonin MR 2 mg nightly for 3 months by a medical practitioner presents to the pharmacy seeking a supply as they have run out. What can a pharmacist prescribe?
This pattern of use is not short term, so a pharmacist would not be able to prescribe melatonin within Schedule 3. Other options may apply, such as using emergency supply provisions relating to Schedule 4 medicines. The criteria for emergency supply by a pharmacist, and quantity of medicine able to be supplied, depends on the state or territory in which the pharmacist is practising.
What options are available to pharmacists to treat jet lag?
Despite the inclusion of immediate-release melatonin for jet lag in Schedule 3 of the Poisons Standard, at the time of writing, there is no commercially available immediate-release product in Australia which can be prescribed as a Pharmacist Only medicine. Pharmacists may compound an immediate-release preparation that contains 5 mg or less of melatonin when a particular person requests this medicine. If a commercial product becomes available, compounding would no longer be appropriate. Patients should be advised to avoid purchasing melatonin via the internet because the melatonin content may be unreliable.6
Poisons Standard Schedule 3 entry for melatonin7
MELATONIN in:
(a) modified release tablets containing 2 mg or less of melatonin for monotherapy for the short-term treatment of primary insomnia characterised by poor quality of sleep for adults aged 55 or over, in packs containing not more than 30 tablets; or
(b) immediate release preparations containing 5 mg or less of melatonin for the treatment of jet lag in adults 18 years and over, in a primary pack containing no more than 10 dosage units.
References
1. Goldstein, CA. Overview of circadian rhythm sleep-wake disorders. UpToDate [updated Dec 2023]. At: https://sso.uptodate.com/contents/overview-of-circadian-rhythm-sleep-wake-disorders?search=melatonin&source=search_result&selectedTitle=3%7E113&usage_type=default&display_rank=3
2. Insomnia in adults. Therapeutic guidelines [updated Mar 2021]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Psychotropic&topicfile=insomnia-adults
3. Treatment guidelines for pharmacists: insomnia. In: Sansom LN, ed. Australian pharmaceutical formulary and handbook. 26th edn. Canberra: Pharmaceutical Society of Australia; 2024.
4. Therapeutic Goods Administration. Notice of final decision to amend the current Poisons Standard in relation to melatonin. 2020. At: www.tga.gov.au/resources/publication/scheduling-decisions-final/notice-final-decision-amend-current-poisons-standard-relation-melatonin
5. Pharmacy Board of Australia. FAQ – For pharmacists on the compounding of medicines. At: www.pharmacyboard.gov.au/documents/default.aspx?record=WD15%2f16635&dbid=AP&chksum=rE0qmZcEafURzzXc3NBiuA%3d%3d
6. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard. 2023. At: www.tga.gov.au/sites/default/files/2023-10/notice-interim-decisions-amend-not-amend-the-current-poisons-standard.pdf
7. Therapeutic Goods (Poisons Standard – June 2024) Instrument 2024. At: www.legislation.gov.au/F2024L00589/latest/text (edited)
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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[post_content] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve patient health and safety.
As the 2024 FIP World Congress continues, Australian Pharmacist reports from Cape Town on some innovative services presented which are improving health across the globe.
South Africa: Improving access to HIV treatment and prevention
There are 7.9 million people in South Africa between the ages of 15 and 49 years living with HIV. Despite strides in treatments and preventative therapies, the rate of new infections remains high.
One project driven by pharmacists is aiming to change this, allowing community pharmacists to initiate high-risk young women and men onto HIV Pre-Exposure Prophylaxis (PrEP). In this implementation study, 10 pharmacies in Gauteng and the Western Cape (Cape Town) initiated high-risk individuals on combination tenofovir and lamivudine/emtricitabine for a period of 13 months. Patients were recruited inside and outside of the pharmacy.
Of the 838 potential participants, 88% (n = 737) were initiated on PrEP between June 2023 and January 2024. Risk assessment found most were sexually active, and more than three quarters (n = 595) engaged in sexual activity without a condom. Initial results from the study were positive, with further analysis to explore patient perceptions of PrEP initiation in community pharmacy.
Spain: Pharmacy reporting of stock shortages helps detect shortages sooner
The General Council of Pharmacists of Spain has developed two systems to prevent and mitigate medicine shortages.
The first is CisMED, a system that generates real-time information on supply incidents at a pharmacy level.
