As pharmacy teams brace themselves for a second wave of Covid-19 and a season of cold and flu, superintendent pharmacist Sobha Sharma Kandel offers some expert advice…
Winter is imminent and with dropping temperatures viruses are bound to be more prevalent, exacerbating health problems among the vulnerable and immunocompromised patients. This can cause serious complications, and therefore, it’s important to know the symptoms, methods to manage them and when to refer.
A healthy person can usually manage the illnesses with over-the counter medication. Colds, flu and Covid-19 are caused by different viruses. As some of their symptoms overlap, it may be hard to tell the difference. However, some key differences are shown in the following figure.
It is also possible to suffer from cold/flu and Covid-19 simultaneously, which can complicate matters. As per NHS guidelines, anyone with fever, cough, loss/change in sense of taste and/or smell has to self-isolate and request a Covid test.
The pharmacy team should advise patients with symptoms to take rest, ensure adequate hydration and take balanced nutrition. Supplements such as Vitamin C, Vitamin D and zinc can also help to boost the immune system and can be recommended.
Pharmacy teams can recommend analgesics such as paracetamol or ibuprofen to help relieve associated muscle pain and headaches, and lower temperature. Paracetamol has an analgesic (painkilling), as well as an antipyretic effect (works on the brain to bring down a fever). It is a safe drug. However, an overdose can be dangerous, and therefore, the pharmacy team should check if the patient is on any other medication that has paracetamol.
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen also inhibits prostaglandins. It has anti-inflammatory, analgesic and antipyretic activity.
The main problem with NSAIDs is their irritant effect on the gastrointestinal system. It should be taken with food and should not be taken by patients with a history of stomach ulcer, indigestion, asthma or kidney disease.
Oral or nasal decongestants reduce nasal swelling and may help ease breathing but should not be used for longer than seven days because they can aggravate congestion. They should also not be used at night as they can inhibit sleep.
Nice guideline suggests honey could be effective in reducing acute coughs except for children under 12 months of age. Other remedies include the herbal remedy pelargonium, and cough medicines containing either guaifenesin or antitussive dextromethorphan (for 12 years and above).
Lozenges, anaesthetic spray or anti-inflammatory spray can be used. Gargling with antiseptic mouth rinse or salt water (not for children) and taking warm drinks with honey can help. Severe sore throat pain and difficulty in swallowing must be referred to a GP as tonsillitis and antibiotics may be needed.
Advice for children
Ensure adequate hydration and rest. Products to recommend: A thermometer to monitor temperature, saline nasal drops or sprays for nasal congestion, analgesics like paracetamol, ibuprofen, glycerin-based cough syrups, topical rubs, and humidifier in the room.
The majority of cold and flu symptoms will clear up in four to five days. However, complete recovery from a cold or flu can take between 10-14 days. Post viral fatigue can also last a couple of weeks. Colds are much more common than flu and less severe.
Many OTC cold and cough medicines contain combinations of analgesics, decongestants and cough suppressants to relieve multiple symptoms; therefore, the pharmacy team needs to advice patients to not take any other remedies with same ingredients to prevent overdose.
Pharmacists and their staff have an essential role to play as they are the first port of call for patients. They should provide reassurance, give advice and recommend safe products and have an important function of signposting or referring patients if and when needed.
Sobha Sharma Kandel is superintendent pharmacist of Neem Tree Pharmacy in London.
This feature also appears in the print edition of Pharmacy Business/Oct 2020.
Will Pike argues how community pharmacists could help patients shift their mindset to think pharmacy first as the sector heads into a challenging winter…
Usually as we head into winter, we can all predict what our patients will be asking us about. But, just like the rest of the year has been like no other in community pharmacy, I’d expect this winter to be different too. This will present us with challenges, but also some great opportunities too.
One shift we have seen over the last seven months of Covid is that more and more people in the community are turning to their pharmacy for help, support and advice. With our doors remaining open throughout the height of the pandemic, we’ve established ourselves firmly at the heart of local healthcare – a trend I’d expect to see continue over the winter, especially now that a second wave, it seems, is upon us.
I think there’s three different types of patients who we’ll be seeing this winter coming to us for help and advice.
First, we’ll see those with a simple winter illness – for example, a common cold. For these patients our advice will be focused around self-care and home treatments. There is a wide range of products that we can recommend in the pharmacy from decongestants to combination products such as Night Nurse and nasal sprays.
This is a great opportunity to suggest the right Pharmacy Only Medicine for the patient, something they may not have considered before. But it’s not just about selling a medicine, we should also advise how the patient should keep themselves warm and well hydrated and advise them about multivitamins and supplements if we feel they may not be getting their requirements from their diet.
If they’re more vulnerable, then also checking that they have some support at home is also a good move. The NHS recommends 400iu of vitamin D over winter as deficiency in vitamin D is associated with increased autoimmunity as well as an increased susceptibility to infection.
