Pharmacy.Biz News

You are what you eat

Summer is here, people want to show off a bit more flesh while exercising caution about what they put in their bodies. Pupinder S Ghatora, Pharmacy Business' Young Pharmacist of the Year 2008, examines the issues...

Nutrition is BIG business and, as in most of my articles, it is a market we as community pharmacists are going to have to explore if we are to survive in the current climate, especially in light of the coalition Government's plans to reduce the country’s debt. I have a feeling category M may not be our only worry in the future.

We have found more and more patients asking about vitamins, dietary supplements, muscle building and more. As a result we have had to increase our product ranges to include nutritional supplements.

Health and fitness supplements have become increasingly popular, especially with our student population. A brand that has become quite popular is Maximuscle, they have a huge range of sports supplements ranging from energy drinks to muscle building protein formulas. The margins on these products are also fairly healthy so we often try to mix and match and come up with promotional offers.

Weight loss is another category that has two peaks during the year, once during the new year period and again at summer time. The body mass index (BMI) is used to determine if your weight is in the healthy range.

You are in the normal range if your BMI is between 18.5 and 25 (kg/m2)
You are overweight if your BMI is between 25 and 30
You are obese if your BMI is 30 or higher
You are morbidly obese if your BMI is 40 or higher

Government figures show that at least one in four men and one in three women are overweight in the UK. The Department of Health predicts that if this trend continues, by 2010 around 6.6 million men will be obese compared to six million women.

Psychologically, being overweight can affect your body image and damage self-esteem. In some cases this can cause social anxiety and depression. Common physical problems include:

Difficulties breathing
Difficulties walking or running
Increased sweating
Pain in the knees and back
Skin conditions such as acne
Gallstones

The following medical conditions are also more common in obese people than in those of normal weight:

High blood pressure
High cholesterol
Cardiovascular disease
Type 2 diabetes
Some types of cancer

These conditions are often known as obesity-related diseases and are some of the most common causes of death before the age of 75. This is why obesity increases your risk of mortality.

What can we as community pharmacists do to help our increasingly overweight population? The obesity epidemic, as the Government has called it, costs the NHS millions every year and results in an unhealthier nation. With the reduction in outdoor activity, increasingly busy work lives and access to cheap fast food, it is becoming easier for our population to become more and more obese and unhealthy.

Community pharmacists are ideally placed to help manage this problem with professional advice, medication and referral if necessary. The market for weight loss products and health and fitness is huge, a multi-million pound concern. There are opportunities for community pharmacy to tap into these markets and help make up the shortfall in funding by the Government for our ‘bread and butter’ dispensing and purchase profits.

A healthier lifestyle is a major part of weight reduction. I always advise my patients, no matter what weight loss product they purchase from me, that they must also increase their physical activity and eat healthy.

For patients who have a BMI value over 28, a major step forward in community pharmacy was the availability of Orlistat as a P medicine. Alli, as we know it over the counter, has become a very popular product in our pharmacy and has enabled us to help these people lose weight and keep the weight off. Not just by taking Alli, but also healthy lifestyle advice. The patients I have on Alli have a weekly five minute meeting with me; we do a weigh-in and brief discussion about their progress. We are in the process of producing our own weight monitoring diaries for our patients which they will purchase as part of their treatment regime. They also include tips for healthy eating and a sample exercise plan. They have been tailored to suit the patients and we asked each patient what they would like to see in the booklet and devised it to suit.

This is just one example of the opportunities available to us as a profession. There are numerous other weight loss products we also supply and we are now looking into health foods. I have tried, with all my products, to stock those which do have some evidence to show that if used correctly they will give results - for example, lipobind and recently lipotrim. The products recommended are equally as important as the input you as a pharmacist or pharmacy team give to your patient to help them achieve their goals. I have also started a referral scheme with a couple of local gyms. Any patients I send and who join are given a free personal training session and I receive commission. It is important to try and think of new ways to integrate the pharmacy business with other aspects of health to benefit all parties. The patient is happy because you are helping them achieve their health goals and you are happy as you are making a difference and also earning some much-needed extra income.

There has also been a surge in herbal products that claim to aid weight loss, including Adios, Appesat and numerous green tea extract products, such as Thermobol. All of these require lifestyle changes to be effective (i.e. less food more exercise!) but there is evidence to show that some of these products do help to increase the rate of weight loss.

One of the other nutritional products that have seen a boost in sales in my pharmacy are the jointcare products. With an ageing population, it is inevitable that the joints are going to need a little help as we get older. I have found that the glucosamine range of products have really seen a positive growth. I also did research into this whilst at Kings College University and was so convinced by its benefits that I am taking them myself. The theory, in simple terms, is that the glucosamine acts as a building block for cartilage, which reduces in production as we age, therefore if we can give our body the ingredients, it has more of a chance of rebuilding what is lost. Personally, I believe that you get what you pay for. So when patients ask me which brand to go for, I explain it is really up to them but I find the Healthaid range to be fantastic. It is not too cheap and not too expensive, just the right price point and quality of product. There are cheaper brands such as Valupak or more expensive brands such as the Health Perception range, although it comes down to personal preference and/or circumstance.

Even after the bad press homeopathy has received, we are still selling a lot of arnica preparations from Nelsons and Weleda. With any muscle injury, if the patient does not ask for it, we are link selling as we have found it does help the healing process, and patients come back and tell us so and in turn buy another batch to keep in their first aid supplies.

Probiotics, although big business in Europe and looked upon as having genuine clinical benefits, are not really acknowledged in the United Kingdom. We have many European patients who are surprised a probiotic is not given with every anti-biotic course. A company we now use for all our products is DTECTA. They have a fabulous range that caters for people taking antibiotics, people who have diarrhoea, people who are travelling and may develop diarrhoea. Every prescription for anti-biotics is accompanied by the option of the DTECTA probiotic. My team have been told to give the patient the option and advise how it could benefit if they are susceptible to gastro-intestinal side effects whilst on anti-biotics. The support offered by DTECTA is also second to none. They are always on hand to give help and advice about their products and how best to use them, as well as giving suggestions on special offers.

Manuka honey is also another product range that has become increasingly popular. We are now stocking a range of honeys and also manuka honey throat sprays which are very popular in winter to help sore throats. The only thing to be aware of is that diabetic patients, due to the sugar content in these products, need to monitor their sugar levels. The honey itself comes from bees that feed on the nectar of the tea tree plant, which has many positive effects on well-being.

The final supplement I have found that goes well in pharmacy is Echinacea. Like the glucosamine range, there are a number of different brands and prices vary. This is a very good seller during the winter months as it is thought to help boost the immune system. It is of most benefit when given just before a full blown cold or flu takes hold and should not be sold as a treatment, more of a prophylactic.

The nutrition market is huge. It is important to try and make the most of any opportunities that arise as life in community pharmacy is set to get tougher.

Giving foot problems the boot

We tend to take our feet for granted but pain has a way of invigorating our awareness, writes Neil Trainis...