Over 10,000 pharmacies participated in this initiative in 2023 – over half of all pharmacies. CisMED reported a 30% increase in medicines that could not be supplied, with over half the alerts generated being for medicines not listed by their regulator, the Spanish Medicines Agency.
The second initiative, FarmaHelp, is a communication system which allows pharmacists to communicate with nearby pharmacies when a request for a medicine cannot be fulfilled. From the 10,000 pharmacies connected to the system, the number of medicines ‘found’ increased from 106,925 to 389,364. This meant 73.5% of the time, the pharmacist was able to offer a solution to the patient due to the FamraHelp system.
In combination, these digital systems have helped pharmacists both contribute to a more accurate and complete medicine shortage database, and allowed pharmacists to find more options to support access to scarce medicines to their patients more often.
The Netherlands: Palliative care kit improves access to care at end-of-life
The decision to initiate palliative care is often a time where medicines need to be prescribed and initiated at short notice, with a new and often complex regimen of medicines.
A project in The Netherlands led by the Royal Dutch Pharmacists Association, is trying to make this a smoother process for patients and their families through the introduction of a ‘palliative care kit’.
Based on the concept of a first-aid kit, the ‘palliative care kit’ contains everything patients will need to facilitate administration of medicines at end-of-life. This includes morphine and midazolam ampoules, syringes, needles, bandages and a urinary catheter with insertion set.
The kit is supplied by a pharmacy, which receives reimbursement for the medicines, and a professional fee for facilitating the supply of the kit.
The kit contains a permission document from the GP to use the supplies when necessary. The kit is delivered to the home of palliative patients when they enter the terminal phase at a time that can be planned. This allows a nurse to immediately use that kit when necessary.
The kit has reduced unnecessary time spent by community nurses, GPs and pharmacists in facilitating palliative care, particularly during evenings, nights and on weekends. Families report the presence of the kit reassuring because they know their loved one will be able to access the medicines they need instantly, should they experience acute deterioration.
Thailand: Medicine reviews for high-risk CKD patients
In Thailand, 30% of people with chronic kidney disease (CKD) use NSAIDs or other herbal medicines which may accelerate the progression of CKD. A pilot project has shown pharmacists can help reduce this.
In this pilot, a nurse at the CKD clinic referred patients (n = 23) with medicine problems to a pharmacy for medicine reconciliation, adherence checks and to review for potential causes of acute kidney injury. Importantly, the pharmacist also managed any problems identified and monitored kidney function for at least 3 months.
Half (52%) of patients stopped using NSAIDs, and kidney function improved from Stage 3 to Stage 2 in five patients within 3 months. While not statistically significant, the small pilot concluded the model of care appeared to reduce costs associated with medicines and CKD management.
Australian pharmacist on SA TV!
Meanwhile, Australian pharmacist and FIP President Paul Sinclair AM MPS has appeared on South African breakfast television to talk about the important role of pharmacists. Paul told SABC’s Expresso Show he was excited about the opportunities around the world for pharmacists.
[caption id="attachment_27480" align="aligncenter" width="507"] FIP President Paul Sinclair AM MPS (left)[/caption]
‘Health care across the world is changing very quickly. It’s being driven by innovation, and pharmacists historically have embraced innovation and technology,' he said.
‘What excites me most about our profession at the moment is that we have the chance to do more. Our scope of practice is expanding rapidly, and with that comes opportunities to help more people deliver more outcomes and improve the health system.'
[post_title] => What are pharmacists doing in other countries?
[post_excerpt] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve health and safety.
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[post_content] => It’s World Patient Safety Day tomorrow (17 September), with this year’s theme around improving diagnosis for patient safety.
Australian Pharmacist examines three health conditions where diagnosis is commonly delayed, incorrect, or missed – and pharmacists’ important role in ensuring an accurate and timely diagnosis to improve treatment outcomes.
COPD is significantly underdiagnosed
Around 50% of people living with Chronic Obstructive Pulmonary Disorder (COPD) are estimated to be undiagnosed.
While patient symptoms and a physical examination can support diagnosis, full spirometry is required to diagnose the condition correctly, said Advanced Practice Pharmacist Associate Professor Debbie Rigby FPS, head of PSA’s Respiratory Care Community of Specialty Interest.
[caption id="attachment_25619" align="alignright" width="270"] Associate Professor Debbie Rigby FPS[/caption]
‘There are many other respiratory conditions that can present as symptoms of COPD such as wheeze, shortness of breath, chest tightness, chronic cough and poor exercise intolerance – including asthma,’ she said.
