s PPI's create multiple nutritional problems. | I2P: Information to Pharmacists - Archive
Publication Date 01/02/2010         Volume. 2 No. 1   
Information to Pharmacists


From the desk of the editor

Welcome to the February 2010 edition of i2P – Information to Pharmacists E-Magazine.

It has been extremely hot and humid in northern NSW where this publication is put together, and I can assure you that this weather has made it quite difficult to concentrate on this production.
But I have finally arrived at the transmission point, and we do have a range of interesting news and opinion items for you this month.

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Recent Comments

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Picking pockets is pretty tricky. It sure is. So who’s picking whose??

James Ellerson

After years of trying unsuccessfully to get pharmacists to use PBS OnLine the Howard government finally capitulated to the Guild’s lobbying.
In January 2007 a 40 cent per script bonus incentive payment for using PBS OnLine was introduced. Within two years the uptake went from 10% to 98%!
An incredible demonstration of how financial incentives can quickly effect change.
Originally opposing the initiative the Guild had proved its point - incentive payments get results.
PBS OnLine was locked in; Medicare Australia was happy and pharmacy owners were delighted with the extra $250 per week on the bottom line for every 625 scripts per week processed.
Pro rata, fully implemented, PBS OnLine was a $65 million initiative.

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The certainty and uncertainty of the future. Is our glass half full or half empty?

Neil Retallick

Community pharmacy enters 2010 with welcome certainty in many areas.
The announcements from the Pharmacy Guild regarding the 5th Community Pharmacy Agreement have come much earlier than many expected.
The detail in these provides community pharmacists across the country with a level of certainty about the future that allows them to plan for the F11 fiscal year with some degree of comfort.
Kos Sclavos, his team and the Government are to be congratulated on what must have been a no-nonsense approach to the negotiations.

Comments: 1

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While you were asleep

Peter Sayers

In mid-January 2009 while everyone was either asleep or on holidays, a number of headlines appeared in pharmacy media almost simultaneously.
They were:
* “New dispensing charter on the cards”,
* “Pharmacists gain e.script incentive” and
* “PSA calls for more emphasis on professional services”.

As these news items contained minimal information on these subjects it was decided to offer commentary, because of the impacts that they will have on pharmacist activity and pharmacy profitability.
On the surface, the Pharmacy Guild of Australia (PGA) seem to have given too much away to the government.
The thought is that the loss of 40c per script through PBS online next July, and no dispensing fee increase for two years is just too high a price to pay for a bit of exclusive (eRx) software.

PGA members need to be asking their executive some very hard questions before they find themselves bound up in unprofitable processes.

Comments: 2

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Visual phenomenon gives insight into mental health

Staff Writer

Researchers have new evidence that a simple eye test could help diagnose inherited mental health conditions such as bipolar disorder (manic depression). Monash University neuroscientist Dr Steven Miller led a national team of researchers to test the binocular rivalry rates of 348 sets of twins -- 128 of which were identical.

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What a good idea

Staff Writer

The Australian Medical Association (AMA) in Victoria wants extra government funding made available over the next four years so that retired doctors can be encouraged to re-enter the public hospital system to teach medical graduates wanting to specialise as surgeons, cardiologists, and obstetricians. It's the type of idea that could be paralleled in pharmacy except for the fact that professional practice has not developed or specialised to any extent. Still, it's an idea that could be worked on, retaining senior pharmacists in respectful work in a teaching and mentoring position, plus developing paid professional services at the same time.

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Apigenin and Leukemia

Staff Writer

Bioflavonoids are known to be potent antioxidants and reducers of inflammation in the body. A new study involving apigenin, commonly found in fruits and vegetables, points the way to complementing the treatment of leukemia. Some care is needed if administered concurrently with other treatments involving chemotherapy.

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Health IT Literacy - still inadequate in the world of GP's (and others)

Staff Writer

In pharmacy, we take for granted that we have an email contact address.
Not so it seems in the world of GP's where it has been found that one third of GP's do not have a practice email address.
Worse still, those that do, seem to have a high level of incorrect addresses recorded at the local hospital. GP's still seem to find comfort in faxing documents and scanning documents into clinical files wasting time and effort (also money).
In this day and age it must be possible to have a regional system for a central database of contact details for all health professionals, that is audited on a regular basis.
As we move into a world of Medisecure and eRx, how will it operate to ensure everyone will at least walk with a uniform step?
It seems unbelievable that so many health professionals (not just GP's) seem unwilling or unable to embrace basic Information Technology systems to create a reasonable level of communication.
It is little wonder that $'s billions have been wasted in developing systems to share information privately and securely, because the IT education level of most health professionals seems to be inadequate.
Is this inadequacy being addressed in prime areas such as incorporation into university courses? Something needs be done.