Next up, we’ll see those who are perhaps suffering from more complex conditions including exacerbations of asthma or COPD. My advice here is to maintain great patient care by reinforcing the best inhaler technique and always recommend keeping a spare reliever inhaler in stock.
Each winter I direct patients to their GP for a rescue pack to keep in their medicine cabinet in case of severe exacerbations. I will be especially vigilant this winter as we want to keep our most vulnerable respiratory patients out of GP surgeries and the pharmacy if they get ill, so having the right tools at home for them is absolutely essential.
This in turn will help reduce hospital admissions this winter. As always we will be encouraging patients to stop smoking and offer a wide range of products in store to help people on this journey.
Then there are those who will need guiding to other services and support. We’re likely to see more of this as people perhaps avoid their GP – either through choice or necessity – and seek out some face-to-face advice. A specific challenge we’re going to face this year is around how some Covid symptoms are similar to those of the flu. Make sure all the team are aware and confident with what different symptoms mean – and keep abreast of any new developments in case new symptoms of Covid get added to the list.
Some patients may just need reassurance around what their symptoms mean, but I’d advise you know how to direct people to get tested and what self-isolation measures they should take if you suspect Covid.
It won’t have escaped anyone’s attention I’m sure the extra emphasis that the government are pushing on getting the flu jab this year. If this is something that you offer, then we must all play our part in helping achieve the levels of vaccination asked for this year.
But we must be responsible. We must explain that the flu vaccination won’t necessarily stop Covid, but it might provide a much-needed boost to the adaptive immune system and may enhance the immune response against a range of pathogens this winter.
However, given how the symptoms of flu and Covid are similar, if a patient has had the flu jab and then show flu-like symptoms, they’ll know to treat this more seriously and not shrug it off as a cold.
It’s also worth thinking about – where available – taking the time with flu jab patients to explain the benefits that a pneumococcal vaccination would also give. With such an emphasis on the flu jab, it’s easy for patients to not even think that there might be something else that can help them stay healthy over the winter.
So, while we may expect to be busier this winter, our core focus is the same – helping patients with their immediate medication needs, but also providing advice as a trusted healthcare professional on how they can prevent themselves from falling foul to winter illnesses in the first place.
And this winter, with the threat of a second wave of Covid seemingly never far away, we have a unique opportunity to encourage patients keep their medicine cabinets stocked up with common OTC products such as loperamide, decongestants, pain killers and linctus so they’re ready to fight whatever winter throws at them even if they have to self-isolate.
And finally, I’d recommend that you reassure your patients that their pharmacist is only a phone call away for advice, particularly if they should need to self-isolate. This is how we’ll help patients shift their mindset to think pharmacy first.
Will Pike is a pharmacist at a Well pharmacy branch in Wonford, Devon.
This feature also appears in the print edition of Pharmacy Business/Oct 2020.
Do you know what the definition of insanity is? Repeating the same action over and over again and expecting a different result. That is what I felt like when I read the article heading “England rationing remdesivir for the most sickest patients”. That England was just repeating the same mistakes that politicians have been making for the past 6 months.
It is like spinning the slots again and again at SlotoCash Casino sure that the next spin will bring the mega jackpot. If our governments (all over the world) don’t stop, go back to the beginning, and relook at the data, they are going to continue to make the same mistakes that they were making for the last 6 months.
History of hydroxychloroquine + zinc treatment
Since the middle of March, 2020, doctors have made observational studies that when hydroxychloroquine + zinc + antibiotics + vitamin D + vitamin C is given to patients within the first 5 days of showing symptoms, it reduces the viral load on the patient, and prevents the virus from progressing to the more critical stage.
Why do some people consider COVID-19 as two separate viruses?
The one major difference from COVID-19 and a lot of other viruses is that starting at day 6 from when symptoms first appear, the virus changes to essentially a completely different virus.
During the first phase, within the first 5 days of symptoms appearing, the virus’s symptoms appear like a lot of other flu (and bad cold viruses) fever, muscle aches, exhaustion, etc. with the exception of pains in the chest and starting to have difficulty breathing.
It is during this beginning phase that it is critical for the patient to begin treatment, because it helps to prevent the virus from progressing to the second phase. It does not cure COVID-19 (like antibiotics cure). It just prevents the virus from getting a worse. The patient is still sick, The patient still needs to quarantine. The patient still needs to rest and let the body heal itself.
But once the second phase kicks in, the patient needs to be admitted to the hospital, go to an ICU unit, and if things get even worse, be put on a respirator.
That is why the “reserving treatment for the sickest patients” is the exact opposite of what doctors should be doing. I am not talking about hoarding or the “just in case” people. I am talking about the ones who show symptoms and within the first 5 days of the illness (especially the symptom of having trouble breathing).