The average person takes between 8,000 and 10,000 steps a day. The law of averages suggests that somewhere along the line wear and tear will give rise to ailments. This notion is reinforced by statistics which paint an extreme picture, such as those stating that the NHS spends £600 million a year on treating foot problems in people with diabetes, with a staggering £252 million of that spent on amputation. Those numbers overshadow the statistic, compiled by CCS Professional Foot Care, a Swedish company specialising in foot care products, proposing that the UK foot skincare market is worth around £19m a year. Foot care brands may be quick to push that number up but such a modest figure can get lost in the glare of a high-powered, corporate business world where number-crunching ostensibly assumes colossal proportions. Its significance, though, lies in the fact that it is misleading in determining the extent to which people suffer from foot problems. Other statistics allow us to scratch the surface a little more. Three-quarters of people get foot pain at some point in their lives and women are four times more likely to get foot problems than men, largely down to wearing high heels. Cold financial numbers appear, it seems, as mere façades rather than genuine illustrations of how big the UK foot skincare industry is, or potentially could be. Unless there is extreme pain or an unsightly blemish, many people with foot problems may find disclosure more of a burden than it is worth, much like a routine headache that does not have serious implications and disappears in a short time.
Nonetheless, feet are far from immune from the problems encountered by other parts of the body. Corns, bunions and blisters, all caused by pressure to different areas of the foot, are becoming increasingly common. Preventative treatments are thus becoming more significant for pharmacists to recommend and stock.
Indeed, diabetes sufferers have an increased risk of infection in their feet because of poor circulation, which can cause healing to be delayed, and even minor cuts and sores can become infected. Bearing in mind Diabetes UK last month warned that over a million people in the UK are unaware that they suffer from type 2 diabetes, the potential pool of sufferers with related foot problems could increase markedly.
The variation in foot ailments, as with other bodily complaints, increases the potential for new treatments and widens revenue streams. Old favourites are still very much apparent; athlete’s foot, corns, calluses, bunions and veruccas. Treatments for those make up almost half of foot care sales.
Athlete’s foot, a type of fungal infection, is usually mild and responds quickly to treatment, although if left untreated can spread to the toenails and other parts of the body. It thrives in warm, moist areas of the body. A popular branded treatment is Canesten HC cream, which contains active ingredients clotrimazole and hydrocortisone. Clotrimazole, an anti-fungal medicine, is used to treat infections with fungi and yeasts and hydrocortisone, a corticosteroid, is applied to the skin to relieve the symptoms of inflammation.
Clotrimazole also kills fungi and yeasts by disturbing their cell membranes, stopping the fungi from producing a substance called ergosterol, an essential component of fungal cell membranes.
Other marketable products for athlete’s foot include Daktacort hydrocortisone cream, which is effective at treating inflamed athlete’s foot and infections and inflammation between the folds of skin due to overgrowth of Candida fungi, Diflucan, a medicine used in certain types of fungal infections and which contains fluconazole, and Lamisil cream, incorporating the active ingredient terbinafine hydrochloride, an anti-fungal medicine used to combat infections caused by fungi. Athlete’s foot sufferers bewildered by the array of options are confronted by other treatments on the market, such as Loceryl, Nizoral, Pevaryl and Sporanox.
Corns, often suffered by women wearing badly fitting shoes or those who stand a lot during the day, are small circles of thick skin that normally develop on the tops and sides of toes. The two main types are hard corns, which are the most common, and soft corns. Hard corns are pea-sized and have a small, hard plug of skin in the centre. The plug can press into the skin and cause pain and swelling. They often occur over a bony area such as the little toe. Soft corns are whitish and rubbery in texture and appear between the toes where the skin is moist from sweat or trapped moisture. They are extremely painful and can become infected by bacteria or fungi.
Rarer types include seed corns, clusters of small, usually painless corns on the bottom of the foot; vascular corns, which develop on blood vessels and bleed if they are cut; and fibrous corns, which endure for a long time and become attached to the deeper layers of skin. Corns also appear on bony feet or as a symptom of other foot problems, such as bunions. Calluses are hard, yellowy or pale areas of skin that can feel rough and are often wider and larger than a corn and do not have such a defined edge.
They can appear where the skin rubs against something, such as a bone, a shoe or the ground, and often form over the ball of the foot, which takes a lot of the weight when walking. Calluses can also occur on the side of the foot, palms and knuckles. Treatments include special creams to rehydrate thick skin, protective corn plasters, customised soft padding or foam insoles, small foam wedges to place between the toes and special silicone wedges that change the position of the toes or redistribute pressure.
Scholl corn and callus removal liquid has proven to be an effective panacea. It contains salicylic acid, which works by breaking down keratin, a protein which forms part of the skin structure, culminating in the shedding of skin cells from the affected area. It can also be applied to warts and verrucas, although patients should refrain from using the product for more than 12 weeks without consulting a doctor.
Bunions, bony swellings at the base of big toes caused when the big toe bends towards the middle of the foot and the second toe, can be treated with bunion pads and painkillers. Aspirin, Codeine/Paracetamol, Diazepam, Diclofenac sodium, Ibuprofen, Naproxen and Paracetamol are names which spring to mind. Lifestyle can, naturally, be preventative. Wearing comfortable, well-fitting shoes and avoiding high-heeled, pointed and tight shoes help, while flat shoes with enough room to move the toes is another shrewd choice. Padding over the bunion may also prevent further rubbing.
Blisters appear when feet get hot and sweaty, making socks stick to the feet. The sock and foot rub against one another and the inside of the shoe, causing fluid to fill up between layers of skin.
Once a blister forms it is advisable to cover it with an adhesive dressing or gauze and if the blister causes pain, cover the area with a soft dressing and change the dressing daily. If it becomes infected, a visit to the doctor for a prescription of antibiotics is called for. Nonetheless, Scholl Party Feet market a range of effective treatments, including blister plasters and gel plasters, sprays and pads, an ideal concoction for pharmacies to stock. Another foot fiend is the verruca, a wart on the sole of the foot. A recent UK study of 1,000 children with warts found that 74% had common warts and 24% had verrucas. Boots Verruca Removal Gel, Salatac Gel and Scholl Seal and Heal Verruca Removal Gel are noticeable treatments. Yet, as with all medications, awareness should extend to potential side effects in striving to alleviate pain.

Back to School

The prospect of returning to school is nerve-racking enough for children who could do without having to contend with head lice, restlessness, fevers and congestion. Neil Trainis looks at the remedies...

Parents should not be duped into believing that their little ones can readily deflect illnesses merely because they have surpassed the baby stage. From the age of five right up to 16, immature immune systems are vulnerable to a variety of ailments. Sore throats, coughs, congestion, catarrh, colds, fevers and runny noses, to name a few, can exacerbate a sense of anxiety in youngsters trying to handle the pressures of schooling without the distraction of sickness.

There are over 200 different cold viruses affecting the nose, throat and sinuses. Adults suffer two to four colds a year yet children can catch seven to 10 colds by comparison. A running or stuffy nose is the most common symptom endured by infants.

All children, at sometime or other, will encounter this problem and, in the majority of cases, the cause is a viral infection or an allergy. A combination of congestion and infection can cause the nose to get blocked and cause the child breathing difficulties and, ultimately, distress. After an acute attack of cold subsides, the nose may continue to run for a prolonged period if the infection is not properly controlled.

A running nose in school children may be embarrassing for both teachers and parents and, although it is often regarded as a minor problem, it needs to be attended to promptly. Symptomatic treatment can be given to make the child comfortable, although children under six should not be given cough or cold medicines at all. If the child is six or older, it is advisable to check if the cough or cold medicine also contains paracetamol or ibuprofen. Older children can take paracetamol tablets or tablets dissolved in water (soluble paracetamol) but it is best to avoid giving paracetamol to any child who has previously had an adverse reaction or sensitivity to it.

Small children are prone to viral infections during a change of weather and any member of the family who has a common cold can spread viral droplets into the air, which are easily inhaled by an infant. The child will have sneezing and a watery discharge from the nose, which may get blocked. There may also be fever and the child may appear sick, so it is very important not to allow anyone suffering from a cold to handle the infant.

Paracetamol syrup should be used instead of aspirin to alleviate the fever, since the latter can cause complications, damaging the liver and brain of the child (Reye’s syndrome). It is important for parents to consult their doctor to decipher whether the child needs antibiotics. If so, it is advisable to complete the full course as ceasing midway through may cause chronic problems.

Cough and colds are self-limiting conditions and will usually get better by themselves but there are simple measures, such as ensuring the child has plenty to drink and gets enough rest. Children under 16 should never be given aspirin but paracetamol (Calpol) or ibuprofen (Nurofen) can be used to reduce the child’s temperature. You should not give the child both medicines at the same time.

When the child has a cold, nasal congestion can be reduced with antihistaminics (Avil, Hisnofil, Phenergan, Triominic) and in case of severe nose blockage, paediatric nasal drops can be used with a doctor’s advice, although adult nasal drops should not be used in children. Steam inhalation with Vicks or eucalyptus oil can also help ease a blocked nose.

Head lice cannot jump or fly but are transmitted by head to head contact. Children with long hair can minimise transmitting lice and contracting them by tying their hair up. An itchy scalp is a sign of head lice and remedies include wet combing or medicated lotions. The wet combing ('bug busting') method involves physically removing lice using a special fine-toothed comb with a spacing of less than 0.3mm. Boots Electronic Head Lice Combs are particularly popular.

Over-the-counter (OTC) insecticide lotions or sprays are also effective - but not 100% effective. Insecticides that kill head lice are available in lotion, mousse and shampoo form and can be obtained on prescription. There are three types available in the UK: malathion (Derbac-M liquid, Prioderm cream shampoo, Prioderm lotion, Quellada-M cream shampoo and Quellada-M liquid), permethrin (Lyclear creme rinse) and phenothrin (Full marks liquid and Full marks lotion). Omega Pharma UK's Lyclear head lice treatment also combats head lice and has been clinically tested and proven to be an effective treatment for head lice infestations.

Growing pains, as well as a variety of other distractions, can hinder a child's concentration but help is at hand. Vitabiotics WellKid multi-vitamins, iron and minerals for active children aged between four and 12 is a popular brand, as is Bassetts Soft and Chewy active health for children over 12, aiding healthy growth and development, healthy eyes, skin, bones and teeth and energy and healthy metabolism. Bassetts early health for children over three, with vitamins A, C, D and E, is similarly effective at prompting vitality and a healthy immune system. Sanatogen market an efficient range of kids' vitamins too. Children may never have an excuse for struggling to concentrate in class again. Of course, vitamins are supplemental and children should eat their five fruit and veg a day.

