September 2013

PsorCARE program to help manage psoriasis more effectively

News Seeing AMD through the eyes of a patient

Feature Natural remedies often first choice for anxiety and insomnia



News | Pharmacy Today | September 2013 

PsorCARE program to help manage psoriasis more effectively
By Saras Ramiya


he Psoriasis Coach All-Round Education (PsorCARE) program aims to enhance the counseling skills of healthcare practitioners to optimize treatment outcomes. Psoriasis is a little-understood skin condition that carries a strong social stigma. Its emotional impact on patients often far outweighs the disease’s physical impact. This is why good support and guidance from healthcare providers is crucial in achieving optimal treatment adherence, one of the main challenges in psoriasis management. PsorCARE is a peer-based training platform that teaches trainees how to achieve a balance between asking, listening and informing when communicating with patients about living with and overcoming the burden of psoriasis. The program also enables trainees to translate theoretical approaches into practical implementation. “Caring for patients with chronic skin diseases such as psoriasis is not only a science but an art which requires continuous support by a dedicated counselor. Nurses best equipped with the necessary knowledge would ensure better outcomes in the management of psoriasis by improving patient adherence to topical treatments which are the mainstay of management of majority of patients,” said Najeeb Ahmad Mohd Safdar, president of the Dermatological Society of Malaysia. The session, held in June, was led by Barbara Page, a dermatology liaison nurse specialist at the Queen Margaret Hospital in Scotland, UK. “Aside from adhering to medical treatments, psoriasis patients also face physical and emotional challenges in their daily

lives and it is important for us, as healthcare providers, to recognize these challenges and provide them with the much needed support. With the PsorCARE program, I am pleased to have the opportunity to share my experiences with other healthcare providers in Malaysia to help enhance our capabilities to further benefit these patients,” said Ms. Page. For patients who require long-term therapy, treatment adherence – whether it be medicinal, behavioral, lifestyle or a combination of treatments – is essential for achieving optimal outcomes. Extensive market research has identified that adherence is founded on good communication and a positive relationship between patients and healthcare practitioners. This applies in particular to nurses who are in regular contact with patients. (J Eur Acad Dermatol Venereol 2011;25 Suppl 4:9-14) Psoriasis patients find it challenging to adhere to their treatment modality because the application of their medicine requires disci-


News | Pharmacy Today | September 2013  prevalence in treatment non-adherence and respond to the patient’s unmet needs,” said Josef De Guzman, president, PsorAsia. “LEO Pharma is committed to partner with healthcare professional, doctors, nurses and pharmacists in helping psoriasis patients improve 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 patients hope and empower them with the ability to control their psoriasis conditions and eventually improve their quality of life,” said Tan Keng Aun, country manager of LEO Pharma Malaysia.

pline and patience, and this impacts their lifestyle. More significantly, the lack of apparent results dampens their morale which, in turn, affects negatively the follow-through with recommended treatment. LEO Pharma developed the PsorCARE program in collaboration with PsorAsia (the Federation of Psoriasis Association in AsiaPacific). “Research has shown that there is a significant need to bridge the gap between administering medical treatments and providing patient support. Programs such as PsorCARE are an essential platform that allows us to share sustainable approaches with healthcare providers to help them address the high

Quit smoking medications are effective
By Rajesh Kumar


icotine replacement therapies (NRT) and other licensed drugs can indeed help people quit smoking, a systematic review has confirmed. The overview of previous Cochrane reviews supports the use of smoking cessation medications that are already widely licensed internationally, and shows that another drug licensed in Russia could hold potential as an effective and affordable treatment. The findings serve as a reassurance to pharmacists and other health professionals involved in smoking cessation programs. In most countries, including the US and Europe, the only medications currently licensed for smoking cessation are NRTs such as nicotine patches and gums, the antidepressant

bupropion and the drug varenicline, which blunts the effects of nicotine on nicotine receptors in the brain. In Russia and other parts of Eastern Europe, cytisine, similar to varenicline, is also licensed for smoking cessation. The researchers combined the findings of

“This review provides strong evidence that the three main treatments. was more effective than placebo. Bupropion. gum. Overall.” existing Cochrane reviews on the subject. The three widely licensed medications and cytisine all improved smokers’ chances of quitting. sprays. “However. which is known to trigger occasional seizures in vulnerable people.804 people.” The researchers also assessed the safety of different medications. UK. If a person stopped smoking for six months or longer. can all help people to stop smoking. nicotine replacement therapy. they collected evidence from 267 studies. and between two and three times higher with varenicline than with placebo. this was considered a successful quit attempt.” said lead researcher Kate Cahill. nortriptyline.5 News | Pharmacy Today | September 2013  ditional improvement when combined with . and the three main treatments with each other. heart or circulatory problems. of the department of primary care health sciences at the University of Oxford in Oxford. The studies covered a wide variety of licensed and unlicensed smoking cessation medications. varenicline was about 50 percent more effective than any single formulation of NRT (patches. these data suggest it has potential as an effective and affordable therapy. The odds of quitting were about 80% higher with single NRT or bupropion than with placebo.” said Dr. bupropion and varenicline. However. but did not offer any ad- READ JPOG ANYTIME. “Although cytisine is not currently licensed for smoking cessation in most of the world. ANYWHERE. comparing the treatments with placebo. although the researchers say the results are currently less clear-cut for varenicline. Among other treatments tested. Download the digital edition today at www. “Further research may be warranted into the safety of varenicline. bupropion and varenicline are considered low-risk treatments. in the trials we looked at we did not detect evidence of any increase in neuropsychiatric.jpog. using all the available data from across individual reviews. cytisine improved the chances of quitting nearly four-fold compared with placebo. did not lead to an increase in the rate of seizures when used for smoking cessation in its slow-release version. another antidepressant drug. Based on two recent trials. lozenges and inhalers). NRT. Cahill. which together involved a total of 101. but similar in efficacy to combining two types of NRT. In total.

Some people will think. Instead of pouring water into a glass.” said Dennis Lewis. Patients commonly have low self-esteem and many suffer from depression as they feel they are a burden on their families and friends because they are no longer able to perform many tasks independently. This is what people live with every day with fully developed AMD. “In the UK. guess what I stroked the other day? It was the hand- bag and not the cat. just small accidents.” AMD is not an eye condition that makes people completely blind.” Mr Lewis related how he once mistook his wife’s black handbag for the cat. but I can step over here and touch the microphone. “If I watch my favorite sport. as the senior person. “I have some notes in front of me which I can’t read easily.6 News | Pharmacy Today | September 2013  Seeing AMD through the eyes of a patient By Leonard Yap T he impact of age-related macular degeneration (AMD) goes far beyond visual impairment as it can also greatly affect a person’s self-esteem and confidence. watching television is a challenge. “I am stupid … I have accidents all the time. I might miss the glass. he was not certain that the audience was looking at him. Many people keep these feelings to themselves.” he said. “My wife has a black handbag with a handle and. particularly as he talked to an audience. “[Suddenly] we are facing a future of having to rely on people for even simple things like pouring a drink.” He also spoke of how his blindness affects his ability to communicate. but I wrote them so I think I should know what I am saying. I can see blue and red. it could happen to somebody who has had a very successful career and feels that these achievements have become history. says an AMD patient. I may walk up two steps and miss my step and fall. It gnaws away at my self-esteem and independence. even if one sits very close to it. Here is my daughter.” he said. which is football. So it . “If I go back past two or four rows. he said. This makes me feel like a fraud. I don’t even know if you are there. So people start to feel that they are going to be a burden on the family and yet. How AMD changes lives Mr Lewis said although he was looking at the audience. which is a challenge.” The ability to read and write is often very difficult. People feel I am a bit of a fraud and this is how it affects the individual. they see it as their responsibility to look after the family. people even become depressed. a patient ambassador for AMD Alliance International. I am legally registered as blind. “People [with AMD] do become very distressed [with their predicament]. Alternatively. and I can see the audience. I would be worried that I will spill it. This feeling is particularly painful when the person is a senior member of the family. In some cases people even consider suicide. It made me feel a bit stupid. I am not completely blind. but I can’t recognize the player.

