Note: OTC medicines are unscheduled, S2 and S3 Pharmacy Retail Management I
The Two Faces of a Pharmacist
• Health Professional
• Business Manager HP/Business Manager
• Require business management skills to:
o Manage inventory (medicines) o Manage staff
o Generate profit (hospital pharmacy dept. or community pharmacy)
• Good pharmacists find the balance b/t practicing as a HP & being a good business manager – managing their pharmacies ethically with a focus on patient-centered care
• Pharmacists manages pharmacies, and hospital pharmacy departments
• Normally do not work alone so need to know how to manage & interact with staff & other HPs Merchandising
• The way in which stock is presented to customers
• Incorporates:
o Pharmacy layout o Customer traffic flow
o The type & placement of products o Space allocation
o Displays o Profitability Pharmacy layout
• What goes where & why
• Substances are scheduled according to degree of control recommended to be exercised over their availability to public o TGA (SUSMP) & H(D&P) Regulation 1996
• Each schedule has a set of requirements incorporating:
o Labeling & containers o Where it can be sold o Who can supply o Where it must be stored
• S2s (Pharmacy medicine) & S3s (Pharmacist only medicine) are behind the counter medicines
• S4s: restricted or prescription-only medicines (POMPAR) o Stored further back from behind the counter
• S8s: controlled drugs (DD)
• Dispensary is located behind the counter, in the back of the store (destination category) o Draws customers through pharmacy
o Minimizes armed robbery
• Wall to create private counseling area (PSA fact cards on walls—customers can self-select health information for consumers
• Pharmacists work in dispensary Pharmacy layout & consumer perceptions
• Layout & merchandising are critical success factors for retailers
• The physical environment is judged by customers on the degree of cleanliness, lighting and noise
• Professional environment cues are: display of professional qualifications & certificates, wearing of pharmacy ID badges, providing CMI i.e. PSA’s Self-care fact cards, provision of professional services
• Big chain pharmacies tend to be more proactive in using physical & professional environment as cues to the professionalism of the pharmacy operation
• Physical layout of pharmacy can significantly affect customer’s perceptions which can have either a positive or negative effect on sales as a result
Customer Traffic Flow
• Gondolas
o Free-standing display unit for displaying stock & control customer traffic flow through pharmacy
o Shelf talkers o Shelf labels
• How are customers walking through Pharmacy controlled o Controlled by placement of gondolas
o 3 types of store layouts
NSAIDS
Use • Anti-inflammatory, analgesic, & antipyretic
• Can be used in addition to Paracetamol if symptom relief is not sufficient with Paracetamol alone
• Can be used instead of Paracetamol where an anti-inflammatory is indicated (i.e. period pain)
• Should be used at the lowest effect dose for the shortest possible time
• Only ONE NSAID can be used at a time (excluding low dose aspirin)
• Not recommended in pregnancies (Category C)
• Safe to use while breastfeeding (AVOID aspirin) Adverse
effects Cardiovascular (heart & bp), renal (kidney), gastrointestinal (stomach) Precautions Elderly (more susceptible to adverse effects
Asthma (shouldn’t be used in pts with prev. hypersensitivity rxn to any NSAID Formulations Tablets, capsule, liquids, soluble/effervescent, gels (applied topically) Anti-
inflammatory efficacy
All have equal anti-inflammatory efficacy Some pts may respond better to one NSAID Some NSAIDs marketed for specific indications Counseling • Take with food
o Reduces risk of stomach upset
• Do not take more than one anti-inflammatory medicine at a time o Low dose aspirin is ok
o Some flu & cold tablets will contain
• Can be used with Paracetamol
• For short term use only (unless prescribed by the doctor) o Reduces risk of side effects
Ibuprofen
Adult Dose (OTC – Unscheduled, S2, S3) 200-400 mg every 4-6 hours Max. 1200mg per 24 hours
Adult Dose (S4—Rx) Max. 2400 mg per 24 hours
Children > 3mo 5-10mg/kg every 4-6 hours
Max. 30mg/kg (3 doses) in 24 hours
Formulations Tablet (200 mg)
Capsule (200 mg)
Liquid (100 mg/5mL, 200 mg/5mL) Gel (topical)
Aspirin
Use Anti-inflammatory or as an anti-platelet (blood thinning) drug depending on the dose Anti-inflammatory Dose 300-900 mg every 4-6 hours (max. 4 g)
Cannot be used with other NSAIDs Anti-platelet Dose 100 mg once daily
Can be used with other NSAIDs Not to be used in children
<16yo Associated with Reye’s syndrome
There are no products formulated for children less than 16y
Cuts, Grazes & Lacerations
Cuts Grazes Lacerations
- Caused by incision in skin by sharp objects such as blades, shards of glass; also paper cuts
- Can be major injury if underlying blood vessels, nerves & muscles are damaged à refer
- Superficial injury where top layers of skin are rubbed, torn or scraped off
- Caused by sliding falls
- Risk of foreign bodies embedded in wound à increased risk of infection
- Usually painful as nerve endings exposed &
pain receptors are activated
- Often occur on thin-skinned bony areas e.g.
