NOVEMBER 2014PROFESSIONAL DEVELOPMENT AND PRACTICE SUPPORT FOR THE SELF CARE PROGRAM

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Low-dose aspirinQCPP

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2 inPHARMation November 2014 I © Pharmaceutical Society of Australia Ltd.

John Bell says

Vol.15 NUMBER 10

NOVEMBER 2014

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Contents

PHARMACIST CPD 4 Facts Behind the Fact Card: Low-dose aspirin

PHARMACY ASSISTANT’S EDUCATION12 Counter Connection: Low-dose aspirin

REGULARS03 Health column

16 Noticeboard

Low-dose aspirin is used as an antiplatelet agent for secondary prevention of cardiovascular events such as myocardial infarction, stroke and vascular death in patients with established cardiovascular disease.See page 4, Facts Behind the Fact Card: Low-dose aspirin

3inPHARMation November 2014 I © Pharmaceutical Society of Australia Ltd.

Assisting with aspirinBy Jill Malek

Aspirin is one of the most commonly used drugs worldwide. Customers have easy access to aspirin both over-the-counter in pharmacies and in supermarkets and convenience stores. It has known benefits in reducing the risk of clotting but also can cause serious side effects.

Aspirin has a dual action as an antiplatelet and anti-inflammatory agent. Its effects are due to the inhibition of the enzyme, cyclo-oxygenase (COX). Aspirin’s effect on COX and its response is dose dependent. At low dose (75–300 mg per day), aspirin causes an antithrombotic effect. At higher doses (>325 mg per day), it causes both antithrombotic as well as analgesic and anti-inflammatory effects.

The use of long-term low-dose aspirin in the secondary prevention of cardiovascular disease (CVD) is well established. Many trials have shown the effectiveness of low-dose aspirin in reducing the risk of future CVD events such as non-fatal stroke, myocardial

infarction (MI) and transient ischaemic attacks in consumers with pre-existing CVD.

In the current Guidelines for the management of Absolute cardiovascular disease risk low-dose aspirin is not routinely recommended in primary CVD prevention. It was previously used in primary CVD prevention but its role is limited by the risk of adverse effects including bleeding (of which gastrointestinal bleeding is the most common).

In this issue of inPHARMation, the role of the pharmacist and pharmacy staff in educating customers about the adverse effects that may occur when taking low-dose aspirin is reviewed. Customers who are taking low-dose aspirin should be monitored and encouraged to report any signs of bleeding including easy bruising, red or brown urine, prolonged bleeding from cuts and wounds and frequent, difficult-to-stop nosebleeds. As aspirin is so readily available, customers may not appreciate that aspirin has harmful

Health column

effects and can interact with other easily available medicines (e.g. NSAIDs). Counter connection highlights which customers should and should not be taking aspirin. It also encourages customers to be shown which medicines they should avoid when taking low-dose aspirin and which medicines are most appropriate when taking low-dose aspirin for conditions such as headache, migraine and inflammation.

Everyone’s blood pressure varies with their daily activities. For example, our blood pressure is usually lower when we sleep and higher when we are excited or anxious. Blood pressure that is constantly higher or lower than the normal range can cause serious problems. The medical name for constantly high blood pressure is hypertension.

Signs and symptomsMost people with high blood pressure have no symptoms and feel well. However, over time, constantly high blood pressure can cause heart and blood vessel disease and lead to problems including:

• brain damage (e.g. stroke, dementia)

• heart damage (e.g. heart attack, heart failure)

Blood pressure is the pressure of blood against artery walls. We all need some blood pressure, called normal blood pressure, to stay alive, but blood pressure that is higher than normal can be dangerous. A healthy lifestyle helps keep blood pressure normal and some medicines can help to reduce high blood pressure.

• kidney damage

• eye damage (e.g. blindness).

The only way to find out if blood pressure is high is to measure it. Regular blood pressure checks can help to detect high blood pressure before any damage is done.

High blood pressure(also called hypertension)

CHRONIC CONDITIONS

Exercise and the heart

Benefits of exerciseSome of the health benefits of regular exercise are:

• lower blood pressure

• lower blood cholesterol

• lower risk of or better control of heart disease

• lower risk of or better control of diabetes

• lower risk of some cancers

• better weight control

• stronger and healthier bones, muscles and joints which reduces the risk of falls and injuries

• better posture

• increased feelings of wellbeing and relief of stress, anxiety and depression

• more energy

• better sleep.

Heart disease is the leading single cause of death in Australia. You can reduce your risk of heart disease by doing some exercise every day. Regular exercise helps lower your blood pressure, blood cholesterol and body weight. You can reduce your risk of heart disease even more by eating a healthy diet as well as doing regular exercise.

EXERCISE

Regular exercise is important for all people, no matter what their age, weight, health problems or abilities. Children and teenagers who do regular exercise are less likely to have high blood pressure, obesity, diabetes and heart disease when they are adults. Regular exercise also helps older people to stay healthy, independent and active.

P: 1300 369 772 » selfcare@psa.org.au » www.psa.org.au/selfcare

Heart healthfor your patients

» Step by step guide to implementing cardiovascular professional services

» Position your pharmacy as a health destination

» Access PPIs and other income streams

» Train your staff

The cardiovascular ACTION kit is here!

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John Bell says

Low-dose aspirinBy Jill Malek

Learning objectivesAfter reading this article, the pharmacist should be able to:

• Discuss the use of low-dose aspirin in primary and secondary prevention of CVD

• Recognise the significance of different doses of aspirin

• Evaluate the adverse effects of low-dose aspirin and their role in limiting its use

• Counsel consumers about low-dose aspirin therapy, with a focus on adverse effects.

Competencies addressed (2010): 4.2, 6.1, 6.2, 6.3, 7.1, 7.2, 7.3.

Aspirin has a dual action as an antiplatelet and anti-inflammatory agent.

This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.

2GROUP 2

UP

TO

CPD CREDITS

Low-dose aspirin is used as an antiplatelet agent for secondary prevention of cardiovascular events such as myocardial infarction (MI), stroke and vascular death in patients with established cardiovascular disease (CVD).1 Its benefit for use in primary prevention is limited by the risk of bleeding (mostly gastrointestinal) and is currently not recommended.1,2 With one in six Australians currently affected by CVD3, research is continuing into the role of low-dose aspirin in primary CVD prevention.

Facts Behind the Fact Card Low-dose aspirin Pharmacist CPD Module number 254

Richard (82 years old) had a coronary stent put in following an MI 3 months ago. He brings in a new prescription for CoPlavix (clopidogrel 75 mg, aspirin 100 mg) one daily. His other medications include Zinopril (lisinopril) 20 mg daily, Lopresor (metoprolol) 100 mg daily and Lipitor (atorvastatin) 80 mg daily.

You explain to Richard that the new medicine is used to reduce the risk of heart attacks and strokes in people who have had a stent put in their heart. It helps to prevent blood clots from forming. You remind him that it is important to tell you and his doctor if he is taking any other medicines, including those bought without a prescription and herbal or complementary medicines.

Action of low-dose aspirinAspirin has a dual action as an antiplatelet and anti-inflammatory agent. Its effects are a result of its irreversible inhibition of the enzyme cyclo-oxygenase (COX). The two forms of COX are COX-1, which facilitates

the production of prostaglandins, and COX-2, which regulates the pain and inflammation response when tissue is damaged.4–6 Aspirin’s effects on COX are dose-dependent:

• Low doses of aspirin (75–300 mg per day) inhibit COX-1, reducing the synthesis of thromboxane A2 (an inducer of platelet aggregation synthesised in platelets), thereby preventing platelet aggregation.7 This action occurs almost immediately and at doses as low as 75 mg.5

• Higher doses of aspirin (≥325 mg per day) inhibit both COX-1 and COX-2, blocking prostaglandin production and producing analgesic and anti-inflammatory effects.4 The synthesis of prostacyclin is also inhibited, which can paradoxically lead to thrombotic effects.7

Inhibition of COX-1 by low-dose aspirin can also lead to damage and ulceration in the gastrointestinal tract (GIT). The enzyme is needed to maintain a thick stomach lining, and regular aspirin use can lead to a thinning of the mucosa that protects the stomach from gastric juices. Ulcers, bleeding and, in some cases, perforation of the stomach can occur.4

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Practice point 1

Low-dose aspirin and cancer

Recent research has shown that low-dose aspirin may reduce the risk of cancer. Long-term daily use of low-dose aspirin may prevent certain types of cancer, including colorectal, oesophageal, stomach, prostate and breast cancer. The effect of aspirin on cancer risk appears not to become evident until a person has been taking aspirin for at least 5 years.27 As is the case with the use of aspirin to prevent cardiovascular events, its benefits in cancer risk reduction must be considered against the risk of bleeding.28

The use of aspirin to prevent cancer is still being investigated. Questions that need to be answered before aspirin can be recommended for cancer prevention include29:

• What is the optimum dose to provide the best protection against cancer with the lowest risk of serious side effects?

