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Social media support package launched by RPS

Social media guidance and support tools have been published this week by the Royal Pharmaceutical Society, to help pharmacy professionals understand how to use websites such as LinkedIn, Twitter and Facebook constructively and effectively.

The comprehensive package of tools includes presentations, podcasts and videos explaining various aspects of social media, including how to blog and tweet, how social media can form part of continuing professional development and hints and tips for effective use.

Several pieces of guidance have also been produced, including a core, six-page document entitled "Social media for pharmacists", which puts networking websites in a professional context and sets out guidelines for building a positive online presence and balancing personal and professional interactions.

Sera Onofrei, from the RPS communications team, stresses that the support tools have been formed with input from the profession, and should continue to be shaped and developed by members. In an article in this week’s Your RPS, she says: "If you have any comments or ideas to share, get in touch with us. This is a living package that will be updated in line with trends, technology, your ideas and your needs. . . . Tweet us (@rpharms) or email us (social@rpharms.com) about this — we are eager to hear from you."

The Society’s main motivation for creating the tools was to help pharmacists use social media to network, learn, share expertise and advance the profession, she says. "Pharmacy can sometimes struggle to have its voice heard in the wider health conversation, and social media represent a big opportunity for us to make sure our expertise is acknowledged and used. . . . Remember that social media can be a powerful advocacy tool."

The social media support package was put together with input from an expert panel comprising hospital, community and academic pharmacists, as well as immediate past-president of the British Pharmaceutical Students’ Association Ryan Hamilton, RPS chief executive Helen Gordon and other members of RPS staff.

All of the resources can be found on a dedicated "#RPSSoMe" (RPS social media) page on the RPS website (www.rpharms.com/SocialMediaGuidance).

See also:

Social media? That is SoMe

Think you can just let loose with your thoughts on social media? Think again!

How savvy are you with social media?

Scottish Government advises healthcare workers to get MMR jab

Healthcare workers in Scotland are being urged to get vaccinated against measles in light of the continuing increased risk of infection across the country.

The Scottish Government has written to frontline staff asking them to contact their occupational health departments about vaccination, with anyone inadequately protected encouraged to have at least a first dose of MMR.

Staff born after 1 January 1970 are being advised to have MMR unless they are certain they have previously had two doses of MMR, definitely had measles, or have had a blood test in occupational health confirming immunity, with GP practices allowed to use NHS vaccine supplies to vaccinate their own staff.

CPS asks pharmacists to report specials shortages

Community Pharmacy Scotland is asking pharmacists to report shortages of any unlicensed medicines (special formulations) listed in Part 7S of the Scottish Drug Tariff.

According to a CPS spokesman, the organisation is working with the Scottish Government to update Part 7S and is interested to hear about any medicines which pharmacists regularly have to request so these can be added to the list and to ensure that prices are fair.

In addition, CPS is calling for information on issues encountered when sourcing prescribed specials, including imported unlicensed medicines which are not listed in Part 7S, such as speed of response by the NHS board or issuing of further guidance.

New Clostridium difficile guidance includes fidaxomicin

Updated guidance on the management and treatment of Clostridium difficile infection (CDI) has been published by Public Health England.

The guidance states that oral fidaxomicin, which was launched in the UK in June 2012, should be considered for patients with severe CDI who are at high risk for recurrence, including elderly patients with multiple co-morbidities who are receiving concomitant antibiotics.

Antibiotics useful for some types of chronic back pain

Certain types of chronic low back pain could be treated with antibiotics, according to researchers from Denmark who report that antibiotics successfully relieved pain in selected patients.

They say that after a herniated (slipped) disc some people develop painful bone oedema in adjacent vertebrae. Bacterial infection is one suggested cause of this, with infection leading to local inflammation. Anaerobic bacteria, predominantly Propionibacterium acnes, have previously been identified in herniated discs.

The researchers report finding anaerobic bacteria in 26 of 61 patients having surgery for herniated disc. Of these patients, 80 per cent had bone oedema in the adjacent vertebrae compared with 44 per cent of those with negative cultures (European Spine Journal 2013;22:690).

A second paper reports a randomised controlled trial of antibiotic therapy in 162 patients with chronic low back pain after previous disc herniation and with oedema in the adjacent vertebrae. A 100-day treatment with amoxicillin/clavulanic acid or placebo was given. At one-year follow-up, the antibiotic group had significant improvement in disease-specific disability questionnaire score and in lumbar pain (primary trial endpoints). Treatment was also better than placebo for leg pain and days off work (ibid, p697).

Richard Larkin, senior clinical pharmacist specialising in chronic pain at City Hospitals Sunderland, said the research is promising for a select group of patients with chronic low back pain but requires further study. "I would not like to think GPs would be giving antibiotics to all patients with low back pain," he said. There would also be some concern over long-term treatment with such a useful antibiotic.

Dispensing errors tops Government board agenda

Decriminalisation of dispensing errors is top of the agenda for the Government board set up to review medicines legislation, it confirmed following its inaugural meeting.

The 23-member rebalancing medicines legislation and pharmacy regulation programme board said in a statement released earlier this month (May 2013): "Discussion was constructive and in particular the proposal to review criminal prosecution in relation to dispensing errors was received very favourably and agreed as an immediate priority."

The roles of the responsible pharmacist and superintendent pharmacist as well as hospital pharmacy and supervision were also flagged as important issues for the board to consider.

The board, which is chaired by Ken Jarrold who also chaired the group which oversaw the establishment of the General Pharmaceutical Council between 2007 and 2009, is due to meet again on 3 June.

Mark Koziol, chairman of the Pharmacists’ Defence Association, welcomed the decision to prioritise the issue of dispensing errors. He said the PDA was told in January at a meeting with the Department of Health and the Medicines and Healthcare products Regulatory Agency that the board’s priority was to consider "whole systems proposals" first before it looked at the decriminalisation issue.

He told PJ Online: "I am pleased that the board is prioritising decriminalisation. What they [the DoH and MHRA] led us to believe at the time was [that] what was more important was the whole issue around remote supervision and how technicians could get involved in the process."

However, he is concerned about the "paucity" of community pharmacists on the board and also of organisations that have experience in the areas the board is addressing, which he describes as a "mistake".

