September 2013 PsorCARE program to help manage...

September 2013

PsorCARE program to help manage psoriasis more effectively

Natural remedies often first choice for anxiety and insomnia

Seeing AMD through the eyes of a patient

News Feature

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News | Pharmacy Today | September 2013 3

By Saras Ramiya

The Psoriasis Coach All-Round Educa-tion (PsorCARE) program aims to en-hance the counseling skills of healthcare

practitioners to optimize treatment outcomes.Psoriasis is a little-understood skin con-

dition that carries a strong social stigma. Its emotional impact on patients often far out-weighs the disease’s physical impact. This is why good support and guidance from health-care providers is crucial in achieving optimal treatment adherence, one of the main chal-lenges in psoriasis management.

PsorCARE is a peer-based training plat-form that teaches trainees how to achieve a balance between asking, listening and in-forming when communicating with patients about living with and overcoming the burden of psoriasis. The program also enables train-ees to translate theoretical approaches into practical implementation.

“Caring for patients with chronic skin dis-eases 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 psoria-sis by improving patient adherence to topical treatments which are the mainstay of man-agement of majority of patients,” said Najeeb Ahmad Mohd Safdar, president of the Der-matological Society of Malaysia.

The session, held in June, was led by Bar-bara Page, a dermatology liaison nurse spe-cialist at the Queen Margaret Hospital in Scot-land, UK. “Aside from adhering to medical treatments, psoriasis patients also face physi-cal and emotional challenges in their daily

lives and it is important for us, as healthcare providers, to recognize these challenges 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 thera-py, treatment adherence – whether it be me-dicinal, behavioral, lifestyle or a combination of treatments – is essential for achieving opti-mal outcomes. Extensive market research has identified that adherence is founded on good communication and a positive relationship be-tween patients and healthcare practitioners. This applies in particular to nurses who are in regular contact with patients. (J Eur Acad Der-matol Venereol 2011;25 Suppl 4:9-14)

Psoriasis patients find it challenging to ad-here to their treatment modality because the application of their medicine requires disci-

PsorCARE program to help manage psoriasis more effectively


pline and patience, and this impacts their life-style. 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 Asia-Pacific).

“Research has shown that there is a signifi-cant need to bridge the gap between admin-istering medical treatments and providing patient support. Programs such as PsorCARE are an essential platform that allows us to share sustainable approaches with health-care providers to help them address the high

prevalence in treatment non-adherence and respond to the 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 im-prove their lives and overcome their burden of disease and treatment. We are aware of the challenges that psoriasis patients face and we want them to know that trained support is available. Our ultimate aim is to give these pa-tients hope and empower them with the ability to control their psoriasis conditions and even-tually improve their quality of life,” said Tan Keng Aun, country manager of LEO Pharma Malaysia.

By Rajesh Kumar

Nicotine replacement therapies (NRT) and other licensed drugs can indeed help people quit smoking, a system-

atic review has confirmed.The overview of previous Cochrane re-

views 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 find-ings serve as a reassurance to pharmacists and other health professionals involved in smoking cessation programs.

In most countries, including the US and Eu-rope, the only medications currently licensed for smoking cessation are NRTs such as nico-tine patches and gums, the antidepressant

bupropion and the drug varenicline, which blunts the effects of nicotine on nicotine re-ceptors in the brain. In Russia and other parts of Eastern Europe, cytisine, similar to vareni-cline, is also licensed for smoking cessation.

The researchers combined the findings of

Quit smoking medications are effective


existing Cochrane reviews on the subject, using all the available data from across in-dividual reviews. In total, they collected evidence from 267 studies, which together involved a total of 101,804 people. The stud-ies covered a wide variety of licensed and unlicensed smoking cessation medications, comparing the treatments with placebo, and the three main treatments with each other. If a person stopped smoking for six months or longer, this was considered a successful quit attempt.

The three widely licensed medications and cytisine all improved smokers’ chances of quitting. The odds of quitting were about 80% higher with single NRT or bupropion than with placebo, and between two and three times higher with varenicline than with placebo. However, varenicline was about 50 percent more effective than any single formu-lation of NRT (patches, gum, sprays, lozenges and inhalers), but similar in efficacy to com-bining two types of NRT. Based on two recent trials, cytisine improved the chances of quit-ting nearly four-fold compared with placebo. Among other treatments tested, nortriptyline, another antidepressant drug, was more effec-tive than placebo, but did not offer any ad-

ditional improvement when combined with NRT.

“This review provides strong evidence that the three main treatments, nicotine replace-ment therapy, bupropion and varenicline, can all help people to stop smoking,” said lead researcher Kate Cahill, of the department of primary care health sciences at the University of Oxford in Oxford, UK. “Although cytisine is not currently licensed for smoking cessa-tion in most of the world, these data suggest it has potential as an effective and affordable therapy.”

The researchers also assessed the safety of different medications. Bupropion, which is known to trigger occasional seizures in vul-nerable people, did not lead to an increase in the rate of seizures when used for smoking cessation in its slow-release version. Overall, NRT, bupropion and varenicline are consid-ered low-risk treatments, although the re-searchers say the results are currently less clear-cut for varenicline.

“Further research may be warranted into the safety of varenicline,” said Dr. Cahill. “However, in the trials we looked at we did not detect evidence of any increase in neuro-psychiatric, heart or circulatory problems.”

READ JPOG ANYTIME, ANYWHERE. Download the digital edition today at www.jpog.com


By Leonard Yap

The impact of age-related macular de-generation (AMD) goes far beyond vi-sual impairment as it can also greatly

affect a person’s self-esteem and confidence, says an AMD patient.

“People [with AMD] do become very dis-tressed [with their predicament], people even become depressed. In some cases people even consider suicide,” said Dennis Lewis, a patient ambassador for AMD Alliance Inter-national.

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, he said.

This feeling is particularly painful when the person is a senior member of the family. Alternatively, it could happen to somebody who has had a very successful career and feels that these achievements have become history.

“[Suddenly] we are facing a future of hav-ing to rely on people for even simple things like pouring a drink. I would be worried that I will spill it. So people start to feel that they are going to be a burden on the family and yet, as the senior person, they see it as their responsibility to look after the family, which is a challenge,” he said.

Some people will think, “I am stupid … I have accidents all the time, just small acci-dents. It gnaws away at my self-esteem and independence. Instead of pouring water into a glass, I might miss the glass. I may walk up two steps and miss my step and fall.”

Mr Lewis related how he once mistook his wife’s black handbag for the cat. “My wife has a black handbag with a handle and, guess what I stroked the other day? It was the hand-

bag and not the cat. It made me feel a bit stu-pid.”

AMD is not an eye condition that makes people completely blind. “In the UK, I am le-gally registered as blind, but I can step over here and touch the microphone. Here is my daughter, and I can see the audience. I am not completely blind. This makes me feel like a fraud. People feel I am a bit of a fraud and this is how it affects the individual. Many people keep these feelings to themselves,” he said.

How AMD changes lives Mr Lewis said although he was looking at the audience, he was not certain that the audience was looking at him. “If I go back past two or four rows, I don’t even know if you are there. This is what people live with every day with fully developed AMD.” He also spoke of how his blindness affects his ability to communi-cate, particularly as he talked to an audience. “I have some notes in front of me which I can’t read easily, but I wrote them so I think I should know what I am saying.”

The ability to read and write is often very difficult; watching television is a challenge, even if one sits very close to it. “If I watch my favorite sport, which is football, I can see blue and red, but I can’t recognize the player. So it

Seeing AMD through the eyes of a patient


becomes very difficult.” “One of the very big symptoms for me is

something that I mentioned earlier, which is recognizing faces and communicating visu-ally, because across a crowded room I don’t know who I know.” He described how he has to walk up to a person and stick his nose right in front of the person to recognize who he is talking to when he attends a confer-ence.

“I am not sure how you would react if I came right up to you and stuck my face into yours and said, ‘I just want to check if I know you.’ We don’t want to do that, it would be in-vading somebody else’s space.” This is a com-mon problem for those with AMD. He also related how he would often be walking down the street and someone would say, “Hey! You walked straight past me. Why are you ignor-ing me?”