• Who is most likely to benefit from aspirin use?

• Which cancers does aspirin protect against?

• How long after stopping aspirin does its anticancer protective effect last?

Until more definitive recommendations can be made, people considering taking aspirin to reduce the risk of cancer should be advised to consult their doctor first.29

Facts Behind the Fact CardLow-dose aspirin Pharmacist CPD Module number 254

Primary preventionPrimary prevention involves taking measures to prevent the onset of a disease or health problem. Primary prevention strategies include immunisation, beneficial lifestyle changes (e.g. smoking cessation, exercise, healthy diet), and preventive pharmacotherapy (e.g. malaria prophylaxis).8

The aim of current primary prevention strategies for CVD (including MI, stroke, transient ischaemic attack (TIA), peripheral vascular disease, angina and heart failure6,9)

is to reduce absolute CVD risk.2 The National Vascular Disease Prevention Alliance (NVDPA) guidelines for the management of absolute cardiovascular disease risk define absolute CVD risk as the likelihood (as a percentage) of a person experiencing a cardiovascular event within the next 5 years. Absolute CVD risk is categorised are low (<10%), moderate (10–15%) and high (>15%).1,9

Previously, primary prevention was based on managing single risk factors. Rather than assessing and managing a patient’s absolute CVD risk, individual risk factors such as hypertension or hyperlipidaemia were treated. Current guidelines recommend reducing absolute CVD risk by managing multiple risk factors. It has been shown that a moderate reduction in several risk factors is more effective in reducing absolute CVD risk than a major reduction in one factor. One aim of this approach is to avoid inappropriate treatment of patients, particularly those in the low-risk category.1,9

In earlier guidelines, low-dose aspirin was recommended for primary prevention in patients without CVD but who were at increased CVD risk.10 However, recent studies have raised doubts about whether the benefits of low-dose aspirin for primary prevention outweigh the risks of gastrointestinal (GI) and intracerebral bleeding.11 Meta-analyses of several primary prevention studies have demonstrated that

low-dose aspirin reduces the relative risk of cardiovascular events by 14% in men and 12% in women, but that this is accompanied by up to a 70% increase in the relative risk of major bleeds. These meta-analyses also demonstrated that low-dose aspirin significantly reduces the risk of stroke in women (but not in men), and of non-fatal MI in men (but not in women). Absolute benefits were calculated to be 0.30% for women and 0.37% for men. Absolute risks were found to be 0.25% in women and 0.33% in men. In practical terms, this means that giving low-dose aspirin for primary prevention for an average of 6.4 years will prevent three cardiovascular events but cause 2.5 major bleeds per 1,000 women, and will prevent four cardiovascular events but cause three major bleeds per 1,000 men. The relatively small benefits need to be balanced against the potential risks. The increasing use of statins may have contributed to the apparent reduction in the benefits of aspirin in recent trials.1,5,7,12

Previously, patients with diabetes were routinely treated with low-dose aspirin, as it was believed that they had the same CVD risk as people with CVD but without diabetes. However, recent studies have found no evidence that primary prevention with low-dose aspirin reduces the risk of cardiovascular events in patients with diabetes.9 The risk of CVD increases with age, but elderly people are also at increased risk of GI bleeding. There is currently not enough information to draw definitive conclusions about the benefits vs. risks of low-dose aspirin for primary prevention in older people.12 The current NVDPA guidelines recommend that low-dose aspirin (and other antiplatelet therapy) should not be routinely recommended for primary prevention of CVD.1 This includes people at high CVD risk and those with type 2 diabetes.1

The use of low-dose aspirin in primary prevention continues to be researched. Many studies have been conducted

Table 1. Low-dose aspirin in CVD prevention5,6

Prevention of CVD

Diagnosis Antiplatelet treatment Duration of treatment

Primary No established diagnosis of CVD

Not routinely recommended n/a

Secondary Established diagnosis of CVD

• Start low-dose aspirin (75–150 mg daily) unless contraindicated

• Consider alternative antiplatelet agent (e.g. clopidogrel 75 mg daily) if aspirin hypersensitivity

Lifelong

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John Bell says

Practice point 2

Risk factors for gastrointestinal bleeding

Aspirin directly damages the gastrointestinal epithelium, leading to gastric ulceration and bleeding. Factors associated with an increased risk of upper GI bleeding and perforation in people taking low-dose aspirin include5,12:

• older age

• history of peptic ulcer disease or upper GI bleeding

• use of other medicines (e.g. anticoagulants, other antiplatelet agents, NSAIDs, selective serotonin reuptake inhibitors (SSRIs), corticosteroids)

• Helicobacter pylori infection

• significant comorbidity

• smoking

• excessive alcohol intake.

Facts Behind the Fact Card

reviewing its role and the impact of adverse effects.11–13 Studies are currently being conducted to clarify aspirin’s role in primary prevention in older people and people with diabetes. These include A Study of Cardiovascular Events iN Diabetes (ASCEND), which aims to provide further data on the effectiveness of aspirin for primary prevention in people with diabetes.14 Another trial, ASPirin in Reducing Events in the Elderly (ASPREE), is currently being conducted in Australian general practice to determine whether the benefits of low-dose aspirin outweigh the risks in healthy people aged ≥70 years. Results of the main ASPREE study should be known in 2018.15

Low-dose aspirin is increasingly being considered for use in the primary prevention of some cancers – particularly bowel cancer.11,16 See Practice point 1.

Secondary preventionSecondary prevention involves preventing complications and slowing progression of established disease.11,12 The use of long-term low-dose aspirin in the secondary prevention of CVD is well established. Many trials have shown the effectiveness of low-dose aspirin in reducing the risk of future cardiovascular events such as non-fatal stroke, MI and TIA in patients with pre-existing CVD. In these patients, the benefits of low-dose aspirin outweigh the risks.10,12

DosingThe usual dose of aspirin for long-term antiplatelet therapy is 75–150 mg once daily. In acute situations (e.g. MI, acute ischaemic stroke, unstable angina, implantation of coronary stent), when an immediate antiplatelet effect is needed, a loading dose of 150–300 mg of aspirin

can be given. This dose produces complete inhibition of thromboxane-mediated platelet aggregation within 30 minutes. The long-term use of aspirin in doses above 300 mg daily does not offer further antithrombotic benefits and increases the risk of clinically significant adverse effects.5,6

Aspirin and bleedingBleeding (particularly GI bleeding) is a recognised adverse effect of aspirin.

GI bleeding is associated with a higher risk of MI and death in patients with CVD. Treatment of CVD with aspirin must therefore be balanced against the risk of GI bleeding.12 See Practice point 2.

The risk of bleeding (including fatal bleeds) is significantly higher with analgesic doses of aspirin (≥300 mg up to 4 times/day) than with lower antiplatelet doses (75–150 mg/day). However, even at lower doses, the risk of GI bleeding is doubled compared with no aspirin.7,12 The risk of GI bleeding is not reduced by using enteric-coated tablets.6 For patients taking low-dose aspirin, concomitant use of a proton pump inhibitor may reduce the risk of aspirin-induced ulceration and bleeding.5,11 See Practice point 3.