Have any double blind clinical trials been completed?
Yes, a clincial trial “to evaluate the efficacy of hydroxychloroquine (HCQ) in reducing progression of Corona Virus Disease 2019 (COVID – 19) and achieving viral clearance” in military personnnel. The clinical trial was conducted at Pak Emirates Military Hospital Rawalpindi, Pakistan. The results of this clinical trial are in.
Both the control group and the test group were given a standard treatment of “daily standard doses of oral Vit C (2g), Vit D (alfacalcidiol 1µg), Zinc (50mg) and paracetamol (as required).”
Standard treatment was “Standard of care (SOC) treatment comprised of daily oral Vit C (2gms), oral Zinc (50mg), oral Vit-D (alfacalcidol 1ug) and tablet Paracetamol (for body aches/fever), intravenous fluids, hemodynamic monitoring, and laboratory testing for SARS-CoV-2 and baseline blood parameters”
Experimental treatment was given standard treatment plus “Patients selected in intervention arm were given HCQ in addition to standard of care treatment. After 12 hours of randomization, HCQ was given. A standard dose of HCQ was 400 mg by mouth twice a day for day one followed by 200 mg 12 hourly for the next 5 days.”
Phase 1 checked for “After the start of treatment, development of fever > 101 F for > 72 hours, shortness of breath by minimal exertion (10-Step walk test), derangement of basic lab parameters (ALC < 1000 or raised CRP) or appearance of infiltrates on CXR during the course of treatment was labeled as progression irrespective of PCR status” (Day 5 check).
Phase 2 checked “PCR negativity on day 7 and 14 after admission”.
What were the test results for the hydroxychloroquine clinical trial completed on August 21, 2020, in Pakistan?
There were 540 patients being observed between the ages of 18 to 65, the group many people are saying should NOT be in lockdown, because they are not a high risk if they get the virus. All of the participants were hospital admittance, but with mild symptoms. They had not yet progressed to moderate, severe or critical patients. They also did not have comorbidity with a life expectancy of less than 6 months.
180 were in the control group 360 were in the experimental group. 4 in the control group and 1 in the intervention group developed a fever for greater than 3 days (became worse, so they had to be moved to other treatments).
After 5 days, number of patients with progression: “After start of treatment, development of fever > 101 F for > 72 hours, shortness of breath by minimal exertion (10-Step walk test), derangement of basic lab parameters (ALC < 1000 or raised CRP) or appearance of infiltrates on CXR during the course of treatment was labeled as progression irrespective of PCR status”
In the control group, 5 patients progressed in the severity of the virus. (3.3%)
In the experimental group, 11 patients progressed in the severity of the virus. (3.2%)
Viral clearance after 14 days has not yet been reported.
Since it does not say what percentage of the 100% non-treatment group progressed to becoming worse, it is hard for the lay person to fully understand this.
But from what I can read, treatment of “daily oral Vit C (2gms), oral Zinc (50mg), oral Vit-D (alfacalcidol 1ug) and tablet Paracetamol (for body aches/fever), intravenous fluids” seems to have an impact for a majority of patients between 18 and 60 who are sick enough to need to go to the hospital, but are still early on, do not have other conditions (expected to die within 6 months). Except for the intravenous fluids, everything else a patient can take over the counter, and obtain from any drug store.
Which is good, because the less patients that end up in the hospital, the less our hosptials will be overwhelmed and more space, resources, and specialized drugs can be reserved for the more severe patients.
What are the results for the other three recent clinical trials for HCQ plus zinc?
There have been 3 other clinical trials that have been completed recently, but the results have not yet been posted.
Migrant workers in a high risk group
This test was designed to test for prevention of COVID-19 in an environment where high risk people are living in close quarters. This could be a college dorm or a nursing home.
The study was completed on September 14, 2020, but the results have not yet been posted. Hopefully, the results will be posted online by the end of October.
How can I find our about more clinical trials being conducted for COVID-19?
All formal clinical trials are listed on the website https://clinicaltrials.gov/
Just type in COVID-19 for the disease being searched and then in the other field, just type in whatever drugs or other criteria you want to search. When the search results come up, you can then refine the search results by location or if the study is still admitting patients or completed or withdrawn.
Even if it turns out that HCQ does nothing, what these clinical trials do show is that “standard treatment” is working, and if it is started even earlier, in a non-hospital setting, it would help even more.
All of those items are over the counter and available in any drug store.
But the zinc and vitamin C is at much higher dosage than the daily recommended amount, and vitamin C is usually not included in a regular daily multivitamin.
So although most of these items are available over the counter, they are not usually taken at the levels needed through regular diet or even a regular multi-vitamin supplement.
