pharmacy today september 2013 my

7/29/2019 Pharmacy Today September 2013 MY

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September 2013

PsorCARE program to help manage

psoriasis more effectively

Natural remedies

oen rst choice for

anxiety and insomnia

Seeing AMD through the

eyes of a paent

News Feature


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News | Pharmacy Today | September 20133

By Saras Ramiya

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

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

dition that carries a strong social stigma. Its

emotional impact on patients oen far out-weighs the diseases physical impact. This iswhy good support and guidance from health-care providers is crucial in achieving optimaltreatment adherence, one of the main chal-lenges in psoriasis management.

PsorCARE is a peer-based training plat-form that teaches trainees how to achievea balance between asking, listening and in-forming when communicating with patientsabout living with and overcoming the burdenof psoriasis. The program also enables train-ees to translate theoretical approaches intopractical implementation.

Caring for patients with chronic skin dis-eases such as psoriasis is not only a science butan art which requires continuous support bya dedicated counselor. Nurses best equippedwith the necessary knowledge would ensure

beer outcomes in the management of psoria-sis by improving patient adherence to topicaltreatments which are the mainstay of man-agement of majority of patients, said NajeebAhmad Mohd Safdar, president of the Der-matological Society of Malaysia.

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

lives and it is important for us, as healthcare

providers, to recognize these challenges andprovide them with the much needed support.With the PsorCARE program, I am pleased tohave the opportunity to share my experienceswith other healthcare providers in Malaysiato help enhance our capabilities to further

benet these patients, said Ms. Page.For patients who require long-term thera-

py, treatment adherence whether it be me-

dicinal, behavioral, lifestyle or a combinationof treatments is essential for achieving opti-mal outcomes. Extensive market research hasidentied that adherence is founded on goodcommunication and a positive relationship be-tween patients and healthcare practitioners.This applies in particular to nurses who are inregular contact with patients. (J Eur Acad Der-matol Venereol 2011;25 Suppl 4:9-14)

Psoriasis patients nd it challenging to ad-here to their treatment modality because theapplication of their medicine requires disci-

PsorCARE program to help manage

psoriasis more effectively


4/40


pline and patience, and this impacts their life-

style. More signicantly, the lack of apparent

results dampens their morale which, in turn,

aects negatively the follow-through with

recommended treatment.LEO Pharma developed the PsorCARE

program in collaboration with PsorAsia (the

Federation of Psoriasis Association in Asia-

Pacic).

Research has shown that there is a signi-

cant need to bridge the gap between admin-

istering medical treatments and providing

patient support. Programs such as PsorCARE

are an essential platform that allows us to

share sustainable approaches with health-

care providers to help them address the high

prevalence in treatment non-adherence and

respond to the patients unmet needs, said

Josef De Guzman, president, PsorAsia.

LEO Pharma is commied to partner with

healthcare professional, doctors, nurses andpharmacists in helping psoriasis patients im-

prove their lives and overcome their burden

of disease and treatment. We are aware of the

challenges that psoriasis patients face and we

want them to know that trained support is

available. Our ultimate aim is to give these pa-

tients hope and empower them with the ability

to control their psoriasis conditions and even-

tually improve their quality of life, said Tan

Keng Aun, country manager of LEO Pharma

Malaysia.

By Rajesh Kumar

Nicotine replacement therapies (NRT)

and other licensed drugs can indeed

help people quit smoking, a system-

atic review has conrmed.

The overview of previous Cochrane re-

views supports the use of smoking cessation

medications that are already widely licensedinternationally, and shows that another drug

licensed in Russia could hold potential as an

eective and aordable treatment. The nd-

ings serve as a reassurance to pharmacists

and other health professionals involved in

smoking cessation programs.

In most countries, including the US and Eu-

rope, the only medications currently licensed

for smoking cessation are NRTs such as nico-

tine patches and gums, the antidepressant

bupropion and the drug varenicline, which

blunts the eects of nicotine on nicotine re-

ceptors in the brain. In Russia and other parts

of Eastern Europe, cytisine, similar to vareni-

cline, is also licensed for smoking cessation.

The researchers combined the ndings of

Quit smoking medications are effective


5/40


existing Cochrane reviews on the subject,

using all the available data from across in-

dividual reviews. In total, they collected

evidence from 267 studies, which together

involved a total of 101,804 people. The stud-ies covered a wide variety of licensed and

unlicensed smoking cessation medications,

comparing the treatments with placebo, and

the three main treatments with each other. If

a person stopped smoking for six months or

longer, this was considered a successful quit

aempt.

The three widely licensed medications

and cytisine all improved smokers chances

of quiing. The odds of quiing were about

80% higher with single NRT or bupropion

than with placebo, and between two and

three times higher with varenicline than with

placebo. However, varenicline was about 50

percent more eective than any single formu-

lation of NRT (patches, gum, sprays, lozenges

and inhalers), but similar in ecacy to com-

bining two types of NRT. Based on two recent

trials, cytisine improved the chances of quit-

ting nearly four-fold compared with placebo.

Among other treatments tested, nortriptyline,

another antidepressant drug, was more eec-

tive than placebo, but did not oer any ad-

ditional improvement when combined with

NRT.

This review provides strong evidence that

the three main treatments, nicotine replace-

ment therapy, bupropion and varenicline, canall help people to stop smoking, said lead

researcher Kate Cahill, of the department of

primary care health sciences at the University

of Oxford in Oxford, UK. Although cytisine

is not currently licensed for smoking cessa-

tion in most of the world, these data suggest

it has potential as an eective and aordable

therapy.

The researchers also assessed the safety of

dierent medications. Bupropion, which is

known to trigger occasional seizures in vul-

nerable people, did not lead to an increase in

the rate of seizures when used for smoking

cessation in its slow-release version. Overall,

NRT, bupropion and varenicline are consid-

ered low-risk treatments, although the re-

searchers say the results are currently less

clear-cut for varenicline.

Further research may be warranted into

the safety of varenicline, said Dr. Cahill.

However, in the trials we looked at we did

not detect evidence of any increase in neuro-

psychiatric, heart or circulatory problems.

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


6/40


By Leonard Yap

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

aect a persons self-esteem and condence,says an AMD patient.

People [with AMD] do become very dis-tressed [with their predicament], people even

become depressed. In some cases people

even consider suicide, said Dennis Lewis, apatient ambassador for AMD Alliance Inter-national.

Patients commonly have low self-esteemand many suer from depression as they feelthey are a burden on their families and friends

because they are no longer able to performmany tasks independently, he said.

This feeling is particularly painful whenthe person is a senior member of the family.

Alternatively, it could happen to somebodywho has had a very successful career and feelsthat these achievements have become history.

[Suddenly] we are facing a future of hav-ing to rely on people for even simple thingslike pouring a drink. I would be worried thatI will spill it. So people start to feel that theyare going to be a burden on the family andyet, as the senior person, they see it as their

responsibility to look aer the family, whichis a challenge, he said.

Some people will think, I am stupid I have accidents all the time, just small acci-dents. It gnaws away at my self-esteem andindependence. Instead of pouring water intoa glass, I might miss the glass. I may walk uptwo steps and miss my step and fall.

Mr Lewis related how he once mistook hiswifes black handbag for the cat. My wifehas a black handbag with a handle and, guesswhat I stroked the other day? It was the hand-

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

AMD is not an eye condition that makespeople completely blind. In the UK, I am le-gally registered as blind, but I can step overhere and touch the microphone. Here is mydaughter, and I can see the audience. I am notcompletely blind. This makes me feel like afraud. People feel I am a bit of a fraud and thisis how it aects the individual. Many peoplekeep these feelings to themselves, he said.

How AMD changes lives

Mr Lewis said although he was looking at theaudience, he was not certain that the audiencewas looking at him. If I go back past two orfour rows, I dont even know if you are there.

This is what people live with every day withfully developed AMD. He also spoke of howhis blindness aects his ability to communi-cate, particularly as he talked to an audience.I have some notes in front of me which Icant read easily, but I wrote them so I think Ishould know what I am saying.

The ability to read and write is oen verydicult; watching television is a challenge,even if one sits very close to it. If I watch my

favorite sport, which is football, I can see blueand red, but I cant recognize the player. So it

Seeing AMD through the eyes of a patient


7/40


becomes very dicult.

