Abbey: Okay.
We'll make a start then. There might be others that join as we go on. So welcome to the webinar this evening for the Community Pharmacist Program.
My name is Abbey Howe and I'm the director of the Primary Care System Reform
team here in the Victorian Department of Health. If we could just go to the next slide, I would like to begin the webinar this evening by acknowledging the traditional owners of the lands on which we're all meeting today and pay my respects to elders past, present and emerging and any Aboriginal and Torres Strait Islander people on the call this evening. Next slide.
So the purpose of the webinar this evening is to provide an overview of three services which were recently added to the Community Pharmacist Program. So this is musculoskeletal pain, mild acne, and Dermatitis.
So Angelo, who is our clinical specialist, is going to take you through those protocols and there'll be an opportunity to ask questions. So please use the Q&A function to put your questions in and we'll pause at the end of each protocol overview to answer any questions.
But before we do that, I'm just going to go through a couple of quick updates. If we go to the next slide, just a reminder about the origins of the Community Pharmacist Program, which started off as a pilot back in 2023, but has since become an ongoing program and is currently being expanded to include new services. So we really value the participation of all the pharmacists that we have in the program, over 900 pharmacies participating across Victoria. And we were pleased to recently pass the milestone of 100,000 occasions of care having been delivered. since the program began. Next slide.
As I mentioned, the program is expanding and will continue to expand through 26-27 to a total of 23 services. This slide has a snapshot of some of the services, of the services that are already live and some of the planned services. and the new services that we are focusing on the webinar, in the webinar this evening, acne, dermatitis and musculoskeletal pain. Next slide.
Just a reminder about some of our key program requirements. Firstly, costs. Patients receiving treatment will need to pay the full medication cost. And just a reminder to speak to patients about this before the consultation. The consultation payment, so Consultations are free for patients and pharmacies receive a $20 payment from the Victorian government per eligible consultation. And the third reminder is just around the requirement for a private consulting room to conduct consultations. More information is available on our website about these requirements. So please feel free to have a look at the website if you are looking for more information. Next slide.
Training requirements for the three services that we're talking about tonight. The training modules have been advised previously in communications to pharmacies, but just a reminder here of the training modules. And just to note that for dermatitis, a new module is being added, a PSA. training module for atopic dermatitis and further information and a link will be provided shortly in relation to that training module. And also a reminder that pharmacists who have completed an APC accredited Pharmacist prescriber course in full do not need to complete the short form training modules. Next slide, please.
Some other program reminders here.
The first one around not supplying cephalexin for UTI. Mandatory reporting of shingles cases. Confirmation of vaccination purpose and contraception service access. So again, more information about those reminders on our website. Okay, so that brings us to the first of the protocols that we're going to provide an overview of this evening, which is the management of acute, mild and musculoskeletal pain. So I'm going to hand over to Angelo Pricolo, who's our senior clinical specialist, and he'll take you through the protocol. Thanks, Angelo.
Angelo 5:59 Thanks, Abbey. That was great. Again, welcome to the Community Pharmacy webinar and thank you for making the time to attend at the end of the day. I know it's difficult to focus, so I'll try and make this concise and an informative session for you. So a bit of background. The first service that we will discuss is the management of acute mild musculoskeletal pain, which is defined as sudden pain affecting muscles, bones, joints, ligaments or tendons lasting less than three months and often resolves as the underlying injury heals. And now this can often occur due to trauma falls or overuse, which are all very common presentations at the pharmacy, I'm sure you will be aware. Examples include things like sprained or strained ankles, where ligaments are involved, bone fractures or muscle strain. And pain can often be referred to as sharp throbbing or core stiffness and muscle ache. The management of acute mild musculoskeletal pain protocol has been developed to support Pharmacist to treat this mild pain. We'll talk a little bit more about defining pain, giving it a pain score where we're treating pain that is less than five on a scale where 10 would be unbearable pain. So if we could go to the next slide, please. So under this protocol, Victorian Community Pharmacist can supply a wider range of NSAIDs for five days treatment of acute mild musculoskeletal pain to patients aged between 18 and 65 years of age if they meet the eligibility criteria. So if we jump to the next slide, we'll have a look at an overview of the protocol under these headings of eligibility, referral, treatment options and some non-pharmacological counselling and follow up advice.