knees, elbows & ankles
- Irregular-shaped wound with jagged or torn edges - Often result of crushing or ripping action &
associated with soft tissue damage & bruising surrounding wound
- Depending on depth of wound, blood vessels &
nerves may be involved causing significant bleeding à if severe refer
Tx - Stop bleeding (apply pressure)
- Clean wound to minimise risk of infection
- Check for foreign bodies – do NOT remove large objects as this can lead to increased bleeding à refer - If dirt is embedded in wound, use diluted antiseptic (Povidine-Iodine or cetrimide) to assist removal and minimise risk of infection. Do not scrub. If unable to remove all the dirt à refer
- Use wound closure strips e.g. Leukostrip if needed
- Apply Solosite gel & protect wound with an island dressing e.g. Primapore or Opsite Post-op or a non- adhesive dressing held in place with tape or bandage
- Grazes often produce a lot of exudate – need to educate patient about moist wound healing &
management Skin Tears
Description Tx
- Most common in the elderly à trauma causes epidermis to separate from dermis
- risk of skin tears in elderly because:
- dermo-epidermal junction flattens out & loses stability à epidermis poorly anchored to dermis
- Aging skin has fewer sweat glands à dry skin o Loss of collagen & elastin fibres à sagging skin (not toned &
firm)
- Walls of blood vessels become thin à causes the skin to bruise & bleed more easily o Loss of body fat à less protection
- Severe à refer
- Stop bleeding & clean wound - Reposition skin flap.
- Apply wound closure strip (e.g. Leukostrip) without tension à tell patient to leave in place until falls off
- Apply hydrogel e.g. Solosite
- Apply appropriate dressing that will protect & cushion the wound. Because skin is fragile do not use adhesive tapes or adhesive dressings but use non-adherent dressing e.g. Allevyn Gentle Border or Melolin with bandages to hold in place Stitches
• Inserted by doctor to close wound
• Need to be kept dry for healing
• Dressings can be used to keep dry & prevent stitches catching on clothing
• Opsite Post-op is suitable choice Friction Blisters
Cause Pathophysiology Tx
Sustained friction of epidermis over dermis i.e. skin rubbing against heal of show
Fluid (serum) released &
collects b/t skin layers forming a bubble
Remove source of friction Do not burst blister
If movement restricted—refer Cushion & protect
i.e. allevyn thin or specialized blister dressing Burns
Description When to refer First Aid Management
Damaged to skin tissue &
underlying structures caused by heat i.e. hot liquids, flames, friction & sun dmg
Seriousness:
Size & depth Location
Age & pt general medical condition
Minor Burns:
Adult: < palm Child: < 20 cent coin Only superficial dmg Heals within 2 wks
- Burns to face, hands, feet, neck, groin or joints
- Size > an adult’s palm
- Size > area of a 20 cent coin on a child
- Large, blistered areas - White patches in the burn or painless areas
- Electrical or chemical burns - Infected burns
- People with medical conditions which may cause complications e.g. Diabetes
- Rapid effective first aid is extremely important with any burn – it will slow the burning process & prevent deeper skin damage
- Remove clothing & jewelry in burned area. Do not remove clothing adhered to the wound
- Place affected area under cool, running water for at least 20 minutes (with frequent breaks)