Another serious loss is the ability to drive. People with AMD cannot drive, thus serious-ly affecting their independence and mobility, he said.

He recounted how AMD took over his life

30 years ago. He used to work in the banking industry, and the onset of the disease ended his career prematurely. “I had to stop work-ing because I could not do my job to the best of my ability anymore.”

Being plundered of good vision did not stop Mr Lewis from living and giving back to fellow AMD sufferers by becoming involved in the Macular Society in the UK. He eventu-ally became a board member of the Macular Society and a founding member of an orga-nization which offers emotional support to people with the condition. “This is a growing organization and we network with each other throughout the UK to make sure emotional support is offered wherever necessary.”

Having AMD is not a death sentence, but it is a huge challenge. With the right help and support, one can overcome it and continue living a good life. But prevention should be the priority and eye health must be taken very seriously, he added.

Mr Lewis was speaking at the recent Retinal Diseases Awareness Week in Petaling Jaya.


By Pank Jit Sin

Urinary incontinence is often mistak-enly associated with immaturity or impaired mental capacity. Thus,

women who suffer from urinary leakage of-ten face embarrassment and a compromised quality of life.

This was the messaged highlighted by a new campaign spearheaded by Poise®, in conjunction with World Continence Week 2013. Armed with the tagline ‘Embracing the Realities of Womanhood and Light Urinary Leakage,’ Poise aimed to inspire people suf-fering from light urinary leakage (LUL) to arm themselves with the right information and the right tools to manage the condition effectively.

The campaign also endeavored to bring positive, empowering LUL education to all women via educational articles in the print media, social media, radio and consumer en-gagement programs in high-traffic locations, and retail outlets.

Poise also unveiled its new LUL pads and

liners during the event. The new pads are en-riched with natural extracts of aloe vera and vitamin E, both proven to protect skin from irritation.

Soo Wan Yee, marketing director of Kim-berly-Clark Malaysia, manufacturer of Poise products, said: “Many women rely on nor-mal liners or sanitary pads to cope with uri-nary leaks, but these aren’t equipped to han-dle them as they aren’t made to absorb fluid quickly or in large volumes, and not made to prevent odor.”

“Hence, using wrong products leaves women susceptible to wetness, leakage and the strong [urine] odor – this unpleasant situ-ation can lead to discomfort, self-conscious-ness and anxiety when they are around oth-ers – friends, family or colleagues,” said Ms Soo.

Celebrity Raja Azura, Poise’s ambassa-dor and advocate for womanly confidence, said: “We need to accept LUL as a reality and embrace the fact that it can be man-aged with a good dose of humor, confi-dence and the right solution – I’m living proof of that!”

LUL affects one-in-four women above 35 years of age at least once a week, and is an issue surrounded by embarrassment, misin-formation and mismanagement.

Don’t let incontinence put a damper on life

wrong products leaves women

susceptible to wetness, leakage and

the strong [urine] odor ...

Relieves & SuppressesChesty Cough


By Malvinderjit Kaur Dhillon

Endometriosis occurs when the endome-trial lining of the uterus attaches and starts to grow on the surfaces of organs

in the pelvic and abdominal areas, where it does not normally grow.

Endometrial cells can implant in the ova-ries, fallopian tubes, outer surface of the uter-us or intestines, or in the pelvic cavity. Less commonly, they can be found in the vagina, cervix and bladder.

Endometrial tissue outside the womb re-acts to changing levels of hormones in the body during the menstrual cycle, causing it to grow. This can cause inflammation and for-mation of scar tissue, leading to pain.

“Endometriosis is a chronic and painful disease. In some women, there is no perma-nent cure. The pain can be both physically and mentally exhausting, greatly impact-ing women in the prime of their lives and affecting their work life and personal rela-tionships,” said gynecological oncologist Dr. Suresh Kumarasamy.

This debilitating disease affects almost a million women during their reproductive years. Risk factors for developing endome-triosis include women starting their period at a young age, who have heavy or long-lasting periods, who have short monthly cycles or who are related to someone who has endo-metriosis. The condition is common among women experiencing infertility; however, it does not prevent conception.

A recent study that investigated the link between endometriosis, and body mass index (BMI), found that the lower a woman’s BMI,

the higher her risk of having endometriosis. (Hum Reprod 2013;28(7):1783-92)

Some common symptoms of endometriosis include chronic pelvic pain, period pain and pain after sexual activity. Other symptoms are fatigue, painful bowel movements during pe-riods and lower back pain.

“A survey in Malaysia revealed that women waited 2 years after experiencing symptoms of endometriosis before they sought treatment. Over 60% of these women delayed seeking treatment as they expected their symptoms to go away. I urge women with symptoms suspi-cious of endometriosis not to suffer in silence and to seek medical attention as early as pos-sible,” said Dr. Suresh.

Diagnosis of endometriosis can be chal-lenging as symptoms may not always be present. Different women experience differ-ent degrees of pain and the amount of pain experienced is not always related to the size or number of endometrial lesions. The lack of awareness surrounding endometriosis causes women to link their symptoms to dysmenor-rhea. Endometriosis is diagnosed by physi-cal and pelvic examinations, ultrasound and magnetic resonance imaging (MRI) tests and, most accurately, laparoscopy. Sometimes, a biopsy is also done to confirm the diagnosis.

Endometriosis – the painful truth


The aim of treatment is to relieve pain, slow the growth of the endometrium-like tis-sue, improve or protect fertility, and prevent the disease from recurring.

“There is pressing need for more effective treatment options for endometriosis. Cur-rent 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. For example, GnRH analogue injections are currently the most effective op-tion for women suffering from endometriosis, but these can only be used for 6 months due

to concerns about side effects, including bone thinning,” said Premitha Damodaran, a con-sultant obstetrician and gynecologist.

Dr. Suresh and Dr. Premitha were speak-ing at the launch of Visanne®, a new oral treat-ment for endometriosis containing dienogest.

Dienogest has been found to significantly reduce pain associated with endometriosis. It also reduced the severity of endometriosis, with one-third of diagnosed women no longer hav-ing evidence of endometriosis after 24 weeks of treatment with dienogest. (Int J Gynaecol Ob-stet 2010;108:21-5)

By Leonard Yap

Alpha lipoic acid (ALA), a compound initially classified as a vitamin when it was first discovered more than half

a century ago, possesses potent antioxidant properties that could prevent healthy cells from getting damaged by free radicals.

The new interest in ALA was after mount-ing evidence showed its potential in the treat-ment of nerve damage and diabetes, said an expert.

Research has shown that ALA is many times more potent as an antioxidant than vi-tamins C and E. This may be due to the fact that ALA dissolves in both fat and water, said Lenny da Costa, a consultant geriatrician, preventive cardiologist and specialist in anti-aging therapy.

This gives it a unique ability to scavenge more wayward free-radical cells than most other antioxidants, which either tend to dis-

solve in fat or in water, he said.ALA exists in many foods. It is also made

naturally in our bodies, but only in tiny amounts. ALA helps protect the mitochon-dria, the cell’s powerhouse, and DNA materi-al from oxidative stress. ALA also works with vitamins C and E by recycling them, making them more effective. Currently, there is no other antioxidant that can perform this feat, said Dr. da Costa.

ALA also assists the B vitamins in produc-ing energy from proteins, carbohydrates and

ALA to the resuce!


FAQs on ED answered

fats from food, he added. It is used in the body to induce the breakdown of carbohydrates and to make energy for organs in the body.

Several studies have found that ALA can improve insulin resistance. They have also discovered that ALA supplements can help with neuropathy, nerve damage caused by diabetes or cancer treatment. ALA appears to reduce symptoms like pain, tingling, and prickling in the feet and legs. It may also help protect the retina from some of the damage that can occur due to diabetes.

There is some early evidence that long-term use of ALA may help with the symp-toms of dementia. Other studies suggest that ALA creams could repair skin damage related to aging. ALA has also been researched as a treatment for many other conditions. These include Amanita mushroom poisoning, glau-coma, kidney disease, migraine and periph-eral arterial disease. The evidence for these indications remain unclear.

Though the effects of ALA on diabetes and

cancer are promising, patients should seek proper medical treatment first.

