Editorial
Welcome to the March edition of i2P – Information to Pharmacists.
You may have noiticed if you receive i2P by email, that we have simplified our mail out presentation.
This was because the code in our earlier version appeared to be too unstable to maintain, hence the simpler presentation.
Columns
Rollo Manning: Pharma-Goss
John Dunlop: Inside NZ
Loretta Marron BSc: Health Watch
Barry Urquhart: Marketing Focus
Harvey Mackay: Strategic Thinking
Mark Neuenschwander: I`ve been thinking about...Recent Comments
Past Editions
Volume 1 Number 1
Volume 1 Number 2
Volume 1 Number 3
Volume 1 Number 4
Volume 1 Number 5
Volume 1 Number 6
Volume 1 Number 7
Volume 2 Number 1
Volume 2 Number 2
Pharma News
Staff Writer: SIGMA Pharmaceuticals suspends share trading before release of revised earnings outlookHospital News
Health Politics
Pat Gallagher: Health Informatics - The State of the Nation
Peter Sayers: The Three-Ring Circus
Dr David More: e-Health IdentifiersEPublications
Clinical Pharmacists - Who is Going to Help?
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Introducing current ideas, perspectives and issues, to the profession of pharmacy | |
Editor’s Note: 2010 also marks the official retirement year for the “baby boomer” population and marks the demographic that will eventually lead to 25% plus of Australia’s population becoming 64 plus years old. To kick start this year I looked for a media item that would best illustrate the conflict that exists between clinical pharmacists and community pharmacy owners – a tension that need not exist if commonsense would prevail and professionalism increased. I found a recent item in Medscape that highlights the result of poor prescribing and the long-term use of proton pump inhibitors. Clinical pharmacists could reduce the need for PPI’s, or even eliminate them. What would be required is a working knowledge of clinical nutrition and an ability to monitor a patient at regular intervals to check progress. The outcome from that process should be: * a more comfortable patient…..the patient would be pleased * a major reduction in prescription numbers for PPI’s…..the PBS would be pleased and they would have more “headroom” for new drugs to be listed. * community pharmacies would develop a loyal patient base provided a good working relationship was formed with a clinical pharmacist contractor. I asked Mark Coleman to comment on the news item below, and a process for a clinical pharmacist.
2010 is now upon us and pharmacy begins this year ill prepared to deliver one of its past strengths – a primary health care service.
In part, this is due to a concentration of wealth and power by the Pharmacy Guild of Australia that drives a range of “top down” policies, systems and services that has driven a professional services gap between clinical pharmacists (mostly non pharmacy owners) and pharmacy proprietors, who are encouraged to pursue retail models of practice that initially create survival dollars and apparent growth. But this will eventually create a model that is extremely vulnerable when matched against the strength of major retailers. No doubt these proprietors are working for the day when Colesworth will take them over by issuing a fat cheque.
Australian pharmacists are totally unprepared to meet the primary care needs of this senior population.
Early 2010 also records the final stages of one of the hottest summers on record and a realisation that climate change is here to stay.
The preparation of primary care service delivery designed to cater for the needs of patients affected by climate change, are not in place in community pharmacies.
They do not have active clinical pharmacists – they are too engaged with the dispensing process.
Also, a fair remuneration for this service needs to be available.
Community pharmacies may be displeased initially at the loss of scripts, but these would be easily replaced with new drugs in different categories.
Patients would be less inclined to seek warehouse type pharmacies as they begin to value the clinical service…..discounting would be diminished.
Small Intestinal Bacterial Overgrowth Common Among Long-Term PPI User
Source: Medscape
http://www.medscape.com/viewarticle/715624
NEW YORK (Reuters Health) Jan 21 - In patients with gastroesophageal reflux disease (GERD), long-term use of proton pump inhibitors (PPI) contributes to bacterial overgrowth in the small intestine, new research from Italy shows.
Small intestinal bacterial overgrowth, in which the small bowel is colonized by large numbers of bacteria ordinarily found in the colon, produces bloating, diarrhea and other symptoms, the researchers explain.
Led by Dr. Lucio Lombardo, of the Mauriziano U.I. Hospital in Torino, the investigators used glucose hydrogen breath tests to look for small intestinal bacterial overgrowth in 450 consecutive patients enrolled in three groups:
-- 200 GERD patients treated with PPIs for a median of 36 months;
-- 200 patients with irritable bowel syndrome (IBS) who had not used PPIs for at least 3 years; and
-- 50 healthy controls who had not used PPIs for at least 10 years.
"The rationale for using IBS as 'pathologic' control stands on the large prevalence of small intestinal bacterial overgrowth in IBS patients and the overlapping of symptoms between the two clinical conditions," the authors said.
According to their article published online in Clinical Gastroenterology and Hepatology, they found small intestinal bacterial overgrowth in 50% of the PPI users with GERD, 24.5% of the IBS patients, and 6% of the healthy controls. There were significant differences in prevalence between GERD/PPI patients and the IBS patients (odds ratio = 3.14; p < 0.001), between GERD/PPI patients and controls (OR = 16.0; p < 0.001), and between IBS patients and controls (OR = 6.12; p < 0.005).