Lung health expert Dr Alison Cook commends community pharmacy teams for providing a ‘lifeline’ for people living with various lung conditions…
For too long, people with lung conditions have seen a lack of progress in their treatment, diagnosis, and care. We know that one in five people will develop a lung condition in their lifetime, but respiratory disease continues to be an area where things are not improving fast enough to support the millions of people who need help.
In fact, every year, lung conditions account for 700,000 hospital admissions, and outcomes for lung disease have not improved in over a decade.
This is where community pharmacy comes in.
More than 1.6 million people visit a community pharmacy each day, and our local chemists can offer a wide range of services for people with lung disease. From ordering and collecting prescriptions to flu vaccinations, stop smoking services and inhaler technique checks, the potential of our local pharmacists to support people living with lung disease has never been clearer.
When the Taskforce for Lung Health-a collaboration of more than 30 different respiratory bodies, patients, charities and organisations looking to improve lung health in England – surveyed over 2,000 people with lung conditions on how they use their local pharmacies, we discovered that 95 per cent of people living with lung disease who use community pharmacies found the services they accessed valuable and essential, or something they ‘could not live without’.
This, alongside our wider findings, highlights just how much untapped potential our local pharmacies hold.
People with lung conditions taking part in the Taskforce survey reflected on the fact that community pharmacy is often much easier to access than other forms of routine care.
According to our survey, three quarters (75 per cent) of people with lung disease who use community pharmacies value their services because they are close to home. Other reasons for valuing the service were convenient opening times (39 per cent), not requiring an appointment (48 per cent) and finding local chemists easier to access than a GP appointment (26 per cent).
But despite the strong understanding of the vital role pharmacies could play in their care, our survey found that people with lung conditions who use community pharmacies were unaware of, or not using crucial services which have the potential to drastically improve their wellbeing.
According to our findings, one in four people (23 per cent) were not aware of the full range of services available in community pharmacies. To ease the pressures faced by the NHS in the pandemic and beyond, it is important to raise awareness of the variety of services community pharmacies offer, encourage more people with lung conditions to make better use of community pharmacy services overall, and expand the range the range of services offered.
For example, inhaler technique checks are a crucial part of basic care for people with lung disease but are often missed or not carried out properly. Poor inhaler technique or incorrect use of inhalers can potentially risk life-threatening exacerbations or asthma attacks.
With nearly half (48 per cent) not using this service, and a quarter of those not using it saying they were unaware it was available, we think that there is a real opportunity to make this service more accessible and improve its uptake among people with lung disease.
Flu jabs are another vital service which community pharmacies offer. However, only one in four respondents (23 per cent) used the service. This suggests that increased uptake of the flu jab in local pharmacies could alleviate winter pressures on hospitals and the NHS as a whole.
Perhaps unsurprisingly, our survey also showed that the pandemic has meant that more than a third of people with lung conditions (37 per cent), began to use pharmacies less than before, due to anxieties about catching the virus.
However, despite this, the majority of respondents stated that they would feel safer using the services if they believed the appropriate measures (e.g. social distancing), had been put in place.
Confidence in the safety of local pharmacies needs to be restored among users with lung conditions in the coming months, to ensure that they continue to play a crucial role in supporting people with lung disease.
People with lung conditions recognize the importance of community pharmacy as a lifeline for their care, but there is clearly still work to do in making the wide variety of services available known to everyone.
Whether it’s flu jabs or inhaler technique checks, the level of untapped resource available at our fingertips to support people with lung conditions and the NHS has never been clearer.
By far the most important change we need to see is an investment into integrating our pharmacies into NHS care pathways. Our local pharmacies play an important role in protecting people with lung conditions, and there are endless benefits to creating a more integrated system of care where people with lung conditions are made aware of, and feel encouraged to access vital services at their local pharmacy.
We have already seen the monumental impact local pharmacies can have with their crucial role in the Covid-19 vaccination effort-it is now vital that everyone is made aware of the wide variety of services pharmacies offer, and that further integration of local pharmacies into the NHS becomes a priority. This would not only better meet the needs of people with lung disease, but also reduce the pressures faced by the NHS during the pandemic and for years to come.
Dr Alison Cook is chair of the Taskforce for Lung Health.
With summer approaching, allergy expert Max Wiseberg says community pharmacists can help patients understand the essential difference between symptoms of hay fever and Covid-19…
A bout 15 to 30 per cent of the UK population suffers from hay fever and there has been a definite increase in the number of moderate to severe hay fever sufferers, with sufferers experiencing more frequent and longer seasons.
And now that the government has announced its plans for the easing of lockdown, community pharmacists can expect to see many more of their patients presenting with more severe symptoms than usual, as there will be more opportunities to spend time outside and be exposed to higher levels of pollen.
Common symptoms include sneezing, a runny stuffed up nose, itchy, watery eyes, nasal congestion and a general stuffed up feeling in the nose and throat.