Dr. da Costa was speaking at the 10th Ma-laysian Conference and Exhibition on Anti-Aging, Aesthetic and Regenerative Medicine in Kuala Lumpur.

Natural sources of ALA Many foods contain ALA in very low amounts. These include spinach, broccoli, yams, pota-toes, yeast, tomatoes, brussels sprouts, car-rots, beets and rice bran.

Red meat, particularly organs like liver, is also a good source.

How much to take?ALA is an unproven treatment and there is no established dose. Some studies used between 600-1,200 mg daily for diabetes and neuropa-thy. One review concluded that the evidence is convincing for the use of 600 mg daily for three weeks to treat symptoms of diabetic neuropathy.

By Malvinderjit Kaur Dhillon

A free booklet entitled ‘Your Question on ED’ is now available to the public. It aims to provide answers to ques-

tions frequently asked by Malaysians about erectile dysfunction (ED).

“Malaysian men and their spouses still find it difficult to talk about their sexual health and address their ED condition with their doctor or healthcare professional. Understanding their sentiments, we collaborated with phar-

macies to make available a ‘private’ platform for members of the public to ask any ques-tions about ED which they deemed too em-barrassing to ask their doctor,” said Vicknesh Welluppillai, medical director of Pfizer.

“We were overwhelmed by the response and hope the answers stated via the booklet will motivate them to seek further treatment of their ED condition via the proper chan-nels as stated in the booklet. The booklet also serves to increase their understanding of ED as a medical condition, which could also be a


pre-cursor to other medical conditions,” said Dr Vicknesh.

Among the questions asked by men and women aged 21 to 65 were ‘Whom should I consult if I suspect that I have ED,’ ‘Can ED be treated?’ and ‘Is ED caused by low testoster-one level or low libido?.’ The most repeatedly asked questions were picked and answered by Ong Teng Aik, a consultant urologist at University Malaya Medical Centre (UMMC).

“People may not be aware that, amongst others, hardness level is the first indication if someone has ED. There are four hardness lev-els for men to gauge if they have ED and the Erection Hardness Score (EHS) Grade, which ranges from 1 until 4, is clearly explained in the booklet. Grade 1 means severe ED, where your erectile hardness is akin to the softness of a tofu, Grade 2 is akin to a peeled banana, Grade 3 an unpeeled banana and Grade 4, a cucum-ber, which is the best erectile hardness you will want. It is important for men and women to be satisfied with erection hardness as penile hardness is associated with satisfaction with sex and with life overall,” said Prof. Ong.

According to the 2009 Ideal Sex Survey, both men and women in Asia agreed that erection hardness or the ability to maintain an erection ranks as the most important ele-ment for ideal sex. Eighty percent of men and women valued the quality of sex over quan-tity of sex.

Late last year, Pfizer Malaysia launched this initiative under its We Love, Sustaining Passions Campaign to encourage couples to ask questions and arm themselves with the power of knowledge on ED. This effort led to couples enjoying greater intimacy and strengthened bonds.

Query boxes were made available at se-lected pharmacies, providing an outlet for the public to drop off any ED-related ques-

tions and have them answered by a qualified healthcare professional.

The booklet also includes facts from the 2009 Ideal Sex Survey and The Asia Pacif-ic Sexual Health and Overall Wellness (AP SHOW) survey. The objectives of these sur-veys were to examine the perception of men and women on ideal sex, and the importance of erectile hardness in their relationship and satisfaction with life overall.

The booklet is available at more than 80 participating pharmacies in three different languages; English, Bahasa Malaysia and Chinese.

Eighty percent of men and

women valued the quality

of sex over quantity of sex

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Tracking of polypharmacy across Dis-trict Health Boards (DHBs) in New Zealand has highlighted a trend of old-

er people taking multiple medications, which may be doing more harm than good.

While rates varied from DHB to DHB, the Health Quality and Safety Commission’s (HQSC) new Atlas of Healthcare Variation shows a high rate of polypharmacy in elderly people across the board, which increases as people age.

Around one-in-four people aged 65 to 74 received five or more long-term medicines in 2011, according to national data.

This figure doubled once people reached 85, and those aged 85 and over were 2.5 times more likely to receive 11 or more medicines than those aged 65 to 74.

The frequency of adverse drug events in-creases with the number of medicines taken: 13% with two medicines, 58% with five medi-cines and 82% when seven or more medicines were taken, the HQSC website said.

While these increased rates do not neces-sarily indicate overprescribing, older people, especially if frail or suffering from multiple conditions, are more vulnerable to medicine-related illness and death.

Possible negative outcomes of polyphar-macy are reduced adherence, high costs for both patients and health services, and in-creased adverse effects and interactions.

Also of concern to the HQSC is an increase in prescriptions of benzodiazepines and anti-psychotics as people get older.

People on these drugs have a substantially higher risk of adverse effects, including im-paired functional ability, agitation, confusion,

blurred vision, urinary retention, constipa-tion, postural hypotension and falls. Combin-ing the two drugs further increases the chance of adverse effects.

According to the HQSC Atlas, up to one-in-five people aged 85 years and over were given benzodiazepines or antipsychotics in 2011.

While the rate of concurrent use of the two is “reassuringly low,” the variation between DHBs indicates a lack of standardized prac-tice, the atlas’ accompanying commentary said.

Auckland DHB had the highest rate of con-current use with 13 elderly people per 1000 on both types of drugs, followed by Canterbury at 12.1, and Nelson-Marlborough at 11.1.

The regions with the lowest concurrent use were Tairawhiti (3.7), West Coast (5.9) and Counties Manukau (6.8).

Challenging informationAs a geriatrician in Canterbury and chair of the HQSC Polypharmacy Expert Advisory Group, Nigel Millar said he found some of the information revealed in the atlas, such as the high rate of polypharmacy for elderly Cantabrians compared with other areas “very challenging.”

The prime purpose of the atlas is to make variations in services visible because whenev-er variations exist, there is usually an oppor-tunity to improve equity in health services, Dr Millar said.

Variation in the supply of medications is generally due to the health system rather than differences in populations, he said.

Benzodiazepines are an example of wide variation in medication. Some areas gave

New data shed light on polypharmacy


them to one-in-20 elderly people, while one-in-10 received them in the highest areas.

In the 85-plus age group, one-in-five people were receiving benzodiazepines in some areas.

Local communities need to decide whether these drugs are absolutely essential treatment for elderly patients.

“We have work to do to look at prescrip-tion patterns and make sure we are doing the right thing,” Dr Millar said.

There is slim to no evidence of the efficacy of many drugs in the frail elderly with mul-tiple comorbidities because clinical trials tend to pick younger test subjects with only one condition, he said.

At the same time, doctors are dealing with the pressures of feeling the need to prescribe drugs to reduce the risk of diseases like heart attacks and strokes.

More research is needed into the benefits and harms of giving multiple medicines to elderly patients with multiple comorbidities, and health professionals need better informa-tion presented to them, with a focus on how likely the drugs will work on an individual, Dr Millar said.

He hopes every pharmacist will look into the information presented in the atlas, ask what it means for them and have a debate about it in the wider community.

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Feature | Pharmacy Today | September 2013 Sleep & Insomnia18

Feature

Insomnia affects people in various ways, from having trouble going to sleep, to hav-ing a disturbed sleep and waking up sev-

eral times throughout the night.Anxiety causes feelings of being tense, ner-

vous and worried, and it can trigger sleeping problems. Both health issues can cause dis-ruptions to people’s everyday lives.

A New Zealand pharmacist, Ban Quillin-ichi, said his Auckland city staff regularly treat people with sleep problems who want to

try a complementary health solution so as to avoid taking prescription medications.

“People always have a concern that they will come to rely on it [prescription medica-tion],” she said.

In such instances, Ms Quillinchi most of-ten recommends magnesium supplements, which help relax the muscles, aiding people to get to sleep. Magnesium is also particular-ly beneficial for those who are have trouble sleeping due to stress.

Natural remedies often first choice for anxiety and insomniaMany insomnia and anxiety sufferers go to the pharmacy for natural health supplements as first-line treatment before seeing a GP, say pharmacy staff, as Pharmacy Today New Zealand reports


Products with passionflower can help peo-ple sleep as it has a drowsiness effect.