One of the very big symptoms for me is

something that I mentioned earlier, which is

recognizing faces and communicating visu-

ally, because across a crowded room I dontknow who I know. He described how he

has to walk up to a person and stick his nose

right in front of the person to recognize who

he is talking to when he aends a confer-

ence.

I am not sure how you would react if I

came right up to you and stuck my face into

yours and said, I just want to check if I know

you. We dont want to do that, it would be in-

vading somebody elses space. This is a com-

mon problem for those with AMD. He also

related how he would oen be walking down

the street and someone would say, Hey! You

walked straight past me. Why are you ignor-

ing me?

Another serious loss is the ability to drive.

People with AMD cannot drive, thus serious-

ly aecting their independence and mobility,

he said.

He recounted how AMD took over his life

30 years ago. He used to work in the banking

industry, and the onset of the disease ended

his career prematurely. I had to stop work-

ing because I could not do my job to the best

of my ability anymore.Being plundered of good vision did not

stop Mr Lewis from living and giving back to

fellow AMD suerers by becoming involved

in the Macular Society in the UK. He eventu-

ally became a board member of the Macular

Society and a founding member of an orga-

nization which oers emotional support to

people with the condition. This is a growing

organization and we network with each other

throughout the UK to make sure emotional

support is oered wherever necessary.

Having AMD is not a death sentence, but

it is a huge challenge. With the right help and

support, one can overcome it and continue

living a good life. But prevention should be

the priority and eye health must be taken very

seriously, he added.

Mr Lewis was speaking at the recent

Retinal Diseases Awareness Week in Petaling

Jaya.


8/40


By Pank Jit Sin

Urinary incontinence is oen mistak-

enly associated with immaturity

or impaired mental capacity. Thus,

women who suer from urinary leakage of-

ten face embarrassment and a compromised

quality of life.

This was the messaged highlighted by a

new campaign spearheaded by Poise, in

conjunction with World Continence Week

2013. Armed with the tagline Embracing the

Realities of Womanhood and Light Urinary

Leakage, Poise aimed to inspire people suf-

fering from light urinary leakage (LUL) to

arm themselves with the right information

and the right tools to manage the condition

eectively.

The campaign also endeavored to bring

positive, empowering LUL education to all

women via educational articles in the print

media, social media, radio and consumer en-

gagement programs in high-trac locations,

and retail outlets.

Poise also unveiled its new LUL pads and

liners during the event. The new pads are en-

riched with natural extracts of aloe vera andvitamin E, both proven to protect skin from

irritation.

Soo Wan Yee, marketing director of Kim-

berly-Clark Malaysia, manufacturer of Poise

products, said: Many women rely on nor-

mal liners or sanitary pads to cope with uri-

nary leaks, but these arent equipped to han-

dle them as they arent made to absorb uid

quickly or in large volumes, and not made to

prevent odor.

Hence, using wrong products leaves

women susceptible to wetness, leakage and

the strong [urine] odor this unpleasant situ-

ation can lead to discomfort, self-conscious-

ness and anxiety when they are around oth-

ers friends, family or colleagues, said Ms

Soo.

Celebrity Raja Azura, Poises ambassa-

dor and advocate for womanly confidence,

said: We need to accept LUL as a reality

and embrace the fact that it can be man-

aged with a good dose of humor, confi-

dence and the right solution Im living

proof of that!

LUL aects one-in-four women above 35

years of age at least once a week, and is anissue surrounded by embarrassment, misin-

formation and mismanagement.

Dont let incontinence put a damper on life

wrong products leaves women

susceptible to wetness, leakage and

the strong [urine] odor ...


9/40

Relieves &SuppressesChesty Cough


10/40


By Malvinderjit Kaur Dhillon

Endometriosis occurs when the endome-

trial lining of the uterus aaches and

starts to grow on the surfaces of organs

in the pelvic and abdominal areas, where it

does not normally grow.

Endometrial cells can implant in the ova-

ries, fallopian tubes, outer surface of the uter-

us or intestines, or in the pelvic cavity. Lesscommonly, they can be found in the vagina,

cervix and bladder.

Endometrial tissue outside the womb re-

acts to changing levels of hormones in the

body during the menstrual cycle, causing it

to grow. This can cause inammation and for-

mation of scar tissue, leading to pain.

Endometriosis is a chronic and painful

disease. In some women, there is no perma-nent cure. The pain can be both physically

and mentally exhausting, greatly impact-

ing women in the prime of their lives and

aecting their work life and personal rela-

tionships, said gynecological oncologist Dr.

Suresh Kumarasamy.

This debilitating disease aects almost a

million women during their reproductive

years. Risk factors for developing endome-triosis include women starting their period at

a young age, who have heavy or long-lasting

periods, who have short monthly cycles or

who are related to someone who has endo-

metriosis. The condition is common among

women experiencing infertility; however, it

does not prevent conception.

A recent study that investigated the link

between endometriosis, and body mass index

(BMI), found that the lower a womans BMI,

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

Some common symptoms of endometriosis

include chronic pelvic pain, period pain and

pain aer sexual activity. Other symptoms are

fatigue, painful bowel movements during pe-

riods and lower back pain.

A survey in Malaysia revealed that women

waited 2 years aer experiencing symptoms of

endometriosis before they sought treatment.Over 60% of these women delayed seeking

treatment as they expected their symptoms to

go away. I urge women with symptoms suspi-

cious of endometriosis not to suer in silence

and to seek medical aention as early as pos-

sible, said Dr. Suresh.

Diagnosis of endometriosis can be chal-

lenging as symptoms may not always be

present. Dierent women experience dier-ent degrees of pain and the amount of pain

experienced is not always related to the size

or number of endometrial lesions. The lack of

awareness surrounding endometriosis causes

women to link their symptoms to dysmenor-

rhea. Endometriosis is diagnosed by physi-

cal and pelvic examinations, ultrasound and

magnetic resonance imaging (MRI) tests and,

most accurately, laparoscopy. Sometimes, a

biopsy is also done to conrm the diagnosis.

Endometriosis the painful truth


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The aim of treatment is to relieve pain,

slow the growth of the endometrium-like tis-

sue, improve or protect fertility, and prevent

the disease from recurring.

There is pressing need for more eectivetreatment options for endometriosis. Cur-

rent treatments oen do not meet the needs

of all women living with endometriosis and

may only be safe and/or eective for a limited

period of time. For example, GnRH analogue

injections are currently the most eective op-

tion for women suering from endometriosis,

but these can only be used for 6 months due

to concerns about side eects, including bone

thinning, said Premitha Damodaran, a con-

sultant obstetrician and gynecologist.

Dr. Suresh and Dr. Premitha were speak-

ing at the launch of Visanne, a new oral treat-ment for endometriosis containing dienogest.

Dienogest has been found to signicantly

reduce pain associated with endometriosis. It

also reduced the severity of endometriosis, with

one-third of diagnosed women no longer hav-

ing evidence of endometriosis aer 24 weeks

of treatment with dienogest. (Int J Gynaecol Ob-

stet 2010;108:21-5)

By Leonard Yap

Alpha lipoic acid (ALA), a compoundinitially classied as a vitamin when

it was rst discovered more than half

a century ago, possesses potent antioxidant

properties that could prevent healthy cells

from geing damaged by free radicals.

The new interest in ALA was aer mount-

ing evidence showed its potential in the treat-

ment of nerve damage and diabetes, said an

expert.Research has shown that ALA is many

times more potent as an antioxidant than vi-

tamins C and E. This may be due to the fact

that ALA dissolves in both fat and water, said

Lenny da Costa, a consultant geriatrician,

preventive cardiologist and specialist in anti-

aging therapy.

This gives it a unique ability to scavenge

more wayward free-radical cells than most

other antioxidants, which either tend to dis-

solve in fat or in water, he said.

ALA exists in many foods. It is also madenaturally in our bodies, but only in tiny

amounts. ALA helps protect the mitochon-

dria, the cells powerhouse, and DNA materi-

al from oxidative stress. ALA also works with

vitamins C and E by recycling them, making

them more eective. Currently, there is no

other antioxidant that can perform this feat,

said Dr. da Costa.

ALA also assists the B vitamins in produc-

ing energy from proteins, carbohydrates and

ALA to the resuce!