- Do not apply:
Ice – causes vasoconstriction & more tissue damage Butter, oils or creams – traps heat in burned area
Dressing needs to:
- Provide moist wound env’t to prevent dehydration & further dmg
- Provide protection to reduce sensitivity - Soothe wound to reduce pain (REFER TO TABLE BELOW)
Insect Bites & Stings Stinging
Insects - Ants, bees & wasps
- Inject venom using a stinger
- Venom contains proteins & chemicals to break down cells to increase penetration of venom
- People can develop allergic reactions to these chemicals in the venom including anaphylaxis (life-threatening allergic reaction which presents as airways constriction, skin & intestinal irritation, heart arrhythmias – can result in complete airways obstruction, shock & death)
- Severe allergic rxns req. epi-pens Clinical
Features - Intense, burning pain
- Erythema & oedema follow – usually subside within a few hours Biting
Insects - Those insects that feed off blood supply of humans & animals - Include mosquitoes, fleas & ticks
- Ticks – Lyme Disease
- Secrete anti-coagulant (blood-thinning) compounds to facilitate feeding - People react to these anti-coagulant compounds
- Sensitivity only occurs after repeated bites Clinical
Features - Itching papules – itch can be intense
- Weals (red, swollen mark on flesh), bulla (fluid-filled blister) & pain - Lesions often localised & grouped together
- Occur on exposed areas (also localized)
Tx - Avoid in first place – insect repellents containing DEET most effective - Anaphylactic reactions – Epipen (Adrenaline) S3
- Topical OTC
• Stingose spray (Aluminium sulphate) – efficacy? Pts like it (its an anecdotal product)
• Local anaesthetics e.g. lignocaine 1%
• Topical corticosteroids eg hydrocortisone 0.5% & 1%
• Crotamiton (Eurax)
• Oral sedating antihistamines eg dexchlorpheniramine, promethazine, to relieve itch (stops scratching) o Pts can request for non-sedation fexofenadine or less-sedating cetirizine
• Medi Quattro– combination of bufexamac (anti-inflammatory), chlorhexidine (antiseptic) & lignocaine (local anaesthetic)
o Non-steroidal have chance of contracting dermatitis Scabies
Aetiology Tx Counseling
- Causative mite: Sarcoptes scabiei (not visible to human eye)
- Highly contagious
- Caused by mite, Sarcoptes scabiei
- Often misdiagnosed as dermatitis – diagnosis confirmed by identification of burrows which is often made difficult by scratching
- Usually transmitted by direct physical contact – holding hands, hugging or sexual contact. Rarely, can be caught from bed linen because mite can survive away from human skin for 24-36 hrs at room temp.
- Female mite burrows into stratum corneum to lay eggs. Faecal pellets she leaves in burrow cause a local hypersensitivity reaction – trigger an allergic reaction causing intense itching
- Itching usually takes 15-20 days to develop in primary infestation (but can take up to 6 weeks) – person is asymptomatic before this – mite is transferred unknowingly – can still pass
- Eggs hatch & mature in 14 days – cycle begins all over again
- All contacts need to be treated at the same time Female mite faeces
Permethrin (Lyclear) cream -Tx of choice, Highest cure rate, -Resistance is rare
-Associated with minimal side effects -Suitable for adults & children > 2 months -Application: Adults & children > 12 yrs use a full tube (or > for full coverage) as a single application.