An additional layer of complexity is the stigma associated with COPD, which is commonly perceived as a disease solely caused by cigarette smoking.
‘However, we know that around 30% of people diagnosed with COPD have never smoked a cigarette,’ said A/Prof Rigby. ‘There are many other factors, including genetic [predisposition] and environmental exposures that can lead to COPD.’
Because of the high rate of underdiagnosis of COPD, the condition is often undertreated.
‘It’s important to appropriately treat COPD, because although it can’t be cured, we can slow the progression in decline in lung function with medications as well as non-pharmacological treatments such as pulmonary rehab,’ she said.
The Lung Foundation Australia’s Lung Health Checklist can help pharmacists identify people who are at risk for COPD, looking at factors such as:
Nicolette Ellis MPS[/caption]
‘The National Pain Report 2024 highlights that while it takes an average of 3 years to diagnose a chronic pain condition, endometriosis typically takes 7–9 years to diagnose,’ she said.
‘This delay is largely due to a lack of education, awareness, and the fact that it can only be definitively diagnosed through invasive laparoscopy.’
However, timely diagnosis is crucial for managing pain and preventing its escalation.
‘Early detection improves outcomes, reducing the physical and emotional toll on patients,’ said Ms Ellis. ‘Delayed diagnosis often leads to feelings of dismissal, with many told the pain is "all in their head," further worsening the vicious cycle of chronic pain.’
Pharmacists should be aware that endometriosis can present with a wide range of symptoms, including:
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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"] Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Melatonin is a naturally occurring hormone responsible for regulating the body’s circadian rhythm. Secretion of melatonin declines during adulthood. Supplemental melatonin can help to reinforce the circadian rhythm, making it useful for treatment of insomnia and jet lag.1
How can pharmacists meet their legal and professional obligations when prescribing melatonin for insomnia?
When prescribing melatonin as a Pharmacist Only medicine, you must establish therapeutic need, determine the medicine is safe for the patient and comply with restrictions of the Schedule 3 listing. This includes that the patient is aged 55 or over and it is for short-term treatment. Routine recording of patient name, address and date of birth supports appropriate provision and is the best way for pharmacists to demonstrate they have met legal and professional obligations.
How long is 'short-term'?
While there is evidence to support the safety and efficacy of melatonin up to 13 weeks,3 patients should be referred to a medical practitioner for review if they require treatment for more than 3 weeks.⁴ Three weeks is consistent with evidence from the pivotal efficacy study noted by the Therapeutic Goods Administration in the final decision to amend melatonin scheduling to Schedule 3.⁵
A patient who has been prescribed melatonin MR 2 mg nightly for 3 months by a medical practitioner presents to the pharmacy seeking a supply as they have run out. What can a pharmacist prescribe?
This pattern of use is not short term, so a pharmacist would not be able to prescribe melatonin within Schedule 3. Other options may apply, such as using emergency supply provisions relating to Schedule 4 medicines. The criteria for emergency supply by a pharmacist, and quantity of medicine able to be supplied, depends on the state or territory in which the pharmacist is practising.
What options are available to pharmacists to treat jet lag?
Despite the inclusion of immediate-release melatonin for jet lag in Schedule 3 of the Poisons Standard, at the time of writing, there is no commercially available immediate-release product in Australia which can be prescribed as a Pharmacist Only medicine. Pharmacists may compound an immediate-release preparation that contains 5 mg or less of melatonin when a particular person requests this medicine. If a commercial product becomes available, compounding would no longer be appropriate. Patients should be advised to avoid purchasing melatonin via the internet because the melatonin content may be unreliable.6
Poisons Standard Schedule 3 entry for melatonin7
MELATONIN in:
(a) modified release tablets containing 2 mg or less of melatonin for monotherapy for the short-term treatment of primary insomnia characterised by poor quality of sleep for adults aged 55 or over, in packs containing not more than 30 tablets; or
(b) immediate release preparations containing 5 mg or less of melatonin for the treatment of jet lag in adults 18 years and over, in a primary pack containing no more than 10 dosage units.
