Altering dosage forms for older adults

Swallowing difficulties in older adults present challenges for medication management, particularly as polypharmacy is so common. It is also important to review the patient's swallowing difficulties and medication management regularly. The limited availability of oral liquids and other dosage forms given by alternative routes means that crushing tablets and emptying capsules is common practice. Altering dosage forms can have adverse clinical consequences. It is important to consider whether the medicines are still necessary. If the medicines are essential, find out if there are alternative formulations. Check guidelines and the product information before altering dosage forms. The legal implications of altering dosage forms can be minimised by following evidence-based practice, clearly documenting the reason for altering the medicine and obtaining written consent from the patient or their carer. Review the patient's swallowing ability and treatment regimen regularly

Pharmacist orientation to rural and remote practice: how are we doing?

Methods: Information was gathered from the four students using narrative techniques, with their journals describing both personal and professional experiences. Content Analysis was then applied to the data, using the Social Representation Theory. Students were also required to generate an orientation brochure, appropriate for a pharmacist commencing employment in a rural and remote location

Barriers and facilitators experienced by migrants and refugees when accessing pharmaceutical care: A scoping review

Background: Pharmacists in the community are often among the first health professionals encountered by new arrivals. Their accessibility and the longevity of the relationship gives pharmacy staff unique opportunities to work with migrants and refugees to meet their health needs. While the language, cultural and health literacy barriers that cause poorer health outcomes are well documented in medical literature, there is a need to validate the barriers to accessing pharmaceutical care and to identify facilitators for efficient care in the migrant/refugee patient-pharmacy staff interaction. Objective: The purpose of this scoping review was to investigate the barriers and facilitators that migrant and refugee populations experience when accessing pharmaceutical care in host countries. Methods: A comprehensive search of Medline, Emcare on Ovid, CINAHL and SCOPUS databases, guided by the PRISMA-ScR statement, was undertaken to identify the original research published in English between 1990 and December 2021. The studies were screened based on inclusion and exclusion criteria. Results: A total of 52 articles from around the world were included in this review. The studies revealed that the barriers to migrants and refugees accessing pharmaceutical care are well documented and include language, health literacy, unfamiliarity with health systems, and cultural beliefs and practises. Empirical evidence was less robust for facilitators, but suggested strategies included improvement of communication, medication review, community education and relationship building. Conclusions: While barriers experienced are known, there is a lack of evidence for facilitators for provision of pharmaceutical care to refugees and migrants and poor uptake of available tools and resources. There is a need for further research to identify facilitators that are effective in improving access to pharmaceutical care and practical for implementation by pharmacies

“Treat us as a person”: A narrative inquiry of experiences and expectations of interactions with pharmacists and pharmacy staff among people who are transgender

Background: Despite the increased visibility of transgender and gender diverse (TGD) people, little is known about their interactions with pharmacists and pharmacy staff while accessing care from the pharmacies. Objectives: The objective of this study was to explore the experiences and expectations of the TGD people regarding their interactions with pharmacists and pharmacy staff in Queensland, Australia. Methods: This study is situated in a transformative paradigm and utilized narrative inquiry to conduct semi-structured interviews with TGD participants. An interview guide based on the relevant literature and the constructs of the Theoretical Framework of Accessibility was developed. Purposive and snowball sampling was used to recruit people who identified as TGD and had previously visited pharmacies to access care. Depending on participants' preferences, interviews were conducted face-to-face or via phone or Zoom application. Interviews were recorded, transcribed, and organized in chronological stories. Data were analyzed to derive themes from the participant stories. Results: A total of 22 participants (transwomen = 11, transmen = 8, non-binary trans masculine = 3) were interviewed. Two major themes were identified, (1) Challenges of accessing care from the pharmacy and (2) Making the most of the interactions between TGD people and pharmacists. Major challenges of accessing care from pharmacies included anticipated anxiety of accessing care, healthcare system constraints, compromised privacy and confidentiality at the pharmacy, and being challenged about their gender. Many avoided interacting with pharmacists and staff or kept their interactions minimal. Participants recognized that pharmacists play a meaningful role in TGD health and provided insights about how pharmacists can improve care provision to TGD people. Conclusion: Cultural and pharmacotherapeutic education in transgender health are crucial for Australian pharmacists and staff to provide inclusive, respectful, and person-centered care to TGD people