because across a crowded room I don’t know who I know. But prevention should be the priority and eye health must be taken very seriously. “This is a growing organization and we network with each other throughout the UK to make sure emotional support is offered wherever necessary. “I am not sure how you would react if I came right up to you and stuck my face into yours and said. Why are you ignoring me?” Another serious loss is the ability to drive. He used to work in the banking industry. Mr Lewis was speaking at the recent Retinal Diseases Awareness Week in Petaling Jaya. “I had to stop working because I could not do my job to the best of my ability anymore.’ We don’t want to do that. “Hey! You walked straight past me. becomes very difficult.7 News | Pharmacy Today | September 2013  30 years ago. one can overcome it and continue living a good life. With the right help and support. He eventually became a board member of the Macular Society and a founding member of an organization which offers emotional support to people with the condition.” “One of the very big symptoms for me is something that I mentioned earlier. and the onset of the disease ended his career prematurely. People with AMD cannot drive. but it is a huge challenge.” Being plundered of good vision did not stop Mr Lewis from living and giving back to fellow AMD sufferers by becoming involved in the Macular Society in the UK.” This is a common problem for those with AMD. ‘I just want to check if I know you. he said. it would be invading somebody else’s space.” Having AMD is not a death sentence. He also related how he would often be walking down the street and someone would say. which is recognizing faces and communicating visually.” 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 attends a conference. he added. He recounted how AMD took over his life . thus seriously affecting their independence and mobility.

’ Poise aimed to inspire people suffering from light urinary leakage (LUL) to arm themselves with the right information and the right tools to manage the condition effectively.. Poise also unveiled its new LUL pads and liners during the event. said: “We need to accept LUL as a reality and embrace the fact that it can be managed with a good dose of humor. and not made to prevent odor. and is an issue surrounded by embarrassment. social media. and retail outlets. Poise’s ambassador and advocate for womanly confidence. family or colleagues. self-consciousness and anxiety when they are around others – friends. misinformation and mismanagement. leakage and the strong [urine] odor .8 News | Pharmacy Today | September 2013  Don’t let incontinence put a damper on life By Pank Jit Sin U rinary incontinence is often mistakenly associated with immaturity or impaired mental capacity. wrong products leaves women susceptible to wetness. using wrong products leaves women susceptible to wetness. leakage and the strong [urine] odor – this unpleasant situation can lead to discomfort. Thus.” “Hence. The campaign also endeavored to bring positive. Celebrity Raja Azura. women who suffer from urinary leakage often face embarrassment and a compromised quality of life. said: “Many women rely on normal liners or sanitary pads to cope with urinary leaks. marketing director of Kimberly-Clark Malaysia. confidence and the right solution – I’m living proof of that!” LUL affects one-in-four women above 35 years of age at least once a week.. manufacturer of Poise products. empowering LUL education to all women via educational articles in the print media. in conjunction with World Continence Week 2013. Soo Wan Yee. radio and consumer engagement programs in high-traffic locations. The new pads are enriched with natural extracts of aloe vera and vitamin E. Armed with the tagline ‘Embracing the Realities of Womanhood and Light Urinary Leakage. but these aren’t equipped to handle them as they aren’t made to absorb fluid quickly or in large volumes. This was the messaged highlighted by a new campaign spearheaded by Poise®. . both proven to protect skin from irritation.” said Ms Soo.

Relieves & Suppresses Chesty Cough .

Sometimes. and body mass index (BMI). who have short monthly cycles or who are related to someone who has endometriosis. Suresh Kumarasamy.” said Dr. greatly impacting women in the prime of their lives and affecting their work life and personal relationships.28(7):1783-92) Some common symptoms of endometriosis include chronic pelvic pain. they can be found in the vagina.” said gynecological oncologist Dr. A recent study that investigated the link between endometriosis. leading to pain. cervix and bladder. (Hum Reprod 2013.10 News | Pharmacy Today | September 2013  Endometriosis – the painful truth By Malvinderjit Kaur Dhillon E ndometriosis occurs when the endometrial lining of the uterus attaches and starts to grow on the surfaces of organs in the pelvic and abdominal areas. This can cause inflammation and formation of scar tissue. period pain and pain after sexual activity. most accurately. I urge women with symptoms suspicious of endometriosis not to suffer in silence and to seek medical attention as early as possible. the higher her risk of having endometriosis. The lack of awareness surrounding endometriosis causes women to link their symptoms to dysmenorrhea. Different women experience different degrees of pain and the amount of pain experienced is not always related to the size or number of endometrial lesions. where it does not normally grow. or in the pelvic cavity. who have heavy or long-lasting periods. causing it to grow. The condition is common among women experiencing infertility. The pain can be both physically and mentally exhausting. Less commonly. Endometrial tissue outside the womb reacts to changing levels of hormones in the body during the menstrual cycle. painful bowel movements during periods and lower back pain. outer surface of the uterus or intestines. Diagnosis of endometriosis can be challenging as symptoms may not always be present. . Suresh. there is no permanent cure. Endometriosis is diagnosed by physical and pelvic examinations. Endometrial cells can implant in the ovaries. however. laparoscopy. Risk factors for developing endometriosis include women starting their period at a young age. This debilitating disease affects almost a million women during their reproductive years. In some women. “A survey in Malaysia revealed that women waited 2 years after experiencing symptoms of endometriosis before they sought treatment. “Endometriosis is a chronic and painful disease. a biopsy is also done to confirm the diagnosis. Over 60% of these women delayed seeking treatment as they expected their symptoms to go away. found that the lower a woman’s BMI. Other symptoms are fatigue. ultrasound and magnetic resonance imaging (MRI) tests and. it does not prevent conception. fallopian tubes.

ALA also works with vitamins C and E by recycling them. preventive cardiologist and specialist in antiaging therapy. the cell’s powerhouse. and DNA material from oxidative stress. ALA also assists the B vitamins in producing energy from proteins.108:21-5) The aim of treatment is to relieve pain. Premitha were speaking at the launch of Visanne®. there is no other antioxidant that can perform this feat. For example. GnRH analogue injections are currently the most effective option for women suffering from endometriosis. he said. said an expert. It also reduced the severity of endometriosis. Dr. It is also made naturally in our bodies.” said Premitha Damodaran. Dienogest has been found to significantly reduce pain associated with endometriosis. which either tend to dis- solve in fat or in water. ALA helps protect the mitochondria. carbohydrates and . a consultant obstetrician and gynecologist. a new oral treatment for endometriosis containing dienogest. Research has shown that ALA is many times more potent as an antioxidant than vitamins C and E. Suresh and Dr.11 News | Pharmacy Today | September 2013  to concerns about side effects. possesses potent antioxidant properties that could prevent healthy cells from getting damaged by free radicals. and prevent the disease from recurring. but these can only be used for 6 months due ALA to the resuce! By Leonard Yap A lpha lipoic acid (ALA). with one-third of diagnosed women no longer having evidence of endometriosis after 24 weeks of treatment with dienogest. a compound initially classified as a vitamin when it was first discovered more than half a century ago. Currently. da Costa. making them more effective. slow the growth of the endometrium-like tissue. said Lenny da Costa. a consultant geriatrician. ALA exists in many foods. Current treatments often do not meet the needs of all women living with endometriosis and may only be safe and/or effective for a limited period of time. “There is pressing need for more effective treatment options for endometriosis. This gives it a unique ability to scavenge more wayward free-radical cells than most other antioxidants. The new interest in ALA was after mounting evidence showed its potential in the treatment of nerve damage and diabetes. said Dr. but only in tiny amounts. improve or protect fertility. This may be due to the fact that ALA dissolves in both fat and water. (Int J Gynaecol Obstet 2010. including bone thinning.