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FAQs on ED answered

fats from food, he added. It is used in the body

to induce the breakdown of carbohydrates

and to make energy for organs in the body.

Several studies have found that ALA can

improve insulin resistance. They have alsodiscovered that ALA supplements can help

with neuropathy, nerve damage caused by

diabetes or cancer treatment. ALA appears

to reduce symptoms like pain, tingling, and

prickling in the feet and legs. It may also help

protect the retina from some of the damage

that can occur due to diabetes.

There is some early evidence that long-

term use of ALA may help with the symp-

toms of dementia. Other studies suggest that

ALA creams could repair skin damage related

to aging. ALA has also been researched as a

treatment for many other conditions. These

include Amanita mushroom poisoning, glau-

coma, kidney disease, migraine and periph-

eral arterial disease. The evidence for these

indications remain unclear.

Though the eects of ALA on diabetes and

cancer are promising, patients should seek

proper medical treatment rst.

Dr. da Costa was speaking at the 10th Ma-

laysian Conference and Exhibition on Anti-

Aging, Aesthetic and Regenerative Medicinein Kuala Lumpur.

Natural sources of ALA

Many foods contain ALA in very low amounts.

These include spinach, broccoli, yams, pota-

toes, yeast, tomatoes, brussels sprouts, car-

rots, beets and rice bran.

Red meat, particularly organs like liver, is

also a good source.

How much to take?

ALA is an unproven treatment and there is no

established dose. Some studies used between

600-1,200 mg daily for diabetes and neuropa-

thy. One review concluded that the evidence

is convincing for the use of 600 mg daily for

three weeks to treat symptoms of diabetic

neuropathy.

By Malvinderjit Kaur Dhillon

Afree booklet entitled Your Question

on ED is now available to the public.

It aims to provide answers to ques-

tions frequently asked by Malaysians about

erectile dysfunction (ED).

Malaysian men and their spouses still nd

it dicult to talk about their sexual health and

address their ED condition with their doctor

or healthcare professional. Understanding

their sentiments, we collaborated with phar-

macies to make available a private platform

for members of the public to ask any ques-tions about ED which they deemed too em-

barrassing to ask their doctor, said Vicknesh

Welluppillai, medical director of Pzer.

We were overwhelmed by the response

and hope the answers stated via the booklet

will motivate them to seek further treatment

of their ED condition via the proper chan-

nels as stated in the booklet. The booklet also

serves to increase their understanding of ED

as a medical condition, which could also be a


13/40


pre-cursor to other medical conditions, said

Dr Vicknesh.

Among the questions asked by men and

women aged 21 to 65 were Whom should I

consult if I suspect that I have ED, Can ED betreated? and Is ED caused by low testoster-

one level or low libido?. The most repeatedly

asked questions were picked and answered

by Ong Teng Aik, a consultant urologist at

University Malaya Medical Centre (UMMC).

People may not be aware that, amongst

others, hardness level is the rst indication if

someone has ED. There are four hardness lev-

els for men to gauge if they have ED and theErection Hardness Score (EHS) Grade, which

ranges from 1 until 4, is clearly explained in the

booklet. Grade 1 means severe ED, where your

erectile hardness is akin to the soness of a

tofu, Grade 2 is akin to a peeled banana, Grade

3 an unpeeled banana and Grade 4, a cucum-

ber, which is the best erectile hardness you will

want. It is important for men and women to

be satised with erection hardness as penilehardness is associated with satisfaction with

sex and with life overall, said Prof. Ong.

According to the 2009 Ideal Sex Survey,

both men and women in Asia agreed that

erection hardness or the ability to maintain

an erection ranks as the most important ele-

ment for ideal sex. Eighty percent of men and

women valued the quality of sex over quan-

tity of sex.Late last year, Pzer Malaysia launched

this initiative under its We Love, Sustaining

Passions Campaign to encourage couples to

ask questions and arm themselves with the

power of knowledge on ED. This eort led

to couples enjoying greater intimacy and

strengthened bonds.

Query boxes were made available at se-

lected pharmacies, providing an outlet for

the public to drop o any ED-related ques-

tions and have them answered by a qualiedhealthcare professional.

The booklet also includes facts from the

2009 Ideal Sex Survey and The Asia Pacif-ic Sexual Health and Overall Wellness (AP

SHOW) survey. The objectives of these sur-

veys were to examine the perception of men

and women on ideal sex, and the importance

of erectile hardness in their relationship and

satisfaction with life overall.

The booklet is available at more than 80

participating pharmacies in three dierent

languages; English, Bahasa Malaysia and

Chinese.

Eighty percent of men and

women valued the quality

of sex over quantity of sex


14/40


15/40


Tracking of polypharmacy across Dis-trict Health Boards (DHBs) in New

Zealand has highlighted a trend of old-

er people taking multiple medications, which

may be doing more harm than good.

While rates varied from DHB to DHB,

the Health Quality and Safety Commissions

(HQSC) new Atlas of Healthcare Variation

shows a high rate of polypharmacy in elderly

people across the board, which increases aspeople age.

Around one-in-four people aged 65 to 74

received ve or more long-term medicines in

2011, according to national data.

This gure doubled once people reached

85, and those aged 85 and over were 2.5 times

more likely to receive 11 or more medicines

than those aged 65 to 74.

The frequency of adverse drug events in-creases with the number of medicines taken:

13% with two medicines, 58% with ve medi-

cines and 82% when seven or more medicines

were taken, the HQSC website said.

While these increased rates do not neces-

sarily indicate overprescribing, older people,

especially if frail or suering from multiple

conditions, are more vulnerable to medicine-

related illness and death.Possible negative outcomes of polyphar-

macy are reduced adherence, high costs for

both patients and health services, and in-

creased adverse eects and interactions.

Also of concern to the HQSC is an increase

in prescriptions of benzodiazepines and anti-

psychotics as people get older.

People on these drugs have a substantially

higher risk of adverse eects, including im-

paired functional ability, agitation, confusion,

blurred vision, urinary retention, constipa-tion, postural hypotension and falls. Combin-

ing the two drugs further increases the chance

of adverse eects.

According to the HQSC Atlas, up to one-in-

ve people aged 85 years and over were given

benzodiazepines or antipsychotics in 2011.

While the rate of concurrent use of the two

is reassuringly low, the variation between

DHBs indicates a lack of standardized prac-tice, the atlas accompanying commentary

said.

Auckland DHB had the highest rate of con-

current use with 13 elderly people per 1000 on

both types of drugs, followed by Canterbury

at 12.1, and Nelson-Marlborough at 11.1.

The regions with the lowest concurrent use

were Tairawhiti (3.7), West Coast (5.9) and

Counties Manukau (6.8).

Challenging information

As a geriatrician in Canterbury and chair of

the HQSC Polypharmacy Expert Advisory

Group, Nigel Millar said he found some of

the information revealed in the atlas, such

as the high rate of polypharmacy for elderly

Cantabrians compared with other areas very

challenging.The prime purpose of the atlas is to make

variations in services visible because whenev-

er variations exist, there is usually an oppor-

tunity to improve equity in health services, Dr

Millar said.

Variation in the supply of medications is

generally due to the health system rather than

dierences in populations, he said.

Benzodiazepines are an example of wide

variation in medication. Some areas gave

New data shed light on polypharmacy


16/40


them to one-in-20 elderly people, while one-

in-10 received them in the highest areas.

In the 85-plus age group, one-in-ve people

were receiving benzodiazepines in some areas.

Local communities need to decide whetherthese drugs are absolutely essential treatment

for elderly patients.

We have work to do to look at prescrip-

tion paerns and make sure we are doing the

right thing, Dr Millar said.

There is slim to no evidence of the ecacy

of many drugs in the frail elderly with mul-

tiple comorbidities because clinical trials tend

to pick younger test subjects with only one

condition, he said.

At the same time, doctors are dealing with

the pressures of feeling the need to prescribe

drugs to reduce the risk of diseases like heart

aacks and strokes.

More research is needed into the benetsand harms of giving multiple medicines to

elderly patients with multiple comorbidities,

and health professionals need beer informa-

tion presented to them, with a focus on how

likely the drugs will work on an individual,

Dr Millar said.

He hopes every pharmacist will look into

the information presented in the atlas, ask

what it means for them and have a debate

about it in the wider community.