Permeability of frog skin to chemicals: effect of penetration enhancers

Rarely do commercial chemical products contain solely the active chemical/ingredient. It is therefore important to consider whether ingredients other than the active may: 1) alter absorption of the active chemical, or 2) be absorbed themselves, resulting in systemic effects. Frogs have highly permeable skin and are routinely exposed to commercial chemical products in the environment or therapeutically. Ethanol and propylene glycol (PG), which have known penetration-enhancing effects, are commonly included in such products. The current study has therefore investigated the in vitro absorption kinetics through Rh. marina skin of three model chemicals - caffeine, benzoic acid, and ibuprofen - formulated individually as solutions containing: 1%, 10% or 30% v/v ethanol, or 20% v/v PG. Differential scanning calorimetry and histology were used to characterise fresh frog skin, investigate the mechanism of these enhancers in frog skin, and to determine whether these enhancers significantly affected skin structure. Results showed that the extent of absorption enhancement was influenced by chemical, enhancer and skin region, and that enhancement was generally not consistent for individual enhancers or skin regions. The exception was 1% v/v ethanol, which did not significantly alter flux across the skin for any of the chemicals evaluated. Caffeine absorption was not enhanced by any of the investigated penetration enhancers, and was in fact significantly reduced by 30% v/v ethanol and PG. Ethanol caused concentration-dependant changes in skin morphology and should be avoided in concentrations ≥ 10% v/v. PG, however, caused minimal changes to the skin and consistently improved absorption of benzoic acid and ibuprofen through all skin regions. Owing to the significant changes in skin structure following ≥ 10% v/v ethanol exposure, it is recommended to avoid its use in frogs. For enhancement of penetration of moderately-to-highly lipophilic chemicals, this study has identified 20% v/v PG should to be the enhancer of choice

Can models of percutaneous absorption based on in vitro data in frogs predict in vivo absorption?

The primary aim of in vitro testing of chemicals delivered via the percutaneous route is to predict the absorption that would ensue if exposure occurred in live animals. While there is mounting evidence that in vitro diffusion studies in mammalian skin can provide valid information regarding likely in vivo absorption, little is known whether such a correlation exists between in vitro diffusion testing and in vivo blood levels in amphibians. The current study used previously-reported in vitro absorption data for caffeine, benzoic acid, and ibuprofen across isolated skin from the cane toad (Rhinella marina) to produce a series of linear mixed-effect models of the absorption parameters flux and permeability coefficient (K-p). Models investigated the relative impacts of animal weight, physicochemical characteristics of the applied chemical (logP or molecular weight), and site of application. The top models were then used to predict the flux, K(p)and serum concentrations of the same three model chemicals. Finally, the absorption of these chemicals was determined in live cane toads, and results compared to the model predictions. LogP and site of application were included in all top models. In vivo absorption rates were lower than predicted for all chemicals, however, the models provided reasonable predictions of serum concentration, with factors of difference (FOD) ranging from 2.5-10.5. Ibuprofen, the chemical with the highest relative lipophilicity, had the poorest predictive performance, consistently having the highest FOD for all predictions. This report presents the first models of percutaneous absorption in an amphibian. These models provide a basic method to establish the approximate in vivo absorption of hydrophilic and moderately-lipophilic chemicals through frog skin, and could therefore be used to predict absorption when formulating such chemicals for treatment of disease in frogs, or for risk-assessments regarding chemical pollutants in frog habitats

Telmisartan Tablets Repackaged into Dose Administration Aids: Physicochemical Stability under Tropical Conditions

Dose administration aids (DAAs) are commonly used to assist patients with chronic disease to manage multiple medications and thus improve adherence. Several brands of telmisartan, commonly prescribed for hypertension, are available in Australia. Manufacturer’s storage advice is to leave tablets in the blister strip until administered to patients. This study aimed to investigate the stability of telmisartan tablets when repackaged and stored in DAAs, to identify a brand, which is sufficiently stable to be repackaged. All available brands of telmisartan tablets in Australia, which contain different excipients, were repackaged into DAAs and stored at 30 °C, 75% RH for 28 days before screening, using visual inspection and physical testing. A candidate brand was then selected for physicochemical and photostability testing using pharmacopoeial methods. Repackaged Mizart® tablets were shown to be sufficiently stable, when repackaged and stored under tropical conditions (30 °C, 75% RH) for 28 days. Several of the other brands were deemed inappropriate for repackaging, due to physical instability, highlighting the importance of considering not only the drug, but also excipients to ensure the stability of repackaged medicines. Although the repackaging of telmisartan tablets is not advised, this study provides evidence to support the Mizart® brand as an option for pharmacists to recommend for repackaging