For children who feel restless and tired Kiwiherb Children’s Chamomile is an effective remedy. Natural, safe and gentle, combining high-potency organic Chamomile with natural flavourings of malt, vanilla, and blackcurrant, it has been developed for children who are regularly over-excited, over-tired and irritable, or suffering from anxiety, nervousness and restlessness. KidzOmega Liquid formulation also provides a rich source of omega-3 essential fatty acids EPA and DHA. Enriched with vitamins A, C, D, E, and folic acid, it helps to optimise brain function and the nervous system and is excellent for developing joints and children’s immune health.

Kiwiherb Children’s Echinacea targets runny noses, sore throats, congestion and catarrh and, in some cases, rasping coughs which can lead to days off school. Medicine continues to ensure that these type of days are kept to a minimum.

Sexual health awareness

Attitudes towards sexual well-being are perforated by ignorance even in the 21^st century. Neil Trainis talks to celebrity doctor and regular health expert on GMTVs This Morning, Rob Hicks, to shed some light on the problems....

An all-too-familiar subject continues to cause unsettling befuddlement. Sexual health remains strangely, and worringly, enigmatic to many people in the UK. The late 1980s and early 1990s saw an intense advertising campaign designed at raising awareness of HIV and Aids. To hammer home the message the public were subjected to TV commercials showing tombstones engraved with the words “Don't die of ignorance”. Hard-hitting images tend to shock audiences into unremitting caution, yet such perils still elude the British psyche, or more to the point, the youthful British psyche.

The emergence of HIV in the 1980s, and with it the availability of testing in 1985, brought such dangers to the surface but, somewhat astoundingly, awareness has dwindled with the sands of time. A practising GP who juggles his time on the GMTV sofa discussing health issues with working in a hospital sexual health clinic, Dr Rob Hicks is not easily shocked but even he struggles to contain an underlying sense of exasperation towards an alarming misconception among Britain's youth.

“HIV is treatable but not curable. People, particularly young people, think it can actually be cured so there is a casual attitude towards sex,” he says with a hint of frustration. “People don't realise it cannot be cured and have unprotected sex.” In the six months leading up to September 30 2008, Durex reported a 10% rise in sales of condoms to £126.4million. Ocado, the online retailer, also reported a 60% increase in sales across its range of contraceptives during the same period. Nonetheless, unfamiliarity with the virus persists and extends right across the board.

Epidemics of infectious syphilis and Lymphogranuloma venereum (LGV) are continuing especially among men who have sex with men (MSM) who are known to be HIV-infected. In fact, 3,762 diagnoses of infectious syphilis were made in 2007, more than in any other year since 1950, and 849 cases of LGV were diagnosed between 2003 and 2008, the majority of whom had symptoms of proctitis (rectal pain, discharge, bloody stools and constipation).

Neisseria gonorrhoea is the second most common bacterial STI in the UK and young people are most commonly infected, with current rates highest in males aged between 20 and 24 and females aged 16 to19. Hicks is similarly frustrated at a lack of awareness, again largely among the younger generation, of STIs on the whole, suggesting that “syphilis and gonorrhoea are thought to be infections of the past” when they are on the up.

“It is a dangerous assumption. In fact there's been an increase in them but because they are old infections people think they have disappeared when they have not,” he insists. Publicity of STIs, aimed at generating awareness, has been heavily focused, in recent years, on chlamydia and gonorrhoea. Hicks is disappointed that syphilis has, to all intents and purposes, been neglected by publicity-mongers in recent times.

“There's been a focus on chlamydia and gonorrhoea and little on syphilis,” he suggests. “But we need awareness of all the infections, genital warts to HIV.” Syphilis concerns Hicks because of the assumptions which have forced it into the background, yet primary and secondary syphilis can be successfully treated with a single dose of penicillin, normally given as an injection into the buttock. Those allergic to penicillin will be prescribed another antibiotic in tablet form. The latter stages of the disease is treated with three penicillin injections at weekly intervals.

Some of the antibiotics used to treat syphilis can adversely affect methods of contraception containing the hormones oestrogen and progestogen, such as the combined pill or contraceptive patch, so additional contraceptive methods may be required to protect the patient from pregnancy.

Antibiotics are commonly used to treat chlamydia and studies have shown that they are more than 95% effective if taken correctly. The course of antibiotics can be either a single dose or a longer course of up to two weeks. The two most commonly prescribed antibiotics to treat chlamydia are Azithromycin (single dose) and Doxycycline (usually two capsules a day for a week) while less commonly prescribed antibiotics include Ofloxacin, Amoxicillin and Erythromycin.

“Many STIs are treated with antibiotics which are decided nationally. The commonest bacterial infections include chlamydia, which can be treated with the antibiotic azithromycin,” Hicks suggests. The current treatment of choice for gonorrhoea is a ceftriaxone 250mg injection. Genital warts, according to the NHS, are “the leading type of (STI) in England, accounting for one in five cases. Each year in England, on average, 80,000 new cases of genital warts are diagnosed by GUM (genito-urinary medicine) clinics.”

In an attempt to resuscitate awareness of chlamydia, and in the process destigmatise the condition, a national screening programme last year “took a major step forward” as GPs ramped up the number of screens done in general practice, according to a report by the Health Protection Agency.

The report praised GPs for the “enormous progress” the profession has made in screening sexually active men and women aged 16-24 for chlamydia and over 1.5 million tests were conducted as part of the programme in 2009/10. That was an increase of 442,000 tests and a 58% rise on the previous year.

Another sexual complaint, genital warts, are most common in sexually active teenagers and young adults. Men aged between 20 and 24 and women between 16 and 19 represent the highest rates of the condition. “Genital warts is a very common viral infection which can be treated with cryotherapy, which entails freezing the wart using liquid nitrogen to kill the cells of the wart by splitting their outer membranes,” Hicks says. Topical treatments include Podophyllotoxin, normally recommended to treat clusters of small warts. It comes in liquid form and works by having a toxic effect on the cells of the warts. Then there is Imiquimod, a type of cream usually recommended to treat larger warts by helping to stimulate the immune system into attacking them, although there are side-effects.

Trichloroacetic acid (TCA) is used to treat small warts that are very hard and is recommended for pregnant women because it is considered the safest of all the topical treatments to use during pregnancy. Warticon cream, a prescription-only topical treatment of condylomata acuminata affecting the penis and the external female genitalia, is another treatment volunteered by Hicks.

The contraceptive pill, he suggested, is “the most popular” preventative product among women but the choices have opened up. “We're seeing more and more women using long-acting and reversible contraceptives like the intrauterine device, more commonly known as the coil,” he says. “We're increasingly finding women choosing this because it's difficult to take the pill. They forget to take it. You'd be surprised how many of us forget to take our pills during the daily grind.”

Erectile dysfunction is another condition which heaps misery many, particularly older men. It is estimated that half of all men between 40 and 70 years of age will experience this at least once. “Viagra, cialis and levitra are the three tablet medications for this,” Hicks says. Other treatments include Viridal, Muse and Caverject.

“Guys seem to like (Viagra, cialis and levitra). They seem to believe in those. Vacuum pumps and injections into the penis are alternatives, though not particularly nice alternatives. They are still used but I haven't seen a guy treated that way in the last 10 years,” Hicks adds. Viagra, he suggests, “is still being prescribed and is still very popular among men.”

The prostate has also been a source of consternation. Prostate cancer is Britain's most common cancer among men and the second highest killer, after lung cancer, with around 35,000 people a year diagnosed with it. The mortality rate stands at around 12,000. “A lot of men with prostate enlargemnent are treated with saw palmetto which is very popular here. There is also tamsulosin which is a daily tablet and effective,” Hicks remarks. Prostacet, a powerful natural supplement designed to keep the prostate healthy,

contains saw palmetto extract and is another effective treatment of choice. Tamsulosin is, according to Hicks, “the most popular treatment” partly because it is now available over the counter. Flomax, used to improve urination in men with benign prostatic hyperplasia, is the brand name pharmacists should look out for.

Similarly, pregnancy is not a peripheral issue. Figures released in February confirmed that the UK still had the highest teenage pregnancy rate in Europe, with some 40,000 underage girls falling pregnant in 2008. Hicks touches on the treatments available. “Folic acid supplements are popular. Women take these for the first three months of pregnancy and vitamin D is used by pregnant women and breast-feeding women in tablets and capsules,” he says. “Pregnacare is a very popular product and Boots do a good range of treatments.”