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Memory and Cognition Loss - a marker for stroke prediction

Staff Writer

Just when you thought there was no concern about your patchy short-term memory, along comes a study that will send your stress levels up.
And with the higher levels of stress, you obviously experience more memory loss and reduced cognition ability.
If we are to accept this study we must also accept that we are on the verge of a stroke epidemic.
What to do?
It seems that this phenomenon is directly linked to higher levels of inflammation in the body that is also linked to all the chronic lifestyle diseases - asthma, arthritis, heart disease, cancer etc that is directly related to our lifestyles, including the food we eat, the air we breathe and the water we drink.
Preventive measure include:
* drinking only filtered water
* eating a high proportion of fresh organic foods
* additionally supplement with anti-inflammatory nutraceuticals such as fish oil and resveratrol
* take regular breaks and holidays
* reduce television viewing and retire around 9pm.
Adequate sleep levels are another factor involved in memory deficits because the brain hormones that cycle from around midnight to 3am are actually involved in kick starting other hormonal cycles, including the stress hormones. Imbalances here become risk factors over time.

No wonder we have become a sick society.

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BMI needs revision for the elderly

Staff Writer

It may be timely to review the body mass index (BMI) classification for older adults as new research suggests that older overweight people are less likely to die over a 10 year period than their normal weight peers.
A statistical measurement which utilises a person's height and weight, the BMI has long been used as a formula by the World Health Organization to enable health professionals to discuss weight problems objectively with their patients.

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Intergenerational Report Underscores Need For More Professional Services in Pharmacy

Staff Writer

The Pharmaceutical Society of Australia has pointed to the importance of increasing the availability of professional services available delivered by pharmacy . The need has been underscored by the release of the Third Intergenerational Report.
Launching the report, the Treasurer Wayne Swan said the proportion of Australia’s population aged 65 and over is expected to almost double over the next 40 years. Today there are five working aged people to every person aged 65 and over but by 2050, this ratio will fall to only 2.7 people.

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Clinical Pharmacists - Who is Going to Help?

Neil Johnston

Editor’s Note:
2010 is now upon us and pharmacy begins this year ill prepared to deliver one of its past strengths – a primary health care service.
In part, this is due to a concentration of wealth and power by the Pharmacy Guild of Australia that drives a range of “top down” policies, systems and services that has driven a professional services gap between clinical pharmacists (mostly non pharmacy owners) and pharmacy proprietors, who are encouraged to pursue retail models of practice that initially create survival dollars and apparent growth. But this will eventually create a model that is extremely vulnerable when matched against the strength of major retailers. No doubt these proprietors are working for the day when Colesworth will take them over by issuing a fat cheque.

2010 also marks the official retirement year for the “baby boomer” population and marks the demographic that will eventually lead to 25% plus of Australia’s population becoming 64 plus years old.
Australian pharmacists are totally unprepared to meet the primary care needs of this senior population.
Early 2010 also records the final stages of one of the hottest summers on record and a realisation that climate change is here to stay.
The preparation of primary care service delivery designed to cater for the needs of patients affected by climate change, are not in place in community pharmacies.

They do not have active clinical pharmacists – they are too engaged with the dispensing process.

To kick start this year I looked for a media item that would best illustrate the conflict that exists between clinical pharmacists and community pharmacy owners – a tension that need not exist if commonsense would prevail and professionalism increased.

I found a recent item in Medscape that highlights the result of poor prescribing and the long-term use of proton pump inhibitors.

Clinical pharmacists could reduce the need for PPI’s, or even eliminate them.

What would be required is a working knowledge of clinical nutrition and an ability to monitor a patient at regular intervals to check progress.
Also, a fair remuneration for this service needs to be available.

The outcome from that process should be:

* a more comfortable patient…..the patient would be pleased

* a major reduction in prescription numbers for PPI’s…..the PBS would be pleased and they would have more “headroom” for new drugs to be listed.
Community pharmacies may be displeased initially at the loss of scripts, but these would be easily replaced with new drugs in different categories.

* community pharmacies would develop a loyal patient base provided a good working relationship was formed with a clinical pharmacist contractor.
Patients would be less inclined to seek warehouse type pharmacies as they begin to value the clinical service…..discounting would be diminished.

I asked Mark Coleman to comment on the news item below, and a process for a clinical pharmacist.

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PPI's create multiple nutritional problems.

Staff Writer

articles by this author...