17/40


18/40

Feature | Pharmacy Today | September 2013 Sleep & Insomnia18

Feature

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

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

vous and worried, and it can trigger sleepingproblems. Both health issues can cause dis-ruptions to peoples everyday lives.

A New Zealand pharmacist, Ban Quillin-

ichi, said his Auckland city sta regularlytreat people with sleep problems who want to

try a complementary health solution so as toavoid taking prescription medications.

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

In such instances, Ms Quillinchi most of-ten recommends magnesium supplements,which help relax the muscles, aiding peopleto get to sleep. Magnesium is also particular-

ly benecial for those who are have troublesleeping due to stress.

Natural remedies often first choice for

anxiety and insomniaMany insomnia and anxiety sufferers go to the pharmacy for natural health supplements as first-line

treatment before seeing a GP, say pharmacy staff, as Pharmacy Today New Zealand reports


19/40


Products with passionower can help peo-ple sleep as it has a drowsiness eect.

Increasingly, people come into her phar-macy aer searching information on the In-

ternet, but oen what they have read is incor-rect, such as dosage information, she said.

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

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

Ms Galbraith agreed there is a stigma ofaddiction to prescription medicines, so peo-ple oen seek a natural alternative.

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

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

As a retail manager, she is clear about

where her limitations lie in recommendingthese products, and will always call a phar-macist into the conversation if the person istaking other prescription medications, or hasother health issues, to check for contraindica-tions.

Tart cherry, valerian root are great aidsMedical researcher Shaun Holt said there are

a number of natural health products whichare eective in treating both insomnia andanxiety issues.

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

Tart cherry contains naturally occurringmelatonin, which helps to promote sleep. Anumber of studies also back its use.

However, both Ms Quillinchi and Ms Gal-

braith are reluctant to recommend tart cherrysupplements, as they say they have more ex-

perience with other supplements.Interestingly, melatonin supplements are

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

from the corner store, but here its classed as ahypnotic, Mr Holt said.

He believes a move to reclassify melatoninas a pharmacy-only medicine would make itmore accessible to New Zealanders sueringfrom sleep deprivation.

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

However, due to its strength, pharmacistsshould make the same recommendationsthey do for alcohol, Mr Holt said.

Do not operate heavy machinery, be carefulwith, and avoid where possible, using othersedatives, and monitor alcohol consumptionif taking valerian root, he added.

People with insomnia and anxiety issuescould also consider kava. Widely used in thePacic islands, the roots are used to create a

drink which has sedative properties.Other products for helping with anxiety

and sleep include tryptophan and 5-hydroxy-tryptrophan, which are both amino acids.

Researchers have found high levels oftryptophan in turkeys, which is said to be thecause of the drowsy feeling aer consuming aturkey dinner, he says.

Aromatherapy can also help relax people,

which may work as a sleep aid. While Mr Holtrecommends all of these products for treatingboth sleep and anxiety, he specically sug-gests vitamin B supplements, in a tablet form,for anxiety.

There is also weak evidence to supportthe use of chamomile tea as a sleep aid, but herecommends the other options rst.

Manage peoples expectations

It is important that pharmacy sta managepeoples expectations when recommending


20/40


natural health supplements for anxiety and

insomnia.

It is sometimes trial and error and [eec-

tiveness] does depend on the individual, Ms

Galbraith said.Products can take two to three weeks to be

eective and people should be aware of this.

The pharmacy sta should also follow up

with people, particularly elderly patients,

about a week aer they have started taking

natural supplements for insomnia, to see

if they have been eective or whether they

should try something else.

Go beyond selling products

The experts all stress the importance of help-

ing people get to the root cause of their in-

somnia or anxiety issues, with a particular

focus on individual lifestyles.

For example, people should take into ac-

count how much caeine they have through-

out the day specically coee and energydrinks.

As both are stimulants, they hype people

up and it may take them a while to fall asleep

at night, Ms Galbraith said.

One customer came into the pharmacy

complaining of trouble going to sleep, but

when asked about her coee drinking habits,

she admied she drank around ve cups a

day.

Sleep disruption is also oen linked to

drinking excessive alcohol or a lack of regular

exercise, Mr Holt said.

Treat anxiety with compassion

New Zealanders are some of the most

anxious people in the world, second

only to Americans, according to Te

Rau Hinengaro the New Zealand Mental

Health Survey (2006; Wellington: the Ministry

of Health).

In a 2004 survey of 13,000 New Zealand-

ers, 14.7% of respondents said they sueredfrom anxiety. The corresponding US gure is

18.2%.

While most people experience a certain

amount of anxiety in their day-to-day lives,

according to the New Zealand Phobic Trust

website, suering from generalized anxiety

disorder can be debilitating. (www.phobic.

org.nz/)

People with generalized anxiety disorder

have chronic and exaggerated worry and ten-

sion, usually without any tangible cause.

Having this disorder means always an-

ticipating disaster.

Sometimes, simply the thought of geing

through the day provokes anxiety.

Suerers realize their reactions are dispro-

portionate, but are unable to control them.

They oen also have trouble sleeping.Physical symptoms can include trembling,

twitching, muscle tension, headaches, irrita-

bility, sweating and hot ushes.

Suerers may feel lightheaded or out of

breath. They may feel nauseated or have to go

to the bathroom frequently, or they might feel

as though they have a lump in the throat.

They tend to feel tired, have trouble con-

centrating and oen also suer from other

mental and/or physical disorders. General-


21/40


ized anxiety disorder is a gradual disease,

most oen developing in childhood or ado-

lescence.

It is diagnosed when someone spends at

least six months worrying excessively about anumber of everyday problems.

However, the Best Practice Journal warns

that conditions which cause symptoms simi-

lar to anxiety should be considered when

making a diagnosis.

This includes hyper- and hypothyroidism,

angina, asthma, depression and substance

misuse, e.g. caeine, amphetamines, canna-

bis, cocaine.

Some medications also cause symptoms of

anxiety, such as anticholinergics and toxicity

from digoxin (Best Practice Journal 2009;25:20-8).

Show compassion and encourage seeking

help

Mental Health Foundation of New Zealand

chief executive Judi Clements said while there

is more awareness of depression due to ad-vertising campaigns, anxiety is also a com-

mon occurrence and the two disorders oen

go hand-in-hand.

Many people suer from anxiety and still

cope well. It is when it tips over into the per-

son not being able to function fully that peo-

ple need to seek help, Ms Clements said.

Some suerers become so anxious that

they cannot cope with life, she said.

The advice for people suering from anxi-

ety is to seek help, to look at their lifestyle,

especially whether they are geing enough

sleep.

Looking aer your mental health is not

something anyone else can do for you, Ms

Clements said.

A pharmacist may be the rst point of callfor those suering from anxiety because they

do not have to make an appointment and it is

free, she said.

People may also come in looking for over-

the-counter supplements to help with anxiety

aer having done their own Internet research.

A good question to ask is whether they

have already talked to someone, such as their

GP, about their anxiety.

If they have suered from anxiety before, it

is helpful to ask who they talked to about it in

the past and what worked for them last time.

Taking the time to listen and asking if they

are alright really helps.

Showing compassion is one of the most im-

portant things you can do for a person with

mental health issues as they are oen already

in a state of hypersensitivity and can easily

feel like they are being ignored or not taken

seriously.

Pharmacists should talk patients through

potential side eects from anxiety medica-

tions and refer them back to their GP if the

drugs are not working for them.

Treatments

Cognitive and anxiety management therapiesare both eective treatments, Otago School of

Medicine lecturer Christopher Gale said in a

clinical review of generalized anxiety disor-

der published in the British Medical Journal

(2007;334:579-81).

Anxiety management therapy is a struc-

tured therapy involving education, relax-

ation training, and gradually increasing

exposure to something which triggers anxi-

ety, oen through visualizations or images.

Showing compassion is

one of the most important things

you can do for a person with

mental health issues


22/40


ResourcesThere are several online resources which pharmacists can direct their patients to:

l The Malaysian Psychiatric Assocation (MPA) oers a range of mental disorders resources

which can be accessed atwww.psychiatry-malaysia.org/listcat.php?cid=6

l The MPA website also provides a list of support groups and a list of private psychia-

trists registered with it.

l The Malaysian Mental Health Association (MMHA) also provides information on

understanding mental health at www.mentalhealth.org.my

lMMHA organizes various programs and activities including two rehabilitation pro-

grams to help people with mental disorders to reintegrate into their community.

l Patients can also turn to Befrienders (www.befrienders.org.my), a safe platform estab-

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

to cry on.