Some experience itching around the face and mouth, with an itchy palette, and burning sensation in the throat. Headaches and wheezing can also occur, as well as an overall achy feeling, or build-up of pressure in the facial area. The sinus area can become painful and constant nose blowing can leave sufferers with skin irritation. This can lead to tiredness and affect sleep, which in turn reduces energy.
The symptoms of hay fever are easily confused with those of Covid-19, so I have produced a table to help community pharmacists and their patients understand the difference.
Several different groups of medicine have been developed for treating allergies. The common ones are:
Patients with hay fever tend to sneeze a lot and so run an increased risk of infecting others through spreading airborne droplets. Alert patients to The Department for Health’s advice on keeping homes ventilated, as letting fresh air in can reduce the risk of infection from coronavirus by over 70%.
It’s important to make patients aware of the fact that many people are spending more time indoors with increased ventilation which could mean an increased exposure to pollen. And this in turn will result in more hay fever sufferers rubbing itchy eyes and blowing noses using hands that might have come in contact with coronavirus. And this could potentially increase their risk of becoming infected.
My calendar explains the causes of hay fever and other airborne allergies at specific times of year…
January – Alder and hazel pollen
February – Start of the peak of alder and hazel tree pollen. Start of elm and willow pollen.
March – Start of early season hay fever, and of birch pollen. Also alder, hazel, elm, willow tree pollen around. Start of ash, oak and oil seed rape pollen and peak of elm and willow season.
April – Alder, hazel, elm, willow, birch, ash, oak, oil seed rape tree pollen. Peak of birch and ash pollen season.
May – Start of main grass and weed pollen seasons – with willow, birch, ash, oak and oil seed rape also present. Peak season for oak and oil seed rape.
June – Peak of grass pollen season, with birch, ash, oak, oil seed rape, grass and weed pollen.
July – Peak of grass and weed pollens.
August – End of grass and weed pollen season.
September – Peak of fungal spores.
October – end of fungal spores peak.
November – Indoor allergies prevalent because of more time spent indoors, e.g. dust, mold and pet.
December – Same as November, but also including Christmas Tree Syndrome.
Max Wiseberg is an airborne allergens expert and creator of the HayMax allergen barrier balm.
Cathy Crossthwaite and Mathew Peters pass their expertise on to community pharmacy teams in helping patients suffering from symptoms of seasonal hay fever and allergies…
Approximately a fifth of the UK population suffers from hay fever, an allergic reaction to pollen from grasses, trees, weeds and plants coming into contact with the mouth, nose, eyes and throat. Symptoms vary from one person to the next and include sneezing, a runny nose, itchy eyes and headaches.
There is no cure for hay fever and you can’t prevent it, so it is a case of managing the symptoms as best as you can. It is important to treat hay fever promptly as it can significantly affect a person’s quality of life.
To get the maximum relief and benefit from hay fever remedies, they should be used daily during the hay fever season which is usually between late March and September when the pollen count is at its highest.
The treatment choice should target the specific symptoms affecting the individual and if experiencing more than one symptom you can combine some remedies to attack the reaction from all angles. The choice of treatment is often based on the individuals’ preference and it is important to take this into consideration before recommending a remedy.
Keeping it at bay
The best hay fever remedy is dependent on the customers’ symptoms. For most, simply taking an over the counter antihistamine tablet daily (e.g. cetirizine/loratadine) will keep their symptoms at bay.
When advising patients on which tablet to take, it’s important to consider the risk of recommending sedating antihistamines, as these may make the patient become sleepy, affecting their ability to drive as well as their working and academic ability.
For some, the more sedating antihistamines will be the only ones that will work but for others these may be avoidable. Long acting, less-sedating oral antihistamines are recommended for regular use.
Those patients with symptoms of itchy and watering of the eyes, and puffiness of the eyelids are typically suffering from allergic conjunctivitis, caused by exposure to an allergen. If they are affected by this seasonally, then it’s part of their hay fever.
As the pollen lands on the surface of the eye, it causes a reaction underneath the eyelids, resulting in slight redness, swelling and sometimes bumpiness of the eyelids. These signs along with the time of year help distinguish allergic conjunctivitis from bacterial conjunctivitis and these symptoms can be treated with eye drops such as sodium cromoglicate.
For others however, where a blocked nose is a problem, a steroid nasal spray may be needed to help further control the symptoms of hay fever. It’s best to recommend patients start using a nasal treatment before the season starts, so a few weeks prior to getting any symptoms and to use it every day.
There has recently been a general move towards natural remedies across various categories as consumers become more conscious about the ingredients within a wide range of health and beauty products.