As for pain during intercourse, Hicks observes the importance of identifying “what is causing the pain. Sometimes it turns out that there's an infection affecting her tubes or a woman is not libricating there.” He proposes KY Jelly and Yes, a range of organic lubricants “which are pretty good treatments for lubrication.” Sexual health continues to immerse pharmacy with problems and treatments in equal measure.

Pain management - a real pain!

Pain can be, well, a real pain to manage if you don't know where to start but PB Young Pharmacist of the Year Pupinder Singh Ghatora surveys the most common complaints and the best products on the market to guide community pharmacists...

Pain is one of the commonest complaints we come across in community pharmacy. The conditions I have come across have varied dramatically, from simple tension headaches to broken limbs (obviously referred to A&E immediately). In this article I want to try and cover the most common pain-related ailments we as community pharmacists are likely to come across, and then how best to treat them.
The pain relief market in Europe is worth in excess of $60 billion. In the UK it is thought to be worth at present in excess of £700 million. This is a market that is not difficult to make the most of. Common ailments we come across in pharmacy are:
Headaches
Sports Injuries
Muscle related pain
Back pain

There are many different types of headaches; one of the most common is the tension headache. Telltale signs are a headache that feels like a band across the forehead. Common causes are the stresses and trials and tribulations of everyday life. Treatments can vary from systemic analgesics containing paracetamol, ibuprofen, aspirin and in combination with the three mentioned, codeine. There are now also many topical preparations and these rely on the cooling sensation to relieve pain.
Whenever I am recommending any treatment for any type of pain I always try to gauge the severity of discomfort by using a number scale: 0 – Mild pain. 5- Moderate pain. 10 – Unbearable pain.
I think patients find it much easier to quantify their pain rather than being asked to describe it. The severity of pain usually determines the type of treatment I recommend. If the pain is not too severe I recommend a paracetamol only based product.
These range from generic products through to the Panadol range. If the headache is more severe, then the treatment takes a step up, in most cases to an Ibuprofen-based product. Ibuprofen is also thought to have a mild muscle relaxant effect and this can be helpful in tension headaches as the pain is often caused by muscular tension. If the headache is causing sever discomfort the treatment is stepped up again to a codeine containing product.
For example, Co-codamol, Nurofen, plus or one of my favourite recommendations Propain or Propain Plus, these both contain paracetamol, codeine and also diphenydramine – a drowsy antihistamine. The combination of these products provide very effective analgesia and also relax the muscles and therefore also help to reduce the severity of pain associated with a tension headache.
Migraines are also another common ailment we come across in my store. Before sumatriptan was switched from POM to P, I used to recommend Nurofen Migraine Relief for moderate migraine symptoms. If however, the pain was more severe, the treatment would consist of a codeine containing product such as Nurofen Plus or Paramol. Now that Imigran Relief is available, this is my primary recommendation for migraine.
It is important to ensure the diagnosis is correct and the headache is definitely a migraine before recommending any products. Nausea is a common symptom that is felt before full blown migraine pain occurs. In this instance the Migraleve range of products are useful as the pink tablet contains paracetamol, codeine and buclizine. The buclizine acts an anti-emetic in combination with paracetamol and codeine and this is quite an effective treatment. It is important when recommending Imigran Recovey that the Glaxo-supplied questionnaire is completed prior to sale to ensure the treatment is suitable for the patient.
There are now also topical preparations available to help in the treatment of headaches. These consist of the 4head range, Kool ‘n’ Soothe and Migrain Ice. They all work using the same principle; cooling the area which can help block pain signals caused by tension headaches and relax the muscles in the head. After applying any of the listed treatments the patient feels a soothing, cooling and tingling sensation. A clinical trial with tension headache found that sufferers confirmed that after applying 4head they could feel the effects of its powerful natural painkiller, pure levomenthol (peppermint), getting to work in just two minutes. I normally recommend these products as link sales with systemic analgesics and so far have had very good feedback from my patients.

Sports injuries are becoming more and more common now since more and more people are working out and perhaps not preparing themselves before carrying out strenuous exercise. Here is where the R.I.C.E acronym comes into effect;
R – Resting the injury
I – Ice reduces swelling
C- Compression again reduces swelling
E – Elevation to reduce inflammation

These are good steps to follow if someone has a muscular injury. Ice and compression are very effective soon after the injury has occurred as it reduces the duration of the inflammatory cycle. The normal healing time for a muscular sprain or strain is normally six weeks for 100% recovery. However, 70-80% healing can take place up to four weeks after.
There is a huge range of treatments available for the treatment of these types of injuries. They include systemic NSAIDs which will reduce pain and also inflammation and hence decrease healing time. These are used when the injury is quite severe, otherwise a topical NSAID will usually suffice, one of the latest being Voltarol gel, a topical diclofenac preparation.
I normally recommend a warming product to use after two weeks of the injury as this often helps to loosen up the muscles and reduce the chance of stiffness occurring as a result of the injury. Perskindol has come up with a novel way of treating minor muscle injuries – the gel actually cools the site of injury initially and therefore reduces the inflammation and then after 10 to 15 minutes it has a warming effect. We have had many positive responses to this product in my pharmacy.
There are also various support and bandages that will give support and compression to the injury site and these vary from the basic Tubigrip products to the more specialised Neoprene-based products which give extra support and warmth to an injury – these are especially useful for athletes who require that extra support.
One of the most common ailments we are asked about is period cramps. These are treated by anti-inflammatories such as Feminax Ultra (Naproxen) or Ibuprofen-based products. In severe cases I may also recommend products that also contain codeine. The NSAIDs, as well as treating pain, also have a muscle relaxant effect and hence are of great benefit in the cramping associated with the menstrual cycle.
A hot water bottle or heat patch such as the Cura-heat period patches are often recommended as a link sale by my staff and are proving to be quite popular. TENS machines have also proved their effectiveness in our business as we now have regular patients buying new electrodes for their machines which were originally sold to them to help period cramps. If pharmacy treatment still does not help, I recommend the patient see their GP who will often put them on a contraceptive pill. This often helps to reduce period pain.
There are also symptoms that should trigger referral straight away, these being: consistently irregular periods, bleeding in between periods, bleeding that become heavier than the previous period and also pain during intercourse. These may indicate the presence of fibroids in the uterus which will require further investigation and perhaps referral to a gynaecologist.
Back pain is an ailment that I am finding is becoming more and more common in my pharmacy. The most common cause is poor posture due to being hunched over a computer screen for a long period of time (yes, all of us do it!). Treatments consist of NSAIDs, both topical and systemic.
One of the newest on the market is Voltarol Pain Eze – my patients who have tried this have found it to be extremely effective. We have now also found many alternative topical therapies, a favourite link sale of which is the Weleda Arnica Massage Balm. The consistency of this product means a little goes a very long way. Arnica is also thought to aid the healing process. Many of my patients find that massaging the area as well as using systemic painkillers do help in relieving most pain symptoms.
In summary it can be seen that the analgesic market is an easily accessible opportunity for community pharmacists to increase their OTC sales and further develop their businesses and, with all the recent POM to P switches in this sector, the opportunities are increasing all the time.

Cut-out quote “I think patients find it much easier to quantify their pain rather than being asked to describe it. The severity of pain usually determines the type of treatment I recommend. If the pain is not too severe I recommend a paracetamol only based product.”

Pet care explosion!

An expanding, lucrative veterinary healthcare market has given more choice to animal lovers seeking out treatments to improve and prolong the lives of their pets but the benefits are laced with hazards, writes Neil Trainis...