Cognitive behavioral therapy involves rec-

ognizing and challenging false underlying

thought paerns which help create anxiety

and depression.

Antidepressants, benzodiazepines, buspi-

rone and kava all reduce anxiety, but they oen

have clinically signicant side eects which

can aect adherence, Dr. Gale said.

Working against the clock makes you fat

Shi work is becoming increasingly common

in our modern, 24/7 society. Gone are the

days when everyone worked 9-to-5 or, as

in earlier eras, rose at dawn and slept at nightfall.

Health website everybody.co.nz denesshi work as work which starts before 8am or

nishes aer 6pm or any work hours which

cause a change in normal sleep paerns.

Many industries literally operate around

the clock, and sta who do shi work need to

learn how to cope with not just a lack of sleep,

but also a range of possible health eects.

It is one of the leading causes of fatigue.If youre working as a truck driver, a nurse or

police ocer, for example, you will at some

stage be required to work when your body is

naturally at rest this disrupts your natural

body clock and can lead to fatigue, physical

and mental ill health and accidents, which are

more common between midnight and dawn,

the website said.

Working at night has a greater impact than

working the same number of hours during the

Staying awake late into the night

and being woken by alarm clocks

means our natural circadian rhythms

are out of synch with modern life


23/40


day. Shi workers lose an average of between

one and one-and-a-half hours sleep each 24-

hour period. Aer four nights, workers will

have lost six hours of sleep. To compensate, they

need at least two consecutive full nights sleep.

The only way to recover from fatigue is

to get adequate sleep. The average amount

of sleep needed to be healthy and alert is be-

tween seven and nine hours a night.

According to the New Zealands Ministry

of Business, Innovation and Employment,

there are three steps to managing workplace

fatigue consultation, evaluation, and train-

ing and education.

Employers should make sure sta take

regular rest breaks, be aware of times people

are most likely to be aected by fatigue, and

manage shi work and overtime so employ-

ees have opportunities to recover.

Creating the right environment to recover

from night shi is vital. Leing family, neigh-

bors and friends know and understand shi

schedules will make them more cooperative.

Keeping the bedroom dark, cool and quiet isimportant, as is having a routine to wake up.

Everybody.co.nz recommends shi work-

ers sleep only long enough aer their last shi

in the cycle to feel refreshed, and still be able

to sleep later that night.

Sleeping longer or napping can delay the

adjustment to a regular, daytime work/sleep-

ing paern.

Exercise and avoiding sleeping pills and al-

cohol are also benecial to normal sleep.

There is a recognized condition suered

by some shi workers known as shi work

sleep disorder, with symptoms including in-

somnia, excessive sleepiness, headaches, ir-

ritability, reduced concentration and a lack

of energy.

Some researchers have also identied a syn-

drome known as social jetlag, which may be

causing not only sleep deprivation, but obesity.

Staying awake late into the night and being

woken by alarm clocks means our natural circa-

dian rhythms are out of synch with modern life.

A team from the University of Munich

has been collecting data from thousands of

participants to learn about social jetlag (doi

10.1016/j.cub, 2012.03.038).Social jetlag quanties the discrepancy

that oen arises between circadian and social

clocks, which results in chronic sleep loss, re-

searcher Till Roennberg said. The circardian

clock also regulates energy homeostasis and

its disruption as with social jet lag may

contribute to weight-related pathologies.

Our results demonstrate that living

against the clock may be a factor contribut-ing to the epidemic of obesity.

Possiblehealtheectsoflostsleepinclude:l mental ill healthl obesityl type 2 diabetesl heart diseasel accidents.

Employees should know about:l

What to eat and when.l The impact of caeine and alcohol

on sleep.

l How to make the most of breaks.

l How to use recovery and rest time

appropriately.

l How to adjust sleeping areas to pro-

mote good sleep.

l How to recognize fatigue.

lGeing to and from work safely.

l The impact of exercise on fatigue.


24/40


Insomnia closely linked to depression

Anyone who has suered from insom-

nia will know what a frustrating andstressful condition it can be. Insomnia

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

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

A sleep researcher at Auckland Universitysschool of population health, Karen Falloon,said depression and anxiety are the biggest

causes of insomnia. They are dierent fromother causes such as temporary life stresses andso-called sleep hygiene issues, including caf-feine or alcohol intake, discomfort and noise.

The rst thing when treating it is to de-termine which sleep disorder you are dealingwith, Dr. Falloon said.

There are simple things which can help,such as reducing or entirely cuing the intakeof caeine. People should also try to get intoa routine and not overcompensate for poorsleep by going to bed too early. Make sure

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

being tired or exhausted but not sleepy.Many people will suer from transient

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

Psychological problems and insomnia canbe closely linked, she added. There is anincrease in the risk of developing depressionand anxiety. However, there is a chicken andegg element, and depression and sleep issuesalso need to be treated separately, and othercauses of insomnia considered.

Insomnia is also being linked to otherhealth issues. There is building evidence that

there are some cardiovascular complicationswhich can occur, Dr. Falloon said. There iseven some evidence about an increased riskof myocardial infarction. And there are thequality of life things such as irritability andrelationship stress, which are not to be takenlightly.

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

Many factors can contribute toinsomnia. These include:l stress

l alcohol, nicotine and caeine con-

sumption

l depression or anxiety

l other medical conditions and medi-

cines

l snoring and breathing diculties

l tooth grinding

l ongoing pain

l restless legs.


25/40

Spotlight| Pharmacy Today | September 201325

Sniffing out the difference between a cold

and the flu

Spotlight

Inuenza and the common cold share

many symptoms, and people oen be-

lieve one is merely a stronger version of

the other.

When someone is suering from a nasty

head cold, blocked nose, streaming eyes, sore

throat and perhaps a cough, its easy to be-

lieve it is u.

However, u is a much more serious ill-

ness, strains of which have been responsible

for countless deaths over the course of history.

Medical experts are quick to point out that

the two ailments are quite dierent.

A community health website, www.my-

health.gov.my, provides information on cold

and u. These are commonly confused with

one another, especially when it comes to treat-

ment.

A fever is oen an indication a person has the u rather than a cold


26/40


However, there are many dierences. The

cold and u are two dierent illnesses caused

by dierent types of viruses. They aect dier-

ent areas of the body, the speed with which the

symptoms emerge dier and they vary in sever-

ity. The u is preventable, while the cold is not.

Cold symptoms typically last from one to

ve days. Usually, irritation in the nose or a

scratchy feeling in the throat is the rst sign,followed within hours by sneezing and a wa-

tery nasal discharge. Colds tend to last about

a week, with perhaps a few lingering symp-

toms, such as a cough, for an additional week

or so.

The u can have much more serious ef-

fects, making suerers feel sick all over. It is

caused by a single family of viruses and con-

tracted by a similar means as the cold, whichis coming into contact with the virus through

touching an infected area door handles, ta-

bles, etc or being around a person infected

who coughs or sneezes.

The u is highly contagious, but short-

lived. Usually, both the cold and u will sub-

side on their own within a week.

However, it is recommended to use medi-

cation to treat the symptoms. If symptomspersist or become more severe aer a week,

medical advice should be sought, advised

www.myhealth.gov.my.

Some New Zealand experts are predicting

a bad u season if the paern seen in the US is

repeated there. The US has had its worst out-

breaks since the inuenza pandemic which

began in 2009.

In that year, more than 1,400 people with

inuenza were treated in New Zealand hos-

pitals.

Pharmacists acknowledge grey areaNew Zealand pharmacist David Postlewaight

has already seen quite a few customers with

winter ailments over the past few weeks.

He described the dierence between a cold

and u as a bit of a grey area.

Its hard to make a distinction between

a cold and the u. I suppose the severity of

symptoms dictates whether or not we refer to

the doctor.

If they are managing to struggle along

with daily tasks and just need symptom re-

lief, we oer OTC products. If its more severe

and the patient is struggling to do normal

daily tasks or seems to have secondary infec-

tion, such as green or brown phlegm, then we

refer to the doctor. Also, if it seems to be a pro-

longed bout, we oen refer.