Pharmacists should advise patients who are taking low-dose aspirin to be alert for signs of bleeding. These include17:

• easy bruising; bruises that take longer than normal to heal

• red or dark-brown urine

• red or black bowel motions

• frequent or persistent nosebleeds

• difficulty breathing or swallowing

• coughing up blood

• heavier than usual menstrual periods

• prolonged bleeding from cuts and wounds

• dark or blood-stained vomit

Low-dose aspirin Pharmacist CPD Module number 254

Table 2. Aspirin dosage in CVD5,6

Aspirin dose Action Counselling

150–300 mg (loading dose)

For immediate antiplatelet effect in MI, unstable angina or acute ischaemic stroke

Full inhibition of platelet aggregation within 30 minutes

Note: Without a loading dose, daily doses of 100 mg achieve maximal inhibition of thromboxane formation and platelet aggregation within 4–5 days

Crushing, sucking or chewing a tablet may give more rapid absorption

Avoid enteric-coated preparations

75–150 mg daily Continuous inhibition of thromboxane production from newly-formed platelets, while minimising GI adverse effects

Take daily at the same time each day.

Remove tablet from packaging just before use to avoid tablet degrading

Take after food or use enteric-coated tablets to reduce GI adverse effects

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Practice point 3

Low-dose aspirin and proton pump inhibitors

Proton pump inhibitors (PPIs) are recommended for use with low-dose aspirin in people who are at high risk of GI bleeding (see Practice point 2), to prevent and treat the upper GI adverse effects of aspirin.5,6

Low-dose aspirin use increases the risk of gastric ulceration. About 1 in 10 long-term users of low-dose aspirin will develop an ulcer, although most will not have any symptoms. Primary prevention with a PPI reduces the absolute risk of peptic ulceration by 6.3% after 6 months and, to a lesser extent, the risk of bleeding.5

Once-daily doses of PPIs (e.g. esomeprazole 20 mg, omeprazole 20 mg, pantoprazole 40 mg) are recommended. In patients who have developed a bleeding peptic ulcer while taking aspirin and still require antiplatelet therapy, PPI use reduces the risk of recurrent ulcer bleeding. Recurrent bleeding is less likely with continued aspirin use and PPI prophylaxis than with a switch from aspirin to clopidogrel.5,6

Facts Behind the Fact Card

Related Fact Cards Exercise and the heart

High blood pressure

Weight and health

Staying a non smoker

• severe headache or dizziness

• unexplained pain, swelling or discomfort.

Aspirin and allergyAspirin can (rarely) cause hypersensitivity characterised by rash, urticaria and angioedema. It can also cause bronchospasm and exacerbate asthma symptoms. People who experience sudden, severe asthma (e.g. admitted to intensive care with asthma), recurring nasal polyps, urticaria, or chronic nasal congestion/rhinitis are at increased risk of developing aspirin-induced asthma.16–18

Symptoms of aspirin allergy may occur 1–3 hours after taking aspirin and include17,18:

• swelling of the face, lips or tongue, making swallowing or breathing difficult

• asthma, wheezing, shortness of breath

• sudden or severe itching, skin rash, hives. Aspirin should be avoided by people who have previously experienced rhinitis or wheezing 1–3 hours after taking aspirin or an NSAID, and anyone who has been diagnosed with aspirin/NSAID-intolerant asthma (AIA).18

Combination therapy with aspirinDual antiplatelet therapy (a combination of low-dose aspirin and another antiplatelet agent, e.g. clopidogrel, prasugrel or ticagrelor) provides more complete platelet inhibition by inhibiting platelet function via different pathways. Dual antiplatelet therapy is recommended after acute coronary syndrome (ACS). ACS is an acute cardiac event due to complete or partial obstruction of a coronary artery, and encompasses unstable angina and MI with or without elevation of the ST segment of the ECG. Dual therapy prevents more thrombotic events after ACS than aspirin alone, but increases the risk of bleeding.6,19–21

Low-dose aspirin can also be used in combination with the antiplatelet agent dipyridamole in the secondary prevention of stroke. The combination of dipyridamole 200 mg and aspirin 25 mg is slightly more effective than aspirin alone and has a comparable risk of bleeding to clopidogrel. Dipyridamole alone has similar antiplatelet efficacy to aspirin, and may be used if there is intolerance to aspirin and clopidogrel. Headache is a common adverse effect of

dipyridamole, and may affect compliance.5,6 See Table 3.

Aspirin resistance

Aspirin resistance is not clearly defined. It is thought to be the inability of standard antiplatelet doses of aspirin (75–300 mg/day) to inhibit thromboxane A2 formation and reduce platelet aggregation. The prevalence of true pharmacological aspirin resistance is believed to be rare (about 1%). The occurrence of a cardiovascular event during low-dose aspirin therapy may not necessarily be due to aspirin resistance. Antiplatelet therapy reduces, but does not eliminate, the risk of cardiovascular events.

In addition, treatment failure may be due to other factors, such as poor compliance, inadequate dose, or delayed and reduced absorption (which has been linked to the enteric coating on some formulations of aspirin). There are currently no reliable tests to confirm aspirin resistance.6,22,23

Role of the pharmacist

As low-dose aspirin is available over-the-counter, pharmacists should advise customers on its use.

• Risk of side effects: GI side-effects are common with aspirin. Uncoated tablets should be taken with or after food. Enteric-coated tablets may reduce the risk of GI upset (but not ulceration or bleeding). Advise customers to tell their doctor or pharmacist if they experience any abdominal pain, melaena (black, tarry faeces) or rectal bleeding. A serious fall or injury may result in internal bleeding. Therefore, suggest that customers report any injuries to their doctor, even if there are no obvious signs of bleeding.6,17

• Taking other medicines: if aspirin is being taken with another antiplatelet agent (e.g. clopidogrel) or an anticoagulant (e.g. warfarin) advise the patient to be extra careful about monitoring for any signs of bleeding.6 See also Practice point 4.

• Take the correct dose: as aspirin is available in different strengths, determine the reason for use to avoid incorrect dosing and the risk of adverse effects. There is no advantage in taking higher analgesic doses of aspirin for preventing thrombotic events.17

• Encourage adherence: up to 40% of patients do not adhere to low-dose aspirin treatment.6 Poor adherence may increase

Low-dose aspirin Pharmacist CPD Module number 254

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John Bell saysFacts Behind the Fact Card

Practice point 4

Aspirin-drug interactions

Medicines that can increase the risk of bleeding with low-dose aspirin include5,6,30:

• anticoagulants (e.g. warfarin, enoxaparin, heparin, dabigatran, rivaroxaban)

• other antiplatelet agents (e.g. clopidogrel, prasugrel, ticagrelor)

• NSAIDs (may also reduce the antiplatelet activity of low-dose aspirin)

• SSRIs (e.g. citalopram, fluoxetine, paroxetine, sertraline)

• corticosteroids

• anagrelide.

Other medicines that can interact with low-dose aspirin include6,30:

• methotrexate – increased risk of GI ulceration; possible increased serum levels of methotrexate (less likely with low-dose aspirin and low doses of methotrexate).

the risk of adverse CV outcomes such as stroke, MI and death.24 The use of a dose administration aid may help to improve compliance.