The concept of health maintainance is habitually linked to human well-being but an evolving animal health market and the emergence of a plethora of veterinary medicines have shunted pet care further into the limelight.
Veterinary pharmacies, specialising in providing veterinary medicines, over-the-counter products and advice to owners of animals and livestock, have come to the fore in recent times as animal lovers embrace more sophisticated methods to cure pet ailments. Dogs, cats and horses are among the most popular pets in the UK and The Daily Telegraph last year revealed that owners of those animals spend on average £270 a year on vets bills, including pills and treatment. The animal health market is worth an estimated $12 billion worldwide, according to pharmaceutical company EctoPharma.
One of the most popular veterinary medicines on the market is Frontline Spot-On flea, tick and lice treatment, manufactured by Merial and which generated the company £130 million in revenue in 2009. “It's been on the market for five years but it's been strong in pharmacy over the last three-and-a-half years. As a brand it's done very well,” said Steve Stowe, Merial's pharmacy business manager for the south.
Rajiv Shah, business development manager at Sigma, identified Frontline and Drontal, a worming medication for cats and dogs manufactured by Bayer, as the “core products” in animal health. “Everything else should be built around those. Frontline is a bigger seller than Nicorette. It's a very powerful brand and generates a significant proportion (of Sigma's revenue),” he said. “Flea sprays also sell very well. Research has shown that 5% of fleas remain on the animal and 95% spread into the environment.” Shah suggested that after Frontline, the next most popular sellers for Sigma are animal specific diet foods.
The evolution in the UK veterinary market has been startling. Stowe insisted that the sector is “very buoyant, increasing 10 to 11% every year over the past three to four years.” Pharmaceutical companies run veterinary divisions and use human drugs as a template in designing animal drugs. Pioneering new products continue to seep into the animal health market.
Onsior, a pain therapy for cats and dogs, was launched on the European market in September, targeting “osteoarthritis in dogs and acute pain in cats.” Novartis Animal Health, a branch of Novartis UK, developed the drug to expand a limited marketplace for pain management in cats. “A big benefit of Onsior is that the drug travels rapidly through the pet's bloodstream to selectively target the tissues in inflammation and pain. The drug takes affect and exits the blood quickly to reduce potential side effects,” according to Novartis. Pain alleviation is achieved while reducing potential side-effects in the gastrointestinal tract and kidneys.
Late last year Pfizer UK promoted Trocoxil, an anti-inflammatory treatment for dogs with degenerative arthritis. Palladia, a pioneering drug available on the US market designed to treat cancer and mast-cell tumours in dogs, is being trialled by referral centres ahead of its anticipated release in the UK.
A tyrosine kinase inhibitor, Palladia destroys tumour cells by cutting the blood supply to the tumour, although trials conducted by The Food and Drug Administration (FDA), the body detailed with regulating the development of new drugs in the US, found that side effects included diarrhea, a decrease or loss of appetite, weight loss, lameness and blood in the stool.
An increasing number of the 12,600 pharmacies in the UK have made the plunge into the animal health market. As competition to exploit the revenue-generating potential within the veterinary pharmaceutical industry intensifies, a greater array of pet cures have presented themselves.
In the wake of the Competition Commission's report seven years ago concluding that veterinary surgeries had an unfair advantage in selling prescription only drugs, the marketplace has swelled from £532 million two years ago to £601 million this year, according to a report in The Times last month.
Although the market for domestic pet medicines has dwindled, with owners' spending on treatments such as annual vaccinations for cats and dogs decreasing in the recession, the sphere of pet care promises to thrive long-term because the amelioration in the quality of medicines has seen animals live longer.
A study carried out by The Institute of Grocery Distribution (IGD) on behalf of The National Office of Animal Health (Noah), the body representing the UK animal medicines industry, highlighted that consumer consciousness of animal medicines has increased markedly in the last two years, sparking the acceleration in demand.
Indeed, 74 per cent of consumers are aware that animals need to be vaccinated to prevent disease, compared with 58 per cent two years ago. As public consciousness has increased, so too has the array of cures.
The cost of undergoing local veterinary treatment, however, has not come cheap. Animal lovers have been tempted away from expensive veterinary surgeries clutching their prescriptions and towards internet retail sites specialising in cheaper animal medicines.
VioVet, an internet retail site created in conjunction with a veterinary practice in Hertfordshire, “supplies pet owners with veterinary medicines at the lowest prices we can achieve.” The company supplies a range of prescription and non-prescription medicines and diets and allows customers to compare its prices with those of other outlets. Indeed, VioVet boasts that it is “substantially cheaper than a typical local vet.”
The group cites cures for pet ailments including allergies, arthritis, cancer, diabetes, asthma, worms and liver, kidney, heart and lung disease, not to mention the ageing process and behavioural problems.
Medication aimed at tackling arthritis in cats includes Cosequin, which VioVet describes as containing “a unique combination of active ingredients that support the cartilage” for £30.30. Seraquin, meanwhile, is capable of decelerating “the progression of osteoarthritis by providing building blocks to stimulate the joints” of cats and small dogs for just £11.56. By contrast dogs enduring degenerative arthritis can undergo stem cell treatment at £2,000 per session, with no guarantee of success. It is little wonder consumers have been enticed by online pet medication and food stores.
“The market is growing all the time. Now and then our vet would mention a product that would do really well on the market. They mentioned Slentrol, which is designed to get dogs to reduce their weight,” Luke Cousins, a partner at VioVet, said. ”It is a prescription medicine and quite hard to get. We sell it very occasionally at £13.32 for a 20ml bottle.”
Internet sites like VioVet provide a cheaper service but their exploits continue to erode the income of local veterinary surgeries selling the same products. Cousins rejects the suggestion that competition generated by veterinary internet retail sites such as his one is damaging to veterinary practices.
“On the one hand we are taking vets' business away from them but I don't think it affects them too much, even if they claim differently,” he suggested. There is, though, a flip-side to the healthy competition and wider consumer choices generated by the expansion of the marketplace.
Phil Sketchley, chief executive of Noah, suggested that the proliferation of internet sites selling animal diets and medicines, though largely beneficial, should not camoflauge “a few bad eggs” in the form of sites which fail to provide adequate information and sell potentially dangerous products.
“We're keen to ensure that medicines are sold safely and correctly (online) and that's particularly important for prescription only medicines,” he said. “I'm quite pleased at the way (sites) are operating. If they improve an animal's health, that's their raison d'etre, a bonus. But some websites where you search for a product and simply add to basket can create problems. Those tend to be outside the UK or outside Europe and are difficult to police.”
The Veterinary Medicines Directorate (VMD), the executive agency responsible for the safe manufacture and use of veterinary medicine in the UK, has flagged up concerns. It intends to create the statutory requirement for all internet sites selling veterinary medicines and diets to be registered with them or face closure and even legal action. Companies buying products from unregistered sites would also be accountable.
“We have concerns of internet trading of medicines. Some have done well, some have not done well. Some websites are run by people not authorised to sell or not complying with the guidelines”, said John FitzGerald, director or operations at VMD.
“We carried out a review of 150 websites and a reasonable number were doing things they shouldn't be. They got back to us and corrected that but others, five or six big websites, caused us concern.”
Of those 150 websites looked at VMD found that half of those were a cause for concern but FitzGerald insisted that part of the battle was persuading legitimate veterinary internet pharmacies and retail sites to report anything suspect.
“We need people in the industry to tell us when things are not being done properly,” he said, before adding that VMD function without any legal powers, at least for now. “We have no legal power over (the internet sites) but we write to them and ask them to comply.”
In striving to attain statutory powers, VMD has started canvassing the opinions of internet sites and that consultation process will this month result in an approach to the new coalition Government on the path towards crystalising as legislation.
Cousins, however, rejected the notion that such a register would provide a panacea for the unscrupulous exploitation of the marketplace. “There's always going to be people who don't follow the law,” he said. “The really dodgy ones aren't going to be affected because they are not following the rules anyway, so forcing more rules on them won't make any difference.”

Skincare: The best products

The booming, billion pound UK skincare industry has been swamped by endless products but Neil Trainis seeks out the wisdom of expert Dr Aamer Khan to sort out the best-selling and most effective treatments on the market.