Man charged after siege at Edinburgh pharmacy

Charges were brought by the police today (16 May 2013) against a 32-year-old-man, in connection with an incident at Edinburgh’s Royal Mile Pharmacy yesterday evening.

News reports of the incident

A news report on the website of The Scotsman say that six people were taken hostage inside the Royal Mile Pharmacy shortly before 6pm yesterday evening (15 May 2013).

Police arrived at the scene soon after this, cordoned off the street and began negotiation attempts with the man and woman involved in the incident. Witnesses reported that the man was holding a Stanley knife, the newspaper says.

The police ended the siege more than two hours later, with the use of a taser, the report says.

Staff and members of the public were prevented from leaving the pharmacy (see Panel) and the police were called out to resolve the situation — which ended with everyone being released physically unharmed, a Police Scotland spokesman told PJ Online.

All of those who had been trapped inside the pharmacy were assisted by police and the Scottish Ambulance Service after their release, the spokesman said.

A man and a woman were detained by the police after the incident. The man has now been charged, and was scheduled to appear at the Edinburgh Sheriff Court today. The woman is being treated at the Royal Infirmary of Edinburgh after taking ill last night, but may yet be charged in connection with the incident, the police spokesman said.

The Royal Mile Pharmacy has not opened today, and no further information is available at this time about welfare of the members of staff who were involved in the incident. However, the pharmacy’s owner was interviewed this afternoon on BBC Reporting Scotland, and the interview is due to be repeated on BBC1 Scotland this evening during the 6.30pm news broadcast.

Evidence does not support racecadotril use, says DTB

On current evidence, racecadotril does not have a place in the management of acute diarrhoea, according to the Drug and Therapeutics Bulletin (2013;51:54).

The DTB review covered five trials in adults: two placebo controlled and three comparing the drug with loperamide. In young children, two systematic reviews of placebo-controlled trials and one loperamide comparison were reviewed.

The bulletin says that for adults and older children there is no evidence of significant benefit over established drugs. For children under four years, there is some evidence for the drug compared with placebo and it appears to be of similar efficacy to loperamide. But many of the studies are not directly applicable to UK practice; also, there is no demonstrated improvement in major clinical outcomes.

Racecadotril (Hidrasec capsules and granules) was launched in the UK in 2012, licensed for use in adults and children. It is an inhibitor of enkephalinase, the first in a new class of antidiarrhoeal drug.

The bulletin points out that there is "a very limited role" for antidiarrhoeal drugs in managing acute diarrhoea and that the 2009 National Institute for Health and Care Excellence guideline on management of diarrhoea and vomiting in children does not recommend use of antidiarrhoeal drugs.

BMJ safety award for pharmacy-led project

A medicines reconciliation project run by a multidisciplinary team at the Chelsea and Westminster Hospital was the winner in the "Improvement in patient safety" category at the BMJ awards held in London earlier this month (May 2013).

The team’s "Improving medication reconciliation at discharge – closing the loop (M@D)" project was founded on the presumption that pharmacy staff are essential to ensuring full medicines reconciliation, and was a pharmacy-run initiative headed up by pharmacist Shirley Kuo, jointly supported by Chelsea and Westminster Hospital and the Collaboration for Leadership in Applied Health Research (CLAHRC) North West London.

The project, which aimed to improve communication about medication changes when patients left hospital and moved into the community, resulted in better quality discharge information, reducing medication errors and improving patient experience.

Karen Robertson, chief pharmacist at Chelsea and Westminster Healthcare NHS Foundation Trust, said: "The project team has improved doctor prescribing and has put in place planned regular education and training sessions for new doctors that ensure the improvements can be sustained long after the project finishes. Pharmacists check that communications about new and changed medicines are accurate and complete so that the patient and their GP are aware within 24 hours of discharge. This starts with the pharmacy staff checking the doctors clerking of patients’ regular medicines on admission.

"I am delighted that the work of the pharmacy team together with CLAHRC and our patient representative has not only delivered such positive results but also been recognised by winning this award. It is particularly rewarding as a pharmacist to win an award for improving patient safety."

Cystic fibrosis patients in Wales to get access to ivacaftor

Cystic fibrosis patients in Wales are to have access to ivacaftor (Kalydeco), despite the All-Wales Medicines Strategy Group advising that the drug should not be made available on the NHS.

In a statement, Minister for Health and Social Services Mark Drakeford commended the work of the AWMSG but said that issues of equity led him to conclude that a way must be found to provide ivacaftor to eligible patients.

The new cystic fibrosis medicine, which is used to treat patients who have the G551D mutation in the CFTR gene, was made available to patients in England earlier this year, although it has not been appraised by the National Institute for Health and Care Excellence. In Scotland, the Scottish Medicines Consortium does not recommend its use, but the drug is being funded by a new mechanism set up by the Scottish Government to respond to orphan medicines.

In his statement, Mark Drakeford pointed out that, in the future, other medicines will fall into the category of orphan and ultra orphan status, and will need an appropriate appraisal process to evaluate them effectively.　

"I have therefore asked the chief pharmaceutical officer to set up a review (involving all relevant interests) of our appraisal process to deal with these new, innovative medicines for rare diseases," he said.

Healthy Start vitamin pilot launched

A pilot through which Healthy Start vitamins will be supplied by community pharmacies in Scotland was officially launched this week (13 May 2013). The vitamins were previously distributed through NHS boards but uptake was low. "We know that some families have had difficulty accessing these vitamins in the past," said Michael Matheson, Minister for Public Health. "By using community pharmacies, we will ensure a consistent, easily understood and sustainable method of distribution across Scotland for those in most need of these vitamins." Details of the pilot were announced earlier this year.

Generic atorvastatin brings £350m in savings

Generic versions of atorvastatin, which was previously only available from Pfizer as Lipitor, have saved the NHS more than £350m in 12 months, according to figures from the British Generic Manufacturers Association. The drug became available as a generic in May 2012 when the Pfizer patent expired.