• Taking aspirin without medical advice: some people may believe that low-dose aspirin is ‘good for the heart’ or ‘prevents heart attacks’. Emphasise that low-dose aspirin does not prevent all cardiovascular events, but can lower the risk in people with pre-existing CVD. Low-dose aspirin should only be taken on the recommendation of a doctor.26

• Pain relief: if the customer needs pain relief (e.g. for a headache), advise the use of paracetamol rather than a non-steroidal anti-inflammatory drug (NSAID) or aspirin. Ensure that consumers are familiar with the names of medicines containing NSAIDs available OTC and in supermarkets.17

• Use in children: aspirin should not be used in children under 16 years of age who have fever and/or chicken pox or measles. There is an association between the use of aspirin in children and the development of Reye’s syndrome.6,25

• Pregnancy and breastfeeding: aspirin is pregnancy category C. Analgesic doses of aspirin are not recommended during the third trimester. However, low-dose aspirin is considered safe to take during pregnancy and breastfeeding.6

• Other medical conditions: aspirin is contraindicated in conditions associated with a high risk of bleeding i.e. bleeding

disorders, erosive gastritis or peptic ulcer disease, severe hepatic disease. Aspirin is also contraindicated in aspirin-sensitive asthma.6

• Surgery: aspirin in analgesic/anti inflammatory doses should, if possible, be stopped at least 7 days before surgery. However, low-dose aspirin can be continued for low-risk procedures (e.g. dental procedures). For high-risk procedures it may be stopped up to 7 days before surgery, but withdrawal of treatment may cause an increased risk of a cardiac event. The decision whether to cease aspirin therapy should be made by the surgeon.6

• When/how to take: advise the customer to take aspirin at about the same time each day. Aspirin breaks down quickly when exposed to air and moisture. The tablets or capsules should be removed from packaging immediately prior to use. If using dispersible tablets, mix with water and take immediately. Do not crush tablets or open capsules.6

A week later, Richard returns to the pharmacy. He asks the pharmacy assistant for a box of Astrix (aspirin 100 mg). He mentions that he forgot to get it last week. After questioning Richard, the pharmacy assistant asks you to speak to him.

You explain that CoPlavix and Astrix both contain aspirin, and advise him to stop

Low-dose aspirin Pharmacist CPD Module number 254

Table 3. Dual antiplatelet therapy with aspirin5,6

Antiplatelet therapy Use Dose Side effects

Aspirin + clopidogrel

Prevention of atherothrombotic events in ACS

Prevention of thrombosis after coronary angioplasty

Aspirin: 300 mg initially, then 75–150 mg daily

Clopidogrel: 300 mg initially, then 75 mg daily

Increased risk of bleeding, diarrhoea, GI ulceration, skin rash

Aspirin + dipyridamole

Secondary prevention of ischaemic stroke and TIA

Aspirin: 25 mg twice daily

Dipyridamole: 200 mg twice daily

Headache, diarrhoea, nausea, vomiting, flushing, hypotension, dizziness

Aspirin + prasugrel Prevention of atherothrombotic events in ACS

Aspirin: 300 mg initially, then 75–150 mg daily

Prasugrel: 60 mg initially then 10 mg daily (5 mg daily if >75 years or <60 kg)

Bleeding

Aspirin + ticagrelor Prevention of atherothrombotic events in ACS

Aspirin: 300 mg initially, then 75–150 mg daily

Ticagrelor: 180 mg initially, then 90 mg twice daily

Bleeding (may be severe), rash, itch

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Facts Behind the Fact CardLow-dose aspirin Pharmacist CPD Module number 254

Practice point 5

Low-dose aspirin and complementary medicines

Although evidence is limited, some complementary medicines may increase the risk of bleeding when taken with low-dose aspirin. They include31,32:

• bilberry

• dong quai

• evening primrose oil

• feverfew

• fish oil (doses >3 g/day)

• garlic

• ginger

• ginkgo

• horse chestnut

• saw palmetto

• red clover

• willow bark.

taking Astrix. You tell him that if he takes both Astrix and CoPlavix, it will increase his risk of bleeding, which is a potentially dangerous side effect of aspirin. It is important for Richard to understand that he should not take any other medicines containing aspirin or any other NSAIDs unless they are recommended by his doctor. A detailed description (including showing him the boxes) of which products (including OTC products) contain aspirin or other NSAIDs may be helpful. You advise him that if he notices any unusual or unexplained bleeding, he should immediately return to the pharmacy or tell his doctor.

You remind Richard that CoPlavix also has other side effects, such as stomach upset/pain and diarrhoea or constipation. He may also bruise more easily. If he experiences any of these side effects and they are severe, he should return to the pharmacy or contact his doctor.

You remind Richard to take the CoPlavix once daily at the same time each day and tell him not to stop taking it unless instructed to by his doctor, as stopping it may increase the risk of a cardiac event. You also remind Richard that, if he has to have surgery, he should tell the surgeon that he is taking CoPlavix.

References1. National Vascular Disease Prevention Alliance. Guidelines

for the management of absolute cardiovascular disease risk. National Stroke Foundation; 2012. At: http://strokefoundation.com.au/site/media/AbsoluteCVD_GL_webready.pdf

2. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009;373(9678):1849–1860. At: www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960503-1/fulltext

3. Heart Foundation. Cardiovascular disease fact sheet. 2012. At: www.heartfoundation.org.au/SiteCollectionDocuments/Factsheet-Cardiovascular-disease.pdf

4. Interactive concepts in biochemistry. Aspirin. Wiley; 2006. At: www.wiley.com/legacy/college/boyer/0471661791/cutting_edge/aspirin/aspirin.htm

5. Therapeutic guidelines: eTG complete. Melbourne: Therapeutic Guidelines; 2014.

6. Rossi S, ed. Australian medicines handbook 2014. Adelaide: Australian Medicines Handbook Pty Ltd; 2014.

7. Berger JS, Roncaglioni MC, Avanzini F et al. Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials. JAMA 2006;295(3):306–313. At: http://jama.jamanetwork.com/article.aspx?articleid=202217

8. South Australia. Dept of Health. Statewide Service Strategy Division. Primary Prevention Plan 2011–2016. Government of South Australia; 2011. At: http://www.sahealth.sa.gov.au/wps/wcm connect/fd31550046cd63e9937dfb2e504170d4/PrimaryPreventionPlan20112016-SSS-HPB-1105.pdf?MOD=AJPERES&CACHEID=fd31550046

cd63e9937dfb2e504170d4

9. Nelson MR, Doust JA. Primary prevention of cardiovascular disease: new guidelines, technologies and therapies. Med J Aust 2013;198(11):606–610. At: www.mja.com.au/journal/2013/198/11/primary-prevention-cardiovascular-disease-new-guidelines-technologies-and#15

10. Hung J. Aspirin for cardiovascular disease prevention. Med J Aust 2003;179(3):147–152. At: www.mja.com.au/journal/2003/179/3/aspirin-cardiovascular-disease-prevention#Box6

11. Patrono C. Low-dose aspirin in primary prevention. Eur Heart J 2013;34(44):3403–3411. At: www.medscape.com/viewarticle/815074_6

12. Park K, Bavry A. Aspirin: its risks, benefits, and optimal use in preventing cardiovascular events. CCJM 2013;80(5):318–326.At: www.ccjm.org/content/80/5/318.full.pdf+html

13. Clinical trial service unit and epidemiological studies unit. Antithrombotic trialists’ collaboration. University of Oxford. At: http://www.ctsu.ox.ac.uk/research/meta-trials/att/att-website

14. British heart Foundation. ASCEND – a study of cardiovascular events in diabetes. At: www.ctsu.ox.ac.uk/ascend/

15. Aspirin in reducing events in the elderly. Monash University; 2010. At: http://www.aspree.org/AUS/aspree-content/aspree-study-details/about-aspree.aspx

16. Patient.co.uk. Antiplatelet drugs. 2012. At: www.patient.co.uk/doctor/Anti-platelet-Drugs.htm

17. NPS MedicineWise. Low-dose aspirin to prevent stroke and heart problems. 2012. At: www.nps.org.au/medicines/heart-blood-and-blood-vessels/anti-clotting-medicines/for-individuals/antiplatelets/for-individuals/active-ingredients/aspirin_low_dose

18. National Asthma Council. Aspirin/NSAID-intolerant asthma: pharmacy notes [revised April 2013]. National Asthma Council Australia; 2009. At: http://www.nationalasthma.org.au/uploads/content/199-2009_pain_relievers_and_asthma_quick_reference_guide.pdf

19. Jayasinghe R, Markham R, Adsett G. Dual antiplatelet therapy - management in general practice. Aust Fam Phys 2013;42(10):702–705. At: www.racgp.org.au/afp/2013/october/dual-antiplatelet-therapy/

20. McCann A. Antiplatelet therapy after coronary occlusion. Aust Prescr 2007;30:92–6. At: www.australianprescriber.com/magazine/30/4/92/6

