From: "Geoff Timbs" warnersbay@amcal.net.au

The last Budget included 2 measures to start on 1/12/09. The first is a new therapeutic group for Atorvastatin and Rosuvastatin and presumably Crestor will be dropping their price or wearing a large premium from Dec 1st....don't do a bulk buy.

The second is to extend reference pricing to "all non-exempt items in a therapeutic group" to remove anomalies and save $61 million. Does anyone have any idea what this means...MA tells me to ask the Dept, the Dept says it is on their website but can't tell me where and the Guild is waiting for more info. This should be something we receive adequate notice to minimise windfall losses on stock on hand.

Geoff Timbs B.Pharm

From: "Michael Post" piosto1@hotmail.com

Patient presents hospital script to me thismorning:

Aspirin 150mg d Simvastatin 40mg 1 n Karvezide 300/25 1 m Metformin 1000mg 1 bd

Me: Why are you taking these meds??

Customer: They thought I might have had a stroke because my speech was slurred for 30 mins on Monday. I had an MRI and they say I'm OK now.

Me:Did they mention the anacronym TIA to you?

Customer: Yes- they said I had a TIA

Me; When are you seeing GP?

Customer: Seeing GP on Monday

Me: Any allergies and have you ever had a heart attack or angina?

Customer: No and no

Me: You need to see your GP righ away to get appropriate medicine to prevent stroke. When you see your GP please ask him/her for a health summary sheet print out. With your permission I would like to be involved in your health and because I am not privy to your medical diagnoses I cannot help fill any gaps that might be missing in your treatment PLUS I can keep an eye on your dispensing history to ensure you are taking the medicines you are supposed to be taking regularly.

Customer: Thankyou so much.

Another life saved.

Asasantin as opposed to aspirin should be prescribed in my customer's case hence he become another stroke victim within 1 week of TIA.

I ask all customers for health summaries from their GP if they want me to become a part of their team rather than a potential contributor to medication misadventure.

Low and behold in the last 2 health summaries I have picked up clinically SIGNIFICANT gaps in treatment.

Geez- we might just complement doctors at this rate- its just a shame its not standard.

Customer

From: "David Haworth" pugnutty@gmail.com

I see Katie Butt from the NPS reads the list - I read the GP's News and Review links but no where did the NPS advise the GP's to avoid PPI's ( exception Somac) due to the Cytochrome interaction (with clopidigrel). Could Katie comment on this?

I advised a GP of the interaction and she called me back saying that explained her patient with thrombolisms who was already on Clopidogrel and Nexium.

David Haworth

From: "amanda cronin" healthglo@hotmail.com

What worries me is that parents have cottoned on and now lie about the age of the child to get it. This leave us in no position to tell them the correct dose for the age so they guess. Potentially more dangerous. And I bet it happens all the time. I have done it myself while on holiday.

From: "Peter Evans" wynnum@amcal.net.au

Andrew Topp wrote: "So where are all these reports of serious adverse events?"

and Ken Harvey wrote: See: "Labelling and packaging of cough and cold medicines - proposed changes to requirements. Consultation". http://www.tga.gov.au/npmeds/consult/drlp-ccmedicines.htmEspecially see, "TGA internal panel report on a review of the safety and efficacy of cough and cold medicines in the treatment of children aged 2-12 years (pdf,153kb)"

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Andrew asked for the evidence, Ken directed us to TGA's report on the matter.

In summary the above report uses the TGA's own Adverse Drug Reaction data, which is a credible idea, better than overseas data about ingredients sold through non-pharmacy outlets and ingredients not even available in Australia.

It wades through some general statistics, then gets down to the only specific evidence of ADRs from cough & cold ingredients offered in the whole report:

2 deaths since 1981, as follows:

'the first occurred in a 1 year old infant administered oxymetazoline and morphine the second death occurred in a 2 year old child administered ipecacuanha (unclear whether ipecacuanha used for its expectorant or emetic properties) in combination with other medications'

That is it! Two deaths, vaguely/maybe linked to oxymetazoline & ipecacuanha in 28 years. These were the only specific cases discussed.