The rural pharmacy practice landscape: challenges and motivators

Background: Health outcome delivery for rural and remote Australian communities is challenged by the maldistribution of the pharmacy workforce. High staff turnover rates, reduced pharmacist numbers, and reliance on temporary staff have placed great strain on both state health services and rural community pharmacies. However, recent changes to the demographic profile of the rural pharmacist including a lower average age and increased time spent in rural practice highlights a more positive future for the delivery of better health outcomes for rural communities. The aim of this study was to investigate the factors that motivate and challenge pharmacists' choice to practice rurally. Methods: Rural pharmacists were invited to participate in semi-structured interviews using purposive non-probability sampling. Twelve pharmacists were interviewed with early-, middle- and late-career pharmacists represented. Participants described their experiences of working and living in rural and remote locations. Three themes emerged: workforce, practice environment and social factors, which were examined to determine the underlying challenges and motivators impacting rural and remote pharmacy practice. Results: Lack of staff presented a workforce challenge, while motivators included potential for expanded scope of practice and working as part of a multidisciplinary team. While social isolation has often been presented as a challenge, an emerging theme highlighted that this may no longer be true, and that notions of "rural and remote communities as socially isolated was a stigma that needed to be stopped". Conclusion: This study highlights that despite the challenges rural pharmacists face, there is a shift happening that could deliver better health outcomes for isolated communities. However, for this to gain momentum, it is important to examine both the challenges and motivators of rural pharmacy practice to provide a platform for the development and implementation of appropriate frameworks and programs to better support the rural pharmacy workforce

Pharmacists' roles in assisted reproductive technology

Background: The global issue of infertility has prompted an increased reliance on Assisted Reproductive Technology (ART) for conception. In Australia, patients have previously accessed ART medications through specialist clinics, however recently due to modifications in ART medication subsidisation, community pharmacists now dispense and counsel patients on ART medications. Patients residing in rural and remote locations face challenges in accessing fertility clinics, which are primarily located in metropolitan and large regional cities. Objective: To investigate the perceived role, experience, confidence, and training requirements that pharmacists have in relation to providing ART medications and counselling to patients. Methods: Purposive sampling related to location of practice, pharmacist experience with ART and self-classification as an ART specialist was used to recruit 19 Australian pharmacists from rural, remote, large regional, and metropolitan areas, who participated in semi-structured interviews based on the Consolidated Framework for Implementation Research (CFIR). Interview transcriptions were transcribed, imported into NVivo, analysed using thematic analysis and mapped to CFIR domains and constructs. Results: Of the nineteen pharmacists interviewed, six were from rural and remote areas and thirteen were from metropolitan or large regional areas. Eight participants perceived themselves as specialist pharmacists in ART, all of which were in metropolitan or large regional locations. Three CFIR domains were identified as relevant for this study, which were further developed, with data mapped to eleven constructs under those domains. Emergent themes were identified that contributed to the pharmacist role including patient needs, external policies, fertility clinics, pharmacist experience and training, procuring ART, and the personal attributes of participants. Some constructs and themes differed between participants dependent on self-reported specialisation status and geographical location (e.g., self-efficacy), whereas others were consistent (e.g., knowledge and belief about the intervention). Pharmacists considered their role not to be limited to the supply and counselling of medication, but to also involve a support role for patients undergoing an emotionally difficult and sensitive journey, without guaranteed success. Conclusion: This study reveals the diverse role of Australian pharmacists in ART, influenced by location, experience, and confidence. Pharmacists have an important role to play in reducing barriers to ART access by offering fertility education, addressing concerns, providing medications and counselling, and monitoring patient well-being, improving outcomes for this cohort of patients particularly in rural and remote areas

Australian pharmacists' perceptions and practices in travel health

Worldwide, pharmacists are playing an increasing role in travel health, although legislation and funding can dictate the nature of this role, which varies from country to country. The aim of this study was to explore the current and potential future practices in travel health for pharmacists in Australia, as well as the perceived barriers, including training needs, for the provision of services. A survey was developed and participation was sought from a representative sample of Australian pharmacists, with descriptive statistics calculated to summarise the frequency of responses. A total of 255 participants, predominantly female (69%), below 50 years (75%) and registered less than 30 years completed the survey. Although over two-thirds (68%) provided travel-related advice in their current practice, the frequency of advice provision was low (less than 2 travellers per week) and limited to responding to travellers questions. Although Australian pharmacists are currently unable to administer travel vaccines and prescription only medications without prescription, they still consider travel health to be an appropriate role and that their clients would seek travel health advice from pharmacies if offered. Currently, key roles for Australian pharmacists are advising travellers who do not seek advice from other practitioners, reinforcing the advice of other health practitioners and referring travellers needing vaccinations and antimalarials. In order to expand these services, the barriers of workload, time, staffing and the need for training in travel health need to be addressed. In summary, the travel health services provided by pharmacies in Australia still have a way to go before they match the services offered by pharmacies in some other countries, however Australian pharmacist are keen to further develop their role in this area