Hay fever is no exception to this with the introduction of several drug-free nasal hygiene sprays designed to help reduce congestion and ease irritation introduced. They do this by diffusing the allergens already inside the nose, form a micro-gel barrier to prevent further allergens from infecting the mucosa and stimulate the clearance of the allergens from the nose by sticking to the gel which is then removed when blowing the nose.
Nasal sprays such as this can be used in conjunction with other hay fever treatments such as antihistamines. Another natural remedy to be considered is a nasal rinse using a normal saline solution, which wash away the allergens from the nose. These can be used as frequently as required and also alongside prescribed or over the counter medications.
For first time or new sufferers, it can take a few attempts to find the remedy that best suits their symptoms. There are a variety of active ingredients for customers to try within a number of formats.
Trial and error
It’s usually a ‘trial and error’ process for customers to know what works for them. Therefore, it’s essential to have a variety within the pharmacy and support customers on their journey to finding the right treatment.
Patients may not be aware which products they can and can’t use alongside each other. Pharmacy is in a great position to offer this advice to customers to help ease symptoms quicker or more effectively.
This also puts pharmacies at an advantage to other retailers such as supermarkets as they may not have the right knowledge to guide customers in cross product usage.
Much of the support provided to allergy and hay fever sufferers is through offering practical tips around living with these irritations, such as cleaning the home and body regularly, particularly following contact with triggers.
Other useful tips include not drying your clothes outside as they can catch pollen, don’t keep fresh flowers in the house and wear wraparound sunglasses when outside to stop pollen getting into your eyes.
Additionally, during high pollen count season people suffering with hay fever should shower and wash their hair when arriving home and change their clothes, as one of the only ways to get rid of pollen is to get it wet.
It’s also best to keep windows closed when indoors, especially in the early mornings when pollen is being released, and in the evening when the air cools and pollen that has been released into the air is falling back to ground level. This advice helps customers manage their symptoms whilst on the journey to finding the right treatment that works for them.
Since the rise of coronavirus, it is also important to help patients differentiate between symptoms of the virus and those of hay fever. Common symptoms shared by both are coughing and the onset of a new cough. Hay fever can cause irritation in the back of the throat and cause you to develop a cough or feel tight-chested. The seasonal nature of hay fever can also bring a persistent cough on quickly.
A runny nose, sneezing and itchy eyes are hay fever symptoms that are not usually associated with coronavirus. A fever with a body temperature above 37.8 degrees centigrade is not a symptom of hay fever as it does not cause a rise in body temperature, so patients suffering with this should take the recommended Covid-19 precautions and self-isolate.
Cathy Crossthwaite is OTC business development executive and Mathew Peters is services development pharmacist at Numark.
Jack Birchall explains how a team of pharmacists carried out remote reviews for patients living with long-term conditions such as asthma and COPD…
There is no doubt that the pandemic has changed the way healthcare professionals work within the primary care setting. The advent of Covid-19 meant that we all had to rapidly modify the way we supported and met the needs of patients, some of whom saw the services they usually took for granted, virtually cease overnight.
There are around 15 million people in England living with long-term health conditions including asthma. These people have the greatest healthcare needs of the whole population with 50 per cent of all GP appointments and 70 per cent of all bed days taken by this cohort of patients, and their treatment and care absorbing 70 per cent of acute and primary care budgets in England.
This situation isn’t going to improve any time soon. In the past, most people had a single condition, today multi-morbidity is becoming the norm. At the start of the pandemic, the Royal College of General Practice and British Medical Association issued guidance to practices on prioritising workload. This included the importance of maintaining long-term condition reviews in asthma, COPD and diabetes, along with appropriate transition of at-risk warfarin patients. These reviews were deemed as essential workstreams for patients considered to be at high risk.
Traditionally, the unique skills set of a pharmacist has meant that we have played a major role in supporting these patients. I work with a team of over 90 clinical pharmacists who, in partnership with individual practices, PCNs, CCGs and STPs, help with the long-term management of people with chronic conditions. But the onset of Covid-19 meant that we now had to plug a potential gap in service provision, and quickly.
Providing support remotely is not a new concept but one that has been relatively slow on the uptake in favour of face-to-face consultations. However, Covid-19 has been a key driver for both healthcare professionals and patients alike to realise the benefits of working remotely to minimise contact between clinicians and patients and reduce risk for very vulnerable groups of patients.
During the pandemic, our remote consultations had two main aims: firstly, to improve management of long-term conditions and promote self-care; and secondly to triage potential patients who were acutely unwell.
Prior to carrying out remote reviews, our pharmacists work closely with individual general practices, PCNs or CCGs to stratify patients with a chronic condition to identify those at greatest risk. A mix of methods are then used to engage these individuals; either a letter will be sent inviting them to a telephone appointment, a pharmacist will ring a patient directly or we utilise a practice’s text messaging service to schedule an appointment. Remote consultations are then carried out predominantly via telephone.