Everyone desires clear skin since it is a sign of health as much an indicator of beauty but when it comes to choosing a suitable treatment things can quickly become blurred.
Professional advice tends to cut through the technical jargon and confusion that sometimes consumes customers, not to mention pharmacists deliberating on the most effective treatments to stock for a variety of ailments, from dry skin and skin infections to acne, psoriasis and eczema.
Dr Aamer Khan is a principle in general practice in the NHS and runs a private medical skin practice in Harley Street, London. His expertise, however, extends beyond skin cosmetics and into the domain of skin care.
The Association of the British Pharmaceutical Industry (ABPI) cited acne, eczema, skin infections and dry skin as the most common skin complaints seen by GPs in the UK. A BBC health study found that over 90% of teenagers are affected by acne, a particular specialism of Dr Khan's. Acne can be treated with retinoids, gels and antibiotics. His practice receives 30 cases a week on average but the alternative to cosmetic treatment is a labyrinthine array of medicated treatments.
“We sometimes get 10 cases a day. Premature ageing from sun damage is very common too but acne is an extremely common complaint. I would recommend alphahydroxy creams and vitamin A retinol products as the best on the market to combat this,” Dr Khan said.
“Alpha betahydroxy, salicylic acid and A retinol products address bacteria, blockages and congestion and excessive oil production. Neostrata as a brand has very good products for acne and there's a whole range of products for dry skin too. These are excellent products.
“Jan Marini products are also very effective but are stronger than over-the-counter products in hydrating the skin and combating acne. Avène is another very good product line. It is very gentle on the skin and there are products for oily skin and and dry skin. Avène is very good for soothing sensitive skin. Products containing low oils are very good and Cetaphil products are great because they work without stripping the skin of its natural oils. Products with low oils are the best products. Low oil and non-comedogenic products are good because they do not block the pores of the skin. Clearasil have a popular line of treatments too.”
There is no known cure for eczema and current treatments are designed to alleviate inflammation and itching rather than eradicate it. It is treated by corticosteroids, medications, immunomodulators, antibiotics, immunosuppressants (ciclosporin, azathioprine, methotrexate) and anti-itch drugs, sedating antihistamines such as promethazine, whose brand name is Phenergan, and diphenhydramine, whose brand name is Benadryl.
Dr Khan's knowledge of eczema is thorough. “With eczema there is a lot of dryness, so anything which hydrates the skin is good. Aqueous creams are effective and diprobase ointments are a very good hydrating produce because they retain oil in the skin,” he said.
“Anything which calms down the skin is effective too, so I would recommend anti-itch, anti-inflammatory products. Antibiotics are also effective but anything with antihistamines in them are good. You have to be careful with these but hay fever treatments are good for itchy skin because they contain antihistamines.” His choice of eczema treatments included corticosteroids such as Eurax HC cream and Eurax hydrocortisone cream because they contain crotamiton which breaks down the dead skin layer and relieves itching to calm the skin.
Skin infections broadly fall into three categories; bacterial, fungal and viral. Treatments in this area continue to flood the market. “I would advise people with skin infections to see their doctor and get a prescription,” Dr Khan suggested. “Antiseptic treatments for bacterial infections can be effective but the problem with bacterial infections is that they spread very quickly so you need to see the doctor as soon as possible.” For fungal infections he highlighted Daktarin and Lamisil and for viral infections he suggested pharmacists would be advised to stock up on antiviral creams such as Zovirax.
Psoriasis, in its numerous guises (Guttate, Plaque, Pustular, Psoriatic Arthritis and Flexural Psoriasis) remains enigmatic. Last year a report on thehealthierlife.co.uk claimed the disease affected 3% of the world's population while talkpsoriasis.com suggested that 1.2 million people in Britain are afflicted, and yet there is still no cure and no definitive cause or catalyst for the condition, although medicine largely believes its origins lie in genetics.
Statistics supplied by emedicine.com identifying western European and Scandinavian populations where psoriasis is most prevalent, with the disease less apparent among Japanese and Inuit peoples, rare among west Africans and African Americans and “nearly absent” in north American Indians, is interesting but not particularly insightful in pinning down psoriasis. Stress, excessive alcohol consumption and smoking are all thought to play a part but a person from any race is susceptible to it despite such epidemiological optimism. Chronic plaque psoriasis remains the most common type of the disease.
Pharmacists and psoriasis sufferers continue to grapple with the three main treatments available; topical, ultraviolet light and systemic. Topical solutions such as ointments and vitamin D creams include Calcipotriol (brand name Dovonex), Calcitriol (Silkis) and Tacalcitrol (Curatoderm). Tests have found that Calcipotriol and Calcitriol are equally effective but Calcipotriol appears to work better than Tacalcitrol. “Outside prescription, anything which helps with inflammation, dryness and the build-up of dead skin. Coal tar is a great treatment. It's anti-inflammatory and soothes the skin,” Dr Khan advises, before promoting the benefits of emollients such as E45 and Diprobase. “Anything with salicylic and glycolic acid can help in the treatment of psoriasis. Diprobase creams are good and Oilatum emollients are recommended.”
Systemic treatments incorporate drugs which must not be taken by pregnant women as they can harm her baby and biological drugs tackling severe psoriasis by affecting the immune system and reducing inflammation have been withdrawn from the market because of the potential health risks they pose. “Again, anything with antihistamines in them will help but the problem with systemic treatments is that they affect the liver and heart and can cause bone marrow suppression. These treatments are designed to suppress activity in the cells and can affect the central nervous system,” Dr Khan said.
He did not single out any particular systemic treatment, maintaining that only “in extreme cases” would he recommend the implementation of systemic drugs and insisted that anyone taking those must be regularly monitored for side effects. “I would say that 85% of patients need topical treatment. They need to look at their lifestyle choices. Cutting out dairy products for example, or trying to reduce stress. Managing stress can help reduce the trigger factors.”
Nonetheless, systemic treatment brands perforate the market and these include Neotigason, Neoral and Remicade, although these are treatments whose potential damage may outweigh the benefits in controlling severe psoriasis. Etanercept, whose brand name is Enbrel, affects the immune system, blocking chemicals in the body known as cytokines that produce inflammation in the body, yet it can cause serious side effects, such as heart problems, severe infections, nervous system diseases, blood problems and allergies.
Dry skin may not generate as much misery as psoriasis or eczema but it has caused a furore for some time. A UK skincare review claimed last year that the facial skincare market was worth around £673 million while women spent £32 million on eye care products in 2008 according to The Daily Mail.
“Dry skin affects more people than psoriasis. It affects older people because as you get older your skin gets drier and you get irritation and cracking. Postmenopausal women suffer from this,” said Dr Khan, who recommended Eurax cream “as this contains shea butter, an emollient, and some people go all the way down to Vaseline products which hold moisture in.”
Among the more common types of skin pain are rashes, infections, boils, blisters, ulcers, shingles and skin allergies. Dr Khan advises pharmacists stock up on flamazine for ulcers as it contains silver sulfadiazine, an antibiotic which soothes the affected area. “Ulcers need managing because they are caused by different things,” Dr Khan said, “like poor blood supply for instance.”

SPECIALS FEATURE

The year ahead for the Specials industry

The Specials market has become a key ally of community pharmacies in delivering medicine to patients. Sarwar Alam speaks to key members of the industry to find out how the Specials market is developing and how it has been effected by the recession.

Specials are always manufactured to meet the individual clinical need of a patient and in the same way that every individual is unique, the same could be said of Specials. For that reason, Development is a continuous process as we and the clinicians who prescribe Specials are always working to prepare an exact formulation that can better meet the patient need.

Alan Krol, managing director of Moorfields
Pharmaceuticals

For example, we have recently added new anti-fungals and anaesthetic eye drops to our portfolio. From a manufacturing perspective we have focused on new and improved presentations such as single-unit dose technology, which will further enable us to provide preservative-free formulations for the many patients. We have also developed pre-filled syringes for theatre use to improve clinical practice, speed and compliance. This is definitely an area where we will see more innovation
in the future.

The recession has not impacted our business, which may also be seen with other suppliers to the industry. Our market model is based on responding to essential patient need, so the purchase of a Special isn’t an optional spend and our business has continued as normal. In fact, if anything, our Specials business has grown in the last two years as the patient population has
risen.

The Specials industry will see a continued increase in demand as more prescribing clinicians want to ensure the appropriate patient treatment. Alongside this growth we all anticipate an inevitable tightening of regulation following the MHRA review of unlicensed medicines, for example, the possible provision of patient information leaflets, PILS.

Customer service is a cornerstone of our business at Moorfields Pharmaceuticals and we have invested in all areas of our service to pharmacists.

We have a dedicated specialist help desk, in particular for ophthalmic queries where we can provide advice based on our long history associated with pharmacy at Moorfields Eye Hospital. In October we launched an online resource for ophthalmic professionals, including pharmacists, giving very specialist information about diagnosis and treatment of dry eye conditions; www.dryeyesmedical.com.

Recently, we have supplemented this with a team of customer representatives who go out and visit pharmacists and clinicians to help educate about our Specials services. We have also taken measures to ensure speed and continuity of supply.

Robert Sludden,
quality and technical services manager at the Specials Laboratory

As always, there is a need to develop and deliver specials medicines as quickly as possible to ensure patient needs are met.
With this in mind, new developments at the Specials Laboratory have related to expanding our technical team to enable a rapid response to ongoing requests for new specials medicines, when the licensed product is not suitable for an individual patient.

In general the pharmaceuticalindustry tends to be less influenced by general market conditions than other industries, so the pharmaceutical industry tends to remain relatively stable during times of recession.

The Specials Laboratory is in the process of building a new on site Quality Control (QC) laboratory with the aim of bringing QC testing of raw materials and products in house during 2010. The Specials Laboratory aims to increase its product development activities and also generate more data on existing products through the new QC laboratory.

Moving into 2010 there is likely to be a continued need for specials medicines for individual patients with special clinical needs
who can’t for example, take the standard tablet version or standard strength available as a licensed product.

While the majority of specials medicines are manufactured at very small volumes and very infrequently, some specials medicines do become regular supply items and move towards a scale where, if combined with a suitable shelf life, larger scale batch manufacture becomes a reality. This in turn can then progress towards the possibility of there being sufficient demand for the medicine to make development of the product through product licensing a real option for several of the medicines currently being supplied as unlicensed specials.

