Specific product requests

Background

Many patients will present in the pharmacy requesting a specific product rather than wanting advice on symptoms. They might have seen the product advertised on the television or been told to purchase it from their doctor. Regardless of the reason why they are asking for the product, it is the responsibility of the pharmacist to ensure that the patient receives the most appropriate therapy. This chapter therefore deals with situations where patients ask for a particular product or class of product but the pharmacist needs to elicit more information from the patient before complying with the request.

Motion sickness

Background

Motion sickness is a symptom complex that is characterised by nausea, pallor, vague abdominal discomfort and occasionally, vomiting. Symptoms of fatigue, weakness, inability to concentrate can also be observed prior to nausea. Over prolonged exposure to motion, symptoms tend to resolve. For example, sea sickness at the beginning of a voyage disappears over time – a characteristic called adaptation or habituation. Pharmacists are frequently asked to recommend a product, especially by anxious parents. Motion sickness can affect any individual and involve any form of movement, from moving vehicles to fairground rides.

Ginger has long been advocated for use as an anti-emetic. A review by Chrubasik and colleagues (2005) identified four exploratory studies of ginger in the prevention of motion sickness. The results of these studies suggested ginger was better than placebo, and similar in efficacy to other pharmacological agents. However, the studies were often in small numbers of patients, and of uncertain quality; the authors of the review concluded that further studies are required to confirm the effectiveness of ginger for motion sickness.

Non-pharmacological approaches to the prevention of motion sickness using acupressure are also available OTC. Bruce et al (1990) investigated the use of Sea Band acupressure bands versus hyoscine and placebo. Eighteen healthy volunteers were subjected to simulated conditions to induce motion sickness. The findings showed that whilst hyoscine exerted a preventative effect, Sea Bands were no more effective than placebo. Further trials have confirmed these findings, although 1 small trial by Stern et al (2001) reported positive findings. However, accurate placement of the Sea Band seems to be important, and further trials are needed as acupressure has shown positive effects for nausea and vomiting associated with pregnancy.

Practical prescribing and product selection

Prescribing information relating to medicines for motion sickness reviewed in the section ‘Evidence base for over-the-counter medication’ is discussed and summarised in Table 10.1. They are most effective when given prior to exposure and products should be selected based on matching the length of the journey with the duration of action of each medicine (see Hints and Tips Box 10.1).

Hints and tips box 10.1: Travel sickness

Table 10.1

Practical prescribing: Summary of medicines for travel sickness

Antihistamines

Antihistamines used in products for motion sickness are first generation H₁ antagonists and are associated with sedation. They therefore have the same side effects, interactions and precautions in use as other first generation antihistamines used in cough and cold remedies. For further information see page 8.

Cyclizine (Valoid)

Cyclizine is prescribed very rarely. It is subject to abuse by drug misusers and many pharmacies do not stock it. If taken, adults and children over 12 should take one tablet (50 mg) three times a day. The dose for children over the age of 6 is half the adult dose.

Cinnarizine (Stugeron 15)

Adults and children over 12 should take two tablets 2 hours before travel. The dose can be repeated every 8 hours (1 tablet) if needed. For children aged between 5 and 12 the dose is half the adult dose.

Meclozine (Sea-Legs)

Adults and children over 12 years should take two tablets (25 mg) 1 hour prior to travel, however as activity lasts 24 hours the dose can be taken the night before travel. Children aged between 6 and 12 years should take half the adult dose (one tablet, 12.5 mg) and for children over 2, half a tablet (6.25 mg) should be taken. The dose can be repeated every 24 hours if needed.

Promethazine (Avomine)

Avomine can be given for both prevention and treatment of travel sickness. For prevention, adults and children over the age of 10 should take one tablet at least 1 or 2 hours before travel. For treatment, 1 tablet should be taken as soon as sickness is felt followed by a second tablet 6 to 8 hours later. For children over 5 the dose should be half that of the adult dose in both prevention and treatment. Promethazine is also available as Phenergan, and can be given to children from the age of 2 years.