Increasingly, people come into her phar-macy after searching information on the In-ternet, but often what they have read is incor-rect, such as dosage information, she said.

Pharmacists should be aware of this and advise customers on options and correct dos-ages, Ms Quillinchi said.

A retail manager at another pharmacy, Del-wyn Galbraith, also regularly gives comple-mentary healthcare advice to people suffering from insomnia and anxiety.

Ms Galbraith agreed there is a stigma of addiction to prescription medicines, so peo-ple often seek a natural alternative.

She also recommends passionflower and magnesium products for insomnia and anxi-ety, as well as chamomile tea for sleep support.

She frequently recommends vitamin B supplements to aid anxiety as it helps to sup-port the nerves.

As a retail manager, she is clear about where her limitations lie in recommending these products, and will always call a phar-macist into the conversation if the person is taking other prescription medications, or has other health issues, to check for contraindica-tions.

Tart cherry, valerian root are great aidsMedical researcher Shaun Holt said there are a number of natural health products which are effective in treating both insomnia and anxiety issues.

While tart cherry is “quite new” to the mar-ket as a sleep aid, Mr Holt says there is some merit to its use.

Tart cherry contains naturally occurring melatonin, which helps to promote sleep. A number of studies also back its use.

However, both Ms Quillinchi and Ms Gal-braith are reluctant to recommend tart cherry supplements, as they say they have more ex-

perience with other supplements.Interestingly, melatonin supplements are

only available on prescription in New Zealand.“In America you can buy it [melatonin]

from the corner store, but here it’s classed as a hypnotic,” Mr Holt said.

He believes a move to reclassify melatonin as a pharmacy-only medicine would make it more accessible to New Zealanders suffering from sleep deprivation.

Valerian root is a safe and natural sedative, and can be used to help treat insomnia and anxiety, he said.

However, due to its strength, pharmacists should “make the same recommendations they do for alcohol,” Mr Holt said.

Do not operate heavy machinery, be careful with, and avoid where possible, using other sedatives, and monitor alcohol consumption if taking valerian root, he added.

People with insomnia and anxiety issues could also consider kava. Widely used in the Pacific islands, the roots are used to create a drink which has sedative properties.

Other products for helping with anxiety and sleep include tryptophan and 5-hydroxy-tryptrophan, which are both amino acids.

Researchers have found high levels of tryptophan in turkeys, which is said to be the cause of the drowsy feeling after consuming a turkey dinner, he says.

Aromatherapy can also help relax people, which may work as a sleep aid. While Mr Holt recommends all of these products for treating both sleep and anxiety, he specifically sug-gests vitamin B supplements, in a tablet form, for anxiety.

There is also “weak evidence” to support the use of chamomile tea as a sleep aid, but he recommends the other options first.

Manage people’s expectationsIt is important that pharmacy staff manage people’s expectations when recommending


natural health supplements for anxiety and insomnia.

“It is sometimes trial and error and [effec-tiveness] does depend on the individual,” Ms Galbraith said.

Products can take two to three weeks to be effective and people should be aware of this.

The pharmacy staff should also follow up with people, particularly elderly patients, about a week after they have started taking natural supplements for insomnia, to see if they have been effective or whether they should try something else.

Go beyond selling productsThe experts all stress the importance of help-ing people get to the root cause of their in-

somnia or anxiety issues, with a particular focus on individual lifestyles.

For example, people should take into ac-count how much caffeine they have through-out the day – specifically coffee and energy drinks.

As both are stimulants, they hype people up and it may take them a while to fall asleep at night, Ms Galbraith said.

One customer came into the pharmacy complaining of trouble going to sleep, but when asked about her coffee drinking habits, she admitted she drank around five cups a day.

Sleep disruption is also often linked to drinking excessive alcohol or a lack of regular exercise, Mr Holt said.

Treat anxiety with compassion

New Zealanders are some of the most anxious people in the world, second only to Americans, according to Te

Rau Hinengaro – the New Zealand Mental Health Survey (2006; Wellington: the Ministry of Health).

In a 2004 survey of 13,000 New Zealand-ers, 14.7% of respondents said they suffered from anxiety. The corresponding US figure is 18.2%.

While most people experience a certain amount of anxiety in their day-to-day lives, according to the New Zealand Phobic Trust website, suffering from generalized anxiety disorder can be debilitating. (www.phobic.org.nz/)

People with generalized anxiety disorder have chronic and exaggerated worry and ten-

sion, usually without any tangible cause.“Having this disorder means always an-

ticipating disaster.”Sometimes, simply the thought of getting

through the day provokes anxiety.Sufferers realize their reactions are dispro-

portionate, but are unable to control them. They often also have trouble sleeping.

Physical symptoms can include trembling, twitching, muscle tension, headaches, irrita-bility, sweating and hot flushes.

Sufferers may feel lightheaded or out of breath. They may feel nauseated or have to go to the bathroom frequently, or they might feel as though they have a lump in the throat.

They tend to feel tired, have trouble con-centrating and often also suffer from other mental and/or physical disorders. General-


ized anxiety disorder is a gradual disease, most often developing in childhood or ado-lescence.

It is diagnosed when someone spends at least six months worrying excessively about a number of everyday problems.

However, the Best Practice Journal warns that conditions which cause symptoms simi-lar to anxiety should be considered when making a diagnosis.

This includes hyper- and hypothyroidism, angina, asthma, depression and substance misuse, e.g. caffeine, amphetamines, canna-bis, cocaine.

Some medications also cause symptoms of anxiety, such as anticholinergics and toxicity from digoxin (Best Practice Journal 2009;25:20-8).

Show compassion and encourage seeking helpMental Health Foundation of New Zealand chief executive Judi Clements said while there is more awareness of depression due to ad-vertising campaigns, anxiety is also a com-mon occurrence and the two disorders often go hand-in-hand.

Many people suffer from anxiety and still cope well. It is when it tips over into the per-son not being able to function fully that peo-ple need to seek help, Ms Clements said.

“Some sufferers become so anxious that they cannot cope with life,” she said.

The advice for people suffering from anxi-ety is to seek help, to look at their lifestyle, especially whether they are getting enough

sleep.“Looking after your mental health is not

something anyone else can do for you,” Ms Clements said.

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, she said.

People may also come in looking for over-the-counter supplements to help with anxiety after having done their own Internet research.

A good question to ask is whether they have already talked to someone, such as their GP, about their anxiety.

If they have suffered from anxiety before, it is helpful to ask who they talked to about it in the past and what worked for them last time.

Taking the time to listen and asking if they are alright really helps.

Showing compassion is one of the most im-portant things you can do for a person with mental health issues as they are often already in a state of hypersensitivity and can easily feel like they are being ignored or not taken seriously.

Pharmacists should talk patients through potential side effects from anxiety medica-tions and refer them back to their GP if the drugs are not working for them.

TreatmentsCognitive and anxiety management therapies are both effective treatments, Otago School of Medicine lecturer Christopher Gale said in a clinical review of generalized anxiety disor-der published in the British Medical Journal (2007;334:579-81).

Anxiety management therapy is a struc-tured therapy involving education, relax-ation training, and gradually increasing exposure to something which triggers anxi-ety, often through visualizations or images.

Showing compassion is

one of the most important things

you can do for a person with

mental health issues


ResourcesThere 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.psychiatry-malaysia.org/listcat.php?cid=6 l� The MPA website also provides a list of support groups and a list of private psychia-

trists registered with it. l The Malaysian Mental Health Association (MMHA) also provides information on

understanding mental health at www.mentalhealth.org.my l��MMHA organizes various programs and activities including two rehabilitation pro-

grams to help people with mental disorders to reintegrate into their community. l Patients can also turn to Befrienders (www.befrienders.org.my), a safe platform estab-

lished to provide emotional support for people who need a listening ear or a shoulder to cry on.

Cognitive behavioral therapy involves rec-ognizing and challenging false underlying thought patterns which help create anxiety and depression.

Antidepressants, benzodiazepines, buspi-rone and kava all reduce anxiety, but they often have clinically significant side effects which can affect adherence, Dr. Gale said.