particularly organs like liver. Some studies used between 600-1. Natural sources of ALA Many foods contain ALA in very low amounts. The booklet also serves to increase their understanding of ED as a medical condition. Other studies suggest that ALA creams could repair skin damage related to aging. brussels sprouts. he added. How much to take? ALA is an unproven treatment and there is no established dose. “Malaysian men and their spouses still find it difficult to talk about their sexual health and address their ED condition with their doctor or healthcare professional. Though the effects of ALA on diabetes and FAQs on ED answered By Malvinderjit Kaur Dhillon A free booklet entitled ‘Your Question on ED’ is now available to the public. which could also be a . migraine and peripheral arterial disease. is also a good source. It may also help protect the retina from some of the damage that can occur due to diabetes. One review concluded that the evidence is convincing for the use of 600 mg daily for three weeks to treat symptoms of diabetic neuropathy. patients should seek proper medical treatment first. yeast. It aims to provide answers to questions frequently asked by Malaysians about erectile dysfunction (ED). They have also discovered that ALA supplements can help with neuropathy. The evidence for these indications remain unclear.12 News | Pharmacy Today | September 2013  cancer are promising. fats from food. carrots. kidney disease. ALA appears to reduce symptoms like pain. potatoes. da Costa was speaking at the 10th Malaysian Conference and Exhibition on AntiAging. tingling. ALA has also been researched as a treatment for many other conditions. tomatoes. There is some early evidence that longterm use of ALA may help with the symptoms of dementia. These include spinach. and prickling in the feet and legs. 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. nerve damage caused by diabetes or cancer treatment.200 mg daily for diabetes and neuropathy. Red meat. we collaborated with phar- macies to make available a ‘private’ platform for members of the public to ask any questions about ED which they deemed too embarrassing to ask their doctor. These include Amanita mushroom poisoning. beets and rice bran. Understanding their sentiments. Aesthetic and Regenerative Medicine in Kuala Lumpur. “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 channels as stated in the booklet. medical director of Pfizer. broccoli. glaucoma. Dr. yams.” said Vicknesh Welluppillai.

’ ‘Can ED be treated?’ and ‘Is ED caused by low testosterone level or low libido?.” said Prof. The booklet is available at more than 80 participating pharmacies in three different languages. both men and women in Asia agreed that erection hardness or the ability to maintain an erection ranks as the most important element for ideal sex.13 News | Pharmacy Today | September 2013  pre-cursor to other medical conditions. and the importance of erectile hardness in their relationship and satisfaction with life overall. . “People may not be aware that. amongst others. Eighty percent of men and women valued the quality of sex over quantity of sex The booklet also includes facts from the 2009 Ideal Sex Survey and The Asia Pacific Sexual Health and Overall Wellness (AP SHOW) survey. providing an outlet for the public to drop off any ED-related ques- tions and have them answered by a qualified healthcare professional. There are four hardness levels for men to gauge if they have ED and the Erection Hardness Score (EHS) Grade. Query boxes were made available at selected pharmacies. Late last year. is clearly explained in the booklet. Grade 2 is akin to a peeled banana. English. Ong. which ranges from 1 until 4. According to the 2009 Ideal Sex Survey. Eighty percent of men and women valued the quality of sex over quantity of sex. The objectives of these surveys were to examine the perception of men and women on ideal sex. It is important for men and women to be satisfied with erection hardness as penile hardness is associated with satisfaction with sex and with life overall. a consultant urologist at University Malaya Medical Centre (UMMC). hardness level is the first indication if someone has ED. This effort led to couples enjoying greater intimacy and strengthened bonds. which is the best erectile hardness you will want.” 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. Pfizer Malaysia launched this initiative under its We Love. Bahasa Malaysia and Chinese. Grade 3 an unpeeled banana and Grade 4. Sustaining Passions Campaign to encourage couples to ask questions and arm themselves with the power of knowledge on ED. Grade 1 means severe ED.’ The most repeatedly asked questions were picked and answered by Ong Teng Aik. where your erectile hardness is akin to the softness of a tofu. a cucumber.


Also of concern to the HQSC is an increase in prescriptions of benzodiazepines and antipsychotics as people get older. The frequency of adverse drug events increases with the number of medicines taken: 13% with two medicines. People on these drugs have a substantially higher risk of adverse effects. 58% with five medicines and 82% when seven or more medicines were taken. Possible negative outcomes of polypharmacy are reduced adherence. While these increased rates do not necessarily indicate overprescribing. which may be doing more harm than good. followed by Canterbury at 12. especially if frail or suffering from multiple conditions. which increases as people age. he said. the atlas’ accompanying commentary said. Variation in the supply of medications is generally due to the health system rather than differences in populations. While the rate of concurrent use of the two is “reassuringly low. Combining the two drugs further increases the chance of adverse effects. Dr Millar said.1.” The prime purpose of the atlas is to make variations in services visible because whenever variations exist. While rates varied from DHB to DHB. Benzodiazepines are an example of wide variation in medication. This figure doubled once people reached 85. Some areas gave . including impaired functional ability. blurred vision. Around one-in-four people aged 65 to 74 received five or more long-term medicines in 2011. according to national data.1.15 News | Pharmacy Today | September 2013  New data shed light on polypharmacy T racking of polypharmacy across District Health Boards (DHBs) in New Zealand has highlighted a trend of older people taking multiple medications. confusion.9) and Counties Manukau (6. up to one-infive people aged 85 years and over were given benzodiazepines or antipsychotics in 2011. such as the high rate of polypharmacy for elderly Cantabrians compared with other areas “very challenging. are more vulnerable to medicinerelated illness and death. constipation. and those aged 85 and over were 2. agitation. The regions with the lowest concurrent use were Tairawhiti (3.7).” the variation between DHBs indicates a lack of standardized practice. Nigel Millar said he found some of the information revealed in the atlas. urinary retention. the HQSC website said. older people. West Coast (5.5 times more likely to receive 11 or more medicines than those aged 65 to 74. and increased adverse effects and interactions. high costs for both patients and health services.8). Challenging information As a geriatrician in Canterbury and chair of the HQSC Polypharmacy Expert Advisory Group. there is usually an opportunity to improve equity in health services. and Nelson-Marlborough at 11. Auckland DHB had the highest rate of concurrent use with 13 elderly people per 1000 on both types of drugs. the Health Quality and Safety Commission’s (HQSC) new Atlas of Healthcare Variation shows a high rate of polypharmacy in elderly people across the board. According to the HQSC Atlas. postural hypotension and falls.

” Dr Millar said. There is slim to no evidence of the efficacy of many drugs in the frail elderly with multiple comorbidities because clinical trials tend to pick younger test subjects with only one condition.16 News | Pharmacy Today | September 2013  At the same time. He hopes every pharmacist will look into the information presented in the atlas. . More research is needed into the benefits and harms of giving multiple medicines to elderly patients with multiple comorbidities. while onein-10 received them in the highest areas. them to one-in-20 elderly people. with a focus on how likely the drugs will work on an individual. one-in-five people were receiving benzodiazepines in some areas. Dr Millar said. he said. ask what it means for them and have a debate about it in the wider community. and health professionals need better information presented to them. doctors are dealing with the pressures of feeling the need to prescribe drugs to reduce the risk of diseases like heart attacks and strokes. Local communities need to decide whether these drugs are absolutely essential treatment for elderly patients. In the 85-plus age group. “We have work to do to look at prescription patterns and make sure we are doing the right thing.


as Pharmacy Today New Zealand reports nsomnia affects people in various ways. which help relax the muscles.” she said. Anxiety causes feelings of being tense. In such instances. Ban Quillinichi. aiding people to get to sleep. nervous and worried. to having a disturbed sleep and waking up several times throughout the night. . Magnesium is also particularly beneficial for those who are have trouble sleeping due to stress. and it can trigger sleeping problems. say pharmacy staff. Both health issues can cause disruptions to people’s everyday lives. from having trouble going to sleep.18 Feature | Pharmacy Today | September 2013  Sleep & Insomnia Feature Natural remedies often first choice for anxiety and insomnia Many insomnia and anxiety sufferers go to the pharmacy for natural health supplements as first-line treatment before seeing a GP . A New Zealand pharmacist. Ms Quillinchi most often recommends magnesium supplements. “People always have a concern that they will come to rely on it [prescription medication]. said his Auckland city staff regularly treat people with sleep problems who want to I try a complementary health solution so as to avoid taking prescription medications.