We are constantly looking at ways in which we can improve the quality and efficiency of our service to ensure each product is delivered to the pharmacist and patient as rapidly as possible. We pride ourselves on providing a customer service and customer relations team that is passionate about helping pharmacists and making their job easier.

Additionally our product development team works closely with customers and is always looking at new formulations, increasing product shelf life and sourcing new products to help meet individual patient needs more effectively.

We are currently delivering well over 90 per cent of orders to our customers within 24 hours. Moving forward the plan is very much to continue what we’re doing and keep improving – invest in our people, ensure product quality and drive lead-time.

Brian Dougherty,
chairman of the Association of Commercial Specials Manufacturers (ACSM)

Recession hasn’t really affected the industry and I think that the Specials market will be one of the last things to be hit during the recession. There is still a steady growth in the market. There hasn’t been any sudden dip or tailing off since the recession hit. Our sales haven’t been effected and I don’t think they will be effected in the near future.

The Specials market is so essential because its for people with real needs its not like we’re doing stuff like cough medicine. People will always pay for medicines for children, cancer patients and that’s the majority of what we do.

We’re right in there with essential services. We are one of the few players in town who can deliver medicine within 24/48 hours. We do fast turnaround and we deal directly with patients. Certain pharmaceutical companies will be hit by recession
because they might lose on funding for projects, their contractors might not buy as much, but with us everything is used straight away by the patients.

As for the future, I think you’ll see an increase in quality in the Specials market as the MHRA get more and more involved in the work we are doing.

As for us, we always looking at new products and better ways to deliver drugs. The association itself delivers 85 per cent of commercial specials. We have invested about £17 million in new products. We always looking for better ways to deliver drugs to patients and better ways to make sure that patients always get the same thing everytime its made, which is quite difficult when you are doing one or two and not full batches of some medicine.

We’re always involved in quality assessment schemes to improve our business. Human error reduction programme is something we are a part of. We’re always improving on our facilities and recently invested £30m on new facilities. That is a total of £50 million a year on facilities and new products and development of new formulations, which is quite a lot for an industry which doesn’t really own any of those formulations. And if you compare that to to what the NHS invested
over three years – which was £42 million - then we are miles ahead.

Vyan Fenwick,
senior production pharmacist at BCM Specials

One of the major developments within the specials industry was the MHRA Interim Report, published in May 2009, outlining the ideas for reform as part of the Review of Unlicensed Medicines. The final reform will determine the direction the industry is heading in the coming year.

It is widely accepted that there is a need for standardisation within the market and we fully support the objectives of reform outlined in this Interim Report. However, as an industry, we must ensure that the major changes or developments proposed
do not compromise the ability to respond to a patient’s urgent clinical need and reduce clinical freedom, delay treatment
or create risks to patient safety.

There is likely to be increased regulation of formulations within the industry as more pharmacoepial monographs for Specials are developed.

At BCM Specials we adopt the attitude that standards should be consistently high, regardless of whether a medicine is licensed or not. BCM Specials makes no differentiation between the rigorous standards of a licensed medicine, which may be made in the hundreds of thousands, and a one off “hand made” special. In addition, BCM Specials is situated in a facility in which licensed medicines are made. This enables us draw on the expertise and learnings from this facility, and have the same exacting standards.

While the specials industry has not been directly affected by the recession, our customers are increasingly understanding
the cost of producing a special compared to licensed products, as well as recognising the safety, liability and patient benefits
associated with ordering a special from a commercial Specials manufacturer, rather than manufacturing under Exemption 10.

BCM Specials has a seventyyear history as a supplier of high quality Specials that people can trust. Our service has benefits for
our customer, as well as their patient, because it frees up time for the pharmacy team, enabling them to concentrate on providing patient services such as advising/counselling, smoking cessation clinics and undertaking Medicines Use Reviews. The breadth of our offer, which includes sterile and non-sterile products, means that we provide a single service that is simple, reliable and convenient to use.

As part of our ongoing commitment to professional good practice, we have recently relaunched our website www.bcmspecials.
co.uk, including a generic patient information leaflet, available for our customers to download. This leaflet is a first for BCM Specials and demonstrates a proactive stance and a commitment to promoting greater patient understanding of the nature of a special.

Jan Flynn,
marketing manager at Rosemont Pharmaceuticals

Rosemont’s expertise lies in oral liquid medicines, which are of particular benefit to patients who have difficulty swallowing solid medications, often older people. With an increasingly ageing population, the need for liquid medicines is continuing to grow.

Two key issues for the Specials industry are the price of Specials and the need for education about the vital role of Special medicines.

Cost is a key issue for the Specials industry and the focus of PCTs and commissioners is increasingly on medicines
expenditure. Transparency of pricing is the way forward and all Specials manufacturers should provide regularly updated
price lists, which are available on request to healthcare professionals. This will facilitate realistic cost comparisons so that informed purchasing / supply decisions can be made. This move is essential to protect the future integrity of the
Specials industry.

There needs to be more education about the vital role that Specials play in managing the conditions of some of the most vulnerable patient groups like older people and children. Specials are an essential aspect of healthcare for many patients who have medical needs which are not met by licensed medicines. This message needs to be widely communicated. Patient concerns about being prescribed an unlicensed medicine need to be addressed and appropriate reassurance given.

Rosemont is continually expanding the range of Specials offered as liquids and actively invite pharmacists to tell us which products they require in this format. We introduced 16 new liquid Specials in 2009 and will continue to introduce more in 2010.
Rosemont’s Specials are manufactured to the same exacting Good Manufacturing Practice standards as our licensed medicines. We do not crush, dissolve or suspend tablets to produce Specials and all products have full batch records and stability testing as well as fully supported shelf lives, most of which are more than nine months.

In addition to our liquid medicines, we are also committed to supporting pharmacists through educational resources. We have just introduced a new paediatric medicines leaflet to complement the recently introduced paediatric guidelines on unlicensed medicines. A new patient leaflet about swallowing difficulties and medicines management is now available. The Rosemont
website is being updated to provide easily accessible information and training for pharmacists including Case Interact - a new pharmacist interactive training programme where participants respond to sets of symptoms and play out real life case scenarios. All results are recorded and a certificate can be printed as evidence for the CPD folder.

Steve Harvey,
sales and marketing director at Martindale Pharma®

As the UK’s leading Specials supplier, Martindale Pharma® fully understand the importance of our Specials service to our customers. We continue to focus on delivering a premium service and are committed to supporting pharmacies, especially in the current economic climate.

Pharmacists and their staff can enhance the service to their community by spending time with customers to offer advice, conduct MURs and deliver other key services. Time is a valuable resource. That is why we make ordering as simple as possible, whether by phone fax or e-mail. In addition we can set up standing orders for repeat prescriptions so that our customers can be confident that their orders will be delivered when they are needed, without having to spend time reordering.

The supply of Specials is extremely competitive, as would be expected in a growth market place. We understand the many
factors driving this growth. For example an increasing elderly population, an increased need for specialist treatments for children and adherence to guidelines that seek to reduce extemporisation.

Martindale Pharma ® leads the market in responding to and driving the expectations of our customers.

We use PolarSpeed as our logistics partner to ensure that our product is delivered in a timely fashion. The majority
of our products are now delivered to our customers within 24 hours of ordering. One of the key reasons we use PolarSpeed, in addition to their reliability, is their expertise in transporting all our products at the correct temperature, whether ambient
or chilled. This means that the care and expertise we devote to manufacturing our Specials continues right to the point of delivery.

Inevitably, growth has attracted external scrutiny of the Specials market, which Martindale Pharma® welcomes. We are confident that the service we deliver is commercially competitive, ethical and constantly evolving in line with
pharmacists’ and Governmental demands.

Underlying all of the decisions we make and actions we have taken to improve our service the key driver is always to make our customers’ lives better. Moreover we are dedicated to supplying a Specials service that can help improve the life of our ultimate customer, the patient – whatever their need might be.

NEW YEAR’S RESOLUTIONS

Weight Management

Following an indulgent Christmas period, it appears that it is not only the turkey that will be stuffed this festive season. The New Year will see many people battling the bulge and trying to squeeze back into their favourite jeans as part of their New Year resolutions.

The body mass index (BMI) is used to determine if your weight is in the healthy range.
• You are in the normal range if your BMI
is between 18.5 and 25 (kg/m2).
• You are overweight if your BMI is between
25 and 30.
• You are obese if your BMI is 30 or higher.
• You are morbidly obese if your BMI is 40 or higher.

Government figures show that at least one in four men and one in three women are overweight in the UK.

The Department of Health predicts that if this trend continues, by 2010 around 6.6 million men will be obese compared to 6 million women.