Working against the clock makes you fat

Shift work is becoming increasingly common in our modern, 24/7 society. Gone are the days when everyone worked 9-to-5 – or, as

in earlier eras, rose at dawn and slept at nightfall.Health website everybody.co.nz 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.

Many industries literally operate around the clock, and staff who do shift work need to learn how to cope with not just a lack of sleep, but also a range of possible health effects.

“It is one of the leading causes of fatigue. If you’re working as a truck driver, a nurse or police officer, for example, you will at some stage be required to work when your body is naturally at rest – this disrupts your natural body clock and can lead to fatigue, physical and mental ill health and accidents, which are more common between midnight and dawn,” the website said.

Working at night has a greater impact than working the same number of hours during the

Staying awake late into the night

and being woken by alarm clocks

means our natural circadian rhythms

are out of synch with modern life


day. Shift workers lose an average of between one and one-and-a-half hours’ sleep each 24-hour period. After four nights, workers will have lost six hours of sleep. To compensate, they need at least two consecutive full nights’ sleep.

The only way to recover from fatigue is to get adequate sleep. The average amount of sleep needed to be healthy and alert is be-tween seven and nine hours a night.

According to the New Zealand’s Ministry of Business, Innovation and Employment, there are three steps to managing workplace fatigue – consultation, evaluation, and train-ing and education.

Employers should make sure staff take regular rest breaks, be aware of times people are most likely to be affected by fatigue, and manage shift work and overtime so employ-ees have opportunities to recover.

Creating the right environment to recover from night shift is vital. Letting family, neigh-bors and friends know and understand shift schedules will make them more cooperative. Keeping the bedroom dark, cool and quiet is important, as is having a routine to wake up.

Everybody.co.nz recommends shift work-ers sleep only long enough after their last shift in the cycle to feel refreshed, and still be able to sleep later that night.

Sleeping longer or napping can delay the adjustment to a regular, daytime work/sleep-ing pattern.

Exercise and avoiding sleeping pills and al-cohol are also beneficial to normal sleep.

There is a recognized condition suffered by some shift workers known as shift work sleep disorder, with symptoms including in-somnia, excessive sleepiness, headaches, ir-ritability, reduced concentration and a lack of energy.

Some researchers have also identified a syn-drome known as ‘social jetlag,’ which may be causing not only sleep deprivation, but obesity.

Staying awake late into the night and being woken by alarm clocks means our natural circa-dian rhythms are out of synch with modern life.

A team from the University of Munich has been collecting data from thousands of participants to learn about ‘social jetlag’ (doi 10.1016/j.cub, 2012.03.038).

“Social jetlag quantifies the discrepancy that often arises between circadian and social clocks, which results in chronic sleep loss,” re-searcher Till Roennberg said. “The circardian clock also regulates energy homeostasis and its disruption – as with social jet lag – may contribute to weight-related pathologies.

“Our results demonstrate that living ‘against the clock’ may be a factor contribut-ing to the epidemic of obesity.”

�Possible�health�effects�of�lost�sleep�include:l mental ill healthl obesityl type 2 diabetesl heart diseasel accidents.

Employees should know about:l What to eat and when.l The impact of caffeine and alcohol

on sleep.l How to make the most of breaks.l How to use recovery and rest time

appropriately.l How to adjust sleeping areas to pro-

mote good sleep.l How to recognize fatigue.l Getting to and from work safely.l The impact of exercise on fatigue.


Insomnia closely linked to depression

Anyone who has suffered from insom-nia will know what a frustrating and stressful condition it can be. Insomnia

literally means ‘without sleep.’ Sleep is essen-tial to health, and being deprived of it can cause many physical and psychological problems.

Whether it is caused by an overactive mind, a health issue or simply extraneous noise, los-ing even small amounts of sleep can have a cumulative effect.

A sleep researcher at Auckland University’s school of population health, Karen Falloon, said depression and anxiety are the biggest causes of insomnia. They are different from other causes such as temporary life stresses and so-called ‘sleep hygiene’ issues, including caf-feine or alcohol intake, discomfort and noise.

“The first thing when treating it is to de-termine which sleep disorder you are dealing with,” Dr. Falloon said.

There are simple things which can help, such as reducing or entirely cutting the intake of caffeine. People should also try to get into a routine and not overcompensate for poor sleep by going to bed too early. “Make sure

you are sleepy when you go to bed.”Curiously, some insomnia sufferers report

being tired or exhausted – but not sleepy.Many people will suffer from ‘transient’

insomnia during their lives and get over it, but others will suffer from chronic insomnia which can last for months or years, Dr. Fal-loon said.

Psychological problems and insomnia can be “closely linked,” she added. There is an increase in the risk of developing depression and anxiety. However, there is a ‘chicken and egg’ element, and depression and sleep issues also need to be treated separately, and other causes of insomnia considered.

Insomnia is also being linked to other health issues. “There is building evidence that there are some cardiovascular complications which can occur,” Dr. Falloon said. “There is even some evidence about an increased risk of myocardial infarction. And there are the quality of life things such as irritability and relationship stress, which are not to be taken lightly.”

But can a lack of sleep actually cause death? “In a nutshell, yes,” Dr. Falloon said. However, she explained, this is more likely to be as a re-sult of accidents, particularly car crashes, rath-er than a physiological cause.

Many factors can contribute to insomnia. These include:l stressl alcohol, nicotine and caffeine con-

sumptionl depression or anxietyl other medical conditions and medi-

cinesl snoring and breathing difficultiesl tooth grindingl ongoing painl restless legs.

Spotlight | Pharmacy Today | September 2013 25

Sniffing out the difference between a cold and the flu

Spotlight

Influenza and the common cold share many symptoms, and people often be-lieve one is merely a stronger version of

the other.When someone is suffering from a nasty

head cold, blocked nose, streaming eyes, sore throat and perhaps a cough, it’s easy to be-lieve it is flu.

However, flu is a much more serious ill-

ness, strains of which have been responsible for countless deaths over the course of history.

Medical experts are quick to point out that the two ailments are quite different.

A community health website, www.my-health.gov.my, provides information on cold and flu. These are commonly confused with one another, especially when it comes to treat-ment.

A fever is often an indication a person has the flu rather than a cold


However, there are many differences. The cold and flu are two different illnesses caused by different types of viruses. They affect differ-ent areas of the body, the speed with which the symptoms emerge differ and they vary in sever-ity. The flu is preventable, while the cold is not.

Cold symptoms typically last from one to five days. Usually, irritation in the nose or a scratchy feeling in the throat is the first sign, followed within hours by sneezing and a wa-tery nasal discharge. Colds tend to last about a week, with perhaps a few lingering symp-toms, such as a cough, for an additional week or so.

The flu can have much more serious ef-fects, making sufferers feel sick all over. It is caused by a single family of viruses and con-tracted by a similar means as the cold, which is coming into contact with the virus through touching an infected area – door handles, ta-bles, etc – or being around a person infected who coughs or sneezes.

The flu is highly contagious, but short-lived. Usually, both the cold and flu will sub-side on their own within a week.

However, it is recommended to use medi-cation to treat the symptoms. If symptoms persist or become more severe after a week, medical advice should be sought, advised www.myhealth.gov.my.

Some New Zealand experts are predicting a bad flu season if the pattern seen in the US is repeated there. The US has had its worst out-breaks since the influenza pandemic which began in 2009.

In that year, more than 1,400 people with influenza were treated in New Zealand hos-pitals.

Pharmacists acknowledge ‘grey area’New Zealand pharmacist David Postlewaight has already seen quite a few customers with ‘winter ailments’ over the past few weeks.

He described the difference between a cold and flu as “a bit of a grey area.”

“It’s hard to make a distinction between a cold and the flu. I suppose the severity of symptoms dictates whether or not we refer to the doctor.

“If they are managing to struggle along with daily tasks and just need symptom re-lief, we offer OTC products. If it’s more severe and the patient is struggling to do normal daily tasks or seems to have secondary infec-tion, such as green or brown phlegm, then we refer to the doctor. Also, if it seems to be a pro-longed bout, we often refer.”