Anticoagulation for pacemaker surgery

Clinically significant device-pocket haematoma is reduced when patients requiring long-term warfarin therapy undergo pacemaker or implantable cardioverter–defibrillator surgery without interruption of warfarin therapy, compared with those who receive bridging therapy with heparin, the current standard (3.5 versus 16.0 per cent, relative risk 0.19, 95 per cent confidence interval 0.10-0.36; P<0.001). Results from the Canadian trial, which was stopped early, cannot be extrapolated to therapy with the new oral anticoagulants, the triallists say (published online in The New England Journal of Medicine, 9 May 2013).

How savvy are you with social media?

This month LinkedIn is 10 years old, and Facebook will hit a decade in 2014. Social media sites are here to stay; but how do pharmacists use them? Sasa Jankovic reports

From keeping in touch with old friends to networking for new business, pharmacists are making use of social media in different ways.

In this news feature, seven e-savvy pharmacy professionals share how they harness social media: what online communication tools they use, how they make use of these in a professional capacity and what they see as the general benefits and risks of using these sites.

The Twitter fan

Anas Hassan, locum pharmacist

“I jointly run the East of Scotland Local Practice Forum Twitter page at @EastScotLPF, as well as my own website at www.officialanashassan.com, and can be found tweeting at @tartanmaganas. I am also on LinkedIn and am a long-time user of Facebook.

“For the East of Scotland LPF, we enlighten our followers on news and forthcoming events taking place. For my Twitter and personal website, I use it to comment on the pharmacy profession.

“If used professionally then the benefits outweigh the risks massively. I’m no advocate of political correctness but you do have to watch what you are saying on social media like Twitter because, potentially, the whole worldwide web can see. Having said that, don’t forget to be a little light-hearted also.

“I have made new contacts, shared ideas and thoughts with my peers, and even found work.

“Don’t be shy. If anything, start with Twitter. It is growing quickly and there are many superb people to talk with in the pharmacy profession who are present on there.

“Once you have a few followers, why not start a blog of your own online? It’s far easier than you would imagine.”

The multi-site user

Ryan Hamilton, PhD student at Liverpool John Moores University

“Facebook is mainly for personal [use] and friends, and I use LinkedIn for professional matters, with my qualifications, professional involvement and experience on there.

“I use Twitter professionally and personally, maintaining a professional outlook and posting a lot of content regarding the pharmacy profession. I also contribute to a number of pharmacy and wider healthcare debates. However, I show some personality on Twitter by expressing my views on wider politics and other interests.

“I also have my own website, which I use to list my publications and promote my work. It is important for PhD students and junior researchers to have a presence online as they can easily become invisible to the wider world.

“I follow a number of pharmacy organisations on Twitter, as well as individual scientific journals. This helps me keep on top of news and newly published research quicker than ever before. I have also been using Twitter to network with other PhD students and share and seek ideas and advice. My personal website has helped me stay involved in the profession since leaving the British Pharmaceutical Students’ Association executive.

“Benefits include allowing me to keep on top of the very busy world of pharmacy, healthcare, science and politics in more confined spaces. Social media lets me select and compile where I receive information from, join in professional debates, seek advice and opinions on the go, and build my professional networks.

“As for the risks, as Avinash Kaushik of Google Analytics said: ‘Social media is like teen sex: everyone wants to do it; nobody knows how. When it’s finally done there is surprise it’s not better.’

“Everyone is aware of the professional risks and the RPS will be publishing guidance around this.

“I developed the social media presence for the BPSA. Since increasing base membership and launching social media strategies, nearly every BPSA event is fully booked. Many member now use the BPSA’s main and events pages to ask questions, which the BPSA either answers directly or invites them to send an email to a specific executive member. This has, in my opinion, made the executive more approachable and look more active.

“Twitter is used by a lot of organisations within pharmacy, including professional bodies and employers. Twitter has now also become a way for the BPSA to promote the work it does to these organisations.

“I’d say just give it a go. It will be daunting at first and could seem pointless but there will come a point when you learn to use it in a way that benefits you and doesn’t take up any more time than is necessary.”

The new business networker

Kandarp Thakkar, deputy chief pharmacist and principal pharmacist for clinical services, Royal National Orthopaedic Hospital NHS Trust

“For personal communication I use Facebook and Twitter, and I’m in the process of setting up my own website. Professionally I use Twitter, LinkedIn, and blog on the RPS website.

“I use [these sites] for sharing good practice, promoting new tools, research etc, networking in a professional capacity, communicating with like-minded individuals or groups, and looking for career and business opportunities.

“The benefits [of these sites] are as above, plus saving time doing this kind of communication over the net as opposed to in person. Risks include gaining attention from individuals or groups that we may not be interested in, and professional business becoming ‘social’.

“[These sites] have helped with promotion and networking for My Medication Passport — a new business I have just launched to help patients record their medicines use and any changes to their medication [PJ 2013;290:459].

“Keep it professional and use [social media] for the right reasons, but be aware of the risks.”

The ad hoc user

Ash Soni, community pharmacist and vice-chairman, English Pharmacy Board

“I use LinkedIn and Twitter for business and Facebook for personal but I’m notoriously bad at using any of them particularly well. I tend to tweet when I remember rather than consistently, and LinkedIn tends to be people using me as a route to others.

“I don’t use the sites to self promote apart from asking all my contacts to vote for me in elections and ask their friends to do the same.

“The main risk from the sites is saying something which gets used in a negative way (as has happened to a number of people in a fairly high profile way recently) but in reverse they are a good way to promote positive messages from conferences and meetings. My view is that all these tools are useful ways of spreading news and promoting and highlighting success.”

The headhunter

Joanne McCaughey, acting clinical services manager at The Clatterbridge Cancer Centre NHS Foundation Trust

“I use Twitter mostly as a professional tool, but I do use it socially, being careful what I post. I find Twitter really useful as I am now networking outside of my usual peers. For example, I used it recently to help with coursework for a non-medical prescribing course. It’s handy to see what others are doing and also for sharing safety issues, and there is a lot of oncology information which is easily available.

“I have also used Twitter for recruitment for jobs I have out for applications. Hopefully my recruitment efforts have been useful to the trust.

“I use Facebook mostly as a personal account but as many pharmacists are friends with me I will sometimes put jobs on for recruitment. I also use LinkedIn, but I’m still not sure it fits in with me.

“I believe that judicious use of social media is helpful, but you need to be careful and sensible. If you wouldn’t say it, don’t tweet it.”