References
1. Goldstein, CA. Overview of circadian rhythm sleep-wake disorders. UpToDate [updated Dec 2023]. At: https://sso.uptodate.com/contents/overview-of-circadian-rhythm-sleep-wake-disorders?search=melatonin&source=search_result&selectedTitle=3%7E113&usage_type=default&display_rank=3
2. Insomnia in adults. Therapeutic guidelines [updated Mar 2021]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Psychotropic&topicfile=insomnia-adults
3. Treatment guidelines for pharmacists: insomnia. In: Sansom LN, ed. Australian pharmaceutical formulary and handbook. 26th edn. Canberra: Pharmaceutical Society of Australia; 2024.
4. Therapeutic Goods Administration. Notice of final decision to amend the current Poisons Standard in relation to melatonin. 2020. At: www.tga.gov.au/resources/publication/scheduling-decisions-final/notice-final-decision-amend-current-poisons-standard-relation-melatonin
5. Pharmacy Board of Australia. FAQ – For pharmacists on the compounding of medicines. At: www.pharmacyboard.gov.au/documents/default.aspx?record=WD15%2f16635&dbid=AP&chksum=rE0qmZcEafURzzXc3NBiuA%3d%3d
6. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard. 2023. At: www.tga.gov.au/sites/default/files/2023-10/notice-interim-decisions-amend-not-amend-the-current-poisons-standard.pdf
7. Therapeutic Goods (Poisons Standard – June 2024) Instrument 2024. At: www.legislation.gov.au/F2024L00589/latest/text (edited)
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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[post_content] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve patient health and safety.
As the 2024 FIP World Congress continues, Australian Pharmacist reports from Cape Town on some innovative services presented which are improving health across the globe.
South Africa: Improving access to HIV treatment and prevention
There are 7.9 million people in South Africa between the ages of 15 and 49 years living with HIV. Despite strides in treatments and preventative therapies, the rate of new infections remains high.
One project driven by pharmacists is aiming to change this, allowing community pharmacists to initiate high-risk young women and men onto HIV Pre-Exposure Prophylaxis (PrEP). In this implementation study, 10 pharmacies in Gauteng and the Western Cape (Cape Town) initiated high-risk individuals on combination tenofovir and lamivudine/emtricitabine for a period of 13 months. Patients were recruited inside and outside of the pharmacy.
Of the 838 potential participants, 88% (n = 737) were initiated on PrEP between June 2023 and January 2024. Risk assessment found most were sexually active, and more than three quarters (n = 595) engaged in sexual activity without a condom. Initial results from the study were positive, with further analysis to explore patient perceptions of PrEP initiation in community pharmacy.
Spain: Pharmacy reporting of stock shortages helps detect shortages sooner
The General Council of Pharmacists of Spain has developed two systems to prevent and mitigate medicine shortages.
The first is CisMED, a system that generates real-time information on supply incidents at a pharmacy level.
Over 10,000 pharmacies participated in this initiative in 2023 – over half of all pharmacies. CisMED reported a 30% increase in medicines that could not be supplied, with over half the alerts generated being for medicines not listed by their regulator, the Spanish Medicines Agency.
The second initiative, FarmaHelp, is a communication system which allows pharmacists to communicate with nearby pharmacies when a request for a medicine cannot be fulfilled. From the 10,000 pharmacies connected to the system, the number of medicines ‘found’ increased from 106,925 to 389,364. This meant 73.5% of the time, the pharmacist was able to offer a solution to the patient due to the FamraHelp system.
In combination, these digital systems have helped pharmacists both contribute to a more accurate and complete medicine shortage database, and allowed pharmacists to find more options to support access to scarce medicines to their patients more often.
The Netherlands: Palliative care kit improves access to care at end-of-life
The decision to initiate palliative care is often a time where medicines need to be prescribed and initiated at short notice, with a new and often complex regimen of medicines.
A project in The Netherlands led by the Royal Dutch Pharmacists Association, is trying to make this a smoother process for patients and their families through the introduction of a ‘palliative care kit’.
Based on the concept of a first-aid kit, the ‘palliative care kit’ contains everything patients will need to facilitate administration of medicines at end-of-life. This includes morphine and midazolam ampoules, syringes, needles, bandages and a urinary catheter with insertion set.
The kit is supplied by a pharmacy, which receives reimbursement for the medicines, and a professional fee for facilitating the supply of the kit.
The kit contains a permission document from the GP to use the supplies when necessary. The kit is delivered to the home of palliative patients when they enter the terminal phase at a time that can be planned. This allows a nurse to immediately use that kit when necessary.