Graeme Brash, from Ascot Amcal Pharma-

cy in Invercargill, New Zealand, agreed there

is confusion among customers about what

constitutes a cold, as opposed to u.

Customers generally lump everything to-

gether as u, Mr Brash said.

Our job is to dierentiate it for them, and

the classic symptom which dierentiates it is

fever.Products which oer symptomatic relief

for both ailments are the pharmacys biggest

sellers during winter, but its also important

to give the right advice, Mr Brash added.

Its really important with u and fever

that patients get uids and electrolytes.

Mr Brash also refers patients to their GP if

symptoms are severe or long-lasting.

... there is confusion among

customers about what constitutes

acold,asopposedtou


27/40


Decongestant spray for relief of nasal

congestion

We all know how frustrating it feelsto not be able to breathe properlyand to have the blocked nose sen-

sation return no maer how many times youblow your nose. It is also inconvenient to haveour hearing and sense of smell impaired

It is a common misconception that nasal

congestion is caused by accumulation of ex-cess mucus, leading to the blocked nose sen-sation.

Nasal congestion is typically caused by theswelling of the mucosal lining. Several biolog-ically active agents such as histamine, tumornecrosis factor-, interleukins and cell adhe-sion molecules contribute to inammation,which can manifest as venous engorgement,increased nasal secretions and tissue swell-

ing/edema. This leads to impaired airowand the sensation of nasal congestion.

Nasal congestion aects various age groupsand can cause discomfort. In older childrenand adolescents, nasal congestion is oen justan annoyance. However, it may cause otherproblems as it can interfere with hearing andspeech development. Nasal congestion canlead to sequelae such as sinusitis and otitis

media. It can accelerate the onset or worsen-ing of mild-to-severe sleep disturbances, in-cluding sleep apnea. These sleep disturbancescan detrimentally aect a persons daytimeenergy levels, mood and daytime functions.This, in turn, can aect performance in schoolor at work.

A study published in Treatments in Respi-ratory Medicine looked at the impact of nasalcongestion on quality of life and work pro-

ductivity in allergic rhinitis. Of the 2,355 par-ticipants, 85% had nasal congestion and this


28/40


was the one symptom that most adults andchildren wished to prevent. It was found thatnasal congestion aected most participants atwork or school, had a notable emotional im-

pact and hampered their ability to performdaily activities. [2005;4(6):439-46]

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

Home remedies can help provide a tempo-rary relief from a blocked nose. It is impor-

tant for the nasal passages to be kept moist asbreathing in dry air dries up the membraneand further irritates it. Patients can use a hu-midier or a vaporizer to prevent the nasalpassages from drying up. Taking a hot show-er and breathing in the steam can also providerelief. An alternative to this is to carefully

breathe in steam from a bowl of boiling water.Increasing uid intake is also recommend-

ed to help thin out the mucus. Patients can

also use a warm compress on the face. Placinga towel soaked in warm water on the face mayhelp open up nasal passages. When sleep-ing, keeping the head elevated by proppingthe head with several pillows can help make

breathing more comfortable.Otrivin, a decongestant nasal spray, helps

provide long-lasting relief from congestion.The spray is applied directly to nasal tissue

and it works right away, with its decongestanteect lasting up to 10 hours.Otrivin is available in exible dosage in

a convenient and easy-to-use packaging. Itcontains the active ingredient xylometazolinehydrochloride, which constricts nasal bloodvessels and increases nasal airow, making itmuch easier for patients with a blocked noseto breathe.

A double-blind placebo-controlled parallel

group study investigated groups of patientswith a common cold who were treated with

Otrivin nasal spray or placebo (saline solu-tion). The study primarily aimed to determinethe decongestion eect. Secondary objectivesof the study were to determine the peak sub-

jective eect, duration of relief of nasal con-gestion, cold symptoms and general well

being of patients and adverse events. [Am JRhinol & Allergy 2008;22:1-6]

The decongestant eect of Otrivin wasfound to be signicantly greater than placeboas demonstrated by nasal conductance at onehour aer spraying with the nasal spray. Na-sal airow remained above the threshold for

nasal obstruction for up to 10 hours.Otrivin was also found to improve commoncold symptoms such as runny nose, blockednose, sore throat and ear ache, leading togreater patient satisfaction with treatment.

Otrivin provides double-acting relief, com-bining a vasoconstrictor eect with a mois-turizing formula. It contains two moistur-izing ingredients which are no strangers tothe pharmaceutical and cosmetics industry

sorbitol and hydroxypropyl methylcellulose(HPMC).

Sorbitol, oen used as a moisturizer, helpsnormalize the level of liquid in mucosa, ensur-ing that dryness and irritation do not occur. Itprovides a soothing eect. HPMC strength-ens the moisturizing eect and prevents nasalmucosa from drying out.

Otrivin is indicated for patients with colds

of various types, to aid drainage in sinus con-ditions, as an adjuvant to decongest the na-sopharyngeal mucosa in otitis media and tofacilitate rhinoscopy.

Contraindications for Otrivin include dryrhinitis, acute angle glaucoma or known hy-persensitivity to ingredients of the product.Caution should be used in patients with hy-pertension, cardiovascular diseases and hy-perthyroidism. Due to its vasoconstrictive

properties, Otrivin should be avoided duringpregnancy as a precaution.


29/40


The right needle matters in insulin therapy

Insulin therapy is primarily injection ther-

apy, and the needle provides the means ofpenetrating the skin barrier.

In addition to penetrating the skin, the

needle provides the means of transporting

insulin through the underlying tissue to the

deposition area near the bloodstream in the

subcutaneous tissue.

Considering these key roles, the design and

structure of the needle plays a pivotal role in

inuencing the successful outcome of insulintherapy. The functional design of the needle in-

uences the usage of the needle, its ease of use,

the application of the correct injection tech-

nique and the ease of choosing an individually

correct needle. All these factors greatly inu-

ence user preference and satisfaction.

Importantly, the structure of the needle

inuences the correct deposition and absorp-

tion of insulin and, thereby, metabolic con-

trol. The needle length determines the correct

depth of the deposition. The diameter deter-

mines the potential post-injection leakage and

the sharpness inuences the severity of both

acute and chronic tissue damage.The injection process will always cause

some tissue damage accompanied with pain

or discomfort, and will usually cause a certain

level of anxiety, especially among new users.

Most people are uncomfortable with the

thought of having injections, especially the

idea of injecting themselves. While this anxi-

ety generally disappears once the person has

tried a few injections, as many as 10% of peo-

ple with diabetes suer from a fear of needles

to the point where needle anxiety is an obsta-

cle to overcome. (J Fam Pract 1995;41(2):169-

75) People with type 2 diabetes might bypass

injections or avoid taking injections for a more

extended time.

It is important to distinguish between the

actual or real pain and perceived pain experi-

enced when using a needle. Real pain causedby the actual stimulation of pain receptors is

mostly inuenced by the needle diameter a

needle with a larger diameter touches more

nerve endings, causing more pain. A longer

needle, on the other hand, causes painful per-

foration of the muscle fascia.

Other factors inuencing the level of real

pain are the sharpness of the needle tip and

the smoothness of the surface.

Perceived pain is psychological in nature,

Most people are uncomfortable

with the thought of having injections ...


30/40


but of signicant clinical importance. It is the

type of pain most oen involved in needle

anxiety and, therefore, a very serious barrier

to the initiation of injection therapy. A key fac-

tor is the appearance of the needle.People with type 2 diabetes are mostly old

or elderly, while people with type 1 diabetes

are oen children when diagnosed. All require

ease of use, good ergonomics, easy handling in

mounting and a low force for injection.

For optimal ease of use, it is important that

a minimum number of steps are involved in

the overall process. In addition, the needle it-

self needs to be easily disposable.

The new NovoFine 32G Tip ETW (Extra

Thin Wall) is now the new standard in gentle

injections. Its Tapered tip technologyTM is a

unique needle geometry where the needle ta-

pers to a 32G tip, making it the thinnest insulin

needle, hence, less pain and bleeding and gen-

tle to insert. (Somatosens Mot Res 2006;23:37-43)

It is chemically polished and silicone coated toremove surface imperfections for a smooth in-

jection, and causes less pain on insertion. Its

thin wall technology results in less force need-

ed when injecting. It is of ideal needle length

(6 mm) and provides safe and eective insulin

injections for most people, with less discom-

fort and psychological fear.