-Leave on for 8-12 hrs before washing -Generally one tube for full coverage Malathion 0.5% Aqueous Liquid (Quellada M)
Adults & children > 6 months
Leave on for 24 hours before washing off – if hands have to be washed during this time the lotion must be reapplied to these areas
Ethanol in product may cause irritation Benzyl Benzoate (Ascabiol Lotion) Listed as second line in Therapeutic Guidelines
Quite irritant – burning & irritation Dilute for use on children
May need to retreat in a week due to recently hatched mites
Itch not eradicated by treatment products & can last some weeks after mite eradicated. Options for relief of itch:
-Crotamiton (Eurax) -Antihistamines eg Sedating:
Dexchlorpheniramine (Polaramine) – help patient sleep; non-sedating:
Cetirizine (Zyrtec) also effective for itch
-Hydrocortisone cream (Dermaid) 0.5%-1%
-Clothes, towels & bed linen should be washed in very hot water to prevent reinfestation & transmission to others
-Tx products should NOT be applied after hot shower or bath – the heat increases systemic absorption of drug & reduces concentration at treatment site
- Must get secondary products
Gastrointestinal II Haemorrhoids (Piles)
Description Swollen & inflamed varicose veins inside rectum & outside anus
Veins swollen & stretched overtime—often after repeated straining on toilet ® veins lose elasticity & blood rather than flowing smoothly—collects & engorges forming balloon
When resolved; blood free flows again & reabsorbed into blood stream Classified: internal or external
High incidence in pregnant women Clinical
Features Bleeding (tears/ ruptures) Perianal itching
Mucus discharge
Pain (external hemorrhoids)—described as a dull ache which n severity when pt defecates
Refer Abdominal pain, blood in stool, fever, persistent change in bowel habit, severe pain associated with defecation
Tx Diet
- fibre—eat more fruit, vegetables, bran & whole meal bread - water intake
Bulk-forming Laxatives
- May take up to 2-3 days to relieve constipation - May take up to 6 wks to improve Sx of haemorrhoids Topical Rectal Products
- Anaesthetics i.e. lignocaine, benzocaine & cinchocaine )—temporary relief of itch & pain - Corticosteroids i.e. hydrocortisone—reduce inflammation
- Zinc oxide to soothe
- Proctosedyl Ointment/ Suppositories
Hydrocortisone & Cinchocaine; Use up to 3x a day - Rectinol Ointment/ Suppositories
Zinc oxide 200mg & Cinchocain 5mg or Cinchocaine + hydrocortisone - Hemocane Ointment: Lignocaine & zinc oxide
- Anusol Ointment/ Suppositories: zinc oxide Osmotic Laxatives
- Lactulose, macrogols (Movicol)
- Act by retaining fluid in the bowel by osmosis - SE: flatulence, abdominal pain
- Can be safely used in pregnancy & breastfeeding & have no drug interactions
Lactulose liquid:
- onset of action – 48 hrs or longer - once daily dosage for constipation Movicol:
- Powder sachets that are reconstituted with water - Indicated for chronic rather than acute constipation so tend to be recommended by GPs and gastroenterologists - Bulks stool—needs to be bulked up to trigger peristalsis - Softens stool—adding ‘retained-water’
- Triggers peristalsis—hydrating & bulking w/ Movicol - Lubricates—adds water & wet stool—less strain comfort
Stool Softeners
- Liquid paraffin (Parahoc), Docusate (Coloxyl)
- Parachoc used to treat constipation in children – works by lubricating bowel wall & softening the faecal mass – makes stool easier to pass – very good for children who ‘hold on’ (encopresis) – stool ‘slips out’
- Children’s Parachoc: dosage instructions Insert ® squeeze ® hold ® withdraw
- Coloxyl w/ Senna & Coloxyl 120mg: 2 tabs once daily after evening meal
- Coloxyl 50mg: 2-3 tabs once daily after evening meal
50mg & 120mg help to increase water content in stools & make them easier to pass
- W/ Senna Tabs (30s & 90s): delivers overnight effective relief.
Have dual action formula: soften stool so easy to pass (Docusate), and sennosides ® stimulate muscles of bowel to persistalic action
- Drops 30mL: contain Poloxamer®gentle stool softener; especially formulated for infants & young children
warnings inspired them to change their behavior
Warning used to be VERY small, now it is plain and large with visuals—the storage in stores is behind the counter behind a cupboard (can’t be shown in plain view)
Smoking location restrictions
Jan 1st 2015: illegal to smoke in premises of hospital or day therapy facility (public or private) in QLD Anyone wanting to smoke needs to move min. 5m from boundary (involves walking across the road) Expect above statistics to in future
7% b/c restrictions in public areas 4% b/c restrictions in workplaces
Tax Average Aus smoker who has 20 cigs /day spending $126/wk on habit
Large amt of this is taxes which act as deterrent to consumers & down payment on future healthcare costs
$9.31 (70%) – government tax
$1.33 (10%) – manufacturer costs
$1.46 (11%) – retailer
$0.80 (6%) – manufacturer profits
tobacco prices due to taxation; one of mst effective measures that gov’t can take to ¯ premature death & disease ® smoking
Price : ¯ cig consumption, attempts to quit & ¯ smoking prevalence, one of most effective ways to stop young people form starting to smoke as young are more price sensitive
Is it working?