21. NPS Radar. Prodigy study: duration of dual antiplatelet therapy under review. 2012. At: www.nps.org.au/__data/assets/pdf_file/0003/159852/Brief-item-dual-antiplatelet-therapy.pdf

22. Schrör K. What is aspirin resistance? Br J Card 2010;17(Suppl 1): S5–S7. At: http://bjcardio.co.uk/2010/03/what-is-aspirin-resistance/

23. Grosser T, Fries S, Lawson JA et al. Drug resistance and pseudoresistance: an unintended consequence of enteric coating aspirin. Circulation 2013;127:377–385. At: http://circ.ahajournals.org/content/127/3/377.full?sid=b172ac70-8fb9-45c1-a079-2c786a6625b6

24. Herlitz J, Tóth PP, Næsdal J. Low-dose aspirin therapy for cardiovascular prevention: quantification and consequences of poor compliance or discontinuation. Am J Cardiovasc Drugs 2010;10(2):125–141. At: http://link.springer.com/article/10.2165%2F11318440-000000000-00000

25. The Royal Children’s Hospital Melbourne. Anticoagulation guidelines. 2014. At: http://www.rch.org.au/clinicalguide/guideline_index/Anticoagulation_Therapy_Guidelines/

26. The Pharmaceutical Society of Australia. Non-prescription medicines in pharmacy – guide to advice and treatment. Canberra: The Pharmaceutical Society of Australia; 2012.

27. Cuzick J, Thorat M.A, Bosetti et al. Estimates of benefits and harms of prophylactic use of aspirin in the general population. Ann Oncol 2014;00:1–10. At: http://annonc.oxfordjournals.org/content/early/2014/07/30/annonc.mdu225.full.pdf+html

28. Cancer Council Australia. Does an aspirin a day keep cancer away? 2013. At: www.cancer.org.au/news/blog/prevention/does-an-aspirin-a-day-keep-cancer-away.html

29. National Cancer Institute. No easy answers about whether aspirin lowers cancer risk. 2014. At: http://www.cancer.gov/cancertopics/research-updates/2014/aspirin

30. Interactions checker. eMIMS. St Leonards: UBM Medica Australia Pty Ltd; 2014.

31. Medline Plus. Herbs and supplements [revised August 2014]. National Institutes of Health; 2014. At: http://www.nlm.nih.gov/medlineplus/druginfo/herb_All.html

32. Complementary medicines monographs. In: Sansom LN, ed. Australian pharmaceutical formulary and handbook. 22nd edn. Canberra: Pharmaceutical Society of Australia, 2012.

Common colds and the ‘flu’ (influenza) are viral infections affecting the nose, sinuses, throat and airways. Antibiotics do not work against viral infections. Colds and the flu usually get better on their own. Medicines may relieve some of the symptoms of colds and flu.

Flu (influenza) symptoms are like cold symptoms, but are usually more severe and may also include:

• fever and chills (sweating and shivering)

• aching muscles and joints• feeling weak • loss of appetite, nausea and vomiting• diarrhoea.

Most cold and flu symptoms usually last less than 10 days. A cough may last longer.

Protection against influenzaA ‘flu injection’ will give protection against the flu. It is best to have the flu vaccine in autumn each year, as influenza is most common from late autumn to early spring. The flu vaccine is especially recommended for people over 65 years and their carers, adults with certain medical conditions, pregnant women, Aboriginal and Torres Strait Islander people aged

Colds and flu

EAR, NOSE & THROAT

When someone has a cold or the flu, the fluid from their nose, mouth and airways contains the infecting virus. Colds and flu spread when this infected fluid passes to someone-else (e.g. by touch, coughing, sneezing). Colds spread easily, especially between children who spend a lot of time together (e.g. at childcare or school). A cold is most easily spread (infectious) in the first one or two days after symptoms develop.

Signs and symptomsCold symptoms include:

• runny nose• blocked nose (congestion)• sore throat• red, watery eyes• sneezing• cough• fever• headache • feeling tired.

Hay fever is the common name for allergic rhinitis. It is an allergic reaction in the nose, throat and eyes. Hay fever often occurs in spring and summer, when it is caused by airborne pollens from trees, plants and grasses. Medicines can relieve and prevent symptoms of hay fever.

• reducedsenseofsmellandtaste

• snoring

• feelingtired,run-down,irritable.

Hayfeversymptomsareoftenworseinthemornings,onwindydaysandafterthunderstorms(whentheamountofpollenintheairishighest).

Hay fever(Allergic rhinitis)

EAR,NOSE&THROAT

Hayfever,orallergicrhinitis,isusuallycausedbyinhalingpollensthatarepresentintheairatcertaintimesoftheyear.Somepeoplehavesymptomsofallergicrhinitisallyearround.Constantsymptomscanbecausedbyallergenssuchasanimalhair,moulds,housedustmitesandcockroaches.Adoctorcanarrange‘allergyskintests’tohelpfindthecauseofallergicrhinitis.

Signs and symptomsSymptomsofallergicrhinitisinclude:

• sneezing

• runnynose

• blockednose(congestion)

• itchingnose,ears,mouthorthroat

• puffy,itchy,wateryandredeyes

• headaches

• post-nasaldrip(mucusfromthenoseandsinusesrunsdownthebackofthethroat),whichcancausecoughing

Relievers Relievers are short term medicines that open airways quickly by relaxing the muscles around the airways. Reliever inhaler devices are normally blue or grey colours.

Examples of relievers include: Airomir, Asmol, Bricanyl, Ventolin inhalers and Symbicort (for Symbicort SMART)*.

Relievers:

• help relieve asthma symptoms within a few minutes. Their effect can last for 4–6 hours (short-acting)

• should be used only ‘as needed’ for quick relief

• may be used before exercise, to prevent exercise-induced asthma.

Some relievers are available from a pharmacist without a prescription.

Some people may feel a little shaky and notice a fast heart beat for a short

You can control your asthma well by managing the factors that trigger it and by using asthma medicines correctly. Most asthma medicines are inhaled (breathed) into the lungs, but sometimes tablets, syrups or injections have to be used. Asthma medicines are grouped into preventers, for long term use and relievers, for short term use.

time after using a reliever inhaler. Ask a doctor or pharmacist for advice.

*Your doctor may prescribe Symbicort Turbuhaler and Symbicort Rapihaler (in Symbicort SMART) which is a combination inhaler including a reliever plus a preventer. You do not need a separate reliever inhaler as it can be used as a fast acting reliever.

PreventersPreventers are long term medicines. Asthma makes the lining of your airways inflamed (red and swollen). Preventers help to reduce the inflammation and reduce the amount of mucus in airways. They also make airways less sensitive to asthma triggers. They can prevent asthma symptoms and lung damage if used every day.

Asthma medicines

CHRONIC CONDITIONS

Simple guides for checking body weight, and the amount and distribution of body fat include:

• Body Mass Index (BMI) – the ratio of weight to height (kg/m2)

• Waist circumference – a measure of fat around the abdomen (stomach)

• Waist to Hip Ratio (WHR) – the ratio of waist circumference to hip circumference.

Often, using more than one measurement (i.e. BMI and waist circumference) is recommended. A doctor or pharmacist can help with these measurements and explain what your results might mean.

Overweight and obesityPeople who are overweight or obese have too much body fat. Fat around the waist (‘apple shape’) is more of a health risk than fat around the hips and thighs (‘pear shape’).

People who are overweight or obese tend to have higher blood pressure and higher blood cholesterol levels than others, and are more likely to develop heart disease, diabetes or a stroke. The main way to lose weight and improve health is to change eating habits and increase physical activity.

Overweight and obese people are more likely to develop a range of medical conditions including:

• high blood pressure

• heart disease

• high blood cholesterol

• some cancers

• diabetes type 2

• stroke

• joint problems (e.g. osteoarthritis, gout)

NUTRITION

Weight and health

Some symptoms of stress and tension

Mental• Problemswiththinkingandfocus

• Poorjudgment

• Worryingaboutlittlethings

• Problemssleepingand/orbaddreams

• Negativethoughts

• Difficultymakingdecisions

• Poormemory

Emotional• Feelingtense,angry,worried,upset

• Crying

• Lackofinterest

• Depression

Relaxation techniques can reduce the physical and emotional effects of stress and tension. They are simple to learn and help the body and mind cope with stress. If used regularly, relaxation techniques can help you to feel more relaxed and improve your sense of wellbeing.