Furthermore, the NovoFine needle is for

single use only. Reused needles may cause in-

creased pain, increased risk of infections, lipo-

hypertrophy, altered insulin ow and change

in insulin concentration.

Pharmacy Update brings you updates on disease management and advances in

pharmacotherapy based on reports from symposia, conferences and interviews,

as well as latest clinical data. This months updates are made possible through

unrestricted educational grants from MSD.

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

Pharmacy UPDATE


31/40

31 Pharmacy Update

Early combination therapy treats diabe-

tes to target, delays insulin initiation

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

insulin initiation, says a prominent endo-crinologist.

Richard OBrien, clinical dean of medi-cine and chair, Academic Center, Univer-

sity of Melbourne, Australia, said currentdata point to the use of multiple treatmentmodalities earlier in the course of diabetesto bring patients to target and to keep themon target for a longer period of time.

In his presentation at a symposiumsponsored by Merck Sharp & Dohme(MSD), Prof OBrien also discussed theAmerican Association of Clinical En-docrinologists (AACE)s recommenda-tion for initial combination therapy inpatients with HbA

1c>7.5 percent on di-

agnosis. This recommendation is meantto tackle the short span of time betweenprescription and failure of treatment,and subsequent addition of other antidi-abetic drugs. (J Clin Pract 2005;59:1345-55) By combining lifestyle modificationswith oral antidiabetic combination ther-

apy, the patient can be brought to tar-get and stay in target for a much longerduration before the eventuality of treat-ment failure and insulin initiation. (JClin Pract 2005;59:1345-55)

The importance of good glycemic con-trol early in the course of diabetes has beendemonstrated by the UK Prospective Dia-

betic Study (UKPDS) post-study follow-

up. Prof OBrien said: Good control earlyin the course of the disease can prevent

complications many years later and myinterpretation [of the legacy eect] is thatwe should probably be more aggressive intreating our patients early in the course ofdiabetes.

In what is commonly known as the lega-cy eect, patients in the intensive glycemic

control arm of the UKPDS were observedto have less diabetes-related deaths, deathsfrom any cause, myocardial infarction,stroke, peripheral and microvascular dis-ease. The benets were observed 10 yearsaer the original study ended. (N Engl J

Med 2008;359:1577-89)Conversely, Prof OBrien said it is proba-

bly beer to less aggressively treat patientswho have more severe diabetes as there isa need to balance glycemic benets withthe risk of hypoglycaemia, especially in el-derly patients; those with long duration ofdiabetes; and those with pre-existing car-diovascular disease.

Comparing dierent oral antidiabeticcombinations, Prof OBrien said the com-

bination of DPP-4 inhibitor sitagliptin plusmetformin (Janumet, MSD) caused less

hypoglycemia compared to a sulfonyl-urea plus metformin combination. (Diabe-tes Obes Metab 2007;9:194-205) Even withmonotherapy, sitagliptin caused less gas-trointestinal symptoms compared withmetformin monotherapy. (Diab Obes Metab2010;12(3):252-61)

The AACE also lists the possibility of us-ing DPP-4 inhibitors as potential rst-line

monotherapy as it is comparable to bothmetformin and sulfonylurea in terms of


32/40

32 Pharmacy Update

HbA1c

reduction, but with fewer side ef-

fects such as weight gain and hypoglyce-

mia. [Diab Obes Metab 2010;12(3):252-61,

2007;9:194-205] Prof OBrien noted that al-though incretin-based therapies have been

suspected of causing pancreatitis, meta-

analysis of randomized trials have shown

no such association.

In countries with a large population of

Muslim diabetics, fasting in the month of

Ramadan can be a challenge as incidents

of hypoglycemia increase during the fast-

ing month. A study carried out in India

and Malaysia on diabetics during Rama-dan showed that by utilizing DPP-4 in-

hibitors such as sitagliptin, the incidence

of hypoglycemia could be halved (1.9%

in sitagliptin versus 3.8 percent in the

sulfonylurea group). (Curr Med Res Opin

2012;28(8):1289-96)


33/40

Pharmacy Practice | Pharmacy Today | September 201333

Managing chronic pain

Pharmacy Practice

Recognised by

Academy of Pharmacy

Earn1CPDpointeverymonth

Dr. Eugene WongConsultant Orthopedic and Spine SurgeonAdjunct Assistant Professor

Perdana University Graduate School of MedicineSerdang, Selangor

Chronic pain is a state in which pain

persists beyond the usual course of an

acute disease or healing of an injury.

It is a persistent or intermient condition usu-

ally dened as lasting for at least six months.

It may or may not be associated with an acute

or chronic pathologic process that causes con-

tinuous or intermient pain over months or

years.

The cause is oen unknown, develops in-

sidiously and is associated with a sense of

hopelessness and helplessness. There are sev-

eral risk factors which predispose one to the

development of chronic pain. (Table 1) This

multifaceted disorder has biopsychosocial

components. It is a debilitating clinical condi-


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Clinical Pharmacy | Pharmacy Today | September 201334

Genetics

Severe initial pain

Sleep dysunction

Fatigue

Level o education

Female gender

Anxiety/depression

HPA (stress) axis dysunction

Time o work

Job satisaction

Younger age

Low sel-help skills

Table 1: Risk factors leading to chronic pain

Anti-inammatories

Steroids, NSAIDs, COX-2 antagonists

Neuropathic pain agents

Tricyclic antidepressants, anticonvulsants, antiarrhythmics

Muscle relaxants

Narcotics

Alternative medicine

Acupuncture, massage therapy, herbal remedies

Pain coaching

Lie counselingCognitive behavioral therapy

Pain psychologist

Sleep evaluation

Rehabilitation

Interventional

blocks, spinal cord stimulator, intrathecal pump

Neurolytic procedures

Table 2: Medical management of chronic pain

tion associated with a variety of disease en-

tities including diabetic neuropathy, low back

pathology, bromyalgia and neurological dis-

orders. Chronic pain produces signicant be-

havioral and psychological changes such asdepression, sleeping disorders, preoccupation

with the pain and a tendency to deny pain.

Persistent pain causes maladaptive changes

that aect pain perception and pain sensations

out of proportion. Hyperalgesia is due to sen-

sitization of peripheral nociceptors, whereas

allodynia is due to activation of low-threshold

mechanoreceptors. Central sensitization is due

to loss of inhibitory eects of myelinated pri-

mary aerents, which causes prolonged exci-

tation or sensitization of spinal pain transmis-

sion neurons.

Chronic pain can be categorized as malig-

nant, nonmalignant or neuropathic (either ma-

lignant or nonmalignant). Drug treatment is

largely dependent on the type of chronic pain

syndrome. Some of the ways to measure pain

include asking and observing the patient, and

evaluating function and mood. The principles

of treatment include the reduction of pain, re-

habilitation and coping. Rehabilitation consists

of reconditioning and pain prevention.

Treatment strategies targeted at underlying

pain mechanisms are most likely to provide

long-term relief of pain. Regimens involve a

multidisciplinary approach utilizing educa-tion, medication, and physical, occupational

and behavioral therapy. The focus of diagnosis

and evaluation of chronic pain should be on

reversible causes of the pain. Initiation of pain

treatment should not be delayed while a diag-

nostic work-up is completed as uncontrolled

pain has signicant adverse eects on quality

of life, functioning and mood. (Table 2)

The combination of medications serves todecrease pain by altering pain pathways in a

multimodal fashion. Start low and go slow ondrugs. The WHO has a simple and validated

three-step approach to pain management.

(Table 3) The basic principles behind the three

steps of the ladder include selecting the appro-

priate analgesic for the pain intensity and indi-

vidualizing the dose by titration of analgesics.

A score of 1-3 on the pain intensity scale

equals to mild pain. Mild pain can be ade-

quately treated with aspirin, acetaminophenand nonsteroidal anti-inammatory drugs


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(NSAIDs). Acetaminophen is the analgesic of

rst choice in patients (who do not have liver

disease and do not consume excessive amounts

of alcohol) with mild-to-moderate pain. This is

a rst-line agent for osteoarthritis. It is a safealternative to NSAIDs for non-inammatory

pain when given up to a maximum of 4 g/day.