Psychologically, being overweight can affect your body image and damage self-esteem. In some cases this can cause social anxiety and depression. Common physical problems include:
• Difficulties breathing
• Difficulties walking or running
• Increased sweating
• Pain in the knees and back
• Skin conditions such as acne
• Gallstones

The following medical conditions are also more common in obese people than in those of normal weight:
• High blood pressure
• High cholesterol
• Cardiovascular disease
• Type 2 diabetes
• Some types of cancer.

These conditions are often known as obesity-related diseases and are some of the most common causes of death before the age of 75. This is why obesity increases your risk of mortality.

The obesity epidemic, as the Government has called it, is costing the NHS millions every year and is resulting in an unhealthier nation. With the reduction in outdoor activity, increasingly busy work lives and access to cheap fast food, it is becoming easier for our population to become more and more obese and unhealthy.

Community pharmacists are ideally placed to help manage this problem with professional advice, medication and referral if
necessary.

The market for weight loss products and health and fitness is huge, a multi-million pound concern. There are opportunities for community pharmacies to tap into these markets and help make up the shortfall in funding by the Government for a pharmacist’s ‘bread and butter’ in dispensing and purchase profits.

A healthier lifestyle is a major part of weight reduction. Pharmacists should always advise their patients, no matter what weight loss product they may purchase, that they must also increase their physical activity and eat healthy.

For patients who have a BMI value over 28, a major step forward in community pharmacy was the availability of
Orlistat as a P medicine. Alli as it is know over the counter, has become a very popular product in our pharmacy and has enabled pharmacists to help these people lose weight and keep the weight off. Not just by taking Alli, but also healthy lifestyle advice.

The patients I have on Alli have a weekly five minute meeting with me; we do a weigh in and brief discussion about their rogress. We are in the process of producing our own weight monitoring diaries for our patients which they will purchase as part of their treatment regime. They also include tips for healthy eating and a sample exercise plan. They have been tailored to suit the patients, we asked each patient what they would like to see in the booklet and have devised it to suit.

This is just one example of the opportunities available to the pharmacists. There are numerous other weight loss products that
pharmacists can also supply, for example adios, lipobind and recently lipotrim.

The products recommended are equally as important as the input you as a pharmacist or pharmacy team give to your patient to help them achieve their goals. I have also started a referral scheme with a couple of local gyms, any patients that I am sending and who join them are given a free personal training session and I receive some commission. It is important to try and think of new and novel ways to integrate the pharmacy business with other aspects of health to benefit all parties. The
patient is happy because you are helping them achieve their health goals and you are happy as you are making a difference and also earning some well needed extra income.

Pharmacy as a profession now need to evolve and accept the fact dispensing and purchase profits will no longer pay the bills as long as the Government keeps clawing back more and more money. Pharmacists need to look at other avenues, such as smoking cessation and weight management, to better the health of the nation and show the Government that community
pharmacy should play a key role in the National Health Service (NHS).

Pupinder S Ghatora is a pharmacist from Woodland Pharmacy and was the Pharmacy Business Young Pharmacist of the Year 2008.

NEW YEAR’S RESOLUTIONS

Put out the smoke

The guilt of Christmas binging and New Year’s partying will lead to a surge of people looking to give up smoking and losing weight. Pupinder S. Ghatora looks at how community pharmacy can be at the forefront of helping people achieve their New Year’s resolutions.

New Year’s resolutions provide an opportunity for Community Pharmacists to help the population with their own personal health goals, a favourite of which is to quit smoking. Recently, some Primary Care Trusts have introduced a Patient Group Directive for smoking cessation and funding has been agreed to match that of local General Practitioners.

With smoking being such a headline issue, pharmacists would be foolish not to maximise the benefit for patients and in the process raise their profile by coming up with ‘rock solid’ methods to help patients quit smoking and stay smoke free!

As the recent drastic category M claw backs are causing serious concerns in the industry, pharmacists must look into other revenue streams to try and compensate for some of this major loss.

There are now various products available to aid quitters; however all of them would be of no use if the patient does not have the willpower to want to give up There are the following main categories of products:

• Patches
• Inhalators
• Oral dosage forms

The aim for our patients is to be smoke free within an eight week period, for some it is longer, for others shorter, but the overall result is to quit in about two months.

An abrupt withdrawal for some smokers leads to undesirable withdrawal symptoms and the temptation to light up again prevails. The reasons for the withdrawal symptoms is simply due to the increase in nicotine receptors in the brain as a result of the stimulation caused by smoking. That is why nicotine replacement therapy is a very effective tool in contributing to the quitting process. They help to reduce the cravings by gradually aiding the reduction of the ‘extra’ nicotine receptors and therefore result in a much lower risk of unpleasant withdrawal symptoms.

With the majority of patients, there are a number of factors which help gauge the level of addiction:

• How many cigarettes they smoke
• Do they need a cigarette on waking?
• Do they like the habitual acts associated with smoking?

If a patient is smoking less than five cigarettes per day, the treatment that a pharmacist should recommend is quite different
to someone who is smoking twenty to thirty a day.

Once the severity of a patient’s addiction has been established, the next step is to tailor the nicotine replacement therapy to their individual needs.

I have devised a simple questionnaire that takes no longer than a few seconds and helps to focus treatment for the patient. Below is an example of the form:

1) How many cigarettes do you smoke per day?
1-5 5-10 10-20 30+

2) Do you need a cigarette on waking?
Yes No

3) Do you like the habitual aspects of smoking, e.g. holding the cigarette?
Yes No

4) Do you like to smoke your cigarette(s) quickly (lasts a few seconds) or slowly (lasts a few minutes)?
QUICK SLOW

As you can see this is a very basic and quick form and is used as a template to build the plan for the patient.

Below is an example of a patient:
• How many cigarettes do you smoke per day?
1-5 5-10 10-20 30+

• Do you need a cigarette on waking?
Yes No

• Do you like the habitual aspects of smoking, e.g. holding the cigarette?
Yes No

• Do you like to smoke your cigarette(s) quickly (lasts a few seconds) or slowly (lasts a few minutes)?
QUICK SLOW

From the number of cigarettes, you can establish that the patient is not a heavy smoker and can therefore is a candidate for the lower strength products, e.g. Niquitin 2mg lozenges, Niquitin patches step 3, Nicorette patches step 3, Nicotinell 1mg lozenges, Nicorette microtabs, Nicorette ihalators or Niquitin minis 2mg.

If a patient needs a cigarette on waking, then perhaps a 24 hour low strength patch can be recommended, e.g. Niquitin step 3 patch. This will give the patient a prolonged low dose of nicotine or you can recommend the Nicorette inhalator, this will give the patient control over the amount of nicotine they inhale and if smoking is more of a habit for them this will be the ideal treatment. Every patient I treat has a very personal treatment regimen. Some patients may even be put on a combination of products if they smoke a large quantity of cigarettes and hence require a large dose of nicotine.

I have some patients on a high strength 24 hour patch as well as Nicorette microtabs or inhalator or another oral therapy.

It is also a very common occurrence for the therapy to change throughout the quit programme. For example, initially the patient will need a high dose of nicotine to curb their initial cravings, so a high strength patch (24 hour if a cigarette is needed on waking or 16 hour if not). This could be combined with other oral therapy: a gum formulation if the patient likes to have a surge of nicotine and a break followed by another surge. If the patient wants an almost instant dose then a Nicorette microtab
or inhalator is recommended. If the patient feels they would like a sustained dose of nicotine, then you can recommend a lozenge formulation, a new one of which is the Niquitin Mini range. These are proving very popular due to their small size and nicotine release nature.

After a couple of weeks the patient’s physiological dependence on nicotine from smoking is significantly reduced and then the
type and strength of therapy will most likely be honed again to suit the patient’s current need. For example, the patient may not feel the urge for a cigarette first thing in the morning but still requires a dose of nicotine to see them through the day. In this case, the patient can opt for a lower strength patch and perhaps even change from a 24 hour to 16 hour formulation.

The pharmacist can also look at reducing the strength of oral therapy and perhaps even the type. Maybe moving away from a preparation that gives an initial high concentration of nicotine, to something that will give a lower dose over a longer period of time, i.e. changing from a Nicorette microtab to a Niquitin mini.

The important thing in any smoking cessation plan is to constantly modify and evolve the therapy to suit the patient and also monitor the progress. There is no point in giving the patient masses of information and nicotine replacement if you are not prepared to help them through the whole quitting cycle.

Your input as a pharmacist to this patient will undoubtedly increase the chance of him or her quitting rather than leaving them to their own devices. I have many patients who have managed to quit smoking due to my input into their therapy regime and for want of a better word ‘coaching’. You will find that the majority of smokers do want to quit they just need some
guidance from their local healthcare expert, which is YOU, to help them along the way.

A community pharmacists smoking cessation service can show that they are an essential part of transforming the country’s health for the better.