Relaxation techniques

Behavioural• Problemswithrelationships

• Unsociable

• Increaseduseofnicotine,alcoholor caffeine

• Poortimemanagement

• Lowproductivity

MENTALHEALTH

P: 1300 369 772 » psc.nat@psa.org.au » www.psa.org.au/selfcare PSA is pharmacy.

Make your pharmacy a health destinationPSA’s NEW Health Promotion Resources help you deliver better patient care and connect with your community.

There are 12 topics to choose from with everything you need to deliver and measure a successful health promotion campaign and meet PPI requirements.

Order your health promotion pack today.

You can access free:

» posters (two A2, four A3 and six A4)

» a comprehensive planner

» staff training presentations

» community awareness presentations (some topics only)

» relevant Fact Cards

» KPI tracking forms and other business support tools.

PSA

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11inPHARMation November 2014 I © Pharmaceutical Society of Australia Ltd.

Circle one correct answer from each of the following questions.

Before undertaking this assessment, you need to have read the Facts Behind the Fact Card article and the associated Fact Cards. This activity has been accredited by PSA as a Group 2 activity. Two CPD credits (Group 2) will be awarded to pharmacists with four out of five questions correct. PSA is accredited by the Australian Pharmacy Council to accredit providers of CPD activities for pharmacists that may be used as supporting evidence of continuing competence.

Please submit your assessment by 31 December 2014

Submit answers

Submit online at www.psa.org.au/selfcare

Fax: 02 6285 2869

Mail: Self Care Answers Pharmaceutical Society of Australia PO Box 42 DEAKIN WEST ACT 2600

Accreditation number: CS140010

This activity has been accredited for 1 hour Group 2 CPD (or 2 CPD credits) suitable for inclusion in an individual pharmacist’s CPD plan.

— — — — — —Personal ID number:

Full name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pharmacy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Suburb: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Low-dose aspirinAssessment questions for the pharmacist

Please retain a copy for your own purposes. Photocopy if you require extra copies.

Facts Behind the Fact CardLow-dose aspirin Pharmacist CPD Module number 254

1. Which of the following statements is CORRECT?

a) Aspirin’s pharmacological effects are dose-dependent.

b) Current guidelines recommend that low-dose aspirin should be routinely used for primary prevention in people at high risk of CVD.

c) Secondary CVD prevention is the practise of treating people without CVD to avoid the development of disease.

d) Current guidelines recommend that people with diabetes should be routinely treated with low-dose aspirin.

2. Which of the following statements is CORRECT?

a) Treatment that aims to slow disease progression is known as primary prevention.

b) Low-dose aspirin has been shown to reduce the risk of non-fatal myocardial infarction in patients with existing CVD.

c) Low-dose aspirin significantly reduces the risk of stroke in men (but not in women).

d) Without a loading dose, aspirin 100 mg/day produces maximal inhibition of platelet aggregation within 48 hours.

3. Which of the following statements is CORRECT?

a) Doses of aspirin >300 mg/day are more effective than lower doses in reducing the risk of cardiovascular events.

b) Enteric-coated low-dose aspirin tablets are associated with a reduced risk of GI bleeding.

c) Low-dose aspirin is routinely recommended for primary prevention in people at high risk of bowel cancer.

d) Cigarette smoking increases the risk of bleeding with low-dose aspirin.

4. Bleeding is an adverse effect of aspirin therapy. Of the following statements, which is CORRECT?

a) Low-dose aspirin is not associated with an increased risk of GI bleeding.

b) Aspirin use in older people is associated with an increased risk of GI bleeding.

c) Recurrent bleeding from a peptic ulcer is less likely to occur with a switch from aspirin to clopidogrel than with continued low-dose aspirin and a PPI.

d) The use of more than one antiplatelet drug lowers the risk of GI bleeding.

5. Mary, 70 years old, has been prescribed Astrix 100 mg daily. She also takes Zoloft 50 mg daily, Monopril 10 mg daily, Noten 50 mg daily and Anginine 600 mcg prn. Which of the following counselling points is MOST appropriate?

a) Advise Mary that Astrix tablets are enteric-coated and are therefore less likely to cause gastrointestinal bleeding.

b) Explain to Mary that she should avoid taking medicines such as Nurofen or Voltaren for pain relief while she is taking Astrix.

c) Reassure Mary that the Astrix will not interact with any of her other medicines.

d) Advise Mary to take the Astrix at the same time each day, preferably on an empty stomach.

12 inPHARMation November 2014 I © Pharmaceutical Society of Australia Ltd.

John Bell says

Pharmacy assistants often have to respond to requests from customers for products containing aspirin. It is important that they are aware of the difference between low-dose aspirin products and aspirin products used for relief of pain and inflammation. They should be able to advise customers about the side effects of aspirin and should know when a customer requesting an aspirin product needs to be referred to the pharmacist.

Low-dose aspirinBy Jill Malek This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.

Counter Connection Low-dose aspirin Pharmacy assistant’s education Module 254

AspirinAspirin is a commonly used medicine. It is part of a group of medicines called non-steroidal anti-inflammatory drugs (NSAIDs).  

Aspirin has several different effects in the body:

• It prevents the formation of blood clots, which can cause heart attacks and strokes. When used for this purpose, aspirin is called an anti-platelet medicine.

• It reduces swelling and inflammation. When used for this purpose, aspirin is called an anti-inflammatory.

• It relieves pain. When used for this purpose, aspirin is called an analgesic.

• It lowers high a temperature (fever). When used for this purpose, aspirin is called an antipyretic.

The action of aspirin depends on the dose:

• At a low dose (75–150 mg) aspirin acts to prevent blood clotting.

• At a higher dose (more than 300 mg) aspirin also acts to reduce inflammation (swelling), pain and fever.

Low-dose aspirin

Low doses of aspirin (75–150 mg) reduce the risk of blood clots forming in blood vessels. Blood clots (or plugs) form to stop bleeding when a blood vessel (vein or artery) is damaged. A chemical is released that makes platelets (cells in the blood) stick together to form the clot. If a blood clot forms in an artery in the heart or brain, it may cause a heart attack or stroke. See Table 1.

Specific low-dose aspirin products containing 100 mg of aspirin, are available over-the-counter in tablet or capsule form. Larger pack sizes (< 100 unit doses) are Pharmacy medicines. The safe use of these products, may require advice from a pharmacist. Some low-dose aspirin tablets and capsules have an enteric coating to reduce gastrointestinal side effects (e.g. nausea, heartburn).

Examples of low-dose aspirin preparations include:

• tablets (e.g. Astrix, Spren, Cardiprin 100)

• enteric-coated tablets (e.g. Cartia, Nyal Low Dose Aspirin)

Low-dose aspirin is available over-the-counter in tablet and capsule form.

Everyone’s blood pressure varies with their daily activities. For example, our blood pressure is usually lower when we sleep and higher when we are excited or anxious. Blood pressure that is constantly higher or lower than the normal range can cause serious problems. The medical name for constantly high blood pressure is hypertension.

Signs and symptomsMost people with high blood pressure have no symptoms and feel well. However, over time, constantly high blood pressure can cause heart and blood vessel disease and lead to problems including:

• brain damage (e.g. stroke, dementia)

• heart damage (e.g. heart attack, heart failure)

Blood pressure is the pressure of blood against artery walls. We all need some blood pressure, called normal blood pressure, to stay alive, but blood pressure that is higher than normal can be dangerous. A healthy lifestyle helps keep blood pressure normal and some medicines can help to reduce high blood pressure.

• kidney damage

• eye damage (e.g. blindness).

The only way to find out if blood pressure is high is to measure it. Regular blood pressure checks can help to detect high blood pressure before any damage is done.