So starting firstly with eligibility criteria. As I said, the protocol includes patients aged between 18 to 65 years of age with a pain score of less than five. Patients must also have trialled paracetamol for pain, but this has been ineffective. But also to not have had a known contraindication to NSAID use and not to be at high risk of gastrointestinal adverse effects and not to be at high risk of other complications, e.g. rheumatic fever.
Now, the exclusions for referral or referral criteria, patients who have symptoms of more severe pain or injury, such as acute swelling, erythema, and significant reduction in joint motion and suspected nerve damage or mononeuropathy, which is damage just to a single nerve. Patients who are showing systemic symptoms such as headache, visual auditory disturbances, neurological signs or nausea and vomiting, which might suggest pain of another cause. More patients who have either had an inadequate response to optimal treatment over 5 days or are requesting therapies that are not in the scope of practice and this would... particularly point to opioids for pain management. So if we skip to the next slide and look at pharmacotherapy.
And this is a snapshot of what is currently available as OTC medication for Pharmacist. And we can see we have the non-selective NSAIDs, which were all very acquainted with ibuprofen and diclofenac. Diclofenac up to 25. milligrams at the moment. And then the selective NSAIDs or the COX-2 inhibitors, celecoxib, 200 milligrams, which is also available. And if we go to the next slide.
And this is a snapshot of the program and the treatments that will now be available. And if we look at diclofenac, firstly, we now have access to 50 milligrams of diclofenac, which makes dosing a bit easier. And if we look at naproxen, we now have access to 750 milligram and 1000 milligram slow-release formulation, so we can use a once daily regimen instead of using multiple doses in a day so that's a big difference. And if we go to the selective NSAIDs, again, we have access to meloxicam, 7.5 milligram and 15 milligrams. So again, we have that long-acting option available to us now as well.
If we go to the next slide.
There is just some information about non-pharmacological care, which again, pharmacists are well aware of, price not just the price of the medication, sorry about that, but also the acronym for rest, ice, compression and elevation and we've added protection. It's important that as pharmacists, and we're well aware that more than just the pharmacotherapy is the additional advice that we offer. At this point, it's probably worth also noting that there are other acronyms that are used now with slightly different care options. One of them is called Peace and the other is called Love. And I'll leave you to look those up yourselves, but in effect, they are newer protocols that are being used by some physios and chiros, probably not as many doctors, and they don't include the use of ice or indeed non-steroidal anti-inflammatories. So although they're not widely accepted or used, I thought I'd mention them because you may start to see reference to them going forward. I think that's really all I want to say at this stage on that protocol. I think it's pretty straightforward and we're really quite well acquainted with the drug classes. If anybody has any questions, I'm happy to address those now or we'll have time at the end. If nothing springs to mind at this stage.
Angie 13:35 Angelo, this is just a question in the Q&A asking about what's the point about prescribing more NSAIDs when pharmacists can already supply schedule 3 celecoxib 200 milligrams capsules.
Angelo 13:52 Look, as we know in medicine, it's just, it's great to have options. And there is a difference between celecoxib and meloxicam. And even if it's just as simple as the longer duration of action, It's an option that we have and sometimes that will increase compliance and sometimes it's just patient preference. So yes, they're all in the same drug class, but there are differences and we now have access to a wider range of NSAIDs.
Okay, I think we'll jump on to, and if anyone has any more questions, as I said, there'll be time at the end, but if we jump on to the management of mild acne.
So acne is defined as a chronic inflammatory condition and it's most common in adolescents and young adults. Diagnosis requires the presence of comedones, which are really just blocked hair follicles with or without papules or pustules and severity is based on the lesion type, the extent and quality of life impact, which can be quite significant. If anyone has young teenage kids, or if you can remember back that far, you would attest to that. The management of acne protocol has been developed to support pharmacist to treat mild acne that is non-scarring with few lesions and usually limited to the T-zone or that zone that covers the forehead, nose and down to the chin. If we look at the protocol scope on the next slide.