We are not told if the links to these specific ADRs were probable, possible or unclear.

So for all we know, the TGA is considering restricting the access of cough & cold medicine relief to any sick child under 12 because an infant died of a morphine ADR, whilst using coincidentally using oxymetazoline administered intranasally or any number of other possibilities unrelated to conventional use. Worse still the ipecacuanha link is so vague I can't believe it was included (and to my knowledge it is only present in Mixt. Ipecac et Tolu, which hardly relates to the extensive list of ingredients under review.

Peter Evans (Community Pharmacist)

From: "Peter Bayly" peter.bayly@bigpond.com

Bill Arnold wrote:

" Please describe for me a calendar pack designed for products where there can be be frequent dosage changes.'

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How about 2 strips of 28. Easy for single dose, easy for double dose. Discard second half of half dose.

Not perfect, but much better for most patients most of the time especially those who don't mark it off on any other record.

Peter B, thankful for the responses :-)

From: "Greg Stark" janshepherd5@bigpond.com

Francis Ip wrote:

"I have a (admittedly cynical) belief that paediatric symptomatic treatments are not for the benefit of the child but for the parents. Most children seems fairly happy to run around with a cough or runny nose that is not going to harm them and causes negligible loss in quality of life. It is the adults who are most affected by the child being sick and suffer a large loss in quality of life (the burden of being a 'bad parent'!). Sometimes I think medicating the adults will provide a better outcome!"

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Anybody remember seeing the release of "Obecalp" capsules a year or 2 ago? It was simply clever marketing of a placebo capsule.

Perhaps it's time for "Obecalp" to bring out a syrup, nasal drops, etc to fill in the obvious gap in our market ;)

From: "amanda cronin" healthglo@hotmail.com

"So the review actually shows 40-67%"

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My problem with this type of testing is it is subjective. The person taking the placebo will feel better becuase there condition is improving so may put it down to the medicine. The same person could also take the medication and the symptoms will improve much more, but with out the other experience to compare it to will rate it the same. It is obvious to any parent who's kid stops crying, the nose stops running( for a few hrs at least)and peace is in the house that they do work. I know I'll be stocking up for my family before this is recheduled.

From: "Ritche Andit" r.andit@bigpond.net.au

Greg Stark wrote:

"By the way, whatever happened to the push to remove Marevan from the market as (if I remember the figures) only 5% of people use the Marevan brand?"

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Marevan is more popular in our area.

From: "Peter Bayly" peter.bayly@bigpond.com

Greg Stark wrote:

"...to bring about someone's death? From my understanding, barbiturates have been the drug of choice."

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check out the toxicity of amitriptyline + alcohol

From: "Michael Jensen" toadsquasher@hotmail.com

michelle gerrie wrote:

"Are we meant to still get a photo ID if someone presents to the pcy with a Rx for Sudafed etc? Had a dodgy looking person come in with a legitimate Rx as he does not have any photo ID."

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No photo ID? How about a Credit/Debit card with the persons name on it. Would be able to establish their identity from that.

From: "Francis Ip" francisi@tpg.com.au

michelle gerrie wrote:

"Are we meant to still get a photo ID if someone presents to the pcy with a Rx for Sudafed etc? Had a dodgy looking person come in with a legitimate Rx as he does not have any photo ID."

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A script is a script. As long as the prescription looks legitimate and you have done your best to ensure it isn't forged then I would dispense it and counsel just like any other script. I believe Project STOP is designed for OTC use, and I haven't heard anyone use it for S4's yet.

In Victoria it is not required for patients to present ID to put in a prescription or to pick up a script (except maybe to verify that it is the correct script to hand out - this is a matter of patient safety, not about legality). I am unsure about laws in other states, though I don't think it would be a requirement because it would wreak havoc on agency issues (i.e. picking up for someone else).