for anxiety. which are both amino acids. There is also “weak evidence” to support the use of chamomile tea as a sleep aid.19 Feature | Pharmacy Today | September 2013  Sleep & Insomnia perience with other supplements. using other sedatives. and can be used to help treat insomnia and anxiety. Ms Quillinchi said. Ms Galbraith agreed there is a stigma of addiction to prescription medicines. Pharmacists should be aware of this and advise customers on options and correct dosages. he says. which may work as a sleep aid. he specifically suggests vitamin B supplements. “In America you can buy it [melatonin] from the corner store. which helps to promote sleep. People with insomnia and anxiety issues could also consider kava. pharmacists should “make the same recommendations they do for alcohol. Other products for helping with anxiety and sleep include tryptophan and 5-hydroxytryptrophan. he added. he said. be careful with. Manage people’s expectations It is important that pharmacy staff manage people’s expectations when recommending Products with passionflower can help people sleep as it has a drowsiness effect. to check for contraindications. people come into her pharmacy after searching information on the Internet. as well as chamomile tea for sleep support. Increasingly.” Mr Holt said. so people often seek a natural alternative. but he recommends the other options first. While Mr Holt recommends all of these products for treating both sleep and anxiety. However. she said. Mr Holt says there is some merit to its use. and will always call a pharmacist into the conversation if the person is taking other prescription medications. Tart cherry contains naturally occurring melatonin. However. such as dosage information. Widely used in the Pacific islands. she is clear about where her limitations lie in recommending these products. and monitor alcohol consumption if taking valerian root. and avoid where possible. as they say they have more ex- . in a tablet form. both Ms Quillinchi and Ms Galbraith are reluctant to recommend tart cherry supplements. due to its strength. She frequently recommends vitamin B supplements to aid anxiety as it helps to support the nerves. which is said to be the cause of the drowsy feeling after consuming a turkey dinner. While tart cherry is “quite new” to the market as a sleep aid. Tart cherry. A retail manager at another pharmacy. A number of studies also back its use. valerian root are great aids Medical researcher Shaun Holt said there are a number of natural health products which are effective in treating both insomnia and anxiety issues. Valerian root is a safe and natural sedative. Researchers have found high levels of tryptophan in turkeys. Interestingly. Do not operate heavy machinery. but often what they have read is incorrect. Aromatherapy can also help relax people. also regularly gives complementary healthcare advice to people suffering from insomnia and anxiety. melatonin supplements are only available on prescription in New Zealand. As a retail manager. the roots are used to create a drink which has sedative properties. He believes a move to reclassify melatonin as a pharmacy-only medicine would make it more accessible to New Zealanders suffering from sleep deprivation. or has other health issues. Delwyn Galbraith. but here it’s classed as a hypnotic. She also recommends passionflower and magnesium products for insomnia and anxiety.” Mr Holt said.

General- . They often also have trouble sleeping. For example. Go beyond selling products The experts all stress the importance of helping people get to the root cause of their in- Treat anxiety with compassion N ew Zealanders are some of the most anxious people in the world. “It is sometimes trial and error and [effectiveness] does depend on the individual. according to Te Rau Hinengaro – the New Zealand Mental Health Survey (2006.000 New Zealanders.” Ms Galbraith said. They tend to feel tired. headaches. second only to Americans. (www. have trouble concentrating and often also suffer from other mental and/or physical disorders. Ms Galbraith said. In a 2004 survey of 13. While most people experience a certain amount of anxiety in their day-to-day lives. with a particular focus on individual lifestyles. They may feel nauseated or have to go to the bathroom frequently. Wellington: the Ministry of Health). usually without any tangible cause.” Sometimes. natural health supplements for anxiety and insomnia. twitching. One customer came into the pharmacy complaining of trouble going to sleep. she admitted she drank around five cups a day. according to the New Zealand Phobic Trust website. The pharmacy staff should also follow up with people. Sufferers realize their reactions are disproportionate. irritability. Products can take two to three weeks to be effective and people should be aware of this. Sufferers may feel lightheaded or out of breath. but are unable to control them. particularly elderly patients. Sleep disruption is also often linked to drinking excessive alcohol or a lack of regular exercise.2%. sweating and hot flushes. about a week after they have started taking natural supplements for People with generalized anxiety disorder have chronic and exaggerated worry and ten- sion. As both are stimulants. The corresponding US figure is 18.phobic. suffering from generalized anxiety disorder can be debilitating. they hype people up and it may take them a while to fall asleep at night. but when asked about her coffee drinking habits. “Having this disorder means always anticipating disaster. Physical symptoms can include trembling. simply the thought of getting through the day provokes anxiety. Mr Holt said. people should take into account how much caffeine they have throughout the day – specifically coffee and energy drinks. or they might feel as though they have a lump in the throat. org. 14. muscle tension. to see if they have been effective or whether they should try something else.7% of respondents said they suffered from anxiety.20 Feature | Pharmacy Today | September 2013  Sleep & Insomnia somnia or anxiety issues.

Some medications also cause symptoms of anxiety. often through visualizations or images. caffeine. cocaine. and gradually increasing exposure to something which triggers anxiety. It is diagnosed when someone spends at least six months worrying excessively about a number of everyday problems. Pharmacists should talk patients through potential side effects from anxiety medications and refer them back to their GP if the drugs are not working for them. asthma. A good question to ask is whether they have already talked to someone. amphetamines. about their anxiety. Anxiety management therapy is a structured therapy involving education. especially whether they are getting enough .and hypothyroidism. People may also come in looking for overthe-counter supplements to help with anxiety after having done their own Internet research.” Ms Clements said. It is when it tips over into the person not being able to function fully that people need to seek help. most often developing in childhood or adolescence. However.334:579-81).21 Feature | Pharmacy Today | September 2013  Sleep & Insomnia sleep. depression and substance misuse. cannabis. anxiety is also a common occurrence and the two disorders often go hand-in-hand. If they have suffered from anxiety before. Taking the time to listen and asking if they are alright really helps. The advice for people suffering from anxiety is to seek help. e.” she said. Treatments Cognitive and anxiety management therapies are both effective treatments. “Looking after your mental health is not something anyone else can do for you. such as anticholinergics and toxicity from digoxin (Best Practice Journal 2009. the Best Practice Journal warns that conditions which cause symptoms similar to anxiety should be considered when making a diagnosis. ized anxiety disorder is a gradual disease.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 advertising campaigns. to look at their lifestyle. Ms Clements said. she said. such as their GP.g. relaxation training. Showing compassion is one of the most important things you can do for a person with mental health issues as they are often already in a state of hypersensitivity and can easily feel like they are being ignored or not taken seriously. “Some sufferers become so anxious that they cannot cope with life. Otago School of Medicine lecturer Christopher Gale said in a clinical review of generalized anxiety disorder published in the British Medical Journal (2007. A pharmacist may be the first point of call for those suffering from anxiety because they do not have to make an appointment and it is free. it is helpful to ask who they talked to about it in the past and what worked for them last time. angina. This includes hyper. Showing compassion is one of the most important things you can do for a person with mental health issues Many people suffer from anxiety and still cope well.