During an asthma review our pharmacist would ensure that the patient has a Personalised Asthma Action Plan (PAAP) in place. This plan helps the patient understand how to optimise the use of their inhaler, how to alleviate symptoms and when to escalate treatment.
If a patient knows how and when to take their treatment and what to do if their symptoms deteriorate, they are much less likely to present at A&E, thereby protecting themselves and NHS staff.
We would use the review as an opportunity to direct them to healthcare literature and resources, for example, a video showing good inhaler technique. The pharmacist would also offer advice about social distancing and the latest guidance regarding Covid-19.
The disadvantage of reviewing remotely is the inability to deliver tests and diagnostics. We couldn’t perform a peak flow check or pulse oximetry for someone with asthma or COPD.
Following the review, the results are shared with a clinician in practice. The pharmacist and clinician can then jointly come to a consensus on any actions that need to be taken. These can include optimising a patient’s medication or referral for a non-pharmacological intervention, i.e. smoking cessation advice or pulmonary rehab.
The pharmacist amends the medication on behalf of the practice and the revised prescription is sent electronically to a community pharmacy. The patient would be followed up via a letter or phone call to advise them of the action that has been taken.
We have found that working entirely remotely through the pandemic has provided a number of unexpected benefits. Patients have reacted very favourably to this method of review often with better attendance rates than face-to-face consultations and many have said that they felt more confident of how to cope with symptoms and using their medication or devices.
Prior to the pandemic, we had already been introducing more remote consultations into long-term condition programmes. What we have seen due to Covid-19 is a much more rapid escalation in the pace of adoption of these.
In the future, I would anticipate that many areas of the health service, including community pharmacy, will continue to work remotely. The New Medicine Service (NMS) lends itself particularly well to this and with patients more accepting, and even welcoming the chance to consult remotely, I think it is definitely here to stay.
Pharmacist Jack Birchall is head of service development at Interface Clinical Services.
On ‘World No Tobacco Day’ (May 31), Johnson & Johnson Consumer Health and the WHO under the Access Initiative for Quitting Tobacco marked the first anniversary of their partnership supporting countries in facilitating the improvement of public health through smoking cessation.
In partnership with the World Health Organisation, Johnson & Johnson’s Nicorette brand is supporting communities with some of the highest rates of tobacco use in the world.
While 60 per cent of the 1.3 billion tobacco users globally have expressed a desire to quit, only 30 per cent have access to the support and tools necessary to help them to do so successfully.
Since the Covid-19 pandemic began, nearly one-third of smokers in the UK report smoking more-a habit linked to increased risk of severe illness.
To-date, J&J has donated $800,000 or £56, 3640 of NRT products to Jordan- where smoking contributes to 80 per cent of premature deaths.
The funds used to support thousands of front-line workers and patients with non-communicable diseases to quit smoking during the Covid-19 pandemic and beyond.
“The donation of nicotine replacement therapy (NRT) has enabled the Ministry of Health in Jordan to scale its comprehensive smoking cessation services, providing over 5,400 people with nicotine patches combined with personal counselling and digital support,” Johnson & Johnson said in an update on it efforts to support smokers to quit their habbit.
William Twomey, senior director Smoking Cessation Franchise, Johnson & Johnson Consumer Health said: “It is with the commitment and support of partners, government and other stakeholders, that we are able to work toward creating greater equity and access to NRTs in the more than 65 countries currently being served by Nicorette.”
“At Johnson & Johnson Consumer Health, we recognize that communities around the world need support to address this public health crisis, which has been exacerbated by Covid-19. This unmet need is a major driver behind the partnership with the WHO to reduce tobacco-related harm with smoking cessation initiatives and expanded access to NRTs where they are needed most.”
Vinayak Prasad, head of the No Tobacco Unit at the WHO said: “Studies show that nicotine replacement therapies like gums and patches can double your chances of quitting. The WHO welcomed the partnership with Johnson & Johnson Consumer Health to help get gums and patches into the hands of people wanting to quit to lower their risk of severe Covid-19.”
Ade Williams’ pharmacy in Bristol works with local e-cigarette outlets to educate and set up a referral pathway to support patients who want to stop smoking…
For a brief period last year, I witnessed an extraordinary phenomenon. In 2016, government figures showed that 15.5 per cent of UK adults smoke, equating to around 6.1 million in the population.
However, as the pandemic took hold in the UK and the risk of more adverse outcomes linked to smoking started to emerge, scores of people, primarily young adults, came into the pharmacy to get cessation aids. It seemed as though Covid-19 would going to deliver what all the government policies and health messages had for years failed to achieve.
The sense of vulnerability and urgency to quit was driven by fear. Sadly, like so many other Covid-19 related issues, the picture over time changed, and not for the better.