Editing and Researching news and stories about global and local Pharmacy Issues

Over the years with a few hundred home medicines reviews under my belt, I have consistently noted the large number of proton pump inhibitors (PPI's) that have been mindlessly prescribed by doctors. Patients have been shunted into thinking that taking a PPI must now be a permanent part of their lifestyle - they are too frightened to come off treatment because they usually have "the mother of all" reflux attacks.
In a sense, they have become medical addicts.
Anyone who has gained a qualification in clinical nutrition knows that without hydrochloric acid in the stomach, proper digestion, and breakdown of proteins in particular, is not possible.
Also, the flow of food from the stomach to the duodenum is impaired when low concentrations of hydrochloric acid exist.
One PPI dose can inhibit hydrochloric acid secretion for up to 36 hours.
The consequence of this is that with impaired food flows, fermentation begins to occur as food remains too long in the stomach and that encourages overgrowth of bacteria, plus the production of acids that are not normally present in the stomach.
Peristalsis develops a faulty stop/go rhythm and food toxins are able to attack the cells of the intestinal tract, setting in place the potential for diverticulitis, polyp formation and stomach and bowel cancers.
Altered intestinal flora thrive on a range of improperly digested foods creating gas, pain and discomfort. With insufficient amino acid being the result of improper digestion, a range of mineral deficiencies begin to occur.
Minerals are unable to chelate appropriately with a specific amino acid because there is insufficient to maintain a health balance.
These "carrier" protein complexes are efficiently absorbed through the intestinal wall.
Oil soluble vitamins also need amino acids for absorption through the intestinal wall.
Vitamin B12 also is inefficiently absorbed with low stomach acid, which can lead to a range of anaemias.

Most GERD sufferers probably sought medical treatment at a time when their acid secretion was low, setting up a range of symptoms that might have been better treated with an actual supplement of hydrochloric acid (usually in the form of betaine).

It is obvious that if PPI's are to be used in any capacity, they should be used with care and only intermittently.
With one form of PPI set to rescheduled as an over-the-counter product, pharmacists may need to intervene if sales of these products indicate overuse.
A strategy designed to wean patients off their PPI's needs to be developed and appropriately supervised.
In my mind, services of this type should be remunerated in some way, because of the eventual savings for the PBS - a case for the independent paid professional services pharmacist.
The following story from Medscape provides evidence for this problem.

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Small Intestinal Bacterial Overgrowth Common Among Long-Term PPI Users

Source: Medscape


NEW YORK (Reuters Health) Jan 21 - In patients with gastroesophageal reflux disease (GERD), long-term use of proton pump inhibitors (PPI) contributes to bacterial overgrowth in the small intestine, new research from Italy shows.

Small intestinal bacterial overgrowth, in which the small bowel is colonized by large numbers of bacteria ordinarily found in the colon, produces bloating, diarrhea and other symptoms, the researchers explain.

Led by Dr. Lucio Lombardo, of the Mauriziano U.I. Hospital in Torino, the investigators used glucose hydrogen breath tests to look for small intestinal bacterial overgrowth in 450 consecutive patients enrolled in three groups:

-- 200 GERD patients treated with PPIs for a median of 36 months;

-- 200 patients with irritable bowel syndrome (IBS) who had not used PPIs for at least 3 years; and

-- 50 healthy controls who had not used PPIs for at least 10 years.

"The rationale for using IBS as 'pathologic' control stands on the large prevalence of small intestinal bacterial overgrowth in IBS patients and the overlapping of symptoms between the two clinical conditions," the authors said.

According to their article published online in Clinical Gastroenterology and Hepatology, they found small intestinal bacterial overgrowth in 50% of the PPI users with GERD, 24.5% of the IBS patients, and 6% of the healthy controls. There were significant differences in prevalence between GERD/PPI patients and the IBS patients (odds ratio = 3.14; p < 0.001), between GERD/PPI patients and controls (OR = 16.0; p < 0.001), and between IBS patients and controls (OR = 6.12; p < 0.005).

All subjects with small intestinal bacterial overgrowth were given high-dose rifaximin for 2 weeks. Treatment was successful in 87% of cases in the PPI group and in 91% of cases in the IBS group.

The authors suggest that PPI-related small intestinal bacterial overgrowth may be under-diagnosed because the symptoms overlap with those of other gastrointestinal disorders.

They point out that while the glucose hydrogen breath test only indirectly detects the condition, it's noninvasive and reproducible, whereas the current standard -- aspiration of duodenal-jejunal content for culture -- is not.

However, they add, the "gold standard for the diagnosis of small intestinal bacterial overgrowth is yet to be defined."

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