High blood pressure(also called hypertension)

CHRONIC CONDITIONS

Exercise and the heart

Benefits of exerciseSome of the health benefits of regular exercise are:

• lower blood pressure

• lower blood cholesterol

• lower risk of or better control of heart disease

• lower risk of or better control of diabetes

• lower risk of some cancers

• better weight control

• stronger and healthier bones, muscles and joints which reduces the risk of falls and injuries

• better posture

• increased feelings of wellbeing and relief of stress, anxiety and depression

• more energy

• better sleep.

Heart disease is the leading single cause of death in Australia. You can reduce your risk of heart disease by doing some exercise every day. Regular exercise helps lower your blood pressure, blood cholesterol and body weight. You can reduce your risk of heart disease even more by eating a healthy diet as well as doing regular exercise.

EXERCISE

Regular exercise is important for all people, no matter what their age, weight, health problems or abilities. Children and teenagers who do regular exercise are less likely to have high blood pressure, obesity, diabetes and heart disease when they are adults. Regular exercise also helps older people to stay healthy, independent and active.

13inPHARMation November 2014 I © Pharmaceutical Society of Australia Ltd.

Counter ConnectionLow-dose aspirin Pharmacy assistant’s education Module 254

• capsules (e.g. Astrix)

• enteric-coated capsules (e.g. Astrix).

Higher doses of aspirin

At higher doses (>300 mg), aspirin reduces the production of chemicals called prostaglandins that cause pain, inflammation and fever. Although aspirin at high doses can also prevent blood clots, it is not used as an antiplatelet medicine at this dose. See Table 1.

Side effects of low-dose aspirinThe risk of side effects from low-dose aspirin is increased if more than the recommended dose is taken. Aspirin’s anti-clotting effect is no greater if it is taken in a higher dose or taken more frequently. Advise customers to take the dose recommended by their doctor.

Side effects that can be caused by low-dose aspirin include:

• Stomach irritation – aspirin can irritate the stomach, causing heartburn, nausea and vomiting. To avoid these side effects, advise customers to take low-dose aspirin after food or to use enteric-coated tablets.

• Stomach ulcers – aspirin can damage the lining of the stomach, causing ulcers (called peptic ulcers) to form. Enteric-coated tablets do not help to prevent peptic ulcers.

• Bleeding – because it prevents blood clotting, aspirin increases the risk of bleeding, particularly in the gastrointestinal tract (bowel). Signs of gastrointestinal bleeding include upper abdominal pains, blood in the urine, black stools, and vomiting blood. Signs of bleeding in other parts of the body include easy bruising, or bruises that take longer than normal to heal, nosebleeds, coughing up blood, and prolonged bleeding from cuts and wounds. If any of these occur, the person should immediately see a doctor or go to the hospital.

• Allergic reactions – aspirin can occasionally cause allergic reaction. Signs of an allergic reaction include hives, skin rash, wheezing, difficulty breathing and swollen lips. If any of these occur, the person should immediately see a doctor. Aspirin can also trigger asthma symptoms in some people who have asthma (this is

called aspirin-intolerant asthma). People who have aspirin-intolerant asthma should avoid taking aspirin and other NSAIDs.

Advise customers to speak to their pharmacist or doctor if they experience any side effects with low-dose aspirin.

Interactions with other medicines Low-dose aspirin can interact with several different types of medicine. These interactions may increase the risk of side effects, especially gastrointestinal bleeding.

Medicines that can increase the risk of bleeding when taken with low-dose aspirin include:

• NSAIDs (e.g. ibuprofen, naproxen) (see Box 1)

• anticoagulant medicines (e.g. warfarin, heparin)

• some antidepressants (SSRIs, e.g.fluoxetine, citalopram)

When a customer requests low-dose aspirin, use a protocol such as What-Stop-Go to determine whether it is suitable for the customer. Always ask if the customer is taking any other medicines before supplying low-dose aspirin. Become familiar with the names of medicines, particularly those available OTC that may interact with aspirin. NSAIDs, used to treat pain and inflammation, are commonly available OTC in pharmacies and supermarkets in tablet, capsule and gel form. These medicines, when taken or used with low-dose aspirin, increase the risk of bleeding. Refer any customer asking for low-dose aspirin and who is taking another medicine to the pharmacist.

Who should take low-dose aspirin?People who have cardiovascular disease

(CVD) – diseases of the heart and blood vessels – are at greater risk of having a heart attack or stroke. Low-dose aspirin is recommended for these patients to lower their risk. People who need to take low-dose aspirin include those who:

• have had a previous heart attack

• have had a previous stroke

• have angina

• have had heart surgery.

Most people with CVD need to take low-dose aspirin for the rest of their lives. Low-dose aspirin should be taken regularly, once a day. If it is not taken regularly, there is a greater risk that the person will develop a potentially dangerous blood clot.

Who should not take low-dose aspirin?Low-dose aspirin is not suitable for everyone. People with stomach or intestinal ulcers are at greater risk of internal bleeding and should avoid aspirin. The risk of bleeding is also increased if aspirin is taken with certain medicines (e.g NSAIDs).

Low-dose aspirin should not be taken if a person:

• has an allergy to aspirin or other NSAIDs

• has a stomach or duodenal ulcer

• has bleeding from the stomach or bowel

• has asthma-intolerant asthma

• is taking another NSAID.

Customers should be advised not to start taking daily low-dose aspirin to prevent a heart attack or stroke without advice from their doctor. People who have not had a heart attack or stroke or do not have cardiovascular problems do not need to take low-dose aspirin. If a customer thinks they are at high risk of having a heart attack, refer them to the pharmacist immediately.

People who take regular aspirin may need

Aspirin Dose Action Use Frequency

Low dose 75–150 mg Prevents the formation of blood clots

Reduce the risk of heart attack or stroke in people with cardiovascular disease

Daily; long-term

Higher dose >300 mg Prevents blood clots

Reduces pain, inflammation and high temperature

Treat mild-to-moderate pain Occasional use

Relieve fever

Reduce swelling and inflammation

Rarely used

Table 1. The effects of aspirin

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John Bell saysCounter Connection

• they are pregnant or breastfeeding

• they have surgery or a dental procedure planned

• they want to use it for a child under 16.

Peter (55 years old) asks for some Voltaren Rapid. He tells you that has re-injured his knee playing football on the weekend. Last time he hurt his knee, he took Voltaren Rapid and it worked well, so he wants to take it again for this injury. Peter also asks for a packet of Astrix (112 tablets). You ask Peter if the Astrix is for himself. He says it is. He had a heart attack about 6 months ago and now takes Astrix every day.

Voltaren Rapid, an NSAID, may not be suitable for Peter as he is taking Astrix, a low-dose aspirin. Taking both of these medicines will increase his risk of developing side effects such as bleeding. Recommend that Peter talk to the pharmacist. Pass on to the pharmacist the information you have obtained from Peter. Make sure the information you are giving the pharmacist is accurate and cannot be overheard by anyone else.

The pharmacist recommends that Peter take 1000 mg paracetamol every 4–6 hours for his painful knee injury. He also suggests that Peter applies ice to the knee and rests it for 2–3 days.

Provide Peter with information about low-dose aspirin and highlight the medicines he should avoid. Remind Peter that he should continue to take the low-dose aspirin every day.

Encourage Peter to return to the pharmacy if his symptoms don’t start improving within a few days.

Provide Peter with the PSA Self Care Fact Card Sprains and strains.

to stop taking it 7 days before having surgery, to reduce the risk of bleeding. Refer any customer who is going to have surgery to the pharmacist.

As part of the What-Stop-Go protocol, determine who requires the medicine and for what condition they want to use it.

CounsellingIf a customer asks for low-dose aspirin, provide the following advice:

• Take non-enteric-coated tablets with food to reduce stomach upset.

• Do not crush or break open enteric-coated tablets or capsules.

• Take the recommended dose and follow the instructions for use.

• Do not start taking low-dose aspirin without consulting a doctor.

• If you are taking low-dose aspirin on your doctor’s recommendation, do not stop taking it without asking your doctor.

• Remove tablets or capsules from the container immediately before use, as they rapidly break down and lose their effectiveness when exposed to light and moisture.

• If taking low-dose aspirin and pain relief is needed, take paracetamol rather than another aspirin product or a NSAID. Speak to your doctor if further pain relief is needed.

