Lactose intolerance can occur when person has insufficient lactase, resulting in the inability to break down lactose and causing maldigestion that leads to undigested lactose passing through to the colon. In the lower bowel natural bacteria ferment the lactose, producing acid and gas which may cause symptoms of lactose intolerance (including abdominal pain, bloating and diarrhoea). Deficiency of lactase varies with race and increases with age. Nutrition Australia suggest that most people with lactose maldigestion do not need to eliminate lactose from their diet completely and the majority of people with low lactase can consume at least one cup of milk (about 12 grams of lactose) per day. 

A randomised double-blind controlled trial comparing the effect of 400 mg of lactose or placebo on patients with proven lactose intolerance showed no difference (in either symptoms or breath H2 excretion test), leading the authors to suggest that lactase deficiency should not be considered a contraindication for most medicines. However there have been isolated reports in the literature of individuals who have developed gastrointestinal symptoms with lactose doses of 100 – 200 mg. 

 The lactose content of most medications is generally small. One study analysed the lactose content of many commonly used gastrointestinal medications, with most preparations containing less than 100mg of lactose per tablet. Even with preparations containing higher lactose content, the total daily lactose is small: for example, one brand of loperamide contains 125 mg lactose/tablet and allowing for a dose of eight tablets per day to treat diarrhoea, this would result in exposure to 1000 mg of lactose per day.

The presence of lactose (though not the amount of lactose) found in individual medication products  is usually indicated in the Product Information, but at times it can be difficult to determine the exact amount of lactose per tablet.

 It is common to find lactose maldigesters who believe that the ingestion of a minimal amount of lactose will result in gastrointestinal symptoms, but in the vast majority of cases the patient can be reassured this is not the case.

 Consideration may need to be made for patients with severe lactose intolerance or on multiple medications where total lactose content may be higher. In many cases (but not all) there may be an alternative brand that does not contain lactose. Even so, there may be clinical issues that require consideration: for instance there is no lactose-free combined oral contraceptive product currently available in Australia.

RGH Pharmacy E Bulletin Volume 46 (10): June 25, 2012

Your Accredited Pharmacist: Susan Gao

You can fax your GP referrals at any time directly to Susan on 

(02) 9803-0140

Susan can be contacted by phone on 0421 531 878

One of the most common topics that I come across in home medication reviews with elderly patients is calcium supplementation.

Recent research has shown that calcium supplements are associated with an increased risk of heart attacks.

As calcium supplements are widely used these modest increases in risk of cardiovascular disease might translate into a large burden of disease in the population.

The study looked at calcium supplements that did not contain vitamin D. Vitamin D deficiency has been associated with increased risk of heart disease and there have been studies showing that vitamin D supplementation is associated with decrease mortality.

An important point to realise is that this study looked at calcium supplementation, not dietary calcium. In previous studies, women with high levels of dietary calcium intake have been found to have a decreased risk of stroke and heart disease.

We know that calcium and vitamin D are important for bone health and can prevent fractures. So what should be recommended to take care of bones but not increase the risk of heart disease?

Until more rigorous studies are done to determine what it is about calcium supplementation that is leading to increase heart disease, the best thing to do is, wherever possible get calcium through food sources including dairy sources like milk, cheese, yoghurt or non dairy sources like almonds, tofu and spinach.

Your Accredited Pharmacist: Susan Gao

You can fax your GP referrals at any time directly to Susan on (02) 9803-0140

Susan can be contacted by phone on 0421 531 878

As you may be aware there was a recent call for a moratorium on home medication reviews (HMR) by the pharmacy guild due to overspend on the program.

I am pleased to announce that the health minister has decided against a moratorium due to the value and importance of HMRs in the community and has increased the funding for the program to continue. She has made some changes to the program to ensure its sustainability and to optimise patient outcome.

Changes include;

- Medication reviews to be conducted in the patient’s home by an accredited pharmacist. Under the program HMRs can only be conducted outside the home of clients where there is pre-approval for defined circumstances – such as patient or pharmacist safety, or for cultural reasons (gained through Medicare)

-To ensure the best result for consumers the Government will also require that reviews, including interviews and written reports for general practitioners, may only be conducted by accredited pharmacists.

Research has shown that this program saves the Government money by reducing the hospital admissions needed to treat patients who accidently use their medicines in a potentially life-threatening way. In fact research shows this program can prevent up to 255,000 hospital admissions per year, representing significant savings for the Government and preventing Australian patients from suffering needless illnesses and death.

The health Minister’s letter confirming the importance of HMRs

“I was reading your website (AusPharmList) and I was interested to read the many first hand examples of how the HMR program is helping people and saving the Government and the health system. In addition, I am very aware that the HMR program has a strong evidence base and has been supported through successive Agreements since 2001. HMRs provided by accredited pharmacists in patients’ homes delivers very real and tangible health outcomes for around 77,000 Australians each year.

I can assure you that through the Fifth Agreement the Government has committed to funding the HMR program through to June 2015 and I’ve decided against a moratorium on HMRs because reducing preventable medication misadventure is too important.

I would also like to congratulate the accredited pharmacists providing HMRs across Australia for the outcomes you have achieved. Some of the examples I have received through letters, emails, and through AusPharmList are remarkable and demonstrate the important and valuable role provided by pharmacists through improving medication management.”

Tanya Plibersek
Minister for Health

Your Accredited Pharmacist: Susan Gao

You can fax your GP referrals at any time to Australian medication reviews on (02) 9803-0140

Susan can be contacted by phone on 0421 531 878

Susan and her accredited pharmacists service all areas of Sydney.