The kit has reduced unnecessary time spent by community nurses, GPs and pharmacists in facilitating palliative care, particularly during evenings, nights and on weekends. Families report the presence of the kit reassuring because they know their loved one will be able to access the medicines they need instantly, should they experience acute deterioration.
Thailand: Medicine reviews for high-risk CKD patients
In Thailand, 30% of people with chronic kidney disease (CKD) use NSAIDs or other herbal medicines which may accelerate the progression of CKD. A pilot project has shown pharmacists can help reduce this.
In this pilot, a nurse at the CKD clinic referred patients (n = 23) with medicine problems to a pharmacy for medicine reconciliation, adherence checks and to review for potential causes of acute kidney injury. Importantly, the pharmacist also managed any problems identified and monitored kidney function for at least 3 months.
Half (52%) of patients stopped using NSAIDs, and kidney function improved from Stage 3 to Stage 2 in five patients within 3 months. While not statistically significant, the small pilot concluded the model of care appeared to reduce costs associated with medicines and CKD management.
Australian pharmacist on SA TV!
Meanwhile, Australian pharmacist and FIP President Paul Sinclair AM MPS has appeared on South African breakfast television to talk about the important role of pharmacists. Paul told SABC’s Expresso Show he was excited about the opportunities around the world for pharmacists.
[caption id="attachment_27480" align="aligncenter" width="507"] FIP President Paul Sinclair AM MPS (left)[/caption]
‘Health care across the world is changing very quickly. It’s being driven by innovation, and pharmacists historically have embraced innovation and technology,' he said.
‘What excites me most about our profession at the moment is that we have the chance to do more. Our scope of practice is expanding rapidly, and with that comes opportunities to help more people deliver more outcomes and improve the health system.'
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[post_content] => It’s World Patient Safety Day tomorrow (17 September), with this year’s theme around improving diagnosis for patient safety.
Australian Pharmacist examines three health conditions where diagnosis is commonly delayed, incorrect, or missed – and pharmacists’ important role in ensuring an accurate and timely diagnosis to improve treatment outcomes.
COPD is significantly underdiagnosed
Around 50% of people living with Chronic Obstructive Pulmonary Disorder (COPD) are estimated to be undiagnosed.
While patient symptoms and a physical examination can support diagnosis, full spirometry is required to diagnose the condition correctly, said Advanced Practice Pharmacist Associate Professor Debbie Rigby FPS, head of PSA’s Respiratory Care Community of Specialty Interest.
[caption id="attachment_25619" align="alignright" width="270"] Associate Professor Debbie Rigby FPS[/caption]
‘There are many other respiratory conditions that can present as symptoms of COPD such as wheeze, shortness of breath, chest tightness, chronic cough and poor exercise intolerance – including asthma,’ she said.
An additional layer of complexity is the stigma associated with COPD, which is commonly perceived as a disease solely caused by cigarette smoking.
‘However, we know that around 30% of people diagnosed with COPD have never smoked a cigarette,’ said A/Prof Rigby. ‘There are many other factors, including genetic [predisposition] and environmental exposures that can lead to COPD.’
Because of the high rate of underdiagnosis of COPD, the condition is often undertreated.
‘It’s important to appropriately treat COPD, because although it can’t be cured, we can slow the progression in decline in lung function with medications as well as non-pharmacological treatments such as pulmonary rehab,’ she said.
The Lung Foundation Australia’s Lung Health Checklist can help pharmacists identify people who are at risk for COPD, looking at factors such as:
Nicolette Ellis MPS[/caption]
‘The National Pain Report 2024 highlights that while it takes an average of 3 years to diagnose a chronic pain condition, endometriosis typically takes 7–9 years to diagnose,’ she said.
‘This delay is largely due to a lack of education, awareness, and the fact that it can only be definitively diagnosed through invasive laparoscopy.’
However, timely diagnosis is crucial for managing pain and preventing its escalation.
‘Early detection improves outcomes, reducing the physical and emotional toll on patients,’ said Ms Ellis. ‘Delayed diagnosis often leads to feelings of dismissal, with many told the pain is "all in their head," further worsening the vicious cycle of chronic pain.’
Pharmacists should be aware that endometriosis can present with a wide range of symptoms, including:
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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"] Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Melatonin is a naturally occurring hormone responsible for regulating the body’s circadian rhythm. Secretion of melatonin declines during adulthood. Supplemental melatonin can help to reinforce the circadian rhythm, making it useful for treatment of insomnia and jet lag.1
How can pharmacists meet their legal and professional obligations when prescribing melatonin for insomnia?