The scenario here could be: this patient tried to get the product OTC but because he 'looked dodgy' and had no ID for Project STOP he was refused. A pharmacist told him the only way was to get a script. He then proceeded to do the right thing and is now back at the pharmacy. To refuse any further at this point I think would be silly - you may as well ban/not stock the product.

In my opinion, pharmacists aren't supposed to be policing medication use in this manner. I believe that the reason they are still S3 is that many people genuinely need the product, and not supplying it to these people would be a failure of care. I also believe that visual appearance isn't the best indicator of authenticity.

If they answer all my questions, and I ask the same set of questions regarding symptoms and other medication/conditions to everyone, and they can satisfy me that there is a need for PSE, I give it out after making a record and counselling. I try to treat everyone equally. I will, however, ask the questions faster if the patient smells funny or puts on too much perfume because I have to hold my breath and I can't hold it for that long. Going to the back to get the product will then allow me to breath again!

-Francis

p.s. can't wait for national legislation so I don't have to qualify all my statements with 'In Victoria'

From: "Peter Evans" wynnum@amcal.net.au

michelle gerrie wrote:

"Are we meant to still get a photo ID if someone presents to the pcy with a Rx for Sudafed etc? Had a dodgy looking person come in with a legitimate Rx as he does not have any photo ID."

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No ID = No Supply

michelle gerrie wrote:

"Are we meant to still get a photo ID if someone presents to the pcy with a Rx for Sudafed etc? Had a dodgy looking person come in with a legitimate Rx as he does not have any photo ID."

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We have had a problem in our town recently with large numbers of people trawling the pharmacies for pse products. we've made it a blanket policy we will ONLY accept a drivers licence (not even 18+ card) for ID, and it MUST be presented for prescriptions as well. The (dodgy) people here have clued on, and some of the nice young drs have been accommodating with prescriptions (inclduing increased quantities AND repeats). Project stop has a little check-box where you can note if the person had a script.

I had one detective describe our town as the amphetamine capital of Australia. (increase in local violence the last couple of months....interesting??)

Having said that, when I called the police station this morning with rego number of a car involved in multiple purchases, I didn't get a great response.

Looking forward to everyone else's response.

**Moderator's note: seems like a good idea to de-identify this one so that the town / doctors / police can't be identified - MD**

From: "Stuart Baker" drugwise@southernphone.com.au

Katie Butt wrote:

"It would be good for your comments about the article ‘Cough and Cold Remedies for Children’ to be addressed by Australian Prescriber. May I suggest that you put them into a letter to the editor?"

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Dear Katie,

Thank you for that suggestion. Before I go to the trouble of spending more time and effort on this subject I would like to see the authors' response to AusPharmList where the debate is being conducted. If they would care to respond to AusPharmList then I will consider writing to the Editor of Australian Prescriber after seeing their response.

Kind Regards,

Stuart Baker

From: "Peter Evans" wynnum@amcal.net.au

Stuart Baker wrote:

"The results as reported in the Australian Prescriber (AP) article are misleading ..."

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Stuart,

You have obviously gone to a lot of trouble to review this article and it seems, as Frances Ip also points out, the statistics are vague enough to be interpreted in different ways. In any case, there doesn't seem to be conclusive evidence to support the statement 'Cough and cold medicines should be avoided in children under two years and should not be recommended in children any age, particularly those with...'(reasons a pharmacist would avoid recommending such products).

If you do submit a response perhaps you could also query the relevance of some of the contents of Table 1 supporting the article. For example has 'serotonin syndrome' ever been reported in an Australian child under 2, who has taken 'Antitussives, Pholcodine/Dextromethorpan' alone?

In Australia, especially Qld & WA, most of these medicines are behind the counter and supplied by trained staff under the supervision of the pharmacist. No other health care provider is more experienced in handling these products(don't get me started on correcting Demazin overdoses inadvertently prescribed by GPs).

Peter Evans