Graeme Brash, from Ascot Amcal Pharma-cy in Invercargill, New Zealand, agreed there is confusion among customers about what constitutes a cold, as opposed to flu.

“Customers generally lump everything to-gether as flu,” Mr Brash said.

“Our job is to differentiate it for them, and the classic symptom which differentiates it is fever.”

Products which offer symptomatic relief for both ailments are the pharmacy’s biggest sellers during winter, but it’s also important to give the right advice, Mr Brash added.

“It’s really important with flu and fever that patients get fluids and electrolytes.”

Mr Brash also refers patients to their GP if symptoms are severe or long-lasting.

... there is confusion among

customers about what constitutes

a�cold,�as�opposed�to�flu


Decongestant spray for relief of nasal congestion

We all know how frustrating it feels to not be able to breathe properly and to have the blocked nose sen-

sation return no matter how many times you blow your nose. 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 ex-cess mucus, leading to the blocked nose sen-sation.

Nasal congestion is typically caused by the swelling of the mucosal lining. Several biolog-ically active agents such as histamine, tumor necrosis factor-α, interleukins and cell adhe-sion molecules contribute to inflammation, which can manifest as venous engorgement, increased nasal secretions and tissue swell-ing/edema. This leads to impaired airflow and the sensation of nasal congestion.

Nasal congestion affects various age groups and can cause discomfort. In older children and adolescents, nasal congestion is often just an annoyance. However, it may cause other problems as it can interfere with hearing and speech development. Nasal congestion can lead to sequelae such as sinusitis and otitis media. It can accelerate the onset or worsen-ing of mild-to-severe sleep disturbances, in-cluding sleep apnea. These sleep disturbances can detrimentally affect a person’s daytime energy levels, mood and daytime functions. This, in turn, can affect performance in school or at work.

A study published in Treatments in Respi-ratory Medicine looked at the impact of nasal congestion on quality of life and work pro-ductivity in allergic rhinitis. Of the 2,355 par-ticipants, 85% had nasal congestion and this


was the one symptom that most adults and children wished to prevent. It was found that nasal congestion affected most participants at work or school, had a notable emotional im-pact and hampered their ability to perform daily activities. [2005;4(6):439-46]

A congested nose may occur when a per-son has the common cold, flu or a sinus in-fection. It can also be caused by hay fever or other allergies, nasal polyps, pregnancy and vasomotor rhinitis.

Home remedies can help provide a tempo-rary relief from a blocked nose. It is impor-tant for the nasal passages to be kept moist as breathing in dry air dries up the membrane and further irritates it. Patients can use a hu-midifier or a vaporizer to prevent the nasal passages from drying up. Taking a hot show-er and breathing in the steam can also provide relief. An alternative to this is to carefully breathe in steam from a bowl of boiling water.

Increasing fluid intake is also recommend-ed to help thin out the mucus. Patients can also use a warm compress on the face. Placing a towel soaked in warm water on the face may help open up nasal passages. When sleep-ing, keeping the head elevated by propping the head with several pillows can help make breathing more comfortable.

Otrivin®, a decongestant nasal spray, helps provide long-lasting relief from congestion. The spray is applied directly to nasal tissue and it works right away, with its decongestant effect lasting up to 10 hours.

Otrivin is available in flexible dosage in a convenient and easy-to-use packaging. It contains the active ingredient xylometazoline hydrochloride, which constricts nasal blood vessels and increases nasal airflow, making it much easier for patients with a blocked nose to breathe.

A double-blind placebo-controlled parallel group study investigated groups of patients with a common cold who were treated with

Otrivin nasal spray or placebo (saline solu-tion). The study primarily aimed to determine the decongestion effect. Secondary objectives of the study were to determine the peak sub-jective effect, duration of relief of nasal con-gestion, cold symptoms and general well being of patients and adverse events. [Am J Rhinol & Allergy 2008;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. Na-sal airflow remained above the threshold for nasal obstruction for up to 10 hours.

Otrivin was also found to improve common cold symptoms such as runny nose, blocked nose, sore throat and ear ache, leading to greater patient satisfaction with treatment.

Otrivin provides double-acting relief, com-bining a vasoconstrictor effect with a mois-turizing formula. It contains two moistur-izing ingredients which are no strangers to the pharmaceutical and cosmetics industry – sorbitol and hydroxypropyl methylcellulose (HPMC).

Sorbitol, often used as a moisturizer, helps normalize the level of liquid in mucosa, ensur-ing that dryness and irritation do not occur. It provides a soothing effect. HPMC strength-ens the moisturizing effect and prevents nasal mucosa from drying out.

Otrivin is indicated for patients with colds of various types, to aid drainage in sinus con-ditions, as an adjuvant to decongest the na-sopharyngeal mucosa in otitis media and to facilitate rhinoscopy.

Contraindications for Otrivin include dry rhinitis, acute angle glaucoma or known hy-persensitivity to ingredients of the product. Caution should be used in patients with hy-pertension, cardiovascular diseases and hy-perthyroidism. Due to its vasoconstrictive properties, Otrivin should be avoided during pregnancy as a precaution.


The right needle matters in insulin therapy

Insulin therapy is primarily injection ther-apy, and the needle provides the means of penetrating the skin barrier.

In addition to penetrating the skin, the needle provides the means of transporting insulin through the underlying tissue to the deposition area near the bloodstream in the subcutaneous tissue.

Considering these key roles, the design and structure of the needle plays a pivotal role in influencing the successful outcome of insulin therapy. The functional design of the needle in-fluences the usage of the needle, its ease of use, the application of the correct injection tech-nique and the ease of choosing an individually correct needle. All these factors greatly influ-ence user preference and satisfaction.

Importantly, the structure of the needle influences the correct deposition and absorp-tion of insulin and, thereby, metabolic con-trol. The needle length determines the correct depth of the deposition. The diameter deter-mines the potential post-injection leakage and the sharpness influences the severity of both acute and chronic tissue damage.

The injection process will always cause some tissue damage accompanied with pain or discomfort, and will usually cause a certain level of anxiety, especially among new users.

Most people are uncomfortable with the thought of having injections, especially the idea of injecting themselves. While this anxi-ety generally disappears once the person has tried a few injections, as many as 10% of peo-ple with diabetes suffer from a fear of needles

to the point where needle anxiety is an obsta-cle to overcome. (J Fam Pract 1995;41(2):169-75) People with type 2 diabetes might bypass injections or avoid taking injections for a more extended time.

It is important to distinguish between the actual or ‘real’ pain and perceived pain experi-enced when using a needle. ‘Real’ pain 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, causing more pain. A longer needle, on the other hand, causes painful per-foration of the muscle fascia.

Other factors influencing the level of ‘real’ pain are the sharpness of the needle tip and the smoothness of the surface.

Perceived pain is psychological in nature,

Most people are uncomfortable

with the thought of having injections ...


but of significant clinical importance. It is the type of pain most often involved in needle anxiety and, therefore, a very serious barrier to the initiation of injection therapy. A key fac-tor is the appearance of the needle.

People with type 2 diabetes are mostly old or elderly, while people with type 1 diabetes are often children when diagnosed. All require ease of use, good ergonomics, easy handling in mounting and a low force for injection.

For optimal ease of use, it is important that a minimum number of steps are involved in the overall process. In addition, the needle it-self needs to be easily disposable.

The new NovoFine® 32G Tip ETW (Extra Thin Wall) is now the new standard in gentle injections. Its Tapered tip technologyTM is a

unique needle geometry where the needle ta-pers to a 32G tip, making it the thinnest insulin needle, hence, less pain and bleeding and gen-tle to insert. (Somatosens Mot Res 2006;23:37-43) It is chemically polished and silicone coated to remove surface imperfections for a smooth in-jection, and causes less pain on insertion. Its thin wall technology results in less force need-ed when injecting. It is of ideal needle length (6 mm) and provides safe and effective insulin injections for most people, with less discom-fort and psychological fear.

Furthermore, the NovoFine needle is for single use only. Reused needles may cause in-creased pain, increased risk of infections, lipo-hypertrophy, altered insulin flow and change in insulin concentration.

Pharmacy Update brings you updates on disease management and advances in pharmacotherapy based on reports from symposia, conferences and interviews, as well as latest clinical data. This month’s updates are made possible through unrestricted educational grants from MSD.