which are more common between midnight and dawn. as in earlier defines shift work as work which starts before 8am or finishes after 6pm – or any work hours which cause a change in normal sleep patterns. Resources There are several online resources which pharmacists can direct their patients to: l  The Malaysian Psychiatric Assocation (MPA) offers a range of mental disorders resources which can be accessed at www. Cognitive behavioral therapy involves recognizing and challenging false underlying thought patterns which help create anxiety and Gale said. l  The Malaysian Mental Health Association (MMHA) also provides information on understanding mental health at www.psychiatry-malaysia. 24/7 society. rose at dawn and slept at nightfall.22 Feature | Pharmacy Today | September 2013  Sleep & Insomnia Antidepressants. Gone are the days when everyone worked 9-to-5 – or. but also a range of possible health l  The MPA website also provides a list of support groups and a list of private psychiatrists registered with it. benzodiazepines. Working against the clock makes you fat S hift work is becoming increasingly common in our modern. a nurse or police l  MMHA organizes various programs and activities including two rehabilitation programs to help people with mental disorders to reintegrate into their community. If you’re working as a truck driver. but they often have clinically significant side effects which can affect adherence. “It is one of the leading causes of fatigue. buspirone and kava all reduce anxiety. l  Patients can also turn to Befrienders ( and staff who do shift work need to learn how to cope with not just a lack of sleep. Dr. 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. a safe platform established to provide emotional support for people who need a listening ear or a shoulder to cry on. physical and mental ill health and accidents.befrienders.” the website said. for 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 Many industries literally operate around the clock. Health website everybody.

nz recommends shift workers sleep only long enough after their last shift in the cycle to feel refreshed. with symptoms including insomnia. but obesity. l  How to adjust sleeping areas to promote good sleep. .23 Feature | Pharmacy Today | September 2013  Sleep & Insomnia Creating the right environment to recover from night shift is vital. Innovation and Employment. excessive sleepiness. The only way to recover from fatigue is to get adequate sleep.038). l Getting to and from work safely. neighbors and friends know and understand shift schedules will make them more cooperative. headaches. and manage shift work and overtime so employees have opportunities to recover. Employers should make sure staff take regular rest breaks. There is a recognized condition suffered by some shift workers known as shift work sleep disorder. Employees should know about: l What to eat and when. “Our results demonstrate that living ‘against the clock’ may be a factor contributing to the epidemic of obesity. l How to recognize fatigue. and training and education. Staying awake late into the night and being woken by alarm clocks means our natural circadian rhythms are out of synch with modern life.” day. l  The impact of caffeine and alcohol on sleep. l The impact of exercise on fatigue.’ which may be causing not only sleep deprivation.” researcher Till Roennberg said. reduced concentration and a lack of energy. 2012. be aware of times people are most likely to be affected by fatigue. workers will have lost six hours of sleep. Exercise and avoiding sleeping pills and alcohol are also beneficial to normal sleep. The average amount of sleep needed to be healthy and alert is between seven and nine hours a night.cub. “The circardian clock also regulates energy homeostasis and its disruption – as with social jet lag – may contribute to weight-related pathologies.1016/j. which results in chronic sleep loss. Letting family. After four nights.03. there are three steps to managing workplace fatigue – consultation. cool and quiet is important. evaluation. Everybody. Sleeping longer or napping can delay the adjustment to a regular. as is having a routine to wake up. Some researchers have also identified a syndrome known as ‘social jetlag. irritability. A team from the University of Munich has been collecting data from thousands of participants to learn about ‘social jetlag’ (doi they need at least two consecutive full nights’ sleep. According to the New Zealand’s Ministry of Business. Shift workers lose an average of between one and one-and-a-half hours’ sleep each 24hour period. “Social jetlag quantifies the discrepancy that often arises between circadian and social clocks.  ossible health effects of lost sleep P include: l mental ill health l obesity l type 2 diabetes l heart disease l accidents. daytime work/sleeping pattern. Keeping the bedroom dark. and still be able to sleep later that night. To compensate. l How to make the most of breaks. l  How to use recovery and rest time appropriately.

she explained. Many people will suffer from ‘transient’ insomnia during their lives and get over it. However.” But can a lack of sleep actually cause death? “In a nutshell. And there are the quality of life things such as irritability and relationship stress. losing even small amounts of sleep can have a cumulative effect. They are different from other causes such as temporary life stresses and so-called ‘sleep hygiene’ issues. Dr. some insomnia sufferers report being tired or exhausted – but not sleepy. However. this is more likely to be as a result of accidents. “The first thing when treating it is to determine which sleep disorder you are dealing with. a health issue or simply extraneous noise. yes. There are simple things which can help. “Make sure you are sleepy when you go to bed.24 Feature | Pharmacy Today | September 2013  Sleep & Insomnia Insomnia closely linked to depression A nyone who has suffered from insomnia will know what a frustrating and stressful condition it can be. and depression and sleep issues also need to be treated separately.” Dr. A sleep researcher at Auckland University’s school of population health. . but others will suffer from chronic insomnia which can last for months or years. People should also try to get into a routine and not overcompensate for poor sleep by going to bed too early. “There is even some evidence about an increased risk of myocardial infarction.’ Sleep is essential to health. Falloon said.” Dr. These include: l stress l  alcohol. Psychological problems and insomnia can be “closely linked.” Dr. Insomnia is also being linked to other health issues. Karen Falloon. Falloon said. Whether it is caused by an overactive mind.” she added. Falloon said. such as reducing or entirely cutting the intake of caffeine. which are not to be taken lightly. “There is building evidence that there are some cardiovascular complications which can occur.  any factors can contribute to M insomnia. rather than a physiological cause. including caffeine or alcohol intake. particularly car crashes. nicotine and caffeine consumption l depression or anxiety l  other medical conditions and medicines l snoring and breathing difficulties l tooth grinding l ongoing pain l restless legs. there is a ‘chicken and egg’ element. discomfort and noise. and other causes of insomnia considered. and being deprived of it can cause many physical and psychological problems. said depression and anxiety are the biggest causes of insomnia. There is an increase in the risk of developing depression and anxiety.” Curiously. Falloon said. Insomnia literally means ‘without sleep.

my. blocked nose. flu is a much more serious ill- ness. especially when it comes to treatment. streaming eyes. .gov. However. These are commonly confused with one another. strains of which have been responsible for countless deaths over the course of history. www.myhealth.25 Spotlight | Pharmacy Today | September 2013  Spotlight A fever is often an indication a person has the flu rather than a cold Sniffing out the difference between a cold and the flu I nfluenza and the common cold share many symptoms. Medical experts are quick to point out that the two ailments are quite different. it’s easy to believe it is flu. sore throat and perhaps a cough. and people often believe one is merely a stronger version of the other. When someone is suffering from a nasty head cold. A community health website. provides information on cold and flu.

Mr Brash added. we often refer. and the classic symptom which differentiates it is fever. there is confusion among customers about what constitutes a cold.” Graeme Brash. However. then we refer to the doctor. New Zealand.26 Spotlight | Pharmacy Today | September 2013  . such as a cough.” Mr Brash said.” “It’s hard to make a distinction between a cold and the flu. making sufferers feel sick all over. medical advice should be sought. as opposed to flu In that year.” Mr Brash also refers patients to their GP if symptoms are severe or The flu can have much more serious effects. agreed there is confusion among customers about what constitutes a cold. advised www. The flu is highly contagious. Colds tend to last about a week. Also. we offer OTC products. “Customers generally lump everything together as flu. tables. both the cold and flu will subside on their own within a week. etc – or being around a person infected who coughs or sneezes. The cold and flu are two different illnesses caused by different types of viruses. “It’s really important with flu and fever that patients get fluids and Pharmacists acknowledge ‘grey area’ New Zealand pharmacist David Postlewaight has already seen quite a few customers with ‘winter ailments’ over the past few weeks. if it seems to be a prolonged bout. “If they are managing to struggle along with daily tasks and just need symptom relief.” Products which offer symptomatic relief for both ailments are the pharmacy’s biggest sellers during winter. Some New Zealand experts are predicting a bad flu season if the pattern seen in the US is repeated there. It is caused by a single family of viruses and contracted by a similar means as the cold. but it’s also important to give the right advice. However. more than 1. If symptoms persist or become more severe after a week. the speed with which the symptoms emerge differ and they vary in severity. for an additional week or so. it is recommended to use medication to treat the symptoms. If it’s more severe and the patient is struggling to do normal daily tasks or seems to have secondary infection.. The US has had its worst outbreaks since the influenza pandemic which began in 2009. Cold symptoms typically last from one to five days. Usually.400 people with influenza were treated in New Zealand hospitals. from Ascot Amcal Pharmacy in Invercargill. irritation in the nose or a scratchy feeling in the throat is the first sign. I suppose the severity of symptoms dictates whether or not we refer to the doctor. but shortlived. with perhaps a few lingering symptoms.. The flu is preventable. He described the difference between a cold and flu as “a bit of a grey area. as opposed to flu.myhealth. Usually. followed within hours by sneezing and a watery nasal discharge. such as green or brown phlegm. which is coming into contact with the virus through touching an infected area – door handles. They affect different areas of the body. “Our job is to differentiate it for them. . there are many differences. while the cold is not.