• Do not take a double dose to make up for a missed dose.

Referral to the pharmacistRefer customers who ask for low-dose aspirin to the pharmacist if:

• they are taking any other medicines

• they have had an allergic reaction to aspirin or NSAIDs

• they have asthma and have a history of asthma symptoms being triggered by aspirin or other NSAIDs

• they have other medical conditions

• they have not discussed taking low-dose aspirin with their doctor

Low-dose aspirin Pharmacy assistant’s education Module 254

15inPHARMation November 2014 I © Pharmaceutical Society of Australia Ltd.

Counter Connection

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Suburb: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Circle one correct answer from each of the following questions.

Before undertaking this assessment, you need to have read the Counter Connection article and the associated Fact Cards.

The pass mark for each module is five correct answers. Participants receive one credit for each successfully completed module. On completion of 10 correct modules participants receive an Achievement Certificate.

Please submit your assessment by 31 December 2014

Please retain a copy for your own purposes. Photocopy if you require extra copies.

Low-dose aspirinAssessment questions for the pharmacy assistant

Submit answers

Submit online at www.psa.org.au/selfcare

Fax: 02 6285 2869

Mail: Self Care Answers Pharmaceutical Society of Australia PO Box 42 DEAKIN WEST ACT 2600

Low-dose aspirin Pharmacy assistant’s education Module 254

1. Low-dose aspirin is used to:

a) treat headaches.

b) treat a sprained ankle.

c) reduce the risk of developing blood clots.

d) lower a high temperature.

2. Low-dose aspirin is suitable for a person who:

a) has had a recent heart attack.

b) is taking the anti-inflammatory medicine Nurofen.

c) is allergic to aspirin.

d) does not have cardiovascular disease.

3. Which of the following is NOT a side effect of low-dose aspirin?

a) Increase in the risk of bleeding.

b) Muscle pain.

c) Allergic reaction causing skin rash and hives.

d) Upset stomach.

4. If low-dose aspirin causes an upset stomach, you could advise the customer to:

a) stop taking low-dose aspirin.

b) try using enteric-coated tablets.

c) use soluble 300 mg aspirin tablets.

d) none of the above.

5. (Answer this question after reading the PSA Self Care Fact Card Migraine). Cathy is a migraine sufferer. She comes into the pharmacy for Nurofen tablets. You ask her if she is taking any other medicine and she says she takes an Astrix tablet every morning. Which of the following statement is CORRECT?

a) Cathy should be referred to the pharmacist.

b) Cathy should be given the Self Care Fact Card Migraine.

c) Both Astrix and Nurofen are NSAIDs and should not be taken together.

d) All of the above.

6. Mr Brown is a regular customer. He says he has heard that aspirin ‘stops heart attacks’ and wants to start taking Cartia like his wife. Which of the following is the MOST appropriate response?

a) Sell Mr Brown a box of Cartia and tell him to take one table every morning.

b) Ask Mr Brown if he is taking any other medicines as they might interact with aspirin.

c) Refer Mr Brown to the pharmacist as he should not start taking any medicine without first discussing it with the pharmacist or doctor.

d) Suggest that Mr Brown take one of his wife’s Cartia tablets each morning.

16 inPHARMation November 2014 I © Pharmaceutical Society of Australia Ltd.

John Bell says

What’s coming up in inPHARMation?Next month’s inPHARMation will focus on smoking cessation. Tobacco smoking is a leading cause of preventable disease across the globe. Although the number of smokers in Australia is declining, illnesses caused by tobacco smoke are still responsible for approximately 15,000 deaths in Australia every year. Pharmacists and pharmacy assistants have a vital role to play in promoting smoking cessation. The December issue of inPHARMation will provide an update on the smoking cessation, including techniques for motivating customers to quit, and new nicotine replacement therapy products.

Self Care achievers Self Care presents certificates to staff who successfully complete a year of Counter Connection modules. We would like to congratulate the following people:

Conferences6th Australian Rural and Remote Mental Health Symposium, 10–12 NovemberAlbury, NSWanzmh.asn.au/rrmh

ASMI Annual Conference18 NovemberWaterview Convention Centre, Sydney, NSW Olympic Parkwww.asmi.com.au

Australasian Pharmaceutical Sciences Association Conference6–7 DecemberBrisbane, Queensland

NAPSA Congress24–30 January, 2015Griffith University, Gold Coast, Queenslandwww.napsacongress.org

Conferences and calendar dates

Year 15Gwenda Foggitt

Year 14Donna Rogers

Year 11Sandra Hope-Johnstone

Year 10Jeanette BrusamarelloSandra CrispinThea Dimopoulos

Year 9Glenda RickerKerry DwyerMarlene AzzouniSandra Tregidga

Year 8Dianne JamesMagdalena LioiMargaret ByeRobyn PikeRosie RichSheila Thorsen

Year 7Helen PhelpsJoanne Johns

Julie VeitchLynne BellMelissa DeakesMelissa NicolleTracey Blood

Year 6 Julie LloydKaren JohnsonKim McKenzieSharyn LeaverSkye HoneymanTiffany Guy

Year 5Bronwyn HendyFelicity BaroneLisa GardnerLorrae PattisonMaree RudderMarian InglisPatsy Lee-SchuellerSandra ForemanSuzzi JansonTina Lawrence

Year 4Alison ReadDebbie Grantham

Ellie DaleJanice BreadenKaren BuhagiarKathy BattersbyKerrie GardemLisa FikkersSelina DanielSilvana NicastroToni Stone

Year 3Amanda SlatteryAnne WheeldonCarol PallotCherie FenechEloise EshmanJacki WoodrowJenny BaileyJessica BoydJo ByronJo Alfred HurtadoJoelene StanleyKaren ParksLeonie OsbornMargaret BorgMarina QuickNadine TeyNancy Audrians

Nataly SpaseskaRuth ShakeshaftSamantha PalmerSarah FitzpatrickZoey Henderson

Year 2Anne-Rene SmithBrooke WardCarol HolmesClare FisherDaline KhengDanielle MazzeoElizabeth GraovacFreda EliasGeraldine MooreGlenda WellardJanelle BurnsJoanne AtkinsonKellie MurphyKerri BoltonKim LachmundKristin SheldonLeanne KennedyLjubica MilevskaMarg DeenMaria FarquharMartelle MalhotraMary GeorgeMary VargasMelissa BoydTasha BraggPaca GorgievskaPauline ReynoldsPip Bailey

Rachel DodgeRachel WebbRhea Von-StieglitzSarah WorsleySue BullockSue LoipTania DowellVicki CadmanWilliam Townsend

Year 1Abbey HerronAnnabelle MoralesBobby MissaghianCara HillCarolyn ShepherdCasey PinataroChloe LambChristina MeheganClaire ComazzettoDaniella DianaElaine GaskinElisabeth HazellEmma BeardEvelyn WilsonGayle PatersonHannah GannonHelena KaragaIsabella GrossJennifer DunlopJennifer SandsJenny GreenJenny McIverKaren SkindbjergKarlie Spiteri

Katherine FinnKatherine WearneKim O’DeaKirsten VineyKirsty CollettKristy HughesKurt BoundyKurt WilliamsLisa FortiMadeline LambMarg PedlerMaria LantourisMaria LeoneMicaela FerringtonMikyla HognoMitchell FischerTasha BraggNicola KnightPaula PossRafiq BaqaieRicki-Leyie MatthewsSandra ArkellSarah McConnonSarah TarrantShannon BarrShari NeilsenSharon ShieldsShona ThorntonSinead AhernSmith KshirsagerSnezana AngelkovskiSuzanne BiniahanTaylah RatajTeresa Forti

Noticeboard

ConferencesAustralian Pharmacy Professional Conference and Trade Exhibition12–15 March, 2015Gold Coast Convention Centre, Queenslandwww.appconference.com

40th PSA Offshore Refresher Conference30 April–10 May, 2015Berlin and Pariswww.psa.org.au/refresher

13th National Rural Health Conference24–27 May, 2015Darwin Convention Centre, NT