NSAIDs can be used if acetaminophen fails

to provide relief, or if the patient has an acute

inammatory condition. There is considerable

risk of gastrointestinal bleeding, sodium reten-

tion and renal impairment in the elderly. COX-

2 inhibitors are recommended for long-term

treatment of individuals who have chronic

pain caused by inammatory or other under-

lying conditions such as osteoarthritis. These

agents reduce, but do not eliminate, risk of

gastrointestinal bleeding. The risk of renal im-

pairment is the same as for NSAIDs.

Tramadol is a centrally acting analgesic and

may be added to acetaminophen or NSAIDS,

either alone or in combination, to manage

moderate-to-severe pain. These drugs dier

from opioids in two important ways in that

there is a ceiling eect to the analgesia where

using more drugs is not associated with greater

pain control, and they do not produce physical

dependence. Acetaminophen is preferable in

patients at risk for side eects of NSAIDs such

as renal failure, bleeding, hepatic dysfunc-

tion and gastric ulceration. NSAIDs or aspirinmay be appropriate if there is an inammatory

component of the pain.

A score of 4-6 equates with moderate pain.

In the initial treatment of moderate pain,

low-dose opioid drugs are added to aspi-

rin, acetaminophen or NSAIDs. For patient

convenience, many opioids are marketed as

combination products containing one of these

agents.When the score exceeds 7, the patient has

severe pain. The treatment of severe pain re-

quires stronger opioid agonist drugs and the

continuation of aspirin, acetaminophen or

NSAIDs, if possible. Codeine, oxycodone, hy-

drocodone, hydromorphone and fentanyl are

commonly used opioids. Codeine, oxycodone

and hydrocodone are available as immediate-

release (short-acting) preparations or in com-

bination with aspirin or acetaminophen. Many

of these are now available both in immediate

and extended-release forms.

Opioid analgesics are appropriate for mod-

erate-to-severe acute pain that is not relievedby other categories of analgesics. Long-term

use of opioids for pain relief does not appear

to cause organ damage and does not cause loss

of control, tolerance or addictive behavior in

most individuals. Patients should be placed

on bowel regimes to avoid constipation. The

tapering of the drug dose is required to avoid

signicant withdrawal symptoms.

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

First Tier

NSAIDs

TENS

Psychological

Nerve Blocks

Second Tier

Opioids

Neurolysis

Thermal

Procedures

Third Tier

Neurostimulation

Implantable

Drug Pumps

Surgical Intervention

Neuromodulation

Intrathecal Inusion

Table 3: Chronic pain treatment continuum


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clock pain control. It is inadvisable to use it as

the initial approach without establishing that

the patient requires continuous opioid use of

10 mg every 4-6 hours. Transdermal opioids

require 24-72 hours to reach a steady stateand may be administered every 48-72 hours. It

may, therefore, be necessary to ensure that the

patient is also being treated with immediate-

release opioids on a scheduled or PRN basis

for the rst 24-72 hours when the transdermal

opioid is started.

Opioids are associated with adverse ef-

fects, especially during the commencement

or change in dosing and administration. The

various medication issues are listed in Table

4. When opioids are used for prolonged peri-

ods, drug tolerance, chemical dependency and

addiction may occur. Ongoing monitoring for

safety and eectiveness is essential, including

regular review of functional progress or main-

tenance, urine drug testing and surveillance

of data from the state prescription monitor-

ing program. (Table 5) Ineective, unsafe or

diverted opioid therapy should be promptly

tapered or stopped.1

Opioids are commonly prescribed for

chronic non-cancer pain and may be eective

for short-term pain relief. Long-term eective-

ness is variable, with evidence ranging from

moderate for the use of transdermal fentanyl

and sustained-release morphine, to limited foroxycodone, and indeterminate for hydrocodo-

ne and methadone.2

Addiction should be distinguished from

physical dependence. Any person who takes

sucient doses of certain types of drugs for a

signicant length of time can have withdrawal

symptoms if the drug is suddenly stopped or

reversed by another medicine. This shows the

presence of physical dependence, but does notconstitute addiction. The risk of addiction is

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

Maximize non-opioid analgesic strategies frst

Inorm subjects o risks beore initiating opioid therapy

Facilitate the use o opioid agreements or patients initi-

ating or increasing opioids

Schedule ollow-up visits at intervals o 2-3 months and

perorm periodic urine tests to confrm adherence

Monitor pain severity and pain-related unctional

impairment at ollow-up visits since analgesic response

may wane in some patients over time

Avoid opioid dose escalations without frst assessing

pain severity and intererence

Consider discontinuing opioids i not benefcial

Consider opioid rotation i tolerance to one opioid is

suspected

Table 5: Opioid management strategy

Addiction

loss of control, harm, focus

Pseudoaddiction

looks like addiction but resolves with adequate pain control

Substance abuse

using medications for alternative reasons

Chemical copers

treating underlying depression, anxiety, insomnia

Table 4: Opioid medication issues


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person. There are four core elements in true ad-

diction compulsive use and preoccupation

with the drug and its supply, inability to con-

sistently control the quantity used, craving the

psychological eects of the drug, and contin-ued use despite adverse eects from the drug.

Some drugs are not to be taken long term.

Certain drugs are not recommended in chron-

ic pain management. These include pethidine,

which has a short half-life and the risk of cen-

tral nervous system toxicity at high doses. Can-

nabis and cocaine have dysphoric side eects.

Indomethacin, piroxicam and meclofenamate

cause serious side eects such as peptic ulcer-

ation, gastrointestinal hemorrhage, confusion,

agitation and hallucinations. Meperidine is

associated with increased confusion. Pentazo-

cine, butorphanol and other agonist-antago-

nist combinations have lile analgesic ceiling

eects and are associated with dysphoria and

hallucinations, and may precipitate withdraw-

al in opioid-dependent patients.

Neuropathic pain is initiated or caused by a

primary lesion or dysfunction in the nervous

system. There is a wide range of medications

used to treat neuropathic pain. (Table 6) Topi-

cal creams with capsaicin are used to treat pain

from a wide range of chronic conditions includ-

ing neuropathic pain. Following application to

the skin, capsaicin causes enhanced sensitivity

to noxious stimuli, followed by a period withreduced sensitivity and, aer repeated appli-

cations, persistent desensitization.3

Coanalgesics or adjuvants used to treat

chronic pain include antidepressants, anticon-

vulsants, topical agents, skeletal muscle relax-

ants and antispasmodic agents. (Table 7)

Interventional techniques can be used to

treat chronic pain. These target the source of

pain. An injection of steroids can be done attrigger points, joints, peripheral nerve and epi-

dural space. This localizes the delivery of the

medication. Nucleoplasty or percutaneous dis-

cectomy is a procedure where a needle aspi-

ration of a portion of the nucleus pulposus is

carried out. Intradiscal thermocoagulation can

be done to stop leakage of the nucleus.

Physical or restorative therapy may be used

as part of a multimodal strategy for patientswith chronic low back pain. Psychological

Antidepressant

amitriptyline, doxepin

Anticonvulsants

carbamazepine, gabapentin

Anti-emetic

scopolamine

Anxiolytics

benzodiazepines

Glucocorticoids

Topical agents

Mixture o ketamine, clonidine, gabapentin and lido-

caine

Table 7: Adjuvant therapy for chronic pain

Tricyclic antidepressants

Nortriptyline

Anticonvulsants

Gabapentin, carbamazepine, pregabalin

Local anesthetics

Parenteral, oral, topicalTopical capsaicin

Opioids

Antiarrhythmics

Bacloen

Carbamazepine

Trigeminal neuralgia

Duloxetine

Peripheral diabetic neuropathy

Gabapentin

Postherpetic neuralgiaLidocaine patch

Postherpetic neuralgia

Pregabalin

Peripheral diabetic neuropathyPostherpetic neuralgia

Table 6: Treatments for neuropathic pain


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treatments include the use of cognitive behav-

ioral therapy, biofeedback or relaxation train-

ing. These interventions may be used as part

of a multimodal strategy for patients with low

back pain, as well as for other chronic painconditions. Supportive psychotherapy, group

therapy and counseling can be used in the

treatment of chronic pain. The elderly are more

likely to have signicant pain issues and are at

particularly high risk of having their pain in-

adequately managed.4

Chronic pain is a multifactorial phenome-

non

pharmacy today september 2013 my

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