All subjects with small intestinal bacterial overgrowth were given high-dose rifaximin for 2 weeks. Treatment was successful in 87% of cases in the PPI group and in 91% of cases in the IBS group.
The authors suggest that PPI-related small intestinal bacterial overgrowth may be under-diagnosed because the symptoms overlap with those of other gastrointestinal disorders.
They point out that while the glucose hydrogen breath test only indirectly detects the condition, it's noninvasive and reproducible, whereas the current standard -- aspiration of duodenal-jejunal content for culture -- is not.
However, they add, the "gold standard for the diagnosis of small intestinal bacterial overgrowth is yet to be defined."
Mark Coleman comments:
Over the years with a few hundred home medicines interviews under my belt, I have consistently noted the large number of proton pump inhibitors (PPI's) that have been mindlessly prescribed by doctors. Patients have been shunted into thinking that taking a PPI must now be a permanent part of their lifestyle - they are too frightened to come off treatment because they usually have "the mother of all" reflux attacks.
In a sense, they have become medical addicts.
Anyone who has gained a qualification in clinical nutrition knows that without hydrochloric acid in the stomach, proper digestion, and breakdown of proteins in particular, is not possible.
Also, the flow of food from the stomach to the duodenum is impaired when low concentrations of hydrochloric acid exist.
One PPI dose can inhibit hydrochloric acid secretion for up to 36 hours.
The consequence of this is that with impaired food flows, fermentation begins to occur as food remains too long in the stomach and that encourages overgrowth of bacteria, plus the production of acids that are not normally present in the stomach.
Peristalsis develops a faulty stop/go rhythm and food toxins are able to attack the cells of the intestinal tract, setting in place the potential for diverticulitis, polyp formation and stomach and bowel cancers.
Altered intestinal flora thrives on a range of improperly digested foods creating gas, bloating, pain and discomfort. With insufficient amino acid being the result of improper digestion, a range of mineral deficiencies begin to occur.
Minerals are unable to chelate appropriately with a specific amino acids because there are insufficient to maintain a health balance.
These "carrier" protein complexes, when they exist, are efficiently absorbed through the intestinal wall.
Oil soluble vitamins also need amino acids for absorption through the intestinal wall.
Vitamin B12 also is inefficiently absorbed with low stomach acid, which can lead to a range of anaemias.
Most GERD sufferers probably sought medical treatment at a time when their acid secretion was low, setting up a range of symptoms that might have been better treated with an actual supplement of hydrochloric acid (usually in the form of betaine).
It is obvious that if PPI's are to be used in any capacity, they should be used with care and only intermittently.
This is now an official recommendation, but has only appeared in recent literature.
With one form of PPI set to re-scheduled as an over-the-counter product, pharmacists may need to intervene if sales of these products indicate overuse.
A strategy designed to wean patients off their PPI's needs to be developed and appropriately supervised.
In my mind, services of this type should be remunerated in some way, because of the eventual savings for the PBS - a case for the independent paid professional services pharmacist – one separated from the actual dispensing process.
Other advantages may begin to flow, one being that manufacturers may more easily begin to down-schedule some of their products because of the care and supervision genuinely on offer.
To protect an individual pharmacy market, private labels can be developed that can maintain a market outside of warehouse discount pharmacies.
In the specific instance of the evidence published by Medscape it goes without saying that a PPI is a major disrupter of a patent’s nutritional status.
Some years ago, the Pharmacy Guild of Queensland developed a College of Clinical Nutrition, an initiative that I was very supportive of.
For whatever reason (none seemed to have been given), the college closed, leaving pharmacists that had qualified unsupported in developing that niche activity.
Did that closure mark the mark the commencement of the professional services gap that has evolved between pharmacy owners and clinical pharmacists?
It was very popular course and some of its graduates have leveraged their qualification to great benefit – but only a handful.
The Medscape patients would also benefit from a consult with one of these pharmacists, as they are ideally suited to provide support treatment during the withdrawal of a PPI.
So would the majority of Australian PPI patients.
I believe that pharmacists should be united in their professional endeavours and that the best interests of the patient must be served at all times.
Dispensing bucketloads of prescriptions for PPI’s is blatantly immoral when services could exist to provide better solutions for patient conditions and treatments.
If pharmacists don’t provide these solutions then maybe nurse practitioners will.
The move to restrict them from operating in pharmacies is the same old knee-jerk protectionist routine followed by the PGA for years. Such a strategy is a failed approach and will continue to be so.
I fear that the lack of cohesion and direction will see pharmacy on the road to self-destruction. Maybe we are already there – sometimes it feels like it.
Can the PSA put up a business case around pharmacist remuneration for consults relating to the elimination/reduction of PPI’s and other drugs?
It is a simple case, and can be funded out of the savings created for these drugs already listed on the PBS.
But please get a move on!
Return to home
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