Early combination therapy treats diabetes to target, delays insulin initiation • • • • • • • • • • • • • • • • • • • •P31

Pharmacy UPDATE

31 Pharmacy Update

Early combination therapy treats diabe-tes to target, delays insulin initiation

The use of multiple treatment modali-ties early in the diagnosis of diabetes allows a longer time frame before

insulin initiation, says a prominent endo-crinologist.

Richard O’Brien, clinical dean of medi-cine and chair, Academic Center, Univer-sity of Melbourne, Australia, 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.

In his presentation at a symposium sponsored by Merck Sharp & Dohme (MSD), Prof O’Brien also discussed the American Association of Clinical En-docrinologists (AACE)’s recommenda-tion for initial combination therapy in patients with HbA1c >7.5 percent on di-agnosis. This recommendation is meant to tackle the short span of time between prescription and failure of treatment, and subsequent addition of other antidi-abetic drugs. (J Clin Pract 2005;59:1345-55) By combining lifestyle modifications with oral antidiabetic combination ther-apy, the patient can be brought to tar-get and stay in target for a much longer duration before the eventuality of treat-ment failure and insulin initiation. (J Clin Pract 2005;59:1345-55)

The importance of good glycemic con-trol early in the course of diabetes has been demonstrated by the UK Prospective Dia-betic Study (UKPDS) post-study follow-up. 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.”

In what is commonly known as the ‘lega-cy effect,’ patients in the intensive glycemic control arm of the UKPDS were observed to have less diabetes-related deaths, deaths from any cause, myocardial infarction, stroke, peripheral and microvascular dis-ease. The benefits were observed 10 years after the original study ended. (N Engl J Med 2008;359:1577-89)

Conversely, Prof O’Brien said it is proba-bly 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, especially in el-derly patients; those with long duration of diabetes; and those with pre-existing car-diovascular disease.

Comparing different oral antidiabetic combinations, Prof O’Brien said the com-bination of DPP-4 inhibitor sitagliptin plus metformin (Janumet®, MSD) caused less hypoglycemia compared to a sulfonyl-urea plus metformin combination. (Diabe-tes Obes Metab 2007;9:194-205) Even with monotherapy, sitagliptin caused less gas-trointestinal symptoms compared with metformin monotherapy. (Diab Obes Metab 2010;12(3):252-61)

The AACE also lists the possibility of us-ing DPP-4 inhibitors as potential first-line monotherapy as it is comparable to both metformin and sulfonylurea in terms of

32 Pharmacy Update

HbA1c reduction, but with fewer side ef-fects such as weight gain and hypoglyce-mia. [Diab Obes Metab 2010;12(3):252-61, 2007;9:194-205] Prof O’Brien noted that al-though incretin-based therapies have been suspected of causing pancreatitis, meta-analysis of randomized trials have shown no such association.

In countries with a large population of Muslim diabetics, fasting in the month of

Ramadan can be a challenge as incidents of hypoglycemia increase during the fast-ing month. A study carried out in India and Malaysia on diabetics during Rama-dan showed that by utilizing DPP-4 in-hibitors such as sitagliptin, the incidence of hypoglycemia could be halved (1.9% in sitagliptin versus 3.8 percent in the sulfonylurea group). (Curr Med Res Opin 2012;28(8):1289-96)

Pharmacy Practice | Pharmacy Today | September 2013 33

Managing chronic pain

Pharmacy Practice

Recognised byAcademy of Pharmacy

Earn 1CPD pointevery month

Dr. Eugene Wong Consultant Orthopedic and Spine Surgeon Adjunct Assistant Professor Perdana University Graduate School of Medicine Serdang, Selangor

Chronic pain is a state in which pain persists beyond the usual course of an acute disease or healing of an injury.

It is a persistent or intermittent condition usu-ally defined as lasting for at least six months. It may or may not be associated with an acute or chronic pathologic process that causes con-tinuous or intermittent pain over months or

years. The cause is often unknown, develops in-

sidiously and is associated with a sense of hopelessness and helplessness. There are sev-eral risk factors which predispose one to the development of chronic pain. (Table 1) This multifaceted disorder has biopsychosocial components. It is a debilitating clinical condi-

Clinical Pharmacy | Pharmacy Today | September 2013 34

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 skillsTable 1: Risk factors leading to chronic pain

Anti-inflammatories Steroids, NSAIDs, COX-2 antagonists

Neuropathic pain agents Tricyclic antidepressants, anticonvulsants, antiarrhythmics

Muscle relaxants

Narcotics

Alternative medicine Acupuncture, massage therapy, herbal remedies

Pain coaching

Life counseling

Cognitive behavioral therapy

Pain psychologist

Sleep evaluation

Rehabilitation

Interventionalblocks, spinal cord stimulator, intrathecal pump

Neurolytic proceduresTable 2: Medical management of chronic pain

tion associated with a variety of disease en-tities including diabetic neuropathy, low back pathology, fibromyalgia and neurological dis-orders. Chronic pain produces significant be-havioral and psychological changes such as depression, sleeping disorders, preoccupation with the pain and a tendency to deny pain.

Persistent pain causes maladaptive changes that affect pain perception and pain sensations out of proportion. Hyperalgesia is due to sen-sitization of peripheral nociceptors, whereas allodynia is due to activation of low-threshold mechanoreceptors. Central sensitization is due to loss of inhibitory effects of myelinated pri-mary afferents, which causes prolonged exci-tation or sensitization of spinal pain transmis-sion neurons.

Chronic pain can be categorized as malig-nant, nonmalignant or neuropathic (either ma-lignant or nonmalignant). Drug treatment is largely dependent on the type of chronic pain syndrome. Some of the ways to measure pain include asking and observing the patient, and evaluating function and mood. The principles of treatment include the reduction of pain, re-habilitation and coping. Rehabilitation consists of reconditioning and pain prevention.

Treatment strategies targeted at underlying pain mechanisms are most likely to provide long-term relief of pain. Regimens involve a multidisciplinary approach utilizing educa-tion, medication, and physical, occupational and behavioral therapy. The focus of diagnosis and evaluation of chronic pain should be on reversible causes of the pain. Initiation of pain treatment should not be delayed while a diag-nostic work-up is completed as uncontrolled pain has significant adverse effects on quality of life, functioning and mood. (Table 2)

The combination of medications serves to decrease pain by altering pain pathways in a

multimodal fashion. Start low and go slow on drugs. The WHO has a simple and validated three-step approach to pain management. (Table 3) The basic principles behind the three steps of the ladder include selecting the appro-priate analgesic for the pain intensity and indi-vidualizing the dose by titration of analgesics.

A score of 1-3 on the pain intensity scale equals to mild pain. Mild pain can be ade-quately treated with aspirin, acetaminophen and nonsteroidal anti-inflammatory drugs


(NSAIDs). 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. This is a first-line agent for osteoarthritis. It is a safe alternative to NSAIDs for non-inflammatory pain when given up to a maximum of 4 g/day.

NSAIDs can be used if acetaminophen fails to provide relief, or if the patient has an acute inflammatory condition. There is considerable risk of gastrointestinal bleeding, sodium reten-tion and renal impairment in the elderly. COX-2 inhibitors are recommended for long-term treatment of individuals who have chronic pain caused by inflammatory or other under-lying conditions such as osteoarthritis. These agents reduce, but do not eliminate, risk of gastrointestinal bleeding. The risk of renal im-pairment is the same as for NSAIDs.

Tramadol is a centrally acting analgesic and may be added to acetaminophen or NSAIDS, either alone or in combination, to manage moderate-to-severe pain. These drugs 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 is preferable in patients at risk for side effects of NSAIDs such as renal failure, bleeding, hepatic dysfunc-tion and gastric ulceration. NSAIDs or aspirin may be appropriate if there is an inflammatory component of the pain.

A score of 4-6 equates with moderate pain. In the initial treatment of moderate pain, low-dose opioid drugs are added to aspi-rin, acetaminophen or NSAIDs. For patient convenience, many opioids are marketed as combination products containing one of these agents.