85% had nasal congestion and this . It is also inconvenient to have our hearing and sense of smell impaired It is a common misconception that nasal congestion is caused by accumulation of excess mucus. These sleep disturbances can detrimentally affect a person’s daytime energy levels. mood and daytime functions.27 Spotlight | Pharmacy Today | September 2013  Decongestant spray for relief of nasal congestion W e all know how frustrating it feels to not be able to breathe properly and to have the blocked nose sensation return no matter how many times you blow your nose. Nasal congestion affects various age groups and can cause discomfort. However. Nasal congestion can lead to sequelae such as sinusitis and otitis media. which can manifest as venous engorgement. It can accelerate the onset or worsening of mild-to-severe sleep disturbances. leading to the blocked nose sensation. Nasal congestion is typically caused by the swelling of the mucosal lining. tumor necrosis factor-α. it may cause other problems as it can interfere with hearing and speech development. In older children and adolescents. Several biologically active agents such as histamine. This. interleukins and cell adhesion molecules contribute to inflammation.355 participants. including sleep apnea. can affect performance in school or at work. Of the 2. increased nasal secretions and tissue swelling/edema. This leads to impaired airflow and the sensation of nasal congestion. A study published in Treatments in Respiratory Medicine looked at the impact of nasal congestion on quality of life and work productivity in allergic rhinitis. nasal congestion is often just an annoyance. in turn.

sore throat and ear ache. Patients can also use a warm compress on the face. A double-blind placebo-controlled parallel group study investigated groups of patients with a common cold who were treated with . Placing a towel soaked in warm water on the face may help open up nasal passages. blocked nose. It can also be caused by hay fever or other allergies. flu or a sinus infection. cardiovascular diseases and hyperthyroidism. HPMC strengthens the moisturizing effect and prevents nasal mucosa from drying out. helps provide long-lasting relief from congestion. with its decongestant effect lasting up to 10 hours. ensuring that dryness and irritation do not occur. [2005. Due to its vasoconstrictive properties. Caution should be used in patients with hypertension. Sorbitol. The spray is applied directly to nasal tissue and it works right away. Otrivin provides double-acting relief. a decongestant nasal spray. cold symptoms and general well being of patients and adverse events. leading to greater patient satisfaction with treatment. Otrivin was also found to improve common cold symptoms such as runny nose. Otrivin should be avoided during pregnancy as a precaution. Nasal airflow remained above the threshold for nasal obstruction for up to 10 hours. pregnancy and vasomotor rhinitis. often used as a moisturizer. Otrivin is indicated for patients with colds of various types.28 Spotlight | Pharmacy Today | September 2013  Otrivin nasal spray or placebo (saline solution). making it much easier for patients with a blocked nose to breathe. was the one symptom that most adults and children wished to prevent. Secondary objectives of the study were to determine the peak subjective effect. Contraindications for Otrivin include dry rhinitis. duration of relief of nasal congestion. to aid drainage in sinus conditions. combining a vasoconstrictor effect with a moisturizing formula. It is important for the nasal passages to be kept moist as breathing in dry air dries up the membrane and further irritates it. acute angle glaucoma or known hypersensitivity to ingredients of the product. An alternative to this is to carefully breathe in steam from a bowl of boiling water. Taking a hot shower and breathing in the steam can also provide relief. It contains the active ingredient xylometazoline hydrochloride.22:1-6] The decongestant effect of Otrivin was found to be significantly greater than placebo as demonstrated by nasal conductance at one hour after spraying with the nasal spray. Patients can use a humidifier or a vaporizer to prevent the nasal passages from drying up. Otrivin is available in flexible dosage in a convenient and easy-to-use packaging. had a notable emotional impact and hampered their ability to perform daily activities. It was found that nasal congestion affected most participants at work or school. as an adjuvant to decongest the nasopharyngeal mucosa in otitis media and to facilitate rhinoscopy. It provides a soothing effect. The study primarily aimed to determine the decongestion effect. It contains two moisturizing ingredients which are no strangers to the pharmaceutical and cosmetics industry – sorbitol and hydroxypropyl methylcellulose (HPMC). Home remedies can help provide a temporary relief from a blocked nose. which constricts nasal blood vessels and increases nasal airflow. [Am J Rhinol & Allergy 2008. keeping the head elevated by propping the head with several pillows can help make breathing more comfortable. Increasing fluid intake is also recommended to help thin out the mucus. Otrivin®. nasal polyps.4(6):439-46] A congested nose may occur when a person has the common cold. When sleeping. helps normalize the level of liquid in mucosa.

the needle provides the means of transporting insulin through the underlying tissue to the deposition area near the bloodstream in the subcutaneous tissue. and the needle provides the means of penetrating the skin barrier. It is important to distinguish between the actual or ‘real’ pain and perceived pain experienced when using a needle. A longer needle.. Importantly. The needle length determines the correct depth of the deposition. its ease of use.41(2):16975) People with type 2 diabetes might bypass injections or avoid taking injections for a more extended time. Perceived pain is psychological in nature. Considering these key roles. Most people are uncomfortable with the thought of having injections. The injection process will always cause some tissue damage accompanied with pain or discomfort. causes painful perforation of the muscle fascia. the structure of the needle influences the correct deposition and absorption of insulin and. especially the idea of injecting themselves. causing more pain. While this anxiety generally disappears once the person has tried a few injections. especially among new users. the design and structure of the needle plays a pivotal role in influencing the successful outcome of insulin therapy. metabolic control. ‘Real’ pain caused by the actual stimulation of pain receptors is mostly influenced by the needle diameter – a needle with a larger diameter touches more nerve endings. Most people are uncomfortable with the thought of having injections . . Other factors influencing the level of ‘real’ pain are the sharpness of the needle tip and the smoothness of the surface. (J Fam Pract 1995. thereby.. and will usually cause a certain level of anxiety. The functional design of the needle influences the usage of the needle. In addition to penetrating the skin. the application of the correct injection technique and the ease of choosing an individually correct needle. The diameter determines the potential post-injection leakage and the sharpness influences the severity of both acute and chronic tissue damage.29 Spotlight | Pharmacy Today | September 2013  The right needle matters in insulin therapy I nsulin therapy is primarily injection therapy. as many as 10% of people with diabetes suffer from a fear of needles to the point where needle anxiety is an obstacle to overcome. on the other hand. All these factors greatly influence user preference and satisfaction.

A key factor is the appearance of the needle. the needle itself needs to be easily disposable. altered insulin flow and change in insulin concentration. Early combination therapy treats diabetes to target. lipohypertrophy. a very serious barrier to the initiation of injection therapy. with less discomfort and psychological fear. it is important that a minimum number of steps are involved in the overall process. (Somatosens Mot Res 2006. Its Tapered tip technologyTM is a Pharmacy UPDATE Pharmacy Update brings you updates on disease management and advances in pharmacotherapy based on reports from symposia. delays insulin initiation • • • • • • • • • • • • • • • • • • • • P31 . therefore. For optimal ease of use. increased risk of infections. It is of ideal needle length (6 mm) and provides safe and effective insulin injections for most people. Its thin wall technology results in less force needed when injecting. In addition. the NovoFine needle is for single use only. Reused needles may cause increased pain. It is the type of pain most often involved in needle anxiety and. People with type 2 diabetes are mostly old or elderly. This month’s updates are made possible through unrestricted educational grants from MSD. Furthermore. as well as latest clinical data. good ergonomics.30 Spotlight | Pharmacy Today | September 2013  unique needle geometry where the needle tapers to a 32G tip. but of significant clinical importance. making it the thinnest insulin needle. The new NovoFine® 32G Tip ETW (Extra Thin Wall) is now the new standard in gentle injections. while people with type 1 diabetes are often children when diagnosed. conferences and interviews. less pain and bleeding and gentle to insert. hence.23:37-43) It is chemically polished and silicone coated to remove surface imperfections for a smooth injection. and causes less pain on insertion. All require ease of use. easy handling in mounting and a low force for injection.