The professional networker

Trevor Jenkins, community health services pharmacy lead, SEPT Community Health Services, Bedfordshire

“Personally I only use Facebook and a handful of websites. Professionally I am on LinkedIn and comment on PJ Online. I also use the RPS online networks — transfer of care, secure environment pharmacists and others — as well as various NHS networks.

“However, the NHS trust I work for blocks (via Websense) Facebook and Twitter and other selected sites that it deems unsuitable, which can cause problems of access to work-related sites.

“PJ Online is very useful to keep up with what’s going on pharmacy-wise, although I find the online polls ill thought out and seeming to seek emotive responses based on populist approaches — but it’s useful to be able contribute all the same. The RPS online networks are very useful for getting advice, views and experiences from others. LinkedIn is OK for keeping up with friends when they move to new jobs, but hasn’t really benefited me, although I never refuse a connection. NHS networks is very useful, too, for getting advice, views and experiences from others.

“The benefits are keeping up with what’s going on and seeing others’ views and advice, and the risks are the usual ones of disclosing or making views known.

“Information and experiences of others can help shape strategy, policy and resolution of clinical issues, which ultimately contributes to improvements in clinical care with medicines, however small or large. However, I still find it far more productive and effective to meet with others to exchange views and resolve issues, or ring them and talk to them. It also builds much better working relationships that both sides value and trust, and these contribute more to the greater good. I would rather talk to the person than read off a screen, although the latter has some, but fewer advantages, too.”

The social-only user

Catherine Truman, clinical pharmacist at Christian Medical College Vellore teaching hospital in India

“I only use Facebook, and look at my own organisation’s site, but I don’t make use of these in a professional capacity at all. When it comes to work, I mainly contact people via email. I’m based in India so Facebook lets me stay in touch with friends, but I don’t have my own computer so I’m not very active. It’s nice to keep up with people who are far apart, but it’s time consuming.

“[Using these sites] hasn’t [specifically benefited my organisation] — we still use Google, email and YouTube for most things instead. I wouldn’t [encourage others to use these sites], because they are so time consuming that it’s easy to get distracted with personal stuff.”

Social media? That is SoMe!

Do you think having a “follower” sounds more like a matter for the police than a cause for celebration? Does the concept of blogging bamboozle you? If you can identify with these sentiments, you are not alone. For many, the steady rise of social networking sites, such as Twitter, LinkedIn and Facebook, has created a digital world that seems impenetrable to all but the young and the technologically adept.

This need not be the case. Gaining proficiency and confidence with social media — or SoMe — is not only easy (with the right instruction), but it can be interesting, informative and, at times, highly entertaining.

There is also a growing need to embrace new media to stay ahead professionally. Blogs and social networking sites are a neat way to receive news, discuss topical issues and share ideas, as well as to promote commercial offerings. And with recruiters increasingly using social media to advertise jobs and hunt for talent, ambitious professionals cannot afford to be left behind.

With this in mind, the Royal Pharmaceutical Society has developed an extensive package of support tools and guidance designed to help members of the profession, whatever their level of new-media experience, gain the knowledge and skills they need to build a strong and constructive online presence. An article in this week’s Your RPS introduces the resource, and explains why getting to grips with social media is so important.

You might be unsure how, exactly, social media can be used in a professional context, or intrigued as to where you sit on the SoMe-skills spectrum. Have a look at our News feature, where several members of the profession have bared all about their new media usage. From the ad hoc user and the professional networker to the Twitter fan and the multi-site user, there should be a profile to which you can relate — or aspire.

Yet beware: wading in to the social media waters is not without its risks. Commenting online may feel conversational and informal but it is, essentially, a form of publication. A careless insult or grumble has the potential to land you in a libel hearing or employment tribunal, as our Article explains. It is crucial to understand enough to stay on the right side of the law while still having the confidence to speak your mind.

If you are already an avid online networker, with fans aplenty and a chirrup of tweets under your belt, there will still be plenty in this issue to help you protect and strengthen your place in the online community. And if you are a nervous e-novice, wondering just what in the world this social media business is all about, read on. We hope to have you saying: “Social media? That is SoMe!”

The 2013 world pharmacy congress is on your doorstep — why not go along?

The International Pharmaceutical Federation congress takes place later this year in Dublin. Kate O’Flaherty, from the Pharmaceutical Society of Ireland, hopes UK colleagues will go

Complex patients, and how pharmacists can support their management is the theme of this year’s International Pharmaceutical Federation (FIP) Congress which will be held in Dublin, Ireland, from 31 August to 5 September.

The Pharmaceutical Society of Ireland (PSI), the pharmacy regulator, along with a number of pharmacy partners, including community, hospital and industrial pharmacists and the three schools of pharmacy in Ireland, is looking forward to welcoming colleagues from around the globe to Ireland later this summer. The local hosts are working with the Irish government’s tourist initiative “The gathering 2013” which encourages the world to make this the year they visit Ireland.

Developments in Ireland

The FIP Congress was last held in Dublin in 1975 and, not surprisingly, a lot has changed since then. Pharmacy in Ireland has undergone particularly significant changes since new legislation to regulate the profession was introduced in 2007.

This new regulatory landscape, underpinned by an educational reform programme, is providing a platform for the development of the profession and pharmacy services in Ireland. In the past two years, new services such as emergency hormonal contraception and seasonal influenza vaccination services, have become available to patients through pharmacies.

In order to future-proof the profession, the qualification for practice in Ireland is moving to a five-year fully integrated master’s degree, with the first graduates expected by 2020. And the introduction of mandatory continuing professional development for pharmacists in Ireland, through a new Irish Institute of Pharmacy that is currently being established, will further facilitate the development of pharmacy practice and services in Ireland in line with international evidence and experience.

“This is an exciting time for the pharmacy profession in Ireland,” said PSI president Paul Fahey, “because the regulatory framework provided by the 2007 Act is enabling pharmacists to develop new roles, as colleagues in many other countries have already done. In particular, the legislation provides specifically for the acquisition of specialisation by pharmacists for the first time, so we have a unique opportunity now to innovate practice in Ireland for the benefit of patients and the wider healthcare system.”