When the score exceeds 7, the patient has

severe pain. The treatment of severe pain re-quires stronger opioid agonist drugs and the continuation of aspirin, acetaminophen or NSAIDs, if possible. Codeine, oxycodone, hy-drocodone, hydromorphone and fentanyl are commonly used opioids. Codeine, oxycodone and hydrocodone are available as immediate-release (short-acting) preparations or in com-bination with aspirin or acetaminophen. Many of these are now available both in immediate and extended-release forms.

Opioid analgesics are appropriate for mod-erate-to-severe acute pain that is not relieved by other categories of analgesics. Long-term use of opioids for pain relief does not appear to cause organ damage and does not cause loss of control, tolerance or addictive behavior in most individuals. Patients should be placed on bowel regimes to avoid constipation. The tapering of the drug dose is required to avoid significant withdrawal symptoms.

The fentanyl transdermal patch is another option for patients who require around-the-

First Tier

NSAIDs

TENS

Psychological

Nerve Blocks

Second Tier

Opioids

Neurolysis

Thermal

Procedures

Third Tier

Neurostimulation

Implantable

Drug Pumps

Surgical Intervention

Neuromodulation

Intrathecal Infusion

Table 3: Chronic pain treatment continuum


clock pain control. It is inadvisable to use it as the initial approach without establishing that the patient requires continuous opioid use of 10 mg every 4-6 hours. Transdermal opioids require 24-72 hours to reach a ‘steady state’ and may be administered every 48-72 hours. It may, therefore, be necessary to ensure that the patient is also being treated with immediate-release opioids on a scheduled or PRN basis for the first 24-72 hours when the transdermal opioid is started.

Opioids are associated with adverse ef-fects, especially during the commencement or change in dosing and administration. The various medication issues are listed in Table 4. When opioids are used for prolonged peri-ods, drug tolerance, chemical dependency and addiction may occur. Ongoing monitoring for safety and effectiveness is essential, including regular review of functional progress or main-tenance, urine drug testing and surveillance of data from the state prescription monitor-ing program. (Table 5) Ineffective, unsafe or diverted opioid therapy should be promptly tapered or stopped.1

Opioids are commonly prescribed for chronic non-cancer pain and may be effective for short-term pain relief. Long-term effective-ness is variable, with evidence ranging from moderate for the use of transdermal fentanyl and sustained-release morphine, to limited for oxycodone, and indeterminate for hydrocodo-ne and methadone.2

Addiction should be distinguished from physical dependence. 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. This shows the presence of physical dependence, but does not constitute addiction. The risk of addiction is

not well defined in chronic use. When it occurs, the drug is a liability rather than an asset to the

Maximize non-opioid analgesic strategies first

Inform subjects of risks before initiating opioid therapy

Facilitate the use of opioid agreements for patients initi-ating 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

Addictionloss of control, harm, focus

Pseudoaddictionlooks like addiction but resolves with adequate pain control

Substance abuseusing medications for alternative reasons

Chemical ‘copers’treating underlying depression, anxiety, insomnia

Table 4: Opioid medication issues


person. There are four core elements in true ad-diction – compulsive use and preoccupation with the drug and its supply, inability to con-sistently control the quantity used, craving the psychological effects of the drug, and contin-ued use despite adverse effects from the drug.

Some drugs are not to be taken long term. Certain drugs are not recommended in chron-ic pain management. These include pethidine, which has a short half-life and the risk of cen-tral nervous system toxicity at high doses. Can-nabis and cocaine have dysphoric side effects. Indomethacin, piroxicam and meclofenamate cause serious side effects such as peptic ulcer-ation, gastrointestinal hemorrhage, confusion, agitation and hallucinations. Meperidine is associated with increased confusion. Pentazo-cine, butorphanol and other agonist-antago-nist combinations have little analgesic ceiling effects and are associated with dysphoria and hallucinations, and may precipitate withdraw-al in opioid-dependent patients.

Neuropathic pain is initiated or caused by a primary lesion or dysfunction in the nervous system. There is a wide range of medications used to treat neuropathic pain. (Table 6) Topi-cal creams with capsaicin are used to treat pain from a wide range of chronic conditions includ-ing neuropathic pain. Following application to the skin, capsaicin causes enhanced sensitivity to noxious stimuli, followed by a period with reduced sensitivity and, after repeated appli-cations, persistent desensitization.3

Coanalgesics or adjuvants used to treat chronic pain include antidepressants, anticon-vulsants, topical agents, skeletal muscle relax-ants and antispasmodic agents. (Table 7)

Interventional techniques can be used to treat chronic pain. These target the source of pain. An injection of steroids can be done at trigger points, joints, peripheral nerve and epi-

dural space. This localizes the delivery of the medication. Nucleoplasty or percutaneous dis-cectomy is a procedure where a needle aspi-ration of a portion of the nucleus pulposus is carried out. Intradiscal thermocoagulation can be done to stop leakage of the nucleus.

Physical or restorative therapy may be used as part of a multimodal strategy for patients with chronic low back pain. Psychological

Antidepressantamitriptyline, doxepin

Anticonvulsantscarbamazepine, gabapentin

Anti-emeticscopolamine

Anxiolyticsbenzodiazepines

Glucocorticoids

Topical agents

Mixture of ketamine, clonidine, gabapentin and lido-caine

Table 7: Adjuvant therapy for chronic pain

Tricyclic antidepressantsNortriptyline

AnticonvulsantsGabapentin, carbamazepine, pregabalin

Local anestheticsParenteral, oral, topical

Topical capsaicin

Opioids

Antiarrhythmics

Baclofen

CarbamazepineTrigeminal neuralgia

DuloxetinePeripheral diabetic neuropathy

GabapentinPostherpetic neuralgia

Lidocaine patchPostherpetic neuralgia

PregabalinPeripheral diabetic neuropathyPostherpetic neuralgia

Table 6: Treatments for neuropathic pain


treatments include the use of cognitive behav-ioral therapy, biofeedback or relaxation train-ing. These interventions may be used as part of a multimodal strategy for patients with low back pain, as well as for other chronic pain conditions. Supportive psychotherapy, group therapy and counseling can be used in the treatment of chronic pain. The elderly are more likely to have significant pain issues and are at particularly high risk of having their pain in-adequately managed.4

Chronic pain is a multifactorial phenome-non. The evaluation of treatment effectiveness

must be based upon several criteria, which include pain reduction, reduction or elimina-tion of inappropriate medication, healthcare utilization, increase in functional ability, return to work and closure of disability claims. The priority of these criteria depends upon who is asked to evaluate the treatment approach. Mul-timodal interventions should be part of a treat-ment strategy for patients with chronic pain. A long-term approach that includes periodic fol-low-up evaluations should be developed and implemented as part of the overall treatment strategy.5

Publisher : Ben Yeo

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Pharmacy Today is published 11 times a year by MIMS Medica, a division of MIMS. Pharmacy Today is on controlled circulation publication to pharmacists in Malaysia. It is also available on subscription to mem-bers of allied professions. The price per annum is US$48 (surface mail) and US$60 (overseas airmail); back issues at US$5 per copy. Editorial matter pub-lished herein has been prepared by professional edito-rial staff. Articles ending with PTNZ have been adapted from Pharmacy Today New Zealand. Views expressed are not necessarily those of MIMS. Although great effort has been made in compiling and checking the information given in this publication to ensure that it is accurate, the authors, the publisher and their servants or agents shall not be responsible or in any way liable for the continued currency of the information or for any errors, omissions or inaccuracies in this publication whether arising from negligence or otherwise howso-ever, or for any consequences arising therefrom. The inclusion or exclusion of any product does not mean that the publisher advocates or rejects its use either generally or in any particular field or fields. The informa-tion contained within should not be relied upon solely for final treatment decisions.

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Editorial Advisory Board

Dato’ Eisah A. Rahman Pharmaceutical Services Division, Ministry of Health

Datuk Nancy Ho President, Malaysian Pharmaceutical Society

Yip Sook Ying Secretary, Malaysian Pharmaceutical Society

Assoc Prof Dr Mohamad Haniki Nik Mohamed Malaysian Academy of Pharmacy

Prof Dr P.T. Thomas Universiti Kebangsaan Malaysia

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