Richard O’Brien. Prof O’Brien said it is probably better to less aggressively treat patients who have more severe diabetes as there is a need to balance glycemic benefits with the risk of hypoglycaemia. peripheral and microvascular disease. (Diab Obes Metab 2010. those with long duration of diabetes. stroke. Australia. and those with pre-existing cardiovascular disease.” In what is commonly known as the ‘legacy effect. said current data point to the use of multiple treatment modalities earlier in the course of diabetes to bring patients to target and to keep them on target for a longer period of time. ( J Clin Pract 2005.9:194-205) Even with monotherapy. delays insulin initiation T he use of multiple treatment modalities early in the diagnosis of diabetes allows a longer time frame before insulin initiation. Prof O’Brien said the combination of DPP-4 inhibitor sitagliptin plus metformin (Janumet®. especially in elderly patients.5 percent on diagnosis.59:134555) By combining lifestyle modifications with oral antidiabetic combination therapy. MSD) caused less hypoglycemia compared to a sulfonylurea plus metformin combination. The benefits were observed 10 years after the original study ended. In his presentation at a symposium sponsored by Merck Sharp & Dohme (MSD).59:1345-55) The importance of good glycemic control early in the course of diabetes has been demonstrated by the UK Prospective Diabetic Study (UKPDS) post-study followup. This recommendation is meant to tackle the short span of time between prescription and failure of treatment. (J Clin Pract 2005. the patient can be brought to target and stay in target for a much longer duration before the eventuality of treatment failure and insulin initiation. (Diabetes Obes Metab 2007. clinical dean of medicine and chair.359:1577-89) Conversely. deaths from any cause.31 Pharmacy Update Early combination therapy treats diabetes to target. says a prominent endocrinologist. myocardial infarction. Comparing different oral antidiabetic combinations. University of Melbourne. (N Engl J Med 2008. Prof O’Brien said: “Good control early in the course of the disease can prevent complications many years later and my interpretation [of the ‘legacy effect’] is that we should probably be more aggressive in treating our patients early in the course of diabetes. Prof O’Brien also discussed the American Association of Clinical Endocrinologists (AACE)’s recommendation for initial combination therapy in patients with HbA 1c >7.12(3):252-61) The AACE also lists the possibility of using DPP-4 inhibitors as potential first-line monotherapy as it is comparable to both metformin and sulfonylurea in terms of .’ patients in the intensive glycemic control arm of the UKPDS were observed to have less diabetes-related deaths. Academic Center. sitagliptin caused less gastrointestinal symptoms compared with metformin monotherapy. and subsequent addition of other antidiabetic drugs.

(Curr Med Res Opin 2012. fasting in the month of Ramadan can be a challenge as incidents of hypoglycemia increase during the fasting month.8 percent in the sulfonylurea group). A study carried out in India and Malaysia on diabetics during Ramadan showed that by utilizing DPP-4 inhibitors such as sitagliptin. In countries with a large population of Muslim diabetics.12(3):252-61.28(8):1289-96) . 2007. the incidence of hypoglycemia could be halved (1. [Diab Obes Metab 2010.9:194-205] Prof O’Brien noted that although incretin-based therapies have been suspected of causing pancreatitis. but with fewer side effects such as weight gain and hypoglycemia. metaanalysis of randomized trials have shown no such association.9% in sitagliptin versus 3.32 Pharmacy Update HbA1c reduction.

Selangor Recognised by Academy of Pharmacy Earn 1 CPD p o every int month C hronic 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 intermittent condition usually defined as lasting for at least six months. (Table 1) This multifaceted disorder has biopsychosocial components. It is a debilitating clinical condi- . Eugene Wong Consultant Orthopedic and Spine Surgeon Adjunct Assistant Professor Perdana University Graduate School of Medicine Serdang. There are several risk factors which predispose one to the development of chronic pain. It may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.33 Pharmacy Practice | Pharmacy Today | September 2013  Pharmacy Practice Managing chronic pain Dr. develops insidiously and is associated with a sense of hopelessness and helplessness. The cause is often unknown.

fibromyalgia and neurological disorders. The WHO has a simple and validated three-step approach to pain management. COX-2 antagonists Neuropathic pain agents Tricyclic antidepressants. Chronic pain can be categorized as malignant. medication. herbal remedies Pain coaching Life counseling Cognitive behavioral therapy Pain psychologist Sleep evaluation Rehabilitation Interventional blocks. Persistent pain causes maladaptive changes that affect pain perception and pain sensations out of proportion.34 Clinical Pharmacy | Pharmacy Today | September 2013  Genetics Severe initial pain Sleep dysfunction Fatigue Level of education Female gender Anxiety/depression HPA (stress) axis dysfunction Time off work Job satisfaction Younger age Low self-help skills Table 1: Risk factors leading to chronic pain tion associated with a variety of disease entities including diabetic neuropathy. spinal cord stimulator. occupational and behavioral therapy. Rehabilitation consists of reconditioning and pain prevention. Drug treatment is largely dependent on the type of chronic pain syndrome. Mild pain can be adequately treated with aspirin. functioning and mood. anticonvulsants. Hyperalgesia is due to sensitization of peripheral nociceptors. acetaminophen and nonsteroidal anti-inflammatory drugs . Chronic pain produces significant behavioral and psychological changes such as depression. which causes prolonged excitation or sensitization of spinal pain transmission neurons. intrathecal pump Neurolytic procedures Table 2: Medical management of chronic pain multimodal fashion. Start low and go slow on drugs. Regimens involve a multidisciplinary approach utilizing education. nonmalignant or neuropathic (either malignant or nonmalignant). The principles of treatment include the reduction of pain. (Table 2) The combination of medications serves to decrease pain by altering pain pathways in a Anti-inflammatories Steroids. and physical. antiarrhythmics Muscle relaxants Narcotics Alternative medicine Acupuncture. whereas allodynia is due to activation of low-threshold mechanoreceptors. massage therapy. Initiation of pain treatment should not be delayed while a diagnostic work-up is completed as uncontrolled pain has significant adverse effects on quality of life. (Table 3) The basic principles behind the three steps of the ladder include selecting the appropriate analgesic for the pain intensity and individualizing the dose by titration of analgesics. and evaluating function and mood. rehabilitation and coping. A score of 1-3 on the pain intensity scale equals to mild pain. NSAIDs. preoccupation with the pain and a tendency to deny pain. low back pathology. Treatment strategies targeted at underlying pain mechanisms are most likely to provide long-term relief of pain. Some of the ways to measure pain include asking and observing the patient. sleeping disorders. The focus of diagnosis and evaluation of chronic pain should be on reversible causes of the pain. Central sensitization is due to loss of inhibitory effects of myelinated primary afferents.