Languages spoken by her team of pharmacists include; English, Mandarin Cantonese, Russian, Ukrainian and Greek.

The prevalence of vitamin D deficiency varies, with the groups at greatest risk including housebound, community-dwelling older and/or disabled people, those in residential care, dark-skinned people (particularly those modestly dressed), and other people who regularly avoid sun exposure or work indoors.

Most adults are unlikely to obtain more than 5%–10% of their vitamin D requirement from dietary sources. The main source of vitamin D for people residing in Australia and New Zealand is exposure to sunlight. A serum 25-hydroxyvitamin D (25-OHD) level of ≥ 50 nmol/L at the end of winter (10–20 nmol/L higher at the end of summer, to allow for seasonal decrease) is required for optimal musculoskeletal health.

Although it is likely that higher serum 25-OHD levels play a role in the prevention of some disease states, there is insufficient evidence from randomised controlled trials to recommend higher targets.

For moderately fair-skinned people, a walk with arms exposed for 6–7 minutes mid-morning or mid-afternoon in summer, and with as much bare skin exposed as feasible for 7–40 minutes (depending on latitude) at noon in winter, on most days, is likely to be helpful in maintaining adequate vitamin D levels in the body.

When sun exposure is minimal, vitamin D intake from dietary sources and supplementation of at least 600 IU (15 μg) per day for people aged ≤ 70 years and 800 IU (20 μg) per day for those aged > 70 years is recommended. People in high-risk groups may require higher doses.

There is good evidence that vitamin D plus calcium supplementation effectively reduces fractures and falls in older men and women.

https://www.mja.com.au/journal/2012/196/11/vitamin-d-and-health-adults-australia-and-new-zealand-position-statement

Abstract
To examine the effectiveness of a multidisciplinary service model delivering medication review to patients at risk of medication misadventure in the community.Methods

The study was carried out in three Australian states; Queensland, New South Wales and Western Australia, and conducted as a randomized, controlled effectiveness trial with the general practitioner (GP) as the unit of randomization. In total, 92 GPs, 53 pharmacists and 400 patients enrolled in the study. The multidisciplinary service model consisted of GP education, patient home visits, pharmacist medication reviews, primary healthcare team conferences, GP implementation of action plans in consultation with patients, and follow-up surgery visits for monitoring. Effectiveness was assessed using the four clinical value compass domains of (i) functional status, (ii) clinical outcomes, (iii) satisfaction and (iv) costs. The domains of functional status (assessed by the health-related quality of life measure SF-36 subscales) and clinical outcomes (as assessed by adverse drug events (ADEs), number of GP visits, hospital services and severity of illness) were measured at baseline and endpoint. Satisfaction was measured by success in implementation and by participant satisfaction at endpoint, and costs (as assessed using medication and healthcare service costs, less intervention costs) were measured preintervention and during the trial. In addition, process evaluation was conducted for intervention patients, in which problems and recommendations from the medication reviews were described.Results

The model was successfully implemented with 92% of intervention GPs suggesting that the model had improved the care of participating patients, a view shared by 94% of pharmacists. In addition, positive trends in clinical outcomes (ADEs and severity of illness) and costs (an ongoing trend towards reduction in healthcare service costs) were evident, although the trial was limited to a 6-month intervention time. No differences between intervention and control groups were identified for the health-related quality of life domain. The cost–effectiveness ratio for the intervention based on cost savings, reduced adverse events and improved health outcomes was small. The most common problems identified in the medication reviews were potential adverse drug reactions, suboptimal monitoring and adherence/lack of concordance issues. In total, 54.4% of recommendations were enacted, and 23.9% were implemented precisely as recommended in the medication review. Follow-up evaluation showed that 70.9% of actions had a positive outcome, 15.7% no effect and 3.7% had a negative outcome.Conclusions
Most studies emphasize efficacy and the best achievable clinical outcomes rather than whether an intervention will be effective in practice. The current trial showed that three of the four domains in the clinical value compass showed trends of improvement or were indeed improved in the relatively short follow-up period of the trial, suggesting that a service based on this model could achieve similar benefits in practice. A domiciliary medication review programme similar to this model has now been implemented into national Australian practice, where GPs and pharmacists are reimbursed by the Australian government for the provision of these services.

For more information on the HMR Process, please click here

….”It is axiomatic that two professionals from complementary but distinct disciplines will provide better care than one professional.  The fact is that doubling the number of health professionals will be a more expensive service.  Understanding what features of collaborative care result in health gains are critical if we are to afford the better health care that we all want.”…

read the article here

The conclusion was that Medicines review in the practice setting is effective in delaying time to next hospitalization for heart failure in those treated with heart failure medicines.

Click here for the full journal article

For more information on the HMR process, please click here

Changes will be made to the Home Medicines Review program as part of the Fifth Community Pharmacy Agreement.

The Home Medicines Review (HMR) is funded under the Fourth Community Pharmacy Agreement designed to assist individuals living at home to maximise the benefits of their medicine regimen and prevent medication related problems. It is not available for in-patients of a hospital, day hospital facility or care recipients in residential aged care facilities.

The review involves the consumer’s general practitioner and preferred community pharmacy and in some cases other relevant members of the healthcare team such as nurses in community practice or carers are included. In cooperation with the individual’s general practitioner, the pharmacist visits the individual at home, reviews their medicine regimen, and provides the general practitioner with a report. The general practitioner and consumer then agree on a medicine management plan. read more