When prescribing melatonin as a Pharmacist Only medicine, you must establish therapeutic need, determine the medicine is safe for the patient and comply with restrictions of the Schedule 3 listing. This includes that the patient is aged 55 or over and it is for short-term treatment. Routine recording of patient name, address and date of birth supports appropriate provision and is the best way for pharmacists to demonstrate they have met legal and professional obligations.
How long is 'short-term'?
While there is evidence to support the safety and efficacy of melatonin up to 13 weeks,3 patients should be referred to a medical practitioner for review if they require treatment for more than 3 weeks.⁴ Three weeks is consistent with evidence from the pivotal efficacy study noted by the Therapeutic Goods Administration in the final decision to amend melatonin scheduling to Schedule 3.⁵
A patient who has been prescribed melatonin MR 2 mg nightly for 3 months by a medical practitioner presents to the pharmacy seeking a supply as they have run out. What can a pharmacist prescribe?
This pattern of use is not short term, so a pharmacist would not be able to prescribe melatonin within Schedule 3. Other options may apply, such as using emergency supply provisions relating to Schedule 4 medicines. The criteria for emergency supply by a pharmacist, and quantity of medicine able to be supplied, depends on the state or territory in which the pharmacist is practising.
What options are available to pharmacists to treat jet lag?
Despite the inclusion of immediate-release melatonin for jet lag in Schedule 3 of the Poisons Standard, at the time of writing, there is no commercially available immediate-release product in Australia which can be prescribed as a Pharmacist Only medicine. Pharmacists may compound an immediate-release preparation that contains 5 mg or less of melatonin when a particular person requests this medicine. If a commercial product becomes available, compounding would no longer be appropriate. Patients should be advised to avoid purchasing melatonin via the internet because the melatonin content may be unreliable.6
Poisons Standard Schedule 3 entry for melatonin7
MELATONIN in:
(a) modified release tablets containing 2 mg or less of melatonin for monotherapy for the short-term treatment of primary insomnia characterised by poor quality of sleep for adults aged 55 or over, in packs containing not more than 30 tablets; or
(b) immediate release preparations containing 5 mg or less of melatonin for the treatment of jet lag in adults 18 years and over, in a primary pack containing no more than 10 dosage units.
References
1. Goldstein, CA. Overview of circadian rhythm sleep-wake disorders. UpToDate [updated Dec 2023]. At: https://sso.uptodate.com/contents/overview-of-circadian-rhythm-sleep-wake-disorders?search=melatonin&source=search_result&selectedTitle=3%7E113&usage_type=default&display_rank=3
2. Insomnia in adults. Therapeutic guidelines [updated Mar 2021]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Psychotropic&topicfile=insomnia-adults
3. Treatment guidelines for pharmacists: insomnia. In: Sansom LN, ed. Australian pharmaceutical formulary and handbook. 26th edn. Canberra: Pharmaceutical Society of Australia; 2024.
4. Therapeutic Goods Administration. Notice of final decision to amend the current Poisons Standard in relation to melatonin. 2020. At: www.tga.gov.au/resources/publication/scheduling-decisions-final/notice-final-decision-amend-current-poisons-standard-relation-melatonin
5. Pharmacy Board of Australia. FAQ – For pharmacists on the compounding of medicines. At: www.pharmacyboard.gov.au/documents/default.aspx?record=WD15%2f16635&dbid=AP&chksum=rE0qmZcEafURzzXc3NBiuA%3d%3d
6. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard. 2023. At: www.tga.gov.au/sites/default/files/2023-10/notice-interim-decisions-amend-not-amend-the-current-poisons-standard.pdf
7. Therapeutic Goods (Poisons Standard – June 2024) Instrument 2024. At: www.legislation.gov.au/F2024L00589/latest/text (edited)
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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[post_content] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve patient health and safety.
As the 2024 FIP World Congress continues, Australian Pharmacist reports from Cape Town on some innovative services presented which are improving health across the globe.
South Africa: Improving access to HIV treatment and prevention
There are 7.9 million people in South Africa between the ages of 15 and 49 years living with HIV. Despite strides in treatments and preventative therapies, the rate of new infections remains high.