• Amount of ex-smokers are growing Smoking is bad
Cancers Chronic Diseases Why
Head or neck, lung, Leukemia, stomach,
kidney, pancreas, colon, bladder, cervix Stroke, blindness, gum infection, aortic rupture, heart disease, pneumonia, hardening of arteries, chronic lung disease
& asthma, reduced fertility, hip fracture
Usually cause slow & painful death Has cosmetic effects on skin, complexion, healing & vascular health
3 clinically significant Compounds
• Hundred of compound identified in tobacco smoke; only 3 are of real clinical importance
Tar-based compounds Carbon monoxide Nicotine
Carcinogenic properties (cause cancer) Coat lungs like soot in chimney Inhale smoke kill cells in lungs
Reduces oxygen-carrying capacity of RBC
RBC have higher affinity for CO than O2 Produces dependence by activation of dopaminergic sys—hard to quit
Assess Nicotine Dependence
• Do you
o Smoke within 30 min of waking? TTFC (time to 1st cig) o Smoke at least 10 cig/day?
o Get withdrawal Sx when try to quit? Headache, shakes, etc.
• If yes to 1+ questions then you are nicotine dependent Nicotine Replacement Therapy: Evidence Base
• Numerous well-designed clinical trials showed that NRT success rate by 1.5-2x compared to placebo regardless of which NRT delivery system used—find out what they tried before & how long they used it
• Not possible to conclude if one NRT delivery system > effective than another ® comparative trials have not been conducted—
personal choice thus determining factor
• Cochrane reviews: systematic reviews of primary research—internationally recognized as highest standard in evidence-based health care; investigate effects of interventions for prevention, Tx, rehabilitation. Also assess accuracy of Dx test for given condition in specific pt group & setting
• Evidence show NRT effect in ST but at least 1/3 quitters began to smoke again after NRT
• NRT replaces cigs as smoker’s source of nicotine in order to ¯ nicotine withdrawal Sx (cravings) while smoker focus on breaking habit.
o Once achieved smoker begins to wean themselves off NRT
• Effectiveness is proportional to amt of additional support smoker receives BUT all forms NRT quit rates about 2-fold at 12 mo compared w/ placebo
Helpful Resources: eTGs, AMH, APF23, PSA Self-Care Cards: ‘smoking’, ‘NRT’ & ‘Staying a non-smoker, Rutter, P ‘ Community Pharmacy:
Sx, Dx & Tx’, quitline
Nicotine Addiction
2 main factors in terms of pharmacology
• Speed of absorption
• High plasma concentration
Situational triggers that form the psychological addiction:
• Behaviors involving: people, places, activities & moods Plasma levels of nicotine
• Lungs ® blood ® BBB ® effect on system
• Averages would go up with increased smoking (20mg/mL to 60mg/mL) Mesolimbic Pathway
• Nicotine ® enters BBB ® bind to nACh receptors ® increase in dopamine release
® relief of withdrawal Sx Nicotine Doses
• Smokers—titrate dose to feel ‘satisfied’ by changing way they smoke (i.e.
inhalation rate—deep or shallow inhalation) ® Compensatory smoking (light cigs)
• Factors influence individual nicotine requirements
• Nicotine overdosing—nausea, stomach cramps, vomiting, headache, sweating, breathing difficulties & palpitations but NOT fatal
Smoking vs. NRT
• Green line I smoking cigarette
• Withdrawal begins 2-3 hours after cigarette
• Patch shows baseline nicotine so don’t have massive cravings o Slowly releases to prevent the urge to smoke Rewarding NT
What we know
• Smokers are all different
o Like alcohol it varies in intensity o Lifelong addiction
o Heritable > 50%
• Nicotine blood levels vary
o 10-80 ng/mL (1ng=10^-6mg)
o Smokers with mental illness—60-70%
o Smokers with Schizophrenia > 80%
o Smokers titrate dose to ng
Metabolism faster or slower in pregnancy? Faster; nicotine breaks down faster thus their urge to smoke
In pregnancy, is NRT recommended in order to quit smoking? Yes, but GP needs to be involved; patch with low dose nicotine Liver enzymes
• Nicotine is metabolized by liver enzyme P450-CYP2A6
• Rates vary—genetic & racial
Fast Metabolizer Slow Metabolizer
Smoke more/ need more nicotine Smoke less
More addicted Less addicted
Don’t do well on NRT NRT usually effective
Inhale deeper—higher lvls of CO Lower levels of CO
More at risk of lung cancer