Hyoscine

Hyoscine can be taken either orally (e.g. Joy Rides and Kwells) or transdermally (e.g. Scopolamine patches – although these were discontinued in September 2006). Products should be taken 20 to 30 minutes before the time of travel; because they have a short half life they have a short duration of action and the dose might therefore have to be repeated on journeys longer than 4 hours. Anticholinergic side effects are more obvious than with antihistamines and it does interact with other medicines that have anticholinergic side effects and should therefore not be co-prescribed. Because hyoscine hydrobromide crosses the blood–brain barrier it can cause sedation. It appears to be safe in pregnancy, although the manufacturers state it should be avoided.

Joy-Rides: Joy rides can be given from age 3 upwards. Children aged between 3 and 4 years should take half a tablet (75 µg) and no more than 1 tablet (150 µg) in 24 hours. Children between the age of 4 and 7 should take one tablet (150 µg) with a maximum of 2 tablets (300 µg) in 24 hours and children aged between 7 and 12 should take one to two tablets.

Kwells: Kwells can only be given to children aged 10 and over. Children over 10 should take to 1 tablet. For adults the dose is one tablet. The dose can be repeated every 6 hours when needed. Tablets should be taken 30 min before travel.

Kwells Kids: Kwells Kids contain half the amount of hyoscine (150 µg) than Kwells and are marketed at children under the age of 10, although older children can take them. Children aged between 4 and 10 should take half to one tablet. Like Kwells, the dose can be repeated every 6 hours when needed and be taken 30 minutes before travel.

References

Bruce, DG, Golding, JF, Hockenhull, N, et al. Acupressure and motion sickness. Aviat Space Environ Med. 1990;61:361–365.

Chrubasik, S, Pittler, M, Roufogalis, B. Zingiberis rhizoma: a comprehensive review on the ginger effect and efficacy profiles. Phytomedicine. 2005;12:684–701.

Spinks, A, Wasiak, J. Scopolamine (hyoscine) for preventing and treating motion sickness. Cochrane Database of Systematic Reviews. 2011. [Issue 6. Art. No.: CD002851. DOI: 10.1002/14651858.CD002851.pub4].

Stern, RM, Jokerst, MD, Muth, ER, et al. Acupressure relieves the symptoms of motion sickness and reduces abnormal gastric activity. Altern Ther Health Med. 2001;7:91–94.

Background

Emergency hormonal contraception (EHC) is one of only a handful of deregulated products, which targets preventative health care and fits with UK government public health policy. Like other Western countries, the UK has high teenage pregnancy rates and associated high abortion rates.

The intention of UK government policy on making EHC available through pharmacies was to improve access for patients requiring EHC at times when other providers might be closed, for example at weekends and evenings. This policy appears to have been effective. Since its launch in the UK in 2001 the percentage of EHC provided through community pharmacies has steadily increased (NHS Statistics 2011). Community pharmacists are now the main provider of EHC, and studies have consistently demonstrated that women obtain EHC more quickly from community pharmacies than from other providers. This is relevant as EHC is more effective the sooner it is taken after unprotected sex. The weekend and Mondays are particularly associated with increased demand for EHC services from community pharmacy.

Aetiology

The active ingredient in EHC is levonorgestrel. Its exact mechanism of action is not clear and appears to have more than one mode of action at more than one site. It is thought to work mainly by preventing ovulation and fertilisation if intercourse has taken place in the pre-ovulatory phase, when the likelihood of fertilisation is the highest. It is also suggested that it causes endometrial changes that discourage egg implantation.

Evidence base for over-the-counter medication

The effectiveness of levonorgestrel is hard to establish because many women will not become pregnant regardless if EHC is taken or not. However, trial data has found it to prevent 86% of expected pregnancies when treatment was initiated within 72 hours. Levonorgestrel is more effective the earlier it is taken after unprotected sex; it prevents 95% of pregnancies if taken within 24 hours of unprotected sex, 85% between 24 and 48 hours, and 58% if used within 48 to 72 hours.

Studies have shown that most women have heard of EHC (>90%), although their knowledge on when it can be taken and its effectiveness is lower; for example, less than half of women are aware of how long EHC remains effective and less than two-thirds are aware it was most effective the sooner it was taken after intercourse.