One project driven by pharmacists is aiming to change this, allowing community pharmacists to initiate high-risk young women and men onto HIV Pre-Exposure Prophylaxis (PrEP). In this implementation study, 10 pharmacies in Gauteng and the Western Cape (Cape Town) initiated high-risk individuals on combination tenofovir and lamivudine/emtricitabine for a period of 13 months. Patients were recruited inside and outside of the pharmacy.
Of the 838 potential participants, 88% (n = 737) were initiated on PrEP between June 2023 and January 2024. Risk assessment found most were sexually active, and more than three quarters (n = 595) engaged in sexual activity without a condom. Initial results from the study were positive, with further analysis to explore patient perceptions of PrEP initiation in community pharmacy.
Spain: Pharmacy reporting of stock shortages helps detect shortages sooner
The General Council of Pharmacists of Spain has developed two systems to prevent and mitigate medicine shortages.
The first is CisMED, a system that generates real-time information on supply incidents at a pharmacy level.
Over 10,000 pharmacies participated in this initiative in 2023 – over half of all pharmacies. CisMED reported a 30% increase in medicines that could not be supplied, with over half the alerts generated being for medicines not listed by their regulator, the Spanish Medicines Agency.
The second initiative, FarmaHelp, is a communication system which allows pharmacists to communicate with nearby pharmacies when a request for a medicine cannot be fulfilled. From the 10,000 pharmacies connected to the system, the number of medicines ‘found’ increased from 106,925 to 389,364. This meant 73.5% of the time, the pharmacist was able to offer a solution to the patient due to the FamraHelp system.
In combination, these digital systems have helped pharmacists both contribute to a more accurate and complete medicine shortage database, and allowed pharmacists to find more options to support access to scarce medicines to their patients more often.
The Netherlands: Palliative care kit improves access to care at end-of-life
The decision to initiate palliative care is often a time where medicines need to be prescribed and initiated at short notice, with a new and often complex regimen of medicines.
A project in The Netherlands led by the Royal Dutch Pharmacists Association, is trying to make this a smoother process for patients and their families through the introduction of a ‘palliative care kit’.
Based on the concept of a first-aid kit, the ‘palliative care kit’ contains everything patients will need to facilitate administration of medicines at end-of-life. This includes morphine and midazolam ampoules, syringes, needles, bandages and a urinary catheter with insertion set.
The kit is supplied by a pharmacy, which receives reimbursement for the medicines, and a professional fee for facilitating the supply of the kit.
The kit contains a permission document from the GP to use the supplies when necessary. The kit is delivered to the home of palliative patients when they enter the terminal phase at a time that can be planned. This allows a nurse to immediately use that kit when necessary.
The kit has reduced unnecessary time spent by community nurses, GPs and pharmacists in facilitating palliative care, particularly during evenings, nights and on weekends. Families report the presence of the kit reassuring because they know their loved one will be able to access the medicines they need instantly, should they experience acute deterioration.
Thailand: Medicine reviews for high-risk CKD patients
In Thailand, 30% of people with chronic kidney disease (CKD) use NSAIDs or other herbal medicines which may accelerate the progression of CKD. A pilot project has shown pharmacists can help reduce this.
In this pilot, a nurse at the CKD clinic referred patients (n = 23) with medicine problems to a pharmacy for medicine reconciliation, adherence checks and to review for potential causes of acute kidney injury. Importantly, the pharmacist also managed any problems identified and monitored kidney function for at least 3 months.
Half (52%) of patients stopped using NSAIDs, and kidney function improved from Stage 3 to Stage 2 in five patients within 3 months. While not statistically significant, the small pilot concluded the model of care appeared to reduce costs associated with medicines and CKD management.
Australian pharmacist on SA TV!
Meanwhile, Australian pharmacist and FIP President Paul Sinclair AM MPS has appeared on South African breakfast television to talk about the important role of pharmacists. Paul told SABC’s Expresso Show he was excited about the opportunities around the world for pharmacists.
[caption id="attachment_27480" align="aligncenter" width="507"] FIP President Paul Sinclair AM MPS (left)[/caption]
‘Health care across the world is changing very quickly. It’s being driven by innovation, and pharmacists historically have embraced innovation and technology,' he said.
‘What excites me most about our profession at the moment is that we have the chance to do more. Our scope of practice is expanding rapidly, and with that comes opportunities to help more people deliver more outcomes and improve the health system.'
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