This strategic approach mirrors well with FIP’s aims of advocating increasing roles for pharmacists in the management of complex patients, and with a key purpose of providing an extensive platform for learning and growth to do just that, FIP has made “complex patients” a priority for 2013.

Thousands of pharmacists from all over the world, and from all areas of pharmacy practice and science, will convene in Dublin to work towards a future in which multidisciplinary approaches maximise healthcare contributions for the full benefit of patients, despite their wide range of social, cultural, medical, biological and medical diversity.

Comprehensive programme

From asking what makes patients complex, to the emerging strategies for treating complex patients, as well as patients’ own perspectives, the comprehensive programme for this year’s congress explores this theme from many angles, with a key focus on the pharmacist’s role in integrated and collaborative care.

Current statistics suggest that complex patients comprise one in four patients in primary care, who fulfil criteria such as those having multiple chronic illness, complex treatments and therapies, and longevity. With complex patient management requiring an ever-increasing multidisciplinary approach, the pharmacist’s main focus is optimising and managing the medicines-related needs of these patients, but as the most accessible healthcare provider, pharmacists are often also at the frontline of care with regard to managing other issues.

The annual FIP congress provides a unique forum for pharmacists from different countries and practice areas to see the challenges and opportunities facing their colleagues around the world, and to share and learn from each other’s experiences and perspectives.

Valuable forum

“Certainly we in Ireland have found FIP and the annual congress to be a valuable forum for growing our international network and sharing experience,” said Mr Fahey. “This was particularly true for example, when we were developing the first core competency framework for pharmacists in Ireland. We used the FIP global framework as a mapping tool and it was an invaluable resource. Now others can learn from our experience in doing that. Similarly when implementing new services such as flu vaccination or developing our CPD model, the experience and insight of colleagues internationally was of immense benefit.”

For colleagues in the UK, Dublin is, of course, a particularly convenient location for the annual congress. The venue is the city’s new riverside Convention Centre, which is just a short walk from the city centre and all the cultural and social delights that Dublin has to offer.

With the welcome reception planned for the city’s top tourist attraction, the Guinness Storehouse, and the FIP “fun run” in the grounds of Trinity College Dublin, there will also be plenty of opportunities for participants to enjoy the city’s attractions.

“We hope that having Ireland as the destination for this year’s FIP congress will enable colleagues from the UK to join us for the event,” said Mr Fahey. “Many Irish pharmacists studied pharmacy in the UK, and so this year’s congress, tied with The Gathering, provides the ideal opportunity to catch up with old friends and colleagues.”

Further information on the congress can be found at www.fip.org/dublin2013 or by emailing FIPDublin2013@thepsi.ie.

On secondment to conduct research

What was your first contact with pharmacy as a profession?

When I was at school I researched many careers and found myself leaning towards a career in healthcare. Pharmacy seemed to combine my interest in medicines and biology with my motivation to help people.

Where did you do your preregistration training?

I did my preregistration training at Aberdeen Royal Infirmary and spent time rotating around different areas.

I enjoyed working in medicines information; we received enquiries from the general public, nurses, GPs and consultants and it was interesting to deal with such a variety of queries.

How were your early years of practice?

I worked as a basic grade pharmacist at ARI for a year before becoming a resident pharmacist for the emergency on-call pharmacy team in the Grampian Health Board area. I worked alone overnight and was responsible for the provision of all pharmaceutical services during those hours. This role presented many challenges. For example, I recall having to source leeches at midnight and sending them to Aberdeen to save a patient’s hand.

I also worked as a community pharmacy locum during this time. After a year I was offered a relief pharmacist post with an independent chain. This gave me the chance to work with a range of patients and during that time I gained a master’s degree in clinical pharmacy.

What is your current role and how did you get there?

I am on secondment from my community pharmacy post to undertake research for my PhD.

I am examining the action taken by patients in the management of early cancer symptoms and investigating the potential role that community pharmacy can play in early cancer detection.

I had openly expressed my interest in research and a colleague at the University of Aberdeen, Christine Bond, invited me to join her experienced research team.

I recently started working part-time for NHS Education for Scotland (NES) as a practice education co-ordinator for its preregistration programme, vocational training scheme, pharmacist prescribing course and pharmacy assistant training programme.

I have always been passionate about education and training and have a postgraduate certificate in higher education, learning and teaching. The team at NES have been welcoming and supportive, and I have enjoyed getting to know the trainees and tutors this past year.

Of which achievement are you most proud?

Gaining funding for my PhD from Pharmacy Research UK through the Sir Hugh Linstead Fellowship was a huge achievement but I could not have done it without the support and guidance of the research team at the University of Aberdeen. I never thought that I could be funded to do something I enjoy so much.

I am also proud to be part of a profession that everyday contributes in some small way to making things better for someone.

What do you hope to achieve in the future?

I am keen to continue my research into pharmacy practice and link this work with my role in NES. I believe working in education and training provides opportunities for researchers like me to develop, implement and evaluate training programmes that have been guided by evidence. I hope that my research will help improve pharmacy training and subsequently patient care.

I would like to encourage early years pharmacists to engage with learning throughout their careers. It opens doors to different opportunities within pharmacy and helps improve job satisfaction. I would also like to continue working as a locum community pharmacist. I think it is important that I remain practising — it will keep me grounded.

In a world without pharmacy, what career would you pursue?

I would like to be a crime scene investigator or a pathologist. This might seem a bit morbid but in fact it often brings comfort to friends and family of the deceased. I think the investigative part would suit my interest in learning and research, and liaising with family and friends would satisfy my drive to support people when they need it most.

Frances Notman, MSc, MRPharmS is a PhD student at the University of Aberdeen. She is also practice education co-ordinator for the north region of NHS Education for Scotland and a community pharmacist.

Diclofenac — a useful drug that may now be entering its twilight years

Diclofenac has been prescribed widely but recently there has been emerging evidence of its cardiovascular side effects. Jenny Bryan investigates

Well into its fourth decade on pharmacy shelves, the non-steroidal anti-inflammatory drug diclofenac (Voltarol) remains a popular choice of treatment for a range of musculoskeletal disorders. But concerns about its cardiovascular (CV) side effects in humans and its links to a rapid decline in vulture populations in India have kept diclofenac in the headlines at a time when most drugs of its age have dropped below the news radar.