Some concerns have been raised about women abusing the EHC because of its greater accessibility. However, a review of international experience with pharmacy supply of EHC found only a small proportion of women use EHC repeatedly (6.8% using it twice in 6 months, and 4.1% using it three times) (Anderson & Blenkinsopp 2006). Further, the review found improved access of the EHC through pharmacies resulted in fewer visits to Accident and Emergency, and did not result in increased transmission of sexually transmitted diseases or risky sexual behaviours.

Practical prescribing and product selection

Prescribing information relating to EHC is discussed and summarised in Table 10.2.

Table 10.2

Practical prescribing: Summary of medicines for EHC

Assessing patient suitability

Prior to any sale or supply of EHC the pharmacist has to be in a position to determine if the patient is suitable to take the medicine. To do this an assessment has to be made on the likelihood that the patient is pregnant:

• First, has the patient had unprotected sex, contraceptive failure or missed taking contraceptive pills in the last 72 hours? EHC can only be given to patients who present within 72 hours. If more than 72 hours have elapsed but less than 120 hours (5 days) then the patient can have an intrauterine device fitted or be prescribed ulipristal.

• Is the patient already pregnant? Details about the patient’s last period should be sought. Is the period late, and if so how many days late? Was the nature of the period different or unusual. If pregnancy is suspected a pregnancy test could be offered.

• What method of contraception is normally used? Patients who take combined oral contraceptives might not need EHC. Guidelines from the Faculty of Sexual and Reproductive Healthcare (2011) state:

For one missed pill (a missed pill is defined as one that is more than 24 hours late)

No additional or emergency contraception is usually necessary. The patient should take the missed pill and continue to take the rest of the pack as usual. Emergency contraception may need to be considered if pills have been missed earlier in the packet or in the last week of the previous packet.

For two or more missed pills:

The patient should take the last pill they missed (even if this means taking two pills in one day) and continue taking the rest of the pack as usual. An additional method of contraception for the next seven days should be used. If the person has had unprotected sex in the previous seven days, and missed two or more pills (i.e. more than 48 hours late) in the first week of a pack, emergency contraception may be needed.

If pills are missed in the first week (Pills 1–7). EHC should be considered if unprotected sex occurred in the pill-free interval or in the first week of pill-taking.

If pills are missed in the second week (Pills 8–14). No indication for EHC if the pills in the preceding 7 days have been taken consistently and correctly (assuming the pills thereafter are taken correctly and additional contraceptive precautions are used).

If pills are missed in the third week (Pills 15–21). OMIT THE PILL-FREE INTERVAL by finishing the pills in the current pack (or discarding any placebo tablets) and starting a new pack the next day.

If the patient uses a progestogen-only form of contraception. After a missed or late pill a woman should be advised to abstain or use additional contraception such as condoms for the next 2 days (48 hours after the pill has been taken). Emergency contraception may be indicated if unprotected sex occurs during this 48-hour period.

A number of useful checklists have been produced and are used in practice. Many pharmacists ask patients to complete one of these forms, instead of asking potentially embarrassing questions in the pharmacy. Once the details of the form are completed, the pharmacist can decide whether EHC can be supplied to the patient.

Levonelle® One Step

Levonelle® should be taken as soon as possible after unprotected sex or contraceptive failure. The dose consists of a single tablet (levonorgestrel 1500 µg). About one in five patients experience nausea but only 1 in 20 go on to vomit. If the patient vomits within 3 hours of the first dose she should be advised that a further supply of EHC would be needed. Taking EHC can affect the timing of the next menstrual period and patients should be told that their period might be earlier or later than usual. However, if the period is different than normal or more than 5 days late then she should be advised to have a pregnancy test. A number of medicines do, theoretically, interact with Levonelle®, most notably those that are enzyme inducers and include anticonvulsants, rifampicin, griseofulvin and St. John’s Wort, although the clinical significance of the interactions appear low as only a handful of drug interaction reports have been received by the manufacturers. It seems prudent, until such time that more substantial evidence is available, that patients taking these medicines are best referred to the GP. In such circumstances, increasing the dose of Levonelle® is commonly practised (although not licensed). If this is not the preferred option then an alternative form of EHC can be given.

Advanced sale of EHC is also permitted. However, pharmacists must consider the clinical appropriateness of a supply, and should consider declining repeated requests for advance supply and advise patients to use more reliable methods of contraception. See Hints and Tips Box 10.2.