Under this protocol, Victorian Community Pharmacist can supply up to six weeks of selected topical acne treatments to patients aged 12 years and over with mild acne and seeking treatment after inadequate response, relapse or review of existing topical therapy if they meet the eligibility criteria patients with moderate to severe widespread or scarring acne cannot be treated under the program. And we'll go into that a little bit more in a sec if we go to the next slide.
And again, we'll look at these subheadings around eligibility, referral, treatment options, and advice and counselling and follow-up.
So if we start with eligibility, as I said, the protocol eligibility includes patients aged 12 years and over with confirmed mild acne. They must have comedones and papules or pustules may be present. They also must have tried previous treatment so have had an inadequate response to OTC treatment, relapse after topical therapy or indeed be at that six week review stage. Patients who have used S4 topical acne treatment used continuously for greater than six months without a GP review cannot be seen and these patients must be referred to their GP. So that's eligibility if we skip to exclusions or referral criteria.
If we have an unclear diagnosis of acne or if acne is moderate or severe. If we have scarring or high risk acne that is painful and cystic including a family history of scarring acne. If the patient is pregnant or planning pregnancy, or if we have medicine induced acne or PMOS, polyendocrine metabolic ovarian syndrome, the presence of that or signs of androgenisation, acne is worsening or the patient has had repeated relapses or a poor response or poor tolerance of topical treatments. It's important that if the patient meets eligibility criteria, treatment may proceed, but pharmacists need to refer if acne has a marked emotional or social impact on the patient. And again, this can be quite prominent with some young people especially. If we jump to pharmacotherapy.
And there are two pathways, starting with the initiation pathway. Treatment selection is based on the dominant acne type. So if we look at this slide, we start off with for mainly comedonal acne, the simple treatment with just the retinoids, and there is a choice of the three retinoids. Now, even though we call that quite simple, of course, we know that the retinoids come with their own specific and very important counselling regarding the slow buildup before it's left on even just overnight. So it's important to make that really clear to patients. And we have the option as we proceed through different types of acne and as it becomes more severe and we have some inflammatory papules or pustules. So papules are just raised lesions, pustules raised lesions with liquid or pus included underneath that raised skin. We can add to the retinoid either benzoyl peroxide or indeed we have access to clindamycin, the antibiotic as well, topically. And.so if we go to the next slide.
And we see that this is the six week review table. And if we have acne that is improving, we can resupply just the simple first treatment, which is the retinoid. or we can switch to a combination product with benzoyl peroxide. If we already have a combination product with benzoyl peroxide, we have the option of using stronger products, but only if acne is improving. If we find that it is not in that category, then we need to refer to a GP. So we have a few options with clindamycin combined with benzoyl peroxide or clindamycin with the retinoid, keeping in mind that if we're using a combination, We use that once a day and just at night. And if we're using clindamycin by itself, then it can be used twice a day. If we go to the next slide. And it's important that we keep in mind the counselling tips that we're going to pass on, which include the amount of time that these products are used, the simple information like benzoyl peroxide staining, clothing and pillows. the, as I said, the slow application or the gradual increase of use with retinoids. And I think that's probably about it. It really does open up the door for a wide range of treatments that we can use. And I think that as we gain more expertise and experience, this is going to be a really handy protocol that we'll be able to lean on. So does anybody have any questions on the mild acne? Not sure if there's anything in the chat yet. If not, we can move on and if anyone, if any questions come to mind, we can address them at the end.
So the management of acute exacerbations of mild to moderate atopic dermatitis. So atopic dermatitis is defined as a chronic or relapsing inflammatory skin condition characterized by a rash and itch. I'm sure we've all seen this present in the pharmacy many, many times. This protocol has been developed to support pharmacists to treat mild and moderate eczema with a flare-up lasting for less than two weeks. There are various ways of scoring or indeed categorizing eczema as we aim to just treat mild exacerbations and there are some links there that you can see. When to refer patients with severe atopic dermatitis, so intense persistent itch, widespread rash, severe lesions that have a major impact on sleep and daily life. And we'll talk more about that in a sec. If we go to the next slide.