A recent poll by Mintel found that 10 per cent of all cigarette users in the UK have started smoking again after quitting due to the outbreak’s strain. The stress of the Covid crisis fuelling a mass embrace of the habit, with more than half of smokers “stress-smoking” more during the pandemic.
Worryingly, 39 per cent of smokers aged 18-34, the same people group I and many community pharmacy colleagues helped last year to pack the habit, now saying they are smoking more regularly.
Reducing the prevalence of cigarette smoking long before Covid-19 has been a primary objective for the government and all devolved administrations.
Smoking is the most significant cause of preventable deaths in England, and the health risks associated with smoking well documented. This not only puts a heavy burden on the healthcare system but also has a substantial social impact.
Its link to health inequalities is more evident because it is more prevalent amongst the most vulnerable in our society, with low educational attainment and poor socioeconomic status.
Even as smoking rates progressively reduced, these patients remained the most difficult
to reach with cessation services.
Recent years have also seen many local authorities stop providing locally commissioned
NHS stop smoking service, citing funding constraints. The postpandemic financial reckoning may yet see more strain on what is left in the coffers.
The Healthy Living pharmacy ethos community pharmacy teams, proactively supporting patients to quit and advising on the best evidence-shaped approach, deliver successful outcomes.
In Bristol, the Bedminster Pharmacy team, even after our local NHS service was decommissioned, continued to provide support. We know it increases access and offers our patients the best chance of quitting. The evidence supports this approach primarily for the ‘hard to reach’ vulnerable group.
Our team collaborates with a variety of local contacts in the community. Local midwives refer pregnant patients and their partners to us. Around one in 10 pregnant women still smoke, and locally, our prevalence is higher than the national rate.
Our own experience demonstrates the unique potential of community pharmacy to provide
healthy living interventions and behavioural change support, expertly tailored to our localities.
Skilled behavioural support with or without a combination of pharmacotherapy evidence is the most effective way to help someone quit smoking. The whole team has a role to play; colleagues are all trained stop smoking advisors and can confidently deliver a personalised service. We know patients are up to four times as likely to quit if supported by trained
Nicotine replacement therapy is an option, alongside other pharmacotherapy options, including Champix or Zyban, both prescriptions only. We can guide patients to make the choice that best suits their needs.
Nicotine replacement products come in different formulations such as patch, chewing gum, inhalator etc. It is always worth noting that patients sometimes have unfounded concerns about taking too much nicotine or becoming addicted to nicotine products.
Not using enough nicotine replacement products is the more significant risk and contributes
significantly to quit attempt failures. Driving that message across is vital.
While the consensus on the merits of pharmacies supporting patients to quit is unequivocal,
much more contentious has been the use of electronic or e-cigarettes.
Electronic or e-cigarette handheld devices allow users to inhale nicotine without producing
as many dangerous chemicals produced by smoking tobacco have become more and more popular. They are now the most effective and widely accepted smoking cessation aid.
In 2016, approximately 2.9 million people in Great Britain used e-cigarettes. They do not produce tar or carbon monoxide – two of the most poisonous substances present in tobacco smoke. Although e-cigarettes may carry a small fraction of the risk of cigarettes, the evidence of their long-term safety profile continues to develop on this with nothing of significant concern yet.
Public Health England unambiguously recommends that patients should be supported to use e-cigarettes to cut down, called the harm reduction approach or to stop smoking altogether. It lays its stall in a comprehensive review of evidence and an accompanying document highlighting the implications of this evidence for policy and practice of evidence on e-cigarettes published in early 2018. This was their fourth report to review e-cigarettes based on emerging information on the effects of long-term use.
The document: ‘Electronic cigarettes: A briefing for stop smoking services’ by the National
Centre for Smoking Cessation and Training (NCSCT) in partnership with Public Health England has been an excellent resource for our team.
I would recommend it to anyone trying to assess the research evidence and learn the best practice guidance around e-cigarette use. The smoking cessation training modules by the NCSCT likewise offer excellent resources to empower and embed best practice.
In the face of growing evidence showing that electronic cigarette can be a helpful stop smoking aid, Bedminster Pharmacy adopted the PHE-advocated harm reduction approach with its acceptance of the role of e-cigarettes to help people. I also helped Bristol commissioners design our city-wide smoking cessation pathway around this.
I know this approach offers a successful practical but safe option underpinned by emerging evidence. Bedminster pharmacy works with local e-cigarette outlets to educate and set up a local referral pathway to support patients.
There is now an ambition to make the nation smoke-free. Community pharmacy must champion and deliver this, working in partnership with other organisations. The social impact alongside the health implications of smoking is well appreciated, we are the bridge to turn the aspiration into saving lives.
Ade Williams is superintendent pharmacist at Bedminster Pharmacy in Bristol.
This article also appeared in the May issue of Pharmacy Business.