Earlier this year, an extensive analysis of CV events with individual NSAIDs concluded that diclofenac carries a CV risk comparable to that of the cyclo-oxygenase 2 (COX2) inhibitor rofecoxib,¹ which led to its withdrawal in 2004.

The review authors recommended that diclofenac should be removed from the World Health Organization Essential Medicines Lists (EMLs), and the European Medicines Agency (EMA) is currently reviewing treatment guidance for the drug.
“GPs are aware of the increased risk of myocardial infarction and stroke with diclofenac, and clinical commissioning groups send reminders to those who continue to prescribe more than other local practices and advice about putting patients on naproxen rather than diclofenac.

However, some patients don’t like naproxen as much as diclofenac so, having discussed the risks with them, I think we still need the option of prescribing diclofenac in a small number of cases,” explains Louise Warburton, president of the Primary Care Rheumatology Society, GP with a special interest in rheumatology and musculoskeletal medicine, Shropshire Community Health NHS Trust, and Telford and Wrekin CCG board member.

Chemists at work

Impressed by the early success of the first NSAIDs, phenylbutazone, mefenamic acid, ibuprofen and indometacin, during the 1960s, chemists at the Swiss pharmaceutical company, Ciba-Geigy (now Novartis) set about finding an “antirheumatic” agent with similar properties.² They wanted a molecule that was weakly acidic with two aromatic rings twisted in relation to each other.²Receptor modelling was still in its infancy but the researchers postulated that the twisted ring structure was essential to fit the cyclo-oxygenase receptor site, and hence inhibit the activity of the enzyme for prostaglandin synthesis. Of more than 200 analogues tested by Ciba-Geigy, it was diclofenac that proved to have the most useful pharmacological properties.²

Musculoskeletal role

In an early clinical trial, diclofenac 100mg per day was shown to produce more relief from pain and stiffness and improved joint mobility in a larger number of patients with osteoarthritis than naproxen 500mg.³

It also appeared to be better tolerated. In another early study, diclofenac appeared superior to indometacin in rheumatoid arthritis.⁴

The drug was launched in the UK in 1979 and a growing body of clinical trials accumulated so that, by the mid-1980s, diclofenac was confirmed as at least as effective as other NSAIDs in the treatment of rheumatoid and osteoarthritis,^5,6 with safety comparable to that of ibuprofen and naproxen, and fewer adverse reactions than other NSAIDs.⁷

Additional formulations — slow release tablets, suppositories, intramuscular injections and gels — followed and indications were extended to a wide range of painful and inflammatory conditions, including ankylosing spondilitis, acute gout, frozen shoulder, low back pain, strains and sprains, and dental and other minor surgery.

“By the time I started in rheumatology in 1992, diclofenac was well established as the NSAID of choice. It was seen as a ‘mid range’ NSAID that wasn’t as potent as indometacin but better tolerated, and a little more effective than ibuprofen. It was also very well marketed, so that was probably part of the reason for its popularity,” recalls Dr Warburton.

Entering the skin

Nearly two decades after diclofenac’s introduction, further clinical research demonstrated the efficacy of 3 per cent diclofenac in 2.5 per cent hyaluronic acid (HA) gel for the topical treatment of actinic keratosis (AK), the epidermal skin lesions which may progress to squamous cell carcinoma. In a series of studies, diclofenac HA gel applied twice daily for 60 or 90 days, produced significant reductions and, in many cases, complete clearance of lesions.⁸

Few comparative studies have been carried out on AK treatments but a recent network meta-analysis of data used in a Cochrane review showed that patients using diclofenac were less likely to achieve complete clearance of AK lesions than with the other commonly used topical agents, 5-FU, imiquimod and ingenol mebutate.⁹ Because skin reactions are common with AK treatments, tolerability and duration of treatment are also likely to play a role in choice of therapy. In the Cochrane review, treatment withdrawal due to adverse events was more common with diclofenac than with imiquimod.¹⁰

Cardiovascular concerns

During most of the time since diclofenac was launched, safety guidance has focused on the risk of gastrointestinal side effects with it and other NSAIDs. But it was the withdrawal of rofecoxib that led to a review of CV events with other NSAIDs.

In 2006, a meta analysis of data from randomised, placebo-controlled trials of COX2 and traditional NSAIDs showed a 42 per cent relative increase in the incidence of serious vascular events (1.2 per cent/year versus 0.9 per cent/year; rate ratio 1.42, 95 per cent confidence interval 1.13 to 1.78; P=0.003) in patients using a selective COX2 inhibitor.¹¹ Overall, the risk for COX2 inhibitors and traditional NSAIDs was similar, but further analysis showed that the rate ratio for vascular events, compared with placebo, was 0.92 (0.67 to 1.26) for naproxen, 1.51 (0.96 to 2.37) for ibuprofen, and 1.63 (1.12 to 2.37) for diclofenac. The same year, warnings about the potential for CV events were added to NSAID prescribing information.

In 2011, a systematic review of community-based controlled observational studies, which included nearly 200,000 CV events and recorded outcomes in over 2.7 million NSAID users, again identified differences in CV risk between agents.¹² The highest overall risks occurred with rofecoxib, 1.45 (95 per cent CI 1.33 to 1.59), and diclofenac, 1.40 (1.27 to 1.55), and the lowest with ibuprofen, 1.18 (1.11 to 1.25), and naproxen, 1.09 (1.02 to 1.16).

Earlier this year, the same authors again reviewed CV risk and related this to NSAID use in 15 low, middle and high income countries, including England.1 Diclofenac and the COX2 Inhibitor, etoricoxib, accounted for one-third of NSAID use across the 15 countries, and diclofenac was by far the most commonly used NSAID. Using 2011 prescribing data for England, the researchers showed that diclofenac was the single most prescribed NSAID.¹ As well as urging that diclofenac should be removed from EMLs, they suggested there were strong arguments for its marketing authorisations to be revoked worldwide.

In October 2012, the EMA published the results of a review of recently published CV safety data for NSAIDs. It concluded that the evidence confirmed findings from previous safety reviews and that these were adequately reflected in current treatment advice for naproxen and ibuprofen. However, as the latest evidence showed a small but consistent increase in CV risk for diclofenac compared with other NSAIDs, similar to the risk of COX2 inhibitors, the Pharmacovigilance Risk Assessment Committee of the EMA was tasked with assessing all available data on diclofenac to see if treatment advice should be updated. Recommendations are expected soon.