Acetaminophen is the analgesic of first choice in patients (who do not have liver disease and do not consume excessive amounts of alcohol) with mild-to-moderate pain. or if the patient has an acute inflammatory condition. COX2 inhibitors are recommended for long-term treatment of individuals who have chronic pain caused by inflammatory or other underlying conditions such as osteoarthritis. This is a first-line agent for osteoarthritis. risk of gastrointestinal bleeding. Acetaminophen is preferable in patients at risk for side effects of NSAIDs such as renal failure. These agents reduce. oxycodone and hydrocodone are available as immediaterelease (short-acting) preparations or in combination with aspirin or acetaminophen. if possible. Patients should be placed on bowel regimes to avoid constipation. There is considerable risk of gastrointestinal bleeding. the patient has Second Tier Opioids Neurolysis Thermal Procedures Third Tier Neurostimulation Implantable Drug Pumps Surgical Intervention Neuromodulation Intrathecal Infusion Table 3: Chronic pain treatment continuum severe pain. It is a safe alternative to NSAIDs for non-inflammatory pain when given up to a maximum of 4 g/day. many opioids are marketed as combination products containing one of these agents. These drugs differ from opioids in two important ways in that there is a ceiling effect to the analgesia where using more drugs is not associated with greater pain control. and they do not produce physical dependence. acetaminophen or NSAIDs. either alone or in combination. The risk of renal impairment is the same as for NSAIDs. but do not eliminate. The treatment of severe pain requires stronger opioid agonist drugs and the continuation of aspirin. The tapering of the drug dose is required to avoid significant withdrawal symptoms. Many of these are now available both in immediate and extended-release forms. hydromorphone and fentanyl are commonly used opioids. NSAIDs or aspirin may be appropriate if there is an inflammatory component of the pain. The fentanyl transdermal patch is another option for patients who require around-the- . 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. low-dose opioid drugs are added to aspirin. A score of 4-6 equates with moderate pain. When the score exceeds 7. acetaminophen or NSAIDs. Tramadol is a centrally acting analgesic and may be added to acetaminophen or NSAIDS. to manage moderate-to-severe pain.35 Clinical Pharmacy | Pharmacy Today | September 2013  First Tier NSAIDs TENS Psychological Nerve Blocks (NSAIDs). hepatic dysfunction and gastric ulceration. For patient convenience. oxycodone. Codeine. sodium retention and renal impairment in the elderly. NSAIDs can be used if acetaminophen fails to provide relief. bleeding. Opioid analgesics are appropriate for moderate-to-severe acute pain that is not relieved by other categories of analgesics. In the initial treatment of moderate pain. Codeine. hydrocodone.

1 Opioids are commonly prescribed for chronic non-cancer pain and may be effective for short-term pain relief. (Table 5) Ineffective. Transdermal opioids require 24-72 hours to reach a ‘steady state’ and may be administered every 48-72 hours. but does not constitute addiction. When opioids are used for prolonged periods. focus Pseudoaddiction looks like addiction but resolves with adequate pain control Substance abuse using medications for alternative reasons Chemical ‘copers’ treating underlying depression. harm. Opioids are associated with adverse effects. Ongoing monitoring for safety and effectiveness is essential. and indeterminate for hydrocodone and methadone. urine drug testing and surveillance of data from the state prescription monitoring program. with evidence ranging from moderate for the use of transdermal fentanyl and sustained-release morphine. the drug is a liability rather than an asset to the . It may. anxiety. insomnia Table 4: Opioid medication issues Maximize non-opioid analgesic strategies first Inform subjects of risks before initiating opioid therapy Facilitate the use of opioid agreements for patients initiating or increasing opioids Schedule follow-up visits at intervals of 2-3 months and perform periodic urine tests to confirm adherence Monitor pain severity and pain-related functional impairment at follow-up visits since analgesic response may wane in some patients over time Avoid opioid dose escalations without first assessing pain severity and interference Consider discontinuing opioids if not beneficial Consider opioid rotation if tolerance to one opioid is suspected Table 5: Opioid management strategy not well defined in chronic use. especially during the commencement or change in dosing and administration. Any person who takes sufficient doses of certain types of drugs for a significant length of time can have withdrawal symptoms if the drug is suddenly stopped or reversed by another medicine. Long-term effectiveness is variable. be necessary to ensure that the patient is also being treated with immediaterelease opioids on a scheduled or PRN basis for the first 24-72 hours when the transdermal opioid is started. including regular review of functional progress or maintenance. The risk of addiction is Addiction loss of control. chemical dependency and addiction may occur. to limited for oxycodone. 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. therefore.36 Clinical Pharmacy | Pharmacy Today | September 2013  clock pain control. The various medication issues are listed in Table 4. When it occurs.2 Addiction should be distinguished from physical dependence. This shows the presence of physical dependence. unsafe or diverted opioid therapy should be promptly tapered or stopped. drug tolerance.

Meperidine is associated with increased confusion. (Table 7) Interventional techniques can be used to treat chronic pain. joints. oral. peripheral nerve and epi- Antidepressant amitriptyline. An injection of steroids can be done at trigger points. Neuropathic pain is initiated or caused by a primary lesion or dysfunction in the nervous system. Pentazocine. carbamazepine. Some drugs are not to be taken long term. pregabalin Local anesthetics Parenteral. and may precipitate withdrawal in opioid-dependent patients. persistent desensitization. Indomethacin. gastrointestinal hemorrhage. piroxicam and meclofenamate cause serious side effects such as peptic ulceration. gabapentin Anti-emetic scopolamine Anxiolytics benzodiazepines Glucocorticoids Topical agents Mixture of ketamine. followed by a period with reduced sensitivity and. skeletal muscle relaxants and antispasmodic agents. These target the source of pain. doxepin Anticonvulsants carbamazepine. and continued use despite adverse effects from the drug. These include pethidine. Intradiscal thermocoagulation can be done to stop leakage of the nucleus. craving the psychological effects of the drug. This localizes the delivery of the medication. topical Topical capsaicin Opioids Antiarrhythmics Baclofen Carbamazepine Trigeminal neuralgia Duloxetine Peripheral diabetic neuropathy Gabapentin Postherpetic neuralgia Lidocaine patch Postherpetic neuralgia Pregabalin Peripheral diabetic neuropathy Postherpetic neuralgia Table 6: Treatments for neuropathic pain person. which has a short half-life and the risk of central nervous system toxicity at high doses. capsaicin causes enhanced sensitivity to noxious stimuli. Nucleoplasty or percutaneous discectomy is a procedure where a needle aspiration of a portion of the nucleus pulposus is carried out. Certain drugs are not recommended in chronic pain management. Cannabis and cocaine have dysphoric side effects. Physical or restorative therapy may be used as part of a multimodal strategy for patients with chronic low back pain. inability to consistently control the quantity used. clonidine. anticonvulsants. Following application to the skin. (Table 6) Topical creams with capsaicin are used to treat pain from a wide range of chronic conditions including neuropathic pain. agitation and hallucinations. Psychological . gabapentin and lidocaine Table 7: Adjuvant therapy for chronic pain dural space. topical agents. confusion. butorphanol and other agonist-antagonist combinations have little analgesic ceiling effects and are associated with dysphoria and hallucinations. after repeated applications. There is a wide range of medications used to treat neuropathic pain.37 Clinical Pharmacy | Pharmacy Today | September 2013  Tricyclic antidepressants Nortriptyline Anticonvulsants Gabapentin. There are four core elements in true addiction – compulsive use and preoccupation with the drug and its supply.3 Coanalgesics or adjuvants used to treat chronic pain include antidepressants.

These interventions may be used as part of a multimodal strategy for patients with low back pain. Supportive psychotherapy. A long-term approach that includes periodic follow-up evaluations should be developed and implemented as part of the overall treatment strategy. healthcare utilization. The priority of these criteria depends upon who is asked to evaluate the treatment approach. group therapy and counseling can be used in the treatment of chronic pain. Multimodal interventions should be part of a treatment strategy for patients with chronic pain. as well as for other chronic pain conditions. which include pain reduction. return to work and closure of disability claims.4 Chronic pain is a multifactorial phenomenon. increase in functional ability.5 treatments include the use of cognitive behavioral therapy. reduction or elimination of inappropriate medication. The evaluation of treatment effectiveness . The elderly are more likely to have significant pain issues and are at particularly high risk of having their pain inadequately managed. biofeedback or relaxation training.38 Clinical Pharmacy | Pharmacy Today | September 2013  must be based upon several criteria.


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