So the protocol scope under this protocol, Victorian Community Pharmacist can supply 7 days of treatment of selected topical corticosteroids for short-term management of acute flare-ups to patients aged between 2 to 65 years of age with a previous diagnosis of eczema if they meet the eligibility criteria. Patients with severe atopic dermatitis, and we've already mentioned what that can look like, cannot be treated under the program. So if we go to the next slide,
And again, we'll look at the different categories starting with eligibility. The protocols eligibility includes patients in the age group 2 to 65 with confirmed previous diagnosis of atopic dermatitis made by a medical or nurse practitioner. They must have had a recent flare, less than two weeks, of mild to moderate atopic dermatitis following stable or intermediate symptoms and both.
Itch and rash should be present with features consistent with the patient's usual atopic dermatitis flares.
If we look at the exclusions or referral criteria, again, severe, widespread or painful rash, non-blanching purple rash, widespread erythema. And then if we start to get to some more systemic symptoms like fever, lethargy, vomiting or headache, blistering or suspected eczema, herpeticum, which is a viral infection associated again with fever, including eye involvement. This requires immediate emergency referral. Or if we have face involvement, suspected infection, broken skin ulcers, sores, severe disease, significant body service area involvement, pregnancy, planning pregnancy, poor feeding or sleep, or concerns about growth or immunocompromise all require medical referral. If we jump to pharmacotherapy.
And as you can see, obviously we already have access to hydrocortisone as Pharmacist, whether it's the cream or an ointment, depending on how that skin presents. We now also have access for eczema on the trunk, limbs, flexures, scalp. of methylprednisolone, ointment or fatty ointment, and the mometasone ointment as well, or cream. If we're treating the scalp, we have access to the lotion or hydrogel. So we have a finer, less viscous product. And for children on the scalp, just the methylprednisolone or Advantin product. We are able to supply adequate quantities for seven days treatment. So again, we can use our discretion as to whether that's going to be one tube, 2 tubes depending on the area that we are treating. And again, as pharmacists, we're all very aware of the counselling and advice that we need to give in conjunction with the use of these products. Using a soap substitute will always be useful, making sure the skin is well hydrated. We know that the corticosteroids will work much better on skin that's well hydrated, so using an appropriate moisturizer as a set of avoiding soap and choosing the right product depending on whether we have dry skin and we may prefer to use an ointment, whether we have red and flame skin and would prefer to use a cream or indeed if we're treating the scalp and we use a lotion. I think that's about all I want to say at this stage. I'm happy.
Abbey 28:50 Looks like. Angelo might have. Frozen. Um... But hopefully everyone can hear me okay.
Angie 29:10 Yes, Abbey, we can hear you.
Abbey 29:11 Great. So I think Angelo was just about to ask if anyone had any questions. I can't see any in the chat at the moment. So I'm going to assume there are no questions at this stage around that update. Angelo, are you back with us now?
Angelo 29:34 Can you hear me?
Abbey 29:35 Yeah, you just, you just momentarily froze.
Angelo 29:39 Okay, sorry about that.
Abbey 29:40 That's okay. So I was just saying we don't seem to have any questions in the chat, so I don't think there are any questions at this stage. So I might just... close the session by saying thank you again to everybody for joining and I hope those that have listened in have found it helpful. There will be more if there are updates and for more information and resources to support the delivery of these services. please once again, visit our website and I think the team is going to drop the link for that in the chat. So that's the place to go for more information. But unless Angelo, was there anything else that you wanted to add at this stage?
Angelo 32:55 Thank you for listening in. As I said, I think this is going to be quite exciting. There are areas where as Pharmacist were already doing quite a bit. This just gives us access to a few extra medications that we can use which can broaden our scope and increase access for so many people.
Abbey 31:05 Great. Well, on that note, thanks everyone and enjoy the rest of your evening.
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