Vulture crisis

Around the same time that the CV effects of diclofenac were being identified, the drug’s likely impact on the Asian vulture population was widely reported. Numbers declined rapidly during the 1990s and early 2000s so that, by 2007, the Indian population of white backed vultures was 0.1 per cent of previous levels and long-billed and slender billed vulture populations were down to 3.2 per cent of earlier levels.¹³ The dramatic mortality was attributed largely to renal failure caused by exposure to diclofenac in livestock carcasses on which the birds fed. Although not the most endearing species, vultures are important environmental scavengers and, since veterinary use of diclofenac was stopped in the region in 2006, the decline in vulture numbers has slowed.¹³

Twilight years

Latest prescribing data show that the message is getting through about the potential disadvantages of diclofenac to human users. Prescription Cost Analysis data for England show a reduction in oral diclofenac prescriptions from 4.7 million in 2011 to 3.2 million in 2012, with an accompanying increase in oral naproxen prescriptions from 4.2 million in 2011 to 5.7 million in 2012. Oral ibuprofen prescriptions remained the same, at around 4.6 million.

“Diclofenac has been a very useful drug, but it is probably nearing the end of its useful life, and the cardiovascular issues may have put the final nail in its coffin,” concludes Dr Warburton. “But there are advantages to keeping a range of treatment options available since evidence can change. Look what happened to the COX2 inhibitors. We never know how new concerns will affect our remaining NSAIDs in the future.”

References

1 McGettigan P, Henry D. Use of non-steroidal anti-inflammatory drugs that elevate cardiovascular risk: an examination of sales and essential medicines lists in low-, middle-, and high-income countries. PLoS Medicine 2013;10:e1001388.
2 Sallmann AR. The history of diclofenac. American Journal of Medicine 1986;80:29–33.
3 Siraux P. Diclofenac (Voltaren) for the treatment of osteo-arthrosis: a double-blind comparison with naproxen. Journal of International Medical Research 1977;5:169–74.
4 Dürrigl T, Vitaus M, Pucar I et al. Diclofenac sodium (Voltaren): results of a multi-centre comparative trial in adult-onset rheumatoid arthritis. Journal of International Medical Research 1975;3:139–44.
5 Caldwell JR. Efficacy and safety of diclofenac sodium in rheumatoid arthritis. Experience in the United States. American Journal of Medicine 1986;80:43–7.
6 Altman R. International experiences with diclofenac in osteoarthritis. American Journal of Medicine 1986;80:48–52.
7 Catalano MA. Worldwide safety experience with diclofenac. American Journal of Medicine 1986;80:81–7.
8 Jarvis B, Figgitt DP. Topical 3% diclofenac in 2.5% hyaluronic acid gel: a review of its use in patients with actinic keratoses. American Journal of Clinical Dermatology 2003;4:203–13.
9 Gupta AK, Paquet M. Network meta-analysis of the outcome “participant complete clearance” in non-immunosuppressed participants of eight interventions for actinic keratosis: a follow-up on a Cochrane review. British Journal of Dermatol 2013 Mar 29. doi: 10.1111/bjd.12343. [Epub ahead of print].
10 Gupta AK, Paquet M, Villanueva E et al. Interventions for actinic keratoses. Cochrane Database of Systematic Review 2012 Dec 12;12:CD004415. doi.
11 Kearney PM, Baigent C, Godwin J et al. Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ 2006;332:1302–8.
12 McGettigan P, Henry D. Cardiovascular risk with non-steroidal anti-inflammatory drugs: systematic review of population-based controlled observational studies. PLoS Medicine 2011;8:e1001098.
13 Prakash V, Bishwakarma MC, Chaudhary A et al. The population decline of Gyps vultures in India and Nepal has slowed since veterinary use of diclofenac was banned. PLoS One 2012;7:e49118. doi: 10.1371/journal.pone.0049118. Epub 2012 Nov 7.

Think you can just let loose with your thoughts on social media? Think again!

When it comes to the law, free speech does not mean free rein. Anyone using social media should be aware of the legal pitfalls, and know how to avoid them. Steve Hemsley explains

The law has struggled to keep up with the internet explosion, yet for anyone using social media the legal implications of defaming someone online are serious. People lose their inhibitions on Facebook and Twitter and often post whatever comes to mind. This has led to an increasing amount of litigation stemming from online harassment and bullying.

Defamation is a civil offence and can be either slander, where the defamatory statement is spoken, or libel, where it is written, broadcast or otherwise published. Most courts have ruled that social media-derived defamation is libel, although chat on an online bulletin board is more like slander.

Royal Pharmaceutical Society commercial, intellectual property and information technology solicitor Kimberly Shields says anyone making defamatory statements on a social network that identify a person or business (even indirectly, if there are enough clues) risks legal action.

“By simply posting the statement on Twitter or Facebook, or retweeting or sharing it, that is considered publication for the purposes of the law,” she says. “Social media users must be aware that any negative or suggestive comments could lead to them losing their jobs, or being taken to court for defamation.”
When it comes to dealing with bullying and harassment on social media sites, any action should be in line with the employer’s policy on workplace bullying. This means treating any abuse online as if it occurred in the workplace.

In allegations of libel, claimants do not have to prove they have suffered financial loss to win a claim. However, the Defamation Bill, which is expected to become law at the end of 2013, will require litigants in England and Wales to show that defamatory statements have caused “substantial harm” to their reputation, up from the current threshold of simply “harm”.

Employees have always moaned to friends and family about work, but negative comments on social media are seen by more people and can spread rapidly.
The test an employer will make is whether the comments would bring the company into disrepute or damage its reputation. Online comments are not automatically seen by large numbers of people, for instance. Yet there are many examples of employees losing their jobs after making negative comments online. For example, 13 Virgin Atlantic cabin crew members were fired after they described passengers as “chavs” and criticised the airline’s approach to safety on Facebook.

Workplace policies

Ideally, pharmacy employers should have a social media policy and specific related clauses in employment contracts. This is important because employers can be held vicariously liable for the actions of their employees.