Hints and tips box 10.2: Emergency hormonal contraception

Who is eligible?	Only patients over the age of 16 can be supplied with Levonelle®, although family planning services, doctors and pharmacists acting under a patient group direction can supply EHC to patients under 16
Do you have to supply EHC?	The supply of EHC is at the discretion of each pharmacist and some, for religious beliefs, might choose not to supply EHC. However, the patient should be advised on other local sources of supply so that she can obtain Levonelle®.

Reference

Anderson, C, Blenkinsopp, A. Community pharmacy supply of emergency hormonal contraception: a structured literature review of international evidence. Hum Reprod. 2006;21(1):272–284.

Background

Smoking represents the single greatest cause of preventable illness and premature death worldwide. In 2010, over 80 000 people in the UK died as a result of smoking; putting this in context, smoking caused about 30% of all cancer deaths, 14% of all circulatory deaths and over 35% of all respiratory disease deaths.

Prevalence and epidemiology

The number of smokers over the age of 16 in the UK is falling – from a high of 45% in 1974 to 21% (21% of men and 20% of women) in 2010. Smoking is most common in those aged under 35; 32% in people aged between 20 and 24, and 27% in those aged 25 to 34. It is least common (12%) in people over 60. Prevalence of smoking amongst people in the routine and manual socio-economic group continues to be greater than amongst those in the managerial and professional group (29 and 14%, respectively).

Recent legislation changes to ban smoking in public places (the first country was the Republic of Ireland in 2004, and others now include England, Scotland, Finland, Italy, Australia, New Zealand, Norway, France and Malta) has been championed as having potential positive impact on smoking rates; for example, by decreasing exposure to passive smoking and increasing quit rates. To establish any effect will take time but statistical data from Ireland has shown a fall in cigarette sales and surveys in Italy show a decrease in tobacco consumption. A study in England that compared smoking prevalence a year after legislation was passed (2007) found no significant difference in the level of smoking (http://www.ic.nhs.uk/webfiles/publications/003_Health_Lifestyles/Statistics%20on%20Smoking%202011/Statistics_on_Smoking_2011.pdf; accessed 22 November 2012).

Aetiology

Hundreds of compounds have been identified in tobacco smoke, however only three compounds are of real clinical importance:

• tar-based products, which have carcinogenic properties

• carbon monoxide, which reduces the oxygen-carrying capacity of the red blood cells

• nicotine, which produces dependence by activation of dopaminergic systems.

Tolerance to the effects of nicotine is rapid. Once plasma nicotine levels fall below a threshold, patients begin to suffer nicotine withdrawal symptoms and will crave another cigarette. Treatment is therefore based on maintaining plasma nicotine just above this threshold.

Evidence base for over-the-counter medication

Nicotine replacement therapy (NRT) has established itself as an effective treatment option. A 2008 Cochrane review (Stead et al 2008) found 111 trials (n > 40 000) comparing NRT to placebo or non-NRT treatments, and the results indicated that NRT increases rates of quitting smoking by 50-70%. It is not possible to say if one delivery system is better than another because comparative trials between delivery systems have not been conducted. Personal choice will therefore be the determining factor in which is chosen as being most suitable. In addition, the effectiveness of NRT is also affected by the level of additional support provided to the smoker and many smoking cessation services are offered through pharmacy as part of their contractual arrangements with local commissioners.

Numerous intervention strategies have been used involving NRT. These include nurse-led services, workplace interventions, GP services and pharmacy-based services. A Cochrane review (Sinclair et al 2004) of pharmacy intervention assessed two trials that met the authors’ inclusion criteria. Findings suggested that trained community pharmacists, providing a counselling and record keeping support programme may have a positive effect on smoking cessation rates. A 2012 review, which included the Cochrane review, reported that there was good evidence that community pharmacists can deliver effective smoking cessation campaigns, and that structured interventions and counselling were better than opportunistic intervention (Brown et al 2012).

It should be noted that relapse is a normal part of the quitting process, and occurs on average three to four times. If a smoker has made repeated attempts to stop and failed, or has experienced severe withdrawal, or has requested more intensive help, then referral to a specialist smoking cessation service should be considered.