In Preece versus JD Wetherspoon Plc, a pub manager was sacked for making inappropriate comments on Facebook about her customers, breaching Wetherspoon’s email and internet usage policy. The employment tribunal in that case held that the dismissal was fair.

Jon Heuvel, a partner at Penningtons Solicitors, says a social media policy could include restrictions on accessing social media sites through the organisation’s IT systems during work time, restrictions on referencing the organisation’s name on social media profiles, and a clear statement that all comments on social media sites will be treated as public, regardless of security settings.

“How people act on social media in their personal life does impact on their professional life. I would argue that nothing put on the internet is private,” says Heuvel. “I use the Daily Mail test. Imagine the headline if your post appeared in the morning papers.”

He adds that pharmacy staff must also be aware of breaches of patient and drug manufacturer confidentiality when using social media. “It will not reflect well on a pharmacy if a member of staff is acting inappropriately. Tweeting about a problem a pharmaceutical company might have could damage the manufacturer’s business, for example.”

Employers and line managers must be careful when trawling through social media to make background checks on potential new staff. The reasons for such a search may be valid, but an employer could face claims for discrimination. Someone’s sexuality or religious beliefs would be unlikely to appear on an application form and might only be revealed on an online search. The pharmacy would have to prove the real reason for the decision not to employ a person.
It is important pharmacy staff are not only aware of their employer’s social media policy but also the potential consequences for them and the company if they breach it.

Social media myth-busting

Myth number 1

I can relax in my anonymity if I post something using an account or user identity that does not identify me

Wrong, says Ms Shields. In 2007 the High Court ordered the operator of a football club fan webpage to disclose the identities of those posting defamatory remarks anonymously. The operators tried to argue that they would be in breach of the Data Protection Act if they disclosed personal information, which included names and addresses.

They were not successful. The courts held that the disclosure was proportionate, because there was no other way to reveal the identities of those making the defamatory statements.

Myth number 2

As long as it is my truly held opinion, then I am free to say what I want

For you to claim the “fair/honest comment” defence, your comment must be a matter of public interest, be recognisable as comment rather than an imputation of fact, be based on facts that are true, and explicitly or implicitly indicate the facts on which the comment is being made. The comment must also be one that an honest person — however prejudiced, exaggerated or obstinate in his or her views — would make.

Myth number3

When I use social media I am disclosing information to a closed user group

Mark Weston, head of commercial, IP and IT law at Matthew Arnold & Baldwin, says that, although many social networks have got better at implementing proper privacy settings, most people do not know how to use them or how to configure things properly. “Another myth is that people think they understand who is getting their information. All the research shows they don’t. It’s not just about competitors. Future employers and insurance companies are also interested in health information.”

Summary

Social media is a great tool to keep in touch with friends, network and even help promote your business. However, it is worth remembering the following advice before you post something online:

• Do not post unkind things online.
• Do not post threats online. It is illegal to send menacing electronic communications, under the Communications Act 2003.
• Do not post offensive comments online. “Vulgar abuse” is not considered defamatory, and Article 10 of the European Convention on Human Rights protects free speech. However, the Malicious Communications Act 1988 has been used to prosecute someone who made fun of dead children on Facebook and YouTube.
• Employers should have tightly drafted policies or codes of conduct.

Case study

Scottish chain Reach Pharmacy has a social media strategy to help its staff keep within the law. Arvind Salwan, director of the Reach Pharmacy Group, would not consider a blanket ban on staff using social media because the technology helps with marketing and building relationships with patients.

“[Members of] the team managing social media activity are fully aware of the legal implications,” says Salwan. “They have received training, and we have a guidelines document, too.”

He says it is not an employer’s job to tell staff what to post on their personal social media pages in relation to their workplace or colleagues, but he would take any policy breaches very seriously. “It is not acceptable for any employee to cause unwarranted potential reputational damage to their employer or industry through personal opinion, even if it has been expressed in a personal context.”

Giving teriparatide with denosumab improves bone density

Combining teriparatide (Forsteo) with denosumab (Prolia) increases bone mineral density (BMD) in postmenopausal women with osteoporosis more than either drug alone, according to research published online in The Lancet today (15 May 2013). Moreover, the increases seen were greater than have been reported with any recommended therapies, say the investigators.

Previous attempts to combine antiresorptive drugs with agents that stimulate the creation of new bone have been unsuccessful, say the researchers.

"Our results demonstrate that the combination of denosumab and teriparatide increases bone density more than either individual therapy, most likely because denosumab is able to potently block bone resorption even when given along with a bone-building agent like teriparatide [which has been shown to interfere with the suppression of bone resorption in previous studies]. While additional studies are needed, the results suggest that this combination may prove to be an effective osteoporosis treatment in women at especially high risk of fracture," said lead author Benjamin Leder of the Massachusetts General Hospital endocrine unit in Boston.

Data from the randomised controlled trial show that bone density at the lumbar spine increased by 9.1 per cent (standard deviation 3.9) with combination treatment, which was greater than the increases seen in the teriparatide alone and denosumab alone groups (6.2 per cent [SD 4.6]; P=0.0139, and 5.5 per cent [SD 3.3]; P=0.0005, respectively). Similar improvements were seen at the femoral neck and at the hip.

The authors of a linked comment, Richard Eastell and Jennifer Walsh, of the Mellanby Centre for Bone Research, University of Sheffield, say: "Whether the combination remains effective needs to be investigated, however, because at 12 months mean concentrations of the bone formation marker PINP no longer differed between the denosumab-alone and combination-therapy groups. The safety of this combination therapy also needs to be explored, as does what happens when teriparatide is stopped (the licence only supports use for a maximum of 24 months). Finally, the reduction in fracture risk needs to be quantified so that cost-effectiveness can be assessed."

Study details

In the study, 100 postmenopausal women determined to be at high fracture risk based on their bone density and other risk factors were randomised to receive teriparatide (20mg daily), denosumab (60mg every six months), or both drugs for 12 months.

The researchers measured changes in lumbar spine, hip bone, and femoral neck using dual energy X-ray absorptiometry and bone biomarkers at the beginning of the trial, and at three, six, and 12 months. The final analysis included 94 women who completed at least one follow-up visit.